Birth and growth of an ultrasound hand surgery center — A review of 900 procedures

Abstract

With local anesthesia and new ultrasound-guided percutaneous procedures, it is now more often possible to perform hand surgery in minimal settings. Indeed, the authors argue that most hand surgery procedures could be performed in office surgeries. They have reported morbidities in a continuous series of 921 ultrasound-assisted hand procedures performed under local anesthesia in a clinic setting. Over a period of 3.5 years, 921 in-office procedures (635 patients) were performed using specific ultrasound-guided techniques (previously published) under local anesthesia. We included 265 trigger fingers, 418 carpal tunnel releases, 25 de Quervain releases and 202 Dupuytren contractures, 3 lateral epicondylitis, 8 flexor tendon sheath ganglions. Exclusion criteria for office surgery were: – ASA (American Society of Anesthesiologists) grade 3 or higher; – allergic history (latex, xylocaine…); – 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. Preoperative: – 18 vagal faintness, including 5 syncopes with spontaneous resolution; – no panick attack. Operative: – no pain felt; – no excessive bleeding, no specific hemostasis procedure needed; – no heart attack. Postoperative: – 1 infection in a trigger finger requiring re-operation; – 19 Sudeck's disease; – 10 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. Three vagal faintness (without syncope) was observed in the last 400 patients. 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.