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Wide-awake Anesthesia No Tourniquet Trapeziometacarpal Joint Prosthesis Implantation

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  • CHUV, Lausanne

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Wide awake local anesthesia no tourniquet (WALANT) hand surgery is a rapidly growing in popularity. WALANT has been used by hand surgeons when operating on bones, tendons, ligaments, nerve entrapments. We offer a case report of the first case in the literature describing WALANT technique when performing trapeziometacarpal joint arthroplasty with prosthesis implantation. We offer technical points on how to perform this procedure and the advantages that are associated with using WALANT for prosthesis arthroplasty.
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INTRODUCTION
Wide awake local anesthetic no tourniquet (WALANT)
hand surgery or “wide-awake” hand surgery is growing in
popularity globally.1 Lidocaine with epinephrine local an-
esthetic is frequently used without concern in the hand
and finger.2 Initially, the technique was described for
small procedures such as trigger finger release and car-
pal tunnel release; however, the spectrum of hand proce-
dures offered using solely local anesthesia is fast growing.3
Hand surgeons utilize WALANT for finger fractures,4,5
flexor tendon repairs,6 tendon transfers,6,7 arthroscopies,
and open triangular fibrocartilage complex (TFCC) re-
pair.8 Trapeziectomy for trapeziometacarpal (TMC) joint
arthritis has been described using wide awake hand sur-
gery, which involves numbing the joint itself.9
TMC joint prosthesis implantation was first described
in 1973, by de la Caffinière.10 This procedure is typically
conducted under general anesthesia or brachial plexus
bloc. We describe the use of WALANT for a TMC joint
prosthesis implantation.
CASE REPORT
A 56-year-old otherwise healthy janitor with long-last-
ing TMC joint arthritis presented to our office after ex-
hausting conservative management options. The patient’s
key-pinch was reduced to 3 kg compared with 6 kg on the
opposite side. Front and lateral x-rays of the trapeziometa-
carpal joint showed: osteoarthritis Eaton II11 and Dell II12
with an articular pinch. No dorsal subluxation was ob-
served. DELL’s stage 1 corresponds to slight narrowing
of joint and subchondral sclerosis; stage 2 to a moderate
narrowing and sclerosis, with slight subluxation of first
metacarpal (less than one-third diameter) and small os-
teophyte, whereas in stage 3, there is important narrow-
ing, sclerosis, and osteophytosis, with subluxation of the
first metacarpal. A total disappearance of joint, flattening
of trapezium, and peritrapezial osteoarthritis corresponds
to a stage 4.
We prepared the local anesthetic injection mixture
according as follows: 100 ml mixture of 40 ml of normal
saline solution, 40 ml of 1% lidocaine with 1:100,000 epi-
nephrine, 4 ml of sodium bicarbonate, and 10 ml of 0.5%
bupivacaine. The bupivacaine was added to prolong the
postoperative antalgic action. The patient was in supine
position. We adapted the infiltration technique described
by Lalonde13 for trapeziectomy. We used a 50 mm long
25-gauge needle to inject 20 ml dorsoproximal to the TMC
joint in a subcutaneous fashion (1) (Fig. 1). Then we in-
filtrated another 20 ml dorso-distal to the TMC joint (2).
Another 10 ml was injected radial to the joint and 10 ml
ulnar to the joint (3) (4). Ten milliliters of local anesthetic
was infiltrated volar to the joint (5), and another 10 ml
was infiltrated between the first and second metacarpal
(6) (Fig. 1). Lastly, during the operation, we distracted the
TMC joint and infiltrated 5 ml in the joint itself. The ter-
minal branches of the radial and median nerves14 must be
From the *Department of the Musculoskeletal System, Hand
and Plastic and Reconstructive Surgery, CHUV, Lausanne,
Switzerland; †Centre of Plastic, Aesthetic, Hand and Reconstructive
Surgery, University of Regensburg, Germany; and ‡Plastic Surgery,
Dalhousie University, Halifax, Canada.
Received for publication October 10, 2017; accepted January 22,
2018.
Summary: Wide awake local anesthesia no tourniquet (WALANT) hand surgery is
a rapidly growing in popularity. WALANT has been used by hand surgeons when
operating on bones, tendons, ligaments, nerve entrapments. We offer a case report
of the first case in the literature describing WALANT technique when performing
trapeziometacarpal joint arthroplasty with prosthesis implantation. We offer tech-
nical points on how to perform this procedure and the advantages that are associ-
ated with using WALANT for prosthesis arthroplasty. (Plast Reconstr Surg Glob Open
2018;6:e1714; doi: 10.1097/GOX.0000000000001714; Published online 4 April 2018.)
Camillo Theo Müller, MD*
Thierry Christen, MD*
Paul I. Heidekruger, MD†
Jessie Lamouille, MD*
Wassim Raffoul, MD*
Daniel McKee, MD‡
Donald H. Lalonde, MD‡
Sébastien Durand, MD, PhD*
Wide-awake Anesthesia No Tourniquet
Trapeziometacarpal Joint Prosthesis Implantation
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.
WALANT Trapeziometacarpal Joint Prosthesis
Müller et al.
xxx
xxx
4
Plastic & Reconstructive Surgery-Global Open
2018
6
Ideas and Innovations
10.1097/GOX.0000000000001714
22January2018
10October2017
4April2018
Hand/Peripheral Nerve
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article. Clickable URL citations appear in the text.
Copyright © 2018 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.
DOI: 10.1097/GOX.0000000000001714
IDEAS AND INNOVATIONS
PRS Global Open 2018
2
numbed with the locally injected anesthesia.15 We waited
at least 26 minutes between injection and skin incision as
proposed by McKee et al.16
The placement of the IVORY prosthesis through a
dorsal approach was performed in a standard fashion
without pain for the patient. A dorsoradial incision was
performed to approach the TMC joint. After identify-
ing and protecting the superficial branches of the radial
nerve, the slips of the abductor pollicis longus muscle
were retracted and preserved. A longitudinal arthrotomy
of the TMC joint was performed, preserving capsule for
closure.17 With an oscillating saw, a thin slice of the dis-
tal trapezium, enough to get a flat surface, and proximal
metacarpal joint surface were excised. A tourniquet was
not necessary, and visualization was excellent even when
grinding and shaping of the socket in the trapezium
(Fig. 2). After placement of the sizer prosthesis, we tested
the fit, and the range of motion of the joint. The Kapand-
ji test for thumb mobility was performed.18 The Kapandji
score assesses the opposition of the thumb, based on
where on their hand the patient is able to touch with the
tip of their thumb. A score 1 means their thumb touches
the radial side of the proximal phalanx of the index fin-
ger, and a score then means that the patient can touch
the distal palmar crease at the fifth metacarpal. Intraop-
eratively the patient scored 5 of 10 and complete thumb
extension. Circumduction of the thumb was possible, and
the TMC joint was stable in all active and passive posi-
tions. Active key-pinch was tested and found to be stable.
The sizer was stable when tested passively and actively.
Intraoperative testing assisted in selecting the proper
prosthesis size for the patient. The patient was also very
interested to see how his thumb moved after the prosthe-
sis was placed and before any pain and swelling set in.
The postoperative care consisted in 2 weeks of splinting.
In follow-up, the patient reported only minimal discom-
fort for a couple of days after the surgery, managed solely
with Ibuprofen and Acetaminophen and Tramadol. At 6
month postoperatively, the patient’s functional testing
showed complete extension of the thumb and a Kapandji
score of 9 of 10 bilaterally. The postoperative x-rays were
satisfying (Fig. 3), and no complications were observed
in follow-up.
Fig. 1. Points of injection: we inject 20 ml dorso-proximal and 20 ml
dorso-distal to the TMC joint in a subcutaneous fashion. Further
10 ml was injected radial to the joint and 10 ml ulnar to the joint. Ten
milliliters of local anesthetic was inltrated volar to the joint, and
another 10 ml was inltrated between the rst and second metacar-
pal. Lastly, during the operation, we distracted the TMC joint and
inltrated 5 ml in the joint itself.
Fig. 2. Intraoperative picture: No tourniquet was applied.
After grinding and shaping of the socket, minimal bleeding was
observed.
Fig. 3. A, Postoperative lateral view after 6 months. B, Postoperative
anteroposterior view after 6 months.
Müller et al. WALANT Trapeziometacarpal Joint Prosthesis
3
CONCLUSIONS
The 10 reasons why hand surgeons should do this
procedure in local anesthesia (see video, Supplemental
Digital Content 1, which displays intraoperative testing of
the trapeziometacarpal prosthesis and the 10 reasons why
hand surgeons should do this procedure in local anesthe-
sia, http://links.lww.com/PRSGO/A694):
1. No pain due to a tourniquet3
2. Minimized anesthetic risk1
3. Maximized cost-effectiveness3 and
4. Decrease inhouse time.
5. Blood less surgical field due to epinephrine19
6. Intraoperative testing of the active and passive sta-
bility of the prosthesis, limited active stability would
change the decision of the size of the prosthesis or
the placement of the pieces of the prosthesis or the
type of intervention.
7. Local anesthesia can be prolonged with a cath-
eter during postoperative course for further pain
release.
8. The patient can observe his active range of motion
during the operation; this could motivate him for
later reeducation.
9. The active mobility and the joint access could be
used for clinical research to measure intraarticular
pressure and force during active movements; may
be this could help to predict disintegration of the
joint.
10. The active mobility could be saved on video and
could be used for patient education and for medico-
legal purpose.
Camillo Theo Müller, MD
Hand and Plastic and Reconstructive Surgery
CHUV
1012- Lausanne Switzerland
E-mail: camillo.muller@chuv.ch
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Video Graphic 1. See video, Supplemental Digital Content 1, which
displays intraoperative testing of the trapeziometacarpal prosthesis
and the 10 reasons why hand surgeons should do this procedure in
local anesthesia, http://links.lww.com/PRSGO/A694.
... 41 Similarly positive analgesic results were reported with olecranon fracture plating, hand fracture fixation, 42 wrist arthroscopy for triangular fibrocartilaginous complex repair, 43 and trapeziometacarpal joint prosthesis implantation. [42][43][44] Repair of an ulna shaft fracture has also been performed under WALANT with the addition of a periosteal nerve block. 45 ...
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... WALANT has also been used for trapeziometacarpal joint prothesis implantation with no complications. 33 Additionally, Tang et al 34 and Xing and Tang 34 extended the use of the WALANT to flap harvesting and transfer in the hand. The authors reported successful execution of the extended Segmuller flap, the homodigital reverse digital artery flap, the dorsal metacarpal artery perforator flap, and the atasoy advancement flap on 27 patients using WALANT. ...
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Background Many surgical treatment options for osteoarthritis (OA) of the trapeziometacarpal (TMC) joint exist. However, no procedure has been proven superior. Good results have been described for TMC joint replacement. Purpose To analyze the results of the Ivory prosthesis in the treatment of symptomatic TMC OA. Patients and Methods A retrospective single-center follow-up study was performed. Visual analogue scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Michigan Hand Outcomes Questionnaire (MHQ), active range of motion, strength, and radiological outcomes were assessed and analyzed. Differences between the operated and nonoperated hand were analyzed using paired t-tests. Twenty patients were included with a mean follow-up duration of 37.0 months. Results Patients experienced minimal pain with a mean VAS pain score of 1.9. DASH and MHQ scores indicated mild to moderate impairments. Eighty-five percent of patients assessed the operation excellent or good. Significant differences were found in measurements of extension and palmar thumb abduction in favor of the contralateral hand. No significant differences in strength between both hands were found. Two patients had a dislocation of the prosthesis; one patient required open reduction and tightening of the joint capsule. The other dislocation was treated with trapeziectomy and interposition of a fascia lata allograft. One patient had a collapse of the trapezium requiring a revision procedure. Conclusion Ivory prosthesis TMC arthroplasty can achieve good results in patients with symptomatic isolated TMC OA. In this series, however, revision surgery was required in 3 of 20 cases.
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