The Case

A woman presented for surgery on her right wrist as a treatment for carpal tunnel syndrome. There were no reported complications during the operation, and the patient was discharged from the hospital the same day. Before discharge, the surgeon instructed her to return in 10 days for suture removal. The surgeon also told the patient not to soak her hand in water, which would reduce the risk of infection. A nurse provided written discharge instructions that stated, “Keep hand clean and dry until sutures removed; no soaking hand in water.” Within three or four days, the patient reported that her wrist felt “warm” to the touch, and the incision area was red. The patient contacted the surgeon’s office and spoke to the medical assistant (MA), but no action was taken. The patient called the surgeon’s office multiple times, asking for more or different pain medications, which were refused. The MA did not document each call but reportedly discussed each call with the surgeon. The MA stated that the patient never reported that the wound was red, hot, foul-smelling, swollen, or anything else suggesting an infection. Approximately 7 to 10 days after the operation, the patient returned for suture removal. The surgeon’s MA removed the patient’s sutures and noted that the wound was not infected or swollen. The surgeon’s physician assistant (PA) also examined the patient and did not find any remaining sutures, nor did she see any infection or redness. One day later, the patient called and asked to see the surgeon, but she was denied because the MA said her wrist was “fine.” The patient continued to report pain, swelling, and redness, noted that her wrist began to ooze at the incision, and reported an odd smell. She called several times, but no follow-up visit was scheduled. The MA claimed that the patient never mentioned redness or pain after the sutures were removed, and if she had reported such symptoms, the MA would have immediately brought the patient in and told the surgeon.

Two weeks after surgery, the patient went to an emergency department (ED) seeking treatment for worsening wrist pain. ED physicians diagnosed an infection, prescribed antibiotics, and told the patient to schedule an appointment with her surgeon. Three days after the ED visit, the patient spoke to the surgeon’s office and made a follow-up appointment for the next day. At that appointment, the surgeon recommended immediate surgery to treat the infection. The patient remained in the hospital for 11 days, during which she underwent two additional operations. She eventually recovered but lost significant use of her right hand.

The Commentary 

By Robert M. Szabo, MD, MPH, FAOA

Background 

Carpal tunnel syndrome is a constellation of signs and symptoms including nocturnal paresthesia and pain, numbness and hand weakness that results from compression of the median nerve within the carpal tunnel.¹ It is the most common compression neuropathy treated by hand, orthopedic, plastic and general surgeons with an incidence of 1 to 3 cases per 1,000 persons per year in the United States and a prevalence of 50 per 1000 persons.² Treatment for carpal tunnel syndrome often begins with nonsurgical management, including night splints, activity modifications, and one or more corticosteroid injections (CSIs). When these interventions are unsuccessful, surgical carpal tunnel release offers significant improvement in measurable clinical outcomes, with most patients being satisfied after surgery.³ Once performed predominantly as an inpatient procedure, 99% of carpal tunnel operations were performed in an ambulatory setting by 2006, so patients go home shortly after surgery with follow-up appointments at 7-10 days for suture removal.² With the increasing use of absorbable sutures and the push for healthcare systems to increase value and decrease cost, this surgery may become completely office-based with no postoperative visits at all.^4,5 There are several methods for performing carpal tunnel surgery including open and endoscopic techniques using general, regional block or local anesthesia. Open carpal tunnel release is the most common technique with at least 18 variations of palmar incisions described.⁶ While the rate of surgical site infection (SSI) after carpal tunnel release is relatively low, there is substantial variation reported in the literature from 0.28% to 6.4%⁷ There is no consistent evidence of increased risk of infection related to the surgical or anesthetic technique,^8,9 where the surgery is performed,^10–12 or whether or not patients receive perioperative antibiotics.^13,14 Much of the variability in reported SSI rates across studies may be due to different definitions of infection.⁷ The largest national study of 855,832 carpal tunnel decompression operations provided evidence that the rate of serious complications (requiring admission to hospital or reoperation) is less than 0.1%.¹⁵ Superficial infections should be distinguished from deep infections, as the former can usually be treated with suture removal and oral antibiotics whereas deep infections require operative incision and drainage with or without debridement, combined with intravenous antibiotics.¹⁶ The rate of superficial infections is likely underreported because of rapid resolution.

The proximity of corticosteroid injection to the time of surgery may play a role in a patient’s risk of postoperative infection. This increased risk of SSIs is most apparent if the CSI is performed within 3 months of surgery, with less risk of infection if the injection occurred earlier.^17,18 The corticosteroid dose, frequency of injection, and steroid injections into other sites in the same hand (as for trigger fingers) are suspected risk factors that require further study.

Perioperative sterile practices have also been studied as risk factors for postoperative SSIs. More than 70% of Canadian carpal tunnel releases are performed in minor procedure rooms with only field sterility. In a prospective randomized controlled study involving 1,504 consecutive carpal tunnel release operations by 6 surgeons from 5 Canadian training centers, a superficial infection rate of 0.4% and a deep infection rate of 0% were reported, confirming the low incidence of postoperative wound infection using only field sterility.¹⁹ The routine use of antiseptic agents for surgical scrubbing of both the surgeons’ hands and the patient’s surgical hand site have also been studied. There is no evidence that one type of hand antisepsis is better than another in reducing surgical site infections. Chlorhexidine gluconate scrubs reduce the number of colony-forming units on skin, compared with povidone iodine scrubs, but the clinical relevance of this difference is unclear.^20,21

Other studies have examined personal risk factors for adverse outcomes after carpal tunnel release surgeries. Diabetes, chronic kidney disease, and smoking have been found to be associated with higher rates of complications after surgery for carpal tunnel syndrome.²² In the largest study of 454,987 Medicare patients who developed 1,466 postoperative infections following open carpal tunnel release (0.32%), independent risk factors were male sex, younger age, tobacco or alcohol use, obesity or morbid obesity (body mass index 30-40 or >40), diabetes, inflammatory arthritis, peripheral vascular disease, chronic liver disease, chronic lung disease, chronic kidney disease, and depression.^23,24 The severity of diabetes as measured by glycated hemoglobin (hemoglobin A1c) has some predictive value for postoperative complications, but the practical threshold for elevated risk may fall anywhere from 7% to 9%.²³ Most surgeons, however, strive to meet the American Diabetes Association guideline target of 7% preoperatively but may proceed with elective surgery at higher levels provided the treatment benefit is determined to exceed the risk of waiting.^25,26

Patients often try to contact their surgeon after surgery either for pain or surgical site problems or for guidance with postoperative directions. These patients are more likely to have depression or anxiety,^25,27 or to have not been given a prescription for opioid use after surgery, based on recent changes in practices due to the opioid epidemic.²⁸ Early postoperative pain scores have demonstrated a statistically significant improvement for patients taking nonopioid medications, now a routine practice, and even when patients are given opioids, the average use in the postoperative period is 3-4 pills surgery with 47% of men and 36% of women consuming no opioids.²⁹ Opioid dependent patients are more likely to need to continue using opioids after surgery. The time spent to read, document, and respond to patient phone calls and messages can be taxing for office staff and hand surgeons as these services are not typically reimbursed within the 90-day global perioperative billing period. The Association of American Medical Colleges reported that the United States will face a workforce shortage of between 13,500 and 86,000 physicians by 2036 and that health systems are responding by expanding the role of nonphysician health care providers.³⁰ In addition, in the outpatient setting, medical assistants (MAs) are being given expanding roles in supporting care teams.^31–33 The person answering the patient’s phone call to an outpatient clinic or office likely will be a nurse practitioner, a registered nurse (RN), a licensed practical nurse (LVN), or MA, depending on the surgeon’s office practice. The conversation with the patient should be probative, carefully documented and communicated to the surgeon or another team member who can evaluate the problem and is skilled and legally responsible to offer care. Since pain is often the patient’s primary reported concern, the underlying cause(s) must be explored carefully to rule out any unexpected or serious problem like infection, bleeding, wound dehiscence, or nerve injury. Medical assistants, often the initial contact person, are more available and less expensive than other trained providers. While the legal scope of an MA’s practice varies by state, they are generally not allowed to provide treatment or medical advice but can be trained to collect and document the important information and to confer with a licensed registered nurse or PA who can contact the patient to establish a path for care.^31,34

Approaches to Improving Safety and Patient Outcomes

By adhering to the following practices, the likelihood of a good surgical outcome with minimal complications can be significantly increased. Good surgical outcomes are measured by relief of preoperative symptoms such as nocturnal paresthesia, decreased pain, numbness, and weakness, and rapid return to work and activities of daily living without any complications.

Preoperative Patient Assessment and Education

• Evaluate and if needed treat the patient’s medical comorbidities and risk factors that might interfere with optimal results from carpal tunnel surgery. These risk factors include diabetes, smoking, alcohol or opioid dependence, thyroid disease, rheumatoid arthritis or other autoimmune diseases, obesity, homelessness, and psychiatric conditions, particularly depression. Plan delaying surgery if a corticosteroid injection has been given in the affected hand within 3 months.
• Review postoperative expectations with the patient about pain and pain management, dressing and wound care, and activity modifications. Instruct the patient who to contact for concerns or issues and what information is important to convey. These directions should also be given to the patient in a written document.

Intraoperative Measures

• Maintain strict aseptic techniques including surgeon and patient hand cleaning with chlorhexidine or povidone products and using sterile gloves, gowns and drapes throughout the procedure.
• Minimize tissue trauma and achieve good hemostasis to promote faster healing and reduce the risk of infection. Choose an appropriate incision site and method (open vs. endoscopic) based on the patient's condition and the surgeon’s experience and setting.

Postoperative Measures

• After carpal tunnel release surgery, provide clear and comprehensive postoperative care instructions to minimize complications. Instruct the patient on proper wound care, including keeping the bandage and wound clean and dry. Avoid submerging the hand in water until the incision has fully healed. Cover the area with a plastic bag or waterproof cover while showering. Offer pain management with limited use of opioids. Most patients will be well managed on over-the-counter medications such as 8-hour extended-release acetaminophen with a nonsteroidal anti-inflammatory medication such as ibuprofen or naproxen. Ice packs can be applied to the surgical site for 15-20 minutes every 2-3 hours during the first 48 hours to reduce swelling and pain. Elevate the hand above heart level, begin gentle finger and wrist motion, and avoid strenuous activities or lifting objects that weigh more than one pound.
• Educate the patient on the signs of infection (redness, swelling, increased pain, warmth, discharge) and advise them to seek medical attention immediately if they occur.
• Schedule a regular follow-up appointment to monitor the healing process and promptly address any problems and reinforce activity modifications. If possible, patient instructions should be given in the presence of a family member or friend who can remind the patient, as some drugs administered during surgery may affect memory.

Communication 

• Providers should explain that some pain and discomfort are normal after surgery, but persistent or worsening symptoms including severe pain, signs of infection, numbness, or loss of function should be reported immediately to the surgeon.
• With expanding roles of physician extenders and MAs, surgeons should consider writing a script to be used for patient calls after surgery specifically asking the patient to describe the pain in detail including its intensity, location, nature (sharp, dull throbbing), and any changes since surgery; checking if the patient has been following postoperative instructions, including medication use, wound care, and activity restrictions; and inquiring about other symptoms like redness, swelling, warmth, discharge, or fever.
• Document all information provided by the patient in their medical record.
• Assess urgency if symptoms suggest a potential complication and require prompt attention such as wound redness, warmth or swelling; surgical incision separation or drainage; fever; increasing pain with requests for more analgesic medication; increasing numbness; or decreased range of finger motion.
• Communicate the patient’s responses with the healthcare team and immediately inform the surgeon, supervising physician or advanced practice provider about the patient’s symptoms. The responsible surgeon should leave instructions as to answers that would trigger an urgent office visit and, in some cases, emergency department (ED) referral. When delegating the monitoring of perioperative events, the operating surgeon should accept complete responsibility for the patient’s well-being and outcomes.
• Reassure the patient that their concern is taken seriously and that appropriate steps are being taken to address it. Advise the patient on what constitutes an emergency and provide instructions on seeking immediate care, including going to the ED if necessary.
  • Completely evaluate and consider patient medical comorbidities preoperatively including timing of previous steroid injections into the hand, diabetes, psychiatric conditions, and opioid use.

Quality Improvement Approach

Optimizing the healthcare system to assure safety and minimize infections or complications for patients undergoing carpal tunnel release surgery involves a multifaceted approach. Best practices as outlined in the 2024 American Academy of Orthopaedic Surgeons’ Clinical Practice Guidelines are mostly based on low levels of evidence and many are consensus-based opinions.³⁵ Not all issues relevant to the patient in this review are covered in practice guidelines so the following recommendations are based on the best available evidence.

• Quality Control and Improvement: Implement a quality improvement program to monitor outcomes and identify opportunities for improvement in treating carpal tunnel syndrome. Use data analytics to track infection rates, complications, and patient outcomes.
• Staff Training and Education: Provide ongoing education and training for healthcare providers including MAs on best practices in surgical care and infection control based on evidence-based practices using the latest research and guidelines to assure the highest standard of care. In this case, there may have been excessive delegation of responsibility to an MA with insufficient training or unclear instructions.
• Patient Follow-up: Ensure robust follow-up systems are in place to monitor patient recovery and address any issues promptly. This approach might include contacting the patient by phone within a few days after surgery to discuss their experience and identify any concerns. Arrange a video visit, which is preferable to a telephone conversation, if an office visit is not planned. Consider a policy for weekends after any operation on Friday. In this case, the refusal of the surgeons’ office to schedule any type of visit, either in-person or by video, other than the routine 7-10 day visit for suture removal, may have allowed the patient’s infection to progress, leading to greater morbidity.

Take Home Points 

• Have a preoperative discussion about post-operative activity limitations and pain management and preferably prescribe 5 or fewer opioid pills and recommend over the counter acetaminophen and non-steroidal anti-inflammatories.
• Document specific postoperative instructions and give a copy to the patient regarding pain management, care of dressing and activity restrictions.
• Employ careful sterile practices including patient and surgeon hand cleansing and attend to meticulous soft tissue surgical techniques to promote uncomplicated wound healing.
• Properly train office personnel to interact with and carefully document unexpected patient post-operative calls. Consider developing a protocol-based management strategy to be used for unexpected phone calls from patients after surgery.

Robert M. Szabo, MD, MPH, FAOA
Distinguished Professor Emeritus of Orthopedics and Surgery
Chief Emeritus, Hand, Upper Extremity & Microvascular Surgery
Department of Orthopedic Surgery
UC Davis Health 
rmszabo@ucdavis.edu

Editor’s Note: this case was adapted from Capozzola DD, Terrence J. Failure to Diagnose and Treat Post-Surgery Infection Leads to $1.18 Million Verdict. Healthcare Risk Management (Relias Media). Published April 1, 2024.

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