Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, we're highlighting new frontiers in hand surgery, nerve transfers, WALANT, and thumb replacement, what referring physicians really need to know.

Joining me is Dr. Peter Tang. He's a Professor at Drexel University College of Medicine, Chief in the Hand Division, and Program director of Hand, Upper Extremity and Microvascular Surgery Fellowship at AHN. Dr. Tang, thank you so much for joining us today. Hand surgery has really evolved rapidly over the last decade from microsurgical innovation to workflow changes like WALANT or Wide Awake Local Anesthesia No Tourniquet. When you look at the field today, what feels fundamentally different compared to even five or 10 years ago?

Dr. Peter Tang: I think something that's been changing rapidly in the last five, 10 years is how we're delivering care in a more efficient manner. And we're trying make it more convenient for patients and trying to cut costs. As we all know, healthcare's cost is going up, and we're trying to be as efficient and economical as we can in hand surgery.

So, one of the newer things that we've been doing that's very popular these days in the United States is WALANT, which is Wide Awake Local Anesthesia No Tourniquet. It was started in Canada because, in their health system, it is difficult in a socialized system to get into the operating room. So, many of those cases, these smaller hand surgery cases like carpal tunnel, trigger fingers, are being done like in the office setting or procedure room instead of the main OR or the surgery center. And that prevents costs. And also, these kind of things allow patients to not have actually anesthesia like twilight sleep. So, they don't need pre-op testing, they don't need someone to drive them home. They can take themselves home. So basically, we'll give them anesthesia in terms of injections that localize the field. And then, we're able to do the surgery without causing pain for the patient safely, and take themselves home at the end of the case.

Melanie Cole, MS: So Dr. Tang, that's been a real paradigm shift. And from your perspective, as we think about what's driving the adoption of WALANT, tell us what procedures you're now routinely using it for that you might not have considered before.

Dr. Peter Tang: So when I first started my practice, I was doing most of of my carpal tunnels with local and sedation. And I was always concerned that when I was operating around the nerve, people would get irritated while we're releasing pressure on the nerve and the patient would jump. But for the most part, patients are very comfortable doing the simple things like a carpal tunnel relsease. It has gotten to the point where, in general, we would also do a lot of digital nerve injuries in the ER with this local. But now, even sometimes, we'll—in certain circumstances, toy know, when patients need it—we'll do, like, amputations in the emergency room or even in the operating room with just local anesthesia. So, we're trying to do more things for the patient to make things easier and convenient for the patient but but still safely.

Melanie Cole, MS: Well, from a patient's experience and from their perspective, how do they feel about this? When, I mean, they're wide awake, it might be a little bit disconcerting or a little scary. Tell us about how you ease their fears about it and what recovery is like.

Dr. Peter Tang: So, there are some patients obviously who are a little bit more anxious than other patients. And then, for those who are very, very anxious, we'll just tell them that you have the option of deep sedation. It'll just make it easier, so they're not awake. But for the most part, people are pretty okay with the idea of doing this.

So, oftentimes, if people get anxious, we'll talk to them during the procedure. We usually have a nurse sitting with them behind the drape. So, we hear about various stories about patient's pets and their family and where they're from. And sometimes, we'll get the whole life history of the patient because we're doing a procedure. And our nurse, as part of the healthcare team, is, like, talking to them, just finding out more about them. And also, in the process, we're like allaying their fears. So, we obviously, you know, try to keep them calm during the procedure. And oftentimes, the procedures are pretty short, and so they're not very long, so the patients are not sitting there or lying there during the procedure for long periods of time.

Melanie Cole, MS: Let's move on to new nerve repair techniques. Tell us a little bit about nerve transfers. This is one of the most exciting areas. And for listeners who may not be using this yet or may not be familiar with it, how do you explain the concept in practical terms? What type of patients are you now able to help that historically had very limited options?

Dr. Peter Tang: So, one of the things we offer at AHN are nerve transfers for severe nerve injuries. And so, the basic concept is when there is a damaged nerve that doesn't have good signs of recovery, there are certain nerves that are in the vicinity that are expendable, where we can take the nerve and transfer it into the side of the injured nerve or into the end of the injured nerve, and then hope for nerve regeneration from the donor nerve into the injured nerve to get important function back. So, This is something that not a lot of places offer, and we offer it as part of like the range of services that we can offer patients at AHN. So, it actually is quite fulfilling seeing a paralyzed muscle that's not working for months, and then you do the surgery. And then, some months later, you see that muscle that wasn't moving at all actually come to life and, like, fire, and that's quite fulfilling. They don't always work. And then, there's some nerve transfers that are better than others. But for the ones that do work, it can be life-changing.

Melanie Cole, MS: Dr. Tang, as I understand it, timing is everything with nerve injury. What should referring physicians be watching for so they don't miss that window? And how are the outcomes comparing to traditional nerve grafting or tendon transfers that we've been doing all these years?

Dr. Peter Tang: Yeah. So, it really depends on the type of injury and type of dysfunction that they have. There's some things that I feel are better with tendon transfers. There's some things that are better with the nerve transfers. It really depends on, like, how your training is and your what philosophy is.

But in general, nerve transfers should be done within a year. So, it is better for us as the people who actually do the transfers to be able to identify these patients early. So whenever someone has a nerve problem that doesn't seem to be recovering, we would prefer to see them the first few months. It's always very sad to me and disappointing for me when I meet with someone that I could have potentially offered them a surgical option that might have helped them, but they ended up seeing me for whatever reason over a year out from their injury. So, that's outside the window.

And the main issue is when a nerve doesn't work it's cut or just not functioning, the connections between the nerve into the muscle, which we call the neuromuscular junction, they start disappearing. It starts happening immediately. So basically, even if you transfer a donor nerve into an injured nerve after a year and the axons regrow down to their target muscle, those connections between the nerve and the muscle are no longer there. So, the transfer will fail . And there is research trying to, like, keep those neuromuscular junctions open or intact, but nothing has shown to, like, successfully do it definitely. So, that's why there's a time limit to it.

Melanie Cole, MS: Well, thank you for telling us about that. Now, tell us about the exciting new thumb replacement surgery for thumb arthritis. It's so critical to hand mechanics, the thumb and the function of it.

Tell us about some of the newest options in reconstruction or replacement, and how are you deciding between these newer reconstructive techniques and arthroplasty or fusion or some of the techniques that have been around a while?

Dr. Peter Tang: So in this country, our standard of care for thumb arthritis, which is a very common problem, for what we call thumb CMC or carpometacarpal joint arthritis basically. And it sounds a little bit unusual, but we take out the trapezium, which is one part of the joint. There are a number of options, many options that are out there where we try to do something where we prevent the thumb metacarpal from falling into space that's left behind after we take out the trapezium.

In the United States, that's been the most common surgical treatment or variation of it for the last probably thirty, fifty years. But interestingly, in Europe, they didn't go that route, they've been actually doing actually thumb replacements, basically, which is basically what we do for total knee and total hips, and that has been shown to be very successful and predictable in terms of good outcomes. But in the States, we just haven't gone that route. But what's happening now is some of their technology and their ideas have been adopted in the United States, and there is a movement here in the States to do thumb replacement surgery for CMC arthritis.

So, we're just in the beginning phases. My division's thinking about actually starting a randomized trial to look at trapeziectomy, which we do in the States versus a thumb replacement and look at outcomes. But much of the literature that's been coming out of Europe has been actually very agreeable for thumb replacement surgery. So, this might be something that we might be doing, maybe the new standard of care in the united States.

Melanie Cole, MS: Yeah, that's so interesting, Dr. Tang. And as I understand it, you have exceptional regional expertise in scapular winging. Tell us a little bit about why this is often underdiagnosed or misdiagnosed, and what clinicians should be looking for on exam. When do you consider surgical intervention versus continued therapy?

Dr. Peter Tang: So, scapular winging is kind of an unusual diagnosis, not very common and not something that a lot of people see. We teach it in our residency and fellowship programs. We often teach it as a nerve injury, because probably the most common way that it happens. So, a common one would be someone has an ear, nose, and throat cancer, and part of their surgical resection is taking the spinal accessory nerve, and that ends up giving the trapezius muscle a palsy, and that causes winging of the scapula. So, I often see those kind of people. And in those situations, the only thing we have as a treatment option is a tendon transfer to try to control the scapular winging.

Another thing that can also happen, I've also seen it, when people have done—it sounds unusual—but a Mohs for skin lesion in the region of the upper trapezius. It's been described in the literature that the spinal accessory nerve, which can be very superficial, can be injured and then also give a palsy. But again, very commonly, it's a nerve problem. But it is described in the literature that people have a tendon rupture of the scapula and that is a less common problem and then, usually, in those situations, we can actually do a tendon repair. I've done it for some patients and I've been able to restore them to, like, normal scapular mechanics. And usually, those people are the people who actually suffer like a trauma, a fall or a car accident, some sort of traumatic injury.

 One of my first patients was a person actually who was bow-hunting and then felt a pop around their scapula. And we had to repair and that really helped with pain. And they were living with the pain and on the transdermal narcotics for about two years' time. And then, after he had his surgery, he got off the pain medicines, which was like very satisfying for the patient and for myself.

Melanie Cole, MS: Yeah. So Dr. Tang, you've built a regional expertise here. I'd like you to speak about what differentiates a center that can really manage some of these complex issues that we're talking about here today, and shifting a little bit to the education aspect of this. How, based on this regional expertise, are you preparing residents and fellows for this new era of hand surgery and decision-making skills?

Dr. Peter Tang: You know, it is always a challenge to balance education and patient care. But we take it as part of our mission at AHN to do both. But it's important to, you know, be teaching the principles of orthopedic surgery and hand surgery to our residents and fellows. Because if we don't, then no one will be there to take care of us in the future. And then, our trainees obviously go out to different parts of the country to help patients and provide them with the care that they need. So, it's always hard, but we feel it's very important.

As part of our teaching, it keeps us at the forefront of what's new and what's out there, because we have these young trainees asking us these very like thoughtful questions, and it makes us thing and it keeps us on our toes. So, there's never a day where it's dull. There's something new going on, and you have to be keep up with what's new, what works, what doesn't work, in order to like teach them and also be able to answer, you know, your questions. So, that's really important to us and I have big passion for teaching my residency fellows.

And I think it's important, my hand division is up-to-date on what's new and innovative. But also, we have the ability to discern what may not pan out to be a good treatment for patients. But my hand division, importantly, can take care of the very simple things that people have, carpal tunnel, and trigger fingers.

But when things go awry or things are a little bit more complex, it's one-stop shopping for the patients. You know, we can take care of all of it. Because at Allegheny General Hospital, which is our level 1 trauma center. We do see very, very sick patients. And we see very, very severe traumas, and we're just used to taking care of complex injuries and complex patients. And so, I often have people traveling an hour or two coming to see us because there just isn't anyone out there who feels comfortable or has ability to take care of them out there. But we're here to offer those services. So, we can take care of very simple things. And it's great to do a simple thing and take care of patients, and people have great results. And then, some people come in for, like, very complex issues that we try to tackle because there really isn't anyone out there who feels comfortable taking care of it or have the resources to take care of it. But we're happy to try to help these people.

Melanie Cole, MS: Dr. Tang, you've given us so much great information to think about. I'd like a final thought, if you could give referring physicians a key takeaway to improve patient outcomes and anything exciting that you see as the next frontier in hand surgery, where the field is going? Give us your best advice and summary here.

Dr. Peter Tang: What I want to tell the people who are referring to our system is that we are very happy to take care of your patients, and that we are available. I personally have a philosophy that patients shouldn't have to wait to see providers. They should at least be get into our system, especially if they feel like the problem's urgent even if it's not urgent, but they're just concerned about it. We try to avoid that kind of worry for the patient, but we're here and available. I always make it a policy in my practice to get people in. If they want to be seen soon, then they just start driving. I'm here. We're available. And we're happy to help. And then, if there's a concern, just reach out to us, call us, message us. We're available. And so, we're happy to take care of them.

One thing that is new and exciting, we're becoming part of a multicenter randomized trial study, where basically there is a new technology that allows us to connect nerves if they're repaired within the first 48 hours to regain normal nerve function. And basically, it entails, like, putting the nerve ends and then placing this certain material and technology around the nerve to connect it in order for the nerve to actually maintain its integrity. Because in normal circumstances, once the nerve is cut, all the axons past the injury site degenerate, and then it has to regenerate. But this new technology allows the axons that are past the injury point that are distal to it, allows them to be maintained. So, this is pretty exciting. It may change the paradigm about nerve repair, because there is a certain time limit to it. But the primary repair needs to be done immediately. There can't be a giant gap in there.

Melanie Cole, MS: Thank you so much, Dr. Tang, for joining us today and sharing your incredible expertise for other providers. To learn more or to refer your patient to Dr. Tang, please call 844-MD-REFER, or you can visit findcare.ahn.org. Thank you so much for listening to this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.