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J Wrist Surg 2012; 01(01): 055-060
DOI: 10.1055/s-0032-1312045
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Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Wide-Awake Wrist Arthroscopy and Open TFCC Repair

Elisabet Hagert
1   Department of Clinical Science and Education, Karolinska Institutet, Hand & Foot Surgery Center, Stockholm, Sweden
,
Donald H. Lalonde
2   Department of Plastic Surgery, Dalhousie University, Saint John, New Brunswick, Canada
› Author Affiliations
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Publication History

Publication Date:
23 August 2012 (online)

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Abstract

The 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 wide-awake 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.

Keywords

arthroscopy - local anesthesia - proprioception - TFCC - wide-awake surgery - wrist
 

  • References

  • 1 Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg 2011; 38 (4) 761-769
    CrossrefPubMedGoogle Scholar
  • 2 Higgins A, Lalonde DH, Bell M, McKee D, Lalonde JF. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg 2010; 126 (3) 941-945
    PubMedGoogle Scholar
  • 3 Lalonde DH, Kozin S. Tendon disorders of the hand. Plast Reconstr Surg 2011; 128 (1) 1e-14e
    PubMedGoogle Scholar
  • 4 Lalonde DH. Wide-awake flexor tendon repair. Plast Reconstr Surg 2009; 123 (2) 623-625
    CrossrefPubMedGoogle Scholar
  • 5 Lalonde DH. An evidence-based approach to flexor tendon laceration repair. Plast Reconstr Surg 2011; 127 (2) 885-890
    CrossrefPubMedGoogle Scholar
  • 6 Bezuhly M, Sparkes GL, Higgins A, Neumeister MW, Lalonde DH. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach. Plast Reconstr Surg 2007; 119 (5) 1507-1512
    CrossrefPubMedGoogle Scholar
  • 7 Nelson R, Higgins A, Conrad J, Bell M, Lalonde DH. The wide-awake approach to Dupuytren's disease: fasciectomy under local anesthetic with epinephrine. Hand (NY) 2010; 5: 117-124
    CrossrefPubMedGoogle Scholar
  • 8 Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. 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 Am 2005; 30 (5) 1061-1067
    CrossrefPubMedGoogle Scholar
  • 9 Ho PC, Lo WN, Hung LK. Arthroscopic resection of volar ganglion of the wrist: a new technique. Arthroscopy 2003; 19 (2) 218-221
    PubMedGoogle Scholar
  • 10 Slutsky DJ, Nagle DJ. Wrist arthroscopy: current concepts. J Hand Surg Am 2008; 33 (7) 1228-1244
    CrossrefPubMedGoogle Scholar
  • 11 Garcia-Elias M, Hagert E. Surgical approaches to the distal radioulnar joint. Hand Clin 2010; 26 (4) 477-483
    CrossrefPubMedGoogle Scholar
  • 12 Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg 2007; 119 (1) 260-266
    CrossrefPubMedGoogle Scholar
  • 13 Nodwell T, Lalonde DH. How long does it take phentolamine to reverse adrenaline-induced vasoconstriction in the finger and hand? A prospective randomized blinded study: the Dalhousie project experimental phase. Can J Plast Surg 2003; 11: 187-190
    PubMedGoogle Scholar
  • 14 Fitzcharles-Bowe C, Denkler KA, Lalonde DH. Finger injection with high-dose (1:1000) epinephrine: does it cause finger necrosis and should it be treated?. Hand 2007; 2: 5-11
    CrossrefPubMedGoogle Scholar
  • 15 Lalonde DH. “Hole-in-one” local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 2010; 126 (5) 1642-1644
    PubMedGoogle Scholar
  • 16 Mustoe TA, Buck II DW, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg 2010; 126 (4) 165e-176e
    PubMedGoogle Scholar
  • 17 Lintner S, Shawen S, Lohnes J, Levy A, Garrett W. Local anesthesia in outpatient knee arthroscopy: a comparison of efficacy and cost. Arthroscopy 1996; 12 (4) 482-488
    PubMedGoogle Scholar
  • 18 Trieshmann Jr HW. Knee arthroscopy: a cost analysis of general and local anesthesia. Arthroscopy 1996; 12 (1) 60-63
    PubMedGoogle Scholar
  • 19 Chatterjee A, McCarthy JE, Montagne SA, Leong K, Kerrigan CL. A cost, profit, and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the United States. Ann Plast Surg 2011; 66 (3) 245-248
    CrossrefPubMedGoogle Scholar
  • 20 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 (NY) 2007; 2 (4) 173-178
    CrossrefPubMedGoogle Scholar
  • 21 Leblanc MR, Lalonde DH, Thoma A , et al. Is main operating room sterility really necessary in carpal tunnel surgery? A multicenter prospective study of minor procedure room field sterility surgery. Hand (NY) 2011; 6 (1) 60-63
    CrossrefPubMedGoogle Scholar
  • 22 Geissler WB, Freeland AE, Savoie FH, McIntyre LW, Whipple TL. Intracarpal soft-tissue lesions associated with an intra-articular fracture of the distal end of the radius. J Bone Joint Surg Am 1996; 78 (3) 357-365
    CrossrefPubMedGoogle Scholar
  • 23 Myers JB, Lephart SM. The role of the sensorimotor system in the athletic shoulder. J Athl Train 2000; 35 (3) 351-363
    PubMedGoogle Scholar
  • 24 Lundborg G, Rosén B. Hand function after nerve repair. Acta Physiol (Oxf) 2007; 189 (2) 207-217
    CrossrefPubMedGoogle Scholar
  • 25 Swanik CB, Lephart SM, Giannantonio FP, Fu FH. Reestablishing proprioception and neuromuscular control in the ACL-injured athlete. J Sport Rehabil 1997; 6: 182-206
    PubMedGoogle Scholar
  • 26 Hagert E. Proprioception of the wrist joint: a review of current concepts and possible implications on the rehabilitation of the wrist. J Hand Ther 2010; 23 (1) 2-16 , quiz 17
    CrossrefPubMedGoogle Scholar