He had been sent back to me by his occupational hand therapist because the area had suddenly become angry and red. How many times have I seen this? When I used to take emergency hand and face calls at Sparrow Hospital—which I did for 15 years—nearly every time I went on call, there would be one or two patients admitted for several days on intravenous antibiotics for a suspected infection. In reality, they likely weren’t infected at all, but were simply suffering from a flare-up of gout.

The “Demon” in the Joint

There are tremendous medieval accounts of gout, including famous illustrations depicting an evil devil biting into a patient’s foot. This describes the most common place gout affects people: the podagra, or the joint just behind the big toe.

However, as a surgeon, I frequently find gout in the wrist and hand joints, where it presents as though it is a serious infection. My patient today had his tophus removed surgically three weeks ago, but suddenly it was hot, red, and fluctuant—just like an abscess. In the office, I performed an aspiration of the fluid to ascertain whether this was truly an infection. Pessimistic, I was expecting to see a classic purulent abscess; instead, I found a bright white fluid that looks more like toothpaste than anything else.

On more than one occasion, I have been exploring a patient for tendonitis or synovitis (inflammation of the tendon lining), only to discover these bright, toothpaste-like white globules of deposits all around the tissue. That is when the penny drops: the patient has gout, and it hasn’t been treated medically.

The Anatomy of Filtration: A Family Connection

To understand gout, we have to understand how our bodies handle waste. Uric acid, as its name suggests, is largely excreted through the urine. It is a byproduct of the breakdown of purines, and in a healthy system, the kidneys act as a precision filter to keep these levels in check.

This process of filtration happens in a microscopic structure called the Bowman’s Capsule. This name has a special significance to me beyond my medical training. If you visit my waiting room, you will see my family history on display; my mother’s ancestors are direct descendants of the mid-19th-century surgeon Sir William Bowman.

Sir William was a pioneer in histology, and he was the first to realize that this capsule’s job is to separate small molecules—like water, salts, and uric acid—from the larger cells and proteins in the blood. We actually have his original sketches of the Bowman’s Capsule on display in our office. When this filtration system is overwhelmed or the kidneys aren’t clearing uric acid efficiently, levels in the blood rise. When the blood can no longer hold this excess, it “precipitates” out—much like sugar crashing out of over-saturated syrup—and forms those sharp, needle-like crystals in the joints.

Managing the “King of Diseases”

Historically, gout was known as the “Disease of Kings” because it was associated with the rich diets of the aristocracy. However, it could also be known as the “King of Diseases” due to how brutal the attacks are. A classic flare involves sudden, intense burning and a swollen, red joint so sensitive that even the touch of a bedsheet can be unbearable.

Dietary Advice for Reducing Risk:

The first line of treatment is reducing uric acid levels through dietary alterations:

• Limit High-Purine Foods: Avoid organ meats (liver, kidneys), red meats, and certain seafood like sardines or shellfish.
• Cut the Sugar: Reduce intake of high-fructose corn syrup and sugary sodas.
• Alcohol Moderation: Limit beer and grain liquors, which are high in purines.
• Hydrate: Drink plenty of water to help the kidneys flush out uric acid.

Medical Risk Factors:

• Obesity: Increases uric acid production.
• Kidney Disease: Impairs the ability to filter waste.
• Genetics: Your genes often dictate how your body processes purines.
• Hypertension & Diabetes: These conditions are frequently linked to gout.

If diet alone doesn’t work, medications like Allopurinol help reduce uric acid production. During a flare, high-dose non-steroidals (like Advil), Indomethacin, or Colchicine are used to stop the cycle. These are managed primarily by primary care physicians and rheumatologists.

The History of the Stout Tudor

King Henry VIII is the most famous historical sufferer. While it is often quoted that his physician said he suffered from a “surfeit of pears, port, and brandy,” this is the eye of the storyteller. Port hadn’t even been invented yet!

What he did have was the diet of an aristocrat: rich in red meat, game, organ meats, sweet wines, and fruit preserves. We know from depictions of the “Stout Tudor” that he became increasingly sedentary as he aged. While medieval doctors blamed “corrupt humors,” we now know those purine-rich feasts were the true culprit. Other famous sufferers include Charles V, Philip II of Spain, Benjamin Franklin, and even Isaac Newton.

Why is it the “Great Pretender”?

Gout mimics other diseases, most commonly infection. However, it can also look like:

• Other Arthritides: Rheumatoid, psoriatic, or regular osteoarthritis.
• Hand Conditions: It can masquerade as trigger finger, simple tendonitis, or carpal tunnel syndrome.

I recently released a man’s trigger finger only to discover that tell-tale “white toothpaste,” realizing he should have been treated with medicine and not my #15 blade. One frustration of diagnosing gout is that by the time symptoms peak, the uric acid in the blood has often “precipitated out” into the joint, meaning a blood test might return as normal. The body identifies these crystals as an “infection,” stimulating an inflammatory cascade that looks like major sepsis when no bacteria are present at all.

The Surgeon’s Role

Gout is not generally a surgical condition, but surgeons help identify it by taking biopsies and aspirations of joints. This assists primary care doctors and rheumatologists in correctly treating the right disease.

Next time you are in the office, feel free to take a look at Sir William Bowman’s original sketches in the waiting room—it’s a reminder that while our understanding of disease has evolved from “corrupt humors” to molecular filtration, the goal of the surgeon remains the same: finding the truth beneath the surface.

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I sometimes joke that if you want the job done right, ask an orthopaedic hand surgeon – but if you want the right job done, ask a plastic surgeon. Underneath the humour is a serious point: in rheumatoid arthritis, the art is choosing just enough surgery, in exactly the right place, to give you the biggest improvement in your life with the least possible disruption.

For many decades, RA of the hand and wrist was synonymous with severe deformity: fingers drifting towards the little finger (ulnar deviation), thumb in a zig-zag “Z” posture, joints dislocating and collapsing, and wrists that gradually lost all alignment. In that era, minimalism simply wasn’t an option; by the time patients reached a surgeon, the disease had often mutilated the hand.

Figure 1. Severe long-standing rheumatoid arthritis with marked deformity and joint destruction. Modern medical treatment means this degree of damage is now much less common, but it illustrates the extreme end of the disease spectrum.

The story today is very different – and that’s the first piece of good news. Modern disease-modifying drugs and biologic therapies (immunomodulators) have dramatically reduced the rate of severe joint destruction in RA. People are diagnosed earlier, treated more aggressively, and, as a result, far fewer will ever develop the extreme deformities that were once common.

But “far fewer” is not “none.” I still see patients with difficult pain, progressive deformity, tendon ruptures, or collapsing wrists. I’ve also met many people – including my own grandmother – whose hands looked profoundly deformed yet who quietly carried on with their daily lives and never felt the need for major surgery. So the challenge is not “Can I operate?” but “Should we operate – and on what, and when?”

This page is here to help you understand the options for rheumatoid arthritis in the hand and wrist, and how I think through those decisions with you.

What rheumatoid arthritis does to the hand and wrist

Rheumatoid arthritis is an autoimmune disease. Your immune system, which is supposed to protect you from infection, mistakenly attacks the lining of your joints (the synovium). That lining becomes inflamed, thickened and overactive. Over time, the inflammation can erode cartilage, bone, ligaments, and tendons.

The hands and wrists are among the most commonly affected areas. RA often starts in the small joints of the fingers and wrists, and it tends to be symmetrical – the same joints on both sides are involved.

Typical changes you may hear about include ulnar deviation (fingers drifting towards the little-finger side of the hand), “windblown” hand deformity, swan-neck and boutonnière deformities of the fingers, thumb “Z” deformity, and collapse or erosion of the wrist and the joint between the radius and ulna (the distal radioulnar joint). These deformities develop because tendons slip out of their normal grooves, ligaments stretch, and bone is gradually eroded by inflammation.

Modern medication – and what surgery is for

Today, the cornerstone of rheumatoid arthritis treatment is medical. Conventional disease-modifying anti-rheumatic drugs (DMARDs) like methotrexate and newer biologic agents targeting specific parts of the immune system have transformed the outlook for many patients. These medications do not cure RA, but they slow it down, reduce pain and swelling, and – crucially – prevent or delay joint destruction. As rheumatologists have used these drugs earlier and more aggressively, several large studies have shown a decline in major hand and foot surgery for RA over time.

So where does surgery fit in now? In broad terms, surgery in rheumatoid hand and wrist disease is about reducing pain that no longer responds to medication, correcting deformity that stops you doing important tasks, preventing or managing tendon ruptures and nerve compressions, and rebalancing the hand so that the joints that are still good can work more efficiently.

The goal is not to give you a textbook-perfect X-ray. It’s to help you function, with your actual life, values, job, hobbies, and tolerance for risk and recovery time. The plan for a concert pianist, a mechanic, and a retired gardener with the same X-ray will probably be very different.

My general philosophy: least intervention, greatest effect

Rheumatoid arthritis tempts surgeons into “big” operations because the deformities can be dramatic. Historically, it wasn’t unusual for patients to undergo multiple staged reconstructions: tendon transfers, joint replacements, wrist fusions, thumb realignment – sometimes all in one limb. Those operations still have a place, but I try to approach things a little differently.

We start with what bothers you most: is it pain, strength, appearance, or a specific task you can’t perform? We then look for small, targeted surgeries that unlock big improvements, always respecting the biology of rheumatoid disease. RA affects ligaments and soft tissues, so we don’t always get the same predictability of healing as in osteoarthritis or trauma. We also plan surgery around your medication, balancing the infection risk of continuing drugs with the risk of a flare if they are stopped.

Sometimes the right choice is no surgery at all, but better splinting, hand therapy, and medical care. Sometimes a single focused procedure, such as straightening and fusing one painful joint, makes your whole hand feel more reliable. And sometimes, in more advanced cases, “salvage surgery” – major tendon and joint reconstruction – really is what gives you back a usable hand.

The metacarpophalangeal (MCP) joints – the “knuckles”

In rheumatoid disease, the MCP joints – the big knuckles where the fingers meet the hand – are often major troublemakers. As the supporting ligaments and tendons are damaged, the MCP joints can slide partly or completely out of their sockets, drift toward the little finger, and in severe cases allow the fingers to “telescope” back into the hand.

When pain is severe and the deformity is fixed, we often talk about MCP joint replacement (arthroplasty). Silicone implants have been used for decades in rheumatoid MCP joints. They act more as a flexible spacer than a true hinge.

Silicone arthroplasty can reliably reduce pain, straighten the fingers, and bring them back over the metacarpal heads. It often improves the ability to open and close the hand for light to moderate everyday use. What it cannot do is restore a completely normal joint or tolerate heavy gripping and impact activities. Over many years the implants can fracture or allow some recurrence of ulnar drift, but for the right patient they can be life-changing.

For more isolated MCP arthritis, particularly in osteoarthritis or psoriatic arthritis, we sometimes consider pyrocarbon joint replacement. Pyrocarbon has mechanical properties closer to bone than metal and can provide an anatomic-looking joint replacement. It offers good pain relief and motion for many patients, but it also has its own potential problems, including instability, loosening and the possibility of further surgery if the implant fails. It is not a “better silicone,” just a different tool that must be matched carefully to the right patient.

Figure 2. Illustration of a pyrocarbon and a silastic metacarpophalangeal (MCP) joint replacement in the finger.

Figure 3. Example of a pyrocarbon joint implant used in selected hand joints.

Figure 4. X-ray views of pyrocarbon joint replacements in small finger joints.

The interphalangeal joints – middle (PIP) and tip (DIP) joints

The joints in the middle (proximal interphalangeal, or PIP) and at the tip (distal interphalangeal, or DIP) of the fingers are frequently involved in RA, but they behave differently.

The DIP joint is biomechanically forgiving. For most people, fusing this joint straight or with a small bend does not noticeably affect function – you can still make a fist, grip tools, and type. So if a DIP joint becomes a small, concentrated source of pain from RA or secondary osteoarthritis, fusion (arthrodesis) is often an excellent, durable solution. The trade-off is simple: no motion, no pain.

Figure 5. X-ray showing fusion of the terminal finger joint (DIP joint) using a compression screw.

The PIP joint is another story. It is crucial for making a fist and for fine handling. Losing motion here has a much bigger functional cost. There are two main surgical ideas: joint replacement (arthroplasty) and fusion. Pyrocarbon and other implants have been used to replace the PIP joint in RA and osteoarthritis, but real-world outcomes have been mixed, with relatively high rates of complications and revision surgery. For that reason, I do not routinely offer PIP joint replacement. Instead, I reserve PIP fusion as a surgery of last resort for joints that are both very painful and functionally useless.

Injections: steroid, hyaluronic acid, and fat

Over the years I have watched (and performed) hundreds of small-joint injections. They are tools, not cures. Steroid injections can quiet inflammation and give good short-term relief, but in many people the effect fades in a matter of weeks or months, and repeated injections may have diminishing returns. Hyaluronic acid, a lubricating gel, has been tried in small joints with mixed and often modest benefit.

Autologous fat injection (lipofilling) has gained interest, particularly for basal thumb (carpometacarpal) arthritis. In these procedures, a small amount of your own fat is harvested, processed, and injected into the affected joint. Clinical studies in basal thumb osteoarthritis show that fat transfer can reduce pain and improve function in a majority of patients, especially in earlier stages of disease. I have also injected fat into finger joints in selected patients. It does not cure the arthritis, but it can make the joint more tolerable – turning down the volume on the pain and sometimes delaying the need for fusion.

The wrist and distal radioulnar joint (DRUJ)

The wrist is a central player in RA. As the carpal bones and the ends of the radius and ulna are attacked, the wrist can lose its normal architecture, collapse, and become both painful and unreliable.

There is a spectrum of surgeries, ranging from relatively conservative to definitive fusion. These include synovectomy and tendon procedures to remove inflamed synovium and protect tendons; partial fusions or proximal row carpectomy to preserve some motion while stabilising the wrist; and total wrist fusion to create a strong, stable platform for grip in the most severely damaged wrists. Total wrist fusion sacrifices wrist motion but can be extremely effective at removing pain.

Figure 6. Dorsal plate used for total wrist fusion, creating a stable, pain-free wrist in advanced rheumatoid arthritis.

The distal radioulnar joint (DRUJ) is where the radius and ulna meet at the wrist. In RA this joint can erode badly, causing pain, instability, and difficulty rotating the forearm (turning the palm up and down). Traditional operations remove part of the ulna or fuse portions of the joint. In selected patients whose DRUJ is the main problem and whose surrounding structures are suitable, I may recommend an implant such as the Aptis prosthesis – a specialised device that replaces the DRUJ while preserving rotation. This is a very successful but relatively rarely indicated option that requires careful patient selection.

Figure 7. X-ray showing an Aptis distal radioulnar joint (DRUJ) prosthesis used to restore forearm rotation.

Tendon rupture and tendon transfer

Because rheumatoid arthritis attacks not just bone and cartilage but also the tendon sheaths, tendons can fray and eventually rupture. This is particularly common in the extensor tendons on the back of the wrist and hand. When a tendon has ruptured, no amount of splinting or medication will restore its function; the mechanical connection is lost.

In these cases, we often borrow a healthy tendon and re-route it to take over the job of the ruptured one. A classic example is transferring the extensor indicis proprius (EIP) tendon, which normally helps extend the index finger, to replace a ruptured extensor pollicis longus (EPL) tendon that extends the thumb. Most patients hardly notice the loss in the index finger, but they regain active extension of the thumb, which is crucial for grip and pinch.

Because functional tension testing is so much easier when the patient is awake and voluntarily following commands, I offer tendon transfer under local anesthetic often in the office procedure room.

Figure 8. Diagram of an extensor indicis proprius (EIP) tendon transfer to restore thumb extension after EPL rupture.

Splinting and rehabilitation

After joint replacement or tendon reconstruction, splinting and hand therapy are absolutely central to a good result. The soft tissues in a rheumatoid hand are often stretched or weakened by inflammation, so they need external support while they heal in their new position.

In addition to resting hand splints, we may use dynamic “outrigger” splints. These use elastic bands attached to a light frame to guide the fingers into better alignment while still allowing gentle active movement. For rheumatoid patients, this external rubber-band system can be the difference between a stable, straight hand and a gradual relapse into deformity.

Figure 9. Dynamic outrigger splint used after joint reconstruction to maintain finger alignment while allowing controlled motion.

What to expect from surgery and recovery

Every operation described here is just one step in a larger journey. For rheumatoid patients in particular, success depends on close coordination with your rheumatologist regarding the timing of DMARDs and biologic drugs around surgery, expert hand therapy to retrain tendons and protect reconstructions, splints and braces that may be worn for weeks to months after surgery, and realistic expectations about what surgery can and cannot do.

In practical terms, many procedures can be done under regional or local anaesthetic, often as day-surgery. Pain after surgery is usually manageable with a combination of elevation, simple painkillers, and nerve-friendly anaesthetic techniques. Regaining confidence in the hand can take time; it’s not just about wounds healing, but about learning to trust the new mechanics.

I will be very honest with you about likely outcomes. A fused joint will not bend. A silicone MCP will not tolerate heavy labour. A wrist fusion will not let you do traditional push-ups. But if these procedures remove a constant source of pain and give you a hand you can rely on, they can be extremely worthwhile.

Pulling it all together – your hand, your life, your choices

When I look at a hand with rheumatoid arthritis, I don’t just see deformity; I see the story of how that person has adapted over time. I have seen patients with extreme ulnar deviation and telescoping fingers who can still cook, dress, garden, and even play music – just as my grandmother did, with profound deformity but remarkable function.

So the central question is always: what do you want your hand to help you do that it can’t do now? For one person, that is picking up a grandchild without fear of dropping them. For another, it is holding a paintbrush, getting back into the workshop, or simply shaking hands without flinching.

Modern RA medications have spared many people from the most severe damage, but there will always be a role for thoughtful, tailored hand and wrist surgery. My job is to listen to your story and priorities, examine not just your X-rays but how you actually use your hands, and offer you the smallest, smartest surgical or non-surgical steps that move you towards your goals, while being honest about limitations, risks, and recovery.

If you live with rheumatoid arthritis in your hands or wrists and you are wondering whether surgery might help, the answer is almost never a simple yes or no. It is a conversation. That conversation starts with you bringing your hands, your questions, and your goals into the room. From there, together, we can decide whether the right thing is splinting and therapy, a precise injection, a carefully chosen joint fusion or replacement, or – quite often – a decision to leave a remarkably adaptable hand alone.

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The patient experience has always been at the heart of surgical practice.

Before the advent of modern anesthesia in the late 19th century, the surgeon–patient relationship was an intensely personal one, grounded in trust and direct communication. In the 125 years since the rise of the OR and general anesthesia, some of this intimacy has been diluted. Now, as more hand surgeons transition procedures out of the main OR and back into the office setting under wide-awake local anesthetic no tourniquet (WALANT), we are rediscovering opportunities once considered obvious: To restore depth, engagement and shared ownership in the surgical journey.

James Clarkson

This rediscovery comes with both challenges and opportunities. A major opportunity lies in patient education. Awake surgery allows surgeons to narrate the procedure, explain pathology in real time and reinforce postoperative expectations. This transforms the patient from a passive recipient into an active partner. At the same time, the challenge of training residents on awake patients introduces a potential stress point, as the “learning curve” may not always be welcomed. The surgeon must now balance technical execution with moment-to-moment patient engagement — a responsibility anesthesia once buffered.

Technology offers solutions. In my practice, for those who choose (about 80%), I have developed Wide Awake VR (WAVR Inc.), an optional immersive tool that patients may use during surgery. Through the virtual reality (VR) headset, patients receive a clear explanation of their condition and treatment. Once underway, they are transported into richly distracting environments — flying over Victoria Falls, touring the International Space Station or strolling the halls of the White House — accompanied by uplifting soundtracks. Data collected across 1,000 patients through patient-reported outcome studies, quality improvement data and direct trials have consistently demonstrated reduced anxiety, decreased pain during injection and higher overall satisfaction. Those who use the headset are more likely to report enjoyment and less likely to report a negative experience.

The mechanism aligns with the Melzack and Wall Gate Control Theory of Pain yet works at a higher neurological level: VR may modulate the thalamus and amygdala through cortical feedback secondary to immersive imagery, reframing their emotional perception of pain or anxiety. Importantly, this is not about relaxation alone — it is about distraction through engagement. A mind filled with vivid experiences has little room left for fear or discomfort.

Far from replacing the doctor–patient relationship, VR enhances it. I often continue to converse with patients while they are immersed, weaving humor or reassurance into their journey. WALANT surgery thus becomes more than an operation: It is a collaborative experience that blends human connection, education and technology to elevate patient care. I believe we have only scratched the surface for the utility of immersive VR with local or regional blocks, and as our population ages, it will inevitably grow to fill the need to avoid central nervous anesthesia.

For more information:

James Clarkson, MD, is co-founder of Walant Surgical Solutions and chief medical officer and chair of the board at WAVR Inc. He can be contacted at jc@walantsurgical.com.

Active patient participation

WALANT surgery has changed hand surgery. With no need for a tourniquet and sedation, many hand cases can move out of the hospital ORs and can be done in the office. The advantages of WALANT include: no need for expensive preoperative evaluations and testing, patients can eat breakfast and continue their usual medications, and some of our patients will drive themselves to the office for surgery.

Robert E. Van Demark Jr.

In 2013, we visited Donald H. Lalonde, MD, BSc, MSc, FRCSC, and saw WALANT surgery in person. Since 2013, our group of five hand surgeons have done more than 6,000 WALANT cases in both hospital and in-office procedure rooms. In 2024, our group did more than 2,000 WALANT cases in the office procedure rooms.

Surgeons have three questions regarding WALANT surgery:

• Is it safe?
• Is it cost-effective?
• Do patients have a good experience?

Based on our experience, the answer to all three questions is yes. In our practice we have seen a low infection rate, significant cost savings and high patient satisfaction. In addition, WALANT is environmentally friendly.

Patient selection is crucial. Most of our patients elect to do WALANT in the office. If patients are concerned about “being awake” during surgery, they can have surgery in the hospital with monitored anesthesia care. For patients who are nervous about office surgery, we have offered them the use of a VR headset as described by James Clarkson, MD. We have found that patients love the VR technology.

Perhaps the biggest advantage of WALANT is that patients can actively participate in their surgery. We have followed Lalonde’s advice: Instead of talking about the weather or football games, you can use that time to talk to the patient. It is a great opportunity to talk about what has been done and to discuss the postoperative plan. Many of our patients love to see their median nerve or flexor tendons — many want a photo on their phone. One engaged patient wanted to watch her surgery. We gave her a mirror to watch her De Quervain’s release.

There is one drawback to WALANT: trainee education. In a recent article by Francine Zeng, MD, and colleagues, only 71% of residents rated their WALANT experience as “excellent or good.” The trainees expressed the need for greater exposure and patient education regarding their involvement in surgery.

In our experience, we have a preoperative discussion with the resident regarding their involvement in the procedure. We also include a post-procedure debriefing to discuss what went well and potential areas of improvement. I also talk to the patient about the resident being part of the surgical team and their potential involvement in the surgery. Of course, this varies from patient to patient and is dependent on patient preferences.

With the advent of value-based care, the use of WALANT will continue to increase. WALANT is safe and cost-effective, has high patient satisfaction, and is good for the environment.

References:

• Derby MJ, et al. HAND (NY). 2024;doi:10.1177/15589447241284814.
• Hoxhallari E, et al. Plast Reconstr Surg. 2019;doi:10.1097/PRS.0000000000005831.
• Lalonde DH. (2016). Wide Awake Hand Surgery. CRC press. Available at: https://books.google.com/books?hl=en&lr=&id=2HGmCwAAQBAJ&oi=fnd&pg=PP1&dq=ROBERT+VAN+DEMARK+AND+WIDE+AWAKE+SURGERY&ots=G9Fol_dYO6&sig=xZ1wdya0O9Vv4tz-CrOC-6xHj7w#v=onepage&q=ROBERT%20VAN%20DEMARK%20AND%20WIDE%20AWAKE%20SURGERY&f=false.
• McKnight KN, et al. J Hand Surg Glob Online. 2022;doi:10.1016/j.jhsg.2022.05.008.
• Thomas TL, et al. J Hand Surg Am. 2025;doi:10.1016/j.jhsa.2024.07.021.
• Van Demark Jr. RE, et al. J Hand Surg Am. 2018;doi:10.1016/j.jhsa.2017.11.007.
• Zeng F, et al. J Hand Surg Glob Online. 2025;doi:10.1016/j.jhsg.2025.100783.

Robert E. Van Demark Jr., MD, FAAOS, FAOA, is clinical professor and section head of orthopedics at the University of South Dakota Sanford School of Medicine. He can be contacted at robert.vandemarkjr@sanfordhealth.org.

Disclosures: Clarkson reports being co-founder of Walant Surgical Solutions and chief medical officer and chair of the board at WAVR Inc.
Van Demark reports no relevant financial disclosures.

Source: https://www.healio.com/news/orthopedics/20251014/how-can-a-surgeon-optimize-the-patient-experience-during-walant-hand-surgery

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One of the key missions at Heritage Hand and Plastic Surgery is to provide patients with the option to avoid Ambulatory Surgery Centers (ASCs) or hospital outpatient departments for procedures that can be safely and efficiently performed in our office procedure room. While we’re not the only practice offering this service in the US, it’s still very, very rare, less than 4% of suitable hand surgery is even offered in the office at all.. Let me explain why this matters.

We all pay for health insurance in one way or another—through premiums, taxes via Medicare and Medicaid, or employer-sponsored plans where employees contribute varying amounts through payroll deductions and added premiums. Since the rising cost of healthcare is a critical factor, prudent patients expect their money to be used efficiently. Unfortunately, that’s often not the case. Having worked in the British National Health Service for 13 years before moving here, the differences are stark.

Consider a frail 85-year-old Medicare patient who needs surgery for Cubital Tunnel Syndrome—a common condition where the ulnar nerve (which can cause hand wasting and pain) becomes trapped behind the “funny bone” at the elbow. Proven methods exist to decompress this nerve under local anesthesia in an office setting, and I’ve performed hundreds of these procedures successfully. Yet, Medicare patients are often told that the “site of service” must be a main operating room, not an office procedure room. Why force them into a more complex environment?

You might assume traveling to another location is no big deal, but that’s overlooking a key issue: Most ASCs and hospitals don’t routinely offer fully awake procedures. Their standard protocols lean toward general anesthesia or sedation. For an elderly patient, this means preoperative labs, chest X-rays, EKGs, and clearances from cardiology or pulmonology—requiring multiple trips and appointments. What could be a simple one-hour office visit turns into half a dozen errands, numerous phone calls, fasting from midnight (leading to dehydration), skipping usual medications, and arranging transportation to and from the facility.

Moreover, there’s growing concern that central nervous system anesthesia—whether light or deep—can lead to postoperative confusion and potential long-term cognitive effects. It’s a significant burden to funnel all patients through this “maximalist” system when simpler alternatives like local anesthesia and office-based surgery are available.

We’ve been offering these services for four months now, but not a single insurance company or health payer has helped cover the extra expenses associated with hosting office surgeries. There’s a regulatory barrier at play: the Certificate of Need (CON), which in most states is treated like a liquor license—issued sparingly and rarely surrendered. Local hospitals and ASCs guard their CON status fiercely, allowing them to charge 10-20 times the surgeon’s fee for “supersized” services that aren’t always necessary. Don’t misunderstand me, when you need that level of care in the US, it’s world class, and very designed.

It’s time to rethink, reset, and innovate. Through a company I co-founded called WSS, I’ve been working with communities across the US to encourage surgeons to perform more procedures in their offices. This hinges on site-neutral payments that follow the patient. If office-based surgery costs far less, the facility fee should be reduced accordingly—but at minimum, it should cover costs and incentivize a top-down recalibration of how we, as a nation, choose to spend our healthcare dollars.

In the meantime, my “experiment” continues here in Lansing, where I continue to offer awake surgery wherever possible in the office setting, making use of immersive technology to make the whole process fun and engaging for my patients, whilst remaining safe and economically lean.

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The human hand manifests an elaborate joint architecture around our tool use, requiring the thumb to not only flex and extend and move across the palm but also rotate, to oppose each finger in plane. Most joints in the body have stability as their key feature, allowing motion in a more limited range of planes, but there is a trade-off.

Somewhere between our late 40s and mid-60s, most of us start to develop osteoarthritis of this joint, which is hypothesized to be as a result of “wear and tear,” although the causes for joint degeneration are likely to be a very mixed bag of ligament laxity due to the slowing of our repair mechanisms, and subsequent inflammation that erodes the cartilage, which cannot regenerate. This is in addition to the more rare autoimmune diseases that I will cover in a different blog.

Characteristically, basal joint arthritis afflicts more of us than any other upper limb arthritis, probably because of this vulnerability. So when do you “need surgery”? The answer lies in the balance between the amount of disability the pain inflicts on your everyday use of the hand, and the individual’s preparedness to go through a surgical procedure that may take 3 months of hand therapy until it fully bears fruit. Call this the line in the sand.

Before I break down the options, I want to share a story.

My own mother, a retired operating room nurse dead set against all non-essential surgery, chose to have a basal joint arthroplasty. Subsequently, she has avoided almost all of the classic orthopedic operations, and her left knee at the age of 86 is crooked—and has been for over 10 years—for which she was simply not prepared to have surgery. The thumb issue for her was personal: she lost her tennis serve at age 72, which was at the heart of her local social life. As I put it to my patients, she had reached a line in the sand that she was not prepared to cross. As we age, we accommodate to many, many changes—some are tolerable, and others intolerable. This is the line that any individual must cross to make the elective decision to have surgery to enhance their form and function through plastic and orthopedic surgery. Use this as a good guide to help make choices from the following options.

Rule out simple causes for pain: Before considering your basal joint to be the cause for your pain, I need to exclude both nerve and tendonitis issues that may be masquerading as joint pain, or simply enhancing it, see my blog on the onion skin model for hand pain.

Initially, basal joint arthritis is managed by hand therapy using small braces that help stabilize the joint, called “Opponens bracing”. This gives you the opportunity to speak to a hand therapist about recovery from surgery and to meet other patients who have had surgery, and it may well be enough for you.

Injections:

I was always trained to offer steroid injections into the joint. I have the advantage of a 15-year training period between the UK and the US, and I was able to observe the white crystalline material that these steroids deposited in the soft tissues when we did surgery. I began to wonder about the effects of steroids, because so many patients appeared to be attending clinics regularly just to have injections that wore off. The steroids used to inject tendons and joints are “catabolic,” meaning they break down inflammatory and collagen tissue as part of their direct action. The initial experience is beneficial, but as the ligaments that are so important to basal joint stability are weakened, I always had the impression that only harm could follow. And given that steroids into joints seemed to wear off over months, I stopped offering them (although they are often effective permanently for tendon issues). For years, it was either hand therapy or surgery that I offered.

As a plastic surgeon, I have worked with fat transfer, particularly in breast reconstruction, and in addition to seeing it first hand I was aware of the literature demonstrating the beneficial effects of fat on tissue that was hard and scarred subsequent to surgery plus radiation. I also observed that when I injected fat beneath scars, they tended to mature and soften, sometimes almost melting away. Then a connection was made in my mind when I read a German study that demonstrated fat transfer into the basal joint was reducing pain for 2–5 years. This seemed totally unsurprising to me, and so immediately I began to offer fat injection into the basal joint, which had the added advantage of something I could offer in the office environment, away from the industrial hospital complex. I have been offering this since late 2022, and about 70-80% of my patients report significant reduction in joint pain by 3 months, and some of those who don’t then go on to improve by 12 months. When I see them a year later, not only has this held true, but the effects seem to have increased. Whatever is going on with fat transfer, it is an “anabolic” phenomenon and appears to be improving overall joint health. There is an emerging science in this regard, and companies are racing to enrich fat with stem cells or to inject alternative sources of stem cells from bone marrow. One thing we don’t know is a fair comparison between techniques, and I prefer to keep it simple between me and the patients: we just harvest a little fat from the tummy under local anesthesia, and it’s working.

There is another technique that may be offered before arthroplasty, which I have not yet adopted, “Denervation” of the joint, which carries some promise. It does however involve an extensive dissection of the soft tissues to remove nerve branches that enter the joint capsule. I have yet to adopt it due to the early data available, the fact that arthritis proceeds unchecked and that it is considerably more traumatic than fat transfer. I also know that nerves regrow, so I remain a skeptic until longer term data is produced. Basal Joint suspension Arthroplasty with trapeziectomy:

The next step up the ladder is a “basal joint arthroplasty.” Traditionally, the trapezium bone under the thumb where the arthritis is found, is simply removed, and time and again clinical trials have failed to show that any other technique is superior. How the trapezium is removed is fairly traumatic, however, and recovery for the first 2–6 weeks significantly limits the use of the hand, permitting typing but little else. The problem that surgeons first encountered after this operation was that the thumb would sink back into the space left behind by the removed bone, eventually causing new arthritis on the next bone in the chain, the scaphoid. So elaborate and varied techniques have evolved to “suspend the thumb”. I have done or assisted in most of these procedures over the past 30 years and currently I have chosen to use the Arthrex FiberLock system with a single incision, again aiming for simplicity—it permits early motion at 2 weeks. Others will offer a variety of tendon graft and transfer techniques, most commonly the “LRTI,” which is a tried-and-tested workhorse requiring immobilization for 4–6 weeks.

Implant arthroplasty: In the UK and the US, we have had many decades of resistance to thumb implant arthroplasty after a series of bad outcomes from various designs. Designing an implant that can support the loads placed through them is intrinsically more predictable when the surface area to volume ratios are small. By this, I refer to the overall size of the implant and the bone in which it must integrate. A knee joint may look like a finger joint, but it is not at all. It’s an optical illusion best explained by the comparison between an elephant and a mouse. A photograph of each shows a rather plump round body, and they appear analogous to each other.

The brain is failing to grasp that the surface area to volume ratio is drastically altered between the two: with the mouse being small, it has a relatively small volume for its surface area, versus the elephant, which has a huge volume, so the volume to surface area ratio is many orders of magnitude smaller. For the dynamics of a small implant versus a large one, this translates into instability, loosening, or dislocations. Thus, when hand surgeons have enterprized into small joint arthroplasty, we have not replicated the great success we see in hips and knees. One of the best examples was seen around the 1980s with Dr. Alfred Swanson in Grand Rapids, who developed a multitude of small implants, most of which had to be removed over the ensuing years. It was thus with distrust that Britain and the US viewed the promising data emerging from France, Belgium, and the Netherlands about implant arthroplasty of the basal joint, but enthusiasm is rising once again. In the US, we have access to a one-sided implant.

I have been offering the BioPro, a Michigan-invented and manufactured implant—like Swanson, so the story has stayed local. Coming soon through the FDA is a two-part implant from Europe, which in their studies has shown great promise. What I tell my implant patients is that the BioPro is a little less traumatic and painful to place: the trapezium remains, so the arch of force is supported bone to bone when pinching, one of the fundamental functions of the thumb. Losing the trapezium arguably weakens the hand a little; the implant helps maintain strength. But I remind my patients that an implant is not necessarily the last operation that they will need, and later in life it may loosen or dislocate. Nevertheless, particularly for younger patients, the implant has a role, and so I offer it.

Summary:

Fat Transfer: Minimally invasive procedure harvesting fat from the abdomen under local anesthesia; provides anabolic benefits like pain reduction in 80% of patients within 3 months, potentially lasting 2-5 years with improving joint health; ideal as a non-surgical step-up from bracing, avoiding bone removal or implants, but lacks long-term comparative data against other methods.

Trapeziectomy: Traditional surgical removal of the trapezium bone, often combined with suspension techniques like Arthrex FiberLock (allows early motion at 2 weeks) or LRTI (requires 4-6 weeks immobilization); effective for severe cases but involves traumatic recovery limiting hand use for 2-6 weeks, with risks of thumb subsidence leading to new arthritis; no superiority shown over simple removal in trials.

Implant Arthroplasty: Uses devices like BioPro to replace joint function while preserving the trapezium for better strength and bone-to-bone support during pinching; similar recovery times to but less traumatic than trapeziectomy, suited for younger patients; however, carries risks of future loosening or dislocation, possibly requiring additional surgeries, and has historical distrust due to past design failures.

Conclusion: Remember, I started this blog with the macabre image of skeletons still carrying their trapezium bones to the grave. Its your life, and only you can know if you have reached a “line in the sand” beyond which you are not willing to go.

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It was there that Frances rescued me. At 16, I was a rather lost adolescent; my dream of becoming a doctor had faded into a fantasy with no grounding in reality. Frances was an extraordinary woman, and it’s through her that I’ve come to understand how age transforms us. Only with hindsight—drawing from her stories, items she left behind, and the recollections of her relatives—do I realize she lived two distinct lives.

As a young woman, Frances was the daughter of a prominent British diplomat, the scion of the Whitehead family, who in the 19th century had invented the torpedo. They lived in an enormous house called Efford Park in the New Forest, surrounded by extraordinary wealth. But the world was changing rapidly, and their wealth was disappearing just as quickly. She fell in love with a much older man: a husband, father, and distinguished military figure from a bygone era of British history. The past is another country when it comes to the mores of extramarital affairs, and Frances became his official mistress. She was not just a companion but was embraced by his family in a way I struggle to fully comprehend. I now realize that many of the people she took me to visit as a child were the children of her lover, and I recall vividly how deeply they loved her. When he died of natural causes, being much older, Frances was left marooned in midlife.

Her story fades into the mists of time until World War II, when she joined UNRRA to aid refugee repatriation. The war devastated England, and Frances bore personal loss when one of her three brothers died in a plane crash. She seemed to embrace the fatalism of the era, sharing stories of the Blitz when she would climb onto the roof to watch the bombers rather than seek safety in bomb shelters. She kept fragments of a bomb on her mantelpiece, remnants of an explosion that nearly killed her. She told me she collected the pieces to remind her of her own mortality. I can still recall every surface of those copper and steel shards, examining them, as she spoke to me in front of her 1970s gas stove, under the US airbase at Greenham Common where they lived. After the war, life had opened again when she met John Bowman, a widower whose deceased wife was her cousin. His two children, aged 9 and 12, desperately needed a mother. For Frances, this was a second chance, and she embraced it with zeal, becoming a beloved and respected stepmother to my mother and my uncle.

What I remember most about Frances is her attentiveness—she was always watching, listening, engaged, and positive. In my late adolescence, she came to my rescue. I had failed to master my subjects, unable to thrive in the rigid English boarding school system, which my time in Canada had not prepared me for. Frances and John, my grandfather, visited me at Bradfield School several times and saw I had no clear path to success there. As I prepared to retake exams after school, Frances suggested tapping into the family diaspora. She mentioned a “wonderful communist” (as she playfully called him)—a nephew, Professor Mike Floyer, the recently retired Dean of the London Hospital Medical School. Mike, I later discovered had one strong thing in common with Frances beyond kinship, as a young doctor at the London Hospital, he too had been up on the rooves of the hospital during the Blitz, only this time, to monitor for direct airstrikes and put out the fires. Mike adored Frances, later telling me she was his favorite aunt, and it’s humbling to realize I likely only got into medical school because of her intervention. She was the beginning and the means of my entry into medicine.

Frances also taught me a lesson about my older patients: they have lived long, rich lives. I never assume the person before me is anything less than a vibrant young bride, a middle-aged mother, a father, a soldier, a lover, a recovered addict, or even a criminal—but always a real person with a long story that has brought them to my exam room to discuss their hand pain and share their lives.

The post The Medicine of Memory: Frances Bowman’s Legacy appeared first on Heritage Hand and Plastic Surgery.

A recent article in The Independent London dentist discovers hidden detail in Da Vinci’s Vitruvian Man revealed a hidden equilateral triangle in the drawing, aligning with modern dental proportions and underscoring da Vinci’s genius in anticipating ideal human geometry. This hidden harmony resonates with my work, where every procedure—whether restoring a hand’s grip, reconstructing a wound or reducing a breast—must align with the individual’s unique needs, balancing the technical with the personal. When selecting our logo, I followed my wife’s wise advice to avoid the stereotypical plastic surgery imagery—often young women in their prime—that can feel body dysmorphic and out of touch. Our patients, many of whom are older, deserve representation that reflects their reality.

Vitruvian Man transcends age and idealized beauty, focusing on the universal proportions and timeless balance that underpin both men and women, much like the reconstructive challenges I tackle daily. I deeply appreciate the aesthetic reconstructive challenges faced by my patients, shaped by age, lifestyle, and multiple childbirths. These experiences leave marks that tell a story, yet as we mature, we may not always be ready to accept the changes wrought by gravity and skin laxity, and only the individual fully understands how that makes them feel.

I see aesthetic surgery as another form of reconstruction—a way to restore confidence and align the body with the self, and I have been offering this surgery for over 15 years.

The post The Vitruvian Man and the Art of Balance in Modern Plastic Surgery appeared first on Heritage Hand and Plastic Surgery.

Ralf was no stranger to hand surgery. Four years earlier, during the pandemic, I had operated on his left thumb, performing a trapeziectomy using the Arthrex Mini TightRope technique. With that successful experience behind him, Ralf didn’t need much convincing when it came to his right thumb. But in the years since, surgical options had continued to evolve.

We discussed the various techniques available, including tendon reconstruction and the Biopro implant, but ultimately settled on the Arthrex FiberLock anchor system—a newer single-incision technique I now favor for many older patients. This approach reduces surgical exposure while providing excellent stabilization, minimizing recovery time and improving comfort.

In early April, we proceeded with the surgery. Just a few weeks later, Ralf was waiting to see me again—this time as my very first patient at Heritage Hand and Plastic Surgery. He has the unique distinction of being both my last surgical patient at MSU and my first at Heritage—a transition that feels deeply symbolic to me.

Over the past nine weeks, Ralf has steadily regained his pinch strength, diligently following his hand therapy program. Our visits have been filled with fascinating conversations about his long career in naval nuclear science—at least the parts he’s permitted to share. In turn, I shared stories from my own family’s medical history, including my grandfather’s post-war assignment from the UK to visit Los Alamos and study the effects of atomic weapons on human casualties—a grim but historically significant report.

Every patient has a story. Ralf’s reminds me why I chose to open Heritage Hand and Plastic Surgery: to offer personal, expert care in an environment where every patient is seen, heard, and given the time and attention they deserve.

The post From Michigan State to Heritage Hand and Plastic Surgery: A Special Patient Journey appeared first on Heritage Hand and Plastic Surgery.

He’s also my great-great-grandfather.

The bust was given to me by my grandmother, his granddaughter. I keep it here not just as a family heirloom, but as a daily reminder of how medicine evolves — and how sometimes, even great innovations can be taken too far.

Lane and the Birth of Sterile Surgery

William Arbuthnot Lane (1856–1943) practiced at a time when surgery was still extraordinarily dangerous. Patients routinely died of infections after even the most minor procedures. In the late 19th century, Joseph Lister had introduced antiseptic surgery — spraying carbolic acid to kill bacteria that contaminated wounds during operations. It was groundbreaking but still imperfect.

Lane took things a major step further. Drawing on two scientific revolutions from continental Europe:

• Louis Pasteur’s germ theory (France), which proved that microscopic organisms caused infections;
• Ernst von Bergmann’s aseptic technique (Germany), which sterilized instruments and created fully sterile surgical fields;

Lane pioneered the modern sterile operating room — abandoning antiseptics entirely and preventing contamination before it occurred. His success in achieving sterility allowed him to perform procedures that had been previously too dangerous, most notably the internal fixation of fractures using metal plates and screws. That work laid the foundation for much of modern orthopedic and trauma surgery.

The 20th Century: When Sterility Was a Lifesaver

Through the 20th century, sterile technique fueled incredible advances: neurosurgery, heart surgery, organ transplants, joint replacements — all required extraordinary levels of sterility to succeed. In these complex, high-risk fields, the operating room evolved into a kind of sterile cathedral: with positive pressure airflow, full surgical suits, and layers of infection control.

In these cases, Lane’s legacy remains absolutely vital. Infection in a joint implant or heart valve can be catastrophic, and the extreme sterility of modern ORs has saved countless lives.

The Problem: When “More Sterility” Becomes Overkill

But over time, something predictable happened: what began as vital patient protection eventually morphed into medical overkill. As American healthcare industrialized, the highly controlled, highly expensive operating room became the default setting for almost any procedure, regardless of the actual risk of infection.

Simple soft-tissue surgeries — like carpal tunnel releases, tendon repairs, many podiatry procedures, oral surgeries, and minor vascular procedures — are now routinely performed in full operating rooms, even though they could be done perfectly safely in simpler outpatient procedure rooms.

The result? Massive added costs to the system and to patients, with no real improvement in safety.

The Evidence Is Clear: Many Procedures Don’t Need Full OR Sterility

In recent years, many surgeons have been re-examining whether full OR sterility is necessary for every surgery — and the data are clear. For many minor surgeries, field sterility — meaning a properly prepped sterile field but without full OR infrastructure — is just as safe.

One of the leading voices is Dr. Don Lalonde, who pioneered a technique called WALANT: Wide Awake Local Anesthesia No Tourniquet. In a 2012 paper, he demonstrated that hand surgeries done under WALANT with field sterility had an infection rate of just 0.5% — identical to full OR sterility, but with less cost, less waste, and far greater patient comfort (Lalonde et al., 2012).

Building on this, my own 2024 study followed infection rates as I transitioned hand surgery cases from the hospital OR to a field-sterile office procedure room. The result? No significant change in infection rates despite eliminating the full OR environment (Clarkson, 2024).

Other studies echo these findings:

• A 2021 study of 265 upper extremity surgeries found a 0.37% infection rate using field sterility (Avoricani et al., 2021).
• A 2019 review found no added benefit from full OR features like laminar airflow, head covers, or specialized footwear for minor hand procedures (Yu et al., 2019).

In other words, once you’ve achieved “good enough” sterility, adding more complexity doesn’t improve safety — it only adds cost.

Why Lane Still Belongs in My Waiting Room

So why keep Lane’s bust here?

Not to glorify sterile excess — but to honor what his work truly represents: courageous scientific evolution. He wasn’t afraid to challenge the orthodoxy of his day and make surgery safer based on new science. But the best way we can honor his legacy today is to follow that same principle — to keep questioning, to keep adapting, and to recognize when further layers of “safety” no longer make patients safer.

Sometimes the hardest thing in medicine is to recognize when we’ve reached “good enough.”

References:

• Lalonde, D., Martin, A., & Bell, M. (2012). Wide-awake flexor tendon repair and early tendon mobilization in zones I and II. Journal of Hand Surgery (European Volume), 37(10), 919-924. PubMed
• Clarkson, J. (2024). Infection Rate Comparison during Transition from Hospital Operating Room to Office-Based Procedure Room for Hand Surgery. Full Text
• Avoricani, A., et al. (2021). WALANT Hand and Upper Extremity Procedures Performed With Minor Field Sterility Are Associated With Low Infection Rates. Plastic Surgery, 30(122-129). Consensus
• Yu, J., et al. (2019). Evidence-based sterility: the evolving role of field sterility in skin and minor hand surgery. Plastic and Reconstructive Surgery Global Open, 7. Consensus

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Throughout my professional career, I have worked as a plastic and hand surgeon within some of the world’s largest healthcare systems — 13 years in the British National Health Service, followed by advanced fellowship training in hand surgery in the United States, and most recently, 15 years on faculty at Michigan State University. What I have come to recognize—something my great-grandfather could have told me generations ago—is that the best care occurs when nothing stands between the patient and their physician. This timeless principle serves as the foundation of Heritage Hand and Plastic Surgery.

Too often in modern healthcare, the simple experience of seeing your surgeon, having a conversation, and proceeding to surgery has been lost in an increasingly institutionalized and bureaucratic system. My goal is to reclaim that experience. From the moment you enter the office, you will find yourself surrounded by my family’s heritage — heirlooms dating back to 1850 — honoring ancestors who were pioneers in ophthalmology, orthopedic implant development, sterile technique, and plastic surgery across multiple generations and through both World Wars. You will be welcomed with coffee, dignity, and respect.

For patients undergoing surgery, the experience is entirely different from that of an ambulatory surgery center or hospital. Surgery is performed in a calm, office-based setting without the unnecessary complexities and costs that often accompany institutional care. Patients may eat beforehand, remain awake, and even drive themselves home afterwards. For those who prefer distraction during their procedure, I offer immersive virtual reality using a system I developed called Wide Awake VR, which has been shown to enhance the patient experience and reduce anxiety.

Office-Based Surgical Offerings

In-office procedures range from simple dermatologic excisions of benign and malignant skin lesions to complex hand surgeries, including:

• Carpal Tunnel Release
• Dupuytren’s Fasciectomy
• Lacertus Fibrosus Release (often an overlooked contributor to hand pain)
• Cubital Tunnel Release
• Ganglion and Mucous Cyst Removal
• Trigger Finger Release (especially common in diabetic and older populations)
• Mohs surgery reconstruction
• Fat transfer to hand tissue and joints

Operating Room-Based Surgical Offerings

While many procedures can be safely and comfortably performed in the office, certain surgeries still require the resources of a fully equipped operating room. In these settings, I provide:

• Complex and deep reconstructive surgeries of the wrist, hand, and forearm
• Thumb arthroplasty and wrist arthroplasty for degenerative joint conditions
• General orthopedic surgeries of the hand and wrist including trauma management
• Plastic surgical reconstructive services, including soft tissue reconstruction, skin grafts and flaps
• Body contouring and aesthetic reconstructive procedures

Why Wide-Awake Surgery?

I believe unnecessary anesthesia is often not in the best interest of patients, particularly as we age. Using specialized techniques I learned directly from Dr. Don Lalonde—the father of awake hand surgery—I perform procedures under local anesthesia without a tourniquet, in what is known as WALANT (Wide Awake Local Anesthesia No Tourniquet) surgery. This technique allows patients to remain fully awake, fully informed, and fully in control.

Because no sedation or general anesthesia is used, patients:

• Have no need to stop medication or seek anesthesia clearance from other specialist
• Recover more quickly
• Retain full mental clarity post-procedure
• Can drive themselves home if they feel safe to do so
• May sign documents and return to work the same day
• Faster recovery

In addition, many patients are now traveling considerable distances to see me, specifically to avoid the complexities, delays, and financial burdens of institutionalized healthcare in their own states and cities. They are seeking not only a streamlined, personalized experience, but also expert-level options for the management of hand pain, peripheral nerve decompression, and complex nerve-related conditions that often go underdiagnosed or undertreated elsewhere.

For many, particularly those with high-deductible health plans, office-based surgery costs only a fraction of what hospital-based care would entail — often saving thousands of dollars without sacrificing safety or outcomes.

A Return to Patient-Centered Care

By focusing on the patient’s experience and wellness, Heritage Hand and Plastic Surgery offers an environment where individuals can actively participate in their care, free from the burdens of large healthcare systems. This model allows me to provide exceptional, independent hand and plastic surgical care in an efficient, cost-effective, and compassionate manner.

I am honored to bring this vision to life and look forward to caring for you and your family.

— James Clarkson MD
Heritage Hand and Plastic Surgery

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