The ratio of malignancy in suspicious soft tissue and bone neoplasms (RMST) has not been often addressed in the literature. However, this value is important to understand whether biopsies are performed too often, or not often enough, and may therefore serve as a quality indicator of work-up for a multidisciplinary team (MDT). A prerequisite for the RMST of an MDT is the assessment of absolute real-world data to avoid bias and to allow comparison among other MDTs. Analyzing 950 consecutive biopsies for sarcoma-suspected lesions over a 3.2-year period, 55% sarcomas were confirmed; 28% turned out to be benign mesenchymal tumors, and 17% non-mesenchymal tumors, respectively. Of these, 3.5% were metastases from other solid malignancies, 1.5% hematologic tumors and 13% sarcoma simulators, which most often were degenerative or inflammatory processes. The RMST for biopsied lipomatous lesions was 39%. The ratio of unplanned resections was 10% in this series. Reorganizing sarcoma work-up into integrating practice units (IPU) allows the assessment of real-world data with absolute values over the geography, thereby enabling the definition of quality indicators and addressing cost efficiency aspects of sarcoma care.
Objective Wide awake local anesthesia no tourniquet (WALANT) hand surgery offers the opportunity to create a bloodless field without using an arm tourniquet. Lidocaine for anesthesia mixed with epinephrine for hemostasis is frequently used without concerns in the hand and finger. This is a major improvement for the patient and the surgeon in terms of patient comfort and having the opportunity to test the hand and finger function intraoperatively. The movement away from tourniquet surgery, which often requires sedation or general anaesthesia is one of the most significant recent advances in hand surgery. Methods A subcutaneous infiltration of a mixture (1:100’000) of lidocaine (1%) and epinephrine (buffered 10:1 with 8.4% bicarbonate) is done with a 27 G canula. The mixture is infiltrated wherever surgical dissection, k-wire insertion, or manipulation of fractured bones will occur. The local anesthetic results in an extravascular Bier block. The injection is done slowly from proximal to distal to minimize injection pain. After the last injection a minimum time of 30 minutes should be waited for maximal epinephrine vasoconstriction in the finger. Results In the beginning WALANT was only used for small procedures like trigger finger or carpal tunnel release. Meanwhile also major hand surgical procedures like finger fractures, flexor tendon repairs, tendon transfers, arthroscopies, arthroplasties and open triangular fibrocartilage complex (TFCC) repair are performed in WALANT. Even procedures like trapeziectomy have been described using wide awake hand surgery, which involves numbing the joint itself. Conclusion The use of WALANT is a proven safe technique that can be used in up to 95% of hand surgical procedures. The benefits for patients and surgeons are obvious. Patients prefer the technique because there are no side effects of opiates or sedation. The anesthetic risk is minimized. Time at hospital is reduced. Patients do not have to suffer tourniquet pain. Surgeons prefer the technique because of the bloodless surgical field without tourniquet, the possibility of intraoperative testing of stability of prosthesis or fracture stabilization, strength of a tendon repair, the movement and gliding properties in the flexor tendon sheath after repair or testing the tension of tendon transfers. These are probably the reasons for the continuously growing popularity of this technique worldwide.
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