All right. Good evening, everyone, and thank you for joining us for this exciting webinar on the advanced applications of Willott. Presented by a very esteemed group of faculty members, we're all challenging the boundaries of what can be done under local anesthesia. It's a very privilege to share the night with them, and it's important to say at the beginning of this webinar that this is a group of surgeons who are not performing these operations under Willott merely to prove that they can be done. Rather, as you will see from their presentations, Willott provides both the surgeon and the patient unique benefits and advantages, and it's our sincere hope that you gain an appreciation for operations beyond just carpal tunnels and trigger fingers, and that you are inspired to experience these benefits and advantages for yourself. We have a very exciting program tonight discussing what I hope are procedures that many of you have not yet tried, and for those who have, I hope that our experienced faculty can impart their tips and tricks to optimize your future procedures. Now we have some housekeeping to do and some final reminders. So first, your audio will be muted during the presentations. This webinar is being recorded and will be available to you. Please use the question and answer section to submit your questions. So during the presentations, we will try to keep up with your Q&A and answer them in the public forum. For those questions that don't get answered, we'll try to address them at the end of the webinar. This is available for CME, and you can claim CME on Monday through your ASSH account, and that's done through your dashboard and through your CME. A reminder that the self-assessment exam is now live, and to register for that. Also, registration for the annual meeting is also live, and that this year our keynote speaker for our Presidential Guest Lecture is Mark Adams. Our Founders Lecture is going to be a joint lecture by Scott Kozen and James Chang, and our International Guest Lecture is going to be by Dr. Bertelli. And a new textbook is being published by ASSH this fall. And lastly, there is a new Hand 100 question bank that's being published to help with your trainees. And so without further ado, I will turn the floor over to Dr. Lalonde to speak about basal joint arthroplasty. Thank you all again for joining. I'm Don Lalonde, and I'm going to talk about basal joint wallant surgery. Take that five cc's of sodium bicarbonate and put that in a 50 cc bag of saline. So 10 cc's of 1% lidocaine with 1 in 100,000 epinephrine with 1 cc of 8.4% bicarbonate turns the pH to 7.4. So there's 20 cc's of 1% lidocaine with 1 in 100,000 epinephrine in this 50 cc bag of saline. And we're going to add 30 cc's more. Then we take 80 cc's of that, draw it up into 8-10 cc syringes so that we now have 80 cc's of 1% lidocaine with 1 in 200,000 epinephrine. So one year ago, you did the trapeziactomy on the right side awake. Tell me how you felt about that. Did you mind being awake? How sore was it and all that? No. Actually, when the freezing went in, I didn't feel anything. And I found it better when I was awake so that when you allowed me to move my fingers a little bit, you noticed if the bone was still touching. And the freezing itself, how much did that hurt? It didn't. Great. Okay, so are you worried today about me doing this one? No, I'm excited about it. I'm anxious to get it done. Okay, great. All right, great. So at the count of three, try not to move, okay? A little poke. Okay. One, two, three. That's the only little sting that this patient felt with a 27-gauge needle when I pushed the skin into the needle instead of pushing the needle into the skin. The less you move, the less likely you are to cause pain. So you see I put a whole 5 cc's in there without moving one little bit. The wider my hair gets, the less I move the needle. So it's white to here. So this is one centimeter inside the white zone. So I don't think she's going to feel this. Did you? No, I did not. Good. You always reinsert the needle one centimeter inside of a clearly two-mesh zone so needle reinsertion doesn't hurt at all. Did you feel that going in the toe? No. All this lady felt was the first poke of the first needle. In all, I want to use at least 60 milliliters and as much as I need. This is half percent lidocaine with 1 in 200,000 epinephrine so that I can use as much as I want. Always we have bicarbonate to make it hurt a little less. And the last place I inject is inside the joint. While I'm injecting the skin, I alternate from volar to palmar to volar to palmar so that the needle reinsertion is guaranteed not to be sore. If you're doing an LRTI flexor carpi radialis ligament reconstruction, you can inject another 20 to 30 milliliters in the volar forearm, always from proximal to distal. I also like to inject the joint capsule under direct vision at surgery, and I like to make sure that the median nerve is blocked. I like to use abductor pollicis longus when I need to do a ligament reconstruction. After I take out the trapezium, we look at active movement with fluoro and see if there's any grinding of the metacarpal base on the scaphoid. Yeah, see there is not grinding at all, so we don't need to add any more surgery to that. We're done. Right, what I'm going to need you to do is do this, but you can't do this without looking at your thumb because it's frozen, so you need to actually see it. That's why we need these grapes down. And it does look like the metacarpal is grinding on the scaphoid there. When you look in the wound, you can actually see the metacarpal grinding on the scaphoid, you can hear it, and so in those cases, I don't stop at trapeziectomy. I reconstruct the ligament with a slip of abductor pollicis longus, and here's the same patient six months after, still not grinding. In the next few days, this hand is on strike, okay? It only does one thing, it stays right here, higher than your heart. No walking around like this, nope, none of this, because both those things cause bleeding in there, bible, and if you get bleeding in there, it's going to turn to scar, and it takes longer to get better. If you hold it up higher than your heart, just like a sleeping baby, don't disturb it, then it won't bleed inside, it's going to hurt less, it's going to swell less, and you're going to get better faster. So we're going to see you again in four days on Monday over at the regional hospital. I'll know if you've been keeping your hand up by whether or not your hand is swollen, like if it's swollen like a football, I know you've been walking around with your hand down. I think that the intraoperative education piece of Wollant is one of the most useful things that I've done in all the years I've been doing Wollant. It really has decreased my complication rate with all my operations, whether it's flexor tendon repair, or fracture surgery, or basal joint surgery. You talk to patients about how to take painkillers properly, so they don't need to take narcotics, and you explain to them to keep it higher than their heart and quiet, and that really solves most of their pain problems. So what was your impression of this whole thing? I thought it was wonderful. Yeah, it didn't bother you too much? No, it didn't bother me a bit. Yeah, and the freezing, how sore was that? It wasn't sore. Well, one little pinch. One pinch, yeah. And then the surgery itself, did the noise bother you very much, or? No. A little annoying? Nothing like what I thought it would be. You didn't like the crunches. I pictured drills and... Right, so it wasn't so bad. No. And talk to me about your diabetes now. So today you had your insulin like you normally do, and you had your breakfast and all that, right? Well, my metformin pills. Right, right. Yeah. And so are you... I feel great. You feeling great? Yeah. No trouble that way? No. And I think you mentioned that a couple of years ago you had a hernia repair. Yeah, it was supposed to be day surgery. Right, and you were in for... For four days. For four days, because of you had... Fluid build up and anesthetic. Right. I couldn't come out of it. Right, hard time waking up. Oh yeah. Right. Okay, well, today you can just go home and have your supper. How's that? That's fine with me. Okay, all right. And I appreciate everything you've done. Okay, you're welcome. So go ahead and move your thumb. You're now three weeks from the trapeziectomy, and you're a veterinary surgeon, and you're planning to go back to work. I know that. Can you give us a brief summary of the whole thing? Well, the initial procedure was done completely under local, which was my first experience, and it was actually a wonderful experience. It was... I experienced absolutely no pain, and then during the procedure, I actually had the ability to to see the surgery, which as a surgeon was something that I found quite rewarding. I was uncomfortable for just a few days after the surgery, and was able to start physio pretty much right away. And as a result, I have excellent range of motion now, and just maybe a slight bit of loss of strength, which is what I anticipated. My plan is to go back to work in about two weeks. In your handouts, there's an open access video paper, and I don't do prostheses, but my European colleagues do. Dr. Camillo Muller in Switzerland talks about this, and has written about this. Dr. Jean-Paul Brutus, who's one of my colleagues in Montreal, also likes to do prostheses, and get patients moving on the table, and early. And those surgeons find Wallant very, very helpful as well. They also like the intraoperative education piece, and they like to make sure that the implant is seated properly with active movement, as opposed to just passive movement, because there is a difference. How many weeks are you now? Four weeks and a day. After joint replacement? After joint replacement. Move your thumb around. There you go. Pinch the index finger, the small finger, and the inside of the hand. There you go. Happy? Very happy. I warn each and every patient after I inject that they might get a little adrenaline rush. If they get it, it's normal, and don't worry. Be happy. The second problem is fainting, and these are all people who are fainting. These are healthy, young volunteers who induce syncope by Valsalva maneuver after hyperventilation. And when nurses see this kind of activity, they think the patient's having a seizure. They're not. And you can tell because it always lasts less than 15 seconds, and they totally are clear-headed when they wake up. So one way to avoid fainting is to always inject patients laying down. If they're sitting up, there's less blood going to their brain. It's all about blood going to the brain. So recognize it by listening to the patient when they say, I'm not feeling very well, or I think I'm going to be sick. Or if you look at them and you see that they're pale between the eyes or around the mouth, or if they start to yawn, all of that means I'm going to faint even though I'm lying down. So when they say that, the first thing I do is reach under their knees, lift up their knees so the two liters of blood in their thighs goes to their brain. I take the pillow out from under the head, more blood to the brain. Put the pillow under the feet, more blood to the brain. And then I put the bed in Trendelenburg so that I get more blood to the brain again. And you see that whole thing takes less than five seconds. And I'm used to doing it because you're going to do this a fair amount if you're going to do patients with Walnut. You're just going to see this. And then just leave them there for a while. Don't rush to get them out of that position. If you set them right back up because they're embarrassed, they're going to faint again. And then after you do these things, leave them there for 15 minutes or so. And then you can let the nurse run and get the cold, wet face cloth, which does nothing for blood flow to the brain. Thank you. That was really great, Don. I haven't seen the fainting videos before. I'm going to have to get those from you. Yeah, thank you. They are helpful because a lot of people see that and they think that's a seizure. Yeah, that was phenomenal. So I'm going to talk about local and regional soft tissue coverage with Walnut. These are my disclosures. So oftentimes people think about lidocaine and epinephrine and flaps and they say, what? Those don't go together. But actually there's precedence for this. Epinephrine and microsurgery have a history, although it's a young one. And it comes out of our colleagues in Taiwan and with, believe it or not, revascularization and replantation. And it's 12 cases of successful revasts and replants done under Walnut and various different levels. But all cases, the fingers survived. And how did this happen? And why did it happen? Well, Jinbo Tang hypothesized about this in his recent article where he talks about some of the flaps that he's done under local anesthesia. And he talks about in his article that epinephrine affects the capillaries and not the digital arteries and that the digital vessels still have flow. And the fact that epinephrine only lasts four to five hours. And so it's not enough time to have ischemia that's going to irreversibly affect the digits. Because as we know, you can have replants that are done 24 hours later under cold ischemia. This is not true. In fact, we know it's not true all the way from the 1940s because since the 1940s, we know that epinephrine doesn't affect the capillaries. It's well known that epinephrine affects the arteries. And in fact, not only does it affect the arteries, it affects the veins. You see, epinephrine constricts the veins. And then after it constricts the arteries and then it goes to the veins, it constricts the veins. So how did they do replants? Well, they injected a very small amount, only about 10 to 12 cc per finger. And they injected at the distal palmar crease. So they didn't inject directly into the fingers. They injected proximal to them. And they didn't inject directly at the digital arteries or the veins. So they avoided bathing the vessels in high volumes of epinephrine. And they permitted collateral flow. They didn't inject on the dorsum of the hands. So then can we extrapolate this to allow us to do flaps? Yes, we can. And Jinbo Tang did do it. So in his article, he talked about doing nine extended signaler flaps, 14 simple advancement flaps, three reverse homodigital island flaps, and one quaba flap. And this is the one that I found interesting. Because in this one, he required a fentolamine rescue because the flap didn't dink up. And he hypothesized that he injected epi either near or in the perforator. And you know what? He probably did. Because the moral of the story is keep the epinephrine away from your pedicle. And I can tell you from other articles that were published on you doing simple lubra flaps, that that's indeed what these authors also found and suggested. In these two articles, you can see where these authors injected, always away from where their pedicle was going to be. And they had great results, but these are random flaps. And I've reproduced this in my own practice with great success. This is a MRSA open PIP joint after debridement had a large wound. I covered with a luber flap with excellent results. And I've done multiple quaba flaps with excellent success as well. But I always keep my injections away from the pedicle. And in all of my flaps, that's the key. So here, these are two CC injections at each of the arrows. You can see the Doppler perforator at the dot and no injections are near that. This was actually a composite quaba flap in which the tendon was, the extensor tendon was absent. So the central third of the flexor tendon was taken and used to reconstruct the extensor tendon. And then the flexor tendon was then centralized. Oh, sorry, the extensor tendon was then centralized. And so that was done for the extensor tendon reconstruction. Here, this was an open MCP joint with another quaba flap reconstruction, keeping again, all the injections away from the pedicle. That's the key every single time. Epinephrine is not your pedicle's friend. FDMA flaps, full thickness skin grafts. Another thing that's easily done under wallop, but you don't want to make your injections deep where the pedicle lies. You want to have it adjacent to the incision, but instead of traditionally where you're going to make it over the incision, you don't do it in this case. So in this case, I'm not going to inject over my incision. I'm going to inject adjacent to it. And so you can get a nice result, but it's a little different from traditionally how we think about it. Same thing with cross finger flaps. You can do a cross finger flap with full thickness skin grafts. You can see here where the injections are made, both fuller and dorsal to accommodate this. But these are done just like the authors in Taiwan did at the palmar crease. What about regional flaps? Well, thanks to COVID, the limits were pushed in my practice and so yes, they are possible. So this gentleman had a microbacterium marinum infection and his thumb. After a large debridement, I did a reverse radial forearm flap and I had 13 injection sites with 10 cc's at each site. Each of these injections was away from the artery. Unlike Don, I did not dilute my lidocaine with epinephrine. So he ended up with 130 cc's, which ended up to be 19 milligrams per kilogram. And we'll talk more about that in my last talk about how that's possible and why it works, but always away from the pedicle. And the same thing here, the lower extremity. Again, COVID pushed the limits. So here's a posterior tibial artery or perforator based propeller flap. And in this case, you want to do the injection away from where you think the perforators are going to be. Use your Doppler to find the perforators, stay away from the artery, stay away from the pedicles. This gentleman had 10 cc's injected at each arrow. Okay, this is true to anesthesia. He ended up with 21 mg's per kg injected, wait an hour, and then perform the flap. So local and regional flaps, they are possible with Walent. The take-home message here is do not inject near the pedicle. Epinephrine does constrict the arteries and the veins, but not the capillaries. And the envelope is just starting to be pushed here. We're just starting to learn what's possible. Thanks so much. Okay, thank you. That was a very good talk, both of you guys. I'm Greg Kolovich. I'm an orthopedic surgeon in Savannah, Georgia. I apologize for the long date. It's supposed to be the 20th. I have no relative conflicts to disclose. So there are two types of advantages. There's patient-specific advantages and the surgical advantages. So the surgical advantages are the patient-specific advantages and the surgeon-specific in any sort of tendon reconstruction. Of course, we talked about the interoperative education and affirmation, which I think is really important. These patients can actually see their tendons move. They know the tension is set. They can look at their tenodesis effect. And it's really important for them to see that at the start. I really like involving the occupational therapists. We're really close with our occupational therapists, especially on these complex cases, having them, inviting them in and seeing it for themselves or providing video for them is really helpful for them in the post-operative treatment. Giving them realistic expectations. That's also very important, especially in complex cases, as we've seen. And what I really like is the no nausea, no tourniquet pain and no letdown, as you saw from Dr. Lalonde's presentation. They really are quite comfortable after and post-operatively. There's just really very little need for narcotics. So those are all very good patient-specific advantages. For me, I think the advantages are even better because I get real-time feedback on the tension. Tension is always tough to determine interoperatively. It's not always what you see is what you get. Sometimes it's tough when you're doing a transfer to determine the amount of excursion. And having them do it themselves really provides the realistic feedback that I need. And when you do tenolysis, especially in complex cases, multiple replants, workers' comp injuries that are just extensive, you could really waste a lot of time when you don't know where the actual tendon is stuck. What's helpful is when they're awake, they can provide me with pinpoint accuracy where I can focus my time and energy. And plus, through active motion, they can actually break up a lot of the scar themselves. So we talked a lot about the Temesit, how we do it. Dr. Nwolan gave a really good opening presentation about that. Really, it's pretty simple. I like to use a lower dose, but as you've seen, sometimes you need a bigger dose. So I buffer with... I do 1 milliliter of bicarb to every 10 milliliters of lidocaine. I use lidocaine 1 in 100,000. And then as you go up in size, you want to dilute everything with normal saline. So if you're using 200 milliliters of Temesit, you're going to have a concentration of 1 in 400,000 as opposed to 100 milliliters, where you have a concentration of 1 in 200,000. Flexor tenolysis, this is a very common procedure that I do. In trauma or zone 2 flexor tendon injuries, a lot of them tend to need a tenolysis postoperatively. And I sort of tell them at the beginning, you know, you may need a tenolysis and they know what to expect. I really, really... This has really helped my practice to have them do this under Wollant because I can really focus a lot of my energy at the exact spot. You know, when you have a complex injury, it can be adhered in many different areas. With Wollant, when you go in, you really do focus it on those specific areas, which makes the patient a lot happier, a lot more comfortable, and really focuses your energy. So I use a 30-gauge short needle. I find this to be very helpful in scar tissue. When you're doing a tenolysis, you're gonna have thick palmar scar tissue. So a 30-gauge short needle is what I use. And I always, sort of a tenant of Wollant, inject proximal to distal, as you saw in Dr. Wollant's video. I start in the carpal tunnel. Essentially for a simple flexor tenolysis, I'll use 30 milliliter solution. I'll do 10 milliliters in the carpal tunnel. As you can see from this diagram, start in the carpal tunnel and then work distally, using less injection each time. So 10 in the carpal tunnel, I use three in those middle spots, right there in the mid palm. And then I use about two milliliters each to really get the digital nerves in those five areas for a typical flexor tenolysis. So the key on this is buffer the solution, one in 10 with bicarb, and use LIDAE with one in 100,000 epinephrine, and use that 30 gauge needle. If you use a 25 gauge needle, it's really, it's sort of painful, and it just doesn't bite through the scar tissue as much as a 30 gauge can. So for tenolysis, some of the tips that I've learned is, you know, what you see is what you get. Don't leave the table till you have full active motion. Now the patient is there, they're awake. They're watching everything you do. They're listening. So, you know, you want to main it. Things can be stressful, particularly when you don't know where the, you know, where that surgery is going sometimes. And sometimes it's a surprise. But what I've noticed when they're awake is they really can lead you to the point of adherence. So really use your patient wisely. This has really made my surgeries much faster and much more efficient. And do not leave until they get that full motion, or at least a reasonable expectation with that patient can be achieved. Having them really pull their fists, making a fist throughout the case is really helpful. I've seen them actually break up their ruptures themselves. It's fantastic to see and to hear. The patient feels very good about it. And it certainly saves you surgical time and dissection. Sedation, again, you know, that's going to interfere with their cooperation memory. These patients need to be wide awake and cooperative. It's very, very satisfying. These patients tend to be extremely happy, extremely grateful. The OT, having them, if you can, I know that's tough. The occupational therapy lives downstairs. In my building, we have a surgery center. So they just come up when we have a complex patient and we collaborate together so they can see it. If not, I'll give them a video so we can all be on the same page. So I've learned this the hard way. I have started, I think anybody does, there's a sort of a journey that we take as surgeons. I've started motion that day. And what I've learned is you really want to give them time to settle. And we always talk about let pain be your guide, but really you got to keep strict elevation, minimal movement for the first two to four days because what can happen is you can get this friction edema to happen and you can get internal bleeding. So you just did a surgery, early motion within the first two, four days can cause postoperative bleeding and this friction edema, which can really, that can bite you in the butt because now you've got a tendon that's just been devascularized. You've done a tenolysis, the blood supply is tenuous and the tendon's already weak from a prior surgery and tenolysis. So what you really don't want to do is pop the tendon. And this internal bleeding is going to lead to these scarring white cells and you really just want to give that patient a few days, probably two to four days for the tendon to recover. I know people differ on this, but having a tendon rupture on day one or postoperative is never a good feeling. So just be cognizant that if you start them too early, you can cause some internal scarring and friction edema, which can really limit them. So I get them in surgery, I get them in OT for active pain guided movement at about day three. So I'm just going to give you a couple of case examples, really common stuff. I don't have a lot of, I didn't post any video. I was afraid it wasn't going to work. I do have pictures of this and videos. If you email me, I'm happy to share. But my point on this talk is really show where to inject because a lot of you are just using Wollant. The confusing part is the injection, right? You guys all know how to do the tendon transfer. I don't need to teach you how to do that or tell you how to do that. These are really simple stuff that I've used. But the injection part is the key to this whole talk. So for an EIP to EPL, we've all done this as a very common surgery. These are your injection spots. I use about 30 to 40 CCs. Again, buffered with one to 10 bicarb. And very simple. You can see that blue area. This is really where you need to get. You need to get over the rupture, which is usually at the wrist dorsally. And you need to get the hardest site over the index MCP. And those two injection sites should cover you for an EIP to EPL transfer. This has been great. Patients, I've had a lot of, I've had a few professional piano players who have ruptured their EPL from whatever reason and really concerned about their thumb extension. And they did not, they wanted their thumb to hyperextend so they can hit that octave. And they were really concerned about that. I said, look, if you're so concerned, let's do it under local and you can watch. And they were really happy. And we confirmed at the time of surgery that they had that thumb hyperextension, which really helped them in their career as a professional piano player. So it's, again, that interoperative patient education, having them see the result. And like you said, don't leave the OR because what you see is what you get. It's not gonna get better with therapy. It's not gonna get more extension with therapy. What you see is what you get. So make sure you leave the operating room happy. And the nice thing about Walon is the patient can also leave the operating room happy. Another common transfer is a FDS to FPL for FPL rupture. This is gonna require a lot more to mess it. It's just a bigger procedure. And 50 to 100 CCs, again, buffered with bicarb. These are your injection sites. Start distally or approximately distal. And whether you do the middle finger or ring finger, it doesn't matter to me. I typically use ring finger. But these are your injection sites. Work slowly, give them time to set up. If there's scar tissue, use that 30 gauge short needle, that really helps. And this is the way we do the injection for a FDS transfer. Radial nerve transfer for radial nerve palsy. This one is huge because I've made the mistake early in my career of not setting the tension appropriately on these. But with Walon, the hard part was the excursion, particularly in the pronator. It was hard for me to get that excursion just right on the PT to ECRV transfer. So with Walon, it's been a blessing because before I do that tendon weave and tie it down and set my tension, I know that they're gonna get the excursion that we need to restore that extension. So this is a big procedure. You're gonna need about 200 milliliters. And you're gonna buffer it with normal saline to get one in 400,000 at a 10 to one bicarb. So dorsally, you wanna cover them pretty significantly for those dorsal tendon transfers. And then bolarly, these are the three spots. You really have to get that periosteal pronator teres because you're gonna be taking it right off the bone, which can be very painful. So I get in there and sort of walk the periosteum. I'll talk a little bit about walking the periosteum when we get to the distal radius part, but get down there, get the tendon, walk that periosteum, get that nice and numb. And you can see there for the pronator teres transfer, and then also on the bolar radial aspect for that FCR to EDC transfer. So again, you're gonna need a big solution and you're going to, when you have a big solution, I agree, you're gonna have to wait a long time here because this is a big procedure. Go in, have them lie down, do the injection and let it set up. Again, make sure they're comfortable. So some tips, patients need to look at their fingers. I mean, there's gonna be lidocaine in there. They're gonna be numb. And it's tough, they can't always see if the... So I'm always having them take the drape down and look at their fingers when I'm telling them what to flex or what to extend. If you want them, the key is with the spinal reflex is if you ask them to flex, it will relax the extensions and vice versa. If you ask them to extend, it will relax the flexors based on the spinal reflex. So if you're trying to find out the excursion, it's really important if you're looking at an extensor to have them flex to relax their flexors so you can truly see what the excursion is and set the tension appropriately and anatomically. I... When you do tendon transfers, it's kind of fun. Most patients intrinsically get it. So when you transfer their FDS to their FPL, most of my patients will immediately flex their thumb and know exactly what to do. But I've been tricked on a few times where they didn't know how to do it and I had to coach them. And one trick that I learned, this is something that can save you a lot of headache, is that ask them to flex that ring finger. So if you did an FDS to ring and you transferred the FPL, there's been a few times that they just couldn't figure it out postoperatively or interoperatively. I've asked them to flex that ring finger and then all of a sudden you'll see the thumb flex. So as they're learning, have them flex that transfer digit. And again, I can't reiterate this enough. What you see is what you get. You're not gonna leave the OR and they're magically gonna get more extension or more flexion. So make sure that you're happy and the patient is happy, more importantly, before you leave the operating room. And use the patient to your advantage. That patient can break up a lot of scar tissue. They can dictate the excursion. They can dictate the tension. They can give you all the tips that you need to make your job a lot easier and a lot more efficient. And then lastly, seeing the transfer convinces the patient it will work. It gives them that confidence to know that the job has been done well and that it just makes a happier patient, a more compliant patient, and then also adding the OT into the mix just makes the perfect triangle for success. So thank you guys. Here's my references. Thank you. So I'll be discussing NERV, and I'm based out of Los Angeles, so I have no disclosures. So there'll be QR codes that are all included in your handout as well. So what do we do know which has been well studied and discussed, especially in these talks, is how valuable Wound is and how beneficial it is to the overall patient experience. There's no need for preoperative testing, there's less office visits, no complications of anesthetic, and of course improved patient satisfaction and pain control. With using field sterility over using main OR sterility, there's been no significant difference, and of course all of these changes lead to sizable cost savings. So because of COVID, there's been really demonstrated the versatility that Wound can be used, specifically when resources are limited. So it highlights how it can be used such that the healthcare system doesn't fail patients when resources are limited. So during COVID, there were surgeons who were discussing with Welland surgeons to assess their practice in order to have access to cases when otherwise they couldn't do this in the past. So what does that look like for NERV cases? So most hand surgeons are pretty comfortable using Welland for carpal tunnels and digital NERV, but what else can be done and how this powerful technique can be used for other NERV procedures to get patients out of the main operating room and have successful outcomes? So I'll use me as an example for starboard cases. So without disclosing my age, I began practice in 2014, and I had used Welland throughout my entire training in both residency and fellowship. However, I was convinced that most NERV procedures had to be done in the operating room. However, I realized very quickly in early practice that this was impossible. So beginning with instrumentation, so other than the basic Welland scent that's been previously described by Dr. Lalonde, I had a small peripheral NERV set included bipolar using three and a half loops or a scope depending on the room, and of course, additional patient padding for comfort. So in order to prepare for this presentation, I was looking at images that I had in my first two months of practice. And so I'll show you a couple of these. So this one in particular, it was a gentleman who had no trauma obviously to the dorsum of the hand. He had significant comorbidities and he had two requests. He wanted all structures repaired, including a six sensory tendons and NERV, and he didn't want to go to the operating room. So he was a patient that I repaired while in clinic, and luckily he did well. This is a second patient who similarly had comorbidities. She also had a significant phobia of the operating room, and she had a schwannoma. And in the procedure room that I was doing this in, it was a clinic room actually for ophthalmology, and they had a microscope. So for her, I did her with a microscope, but under Welland, and she was quite comfortable and did well. And even though this isn't a NERV per se, this lipoma was very intimate with the recurrent prevention pulmonary cutaneous nerve. And so this was another starter case for me that was easily done under Welland. And again, luckily there wasn't any issues, but there's more complex NERV cases that can be done. And that's what I think is important about this presentation. So I'm using a lot of published videos from Dr. Kohler here in order to demonstrate how complex cases, including multiple cases can be done on one patient. So if we look at this, this is from PRS Global Open. So you can see he's doing a media NERV reconstruction. He's going to use a seral NERV graft. So I've spent up the video for sake of time. You can see he's doing the local injection here. There's no tourniquet. It's not done in an operating room. He's then doing local injection for the donor site. He's making incision over the traumatic area. Of course, everything that we would normally do in the main operating room, which is dissecting of the media NERV, looking for the damaged structure and excising it, you know, measuring the actual length of defect before harvesting the donor NERV. And you can see both sites are done under local with no tourniquet, patient awake and totally comfortable. Again, just a reminder, this video was sped up just for time's sake. So then harvesting the NERV. And then nicely co-opting it. So, you'll see the finished product in the following image. You'll see the sutures that are available on the NERV. Co-opted and then completed. So, again, this video was sped up just for time's sake. So, again, this video was sped up just for time's sake. So, again, this video was sped up just for time's sake. 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And the key on this one is you got to inject the DREJ when they have a wrist fracture, they inevitably tear their TFCC. It's just part of the deal. And that can be pretty painful when you're reducing the fracture. So I've learned to inject the DREJ as well with about 10 to 30 milliliters. So the subcutaneous injection is seen bole and dorsally. Obviously you're going to inject on the incision site bole, and you're going to inject dorsally. Make sure you get some temescent into the DREJ to protect that TFCC. And you want to do this periosteal walk, which is important because what's really going to hurt is when you're manipulating the fracture and putting in the screws and drilling the holes. So I use a 27 gauge needle, a pinch to skin to add sensory noise. Again, you always want to err on the side of too much local anesthesia rather than not enough. You want it to be comfortable. And inject proximal to distal. So I'm going to go over this periosteal injection. So there's four basic zones. The first one is that subcutaneous injection, which was seen in blue. These next three injections, two, three, and four, there's periosteal walk. So you see the radial border. You're going to inject in about two centimeters proximal to where you think the plate is going to be. So if you're using, you know the length of your plate, you can just take the plate out and put it on the skin. And basically mark out two centimeters proximal to this. And that's where you're going to start your proximal injection. Again, always inject proximal to distal. And 27 gauge needle, make sure it's long enough to get down to the radius. And I inject about three milliliters directly into the periosteum at level two. And then I don't take the needle out and I basically drop my hand and go volar and inject another three to five milliliters. And then again, keeping my needle into the periosteum, drop dorsal by raising my hand, bathing that whole periosteum at zone two with about 13 to 15 milliliters of comescent solution. And then for zone three and zone four, you're gonna do the same thing. Again, go straight down, bathe the radius and then drop your hand, get it volarly, bathe the periosteum volarly, and then raise your hand and get it dorsally. 10 to 13 to 15 milliliters total. Here's a good depiction of how you do it. Again, go straight in, get the periosteum, and then you're gonna sort of walk the needle dorsally and volarly without removing it. 13 to 15 each at those three zones. Some tips that I've learned. When I first did it, I actually didn't inject the DREJ and the patient was pretty painful in that area. So I've learned that lesson the hard way. Again, it has to do with when you break your wrist, you inevitably tear your TFCC and you really wanna inject that area. Radial artery, again, just inject lateral to the artery. And you all know what the radial artery is, so you really shouldn't be at risk for injuring the radial artery, it's easy. There's no tourniquet, so you'll be able to feel it and palpate it. When you do the periosteal walk, you just basically guide it volatily and dorsally. You don't have to move the needle once you've injected, you can just keep it in there and drop your hand and raise your hand, walk it around the periosteum to circumferentially bathe that radius. We're gonna reiterate this many times, don't rush the injection. This is a process and the patient's lying down, as Dr. Lalonde pointed out. This is a 30-minute process. You're in the pre-op unit, take your time. Use your time wisely. I mean, have the patient be comfortable, let the injection set up, make sure you give sufficient time to allow the epinephrine to take effect. And again, just make sure they're lying down. I have not seen them pass out yet, but I'm sure as I continue to do it, I will. And that can be a scary thing, not only for the patient, but also for the nurses around, because that can send everyone to hysteria and certainly cause, well, you just don't want that to happen. And if you do, just make sure you take control like Dr. Lalonde does and get their feet up, get blood to the brain and just make sure it's a controlled thing, because you can really mitigate that situation. It can be a very scary situation for people who are noticing, but if you control it and you're on top of it, and you've also explained to him that this can happen, that's a really good way to mitigate that before it happens. What's really nice is once the surgery is done and you put the plate in, there's no need to cauterize anything. You don't have to worry about the radio artery. You know, it's going to be intact. You know, there's not going to be anything that you got to find and then cauterize. You can simply flush out the wound and start closing. I do close with absorbable sutures. I think like you guys do that it just saves time, makes the incision look a little nicer. And patients seem to like it better. And really, really, I can't stress it enough. You got fluoro in there, use the fluoro, show them. They're a participant. And, you know, I stress that. Once I put that plate in the screws, I stress the fracture. I make sure that it's stable. And I trust my reduction and I trust my stabilization. So I'm going to stress it a little bit interoperatively and I make sure that the patient's watching the screen. It really does help them postoperatively. And it's really, really important for that patient to have that affirmation that they can move their wrist. So thank you. Greg, I love that. I've done maybe about 25 distal radiuses now under Willott. And I agree with you about the DRUJ. But, you know, the other thing that I've seen about it is you also start to see when your reductions are not perfect. And you start to see when your sigmoid notch is a little off and how that affects the active motion that you might not have seen when you're just fiddling around under fluoro, moving the patient's wrist. And suddenly they move it themself and you're like, oh, I need to adjust my plate a little here. And what an eyeopening experience that's been for me. And I think that's something that's not captured by the evidence and the literature. But anecdotally, that's been something that I would love to find a way to report. And that's what we're going to start talking about here in the evidence-based medicine of Willott. But is there are those things, those things that are hard to capture that we are all seeing is the intangibles that Willott gives us. So kind of changing a little bit, we're going to talk about the tangibles. And that's the evidence-based medicine Willott that Greg introduced us to just now. So lots of you have started, lots of you want to get started, and you may be meeting resistance in getting Willott started in your office or clinic or hospital. And many of the reasons for resistance are, it doesn't fit the mold. Field sterility is seemingly at odds with AORN or anesthesiologists feel cut out, or the nurses feel cut out, or you're worried that you're going to lose facility fees at your institution, or you think that patients in your area just don't go for it. And you're worried the patient's pain is not going to be adequately controlled. And there's mountains, like we just talked about, mountains of anecdotal evidence. We've got talks like this one. There's tons of videos, and surgeons around the world are using it. And I need to update that picture because we have wide awake surgery textbook 2.0 already out. But the reality is, is that there's also lots of evidence to argue your case with the stakeholders. So the first one is, is local anesthesia systemic toxicity actually a concern? And the reality is, is that all local anesthetics are not equal. So bupivacaine or Marcaine has clear cardiotoxicity. This is the one where if you have an intravascular injection you have clear cardiotoxicity. The patient can go into cardiac arrest. They need intravenous lipid emulsion to treat that. Lidocaine is not that. Lidocaine you give in cardiac arrest, right? Remember your ACLS. So Lidocaine is safe, all right? And the max dose of seven mgs per kg, which everybody quotes and talks about, is actually based on 1948 epidural dosing from the FDA. It is actually not based on dosing in the extremities. So in the literature, up to 28 milligrams per kilogram have been reported. A lot of that has been reported for tumescent anesthesia. Some of it's been in the literature for liposuction. And in those cases, that is being sucked out. But I have reported in the literature on up to 22 milligrams per kilogram. It is safe, okay? So you can use very large doses to do very large procedures. In this case, we had 265 cases and 217 patients. They were all, they had ASA3 and ASA4 patients. 16 wrist and forearm ORIFs were done. Seven major nerve reconstructions administered up to 22 mgs per kg of Lidocaine with epi. No instances of last. Single circulating RN, none of the patients were monitored. What about infection with field sterility? In this study, 1,500 patients had carpal tunnel surgeries, 14 day infection rates, only 0.4% superficial infections and no deep infections. In a military series of 100 patients, they had 1% superficial infections at 14 days. And in my own series of patients of again, 265 cases, in a population that is traditionally looked upon to have high infection rates. This is a population where over half the population had Medicaid and 25% of them were uninsured and far beyond carpal tunnels. In which I do not give perioperative antibiotics pre or post, had three, both bone ORIFs, 13 distal radiuses, seven nerve reconstructions with sterile nerve, 0% 14 day infections. And one patient had a infection within 30 days. It occurred in a delayed flexor tendon repair at day 28. That's lower than the main OR. What about patient anxiety? Well, in a randomized controlled trial of local without tourniquet versus with a tourniquet of 72 patients, assessing their visual analog scale for pain, Wallet had a lower one. 94% of patients would choose it again and they reported less pain than that of a dental procedure. And preoperative anxiety levels were lower than sedation with anesthesia. What about pain control? We're in the middle of an opioid epidemic and it hasn't changed even though we all keep talking about the opioid epidemic. Comparing in 24 patients with bilateral carpal tunnel in which they had a beer block on one side versus Willant on the other, 83% preferred Willant. In Willant versus general anesthesia, they had 42 patients with a beer block and 42 patients in a cubital tunnel cohort and 62 patients in a carpal tunnel cohort. The Willant patients had less postoperative pain than the general anesthesia cohort. When we looked at opioid consumption, the Willant patients and the monitored anesthesia care patients under sedation had same opioid consumption, which leads me to question, do we even need opioids? And do we even need sedation, right? The point is we don't, we don't need either. So in this study, this is a prospective cohort study where we had three cohorts. We had sedation with opioids afterwards. We had sedation with simply over-the-counter medication and we had Willant with over-the-counter. And we could tell if the patients were gonna cheat because we used the statewide opioid prescribing database to see. And we were able to see that 2% of the Willant patients cheated versus 26% of the patients who were given opioids cheated and got more opioids. And only 61% of the Willant patients were opioid naive. That's generally in the opioid literature a contraindication. Generally they say, oh my gosh, if they're opioid exposed and you don't give them opioids after, they're gonna go and cheat. This proves that's not true. And when you look at the procedures, they're all matched procedures. When you look at the pain scores, the preoperative pain scores are lower for the Willant patients. Fascinating. The postoperative pain scores are far lower. Also fascinating. Why is that? Well, we hypothesize it's because the patients are not anxious because they're not afraid. They're not afraid that they're going under anesthesia. They're not afraid that they're being wheeled into the operating room. They're not afraid because they're talking to you. They understand what's going on. And what's really interesting is that when you control and take out opioids completely, and you just control for the type of anesthesia, what matters the most is the type of anesthesia, not the opioids. And so it's actually Willant in and of itself that improves the postoperative pain and not what the patients take afterwards. And so the benefits of Willant actually transcend sex, age, comorbidities, insurance status, and what they take afterwards. What about the money? Greg was already talking about the money. Willant in the office is four times cheaper than in the operating room, just if you're doing carpal tunnel. If you look at doing carpal tunnel in the United States, it's also four times cheaper. And in the operating room, you lose money. In the military health system, when Peter Reed did his first 100 cases, he saved the military $400,000. And the next part's my favorite. If 2000 of us each did 100 carpal tunnels only in the US, we would save $2.13 million and 500 tons of waste. But here's the kicker. If we all did all of our carpal tunnels, just the carpal tunnels in the US, we would save $3.6 billion in a decade. Imagine what that would do to the waste. So the evidence is vast and robust. It's increasing on a monthly basis. It's safe, effective. It's actually better for patients. It saves money and it's green. Thank you everyone for listening. If you did not get an opportunity to get your questions in, please send them in. We have time built in to answer them. We have everybody available. So feel free to type them into the QA area and we can answer them as they come in. That's great. Well, people are thinking, can I make a comment, Steve? Yeah. Yeah, so the comment I thought of making is, when you're doing something like a spaghetti wrist where you've got big nerves that are cut and so you're doing the median ulnar nerve and you're doing the tendons, one really good way to numb those nerves, because the bigger the nerve, the longer it takes to numb. And that's a big problem. That's why we've all seen brachial plexus blocks fail. It just takes a long time for the lidocaine to get to the center of the nerve, right? So if you have a spaghetti wrist, you got two big nerves that are cut. So the best way to do that in my experience is you blow up the skin. You know that the median and ulnar nerves are between FDS and FTP muscle bellies. So that's a hard place to guess where your needle is when you're blowing it up when you're injecting originally. So blow up the skin flaps to mess them and cut the skin flaps and look proximally, find the nerve stumps. Don't touch them because if you touch them, it's going to hurt. You're touching live wires. Pick up the epineurium with a fine forcep, you know, a Castro Viejo, if you've got one, jewelers, something fine, and just pick up the epineurium. Don't touch the perineurium or the group fascicles because that's going to hurt. And then take a very fine needle, like a 30 gauge needle, and stick that in the epineurium, not in the perineurium. You never want to inject in a nerve because not only does it hurt like hell, but you damage it. So pick up that loose epineurial tissue. And as soon as your bevel of your needle is in there and you start blowing it up, it blows up like a hot dog on a stick, okay? And so blow up the epineurium like a hot dog on a stick and the proximal nerve stumps, then go find your tendons, do your tendon repairs. And by the time you got all that done, your nerves are going to be nicely cooked and you can do your nerve repair. And one other thing in a spaghetti wrist that I was taught by one of the Chinese surgeons this year is when you're trying to match the tendons, and especially in a table saw injury where they're not pretty, you can find the distal ends pretty easily just by pulling on the tendon and you see which finger moves, but the proximal end can be a bit of a challenge. But in the awake patient, they can feel which muscle you're pulling on. So if you pull on a proximal tendon and ask the patient, say, which finger am I pulling on? They're going to say, oh, you're pulling on my index finger because the motor is still alive and they're awake. So that's how you can identify the proximal end, just ask the patient. And I think Greg made a really good point. If the patient can't see their finger move during a tenolysis or a flexor tendon repair, they don't know where it is in space. And I have seen, sadly, some videos of surgeons who are doing a walnut flexor tendon repair, and they're yelling at the patient, move your long finger, like the patient heard them the first time. He just can't move his long finger because he can't see where it is. So you've got to take down that pseudo sterile drape, which does squat, take it down and let the patient see. And if they don't want to see red stuff, just put gauze on the bobo and they have to see their finger move. And like Greg said, sometimes in a tenolysis, you get them, you think it's stuck here and you'll hear it and the patient will say, I just felt something rip in my wrist. And sure enough, there it goes. Anyway, I'll stop my comments there for good. Yeah, I'll piggyback on that for a second, Dawn, about the nerve. I think that's true in a fresh spaghetti wrist. If you get to it late and there's a neuroma that you need to resect, I find it really helpful to not inject the nerve of the epineurium. Because when you cut back the nerve, what I find is when you have it, when you've tumest it, once you cut back to that healthy blossoming fascicles and let's say, you don't have a microscope and you're under loops, when you get back to where you think it's healthy, the patients will say, ooh, that was weird. Every time, because sometimes I'll pull out like my six X loops and I'll look at it, that nerve looks pristine just at that spot. But if you were two millimeters more distal, you'll see scar between those fascicles. And it's really this amazing phenomenon. I mean, it doesn't work if you're distal and you're cutting back, but approximately it's this amazing phenomenon that I've found every time I do these nerve reconstructions. If you're gonna blow up the epineurium, it won't work. Yeah, and one of the questions on the Q&A box was what kind of sutures do you use to close the wound? So I personally like 5-0 simple interrupted buried dermal sutures with no transcutaneous component, just straight up buried. And in fact, I posted a video of that on Listserv just last week. And there's a video on how I actually do that in the second Wal-Mart book, the second edition has just come out in November. Or if you just email me, I'll send you the video. Yeah, we had a huge thread about that on the Listserv. We won't, I won't digress into that. Yeah, and I liked Sarah's, I like all three talks, they were great, but Sarah, your talks about getting the patient to be comfortable, isn't that true? Like with the shoulder business, doing an ulnar nerve, it's so much easier if you don't have a tourniquet there and they can turn on their side, right? If that's what they're comfortable at, you can even do them on their belly sometimes. Yeah, and I think it's more important, in addition to that, like having them do it beforehand, that way you're not in the middle of something and say, wait, I have to move my shoulder or wait, I have to move my elbow. And then it kind of throws off where my operative plan is gonna be. So I have them set themselves up first. And I do that for every case, even if it's a carpal tunnel, like, are you comfortable? Is that, you know, are you okay to lay like this for, you know, 15 minutes or so? So, yeah. You know, since I've stopped doing ulnar nerves to sleep, it's really become, and since I've stopped transposing it, I think those two things together have been so powerful. Like ulnar nerves used to be a real big deal for patients, you know, going through the whole general anesthesia business, and they had a lot of pain with anterior transposition. They really did. For, in my patients, anyway, I caused a lot of morbidity doing that. As soon as I stopped doing that, for most cases, I mean, the occasional time, if they're subluxating, you gotta do something if it's painful, because a lot of subluxations are not painful. You can leave them alone. But if they're annoyed by it, you have to do something. But if you just de-roof them and do them under local, the morbidity for me is down to the same morbidity as a carpal tunnel. So doing both the ulnar nerve and the carpal tunnel at the same time under local is a piece of cake, actually. In fact, last week I did a Laserdus and ulnar nerve and carpal tunnel in the hospital, and it really was a piece of cake. The patient did very well. You can do multiple nerve things, because we're doing a lot less dissection. We're doing, you know, a lot less grief because of the local, and it just makes nerve surgery so much easier and better. So thanks for that. Yeah, I agree. You know, it's also nice when you're doing it in situ. You know, there are patients that have robust triceps, and when they activate their triceps, which you can't do when they're under anesthesia, you'll see the subluxation of the ulnar nerve over the epicondyle all of a sudden. And those are the patients that do need a transposition. And those are the patients who, after an in situ decompression, are not happy. So it's a powerful technique in those cases. Yeah, you can see it. And I think your paper, Steve, about the narcotics, you know, with Wallant and General Anesthesia, that's a brilliant paper. I think that's such an important paper. And I think you're absolutely right. You know, my patients, well, I know they don't need narcotics. We just published a prospective randomized control trial, multicenter, American and Canadian. It's not just Canadians, okay? Because I frequently have a number of my American colleagues saying, oh, you guys up in Canada are tough. We're a bunch of wusses down here. It's not true. We're just as wussy as you are. We proved it in our study. And you don't need narcotics after control. You just need Advil, Tylenol. It's not superior to use- You don't need- Your study is awesome, because it just like, boom, enough already. Stop that. Stop the routine prescription of narcotics after carpal tunnel. Stop it already. Like, okay- Stop it after everything. I don't give it- Stop it after everything. Look at the procedures done in those cases for patients who traditionally are looked at as, you know, high-risk patients who seek narcotics. And the answer is they don't use them. They don't need them. They don't go and seek them. I think one of the main things for me is the intraoperative education piece. I tell each and every patient, you know, we didn't spend 2 billion years evolving pain because it's bad for us. It's nature's only way for your body to say to you after an operation, hey, would you quit that? I'm trying to heal in here and you're screwing it up. Stop that. And that's a little voice in your head you want to listen to, but you can't hear it with Advil or Tylenol in your ears. So you want to get off that stuff after a day or two and just don't do stuff that hurts. Pain guided healing. It's also called common sense. And almost every patient nods wisely and goes, yeah, you know, you're right. And that's how you don't give them narcotics. You start out by saying, so what do you normally take for a headache? Advil, Tylenol, nothing? And they say, oh, I don't know, Advil. Great, that's all you're going to need for this. You're not going to need any more than that, especially if you follow the rules. And then you tell them. I warn patients in the preoperative setting that I don't give narcotics postoperatively. So in the consultation, I even say that. So then they set very low expectations for getting it during the case and after the case. Yeah. Yeah, and Greg, thanks for your tips on distal radius fracture, because I don't do that in my practice. And I'm so glad that you and Steve are both here to talk about that. You know, I think that walking the periosteum, as you so nicely described, is really important, eh? You just keep the needle right on it, and that way you're not likely to inject in the radial artery. By the way, I did that one time. I injected in the ulnar artery. The whole hand went quite white. But it didn't last very long, because the half-life of epinephrine, intravascularly, is 1.7 minutes. So, like, it was, like, white. And then, like, a couple of minutes later, it was all pink. And I looked at it, and I went, like, oh, crap. I'm honest. I got the ulnar artery. I know I did, because every finger's white. And I just watched it. And then I watched it go pink. And the patient's going, oh, that's cool. And I'm going, well, okay. This was, like, about 30 years ago. So. One of the blessings I have in my practice is I take care of a lot of college athletes, some professional athletes, and, you know, surgeons. And my partner, my sports partner, broke his hand falling down the stairs. And I operated on him the next day with an intramedullary screw under a lot. He literally went to operate the next day. Did not miss a day at work. I mean, it's truly amazing how far you can push these limits. The implants are getting better. The intramedullary stuff is just getting better. These screws are phenomenal. You put them in local, they take five minutes. And then you just get them moving. It's quite remarkable where we're going. I know even with K wires, when I do fingers, and I take them through a full range of motion under fluoro, and the fracture doesn't move at all, I know I can do early protected movement at three to five days and do half a fist. If I can have them do a whole fist in the OR and fracture doesn't move at all, I know three to five days later, I can do half a fist. So we do early protected movement with all our K wired finger fractures in reasonable people, not drug addicts and stuff, but in reasonable people. And, you know, Amir Ahmad in Malaysia, I've seen him do a number of lower limb fractures and people walking like way early. And Greg, I'm hearing you say- His tibia fractures. Yeah. I'm seeing you here that you're moving them early. I think your ability to see the stability of the plates and screws is probably gonna stimulate you to move people earlier and perhaps cast less and do all that kind of stuff. It'll be interesting to see what the prospective studies show for stiffness and early movement with wall ant reduced long bone fractures. I'm sure there's a lot of good papers gonna come out about that. The other thing I wanted to mention, Don, is, you know, when the patients are awake, you can talk to them about, you know, the wound care. You and I both mentioned that we have the patients take off their dressings and wash their wounds the next day. And, you know, patients are always like, really? You can wash them? I'm like, yeah, wash your wounds. Otherwise they're gonna smell and get infected and gross. And don't pour weird things on them, like hydrogen peroxide and kill all your good skin. And don't do weird things. And, you know, we mentioned that, you know, neither of us use perioperative antibiotics. And if you have good hygiene, you don't need to. There's this amazing, strange mindset amongst people that when they have a wound, all of a sudden they think, oh, I need to either cover it up and never look at it and let it fester, or I need to air it out, dry it out and let it die. And dry skin's dead skin. And so, you know, I think the perioperative education of the patient is a very liberating thing. I wanted to ask you guys just sort of a poll as we get ready to close here. Like, did you ever get like, every time I do stuff like this, people, like they shake their head. They're like, you don't use antibiotics. You don't use anesthesia. They think I'm like some sort of freak. Like, no, this is pretty well documented. I mean, it's weird how people's heads just spin. Like, I totally believe that lidocaine is safe. I've told that, I'm glad you said it because I've always wanted to do more and I have done more. But people will crucify you with that seven milligram 1948 study. And just other stuff that you learn from the, like just taking call, like, oh yeah, just put a dressing on it and I'll take it out. I'll do it tomorrow in clinic. And they're like, no, you need to come in tonight and do it. I'm like, no, I would rather do it in a controlled setting. And you start telling ER docs this and they think you're like, you know, going against the standard of care. But I think what we're doing is we're reinventing the standard of care in a very good way. We're improving the standard of care. Improving, yes, exactly. Letting people get in the shower the day after surgery is an improvement in the standard of care. Oh yeah. Steve, hit it on the head, you know, like we, a lot of surgeons have this crazy idea that if you clean the wound with clorhexidine and bridine that it stays sterile for days. Like have they forgotten about pores and all the germs that live in pores? And that's why it stinks when you take a bandage off at seven days, because it's sterile. Give me a break. I know. Let those patients get in the shower the next day, please. We've been doing it forever here and it's a damn good idea. When I had my own carpal tunnel, I got into the shower the next day. Thank you. One of the questions about Fentolamine. So you can buy Fentolamine as Fentolamine or you can buy it as Oroverse. That's what I typed. Oh, you did. Okay. I typed as, that's exactly how I buy it. Yeah. Your dental colleagues can get, it's exactly the same drug. Yeah. Well, we are, we're five minutes over, so we have to wrap up. But I put my email in the QA box. And so feel free anybody to shoot me an email if you need to get in touch with me. I'm going to put my email in the chat box right now. Put my note too. Anybody can email me anytime. Same. And it's real easy to remember, dlaban.drlaban.ca. Thank you. Thanks you guys. Those are great talks. I learned something from all three of you. It was wonderful. Always appreciate hearing everything you say. Thank you so much.

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Walant technique

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