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Hands, Wrists & Elbows
How your ortho service line can benefit from upper-extremity procedures.
R. Glenn Gaston
Publish Date: July 25, 2014   |  Tags:   Orthopedics
hand surgeons KEY CONTRIBUTORS Hand surgeons are high-volume producers for orthopedic surgery centers.

More upper-extremity surgeries are moving to the outpatient setting, thanks to advances in regional anesthesia and refined arthroscopic techniques that result in less tissue dissection. Most cases are performed relatively quickly with rapid room turnovers, making upper extremities a high-volume specialty with no shortage of patients. Professional athletes with finger fractures and desk workers with carpal tunnel syndrome are all seeking out facilities with talented hand, wrist and elbow specialists. Let's take a closer look at some of the procedures that make up most upper-extremity surgeons' caseloads.

  • Carpal tunnel release is typically a hand and wrist surgeon's highest volume procedure. Surgeons perform the release as a standard open procedure or endoscopically through 1 or 2 incisions. Clinical research has yet to identify one approach as better than the other, so surgeons should perform the technique they're most comfortable with. Most opt for a limited open technique, which involves a small palm approach through a less-than-1-inch incision.

Whether performed open or endoscopically, the surgery involves releasing the transverse carpal ligament to relieve pressure on the median nerve. The outcomes are essentially the same following either technique, although some studies have suggested a patient's return to work is slightly faster following endoscopic procedures. Additionally, risk of injury to the median nerve is slightly higher, but still relatively rare, if the procedure is performed endoscopically. Perioperative patient care is the same for both approaches.

  • Lateral epicondylitis — tennis elbow — is another common injury cared for in the outpatient setting. It involves debriding the origin of the extensor carpi radialis brevis (ECRB) tendon arthroscopically or through a small incision. As with carpal tunnel release, clinical studies have shown similar outcomes for both techniques.

It should be noted that 80% of tennis elbow cases resolve over time. I'll treat patients conservatively with physical therapy or injections for 6 months to a year before resorting to surgery to address lingering discomfort.

  • Wrist arthroscopies, which I perform the overwhelming majority of in the outpatient setting, involve burrs to remove bony prominences or shavers to debride other areas before repairing torn structures. For example, the triangular fibrocartilage complex (TFCC) is located on the small finger side of the wrist. Like the knee's meniscus, it's commonly torn with twisting activities. When torn in its periphery, it can be repaired arthroscopically. When torn centrally, however, debridement is typically the best treatment option.
  • Trauma fractures such as distal radius fractures and severe finger fractures are extremely common repairs. So, too, are fractures of the scaphoid, one of the wrist's carpal bones. These breaks are often mistaken for severe sprains, but misdiagnosis results in high morbidity and can cause problematic non-union — the failure of a broken bone to heal.
regional anesthesia AROUND THE BLOCK Regional anesthesia is key to keeping the surgical schedule on track.

Revving up with regional
A good regional anesthesia program allows procedures historically performed in a hospital or inpatient setting to be done in the outpatient arena, including bony complex cases such as distal fractures, elbow fractures, osteotomies and partial or total wrist fusions.

Ultrasound-guided blocks for procedures performed on the upper arm, elbow or wrist involve combinations of interscalene, supraclavicular and axillary. They help control post-op pain, but in many of these cases they're used as the primary modality of intraoperative pain control to avoid the need for general anesthesia. That is particularly helpful for patients undergoing wrist fracture repairs, for whom general anesthesia is contraindicated.

Regional anesthesia also limits or eliminates the need for opioids to manage patients' post-op discomfort, which lessens risks of nausea, vomiting and respiratory depression — the complications that lengthen recoveries.

SPEEDY RECOVERY
Orthobiologics Help Fractures Heal

fracture repair GAME CHANGER Glenn Gaston, MD, says orthobiologics are playing a more prominent role in fracture repair.

Orthopedic surgeons are using natural substances found in the body and genetically engineered materials to speed the healing of bone fractures and return functionality to pre-injury levels. Here's a brief primer on how orthobiologics improve patients' recoveries.

  • Growth factors. Human growth factors are the natural proteins found in the body that help heal injured areas. The proteins attract stem cells to the injury site, where they develop into "repair" cells. This chemoattraction is effective only when there's an adequate blood supply around the injured area. Genetic engineering can produce higher quantities of the natural growth factors found in bones. In addition, synthetic bone morphogenetic proteins can be produced to aid in muscle, tendon and cartilage healing.
  • Matrix. This is the conductive material that houses the stem cells during the healing process. Autograft (taken from the patient) and allograft (taken from a cadaver) bone grafts are typically used to form a base for stem cells in gaps where injured bones are missing or have broken into small pieces. Calcium phosphate, with properties that closely resemble human bone, is also used to fill the gaps and promote stem cell growth.

The future of orthobiologics is evolving rapidly, with many developments in the pipeline that promise to improve fracture repair techniques that are already on the cutting edge of care.

— Daniel Cook

Tools of the trade
My surgical success requires a high-quality laparoscopic camera designed specifically for small joints (2.7mm or smaller), 2.7mm and 3.5mm shavers, and an arthroscopic pump with variable pressure settings. The standard 70 or 80mmHg flow delivers high levels of fluid through the small joints, which causes swelling and impedes my ability to visualize the operative field and maneuver in already tight spaces. I'll employ gravity in-flow or turn the pumps way down to approximately 20mmHg to prevent the joints from becoming overdistended.

I also work with a mini C-arm that provides high-quality intraoperative imaging from a small footprint. It keeps valuable OR space clear and lets me maneuver freely around the patient. Surgeons need to consider a unit's X-ray power, size, arm rotation angle, safety features and digital image storage capabilities when selecting the model that's right for your facility.

Tourniquets are used for almost all of my hand and wrist cases. They let me perform intricate techniques in a bloodless field, which improves the efficiency and ultimate outcomes of the procedures. We ensure a tourniquet's cuff fits properly around the arm of each patient, particularly on obese individuals, so pressure is applied evenly.

Although tourniquets should be set to the lowest pressure possible to limit blood flow, use of the devices carries risk of pressure-related complications such as muscle damage, nerve damage, coagulation issues and edema, but the rapid pace of upper-extremity procedures significantly minimizes these risks.

compact C-arms VISUAL AID Compact C-arms provide intraoperative imaging without limiting surgeon and staff maneuverability.

Future growth
The role of orthobiologics in fracture repair is increasing rapidly (see "Orthobiologics Help Fractures Heal"). In addition, peripheral nerve surgery is growing in popularity, thanks to the use of nerve allografts to replace injured or missing nerve segments. Surgeons previously used nerve tubes, which served as conduits through which implanted nerves grew. The newer nerve allografts avoid having to harvest patients' own nerves for replantation.

Fracture-specific plates are also changing the effectiveness of injury repair. Distal radius plates are contoured to specific anatomy in the wrist. Similarly, in the elbow, pre-contoured plates eliminate having to bend conventional plates to fit individual anatomy in places they weren't really designed to work. The anatomy-specific plates result in stronger initial fixations and limit the need to remove and replace the hardware in the future.

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