Randy -

I use to think it was just ignorance among the hand surgeon community. In my cynical old age, I am beginning to think that money talks and .... walks, or as Bob Dylan said, money doesn't talk, it screams. Almost 5 years ago I had NA done for $700. I was 100% satisfied with the outcome. Out of that $700 my hand surgeon, since he had his own office, had to pay a portion of that to his nurse, his secretary, the electric company, the bank, the landlord, etc. etc.

Now let's go to surgery. In my neck of the woods, the surgeon gets paid by the procedure by the insurance company or HMO. The hospital gets a separate fee to cover all of the above plus profit. My question is what is the surgeon's fee and what is the anesthiologist's fee when performing hand surgery to alleviate Dupuytren's. I would be willing to bet that it is a lot more than $700. And that's 100% income for the surgeon; none of the above expenses for overhead.

I know that several hand surgeons follow this forum. Various hand surgeons have indicated that the total cost for surgery is 10 to 20 times as much as for the needle procedure. Perhaps they could enlighten us as to what the surgeon takes home for performing this procedure.

Steve Abrams

A lot of it may be money - whether or not these MDs are really admitting that to themselves.

But I also think a surgeon sees NA as just a riskier, more difficult way to do something he already knows how to do quite well. Hand surgeons are quick to describe NA as "blind" and talk about possible nerve damage. I think if I were a surgeon I'd have these concernes too. I'd want to open up the hand as much as possible, so I could see what I was doing, and not expose myself to risk of a lawsuit if for cutting a nerve. And as we all know, malpractice suits are a big factor here in the US.

I can respect that, but I'm seeing this from a patient's point of view in which the surgery is just the beginning of months of tedium and misery, trying to heal and repair the damage done by the surgery itself. I also know I'll be dealing with this for the rest of my life, and scarring from surgery can close off future treatement possibilities.

Dr. Rizzo at Mayo preceeded my NA with an ultrasound to locate the major blood vessels and nerves. This might be seen as taking NA to the next level - adding cost but removing risk.

So it's down to ignorance or greed, or some combination thereof. Either way it doesn't look good for members of the American Society for Surgery of the Hand.

I'm having trouble with the greed hypothesis. We need more input from surgeons on this. "chs" says no, that surgeons don't get all that much out of OS compared to NA. We need conformation. While money does scream, that *can't* be all that drives most doctors. Maybe I'm naive in my middle age.

Then their's ignorance. One again NA was discussed during an instructional course at the yearly ASSH meeting in May: "Dupuytren’s Disease: Past, Present, and Future"....."the available treatment options for Dupuytren’s disease, including regional fasciectomy, fasciotomy, dermofasciectomy, and needle aponeurotomy. Clinical outcomes of these techniques, as well as reported complications, will be discussed." While I don't see any NA guys on the faculty of this one, the data for NA's safety and effectiveness as a first line procedure is well established and should speak for itself.

But then, there's that word "should" (speak). "People hear what they want to hear and disregard the rest" (Paul Simon). So maybe what we have here is simple professional inertia. "This is the way we do this. Don't confuse me with facts."

Meanwhile, there was another lecture called "Operations I No Longer Perform"

OVERVIEW
"Over time, procedures once believed to be tried and true have been challenged by colleagues and in the peer review literature. This symposium will address four such procedures that have been questioned or come ‘under fire’ in recent years."

One topic was "Discuss indications and results of fasciotomy for Dupuytren’s disease" Gee whiz, Dr. Charles Eaton was on *that* panel. I wonder what he had to say.

To see the words "under fire" in the same context as "fasciotomy" on the ASSH web site has made my day. Maybe my month. I think this puts Eaton on the Ignorance side of our discussion, and he's hell bent to do something about it.

You go Charlie!

I've had 2 conventional surgeries and 1 NA procedure - and 1 cut nerve. Ironically, the nerve was cut during one of the surgeries. I will point out however that since the surgery was done in a well-equipped facility, and the hand was open, the surgeon was able to bring in the micro-surgical gear and reconnect the nerve.

I have a lot of respect for hand surgeons after spending time at a hand therapy clinic. Think about the cases they see - many are grisly injuries from accidents involving industrial or farm equipment. I personally know 2 people who had severed, or nearly severed, fingers successfully reattached. These surgeons aren't doing Botox injections on the idle rich - they earn their money by taking on tough, traumatic cases and performing extensive and delicate repairs in real life emergencies. Not surprisingly they develop strong opinions and expect to do things their own way.

NA is now spreading steadily around the US. It would have been nice (and a lot cheaper) if it had been available from a surgeon in my city, and on my health insurance plan, but at least I was able to get it done within a 2 hour driving distance. The fact that it's now happening at Mayo will give it another boost.

Edited 06/22/09 22:46

Dr Denkler worked on my hands last week. Five years ago I went to Dr Eaton for NA. So, I have now had experience with both of these doctors. Dr Denkler is definitely more aggressive and he will tell you that he is. With Dr Eaton I walked out of the office with bandaids. After NA with Dr Denkler I had bandaged hands that I had to keep above my heart to prevent swelling. I had one hand done on Monday and the other done on Thursday. I would have had difficulty driving the car back to the hotel. I thought that both doctors did an excellent job.

This time I had both thumbs released and 3 fingers. I have more movement now than I have had in a very long time. For the first time in about 8 yrs I can wear a ring on my right hand. I am very pleased. Dr. Denkler is very personable and although these procedures were more than I bargained for, I would not hesitate to have him work on my hands again.

My husband, son and I had a great week in San Francisco.

Marilyn