Self-induced Hot Water Finger Burn Trying to Get Feeling Back after Ropivacaine Block.

This case report is about a patient with self-induced hot water burns several hours after an infraclavicular block with ropivacaine for a scaphoid fracture operation. This patient was honest about what happened. However, some patients are too embarrassed to admit what they did to themselves. The injury may be misdiagnosed by the emergency department physician or by the surgeon because the history is incomplete. The resulting burn, which can lead to fingertip loss when severe, can be erroneously misdiagnosed as an ischemic injury after lidocaine with epinephrine local anesthesia. Most hand surgeons have seen ischemic finger injuries the morning after failed finger replantation. Acutely ischemic fingers from arterial insufficiency do not have parallel hot water burn lines, reactive hyperemia at the base of the burn, or burn blisters at the fingertips. The purpose of this article and its video is to help physicians and nurses recognize the three signs of self-induced hot water finger burns after local anesthesia: (1) a parallel hot water line in the fingers at the proximal burn level; (2) reactive hyperemia just proximal to the burn line; (3) burn blisters in the submerged fingertips. When seeing postoperative patients with these signs, the examining clinician may tactfully ask: "Did you try to get the feeling back in your fingers by warming them?" It is hoped that the patient may then reveal that he tried warming the finger in water, and that may lead to the truth that the water was indeed too hot.

Tips, Tricks, and Pearls for a Superior Patient and Surgeon Experience for Wide-awake Dupuytren Surgery.

Fasciectomy for Dupuytren disease is a common procedure traditionally performed with a tourniquet under general or regional anesthesia. Since the year 2001, the wide-awake local anesthesia no tourniquet (WALANT) approach has been applied successfully to Dupuytren surgery, with current excellent surgeon and patient satisfaction. However, using WALANT for Dupuytren surgery may be intimidating for hand surgeons who want to begin using this method. The purpose of this article is to offer a series of tips and tricks the authors have learned after having performed hundreds of WALANT fasciectomies, to make this technique easier for surgeons and a more pleasurable experience for patients.

Below-knee Amputation with Minimally Painful Injection of Tumescent Local Anesthesia.

We successfully performed minimally painful injection of tumescent local anesthesia to eliminate the need for the tourniquet and sedation for a below-knee amputation in a frail patient with multiple medical comorbidities in Mombasa, Kenya. Minimal pain injection of WALANT (wide awake local anesthesia no tourniquet) pure local anesthesia can be a good alternative for lower limb amputation in frail patients when safe sedation services are unavailable or unaffordable in many countries.

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery.

¼ Wide-awake local anesthesia no tourniquet (WALANT) technique featuring tumescent infiltration of lidocaine with epinephrine at the operative site has broad application in hand surgery including both soft-tissue and bone procedures.¼ The advantages of wide-awake anesthesia include high patient satisfaction, preserved intraoperative finger and wrist motion, cost-effectiveness, improved operating room efficiency, fewer opioids during recovery, and improved access to hand surgery, which may be performed in an office-based setting without the need for anesthesia personnel.¼ In properly selected patients, use of lidocaine with epinephrine in the hand and fingers is safe. Rare postprocedure digital ischemia may be effectively treated with phentolamine rescue.¼ Barriers to adopting wide-awake anesthesia may be overcome by educating resistant stakeholders, including hospital administrators, nurse leaders, and anesthesia colleagues, about the advantages of the WALANT method.¼ The risk of postoperative complications after hand procedures may be mitigated by using the wide-awake technique instead of regional anesthesia with sedation or general anesthesia.

Clinically Important Pharmacologic Considerations for Wide Awake Local No Tourniquet (WALANT) Hand Surgery.

Understanding the clinically important pharmacokinetics (what the body does to the drug) and pharmacodynamics (what the drug does to the body) of medications utilized in surgery will help surgeons to utilize them more safely and effectively. The goal of this article is to provide an overview of these considerations for the two medications, lidocaine, and epinephrine, utilized in Wide Awake Local Anesthesia No Tourniquet (WALANT) upper extremity surgery. After review of this article, the reader should have a better understanding of lidocaine and epinephrine for tumescent local anesthesia, as well as adverse reactions and how to manage them.

Tips to Successful Flexor Tendon Repair and Reconstruction with WALANT.

WALANT has generated many changes that have improved flexor tendon repair and reconstruction in the last 10 years. Seeing awake unsedated educable patients move repaired reconstructed tendons during the surgery has changed how we do surgery and therapy in many ways for the better. This article offers many tips on how to get better results in using these new techniques with the help of WALANT.

Cancer Metastases to the Hand: A Systematic Review and Meta-analysis.

BACKGROUND: Metastatic lesions to the hand or wrist are rare and can mimic inflammatory and benign processes such as gout and infections. This often leads to misdiagnosis, underreporting, and delays in treatment. The purpose of this study was to examine all known cases of metastasis to the hand or wrist available in the literature and to analyze demographic trends, metastasis characteristics, and clinical course, and provide recommendations for management. METHODS: An online systematic review of MEDLINE, Embase, PubMed, and the Cochrane Library from inception to January 7, 2022, was completed. Studies outlining the care of a patient with acrometastases of the hand were included. Data extracted included age, sex, site of primary tumor and metastasis, presence of other metastases, time from primary diagnosis to acrometastasis diagnosis, misdiagnosis, treatment, and survival. RESULTS: Between 1889 and present, 871 lesions were described in 676 patients who met the inclusion criteria. There was no predilection for hand dominance or site of previous trauma. The mean age among patients was 59.5 (1.5-91) years, and male sex was more common (64.6%). The most common primary cancer source was the lung (39.2%), followed by the kidney (10.8%). The distal phalanx was the most frequently cited tumor location (33.7%). Mean survival after diagnosis of acrometastasis was 6.3 months (0.25-50) ± 11.5 months. CONCLUSION: Acrometastasis remains an uncommon presentation of metastatic disease with poor prognosis. Treatment currently focuses on pain management and optimizing functional outcomes. Our review led to the development of 7 treatment recommendations when managing these patients.

The impact of WALANT anesthesia and office-based settings on patient satisfaction after carpal tunnel release: A patient reported outcome study.

HYPOTHESIS: Wide awake local anesthesia with no tourniquet (WALANT) and office-based procedures are used in hand surgery. There are limited literature data on patient satisfaction when comparing methods of anesthesia and location of surgery. METHODS: We conducted a retrospective single-surgeon study with patient reported satisfaction in three groups. We compared patient impressions of anesthesia type; WALANT vs locoregional anesthesia plus sedation. We also compared satisfaction in three surgery settings; office surgery vs hospital ambulatory minor procedure room vs main operating room. Group 1 office surgery patients had ultrasound guided surgery with WALANT. Group 2 main operating room surgery patients also had ultrasound guided surgery with WALANT. Group 3 main operating room patients had endoscopic surgery with sedation and a tourniquet. Each group had 30 patients with a minimum follow up of 2 months. We measured overall satisfaction, satisfaction with the organization of care, satisfaction with the administration of anesthesia, and satisfaction with the quality of anesthesia. We also collected secondary data on the resolution of the neuropathic symptoms. RESULTS: Procedures performed in an office-based setting showed higher rates of patient satisfaction when compared to the ambulatory day surgery setting. WALANT anesthesia also showed significantly higher rates of patient satisfaction on a numerical analog scale when compared to sedation based on, irrespective of the surgical setting. All patients had resolution of their neuropathic symptoms regardless of the technique performed. CONCLUSION: We found that carpal tunnel releases performed in an office-based setting produces superior patient satisfaction. WALANT anesthesia also provides improved patient satisfaction when compared to sedation and monitoring techniques, irrespective of the surgical setting and location. Carpal tunnel release with WALANT in an office-based setting is better for patient comfort and satisfaction, with no evidence of lesser clinical outcomes at a short term follow-up. LEVEL OF EVIDENCE: III.

K-wire Fixation of Closed Hand Fractures Outside the Main Operating Room Does Not Increase Infections.

Closed reduction and internal fixation (CRIF) of closed hand fractures in the main operating room (OR) is much more expensive than outside of the OR. However, there is a reluctance to fix fractures out of the OR due to the perceived increase in infections. Our goal was to prospectively analyze the infection rates of performing CRIF of closed metacarpal and phalangeal fractures in these two settings. Methods: A multicenter prospective analysis of patients undergoing CRIF of metacarpal or phalangeal fractures inside or outside the OR was performed. Demographic data, injury characteristics, surgery information and postoperative infectious complications were recorded, including cellulitis, frank pus, and osteomyelitis. Results: The study involved 1042 patients with a total of 2265 Kirschner-wires (K-wires). Infection rates were not statistically higher in the 719 patients who had CRIF outside of the OR (cellulitis 2.5%, frank pus 1.4%) compared with the 323 patients with CRIF in the OR group (cellulitis 3.4%, frank pus 2.5%). The OR group had a longer time to operation and a longer procedure time, but a shorter time with the K-wires in place. Conclusion: K-wire fixation of closed hand fractures outside of the OR under field sterility is safe because it does not increase infectious complications compared to CRIF in the main OR under full sterility.

Effective Things Surgeons Can Tell Patients During Wide-Awake Local Anesthesia No Tourniquet Surgery to Decrease Complications and Improve Outcomes.

Surgeons are familiar with surgical technique articles that provide step-by-step details of various surgical procedures relevant to clinical practice. This article is a communications technique article that provides step-by-step things that a surgeon can say to a wide-awake patient during the surgery to improve outcomes in clinical practice. The absence of anamnestic sedation enables memorable patient education from their surgeon to decrease the risk of postoperative complications.

Current Trends in Use of Epinephrine in Hand Surgery.

BACKGROUND: Epinephrine use during hand surgery has been stigmatized due to a fear of digital necrosis. Clinical experience in the past 2 decades has shown epinephrine in local anesthetic to be safe. We sought to analyze the use of epinephrine among hand surgeons and identify variables associated with it. METHODS: A deidentified 21-question survey was distributed via email to the 914 and 415 members of the American Association for Hand Surgery and the Canadian Society for Surgery of the Hand, respectively. Questions included residency type, years of practice, practice setup/ownership, practice leadership, usage of epinephrine, availability of reversal agents, and reasons for or against usage. RESULTS: Of 188 responders, 170 (90%) used epinephrine in local anesthetic for hand surgery procedures. By nationality, 100% (43) of Canadian surgeons and 89% (108) of US surgeons use epinephrine (P = .01). Among surgeons with practice ownership, 88% (102) used epinephrine compared with 93% (85) of those surgeons that we employed (P = .28). Comparing surgeons with teaching responsibilities versus those without training responsibilities showed that surgeons who did not teach used epinephrine at a higher rate (87% vs 98%, P = .04). In addition, plastic surgery-trained surgeons (111) used epinephrine in 97.2% of cases while orthopedic surgery-trained surgeons (57) used epinephrine in 80.2% of cases (P = .0003). No difference was found when examining the use of epinephrine and surgeon age (P = .28). CONCLUSIONS: Most respondents believe that epinephrine is safe. Training background, location, and practice setup are significant factors in the use of epinephrine, whereas practice ownership and physician age are not major factors.

Reconstructive Surgery in a Patient with High Radial Nerve Palsy Using the WALANT Technique.

Tendon transfers can be tied too tight or too loose. Both impede good function after surgery. Performing tendon transfers without sedation and pain during the surgery and then watching the patient move the transfer have helped us adjust the tension more accurately. This method can be applied to complex transfers such as radial nerve palsy triple tendon transfers. We describe the technique and results of a triple tendon transfer using wide-awake local anesthesia no tourniquet in a patient with a high radial nerve palsy. This was a complex case of reconstruction after five operations at the level of the humerus. This left him with a pseudoarthrosis of the humerus and a complete radial nerve palsy. We performed tendon transfers of pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, and palmaris longus to extensor pollicis longus tendons. Eighteen months after the triple tendon transfer surgery for the radial nerve palsy, the patient has good extension of the fingers, wrist, and thumb. He can open and close the hand properly. He has excellent function and mobility allowing him to perform most activities in a manner that is practically normal. Wide-awake local anesthesia no tourniquet can be used safely and successfully in complex cases requiring triple radial nerve tendon transfers of pronator teres to extensor carpi radialis brevis, flexor carpi ulnaris to extensor digitorum communis, and palmaris longus to extensor pollicis longus tendons.

Internal Fixation of Finger Fractures: Field Sterility for Surgery and Earlier Removal of K-Wires Are Safe.

Field sterility for K-wire insertion outside the main operating room is much cheaper and greener (ie, there is less waste). It permits increased access to more affordable surgery because unnecessary sedation and full sterility are eliminated. Early pain-guided protected movement of K-wired finger fractures at 3 to 5 days leads to less stiffness. It will not result in loss of reduction or infection around K-wires if patients avoid "pain" (ie, do not perform movements that hurt). Early protected movement and early removal of K-wires at 2 to 4 weeks contribute to less stiffness after operative hand/finger fracture reduction and stabilization.

Ten Questions About Wide Awake Local Anaesthesia No Tourniquet (WALANT) Surgery.

The aim of this review article is to provide many important tips and tricks for surgeons to start Wide Awake Local Anaesthesia No Tourniquet (WALANT) hand surgery in their practice. The massive cost reduction of this disruptive new approach will enable them to increase access to hand surgery for their patients who cannot afford unnecessary sedation or unnecessary sterility of the expensive main operating room environment. Evidence-based sterility will permit surgeons to move a lot of their surgery out of the main operating room to minor procedure rooms without a significant increase in infection rates. Important pointers on how to inject minimally painful local anaesthesia will have patients thinking the surgeon injector is a bit of a magician. WALANT enables surgeons to improve the outcomes of many hand surgery procedures. Level of Evidence: Level V (Therapeutic).

Time to Stop Routinely Prescribing Opiates after Carpal Tunnel Release.

BACKGROUND: North American surgeons continue to routinely order narcotic medication for postoperative pain relief after carpal tunnel surgery. For some patients, this instigates persistent use. This double-blind, multicenter trial investigated whether over-the-counter medications were inferior to opioid pain control after carpal tunnel release. METHODS: Patients undergoing carpal tunnel release in five centers in Canada and the United States (n = 347) were randomly assigned to postoperative pain control with (opioid) hydrocodone/acetaminophen 5/325 mg versus over-the-counter ibuprofen/acetaminophen 600/325 mg. The two primary outcome measures were the Numeric Pain Rating Scale (0 to 10) and the six-item Patient-Reported Outcome Measurement Information System Pain Interference T-score. Secondary outcome measures were total medication used and overall satisfaction with pain medication management. RESULTS: The authors found no significant differences between opioid and over-the-counter patients in the Numeric Pain Rating Scale scores, Pain Interference T-scores, number of doses of medication, or patient satisfaction. The highest Numeric Pain Rating Scale group difference was the night of surgery, when opiate patients had 0.9/10 more pain than over-the-counter patients. The highest group difference in Pain Interference T-scores (2.1) was on the day of surgery, when the opiate patients had more pain interference than the over-the-counter group. Patient nationality or sex did not generate significant pain score differences. CONCLUSIONS: Pain management is not inferior for patients managed with over-the-counter acetaminophen/ibuprofen versus opioids. This study provides high-quality evidence that U.S. and Canadian surgeons should stop the routine prescription of narcotics after carpal tunnel surgery for patients who are not taking pain medicines daily before surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.