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Inadequate Hand Surgical Operating Room (OR) Size Allocation: A Comparative OR Space Utilization Study
randomly for either injection of 0.9 mg of collagenase (group I) or 0.58 mg (group II). The injection technique was the same. Patients were seen after 24 hours for the extension procedures under local anesthesia. There were 37 digits in 27 patients in group I and 34 digits in 29 patients in group II. Age averaged 58 years in group I and 61 years in group II. There were 23 males in group I and 24 in group II. Isolated Metacarpophalangeal (MP) joints were involved in 21 digits in group I and 18 digits in group II. Isolated proximal interphalangeal (PIP) joints were involved in 4 digits in group I compared to 6 in group II. Both MP and PIP joints were involved in 12 digits in group I and 10 digits in group II. Flexion deformities of MP joints averaged 69 degrees in group I compared to 72 degrees in group II while PIP joint flexion deformities averaged 41 degrees in group I compared to 39 degrees in group II. Results: All patients in both groups exhibited bruising and swelling of the involved hand after injection with no significant difference. Correction of flexion deformities of MP joints to 0 degrees-5 degrees was achieved in 26 digits (79%) in group I compared to 17 digits (61%) in group II, which was statistically significant (P ¼ 0.01). Correction of PIP joints to 0 degrees-5 degrees was achieved in 10 digits (63%) in group I compared to 8 digits (50%) in group II (P ¼ 0.02). The mean improvement in MP joints was 40 degrees in group I compared to 28 degrees in group II (P ¼ 0.02). The mean improvement of PIP joints was 27 degrees in group I compared with 17 degrees in group II (P ¼ 0.02). DASH scores were similar in both groups (P ¼ 0.3). In terms of complications, 1 patient in group I had axillary lymphadenopathy that improved in 1 week. Four patients in group I and 1 patient in group II had skin tears that healed within 2 weeks. Summary Points: Increasing the dosage of collagenase injections to 0.9 mg increases the effectiveness of correcting flexion deformities with Dupuytren contractures. There is no increase of risk or complications.
equipment and personnel. Laparoscopic appendectomy and cholecystectomy were selected for general surgery. Cephalomedullary nail (CMN) fixation of intertrochanteric femur fractures and anterior total hip arthroplasties (THA) were selected as large orthopaedic cases. Closed reduction and percutaneous pinning (CRPP) of phalanx fractures and microvascular finger replantation were selected as hand procedures. Space needed for anesthesia staff, circulating OR nurse, and anesthesia equipment were deemed comparable inbetween disciplines and excluded. Percentage differences between total space needed for all cases were calculated. Results: With 101.5 ft2, microvascular finger replantation necessitated the most OR space compared to general surgery and large orthopaedic procedures. Both general surgery cases needed 55.8 ft2. 93.5 ft2 and 95.5 ft2 were respectively needed for CMN fixation of an intertrochanteric femur fracture and anterior THA. CRPP of phalanx fractures required 73.3 ft2. There was a 58.1% difference between space needed for microvascular finger replantation versus laparoscopic appendectomy/cholecystectomy. Compared to CMN or anterior THA, finger replantation respectively needed 8.2% and 6.1% more space (rounded percentages). While CRPP of phalanx fractures did not require more OR space than both large orthopaedic cases, it utilized more space than the general surgery cases with a percentage difference of 27.1%. Summary Points: There exists no data on OR space requirements for hand surgical cases. The preconceived notion of matching OR room size to operated body part is common practice, even in large microvascular tertiary referral centers. In this study, CRPP of phalanx fractures required more OR space than typical general surgery cases. Space needed for complex microvascular finger replantations far exceeded that needed for typical general surgery cases, even surpassing the space utilization of large orthopaedic procedures. The misconception of scheduling small body part surgery into small operating rooms may lead to OR crowding of resource intensive hand procedures, possible sterile field breach and decreased operative workflow efficiency.
REFERENCES 1. Badalamente MA, Hurst LC, Benhaim P, Cohen BM. Efficacy and safety of collagenase clostridium histolyticum in the treatment of proximal interphalangeal joints in dupuytren contracture: combined analysis of 4 phase 3 clinical trials. J Hand Surg Am. 2015;40(5):975e983. 2. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361(10):968e979.
PAPER 12 Clinical Paper Session 2: Education/Practice Management Friday, September 30, 2016 8:59e9:04 AM Medical/Legal
Inadequate Hand Surgical Operating Room (OR) Size Allocation: A Comparative OR Space Utilization Study N/A - Not a clinical study
Jue Cao, MD Seth Tebockhorst, MD Krister Freese, MD Michael Pensak, MD Stephanie D. Malliaris, MD Kyros Ipaktchi, MD COI: There is no financial information to disclose. Hypothesis: Inadequate operative room (OR) size assignment for hand surgical cases is common. We hypothesize that hand surgery cases require more square footage than assigned by schedulers. Methods: Two typical cases were chosen for general surgery, orthopaedic surgery and hand surgery. Required equipment was photodocumented and measured during routine OR setup. Total OR space needed, in square feet (ft2), for each case was calculated by adding measured area occupied by S8
PAPER 13 Clinical Paper Session 2: Education/Practice Management Friday, September 30, 2016 9:06e9:11 AM Treatment; Billing/Coding
Variation in Physician Charges and Medicare Payments for Hand Surgery Level 3 Evidence
Mariano E. Menendez, MD Raymond C. Parrish II, BS David C. Ring, MD, PhD Neal C. Chen, MD COI: Royalty: Wright Medical, Skeletal Dynamics, Biomet, Medartis (Ring) Receipt of Intellectual Property Rights/Patent Holder: Wright Medical, Skeletal Dynamics, Biomet, Medartis (Ring) Consulting Fee: Acumed, Biomet (Ring)
equipment and personnel. Laparoscopic appendectomy and cholecystectomy were selected for general surgery. Cephalomedullary nail (CMN) fixation of intertrochanteric femur fractures and anterior total hip arthroplasties (THA) were selected as large orthopaedic cases. Closed reduction and percutaneous pinning (CRPP) of phalanx fractures and microvascular finger replantation were selected as hand procedures. Space needed for anesthesia staff, circulating OR nurse, and anesthesia equipment were deemed comparable inbetween disciplines and excluded. Percentage differences between total space needed for all cases were calculated. Results: With 101.5 ft2, microvascular finger replantation necessitated the most OR space compared to general surgery and large orthopaedic procedures. Both general surgery cases needed 55.8 ft2. 93.5 ft2 and 95.5 ft2 were respectively needed for CMN fixation of an intertrochanteric femur fracture and anterior THA. CRPP of phalanx fractures required 73.3 ft2. There was a 58.1% difference between space needed for microvascular finger replantation versus laparoscopic appendectomy/cholecystectomy. Compared to CMN or anterior THA, finger replantation respectively needed 8.2% and 6.1% more space (rounded percentages). While CRPP of phalanx fractures did not require more OR space than both large orthopaedic cases, it utilized more space than the general surgery cases with a percentage difference of 27.1%. Summary Points: There exists no data on OR space requirements for hand surgical cases. The preconceived notion of matching OR room size to operated body part is common practice, even in large microvascular tertiary referral centers. In this study, CRPP of phalanx fractures required more OR space than typical general surgery cases. Space needed for complex microvascular finger replantations far exceeded that needed for typical general surgery cases, even surpassing the space utilization of large orthopaedic procedures. The misconception of scheduling small body part surgery into small operating rooms may lead to OR crowding of resource intensive hand procedures, possible sterile field breach and decreased operative workflow efficiency.
REFERENCES 1. Badalamente MA, Hurst LC, Benhaim P, Cohen BM. Efficacy and safety of collagenase clostridium histolyticum in the treatment of proximal interphalangeal joints in dupuytren contracture: combined analysis of 4 phase 3 clinical trials. J Hand Surg Am. 2015;40(5):975e983. 2. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, et al. Injectable collagenase clostridium histolyticum for Dupuytren’s contracture. N Engl J Med. 2009;361(10):968e979.
PAPER 12 Clinical Paper Session 2: Education/Practice Management Friday, September 30, 2016 8:59e9:04 AM Medical/Legal
Inadequate Hand Surgical Operating Room (OR) Size Allocation: A Comparative OR Space Utilization Study N/A - Not a clinical study
Jue Cao, MD Seth Tebockhorst, MD Krister Freese, MD Michael Pensak, MD Stephanie D. Malliaris, MD Kyros Ipaktchi, MD COI: There is no financial information to disclose. Hypothesis: Inadequate operative room (OR) size assignment for hand surgical cases is common. We hypothesize that hand surgery cases require more square footage than assigned by schedulers. Methods: Two typical cases were chosen for general surgery, orthopaedic surgery and hand surgery. Required equipment was photodocumented and measured during routine OR setup. Total OR space needed, in square feet (ft2), for each case was calculated by adding measured area occupied by S8
PAPER 13 Clinical Paper Session 2: Education/Practice Management Friday, September 30, 2016 9:06e9:11 AM Treatment; Billing/Coding
Variation in Physician Charges and Medicare Payments for Hand Surgery Level 3 Evidence
Mariano E. Menendez, MD Raymond C. Parrish II, BS David C. Ring, MD, PhD Neal C. Chen, MD COI: Royalty: Wright Medical, Skeletal Dynamics, Biomet, Medartis (Ring) Receipt of Intellectual Property Rights/Patent Holder: Wright Medical, Skeletal Dynamics, Biomet, Medartis (Ring) Consulting Fee: Acumed, Biomet (Ring)