Decreased Wait Times After Institution of Office-Based Hand Surgery in a Veterans Administration Setting

Carpal tunnel syndrome is a common peripheral nerve compression disorder causing symptoms of numbness, tingling, weakness, and muscle atrophy. Open carpal tunnel release (CTR) is a common treatment modality traditionally performed in the operating room with sedation or general anesthesia. It can also be performed in the surgeon’s office under local anesthesia only.¹ In our study, we examined the number of days from initial consultation and visit to operative intervention in a Veterans Administration (VA) setting. A significant decrease in wait time from initial consultation to operative intervention and from initial visit to operative intervention was hypothesized to occur with the transition to office-based hand surgery procedures, without an increase in complications.

Institutional review board approval from the Richard L. Roudebush VA Medical Center was obtained to construct a database of recent surgical procedures performed for carpal tunnel syndrome by the plastic surgery service. Operations including CTR in conjunction with other procedures were excluded. The minor procedure room is located within the plastic surgery clinic, with a single nurse serving as a circulating nurse. The hand and forearm are prepped and draped, and both monopolar cautery and bipolar cautery are available. A more specific description to a similar configuration can be found in Leblanc et al.² The study variables collected were age, sex, tobacco use, procedure, time from initial consultation to surgery (in days), time from initial clinic visit to surgery (in days), location of the procedure (the minor procedure room in the surgeon’s office or the operating room), and complications. An independent 2-tailed t test was used to compare mean values using SPSS version 20 (IBM).

Two separate types of CTR were analyzed: office-based CTR (44 patients) and operating room–based CTR (54 patients). The Table contains a comparison of the 2 groups of patients who underwent 1 of the 2 types of CTR. Significant decreases in time from initial consultation to surgery and from initial clinic visit to surgery were observed in the office-based group (P < .05). There was no difference in complications between the 2 groups. Complications in the operating room–based group included 2 infections requiring oral antibiotics and 4 minor wound dehiscences that resolved with local wound care. In the office-based group, there were 2 infections (one requiring intravenous antibiotics and the other resolving with oral antibiotics) and 2 minor wound dehiscences.

Office-based hand surgery procedures have been validated in a variety of settings but are not the default method of performing hand surgery procedures in the United States. We have demonstrated a significant decrease in time to procedure with the use of an office-based procedure in a VA setting, without sacrificing quality. Open CTR can be completed safely in the office; the complication rate was not statistically different between the 2 groups in our series. To our knowledge, this is the first description of decreased times to surgery due to the institution of office-based open CTR. Previous studies demonstrated that early intervention is associated with a faster return to daily activities of living and to normal function compared with late intervention.³ The limitations of our study include its retrospective nature and the steps of conservative management, including steroid injections, which are often offered to patients who do not wish to undergo surgery immediately. A wider application of office-based minor hand surgery would likely result in significantly increased patient access to surgery in the VA system.

Corresponding Author: Sunil Tholpady, MD, PhD, Division of Plastic Surgery, Department of Surgery, Indiana University, RI 2514, 705 Riley Hospital Dr, Indianapolis, IN 46202 (stholpad@iupui.edu).

Published Online: December 23, 2014. doi:10.1001/jamasurg.2014.1239.

Author Contributions: Drs Duquette and Tholpady had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Duquette and Nosrati contributed equally to the manuscript and are considered as co–first authors.

Study concept and design: Duquette, Nosrati, Tholpady.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Duquette, Nosrati, Tholpady.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Duquette, Nosrati, Tholpady.

Administrative, technical, or material support: Nosrati, Cohen, Tholpady.

Study supervision: Nosrati, Cohen, Munshi, Tholpady.

Conflict of Interest Disclosures: None reported.

Previous Presentation: This paper was presented at the 38th Annual Surgical Symposium of the Association of VA Surgeons; April 6, 2014; New Haven, Connecticut.