Wide-Awake Wrist Arthroscopy and Open TFCC Repair

Abstract

The wide-awake approach to hand surgery involves the subcutaneous and intra-articular injection of large volumes of diluted lidocaine and epinephrine in the forearm, wrist, hand, and fingers. Benefits include the deletion of the risks and inconveniences of general anesthesia and the ability to watch the patient take reconstructed hand tissues through an active range of motion for adjustment of the reconstruction before the skin is closed. 1Watching comfortable patient's active movement during the surgery has shown major benefit in allowing reduced rupture rates in flexor tendon repair, 2-5 as well as improved tension setting in tendon transfers. 6 Wide-awake surgery has Keywords ► arthroscopy ► local anesthesia ► proprioception ► TFCC ► wide-awake surgery ► wrist AbstractThe wide-awake approach to hand surgery entails the use of local infiltration anesthesia using lidocaine with epinephrine and no tourniquet. The technique provides practitioners with an option to perform advanced hand surgical care in an ambulatory setting, without the need for general or regional anesthetics. We present our results using wideawake approach in wrist surgery, both open and arthroscopic. Between June and August 2011, the wide-awake approach was used in nine elective wrist surgery cases; three arthroscopic procedures, four open triangular fibrocartilage complex (TFCC) repairs, and two combined arthroscopy/open surgery (eight men/one woman). The arthroscopic patients were anesthetized using dorsal infiltration of lidocaine with epinephrine (20 mL) with an additional intra-articular 5 mL injection 30 minutes before surgery. The open surgery patients received 40 mL of lidocaine with epinephrine around the ulnar aspect of the forearm, from 8-cm proximal to 3-cm distal to the distal radioulnar joint. Standard diagnostic radio-and midcarpal arthroscopies were performed, where one patient had a loose body removed and two patients underwent TFCC debridements due to central TFCC tears. The six open cases were all due to TFCC foveal disruptions, which were reinserted using osteosutures in the distal ulna. Following placement of the ligament sutures, a preliminary knot allowed active and passive motion testing of pronosupination, to determine the adequate amount of tension in the ligaments. The wide-awake approach to wrist surgery is a plausible and reliable technique that eliminates the need for general anesthesia, removes the need of a tourniquet, and provides a cost-efficient and safe approach to wrist surgery. The ability to control ligament reconstructions using active motion may additionally enhance the rehabilitation of these patients, both through early proprioceptive awareness and adequate tensioning of soft tissues.

Wide-awake Anesthesia No Tourniquet Trapeziometacarpal Joint Prosthesis Implantation

“… 3 Hand surgeons utilize WALANT for finger fractures, 4 , 5 flexor tendon repairs, 6 tendon transfers, 6 , 7 arthroscopies, and open triangular fibrocartilage complex (TFCC) repair. 8 Trapeziectomy for trapeziometacarpal (TMC) joint arthritis has been described using wide awake hand surgery, which involves numbing the joint itself. 9 …”

Arthroscopic assisted treatment of distal radius fractures and concomitant injuries

“…Although simple diagnostic wrist arthroscopy and soft tissue procedures can be performed under wide awake local anesthesia and no tourniquet (WALANT) surgery [21], patients with intra-articular DRFs are usually treated under general or regional anesthesia, in case of the need for manipulation of fracture fragments, which might be painful [19]. The patients are in supine position with the fingers hanging by the use of extension sleeves (Fig.…”

A cost and efficacy analysis of performing arthroscopic excision of wrist ganglions under wide-awake anaesthesia versus general anaesthesia

“…It has been widely used in flexor tendon repairs and other common hand procedures, such as carpal tunnel release, trigger finger release, flexor tendon ganglion excision, hand fractures, and Dupuytren contracture [5,7]. Few studies have verified the feasibility of WALANT in wrist arthroscopy [8,9]. One study of WALANT in wrist arthroscopy was published by Hagert and Lalonde [8], in which they reported the clinical outcomes and cost-effectiveness of wide-awake wrist arthroscopy.…”

“…Few studies have verified the feasibility of WALANT in wrist arthroscopy [8,9]. One study of WALANT in wrist arthroscopy was published by Hagert and Lalonde [8], in which they reported the clinical outcomes and cost-effectiveness of wide-awake wrist arthroscopy. However, no functional outcomes had been assessed.…”