WALANT: Perceptions, approaches, and contraindications in a tertiary hand surgery unit.

Wide awake local anesthetic no tourniquet (WALANT) is gaining popularity amongst hand surgeons. Digital adrenaline use has been shown to be safe in multiple studies and the misconception forbidding it is receding. Phentolamine has been shown to safely reverse the effects of adrenaline should the feared complication of digital ischemia occur. A survey was circulated to 40 specialist practitioners who regularly perform hand procedures at a major tertiary plastic and hand surgery unit. Knowledge and understanding of WALANT, onset and duration of adrenaline effects and reversal was assessed. Whilst the majority of respondents (80%) recognized digital adrenaline use as safe, only 65% were aware of the delay until adrenaline takes full effect. Similarly, only 25% of respondents were aware of the duration of effect of adrenaline. Half of respondents were aware that phentolamine is the established reversal agent for adrenaline with only 20% knowing the correct dose. Given the lack of clinician knowledge surrounding adrenaline and its reversal, we feel that to safely undertake WALANT surgery at our Unit a WALANT protocol must be implemented. Drawing on the successes in the airline industry, a variety of safety frameworks have been established to deliver targeted education for prevention and eventual management of predictable risks. We plan to develop a checklist style protocol targeting the knowledge gaps raised in the survey. This will educate and equip all practitioners working with adrenaline with the knowledge to safely manage complications should they occur. LEVEL OF EVIDENCE: Level 5 (UK Oxford Centre for Evidence based Medicine (CEBM) Levels of Evidence).

Response to chicco et al. communication entitled 'Management and outcomes of mammalian bite injuries during COVID-19 and implications for future practice' Published: November 07, 2020DOI:https://doi.org/10.1016/j.bjps.2020.10.090.

The Covid-19 pandemic has forced us to treat mammalian bite injuries more conservatively as resources were redirected to the Covid effort resulting in limited availability of hospital beds and theatre space. When comparing our outcomes before and during the first Covid-19 lockdown, this more conservative approach, which resulted in 24% less admissions and 19% less washouts in theatre, did not result in an increased infection rate. An increased rate of bite injuries during the national lockdown period was also noted. We support the conclusion by Chicco et al. that the majority of patients with bite injuries can 'safely be managed with washout under local anaesthesia, oral antibiotics and discharge on the same day with safety net advice'. It is interesting that in some aspects of our care we may find Covid-19 has been beneficial in de-medicalising management of certain injuries and conditions.

Benefits expected from simple conformal radiotherapy in the treatment of pelvic tumours.

In 20 patients with invasive bladder cancer suitable for radical radiotherapy, a simple conformal planning technique has been compared with conventional beam arrangements in terms of normal tissue sparing. The median treatment volume for the group was reduced from 2275 to 1416 cm3 by the introduction of conformal planning. More specifically, in 13/20 patients (65%) the percentage volume of rectum irradiated to 90% of the isocentric dose was reduced by more than 30%, although the extent of rectal sparing varied greatly between patients. Overall, conformal planning appeared to be less successful at reducing the volume of large and small bowel irradiated to high dose. However, the data suggest that considerable benefit can be expected for those patients most at risk of morbidity by virtue of high bowel volumes included within the treatment length. A randomised trial is now being set up to determine the clinical impact of this planning technique in terms of reduced bowel morbidity.

[Intra-ocular foreign bodies. Microsurgical technics of extraction and prevention of retinal detachment: apropos of 30 cases]. / Corps étrangers intra-oculaires. Techniques micro-chirurgicales d'extraction et prévention du décollement de rétine: à propos de 30 cas.

Surgery was performed in 30 cases to extract foreign bodies located in the posterior segment of the eye, between october 1st, 1985 to november 15th, 1986 in the Hotel-Dieu of Paris Department of Ophthalmology. In 20 cases, the foreign bodies were lead-shot fragments resulting from assaults in 17 cases, from hunting accidents in 3 cases. In 10 cases they were other metallic bodies, resulting from working or pottering accidents. We present the anatomical lesions and the surgical techniques employed, in particular vitrectomy in conjunction with foreign body extraction using the diamond coated jaws forceps. Anatomical results are 83.3% flat retinas. 60% of the patients achieved visual acuity between 0.1 and 1.0. The following points are discussed: true opportunity to perform retinopexy around the retinal tears; problems created by the foreign bodies embedded into the eyeball; operative timing, taking into consideration both the haemorrhagic conditions, i.e. hyphema, choroïdals, massive intra-vitreal bleeding, and the prevention of tractionnal retinal detachment.