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Abstract

Supplemental Digital Content is available in the text.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
www.PRSGlobalOpen.com 1
VIDEO
Operative Technique
Wide Awake Local Anesthesia No Tourniquet
(WALANT) is a good alternative technique to se-
dation and the tourniquet, when performing tra-
peziectomy with or without ligament reconstruction. The
purpose of this article was to demonstrate with clear video
the local anesthetic injection, surgery, intraoperative pa-
tient interaction, and postoperative patient satisfaction.
PREOPERATIVE PLANNING
We inject only lidocaine, epinephrine, and bicarbonate
in our supine patients on a stretcher outside the operating
room and we allow a minimum of 30 minutes for the local
anesthetic to provide good hemostasis and a pain-free expe-
rience.1 Eliminating the tourniquet and the pain associated
with local anesthesia2 removes the need for sedation and in-
travenous insertion. Avoiding sedation related complications
is especially important for patients with medical comorbidi-
ties. Patients do not have to undergo unnecessary preopera-
tive testing: ECG = electrocardiography, chest radiographs,
anesthesia consultation, or blood tests. There is no need to
risk discontinuing anticoagulation medication in most cases.
LOCAL ANESTHETIC INJECTION
See video, Supplemental Digital Content 1, which shows
how to perform minimal pain local anesthesia injection for
WALANT trapeziectomy. This video is available in the “Re-
lated Videos” section of the Full-Text article on PRSGlobal
Open.com or available at http://links.lww.com/PRSGO/A498.
We inject 50–60 cc of 0.5% lidocaine with 1:200,000
epinephrine (buffered with 8.4% sodium bicarbonate
at a 10:1 ratio lidocaine/epinephrine:bicarbonate)
with a 27-gauge needle. We begin with 10 ml in the fat
under the center of the incision and inflate the radial
hand all around the trapezium as shown in the video.
We no longer routinely perform FCR = flexor carpi radi-
alis ligament reconstructions. However, this is easily done
after injection of an additional 20–30 cc over the donor
tendon from proximal to distal with the same solution.
It is important to use minimal pain injection tech-
niques that include perpendicular needle insertion,
reinsertion of the needle into areas that are clearly
numb, and slow antegrade injection of the local to
avoid sharp needle penetration of sensate areas.2
TRAPEZIECTOMY PROCEDURE
See video, Supplemental Digital Content 2, which
shows trapeziectomy exposure using wide-awake local
anesthesia no tourniquet surgery. This video is available
in the “Related Videos” section of the Full-Text article on
PRSGlobalOpen.com or available at http://links.lww.com/
PRSGO/A499.
See video, Supplemental Digital Content 3, which
shows trapeziectomy surgical decision making using wide-
awake local anesthesia no tourniquet hand surgery. This
video is available in the “Related Videos” section of the
Full-Text article on PRSGlobalOpen.com or available at
http://links.lww.com/PRSGO/A500.
xxx
10.1097/GOX.0000000000001435
8
Sudharshini
2017
5
Operative Technique Video Articles
14June2017
19February2017
© 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society
of Plastic Surgeons.
Wide Awake Trapeziectomy for Thumb Basal Joint
Arthritis
Daniel Mckee, MD; Donald Lalonde, MD
Disclosure: The authors have no financial interest to declare
in relation to the content of this article. The Article Processing
Charge was paid for by the authors.
Supplemental digital content is available for this
article. Clickable URL citations appear in the text.
From the Dalhousie University, Saint John, NB, Canada. Division of
Plastic Surgery, Department of Plastic Surgery, Dalhousie University.
Received for publication February 19, 2017; accepted June 14,
2017.
Copyright © 2017 The Authors. Published by Wolters Kluwer Health,
Inc. on behalf of The American Society of Plastic Surgeons. This is
an open-access article distributed under the terms of the Creative
Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the
work provided it is properly cited. The work cannot be changed in
any way or used commercially without permission from the journal.
Plast Reconstr Surg Glob Open 2017;5:e1435; doi: 10.1097/
GOX.0000000000001435; Published online 7 August 2017.
Video Graphic 1. See video, Supplemental Digital Content 1, which
shows how to perform minimal pain local anesthesia injection for
WALANT trapeziectomy. This video is available in the “Related Vid-
eos” section of the Full-Text article on PRSGlobalOpen.com or avail-
able at http://links.lww.com/PRSGO/A498.
2017
Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
PRS Global Open 2017
2
Several prospective randomized controlled trials have
shown simple trapeziectomy to be just as effective as
trapeziectomy with ligament reconstruction, but with
less morbidity.3
After we remove the trapezium, we get the comfort-
able, drug-free, pain-free, and cooperative patient
to actively move the thumb during the procedure.
We can easily assess for: stability, persistent grinding
due to osteophytes, the base of the metacarpal rub-
bing on the scaphoid, and persistent hyperextension
of the MP = metacarpal phalangeal joint. These may
all require correction if present. When we see persis-
tent grinding of the metacarpal on the scaphoid, we
prefer using a Weilby-type abductor pollicis longus or
suture suspension procedure.4
We then verify the strength of our reconstruction with
further active movement before we close the skin. Pa-
tients can see their thumb move during surgery. Pa-
tients remember this thumb movement goal after the
postoperative swelling, pain, and stiffness dissipate.
Patients interact with their surgeon during the proce-
dure and receive additional education on how to care
for their hand postoperatively.5
POSTOPERATIVE COURSE
See video, Supplemental Digital Content 4, which
shows an orthopedic veterinary surgeon as the patient,
and her perspective in follow-up, after undergoing wide
awake trapeziectomy. This video is available in the “Re-
lated Videos” section of the Full-Text article on PRS-
GlobalOpen.com or available at http://links.lww.com/
PRSGO/A501.
No sedation means no nausea, vomiting, urinary re-
tention, or other unwanted side effects. Most patients
simply get up and go home after the procedure as if it
were a visit to the dentist office.
• Costs of the procedure are largely reduced.
Daniel Mckee, MD
Suite C204
600 Main Street
Saint John
NB E2K 1J5 Canada
E-mail: Daniel.mckee@medportal.ca
REFERENCES
1. Mckee DE, Lalonde DH, Thoma A, et al. Achieving the optimal
epinephrine effect in wide awake hand surgery using local anes-
thesia without a tourniquet. Hand (N Y). 2015;10:613–615.
2. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local
anesthesia injection. Plast Reconstr Surg. 2013;132:675–684.
3. Li YK, White C, Ignacy TA, et al. Comparison of trapeziectomy
and trapeziectomy with ligament reconstruction and tendon
interposition: a systematic literature review. Plast Reconstr Surg.
2011;128:199–207.
4. Lalonde D, Amadio P, Cook G. Chapter 27 trapeziectomy with or
without ligament reconstruction for thumb basal joint arthritis.
In: Lalonde D, ed. Wide Awake Hand Surgery. New York, N.Y.:
Thieme Pub; 2016:165–174.
5. Farhangkhoee H, Lalonde J, Lalonde DH. Wide-awake trapeziec-
tomy: video detailing local anesthetic injection and surgery. Hand
(N Y). 2011;6:466–467.
Video Graphic 3. See video, Supplemental Digital Content 3, which
shows trapeziectomy surgical decision making using wide-awake
local anesthesia no tourniquet hand surgery. This video is available
in the “Related Videos” sec tion of the Full-Text article on PRSGlobalO-
pen.com or available at http://links.lww.com/PRSGO/A500.
Video Graphic 4. See video, Supplemental Digital Content 4, which
shows an orthopedic veterinary surgeon patient perspective in fol-
low-up, after undergoing wide awake trapeziectomy. This video is
available in the “Related Videos” section of the Full-Text article on PRS-
GlobalOpen.com or available at http://links.lww.com/PRSGO/A501.
Video Graphic 2. See video, Supplemental Digital Content 2, which
shows trapeziectomy exposure using wide-awake local anesthesia
no tourniquet surgery. This video is available in the “Related Videos”
section of the Full-Text article on PRSGlobalOpen.com or available at
http://links.lww.com/PRSGO/A499.
Article
Learning objectives: After studying this article, the participant should be able to: 1. Comprehend anatomy and biomechanics of the normal and arthritic trapeziometacarpal joint. 2. Evaluate best evidence for diagnosis and for operative and nonoperative treatment of thumb osteoarthritis. 3. Understand treatment pitfalls of basilar joint arthritis and complication avoidance. Summary: Articular and ligamentous anatomy of the trapeziometacarpal joint enables complex motions. Disability from arthritis, common at the trapeziometacarpal joint, is debilitating. Furthering the understanding of how trapeziometacarpal arthritis develops can improve treatment. The authors provide current best evidence for diagnosis and treatment of basilar joint arthritis. Pitfalls in treatment are discussed.
Article
Wide awake local anesthesia no tourniquet (WALANT) refers to an anesthesia technique with low bleeding and complication rates, which enables interventions on the hand in an awake patient without the use of a tourniquet. Bleeding control is achieved through addition of vasoconstrictors to the infiltration solution. Since the motor function of the extremity is not affected, it offers the additional possibility of intraoperative active function testing. The WALANT procedure constitutes an established, effective, easily learnt and resource-sparing technique. The spectrum of surgical possibilities with WALANT is wide and covers nearly all elective and many emergency procedures. Due to multiple advantages in contrast to other regional and general anesthesia procedures, WALANT features an increasing spectrum of surgical applications and practitioners. It is therefore of interest for hand surgeons working both in hospitals and private practices.
Article
Introduction: Ankle fractures frequently occur and must be treated with open reduction for long-term stability. The existing anaesthesia methods include general anaesthesia, spinal and epidural anaesthesia, peripheral nerve block and local anaesthesia with IV sedation. However, each method has its inherent risks and potential costs, and the use of a tourniquet is inevitable. Therefore, the wide-awake local anaesthesia no tourniquet (WALANT) technique provides an alternative method for equivalent haemostasis and pain control without the use of a tourniquet. Patients and methods: We prospectively enrolled 13 consecutive patients (9 males and 4 females) who presented ankle fractures and required ORIF from January 2017 to December 2017. The fracture types of the 13 patients included lateral malleolar fracture (three patients), bimalleolar fracture (two patients), bimalleolar equivalent fracture (three patients), medial malleolar fracture (two patients) and trimalleolar fracture (three patients; articular surface involvement <25%). We used a solution of 1% lidocaine mixed with 1:40,000 epinephrine for WALANT. Results: All patients underwent surgery if they exhibited an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet. Only two patients required an additional 5 ml of local anaesthesia due to NPRS score elevation during the surgery; no dose exceeded the safe limit of 7 mg/kg. No local complications occurred, and no shifts to other anaesthesia methods were required due to the failure of WALANT. Conclusions: WALANT simplified surgical preparations and provided a safe and reliable method for ankle fracture management. Because the use of a tourniquet was not required, reduced postsurgical pain was observed. Moreover, the use of local anaesthesia resulted in more satisfied patients and facilitated easier recovery.
Article
The implementation of the wide-awake local anesthetic no tourniquet (WALANT) approach to surgical procedures in Cyprus has led to significant cost savings. In the United Kingdom, the implementation of WALANT has led to shorter waiting times for hand surgical procedures, cost savings for the National Health Service, and high patient satisfaction rates. In both countries, patient education is a prerequisite for WALANT surgery. It increases the satisfaction rate among patients and enhances the patient-surgeon relationship. Patients need to know they can participate actively in a procedure, because a patient moving the hand during a procedure can improve the outcome.
Article
Full-text available
Background: In our experience, for all surgeries in the hand, the optimal epinephrine effect from local anesthesia-producing maximal vasoconstriction and visualization-is achieved by waiting significantly longer than the traditionally quoted 7 min from the time of injection. Methods: In this prospective comparative study, healthy patients undergoing unilateral carpal tunnel surgery waited either 7 min or roughly 30 min, between the time of injection of 1 % lidocaine with 1:100,000 epinephrine and the time of incision. A standardized incision was made through dermis and into the subcutaneous tissue followed by exactly 60 s of measuring the quantity of blood loss using sterile micropipettes. Results: There was a statistically significant reduction in the mean quantity of bleeding in the group that waited roughly 30 min after injection and before incision compared to the group that waited only 7 min (95 % confidence intervals of 0.06 + -0.03 ml/cm of incision, compared to 0.17 + -0.08 ml/cm, respectively) (P = 0.03). Conclusions: Waiting roughly 30 min after injection of local anesthesia with epinephrine as oppose to the traditionally taught 7 min, achieves an optimal epinephrine effect and vasoconstriction. In the hand, this will result in roughly a threefold reduction in bleeding-making wide awake local anesthesia without tourniquet (WALANT) possible. This knowledge has allowed our team to expand the hand procedures that we can offer using WALANT. The benefits of WALANT hand surgery include reduced cost and waste, improved patient safety, and the ability to perform active intraoperative movement examinations.
Article
Local anesthetic injection is often cited in literature as the most painful part of minor procedures. It is also very possible for all doctors to get better at giving local anesthesia with less pain for patients. The purpose of this article is to illustrate and simplify how to inject local anesthesia in an almost pain-free manner. The information was obtained from reviewing the best evidence, from an extensive review of the literature (from 1950 to August of 2012) and from the experience gained by asking over 500 patients to score injectors by reporting the number of times they felt pain during the injection process. The results are summarized in a logical stepwise pattern mimicking the procedural steps of an anesthetic injection-beginning with solution selection and preparation, followed by equipment choices, patient education, topical site preparation, and finally procedural techniques. There are now excellent techniques for minimizing anesthetic injection pain, with supporting evidence varying from anecdotal to systematic reviews. Medical students and residents can easily learn techniques that reliably limit the pain of local anesthetic injection to the minimal discomfort of only the first fine needlestick. By combining many of these conclusions and techniques offered in the literature, tumescent local anesthetic can be administered to a substantial area such as a hand and forearm for tendon transfers or a face for rhytidectomy, with the patient feeling just the initial poke.
Article
Unlabelled: The use of local anesthesia with epinephrine and no tourniquet/no sedation is becoming an excellent alternative for hand surgeries. This wide-awake approach is the most commonly used method of anesthesia for carpal tunnel release in Canada. The purpose of this paper is to provide a video detailing this technique for trapeziectomy for trapeziometacarpal joint osteoarthritis. Electronic supplementary material: The online version of this article (doi:10.1007/s11552-011-9367-z) contains supplementary material, which is available to authorized users.
Article
Trapeziectomy with ligament reconstruction and tendon interposition is currently the most popular technique for operative treatment of trapeziometacarpal osteoarthritis. Based on the evidence, however, it is uncertain whether the addition of ligament reconstruction and tendon interposition to trapeziectomy confers any advantage. The aim of this study was to systematically review the literature and determine which procedure, trapeziectomy or trapeziectomy with ligament reconstruction and tendon interposition, offers the best results to patients. A literature search was undertaken of the following electronic databases: Cochrane, AMED, EMBASE, HaPI, HealthSTAR, MEDLINE, TRIP, and Proceedings First (2002 to 2009). Studies were selected by two independent assessors if (1) the study population included patients with trapeziometacarpal osteoarthritis and (2) the study was a randomized controlled trial or systematic review comparing the two procedures. Objective (i.e., range of motion, grip strength, pinch strength, health cost, and postoperative complications) and subjective (i.e., pain relief, hand function, overall satisfaction, and quality of life) outcomes were extracted. Statistical pooling and power analyses were performed with available data. Two systematic reviews and four randomized controlled trials were identified and included. There were no statistically significant differences in postoperative grip strength (p = 0.77); tip pinch strength (p = 0.72); key pinch strength (p = 0.90); pain visual analogue scale score (p = 0.34); Disabilities of the Arm, Shoulder and Hand score (p = 0.75); and number of adverse events (p = 0.13). No studies reported health costs or quality of life. Neither procedure produced greater benefit in terms of outcomes investigated. Therapeutic, II.(Figure is included in full-text article.).
Chapter 27 trapeziectomy with or without ligament reconstruction for thumb basal joint arthritis
  • D Lalonde
  • P Amadio
  • G Cook
Lalonde D, Amadio P, Cook G. Chapter 27 trapeziectomy with or without ligament reconstruction for thumb basal joint arthritis. In: Lalonde D, ed. Wide Awake Hand Surgery. New York, N.Y.: Thieme Pub; 2016:165-174.