Drs. Anthony Parrino and Joel Ferreira, UConn Health hand, wrist and elbow surgeons, offer an approach to hand surgery that is not widely available in American health care. They can repair problems like trigger finger and carpal tunnel syndrome using a local anesthetic, enabling the patient to remain awake and test the repair during the procedure. They join Carolyn and Chris to explain the advantages of this technique, known as “wide-awake hand surgery.”
(Dr. Anthony Parrino, Dr. Joel Ferreira, Carolyn Pennington, Chris DeFrancesco, October 2020)
Chris: Carpal tunnel, trigger finger, other hand problems… What if, while undergoing surgery to repair them, you are able to talk through the procedure with your surgeon?
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With Carolyn Pennington, I’m Chris DeFrancesco. Hand surgeons are now able to treat certain conditions with a technique that takes general anesthesia out of the equation.
Carolyn: It’s called wide-awake surgery, and here to tell us more about it are the two UConn Health hand, wrist and elbow surgeons with specialized training in this technique, Drs. Joel Ferreira and Anthony Parrino from the UConn Musculoskeletal Institute. Welcome, and thanks for joining us. Now why would I want to be awake while you’re operating on my hand?
Dr. Parrino: I think the biggest benefit that patients have from this is a convenience factor. It takes, relatively simple procedures that are done very commonly in hand surgery and eliminates needs for physicals, anesthesia, fasting or not eating the morning of, and it actually can quicken their recovery. And it’s done in a painless fashion where there’s no increase in discomfort that they’ll actually experience. They actually have less discomfort afterwards, that we find.
Chris: Dr. Ferreira, how does it make the recovery quicker though? I mean, you’re doing the same surgery, aren’t you?
Dr. Ferreria: I just find that patients are able to usually go back very quickly to the things they want to do, because a lot of these surgeries are ones that don’t require significant immobilization afterwards. So it allows the patients to get back in a little bit quicker.
Dr. Parrino: I think in addition to that, we can actually teach them while we’re doing the surgery or immediately after the surgery, what they need to do in the next several days to maximize their outcome, and it’s fresh in their mind. They don’t have anesthetic on board where their thinking is cloudy and they don’t start right away. So I think from that standpoint, it’s very helpful.
Dr. Ferreria: And also just because those patients are awake during the surgery, we have them move their hands and we actually show them the hand to show that they can move it and that what they can expect afterwards. So they have a goal to achieve afterwards, postoperatively.
Carolyn: Are patients actually talking with you during the procedure?
Dr. Ferreria: Absolutely. Yes they are. Yes. And especially certain procedures. We do like trigger finger releases, that’s due to a finger that gets caught or locked, usually typically in a flex position, we release that and then we show them their hand and ask them to fully flex and extend. And it’s astounding how many times they’re like just astounded by the fact that they can move their finger and nothing bothers them.
Chris: You can actually move your trigger finger, in that example, you’re giving, as a patient, I can actually move my hand, but I still don’t feel the incision or anything that you’re doing?
Dr. Ferreria: Absolutely. Because many of the muscles in the hand are actually controlled by the muscles that are outside of the hand, so in the forearm region, so even though we numb up the hand, you still have control and able to fire those muscles.
Dr. Parrino: The way we numb those patients up or just for the incision is where we’re working, where the fingers should be moving and working afterwards. Patients don’t always expect that, how much motion they have after, and it allows them to actually drive themselves to and from the procedure as well, which goes along with the convenience factor of this.
Carolyn: So what kind of anesthesia is this? Like a Novocaine or like what you get in a dentist’s office?
Dr. Parrino: It’s lidocaine with epinephrine typically. Epinephrin will clamp down on the circulation in the area that we’re working on. That allows us to not place a tourniquet on the arm. So it eliminates the pain of that. And it’s the same medication that dentists use when they’re working on a patient’s mouth and gums.
Chris: Drs. Anthony Parrino and Joel Ferreira from the UConn Musculoskeletal Institute, hand wrist and elbow surgeons at UConn, we’re talking about wide-awake hand surgery. What are some conditions that are treatable using this approach?
Dr. Ferreria: One of the most common that we see is something called carpal tunnel syndrome, which is numbness and tingling and loss of sensation, basically in the thumb index and middle finger. And it’s also associated sometimes with significant nighttime pain patients waking up at night, significant burning pain, unable to fall back asleep, needing to kind of shake their hands, to kind of wake them back up. I’d say that’s the most common thing we treat.
We also treat something called trigger finger, which is caused by inflammation of the tendons in your palm. And it leads to swelling and the finger typically gets locked in a flex position.
Chris: Dr. Parrino, what are maybe some examples of some hand problems that might not be a good fit for this approach?
Dr. Parrino: Typically those are procedures that are longer, more involved. So for the most part, those are wrist fractures, elbow fractures some arthritic procedures where we need to remove bone or do tendon transfers, those aren’t great candidates just because it’s a longer procedure. The patient would be on the table for a while. These are typically procedures that we hope to do that are straightforward, routine, that we know exactly what we’re getting into as we go in and out and we can reproduce them rather easily.
Carolyn: So along those lines, are there some patients that have previous medical conditions that might not be appropriate for this?
Dr. Ferreria: Actually, I find it’s the exact opposite. We have a lot of patients that come in that have significant medical problems, on chronic oxygen, and wouldn’t be able to undergo general anesthesia. So in those instances with some of those surgeries, they wouldn’t be able to have the surgery, but with this, we’ve been able to do those patients wide-awake as long as it’s those conditions that we treat for it.
Dr. Parrino: Initially, when this technique was developed, it was thought to be safer for patients. That was the real advantage. But as we can apply this to almost any patient, that safety is still there, that convenience is there for patients who don’t have medical issues. In addition to our routine procedures, we do make exceptions for patients who do have significant medical conditions, where they can’t have general anesthesia, and on a case-by-case basis, we can sometimes do some of the bigger procedures for them as well.
Chris: To repair a carpal tunnel, traditionally,taking into account the amount of time it takes to get the anesthesiologist involved, how much time are you saving when you don’t have that piece of it?
Dr. Ferreria: I think you’re saving actually quite a bit of time, not only in the preoperative area before the surgery, but actually in the recovery area. After anesthesia, you have to be monitored usually for about 45 minutes to an hour, to make sure that your vitals and everything are fine. With our wide-awake surgery, there’s none of that general anesthesia and patients typically get dressed, have their blood pressure taken once and then are out the door within five to 10 minutes.
Dr. Parrino: We’ve actually looked at a study of our patients, those who had general anesthesia and those who had local medication, wide-awake surgery, for this. And the average time the wide-awake patients were here from the time they checked in to the time they left was about an hour and a half to an hour and 45 minutes, whereas those who have anesthesia are typically four to five hours, that they’re in the building total.
Carolyn: So what is the reaction from patients? What do they tell you after their procedure?
Dr. Parrino: The typical response is, “That’s not as bad as I thought it was. That was fine. It was no issues at all.” I haven’t had any patients say no to doing it wide-awake again, if they needed another procedure. Our staff that we work with pretty closely, who helps us run the rooms very efficiently, they actually got us a present, that says, “Dr. Ferreira and Dr. Parrino, it’s not as bad as I thought.” It’s what patients would typically tell us.
Carolyn: That’s great.
Dr. Ferreria: I had recently had a patient that was totally against wide-awake surgery. So I did her surgery under anesthesia for carpal tunnel release. And she actually had awful reaction to the anesthetic, had to be admitted because of intractable nausea, and vomiting. So she comes back and sees me and her other side’s still bothering her. I was like, “I would really recommend wide-awake,” and we did wide-awake. And the first thing she said was, “I should have done my first side wide-awake.”
Chris: So let’s say I’m a candidate for this. I can wake up — normally, if I have a procedure, I’ve got to like fast from the day before, I can’t have anything to eat after a certain time, I wake up early — I want to go first thing, someone’s got to drive me home. So you’re saying under wide-awake hand surgery, if I had like a trigger finger repair using this approach, I can wake up, I can have breakfast, go in to see you, you guys take care of me and I’m driving myself home that same day?
Dr. Ferreria: And actually we have some patients that will go to work for a morning, so they don’t have to take the complete day off of work, and then leave at noontime, come and have surgery, or vice versa, have surgery in the morning and then are back to work, with certain restrictions, but able to go back to work that same day.
Carolyn: Wow, that’s great. Why can’t more procedures be done this way?
Dr. Parrino: I think going forward, we’re expanding what we can and cannot do with wide-awake surgery. This technique is actually much more popular in other countries, where it’s difficult to secure an operating room. So there are some studies that show that it can be done with distal radius fractures, arthritic surgeries. I think just bringing it on slowly so people can get accustomed to it here is crucial to just introducing it to our patients rather than trying to do everything with wide-awake.
Carolyn: But down the road, you do foresee that that’s a possibility.
Dr. Ferreria: I definitely think so, on a case-by-case basis. Certain patients, one that comes to mind had a finger fracture and she also had a concussion at the time. This was prior to COVID. So we really are against giving her general anesthesia. I was able to numb up her finger and do the surgery with her wide-awake. Again, it’s also kind of patient-dependent too, because you’re hearing the drills, you’re hearing different things, to make sure that they are also OK with it.
Chris: I could imagine I would have a little trouble with that. But, you could make it so I can’t see what’s happening, right, like to put curtain down or something like
Dr. Parrino: that?
Our room is actually set up really well. We typically have the same one or two nurses in there. There’s our drape that goes up with the curtain so they cannot see what we’re doing. I’m talking to them during my procedure, but most of importantly, the nurse who’s sitting right next to them just talking to them about day-to-day stuff, trying to keep their mind off of what’s going on because people are nervous as we’re doing this. There are some things that we do that can show up on the screen. So if patients want to see that we can actually show them that, in addition to at the end, when we can show them their motion of the hand and what they should be doing immediately after for their recovery.
Carolyn: So in the community, how common is this?
Dr. Parrino: I find that here in our community, it’s not typically done very often. It’s probably more on a case-by-case basis. Dr. Ferreira and I were both residents here and we didn’t do any wide-awake procedures, and this is from 2010 to 2015. My first day in fellowship was just a wide-awake surgery room in upstate New York, where we did 15 cases. And that was the norm for them, each surgeon would do that once, once a week. So we really made it a point when we came back to try to bring that to the area because it wasn’t available to patients.
Dr. Ferreria: Echoing with Dr. Parrino said, I had really no experience until I went to my fellowship and same thing, it was seeing these patients wide-awake. It was kind of awe-inspiring to see that and trying to get that and bring that back to here at UConn with us.
Chris: Dr. Joel Ferreria, Dr. Anthony Parrino from the UConn Musculoskeletal Institute,I did want to touch on that. You both did your residency training here under Dr. Rodner, but you didn’t learn the technique here. You went and did that at fellowship, then you brought it back. Was that the plan all along, to kind of bring that to UConn, or did it just kind of work out that way because you had a relationship with UConn and you wanted to come back here. How did that all come together?
Dr. Parrino: I think that the circumstances just kind of broke right. At the time that I was finishing my fellowship, one of the prior hand surgeons was leaving here, which left a vacancy, and our orthopedic chairman decided to bring two hand surgeons on board to cover more of the state. And it’s actually worked out very well for me. I got to join Dr. Rodner ,who was a great mentor, nicest guy you could ever meet, great surgeon, really good partner, and then joining with dr. Ferreira, who is actually really close friend, excellent surgeon as well, good person. And it’s been interesting and it’s been fun trying to bring it back ,what we’ve learned outside of the typical stuff that’s seen in the state. And the unique thing is we’ve gone from, Dr. Rodner had shown us things the way he does them and teaching us, and now this is actually something we’ve been able to show him and he’s actually using it in his practice as well. So I think as we go on, we’ll have three surgeons who are doing this full time, multiple patients in a week.
Chris: You two do these regularly, like every week or something like that, right?
Dr. Ferreria: Yes.
Carolyn: Well, carpal tunnel is so common, and trigger finger, right? I mean, it’s a common ailment.
Dr. Ferreria: Absolutely. Yes, we see it. I mean, I don’t even know how many times in a day in my office that I see that those two patients that I always echo, wide-awake surgery is great, especially with trigger fingers though, definitely come in for evaluation because there are some conservative things like injections that sometimes can be curative and lends you to not have to go to surgery. But surgery is always there if you need it.
Dr. Parrino: For carpal tunnel and trigger finger, it’s probably the two most common things that we see. If it’s something that they do need surgery for, it’s 95%, 98% of the time, my recommendation is they do it under a wide-awake anesthetic, especially if it’s in an isolated situation.
Chris: Someone who might be listening to this, who isn’t familiar with whether he’s a candidate for this or not sure where to go to get an opinion on this. What should the public know about this as an option for them, what they might want to ask their own doctors, “Hey, is this something I should think about doing, what do you know about those guys at UConn?”
Dr. Ferreria: I just find that wide-awake surgery is exceedingly safe. For the past four years we’ve been doing this and had great success with it. So if it’s a person that has some hand issues or hand ailments, and they just have never seen anybody because they’re deathly afraid, “Oh gosh, I might have to undergo actual anesthesia and be put to sleep,” definitely be evaluated for it because there are options from us to be able to help you.
Dr. Parrino: Just echoing that, if you have a hand condition, especially common procedures, most of them could be taken care of in a wide-awake fashion. It can take away the fears of general anesthesia, it can take away the apprehension of people having to go through a workup and the hoops they may have to go through to get cleared for surgery, with anesthesia. And these patients all have great outcomes. We have patients who ask us, “I’m not sure I’m going to react on the table,” even patients who really don’t like having office injections, they do very well. We joke that we’ve never had anyone run out of the room or cancel day-of once they’re getting their injection. And they’ve all said, “You know, I’d do it again this same way.”
Chris: He’s Dr. Anthony Parrino, also with us, Dr. Joel, Ferreira, both from the UConn Musculoskeletal Institute, hand, wrist and elbow surgeons specializing in wide-awake hand surgery.
And that’s our time for today. For Dr. Anthony Parrino, Dr. Joel Ferreira and Carolyn Pennington, I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Be sure to subscribe so you can catch us next time, and please share with a friend.