Proximal Interphalangeal Joint Arthroplasty Using the Wide-Awake Local Anesthesia No Tourniquet Technique

Abstract

Background:

Proximal interphalangeal joint (PIPJ) osteoarthritis is a common condition that results in pain, stiffness, and loss of function in the affected hand. Proximal interphalangeal joint arthroplasty is an effective treatment option when conservative methods have failed. The wide-awake local anesthesia no tourniquet (WALANT) technique to perform surgery carries advantages such as lack of tourniquet discomfort, reduces the staffing and costs associated with anesthesia and sedation, and allows faster recovery. We aimed to determine whether the WALANT technique was safe and effective in the context of PIPJ arthroplasty.

Methods:

Patients were enrolled retrospectively from January 2015 to October 2020 by examining operating theater records and surgeon logbooks. Electronic patient records were examined to obtain patient data. Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires and Visual Analog Scale (VAS) for pain were sent by post to patients—with a separate DASH and VAS for each digit operated on.

Results:

Twenty-nine PIPJ arthroplasties were carried out using WALANT technique by 3 different surgeons all using the dorsal approach. All cases were successfully carried out as day-case procedures. There was a significant correlation with increasing VAS and increasing DASH score. Proximal interphalangeal joint arthroplasty improved range of motion from 28.9 ± 5.5° to 79.4 ± 13.3° (P < .0001). Two cases developed complications related to surgery.

Conclusions:

Our study is the first to report the use of WALANT to perform PIPJ arthroplasty, and shows comparable results with traditional methods. Larger, multicenter prospective trials are required to determine the efficacy of this technique and to quantify its economical benefit.

Introduction

Proximal interphalangeal joint (PIPJ) osteoarthritis (OA) is a common condition which results in pain, stiffness, and loss of function in the affected hand. The prevalence of PIPJ OA in adults over the age of 50 years is approximately 18%.^1,2 Mild symptoms can be treated with conservative measures such as anti-inflammatory or analgesic medications and intra-articular steroid injections; however, severe symptoms or instability necessitate surgical measures. Options include arthrodesis and arthroplasty, with the latter having the benefit of preserving joint motion (albeit with a higher rate of complications^3,4). The use of arthroplasty has been reported to improve hand pain and grip strength; however, improvement in range of motion (ROM) was less pronounced.^5,6 The overall complication rate for silicone arthroplasty has been reported at 11% (soft tissue complications being most common) with a revision rate of 3.3% to 12.8%.^6,7 High rates of migration and loosening have also been reported. ⁵ Despite this, PIPJ arthroplasty remains a common procedure for PIPJ OA as it preserves joint motion, improves symptoms, and retains the possibility of arthrodesis at a later date if symptoms persist or complications arise.

Hand surgery is commonly carried out using an upper-arm tourniquet for hemostasis; however, this has associated morbidity: Tourniquet discomfort often requires sedation or anesthesia and therefore prolongs hospital stay. The use of sedation or anesthesia requires preoperative testing, increased staffing and costs, longer recovery, and also generates aerosol particles that can cause COVID-19 transmission. ⁸ Tourniquet burns can result from skin preparation solutions seeping between the tourniquet and the skin. The use of the wide-awake local anesthesia no tourniquet (WALANT) technique is gaining popularity due to its benefits: no tourniquet site pain, faster recovery, intraoperative testing of repairs, and reduced staffing and health care costs.^8-10 The addition of 1:200 000 adrenaline to the local anesthetic provides adequate hemostasis. The use of the WALANT technique has been reported for various hand and wrist procedures, both trauma and elective.^11-15 However, to the best of our knowledge, its use in PIPJ arthroplasty has not previously been reported.

In this study, we aimed to determine whether performing PIPJ arthroplasty using the WALANT technique is a safe and effective option.

Methods

Patients were enrolled retrospectively from January 2015 to October 2020 by examining operating theater records and surgeon logbooks. Patients were enrolled if they underwent silicone PIPJ arthroplasty on 1 or more digits using the WALANT technique. Electronic patient records were examined to obtain demographic data, operation notes, and clinic letters as well as the presence of any preoperative and postoperative symptoms or examination findings. Records were also examined to determine whether patients had suffered any postoperative complications. Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires and Visual Analog Scale (VAS) for pain were sent by post to patients—with a separate DASH and VAS for each digit operated on. For those who did not return DASH and VAS scores within 8 weeks, a single attempt was made at contacting them via telephone to complete scores. Data are presented and analyzed using Prism (GraphPad, San Diego).

Results

Eighteen individual patients (17 women and 1 man) were included in this study with a total number of 29 PIPJ arthroplasties carried out using WALANT technique by 3 different surgeons all using the dorsal approach. All cases were successfully carried out as day-case procedures. No patients required conversion to or supplementation with anesthesia or sedation, and all cases were carried out successfully using local anesthesia exclusively. Mean age was 65.4 years (range: 51-81). All patients had an American Society of Anesthesiologists (ASA) grade of 1 or 2. The most common digits operated on were the middle (17) and index (9) digits. Completed postoperative DASH scores were returned for 20 PIPJ arthroplasties (13 patients), with a mean of 26.5 ± 24.1 (range: 0.86-68.3). Visual Analog Scale scores were available for 22 arthroplasties, with a mean of 2.3 ± 2.7 (range: 0-8.3). Where DASH and VAS scores were available for the same digit, there was a significant correlation with increasing VAS and increasing DASH score (Figure 1; r² = 0.79, P < .0001 using Spearman rank test). For patients with preoperative and postoperative ROM values available (9 arthroplasties), PIPJ arthroplasty improved ROM from 28.9 ± 5.5° to 79.4 ± 13.3° (P < .0001 using 2-tailed paired t test; Figure 2). Two cases developed complications related to surgery: 1 patient developed swan-neck deformity of the middle finger and 1 patient developed persistent postoperative pain and is awaiting revision/fusion surgery.

Figure 1.

Linear regression analysis of DASH and VAS scores with 95% confidence limits. r² = 0.79, P < .0001 using Spearman rank test.

Note. DASH = Disabilities of the Arm, Shoulder, and Hand; VAS = Visual Analog Scale.

Figure 2.

Preoperative and postoperative range of motion analyzed using paired 2-tailed t test. P < .0001.

Discussion

All surgeries were carried out successfully, without the need for sedation/anesthesia or tourniquet, indicating that the WALANT technique is suitable for PIPJ arthroplasty. The mean postoperative VAS score reported in our patients (2.3) is similar to the mean score reported by Richards et al, ⁷ who used local anesthesia and a digital tourniquet. The improvement in ROM following PIPJ arthroplasty seen in our series is also similar to what has been previously reported.^16,17 The complication rate seen in our series (8.33%) is similar to previous reported case series^6,7,18; however, a more recent case series reported a much higher complication rate (37%) with no improvement in ROM. ¹⁹ A recent meta-analysis reported higher rates of complications; however, the involved studies were limited to pyrocarbon and ceramic prostheses only. ⁵ A case series of silicone PIPJ arthroplasty using a lateral approach described coronal plane instability complications; ¹⁶ a complication which was not detected in our series, potentially due to the different approach used.

Our study is limited in its small size and also its retrospective nature. Clinical information was collected retrospectively from patient records rather than prospectively at follow-up. Disabilities of the Arm, Shoulder, and Hand and VAS scores were not collected preoperatively and so we are unable to comment on the effect on pain and function levels following PIPJ arthroplasty using the WALANT technique. Our response rate for DASH and VAS scores was 72.2% and 83.3%, respectively. Although this is a good response rate, we cannot exclude selection bias with patients with better outcomes self-selecting themselves for inclusion in our study—1 patient was deceased at time of study, 2 patients did not respond to letter or telephone questionnaire, and 2 patients submitted incomplete DASH questionnaires which were not included in the study. Range of motion data preoperatively and postoperatively were only available for 9 arthroplasties—this selection bias may be responsible for the improved postoperative ROM seen in our series.

Despite these limitations, our study represents the first reported use of the WALANT technique in performing silicone PIPJ arthroplasty. The results obtained in our study, with a high response rate, are similar to those reported previously using conventional methods, and in some cases better. The mixed results reported on silicone PIPJ arthroplasty through multiple case series performed at different centers point to the need for larger, prospective, randomized trials to ascertain the benefits and complications of PIPJ arthroplasty, particularly in the long term. We have shown here that PIPJ silicone arthroplasty is possible using the WALANT technique, with results comparable to traditional methods using tourniquets and sedation/anesthesia. There is a need for further prospective research on the use of WALANT to perform PIPJ arthroplasty.