AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

AAHS/ASRM/ASPN Outstanding Nerve Papers
Comparison of Return to Work: Endoscopic Cubital Tunnel Release versus Anterior Subcutaneous Transposition
of the Ulnar Nerve
Institution where the work was prepared: Orthopaedic Specialists, Davenport, IA, USA
TYSON Cobb, MD; Patrick T Sterbank, PA-C; ORTHOPAEDIC SPECIALISTS, P.C
Endoscopic Cubital Tunnel Release (ECTR) is an emerging technique with speculated advantage of a smaller incision and earlier return to activity. Several earlier
studies have demonstrated clinical efficacy of ECTR but early return to activity has not been clearly documented. The purpose of the study was to compare
the return to work time for patients undergoing ECTR versus Anterior Subcutaneous Transposition of the Ulnar Nerve (ASTUN).
METHODS:
A retrospective review of 30 consecutive cases was used to determine the time from surgery to return to work. Follow-up time averaged one year for both
groups. All patients had electrical studies prior to surgery. All patients had positive Tinel's and Elbow Flexion test. Severity of symptoms was rated preoperatively
using Dellon's classification. Postoperative results were graded using Bishop 12 point rating system.
The ECTR study group consisted of 15 patients, 6 females and 9 males, 11 workmen's compensation and 4 group insurance; average age was 49 years, range
28 to 69. Dominant side surgery occurred in 8 cases (54%). Average length of preoperative symptoms was 26 months. 10 (68%) patients had a positive electrical
study for Cubital Tunnel. Preoperative symptoms based on Dellon's classification were 10% Mild, 60% Moderate and 30% Severe.
The ASTUN group consisted of 5 males and 10 females, 12 involved workmen's compensation and 3 private insurance, average age was 44 years, range 23 to
57. Dominant side surgery occurred in 9 cases (60%). The average length of preoperative symptoms was 28 months. 9 (60%) patients had positive electrical
studies for Cubital Tunnel. Preoperative symptoms based on Dellon's classification was 7% Mild, 63% Moderate and 30% Severe.
RESULTS:
The ECTR results were 10 (68%) Excellent, 3 (20%) Good, 1 (6%) Fair and 1(6%) Poor utilizing the Bishop12 point rating system. The average return to modified
work was 2 days (range 1 to 3) and to regular work 7 days (range 5 to 9).
The ASTUN group average return to modified work was 17 days (range 12 to 22) and for full duty 70 days (range 60 to 80). Results based on the Bishop 12
point rating system was 10% Excellent, 62% Good, 22% Fair and 6% Poor.
All patients returned to their usual preoperative activities.
CONCLUSION:
Endoscopic Cubital tunnel release provides good to excellent symptom relief in most patients with an earlier return to activity compared to ASTUN. The differences
in recurrence, complications, and long-term outcome require additional study.
A Detailed Cost and Efficiency Analysis of Performing Carpal Tunnel Surgery in the Main Operating Room
Versus the Ambulatory Setting
Institution where the work was prepared: Dalhousie University / Saint John Regional Hospital, Saint John, NB, Canada
Martin R. LeBlanc, BSc, MD; Janice Lalonde, RN; Donald H. Lalonde, BSc, MSc, MD; Dalhousie University
Objectives:
Our goal was to analyze the cost and efficiency associated with performing carpal tunnel release (CTR) in the main operating room versus the ambulatory setting.
We sent out a survey to members of the Canadian Society of Plastic Surgeons to document the venue of carpal tunnel surgery practices in Canada.
Methods:
A detailed analysis of the salaries of each involved person and the cost of materials involved in CTR performed in the main operating room versus the ambulatory
setting was done. A survey was emailed to practicing plastic surgeons in Canada to determine the venue of CTR performed by most of the surgeons.
Results:
For a standard 3 hour surgical block, we are able to perform 9 CTR in the ambulatory setting vs. 4 operations in the main operating room. The calculated cost
of performing CTR in the office setting is $296/case ($2664/9 cases), $333 ($3000/9 cases) in our clinic, and $401 ($3606/9 cases) in the main operating
room. All of these costs assume use of local anesthesia with no sedation and no tourniquet (wide awake approach). Our survey demonstrated that 18% of
respondents used the main operating room exclusively for CTR, while 63% used this setting for some of their CTR. The ambulatory setting was used exclusively
for CTR cases by 37% and 69% used this type of setting for greater than 95% of their cases. Most surgeons, 75%, did greater than 50 cases of CTR a year.
Conclusion:
It would seem logical that CTR can be performed in an ambulatory setting at a reduced cost when compared to performing CTR in the main operating room.
Our findings confirm this, and demonstrated a $105 per case maximum differential between CTR performed in an ambulatory setting versus the main operating
room. Even more importantly, we are only capable of performing 4 CTRs in the main operating room versus 9 CTRs in the ambulatory setting for a 3 hour
standard surgical block. Therefore, less than half the numbers of patients are treated in the main operating room in the same time invested in the ambulatory
setting. The use of the main operating room for CTR is more expensive, and less than half as efficient as CTR in an ambulatory setting. Our survey also
demonstrated that many surgeons in Canada continue to use the more expensive, less efficient venue of the main operating room for CTR.
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