A Study of Hand Flap Viability when Using a Wide Awake Local Anesthesia No Tourniquet (WALANT) Technique.

Objectives Flap surgery using a wide awake local anesthesia no tourniquet (WALANT) technique has historically been avoided because of technical challenges and concerns regarding the vasoconstriction caused by the necessary injection of epinephrine alongside the local anesthetic. The objective of our work was to evaluate the viability of the hand flaps performed using a WALANT technique compared with those performed under regional with a tourniquet. Materials and Methods Seventy-four patients were enrolled in a prospective comparative single-center study and subsequently divided into two groups: 36 patients in the locoregional anesthesia group and 38 patients in the WALANT group. Flap viability was evaluated on day 2 and day 10 using predetermined criteria. Results We did not find any significant difference in outcomes assessed for flap viability between the two groups postoperatively. Conclusion There was no evidence to suggest that vascularization of the flaps was compromised by the injection of epinephrine. The WALANT technique may, therefore, potentially be able to be safely deployed within this population.

Hand wounds: An analysis of topography and related damage to underlying structures.

INTRODUCTION: Hand wounds account for 35 to 51% of hand traumas. Damage to underlying anatomical structures depends on the location of the wound. The objective of this study is to describe the topographic distribution of hand wounds allowing for subsequent evaluation of the link between affected surface area and underlying lesion. METHODS: We retrospectively reviewed the medical records of 1058 patients with a total of 1319 wounds over a period of 2 years. Wound location was described according to the cutaneous projection of IFSSH zones for flexors and extensors. Any associated deep lesions were evaluated. Topographical distribution was modeled graphically using a heat-map. We compared the proportion of underlying lesions between each cutaneous zone. Sub-group analysis for lesions' rate regarding zone groups were performed. RESULTS: 58.9% of wounds were located on the palmar surface and 41.1% on the dorsal surface. 71% of wounds affected only the digits. The index finger was the most affected. The most damaged region was zone 2 for palmar wounds and zone 3 for dorsal wounds. 45.5% of wounds resulted in injury to a significant underlying anatomical structure. This frequency was 36.4% and 58.5% for palmar and dorsal wounds respectively. More than 50% of wounds in palmar zone 5 and dorsal zones 1, 3, 5, 6 and 7 presented at least one lesion. A lesion of major structure was more frequently found in palmar zone 5 (p <0.001). Dorsally, no zone predominated. Subgroup analysis for dorsal wounds revealed that wounds overlying joints had more major lesions including more tendons injuries and more articular violations with zone 3 presenting a rate of 68%. CONCLUSION: We provided the first graphical representation for the topographical distribution of hand wounds. Dorsal wounds have a higher association with injury to underlying structures. These results generally support surgical exploration of all hand wounds regardless of their location. LEVEL OF EVIDENCE: IV Study type: Epidemiological study.

Novel robotic technology for the rapid intraoperative manufacture of patient-specific instrumentation allowing for improved glenoid component accuracy in shoulder arthroplasty: a cadaveric study.

BACKGROUND: Accurate prosthesis placement in arthroplasty is an important factor in the long-term success of these interventions. Many types of guidance technology have been described to date often suffering from high costs, complex theater integration, time inefficiency, and problems with day-to-day usability. We present a novel, intraoperative robotics platform, capable of rapid, real-time manufacture of low-cost patient-specific guides while overcoming many of the issues with existing approaches. METHODS: A prototype robotics platform was assessed in a 24-specimen cadaveric trial during sequential simulated shoulder arthroplasty procedures. The platform consisted of a tableside robot with sterile drapes and sterile disposable components. The robot itself comprised a 3D optical scanner, a 3-axis sterile robotic drill, and a 2-axis receptacle into which the disposable consumables were inserted. The consumable was composed of a region of rapidly setting moldable material and a clip allowing it to be reversibly attached to the robot. Computed tomographic (CT) imaging was obtained for all cadaveric specimens, and a surgical plan was created focusing on glenoid component position-specifically, guidewire position to allow for accurate glenoid preparation before implant insertion. Intraoperatively, for every specimen, the relevant osseous anatomy was exposed and humeral and glenoid preparation undertaken in the usual manner. The sterile disposable was used to create a mold of the joint surface. Once set, the mold was inserted into the robot and an optical scan of the surface was undertaken followed by automatic surface registration with the CT data and surgical plan. An automatic guide hole was subsequently drilled into the molded blank, which was removed from the robot and placed back into the patient, with the melded surface ensuring exact replacement. The guidewire was then driven through the guide hole in accordance with the preoperative plan. RESULTS: The novel robotic platform achieved average angular accuracies of 1.9° (standard deviation [SD] 1.3) version and 1.2° (SD 0.7) inclination with positional accuracy of 1.1 mm (SD 0.7) compared to a preoperative plan. DISCUSSION: We have described a novel robotics platform that is able to reliably produce patient-specific intraoperative guides to allow for accurate guidewire placement. Guidance is provided using a portable intraoperative device. The results suggest achieved accuracy levels may be equivalent to those seen in other existing guidance technologies; however, eventual in vivo trials and analysis is required. This technology has potential transferability to improve accuracy in other areas of arthroplasty.

Mixed Reality Assisted Percutaneous Scaphoid Fixation: A Proposed New Surgical Technique.

The success of percutaneous fixation of non or minimally displaced scaphoid waist fractures is reliant on optimal placement of the screw. This can be challenging for surgeons to achieve, potentially involving a large volume of intraoperative imaging, and surgical time. Mixed reality (MR) is a new technology that allows the projection of holographic imagery within the surgeon's field of vision intraoperatively. This imagery can include surgical planning data and 3D reconstructions of a patient's anatomy that can be used in order to aid the surgeon in achieving accuracy. We describe a technique for how this novel technology might be used in the future to fix scaphoid fractures-MR assisted percutaneous scaphoid fixation. This is done using cadaveric modeling. MR assisted percutaneous scaphoid fixation may have the potential to aid surgeons in achieving an optimal guidewire placement with the ability to reduce surgical time and radiation exposure.

The Glenoid Vault Outer Cortex a new more accurate radiological reference for shoulder arthroplasty.

INTRODUCTION: Correct positioning of the glenoid component is an important determinant of outcome in shoulder arthroplasty. We describe and assess a new radiological plane of reference for improving the accuracy of glenoid preparation prior to component implantation - the Glenoid Vault Outer Cortex (GvOC) plane. METHODS: One hundred and five CT scans of normal scapulae were obtained. Forty six females and 59 males aged between 22 and 30 years. The accuracy of the GvOC plane was then compared against the current "gold standard" - the scapular border (SB). Measurements of glenoid inclination, version, rotation, and offset were obtained using both the GvOC and SB planes. These were then compared to actual values. RESULTS: The mean difference between version obtained using the GvOC plane and the actual value was 1.8° (-2 to 5, SD 1.6) as compared to 6.7° (-2 to 17, SD 4.3) when the SB plane was used, (p < 0.001). The mean difference between estimates of inclination obtained using the GvOC plane and the actual were 1.9° (-4 to 6, SD 1.6) as compared to 11.2° (-4 to 25, SD 6.1) when the SB plane was used, (p < 0.001). CONCLUSIONS: The GvOC plane produced estimates of glenoid version and inclination closer to actual values with lower variance than when the SB plane was used. The GvOC may be a more accurate and reproducible radiological method for surgeons to use when defining glenoid anatomy prior to arthroplasty surgery.

Os acromiale: a review of its incidence, pathophysiology, and clinical management.

An os acromiale occurs when any of the primary ossification centres of the acromion fail to fuse with the basi-acromion. It is present in approximately 8% of individuals, and whilst the majority of these individuals are unaffected it can cause significant pain and disability. It can impact seemingly unrelated surgical intervention in the region such as subacromial decompression and reverse shoulder arthroplasty. A painful os acromiale can be both a diagnostic challenge, and difficult to manage. There remain a wide variety of surgical practices with variable outcomes achieved. We present an evidence-based discussion of the surgical techniques described to date in the literature, alongside a comprehensive review of the incidence and pathophysiology of os acromiale.This review was written after a comprehensive analysis of the literature to date relating to os acromiale. Particular focus was given to material examining surgical management techniques, and the condition's incidence across different population groups.Open reduction and internal fixation using cannulated screws, or tension band wiring have superior outcomes in the literature in the treatment of symptomatic os acromiale. There may be a biomechanical advantage of combining the two techniques. Preservation of large anterior deltoid attachment is necessary, with consideration being given to the local blood supply. There is likely no additional benefit from iliac crest vs local bone grafting. Research in this area remains of a low evidence level with small samples sizes. Appropriately powered clinical research of a higher-level evidence methodology is needed in order to differentiate further in the choice of surgical intervention. Cite this article: EFORT Open Rev 2019;4:525-532. DOI: 10.1302/2058-5241.4.180100.

Occult myometrial recurrence after progesterone therapy to preserve fertility in a young patient with endometrial cancer.

OBJECTIVE: We report a case of endometrial cancer treated by fertility-preserving P therapy, who subsequently presented with an abnormal magnetic resonance imaging (MRI) of the myometrium despite normal endometrial biopsies. DESIGN: Case report. SETTING: Tertiary referral university hospital. PATIENT(S): A 31-year-old patient with grade 1, stage I endometrial cancer presented for treatment with fertility-preserving P therapy. Multiple endometrial samples were all normal. Four years later, she presented with an abnormal pelvic MRI in the absence of any other signs or symptoms. Hysterectomy and oophoropexy confirmed normal endometrium with deeply invasive cancer. She remains cancer-free 2 years later with two normal children from surrogacy. INTERVENTION(S): Progestogen therapy, laparoscopic-assisted vaginal hysterectomy, oophoropexy, and assisted reproductive techniques (ART) and surrogate. MAIN OUTCOME MEASURE(S): Cancer disease status and fertility preservation. RESULT(S): Eight years after initial diagnosis, the patient remains cancer free and has conceived by surrogate reproductive techniques. CONCLUSION(S): Reproductive options remains a meaningful quality of life goal even for patients with cancer. Routine pelvic MRI should be considered for follow-up of endometrial cancer patients who retain their uterus. Hysteroscopy and dilation and curettage may not be sufficient.