by the surgeon. There's no tourniquet that is applied or inflated. And the patient's wide awake the entire time, able to move hand, wrist, and forearm, able to perform instruction. So as we know, wide awake surgery, Welland is expanding in the hand surgery world. And of course, our scope of practice is opening up because of it. There's multiple procedures now beyond carpal tunnel and trigger fingers that we can do under Welland, such as fracture fixation, nerve transfers, tendon transfers, et cetera. Even our surgical colleagues are also using wide awake surgery to apply that. And of course, the pandemic would force surgeons to think outside the box, out of the comfort box, and apply wide awake surgery to cases when resources, such as the operating room time, is limited. Or else the cosmetic guy is going to do Brazilian butt lift. What about soft tissue coverage? Who is doing it? Why are we not doing it enough? And what kind of procedures can be performed? So there are studies that show it, that demonstrate that it can be done. And we'll look at a couple of these. So looking specifically at this article from Jay Wong, who successfully did 13 revascs and replants, just using 11 ml of lidocaine with epi. He used a 2% lidocaine with epi. Only three of the fingers required a tourniquet for under 20 minutes. And that's just to identify structures quickly. But then it was removed. All of the patients had improved outcome. And all of them had returned to work. This one here from Jim Botang did 27 flaps of a variety. And again, using 1% lidocaine with epi. And added the sodium bicarbonate 10 to 1 ratio. On average, depending on the procedure, depending on the flap, he would use approximately 19 ml per digit or ray. Some of the flaps that he used were segmullar, reverse digital artery adesoy, and a quaba. And you can see there, we'll come back to that example in a moment. But all the flaps survived. He did use pentelamine once as a rescue. And that was for the quaba flap. And interestingly, in this article, he demonstrated where the injections were done. Some people had different techniques. And you can see for his quaba, one of the injections was 5 ml in the middle of the flap. So what does epinephrine do to the flap, to the finger? Well, the landmark study in 2013 by Dr. Lalonde shows that it's safe to use lidocaine with epi in the finger. So that's what we've been using a lot. The plastic surgeons have been doing this technique for quite some time. So what we do know is that the vasoconstriction of the vessels is predominantly nonspecific alpha receptor stimulation of the arterioles and the venules. But it does not cause a vasoconstriction of the capillaries. So where is the best place to inject when you're looking at a flap or elevating a flap? Always, it's important to inject away from the pedicle or any perforators, of course. You want to avoid any trauma causing a neighboring hematoma. Not only does that damage the vessel, but that can also compromise soft tissue healing at the donor site or upon transfer. You want to avoid injecting within or beneath the flap. For most people, unless you're absolutely positive you know where the perforator is. So this could have been taken into consideration. This might have been one of the considerations causing the phentalamine rescue in the previous article. Also, for perfect planning, it's prudent to have a Doppler available in order to identify it. And of course, using the technique for good injection for anything wide awake, you always want to start proximal to distal. You want to inject around the incision. You want to have local anesthetic ahead of the needle and use a small gauge needle. Personally, I use 27 or 30. In the image on the right is an example using FDMA flap where you would inject, again, from proximal to distal around the incision away from the pedicle to avoid damage. For small examples, this is a skin graft. It's going through the variety of soft tissue coverage. This is an 89-year-old gentleman who had significant comorbidities and had severe dementia, and he had a skin cancer on the digit. Some surgeons would have taken this into the operating room. This was done in a minor procedure room with a small digital block and a small field block. This was done at the donor's side of the proximal forearm. This technique for him was the only acceptable way that he and his caregiver would tolerate having the procedure done. So he went on to do well. It was a very quick procedure. Luckily, he had clear margins, no healing issues, and no contracture. It's not my ideal coverage for this area, but it's specific for this patient, it worked well. Looking at a quaba flap, I like the image of this one, this is a 35-year-old right-hand dominant gentleman who had a illegal work-related trauma injury. So he had a two-by-three-centimeter open wound over the PIP joint. So a quaba flap was planned for it. A Doppler was used in order to assess the perforator, and the template was made over the dorsal aspect of the hand as we've all done. So a block was done. A total of 15 mL was used in three points. One was a median nerve block, and the second two were at the, where you see the yellow diamonds, the proximal wrist crease, in order to give dorsal anesthetic. So you'll see direct, immediately afterwards, and the immediately post-inset, you see the distal aspect of the flap looking a little bit sad, but not worrisome. No fentanylamine was used, there was no rescue required. Post-operatively, he did really well. He refused hand therapy, and he went on to heal quite well. There was no soft tissue issues. Looking at a Zotelli flap, this is another gentleman who had a old fight bite, and he was seen in the emergency room. He was, again, was another patient that wouldn't come back. So he said, if you have to do anything, do it here. This is pretty commonplace for some surgeons who have limited resources. I trained in Canada, so I was used to this type of procedure in the emergency room. So for this particular patient, he had good extensor function. The wound looked relatively clean, even though being open, so he had a modified Zotelli flap using a field block. Eight ml of 1% lidocaine. Arguably, I would have used less in future patients, but he went on to do well. He was kind enough to come back to get the sutures removed, and he did really well, had full range of motion, no wound complications, and did not need to attend hand therapy. And then regional flap. This is actually a case by Dr. Koehler here. It's a great example of how regional and local flaps can be done under local. And this particular patient had a mycobacterial infection on the dorsal radial aspect of the hand. There was 13 sites that were injected, a total of 10 ml per site. And you can see using the, where the diamonds are placed, that's where the actual multiple injection sites were done. So nothing underneath the flap, nothing near the vessel, but provided good anesthetic. And one hour wait time was performed, and the operating time was less than the wait hour, was approximately four to five minutes. So it's pretty special and powerful, this technique and what it can be used for soft tissue coverage. This patient, again, went on for a good range of motion and went on to heal quite well. I should also mention there's always a lot of discussion about safe dose, and so LIDA came with epinephrine. The standard for the commercial, like off-the-shelf bottle, is seven milligrams per kilo. You know, oftentimes it's argued that it's pretty conservative, which it probably is. And if you're using a tumescent fluid, that's when it's diluted. The average is 35 milligrams per kilo. Of course, that depends on the size of the person. It can be up to 50 milligrams per kilo. You should note that they're two different concepts, because tumescent fluid is different from the undiluted. The reason why is the, I'm gonna talk fast, the reason why is the diluted one is considered safe because there's less concentration of epinephrine that crosses the epithelial wall. And of note, you know, one gram of fat tissue, when you're giving it as a tumescent, kind of holds one mil of lidocaine. So you get a slower absorption rate, making it capable, that's why it's capable to have higher doses. So you can't really use them interchangeably if you're using a tumescent versus out-of-the-bottle. So the takeaway for soft tissue coverage, it's possible, it's definitely done. And important points is to inject away from the perforators or the pedicle, to avoid going underneath the flap if possible in order to protect the flap itself and protect the donor site. And then, like with anything with Welland or with anything new, you wanna start with cases that you're most familiar with, that's easy in your hands in order to do so. Thank you. Awesome. I did say, I talk fast. Thanks, John. All right, I have a couple of disclosures, none relevant to the talk. We'll close. All right. So I wanted to then talk a little bit All right. So I wanted to then segue into nerve procedures and kind of keep a perspective of what can you do and how far can you push things. So the first thing is I do a lot of Welland and one of the keys is just keeping it simple. I have a very basic tray that contains all the instruments that I need. And then when I need to do something more extensive, I'll have add-on trays. Don't use peel-packed instruments, just maintaining little in the procedure room that's necessary and really embracing field sterility. So most people think about doing carpal tunnels like this under Welland or flexor tendons. There are some of us who are even expanding it to doing sort of the in situ cubital tunnel releases like so. But you can actually do so much more than just that. And so what are the tips and tricks to expanding that? So first off, as Sarah said, tumescent local anesthesia means big volume. So you can dilute it to get more volume so that you don't have to worry about that seven mgs per kg warning from the FDA about should you go over, should you not go over. I don't wanna run into any problems or issues. I don't wanna be in a situation where I have local anesthetic systemic toxicity. But in reality, you can go much more. That's actually based on a 1948 study where they were doing epidural doses of lidocaine with epinephrine. And so what you can actually go up to, even if you're not doing a tumescent case with liposuction, which they'll go into the 30s, but at the same time, right, they're sucking it out with the fat, is it's been reported even up to 28 mgs per kg. I will comfortably do around 22 with no issues. And occasionally you'll see an adrenaline rush from those patients. But an adrenaline rush, I warned them before, it's like you had a couple shots of espresso, it's gonna pass pretty quickly. But I don't monitor the patients or anything like that. I never use bupivacaine, okay, just epinephrine, because bupivacaine does have systemic cardiac toxicity. So if you're gonna use big doses, you really don't wanna get into that. So for average adult, 80 to 100 cc's, I don't even think about it and I don't dilute it either. So just looking at that, I collected 265 of my cases. And took a look and see, did I have any issues at all? On average, these were ASA two or three patients. Nothing was monitored. Up to 22 mgs per kg, like I said. 16 wrist fractures, seven major nerve reconstructions with seral nerve grafts, and not a single problem from doing that. So that's just what I collected. I continue to kind of push the envelope. One of the keys is giving time for it to set. I'd say that's the number one problem, that's why nobody likes going to the dentist, because they inject you and then they go right in with the drill. So I always make sure that patients have time for a long case. One, I inject them and I let them go pee, so they clear their bladder. You don't need to run an IV, right? You're hopefully in a procedure room, and if you're in the OR, you just tell your anesthesiologist not to do anything. And you get that 30 minutes to ensure that things are going. And if you wait, you can even have it really dry. So this is a spaghetti forearm. I ended up waiting around an hour and a half for this one. You can see how dry it is. That's not under tourniquet. The patients await, and I waited 90 minutes for this. But at least 60 minutes, I think, is important for doing these big, big procedures, whether it's soft tissue coverage or nerve reconstructions. This is kind of the setup or the flow that I use to do it. So if I'm doing four patients, for example, what I'll do is I'll have that nerve patient come first. They'll be injected first. I'll then consent and inject the other patients, then do the other patients. So that second, maybe, carpal tunnel will be done. And then by the time I get to the fourth case, it's like an hour and 20 minutes that they've been waiting. So it's adequate time for the anesthetic. I tell patients, bring a snack, bring a book, bring a movie on your iPad or whatever, and that's how they pass the time. So let's get into some complex nerve cases. So this is a median nerve reconstruction here with Allograft. You can see the different sites of injection around there. Each of those were 10 cc's. To get something that is pretty dry, but it's got that wallent soupiness that you sort of need to get used to. It's not bone dry like a tourniquet. And that's important to note. So how do you know where you're at in a healthy nerve? Like I'm doing this in the office under loops. I don't have a microscope. I'm certainly not sending specimens to pathology saying, hey, am I at healthy nerves? Have I gotten rid of all the scar? What's really cool about doing it under wallent is the patient's gonna tell you when you're at healthy nerve because they say, ouch. If you bread loaf up, there will come a point where they actually feel it again. And that lets you know when you're at healthy nerve. Now, distally, obviously you're not gonna get an ouch. So you do have to kind of judge it by the blossoming fascicles. But I'll tell you approximately, it's pretty remarkable when you get to it. And I warned the patients. I said, let me know when you feel something because then we're at healthy nerve and we can do your reconstruction. Dawn talks about often doing an injection into the epineural sheath. And if you're doing, I have like Amir who's in Malaysia, he's done a lot of amputations under this. So whether it's like AKs or BKAs, he'll do it under wallent. And he injects in the epineural sheath of the nerve, lifting up the epineurium, injecting in there. The problem with doing that when you're doing a nerve procedure is one, you're not gonna get the ouch. Two, you're gonna disrupt the normal architecture of the fascicles. And three, you risk developing after the lidocaine or the epi has worn off. If you hit any of the intrafascicular vessels, you can get intraneural hematoma and you're not gonna have a good outcome. So that I don't recommend if you're doing a nerve case. So again, here's a example of waiting 90 minutes before starting the case. You can see how dry it is. You can see where the injections were placed around the wound and the incision that was made. And it's really, really easy to do that. So liberally inject along the nerve. This is a case for an ulnar nerve reconstruction with a cabled autograft. And you can get a sense of what things look like. And you can raise autograft and you can also do supercharging. So in the office, I'll do a reverse end to side. This is after I've done things. Here raising the flexors in the wrist and to expose where I need to be as the AIN comes in to the PQ. And the thing to note here is that the deeper structures are not going to be anesthetized. So the pronator quadratus is innervated and they're gonna feel it. So I always save some lidocaine with that be on the field. So once I get deep, I inject that, give it a couple seconds for the lidocaine to kick in cause you're not gonna have the epinephrine effect, right? And then go ahead and dissect into it. Same principle when I'm doing a distal radius, for example. This is all done under loop dissection and something you can easily apply to the office. Like I said, you can do harvests on a sural nerve as well. So the key here, of course, is to make sure you have good anesthesia. Always following principles of a perpendicular injection and then a lot of the anesthesia needs to go in there. There we go. And you can see, you know, there's a soupiness to it. And it's just something that you have to get used to and not be afraid of and not shy away from. You can see the four by fours that are collecting next to it. And then as you bread loaf up where you think it's gonna be, you know, when you get that patient saying, ouch, then you're like, all right, that's the right section. That's where I need to be. And then I can go distally, take out my neuroma and then move to harvesting. Harvesting, the injection's done same time I'm injecting the wrist with the assumption I tell them that, hey, look, we're gonna be harvesting, we're potentially gonna be harvesting sural nerve. And if we don't need it for whatever reason, okay, you're just gonna have a numb leg for a couple hours. It's not a big deal. You make your cable autographs just like you would normally do in life and you can inset it, no problem. So, you know, do things differ when you're doing major nerve reconstruction? And the answer is really no. I mean, you saw there, I wasn't wearing a gown. I clearly had just gloves on and I'm doing this big nerve reconstruction, definitely going over, you know, an hour in the OR. I don't give antibiotics to my patients in the main OR anyway unless they're infected or I have a case going over four hours, even for hardware. I certainly don't do it for this. And so when you're looking at field sterility on these cases I think the thing that matters is that you don't have a million people with their hands in the cookie jar. You're driving the ship, it's just you. And one assist, I think that makes a big difference. And so even in a challenging population, doing these things and not giving anything, right? Low infection rates. So I track my infection rate. I published it here. I continue to track it just on my own. And usually I'm right around here, like 0.4, 0.5% infection rate. And in this case, you know, it happened at day 28 that the woman actually came back with an infection after she was doing something naughty. So the reality is, is that it's possible to do these big cases. You don't always need to do it this way, right? But if you're in challenging situations and COVID really pushed the envelope for a lot of what I started to do, it can be done. So we're going to piggyback on that with a, oh, I got closed. With a very similar theme of doing big things, you know, in the forearm. So I pass it over to Dr. Kolovich. So I'm an orthopedic surgeon in Savannah, Georgia, private practice. So I got onto Wellant for a few reasons. There's mainly because we've all had patients who are sort of had, you know, old osteoporotic patients who were sort of too old and too sick for distal radius, right? And anesthesia would say there's no way, there's no way. But they're just horribly, horribly, like, displaced. And you feel bad. And you know it's not going to stay even if you reduce it, and they're not going to tolerate a cast. So we sort of had to push the envelope to treat these patients effectively, whether it's with pinning or with plating. But I've always been partial to plating because I think, you know, for some of these complex fractures, you'll get more of a stabilized reduction. So we had to push the envelope in our practice so we could take care of these patients appropriately. And I think there's two main advantages for Wallot and distal radius. There's patient-specific ones, and there's surgeon-specific ones. So the first advantage that I see for patients is that they walk out of there. They're not nauseous. They don't have that grogginess. There's no tourniquet pain, which is a real thing, if you guys actually ask. People hate the tourniquet. And especially, like, postoperatively, like, they'll come in and say everything was fine, but my arm hurts. Sometimes I'll get bruising there. It could be a problem if you look for it. It's far cheaper. We're in private practice, so we definitely have to fight overhead. And this has really, really helped, particularly in underinsured patients or, you know, all types of things. It's just generally cheaper because, you know, you sort of cut the anesthesiologist out of it. And the great thing, and I think this is the biggest advantage, is that they're awake. So for flexor tendons, it's obvious. You can see, you know, if they can move everything. For distal radius, you can show them the plate. You can show that everything's moving. And they actually see how small the plate is. They always comment, like, wow, that's really, really thin. It's not as big as I thought. And it's smaller than I thought. And it really is giving them an idea of they're participating in their own care, which is really important. And actually, I think it, you know, anecdotally, I think it benefits their compliance. And you can also give that last second interoperative affirmation. This helps us sleep at night. We can show them the x-ray. We can show that the screws are not in the joint. We can show that everything's moving as a unit. And it's really, really helpful, again, and patients appreciate that. You're educating them as you go. So they really, really think it helps you bond with your patient. And of course, I think it drives compliance and results. Now, for us, as surgeons, of course, the interoperative assessment of movement is just phenomenal because they can move their hand. You can look at the FPL tendon. You can make sure you're not on the watershed or you're rubbing against the FPL tendon. I think, you know, we always fight patients with CRPS or RSD. And a lot of that is sort of mental, right? Like I'm afraid to move my hand. I'm overreactive, parasympathetic, hypersensitivity, all that kind of thing. When they can see their hand move in real time, it's really, really, really beneficial. And I think it helps fight those dreaded complications of CRPS and compliance. You wouldn't believe this until you do it, but I think it's an easier closure. You get less swelling. There's no letdown bleeding. And you don't have to spend time like zapping all those little bleeders. So I think the closure is much easier. And I think you get by far less postoperative swelling. These are the advantages that I hypothesize are better. And I'll show you some articles that have proven this. But of course, is it safer? You know, that's to be debated. That's for you to decide. That's tough to prove, obviously. But we've shown in some studies recently that there's fewer complications, shorter hospital stays, quicker recovery. I do a ton of workers' comp. So you're sort of fighting the employer versus the employee. But we've shown pretty substantially there's a quicker return to work. So this is a recent study done by Huang et al., 2015 to 2017, 47 patients. And it was 26 under general anesthesia, 21 under Willant. And the main benefits were sort of proving these idealistic benefits. So they had a lower VAS, shorter hospitalization, and a lower mean blood loss, all three things that were proven in this study. There wasn't an advantage in range of motion. You wouldn't expect that. I mean, you're still plating a wrist. So I wouldn't expect them to have greater motion or anything. But none of those were statistically significant. But the key points here is that there was lower blood loss, shorter hospitalization, and lower VAS score. Here's another study. This is a randomized control test. And they looked at beer block, which I no longer do. I don't know if many people are doing beer blocks anymore. But general beer blocks and Willant. This looked at missed days of work and the mean cost. So for us in private practice, you know, we get these bundled payments. And sometimes, the anesthesia fee sucks up all our reimbursements. So cutting them out. And of course, these plates aren't getting cheaper either. So sort of cost is a big thing for us. And that's something that we have to always fight the insurance company for. This is another way that can benefit your practice. This was 169 patients. And Willant was statistically significant in missed days of work. 7.8 versus 20. And the mean cost was 428 versus 630. Which is pretty low. It's a pretty low mean cost. But still, Willant was better on both accounts. Fewer complications. And then also higher patient satisfaction. So I can never get good operative videos. I don't know why. They always come out kind of blurry. So I'm just going to show you how to do it. I think it's better. And my videos never work any time I do a presentation anyways. And a lot of it, I go to Africa every year and I always have to sort of, you know, get patients who don't speak English to sort of shoot a video for me. It never comes out right. So I've done plenty of these. But this is sort of how you do it. And you create a tumescent fluid. And it's 50 milliliters of 1% lidocaine. This is what I use. And 1 in 100,000 epinephrine. And I mix it with 8.4% bicarb at 5 milliliters. And then I dilute it with 50 milliliters of saline. So now you get a concentration of epinephrine of 1 in 200,000. And these are sort of the injection areas. And I'll sort of go over how to do this. Because if you really take your time and do the injection right and you time it, hand surgeons have the luxury of multitasking. That's what we do. That's how we butter our bread. So if you're in and I might have five patients in pre-op waiting for me. So if I can go in and sort of knock out the easy ones while I'm waiting, you sort of have to get a feel for it. And use your PAs or your assistants wisely. This can be done very, very efficiently. So there's two main injection sites. There's the pink side, which I'll go over in detail. And then there's the injection site. I'm sorry, the incision site. And what I think is the most important for distal radius is the DREJ. You know, when you have an inarticular distal radius, you inevitably tear your TFCC or you sprain your TFCC. And that can be a very, very painful site, especially when you're manipulating the fragments. So I've found it very important to not only inject the injection site, the radius, and also the DREJ. And I'll kind of go over my tips on this one. So again, long 27 gauge needle, you got to get down to the radius depending on their habitus. A one and a half needle is usually pretty good. You can use cold spray or pinch the skin. I find pinching the skin is a little bit easier. It adds a little bit of sensory noise. You can always err on the side of local anesthesia of too much. Like Dr. Kohler said, I mean you can get crazy amounts of epinephrine. So I don't use that much, but you know, 100 cc's of Temesin is more than enough for most patients. But always err on the side of being too much as opposed to less. You don't want them to be, you don't want them to feel everything. You want them to be comfortable, right. And then always inject proximal to distal. That's just, you know, common sense. So I inject the incision site and that's that zone one. I do about 20 milliliters injecting subcutaneously proximal to distal. And then I start injecting these three areas, zone two, three, and four. I start proximal to distal, so I'll start in zone two. And there's a way you can go, there's three, there's three injections in that zone. You go directly lateral or sorry, directly radial right down the bump. And this is sort of called walking the radius. So let's get to that here. So this is what it looks like. So if you look at the top picture, you go in straight with the needle and you inject about three milliliters directly in the radius at that zone two. I'm sorry, zone two. And then you sort of keep the needle in and you drop your hand and you walk it boldly and then you walk it dorsally. The key is you don't have to take the needle out. You can literally drop your hand, slide it. This is that periosteal injection. And you want to get a total of about 15 milliliters. I pretty much do five, five, and five. And you do it in these three zones. So you'll do it in zone two, three, and four. Again, proximal to distal. And go straight into the radius, feel the radius, and sort of walk it boldly, drop your hand, and then go down dorsally and then get about 15 milliliters. So you got about 30 cc's of injection into the injection site, now you've got 45 cc's. So where does the other 15 to 30 cc's? I always put it in DRUJ. So I've done the injection site, I've walked the radius, and then the rest goes into DRUJ. Because the times that before, when I started doing it, I neglected the DRUJ and that's sort of where they were painful. So I take the other 10 to 30 and I go right into DRUJ. Of course, when you're in zone four, avoid the radial artery, that's obvious. There's no tourniquet, so you'll feel their pulse. You're doing this in pre-op. So again, take your time. You're not going to hit the radial artery if you know exactly where it is. You can palpate it, but basically just go directly lat on the radius and you shouldn't be anywhere near it. So the key is go in once and then just sort of walk the needle. Drop your hand, go subperiosteal and dorsal. About 15 each side. Don't rush the injections. This is a process and you know, impatient people will fail here. You have to really take your time. You have to make sure they're lying down. Dr. Lalonde will tell you about a patient he's had that faint and hit their head. I have not had that happen yet, thank God, but that's because I heeded his warning. I have them lie down. They're usually lying down on a gurney and I'm doing this and I'm taking my time. Believe it or not, until you start getting used to it, you actually save time in the end. You know, the whole setup with the tourniquet and all this other stuff and the let down bleeding. Believe it or not, this 30 minutes that you're investing in the patient, you'll get it back on the back end, with the ease and simplicity of Wallant. I don't rush this process. I have my PAs do it. I do it a lot, but I've coached them very well on how to do it. It is a team process. Again, for distal radius, an hour probably is a little bit too long. I'm not doing a spaghetti wrist or anything like that. I've done it with Wallant, but this you probably need about 30, maybe 45 minutes max. And then again, have your patients lie down. You don't want them to faint. You can have that adrenaline rush and it can be very scary for the patient and for everybody involved. So, last tips. I mean, what I love about this is once you're done, you're done. You don't have to let tourniquet down. You don't have to get your bipolar ready. You simply dilute the wound and start closing. You don't get a lot of swelling. You literally just start closing. There's not a lot of bleeding. And then I always show the patients the plate. They really like to look inside and they see the plate and they see their tendons moving and their fingers moving. They really do appreciate that. I think it drives compliance. And then I show them an x-ray. I'll show them that this is where the plate is and the screws look good and everything's moving. And they come back in two weeks and they always say, wow, I saw my wrist move. I know this is going to be fine. I have not had a CRPS. I don't know if we've ever studied that, but that would be an interesting study to look at the onsite of people being CRPS, RSD or some sort of pain syndrome that can be involved with distal radius, which we've all seen. I wonder if this, that would be something I'd be interested to see if this drops that prevalence. And then I just simply close it in the way you normally close it. So, again, thank you for inviting me. I'm really passionate about this. I think it can help a lot of patients. So Dr. Franco is scheduled for two ICLs at the same time. So when he gets here, we'll have him jump in and present on basal joint. But in the meantime, I wanted to engage faculty here and we'll talk a little bit about sort of advanced tendon reconstruction. And then, yes. I just had a quick question for you about once you get to the ouch on the nerve repair, then how do you anesthetize the nerve so you can sew into it? So the ouch comes from cutting the fascicles, not the epineurium. So with epineurial sutures, there's no pain. But, you know, the ouch is the intact fascicles that are returning that pain signal. It was a good question. But we'll talk a little bit, even though we're not talking about flexor tendons and the basics of doing that, we'll talk about some of the advanced tendon techniques. So Greg already talked about some of the advantages. Obviously, when you're doing tendon work, you know, we all know it's great because you can get your tension set. You can really see if you have adequate muscle excursion for your transfers. And when you're doing a tenolysis, the patients can basically show you where the tendon's stuck. Like, where do I need to go further? And you can engage them in helping to free that tendon. Once you've given enough freedom and the patients start moving, they'll do their own little mini tenolysis and kind of tear some of those remaining adhesions just by having them forced through. So, but not everything is simple. So, you know, what if you have a skin defect or you're anticipating a buller skin defect? I toss it to you, Sarah, since you gave the soft tissue coverage. Can't see. Yeah. Is that from like a, what is that from? This was a 13-year-old girl. She had a, an open, like, flap with it that ended up becoming ischemic and dying. So it had a very small amount of soft tissue attachment on the radial side of the middle finger. And so on, you know, it's like raising a thin bruner sometimes and losing that flap. Same thing in her, except that she hasn't had anything fixed yet. And you're looking at having exposed tissue. Yeah. It's too bad that she's a, oh, do you want to switch over it? Make him talk too. So for her, so for her, you know, I, I don't like really putting, you know, on young people. I hate kind of putting dorsal scars, but for her, I'd probably just do, you know, she's young. I'd probably just do like a cross finger. If there's anything, if I was to bride it and there's anything exposed, I would probably just do a cross finger on her, depending on what was exposed beneath. So, you know, obviously you were repairing the flexors underwallant. You can see that index finger was also marked for her later cross finger flap. That's exactly what I did. And when you're anticipating doing this, you have to remember that you need to also cover your donor site, right? So full thickness skin graft taken from her distal wrist crease for that coverage. And then I start immediate motion on my flexor tendons. Obviously it's important that they're moving as a unit, which they should be doing anyway with an FTP. And so no loss issues on motion here with good take of the graft and just five weeks out, you know, she's touching down into her palm. So she's well on her way to, you know, a good outcome. You can see the donor sites minimal there on the wrist. And of course the dorsum of the finger is going to catch up when it needs to be. So what about FDS? What are your thoughts on FDS, Greg? You fix the FDS in a small finger zone to lack. Do you excise it? How do you make that decision? It depends. So, I mean, if it's there, it's for the taking, I can fix it. Sometimes I'll take a slip out. It just really depends on, it really depends on looking at tendon. I mean, sometimes like, you know, sometimes you go fix the FTP. I always fix the FTP and then I follow it and then I look at the FDS. If it's a little bulky and I'm worried that it's going to bunch up, I'll take a slip of FDS. If it's truly just, you know, blown up and the FDS is problematic, you know, just excising it is one thing. It really just depends on what you get after. Look at the pulleys. I mean, depending on the area, if I've got to worry about it, you know, getting stuck through the pulleys, then I really make that decision interoperably. And that's really, to your testament, that's an advantage of Wal-Mart because they can decide for me. So I'll have them pull and I'll look at, I just look at the FTP. Always fix the FTP and then assess the FDS after. But taking a slip out has never been a problem. Even taking the whole thing out with a small finger, usually not a problem. But I try to keep it if I can. Yeah. I feel the same way. You know, the benefit is Wal-Mart can guide you. Vent is needed and FDS can be fixed and doesn't always have to be, you know, avoided. So here I fixed both of them without an issue to the small finger. And, you know, what you can see is that I've vented a lot of the pulley here. And I've found that I can be pretty liberal without having an issue of bowstringing. Mind you, when the flaps of the skin are retracted back, right, that's when you're going to have the most bowstringing because you don't have any bowler structures to push the tendon back down against the bone. You do get some help against bowstringing with the soft tissues. So if they're not bowstringing on the table with everything open, they're not going to bowstring in your office post-op either. And, you know, even at eight weeks, moving along to where they need to go. So I do think it's important just to mention I always fix the FDS in an index and a middle finger. It's really important, I think, for dexterity, for pinch, for those two fingers in particular. The ring finger depends. Sometimes I fix it, sometimes I don't. And, you know, the small finger, same thing. But the small finger in particular, like Greg said, I have a low threshold to excise it if necessary. But it's certainly not a blanket statement of, oh, I take out the FDS in everybody because I don't have to. You can take a look and see. How liberally can you vent pulleys? What are your thoughts, Oren? What are you doing? Fairly liberally. I have zero respect for A4. And I have moderate respect for A2. But I think you only need probably 25 to 33 percent of it generally. So, you know, for me, again, when the patient's awake and you can test it, so often you catch up on that proximal lip of A2. And so I'll release a little bit and I'll have him make a fist and it catches just a little bit more and I'll just release a little bit more. Yeah. Do you just release down the midline or do you excise it? That's a great question. I just released down the midline. I didn't think excision was an option. Yeah. But do other people do that? No. I mean, some people do. So, I mean, worried about postoperative adhesions on your tendons, if you excise it, then obviously it's not going to happen. I don't generally excise it, but I go down the midline. But in my readings, I found quite a few people that excise it. And so, you know, Jin Bo-Teng has published immensely on how much you can vent the pulleys. And he said pretty much the same thing. You can get rid of all of A4 and really only have about 33 percent of A2 intact to avoid bow stringing. But in general, the rule of thumb is two centimeters of pulley can be vented, but not beyond that. And I kind of use that as opposed to saying, oh, which pulley is intact or not intact and saying, if I have a two centimeter window there, I'm going to be fine and evaluate on the table. And, you know, here, a massive amount of pulley was vented for this patient. Fixed both, you know, FTP and both slips of FDS. It was a late repair, so pretty challenging. But again, you know, when the skin's open, tack back the flaps, and then I have them start moving, you know, you're going to see if you're going to run into bow stringing or not. And it's not, you know, you'll know if it's going to be an issue. So how about flexor tendon reconstruction? What's your kind of go-to, Sarah, using Wallent? With Wallent, you know, for tendon reconstruction, it kind of depends maybe on what it is. But I tend to do, like, it's easy to do a lot of tenant transfers under Wallant, but not much of a single-stage reconstruction. Warren or Greg, you guys do any single-stage or intercalary? A lot of them are revision stuff, so it's all scarred in. So there's no pulley system. And you've got to wipe everything out, and put a silicone rod in, and then reconstruct it. So the chronic cases, I just don't think there's anything other than a stage reconstruction that you can do. Tenant transfers are always nice, but would you do that primarily in a scarred finger? Probably not. I mean, that would make zero sense to me, especially when the pulley system is gone. So for me, in revision, which is mostly what I get, it was fixed somewhere else, and they come in to me a year later, and they can't move their finger. I've got to wipe everything out, and then I'm basically hoping, well, the whole idea is you put the silicone rod in, and you create the pseudo-sheath, right? And that's your new pulley system. So that's the only way I'm going to get them moving again. I don't have enough volume with this kind of stuff. I used to think the same thing. And then I was talking to Don Wallant about it, and he's like, you know, I was in Kenya or Nepal, and he's like, we didn't have hunter rods. And he's like, I was looking at it, and I was like, you know, maybe the pulleys are actually still there. Maybe I can actually open them up. And he didn't have Miele's tenotomy knives to do it, but he used his Stevens scissor and kind of pushed along the bone and found the lip of the pulley and was using the Stevens scissor to open it up and dilate it. And then all of a sudden, he started to have it work. And he routinely does that now. And so I've done it as well. And you know, traditionally, everybody's like, oh, two-stage. I hate two-stage flexor tendons. Am I the only one that hates it? It sucks. So I would much rather operate on somebody one time instead of twice and have them just do their rehab. And nobody does intercalary flexor tendons, right? It's like mind-blowing that you would even consider it. But you know what? Works. And you know, this is a woman that had a, believe it or not, a trigger finger where I don't know how they lacerated it, but she ended up with this huge gap and two-centimeter gap. And so I took her FDS and used FDS to make FTP, kept it intact, and used on the table, judged the amount of graft that needed to be in there by just having her repeatedly flex till we got to the excursion we wanted. And we weren't going to end up with a lumbrical plus or quadriga. And then started her on media-protected motion. So. I think that's also an important point, like doing it wide awake with doing anything tendon. I think you've all kind of mentioned it, is that if the patient can see what they can accomplish, it kind of helps with the post-operative course. That's a really strong component of the interoperative education. And if the patients can see that they can make a fist, it will help them encourage them in hand therapy afterwards in order to do so. That way you prevent, just like what you were saying, preventing for people from coming back, well, I can't, I can't, I can't. But you saw it in the operating room. So I think that really helps. I mean, if my hand therapist can be in the procedure room, that's awesome. I vastly prefer that. Often that's not possible. So I take videos for them also. So the hand therapist see the repair, see the reconstruction, see, I talk to them about how many sutures were used, core sutures. I show them how much on the table the patient can flex. Or then afterwards, where I want them to stop flexion in the office initially, because I do usually like a half fist. But not always. Like sometimes you talk to them. You're like, it was a tough repair. It can hold this, no problem. We should do a lot of this here, but I don't want to go further for a little while. You take a video of that and give it to a therapist, very empowering to them too. Not to say I never do second stages. Obviously, sometimes I'm stuck with them. But in this case here, again, you're setting that tension and trying to figure out what's possible with this. This was really tough in her case, because she did not have, we had failed at putting in anchors distally and pull out to FTP. And the tissues there were not great. And so she was like, look, I just want, and I'm happy with an FDS finger. And so this was actually the third or fourth revision going in on her, which sounds miserable. And so I just made an FDS reconstruction in her. And when you're doing these revision, revision, revisions, I think that's, this is a powerful technique to do it. Even though you know you're going to be encountering a lot of scar. And I will do single stage reconstructions. I love them. Highly recommend them if you haven't used them before. I use the hunter rod to pull my tendon through, and not to put it in there primarily. You can see my palmaris harvest there. And when you do a single stage, it's a big whack. Because you have to get in there, clear up the scar, reconstitute the pulleys, not reconstruct them, because they are there usually, as Don showed me. And then you can pull it through and set your tendon. And immediately, even before you have them wrapped up, you can instruct them on how you want them to do stuff. He's starting place and hold right away for his tendon reconstruction. So it's a powerful opportunity and technique. And I do it more and more because two stage are miserable. How are you securing it distally? With an anchor? Pull out. Yeah, so I pull. What I do is I use Keith needles. And I go around P3 and through the nail plate. And usually there's a little bit of FTP footprint remaining. And what I'll do is I'll cut it down the midline and reflect it as little flaps. And so once I pull through, I'll tie down on the nail plate. I never use a button, and I've never had a problem tying on the nail plate. I do it always. You use ProLink? ProLink, yeah, yeah. And then what I do is fold those little flaps back down over the tendon and sew those into the tendon as well. So it's kind of like a vest over pants concept. And then you talk to them and you tell them, I like the pull through because it's also kind of the canary in the coal mine. It's true. Like if something happens to the ProLink or if all of a sudden the patient's like, yeah, ProLink just came right out. You're like, well, that's not good. There's no like, oh, let's see, or let me ultrasound you. You know exactly what happened. So what about like tenolysis? Greg, you've talked about this before. You know, how extensive do you prep the hand for your wide awake tenolysis? Oh, well, I have a whole guide that I can email with you guys if you want about the injection sites. But again, proximal to distal, use more. And then, you know, you gotta, I start in the mid palm and start to work down. It depends on if I'm working on a flexor tendon. Nice thing about the fingers, you can get the finger, you know, dead to the world with just a digital block. So it's not rocket science. So you don't need to do anything past the finger. The finger's completely dead to the world with the digital block. But the palm can be very, very problematic. So you may want to think about going proximal on their hand too, because they're going to be pretty sore when they start pulling. But yeah, you know, at tenolysis, this is what Wellant was built for, I guess. I mean, if you think about it, they're doing the work for you. I don't really know where they're caught sometimes. Even until I see them pull and I see it, the tendon, they'll tell you when you're open, you'll see where they're getting stuck. So that saves me a lot of time and a lot of dissection. So I can sort of skip around when I see their tendon moving approximately in the palm. I know it's caught here. I can go directly to that area, which is less incision, quicker time. I really think Wellant is the gold standard for tenolysis, in my opinion. Yeah. I mean, I've had, I like that you mentioned going proximal, because I think the books underestimate what you're supposed to do. Don's book has a great picture in it, but he has nothing proximal, you know, in the distal forearm. And the problem is, if you're suddenly going to start skipping around, and you didn't block or anesthetize that site, it's real pain. Yeah, you can put some 2% lidocaine in there for a really fast onset, but you have no epinephrine effect, right? So now you're gonna be swimming in blood. So I always go into the distal forearm and tell the patient, we're gonna make as big an incision as we need to, and, you know, get them on board with that. And so, you know, in this case, had to go all the way into the distal forearm to get her freed and open. And then she's able to see what can be done right away, right, because they're watching it. And so I think that that makes all the difference. So, you know, keep going until you have full range of motion. Like Greg said, you can have the patients do those little mini ruptures. Sometimes you don't need to extend the incision, you just have them go pretty hard and they can do it. You do need to be careful, because a flexor tendon that's been tenalized is also delicate too. And I think that's important to remember. And what I would say is, even though you might not need a lot of cauterization when you're doing a distal radius fracture, you don't want blood on the tendon that's been freed, right? So I do a lot of careful hemostasis with bipolar before I close, because when the epinephrine effect wears off, you don't want them to have bleeding on the tendon and fibrin collect and then you're in adhesions again. And I always video it for them, you know, so that the patient has the video as well as the therapist has the video. I think that makes a huge difference. But like I said, it does weaken the tendon. So I'm pretty easy on their motion immediately. I don't have them move right away with therapy. I actually let them cool off like three days or so. So I'll do it on a Friday. They can start therapy, you know, Monday. Just gentle protected motion with them, depending on how extensive your tenolysis is, because you don't want them to rupture. And then hemostasis, I don't think can be advocated enough. It's really, really important in this procedure. Do you guys do right away or do you let them cool off before you move them? That friction bleeding is real. I've been burned by that. You know, we all know tendon after you repair it is weakest at week two. That friction bleeding in that first two to four days can really burn you after tenolysis. So I think you got to start them at day three, day four. I'm sorry, day five even. You know, you're not going to win it in a day. You can set them back by getting a hematoma or a friction bleeding. So they know they can move it and they're not going to scar in, in like a day. So just be wary of that two to four day friction bleeding because that can really set you back. Especially with nerve injury, cubital tunnel, that's another one too. You do a beautiful cubital tunnel, five minute surgery, whatever, and then they start moving their elbow and they get that friction bleeding and all of a sudden it scars in the nerve. So that friction bleeding is something that you're going to have to learn the hard way seven years in practice. So, Oren, I'm going to hand it over to you to have you finish up with our basal joint. Thank you. Sorry I came in a little late. So I'll be excited to talk about some bones now. So first question, of course, is why, right? Why Wollant, or in my case, Wollat? And I'll get into that. So patient preference. I just talked to patients, I give them this option and many of them would prefer to be awake. They're afraid of anesthesia. Lower medical risk for certain patients, for sure. Scheduling flexibility, and this is related to anesthesia shortage. Is anyone else having an issue getting anesthesiologists in your neck of the woods? I know it's not universal, but where I am, I mean, the anesthesia groups have literally imploded overnight. And I've shown up at my surgery center with a patient ready to go and they said, I'm sorry, we don't have anesthesia. So this is extraordinarily empowering to have another option. It's fun for the surgeon and patient. I do enjoy talking to patients and they think it's really cool. And it's really just another tool in your toolbox. And as we all know, not every patient is a good candidate, but my experience is that the vast majority are. So the caveat for LRTI, or let's just more generally say thumb arthroplasty, is first of all, I use a tourniquet. So I find that patients can tolerate about 22 to 28 minutes of a tourniquet, and it's just easier. So I still put epi in the injection. When the tourniquet comes down, it's not profusely bleeding, but if I have to let it down, I don't have a problem with that. I do perform this in the OR. This is not in like an office-based procedure room. I have power and anything else available if I need it. And I will admit, I inject much faster than Dr. Lalonde does, and it's not painless. And I tell patients, I said, you know what? I used to tell them, this is not gonna hurt, I'm gonna go slow, and it's still painful. So I just tell them it's gonna hurt, it's gonna feel like a shot, it's gonna be about 30 seconds, and then once the first bit numbs up, it's much easier after that. And I had previously modified the more traditional LRTI that I used to do to the suture suspension sling, which I just find simpler, and that certainly lends itself more to doing it under local, simply because you only have one incision and you're working through the same spot. But I have no issue with you trying to do it any other way, because I certainly think you can do it even with harvesting FCR. And then lastly, you can always add intraop, always, always, always, and for your first few times doing an LRTI, you might have to, and I'll explain why. So in terms of the technique, if you're not familiar with it, it's basically just sewing APL and FCR together. You're working through the same incision. Now this particular, or sorry, not this paper, but there was another paper that talks about the benefits of doing it with the patient wide awake so that you can get the tension on that suture just right. I have not found that to be a particular problem, but I suppose you could use that as a rationale if you need it. So in terms of the actual details of the injection, and by the way, I should say, I don't view this as my job to teach you a new technique. Everybody knows how to inject local and everybody knows how to do a thumb arthroplasty. But I want to show you that it's possible, because many of you, I assume, have never tried because you just didn't know it was possible. And so maybe once you see that it is, you'll get the confidence and try it out and see how it goes. So I find that it's about 30 to 40 cc's. I use a mix of marcaine and epi with, or marcaine and lidocaine with epi in at least one of them. And the challenging location is where the star is. So I usually start around the first dorsal compartment as if I'm doing a de Quervain's, and I inject from there up to the thumb. And then I come volar and I inject the Wagner incision and I get FCR and I kind of direct my needle a little bit towards the median nerve and maybe get a little bit of a median nerve block there in the distal forearm. But then I go dorsally and I go to where that star is. And you need to inject basically at the convergence between the base of the second metacarpal and the trapezium slash first metacarpal, and you get it dorsally, and then you get that needle right in that groove and you go volarly and you inject like five or more cc's in there. Because that's the hardest corner to get. And when you're doing it your first few times, that's when the patient's gonna have pain when you're pulling out the trapezium deep, deep, deep in that corner at the base of the second metacarpal. And when they say, you know what, I can feel that a little bit, you get a needle and you just squirt a little more lidocaine in there because it's wide open. So that's the only challenging part. But once you do that, really the surgery is a breeze. So here's me injecting. I don't sugar coat it. I don't wear gloves. I do it right in pre-op. My patients are usually just sitting there comfortably and I adjust to whatever position they're in. And just give the injection. It only takes about maybe three to four minutes most. It's only three or four syringes. And I give it about 20 minutes to set up. By the time we roll into the OR, the timing is set up. As I mentioned, I use a Wagner approach. I take out the trapezium in one piece. It's a pretty quick procedure in general. It doesn't normally take me longer than 22 minutes to do the operation. And I do leave the tourniquet up until the very end when I do let it down to control bleeding. And I do have the patient show me that they can move their thumb. I make sure that the metacarpal is suspended and that it's not subsiding back down onto the scaphoid. But I don't think that's necessary. But because the patient's awake, I think it's cool. I have them give me a thumbs up. And so here's the patient kind of putting her thumb up so I can show you that. And then post-operatively, they typically walk out of the OR. One of my surgery centers requires them to go on a gurney. But here she is waving, saying thank you. She's very comfortable. And then everything after that is perfectly routine. You know, I bring them back for splinting or casting and therapy. But the number one thing that this gives me is confidence. You know, when I know that I can do surgery under local, then I don't stress. If the block's not working well, if the local's not working well and I need to give more local, or if my anesthesiologist doesn't show up, I can make it work. So I've used local only for proximal ulna. I've done a lot of distal radius. I have a scaphoid on Monday with bone grafting that I'm using because I'm just confident that I can get the patient comfortable. And if they're not, then I can intraoperatively give a little more to make them comfortable. So it gives me a lot of flexibility in my setup. That's all I got. Great, thank you. Thank you. to our panel, and we can just keep it nice and chill. Yeah. How do you peel off the trapezium in one piece off the FCR without bagging the FCR? That's a good question. That's probably hard to describe verbally, but you come over the FCR sheath, and then you pull the FCR back with a rag now, and your knife can slide right underneath along the underside of the trapezial ridge, and it's kind of blind. You just have to trust it. You just aim straight for that second metacarpal underneath the FCR, and if that rag now is holding it back, you can usually just slide it right in, and if you're concerned about it, you can take a ranger and take off that trapezial ridge, and then you can see the FCR and do the same thing. Do you use a knife to do the whole excision? Whole thing, yeah. Good question. Typically forearm for this, if I'm doing a distal radius or proximal, I do put an arm tourniquet on, but for this I would use a forearm tourniquet. I don't. I have in the past, but I haven't found it to be that useful. I do 250. I think you could probably go 225 and be okay, depending on their blood pressure. When they start to squirm, I just, you know, it's always the tourniquet. And I just tell them, you know, we can let it down now, depending on where I am. But as it's going up, I say, you're going to feel a blood pressure cuff that's going to stay on. It's going to get uncomfortable. And if it does, just let me know and we'll let it down. Right. Yeah, I think it's a great question. First off, I think it's important to understand how long you're gonna have an epinephrine effect. I mean, from experience, as well as injecting myself a billion times, you stay anesthetized on average like seven, eight hours, but the epinephrine effect only lasts about four to five hours. So if you're gonna butt up against that four hour mark on a case, especially if you already burned through an hour of that while they're waiting or an hour and a half of that while they're waiting to get in there, you do need to be mindful of your timing and be aware of how long does it take you to do a case. Surgeons are notoriously bad at that, which is why anesthesiologists don't like us when we say it'll only take 10 minutes. Yeah. But you have to be honest with yourself about how long do you take to do something. And if you don't time yourself already, I recommend you do. Number one, I do it. I keep a log of all my times for all my CPT codes. And so when I book a case, I know exactly how long it takes me. Anesthesiologists then start loving you, number one, and you'll get all the extra rooms you want and add-ons, no problem. But number two, then you know how long it takes you to do these things. And you can appropriately adjust for what you're doing. And in terms of the case duration, I mean, number one, I tell the patient, it's okay to move, don't worry about it. Just tell me if you're gonna shift and we'll stop and let you reposition, wiggle around. You wanna roll on your side? You wanna reposition? No problem, just tell me. So I take the knife away. Number two, I let them watch movies. I let them listen to music. It's not uncommon they fall asleep on the stretcher during a long case. I'd say that's usually the case. But especially when I'm doing kids, they sit there with an iPad and they're watching Spider-Man or whatever. And it works out really well. So I think those are the things to keep in mind, at least that I've experienced in the big, long cases. You guys have anything else to add? Not necessarily for long cases, but for patients who aren't comfortable supine, it's such a great benefit that I let them lay on their side if they have a bad back. Or I've had patients who just stay in their wheelchair and put their arm out, and that's really nice. I just think for those of you who are trying to build your practice, I think it's a great niche. I think you can do so much more. You can reduce fractures in people with incredible comorbidities that need surgery, but they just can't tolerate anesthesia. The other thing is I take care of a lot of athletes, so it's always pressure to get them back on the field. They come into my clinic on a Monday morning with a scaphoid fracture, and I can literally do it after my clinic. They eat, right? I mean, they always come in eating, right? So I'm like, okay, well, my clinic ends in an hour. Let's go upstairs and do it. So any sort of open trauma, you can just do it. You don't have to go to a hospital and wait all night. I mean, it just allows you to be so flexible with your time and get home to your family. Plus, you're gonna generate revenue for your practice where you couldn't otherwise instead of sending things to a hospital system. Sarah, anything you'd add to that? No, the same. I kind of agree. I'm time-dependent. I'm a plastic surgeon, so I'm slower than some of the ortho guys. So I tend to take time into consideration. So I don't do dysterratious fractures under Welland yet. Just on the athlete side of things, I take care of a pro team as well, and it's all about getting them back. What can the fracture tolerate? It's pretty nice having them under local, under fluoro. Move, do stuff, stress the fracture. You're gonna know how good your fixation actually is. If you're pinning, you're gonna see if you need to add a pin or if you need to move it, if it's gonna shift. If it's gonna shift in the OR, it's definitely gonna shift when you're out of the OR. So I've moved to doing that as much as possible for my fracture fixation. And I actually do a lot of intramedullary nailing, nailing with screws. And so the benefit of, and I do it under local, and then I'll have them move and see how stable is my fracture? How is everything holding up? Is my extensor tendon getting stuck on anything I need to free up after I went through it? Stuff like that. And it's pretty nice. You can get people back on the field really quickly. I highly recommend it for your finger fractures. It's awesome. And it's a digital block. Everybody can do that. Yeah. So there's a second edition of the Walnut textbook that Don Lalonde is the editor. But each chapter in there is by different kind of leading experts in the field for those things. There's a ton of video with it as well. So it's not just a textbook, but there's a lot of video that goes into it too. So it's a great, great starting learning resource. I highly recommend it. And the resources on the ESSH site also has previous Walnut talks that are really helpful. Yeah. And if you buy Don's book, he donates all the proceeds too. So you don't have to feel like you're padding his pocket. It goes to Nepal, Kenya, random other places. It was it was a big problem after the hurricane. Yeah, Puerto Rico. Yeah, really big problem Yeah, that's also where all the normal saline bags. Yeah But you can you can also you can make it up I mean, it's a pain right you can make up your own to mess it with you know a bag of saline and an ampule of epinephrine you know when I do I Mean, that's what I do when I do lipo and make my own to mess it before I inject it, right? I'm not pouring a bunch of little bottles of light. Would that be in there making it myself? Just with an ampule that be in a liter bag of saline So I've had to use it once I actually thought about putting the picture in here when I was I did pre-screening That's by the way, you should do that. You can't give this to people sclera. You can't do this in people scleroderma Big mistake if they actually have Raynaud's I would counsel you not to do it They usually don't know that it's called Raynaud's So if you ask them like no, I don't have that like do your fingers turn different colors like blue Red white when you're in the cold, can you tolerate that? And if they say yes I would not do it because the only time I had to do a rescue was in a Raynaud's patient who Said no, I don't have Raynaud's but she had no idea what that actually meant And she came To the ER. I think it was like 36 hours later with a finger. That wasn't white. It was dusky And I was like, oh my god. I'm killing a finger and Injected fintolamine which hurts by the way If you've never done it Before it's a painful injection because they get the rush of blood back for the reperfusion and the reperfusion is pretty painful so And luckily everything was fine after I did that and it's immediate like you inject it and it's like boom pinks right back up It was amazing So it was that's the only time I've done it but before my flaps I have it on the side Just because you know, sometimes If your injections aren't great, you're doing something big you're by the pedicle You kind of worry about having that vasospasm there So it's not a bad thing to have available for you for like the bigger things Dupuytren's severe dupuytren's is another one that that you got to worry about when you straighten them out. They can spasm a lot. So You know if you got a severe Dupuytren's now, you're afraid you want to check Make sure that finger pinks up. That's another one. You want to probably have that available or maybe not do it at all Or a verse what you do is you buy or a verse it's what the dentists use That's what I buy. That's what I carry around and you know in my office and in my bag And it's been Ptolemy Called by a different name. It's way cheaper. And when you buy been Ptolemy you just buy or a verse because they sell it to the dentists Yeah, and and and you can get it from like Henry Schein for pennies Pennies cheap really cheap Oh god. Yeah, I mean, I think for getting it to patients, it's all about how you talk to them about it. I mean, I have videos in the talk, right? I have a bunch of videos I show patients, too. I'm like, no, it's going to be so easy. Look at this. And then you're going to go walk right out of the OR, and you're going to drive yourself home, and it's not going to be a problem. But as for getting it into places, I've started three Walnut Rooms in academic centers, different ones. And yeah, it can be a real uphill battle. But there's a couple of ways to beat it. One, and what I found is I go to the person that has the purse strings. Usually they're pretty high up in the hospital, and you show them how you're going to save them money. And all of a sudden, they're like, I can get a bonus this year. And then they're on your side, right? Because they only get bonuses if they save money by cutting things. So that's number one. Number two, AORN has changed their guidelines. So your nurses are actually not following current AORN guidelines. Current AORN guidelines were changed to reflect that only one nurse needs to be in the OR for a local procedure. So you can throw their own regulations at them. I think, yeah, I mean, they need to know, right, they need to know. The other thing, too, is that, so I run into this sometimes, and even in private practice, my partners are like, why are you doing, especially if you work for a hospital, the hospital sees a facility fee if you're taking it out of the facility and doing it in your office. Well, there's certain ways around that, but for me, my partner's like, well, why aren't you doing it in our OR that we pay for, and then we can get a facility fee. And I'm like, well, I could do it in the office and I could have my spine partner doing a more complicated case. So if you all work together as a team in private practice, we understand that me doing surgery sort of outside of a big OR with very expensive anesthesia and nurses, keeping those resources on the bigger cases, your spine cases, your joint cases, for me, has helped our group as a whole. So it's a little bit of a selfless thing on my part. I'm willing to sacrifice my time and energy to doing this new procedure and keeping them in the OR where they belong. So, in your case, maybe just show that I can stay out of the OR and the other hospital employee orthopedic surgeons can be doing a better allocation of resources. Yeah, because obviously, if I do it in the office, then I can still do it in the OR. Right, right, right, but as a hospital employee, depending on where you're working, like, I mean, I'm in New York, so you have to be in Article 28 in New York State to be charged a facility fee. Well, that just means that instead of doing it maybe in my off-site office, I'm gonna do all my wallet procedures in the office that's in the hospital. And then the hospital can bill a facility fee, right? So you sometimes have to adjust things for where you wanna do it. Like, the wallet room I currently have set up is in the hospital building above the surgery center. So it's in the same facility, and they charge a facility fee. That's one of the selling points to doing it. Yeah. At one of the hospitals I was working at in the clinic itself had a procedure room. There was a room that was converted into a procedure room, which was really helpful, because if you're seeing a patient just for time-wise, if you're seeing for the smaller cases in consultation, you can have them just walk directly over, two rooms over, and do the procedure there. And I feel like that was a good setup in hospital-based practices. The last part is, yeah, I mean, you probably don't get to negotiate your contracts, but in private practice we do. So we can use that as a selling point, say, look, okay, we're cutting out anesthesia here, so we want a higher physician fee, or we're actually, we're with a group right now that are talking about even getting the CPT coded, for you're basically doing your own anesthesia, which I think you should be able to bill for. So as the movement continues, I think you're gonna see a lot of payers, especially sort of attracted to it, particularly because it's cheaper, faster, quicker return to work, and it's safer, yeah. But I think also we may even be able to bill for our own anesthesia, which would be a huge selling point. That'd be great. In my old practice, before I was full academic, we negotiated, my group negotiated with Empire Blue Cross Blue Shield, and we told them, hey, look, we're gonna take certain codes, but for example, all the carpal tunnels, all your patients' carpal tunnels are gonna be done in the procedure room, unless it's medically necessary to do it in the OR. They have scleroderma, they have Raynaud's, whatever, right? And in return, for us doing that, there's a cost to doing it in our procedure room, and we're cutting out anesthesia for you, we negotiated 50% higher rates on my professional fee codes. So some payers were like, no, they didn't even wanna talk about it, but other payers came to the table, and that makes a big difference. Yeah, for the Medicaid, right. Right, Medicaid, you're losing less, Medicare, you're losing less, but Blue Cross Blue Shield, Cigna, Aetna, whatever, sometimes they'll come to the table. Yeah, but they can save money, you know? I mean, you're in the hospital, too, but you can tell your hospital, hey, still bill the facility fee, and use the OR for something else. All right, thank you guys so much for giving up your afternoon.

hand surgeries

wide awake surgery

local anesthesia

epinephrine

lidocaine with epinephrine

soft tissue coverage

nerve procedures

postoperative swelling

patient compliance

recovery times

flexor tendon repair

patient autonomy