Article

The Wide-Awake Approach to Dupuytren’s Disease: Fasciectomy under Local Anesthetic with Epinephrine

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Abstract

The Wide-Awake Approach to Dupuytren's contracture involves fasciectomy under local anesthetic with epinephrine and no tourniquet. The goal of this study is to show that the Wide-Awake Approach produces equivalent outcomes to fasciectomy under general anesthetic with a tourniquet, with fewer risks to the patient. A multicenter retrospective review was conducted on 111 patients with fasciectomies under local or general anesthetic between 2001 and 2007. Data on patient demographics, comorbidities, cost, as well as range of motion was collected and evaluated using Microsoft Excel and SAS. Of 148 fingers, 102 were treated under local and 46 under general anesthetic. The average postoperative Total Active Motion (TAM) for general anesthetic patients was 199.0 ± 29.6 (D5), 223.9 ± 29.3 (D4), 234.6 ± 14.6 (D3), and 246.7 ± 14.4 (D2). The average postoperative TAM for local anesthetic patients was 168.3 ± 62.2 (D5), 195.9 ± 67.5 (D4), 173.0 ± 72.6 (D3), and 177.5 ± 31.8 (D2). There were no significant differences between any of these individual groups (p = 0.09, 0.26, 0.12, and 0.20, respectively); however, when pooled, the overall TAM was significantly greater in the general anesthesia group (222.0 ± 29.7 vs. 186.0 ± 63.0, p = 0.002.). Complication rates and types were similar with both techniques. The Wide-Awake Approach to Dupuytren's contracture avoids general anesthetic risks and has cost benefits to healthcare providers. Although it yields similar range of motion outcomes to fasciectomy performed under general anesthesia, total active motion may be better with fasciectomy done under general anesthesia.

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... general anesthesia (GA). 4 This is advantageous for patients with preexisting medical problems who are more likely to be denied surgery or to have delayed surgery until they are deemed medically fit for GA. 2 The lack of any form of sedation means that patients are not required to undergo preoperative visits for testing or intraoperative monitoring or to receive postoperative anesthetic care. 2 As such, using WALANT potentially saves costs because there is no need for anesthetists during the surgery and there is a shorter postoperative hospital stay. 4,5 The use of epinephrine to achieve hemostasis obviates the need for a tourniquet, reducing discomfort for patients and postoperative swelling of soft tissues. ...
... 4 This is advantageous for patients with preexisting medical problems who are more likely to be denied surgery or to have delayed surgery until they are deemed medically fit for GA. 2 The lack of any form of sedation means that patients are not required to undergo preoperative visits for testing or intraoperative monitoring or to receive postoperative anesthetic care. 2 As such, using WALANT potentially saves costs because there is no need for anesthetists during the surgery and there is a shorter postoperative hospital stay. 4,5 The use of epinephrine to achieve hemostasis obviates the need for a tourniquet, reducing discomfort for patients and postoperative swelling of soft tissues. 2,6 Hand surgeons also prefer the WALANT approach to hand surgery because it aids them in surgery. ...
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... 5 A wide range of elective upper limb surgery has been performed under wide-awake local anaesthetic, no tourniquet surgery (WALANT) in minor operative settings, including carpal tunnel release, A1 pulley release, cubital tunnel release, benign tumour resection, flap transfer and Dupuytrens fasciectomy. [6][7][8] Cost analysis of the individual surgeries has shown significant savings to health system including 62% savings for carpal tunnel release, 9 70% for A1 pulley release 5 and 92% for Dupuytrens fasciectomy. 6 Furthermore, trauma surgeries, including flexor and extensor tendon repair, digital nerve repair and even forearm trauma cases can all be performed under WALANT conditions. ...
... [6][7][8] Cost analysis of the individual surgeries has shown significant savings to health system including 62% savings for carpal tunnel release, 9 70% for A1 pulley release 5 and 92% for Dupuytrens fasciectomy. 6 Furthermore, trauma surgeries, including flexor and extensor tendon repair, digital nerve repair and even forearm trauma cases can all be performed under WALANT conditions. [10][11][12] In addition to the benefits outlined above, trauma surgery, in this manner, has been shown to be safe when compared with main theatre. ...
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Introduction The advent of wide-awake local anaesthesia has led to a reduced need for main theatre for trauma and elective plastic procedures. This results in significant cost-benefits for the institution. This study aims to show how a dedicated 7 days/ week plastic surgery procedural (PSP) unit, performing both elective and trauma surgeries, can lead to significant cost-benefits for the institution. Methods Retrospective review of all cases performed in the PSP unit between 1 September and 31 August 2018. We utilised hospital directory admissions data and the hospital's intranet operating theatre system to calculate hospital days saved. Cost analysis was performed using Saolta financial data. Results A total of 3058 operations were performed. Of these operations, 2388 cases were elective and 670 were trauma cases. The average waiting time for trauma cases for main operating theatre was 1.4 days, saving a total of 487 hospital days. The total savings associated with hospital bed days were €347,861. The estimated resource savings from performing a procedure in PSP compared with main theatre with regional anaesthesia were €529.00 and €391.00 without regional anaesthesia. The cost saved due to resources was therefore €337,226. The total cost-benefit associated with performing surgeries in PSP including hospital days and resources saved was calculated as €685,087. Conclusion This study shows the benefit of performing elective and trauma operations in minor procedure units such as PSP. PSP results in a more efficient service, reducing waiting times for surgery, shorter hospital stay, reduced operating cost and an overall significant cost saving.
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Article
Learning objectives: After studying this article, the participant should be able to: 1. Understand updates in the basic science, epidemiology, and treatment of Dupuytren's disease. 2. Understand treatment with needle aponeurotomy, collagenase, and fasciectomy. 3. Understand advanced needle techniques for Dupuytren's contracture. 4. Understand the safety and effectiveness of a new treatment, collagenase. Summary: The literature on Dupuytren's disease encompasses many specialties. Its treatment is generally by perforating, excising, or dissolving the affected tissues. This article reviews the changing understanding of this disease and treatment options.
... The patients within the nested complication cohorts were generally older, had more comorbidities, and resided in areas with a higher index of multiple deprivation. These data should prompt more surgeons to consider undertaking these procedures under local anaesthesia, especially in higher risk patients 15 . ...
Article
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... Patients who would have otherwise been denied surgery because of comorbidities can have an operation. Finally, potential cost savings can be achieved by providing a day-case service without the need for anaesthetists, pre-assessment visits, and pre-operative investigations (Bismil et al., 2012;Lalonde, 2011;Nelson et al., 2009). ...
Article
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... Wide awake local anesthetic no tourniquet DD surgery is equivalent to general anesthesia or block anesthesia with a tourniquet. 34,43 Although current general or regional block anesthesia as currently practiced is exceedingly safe, an extensive review of over 153,376 DD operations showed significant risks for LF and DF surgeries using these techniques versus strictly local anesthesia PNF. 36 Serious systemic complications at 90 days after LF and DF included myocardial infarction (0.88%), acute kidney injury (0.09%), and lower respiratory tract infection (0.22%). ...
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Die partielle Aponeurektomie ist beim Morbus Dupuytren als Therapie der Wahl dann erforderlich, wenn minimalinvasive Therapieformen, wie z. B. die perkutane Nadelaponeurotomie oder die Kollagenaseinjektionstherapie, aufgrund der Morphologie oder eines fortgeschrittenen Kontrakturstadiums nicht zu empfehlen sind. Auch bei einem geringgradigeren Stadium bietet die partielle Aponeurektomie Vorteile gegenüber minimalinvasiven Verfahren. Diese Vorteile beziehen sich sowohl auf die niedrigere Rezidivrate der Dupuytren-Kontraktur als auch auf den Schweregrad verbleibender Restkontrakturen, insbesondere im Bereich des proximalen Interphalangealgelenkes.
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Chapter
Wide awake hand surgery is performed under local anaesthesia with low-dose adrenaline without (the risks of) general anaesthesia, regional anaesthesia, sedation or tourniquets, is applicable to the majority of hand surgery procedures and is especially suited to soft tissue conditions including Dupuytren’s contracture (Bismil et al., World wide awake hand surgery consensus statement. http:// www. worldwideawake. net/ 3. html). Wide awake hand surgery is gaining increasing popularity worldwide because of the opportunities it provides to optimise surgery and rehabilitation [Lalonde, J Hand Ther 26(2):175–178, 2013], streamline the patient pathway [Bismil et al., JRSM Short Rep 3(4):23, 2012], and give patient-centred care with excellent outcomes and patient satisfaction [Bismil et al., JRSM Short Rep 3(4):23, 2012; Teo et al., J Hand Surg Eur Vol 38(9):992–999, 2013]. The continued evolution of wide awake hand surgery relies on worldwide collaboration among surgeons, therapists and not least hand surgery patients who recognise the potential advantages of the techniques. Wide awake Dupuytren’s fasciectomy is the product of such worldwide collaboration, with patients at the centre. The origins of wide awake fasciectomy for Dupuytren’s contracture can be traced to the early 1980s when TH Robbins, an Australian plastic surgeon, published, in the Annals of the Royal College of Surgeons of England, a paper on Dupuytren’s Z-plasty under local anaesthesia [Robbins, Ann R Coll Surg Engl 63(5):357–358, 1981]. Subsequently, centres in Canada [Denkler, Plast Reconstr Surg 115(3):802–810, 2005], the United States [Nelson et al., Hand (N Y) 5(2):117–124, 2010] and the United Kingdom [Bismil et al., JRSM Short Rep 3(7):48, 2012] have published their results.
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Background: Evidence is lacking to support the use of specialized anesthesia providers in minor surgical operations for patients without medical necessity. We sought to estimate the extent of potentially discretionary service use (anesthesiologist-administered anesthesia services among low-risk patients). Methods: We performed a retrospective claims analysis using the Truven Marketscan Database to estimate the prevalence and cost of anesthesiologist-administered anesthesia services provided to patients undergoing minor hand surgery (carpal tunnel release, trigger finger release, or de Quervain release) from 2010-2015. A predictive probability model was created to estimate patient risk-status. We examined the relationship between patient risk-status and anesthesia use using multivariable regression models. Results: Of 441,579 eligible procedures, 352,779 (80%) involved anesthesiologist-administered anesthesia services. The total proportion of estimated anesthesiologist-administered anesthesia use in low-risk patients who do not need anesthesiologist support declined over the study period (69.7% in 2010 to 65.8% in 2015). Although total payments for anesthesiologist-administered anesthesia services remained steady between 2010 and 2014, the average payment per procedure increased regardless of procedure type (from $376.8 in 2010 to $427.9 in 2015 for a carpal tunnel release operation). Approximately 83.7% ($133 million) of payments to anesthesia providers is credited to services in low-risk patients. Conclusions: Anesthesiologist-administered anesthesia services are commonly rendered to low-risk surgical patients. Existing health reform efforts do not adequately address discretionary services that can be a targeted area for cost saving. It is important to consider the implications of potentially discretionary use of specialized anesthesia providers particularly with the advancement of bundled payment models.
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Background: The American Board of Plastic Surgery collects data on 20 common plastic surgery operations as part of the Continuous Certification process. The goal of this study was to describe clinical trends in Dupuytren contracture repair since 2008 as they relate to evidence-based medicine articles published in this timeframe. Methods: Cumulative tracer data for Dupuytren contracture were reviewed for the period from February of 2008 to March of 2020 and compared with evidence-based medicine articles published in Plastic and Reconstructive Surgery. Topics were categorized as (1) pearls, addressed in both the tracer data and evidence-based medicine articles, (2) topics only addressed in tracer data, and (3) topics only addressed in evidence-based medicine articles. Results: As of March of 2020, 230 cases of Dupuytren contracture had been entered. The median age at time of surgery was 65 years (range, 38 to 91 years). Practice patterns from 2008 through 2014 were compared with those between 2015 and 2020. The most common surgical technique was limited fasciectomy (62 percent of cases). Differences in practice between these time periods included decrease in the use of radical fasciectomy (34 percent versus 16 percent, p = 0.002), increase in percutaneous cordotomy (0 percent versus 13 percent), and increase in the use of collagenase injections (0 percent versus 9 percent, p = 0.001). Use of Bier blocks increased (1 percent versus 7 percent), and tourniquet use decreased (97 percent versus 80 percent). Significant changes were also noted in postoperative management. Conclusion: By examining American Board of Plastic Surgery tracer data, the authors have described national trends in presentation and surgical techniques for Dupuytren contracture repair over a 14-year period.
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Background: A patient's ability to move his/her fingers during hand surgery may be helpful to surgeons because it allows the effectiveness of the intervention evaluation and prediction of hand function in the postoperative period. The purpose of this case series is to demonstrate the efficacy of an ultrasound-guided peripheral nerve block technique to maintain the hand flexor and extensor muscles motor function and discuss the benefits of the technique for trigger finger surgery. Case report: Ten patients scheduled to undergo trigger finger surgery were selected. The goal was to maintain flexion and extension of the fingers during the procedure. Thus, ultrasound-guided ulnar, radial, and medial nerve block was performed in the distal third of the forearm, at 5-7 cm proximal to the wrist. The block was performed with 5 mL of 0.375% bupivacaine on each nerve. All procedures were uneventfully performed maintaining the flexion and extension of the fingers. In two cases, it was observed that the motricity maintenance and the patients' ability to move their fingers when requested allowed the success of the surgical procedure after the third intraoperative evaluation. Conclusion: This case series shows that it is possible to maintain the motor function of the hand flexor and extensor muscles to perform finger trigger surgeries using specific ultrasound-guided distal blocks.
Article
The wide awake anesthesia technique is a useful tool in secondary tendon reconstruction. With active participation of the patient, the tendon repair can be adjusted appropriately to prevent repairs that are too tight or too loose. Areas of tendon scarring or triggering can be identified and released. Other advantages of active participation include reduction of gapping, ensuring adequate strength of repair, and avoiding tendon imbalances. Last, it allows intraoperative patient education and may therefore increase patient satisfaction. This article discusses how the technique can be applied to tenolysis, 2-stage tendon reconstruction, and tendon transfer.
Article
Wide-awake local anesthesia no tourniquet (WALANT) is a promising development for surgeons and patients through improved operation outcomes in hand and wrist surgery. The authors have mostly used WALANT for flexor and extensor tendon repair, tenolysis, and tendon transfer. Its application at W Hospital in korea has bolstered surgeon confidence in tendon repair integrity, gliding ability, and transfer tension via direct observation and patient feedback. The authors do not use WALANT in complicated tenolysis or in secondary surgeries in previous severe injury situations. The procedure has proven similarly unsuitable in incomplete or complete digit replantation.
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Purpose: Studies assessing intraoperative pain during surgery with wide-awake local anesthesia typically use a unidimensional pain scale, which provides a limited view of the pain experience. The present paper describes two studies that assessed qualitative aspects of intraoperative pain using a multidimensional pain measure. Methods: The first study was a retrospective survey of 24 patients who received a variety of foot and ankle procedures under wide-awake local anesthesia. Patients completed a copy of the Short-Form McGill Pain Questionnaire (SF-MPQ) through the mail an average of six months following surgery. The second study was a prospective assessment of 40 patients receiving forefoot procedures under the same anesthesia. Patients completed a copy of the SF-MPQ directly after the surgery. Results: Patients in the first study selected an average of 1.17 pain descriptors (SD = 3.02) on the SF-MPQ, whereas patients in the second study selected an average of 1.90 pain descriptors (SD = 1.82). In general, both studies found that sensory descriptors of pain (e.g., sharp, shooting, tender) were more common than affective descriptors. However, mean intensity ratings were low for all descriptors. Conclusion: The results of these studies provide a more comprehensive understanding of the patient experience during surgery with wide-awake local anesthesia.
Article
Background: Carpal tunnel release (CTR) can be performed with a variety of anesthesia techniques. General anesthesia is associated with higher risk profile and increased resource utilization, suggesting it should not be routinely used for CTR. The purpose of this study was to examine the patient factors associated with surgeons' requests for general anesthesia for CTR and the frequency of routine use of general anesthesia by Veterans Health Administration (VHA) surgeons and facilities. Methods: National VHA data for fiscal years 2015 and 2017 were used to identify patients receiving CTR. Mixed-effects logistic regression was used to evaluate patient, procedure, and surgeon factors associated with requests by the surgeon for general anesthesia versus other anesthesia techniques. Results: In all, 18 145 patients underwent CTR performed by 780 surgeons in 113 VHA facilities. Overall, there were 2218 (12.2%) requests for general anesthesia. Although some patient (eg, older age, obesity), procedure (eg, open vs endoscopic), and surgeon (eg, higher volume) factors were associated with lower odds of requests for general anesthesia, there was substantial facility- and surgeon-level variability. The percentage of patients with general anesthesia requested ranged from 0% to 100% across surgeons. Three facilities and 28 surgeons who performed at least 5 CTRs requested general anesthesia for more than 75% of patients. Conclusions: Where CTR is performed and by whom appear to influence requests for general anesthesia more than patient factors in this study. Avoidance of routine use of general anesthesia for CTR should be considered in future clinical practice guidelines and quality measures.
Article
Background: Full-awake hand surgery (FAHS) has been gaining attention in recent years. However, the extent of full-awake approach for longer and more complicated major surgeries for the hand in trauma cases remains unclear. This study aimed to report the clinical nature of major flexor tendon trauma cases with subsequent repair under FAHS. Methods: Retrospective study was performed on 9 male patients with an average age of 32.22 (SD, 9.67) years who experienced surgery for major flexor tendon ruptures under FAHS. Besides involving 3 digits in fingers, hand, or forearm, extensive surgery involved 3 cases with surgical dissection similar to the one needed to repair flexor tendons of 3 digits in zone 2. Results: The assessment that was performed at least 3 years after surgery included not only the efficacy of FAHS but also the total active range of motion, opposition function, Medsger severity scale, and Disabilities of Arm, Shoulder, and Hand score. All repairs and explorations were performed under FAHS with 2 subjects who needed conversion to general anesthesia owing to intraoperative visual analog scale score of greater than 4. Average surgery duration under FAHS was 225 (170-309) minutes. Through an average follow-up of 4.1 years, all patients showed normal Medsger scale, with 7 cases that had excellent total active range of motion and 8 cases, excellent opposition. Median Disabilities of Arm, Shoulder, and Hand score was 15 (9-28.5). Conclusions: Full-awake hand surgery is potential surgical approach for major flexor tendon trauma cases resulting in satisfactory long term functional outcome.
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Purpose: Patients receiving surgery with wide-awake local anesthesia typically report little or no intraoperative pain. However, self-report assessments of pain are susceptible to bias. In the present study, patient self-report ratings were supplemented with objective physiological measures of electrodermal activity. Methods: Fifteen patients receiving forefoot surgery using wide-awake local anesthesia were recruited. Pain ratings and skin conductance responses were acquired during the initial anesthetic injection (into unanesthetized tissue), during a follow-up anesthetic injection (into anesthetized tissue), and during five intraoperative procedures. Results: The highest ratings of self-reported pain coincided with the initial anesthetic injection, and pain ratings were similarly low at all remaining measurement points. Fourteen patients reported no pain beyond the initial injection, whereas one patient reported minimal pain during two intraoperative procedures. Skin conductance data were consistent with pain ratings such that responses to the initial injection were significantly larger than responses at any subsequent measurement point. Conclusion: These results provide further evidence that patients experience little or no pain during surgery with wide-awake local anesthesia.
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Purpose To define self-reported WALANT use among American Society for Surgery of the Hand (ASSH) members. We aimed to define surgeon and practice demographics relative to WALANT use and identify potential barriers for WALANT implementation. Methods An anonymous multiple-choice survey was electronically distributed to all active ASSH members. Incomplete surveys were included in the final analysis. Surgeons were asked to provide reasons for not performing WALANT, which were categorized based on general themes. We compared practice and surgeon demographic information relative to WALANT use. Results Of 3,826 ASSH members, 869 responded (23%). A total of 79% of respondents had performed at least one WALANT procedure; 62% currently incorporated WALANT into their practice. Hospital-owned outpatient surgery centers were the most common location for WALANT procedures (31%). Canadian surgeons were more likely to use WALANT, compared with US and international surgeons. Surgeons with fewer years in practice and higher-volume surgeons were more likely to use WALANT. There was no statistically significant association between either practice or income structure and WALANT use. For carpal tunnel release (CTR), 13% did not offer patients WALANT, whereas 43% offered WALANT to all patients. Moreover, 51% of surgeons reported that anesthesia staff was required to be present for WALANT cases at their institution. In determining reasons for not using WALANT, 16% reported that they preferred a tourniquet for visualization. Only 2% had concerns regarding epinephrine use in the hand. Conclusions The results of this survey illustrate current WALANT use among ASSH members and defines the demographics of those employing WALANT. Lack of familiarity with WALANT and an acceptance of the use of epinephrine in the hand has increased from prior ASSH surveys. Lack of familiarity with the technique, concerns regarding operating room efficiency, and patient preferences remain considerable barriers to more widespread adoption of WALANT procedures. Type of study/level of evidence Economic and Decision Analysis V.
Article
The injection of collagenase followed by cord manipulation is one of the most popular treatments for Dupuytren's contracture. This is traditionally performed under local anesthesia or regional nerve block potentially with sedation. Neither the treatment with collagenase, nor the wide-awake anesthesia are novel techniques for hand surgeons. Nevertheless, we report the first experience of cord manipulation using the wide-awake approach. In this prospective study, we compared the pain perception of patients who underwent wide-awake anesthesia versus traditional local anesthesia. We recorded the pain sensation on a visual analog scale (VAS) (0 to 10) during anesthetic injection, during cord manipulation and before discharge. Wide-awake anesthesia significantly reduced pain levels during anesthetic injection (p=0.003) and cord manipulation (p=0.0009). Pain levels did not differ significantly right before discharge in the two groups (p=0.54). Wide-awake anesthesia can be successfully applied to cord manipulation after collagenase injection in Dupuytren's contracture. This way, it is possible to improve the patient's subjective perspective of the procedure.
Article
Background We attempted to evaluate patient satisfaction and overall experience during wide awake, local anesthesia, with no tourniquet (WALANT) hand surgery and quantify surgery-related outcomes. Methods We conducted a retrospective analysis of patient demographics, comorbidities, and patient reported outcomes via Single Assessment Numeric Evaluation (SANE) scores collected pre- and postoperatively of patients undergoing WALANT surgery by the 2 participating senior authors. A solution of 1% lidocaine with 1:100,000 epinephrine was used by 1 surgeon, while the other used a 1:1 ratio of 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine for local anesthetic injection. Patients were administered a postoperative survey to assess patient experience, including anxiety and pain levels, and overall satisfaction in the perioperative period. Results Overall, 97.7% of patients indicated that they would undergo a WALANT-style surgery if indicated in the future, 70.5% ate the day of surgery, and a total of 39.1% of patients reported driving to and from surgery. Postoperative SANE scores increased as compared with preoperative scores across all patients. The use of combination 1% lidocaine with 1:100,000 epinephrine and 0.5% bupivacaine was associated with lower intraoperative and postoperative visual analog scale pain scores. Conclusions WALANT hand surgery was generally well tolerated with excellent surgical outcomes. Patients reported ease of preparation for surgery, faster recovery, and lack of anesthetic side effects as the main benefits of wide-awake surgery. Combination use of lidocaine and bupivacaine may be better than lidocaine alone with respect to pain control in the initial recovery period.
Article
Dupuytren's disease is a fibroproliferative condition that causes shortening, thickening, and fibrosis of the palmar fascia and a flexion deformity of metacarpophalangeal and proximal interphalangeal joints. Although the etiology is unknown, a variety of risk factors, such as age greater than 50 years, male sex, family history, or tobacco and alcohol use may lead to disease development. At the present time there is no cure and symptoms may recur; however, surgical procedures (eg, limited fasciectomy) and nonsurgical treatment (eg, needle aponeurotomy, injection of collagenase clostridium histolyticum) can help patients manage the disease's symptoms. Patients may experience wound-healing complications after fasciectomy and skin fissures after needle aponeurotomy. Recurrence rates for needle aponeurotomy and collagenase clostridium histolyticum injection are similar. Perioperative nurses should provide individualized patient care during procedures, participate in effective team communication regarding patient needs, and provide patient education throughout the perioperative continuum.
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To document the transition to a totally one-stop (patient seen and treated in one appointment) wide-awake (local anaesthesia only) hand surgery service. Retrospective review of 10 year service with detailed analysis of last 1000 cases including process and cost-effectiveness and efficiency analysis. Purpose-built CQC-certified day-case surgical facility where we have pioneered the UK's first totally one-stop wide-awake orthopaedic service. Approximately five thousand orthopaedic patients treated in the last ten years. Surgical outcomes, patient satisfaction and cost-effectiveness and efficiency. The OSWA model is safe, efficient and effective; with a low complication rate, extremely high patient satisfaction; and cost-savings to the NHS of 50-75% of the national tariff. The service saved the NHS approximately £750,000 for the 1000 cases presented; and over £2 million since the inception of the service. A totally one-stop wide-awake hand surgery service is a practicable and feasible alternative to the conventional treatment pathway with benefits in terms of efficiency and cost-effectiveness.
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Postoperative nausea and vomiting (PONV) is a common problem affecting nearly one third of all surgical patients. In addition to making the patient feel miserable, PONV is a major cause of prolonged recovery, unintended hospital admission, and poor patient satisfaction after surgery. Retching and vomiting can also lead to hematoma formation, wound and suture dehiscence, and aspiration. Thus, the prevention of PONV is an important goal in the overall outcome of surgery and, in particular, plastic surgery. The etiology of PONV is multifactorial, and several important risk factors have been identified. These factors include female gender, nonsmoking status, and a history of PONV or opioid-induced nausea and emesis. Volatile anesthetics and long operative duration also increase the risk of PONV. Reduction in the incidence of PONV requires careful assessment of patient-related risk factors as well as the appropriate use of prophylactic antiemetics. There are many antiemetic medications on the market today. Ondansetron, a serotonin 5-hydroxytryptamine antagonist, appears to be the current drug of choice for PONV prophylaxis. It has greatest efficacy and cost-effectiveness when used in patients at moderate to high risk. In addition, surgeons can consider using intravenous propofol or conscious sedation instead of general anesthesia where appropriate.
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Conclusion The most recent studies suggest that in the absence of antiemetics the incidence of emetic problems associated with anaesthesia is still around 30 per cent. Although not strictly comparable, these observations are little different from those in the last two or three decades. In this review we have discussed the part played by age, sex, obesity, operative site and duration of anaesthesia and unfortunately these are all predetermined. Postoperative vomiting, however, is rarely the result of a single factor and it is for this reason that management may not be successful. The anaesthetist has therefore been forced to adopt a practice reliant on antiemetics for symptomatic control. Of the factors under our control the evidence available would indicate that large doses of opiates, and over-enthusiastic manual ventilation by mask may adversely affect the incidence of postoperative vomiting. However, prompt pain relief, normotension and gentle care during the postoperative period are preventative measures that may also help reduce the distressing symptoms of emesis. In part II of this review we will discuss the general and specific measures available for the prevention and treatment of emesis during the postoperative period.
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Admission for overnight or longer hospital stay from a day-case unit is an unwelcome event. This audit was designed to identify the incidence of unplanned admissions and also to detect the potential factors for such overstays. Details of plastic surgical day-case patients were obtained from the hospital records for a period of 6 months (February 2002 to July 2002). The total number of unplanned admissions was 28 (3.55%). High rates were recorded in patients above the age of 80 years, male patients and body mass index > 30 kg/m2. Duration of surgery (> 45 min) and waiting time in the day surgery unit (> 2.5 h) had significant correlation with the overstays. Grade of the surgeon was not an important determinant factor. Of procedures which resulted in an unexpected admission, the most frequent were otoplasty (8.4%; n = 71) and fasciectomy for Dupuytren's contracture (14.5%; n = 41). Unexpected admissions were also high following rhinoplasty and nipple reconstruction but the total number of operations performed were not significant (n = 12 in each group). Overall, the cause of the overstays were mostly surgical (71.4%) followed by anaesthetic (28.5%) and social (7.1%). With an overall unplanned admission rate of 3.55%, our unit is close to the national standard of 2-3%, as advocated by The Royal College of Surgeons of England. Postoperative bleeding (60%) was the most important surgical reason for overstays followed by intravenous antibiotics, wound drainage, excessive duration of the procedure and additional, unplanned procedures. Among the anaesthetic factors, postoperative pain was the leading cause (62.5%) followed by nausea, vomiting and adverse anaesthetic reaction. The reasons for unplanned admissions are multifactorial and merit appropriate patient selection and proper estimation of the disease process.
Article
Author Information The S3A-409 and S3A-410 Study Groups. (Fortney, Gan, Parrillo, Glass) Department of Anesthesiology, Duke University, Durham, North Carolina; (Graczyk) Department of Anesthesiology, Baptist Medical Center, Columbia, South Carolina; (Wetchler) Department of Anesthesiology, University of Illinois, Chicago, Illinois; (Melson) Anesthesia Consultants of the Shoals, Muscle Shoals, Alabama; (Khalil) Department of Anesthesiology, University of Texas Medical Center, Houston, Texas; (McKenzie) Department of Anesthesiology, Magee Women's Hospital, Pittsburgh, Pennsylvania; (Moote, Wermeling) Department of Anesthesiology, University Hospital, London, Ontario, Canada; (Moote, Wermeling) Department of Anesthesiology, University of Kentucky, Lexington, Kentucky; and (Parasuraman, Duncan, Creed) Division of Medical Affairs, Glaxo Wellcome Inc, Research Triangle Park, North Carolina. Section Editor: Paul F. White. This work was supported by a grant from Glaxo Wellcome Inc. Accepted for publication December 23, 1997. Correspondence and reprint requests to Jennifer T. Fortney, MD, Box 3094, Duke University Medical Center, Durham, NC 27710.
Article
Two cases are presented to illustrate a complication which understandably could happen in spite of attention and precautions. The first patient was a man undergoing surgical therapy for Dupuytren's contracture. During performance of axillary block, median nerve paresthesias were elicited. The block was not completely satisfactory and required supplementation with general anesthesia. Postoperatively, the patient complained of numbness in the radial-nerve distribution. This numbness rapidly lessened in the early postoperative period and completely disappeared during a period of postoperative follow-up. Total tourniquet time was 28 minutes, at a gauge pressure of 250 mm Hg. The second patient also had excision of Dupuytren's contracture on the same day, in the same operating room. General anesthesia was used for this patient. Postoperatively, he complained of inability to move his fingers and of numbness of the long, ring, and small fingers. These findings improved rapidly immediately, and returned to normal during the follow-up
Article
At the Dalhousie Plastic Surgery Alumni Reunion at the Atlantic Plastic Surgery meeting in Halifax, Nova Scotia, in September 2001, 22 subjects, including 18 certified hand surgeons, were injected with 1.8 mL of 2% lidocaine with 1:100,000 adrenaline in three places in one finger of each hand. One hour later, the same sites of one hand were injected with phentolamine (1 mg in 1 mL), and the other hand was injected with saline. Subjects were blinded as to which hand received the phentolamine. It took an average of 85 min for the adrenaline-injected fingers to return to normal colour after phentolamine injection. It took an average of 320 min for the adrenaline-injected fingers to return to normal colour after saline injection (no phentolamine). We also observed that lidocaine with adrenaline provided an average of 549 min of anesthesia in nonphentolamine-injected fingers. Phentolamine consistently and reliably reversed adrenaline-induced vasoconstriction in the finger.
Article
Two identical, randomized, double-blind, placebo-controlled studies enrolled 2061 adult surgical outpatients at high risk of postoperative nausea and vomiting (PONV) to compare IV ondansetron 4 mg with droperidol 0.625 mg and droperidol 1.25 mg for the prevention of PONV. The antiemetic drugs or placebo were administered IV 20 min before the induction of anesthesia with a barbiturate compound, followed by maintenance with N2O/isoflurane/enflurane. Nausea, emetic episodes, adverse events, and patient satisfaction were analyzed for the 0 to 2 h and 0 to 24 h postoperative periods. In the 0 to 2 h postoperative period, there was a complete response (no emesis or rescue antiemetic) in 46% of subjects given placebo (P < 0.05 versus antiemetic groups), in 62% given ondansetron, in 63% given droperidol 0.625 mg, and in 69% given droperidol 1.25 mg (P < 0.05 versus ondansetron). In the 0 to 24-h postoperative period, there were no significant differences in complete response between the ondansetron and droperidol 0.625 or 1.25 mg groups; all groups remained superior to placebo. The proportion of patients without nausea during the 0 to 24 h postoperative period was greater in the antiemetic groups compared with the placebo group; however, droperidol 125 mg was more effective than ondansetron 4 mg or droperidol 0.625 mg (43% vs 29% or 29%, respectively). Headache incidence was higher in the ondansetron group compared with either droperidol group. Patient satisfaction scores did not differ significantly among antiemetic treatment groups, although all were superior to placebo. In conclusion, all antiemetic treatment regimens were superior to placebo for the prevention of PONV in the immediate postoperative period; however, droperidol 1.25 mg was more efficacious than ondansetron during the early recovery period (0-2 h). There were no significant differences between ondansetron and either droperidol dose for emesis prevention during the 0 to 24 h postoperative period. Implications: More than 2000 patients at high risk of postoperative nausea and vomiting were given either placebo, ondansetron 4 mg, or droperidol 0.625 mg or 125 mg IV before the administration of general anesthesia. After surgery, the incidence of nausea, vomiting, medication side effects, and patient satisfaction were evaluated for 24 h. Droperidol 0.625 or 125 mg IV compared favorably with ondansetron 4 mg IV for the prevention of postoperative nausea and vomiting after ambulatory surgery.
Article
In the early part of the century, when adrenaline first became widely available, it was used in an uncontrolled manner and cases of ischaemic necrosis led to it falling into disfavour for hand surgery. Local anaesthesia with adrenaline is currently widely used for palmar and dorsal hand surgery but there remains a very deeply ingrained resistance to its use for digital anaesthesia. It is widely thought that it will cause irreversible digital artery vasospasm. This prospective study reports the effect of 2% lignocaine with 1:80,000 adrenaline digital blocks on various parameters of digital arterial blood flow in 100 consecutive patients. Our findings show that adrenaline only temporarily reduced digital blood flow. Perfusion of the digits persisted in every case.
Article
Our goals were to analyze cost and efficiency of performing carpal tunnel release (CTR) in the main operating room (OR) versus the ambulatory setting, and to document the venue of carpal tunnel surgery practices by plastic surgeons in Canada. A detailed analysis of the salaries of nonphysician personnel and materials involved in CTR performed in these settings was tabulated. Hospital statistical records were used to calculate our efficiency analysis. A survey of practicing plastic surgeons in Canada documented the venue of CTR performed by most. In a 3-h surgical block, we are able to perform nine CTRs in the ambulatory setting versus four in the main OR. The cost of CTR in the ambulatory setting is $36/case and $137/case in the main OR in the same hospital. Only 18% of Canadian respondents use the main OR exclusively for CTR, whereas 63% use it for some of their cases. The ambulatory setting is used exclusively by 37%, whereas 69% use it for greater than 95% of their cases. The majority of CTR cases (>95%) are done without an anesthesia provider by 73% of surgeons. Forty-three percent use epinephrine routinely with local anesthesia and 43% avoid the use of a tourniquet for at least some cases by using epinephrine for hemostasis. The use of the main OR for CTR is almost four times as expensive, and less than half as efficient as in an ambulatory setting. In spite of this, many surgeons in Canada continue to use the more expensive, less efficient venue of the main OR for CTR.
Article
Data was collected prospectively on all patients from one health district attending the Hand Unit at Derbyshire Royal Infirmary to determine the needs for hand surgery and the resources utilised to meet them. 475 patients per 100,000 population presented with hand injuries and 289 patients per 100,000 with elective hand disorders each year. For every 100,000 population, the trauma cases required 139 inpatient days and 1723 outpatient visits. Elective cases required 221 inpatient days and 1039 outpatient visits.
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The experience in treating 100 patients with Dupuytren's contracture is reviewed. Clinical characteristics, indications for surgery, types of incisions and operations, attendant complications and their effect on results are presented. Partial fasciectomy through a longitudinal incision with one or more Z-plasties as required, is preferred; transverse incisions have a higher incidence of complications and poorer end results.
Article
This chapter is an overview of the management of a patient who has undergone a surgical procedure in an outpatient setting. It addresses the complications that are most common in this setting and their management. Without attempting a thorough discussion of every conceivable complication, this discussion seeks nonetheless to be reasonably comprehensive. Perhaps the most straightforward means of presenting this information is to follow chronologically the patient's experience from the moment the procedure has been concluded, through his recovery room care, and finally look at the patient's needs and experiences after leaving the ambulatory care facility.
Article
Since the introduction of the laryngeal mask airway (LMA) into the United States in 1991, the device has become widely used in anesthesia practice. The purpose of this economic analysis was to use existing data to evaluate the costs of the LMA relative to three other common airway management techniques and to identify the variables that had the greatest effect on cost efficiency. We evaluated four airway management techniques for healthy adults receiving an isoflurane-nitrous oxide-oxygen anesthetic for elective outpatient surgery: (1) LMA with spontaneous ventilation; (2) face mask with spontaneous ventilation; (3) tracheal intubation after succinylcholine with subsequent spontaneous ventilation; and (4) tracheal intubation after nondepolarizing neuromuscular blockade and controlled ventilation. We analyzed published clinical studies of the LMA and obtained cost data from Stanford University Medical Center. The best available estimates of the independent variables were incorporated into a baseline case. For each airway technique we derived cost equations that excluded costs common to all four techniques. Relative to airway management with an LMA, calculated values for the baseline analysis included additional isoflurane costs for use of a face mask ($ 0.12/min) and for tracheal intubation with ($ 0.043/min) and without neuromuscular blockade ($ 0.06/min). With a neuromuscular blocking drug cost of $ 0.21/min and an LMA cost per use of $ 20, the face mask with spontaneous ventilation was the cost-efficient airway choice for anesthetics lasting as long as 100 min. Increasing the LMA reuse rate from 10 to 25 made the LMA the least costly airway technique for cases lasting more than 70 min. If the LMA is reused 40 times, the LMA is the cost-efficient airway choice for outpatients receiving an isoflurane-nitrous oxide-oxygen anesthetic lasting longer than 40 min. This finding does not change if the cost of neuromuscular blockade or the incidence of airway-related complications is varied over a clinically relevant range.
Article
There is general agreement that Dupuytren's contracture is a genetic disorder that occurs predominantly in white men of Northern European ancestry. It appears rarely in the purely black population. We present our experience from Temple University of 8 black patients with Dupuytren's contracture. We also present a review of the world literature dealing with the black population and Dupuytren's disease. A total of 23 patients are reviewed, including our group. They all fall into the category of no Caucasian admixture and negative family history of Dupuytren's contracture. Every patient reviewed has at least 1 hand involved. History and presentation of disease, as well as epidemiological associations (e.g., age distribution, diabetes, and epilepsy), in our review are similar to that seen in the Caucasian population. The diathesis or predisposition for Dupuytren's contracture appears to be less extensive in our series of 8 black patients. History taking, with regard to occupation and possible traumatic etiology, remains a very useful tool.
Article
The results of long-term follow-up (range 9-19 years) are presented in a continuous series of patients treated for Dupuytren's contracture by one surgeon using the open palm technique. Mean preoperative total range of movement was 48% rising to 96% postoperatively. Mean total range of movement was 92% at follow-up. Survivorship analysis revealed 86% survival at 10 years and 77% survival at 19 years. There was one digital nerve injury and one case of algodystrophy. This technique gives good long-term results without the use of night splintage or physiotherapy.
Article
Breast surgery is associated with a high incidence of postoperative nausea and vomiting. Propofol and prophylactic administration of ondansetron are associated with a lower incidence of postoperative nausea and vomiting. To date no comparison of these two drugs has been reported. A randomized study was done to compare the efficacy of ondansetron and intraoperative propofol given in various regimens. Study participants included 89 women classified as American Society of Anesthesiologists physical status 1 or 2 who were scheduled for major breast surgery. Patients were randomly assigned to one of four groups. Group O received 4 mg ondansetron in 10 ml 0.9% saline and groups PI, PIP, and PP received 10 ml 0.9% saline before anesthesia induction. Group O received thiopental, isoflurane, nitrous oxide-oxygen, and fentanyl for anesthesia. Group PI received propofol, isoflurane, nitrous oxide-oxygen, and fentanyl. Group PIP received propofol, isoflurane, nitrous oxide-oxygen, and fentanyl. Thirty minutes before expected skin closure, isoflurane was discontinued and 50 to 150 micrograms.kg-1.min-1 propofol was given intravenously to maintain anesthesia. Group PP received propofol for induction and maintenance of anesthesia, nitrous oxide-oxygen, and fentanyl. Postoperative pain relief was provided with morphine administered by a patient-controlled analgesia pump. The incidence of nausea and vomiting, requests for rescue antiemetic and sedation, pain scores, and hemodynamic data were recorded for 24 h. Within 6 h of surgery, groups O and PP had a lower incidence of nausea compared with groups PI and PIP (P < 0.05). Fewer patients in group PP (19%) vomited during the 24-h period compared with groups O (48%), PI (64%), and PIP (52%) (P < 0.05). The incidence of antiemetic use was also less in group PP (P < 0.05). Patients in group PP had lower sedation scores at 30 min and at 1 h (P < 0.05). There were no differences among the groups in pain scores, blood pressure, heart rate, respiratory rate, and incidence of pruritus. Propofol administered to induce and maintain anesthesia is more effective than ondansetron (with thiopental-isoflurane anesthesia) in preventing postoperative vomiting and is associated with fewer requests for rescue antiemetic and sedation in the early phase of recovery. It is equally effective in preventing postoperative nausea as ondansetron in the first 6 h after operation. Propofol used only as an induction agent or for induction and at the end of surgery were not as protective against postoperative nausea and vomiting.
Article
Unlabelled: Two identical, randomized, double-blind, placebo-controlled studies enrolled 2061 adult surgical outpatients at high risk of postoperative nausea and vomiting (PONV) to compare i.v. ondansetron 4 mg with droperidol 0.625 mg and droperidol 1.25 mg for the prevention of PONV. The antiemetic drugs or placebo were administered i.v. 20 min before the induction of anesthesia with a barbiturate compound, followed by maintenance with N2O/isoflurane/enflurane. Nausea, emetic episodes, adverse events, and patient satisfaction were analyzed for the 0 to 2 h and 0 to 24 h postoperative periods. In the 0 to 2 h postoperative period, there was a complete response (no emesis or rescue antiemetic) in 46% of subjects given placebo (P < 0.05 versus antiemetic groups), in 62% given ondansetron, in 63% given droperidol 0.625 mg, and in 69% given droperidol 1.25 mg (P < 0.05 versus ondansetron). In the 0 to 24-h postoperative period, there were no significant differences in complete response between the ondansetron and droperidol 0.625 or 1.25 mg groups; all groups remained superior to placebo. The proportion of patients without nausea during the 0 to 24 h postoperative period was greater in the antiemetic groups compared with the placebo group; however, droperidol 1.25 mg was more effective than ondansetron 4 mg or droperidol 0.625 mg (43% vs 29% or 29%, respectively). Headache incidence was higher in the ondansetron group compared with either droperidol group. Patient satisfaction scores did not differ significantly among antiemetic treatment groups, although all were superior to placebo. In conclusion, all antiemetic treatment regimens were superior to placebo for the prevention of PONV in the immediate postoperative period; however, droperidol 1.25 mg was more efficacious than ondansetron during the early recovery period (0-2 h). There were no significant differences between ondansetron and either droperidol dose for emesis prevention during the 0 to 24 h postoperative period. Implications: More than 2000 patients at high risk of postoperative nausea and vomiting were given either placebo, ondansetron 4 mg, or droperidol 0.625 mg or 1.25 mg i.v. before the administration of general anesthesia. After surgery, the incidence of nausea, vomiting, medication side effects, and patient satisfaction were evaluated for 24 h. Droperidol 0.625 or 1.25 mg i.v. compared favorably with ondansetron 4 mg i.v. for the prevention of postoperative nausea and vomiting after ambulatory surgery.
Article
The studies were carried out in 163 children aged 3-16 years operated in a one-day hospital. The patients were divided into 3 groups administered different types of induction anesthesia: 1) ethrane inhalation up to 3 vol% and N2O with O2 in 1:1 ratio (56 children); 2) fluothane up to 3.5 vol% and N2O with O2 in 2:1 ratio (87 children); and 3) intravenous calipsol in a dose of 2-4 mg/kg (20 children). Central hemodynamic parameters, cardiointervalograms, and external respiration function were analyzed. Induction with ethrane was longer (4-12 min) than with fluothane (3-5 min). The reaction of central hemodynamics was less expressed after induction anesthesia with ethrane and fluothane in combination with N2O and O2 than after calipsol, leading to a decrease in the sympathetic tone and a higher activity of the parasympathetic component of the autonomic nervous system. Calipsol induction was associated with the predominance of the sympathetic component of the autonomic nervous system.
Article
This study was designed to assess the subjective and objective results following surgery for recurrent Dupuytren's disease. Nineteen patients (28 fingers) were treated surgically for recurrent contracture and were located for follow-up analysis at a median of 4 years (range, 1-15 years). Seventeen of 28 recurrences involved the small finger and 16 patients had at least one component of Dupuytren's diathesis. For the purpose of analysis the patients were divided into 3 groups: group A (total active range of motion [TAM] < 150 degrees ) consisted of 7 digits treated with limited fasciectomy and interphalangeal arthrodesis, group B (TAM >/= 150 degrees ) consisted of 8 digits treated with dermatofasciectomy and full-thickness skin graft, and group C (TAM >/= 150 degrees ) consisted of 13 digits treated with fasciectomy and local flaps. Total active range of motion reflecting the preoperative, immediately postoperative, and final follow-up values revealed that group C (fasciectomy and local flap) was the only group to maintain a statistically significant TAM improvement from preoperative (205 degrees ) to final follow-up (230 degrees ) analysis. Dermatofasciectomy and full-thickness skin grafting did not prevent recurrent contracture (preoperative TAM = 175 degrees; final follow-up TAM = 150 degrees ). Thirteen patients had abnormal Semmes-Weinstein monofilament testing and 8 had abnormal 2-point discrimination. There were 3 anesthetic digits. Despite these findings, 18 of the 19 patients were unconditionally satisfied with their experience and would undergo the procedure again.
Article
The purpose of this study was to examine the role for epinephrine augmentation of digital block anesthesia by safely prolonging its duration of action and providing a temporary hemostatic effect. After obtaining approval from the review board of the authors' institution, 60 digital block procedures were performed in a prospective randomized double-blinded study. The digital blocks were performed using the dorsal approach. All anesthetics were delivered to treat either posttraumatic injuries or elective conditions. Of the 60 digital block procedures, 31 were randomized to lidocaine with epinephrine and 29 to plain lidocaine. Of the procedures performed using lidocaine with epinephrine, one patient required an additional injection versus five of the patients who were given plain lidocaine (p = 0.098). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (p < 0.002). Two patients experienced complications after plain lidocaine blocks, while no complications occurred after lidocaine with epinephrine blocks (p = 0.23). By prolonging lidocaine's duration of action, epinephrine may prevent the need for an additional injection and prolong post-procedure pain relief. This study demonstrated that the temporary hemostatic effect of epinephrine decreased the need for, and thus the potential risk of, using a digital tourniquet (p < 0.002). As the temporary vasoconstrictor effect is reversible, the threat of complication from vasoconstrictor-induced ischemia is theoretical.
Article
The prohibition against the use of local anesthetics with epinephrine for digital blocks or infiltration is an established surgical tradition. The present article provides a comprehensive review of all reported digital necrotic and ischemic complications with epinephrine in the digits in an effort to understand whether the current prohibition is based on documented reports. A comprehensive review of articles showing the successful use of local anesthetic with epinephrine in the digits is presented.A review of Index Medicus from 1880 to 1966 and a computer review of the National Library of Medicine database from 1966 to 2000 were performed using multiple keywords. Selected major textbooks from 1900 to 2000 were also reviewed.A total of 48 cases of digital gangrene after anesthetic blocks (mostly using cocaine or procaine) have been reported in the world literature. Only 21 cases involved the use of epinephrine; 17 involved an unknown concentration based on manual dilution. Multiple other concurrent conditions (hot soaks, tight tourniquets, and infection) existed in these case reports, making it difficult to determine the exact cause of the tissue insult. There have been no case reports of digital gangrene using commercial lidocaine with epinephrine (introduced in 1948). Multiple studies involving thousands of patients support the premise that the use of lidocaine with epinephrine is safe in the digits. An extensive literature review failed to provide consistent evidence that our current preparations of local anesthesia with epinephrine cause digital necrosis, although not all complications are necessarily reported. However, as with all techniques, caution is necessary to balance the risks of this technique with the dangers of mechanical tourniquets and upper extremity block anesthesia.
Article
Epinephrine is currently added to local anesthetics for its advantageous vasoconstrictive effects. Traditionally, however, its use is not advised for digital block anesthesia due to the risk of digital gangrene. To observe vasoconstrictive effect of epinephrine in digital block anesthesia. Digital blocking with epinephrine containing lidocaine was performed in 24 subjects undergoing surgical procedure of their finger and toes. Digital artery blood flows were studied with color Doppler ultrasonography before digital blocking and at 10th, 60th, and if needed 90th minutes after blocking. Doppler parameters such as peak systolic velocity, end diastolic velocity, and resistive index values were studied. There were statistically significant decrease of blood flow rates and an increase of resistive index in all patients within 10 minutes. At the 10th minute of digital block, four patients had no measurable blood flow, which was restored within 60 or 90 minutes. Others showed diminished but persistent blood flow, which returned to normal within 60 minutes. No systemic or local complication related with epinephrine usage was observed. Vasoconstrictive effect of epinephrine in local anesthetics is not persistent and resolves within 60 or 90 minutes. Its use seems to be safe in selected patients.
Article
The prohibition against the use epinephrine with local anesthetics for digital blocks or infiltrative anesthesia is an established dogma in dermatologic surgery. Major textbooks reinforce this teaching suggesting that there is substantial risk of digital gangrene caused by local anesthesia containing epinephrine. To provide a comprehensive literature review of the cases of digital necrosis associated with the use of local anesthesia containing epinephrine. A PubMed search of the National Library of Medicine database using the terms "lidocaine" and "epinephrine" and "finger" with no specified limits was performed. A total of 16 papers were referenced and only 6 papers dealt with digital anesthesia. A total of 50 cases of digital gangrene were reported, mostly in the early part of the 20th century. In 21 cases digital gangrene was associated with anesthetic mixed with epinephrine. Actual concentration of epinephrine was known in only 4 cases. Careful analysis of all cases of necrosis did not support epinephrine itself as a cause. Other contributing factors including older compounds (cocaine, eukaine, and procaine), non-standardized inaccurate methods of mixing epinephrine with lidocaine, inappropriate use of a tourniquet, postoperative hot soaks, infection, or large anesthetic volume were also present. None of the reported cases were associated with the use of a commercial lidocaine-epinephrine mixture. A literature review failed to provide evidence to support the dogma that block or infiltrative anesthesia with lidocaine and epinephrine produces digital necrosis. Proper injection technique and adequate selection of patients (absence of thrombotic, vasospastic conditions, or uncontrolled hypertension) are mandatory to minimize complications. The addition of epinephrine, in fact, reduces the need for the use of tourniquets and large volumes of anesthetic and provides better and longer pain control during digital procedures.
Article
Dupuytren's contracture is a common hand problem. Its treatment, other than percutaneous fasciectomy, is an outpatient operation performed with the patient under regional or general anesthesia. If local anesthetics are used, they are used without epinephrine, and an arm or forearm tourniquet is essential. Multiple reviews have described the safety of local anesthetics with epinephrine in the digits. This study is a retrospective review of operations performed by the same surgeon in the hospital (43 digits) versus the office using local anesthetics with epinephrine and no tourniquet (60 digits). Results and complications were compared and tabulated. The hospital and epinephrine groups were comparable regarding preoperative measurements. Postoperative improvement in extension at the metacarpophalangeal and proximal interphalangeal joints was similar in both the hospital and epinephrine groups. Complications, including digital nerve and artery injuries, infections, and hematomas, were similar between the groups. There were no cases of digital necrosis or gangrene in the epinephrine group, even though one patient sustained a transection of a digital artery at the proximal interphalangeal joint. Because of the similarities in results and complications, there does not seem to be an advantage to performing Dupuytren's excisions with full arm tourniquet and outpatient admission in many cases. Local anesthetics with epinephrine are safe in the treatment of Dupuytren's contracture, although both the use of digital epinephrine and the use of mechanical tourniquets carry the potential for complications. Visibility is similar to that for facial or head and neck surgery and is aided by the use of loupe magnification. The old dogma against its use in the fingers is refuted, as seen by the results in these 60 consecutive Dupuytren's fasciectomies and the results of other authors.
Article
We recorded all elective admissions for Dupuytren's disease from the French National Hospital Database. We used the data from first hospitalizations to calculate the 2001 hospitalization rates for this condition and determine geographical differences between different regions of France. We also calculated the hospital costs of treating admissions with this disease. Fourteen thousand eight hundred and sixty hospitalizations for Dupuytren's disease were reported in France in 2001, of which 93% were for a first treatment. The disease was mostly present in men and was mostly managed by surgical fasciectomy. Most operations were carried out in private hospitals, with a mean stay of 2 days. Geographical differences were found in men only. The total hospital cost for all elective admissions was 14, 179, 998 Euros, indicating the considerable financial burden to the State of treating this condition.
Article
To examine prospectively the incidence of digital infarction and phentolamine rescue in a large series of patients in whom local anesthesia with adrenaline was injected electively into the hand and fingers. There continues to be a commonly held belief that epinephrine injection is contraindicated in the finger despite a lack of valid evidence to support this concept in the literature. From 2002 to 2004 there were 9 hand surgeons in 6 cities who prospectively recorded each consecutive case of elective hand and finger epinephrine injection. They recorded each instance of skin or tissue loss and the number of times phentolamine reversal of adrenaline vasoconstriction was required. There were 3,110 consecutive cases of elective injection of low-dose epinephrine (1:100,000 or less) in the hand and fingers and none produced any instance of digital tissue loss. Phentolamine was not required to reverse the vasoconstriction in any patients. The true incidence of finger infarction in elective low-dose epinephrine injection into the hand and finger is likely to be remote, particularly with the possible rescue with phentolamine.
Article
To determine the complication rate of a modified Skoog's technique in the surgical treatment of Dupuytren's contracture. A retrospective analysis was performed on 253 patients who had surgery by 1 surgeon using 1 technique with a mean follow-up period of 3.6 years. We studied the complication rate of the modified Skoog's procedure, relating it to a grading system for disease severity. A separate prospective long-term study was performed with an unselected cohort in which disease recurrence producing contracture was investigated prospectively in a group of 75 patients. Complications occurred in 46 patients. Thirty-five patients had 1 complication and 11 patients had more than 1 complication. Intraoperative complications included 6 patients with nerve injury and 1 patient with an arterial injury. Early postoperative complications before wound healing included 5 patients with digital hematoma, 24 patients with wound infection, 6 patients with sympathetic dystrophy, and 6 patients with skin slough. Late postoperative complications included 3 patients with scar contraction and 2 patients with carpal tunnel syndrome. There were 3 non-hand-related complications: 1 urinary retention, 1 left ventricular failure, and 1 myocardial infarction. Recurrence of Dupuytren's disease occurred in 23 of 75 patients after a mean follow-up period of 9.4 years. The complication rate increased with the severity of disease particularly if the proximal interphalangeal joint contracture was 60 degrees or more. There was no difference in the complication rate for patients who had surgery for primary or recurrent disease.
Article
This multi-centre postal questionnaire study was conducted by the Audit Committee of the BSSH to assess the outcomes of surgery for Dupuytren's Contracture using subjective data provided by 1177 patients at a mean follow-up of 27 (SD 8) months after surgery. Surgery for Dupuytren's contracture achieved a high rate of full, or almost full, correction in 826 patients (75%) but had a high incidence of post-operative patient-reported complications of 46%. A higher complication rate was seen in those patients with worse initial deformities. The rate of contracture recurrence or persistence was 158 of 1037 (15%). The severity of contracture correlated with the final hand function measured using the PEM score. Recurrence was more common in patients with greater initial deformity. Recurrence was less common if good correction was achieved at surgery. The relevance and limitations of this data are discussed.
Article
This article reviews the basic science elements involved in the pathogenesis of Dupuytren's disease. Dupuytren's contracture is effected by a multitude of complex processes at the cellular level and the exact relative contribution of each is unknown. Various investigators have proposed different theories and documented individual findings regarding the pathophysiology of Dupuytren's contracture. The current report attempts to summarize many of these findings together in a schema of pathogenesis.
Article
Medical texts continue to perpetuate the belief that epinephrine should not be injected in fingers. Little attention has been paid to analyze the evidence that created this belief to see whether it is valid. The significance is that elective epinephrine finger injection has been shown to remove the need for a tourniquet, and therefore delete sedation and general anesthesia for much of hand surgery. All of the evidence for the antiadrenaline dogma comes from 21 mostly pre-1950 case reports of finger ischemia associated with procaine and cocaine injection with epinephrine. The authors performed an in-depth analysis of those 21 cases to determine their validity as evidence. They also examined in detail all of the other evidence in the literature surrounding issues of safety with procaine, lidocaine, and epinephrine injection in the finger. The adrenaline digital infarction cases that created the dogma are invalid evidence because they were also injected with either procaine or cocaine, which were both known to cause digital infarction on their own at that time, and none of the 21 adrenaline infarction cases had an attempt at phentolamine rescue. The evidence that created the dogma that adrenaline should not be injected into the fingers is clearly not valid. However, there is considerable valid evidence in the literature that supports the tenet that properly used adrenaline in the fingers is safe, and that it removes the need for a tourniquet and therefore removes the need for sedation and general anesthesia for many hand operations.
Article
The elective use of low-dose epinephrine in hand surgery has allowed for the performance of simple operative procedures with tourniquet-free pure local anesthesia (the wide-awake approach). The absence of general anesthesia or sedation has, in turn, allowed for the observation of how quickly the sensorimotor cortex adapts following procedures such as tendon transfer. Seven patients underwent a wide-awake transfer of the extensor indicis proprius to the extensor pollicis longus between February of 2002 and May of 2005 for restoration of thumb extension using local lidocaine with epinephrine alone. One of the seven patients experienced rupture of the initial transfer, necessitating transfer of the extensor carpi radialis longus to the extensor pollicis longus using the wide-awake approach. All seven patients were able to extend their thumbs fully by means of extensor indicis proprius intraoperatively immediately following transfer suture placement. Restoration of function was not ablated by loss of proprioception or visual feedback. At a mean follow-up of 15 months, thumb extension was restored to within normal limits in the affected thumb, with a slight decrease in grip and tripod pinch strength. The wide-awake approach has allowed the authors to adjust tendon transfer tension with active movement before skin closure without the risks associated with general or regional anesthesia. In addition, it has allowed them to observe immediate cortical adaptation in the context of a simple tendon transfer. The authors hypothesize that the brain's ability to immediately use extensor indicis proprius for thumb extension stems from the activation of preexisting synergistic cortical finger movement programs.
Article
In the medical community there is a widely held belief that epinephrine should not be used with lidocaine when attempting a digital block because it will cause tissue gangrene. This belief is reinforced by several of the more prominent emergency textbooks, but a review of the medical literature fails to reveal a sound basis for this dogma.
Article
A 9-year-old girl accidentally injected her right thumb with an adult dose of epinephrine through an auto-injector syringe, delivering 0.3 mg of 1:1000 epinephrine. This injection caused immediate ischemic changes in the digit. This is the first reported case of accidental self injection by a child of an adult dose of epinephrine and its successful treatment with low-dose phentolamine simultaneously infiltrated directly into the puncture area and along the course of the digital artery. The use of phentolamine as a specific competitive alpha-adrenergic antagonist to epinephrine has been well documented in adults and animal models. This report compares the management of a pediatric case to that of all reported adult cases of accidental subcutaneous epinephrine injections. This case suggests a pattern of infiltration with low-dose phentolamine that may be the most effective form of treatment for this condition in a patient of any age.
Article
A consecutive sample of 97,537 miners seeking compensation for Hand-Arm Vibration Syndrome were examined in a medical assessment process which included documentation of age, hand dominance, Dupuytren's disease, years of vibration exposure, history of diabetes, smoking habits and units of alcohol consumption per week. The prime determinant of prevalence of Dupuytren's disease was age, and all other factors investigated were corrected for age. There was no statistically significant correlation between years of exposure to vibration and the prevalence of Dupuytren's disease. There was a statistically significant association with smoking, alcohol consumption and diabetes mellitus, with the heaviest smokers having an odds ratio (OR) of 1.31 (95% CI, 1.17, 1.47), the heaviest drinkers (in excess of 22 units a week) having an OR of 1.59 (95% CI, 1.47, 1.72) and diabetes mellitus patients having an increase in the odds of having Dupuytren's disease of 1.52 (95% CI 1.30, 1.77).
Anesthesia and emesis. I. Etiology
  • Mga Palazzo
  • Strunin
Palazzo MGA, Strunin L. Anesthesia and emesis. I. Etiology. Can Anaesth Soc J. 1984;31:178–87.
Providing care for hand disorders: trauma and elective. The Derby Hand Unit experience
  • Dias Jj Lunn
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  • Bradley
Burke FD, Dias JJ, Lunn PG, Bradley M. Providing care for hand disorders: trauma and elective. The Derby Hand Unit experience (1989–1990). J Hand Surg [Br]. 1991;16(1):13–8.
Canada e-mail: r.nelson@dal.ca A. Higgins Department of Occupational Therapy
  • R Nelson
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  • Canada
R. Nelson (*) : D. Lalonde Department of Plastic Surgery, Dalhousie University, Suite C204, 600 Main St, Saint John, NB E2K 1J5, Canada e-mail: r.nelson@dal.ca A. Higgins Department of Occupational Therapy, Dalhousie University, Suite C204, 600 Main St, Saint John, NB E2K 1J5, Canada J. Conrad Department of Plastic Surgery, University of Ottawa, 1919 Riverside Drive, Suite 402, Ottawa, ON, Canada K1H 1A2 M. Bell Department of Occupational Therapy, University of Ottawa, 1919 Riverside Drive, Suite 402, Ottawa, ON, Canada K1H 1A2 HAND (2010) 5:117–124 DOI 10.1007/s11552-009-9239-y
Green's operative hand surgery
  • Ramamurthy S Hickey
  • R Anesthesia Green Dp
  • Hotchkiss Rn Pedersen
Ramamurthy S, Hickey R. Anesthesia. In: Green DP, Hotchkiss RN, Pedersen WC, editors. Green's operative hand surgery. 4th ed. New York: Churchill Livingstone; 1999. p. 22–47.
Dupuytren’s contracture Hand surgery
  • Jt Hueston
In: Green DP, Hotchkiss RN, Pedersen WC, editors. Green’s operative hand surgery
  • S Ramamurthy
  • R Hickey
  • Anesthesia