Wide Awake Trigger Finger Release Surgery: Prospective Comparison of Lidocaine, Marcaine, and Exparel

Enhanced Recovery After Surgery: Standardized Postoperative Instructions in Hand Surgery

Background: Enhanced Recovery After Surgery (ERAS) is a standardized approach to care of the surgical patient. Postoperative patient instructions, an aspect of ERAS protocols, are difficult to standardize in hand surgery because of the diversity of procedures. The aim of this study was to determine the effect of standardized hand surgery postoperative instructions on the number of unscheduled postoperative patient encounters. Methods: The study was an institutional review board-approved prospective cohort in which all hand surgery patients from 6 surgeons at a single, hospital-based academic institution were included. For a 6-month period, both before and after establishing a standardized postoperative instructional handout, data were collected on unscheduled postoperative encounters within 14 days of surgery. Results: There were 330 patients in the control group versus 282 who received standardized postoperative instructions. Trauma comprised 24.6% of cases in comparison to 75.4% elective. Individual surgeons did not significantly influence whether patients had an encounter. Overall, patients who received standardized instructions were just as likely as the control group to have unscheduled encounters (41.5% vs 43.9%, respectively). Notably, elective patients were significantly more likely to have encounters (46%) versus trauma patients (33.1%; P = .007); however, the standardized instructions did not influence the number of encounters for either group. Conclusions: This study did not demonstrate a difference in unscheduled postoperative encounters after initiation of standardized postoperative instructions for hand surgery patients. These findings may help providers save time and resources by tailoring the use of ERAS in this distinct patient population.

Wide Awake Local Anesthesia No Tourniquet Technique in Hand Surgery: The Patient Experience

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.

Will the Use of Intraoperative Liposomal Bupivacaine During Thumb Carpometacarpal Arthroplasty Decrease Postoperative Use of Opioids? A Prospective Randomized Study

PURPOSE

This study evaluated the use of intraoperative local injection of liposomal bupivacaine to decrease opioid use in the early postoperative period for patients undergoing outpatient thumb carpometacarpal joint arthroplasty.

METHODS

A prospective, randomized, controlled, single-blinded study was designed to compare 2 groups of patients for opioid use, pain scores, and nonopioid pill consumption within 5 days after surgery. The investigational group received an intraoperative injection of 10 ml (133 mg) liposomal bupivacaine. The control group received no local anesthetic. All patients were anesthetized with a standardized supraclavicular nerve block and were prescribed equal amounts of oral narcotic analgesic. Outcomes were assessed by collecting the data from postoperative patient-reported diaries.

RESULTS

The experimental group reported a significantly lower total opioid consumption for the 5 days after surgery. Daily opioid use, as measured by both opioid pill equivalent count and morphine milligram equivalent in addition to postoperative pain scores and nonopioid pill consumption, was not different between groups.

CONCLUSIONS

Intraoperative injection of liposomal bupivacaine was shown to decrease total opioid intake during the 5 days after thumb carpometacarpal arthroplasty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Patient Satisfaction and Opioid Use With a Postoperative Opioid Protocol After Common Hand Procedures

Purpose

Given the state of the opioid crisis and national pressure to minimize prescriptions, pain management after common hand procedures can pose a challenge for patients and providers. Despite the volume of recent literature on prescribing protocols and over-the-counter (OTC) medications, patient satisfaction has not been adequately assessed. The purposes of this study were (1) to investigate patient satisfaction with pain management using an opioid prescribing protocol after common hand procedures, and (2) to evaluate medication use in the postoperative period using this opioid prescribing protocol.

Methods

A prospective survey was administered to 100 consecutive patients undergoing common soft tissue hand procedures at a Level I academic institution over a 5-month period. The medical record was reviewed for demographics and the number or dosage of opioid pills prescribed. The survey was conducted at 2 time points within 2 weeks after the procedure and assessed the number of opioid pills taken, use of OTC medications, visual analog scale (VAS) pain score, and satisfaction with pain management and surgery.

Results

Mean number of opioid pills consumed at 2 weeks after the procedure was 1.5; 19 patients consumed all of their prescribed opioid pills. Acetaminophen was the most commonly used OTC medication and 84 patients reported using OTC medication in the postoperative period. The average VAS score at the end of the study period was 1.7. Nearly all patients were satisfied with the pain management and surgery; no patients received a second opioid prescription.

Conclusions

We found that patients consumed far fewer opioid pills than were prescribed to them. We also found that patients who took more opioid pills had higher VAS pain scores, with lower satisfaction in both categories. The cohort demonstrated effective control of pain with high satisfaction, indicating that an opioid protocol is a successful and patient-accepted tool for managing postoperative pain.

Type of study/level of evidence

Therapeutic IV.

Office-based, Minimal-Incision Modified Fenestration Technique for Symptomatic Hydroceles Under Local Anesthesia

OBJECTIVE

To describe a minimal-incision modified fenestration technique (MIMFeT) for symptomatic hydroceles utilizing local anesthesia.

METHODS

A database was maintained for men undergoing in-office MIMFeT for symptomatic hydroceles between June 2015 and August 2018. Following local anesthesia, the hydrocele was sequentially everted through a small upper hemiscrotal incision, excised, and oversewn without delivering the testicle through the wound. Patient demographics and clinical outcomes were subsequently reviewed.

RESULTS

A total of 54 men (median age 67) underwent MIMFeT under local anesthesia for symptomatic hydrocele. Median estimated hydrocele size was 250 mL (IQR 150;500). Medical comorbidities included coronary artery disease (12%), hypertension (43%), diabetes (13%), and current antiplatelet or anticoagulant (44%) use. Six patients (11%) were deemed unsafe for monitored or general anesthesia. About 48 patients had follow-up data available (median 9 months; IQR 2-18). Mild recurrent scrotal swelling occurred in 4 patients (8%) and 9/48 (18%) experienced postoperative complications including hematoma (n = 2), prolonged pain (n = 3), wound infection (n = 2), and partial incisional separation (n = 2). No patient required repeat hydrocelectomy.

CONCLUSION

Our early results suggest that the MIMFeT for management of symptomatic hydroceles can be safely performed in the office setting under local anesthesia, including in those patients who are determined to be unsafe for monitored and general anesthesia.

Opioid-Sparing Pain Management in Upper Extremity Surgery: Part 1: Role of the Surgeon and Anesthesiologist

A multimodal pain management strategy combines complementary medications and techniques, targeting unique pathways, to improve overall analgesic effect and reduce opioid requirements. In this 2-part review, we examine the literature identifying nonopioid analgesic modalities and their targets in the pain pathway as well as anesthetic techniques found to be opioid-sparing in the practice of upper extremity surgery. First, we focus on operative anesthesia and analgesia and areas for future research specific to upper extremity surgery. In part 2, we discuss the nonopioid options available after surgery.

A Critical Appraisal of Adult Trigger Finger: Pathophysiology, Treatment, and Future Outlook

Trigger finger (TF) is a common referral to a hand surgeon, with people with diabetess being the most at-risk population. Abnormal thickening, scarring, and inflammation occur at the A1 pulley and flexor tendon, and histological changes correlate well with the clinical severity of TF. Corticosteroid injections decrease the thickness of the A1 pulley and are considered a first-line treatment. However, corticosteroids are only moderately effective, especially for people with diabetes. Patients may elect for surgery if nonoperative treatments prove ineffective; some may choose immediate surgical release instead. To release the A1 pulley, patients have the option of an open or percutaneous approach. The open approach has a greater risk of infection and scar tissue formation in the short run but an overall superior long-term outcome compared with the percutaneous approach.

METHODS

We critically reviewed the efficacy and cost-effectiveness of the treatment methods for TF through a comprehensive search of the PubMed Database from 2003 to 2019.

RESULTS

To reduce costs, while still delivering the best possible care, it is critical to consider the likelihood of success for each treatment method in each subpopulation. Furthermore, some patients may need to return to work promptly, which ultimately may influence their desired treatment method.

CONCLUSIONS

Currently, there is no universal treatment algorithm for TF. From a purely financial standpoint, women without diabetes presenting with a single triggering thumb should attempt 2 corticosteroid trials before percutaneous release. It is the most cost-effective for all other subpopulations to elect for immediate percutaneous release.

Nanotechnology: A Promising New Paradigm for the Control of Pain

Objective

The objective of this article is to critically review both preclinical and clinical studies that focus on the use of nanotechnology for both acute and chronic pain management, surveying both diagnostic and therapeutic applications. The article also provides information on nanotechnology for pain practitioners, so that they may better understand how this technology works and how it may be applied to their day-to-day clinical practice.

Study Design

Narrative review.

Methods

The Pubmed NCBI and EMBASE databases were utilized to review published reports of in vivo and clinical studies that focus on using nanotechnology for pain management applications in both the acute and chronic pain settings.

Results

Articles were screened by title, abstract, and full article review. They were then analyzed by specific clinical indications, and appropriate data were presented based on a critical analysis of those articles.

Conclusions

As the development of nanomedical applications in acute and chronic pain management continues, medical practitioners should consider their growing potential to enhance the care of patients who are consistently living with pain. Current barriers to implementation include manufacturing scale-up for commercial viability, long-term nanoparticle toxicity considerations, and high cost for successful passage through clinical trials. These challenges will need to be overcome with ongoing translational research efforts in collaboration with industry and government bodies such as the Food and Drug Administration (FDA).

Opioid Use After Upper Extremity Surgery

Ever since the institution of pain as the fifth vital sign, there has been a rising opioid epidemic in the United States, with Americans now consuming 80% of the global opioid supply while representing only 5% of the world's population. Surgeons are tasked with the duty of both managing patients' pain in the perioperative period and following responsible prescribing behaviors. Several articles have been published with the goal of evaluating opioid use after upper extremity surgery, risk factors for opioid misuse/abuse, the impact of anesthetic type, and the role of multimodal pain management regimens. These studies have found that, on average, surgeons prescribe 2 to 5 times more opioids than patients consume. Multimodal pain management strategies are effective for decreasing postoperative opioid consumption. Risk factors for prolonged opioid use and/or misuse are younger age, history of substance abuse, psychological disorders, and previous pain diagnoses. Use of regional blockade anesthesia, particularly with long-acting agents or indwelling catheters, can be helpful in the management of postoperative pain. This review article summarizes the available literature regarding opioid use after upper extremity surgery to provide the surgeon with additional information to make informed decisions regarding postoperative opioid prescription.

A Prospective Randomized Study Comparing Bupivacaine Hydrochloride Versus Bupivacaine Liposome for Pain Management After Distal Radius Fracture Repair Surgery

PURPOSE

To compare pain experience and opioid use after distal radius fracture repair surgery performed with perioperative infiltration of the local anesthesia bupivacaine hydrochloride (Marcaine; Pfizer, New York, NY) or bupivacaine liposome (Exparel; Pacira, Parsippany, NJ).

METHODS

We conducted a prospective comparison of consecutive patients scheduled to undergo distal radius fracture repair surgery. Patients were randomized to either Marcaine or Exparel. Patients in the Marcaine group received 20 mL 0.5% bupivacaine without epinephrine into the incision and surgical site before incision. Patients in the Exparel group first received 10 mL 0.5% Marcaine with no epinephrine into the incision and surgical site before incision; then, upon completion of the surgery and wound closure, they also received 10 mL Exparel into the same site that had been preinjected with Marcaine. All operations were performed with the same surgical technique. Daily opioid pill consumption, pain levels, and any adverse reactions were recorded from postoperative days 0 to 5.

RESULTS

On the day of surgery, patients in the Exparel group reported significantly lower pain levels (3.9 vs 5.8) and consumed significantly fewer prescribed opioid pills (1.2 vs 2.0) compared with patients in the Marcaine group. However, there were no other significant differences between the Exparel and Marcaine groups on any subsequent days or in the total number of pills consumed at the end of the study period (7.5 vs 8.9 pills, respectively). No major adverse reactions were noted in either group.

CONCLUSIONS

Exparel use was found to result in decreased pain and opioid consumption only on the day of surgery and not thereafter.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Perioperative Pain Management for Upper Extremity Surgery

Upper extremity surgeons are currently faced with a daunting array of anesthesia techniques, ranging from traditional general anesthesia to wide-awake surgery, during which patients can watch their surgeons operate in the morning and return to work as soon as that afternoon. This range of options means that surgeons must consider patient-related factors such as disease process and relevant comorbidities, as well as surgery-related factors such as anatomic location, complexity, length of procedure, and postoperative pain expectations. In general, the least invasive technique is favored, but each patient must be considered individually to ensure the best anesthesia choice.