Laboratory for the Research of the Musculoskeletal System University of Athens, Athens, Greece Department of Hand Surgery and Microsurger Kifissia, 15125 Athens, Greece Received 19 June 2005; Accepted 10 November 2006 ABSTRACT
The purpose of this study was to evaluate the safety and efficiency of transdermal anaesthesia using eutectic mixture of lidocaineand prilocaine (EMLA) in patients undergoing percutaneous trigger finger release and to compare it with lidocaine infiltration.
In this prospective, randomised study percutaneous release of the A1 annular pulley was performed to treat stenosing tenosynovitis (trigger finger syndrome) in 50 patients (50 fingers). The procedure was performed either under transdermal anaesthesia usingEMLA applied transcutaneously 120 minutes prior to the operation (Group A, n = 25) or using local infiltration anaesthesia usinglidocaine (Group B, n = 25). Pain experienced during administration of anaesthesia and during the operation was assessed usinga 10-point Visual Analogue Pain Scale (VAPS), while all patients rated the effectiveness of anaesthesia with a 5-point scale.
There were no significant differences between the two groups in the VAPS during the operation (1.33 ± 0.52 versus 1.59 ± 0.87) and the satisfaction scores (4.6 ± 0.2 versus 4.4 ± 0.3). The VAPS score during the administration of anaesthesia was statisticallysignificantly less in the EMLA group (0 versus 5.96 ± 2.41). All patients were satisfied with the final result of the operation.
Percutaneous trigger finger release can be performed as an office procedure with the use of EMLA avoiding the use of injectable Keywords: Anaesthesia; Eutectic Mixture of Lidocaine and Prilocaine; Percutaneous Release; Trigger Finger.
Correspondence to: Dr. Christos K. Yiannakopoulos, Byzantiou 2, 171 21 Nea Smyrni, Athens, Greece. Tel: (+30) 697-209-9911, Fax: (+30) 210-363-6181, C. K. Yiannakopoulos & I. A. Ignatiadis INTRODUCTION
Table 1 Patient Demographic and Results.
Surgical release of the A1 annular pulley is recommended when conservative treatment of trigger finger syndrome has n = 25
n = 25
failed. The release can be performed either as an open pro- cedure or percutaneously with success and without serious complications.1 With either technique the use of local injectable anaesthesia is necessary. Local anaesthesia is accompanied with injection pain and occasionally with systemic symptoms attributed to the absorption of the local anaesthetic used, usu- ally lidocaine. EMLA® cream (Astra Zeneca, Halandri, Athens, Greece) is used in patients of almost every age, from neonates to geriatric patients, to provide transcutaneous anaesthesia which enables the performance of a variety of procedures and operations, including arterial and venous cannulation, split VAPS = Visual analogue pain scale; EMLA = Eutectic mixture of local thickness skin grafting, mechanical ulcer debridement, carpal tunnel syndrome anaesthesia, prevention of acute and chronicpain etc.2–7 The purpose of this study was to investigate the safety and landmarks on the skin of the palm were marked, the skin was efficacy of EMLA cream as an alternative method of local anaes- cleaned and the finger MCP joint was held in hyperextension thesia in percutaneous trigger finger release and to compare it by an assistant. The proximal and distal ends of the A1 pul- ley were determined and marked using surface landmarks.8The position of the needle was confirmed by asking the patientto flex and extend the corresponding finger. Intratendinous MATERIALS AND METHODS
position of the needle caused mild pain. The proximal end A prospective, randomised trial was performed including and the stoma of the A1 pulley were identified with palpation 50 patients with stenosing tenosynovitis (trigger finger syn- and release was performed in a proximal to distal direction. A drome), who underwent percutaneous A1 pulley release. The typical grating sound and a similar sensation during A1 pul- study was approved from the Ethics and Research Commit- ley release ensured the success of the release. The patient tee of our Institution. All patients had a palpable, tender was asked to flex and extend the finger. Absence of trigger- tendon nodule and characteristic mechanical triggering. On ing was regarded as a sign of complete release. The wound the whole, 50 trigger fingers were treated surgically. The was covered with a soft compressive bandage and the patient patients were randomly allocated in two Groups. In Group A was advised to keep his/her hand elevated for 48 hours, while (n = 25) skin anaesthesia was provided using EMLA and in active finger motion was encouraged as soon as the patient was Group B (n = 25) the skin was infiltrated with 3 ml lidocaine 1%. The demographical data of all patients are presented in Pain experienced during the administration of anaesthesia and during the operation was assessed by an independent research The patient arrived at the office two and a half hours prior nurse using a 10-point Visual Analogue Pain Scale (VAPS), while to the scheduled operation time, where a thick layer of 5 mg all patients rated the effectiveness of anaesthesia during the EMLA® cream was applied on the palmar skin correspond- procedure on a 5-point scale. A score of 1 was considered as a ing to the location of the A1 pulley to be released and the measure of insufficient anaesthesia and a score of 5 as a measure cream was then covered with an occlusive dressing (Tega- of excellent anaesthesia. Normally distributed continuous data derm, 3M, St. Paul, MN). The dressing was removed prior were analysed with a paired Student’s t-test and categorical data to the operation and the cream was wiped off. The opera- were analysed with the chi-square test with Yates’ continuity tions were performed under forearm tourniquet using the tip correction. A p value of <0.05 was considered statistically of an 18-gauge needle, mounted on a 3 ml syringe. The surface Transdermal Anaesthesia for Percutaneous Trigger Finger Release DISCUSSION
The average duration of the operation in Groups A and B was Percutaneous trigger finger release is a safe procedure and its 3.2 ± 1.5 and 3.4 ± 1.2 minutes, respectively and no case had efficacy has been proved by clinical and cadaveric studies.9–11 to be cancelled because of insufficient anaesthesia (Table 1).
Complications following surgical management of trigger fin- The two groups did not differ significantly in age, sex and finger ger are not very common but when occurring they may be operated. There were no significant intraoperative complica- severe.11,12 The most important complications are digital nerve tions or any recurrences. There were no infections, nerve or transection, inadvertent A2 pulley release and tendon bow- vessel injuries or incomplete pulley release. Skin blanching was stringing. Complications such as scar tenderness, infection, noted in four patients upon removal of the occlusive dressing haematoma and stiffness may be more common after an open in Group A. There were no significant differences between the procedure, while complications such as digital nerve injury or two groups in the VAPS during the operation and satisfaction tendon bowstringing may appear both after open and percuta- scores (Fig. 1). The difference in the VAPS score during admin- neous procedures. Probably, the most common complications istration of anaesthesia was statistically significant in favour of after percutaneous release using a needle are incomplete release the EMLA group. The VAPS score for anaesthesia was in the and flexor tendon injury. The first complication can be pre- EMLA group 0, while in the infiltration group 5.96 ± 2.41.
vented if complete resolution of triggering is ascertained with The mean VAPS score, representing the level of pain during finger movement. The second complication is usually not sig- the operation was in Group A 1.33 ± 0.52 and in Group B nificant and can be avoided with a meticulous technique and 1.59 ± 0.87. This difference was not significant. All patients who received infiltration anaesthesia considered the injection Local anaesthetics are used whenever a surgical procedure or as the most painful part of the procedure. The patients were intervention is going to cause pain and discomfort to the patient.
reviewed one, six and 12 weeks after the operation. All patients The most common hand operations are carpal tunnel decom- returned to work and their previous activities within two days.
pression and trigger finger release, which is performed as office Full unobstructed range of finger flexion was obtained and the procedures under local anaesthesia. Local anaesthesia can be final cosmetic result was excellent. In most patients, only a small performed using an appropriate local anaesthetic agent admin- spot of skin discolouration could be noted at the site of the nee- istered in three ways: topical application, local infiltration and dle insertion. All patients were satisfied with the final result of field block.11 Infiltration anaesthesia is effective but has the dis- advantage of painful and uncomfortable injections, especiallywhen large or sensitive areas are to be anaesthetised. Localinfiltration anaesthesia may also have several complications:anaesthesia failure, pain or burning on injection, haematoma,infection, persistent anaesthesia, overdose, hypersensivity reac-tions, etc.2,11 EMLA, an acronym for Eutectic Mixture of LocalAnesthetics containing lidocaine 2.5% and prilocaine 2.5%, canbe used prior to local anaesthetic infiltration to reduce painassociated with procedures such as carpal tunnel syndromeand prominent ear correction.2,12 With the use of EMLA percutaneous trigger finger release can be performed easily and safely in the outpatient clinic or inthe office, reducing the costs of surgical treatment. The onlydisadvantage is the need to apply the cream at least 120 minutesprior to the operation to optimise its effectiveness. In our study,EMLA has provided adequate anaesthesia to perform percu-taneous release and was well tolerated. The most importantlimitations in the use of EMLA is the delay necessary to obtain Fig. 1 The VAPS scores between Groups A and B (*p < 0.05).
anaesthesia since skin penetration of topical anaesthetics is C. K. Yiannakopoulos & I. A. Ignatiadis time-dependent and the limited depth of dermal anaesthesia, 5. Lawrence T, Desai VV, Topical anaesthesia to reduce pain associated with which is approximately 5 mm after 90 minutes.13 carpal tunnel surgery, J Hand Surg [Br] 27:462–464, 2002.
EMLA use is virtually complication-free and the most com- 6. Olday SJ, Walpole R, Wang JY, Radial artery cannulation: topical ametho- caine gel versus lidocaine infiltration, Br J Anaesth 88:580–582,
mon side-effect is transient skin blanching noted upon removal of the dressing.14 Blood levels of lidocaine and prilocaine 7. Wahlgren CF, Lillieborg S, Split-skin grafting with lidocaine-prilocaine after application of EMLA cream are well below toxic levels.15 cream: a meta-analysis of efficacy and safety in geriatric versus non- Methaemoglobinaemia attributed to a metabolite of prilocaine geriatric patients, Plast Reconstr Surg 107:750–756, 2001.
prohibits its use in infants younger than six months.16 8. Wilhelmi BJ, Snyder N, Verbesey JE, Ganchi PA, Lee WP, Trigger finger In conclusion, release using EMLA anaesthesia is safe, non- release with hand surface landmark ratios: an anatomic and clinical
study, Plast Reconstr Surg 108:908–915, 2001.
invasive and more comfortable than infiltration anaesthesia. The 9. Bain GI, Turnbull J, Charles MN, Roth JH, Richards RS, Percutaneous major drawback is the necessity to apply the cream at least A1 pulley release: a cadaveric study, J Hand Surg [Am] 20:781–784,
120 minutes before the operation. The two to three hours of extra time may be a substantial inconvenience for many patients 10. Eastwood DM, Gupta KJ, Johnson DP, Percutaneous release of the trigger and this should be discussed with them before scheduling the finger: an office procedure, J Hand Surg [Am] 17:114–117, 1992.
11. Smith DW, Peterson MR, DeBerard SC, Local anesthesia. Topical appli- cation, local infiltration, and field block, Postgrad Med 106:57–60,
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