Aims

The incidence of limb fractures in patients living with HIV (PLWH) is increasing. However, due to their immunodeficiency status, the operation and rehabilitation of these patients present unique challenges. Currently, it is urgent to establish a standardized perioperative rehabilitation plan based on the concept of enhanced recovery after surgery (ERAS). This study aimed to validate the effectiveness of ERAS in the perioperative period of PLWH with limb fractures.

Introduction. Day stay surgery for anterior cruciate ligament (ACL) reconstructions is an increasingly common practice and has driven clinicians to come up with postoperative pain regimes that allow same day mobilisation and a safe and timely discharge. There is a paucity of literature surrounding the use of intraosseous (IO) ropivacaine used as a Bier's block to provide both intraoperative and postoperative analgesia in lower limb surgery. Methods. This patient blinded, pilot study randomised 15 patients undergoing ACL reconstruction to receive either IO ropivacaine 1.5 or 2.0 mg/kg; or 300 mg of ropivacaine as local infiltration (standard of care). Toxic plasma levels of ropivacaine have been defined in the literature and therefore the primary outcome for this study was arterial plasma concentration of ropivacaine as a means to determine its safety profile. Samples were taken via an arterial line at prespecified times after tourniquet deflation. Secondary outcomes that we were interested in included immediate postoperative pain scores using the visual analogue scale (VAS) and perioperative opioid equivalent consumption. Results. Participants had a mean age of 27.8 (SD 9.2) years and 87% (13/15) were male. All patients in the intervention group receiving IO ropivacaine had plasma concentrations well below the threshold for central nervous system (CNS) toxicity (0.60 µg/ml). The highest plasma concentration was achieved in the intervention group receiving 1.5 mg/kg dose of ropivacaine reaching 3.59 mg/ml. This would equate to 0.22 µg/ml of free plasma ropivacaine. There were no differences across the three groups regarding pain scores or perioperative opioid consumption. Conclusions. This study demonstrates that IO administration of 0.2% ropivacaine is both safe and effective in reducing perioperative pain in patients undergoing ACL reconstruction. There may be scope to increase the IO dose further or utilise other analgesics via the IO regional route to improve perioperative pain relief

The current study aims to find the role of Enhance Recovery Pathway (ERP) as a multidisciplinary approach aimed to expedite rapid recovery, reduce LOS, and minimize morbidity associated with Non Fusion Anterior Scoliosis Correction (NFASC) surgery. A retrospective analysis of 35 AIS patients who underwent NFASC with Lenke 1 and Lenke 5 curves with a minimum of 1 year of follow-up was done. Patient demographics, surgical details, postoperative analgesia, mobilization, length of stay (LOS), patient satisfaction survey score with respect to information and care, and 90 days complications were collected. The cohort included 34 females and 1 male with a mean age of 15.2 years at the time of surgery. There were 16 Lenke 1 and 19 Lenke 5 in the study. Mean preoperative major thoracic and thoracolumbar/lumbar Cobb's angle were 52˚±7.6˚ and 51˚±4.5˚ respectively. Average blood loss and surgical time were 102 ±6.4 ml and 168 ± 10.2 mins respectively. Average time to commencing solid food was 6.5±1.5 hrs. Average time to mobilization following surgery was 15.5± 4.3 hrs. The average duration to the stopping of the epidural was 42.5±3.5 hrs. The average dose of opioid consumption intraoperatively was 600.5±100.5 mcg of fentanyl i.v. and 12.5±4.5 mg morphine i.v. Postoperatively opioids were administered via an epidural catheter at a dose of 2 mg of morphine every 24 hours up to 2 days and an infusion of 2mcg/hr of fentanyl along with 0.12-0.15% ropivacaine. The average duration to transition to oral analgesia was 55.5±8.5 hrs .20 patients had urinary catheter and the average time to removal of the catheter was 17.5±1.4 hrs. 25 patients had a chest tube and the average time to remove of chest tube was 25.5±3.2 hrs. The average length of hospital stay was 3.1±0.5 days. No patient had postoperative ileus or requirement of blood transfusion or any other complications. No correlation was found between LOS and initial cobb angle. The application of ERP in AIS patients undergoing NFASC results in reduced LOS and indirectly the cost, reduced post-operative opioid use, and overall improve patient satisfaction score

Aims

There is evidence that morbidly obese patients have more intra- and postoperative complications and poorer outcomes when undergoing total hip arthroplasty (THA) with the direct anterior approach (DAA). The aim of this study was to determine the efficacy of DAA for THA, and compare the complications and outcomes of morbidly obese patients with nonobese patients.

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. Methods. This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain. Results. The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014). Conclusion. Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA. Cite this article: Bone Jt Open 2021;2(12):1082–1088

Aims

In 2020, the COVID-19 pandemic meant that proceeding with elective surgery was restricted to minimize exposure on wards. In order to maintain throughput of elective cases, our hospital (St Michaels Hospital, Toronto, Canada) was forced to convert as many cases as possible to same-day procedures rather than overnight admission. In this retrospective analysis, we review the cases performed as same-day arthroplasty surgeries compared to the same period in the previous 12 months.

Aims

The proportion of arthroplasties performed in the ambulatory setting has increased considerably. However, there are concerns whether same-day discharge may increase the risk of complications. The aim of this study was to compare 90-day outcomes between inpatient arthroplasties and outpatient arthroplasties performed at an ambulatory surgery centre (ASC), and determine whether there is a learning curve associated with performing athroplasties in an ASC.

Aims

Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes.

Aims

Intravenous dexamethasone has been shown to reduce immediate postoperative pain after total hip arthroplasty (THA), though the effects are short-lived. We aimed to assess whether two equivalent perioperative split doses were more effective than a single preoperative dose.

Aims

Although periarticular injection plays an important role in multimodal pain management following total hip arthroplasty (THA), there is no consensus on the optimal composition of the injection. In particular, it is not clear whether the addition of a corticosteroid improves the pain relief achieved nor whether it is associated with more complications than are observed without corticosteroid. The aim of this study was to quantify the safety and effectiveness of cortocosteroid use in periarticular injection during THA.

Chronic postsurgical pain (CPSP) can occur after elective mid/hindfoot and ankle surgery. Effective treatment approaches for CPSP in this population have not been extensively investigated. The impact of multimodal strategies on CPSP following elective mid/hindfoot surgery is unknown due to both the heterogeneity of acute pain management and the lack of a recognized definition specific to this type of surgery. This study aimed to identify and evaluate current pain management strategies after elective mid/hindfoot and ankle surgery. We conducted a systematic review under Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three databases (MEDLINE, Embase and Cochrane Library) were electronically searched for English studies published between 1990 and July 2017. Reference lists of relevant systematic reviews were also manually searched. Comparative studies of adults undergoing elective mid/hindfoot and ankle surgery were included. Two reviewers independently reviewed studies and assessed their methodological quality. Of 1,159 studies, seven high-quality randomized controlled trials met our inclusion criteria. Though all studies examined regional anesthesia techniques, intervention heterogeneity precluded meta-analysis. Participants were typically followed up to 48 hours post-operatively. Interventions effective at reducing postoperative pain and/or opioid consumption included inserting popliteal catheters under ultrasound instead of nerve stimulation guidance, infusing perineural dexamethasone, bupivacaine, or ropivacaine perioperatively, and adding a femoral catheter infusion to a popliteal catheter infusion. Only one study assessed pain six months following elective mid/hindfoot and ankle surgery, demonstrating significant pain reduction with activity with the addition of a femoral to popliteal catheter infusion. There is an overwhelming lack of evidence regarding CPSP and its management for patients undergoing elective mid/hindfoot and ankle surgery. Although specific regional anesthesia techniques and adjuncts may be effective at reducing in-hospital pain and opioid consumption after elective mid/hindfoot and ankle surgery, our systematic review identified only seven studies addressing multimodal pain management in this population. Further comparative studies with longer-term follow-up are required

Polymethylmethacetate (PMMA) is a bone cement used in over 725,000 primary hip arthroplasties in 2018. Cement integrity is affected by external factors, including temperature, mixing technique and moisture uptake, which can influence cement microstructure. Changes in the cement microstructure may ultimately threaten the survivorship of the implant. The introduction of enhanced recovery and various local anaesthetic infiltration techniques have been adopted in an attempt to facilitate early mobilisation and reduce length of stay. Our study aims to investigate if the mechanical properties of PMMA are altered with exposure to Ropivacaine LA. Cements were cured in three separate states (air, serum and serum with LA) and the mechanical properties tested at 24 hours and 28 days. Using Refobacin bone cement provided by ZimmerBIOMET, cylindrical molds (12×6mm) were constructed with a split-mold. The LA used was 2mg/ml Ropivacaine hydrochloride solution. Using pilot data, this study was powered to 80% and a sample size of 10 per group (n=60) was calculated. Cement samples were subjected to compressive loading using a universal testing apparatus (Zwick/Roell). Yield-strength and modulus values were extracted from the respective stress versus strain curves. Significant differences were determined by one-way anova for each time point, and Bonferroni post-hoc testing to determine significance between actual groups. At 24-hours there were no significant differences in strength or modulus between groups. At 28-day strength and modulus increased in all groups. Compared to the air group, both serum and LA groups show a significant decrease in compressive strength. The modulus for the LA group is significantly less stiff compared to the air group. The results suggest that the initial exposure to LA has a significant impact on the physical properties of the PMMA. We propose increased awareness of the potential effects this may have on the longevity and survivorship of cemented implants

Dexmedetomidine, an alpha 2 agonist, has been approved for providing sedation in the intensive care unit. Along with sedative properties, it has analgesic activity through its highly selective action on alpha 2 receptors. Recent studies have examined the use of dexmedetomidine as an adjuvant to prolong the duration of peripheral nerve blocks. Studies showing effectiveness of dexmedetomidine for adductor canal block in knee surgery are small. Also, its effectiveness has not been compared to Epinephrine which is a strong alpha and beta receptor agonist. In a previous study, we showed that motor sparing knee blocks significantly increased the duration of analgesia compared with periarticular knee infiltration using local anesthetic mixture containing Epinephrine following total knee arthroplasty (TKA). In this study, we compared two local anesthetic mixtures: one containing Dexmedetomidine and the other Epinephrine for prolongation of motor sparing knee block in primary TKA patients. After local ethics board approval and gaining Notice of Compliance (NOC) from Health Canada for use of Dexmedetomidine perineurally, 70 patients between the ages 18 – 95 of ASA class I to III undergoing unilateral primary total knee arthroplasty were enrolled. Motor sparing knee block − 1) Adductor canal continuous catheter 2) Single shot Lateral Femoral Cutaneous Nerve block 3) Single shot posterior knee infiltration was performed in all patients using 60 ml mixture of 0.5% Ropivacaine, 10 mg Morphine, 30 mg Ketorolac. Patients randomized into the Dexmedetomidine group (D) received, in addition to the mixture, 1mcg/kg Dexmedetomidine and the Epinephrine (E) group received 200mcg in the mixture. The primary outcome was time to first rescue analgesia as a surrogate for duration of analgesia and secondary outcomes were NRS pain scores up to 24 hours and opioid consumption. The time to first rescue analgesia was not significantly different between Epinephrine and dexmedetomidine groups, Mean and SD 18.45 ± 12.98 hours vs 16.63 ± 11.80 hours with a mean difference of 1.82 hours (95% CI −4.54 to 8.18 hours) and p value of 0.57. Pain scores at 4, 6, 12, 18 and 24 hours were comparable between groups. Mean NRS pain scores Epinephrine vs Dexmedetomidine groups were 1.03 vs 0.80 at 4 hours, 1.48 vs 3.03 at 6 hours, 3.97 vs 4.93 at 12 hours, 5.31 vs 6.18 and 6.59 v 6.12 at 24 hours. Opioid consumption was also not statistically significant between both groups at 6, 12 18, 24 hours (p values 0.18, 0.88, 0.09, 0.64 respectively). Dexmedetomidine does not prolong the duration of knee motor sparing blocks when compared to Epinephrine for total knee arthroplasty. Pain scores and opioid consumption was also comparable in both groups. Further studies using higher dose of dexmedetomidine are warranted

Aims

The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid.

Aims

Enhanced perioperative protocols have significantly improved patient recovery following primary total knee arthroplasty (TKA). Little has been investigated the effectiveness of these protocols for revision TKA (RTKA). We report on a matched group of aseptic revision and primary TKA patients treated with an identical pain and rehabilitation programmes.

Introduction. Controlling post-operative pain and reducing opioid requirements after total knee arthroplasty (TKA) remains a challenge, particularly in an era stressing rapid recovery protocols and early discharge. A single shot adductor canal block (ACB) has been shown to be effective in decreasing post-operative pain. This requires a specialty-trained Anesthesiologist skilled in ultrasound techniques, which imposes cost, time and skill barriers. Cadaveric studies and magnetic resonance imaging data have shown that access to the adductor canal is possible from within the joint, and thus the potential for intraoperative, intra-articular, surgeon administered ACB through a standard surgical approach is a feasible alternative to ultrasound guided ACB at the time of TKA. The purpose of the present study is to compare the efficacy of surgeon administered intraoperative ACB to anesthesiologist administered ACB. Methods. Patients' undergoing primary TKA were prospectively randomized to receive either an Anesthesiologist administered (Group 1) or Surgeon administered (Group 2) ACB using 15 ml of Ropivacaine 0.5%, both in conjunction with spinal anesthesia. Perioperative multimodal anesthesia was standardized for the two groups. Primary outcomes were pain visual analogue scale (VAS), range of motion, and opioid consumption. Secondary outcomes were patient satisfaction scores and length of stay (LOS). Results. 51 patients were enrolled and followed for a minimum of 6 weeks. 28 were randomized to Group 1 and 23 to Group 2. Opioid equivalents consumed were equal on POD 0,1, and 2 (p=0.86, 0.68, 0.47). Patients in Group 1 had significantly less pain on POD 0 [46.9 vs 61.8] (p=0.014), but there was no difference in pain on POD 1 or 2 (p=0.4, p=0.95). There was no difference in active flexion on post-operative day (POD) 0, POD 1 or 6 weeks post op (p=0.86, 0.074 and 0.59) and no difference in active extension on POD 0, 1, or 6 weeks (p=0.38,0.07and p=0.3). There was no difference in patient satisfaction with pain control on POD 0, 1, or 2 (p=0.6, p=0.7, p=0.9). There was no difference in LOS (1.3 vs 1.4 days p=0.34). Conclusion. Surgeon administered ACB is not inferior to Anesthesiologist administered ACB with respect to range of motion, patient satisfaction, or opioid consumption, although pain on the day of surgery may be greater. Surgeon administered ACB is an effective and cost- and time- efficient alternative to Anesthesiologist administered ACB. For figures, tables, or references, please contact authors directly

Introduction. 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. Materials and Methods. 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/m. 2. . 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. Results. 72 people were enrolled in the study and three withdrew. There were 35 people in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the Post Anesthesia Care Unit (PACU), the average (P=0.0122) and worst (P=0.0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy. (P=0.2080) There was no difference in opioid consumption in the PACU (P=0.7928), at 8 hours (P=0.2867), 16 hours (P=0.2387), 24 hours (P=0.7456), or 30 hours (P=0.8029). There was no difference in pain scores on POD 1 in the AM (P=0.4597) or PM (P=0.6273), nor was there any difference in walking distance (P=0.5197). There was also no difference in length of stay in the PACU (P=0.9426) or hospital (P=0.2141) between the two groups. Discussion/Conclusion. Overall, pain was well controlled between the two groups. The IPACK group had lower pain scores at rest in the PACU, but this may not be clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be use of the IPACK block as a rescue block or in patients whom have contraindications to our standard multimodal treatment regimen, or in patients with chronic pain or opioid dependence

Aims

Adductor canal block (ACB) has emerged as an alternative to femoral nerve block (FNB) for analgesia after total knee arthroplasty (TKA). The optimal duration of maintenance of the ACB is still questionable. The purpose of this study was to compare the analgesic benefits and physiotherapy (PT) outcomes of single-shot ACB to two different regimens of infusion of the continuous ACB, 24-hour and 48-hour infusion.