Adjunctive Surgical Procedures Research Articles

Blanket or tailored prescription of retainers in orthodontics: a questionnaire-based study.

To explore retainer protocols and how they are influenced by orthodontic presentation and the nature of occlusal correction. A prepiloted 45-item online questionnaire targeting orthodontists was developed. The questionnaire covered clinical preferences in terms of retainer type, fabrication, and follow-up during retention; the clinical indications for adjunctive surgical procedures; and the use of active designs to mitigate relapse in specific malocclusions. A total of 206 responses were obtained. The majority of the respondents prescribed maxillary removable and mandibular fixed retainers, with almost half (49.1%) reviewing patients for more than 1 year primarily in person (95.1%). The majority prescribed vacuum-formed (69.6%) 1-mm-thick (44.3%) retainers. Only 37.3% were aware of the type of material used, with polyethylene terephthalate glycol copolymer, followed by polypropylene, being the most common. Hawley retainers were preferred following nonsurgical maxillary expansion and with suboptimal interdigitation. A preference for clear retainers and/or fixed retainers was found in open-bite cases and deep-bite cases. Supracrestal fiberotomy was prescribed commonly (61.1%) for rotations greater than 90°. No retainer was rarely prescribed except after the correction of an anterior crossbite. Blanket prescription of orthodontic retention is common, with limited awareness of clear plastic retainer materials. Future trials evaluating the effectiveness of approaches for retainer prescription based on the presenting malocclusion would be timely.

Postoperative Management of Osteochondral Lesions of the Ankle: A Survey Among German-Speaking Foot and Ankle Surgeons.

To assess the current treatment of osteochondral lesions of the ankle (OCLA) by German-speaking foot and ankle surgeons, focusing on the management of postoperative care and rehabilitation. A questionnaire was created by a panel of 4 experienced foot and ankle surgeons on behalf of the "Clinical Tissue Regeneration" (CTR) working group of the German Society of Orthopaedics and Trauma Surgery (DGOU), and distributed electronically to members of the CTR, participants of the German Cartilage Registry (Knorpelregister DGOU©), and members of 6 German-speaking orthopedics or sports medicine societies. Results were classified depending on the consensus within the answers (agreement ≥75% "strong tendency," 50%-74% "tendency," 25%-49% "weak tendency," <25% "no tendency"). A total of 60 participants returned the questionnaire. The main results are as follows: regarding the frequency of surgical procedures for OCLA, refixation of the fragment, retrograde drilling, and bone marrow stimulation with or without using a matrix were performed by at least 75% of the surgeons and was considered a strong tendency. There was a strong tendency to stabilize the ankle (76.7%) and perform corrective osteotomies (51.7%). In total, 75.5% and 75% of the surgeons performed bone marrow stimulation with and without using a matrix, respectively. Corrective osteotomy and ankle stabilization were performed in 64.5% and 65.2% cases, respectively. Most participants included published recommendations on postoperative rehabilitation and the return to sports activities in their postoperative management. The main surgical procedures were considered the most critical factor in influencing the postoperative management by 81% of the participants (strong tendency). Adjunct surgical procedures such as corrective osteotomy and stabilization of the ankle were considered important by 67.8% of the respondents (tendency). The management of OCLA varies among German-speaking foot and ankle surgeons. Therefore, guidelines remain essential to standardize the management of OCLA, to achieve improved and stable results. This survey will assist clinicians and patients with rehabilitation to return to sports after treating the ankle's cartilage injury.

Interrupted Versus Running Sutures for Amniotic Membrane Fixation in Cases of Resistant Infected Corneal Ulcers

Background: Infected corneal ulcers that don't show any healing within two weeks despite proper medical treatment are considered resistant and need surgical intervention [1] the amniotic membrane transplantation has been used to treat resistant corneal ulcers because it acts as a bioactive substratum that accelerates epithelial healing [2].&#x0D; Aim of the Work: comparison between interrupted and running sutures for amniotic membrane fixation in cases of resistant infected corneal ulcers.&#x0D; Patients and Methods: This prospective, comparative, interventional randomized study was carried out on 40 eyes with resistant infected corneal ulcers. They underwent amniotic membrane transplantation as an adjunctive to the medical treatment. Divided into 2 groups: group A (interrupted suture group) and group B (running suture group). The duration of study was 12 months.&#x0D; Results: The duration of healing in group A ranged from 25 to 40 days with mean duration of 34.25±4.94 days, while in group B the duration of healing ranged from 20 to 40 days with mean duration of 31.0±6.61 days. UDVA didn’t improve in 65% of cases in group A and 45% of cases in group B.&#x0D; Conclusion: Amniotic membrane transplantation is an adjunctive surgical procedure for the management of infectious corneal ulcer by promoting wound healing and reducing inflammation. We noticed that the running suture adhered the amniotic membrane firmly to the entire corneal surface so it accelerated the corneal epithelial healing and made it less affected with eyelid movement and less annoying to patient.

Cervical Ligament Insufficiency in Progressive Collapsing Foot Deformity: It May Be More Important Than We Know

Category: Hindfoot; Midfoot/Forefoot Introduction/ Purpose: Subluxation at the subtalar joint is one of the major radiographic features that characterize progressive collapsing foot deformity (PCFD). Although it is recognized that the cervical ligament plays an important function in maintaining the subtalar joint's stability, its role and involvement in PCFD is largely unknown. The purpose of this study was to assess the prevalence of cervical ligament insufficiency in patients with PCFD and to establish if its integrity of it changes with increasing axial plane deformity. We hypothesized that there will be a higher prevalence of cervical ligament insufficiency in a PCFD cohort compared to that of a control group. Additionally, we hypothesized that those with higher degrees of cervical ligament insufficiency will have a more severe abduction deformity and talocalcaneal subluxation. Methods: This study retrospectively reviewed magnetic resonance imaging (MRI) of 78 PCFD patients and age- and gender- matched controls. A radiologist specializing in musculoskeletal disorders evaluated the structural derangement of the cervical ligament into five grades (Grade 0 indicating normal and Grade 4 indicating a tear greater than 50% of the cross-sectional area), as previously described. To compare its involvement in PCFD, two commonly involved ligaments (spring and interosseous) in PCFD were also evaluated. Plain radiographic parameters, including the talonavicular coverage angle (TNC), lateral talo-1st metatarsal (Meary’s) angle, calcaneal pitch, and hindfoot moment arm, as well as axial plane orientation of the talus (TM-Tal) and calcaneus (TM-Calc) relative to the transmalleolar axis and talocalcaneal subluxation (Diff Calc-Tal), were correlated with the cervical ligament MRI grading system. Results: The overall distribution of the degree of cervical ligament involvement was significantly different between the PCFD and control groups (P &lt; .001, Table 1). MRI evidence of a tear (Grades 3 or 4) in the cervical ligament was identified in 47 of 78 (60.3%) feet in the PCFD group, which was significantly higher than the control group (10.9%) and greater than that of superomedial spring (43.6%) and talocalcaneal interosseous (44.9%) ligaments. Univariate ordinal logistic regression modelling demonstrated a predictive ability of TM-Calc (Odds ratio [OR]: 1.17, 95% confidence interval [CI]: 1.06-1.30, p=.004), Diff Calc- Tal (OR: 1.15, 95% CI: 1.06-1.26, p=.002), TNC (OR: 1.08, 95% CI: 1.03-1.13, p=.003), and Meary’s angle (OR: 1.05, 95% CI: 1.02-1.10, p=.006) in determining higher cervical ligament grade on MRI (Figure 1). Conclusion: We found that cervical ligament insufficiency is a significant component of PCFD and is more common than anticipated in this study. Based on the radiographic findings in the current study, cervical ligament insufficiency appears to be primarily associated with axial plane midfoot and hindfoot deformity. If its biomechanical properties are established in the future studies, we think the reconstruction of the cervical ligament may be a potential adjunct surgical procedure for PCFD patients with significant axial plane deformity.

The Role of Orthodontics, Orthognathic Surgery and Adjunct Surgical Procedures in the Esthetic Rehabilitation of the Face and Smile: Potential and Limitations

For nearly a century, orthodontists have mainly focused on occlusion as the primary objective of orthodontic therapy. The introduction of the soft tissue paradigm has shifted treatment planning from hard tissue to soft tissue and reinforced the key role of facial esthetics in orthodontic diagnosis and treatment planning. Whereas occlusion is rooted in measurable definitions of Class I and other “keys to occlusion”, esthetics is more subjective, based not only on the orthodontist's assessment but also on personal and cultural preferences rather than rigid norms. The aim in this paper is to demonstrate that orthognathic surgery potentially narrows the gap between esthetics and function, even though surgery may have its own limitations. Three reports are presented on patients whose clinical examination, records evaluation and treatment planning have focused on facial and smile esthetics, and treatment approaches that combined orthodontics, orthognathic surgery and appropriate adjunct procedures to enhance the overall esthetic outcome.

Current surgical techniques for the management of pediatric glaucoma: A literature review

Pediatric glaucoma surgery is challenging due to its diverse and complex pathophysiology, altered anterior segment anatomy, greater potential for failure, and complications compared to adult patients. Moreover, numerous challenges are associated with long-term postoperative management. Thus, when dealing with childhood glaucoma, it is important to consider the potential complications in addition to the benefits of each intervention. The purpose of this article is to review recently published literature to shed light on the most recent surgical techniques for the safe and effective treatment of childhood glaucoma. Current literature shows that goniotomy and trabeculotomy are the first choices for the management of primary congenital glaucoma. Although older children with phakic eyes seem to benefit from trabeculectomy with adjunctive mitomycin C, it carries a long-term risk of bleb-related endophthalmitis. Glaucoma drainage devices may be preferred for patients with secondary or refractory glaucoma. However, hypotony or tube-related complications are common and encountered more often in children than in adults. Cyclodestructive procedures are also an option for cases in which filtering surgery has failed, but they can also be used as a temporizing measure to reduce the rate of complications in high-risk patients. However, their outcomes can be unpredictable, in terms of efficiency and complications. Finally, minimally invasive glaucoma surgery (MIGS) as the sole alternative treatment or as an adjunctive surgical procedure is a relatively new path for pediatric patients.

Posterior Fossa Decompression with or Without Duraplasty for Chiari I Malformation.

Posterior fossa decompression (PFD) with/without duraplasty is the standard surgical treatment for symptomatic CM-1. Posterior fossa decompression without duraplasty (PFD) may be associated with shorter operative times and hospital stays, fewer complications, and may yield improvements in symptoms and syrinx sizes. Posterior fossa decompression with duraplasty (PFDD) may be associated with superior long-term symptomatic improvements, larger syrinx reductions, and a lower need for revision decompression. Various dural graft materials may be used for PFDD, though the ideal type of graft has not been definitively established. Other adjunct surgical procedures may be added to PFD/PFDD given certain symptomatic or anatomical considerations.

Establishing a Virtual Corneal Clinic: A Real-Time Teleophthalmology Approach.

Keratoplasty patients require regular and timely follow-ups. During this COVID-19 pandemic which restricted global travel, we developed a novel real-time, hybrid teleophthalmology approach to comanage international keratoplasty patients between Singapore and Indonesia. A retrospective consecutive observational study of 72 corneal patients (63 were postkeratoplasty) who attended a virtual corneal clinic (VCC) between June 2020 and April 2021 at JEC Eye Hospitals (JEC) in Jakarta, Indonesia. ZOOM Meeting software (Zoom Video Communication Inc, San Jose, CA) was used to simultaneously connect the Singapore corneal specialist at Eye & Cornea Surgeons (ECS), Singapore, using a real-time approach. Clinical examinations included full panels of video-linked corneal, glaucoma, and retinal imaging and investigations performed before real-time video-linked slit-lamp examination, with immediate clinical decision making between corneal specialists and patients. VCC enabled effective real-time clinical evaluation and collaborative clinical decisions, with full patient interaction, with the aim of maintenance of graft clarity, visual function, and management of comorbidities-a) topical and systemic medications were adjusted in 79.2% of patients; b) further referrals to glaucoma, retinal, and oculoplastic subspecialists were made in 16.6% of cases; c) additional adjunctive surgical procedures were performed at JEC in 6.9% cases; and d) government permission was obtained for 4 patients (5.6%) to fly to Singapore for urgent corneal surgery. The virtual corneal clinic is a novel real-time hybrid teleophthalmology approach which is effective in the comanagement of international keratoplasty patients and represents the advances in ophthalmic telemedicine.

A case report of persistent drug-sensitive pulmonary tuberculosis after treatment completion

BackgroundMycobacterium tuberculosis (Mtb) has been found to persist within cavities in patients who have completed their anti-tuberculosis therapy. The clinical implications of Mtb persistence after therapy include recurrence of disease and destructive changes within the lungs. Data on residual changes in patients who completed anti-tuberculosis therapy are scarce. This case highlights the radiological and pathological changes that persist after anti-tuberculosis therapy completion and the importance of achieving sterilization of cavities in order to prevent these changes.Case presentationThis is a case report of a 33 year old female with drug-sensitive pulmonary tuberculosis who despite successfully completing standard 6-month treatment had persistent changes in her lungs on radiological imaging. The patient underwent multiple adjunctive surgeries to resect cavitary lesions, which were culture positive for Mtb. After surgical treatment, the patient’s chest radiographies improved, symptoms subsided, and she was given a definition of cure.ConclusionsMedical therapy alone, in the presence of severe cavitary lung lesions may not be able to achieve sterilizing cure in all cases. Cavities can not only cause reactivation but also drive inflammatory changes and subsequent lung damage leading to airflow obstruction, bronchiectasis, and fibrosis. Surgical removal of these foci of bacilli can be an effective adjunctive treatment necessary for a sterilizing cure and improved long term lung health.

Comparison of Nasal Obstruction Symptom Evaluation Score Outcomes After Autologous Cartilage Grafts and Latera Nasal Implants.

To compare quantitative Nasal Obstruction Symptom Evaluation (NOSE) scores for ACG and Latera implants for nasal valve repair. Retrospective chart review of patients who underwent ACG or Latera placement between January 2016 through May 2019 by a single surgeon. Patients who had completed NOSE surveys pre- and post-operatively were identified and eligible for inclusion. Data regarding baseline demographic characteristics, adjunctive surgical procedures, NOSE scores at 1, 3, and 6-month post-operative visits, complications, and total operative time were collected. Unpaired t-tests and linear mixed models were performed to analyze differences between study groups. There were 24 and 39 patients who underwent ACG and Latera, respectively, who met eligibility criteria. There were no differences in demographic characteristics or pre-operative baseline NOSE scores (ACG: 65.1 and Latera: 64.4; P = .92) between groups. Mean operative times were not significantly different between groups (ACG: 113 minutes and Latera: 102 minutes; P = .76). Within each group, NOSE scores were significantly improved at each post-operative visit compared to pre-operative baselines. Between groups, mean NOSE scores were lower at each post-operative visit for ACG compared to Latera (1-month ACG: 21.7 and Latera: 45.9, P = .002 ; 3-month ACG: 14.5 and Latera: 39.9, P = .034; 6-month ACG: 8.4 and Latera: 44.2, P = .003). Both ACG and Latera offer significant improvements in patient-reported nasal obstruction severity; however, ACG may yield more favorable subjective symptom scores.

Need for organ preservation in postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).

5031 Background: The aim ofPC-RPLND for advanced nonseminomatous germ cell tumors is to resect all remaining metastatic tissue. So far, the resection of adjacent visceral or vascular organs is also commonly performed to achieve complete resection of the residual mass. To determine the possibility of more organ preservation, we aimed to analyze the pathohistology of patients with adjunctive surgery as the frequency of metastatic involvement in those organs with teratoma or vital cancer is currently unknown. Methods: We reviewed a cohort of 1204 patients who underwent PC-RPLND between 2008 and 2021 as a 2-center study and identified 242 (20.1%) cases of adjunctive surgery during PC-RPLND. We analysed the pathohistological presence of germ cell tumor elements in the resected organs: viable tumor (V), teratoma (T) or necrosis / fibrosis (N). Surgery associated complications were reported according to the Clavien-Dindo classification. Outcomes of subgroups were compared by using log-rank test. Results: V, T and N were present in 54 (22%), 94 (39%) and 94 (39%) of all patients with adjunct resected organs. In 242 patients, 325 adjunct organs were resected with 66 (27.3%) of these patients receiving a resection of multiple organs. The kidney was the most often resected organ (n = 77; V: 29% T: 39% N: 32%), followed by V. Cava (n = 67; V: 25% T: 36%, N: 39%) and partial liver resections (n = 50; V: 16%, T: 30%, N: 54%). Postoperative complications occurred in 30% of which 22% were Clavien grade III-V, showing no significant differences between V, T and N; p = 0.093. 27% of all patients suffered from a relapse during a median follow-up of 22 months [0-180]. Patients with T or V in the resected specimens had a significantly reduced 5-year RFS compared to patients with only N (39%, 81%, p &lt; 0.001). Conclusions: This study shows tremendous need for more organ preservation as 40% of all resections of adjunct organs are oncologically unnecessary due to the presence of N only in the pathological specimens. Therefore, in case of doubt, we should increase intraoperative frozen section to avoid oncologically unnecessary adjunctive surgeries, especially nephrectomies and vascular resections. Additionally, serological or image-based means for a more accurate presurgical workup are required to spare patients with N from PC-RPLND in general.

Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable?

Do Proposed Quality Measures for Carpal Tunnel Release Reveal Important Quality Gaps and Are They Reliable?

The Controversial Role of Concurrent Crural Plasty in Bariatric Surgery: Where Is the Evidence?

Gastroesophageal reflux disease is diagnosed at an alarming rate after laparoscopic sleeve gastrectomy. Revisional surgery with conversion to Roux-en-Y gastric bypass does not guarantee reflux control and is associated with morbidity. There is a need to optimize the objective foregut patient pathway prior to bariatric surgery and to perform concurrent hiatal repair in individuals with a defective esophago-gastric junction and abnormal esophageal acid exposure. The role of adjunctive surgical procedures (hiatal reinforcement, fundoplication, magnetic sphincter augmentation) is still controversial due to lack of follow-up and standardized reporting, and current recommendations are based on expert opinion or case series.

Eyes wide shut: necessity and effect of adjunctive procedures after decompression surgery in patients with endocrine orbitopathy

BackgroundOrbital decompression surgery is frequently the last therapeutic measure in the surgical treatment of endocrine orbitopathy (EO). Additional rehabilitative and corrective surgical treatments are often used to improve the resulting eyelid stigmata, such as an increased lid aperture and scleral show. The aim of the study was to evaluate the effect of adjunctive surgical procedures after orbital decompression surgery in patients with EO.MethodsA total of 120 orbitae from 65 patients with EO from 2010 to 2020 at a tertiary care center in Germany were retrospectively evaluated. Ocular surface area (OSA) and vertical palpebral fissures were three-dimensionally analyzed at the following stages: presurgical decompression, postsurgical decompression, and post-adjunctive surgical procedures. For the analysis of vertical palpebral fissures, predefined vertical line distances were measured on the upper and lower lids in the central, medial, and lateral pupillary regions.ResultsThe initial OSA was 2,98 ± 0.85 cm2, and it decreased significantly after decompression surgery to 2.52 ± 0.62 cm2. After adjunct surgical procedures, OSA further decreased to 2,31 ± 0,55 cm2. Furthermore, a statistically significant reduction in all pupillary parameters was noted after each treatment step. More lid-lengthening procedures were performed on the lower lid than on the upper lid. Canthoplasty (n = 13) was the most frequently performed procedure during rehabilitation.ConclusionSurgical decompression surgery improves OSA and leads to a significant reduction in lid aperture. Adjunctive surgical procedures, addressing the upper and lower lid, have a significant influence on the ongoing clinical course and contribute to a reduction in OSA.

Direct puncture of an occluded common femoral artery as a new approach for endovascular aortic aneurysm repair

BackgroundAbdominal aortic aneurysms (AAA) which present with a hostile access are not uncommon. When an arterial occlusion continuously involves from the iliac to the femoropopliteal artery, endovascular aneurysm repair (EVAR) can become complex, necessitating an adjunctive surgical procedure. The present report outlines a successful EVAR which was conducted without any adjunctive surgical procedure for an AAA complicated by extensive access vessel occlusion.Case presentationThe patient, an 82-year-old male, had a fusiform 50 mm infrarenal AAA. He had a history of above knee amputation of the right leg due to a gangrene from Buerger’s Disease. Despite the continuous occlusions of the right external iliac artery (EIA), common femoral artery (CFA), and superficial femoral and profunda femoris artery, limb ischemia was not observed in his right leg. Since revascularization of the occluded right iliac and femoral arteries was deemed to be too complex technically and no ischemic symptoms were observed, EVAR was performed using the occluded access only for the delivery of the stent graft without restoring the flow. Firstly, the occluded right CFA was punctured under ultrasound guidance. Next, a 0.014 in. guidewire and a microcatheter were successfully navigated to the subintimal space of the right common iliac artery (CIA), these were then exchanged with a reentry device. The reentry device allowed the advancement of a guidewire into the true lumen of the right CIA. Then, a 12Fr sheath for delivery of a contralateral limb was advanced via the occluded right access to aorta, and a 16 Fr sheath for delivery of a main body graft was advanced via a patent left iliac artery. A standard EVAR procedure was subsequently performed.ConclusionsEVAR was successfully performed for an AAA complicated with an arterial occlusion from the EIA to the SFA using direct puncture of the occluded CFA. This technique could be an effective measure for cases with a hostile access involving the CFA.

Feasibility and Oncologic Outcome of Salvage Surgery in Isolated Seminal Vesicle Remnants after Radical Prostatectomy

Background: To demonstrate the feasibility of resecting isolated locally relapsing seminal vesicle remnants after primary radical prostatectomy and radiotherapy. Early oncologic outcomes and prognostic risk factors for relapse are demonstrated. Objectives and Methods: A total of 32 patients underwent open resection of locoregional prostate cancer recurrence in seminal vesicles, as documented on either MRI, ¹¹C-choline, or ⁶⁸Ga-PSMA PET/CT scans. Age, PSA-DT, PSA, and time to recurrence after primary treatment resection status were used in a uni- and multivariate Cox regression analysis for biochemical relapse after surgery. Results: Median patient age at time of salvage surgery was 70 (57–77) years. Median PSA and PSA-DT was 2.79 (0.4–61.54) ng/mL and 5.4 (1.6–20.1) months, respectively. Median surgical time and hospital stay was 132 (75–313) min and 5.5 (4–13) days, respectively. After a mean follow-up of 29 (2–92) months, 3 patients died at 8, 14, and 40 months after salvage surgery, and 6 (18.75%) patients remain without biochemical relapse and further treatment. Median progression-free survival was 12 (1–81) months. In the univariable Cox regression analysis, age at time of surgery, preoperative PSA, and the time from primary treatment to salvage surgery were identified as significant parameters for biochemical relapse. Only the interval from primary to salvage surgery was significant in the multivariate analysis with a hazard ratio of 1.008 (95% CI: 1.001–1.015, p = 0.018). In the entire cohort, 4 adjunctive surgeries (3 ureteroneocystostomies and 1 nephrectomy) were needed due to local progressive disease. Conclusion: Seminal vesicle resection is feasible with no significant intra- or postoperative complications. Almost all patients progressed to biochemical or systemic relapse. Salvage surgery must be seen as a preventive for local symptoms, in our experience most often postrenal ipsilateral obstruction.

Predictors of Red Blood Cell Transfusion in Bimaxillary Orthognathic Surgery: A Retrospective Study.

Background: Orthognathic surgery requires red blood cell (RBC) transfusions more frequently than other oral and maxillofacial surgeries. The purpose of this study was to identify reliable predictors for RBC transfusion during bimaxillary orthognathic surgery (BOS).Methods: This retrospective study reviewed 1,616 electronic medical records of patients who underwent BOS during a 5-year period at Seoul National University Dental Hospital. The perioperative variable data were collected from electronic medical records and analyzed by dividing patients into the two groups (non-transfusion and transfusion group).Results: Of the 1,616 patients, 1,311 patients were excluded. The remaining 305 patients were divided into non-transfusion (NTF, n = 256) and transfusion (TF, n = 49) groups. Univariate logistic regression analysis revealed that age, body mass index, the presence of several adjunctive surgeries (including genioplasty, extraction, and mandibular angle reduction), preoperative hemoglobin (Hb) and prothrombin time, surgical time, amount of fluid infusion and blood loss, and mean pulse rate during surgery were significant factors predicting RBC transfusion. Multivariate logistic regression analysis revealed that preoperative Hb and blood loss amount during surgery were significantly related to RBC transfusion in BOS patients.Conclusion: Since blood loss amounts could not be measured preoperatively, we found that the independent predictor associated with RBC transfusion during BOS was a low preoperative Hb level.

Testing proposed quality measures for treatment of carpal tunnel syndrome: feasibility, magnitude of quality gaps, and reliability

BackgroundThe American Academy of Orthopaedic Surgeons and American Society for Surgery of the Hand recently proposed three quality measures for carpal tunnel syndrome (CTS): Measure 1 - Discouraging routine use of Magnetic resonance imaging (MRI) for diagnosis of CTS; Measure 2 - Discouraging the use of adjunctive surgical procedures during carpal tunnel release (CTR); and Measure 3 - Discouraging the routine use of occupational and/or physical therapy after CTR. The goal of this study were to 1) Assess the feasibility of using the specifications to calculate the measures in real-world healthcare data and identify aspects of the specifications that might be clarified or improved; 2) Determine if the measures identify important variation in treatment quality that justifies expending resources for their further development and implementation; 3) Assess the facility- and surgeon-level reliability of measures.MethodsThe measures were calculated using national data from the Veterans Health Administration (VA) Corporate Data Warehouse for three fiscal years (FY; 2016–18). Facility- and surgeon-level performance and reliability were examined. To expand the testing context, the measures were also tested using data from an academic medical center.ResultsThe denominator of Measure 1 was 132,049 VA patients newly diagnosed with CTS. The denominators of Measures 2 and 3 were 20,813 CTRs received by VA patients. The median facility-level performances on the three measures were 96.5, 100, and 94.7%, respectively. Of 130 VA facilities, none had < 90% performance on Measure 1. Among 111 facilities that performed CTRs, only 1 facility had < 90% performance on Measure 2. In contrast, 21 facilities (18.9%) and 333 surgeons (17.8%) had lower than 90% performance on Measure 3 (Median facility- and surgeon-level reliability for Measure 3 were very high (0.95 and 0.96 respectively).ConclusionsMeasure 3 displayed adequate facility- and surgeon-level variability and reliability to justify its use for quality monitoring and improvement purposes. Measures 1 and 2 lacked quality gaps, suggesting they should not be implemented in VA and need to be tested in other healthcare settings. Opportunities exist to refine the specifications of Measure 3 to ensure that different organizations calculate the measure in the same way.

Feasibility of Quality Measures for the Diagnosis and Treatment of Carpal Tunnel Syndrome

The American Academy of Orthopaedic Surgeons and the American Society for Surgery of the Hand developed candidate quality measures for potential inclusion in the Merit-Based Incentive Program and National Quality Forum in the hope that hand surgeons could report specialty-specific data. The following measures regarding the management of carpal tunnel syndrome (CTS) were developed using a Delphi consensus process: (1) use of magnetic resonance imaging (MRI) for diagnosis of CTS, (2) use of adjunctive surgical procedures during carpal tunnel release (CTR), and (3) use of formal occupational and/or physical therapy after CTR. This study simulated attempts to identify outlier regions in an insurance claims database, which is an important step in establishing feasibility of these measures. Using the Truven Health MarketScan, we identified 643,357 patients who were given a diagnosis of CTS between 2012 and 2014. We reported the percentage of metropolitan statistical areas (MSA) with one or more claims for MRI within 90 days of CTS diagnosis, one or more adjunctive surgical procedures, and one or more formal referrals for physical and/or occupational therapy within 6 weeks of CTR, and we calculated the rate of use for each of these diagnostic or treatment modalities. In addition, we report the precision ratio (signal to noise), SD, and 95% confidence interval. A high percentage of patients given a diagnosis of CTS did not have MRI (99%), and the precision ratio was considered high (0.99). Over 30% of all observed MSAs had at least one claim for MRI as a diagnostic modality in CTS. Most patients (98%) did not have adjunctive surgical procedures. For the observed years, over 28% of MSAs had at least one insurance claim for an adjunctive procedure. A total of 86% of patients did not receive formal occupational or physical therapy after CTR. In addition, 92% of MSAs had at least one claim for therapy. The precision ratio was considered high (approximately 0.85). There is regional variation in the utilization rate of diagnostic MRI for CTS, adjunctive surgical procedures, and formal referral for physical and occupational therapy. For the proposed quality measures, outlier regions can be detected in insurance claims data. Use of MRI in diagnosis, adjunctive surgical procedures, and formal therapy after surgery are feasible quality measures for the Merit-Based Incentive Program and National Quality Forum.

Feasibility and oncologic outcome of salvage surgery in isolated seminal vesical remnants after radical prostatectomy.

137 Background: Improved imaging modalities identify metastatic prostate cancer earlier. Atypical and oligometastatic disease is identified more often. Thus a more individual treatment approach in oligometastatic prostate cancer is getting more popular. We demonstrate our results in recurrent disease in seminal vesical remnants after radical prostatectomy and radiotherapy. Methods: A total of 33 patients underwent open resection of locoregional recurrence in seminal vesicals. In case of suspicious 68Ga-PSMA-PET findings in the small pelvis an additional ipsilateral lymph node dissection was performed in 10 patients. 11 patients already received hormone treatment fulfilling the definition of castration resistant prostate cancer. Age, PSA-DT, PSA, time to recurrence after primary treatment resection status were used in a uni and multivariate-cox regression analysis for biochemical relapse after surgery. Results: Median patient age at time of salvage surgery was 70(57-77) years. Median PSA and PSA-DT was 2.79(0.4-61.54)ng/ml and 5.4(1.6-20.1)months respectively. Median surgical time and hospital stay was 132 (75-313)min and 5.5(4-13)days. Median progression-free survival was 29 (8-47) months. After a mean follow-up of 22 months (3-68) months three patients died 8, 14, and 40 months after salvage surgery. In a univariable cox-regression analyses age at time of surgery, preoperative PSA and the time from primary treatment to salvage surgery have been identified as significant parameters for biochemichal relapse. Only the interval from primary to salvage surgery was significant with a Hazard ratio of 1.008 (95%-CI 1.001-1.015, p=0,018) in multivariate analysis. 4 adjunctive surgeries (Ureterovericoneostomy n=3 and one nephrectomy) were needed due to local progressive disease. Conclusions: Seminal vesicle resection is feasible with no significant intra and postoperative complications even in CRPC. Although there is a good median progression-free survival after 5 years almost all patients had biochemical or systemic relapse. Salvage surgery must be seen as prevention for local symptoms, to our experience most often postrenal ipsilateral obstruction.