Surprising # of Median Nerve Harvest Mistakes; Outpatient vs Inpatient THA; Warfarin NO Barrier to Fast Fracture Repair?
Elizabeth Hofheinz, M.P.H., M.Ed. • Wed, August 16th, 2017
Surprising # of Median Nerve Harvest Mistakes
New research into mis-harvesting of the median nerve uncovers a surprisingly high frequency.
The study, “Inadvertent Harvest of the Median Nerve Instead of the Palmaris Longus Tendon,” appeared in the July 19, 2017 edition of The Journal of Bone & Joint Surgery.
Co-author author Bruce Leslie, M.D., an orthopedic surgeon with Newton-Wellesley Hospital in Newton, Massachusetts, told OTW, “I was asked to review a patient chart documenting the inadvertent harvest of the median nerve. As a hand surgeon who felt comfortable around tendons and nerves I had a hard time understanding how a surgeon could confuse the two structures. I figured if anyone had seen an inadvertent harvest it would be a member of the American Society for Surgery of the Hand (ASSH).”
“I inquired of the ListServe if anyone had heard of, treated or seen a patient who had an inadvertent harvest of the median nerve. To my surprise, a number of ASSH members had. I contacted the members who had seen, treated or heard of an inadvertent harvest of the median nerve. Those contacts led to other cases. The result of my original inquiry was the recently published paper.”
“Other studies rely on a survey to obtain data. The data for this study was obtained by actually contacting physicians who were involved and/or cared for the patient. This allowed for follow-up questions and more detailed data.”
The authors wrote, “The most common initial procedure was a reconstruction of the elbow ulnar collateral ligament, followed by basal joint arthroplasty, tendon reconstruction, and reconstruction of the ulnar collateral ligament of the thumb metacarpophalangeal joint. Only 7 of the inadvertent harvests were recognized intraoperatively; in the remaining 12 cases the nerve was used as a tendon graft. The sensory loss was not recognized as being due to the inadvertent harvest until the first postoperative visit (2 subjects), 3 to 4 weeks (2 subjects), 2 to 3 months (2 subjects), 5 to 7 months (2 subjects), 1 year (1 subject), 3 years (1 subject), or 10 years (1 subject). Preoperative clinical identification of the presence or absence of a palmaris longus did not necessarily prevent an inadvertent harvest.”
Dr. Leslie commented to OTW, “The most important results were actually who experienced and who did not experience inadvertent harvests. None of the cases we reported were performed by a surgeon who completed an upper extremity fellowship. This underscores that an inadvertent harvest can be avoided with education and proper training. In our series, inadvertent harvests were more frequently experienced by sports medicine physicians with the most the most common index procedure being a UCL [ulnar collateral ligament] reconstruction of the elbow.”
“It was surprising that in 12 cases the surgeon actually used the median nerve as a graft and passed through drill holes, rolled up and used as a spacer or interposed as a tendon graft. Surgeons are human…errors occur. When they occur we would like to think that we recognize and correct them. The truth is we do not always recognize our errors.”
“Whether such errors are due to Dunning-Kruger [tendency to overestimate competence], perceptional blindness, or simply a reluctance to acknowledge our mistake, cannot be determined from this paper.”
“The inadvertent harvest of the median nerve is an avoidable complication. The relationship between the PL [palmaris longus] and the median nerve is described in detail in the article. The MR photograph shows the relationship between the two structures. Better supervision of residents and fellows will also help.”
Outpatient vs Inpatient THA Outcomes
If done right, says new data from Rothman, total hip arthroplasty (THA) patients should be able to experience safe and effective surgery in either an orthopedic specialty hospital or a general hospital.
The research, “Comparison of Short-Term Outcomes After Total Hip Arthroplasty Between an Orthopedic Specialty Hospital and General Hospital,” appears in the August 2017 edition of The Journal of Arthroplasty.
William J. Hozack, M.D., an orthopedic surgeon at Rothman Institute in Philadelphia and co-author commented to OTW, “We are always involved in matters of quality of healthcare delivery as related to THA [total hip arthroplasty]. As we operate at both an OSH [orthopedic specialty hospital] and a GH [general hospital] and we felt that our outcomes were equivalent (for the most part), we felt it important to evaluate the validity of our general impressions (comparing length of stay, 90 day readmissions, mortality, reoperations).”
“This particular study is unique in that patients were matched for a variety of co-morbidities in order to eliminate the negative bias of operating on ‘healthier’ patients at OSH as opposed to GH. We further refined the analysis to remove patients who ultimately go to a rehabilitation hospital postoperatively—focusing primarily on patients who are discharged HOME from either institution. This eliminates further negative bias against the GH—patients who go to rehabs are generally ones who will automatically spend a longer period of time in the hospital prior to discharge.”
“Perioperative outcomes (length of stay, 90 day readmissions, mortality, reoperations) were the SAME in both OSH and GH, implying equal safety and efficacy. GH have a higher rehab discharge rate which is likely multifactorial in nature. Of importance, the LOS [length of stay] in BOTH the GH and the OSH was substantially lower than the national average.”
“In medically optimized patients, primary THA can be performed safely at either an OSH or a GH with low perioperative mortality, readmission and reoperation rates. LOS can be effectively reduced in both OSH and GH with the implementation of accelerated rehabilitation protocols and proper patient selection.”
“Increased costs are related to admission to a rehabilitation hospital postoperatively and also to unexpected complications. Patient selection, standardized protocols and a home discharge program decrease LOS and cost with no decrement in quality of care. A GH can be utilized with equal success as an OSH if the above are implemented.”
Warfarin NO Barrier to Fast Fracture Repair?
“What are the risks and benefits of delaying surgery in hip fracture patients on warfarin?” asked a recent study entitled, “The Hip Fracture Patient on Warfarin: Evaluating Blood Loss and Time to Surgery.” The work, which appears in the August 2017 edition of the Journal of Orthopaedic Trauma, was co-authored by Ashley Levack, M.D., an orthopedic surgery resident at Hospital for Special Surgery (HSS) in New York.
Dr. Levack told OTW, “Over the past several years an increasing body of literature has highlighted the importance of timely surgery for hip fracture patients. At our institution we treat over 300 hip fractures per year, and are seeing an increasing number of patients with hip fractures come into the hospital on chronic anticoagulation.”
“We noticed that the perioperative management and timing of surgery in patients admitted with an elevated INR [international normalized ratio] due to warfarin therapy varies depending on the medical team, anesthesiologist and surgeon. With an ultimate goal of optimizing time to surgery and patient outcomes in this population, we sought to better characterize the practices surrounding management of hip fracture patients on warfarin and their outcomes at our institution.”
“This was a case-control study of low energy, acute, non-pathologic hip fracture patients over 55 years of age. Non-anticoagulated patients were matched to patients admitted on warfarin with other matching parameters to ensure similar demographics. In advance of this study, we instituted a ‘Fragile Bone Registry’ at our institution in which demographics, fracture and operative characteristics and patient outcomes are recorded prospectively. This registry will be used to further define areas for improvement in the management of these patients and develop institutional protocols in the future.”
“The study revealed that 6% of hip fractures that were admitted to our institution were on long term warfarin therapy at the time of injury. Patients admitted on warfarin had no higher risk of transfusion or adverse events compared to non-anticoagulated controls. Awaiting normalization of INR was associated with a significantly longer time from presentation to surgery without reducing transfusions, calculated blood loss, or preventing complications.”
“There is currently no recommendation for how far the INR must normalize before proceeding with surgery in this population. Although anesthesiologists may require a lower INR if considering regional anesthesia, the risks and benefits of delaying surgery to await normalization versus proceeding with urgent surgery in the setting of an elevated INR is an important clinical consideration. This study provides initial evidence that hip fracture surgery may be safe with higher than normal INRs. Additional research is underway to further define an optimal threshold.”
“In light of growing evidence supporting the importance of reducing delay to the operating room for hip fracture patients and more and more patients being prescribed chronic anticoagulation, it is important to consider the implication that these medications have on timing of surgery and how to safely optimize time to surgery in these patients. Newer, non–reversible, oral anticoagulants will require careful study before recommendations can be provided.”