Wide-Awake Local Anesthesia, No Tourniquet Surgery in the Philippines.

The use of wide-awake local anesthesia, no tourniquet (WALANT) has been adapted by most hand surgeons in the Philippines. This is especially true for centers with a large volume of patients needing specialized care for the hand. The use of WALANT has enabled surgeons to do procedures on an outpatient basis, thus potentially creating cost-saving measures for patients and health care facilities. Aside from common outpatient procedures like carpal tunnel syndrome, trigger finger, and de Quervain tenosynovitis, open reduction internal fixation of hand fractures, acute tendon repairs, tendon transfers, and reconstructions have been performed under WALANT as outpatient procedures. The future of WALANT surgery in the Philippines is promising. Teaching WALANT to other areas of the country can counterbalance the large disproportion of hand surgeons to patients and the concentration of specialized care in urban areas. This will enable patients to receive surgical hand care without going to large urban centers.

The Validity, Reliability and Internal Consistency of the Cross-Cultural Adaptation of the FIL-DASH (Filipino Version of the Disability of the Arm, Shoulder and Hand) Questionnaire in Patients with Traumatic Brachial Plexus Injuries.

Background: The objective of this paper was to determine the validity, reliability and internal consistency of the translated FILIPINO DASH (FIL-DASH) questionnaire in patients with traumatic brachial plexus injuries. Methods: Thirty-five adult patients with traumatic brachial plexus injury were enrolled in the validation stage. The same questionnaire was given to the patient between 7 to 14 days for the test-retest reliability. The validated Filipino version of the SF-36 was used as the gold standard to determine the construct validity of the translated DASH. We also compared the DASH score with the SF-36 total and subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Acuity Scale (VAS) for Pain. Results: The internal consistency was adequate, with Cronbach's Alpha for the 30 items of 0.93 and an average inter-item covariance of 0.399. The test-retest reliability was 0.87 (p < 0.001). There was no significant difference in establising the validity of the translated DASH against SF-36 total and Subscale, validated Brief Pain Inventory Severity and Interference Scale and the Visual Analogue Scale (VAS). Conclusions: The translated DASH (FIL-DASH) questionnaire was internally consistent and showed no difference in testing for test-retest reliability and validity against functional outcome measures and pain scales validated for adult Filipinos.

The usefulness of performing extensive debridement to prevent infections in open flexor tendon injuries of the hand

BACKGROUND: Infection after flexor tendon repair in the hand is uncommon but may cause debilitating problems if not prevented. In centers where delayed presentation after injury happens often, early bacterial colonization is assumed and an initial debridement is indicated ensuring a clean environment for subsequent repair. Preference for the type of initial debridement differ from surgeon to surgeon. OBJECTIVE: This paper aims to compare limited and extensive initial debridement in preventing post-operative infection in patients treated more than 24 hours after open tendon injury. METHODS: A retrospective review of records for demographics, the type of debridement and occurrence of infection was performed. Statistical comparison of proportions of post-operative infection was done. RESULTS: Of thirty-one records included, twenty-four patients underwent extensive debridement while 7 had limited. Two patients from each group developed infections resulting to 8.3 % infection in the extensive group and 28.6 % in the limited group. The difference is not statistically significant. CONCLUSION: The trend for a higher infection rate in the limited group supports the need for aggressive debridement in managing delayed presenting patients with open tendon injuries. While the non-significant difference potentially supports the less cumbersome option, a better powered study is recommended to confirm.

Functional outcome after treatment of tuberculosis of the upper extremity

OBJECTIVE: Tuberculosis of the upper extremity, while rare, is still a problem in the Philippines. Included in the primary aim of TB treatment is cure of the patient and restoration of quality of life and productivity. The purpose of this paper is to describe a series of patients treated for Tuberculosis of the upper extremity in the context of level of function and possible factors contributing to disability.METHOD: Records of the University of the Philippines-Philippine General Hospital Department of Orthopaedics were reviewed to recruit adult patients treated for Tuberculosis of the upper extremity from 2009-2013. Patients who consented were asked to answer a Disability of Arm, Shoulder and Hand questionnaire (DASH) validated for Filipinos.RESULTS: Fifteen (15) patients presenting with conditions ranging from synovitis to arthritis, treated medically and surgically, were evaluated for function at least 6 months after treatment. The average disability for strenuous activities. Patients reported minimal limitations in doing activities of daily living.CONCLUSION: Patients treated for Tuberculosis of the upper extremity still present with relatively low levels of disability. Activities of daily living were generally performed without problems but activities requiring exertion were consistently reported as a difficult task for most participants.

Reconstruction of the first metacarpal after giant cell tumor excision using non-vascularised fibular autograft, ligament reconstruction and tendon interposition arthroplasty of the carpometacarpal joint

We report an innovative approach to reconstructing the defect after excision of giant tumor cell (GCT) involving the entire first metacarpal. Reconstruction was performed using non-vascularized fibular autograft fused at the metacarpo-phalangeal (MP) joint and soft tissue arthroplasty using ligament reconstruction and tendon interposition (LRTI) at the carpo-metacarpal (CMC) joint of the thumb. Two years after the procedure, the CMC joint had functional pain-free motion and radiographs showed fusion of the MP joint. The patient did not present with any major complication and was satisfied with the outcome of the procedure.

Investigation on the level of evidence in researches done by orthopedic residents of the Department of Orthopedics, Philippine General Hospital over the past twenty-seven years

BACKGROUND: Clinical research has been part of the orthopedic residents' training program over the past 27 years of the Department of Orthopedics, Philippine General Hospital. The purpose of the present study was to determine the levels of evidence in the researches done by orthopedic residents in training from January 1983 to December 2010. METHODS: The authors reviewed all completed research performed by the department's orthopedic residents in training from January 1983 to December 31, 2010. The exclusion criteria for the study were as follows: review articles, research articles whose full texts were not available and those research articles in which consultants were primary authors. The research articles were scored according to the level of evidence proposed by the Journal of Bone and Joint Surgery (American Volume), and were categorized according to decade: 1980s, 1990s, and 2000s.  RESULTS: A total of 24 research articles were retrieved and reviewed. There were no Level I studies performed in the department by the residents since 1983. There was a significant increase in the number of Level II and Level III studies from the 1980s to the 2000s (p=0.0001). The Hand Section had the highest number of Level II studies 8.6% (3 out of 35) while the Adult Section had the highest number of Level III studies at 21% (11 out of 53). The Pediatric Section had the highest number of Level IV studies at 91% (30 out of 33). CONCLUSION: The level of evidence in research conducted by the orthopedic residents in training of the Department of Orthopedics, Philippine General Hospital has improved significantly in the past 27 years.

Carpal boss in an adolescent: case report.

Carpal boss is a relatively uncommon cause of pain and swelling on the dorsum of the wrist and usually presents in adult patients. However, it is occasionally seen in adolescents. We describe an unusual case of a 15-year-old girl with a carpal boss treated surgically after failed conservative treatment. Surgical excision of the carpal boss resulted in relief of symptoms with no complications.

Accuracy of fluoroscopy in closed reduction and percutaneous fixation of simulated Bennett's fracture.

PURPOSE: Restoration of joint congruity has been shown to be an important factor in the prevention of arthritis in patients with Bennett's fracture. It is for this reason that surgical management is generally recommended for displaced intra-articular fractures of the base of the thumb metacarpal. Adequacy of closed reduction after pinning of Bennett's fracture is usually evaluated by fluoroscopic examination. The purpose of this study is to determine the accuracy of fluoroscopic examination compared to plain radiographs and direct visualization in closed reduction and percutaneous pin fixation of simulated Bennett's fractures. METHODS: In 8 fresh-frozen cadaveric hands, Bennett's fractures were created and the incisions were closed. Under fluoroscopic visualization the fractures were close reduced and pinned using 1.14-mm (0.045-in) K-wires. These reductions were all judged to be acceptably aligned with fracture stepoff and displacement less than 1.5 mm under fluoroscopy. Anteroposterior and lateral plain radiographic films were then taken to assess the reduction. Finally, the carpometacarpal joint was opened and visualized to directly assess the reduction for fracture stepoff, displacement, and gap. RESULTS: After percutaneous fixation, all closed reductions were deemed acceptable. Examination with plain radiographs demonstrated an average anteroposterior view displacement of 0 mm, lateral view gap of 0.1 mm, and articular stepoff of 1.1 mm. Direct examination of the joints showed an average articular gap of 0.9 mm, stepoff of 2.1 mm, and displacement of 3.1 mm. The values for stepoff and displacement were significantly different when the direct measurements were compared to the fluoroscopic measurements. Radiographic measurements were significantly different from direct measurements for displacement of the fracture fragments. CONCLUSIONS: After closed reduction and percutaneous pinning of simulated Bennett's fractures in a cadaver model, the assessment of the articular gap, stepoff, and displacement as detected by fluoroscopy is often in error compared to that detected by plain radiographs and direct examination.

Percutaneous management of scaphoid nonunions.

Scaphoid nonunions pose a formidable challenge to surgeons because of the multiple factors that may contribute to their causation. The etiology of the nonunion may be because of anatomic variations, fracture configuration, vascular problems, underlying metabolic problems, or the inadequacy of initial treatment. Percutaneous management of scaphoid nonunions offers the advantage of inducing minimal trauma to the soft tissues while adequately stabilizing the fracture site to induce union in a high percentage of cases. These minimally invasive techniques of fixation can also be combined with arthroscopy and some of the new biologic bone grafting techniques. The indications, advantages, and techniques of the dorsal and volar percutaneous approaches are described in this paper.

Osteochondral autografting for acute articular defect of the metacarpal head: case report.

Osteochondral injuries in the hand are common. The small size of the joints and associated articular surfaces make repair of these injuries difficult. Osteochondral autografting has been described in the knee for some time and has recently been reported for hand injuries. We describe the use of an osteochondral graft taken from the dorsal nonarticular portion of the metacarpal head for a defect in the metacarpophalangeal joint surface.

Biomechanical stability of different fixation constructs for ORIF of radial neck fractures.

Radial head and neck fractures are common and at times require operative fixation. There is no consensus on the ideal fixation construct for unstable radial neck fractures. Using 7 fresh frozen cadaveric radii, fractures of the radial neck were created 2 cm from the articular surface. The fractures were stabilized with 5 different commonly used constructs: crossed K-wires; a 2.4-mm T-plate using screws in the head (T-plate and nonlocked screw construct); a T-plate using a screw and locked buttress pin in the head (T-plate and locked buttress pin construct); a T-plate with an interfragmentary screw from the shaft retrograde, through the plate into the head (retrograde interfragmentary screw construct); and a T-plate with an interfragmentary screw from a nonarticular portion of the head antegrade into the shaft (antegrade interfragmentary screw construct). All constructs were tested for bending and torsional rigidity using an Instron mechanical testing machine (Model 306; MTS Systems, Eden Prairie, Minnesota). The highest rigidity in both bending and torsion was the antegrade interfragmentary screw construct. During bending, the antegrade interfragmentary screw construct was significantly stronger than a T-plate and nonlocked screw construct. In torsion, the retrograde interfragmentary screw construct was significantly stiffer than K-wires and approached significance over a T-plate and locked buttress pin construct. Locking bolts vs screws into the head did not significantly increase rigidity in torsion or bending. In this model, plating showed an increase in stiffness in torsional loading as compared to K-wires. The addition of a lag screw across the neck fracture consistently showed an increase in torsional and bending stiffness of the constructs. These data may assist orthopedic surgeons in determining the best fixation for radial neck fractures.