Wide-awake hand surgery

This new concept of hand surgery was advocated by Dr Donald Lalonde and colleagues in 2007. Dr Lalonde has performed over 2000 surgeries using this approach—eliminating anesthesia-induced complications—and reports high clinical safety rates. In just a few years, we now see widespread popularization of this method in many countries. This has been an important and well-integrated surgical method in hand surgery. The anesthesia is achieved by injecting 1% lidocaine with 1:100,000 epinephrine in the hand (or 0.5% lidocaine with 1:200,000 epinephrine when 50 to 100 mL is injected; see refs. ). The following are recognized fields utilizing this technique.

Tendon transfer surgery is most benefited from this approach. Proper tension of the transferred tendon can be judged and adjusted by prompting the patient to actively move his or her digit intraoperatively. This approach works well in almost all tendon transfers, including the transfer of the extensor indicis proprius to the extensor pollicis longus tendon, the flexor digitorum superficialis of the ring finger to the flexor pollicis longus or abductor pollicis brevis, and so on.

Primary flexor and extensor tendon repairs are also ideal for wide-awake surgery. Gapping and tension at the repair site can be assessed under direct visualization on the operating table with the patient actively flexing or extending his or her digit. This technique allows for the most reliable judgment of tendon repair that can safely proceed to early active motion. A surgeon should ensure the absence of gapping between tendon ends under active digital motion before leaving the operating room.

Carpal tunnel release, cubital tunnel release, and release of compression of the anterior or posterior interosseous nerves can also be performed under just local anesthesia. In the operating room, this technique allows surgeons to confirm immediate return of muscle strength (when muscle atrophy is not present) after the release, confirming adequate relief of nerve compression.

Currently, more and more hand surgeons recognize that the wide-awake surgical approach can be used in virtually all surgeries that do not need observation of tissue blood supplies in the hand . Among others, applications include wrist arthroscopy, digital joint ligament or volar plate surgery, internal fixation of carpal and metacarpal fractures, and repair of the ulnocarpal soft tissues.

Extension-flexion test and early active motion of the tendon

After primary flexor tendon repair, the digit is passively, or actively (during wide-awake surgery), extended to ensure no gapping at the repair site; then, the digit is passively or actively flexed to ensure that the tendon smoothly glides and reaches near full digital flexion without impinging the pulleys. This “ extension-flexion test ,” performed on the operating table before skin closure, is now proposed as an important measure to ensure that a repair is satisfactory and that the patient can safely proceed to early active motion postoperatively. If the test fails, the surgeon should revise the repair by strengthening tendon approximation or venting a pulley.

Limited or partial range early active motion has become a popular means of postoperative tendon rehabilitation. In the first 3 or 4 weeks after flexor tendon repair, active digital flexion starting from full extension covers only the initial one-third to two-thirds flexion range. Extreme flexion is avoided. After 3 to 4 weeks, the active digital motion is gradually increased to full flexion. In each exercise session, full range of passive motion of the repaired digit is initiated multiple times, reducing joint stiffness on subsequent active motion.

When paired with a strong surgical repair, the extension-flexion test of the repaired tendon verifies the surgical repair before early active tendon motion, making exercises safer and reducing risk of rupture.