A Review of 1228 In-Office Hand Surgery Procedures With Wide Awake Local Anesthesia No Tourniquet (WALANT) at a Single Private Practice.

BACKGROUND: This study examined the complication rate of Wide Awake Local Anesthesia No Tourniquet (WALANT) technique in the clinic setting with field sterility at a single private practice. We hypothesized that WALANT is safe and effective with a low complication rate. METHODS: This retrospective chart review included 1228 patients who underwent in-office WALANT hand procedures at a single private practice between 2015 and 2022. Patients were divided into groups based on type of procedure: carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, foreign body removal, and needle aponeurotomy. Patient demographics and complications were recorded; statistical comparisons of cohort demographics and risk factors for complications were completed, and P < .05 was considered significant for all statistical comparisons. RESULTS: The overall complication rate for all procedures was 2.77% for 1228 patients including A1 pulley release (n = 962, 2.7%), mass excision (n = 137, 3.7%), extensor tendon repair (n = 23, 4.3%), and first dorsal compartment release (n = 22, 8.3%). Carpal tunnel release, foreign body removal, and needle aponeurotomy groups experienced no complications. No adverse events (e.g. vasovagal reactions, digital ischemia, local anesthetic toxicity, inadequate vasoconstriction) were observed in any group. Patients with known autoimmune disorders and those who were currently smoking had a statistically significant higher complication rate. CONCLUSIONS: Office-based WALANT procedures with field sterility are safe and effective for treating common hand maladies and have a similar complication profile when compared to historical controls from the standard operating room in an ambulatory center or hospital.

Efficacy of Abductor Pollicis Longus Suspensionplasty Compared to Ligament Reconstruction and Tendon Interposition.

Background: Multiple surgical techniques are described for basal joint osteoarthritis. This study compares clinical outcomes and patient satisfaction with trapeziectomy and abductor pollicis longus (APL) suspensionplasty compared to trapeziectomy with ligament reconstruction and tendon interposition (LRTI) when performed by 2 fellowship-trained hand surgeons. Methods: A retrospective review of 51 consecutive patients undergoing APL suspensionplasty (53 hands) was performed. With this technique, a distally based APL slip is brought through and sewn to the flexor carpi radialis (FCR). The remaining APL is placed in the trapeziectomy void. This technique was compared to 151 patients (166 hands) who underwent LRTI using the FCR tendon. Outcomes assessed included postoperative pain relief, grip and pinch strength, complications, and need for reoperation. Two-tailed, Fisher's exact test was used for data analysis. Results: APL suspensionplasty resulted in postoperative pain relief in 92.5% (n = 49) compared to 94.0% (n = 156) with LRTI (P = .758). Mean postoperative grip and pinch strengths with APL suspensionplasty were 41.2 and 10.4 kg, respectively. With LRTI, average grip strength was 42.0 kg, and pinch was 10.1 kg. Both techniques were well tolerated with minimal complications. In the APL group, 1 patient had a postoperative infection requiring drainage. Among the LRTI cases, 1 wound dehiscence required closure, and 2 minor postoperative wound infections resolved with oral antibiotics. Mean follow-up time among APL suspensionplasty patients was 3.3 months compared to 8.4 months following LRTI. Conclusions: APL suspensionplasty is a safe, effective procedure which provides similar pain relief and functional outcomes compared to LRTI.

Current Techniques in Scapholunate Ligament Reconstruction.

Scapholunate ligament injuries are common and can lead to a predictable pattern of arthritis (scaphoid lunate advanced collapse wrist) if unrecognized or untreated. This article describes the relevant anatomy, biomechanics, and classification system, and provides an up-to-date literature-based review of treatment options, including acute repair and various reconstruction techniques. It also helps guide surgeons in making decisions regarding a systematic treatment algorithm for these injuries.

An Unusual Radial Neuropathy.

A 23-year-old woman presented to her physician for left forearm pain of insidious onset, inability to extend the wrist, and numbness in the dorsal hand. An electromyogram (EMG) and nerve conduction study (NCS) demonstrated radial neuropathy, while magnetic resonance imaging (MRI) of the left elbow/forearm, performed 2 months later, revealed edema and atrophy of the wrist extensor muscles, but no compressive lesion. Following a lack of improvement and consultation with an orthopaedic surgeon, a second, more detailed EMG/NCS was performed, revealing a severe radial motor and sensory neuropathy, with compression between the lateral and long heads of the triceps. J Orthop Sports Phys Ther 2019;49(7):558. doi:10.2519/jospt.2019.7927.

Flexor Tenosynovitis.

For patients with suspected flexor tenosynovitis, the mainstay of diagnosis is a thorough history and physical examination. The examination is guided by evaluating the patient for Kanavel's four cardinal signs. Empiric antibiotics should be started immediately on diagnosis covering skin flora and gram-negative bacteria. Typically, surgery is required. Appropriate exposure is required for adequate treatment and incisions should be tailored to preserve areas of skin compromised from draining sinuses and abscess pressure. Diabetes mellitus and peripheral vascular disease place patients at higher risk of poor outcomes including stiffness and amputation; early administration of antibiotics is the intervention that correlates most closely with good outcomes.

Atypical Hand Infections.

Atypical infections of the hand are caused by organisms such as Mycobacterium, fungi, and viruses, and often do not respond to conventional management. They exist within a wide spectrum of presentations, ranging from cutaneous lesions to deep infections such as tenosynovitis and osteomyelitis. Having a high clinical suspicion for atypical hand infections is vital because diagnosis often requires special tests and/or cultures. Obtaining a detailed medical, work, and travel history is extremely important. An indolent clinical course, late diagnosis, and delayed treatment are common. In addition to medical therapies, surgical debridement is often required to effectively treat these infections.

Amputations in U.S. military personnel in the current conflicts in Afghanistan and Iraq.

OBJECTIVES: To determine rates of major limb amputation in U.S. military casualties in the current conflicts in Afghanistan and Iraq, to correlate these with mechanism of injury, and compare the rate with that seen in U.S. casualties from the Vietnam War. DESIGN: Retrospective study of all U.S. casualties recorded for the current conflicts from the start in October 1, 2001 to June 1, 2006. SETTING: Records from U.S. military forward surgical teams (Level IIb) and combat support hospitals (Level III) in theater, evacuation (Level IV, Germany), and major military medical centers (Level V, United States). PATIENTS/PARTICIPANTS: All recorded U.S. military casualties from the Afghanistan and Iraq theaters with injuries requiring evacuation out of theater or prohibiting the individual from returning to duty for more than 72 hours. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Major limb injury, level of amputation, principal mechanism of injury. RESULTS: Over the past 56 months, of the 8058 military casualties meeting the listed criteria, 5684 (70.5%) were recorded as having major limb injuries. Of these, 423 (5.2% of all serious injuries; 7.4% of major limb injuries) underwent major limb amputation or amputation at or proximal to the wrist or ankle joint. The mechanism of injury for 87.9% was some form of explosive device. The major amputation rate during Vietnam was 8.3% of major limb injuries. CONCLUSIONS: Overall, major limb amputation rates for the current U.S. engagement in Afghanistan and Iraq are similar to those of previous conflicts.

Levels of medical care in the global war on terrorism.

Trauma care for military personnel injured in Iraq has become increasingly sophisticated. There are five levels, or echelons, of care, each progressively more advanced. Level I care provides immediate first aid at the front line. Level II care consists of surgical resuscitation provided by highly mobile forward surgical teams that directly support combatant units in the field. Level III care is provided through combat support hospitals--large facilities that take time to become fully operational but offer much more advanced medical, surgical, and trauma care, similar to a civilian trauma center. Level IV care is the first echelon at which definitive surgical management is provided outside the combat zone. Level V care is the final stage of evacuation to one of the major military centers in the United States, where definitive stabilization, reconstruction, or amputation of the injured extremity is performed.

Measuring medical education and curriculum during orthopedic surgical residency.

BACKGROUND: Evaluating residency programs requires objective assessment tools, but few are readily available. The purpose of this study was to measure education by correlating resident test scores with several measurements of educator performance. MATERIALS AND METHODS: The study group included residents and educators from a single residency program. We performed a retrospective analysis of scores from the Orthopaedic In-Training Examination collected during a 6-year period. Resident examination scores were indexed by dividing program averages by national averages to determine yearly score trends and then were correlated with educator attendance and teaching hours. Subspecialty scores were ranked to gauge residency strengths and weaknesses. Teaching hours devoted to subspecialties were compared with test scores to measure curricular emphases and to appraise teaching efficiency. RESULTS: Yearly average examination scores were proportional to national averages (P < 0.001). However, of 3436 possible educator-score associations, only 15 scores correlated highly (r > 0.9) with educators, and only 26 were significant (P < 0.05). Trend analysis put subspecialty scores in yearly perspective. Ranking was inaccurate until scores were indexed to the national average. In 2002, the distribution of 238 teaching hours ranged from 4 to 48 h for subspecialties, and 9 of 12 subspecialties were emphasized disproportionately to the examination. Teaching efficiency varied more than 10-fold by subspecialty. CONCLUSIONS: The creation of a score index helped to identify and address imbalances between teaching hours devoted to subspecialties and resident needs as evidenced by low In-Training examination scores. The present study improved educator accountability by correlating measurements of teaching and learning.