Inspiration Results of Wide Awake, Open Carpal Tunnel Release in - - PowerPoint PPT Presentation

5/10/2013 1

Results of Wide Awake, Open Carpal Tunnel Release in the Office: 312 Cases and 288 Operating Room Controls

Michael C. MacAvoy, MD Diane Putney, NP James E. Johnson, MD

Inspiration

• James E Johnson, MD, TPMG SSF
• Has been performing CTR in the office since the

1980s

• Many thousands performed.
• Other institutions have emulated this
• In most university or private practice settings CTR

is done in the OR. Office release has been done in the military, and in Canada

• The trend toward endoscopic carpal tunnel has

increased OR expenses, use of general anesthesia

Office Carpal Tunnel Release

• Has been described. Freeman, GC, Orthopaedics, 1996.,

Derkash, RS 1996

• No apparent controlled studies of any size.
• “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.

Hypothesis

“Wide awake” Open Carpal Tunnel Release, performed in an office setting is safe, effective, and low cost.

5/10/2013 2

Cost

• Different definitions of cost (Macario J. Clin Anes 2010).

– Cost to hospital – Charges to patient/insurer

• Non physician OR cost to the hospital is at least $20 per minute.

An hour in the OR, with physician charges, is at least $1600.

• Charges to the patient/insurer are around double, about $3000.
• Fixed cost is about half the cost
• Office Costs are about a fifth of the OR cost.
• 500,000 carpal tunnels per year in the U.S.
• Savings could amount to $1 Billion per year

Methods

• Office Procedure

Room

• Forearm

tourniquet

• No sedation
• No anesthetist
• Medical Assistant

performs circulator and scrub function

Methods

• 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

Methods: Patients

5/10/2013 3

Methods: Patients Methods: Patients Results: Infection Rates Results: Pain Outcome Minimum Two Year Follow Up

• 82% f/u in
• ffice group

at 2 yrs

• 86% f/u in

OR group at 2 yrs

5/10/2013 4

Results: Reoperation, Minimum two year follow up Results: Any Poor Outcome 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