Wide awake hand surgery

The majority of the surgery that I do perform, when required, is "wide-awake, under local anaesthesia". Occasionally I will have to put a patient to sleep, or put their arm to sleep with a block, but increasingly I like to use local anaesthetic techniques without the need for a painful tourniquet which is like a tight blood pressure cuff throughout your operation. We can remove that now because we add adrenalin to the local anaesthetic. This gives me a relatively bloodless field that I can perform the surgery. It is particularly useful when I need bio-feedback during the operation, and this may be for example if I am doing a joint replacement on one of your finger joints. During the operation I will ask you to move the fingers with the trial implant in place. If the range of movement is good and the implant feels stable you can see the range of movement yourself if you want, and then that will be the implant we will put in. If, however, it is quite stiff without a good range of movement I may want to resect a little bit more bone and then ask you to move it again, and we will only put the definitive implant in when we are happy on table that that is the right implant for you. If, once we have taken some bone away and we have put the implant in, if it feels a little unstable then we can perhaps put in a slightly bigger implant just to get the balancing just right. Wide-awake surgery under local anaesthetic with patient bio-feedback is really good and important when we are doing tendon-type work, whether this be a tendon transfer moving tendons across the back of the hand, or repairing flexor tendons on table I can ask you to make a fist. I want to make sure the tendons are working well and there is no catching. If you are asleep we just simply would not get that bio-feedback to see whether the tendon is running freely or not. Once you have had your procedure you will then be taken back to the ward from where you came. If it is under local anaesthetic well then you will be on your way pretty soon out of the hospital, probably within half an hour or so, once you have all your appointments in place and your post-operative medication. If you have had a general anaesthetic the ward staff may want to keep you for a little bit longer, and generally speaking once you are up on your feet, walking around, comfortable, you have had something to eat and drink, you have perhaps been to the bathroom, then you will be fit for discharge. Then there will be a variety of follow ups. One of them may be with a nurse in a couple of days to reduce a dressing, but generally speaking you should keep your wounds clean and covered for the first 10 days or so. You may be seen by one of my Hand Therapists for splinting or for cast removal and re-splinting, or you may be seen by myself several weeks later for a tele-medicine consultation, or a face-to-face clinic consultation.

Advantages of “wide awake” hand surgery help both the patient and the hand surgeon.

Surgery has been performed under local anaesthetic for many years, but recently the indications in hand surgery have exploded.  Now many of the patients that undergo surgery by consultant hand surgeon Mike Hayton for are suitable for this method.

Mike perfected this technique from Don Lalonde a hand surgeon from Canada.Mike first saw the method demonstrated by Don when they were both the invited guest speakers at the American Association for Hand Surgery in 2011.

Since then they have become good friends and are both often joint faculty at the leading North American conferences.

The benefits are pretty obvious to his patients with no immediate post operative pain, no post operative grogginess or nausea and an earlier discharge from the hospital that may occur with a general anaesthetic.

But there are also significant advantages for the surgeon and Mike puts this down to the fact that wide awake surgery is more dynamic and he can interact in real time with his patient and the tissue on which he is operating.

A few examples

Finger joint replacement

The implants can be inserted and tested for range of movement immediately on the table with the patient wide awake, if too stifthen more bone can be resected until the movement is perfect.

Tendon repair and transfer

Tendons that are repaired or transferred are assessed for correct tensioning and gliding immediately at the time of repair with the patient being asked to actively move their own hand. Any problems can be identified, rectified and re checked.

Release of catching structures

Operations to remove catching tissues such as bone, tendons or ligaments can be performed with enhanced results, as the feedback is immediate and in real time.  

For example, if after removing some offending bone the catching continues, Mike can take away a little more until the structures run free and the problem solved.

Such “active” fine-tuning would not be possible with a patient under general anaesthetic without the dynamic feedback from the wide-awake patient.

It’s a bit like a wide awake “surgical test drive”

Mike sometimes looks on the advantages of wide-awake surgery a bit like a new car “test drive”. He gets to see the results of his surgery immediately and can micro adjust at the time.

Whilst the majority of patients are suitable for “wide awake” hand surgery  some are not suitable and this would be discussed pre operatively in the out patient clinic.