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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.