Wide awake local anesthesia no tourniquet (WALANT) versus axillary brachial plexus block for carpal tunnel release in a French public university hospital: Care pathways and operating room costs.

INTRODUCTION: The wide awake local anesthesia no tourniquet (WALANT) is a local anesthetic technique that theoretically cuts costs and shortens surgical waiting times, but this has yet to be demonstrated in France. The main objective of this study was to assess and compare the comprehensive care pathways and costs of performing carpal tunnel release (CTR) procedures in the ambulatory surgery unit using WALANT and axillary brachial plexus block (ABPB). METHODS: A total of 72 CTRs in 66 patients were reviewed after a minimum follow-up of 6 months. The anesthesia was performed by an anesthesiologist after a preoperative consultation. The surgical waiting time, operating room occupancy time, total time taken off work (TOW) and the return to work rate were recorded. The estimated total direct cost per patient (TDCPP) was the sum of the specialist consultation fees, the French diagnosis-related group (DRG) rates and the minimum daily cost of TOW (€27.30/day). RESULTS: Only the total operating room occupancy time differed significantly: 27minutes for the WALANT versus 37minutes for the ABPB (p=0.004). There were no complications or reoperations in either group. The total cost for the cohort was estimated at €190,970. The mean estimated TDCPP was €2,870 for the entire cohort, €2,543 for the ABPB and €2,713 for the WALANT (p=0.791). Twenty-seven of the 45 patients returned to work after a mean TOW of 3.1 months. Fourteen CTRs were preceded by a mean preoperative TOW of 27 days, which resulted in a cost of €24,948 (13% of the total cost). There were no significant differences in TOW or revision rate between WALANT and ABPB. CONCLUSION: Although WALANT significantly reduced operating room occupancy times in our public hospital, the societal costs were the same regardless of the anesthesia technique. Reducing surgical waiting times in France could result in a theoretical saving of nearly €14 million annually. LEVEL OF EVIDENCE: IV.

A comparative study of fixation methods in adults with two-thirds distal isolated ulnar shaft fractures with a minimum of 2 year follow-up.

BACKGROUND: Adult isolated ulnar shaft fractures (IUSF) are rare. There remains a need to establish the best methods to manage these fractures. The aim of this study was to compare two forms of treatment for IUSF: intramedullary stabilization by k-wire (IMF) versus Open Reduction Internal Fixation by plating (ORIF), in order to identify differences in clinical (1) and radiological outcomes (2), as well as comparative costs (3). HYPOTHESIS: The hypothesis of this study was assessing whether intramedullary stabilization was as feasible as plating in the treatment of isolated ulnar shaft fractures in clinical practice. PATIENTS AND METHODS: A retrospective analysis was undertaken on patients diagnosed IUSF between January 2015 and March 2017 with a minimum of 2 years follow-up. They were treated with IMF (group 1) or ORIF (group 2). Demographic information, clinical outcomes and complications were collected. Cost, including implant cost, operative time, sterilization and inpatient stay were compared. Radiographs were reviewed to evaluate axial angulation, shortening, displacement and residual deformity. RESULTS: 54 patients with a mean age of 41.2 years were treated by IMF (27/54) and ORIF (27/54). The mechanism of injury included high-energy (55%) and low-energy falls (45%). AO/OTA 2018 fracture classification was simple (39/54), wedge (14/54) and complex (1/54). The locations were 37/54 (70%) distal third and 17/54 (30%) mid-shaft fractures. There was no significant difference pre and post-operatively between the 2 groups regarding radiologic criteria. 3 cases of non-union, 4 delay-union and 1 regional complex syndrome occurred in group 2. No complication was reported in group 1. The function determined by range of motion (ROM) at wrist and elbow was excellent in 72% (group 1) and 80% (group2), 18% satisfactory in group 1 and 20% in group 2. There was no difference for QuickDASH and pain. Implant removal was necessary in 70% of patients without sequelae in nailing, 11% after plating. Average operation time was 29 ± 5 min for ORIF and 18 ± 6 min for IMF. Total estimated cost per patient was 3678.4€ for IMF and 7051.9€ for ORIF. CONCLUSIONS: Compared with ORIF, IMF significantly reduced the operation time and cost with lower complications. TYPE OF STUDY: Retrospective study. TYPE OF PROOF: Level 4.

Dynamic Changes in Microbial Composition During Necrotizing Soft-Tissue Infections in ICU Patients.

Introduction: Recent studies described the threat of emerging multidrug-resistant (MDR) bacteria in intensive care unit (ICU) patients, but few data are available for necrotizing skin and soft tissue infections (NSTI). In a cohort of ICU patients admitted for NSTI, we describe the dynamic changes of microbial population during repeated surgeries. Materials and Methods: This retrospective study compiled consecutive cases admitted for the management of severe NSTI. Clinical characteristics, NSTI features, morbidity and mortality data were collected. The microbiological characteristics of surgical samples obtained during initial surgery were compared with those obtained during the first reoperation, including persistence of initial pathogens and/or emergence of microorganisms. Risk factors for emergence of microorganisms and MDR bacteria were assessed by univariable and multivariable analyses. Results: Among 100 patients {63% male, 58 years old [interquartile ratio (IQR) 50-68]} admitted for NSTI, 54 underwent reoperation with a median [IQR] delay of 3 (1-7) days. Decreased proportions of susceptible strains and emergence of Gram-negative bacteria, including Pseudomonas aeruginosa, staphylococci and enterococci strains, were reported based on the cultures of surgical specimen collected on reoperation. On reoperation, 22 (27%) of the isolated strains were MDR (p < 0.0001 vs. MDR bacteria cultured from the first samples). Broad-spectrum antibiotic therapy as first-line therapy was significantly associated with a decreased emergence of microorganisms. Adequate antibiotic therapy from the initial surgery did not modify the frequency of emergence of microorganisms (p = 0.79) and MDR bacteria (p = 1.0) or the 1-year survival rate. Conclusion: The emergence of microorganisms, including MDR bacteria, is frequently noted in NSTI without affecting mortality.

Arthroscopic Rotator Cuff Repair With a Knotless Suture Bridge Technique: Functional and Radiological Outcomes After a Minimum Follow-Up of 5 Years.

PURPOSE: To evaluate clinical and radiological outcomes of knotless suture bridge repair after a minimum of 5 years of follow-up. METHODS: A prospective consecutive series of full-thickness supraspinatus atraumatic chronic tears was evaluated in the study. Tears were medium or large. Further inclusion criteria were minimum clinical follow-up of 5 years with magnetic resonance imaging (MRI) at 24 months and fatty infiltration <2. Patients with shoulder stiffness, arthritis, or rotator cuff tear involving the subscapularis tendon were excluded. An arthroscopic cuff repair was performed using a knotless double-row suture bridge technique with braided suture tapes. Clinical outcomes were evaluated using the Constant score, the American Shoulder and Elbow Surgeons score, strength score, and a visual analog scale. Tendon healing was analyzed according to Sugaya MRI classification at 24 months. A Sugaya score of 1 or 2 was considered as tendon healing. Statistical analysis was performed with the Student's t-test. P = .05 were considered statistically significant. RESULTS: Sixty-eight patients were included in this series. Mean follow-up was equal to 68.8 ± 7 months. At last follow-up, the mean visual analog scale, American Shoulder and Elbow Surgeons score, and Constant scores improved significantly from 5.5 ± 1.6, 48.2 ± 13.1, 37.8 ± 8.3, to 2.1 ± 2.1 (P = 5.43 E-14), 87.4 ± 15.8 (P = 7.15 E-27), and 82.8 ± 14.7 (P = 1.01 E-33), respectively. Anteflexion improved from 99.3° ± 13.4° preoperatively to 136.6° ± 15.9° at last follow-up (P = 3.08 E-21). Strength score was significantly higher postoperatively (18.4 ± 6.7 vs 8.3 ± 3.5). MRI showed 88% (n = 57) of Sugaya 1-2 repairs. Patients with unhealed rotator cuffs showed significantly lower functional results than the Sugaya 1-2 group. No correlation between degree of retraction and rate of healing was observed. Four symptomatic patients (6%) required revision for failed rotator cuff repair. CONCLUSIONS: Despite potential confounding factors, arthroscopic knotless suture bridge repair of rotator cuff tears with acromioplasty demonstrated excellent long-term results of tendon healing, pain relief, and improvement of shoulder function. LEVEL OF EVIDENCE: Level IV, therapeutic case series.