Archives of Plastic Surgery

Korean Society of Plastic and Reconstructive Surgeons (대한성형외과학회)
권호 표지
DOI QR코드

DOI QR Code

Tumescent Local Anesthesia for Hand Surgery: Improved Results, Cost Effectiveness, and Wide-Awake Patient Satisfaction

  • Received : 2013.08.05
  • Accepted : 2013.09.08
  • Published : 2014.07.15
Download PDF
⟨ Previous Next ⟩

Abstract

This is a review article of the wide-awake approach to hand surgery. More than 95% of all hand surgery can now be performed without a tourniquet. Epinephrine is injected with lidocaine for hemostasis and anesthesia instead of a tourniquet and sedation. This is sedation-free surgery, much like a visit to a dental office. The myth of danger of using epinephrine in the finger is reviewed. The wide awake technique is greatly improving results in tendon repair, tenolysis, and tendon transfer. Here, we will explain its advantages.

Keywords

References

  1. Lalonde DH. Reconstruction of the hand with wide awake surgery. Clin Plast Surg 2011;38:761-9. https://doi.org/10.1016/j.cps.2011.07.005
  2. Lalonde D, Martin A. Epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. J Am Acad Orthop Surg 2013;21:443-7. https://doi.org/10.5435/JAAOS-21-08-443
  3. Thomson CJ, Lalonde DH, Denkler KA, et al. A critical look at the evidence for and against elective epinephrine use in the finger. Plast Reconstr Surg 2007;119:260-6. https://doi.org/10.1097/01.prs.0000237039.71227.11
  4. Terp P. Hydrolysis of procaine in aqueous buffer solutions. Acta Pharmacologica et Toxicologica 1949;5:353-62.
  5. Uri J, Adler P. The disintegration of procaine solutions. Curr Res Anesth Analg 1950;29:229-34.
  6. Food and Drug Administration. Warning-procaine solution. JAMA 1948;138:599.
  7. Denkler K. A comprehensive review of epinephrine in the finger: to do or not to do. Plast Reconstr Surg 2001;108:114-24. https://doi.org/10.1097/00006534-200107000-00017
  8. Nodwell T, Lalonde D. 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;11:187-90.
  9. Fitzcharles-Bowe C, Denkler K, Lalonde D. Finger injection with high-dose (1:1,000) epinephrine: Does it cause finger necrosis and should it be treated? Hand (N Y) 2007;2:5-11. https://doi.org/10.1007/s11552-006-9012-4
  10. 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 (N Y) 2007;2:173-8. https://doi.org/10.1007/s11552-007-9043-5
  11. 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 (N Y) 2011;6:60-3. https://doi.org/10.1007/s11552-010-9301-9
  12. Henry SL, Hubbard BA, Concannon MJ. Splinting after carpal tunnel release: current practice, scientific evidence, and trends. Plast Reconstr Surg 2008;122:1095-9. https://doi.org/10.1097/PRS.0b013e31818459f4
  13. Davison P, Cobb T, Lalonde D. The patient's perspective on carpal tunnel surgery related to the type of anesthesia: a prospective cohort study. Hand 2013;8:47-53. https://doi.org/10.1007/s11552-012-9474-5
  14. Mustoe TA, Buck DW 2nd, Lalonde DH. The safe management of anesthesia, sedation, and pain in plastic surgery. Plast Reconstr Surg 2010;126:165e-76e. https://doi.org/10.1097/PRS.0b013e3181ebe5e9
  15. Jeske AH. Xylocaine: 50 years of clinical service to dentistry. Tex Dent J 1998;115:9-13.
  16. Strazar R, Lalonde D. Minimizing injection pain in local anesthesia. CMAJ 2012;184:2016. https://doi.org/10.1503/cmaj.111780
  17. Chatterjee A, McCarthy JE, Montagne SA, et al. 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;66:245-8. https://doi.org/10.1097/SAP.0b013e3181db7784
  18. Bismil M, Bismil Q, Harding D, et al. Transition to total one-stop wide-awake hand surgery service-audit: a retrospective review. JRSM Short Rep 2012;3:23. https://doi.org/10.1258/shorts.2012.012019
  19. McKee DE, Lalonde DH, Thoma A, et al. Optimal time delay between epinephrine injection and incision to minimize bleeding. Plast Reconstr Surg 2013;131:811-4. https://doi.org/10.1097/PRS.0b013e3182818ced
  20. Lalonde DH. "Hole-in-one" local anesthesia for wide-awake carpal tunnel surgery. Plast Reconstr Surg 2010;126:1642-4. https://doi.org/10.1097/PRS.0b013e3181f1c0ef
  21. Farhangkhoee H, Lalonde J, Lalonde DH. Teaching medical students and residents how to inject local anesthesia almost painlessly. Can J Plast Surg 2012;20:169-72. https://doi.org/10.1177/229255031202000315
  22. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia injection. Plast Reconstr Surg 2013;132: 675-84. https://doi.org/10.1097/PRS.0b013e31829ad1e2
  23. Lalonde DH. Wide-awake flexor tendon repair. Plast Reconstr Surg 2009;123:623-5. https://doi.org/10.1097/PRS.0b013e318195664c
  24. Higgins A, Lalonde DH, Bell M, et al. Avoiding flexor tendon repair rupture with intraoperative total active movement examination. Plast Reconstr Surg 2010;126:941-5. https://doi.org/10.1097/PRS.0b013e3181e60489
  25. Lalonde D. How the wide awake approach is changing hand surgery and hand therapy: inaugural AAHS sponsored lecture at the ASHT meeting, San Diego, 2012. J Hand Ther 2013;26:175-8. https://doi.org/10.1016/j.jht.2012.12.002
  26. Bezuhly M, Sparkes GL, Higgins A, et al. Immediate thumb extension following extensor indicis proprius-to-extensor pollicis longus tendon transfer using the wide-awake approach. Plast Reconstr Surg 2007;119:1507-12. https://doi.org/10.1097/01.prs.0000256071.00235.d0

Cited by

  1. Achieving the Optimal Epinephrine Effect in Wide Awake Hand Surgery using Local Anesthesia without a Tourniquet vol.10, pp.4, 2014, https://doi.org/10.1007/s11552-015-9759-6
  2. Systematic Injection Patterned-Technique of One-Per-Mil Tumescent Solution for Perforator-Based Skin Flap: Is it Better Than the Random Patterned-Technique? vol.100, pp.9, 2014, https://doi.org/10.9738/intsurg-d-14-00290.1
  3. Improving Outcomes in Tendon Repair: A Critical Look at the Evidence for Flexor Tendon Repair and Rehabilitation vol.138, pp.6, 2016, https://doi.org/10.1097/prs.0000000000002769
  4. Tumescent anaesthesia: its applications and well tolerated use in the out-of-operating room setting vol.30, pp.4, 2017, https://doi.org/10.1097/aco.0000000000000486
  5. Wide Awake Open Reduction of Irreducible Metacarpal Phalangeal Joint Dislocations vol.5, pp.7, 2014, https://doi.org/10.1097/gox.0000000000001394
  6. Wide Awake Hand Surgery vol.22, pp.3, 2014, https://doi.org/10.1142/s0218810417500320
  7. Prevention of Surgical Site Infections and Biofilms: Pharmacokinetics of Subcutaneous Cefazolin and Metronidazole in a Tumescent Lidocaine Solution vol.5, pp.5, 2014, https://doi.org/10.1097/gox.0000000000001351
  8. Evidence-Based Medicine: Current Evidence in the Diagnosis and Management of Carpal Tunnel Syndrome vol.140, pp.1, 2014, https://doi.org/10.1097/prs.0000000000003477
  9. An Economic Analysis of MAC Versus WALANT: A Trigger Finger Release Surgery Case Study vol.12, pp.4, 2014, https://doi.org/10.1177/1558944716669693
  10. Use of Fibrin Sealant for Split-Thickness Skin Grafts in Patients with Hand Burns: A Prospective Cohort Study vol.31, pp.12, 2018, https://doi.org/10.1097/01.asw.0000547413.61758.27
  11. A Cost Analysis of Carpal Tunnel Release Surgery Performed Wide Awake versus under Sedation vol.142, pp.6, 2014, https://doi.org/10.1097/prs.0000000000004983
  12. Open reduction and internal fixation of intra-articular distal radius fractures under wide-awake local anesthesia with no tourniquet vol.46, pp.10, 2014, https://doi.org/10.1177/0300060518793036
  13. Wide-Awake Hand Surgery : Principles and Techniques vol.6, pp.5, 2018, https://doi.org/10.2106/jbjs.rvw.17.00142
  14. Endoscopic Carpal Tunnel Release with and without Sedation vol.141, pp.3, 2018, https://doi.org/10.1097/prs.0000000000004113
  15. Wide-awake Anesthesia No Tourniquet Trapeziometacarpal Joint Prosthesis Implantation vol.6, pp.4, 2014, https://doi.org/10.1097/gox.0000000000001714
  16. Use and Associated Spending for Anesthesiologist-Administered Services in Minor Hand Surgery vol.141, pp.4, 2014, https://doi.org/10.1097/prs.0000000000004230
  17. Functional and Quality of Life Outcomes of a Hand Surgery Mission to Honduras vol.13, pp.3, 2014, https://doi.org/10.1177/1558944717704515
  18. Novel Axillary Block Management for Tendon Transfer Surgery : A Case Report vol.12, pp.12, 2014, https://doi.org/10.1213/xaa.0000000000000954
  19. Comparison of Wide-Awake Local Anesthesia No Tourniquet With General Anesthesia With Tourniquet for Volar Plating of Distal Radius Fracture vol.42, pp.1, 2014, https://doi.org/10.3928/01477447-20181206-01
  20. The safety of one-per-mil tumescent infiltration into tissue that has survived ischemia vol.46, pp.2, 2019, https://doi.org/10.5999/aps.2018.00248
  21. Wide Awake Local Anesthesia No Tourniquet: A Pilot Study for Carpal Tunnel Release in the Philippine Orthopedic Center vol.24, pp.4, 2014, https://doi.org/10.1142/s2424835519500486
  22. Wide-Awake Local Anesthesia No Tourniquet (WALANT) versus Local or Intravenous Regional Anesthesia with Tourniquet in Atraumatic Hand Cases in Orthopedics: A Systematic Review and Meta-Analysis vol.24, pp.4, 2014, https://doi.org/10.1142/s2424835519500619
  23. Utility of local anesthesia for open carpal tunnel release in patients with psychiatric diagnoses vol.23, pp.None, 2020, https://doi.org/10.1016/j.jpra.2019.10.002
  24. Ultrasound (US) Changes in the Median Nerve Cross‐Sectional Area After Microinvasive US‐Guided Carpal Tunnel Release vol.39, pp.4, 2020, https://doi.org/10.1002/jum.15146
  25. Plating of clavicle fracture using the wide-awake technique vol.29, pp.11, 2014, https://doi.org/10.1016/j.jse.2020.03.003
  26. Open carpal release using local anesthesia without a tourniquet: Does bleeding tendency affect the outcome? vol.47, pp.6, 2014, https://doi.org/10.5999/aps.2020.01732
  27. Maintaining Access to Orthopaedic Surgery During Periods of Operating Room Resource Constraint: Expanded Use of Wide-Awake Surgery During the COVID-19 Pandemic vol.4, pp.12, 2014, https://doi.org/10.5435/jaaosglobal-d-20-00100
  28. Optimizing Costs and Outcomes for Carpal Tunnel Release Surgery : A Cost-Effectiveness Analysis from Societal and Health-Care System Perspectives vol.103, pp.23, 2021, https://doi.org/10.2106/jbjs.20.02126
  29. Use of local anesthetics with an epinephrine additive on fingers and penis - dogma and reality vol.19, pp.2, 2021, https://doi.org/10.1111/ddg.14434
  30. Verwendung von Lokalanästhetika mit Adrenalinzusatz an den Fingern und am Penis - Dogma und Realität vol.19, pp.2, 2014, https://doi.org/10.1111/ddg.14434_g
  31. Benefits, safety and side effects of tumescent local anesthesia in dermatologic surgery in infants vol.19, pp.3, 2014, https://doi.org/10.1111/ddg.14340
  32. Development of a Low-Resource Operating Room and a Wide-Awake Orthopedic Surgery Program During the COVID-19 Pandemic vol.28, pp.2, 2014, https://doi.org/10.1177/15533506211003530
  33. The management of clenched fist injuries with local anaesthesia and field sterility vol.46, pp.4, 2014, https://doi.org/10.1177/1753193420960588
  34. Comparison of Complication Risk for Open Carpal Tunnel Release: In-office versus Operating Room Settings vol.9, pp.7, 2014, https://doi.org/10.1097/gox.0000000000003685