ADVANTAGES OF WALANT VERSUS SEDATION AND TOURNIQUET IN TRAPEZIECTOMY

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  After you remove the trapezium, you can see whether the base of the metacarpal impinges on the scaphoid when you ask the patient to move the thumb all around. If it does, you can then add a ligament reconstruction in any way that you choose—with the abductor pollicis longus (APL), flexor carpi radialis (FCR), sutures, tightrope, and so on. After the suspension repair, you can verify that the reconstruction is keeping the metacarpal away from the scaphoid when you ask the patient to move the thumb again before you close the skin.

  
  
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  Clip 27-1 discusses intraoperative decision-making about simple trapeziectomy versus a ligament reconstruction and tendon interposition (LRTI) based on what you see with active movement. (Also see the videos in the Tips and Tricks section of this chapter showing both impinging and nonimpinging metacarpals.)

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  After you finish with the basal joint work, you can assess the position and active movement of the thumb metacarpophalangeal (MP) joint. If the MP joint is still hyperextending, you can deal with it while the patient′s hand is numbed. Ask the patient to move the thumb again after whichever MP joint surgery you choose. You can be sure both the basal and MP joints are actively moving well before you close the skin.

  
  
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  Movement without impingement after the trapeziectomy may help you to decide to stop there and close the skin without ligament reconstruction.

  
  
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  You can hear the thumb move through a full active range of motion after you remove the trapezium. You will sometimes hear remaining osteophytes grinding through the open wound with active movement. You can then find and remove them.

  
  
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  Patients get to see that the thumb will be able to move through a full range of motion before the skin is closed. They know that all can work well once they get past the postoperative discomfort and stiffness.1

  
  
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  Many of these patients have medical comorbidities. Because they are not sedated in any way, they simply get up after surgery and go home, as they would after a dental procedure.

  
  
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  All of the general advantages listed in Chapter 2 apply to both the surgeon and the patient.

WHERE TO INJECT THE LOCAL ANESTHETIC FOR A TRAPEZIECTOMY

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  See Chapter 1, Atlas, for more illustrations of the anatomy of diffusion of tumescent local anesthetic in the forearm, wrist, and hand.

SPECIFICS OF MINIMALLY PAINFUL INJECTION OF LOCAL ANESTHETIC IN A TRAPEZIECTOMY

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  Clip 27-4 shows real-time 8-minute injection of a patient with minimal pain for a trapeziectomy and ligament reconstruction. Surgery for this patient is shown in the ligament reconstruction in Clip 27-6, an APL procedure.

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  Clip 27-5 shows cannula injection of local anesthetic for a trapeziectomy with a 40 mm long blunt-tipped 25-gauge cannula in a hole made with a 20-gauge needle (also see Chapter 5).

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  We inject the anesthetic solution a minimum of 30 minutes before surgery to allow the epinephrine to take optimal effect and provide an adequately dry working field, as outlined in Chapters 3, 4, and 14.

  
  
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  We inject supine patients lying down on stretchers in a waiting area to decrease the risk of their fainting (see Chapter 6).

  
  
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  Start by injecting 10 ml of the mixture under the skin at the proximal trapeziectomy incision red dot injection point.

  
  
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  After the first 10 ml, inject another 10 ml on the dorsal side of the trapezium, staying near the metacarpal base.

  
  
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  After the second 10 ml on the dorsal side, inject another 10 ml on the volar side of the trapezium, staying near the metacarpal base.

  
  
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  After the third 10 ml on the volar side, inject a fourth 10 ml slowly between the thumb and index metacarpal bases going from the dorsal articulation to the volar side where the metacarpals meet the trapezium, staying near the bone.

  
  
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  Finally, distract (pull on) the thumb and inject 5 ml into the basal metacarpal trapezial joint. This last 5 ml can also be injected into the joint capsule under direct vision after the skin incision during the surgery.

  
  
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  If performing an LRTI with the flexor carpi radialis, inject 20 to 40 ml of the mixture from proximal to distal so there is at least 2 cm of visible or palpable local anesthetic beyond everywhere you will dissect.

  
  
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  If performing an LRTI with the abductor pollicis longus, you may need another 10 ml of the mixture over the proximal APL so there is at least 2 cm of visible or palpable local anesthetic outside of everywhere you will dissect. In Clip 27-6, an APL reconstruction, no further local anesthetic was needed after the original 40 ml.

  
  
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  To minimize pain of injection, start with a fine 27-gauge needle (not a 25-gauge).

  
  
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  Ask the patient to look away. Press with a fingertip just proximal to the injection site before you put in the needle to add the sensory “noise” of pressure to decrease the pain.

  
  
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  Insert the first needle perpendicularly into the subcutaneous fat. Stabilize the syringe with two hands to avoid the pain of needle wobble until the skin needle site is numb. Inject the first visible 0.5 ml bleb and then pause. Wait 15 to 45 seconds until the patient tells you that all the needle pain is gone. Inject the rest of the first 10 ml slowly (over 2 minutes) without moving the needle.

  
  
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  When you have to reinsert the needle, always put it back into skin that is clearly white with epinephrine. If you reinsert within 1 cm of clearly white vasoconstricted skin that has functioning lidocaine and epinephrine, needle reinsertion will be pain free.

  
  
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  Continue injecting from proximal to distal, blowing the local anesthetic slowly ahead of the needle so there is always at least 1 cm of visible or palpable local anesthesia ahead of the sharp needle tip point that the patient would feel if you advanced it into “live” nerves. “Blow slow before you go.” (See Chapter 5 for further tips on how to inject local anesthetic with minimal pain.)

  
  
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  The goal of the injection is to bathe local anesthetic 2 cm beyond wherever you think you even have a small chance of dissecting or inserting a K-wire.

  
  
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  We keep the total dose of infiltration less than 7 mg/kg. If we need less than 50 ml of tumescent local anesthetic (see Chapter 4), we use premixed 1% lidocaine with 1:100,000 epinephrine (buffered with 10 ml lido/epi:1 ml of 8.4% sodium bicarbonate). If we need 50 to 100 ml, we dilute the 50 ml of 1% lidocaine with 1:100,000 epinephrine with 50 ml of saline solution to a concentration of 0.5% lidocaine with 1:200,000 epinephrine. If we need 100 to 200 ml of volume, we dilute 50 ml of 1% lidocaine with 1:100,000 epinephrine with 150 ml of saline solution to get 200 ml of 0.25% lidocaine with 1:400,000 epinephrine, which is clinically very effective.