Wide-Awake Olecranon Fracture Fixation: Is it Possible?

Purpose

The wide-awake local anesthesia no tourniquet technique has been widely performed in hand and wrist surgery with remarkable results. However, its use on the elbow has rarely been reported. Here we describe the use of wide-awake local anesthesia no tourniquet in olecranon fracture fixation in 4 cases.

Methods

Tumescent anesthesia was injected from the proximal ulna to approximately 10 cm distally and into the periosteum and fracture site, approximately 25 minutes before skin incision. The fracture underwent closed reduction and was fixed using a long 6.5-mm cancellous screw with a washer through a small incision. No tourniquet was applied and none or mild sedation was administered. At the end of the operation, patients were asked to perform active elbow flexion-extension and forearm pronosupination movements under an image intensifier to test the range of motion and fracture stability.

Results

The surgical procedure was completed in all 4 cases. Two patients reported mild pain during ulnar medullary canal reaming, with pain scores of 3 and 4 on a 10-point scale, respectively. One case was resolved with additional local anesthetic injection. The other case required the administration of intravenous propofol. Both patients were able to actively move the elbow at the end of the operation.

Conclusions

The use of wide-awake local anesthesia no tourniquet for olecranon fracture fixation has the advantage of obviating the need for an arm tourniquet, general anesthesia or heavy sedation, preoperative tests, and discontinuing routine medications (including anticoagulants). The stability of the elbow fixation was tested by active motion during surgery. This simple, safe, low-cost, and reproducible technique may be a good option for patients with contraindications or high risk of general or regional nerve block anesthesia.

Type of study/level of evidence

Therapeutic IV.

WALANT Technique in Percutaneous Scaphoid Osteosynthesis

Scaphoid fractures account for 50 to 70% of all carpal bone fractures. Percutaneous scaphoid osteosynthesis can use the dorsal or volar approach, both with good results, and is most commonly performed under general anesthesia or regional nerve block. The wide-awake local anesthesia no tourniquet (WALANT) technique is already considered a safe and cost-effective technique in hand surgery around the world. Local anesthesia with epinephrine causes vasoconstriction, which obviates the need for tourniquet and, consequently, the need to use patient sedation. Thus, the possibility of testing fixation stability under physiological forces is another great advantage of using local anesthesia. In the technique described in the present paper, active wrist and hand motion can be tested immediately after scaphoid fixation. Wide-awake local anesthesia no tourniquet has been increasingly used in soft-tissue hand surgery and in the fixation of metacarpal and phalangeal fractures. However, to date, there is no published literature addressing the use of this technique in percutaneous scaphoid osteosynthesis. The purpose of the present technical note is to describe the use of WALANT for both the dorsal and volar approaches in percutaneous scaphoid osteosynthesis.

Osteosynthesis of Fractures of the Metacarpal Neck with Self-Compressing Screw - Preliminary Analysis of 21 Cases

Objective  The present study aims to analyze the clinical results of the surgical treatment of metacarpal neck fractures with retrograde intramedullary fixation using cannulated headless screws (Herbert type).

Methods  Retrospective study of 21 closed fractures deviated from the metacarpal neck in 21 patients operated between April 2015 and November 2018.

Results  The sample included 19 men and 2 women. The mechanisms that caused the trauma were punching, falling to the ground and motor vehicle accident (n = 14, 5 and 2). The affected metacarpals were the 5 ^th , 3 ^rd , and 2 ^nd (n = 19, 1 and 1). Surgical indications were neck-shaft diaphysis of the metacarpal > 30° for the 2 ^nd and 3 ^rd metacarpals and > 40° for the 5 ^th metacarpal, shortening ≥ 5mm, rotational deviation, and the desire of the patient not to use plaster cast. In the immediate postoperative period, patients remained without immobilization and were instructed to mobilize their fingers according to tolerance. All patients had total active mobility > 240° and returned to their former occupations. All fractures consolidated and there were no reinterventions.

Discussion  The great advantages of the headless screw technique are its low morbidity, sufficient stability to avoid external immobilization, and reproducibility at low cost.

Conclusion  This is an easy, fast technique that has excellent results for the surgical treatment of displaced fractures of the neck of the metacarpals.

Height of the foot longitudinal arch and anterior cruciate ligament injuries

OBJECTIVE:

To evaluate the association between the height of the medial longitudinal arch of the foot and non-contact injuries of the anterior cruciate ligament.

METHODS:

One hundred and five patients were included in this case-control study. The case group consisted of 52 patients with non-contact injury of the anterior cruciate ligament. Fifty-three individuals with no history of symptoms regarding to feet or knees comprised the control group. An anthropometric assessment of the bony arch index was performed, which consisted of measuring the ratio of the height between the navicular bone to the ground and the distance from the most posterior support point of the calcaneus to the first metatarsal-phalangeal joint. Gender, height, weight, body mass index and the frequency of sports practice were also evaluated.

RESULTS:

Subjects in the case group had significantly higher medial longitudinal arches than individuals in the control group.

CONCLUSION:

Individuals with rupture of the anterior cruciate ligament had higher arches than the corresponding controls, suggesting an association between a high medial longitudinal arch of the foot and injury of the anterior cruciate ligament. Level of Evidence III, Case-Control Study

Reconstruction of neglected patellar tendon ruptures using the quadriceps graft

Several techniques using different grafts have been described for reconstruction of the patellar tendon after a neglected rupture. Retraction of the quadriceps tendon may compromise repair integrity due to progressive stretching of the graft. The authors present a surgical technique using the central one-third of the quadriceps tendon. This is supported by the fact that the resistance to traction of this segment of the quadriceps tendon equals that of a double-looped semitendinosus graft and that the harvesting of this specific graft promotes muscle inhibition, thus protecting the reconstruction during the recovery period.