BackgroundThe Wide-Awake-Local-Anaesthesia-No-Tourniquet (WALANT) technique achieves an almost bloodless field for clear visualization during surgeries. WALANT utilizes lidocaine and epinephrine for anesthesia and hemostasis, respectively, without the usage of sedation and tourniquet. This avoids the potential side effects of tourniquet-related pain and sedation-related complications. However, acceptance is still low due to concerns regarding the safety of epinephrine injection in the finger. There is a persistent belief that epinephrine can cause digital ischemia. PurposeTo evaluate retrospectively possible complications of hand surgeries performed using the WALANT technique. MethodsAll finger and hand procedures performed under the WALANT technique from June 2016 to May 2021 in an urban tertiary hospital were studied retrospectively. ResultsThere were a total of 1073 cases, of which 694 were females and 379 were males. The mean age was 55 years. Finger surgeries (e.g., trigger finger release, excision of finger lesions, removal of implants) consisted of 707 cases; and the rest (366 cases) were hand surgeries (e.g., carpal tunnel release, excision of hand lesions, removal of implants). In all cases reviewed, there were no instances of circulatory compromise. There were also no circumstances where usage of reversal with phentolamine is recorded. ConclusionWe believe that performing finger and hand surgeries using the WALANT technique is safe and beneficial. The usage of WALANT in hand surgeries avoids tourniquet pain. However, WALANT should be used with caution in those with vascular insufficiency or disease.

The present concepts in Total Hip Arthroplasty advocate mechanical cement interlock with trabecular bone utilising the third-generation cementing technique. However, the force generated can easily reach peak pressure of 122 kPa to 1500 kPa, leading to extrusion of cement through nutrient foramina into femoral cortex into nutrient vessels, henceforth the retrograde arteriovenogram. A 76 years old lady who premorbid ADLindependent had a fall and sustained a closed right neck of femur fracture. She underwent cemented right total hip arthroplasty. Acetabulum cup of 47mm and femoral stem size 1 was utilized. Femoral canal was prepared and medullary cavity plug inserted before retrograde cement was introduced using the cementing gun. Intraoperative no complications were noted. This case has been followed up to a year with no adverse effect. The post-operative radiograph demonstrated a linear radio-opacity communicating with the posterior aspect of the femoral shaft which continues proximally and medially for approximately 10cm. Its uniformity in shape and position corresponds to the vascular supply of proximal femur. In Farouk et al cadaveric study, nutrient vessel arises in 166 ± 10 mm from the greater trochanter and is a branch of the second perforating artery from the deep femoral artery. Knight et al infer that retrograde cement extrusion occurs in female patients with small stature and small endosteal canal. Cement extrusion unlikely will influence the long haul survival of prosthesis as shown in the radiograph that cement is well pressurized to interlock with the endosteal bone. Moreover, because of extensive anastomoses of perforating branches of the deep femoral artery, segmental obliteration of nutrient artery alone is unlikely to lead to vascularity issues. Cement extrusion into the nutrient foramen is a vital differential in presence of posterior medial cement in the diaphysis of the femur following total hip replacement. This is to differentiate from extra osseous extrusions due to the iatrogenic breach of the femoral cortex suggesting periprosthetic fracture which affects the long term survival of prosthesis.

Disseminated idiopathic skeletal hyperostosis (DISH) is a form of ankylosing spinal disorders, which is at high risk of fracture because of the rigidity of the spinal column and reduced bone quality. The patients with DISH are at higher risk of fall because of the poor muscle tone, rigid spine column, and positive sagittal balance. The management of spinal fractures in these patients proves to be challenging because of the altered biomechanics and alignment of the spine. Furthermore, most patients have multiple comorbidities with high intraoperative burden, and osteoporosis itself will impair any implant purchase of the bone. Here, we report a case of thoracolumbar fracture in DISH where both conservative and surgical approaches were utilized, with unfortunate results in both, and a brief review of the literature on its management.

Neer first popularised the use of primary hemiarthroplasty to treat complex proximal humerus fractures, especially when the humeral head is nonviable or not reconstructable with internal fixations, and with younger patients. A 16-year-old boy had a motor vehicle accident and sustained a closed right proximal humerus fracture dislocation without neurovascular injury. Intraoperatively, due to difficulty retrieving the humeral head which dislocated and positioned behind the clavicle, hemiarthroplasty was done to avoid injuring the brachial plexus, vessels and lung. Mr Y, a 34-year-old man similarly sustained closed left proximal humerus fracture dislocation with an irretrievable head. He too underwent hemiarthroplasty. Both patients were followed up for a year with no pain and fairly good range of movement and muscle power. In complex proximal humerus fractures, there is still debate regarding primary hemiarthroplasty. There are risks of secondary displacement of fracture fragments and head necrosis after internal fixation. Neer and Cofield reported over 90% patients had relief of pain and 66% patients had free range of movement post hemiarthroplasty. Other authors described primary malposition and subsequent migration or deficient osseous integration as a complication after prosthesis. In a thirteen-year observational cohort study of 163 patients with hemiarthroplasty, the overall rate of prosthetic survival was 96.9% at one year, 95.3% at five years, and 93.9% at ten years. Of the factors that were assessed, the age is most important due to factors such as degenerative changes in the rotator cuff, osteoporosis, and motivation to achieve a good range of motion. Successful treatment of acute proximal humerus fractures with prosthetic replacement is challenging to orthopaedic surgeons as it requires proper patient evaluation, good surgical technique, especially in soft-tissue tensioning and stability, and meticulous rehabilitation. In young patients with good bone quality and irretrievable head, hemiarthroplasty is a choice.