Percutaneous Retrograde Technique Using Intramedullary Headless Compression Screws for Metacarpal Fractures Under Wide-Awake Local Anaesthesia No Tourniquet.

Background The common modality of treatment of metacarpal fractures is nonsurgical. There are, however, a subset of patients and fracture types that require surgical correction, but surgery comes with its own problems like stiffness and scarring. Therefore, surgical operations must be minimally invasive barring complications of anaesthesia and the procedure. Therefore, we conducted this study to assess patient outcomes following treatment with percutaneous intramedullary screw fixation via the wide-awake local anaesthesia no tourniquet (WALANT) approach for unstable metacarpal fractures. Methodology We retrospectively analysed the records of 21 patients who received metacarpal fixations with headless compression screws at two district general hospitals in the United Kingdom from 2018 to 2020. We used wide-awake anaesthesia with 10 mL (1% lidocaine and 1 mL 8.4% sodium bicarbonate as a buffer) infiltrated around the superficial tissues on the dorsal aspect of the metacarpal bone, including the periosteum. The Jahss manoeuvre was used to reduce the fracture under the guidance of a mini C-arm. All patients had 3-mm Medartis cannulated compression screws (Medartis AG, Basel, Switzerland) (self-tapping) inserted retroactively using a 5-mm skin incision. The range of movement of the metacarpophalangeal joint was checked intraoperatively and shown to the patient for optimal postoperative rehabilitation. Patients underwent a two-week follow-up wound check and examination for pain (using the visual analogue scale (VAS)) or stiffness requiring physiotherapy. We used the Manchester-modified (M2) disability of the arm, shoulder, and hand (DASH) score to scrutinize the fracture union and the functional outcome of the hand. We also assessed the time to return to work. Results The study included 18 men and two women with a mean age of 22.6 years (range, 18 to 40). The fifth (n=16), fourth (n=4), and second metacarpals (n=1) were involved, and we saw transverse (n=10) and short oblique (n=11) fractures. Fractures healed in five weeks (range, four to six weeks). The mean M2 DASH score was 0.8 (range, 0 to 6), and mean total active motion was 240° (range, 230° to 260°). At the final follow-up, the mean extensor lag for the metacarpophalangeal joint was 5° (range, 0° to 15°), 7° for the proximal interphalangeal joint (range, 0° to 15°), and no lag at the distal interphalangeal joint. The average VAS score at the end of two weeks was 8/10 (range, 7 to 9). The average time for the return to daily activities was 2.56 weeks. We found no intraoperative complications in any of the patients. All patients went home on the same day postoperatively and gave feedback that their experience with WALANT was good to excellent. All patients had a good range of motion at the two-week follow-up, and the mean time to return to normal work was two to three weeks. The M2 DASH score measured was satisfactory. Conclusions This retrospective study assessed patient outcomes following treatment with percutaneous intramedullary screw fixation via the WALANT approach for unstable metacarpal fractures. WALANT was a quick and reliable alternative to fix unstable metacarpal fractures, especially for high-demand patients requiring a short recovery period before returning to regular activity. Further research with a larger sample size and a longer follow-up to analyse the outcome is warranted before an actual guideline can be established.

The Consent Process for Elective Hip and Knee Arthroplasty: Does Information on Handwritten Forms Meet Prescribed Standards?

Introduction The process of informed consent is vital, not only to good clinical practice and patient care, but also to avoid negligence and malpractice claims. Elective hip and knee arthroplasty numbers are increasing globally, and the British Orthopaedic Association (BOA) has endorsed standards for obtaining written consent for these procedures. Many centres in the United Kingdom and globally, use handwritten consent forms to document informed consent, leaving open the potential for missing out important procedure and risk-related information. Our study aimed to assess whether information on handwritten consent forms was compliant with BOA standards for elective arthroplasty of the hip and knee. Methods We retrospectively reviewed 70 handwritten consent forms, across theatre lists of 12 arthroplasty consultants at our elective arthroplasty centre. These included 35 forms each for hip and knee arthroplasty respectively. We compared the information on these forms to the standards prescribed by the BOA. We assessed compliance of the forms with common, less common and rare risks of hip and knee replacement, as described by the BOA. We also noted the designation of the person filling out the form (consultant, registrar or nurse practitioner) and whether this affected information on the form. We assessed the forms for legibility issues, and whether the setting (clinic/pre-operative ward) affected information on the form. Results None of the 70 forms reviewed achieved full compliance with BOA standards. When assessed for common risks of hip and knee arthroplasty, the number of compliant forms was 25.7% and 42.8%, respectively. None of the forms mentioned all rare risks of either hip or knee arthroplasty. We identified legibility issues in 12 of 70 (17.1%) forms. There was no significant difference in information written on forms filled out by consultants, registrars or nurse practitioners, or between forms filled out in the clinic versus those on the pre-operative ward. Conclusion Handwritten forms lack compliance with prescribed standards for written informed consent in elective hip and knee arthroplasty. Ideally, a pre-written consent form should be used, but with the option of adding information individually tailored to the patients' background. This ensures that good clinical practice is optimally followed, and reduces the potential risk of any litigation.

Correlation between tibial nail length and olecrenon to 5th metacarpal head measurement: An anthropometric study.

PURPOSE: During fracture fixation, the size of tibial nail is a vital factor affecting the outcomes and thus preoperative estimation of tibial nail length is very important. This study aims to find out whether "olecranon to 5th metacarpal head" (O-MH) measurement can be used to reliably predict the tibial nail length. METHODS: This was a cross sectional study involving 100 volunteers. Measurements were done and recorded by two observers on two separate occasions. Tibial nail length estimation measurement was done from highest point of tibial tuberosity to the tip of the medial malleolus (TT-MM). O-MH measurement was taken from tip of olecranon to the tip of 5th metacarpal head with wrist in neutral position and hand clenched. Statistical analysis was done to find out correlation between two measurements and influence of age, gender and body mass index on them. RESULTS: Paired t-test showed no systematic error between the readings. Intraclass correlation coefficient showed strong agreement in inter and intra observer settings. Strong correlation was found between the TT-MM & O-MH measurements using Pearson's correlation coefficient test (r = 0.966). Hierarchical regression analysis showed age, gender and BMI have no statistically significant bearings on these measurements and their correlations. CONCLUSION: O-MH measurement is a useful and accurate means of estimating tibial nail length preoperatively.

Comparative study of the efficacy of gentamicin-coated intramedullary interlocking nail versus regular intramedullary interlocking nail in Gustilo type I and II open tibia fractures.

PURPOSE: Open tibia fracture is prone to infection, consequently causing significant morbidity and increasing the hospital stay, occupational loss and onset of chronic osteomyelitis. Intramedullary nailing is one choice for treating tibia shaft fractures. To improve the delivery of antibiotics at the tissue-implant interface, many methods have been proposed as a part of prophylaxis against infection. This study was conducted to study the role of gentamicin-impregnated intramedullary interlocking (IMIL) nail in the prevention of infection in Gustilo type I and II open tibia fractures and to compare the results with regular intramedullary nail. METHODS: The study included 28 patients with open tibia fractures (Gustilo type 1 or type 2); of them 14 underwent regular IMIL nailing and the other 14 were treated with gentamicin-coated nailing. Randomization was done by alternate allocation of the patients. Follow-up was done postoperatively (day 1), 1 week, 6 weeks, and 6 months for bone union, erythrocyte sedimentation rate (ESR), hemoglobin and C-reactive protein (CRP). Statistical significance was tested using unpaired t-test. A p value less than 0.05 was considered significant. RESULTS: There were 4 cases of infection in controls (regular IMIL nail) and no infection among patients treated with gentamicin-coated nail during the follow up (X2 = 4.66, p = 0.031). At 6 months postoperatively, CRP (p = 0.031), ESR (p = 0.046) and hemoglobin level (p = 0.016) showed significant difference between two groups. The bone healing rate was better with gentamicin-coated nail in comparison to regular IMIL nail at 6 months follow-up (p = 0.016). CONCLUSION: Gentamicin-coated IMIL nail has a positive role in preventing infection in Gustilo type I and II open tibia fractures.