Dupuytren's Fasciectomies in 60 Consecutive Digits Using Lidocaine with Epinephrine and No Tourniquet

Author(s): Denkler K.

Source:  Plastic and Reconstructive Surgery 115:  802-810, 2005.

Summary:


This author presents his own retrospective review of 60 cases of Dupuytren's contracture treated with palmar fasciectomy using a tourniquet in a hospital setting versus epinephrine digital and local cutaneous blocks, without the use of a tourniquet, in an office operating suite.  The cases were individually selected, not randomized, but had approximate equivalence with respect to patient numbers, degree of joint contracture, and associated medical conditions.  There is no description of the surgical design, other than "a regional fasciectomy removing diseased fascia."  Results and complication rates are tabulated for each group.  Unfortunately,  no statistical analysis is provided, despite the author's statement that "two independent statisticians reviewed, analyzed, and commented on all statistical data."  No p-values are reported.  The results from the two groups are indeed very similar, with an overall complication rate of 18% and 7% nerve/artery injuries divided roughly equally between the two groups.  No fingers were lost to ischemia in either group, although the epinephrine group contained one patient with prolonged ischemia due to an arterial injury, requiring use of topical nitroglycerine.  The author concludes that resection of Dupuytren's disease in the hand is equally safe and efficacious with either a tourniquet or local blockade with no tourniquet.

The real question is “why?”  In the introduction, the author states that "tourniquets are known to have potentially severe complications."  Yet, in his tourniquet series, there are no tourniquet complications amongst the numerous other complications listed.  He cites the use of epinephrine solutions to aid in hemostasis in head and neck surgery, facial surgery, and neurosurgery, and thus states that visibility should not be an issue in hand surgery without the use of a tourniquet.  But, for those of us who have performed head and neck, facial, and neurosurgery (in addition to hand surgery), there is little doubt that we would use a tourniquet for those operations if we could without obvious repercussions, such as transient disruption of blood flow to the brain?  The author cites the desirability of operating in an office setting for reasons of time savings and convenience.  However, how many surgeons have an operating room microscope available in the office, which might be required for intraoperative complications in a Dupuytren’s case? One also wonders why the author simply does not procure a tourniquet for his office operating room, thus obtaining the benefits of both surgical options without the potential disadvantage of operating in the hand without adequate visualization?

 

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