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Aims In the UK, fasciectomy for Dupuytren’s contracture is generally performed under general or regional anaesthetic, with an arm tourniquet and in a hospital setting. We have changed our practice to use local anaesthetic with adrenaline, no arm tourniquet, and perform the surgery in a community setting. We present the outcome of a consecutive series of 30 patients. Methods Prospective data were collected for 30 patients undergoing open fasciectomy on 36 digits (six having two digits affected), over a one-year period and under the care of two surgeons. In total, 10 ml to 20 ml volume of 1% lidocaine with 1:100,000 adrenaline was used. A standard postoperative rehabilitation regime was used. Preoperative health scores, goniometer measurements of metacarpophalangeal (MCP), proximal interphalangeal (PIP) contractures, and Unité Rheumatologique des Affections de la Main (URAM) scores were measured pre- and postoperatively at six and 12 weeks. Results The mean preoperative contractures were 35.3° (0° to 90°) at the metacarpophalangeal joint (MCPJ), 32.5° (0° to 90°) at proximal interphalangeal joint (PIPJ) (a combined deformity of 67.8°). The mean correction was 33.6° (0° to 90°) for the MCPJ and 18.2° (0° to 70°) for the PIPJ leading to a combined correction of 51.8°. There was a complete deformity correction in 21 fingers (59.5%) and partial correction in 14 digits (37.8%) with no correction in one finger. The mean residual deformities for the partial/uncorrected group were MCP 4.2° (0° to 30°), and PIP 26.1° (0° to 85°). For those achieving a full correction the mean preoperative contracture was less particularly at the PIP joint (15.45° (0° to 60°) vs 55.33° (0° to 90°)). Mean preoperative URAM scores were higher in the fully corrected group (17.4 (4 to 31) vs 14.0 (0 to 28)), but lower at three months post-surgery (0.5 (0 to 3) vs 4.40 (0 to 18)), with both groups showing improvements. Infections occurred in two patients (three digits) and both were successfully treated with oral antibiotics. No other complications were noted. The estimated cost of a fasciectomy under local anaesthetic in the community was £184.82 per patient. The estimated hospital theatre costs for a fasciectomy was £1,146.62 under general anaesthetic (GA), and £1,085.30 under an axillary block. Conclusion This study suggests that a fasciectomy performed under local anaesthetic with adrenaline and without an arm tourniquet and in a community setting is safe, and results in favourable outcomes regarding the degree of correction of contracture achieved, functional scores, and short-term complications. Local anaesthetic fasciectomy in a community setting achieves a saving of £961.80 for a GA and £900.48 for an axillary block per case. Cite this article: Bone Joint J 2020;102-B(10):1354–1358.

Background This was a retrospective study presenting our results and survivorship of the Acclaim total elbow when used as a revision implant. Methods Between May 2001 and July 2005, 29 revision elbow replacements were carried out on 28 patients in our institution. Five were redo revisions and one received the fourth sequential implant. A variety of implants were removed for aseptic loosening (17), periprosthetic fracture (7), dislocation (3) and infection (2). Two patients had died and one was unavailable for follow-up. Results At a mean follow-up of 50 months (12 to 80 months) pain, functional assessment scores and radiographs were assessed and a Kaplan-Meier survival curve created. Symptoms were reliably relieved with 72% reporting no pain. Mean flexion was 128° with loss of full extension of 34°. Complications were noted in six cases of which three patients underwent further surgery. None of the 29 revisions has been re-revised till date. Conclusion The medium term results for this implant suggest it is an effective revision prosthesis.

We describe the use of a readily available ulnar shortening guide to perform large ulnar shortenings.

Bilateral anterior shoulder dislocation is an uncommon injury with around 30 cases reported in literature [1]. Chronic undiagnosed bilateral anterior shoulder dislocation is extremely rare with only five cases (Table 1) identified in literature [2–6]. Of 32 cases of chronic shoulder [7] dislocation, all were unilateral (31 anterior subcoracoid and one posterior) dislocations. The patients in this case report of chronic bilateral anterior shoulder dislocation presentedwith pain and shoulder dysfunction. Partial collapse of the posterior humeral head had occurred and in the right shoulder this mimicked a large Hill–Sachs defect. To our knowledge, such a case has never been reported in literature.

We report a traumatic rupture of the extensor hood of the dominant middle finger in an elite boxer. Surgical repair of the extensor hood with the metacarpophalangeal joint (MCPJ) in 90° of flexion and immobilisation of the MCPJ in flexion for 4 weeks allowed successful return of function to an international level.

The modern practice of hand surgery was pioneered by Dr Sterling Bunnell in San Francisco, who had a keen interest in surgery of the hand. He wrote a seminal article on tendon repair in 1918. He was asked to improve the management of hand trauma patients in the Second World War by US Army Surgeon General Norman Kirk who recognized the need for specialist and coordinated care to treat the various extremity injuries seen in combat. He set up a series of hand centers at Army hospitals across the US and educated surgeons. He published ‘Surgery of the Hand’ in 1944, which was the authoritative text for 30 years, and was instrumental in the formation of the American Society for the Surgery of the Hand in 1946. Surgeons such as Kanavel treating infections, Kleinert treating tendon injuries, Buck-Gramcko and others on congenital abnormalities and Gillies on skin flap coverage made further advances in this area. More recently plastic hand surgeons have made advances in microvascular techniques and in the understanding of nerve healing to allow procedures such as digital replantation to occur.

86.5 Summary A case series of 60 patients with a Colles fracture, treated in a standard manner with closed reduction and plaster immobilization in the same institution and followed up radiologically and by clinical examination at 1 year. A radiological classifi cation scoring system was proposed based on the presence or absence of joint involvement, metaphyseal comminution and/or angular deformity. Lindstrom later expanded this in 1959 to six groups, describing the fragment displacement in further detail, along with joint involvement. The Gartland and Werley score was introduced as an outcome measurement for evaluating wrist and hand function.

Chronic exertional compartment syndrome (CECS) of the forearm may occur in sports requiring prolonged grip strength. CECS is a function of increasing pressure following muscle expansion within an inelastic tissue envelope resulting in compromise of perfusion and tissue function. Typical symptoms are pain, distal paraesthesia and loss of function. The condition is self-limiting and resolves completely between periods of activity. With no effective medical treatment, the gold standard remains four compartment open fasciotomy (Söderberg, J Bone Joint Surg Br 78(5):780–2, 1996; Wasilewski and Asdourian, Am J Sports Med 19(6):665–7, 1991). Minimally invasive techniques have been described (Croutzet et al., Tech Hand Up Extrem Surg 13(3):137–40, 2009) but have a risk of neuro-vascular injury, especially to the ulnar nerve while releasing the deep flexor compartment. We present a safe technique used with six elite rowers for mini-open fasciotomy to minimise scarring and time away from training while reducing the risk of neurovascular injury.

Introduction Acutrak 2 screws are commonly used for scaphoid fracture fixation. To our knowledge, the variation in compressive force along the screw has not been investigated before. The objectives of our study were to measure variance in compression along the length of the standard Acutrak 2 screw, to identify the region of the screw which produces the greatest compression and to discuss the clinical relevance of this to the placement of the screw for scaphoid fractures. Materials and methods A laboratory model was set up to test the compressive force at 2 mm intervals along the screw, using solid polyurethane foam (Sawbone) blocks of varying width. The Acutrak 2 screws were introduced in the standard method. Forces were measured using a custom-made load cell washer introduced between the Sawbone blocks and were plotted as a graph along the whole length of the screw. Results Maximum compression was at the mid-point of the screw. Overall compressive forces were higher in the proximal half of the screw by 19% when compared with the distal half. Minimum compression was seen at 4 mm or less from either end of the screw. Conclusions There is variation in compression along the length of the standard Acutrak 2 screw and the maximum compression was obtained at the mid-point of the screw. From this study, we would recommend when using an Acutrak 2 screw for internal fixation of scaphoid fractures, to attain maximum compressive force, place the fracture at the mid-point of the Acutrak screw. If this is not possible, then place the fracture towards the proximal half of the screw.