Aims

The objective of our study is to identify the causes for recurrence and to evaluate the results of our technique.

Introduction

The role of in-situ decompression in patients with severe ulnar nerve compression is still controversial. The authors present a prospective study on the results of in-situ decompression in this selected group of patients treated through a mini open incision (4cms) and complete decompression by appropriate patient positioning.

Introduction: Common pathologies seen in hand clinics include Dupuytren’s contracture, ganglia and trigger digits. Some patients can be treated in the out patient department by percutaneous fasciotomy, aspiration, or percutaneous A1 pulley release. The effectiveness and safety of these procedures has been documented in the literature. There are no studies investigating the cost effectiveness these of treatments.

Aim: Our aim was to compare the cost of treatment of Dupuytren’s contracture, ganglia and trigger digits in the out-patient department with the operating theatre.

Methods: All patients seen in a new patient hand clinic with a diagnosis of Dupuytren’s contracture, trigger digit or ganglion of the wrist or hand were prospectively identified over a 6 month period.. The number undergoing a procedure in the out-patient clinic or theatre was recorded.

Costings of theatre time and out-patient time were obtained from the hospital management.

Results: 80, 26, and 52 patients were treated with regard to Dupuytrens contracture, ganglia, and trigger digits respectively over the 6-month period. Of these, 37, 23, and 44 were treated by an out patient procedure, and 43, 3 and 8 underwent a formal operation.

Based on a cost of £216 per out-patient clinic session, the cost of the out-patient procedures was calculated at £1872 over 6 months, or £3744 per annum. Based on a theatre cost of £1785 per session, to perform all the clinic procedures as formal operations would have cost £60,690 over 6 months, or £121380 per annum. The cost savings were therefore £117636 per annum.

Discussion: We conclude that outpatient interventions for dupuytrens disease, ganglions and trigger digits results in significant cost savings over formal surgical treatment.

We set out to ascertain if there is a consensus in elective orthopaedic practice for the screening and management of MRSA. A questionnaire was distributed to all British Orthopaedic Association Linkmen, with prepaid return envelopes.

A response rate of 60% (159 of 250) was recorded. 62% do have a screening policy in practice: all admissions (44%), high risk patients only (22%), only patients for joint replacement (12%), both patients for joint replacement and patients at high risk of carriage (21%). Eradication therapy is used in a MRSA - positive patient prior to joint replacement surgery by 91%, following which the MRSA status would be checked by 88%. The efficacy of eradication would be confirmed by obtaining: one set (29%), two sets (13%), and three sets (49%) of negative swabs, prior to proceeding with surgery. A 2nd generation Cephalosporin (77%), followed by Teicoplanin/Vancomycin (16%) are in routine use for antibiotic prophylaxis.

The majority of responders have adopted a practice of screening patients; however, significant differences exist in the population that is selected for screening. Eradication in MRSA positive patients is a common practice, but there is variation in the number of subsequent screens performed. Cephalosporins remain the antibiotic of choice for prophylaxis but first line therapeutic agents are also being used which may have implications for resistance. These variations can be partly attributed to the lack of evidence from which practical guidelines can be drafted, as highlighted by national guidelines published in 1998. Until further research is done into the cost effectiveness of screening and the further management of MRSa we have to rely on strict adherence to infection control practices, and appropriate use of antibiotics.

Purpose: To compare the analgesia provided by pure subcutaneous infiltration (Gale technique) of lignocaine with that provided by infiltration of lignocaine into the carpal tunnel in addition to the subcutaneous tissue (Altissimi technique) for carpal tunnel decompression

Methods: 20 patients with bilateral carpal tunnel syndromes were chosen for the study. Patients were randomised to receive one local anaesthetic technique on one side and the other on the other side. The pain scores were recorded intraoperatively and 2 and 4 hours postoperatively.

Results: 5 patients experienced intra-operative pain with the Gale technique, while one did with the Altissimi technique (p=0.15 using Mann Whitney U test). Postoperative analgesia at 2 hours was significantly better with the Altissimi technique (p= 0.009). Patients with the Altissimi technique also required less number of analgesic tablets over 24 hours post surgery (p=0.01).

Conclusions: We found no statistically significant difference in the intra-operative pain scores with the two techniques. However, postoperative pain relief was much better with the Altissimi technique.

To compare the results of standard open carpal tunnel release against minimal access release using the ‘Stryker Knifelight’ in the same patients.

A prospective, randomised trial was carried out recruiting all patients with bilateral carpal tunnel syndrome. There were 26 patients (18 females and 8 males), with a mean age of 48 years. The patients were randomised to having the ‘Knifelight’ on one side and therefore acted as their own controls. They were assessed preoperatively, and at 2 and 6 weeks postop by questionnaire, and grip strength measurements.

All sides were improved following release but those done by the open method were more likely to have complete resolution at 6 weeks. In contrast, the ‘Knife-light’ sides had better grip strength and allowed earlier return to work. In terms of preference, the patients were split equally between the 2 techniques. 2 patients had minor complications following minimal access release including one with numbness over the thenar eminence for 6 weeks.

This study shows that open carpal tunnel release remains the ‘gold standard’ but the minimal access technique offers some advantages in terms of quicker recovery.