Transient tourniquets and electrocauterization in surgeries for metacarpal fractures under local anesthesia with epinephrine

Introduction

Surgeries of the finger and hand usually require a tourniquet to obtain a bloodless surgical field, which facilitates visualization of delicate structures such as nerves, vessels, and tendons (1–3). Sedation, Bier block, brachial plexus block, and general anesthesia are often used to improve patient tolerance of the discomfort caused by tourniquet compression (4). However, these methods render patients unable to cooperatively move the reconstructed hand and finger structures during surgery. Epinephrine, when injected into the fingers, nose, ears, and toes, was thought to cause infarction in body parts with end arteries, but this was found not to be valid. Although some cases of acral necrosis have been reported (5), local anesthesia using lidocaine with epinephrine has become increasingly popular in routine hand surgery (6, 7). In fact, the extremely acidic procaine has been found to induce tissue necrosis, and phentolamine can reverse the vasoconstrictive effect of epinephrine (8). Even a high concentration of epinephrine (1:1,000) injected into fingers voluntarily or accidentally has never caused finger necrosis (9). Local anesthesia using lidocaine and epinephrine can be used in the majority of hand surgeries with no tourniquet control and is termed wide-awake local anesthesia with no tourniquet (WALANT) (10–13). However, there is a necessary interval of approximately 25 min from the epinephrine injection to the achievement of adequate hemostasis for surgery (14), which leads to low efficiency in some developing countries where hand trauma frequently occurs. A recent report showed that tourniquets for short, wide-awake procedures are feasible and well-accepted (15). We hypothesized that for relatively long surgeries, such as metacarpal fractures, with electrocauterization and a transient tourniquet, local anesthesia with epinephrine could achieve the same wide-awake effect while saving time.

Material and methods

We performed open reduction and internal fixation (ORIF) for metacarpal fractures in 50 consecutive cases from 2020 in our unit, six of which were excluded due to the use of general anesthesia (Table 1). Our hospital ethics committee approved this study (2020KY234). According to hospital policy, the patients were hospitalized 1 day before surgery or on the day of surgery and were discharged 1 day after surgery. Generally, ORIF is performed as soon as the special preparations (mostly hardware sterilization) are completed.

Table 1. Patients’ data.

1 = first metacarpus, 2 = second metacarpus, 3 = third metacarpus, 4 = fourth metacarpus, 5 = fifth metacarpus. B, base, S, shafts, N, neck.

After hospitalization, each patient had a detailed conversation with a senior surgeon regarding the anesthesia and surgery, as follows. Local anesthesia involves the injection of lidocaine and epinephrine into the operative site; it is safe and does not require controlling the patient's pre-existing conditions, such as hypertension or dysfunctions of the heart, kidney, lung, or brain. The patient may eat and drink as usual. Only an initial poking pain (like a mosquito sting) occurs, and the injected anesthetic drugs have little systemic effect on the patient. The intraoperative transient tourniquet, applied to save time, is uncomfortable but causes no harm to the patient, and we can release it at any time if the patient is unable to tolerate it. The entire procedure is performed while the patient is wide awake, without any sedation, which allows both the surgeons and the patient to observe the surgical effect at any step. The patient can be discharged after surgery. This conversation was repeated when the patient entered the operating room and included our subjective experience with tourniquet compression and release.

The tourniquet was applied to the upper third of the affected upper limb. After sterilization and draping, the operative site was injected with a solution of 1% lidocaine with 1:100,000 epinephrine and bicarbonate (1 mL of 8.4% bicarbonate added to 10 mL of 1% lidocaine with 1:100,000 epinephrine to reduce acidity). We strictly followed Lalonde's recommendations for performing this anesthesia (12). The electrocautery device was then set to desiccate mode (coagulation) at a power of 20 watts or less; we preferred coagulation for tissue dissection due to its hemostatic effect. The tourniquet was inflated, and the surgery began. Only the epidermis was incised with a scalpel; deeper tissue was dissected using electrocauterization. We pushed aside and cut the connective tissue using the thin, narrow, blunt blade of the electrocautery device. After gently wiping away some edema with gauze, we coagulated visible vessels and were able to discern and protect vital structures, such as nerves, in the bloodless surgical field. The metacarpal fracture was exposed, reduced, and temporarily fixed with Kirschner wires (K-wires). Typically, for a single metacarpal fracture, the operative time up to this step was approximately 25 min. We then released the tourniquet and took X-rays to monitor the reduction (Figure 1). If the patient indicated that the discomfort was acceptable, we continued using the tourniquet for the subsequent surgical steps. All the patients felt discomfort due to tourniquet compression, but the majority could tolerate it until the completion of the reduction and temporary fixation. For the few patients who could not tolerate it, we released the tourniquet and continued operating in a somewhat bloody surgical field. Generally, 2 min after tourniquet release, the patient felt comfortable and motor function was recovered, allowing the patient to move their fingers cooperatively so that the reconstructive effect could be observed. By this time, more than 25 min had usually elapsed since the injection, and the hemostatic effect of epinephrine had become established, lasting until the end of the remaining procedures (e.g., fixation of the metacarpal fracture with plates and screws, repair and reconstruction of concomitant injured structures, and skin closure). In all cases, fractures were aligned and fixed to satisfy hand movement requirements. We recorded the time at various points during the surgical procedure for evaluation.

Prior to our clinical investigation, we conducted an experiment to elucidate specific experiences with tourniquet compression and release, involving two of the authors and four of their close friends. All participants were informed of the experimental aim and understood that no permanent harm would occur. The elapsed time and sensations at various stages were recorded (Table 2).

Table 2. Normal volunteers’ experience with a tourniquet around an arm.

Descriptive statistics were used to analyze the results.

Results

The tourniquet was released earlier than 25 min after the injection in two cases. The time required to set up the electrocautery device was approximately 2 min. All the patients felt discomfort due to tourniquet compression, which began after approximately 16 min and was relieved after approximately 29 min (Table 1). Sensation and movement were recovered within several minutes (we did not record the exact time). Following the surgeon's instructions, all the patients were able to move their fingers and hands so that we could evaluate the reconstructive effect. All the patients remained wide awake throughout the entire surgery and expressed no complaint about tourniquet use when asked after the surgery. All the surgeries were performed successfully, without the need to convert to another type of anesthesia, and no excessive bleeding that impeded dissection was noted in the surgical field. Moreover, there was no obvious waiting period for the hemostatic effect of epinephrine; in other words, we saved time with this modified local anesthesia technique. Postoperative daily inspection and wound care showed normal findings, with no extra edema or oozing secretion. Sutures were removed routinely on time.

Discussion

As Lalonde and others have experimentally demonstrated and illustrated, the prejudice regarding infarction in body parts with end arteries arising from epinephrine-induced vasoconstriction has been gradually corrected. That complication was actually a type of tissue necrosis caused by expired, extremely acidic procaine. Epinephrine has been revived, and its hemostatic effect can eliminate the need for a tourniquet in finger and hand surgery. Without a tourniquet, there is no need for sedation, Bier block, brachial plexus block, or general anesthesia, which allows the patient to remain wide awake and to actively move the repaired or reconstructed structures during surgery (6–10, 12, 13). Surgeons can evaluate the surgical result for further treatment (10, 12, 13), and patients' observation of the return of normal movement can enhance their confidence in postoperative rehabilitation. Moreover, local anesthesia is much more economical, rapid, and efficient than other techniques; it requires no anesthesiologist and does not require correction of vital organ dysfunction (13, 15–18). Today, WALANT is widely used in upper limb surgery, including procedures on the fingers, hand, forearm, and elbow (19–21). However, it takes time for epinephrine to constrict the vessels sufficiently to create a relatively bloodless field for visual dissection. Bashir et al. found that an interval of 25 min provides a vastly superior operative field (14). In some developing countries, many employees without professional skills or knowledge of system safety protection work overtime frequently, resulting in a high incidence of hand injuries. In addition to other hand diseases, hand surgeons in these areas are very busy, with a single surgical team often handling 15–20 cases per operative day. Waiting 25 min per patient for the hemostatic effect is clearly impractical. For minor hand surgeries of short duration, we often use a tourniquet to achieve a bloodless surgical view (22, 23). We hypothesized that in complex hand surgery, with the help of electrocauterization, we could complete a precise dissection within the patient's tolerance of the tourniquet. Then, the remaining surgical procedures could be conducted in an area with relatively less bleeding due to epinephrine-induced vasoconstriction. Thus, in major hand surgery, surgeons can enjoy the benefits of having a patient in a wide-awake state and time saving while using local anesthesia with electrocauterization and a transient tourniquet.

The reduction of metacarpal fractures must be very precise. The most important intraoperative check is for unacceptable rotational deformity, which often affects adjacent fingers and causes significant cosmetic or functional problems. When flexed, two fingers may overlap like scissors, and surgical osteotomy can yield an ideal result (24, 25). Subjective flexion and extension of the fingers by the patient to evaluate the repaired or reconstructed effect is therefore preferred. Brachial plexus block and general anesthesia with sedation are not suitable for this purpose. Thus, WALANT is playing an increasingly important role, replacing the previously used Bier block and leading to the recovery of sensation and movement.

In a small volunteer experiment (including two of the authors, Table 2) with an arm tourniquet inflated to 250 mmHg, we subjectively recorded our sensation during the procedure. Sensation and movement in the area distal to the tourniquet gradually disappeared from the proximal to the distal part. Slight movement could still be present for a few seconds after sensation completely disappeared. When fully anesthetized, a residual deep body sensation remained—a kind of dull numbness when touched. This unusual feeling may sometimes reduce the patient's tolerance of the tourniquet, which may explain why two of our patients requested tourniquet release before 25 min. There was no pain intolerance upon tourniquet release. A few seconds after release, a dramatic spasm sensation occurred throughout the area distal to the tourniquet, which gradually disappeared as sensation and movement returned. We documented our experience to use in preoperative conversations with patients.

In our consecutive case series, we performed local anesthesia with electrocauterization and a transient tourniquet. We believe that two thorough preoperative conversations with the patient can reduce anxiety, especially by reassuring the patient that transient tourniquet compression, although uncomfortable, causes no permanent harm. Our clinical data indicate that all the patients recovered motion shortly after tourniquet deflation and experienced no postoperative discomfort.

Electrocauterization is widely used in two common modes—cut and coagulation—to speed up surgery (26). With precise adjustment of power and the extent of tissue reaction, it can be used for dissection in flap surgery (27). We found that 20 watts in desiccate mode (coagulation) was suitable for the edematous tissue infiltrated with local anesthesia. Using a tweezer as a combined retractor and grasper, the high-frequency electrocautery device could incise, separate, and coagulate efficiently. We had to take time to ligate visible vessels when using a tourniquet without electrocauterization; otherwise, bleeding often blurred the view and prevented precise dissection. Intraoperative gauze wiping may absorb some of the anesthetic solution, but this did not affect the hemostatic effect of epinephrine. We found no obvious bleeding in the surgical field with the combined use of epinephrine-induced vasoconstriction and electrocauterization (Figure 2).

Several studies have demonstrated a safe range. In our cases, the tourniquet was instantly inflated to 250 mmHg, and we did not adjust the pressure according to individual factors such as sex, age, body weight, or blood pressure. Although tourniquet compression at 250 mmHg for less than 30 min causes no tissue harm, we believe that lower pressure results in less discomfort, as illustrated by Lim et al. (28).

The hemostatic effect of epinephrine-induced vasoconstriction is essential for wide-awake hand surgery, even when the major dissection is completed under tourniquet control. Less time under tourniquet compression means greater comfort and less potential harm to the tissue. Moreover, for most metacarpal fractures, a single reduction achieving visual alignment may not be sufficient to ensure normal finger movement, as small degrees of angulation or rotation of the fragments can cause dysfunction. Epinephrine-induced vasoconstriction can reduce the amount and speed of bleeding, providing a clear field for further adjustment of reduction and fixation, and for closure of the dissected tissue.

In this study, we used descriptive statistics because some of the data were relatively subjective.

Despite the discomfort caused by transient tourniquet compression, which causes no permanent harm, local anesthesia with electrocauterization and epinephrine can save time while keeping the patient wide awake. This technique may be an option for hand surgeons who favor it.

Our study has several limitations. We only presented our clinical experience and outcomes and we did not include a control group. Some of our descriptions are subjective and may not be entirely accurate. Subjective data can introduce bias depending on the sample. To perform a scientific analysis that follows strict research regulations, we would need a longer study period and a much larger sample size. We have presented our experience of the efficiency and effective outcomes of WALANT to provide some recommendations for hand surgeons, which they could potentially implement immediately.

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Footnotes

Edited by: Hong Liu, UC Davis Health, United States

Reviewed by: Markus Köstenberger, Klagenfurt Clinic, Austria

Bruno Ribeiro, Universidade Estadual de Ponta Grossa, Brazil