Time to Stop Routinely Prescribing Opiates after Carpal Tunnel Release.

BACKGROUND: North American surgeons continue to routinely order narcotic medication for postoperative pain relief after carpal tunnel surgery. For some patients, this instigates persistent use. This double-blind, multicenter trial investigated whether over-the-counter medications were inferior to opioid pain control after carpal tunnel release. METHODS: Patients undergoing carpal tunnel release in five centers in Canada and the United States (n = 347) were randomly assigned to postoperative pain control with (opioid) hydrocodone/acetaminophen 5/325 mg versus over-the-counter ibuprofen/acetaminophen 600/325 mg. The two primary outcome measures were the Numeric Pain Rating Scale (0 to 10) and the six-item Patient-Reported Outcome Measurement Information System Pain Interference T-score. Secondary outcome measures were total medication used and overall satisfaction with pain medication management. RESULTS: The authors found no significant differences between opioid and over-the-counter patients in the Numeric Pain Rating Scale scores, Pain Interference T-scores, number of doses of medication, or patient satisfaction. The highest Numeric Pain Rating Scale group difference was the night of surgery, when opiate patients had 0.9/10 more pain than over-the-counter patients. The highest group difference in Pain Interference T-scores (2.1) was on the day of surgery, when the opiate patients had more pain interference than the over-the-counter group. Patient nationality or sex did not generate significant pain score differences. CONCLUSIONS: Pain management is not inferior for patients managed with over-the-counter acetaminophen/ibuprofen versus opioids. This study provides high-quality evidence that U.S. and Canadian surgeons should stop the routine prescription of narcotics after carpal tunnel surgery for patients who are not taking pain medicines daily before surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The hyperthermic effect of a distal volar forearm nerve block: a possible treatment of acute digital frostbite injuries?

BACKGROUND: The authors have observed that carpal tunnel surgery nerve blocks consisting of subfascial distal volar forearm injection of 10 cc of 1% lidocaine with epinephrine result in fingers that appear hyperemic, warm, and numb in both median and ulnar nerve distributions. The purposes of this study were to (1) determine whether forearm nerve blocks in patients undergoing carpal tunnel releases result in an objective increase in finger temperature, and (2) document the location and duration of finger anesthesia. METHODS: Thirty-nine patients undergoing unilateral carpal tunnel release were studied prospectively. An infrared thermometer was used to measure the temperature in the fingers of operative and nonoperative hands before and after injection of local anesthetic. The distal volar forearm block was performed using 10 cc of 1% lidocaine with 1:100,000 epinephrine deep to the forearm fascia between the median and ulnar nerves 1 cm proximal to the wrist crease. Before and after carpal tunnel release, bilateral finger temperatures were measured at hourly intervals. Statistical analysis included a one-sample test of proportions. RESULTS: The finger temperature of the operative hand was significantly warmer than the unoperated hand over the first 2 hours after the nerve block. Seventy-four percent of patients had a statistically significant increase in temperature. On average, the nerve block lasted 6.27 hours in the median nerve distribution and 5.78 hours in the ulnar nerve distribution. CONCLUSIONS: Forearm nerve blocks produce a chemical sympathectomy that provides a significant increase in skin temperature as a result of vasodilatation in most patients. They also provide prolonged finger numbness. This could be of clinical benefit in patients with acute finger frostbite injuries.

Gillies elevation and percutaneous Kirschner wire fixation in the treatment of simple zygoma fractures: long-term quantitative outcomes.

BACKGROUND: The objective of zygoma fracture repair is to restore preinjury function and appearance. The optimal surgical technique represents a balance between accurate fracture reduction and soft-tissue morbidity. METHODS: Fifty patients were eligible for review after treatment for isolated simple zygoma fractures using a combination of Gillies elevation and percutaneous Kirschner wire fixation between 1992 and 2003. Fourteen patients were available for examination at a mean follow-up of 8.7 years. Quantifiable parameters, including orbitozygomatic complex position, ocular globe projection, and infraorbital nerve function, were measured. All patients underwent qualitative assessment by independent, blinded observers. Negative soft-tissue sequelae were recorded. RESULTS: The mean differences between injured and uninjured sides of the face for malar eminence projection, height, and lateral position were 2.5, 2.7, and 2.3 mm, respectively. The mean difference in ocular globe projection was 1.23 mm. When these results were compared with those previously published for open reduction and internal fixation, no statistically significant difference was noted. The qualitative observers were able to identify the affected side 12 percent of the time. Other than a small punctate scar noted in one patient at the Kirschner wire insertion site, no other negative cutaneous or eyelid sequelae were noted. CONCLUSIONS: This study objectively shows that Gillies elevation combined with percutaneous Kirschner wire fixation provides facial contour restoration that is not significantly different from that of open reduction and internal fixation, with less soft-tissue morbidity. The technique is safe, easy to learn, and easy to perform, and should be considered in cases of isolated simple zygoma fractures.

A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada.

BACKGROUND: Our goals were to analyze cost and efficiency of performing carpal tunnel release (CTR) in the main operating room (OR) versus the ambulatory setting, and to document the venue of carpal tunnel surgery practices by plastic surgeons in Canada. METHOD: A detailed analysis of the salaries of nonphysician personnel and materials involved in CTR performed in these settings was tabulated. Hospital statistical records were used to calculate our efficiency analysis. A survey of practicing plastic surgeons in Canada documented the venue of CTR performed by most. RESULTS: In a 3-h surgical block, we are able to perform nine CTRs in the ambulatory setting versus four in the main OR. The cost of CTR in the ambulatory setting is $36/case and $137/case in the main OR in the same hospital. Only 18% of Canadian respondents use the main OR exclusively for CTR, whereas 63% use it for some of their cases. The ambulatory setting is used exclusively by 37%, whereas 69% use it for greater than 95% of their cases. The majority of CTR cases (>95%) are done without an anesthesia provider by 73% of surgeons. Forty-three percent use epinephrine routinely with local anesthesia and 43% avoid the use of a tourniquet for at least some cases by using epinephrine for hemostasis. CONCLUSION: The use of the main OR for CTR is almost four times as expensive, and less than half as efficient as in an ambulatory setting. In spite of this, many surgeons in Canada continue to use the more expensive, less efficient venue of the main OR for CTR.

The no vertical scar breast reduction: a minor variation that allows to remove vertical scar portion of the inferior pedicle wise pattern T scar.

For the last 7 years, D.H. Lalonde has added the No Vertical Scar breast reduction to his armamentarium of reduction techniques. This operation is almost the same as the inferior pedicle T scar reduction. However, a small modification of the Wise pattern permits the deletion of the vertical portion of the T scar. The first 14 years of the Dr. Lalonde's practice consisted almost exclusively of the T scar reduction. He currently uses the Vertical reduction, the T reduction, and in over 150 cases, the No Vertical Scar reduction. Indications, technical details, and results of the No Vertical Scar reduction are discussed here.