Fluoroscopic Exposure With Use of Mini-C-Arm During Routine Hand Surgery: A Prospective Comparison of Hand Versus Eye Radiation Dosage.

Radiation exposure with use of intraoperative fluoroscopy is a potential orthopedic occupational risk factor. The purpose of this study was to perform a prospective comparison of hand versus eye radiation exposure associated with mini-C-arm utilization and to test the hypothesis that routine mini-C-arm does not yield hand or eye dosages exceeding current recommended levels. Over a 12-month period, hand and eye radiation exposure was prospectively measured in a single board-certified hand surgeon using mini-C-arm fluoroscopy. Twenty-five cases were performed utilizing mini-C-arm fluoroscopy. Average monthly hand radiation dosage (45.81±14.49 mrem) was significantly higher (p = .01) than eye radiation dosage (<30 mrem). Both recorded values were below their respective critical exposure limits, as reported by the International Commission on Radiological Protection. The findings suggest that hand and eye exposure associated with mini-C-arm utilization during routine surgery does not approach reported levels of critical radiation loads.

Hand Surgery and Fluoroscopic Eye Radiation Dosage: A Prospective Pilot Comparison of Large Versus Mini C-Arm Fluoroscopy Use.

Background: The purpose of this study is to (1) perform a prospective pilot comparison of the impact of large versus mini C-arm fluoroscopy on resultant eye radiation exposure and (2) test the hypothesis that the use of either modality during routine hand surgery does not exceed the current recommended limits to critical eye radiation dosage. Methods: Over a 12-month period, eye radiation exposure was prospectively measured by a board-certified hand surgeon using both large and mini C-arm fluoroscopy. For each modality, accumulated eye radiation dosage was measured monthly, while fluoroscopic radiation output was recorded, including total exposure time and dose rate. Results: A total of 58 cases were recorded using large C-arm and 25 cases using mini C-arm. Between the 2 groups, there was not a significant difference with total exposure time (P = .88) and average dose rate per case (P = .10). With the use of either modality, average monthly eye radiation exposure fell within the undetectable range (<30 mrem), significantly less than the current recommended limit of critical eye radiation (167 mrem/month). Conclusions: The impact of various fluoroscopic sources on eye radiation exposure remains relatively unexplored. In this study, the minimal detectable eye radiation dosages observed in both groups were reliably consistent. Our findings suggest that accumulated eye radiation dosage, from the use of either fluoroscopic modality, does not approach previously reported levels of critical radiation loads.

A Prospective Evaluation of Opioid Utilization After Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines.

BACKGROUND: Although adequate management of postoperative pain with oral analgesics is an important aspect of surgical procedures, inadvertent overprescribing can lead to excess availability of opioids in the community for potential diversion. The purpose of our study was to prospectively evaluate opioid consumption following outpatient upper-extremity surgical procedures to determine opioid utilization patterns and to develop prescribing guidelines. METHODS: All patients undergoing outpatient upper-extremity surgical procedures over a consecutive 6-month period had the following prospective data collected: patient demographic characteristics, surgical details, anesthesia type, and opioid prescription and consumption patterns. Analysis of variance and post hoc comparisons were performed using t tests, with the p value for multiple pairwise tests adjusted by the Bonferroni correction. RESULTS: A total of 1,416 patients with a mean age of 56 years (range, 18 to 93 years) were included in the study. Surgeons prescribed a mean total of 24 pills, and patients reported consuming a mean total of 8.1 pills, resulting in a utilization rate of 34%. Patients undergoing soft-tissue procedures reported requiring fewer opioids (5.1 pills for 2.2 days) compared with fracture surgical procedures (13.0 pills for 4.5 days) or joint procedures (14.5 pills for 5.0 days) (p < 0.001). Patients who underwent wrist surgical procedures required a mean number of 7.5 pills for 3.1 days and those who underwent hand surgical procedures required a mean number of 7.7 pills for 2.9 days, compared with patients who underwent forearm or elbow surgical procedures (11.1 pills) and those who underwent upper arm or shoulder surgical procedures (22.0 pills) (p < 0.01). Procedure type, anatomic location, anesthesia type, age, and type of insurance were also all significantly associated with reported opioid consumption (p < 0.001). CONCLUSIONS: In this large, prospective evaluation of postoperative opioid consumption, we found that patients are being prescribed approximately 3 times greater opioid medications than needed following upper-extremity surgical procedures. We have provided general prescribing guidelines, and we recommend that surgeons carefully examine their patients' opioid utilization and consider customizing their opioid prescriptions on the basis of anatomic location and procedure type to prescribe the optimal amount of opioids while avoiding dissemination of excess opioids.

Radiation exposure to hand surgeons' hands: a practical comparison of large and mini C-arm fluoroscopy.

PURPOSE: To determine and compare the radiation exposure to surgeons' hands with large and mini C-arm fluoroscopy in a practical, clinically based model. METHODS: Two hand surgeons monitored radiation exposure to their hands with a ring dosimeter over a 14-month period using large and mini C-arm fluoroscopic units. One surgeon performed all cases with a large C-arm unit in a hospital setting, and the other performed all cases with mini C-arms in surgical centers. For each case, fluoroscopic time, the output displayed by the unit, radiation by time, and ring dosimeter absorption were recorded and analyzed. RESULTS: A total of 160 consecutive cases were reviewed with 71 cases and 89 cases in the large and mini C-arm groups, respectively. The median output displayed by the large C-arm was 0.7 mGy/case, and the median output displayed by the mini C-arm was 10.0 mGy/case. With output as a product of time, the median calculated values were 0.02 mGy/s for the large C-arm group and 0.28 mGy/s for the mini C-arm group. Cumulative ring dosimeter absorption to the surgeons' hands was found to be 380 mrem for 71 cases in the large C-arm group versus 1,000 mrem for 89 cases in the mini C-arm group. CONCLUSIONS: In our model, the use of the mini C-arm resulted in more than a 10-fold increase in the rate of output and approximately double the dosimeter absorption to the surgeon's hand compared with the large C-arm. Although it has been shown that the mini C-arm produces less radiation scatter, in a practical model, it may not be a safer alternative with respect to the surgeon's hands. Based on these findings, we recommend that surgeons be more aware of radiation exposure risk, know their C-arm unit's specifications, and try to minimize radiation exposure. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Ethical and educational considerations in coding hand surgeries.

PURPOSE: To assess treatment coding knowledge and practices among residents, fellows, and attending hand surgeons. METHODS: Through the use of 6 hypothetical cases, we developed a coding survey to assess coding knowledge and practices. We e-mailed this survey to residents, fellows, and attending hand surgeons. In additionally, we asked 2 professional coders to code these cases. RESULTS: A total of 71 participants completed the survey out of 134 people to whom the survey was sent (response rate = 53%). We observed marked disparity in codes chosen among surgeons and among professional coders. CONCLUSIONS: Results of this study indicate that coding knowledge, not just its ethical application, had a major role in coding procedures accurately. Surgical coding is an essential part of a hand surgeon's practice and is not well learned during residency or fellowship. Whereas ethical issues such as deliberate unbundling and upcoding may have a role in inaccurate coding, lack of knowledge among surgeons and coders has a major role as well. CLINICAL RELEVANCE: Coding has a critical role in every hand surgery practice. Inconstancies among those polled in this study reveal that an increase in education on coding during training and improvement in the clarity and consistency of the Current Procedural Terminology coding rules themselves are needed.

Treatment of carpal tunnel syndrome by members of the American Society for Surgery of the Hand: a 25-year perspective.

PURPOSE: In 1987, Duncan et al.(1) reported on a survey of the members of the American Society for the Surgery of the Hand (ASSH) about their practices in treating carpal tunnel syndrome (CTS). To better understand changes in the treatment of CTS over the past 25 years, we repeated the survey while incorporating present-day controversies. METHODS: With the approval of the ASSH, an Internet-based survey was e-mailed to all members of the Society. This included 33 primary questions focusing on 4 areas of study: surgeon demographic information, nonoperative treatment, surgical technique, and postoperative care. A total of 1,463 surveys were delivered and 707 surveys were completed and returned, for a response rate of 48%. Responses were compared with the responses from Duncan et al. published 25 years ago.(1) RESULTS: In contrast to the practice patterns identified 25 years ago, this survey identified several changes in current clinical practices including the following statistically significant findings: Preoperatively, surgeons have increased the use of splints and corticosteroid injections, treat nonoperatively longer, and have narrowed their surgical indications. Regarding surgical technique, surgeons now are using tourniquets less, infiltrate the carpal tunnel with corticosteroids less, and place deep sutures less often. Furthermore, performing concomitant procedures along with release of the transverse carpal ligament has decreased. Orthotic use and duration postoperatively also decreased. CONCLUSIONS: Although significant differences are evident between management of CTS between 1987 and 2011, no consensus has emerged.

Open versus endoscopic carpal tunnel release.

Carpal tunnel syndrome is a very common hand condition, which after a failure of conservative treatment can be treated successfully with surgical decompression in either an open or endoscopic manner. On comparing the two techniques there may be some subtle differences; however, both can provide an excellent outcome. This article provides a detailed review of each technique as well as their comparative differences in terms of technique, outcomes, and complications.

Ultrasound-guided injections for de Quervain's tenosynovitis.

BACKGROUND: Nonsurgical management of de Quervain's tenosynovitis often includes corticosteroid injections. If the injection does not enter the compartment, or all subcompartments, response to the injection is variable. To ensure proper location of injections we evaluated the role of ultrasound. QUESTIONS/PURPOSES: We determined (1) the incidence of two or more subcompartments, (2) the incidence of anatomic variations during surgical release after failed injections, and (3) the relief of pain after ultrasound-guided injections. PATIENTS AND METHODS: A prospective series of 40 consecutive patients (42 wrists) diagnosed with de Quervain's tenosynovitis by clinical examination were referred to a radiologist for an ultrasound-guided injection. The radiologist injected the first dorsal compartment and noted any septations. Patients returned for followup where outcomes, DASH, and VAS scores were calculated. The treating surgeon was blinded to any anatomic variations. Followup was at 6 weeks and a minimum of 6 months (mean, 6 weeks, range, 3-17 months; mean, 11 months, range, 7-18 months). Four patients were lost to followup. RESULTS: Multiple subcompartments were noted in 22 of 42 (52%) wrists. At the 6-week followup, 36 of the 37 wrists examined in 36 patients (97%) had at least partial resolution of symptoms. Multiple subcompartments were identified in 52% of cases. At last followup, the mean DASH and VAS scores were 18.4 and 2.2, respectively. However 14% of wrists had recurrence of symptoms, all of which had subcompartments on ultrasound. No adverse effects from the injections were noted. CONCLUSION: We found ultrasound-guided injections to be useful for treatment of de Quervain's tenosynovitis. Our success with ultrasound-guided injections was slightly better than that reported in the literature and without adverse reactions.

Subchondral bone marrow lesions associated with knee osteoarthritis.

Knee osteoarthritis (OA) is a prevalent condition typically measured by the level of joint space thinning. However, it has been shown that the degree of joint space narrowing correlates poorly with the incidence and magnitude of knee pain. A review of recent and past literature suggests that chronic bone marrow edema (BME) or bone marrow lesions may be linked to pain, the progression of cartilage damage, and the acceleration of joint degeneration. The literature further provides strong support that chronic BME may be an additional target for treatment. This case study has shown that a treatment to repair BME by restoring support and relieving abnormal stresses with accepted internal fixation and bone stimulating surgical techniques is effective in relieving knee OA pain. The literature review and case study herein are provided as a basis for the treatment of chronic BME as an important addition to the current knee OA treatment paradigm.

Skin cancers of the hand and upper extremity.

Skin cancers represent the most common primary malignancies of the hand. They typically present as painless lesions on areas of high sun exposure, such as the dorsum of the hand and upper extremity. The most common malignancy is squamous cell carcinoma, followed by basal cell carcinoma and melanoma. The key to successful treatment is early and accurate diagnosis and treatment. Unlike open biopsies, which are indicated for deep soft tissue and bone lesions, biopsies for skin cancer can be performed under local anesthesia in the office setting in the form of shave or punch biopsies. A number of nonsurgical treatment options are available for treatment. However, when surgical excision is indicated, appropriate margin resections are dictated by the grade and stage of the malignancy.

Distal intersection tenosynovitis of the wrist: a lesser-known extensor tendinopathy with characteristic MR imaging features.

OBJECTIVE: To present the MRI imaging findings of extensor tenosynovitis at the distal intersection or crossover between the second (extensor carpi radialis longus (ECRL) and brevis (ECRB)) and third (extensor pollicis longus (EPL)) extensor compartment tendons, and the anatomical details that may play a role in the pathogenesis of this condition. DESIGN AND PATIENTS: The imaging studies and clinical records of five patients (three females and two males, with ages ranging between 22 and 78 years; mean age, 49 years) presenting with pain on the dorsal and radial aspect of the wrist were reviewed by two musculoskeletal radiologists in consensus. Three cases were identified serendipitously during routine clinical reading sessions; a follow-up computerized database search for additional cases reported in the prior two years yielded two additional cases. The overall number of cases screened was 1,031. The diagnosis of tendinopathy affecting the second and third compartment extensor tendons was made on the basis of MRI findings and clinical follow-up, or synovectomy. RESULTS: All patients showed signs of tenosynovitis: in four patients both the tendons of the second and third extensor compartments were affected; the fifth patient showed signs of tenosynovitis of the EPL tendon, and tendinosis of the extensor carpi radialis tendons. Three patients showed tenosynovitis proximal and distal to the point of intersection; and in two of them, a discrete point of constriction was appreciated at the crossover site in relation to the extensor retinaculum. Two patients showed tenosynovitis limited to the segment distal to the point of decussation. Tendinosis tended to follow the presence of tenosynovitis. In one of the patients, subtendinous reactive marrow edema in Lister's tubercle was noted. CONCLUSION: Distal intersection tenosynovitis may be related to the biomechanical pulley effect exerted by Lister's tubercle on the EPL tendon as it leaves the third compartment and crosses over the extensor carpi radialis tendons, as well as the constraining effect of the extensor retinaculum. These anatomical features determine the presence of characteristic MR imaging findings.

Brachial plexus anatomy.

The brachial plexus may be visualized simply as beginning with five nerves and terminating in five nerves. It begins with the anterior rami of C5, C6, C7, C8, and the first thoracic nerve. It terminates with the formation of the musculocutaneous, median, ulnar, axillary, and radial nerves. The intermediate portions are displayed in sets of threes: three trunks are formed, followed by three divisions, then three cords. Each trunk gives rise to two divisions and each cord gives rise to two branches. The lateral cord divides into the musculocutaneous nerve and the lateral branch of the median nerve. The medial cord divides into the medial branch of the median nerve and the ulnar nerve. The posterior cord divides into the axillary and the radial nerves. The anatomy of the brachial plexus can be confusing, especially because of frequent variations in length and caliber of each of its components.

Current trends in treatment of thoracic outlet syndrome.

Even though the response from this survey was decent, it is not large enough to draw statistical conclusions. The data therefore are being presented from an interest standpoint and do reflect the current trends of treatment for TOS. Physicians who do not treat TOS do not have an accurate view of this disorder, its treatment, or the success rate of treatment. Surgeons who deal with this problem have encouraging results. Conservative treatment seems effective in approximately half of the patients afflicted with this condition. Surgery carries what seems to be a long-term cure rate of 65% and partial relief in 20% of patients. Significant complications are rare.