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Wide-awake Anesthesia No Tourniquet Trapeziometacarpal Joint Prosthesis Implantation

  • 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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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.
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
Hand/Peripheral Nerve
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
any way or used commercially without permission from the journal.
DOI: 10.1097/GOX.0000000000001714
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
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
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
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
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
1012- Lausanne Switzerland
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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
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Surg. 2009;123:623–625.
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
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
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
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. 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,
... 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 ...
Full-text available
Wide-awake, local anesthesia, no tourniquet (WALANT) is a technique that removes the requirement for operations to be performed with a tourniquet, general/regional anesthesia, sedation or an anesthetist. We reviewed the WALANT literature with respect to the diverse indications and impact of WALANT to discuss the importance of future surgical curriculum integration. With appropriate patient selection, WALANT may be used effectively in upper and lower limb surgery; it is also a useful option for patients who are unsuitable for general/regional anesthesia. There is a growing body of evidence supporting the use of WALANT in more complex operations in both upper and lower limb surgery. WALANT is a safe, effective, and simple technique associated with equivalent or superior patient pain scores among other numerous clinical and cost benefits. Cost benefits derive from reduced requirements for theater/anesthetic personnel, space, equipment, time, and inpatient stay. The lack of a requirement for general anesthesia reduces aerosol generating procedures, for example, intubation/high-flow oxygen, hence patients and staff also benefit from the reduced potential for infection transmission. WALANT provides a relatively, but not entirely, bloodless surgical field. Training requirements include the surgical indications, volume calculations, infiltration technique, appropriate perioperative patient/team member communication, and specifics of each operation that need to be considered, for example, checking of active tendon glide versus venting of flexor tendon pulleys. WALANT offers significant clinical, economic, and operative safety advantages when compared with general/regional anesthesia. Key challenges include careful patient selection and the comprehensive training of future surgeons to perform the technique safely.
... 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. ...
Full-text available
The wide-awake local anesthesia with no tourniquet (WALANT) technique has become popularized for various hand/upper extremity procedures. Before surgery, patients receive local anesthetic, consisting of lidocaine with epinephrine, and remain awake for the entire procedure. The purpose of this review was to investigate the advantages, diverse application, outcomes, cost benefits, use in challenging environments, patient considerations, and contraindications associated with WALANT. Methods: A comprehensive review of the literature on the WALANT technique was conducted. Search terms included: WALANT, wide-awake surgery, no tourniquet, local anesthesia, hand, wrist, cost, and safety. Results: The WALANT technique has proven to be successful for common procedures such as flexor tendon repair, tendon transfer, trigger finger releases, Depuytren disease, and simple bony procedures. Recently, the use of WALANT has expanded to more extensive soft-tissue repair, fracture management, and bony manipulation. Advantages include negating preoperative evaluation and testing for anesthesia clearance, eliminating risk of monitored anesthesia care, removal of anesthesia providers and ancillary staff, significant cost savings, and less waste produced. Intraoperative evaluations can be performed through active patient participation, and postoperative recovery and monitoring time are reduced. WALANT is associated with high patient satisfaction rates and low infection rates. Conclusions: The WALANT technique has proven to be valuable to both patients and providers, optimizing patient satisfaction and providing substantial healthcare savings. As its application continues to grow, current literature suggests positive outcomes.
... In recent years, local anaesthesia has become popular and gained acceptance among hand surgeons from many countries (Gong and (Codding et al., 2017) to more complex procedures such as nerve transposition, tendon transfers (Lamouille et al., 2017) or trapeziometacarpal joint replacements (Müller et al., 2018). One of those techniques, also referred to as ''wide awake local anaesthesia no tourniquet'' (WALANT) (Lalonde, 2017), implies that the patient's anaesthesia is achieved by local injections by the surgeon, thus removing the need for an anaesthesiologist. ...
PURPOSE : Recently, local anaesthesia has become popular among hand surgeons. We hypothesized that using the ‘’wide awake local anaesthesia, no tourniquet’’ (WALANT) approach would result in lower global costs and in an increase of the operating room's efficiency. METHODS : All cases of carpal tunnel and trigger finger releases performed over 2016 and 2017 were divided into four groups, following which anaesthesia method was used. Total operating room occupation time, surgical time and the ‘’all but surgery’’ time were analysed. A common minimal bill per anaesthesia was generated. RESULTS : WALANT or local anaesthesia & tourniquet increase the operating room's throughput by having shorter operation room occupation times than other methods (17.5-33%). Costs of the two procedures are reduced by 21-31% when using local anaesthesia methods. CONCLUSION : Preferring those techniques for carpal tunnel and trigger finger releases has a notable beneficial impact on the costs and on the operating room's efficiency. This effect is more evident on short surgical procedures. LOE : Level of evidence III, economic analysis.
... Ide tartoznak a nagyobb csont-ízüle műtétek, például csukló arthrodesis, carpectomia stb. Megjegyzem, WALANT érzéstelenítéssel végze nyeregízüle arthroplas cáról, distalis orsócsont törés lemezes osteosynthesiséről már beszámoltak (5,12). ...
... SR implant surgery has increased in popularity during the last decades. The surgery is relatively straight forward and can be done in wide-awake local anesthesia no tourniquet (WALANT) technique [27,28]. In this perspective, it is easy to forget or overlook old techniques such as perichondrium transplantation performed in general anesthesia. ...
Full-text available
Background: The aim of our study was to compare the long-term outcome after perichondrium transplantation and two-component surface replacement (SR) implants to the metacarpophalangeal (MCP) and the proximal interphalangeal (PIP) joints. Methods: We evaluated 163 joints in 124 patients, divided into 138 SR implants in 102 patients and 25 perichondrium transplantations in 22 patients. Our primary outcome was any revision surgery of the index joint. Results: The median follow-up time was 6 years (0-21) for the SR implants and 26 years (1-37) for the perichondrium transplants. Median age at index surgery was 64 years (24-82) for SR implants and 45 years (18-61) for perichondium transplants. MCP joint survival was slightly better in the perichondrium group (86.7%; 95% confidence interval [CI]: 69.4-100.0) than in the SR implant group (75%; CI 53.8-96.1), but not statistically significantly so (p = 0.4). PIP joint survival was also slightly better in the perichondrium group (80%; CI 55-100) than in the SR implant group (74.7%; CI 66.6-82.7), but below the threshold of statistical significance (p = 0.8). Conclusion: In conclusion, resurfacing of finger joints using transplanted perichondrium is a technique worth considering since the method has low revision rates in the medium term and compares favorable to SR implants. Level of evidence: III (Therapeutic).
Full-text available
Purpose We investigated the frequency of wide-awake local anesthesia no tourniquet (WALANT) use for hand surgery in the a 10- to 18-year–old age group and patients’ experiences. Methods Patients aged 10–18 years who had hand surgery in June 2016 to March 2020 were identified. The frequency of patients who agreed to have surgery under WALANT was calculated (%). Patients who received WALANT over the previous year were interviewed for their surgical experiences. Results A total of 69 patients were identified, and 46 of them received WALANT. The mean age was 14.5 ± 2 years, and 22 of them were boys. Sixteen patients were called for a surgical experience assessment via questionnaire. They reported pain less than 1/10 during anesthesia injection and surgery. Ten patients (62%) found their operation easy, and 14 (87.5%) would prefer WALANT again. Conclusions This study showed that most patients in the 10–18 years age group accepted WALANT, and their surgical experiences were positive. For its advantages, WALANT should be considered in hand surgery for compliant patients in this age group. Type of study/level of evidence Therapeutic III.
Purpose Wide-Awake Local Anesthetic No Tourniquet (WALANT) hand surgery avoids many medical risks associated with traditional anesthesia options. However, patients may be hesitant to choose the WALANT approach because of concerns about being awake during surgery. The purpose of this study was to characterize patients’ thoughts and concerns about being awake during hand surgery and determine factors that may affect their decision about anesthesia options. Methods Qualitative interviews were conducted with 15 patients with a diagnosis of carpal tunnel syndrome, trigger finger, or De Quervain’s tenosynovitis who were receiving nonoperative care. Interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was used to identify themes, concerns, and potential intervention targets. Results Eight participants reported that patients have a general bias against being “knocked out,” 7 of whom described concerns of uncertainty about emerging from anesthesia. All participants would consider WALANT, with some reservations. Recurrent themes included ensuring they would not feel, see, or hear the surgery and a preference toward distractions, such as music or engaging conversation. Of 15 participants, 13 would not want to see the surgery. For patients who found WALANT appealing, they valued the decreased time investment compared to sedation and the avoidance of side effects or exacerbation of comorbidities. A recurring theme of trust between surgeon and patient arose when deciding about anesthesia type. Conclusions Most patients are open to WALANT, but have concerns of hearing the surgery or feeling pain. Potential interventions to address these concerns, beyond establishing a trusting physician-patient relationship, include music or video with headphones and confirming skin numbness prior to surgery. Clinical relevance This study provides insights into patients’ thought processes regarding WALANT hand surgery and give the surgeon talking points when counseling patients on their anesthesia type for hand surgery.
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.
We hypothesized that WALANT would provide similar perioperative analgesic comfort compared to local anesthesia with peripheral nerve blocks (LAPNV). We analyzed whether the patient’s active participation during surgery would improve its early functional results. We did a retrospective, single study in an outpatient surgery unit, comparing two types of surgery: trapeziometacarpal arthroplasty (TMCA) under LAPNV and TMCA under WALANT. Fifteen patients were included per group. Pain levels were determined during anesthesia induction, intraoperatively, postoperatively, at rest and during activity at the last follow-up visit. The overall satisfaction with the surgery and time to resume daily activities and work were documented. The statistical analysis was performed on SAS software with an ANOVA. The significance threshold was set at 0.05. The groups were comparable on age, sex, dominant side, and operated side. No patients were lost to follow-up. The mean follow-up was 4 months (2.3–11). The QuickDASH score was 4.93 for TMCA under WALANT vs. 13.47 for TMCA under LAPNV (p = 0.01). There was no loosening, dislocation, or major complication. Our study showed that TMCA performed with WALANT yields similar results to the same procedure with LAPNV for perioperative pain relief without additional complications. Functional scores seem to be slightly improved with WALANT compared to LAPNV, but these results should be confirmed with longer follow up.
We conducted a descriptive study of 50 consecutive cases of total trapeziometacarpal joint arthroplasty by one surgeon using wide awake local anaesthetic no tourniquet to assess the usefulness and reliability of the anaesthesia, any adverse effects and patient acceptance. No difference was found when comparing the duration of surgery with 50 cases of total trapeziometacarpal joint arthroplasty inserted in a bloodless field under general or regional anaesthesia by the same surgeon. Wide awake local anaesthetic no tourniquet was found to be useful in providing adequate anaesthesia and haemostasis, and to be reliable and safe with no adverse effects. Patient satisfaction was high with 100% willing to repeat. Overall, wide awake local anaesthetic no tourniquet was a satisfactory method of anaesthesia for trapeziometacarpal joint arthroplasty with the potential for significant benefits to both patient and surgeon compared with traditional general anaesthesia and regional block. Level of evidence: II
Full-text available
Tendon surgery is unique because it should ensure tendon gliding after surgery. Tendon surgery now can be performed under local anesthesia without tourniquet, by injecting epinephrine mixed with lidocaine, to achieve vasoconstriction in the area of surgery. This method allows the tendon to move actively during surgery to test tendon function intraoperatively and to ensure the tendon is properly repaired before leaving the operating table. I applied this method to primary flexor tendon repair in zone 1 or 2, tenolysis, and tendon transfer, and found this approach makes tendon surgery easier and more reliable. This article describes the method that I have used for tendon surgery.
Full-text available
This is a review article of the wide-awake approach to hand surgery. More than 95% of all hand surgery can now be performed without a tourniquet. Epinephrine is injected with lidocaine for hemostasis and anesthesia instead of a tourniquet and sedation. This is sedation-free surgery, much like a visit to a dental office. The myth of danger of using epinephrine in the finger is reviewed. The wide awake technique is greatly improving results in tendon repair, tenolysis, and tendon transfer. Here, we will explain its advantages.
Full-text available
The wide-awake approach to hand surgery entails the use of local infiltration anesthesia using lidocaine with epinephrine and no tourniquet. The technique provides practitioners with an option to perform advanced hand surgical care in an ambulatory setting, without the need for general or regional anesthetics. We present our results using wide-awake approach in wrist surgery, both open and arthroscopic. Between June and August 2011, the wide-awake approach was used in nine elective wrist surgery cases; three arthroscopic procedures, four open triangular fibrocartilage complex (TFCC) repairs, and two combined arthroscopy/open surgery (eight men/one woman). The arthroscopic patients were anesthetized using dorsal infiltration of lidocaine with epinephrine (20 mL) with an additional intra-articular 5 mL injection 30 minutes before surgery. The open surgery patients received 40 mL of lidocaine with epinephrine around the ulnar aspect of the forearm, from 8-cm proximal to 3-cm distal to the distal radioulnar joint. Standard diagnostic radio- and midcarpal arthroscopies were performed, where one patient had a loose body removed and two patients underwent TFCC debridements due to central TFCC tears. The six open cases were all due to TFCC foveal disruptions, which were reinserted using osteosutures in the distal ulna. Following placement of the ligament sutures, a preliminary knot allowed active and passive motion testing of pronosupination, to determine the adequate amount of tension in the ligaments. The wide-awake approach to wrist surgery is a plausible and reliable technique that eliminates the need for general anesthesia, removes the need of a tourniquet, and provides a cost-efficient and safe approach to wrist surgery. The ability to control ligament reconstructions using active motion may additionally enhance the rehabilitation of these patients, both through early proprioceptive awareness and adequate tensioning of soft tissues.
Full-text available
Background: The complex configuration of the thumb carpometacarpal (CMC-1) joint relies on musculotendinous and ligamentous support for precise circumduction. Ligament innervation contributes to joint stability and proprioception. Evidence suggests abnormal ligament innervation is associated with osteoarthritis (OA) in large joints; however, little is known about CMC-1 ligament innervation characteristics in patients with OA. We studied the dorsal radial ligament (DRL) and the anterior oblique ligament (AOL), ligaments with a reported divergent presence of mechanoreceptors in nonosteoarthritic joints. Questions/purposes: This study's purposes were (1) to examine the ultrastructural architecture of CMC-1 ligaments in surgical patients with OA; (2) to describe innervation, specifically looking at mechanoreceptors, of these ligaments using immunohistochemical techniques and compare the AOL and DRL in terms of innervation; and (3) to determine whether there is a correlation between age and mechanoreceptor density. Methods: The AOL and DRL were harvested from 11 patients with OA during trapeziectomy (10 women, one man; mean age, 67 years). The 22 ligaments were sectioned in paraffin and analyzed using immunoflourescent triple staining microscopy. Results: In contrast to the organized collagen bundles of the DRL, the AOL appeared to be composed of disorganized connective tissue with few collagen fibers and little innervation. Mechanoreceptors were identified in CMC-1 ligaments of all patients with OA. The DRL was significantly more innervated than the AOL. There was no significant correlation between innervation of the DRL and AOL and patient age. Conclusions: The dense collagen structure and rich innervation of the DRL in patients with OA suggest that the DRL has an important proprioceptive and stabilizing role. Clinical relevance: Ligament innervation may correlate with proprioceptive and neuromuscular changes in OA pathophysiology and consequently support further investigation of innervation in disease prevention and treatment strategies.
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A pneumatic tourniquet is generally used to achieve a bloodless operation field in hand surgery. However, this has changed with tumescent solution-based wide-awake surgery. This study is a preliminary prospective case series study to elaborate the formula and indications of the tumescent technique in hand surgery without a tourniquet. Seven patients (age range, 4 months to 37 years) underwent hand or upper extremity surgery for conditions such as nerve palsy, electric burn defect, fingertip injury, contracture, constriction ring syndrome, or acrosyndactyly. A "one-per-mil" tumescent solution (epinephrine 1:1,000,000+20 mg lidocaine/50 mL saline) was used to create a bloodless operating field without a tourniquet. Observation was performed to document the amount of solution injected, the operation field clarity, and the postoperative pain. The "one per mil" epinephrine solution showed an effective hemostatic effect. The tumescent technique resulted in an almost bloodless operation field in the tendon and in the constriction ring syndrome surgeries, minimal bleeding in the flap and contracture release surgeries, and acceptable bleeding in acrosyndactyly surgery. The amount of solution injected ranged from 5.3 to 60 mL. No patient expressed significant postoperative pain. Flap surgeries showed mixed results. One flap was lost, while the others survived. Epinephrine 1:1,000,000 in saline solution is a potential replacement for a tourniquet in hand surgery. Further studies are needed to delineate its safety for flap survival.
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.
Background: Approaches to upper extremity anesthesia in hand surgery include regional blocks, wide-awake hand surgery with local anesthesia, and stellate ganglion blocks. Methods: Retrospective review of the literature from 2000 to 2014 published on the delivery of local and regional anesthesia during hand surgery. Included studies describe techniques of administration and treatment outcomes to identify common practices of pain management in hand surgery. Results: Regional blocks provide sufficient anesthesia for hand surgery and have been found to improve postoperative pain and measured outcome scores. Wide-awake surgery offers many advantages including minimizing anesthetic risk and expense, permitting patient participation in operative evaluation, decreasing hospital time, and improving functional outcomes scores. Conclusions: Pain management in hand surgery can be achieved through regional blocks and wide-awake techniques that do not necessitate general anesthesia in an effort to improve safety, convenience, cost savings, and efficiency.
We prefer wide-awake finger fracture reduction, closed percutaneous K-wire fixation, and early protected movement to treat phalangeal fractures. This approach allows intraoperative visualization of active movement after K-wire fixation with the possibility of adjustments during the case. It also negates the need for extensive dissection with subsequent scar formation between the tendons and the bone. It provides the same advantages that are provided by early protected movement after flexor tendon repair.
Traditionally, surgeons were taught that local anesthesia containing epinephrine should not be injected into fingers. This idea has since been refuted in many basic and clinical scientific studies, and today, injection of lidocaine plus epinephrine is widely used for digital and hand anesthesia in Canada. The key advantages of the wide-awake technique include the creation of a bloodless field without the use of an arm tourniquet, which in turn reduces the need for conscious sedation. The use of local anesthesia permits active motion intraoperatively, which is particularly helpful in tenolysis, flexor tendon repairs, and setting the tension on tendon transfers. Additional benefits of wide-awake anesthesia include efficiencies and cost savings in outpatient surgical case flow due to the absence of conscious sedation.
In order to test the opposition and the counter-opposition (reposition) of the thumb, the method proposed here does not require the measuring of angles ; rather, the hand itself is used as the system of reference. The opposition test consists of touching the four long fingers with the tip of the thumb : the score is 1 for the lateral side of the second phalanx of the index finger, 2 for the lateral side of the third phalanx, 3 for the tip of the index finger, 4 for the tip of the middle finger, 5 for the ring finger and 6 for the little finger. Then, moving the thumb proximally along the volar aspect of the little finger, the score is 7 when it touches the DIP crease, 8 on the PIP crease, 9 on the proximal crease of the little finger and 10 when it reaches the distal volar crease of the hand. This test is valid only if the first stages are possible : a crawling thumb in the palm is not an opposition motion. The counter-opposition test (or reposition test) needs the other hand as a reference system. The hand to be tested is set upon the table palm-down while ; the other hand is laid on the table on its medial side, close to the tip of the first hand thumb ; now this thumb is actively drawn up as high as possible. The upper point is noted by reference of the MP joints of the second hand : 1 for the MP joint of the little finger, 2 for the MP joint of the ring finger, 3 for that of the middle finger and 4 for that the index finger.