When you feel comfortable using the high volumes of LA and where to put it for maximum effect, a trapeziectomy using Walant is within your grasp. It is not for the uninitiated! The bone does ooze and you often have to top up the LA into the joint once you get deeper to prevent the patient feeling it in the depths of the wound.

Getting the last few pieces of trapezium out can be difficult with slightly more limited vision but it is worth it when you see the result of the capsular interposition arthroplasty or suspensionplasty performing its job under active intra-operative movements. It may well be that we will do less invasive slings etc. once we know that the metacarpal does not descend onto the scaphoid or impinge elsewhere. This can only be done using Walant and active movements.

Initially we would recommend using up to 60 mls of LA, as a mixture of short and long-acting (mostly short-acting). The bony work tends to be more painful for longer and using some bupivicaine can be helpful. 10 mls should suffice or this can be infiltrated at the end of the operation. Bupivicaine will give up to 15 hours anaesthesia but pain sensation will return before protective sensation and some patients don't like that. We're sure they prefer it to having the pain for longer however, so it is a balance.

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