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
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,
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.
Plastic & Reconstructive Surgery-Global Open
Ideas and Innovations
Supplemental digital content is available for this
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
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IDEAS AND INNOVATIONS
PRS Global Open • 2018
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
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 inltrated volar to the joint, and
another 10 ml was inltrated between the rst and second metacar-
pal. Lastly, during the operation, we distracted the TMC joint and
inltrated 5 ml in the joint itself.
Fig. 2. Intraoperative picture: No tourniquet was applied.
After grinding and shaping of the socket, minimal bleeding was
Fig. 3. A, Postoperative lateral view after 6 months. B, Postoperative
anteroposterior view after 6 months.
Müller et al. • WALANT Trapeziometacarpal Joint Prosthesis
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-
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
8. The patient can observe his active range of motion
during the operation; this could motivate him for
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
10. The active mobility could be saved on video and
could be used for patient education and for medico-
Camillo Theo Müller, MD
Hand and Plastic and Reconstructive Surgery
1012- Lausanne Switzerland
1. Albino FP, Fleury C, Higgins JP. Putting it all together: recom-
mendations for improving pain management in plastic surgical
procedures: hand surgery. Plast Reconstr Surg. 2014;134:126S–
2. 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.
3. Lalonde D, Martin A. Tumescent local anesthesia for hand sur-
gery: improved results, cost effectiveness, and wide-awake patient
satisfaction. Arch Plast Surg. 2014;41:312–316.
4. Gregory S, Lalonde DH, Fung Leung LT. Minimally invasive ﬁnger
fracture management: wide-awake closed reduction, K-wire ﬁxa-
tion, and early protected movement. Hand Clin. 2014;30:7–15.
5. Lalonde D. How the wide awake approach is changing hand sur-
gery and hand therapy: inaugural AAHS sponsored lecture at the
ASHT meeting, San Diego, 2012. J Hand Ther. 2013;26:175–178.
6. Tang JB. Wide-awake primary ﬂexor tendon repair, tenolysis, and
tendon transfer. Clin Orthop Surg. 2015;7:275–281. Accessed January
2018. Available at http://dx.doi.org/10.4055/cios.2015.7.3.275.
7. Lalonde DH. Wide-awake ﬂexor tendon repair. Plast Reconstr
8. Hagert E, Lalonde DH. Wide-awake wrist arthroscopy and
open TFCC repair. J Wrist Surg. 2012;1:55–60. doi:10.1055
9. Farhangkhoee H, Lalonde J, Lalonde DH. Wide-awake trapezi-
ectomy: video detailing local anesthetic injection and surgery.
Hand (N Y). 2011;6:466–467.
10. de la Cafﬁnière JY. [Total trapezo-metacarpal prosthesis].
Revue de chirurgie orthopédique et réparatrice de l’appareil moteur.
1974;60:299–308. Available at http://www.ncbi.nlm.nih.gov/
pubmed/4281097. Accessed September 28, 2016.
11. Eaton RG, Littler JW. Ligament reconstruction for the
painful thumb carpometacarpal joint. J Bone Joint Surg.
1973;55:1655–1666. Available at http://www.ncbi.nlm.nih.gov/
pubmed/4804988. Accessed July 14, 2017.
12. Dell PC, Brushart TM, Smith RJ. Treatment of trapeziometa-
carpal arthritis: results of resection arthroplasty. J Hand Surg.
1978;3:243–249. Available at http://www.ncbi.nlm.nih.gov/
pubmed/659819. Accessed July 20, 2017.
13. Lalonde DH. Wide Awake. 1st ed. CRC Press; 2016.
14. Mobargha N, Ludwig C, Ladd AL, et al. Ultrastructure and
innervation of thumb carpometacarpal ligaments in surgi-
cal patients with osteoarthritis. Clin Orthop Relat Res. 2014;472:
15. Miki RA, Kam CC, Gennis ER, et al. Ulnar nerve component
to innervation of thumb carpometacarpal joint. Iowa Orthop J.
16. McKee D, Lalonde D, Thoma A, et al. Optimal time delay be-
tween epinephrine injection and incision to minimize bleeding.
Plast Recontr Surg. 2013;131:811–814.
17. Spaans AJ, van Minnen LP, Weijns ME, et al. Retrospective study
of a series of 20 ivory prostheses in the treatment of trapezio-
metacarpal osteoarthritis. J Wrist Surg. 2016;5:131–136.
18. Kapandji A. [Clinical test of apposition and counter-apposition of
the thumb]. Annales de chirurgie de la main : organe ofﬁciel des societes
de chirurgie de la main. 1986;5:67–73. Available at http://www.ncbi.
nlm.nih.gov/pubmed/3963909. Accessed July 14, 2017.
19. Prasetyono TOH. Tourniquet-free hand surgery using the one-
per-mil tumescent technique. Arch Plast Surg. 2013;40:129–133.
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.