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This study compared outcomes of plating distal radius (DR) fractures using wide-awake local anesthesia no tourniquet (WALANT) versus general anesthesia (GA). Methods: From March 2018 to March 2019, 20 patients with DR fracture underwent plating using WALANT whereas 20 patients who underwent plating under GA were used as controls. Outcomes evaluated were pain control, waiting time for the operation, hemodynamic changes, blood loss, the occurrence of adverse effects of medications used in WALANT and GA, and the duration of postoperative stay. Results: The WALANT group experienced a significantly shorter waiting time for surgery (6 vs 20 days; P < .001) and a shorter postoperative stay (1 vs 2 days; P ¼ .009) compared with the GA group. They also reported mild to no pain during surgery. The groups were similar with regard to blood pressure, blood loss, and operative time. None in the WALANT group required conversion to GA during surgery and no adverse effects were reported. Conclusions: The WALANT approach is a viable alternative to GA for plating of DR fractures. Type of study/level of evidence: Therapeutic III.

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Introduction: Wide-awake local anesthesia and no tourniquet (WALANT) has come a long way. It has been reported to be successful in the surgery of distal radius and ulna fractures. We report a case of olecranon fracture plating under WALANT. Methods: Surgery was performed with the patient fully conscious where tumescent anesthesia was injected into the surgical site without application of tourniquet 30 minutes before the first incision. Posterior approach to the elbow was used, and the fracture was fixed with anatomical locking plates. Results: The surgery was successfully completed without pain. The numerical pain rating score was 0 throughout the surgery. Conclusions: The use of WALANT for surgical fixation can be expanded beyond the hand and wrist. This is a safe and simple option for patients at high risk of general anesthesia, producing similar surgical outcomes without intraoperative and postoperative complications.

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Introduction: Distal end radius fractures are common fractures commonly treated with an option of open reduction and plating. Traditionally, plating is performed under general anesthesia (GA) or regional block. Recently, a new technique of plating under wide-awake local anesthesia with no tourniquet (WALANT) has been introduced. We aim to compare the preoperative anxiety level, intraoperative pain scores, post-operative pain scores, operating time, blood loss and clinical outcome of distal end radius plating with WALANT versus GA with tourniquet. Methods: We conducted a randomized controlled study on patients with closed fracture of the distal end of the radius requiring open reduction and plating from January 2019 till April 2020. We recruited 65 patients (33 patients in the WALANT group and 32 patients in the GA group). Randomization was done via block randomization. Data were collected to evaluate preoperative anxiety using the Amsterdam Preoperative Anxiety and Information Scale (APAIS) score, intraoperative pain score during injection (baseline) (V1), 10 minutes after injection (V2), during incision (V3), during gentle manipulation (V4), during aggressive manipulation (V5) and during first drilling of screw (V6), blood loss, duration of surgery and post-operative pain score. Additionally, intraoperative visual analog scale (VAS) score was obtained in the WALANT group. At three weeks, six weeks, three months and six months after operation, the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) scores and range of motion (ROM) of the wrists were obtained. Results: The average age in the WALANT group was 47.19 (range, 36-64) years and GA group was 49.48 (range, 38-60) years. The mean APAIS score obtained was 7.78 (WALANT group) and 7.36 (GA group) with no statistical difference. For intraoperative VAS, only during V4 and V5 were the scores 1/10; otherwise at all other phases, the VAS score was 0. The average time for surgery was statistically longer in the WALANT group (61.22 minutes) compared to the GA group (55.33 minutes) (p = 0.003). There was no statistical difference in mean blood loss in both groups. The average post-operative VAS showed statistical significance only at 1 hour and 12 hours post-operation with no statistical difference at 2 and 24 hours post-operation. There was no difference in the post-operative ROM including wrist flexion, extension, supination and pronation for both groups up to six months’ follow-up. Conclusion: There was no statistically significant difference in terms of preoperative anxiety level, intraoperative and post-operative VAS score, amount of blood loss and clinical outcome in both groups for plating of the distal end radius. However, the operating time was slightly longer in the WALANT group. We conclude that distal radius plating under WALANT has similar outcomes to GA. In centres with limited resources, WALANT offers a safe, reliable and cheaper option, reserving GA time for head, abdominal and thoracic surgery.

Summary: Tendon transfer for radial nerve palsy is a common procedure done under general anesthesia. We describe a surgical technique of triple tendon transfer with wide awake local anesthesia no tourniquet (WALANT). We transfer flexor carpi radialis to extensor digitorum communis, palmaris longus to extensor pollicis longus, and pronator teres to extensor carpi radialis brevis. This is commonly known as the Brand transfer. Our anesthetic or WALANT solution consists of up to 200 mL of 1:400,000 epinephrine, 0.25% lidocaine buffered with sodium bicarbonate. This technique overcomes the problem of judging the appropriate amount of transfer tension by observing awake patients actively extend their fingers, thumb, and wrist during the surgery and making adjustments before we close the wound. In our experience, there is no need of brain retraining because a patient is able to immediately use the flexor muscles to perform extension movements. WALANT is a safe and viable option for radial nerve tendon transfers.

In peripheral nerve injuries, Schwann cells (SC) play pivotal roles in regenerating damaged nerve. However, the use of SC in clinical cell‐based therapy is hampered due to its limited availability. In this study, we aim to evaluate the effectiveness of using an established induction protocol for human bone marrow derived‐MSC (hBM‐MSCs) transdifferentiation into a SC lineage. A relatively homogenous culture of hBM‐MSCs was first established after serial passaging (P3), with profiles conforming to the minimal criteria set by International Society for Cellular Therapy (ISCT). The cultures (n = 3) were then subjected to a series of induction media containing β‐mercaptoethanol, retinoic acid, and growth factors. Quantitative RT‐PCR, flow cytometry, and immunocytochemistry analyses were performed to quantify the expression of specific SC markers, that is, S100, GFAP, MPZ and p75 NGFR, in both undifferentiated and transdifferentiated hBM‐MSCs. Based on these analyses, all markers were expressed in undifferentiated hBM‐MSCs and MPZ expression (mRNA transcripts) was consistently detected before and after transdifferentiation across all samples. There was upregulation at the transcript level of more than twofolds for NGF, MPB, GDNF, p75 NGFR post‐transdifferentiation. This study highlights the existence of spontaneous expression of specific SC markers in cultured hBM‐MSCs, inter‐donor variability and that MSC transdifferentiation is a heterogenous process. These findings strongly oppose the use of a single marker to indicate SC fate. The heterogenous nature of MSC may influence the efficiency of SC transdifferentiation protocols. Therefore, there is an urgent need to re‐define the MSC subpopulations and revise the minimal criteria for MSC identification.