Extensor Retinaculum Reconstruction Using the Wide-Awake Approach.

De Quervain tenosynovitis is often treated by simple release of the first compartment. However, patients can suffer from persistent postoperative problems, including "clumsy" use of the thumb, as a result of redislocation or bowstringing of the extensor pollicis brevis/abductor pollicis longus tendons or irritation of the superficial branch of the radial nerve. Here we describe our method for first compartment reconstruction, in which the flaps are sutured after double-flap incision of the compartment. Because the tendons can become recompressed or redislocate if the sutures are too tight or loose, respectively, we achieve proper tension by suturing the flaps with the patient fully awake, under local anesthesia, and without a tourniquet. This allows the patient to actively move the thumb during the procedure, in turn enabling the surgeon to confirm the presence or absence of dislocation or stenosis. We describe the details of the local anesthesia, compartment incision and reconstruction, and how to avoid disturbing the superficial branch of the radial nerve in patients with de Quervain tenosynovitis during surgery. These procedures can be broadly applied without the need for specialized equipment and can be used for a variety of different procedures in which intraoperative surgical judgment is required to optimize function.