endoscopic cubital tunnel release · cubital tunnel syndrome: studies - results setting...
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Endoscopic
Cubital Tunnel
Release
Cobb TK, Walden AL, Lemke JH, Merrell PT. Setting
expectations following endoscopic cubital tunnel
release. HAND. April 2014. DOI 10.1007/s11552-014-9629-7
2
Cubital Tunnel Syndrome:
Minimally Invasive Treatment
Endoscopic cubital tunnel release
Old Anterior Nerve Transposition
Endoscopic Cubital Tunnel Surgery
Setting Expectations following
Endoscopic Cubital Tunnel
Release
Cobb TK, Walden AL, Lemke JH, Merrell PT. Setting
expectations following endoscopic cubital tunnel
release. HAND. April 2014. DOI 10.1007/s11552-014-9629-7
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 2014.
6
Cubital Tunnel: Return to Work
27
17
70
0
20
40
60
80
Modifed Work Regular Work
Nu
mb
er
of
Days
ECTR
Open
7
Cubital Tunnel Syndrome:
Studies - Clinical Significance
Time off work
Endoscopic benefit
Cubital tunnel surgeries per year = 73,673
Return to work 63 days sooner with endoscopic procedure
Cost savings
Daily cost of disability = $94
$94 (per day) x 63 days (RTW) = $5,922 per patient
x 73,673 cases = over $436 million per year
Davis et. al Issue Brief Common Fund 2005; CDC Sept.
18, 2013; Macario A J Clini Anesth 2010
Operative costs
Difference in tourniquet time (49 min)
Endoscopic 10 min vs open 59 min
Cost of OR time
$29 per minute
Cost savings
49 min x $29/min = $1,421 per pt
x 73,673 cases = $72,199,540 per year
Anesthesia costs
Billed Base Rate of $65 per 15 min block
Approx 45 min less time (3 blocks)
$65/block x 3 = $195 per pt
x 73,673 cases = $14,366,235 per year
Total Estimated
Annual Savings for
U.S.
= $520 million
Prospective Multicenter Evaluation of
Endoscopic Cubital Tunnel Release
Tyson Cobb, Blain Samuelson, Jon Lemke, Anna Cobb, Steven
Topper
Methods
230 cases (Females=107, Males=123)
211 patients
4 Private Orthopaedic Practices
Miami, FL
Davenport, IA
Denver, CO
Owings Mills, MD
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 230 123 (53) 107 (47)
0
50
100
150
1 2 3 4
Pa
tie
nts
(n
) Number of Patients by Rank Working rank Count (%)
1-mild 131 (58)
2-moderate 13 (6)
3-heavy 22 (10)
4-unemployed 61 (27)
0
20
40
60
80
100
120
140
IA MD CO FL
Pa
tie
nts
(n
)
Number of Patients by Site
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 125 70 19 16 230
*Parentheses show percentage of Dellon’s classification by each site
Amount of Time for Surgery
(minutes)
Site Mean Std. Dev. Median Min Max
IA 7 3.4 7 2 18
MD 16 5.5 15 7 30
CO 21 4.9 20 15 30
FL 18 3.0 18 12 24
Pre Op vs. Intra Op
Subluxation Measure:
False Negative: 7 of 204 = 3%
95% CI: (1.4-6.9)
False Positive: 12 of 15 = 80%
95% CI: (51.9-95.7)
Specificity: 197 of 209 = 94%
95% CI: (90.2-97.0)
Sensitivity: 3 of 10 = 30%
95% CI: (6.7-65.2)
Intra Op Subluxation (truth)
Clinical
Observation
-Pre Op
No Yes Total
No 197 7 204
Yes 12 3 15
Total 209 10 219
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
First Follow Up Dates
Site N Mean Median Min Max
IA 106 19 8 3 538
MD 70 19 11 2 159
CO 18 47 15 9 187
FL 16 24 7 0 180
Can’t determine rate of resolution until you have at least your first follow
up. These significantly increase your days to resolution data
Resolution of Symptoms
Numbness and Tingling
Site
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
Numbness and Tingling
Dellon’s Class
Positive Pre-Op
Test
Resolution Time to
Resolution
N (%) N (%) Median Days
1 34 (16) 30 (88) 15
2 86 (40) 63 (73) 36
3 89 (42) 62 (70) 159
No Score 4 (2) 4 (100) -
Total 213 (93) 159 (75) 90
Numbness and Tingling
Operated Hand
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
Resolution of Symptoms
Pain
Site
Positive Pre-Op
Test 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
Satisfaction by Dellon’s Class
Dellon's Class
Satisfaction – n (%)
Very
Dissatisfied
1
2 3 4
Very
Satisfied
5
1 - 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)
Pre-Op Dellon’s Class vs. Post-Op
Bishop’s
Pre Dellon's Class
Post Bishop's Ranking
Poor
0 to 2
Fair
3 to 4
Good
5 to 7
Excellent
8 to 9 Total
1 - mild 0 0 7 (21) 27 (79) 34
2 - moderate 0 1 (1) 19 (27) 51 (72) 71
3 - severe 3 (4) 6 (7) 21 (25) 55 (65) 85
Total 3 (2) 7 (4) 47 (25) 133 (70) 190
Days to Return to Work Normal By Site
Work Comp on RTW
Work
Comp N Mean Median
Std.
Dev. IQR
No 171 12 7 20 12
Yes 28 35 8 59 40
P value: 0.050
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
Thank you!
Questions?