5/10/2013 Inspiration Results of Wide Awake, Open Carpal Tunnel Release in the • James E Johnson, MD, TPMG SSF Office: 312 Cases and 288 • Has been performing CTR in the office since the Operating Room Controls 1980s • Many thousands performed. • Other institutions have emulated this Michael C. MacAvoy, MD • In most university or private practice settings CTR Diane Putney, NP is done in the OR. Office release has been done in James E. Johnson, MD the military, and in Canada • The trend toward endoscopic carpal tunnel has increased OR expenses, use of general anesthesia Office Carpal Tunnel Release Hypothesis • Has been described. Freeman, GC, Orthopaedics, 1996., “Wide awake” Open Carpal Tunnel Release, Derkash, RS 1996 performed in an office setting is safe, • No apparent controlled studies of any size. effective, and low cost. • “Wide awake approach”, described by Lalonde, DH, Clin Plastic Surgery 2011: use of epinephrine, no tourniquet. • Little if any description of wide awake surgery with tourniquet. 1
5/10/2013 Cost Methods • Different definitions of cost (Macario J. Clin Anes 2010). • Office Procedure – Cost to hospital Room – Charges to patient/insurer • Non physician OR cost to the hospital is at least $20 per minute. • Forearm An hour in the OR, with physician charges, is at least $1600. tourniquet • Charges to the patient/insurer are around double, about $3000. • No sedation • Fixed cost is about half the cost • Office Costs are about a fifth of the OR cost. • No anesthetist • 500,000 carpal tunnels per year in the U.S. • Medical Assistant • Savings could amount to $1 Billion per year performs circulator and scrub function Methods Methods: Patients • 312 office procedures (Cases) • 288 OR procedures (Controls) • Identified in the electronic medical record, from 2005-2008 • All patients with isolated diagnosis of CTS who had open surgery were included • EMR used to locate information regarding reoperation, infection, and pain. • Minimum follow up was 2 years for pain or reoperation, 3 months for infection 2
5/10/2013 Methods: Patients Methods: Patients Results: Pain Outcome Results: Infection Rates Minimum Two Year Follow Up • 82% f/u in office group at 2 yrs • 86% f/u in OR group at 2 yrs 3
5/10/2013 Results: Reoperation, Results: Any Poor Outcome Minimum two year follow up Discussion • This study suggests that wide awake carpal tunnel release, in the office with tourniquet, is safe, effective, and cost effective. • Strengths of this study are its size, multicenter nature, and the presence of controls. • Future work could include prospective randomized study 4
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