Is Full-Awake Local Anesthesia No-Tourniquet Hand Surgery

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07/17/2020

Is Full-Awake Local Anesthesia No-Tourniquet Hand Surgery

More Suitable for Major Flexor Tendon Trauma?

Dear Editor,

W

e read with great interest the recent orig- inal article by Prasetyono and Tunjung,¹

“Long-term Follow-up of Full-Awake Hand Surgery in Major Flexor Tendon Injury of the Hand and Forearm,”published in Annals of Plastic Surgery. The authors performed a retro- spective study including 9 male patients who underwent full-awake local anesthesia no- tourniquet hand surgery due to major flexor tendon ruptures. All explorations and repairs were performed with full-awake local anesthesia no-tourniquet hand surgery, with 2 cases turned to general anesthesia because intraoperative visual analog scale score was more than 4, which is a pain evaluation method. Results of long-term (>3 years) follow-up indicated that all patients showed normal Medsger scale, with 7 cases that had excellent total active range of motion, and 8 cases, excellent opposition. Me- dian Disabilities of Arm, Shoulder, and Hand score was 15 (9–28.5).¹

It was the first study to report long-term follow-up results of full-awake local anesthesia no-tourniquet hand surgery in treating major flexor tendon ruptures. We think it could ex- tend the application of full-awake local anesthesia no-tourniquet hand surgery, if this technique is used properly. We are really inter- ested in this application, and we have some questions about this study. As far as we know, major flexor tendon ruptures in the hand are usually explored and repaired under brachial plexus block anesthesia or general anesthesia, because the ends of the tendon would rebound and it becomes harder to explore them.²^–⁴In this study, 2 cases were changed to general anesthesia, because their visual analog scale scores were more than 4. Because the lidocaine dosage used in these 2 patients was under safe scope, we wonder if a higher dose of lidocaine could relieve their pain and make the surgery success- fully completed with full-awake local anesthesia no-tourniquet hand surgery.

In this study, patients were instructed to perform exercise immediately after surgery when they were in the operation room, and their hands were not fixed. Commonly, gypsum splint will be used to externally fix the arm and hand after ruptured major flexor tendons are repaired for 3 to 4 weeks.^5,6 Therefore,

postoperative tendon ultrasound examination will describe the recovery conditions more clearly. The intraoperative pain of full-awake local anesthesia no-tourniquet hand surgery was compared with dental procedure in all 9 cases.

We wonder if all these 9 patients had a dental procedure before the hand surgery. The 2 patients converted to general anesthesia were obviously nervous during this surgery, and this can affect the full-awake local anesthesia no- tourniquet hand surgery. For this problem, a recent study indicated that readily available virtual reality hardware and software can provide a virtual reality experience that reduces patient anxiety both during the injection of local anesthesia and during the surgical procedure.⁷ Finally, open major flexor tendon ruptures are usually treated with emergency surgery.⁸ Commonly, it takes nearly 20 minutes to begin the surgery after injecting local anesthesia during full-awake local anesthesia no-tourniquet hand surgery. Under this condition, it is not ideal for active bleeding wound. Xing and Mao⁸recommended temporary tourniquet use after epinephrine injection to expedite wide- awake emergency hand surgeries. We think the temporary tourniquet use can be combined with full-awake local anesthesia no-tourniquet hand surgery to reach better outcomes. In this study, cost savings accounted for approximately 70% to 80% when compared with traditional hand surgery, like carpal tunnel syndrome. Ac- tually, carpal tunnel syndrome now can be treated with 1- to 2-cm incision surgery under local anesthesia, and the time of using tourniquet will not exceed 15 minutes, which is a bearable time for most patients.^9,10Therefore, the cost will not be much more than a full-awake local anesthesia no-tourniquet hand surgery.

We hope that the authors can take our sug- gestions into consideration and make more de- tailed explanations or conduct further research, to produce more meaningful guidance to the clinical work.

Qi Zeng, MD Department of Plastic Surgery Jiangxi Provincial People's Hospital Jiangxi, China zengqi105@163.com Dan Zou, MD Department of Dermatology Dongguan City Fifth People's Hospital Guangdong, China Yun-Gang Hu, MD Department of Plastic Surgery Jiangxi Provincial People's Hospital Jiangxi, China Bao-Fu Yu, MD Department of Hand Surgery Huashan Hospital, Fudan University Shanghai, China

REFERENCES

1. Prasetyono TOH, Tunjung N. Long-term follow-up of full-awake hand surgery in major flexor tendon injury of the hand and forearm.Ann Plast Surg.

2019;83:163–168.

2. Tang JB. Local anesthesia without tourniquet in hand and forearm surgery: my story of using and promoting it.Hand Clin. 2019;35:xv–xx.

3. Pires Neto PJ, Ribak S, Sardenberg T. Wide awake hand surgery under local anesthesia no tourniquet in South America.Hand Clin. 2019;35:51–58.

4. Rhee PC. The current and possible future role of wide-awake local anesthesia no tourniquet hand surgery in military health care delivery.Hand Clin.

2019;35:13–19.

5. Ruxasagulwong S, Kraisarin J, Sananpanich K.

Wide awake technique versus local anesthesia with tourniquet application for minor orthopedic hand surgery: a prospective clinical trial.J Med Assoc Thai. 2015;98:106–110.

6. Dushoff IM. Hand surgery under wrist block and local infiltration anesthesia, using an upper arm tourniquet.Plast Reconstr Surg. 1973;51:

685–686.

7. Hoxhallari E, Behr IJ, Bradshaw JS, et al. Virtual reality improves the patient experience during wide- awake local anesthesia no tourniquet hand surgery:

a single-blind, randomized, prospective study.Plast Reconstr Surg. 2019;144:408–414.

8. Xing SG, Mao T. Temporary tourniquet use after epinephrine injection to expedite wide awake emergency hand surgeries.J Hand Surg Eur Vol. 2018;

43:888–889.

9. Martínez-Catasús A, Lobo-Escolar L, García-Bonet J, et al. Comparison between single portal endoscopic and 1-cm open carpal tunnel release.Hand Surg Rehabil. 2019;38:202–206.

10. Tang X, Gong F, Yu B. Letter to editor regarding

“Comparison between single portal endoscopic and 1-cm open carpal tunnel release”: could the 1-cm open carpal tunnel release surgery miss space- occupying lesions. Hand Surg Rehabil. 2019;

38:276–277.

FAHS (Full-Awake Hand Surgery) for Major Flexor

Tendon Injury

To the Editor:

I

t is a great pleasure for me to be invited to write a response to our recent publication on the matter of suitability of FAHS (full-awake hand surgery) for major flexor tendon injury.¹ FAHS has been widely practiced across the globe, mostly influenced by the educational campaigns and publications of the guru, Don Lalonde.^2,3In terms of the application of FAHS for major flexor tendon surgery, extensive dis- section in flexor region has also been demon- strated in a recent scientific sharing.⁴ Thus,

Conflicts of interest and sources of funding: none declared.

ISSN: 0148-7043/20/8502–0202 DOI: 10.1097/SAP.0000000000002151

Conflicts of interest and sources of funding: none declared.

ISSN: 0148-7043/20/8502–0202 DOI: 10.1097/SAP.0000000000002152

L ETTERS AND C OMMENTARY

202 www.annalsplasticsurgery.com Annals of Plastic Surgery • Volume 85, Number 2, August 2020

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the adoption of FAHS for major flexor tendon surgery becomes more convincing.

It was not mentioned in our study, unfortu- nately, that all cases were treated as urgent or de- layed procedure. Actually, all the 9 cases were not managed as emergency surgery, merely by the unavailability of public insurance status that needed to be settled up for several days. Only the open wound got stitched at the emergency unit, and the patients were dispatched home.

Although I learned that injecting solution in the closed wound is much more effective than performing it in open wound to create effective tumescent effect, both conditions are not an important issue to debate.

Responding to the inquiry whether our subjects have ever experienced dental procedure, I admitted that it was not stated and clarified methodologically in details about what sort of dental procedures they have ever had. In fact, it was not easy for us to create a perfect defini- tion about this subjective feeling. Root canal and nerve treatment may be a real painful procedure, while a wisdom tooth extraction may come as a painless and very short procedure.

The level of visual analogue scale (VAS) in molar extraction could be scored 0, whereas the injection of local anesthesia and overall procedures might reach a VAS score of 3 to 9.⁵Besides, negative experience, social background, fright- ening portrayals, and so on, play a role in pain perception as well.⁶Thus, it is no wonder that comparing the FAHS with the dental procedure was not a strong methodology unless the subjects are homogenously selected.

Referring to VR (virtual reality),⁷although the study is considered valid and important, it may not be applicable. Subjects may feel still anxious about the idea of“being taken away” with the VR, even in a relatively short procedure. They would want to know about what sort of things are being performed on them. In the author's practice, interactive communication with the patient subjects by, for example, talking about general topics, songs, hobbies, singing along with the patient, and listening to music played from apps, and so on, would be providing more bonding doctor-patient relationship. On the other hand, seeing a movie or a reality show from a tablet³or TV screen is a common setup, because the patient still has the access to know what would be happening on him/her.

The author does not agree with the idea of using tourniquet as a hybrid technique. At least there are 4 reasons for that. First, taking a sim- ple and traditional principle to put our own feet in the patient's shoes into our concern, the application of tourniquet that goes on until the patient feels uncomfortable would not be a good idea because the patient might become nervous

and thus worsen the anxiety level. The pain level of hybrid technique is also significantly higher than the one with a procedure under FAHS.⁸A pressure as high as 250 mm Hg is

“no kidding”a high pressure, which may come with a range of individual acceptance. A well- designed clinical trial published in the year 2015 shows an average of 15 minutes' tourniquet time for subjects to have a VAS score of 4. Only if the subjects are given 50% inhaled oxygen 3 minutes before and all the way during tourniquet inflation, the tourniquet time could reach as long as 22 minutes.⁹We would not be lucky to get a patient start complaining the discomfort in 15 minutes and feel more nervous and irritated.

Second, the time delay of the epinephrine, which is not adequate yet by the time the tourniquet was released, would be a factor for the failure to reach the chemical hemostatic effect.

Third, concerning 5 to 10-minute tourniquet time before incision as indicated in a short report,¹⁰ it is not irksome for surgeons who are patient enough to wait for the optimal time delay while performing FAHS. In my practice, using one-per-mil tumescent solution, I need only 7 minutes to start the surgery.¹¹

Fourth, although tourniquet is a powerful tool to provide a bloodless operating field, we could not avoid bleeding as a rebound effect from the previous blood flow block. We do need scientific proof whether the vasoconstriction effect by epinephrine would be taking the rebound effect from the proximal blood vessels that are not taking the epinephrine effect. The sudden change of hy- drostatic pressure in the blood vessels is still a subject to study. Interestingly, the issue has been also a concern by the authors reporting the hybrid technique combining the tumescent and tourniquet technique.¹⁰After the neutralizing reperfusion effect, most probably the natural hemostasis works, helping the surgeon, and may not be relying on the epinephrine effect. Nevertheless, the issue is still a subject to further studies. Lalonde,¹² the father of WALANT (wide-awake local anesthesia, no tourniquet) technique, even pre- dicted that by 2050 the WALANT technique would become the criterion standard of practice for tendon surgery.

In regard to cost saving, it was wrong to perceive 70% savings; in fact, we managed to save approximately only 17% with the mentioned reasons.¹A study reported that surgery for a single trigger finger release under FAHS is more cost-effective than the surgery under MAC (mon- itored anesthesia care).¹³ Although we have never had a history of performing trigger finger release under MAC and always under local anesthesia, we are convinced that FAHS is gen- erally cost saving.^14,15

Theddeus Octavianus Hari Prasetyono, MD, PhD From the Division of Plastic Surgery Department of Surgery Cipto Mangunkusumo Hospital/Faculty of Medicine Universitas Indonesia Jakarta, Indonesia teddyohprasetyono@yahoo.com

T.O.H.P. contributed to this article by creating the letter to the Editor.

REFERENCES

1. Prasetyono TOH, Tunjung N. Long-Term Follow-up of Full-Awake Hand Surgery in Major Flexor Tendon Injury of the Hand and Forearm.Ann Plast Surg.

2019;83:163–168.

2. Lalonde DH. Conceptual origins, current practice, and views of wide awake hand surgery.J Hand Surg Eur Vol. 2017;42:886–895.

3. Tang JB. Local anesthesia without tourniquet in hand and forearm surgery: my story of using and promoting it.Hand Clin. 2019;35:xv–xx.

4. Woo SH, Yoo MJ, Ahn HC. Lessons Learned in the Authors' First Years of Wide-Awake Hand Sur- gery at the W Hospital in Korea. Hand Clin.

2019;35:59–66.

5. Jagtap B, Bhate K, Magoo S, et al. Painless injections-a possibility with low level laser therapy.

J Dent Anesth Pain Med. 2019;19:159–165.

6. Sweta VR, Abhinav RP, Ramesh A. Role of virtual reality in pain perception of patients following the administration of local anesthesia.Ann Maxillofac Surg. 2019;9:110–113.

7. Hoxhallari E, Behr IJ, Bradshaw JS, et al. Virtual Re- ality Improves the Patient Experience during Wide- Awake Local Anesthesia No Tourniquet Hand Surgery:

A Single-Blind, Randomized, Prospective Study.Plast Reconstr Surg. 2019;144:408–414.

8. Gunasagaran J, Sean ES, Shivdas S, et al. Perceived comfort during minor hand surgeries with wide awake local anesthesia no tourniquet (WALANT) versus local anesthesia (LA)/ tourniquet.J Orthop Surg.

2017;25:1–4.

9. White N, Dobbs TD, Murphy GR, et al. Oxygen reduces tourniquet-associated pain: a double-blind, randomized, controlled trial for application in hand surgery.Plast Reconstr Surg. 2015;135:721e–730e.

10. Xing SG, Mao T. Temporary tourniquet use after epinephrine injection to expedite wide awake emergency hand surgeries.J Hand Surg Eur Vol. 2018;43:888–889.

11. Prasetyono TO, Biben JA. One-per-mil tumescent technique for upper extremity surgeries: broadening the indication.J Hand Surg Am. 2014;39:3–12.e7.

12. Lalonde DH. Latest advances in wide awake hand surgery.Hand Clin. 2019;35:1–6.

13. Codding JL, Bhat SB, Ilyas AM. An economic analysis of MAC versus WALANT: a trigger finger release surgery case study.Hand (N Y). 2017;12:348–351.

14. Rhee PC, Fischer MM, Rhee LS, et al. Cost Savings and Patient Experiences of a Clinic-Based, Wide- Awake Hand Surgery Program at a Military Medical Center: A Critical Analysis of the First 100 Proce- dures.J Hand Surg Am. 2017;42:e139–e147.

15. Wheelock M, Petropolis C, Lalonde DH. The Cana- dian model for instituting wide-awake hand surgery in our hospitals.Hand Clin. 2019;35:21–27.

Annals of Plastic Surgery • Volume 85, Number 2, August 2020 Letters to the Editor