Many hand surgeons are moving away from traditional surgery to an approach that utilizes wide-awake local anesthesia.
In this segment, Dr.Naoh Shaftel, explains hand/wrist surgery utilizing a local anesthesia for certain procedures. The patient is wide awake during the surgery and can fully cooperate with the physician during the procedure.
The patient may be able to drive themselves to and from their surgery and there are limited side effects compared to general anesthesia. In addition, patients may be able to cut down on pain pills needed after surgery as patients might have pain relief just hours after surgery.
Selected Podcast
Local Anesthesia for Hand/Wrist Procedures
Featured Speaker:
Learn more about Noah Shaftel, MD
Noah Shaftel, MD
Noah Shaftel, MD earned his medical degree from The Ohio State University College of Medicine and Public Health, completed his residency at the University of Chicago Hospitals, and completed his specialty fellowship training in hand and upper extremity surgery at New York University's Hospital for Joint Diseases.Learn more about Noah Shaftel, MD
Transcription:
Local Anesthesia for Hand/Wrist Procedures
Melanie Cole (Host): Many hand surgeons are moving away from traditional surgery to an approach that utilizes wide awake local anesthesia. The goal of anesthesia for procedures involving the upper extremity is to provide the most comfortable and safe experience for the patient during surgery. Various options are available, each of which has particular benefits and risks. My guest today, is Dr. Noah Shaftel. He’s an Orthopedic Surgeon specializing in Hand and Upper Extremity Surgery with the Christ Hospital Health Network. Welcome to the show, Dr. Shaftel. Tell us a little bit about hand surgery. Has this been around awhile?
Dr. Noah Shaftel (Guest): Hand surgery really came into its own after World War II. Prior to that, there wasn’t a whole lot of focus on treatment for the hand. As the veterans returned from World War II with horrific hand injuries, a gentleman by the name of Sterling Bunnell was the first hand surgeon to address this. He set up several focused hand centers around the country for the military with the sole focus of treating the people coming home from war. Over the last 60 to 70 years now, developed what’s called the American Society for Surgery of the Hand, which is our big, National Organization, and has become a significant subspecialty in Orthopedics in terms of really, truly focused around treating the hand and the upper extremity.
Melanie: Explain a little bit about common reasons for hand and wrist procedures. What are you seeing today?
Dr. Shaftel: The most common things that hand surgeons typically see in their office are things related to carpal tunnel syndrome or trigger fingers. Those are probably the two most common diagnoses, although we treat a wide variety of problems from fractures in the hand and wrist to ligament injuries to tendon and nerve lacerations. Pretty much anything that falls into the hand or upper extremity lies within our subspecialty field.
Melanie: Give us some examples of surgeries that can be performed under local anesthetic.
Dr. Shaftel: The most common ones continue to be the things we see the most, so for instance, carpal tunnel syndrome, trigger fingers, or something called De Quervain’s releases. These are all surgeries that in the past had been done with either general anesthetic or a local anesthetic with sedation. Now, more and more frequently, we’re just doing under a local anesthetic. That applies to things like tendon repairs. It applies to things like fractures in the fingers and mass excisions, and other commonly seen diagnoses in the hand.
Melanie: Doctor, just because these surgeries you’re mentioning can be performed under local anesthetic, does it mean they should necessarily be performed that way?
Dr. Shaftel: They absolutely don’t have to be. For a long, long time, none of these procedures were done under local anesthetics. Recently, over the last five to ten years, or so, doing more and more things under local anesthetic has been popularized in the United States largely by the Canadian experience. A Canadian Hand Surgeon named Don LaLonde has quite a series of doing a lot of these types of procedures under local anesthetic and just brought it to the United States and started presenting at some of our meetings. It’s really taken off.
In my mind, the real reason that – the reason to do things under local anesthetic is number one, it’s safest for the patients. Even very sick patients -- patients who take blood thinners who previously would have been an anesthetic risk, can safely have their surgery under local anesthetic -- in a situation, which is really no different than if you were to go to the dentist, let’s say, to have a procedure. By far, it’s the safest. Number two, patients tend to like it. They’re awake and can chit-chat with you during the surgery, but they don’t have the grogginess or the nausea and vomiting that they can have under sedation or general anesthesia. That’s a big bonus. Patients love the fact that they don’t have to be fasting for surgery, that they can leave – literally change their clothes and leave right after the surgery. They sometimes can drive themselves to and from surgery without having anybody else with them. It really makes for a very efficient, smooth patient experience.
The last part of it, especially nowadays when people are very cost conscious or very cognizant of what they are responsible for in their medical bills is that it doesn’t require a clearance visit with their primary care doctor and the co-pay associated with that. It doesn’t require any charges for an anesthesia team with an anesthesiologist or the anesthesia to actually be administered. It actually has brought the cost down as well, in terms of what types of bills the patients are seeing after these surgeries. From a cost standpoint, from a convenience standpoint, and certainly, from a safety standpoint, it is certainly the easiest way to do it.
Melanie: Are there any disadvantages or clinical contraindications for the use of local?
Dr. Shaftel: Not very commonly. The medication we typically use is called Lidocaine with Epinephrine. The Lidocaine is the numbing portion of the medication, and the Epinephrine is a vasoconstricting or blood vessel constricting part of the medication that allows us to do the surgery without using a tourniquet. Allergies to either of those medications are exceedingly, exceedingly rare, and those medications have a long, well-documented history of being safe in just about anybody. The only times that we ever worry are very fragile patients from a cardiac standpoint, but most of them can certainly tolerate the amount of medication that we’re giving them. Other than that, most patients tolerate it very well without significant allergy. And really, there are very few exceptions to folks who can actually have a local anesthetic.
Melanie: Is there an issue regarding the metabolism of local anesthetic?
Dr. Shaftel: Not typically. The medications we use for this typically lasts for about three to five hours. Although, the actual concentrations in the blood are fairly low, but most folks don’t have any issues with the metabolism of it. There are occasionally people who seem to have difficulty getting numb, and people have expressed that to me in the past in terms of when they go to the dentist they have difficulty with being numbed up or things like that. The fact of the matter is that folks that really can’t be numbed up with this medication is exceedingly rare and only present in case reports in the medical literature.
Most people tolerate it well without any significant difficulties. The most common side effect of the medication is people just feeling a little bit jittery for a while, sort of like drinking a cup of coffee. Otherwise, it’s very well tolerated.
Melanie: Are you using the WALANT Approach?
Dr. Shaftel: Yes, so WALANT is the acronym that the gentleman from Canada had put together. It stands for Wide Awake Local Anesthesia with No Tourniquet. That’s been the technique that’s been starting to become popular in the United States, now.
Melanie: And that’s really increased the number that you can do in the same amount of time, yes? With the less cost as you mentioned earlier?
Dr. Shaftel: Correct. In the Operating Room, we don’t have to wait for the patient to be put under general anesthetic or sedation. We don’t have the time of waking up and going to sleep for surgery. The patients, we usually numb them up about 20 to 30 minutes before their surgery. They come in for surgery and then go home. They don’t have to spend much time in the recovery room waking up or dealing with nausea, so it really has streamlined the way we do surgery.
Melanie: And where do you perform these types of procedures? What locations are you available?
Dr. Shaftel: We typically perform these procedures at our surgery center on an outpatient basis. The vast majority of hand surgical cases can be done in an outpatient setting without the need for an inpatient stay. That’s where I’d say probably 95% of my cases are done in an outpatient surgery center.
Melanie: In summary, Doctor, tell other physicians what you’d like them to know about using local anesthesia for hand and wrist procedures and when to refer to a specialist.
Dr. Shaftel: Absolutely, I think it’s revolutionizing the practice of hand surgery. It certainly has done so in Canada, but it is starting to in the United States. It allows us to operate on folks who are much more critically sick without the typical risks associated with anesthesia. For all of the reasons we discussed previously – it makes it easier on the patient; it makes it easier on the surgeon, and I think everybody is happier.
The real time to refer to a hand specialist is for folks who have a hand, or wrist, or upper extremity problems that aren’t getting better with typical, conservative management options. Certainly, that’s the time when a referral is appropriate. I think even for patients we previously thought wouldn’t be able to tolerate surgery; this is certainly a way that allows them to have surgery that they need without introducing the risks that we previously had with anesthesia.
Melanie: And what can a physician expect from your team at the Christ Hospital Health Network after referral insofar as communication with the referring physician and your team approach?
Dr. Shaftel: Sure, so everybody, when they’re seen in the office here, every physician gets a letter reviewing what we discussed in the office and what the treatment plan is. That gets sent out at every visit to the referring physician. And certainly, if they have any concerns, we certainly encourage them to voice it. And otherwise, we have a very streamlined approach to getting people in, taking good care of them, and if they need surgery making sure that they have a good surgical experience.
Melanie: Thank you, so much, for being with us today. You’re listening to Expert Insights, Physician Views and News with the Christ Hospital Health Network. For more information on Dr. Shaftel and all of the Christ Hospital physicians, you can go to TCHPConnect.org, that’s TCHPConnect.org. This is Melanie Cole. Thanks, so much, for listening.
Local Anesthesia for Hand/Wrist Procedures
Melanie Cole (Host): Many hand surgeons are moving away from traditional surgery to an approach that utilizes wide awake local anesthesia. The goal of anesthesia for procedures involving the upper extremity is to provide the most comfortable and safe experience for the patient during surgery. Various options are available, each of which has particular benefits and risks. My guest today, is Dr. Noah Shaftel. He’s an Orthopedic Surgeon specializing in Hand and Upper Extremity Surgery with the Christ Hospital Health Network. Welcome to the show, Dr. Shaftel. Tell us a little bit about hand surgery. Has this been around awhile?
Dr. Noah Shaftel (Guest): Hand surgery really came into its own after World War II. Prior to that, there wasn’t a whole lot of focus on treatment for the hand. As the veterans returned from World War II with horrific hand injuries, a gentleman by the name of Sterling Bunnell was the first hand surgeon to address this. He set up several focused hand centers around the country for the military with the sole focus of treating the people coming home from war. Over the last 60 to 70 years now, developed what’s called the American Society for Surgery of the Hand, which is our big, National Organization, and has become a significant subspecialty in Orthopedics in terms of really, truly focused around treating the hand and the upper extremity.
Melanie: Explain a little bit about common reasons for hand and wrist procedures. What are you seeing today?
Dr. Shaftel: The most common things that hand surgeons typically see in their office are things related to carpal tunnel syndrome or trigger fingers. Those are probably the two most common diagnoses, although we treat a wide variety of problems from fractures in the hand and wrist to ligament injuries to tendon and nerve lacerations. Pretty much anything that falls into the hand or upper extremity lies within our subspecialty field.
Melanie: Give us some examples of surgeries that can be performed under local anesthetic.
Dr. Shaftel: The most common ones continue to be the things we see the most, so for instance, carpal tunnel syndrome, trigger fingers, or something called De Quervain’s releases. These are all surgeries that in the past had been done with either general anesthetic or a local anesthetic with sedation. Now, more and more frequently, we’re just doing under a local anesthetic. That applies to things like tendon repairs. It applies to things like fractures in the fingers and mass excisions, and other commonly seen diagnoses in the hand.
Melanie: Doctor, just because these surgeries you’re mentioning can be performed under local anesthetic, does it mean they should necessarily be performed that way?
Dr. Shaftel: They absolutely don’t have to be. For a long, long time, none of these procedures were done under local anesthetics. Recently, over the last five to ten years, or so, doing more and more things under local anesthetic has been popularized in the United States largely by the Canadian experience. A Canadian Hand Surgeon named Don LaLonde has quite a series of doing a lot of these types of procedures under local anesthetic and just brought it to the United States and started presenting at some of our meetings. It’s really taken off.
In my mind, the real reason that – the reason to do things under local anesthetic is number one, it’s safest for the patients. Even very sick patients -- patients who take blood thinners who previously would have been an anesthetic risk, can safely have their surgery under local anesthetic -- in a situation, which is really no different than if you were to go to the dentist, let’s say, to have a procedure. By far, it’s the safest. Number two, patients tend to like it. They’re awake and can chit-chat with you during the surgery, but they don’t have the grogginess or the nausea and vomiting that they can have under sedation or general anesthesia. That’s a big bonus. Patients love the fact that they don’t have to be fasting for surgery, that they can leave – literally change their clothes and leave right after the surgery. They sometimes can drive themselves to and from surgery without having anybody else with them. It really makes for a very efficient, smooth patient experience.
The last part of it, especially nowadays when people are very cost conscious or very cognizant of what they are responsible for in their medical bills is that it doesn’t require a clearance visit with their primary care doctor and the co-pay associated with that. It doesn’t require any charges for an anesthesia team with an anesthesiologist or the anesthesia to actually be administered. It actually has brought the cost down as well, in terms of what types of bills the patients are seeing after these surgeries. From a cost standpoint, from a convenience standpoint, and certainly, from a safety standpoint, it is certainly the easiest way to do it.
Melanie: Are there any disadvantages or clinical contraindications for the use of local?
Dr. Shaftel: Not very commonly. The medication we typically use is called Lidocaine with Epinephrine. The Lidocaine is the numbing portion of the medication, and the Epinephrine is a vasoconstricting or blood vessel constricting part of the medication that allows us to do the surgery without using a tourniquet. Allergies to either of those medications are exceedingly, exceedingly rare, and those medications have a long, well-documented history of being safe in just about anybody. The only times that we ever worry are very fragile patients from a cardiac standpoint, but most of them can certainly tolerate the amount of medication that we’re giving them. Other than that, most patients tolerate it very well without significant allergy. And really, there are very few exceptions to folks who can actually have a local anesthetic.
Melanie: Is there an issue regarding the metabolism of local anesthetic?
Dr. Shaftel: Not typically. The medications we use for this typically lasts for about three to five hours. Although, the actual concentrations in the blood are fairly low, but most folks don’t have any issues with the metabolism of it. There are occasionally people who seem to have difficulty getting numb, and people have expressed that to me in the past in terms of when they go to the dentist they have difficulty with being numbed up or things like that. The fact of the matter is that folks that really can’t be numbed up with this medication is exceedingly rare and only present in case reports in the medical literature.
Most people tolerate it well without any significant difficulties. The most common side effect of the medication is people just feeling a little bit jittery for a while, sort of like drinking a cup of coffee. Otherwise, it’s very well tolerated.
Melanie: Are you using the WALANT Approach?
Dr. Shaftel: Yes, so WALANT is the acronym that the gentleman from Canada had put together. It stands for Wide Awake Local Anesthesia with No Tourniquet. That’s been the technique that’s been starting to become popular in the United States, now.
Melanie: And that’s really increased the number that you can do in the same amount of time, yes? With the less cost as you mentioned earlier?
Dr. Shaftel: Correct. In the Operating Room, we don’t have to wait for the patient to be put under general anesthetic or sedation. We don’t have the time of waking up and going to sleep for surgery. The patients, we usually numb them up about 20 to 30 minutes before their surgery. They come in for surgery and then go home. They don’t have to spend much time in the recovery room waking up or dealing with nausea, so it really has streamlined the way we do surgery.
Melanie: And where do you perform these types of procedures? What locations are you available?
Dr. Shaftel: We typically perform these procedures at our surgery center on an outpatient basis. The vast majority of hand surgical cases can be done in an outpatient setting without the need for an inpatient stay. That’s where I’d say probably 95% of my cases are done in an outpatient surgery center.
Melanie: In summary, Doctor, tell other physicians what you’d like them to know about using local anesthesia for hand and wrist procedures and when to refer to a specialist.
Dr. Shaftel: Absolutely, I think it’s revolutionizing the practice of hand surgery. It certainly has done so in Canada, but it is starting to in the United States. It allows us to operate on folks who are much more critically sick without the typical risks associated with anesthesia. For all of the reasons we discussed previously – it makes it easier on the patient; it makes it easier on the surgeon, and I think everybody is happier.
The real time to refer to a hand specialist is for folks who have a hand, or wrist, or upper extremity problems that aren’t getting better with typical, conservative management options. Certainly, that’s the time when a referral is appropriate. I think even for patients we previously thought wouldn’t be able to tolerate surgery; this is certainly a way that allows them to have surgery that they need without introducing the risks that we previously had with anesthesia.
Melanie: And what can a physician expect from your team at the Christ Hospital Health Network after referral insofar as communication with the referring physician and your team approach?
Dr. Shaftel: Sure, so everybody, when they’re seen in the office here, every physician gets a letter reviewing what we discussed in the office and what the treatment plan is. That gets sent out at every visit to the referring physician. And certainly, if they have any concerns, we certainly encourage them to voice it. And otherwise, we have a very streamlined approach to getting people in, taking good care of them, and if they need surgery making sure that they have a good surgical experience.
Melanie: Thank you, so much, for being with us today. You’re listening to Expert Insights, Physician Views and News with the Christ Hospital Health Network. For more information on Dr. Shaftel and all of the Christ Hospital physicians, you can go to TCHPConnect.org, that’s TCHPConnect.org. This is Melanie Cole. Thanks, so much, for listening.