Arch Hand Microsurg.  2021 Mar;26(1):1-11. 10.12790/ahm.20.0073.

Wide-Awake Hand surgery

• Kim YW

• KMID: 2513200
• DOI: http://doi.org/10.12790/ahm.20.0073

Abstract

Wide-awake surgery is a surgical procedure which is not used a tourniquet and any sedation by using the function of lidocaine and epinephrine through the tumescent injection technique. The biggest advantages of wide-awake surgery are the prevention of the systemic risk of general anesthesia and the surgeon can confirm the result of surgery by moving the patient’s joint and tendon during the operation. But some modification of wide-awake surgery may be beneficial for the surgeon and patient. For decreasing the patient anxiety, low-grade sedative can be used and short-time use of tourniquet during initial dissection of the operating site can prevent the unexpected complication.

Keyword

Wide-awake; Anesthesia; Tourniquets; Hand surgery

Figure

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  Fig. 1. Prepare the 20 mL of 1% lidocaine mixed with the 0.2-mL 1:100,000 epinephrine (buffered at a ratio of 10 mL of lidocaine/epinephrine to 1 mL of 8.4% sodium bicarbonate). The 25–27 gauge needles are used during the injection.

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  Fig. 2. The usual amount of injection for the wide-awake local anesthesia at the hand volar side surgery.

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  Fig. 3. In case of long-lasting arterial constriction in the finger after injection, Phentolamine Mesylate (Reyon Pharm., Seoul, Korea; alpha-adrenergic blocking agent) can be injected around the ischemic area.

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  Fig. 4. (A, B) Wide-awake local anesthesia for a case with a complete zone II flexor tendon profundus cut in the small finger. Inject 2 mL of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 mL of lidocaine/epinephrine to 1 mL of 8.4% sodium bicarbonate) in subcutaneous fat. (C, D) Venting the A4 pulley enhances the motion of the flexor digitorum profundus tendon. (E, F)The range of motion of the small finger 8 months later. Written informed consent was obtained for publication of these images.

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  Fig. 5. (A, B) Preoperative view of rupture of the flexor tendons to the left small finger in a 28-year-old man. (C) Ruptured the sharp margin of the fifth flexor digitorum sublimis (FDS) and flexor digitorum profundus (FDP) tendon was shown at zone II. Simultaneous suturing of the ruptured FDS and FDP tendon at zone II increased the size of the two tendons. (D–F) Full release of A4 pulley and partial venting of A2 pulley will prevent the motion limitation of finger flexion. (G, H) Intraoperative views show full flexion and extension of small fingers after tendon repair. Written informed consent was obtained for publication of these images.

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  Fig. 6. (A, B) A 46-year-old man, a professional golf player, had been fractured hook of hamate and attritional rupture of both fifth flexor digitorum tendon at zone III. (C) With wide-awake anesthesia, the small profundus tendon was reconstructed with the ring finger superficialis tendon transfer. (D) Interweaving sutures are made fourth flexor digitorum sublimis to the fifth flexor digitorum profundus with adjusting tension. (E, F) Intraoperative assessment of the motion after tendon transfer. (G, H) The range of motion of the small finger 6 months later. Written informed consent was obtained for publication of these images.

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  Fig. 7. A 33-year-old man had extensor tendon subluxation by sagittal band rupture. (A) At the dorsum of metacarpophalangeal (MCP) joint, inject 10 mL of 1% lidocaine with 1:100,000 epinephrine (buffered at a ratio of 10 mL of lidocaine/epinephrine to 1 mL of 8.4% sodium bicarbonate) in subcutaneous fat. (B) Extensor tendon subluxation during MCP joint flexion. (C, D) The patient can regain the stability of the extensor tendon. Written informed consent was obtained for publication of these images.

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  Fig. 8. (A) A 29-year-old man had lower radial nerve palsy of the right arm for 2 years. (B) Around one incision over the radio-dorsal wrist, 50 mL of 0.5% lidocaine with 1:200,000 epinephrine was used to decrease the total amount of injected epinephrine. (C) Skin incision and dissection of both the palmaris longus tendon and extensor pollicis longus tendon, and flexor carpi radialis and extensor digitorum communis are dissected under tourniquet. (D) Intraoperative assessment of the motion after tendon transfer. (E, F) Finger and thumb extension 6 months later. Written informed consent was obtained for publication of these images.

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  Fig. 9. (A) A 27-year-old man had previous fifth metacarpal fracture and limitation of metacarpophalangeal (MCP) joint flexion. (B) Severe adhesion of extensor tendon and was seen. (C) After tenolysis of extensor tenon, but no improvement of range of motion by MCP joint dorsal capsule thickening. (D) Immediate postoperative view. After dorsal capsulectomy, full flexion of the MP joint was possible. Written informed consent was obtained for publication of these images.

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  Fig. 10. (A, B) Flexion and extension contracture of the interphalangeal joints of the small finger after flexor tendon repair. (C) After opening the tendon sheath, the authors found severe adhesions between the flexor digitorum sublimis and flexor digitorum profundus (FDP) tendons as well as between flexor tendons and pulleys. (D) Tenolysis with FDP tendon. (E, F) Test of full digital extension and flexion during surgery. (H, I) Postoperative view 6 months later. Full flexion and extension were possible. Written informed consent was obtained for publication of these images.

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  Fig. 11. A 55-year-old man underwent K-wire fixation for a closed proximal phalanx fracture of the index finger. (A–D) Intraoperative view of the index finger motion before and after fixation of K-wire. (E) Ultrasonogram showed catching of the flexor digitorum profundus tendon. (F, G) Preoperative radiographic findings. Written informed consent was obtained for publication of these images.

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