Complications and side effects of Wide-Awake Local Anaesthesia No Tourniquet (WALANT) in upper limb surgery: a systematic review and meta-analysis.

PURPOSE: Wide-Awake Local Anaesthesia No Tourniquet (WALANT), a groundbreaking anaesthetic technique resurging in practice, warrants a comprehensive safety analysis for informed adoption. Our study aimed to identify complications/side effects of WALANT upper limb procedures through a systematic review and meta-analysis. METHODS: This PROSPERO-registered study was performed with strict adherence to PRISMA guidelines. Embase, OVIDMedline, Cochrane, Web of Science, and Scopus databases were searched until February 2023. Inclusion criteria involved English articles, reporting complications/side effects in primary WALANT upper limb surgeries. Outcomes included all complications and side effects, data on the anaesthetic mixture, publication year/location, study type, and procedures performed. The meta-analysis employed the Freeman-Tukey Double Arcsine Transformation, computed I2 statistics, and utilized common or random effects models for pooled analysis. RESULTS: 2002 studies were identified; 79 studies met the inclusion criteria representing 15,595 WALANT patients. A total of 301 patients had complications, and the meta-analysis using a random effects model provided a complication rate of 1.7% (95% CI: 0.93-2.7%). The most reported complications were superficial infection (41%, n = 123/300), other/specified (12%, n = 37/300), and recurrent disease (6.7%, n = 20/300). A decade-by-decade analysis revealed no statistically significant difference in complication rates spanning the last three decades (p = 0.42). Adding sodium bicarbonate to the anaesthetic solution significantly reduced postoperative complications (p = 0.025). CONCLUSION: WALANT has a low overall complication rate of 1.7%, with no significant temporal variation and a significant reduction in complications when sodium bicarbonate is added to the anaesthetic solution. Our findings support the safety of WALANT in upper limb procedures. REGISTRATION: PROSPERO: CRD42023404018.

Comparison of the Effects of Aromatherapy With Damask Rose and Chamomile Essential Oil on Preoperative Pain and Anxiety in Emergency Orthopedic Surgery: A Randomized Controlled Trial.

PURPOSE: Patients who are awaiting emergency surgery experience high levels of anxiety and pain. This study aimed to compare the effects of aromatherapy with damask rose and chamomile essential oil on the preoperative pain and anxiety associated with emergency orthopedic surgery. DESIGN: A parallel-group randomized controlled design was used. METHODS: Ninety participants were selected and randomly assigned to three groups: the damask rose group (n = 30), the chamomile group (n = 30), and the control group (n = 30). In the damask rose and chamomile groups, three drops of 40% essential of each plant were used for inhalation aromatherapy (three drops every hour for 3 hours) Visual Analog Scales were used to evaluate participants' pain and anxiety levels at baseline, immediately after the intervention, and 1 hour after the intervention. FINDINGS: The results of repeated measures Analysis of Variance (ANOVA) showed that both of the intervention groups experienced a decrease in pain and anxiety over time compared to the control group (P < .001). ANOVA results showed that immediately after the intervention, the anxiety level of the damask rose group compared to the chamomile and control groups was significantly lower (P = .01). However, there was no significant difference in terms of anxiety between the damask rose and chamomile groups 1 hour after the intervention (P = .07). CONCLUSIONS: The use of damask rose and chamomile in aromatherapy was found to effectively lower anxiety and pain levels in emergency orthopedic surgery patients. The antianxiety effect of damask rose is faster than chamomile.

Perspectives and Practice in Eastern and Western Medicine for Pain Management in Rehabilitation Training after Orthopedic Trauma Surgery: A Qualitative Study.

BACKGROUND: Despite the increasing emphasis on rehabilitation training after orthopedic surgery, little is known about the pain caused by the procedure itself. Clinical practice is driven by beliefs in pain management. AIMS: This study aimed to explore the perspective of pain management during rehabilitation training after orthopedic trauma in China and its influencing factors from different perspectives in traditional Chinese medicine and Western medicine, respectively. DESIGN: A phenomenological qualitative study involving semi-structured interviews. SETTINGS:   METHODS: A qualitative study was conducted with 16 medical workers working in the Rehabilitation Medicine Department in eastern China from July 2022-February 2023. A directed method to thematic analysis was used to code the transcribed data and identify themes. RESULTS: Four main themes emerged. (1) Inconsistent perspectives and practice: Chinese doctors majoring in Western medicine felt sympathy, helpless, and had a lack of knowledge and misconception about pain. Traditional Chinese medicine deemed that pain is a protective mechanism and attached importance to holism and unique means. (2) Consistent outcome: Insufficient pain management will have a series of negative consequences for patients' recovery, forming a vicious cycle. (3) Expectations: Though they are not optimistic about traditional analgesics, enhancement, cooperation and ideal analgesic methods still be expressed, and (4) Concept transformation: Conducting nitrous oxide is a process not only to promote analgesic technology but also to promote the awareness and concept of pain management. CONCLUSIONS: Our study emphasized that medical workers should be aware of the importance of pain management at the same time while treating the disability. The study provides insight into pain management experiences within different educational backgrounds. The findings enable professionals to recognize the importance of pain management and its influencing factors to provide feasible and effective pain management strategies.

Percutaneous release for trigger thumb in children under local anesthesia.

Trigger thumb surgery can be performed through open surgery or percutaneous release. Open surgery often requires hospitalization, an operating room, a surgical incision, and postoperative wound care; however, percutaneous release does not require hospitalization or surgery, and is relatively easier and faster. We aimed to assess the results of percutaneous A-1 pulley release using local anesthesia without hospitalization for the treatment of pediatric trigger thumb. In this retrospective study, we included patients operated on between March 2013 and August 2020 with the diagnosis of trigger thumb. The percutaneous release under local anesthesia was applied to all the children by one orthopedic surgeon. All percutaneous release procedures were performed in outpatient clinic conditions. There were 183 children (218 thumbs) who were enrolled in the clinic. Eighty-seven patients were male (47.5%) and 96 were female (52.5%). The average follow-up duration was 5 years (1-8.5 years). Among the 218 trigger thumb cases, 211 were satisfactory (successful result rate 96.8%). Relapse was seen in only 3 thumbs in the early postoperative period. No patient experienced neurovascular deficit or infection. The percutaneous surgical release in pediatric trigger thumb treatment is a simple, minimally invasive procedure that can be done in an outpatient setting under local anesthesia. In addition, the procedure duration is short and has minimal complication rates and maximum patient satisfaction. Level of Evidence III.

Guidelines for Wide-Awake Local Anesthesia Surgery with No Tourniquet in the Office Setting Using Field Preparation Sterility.

SUMMARY: Wide-awake local anesthesia surgery with no tourniquet, or WALANT, has become popular in surgery, especially among hand surgeons. With the increasing number of surgeons performing office-based procedures, this article provides guidelines that may be used in the office setting to help transition more traditional hospital operating room-based procedures to the office setting. This article outlines the benefits of performing office-based wide-awake local anesthesia surgery with no tourniquet and provides a step-by-step guide to performing procedures that can be easily incorporated into any hand surgeon's practice successfully and safely.

Optimizing the Use of Operating Rooms by Transitioning Common Hand Surgeries Into the Office Setting.

PURPOSE: The purpose of this study was to examine the true monetary implications, at the health system level, of moving simple hand procedures, performed with wide-awake local anesthesia no tourniquet surgery, from the ambulatory surgery center (ASC) to office setting. METHODS: We analyzed the costs, revenues, case times, and patient demographics for 2 cohorts of patients who underwent hand and non-hand surgical procedures over a 2-year period. We calculated the mean margin per minute for the top 5 procedures in non-hand orthopedic surgery subgroups, complex plastics hand, and non-hand plastic surgery. We then calculated the following: (1) hours operating room or ASC time gained by moving hand procedures to the office, (2) additional subgroup patients theoretically treated by using the ASC hours gained, and (3) net margin (in dollars) because of additional procedures. RESULTS: Six board-certified hand surgeons performed 623 simple ASC and 808 in-office procedures, consisting of 795 carpal tunnel releases, 84 first dorsal compartment releases, and 446 trigger finger releases. The net margin per minute for simple ASC and in-office hand procedures was $25.01/min and $5.63/min, respectively. In the office setting, hand surgery freed up 821 hours of ASC time, which could be theoretically used to treat over 300 additional patients awaiting outpatient orthopedic hand or plastic surgery. Depending on the subspecialty and type of substituted cases, the theoretical net margin varied from -$150,413 to $3.9 million. CONCLUSIONS: Transitioning simple hand operations out of ASCs realized a mean cost savings of 82% per case ($1,137 vs $206) and effectively opened 821 additional hours of operating room time over a 2-year period. CLINICAL RELEVANCE: Transitioning simple hand operations out of the operating room setting and into the office setting reduces the cost of hand surgical care, improves operating room access for alternate procedures or patients, and validates the sustainability of safe and effective wide-awake local anesthesia no tourniquet surgery from a hospital system's financial standpoint.

Orthopedic and neurosurgical care of X-linked hypophosphatemia.

X-linked hypophosphatemia (XLH) is due to mutations in the PHEX gene leading to unregulated production of FGF23 and uncontrollable hypophosphatemia. XLH is characterized in children by rickets, short stature, waddling gait, and leg bowing of variable morphology and severity. Phosphate supplements and oral vitamin D analogs partially or, in some cases, fully restore the limb straightness. XLH patients may also be affected by premature, complete, or partial ossification of sutures between cranial bone, which could eventually result in cranial dysmorphia, decreased intracranial volume, and secondary abnormally high intracranial pressure with a cerebral compression. Our goal is to address the criteria and the management of the skeletal complications associated with XLH, mainly orthopedic and neurosurgical care, and reflect on decision-making and follow-up complexities.

WALANT Protocol: Stop before you block.

The use of Wide Awake Local Anaesthetic No Tourniquet (WALANT) amongst Plastic and Orthopaedic Hand Surgeons has been accelerated by the impact of the COVID-19 pandemic and associated risks of general anaesthesia. Benefits of WALANT include a bloodless field, improved recovery, on-table testing, as well as cost and time savings. Whilst more clinical trials are underway to fully elucidate safety-profile and outcomes, there is a lack of consensus and clarity over contraindications to WALANT. A survey of trainees identified that only one-in-five were aware of the appropriate reversal agent in the event of inadequate perfusion. We feel that a WALANT checklist should be developed and implemented for use immediately prior to administration of local anaesthetic with adrenaline to an extremity, building on the successes of the World Health Organisation (WHO) and the Royal College of Anaesthetists checklists. Such a checklist should include contraindications to WALANT and make the operator aware of the availability, dose and location of Phentolamine as a reversal agent. Introducing this checklist will help to facilitate safer and more effective use of WALANT within Hand Surgery.

WALANT Hand Surgery Does Not Require Postoperative Opioid Pain Management.

BACKGROUND: Currently, opioids are the standard of care for postoperative pain management. Avoiding unnecessary opioid exposure in patients is of current interest because of widespread abuse. METHODS: This is a prospective cohort study in which wide-awake, local anesthesia, no-tourniquet (WALANT) technique was used for 94 hand/upper extremity surgical patients and compared to patient cohorts undergoing similar procedures under monitored anesthesia care. Patients were not prescribed opioids postoperatively but were instead directed to use over-the-counter pain relievers. Pain scores on a visual analogue scale were collected from patients preoperatively, and on postoperative days 1 and 14. WALANT visual analogue scale scores were compared to those of the two patient cohorts who either did or did not receive postoperative opioids after undergoing similar procedures under monitored anesthesia care. Electronic medical records and New York State's prescription monitoring program, Internet System for Tracking Over-Prescribing, were used to assess prescription opioid-seeking. Information on sex, age, comorbidity burden, previous opioid exposure, and insurance coverage was also collected. RESULTS: Decreased pain was reported by WALANT patients 14 days postoperatively compared to preoperatively and 1 day postoperatively, with a total group mean pain score of 0.37. This is lower than mean scores of monitored anesthesia care patients with and without postoperative opioids. Only two WALANT patients (2.1 percent) sought opioid prescriptions from outside providers. There was little evidence suggesting factors including sex, age, comorbidity burden, previous opioid exposure, or insurance status alter these results. CONCLUSION: WALANT may be a beneficial technique hand surgeons may adopt to mitigate use of postoperative opioids and reduce risk of abuse in patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Ultrasound-guided surgery for lateral snapping hip: a novel ultraminimally invasive surgical technique.

BACKGROUND: Greater trochanteric pain syndrome encompasses a range of causes of lateral hip pain including greater trochanteric bursitis, tendinopathy and tears of the gluteus minimus and medius, and lateral snapping hip (LSH). Surgical options for LSH range from open surgery to endoscopic surgery, including a diamond-shaped cut or a simple transversal release to gluteus maximus tendon release. Resection of an area of proximal iliotibial band (ITB) and step-cut or z-plasty lengthening have not proven superior to transverse release of the ITB. Therefore, making a complete and effective transverse cut guided by ultrasound may represent a potential advance over endoscopic surgery. PURPOSE: In this case series study, we describe how to perform proximal release of the ITB guided by ultrasound. METHODS: The surgical technique-either z-plasty or transverse section of the ITB-was first validated on 10 cadaver specimens and then used in clinical practice. Fourteen patients (5 males and 9 females) were operated from 2014 to 2018. Mean age was 43 years (29-62). RESULTS: The snap resolved in all patients, as verified actively during the surgical procedure as the patient has only local anesthesia. The VAS score for sports activity improved from 7 (5-9) before surgery to 0 (0-2) after 1 year. The HSS score improved from 58 points (47-72) to 96 at 1-2 years. There were no complications other than minor hematomas nor recurrences. CONCLUSION: Ultrasound-guided release of the LSH is a novel surgical option with encouraging results in patients for whom conservative protocols have failed. It can be performed under local anesthesia in an outpatient setting with minimal aggressiveness. It is relatively easy, quick, and painless; no stitches are required. Weight bearing is immediate, and patients usually need crutches for only 2-3 days. Although complete recovery may take 3 months, the rehabilitation protocol is fast and painless.

A meta-analysis of randomized clinical trials on the impact of oral vitamin C supplementation on first-year outcomes in orthopedic patients.

This meta-analysis aimed at investigating the impact of oral vitamin C supplementation on the post-procedural recovery of orthopedic patients, including functional outcomes and complex regional pain syndrome type I (CRPS I). Literature search using the Medline, Cochrane Library, and Embase databases from inception till March 2021 identified seven eligible randomized controlled trials with 1,361 participants. Forest plot revealed no significant difference in the functional outcomes at 6-12 months [standardized mean difference (SMD) = -0.00, 95% CI - 0.19 to 0.18, 467 patients], risk of overall complications (RR = 0.98, 95% CI 0.68 to 1.39, 426 patients), and pain severity at 3-6 months (SMD = - 0.18, 95% CI - 0.49 to 0.12, 486 patients) between patients with and without oral vitamin C supplementation. Pooled analysis showed that vitamin C treatment reduced the risk of CRPS I regardless of dosage (RR = 0.46, 95% CI 0.25 to 0.85, 1143 patients). In conclusion, the current meta-analysis demonstrated that oral vitamin C supplementation may reduce the risk of complex regional pain syndrome type I but did not improve the functional outcomes in orthopedic patients. Nevertheless, because of the small number of trials included in the present study, further large-scale clinical studies are warranted to support our findings.

Development of a Low-Resource Operating Room and a Wide-Awake Orthopedic Surgery Program During the COVID-19 Pandemic.

Introduction. The COVID-19 pandemic resulted in significant medication, supply and equipment, and provider shortages, limiting the resources available for provision of surgical care. In response to mandates restricting surgery to high-acuity procedures during this period, our institution developed a multidisciplinary Low-Resource Operating Room (LROR) Taskforce in April 2020. This study describes our institutional experience developing an LROR to maintain access to urgent surgical procedures during the peak of the COVID-19 pandemic. Methods. A delineation of available resources and resource replacement strategies was conducted, and a final institution-wide plan for operationalizing the LROR was formed. Specialty-specific subgroups then convened to determine best practices and opportunities for LROR utilization. Orthopedic surgery performed in the LROR using wide-awake local anesthesia no tourniquet (WALANT) is presented as a use case. Results. Overall, 19 limited resources were identified, spanning across the domains of physical space, drugs, devices and equipment, and personnel. Based on the assessment, the decision to proceed with creation of an LROR was made. Sixteen urgent orthopedic surgeries were successfully performed using WALANT without conversion to general anesthesia. Conclusion. In response to the COVID-19 pandemic, a LROR was successfully designed and operationalized. The process for development of a LROR and recommended strategies for operating in a resource-constrained environment may serve as a model for other institutions and facilitate rapid implementation of this care model should the need arise in future pandemic or disaster situations.

Non-radicular low back pain: Assessment and evidence-based treatment.

BACKGROUND: Low back pain (LBP) is a common presentation in general practice. Clinical workup must exclude sinister underlying diseases. Treatment of central LBP is difficult given the numerous treatment options available. OBJECTIVE: The aim of this article is to help clinicians assess patients with LBP and formulate evidence-based treatment decisions. DISCUSSION: Patient presentations can be stratified according to the presence of red flags and pain type (ie non-spinal, radicular, non­organic and central). The vast majority of patients with acute central back pain experience improvement of their symptoms. Treatment options include education, lifestyle modification, heat, massage, graduated return to early activity, nonsteroidal anti-inflammatory medications and muscle relaxants when appropriate. Chronic LBP treatment can also include paracetamol and physiotherapy. Second-line treatment can include psychological therapy, multidisciplinary rehabilitation, targeted injections and antidepressants. Tapentadol is a safe and effective medication for treating severe LBP. Pain specialist referral should be considered if patients require controlled analgesia. Surgical treatment has narrow indications in central non-radicular back pain and is considered as a last-line treatment in selected patients.

Wide-Awake Surgery With Local Anesthesia and Epinephrine Is Safe.

Hand and upper extremity surgery performed with the patient wide awake involves the use of a local anesthetic and epinephrine. Controversy persists as to whether epinephrine is safe for use in the hand. The goal of this study was to evaluate the safety of epinephrine in hand and upper extremity surgery. The hypothesis was that epinephrine is safe and can be used for a wide breadth of surgical procedures of the hand and upper extremity. A 4-year retrospective chart review was conducted of consecutive patients undergoing wide-awake surgery performed by 2 surgeons at a single institution. All procedures were performed with local anesthesia and epinephrine. Data collected included patient demographics, procedure volume, procedure type, surgical setting, and complications related to epinephrine use. During the study period, 4054 consecutive patients underwent 4287 wide-awake procedures with local anesthesia and epinephrine. Average patient age was 59 years, and 64% of patients were female. No complications occurred as a result of the use of epinephrine, and no tissue necrosis, phentolamine reversal, anaphylaxis, or readmissions occurred. No patients required conversion to general anesthesia or monitored anesthesia care. This analysis of more than 4000 consecutive patients undergoing wide-awake hand and upper extremity surgery with epinephrine confirmed that epinephrine use is safe, with no reported cases of tissue necrosis, reversal, readmission, anaphylaxis, or anesthetic conversion. Epinephrine is safe for use in the hand and upper extremity for patients undergoing wide-awake hand surgery with a local anesthetic. [Orthopedics. 2020;43(6):e529-e532.].

Current Concepts in the Management of Trigger Finger in Adults.

Trigger finger (TF) is one of the most common causes of hand disability. Immobilization of TF with a joint-blocking orthosis has been demonstrated to effectively relieve pain and improve function. The efficacy of steroid injections for TF varies based on the number of affected digits and the clinical severity of the condition. Up to three repeat steroid injections are effective in most patients. When conservative interventions are unsuccessful, open surgical release of the A1 pulley effectively alleviates the subjective and objective manifestations of TF and currently remains the benchmark procedure for addressing TF. Although several studies have emerged suggesting that a percutaneous approach may result in improved outcomes, this technique demands a learning curve that may predispose patients to higher risk of procedure-related complications. There is no role for preoperative antibiotics in patients who undergo elective soft-tissue procedures of the hand. WALANT anesthesia has gained popularity because it has been associated with improved patient outcomes and a clear cost savings; however, proper patient selection is critical. Similar to other soft-tissue hand procedures, TF surgery rarely necessitates a postoperative opioid prescription.

Bone defect reconstruction with a novel biomaterial containing calcium phosphate and aluminum oxide reinforcement.

BACKGROUND: Reconstruction of metaphyseal fractures represents a clinical challenge for orthopedic surgeons. Especially in osteoporotic bone, these fractures are frequently accompanied by osseous substance defects. In order to ensure rapid mobilization of patients, high stability requirements must be met by osteosynthesis. Various bone graft materials have been introduced in the past, such as autologous bone or exogenous bone substitute materials. These are used as bone void fillers or as augmentation techniques to ensure safe fixation of osteosynthesis. New calcium phosphate-based bone void-filling materials could be a promising alternative to autologous bone or to the currently and widely used polymethylmethacrylate (PMMA)-based cement. The aim of this study was to evaluate a novel paste-like bone void filler in vivo and in vitro with regard to biocompatibility and osteoconductivity. METHODS: In addition to in vitro testing of cell compatibility using pre-osteoblasts (MC3T3-E1), 35 Wistar rats were treated in vivo with implantation of various material mixtures based on calcium phosphate and aluminum oxide reinforcement in a metaphyseal drill hole defect. After 4 weeks, an examination by micro-computed tomography (µCT) and histology was performed. RESULTS: The in vitro analysis showed good biocompatibility with a high cell survival of osteoblasts. In the in vivo experiments, a significantly higher bone ingrowth compared to the empty defect was shown by µCT and histological analysis. Here, the group receiving material reinforced with aluminum oxide (Al2O3) showed a bone volume/tissue volume (BV/TV) of 89.19% compared to a BV/TV of 83.14% for the empty defect (p = 0.0013). In the group treated with a polysaccharide matrix, no increase in BV/TV was observed given a mean ratio of 80.14%. Scoring of histological sections did not reveal a significant difference between CaP and CaP that was substituted with Al2O3. CONCLUSION: The results of this study show an encouraging first step towards the development of new pasty, bone void-filling materials. We demonstrated that a new paste-like bone-filling material, based on calcium phosphate granulates and aluminum oxide to provide strength, exhibits good biocompatibility and osteoconductivity. Further biomechanical test in an osteoporotic animal model will have to be performed, to prove feasibility in metaphyseal defects.

Medium-term results after treatment of percutaneous tennis elbow release under local anaesthesia.

BACKGROUND: The purpose of this study was to evaluate  the results of the technique of percutaneous release of common extensor procedure under local anesthesia for lateral epicondylitis and to emphasize its simplicity. METHODS: Forty seven elbows (41 patients) were treated surgically for lateral epicondylitis in the outpatient minor procedure room under local anaesthesia. The indication for surgery was continuation of sypmtoms (such as pain, movement and power loss) despite conservative treatment lasting more than six months The treatment results were assessed using the visual analogue scale (VAS) and Mayo Elbow Performance Score (MEPS). RESULTS: Twentysix  right elbows and fifteen left elbows were treated surgically. Dominate elbow rate was 74%. The follow-up period was 36 to 72 months (mean 52 months). All patients had full range of motion. The average post operative pain score was 2.6(range 0 to 9).The average post operative MEPS score was 82 (range 40 to 100). ). Sixteen patients had excellent, twenty  patients had good, two patients had fair and three patients had poor outcomes (repetitive problems). CONCLUSION: The percutaneous release of the common extensor origin is an important treatment option with minimal morbidity, safety, simplicity and good to excellent results in most patients. The procedure can be performed under local anaesthetic and leave a rarely visible scar.

Growth Modulation for Knee Coronal Plane Deformities in Children With Nutritional Rickets: A Prospective Series With Treatment Algorithm.

To report prospectively the radioclinical outcome of guided growth surgery for coronal plane deformities around the knee in young children with nutritional rickets on the intermediate term, to assess the responsiveness of torsional deformities of the tibias to guided growth regarding function and objective clinical parameters, and to propose a treatment algorithm. Methods: Fifty children (male:female, 27:23) with knee coronal plane deformities (knees:physes, 86:99), (varum:valgum, 51:35) secondary to nutritional rickets were subjected to femoral and/or tibial temporary hemiepiphysiodesis using a two-hole 8-plate. The mean age at implantation was 3.8 ± 1.5 years (range 2.5 to 5). The mean follow-up was 2.8 years (range 2 to 4). All children received a standing full-length AP radiographs of both lower limbs in neutral rotation to measure the mechanical axis deviation, tibiofemoral angle, and joint orientation angles. Tibial torsion was objectively assessed by measuring the bimalleolar axis. Results: The radiologic measurements, tibiofemoral angle, mechanical axis deviation, mechanical lateral distal femoral angle, medial proximal tibial angle, and Hilgenreiner-epiphyseal angle, showed a highly statistically significant improvement (P ≤ 0.001). Radiographic outcomes correlated with their clinical counterparts. The mean duration of correction of the mechanical axis was 10.8 ± 2.4 months (7 to 21). The mean follow-up for rebound of the deformity was 1.5 years (range 1 to 3). Conclusion: The radioclinical outcome is rewarding with a tolerable complication profile. The mechanical complications were mostly related to lengthy implant retainment encountered in severe deformities. Internal tibial torsion seems profoundly responsive to correction of coronal plane deformity. And, derotation osteotomies are rarely justified. Our proposed algorithm may be used as a decision-taking guide for achieving the desired growth modulation in a more efficient manner.

Can an Integrative Care Approach Improve Physical Function Trajectories after Orthopaedic Trauma? A Randomized Controlled Trial.

BACKGROUND: Orthopaedic trauma patients frequently experience mobility impairment, fear-related issues, self-care difficulties, and work-related disability []. Recovery from trauma-related injuries is dependent upon injury severity as well as psychosocial factors []. However, traditional treatments do not integrate psychosocial and early mobilization to promote improved function, and they fail to provide a satisfying patient experience. QUESTIONS/PURPOSES: We sought to determine (1) whether an early psychosocial intervention (integrative care with movement) among patients with orthopaedic trauma improved objective physical function outcomes during recovery compared with usual care, and (2) whether an integrative care approach with orthopaedic trauma patients improved patient-reported physical function outcomes during recovery compared with usual care. METHODS: Between November 2015 and February 2017, 1133 patients were admitted to one hospital as orthopaedic trauma alerts to the care of the three orthopaedic trauma surgeons involved in the study. Patients with severe or multiple orthopaedic trauma requiring one or more surgical procedures were identified by our orthopaedic trauma surgeons and approached by study staff for enrollment in the study. Patients were between 18 years and 85 years of age. We excluded individuals outside of the age range; those with diagnosis of a traumatic brain injury []; those who were unable to communicate effectively (for example, at a level where self-report measures could not be answered completely); patients currently using psychotropic medications; or those who had psychotic, suicidal, or homicidal ideations at time of study enrollment. A total of 112 orthopaedic trauma patients were randomized to treatment groups (integrative and usual care), with 13 withdrawn (n = 99; 58% men; mean age 44 years ± 17 years). Data was collected at the following time points: baseline (acute hospitalization), 6 weeks, 3 months, 6 months, and at 1 year. By 1-year follow-up, we had a 75% loss to follow-up. Because our data showed no difference in the trajectories of these outcomes during the first few months of recovery, it is highly unlikely that any differences would appear months after 6 months. Therefore, analyses are presented for the 6-month follow-up time window. Integrative care consisted of usual trauma care plus additional resources, connections to services, as well as psychosocial and movement strategies to help patients recover. Physical function was measured objectively (handgrip strength, active joint ROM, and Lower Extremity Gain Scale) and subjectively (Patient-Reported Outcomes Measurement Information System-Physical Function [PROMIS®-PF] and Tampa Scale of Kinesiophobia). Higher values for hand grip, Lower Extremity Gain Scale (score range 0-27), and PROMIS®-PF (population norm = 50) are indicative of higher functional ability. Lower Tampa Scale of Kinesiophobia (score range 11-44) scores indicate less fear of movement. Trajectories of these measures were determined across time points. RESULTS: We found no differences at 6 months follow-up between usual care and integrative care in terms of handgrip strength (right handgrip strength ß = -0.0792 [95% confidence interval -0.292 to 0.133]; p = 0.46; left handgrip strength ß = -0.133 [95% CI -0.384 to 0.119]; p = 0.30), or Lower Extremity Gain Scale score (ß = -0.0303 [95% CI -0.191 to 0.131]; p = 0.71). The only differences between usual care and integrative care in active ROM achieved by final follow-up within the involved extremity was noted in elbow flexion, with usual care group 20° ± 10° less than integrative care (t [27] = -2.06; p = 0.05). Patients treated with usual care and integrative care showed the same Tampa Scale of Kinesiophobia score trajectories (ß = 0.0155 [95% CI -0.123 to 0.154]; p = 0.83). CONCLUSION: Our early psychosocial intervention did not change the trajectory of physical function recovery compared with usual care. Although this specific intervention did not alter recovery trajectories, these interventions should not be abandoned because the greatest gains in function occur early in recovery after trauma, which is the key time in transition to home. More work is needed to identify ways to capitalize on improvements earlier within the recovery process to facilitate functional gains and combat psychosocial barriers to recovery. LEVEL OF EVIDENCE: Level II, therapeutic study.