Wide Awake Trapeziectomy for Thumb Basal Joint Arthritis

Wide Awake Local Anesthesia No Tourniquet (WALANT) is a good alternative technique to sedation and the tourniquet, when performing trapeziectomy with or without ligament reconstruction. The purpose of this article was to demonstrate with clear video the local anesthetic injection, surgery, intraoperative patient interaction, and postoperative patient satisfaction. PREOPERATIVE PLANNING We inject only lidocaine, epinephrine, and bicarbonate in our supine patients on a stretcher outside the operating room and we allow a minimum of 30 minutes for the local anesthetic to provide good hemostasis and a pain-free experience.1 Eliminating the tourniquet and the pain associated with local anesthesia2 removes the need for sedation and intravenous insertion. Avoiding sedation related complications is especially important for patients with medical comorbidities. Patients do not have to undergo unnecessary preoperative testing: ECG = electrocardiography, chest radiographs, anesthesia consultation, or blood tests. There is no need to risk discontinuing anticoagulation medication in most cases. LOCAL ANESTHETIC INJECTION See video, Supplemental Digital Content 1, which shows how to perform minimal pain local anesthesia injection for WALANT trapeziectomy. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A498.Video Graphic 1.: See video, Supplemental Digital Content 1, which shows how to perform minimal pain local anesthesia injection for WALANT trapeziectomy. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A498. We inject 50–60 cc of 0.5% lidocaine with 1:200,000 epinephrine (buffered with 8.4% sodium bicarbonate at a 10:1 ratio lidocaine/epinephrine:bicarbonate) with a 27-gauge needle. We begin with 10 ml in the fat under the center of the incision and inflate the radial hand all around the trapezium as shown in the video. We no longer routinely perform FCR = flexor carpi radialis ligament reconstructions. However, this is easily done after injection of an additional 20–30 cc over the donor tendon from proximal to distal with the same solution. It is important to use minimal pain injection techniques that include perpendicular needle insertion, reinsertion of the needle into areas that are clearly numb, and slow antegrade injection of the local to avoid sharp needle penetration of sensate areas.2 TRAPEZIECTOMY PROCEDURE See video, Supplemental Digital Content 2, which shows trapeziectomy exposure using wide-awake local anesthesia no tourniquet surgery. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A499.Video Graphic 2.: See video, Supplemental Digital Content 2, which shows trapeziectomy exposure using wide-awake local anesthesia no tourniquet surgery. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A499.See video, Supplemental Digital Content 3, which shows trapeziectomy surgical decision making using wide-awake local anesthesia no tourniquet hand surgery. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A500.Video Graphic 3.: See video, Supplemental Digital Content 3, which shows trapeziectomy surgical decision making using wide-awake local anesthesia no tourniquet hand surgery. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A500. Several prospective randomized controlled trials have shown simple trapeziectomy to be just as effective as trapeziectomy with ligament reconstruction, but with less morbidity.3 After we remove the trapezium, we get the comfortable, drug-free, pain-free, and cooperative patient to actively move the thumb during the procedure. We can easily assess for: stability, persistent grinding due to osteophytes, the base of the metacarpal rubbing on the scaphoid, and persistent hyperextension of the MP = metacarpal phalangeal joint. These may all require correction if present. When we see persistent grinding of the metacarpal on the scaphoid, we prefer using a Weilby-type abductor pollicis longus or suture suspension procedure.4 We then verify the strength of our reconstruction with further active movement before we close the skin. Patients can see their thumb move during surgery. Patients remember this thumb movement goal after the postoperative swelling, pain, and stiffness dissipate. Patients interact with their surgeon during the procedure and receive additional education on how to care for their hand postoperatively.5 POSTOPERATIVE COURSE See video, Supplemental Digital Content 4, which shows an orthopedic veterinary surgeon as the patient, and her perspective in follow-up, after undergoing wide awake trapeziectomy. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A501.Video Graphic 4.: See video, Supplemental Digital Content 4, which shows an orthopedic veterinary surgeon patient perspective in follow-up, after undergoing wide awake trapeziectomy. This video is available in the “Related Videos” section of the Full-Text article on PRSGlobalOpen.com or available at https://links.lww.com/PRSGO/A501. No sedation means no nausea, vomiting, urinary retention, or other unwanted side effects. Most patients simply get up and go home after the procedure as if it were a visit to the dentist office. Costs of the procedure are largely reduced.

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