Aims We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue. Methods This was a randomized control trial of 169 patients who required surgery for closed isolated distal radius fractures. The study was performed between March 2016 and April 2019 at a public sector level 1 trauma centre. General anaesthesia was used in 56 patients, Bier’s block in 58 patients, and WALANT in 55 patients. Data were collected on pre-, peri-, and postoperative parameters, clinical outcome, hospital costs, and patient satisfaction. One-way analysis of variance (ANOVA) was used with a p-value of 0.05 being significant. Results Operations with WALANT proceeded sooner, and patients recovered faster, resulting in mean fewer missed working days (7.8 (SD 1.67)) compared with general anaesthesia (20.1 (SD 7.37)) or Bier’s block (14.1 (SD 7.65)) (p < 0.001). The WALANT patients did not develop complications, while the other patients did (p < 0.04). Clinical outcomes did not differ, nor did surgeon qualification affect clinical outcomes. Mean hospital costs were lower for WALANT ($428.50 (SD 77.71)) than for general anaesthesia ($630.63 (SD 114.77)) or Bier’s block ($734.00 (SD 37.54)) (p < 0.001). Patient satisfaction was also higher (p < 0.001). Conclusion WALANT for distal radius fractures results in a faster recovery, is more cost-effective, has similar clinical outcomes, and has fewer complications than general anaesthesia or Bier's block. This makes WALANT an attractive technique in any setting, but especially in middle- and low-income countries. Cite this article: Bone Joint Res 2020;9(7):429–439.

Introduction The use of a tourniquet during total knee arthroplasty (TKA) is still a topic of debate, given the conflicting results in the literature with respect to complications, pain, functional outcome, and blood loss. However, due to a lack of convincing data on early patient-reported outcomes (PROMS), this study aims to compare pain and functional outcomes in total knee arthroplasty patients with and without a tourniquet. Methods A randomized controlled trial was set up at a tertiary care hospital that spanned from 1 st February 2015 to 31 st July 2018. We included all primary total knee arthroplasties performed for patients aged between 50 and 80 years. Oxford Knee Score (OKS), Numerical Pain Rating Score (NPRS), Visual Analogue Scale (VAS) for satisfaction, active range of knee motion, and Short Form-12 Survey (SF-12) scores were collected pre-surgery and then at six-weeks and six-months interval with a p-value of 0.05 considered to be significant. Results Two hundred and forty patients participated in the study; 117 patients were randomized to surgery with the tourniquet inflated and 123 to surgery with the tourniquet deflated. There were 43.4% males, and 56.6% females in the tourniquet inflated group with an average age of 62.29±9.63 years while in tourniquet deflated group, there were 46.7% males and 53.3% females with a mean age of 65.41±9.042 years (p-value for age is 0.404; the p-value for gender is 0.086). Despite the increase in intraoperative blood loss in both the groups, there was no significant increase in blood transfusions as both groups recorded the need for postoperative blood transfusion - 12 patients in the tourniquet group and 19 in the non-tourniquet group, but this difference was statistically insignificant (p=0.231). The perioperative blood loss was significantly lower (p<0.001) in the tourniquet group (490.29±47.752) compared to in the non-tourniquet group (526.18±12.796), while the duration of surgery was comparable in both groups (p=0.156). The length of stay for the two groups did not statistically differ (p=0.976) - the mean length of stay for the tourniquet group was 6.16±2.38 days and for the non-tourniquet group it was 6.18±2.34 days. There were no significant differences between the two groups regarding patient-reported outcomes (PROMS) at six-weeks and six-months. However, during the in-hospital stay, only the NPRS score for knee pain showed that the non-tourniquet patients had a lower NPRS compared to the tourniquet group and this difference was statistically significant (p=0.02). During the postoperative hospital stay, there was no significant difference among the two treatment groups for VAS, OKS, SF-12, and range of motion (flexion/extension). At the six weeks follow-up, both groups had similar outcomes for the range of movements and pain scores. Besides, no difference was noted among the tourniquet and non-tourniquet gro...

Aims It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT. Methods This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples t-test were applied for secondary outcomes. Analyses of primary and secondary outcomes were performed using SPSS v. 22.0.1 and p-values of < 0.05 were considered significant. Results A total of 486 patients were randomized between January 2016 and December 2018. Overall 206 (49.04%) patients underwent NPWT, while 214 (50.95%) patients were allocated to the standard dressing group. There was no statistically significant difference in DRI at 12 months between NPWT and standard dressing groups (mean difference 0.5; 95% confidence interval (CI) -0.08 to 1.1; p = 0.581). Regarding SF-12 scores at 12 months follow-up, there was no significant difference at any point from injury until 12 months (mean difference 1.4; 95% CI 0.7 to 1.9; p = 0.781). The 30-day deep infection rate was slightly higher in the standard gauze dressing group. The non-union odds were also comparable (odds ratio (OR) 0.90, 95% CI 0.56 to 1.45; p = 0.685). Conclusion Our study concludes that NPWT therapy does not confer benefit over standard dressing technique for open fractures. The DRI, SF-12 scores, wound infection, and nonunion rates were analogous in both study groups. We suggest surgeons continue to use cheaper and more readily available standard dressings. Cite this article: Bone Joint J 2020;102-B(7):912–917.

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