A Comparison between the Use of Patient-worn Virtual Reality in Wound Care and Hand Surgery: How Does Virtual Reality Work?

As virtual reality (VR) technology becomes smaller and more affordable, it is gaining in popularity as a tool to address the patient experience of pain and anxiety during invasive procedures. In this study, we explore the effect of VR on the patient experience in two clinical environments of different anxiety levels to propose a possible mechanism of VR on pain and anxiety reduction. Method: Twenty-five wound care patients were randomly assigned to either a VR group or non-virtual reality (NVR) group, singly blinded. Pre-debridement, peri-debridement, and immediately postdebridement anxiety, fun, and pain scores were collected using a Likert scale (0 = least; 10 = most) from each group of patients. These measurements were compared among the VR versus NVR group in the setting of routine wound debridement procedures. The results are compared with our previously published data on patients who underwent wide awake local anesthesia no tourniquet (WALANT) hand surgery. Results: The WALANT surgery patients using VR experienced significant reduction in anxiety and increase in fun compared with the NVR group. In the wound debridement group with VR, there was improved fun, but no statistically significant reduction in pain or anxiety when compared with the NVR group. The mean score for anxiety was higher for awake hand surgery than for wound debridement cases (3.3 versus 1.7, P = 0.004). Conclusions: VR seems to be more effective in higher anxiety settings, could VR work via a neurological mechanism akin to the Melzack and Wall gate control theory of pain? VR may act primarily on the anxiety axis, providing negative feedback via cortical pathways to the amygdala.

Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility.

SUMMARY: Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

Virtual Reality Improves Patient Experience and Anxiety During In-office Carpal Tunnel Release.

Background: This study examined how wide- awake local anesthesia no tourniquet (WALANT) surgery in the office versus the standard operating room (OR) impacts patient experience, and the effect wide awake virtual reality (WAVR) has in conjunction with WALANT on patient experience. Methods: This is a patient-reported outcome study of patients undergoing carpal tunnel release by a single surgeon between August 2017 and March 2021. Patients were classified by location; traditional OR versus WALANT in-office. In-office patients were further classified by whether they chose to use WAVR or not. Patients rated overall experience, enjoyability, and anxiety using a Likert scale (1-7). Results: The online survey had a 44.8% response rate. OR patients were twice as likely to report a neutral or negative experience (23% versus 11%, P = 0.03), significantly lower enjoyment scores (44% versus 20%, P = 0.0007)' and higher anxiety (42% versus 26%, P = 0.04) compared with office-based WALANT patients. With the addition of WAVR, office patients reported higher enjoyment than those who did not use WAVR (85% versus 73%, P = 0.05). Patients reporting an anxiety disorder were more likely to choose WAVR when compared with patients without anxiety disorder (73.8% versus 56.4%). When they chose WAVR, they had greater anxiolysis (79% versus 47%, P = 0.01)' and increased enjoyment (90% versus 59%, P = 0.005). Conclusions: This study demonstrates improved patient experience in the office setting, further amplified by WAVR. Preexisting anxiety disorder is a positive predictive variable toward the patients' choice to use WAVR.

Infection Rate Comparison during Transition from Hospital to Office WALANT Enabled by Virtual Reality.

We transitioned our hand practice from the operating room (OR) to our office-based procedure room (OPR) to offer wide-awake, local anesthesia, no tourniquet (WALANT). We have established that using wide-awake virtual reality improves patient comfort and anxiety during wide-awake procedures and helps facilitate our patients' choice of venue. We aimed to assess the effect of this transition on infection rates for procedures performed by a single surgeon in the OR versus the OPR. Methods: A retrospective chart review was performed on a single surgeon's adult patients who underwent elective and closed traumatic upper limb surgeries. A surgical site infection was defined as superficial or deep, based on clinical examination conducted by the surgeon, and was treated with antibiotics within a 4-week postoperative window. Results: From August 2017 to August 2019, 538 (216 OR and 322 OPR) consecutive cases met inclusion criteria. There were six (2.78%) superficial infections and zero deep space infections in the OR cohort compared with four (1.24%) superficial and zero deep space infections in the OPR cohort with no statistical significance. Two-thirds of cases were converted to WALANT and delivered in the office. Conclusions: This narrative study concurs with the current literature that WALANT in the office setting is as safe as the hospital OR-based procedures for selected elective cases. By transitioning suitable cases from the OR to the OPR, a surgeon's overall infection rate should not change.

Superior gluteal artery perforator flap salvaged via hyperbaric oxygen therapy.

The superior gluteal artery perforator (SGAP) flap can be challenging and in common with all flaps can develop venous and arterial insufficiency. Several prior studies have demonstrated the successful utility of hyperbaric oxygen therapy (HBOT) in the salvage of compromised flaps, mainly with deep inferior epigastric perforator, latissimus dorsi or transverse rectus abdominis myocutaneous flaps. SGAP flaps are autologous alternatives to abdominal-based flaps and provides adequate adipose tissue for breast reconstruction. We report a case of a woman in her 50s who underwent a delayed bilateral breast reconstruction using SGAP free flaps. Postoperatively, venous congestion of her right breast flap was noted for which she was referred for HBOT. An acceptable aesthetic result was achieved following 17 HBOT treatments. This is the first case we can find in the published literature of ischaemic SGAP free flap being salvaged by HBOT.

Virtual Reality Improves the Patient Experience during Wide-Awake Local Anesthesia No Tourniquet Hand Surgery: A Single-Blind, Randomized, Prospective Study.

Wide-awake local anesthesia no tourniquet surgery has been shown to decrease cost and hospital length of stay. The authors studied the use of virtual reality during wide-awake local anesthesia no tourniquet outpatient upper extremity surgery to assess its effect on patient pain, anxiety and fun. Patients undergoing wide-awake local anesthesia no tourniquet surgery were randomized to use (virtual reality) or not use (non-virtual reality) virtual reality during their procedures. Pain, fun, and anxiety were measured with a Likert scale at several time points, as were blood pressure and heart rate. A postoperative questionnaire was used to assess overall satisfaction. Virtual reality patients exhibited lower anxiety scores during injection, during the procedure, and at the end of the procedure. There were no differences in blood pressure, heart rate, or pain scores. Compared with non-virtual reality patients, virtual reality patients' fun scores were higher. Virtual reality patients felt the experience helped them to relax, and they would recommend virtual reality-assisted wide-awake local anesthesia no tourniquet surgery. Among patients with self-reported preexisting anxiety, virtual reality patients had lower pain and anxiety scores during injection of local anesthesia compared with non-virtual reality patients. This study demonstrates that readily available virtual reality hardware and software can provide a virtual reality experience that reduces patient anxiety both during the injection of local anesthesia and during the surgical procedure. (Plast. Reconstr. Surg. 144: 408, 2019.) CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, II.

An evaluation of the information gained from the use of intraoperative nerve recording in the management of suspected brachial plexus root avulsion.

BACKGROUND: The authors examine the information gained from the use of intraoperative nerve recording in the management of suspected brachial plexus root avulsion. METHODS: A retrospective chart review examined 25 patients who had undergone intraoperative nerve recording for a brachial plexus injury. Thirty-seven preganglionic root avulsions were demonstrated by somatosensory evoked potentials, C4 to T1, during intraoperative nerve recording. To measure the information gain derived from intraoperative nerve recording, the authors compared the number of roots diagnosed as preganglionic root avulsions preoperatively to those diagnosed by intraoperative nerve recording. From this, the authors can demonstrate the positive and negative predictive values of their preoperative multimodality assessment for brachial plexus root avulsion and compare this to the result of intraoperative nerve recording to derive the gain of information. In addition, the authors examined the validity of the intraoperative nerve recording somatosensory evoked potentials when this produced a diagnosis of an intact root in this cohort by performing a clinical outcome analysis for those roots used for reconstruction. RESULTS: Twenty-five patients underwent intraoperative nerve recording for unilateral brachial plexus injury; 15 patients were diagnosed with 55 preganglionic root avulsions from C4 to T1 preoperatively by multimodality assessment. Fourteen of 55 roots thought to be avulsed preoperatively were found to be intact with intraoperative nerve recording, representing a gain of information of 25 percent derived from intraoperative nerve recording for roots thought to be avulsed preoperatively. CONCLUSION: Intraoperative nerve recording adds useful information during exploratory brachial plexus surgery.

Prevention by organization: the story of no. 4 maxillofacial surgical unit in North Africa and Italy during the Second World War.

BACKGROUND: Written to commemorate the 60th anniversary of Victory in Europe, this article outlines the experience of No. 4 Maxillofacial Surgical Unit, stationed near Cassino, Italy, during the Allied assault in 1944. METHODS: Private archive material including the original data and case photography are used to illustrate the problems of severe maxillofacial injury and burns management in the theater of war. Trained by Harold Gillies, Patrick Clarkson was commanding medical officer of this small innovative unit. With his trainee Rex Lawrie, he overcame huge surgical challenges using the tool kit of wartime plastic surgery. RESULTS: Between 1942 and 1945, they managed 5000 casualties, including 3000 maxillofacial injuries and 1000 burns. To cope with such numbers, the Unit developed novel and aggressive strategies that opposed contemporary conservative practices. These included early primary closure of missile wounds to the face, which reduced union time for fractures and halved the number of late sequestrectomies. Early excision and skin grafting of large burns resulted in the successful management of burns of up to 72 percent body surface area, marking a shift toward the modern era of surgical burns excision. Cases presented include the first report of skin grafting to the calvarial diploe and a series of medullary bone grafts to restore frontal contour defects. CONCLUSIONS: The drive to return injured men to duty without evacuation put great evolutionary pressure on the development of plastic surgery, and much is strikingly recognizable in current practice 60 years later. Were these early surgical lessons forgotten?

The patient's experience of a nurse-led nipple tattoo service: a successful program in Warwickshire.

INTRODUCTION AND AIMS: Although once the preserve of tattoo artists, units within the UK have increasingly begun making use of the Clinical Nurse Specialist (CNS) to perform areola tattooing. Bringing the technique within the Breast Unit enhances continuity of care and makes use of skills that can be provided by the CNS. Our CNS is involved with both the patients' oncological management and the areola tattoo service. MATERIALS AND METHODS: The CNS-led service was investigated and patients' experiences of nipple tattooing were assessed. We present the results of a postal questionnaire and a prospective clinical audit of the procedure. RESULTS: Forty tattoos were done over a 2-year period with one self-limiting complication. Patient satisfaction was high both with the outcome and the experience of the procedure. Fading of the tattoo is a consistent finding frequently requiring further shading. CONCLUSION: Overall the patient's experience of a nurse lead 'in-house' tattoo service has been highly satisfactory and this is reflected by their high confidence rating and ease of access to the nurse. We believe that the role of the CNS in oncological treatment and reconstructions helps integrate the multidisciplinary experience for the patient.

Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis.

The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%-8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2-5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.