Studies have shown significantly shorter hospital stays and earlier return to mobilization when epidural analgesia was used in lower extremity surgeries. This study quantified the effects of epidural analgesia on lower extremity kinetics and kinematics during gait. There were no significant differences found in hip, knee, or ankle joint moments or angles between baseline (no drug) and epidural trials, using two different drugs. These findings indicate that epidural analgesia does not alter normal gait in healthy subjects, suggesting that patients requiring epidural analgesia following orthopaedic surgery may also be able to participate in rehabilitation without significant epidural-related changes in gait. Epidural analgesia has been used post-operatively following chest, abdominal and lower extremity surgery, with significantly shorter hospital stay and earlier return to mobilization demonstrated. This study quantified the effects of epidural analgesia on lower extremity kinetics and kinematics during gait. Ten healthy volunteers were tested on different days with two drugs. With the catheter (L3-L4 intervertebral space) in place but prior to drug administration, gait was assessed. Testing was repeated 30 min after drug administration. Motion and ground reaction force data were recorded during walking with a four-camera video-based system (Motion Analysis Corp) and force platform (Kistler). No significant differences existed in 3-D hip, knee, or ankle joint moments or angles among baseline (no drug) and drug trials. These findings indicate that epidural analgesia does not alter normal gait in healthy subjects, suggesting that patients requiring epidural analgesia following orthopaedic surgery may also be able to participate in rehabilitation without significant epidural-related changes in gait. It is well documented that early mobilization and rehabilitation following orthopaedic surgery improve healing and shorten hospital stay. However, pain often limits full participation. Epidural analgesia appears to be an appropriate mode of pain relief that, despite somatosensory changes, may allow normal gait. Epidural analgesia in healthy volunteers does not alter lower extremity kinetics or kinematics, suggesting that it may be an effective mode of pain relief that will allow better participation in therapy following orthopaedic surgery. Funding: McCaig Professorship Program Development Fund, Wood Professorship, The Foothills Hospital Obstetric Anesthesia Research Fund, The National Science and Engineering Research Council of Canada, and The University of Calgary Biomedical Engineering Program

Use of epidural analgesia post-operatively in spinal surgery is becoming increasingly common. We have conducted a prospective study examining the side-effects associated with epidurals and the need for additional analgesia in 36 adult patients undergoing either lumbar spine decompression, lumbar spine fusion, or a combination of decompression and fusion. A mixture of bupivacaine and fentanyl was used for up to 72 hours post-operatively via an epidural catheter placed under direct vision at the time of surgery. All patients had urinary catheters inserted peri-operatively. 15 patients experienced one or more side-effects; 6 patients had a subjectively unpleasant sensory block, 3 patients developed a motor block, 4 patients had pruritus, 3 developed hypotension, and 2 had episodes of nausea or vomiting. All these features resolved upon reduction of the epidural rate or cessation of the epidural. All patients required additional oral analgesia at some point during their observation. There were no serious complications, such as infection, permanent neurological deficit, or cord compression. We conclude epidural analgesia following lumbar spine surgery is a safe practice, although the high rate of side-effects necessitates close observation by fully trained staff. It appears additional oral analgesia is required to obtain satisfactory levels of analgesia

Introduction: Postoperative overdistention of the bladder produces chronic, irreversible changes in the detrusor muscle. This study investigated whether an effective epidural, may cause postoperative overdistention of the bladder. Methods: A retrospective single surgeon/unit study of 144 male patients who had undergone spinal surgery over a two year period was undertaken. Data was collected into two groups: Patients requiring catheterisation and those that did not. All patients received a 16G epidural catheter inserted at the end of the procedure. Demographics, operation type and epidural rate were all correlated with the need for catheterization. In all cases the residual volumes were recorded. Results: Patients remained on postoperative epidural analgesia for an average of 50hours. 54 patients required urinary catheterisation. The average postoperative duration until catheterisation was 18hours, with a maximum of 33hours. The average residual volume at catheterization was 936mls, with a maximum of 2200mls. All patients were managed with intermittent catheterisation, most, (63%) requiring only a single episode before spontaneously voiding. Discussion: Although patients in the catheterised group were older, (p< 0.05), we found no other significant differences in patients that subsequently required catheterisation, when compared for operation type, or epidural infusion rates. We were therefore unable to predict which patients would require catheterisation. Questioning and bladder palpation was found to be unreliable when assessing overdistention. Our study demonstrated that patients undergoing spinal surgery using epidural analgesia should be closely monitored in order to prevent overdistention of the bladder and has led to a proactive regimen for spinal patients with epidural analgesia in our unit

Introduction: Inadequate control of postoperative pain after total knee arthroplasty (TKA) has been associated with a poor functional recovery. This study investigated whether the addition of a single injection femoral nerve block (FNB) to continuous epidural analgesia (EA) provides improved pain control, lowered side effects, and a further acceleration in achievement of rehabilitation goals. Material and methods: Eighty patients undergoing TKA and receiving EA with 18 ml of 0.5% marcaine were randomized whether to receive or not a single dose of FNB. A nerve stimulator and 30 ml of 0.375% marcaine with 5 μg/ml of epinephrine were used to perform FNB prior to surgery. Post-operative continuous EA was self-administered by the patient adding bolus (up to 4bolus/hour) to the basal infusion rate of 2 ml/hour of 0.175% marcaine. Standardized post-operative rehabilitation protocol were followed for both groups. Therapists and clinicians were blinded to treatment group. Overall narcotic consumption, bolus dosing, and side effects were recorded. Outcomes measurements included postoperative strength and sensation, range of motion and progression, pain score (VAS), achievements of functional milestones and length of stay. Results: Femoral nerve block group had significantly lower pain scores and lower epidural consumption in comparison to the group without block (p< 0.01). Range-of-motion was significantly greater through post-operative day three in the FNB group (p< 0.04). There was a consistent trend toward improved achievements in rehabilitation milestones after FNB. Decreased quadriceps strength was noted in 33% of the FNB patients on post-operative day one compared to 10% of the patients with isolated EA. Discussion: We found significant improvements both in terms of analgesia and in functional parameters adding a FNB to continuous EA following TKA. Combination of the two techniques has a sound basis for preventing severe post-operative pain after TKA

Aims. The aim of this meta-analysis was to determine the pooled incidence of postoperative urinary retention (POUR) following total hip and knee arthroplasty (total joint replacement (TJR)) and to evaluate the risk factors and complications associated with POUR. Methods. Two authors conducted searches in PubMed, Embase, Web of Science, and Scopus on TJR and urinary retention. Eligible studies that reported the rate of POUR and associated risk factors for patients undergoing TJR were included in the analysis. Patient demographic details, medical comorbidities, and postoperative outcomes and complications were separately analyzed. The effect estimates for continuous and categorical data were reported as standardized mean differences (SMDs) and odds ratios (ORs) with 95% CIs, respectively. Results. A total of 31 studies were included in the systematic review. Of these, 29 studies entered our meta-analysis, which included 3,273 patients diagnosed with POUR and 11,583 patients without POUR following TJR. The pooled incidence of POUR was 28.06%. Demographic risk factors included male sex (OR 1.81, 95% CI 1.26 to 2.59), increasing age (SMD 0.16, 95% CI 0.04 to 0.27), and American Society of Anesthesiologists grade 3 to 4 (OR 1.39, 95% CI 1.10 to 1.77). Patients with a history of benign prostatic hyperplasia (OR 1.99, 95% CI 1.41 to 2.83) and retention (OR 3.10, 95% CI 1.58 to 6.06) were more likely to develop POUR. Surgery-related risk factors included spinal anaesthesia (OR 1.44, 95% CI 1.19 to 1.74) and postoperative epidural analgesia (OR 2.82, 95% CI 1.65 to 4.82). Total hip arthroplasty was associated with higher odds of POUR compared to total knee arthroplasty (OR 1.10, 95% CI 1.02 to 1.20). Postoperatively, POUR was associated with a longer length of stay (SMD 0.21, 95% CI 0.02 to 0.39). Conclusion. Our meta-analysis demonstrated key risk variables for POUR following TJR, which may assist in identifying at-risk patients and direct patient-centered pathways to minimize this postoperative complication. Cite this article: Bone Jt Open 2024;5(7):601–611

Background

We compared pain relief after total hip arthroplasty using periarticular intraoperative injection along with single dose post operative injection of local anesthetic (THA) with the well-established practice of epidural infusion.

Background. Evidence from recent trials has supported the efficacy of periarticular analgesic injection for pain control following total knee arthroplasty (TKA). However, no randomized controlled trial has compared the efficacy of periarticular analgesic injection with that of other regimens for simultaneous bilateral TKA. Methods. We conducted a randomized controlled trial in which patients scheduled for simultaneous bilateral TKA were randomly assigned to receive periarticular analgesic injection or epidural analgesia. In the periarticular analgesic injection group, the injection contained 7.5 mg/ml ropivacaine 40 ml, 10 mg/ml morphine hydrochloride hydrate 1.0 ml, 1.0 mg/ml epinephrine 0.6 ml, methylprednisolone 80 mg, and ketoprofen 50 mg. These agents were mixed with normal saline to a combined volume of 120 ml. The 60 ml of the cocktail was injected into each knee. In the epidural analgesia group, the catheter was placed at the L2–3 or L3–4 level, and connected to an infusion pump delivering continuous infusion (flow rate: 4 ml/h) of 100 ml of 2 mg/ml ropivacaine plus 1.0 ml of 10 mg/ml morphine hydrochloride hydrate. Surgery was managed under spinal anaesthesia. Surgical techniques and postoperative medication protocols were identical in both groups. The primary endpoint was postoperative pain at rest, quantified as the area under the curve (AUC) of the score on a visual analogue scale. Results. Seventy-one patients with 142 knees were randomly assigned to receive periarticular analgesic injection or epidural analgesia. The flow chart presented in Figure 1 outlines the trial. The periarticular analgesic injection group had a significantly lower AUC at 4–24 hour compared with the epidural analgesia group (174.9 ± 181.5 versus 360.4 ± 360.6; p = 0.0073), while no difference in the AUC was noted at 24–72 hour (1388.1 ± 727.2 versus 1467.3 ± 810.1; p = 0.67). The consumption of diclofenac sodium suppositories as rescue analgesia was significantly lower in the periarticular analgesic injection group than in the epidural analgesia group on the night of surgery (0.16 ± 0.4 versus 0.70 ± 0.9; p = 0.0013). The incidence of nausea on the night of surgery and postoperative day 1 and that of pruritus were significantly lower in the periarticular analgesic injection group than in the epidural analgesia group (7.4 % versus 45.5 %; p = 0.0031, 7.4 % versus 54.5 %; P = 0.0003, and 0 % versus 15.2 %; p = 0.014, respectively). Conclusions. Compared with epidural analgesia, periarticular analgesic injection following simultaneous bilateral TKA was associated with better postoperative pain relief and decreased opioid-related side-effects. Periarticular analgesic injection is preferable to epidural analgesia for postoperative pain relief after simultaneous bilateral TKA

Background. Adequate pain management is mandatory for patients' early rehabilitation and improvement of outcome after total knee arthroplasty (TKA). Conventional pain management, consisted of mainly opioids, has some adverse effects such as dizziness and nausea. Motor blockade occasionally resulted from epidural analgesics. A novel multimodal analgesic strategy with peripheral nerve block, peri-articular injection (PAI) and intravenous patient controlled analgesia (IVPCA) were utilized for our patients receiving TKA. In this study, we compared the clinical efficacy and adverse effects in the group of multimodal analgesia (MA) or epidural analgesia alone. Methods. One hundred and eighteen patients undergoing TKA with spinal anesthesia were enrolled. Patients of TKA received either our protocol of multimodal analgesia or patient controlled epidural analgesia (PCEA) alone. MA included ultrasound guided nerve block in femoral and obturator nerves before spinal anesthesia, and PAI mixed with NSAID, morphine, ropivacaine and epinephrine, as well as IVPCA after surgeries. The analgesic effect with numeric rating scale (NRS) and occurrence of adverse effects, including motor blockade, numbness, postoperative nausea/vomiting (PONV), and dizziness were recorded for all patients. Results. Thirty-one patients received MA, and eighty-seven patients received PCEA. No significant difference of NRS in MA and PCEA group within 24 hours after surgery either in rest (0.2 ± 1 compared with 0.22 ± 0.98; p = 0.930) or motion (0.40 ± 1.56 compared with 0.31± 1.23; p = 0.764). MA group sustained lesser motor blockade than PCEA (6.45% compared with 22.98%; p = 0.028) beyond 24 hours after surgery. The occurrence of numbness is lower in MA group (18.52%) compared with PCEA group(43.33%) (p=0.031). No statistic difference of PONV and dizziness is noted between two groups. However, there is a trend that lesser PONV and dizziness occurred in MA group than PCEA group. Conclusion. TKA patients receiving either MA or PCEA have adequate analgesic efficacy after surgeries. MA group has a lower incidence of motor blockade and PONV than PCEA. This multimodal analgesia proposed here has shown patients' safety and improved pain control after TKA, decreased narcotics use and their associated side effects. Besides, lesser motor blockade and adequate pain relief may encourage patient's early rehabilitation

The purpose of this study was the investigation and treatment of all the complications that may occur from the epidural postoperative analgesia in patients who have undergone major orthopaedic surgery. From October 1999 to April 2002, 200 patients ASA I- III, aged 45–90 (average 72) were studied. They all received postoperative epidural analgesia and were given a mixture of local anaesthetic and Opioid analgesic, more specifically Ropivacaine 2% 10 ml/h and Morphine 0, 1 ug/h via the epidural catheter by means of a stable infusion pump. The analgesic effect covers the patients for the first 2–3 postoperative days and permits earlier and pain free mobilization and physiotherapy. The analgesic result of this method was completely satisfactory with a mean of VAS 96. The most frequent side-effects were nausea and vomiting. Pruritus, mild hypotension, hypaesthesia and motor blockage were documented as well but in a very small percentage. No case of respiratory depression or medical toxicity was mentioned, neither epidural haematoma nor infection due to the placement of epidural catheter. The complications during the recovery phase were treated easily by discontinuation of the infusion or by symptomatic therapy. Epidural analgesia with a steady infusion pump is a secure method of analgesia. However it is of great importance that the patient is informed about the epidural anaesthesia and postoperative analgesia, in a such a way as to attain his/ her consent, participation and collaboration for the best therapeutic result

The aim of this retrospective study is to compare the different anaesthetic techniques in children undergoing circular frame application for lengthening and deformity correction. Data was collected from 68 cases on severe pain episodes, postoperative duration of analgesia, requirement for top-up analgesia, complications and side-effects and number of osteotomies. The three analgesic methods used were morphine infusion (M), epidural analgesia (E) and continuous peripheral nerve blocks (CPNB). There was a significant difference between the number of episodes of severe pain experienced by the patients receiving a morphine infusion when compared to the epidural and CPNB groups (M vs. E p<0.0001, M vs. CPNB p=0.018). CPNB were associated with the lowest incidence of severe pain episodes and top-up analgesia requirements. The difference in the incidence of nausea and vomiting between the methods was approaching significance (p=0.06). A significant difference was found when comparing epidural and morphine infusions (p=0.05). Epidural analgesia was associated with significantly more nausea and vomiting (p=0.023), and motor blockade (p<0.01) than CPNB. The results show the most effective method of post-operative analgesia for our paediatric patients, in light of pain episodes and associated side-effects, is sciatic nerve catheterisation with continuous infusion

Background: Post-operative analgesia using parenteral opioids or epidural analgesia can be associated with troublesome side effects. Locally administered pre-emptive analgesia is effective, reduces central hyper sensitisation and avoids systemic drug related side-effects and may be of benefit in total knee replacement. Materials and Methods: 64 patients undergoing total knee replacement were randomised to receive a periarticular intra-operative injection containing ropivacaine, ketorolac, epimorphine and epinephrine or nothing. All patients received patient controlled analgesia (PCA) for 24 hours post surgery, followed by standard analgesia. Visual Analogue Scale (VAS) pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at 6 week follow up. PCA consumption and overall analgesic requirement were measured. Results: PCA use at 6,12 and over 24 hours post surgery was significantly less in patients receiving the injection (P< 0.01, P=0.016, P< 0.01). Patient satisfaction in PACU and 4 hrs post operation was greater (P=0.016, P=0.013). VAS for pain during activity in PACU and at 4 hrs were significantly less (P= 0.04, P=0.007) in the injected group. The average ROM at 6 weeks was no different. Overall hospital stay and the incidence of wound complications was not different between the two groups. Conclusion: Peri-articular intra-operative multimodal analgesia significantly reduces post-operative PCA requirement. Patient satisfaction was greater in the injection group

Introduction: Post-operative analgesia using parenteral opioids or epidural analgesia can be associated with troublesome side effects. Good peri-operative analgesia facilitates rehabilitation, improves patient satisfaction and may reduce hospital stay. Locally administered pre-emptive analgesia is effective, reduces central hyper-sensitisation and avoids systemic drug related side-effects and may be of benefit in minimally invasive joint replacement. Materials and methods: 64 patients undergoing total knee replacement were randomised to receive a peri-articular intra-operative injection containing ropiva-caine, ketorolac, epimorphine and epinephrine. The anaesthetic analgesic regime was standardised. All patients received patient controlled analgesia (PCA) for 24 hours post surgery, followed by standard analgesia. VAS pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at 6 week follow up. PCA consumption and overall analgesic requirement were measured. Results: PCA use over 24 hours post surgery was significantly less in patients receiving the injection (P=0.013). Patient satisfaction at 4 hrs post operation was greater (P=0.003). VAS for pain during activity at 4 hrs and 24 hours were significantly less (P=0.001) in the injected group. The average ROM at 6 weeks was no different. Overall hospital stay and the incidence of wound complications was not different between the 2 groups. Discussion: Peri-articular intra-operative multimodal analgesia significantly reduces post-operative analgesia requirement. Patient satisfaction is greater in the injection group. No cardio and central nervous system toxicity was observed

Background: Knee stiffness from peri-articular fractures, arthroplasty or limb lengthening surgery, if intractable after an extensive programme of physiotherapy, may be resolved by quadricepsplasty. We describe the recovery of knee function in a cohort of 12 patients who underwent a Judet quadricepsplasty for loss of knee flexion. Material and Methods: 12 adult patients underwent a Judet quadricepsplasty for recovery of knee flexion range. The causes of stiffness were trauma, arthroplasty, infection and limb lengthening surgery. A protocol of continuous passive knee movement under epidural analgesia was maintained after surgery. Continuous passive motion was continued at home for a further 4–6 weeks together with regular out-patient physiotherapy attendances. Outcome measures were range of movement, extensor lag, a modified WOMAC score for physical function, KINCOM data (with the contralateral limb as control), SF-36 and complications of surgery. Results: There were 11 male patients and 1 female. The mean age was 30 years (20–71). The median period of follow-up was 3 years (0.8–7 years). The difference between pre-operative and final knee motion ranges was statistically significant (p=0.0048). The medians for flexion before surgery was 41 degrees (SD=18; at surgery 110 degrees (SD =15); final follow-up 105 degrees (SD=20). Extensor lag after surgery was 27.5 degrees (SD18) reducing 3.5 degrees (SD=3.5) finally. KINCOM data against a contralateral control showed a highly significant difference (p< 0.001) in quads strength. The medians for the WOMAC score was 38; PCS of the SF36 34.7 (SD13) and the MCS 53.7 (SD 13). Wound complications occurred in 7 patients and three needed further surgery. Conclusion: Improvement in knee flexion after a Judet quadricepsplasty is maintained at one year. Extensor lag is common after the procedure but recovers. Most patients found the improvement beneficial but objective measures of knee function showed a return to normal had not been achieved

Purpose: Post-operative analgesia using opioids or epidural analgesia can be associated with troublesome side effects. Effective peri-operative analgesia facilitates rehabilitation, improves patient satisfaction and may reduce hospital stay. Locally administered analgesia is effective, avoids systemic drug related side-effects and may be of benefit in minimally invasive joint replacement. This study compares the effects of a peri-articular injection cocktail in patients undergoing total knee and hip replacement surgery. Methods: 128 patients undergoing total knee (TKR) and hip (THR) replacement were randomised to receive a peri-articular intra-operative injection containing ropivacaine, ketorolac, epimorphine and epinephrine or nothing. The anaesthetic analgesic regime was standardised. All patients received patient controlled analgesia (PCA) for 24 hours post surgery, followed by standard analgesia. VAS pain scores during activity and at rest and patient satisfaction scores were recorded pre and post operatively and at 6 week follow up. PCA consumption and overall analgesic requirement were measured. Results: Both TKR and THR patients used significantly less PCA 6 hours after surgery (p = 0.02 THR, p< 0.01 TKR). TKR patients receiving the injection used significantly less PCA use over 24 hours post surgery (p = 0.013). VAS for pain at 4 hrs post operation was significantly lower in the both groups (p = 0.003 TKR)(p = 0.017 THR). VAS for pain during activity at 24 hours was significantly less (p = 0.001) in the injected TKR group. Overall hospital stay and wound complications were not different between the groups. Conclusions: Peri-articular analgesia significantly reduces post-operative analgesia requirement in TKR and THR patients. Greater satisfaction and pain relief was seen in TKR patients compared with THR

Introduction: The ideal regimen for safe and effective post operative pain relief inspinal surgery remains elusive. Numerous studies have been conducted comparing epidural with patient controlled analgesia with no firm conclusion as to which is best. Aims: To determine the efficacy of acute pain relief between surgical placed epidural catheter and patient controlled analgesia for lumbar spinal surgery. Method: A 42 month retrospective survey of 82 spinal surgery patients case notes and anaesthetic charts performed by a consultant spinal surgeon and his registrar from 2002 to 2005. There were 34 epidural and 48 PCA patients. Visual analogue Score (0–10) at 6 hourly intervals up to 36 hours, complications and age of patient were looked at. Exclusion criteria for epidural were dural tear, history of hypotension, unexplained neurological symptoms, and bleeding disorders and surgeon choice. Epidural infusion consisted of bupivacaine 0.1% with 5mls loading dose and 10mls/ hour infusion and PCA consisted of morphine sulphate 2mg/ml with a 1ml loading dose and 5 minute lockout interval.All patients were on standard analgesia which included oromorph 5mg four hourly orally and paracetamol 1gram six hourly as required orally. No radiographic evidence of epidural catheter placement was performed. Post-operative complications which included hypotension, nausea, vomiting, and drowsiness were monitored. Results: The average age for the epidural group was 46.9 and PCA group 49.8. The most striking finding was that the average pain score at each six hourly interval waslower in the epidural group. This was significant in the first 18 hours post-operatively.However, 3 complications occurred in the epidural group which included hypotension. In addition, 3 epidural infusions were stopped and changed to PCA most likely due to improper placement of catheter. There were no complications with the PCA group. Conclusion: This observational study demonstrates clinically and statistically that in the acute post-operative phase and up to 36 hours that epidural analgesia for lumbar spine surgery is more effective than PCA. From this survey, the risk of epidural was higher, although no serious complications occurred. Surgeon placement of catheter is also important in the effective delivery of epidural pain relief. The lower efficacy of the PCA may have been due to poor patient understanding of the concept of PCA and thereforeits

In a society dependent upon the motor car, impaired driving ability is a significant disability which may affect patients with total knee replacement during the postoperative rehabilitation. Recently, there has been much interest in minimally invasive surgery for total knee arthroplasty (TKA). This study evaluated the hypothesis that a minimally invasive technique using a small incision (7 to 10 cm), and a minimal quadriceps muscle splitting without eversion of the patella (MIS approach) would have a beneficial effect on driving reaction time. 15 patients undergoing a primary TKA with the MIS approach were compared with 15 TKAs using a standard approach. An experimental car was used to measure the force and timing of pressure by the foot on accelerator and break pedals. The mean reaction time for normal adults was 0.442 s to go from the accelerator to the brake pedal. This time falls well within the code guideline of 0.7 s. The driving reaction times of the patients with knee arthroplasty were measured at one, two and three months after the operation. The ability to perform an emergency stop was assessed as the time taken to achieve a brake pressure of 100 N after a visual stimulus.The patients have an actual follow-up of 2 years. A clinical and radiological evaluation was performed. Radiographic analysis included evaluation of postoperative alignment variables and progressive radioluciencies. Over all 27 among the 30 knees have good and excellent objective knee Society Scores and patient satisfaction indices. The patients in the MIS group had a statistically shorter time until they could straight leg raise, used less epidural analgesia, used less overall analgesics and had a more rapid regaining of flexion. Patients with standard approach and technique for total knee replacement recovered sufficient knee function to return to driving at only three months after the operation according to the time and the force necessary to the brake pedal. Patients with mini invasive surgery approach have recovered sufficient knee function to return driving at one month after the operation. There was no significant difference in alignment of implants and in alignment of the knee between the two groups. Three knees had radioluciencies (two with a standard incision and one with a MIS approach). Using a small incision without patellar eversion does not jeopardize the alignment of the implants and improves postoperative rehabilitation

The incidence of hip fractures is rising, and at the same time the patients are getting increasingly frail and elderly. Patients in Europe have a median hospitalization time of as much as 28 days, and the peri-operative morbidity and mortality is high. 1. Most interventional studies have been unimodal with very heterogeneous results and at present, limited data are available from multimodal intervention according to the established principles of fast-track care. 2. This study has very positive results with a reduction in hospitalization from 21 till 11 days. Anaesthesiological intervention in a fast track regimen must be peri-operative in such a high-risk group of patients. Early operation is probably preferable. 3. Pre-operative regional analgesia potentially reduces cardiovascular morbidity, if instituted immediately after arrival. 4. The effect of regional anaesthesia and postoperative regional analgesia on morbidity and mortality in hip fracture patients may be advantageous. 5. . Postoperative epidural analgesia can be provided without restrictions on patient mobility and rehabilitation, provides superior dynamic pain relief and reducing the influence of pain as a restricting factor on physiotherapy. 6. A potential effect of intra-operative volume optimization has been shown, although the effect on morbidity and mortality is unclear. 7. No information exists for postoperative fluid therapy regimens, but fluid excess is probably important to avoid. 8. Hip fracture patients often suffer from malnutrition at the time of admission and protein and energy supplementation potentially reduces mortality and morbidity. 9. Therefore a short perioperative fasting period combined with aggressive peri-operative oral nutrition and anaesthesia and analgesia techniques, that minimizes catabolism and PONV seems rational. Since mortality and morbidity is so high these patients should be treated in close cooperation between surgeons and anaesthesiologists both in the pre and postoperative phase. 10. , as established practice in other high risk patients. Mortality is not the optimal parameter the for success of intervention in this population, as effects are extremely difficult to document, since as much as 50–75 % of the perioperative mortality may be unrelated to the treatment regimen. 11. . The cumulated evidence for the peri-operative care of this patient group is scarce and fast-track rehabilitation regimens should look to other operational procedures for available evidence. 12. Future research should focus on broadening the evidence for relevant pre-operative optimization, the influence of regional analgesia on rehabilitation potential and optimized peri-operative fluid therapy, transfusion and nutrition regimens

Background. Continuous epidural anesthesia or femoral nerve block has decreased postoperative pain after total knee arthroplasty to some extent. Although the established efficacy of these pain relief method, some adverse events such as hematoma or muscle weakness are still problematic. Intraoperative local infiltration of analgesia (LIA) has accepted as a promising pain control method after total knee arthroplasty. The safety and efficacy of LIA has been reported, although there are still limited evidence about the effect of LIA on quadriceps function and recovery of range of motion in early post-operative phase. The purpose of this study is to compare the quadriceps function and range of motion after TKA between the LIA with continuous epidural anesthesia and continuous epidural anesthesia alone. Methods. Thirty patients with knee osteoarthritis who underwent primary TKA were included in this study. Patients who took anticoagulants were treated continuous epidural anesthesia alone (n=11) and the other patients were treated with LIA with continuous epidural anesthesia (n=19). A single surgeon at our department performed all surgeries. Surgical procedure and rehabilitation process was identical between two groups. Before the implantation, analgesic drugs consisting of 20 ml of 0.75 % ropivacaine and 6.6 mg of dexamethasone were injected into the peri-articular tissues. In each group, fentanyl continuous epidural patient-controlled analgesia (PCA) was also used during 48-h post-operative period. Knee flexion and extension angle were evaluated before surgery, post-op day 3, 7, 10 and 14. The quadriceps function was evaluated by quadriceps peak torque at 30° and 60° flexion using VIODEX. The peak torque was recorded preoperatively, day 14 and 3 month after surgery. The difference between two groups was analyzed by Mann Whitney U-test using Prism 6, a statistical software. Results. LIA group showed better postoperative flexion angle until day 7 (Fig. 1). Then the discrepancy became smaller and came to the same degree at day14. The peak torque at 30° and 60° flex is higher in LIA group compared to epidural anesthesia alone. The LIA group showed less peak torque decrease at 2 weeks after surgery than epidural anesthesia alone group (Fig. 2, 3). No adverse events such as were observed in each group. Discussion. This paper demonstrated that LIA in addition to the continuous epidural anesthesia after TKA provides better quadriceps function and early recovery in knee range of motion. In this study we also used continuous epidural anesthesia, thus this study can not evaluate the stand alone LIA effects on quadriceps function and range of motion recovery. Furthermore the patients were not randomly assigned in this study, this might be another limitation of this study. In conclusion, LIA provide better quadriceps function and early recovery of range of motion in addition to the pain relief. To view tables/figures, please contact authors directly

Aims

Psychoeducative prehabilitation to optimize surgical outcomes is relatively novel in spinal fusion surgery and, like most rehabilitation treatments, they are rarely well specified. Spinal fusion patients experience anxieties perioperatively about pain and immobility, which might prolong hospital length of stay (LOS). The aim of this prospective cohort study was to determine if a Preoperative Spinal Education (POSE) programme, specified using the Rehabilitation Treatment Specification System (RTSS) and designed to normalize expectations and reduce anxieties, was safe and reduced LOS.

Aims

Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone.