Wide-Awake REGIONAL Anesthesia – Surgeon Administered

Wide-Awake REGIONAL Anesthesia – Surgeon Administered

Over the last 10 years, the concept of "WALANT" has greatly reduced the importance of sedation and general anesthesia for hand surgery.  Many surgeons have transitioned towards performing wide-awake, local-only anesthesia with or without a tourniquet.  In many cases, this has allowed for a reduction in cost by transitioning procedures to the office setting, a reduction in cost by avoiding surgery center facility fees, and reducing the patient complications and inconvenience of sedation. However, WALANT technique is most commonly used for "smaller" hand cases: carpal tunnel, trigger fingers, tendon surgery in palm or fingers, etc.  Although some surgeons have utilized WALANT technique for distal radius fractures and other forearm or elbow injuries, this is not widely practice.  Rather, most surgeons perform upper extremity fracture fixation under regional anesthesia with sedation or general anesthesia. Manu member Dr. Orrin Franko has been utilizing surgeon-administered, axillary regional anesthesia, taught to him by his partner Dr. Andrew Stein, since starting practice 3.5 years ago.  Dr. Stein has...
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Case Report: Unexpected DRUJ Mass

Case Report: Unexpected DRUJ Mass

In most areas of medicine, and certainly orthopedics, common problems present commonly.  A relatively finite number of diagnoses make up the majority of what we see.  Through experience, we develop heuristics, or “mental shortcuts” which through pattern recognition, allow us to relatively efficiently arrive at a diagnosis, or set of potential diagnoses.  One of the challenges in hand surgery, and all of medicine, is when a patient falls outside of that for which we have a heuristic.  Such was the case of the following patient. The patient is a 42 year old, right hand dominant female who presented with 4 years of vaguely localized pain over the distal 25% of her forearm.  She was unable to clearly sense if it was more volar or dorsal.  Described a motor vehicle collision a couple months before the onset of her symptoms which she think may be related, but no immediate pain following the accident.  The last 2 years have been particularly bothersome and...
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“Pin Under Plate” Technique for Distal Radius Fractures

“Pin Under Plate” Technique for Distal Radius Fractures

"Pin Under Plate" Technique for Distal Radius Fractures By Dr. Orrin Franko Distal radius fractures are quite fun to treat, often because of the great variety of "tips and tricks" available to surgeons in the procedure.  Personally, one of my favorite tricks us to use 0.35 K-wires held beneath a volar plate to capture and provide stability to small or challenging fragments that would otherwise be difficult to stabilize with a screw.  I cannot take credit for this technique, rather it has been published by Dennison & Moore in 2014 in a small series.  However, my preferred technique varies somewhat from their recommendation based on experience with over 30 fractures.  I have highlighted my tips and tricks below, with example images. The concept is simple: fracture fragments that are either too small or too distal to be securely fixed with a traditional locking screw can be stabilized with a K-wire.  That k-wire can be subsequently secured beneath a traditional plate.  Together, a rigid construct...
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Post-Operative Average Recovery Trajectories

Post-Operative Average Recovery Trajectories

Post-Operative Average Recovery Trajectories By: Orrin Franko Background: Patients frequently ask about the recovery period following elective surgical interventions; critical information when planning time off work, personal travel, or other life events. Yet despite extensive literature detailing long term outcomes for common procedures, information regarding the recovery time or return to work time is often lacking. The study utilized a hand surgery registry to graph the recovery rate for common hand surgery procedures. Methodology: A prospective, hand surgery registry was utilized to evaluate the recovery curves for carpal tunnel surgery, trigger finger release, 1st dorsal compartment release, basal joint surgery, metacarpal/phalangeal fractures and wrist fractures. Recovery was monitored over time and recorded as a mean QDASH Score. The term “fully recovered” was set at an average QDASH score of 15 based on the best available literature for population averages. Results: The hand registry database included on-going data collection for 2,046 patients after hand surgery. A total of 990 patients met criteria for this study,...
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Integrating an Opioid-Reduction Pain Management Protocol in a Small Private Hand Surgery Practice

Integrating an Opioid-Reduction Pain Management Protocol in a Small Private Hand Surgery Practice

Orrin I. Franko, MD & Andrew J. Stein, MD – East Bay Hand Medical Center in San Leandro, CA Presented at the American Society for Surgery of the Hand (ASSH) 2019 Conference in Las Vegas, NV Background Media attention and scientific reports have highlighted the current opioid crises Large, integrated medical centers have demonstrated the feasibility of reducing opioid prescriptions for hand surgery patients We report the experience of transitioning to an opioid reduction pain management protocol in a small private practice Methods July 2017: a two-person orthopedic hand surgery practice transitioned to an opioid reduction pain management protocol Included the use of automated emails to provide pain management handouts and pre-operative videos on pain and discomfort Reduced the default prescriptions given for routine operative procedures Patient pain was surveyed pre- and post-operatively on a 10-point Likert scale at 3, 6, 12, 24, and 52-weeks Results 450 patients enrolled in the “traditional” pain management group and 693 patients enrolled in the opioid reduction protocol...
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Comparing Pain and Satisfaction Outcomes for Endoscopic Versus Open Carpal Tunnel Release

Comparing Pain and Satisfaction Outcomes for Endoscopic Versus Open Carpal Tunnel Release

Orrin I. Franko, MD & William Slikker, MD – East Bay Hand Medical Center in San Leandro, CA Presented at the American Society for Surgery of the Hand (ASSH) 2019 Conference in Las Vegas, NV Background: Many studies have compared endoscopic versus open carpal tunnel release, but few have compared the differences in patient reported outcomes We hypothesize that patient reported outcomes (QuickDASH score) will be improved following endoscopic carpal tunnel release (ECTR) compared to open carpal tunnel release (OCTR). Methods A prospective, hand surgery registry was created to evaluate patient reported outcomes and track patient recovery Outcomes for QuickDASH score were collected with automated electronic surveys A total of 1,131 patients who underwent either open (892 patients) or endoscopic (239 patients) carpal tunnel release were included in this study Results Both groups showed marked improvement in QuickDASH function scores over the first three weeks The ECTR group had lower QuickDASH scores and better function throughout the recovery process At 1 year, the ECTR...
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Carpometacarpal Dislocations II-V Case Report

Carpometacarpal Dislocations II-V Case Report

Members of Manu Amici have recently discussed their experience with complete carpometacarpal dislocations of the lesser digits (2-5).  This is reportedly a rare injury according to various literature sources [1, 2, 3, 4, 5] and yet when presented to the group, 3 members had a combined experience of 6 cases over the prior few years.  Treatments range from a combination of both open and closed reductions, as well as percutaneous, open, and non-operative stabilization.  Literature suggests that long term outcomes are quite good overall, but no study is large enough to recommend one stabilization method over another.  Manu Amici will continue to follow these injuries and consider writing a case series once we have adequate follow-up. Dr. Al-Shihabi's case demonstrates CRPP for stabilization. ...
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