Tight application of a surgical tourniquet prior to inflation increases venous pressure in the upper limb; Potentially resulting in increased blood loss and poorer visibility.

BACKGROUND: Tourniquets are commonly used in extremity surgery to help provide a bloodless operative field to improve visibility and reduce length of procedures. With the development of WALANT (wide awake, local anaesthetic, no tourniquet) techniques, many surgeons undertake surgery without tourniquet inflation. The correct technique of pneumatic tourniquet application is poorly understood by healthcare staff. The application of a tight tourniquet when applied for optional use or use for only a portion of a procedure, rather than for inflation throughout can cause venous engorgement of an extremity leading to increased blood loss and reduced operative field visualisation thereby discouraging surgeons from persevering with WALANT strategies. AIM: To determine the effect of tourniquet application tension on limb volume prior to skin incision. METHODS: 30 volunteers had the volume of their non-dominant forearm measured post-inflation of a surgical tourniquet using two different application techniques. Tight application was defined as the tourniquet fastened using a dynamometer to a tension of 100 N. Loose application was defined as the tourniquet fastened using a dynamometer to a tension of 50 N. The tourniquet was then inflated to 200 mmHg after both application techniques. Exsanguination was performed by elevation of the arm for 1 min prior to tourniquet inflation. At 5 min the forearm volume was measured using a volume displacement technique. RESULTS: 93 % of participants (28/30) had a higher volume of water displaced when the tourniquet was applied tightly. The mean difference between the loose and tight applications was 30.06 mls. CONCLUSION: The increase in volume in tightly applied tourniquets is believed to result from increased intravascular volume. This increase in blood volume can lead to increased intra-operative blood loss and poor intra-operative visualisation when operating without tourniquet inflation. Loose application of the tourniquet pre-inflation appears to prevent sequestration of venous blood in the limb, therefore decreasing operative blood loss and improving view for operating. LEVEL OF EVIDENCE: Level 1; Symptom Prevalence Study.

Girdlestone resection arthroplasty of the hip (GRA): a case series-outdated procedure or acceptable outcome?

Despite considerable legacy issues, Girdlestone's resection arthroplasty (GRA) remains a valuable tool in the armoury of the arthroplasty surgeon. When reserved for massive lysis in the context of extensive medical co-morbidities which preclude staged or significant surgical interventions, and/or the presence of pelvic discontinuity, GRA as a salvage procedure can have satisfactory outcomes. These outcomes include infection control, pain control and post-op function. We describe a case series of 13 cases of GRA and comment of the indications, peri, and post-operative outcomes.

Single-surgeon perspective: is there ever a need to open extension-type supracondylar fractures?

BACKGROUND: Supracondylar humerus fractures (SCHFs) represent the most common pediatric elbow fracture, constituting approximately 12-17% of all pediatric fractures. The vast majority of operative supracondylar humerus fractures are treated with closed reduction and percutaneous pinning (CRPP); however, the estimated rate of SCHFs requiring open reduction is approximately 12.7%. AIM: This study aims to analyze the likelihood of open reduction in pediatric extension-type SCHFs and to reaffirm the traditional teaching of reduction techniques described by Smith and Rang. METHODS: A single-surgeon retrospective analysis of 56 operative pediatric SCH cases (51 extension-type, 6 flexion-type) who underwent either CRPP or open reduction over a 16-year period was performed. All cases were performed using the aforementioned reduction technique. The Modified Gartland's classification was utilized in the analysis of extension-type SCHF radiographs. RESULTS: Gartland IIA fractures constituted 38% of SCHFs, 9% of Gartland IIB, 43% of Gartland III, and 7% of flexion-type. The rate of open reduction in SCHFs was 1.8% (1 out of 56 cases), performed in a flexion-type injury. All extension-type fractures were successfully managed with either CRPP or manipulation and casting alone. Of the cases requiring CRPP, 45% were divergent lateral wires, and 55% were crossed wires. CONCLUSIONS: In our series, a 1.8% rate of open reduction was indicated in flexion-type SCH fractures. All 52 cases of extension-type SCHFs were successfully managed with closed reduction with or without percutaneous pinning. Successful closed reduction using the concept of intact periosteal hinge to aid and maintain reduction is crucial.

Improving Acute Orthopaedic Admission Note Documentation Standards at a Tertiary Centre Through Proforma Introduction: A Quality Improvement Initiative.

Background Clear, accurate written documentation plays an important role in the handover of medical information, helping to improve care efficiency and avoid medical errors. Both HSE and the Irish National Orthopaedic Models of Care guidelines include key documentation standards for admission notes. Standardised medical admission proforma can help improve documentation standards, but their usage across Irish orthopaedic units is limited to three centres. We evaluated whether an admission proforma improved the documentation standards of acute orthopaedic trauma admission notes within our regional trauma unit. Methods Cycle 1 consisted of a retrospective review of 50 consecutive acute orthopaedic trauma admissions. Exclusion criteria included planned admissions, age <16 years, spinal or pelvic trauma, and 'hip' fractures for whom an existing proforma was in use. Cycle 2 consisted of a prospective review of 50 consecutive acute trauma admissions using the new proforma. Each cycle was scored against a pre-determined checklist incorporating Irish Health Service Executive and Orthopaedic Models of Care documentation standards, with results collated and statistical analysis then performed using Fisher's exact test. Findings Significant improvements in admission note compliance with national documentation were observed. This encompassed multiple domains including clinical identification, e.g., consultant identification (78% to 100% p=0.0005), clinical history, time of injury (72% to 100% p=0.0001), medical history, smoking status (86% to 100% p=0.0001), and patient assessment, vital signs (28% to 70% p=0.0001). Conclusion Improvements in admission note compliance with national documentation standards followed the introduction of a standardised proforma. These findings may encourage the introduction of similar proforma in other units, with potential benefits in patient care.