Wrist block has been used to provide pain relief
for many procedures on the hand and wrist but its role in arthroscopy
of the wrist remains unexplored. Chondrotoxicity has been a concern
with the intra-articular infiltration of local anaesthetic. We aimed
to evaluate and compare the analgesic effect of portal and wrist
joint infiltration with a wrist block on the pain experienced by
patients after arthroscopy of the wrist. A prospective, randomised, double-blind trial was designed and
patients undergoing arthroscopy of the wrist under general anaesthesia
as a day case were recruited for the study. Levo-bupivacaine was
used for both techniques. The effects were evaluated using a ten-point
visual analogue scale, and the use of analgesic agents was also
compared. The primary outcomes for statistical analyses were the
mean pain scores and the use of analgesia post-operatively. A total of 34 patients (63% females) were recruited to the portal
and joint infiltration group and 32 patients (59% males) to the
wrist block group. Mean age was 40.8 years in the first group and
39.7 years in the second group (p >
0.05). Both techniques provided
effective pain relief in the first hour and 24 hours post-operatively
but wrist block gave better pain scores at bedtime on the day of
surgery (p = 0.007) and at 24 hours post-operatively (p = 0.006). Wrist block provides better and more reliable analgesia in patients
undergoing arthroscopy of the wrist without exposing patients to
the risk of chondrotoxicity. Cite this article:
Osteoarthritis of the first trapeziometacarpal joint (TMCJ) is a disabling disease which reduces the function of the thumb and the hand. Replacement arthroplasty offers a pain free joint as well as mobility, stability and strength. This study reviews the results of TMCJ arthroplasty using a cemented metal-on-polyethylene implant (Sr TMC, Avanta®). Between 2001–2005 seventy two (n = 72) TMCJ cemented Arthroplasties were performed by a single surgeon. Patients were followed in the clinics for up to six years (median follow up 36 months, range 24–72). Patients were reviewed clinically and radiologically by two independent assessors. For outcome, Sollerman and Quick-DASH scores were used. A Jamar dynamometer was used to assess the grip and pinch strengths. Thirty six patients (46 joints), were seen at final follow up. There were 13 male and 23 female patients. Ten patients had bilateral TMCJ replaced. Six patients were revised to trapeziectomy and ligament reconstruction with tendon interposition. Four for aseptic loosening and two for traumatic dislocation. Survival after a median follow up of 36 months was 91%. At final follow up mean Quick DASH score was 29.2 and mean Sollerman Score was 77.1. Radiological review of the surviving joints showed lucencies around trapezial component in 8 joints, 4 of which were loose. However these patients had good hand function and grip strength and therefore declined revision surgery. We found that the radiological findings did not correlate with clinical findings. 83% patients were satisfied with the outcome of their treatment. Early results of Sr-TMC (Avanta) joint replacement are encouraging. We recommend the use of this prosthesis for osteoarthritis of the trapeziometacarpal joint.
Patients who sustain hip fractures should be operated on within 24 hours of admission according to the Royal College Of Physician Guidelines. A delay to theatre of more than 4 days is associated with an increase in inpatient mortality. A high proportion of patients with hip fractures are elderly and take aspirin, clopidogrel or warfarin. A retrospective review of 100 patients admitted between December 2006 and July 2007 with a hip fracture was conducted. Our aims were to assess the proportion of patients taking antithrombotic medication, when the antithrombotic medication was stopped pre-operatively and see whether there was a delay to theatre. We also evaluated any association between patients taking antithrombotic medication and a return to theatre, post-operative morbidity and mortality and length of inpatient stay. 47 patients were taking aspirin, 1 was taking clopidogrel, 2 were on aspirin and clopidogrel and 3 patients were taking warfarin. The aspirin group had an increased delay to theatre compared to the no antithrombotic group, however, both groups had similar numbers operated on within 24 hours. 68% (32/47) patients had the aspirin stopped on the same day as the operation. 1 patient taking aspirin returned to theatre for evacuation of a haematoma. The main post-operative complication was pneumonia (n=9). 8 patients required a blood transfusion of which 5 were taking aspirin. The main causes of mortality were ischaemic heart disease (n=7) and pneumonia (n=5). The mean lengths of inpatient stay were 22.48 days in the aspirin group, 50 days in the aspirin and clopidogrel group, 66 days in the clopidogrel group, 24.33 in the warfarin group and 24.81 days in the no antithrombotic group. It is suggested from this small study that there is no advantage in stopping aspirin prior to hip fracture surgery. However, further studies need to be undertaken.
Six patients were revised to trapeziectomy and ligament reconstruction with tendon interposition. Four for aseptic loosening and two for dislocation. With revision as end point the survival rate at median follow up of 36 months was 89%. At final follow up mean Quick DASH score was 29.2 and mean Sollerman Score was 77.1. Radiological review of the surviving joints showed subsidence of trapezial component in 4 joints. However these patients had good hand function and grip strength and therefore declined revision surgery. We found that the radiological findings did not correlate with clinical findings. 83% patients were satisfied with the outcome of their treatment.
