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Einsatz der WALANT(„wide awake local anesthesia no tourniquet“)-Narkoseart in der HandchirurgieImplementation of the wide awake local anesthesia no tourniquet (WALANT) type of anesthesia in hand surgery

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Abstract

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.

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... WALANT is a form of anesthesia, which enables the surgeon to operate on conscious patients by injection of an anesthetic solution containing lidocaine and adrenaline [2,3]. The additive adrenaline produces a bloodless operative site via its vasoconstrictive effect, thereby allowing the procedure to be performed without the use of a tourniquet [3,4]. This vasoconstrictive effect further serves to prolong the effect of the local anesthetic agent [4]. ...
... The additive adrenaline produces a bloodless operative site via its vasoconstrictive effect, thereby allowing the procedure to be performed without the use of a tourniquet [3,4]. This vasoconstrictive effect further serves to prolong the effect of the local anesthetic agent [4]. ...
... Not all patients can be treated in tumescence anesthesia. Absolute contraindications include a known, hypersensitivity to lidocaine or adrenaline, a bleeding diathesis, non-cooperative patients, pediatric patients and patients with peripheral vascular disease [4,11,20]. ...
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Backround The aim of this study was to determine, if Wide Awake Local Anesthesia No Tourniquet (WALANT) can be used as an alternative method of providing anesthesia in management of deep infections of the hand. Since the advent of WALANT in 2003, infections of the hand have been regarded as a contraindication to its use. Occasional shortage of anesthesiologic manpower, especially during busy call hours and the current COVID-19 pandemic can lead to delay of treatment where urgent surgery is needed, to prevent progress of an infection, that can result in severe morbidity. Methods In the period from 2015 to 2020, 16 patients with various infections of the hand underwent 17 operations using WALANT in a Hand Trauma and Replantation Center (HTRC) in Germany. Retrospective cohort analysis of their operation reports, with emphasis on location of infection, time and duration of the operation, intraoperative incidents and complications were carried out. We also evaluated the need for revision surgery or necessity to convert to general anesthesia and factors causing delay till the time of surgery. Results No case of inadequate analgesia, the need to convert to general anesthesia, ischemic events or cardiovascular complications with the use of the WALANT solution containing adrenaline and lidocaine in the treatment of deep tissue infections. The highest priority of limb preservation was ensured as no patient progressed to amputation of a digit or the hand. There was a statistically significant difference (p≤0.01) in delay from the time of admission until surgery of up to 9h24m (SD±3h34m) during the week and 4h10m (SD±2h28m) during the weekend. Conclusion The status of infection as an absolute contraindication to the use of WALANT should be revised. Especially when human resources are limited, WALANT is an adequate technique to enable quick anesthesia for urgent treatment to prevent progression of hand infections.
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About 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.
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Background: The wide-awake local anesthesia no tourniquet (WALANT) technique is applied during various hand surgeries. We investigated the perioperative variables and clinical outcomes of open reduction and internal fixation (ORIF) for distal radius fractures under WALANT. Methods: From January 2015 to January 2017, 60 patients with distal radius fractures were treated, and 24 patients (40% of all) were treated with either a volar or a dorsal plate via WALANT procedure. Of these 24 patients, 21 radius fractures were fixed with a volar plate, and the other 3 were fixed with a dorsal plate. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated. Results: One of the 24 patients could not tolerate the WALANT procedure and was reported as a failed attempt at WALANT. In the cohort, 23 patients successfully received distal radius ORIF under WALANT procedure. The average age is 60.9 (range, 20-88) years. The average operation time was 64.3 (range, 45-85) minutes, the average blood loss was 18.9 (range, 5-30) ml, and the average of duration of hospitalization is 1.8 (range, 1-6) days. The average postoperative day one VAS was 1.6 (range, 1-3). The average time of union was 20.7 (range, 15-32) weeks. The mean follow-up period was 15.1 (range, 12-24) months. Functional 1-year postoperative outcomes revealed an average Quick DASH score of 7.60 (range, 4.5-13.6) and an average wrist flexion and extension of 69.6° (range, 55-80°) and 57.4° (range, 45-70°). There was no wound infection, neurovascular injury, or other major complication noted. Conclusions: WALANT for distal radius fracture ORIF is a method to control blood loss by the effects of local anesthesia mixed with hemostatic agents. Without a tourniquet, the procedure prevents discomfort caused by tourniquet pain. Without sedation, patients could perform the active range of motion of the injured wrist to check if there is impingement of implants. It eliminates the need of numerous preoperative examinations, postoperative anesthesia recovery room care, and side effects of the sedation. However, patients who are not amenable to the awake procedure are contraindications.
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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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Purpose: Minor hand surgeries can be done under field sterility in procedure rooms. Surgeons are still sceptical about the usage of wide awake local anaesthesia no tourniquet (WALANT) technique. They perceive that patients can tolerate tourniquet for a brief period while they perform minor surgeries under local anaesthesia (LA). We compared the perceived comfort experienced by patients during minor hand surgeries with WALANT and LA/tourniquet. We investigated the difference in preoperative preparation time, operating time and blood loss between the two groups. Methods: Between July and October 2016, a total of 72 patients were diagnosed with carpal tunnel syndrome, trigger finger or ganglion, at the University Malaya Medical Centre. Forty patients consented to participate in this study and were randomized into WALANT and LA/tourniquet groups. Anaesthesia was administered accordingly and tourniquet was applied. The time taken for preoperative preparation and surgery was recorded. Each surgeon estimated the blood loss. The perceived comfort level of each patient was quantified using a visual analogue score (VAS). Data were analysed using SPSS. Results: The mean VAS for the WALANT group was 2.33 ± 1.94, whereas it was 4.72 ± 3.05 for the LA/tourniquet group, and the difference was statistically significant ( p < 0.05). The mean time for preoperative preparation in WALANT group was 19.17 ± 12.61 min and LA/tourniquet group was 7.05 ± 3.44 min. The difference between these groups was statistically significant ( p < 0.01). There was no significant difference in operating time and blood loss. Conclusion: WALANT technique was associated with better patient comfort. Tourniquet was the main reason for discomfort during surgeries. WALANT is an alternative in minor hand surgeries for a bloodless surgical field without the discomfort of tourniquet application.
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Isolated fractures of shaft of ulna are common. Plate fixation with anatomic reduction is thought to produce the best functional results in closed or open fractures. Surgery can be done under general and various types of regional anaesthesia. We report a case of fracture shaft of ulna treated by plating under a combination of WALANT (wide awake, local anaesthesia, no tourniquet) using tumescent anaesthesia and periosteal nerve block as a day care procedure.
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To assess, through a systematic literature review, whether or not it is necessary to suspend antithrombotic medications (warfarin, aspirin, and clopidogrel) to perform elective wrist and hand surgeries. The search for articles was performed using a combination of keywords in the databases available, without scientific design constraints, being selected series with five or more surgeries; the selected articles were analyzed regarding serious (need for surgical treatment) and mild complications (without surgery). Seven articles were retrieved and analyzed; 410 wrist and hand surgeries were performed in patients on warfarin or aspirin and clopidogrel, with three serious complications (0.7%) and 38 mild (9.2%); 2023 surgeries were performed in patients without use of antithrombotics, with zero serious and 18 (0.8%) minor complications. Patients using warfarin or oral antiplatelet (aspirin, clopidogrel, and aspirin associated with clopidogrel) need not suspend the medication to undergo wrist and hand surgery.
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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.
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Over 70% of Canadian carpal tunnel syndrome (CTS) operations are performed outside of the main operating room (OR) with field sterility and surgeon-administered pure local anesthesia [LeBlanc et al., Hand 2(4):173-8, 14]. Is main OR sterility necessary to avoid infection for this operation? This study evaluates the infection rate in carpal tunnel release (CTR) using minor procedure room field sterility. This is a multicenter prospective study reporting the rate of infection in CTR performed in minor procedure room setting using field sterility. Field sterility means prepping of the hand with iodine or chlorhexidine, equivalent of a single drape, and a sterile tray with modest instruments. Sterile gloves and masks are used, but surgeons are not gowned. No prophylactic antibiotics are given. One thousand five hundred four consecutive CTS cases were collected from January 2008 to January 2010. Six superficial infections were reported and four of those patients received oral antibiotics. No deep postoperative wound infection was encountered, and no patient required admission to hospital, incision and drainage, or intravenous antibiotics. A superficial infection rate of 0.4% and a deep infection rate of 0% following CTR using field sterility confirm the low incidence of postoperative wound infection using field sterility. This supports the safety and low incidence of postoperative wound infection in CTR using minor procedure field sterility without prophylactic antibiotics. The higher monetary and environmental costs of main OR sterility are not justified on the basis of infection for CTR cases.
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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.
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The arterial tourniquet is widely used in upper and lower extremity surgery and in intravenous regional anaesthesia. The local and systemic physiological effects and the anaesthetic implications are reviewed. Localised complications result from either tissue compression beneath the cuff or tissue ischaemia distal to the tourniquet. Systemic effects are related to the inflation or deflation of the tourniquet. Safe working guidelines for the application of an arterial tourniquet have not been clearly defined.
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Introduction : Approximately 2% of the population are anticoagulated and over 50% of over 65-year-olds are prescribed antiplatelet agents. Several systematic reviews have shown the safety of interrupting anticoagulation and antiplatelets for non-emergency surgery, although such reviews excluded upper limb procedures and represents the rationale for this review. Methods : The literature was systematically searched for studies concerning the outcomes of adult hand or wrist surgery on patients receiving anticoagulation or antiplatelet agents in direct comparison to controls (no anticoagulation or antiplatelet agents, or interruption of either). The primary outcome was reoperation for any complication related to postoperative bleeding, within 30 postoperative days. Results : Nine cohort studies (3628 individuals; 3863 operations) were included. Based on very low-quality evidence, anticoagulation did not affect the risk of reoperation for bleeding (RR 2.4 [95% CI 0.1, 57]; n=443) or bruising (RR 2.5 [95% CI 1.0, 6.3]; n=124; I²=0%). Based on low quality evidence, antiplatelet agents did not affect the risk of reoperation for bleeding (RR 0.8 [95% CI 0.3, 1.8]; 6 studies, n=1885; I²=0%) or bruising (RR 3.2 [95% CI 0.2, 44]; n=571; I²=66%). A sensitivity analysis showed that carpal tunnel decompression on patients receiving anticoagulants or antiplatelets appeared to be safe (RR 0.8 [95% CI 0.3, 1.8]; 6 studies, n=2077; I²=0%). Conclusions : Given the sparsity of events (bleeding and bruising) and low-quality of the literature, no firm conclusions can be drawn. The decision to interrupt antiplatelets or anticoagulants should be made jointly with expert physicians and the patient. Registration : PROSPERO ID CRD42018087755
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Background: We conducted a prospective study to compare patients' intraoperative experience of open carpal tunnel release (CTR) under "wide awake local anesthesia no tourniquet" (WALANT) on one hand and intravenous regional anesthesia (IVRA) on the contralateral hand. We hypothesized that WALANT would offer better intraoperative experience than IVRA. Methods: There were 24 bilateral CTS patients who had one hand operated on using WALANT and the contralateral hand with the IVRA method. At the postoperative second hour, patients were asked to complete a questionnaire to quantify their pain levels on a numerical rating scale (NRS) and compare the operation to dental procedures. They were also asked about their expectations and their feelings about re-operation with the anesthesia methods. The results were compared for the two anesthesia methods. Results: There were no significant differences between NRS pain values during anesthetic administration and between NRS pain values for surgical site pain on the WALANT and IVRA sides. Patients reported moderate tourniquet pain for IVRA sides. For WALANT sides, a significantly higher number of patients reported CTR to be an easier procedure than dental procedures (91.6% WALANT and 37.5% IVRA). When compared with patients' expectations, patients reported CTR with WALANT and IVRA [91.6% and 50%, respectively] to be an easier procedure than they expected. For the re-operation anesthesia method; 83.3% of patients preferred WALANT, 8.3% preferred IVRA, and 8.3% reported no preference. Conclusions: WALANT offered a better intraoperative experience. Tourniquet pain, preoperative preparation basics, and the extended anesthesia duration are likely the major drawbacks of the IVRA method.
Article
Background: The wide-awake approach enables surgeons to perform optimal tensioning of a transferred tendon intraoperatively. We hypothesized that the extensor indicis proprius (EIP)-to-extensor pollicis longus (EPL) tendon transfer using the wide-awake approach would yield better results than conventional surgery. Methods: A retrospective analysis was performed of the prospectively collected data of 29 consecutive patients who underwent EIP-to-EPL tendon transfer. Patients were treated with the wide-awake approach (group A=11) and conventional surgery under general anesthesia (group B=18). The groups were compared retrospectively for thumb interphalangeal (IP) and metacarpophalangeal (MP) joint motion, grip and pinch strength, specific EIP-EPL evaluation method (SEEM), and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score at 6 weeks and 2, 4, 6, and 12 months postoperatively. Results: Group A showed significantly better IP joint flexion and total arc of motion at 6 weeks and 2, 4, and 6 months. Group A also showed significantly better MP joint flexion and total arc of motion at all time points. IP and MP joint extension showed no difference at all time points. Group A showed significantly better SEEM scores at 2 and 4 months, and DASH scores at 4, 6, and 12 months. Grip and pinch strength showed no difference at all time points. The complication rate and duration until return to work were not different between groups. Conclusions: Compared with the conventional approach, the wide-awake approach showed significantly better results in the thumb's range of motion and functional outcomes, especially in the early postoperative periods.
Article
Background: To compare outcomes of atraumatic hand surgeries using the WALANT technique versus intravenous regional anesthesia or local anesthesia with tourniquet. Methods: We conducted a comprehensive literature search using PubMed, MEDLINE, Embase, and Cochrane Library from inception to October 2018. All randomized or quasi-randomized trials and cohort studies comparing WALANT procedure versus local anesthesia or intravenous regional anesthesia with tourniquet among atraumatic hand surgeries were included. Methodological quality and risk of bias of eligible studies were assessed by three independent reviewers. The random effects model was used due to both statistical and clinical heterogeneity among studies. Results: The search yielded 496 records, of which 9 studies were included in the systematic review. We were able to pool findings for operative time, post-operative pain scores, patient satisfaction, and complication rates. On the average, the WALANT group had longer operative times by 2.06 minutes (pooled mean difference, random effects, 95% confidence interval 0.46 to 3.67 minutes, p = 0.01, I ² 0%, p = 0.66). The post-operative pain scores were lower in the WALANT group by an average of two VAS points (random effects, pooled mean difference −2.40, 95% confidence interval −3.41 to −1.38, p < 0.00001; I ² 0% p = 0.99). We had insufficient evidence to demonstrate a difference in terms of patient satisfaction (random effects, pooled risk ratio 0.98, 95% confidence interval 0.93 to 1.03, p = 0.36, I ² 0%, p = 0.64) and complication rates (random effects, pooled risk ratio 0.40, 95% confidence interval 0.07 to 2.18, p = 0.29, I ² 60% p = 0.08) between WALANT versus conventional methods. Conclusions: The WALANT group reported lower post-operative pain scores, but had slightly longer operative times. There are no significant differences between WALANT and conventional methods in terms of patient satisfaction and complication rates.
Article
Introduction: Wide-awake local anesthesia and no tourniquet (WALANT) has come a long way. It has been reported to be successful in the surgery of distal radius and ulna fractures. We report a case of olecranon fracture plating under WALANT. Methods: Surgery was performed with the patient fully conscious where tumescent anesthesia was injected into the surgical site without application of tourniquet 30 minutes before the first incision. Posterior approach to the elbow was used, and the fracture was fixed with anatomical locking plates. Results: The surgery was successfully completed without pain. The numerical pain rating score was 0 throughout the surgery. Conclusions: The use of WALANT for surgical fixation can be expanded beyond the hand and wrist. This is a safe and simple option for patients at high risk of general anesthesia, producing similar surgical outcomes without intraoperative and postoperative complications.
Article
Purpose: Carpal tunnel syndrome is a common disease treated operatively. During the operation, the patient may be wide-awake or sedated. The current literature has only compared separate cohorts. We sought to compare patient experience with both local-only anesthesia and sedation. Methods: Staged bilateral carpal tunnel release utilizing open or endoscopic technique was scheduled and followed through to completion of per-protocol analysis in 31 patients. Patients chose initial hand laterality and were randomized regarding initial anesthesia method: local-only or sedation. Data collection via questionnaires began at consent and continued to 6 weeks postoperatively from second procedure. Primary outcome measures included patient satisfaction and patient anesthesia preference. Results: At final follow-up, 6 weeks postoperatively, high satisfaction (30 of 31 patients per method) was reported with both types of anesthesia. Among these patients, 17 (54%) preferred local-only anesthesia, 10 (34%) preferred sedation, 2 had no preference, and 2 opted out of response. Although anesthesia fees were approximately $390 lower with local-only anesthesia, total costs for carpal tunnel release were not significantly different with respect to the anesthesia cohorts. Total time in surgical facility was approximately 26 minutes quicker with local-only anesthesia, largely due to shorter time in the post-anesthesia care unit. Scaled comparison of worst postoperative pain following the 2 procedures revealed no difference between local-only anesthesia and sedation. Conclusions: Patients reported equal satisfaction scores with carpal tunnel release whether performed under local-only anesthesia or with sedation. In addition, local-only anesthesia was indicated as the preference of patients in 59% of cases.
Article
Most unstable metacarpal and phalangeal fractures for which operative treatment is indicated can be reduced and stabilized with either open or closed techniques using local anesthetic with epinephrine instead of intravenous sedation or general anesthesia. With the patient wide-awake during surgery, the hand can be taken through active range of motion to assess fracture stability. In this article, the authors review the rationale and technique for wide-awake, local anesthesia, no tourniquet surgery in the treatment of phalangeal and metacarpal fractures and impart pearls to optimize the patient experience and illustrate common fixation techniques using percutaneous Kirschner wires. The intraoperative assessment of fracture stability permits an accelerated, protected-range-of-motion protocol that minimizes postoperative stiffness and facilitates expedient recovery.
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The minimally invasive nature of wrist and small joint arthroscopy renders it particularly suitable for the application of the wide-awake local anesthesia no tourniquet (WALANT) technique. The application of WALANT wrist and small joint arthroscopy has given surgeons the ability to visualize both static and dynamic movements of a joint, to show the pathology and discuss with the patient, and to visualize a patient's repaired structures. This reinforces confidence in surgeons and encourages patients to comply with postoperative rehabilitation.
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The authors’ experience demonstrates that wide-awake flap surgery in the hand is safe. The authors used this approach in 4 commonly used flaps in the hand in 27 patients: the extended Segmuller flap, the homo-digital reverse digital artery flap, the dorsal metacarpal artery perforator flap, and the Atasoy advancement flap. Wide-awake flap surgery works very well and safely achieved excellent anesthetic and vasoconstrictive effects in the authors’ cases. The authors found that vasoconstriction caused by epinephrine mainly affects the capillaries and does not affect digital arteries and their major branches in the hand.
Article
Fractures of the distal radius are one of the most common types of injuries encountered in hand surgery. Plate osteosynthesis is recommended for unstable fractures. Because distal radius fracture fixation is usually performed under general or regional anesthesia with the use of a tourniquet, this exposes patients, especially elderly people with extensive comorbidities, to adverse effects commonly associated with these forms of anesthesia. As such, many of these patients are unable to undergo surgery in a timely manner until they are deemed medically fit for surgery or anesthesia, and some may still be treated nonsurgically. Injecting local anesthetic of lidocaine and epinephrine into the surgical field and without using a tourniquet is known to be advantageous for various surgical procedures of the hand. However, this approach, also known as wide-awake local anesthesia no tourniquet (WALANT), has not been used in the fixation of fractures beyond the wrist. Using the WALANT approach as an alternative anesthetic for plating of distal radius fractures may enable patients who are normally denied surgery owing to their age or medical comorbidities to undergo plate fixation for the fractures. This article outlines the WALANT approach used for a single case of fixation of distal end radius fracture with a detailed description of the technique of administering local anesthesia.
Article
This article reviews historical background, essential practice principles, and the new emerging area of wide awake hand surgery. It outlines the reasons that wide awake, local anaesthesia, no tourniquet surgery has emerged so quickly in the last 10 years over the world. I explain the origin of the concepts and some of the challenges of getting the technique accepted; in particular, the debunking of the myth of epinephrine danger in the finger. I review the most recent developments in several operations in this rapidly changing field of the tourniquet-free approach. Finally, this review includes speculations on the future of this technique.
Article
Background: Wide-awake local anesthesia and no tourniquet (WALANT) has become more popular in hand surgery. Without a tourniquet, there is no need for preoperative testing or sedation. The use of lidocaine with epinephrine has allowed a larger variety of cases to be done safely in an outpatient setting instead of the hospital. "Minor field sterility," which uses fewer drapes and tools to accomplish the same procedures, is a concept that is also gaining recognition. Methods: Investigation of hand surgeons performing a majority of cases using WALANT and minor field sterility was the beginning of seeing its potential at our institution. Administration was concerned about patient safety, cost-effectiveness, and patient satisfaction of the proposed changes. Analysis of our institution to determine location of these procedures was also imperative to using WALANT. Results: An in-office procedure room was built to allow for WALANT and minor field sterility. The requirements and logistics of developing an in-office procedure room for wide-awake surgery are reviewed in this article. Conclusions: The concurrent use of WALANT and minor field sterility has created a hand surgery practice that is cost-effective for the patient and the facility and resulted in excellent patient outcomes and satisfaction.
Article
Background Carpal tunnel release (CTR) is the most common surgery of the hand, and interest is growing in performing it under local anesthesia without tourniquet. To better understand differences, we hypothesized that patients undergoing CTR under wide-awake local anesthesia with no tourniquet (WALANT) versus sedation (monitored anesthesia care [MAC]) would not result in a difference in outcome. Methods Consecutive cases of electrodiagnostically confirmed open CTR across multiple surgeons at a single center were prospectively enrolled. Data included demographic data, visual analog scale, Levine-Katz carpal tunnel syndrome scale, QuickDASH questionnaire, customized Likert questionnaire, and complications. Results There were 81 patients enrolled in the WALANT group and 149 patients in the MAC group. There were no reoperations in either group or any epinephrine-related complications in the WALANT group. Disability and symptom scores did not differ significantly between WALANT and sedation groups at 2 weeks or 3 months. Average postoperative QuickDASH, Levine-Katz, and VAS pain scales were the same in both groups. Both groups of patients reported high levels of satisfaction at 91 versus 96% for the WALANT versus MAC groups, respectively (p > 0.05). Patients in each group were likely to request similar anesthesia if they were to undergo surgery again. Conclusion Patients undergoing open CTR experienced similar levels of satisfaction and outcomes with either the WALANT or MAC techniques. There was no statistically significant difference between either group relative to the tested outcome measures. These data should facilitate surgeons and patients' choosing freely between WALANT and MAC techniques relative to complications and outcomes.
Article
This review highlights pathways regarding the handling of anticoagulation in elective hand surgery based on current literature. © Georg Thieme Verlag KG Stuttgart · New York.
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Background: Postoperative pain management and opioid consumption following carpal tunnel release (CTR) surgery may be influenced by many variables. To understand factors affecting opioid consumption, a prospective study was undertaken with the hypothesis that CTR performed under local anesthesia (wide awake local anesthesia with no tourniquet [WALANT]) would result in increased opioid consumption postoperatively compared with cases performed under sedation. Methods: All patients undergoing open CTR surgery were consecutively enrolled over a 6-month period. Information collected included patient demographics, surgical technique, amount and type of narcotic prescribed, number of pills taken, and type of anesthesia. Results: 277 patients were enrolled (56% women, 44% men). On average, 21 pills were prescribed, and 4.3 pills (median = 2) were consumed. There was no difference in consumption between patients who received WALANT (78 cases) versus (198 cases) sedation (4.9 vs 3.9 pills, respectively) (P = .22). There was no difference in opioid consumption based on insurance type (P = .47) or type of narcotic (P = .85). However, more men consumed no opioids (47%) compared with women (36%) (P < .05) and older patients consumed less than younger patients (P < .05). Conclusions: Opioid consumption following CTR is more influenced by age and gender, and less influenced by anesthesia type, insurance type, or the type of opioid prescribed. Many more opioids were prescribed than needed, on an average of 5:1. Many patients, particularly older patients, do not require any opioid analgesia after CTR.
Article
At the Dalhousie Plastic Surgery Alumni Reunion at the Atlantic Plastic Surgery meeting in Halifax, Nova Scotia, in September 2001, 22 subjects, including 18 certified hand surgeons, were injected with 1.8 mL of 2% lidocaine with 1:100,000 adrenaline in three places in one finger of each hand. One hour later, the same sites of one hand were injected with phentolamine (1 mg in 1 mL), and the other hand was injected with saline. Subjects were blinded as to which hand received the phentolamine. It took an average of 85 min for the adrenaline-injected fingers to return to normal colour after phentolamine injection. It took an average of 320 min for the adrenaline-injected fingers to return to normal colour after saline injection (no phentolamine). We also observed that lidocaine with adrenaline provided an average of 549 min of anesthesia in nonphentolamine-injected fingers. Phentolamine consistently and reliably reversed adrenaline-induced vasoconstriction in the finger.
Article
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.
Article
The infiltration of local anesthetics can be painful, which is likely due, in part, to their acidity. In spite of a Cochrane study that recommended neutralizing lidocaine with bicarbonate to decrease the pain of injection, not many surgeons have adopted the practice, and there are many 'recipes' for how much bicarbonate one should add. To determine the acidity of lidocaine and the correct ratio of bicarbonate that should be added to neutralize lidocaine to achieve body pH. Fifty samples each of commonly used anesthetics (lidocaine 1% and 2%, with and without epinephrine 1:100,000) were obtained and tested for pH. Data were also analyzed according to whether the vials had been previously opened. Ten additional samples of lidocaine 1% with 1:100,000 epinephrine were titrated against sodium bicarbonate 8.4% and tested for pH and the presence of precipitate. A solution of 1% lidocaine with 1:100,000 epinephrine had a mean (± SD) pH of 4.24±0.42, and 2% lidocaine with 1:100,000 epinephrine had a mean pH of 3.93±0.43. Plain 1% lidocaine had a pH of 6.09±0.16, and plain 2% lidocaine had a pH of 6.00±0.27. Epinephrine-containing solutions were more acidic when they had been previously opened. One per cent lidocaine with epinephrine required 8.4% sodium bicarbonate at a ratio of 1.1 mL:10 mL to 1.8 mL:10 mL to achieve the target tissue pH of 7.38 to 7.62. Lidocaine with epinephrine was approximately 1000 times more acidic than subcutaneous tissue. The addition of bicarbonate to the local anesthetic solution is simple to perform and is inexpensive. The proper volume ratio of 8.4% sodium bicarbonate to 1% lidocaine with 1:100,000 epinephrine is approximately 1 mL:10 mL. Surgeons should be more aware of the simplicity and value of buffering with bicarbonate to decrease the pain of injection.
Article
The wide-awake approach to flexor tendon repair has decreased our rupture and tenolysis rates and permitted us to get consistently good results in cooperative patients. The wide-awake surgery allows the repair of gaps of the surgical repair site revealed with intraoperative active movement testing of the repair We are now doing midrange active movement after primary tendon repair. After tenolysis, full-range active motion is possible even before skin closure. We no longer perform flexor tendon repair with the tourniquet, sedation, and muscle paralysis of general or block (Bier or axillary) anesthesia.
Article
: The goals of this study are threefold: (1) to determine what effect epinephrine has on the duration of bupivacaine finger block anesthesia; (2) to see whether the duration of action of bupivacaine on digital pain relief is the same duration as numbness to touch/pressure; and (3) to assess the fingertip temperature changes that result from bupivacaine digital blocks. : The ring fingers of both hands of 44 volunteers were randomized to injection of bupivacaine with or without 1:200,000 epinephrine. The durations of time for digits to return to normal pain, touch, pressure sensation, and fingertip temperature were measured and recorded. : There were three main findings: (1) the pain block of bupivacaine lasts only half as long (15 hours) as the return to normal sensation (30 hours); (2) the effect of adding epinephrine to bupivacaine prolongs the duration of pain relief in a finger block for only an additional 1.5 hours; (3) in addition to pain relief, bupivacaine finger blocks cause fingertip hyperemia with consistent significant fingertip temperature elevation that lasts 15 hours. : The duration of bupivacaine pain relief is the clinically important factor that needs to be reported in bupivacaine trials. Patients should be informed that the return of pain will occur much sooner than the return of normal sensation. Adding epinephrine to bupivacaine does not add a clinically significant length of time to pain relief. Bupivacaine finger blocks provide prolonged hyperemia and pain block to fingertips, which may be useful in the treatment of acute frostbite. : Therapeutic, I.
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
Epinephrine autoinjectors are known to result in accidental digital injections. Treatment recommendations and adverse outcomes are based on case reports. The objective of our study is to determine the frequency of digit ischemia after epinephrine autoinjector digital injections. In addition, we describe the frequency of epinephrine digital injections, treatments used, adverse local effects, and systemic effects. We performed a retrospective cohort study on cases reported to 6 poison centers during 6 years, using a search of the Texas Poison Center Network database. Patients who had an epinephrine injection of the hand were reviewed, and digital injections were included. Variables collected included demographics, local and systemic effects, symptom duration, treatments used, comorbidities, and whether admission, surgery, or hand surgery consultation was used. One trained abstractor used a standard electronic data collection form. There were 365 epinephrine injections to the hand identified for the 6-year period. Of these, 213 were digital injections, and 127 had follow-up. All patients had complete resolution of symptoms. None of the patients were hospitalized or received hand surgery consultation or surgical care. Significant systemic effects were not reported. Pharmacologic vasodilatory treatment was used in 23% (29/127) of patients. Ischemic effects were documented for 4 patients, and 2 of these had symptom resolution within 2 hours. All 4 patients received vasodilatory therapy and were discharged home, with complete resolution of symptoms. In our series of patients using poison center calls about digital epinephrine autoinjections, there were no cases in which clinically apparent systemic effects were recorded and few patients had ischemia. No patient was admitted or had surgery. Most clinicians did not use vasodilation medications or techniques.
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
Medical texts continue to perpetuate the belief that epinephrine should not be injected in fingers. Little attention has been paid to analyze the evidence that created this belief to see whether it is valid. The significance is that elective epinephrine finger injection has been shown to remove the need for a tourniquet, and therefore delete sedation and general anesthesia for much of hand surgery. All of the evidence for the antiadrenaline dogma comes from 21 mostly pre-1950 case reports of finger ischemia associated with procaine and cocaine injection with epinephrine. The authors performed an in-depth analysis of those 21 cases to determine their validity as evidence. They also examined in detail all of the other evidence in the literature surrounding issues of safety with procaine, lidocaine, and epinephrine injection in the finger. The adrenaline digital infarction cases that created the dogma are invalid evidence because they were also injected with either procaine or cocaine, which were both known to cause digital infarction on their own at that time, and none of the 21 adrenaline infarction cases had an attempt at phentolamine rescue. The evidence that created the dogma that adrenaline should not be injected into the fingers is clearly not valid. However, there is considerable valid evidence in the literature that supports the tenet that properly used adrenaline in the fingers is safe, and that it removes the need for a tourniquet and therefore removes the need for sedation and general anesthesia for many hand operations.
Article
The elective use of low-dose epinephrine in hand surgery has allowed for the performance of simple operative procedures with tourniquet-free pure local anesthesia (the wide-awake approach). The absence of general anesthesia or sedation has, in turn, allowed for the observation of how quickly the sensorimotor cortex adapts following procedures such as tendon transfer. Seven patients underwent a wide-awake transfer of the extensor indicis proprius to the extensor pollicis longus between February of 2002 and May of 2005 for restoration of thumb extension using local lidocaine with epinephrine alone. One of the seven patients experienced rupture of the initial transfer, necessitating transfer of the extensor carpi radialis longus to the extensor pollicis longus using the wide-awake approach. All seven patients were able to extend their thumbs fully by means of extensor indicis proprius intraoperatively immediately following transfer suture placement. Restoration of function was not ablated by loss of proprioception or visual feedback. At a mean follow-up of 15 months, thumb extension was restored to within normal limits in the affected thumb, with a slight decrease in grip and tripod pinch strength. The wide-awake approach has allowed the authors to adjust tendon transfer tension with active movement before skin closure without the risks associated with general or regional anesthesia. In addition, it has allowed them to observe immediate cortical adaptation in the context of a simple tendon transfer. The authors hypothesize that the brain's ability to immediately use extensor indicis proprius for thumb extension stems from the activation of preexisting synergistic cortical finger movement programs.
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