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Transient Tourniquet and Electro-cauterization applied for Surgery in Metacarpal Fractures Under Local Anesthesia with Epinephrine

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Background : The purpose of this study is to illustrate whether the electro-cauterization and transient tourniquet enhanced efficiency of local anesthesia with epinephrine in surgery of metacarpal fractures. Methods : Forty-four consecutive cases of metacarpal fractures with estimated major operative time more than 30 minutes were enrolled. Local anesthesia with epinephrine, electro-cauterization and transient tourniquet were performed. Data regarding anesthesia effect, bleeding in the surgical field (with inflating and deflating tourniquet), time when patient felt uncomfortable with tourniquet, inspection of the surgical outcome, and some other surgical tricks were collected and evaluated. Results : All patients felt no pain for whole surgical period in the surgical field. Time when patient felt uncomfortable with tourniquet was about 16 minutes. Mean tourniquet time was about 29 minutes. There was no or less bleeding in the surgical field for whole surgical period. The anatomical structures, such as nerve, tendon and vessel can be easily distinguished and dissected. Outcome of repair and reconstruction could be examined with instructed movement. Postoperative inspection showed no symptom of inflammation. Conclusions : Local anesthesia with epinephrine, electro-cauterization and transient tourniquet for major hand surgery can save time and obtain wide-awake effect, which would satisfy both doctors and patients.
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Transient Tourniquet and Electro-cauterization applied for Surgery in
Metacarpal Fractures Under Local Anesthesia with Epinephrine
Ren-Guo XIE ( renguo.xie@gmail.com )
Shanghai General Hospital Department of Orthopaedics: Shanghai Jiaotong University First People's Hospital Department of Orthopaedics
https://orcid.org/0000-0001-8100-5097
Research Article
Keywords: Local Anesthesia, Tourniquet, Electro-cauterization, Wide-Awake, Hand Surgery
DOI: https://doi.org/10.21203/rs.3.rs-816248/v1
License: This work is licensed under a Creative Commons Attribution 4.0 International License.  Read Full License
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Abstract
Background : The purpose of this study is to illustrate whether the electro-cauterization and transient tourniquet enhanced eciency of local anesthesia with
epinephrine in surgery of metacarpal fractures.
Methods : Forty-four consecutive cases of metacarpal fractures with estimated major operative time more than 30 minutes were enrolled. Local anesthesia
with epinephrine, electro-cauterization and transient tourniquet were performed. Data regarding anesthesia effect, bleeding in the surgical eld (with inating
and deating tourniquet), time when patient felt uncomfortable with tourniquet, inspection of the surgical outcome, and some other surgical tricks were
collected and evaluated.
Results : All patients felt no pain for whole surgical period in the surgical eld. Time when patient felt uncomfortable with tourniquet was about 16 minutes.
Mean tourniquet time was about 29 minutes. There was no or less bleeding in the surgical eld for whole surgical period. The anatomical structures, such as
nerve, tendon and vessel can be easily distinguished and dissected. Outcome of repair and reconstruction could be examined with instructed movement.
Postoperative inspection showed no symptom of inammation.
Conclusions : Local anesthesia with epinephrine, electro-cauterization and transient tourniquet for major hand surgery can save time and obtain wide-awake
effect, which would satisfy both doctors and patients.
Introduction
Surgeries in the nger and hand usually need a tourniquet to obtain a bloodless eld to facilitate discerning the detail of the delicate structures (nerves,
vessels and tendons) 1,2,3. Sedation, Bier block, brachial plexus block, or general anesthesia would be performed to enhance the patients’ endurance of the
uneasy of the tourniquet compression4, which would make the patients unable to cooperatively move the reconstructed hand and nger structures
intraoperatively. Since the myth, epinephrine when injected into the ngers, nose, ears, and toes would cause infarction in body parts with end arteries, was
found to be not valid. Lidocaine with epinephrine has become more popular for routine hand surgery5,6. In fact, the extremely acidic procaine induces the
tissue necrosis, and phentolamine can reverse the vasoconstrictive effect of epinephrine7. Even the high concentrated epinephrine of 1:1000 injected into
ngers voluntarily or accidentally never cause a nger death8. Local anesthesia of lidocaine and epinephrine could satisfy most hand surgery under no
tourniquet control, which now named as wide awake local anesthesia no tourniquet (WALANT) 9,10,11,12. However, there has to be about 25 minutes interval
from epinephrine injected to hemostasis effect available for surgery13, which means low eciency in some developing countries where hand trauma
frequently occurs. Recent report showed that tourniquets for short wide-awake procedures are feasible and well accepted14. We hypothesized, in relatively long
surgery such as metacarpal fractures, that with the help of electro-cauterization and transient tourniquet, local anesthesia with epinephrine could yield the
same wide awake effect and save the time.
Material And Methods
We did surgery (open reduction and internal xation, ORIF) in metacarpal fractures of 50 consecutive cases from 2020 in our unit, six of which were excluded
for the general anesthesia (Table1). Our hospital ethics committee approved this study (2020 KY234). The patient was hospitalized one day before surgery or
at the surgery day, and was discharged one day after surgery, according to our hospital policy. The institutional review board of our hospital approved this
study. Generally, the ORIF was performed whenever some special preparation (mostly hardware sterilized) completed.
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Table 1
Patients’ Data
Case
No
Sex Age
(yrs) Fx type & Treatment Electro-
cautery
setup
time
(mm:ss)
Uncomfortable with
tourniquet
staring time
(mm:ss)
Tourniquet
Release
time
(mm:ss)
Operation
Time
(hh:mm)
Surgical
eld
bleeding
Delicate dissection
completed, when
Tourniquet
Released
1 F 24 1B + 4S, Plate + K-wire 2:15 18:30 30:48 2:20 Less 1B K-wire
2 M 36 5B, Plate + K-wire 2:00 10:10 28:04 1:12 Less K-wire
3 F 51 L1B, Plate + K-wire 2:08 16:40 26:45 0:50 Less K-wire
4 M 33 R5N, Plate 1:58 19:25 28:15 1:05 Less K-wire
5 F 60 L4S, Plate 2:05 17:35 32:55 1:45 Less Plate
6 M 27 R5N, Plate 2:16 15:05 30:33 1:20 Less K-wire
7 M 45 R2S + R3S, Plate + 
Cannula screw 2:00 17:16 35:22 1:40 Less R3S, Plate
8 M 31 L5S, Plate 2:03 15:01 25:15 1:30 Less Plate
9 M 49 L2S, Plate 2:09 12:53 29:15 2:00 Less Plate
10 F 49 L3S, Plate 1:50 13:50 19:05 2:10
11 M 49 R1B, Plate 2:26 15:48 28:14 1:49 Less K-wire
12 F 49 R1B, Plate 2:10 11:29 18:10 1:30
13 M 51 L5B, Plate + K-wire 2:01 16:00 36:22 2:19 Less K-wire
14 M 57 L1B, Plate + K-wire 2:15 19:11 30:51 1:55 Less K-wire
15 F 64 L4S, Plate 2:08 16:20 30:48 1:10 Less Plate
16 M 25 R5N, Plate 2:10 12:31 27:12 1:05 Less K-wire
17 M 29 R5B, Plate 2:12 21:36 25:24 1:35 Less K-wire
18 M 29 L3S, Plate 2:07 15:40 25:00 0:45 Less Plate
19 M 55 R5S, Plate 1:59 19:55 28:29 2:00 Less Plate
20 M 21 L5S, Plate 1:51 12:42 35:33 1:35 Less Plate
21 F 56 R5N, Plate 2:21 18:32 30:49 0:35 Less K-wire
22 M 19 R5S, Plate 2:24 22:16 33:10 0:45 Less Plate
23 M 43 R5S, Plate 2:05 11:31 31:18 1:00 Less Plate
24 F 31 L2N, Plate 2:08 17:31 26:43 1:25 Less K-wire
25 F 33 L5S, Plate 2:20 16:09 33:49 1:30 Less Plate
26 M 32 R4S, Plate 1:55 11:05 29:30 1:30 Less Plate
27 M 46 R5S, Plate 2:24 15:23 29:10 1:55 Less Plate
28 M 27 R5N, Plate 2:09 21:19 35:05 1:04 Less K-wire
29 M 28 L3S, Plate 2:20 12:45 30:55 1:35 Less Plate
30 M 20 R5N, Plate 1:54 21:20 34:30 1:15 Less K-wire
31 M 51 L2S, Plate 1:57 18:14 27:45 1:05 Less Plate
32 M 55 R1B, Plate + K-wire 2:03 14:33 25:40 1:50 Less K-wire
33 M 54 L3B + L4B, Plate + K-
wire 2:05 13:41 33:55 2:30 Less L3B + L4B, K-wire
34 F 48 R1B, Plate + K-wire 2:18 16:09 29:20 0:55 Less K-wire
35 M 20 R1B, Plate + K-wire 1:53 20:01 25:06 0:45 Less K-wire
36 M 34 L5B, Plate + K-wire 2:18 15:09 33:34 1:00 Less K-wire
*1 = rst metacarpus, 2 = second metacarpus, 3 = third metacarpus, 4 = fourth metacarpus, 5 = fth metacarpus. B = base, S = shafts, N = Neck.
Page 4/8
Case
No
Sex Age
(yrs) Fx type & Treatment Electro-
cautery
setup
time
(mm:ss)
Uncomfortable with
tourniquet
staring time
(mm:ss)
Tourniquet
Release
time
(mm:ss)
Operation
Time
(hh:mm)
Surgical
eld
bleeding
Delicate dissection
completed, when
Tourniquet
Released
37 M 34 R5B, Plate + K-wire 2:09 17:05 27:08 1:40 Less K-wire
38 M 22 R4B + R5B, Plate + K-
wire 2:19 12:38 24:10 2:50 Less R5B, K-wire
39 M 63 L1B, Plate + K-wire 2:29 22:17 25:35 2:05 Less K-wire
40 M 19 L1B, Plate + K-wire 1:59 13:46 26:12 1:35 Less K-wire
41 M 41 L5B, Plate + K-wire 2:07 15:18 29:42 1:15 Less K-wire
42 M 45 R4S, Plate 1:56 13:27 32:42 1:00 Less Plate
43 M 46 R4S, Plate 2:26 12:06 36:34 1:10 Less Plate
44 F 63 L5N, Plate + K-wire 2:03 15:20 25:45 0:56 Less K-wire
Mean 2:08 16:00 29:20
SD 0:10 3:05 4:12
*1 = rst metacarpus, 2 = second metacarpus, 3 = third metacarpus, 4 = fourth metacarpus, 5 = fth metacarpus. B = base, S = shafts, N = Neck.
After hospitalized, the patient would be arranged for a conversation with a senior surgeon in detail on the anesthesia and the surgery, as followed. The local
anesthesia was a kind of injection of lidocaine and epinephrine into the operative site, which was safe and no need of controlling the patient’s condition, such
as the blood hypertension and dysfunctions of heat, kidney, lung and brain. The patient could eat and drink as usual. Only onset-poke-pain like a mosquito
sting would occur and the injected so-called narcotic drags would be little effect to the patient. The intraoperative transient tourniquet application with the aim
to save time would be uncomfortable and no any harm to the patient, and we could release it at any time the patient was unable to endure. The whole
procedure would be wide-awake and no any sedation, which could facilitate observing the surgical effect for surgeons and the patient at any operative step.
The patient could be discharged after surgery. This conversation would be duplicated while the patient entering the operating room.
The tourniquet was banded to the 1/3 upper part of the suffered upper limb. After sterilizing and draping, the operative site was injected the combined
solution, 1% lidocaine with 1:100,000 epinephrine and soda (1 ml of 8.4% bicarbonate added into 10 ml of 1% lidocaine with 1:100,000 epinephrine to alleviate
the acidity). We completely tracked Lalonde’s recommendation to perform this anesthesia12. Then the electro-cauterization was set up to desiccate mode and
power of 20 watts or less, and we preferred coagulation to dissect the tissue for its hemostasis effect, which would consume about 2 minutes. The tourniquet
was inated and the surgery was started. Only the epidermis was lanced with a scalpel, and the deeper tissue was dissected with the electro-cauterization. We
pushed away and cut to separate the connect tissue with the thin, narrow and blunt blade of the electro-cauterization. Slightly wiping to eliminate some edema
with gauze, we coagulated some visible vessels and could discern and protect some vital structures like nerves in the bloodless tissue. The metacarpal
fracture was exposed reduced and temporarily xed with Kirschner wire. Usually surgery for one metacarpal fracture till this step, the operative time would be
25 minutes more or less. We could release the tourniquet and took X-rays to monitor the reduction (Fig.1). We would elongate the tourniquet to the next
surgical steps, if the patient did not express unacceptable uneasy. The patients always felt uncomfortable with the tourniquet compression, and most of them
could endure to nish of the reduction and temporary xation. For a few patients unable to endure we released the tourniquet, and we could go on operating in
some bloody eld. Generally, 2 minutes after the tourniquet released, the patient felt easy and the motor function would recover, which could make the patient
move his ngers cooperatively to observe the reconstructive effect. Till now, more than 25 minutes from the injection elapsed, the hemostatic effect of
epinephrine came on and would last to the end of the rest procedure, such as metacarpal fracture xed with plates and screws, concomitant injured structures
repaired and reconstructed, and skin closed. Anyway, fractures should be aligned and xed to satisfy the hand movement. We recorded the time at some spot
of the surgical procedure and evaluated.
We conducted an experiment to elucidate specic experience with tourniquet compression, in which the author and his ve close friends were involved. All was
told the experimental aim and no permanent harm in advance. The lapsing time and feeling at some stage were record (Table2).
Page 5/8
Table 2
Normal Volunteers’ Experience with Tourniquet in Arm
No Gender Age
(yrs) Weight
(Kg) Heigth
(cm) Blood
Pressure(mmHg) Occupation Forearm
width(cm) Uncomfortable
with
tourniquet
staring time
(mm:ss)
Tourniquet
Release
time
(mm:ss)
Sensation
starting
recovery
(mm:ss)
Movement
starting
recovery
(mm:ss)
Fu
rec
(m
1 M 49 75.7 170 140/90 Doctor 30.9 27:28 38:01 40:08 40:04 54
2 M 31 75.6 177 120/80 Doctor 35.3 29:53 32:23 34:54 34:87 44
3 F 32 75.2 163 125/80 Engineer 30.9 25:46 29:45 32:48 32:08 41
4 F 59 70.0 168 130/90 Teacher 30.3 31:03 35:21 38:44 39:01 52
5 F 28 63.7 170 110/70 Nurse 29.3 25:45 27:35 29:45 29:89 42
6 M 39 90.1 180 125/80 Manager 31.8 26:08 28:45 31:13 31:04 47
Descriptive statistics was used to collect and analyse the results.
Results
Tourniquet was released less than 25 minutes from injection in two cases. The time for setting up the electro-cauterization was about 2 minutes. All patients
felt uncomfortable with the tourniquet compression, which started at about 16 minutes, released at 29 minutes less or more. Sensation and movement
recovered in several minutes (we didn’t record). All patients were able to move the nger and hand to inspect the reconstructive effect, according to the doctor’s
instruction. All patients kept wide awake during whole surgery, and expressed no complaint about the tourniquet application while inquiring after surgery. All
surgery was performed successfully with no need of converting to another anesthesia and no too much bleeding was noted in the surgical eld impeding
dissection. Moreover, there was no obvious interval to wait the hemostatic effect of epinephrine, that is to say, we saved the time with this modied local
anesthesia. Postoperative daily inspection and wound care showed normal, no extra edema and oozed secretion. Sutures were removed routinely on time.
Discussion
As Lalonde and some others experimented and illustrated, the prejudice regarding infarction in body parts with end arteries arisen from the vasoconstriction of
epinephrine had been gradually rectied, which was eventually kind of tissue necrosis caused by the expired extremely acid procaine. Epinephrine was getting
revived and its hemostatic effect could eliminate the tourniquet in surgery of the nger and hand. Without tourniquet, there would be no need of sedation, Bier
block, brachial plexus block, or general anesthesia, which would keep the patient wide-awake to move his repaired or reconstructed structures subjectively
during surgery5,6,7,8,9,10,12. Doctors could evaluate the surgical result for further treatment9,10,12, and patients’ seeing of the recovery of normal movement could
enhance their condence in the post-operative rehabilitation. Moreover, local anesthesia was much more economical, rapid and ecient than the others, no
need of anesthetists and no need of improvement some vital organs’ malfunction12,14,15,16,17. Nowadays, wide awake local anesthesia no tourniquet
(WALANT) was wide used in upper limb surgery, like ngers, hand, forearm and elbow18,19,20. However, it takes time for the epinephrine to constrict the vessels
enough to form a less errhysis eld for visual dissection. Bashir MM, et al found an interval of 25 minutes provides vastly superior operative eld visibility13. In
some developing countries, many employees without professional skill or the knowledge of system safety protection work overtime frequently, which would
result in high incidence of hand injuries. Plus the other hand diseases, hand surgeons in these areas are very busy, and one team surgeons always have to do
with 15 to 20 cases per operative day. 25 minutes per patient to wait for the hemostatic effect is denitely impracticable. For minor hand surgery of short time,
we usually use the tourniquet to achieve a bloodless surgical view21,22. We hypothesized in complicated hand surgery with the electro-cauterization to speed
we could complete the accurate dissection until the patients endurance of the tourniquet. And then, the left surgery could continue in a relatively less bleeding
area with the epinephrine vasoconstriction. We could enjoy the benet from wide-awake and timesaving of the local anesthesia with electro-cauterization and
transient tourniquet for major surgery in hand.
Metacarpal fractures reduction should be very perfect. The most important intraoperative check is for the unacceptable rotational deformity, which usually
affected adjacent ngers and caused signicant cosmetic or functional problems. When exed, two ngers would overlap to scissors-like interference, and
surgical osteotomy could yield an ideal result23,24. Patients’ subjectively exing and extending the ngers to evaluate the repaired or reconstructed effect is of
preference. The brachial plexus block and the general anesthesia with sedation are not suitable. WALANT is playing an important role instead of the ever-used
Bier block.
A volunteers’ experiment of small cases (two authors included, Table 2) with arm-tourniquet inated to 250 mmHg being conducted, we subjectively obtained
our own feeling during whole procedure as followed. Sensation and movement of the distal zone to the tourniquet gradually disappeared from the proximal
part to the distal end. Slight movement could exist a few seconds after the full sensation disappeared. When completely anesthesia, there still existed residue
deep body sensation, which was a sort of blunt numbness if touch applied. This kind of uncommon feeling may sometimes frustrate the patient’s endurance
with the tourniquet. This may be the reason that two of our patients ended the tourniquet less than 25 minutes. There was no pain intolerance when we
released the tourniquet. A few seconds later there always dramatically spasm feeling of the whole zone distal to the tourniquet and gradually disappeared,
and the sensation and movement recovered. We recorded our experience as a preoperative conversation with the patient.
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In our consecutive cases, we performed the local anesthesia with electro-cauterization and transient Tourniquet. Twice preoperative thorough conversation
with the patient could lessen his anxiety, we thought, especially in reassuring him that there would be no permanent hazard of transient tourniquet
compression although uncomfortable. Our clinical data indicated that all patients recovered motion shortly after the tourniquet deated and no any
postoperative uneasy.
Electro-cauterization is widely used with two common modes of cut and coagulation to speed up in surgery25. With its power and the reaction extent precise
adjusted, it could be used to dissect in ap surgery26. We found the 20 watts and desiccate mode of coagulation suitable for the watery tissue inltrated with
local anesthesia. With a tweezer acted as a reciprocal retractor and pincher, the high frequency electricity scalpel could incise, separate, and coagulate
eciently. We had to take time to ligate some visible vessels with tourniquet and no electro-cauterization, or vice versa, the bleeding usually blurred the view
and stopped us from the precise dissecting. Intra-operative the gauze wiping might absorb some anesthesia solution, and it did not affect the hemostatic
effect of epinephrine. Additionally, we found the surgical eld was less bleeding with the epinephrine vasoconstriction and electro-cauterization (Figs. 2).
Some documents demonstrated a safe scale. In our cases, tourniquet was instantly inated to 250 mmHg, and we did not set the respective pressure, with
regard to individual situation, such as gender, age, body weight and blood pressure. Although tourniquet compression with 250 mmHg of less than 30 minutes
was no harm to the tissue, we believed, less pressure, less uncomfortable, as illustrated by Lim E, et al27.
The hemostatic effect from epinephrine vasoconstriction is compulsory for the wide-awake surgery in the hand, although sometimes the major dissection is
completed under the control of the tourniquet. Less time with the tourniquet compression, more comfortable and less potential harm to the tissue. Moreover,
one reduction even to visually alignment for most metacarpal fractures could not suce for the normal movements of nger, which could be from some little
angulation or rotation of the fragments. The epinephrine vasoconstriction could lessen the amount and speed of bleeding and yield a clear eld available for
the further adjustment of the reduction and xation, and the split tissue closing.
In this study, we performed the descriptive statistics, because some data were relatively subjective.
Despite of the uncomfortable and no permanent harm with transient tourniquet compression, the local anesthesia with electro-cauterization and epinephrine
could save time and keep wide awake. This could be an optional for some hand surgeons in their favor.
Declarations
Ethics statement:
Written informed consent of patients and volunteers was obtained following a detailed explanation of the procedures that they may undergo. This study was
approved by the ethics review committee of our hospital (No.2020ky234).
Declaration of conicting interest:
The authors declare that there is no conict of interest.
Funding:
This research received no specic grant from any funding agency in the public, commercial, or not-for-prot sectors.
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Figures
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Figure 1
The base fracture of the fth metacarpal bone. About 28 minutes was consumed, when surgery proceeded to three K-wires xing the reduced fragments. The
tourniquet was released, no apparently bleeding occurred (R). X-rays showed the anatomical alignment of the fractures, and the rational position of the
implant (L).
Figure 2
The shaft fracture of the rst metacarpus. Mini-plate and screws were directly used to x the reduced fragments. The tourniquet was released at about 32
minutes, no apparently bleeding occurred (R). X-rays showed the anatomical alignment of the fractures, and the rational position of the implant (L). This
patient suffered the base fracture of the thumb proximal phalanx as well, and we xed it with three K-wires.
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Background: “Wide awake hand surgery”, where surgery is performed in local anaesthesia with adrenaline, without sedation or a tourniquet, has become widespread in some countries. It has a number of potential advantages and we wished to evaluate it among our patients. Methods: All 122 patients treated by this method during one year were evaluated by the surgeons and the patients on a numerical scale from 0 (best/least) to 10 (worst/most). Theatre time was compared to that recorded for a year when regional or general anaesthesia had been used. Results: The patients’ mean score for the general care they had received was 0.1 (SD 0.6), for pain during lidocaine injection 2.4 (SD 2.2), for pain during surgery 0.9 (SD 1.5), and for other discomfort during surgery 0.5 (SD 1.4). Eight reported that they would want general anaesthesia if they were to be operated again. The surgeons’ mean evaluation of bleeding during surgery was 1.6 (SD 1.8), oedema during surgery 0.4 (SD 1.1), general disadvantages with the method 1.0 (SD 1.6) and general advantages 6.5 (SD 4.3). The estimation of advantages was 9.9 (DS 0.5) for tendon suture. 28 patients needed intra-operative additional anaesthesia. The proportion was lower among trained hand surgeons and fell significantly during the study period. Non-surgical theatre time was 46 (SD 15) minutes during the study period and 55 (SD 22) minutes during the regional/general period (p < 0.001). This gain was cancelled out by a longer surgery time during the wide awake period. Conclusions: Wide awake surgery is fully acceptable to most patients. It has a number of advantages over general or regional anaesthesia, but we feel it is unlikely to improve the efficiency of the operating theatre.
Article
Purpose: Wide-awake local anesthesia no tourniquet (WALANT) is an increasingly popular surgical technique. However, owing to surgeon preference, patient factors, or hospital guidelines, it may not be feasible to inject patients with solutions containing epinephrine the recommended 25 minutes prior to incision. The purpose of this study was to assess pain and patient experience after short hand surgeries done under local anesthesia using a tourniquet rather than epinephrine for hemostasis. Methods: Ninety-six consecutive patients undergoing short hand procedures using only local anesthesia and a tourniquet (LA-T) were assessed before and after surgery. A high arm pneumatic tourniquet was used in 73 patients and a forearm pneumatic tourniquet was used in 23. All patients received a local, unbuffered plain lidocaine injection. No patients received sedation. Pain related to local anesthesia, pneumatic tourniquet, and the procedure was assessed using a visual analog scale (VAS). Patient experience was assessed using a study-specific questionnaire based on previous WALANT studies. Tourniquet times were recorded. Results: Mean pain related to anesthetic injection was rated 3.9 out of 10. Mean tourniquet related pain was 2.9 out of 10 for high arm pneumatic tourniquets and 2.3 out of 10 for forearm pneumatic tourniquets. Patients rated their experience with LA-T favorably and 95 of 96 patients (99%) reported that they would choose LA-T again for an equivalent procedure. Mean tourniquet time was 9.6 minutes and only 1 patient had a tourniquet inflated for more than 20 minutes. Tourniquet times less than 10 minutes were associated with less pain than tourniquet times greater than 10 minutes (P < .05); however, both groups reported the tourniquet to be on average less painful than the local anesthetic injection. Conclusion: Short wide-awake procedures using a tourniquet are feasible and well accepted. Local anesthetic injection was reported to be more painful than pneumatic tourniquet use. Tourniquets for short wide-awake procedures can be used in settings in which preprocedure epinephrine injections are logistically difficult or based on surgeon preference. Type of study/level of evidence: Therapeutic IV.
Article
WALANT (wide-awake local anesthesia no tourniquet) appears to be a safe and effective anesthesia technique for many hand and wrist surgeries. Patient satisfaction is high because of the avoidance of preoperative testing and hospital admission. Postoperative recovery is rapid, and procedures can be done in outpatient settings, resulting in substantial savings in time and money.
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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.
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In China, wide-awake surgeries are increasingly used by surgeons in a growing number of hospitals for hand and upper extremity surgeries. Experience suggests that wide-awake surgery is safe, economical, and patient-friendly, optimizing hospital resource allocation and increasing efficiency. This article discusses which procedures are most suitable, variations in procedures, departmental impacts, and future direction.
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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
To determine the optimal time interval between tumescent local anesthesia infiltration and the start of hand surgery without a tourniquet for improved operative field visibility. Patients aged 16 to 60 years who needed contracture release and tendon repair in the hand were enrolled from the outpatient clinic. Patients were randomized to 10-, 15-, or 25-minute intervals between tumescent anesthetic solution infiltration (0.18% lidocaine and 1:221,000 epinephrine) and the start of surgery. The end point of tumescence anesthetic infiltration was pale and firm skin. The surgical team was blinded to the time of anesthetic infiltration. At the completion of the procedure, the surgeon and the first assistant rated the operative field visibility as excellent, fair, or poor. We used logistic regression models without and with adjustment for confounding variables. Of the 75 patients enrolled in the study, 59 (79%) were males, 7 were randomized to 10-minute time intervals (further randomization was stopped after interim analysis found consistently poor operative field visibility), and 34 were randomized to the each of the 15- and 25-minute groups. Patients who were randomized to the 25-minute delay group had 29 times higher odds of having an excellent operative visual field than those randomized to the 15-minute delay group. After adjusting for age, sex, amount of tumescent solution infiltration, and duration of operation, the odds ratio remained highly significant. We found that an interval of 25 minutes provides vastly superior operative field visibility; 10-minute delay had the poorest results. Therapeutic I. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
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The ability to tolerate a tourniquet is often the limiting factor to elective and emergent procedures of the upper limb performed under local anaesthesia. This study aims to demonstrate that upper limb tourniquets are more predictably and better tolerated when inflated to 200 mmHg than to the traditional inflation pressure of 250 mmHg in awake, unsedated subjects. Forty healthy volunteers were randomized to have a tourniquet applied at either 200 or 250 mmHg for 20 min. Vital signs and pain scores were measured pre-test, at intervals throughout the time the tourniquet was inflated and post-deflation until the parameters normalized. Grip strength was measured pre-test, immediately post-deflation of the tourniquet and every 2 min until return of normal strength. All subjects were able to tolerate a tourniquet inflated for the allocated 20 min irrespective of the inflation pressure; however, there was a statistically significant lower average pain score in the group where the tourniquet was inflated to 200 mmHg compared with 250 mmHg. There was a quicker return of normal grip strength, although this was not shown to be statistically significant. Tourniquets inflated to 200 mmHg are better tolerated in awake, unsedated subjects that would allow predictably short procedures of the hand, wrist and forearm to be performed under local anaesthesia. It represents a pilot study prior to a further clinical study investigating the efficacy of tourniquets inflated to a lower pressure in maintaining an effective bloodless field.
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Traditionally, the knife has been used to make surgical incisions on the skin, but recent data suggest that diathermy blade allows the incision to be made more quickly, with less blood loss, less postoperative pain and no adverse effects on wound healing or cosmetic effect.