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.

Clinical and Radiological Outcomes of Scaphocapitate Fusion in Kienböck Disease: A Systematic Review and Meta-Analysis.

Purpose: To report the functional and radiological outcomes of scaphocapitate (SC) arthrodesis in the treatment of Kienböck disease. Methods: This meta-analysis was conducted with adherence to PRISMA guidelines. Google Scholar, PubMed, Cochrane and Virtual Health Library were searched from inception until November 2022. All original studies that investigated the outcomes of scaphocapitate fusion in Kienböck disease were included. Exclusion criteria were arthroscopically performed fusions, concomitant radial shortening, traumatic or other etiologies of lunate avascular necrosis, and studies published in languages other than English. Outcomes of interest were pre- and post-operative wrist range of motion, VAS score, functional scores, radiological outcomes, surgical technique, complication rate and reoperation rate. Results: The total number of included participants was 203 from 11 articles. The results showed no significant differences pre- and post-operatively in terms of wrist flexion, extension and ulnar deviation. However, there was a significant reduction in radial deviation after the surgery (WMD -2.30; 95% CI, -4.26 to -0.33). Moreover, a significant increase was noticed in grip strength in Kg (WMD 13.29; 95% CI, 3.21-23.37) and mmHg post-operatively (WMD 23.75; 95% CI, 17.56-29.94). In addition, the models demonstrated significant decrease in carpal height (WMD -0.01; 95% CI, -0.02 to 0.00), scapholunate angle (WMD -12.11; 95% CI, -20.46 to -3.77) and radioscaphoid angle after the surgery (WMD -12.09; 95% CI, -15.51 to -8.67). The pooled overall rate of complication and reoperation rates were 24% (95% CI, 6%-47%) and 14% (95% CI, 3%-31%), respectively. Conclusions: Scaphocapitate arthrodesis is an effective procedure for treatment of Kienböck disease. This procedure is associated with satisfactory functional outcomes and significant improvement in pain scores and grip strength. Further studies with larger sample sizes and reduced heterogeneity are needed for a better evaluation of the results. Clinical relevance: Scaphocapitate arthrodesis is a recommended surgery for Kienböck disease with satisfactory functional and radiological outcomes. However, patients should be counseled on the possible complications and reoperation rate.

A 60-Year-Old Woman with Symptoms of Combined Carpal Tunnel Syndrome and Cubital Tunnel Syndrome Due to an Elastofibroma Causing Compression of the Median and Ulnar Nerves.

BACKGROUND Cubital tunnel syndrome results from pressure or stretching of the ulnar nerve, and carpal tunnel syndrome involves the median nerve. Elastofibroma is a rare, benign, slow-growing soft-tissue tumor that commonly occurs as a bilateral infrascapular tumor in elderly women. This report is of a 60-year-old woman who presented with combined carpal tunnel syndrome and cubital tunnel syndrome due to an elastofibroma causing compression of the median and ulnar nerves. CASE REPORT We report the case of a 66-year-old woman with left-hand numbness, tingling along the fingers, sleep disturbance, and weakness in pinching or holding objects for an extended period. The clinical examination and nerve conduction studies established the diagnosis of combined carpal tunnel syndrome (CTS) and cubital tunnel syndrome (CuTs) complicated by intrinsic muscle wasting. The patient underwent left carpal and cubital tunnels release surgery and end-to-side anterior interosseous nerve transfer to the motor component of the ulnar nerve. Pathologic evaluation of the entire specimen showed collagen bundles alternating with refractive cylinders stained with Verfoeff-van Gieson elastic stain. CONCLUSIONS This report is of a rare case of a histologically-confirmed single, peripheral, benign elastofibroma involving compression of the ulnar and median nerves. This case highlights the importance of histopathology in diagnosing rare soft-tissue tumors arising at an uncommon site and presenting with rare symptoms.

Acute irreducible volar distal radioulnar joint dislocation treated with open reduction through dual approaches: A case report and literature review.

Introduction: Acute dislocation of distal radioulnar joint (DRUJ) is a rare pathology. Most cases were managed with closed reduction, and few patients required open reduction through dorsal or volar approaches. We describe a patient who required open reduction using dual approaches. Case presentation: This paper reported a case of acute DRUJ volar dislocation that failed closed reduction. Open reduction was tried using a dorsal approach which failed to achieve joint reduction. A second volar approach to release volar joint capsule had only achieved joint reduction. Discussion and conclusion: This case report highlighted the importance of open reduction when treating acute DRUJ injuries that failed closed reduction. We strongly recommend that surgeons should be ready to utilize dual approaches for this injury and to appraise patients about this possibility.

In Vitro Comparison between the Pulvertaft Weave and the Modified Core Suture Pulvertaft Weave.

Background: The Pulvertaft weave was described more than 50 years ago and is still used in tendon transfers. The aim of this study was to evaluate the strength of a modified core suture Pulvertaft weave technique and compare it to the original Pulvertaft weave traditionally used in tendon transfer surgery. Methods: 12 extensor pollicis longus tendons and extensor indices proprius tendons were harvested from fresh frozen cadavers. Six Pulvertaft weaves were performed using FiberWire 4.0 and six core suture tendon weave were performed using FiberLoop 4.0. Biomechanical analysis was performed and stifness, first failure load and ultimate failure load were measured for both set of repairs. Results: The stiffness of the core suture tendon repair (9.5 N/mm) was greater than that of the Pulvertaft repair (2.5 N/mm) The first failure load of the core suture tendon repairs (68.9 N) was greater than the Pulvertaft repairs (19.2 N) and the ultimate failure load of the core suture tendon repairs (101.8 N) was greater than the Pulvertaft repairs (21.9 N). All of these differences were statistically significant. Conclusions: The core suture Pulvertaft weave is a modification to the Pulvertaft weave used in tendon transfers. The results of this cadaveric study suggest it is 5 times stronger than the traditional Pulvertaft repair, potentially allowing it to be used with early active motion protocols after tendon transfers.

Avascular necrosis of the lunate secondary to perilunate fracture dislocation: Case report and review of the literature.

This is a 39-year-old male, fell from a bike, left wrist with trans-styloid perilunate fracture dislocation that underwent open reduction internal fixation, 20 months after surgery the patient developed avascular necrosis of the lunate, final wrist fusion was performed secondary to the arthritic changes on the wrist. Anatomic dissection was performed and vascularity of the lunate was identified, its origin is from the volar palmar arch, when dislocated palmarly and more than 90 degrees the vessel is still intact. More than 512 patients with perilunate dislocation and perilunate fracture dislocation are included we identified in the literature transient avascular necrosis of the lunate in nine and seventeen of pure avascular necrosis of the lunate. Concluding that avascular necrosis of the lunate after perilunate dislocation or perilunate fracture dislocation is an infrequent finding especially when the volar ligaments are intact.

Open Versus Arthroscopic Treatment of Chronic Lateral Epicondylitis and Worker's Compensation.

PURPOSE: To compare the short-term outcomes between arthroscopic and open procedures for the treatment of lateral epicondylitis. Because a significant portion of patients have worker's compensation (WC), the outcomes in these subgroups were separately analyzed. METHODS: A retrospective analysis of patients who had surgical treatment of lateral epicondylitis by a single surgeon from 2010 to 2017 was performed. Patients who were symptomatic after 9 months of conservative treatments including nonsteroidal medications, steroid injections, and physical therapy were offered surgical intervention. The type of surgery was selected after detailed consultation with the patient. Charts were reviewed for preoperative pain, grip strength as measured by dynamometer, smoking status, and WC status. Postoperative assessments included pain and grip strength at 6 weeks and time taken to return to full duty. Two groups were compared using unpaired t test and chi-squared tests. Results were compared with similar studies in the literature. RESULTS: The study included 30 patients in the arthroscopic debridement group and 42 patients in the open tenotomy and reinsertion group. Eighteen patients (25%) had WC. Compared with the open group, the arthroscopic group had earlier return to full duty (mean 7.13 weeks, confidence interval [CI] 6.21 to 8.05 versu mean of 12.22 weeks, CI 11.21 to 13.24; P < .001) and less time for complete pain relief (mean 7.4 weeks, CI 7.02 to 7.93 versus 9.5 , CI 8.68 to 10.44; P = .043). No difference was seen among the groups in terms of unfavorable outcome (persistent pain and recurrence of pain), JAMAR hand dynamometer score at 6 weeks, and visual analog score at 6 weeks. A total of 11 patients (15%) had unfavorable outcome. Incidence of unfavorable outcomes was more in patients with WC insurance (36% in WC versus 7% in non-WC; P = .023). No association was seen with smoking status. WC patients also had a longer time to return to full duty (16.68 weeks for WC versus 7.65 weeks for non-WC; P < .001) and a longer time to get complete pain relief (12.4 weeks for WC versus 7.5 weeks for non-WC; P < .001). CONCLUSION: The arthroscopic technique offers advantages of earlier return to work and shorter recovery period along with additional advantages of joint inspection and ability to treat coexisting pathologies. WC patients had a longer time to return to full duty and time for complete pain relief. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Orthopedic Professionals' Recognition and Knowledge of Pain and Perceived Barriers to Optimal Pain Management at Five Hospitals.

Pain is a challenge for orthopedic healthcare professionals (OHCP). However, pain studies examined the competencies of a single OHCP category, did not consider various pain management domains or barriers to optimal pain service, and are deficient across the Arabic Eastern Mediterranean region. We surveyed OHCP's recognition and knowledge of pain and perceived barriers to optimal pain service (361 OHCP, five hospitals). Chi square compared doctors' (n = 63) vs. nurses/physiotherapists' (n = 187) views. In terms of pain recognition, more nurses had pain management training, confidently assessed pediatric/elderly pain, were aware of their departments' pain protocols, and felt that their patients receive proper pain management. More doctors comfortably prescribed opiate medications and agreed that some nationalities were more sensitive to pain. For pain knowledge, more nurses felt patients are accurate in assessing their pain, vital signs are accurate in assessing children's pain, children feel less pain because of nervous system immaturity, narcotics are not preferred due respiratory depression, and knew pre-emptive analgesia. As for barriers to optimal pain service, less nurses agreed about the lack of local policies/guidelines, knowledge, and skills; time to pre-medicate patients; knowledge about medications; complexity of the clinical environment; and physicians being not comfortable prescribing pain medication. We conclude that doctors required confidence in pain, especially pediatric and geriatric pain, using vital signs in assessing pain and narcotics use. Their most perceived barriers were lack of local policies/guidelines and skills. Nurses required more confidence in medications, caring for patients on narcotics, expressed fewer barriers than doctors, and the complexity of the clinical environment was their highest barrier. Educational programs with clinical application could improve OHCPs' pain competencies/clinical practices in pain assessment and administration of analgesics.

Vitamin D and tibiofemoral joint orientation angles in children.

Vitamin D is an important component in musculoskeletal development and function in children. The aim of our study was to investigate serum vitamin D levels and tibiofemoral joint orientation angles in children. We performed a retrospective review on a consecutive series of children presenting with lower limb complaints. The children underwent an assessment of serum vitamin D level and full-length standing lower limb anteroposterior radiographs, and were divided into normal and deficient vitamin D groups. Tibiofemoral angles (TFAs) [lateral distal femoral angle (LDFA); medial proximal tibial angle (MPTA)] were measured by three independent observers and compared between the groups. Correlation tests between serum vitamin D level and TFAs were also performed. Sixty (39 boys, 21 girls) children were reviewed. The mean serum vitamin D level for the entire group was 26.8 ng/ml and 75% of the children were deficient. The mean serum vitamin D levels in the normal (11 boys, four girls) and deficient (28 boys, 17 girls) groups were 46.7 ng/ml (range: 32-100) and 20.2 ng/ml (range: 4-29), respectively. The mean right and left LDFAs were significantly higher in the normal compared to the deficient vitamin D group (right LDFA: 98.7° vs. 92.2°, P=0.031; left LDFA: 99.1° vs. 92.6°, P=0.018). We also found a correlation between serum vitamin D level and LDFAs (right ρ=0.29, P=0.03; left ρ=0.30, P=0.02). We found no difference in the right and left MPTAs in the normal and deficient vitamin D groups. In addition, we could not find a correlation between serum vitamin D level and MPTAs. The majority of children were vitamin D deficient. Serum vitamin D level was associated with a change and correlation to the LDFAs compared to MPTAs. Further work is required to investigate the effect of vitamin D supplementation on TFAs in children.

Locked volar distal radioulnar joint dislocation.

INTRODUCTION: Volar dislocation of the distal radioulnar joint is a rare injury which is commonly missed in the emergency departments. A thorough review of literature showed very few reported cases and the cause for irreducibility varied in different cases, Lack of suspicion and improper X-ray can delay the diagnosis. CASE PRESENTATION: Our article discusses a case 40 year old construction worker, who presented to the Emergency with work-related injury, complaining of left wrist pain, deformity and inability to rotate his forearm. X-rays revealed a volar dislocation of distal ulna which was reducible after manipulation under General Anesthesia (GA). The joint was stable after the reduction. DISCUSSION: Isolated dislocation of the distal radioulnar joint can be either volar or dorsal, although dorsal dislocation is more common. The distal radioulnar articulation plays an important role in the rotational movement of the forearm. It allows pronation and supination which are essential for the function of the upper limb. Pronator Quadratus muscle spasm is an important blockade to reduction and was preventing reduction in this case. METHODS: The work has been reported in line with the CARE criteria [9]. CONCLUSION: Volar locked dislocation of Distal Radio ulnar joint is a rare injury. High degree of clinical suspicion and proper X-ray is required for prompt detection. The importance of this case is to raise the awareness among physicians in treating these kind of injuries by careful assessment of the patient and radiographs, and to consider pronator quadratus as an important cause for the blockade to reduction.