A Tale of Two Health-Care Systems: Cost-Utility Analysis of Open Carpal Tunnel Release in Canada and the United States.

PURPOSE: Canadian health care is often criticized for extended wait times, whereas the United States suffers from increased costs. The purpose of this pilot study was to determine the cost-utility of open carpal tunnel release in Canada versus the United States. METHODS: A prospective cohort study evaluated patients undergoing open carpal tunnel release at an institution in Canada and the United States. All costs from a societal perspective were captured. Utility was measured using validated health-related quality of life (HRQOL) scales-the EuroQol-5D and the Michigan Hand Outcome Questionnaire. RESULTS: Twenty-one patients at the Canadian site and 8 patients at the US site participated. Mean total costs were US $1581 ± $1965 and $2179 (range: $1421-$2741) at the Canadian and US sites, respectively. Health-related quality of life demonstrated significant improvements following surgery (P < .05). Patient utilities preoperatively and at 6 weeks and 3 months postoperatively were 0.72 ± 0.20, 0.86 ± 0.11, and 0.83 ± 0.16 at the Canadian site and 0.81 ± 0.09, 0.86 ± 0.10, and 0.86 ± 0.12 at the US site. Improvements in HRQOL directly related to surgery were not significantly different between patients in Canada and the United States. American patients, however, attained improved HRQOL sooner due to shorter wait times (27 ± 10 vs 214 ± 119 days; P < .001). The incremental cost-utility of the US system was $7758/quality-adjusted life year gained compared to the Canadian system. Sensitivity analyses confirmed that these results were robust. CONCLUSION: This pilot study suggests that carpal tunnel surgery is more cost-effective in the United States due to prolonged wait times in Canada.

OBJECTIF: Le système de santé canadien est souvent critiqué pour ses temps d'attente prolongés, tandis qu'aux États-Unis, les coûts sont élevés. La présente étude pilote visait à déterminer le rapport coût-utilité de la libération ouverte du canal carpien au Canada par rapport aux États-Unis. MÉTHODOLOGIE: Les chercheurs ont réalisé une étude prospective de cohorte sur des patients qui subissaient une libération ouverte du canal carpien dans un établissement du Canada ou des États-Unis. Ils ont colligé tous les coûts sociétaux et ont mesuré l'utilité à l'aide d'échelles validées de la qualité de vie liée à la santé (QdVLS), soit l'EuroQol-5D et le questionnaire Michigan sur le résultat clinique de la main. RÉSULTATS: Vingt et un patients de l'établissement canadien et huit de l'établissement américain ont participé à l'étude. Les coûts totaux moyens s'élevaient à 1 581 $US ± 1 965 $ et à 2 179 $ (plage de 1 421 $ à 2 741 $) dans les établissements canadiens et américains, respectivement. La QdVLS s'est accrue de manière significative après l'opération (P<0,05). L'utilité des patients avant l'opération, puis six semaines et trois mois après l'opération, était de 0,72 ± 0,20, de 0,86 ± 0,11 et de 0,83 ± 0,16 dans l'établissement canadien et de 0,81 ± 0,09, de 0,86 ± 0,10 et de 0,86 ± 0,12 dans l'établissement américain. Les améliorations de la QdVLS découlant directement de l'opération ne différaient pas de manière significative entre le Canada et les États-Unis. Cependant, les patients américains voyaient leur QdVLS s'améliorer plus rapidement puisque les temps d'attente étaient moins longs (27 ± 10 jours par rapport à 214 ± 119 jours; P<0,001). Le coût-utilité incrémentiel du système américain s'établissait à 7 758 $/année de vie pondérée par la qualité par rapport au système canadien. Des analyses de sensibilité ont confirmé la solidité de ces résultats. CONCLUSION: D'après cette étude pilote, la libération du canal carpien présente un meilleur rapport coût-utilité aux États-Unis en raison des temps d'attente prolongés au Canada.

Intraneural Ganglions of the Hand and Wrist.

PURPOSE: To review 15 patients who were treated for intraneural ganglions of the hand and wrist. METHODS: Between 1990 and 2012, 15 patients were treated for intraneural ganglions of the hand and wrist. There were 9 women and 6 men, averaged age 42 years. Ten patients presented with a mass and 5 with symptoms of entrapment neuropathy. The ganglions involved the ulnar nerve at the wrist in 5 patients, the dorsal branch of the ulnar nerve in 2, the superficial radial nerve in 2, a digital nerve in 4, and the dorsal branch of a digital nerve in 2. Eight patients had magnetic resonance imaging evaluations that showed cystic masses that did not confirm intraneural ganglions. In all patients diagnosis was made intraoperatively. Ganglions were treated by intraneural dissection and excision of the cyst in 10 patients, excision of the articular branch and decompression of the cyst in 4, and excision of the ganglion and the nerve in 1. RESULTS: Postoperative follow-up averaged 57 months. There were no complications or recurrences. Five patients had transient paresthesias that improved after an average of 2 months. Preoperative symptoms improved in all patients. Patients returned to normal daily and work activities at an average of 10 days. CONCLUSIONS: Intraneural ganglions should be considered in the differential diagnosis of a mass in the vicinity of a nerve. Surgical excision is usually curative but simple excision of the articular branch and decompression of the cyst seems simpler and equally effective. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Advanced technology and confidentiality in hand surgery.

Advanced technology has the potential to improve the quality of care for our patients, but it also poses new challenges, especially in maintaining patient confidentiality. The Health Insurance Portability and Accountability Act and the newly enacted Health Information Technology for Economic and Clinical Health Act provide certain guidelines governing patients' medical record confidentiality. This article discusses the other new challenges facing hand surgeons, such as the use of social media, telemedicine, e-mails, and the Internet.

Multicentric giant cell tumor of the fourth and fifth metacarpals with lung metastases.

Giant cell tumors of bone (GCTB) are generally benign neoplasms, but recently, some authors consider them to be low-grade malignant neoplasms because they have a relatively high rate of recurrence and at least some potential for metastases. The majority of GCTB are unifocal, and less than 1 % are multicentric. We report a rare case of a multicentric GCTB arising simultaneously in the non-dominant fourth and fifth metacarpals of a 25-year-old female. The patient underwent ray amputation of the two involved digits, and the surgical margins were histologically negative for tumor. The tumor had the classic histologic appearance of a benign GCTB. A year after the amputation, the patient developed pulmonary metastasis which was treated with pulmonary lobe resection. She is currently over 2.5 years postsurgical treatment of the primary lesion with no evidence of local recurrence or distant metastasis.

Drosophila social clustering is disrupted by anesthetics and in narrow abdomen ion channel mutants.

Members of many species tend to congregate, a behavioral strategy known as local enhancement. Selective advantages of local enhancement range from efficient use of resources to defense from predators. While previous studies have examined many types of social behavior in fruit flies, few have specifically investigated local enhancement. Resource-independent local enhancement (RILE) has recently been described in the fruit fly using a measure called social space index (SSI), although the neural mechanisms remain unknown. Here, we analyze RILE of Drosophila under conditions that allow us to elucidate its neural mechanisms. We have investigated the effects of general volatile anesthetics, compounds that compromise higher order functioning of the type typically required for responding to social cues. We exposed Canton-S flies to non-immobilizing concentrations of halothane and found that flies had a significantly decreased SSI compared with flies tested in air. Narrow abdomen (na) mutants, which display altered responses to anesthetics in numerous behavioral assays, also have a significantly reduced SSI, an effect that was fully reversed by restoring expression of na by driving a UAS-NA rescue construct with NA-GAL4. We found that na expression in cholinergic neurons fully rescued the behavioral defect, whereas expression of na in glutamatergic neurons did so only partially. Our results also suggest a role for na expression in the mushroom bodies (MBs), as suppressing na expression in the MBs of NA-GAL4 rescue flies diminishes SSI. Our data indicate that RILE, a simple behavioral strategy, requires complex neural processing.

Functional outcome of collagenase injections compared with fasciectomy in treatment of Dupuytren's contracture.

BACKGROUND: This study was designed to provide comparative information on the safety and efficacy of injection with collagenase clostridium histolyticum (CCH) and fasciectomy for patients with Dupuytren's contracture (DC). METHODS: A single-center, retrospective, observational, longitudinal chart review was conducted of 25 patients treated with CCH injections and 21 patients undergoing fasciectomy. Patients were assessed at 1 week, monthly for 3 months and then yearly for a minimum of 2 years after treatment for changes in contracture and range of motion, time to return to work/normal activities, patient satisfaction, and Disabilities of Arm, Shoulder and Hand (DASH) score. RESULTS: Post-procedure follow-up averaged 32 months for the injection group compared with 39 months for fasciectomy group. For the CCH group, the mean postinjection contracture was 3.6° for the metacarpophalangeal and 17.5° for the proximal interphalangeal joints compared with 3.7° and 8.1° in the fasciectomy group, respectively. Patients treated with injections returned to normal activities after a mean of 1.9 days compared with 37.4 days for fasciectomy patients (p < 0.0001). DASH scores for 13 CCH and 15 fasciectomy patients were obtained. The mean DASH score was significantly lower in the injection group in the first 3 months (p < 0.01). At the 2-year follow-up visit, patients were satisfied with their outcomes following either treatment (92 % and 96 % of CCH and fasciectomy patients, respectively). CONCLUSION: CCH injections are safe and effective and may be a viable alternative to fasciectomy for treating DC. It also allows earlier return to work and daily activities.

Radial tunnel syndrome.

Radial tunnel syndrome is a pain syndrome resulting from compression of the posterior interosseous nerve at the proximal forearm. It has no specific radiologic or electrodiagnostic findings. Treatment should be started conservatively; if not successful, surgical treatment is indicated. The posterior interosseous nerve may be explored through dorsal or anterior approaches. All the potential sites of entrapment should be released, including complete release of the superficial head of the supinator muscle. Surgical treatment is generally successful, but patients who have associated lateral epicondylitis or those who are involved in workers' compensation claims have less successful outcomes.

Functional outcome of open reduction of chronic perilunate injuries.

PURPOSE: Perilunate injuries are complex and occasionally go unrecognized acutely. Open reduction and internal fixation is a valid treatment option for these injuries. The purpose of this study was to evaluate the functional outcome of treating chronic perilunate injuries with open reduction and internal fixation. METHODS: Between 1998 and 2007, we treated 24 patients for chronic perilunate injuries. We excluded 5 patients from this study because they underwent proximal row carpectomy or limited wrist arthrodesis. We treated the remaining 19 patients with open reduction and internal fixation. Mean time from injury to surgery was 29 weeks. All patients were men, with a mean age of 27 years. A total of 13 patients had fracture dislocations (group 1); of these, 11 were transscaphoid and 2 were transscaphoid transcapitate fracture dislocations. Six patients had perilunate dislocations (group 2). RESULTS: Postoperative follow-up averaged 58 months. All carpal fractures healed at an average of 18 weeks. At final evaluation, the average pain scores during rest, daily activities, and manual work on a 20-point visual analog scale were 0, 2, and 3, respectively, with no significant difference between groups. The active extension and flexion of the wrist averaged 39% and 52% of the uninjured side, respectively. Grip strength averaged 87% of the uninvolved extremity. According to the Mayo wrist scoring system, 58% of all patients (69% of group 1 and 33% of group 2) achieved good to excellent results. A total of 18 patients returned to their original work activities; 14 patients (74%) were very satisfied. No patients required secondary procedures. CONCLUSIONS: Despite late presentation, patients with chronic perilunate injuries can be treated with open reduction internal fixation, with satisfactory results. Patients with lesser arc injuries have less successful outcome. Patients with irreducible dislocations or major articular damage may require wrist salvage procedures.

Synovial fistula as a complication of recurrent dorsal wrist ganglion excision: case report.

A wrist synovial fistula is rare. The author reports a patient who developed a synovial fistula following excision of a recurrent dorsal wrist ganglion.

Flexor tenosynovial fistulas in the palm.

PURPOSE: Tenosynovial fistulas in the palm are rare. If conservative treatment is unsuccessful, surgical treatment may include excision of the fistula and local flap coverage. In this article, I report 15 patients who were surgically treated for tenosynovial fistulas in the palm. METHODS: Between 1996 and 2009, I treated 15 patients for tenosynovial fistulas in the palm. There were 9 women and 6 men, with an average age of 42 years (range, 21-63 y). The index finger was involved in 5 patients, the long finger in 7, and the ring finger in 3. One patient had a fish fin injury, 6 had multiple surgeries for release of stenosing flexor tenosynovitis with intraoperative steroid injections, 1 had a pellet gun injury, and 7 had lacerations in the distal palm. Four patients had had unsuccessful closure of the fistula. All patients presented with a distal palm sinus draining clear frothy fluid. There were no signs of infection. Gram stains and cultures were negative. Smear and culture for Mycobacterium marinum were negative in the patient who had the fish fin injury. I tried conservative treatment in all patients for an average of 7 weeks. All patients were treated with excision of the sinus tract with partial resection of the A1 pulley and soft tissue coverage with a transposition flap. Pathological examination revealed epithelialization with nonspecific chronic inflammation. RESULTS: Postoperative follow-up averaged 59 months (range, 6-148 mo). All fistulas healed. Patients regained full range of motion and normal grip and pinch strength. One patient had transient tenderness of the scar for 3 months. There were no recurrences. CONCLUSIONS: Tenosynovial fistulas may develop after an injury to the flexor tendon sheath or following the use of steroids after release of trigger fingers recurring after an initial surgical release. Surgical treatment with excision of the fistula and local flap coverage yields excellent results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Short telomeres result in chromosomal instability in hematopoietic cells and precede malignant evolution in human aplastic anemia.

In cell and animal models, telomere erosion promotes chromosomal instability via breakage-fusion-bridge cycles, contributing to the early stages of tumorigenesis. However, evidence involving short telomeres in cancer development in humans is scarce, epidemiological and indirect. Here we directly implicate telomere shortening as a critical molecular event for malignant evolution in aplastic anemia (AA). Patients' telomere lengths at diagnosis of AA, while comparable to age-matched controls, inversely correlated with the probability of developing a cytogenetically abnormal clone. A significantly increased number of telomere signal-free chromosomal ends and chromosomal numerical and structural abnormalities were observed in bone marrow cells of patients with shorter telomeres in comparison with patients with longer telomeres and healthy subjects. The proportion of monosomy-7 cells in the bone marrow at diagnosis of AA inversely correlated with telomere length, years before the emergence of an autonomous and clinically detectable abnormal clone. Marrow cells of clinically healthy individuals carrying loss-of-function telomerase mutations and with extremely short telomeres also showed chromosomal instability in vitro. These results provide the first clinical direct evidence in humans that short telomeres in hematopoietic cells are dysfunctional, mediate chromosomal instability and predispose to malignant transformation in a human disease.