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Wide Awake Flexor Pollicis Longus and Digital Nerve Repairs on a Patient in the Prone Position

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  • Hand and Ultrasound Surgery Center

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Wide awake, local anesthesia, no tourniquet hand surgery is a growing field of hand surgery with many advantages described in the literature. This technique is safely performed with the patient in prone position and offer several advantages.
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Case Report
Wide Awake Flexor Pollicis Longus
and Digital Nerve Repairs on a Patient
in the Prone Position
Thomas Apard
1,2
, Gilles Candelier
2
, Daniel McKee
3
,
and Donald Lalonde
4
Abstract
Wide awake, local anesthesia, no tourniquet hand surgery is a growing field of hand surgery with many advantages described in the
literature. This technique is safely performed with the patient in prone position and offer several advantages.
Keywords
prone, hand, surgery, thumb, walant, flexor
Introduction
Wide awake local anesthesia no tourniquet (WALANT) hand
surgery has several advantages in flexor tendon repair.
1,2
For
an awake patient in supine position, the thumb tends to flex
making exposure difficult. We describe our first experience
using this technique with a wide awake patient positioned on
his abdomen (prone) for improved exposure of the thumb
structures.
Case report
We performed a primary repair of a laceration of flexor pollicis
longus (FPL) and both palmar digital nerves at the level of the
proximal phalanx. The patient was positioned in a prone posi-
tion during the injection of local anesthesia and for surgery. We
injected local anesthesia (20 mL of 1%lidocaine with
1:100,000 epinephrine:2 mL of bicarbonate 8.4%) using tumes-
cent local anesthesia technique in order to reduce pain, provide
adequate anesthesia, and provide adequate vasoconstriction
without a tourniquet (Figure 1).
3-5
Waiting at least 26 minutes
after injection and before cutting is important to achieve max-
imal vasoconstriction.
6
We waited 45 minutes in this case.
There was no need for any additional local anesthesia injec-
tions during the procedure which took 70 minutes from incision
to closure. No tourniquet was required, and visualization was
excellent.
1
Center of Ultrasound Guided Hand Surgery, Private Hospital Les
Franciscaines, Versailles, France
2
Center of Hand Surgery Private Hospital of Saint Martin, Caen, France
3
Division of Plastic and Reconstructive Surgery, Dalhousie University, Saint
John, Canada
4
Saint John, Canada
Corresponding Author:
Thomas Apard, Private Hospital Les Franciscaines, 7 bis rue de la Porte de Buc,
Versailles 78000, France.
Email: thomasapard@yahoo.fr
Figure 1. Tumescent local anesthesia with lidocaine and epinephrine
in all possible areas of dissection.
Plastic Surgery Case Studies
Volume 5: 1-3
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In the usual supine position with the patient on his back, the
wrist is supinated and the thumb position causes the surgeon to
tilt his head to accommodate. We found the prone position
offered improved exposure of the palmar thumb because it
tends to lay flat against the table. This was especially advanta-
geous when we performed wide awake microsurgical digital
nerve repair.
The prone position can also be helpful to decrease hand
movement during local anesthetic needle insertion. Our patient
was somewhat anxious in the beginning, so the prone position
was helpful since it made it harder for him to look at his hand.
He was easily distracted with a movie playing on a laptop
computer easily positioned at his eye level (Figure 2). He was
comfortable lying on his abdomen with a pillow for head sup-
port. After the repair, he was able to move the thumb without
difficulty when we asked him to so, we could perform the
intraoperative total active movement examination.
1
Discussion
With wide awake surgery, we were able to enjoy the advan-
tages of prone position for thumb FPL and digital nerve micro-
surgery repair, while avoiding the risks associated with prone
position in patients under general anesthesia. We were able to
educate the patient with verbal postoperative instructions as we
closed the skin and applied the splint.
7
Prone positioning in patients who are unconscious, unpro-
tected, and under general anesthesia has a list of potential risks
and complications associated with it.
8,9
These risks do not
apply to fully awake patients. Awake patients who can tolerate
lying on their abdomen while sleeping can tolerate the same
position while undergoing WALANT. If the patient becomes
uncomfortable in this position, they can tell the surgical team to
switch them to a supine position for the remainder of the oper-
ation. Surgeons have been safely using prone positioning for
awake patient for decades when excising skin lesions from the
occiput, posterior neck, or back, under local anesthesia in the
office.
The ideal patient positioning for wide awake hand surgery is
where both the patient is fully comfortable, and the surgeon
gains technical advantages and improved visualization from
the positioning. We have already found the arm above the head
position to be helpful in wide awake ulnar nerve transposition
at the elbow.
10
We suggest that surgeons consider the prone
position for thumb surgery in the wide awake patient. We will
continue to explore the advantageous of this position for other
procedures in the upper extremity while using WALANT.
Statement of Human and Animal Rights
All procedures followed were in accordance with the ethical standards
of the responsible committee on human experimentation (institutional
and national) and with the Helsinki Declaration of 1975, as revised in
2008. Informed consent was obtained from all patients for being
Figure 2. Intraoperative prone position for wide awake thumb surgery.
2Plastic Surgery Case Studies
included in the study. Additional informed consent was obtained from
all patients for which identifying informationisincludedinthis
article.
Statement of Informed Consent
Informed consent was obtained from all individual participants
included in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
References
1. Higgins A, Lalonde D, Bell M, et al. Avoiding flexor tendon
repair rupture with intraoperative total active movement exami-
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tendon transfer. Clin Orthop Surg 2015; 7: 275-281.
3. Lalonde D, Phillips A, McGrouther D. Chapter 4. Tumescent
local anesthesia. In: Lalonde D, ed. Wide Awake Hand Surgery.
Boca Raton, FL: Taylor and Francis Group; 2016:29-35.
4. Lalonde D, Bell M, Benoit P, et al. A multicenter prospective
study of 3,110 consecutive cases of elective epinephrine use in
the fingers and hand: the Dalhousie project clinical phase. J Hand
Surg Am. 2005; 30(5): 1061-1067.
5. Lalonde D, Jagodzinski N, Phillips A. Chapter 5 How to inject
local anesthetic with minimal pain. In: Lalonde D, ed. Wide
Awake Hand Surgery. Boca Raton, FL: Taylor and Francis Group;
2016:37-47.
6. Mckee D, Lalonde D, Thoma A, et al. Optimal time delay
between epinephrine injection and incision to minimize bleeding.
Plast Reconstr Surg. 2013; 131(4): 811-814.
7. Lalonde D, MacGrouther D. Chapter 8. Talking with patients
during surgery save time. In: Lalonde D, ed. Wide Awake Hand
Surgery. Boca Raton, FL: Taylor and Francis Group; 2016:
59-63.
8. Edgcombe H, Carter K, Yarrow S. Anaesthesia in the prone posi-
tion. Br J Anaesth. 2008;100(2):165-183.
9. Chui J, Craen RA. An update on the prone position: continuing
professional development. Can J Anaesth. 2016; 63(6):
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sion of the ulnar nerve. In: Lalonde D, ed. Wide Awake Hand
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Apard et al 3
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Article
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.
Article
Full-text available
Wide-awake flexor tendon repair in tourniquet-free unsedated patients permits intraoperative Total Active Movement examination (iTAMe) of the freshly repaired flexor tendon. This technique has permitted the intraoperative observation of tendon repair gapping induced by active movement when the core suture is tied too loosely. The gap can be repaired intraoperatively to decrease postoperative tendon repair rupture rates. The authors record their rupture rate in the first 15 years of experience with iTAMe. This was a retrospective chart review of 102 consecutive patients with wide-awake flexor tendon repair (no tourniquet, no sedation, and pure locally injected lidocaine with epinephrine anesthesia) in which iTAMe was performed by two hand surgeons in two Canadian cities between 1998 and 2008. Intraoperative gapping and postoperative rupture were analyzed. The authors observed intraoperative bunching and gap formation with active movement in flexor tendon repair testing (iTAMe) in seven patients. In all seven cases, they redid the repair and repeated iTAMe to confirm gapping was eliminated before closing the skin, and those seven patients did not rupture postoperatively. In 68 patients with known outcomes, four of 122 tendons ruptured (tendon rupture rate, 3.3 percent) in three of 68 patients (patient rupture rate, 4.4 percent). All three patients who ruptured had accidental jerk forced rupture. All those patients who did what we asked them did not rupture. Tendons can gap with active movement if the core suture is tied too loosely. Gapping can be recognized intraoperatively with iTAMe and repaired to decrease postoperative rupture.
Article
Purpose: The purpose of this Continuing Professional Development module is to provide information needed to prepare for and clinically manage a patient in the prone position. Principal findings: Prone positioning is required for surgical procedures that involve the posterior aspect of a patient. We searched MEDLINE(®) and EMBASE™ from January 2000 to January 2015 for literature related to the prone position and retrieved only original articles in English. We reviewed the advantages and disadvantages of various equipment used in prone positioning, the physiological changes associated with prone positioning, and the complications that can occur. We also reviewed strategies for the safe conduct and management of position-related complications. Conclusion: Increased age, elevated body mass index, the presence of comorbidities, and long duration of surgery appear to be the most important risk factors for complications associated with prone positioning. We recommend a structured team approach and careful selection of equipment tailored to the patient and surgery. The systematic use of checklists is recommended to guide operating room teams and to reduce prone position-related complications. Anesthesiologists should be prepared to manage major intraoperative emergencies (e.g., accidental extubation) and anticipate postoperative complications (e.g., airway edema and visual loss).
Article
Background: The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin. Methods: This was a prospective, randomized, triple-blind study where 12 volunteers were injected simultaneously in each arm with either 1% lidocaine with epinephrine (study group) or 1% plain lidocaine (control group), after which the relative hemoglobin concentration of the underlying skin and soft tissues was measured over time using spectroscopy. Results: In the epinephrine group, the mean time at which the lowest cutaneous hemoglobin level was obtained was 25.9 minutes (95 percent CI, 25.9 ± 5.1 minutes). This was significantly longer than the historical literature values of 7 to 10 minutes for maximum vasoconstriction after injection. Mean hemoglobin index values at every time measurement after postinjection minute 1 were significantly different between the study group and the control group, with use of a two-tailed paired t test (p < 0.01). Conclusions: If optimal visualization is desired, the ideal time for the surgeon to begin the incision should be 25 minutes after injection of local anesthetic with epinephrine. It takes considerably longer than 7 to 10 minutes for a new local equilibrium to be obtained in relation to hemoglobin quantity.
Article
To examine prospectively the incidence of digital infarction and phentolamine rescue in a large series of patients in whom local anesthesia with adrenaline was injected electively into the hand and fingers. There continues to be a commonly held belief that epinephrine injection is contraindicated in the finger despite a lack of valid evidence to support this concept in the literature. From 2002 to 2004 there were 9 hand surgeons in 6 cities who prospectively recorded each consecutive case of elective hand and finger epinephrine injection. They recorded each instance of skin or tissue loss and the number of times phentolamine reversal of adrenaline vasoconstriction was required. There were 3,110 consecutive cases of elective injection of low-dose epinephrine (1:100,000 or less) in the hand and fingers and none produced any instance of digital tissue loss. Phentolamine was not required to reverse the vasoconstriction in any patients. The true incidence of finger infarction in elective low-dose epinephrine injection into the hand and finger is likely to be remote, particularly with the possible rescue with phentolamine.
Article
Prone positioning of patients during anaesthesia is required to provide operative access for a wide variety of surgical procedures. It is associated with predictable changes in physiology but also with a number of complications, and safe use of the prone position requires an understanding of both issues. We have reviewed the development of the prone position and its variants and the physiological changes which occur on prone positioning. The complications associated with this position and the published techniques for various practical procedures in this position will be discussed. The aim of this review is to identify the risks associated with prone positioning and how these risks may be anticipated and minimized.
Chapter 4. Tumescent local anesthesia
  • D Lalonde
  • A Phillips
  • D Mcgrouther
Lalonde D, Phillips A, McGrouther D. Chapter 4. Tumescent local anesthesia. In: Lalonde D, ed. Wide Awake Hand Surgery. Boca Raton, FL: Taylor and Francis Group; 2016:29-35.
Chapter 8. Talking with patients during surgery save time
  • D Lalonde
  • D Macgrouther
Lalonde D, MacGrouther D. Chapter 8. Talking with patients during surgery save time. In: Lalonde D, ed. Wide Awake Hand Surgery. Boca Raton, FL: Taylor and Francis Group; 2016: 59-63.
Chapter 5 How to inject local anesthetic with minimal pain
  • D Lalonde
  • N Jagodzinski
  • A Phillips
Lalonde D, Jagodzinski N, Phillips A. Chapter 5 How to inject local anesthetic with minimal pain. In: Lalonde D, ed. Wide Awake Hand Surgery. Boca Raton, FL: Taylor and Francis Group; 2016:37-47.
Cubital tunnel decompression of the ulnar nerve
  • D Lalonde
  • A Phillips
Lalonde D, Phillips A. Chapter 19. Cubital tunnel decompression of the ulnar nerve. In: Lalonde D, ed. Wide Awake Hand Surgery. Boca Raton, FL: Taylor and Francis Group; 2016: 137-140.