Wide Awake Dupuytren’s Fasciectomy: A Pathoanatomical Approach

Abstract

Wide awake hand surgery is performed under local anaesthesia with low-dose adrenaline without (the risks of) general anaesthesia, regional anaesthesia, sedation or tourniquets, is applicable to the majority of hand surgery procedures and is especially suited to soft tissue conditions including Dupuytren’s contracture (Bismil et al., World wide awake hand surgery consensus statement. http://www.worldwideawake.net/3.html). Wide awake hand surgery is gaining increasing popularity worldwide because of the opportunities it provides to optimise surgery and rehabilitation [Lalonde, J Hand Ther 26(2):175–178, 2013], streamline the patient pathway [Bismil et al., JRSM Short Rep 3(4):23, 2012], and give patient-centred care with excellent outcomes and patient satisfaction [Bismil et al., JRSM Short Rep 3(4):23, 2012; Teo et al., J Hand Surg Eur Vol 38(9):992–999, 2013].

The continued evolution of wide awake hand surgery relies on worldwide collaboration among surgeons, therapists and not least hand surgery patients who recognise the potential advantages of the techniques. Wide awake Dupuytren’s fasciectomy is the product of such worldwide collaboration, with patients at the centre. The origins of wide awake fasciectomy for Dupuytren’s contracture can be traced to the early 1980s when TH Robbins, an Australian plastic surgeon, published, in the Annals of the Royal College of Surgeons of England, a paper on Dupuytren’s Z-plasty under local anaesthesia [Robbins, Ann R Coll Surg Engl 63(5):357–358, 1981]. Subsequently, centres in Canada [Denkler, Plast Reconstr Surg 115(3):802–810, 2005], the United States [Nelson et al., Hand (N Y) 5(2):117–124, 2010] and the United Kingdom [Bismil et al., JRSM Short Rep 3(7):48, 2012] have published their results.

Copyright

The authors and the Worldwide Awake Hand Surgery group grant copyright to all materials herein to Springer, without restriction, with the proviso that the authors have relied upon the 13 referenced articles and works, the 2 anaesthetic review articles for the appendix; and the original authors and copyright owners are thus respected.

Declarations

MSK Bismil and QMK Bismil are founder members of the Worldwide Awake Hand Surgery group and the founders of one-stop wide awake hand surgery.

The Worldwide Awake Hand Surgery Group  

The Worldwide Awake Hand Surgery group was founded by TH Robbins, MSK Bismil and QMK Bismil circa 2012 and is delighted to assist hand surgeons in their transition to wide awake hand surgery.

www.worldwideawake.net

Appendix on Wide Awake Anaesthesia : Key Points to Wide Awake Fasciectomy

Local Anaesthetics

• Local anaesthetics disrupt the inflow of sodium through channels in the membranes of neurones.

• They work better in smaller and rapidly firing nerves.

• This is why in wide awake hand surgery the pain fibres are invariably blocked whilst motor (movement) fibres are usually unaffected. Thus, our patients can benefit from pain-free surgery whilst feeling touch and being able to move the fingers and hand.

• This also means the wide awake hand surgeon can re-assess the hand during the procedure, with active movement.

Dosage Information as a Guide Only

Please see our principal source, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3403589.

• The maximum dose of lignocaine without adrenaline is 3 mg/kg.

• The maximum dose of lignocaine with adrenaline is 7 mg/kg.

• Thus, in a 70-kg patient, do not use more than

  • 20 ml of 1 % plain lignocaine or

  • 10 ml of 2 % plain lignocaine or

  • 48 ml of 1 % lignocaine with adrenaline or

  • 24 ml of 2 % lignocaine with adrenaline

Patients Not Suitable for Wide Awake Surgery

The only absolute contraindication is local anaesthetic allergy, which is rare. If there is any doubt that a patient may have a local anaesthetic allergy, he should be referred to an allergy specialist for evaluation and surgery should not be performed.

Rather than having a true allergy, patients are more likely to faint or to react to adrenaline (either their own adrenaline or that administered—adrenaline is a beta-1 adrenergic agonist). In our experience with wide awake hand surgery over 15 years, we have not encountered a patient who was confirmed to have a local anaesthetic allergy.

The least allergenic local anaesthesia would be an alternate amide such as prilocaine; use it without adrenaline and use a single-use vial (with no preservative).

If there are any doubts, postpone the surgery and refer to an allergy specialist.

Vasopressors

Vasopressors, such as low-dose adrenaline, for instance, at 1:200,000, are commonly used in wide awake hand surgery to provide constriction of blood vessels and hence minimise bleeding by activating alpha-1 adrenergic receptors. In addition to minimising bleeding in the operative field, low-dose adrenaline delays anaesthetic absorption, enabling pain-free surgery for more complex procedures. Delayed absorption of local anaesthetics reduces the risk for systemic toxicity and prolongs the duration of anaesthesia.

Low-Dose Adrenaline Contraindications Within Our Practice

Absolute

• Tricyclic and monoamine oxidase inhibitor antidepressants

• Digoxin

• Thyroid hormone

• Sympathomimetics used for weight control or attention deficit disorders

• Stimulant drug abuse (e.g., cocaine)

• Documented prior clinical problems with finger circulation or vascular supply to hand/upper limb

• Allergy (see above)

• Patient’s expression at informed consent he or she wishes to avoid use of low-dose adrenaline in his or her case for whatever reason

Relative

• Cardiovascular disease

• Hypertension

• Vascular disease

• History of hand/upper limb circulatory problems (e.g., Raynaud’s syndrome, vibration-induced white finger

• Beta blockers

Best Advice with Regards to Low-Dose Adrenaline Injection from Our Practice

• If you have any doubt, use plain local anaesthesia. Via anatomical dissection and intermittent firm point pressure with a rolled swab, any bleeding can be controlled without vasopressor use.

• The peak vasoconstrictor action/absorption of adrenaline is around 5 minutes after the injection and tails off each minute after this; hence, manage the risk of injury to the neurovascular structures or tendon mechanism accordingly. This is why we advocate straight incisions (see the section entitled ‘Discussion’) with Z-plasty as required (at the end of the procedure, deferred to a second stop or not done at all).