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Trigger Finger Release Surgery Performed Wide Awake : Prospective Comparison of Lidocaine, Marcaine, and Exparel
Asif Ilyas, MD, Constantinos Ketonis, MD; Nayoung Kim, MD; Mitchell Maltenfort, MD; Jonas Matzon, MD; Charles Leinberry, MD; Mark Wang, MD; Christopher Jones, MD; William Kirkpatrick, MD; Frederic Liss, MD
Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA

Hypothesis: Local anesthetics are routinely used in hand surgery for procedures such as trigger finger releases. Moreover, wide awake hand surgery rely on local anesthetics with epinephrine to facilitate surgery without other anesthesia or tourniquet use. A number of local anesthetics are readily available including lidocaine, bupivacaine (Marcaine), and more recently bupivacaine liposome suspension (Exparel). To better understand the efficacy and safety of these agents in hand surgery, we prospectively evaluated the efficacy of these local anesthetics in controlling post-operative pain, opioid usage, and adverse reactions following trigger finger release surgery.
Methods: After obtaining IRB approval, all consecutive patients undergoing single digit trigger finger release surgery under local anesthesia without sedation by 7 fellowship-trained orthopaedic hand surgeons were invited. Surgeries were performed with either lidocaine (L), bupivacaine (M), or bupivacaine with post-operative bupivacaine liposome injection (E). Patients were contacted post-operatively on days (POD) 0, 1, 2, and 3 to determine their pain on a visual analog scale (VAS), daily opioid consumption, and any adverse reactions.
Results: A total of 163 patients were included in the study. On POD 0 patients in the Lidocaine group reported greatest pain with VAS of 4.40 (p=0.01), and Exparel with the least. By POD1, the Marcaine group reported increasing pain at VAS of 2.90 but still lower than the lidocaine group at 3.73 (p=0.08), whereas the Exparel group continued to experience the least pain at VAS of 2.33 (p=0.006). However, by POD2 and POD3 the differences were more subtle and similar. On POD 0 only 27% of patients in the Exparel group used opioids as opposed to 58% (p=0.01) and 59% (p=0.004), in the Marcaine and Lidocaine groups, respectively. Additionally on POD 0, 50% of patients in the Exparel group required no pain medications as compared to 21.8% and 29.1% in the Lidocaine and Marcaine groups, respectively (p=0.02). Only 3% of the Exparel patients reported adverse reactions as opposed to 13% and 12% in the Lidocaine and Marcaine groups, respectively (p=0.005).
Summary Points:

  • To the best of our knowledge this is the first report on the efficacy of Exparel in ambulatory hand surgery.
  • Overall, trigger finger release surgery results in low pain, but patients in the Lidocaine group reported the highest pain score on POD 0-1.
  • Patients who received Exparel had lower pain scores and consumed less opioids on POD 0-2 as compared to Lidocaine and Marcaine.
  • By POD 3, patientsí pain experiences were similar.

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