Optimizing Nerve Surgery with WALANT Techniques

Introduction: Tendon transfer surgery plays a crucial role in the functional reconstruction of patients with peripheral nerve injuries. However, traditional procedures performed under general anesthesia hinder the assessment of tendon function during surgery. Recent advancements in wide-awake tendon transfer surgery have addressed this challenge by allowing intraoperative testing, resulting in improved outcomes before the patient leaves the operating table. This presentation shares our experiences with wide-awake tendon transfer for functional reconstruction, focusing on cases involving the radial nerve, median nerve, and common peroneal nerve. 

Method: Our anesthetic approach, known as Wide Awake Local Anesthesia No Tourniquet (WALANT), utilizes the solution combines 0.25% lidocaine buffered with sodium bicarbonate and up to 200mL of 1:400,000 epinephrine. By utilizing WALANT, we can obtain immediate feedback during surgery by assessing active finger, thumb, and wrist extension. This real-time evaluation allows us to make necessary adjustments to ensure accurate tendon functionality before wound closure. 

Results: Based on our experience, wide-awake tendon transfer surgery has emerged as a safe and reliable method for functional reconstruction following peripheral nerve injuries. For example, in cases of high radial nerve palsy through the implementation of the Brand transfer technique. This involves transferring the flexor carpi radialis to the extensor digitorum communis, the palmaris longus to the extensor pollicis longus, and the pronator teres to the extensor carpi radialis brevis. Patients demonstrate immediate utilization of their flexor muscles for extension movements intraoperatively, significantly reducing the need for extensive postoperative brain retraining. 

Conclusion: Wide-awake tendon transfer surgery represents an effective approach for functional reconstruction in peripheral nerve injuries. The adoption of wide-awake tendon transfer surgery should be considered as a valuable option for upper limb surgeons, enabling enhanced functional recovery and patient satisfaction.