Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures. We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs. This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated. Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07). HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments

Osseous first ray surgery is a common day case procedure. Patients are often given regional blocks. We sought to find if there is a difference between ankle block and metatarsal block in this group of patients. After ethical approval was granted and power analysis performed, 25 patients were recruited into each arm of the study. These patients were having either an osteotomy or arthrodesis. All patients had standardised general anaesthesia and received 20mls of 0.5% chirocaine for the blockade. The cohort having the ankle block had infiltration under ultrasound guidance in the anaesthetic room; and the cohort receiving the metatarsal block had infiltration at the end of the procedure. The timings of both the anaesthesia and the operation were recorded for each patient. Patients scored their pain level at 2, 6 and 24 hours. The amount of post-operative analgesia used in the first 24 hours was also recorded by the research nurse. All patients were discharged home with a standardised prescription of analgesia. Analysis of the pain scores showed that there was no difference between the two blocks at any measured time period. Nor was there a difference in the analgesic requirement in the first 24 hours. There was, however, a difference in the time taken for the whole procedure: with the ankle block taking an average of ten minutes more. We conclude that metatarsal blocks are as effective as ankle blocks in providing pain relief after osseous first ray surgery, and may be a more efficient use of time

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

Background: Subacromial decompression surgery is associated with significant postoperative pain. We compared the effect of intrascalene block (ISB) and sub-acromial bursa block (SBB) with simple opiate based analgesia. Methods: In a prospective, randomised controlled trial, fifty-three (n = 53) patients scheduled for arthroscopic subacromial decompression were randomised into three groups receiving Intrascalene block (n =19), Subacromial Bursa block (n =19) or neither of the two blocks (n =15 controls). Patients with cuff pathology were excluded. ISB was performed preoperatively with 20 mls of 1% Prilocaine and 10 mls of 0.5 % Bupivacaine. SBB was given with 20 mls of 0.5% Bupivacaine postoperatively. All patients received standardised general anaesthetic and postoperative analgesia. Pain, sickness and sedation scores were noted at 1, 2, 4, 8, 12 and 24 hours postoperatively. The postoperative consumption of morphine and the time when the first bolus of morphine was required were also noted. Results: The visual analogue pain scores in the ISB and SBB group were lower than the control group in the first twelve hours postoperatively achieving statistical significance but there were no significant differences between the SBB and ISB groups. The controls consumed more morphine postoperatively (mean 32.3 mls) than SBB (21.21 mls) and ISB groups (14.00 mls) (p < 0.001). The time for first bolus was earlier in the controls (mean 30.2 mins) as compared to both SBB (72.7 mins) and ISB groups (105.8 mins) (p< 0.001). The oral analgesic intake was less in the SBB and ISB groups than the controls (p = 0.004), but there was no difference between the two treatment groups. Conclusion: Whilst intrascalene block remains the gold standard where expertise is available for its administration, subacromial bursa block is a safe alternative in patients with intact rotator cuff undergoing arthroscopic subacromial decompression

Aims. There are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) fixation. Methods. Eight finite element models (FEMs), comprising four different femoral diameters, with and without blocking screws, were constructed, and unstable intertrochanteric fractures fixed with short CMNs were reproduced in all FEMs. Micromotions of distal shaft fragment related to proximal fragment, and stress concentrations at the nail construct were measured. Results. Micromotions in FEMs without a blocking screw significantly increased as nail/medullary canal mismatch increased, but were similar between FEMs with a blocking screw regardless of mismatch. Stress concentration at the nail construct was observed at the junction of the nail body and lag screw in all FEMs, and increased as nail/medullary canal mismatch increased, regardless of blocking screws. Mean stresses over regions of interest in FEMs with a blocking screw were much lower than regions of interest in those without. Mean stresses in FEMs with a blocking screw were lower than the yield strength, yet mean stresses in FEMs without blocking screws having 8 mm and 10 mm mismatch exceeded the yield strength. All mean stresses at distal locking screws were less than the yield strength. Conclusion. Using an additional anteroposterior blocking screw may be a simple and effective method to enhance fixation stability in unstable pertrochanteric fractures with a large nail/medullary canal mismatch due to osteoporosis. Cite this article: Bone Joint Res 2022;11(3):152–161

The postoperative pain after hip arthroscopy remains a major challenge in the immediate postoperative period. Adequate postoperative analgesia has been associated with increased patient satisfaction and decreased consumption of opioids. We evaluated the efficacy of pericapsular nerve group block (PENG) versus fascia iliaca block (FIB) in reducing post-operative pain and analgesic consumption within the first 24 hours following arthroscopic management of femoroacetabular impingement (FAI). Thirty-nine patients (17 females and 25 males, ages 18–42 years, mean ± SD (27.9 ± 6.2), and mean BMI of 25.13±5.08 kg/m2 were scheduled for primary arthroscopic management of FAI. Included patients were randomized into two groups according to the block used in each. Group (A) 19 patients were included and had FIB and group (B) 20 patients were included and received PENG block. The efficacy of both techniques was clinically and statistically valuated using VAS score and quadriceps muscle power. There was a statically significance difference in the mean at rest between the two groups at all measured time points following surgery (6, 12, 18 and 24 h). Also, in dynamic pain scores (with hip flexion) scores were statistically significant at 24 hours post-operative (P = .001). Total opioid consumption in the first 24 hours postoperative was lower in the PENG group with significant difference of mean 16.5 ±9.9 mg for PENG group versus 27.5±9.6 mg for FIB group (P < .005). Five patients (26.31%) in FIB group had weaker quadriceps muscle power while none in PENG group patients had quadriceps weakness. PENG block might be considered as an ideal regional anesthesia modality for hip arthroscopy. As an alternative to more conventional regional nerve blocks such as a fascia iliaca block. PENG block is easily performed in the preoperative setting, and appears to spare motor function while providing a prolonged sensory pain relief

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery

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. Methodology. Prospective single-surgeon case-series evaluating patients undergoing surgery by this technique. 76 cases (mean age of 33.2 years) who had primary ACL reconstruction with BTB or quadriceps tendon with bone block, were divided into 2 matched groups (age, sex and type of graft) of 38 each based on the method of femoral fixation used (interference screw or adjustable cortical suspension). Patients were followed up clinically and using PROMS from NLR with EQ-5D, KOOS, IKDC and Tegner scores. Complications and return to theatre were noted. Paired two-tailed student t-tests and Chi-square tests were employed for statistical analysis. Results. At a mean follow-up of 82 months, peri-operative mean EQ-5D VAS, EQ-5D Index, KOOS, IKDC and Tegner activity scores showed significant improvement (p<0.05), but no significant difference between the two groups (p>0.05). Mean graft length and diameter was 77mm and 9.3 respectively. Mean interval from injury to surgery was 10.5 months. 18(23.7%) patients had associated meniscal tear with 73.3 % undergoing repair. 10 cases (13.2 %) returned to theatre including, MUA for arthrofibrosis (n=2) and intra-substance graft failure (n=2). 3 cases had to be converted to interference screw fixation due to the tightrope cutting through from the femoral bone block as a result of a technical pitfall. Conclusion. Primary ACL reconstruction using adjustable cortical suspension on femoral side for BTB or quadriceps bone-block tendon graft is a safe technique with added advantages of 360 degree bone ingrowth and no screw in the femoral tunnel

Aims

Control of acute pain following knee arthroplasty (KA) with a perioperative peripheral nerve block (PNB) may improve functional outcomes and reduce the risk of chronic postoperative knee pain (CPKP). The aims of this study were to assess whether a PNB influences patient-reported outcomes and risk of CPKP at one year following KA.

Introduction. Multimodal pain management strategies are now commonplace in perioperative management of total knee arthroplasty (TKA), although controversy remains regarding the role of adductor canal blocks (ACB) in this algorithm. Proposed benefits include theoretical decreased role of perioperative narcotic pain medication, improved function with physical therapy postoperatively, shorter duration of hospital stay and improved patient satisfaction. Those opposed cite increased cost and risk of complications including inadvertent motor blockade. The purpose of this study was to independently evaluate the effect of adductor canal block on short-term post-operative outcomes including (1) length of stay (LOS), (2) post-operative narcotic utilization, and (3) function with physical therapy in the era of modern TKA. Methods. Our institutional database was utilized to retrospectively identify a cohort of consecutive patients from January 2014-January 2018 who had undergone unilateral primary TKA with a single surgeon utilizing a preoperative single-shot ACB in addition to a standardized multimodal pain regimen versus those that only received the same multimodal pain regimen (no-ACB). The primary reason that a patient did not receive a preoperative block was lack of availability of the block team The time period of interest was selected based on the implementation of our current pain protocols. The multimodal pain regimen consists of: preoperative Tylenol, a periarticular injection intraoperatively including 0.5% Marcaine and Toradol, IV Toradol postoperatively, Percocet, Celebrex and IV narcotic medication for breakthrough pain. These 2 groups were compared utilizing independent sample T-tests with primary endpoints of interest being LOS (in total hours and as %day 1 discharges (%POD1)), distance ambulated with inpatient therapy on postoperative day 1, and inpatient narcotic use as measured in morphine equivalents per hour. A sub-cohort of patients with adductor canal block was then selected based on time of surgery to control for time of discharge and hours in the hospital to isolate the effect of the block. Results. There were 624 patients in the ACB group, with a mean age of 64.5 years. The group without ACB consisted of 69 patients, with a mean age of 67.2 years. The no-ACB group was slightly older (p=0.024) but not significantly different in terms of BMI (32.6 vs 31.7, p=0.291). The ACB group ambulated significantly further with inpatient therapy on postoperative day 1 (75.8 vs 59.9 ft, p=0.008), had a shorter LOS in both total hours and %POD1 (34.8 vs 40.6 hours, p=0.01, 83% vs 66.6%, p=0.01). Finally, there was no significant difference between the 2 groups in narcotic utilization postoperatively (2.361 vs 2.0 97, p=0.088). The subcohort of patients that had adductor canal blocks who had their surgery in the afternoon (n=157) were compared to the remainder of the patients to control for LOS data and no statistical differences were seen in either total hospital hours or %POD1. Conclusion. Adductor canal blocks did not decrease post-operative pain medication utilization. The modest improvement in distance ambulated with therapy on POD1 (16 ft) and length of stay (16% greater POD1 discharges) of hospitalization may not support the cost effectiveness of this intervention

Purpose of the study: The purpose of this study was to determine the feasibility and reproducibility of a new arthroscopic procedure combining a Bristow-Latarjet lock with Bankart reinsertion of the lambrum. Material and methods: Forty-seven consecutive patients with significant bone defects in the glenoid and a deficient capsule were treated arthroscopically: arthroscopic Bankart had failed in six. The procedure was performed exclusively arthroscopically using a special instrumentation: after its osteotomy and identification of the axiallary nerve, the coracoids was passed through the subcapular muscle with its tendon; the block was fixed on the scapular neck after 90° lateral rotation so as to prolong the natural concavity of the glenoid. Anchors and sutures were then used to refix the capsule and the labrum onto the glenoid border, leaving the block in an extra-articular position. Follow-up included a physical examination and standard x-rays at 45, 90 and 180 days; 31 patients had a postoperative scan. Three independent operators read the images. Results: The procedure was completed arthroscopically in 41 of 47 patients (8%); conversion to a deltopectoral approach was required for six patients (12%). The axillary nerve was successfully identified in all shoulders. The block had a subequatorial position in 98% (46/47 shoulders) and equatorial in one. The block was tangent to the surface of the glenoid in 92% (43/47), lateral in one (2%) and too medial (> 5mm) in three (6%). One patient presented an early fracture of the block and five patients exhibited block migration; there was a partial lysis of the block in two patients. The final rate of nonunion of the block was 13% (6/47). Fractures, migrations and non-unions were related to technical errors: screws too short (unicortical) and/or poorly centred in the block. Conclusion: Our results show that arthroscopic transfer of the coracoids to the scapular neck is a safe and successful operation. The rate of correctly positioned healed blocks was equivalent or superior to conventional techniques. The complications observed show that the arthroscopic block technique is difficult with a long learning curve

Occlusion of the femoral canal is an important step in cemented hip arthroplasty. The goal of occlusion is to allow cement pressurisation and prevent cement egress into the femoral diaphysis. There are numerous designs of cement plugs made out of different materials but there is no consensus or clinical guideline for the choice of cement restrictors. At our centre two types of plugs are used – autologous bone block from femoral canal and the gelatine C-plug (Depuy International). We conducted this study to evaluate the stability of these two plugs and their effect on quality of cementation. The purpose of our study was to assess retrospectively both the length of the “cement tail” i.e. the length of the cement column distal to the stem tip and the cement mantle quality in both groups. A retrospective comparative review was designed after approval from the local R & D department. Power analysis indicated that a minimum of 74 patients per group would be needed. A total of 203 consecutive patients were analysed, 89 received an autologous bone block and 114 had C-plugs. Apart from the plugs both the groups were treated similarly with regards to surgical approach, cementing and operative technique. Surgical technique was to achieve adequate pressurisation and a minimum length of cement tail. Immediate post-operative radiographs were used for analysis. The primary outcome measure was the length of the cement tail, i.e. the length of the cement column from the tip of the stem. The secondary outcome measure was the quality of cementing which was quantified using Barrack's grading. The data was tested for normality using the Shapiro-Wilk test. The means of cement tail lengths in between the two groups were compared using the Wilcoxon ranked sum test. The cementation grades were compared using ANOVA. The correlation between the length of cement tail and the quality of cementation was calculated using ordinal regression. Both the groups were similar in terms of age, sex and primary diagnosis. The mean cement tail length was 6.42 (SE 0.71 mms; range-0–31) in the bone block group and 17.11 (SE-1.34 mms; range 0–65.7 mms) in the C-plug group. This difference was statistically significant (p< 0.0001). The proportion of patients with good quality of cementation (grade A) was significantly higher in the bone block group (80.6%) as compared to the C-plug group (56%) (p < 0.0001). There was a negative correlation between the length of the cement tail and the Barrack grade (rho=0.398), indicating that a short cement tail is associated with better quality cementation. Quality of cementation is of paramount importance in cemented hip arthroplasty. Revision surgery can be more difficult and higher risk in the presence of a long cement tail. We have shown that better quality cementation and shorter cement tails can be achieved with the cheapest of all options for canal occlusion, an autologous bone block and recommend its use

Abstract. Objective. To investigate the safety and cost-effectiveness of interscalene brachial plexus block/regional anaesthesia (ISB-RA) in patients undergoing reverse total shoulder replacement. Methods. This retrospective study included 15 patients with symptomatic rotator cuff arthropathy who underwent reverse total shoulder arthroplasty (rTSA) under ISB-RA without general anaesthesia in the beach chair position from 2010 to 2018. The mean patient age was 77 years (range 59–82 years). Patients had associated medical comorbidities: American Society of Anesthesiologists (ASA) grade 2–4. Assessed parameters were: duration of anaesthesia, intra-operative systolic blood pressure variation, sedation and vasopressor use, duration of post-operative recovery, recovery scores, length of stay, and complications. A robust cost analysis was also performed. Results. The mean (range) duration of anaesthesia was 38.66 (20–60) min. Maximum and minimum intra-operative systolic blood pressure ranges were 130–210 and 75–145 mmHg, respectively (mean [range] drop, 74.13 [33–125] mmHg). Mean (range) propofol dose was 1.74 (1–3.0) mg/kg/h. The Median (interquartile range) post-operative recovery time was 30 (20–50) min. The mean (range) postoperative recovery score (local scale, range 5–28 where lower values are superior) was 5.2 (5–8). The mean (range) length of stay was 8 (1–20 days); the two included patients with ASA grade 2 were both discharged within 24 hours. One patient with predisposing history developed pneumonia; however, there were no complications related to ISB-RA. The mean (range) cost per patient was £101.36 (£59.80-£132.20). Conclusions. Our data demonstrate that rTSA under ISB-RA is safe, cost-effective and a potentially viable alternative for patients with multiple comorbidities. Notably, patients with ASA grade 2 who underwent rTSA under ISB-RA had a reduced length of stay and were discharged within 24 hours

Abstract. Introduction. To compare the efficacy of adductor canal blocks (ACB) and periarticular anesthetic injections (PAI) with bupivacaine in total knee arthroplasty. Methods. 90 patients undergoing primary total knee arthroplasty under spinal anesthesia were randomized to 1 of 3 groups: ACB alone (15 mL of 0.5% bupivacaine), PAI alone (50 mL of 0.25% bupivacaine with epinephrine) and ACB + PAI. Primary outcome in this study was the visual analog scale (VAS) pain score in the immediate postoperative period. Secondary outcomes included postoperative opioid use, activity level during physiotheraphy, length of hospital stay and ROM. Results. Mean VAS pain score was significantly higher with ACB alone, compared with the score after use of ACB+PAI, on POD1 and POD3. Total opioid consumption through POD3 was significantly higher when ACB alone had been used compared with PAI alone and ACB+PAI. Opioid consumption in the ACB-alone group was significantly higher than that in the ACB + PAI group on POD2 and POD3 and significantly higher than that in the PAI alone group on POD2. There was no significant difference in opioid consumption between the patients treated with PAI alone and those who received ACB + PAI. The activity level during physiotherapy on POD0 was significantly lower after use of ACB alone than after use of PAI alone or ACB + PAI. Conclusion. Higher pain scores after total knee arthroplasty done with an ACB and without PAI, suggesting that ACB alone is inferior for perioperative pain control. There were no significant differences between ACB alone, PAI alone and ACB + PAI inparameters measured

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

Regional anaesthetic for foot surgery has been discussed as a method of post operative analgesia. Ankle block as the sole anaesthetic for foot surgery has not been extensively reviewed in the literature. We aimed to describe our experience of forefoot surgery under ankle block alone. 21 consecutive forefoot procedures (18 patients) were carried out under ankle block. The blocks were performed by the senior authors. A mixture of 10ml 2% Lidocaine with 10ml 0.5 % Bupivacaine was administered to the superficial peroneal, deep peroneal, sural and saphenous nerves. Ankle tourniquet was employed in all procedures. The patients were contacted post operatively and completed a standardised questionnaire including an incremented pain assessment ranging from 0-10 (0 no pain, 10 severe pain). 17 female and 1 male patients were contacted (age range 33-67y). Procedures included 13 first metatarsal osteotomies, 3 cheilectomies, 2 first MTP joint replacements, and 5 fusions. 14 patients requested a short acting sedative (midazolam). 5 patients (27 %) reported some discomfort during the block procedure (average pain score 1.2). No patients reported any pain during their operation(s). 4 patients (22%) required supplementation of the block. Average pain score at 6, 12, 24 and 48 hours following surgery were 0.66, 2.9, 2.4 and 1.3 respectively. All patients were discharged home and walking on the same day. None complained of nausea or required parenteral analgesia; there were no readmissions. Each patient confirmed they would have surgery under local block rather than general anaesthesia and would recommend this technique to family and friends. Forefoot surgery under ankle block alone is safe and effective. Anaesthesia obtained permits the majority of forefoot procedures and provides lasting post-operative analgesia. Combined with intraoperative sedation, use of ankle tourniquet and same day discharge, it has very high patient acceptance and satisfaction

Introduction. Fast track arthroplasty regimens require preservation of motor power to perform early rehabilitation and ensure early discharge (1). Commonly performed nerve blocks like femoral and Sciatic nerve blocks results in motor weakness thereby interfering with early rehabilitation and may also predispose to patient falls (2, 3). Hence, targeting the terminal branches of the femoral and sciatic nerves around the knee joint under ultrasound is an attractive strategy. The nerve supply of interest for knee analgesia are the terminal branches of the femoral nerve, the genicular branches of the lateral cutaneous nerve of thigh, obturator and sciatic nerves (4). Methods. We modified the performance of the adductor canal block and combined it with US guided posterior pericapsular injection and lateral femoral cutaneous nerve block to provide analgesia around the knee joint. The femoral artery is first traced under the sartorius muscle until the origin of descending geniculate artery and the block is performed proximal to its origin. A needle is inserted in-plane between the Sartorius and rectus femoris above the fascia lata and 5 ml of 0.5% ropivacaine (LA) is injected to block the intermediate cutaneous nerve of thigh. The needle is then redirected to enter the fascia of Sartorius to deliver an additional 5ml of LA to cover the medial cutaneous nerve of thigh following which it is further advanced till the needle tip is seen to lie adjacent to the femoral artery under the Sartorius to perform the adductor canal block with an additional 15–20 ml of LA to cover nerve to vastus medialis, saphenous nerve and posterior division of the obturator nerve (Fig 1). The lateral cutaneous nerve of thigh is optionally blocked with 10 ml of LA near the anterior superior iliac spine between the origin of Sartorius and tensor fascia lata (Fig 2). The terminal branches of sciatic nerve to the knee joint is blocked by depositing 25 ml of local anesthetic solution between the popliteal artery and femur bone at the level of femoral epicondyles (Fig 3). Results. The initial experience of the block performed on 10 patients reveal the median (IQR) block duration is noted to be around 20 (±6.5) hours. The median (IQR) pain scores in the first 24 postoperative hours ranged from 0 (±0.5) to 3 (±2.5) at rest and 1.5 (±3.5) to 5.5 (±1) on movement. All patients were successfully mobilized on the morning of the first postoperative day. Conclusion. Motor sparing from the blocks while providing adequate analgesia can be achieved by selectively targeting the sensory innervation of the knee joint. Future comparative studies are needed to evaluate the performance of the block against other modes of analgesia for knee arthroplasty

We present the long-term outcome, at a median of 18 years (12.8 to 23.5) of open posterior bone block stabilisation for recurrent posterior instability of the shoulder in a heterogenous group of 11 patients previously reported on in 2001 at a median follow-up of six years. We found that five (45%) would not have chosen the operation again, and that four (36%) had further posterior dislocation. Clinical outcome was significantly worse after 18 years than after six years of follow-up (median Rowe score of 60 versus 90 (p = 0.027)). The median Western Ontario Shoulder Index was 60% (37% to 100%) at 18 years’ follow-up, which is a moderate score. At the time of surgery four (36%) had glenohumeral radiological osteoarthritis, which was present in all after 18 years. This study showed poor long-term results of the posterior bone block procedure for posterior instability and a high rate of glenohumeral osteoarthritis although three patients with post-traumatic instability were pleased with the result of their operations

The evaluation of our results from the use of transscalen block in shoulder surgery. During September 2008 – March 2009, in our institution 25 patients underwent different types of shoulder surgery. Fifteen patients were male and ten female with mean age 56 y.o. Shoulder pathology included fractures, rotator cuff tears, subacromial decompression. Two of the patients received general anaesthesia because of anatomic variations to the neck and the rest twenty three of them underwent a transcalen block as method for anaesthesia. For the block all the patients received 20 ml Naropeine 7.5% and 10 ml NaCl 0. Two out of twenty three patients received, during the beginning of surgery, general anaesthesia because of pain. There were no other complications, regarding the anaesthesia, during the surgery. The postoperative analgesia was 8.5 hours in average. None of the patients received postoperatively any strong analgetics. We believe that the use of transcalen block is a safe and secure method of anaesthesia for the shoulder surgery with excellent analgetics results