The Critical Portions of Carpal Tunnel Release, Ulnar Nerve Transposition, and Open Reduction and Internal Fixation of the Distal Part of the Radius

Abstract

Background: Overlapping surgery is attracting increased scrutiny. The American College of Surgeons states that the attending surgeon must be present for all critical portions of a surgical procedure; however, critical portions of surgical procedures are not defined. We hypothesized that a Delphi panel process would measure consensus on critical portions of 3 common hand surgical procedures. Methods: We used a Delphi process to achieve consensus on the critical portions of carpal tunnel release, ulnar nerve transposition, and open reduction and internal fixation of the distal part of the radius. The panelists were 10 hand surgeons (7 fellowship-trained surgeons and 3 fellows). Following an in-person discussion to finalize steps for each procedure, 2 online rounds were completed to rate steps from 1 (not critical) to 9 (extremely critical). We operationalized consensus as ‡80% of ratings within the same range: 1 to 3 (not critical), 4 to 6 (somewhat critical), and 7 to 9 (critical). Because of a lack of consensus on some steps after round 2, another in-person discussion and a third online round were conducted to rate only steps involving disagreement or somewhat critical ratings using a dichotomous scale (critical or not critical). Results: Following the first 2 rounds, there was consensus on 19 of 24 steps (including 3 steps being somewhat critical) and no consensus on 5 of 24 steps. At the end of round 3, there was consensus on all but 2 steps (identification of the medial antebrachial cutaneous nerve in ulnar nerve transposition and clinical assessment of joint stability in open reduction and internal fixation of the distal part of the radius), with moderate disagreement (3 compared with 7) for both. Conclusions: The panel reached consensus on the designation of critical or noncritical for all steps of a carpal tunnel release, all but 1 step of an ulnar nerve transposition, and all but 1 step of open reduction and internal fixation of the continued

Working Definitions of “Critical Portions”

“…Second, although we found consistency in reported definitions across a range of surgical specialties and perceptions, how surgeons apply these definitions to a given case may vary (eg, defining a "delicate" structure). This is where efforts at consensus around the critical portions of particular procedures [13][14][15] will be useful, and might be bolstered by our framework as discussed above.…”

Management of Anticoagulation/Antiplatelet Medication and Venous Thromboembolism Prophylaxis in Elective Spine Surgery: Concise Clinical Recommendations Based on a Modified Delphi Process

“…Delphi surveys are commonly used to foster consensus and best-practice guidelines among physicians regarding medical practices with insufficient scientific evidence to guide decision-making 26,27. Delphi surveys have been used in orthopedics,28,29 neurosurgery,30,31 and other specialties 32–34.…”

“…Delphi surveys are commonly used to foster consensus and best-practice guidelines among physicians regarding medical practices with insufficient scientific evidence to guide decisionmaking. 26,27 Delphi surveys have been used in orthopedics, 28,29 neurosurgery, 30,31 and other specialties. [32][33][34] A modified Delphi process was used to gain consensus on three questions regarding AC/AP management and VTE chemoprophylaxis in spine surgery.…”