Wide-Awake Hand Surgery



Wide-Awake Hand Surgery


Julie E. Adams, MD, MS


Dr. Adams or an immediate family member has received royalties from Arthrex, Inc., Biomet, and Zimmer; serves as a paid consultant to or is an employee of Arthrex, Inc.; and serves as a board member, owner, officer, or committee member of the American Association for Hand Surgery, the American Shoulder and Elbow Surgeons, and the American Society for Surgery of the Hand.



PATIENT SELECTION



Indications

Wide awake hand surgery, sometimes known as WALANT (wide awake local anesthesia no tourniquet), is particularly useful for surgery of the hand. This technique involves use of local anesthesia with epinephrine in the surgical field for purposes of hemostasis and prolonging the effect of the local anesthesia. In contrast to a wrist block, the concept is to provide a large amount of anesthetic infiltrated into or near the surgical field.

The advantages of this technique include the potential ability to perform surgery outside the operating room and without a tourniquet. Traditionally, many hand surgical cases required use of a tourniquet for hemostasis and to facilitate adequate visualization. This can be difficult for the patient to tolerate on the forearm or upper arm, especially for longer procedures. Traditionally, in many cases, patients have undergone general anesthesia or sedation by an anesthesia care provider in the operating room. However, use of the wide awake technique facilitates patients having surgery under local anesthesia alone without sedation and obviates the need for tourniquet control. Because of this, many procedures do not need to be performed in the operating room and can be performed in a clinic setting. Furthermore, because patients do not need sedation or anesthesia, there is no need for preoperative medical testing, preoperative medical clearance, or placement of an IV, and no need for the patient to refrain from eating or drinking prior to the procedure. Furthermore, with the use of epinephrine in the local anesthetic, patients may continue preoperative medications including blood thinners such as warfarin, aspirin, clopidogrel, apixaban, or other blood thinners. Because patients are awake during the procedure, this technique is particularly useful for procedures that benefit from patient participation, such as tendon transfers in which a surgeon may wish to assess the appropriate tension of the transfer, flexor tendon repairs, in which the surgeon wishes to rule out any gapping or bunching at the surgical repair, tenolysis, or contracture releases.

Because the operating room may not be necessary, preoperative testing and IVs are not usually necessary, and because systemic anesthetics are not necessary, the procedure is not only safer for but also less costly with less medical waste generated.

Examples of procedures that are very commonly done with the wide awake technique include carpal tunnel release, trigger finger release, extensor tendon repair, flexor tendon repair, mass excision, deQuervain’s release, mucous cyst excision, thumb CMC arthroplasty, tendon transfer procedures, fixation of finger fractures, irrigation and débridement of soft-tissue infections, foreign body removals, nail bed repairs, cubital tunnel decompression, and other procedures.



Contraindications

Contraindications to the wide awake technique include patient anxiety or unwillingness or inability to tolerate being awake during the procedure (which sometimes may be a relative contraindication if the patient can be talked through the procedure, distracted, or if the patient wishes to take an oral anxiolytic agent). The technique is used with caution in the setting of patients who have poorly vascularized digits or a substantial cardiovascular history. Because epinephrine is used in the local anesthetic, one must ensure that there is adequate vascularity to the digit before using the local anesthetic with epinephrine. In general, it is almost always safe to proceed in the setting of a digit that is pink and well vascularized before the procedure. The general rule of thumb is that if the digit is well vascularized before initiation of the local anesthesia with epinephrine, it will remain so following administration of this. Additionally, patients in whom one is concerned about the cardiovascular effects of epinephrine (such as patients who have a substantial ischemic cardiovascular history) may bear more scrutiny, although generally the alterations in cardiovascular parameters are minimal.1





PROCEDURE


Room Setup/Patient Positioning

The setup for wide awake hand surgery includes the critical aspect of infiltration of local anesthesia with sufficient time for the epinephrine to exert its hemostatic effect (ie, > 30 minutes prior to incision), which may present an opportunity for surgeons to inject the patient in a preoperative waiting area or an examination room. Furthermore, there are certain techniques that have described to limit pain of injection that may be helpful.


Special Instruments/Equipment/Implants

Typically, we have available local anesthesia with epinephrine (usually 1% lidocaine 1:100,000 with epinephrine), bicarbonate solution to buffer the local anesthesia, and sometimes, if the procedure requires tumescent anesthesia or a large field, saline to dilute the local anesthesia to create a large surgical field. Other solutions (example 0.5% lidocaine 1:200,000 with epinephrine) may be used alternatively.


Surgical Technique

The critical aspect of WALANT involves using sufficient local anesthesia, injecting it early enough to let the epinephrine take effect, and minimizing pain of injection.

Lalonde and colleagues offer several tips for minimalizing pain associated with the local anesthetic injection.2



  • To decrease the acute pain from injection of the local anesthetic, it is helpful to buffer the solution to neutralize the pH. One milliliter of 8.4% bicarbonate is mixed with 10 cc of 1% lidocaine 1:100,000 with epinephrine.


  • Warm local anesthetic is less painful than colder temperatures, and some surgeons warm the bottle of local anesthesia by holding it in their hands or placing it temporarily adjacent to skin.


  • A smaller bore needle (27 or 30 g) is less painful than a larger bore needle (Figure 1).


  • Injecting perpendicular to the skin rather than an oblique angle allows the needle to pass through fewer pain fibers (Figure 2).


  • It is helpful to inject slowly and advance the needle slowly. Typically, a small amount of local medication is injected first and then the surgeon pauses, then slowly advances the needle as he or she is slowly injecting, trying to always keep the “wheel” of the injection advancing faster than the needle so that the needle then goes through an already numb area (Figure 3).


  • A steady hand limits movement of the needle, which can be painful.






FIGURE 1 Photograph of buffered lidocaine 1:100,000 with epinephrine being drawn up and prepared to be injected. The volume used depends upon the location of surgery and procedure type. Usually 20 cc is used for a carpal tunnel release.

There are several other tips that are helpful as one considers using this technique for surgery.

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Feb 2, 2020 | Posted by in ORTHOPEDIC | Comments Off on Wide-Awake Hand Surgery

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