Evaluating the Safety of the Hand Surgery Procedure Room: A Single-Center Cohort of 1,404 Surgical Encounters

Published:January 21, 2021DOI:


      Performing hand surgeries in the procedure room (PR) setting instead of the operating room effectively reduces surgical costs. Understanding the safety or complication rates associated with the PR is important in determining the value of its use. Our purpose was to describe the incidence of medical and surgical complications among patients undergoing minor hand surgeries in the PR.


      We retrospectively reviewed all adult patients who underwent an operation in the PR setting between December 2013 and May 2019 at a single tertiary academic medical center by 1 of 5 fellowship-trained orthopedic hand surgeons. Baseline patient characteristics were described. Complication rates were obtained via chart review.


      For 1,404 PR surgical encounters, 1,796 procedures were performed. Mean patient age was 59 ± 15 years, 809 were female (57.6%), and average follow-up was 104 days. The most common surgeries were carpal tunnel release (39.9%), trigger finger release (35.9%), and finger mass or cyst excision (9.6%). Most surgeries were performed using a nonpneumatic wrist tourniquet (58%), whereas 42% used no tourniquet. No patient experienced a major medical complication. No procedure was aborted owing to intolerance. No patient required admission. No intraoperative surgical or medical complications occurred. Observed complications included delayed capillary refill requiring phentolamine administration after a trigger thumb release performed using epinephrine without a tourniquet (n = 1; 0.1%), complex regional pain syndrome (n = 3; 0.2%), infection requiring surgical debridement (n = 2; 0.2%), and recurrent symptoms requiring reoperation (n = 8; 0.7%).


      In this cohort of patients in whom surgery was performed in a PR, there were no major intraoperative surgical or medical complications. There was a low rate of postoperative infection, development of complex regional pain syndrome, and a low need for revision surgery. These observations do not support the concern for safety as a barrier to performing minor hand surgery in the PR setting.

      Type of study/level of evidence

      Therapeutic IV.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lee V.S.
        • Kawamoto K.
        • Hess R.
        • et al.
        Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality.
        JAMA. 2016; 316: 1061-1072
        • Porter M.E.
        What is value in health care?.
        N Engl J Med. 2010; 363: 2477-2481
        • Porter M.E.
        Value-based health care delivery.
        Ann Surg. 2008; 248: 503-509
        • Porter M.E.
        A strategy for health care reform—toward a value-based system.
        N Engl J Med. 2009; 361: 109-112
        • Porter M.E.
        • Lee T.H.
        From volume to value in health care: the work begins.
        JAMA. 2016; 316: 1047-1048
        • Davison P.G.
        • Cobb T.
        • Lalonde D.H.
        The patient’s perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study.
        Hand (N Y). 2013; 8: 47-53
        • Kazmers N.H.
        • Presson A.P.
        • Xu Y.
        • Howenstein A.
        • Tyser A.R.
        Cost implications of varying the surgical technique, surgical setting, and anesthesia type for carpal tunnel release surgery.
        J Hand Surg Am. 2018; 43 (971.e1–977.e1)
        • Kazmers N.H.
        • Stephens A.R.
        • Presson A.P.
        • Yu Z.
        • Tyser A.R.
        Cost implications of varying the surgical setting and anesthesia type for trigger finger release surgery.
        Plast Reconstr Surg Glob Open. 2019; 7: e2231
        • Leblanc M.R.
        • Lalonde J.
        • Lalonde D.H.
        A detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in Canada.
        Hand (N Y). 2007; 2: 173-178
        • Lalonde D.
        • Martin A.
        Tumescent local anesthesia for hand surgery: improved results, cost effectiveness, and wide-awake patient satisfaction.
        Arch Plast Surg. 2014; 41: 312-316
        • Rhee P.C.
        • Fischer M.M.
        • Rhee L.S.
        • McMillan H.
        • Johnson A.E.
        Cost savings and patient experiences of a clinic-based, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures.
        J Hand Surg Am. 2017; 42: e139-e147
        • Williamson M.
        • Sehjal R.
        • Jones M.
        • James C.
        • Smith A.
        How critical cost analysis can save money in today’s NHS: a review of carpal tunnel surgery in a district general hospital.
        BMJ Open Qual. 2018; 7e000115
        • Chatterjee A.
        • McCarthy J.E.
        • Montagne S.A.
        • Leong K.
        • Kerrigan C.L.
        A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States.
        Ann Plast Surg. 2011; 66: 245-248
        • Maliha S.G.
        • Cohen O.
        • Jacoby A.
        • Sharma S.
        A cost and efficiency analysis of the WALANT technique for the management of trigger finger in a procedure room of a major city hospital.
        Plast Reconstr Surg Glob Open. 2019; 7: e2509
        • Lalonde D.
        • Martin A.
        Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia.
        J Am Acad Orthop Surg. 2013; 21: 443-447
        • Denkler K.
        Dupuytren’s fasciectomies in 60 consecutive digits using lidocaine with epinephrine and no tourniquet.
        Plast Reconstr Surg. 2005; 115: 802-810
        • Stephens A.R.
        • Yu S.
        • Presson A.P.
        • Tyser A.R.
        • Kazmers N.H.
        Cost implications of varying the surgical setting and anesthesia type for de Quervain release surgery.
        J Wrist Surg. 2020; 9: 289-297
        • Halvorson A.J.
        • Sechriest II, V.F.
        • Gravely A.
        • DeVries A.S.
        Risk of surgical site infection after carpal tunnel release performed in an operating room versus a clinic-based procedure room within a Veterans Affairs medical center.
        Am J Infect Control. 2020; 48: 173-177
        • Leblanc M.R.
        • Lalonde D.H.
        • Thoma A.
        • et al.
        Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery.
        Hand (N Y). 2011; 6: 60-63
        • Bismil M.
        • Bismil Q.
        • Harding D.
        • Harris P.
        • Lamyman E.
        • Sansby L.
        Transition to total one-stop wide-awake hand surgery service-audit: a retrospective review.
        JRSM Short Rep. 2012; 3: 23
        • Nodwell T.
        • Lalonde D.
        How long does it take phentolamine to reverse adrenaline-induced vasoconstriction in the finger and hand? A prospective, randomized, blinded study: the Dalhousie project experimental phase.
        Can J Plast Surg. 2003; 11: 187-190
        • Krunic A.L.
        • Wang L.C.
        • Soltani K.
        • Weitzul S.
        • Taylor R.S.
        Digital anesthesia with epinephrine: an old myth revisited.
        J Am Acad Dermatol. 2004; 51: 755-759
        • Lipira A.B.
        • Sood R.F.
        • Tatman P.D.
        • Davis J.I.
        • Morrison S.D.
        • Ko J.H.
        Complications within 30 days of hand surgery: an analysis of 10,646 patients.
        J Hand Surg Am. 2015; 40 (1852.e3–1859.e3)
        • Farhangkhoee H.
        • Lalonde J.
        • Lalonde D.H.
        Wide-awake trapeziectomy: video detailing local anesthetic injection and surgery.
        Hand (N Y). 2011; 6: 466-467
        • Huang Y.C.
        • Hsu C.J.
        • Renn J.H.
        • et al.
        WALANT for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet.
        J Orthop Surg Res. 2018; 13: 195
        • Ahmad A.A.
        • Yi L.M.
        • Ahmad A.R.
        Plating of distal radius fracture using the wide-awake anesthesia technique.
        J Hand Surg Am. 2018; 43: 1045.e1-1045.e5
        • Tosti R.
        • Fowler J.
        • Dwyer J.
        • Maltenfort M.
        • Thoder J.J.
        • Ilyas A.M.
        Is antibiotic prophylaxis necessary in elective soft tissue hand surgery?.
        Orthopedics. 2012; 35: e829-e833
        • Platt A.J.
        • Page R.E.
        Post-operative infection following hand surgery: guidelines for antibiotic use.
        J Hand Surg Br. 1995; 20: 685-690
        • Harness N.G.
        • Inacio M.C.
        • Pfeil F.F.
        • Paxton L.W.
        Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis.
        J Hand Surg Am. 2010; 35: 189-196
        • Kleinert J.M.
        • Hoffmann J.
        • Miller Crain G.
        • Larsen C.F.
        • Goldsmith L.J.
        • Firrell J.C.
        Postoperative infection in a double-occupancy operating room: a prospective study of two thousand four hundred and fifty-eight procedures on the extremities.
        J Bone Joint Surg Am. 1997; 79: 503-513
        • Coady-Fariborzian L.
        • McGreane A.
        Risk factors for postoperative complications in trigger finger release.
        Fed Pract. 2015; 32: 21-23
        • Will R.
        • Lubahn J.
        Complications of open trigger finger release.
        J Hand Surg Am. 2010; 35: 594-596
        • da Costa V.V.
        • de Oliveira S.B.
        • Fernandes Mdo C.
        • Saraiva R.A.
        Incidence of regional pain syndrome after carpal tunnel release: is there a correlation with the anesthetic technique?.
        Rev Bras Anestesiol. 2011; 61: 425-433
        • Shinya K.
        • Lanzetta M.
        • Conolly W.B.
        Risk and complications in endoscopic carpal tunnel release.
        J Hand Surg Br. 1995; 20: 222-227
        • Kern B.C.
        • Brock M.
        • Rudolph K.H.
        • Logemann H.
        The recurrent carpal tunnel syndrome.
        Zentralbl Neurochir. 1993; 54: 80-83
        • Eroglu A.
        • Sari E.
        • Topuz A.K.
        • Simsek H.
        • Pusat S.
        Recurrent carpal tunnel syndrome: evaluation and treatment of the possible causes.
        World J Clin Cases. 2018; 6: 365-372
        • Fiorini H.J.
        • Tamaoki M.J.
        • Lenza M.
        • Gomes Dos Santos J.B.
        • Faloppa F.
        • Belloti J.C.
        Surgery for trigger finger.
        Cochrane Database Syst Rev. 2018; 2: CD009860