Along with the research in orthobiologics, is this one of the directions the future of sports medicine will be moving?
Any thoughts on interventional ortho procedures such as micro invasive carpal tunnel release with the sonex microknife?
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Who knows - but I hope so! Who would have thought that invasive cardiology would be doing so many procedures infringing on the turf of CT surgery, but here they are replacing valves. It is not unreasonable to think that over the next 10-20 years, minimally invasive sports medicine procedures and technology will progress in a similar manner.
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And what happens when you bag the ulnar nerve or artery or there is an aberrant median nerve variant? We’re talking micro invasive outpatient carpal tunnel procedure, are you gonna pack it up and send it to the ED?
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All of the above should be appropriately identified on transverse ultrasound. Colorflow for the arteries and starry night appearance of the nerves.
With that said, I have no interest in the procedure because:
1. The current standard of care/procedure is generally very effective/fast/safe a
2. It would likely irritate the orthopaedists that I receive referrals from for cases/patient types that I have a much greater passion/interest in
3. Volume - I dont think I would do it often enough to feel good about it, compared to someone who does 10/week
4. Merit - may sound lame, but the orthos and surgeons in general worked tirelessly for a long time and Id prefer to leave them to their procedures . I dont think I really got it until I spent “free time” with the trauma service to get more fracture experience during fellowship.
A better use of ultrasound believe it or not, in my opinion, is helping general surgeons with subtle hernias or deal with post operative scar entrapment on inguinal region nerves, as thats a group of people that the surgeons cant help as easily.
With that said, I have no interest in the procedure because:
1. The current standard of care/procedure is generally very effective/fast/safe a
2. It would likely irritate the orthopaedists that I receive referrals from for cases/patient types that I have a much greater passion/interest in
3. Volume - I dont think I would do it often enough to feel good about it, compared to someone who does 10/week
4. Merit - may sound lame, but the orthos and surgeons in general worked tirelessly for a long time and Id prefer to leave them to their procedures . I dont think I really got it until I spent “free time” with the trauma service to get more fracture experience during fellowship.
A better use of ultrasound believe it or not, in my opinion, is helping general surgeons with subtle hernias or deal with post operative scar entrapment on inguinal region nerves, as thats a group of people that the surgeons cant help as easily.
Sorry but what're you talking about. As the above poster mentioned it’s under direct US visualization and the device has safety features in place to protect the surrounding anatomy. Some of the studies I’ve read actually show that it has decreased healing time and a faster return to functionality with compared to endoscopic procedures performed in the OR. Obviously it’s in the infant stages and the research is limited, but your argument is basically don’t do any outpatient procedure because...complications. I appreciate the input, although a bit negative, but either way have a great night.
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I am considering it. It was displayed at the recent advanced team physician course in las vegas. Being developed at Mayo. Dr. F talked about progression of our field. Argument included cards, intervention rads vs. ctvs and neurosurg. There has not been a bad outcome of any cases to date. Dr. F made a great point stating with any cutting or procedure you need to expect a bad outcome at some point. I will await more research as we really need to know outcomes including bad ones to inform patients who make the ultimate decision. Given what I have seen thus far I would want this done on myself rather than current practice not just for recovery time/ no anesthesia but cost. I guess the biggest question is would I rather a non-op sports like myself doing the procedure or an ortho hand?
slippery_when_wet
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where would you guys get the patient referral?
any minimally educated person, I imagine, would prefer hand/wrist ortho guys to do the procedure.
not trying to start any wars, just honestly wondering where the patients would come from.
any minimally educated person, I imagine, would prefer hand/wrist ortho guys to do the procedure.
not trying to start any wars, just honestly wondering where the patients would come from.
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As the procedure gained traction, the referrals would follow (I would think.) Particularly those who do SM as a member of an Ortho practice may find some of these patients in their clinic. Carpal tunnel release is done by any community Ortho, it doesn’t require a sub-specialized hand surgeon. My experience with those trained in hand is that they are interested in finger replants, nerve/tendon repair, and probably fracture care, not a run-of-the-mill carpal tunnel release that requires 3 minutes of tourniquet time.
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Do these reimburse well?
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Not sure on reimbursement.
I hear you on progression of our field and I think that as we continue to push the border on what can be performed and diagnosed with ultrasound, there is no reason why we couldn't add it.
In my personal situation I just had other fish to fry.
The anatomy is certainly so clear with ultrasound I don't see why it should be a problem.
I hear you on progression of our field and I think that as we continue to push the border on what can be performed and diagnosed with ultrasound, there is no reason why we couldn't add it.
In my personal situation I just had other fish to fry.
The anatomy is certainly so clear with ultrasound I don't see why it should be a problem.
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In my practice I have at least 20 patients that are not surgical candidates for one reason or another. My injections are more accurate due to ultrasound and get a better response. This is known in my community and patients are sent my way. This is where I would start. It would not be a money grab for me (I am busy enough); although carp tun release is about 5 wrvu and this procedure it took less than 6 minutes if I remember correctly. As to: anyone would prefer hand/wrist/ortho; perhaps, they will need to catch up on my ultrasound skills although I agree the anatomy is rather easy.
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Are you implying that there will be no complications or risks? My question is what will you do if there is a complication, that’s all.
Btw, there are written reports of ulnar nerve laceration/Palmer arch laceration with open carpal tunnels. It’s rare, but it happens every now and then. And that is with open approach where you can see everything.
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I would have an ortho surg backup agreement most likely before doing the procedure depending on the studies. Do you not inject joints because of infection risk? What would you do if there was an infection? The risk is very low and is acceptable to me in regards to joint injection. We will need to see with other procedures. I would argue that if the ulnar nerve was lacc with open approach it was not seen. I can see everything under ultrasound and if I could not identify all the anatomy I would not consider doing the procedure.
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Any procedure involves risks, and then of course there are the risks of not offering the procedure, which are equally real as well.
The big risk with this procedure would be a compressive lesion of the median nerve as the small "balloons" inflate and/or damage to the nerve with the retraction of the "hook" of the Sonex knife.
I think that your (Dark Horizon) discomfort with the idea of us performing this procedure is not having a reference point for what we see with ultrasound and the nature of the retraction process itself with the device. Please consider watching a video of how it works if you have not done so.
As for what we would do with complications:
- neuro: if I have post procedural paresthesia/numbness, I would hold them for observation. My first assumption would be numbness from the topical lidocaine and I would keep them at the hospital (where I would do the procedure, I base this upon the fact that I do my prp injections the hospital as opposed to my office - blood banking licensing silliness). I would then based upon length of time, decide if they could be given instructions on when to return to hospital if I let them go home, or send them to our ED. After chatting about procedure with the ED physician, I would hang around and see how it played out from there (consults/dispo) until satisfied with end point.
As for vascular, I would use color flow to see what the status of the arteries are pre/post procedure and ensure that that is on point, and if there was a concern for a nick of a vessel, then I would apply firm compression, and consult whomever is covering hand and transfer ED, or reverse order, since it would be the EP's show.
Again I say this as someone not interested in the procedure because of my deference to ortho and my overall appreciation for orthopaedic trauma docs in particular for what I learned during fellowship. With that said, I am not happy with the local option for upper extremity work in my new practice area and am inclined to add the procedure for that reason. If the ortho in my area were like the ones I trained with I would not have this as an issue.
To put it in perspective, can you imagine doing a rotator cuff repair if a PCSM doc sends you a note with labeled ultrasound pictures and description of the rotator cuff tendon tears and also proof (through color flow) that there is biceps long head tendonosis AND subluxation of the biceps long head tendon into a subscapularis tear, captured as a video and uploaded to your radiology EMR? That was standard by the end of my fellowship. The point being is that that is a far cry from you as the surgeon having to order/look at an MRI to make that call. The point being is that what we can do and the relationship with our colleagues is on a spectrum, like anything else and is very individual dependent.
I think that this is neat conversation and I enjoy it. I'll see where this settles out. On the flip side, if my ortho colleagues ask me not to do it, I would probably listen because I depend upon them for referrals for other matters/cases that are of greater interest to me. I am curious about what was posted above about the outcomes with the procedure vs standard of care (open). This is one of the things I will think about when I go to our annual conference and then if I did want to move on it, would have to start the whole process with the hospital.
The big risk with this procedure would be a compressive lesion of the median nerve as the small "balloons" inflate and/or damage to the nerve with the retraction of the "hook" of the Sonex knife.
I think that your (Dark Horizon) discomfort with the idea of us performing this procedure is not having a reference point for what we see with ultrasound and the nature of the retraction process itself with the device. Please consider watching a video of how it works if you have not done so.
As for what we would do with complications:
- neuro: if I have post procedural paresthesia/numbness, I would hold them for observation. My first assumption would be numbness from the topical lidocaine and I would keep them at the hospital (where I would do the procedure, I base this upon the fact that I do my prp injections the hospital as opposed to my office - blood banking licensing silliness). I would then based upon length of time, decide if they could be given instructions on when to return to hospital if I let them go home, or send them to our ED. After chatting about procedure with the ED physician, I would hang around and see how it played out from there (consults/dispo) until satisfied with end point.
As for vascular, I would use color flow to see what the status of the arteries are pre/post procedure and ensure that that is on point, and if there was a concern for a nick of a vessel, then I would apply firm compression, and consult whomever is covering hand and transfer ED, or reverse order, since it would be the EP's show.
Again I say this as someone not interested in the procedure because of my deference to ortho and my overall appreciation for orthopaedic trauma docs in particular for what I learned during fellowship. With that said, I am not happy with the local option for upper extremity work in my new practice area and am inclined to add the procedure for that reason. If the ortho in my area were like the ones I trained with I would not have this as an issue.
To put it in perspective, can you imagine doing a rotator cuff repair if a PCSM doc sends you a note with labeled ultrasound pictures and description of the rotator cuff tendon tears and also proof (through color flow) that there is biceps long head tendonosis AND subluxation of the biceps long head tendon into a subscapularis tear, captured as a video and uploaded to your radiology EMR? That was standard by the end of my fellowship. The point being is that that is a far cry from you as the surgeon having to order/look at an MRI to make that call. The point being is that what we can do and the relationship with our colleagues is on a spectrum, like anything else and is very individual dependent.
I think that this is neat conversation and I enjoy it. I'll see where this settles out. On the flip side, if my ortho colleagues ask me not to do it, I would probably listen because I depend upon them for referrals for other matters/cases that are of greater interest to me. I am curious about what was posted above about the outcomes with the procedure vs standard of care (open). This is one of the things I will think about when I go to our annual conference and then if I did want to move on it, would have to start the whole process with the hospital.
