Hypothesis: What were the most important lessons learned in the first 1400 consecutive cases of wide awake hand surgery in a single surgeon’s practice?

 Methods: Wide awake hand surgery is performed with no sedation, no general anesthesia, and no tourniquet. Only lidocaine with epinephrine is injected directly into the affected parts of the hand and fingers for anesthesia and hemostasis. The author has kept careful records of all of the patients in his hand surgery practice in which 95% of surgery is now performed with the wide awake approach.

 Results: The first 1400 consecutive wide awake cases included 628 carpal tunnels, 167 trigger fingers, 129 operative reduction of hand fractures, 51 Dupuytren’s, 34 extensor tendon repairs, 22 flexor tendon repairs, 11 trapeziectomies for basal joint arthritis, 6 tendon transfers and 2 tendon grafts.

 Summary: The wide awake approach has its greatest advantages in flexor and extensor tendon surgery (repairs, transfers, and grafting), in finger fracture surgery, and in complex secondary procedures because the surgeon can watch cooperative comfortable patients actively move reconstructed tendons and bones during the surgery and he can make adjustments to the repair before closing the skin. Carpal tunnels and trigger fingers can be performed with great convenience and efficiency for both the patient and the surgeon. Elderly patients or those on multiple medications avoid the risks and inconveniences of general anesthesia and hospital admission. However, repeat surgery for Dupuytren’s contracture remains a challenge because of persisting bleeding in spite of epinephrine injection.