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What a Waste! The Impact of Unused Surgical Supplies in Hand Surgery and How We Can Improve

Bravo, Dalibel; Thiel, Cassandra; Bello, Ricardo; Moses, Akini; Paksima, Nader; Melamed, Eitan
BACKGROUND/UNASSIGNED:The US health care system is the second largest contributor of trash. Approximately 20% to 70% of waste is produced by operating rooms, and very few of this waste is recycled. The purpose of this study is to quantify the opened but unused disposable supplies and generate strategies to reduce disposable waste. METHODS/UNASSIGNED:-e), a measure of greenhouse gas emissions. RESULTS/UNASSIGNED:-e during the study period. CONCLUSIONS/UNASSIGNED:This study highlights the excessive waste of unused disposable products during hand surgery cases and identifies ways of improvement.
PMID: 35485263
ISSN: 1558-9455
CID: 5217682

The Cutting Edge: Surface Texture Analysis following Resection of Nerve Stumps Using Various Instruments

Rose, Ryan Adam; Bliss, Ryan; Bromage, Timothy; Hu, Bin; Gopman, Jared M; Melamed, Eitan
Background/UNASSIGNED:Preparation of nerve ends is an essential part of nerve repair surgery. Multiple instruments have been described for this purpose; however, no consensus exists regarding which is the least traumatic for tissue handling. We believe that various instruments used for nerve-end excision will lead to different surface roughness. Methods/UNASSIGNED:Median and ulnar nerves from fresh frozen cadavers were dissected, and 1-2 cm lengths were excised using a No. 11 blade, a razor blade, or a pair of scissors. Using electron microscopy, 3-dimensional surface analysis of roughness (Sa) for each specimen was performed using ZeeScan optical hardware and GetPhase software (PhaseView, Buisson, France). An ANOVA or Kruskal-Wallis test compared roughness measures among cutting techniques. Results/UNASSIGNED:= 0.003), with the lowest by No. 11 blade (3 µM, IQR: 1.87-4.38), followed by scissors (3.29 µM, IQR: 1.56-4.96), and razor (5.41 µM, IQR: 4.95-6.21). Conclusion/UNASSIGNED:This novel technique of 3-dimensional surface analysis found razor blade use demonstrated poor roughness, whereas a No. 11 blade or nerve-specific scissors led to equivocally smooth nerve ends.
PMCID:8116000
PMID: 33996348
ISSN: 2169-7574
CID: 5017922

Musculoskeletal Ultrasonography of the Extremities: Clinical and Ultrasonographic Correlation

Azad, Ali; De Tolla, Jadie; Walter, William; Paksima, Nader; Melamed, Eitan
Ultrasonography as a diagnostic and therapeutic tool has become a resource for musculoskeletal injuries. It can be a useful imaging modality for clinical correlation of physical examination findings as well as an aid for image-guided procedures. Understanding the settings in which it is a helpful adjunct will have implications on efficiency and cost utility. The objectives of this chapter are to provide a background of ultrasonography as a musculoskeletal imaging modality, provide clinical correlation for ultrasonographic findings for common upper extremity pathology, review the diagnostic efficacy of ultrasonography for image-guided procedures, and provide insight into the cost utility of ultrasonography guidance for therapeutic injections.
PMID: 33438941
ISSN: 0065-6895
CID: 4746862

Environmentally Responsible Hand Surgery: Past, Present, and Future

Bravo, Dalibel; Gaston, R Glenn; Melamed, Eitan
Health care is an important contributor to environmental waste. In 2013, the health care sector was responsible for substantial fractions of national air pollution emissions and impacts, including acid rain (12%), greenhouse gas emissions (10%), smog formation (10%), air pollutants (9%), stratospheric ozone depletion (1%), and carcinogenic and noncarcinogenic air toxins (1% to 2%). Operating rooms produce between 20% and 70% of total hospital waste. Hand surgery, with short, high-volume cases, is a notable contributor to this environmental and subsequent financial burden. This article aims to highlight the Lean and Green initiative proposed by the American Association for Hand Surgery along with the American Society for Surgery of the Hand, the American Society for Peripheral Nerve Surgery, and the American Society of Reconstructive Microsurgery in 2015, to reduce the amount of waste generated by hand surgery. We have reviewed the literature to propose multiple ways to reduce both material and nonmaterial waste-energy consumption, sterilization techniques, reprocessing of devices, patient transportation, production of surgical supply, anesthesia, and sanitation in hand surgery.
PMID: 31928797
ISSN: 1531-6564
CID: 4264212

Trends in Proximal Interphalangeal and Metacarpophalangeal Joint Arthroplasty Utilization Using Statewide Databases

Vranis, Neil M; Marascalchi, Bryan; Melamed, Eitan
Background: Arthritis can have profound debilitating effects on the hand secondary to finger deformities and pain. Arthroplasty of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) can be performed to reduce pain while maintaining joint range of motion. Methods: We used outpatient surgery registries from the states of California and Florida to assess the trends of arthroplasty across several recent years and to determine if the outcomes differ based on disease etiology. Results: We found that there has been a steady decline in number of MCP arthroplasty procedures performed annually between 2005 and 2011 while PIP arthroplasty procedures peaked in 2007 and have since also declined. There was an overall complication rate of 2.4% and no difference in cardiac, respiratory, deep venous thrombosis and infection between patients with osteoarthritis and other arthritic etiologies. However, the risk of device failure in patients with rheumatoid arthritis is found to be significantly higher than for patients with osteoarthritis (p < 0.01). Conclusions: PIP and MCP arthroplasty are safe procedures with an overall low complication rate. The increased risk of device related complications observed in patients with rheumatoid arthritis can be used to appropriately counsel this patient population regarding post-operative expectations and prognosis.
PMID: 32000595
ISSN: 2424-8363
CID: 4294322

An Assessment of Sleep Disturbance in Patients before and after Carpal Tunnel Release

Erickson, John; Polatsch, Daniel; Beldner, Steven; Melamed, Eitan
Background: Night time numbness is a key characteristic of CTS and relief of night time symptoms is one of the outcomes most important to patients. This study tested the null hypothesis that there is no difference between sleep quality and night symptoms before and after carpal tunnel release (CTR). Methods: Forty-four, English-speaking adult patients requesting open CTR for electrodiagnostically confirmed carpal tunnel syndrome completed questionnaires before and after surgery. Average age was 59, 24 patients were men and 20 were women. Patient with a primary or secondary sleep disorder were excluded. Before surgery, patients completed the Pittsburg Sleep Quality index (PSQI). At an average of 3 months after surgery, participants completed PSQI questionnaires. Onset of sleep quality improvement was specifically addressed. Differences between preoperative and postoperative sleep quality were evaluated using the paired t-test. Spearman correlations were used to assess the relationship between continuous variables. Results: Of the 44 patients, 32 (72%) were classified as poor sleepers (PSQI > 5.5) prior to surgery. At 3 months follow up, there was a significant improvement PSQI global scores (7.8 ± 5.1 vs 4 ± 3.5, p < 0.001) as well as subdivisions. Daytime dysfunction (0.2 ± 0.4, p < 0.001) and medication use (1.0 ± 1.2 vs 0.9 ± 1.2, p < 0.045) secondary to sleep disturbance and was improved as well. In all patients, onset of improvement was within 24 hours of surgery. Conclusions: CTR is associated with improvement in sleep quality at 3 months follow-up. CTR improves daytime dysfunction related to the sleep disturbance. The onset of sleep improvement is 24 hours after surgery in most cases.
PMID: 31035874
ISSN: 2424-8363
CID: 3854472

Multistate Comparison of Cost, Trends, and Complications in Open Versus Endoscopic Carpal Tunnel Release

Williamson, Emilie R C; Vasquez Montes, Dennis; Melamed, Eitan
BACKGROUND:Surgical carpal tunnel release is performed by either open carpal tunnel release (OCTR) or endoscopic carpal tunnel release (ECTR). The purpose of this study was to assess differences in intraoperative and postoperative complications, trends, and costs between OCTR and ECTR. METHODS:State Ambulatory Surgery and Services Databases (SASD) files for California, Florida, and New Jersey were queried for patients who underwent OCTR and ECTR between 2000 and 2014. Patient demographics, comorbidities, intraoperative and postoperative complications, and cost were compared between OCTR and ECTR. The frequency of each procedure was used to formulate trends in OCTR and ECTR. RESULTS:A total of 571 403 patients were included in this study. Sex was significantly different by a small percentage (OCTR = 64.8% female, ECTR = 65.4% female). A higher proportion of Hispanic patients underwent ECTR ( P < .001). The patients who underwent OCTR had a greater comorbidity burden in terms of diabetes and rheumatoid arthritis ( P < .001). None of the aforementioned complication rates were statistically significant between the 2 procedures. Endoscopic carpal tunnel release was significantly more costly by almost $2000. Open carpal tunnel release has remained stable over the years studied, whereas ECTR increased 3-fold. CONCLUSIONS:Our findings demonstrate no significant differences between OCTR and ECTR regarding intraoperative and postoperative complications and patient outcomes. Endoscopic carpal tunnel release was found to be significantly more costly.
PMID: 30924367
ISSN: 1558-9455
CID: 3778972

Repair of Chronic Concomitant Avulsion Fractures of the Extensor Carpi Radialis Longus and Brevis

Beutel, Bryan G; Melamed, Eitan
Combined simultaneous radial wrist extensor injuries, namely ipsilateral extensor carpi radialis longus (ECRL) and brevis (ECRB) avulsion fractures, are rare. While non-operative management with cast immobilization has been described, most recommend operative intervention in the acute setting. Surgical repair of chronic injuries, however, has received little attention in the literature. This case describes a 50-year-old male who sustained combined ipsilateral ECRL and ECRB avulsion fractures from the bases of the index and middle metacarpals. Five months after the initial trauma, he underwent surgical repair with lengthening of the tendons using a novel technique and suture anchor fixation. This case demonstrates that successful repair of this rare injury can be achieved with retracted extensor tendons in the chronic setting.
PMID: 30760149
ISSN: 2424-8363
CID: 3689962

The Stener Lesion and Complete Ulnar Collateral Ligament Injuries of the Thumb A Review

Beutel, Bryan G; Melamed, Eitan; Rettig, Michael E
A Stener lesion is a complete tear of the ulnar collateral ligament (UCL) from the thumb proximal phalanx at the level of the metacarpophalangeal (MCP) joint that is displaced superficial to the adductor pollicis aponeurosis, leading to interposition of the aponeurosis between the UCL and the MCP joint. The interposition of the adductor aponeurosis distinguishes the Stener lesion from other UCL injuries and impedes healing, thereby necessitating surgery. A thorough clinical examination, including valgus stress testing of the MCP joint, is crucial to the diagnosis. In cases where the clinical evaluation is equivocal, imaging studies including ultrasound or magnetic resonance can be performed. Acute Stener lesions can be treated with repair of the UCL primarily through direct suture, suture anchor, or pull-out suture techniques. Chronic injuries are treated with dynamic (via tendon transfer) or static (via grafting) reconstruction methods, while MCP arthrodesis or arthroplasty can be reserved for cases where MCP joint osteoarthritis is present. Overall, patient outcomes are generally good with operative treatment of Stener lesions. This article reviews the relevant anatomy and pathogenesis, clinical evaluation, diagnostic studies, management, outcomes, complications, and an illustrative case of Stener lesions and complete UCL injuries of the thumb.
PMID: 30865860
ISSN: 2328-5273
CID: 3748002

A Unique Presentation of Scaphocapitate Syndrome With Extrusion Into the Carpal Tunnel: A Case Report

Akinleye, Sheriff D; Melamed, Eitan
BACKGROUND:Scaphocapitate syndrome is a rare variety of perilunate instability, described as a trans-scaphoid, trans-capitate fracture, with rotation of the capitate head either 90° or 180°. METHODS:We present a unique case of scaphocapitate syndrome in which the rotated proximal capitate fragment expelled into the carpal canal. RESULTS:The capitate head was extricated from the carpal tunnel via the volar approach, and was anatomically aligned and fixed through the dorsal approach using two 2.0 mm headless compression screws. The scaphoid fracture was then also reduced through the dorsal approach and stabilized with a 2.5 mm headless compression screw. All intercarpal ligaments appeared intact. CONCLUSIONS:Volar dislocation of the proximal capitate into the carpal tunnel in scaphocapitate syndrome presents a unique challenge that can be addressed with a combined volar and dorsal approach.
PMID: 30205706
ISSN: 1558-9455
CID: 3278262