Background: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. Methods: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. Results: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. Conclusion: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients.
Background: The use of minor field sterility in hand/upper extremity cases has been shown to improve workflow efficiency while maintaining patient safety. As this finding has been limited to specific procedures, we investigated the safety of performing a wide array of hand/upper extremity procedures outside the main operating room using minimal field sterility with Wide-Awake Local Anaesthesia No Tourniquet (WALANT) anaesthesia by evaluating superficial and deep infection rates across a diverse series of cases. Methods: This study was a case series conducted between October 2017 and June 2020. Of all, 217 patients underwent hand/upper extremity procedures performed in a minor procedure room via WALANT technique with field sterility. Primary outcome measures include superficial and deep surgical site infections within 14 days post-surgery. Results: Of all, 217 patients were included in this study; 265 consecutive hand/upper extremity operations were performed by a single surgeon, with notable case diversity. The majority of patients (n = 215, 99.1%) did not report or present with signs of infection before or after their operation. We report 0% 14-day and 0.37% 30-day surgical site infection rates for such hand/upper extremity procedures performed in a minor procedure room with field sterility. Conclusion: Hand/upper extremity procedures performed via WALANT technique with field sterility in a minor procedure room are associated with low surgical site infection rates. These rates are comparable to surgical site infection rates for similar surgeries performed in main operating rooms with standard sterilization procedures. Thus, the implementation of this technique may allow for improved workflow efficiency and reduced waste, all while maintaining patient safety.
Introduction Despite growth in hand/upper extremity investigation, impactful studies have not been thoroughly identified. Previous studies have been limited in scope. This study sought to identify and characterize the most impactful orthopaedic papers in hand/upper extremity over the past 25 years. Materials and Methods The top 1,000 hand/upper extremity orthopaedic studies published from 1992 to 2017 were identified with Web of Science. After screening for relevance in order of decreasing citation number, the top 100 articles were identified for bibliometric analysis. Results The mean number of authors and citations were 4.51 (range, 1–21) and 169.4 (range, 105–863). Common study types included, case series (n = 52), randomized controlled trial (n = 17), and prospective cohort (n = 16), which predominantly covered topics related to shoulder (n = 34), wrist/forearm (n = 21), and hand (n = 17). Among wrist/forearm and hand studies, distal radius fractures (n = 12) and nerve-related topics (n = 10) were most frequently analyzed. Most studies were of level IV (n = 51) and level II (n = 16) evidence. Recent studies had greater impact (mean citations/year: 2011, 82.7/year vs. 1992, 16.1/year). Conclusion Most of the 100 top orthopaedic articles in hand/upper extremity were of level IV or II evidence, retrospective, and nonrandomized. Despite an observed recent increase in level I studies, a lack of prospective, randomized trials is apparent.
Introduction: Between 2008 and 2017, the American Pyrotechnics Association reported a 41% increase in revenue from firework sales, with 2017 showing $885 million US dollars in consumer sales. We sought to evaluate the epidemiology of firework-related upper extremity injuries during this 10-year period, hypothesizing that hand/upper extremity injuries from fireworks were increasing in the United States. Methods: Observational epidemiologic assessment of a weighted cohort of patients via the National Electronic Injury Surveillance System from 2008 to 2017. The National Electronic Injury Surveillance System provides a nationwide probability sample of injuries related to consumer products based on emergency department visits collected from a cohort of about 100 US hospitals. Results: A total of 1,079 patients representing an estimated 41,195 firework-related upper extremity injuries presented to US emergency departments from 2008 to 2017. The number of injuries increased significantly from 2,576 in 2008 to 5,101 in 2017 (R2 = 0.85, R = 0.92, P < 0.001). A Spearman rank-order correlation determined that there was a strong, positive correlation between the increase in firework sales and the increase in injuries (rs = 0.939, P < 0.01). The overwhelming majority of firework-related injuries were seen in males (77%) aged 11 to 29 years (48%). The hand and fingers accounted for 85.8% of injuries, with the thumb being the most commonly injured body part (51.3%). Burns were the most common injury across all body sites except the wrist, where fractures were most common. Conclusion: Ten-year firework-related upper extremity injuries increased, corresponding to increased consumer sales across the same period. This study provides previously absent population-level data to provide a framework for discussion among policy makers and physicians alike in an attempt to mitigate the use of fireworks and their associated upper extremity injuries. Level of Evidence: Level III
With this patient-centered focus becoming the standard of care, the patient-physician relationship has simultaneously evolved. Many studies have documented a transition that emphasizes relationship-building. Physicians can provide better treatment when an emphasis is placed on communication of patient preferences, visit expectations, and overall goals for both patient and provider. 6 However, more socially taboo topics, such as sexual function, are often ignored. A questionnaire administered to 526 orthopedic surgeons and residents evaluated their ability to discuss sexual function with patients undergoing total hip arthroplasty. 7 This study found that 78% of respondents almost never addressed sexual function, mostly because Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com. Disclosure: Dr. Koehler is a committee member of the American Society for Surgery of the Hand (ASSH), a paid consultant for Integra LifeSciences, Inc, a paid consultant for Tissium, Inc., a stockholder and member of the medical advisory board for Reactiv, Inc., and a consultant for TriMed, Inc. The other authors have no financial interest to declare.
Background: Collagen nerve wraps (CNWs) theoretically allow for improved nerve gliding and decreased perineural scarring, and create a secluded environment to allow for nerve myelination and axonal healing. The goal of this study was to investigate the effect of CNWs on nerve gliding as assessed by pull-out strength and nerve changes in a rabbit model of peripheral neuropathy. Methods: Ten New Zealand rabbits were included. Sham surgery (control) was performed on left hindlimbs. To simulate compressive neuropathy, right sciatic nerves were freed of the mesoneurium, and the epineurium was sutured to the wound bed. Five rabbits were euthanized at 6 weeks [scarred nerve (SN); n = 5]. Neurolysis with CNW was performed in the remaining rabbits at 6 weeks (CNW; n = 5), which were euthanized at 22 weeks. Outcomes included peak pull-out force and histopathological markers of nerve recovery (axonal and Schwann cell counts). Results: The CNW group demonstrated significantly higher pull-out forces compared with the CNW sham control group (median: 4.40N versus 0.37N, P = 0.043) and a trend toward greater peak pull-out forces compared with the SN group (median: 4.40N versus 2.01N, P = 0.076). The CNW group had a significantly higher median Schwann cell density compared with the CNW control group (CNW: 1.30 × 10 −3 cells/μm 2 versus CNW control: 7.781 × 10 −4 cells/μm 2 , P = 0.0431) and SN group (CNW: 1.30 × 10 −3 cells/μm 2 versus SN: 7.31 × 10 −4 cells/μm 2 , P = 0.009). No significant difference in axonal density was observed between groups. Conclusion: Our findings suggest using a CNW does not improve nerve gliding, but may instead play a role in recruiting and/or supporting Schwann cells and their proliferation.
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