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A-1124 Getting Better Results with Wide Awake Surgery
Donald Lalonde, Canada
Thursday, June 14, 2018 · 8:02 a.m. · 18m 43s
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that's very kind of you to all come up so early in the morning and be wide awake a welcome uh
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there are many reasons that i think we get better results with wide awake surgery and
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the more years that i do this the more i realised that
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inter operative patient participation uh it is a very important part
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this slide was given to me by my cake and from
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the u. k. this woman is a professional mountain climber
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and she ruptured eight to a three and a for a while
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climbing they were all gone and mike did a pulley reconstruction
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using the extent to redneck alum from the rest
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and it was very nice for him to see that the police were
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all working and it was very good for the patient to see
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that the hand could work because you can imagine the rehabilitation knowing that
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she could get a better result and also there was no bow string on the wrist which was helpful for him
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tom up out who's uh in the audience uh to date
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i did this case of somewhat saving extends occur peel merits
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and when you're in there it's very nice to be able to see exactly why it's
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a black siding with active movement and also to make sure that you get
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a good result on the table with active movement not
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just hoping it's going to work with passive movement
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and i think that the concept of inter operative
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teaching of the patient to decrease complications is extremely important
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much more important than talking to the nurses about the weather or the has the z. all just about a sailboat
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ah
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ah ah ah ah us how ah ah ah ah yes
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oh ha ha ha ha ha ha ha
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ah
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ah ah ah ah now or are now only one yeah i ah
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our ah ah ha ha
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we teacher patients how to take painkillers it's part of the
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reason that i never need opiates for carpal tunnels
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n. trigger fingers because they know what's going to work and i say to them so what do you normally take for pain advil
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tylenol nothing they say add aussie perfect that's all you're gonna need for carpal tunnel it's not gonna hurt more than that
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then this is a case that i learned a lot from this was a man
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where i got a great results on the table for flex or ten repair
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and then he ruptured and part of the reason he ruptured is because the day that i did his surgery
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i spent most of my time teaching the residence during the case and i did not spend enough time
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educating and getting to know the most person important person in the room who's the patient
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and i totally miss the fact that he was a drug addict uh he still
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might have ruptured let's face it but maybe not you know maybe i would
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have put him in a cast maybe i would've done things differently but the case
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type any but the most important person in the room is the patient
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and that's where i should be focusing my time during surgery is to educate
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the patient when you're yeah what can we turn up the volume things
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all right please turn up the volume yeah
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moving just a little that so it doesn't get star
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uh_huh right but not to move to match so do represent part
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it doesn't take much to her heart
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uh are only one as strong as your time
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so they won't tolerate movement they will not tolerate using
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you're not a name use a hat all you're just gonna
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move a just hum so it doesn't get star
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ah what's the most important rule
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you start moving
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what okay her rule when you turn right or whatever
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so it's monday morning you've got no every moment how on board were three days after
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what certain number was the most important rule me like the movie mogul product reviews
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and i think you're starting to see a pattern here and i do it
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every case every time every operation i'm teaching patients all the time
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and it's it's a golden opportunity to uh get a better result
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now many people can now afford hand surgery where they could not afford it before wide awake and surgery
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there's a wide awake hand surgery operating room income messy again and now that wow we opened in
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last year before that the patients had to pay a minimum
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of one thousand five hundred american dollars to have any hand operation and the main operating
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room people income s. again i could not afford that and most people just
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didn't have their hands operated on that come to the hospital and
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leave without having their flights or ten record then now
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this is right outside the main operating room it's with field sterility and they can
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uh have their hands repaired for seven hundred and fifty dollars because it's now
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it's become is still very expensive for them but at least some of them
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can now afford it and they're using this room all the time now
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that this is a doctor near a mob from kuala lumpur and
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uh this is his case of various carefully need fusion
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and he's just published in the american journal hand surgery a
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distal radius fracture but he's not the only one
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doing it to a should come to the aid to mop are in a number of other people
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uh christos um have also started plating distal radius and it's not because
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there's so much you seen the movement it's just the cost
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in many countries like in canada people are gonna have it done and don't have to pay but in many countries of the world
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they can't afford the surgery because they can't afford the anaesthesia uh
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obviously you're still gonna needful sterility to do these cases
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patience to see their result during surgery have realistic expectations of what they will get
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after surgery so they know that they're not expecting more than they're gonna get
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but they work harder because they remember seeing it during the surgery if there's zero sedation
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if they're sedation then they don't remember which is why wide awake no sedation
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so this patient had a very bad to patrons and during the
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surgery he told us you know i look after my wife
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uh she has alzheimer's i washer everyday i bathe her
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so we knew what he was going home to
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so we simulate a relative motion flexion split because
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uh with m. p. hyper extension he could hardly extend his hand actively extend his p.
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i. p. actively so he knew why we wanted him to where the split
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we put him in this three days after surgery so that his m. p. would not hyper extend and
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his p. i. p. would extend and so he went home any bathe his wife and showered her
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he wore the split at night
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any came back two and a half weeks after surgery and you can see that he's been wearing the
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split just as we asked them to do he knew why he had to wear the splint
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and look at that p. i. p. extension after a solid the i. p. and
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p. i. p. do patron scored because the m. p.s not hyper extended
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and he understood it and here is a year later after the surgery with the still a pretty good result
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this lady came to me after she had been treated with four weeks in cast
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then the plate another four weeks in test then attain a license under general anaesthesia
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but they left the played him so i inherited it totally stephan p. joint
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so we took out the plate there i'm lifting up the extent sir tendon
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there i'm underneath the joint capsule which i'm going to divide anterior
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really right there then i divide the collateral ligaments right there
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and then we get the patient to actively move helped me get rid of
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the last few it he asians 'cause that's always how over our
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is pretty forward
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yeah
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oh yeah yeah yeah
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argue over there
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no
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yeah
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yeah
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oh my what a reason why ah
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our room
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oh so she knew that she might not be able to abducted
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she knew that she wasn't gonna get a full first
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i knew that her act her active was not as good as the passive
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and also with active movement i could see that she was sublet saving a little
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but so i decided to put a temporary k. wire for ten days
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and at ten days i took out that k. where we put her in a relative motion flexion splint
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uh so that we could drive the p. i. p. extension to the p. i. p. joint take it away from the m. p. joint
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and here she is it for months post op and she managed to maintain what she had in the operating room because she knew
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that's what she was gonna get that you did not have an unrealistic expectation and i think that's a very important thing
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did you get a clean cut flex or tendon in a cooperative patient you
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should get a good result almost every time in two thousand eighteen
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jen boat paying has taught us that you can vent the a four
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and here you see in this case the a four is vented
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there's no clinically significant bow stringing during the surgery
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and there's no clinically significant bow stringing after the surgery i'm gonna show you three more cases of
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that's for those of you who still think that the a four probably as a sacred cow
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this one eight three and a four are both that that there's no clinically significant those training during
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the surgery i say to the resonant worse the boss tray you see i don't yeah
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and there was no politically significant pose stringing after the surgery think i had to fit under the eight to array
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for probably now i know i don't need to worry about that anymore and i can make a poppy repair
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my bulky repair will not come apart and gap the grandma
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cats repair comes apart and gaps let me show you
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this is a patient tom up are taught me that i can do f. p. l. problem
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and so we did her f. p. l. prone that looks nice doesn't that nice
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looking repair now watch when i test it watch it start to gap
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there's the gap moo moo moo
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ooh that's bad right patients are sleep
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but when they're awake you see it you fax it and then they don't rupture and that's a good thing
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seven percent of the time these graham marcus repairs come
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apart because when the patients do active movement
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to the tendon bunches in the suture with the forces interactive movement
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you think your to your sutures tight enough but it's not
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and so we know that we decreased our rupture rate by seven percent
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because in this series that i did with mike bell from ottawa
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seven percent of the time we saw these graham marcus repairs come
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apart during surgery and then we had the fax them
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and so no more grandma repairs for me i make it bulky and make sure that it
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fits through the repair you need both you need to make sure there's no gap
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and you need to make sure that it fits through the pulleys and you just
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divide enough poly so that you're not gonna get clinically significant pose stringing
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and you make sure that there's no gap with repeated
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full first flexion and extension testing during surgery
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and if one of you in this room gets a clean cut in two thousand eighteen
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anybody in this room should be able to get a consistently good repair and a good result
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which when i started my surgery thirty years of thirty five four years ago i gotta tell you
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my results sort they were no that occasionally i would get a good result but now
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we should get a good result every time so don't tell me there's nothing human tendons or
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a lot here that anymore we no longer do full first place and hold either
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we do up to have a festive true active movement so
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let me show you simulating full first place and hold
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when you passively flex its stop spending right there you see the tendons not bending
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it's boggling and then when i say that the patient okay hold that watches jerk right
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there you see that jerk also to you again you passively little but it stops moving at half a first and
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then you bring it in all the way it's not moving and then you say that the patient hole that
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and when they hold it it jerks right there so we call that full first place and jerk
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we don't call it fulfils place and hold anymore and i don't wanna jerk of freshly repaired flex or tendon
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so true active movement is the way to go by the way in his case we vented
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a three and a four and there was no clinically significant most training after surgery
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the second reason we don't do full first place and holders because wide awake
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flex or ten repair has taught us that we only need half
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of best to give us five to fifteen millimetres of profound disquiet we
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don't need the full first we only need half a first
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if patients have that medical co morbidity is the safest sedation
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is no sedation like going to the dentist will
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this patient was a high risk here
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she had diabetes
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oh
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ah
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right so here are two weeks we just make it fast
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and straighten out great
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was looking pretty gonna or i would not put this guy to sleep so i'm sure might be a nice that just wouldn't
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seeing the matter carpal grinding or not on the scale for it is helpful to decide me if i want to do
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a ligament reconstruction after trip easy acting yeah this is the
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base of the mother for o. k. for a while
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what are the hooves oh two or four so who phone
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oh okay so in that case i did a ligament reconstruction
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but most of the time when they do that there's no grinding so i stopped at the
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trip easy active me as six prospective randomised control trials have told me that i should
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better results for the environment
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more than ninety percent of canadian carpal tunnels or don't like this with field sterility
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and we proved with one thousand five hundred consecutive cases that
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this is very safe from an infection point of view
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only six people got superficial infections nobody got incision and
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drainage or i. v. antibiotics or anything like that
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and so for carpal tunnels and trigger fingers you don't need all of this garbage
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this is the main operating room full sterility garbage for one case
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and this is the minor procedure room field sterility for one case
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which is how we're doing them almost all in canada now
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think of all of the garbage that we put in the environment that's
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totally unnecessary what we really need is evidence based sterility we
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have to stop this business of if some is good more must
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be better sterility it's nuts we only live on one planet
