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Replantation and Revascularization Under Wide Awake Anesthesia
Chung-Chen Hsu, MD1; Wang Jason, MD2; Cheng-Hung Lin, MD1; Nai-Jen Chang, MD1, Hung-Chang Chen, MD1; Yu-Te Lin, MD1; Chih-Hung Lin, MD1
1Chang Gung Memorial Hospital, Chang Gung University, Taoyaun, Taiwan; 2University of Manchester, United Kingdom

Introduction: The use of local anesthesia with adrenaline for hand surgery is a new trend that is gaining popularity among hand surgeons worldwide. As with most new trends, appreciating the limits of its use can sometimes be difficult in circumstances where vascularity is already impaired. Like revascularization or replantation, the use of Wide-Awake hand surgery might be considered an absolute contraindication. However, we present a series of 12 cases that illustrate the use of the Wide-Awake technique for digital revascularization and replantation without detriment to the traumatized digit.

Materials and Methods: From 2013 to 2015, 12 patients (13 digits) received microsurgery under wide awake anesthesia. 5 digit revascularizations and 8 digit replantations were performed using 1% lidocaine and 1:100000 epinephrine digital blockade. The mean age of patients was 44.5 years (range 21-65). The ratio of clean cut to crush injuries was 5:8. Five of the twelve cases were smokers (42%) and three patients had significant co-morbidities (25%). The zone of injury was at the level of the distal phalanx in five cases (42%), the middle phalanx level in one case (8%) and proximal phalanx level in six cases (50%). Vein grafts from volar forearm were harvested in 5 digits. The average surgical time was 3.3 hours (range 1.3 to 5.6).The injection amount was 16.4 ml (range 6 to 55ml). A short-term (10-20 minutes) temporary tourniquet was used in three replantations only to aid in the identification and dissection of recipient structures. The adrenaline on replanting digits reduced local tissue blood perfusion but good spurting from the healthy artery stump was still checked. Therefore, safe anastomosis could be performed with reestablishment of flow.

Results: All the replantated or revascularized parts survived. Two revascularized and one replanted digits presented superficial necrosis. The wounds were healed by secondary intension and one local flap.

Discussion: The use of Wide-Awake anesthesia for hand microsurgery simplifies the organization of requirements for any particular operation thereby saving on resources and cost. But ultimately it requires the patient to be accommodating and surgeon to be completely familiar with the technique and confident with microsurgical anastomosis. We advocate this procedure in selected cases when urgent reestablishment of blood flow is required but resources are limited.

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