Opioid Sparing in Cleft Palate Surgery.

OBJECTIVE: This study aimed to determine whether intraoperative acetaminophen was able to decrease opioid consumption, pain scores, and length of stay while increasing oral intake in cleft palate surgery. DESIGN/SETTING/PATIENTS: One hundred consecutive patients with cleft palate who underwent a von Langenbeck or 2-flap palatoplasty and intravelar veloplasty at a tertiary medical center by the 2 senior authors from 2010 to 2015 were reviewed. INTERVENTIONS: Three intraoperative treatment groups were analyzed: intravenous (IV) acetaminophen, per rectal (PR) acetaminophen, and no acetaminophen. All patients received long-acting local anesthesia infiltration before incision. Additionally, all patients were admitted overnight and given weight-based per oral (PO) acetaminophen and oxycodone and IV morphine as needed based on pain scores. OUTCOMES MEASURED: The study outcomes included pain scores, opioid requirement, length of stay, and oral intake. RESULTS: The treatment groups were comprised of 40 patients who received IV acetaminophen, 22 PR acetaminophen, and 35 none. Concerning demographic data, there was no statistical difference between treatment groups. There was no statistically significant difference for opioid intake, although both IV and PR acetaminophen groups had decreased pain scores ( P = .029). There was no difference in oral intake ( P = .13) or length of stay ( P = .31) between treatment groups. CONCLUSION: In this study, intraoperative administration of acetaminophen was associated with decreased pain scores, but no opioid-sparing effect. As other studies have shown an opioid-sparing effect with postoperative acetaminophen, we recommend withholding the intraoperative dose and beginning therapy in the immediate postoperative period.

Choice of Corticosteroid Solution and Outcome After Injection for Trigger Finger.

Background: Many techniques for injection of trigger fingers exist. The purpose of this study was to determine whether the type of steroid or technique used for trigger finger injection altered clinical outcomes. Methods: Six hand surgeons at a single institution were surveyed regarding their injection technique, preferred steroid used, and protocol for repeat injection or indication for surgery for symptomatic trigger finger. A retrospective chart review of patients who underwent trigger finger injections was performed by randomly selecting 35 patients for each surgeon between January 2013 and December 2015. Demographic data at the time of presentation were collected. Outcome data during follow-up appointments were also recorded. Results: A total of 210 patient charts were reviewed. Demographic data and initial presenting grade of triggering were similar among all groups. There was no significant difference in clinical course or eventual outcomes noted with injection technique. There were 70 patients in each steroid cohort. Patients receiving triamcinolone required additional injections compared with those receiving methylprednisolone and dexamethasone. Eventual surgical intervention was significantly higher in those patients receiving methylprednisolone. The methylprednisolone group also underwent operative release significantly earlier. Conclusions: Trigger finger injections with triamcinolone demonstrate a higher rate of additional injections when compared with dexamethasone and methylprednisolone. Patients who underwent methylprednisolone injection had surgical release performed earlier and more frequently than the other 2 groups. The choice of corticosteroid significantly affected clinical outcome in this study population. Clinicians performing steroid injections for trigger finger may wish to consider these results when selecting a specific agent.

Dupuytren Disease Management Trends: A Survey of Hand Surgeons.

Background: Indication for intervention in Dupuytren disease is influenced by many factors, including location and extent of disease, surgeon preference, and comfort level with different treatment techniques. The aim of this study was to determine current Dupuytren disease management trends. Methods: A questionnaire was sent through the American Society for Surgery of the Hand to all members. In addition to demographic data, questions focused on indications for different procedural interventions based on location of disease, age, and activity level of the patient. Results: Approximately 24% of respondents completed the survey. Respondents were mostly orthopedic surgeons in private practice who do not work with residents or fellows. Respondents preferred collagenase over needle aponeurotomy and limited fasciectomy for primary Dupuytren disease involving only the metacarpophalangeal (MCP) joint. Limited fasciectomy was the preferred treatment for primary Dupuytren disease involving the MCP and proximal interphalangeal joints. For a patient amenable to any treatment option, the majority would use collagenase, although 87.1% felt that fasciectomy offered the longest disease-free interval. Furthermore, given the option of a young, working patient, 42.7% would use collagenase, while plastic and general surgeons were more likely to treat this patient with limited fasciectomy. More plastic surgeons (vs orthopedic) believe that limited fasciectomy yields the longest disease-free interval. For a patient amenable to any surgical option, orthopedic surgeons prefer collagenase, whereas plastic hand surgeons prefer a limited fasciectomy. Conclusion: There are several procedural options for the treatment of Dupuytren disease. This study details current practice patterns among hand surgeons and reveals the increasingly prevalent use of collagenase.