Background: This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance. Methods: A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants' knowledge and skills were assessed using pre- and postcourse questionnaires. Results: A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p < 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives. Conclusions: This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated.
Purpose: The lacertus fibrosus or bicipital aponeurosis is a sheet of ligamentous tissue just distal to the elbow joint and can be a compression point for the median nerve. Essentially, lacertus syndrome is a subset of pronator syndrome and an uncommon diagnosis by itself. Surgical release of the lacertus consists of a small 2-cm incision that can be performed under local anesthesia. This study aimed to evaluate the outcome of lacertus release in resolving median nerve symptoms. Methods: This retrospective study was performed at Prince Court Medical Centre, Kuala Lumpur, Malaysia, from January 2020 until June 2021. Ninety-three patients who presented with numbness of fingers, hand, or upper limb; forearm pain; and muscle weakness. They were diagnosed with lacertus syndrome on the basis of local tenderness at the lacertus fibrosus with either weakness of flexor pollicis longus and flexor digitorum profundus of the index finger or paresthesia over the thenar eminence. The patients underwent 3 months of hand therapy, and those with no symptom improvement were offered lacertus release performed by a single surgeon. The surgical technique consists of a surgical incision starting from a point 2 cm distally and 2 cm radially to the medial epicondyle. The incision projects 2 cm distally in an oblique fashion toward the radial styloid. A wide-awake local anesthesia no tourniquet (WALANT) technqiue was utilized and 20 mL of local anesthesic was injected subcutaneously around this region at least 20 minutes before the surgery. Careful dissection was made subcutaneously, and the lacertus fibrosus was identified as a thickened, shiny white structure and released. The Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, grip strength, and pinch strength were tested before and after surgery. At 6 months after surgery, the QuickDASH score was again assessed with a WALANT satisfactory questionnaire. Results: A total of 93 patients were included in the study. The mean age of the patients was 38.7 years, and most were women (77.4%). The mean operating time was 70 minutes. The mean preoperative QuickDASH score was 53, which significantly reduced immediately after surgery to 7.8 (P < .001) and remained low at 6 months after surgery (10.6). The mean grip strength showed a significant increase from a preoperative mean of 16 kg to a postoperative mean of 24 kg (P < .001). Pinch strength also significantly increased from a preoperative mean of 9 kg to 13 kg after surgery (P < .001). Conclusions: Lacertus syndrome remains an underdiagnosed disease that can be treated efficiently with a directed minimal surgical incision under wide-awake local anesthesia. Lacertus release appears to significantly reduce pain and numbness with markedly improved hand grip and pinch strength. The corresponding QuickDASH scores also improved significantly after surgery. This study is vital to our understanding of proximal median nerve entrapment and to accurately diagnose it. Type of study/level of evidence: Therapeutic III.
INTRODUCTION: Kirschner wires (K-wires) are used in fracture fixations but are often associated with pin tract infections. This prospective study compared the infection rate between buried and exposed K-wires in closed injuries of the wrist and hands in individuals with no comorbidities. METHODS: Fifteen patients were recruited with a total of 41 K-wires (21 buried K-wires; 20 exposed K-wires). Clinical and radiographic evidence of infection was assessed at three months based on the Modified Oppenheim classification. RESULTS: Two out of 21 wires in the buried group developed grade 4 infection, while 20 wires in the exposed group did not have any significant infection. No significant difference in infection rate based on K-wire size or number in both groups. CONCLUSION: There is no significant difference in infection rate between buried and exposed K-wires in healthy individuals with closed injuries of the wrist and hand.
Purpose: This study evaluated the clinical and biochemical safety profile of infiltration of lidocaine with adrenaline in wide-awake local anesthesia no tourniquet for distal radius plating. Methods: Twenty-four participants were randomly assigned to the therapeutic group (n = 19) (1% lidocaine in 1:100,000 adrenaline) and control group (n = 5) (2% lidocaine alone). Clinical parameters, including skin necrosis, duration of recovery of sensation, and lidocaine toxicity, were monitored. The serum lidocaine level was measured at different time intervals using a high-performance liquid chromatography reagent. Results: No lidocaine toxicity was recorded in any participant. The therapeutic group had a longer time for recovery of sensation. There was a significant difference in the serum lidocaine levels between both the groups at all time intervals up to 6 hours, with all participants exhibiting serum lidocaine levels below the mild toxicity level of 6.0 µg/mL. Conclusions: Lidocaine used within a safe recommended dose in wide-awake local anesthesia no tourniquet for distal radius plating is clinically and biochemically safe. Clinical relevance: Determining the clinical and biochemical safety profile of lidocaine with adrenaline in wide-awake local anesthesia no tourniquet can promote wider use of this technique.
Kaposi hemangioendothelioma (KHE) is a rare vascular neoplasm that presents usually within the first year of life. Because of its rarity and complexity, there is often a delay in diagnosis. KHE could be associated with a life-threatening consumptive coagulopathy named the Kasabach-Merritt phenomenon (KMP). Here, we present the case of a 2-month-old girl who presented with progressive redness and swelling of her right upper limb over 6 weeks. Multiple health practitioners misdiagnosed her condition as an insect bite, cellulitis, and necrotizing fasciitis and gave treatment accordingly, which proved futile. A full blood count revealed bicytopenia of anemia and thrombocytopenia, a normal coagulation cascade, low fibrinogen, and raised D-Dimer levels. The imaging was suggestive of a high-flow vascular tumor likely to be a KHE. Subsequently, she was started on single-agent oral sirolimus with a dose increment to achieve satisfactory therapeutic levels and was treated for 1 year. She successfully completed the treatment regimen and had only transient hypertriglyceridemia, which resolved upon the completion of treatment. Currently, she is in remission 3 years after treatment. Keeping her case as an example, we would like to highlight the potentially lethal misdiagnosis of KHE with KMP, the importance of an early diagnosis of this condition, and the successful treatment outcome with single-agent sirolimus.
A 48-year-old man with drug addiction presented with gangrene of the right hand following an inadvertent intra-arterial administration of crushed dihydrocodeine tartrate (DF 118) tablets (GlaxoSmithKline S.A.) dissolved in water; the solution was injected into his right antecubital fossa. After 3 weeks of pain, paresthesia, and cyanosis, his right hand became gangrenous. We performed a right forearm amputation by use of the wide-awake local anesthesia no tourniquet technique. After surgery, his wound healed well, and he was successfully fitted with a hand prosthesis.
Purpose: Excision of wrist ganglions is a common procedure in hand surgery. Our objective was to determine whether the type of anesthesia (general anesthesia [GA] vs wide-awake local anesthesia no tourniquet [WALANT] technique) would affect patient satisfaction regarding intraoperative pain control, postoperative pain management, and anxiety. Methods: This was a prospective study with patients divided into either the WALANT or GA cohort. The waiting time for surgery, Amsterdam Preoperative Anxiety and Information Scale, blood pressure, and heart rate were measured. Postsurgical questionnaires with the visual analog scale were completed. The surgeon's feedback on the ease of ganglion stalk visibility and usage of diathermy as a measure of a bloodless field was recorded. Patients reported the amount of analgesia consumed and overall satisfaction with the operation via the Surgical Satisfaction-8 questionnaire. Results: A total of 42 patients underwent wrist ganglion excision in 2 orthopedic centers over a period of 2 years, with 21 undergoing GA and 22 undergoing WALANT. The GA group was more anxious about anesthetic use with a higher demand for information about GA (P = .04). The duration of surgery was significantly shorter in the WALANT group and with a lower diathermy usage (P < .001). There was no difference in terms of surgical difficulty and stalk visualization. The visual analog scale pain score was significantly lower in the WALANT group than in the GA group immediately after surgery (P = .04) and on discharge (P = .004). While at home for 2 weeks, the WALANT group (mean = 2.91 tablets) consumed significantly fewer analgesic tablets than the GA group (mean = 6.25 tablets). However, both groups were satisfied with their experience. Conclusions: Wide-awake local anesthesia no tourniquet technique in the excision of ganglions provides another option of anesthesia with painless experiences, and no pain rebound after surgery. Patients were less anxious about WALANT than GA. Excision can be performed without diathermy usage with similar visualization of the stalk. Type of study/level of evidence: Therapeutic II.
INTRODUCTION: In neurotization or nerve transfer, a healthy but less valuable nerve is transferred to re-innervate a more important motor territory that has lost its innervation through irreparable damage to its nerve. METHODOLOGY: In this study, the outcomes of surgery were analyzed in relation to the muscle strength, range of motion of the upper limb, and functional outcome. The results were analyzed in 19 patients who were operated on between 2008 and 2016 with adequate follow-up. Result: Of the 19 patients (15 complete brachial plexus injuries and four incomplete brachial plexus injuries), 13 patients (68%) recovered partial function after the neurotization surgery. Shoulder abduction and elbow flexion were achieved in 11 patients (58%). Six of the 10 patients (32%) in complete pre-ganglionic brachial plexus injury had recovered partial function. Whereas five of the six patients (83%) in complete post-ganglionic had recovered partial function. In incomplete upper trunk brachial plexus injury, three of the four patients (75%) recovered some function after the neurotization surgery. CONCLUSION: Nerve transfer is an effective treatment option to restore the function of the affected upper limb. Neurotization without intervening nerve graft shows better recovery. Earlier surgical intervention at a younger age can yield better outcomes.
Peripheral nerve injury (PNI) is a worldwide problem which hugely affects the quality of patients' life. Nerve conduits are now the alternative for treatment of PNI to mimic the gold standard, autologous nerve graft. In that case, with the advantages of electrospun micro- or nano-fibers nerve conduit, the peripheral nerve growth can be escalated, in a better way. In this systematic review, we focused on 39 preclinical studies of electrospun nerve conduit, which include the in vitro and in vivo evaluation from animal peripheral nerve defect models, to provide an update on the progress of the development of electrospun nerve conduit over the last 5 years (2016-2021). The physical characteristics, biocompatibility, functional and morphological outcomes of nerve conduits from different studies would be compared, to give a better strategy for treatment of PNI.
Peripheral Nerves , Prostheses and Implants , Animals , Nerve Regeneration/physiology , Sciatic Nerve/physiology , Tissue Scaffolds
INTRODUCTION: The COVID-19 pandemic has enormously affected the psychological well-being, social and working life of millions of people across the world. This study aimed to investigate the psychological distress, fear and coping strategies as a result of the COVID-19 pandemic and its associated factors among Malaysian residents. METHODS: Participants were invited to an online cross-sectional survey from Aug-Sep 2020. The study assessed psychological distress using the Kessler Psychological Distress Scale, level of fear using the Fear of COVID-19 Scale, and coping strategies using the Brief Resilient Coping Scale. Univariate and multivariate logistic regression analyses were conducted to adjust for potential confounders. RESULTS: The mean age (±SD) of the participants (N = 720) was 31.7 (±11.5) years, and most of them were females (67.1%). Half of the participants had an income source, while 216 (30%) identified themselves as frontline health or essential service workers. People whose financial situation was impacted due to COVID-19 (AOR 2.16, 95% CIs 1.54-3.03), people who drank alcohol in the last four weeks (3.43, 1.45-8.10), people who were a patient (2.02, 1.39-2.93), and had higher levels of fear of COVID-19 (2.55, 1.70-3.80) were more likely to have higher levels of psychological distress. Participants who self-isolated due to exposure to COVID-19 (3.12, 1.04-9.32) and who had moderate to very high levels of psychological distress (2.56, 1.71-3.83) had higher levels of fear. Participants who provided care to a family member/patient with a suspected case of COVID-19 were more likely to be moderately to highly resilient compared to those who did not. CONCLUSION: Vulnerable groups of individuals such as patients and those impacted financially during COVID-19 should be supported for their mental wellbeing. Behavioural interventions should be targeted to reduce the impact of alcohol drinking during such crisis period.
COVID-19 , Fear , Mental Health/statistics & numerical data , Pandemics , Psychological Distress , Adolescent , Adult , COVID-19/epidemiology , COVID-19/psychology , Cross-Sectional Studies , Female , Humans , Malaysia/epidemiology , Male , Middle Aged , Surveys and Questionnaires , Young Adult
A flap is done to cover expose structures such as bone, tendon and ligament. Chest wall flaps are usually performed under general anaesthesia due to a fairly large area of surgery and at two different sites which are the chest and the hand. This is the first known reported case of a chest wall flap for coverage of the hand under Wide awake local anaesthesia no tourniquet technique (WALANT). We here report the case of a 32-year-old man who had a firecracker injury over his right hand with bone exposed in his right index and middle finger and distal amputation of the thumb with first carpometacarpal joint dislocation. Chest wall flap reconstruction for coverage of a severe blast injury in the hand is possible and safe under WALANT. The proper technique and administration will lead to a successful surgery without general anesthesia complications and risks. This alternative option may be useful in districts or smaller hospitals where resources are limited.
Background The Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) technique achieves an almost bloodless field for clear visualization during surgeries. WALANT utilizes lidocaine and epinephrine for anesthesia and hemostasis, respectively, without the usage of sedation and tourniquet. This avoids the potential side effects of tourniquet-related pain and sedation-related complications. However, acceptance is still low due to concerns regarding the safety of epinephrine injection in the finger. There is a persistent belief that epinephrine can cause digital ischemia. Purpose To evaluate retrospectively possible complications of hand surgeries performed using the WALANT technique. Methods All finger and hand procedures performed under the WALANT technique from June 2016 to May 2021 in an urban tertiary hospital were studied retrospectively. Results There were a total of 1073 cases, of which 694 were females and 379 were males. The mean age was 55 years. Finger surgeries (e.g., trigger finger release, excision of finger lesions, removal of implants) consisted of 707 cases; and the rest (366 cases) were hand surgeries (e.g., carpal tunnel release, excision of hand lesions, removal of implants). In all cases reviewed, there were no instances of circulatory compromise. There were also no circumstances where usage of reversal with phentolamine is recorded. Conclusion We believe that performing finger and hand surgeries using the WALANT technique is safe and beneficial. The usage of WALANT in hand surgeries avoids tourniquet pain. However, WALANT should be used with caution in those with vascular insufficiency or disease.
A snapping tendon on the dorsal aspect of the thumb is a rare condition as opposed to the common triggering on the volar aspect of the thumb. This condition is known as triggering of the extensor pollicis longus (EPL). A 21-year-old female presented with a clicking or snapping sensation that was felt on the dorsum of her thumb when it is extended. There was no history of trauma. She worked in an ice-cream parlor with repetitive scooping ice-cream motions. Her triggering immediately resolved on releasing the EPL fascia ulnar to Lister's tubercle. Upon wake-up surgery, we could immediately confirm this. We recommend dynamic ultrasound as an investigation and do not recommend MRI. The surgical method of choice is either wake-up surgery or wide-awake local anesthesia no tourniquet (WALANT) surgery.
We have all heard the old aphorism, "Necessity is the mother of invention." While the provenance of the proverb is uncertain, its truth is not in doubt. This is true for the development of hand surgery in Malaysia. As part of the management for leprosy, patients with high ulnar nerve palsies were managed by the pioneers of hand surgery in Malaysia. They did tendon transfers to improve the quality of life of these patients. Since then, hand surgery in Malaysia have grown leaps and bounds. From a small humble beginning in the suburb of Sungai Buloh to organizing the 10th Congress of Asian Pacific Federation of Societies for Surgery of the Hand, hand surgery in Malaysia will only get better with time.
Introduction Closed reduction is an effective method of treatment for distal end radius fractures. We present a case series of patients with distal end radius fractures who underwent closed manipulative reduction using the periosteal block. We describe the technique in detail and examine its efficacy in pain lowering effect during closed reduction. Methods Nineteen patients with distal end radial and ulnar fractures were included and grouped based on the Frykman classification. The reduction was performed using a periosteal block of 10 ml of 2% lignocaine injection. The severity of pain was recorded by utilizing the visual analog scale (VAS) in five phases: 1) before injection, 2) after 15 minutes of analgesia in a resting position, 3) during minimal motion, 4) during full manipulation and reduction, and 5) post-procedure. The VAS scoring was classified as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above). Results The study included 19 patients [median age of 53 years (range: 18-88 years)]; there were 11 (58%) males and eight (42%) females. The mechanism of injury was a fall (n=12, 63%) or a motor vehicle accident (n=7, 37%). There was a statistically significant reduction of pain between phase one and all the other phases. Between the different fracture configurations, there was no significant difference in pain reduction. The most painful phase was expected to be phase four, ie, during full manipulation, in which four (21%) patients had a VAS score of 0, 12 (63%) patients had a VAS score between 1-3, and three (16%) patients had a VAS score of 4. Thus, 16 out of 19 patients (84%) had no or minimal pain during the most painful phase. There were no complications from the periosteal blocks. Conclusions The periosteal nerve block is an effective procedure providing satisfactory analgesia during the reduction of distal radial and ulnar fractures. It has no side effects and is free from complications associated with conventional sedation.
INTRODUCTION: Distal end radius fractures are common fractures commonly treated with an option of open reduction and plating. Traditionally, plating is performed under general anesthesia (GA) or regional block. Recently, a new technique of plating under wide-awake local anesthesia with no tourniquet (WALANT) has been introduced. We aim to compare the preoperative anxiety level, intraoperative pain scores, post-operative pain scores, operating time, blood loss and clinical outcome of distal end radius plating with WALANT versus GA with tourniquet. METHODS: We conducted a randomized controlled study on patients with closed fracture of the distal end of the radius requiring open reduction and plating from January 2019 till April 2020. We recruited 65 patients (33 patients in the WALANT group and 32 patients in the GA group). Randomization was done via block randomization. Data were collected to evaluate preoperative anxiety using the Amsterdam Preoperative Anxiety and Information Scale (APAIS) score, intraoperative pain score during injection (baseline) (V1), 10 minutes after injection (V2), during incision (V3), during gentle manipulation (V4), during aggressive manipulation (V5) and during first drilling of screw (V6), blood loss, duration of surgery and post-operative pain score. Additionally, intraoperative visual analog scale (VAS) score was obtained in the WALANT group. At three weeks, six weeks, three months and six months after operation, the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores and range of motion (ROM) of the wrists were obtained. RESULTS: The average age in the WALANT group was 47.19 (range, 36-64) years and GA group was 49.48 (range, 38-60) years. The mean APAIS score obtained was 7.78 (WALANT group) and 7.36 (GA group) with no statistical difference. For intraoperative VAS, only during V4 and V5 were the scores 1/10; otherwise at all other phases, the VAS score was 0. The average time for surgery was statistically longer in the WALANT group (61.22 minutes) compared to the GA group (55.33 minutes) (p = 0.003). There was no statistical difference in mean blood loss in both groups. The average post-operative VAS showed statistical significance only at 1 hour and 12 hours post-operation with no statistical difference at 2 and 24 hours post-operation. There was no difference in the post-operative ROM including wrist flexion, extension, supination and pronation for both groups up to six months' follow-up. CONCLUSION: There was no statistically significant difference in terms of preoperative anxiety level, intraoperative and post-operative VAS score, amount of blood loss and clinical outcome in both groups for plating of the distal end radius. However, the operating time was slightly longer in the WALANT group. We conclude that distal radius plating under WALANT has similar outcomes to GA. In centres with limited resources, WALANT offers a safe, reliable and cheaper option, reserving GA time for head, abdominal and thoracic surgery.
Introduction: Wide-awake local anesthesia and no tourniquet (WALANT) has come a long way. It has been reported to be successful in the surgery of distal radius and ulna fractures. We report a case of olecranon fracture plating under WALANT. Methods: Surgery was performed with the patient fully conscious where tumescent anesthesia was injected into the surgical site without application of tourniquet 30 minutes before the first incision. Posterior approach to the elbow was used, and the fracture was fixed with anatomical locking plates. Results: The surgery was successfully completed without pain. The numerical pain rating score was 0 throughout the surgery. Conclusions: The use of WALANT for surgical fixation can be expanded beyond the hand and wrist. This is a safe and simple option for patients at high risk of general anesthesia, producing similar surgical outcomes without intraoperative and postoperative complications.
Olecranon Process , Ulna Fractures , Anesthesia, Local , Bone Plates , Humans , Olecranon Process/surgery , Ulna Fractures/surgery , Wrist
Purpose: Synthetic ligaments have been widely used in the knees for anterior cruciate ligament reconstruction and in the shoulder rotator cuff repair, but they have been rarely used in the hand. The only reported usage is in the Artelon space for carpometacarpal joint osteoarthritis. We describe our experience using the synthetic ligament or scaffold known as Orthotape (its predecessor was known as the Leeds-Keio ligament) in the hand and fingers. Methods: We retrospectively reviewed all patients in whom polyester synthetic ligament (Orthotape) was used to reconstruct absent tendons involving both flexor and extensor compartments between 2011 and 2016. The reconstruction procedures were performed as elective surgeries. The tendons were absent due to either trauma or infection. We collected data on demographics, the injury mechanism, prior surgeries, the zone of tendon loss, the presence of skin flaps, and the number of strips of ligament inserted. Results: We inserted 18 strips of Orthotape in the hands of 9 patients. The follow-up period was 3-7 years, and the mean duration of Orthotape in the hand was 44.1 (range, 1-91) months. Four strips extruded, resulting in a 22.2% extrusion rate. Of the 9 patients, 5 retained the Orthotape within their hand for time periods ranging from 60 months (5 years) to 91 months (7.5 years). The extruded strips were in the superficial areas of the hand. Seven patients had traumatic injuries with varying severity and 2 had infections. Conclusions: The high extrusion rate of Orthotape discourages its use in the superficial areas of the hand, including flexor and extensor surfaces of the fingers and hand. We recommend its usage in regions with a thick skin cover such as underneath a flap or in deep areas such as the palm. Nevertheless, it remains as a possible option in cases of complex reconstruction with a limited availability of donor tendons. Type of study/level of evidence: Therapeutic IV.
