Download The first 1500 consecutive cases of wide awake hand surgery in a

The First 1400 Consecutive Cases of Wide Awake Hand Surgery in a Single
Surgeon’s Practice: Lessons Learned
Donald Lalonde and Janice Lalonde
INTRODUCTION: What were the most important lessons learned in the first
1400 consecutive cases of wide awake hand surgery in a single surgeon’s
practice?
METHODS: Wide awake hand surgery is performed with no sedation, no
general anesthesia, and no tourniquet. Only lidocaine with epinephrine
is injected directly (tumesced) into the affected parts of the hand and
fingers for anesthesia and hemostasis12. The author has kept careful
records of all of the patients in his hand surgery practice in which
95% of surgery is now performed with the wide awake approach.
RESULTS: The first 1400 consecutive wide awake cases included 628
carpal tunnels, 167 trigger fingers, 129 operative reduction of hand
fractures, 51 Dupuytren’s, 34 extensor tendon repairs, 22 flexor tendon
repairs, 11 trapeziectomies, 6 tendon transfers and 2 tendon grafts.
CONCLUSION: The wide awake approach has its greatest advantages in
flexor and extensor tendon surgery (repairs, transfers, and grafting),
in finger fracture surgery, and in complex secondary procedures because
the surgeon can watch cooperative comfortable patients actively move
reconstructed tendons and bones during the surgery and he can make
adjustments to the repair before closing the skin.
Figure 1
Figure 2
Figure 1 legend
Wide awake flexor tendon repair, location of injection of the first 6
cc of lidocaine 1% with epinephrine 1:100,000
Figure 2 legend
Wide awake flexor tendon repair. Injection of 2cc of lidocaine with
epinephrine per phalanx
In flexor tendon surgery, the repair will occasionally be seen to gap
when the suture bunches in the tendon with active movement, and this
can be repaired before the skin is closed. The repair can be observed
moving through the pulleys with active movement, and pulley releases
can be performed before suturing the wound if required (figures 1 and
2). In tendon transfers such as EI to EPL, the tension of the transfer
can be accurately adjusted to be not too tight or not too loose before
the skin is closed3. Patient education during tendon transfers and
tendon repairs is greatly facilitated by the absence of sedation. The
surgeon has uninterrupted time to educate and assess his patient.
Carpal tunnels and trigger fingers can be performed with great
convenience and efficiency for both the patient and the surgeon4.
Elderly patients or those on multiple medications avoid the risks and
inconveniences of general anesthesia and hospital admission. Wide awake
hand surgery patients just get up and go home as when they go to the
dentist. They never get nausea and vomiting. However, repeat surgery
for Dupuytren’s contracture remains a challenge because of persisting
bleeding in spite of epinephrine injection.
References
1
Thomson CJ, Lalonde DH, Denkler KA, et al: A Critical Look at the Evidence for and against Elective
Epinephrine Use in the Finger. Plas Reconstr Surg, 119(1):260,2007.
2
Lalonde DH, Bell M, Benoit P, et al: A Multicenter Prospective Study of 3,110 Consecutive Cases of
Elective Epinephrine Use in the Fingers and Hand: the Dalhousie Project Clinical Phase: J Hand Surg,
30(5):1061,2005.
3
Bezuhly M, Sparkes GL, Higgins A, Neumeister M, Lalonde DH.: “Immediate Thumb Extension
following Extensor Indicis Proprius to Extensor Pollicis Longus Tendon Transfer Using the Wide Awake
Approach". Plas Reconst Surg, 119(5):1507,2007.
4
Leblanc MR, Lalonde J, Lalonde DH.: A Detailed Cost and Efficiency Analysis of Performing Carpal
Tunnel Surgery in the Main Operating Room versus the Ambulatory Setting in Canada. Hand. 2(4):173,
2007.