Wide Awake Open Carpal Tunnel Release: The Effect of Local Anesthetics in the Postoperative Outcome

Introduction  Wide awake open carpal tunnel decompression is a procedure performed under local anesthesia. This study aimed to present the effect of various local anesthetics in peri and postoperative analgesia in patients undergoing this procedure. Materials and Methods  A total of 140 patients, with 150 hands involved, underwent carpal tunnel release under local anesthesia. Patients were divided in five groups according to local anesthetic administered: lidocaine 2%, ropivacaine 0.75%, ropivacaine 0.375%, chirocaine 0.5%, and chirocaine 0.25%. Total 400 mg of gabapentin were administered to a subgroup of 10 cases from each group (50 cases totally), 12 hours before surgery. Patients were evaluated immediately, 2 weeks and 2 months after surgery according to VAS pain score, grip strength, and two-point discrimination. Results  In all patients, pain and paresthesia improved significantly postoperatively, while the use of gabapentin did not affect outcomes. Grip strength recovered and exceeded the preoperative value 2 months after surgery, without any difference between the groups. No case of infection, hematoma, or revision surgery was reported. Conclusion  Recovery after open carpal tunnel release appears to be irrelevant of the type of local anesthetic used during the procedure. Solutions of low local anesthetic concentration (lidocaine 2%, ropivacaine 0.375%, and chirocaine 0.25%) provide adequate intraoperative analgesia without affecting the postoperative course.     

Updates in our understanding of local anaesthetic systemic toxicity: a narrative review

Despite advances in clinical practice, local anaesthetic systemic toxicity continues to occur with the therapeutic use of local anaesthesia. Patterns of presentation have evolved over recent years due in part to the increasing use of ultrasound which has been demonstrated to reduce risk. Onset of toxicity is increasingly delayed, a greater proportion of clinical reports are secondary to fascial plane blocks, and cases are increasing where non-anaesthetist providers are involved. The evolving clinical context presents a challenge for diagnosis and requires education of all physicians, nurses and allied health professionals about these changing patterns and risks. This review discusses: mechanisms; prevention; diagnosis; and treatment of local anaesthetic systemic toxicity. The local anaesthetic and dose used, site of injection and block conduct and technique are all important determinants of local anaesthetic systemic toxicity, as are various patient factors. Risk mitigation is discussed including the care of at-risk groups, such as: those at the extremes of age; patients with cardiac, hepatic and specific metabolic diseases; and those who are pregnant. Advances in the changing clinical landscape with novel applications and settings for the use of local anaesthesia are also described. Finally, we signpost future directions to potentially improve the management of local anaesthetic systemic toxicity. The utility of local anaesthetics remains unquestionable in clinical practice, and thus maximising the safe and appropriate use of these drugs should translate to improvements in patient care.     

Reconstruction of Soft Tissue Defects in the Hand with a Free Anterolateral Thigh Deep Fascia Flap

ObjectiveTo report our experience in the reconstruction of soft tissue defects in the hand with a free anterolateral thigh deep fascia flap and describe the clinical outcomes.MethodsThis study was a retrospective trial. From November 2016 to January 2020, six patients (four men and two women) with soft tissue defects in the hand were included in this study. The average age of the patients was 33.7 ± 12.7 years (range, 20 to 50 years). All patients underwent reconstructions with free anterolateral thigh deep fascia flaps. Relevant clinical characteristics were recorded prior to surgery. The size and thickness of the deep fascia flap and the thickness of the skin were measured intraoperatively. The survival of the flaps and skin grafts and the occurrence of infection were recorded after the operation. At follow‐up, donor site complications and postoperative effects were evaluated according to the outcome satisfaction scale. The pain in the injured hand was assessed using the visual analog scale.ResultsThe average body mass index (BMI) was 26.6 ± 1.7 kg/m² (range, 23.9 to 28.7 kg/m²). The defect sizes ranged from 5 cm × 5 cm to 13 cm × 8 cm (average, 53.1 ± 27.9 cm²). The six anterolateral thigh deep fascia flaps ranged from 7 cm × 6 cm to 14 cm × 9 cm in size (average, 71.8 ± 29.1 cm²). The thicknesses of skin ranged from 25 mm to 40 mm (average, 32.5 ± 4.8 mm), and the thicknesses of the deep fascia flaps ranged from 2 mm to 3 mm (average, 2.5 ± 0.5 mm). After the operation, the blood supply of the deep fascia flap was normal in all cases. The second‐stage skin grafts of most patients survived completely. The skin graft in one case was partially necrotic and healed after a dressing change. No infection occurred. At follow‐up (average, 16.3 ± 6.9 months), there was only a linear scar and no loss of sensation at the donor site of each patient. According to the outcome satisfaction scale, the outcome satisfaction score ranged from 6 to 8 (average, 7.2 ± 0.9), all of which were satisfactory. Apart from one patient who reported mild pain, all the other patients reported no pain. Three typical cases are presented in this article.ConclusionsThe free anterolateral thigh deep fascia flap, which is suitable for reconstruction of soft tissue defects in the hand, can provide very good outcomes both functionally and aesthetically.     

Continuous blockade of the lumbar plexus after knee surgery: a comparison of the plasma concentrations and analgesic effect of bupivacaine 0.250% and 0.125%

In 20 patients a continuous block of the lumbar plexus was administered after knee-joint surgery, and the analgesic effect of two different concentrations of bupivacaine was compared. The same volume of bupivacaine was given to both groups of patients: a bolus dose of 0.4 ml/kg, 0.5% or 0.25%, followed by infusion of 0.14 ml/kg/h, 0.25% or 0.125%, respectively, via a catheter placed in the neurovascular fascial sheath of the femoral nerve according to the "3-in-1 block" technique. The median morphine consumption during the first 16 h postoperatively was 6.0 mg when bupivacaine 0.5/0.25% was used and 9.5 mg when 0.25/0.125% was used. This difference is not significant. The visual analogue pain scores were also similar in the two groups (P greater than 0.05). All plasma concentrations were below 4 micrograms/ml, the highest concentration measured being 3.6 micrograms/ml. It is concluded that when used for a continuous block of the lumbar plexus after knee-joint surgery, bupivacaine in a concentration of 0.125% offers the same pain relief as a concentration of 0.25%, and the risk of toxic reactions is reduced.     

大鼠皮瓣血液循环的磁共振波谱学初步研究

观察皮瓣的能量代谢。方法：利用磁共振波谱技术分别对大鼠皮瓣在正常灌注、动脉阻流、静脉阻流、失活等条件下ＡＴＰ、ＰＣｒ、Ｐｉ峰形的变化进行分析。结果正常时,Ｐｉ低于ＡＴＰ的γ及α峰。     

The distally based subcutaneous tarsometatarsal flap

Injuries to the distal part of the foot, or even the toes, can still provide reconstructive problems. It is not always wise to amputate the damaged, distal part of the foot. Some surgeons have stated that reconstruction of the distal foot is not necessary, but it is our opinion that it has a similar priority to reconstruction of the hand. While large defects are mostly reconstructed by free flaps, minor defects should also be considered for reconstruction. As in a previous paper, Small toe muscles for defect coverage [12], we are presenting a new way to reconstruct damaged tissue distal to the tarsometatarsal region.Correspondence to: G. Wechselberger     

Transanaler rektaler Verschiebelappen (rectal advancement flap) versus mukosaflap mit internusnaht im management komplizierter fisteln des anorektums Eine prospektive klinische und manometrische studie

A prospective study was carried out on 55 patients with complicated anal fistulas (41 transsphincteric, 5 suprasphincteric and 9 rectovaginal) to evaluate the value of two sphincter-conserving techniques with primary occlusion of the internal ostium and endorectal advancement flap (group A, n=34) or mucosal flap (group B, n=21). Ten of the patients had Crohn's disease. Both techniques consist in one-stage fistulectomy without drainage of the intersphincteric space. The inflamed proctodeal and granulation tissue was carefully cleared. The site of the former primary orifice of the fistula was adapted by means of two or three peranally performed single stitches. The peranally applied suture included the layers of the internal anal sphincter muscle only. A mobilized flap of rectal wall (group A) and rectal mucosa and submucosa (group B) about 4 cm × 3 cm in size was stitched below the muscular sphincter. The perianal part of the wound was left to heal by second intention. Postoperatively there were 16 cases of suture leakage (23.5% in group A, and 38% in group B), and 19 patients (26% or 47% in both groups) had to have revision surgery because of recurrent fistula or sutur leakage; 2 patients (3.6%) developed incontinence with intermittent fecal soiling. Complete incontinence was not observed in any patient. No significant difference in clinical and functional results was determined between the two groups.

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Transanaler rektaler Verschiebelappen (rectal advancement flap) versus mukosaflap mit internusnaht im management komplizierter fisteln des anorektums Eine prospektive klinische und manometrische studie

Zusammenfassung Bei 55 Patienten mit komplizierten Analfisteln (41 transsphinktere, 5 suprasphinktere, 9 rektovaginale Fisteln) wurde eine prospektive Studie zur Bewertung von 2 sphinktererhaltenden Techniken mit primärem Verschlu des inneren Fistelostiums and anschlieender Deckung durch einen endorektalen Verschiebelappen (Gruppe A, n=34) oder Mukosalappen (Gruppe B, n=21) durchgeführt. Zehn Patienten hatten M. Crohn. Beide Techniken bestehen aus einer einzeitigen Fistulektomie ohne Drainage des Intersphinkterraumes. Das entzündlich veränderte Procdodealdrüsen- und Granulationsgewebe wurde vorsichtig mit dem scharfen Löffel entfernt. Der Ort der früeren Primäröffnung der Fistel wurde mit zwei bzw. drei peranal angelegten Einzelknopfnähten verschlossen. Die peranal gelegte Naht umfate die Schichten des M. spincter ani internus. Ein mobilisierter Rektumwandlappen (Gruppe A) oder ein Mukosa-Submukosalappen (Gruppe B), in einer Gröe von ca. 4×3 cm wurde versetzt und über den muskulären Verschlu gedeckt. Der perianale Teil der Wunde heilte sekundär. Postoperativ trat bei 16 Fällen eitle Nahtinsuffizienz auf (23,5% in Gruppe A, 38% in Gruppe B). Neunzehn Patienten (26% gegenüber 47% in beiden Gruppen) erforderten eine erneute Operation aufgrund von wiederkehrenden Fisteln oder Nahtinsuffizienzen. Zwei Patienten (3,6%) entwickelten eine Inkontinenz in Hinblick auf intermittierendes Stuhlschmieren. Eine völlige Störung der Kontinenz wurde in keinem Fall beobachtet. Ein signifikanter Unterschied zwischen beiden Gruppen war weder in klinischen noch in den funktionellen Ergebnissen zu ermitteln.

     

胫后侧逆行岛状筋膜蒂皮瓣修复踝周围软组织缺损

总结１９９３年５月－１９９８年８月,应用胫后侧二种逆行岛状筋膜蒂皮瓣多向转位修复踝部周围皮肤缺损的临床效果。利用胫后动脉肌间隙的穿动脉,腓动脉肌间隙支,腓动脉外踝支与腓肠浅动脉广泛吻合,设计胫后侧两种筋膜蒂皮瓣。