Ambulatory Upper Limb Surgery Under Local Anaesthesia Alone- Comprehensive Application Across Two Centres to Improve Patient Outcome, Theatre Usage, and Cost Effectiveness

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Authors (including presenting author) :
MCK Mak(1), YW Hung(2), SC Koo(2), WL Tse(1), J Ting(1), WK Lai(1), PC Ho(1)
Affiliation :
(1) Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, HKSAR (2) Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, Taipo, HKSAR
Introduction :
In current manpower shortage of public healthcare system, anaesthesiology services & operating suites are particularly affected. To maintain our scope of service, we applied concept of local anaesthesia(LA) to open upper limb surgery of various complexities since 1998 with our pioneering experience of using LA for wrist arthroscopy – Port site LA(PSLA). In HK, upper limb surgery is usually performed under general or plexus anaesthesia(GA/PA) for high-volume procedures such as cubital tunnel decompression, hand fractures & tendon transfer. Since 2015, Hand & Microsurgery Team at Prince of Wales(PWH) & Alice Ho Miu Ling Nethersole(AHNH) Hospitals have been performing complex hand surgery operations under Wide Awake Surgery under LA(WALANT) & PSLA. Though many centres would consider impossible, we have shown these can be safely & effectively performed under LA as a day-case basis.
Objectives :
To demonstrate that complex upper limb operations can be performed under LA, with little patient discomfort, low morbidity whilst improving theatre utilization & increasing cost effectiveness.
Methodology :
Outcomes, efficiency of theater usage, & cost effectiveness in common upper limb surgeries done under GA/PA vs LA in 2015-2017 across 2 hospitals were compared. These included 1)all cases of hand & carpal fracture fixation except for distal phalanx, 2)cubital tunnel decompression & 3)tendon transfer, tendon graft or tenolysis surgeries. Floor duration, theater duration, operation time & cost were also analyzed. All wrist arthroscopy cases under PSLA in 2007-2009 were reviewed & subjective effectiveness was assessed using phone questionnaires.
Result & Outcome :
In 2015-2017, 361 GA/PA & 320 LA procedures were performed. Efficiency of theatre usage was found to be increased consistently for WALANT procedures. The cost of GA/PA arises mainly from anaesthetic agents, equipment & anaesthetists. Under LA, >$1.3 million/year would be saved without including the cost of pre-operative anaesthetic assessment. LA patients only occupied 40% of total floor time compared GA/PA patients due to decreased time of anaesthesia, reversal & recovery room observation. These were no difference in the complication rate & self-reported discomfort. The scope of surgery performed included all level of complexity. 926 LA day surgeries were performed in AHNH, including 14% ultramajor, 29.5% major, 42% intermediate & 14% minor in magnitude. 27 patients had cubital tunnel decompression with medial epicondylectomy under WALANT in 2015-2017. Subjective satisfaction was 89/110 after procedure, no patients were intolerant of the surgery & no complications were reported. High satisfaction rate was in part because tourniquet was not required. Optimal tensioning & dynamic assessment intra-operatively with patient participation resulted in favourable clinical results of tendon transfer & reconstruction surgery that is impossible under GA. Bony procedures(radial styloidectomy, wafer procedure, medial epicondylectomy) were all well tolerated under LA showed that LA was able to penetrate to deeper tissue despite common belief of many surgeons. In 2007-2009, 111 patients received wrist arthroscopy under LA. Their subjective rating was: very comfortable(5.4%), comfortable(26.1%), acceptable(57.7%) & barely acceptable(10.8%). No intolerable pain was reported. 52% reported better understanding of the condition after watching procedure intraoperatively & 79% stated they would choose LA again. In summary, LA could facilitate a wide scope of surgery in various levels of complexity and had good penetrance to deep layers including bone. Its use obviated the risk of GA, and avoided discomfort & risk of tourniquet, allowed patient-doctor interaction to enhance patient understanding & rehabilitation and allowed patients’ voluntary motor control for dynamic assessment to improve outcomes. Theatre utilization was enhanced while improving cost effectiveness. It should be widely adopted for use in hand surgery across the territories.

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