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Rutenberg TF, Galvis EL, Michaeli O, Ozyurekoglu T. Safety of immediate open traumatic extensor tendon repair performed at an emergency department minor procedure room. Arch Orthop Trauma Surg 2024; 144:537-542. [PMID: 37947871 DOI: 10.1007/s00402-023-05115-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/15/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION The superficial location of the extensor tendons makes them particularly vulnerable to lacerations. Patients most commonly present to the emergency department (ED) after these injuries. We aimed to measure the safety of immediate surgical repair of traumatic open extensor tendon injuries in an ED minor procedure room (MPR) under local anesthesia, and the associated post-operative infection and complication rates. MATERIALS AND METHODS We retrospectively evaluated all patients undergoing traumatic open extensor tendon repairs in the ED MPR over a 3.75-years period. Data collected included demographic information, comorbidities, mechanism of injury, additional procedures performed, and post-operative complications. All patients were operated under local anesthesia by a hand surgery fellow aided by an ED technician. RESULTS Two hundred and forty eight patients (278 tendons) were treated for extensor tendon injuries during the study period. 220 patients (245 tendons) have complied with follow-up. No intra-procedural medical complications were encountered. The post-operative infection rate was 1.4%. The rate of other post-operative complications was not related to the number of tendons repaired, additional digit involvement, or if the nature of the injury was work-related. CONCLUSIONS In this cohort, traumatic extensor tendon repairs performed in an ED MPR were found to be medically safe and to associate with a low postoperative infection rate. As preoperative assessment is simple and practical, and limited medical personnel is utilized, this surgical setting may enable us to reduce medical costs.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, 40402, USA.
- Rabin Medical Center, Beilinson Hospital, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Elkin Leon Galvis
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, 40402, USA
| | - Oren Michaeli
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, 40402, USA
| | - Tuna Ozyurekoglu
- Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY, 40402, USA
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Zhuang T, Fox P, Curtin C, Shah KN. Is Hand Surgery in the Procedure Room Setting Associated with Increased Surgical Site Infection? A Cohort Study of 2,717 Patients in the Veterans Affairs Population. J Hand Surg Am 2023:S0363-5023(23)00117-X. [PMID: 36973100 DOI: 10.1016/j.jhsa.2023.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/11/2023] [Accepted: 03/01/2023] [Indexed: 03/29/2023]
Abstract
PURPOSE Procedure rooms (PRs) are increasingly used for hand surgeries, but few studies have directly compared surgical site infection (SSI) rates between the PR and operating room. We tested the hypothesis that procedure setting is not associated with an increased SSI incidence in the VA population. METHODS We identified carpal tunnel, trigger finger, and first dorsal compartment releases performed at our VA institution from 1999 to 2021 of which 717 were performed in the main operating room and 2,000 were performed in the PR. The incidence of SSI, defined as signs of wound infection within 60 days of the index procedure, which was treated with oral antibiotics, intravenous antibiotics, and/or operating room irrigation and debridement, was compared. We constructed a multivariable logistic regression analysis to assess the association between procedure setting and SSI incidence, adjusting for age, sex, procedure type, and comorbidities. RESULTS Surgical site infection incidence was 55/2,000 (2.8%) in the PR cohort and 20/717 (2.8%) in the operating room cohort. In the PR cohort, five (0.3%) cases required hospitalization for intravenous antibiotics of which two (0.1%) cases required operating room irrigation and debridement. In the operating room cohort, two (0.3%) cases required hospitalization for intravenous antibiotics of which one (0.1%) case required operating room irrigation and debridement. All other SSIs were treated with oral antibiotics alone. The procedure setting was not independently associated with SSI (adjusted odds ratio, 0.84 [95% confidence interval, 0.49, 1.48]). The only risk factor for SSI was trigger finger release (odds ratio, 2.13 [95% confidence interval, 1.32, 3.48] compared with carpal tunnel release), which was independent of setting. CONCLUSIONS Minor hand surgeries can be performed safely in the PR without an increased rate of SSI. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Thompson Zhuang
- Department of Orthopedic Surgery, University of Pennsylvannia, Philadelphia, PA
| | - Paige Fox
- Department of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA
| | - Catherine Curtin
- Department of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA
| | - Kalpit N Shah
- Department of Orthopaedic Surgery, Scripps Clinic, San Diego, CA.
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Saleh JR, Mitchell A, Kha ST, Outterson R, Choi A, Allen L, Chang T, Ladd AL, Goodman SB, Fox P, Chou L. The Environmental Impact of Orthopaedic Surgery. J Bone Joint Surg Am 2023; 105:74-82. [PMID: 36574633 DOI: 10.2106/jbjs.22.00548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
➤ There are a growing number of opportunities within the field of orthopaedic surgery to address climate change and investigate ways to promote sustainability. ➤ Orthopaedic surgeons can take a proactive role in addressing climate change and its impacts within the areas of operating-room waste, carbon emissions from transportation and implant manufacturing, anesthetic gases, and water usage. ➤ Future studies are needed to further these initiatives on quantifying and decreasing environmental impact and furthering sustainable use of our resources.
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Affiliation(s)
- Jason R Saleh
- VA Palo Alto Health Care System, Palo Alto, California
| | - Allison Mitchell
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Stephanie T Kha
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Rachel Outterson
- Department of Anesthesia, Perioperative and Pain Medicine, Stanford University, Redwood City, California
| | - Aiden Choi
- Stanford University, Stanford, California
| | | | - Tony Chang
- Stanford University, Stanford, California
| | - Amy L Ladd
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
| | - Stuart B Goodman
- Departments of Orthopaedic Surgery and Bioengineering, Stanford University, Redwood City, California
| | - Paige Fox
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Stanford University, Stanford, California
| | - Loretta Chou
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California
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Randall DJ, Peacock K, Nickel KB, Olsen MA, Kazmers NH. Moving Minor Hand Surgeries Out of the Operating Room and Into the Office-Based Procedure Room: A Population-Based Trend Analysis. J Hand Surg Am 2022; 47:1137-1145. [PMID: 36471499 PMCID: PMC9731346 DOI: 10.1016/j.jhsa.2022.08.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 07/22/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE Our primary purpose was to quantify the proportion of minor hand surgeries performed in the procedure room (PR) setting in a population-based cohort. Given the increase in the literature that has emerged since the mid-2000s highlighting the benefits of the PR setting, we hypothesized that a trend analysis would reveal increased utilization over time. METHODS We used the 2006-2017 MarketScan Commercial Database to identify adults who underwent isolated minor hand surgeries performed in PR and operation room surgical settings in the United States. The Cochran-Armitage trends test was used to determine whether the proportion of all procedures (PR + operation room) changed over time. RESULTS A total of 257,581 surgeries were included in the analysis, of which 24,966 (11.5%) were performed in the PR. There was an increase in the overall number of surgeries under study as well as increased utilization of the PR setting for open carpal tunnel release, trigger digit release, DeQuervain release, hand or finger mass excision, and hand or finger cyst excision. The magnitude of the increases in PR utilization was small: between 2006 and 2017, the PR utilization increased by 1.4% for open carpal tunnel release, 5.4% for trigger digit release, 2.9% for DeQuervain release, 10.1% for hand or finger mass excision, and 6.5% for hand or finger cyst excision. CONCLUSIONS Despite the published benefits of the PR setting, we observed that the majority of these 5 common minor hand surgeries are performed in the operation room setting. Between 2006 and 2017, the office-based PR utilization increased slightly. The identification of barriers to PR utilization is needed to improve the value of care. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic II.
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Affiliation(s)
- Dustin J Randall
- Oakland University William Beaumont School of Medicine, Rochester, MI; Department of Orthopaedics, University of Utah, Salt Lake City, UT
| | - Kate Peacock
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
| | - Katelin B Nickel
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
| | - Margaret A Olsen
- Center for Administrative Data Research, Institute of Clinical and Translational Sciences, Washington University in St. Louis, St. Louis, MO
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Michaud JB, Zhuang T, Shapiro LM, Cohen SA, Kamal RN. Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis. J Hand Surg Am 2022; 47:1057-1067. [PMID: 35985865 DOI: 10.1016/j.jhsa.2022.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/29/2022] [Accepted: 06/15/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Rising patient out-of-pocket (OOP) costs and financial distress have been associated with reduced access to and delays in care. We evaluated whether OOP and total costs for common hand procedures have increased from 2008 to 2016 and identified key drivers of these costs. METHODS Using the IBM MarketScan Research Databases, we identified patients who underwent trigger finger release, open carpal tunnel release, thumb carpometacarpal joint arthroplasty, cubital tunnel release, or open treatment of distal radius fracture in the outpatient setting between 2008 and 2016. Patient OOP costs included copayment, coinsurance, and deductible payments. Costs not directly related to medical care, such as transportation and childcare costs, were not included. The overall cost was defined as the sum of the patient OOP cost and insurer reimbursements. We calculated changes in OOP and total overall costs over the study period. We also performed multivariable linear regressions to evaluate the associations between costs and procedure type, insurance type, region, and site of service. RESULTS The mean patient OOP cost increased by 55% to 71% and the total overall cost increased by 20% to 45%, depending on the procedure, between 2008 and 2016. Facility overall costs increased by 38%, whereas professional overall costs increased by 9%. Procedures performed in an office-based setting were associated with the lowest patient OOP and total overall costs, whereas high-deductible health plans were associated with the highest OOP costs. CONCLUSIONS Patient OOP and total overall costs increased for the most common hand procedures between 2008 and 2016, driven by a substantial increase in facility costs. Office-based procedures were associated with the lowest costs. CLINICAL RELEVANCE To alleviate the rising patient cost burden, hand surgeons could incorporate OOP cost considerations into shared decision-making tools, identify patients who may benefit from financial counseling, and shift procedures to an office-based setting.
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Affiliation(s)
- John B Michaud
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Thompson Zhuang
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA
| | - Samuel A Cohen
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA.
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Wide-Awake Hand Surgery Has Its Benefits: A Study of 1,011 Patients. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:394-398. [DOI: 10.1016/j.jhsg.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 05/23/2022] [Indexed: 11/18/2022] Open
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Bohn DC, Wise KL. What's New in Hand and Wrist Surgery. J Bone Joint Surg Am 2022; 104:489-496. [PMID: 35044967 DOI: 10.2106/jbjs.21.01374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Deborah C Bohn
- Department of Orthopedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota
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Wood SM, Kim YJ, Seyferth AV, Chung KC. Quality Metrics in Hand Surgery: A Systematic Review. J Hand Surg Am 2021; 46:972-979.e1. [PMID: 34272097 DOI: 10.1016/j.jhsa.2021.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 05/05/2021] [Accepted: 05/19/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE The enactment of the Patient Protection and Affordable Care Act in 2010 placed an emphasis on measuring the quality of care. However, the issue of how best to measure quality remains in question. Although some surgical specialties frequently rely on quality measures such as the mortality rate, measuring quality in hand surgery necessitates the use of metrics beyond this traditional scope. A review was performed of the potential quality metrics used in the hand surgery literature published after the Affordable Care Act was enacted, to identify current trends in quality measurement and guide efforts to improve the quality of care in hand surgery. METHODS We searched the PubMed and EMBASE databases to identify original research articles within hand surgery to assess how care is being measured. Data extracted from the articles included study characteristics, quality metrics, and the domain(s) of quality. RESULTS A total of 7,308 articles were identified, and 63 prospective and retrospective articles were included in the analysis. The most common quality measure reported in the hand surgery literature was an outcome measure (100%) and the least common was a structure measure (30.2%). The most common metrics were pain (44.4%) and patient-reported measures (41.3%). Effectiveness (42.9%) was the most frequently assessed domain of quality, whereas efficiency (3.2%) was the least studied. CONCLUSIONS We identified quality measures used in contemporary hand surgery literature and found a substantial variation in the representation of quality metrics. Structure and process measures can be leveraged to provide a more holistic assessment of the quality of care in hand surgery. CLINICAL RELEVANCE Although outcome measurements are critical to understanding effectiveness, structure and process measures should be considered and reported as necessary, because these metrics may influence treatment outcomes and the development of quality measures.
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Affiliation(s)
- Shannon M Wood
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - You J Kim
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
| | | | - Kevin C Chung
- Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
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Comparison of Complication Risk for Open Carpal Tunnel Release: In-office versus Operating Room Settings. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3685. [PMID: 34262842 PMCID: PMC8274797 DOI: 10.1097/gox.0000000000003685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/17/2021] [Indexed: 12/02/2022]
Abstract
Background: Performing open carpal tunnel release (oCTR) in an office-based procedure room setting (PR) decreases surgical costs when compared with the operating room (OR). However, it is unclear if the risk of major medical, wound, and iatrogenic complications differ between settings. Our purpose was to compare the risk of major medical complications associated with oCTR between PR and OR settings. Methods: Utilizing the MarketScan Database, we identified adults undergoing isolated oCTR between 2006 and 2015 performed in PR and OR settings. ICD-9-CM and/or CPT codes were used to identify major medical complications, surgical site complications, and iatrogenic complications within 90 days of oCTR. Multivariable logistic regression was used to compare complication risk between groups. Results: Of the 2134 PR and 76,216 OR cases, the risk of major medical complications was 0.89% (19/2134) and 1.20% (914/76,216), respectively, with no difference observed in the multivariable analysis (adjusted odds ratio [OR] 0.84; 95% CI 0.53–1.33; P=0.45). Risk of surgical site complications was 0.56% (12/2134) and 0.81% (616/76,216) for the PR and OR, respectively, with no difference in the multivariable analysis (OR 0.68; 95% C.I. 0.38–1.22; P=0.19). Iatrogenic complications were rarely observed (PR 1/2134 [0.05%], OR 71/76,216 [0.09%]), which precluded multivariable modeling. Conclusion: These results support a similar safety profile for both the PR and OR surgical settings following oCTR with similar pooled major medical complications, pooled wound/surgical site complications, and iatrogenic complications.
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