Posted on Thursday - 07/29/2021 to Up Close
Cathy Holen woke up on a recent morning and her right thumb clicked and popped every time she tried to bend it. Holen types every day at her job at the U.S. Department of Agriculture in helping farmers apply for federal crop insurance, and suddenly she had limited use of her thumb.
“I had no grasp. I couldn’t grab things. I had no strength in it. And it hurt. It hurt really bad. And over time, it kept getting worse,” she said. “It wasn’t just clicking and popping any more, it was locking.”
Holen was diagnosed with stenosing tenosynovitis or “trigger finger,” a relatively common and painful condition in which a finger or thumb freezes in a bent position. Holen sought care from Nathan A. Hoekzema, MD, a UCSF Fresno orthopaedic surgeon who specializes in surgery of the hand, wrist and elbow. Dr. Hoekzema had treated her three years prior for a joint issue with another finger.
Steriod injections often resolve a trigger finger, but in some patients, surgery is necessary. In Holen’s case, her symptoms did not disappear after a steroid shot and she prepared herself for surgery and all it would involve, including a hospital admission. To her surprise, Dr. Hoekzema gave her a choice of having the surgery in a hospital – or at the University Orthopaedic Associates office in Clovis.
“He said, ‘you can either come in the office and just have it numbed and be awake for it (the surgery) or you can go to the hospital and they can sedate you.’ And I chose to come here and not be sedated. It doesn’t make any sense. You always feel awful afterwards and I just didn’t want to do that,” Holen said.
University Orthopaedic Associates has been offering in-office surgery for trigger finger for about four months. It requires a procedure area, but Dr. Hoekzema said the surgery itself is something that can easily be done in an office. It involves making a small incision to release the bulge or knot that the tendon is catching on. It does not require a lot of cutting or equipment, he said. Patients are given a local anesthesia, called WALANT, to numb the hand area. The anesthesia makes office-based procedures easier because it minimizes bleeding and maximizes visualization of the surgery site.
In-office surgery is efficient, Dr. Hoekzema said. It takes about 30 minutes from check-in at the front desk to walking out, he said. By contrast, having surgery for trigger finger in a hospital can take three hours, including time for blood tests, insertion of an intravenous line for anesthesia, visits with nurses and an anesthesiologist, and time for recovery. Surgery in an office also is less costly than a hospital procedure, which makes it an attractive option for patients who are uninsured, under-insured, using a Health Care Savings Account or who have high insurance deductibles.
While having surgery in the office is all-around more efficient than going to the hospital, Dr. Hoekzema reminds patients that “it’s not like you’re cutting corners or getting out easy from an operation. You still have to heal. You still have to go through all the healing milestones. But the procedure itself is a bit easier. And you avoid some of the things that anesthesia needs, like labs, chest X-rays and EKG (electrocardiogram). We don’t need those in the office because it’s straight, local anesthesia.”
But in-office surgery is offered only as an option for patients with trigger finger, Dr. Hoekzema said. “It’s never mandatory.” He understands some patients prefer surgery to be done in the hospital.
Besides offering in-office surgery for trigger finger, Dr. Hoekzema also provides the choice for DeQuervain’s surgery to release pressure on a pinched tendon that runs along the side of the wrist near the thumb. Both trigger finger and DeQuervain’s are common conditions. “We probably had five patients today with it (trigger finger) today,” he said recently.
Holen said her in-office surgery was fast and easy. “After receiving an injection that numbed her hand, “I felt a little bit of pressure, but I didn’t feel any pain whatsoever,” she said. Once her hand has healed, she looks forward to cooking and baking, among other activities. Her husband is a drag racer and a race is tentatively scheduled for October at a campsite outside Dos Palos. She is responsible for some of the cooking during races. “Everyone makes a meal and we just have a great time.”
Dr. Hoekzema said most patients are surprised and pleased that surgery for trigger finger can be quickly and safely done in the office. UCSF Fresno orthopeadic surgeons are pleased to offer this as a surgical option, he said. “We are always happy to be able to expand our service lines and this is something we can provider that is great for some of our patients.”