Category Archives for "Education"

Want to decrease your complication rates after surgery? Who doesn’t? What patient does not want to avoid trouble after surgery.
When patients are sedated or have a tourniquet on their arm, there's no point talking to them because they cannot hear and remember well. When they are asleep, what a waste of time talking to the nurses about the weather, or to the anesthetist about his holiday!
When patients are awake, tourniquet-free, pain-free, and just lying there listening to nice music, consider this;

What a great time to spend talking to them about what to do and what not to do after surgery to make recovery sail beautifully!
During flexor tendon repair, I tell patients that the hand “is on strike” and only does one thing for 3-5 days after surgery until I see them again. “It stays higher than your heart!” “None of this” I say as I pretend to walk with my hand by my side and then cross my hands down like a referee and say “No! None of this” I say as I open and close my hand and then cross my hands down like a referee and say “No! Walking with your hand by your side and moving your fingers will cause bleeding in the wound. Bleeding becomes a blood clot which occupies space. Blood clots take weeks to dissolve and turn to scar”.

"Don’t disturb it! Keep it higher than your heart without moving it until I see you again in 4 days. We will start early protected movement when all the swelling is gone and you are off all pain killers”.

During every operation, I talk to patients about how to take pain killers properly. I start with “What do you normally take for pain; Advil? Tylenol? Nothing?”. If they reply Advil, I tell them that is all they will need for this operation (most procedures except bad fractures and big nerve repairs). I then say: “With every operation, there are 2 kinds of pain; 1) the sting of the cut which lasts for a day or two, and then 2) the pain of “Gee doctor, now it only hurts when I put down my hand or when I try to do things”. I tell them this: “When you get to the point of “Gee doctor, now it only hurts when I put down my hand or when I try to do things”, that is when you quit taking pain killers and listen to your body. We did not spend 2 billion years evolving pain because it is bad for us! Pain is your body’s only way to say to you: “Hey, would you quit that Mary (if the patient’s name is Mary!)?

That is a little voice in your head you WANT to listen to, and you can’t hear it with Advil in your ears. So you stop taking pain killers after a day or two and only do what does not hurt, including putting your hand down. This is called “pain guided healing” or “Common sense” or “Instinct”
After carpal tunnel, I tell them they can get in the shower the day after their surgery without their bandage because fresh wounds love to be washed. I tell them to reapply a “Hollywood bandage” after their shower.

“Bandages do not stop infection or bleeding. All they do is remind you and those around you that you cannot do all the things you normally do. I know you will forget this and go to use your hand when you go to the restroom or get ready for bed tonight. When you go to use your hand to eat, you will see the Hollywood bandage and it is going to talk to you. It will have my annoying little voice and it will say: “What part of keep your hand up and on strike can’t you remember?...!”

You can ask them: “What WERE you planning to do this week” as you pin their fracture or repair their tendon. Then you tell them about their new reality, and how their hand injury will change their life in the next few weeks. Better coming from you than from a complication you could have avoided!

Time invested in talking to your patient during surgery or painless injection of local anesthesia saves time talking to them in the office or recovery room (where they won’t remember any of it).

Try it! You will watch your complication rate go down! You will also have patients who get to know you, respect you, and want to be part of your team that helps them get better faster!!!

Find out more about how to do and use Walant at the Walant University.

Imagine having closed fracture cases of the upper limb in the ward waiting to be operated on. When you have to share emergency theatre space with other specialities, those life-threatening cases eg. laparotomy, caesarean section cases will be done first. The last on the list will be orthopedic cases. Even then, open fractures will be done first, followed by closed fractures of the lower limb as these patients will be either bed or wheelchair bound without the surgery.

Where does this leave our upper limb patients?

Usually, these patients will only be listed after a week or sometimes more than that because of not enough general / regional anaesthesia time. Unfortunately, this is the typical setting in our country and I believe similar in other 3rd world countries. So, this is the story how Walant transformed my practice.

It all started in 2015 in Seattle when I first heard about Walant. Dr Lalonde gave an inspiring speech on his excellent results in performing all sorts of soft tissues and bony procedures in the hand under WALANT. Videos of his patient's satisfaction does wonders to convince me that WALANT is the way forward. This inspired me to start doing Walant surgery in my practice back home in Malaysia.

With Dr Lalonde and Prof Shalimar at ASSH meeting in Seattle (2015)

I started doing minor cases such as trigger finger and carpal tunnel release under WALANT. My patients gave good feedback and would recommend other people to go for WALANT whenever possible. This motivated me even more and I started doing tendon injuries and tendon transfers under WALANT. Again, patients were very satisfied as they can start protective movement of their joints early as I was confident with my tendon anastomosis as they were mobilizing it intraoperatively under WALANT.

So where do we go from here?

In my hospital, closed upper limb fractures were deemed as having lower priority as compared to closed lower limb fractures such as femur or tibia fractures. This leads to long waiting time for surgery as we have limited operating time for cases needing general or regional anaesthesia.

This lead me to think, is it possible to do fixation of radius or ulna fractures under WALANT. Dr Lalonde has demonstrated successfully that fracture fixation of the hand is possible. Fixation of wrist fractures has been done and published so why not fractures proximal to the wrist?

So I went away and did my own research regarding bone pain. Early studies noted that direct mechanical stimulation of the periosteum produced pain in human subjects (Inman and Saunders, 1944). This pain is often described as sharp and well-localized and occurs for example in fractures (Santy and MacKintosh, 2001). In addition, patients often perceive bone pain in in pathologies confined to the bone marrow that have no obvious periosteal involvement (eg. Intra-osseous engorgement syndrome) (Lemperg and Arnoldi, 1978; Arnoldi, 1990). In these cases, the pain is often described exclusively as dull and diffuse and difficult to localize. Thus, it appears that...

...both the periosteum and the marrow cavity of bones must be innervated by primary afferent neurons capable of transducing and transmitting nociceptive information.

Armed with these knowledge, I was quite sure that WALANT will work if I inject it subperiosteally. It will go through the perforating Volkmann's canal to give effect to the bone marrow. I started doing WALANT for simple fracture eg. Nightstick fracture (isolated distal 3rd ulna fracture) as the ulna is very superficial. Patient's pain score was 0.

I find looking at the guidelines and protocols presented here very daunting. In my case, I came to this technique slowly and organically over many years. When I first started practice, I decided that I wanted to be able to treat some simple things in the office, e.g., finger tip injuries, simple fractures, foreign body and hardware removal, small tumors, and trigger fingers. I purchased two simple instrument kits, and a battery powered k-wire inserter. I appropriated an out of date nitrogen powered tourniquet box when the OR switched to the more modern and safer boxes.

I am old enough to know how to use an Esmarch as a tourniquet (actually the way it was meant to be used).

During my fellowship, we pinned fractures in the emergency room using field sterility and plane radiographs.

So, to me, our cast room was perfectly acceptable. I have since read about the safety and cost advantages of field sterility versus OR sterility and kept this in mind as I expanded my capabilities with office surgery.

Aha Moment #1
I received a call one day from an ER about a seamstress who fell on a sewing needle and it was imbedded in the volar aspect of wrist. The physician said that the thread was sticking out of the skin. I said "just pull it out." He resisted not wanting to break the thread. After another attempt to convince him to try, I demurred and had the patient sent to the office. She came with radiographs on which the needle was present. Sure enough, the thread was visible and I tugged, but nothing happened. I assumed, like a fishhook, that the way to remove this was antegrade. I gave her some xylocaine and made a small incision following the thread. I exsanquinated by elevation and used a forearm tourniquet. Before long and with more xylocaine, I soon found that I was in the carpal tunnel and that the needle was in a flexor tendon. And there I was in the cast room. I then started to think that this was surprisingly well tolerated and maybe I should think of doing CTRs in the right person in the office. I found that forearm tourniquets were well tolerated for about 15 minutes and began doing more things in this fashion.

I usually did these cases before the start of the day as the cast room was shared by up to six physicians at a time and was therefore a busy place.

During my fellowship, we pinned fractures in the emergency room using field sterility and plane radiographs.

The patients liked the simplicity of the procedure. But one day there was an edict saying that local with sedation was acceptable for the ASC, but straight local was not.
At about the same time I was becoming aware of Don Lalonde's writings and wanted to try. I was scared. I had always done most of my cases with a pneumatic tourniquet although digital cases might be done with a penrose drain or tournicot. This was the way I was trained. To overcome my fear, I started performing cases under sedation and local anesthesia (xylocaine with epinephrine). A tourniquet was placed, but not used unless absolutely necessary. I started to get more comfortable. Masses, CTRs, extensor tendon repairs, tenolyses, and nerve repairs were some of my first successes.

Aha Moment #2.
A woman with a ruptured EPL presented for EIP transfer. After arrival in the ASC, she refused all sedation. I was worried about tourniquet discomfort but decided to proceed with WALANT. She did give me permission to use the tourniquet if I absolutely felt it was necessary. Guess what? Not only was it not needed, but the ability to set the tension was enhanced by the patients ability to try things out.

Aha Moment #3
I was getting confident but was still fearful of a bloody field when doing Dupuytren surgery. One afternoon a woman arrived at the ASC. Her driver had a flat, so she took two buses and the Metro to get to the center. The rules of the center were that if she did not have transportation home, then she could not have surgery with sedation. I was not about to send this woman home. I prepared her for WALANT, but she agreed that she could tolerate a tourniquet for a while if needed. Things went very smoothly. I put the cuff up briefly to deal with a spiral cord. Of course, her condition was bilateral and she wanted the other side done. The rules of the ASC were such that I could not schedule her straight local. She lived much closer to my office, so I agreed to do it there. This really opened my eyes to what I could do in an office.

Nuts and Bolts:
I worked at Kaiser Permanente so there were opportunities for institutional support that might not be available in different practice scenarios especially as it relates to funding purchases and sterilization as autoclaves were no longer the standard of care.
Cases were done in an existing procedure room. I created a schedule to do six 45 minute cases in a morning block. Eight basic instrument sets were purchased.

Cases were done on a stretcher with a wheeled hand table. There was a single movable overhead light.