Introduction and Objective. Wide awake local anaesthetic no tourniquet (WALANT) is being used for a wide variety of hand and wrist surgery. It has recently been used in distal radius fracture fixation. The purpose of this systematic review and meta-analysis was to assess the effectiveness of the WALANT technique in open reduction internal fixation. Materials and Methods. Pubmed, Embase, and Scopus databases were searched on 02/03/21 with the following search terms: radius, WALANT, local anesthetic, wide awake surgery. The primary outcome measure was conversion to general anaesthetic and mean intra-operative visual analogue scale (VAS) pain scores. Secondary measures were operative times, mean intraoperative blood loss, post-operative functional and radiological outcomes. Results. 110 articles were identified; eight studies were deemed eligible with 212 in the WALANT group and 247 in the comparative groups of regional anaesthesia and general Anaesthesia (GA). Two patients in the WALANT group required conversion to general anaesthesia due to anxiety rather than pain. Intra-operative VAS pain scores in the WALANT and regional anaesthetic group were 1.75 and 2.86 respectively (p<0.001). There was no statistically significant difference in Q-DASH scores, range of motion or radiological outcomes. There was a slight increase in mean blood loss in the WALANT group compared with those given a GA or regional anaesthetic with tourniquet (22.5ml vs 12.15ml, p<0.001). Conclusions. The WALANT technique is a viable option for anaesthetic when performing distal radius fracture fixation. It is well tolerated, giving similar post-operative outcomes to other anaesthetic methods. It is a potentially useful technique in a centre with an underresourced anaesthetic department or for patients who may not tolerate regional and general anaesthetic methods. Adequate patient counselling prior to the procedure should be performed with appropriate patient selection

Abstract: Plantar fasciitis is the most common cause of heel pain for which medical care is sought. It is associated with significant morbidity placing activity limitations on the patients. The response of plantar fasciitis to any treatment is unpredictable. Many different modalities of treatment are used in its management. Injection of plantar fascia with local anaesthetic and steroids under general anaesthesia was carried out in 50 patients who had a clinical diagnosis of plantar fasciitis of greater than 3 month duration. Following induction of general anesthesia, a 20-gauge needle was guided toward and into the plantar fascia. 5mls of local anaesthetic and steroid was injected into the proximal plantar fascia. The patients were followed up over a mean of 6 months. Pain intensity was graded on an 11-point visual analog scale (VAS). Questionnaires with the VAS were filled out after treatment to determine the effectiveness of the procedure. The mean pain score decreased by 5.4 points. There were no complications during or after the procedure. Patients were questioned in relation to their occupational, athletic and recreational activities pre and post the injection. Injection of the plantar fascia under general anaesthesia is a safe and effective method for the relief of conservatively unmanageable heel pain due to plantar fasciitis. A larger patient population and a greater than 1 year follow up would be helpful to determine the long term benefits & outcomes of this treatment

Objective. To study the effect of hyaluronic acid (HA) on local anaesthetic chondrotoxicity in vitro. Methods. Chondrocytes were harvested from bovine femoral condyle cartilage and isolated using collagenase-containing media. At 24 hours after seeding 15 000 cells per well onto a 96-well plate, chondrocytes were treated with media (DMEM/F12 + ITS), PBS, 1:1 lidocaine (2%):PBS, 1:1 bupivacaine (0.5%):PBS, 1:1 lidocaine (2%):HA, 1:1 bupivacaine (0. 5%):HA, or 1:1 HA:PBS for one hour. Following treatment, groups had conditions removed and 24-hour incubation. Cell viability was assessed using PrestoBlue and confirmed visually using fluorescence microscopy. Results. Media-treated groups had a mean of 1.55×10. 4. cells/well (. sem. 783). All treated cells showed statistically significant reduced viability when compared with media alone (all p < 0.003). Cells treated with bupivacaine + HA (6.70×10. 3. cells/well (. sem. 1.10×10. 3. )) survived significantly more than bupivacaine (2.44×10. 3. cells/well (. sem . 830)) (p < 0.001). Lidocaine + HA (1.45×10. 3. cells/well (. sem. 596)) was not significantly more cytotoxic than lidocaine (2.24×10. 3. cells/well (. sem. 341)) (p = 0.999). There was no statistical difference between the chondrotoxicities of PBS (8.49×10. 3. cells/well (. sem. 730) cells/well) and HA (4.75×10. 3. cells/well (. sem. 886)) (p = 0.294). Conclusions. HA co-administration reduced anaesthetic cytotoxicity with bupivacaine but not lidocaine, suggesting different mechanisms of injury between the two. Co-administered intra-articular injections of HA with bupivacaine, but not lidocaine, may protect articular chondrocytes from local anaesthetic-associated death. Cite this article: Bone Joint Res 2013;2:270–5

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

To our knowledge, we are the only centre in the UK where Achilles tenotomies (TA) for CTEV Ponseti correction are performed in outpatient clinic under local anaesthetic by an Advanced Physiotherapy Practitioner (APP) in orthopaedics. This study aims to present the outcomes and safety of this practice. Retrospective analysis of cases of idiopathic CTEV undergoing Ponseti correction January 2020 to October 2022. Demographic data: Pirani score and number of casts before boots and bar. Patients were divided into five groups: Group 1: TA performed by an Orthopaedic consultant under general anaesthetic (GA) in theatre. Group 2: TA performed by an Orthopaedic consultant under local anaesthetic (LA) in theatre. Group 3: TA performed by APP under GA in theatre. Group 4: TA performed by APP under LA in theatre. Group 5: TA performed by an APP under LA in outpatient clinic. Complications recorded: revision TA, infection, neurovascular injury or need for re-casting. Mean follow up 18 months. 45 feet included. Mean Pirani score 5.5, age started casting 33 days and total number of casts 6. No significant difference in demographic details between groups. 6, 4, 20, 5 and 10 tenotomies were performed in groups 1, 2, 3, 4, and 5 respectively. Complications were 1 revision tenotomy from group 2, one from group 4 and 1 renewal of cast from 3. This study demonstrates that TAs performed in outpatient clinic under LA by an APP is safe and feasible. No increase in complications were observed compared to TAs performed by orthopaedic consultants

Abstract. Introduction. Local anaesthetic injections are regularly used for perioperative pain relief for shoulder arthroscopies. In our practice all shoulder arthroscopies were performed under general aneasthesia supplemented by perioperative subacromial local anaesthetic injections or landmark guided axillary nerve together with suprascapular nerve injections. We compared pain relief achieved with these two methods. We hypothesized that the selective nerve blocks would provide better post operative pain relief as described in literature. Methods. We conducted a retrospective cohort study on two patient groups with 17 patients each. Group one patients received 20mls 50:50 mixture of 1% lignocaine and 0.5% chirocaine injections before and after start of procedure and group two patients received 20 mls of chirocaine around the axillary and suprascapular nerves. VAS scores were collected at 1 and 4 hours and analgesia taken during the first 24 hours was recorded. Results. No significant difference in pain scores was noted but analgesia requirements in the nerve block group were higher. Conclusion. Landmark guided nerve blocks did not show any advantage over subacromial local anaesthetic in our study. This is in contrast to published literature and we believe subacromial injections are more reliable and reproducible. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Conventional teaching advises against using adrenaline with local anaesthetic near end-arteries due to risks of irreversible vasospasm, however there are benefits of adjunctive adrenaline including enhanced anaesthetic effect, prolonged duration and temporary haemostasis. Retrospective analysis was undertaken for all elective finger and distal palmar surgery using digital nerve or field blocks performed by four orthopaedic hand surgeons, during a two-year period in a large teaching hospital. Data collected from theatre databases and clinical notes included procedure type, anaesthetic agent, adrenaline use, tourniquet use and evidence of post-operative digital ischaemia or wound complications. 230 procedures (mean age 59 years) were performed, including 158 cases with plain anaesthetic only (2%, 1% Lidocaine or 0.25% Bupivicaine in 150, 4 and 4 cases respectively) and 72 cases with 0.25% Bupivicaine and adrenaline (1:200,000.) Mean anaesthetic volume was 7.5ml (7.2ml vs 8.0ml without and with adrenaline respectively.) Tourniquet was used in all cases without adrenaline but was not used in 21 (29%) of cases with adrenaline. Mean tourniquet time in each group was 16 minutes. Two post-operative infections occurred in the group without adrenaline with none in the adrenaline group and there were no cases of digital necrosis in either group. In the elective setting, adjunctive adrenaline with local anaesthetic does not increase the risk of post-operative infections or digital ischaemia. For proximal finger surgery, where digital tourniquets are often restrictive, using adrenaline can prevent the need for painful arm tourniquets

The effect of timing of a manipulation under anaesthetic (MUA) and injection of corticosteroid and local anaesthetic for the treatment of frozen shoulder has attracted little attention to date. All studies describe a period of conservative treatment before proceeding to an MUA. Delay has been associated with a poorer outcome. We present a retrospective review of a prospectively collected, single-surgeon, consecutive series of 246 patients with a primary frozen shoulder treated by MUA within four weeks of presentation. The mean duration of presenting symptoms was 28 weeks (6 to 156), and time to initial post-operative assessment was 26 days (5 to 126). The Oxford shoulder score (OSS) improved by a mean of 16 points (Wilcoxon signed-ranks test, p < 0.001) with a mean OSS at this time of 43 (7 to 48). Linear regression analysis showed no correlation between the duration of presenting symptoms and OSS at initial follow-up (R2 < 0.001) or peri-operative change in OSS (R2 < 0.001) or OSS at long-term follow-up (R2 < 0.03). Further analysis at a mean of 42 months (8 to 127) revealed a sustained improvement with a mean OSS of 44 (16 to 48). A good outcome follows an MUA and injection of corticosteroid and local anaesthetic in patients with primary frozen shoulder, independent of the duration of the presenting symptoms, and this improvement is maintained in the long term

Lower-extremity orthopaedic procedures may be performed under either regional or general anaesthesia, or a combination of both techniques. There is a growing body of evidence supporting the benefits of regional anaesthesia, with meta-analyses of randomised controlled trials and registry data suggesting decreases in deep surgical site infections, thromboembolic events, cardiopulmonary complications and length of stay associated with use of regional anaesthesia. In patients undergoing foot and ankle surgery specifically, there is evidence demonstrating decreased post-operative pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports an increased role for the use in regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict the type of anaesthetic used in patients undergoing foot and ankle surgery. Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analysed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used. General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p<0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure (<0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 +/− 77 minutes, whereas patients provided with regional anaesthesia had a mean length of procedure 83 +/− 64 minutes. With increasing evidence supporting the benefits of regional anaesthesia in patients undergoing lower extremity surgery, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure may be a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be considered candidates for regional anaesthesia

Aims. Manipulation under anaesthetic (MUA) is a recognised form of treatment for patients with a frozen shoulder. However, not all patients benefit. Some have persistent or recurrent symptoms. There are no clear recommendations in the literature on the optimal management of recurrent frozen shoulder after a MUA. We aimed to address this issue in this study. Patients and Methods. We analysed a prospectively collected, single-surgeon, consecutive series of patients who underwent MUA for frozen shoulder between January 1999 and December 2015. The Oxford Shoulder Scores (OSS) and range of movement were the outcome measures. . Results. A total of 730 patients (792 shoulders) underwent MUA during the study period. A further MUA was undertaken in 141 shoulders (17.8%), for which we had complete data for 126. The mean improvement in OSS for all patients undergoing MUA was 16 (26 to 42), and the mean post-operative OSS in those requiring a further MUA was 14 (28 to 42; t-test, no difference between mean improvements, p = 0.57). Improvement was seen after a further MUA, regardless both of the outcome of the initial MUA, and of the time of recurrence. Patients with type-1 diabetes mellitus were at a 38% increased risk of requiring a further MUA, compared with the 18% increased risk of the group as a whole (p < 0.0001). Conclusion. Patients with a poor outcome or recurrent symptoms of a frozen shoulder after a MUA should be offered a further MUA with the expectation of a good outcome and a low complication rate. Cite this article: Bone Joint J 2017;99-B:812–17

Intra-articular injections of steroid into the hip are used for a variety of reasons in current orthopaedic practice. Recently their safety prior to ipsilateral total hip replacement has been called into question owing to concerns about deep joint infection. We undertook a retrospective analysis of all patients who had undergone local anaesthetic and steroid injections followed by ipsilateral total hip replacement over a five-year period. Members of the surgical team, using a lateral approach to the hip, performed all the injections in the operating theatre using a strict aseptic technique. The mean time between injection and total hip replacement was 18 months (4 to 50). The mean follow-up after hip replacement was 25.8 months (9 to 78), during which time no case of deep joint sepsis was found. In our series, ipsilateral local anaesthetic and steroid injections have not conferred an increased risk of infection in total hip replacement. We believe that the practice of intra-articular local anaesthetic and steroid injections to the hip followed by total hip replacement is safer than previously reported

Carpal tunnel syndrome is the commonest nerve entrapment syndrome. There is still controversy over the method of anaesthesia for this procedure. There have been many studies to show the effectiveness of local infiltration anaesthesia. However, patients do not always tolerate it, as one of the disadvantages of local anaesthetic is pain on infiltration. Experimental studies have shown that warming local anaesthetic can reduce the pain of injection in normal subjects. The aim of our study is to assess the effect of warming local anaesthetic for carpal tunnel surgery. We conducted a prospective randomised controlled trial. Sample size was calculated. The study group consisted of patients undergoing carpal tunnel surgery. The treatment group received local anaesthetic at 37°C, the control group at room temperature. Patients were asked to indicate the degree of discomfort on a visual analogue scale (0 to 100). There was a significant reduction in pain scores in the treatment group. Warming the local anaesthetic produced a mean visual analogue score of 13.8 versus 43 for the control group. These results were statistically significant (p< 0.05). Many carpal tunnel releases are performed under General Anaesthetic . One of the main reasons cited was poor patient tolerance to local anaesthetic infiltration due to pain. Our results show a significant reduction in the reported pain by warming the local anaesthetic for carpal tunnel release. We suggest that warming local anaesthetic should be best practice for anaesthesia in carpal tunnel release

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

Intra-operative, peri-articular injection of local anaesthesia is an increasingly popular way of controlling pain following total knee replacement. At the same time, the problems associated with allogenic blood transfusion have led to interest in alternative methods for managing blood loss after total knee replacement, including the use of auto-transfusion of fluid from the patient’s surgical drain. It is safe to combine peri-articular infiltration with auto-transfusion from the drain. We performed a randomised clinical trial to compare the concentration of local anaesthetic in the blood and in the fluid collected in the knee drain in patients having either a peri-articular injection or a femoral nerve block. Clinically relevant concentrations of local anaesthetic were found in the fluid from the drains of patients having peri-articular injections (4.92 μg/ml (. sd. 3.151)). However, none of the patients having femoral nerve blockade had detectable levels. None of the patients in either group had clinically relevant concentrations of local anaesthetic in their blood after re-transfusion. The evidence from this study suggests that it is safe to use peri-articular injection in combination with auto-transfusion of blood from peri-articular drains during knee replacement surgery

Introduction. Local anaesthetic has been reported to have a detrimental effect on human chondrocytes both in vitro and in vivo. Magnesium, an NMDA-receptor antagonist, may be an alternative intra-articular analgesic agent following arthroscopy. We aimed to report the dose response effect of commonly used local anaesthteitc on chondrocyte viability and also report on the effect of adding magnesium to local anaesthetic. Methods. Human chondrocytes were grown under standard conditions. Cells were exposed to either lignocaine (0.5, 1, 2%), levobupivacaine (0.125, 0.25, 0.5%), bupivacaine (0.125, −.25, 0.5%) or ropivacaine (0.1875, 0.375, 0.75%) for 15 minutes. Cells were also exposed to a local anesthetic agent with the addition of magnesium (10, 20, or 50%). Cells exposed to media or saline served as controls. The MTS assay was used to assess cell viability 24-hours after exposure. Results. One-way ANOVA showed an expected dose response in all local anaesthetic groups with the exception of lignocaine. Magnesium alone was no more toxic than normal saline (P>0.3). 50% magnesium showed similar effect on cell viability to the least toxic local anaesthetic (lignocaine 1%, P=0.31). The addition of magnesium to the local anesthetic agents resulted in greater cell viability than when cells were treated with the respective local anaesthetic alone (lignocaine (P=0.033), levobupivacaine (P=0.007), bupivacaine (P<0.001), ropivacaine (P<0.001)). Conclusion. We have shown that cell viability is greater in the presence of magnesium than selected local anaesthetics and also with the addition of magnesium to local anaesthetic compared to the local anesthetic agent alone. We believe that these findings offer support to an alternative intra-articular analgesia following arthroscopy

Introduction. Operating theatre airflow can be measured using pulsed lasers (particle image velocimetry) but the process is difficult to do in 3D. Cup, vane or hot wire anemometers provide only 2D information. 3D measurements enable better understanding of airflow. Patients/Materials & Methods. We used a Windmaster ultrasound 3D anemometer (Skyview systems), which uses three ultrasound transmitters to measure velocity in XYZ planes, with a sampling rate of 32 Hz. Post processing was done using MATLAB. An operating theatre with an Howorth Exflow canopy was studied. Equipment, including lights, was moved. A 50 cm grid was marked, and measurements were made at intervals up to the ceiling. Door opening was observed within the clean zone and the peripheral zone, next to the door and on the opposite side of the room. Anaesthetic screens were studied during operating. Airflow was visualised initially using video of smoke puffs and subsequently measured using the aeronometer. Results. In the upper part of the ultraclean canopy air velocity was 0.34 m/s with a standard deviation of 0.02 m/s, indicating an almost constant velocity. In the periphery there was more turbulence and horizontal air movement. Door opening had no effect on air movements in the clean zone. In the periphery there was an increase in horizontal airflow when the doors are closed. There is a pattern of upward airflow against an anaesthetic screen. This is unlikely to be caused by warming blankets. If the partial wall of the enclosure is lowered this results in a fast washout of air towards the anaesthetist. Discussion. Traditional anaesthetic screens may interfere with airflow. Door opening is a lesser effect. Conclusion. The 3D anemometer enables detailed mapping of airflow within an ultra clean air operating theatre. The data obtained will enable the construction of more accurate computational fluid dynamic models of operating theatres

Introduction: Despite clinical history, examination and plain radiography it is occasionally difficult to locate the origin of hip pain. This is particularly relevant where the management will be a total hip arthroplasty. Local anaesthetic arthrogram of the hip may provide a simple, safe and reliable test to determine if the hip is the source of the patient’s symptoms. The aim of this study was to establish the use of this investigation in the management of hip pain. Methods: All local anaesthetic hip arthrograms were reviewed from 1999 to 2005. All patients had completed a pain questionnaire following the arthrogram. Patients were classified into 3 groups; 1) Mild osteoarthritic changes on plain radiographs with possible referred pathology; 2) Minimal radiological changes but no obvious other pathology to refer pain; 3) Previous hip arthroplasty with unexplained pain. Those who subsequently had a primary or revision hip arthroplasty were assessed post-operatively by means of the Oxford hip score. Results: Fifty-seven patients in total underwent a local anaesthetic hip arthrogram. From all the groups 34 patients obtained pain relief and 24 proceeded to primary or revision hip arthroplasty. Twenty three (96%) had a satisfactory post-operative outcome at an average follow-up of 2 years (average Oxford score 28). The remaining 10 patients with positive arthrograms are still waiting for surgery. All negative arthrogram patients were successfully discharged. Discussion: A positive response to local anaesthetic hip arthrogram predicts a successful response to surgery. This permits accurate information of the results of hip surgery to be given to patients and aids in a management plan for a group of patients that can be otherwise challenging

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again

There is no consensus on the management of TA rupture. For operative management, TA have been repaired under general/spinal anaesthetic (GA) or LA. LA repair may be at least as effective and can reduce anaesthetic complications. LA can be performed as a day case and could have significant cost savings. We retrospectively reviewed 80 patients (sample size 120), during the five year period 2001–2005 at Nelson Hospital, who’s ruptured TA was repaired under general anaesthetic (GA) or local anaesthetic (LA). All patients reviewed were at least six months post-op. We assessed at a clinic their long-term outcome, including pain and function. This included their range of motion and strength. Epidemiological data including risk factors was collected. Patients completed a Foot and Ankle questionnaire developed by the American Academy of Orthopaedic Surgeons. Complications such as infection or nerve damage were noted. Further patients are currently being seen to increase sample size. Of the 80 TA that were repaired, 51 (64%) were repaired under GA, 29 (36%) under LA. Results thus far show similar levels of patient satisfaction. 82% of GA patients and 83% of LA patients reported no pain. Patient-reported weakness was 27% (GA) and 24% (LA). Single leg hop distance comparing injured with uninjured was 94% (GA) and 91% (LA). Maximum calf raises in 30 seconds comparing injured with uninjured was 84% (GA) and 82% (LA). Calf diameter on the injured side was 97% (GA) and 96% (LA) compared with the uninjured. The average theatre time was 38 minutes (LA) compared with 65 minutes. LA patients spent on average 0.26 days in hospital compared with 1.2 days, reflecting a greater proportion of day cases. LA patients had a quicker return to work, average 21 days versus 30. Complications in the GA group, included two deep vein thromboses and two pulmonary emboli. One patient from each group had a re-rupture. Results will be reviewed and further statistical analysis done once further patients have been seen. There is no disadvantage in repairing a ruptured TA under LA with regards to long-term pain, function and patient satisfaction. LA repair avoids anaesthetist involvement and anaesthetic complications. Repair under LA results in significant cost savings due to less theatre time, a shorter hospital stay and a quicker return to work

Background. There are several case reports of chondrolysis following joint arthroscopy. Continuous post-operative infusion of local anaesthetic solutions, especially 0.5% Bupivacaine, has been implicated as the causative factor in many of these cases. Recent in vitro studies have shown that even a single exposure of articular cartilage to different local anaesthetic solutions can cause apoptosis and mitochondrial dysfunction in chondrocytes leading to cell death. There is currently no study looking at methods to prevent this toxicity of local anaesthetic solutions to articular cartilage. Glucosamine has a protective and reparative effect on articular cartilage and a Cochrane review in 2007 found that it provides mild benefit in pain and function in patients with arthritis. Aims. Oncologic: To compare the effect of a single exposure, in vitro, of different local anaesthetic solutions on human articular cartilage. To investigate the protective and reparative effects of Glucosamine on articular cartilage exposed to 0.5% Bupivacaine. Methods. Chondral explants (n = 354) were obtained from femoral heads of 14 fracture neck of patients undergoing hemiarthroplasty. To compare the effect of local anaesthetics, each specimen was exposed to one of 8 test solutions for one hour. After this exposure, the specimens were washed and incubated in culture medium containing radio-labelled 35-sulphur for 16 hours. The unbound radioactivity was then washed off and the chondral specimens were digested with proteinase for 24 hours. The uptake of 35-S by each specimen was measured and this gave an estimate of proteoglycan metabolism. Test solutions: 1. 1% Lidocaine; 2. 2% Lidocaine; 3. 0.25% Bupivacaine; 4. 0.5% Bupivacaine,. 5. 0.5% Levo-Bupivacaine; 6. Control solution of M199 culture medium. 7. To investigate its protective effect, 100 micrograms of Glucosamine was added along with 0.5% Bupivacaine; 8. To investigate the reparative effect of Glucosamine, the specimen was exposed to 0.5% Bupivacaine for one hour. After washing, 100 mcg of Glucosamine was added to the culture medium in which the chondral specimen was incubated. Results. Compared to the control culture medium, the inhibition of proteoglycan metabolism was 54% with 1% Lidocaine (p<0.001), 75% with 2% Lidocaine (p<0.01), 50% with 0.25% Bupivacaine (p = 0.04), 78% with 0.5% Bupivacaine (p<0.001) and 73% with 0.5% Levo-Bupivacaine (p<0.001). Adding Glucosamine for protection reduced the toxicity of 0.5% Bupivacaine to 43%, compared to 78% without. However, Glucosamine was not able to repair the damage caused by 0.5% Bupivacaine, with inhibition of proteoglycan metabolism at 70% even after 16 hours of incubation. Conclusion. All local anaesthetic solutions tested were toxic to articular cartilage, 0.5% Bupivacaine being the worst offender. Higher concentrations were more harmful. The addition of Glucosamine to 0.5% Bupivacaine protected against its toxicity to articular cartilage but was not able to repair the damage caused

It has been reported that some of the local anaesthetic agents possess antimicrobial activity against clinically-significant bacteria. Although bupivacaine exhibits a bacteriostatic effect at concentrations above 0.25% there are concerns that it might interact with some of the other antibiotics administered to patients. Whilst these interactions may be potentially benign, the risk is that they are antagonistic and that local bupivacaine might predispose the patient to a higher risk of infection. Bupivacaine is commonly administered as a local anaesthetic following knee arthroplasy; the purpose of this study was to assess its potential interactions with gentamicin eluting from the cement used to fix the device. A strain of Saphylococcus aureus (29213) with established susceptible Minimal Inhibition Concentration (MIC) and Minimal Bactericidal Concentration (MBC) for gentamicin was used. This organism was inoculated into four types of broth; Mueller-Hinton broth (MH), MH with different concentrations of gentamicin, MH with 0.25% and 0.125% bupivacaine and MH with various combinations of gentamicin and bupivacaine. The broths were incubated at 37C and at 0.5, 1, 2, 3, 6 and 24 hours post inoculation the number of bacteria remaining were counted. From these data kill-curves were generated describing the absolute and individual rates of killing seen with bupivacaine and gentamicin alone and when in combination. Bupivacaine showed a bacteriostatic effect only at concentrations of 0.25% and higher. All concentrations of gentamicin above or equal to the expected MBC showed bactericidal effect. However, in combination with both strengths of Bupivacaine (0.25 and 0.125%) the bacteriocidal effect of gentamicin was seen at a lower concentration and the rate of killing of bacteria was enhanced. Bupivacaine has bacteriostatic effect at concentrations above 0.25% in line with published data. In these experiments we have shown that the use of bupivacaine together with gentamicin does not reduce the bactericidal property of the antibiotic and that the bactericidal effect of gentamicin appears to be enhanced by bupivacaine. This would suggest that the local use of bupivacaine is unlikely to increase the risk of infection in patients undergoing knee arthroplasty and may actually be beneficial

Introduction. New methods to reduce inpatient stay, post-operative complications and recovery time are continually being sought in surgery. Many factors affect length of hospital stay, such as, analgesia, patient and surgeon expectations, as well as provision of nursing care and physiotherapy. Development of the use of postoperative local anaesthetic infiltration delivered intra-articularly by a catheter appears to be an effective analgesic method which reduces patient's opioid requirements and allows early physiotherapy without motor blockade of muscles. Our study aimed to explore if the use of local anaesthetic infiltration intra-articularly following joint athroplasty affected the patient's duration of hospitalisation. Methods. Looking retrospectively at arthroplasty audit data, we compared two groups of age and sex-matched patients who underwent primary hip arthroplasty (replacement and resurfacing) and knee arthroplasty performed by a single surgeon using the same surgical techniques. The surgeon began to utilize local anesthetic infiltration intra-articularly in 2009. The first group included patients operated on the year prior to the change and the second group were those operated on within a year of the change of practice. There were 103 patients (27 resurfacings, 28 knees, 48 hips) in the local anaesthetic group and 141 patients (48 resurfacings, 36 knees, 64 hips) in the non-local anaesthetic group. The length of stay was investigated for plausible Normality using the Shapiro Wilks statistic. Between-treatment group differences were examined using one-way analysis of variance (ANOVA). Factors observed were, use of local anaesthetic (yes/no), joint (hip/knee) and day of surgery (weekend/not weekend). Between treatment group differences in gender and complications were investigated using Chi-squared methods. Results. Patients who received local anaesthetic had shorter stays, irrespective of the joint or day of operation. Patients undergoing hip arthroplasty discharged sooner when local anaesthetic was used compared with those without (mean 4.0 days and 4.4 days respectively P=0.04). Patients undergoing knee replacement also discharged sooner when local anaesthetic was used compared with those without (mean 4.9 days and 6.1 days respectively P=0.09). When knee and hip figures were combined and analysed to measure the significance of effects of treatment on the length of stay, local anaesthetic use was found to be statistically significant in reducing length of stay (P=0.01). There were no between-treatment group differences in proportions of complications, gender or day of surgery. Conclusion. The findings of this study highlight that local anaesthetic infiltration reduces duration of in-patient stay following knee and hip joint athroplasty and there is no associated significant increase in immediate post-operative complications

We investigated 42 patients who were being considered for primary total hip arthroplasty (THA), but in whom it was uncertain whether the hip was the source of their pain. They were given an injection of local anaesthetic into the joint space. Of 33 patients who gained pain relief from their injection, 32 subsequently had successful THA. The remaining patient has not had surgery. The intra-articular injection of local anaesthetic is thus at least 96% sensitive. Of the nine patients who had no or only minimal pain relief from injection, one has had an unsuccessful THA, three have been successfully treated for other conditions and five have unresolved pain for which no organic basis has been established. We believe that the injection of local anaesthetic into the hip is a reliable test, with low morbidity. In difficult cases it will aid in the clarification of the cause of pain which possibly arises from the hip

Introduction. Local anaesthetic has been reported to have a potentially detrimental effect on human chondrocytes both in vitro and in vivo. Due to chondroproliferative effects, magnesium may be an alternative intra-articular analgesic agent following arthroscopy. We aimed to examine the dose response effect of commonly used local anaesthetics on chondrocyte viability and also to report on the effect of adding magnesium to the local anesthetic agent. Methods. Human chondrocytes were grown under standard culture conditions. Cells were exposed to either lignocaine (0.5, 1, 2%), levobupivacaine (0.125, 0.25, 0.5%), bupivacaine (0.125, 0.25, 0.5%) or ropivacaine (0.1875, 0.375, 0.75%) for 15 minutes. Cells were also exposed to a local anesthetic agent with the addition of magnesium (10, 20, or 50%). Cells exposed to culture media or saline served as controls. The MTS assay was used to assess cell viability 24 hours after exposure. One-way ANOVA were used to test for statistical significance. Results. One-way ANOVA showed a dose response in all local anesthetic groups with the exception of lignocaine with higher concentrations leading to lower levels of cell viability. Magnesium alone was no more toxic than normal saline (P>0.3) compared to untreated cells. 50% magnesium showed similar effect on cell viability to the least toxic local anesthetic (lignocaine 1%, P=0.31). The addition of magnesium to the local anesthetic agents resulted in greater cell viability than when cells were treated with the respective local anaesthetic alone (lignocaine (P=0.033), levobupivacaine (P=0.007), bupivacaine (P<0.001), ropivacaine (P<0.001)). Conclusion. We have showed that cell viability is improved with the addition of magnesium to local anaesthetic compared to the local anesthetic agent alone. We believe that these findings offer support to an alternative intra-articular analgesia following arthroscopy. However, the optimum doses and combinations of local anaesthetic and magnesium are yet to be shown

Adductor canal blocks offer an alternative to femoral nerve block for postoperative pain relief in knee arthroplasty. They may reduce the risk of quadriceps weakness, allowing earlier mobilisation of patients postoperatively. However, little is known about the effect of a tourniquet on the distribution of local anaesthetic in the limb. Ultrasound-guided adductor canal blocks were performed on both thighs of five human cadavers. Left and right thighs of each cadaver were randomised to tourniquet or no tourniquet for one hour. Iohexol radio-opaque contrast (Omnipaque 350) was substituted for the local anaesthetic for X-Ray imaging. All limbs underwent periodic flexion and extension during this hour to simulate positioning during surgery. The cadavers were refrozen. Fiducial markers were inserted into the frozen tissue. X-rays were obtained in 4 planes (AP, lateral 45° oblique/medial oblique, lateral). University Research Ethics Approval was obtained and cadavers were all pre-consented for research, imaging and photography according to the Anatomy Act (1984). Analysis of radiographs showed contrast distribution in all thighs to be predominantly on the medial aspect of the thighs. The contrast margins were entire and well circumscribed, strongly suggesting it was largely contained within the aponeurosis of the adductor canal. Tourniquets appeared to push the contrast into a narrower and more distal spread along the length of the thigh compared to a more diffuse spread for those without. Proximal spread towards the femoral triangle was reduced in limbs without tourniquets. The results suggest that contrast material may remain within the adductor canal structures during adductor canal blocks. Tourniquets may cause greater distribution of contrast proximally and distally in the thigh, but this does not appear to be clinically significant. Further studies might include radio-stereo photometric analysis using the fiducial markers in the limbs and in vivo studies to show the effect of haemodynamics on distribution

Aims: To prospectively compare the progress and outcomes during a follow-up period of two years in patients who were in the ‘freezing phase’ of Primary (Idiopathic) Frozen Shoulder following either manipulation of the shoulder under general anaesthetic (MUA) or intra-articular shoulder joint distension injections using steroid and local anaesthetic. Methods: 53 consecutive patients aged between 40 and 75 years with Frozen Shoulder were randomised to receive either MUA followed by out-patient physiotherapy or up to 3 distension injections at six weekly intervals in the first 12 weeks. Outcomes were measured using Constant-Murley Shoulder Function Assessment Score (CS), Visual Analogue Score (VAS) for pain level, and the SF-36 Health Evaluation Questionnaire. All patients were reviewed at 2, 6 and12 weeks, then at 6, 9, 12, 18 and 24 months. At each visit the CS and the VAS were repeated. The SF-36 was undertaken at initial and final visits. Results: Group 1 (MUA) contained 28 patients of which 15 (54%) were female. Group 2 (Distension Injection) contained 25 patients of which 20 (80%) were female. No statistical difference was identified between the 2 groups in terms of outcome for the affected shoulders, for the SF36 scores, CS and the VAS. Maximum benefit was seen by 12 weeks in both groups. In group 2 this equated to 2 distension injections. No complications were noted in either group. Conclusion: Frozen Shoulder is accepted to be a self-limiting condition with resolution by 2 years from onset. Any treatment aims to reduce this period of pain and disability. The potential risks of MUA include fracture and rotator cuff ruptures are well documented in the literature. Distension injections are easily performed in clinic without the need for admission, a general anaesthetic, or the risk of the complications associated with MUA. In view of there being no difference between the treatment modalities we recommend the use of 2 distension injections as the first line treatment for Frozen Shoulder

We aimed to determine the impact of anaesthetic techniques on post-operative analgesic utilisation in people undergoing total knee arthroplasty. We conducted a prospective study at a district general hospital to assess post-operative analgesia use via patient controlled analgesia (PCA) in patients undergoing a elective total knee arthroplasty. Subjects were divided into three groups; group 1 (general anaesthetic and local nerve block, n = 39), group 2 (spinal only, n= 39) and group 3 (general anaesthetic only, n = 38). The primary outcome measure was post-operative morphine consumption through a PCA within the first 24 hours. All subjects were followed up post-operatively by a dedicated pain control nurse. Data was analysed using SPSS version 17 for Windows (SPSS Inc, Chicago, IL, USA). Results are reported as mean (SD) unless stated otherwise. No significant difference in the age or sex distribution between groups was demonstrable. There was no statistical difference in the average usage of morphine when comparing Group 1 compared to group 2, (77.57 (49.56) vs 65.80 (44.71), p=0.27), group 1 compared to group 3, (77.57 (49.56) vs 77.80 (45.52) p=0.98) and finally group 2 compared to group 3, (65.80 (44.71) vs 77.80 (45.52), p=0.25). In this cohort of patients undergoing total knee arthroplasty the anaesthetic technique used does not appear to have an influence on the post-operative pain management

Background. Continuous post-operative infusion of local anaesthetic solutions has been implicated as the causative factor in many cases of chondrolysis. Recent in-vitro studies have shown that even a single exposure to local anaesthetic can cause apoptosis and mitochondrial dysfunction leading to chondrocyte death. Glucosamine has been shown to have a protective and reparative effect on articular cartilage. Aims. To compare the effect of a single exposure of different local anaesthetic solutions on human articular cartilage and to investigate the protective and reparative effects of Glucosamine on articular cartilage exposed to 0.5% Bupivacaine. Methods. Chondral explants (n=354) were obtained from femoral heads of hip fracture patients undergoing hemiarthroplasty. Each specimen was exposed to one of 8 test solutions for one hour. The specimens were then incubated in culture medium containing radio-labelled 35-sulphur for 16 hours. The uptake of 35-S by each specimen was measured to give an estimate of proteoglycan metabolism. Test solutions. 1. 1% Lidocaine 2. 2% Lidocaine 3. 0.25% Bupivacaine, 4. 0.5% Bupivacaine, 5. 0.5% Levo-Bupivacaine 6. Control solution of M199 culture medium. 7. To investigate its protective effect, 100 micrograms of Glucosamine was added along with 0.5% Bupivacaine 8. To investigate its reparative effect, Glucosamine was added after exposure to Bupivacaine for an hour. Results. Compared to the control solution, the inhibition of proteoglycan metabolism was 64% with 1% Lidocaine(p< 0.001), 79% with 2% Lidocaine(p< 0.001), 61% with 0.25% Bupivacaine(p< 0.001), 85% with 0.5% Bupivacaine(p< 0.001) and 77% with 0.5% Levo-Bupivacaine(p< 0.001). Adding Glucosamine reduced Bupivacaine toxicity to 43%(p< 0.001). Glucosamine marginally repaired the damage caused by Bupivacaine, with inhibition of proteoglycan metabolism at 70%(p=0.004). Conclusion. All local anaesthetic solutions were toxic to articular cartilage. The addition of Glucosamine to 0.5% Bupivacaine protected against its toxicity to articular cartilage

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

We report a case of iatrogenic sciatic nerve injury caused by pre-operative intraneural injection of local anaesthetic at total hip replacement. To our knowledge, this is unreported in the orthopaedic literature. We consider sacral nerve blockade in patients undergoing total hip replacement to be undesirable and present guidelines for the management of peri-operative sciatic nerve injury

Patients due to have a major orthopaedic operation should be assessed in advance, in order to be fully prepared for the operation the scheduled day the without cancellations and be cost-effective. We studied 208 patients the last 2 years scheduled for hip and knee replacement. Mean Age 68.7. F=150, M=58. The patients were formally admitted in the assessment stay unit where a fully orthopaedic and anaesthetic examination was done and appropriate lab tests were carried out. The whole procedure lasted 4 hours and was charged 88 Euros. Only 37 patients have no medical problems. 98 suffered from hypertension and 10 of them needed further adjustment of their treatment. Out of 27 patients who had coronary artery disease, 12 referred to a cardiologist. All of the 12 patients with various heart problems needed further assessment. Readjustment of their treatment needed 3 out 15 diabetic patients. 1 out of the 8 patients with rheumatoid arthritis 1 needed reevaluation and 1 out 19 who suffered from various diseases 1 needed reassessment (Renal failure). Statistically 39 out of 208 had problems p< 0.001. The anaesthetic assessment contributes to 1.Reduction of cancellations due to medical reasons. 2. Effective use of the theatre time. 3. Reduction of cost

1. There seem to be two distinct methods of destruction of the foot, once pain sensibility has been lost: the first is a slow erosion and shortening associated with perforating ulcers under the distal weight-bearing end of the foot. The second is a proximal disintegration of the tarsus in which mechanical forces often determine onset and progress of the condition. 2. Once the tarsus begins to disintegrate it is difficult to halt the rapid destruction of the foot. 3. It is possible to detect early stages of this condition in time to take preventive measures. Routine palpation of anaesthetic feet will reveal patches of warmth localised to bones and joints which are in a condition of strain. Radiographs of such feet and a study of posture and gait may define early changes which point to one of several possible patterns of disintegration which may follow. 4. These patterns are described and discussed and suggestions made for preventive and corrective measures

Introduction: Many patients admitted to acute fracture units with femoral neck fractures are frail and elderly, dehydrated and malnourished, often with associated medical conditions. Surgery may be delayed for investigation, prolonged management and inadequate review of their medical problems, leading to clinical deterioration with poor outcome. Local anaesthetic techniques have been described for intracapsular fractures. We describe a technique effective for the treatment of the more difficult extracapsular type. Aims: To provide a safe and effective technique using local anaesthetic and sedation, for the insertion of a dynamic hip screw in high risk elderly patients with extracapsular femoral neck fractures. Method: Fifty elderly patients who sustained an inter-trochanteric fracture of their femoral neck underwent dynamic hip screw insertion under local anaesthetic and sedation. These patients were medically assessed following admission, all were ASA grade 4, had an additional medical condition (recent MI, CVA, chest infection, aortic stenosis) and were deemed unfit for either general or spinal anaesthesia. All patients not fit for traditional anaesthetic methods were assessed for their suitability for operation under LA, consented and placed on the next available theatre list. A femoral nerve block was performed, with the aid of a nerve stimulator for accurate location, in the anaesthetic room; skin and periosteal infiltration was performed using a 22g spinal needle, with caution to include the distribution of the lateral cutaneous nerve. The patient was then placed on the fracture table and mild sedation (Ketamine, Diazemul, 02/N20) was administered, titrated against the patients requirements. The fracture was reduced using traction and internal rotation, and the DHS inserted. Local Anaesthetic:Infiltration; * 20mls O.25% marcaine/1 in 200,000 adrenaline diluted to 40mls with sterile water. (30mls used with 10mls reserved) * 20mls 1% lidocaine diluted in 40mls of sterile water. (10mls used for skin). Local Anaesthetic femoral nerve block; * 10mls 0.25% plain marcaine. The combined amount of local anaesthetic used is well below safe limits recommended by the World Federation of Societies of Anaesthesiologists. Conclusion: This technique is a safe, simple and effective method of allowing high risk, medically unfit patients to undergo surgery. It reduces operative bleeding and postoperative analgesia requirements, no peri-operative deaths occurred and one patient had evidence of post operative tachycardia that settled within 12 hours

Background. Total hip replacement (THR) and total knee replacement (TKR) are usually effective at relieving pain; however, 7–23% of patients experience chronic post-surgical pain. These trials aimed to investigate the effect of local anaesthetic wound infiltration on pain severity at 12 months after primary THR or TKR for osteoarthritis. Methods. Between November 2009 and February 2012, 322 patients listed for THR and 316 listed for TKR were recruited into a single-centre double-blind randomised controlled trial. Participants were randomly assigned (1:1) to receive local anaesthetic infiltration and standard care or standard care alone. Participants and outcomes assessors were masked to group allocation. The primary outcome was pain severity on the WOMAC Pain scale at 12 months post-surgery. Analyses were conducted using intention-to-treat and per-protocol approaches. Ethics approval was obtained from Southampton and South West Hampshire Research Ethics Committee. Results. In the hip trial, patients in the intervention group had significantly less pain at 12 months post-operative than patients in the standard care group (differences in means 4.74; 95% CI 0.95, 8.54; p=0.015), although the difference was not clinically significant. Post-hoc analysis found that patients in the intervention group were more likely to have none to moderate pain than severe pain at 12 months than those in the standard care group (odds ratio 10.19; 95% CI 2.10, 49.55; p=0.004). In the knee trial, there was no strong evidence that the intervention influenced pain severity at 12 months post-operative (difference in means 3.83; 95% CI −0.83, 8.49; p=0.107). Conclusions. In conclusion, routine use of infiltration could be beneficial in improving long-term pain relief for some patients after THR. Level of evidence. Randomised controlled trial. Funding. This article presents independent research funded by the National Institute for Health Research (NIHR) in England under its Programme Grants for Applied Research programme (RP-PG-0407-10070). The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The research team acknowledge the support of the NIHR, through the Comprehensive Clinical Research Network

Introduction. Pneumatic tourniquets (PTs) are commonly used in local anaesthetic cases in the upper limb to provide a bloodless operating field. They give excellent efficacy however their limitations have prompted the introduction of a new single-use sterile silicone ring tourniquet (SRT). The evidence of use of the SRT over the standard PT is limited. Aim. To compare the level of perceived pain, and therefore tolerance, of the Silicone Ring and Pneumatic tourniquets when applied to the upper arm and to evaluate whether there was a clear benefit of use of either tourniquet in local anaesthetic procedures of the upper limb. Materials and methods. 30 volunteers, 15 male and 15 female, with a median age of 42 were recruited to compare the two tourniquets. Pain was measured using a VAS pain scale on application and at 1, 5 and 10 minutes. Results. Volunteers experienced significantly more pain on application and at 1 and 5 minutes with the SRT. This difference in pain perceived was most marked upon application. Two volunteers could not tolerate application of the SRT. Three volunteers experienced bruising of the arm and/or forearm following use of the SRT. There was no difference in pain scores at 10 minutes. Conclusion. Due to the severe pain experienced on application of the SRT it would not be suitable for local anaesthetic procedures in the upper limb. In addition the degree of pain may reduce the patients confidence and adversely affect their experience of the procedure. The PT is more suitable for local procedures. However the SRT may have a role in procedures performed under general anaesthetic

Anterior cruciate ligament reconstruction has been traditionally performed as an inpatient due to post-operative analgesic requirements. Increased patient demands and pressures of bed shortages have led to the development of day case surgery. Day case anterior cruciate ligament (ACL) reconstruction surgery using an analgesic pump was assessed. 24 consecutive ACL reconstructions using arthroscopic hamstring technique were performed as day case procedures. All received a standard anaesthetic of propofol, fentanyl, tenoxicam, and morphine. And an intra-articular administration of 10mls 0. 75% Ropivicaine Hydrochloride at the end of surgery. 0. 2% Ropivicaine at a rate of 2mls/hr was infused over 48hrs using a compression spring infusion pump (Pain Control Infusion Pump – Sgarlato Labs) via an intraarticular catheter. Post operative pain was assessed by a Visual Analogue Score (VAS) recorded by the patient onto an unmarked 1 Ocin line (0 – no pain ; 1 0 – maximum pain). For the 48hrs the pump was infusing the average VAS was 2. 7 with minimal additional analgesia required. Following pump removal by a District Nurse, the average VAS score was 1. 9 with similar analgesia requirements. All patients were satisfied with their care; none had problems related to the use of or removal of the pump; none required re-admission or review from their GP; or suffered post-operative complications. The cost for day case surgery was 260 (including theatre time; pump and drug costs; District Nurse costs) compared to 1072 for an average in-patient stay of 4 days (both exclude ACL specific implants, surgeon and anaesthetist costs). The intra-articular infusion of local anaesthetic has been shown to be well received by patients with no additional risks. It is an effective and cost-effective means of providing post-operative analgesia allowing day case ACL Reconstruction surgery to be performed. This study has demonstrated that there are no requirements for additional resources from primary care

Spinal anaesthetic (SA) with intrathecal diamorphine and general anaesthetic (GA) with blocks and/or patient control analgesia (PCA) are commonly used in hip and knee replacement surgery. Drop in blood pressure, feeling light-headed and drowsiness, itching are known early complications respectively. This causes delay in patient mobilization post operatively. Our study examines the use of a local anaesthetic infuser device (LAID) (pain buster pump) for post operative pain relief after total hip or knee replacement surgery. Forty six patients (25) THRs and (21) TKRs were included in this study. Each were given a LAID which consisted of 0.25% bupivicaine infused at 4ml/hr via an elastometric pump over 48 hours. 100mls of 0.1% bupivicaine with 0.5mg adrenaline was infiltrated locally into the wound at closure. All patients were prescribed regular analgesic as per the multimodal pain regime and an hourly pain score maintained. Rescue opioids were prescribed if pain score crossed 5. Patient satisfaction score was recorded as excellent, some or no pain relief. Eleven patients were given general anaesthetic and 25 patients were given spinal anaesthetic. 26% were able to sit out of bed within 6 hours of surgery and 65% (30 patients) were sitting out by the first post operative day. Average length of stay was 6.15 days, decreased to 4 days for patients mobilised on day zero and compared to eight days prior to this study. 21% had excellent result, 29% had some pain and 6% had poor result. 90% needed oral rescue analgesia within the first 48 hours. LAID allowed some patients to be mobilised within 6 hours of surgery. The use of LAID helps avoids the need for PCA or diamorphine and hence its associated complications though some amount of oral rescue analgesia was necessary. Patient compliance was satisfactory. The early results are encouraging and further studies are been conducted at our hospital

Urinary catheterization in the postoperative period is known to increase the risk of deep joint infection following arthroplasty. A number of studies have attempted to elucidate the individual patient factors and surgical procedural factors which predispose patients to postoperative urinary retention. We conducted a retrospective observational study of three hundred patients to specifically determine the effect of the anaesthetic technique on the incidence of urinary retention following elective lower limb arthroplasty. One hundred consecutive patients were surveyed in each of three groups differing by the type of the anaesthetic technique and the drug administered; 1) general anaesthesia with femoral nerve block, 2) spinal anaesthesia with intrathecal fentanyl, and 3) spinal anaesthesia with intrathecal morphine. The incidence of urinary retention requiring catheterisation in male patients receiving intrathecal morphine was 58% compared with 10% and 6% for those who had general anaesthesia with femoral nerve block and intrathecal fentanyl, respectively. This difference was statistically significant (p<0.01). The incidence of urinary retention in females across all groups was =2%. The average residual volume of urine following catheterisation was 750ml (460-1500ml). Our findings show that the use of intrathecal morphine greatly increases the risk of postoperative urinary retention in male patients, whereas no significant increase was found amongst female patients. This risk should be carefully considered when choosing the type of intraoperative anaesthetic/analgesic combination employed in male patients and be rationalised against the intended benefits to the patient

Introduction. It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinico-radiological features and concomitant hip and lumbar spine arthritis. It has been hypothesized that an anaesthetic hip arthrogram can help identify the source of pain in these cases. The purpose of this study is to analyze our experience with this technique in order to verify its accuracy. Methods. We undertook a retrospective analysis of 204 patients who underwent a hip anesthetic-steroid arthrogram for diagnostic purposes matching our inclusion criteria. Patient charts were scrutinized carefully for outcomes of arthrogram and treatment. Harris Hip Score was used to quantify outcome. Results. The results show that out of 204, 162 patients had positive and 42 had negative response to arthrogram. Of the positive responders (N=162), 76 underwent uncemented Total Hip Arthroplasty (THA), all with good results, and the rest are being treated conservatively. From the negative responder group (N=42), 33 were successfully treated for spinal and other disorders, 8 underwent successful THA and 1 had an unsuccessful THA. Conclusion. Our findings suggest that the relief of symptoms following instillation of local anaesthetic and steroid into the hip joint has a positive predictive value and specificity of 100%, sensitivity of 95% and negative predictive value of 89.5%. We thereby believe that this is useful and reliable test with low morbidity for distinguishing between pain arising from the hip and other sources and can predict the potential benefit of THA in this diagnostic challenging group of patients

STUDY PURPOSES. To evaluate the role of “top up” intra-articular local anaesthetic injection in patients who have had UKR. METHOD AND RESULTS. 43 patients scheduled to have a cemented Oxford UKR were prospectively recruited and randomised. All patients had the same initial anaesthetic regime of general anaesthesia, femoral nerve block and intra-operative intra-articular infiltration. All patients had a multi-holed epidural catheter placed intra-articularly prior to wound closure. Patients had the same operative technique, post operative rehabilitation and rescue analgesia. An independent, blinded observer recorded post-operative pain scores using a visual analogue score every 6 hours and any rescue analgesia. On the morning after surgery, 22 patients, (Group I), received 20 mls of 0.5% bupivicaine through the catheter whilst 21, (Group II), patients had 20 mls of normal saline by the same observer, after which the catheter was removed. No statistical difference was found in pain scores on the day of operation between the groups. However, patients in Group I had a significantly better pain score initially post top up and at 6 hours (2.4 (0-8) vs 5.7 (2-9), p<0.001). This cohort of patients required less rescue analgesia (p<0.001). In addition, Group I had statistically significant higher patient satisfaction outcome scores after the infiltration, (p<0.001). CONCLUSION. Our study has shown that injection of local anaesthesia via an intra-articular catheter does reduce pain scores when compared to placebo. This implies that this technique may have a role in providing optimal pain relief after UKR

Introduction. The peri-operative analgesic management of patients having either Total Knee Replacement (TKR) or Unicompartmental Knee Replacement (UKR) is an area that continues to have prominence, driven in part by the desire to reduce hospital stay, while maintaining high patient satisfaction. This is particularly relevant in the current climate of healthcare cost savings. We evaluated the role of “top up” intra-articular local anaesthetic injection after identifying that an appreciable number of patients in the unit suffered “breakthrough pain” on the first post-op day, when the effects of local analgesia are wearing off. Method. 43 patients, who were scheduled to have a cemented Oxford UKR, were prospectively recruited and randomised. All patients had the same initial anaesthetic regime of general anaesthesia, femoral nerve block and intra-operative intra-articular infiltration of the cocktail. All patients had a 16G multi-holed epidural catheter placed intra-articularly prior to wound closure. Patients had the same operative technique, post operative rehabilitation and rescue analgesia. An independent observer recorded post-operative pain scores using a visual analogue score (1–10) every 6 hours and any rescue analgesia that was required. On the morning after surgery, 22 patients, (Group I), received 20 mls of 0.5% bupivicaine through the catheter whilst 21 patients, (Group II), had 20 mls of normal saline by the same observer, (who was blinded to the contents of the solution being injected), after which the catheter was removed. Results. When comparing these two groups there was no statistical difference found in their pain scores on the day of operation. However, patients in Group I had a significantly better pain score initially post top up and then at 6 hours (2.4 (0–8) vs 5.7 (2–9), Mann-Whitney p<0.001). This cohort of patients required less rescue analgesia (22% vs 75%, Mann-Whitney p<0.001). In addition, Group I had statistically significant higher patient satisfaction outcome scores after the infiltration, (p<0.001), with 16 reporting very good satisfaction in comparison to 1 in Group II. There were no complications in either group. Discussion. Our study has shown that injection of local anaesthesia via an intra-articular catheter does reduce pain scores when compared to placebo. This implies that this technique may have a role in providing optimal pain relief after UKR

Seven subjects with normal joints were tested for active and passive position sense of ankle inversion, peroneal reflex reaction time to sudden ankle inversion, and postural stability during single-leg stance. The tests were performed before and after regional block of the ankle and foot with local anaesthetic. Passive position sense, assessed with the muscles relaxed, was greatly impaired by anaesthesia but active position sense, with the calf muscles activated, was preserved, and the peroneal reaction time to sudden ankle inversion was not altered. The magnitude of postural sway during single-leg stance was also unchanged by anaesthesia of the ankle and foot. The results suggest that the afferent input from intact lateral ankle ligaments is important in sensing correct placement of the foot at heel-strike, but that this input can be replaced by afferent information from active calf muscles. Afferent input from these muscles seems also to be responsible for dynamic ankle protection against sudden ankle inversion and is adequate to allow stable single-leg stance

Purpose: Single anesthetic bilateral total knee arthroplasty (SABTKA) is a controversial procedure with a questionable safety profile. The purpose of this study was to determine if specific, individual preoperative medical co-morbidities can predict perioperative complications in patients undergoing SABTKA. Method: The records of all SABTKA performed between 1997 and 2007 at 1 large community hospital and 1 academic, university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities (cardiovascular disease, COPD, diabetes, and hypertension), and perioperative complications for 156 patients were collected and analyzed using logistic multivariate regression analysis. Comparison was made to an age, gender, and co-morbidity matched cohort of patients treated with unilateral TKA. Results: In the SABTKA group only 11% of patients had a preoperative history of cardiovascular disease yet 89% of all post operative myocardial infarctions (MI) occurred in this population (p< 0.001, Odds Ratio 57.8). Cardiovascular disease also predicted need for admission to ICU (p< 0.001, Odds Ratio 50.8), and number of days spent in the ICU (p< 0.001). In those patients without preoperative cardiovascular disease or COPD the rate of MI was only 0.64%. All differences were significant when compared to the matched unilateral TKA cohort. Age, gender, diabetes, and hypertension did not predict perioperative complications in the SABTKA cohort. Conclusion: The literature indicates there are certain populations of patients at higher risk for perioperative complications after SABTKA. This study clearly identifies a subpopulation of patients that have cardiovascular disease and are at an unacceptably high risk of perioperative MI. Cardiovascular disease should likely be considered an absolute contraindication to SABTKA

Purpose. To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure. Methods. We prospectively analysed all patients who required MUA post TKA performed by 2 surgeons using the same prosthesis from 2003 to 2008 and compared them to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. In addition risk factors were identified including warfarin and statin use, diabetes and body mass index. Results. Seventy-two patients required an MUA out of 1313 TKAs (5.5%) and were compared to a control group of 50 patients. The mean arc of motion preoperatively was 89.0° (MUA group) vs 92.2° (control) (p=0.47), at discharge 71.0° vs 76.8° (p<0.05) and 6 weeks follow-up 64.0° vs 97.3° (p<0.0001). Post manipulation the mean arc of motion was 108° on table, 83.1° at 3 months follow-up and 81.9° at 12 months. Patients whose manipulation was within 3 months of TKA (23 patients) improved their mean arc of motion from 53.6° to 78.0° (p<0.0025), those 3-12 months (42 patients) from 67° to 83.0° (p<0.0001) and those >12 months (7 patients) 81° to 89° (p=0.32). Mean increase of extension was 3.7° on table and 3.6° at 12 months. Mean flexion increase was 40.5° on table and 15.7° at 12 months. The relative risk factor for requiring an MUA was 6.97 warfarin (p<0.05), 1.58 statins, 2.85 diabetes and 1.17 obesity. Conclusions. MUA for patients with stiffness after primary TKA improves their range of motion if done within 12 months, however only 40% flexion improvement is maintained. Patients who will require an MUA have a reduced motion at discharge. Patients on warfarin therapy are more likely to get stiffness

Aim: This study aimed at investigating the diagnostic value of local anaesthetic hip injection test to differentiate between hip and spinal pain in patients presenting with symptoms attributable to both hip and spine pathology. Study design: Prospective cohort. Materials and Methods: 48 patients with such diagnostic dilemma under one the care of one spinal surgeon in one centre were carefully selected. All patients had radiographs of the hip joint confirming varying degrees of osteoarthritis. Most of the patients also had different types of spinal imaging showing degenerative spinal changes. The hip injection test involved intraarticular injection of 0.5% Bupivacaine under strict aseptic precautions in a laminar airflow theatre under fluoroscopic control. Results: 37 patients had a significant relief of pain to the injection. Of these, 33 (89%) underwent successful total hip replacement with relief of pain. The patients with a negative response to the test responded satisfactorily to treatment directed towards their spinal pathology. The sensitivity of this test is at least 97% and specificity 90%. These results are similar to those of previous studies on this topic. Conclusion: Local anaesthetic hip injection test is a safe, inexpensive and reliable diagnostic tool in identifying the source of the pain in patients with attributable dual pathology

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail. We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy. Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation. This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group

Purpose. To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure. Methods. Prospective analysis of patients who required MUA post TKA performed by two surgeons using the same prosthesis from 2003 to 2008. Compared to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. Risk factors were identified including warfarin and statin use, diabetes and body mass index. Results. Seventy-two patients required an MUA out of 1313 TKAs (5.5%) compared to a control group of 50 patients. The mean arc of motion preoperatively was 89.0° (MUA group) vs 92.2° (control) (p=0.47), at discharge 71.0° vs 76.8° (p< 0.05) and 6 weeks follow-up 64.0° vs 97.3° (p< 0.0001). Post manipulation the mean arc of motion was 108° on table, 83.1° at 3 months follow-up and 81.9° at 12 months. Patients whose manipulation was within 3 months of TKA (23 patients) improved their mean arc of motion from 53.6° to 78.0° (p< 0.0025), those 3–12 months (42 patients) from 67° to 83.0° (p< 0.0001) and those >12 months (7 patients) 81° to 89° (p=0.32). Mean increase of extension was 3.7° on table and 3.6° at 12 months. Mean flexion increase was 40.5° on table and 15.7° at 12 months. The relative risk factor for requiring an MUA was 6.97 warfarin (p< 0.05), 1.58 statins, 2.85 diabetes and 1.17 obesity. Conclusions. MUA following primary TKA improves their range of motion if done within 12 months, however only 50% improvement is maintained. Patients with less than 75° flexion at discharge or those on warfarin therapy are likely to require a manipulation to improve their range of movement

Abstract

Background. The Arthroplasty Pain Experience (APEX) studies are two randomised controlled trials in primary total hip (THR) and knee replacement (TKR) at a large UK orthopaedics centre. APEX investigated the effect of local anaesthetic wound infiltration (LAI), administered before wound closure, in addition to standard analgesia, on pain severity at 12 months. This abstract reports results of the within-trial economic evaluations. Methods. Cost-effectiveness was assessed from the health and social care payer perspective in relation to quality adjusted life years (QALYs). Resource use was collected from hospital records and patient-completed postal questionnaires, and valued using unit cost estimates from local NHS Trust and national tariffs. Missing data were imputed using chained equations. Costs and outcomes were compared per trial arm and plotted in cost-effectiveness planes. The economic results were bootstrapped incremental net monetary benefit statistics (INMB) and cost-effectiveness acceptability curves. One-way deterministic sensitivity analyses explored any methodological uncertainty. Results. In both trials, LAI was cost-saving and more effective than standard care. Using the £20,000 per QALY threshold, in THR, the INMB was £1,125 (95%BCI, £183 to £2,067) and the probability of being cost-effective was over 98%. In TKR, the INMB was £264 (95%BCI, −£710 to £1,238), with only 62% probability of being cost-effective. Considering an NHS perspective only, LAI was no longer dominant in THR, but still highly cost-effective, with an INMB of £961 (95%BCI, £50 to £1,873). Conclusions. Administering LAI is a cost-effective treatment option in THR and TKR surgeries. The evidence is stronger for THR, because of larger QALY gain. In TKR, there is more uncertainty around the economic result, and smaller QALY gains, but results point to LAI being cheaper than standard analgesia, which includes a femoral nerve block. Trial Registration. ISRCTN96095682, 29/04/2010. Funding. NIHR Programme Grant for Applied Research RP-PG-0407-10070

Introduction. The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically. Methods. Patients attending a designated shoulder clinic and diagnosed by an experienced shoulder surgeon as having a SAIS between January 2009 and December 2011 were considered for inclusion in the study. 67 of 86 patients screened completed the study (3 did not meet inclusion criteria; 9 declined to participate; 3 lost to follow-up; 4 developed frozen shoulder syndrome). Each patient had a pre-injection Oxford Shoulder Score (OSS) and was given one subacromial injection of 10ml 0.25% levobupivacaine(Chirocaine) + 40 mg triamcinolone(Kenalog) through the posterior route. Radiograph imaging was also assessed. Follow-up was carried out at 6 to 12 weeks post injection when OSS was repeated. A 6 month follow-up assessment to assess if the patient's improvement in functionality and absence of symptoms indicated that a subacromial decompression operation was not necessary. The percentage of patients showing improvement in OSS was calculated and the difference in OSS pre- and post-injection assessed using a Wilcoxon Signed Rank test. Results. The median OSS pre-injection was 29 (range 2–43) and post-injection was 40 (range 2–48) (p=< 0.001; z=−6.0; r=−0.5). 45/69 (71%) of patients benefited significantly from subacromial injection at 6 to 12 weeks post-injection. However only 28/53 (53%) benefited significantly from injection by 6 months post-injection. These results support the continued use of sub-acromial corticosteroid injections in the treatment of SAIS. 31% of these patients were subsequently treated with an arthroscopic subacromial decompression operation. Previous injection history had no impact on the results. Conclusions. We recommend that all patients with SAIS should be offered at least one subacromial injection before being considered for an arthroscopic subacromial decompression operation

Objective The hypothesis of this study is that the flexibility of idiopathic scoliosis curves as measured by traction radiography performed under general anaesthetic (TUA) will be superior to supine bending radiography. Subsequently, this may aid in determining the surgical approach, sparing patients anterior release surgery, and show greater correlation with the postoperative result. This is a new technique, not previously reported in the literature. Design A prospective comparison between TUA and supine bending radiography to determine curve flexibility, and examine their relationship with anterior release surgery and postoperative correction. Subjects This study was based on 21 patients with a diagnosis of idiopathic scoliosis, admitted for corrective surgery at our unit. Outcome measures The amount of correction achieved by each of the two methods on the preoperative curve was examined using a paired t-test. The influence of the TUA on the decision for anterior release surgery was noted, along with the correlation of each method with postoperative correction. Results On statistical analysis with a paired t-test, TUA showed significantly greater curve flexibility than that shown by supine bending radiographs (p< 0.001) irrespective of curve classification or magnitude. Of the 11 patients planned for anterior release surgery with posterior fusion, the use of TUA obviated this in 9 (82%) by demonstrating greater preoperative curve flexibility. Excluding thoracolumbar curves, TUA showed significantly greater postoperative correlation than supine bending radiography (R=0.79, R=0.61 respectively). Conclusion In our unit, traction radiography performed under general anaesthetic is superior to supine bending radiography in assessing curve mobility prior to surgery. Performing TUA has significant benefits to patients in avoiding unnecessary anterior release surgery, and has greater correlation with postoperative correction. In studying fulcrum bending radiographs, Cheung. 1. showed similar benefits in avoiding anterior release and we therefore recommend the use of these methods by other institutions

Intra-operative infiltration of local anaesthetic into peri-operative tissue has become part of the protocol of many units worldwide. It is claimed that this reduces post operative pain and improves the speed of mobilisation thereby improving the comfort of the patient and decreasing the hospital stay. In order to test the validity of this concept we conducted a prospective randomised controlled clinical trial of 100 patients undergoing primary total hip arthroplasty or hip resurfacing. All procedures were performed by one surgeon (Miss Muirhead-Allwood) using a posterior-lateral approach. Patients were randomised to receive 30ml of 0.5% Marcaine injected under direct vision at the time of closure or no injection (placebo). Post-operatively patients in both groups received a standardised regime of intravenous infusion of diclofenac for 48 hours and ‘rescue’ intramuscular injections of morphine on demand. Patients’ pain levels post-operatively were independently recorded using both a verbal rating score (VRS) and a visual analogue scale (VAS) at regular intervals for the first five post-operative days. Periodicity of requests for opiate analgesia was documented. Time taken to reach mobility ‘goals’ were also documented as was time taken to discharge and patient satisfaction with the whole process. Our results show no significant difference in the two groups previously defined and we suggest that routine use of intracapsular local anaesthetic is not indicated in primary hip replacements and surface replacements provided an adequate post-operative pain regime is already in use

Introduction: Carpal tunnel decompression is the most commonly performed procedure in hand surgery. This study was done to assess the effectiveness and acceptability by patients of open carpal tunnel release under local anaesthetic and compare our results with previous published work from our department following alterations to our operative techniques. Methods: 92 carpal tunnel releases were performed on 80 patients over a four year period, 2001 to 2004. 55 were females and 25 were males. A patient satisfaction survey was done by a postal questionnaire which addressed opinion regarding preference for LA over GA, pain due to LA infiltration, effectiveness of LA, patient comfort during surgery, outcome of surgery and overall satisfaction with the procedure. In this cohort of patients we did not use a tourniquet which caused severe pain in 29% of cases in the previous study. We also administered LA with adrenaline using a dental syringe to reduce pain which was previously reported as severe in 20% of cases. Results: 62 patients replied to the questionnaire, a response rate of 77.5%. Preference for LA over GA was 90% as compared to 70% in the previous study. Pain due to tourniquet use was previously reported as severe in 29% of cases but this did not apply in this subset of patients. Pain due to infiltration of LA with a dental syringe was severe in 9% of cases compared to 20% with a 25G needle. Effectiveness of LA, outcome of surgery and overall satisfaction with the procedure remained unchanged. Conclusion: Carpal tunnel decompression is a quick, convenient, inexpensive and safe method of treatment. We have demonstrated that injecting LA with adrenaline using a dental syringe obviates the need for tourniquet and improves patients’ acceptability and tolerance of this procedure

Manipulation under anaesthetic (MUA) is an established treatment for frozen shoulder. Frozen shoulder may coexist with other shoulder conditions, whose treatment may differ from MUA. One such condition is calcific tendonitis. Only one study to date documents treatment of patients with frozen shoulder and concurrent calcific tendinitis. The objective was to demonstrate that MUA and injection is a satisfactory treatment for concurrent diagnosis of frozen shoulder and calcific tendinitis. Patients with a clinical diagnosis of frozen shoulder and radiological evidence of calcific tendinitis were prospectively recruited from Jan 1999 – Jan 2009. Treatment by MUA and injection was performed. Clinical examination, Oxford Shoulder Scores and need for further treatment were used as outcome measures. Fourteen patients (median age 53.5 years) were identified with frozen shoulder and concurrent calcific tendinitis. Significant improvement in both Oxford Shoulder Score and range of movement was achieved following MUA (P values < 0.001). Two patients required further treatment (not for calcific tendinitis). This improvement was maintained in the long term (median 107 wks). It is our belief that MUA and injection is a safe and effective treatment, addressing the frozen shoulder with MUA takes priority, and as such frozen shoulder “trumps” other pathologies occurring simultaneously

With the aim of controlling pain after Keller's operation, a solution of a long-acting local anaesthetic was instilled into the field before closure in a series of thirty patients. In a controlled prospective trial this simple technique by itself proved to be significantly better than either foot block at the ankle or the usual analgesics and was free from local or systemic complications

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

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total hip replacement (THR). We assessed the effectiveness of LAI using a systematic review and a fully powered randomised controlled trial (RCT) with economic evaluation. We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving THR. Two reviewers screened abstracts, extracted data, and liaised with authors. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. If feasible, we conducted meta-analysis. In the APEX RCT, we randomised 322 patients awaiting THR to receive additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline) or standard anaesthesia alone. Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation. Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires. In the systematic review, we identified 13 studies (909 patients). Patients undergoing THR receiving LAI experienced greater pain reduction at 24 hours at rest, standardised mean difference (SMD) −0.61 (95%CI −1.05, −0.16; p=0.008) and at 48 hours during activity, SMD −0.43 (95%CI −0.78, −0.09; p=0.014). Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Long-term outcomes were not a focus of these studies. In the APEX RCT, pain levels in hospital were broadly similar between groups, probably due to patient-controlled analgesia. Opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. Patients receiving LAI were less likely to report severe pain at 12 months than those receiving standard care, odds ratio 10.2 (95%CI 2.1, 49.6; p=0.004). Complications were similar between groups. In the economic evaluation, LAI was associated with lower costs and greater cost-effectiveness than standard care. Using a £20,000 per QALY threshold, the incremental net monetary benefit was £1,125 (95%CI £183, £2,067) and the probability of being cost-effective was greater than 98 %. The evidence suggests that peri-operative LAI is a cost-effective intervention for reducing acute and chronic post-surgical pain after THR

Robust evidence on the effectiveness of peri-operative local anaesthetic infiltration (LAI) is required before it is incorporated into the pain management regimen for patients receiving total knee replacement (TKR). To assess the effectiveness of peri-operative LAI for pain management in patients receiving TKR we conducted a systematic review, fully powered randomised controlled trial (RCT) and economic evaluation. We searched MEDLINE, Embase and Cochrane databases for RCTs of peri-operative LAI in patients receiving TKR. Two reviewers screened abstracts and extracted data. Outcomes were pain, opioid use, mobilisation, hospital stay and complications. Authors were contacted if required. When feasible, we conducted meta-analysis with studies analysed separately if a femoral nerve block (FNB) was provided. In the APEX RCT, we randomised 316 patients awaiting TKR to standard anaesthesia which included FNB, or to the same regimen with additional peri-operative LAI (60mls 0.25% bupivacaine plus adrenaline). Post-operatively, all patients received patient-controlled morphine. The primary outcome was joint pain severity (WOMAC-Pain) at 12 months. Patients and outcome assessors were blinded to allocation. Within APEX, cost-effectiveness was assessed from the health and social-care perspective in relation to quality adjusted life years (QALYs) and WOMAC-Pain at 12-months. Resource use was collected from hospital records and patient questionnaires. In the systematic review, 23 studies including 1,439 patients were identified. Compared with patients receiving no intervention, LAI reduced WOMAC-Pain by standardised mean difference (SMD) −0.40 (95%CI −0.58, −0.22; p<0.001) at 24 hours at rest and by SMD −0.27 (95%CI −0.50, −0.05; p=0.018) at 48 hours during activity. In three studies there was no difference in pain at any time point between randomised groups where all patients received FNB. Patients receiving LAI spent fewer days in hospital, used less opioids and mobilised earlier. Complications were similar between groups. Few studies reported long-term outcomes. In the APEX RCT, pain levels in hospital were broadly similar between groups. Overall opioid use was similar between groups. Time to mobilisation and discharge were largely dependent on local protocols and did not differ between groups. There were no differences in pain outcomes between groups at 12 months. In the economic evaluation, LAI was marginally associated with lower costs. Using the NICE £20,000 per QALY threshold, the incremental net monetary benefit was £264 (95%CI, −£710, £1,238) and the probability of being cost-effective was 62%. Although LAI appeared to have some benefit for reduced pain in hospital after TKR there was no evidence of pain control additional to that provided by femoral nerve block, however it would be cost-effective at the current NICE thresholds

The purpose of this study was to compare clinical outcomes of total knee arthroplasty (TKA) after manipulation under anaesthesia (MUA) for post-operative stiffness with a matched cohort of TKA patients who did not requre MUA.

In total 72 patients (mean age 59.8 years, 42 to 83) who underwent MUA following TKA were identified from our prospective database and compared with a matched cohort of patients who had undergone TKA without subsequent MUA. Patients were evaluated for range of movement (ROM) and clinical outcome scores (Western Ontario and McMaster Universities Arthritis Index, Short-Form Health Survey, and Knee Society Clinical Rating System) at a mean follow-up of 36.4 months (12 to 120). MUA took place at a mean of nine weeks (5 to 18) after TKA. In patients who required MUA, mean flexion deformity improved from 10° (0° to 25°) to 4.4° (0° to 15°) (p < 0.001), and mean range of flexion improved from 79.8° (65° to 95°) to 116° (80° to 130°) (p < 0.001). There were no statistically significant differences in ROM or functional outcome scores at three months, one year, or two years between those who required MUA and those who did not. There were no complications associated with manipulation.

At most recent follow-up, patients requiring MUA achieved equivalent ROM and clinical outcome scores when compared with a matched control group. While other studies have focused on ROM after manipulation, the current study adds to current literature by supplementing this with functional outcome scores.

Cite this article: Bone Joint J 2015;97-B:1640–4.

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.

This in vivo controlled laboratory study was performed to evaluate various intra-articular clinical injection regimes that might be less toxic than some in vitro studies suggest. We hypothesised that low-concentration, preservative-free, pH-balanced agents would be less toxic than high-concentration non-pH-balanced agents with preservatives, and that injections of individual agents are less toxic than combined injections. The left knees of 12- to 13-week-old Sprague–Dawley rats were injected once with eight different single agents, including low and high concentrations of ropivacaine and triamcinolone, alone and in combination, as well as negative and positive controls. The rats were killed at one week or five months, and live–dead staining was performed to quantify the death of chondrocytes. All injections except pH-balanced 0.2% ropivacaine combined with preservative-free 1 mg/ml triamcinolone acetonide resulted in statistically significant decreases in chondrocyte viability, compared with control knees, after one week and five months (p < 0.001). After one week there was no significant difference in viability between 0.2% and 0.5% ropivacaine; however, 4 mg/ml triamcinolone resulted in a lower viability than 1 mg/ml triamcinolone.

Although many agents commonly injected into joints are chondrotoxic, in this in vivo study diluting preservative-free 10 mg/ml triamcinolone 1:9 in 0.2% pH-balanced ropivacaine resulted in low toxicity.

Cite this article: Bone Joint J 2015; 97-B:933–8.

Aims. The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources. Methods. Day-case TKAs, defined as patients discharged on the same calendar day as surgery, were retrospectively reviewed with a minimum follow-up of six months. Analysis of hospital and primary care records was performed to determine readmission and reattendance rates. Telephone interviews were conducted to determine patient satisfaction. Results. Since 2016, 301/7350 TKAs (4.1%) in 290 patients at our institution were discharged on the day of surgery. Mean follow-up was 31.4 months (6.2 to 70.0). In all, 28 patients (9.3%) attended the emergency department or other acute care settings within 90 days of surgery, most often with wound concerns or leg swelling; six patients (2.0%) were readmitted. No patients underwent a subsequent revision procedure, and there were no periprosthetic infections. Two patients (0.7%) underwent secondary patella resurfacing, and one patient underwent arthroscopic arthrolysis after previous manipulation under anaesthetic (MUA). Three patients (1.0%) underwent MUA alone. Primary care consultation records, available for 206 patients, showed 16 patients (7.8%) contacted their general practitioner within two weeks postoperatively; two (1.0%) were referred to secondary care. Overall, 115/121 patients (95%) telephoned stated they would have day-case TKA again. Conclusion. Day-case TKA can be safely delivered in the NHS with no additional resources. We found low incidence of contact with primary and secondary care in the postoperative period, and high patient satisfaction. Cite this article: Bone Jt Open 2023;4(8):621–627

Aims. Postoperative length of stay (LOS) and discharge dispositions following arthroplasty can be used as surrogate measurements for improvements in patients’ pathways and costs. With the increasing use of robotic technology in arthroplasty, it is important to assess its impact on LOS. The aim of this study was to identify factors associated with decreased LOS following robotic arm-assisted total hip arthroplasty (RO THA) compared with the conventional technique (CO THA). Methods. This large-scale, single-institution study included 1,607 patients of any age who underwent 1,732 primary THAs for any indication between May 2019 and January 2023. The data which were collected included the demographics of the patients, LOS, type of anaesthetic, the need for treatment in a post-anaesthesia care unit (PACU), readmission within 30 days, and discharge disposition. Univariate and multivariate logistic regression models were used to identify factors and the characteristics of patients which were associated with delayed discharge. Results. The multivariate model identified that age, female sex, admission into a PACU, American Society of Anesthesiologists grade > II, and CO THA were associated with a significantly higher risk of a LOS of > two days. The median LOS was 54 hours (interquartile range (IQR) 34 to 78) in the RO THA group compared with 60 hours (IQR 51 to 100) in the CO THA group (p < 0.001). The discharge dispositions were comparable between the two groups. A higher proportion of patients undergoing CO THA required PACU admission postoperatively, although without reaching statistical significance (7.2% vs 5.2%, p = 0.238). Conclusion. We found that among other baseline characteristics and comorbidities, RO THA was associated with a significantly shorter LOS, with no difference in discharge destination. With the increasing demand for THA, these findings suggest that robotic assistance in THA could reduce costs. However, randomized controlled trials are required to investigate the cost-effectiveness of this technology. Cite this article: Bone Joint J 2024;106-B(3 Supple A):24–30

Aims. Management of displaced paediatric supracondylar elbow fractures remains widely debated and actual practice is unclear. This national trainee collaboration aimed to evaluate surgical and postoperative management of these injuries across the UK. Methods. This study was led by the South West Orthopaedic Research Division (SWORD) and performed by the Supra Man Collaborative. Displaced paediatric supracondylar elbow fractures undergoing surgery between 1 January 2019 and 31 December 2019 were retrospectively identified and their anonymized data were collected via Research Electronic Data Capture (REDCap). Results. A total of 972 patients were identified across 41 hospitals. Mean age at injury was 6.3 years (1 to 15), 504 were male (52%), 583 involved the left side (60%), and 538 were Gartland type 3 fractures (55%). Median time from injury to theatre was 16 hours (interquartile range (IQR) 6.6 to 22), 300 patients (31%) underwent surgery on the day of injury, and 91 (9%) underwent surgery between 10:00 pm and 8:00 am. Overall, 910 patients (94%) had Kirschner (K)-wire) fixation and these were left percutaneous in 869 (95%), while 62 patients (6%) had manipulation under anaesthetic (MUA) and casting. Crossed K-wire configuration was used as fixation in 544 cases (59.5%). Overall, 208 of the fixation cases (61%) performed or supervised by a paediatric orthopaedic consultant underwent lateral-only fixation, whereas 153 (27%) of the fixation cases performed or supervised by a non-paediatric orthopaedic consultant used lateral-only fixation. In total, 129 percutaneous wires (16%) were removed in theatre. Of the 341 percutaneous wire fixations performed or supervised by a paediatric orthopaedic consultant, 11 (3%) underwent wire removal in theatre, whereas 118 (22%) of the 528 percutaneous wire fixation cases performed or supervised by a non-paediatric orthopaedic consultant underwent wire removal in theatre. Four MUA patients (6%) and seven K-wire fixation patients (0.8%) required revision surgery within 30 days for displacement. Conclusion. The treatment of supracondylar elbow fractures in children varies across the UK. Patient cases where a paediatric orthopaedic consultant was involved had an increased tendency for lateral only K-wire fixation and for wire removal in clinic. Low rates of displacement requiring revision surgery were identified in all fixation configurations. Cite this article: Bone Joint J 2023;105-B(1):82–87

Aims. Historically, patients undergoing surgery for adolescent idiopathic scoliosis (AIS) have been nursed postoperatively in a critical care (CC) setting because of the challenges posed by prone positioning, extensive exposures, prolonged operating times, significant blood loss, major intraoperative fluid shifts, cardiopulmonary complications, and difficulty in postoperative pain management. The primary aim of this paper was to determine whether a scoring system, which uses Cobb angle, forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and number of levels to be fused, is a valid method of predicting the need for postoperative critical care in AIS patients who are to undergo scoliosis correction with posterior spinal fusion (PSF). Methods. We retrospectively reviewed all AIS patients who had undergone PSF between January 2018 and January 2020 in a specialist tertiary spinal referral centre. All patients were assessed preoperatively in an anaesthetic clinic. Postoperative care was defined as ward-based (WB) or critical care (CC), based on the preoperative FEV1, FVC, major curve Cobb angle, and the planned number of instrumented levels. Results. Overall, 105 patients were enrolled. Their mean age was 15.5 years (11 to 25) with a mean weight of 55 kg (35 to 103). The mean Cobb angle was 68° (38° to 122°). Of these, 38 patients were preoperatively scored to receive postoperative CC. However, only 19% of the cohort (20/105) actually needed CC-level support. Based on these figures, and an average paediatric intensive care unit stay of one day before stepdown to ward-based care, the potential cost-saving on the first postoperative night for this cohort was over £20,000. There was no statistically significant difference between the Total Pathway Score (TPS), the numerical representation of the four factors being assessed, and the actual level of care received (p = 0.052) or the American Society of Anesthesiologists grade (p = 0.187). Binary logistic regression analysis of the TPS variables showed that the preoperative Cobb angle was the only variable which significantly predicted the need for critical care. Conclusion. Most patients undergoing posterior fusion surgery for AIS do not need critical care. Of the readily available preoperative measures, the Cobb angle is the only predictor of the need for higher levels of care, and has a threshold value of 74.5°. Cite this article: Bone Joint J 2024;106-B(7):713–719

Aims. National hip fracture registries audit similar aspects of care but there is variation in the actual data collected; these differences restrict international comparison, benchmarking, and research. The Fragility Fracture Network (FFN) published a revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability. Our aim was to assess compatibility of existing registries with the MCD. Methods. We compared 17 hip fracture registries covering 20 countries (Argentina; Australia and New Zealand; China; Denmark; England, Wales, and Northern Ireland; Germany; Holland; Ireland; Japan; Mexico; Norway; Pakistan; the Philippines; Scotland; South Korea; Spain; and Sweden), setting each of these against the 20 core and 12 optional fields of the MCD. Results. The highest MCD adherence was demonstrated by the most recently established registries. The first-generation registries in Scandinavia collect data for 60% of MCD fields, second-generation registries (UK, other European, and Australia and New Zealand) collect for 75%, and third-generation registries collect data for 85% of MCD fields. Five of the 20 core fields were collected by all 17 registries (age; sex; surgery date/time of operation; surgery type; and death during acute admission). Two fields were collected by most (16/17; 94%) registries (date/time of presentation and American Society of Anesthesiologists grade), and five more by the majority (15/17; 88%) registries (type, side, and pathological nature of fracture; anaesthetic modality; and discharge destination). Three core fields were each collected by only 11/17 (65%) registries: prefracture mobility/activities of daily living; cognition on admission; and bone protection medication prescription. Conclusion. There is moderate but improving compatibility between existing registries and the FFN MCD, and its introduction in 2022 was associated with an improved level of adherence among the most recently established programmes. Greater interoperability could be facilitated by improving consistency of data collection relating to prefracture function, cognition, bone protection, and follow-up duration, and this could improve international collaborative benchmarking, research, and quality improvement. Cite this article: Bone Joint J 2023;105-B(9):1013–1019

Aims. Ankle fracture is one of the most common musculoskeletal injuries sustained in the UK. Many patients experience pain and physical impairment, with the consequences of the fracture and its management lasting for several months or even years. The broad aim of ankle fracture treatment is to maintain the alignment of the joint while the fracture heals, and to reduce the risks of problems, such as stiffness. More severe injuries to the ankle are routinely treated surgically. However, even with advances in surgery, there remains a risk of complications; for patients experiencing these, the associated loss of function and quality of life (Qol) is considerable. Non-surgical treatment is an alternative to surgery and involves applying a cast carefully shaped to the patient’s ankle to correct and maintain alignment of the joint with the key benefit being a reduction in the frequency of common complications of surgery. The main potential risk of non-surgical treatment is a loss of alignment with a consequent reduction in ankle function. This study aims to determine whether ankle function, four months after treatment, in patients with unstable ankle fractures treated with close contact casting is not worse than in those treated with surgical intervention, which is the current standard of care. Methods. This trial is a pragmatic, multicentre, randomized non-inferiority clinical trial with an embedded pilot, and with 12 months clinical follow-up and parallel economic analysis. A surveillance study using routinely collected data will be performed annually to five years post-treatment. Adult patients, aged 60 years and younger, with unstable ankle fractures will be identified in daily trauma meetings and fracture clinics and approached for recruitment prior to their treatment. Treatments will be performed in trauma units across the UK by a wide range of surgeons. Details of the surgical treatment, including how the operation is done, implant choice, and the recovery programme afterwards, will be at the discretion of the treating surgeon. The non-surgical treatment will be close-contact casting performed under anaesthetic, a technique which has gained in popularity since the publication of the Ankle Injury Management (AIM) trial. In all, 890 participants (445 per group) will be randomly allocated to surgical or non-surgical treatment. Data regarding ankle function, QoL, complications, and healthcare-related costs will be collected at eight weeks, four and 12 months, and then annually for five years following treatment. The primary outcome measure is patient-reported ankle function at four months from treatment. Anticipated impact. The 12-month results will be presented and published internationally. This is anticipated to be the only pragmatic trial reporting outcomes comparing surgical with non-surgical treatment in unstable ankle fractures in younger adults (aged 60 years and younger), and, as such, will inform the National Institute for Health and Care Excellence (NICE) ‘non-complex fracture’ recommendations at their scheduled update in 2024. A report of long-term outcomes at five years will be produced by January 2027. Cite this article: Bone Jt Open 2024;5(3):184–201

We carried out a comparison of the analgesic requirements, length of stay in hospital, complications and cost effectiveness of patients who had either a continuous disposable infusion pump or standard treatment for unicompartmental knee replacement.

This study began as an audit. We completed the audit loop with a prospective study after implementing our recommendations. The device is a single use disposable elastometric pump, set immediately after surgery to deliver a continuous flow of 0.5% bupivacaine at a rate of 2mls per hour for 48 hrs into the knee joint via a fine catheter with a fenestrated tip.

The case notes of all patients in the study were analysed to establish their total analgesic requirements for 48hrs following surgery. Complications and length of stay in hospital were recorded This has changed our clinical practice. Results of our study of 50 patients, 25 in each group (age and sex matched) confirmed that there was a significant reduction in opiate requirements after introduction of the pain pump. Length of stay in hospital was reduced from 5.7 to 3.9 days. Patients' requirements for NSAIDs were reduced. There were no significant complications in the pain pump group. The costs of the pump (£40) were offset by the reduction in analgesic requirements and shortened length of stay in hospital.

We conclude this form of analgesia is safe, effective and cost effective. Our department has now changed to using the pump for all unicompartmental knee replacements.

Aims. To determine the likelihood of achieving a successful closed reduction (CR) of a dislocated hip in developmental dysplasia of the hip (DDH) after failed Pavlik harness treatment We report the rate of avascular necrosis (AVN) and the need for further surgical procedures. Methods. Data was obtained from the Northern Ireland DDH database. All children who underwent an attempted closed reduction between 2011 and 2016 were identified. Children with a dislocated hip that failed Pavlik harness treatment were included in the study. Successful closed reduction was defined as a hip that reduced in theatre and remained reduced. Most recent imaging was assessed for the presence of AVN using the Kalamchi and MacEwen classification. Results. There were 644 dislocated hips in 543 patients initially treated in Pavlik harness. In all, 67 hips failed Pavlik harness treatment and proceeded to arthrogram (CR) under general anaesthetic at an average age of 180 days. The number of hips that were deemed reduced in theatre was 46 of the 67 (69%). A total of 11 hips re-dislocated and underwent open reduction, giving a true successful CR rate of 52%. For the total cohort of 67 hips that went to theatre for arthrogram and attempted CR, five (7%) developed clinically significant AVN at an average follow-up of four years and one month, while none of the 35 hips whose reduction was truly successful developed clinically significant AVN. Conclusion. The likelihood of a successful closed reduction of a dislocated hip in the Northern Ireland population, which has failed Pavlik harness treatment, is 52% with a clinically significant AVN rate of 7%. As such, we continue to advocate closed reduction under general anaesthetic for the hip that has failed Pavlik harness. Cite this article: Bone Jt Open 2021;2(8):594–598

Aims: To determine whether lumbar spinal injection in conjunction with general anaesthesia decreases peri-operative blood loss and thereby transfusion rates as compared to general anaesthesia alone in patients undergoing primary hip arthroplasty.

Methods: This is an observational study of 47 consecutive patients who underwent unilateral primary total hip arthroplasty. These were all performed by the same surgeon using the same approach, prosthesis and postoperative care. Group I consisted of 28 patients who had combined lumbar spinal and general anaesthesia performed by the same anaesthetist. Group II consisted of 19 patients who had general anaesthesia alone. Analysis was made of intra-operative blood pressure, post-operative haemoglobin levels using Mann-Whitney test and of transfusion rates using Fischer’s exact test.

Results: Group I had a mean intra-operative mean arterial pressure of 53 (range 38–72.5) compared to 65 (range 45–94) in group II. This was a statistically significant difference (p = 0.0006). There was a mean drop in haemoglobin of 29 (range 9–53) in group I and of 40 (range 22–56) in group II. This was a statistically significant difference (p = 0.0006). 2 patients ( 7.1%) in group I required blood transfusion as compared to 8 (42.1%) in group II. Again this result was significantly different (p = 0.0086).

Conclusion: Some previous studies have shown transfusion rates as high as 75 %. We recommend the use of combined lumbar spinal and general anaesthesia in primary total hip arthroplasty as it significantly reduces peri-operative blood loss and transfusion rates, in our study to only 4.1%. This may reduce the risk of infection and improve the bone cement interface in a cemented hip arthroplasty.

Patients with proximal femoral fracture are frail with multiple comorbidities and the anaesthesia often proves a greater challenge than the surgery itself. The aim was firstly, to determine whether general, compared to regional anaesthesia, caused a decrease in the mental test score (MTS) of patients with proximal femoral fracture. Secondly, what effect does a reduced MTS have on the general outcome for such patients?

A prospective observational study was conducted in a regional trauma centre. 170 consecutive patients over 60 years of age (mean age 82.6 years) were included. Age under 60 years was the only exclusion criterion. Pre- and postoperative (day 5) MTS values were recorded by the same clinician.

The MTS decreased by 2.43 points when general anaesthesia was administered compared to 1.5 for regional anaesthesia (p< 0.01 Mann Whitney). Lower postoperative MTS values were associated with increased mortality (p< 0.001 Mann Whitney). The greater the decrease in MTS (between pre- and postoperative values) the more likely it is that the patient will be institutionalised (p< 0.01 Mann Whitney).

Reduced mental function as observed after general anaesthesia is associated with increased mortality and institutionalisation. Thus the increased use of regional anaesthesia is advocated.

This is a prospectively randomised blind study to determine which treatment- Manipulation under anaesthesia (MUA) or Hydrodilatation is more effective for proven shoulder adhesive capsulitis. Forty patients with adhesive capsulitis were randomised to receive either of the two treatments. All patients were assessed by an independent investigator, with Visual Analogue Scores (VAS) and Constant scores, at three intervals “ pre-treatment, 2 months and 6 months following treatment. Twenty patients (mean age 55.2 years (44–70); duration of symptoms 33.7 weeks (8–76)) received hydrodilatation and eighteen (mean age 54.5 years (39–69); duration of symptoms 43.5 weeks (12–102)) underwent MUA (two patients dropped out). VAS scores in the hydrodilatation group were pre treatment 6.1 (n=20), 2.4 (n=18;p=0.001) at 2 months and 1.7 (n=17; p=0.0006) at 6 months. VAS scores in the MUA group were pre treatment 5.7 (n=18), 4.7 (n=16) at 2 months, and 2.7 (n=15;p=0.0006) at 6 months. The VAS pain scores in the hydrodilatation group were significantly better than the MUA group over the six month follow-up (p< 0.0001)Constant scores in the hydrodilatation group were 30.8 pre treatment, 57.4 (p=0.0004) at 2 months and 65.9 (p=0.0005) at 6 months. In the MUA group, Constant scores were 38 pre treatment, 60.2 (p=0.001) at 2 months and 59.5 (p=0.0006) at 6 months. Constant scores in the hydrodilataion group were again significantly better than the MUA group over the six month follow-up (p= 0.02). At final follow up, 93% of patients were satisfied or very satisfied after hydrodilatation compared to 71% of those receiving an MUA.

We have for the first time prospectively measured the outcome of two treatments “ MUA and hydrodilatation in patients with adhesive capsulitis. Our results suggest that although both treatments are effective in the majority of patients, hydrodilatation is significantly more effective than a manipulation under anaesthesia.

A prospective randomised study was carried out to compare two methods of pain control following arthroscopically assisted ACL reconstruction.

Twenty patients each were randomly recruited to receive either femoral nerve block with 0.5% Bupivicaine or an intra-articular injection with the same. Both groups were prescribed Diclofenac regularly and Coproxamol as required. Visual analogue scores (VAS) were used to assess pain levels preoperatively, four hours postoperatively and on the morning after. The duration between surgery and the first dose of PRN analgesia was recorded, along with the total quantity of analgesia required before discharge. Patients with associated PCL or collateral ligament injuries were excluded beforehand.

Both groups were evenly matched for age (t-test p< 0.05). Tourniquet time did not differ significantly between the groups (t-test p:0.24). The VAS pain levels were not significantly different at four hours and the first morning postoperatively in both groups. Femoral block (Ave VAS: 21 & 25) did not confer a significant advantage (t-test p: 0.69, 0.7) over intra-articular injections of Bupivicaine (Ave VAS: 25 & 22). The total quantity of Coproxamol consumed did not vary significantly (p=0.99). There was no correlation between tourniquet time and postoperative pain (r=0.19, 0.08). All but one patient was discharged home on the first postoperative morning.

Our study demonstrates that pain levels can be sufficiently controlled by intra-articular infiltration of Bupivicaine coupled with oral analgesia. The level of pain relief achieved could allow this procedure to be increasingly performed in a day surgery setting without the need for femoral block thereby allowing for quicker mobilisation.

Background: The use of psoas compartment block provides good analgesia but poor surgical anaesthesia. In Ortho-geriatric care different nerve blockade had been used to avoid the systemic adverse effect of centrally acting agents and provide long duration of unilateral limb analgesia after arthroplasty.

Aim: The aim of the study is to establish the quality of pain control, incidence of side effects and complications achieved with a psoas compartment block (PCB) following surgery for fractured neck of femur.

Study design: Prospective, Non randomised, longitudinal, Cohort. A Pilot Study period January 2003 -December 2004

Materials & Method: 10 patients of mean age 74.8 years (Range 23–93), 3 males and 9 females had unilateral hip surgery with general or a spinal (with no intrathecal opiate administration) as the main anaesthesia and a psoas Compartment Block for continuous infusion of bupivacaine for postoperative pain control (a total dose of 2mg/kg given in theatre and received a continuous infusion of bupivacaine 0.1% at a rate of 25ml/hour for 48 hours) and assessed by nurse led pain team.

Result & analysis: All the patients in this study group had excellent pain control. On the first post operative day only one patient had mild pain, and another had moderate pain. On the second day 3 patients had mild pain [chart 1].

Conclusion: These patients had excellent to good post operative pain control without having any adverse side effects. This study will help us to treat pain among elderly geriatric patients particularly in the demented group in immediate post-operative period. We need randomised comparative study to advocate this practice.

Paediatric wrist fractures are routinely managed with closed reduction and a molded cast. Gap(GI) and Cast indices(CI) are useful in predicting re-displacement following application of cast. Over 6 months we audited the efficacy of molded cast application following closed reduction of distal radial fractures in paediatric patients. The standard was that proposed by Malviya et al where GI >0.15 and CI >0.8 indicate an increased risk of re-displacement. Age, date and time of operation and surgeon's grade were collected. Pre-op displacement, post-reduction GI and CI and subsequent re-displacement were measured using imaging. Post audit intended changes to practice were presented to all surgeons, a “one-pager” was placed above scrub sinks. Re-audit was conducted at 1 year. The audit and re-audit included 28 and 24 patients respectively. Cast molding (CI) improved minimally following intervention (32% to 29%). Cast padding (GI) improved significantly (82% to 63%). Loss of reduction decreased slightly (14% to 12%), this was not accurately predicted by GI and CI in the re-audit. Audit demonstrated that casts were loose, over-padded and did not hold reduction adequately. Re-audit demonstrated that tighter, less padded but still inadequately molded casts were being applied with minimal change in loss of reduction.

A neck of femur fracture is known to be a high risk factor for the development of pressure sores with an associated morbidity, mortality and cost. We have attempted to identify risk factors in these patients for the development of pressure sores

We have analysed prospectively collected data of 4654 consecutive patients (1003 males/3473 females).

3.8% developed pressure sores in the sacral, buttock or heel areas. Patients factors that increased the risk of pressure sores were increased age (82.1 years versus 76.6 years), lower mental test score (5.7 versus 6.7), diabetes mellitus (pressure sore incidence 9.4%), higher ASA score (3.0 versus 2.7) and lower admission haemoglobin concentration (120gms versus 124gms). Those patients with an extracapsular fracture were more likely to develop pressure sores compared to patients with an intracapsular fracture (4.5% versus 3.1%). Being male was not a risk factor. Among surgical factors related to an increased risk was a fall in blood pressure during surgery (5.6%). Patients who underwent a dynamic hip screw were more likely to develop pressure sores (pressure sore incidence 4.7%). Patients with an intracapsular fracture treated with internal fixation were less likely to develop pressure sores in comparison to those fractures treated with a hemiarthroplasty or a sliding hip screw (2.0% versus 4.7 versus 4.4%). No relationship was seen related to length of surgery of type of anaesthesia.

Our study indicates that the current incidence of pressure sores is lower that that previously reported (30%). Whilst it is possible in a large population of patients to determine factors that increase the risk of pressure sores, these are not sufficiently reliable to be used for an individual patient.

Introduction

This study was performed to investigate the efficacy of steroid and local anaesthesia (LA) in reducing post-operative pain in lumbar discectomy.

Introduction: This study is performed to investigate the efficacy of steroid, local anaesthesia (LA) or combination of both in reducing post operative pain in lumbar discectomy.

Materials and Methods: The study was ethically approved. Patients undergoing primary single level lumbar discectomy were randomised by a closed envelope system into 4 groups of 1ml of steroid and 1ml of LA, 1ml of steroid and 1ml of saline, 1ml of LA and 1ml of saline and 2mls of saline as control. 10mg of adcortyl in 1ml and 1ml of 0.5% marcaine were used. Combinations of above were applied topically over the nerve root prior to closure. Preoperative, day 1 and eight weeks post operative visual analogue pain score were recorded. 10cm visual analogue pain score chart was used. 24 hours post operative opiate analgesia requirements and duration of inpatient stay were recorded. Data was analysed using Student t-test and Fisher exact t-test.

Results: No significant differences seen in the mean pre operative pain score between all groups. Mean Day 1 post operative pain and analgesia requirement in steroid and LA, steroid only, LA only and control group were 0.9, 2.5, 2.1 and 3.3 respectively. Mean opiate analgesia requirement 24 hours post operatively were 32.4mg, 54mg, 32.4mg and 56.8mg respectively. Mean inpatient stay were 2.2day, 3.91day, 4.62day and 3.63day respectively. At 8 weeks post operatively, no significant differences in the pain score in all groups.

Conclusions: Significant post operative pain reduction was achieved in the steroid and local anaesthesia group compared with other groups (p< 0.05). The results are reflected as well in significant reduction in the post operative analgesia requirement (p< 0.05) and the significant reduction in inpatient stay. (p< 0.05) We recommended the use of perioperative steroid and LA infiltration in lumbar discectomy. Improved post operative pain control reduces post operative opiate analgesia requirement and reduced inpatient stay.

Aims

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Aims

In the UK, the agricultural, military, and construction sectors have stringent rules about the use of hearing protection due to the risk of noise-induced hearing loss. Orthopaedic staff may also be at risk due to the use of power tools. The UK Health and Safety Executive (HSE) have clear standards as to what are deemed acceptable occupational levels of noise on A-weighted and C-weighted scales. The aims of this review were to assess the current evidence on the testing of exposure to noise in orthopaedic operating theatres to see if it exceeds these regulations.

Aims

The aim of this study was to explore current use of the Global Fragility Fracture Network (FFN) Minimum Common Dataset (MCD) within established national hip fracture registries, and to propose a revised MCD to enable international benchmarking for hip fracture care.

Aims. Intra-articular (IA) injection may be used when treating hip osteoarthritis (OA). Common injections include steroids, hyaluronic acid (HA), local anaesthetic, and platelet-rich plasma (PRP). Network meta-analysis allows for comparisons between two or more treatment groups and uses direct and indirect comparisons between interventions. This network meta-analysis aims to compare the efficacy of various IA injections used in the management of hip OA with a follow-up of up to six months. Methods. This systematic review and network meta-analysis used a Bayesian random-effects model to evaluate the direct and indirect comparisons among all treatment options. PubMed, Web of Science, Clinicaltrial.gov, EMBASE, MEDLINE, and the Cochrane Library were searched from inception to February 2023. Randomized controlled trials (RCTs) which evaluate the efficacy of HA, PRP, local anaesthetic, steroid, steroid+anaesthetic, HA+PRP, and physiological saline injection as a placebo, for patients with hip OA were included. Results. In this meta-analysis of 16 RCTs with a total of 1,735 participants, steroid injection was found to be significantly more effective than placebo injection on reported pain at three months, but no significant difference was observed at six months. Furthermore, steroid injection was considerably more effective than placebo injection for functional outcomes at three months, while the combination of HA+PRP injection was substantially more effective at six months. Conclusion. Evidence suggests that steroid injection is more effective than saline injection for the treatment of hip joint pain, and restoration of functional outcomes. Cite this article: Bone Joint J 2024;106-B(6):532–539

Aims. As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. Methods. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. Results. In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). Conclusion. Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886–892

Orthopedic device-related infection (ODRI) preclinical models are widely used in translational research. Most models require induction of general anesthesia, which frequently results in hypothermia in rodents. This study aimed to evaluate the impact of peri anesthetic hypothermia in rodents on outcomes in preclinical orthopedic device-related infection studies. A retrospective analysis of all rodents that underwent surgery under general anesthesia to induce an ODRI model with inoculation of Staphylococcus epidermidis between 2016 and 2020 was conducted. A one-way multivariate analysis of covariance was used to determine the fixed effect of peri anesthetic hypothermia (hypothermic defined as rectal temperature <35°C) on the combined harvested tissue and implant colonies forming unit counts, and having controlled for the study groups including treatments received duration of surgery and anesthesia and study period. All animal experiments were approved by relevant ethical committee. A total of 127 rodents (102 rats and 25 mice) were enrolled in an ODRI and met the inclusion criteria. The mean lowest peri-anesthetic temperature was 35.3 ± 1.5 °C. The overall incidence of peri-anesthetic hypothermia was 41% and was less frequently reported in rats (34% in rats versus 68% in mice). Statistical analysis showed a significant effect of peri anesthetic hypothermia on the post-mortem combined colonies forming unit counts from the harvested tissue and implant(s) (p=0.01) when comparing normo- versus hypothermic rodents. Using Wilks’ Λ as a criterion to determine the contribution of independent variables to the model, peri-anesthetic hypothermia was the most significant, though still a weak predictor, of increased harvested colonies forming unit counts. Altogether, the data corroborate the concept that bacterial colonization is affected by abnormal body temperature during general anesthesia at the time of bacterial inoculation in rodents, which needs to be taken into consideration to decrease infection data variability and improve experimental reproducibility

Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation. Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions. Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient. The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort

Aims. Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital. Methods. A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway. Results. Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001). Conclusion. Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty. Cite this article: Bone Jt Open 2021;2(11):900–908

Aims. Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m. 2. (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. Results. Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. Conclusion. IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126–130

Aims. To achieve expert clinical consensus in the delivery of hydrodilatation for the treatment of primary frozen shoulder to inform clinical practice and the design of an intervention for evaluation. Methods. We conducted a two-stage, electronic questionnaire-based, modified Delphi survey of shoulder experts in the UK NHS. Round one required positive, negative, or neutral ratings about hydrodilatation. In round two, each participant was reminded of their round one responses and the modal (or ‘group’) response from all participants. This allowed participants to modify their responses in round two. We proposed respectively mandating or encouraging elements of hydrodilatation with 100% and 90% positive consensus, and respectively disallowing or discouraging with 90% and 80% negative consensus. Other elements would be optional. Results. Between 4 August 2020 and 4 August 2021, shoulder experts from 47 hospitals in the UK completed the study. There were 106 participants (consultant upper limb orthopaedic surgeons, n = 50; consultant radiologists, n = 52; consultant physiotherapist, n = 1; extended scope physiotherapists, n = 3) who completed round one, of whom 97 (92%) completed round two. No elements of hydrodilatation were “mandated” (100% positive rating). Elements that were “encouraged” (≥ 80% positive rating) were the use of image guidance, local anaesthetic, normal saline, and steroids to deliver the injection. Injecting according to patient tolerance, physiotherapy, and home exercises were also “encouraged”. No elements were “discouraged” (≥ 80% negative rating) although using hypertonic saline was rated as being “disallowed” (≥ 90% negative rating). Conclusion. In the absence of rigorous evidence, our Delphi study allowed us to achieve expert consensus about positive, negative, and neutral ratings of hydrodilatation in the management of frozen shoulder in a hospital setting. This should inform clinical practice and the design of an intervention for evaluation. Cite this article: Bone Jt Open 2022;3(9):701–709

Aims. We studied the outcomes of hip and knee arthroplasties in a high-volume arthroplasty centre to determine if patients with morbid obesity (BMI ≥ 40 kg/m. 2. ) had unacceptably worse outcomes as compared to those with BMI < 40 kg/m. 2. . Methods. In a two-year period, 4,711 patients had either total hip arthroplasty (THA; n = 2,370), total knee arthroplasty (TKA; n = 2,109), or unicompartmental knee arthroplasty (UKA; n = 232). Of these patients, 392 (8.3%) had morbid obesity. We compared duration of operation, anaesthetic time, length of stay (LOS), LOS > three days, out of hours attendance, emergency department attendance, readmission to hospital, return to theatre, and venous thromboembolism up to 90 days. Readmission for wound infection was recorded to one year. Oxford scores were recorded preoperatively and at one year postoperatively. Results. On average, the morbidly obese had longer operating times (63 vs 58 minutes), longer anaesthetic times (31 vs 28 minutes), increased LOS (3.7 vs 3.5 days), and significantly more readmissions for wound infection (1.0% vs 0.3%). There were no statistically significant differences in either suspected or confirmed venous thromboembolism. Improvement in Oxford scores were equivalent. Conclusion. Although morbidly obese patients had less favourable outcomes, we do not feel that the magnitude of difference is clinically significant when applied to an individual, particularly when improvement in Oxford scores were unrelated to BMI. Cite this article: Bone Jt Open 2021;2(7):515–521

Objective. Carpal tunnel release surgery is a commonly performed procedure for alleviating symptoms of median nerve compression and restoring hand function. With pressure on theatre time these procedures are now commonly performed in a step-down out-patient facility under local anaesthetic. The choice of suture for skin closure in this procedure can impact the quality of wound healing, patient outcomes and the follow-up required however the question of the best type of suture remains unanswered. The purpose of this study was to compare the outcomes of absorbable and non-absorbable sutures using a randomised control trial design. Methods. Eighty patients diagnosed with bilateral carpal tunnel syndrome were enrolled and underwent outpatient carpal tunnel release surgery under local anaesthetic in a staged fashion. Random number generation was used to assign each hand to receive interrupted nylon or Vicryl Rapide sutures. Pre-operative data collection included patient demographics, ASA, inflammatory conditions, smoking status as well as a Boston Carpal Tunnel Questionnaire (BCTQ) for each hand. Patients were followed up at 2 and 6 weeks after each operation and the BCTQ was repeated along with the Patient and Observer Scar Assessment Scale and the VAS score for wound discomfort. This study has approval from the DHB ethics committee, Local Iwi, HDC and ANZ Clinical Trials:ACTRN12623000100695. Results. Statistical analysis assessed patient preference and the scores between the groups. Multi-variate analysis was performed to assess the factors that may be contributing to patient choice. Conclusion. Insights into patient preference and clinical outcomes associated with absorbable sutures and non-absorbable sutures in the setting of out-patient surgery are discussed

Abstract. Background. Different surgical sub specialities rely on fixed number of porters each morning to bring patients to operating theatre. In daily morning trauma meetings usual practice is to present the whole list of one theatre and then move on to next theatre list. Once all the theatres trauma list are presented, porters are sent to get patients to theatre. With different sub-specialities starting simultaneously and competing for fixed numbers of porters, this can cause significant delay in getting the patients to anaesthetic room. Methods. Retrospective pilot project in level 1 major trauma centre were more that two trauma list a day is a common norm. Pilot project:. First (Golden) patient for every trauma list would be presented at the start of the trauma meeting. Meeting would pause and consultant chairing the meeting would request the trauma theatre representative to send for these patients. Once this is done the meeting would recommence as usual. Results. (a). The porters were sent on an average more than 30 minutes earlier in the pilot week. (b). This was further reflected in the patients being brought into holding bay. (c). The patients were in the anaesthetic room on an average 40 minutes before in pilot group compared to usual practice. Conclusion/Findings. Presenting first patient of each trauma list and then asking theatre to send porter to get the patient to theatre can save appreciable time. Implications. To run an hour of theatre costs £1200. This initiative can save lot of money for NHS

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation

Background. Procedural sedation (PS) requires two suitably qualified clinicians and a dedicated monitored bed space. We present the results of intra-articular haematoma blocks (IAHB), using local anaesthetic, for the manipulation of closed ankle fracture dislocations and compared resource use with PS. Methods. Patients received intra-articular ankle haematoma blocks for displaced ankle fractures requiring manipulation between October 2020 to April 2021. The technique used 10ml of 1% lignocaine injected anteromedially into the tibiotalar joint. Pain scores (VAS), time from first x-ray to reduction, and acceptability of reduction were recorded. A comparison was made by retrospective analysis of patients who had undergone PS for manipulation of an ankle fracture over the six month period March – August 2020. Results. During the periods assessed, 25 patients received an IAHB and 28 received PS for ankle fractures requiring manipulation (mean age 57.8yr vs 55.1yr). Time from first x-ray to manipulation was 65.9 min (IAHB) vs 82.9 min (PS) (p = 0.087). In the IAHB group mean pain scores pre, during and post manipulation were 6.1, 4.7 and 2.0 respectively (‘pre’ to ‘during’ p < 0.05; ‘pre’ to ‘post’ p < 0.01). In the IAHB group, 23 (92%) had a satisfactory reduction without need of PS or general anaesthetic. In the PS group 23 (82%) had a satisfactory reduction. There was no significant difference in the number of unsatisfactory first attempt reductions between the groups. There were no cases of deep infection post operatively in either group. Conclusion. Intra-articular haematoma block of the ankle appears to be an efficacious, safe and inexpensive means of providing analgesia for manipulation of displaced ankle fractures. Advantages of this method include avoiding the risks of procedural sedation, removing the requirement of designated clinical space and need for qualified clinicians to give sedation, and the ability to re-manipulate under the same block

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Aims. The coronavirus disease (COVID)-19 pandemic forced an unprecedented period of challenge to the NHS in the UK where hip fractures in the elderly population are a major public health concern. There are approximately 76,000 hip fractures in the UK each year which make up a substantial proportion of the trauma workload of an average orthopaedic unit. This study aims to assess the impact of the COVID-19 pandemic on hip fracture care service and the emerging lessons to withstand any future outbreaks. Methods. Data were collected retrospectively on 157 hip fractures admitted from March to May 2019 and 2020. The 2020 group was further subdivided into COVID-positive and COVID-negative. Data including the four-hour target, timing to imaging, hours to operation, anaesthetic and operative details, intraoperative complications, postoperative reviews, COVID status, Key Performance Indicators (KPIs), length of stay, postoperative complications, and the 30-day mortality were compiled from computer records and our local National Hip Fracture Database (NHFD) export data. Results. Hip fractures and inpatient falls significantly increased by 61.7% and 7.2% respectively in the 2020 group. A significant difference was found among the three groups regarding anaesthetic preparation time, anaesthetic time, and recovery time. The mortality rate in the 2020 COVID-positive group (36.8%) was significantly higher than both the 2020 COVID-negative and 2019 groups (11.5% and 11.7% respectively). The hospital stay was significantly higher in the COVID-positive group (mean of 24.21 days (SD 19.29)). Conclusion. COVID-19 has had notable effects on the hip fracture care service: hip fracture rates increased significantly. There were inefficiencies in theatre processes for which we have recommended the use of alternate theatres. COVID-19 infection increased the 30-day mortality and hospital stay in hip fractures. More research needs to be done to reduce this risk. Cite this article: Bone Joint Open 2020;1-9:530–540

Aims. The aim of this study is to determine the effects of the UK lockdown during the COVID-19 pandemic on the orthopaedic admissions, operations, training opportunities, and theatre efficiency in a large district general hospital. Methods. The number of patients referred to the orthopaedic team between 1 April 2020 and 30 April 2020 were collected. Other data collected included patient demographics, number of admissions, number and type of operations performed, and seniority of primary surgeon. Theatre time was collected consisting of anaesthetic time, surgical time, time to leave theatre, and turnaround time. Data were compared to the same period in 2019. Results. There was a significant increase in median age of admitted patients during lockdown (70.5 (interquartile range (IQR) 46.25 to 84) vs 57 (IQR 27 to 79.75); p = 0.017) with a 26% decrease in referrals from 303 to 224 patients and 37% decrease in admissions from 177 to 112 patients, with a significantly higher proportion of hip fracture admissions (33% (n = 37) vs 19% (n = 34); p = 0.011). Paediatric admissions decreased by 72% from 32 to nine patients making up 8% of admissions during lockdown compared to 18.1% the preceding year (p = 0.002) with 66.7% reduction in paediatric operations, from 18 to 6. There was a significant increase in median turnaround time (13 minutes (IQR 12 to 33) vs 60 minutes (IQR 41 to 71); p < 0.001) although there was no significant difference in the anaesthetic time or surgical time. There was a 38% (61 vs 38) decrease in trainee-led operations. Discussion. The lockdown resulted in large decreases in referrals and admissions. Despite this, hip fracture admissions were unaffected and should remain a priority for trauma service planning in future lockdowns. As plans to resume normal elective and trauma services begin, hospitals should focus on minimising theatre turnaround time to maximize theatre efficiency while prioritizing training opportunities. Clinical relevance. Lockdown has resulted in decreases in the trauma burden although hip fractures remain unaffected requiring priority. Theatre turnaround times and training opportunities are affected and should be optimised prior to the resumption of normal services. Cite this article: Bone Joint Open 2020;1-8:494–499

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