gms | German Medical Science

Objectives/Interrogation: With local anesthesia and ultrasound-guided percutaneous procedures, it is now more often possible to perform hand surgery in minimal settings.

Indeed, the authors have reported morbidities in a continuous series of 1167 ultrasound-assisted hand procedures performed under local anesthesia in a clinic setting.

Methods: Over a period of 4 years, 1167 in-office procedures (787 patients) were performed using specific ultrasound-guided techniques (previously published) under local anesthesia. We included 372 trigger fingers, 516 carpal tunnel releases, 29 de Quervain releases and 243 Dupuytren contractures, 7 epicondylitis.

Exclusion criteria for office surgery were:

• ASA (American Society of Anesthesiologists) grade 3 or higher
• allergic history (latex, lidocaine)
• age over 85

Asepsis was achieved with a preoperative iodine shower and a 5-step antiseptic skin preparation.

Fasting was forbidden and disease-modifying treatments, including anticoagulants, taken as usual.

The WALANT technique was used for local anesthesia.

All procedures were performed percutaneously under ultrasound guidance. Surgical blades were proscribed, only a 18 gauge needle was used for skin incision. All the instruments were thinner than 1.5 mm, non-disposable and cost less than 50. Bandages were removed by the patient the day after surgery.

Morbidities were reported systematically:

• before surgery, during local anesthesia (vagal faintness, panic attack)
• during surgery (pain, excessive bleeding, faintness, mild heart attack)
• after surgery (infection, Sudeck's disease, hematoma, scarring problem)

Individual procedure efficacy was assessed in previous studies and not included in this series.

Results and Conclusions: Preoperative:

• 21 vagal faintness, including 7 syncopes with spontaneous resolution; 5 faintness with 3 syncopes in the last 1000 patients
• no panick attack

Operative:

• no pain felt
• no excessive bleeding, no specific hemostasis procedure needed

Postoperative:

• 1 infection in a trigger finger requiring re-operation
• 15 Sudeck's disease
• 9 mild hematoma after carpal tunnel release with spontaneous resolution

The combination of the WALANT technique and ultrasound-assisted procedures provides an original approach that can be used in a clinic setting.

The morbidities reported were at least equivalent to those published in standard operating theatre procedures; only one patient was re-operated (case of infection).

Hand surgery can be performed in good conditions as in-office surgery using local anesthesia and ultrasound guidance.