Endoscopic Cubital Tunnel Release
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1 Endoscopic Cubital Tunnel Release Cobb TK, Walden AL, Lemke JH, Merrell PT. Setting expectations following endoscopic cubital tunnel release. HAND. April DOI /s
2 Cubital Tunnel Syndrome: Minimally Invasive Treatment Endoscopic cubital tunnel release Old Anterior Nerve Transposition 2
3 Endoscopic Cubital Tunnel Surgery
4 Setting Expectations following Endoscopic Cubital Tunnel Release Cobb TK, Walden AL, Lemke JH, Merrell PT. Setting expectations following endoscopic cubital tunnel release. HAND. April DOI /s
5 Cubital Tunnel Syndrome: Studies - Results Setting Expectations following Endoscopic Cubital Tunnel Release 1/2 of endoscopic release pts returned to work in 1 week Open release pts returned to work in 2 months Improvement in preoperative signs/symptoms Signs/symptoms Pre-op % Resolution Numbness/tingling 94% 79% Pain 55% 81% Weakness 44% 86% Abnormal 2 pt 28% 76% Atrophy 27% 78% Wartenberg s 15% 65% Cobb, Walden, Lemke, and Merrell. HAND. April
6 Number of Days Cubital Tunnel: Return to Work ECTR Open Modifed Work Regular Work 6
7 Time off work Cubital Tunnel Syndrome: Studies - Clinical Significance Operative costs Endoscopic benefit Difference in tourniquet time (49 min) Cubital tunnel surgeries per Endoscopic 10 min vs open 59 min year = 73,673 Cost of OR time Return to work 63 days Total sooner Estimated $29 per minute with endoscopic procedure Cost savings Cost savings Annual Savings for 49 min x $29/min = $1,421 per pt Daily cost of disability = $94 x 73,673 cases = $72,199,540 per year $94 (per day) x 63 days (RTW) U.S. = $5,922 per patient Anesthesia costs x 73,673 cases = = $520 million Billed Base Rate of $65 per 15 min block over $436 million per year Approx 45 min less time (3 blocks) $65/block x 3 = $195 per pt x 73,673 cases = $14,366,235 per year Davis et. al Issue Brief Common Fund 2005; CDC Sept. 18, 2013; Macario A J Clini Anesth
8 Prospective Multicenter Evaluation of Endoscopic Cubital Tunnel Release Tyson Cobb, Blain Samuelson, Jon Lemke, Anna Cobb, Steven Topper
9 Methods 230 cases (Females=107, Males=123) 211 patients 4 Private Orthopaedic Practices Miami, FL Davenport, IA Denver, CO Owings Mills, MD
10 Patients (n) Patients (n) Demographics Site Total (%) Male (%) Female (%) IA 125 (54) 78 (62) 47 (38) MD 70 (31) 32 (46) 38 (54) CO 19 (9) 4 (21) 15 (79) FL 16 (7) 9 (56) 7 (44) Total (53) 107 (47) Number of Patients by Site IA MD CO FL Working rank Count (%) 1-mild 131 (58) 2-moderate 13 (6) 3-heavy 22 (10) 4-unemployed 61 (27) Number of Patients by Rank
11 Pre Op Data by Site Compile all 4 sites or analyze each separately? Dellon s IA MD CO FL Total 1-mild 25 (20) 12 (17) 5 (26) 2 (13) 44 (19) 2-moderate 45 (36) 28 (40) 12 (63) 10 (63) 95 (41) 3-severe 55 (44) 30 (43) 2 (11) 4 (25) 91 (40) Total *Parentheses show percentage of Dellon s classification by each site
12 Amount of Time for Surgery (minutes) Site Mean Std. Dev. Median Min Max IA MD CO FL
13 Pre Op vs. Intra Op Subluxation Measure: Clinical Observation -Pre Op Intra Op Subluxation (truth) No Yes Total No Yes Total False Negative: 7 of 204 = 3% 95% CI: ( ) False Positive: 12 of 15 = 80% 95% CI: ( ) Specificity: 197 of 209 = 94% 95% CI: ( ) Sensitivity: 3 of 10 = 30% 95% CI: ( )
14 Using Final Follow Up Final Follow Up range Longest was almost 5 years Shortest was one week Issue of Final Follow up vs. First Resolution Rate of resolution differences (pain, NT, weakness, etc.) Issue with this type of surgery-easy to hit Not due to surgery not lasting, just due to how frequently you can hit this nerve
15 First Follow Up Dates Site N Mean Median Min Max IA MD CO FL Can t determine rate of resolution until you have at least your first follow up. These significantly increase your days to resolution data
16 Resolution of Symptoms Site Numbness and Tingling Positive Pre-Op Test Resolution Time to Resolution N (%) N (%) Median Days IA 113 (53) 96 (85) 30 MD 68 (32) 40 (59) 381 CO 17 (8) 12 (71) 67 FL 15 (7) 11 (73) 145 Total 213 (93) 159 (75) 90
17
18 Dellon s Class Numbness and Tingling Positive Pre-Op Test Resolution Time to Resolution N (%) N (%) Median Days 1 34 (16) 30 (88) (40) 63 (73) (42) 62 (70) 159 No Score 4 (2) 4 (100) - Total 213 (93) 159 (75) 90 Operated Hand Numbness and Tingling Positive Pre-Op Test Resolution Time to Resolution N (%) N (%) Median Days Dominant 96 (45) 78 (81) 46 Nondominant 108 (51) 73 (68) 136 Undetermined 9 (4) 8 (89) 1184 Total 213 (93) 159 (75) 90
19 Resolution of Symptoms Site Positive Pre-Op Test Pain Resolution Time to Resolution N (%) N (%) Median Days IA 54 (44) 52 (96) 15 MD 46 (37) 38 (83) 39 CO 11 (9) 11 (100) 82 FL 13 (10) 11 (85) 89 Total 124 (54) 112 (90) 31
20
21 Satisfaction by Dellon s Class Satisfaction n (%) Dellon's Class Very Dissatisfied Very Satisfied mild 0 1 (3) 3 (9) 7 (21) 22 (67) 2 - moderate 2 (3) 2 (3) 7 (10) 21 (30) 39 (55) 3 - severe 1 (1) 4 (5) 21 (24) 18 (21) 42 (49) Total 3 (2) 7 (4) 31 (16) 46 (24) 103 (54)
22 Pre-Op Dellon s Class vs. Post-Op Bishop s Pre Dellon's Class Poor 0 to 2 Post Bishop's Ranking Fair 3 to 4 Good 5 to 7 Excellent 8 to 9 Total 1 - mild (21) 27 (79) moderate 0 1 (1) 19 (27) 51 (72) severe 3 (4) 6 (7) 21 (25) 55 (65) 85 Total 3 (2) 7 (4) 47 (25) 133 (70) 190
23
24 Days to Return to Work Normal By Site
25 Work Comp on RTW Work Comp N Mean Median Std. Dev. IQR No Yes P value: 0.050
26 Summary Differences in Pre Op Data Who they perform the surgery on Dellon s, sex, working rank Learning Curve of the surgery Time in surgery Changes in sample population Incomplete data; due to lack of follow up or phone call Final Follow Up issues Long time, easy to re-injure, lower post op scores Work Comp on RTW
27 Thank you! Questions?
Setting expectations following endoscopic cubital tunnel release
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