Telemedicine during the COVID-19 Pandemic: A Hand Surgery Perspective
Orthopaedic Urgent Care Versus the Emergency Department: Cost Implications for Low-energy Fracture Care
INTRODUCTION/BACKGROUND:This study compared costs, length of visit, and utilization trends for patients with fractures seen in an immediate care orthopaedic center (I-Care) versus the emergency department (ED) in a major metropolitan area. METHODS:A retrospective chart review of consecutive patients seen on an outpatient basis in the ED and I-Care over a 6-month period was conducted. Patient demographics, procedures done, care category, estimated costs, and disposition information were included for statistical analysis. Within the low-acuity fracture care group, a cost-comparison analysis was conducted. RESULTS:A total of 610 patients met inclusion criteria with 311 seen in I-Care and 299 in the ER. I-Care patients were more likely to have low-acuity injuries compared with ED patients (60.1% versus 18.1%, P < 0.001). The length of visit was longer for patients seen in the ED compared with I-Care (6.1 versus 1.43 hours, P value < 0.001). A cost analysis of low-acuity patients revealed that an estimated $62,150 USD could have been saved in healthcare costs by the initial diversion of low-acuity patients seen in the ER to I-Care during the study period. DISCUSSION/CONCLUSIONS:These results suggest that the I-Care orthopaedic urgent care model is a more cost-effective and more efficient alternative to the ED for patients with fractures requiring procedural treatment and low-acuity patients managed on an outpatient basis.
Patient and Physician Satisfaction with Telehealth During the COVID-19 Pandemic: Sports Medicine Perspective
The Variable Insertional Anatomy of the Abductor Pollicis Longus: Functional Relevance and Relationship to Adjacent Thumb Extensors
BACKGROUND:The abductor pollicis longus (APL) is classically described as inserting on the base of the first metacarpal. This study analyzed APL insertional anatomy and quantified the size of various elements of the extensor side of the thumb to determine associations with size and function. METHODS:Twenty-four formalin-preserved upper limbs were dissected. The insertional anatomy of the APL, extensor pollicis brevis, and extensor pollicis longus were characterized, and the capacity of APL tendon slips to perform palmar abduction of the first digit was quantified based on slip size and insertion. RESULTS:The mean number of APL tendon slips observed was 2.3. Abductor pollicis longus insertion sites included the base of the first metacarpal, trapezium, abductor pollicis brevis, and opponens pollicis. Only 4 specimens had a solitary metacarpal slip, while 83% of specimens had insertions onto at least 1 thenar muscle. A total of 62.5% of APL tendons exhibited some form of branching that we categorized into "Y" and "Z" patterns. In assessing palmar abduction capacity, we found that APL tendon slips inserting into the base of the first metacarpal were larger in cross-sectional area than nonmetacarpal slips and reproduced complete palmar abduction of the digit in the absence of nonmetacarpal slips. The abduction capacity of APL tendon slips was not correlated to the cross-sectional area. CONCLUSIONS:There is significant variability in APL tendon slips, branching patterns, and insertional anatomy. These findings provide further understanding of the function of the APL and its surgical implications.
Patient and Surgeon Satisfaction with Telehealth During the COVID-19 Pandemic
BACKGROUND:Until recently, telehealth represented a small fraction of orthopedic surgery patient interactions. The COVID-19 pandemic necessitated a swift adoption of telehealth to avoid patient and provider exposure. This study analyzed patient and surgeon satisfaction with telehealth within the department of orthopedic surgery during the height of the COVID-19 pandemic. METHODS:All orthopedic surgery patients who partici-pated in telehealth from March 30 to April 30, 2020, were sent a 14-question survey via e-mail. Orthopedic surgeons who used telehealth were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate proportional odds and multivariate partial proportional odds models. RESULTS:Three hundred and eighty-two patients and 33 surgeons completed the surveys. On average, patients were "satisfied" with telehealth (4.25/5.00 Â± 0.96), and 37.0% preferred future visits to be conducted using telehealth. Multivariate partial proportional odds modeling determined that patients who found it easiest to arrange the telehealth visit had greater satisfaction (5.00/5.00 vs. 1.00-3.00/5.00: OR = 3.058; 95% CI = 1.621 to 5.768, p < 0.001), as did patients who believed they were able to communicate most effectively (5.00/5.00 vs. 1.00-4.00/5.00: OR = 20.268; 95% CI = 5.033 to 81.631, p < 0.001). Surgeons were similarly "satisfied" with telehealth (3.94/5.00 Â± 0.86), and while their physical examinations were only "moderately effec-tive" (2.64/5.00 Â± 0.99), they were "fairly confident" in their diagnoses (4.03/5.00 Â± 0.64). Lastly, 36.7% Â± 24.7% of surgeons believed that their telehealth patients required an in-person visit, and 93.9% of surgeons will continue using telehealth in the future. CONCLUSIONS:Telehealth emerged as a valuable tool for the delivery of health care during the COVID-19 pandemic. While both patients and surgeons were satisfied with its use, this study identifies areas that can improve the patient and surgeon experience. The effectiveness and satisfaction with telehealth should inform regulatory and reimbursement policy.
Tourniquet Use for Short Hand Surgery Procedures Done Under Local Anesthesia Without Epinephrine
PURPOSE/OBJECTIVE:Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. METHODS:Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a study-specific questionnaire based on previous WALANT studies. Tourniquet times were recorded. RESULTS:Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. CONCLUSION/CONCLUSIONS:Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. TYPE OF STUDY/LEVEL OF EVIDENCE/METHODS:Therapeutic IV.
Factors Affecting Operative Duration in Isolated Open Carpal Tunnel Release
Background â€ƒOpen carpal tunnel release (CTR) is one of the most commonly performed operative procedures with operative duration being a primary metric of operating room efficiency. The purpose of this study was to identify factors associated with prolonged operative duration, in performing CTR. Materials and Methods â€ƒCTR cases performed by a single surgeon from September 2013 to October 2015 were reviewed. Patient age at the time of surgery, sex, location of surgery (specialty orthopaedic hospital versus ambulatory surgery center), body mass index (BMI), American Society of Anesthesiologists classification, total operative duration (TOD), and procedure time (PT) were recorded. Obesity was defined as BMIâ€‰>â€‰30 and morbid obesity was defined as BMIâ€‰>â€‰35. Data were analyzed to identify factors associated with prolonged TOD or PT. Results â€ƒOne hundred and nine consecutive patients underwent isolated CTR. Mean age at time of surgery was 62 years (range: 24-92 years). Nonobese patients were found to have significantly shorter TOD than obese patients (22.3 vs. 24.4 minutes). Similarly, patients who were not morbidly obese had significantly shorter TOD than morbidly obese patients (22.6 vs. 26 minutes). No other factors were associated with prolonged TOD. No difference in PT was found between normal weight, obese, and morbidly obese groups. Conclusions â€ƒTOD, but not procedure time, is significantly affected by obesity. Our findings are relevant when scheduling and preparing obese patients for surgery, which may have a significant impact on health resource utilization. Level of Evidence â€ƒThis is a Level III, economic/decision analysis study.
Radial Shaft Convergence in Distal Radius Fractures: Diagnosis and Treatment
Radial shaft convergence in distal radius fractures is often misdiagnosed. This common deformation is often associated with a radial translation of the distal fragment. This parameter has to be corrected because of the increased risk of distal radioulnar joint instability due to detensioning of the distal interosseous membrane if there is an associated triangular fibrocartilage complex lesion. A new radiologic sign for diagnosis of proximal radius convergence during distal radius fracture is presented as well as technical tips for correction of this deformity.
Flexor Tendon Injuries
Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.
Wide Awake Hand Surgery
Wide awake hand surgery employs local-only anesthesia with low-dose epinephrine to create a bloodless field without the use of an arm tourniquet. Despite traditional teaching, evidence-based medicine suggests epinephrine is safe for use in hand and digital anesthesia. Eliminating an arm tourniquet reduces the requirement for sedation and general anesthetic. This confers particular advantage in surgeries such as tendon repairs, tendon transfers, and soft tissue releases in which intraoperative active motion can used to optimize outcomes. The wide awake approach also confers significant benefit to patients, providers, and health care systems alike due to efficiencies and cost savings.