Summary: Wide-awake local anesthesia no tourniquet surgery has been shown to decrease cost and hospital length of stay. The authors studied the use of virtual reality during wide-awake local anesthesia no tourniquet outpatient upper extremity surgery to assess its effect on patient pain, anxiety and fun. Patients undergoing wide-awake local anesthesia no tourniquet surgery were randomized to use (virtual reality) or not use (non–virtual reality) virtual reality during their procedures. Pain, fun, and anxiety were measured with a Likert scale at several time points, as were blood pressure and heart rate. A postoperative questionnaire was used to assess overall satisfaction. Virtual reality patients exhibited lower anxiety scores during injection, during the procedure, and at the end of the procedure. There were no differences in blood pressure, heart rate, or pain scores. Compared with non–virtual reality patients, virtual reality patients’ fun scores were higher. Virtual reality patients felt the experience helped them to relax, and they would recommend virtual reality–assisted wide-awake local anesthesia no tourniquet surgery. Among patients with self-reported preexisting anxiety, virtual reality patients had lower pain and anxiety scores during injection of local anesthesia compared with non–virtual reality patients. This study demonstrates that readily available virtual reality hardware and software can provide a virtual reality experience that reduces patient anxiety both during the injection of local anesthesia and during the surgical procedure. (Plast. Reconstr. Surg. 144: 408, 2019.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

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The sensitivity and specificity of radiological detection of extranodal spread from head and neck squamous cell carcinoma is not well reported in the literature. Accuracy of reporting improves in the hands of experienced head and neck radiologists. This finding has clinical implications for surgical planning and adjuvant therapy requirements.

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Ann R Coll Surg Engl 2005; 87: 461-465 461The NHS is in constant change; the implementation of change is fraught with difficulty and the risk of short-term failure. Cleft services for the UK are no exception to this principle, and have undergone rigorous restructuring since the publication of the findings from Clinical Standards Advisory Group (CSAG) for cleft lip and palate in 1998.1 As a result of this, the West Midlands regional cleft service has become centralised to the Birmingham Children's Hospital (BCH). Our experience illustrates the practical difficulties that reorganisation has had on our specialty. However, the quality of service has improved subsequent to this implementation. This report provides data for national comparison.We report a retrospective clinical process audit taken from the hospital notes and a radiological assessment of one outcome measure for this service -the alveolar bone graft (ABG) success rate. We compare our results to the CSAG study findings prior to local implementation of its recommendations. We discuss the organisational shortfalls revealed by our audit and make proposals for local restructuring of the service based on our findings.We have chosen to measure alveolar bone grafting as our clinical outcome because of the availability of validation by Bergland scores 2 and because this parallels the main outcome measure used by CSAG for comparison. Bergland established a four-point assessment score of the inter-alveolar height after bone grafting. CSAG recognised types I and II as success and types III and IV as failure.The CSAG study identified 647 children under the care of 50 different cleft teams. Not all of these children had required alveolar bone grafting and 183 radiographs were (BCH) is the centre for a regional comprehensive cleft service attempting to implement the national guidelines for minimum standards of care. A national audit of cleft management (CSAG) found that 58% of alveolar bone grafts were successful; published series suggest that success rates can be of the order of 95%. We present the results of an audit of alveolar bone grafting over a 33-month period, after implementation.

An unusual case of a female infant with Catel-Manzke syndrome is presented. Additional features not previously reported include three accessory ossicles at the bases or associated with the proximal phalanx of the index, middle, ring and little fingers bilaterally. There are also numerous bony abnormalities in both feet. Previous cases have shown no more than 2 accessory ossicles in the hand and these usually involve the index alone. The foot abnormalities are more extensive than any previously seen in this syndrome. This is only the 8th female case out of a total of 27 reported cases.

Background: This study examined how wide- awake local anesthesia no tourniquet (WALANT) surgery in the office versus the standard operating room (OR) impacts patient experience, and the effect wide awake virtual reality (WAVR) has in conjunction with WALANT on patient experience. Methods: This is a patient-reported outcome study of patients undergoing carpal tunnel release by a single surgeon between August 2017 and March 2021. Patients were classified by location; traditional OR versus WALANT in-office. In-office patients were further classified by whether they chose to use WAVR or not. Patients rated overall experience, enjoyability, and anxiety using a Likert scale (1–7). Results: The online survey had a 44.8% response rate. OR patients were twice as likely to report a neutral or negative experience (23% versus 11%, P = 0.03), significantly lower enjoyment scores (44% versus 20%, P = 0.0007)‚ and higher anxiety (42% versus 26%, P = 0.04) compared with office-based WALANT patients. With the addition of WAVR, office patients reported higher enjoyment than those who did not use WAVR (85% versus 73%, P = 0.05). Patients reporting an anxiety disorder were more likely to choose WAVR when compared with patients without anxiety disorder (73.8% versus 56.4%). When they chose WAVR, they had greater anxiolysis (79% versus 47%, P = 0.01)‚ and increased enjoyment (90% versus 59%, P = 0.005). Conclusions: This study demonstrates improved patient experience in the office setting, further amplified by WAVR. Preexisting anxiety disorder is a positive predictive variable toward the patients’ choice to use WAVR.

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