Regional anesthesia is commonly utilized to minimize postoperative pain, improve function, and allow earlier rehabilitation following Total Knee Arthroplasty (TKA). The adductor canal block (ACB) provides effective analgesia of the anterior knee. However, patients will often experience posterior pain not covered by the ACB requiring supplemental opioid medications. A technique involving infiltration of local anesthetic between the popliteal artery and capsule of knee (IPACK) targets the terminal branches of the sciatic nerve, providing an alternative for controlling posterior knee pain following TKA. IRB approval was obtained, a power analysis was performed, and all patients gave informed consent. Eligible patients were those scheduled for an elective unilateral, primary TKA, who were ≥ 18 years old, English speaking, American Society of Anesthesiologists physical status (ASA PS) classification I-III. Exclusion criteria included contraindication to regional anesthesia or peripheral nerve blocks, allergy to local anesthetics, allergy to nonsteroidal anti-inflammatory drugs (NSAIDs), chronic renal insufficiency with GFR < 60, chronic pain not related to the operative joint, chronic (> 3 month) opioid use, pre-existing peripheral neuropathy involving the operative limb, and body mass index (BMI) ≥ 40 kg/m2. Patients were randomized into one of two treatment arms: Continuous ACB with IPACK (IPACK Group) block or Continuous ACB with sham subcutaneous saline injection (No IPACK Group). IPACK Group received single injection of 20 mL 0.25% Ropivacaine. Postoperatively, all patients received a standardized multimodal analgesic regimen. The study followed a double-blinded format. Only the anesthesiologist performing the block was aware of randomization status. Following surgery, a blinded medical assessor recorded cumulative opioid consumption, average and worst pain scores, and gait distance.Introduction
Materials and Methods
It is likely that league tables will to some extent determine hospital finance in the future. The major indicator used in league table calculations in orthopaedics is mortality rates following surgery. Therefore, our study audited the accuracy of mortality data. A previous audit of our department by an external audit company was found to show an apparent excess mortality rate, due to the company’s failure to distinguish between true operations and certain procedures, i.e. urethral catheterisation. We were concerned that these flawed results may find their way into the publicised tables of the Department of Health (DH). We thus audited deaths in 2000/1 and compared the results with DH data. DH league table figures combine the mortality numbers for all surgical specialities. Our analysis was based on DH criteria [ From review of the notes, the criteria for post-operative death were fulfilled by 54/131 deaths (41%). By speciality, these included 14/33 deaths in orthopaedics, general surgery (25/73) and neurosurgery (15/25). The DH identified 64 post-operative deaths in this period. DH calculations were applied to compare our postoperative mortality results (54 deaths) with those of the DH (64 deaths). Although there was no significant difference between our observed death rate and the DH’s, using our results the hospital’s ranking improved from twelfth to sixth place in 42 small acute hospitals. The observed mortality rate in our hospital is very close to that published by the DH and the national average. From the results of our study, we are confident that the flawed data from the external company did not enter the system and distort the DH’s league tables. Therefore, hospitals should not wast money on audits by external companies.
