Chapter 31 Open Triangular Fibrocartilage Complex Repair
ADVANTAGES OF WALANT VERSUS SEDATION AND TOURNIQUET IN OPEN TRIANGULAR FIBROCARTILAGE COMPLEX (TFCC) REPAIR
A diagnostic wrist arthroscopy (see Chapter 30) often precedes this surgery to verify the need to perform a TFCC repair as a result of foveal detachment of the dorsal and/or volar radioulnar ligaments (DRUL/VRUL).
Because the patient is awake, you can discuss the need to continue with an open repair. Thus the unsedated patient can actively participate in this decision.
When performing the reattachment of the DRUL/VRUL to the fovea with either osteosutures or a bone anchor, you can test the tension in the ligaments with the patient′s active movement.
If you reattach the ligaments too loosely, you will see instability with the distal radioulnar joint (DRUJ) shift test.
If you reattach the ligaments too tightly, the patient will not have full range of active pronation and supination.
Because awake patients can see their hand move through a full range of pronation and supination after the reconstruction, they know that they can achieve it again after they go through postoperative immobilization and subsequent rehabilitation.
All of the general advantages listed in Chapter 2 apply to both the surgeon and the patient.
WHERE TO INJECT THE LOCAL ANESTHETIC FOR OPEN TFCC REPAIR
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 ANESTHESIA IN OPEN TFCC REPAIR
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 4 and 14.
We inject supine patients lying down on stretchers in a waiting area to decrease the risk of their fainting (see Chapter 6).
The tumescent local anesthetic will block the dorsal cutaneous branch of the ulnar nerve and the terminal branch of the posterior interosseous nerve to ensure a pain-free procedure.1
Begin the injection 5 to 7 cm proximal to the DRUJ, along the ulnar border of the forearm. Slowly inject 20 ml along the ulnar border and dorsal distal ulna. Inject about 10 ml along the dorsal wrist, making sure to add 2 ml in the area of the PIN at the level of Lister′s tubercle. Finally, inject the remaining 5 to 10 ml in the ulnocarpal region, with a few milliliters into the ulnocarpal joint for maximum effect.
The goal of the injection is to bathe local anesthetic 2 cm beyond wherever you think you have even a small chance of dissecting.
To minimize the pain of injection, use a 27-gauge needle (not a 25-gauge).
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.
Insert the first needle perpendicularly into the subcutaneous fat. Stabilize the syringe with two hands and have your thumb ready on the plunger 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 to 3 minutes) without moving the needle.
Reinsert the needle farther distally within 1 cm of clearly vasoconstricted blanched skin that has functioning lidocaine and epinephrine so the needle reinsertion is pain free.
Continue injecting from proximal to distal, blowing the local anesthesia slowly ahead of the needle so there is always at least 1 cm of visible or palpable local anesthetic ahead of the sharp needle tip 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 the local anesthesia with minimal pain.)
We keep the total dose of infiltrated anesthetic to less than 7 mg/kg. If less than 50 ml will be required to produce tumescent local anesthesia, we use premixed 1% lidocaine with 1:100,000 epinephrine. If 50 to 100 ml is required, we dilute 50 ml of lidocaine and epinephrine with 50 ml of saline solution to a concentration of 0.5% lidocaine with 1:200,000 epinephrine.
If you have access to blunt-tipped injection cannulas,2 you can inject the local anesthetic more quickly than you can with a sharp needle tip in a minimally painful fashion (see Chapter 5).