Aims

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

Porous tantalum is a highly osteoinductive biomaterial, initially introduced in orthopedics in 1997, with a subsequent rapid evolution of orthopedic applications. The use of porous tantalum for the acetabular component in primary total hip arthroplasty (THA) has demonstrated excellent short-term and mid-term results. However, long term data are scarce. The purpose of this prospective study is to report the long-term clinical and radiological outcome following use of an uncemented porous tantalum acetabular component in primary THA with a minimum follow-up of 17.5 years, in a previously studied cohort of patients.

We prospectively followed 128 consecutive primary THAs in 140 patients, between November 1997 and June 1999. A press-fit porous tantalum monoblock acetabular component was used in all cases. The presence of initial gaps in the polar region, as sign of incomplete seating of the monoblock cup, was assessed on the immediate postoperative radiographs. All patients were followed clinically and radiographically at 6, 12, and 24 weeks and 12 months and then at 2, 5, 8, 10, and 19 years, for a mean of 18.1 years (range 17.5 – 19 years). Periacetabular dome gap filling, acetabular cup migration and polyethylene wear were assessed by the EBRA digital measurement system, until 2 years postoperatively.

Mean age of patients at the time of operation was 60.4 years old (range 24 – 72). Harris hip score, Oxford Hip Score and range of motion (ROM) were dramatically improved in all cases (p < 0.001). In the initial postoperative radiographs, periacetabular dome gaps were observed in the 15% of cases, and were progressively filled within 6 months. In 2 years postoperatively, the mean component migration, as shown in EBRA study, was 0.67 mm. At last follow-up, all cups were radiographically stable with no evidence of migration, gross polyethylene wear, progressive radiolucencies, osteolytic lesions or acetabular fractures. The survivorship with re-operation for any reason as end point was 92.8%, whereas the survivorship for aseptic loosening as an end point was 100%. Upon visual inspection, two removed acetabular components due to recurrent dislocation and infection, respectively, showed extensive bone osseointegration.

In our primary THA series, the porous tantalum monoblock cup demonstrated excellent clinical and radiographic outcomes with no failures because of aseptic loosening at a mean follow-up of 18.1 years. Porous tantalum acetabular components showed excellent initial stability, produced less wear debris and revealed a great potential for bone ingrowth. Due to its unique osteoinductive properties and elliptical shape, porous tantalum monoblock cups have demonstrated superior short and long-term survivorship compared to other press fit prostheses in the market.

Introduction

Version abnormalities of the femur, either retroversion or excessive anteversion, cause pain and hip joint damage due to impingement or instability respectively. A retrospective clinical review was conducted on patients undergoing a subtrochanteric derotation osteotomy for either excessive anteversion or retroversion of the femur.

Septic arthritis induced by Staphylococcus aureus causes a rapid destruction of joint cartilage and periarticular bone. The mechanisms behind this phenomenon are not fully understood. Toll-like receptors (TLRs) are essential in host defense against pathogens by virtue of their capacity to detect microbes and initiate the immune response. TLR2 is seen as the most important receptor for gram-positive bacteria. TLR2 signaling can lead to the activation of NF-kB through myeloid differentiation factor 88 (MyD88) dependent pathway. The purpose of this study was to examine the catabolic role of TLR2 mediated by the NF-kB pathway in human septic arthritic chondrocytes.

Septic arthritic (SA) chondrocytes (n=7) and fibroblast-like synoviocytes (n=7) infected by gram-positive bacteria, mainly Staphylococcus aureus, as well as chondrocytes from healthy individuals (n=5) were used for this study.

The expression of TLR2 in septic articular cartilage and normal cartilage was analyzed by real time reverse transcription polymerase chain reaction as well western blot analysis. Production of matrix metalloproteinase MMP- 13 and IL-1b was evaluated by enzyme-linked immunosorbent assay. MyD88 protein expression levels and NF-kB activation were evalutated by western blot analysis. Downregulation of TLR2 expression was achieved after transfection with specific siRNA against TLR2 using liposomes.

We observed that TLR2 mRNA and protein expression was significantly up-regulated in septic arthritic cartilage. Also MMP-13 and IL-1b production were significantly increased in septic arthritic chondrocytes compared to normal. Blocking TLR2 in septic chondrocytes resulted in significant reduction of MyD88 and NF-kB protein levels as well as reduction in MMP-13 and IL-1b expression.

It could be suggested that stimulation of TLRs by microbial components may represent the initial signal promoting a pro-inflammatory environment that will enhance degeneration of articular cartilage and the surrounding synovial cells. Targeting NF-kB signalling pathway through TLR2 gene silencing may be of potential therapeutic value in treatment of joint diseases.

Our study aimed to investigate the role of an HMG-CoA reductase inhibitor (atorvastatin) in human osteoarthritic chondrocytes and to test the in vivo effects of intra-articular injections of atorvastatin in a rabbit experimental osteoarthritis model.

Human articular osteoarthritic chondrocytes were cultured in the presence and absence of atorvastatin. mRNA and protein expression of MMP-13, COL2A1 and aggrecan were measured using real-time PCR and Western Blot analysis.

New Zealand rabbits (n=15) underwent bilateral anterior cruciate ligament transection (ACLT) to induce osteoarthritic degeneration and received intra-articular injections of atorvastatin and normal saline in the left and right knees respectively. The first injection was at the time of ACLT and injections were repeated every 3 days for 3 weeks. Data were obtained from macroscopic and histological evaluation as well as from gene expression analysis for COL2A1, aggrecan and MMP-13.

Incubation of the cultures with atorvastatin produced a decreasing effect in MMP-13 expression. Regarding aggrecan and COL2A1 expression a significant increase was observed.

Gross morphologic evaluation showed that the joints which received atorvastatin injections, showed minimal cartilage erosion, compared to the non-treated knees where the cartilage was markedly eroded, especially on the medial knee compartment. These results were supported by histological and gene expression analysis. The mRNA expression of MMP-13 was significantly reduced in the cartilage of the statin-treated knee joints, while the expression of COL2A1 and aggrecan was increased.

The clinical relevance of our results indicates a potential protective effect of atorvastatin on articular cartilage undergoing osteoarthritic degeneration.

It is known that wide variability exists among patients in the susceptibility to and outcome from infection. Polymorphisms in genes coding for proteins involved in the response to bacterial pathogens as tumor necrosis factor-alpha(TNF-a), interleukin (IL)-1alpha, IL-1beta, IL-1 receptor agonist, IL-6, IL-10 can influence the amount or function of the protein produced in response to bacterial stimuli. These genetic polymorphisms may influence the susceptibility to and outcome from infection.

The aim of the study was to investigate whether genetic variation in genes coding for components of the innate immune response might be a critical determinant of the inflammatory response and the risk for and outcome from severe bacterial infection in individuals with musculoskeletal infections. The relationship between single nucleotide polymorphisms (SNPs) in the above mentioned genes and susceptibility to infection was evaluated.

Forty patients with musculoskeletal infections hospitalised at the Orthopaedic Clinic of University Hospital of Larissa, as well as 80 healthy controls were included in the study. Genomic DNA was isolated from peripheral blood from all cases and controls and was extracted according to standard procedures. The following genes with their polymorphic positions were studied: IL 1α (IL 1α promoter −889), IL 1β (IL 1β promoter −511, pos. +3962), IL 1R (IL 1R pos. pst1 1970), IL 1RA (IL 1RA pos. mspa1 11100), IL 4Rα (IL 4Rα pos. +1902), IL 12 (IL 12 promoter −1188), TGF-β (TGF-β exon 1 codon 10, codon 25), TNF-α (TNF-α promoter −308, −238), IL 2 (IL 2 promoter −330, pos. +166), IL 4 (IL 4 promoter −1098, −590, −33), IL 6 (IL 6 promoter −174, pos. +nt 565) and IL 10 (IL 10 promoter −1082, −819, −592). Genotype distribution and allele frequencies in patients and controls were evaluated.

There was a significant difference in genotype and allele frequency of IL-1a (T/C −889) p=0.000 (CC, TC) between patients and the control group. Moreover, 2 SNPs of interleukin 4 [IL-4 (T/G −1098) p=0.000 (GG, GT) p=0.009 (TT) and IL-4 (T/C-590) p=0.000 (CC, CT) p=0.006 (TT)] showed significant genotypic and allelic differences between the two groups. Finally, 2 SNPs of interleukin 6 [IL-6 (G/C-174) p=0.000 (CC) p=0.014 (GG), IL-6 G/A nt565) p=0.000 (AA,GA,GG)] and TNF-a [(G/A-308) p=0.034 (AG)] showed significant differences in genotype and allele frequencies between patients and the control group.

We observed, for the first time, significant differences in genotype and allele frequencies of TNF-a (G/A-308), IL-1a (T/C -889), IL-4 (T/G -1098), IL-4 (T/C-590), IL-6 (G/C-174) and IL-6 G/A (nt565) in patients with musculoskeletal infections, a fact which points towards the involvement of cytokine gene polymorphisms in the pathogenesis of infection.

Two-staged revision TKA is a common strategy for the management of infected TKA (i-TKA) in properly selected patients. However, there is considerable variation in the parameters (e.g. the duration of intravenous administration of antibiotics and of the time interval between the stages, the intraoperative use of frozen sections, the use of knee aspiration etc.) of the treatment protocol among Orthopaedic Centres making the comparative evaluation of results difficult. The aim of this study is to present a standardised two-staged revision protocol with satisfactory mid-term clinical outcome.

Thirty-four consecutive cases of infected primary TKAs were treated in our department between 2000 and 2006. For 24 of them the postoperative follow-up is greater than 2 years. All patients underwent the same treatment protocol: knee aspiration prior to implant removal and surgical debridement, more than 5 specimens for frozen sections and cultures (aerobic, anaerobic and fungi) during the first stage, custom antibiodic impregnated cement spacers, intravenous administration of antibiotics for 3 weeks followed by 3 weeks of per os administration based on culture and antibiogram, a 6-week interval free from antibiotics, second aspiration and second stage with repetition of frozen sections and cultures. In the case of positive frozen section specimens during the second stage the implantation of a new prosthesis was cancelled and a different management strategy was introduced. Preoperative and postoperative data were collected in the form of Total Knee Society Score (knee score and functional score), Oxford-12 Score, laboratory parameters and radiographs at regular intervals.

At the final follow-up 22 out of 24 patients were free of infection. In four patients (2 Host C and 1 Host B) the 2nd stage was repeated (2–6 times) due to polymicrobial infection and positive intraoperative frozen sections. In one of them a knee arthrodesis was finally performed. The diagnostic accuracy of knee aspiration before the 1st stage was low. Total Knee Society Score rose from a preoperative average of 64 (50 to 95) to a postoperative average of 145 (130 to 180). The Oxford 12 score also rose from a preoperative average of 52 (44 to 58) to a postoperative average of 30 (23 to 38). At the final follow-up no radiological signs of implant loosening were observed.

The above standardised protocol of two-staged revision in i-TKA, when indicated, can provide satisfactory mid-term clinical results.

Deep infection following total knee arthroplasty (TKA) is a devastating complication for the patient and a costly one for patients, surgeons, hospitals and payers. The aim of this study is to compare revision TKA for infection, revision TKA for aseptic loosening and primary TKA with respect to their impact on hospital and surgeon resource utilisation. The evaluation of hospital cost was carried out on a microeconomic basis in order to best evaluate the true cost.

Demographic, clinical and economic data were obtained for 25 consecutive patients with an infection after TKA who underwent a two-stage revision arthroplasty (Group 1), 25 consecutive patients who underwent revision of both components because of aseptic loosening (Group 2) and 25 consecutive patients who underwent a primary TKA (Group 3), all of which where admitted at our institution between January 2000 and December 2005. The economic evaluation included both surgical treatment and hospitalisation cost. Because fixed charges do not depict accurately real resource consumption, total cost was calculated through direct cost analysis. All direct health sector costs such as medical supplies, drugs, implants, laboratory and radiology tests, salaries and wages and overhead expenses, including equipment and plant depreciation were calculated. All patients were followed up for a twelve-month period.

Revision procedures for infection were associated with longer operative time, more blood loss and a higher total number of operations compared with both revisions for aseptic loosening and primary TKA. Furthermore, revisions for infection compared to revisions due to aseptic loosening and primary TKAs were associated with twofold and 2.6 times higher total number of hospitalisations, 2.5 and 5.6 times higher total number of inpatient days, 10.2 and 53.8 times higher cost of inpatient drugs and 1.2 and 2.37 times higher cost of implants, respectively. The costing evaluation of the three operative techniques is still on progress.

Patients’ treatment with an infection after TKA is associated with significantly greater hospital and physician resource utilisation compared with that used for patients with a revision due to aseptic loosening or a primary TKA.

Flaps constitute an integral part of the treatment of soft tissue and skeletal infections of the extremities, focusing on the coverage and augmentation of the local biology.

In a 6-year period, a total of 33 septic defects of the upper (6) and lower (27) extremities were treated with 4 free and 29 pedicled flaps, after extensive surgical debridement of the septic site. In the lower extremity, treatment included 3 free (2 latissimus dorsi and 1 serratus anterior), and 24 pedicled flaps (5 heads of gastrocnemius, 7 soleus, 1 abductor hallucis, 9 reverse fasciocutaneous, 1 combined medial head of gastrocnemius and soleus and 1 extensor longus hallucis) for 3 cases of soft tissue sepsis and 24 septic defects of the skeleton. In the upper extremity, 1 free vascularised fibular graft (combined with muscle-skin) and 5 pedicled flaps (2 homodigital, 1 heterodigital, 1 cross-finger, 1 periosteal) were used for 3 soft tissue and 3 skeletal septic defects. All but one flaps of the lower extremities were covered with split thickness skin (simultaneously or within 7 days), whereas flaps of the upper extremity included skin in all cases.

Three flaps (2 reverse fasciocutaneous and one soleus) were revised (with latissimus dorsi, serratus anterior and extensor longus hallucis flaps respectively) in a mean period of 4 months due to persistent infection and 4 skin grafts were revised due to superficial infection. In a minimum follow-up period of 9 months (9–60 months) full coverage of the defect and treatment of infection was accomplished in all patients, resulting in a good functional and aesthetic outcome. Except for 2 patients, all were able to walk and use their extremity and returned to previous activities.

The use of flaps in the treatment of septic skeletal or soft tissue defects leads to a functional upper or lower extremity and successfully prevents amputation.

Introduction The aim of this study was firstly to investigate the prevalence of icaABCD-operon which codes the production of the polysaccharide intracellular adhesin(PIA), responsible for biofilm production, in a collection of clinically significant staphylococci isolated from orthopaedic infections and secondly to assess the relationship between biofilm production and the presence or not of ica-operon.

First Step – Material & Methods Between 1/2003 and 12/2005 200 CoNS were isolated from orthopaedic patients associated with soft tissue and bone infections(group I) and 200 CoNS from blood cultures of hospitalized patients from different wards of the same Hospital(group II). Identification was carried out by Gram-stain, catalase and coagulase tests and the API Staph System. Detection of icaADBC genes was performed by PCR. Production of biofilm was tested by the method of Christensen.

Results In group I, 62(31.37%) carried the entire ica-operon; from these isolates biofilm formation was detected in 35(17.5%). 5 isolates, despite biofilm production, did not carry any gene of ica-operon. In group II, 70(35.5%) carried entire the ica-operon; biofilm formation was detected in 37(18.5%) of these isolates. 3 S. capitis, 1 S. epidermidis and 1 S. hominis carried only the icaADB, icaA and icaB genes respectively.

Second Step – Material & Methods Based on the observation of PIA-production only in (50%) of ica(+) CoNS, 20 S. epidermidis isolates recovered from clinical specimens (pus) of orthopaedic patients and belonging to distinct PFGE clones, were selected on the basis of the presence of the entire ica operon. Nevertheless, only 10 of them produced biofilm. Nucleotide sequence analysis of ica-operon was carried out in all isolates; expression of icaADBC genes was also tested by RT-PCR.

Results Sequencing analysis revealed that all isolates carried an intact ica-operon, without point mutations. Concerning icaADBC mRNA production, all genes of ica-operon were expressed in biofilm-producing isolates, whereas in the no-biofilm producing strains the icaA and icaC genes were not expressed, while a faint expression was observed for the icaB and icaD genes.

Discussion Biofilm-forming capacities of CoNS from orthopaedic infections was not significantly greater than those from other infections (p> 0,05). The capacity of ica-operon(+) staphylococcal isolates to form biofilm seems to be dependent on the expression of ica-genes, specifically of icaA and icaC. The inability of ica(+) isolates to produce biofilm emphasizes that some unknown mechanisms influence icaADBC expression. Finally, the recognition of biofilm-producing CoNS without carrying any gene of ica operon underlined the existence of unidentified also mechanisms controlling biofilm production, apart from icaADBC expression.

Introduction: TKA is usually performed under general or spinal anaesthesia (SA). Most of the patients who undergo this procedure are old and their postoperative rehabilitation could be compromised due to the adverse effects of the relevant anaesthesia. Lumbar Plexus and Sciatic nerve Block (LPSB) have been increasingly applied for intraoperative and postoperative analgesia. The aim of this study is to compare the time required for the performance of the anaesthesia technique, the quality of intraoperative anaesthesia and postoperative analgesia, the incidence of intraoperative or postoperative complications, the blood loss at the recovery room and the required intraoperative intravenous (IV) administration of fluid volume.

Material & Methods: Fifty (50) patients, mean age 70± 5years, ASA I-III were randomly divided into two groups to receive spinal anaesthesia (group A) or LPSB (group B). Patients in group A (n=25) received hyperbaric Bupi-vacaine 0.5% plus 15mcq Fentanyl through atraumatic 25g needle. Lumbar plexus and sciatic nerve block were performed with a 15cm insulated needle (Brown) and nerves were identified by a peripheral electric nerve stimulator. 30 and 15 ml of Ropivacaine (0.5%) were used for each block respectively. All patients received 0.2mg/ Kg of Midazolam and 50μg of Fentanyl IV. The success of the technique was defined as a complete sensory and motor block. All patients received postoperatively Patient-Controlled Anaesthesia (PCA) with morphine intravenously. Time to perform blockade, sensory and complete motor block, hemodynamic parameters, blood loss, IV fluid volume, postoperative analgesic requirements and satisfaction score were recorded. Results were analyzed with Chi Square test and Student’s t-test (level of significance: p< 0.05).

Results: Demographic data, operating time and hemo-dynamic parameters were similar in both groups. Three patients (group B) had insufficient blocks and were converted to general anaesthesia. Although SA is performed and accomplishes complete motor and sensory blockade faster (p< 0,05), LPSB leaded to decreased necessity of intraoperative fluid loading and blood loss at the recovery room (p< 0,05). Overall patient’s satisfaction till leaving the recovery room, Visual Analogue Score (VAS) intraoperatively, 4 and 8hours postoperatively and analgesic counts (recorded through the PCA) in the first 24hours were statistically significant between two groups, in favor of patients with LPSB.

Conclusion: PLSB is an effective alternative to spinal anesthesia taking into account basic clinical and anaesthesiological parameters intraoperatively and immediate postoperatively. Concerning postoperative pain and required administration of analgesics during the first 24hours, LPSB is more efficient compared to SA, underlining the importance of overall patient’s satisfaction during the first postoperative day.

INTRODUCTION: The process of ligamentization includes the histological and structural remodelling of the tendons graft to ligamentous tissue. There is little information documenting the mechanism of ligamentization process in molecular level. A number of essential genes are involved in this process and their expression can be regulated through complex biochemical pathways. Animal studies have shown that transcutaneous application of low intensity pulsed ultrasound (LiUS) accelerate the tendon and ligament healing process and recent reports have proven the efficacy of the transosseous application of LiUS for both enhancement and monitoring of the bone healing. The purpose of this study is to investigate the effect of transosseous low-intensity pulsed ultrasound (LiUS) during lingamentization process on the healing at tendon graft-bone interface in rabbits, by examining the expression levels of TGF-β1, biglycan and collagen I using semi-quantitive RT-PCR.

MATERIALS AND METHODS: Twenty-eight New Zealand rabbits were used in this study. The anterior cruciate ligament was excised and replaced with the long digital extensor. Custom-made ultrasound transducers were implanted onto the bone fragment and along the surface of the bone tunnel at the right knees of the rabbits (study group). The LiUS-treated animals received 200-μsec bursts of 1 MHz sine waves with pulse repetition rates of 1 KHz and average intensity of 30 mW/cm2, for 20 minutes daily, while the left knee received no LiUS (control group). Semi-quantitative RT-PCR was performed from RNA samples representing both study and control groups at 1, 2, 3, 5, 7, 8, 9, 12, 14 and 21 days, using specific primers.

RESULTS: Analysis of the RT-PCR products showed that there is significant up-regulation of biglycan and collagen-encoding genes in the study group compared to the control group. In addition, TGFb1-encoding gene exhibits a bimodal profile. In the study group, it represses its mRNA levels from day 1 until day 9 and then the initial expression levels are restored. The control group showed no essential alteration of expression levels for TGFb1.

DISCUSSION: Transosseous LiUS treatment affects the expression levels of significant genes like TGF-β1, big-lycan and collagen type I. All the above studied genes mediate important biochemical pathways in lingamentization process and possibly enhance the healing rate of the tendon graft-bone interface in a bone tunnel in rabbits. The present report is supportive of the hypothesis that transosseous application of LiUS enhances tendon graft healing to bone through effects on molecular level. These present findings suggest that indeed ultrasound treatment after joint ligament reconstruction may facilitate earlier rehabilitation.

We report the clinical and radiological results of a two- to three-year prospective randomised study which was designed to compare a minimally-invasive technique with a standard technique in total knee replacement and was undertaken between January 2004 and May 2007. The mini-midvastus approach was used on 50 patients (group A) and a standard approach on 50 patients (group B). The mean follow-up in both groups was 23 months (24 to 35).

The functional outcome was better in group A up to nine months after operation, as shown by statistically significant differences in the mean function score, mean total score and the mean Oxford knee score (all, p = 0.05). Patients in group A had statistically significant greater early flexion (p = 0.04) and reached their greatest mean knee flexion of 126.5° (95° to 135°) 21 days after operation. However, at final follow-up there was no significant difference in the mean maximum flexion between the groups (p = 0.08). Technical errors were identified in six patients from group A (12%) on radiological evaluation.

Based on these results, the authors currently use minimally-invasive techniques in total knee replacement in selected cases only.

We have evaluated the effect of the short-term administration of low therapeutic doses of modern COX-2 inhibitors on the healing of fractures.

A total of 40 adult male New Zealand rabbits were divided into five groups. A mid-diaphyseal osteotomy of the right ulna was performed and either normal saline, prednisolone, indometacin, meloxicam or rofecoxib was administered for five days. Radiological, biomechanical and histomorphometric evaluation was performed at six weeks.

In the group in which the highly selective anti-COX-2 agent, rofecoxib, was used the incidence of radiologically-incomplete union was similar to that in the control group. All the biomechanical parameters were statistically significantly lower in both the prednisolone and indometacin (p = 0.01) and in the meloxicam (p = 0.04) groups compared with the control group. Only the fracture load values were found to be statistically significantly lower (p = 0.05) in the rofecoxib group. Histomorphometric parameters were adversely affected in all groups with the specimens of the rofecoxib group showing the least negative effect.

Our findings indicated that the short-term administration of low therapeutic doses of a highly selective COX-2 inhibitor had a minor negative effect on bone healing.

Introduction: Surgery in the foot and ankle is usually performed under general or spinal anaesthesia. Peripheral nerve blocking is gaining the preference of both surgeons and patients. The aim of this study is to evaluate the adequacy of anaesthesia with the method of triple nerve blocking at the region of the knee.

Materials and methods: One hundred and forty-four patients (79 men and 65 women) that were diagnosed with ankle and foot injuries or diseases underwent surgery using triple nerve blocking at the knee region as a method of anaesthesia. Surgical procedures included bone and soft tissue procedures and especially fracture fixation, osteotomies, tendon repairs, neuroma and tumor excisions, nerve decompressions and arthrodeses. The common peroneal, tibial and saphenous nerves were blocked with injection of 8 ml ropivacaine 2% for each nerve. The injection was performed by an Orthopaedic surgeon with the use of a neurostimulator. An anesthesiologist was available when necessary.

Results: Ninety-four patients tolerated the procedure without the need of additional injection of anaesthesia or analgesia. In 45 patients additional injection of local anesthetic was necessary. Five patients needed intravenous injection of analgesia in order to complete the procedure. Patients were mobilized the day of surgery, reducing in that way hospital stay. Hospitalization ranged from 0 to 1 days with 58 patients discharged the day of the operation. No complication related to the injection of the anestheric was observed.

Conclusion: Triple nerve blocking at the knee, as a method of anaesthesia, is proposed for certain procedures in the foot and ankle; it allows early mobilization of patients and reduces length of hospital stay. If the neurostimulator is used appropriately, the rate of patients that needs additional analgesia intraoperatively is diminished and no adverse effects of the local anestheric are observed. Complications observed with the practice of spinal or general anesthesia are avoided.