Chapter 64 Basic Surgical Technique and Postoperative Care
The hand is the most complex and versatile structure in the human body. Formed of 27 bones, the hand and wrist require more than 30 muscles and a vast web of ligaments and tendons to move them into the myriad postures required for the countless tasks the hand performs every day. The complexity of hand function is reflected by the large amount of brain space dedicated to it. Injury to or dysfunction of any element of hand function can cause significant disability. Because of the importance of the hand to every aspect of life, it is essential for the surgeon to make the correct diagnosis and perform the appropriate and needed procedures, avoiding both undertreatment and overtreatment.
A carefully taken history and detailed physical examination of the involved part frequently are sufficient to determine the appropriate diagnosis. Routine anteroposterior, lateral, and oblique radiographic hand and wrist views may be supplemented with additional special views of the wrist, thumb base, and fifth carpometacarpal joint. MRI and CT can provide sufficient additional information to clarify some bone and soft tissue problems in the hand and wrist. Radionuclide bone scanning may show areas of bone involvement before they can be seen on plain radiographs. Electrodiagnostic studies (electromyography and nerve conduction velocities) may localize areas of nerve compression and reveal other conditions (e.g., peripheral neuropathy). In patients with suspected but undiagnosed systemic illnesses, such as the inflammatory arthritides, assessment by appropriate medical specialists is helpful in determining appropriate nonoperative management. Patients who are taking warfarin, corticosteroids or other antiinflammatory medications, immunosuppressive drugs, aspirin, herbal and complementary preparations, and medications for diabetes may require modification of dosage or discontinuation of the medications during the immediate preoperative and intraoperative periods.
Most important is that the patient and surgeon have realistic expectations about the operative outcome before the procedure is performed. The patient should understand the options; the alternatives to surgery; the expected outcome with and without surgical treatment; the potential risks, hazards, and benefits of the surgery; the nature and location of the incisions; the potential need for incisions to be made on other parts of the body for the harvesting of grafts; and the possible use of internal fixation, drains, and other types of implants. The patient should understand the nature of immobilization after surgery, including the use of splints and casts, and he or she should understand that recovery and rehabilitation might be prolonged, especially after major reconstructive procedures.
As part of the preoperative preparation, patients are instructed to keep their hands clean for several days before surgery and to avoid skin injury to minimize the potential for infection. From currently available information, an infection rate of 0.5% to 3.0% might be expected. If the patient has evidence of cuts or skin or remote infections, the operation may best be delayed. If the fingernails are long or dirty, they should be trimmed and cleaned to remove potential sources of bacterial contamination, and excessive hair in the incision area should be removed before scrubbing the operative extremity.
Although surgical site infections are rare after hand surgery, postoperative infection can be a disastrous complication in the hand, causing impairment of hand function, delaying rehabilitation and return to work. Severe infection may require multiple surgical procedures and result in permanent damage to the hand. The routine use of perioperative antibiotics for many orthopaedic procedures in the hand remains questionable. In two recent large series—one retrospective study involving 8850 patients and one prospective, randomized study involving 1340 patients—there was no significant difference in the frequency of infection in patients who received perioperative antibiotics and those who did not. The prospective study also found no difference between elective and emergency surgery, between operations lasting 2 hours and those lasting longer, or between “clean” and “crush/dirty” wounds. Even in “high-risk” patients (smokers, those with diabetes mellitus, and those with longer operative procedure times) in the retrospective study, prophylactic antibiotics did not reduce the frequency of surgical site infection. The authors of both studies concluded that antibiotic prophylaxis should not be routinely administered for surgery of the hand.
Because surgical results depend considerably on the skill, judgment, and precise work of the surgeon, it is important to keep intraoperative distractions to a minimum. Disorganization, fatigue, and uncertainty diminish the efficiency of the operating team. It is important for the surgeon to establish a standard routine that is followed regularly (Fig. 64-1). Each assistant can then depend on this routine. The activities of the assistants in following this routine should not be disrupted by the surgeon with irregular, unexpected, or inconsistent demands. A standard routine makes it possible for assistants to know what is expected of them at each step in the operation and allows them to perform without hesitation, delay, or wasted motion.
FIGURE 64-1 Standard routine is used in operating room, regardless of procedure being performed. Light passes over surgeon’s left shoulder. Assistant’s head is 8 to 10 cm higher than surgeon’s head. Assistant holds patient’s hand firm and motionless. Basic instruments always are arranged in same order. Surgeon’s elbows rest on sturdy table, knees are almost level with hips, and feet rest flat on floor. Vertical draping prevents contamination of operative field by patient’s face or by anesthesiologist. Surgeon sits holding the back comfortably erect on a firm and stable stool.
The operating room should always be pleasant. If a local anesthetic is being used and the patient is awake, loud or inappropriate noises or bursts of conversation may alarm the patient and should be avoided. Sometimes music of the patient’s choosing is comforting.
If the surgical procedure is being arranged with the operating room staff, it is helpful to make requests regarding special needs for the case under consideration. Making advance arrangements for instruments, sutures, operating microscope, special implants, additional assistants, and other items enhances the efficiency of the operating team on the day of the procedure. Radiology support, including the use of C-arm fluoroscopy, should be arranged beforehand as well.
The operating surgeon usually sits on a firm, comfortable, and stable stool and occasionally stands for some procedures. When sitting, the surgeon’s knees are almost level with the hips and the feet rest flat on the floor without strain. The working surface of the operating hand table should be at elbow height to provide a comfortable support for the forearms. When the light is directed from above the surgeon’s left shoulder (for a right-handed surgeon), it shines directly on the operative field, and shadows are avoided.
Seated opposite the surgeon, the assistant should view the operative field from 8 to 10 cm higher than the surgeon to allow a clear line of vision without having to bend forward and obstruct the surgeon’s view. Although mechanical hand holders are available, they are not as good as a motivated and well-trained assistant. It is especially helpful for the assistant to be familiar with each procedure. Usually, the primary duty of the assistant is to hold the patient’s hand stable, secure, and motionless, retracting the fingers to provide the surgeon with the best access to the operative field (Figs. 64-2 and 64-3).
The hand operating table should be stable and immobile. Space should be sufficient for the patient’s hand and for resting the elbows and forearms of the surgeon and assistant, minimizing muscle fatigue. For most procedures, the surgeon should sit on the axillary side of the involved extremity, allowing the anatomy of either hand to be seen in the same relative position. Some procedures on the dorsum of the hand and wrist may be performed more easily from the cephalic side. If the surgeon changes sides, it is important to keep in mind the change in routine to avoid anatomical disorientation.
The tray holding the basic instruments often is placed on a shelf extending from the operating table, level with the working surface. The instruments always should be arranged in the same order (Fig. 64-4). This arrangement allows the surgeon to save time by routinely reaching for instruments from the basic tray. With practice, this can be done without the surgeon looking at the instruments.
FIGURE 64-4 Basic instruments for any surgical procedure on hand. Octagonal knife handle is preferable to flat handle because knife is more commonly held by precision pinch in hand surgery. Instruments shown are knife handle, small rat-tooth forceps, dissecting scissors, small hemostats, ruler, marking pencil, double-hook Lovejoy retractors, and probe.
Using the so-called drop technique, the surgeon discards an instrument after using it, and the nurse returns it to its place on the tray. The discarded knife, tissue forceps, and dissecting scissors that are used constantly are not retrieved by the nurse, unless requested by the surgeon. Special instruments should be readily available on another large table so that they can be handed quickly to the surgeon on request. Additional knife blades and special sutures and needles also should be immediately available.
Drugs used for local and regional anesthesia should become effective within a few minutes after injection, should cause minimal local irritation, and should have low systemic toxicity. Lidocaine seems to fulfill these requirements. Mepivacaine (Carbocaine) is longer acting but may be slower in onset. Many surgeons prefer bupivacaine (Marcaine) because it is effective for 8 hours or longer. It can be used for axillary brachial block to avoid the use of a general anesthetic. Each of these agents has a toxicity level based on milligrams per kilogram of body weight, and this should be calculated before administration (Table 64-1).
|ANESTHETIC||MAXIMAL RECOMMENDED DOSE|
|Bupivacaine with epinephrine||3.0 mg/kg|
|Levobupivacaine with epinephrine||3.0 mg/kg|
|Ropivacaine with epinephrine||3.0 mg/kg|
Modified from Bruce BG, Green A, Blaine TA, Wesner LV: Brachial plexus blocks for upper extremity orthopaedic surgery, J AAOS 20:38, 2012.
Unsatisfactory anesthesia for hand and upper extremity operations prevents the surgeon from accomplishing his or her goals and is likely to compromise the surgical result. For accurate and precise work, the part must be motionless, the procedure should be completely painless, and the patient should be comfortable. All anesthetic techniques carry some risks, and the selection of the technique depends on the needs of the patient and the preferences of the surgeon and anesthesiologist. The selection should be part of the preoperative planning.
At times, general anesthesia is preferred. Factors that favor the use of this type of anesthesia include extensive and prolonged hand and upper extremity operations, performance of procedures on other parts of the body (chest or abdomen or harvesting of various tissue grafts), extensive operations in young children, the presence of infection in a region that would preclude injecting a local anesthetic agent, and the preference of a particularly uneasy or anxious patient.
Regional anesthesia has many advantages in hand and upper extremity surgery. Satisfactory regional anesthesia can be achieved for emergency procedures performed on patients with a full stomach; in these situations and in elective operations, a regional anesthetic blocks vasoconstrictive afferent impulses from the surgical wound and avoids some of the unpleasant postoperative complications of general anesthesia. Outpatient surgery can be performed safely using regional anesthetic blocks, which reduce the need for postoperative nursing care. A regional anesthetic may allow operations to be done on the hand and upper extremity in patients with unstable cardiac or severe pulmonary or renal problems that would create an increased risk with general anesthesia.
Regional anesthesia is less satisfactory in children or extremely nervous, anxious, or uncooperative adults. It should be avoided in patients with documented, true allergies to local anesthetic agents and in patients taking anticoagulants. A regional anesthetic agent may be difficult to administer in patients with contractures or involvement of joints that limit positioning of the limb for satisfactory blocks and in patients whose veins or blood pressure elevation do not allow the use of the intravenous technique. Care should be taken when administering regional anesthetic agents to avoid complications such as overdosage, intravascular injection (when doing nerve blocks), pneumothorax (when doing supraclavicular brachial plexus blocks), and the dissemination of infection.
For operations on the hand and upper extremity, four methods of regional anesthesia are in widespread use: (1) brachial plexus blocks using the interscalene, axillary, or supraclavicular approach; (2) intravenous regional blocks; (3) peripheral nerve blocks distal to the axilla, including blocks of the median, radial, ulnar, and digital nerves; and (4) local infiltration of anesthetic agents. It is helpful to have the patient satisfactorily sedated before surgery. In many situations, especially in elective surgery, simple nerve blocks at the wrist or fingers require little premedication. The use of regional anesthesia requires that sufficient time be allowed in the immediate period before surgery for preparation of the patient, for the administration of the regional anesthetic agents, and for the anesthetic to become effective before the skin incision is made.
The traditional approaches for administering anesthesia to the major components of the brachial plexus include the axillary, interscalene, and supraclavicular and infraclavicular routes (Fig. 64-5). The axillary and interscalene approaches we use most commonly probably are safer than the supraclavicular route, which carries the risk of a low incidence (1% to 5%) of pneumothorax. Infraclavicular and supraclavicular blocks are more commonly done now with ultrasound guidance. The interscalene block covers the supraclavicular nerves emanating from the third and fourth cervical roots and is ideal for shoulder surgery. Interscalene blocks can also be used for elbow surgery. Supraclavicular blocks are useful for surgery in the upper arm distal to the shoulder, whereas infraclavicular blocks can provide regional anesthesia for surgery of the elbow, forearm, wrist, and hand. An axillary block provides anesthesia similar to that of an infraclavicular block. Access to the axillary space requires the patient to abduct the arm 90 degrees, which may be difficult for those with trauma or contractures. Needle placement for brachial plexus blocks was traditionally based on anatomic landmarks and nerve localization with a nerve stimulator, but more recent approaches use an ultrasound approach. A meta-analysis of 13 studies comparing neurostimulation with ultrasound-guided blocks found that ultrasound-guided blocks were more likely to be successful, took less time, had a faster onset, and decreased the risk of vascular puncture. A study of the multiple-injection technique for axillary block showed that ultrasound guidance resulted in fewer needle passes, a shorter time to onset of anesthesia, and less procedure-related pain than nerve stimulation techniques. Limitations of ultrasound include availability, a limited plane of view, and highly operator-dependent image quality.
(Redrawn from Chelly JE, editor: Peripheral nerve block, ed 3, Philadelphia, 2008, Lippincott Williams & Wilkins.)
Short- and long-acting local anesthetic agents can be used for brachial plexus blocks. The dose depends on the agent used, the technique used, and the preference of the administering physician. Although the amount of anesthetic used is not standardized, maximal amounts have been recommended (see Table 64-1).
Complications of brachial plexus blocks are few (<1%). Reported systemic complications include cardiac arrest, respiratory failure, and seizures. Peripheral nerve injury can be caused by mechanical trauma from needles or catheters, drug neurotoxicity, ischemia, compression, or stretch, but permanent neurologic sequelae occur in fewer than 1% of patients. Pneumothorax is most common with supraclavicular blocks (as high as 6%) but has been reported with interscalene and infraclavicular blocks. Ultrasound-guided technique has been suggested to reduce the risk of pneumothorax: a prospective study found no clinically apparent pneumothoraces in 510 patients who had ultrasound-guided supraclavicular blocks.
Dysesthesias and “brachialgia” may persist after brachial plexus blocks, and the patient should understand this before the block. It also might create difficulty in patients who require fine manipulation of the hands in their occupation.
The intravenous regional anesthesia technique using a double tourniquet (Bier) is useful, especially for procedures of relatively short duration (60 to 90 minutes). A specially designed double tourniquet is used. The patient should be satisfactorily premedicated, and intravenous infusion should be in place in the contralateral arm. The usual anesthetic agent is lidocaine. In most situations, 30 to 60 mL of 0.5% lidocaine provides sufficient and safe anesthesia. The dosage used should take the patient’s age and body weight into consideration. Satisfactory anesthesia can be obtained in a short time. The tourniquet is left inflated for a minimum of 30 minutes after injection of the anesthetic agent into the extremity. In the usual situation, the limb is exsanguinated; the proximal tourniquet is inflated to a level 100 mm Hg greater than the systolic pressure (usually 250 to 300 mm Hg); and, using sterile technique, the anesthesiologist intravenously introduces the previously determined volume of anesthetic agent (Fig. 64-6). As the more proximal tourniquet becomes uncomfortable, the distal tourniquet is inflated and the proximal tourniquet is deflated. Reported reactions during intravenous regional anesthesia include cardiac arrhythmias (bradycardia and cardiac arrest), unconsciousness, vertigo, and nystagmus.
The use of a forearm tourniquet for intravenous regional anesthesia has been suggested, with reported advantages of safety, preservation of hand motor function, lower anesthetic dose, and reduced risk of complications.
The median, radial, and ulnar nerves can be blocked at the elbow and wrist, and these blocks are extremely helpful for brief procedures (Fig. 64-7). A tourniquet may not be required or may be used only for a short period (usually ≤ 30 minutes). It is essential to know the location of the respective nerves before attempting regional blocks. Blocks at the wrist can be especially useful for procedures such as tenolyses and capsulotomies because motion of the fingers can be observed during surgery. The patient can be kept comfortable, and a tourniquet can be used longer than 30 minutes if the patient is adequately sedated.
Digital nerve blocks provide excellent anesthesia for procedures on the fingers (Fig. 64-8). Usually, perineural injection around the digital nerves proximal to the finger web spaces is a safer technique than injection of the nerves at the base of the fingers. Because ischemia may develop after injection of an anesthetic agent in a circle around the base of the finger, this technique should be avoided. Digital blocks using a transthecal (flexor sheath) approach have shown no advantage compared with the traditional digital block technique (Fig. 64-9). We rarely use epinephrine in the local anesthetic agent in the digits, although it can be used safely.
FIGURE 64-9 For procedures that require anesthesia from mid-middle phalanx distally (e.g., nail bed regions and distal interphalangeal joint distributions and fusions) digital anesthesia can be easily achieved by single volar injection technique. A, Just proximal to palmar digital crease through pinched skin 3 to 5 mL of local anesthetic is injected superficial to flexor sheath. B, Anesthesia achieved (colored area) from block of proper and dorsal sensory digital nerve branches. Note, if more proximal anesthesia is needed additional block can be given at metacarpophalangeal joint dorsally as shown.
If hemostasis is required, traditionally a Penrose drain or a French rubber catheter applied around the finger has provided satisfactory and safe ischemia. Commercially available finger tourniquets and the finger of a rubber glove cut to allow it to be rolled onto the finger as a tourniquet also are effective tools. Pressures achieved beneath these tourniquets cannot be determined accurately; caution is advised. At times, especially in the elderly and patients with vascular disorders in the fingers (e.g., Raynaud disease, atherosclerosis, diabetes), vascular insufficiency may develop in the digit, and care should be taken when using digital tourniquets in these patients (Fig. 64-10).
FIGURE 64-10 Broad-based finger tourniquet can be cut from Esmarch wrap, which usually accompanies upper extremity packages. A, Long and short strips 2.5 cm wide are cut from opposite sides of Esmarch bandage. B, Short strip is loosely applied across finger base and is held in place with curved hemostat. Longer strip is used to exsanguinate finger. C, Tension is applied to short section, and hemostat is applied close to dorsal skin with the two limbs of short Esmarch section fully opposed.
Local infiltration of an anesthetic agent may be used for more proximal conditions that do not require deep, extensive dissection. This method is satisfactory for trigger digit release, small scar revision, and excision of benign masses from the skin and subcutaneous tissues of the forearm, hand, and fingers.
Regardless of the procedure, the method of preparing and draping the upper extremity and hand should be the same. This helps to standardize the routine and allows movement about the operative field while minimizing the risk of bacterial contamination. The preparation of other areas for graft donor sites varies depending on the requirements of the procedure. If skin, tendon, bone, nerve, or other grafts are required, the patient should be positioned to allow easy access to the specific areas. Care should be taken to pad and protect neurovascular structures. The electrocautery grounding pads should be attached in a safe and secure manner. Usually, the hand and forearm are scrubbed before the time of the surgery. The hair is removed with electric clippers from the areas where skin incisions will be made on the hand, forearm, and elsewhere as needed; this often is done before the patient is transported to the operating room. A well-padded tourniquet is applied to the arm or the forearm, depending on the surgeon’s preference; however, it is not inflated until all preparations have been completed (unless a Bier block is being used). After the patient has been satisfactorily anesthetized, the hand and forearm are scrubbed by an assistant while the surgeon scrubs his or her own hands. The surgeon puts on gloves and prepares the skin with an antiseptic solution of choice. Iodophor soaps and skin preparation solutions and combinations of chlorhexidine and alcohol have been found to be effective (Table 64-2). Wetting the padding beneath the tourniquet with these solutions should be avoided to minimize skin reactions. A waterproof sheet is placed on the well-padded hand surgery table, followed by a sterile drape-sheet. Combinations of sterile towels and sheets are applied, leaving exposed the upper extremity and hand and other areas that may require access during the operation. The gloves used in preparation of the surgical field are removed, and the surgeon dons a gown and gloves and sits down, usually on the axillary side of the forearm. The operating lights are adjusted, and the skin incisions are outlined.
|Alcohol||Good immediate skin disinfectant, but dries quickly and has less long-term effect|
|95% alcohol better than 75% because of dilution by moist skin|
|Hexachlorophene (pHisoHex)||Forms a film that retains bacteriostatic properties|
|Easily washed off|
|Requires multiple applications to be effective|
|May be toxic in infants|
|Effective against gram-positive organisms; less effective against gram-negative organisms|
|Alcoholic (tincture)||Frequent skin irritation (can be lessened by adding iodine)|
|Aqueous (Lugol’s solution)||True allergic reactions|
|Iodophors (povidone-iodine [Betadine])||Advantages over iodine|
|Iodine and polyvinyl pyrrolidine or povidone||Slower release of iodine|
|Fewer skin reactions|
|Effective against gram-negative and gram-positive organisms|
|Chlorhexidine (Hibiclens) 70% alcoholic solution||Some studies have shown it superior to Betadine and pHisoHex|
|Repeated washings may have a cumulative effect|
Adapted from Green DP: General principles. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, editors: Green’s operative hand surgery, ed 6. Philadelphia, 2011, Elsevier.
A bloodless field is essential for accurate dissection to avoid damaging small vital structures. The inherent dangers of tourniquet use are ischemia and its complications, including muscle contracture and nerve paralysis. Because the pressure can be monitored and controlled more reliably with a pneumatic tourniquet, complications are believed to be less likely with this type than with an elastic or rubber bandage tourniquet. Regardless of the tourniquet used, temporary or permanent disproportionate or prolonged edema, stiffness, diminished sensibility, and weakness or paralysis may result. Based on animal studies, Pedowitz et al. emphasized that biochemical, biomechanical, microvascular, and cellular mechanisms combine to produce significant neuromuscular injury from the use of tourniquets even at clinically allowable pressures and durations.