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Is Main Operating Room Sterility Really Necessary in Carpal Tunnel Surgery? A Multicenter Prospective Study of Minor Procedure Room Field Sterility Surgery

Authors:

Abstract

Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.
SURGERY ARTICLES
Is main operating room sterility really necessary
in carpal tunnel surgery? A multicenter prospective study
of minor procedure room field sterility surgery
Martin R. LeBlanc &Donald H. Lalonde &Achilleas Thoma &Mike Bell &Neil Wells &
Murray Allen &Peter Chang &Daniel McKee &Jan Lalonde
#American Association for Hand Surgery 2010
Abstract
Background Over 70% of Canadian carpal tunnel syn-
drome (CTS) operations are performed outside of the main
operating room (OR) with field sterility and surgeon-
administered pure local anesthesia [LeBlanc et al., Hand 2
(4):1738, 14]. Is main OR sterility necessary to avoid
infection for this operation? This study evaluates the
infection rate in carpal tunnel release (CTR) using minor
procedure room field sterility.
Methods This is a multicenter prospective study reporting the
rate of infection in CTR performed in minor procedure room
setting using field sterility. Field sterility means prepping of
the hand with iodine or chlorhexidine, equivalent of a single
drape, and a sterile tray with modest instruments. Sterile
gloves and masks are used, but surgeons are not gowned. No
prophylactic antibiotics are given.
Results One thousand five hundred four consecutive CTS
cases were collected from January 2008 to January 2010. Six
superficial infections were reported and four of those patients
received oral antibiotics. No deep postoperative wound
infection was encountered, and no patient required admission
to hospital, incision and drainage, or intravenous antibiotics.
Conclusions A superficial infection rate of 0.4% and a deep
infection rate of 0% following CTR using field sterility
M. R. LeBlanc (*)
Dalhousie University,
Apartment 102, 72 Fairfax Drive,
Halifax, NS B3H1P3, Canada
e-mail: mleblanc4@dal.ca
D. H. Lalonde :J. Lalonde
Dalhousie University,
Suite C204, 600 Main St.,
Saint John, NB E2K 1J5, Canada
D. H. Lalonde
e-mail: labtrio@nbnet.nb.ca
J. Lalonde
e-mail: labtrio@nbnet.nb.ca
A. Thoma
Plastic Surgery, McMaster University,
Suite 101, 206 James Street South,
Hamilton, ON L8P 3A9, Canada
e-mail: athoma@mcmaster.ca
M. Bell
Plastic Surgery, Ottawa University,
402-1919 Riverside Drive,
Ottawa, ON K1H 1A2, Canada
e-mail: msgbell@cyberus.ca
N. Wells
Plastic Surgery, University of British Columbia,
808-1200 Burrard St,
Vancouver, BC V62 2G7, Canada
e-mail: njwells@axion.net
M. Allen
Plastic Surgery, Ottawa University,
1385 Bank St. #415,
Ottawa, ON K1H 8N4, Canada
e-mail: murray.allen@rogers.com
P. Chang
Plastic Surgery, University of Saskatchewan,
2125 11th Avenue #605,
Regina, SK S4P 3X3, Canada
e-mail: dr.chang@accesscomm.ca
D. McKee
Ottawa University,
6 Hastings St.,
Nepean, ON K2H 8C3, Canada
e-mail: dmcke090@uottawa.ca
HAND
DOI 10.1007/s11552-010-9301-9
confirm the low incidence of postoperative wound infection
using field sterility. This supports the safety and low
incidence of postoperative wound infection in CTR using
minor procedure field sterility without prophylactic anti-
biotics. The higher monetary and environmental costs of
main OR sterility are not justified on the basis of infection
for CTR cases.
Keywords Carpal tunnel surgery .Carpal tunnel
syndrome .Infection .Field sterility .Local anesthesia .
Superficial infection .Deep infection .Main operating room
Introduction
More than 70% of Canadian carpal tunnel release (CTR)
operations are now performed in minor procedure rooms
with field sterility under pure local anesthesia, mostly
without a tourniquet and with lidocaine with epinephrine
[1]. Canadian surgeons feel that this shift from the main
operating room to the minor procedure room has increased
patient and surgeon convenience, decreased costs, and
decreased wait times for surgery, but has not increased
wound infection rates. Yet, some centers in the world
continue to use traditional main operating room with full
sterility for carpal tunnel release with regional or general
anesthesia. Likely, this is mostly related to the unknown
possibility of increased infection rates with use of minor
procedure room field sterility for CTR compared to full
room sterility of the main operating theater.
The objective of the study was to accurately record
prospectively the risk of infection in performing CTR using
minor procedure field sterility. The outcome measure was
the postoperative infection rate in a large multicenter series
of consecutive patients.
Methods
The study evaluated prospectively the rate of infection in
CTR using surgeon-administered pure local anesthesia in a
minor procedure room setting using field sterility by six
surgeons in five Canadian teaching centers from January
2008 to January 2010. The outcome measure was the
postoperative infection rate. In each center, ethical review
board approval and patient consent to participate in the
study were obtained. Inclusion criteria were patients who
would be good candidates for carpal tunnel release based
on both the surgeons clinical assessment and on nerve
conduction studies. Patients were excluded from the study
if they were unable to adhere to prescribed follow-up
appointments. Postoperative care included at least one visit
at between 1 and 2 weeks after surgery. For the purposes of
this study, the time horizon was 2 weeks. It was thought
unlikely for patients to suffer infection beyond this time
frame. Patients were directed to contact the surgeon if they
felt they had an infection. A detailed information sheet was
given to patients detailing what to look for with respect to
infection and they were provided with specific contact
information, so as to be able to contact and alert the
attending surgeon or his surgical designate if the patient felt
he/she had an infection. The whole process was also
explained to the patient verbally when they consented to
enter the study. The attending surgeon or his designate
examined the patients who felt they were infected and then
documented accurately any real infections as defined below
and administered appropriate treatment. The infections
were determined by the surgical staff and not by emergency
room or family doctors.
The definition of a superficial infection for this study
was suture abscess or cellulitis of the hand with or without
lymphangitis. Deep infection was defined as a wound
infection with pus in the depth of the wound that needed
incision and drainage or drained spontaneously. The
requirement for oral or intravenous antibiotics was
recorded.
All CTR cases in this trial were open procedures (non-
endoscopic) performed using field sterility in a minor
procedure room setting. Minor procedure room means a
minor procedure operating room outside of the main
operating theater block. These rooms are the same in which
minor procedures such as skin cancer excisions are
performed. There is no washing of all room structures
between cases and no defined airflow control. One nurse
serves as circulator and assistant. In this study, field sterility
means prepping of the hand with iodine or chlorhexidine,
the equivalent of a single 25×25 cm drape with a hole in it
to expose the palm, and a sterile tray with a modest supply
of basic instruments and retractors. Sterile gloves and
masks are used, but the surgeons are not gowned or capped.
No prophylactic antibiotics are given. All of the surgeons
agreed in teleconferences to using the same surgical
protocol as well as pre- and postoperative management for
the purposes of this study, and this was consistent in all
centers and in all patients in the study.
Results
A total of 1,504 consecutive CTR cases were collected
from January 2008 to January 2010. Six surgeons from five
Canadian training centers contributed patients to this study.
There were 301 patients in Saint John, 1,005 in Ottawa
(two surgeons), 75 in Hamilton, 58 in Regina, and 65 in
Vancouver. This study did not exclude any patients on the
basis of medical comorbidities such as diabetes, steroids,
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renal failure, etc. Our patient sample therefore included the
normal Canadian distribution of patients with medical
comorbidities.
Six superficial infections were reported; four of those six
patients received oral antibiotics and two were not severe
enough to require antibiotics. Not a single deep postoper-
ative wound infection was encountered. No patient required
admission to hospital for a serious infection. No patient
received or required an incision and drainage or intravenous
antibiotics.
Discussion
A superficial infection rate of 0.4% and a deep infection
rate of 0% following carpal tunnel surgery using field
sterility in a minor procedure room outside of the main
operating theater block with no prophylactic antibiotics in
this study confirm the inherently low incidence of infection
and the safety of this approach. This infection rate
compares favorably with Hansens deep infection rate of
0.47% in 3,620 carpal tunnel releases done at their
institution in the main operating room [11]. It also
compares favorably with Harness[12] study of 3,003
main operating room CTR patients who had 11 surgical site
infections, four deep and seven superficial. Our study
supports Harnessconclusion that the routine use of
antibiotic prophylaxis in carpal tunnel release surgery is
not justified.
No single study in the literature has prospectively looked
at infection rates in CTR as a primary outcome. Many
papers report on infection as part of their complications of
CTR, but few even define their criteria for wound infection
and most do not even report on rates of infection as an item
in their data. Most studies looking at complications in CTR
have reported infection rates of 0% to 6% [36,810,13,
16,17].
Defining wound infection is very important, as Atherton
et al. showed that general practitioners reported infection
rates of 14% versus 0% by the specialist hand clinic in a
randomized prospective study looking at postoperative
follow-up in CTR [1]. We chose the definition of infection
described in the method section of this study as it is a
practical one, which essentially divides infection into severe
(deep infection requiring surgery or intravenous antibiotics)
and non-severe (superficial requiring only oral or no
antibiotics), simple practical categories understandable to
colleague hand surgeons.
The cost of using the main operating theater is more than
four times as expensive and only half as efficient as the
minor procedure room in carpal tunnel surgery, even
without the presence of an anesthesiologist (surgeon-
administered local anesthesia) [14]. Office or minor
procedure room CTR with wrist block and wrist tourniquet
was evaluated by Derkash et al. and resulted in satisfactory
results from CTR, with no significant complications [7].
They also reported that the associated cost of office CTR
was approximately 80% of the hospital cost [7].
In spite of the availability of less expensive alternatives,
many centers continue to use the main operating room with
full sterility for carpal tunnel release with local, regional or
general anesthesia, often with the included costs of
anesthesiology. Carpal tunnel syndrome incidence in the
United States has been estimated at one to three cases per
1,000 persons per year [2]. Prevalence is approximately 50
cases per 1,000 persons in the general population [2]. One
million adults are diagnosed with carpal tunnel syndrome
each year in the United States [15]. The cost saving which
is possible by converting main operating room procedures
to minor procedure field sterility and/or deleting the
anesthesiology component of this 510 min operation is
substantial. In addition, for most of the developing world
that cannot afford main operating room sterility and/or
anesthesiology, this step would put common hand surgery
within reach of affordability to many of the planets poor
who now are forced to go without hand surgery.
The reasons for not using wide-awake carpal tunnel
release with field sterility include: tradition, reimbursement,
inability to re-cooperate tray fees, office availability of
instruments, sterilization equipment, and patient preference
(the desire for sedation). This paper has provided carefully
documented evidence that fear of infection should not be
one of these reasons.
We did not separate the patients into risk groups in this
study because they are not separated into risk groups in real
Fig. 1 Right side includes disposable materials (waste) from one
carpal tunnel syndrome case in the main operating room compared to
similar case in the minor procedure room setting on the left
HAND
clinical practice in most Canadian centers. All patients are
treated equally as wide-awake carpal tunnel releases with
field sterility in the majority of Canadian centers regardless
of their medical comorbidity status. The reason is that this
approach takes the operation to the simplicity level of a
visit to the dentist. Very few patients are unable to tolerate
the minimal pain of the local anesthetic injection without
sedation in our experience, and most patients with medical
comorbidities are much easier to handle when sedation is
taken out of the local anesthetic equation. It is the sedation/
general anesthetic component of simple operations that
makes stratification into risk groups more important, not the
surgery or the location of the surgery.
Figure 1suggests a possible environmental impact of
using main OR sterility. Although we have not studied this
in detail, we estimate that the amount of garbage that is
generated by main OR sterility is at least ten times that of
minor procedure field sterility.
Current economic and environmental needs dictate that
we find alternative ways to practice if they do not
compromise patient safety. It is important that all surgeons
re-examine traditional and ritualisticsurgical practices
and adopt evidence-based approaches to surgery. The
evidence from this study confirms that carpal tunnel surgery
with surgeon-administered local anesthesia performed in
minor procedure room settings with field sterility do not
lead to increase in infection rate.
Conflict of interest The authors declare that they have no conflict of
interest.
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... 2e29 There is also a decrease in the waste generated by these procedures, as they are typically done under minor field sterility, which consists of sterile prep, a single drape, a minor instrument tray, sterile gloves and a mask (no gown or antibiotics), and local anesthesia. 16,29 ...
... 31e36 Another breakthrough in hand surgery is the concept of field sterility. 29 Field sterility has allowed procedures to be done outside of a formal operating room, with a minimal amount of equipment needed and with similar infection rates to those of procedures performed in operating rooms. After the advent of WALANT, there were concerns about potential increases in infection rates in procedures done outside of the traditional operating room. ...
... 15 The ability to minimize surgical waste with minor hand procedures has also been documented by other authors. 6,26,29,41,42 Patients have been pleased with WALANT surgery done in procedure rooms. High patient satisfaction rates have been reported both in the United States and abroad. ...
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Purpose Wide-awake local anesthesia with no tourniquet has dramatically changed hand surgery practice. Using lidocaine with epinephrine and no tourniquet has allowed many procedures to be moved from the main operating room to an in-office procedure room. Previous studies have shown that using local anesthesia is safe and cost effective, with high patient satisfaction. This study evaluated patient satisfaction and complications for the first 1,011 elective hand surgeries performed using wide-awake anesthesia in an in-office procedure room. Methods The first 1,011 patients who underwent elective hand surgery in an in-office procedure room were surveyed regarding their satisfaction. The patients were monitored for postoperative complications. Patient survey results and complications were logged in a database and analyzed. Results Single-digit trigger finger release was the most common procedure performed (n = 582), followed by mass excision (n = 158), multiple-digit trigger finger releases (n = 109), and carpal tunnel release (n = 41). There were 43 (4.3%) superficial skin infections, with the majority seen in single-digit trigger finger releases (n = 27). There were no deep wound infections. All infections were managed nonsurgically with oral antibiotics and local wound care. Ninety-nine percent of the patients rated the in-office procedure room experience as the same as or better than a dental visit, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Using “lean and green” hand packs saved our institution more than $65,000 and saved 18.4 tons of waste during this study period. Conclusions Surgical procedures performed with wide-awake local anesthesia with no tourniquet in an in-office procedure room can be performed safely with a low infection rate, are cost effective, and have high patient satisfaction. Clinical relevance Minor hand surgery done in an in-office procedure room is safe, is cost effective, and has high patient satisfaction.
... With this trend, it is important to consider how the procedure room differs from the traditional operating room. First, the use of field sterility instead of main-operating-room sterility has allowed for considerable cost and waste reductions, without impacting upon the likelihood of surgical site infections ( Figure 1) [29][30][31]. Instead of needing the full standard set-up for main-operating-room sterility (which includes head covers, neck-to-knee sterile surgeon gowns, shoe covers, laminar airflow, and full-patient-body sterile draping), CTR can safely be performed in a clinic's procedure room with nothing more than a mask, sterile gloves, and single drape. Importantly, where CTR is performed in such settings, the absence of costly, specialized ventilation systems such as laminar air filtration or high-efficiency particulate air filters has not been linked to worse outcomes. ...
... Thus, it is possible that WALANT could be associated with more surgical site infections. However, no studies to date have demonstrated higher infection rates when WALANT has been used, regardless of operative location, type of sterility used, or composition of personnel present for the procedure [29,30,33,[35][36][37][38][39]. ...
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As surgical management of carpal tunnel release (CTR) becomes ever more common, extensive research has emerged to optimize the contextualization of this procedure. In particular, CTR under the wide-awake, local-anesthesia, no-tourniquet (WALANT) technique has emerged as a cost-effective, safe, and straightforward option for the millions who undergo this procedure worldwide. CTR under WALANT is associated with considerable cost savings and workflow efficiencies; it can be safely and effectively executed in an outpatient clinic under field sterility with less use of resources and production of waste, and it has consistently demonstrated standard or better post-operative pain control and satisfaction among patients. In this review of the literature, we describe the current findings on CTR using the WALANT technique.
... 13,14 Utilization of field sterility reduces the environmental impact of theater waste, and numerous studies have found no differences in infection rates between field sterility and theater sterility. [15][16][17] A 2019 study analyzed the economic impact of WALANT surgery for 150 carpal tunnel and trigger finger surgeries performed in an outpatient setting; they found an average saving of over €1,000 per case with superior postoperative pain scores. 18 In a separate A1 pulley release study, WALANT led to a shorter mean turnover time versus regional anesthesia and tourniquet (mean: 31.1 vs. 65.3 ...
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... Office-based surgery has been popularized for hand surgery by Dr. Lalonde for over 15 years‚ and uptake of this method has become a worldwide phenomenon. [2][3][4] Within the United States, WALANT has had less penetration than internationally, with "business as usual" still driving patients into surgery centers and hospital ORs for MAC and GA. Rapid innovation and change are stimulated by wars and pandemics. ...
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Background The purpose of this systematic review was to analyze the available literature on fixation of distal radius fractures (DRFs) under wide-awake local anesthesia no-tourniquet (WALANT), and to examine postoperative pain scores and functional outcomes, operative data including operative time and blood loss, and the frequency of adverse events. Methods Embase, MEDLINE, Web of Science, and SCOPUS were searched from inception until May 2022 for relevant studies. Studies were screened in duplicate, and data on pain scores, functional outcomes, and adverse events were recorded. Due to methodological and statistical heterogeneity, the results are presented in a descriptive fashion. Results Ten studies were included comprising 456 patients with closed, unilateral DRFs, of whom 226 underwent fixation under WALANT. These patients had a mean age of 52.8 ± 8.3 years, were 48% female, and had a mean follow-up time of 11.6 months (range: 6-24). Operative time for WALANT patients averaged 60.4 ± 6.5 minutes, with mean postoperative pain scores of 1.4 ± 0.6 on a 10-point scale. Studies that compared WALANT to general anesthesia found shorter hospital stays with most WALANT patients being sent home the same day, decreased postoperative pain scores, and decreased costs to the healthcare system. No adverse events were reported for WALANT patients. Conclusions A growing body of literature reports that for closed, unilateral DRF, surgical fixation under WALANT is a safe and effective option. It allows patients to have surgery sooner, with improved pain scores and good functional outcomes, with a very low incidence of adverse events.
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Résumé Hypothèse La WALANT (Wide awake local anesthesia with no tourniquet) ainsi que les procédures de type « office surgery » deviennent de plus en plus populaires en chirurgie de la main. Il n’y a que peu de données dans la littérature concernant la satisfaction des patients comparant les méthodes d’anesthésie et la localisation de réalisation du geste chirurgical. Méthodes Nous avons réalisé une étude rétrospective, monocentrique, rapportant la satisfaction des patients répartis en trois groupes, en comparant le ressenti des patients vis-à-vis de l’anesthésie type WALANT et l’anesthésie loco-régionnale. Nous avons également comparé trois types de prise en charge : office surgery vs. bloc opératoire ambulatoire vs. bloc opératoire principal. Le Groupe 1 comporte des patients pris en charge sous WALANT en « office surgery » avec une procédure écho-guidée. Le Groupe 2 concerne des patients pris en charge sous WALANT en salle opératoire sans personnel d’anesthésie avec une procédure écho-guidée. Le Groupe 3 concerne la prise en charge au bloc principal, sous ALR avec utilisation d’un garrot et sous endoscopie. Chaque groupe comprend 30 patients avec un recul minimum de 2 mois postopératoire. Les critères d’évaluations regroupent : la satisfaction globale, la satisfaction concernant l’organisation du parcours de soin, l’administration et la qualité de l’anesthésie. Nous avons également recueilli les données concernant la résolution du syndrome acroparesthésique, la survenue de complications neurologiques, vasculaires ou infectieuses. Résultats Les procédures réalisées en « office surgery » montrent un taux de satisfaction plus élevé comparé à la prise en charge au bloc, de même que l’anesthésie type WALANT comparé à l’ALR quel que soit le lieu de prise en charge. Nous n’avons pas mis en évidence de majoration des complications. Une résolution des symptômes neuropathiques a été constatée chez tous les patients. Conclusion Les résultats de cette étude montrent une augmentation de la satisfaction des patients pour les procédures réalisées en « office surgery ». Les résultats montrent également une augmentation de la satisfaction des patients sous WALANT comparé à l’ALR quel que soit le lieu de prise en charge. En conclusion il semblerait que la libération du canal carpien sous WALANT en « office surgery » apporte une amélioration significative du confort et de la satisfaction des patients, sans différence significative concernant les résultats cliniques. Niveau de preuve III.
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INTRODUCTION: Carpal tunnel syndrome is a neuropathy caused by compression of the median nerve within the carpal tunnel. However, the severity of symptoms and signs does not often correlate well with the extent of nerve damage.
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We prospectively randomized 100 patients following carpal tunnel decompression who were having a 2-week postoperative assessment and removal of stitches to either their local general practitioner (GP) or the hospital outpatient department. All patients were seen at hospital 6 weeks postoperatively for a final assessment. The waiting time for assessment and suture removal was shorter at the GP surgery than in the outpatient department (mean 13 min and 28 min respectively) but significantly more patients were diagnosed as having wound infections (14% and 0% respectively); most were given antibiotics, perhaps unnecessarily.
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Complications from carpal tunnel release surgery are diverse in nature, ranging from postoperative wound infections to median nerve laceration. Although significant injury to an underlying neurovascular structure rarely occurs during carpal tunnel surgery, when it does happen, the outcome can be emotionally and physically devastating to patients. More commonly, patients suffer from recurrent symptoms because of incomplete release of the transverse carpal ligament or secondary traction neuritis from excessive scarring. Early and accurate diagnosis of a complication or recurrence from carpal tunnel release facilitates the development of a successful treatment plan for improved patient outcome. The common elements in operative management of complications from carpal tunnel surgery include complete external neurolysis, nerve repair or grafting, and autologous soft tissue coverage to prevent the formation of postoperative adhesions. Treating physicians should be aware that complications after carpal tunnel surgery can have a profound impact not only on a patient's hand function, but also on a patient's psyche.
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To determine the rate of postoperative wound infection and the association with prophylactic antibiotic use in uncomplicated carpal tunnel release surgery. We performed a multicenter, retrospective review of all the carpal tunnel release procedures performed between January 1, 2005, and August 30, 2007. Data reviewed included the use of prophylactic antibiotics, diabetic status, and the occurrence of postoperative wound infection. We determined the overall antibiotic usage rate and analyzed the correlation between antibiotic use and the development of postoperative wound infection. The rate of surgical site infections in the 3003 patients who underwent carpal tunnel release surgery (group A) was 11. Antibiotic usage data were available for 2336 patients (group B). Six patients without prophylactic antibiotics had infection, as did 5 patients with prophylactic antibiotics. This difference was not statistically significant. Of the 11 surgical site infections, 4 were deep (organ/space) and 7 superficial (incisional). The number of patients with diabetes in the overall study population was 546, 3 of whom had infections. This was not statistically different from the nondiabetic population infection rate (8 patients). The overall infection rate after carpal tunnel release surgery is low. In addition, the deep (organ/space) infection rate is much lower than previously reported. Antibiotic use did not decrease the risk of infection in this study population, including patients with diabetes. The routine use of antibiotic prophylaxis in carpal tunnel release surgery is not indicated. Surgeons should carefully consider the risks and benefits of routinely using prophylactic antibiotics in carpal tunnel release surgery. Therapeutic III.
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Our goals were to analyze cost and efficiency of performing carpal tunnel release (CTR) in the main operating room (OR) versus the ambulatory setting, and to document the venue of carpal tunnel surgery practices by plastic surgeons in Canada. A detailed analysis of the salaries of nonphysician personnel and materials involved in CTR performed in these settings was tabulated. Hospital statistical records were used to calculate our efficiency analysis. A survey of practicing plastic surgeons in Canada documented the venue of CTR performed by most. In a 3-h surgical block, we are able to perform nine CTRs in the ambulatory setting versus four in the main OR. The cost of CTR in the ambulatory setting is $36/case and $137/case in the main OR in the same hospital. Only 18% of Canadian respondents use the main OR exclusively for CTR, whereas 63% use it for some of their cases. The ambulatory setting is used exclusively by 37%, whereas 69% use it for greater than 95% of their cases. The majority of CTR cases (>95%) are done without an anesthesia provider by 73% of surgeons. Forty-three percent use epinephrine routinely with local anesthesia and 43% avoid the use of a tourniquet for at least some cases by using epinephrine for hemostasis. The use of the main OR for CTR is almost four times as expensive, and less than half as efficient as in an ambulatory setting. In spite of this, many surgeons in Canada continue to use the more expensive, less efficient venue of the main OR for CTR.
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Analyzed are data on 430 operations in 326 patients for median nerve compression at the wrist. Follow-up data from a patient self-evaluation questionnaire were available for 71% of patients. Incidence was highest in the fifth and sixth decades of life, and 65% of patients were female. For most patients, symptoms were worse at night or with excessive hand use or both. Self-evaluation questionnaires showed total relief of symptoms after operation in 51% of cases, 75% or greater improvement in 31%, and 50% or greater improvement in 10%. The dominant hand was more severely involved in two thirds of the patients and 78% of patients had occupations involving considerable use of their hands, suggesting that an occupational factor might be involved in the genesis or aggravation of median nerve compression.
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Between January 1976 and December 1985, 3620 carpal tunnel releases were done at the Mayo Clinic. A deep postoperative infection developed in 17 (0.47%) patients. These 17 were compared control group of 102 patients to identify possible risk factors. Statistically significant risk factors included intraoperative instillation of steroid solution into the carpal canal, flexor tendon synovectomy, prolonged operative time, and use of a surgical drain. Infection incidence was 0.87% in males and 0.25% in females (statistically significant). Seven (41%) of the 17 patients had a suboptimal result at final follow-up.
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The results of 278 endoscopic carpal tunnel releases using the extrabursal dual portal Chow technique were analyzed prospectively. The majority of patients were pain free by the 57th postoperative day. The perioperative complication rate was 1.7%. The late complication rate was 2.8%. Two cases were converted to open carpal tunnel release. The average time to return to full-duty work was 65 days in those patients covered by worker's compensation, whereas it was 21 days in the privately insured (non-worker's compensation) patients. The endoscopic release of the transverse carpal ligament is an effective technique for the treatment of carpal tunnel syndrome with a low complications rate. Return to full employment requires more time in those patients covered by worker's compensation.
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A study of endoscopic carpal tunnel release was carried out in three parts, consisting of initial cadaveric dissections, a prospective pilot study of 20 patients and a prospective, randomized trial of 71 patients comparing endoscopic with open decompression. In the main trial, 25 patients with bilateral symptoms underwent simultaneous endoscopic and open release, with the remainder randomized to one or other technique. Both techniques effectively decompressed the median nerve. A significant improvement in group and pinch strength over 3 months was achieved in those undergoing endoscopic surgery. Average return to work was 14 days in the endoscopic series and 39 days in the open series. A complication rate of 35% was achieved with the transbursal endoscopic technique, 3.7% with the extrabursal endoscopic technique and 13.5% in the open series.