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.
Single shot interscalene blocks are an effective analgesic for arthroscopic shoulder surgery. However, patients receiving these blocks are often found to be in significant pain when the block wears off, usually in the late evening or early hours of the morning. Overnight admission is currently routine in our unit, to ensure adequate analgesia can be administered during this period. Recent studies have suggested that adding dexamethasone to the local anaesthetic agent can prolong the duration of the block. We carried out a prospective study to assess whether addition of dexamethasone to brachial plexus blocks could reduce patient's post-operative analgesic demands and allow safe discharge on the same day after surgery. Twenty-six patients undergoing arthroscopic shoulder surgery during a morning theatre list, had ultrasound guided brachial plexus blocks using a mixture of 0.25% bupivacaine 20–30ml with 2–3mg of dexamethasone. All were admitted to the ward afterwards for analgesia and physiotherapy. Pain numerical rating scores (0–10) were recorded at rest in recovery one hour postoperatively by the attending anaesthetist and on active movement of the shoulder joint 24 hours after surgery by the attending physiotherapist. A standardised analgesia regime was prescribed with regular and as required medication, including as required strong opiates. Mean pain scores in recovery were 0.31 and on the morning after surgery were 2.38. Sixteen out of 26 required no further analgesia, with only 3 out of the 10 who did requiring opiates. The use of dexamethasone provides adequate analgesia for a prolonged period for most patients after brachial plexus block for shoulder surgery and does not result in a significant analgesic requirement when the block wears off. This may provide support for avoiding overnight admission in selected patients after arthroscopic shoulder surgery.
Intervention is rare following minimally displaced radial head fractures or positive elbow ‘fat pad’ signs. A pilot study (n=20) found no patient required active treatment after discharge following their first fracture clinic visit. We therefore initiated routine discharge from A&E with an advice sheet, and an ‘open-door policy’ if patients failed to progress. 51 patients were managed by A&E according to this protocol over a six-month period. A standardised assessment of symptoms, satisfaction and functional limitation was completed for 24 patients by phone; average time to follow-up 4.2 months (range 2–9 months). Fourteen (58.4%) reported no pain. The 10 patients (41.6%) with on-going pain reported a median visual analogue score (VAS 0–10) of 0.7 (0–4) at rest, 0.25 (0–4) at night, 3.0 (0–10) carrying heavy objects and 2.75 (0–10) during repetitive movement. 4 of 24 (16.7%) reported minor functional impairment. 3 of 24 (12.5%) patients requested orthopaedic review, but all were satisfied with outcome, seeking reassurance and discharged without any intervention. 3 of 24 (12.5%) were unhappy with their progress, but all had suffered from chronic pain or psychological conditions predating their injury. When offered further review, none of these patients accepted. 22 (91%) were satisfied with their treatment and 23 (95.8%) returned to work and hobbies. This data suggests routine discharge from A&E with advice does not compromise care, as no intervention is usually required beyond advice. These findings have obvious positive clinical and financial implications in streamlining clinical workload.
Doubt has been cast over the accuracy of dermatome charts. This study investigated a large group of patients with known lumbar nerve root compression (NRC), and identified whether their radicular pain corresponded with the predicted distribution on a dermatome chart. The study included 209 patients that presented with lumbar radiculopathy. 106 were confirmed as L5 NRC and 103 as S1 NRC, by MRI. Each patient used an interactive computer assessment program to record their pain on a body map image. The coordinates were then used to compare the sensory distribution to a standard dermatome chart.Background
Methods
The reinfusion of perioperative cell salvage is one method employed to reduce exposure to donor blood. Data on the safety of this process, however, are scant. Notably, the effect of intraoperative, washed cell salvage reinfusion on prothrombotic markers has not been demonstrated. The risk of postoperative venous thromboembolism following major orthopaedic operations is not insignificant. The study objective was to assess the effect of cell salvage reinfusion on coagulation and platelet activation. Twenty-one patients undergoing elective primary hip operations were recruited. Nine patients received washed cell salvage intraoperatively, and were compared with 12 patients undergoing similar surgery that did not. Two patients in the cell salvage group also received postoperative, unwashed cell salvage. Blood samples were collected pre-operatively, immediately post-operatively, and one day post-operatively for assays of platelet activation markers, P-selectin expression and fibrinogen binding by flow cytometry in diluted whole blood; coagulation activation marker, thrombin-antithrombin complex (TAT); D-dimer by ELISA, thrombin generation by chromogenic assay, and full blood count. Samples of cell salvage material were also analysed for prothrombotic markers. There were no significant differences between the groups preoperatively. Postoperatively haemoglobin levels did not differ significantly between the cell salvage group and controls. Postoperative TAT and D-dimer were significantly higher in the cell salvage group compared with controls (p<0.05). One day postoperatively, there were significantly higher platelet P-selectin expression (p=0.006) and platelet fibrinogen binding (p=0.004) in the cell salvage group compared with controls. The white cell count (WCC) was also significantly higher (p=0.04). In the intraoperative washed cell salvage material, and in postoperative cell salvage, the platelet count was low, but significant proportions of platelets were activated, and levels of D-dimer were elevated compared with venous blood. The postoperative salvage material also contained high levels of TAT. The results from this pilot study show the induction of a prothrombotic state following reinfusion of intraoperative, washed cell salvage in recipients undergoing primary elective hip operations. An inflammatory response to reinfusion is also indicated by the raised WCC. Further investigation into the safety of cell salvage is indicated.
Injuries to the spinal cord may be associated with increased healing of fractures. This can be of benefit, but excessive bone growth can also cause considerable adverse effects. We evaluated two groups of patients with fractures of the spinal column, those with neurological compromise (n = 10) and those without (n = 15), and also a control group with an isolated fracture of a long bone (n = 12). The level of transforming growth factor-beta (TGF-β), was measured at five time points after injury (days 1, 5, 10, 42 and 84). The peak level of 142.79 ng/ml was found at day 84 in the neurology group (p <
0.001 Our findings suggest that TGF-β may have a role in the increased bone turnover and attendant complications seen in patients with acute injuries to the spinal cord.
