Basic Surgical Technique and Postoperative Care

Perioperative antibiotics

Although surgical site infections are uncommon after hand surgery, postoperative infection can occur, causing impairment of hand function, delaying rehabilitation and return to work. Severe infection may require multiple surgical procedures and result in permanent damage to the hand. The routine use of perioperative antibiotics for many orthopaedic procedures in the hand remains questionable. In three large series (one retrospective study involving 8850 patients, one prospective, randomized study involving 1340 patients, and one retrospective analysis of 516,986 patients gathered from a multistate commercial insurance claims database) there was no significant difference in the frequency of infection in patients who received perioperative antibiotics and those who did not. The prospective study also found no difference between elective and emergency surgery, between operations lasting 2 hours and those lasting longer, or between “clean” and “crush/dirty” wounds. Even in “high-risk” patients (smokers, those with diabetes mellitus, and those with longer operative procedure times) in the retrospective study, prophylactic antibiotics did not reduce the frequency of surgical site infection. Another study that evaluated the use of antibiotics for carpal tunnel release in patients with a prosthetic joint also found that antibiotics were not indicated. Although numerous studies have concluded that antibiotic prophylaxis should not be routinely administered for surgery of the hand, the rate of antibiotic use has steadily increased, with antibiotics being used in one of five clean soft-tissue hand surgeries.

Arrangement and routine in the operating room

Because surgical results depend considerably on the skill, judgment, and precise work of the surgeon, intraoperative distractions should be kept to a minimum. It is important for the surgeon to establish a standard routine that is followed regularly. Each assistant can then depend on this routine. The activities of the assistants in following this routine should not be disrupted by the surgeon with irregular, unexpected, or inconsistent demands. A standard routine makes it possible for assistants to know what is expected of them at each step in the operation and allows them to perform without hesitation, delay, or wasted motion.

The operating room should always be pleasant. If a local anesthetic is being used and the patient is awake, loud or inappropriate noises or bursts of conversation may alarm the patient and should be avoided. Sometimes music of the patient’s choosing is comforting.

If the surgical procedure is being arranged with the operating room staff, it is helpful to make requests regarding special needs for the case under consideration. Making advance arrangements for instruments, sutures, operating microscope, special implants, additional assistants, and other items enhances the efficiency of the operating team on the day of the procedure. Radiology support, including the use of C-arm fluoroscopy, should be arranged beforehand as well.

Five “be” attitudes on the part of the surgeon can increase efficiency in the operating room: (1) be punctual—if possible, be early; (2) be available—being present signifies to the surgical team that you are a member of the team; (3) be predictable—the less variation in the operating room routine, the more efficient it becomes; (4) be progressive—go from simple to complex; and (5) be gracious—it costs nothing, but buys a lot of goodwill.

The operating surgeon usually sits on a firm, comfortable, and stable stool and occasionally stands for some procedures. When sitting, the surgeon’s knees are almost level with the hips and the feet rest flat on the floor without strain. The working surface of the operating hand table should be at elbow height to provide a comfortable support for the forearms. When the light is directed perpendicular to the surgeon’s view, it shines directly on the operative field, and shadows are avoided.

Seated opposite the surgeon, the assistant should view the operative field from 8 to 10 cm higher than the surgeon to allow a clear line of vision without having to bend forward and obstruct the surgeon’s view. Although mechanical hand holders are available, they are not as good as a motivated and well-trained assistant ( Fig. 64.1 ). It is especially helpful for the assistant to be familiar with each procedure. Usually, the primary duty of the assistant is to hold the patient’s hand stable, secure, and motionless, retracting the fingers to provide the surgeon with the best access to the operative field ( Fig. 64.2A and B ). Using a mechanical holder such as a lead hand is better with untrained assistants.

The hand operating table should be stable and immobile. Space should be sufficient for the patient’s hand and for resting the elbows and forearms of the surgeon and assistant, minimizing muscle fatigue. For most procedures, the surgeon should sit on the axillary side of the involved extremity, allowing the anatomy of either hand to be seen in the same relative position. Some procedures on the dorsum of the hand and wrist may be performed more easily from the cephalic side. If the surgeon changes sides, keep in mind the change in routine to avoid anatomic disorientation.

The tray holding the basic instruments is often placed on a shelf extending from the operating table, level with the working surface. The instruments always should be arranged in the same order ( Fig. 64.3 ). This arrangement allows the surgeon to save time by routinely reaching for instruments from the basic tray. With practice, this can be done without the surgeon looking at the instruments.

Using an instrument pan or designated “hands-free” zone, the surgeon discards an instrument after using it, and the surgery technician returns it to its place on the tray. The discarded knife, tissue forceps, and dissecting scissors that are used constantly are not retrieved by the surgery technician unless requested by the surgeon. Special instruments should be readily available on another large table so that they can be handed quickly to the surgeon on request. Additional knife blades and special sutures and needles also should be immediately available.

Numerous hand conditions, such as infection, foreign bodies, and fractures, may now be effectively treated in procedure rooms with local anesthesia as opposed to formal operating rooms when appropriate. Studies have shown a significant reduction in the cost of these procedures without a significant difference in risk of complications.

Brachial plexus blocks

The traditional approaches for administering anesthesia to the major components of the brachial plexus include the axillary, interscalene, and supraclavicular and infraclavicular routes ( Fig. 64.4 ). The axillary and interscalene approaches we use most commonly probably are safer than the supraclavicular route, which carries the risk of a low incidence (1% to 5%) of pneumothorax. Infraclavicular and supraclavicular blocks are more commonly done now with ultrasound guidance. The interscalene block covers the supraclavicular nerves emanating from the third and fourth cervical roots and is ideal for shoulder surgery. Interscalene blocks can also be used for elbow surgery. Supraclavicular blocks are useful for surgery in the upper arm distal to the shoulder, whereas infraclavicular blocks can provide regional anesthesia for surgery of the elbow, forearm, wrist, and hand. An axillary block provides anesthesia similar to that of an infraclavicular block. Access to the axillary space requires the patient to abduct the arm 90 degrees, which may be difficult for those with trauma or contractures. Needle placement for brachial plexus blocks was traditionally based on anatomic landmarks and nerve localization with a nerve stimulator, but more recent approaches use an ultrasound approach. A meta-analysis of 13 studies comparing neurostimulation with ultrasound-guided blocks found that ultrasound-guided blocks were more likely to be successful, took less time, had a faster onset, and decreased the risk of vascular puncture. A study of the multiple-injection technique for axillary block showed that ultrasound guidance resulted in fewer needle passes, a shorter time to onset of anesthesia, and less procedure-related pain than nerve stimulation techniques. Limitations of ultrasound include availability, a limited plane of view, and highly operator-dependent image quality.

Short- and long-acting local anesthetic agents can be used for brachial plexus blocks. The dose depends on the agent used, the technique used, and the preference of the administering physician. Although the amount of anesthetic used is not standardized, maximal amounts have been recommended ( Table 64.1 ). Evidence exists that multiple-injection block is more effective than single or double-injection block in obtaining and maintaining anesthesia; no statistically significant differences have been noted regarding secondary analgesia failure, complications, or patient discomfort.

Complications of brachial plexus blocks are few (<1%). Reported systemic complications include cardiac arrest, respiratory failure, and seizures. Peripheral nerve injury can be caused by mechanical trauma from needles or catheters, drug neurotoxicity, ischemia, compression, or stretch, but permanent neurologic sequelae occur in less than 1% of patients. Pneumothorax is most common with supraclavicular blocks (as high as 6%) but has been reported with interscalene and infraclavicular blocks. Ultrasound-guided technique has been suggested to reduce the risk of pneumothorax: a prospective study found no clinically apparent pneumothoraces in 510 patients who had ultrasound-guided supraclavicular blocks.

Contraindications to axillary brachial plexus block include infection in the axilla, axillary lymphadenopathy, and malignancy.

Dysesthesias and “brachialgia” may persist after brachial plexus blocks, and the patient should understand this before the block. It also might create difficulty in patients who require fine manipulation of the hands in their occupation.

Intravenous regional anesthesia

The intravenous regional anesthesia technique using a double tourniquet (Bier) is useful, especially for procedures of relatively short duration (60 to 90 minutes). A specially designed double tourniquet is used. The patient should be satisfactorily premedicated, and intravenous infusion should be in place in the contralateral arm. The usual anesthetic agent is lidocaine. In most situations, 30 to 60 mL of 0.5% lidocaine provides sufficient and safe anesthesia. Adjuncts to lidocaine also have shown some benefit in analgesia and tourniquet pain. The dosage used should take the patient’s age and body weight into consideration. Satisfactory anesthesia can be obtained in a short time. The tourniquet is left inflated for a minimum of 30 minutes after injection of the anesthetic agent into the extremity. In the usual situation, the limb is exsanguinated; the proximal tourniquet is inflated to a level 100 mm Hg greater than the systolic pressure (usually 250 to 300 mm Hg); and, using sterile technique, the anesthesiologist intravenously introduces the previously determined volume of anesthetic agent ( Fig. 64.5 ). As the more proximal tourniquet becomes uncomfortable, the distal tourniquet is inflated and the proximal tourniquet is deflated. Reported reactions during intravenous regional anesthesia include anesthetic toxicity, cardiac arrhythmias (bradycardia and cardiac arrest), unconsciousness, seizures, vertigo, nystagmus, and compartment syndrome.

The use of a forearm tourniquet for intravenous regional anesthesia has been suggested, with reported advantages of safety, preservation of hand motor function, lower anesthetic dose, and reduced risk of complications. One study of 430 patients demonstrated no major complications when tourniquet time was less than 20 minutes.

Peripheral nerve blocks

The median, radial, and ulnar nerves can be blocked at the wrist. In terms of surgical time, tourniquet time, and postoperative pain, no difference has been noted between forearm blocks and brachial plexus blocks; however, forearm blocks are extremely helpful for brief procedures ( Fig. 64.6 ), and a tourniquet may not be required or may be used only for a short period (usually ≤30 minutes). Blocks at the wrist can be especially useful for procedures such as tenolysis and capsulotomy because motion of the fingers can be observed during surgery. The patient can be kept comfortable, and a tourniquet can be used longer than 30 minutes if the patient is adequately sedated. Kocheta and Agrawal described adding posterior interosseous and anterior interosseous nerve blocks to a wrist block for more effective carpal surgery. Regardless of the surgical location, it is essential to know the location of the respective nerves before attempting regional blocks. Ultrasound may be useful in this regard. One study found that nonultrasound-guided median nerve blocks at the wrist were unreliable in effectiveness and took up to 40 minutes for maximal numbness to occur and up to 100 minutes for maximal anesthesia. Contraindications to peripheral nerve blocks include infection in the proposed area of injection, history of allergy to the anesthetic, or a patient who is unable to communicate pain.

Digital nerve blocks

Digital nerve blocks provide excellent anesthesia for procedures on the fingers ( Fig. 64.7 ). Usually, perineural injection around the digital nerves proximal to the finger web spaces is a safer technique than injection of the nerves at the base of the fingers. Because ischemia may develop after injection of an anesthetic agent in a circle around the base of the finger, this technique should be avoided. Digital blocks using a transthecal (flexor sheath) approach have shown no advantage compared with the traditional digital block technique ( Fig. 64.8 ), but may be tolerated better because it is a single injection rather than two separate injections. We rarely use epinephrine in the local anesthetic agent in the digits, although it can be used safely.

If hemostasis is required, traditionally a Penrose drain or a French rubber catheter applied around the finger has provided satisfactory and safe ischemia. Commercially available finger tourniquets and the finger of a rubber glove cut to allow it to be rolled onto the finger as a tourniquet also are effective tools ( Fig. 64.9 ). Pressures achieved beneath these tourniquets cannot be determined accurately; caution is advised. At times, especially in the elderly and patients with vascular disorders in the fingers (e.g., Raynaud disease, atherosclerosis, diabetes), vascular insufficiency may develop in the digit, and care should be taken when using digital tourniquets in these patients ( Fig. 64.10 ). If a rubber glove is used, special attention is essential to ensure it is removed at the end of the procedure: there are reports of catastrophic consequences after such a tourniquet was left on a digit.

Local infiltration

Local infiltration of an anesthetic agent may be used for more proximal conditions that do not require deep, extensive dissection. This method is satisfactory for trigger digit release, small scar revision, and excision of benign masses from the skin and subcutaneous tissues of the forearm, hand, and fingers.

Walant approach

There has been a move away from the traditional tourniquet and sedation protocol to the WALANT approach for outpatient hand and wrist surgery. Suggested benefits of the WALANT approach include (1) increased patient comfort and convenience, (2) decreased operative time for minor procedures such as carpal tunnel and trigger finger releases, (3) significant cost reductions, and (4) ability to see sutured tendons, and bones and joints with fracture fixation, during a full range of active movement, which can improve functional outcomes. The WALANT approach can be used for a variety of outpatient hand and wrist procedures, with the location of injection and the volume of anesthetic agent differing between them ( Table 64.2 ). Although the technique is not appropriate for all patients, it can be used in most patients who can, for instance, have dental procedures without sedation. Specific procedures for which WALANT is effective include flexor tendon repair, tendon transfer, and soft-tissue releases. It has also been used for phalangeal and metacarpal fracture treatment. The primary advantage of this procedure is that it avoids the use of a tourniquet, reducing patient pain and the risk of injury to the nerves or skin. Patient satisfaction is high with this method because there are no sedation side effects, and faster recovery has been noted. Also postoperative narcotic use has been reported to be less than with other forms of anesthesia.

TABLE 64.2

Typical Volumes Used for Common Operations

Modified from Lalonde DH, Wong A: Dosage of local anesthesia in wide awake hand surgery, J Hand Surg 38:2025, 2013.

Operation	Typical Volume of 1% Lidocaine with 1:100,000 Epinephrine and 8.4% Bicarbonate (Mixed 10 mL:1 mL)	Location of Injection
Carpal tunnel	20 mL	10 mL between ulnar and median nerves (5 mm proximal to wrist crease and 5 mm ulnar to median nerve); another 10 mL under incision
Trigger finger	4 mL	Subcutaneously beneath the center of the incision
Finger sensory block (SIMPLE)	2 mL	Volar middle of proximal phalanx just past palmar-finger crease
Finger soft-tissue lesions or other surgery when finger base tourniquet is not desirable and finger epinephrine is used for hemostasis	5 mL volar distributed among 5 phalanges, 4 mL dorsal split between 2 phalanges	2 mL volar and 2 mL dorsal subcutaneous midline fat, in both proximal and middle phalanges. Distal phalanx gets only 1 mL midline volar, just past the DIP crease
PIP arthrodesis	8 mL total, 4 mL volar (2 in each phalanx) and 4 mL dorsal (2 in each phalanx)	2 mL midvolar and another 2 mL middorsal of both proximal and middle phalanges
Thumb MCP arthrodesis and collateral ligament tears of the MCP joint	15 mL	2 mL on each of volar and dorsal aspects of proximal phalanx and the rest all around the metacarpal head
Dupuytren contracture or zone II flexor tendon repair	15 mL/ray	10 mL (or more) in the palm; 2 mL in the proximal and middle phalanges and 1 mL in the distal phalanx (if required)
Trapeziectomy or Bennett fracture	40 mL	Radial side of the hand under the skin and all around the joint, including the median nerve. If LRTI is performed, decrease concentration to 0.5% lidocaine with 1:200,000 epinephrine, and also inject all around where FCR or APL will be dissected
Metacarpal fractures	40 mL	All around the metacarpal where dissection or K-wires will occur

APL , Abductor pollicis longus; DIP , distal interphalangeal joint; FCR , flexor carpi radialis; LRTI , ligament reconstruction and tendon interposition; MCP , metacarpophalangeal joint; PIP , proximal interphalangeal joint; SIMPLE , single subcutaneous injection in the middle of the proximal phalanx with lidocaine and epinephrine.

WALANT uses a combination of lidocaine or bupivacaine and epinephrine to obtain hemostasis and anesthetize the area of the surgical procedure. As with any local anesthetic use, adverse reactions are possible but rare. Nevertheless, patients require monitoring for hypotension, seizures, cardiac dysrhythmias, and other complications. In the past the use of epinephrine in the hand or foot was believed to cause necrosis and gangrene, but this has been refuted by several studies. In a multicenter, prospective study of 3110 patients who had hand or finger epinephrine injections, none developed skin necrosis or digital tissue loss. If a local adverse reaction occurs from the use of epinephrine in the finger, phentolamine, a vasodilator, can be used for reversal of epinephrine-induced vasoconstriction.

Walant Administration ( Box 64.1 )

Two mL of 1% lidocaine with epinephrine (1:100,000) is injected into the palmar and dorsal subcutaneous tissues ( Fig. 64.11 ). If only a sensory block is required, a single subcutaneous dose of lidocaine and epinephrine is injected in the midline of the proximal phalanx (SIMPLE technique) ( Fig. 64.11A ). Lalonde and Wong recommend no more than 1 mL for distal phalangeal procedures. Although some studies support the safe use of up to 35 mg/kg of lidocaine with epinephrine, the accepted maximal dose is 7 mg/kg (50 mL for 150 lb patient).

BOX 64.1

Tips for Administering WALANT (Lalonde & Wong 2013)

From: Steiner MM, Calandruccio JH: Use of wide-awake local anesthesia no tourniquet in hand and wrist surgery, Orthop Clin North Am 49(1):63, 2018.

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  Pain during administration can be reduced by several methods:

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    Buffering the solution: a solution of lidocaine 1% with 1:100,000 epinephrine has a pH of 4.2, which likely contributes to the pain with injection. A 1:20 ratio of 8.4% sodium bicarbonate to lidocaine 1% with 1:100,000 epinephrine has a more physiologic pH of 7.4. A Cochrane review concluded that patients much preferred buffered lidocaine to unbuffered lidocaine; the difference was even more pronounced when the solution contained epinephrine.

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    Warming the solution.

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    Using a smaller needle (27- or 30-gauge or smaller).

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    Choosing the correct angle for needle insertion: A randomized, controlled crossover trial of 65 patients showed that injections with needles oriented at 90 degrees were significantly less painful than those with needles oriented at 45 degrees.

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    Injecting the solution under the dermis: In their double-blind, prospective trial, Arndt et al. found that subdermal injections produced less pain than intradermal injections. Strazar et al. suggested that this occurred because the space-occupying effect of the solution stretches the tissue, producing more pain in the densely innervated dermal tissue.

Some surgeons prefer bupivacaine to lidocaine because of its longer action, but intravascular bupivacaine has been associated with cardiotoxicity, and the pain block provided by bupivacaine lasts only half the time as the return to normal sensation. Pain while the area is still numb is a common complaint in patients. Adding epinephrine will prolong the pain relief but only for about 1.5 hours; patients should be informed that pain sensation will return before the numbness resolves. Using lidocaine, pain and sensation return at the same time, and most surgeries in the hand can be done within the anesthesia time provided by lidocaine with epinephrine (5 hours in the wrist, 10 hours in the finger). Bupivacaine can be used for procedures expected to last 3 hours, although pain may be severe thereafter.

Maximal vasoconstriction after injection of lidocaine with epinephrine can be expected at 25 minutes, after which time optimal visibility of the operative field is obtained. McKee et al. recommend waiting 30 minutes after injection before incision.