Contrary to our hypothesis, 87% of the clavicle fracture surgery patients who underwent plate removal under local anesthesia responded that they would prefer local anesthesia were they to require the same procedure again in the future. Although the great majority of patients who underwent the procedure under local anesthesia experienced some degree of pain, 83.8% responded that this was within the range they had anticipated. However, only 7 (22.5%) of these patients had chosen local anesthesia for themselves, with the great majority having been recommended it by their attending surgeon. Three of the 4 patients who expressed a preference for general anesthesia in a subsequent procedure did so because of pain, but 1 also mentioned other reasons, including discomfort with the surgeon’s conversation during the procedure. This demonstrated the importance of paying careful attention during the procedure, not only to pain, but also to other matters such as conversation with the patient.
Conversely, 78.9% of those patients who underwent the procedure under general anesthesia responded that they would prefer general anesthesia were they to require the same procedure again in the future, with 21.1% expressing a preference for local anesthesia. It was anticipated that factors such as postoperative nausea would contribute to dissatisfaction with general anesthesia, but, in fact, 40% of patients reported dissatisfaction with compulsory bed rest as the most unpleasant part of their postoperative experience. A further 21.1% complained of discomfort from the urinary catheter. For the participants in this study, the durations of postoperative bed rest and urinary catheterization were not standardized, but were both at the discretion of the attending surgeon or anesthetist. By itself, the results of the present study suggest that efforts to minimize the duration of postoperative bed rest and avoid urinary catheterization may improve patient satisfaction with clavicle implant removal under general anesthesia.
Although numerous reports have addressed implant removal after clavicle fracture surgery (3),(4), (5), (6),(10),(7),(9), most of these studies have either not mentioned the method of anesthesia or have involved general anesthesia, and as far as we have been able to ascertain, no previous report has described clavicle plate removal under local anesthesia, although Pogetti et al. reported fibula plate removal under local anesthesia (11). Comparative studies of local and general anesthesia have been widely reported. In a comparison using the same patients, Knežević et al. conducted bilateral dacryocystorhinostomy in 50 patients, with the operation conducted under local anesthesia on one side and under general anesthesia on the other(12). In dacryocystorhinostomy, few patients complained of immediate postoperative pain even when the procedure was conducted under local anesthesia, and the rate of postoperative nausea and vomiting was significantly higher after general anesthesia. The authors reported that, in light of their results, patient satisfaction was higher after local anesthesia. In the hand surgical field, good outcomes have recently been reported for plate fixation of distal radius fractures using the wide-awake local anesthesia no tourniquet (WALANT) technique (13), (14), (15). In a randomized, controlled trial (RCT) that compared the WALANT technique with plate fixation of distal radius fractures under general anesthesia, there were no significant differences between the two groups in intraoperative or postoperative pain, amount of hemorrhage, or clinical outcomes (16). Because clavicle plate removal involves a large skin incision, a simple comparison cannot be made, but in the present study, the level of satisfaction with local anesthesia was comparatively high, giving the impression that it is far more acceptable to patients than had been anticipated. All patients in the present survey who underwent the procedure under local anesthesia were admitted, as were the patients who received general anesthesia, and were it to be offered as day surgery, the number of patients choosing local anesthesia might increase further.
There is as yet no consensus regarding the nerve supply in the area around the clavicle. According to the latest report, it may be innervated from the cervical plexus via the supraclavicular nerve, or, alternatively, from the brachial plexus via the infraclavicular nerve, the long thoracic nerve, or the suprascapular nerve, and this anatomical uncertainty indicates the difficulty of choosing a method for anesthetizing the area around the clavicle(17),(18). Recently, a few reports have described the use of interscalene block and other types of regional block for clavicle surgery. Olofsson et al. added ultrasound-guided interscalene block during clavicle fracture surgery, and they reported that its use significantly improved postoperative pain(19). Ryan et al. also compared the combined use of interscalene block and general anesthesia with the combined use of interscalene block and modified superficial cervical block for clavicle fracture surgery, and they reported that operating time was significantly shorter when modified superficial cervical block was used (10). No patient in that group required conversion to general anesthesia, but there was no mention of intraoperative pain, and it is unclear whether complete analgesia was achieved by the use of anesthesia. Regional anesthesia by block injections may also be effective, but in light of the trouble involved in block injections and their potential complications, implant removal under local anesthesia alone may be an option. Going forward, one possibility may be to ask patients to choose their preferred method of anesthesia during surgery while showing them these data.
This study had the following limitations. First, the sample size was small, particularly for the local anesthesia group. Second, because the procedure was conducted in different hospitals, factors including the method of anesthesia during the initial surgery were not consistent. Third, factors such as the length of the skin incision and the type of plate were not taken into account. Since the length of the skin incision and whether a locking plate or another type of plate was used will have had a major impact, they must be investigated in more detail in the future. Fourth, because surgeons may recommend general anesthesia from the start depending on the patient’s character, were such patients to undergo the procedure under local anesthesia, this might have an impact on the data.