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

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

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

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

Forefoot surgery causes postoperative pain which requires strong painkillers. Regional blocks are now increasingly used in order to control postoperative pain especially in the first twenty four hours when the pain is at its worst. We conducted a study to see whether timing of ankle block i.e. before or after application of tourniquet shows any difference in efficacy in postoperative analgesia in first twenty four hours. A prospective study was conducted between September and March 2011 involving 50 patients. Group A had ankle block after and Group B had block before application of tourniquet. Both group had twenty five patients each. Patients were given assessment forms to chart their pain on Visual Analogue Scale (VAS) at 4hrs and twenty four hours after surgery. Both groups demonstrated good postoperative pain control. Average pain score at four and twenty fours after surgery was 2.5 and 5 in Group A and 3.5 and 6.1 in Group B respectively. Pain control, both at four and twenty four hours surgery was better in Group A but this was not statistically significant. Ankle block should be routinely used in forefoot surgery to control postoperative pain. Ankle block before or after the application of tourniquet had comparable pain relief with no statistical difference

Introduction. Revision total knee arthroplasy (TKA) has been often used with a metal block augmentation for patients with poor bone quality. However, bone resorption beneath metal block augmentation has been still reported and little information about the reasons of the occurrence of bone resorption is available. The aim of the current study is to identify a possibility of the potential occurrence of bone resorption beneath metal block augmentation, through evaluation of strain distribution beneath metal block augmentation in revision TKA with metal block augmentation, during high deep flexion. Materials and Method. LOSPA, revision TKA with a metal block augmentation (Baseplate size #5, Spacer size #5, Stem size Φ9, L30, Augment #5 T5) was considered in this study. For the test, the tibia component of LOSPA was implanted to the tibia sawbone (left, #3401, Sawbones EuropeAB, Malmö, Sweden), which was corresponded to a traditional TKR surgical guideline. The femoral component of LOSPA was mounted to a customized jig attached to the Instron 8872 (Instron, Norwood, MA, USA), which was designed specially to represent the angles ranged from 0° to 140° with consideration of a rollback of knee joint (Figure. 1). Here, a compressive load of 1,600N (10N/s) was applied for each angle. Strain distribution was then measured from rossete strain gauge (Half Bridge type, CAS, Seoul, Korea) together (Figure 1). Results and Discussions. The strain distribution on the cortical bone of the tibia was shown in Figure 2. The results showed that the strains on the posterior region were gradually increased from extension to high deep of the knee joint and generally larger than the other regions. In contrast to the results on the posterior region, the strains on the medial region were gradually decreased after 60° or 90° flexion position and relatively lower than the other regions. Particularly, the strains on the medial region were generally lower than 50–100 µstrain, which is known as critical value range able to inducing bone resorption, during high deep flexion. This fact indicate that a possibility of the potential bone resorption occurrence in revision TKA used with a metal block augmentation may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. This study may be valuable by identifying for the first time a possibility of the potential bone resorption occurrence through evaluation of the strain distribution beneath metal block augmentation in revision TKA used with a metal block augmentation during high deep flexion. Conclusion. A possibility of the potential bone resorption occurrence in revision TKA used with a metal block augmentation may be dependent on loading patterns applied on the knee joint related to personal lifestyle history. Particularly, it may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. Acknowledgements. This study was supported by a grant from the New Technology Product Evaluation Technical Research project, Ministry of Food and Drug Safety (MFDS), Republic of Korea

Introduction. Revision total knee arthroplasty (TKA) has been often used with a metal block augmentation for patients with poor bone quality. However, bone defects are frequently detected in revision TKA used with metal block augmentation. This study focused on identification of a potential possibility of the bone defect occurrence through the evaluation of the strain distribution on the cortical bone of the tibia implanted revision TKA with metal block augmentation, during high deep flexion. Materials and Methods. Composite tibia finite element (FE) model was developed and revision TKA FE model with a metal block augmentation (Baseplate size #5 44AP/67ML, Spacer size #5 44AP/67ML, Stem size Φ9, L30, Augment #5 44AP/67ML thickness 5mm) was integrated with the composite tibia FE model. 0°, 30° 60°, 90°, 120° and 140° flexion positions were then considered with femoral rollback phenomenon [Fig 1.A]. A compressive load of 1,600N through the femoral component was applied to the composite tibia FE model integrated with the tibia component, sharing by the medial and lateral condyles, simulating a stance phase before toe-off [Fig 1.B]. Results and Discussions. The strain distribution on the cortical bone of the tibia was shown in [Fig 2]. The results showed that the strains on the posterior region were gradually increased from extension to high deep of the knee joint and generally larger than the other regions. This fact was favorably corresponded to the femoral rollback phenomenon in the knee joint, showing a good accuracy of our FE model. In contrast to the results on the posterior region, the strains on the medial region were gradually decreased after 60° or 90° flexion position and relatively lower than the other regions. Particularly, the strains on the medial region were generally lower than 50–100 µstrain, which is known as critical value range able to inducing bone loss, during high deep flexion. This fact indicate that a potential possibility of bone defect occurrence in revision TKA used with a metal block augmentation may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. This study may be valuable by identifying for the first time a potential possibility of the bone defect occurrence through evaluation of the strain distribution beneath metal block augmentation in revision TKA used with a metal block augmentation during high deep flexion. Conclusions. A potential possibility of bone defect occurrence in revision TKA used with a metal block augmentation may be dependent on loading patterns applied on the knee joint related to personal lifestyle history. Particularly, it may be relatively increased in patients who are frequently exposed to a personal lifestyle history with the loading conditions of the high flexion. Acknowledgements. This study was supported by a grant from the New Technology Product Evaluation Technical Research project, Ministry of Food and Drug Safety (MFDS), Republic of Korea

Hypothesis. Custom cutting blocks can produce similar alignment compared to computer navigated and conventional total knee arthroplasty (TKA) techniques. Method. We conducted a retrospective review of 37 patients who underwent TKA by a single surgeon in a teaching hospital setting. Groups were conventional method (10), computer assisted navigation (10), and custom blocks (18). The custom group was further subdivided to CT and MRI based blocks. Post-operative alignment was measured (blinded) using full length weight bearing radiographs at 18 weeks on average. Hospital records were reviewed to determine operative time, transfusion requirements, length of hospital stay, complications and cost. Results. Post-operative mechanical axis was within 3 degrees of neutral in 100% of the navigation group, 70% of the conventional group and 50% of the custom block group. Average alignment was within 1.8, 3.1 and 3.6 degrees of neutral for each group respectively. The operative time was greater for the computer navigation group (86.7 min) compared to the conventional (72.1) and MRI custom block groups which involved unfamiliar instrumentation (73.8). CT based block procedures involved otherwise familiar instruments and averaged 61.2 minutes. Length of hospital stay and complications were similar for all three groups. Total cost was the least for the conventional group. Increased costs were associated with computer equipment, pre-operative advanced imaging and custom blocks. Conclusions. Custom cutting blocks in this small series obtain worse radiographic positioning of total knee arthroplasty components compared to conventional and computer navigation techniques. Further studies with greater number of patients, CT alignment analysis and long-term follow-up are required

Introduction. We hereby present results of controlled randomized trial of use of popliteal block for pain relief in ankle and hind foot surgery. Materials and methods. We have studied 63 patients over period of 9 months. Patients who needed ankle or hind foot procedure were selected for trial. Patients were explained about the trial and popliteal block along with leaflets at preoperative clinics. Patients were randomized on the day of surgery. A sealed envelop stating whether patient will go to block group (A) or no block group (B) was opened in the anaesthetic room before the patient was anaesthetized. Patients were evaluated for subjective pain scores at 30 min, 6 hrs, 12 hrs and 24 hrs after surgery. Amount of anaelgesic required and time to first dose was documented. Popliteal blocks were given by one foot and ankle consultant and one trained fellow. The block was administered in lateral position at 0.8 mA stimulus to detect the nerve. The data was compared statistically between group A and B. Results. The average pain scores in Group A (33 pts) were 0.72, 1.60, 1.51 and 1.03 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. While in Group B (30 pts) it was 2.73, 5.5, 6.03 and 3.33 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. There was statistically significant difference in pain scores at 6 and 12 hrs. There was no statistically significant difference in pain scores at 30 min and 24 hrs. Time to the request for first analgesic was statistically longer in Group A. Conclusion. Popliteal block offers an effective way of pain relief in ankle and hind foot surgery. We believe that it may reduce amount of anaesthetic or anaelgesic drug requirement as well

Blockade of the suprascapular nerve (SSN) with local anaesthetic is used frequently in shoulder surgery and for chronic shoulder pain. Anatomical landmarks may be used to locate the nerve prior to infiltration with local anaesthetic, but ultrasound is becoming a popular to locate the nerve. Twelve cadaveric shoulders from 6 specimens were injected with dye using the landmark and ultrasound technique. The shoulders were scanned with computed tomography, and then dissected to ascertain the accuracy of each technique. Using CT scan results, we found the ultrasound group to be more accurate in placing the anaesthetic needle close to the suprascapular notch, and therefore nerve, and this was significant (p = 0.0009). When analysing the ink data, although we did not observe a significant difference in amount of nerve covered by ink, we did note a correlation, and, given this study group is small, that may be considered a statistical trend. This study, which is one of the largest cadaveric studies investigating landmark and ultrasound guided block of the suprascapular nerve and we believe the first to use CT, demonstrates that ultrasound guided block is significantly more accurate than the landmark technique, and would therefore recommend that ultrasound guidance be used when blocking the suprascapular nerve, given its higher accuracy and lower complication rate

Purpose. There is a large gap between UKA and TKA in terms of tissue preservation including bone stock and knee ligament. We have recently introduced bicompartmental UKA (Bi-UKA) to fill the gap and achieve more “physiological” knee than TKA. In this study, we report the short-term results of Bi-UKA. Subjects and Methods. Thirty knees in twenty-nine osteoarthritis patients who underwent Bi-UKA from December 2010 to December 2013 (6 males and 23 females, average age of 75) were clinically and radiologically evaluated with an average observation period of 19 months. The operative indications were (1)confirmed diagnosis of medial and lateral osteoarthritis or osteonecrosis with preserved status of patellofemoral joint; (2)range of knee flexion greater than 110°; (3)flexion contracture less than 20°; (4)clinically stable knee in the frontal and sagittal plane; (5)correctable knee deformity with fine knee congruency. In all cases, fixed type UKA was implanted through a tibia dependent cut using a spacer block. Zimmer Uni and TRIBRID UKA (Kyocera Medical Corporation) were implanted in 18 and 12 cases, respectively. Results. The mean JOA score improved significantly from 57 points preoperatively to 89 points postoperatively. With regard to ROM, the mean extension significantly improved from −6° to −1° (p<0.001), and the mean flexion was almost unchanged from 134° to 139°. Six knees achieved maximum flexion angles of more than 150°. The mean leg alignment was unchanged from 174.5° to 175.2°, although there were five knees in which alignment was corrected by more than 10° after the surgery. All implant alingnments were reasonably acceptable and particularly, the gaps of setting angle between medial and lateral components were quite small in lateral view radiograph. A only major postoperative complication we have experienced was a periprosthetic tibia fracture, which had been successfully treated with screw fixation. Discussion. Bi-UKA is a bone- and ligament-sparing procedure that may provide better knee function and patient satisfaction than does TKA. Complicated surgical procedure, relationship of placement position between medial and lateral prostheses, ligament balancing, and longer-term results remain subjects to be resolved. However, tibia dependent cut technique using spacer block was quite useful to improve the accuracy of implants positioning during Bi-UKA procedure. Our short-term results of Bi-UKA were well acceptable although there were a few complaints or complications. We would like to confirm the usefulness of this procedure and further establish the best indication by increasing the number of patients in the future

Fascia iliaca compartment block (FIB), performed in the Emergency Department (A&E) in patients presenting with femoral neck fracture, has gained increasing recognition as an adjunctive analgesic. The purpose of this study was to investigate whether FIB significantly reduced the requirement for systemic opiates in the pre-operative setting. Analgesia requirements for all patients admitted with fractured neck of femur to one unit over a four month period were gathered prospectively. 33% patients had received FIB at diagnosis in ED, dependant on the expertise of the attending physician. Morphine requirements on arrival on the ward between groups were analysed. Over a four month period 144 patients were admitted with fractured neck of femur. Over this time period, introduction of an informal educational programme in A&E increased the incidence of FIB provision at diagnosis and reduced the average amount of morphine administered. Administration of FIB reduced the average morphine requirement in A&E by 56%, when compared with those who received systemic analgesia alone (CI 0.4–3.5, p=0.014). No adverse effects were reported with FIB. Fascia Iliaca Compartment Block is a safe and effective method of providing analgesia to patients with fractured neck of femur and reduces morphine requirement

Introduction. Knee osteoarthritis is a leading cause of disability around the world. Traditionally, total knee arthroplasty (TKA) is the gold standard treatment; however, unicompartmental knee arthroplasty (UKA) has emerged as a less-invasive alternative to TKA. Patients with UKAs participate earlier with physical therapy (PT), have decreased complications, and faster discharges (1, 2). As UKA has evolved, so has computer navigation and robotic technology. The Robotic Assisted UKA combines the less invasive approach of the UKA with accurate and reproducible alignment offered by a robotic interface (3)(Figure1). A key part of a patient's satisfaction is perioperative pain control. Femoral nerve blocks (FNB) are commonly performed to provide analgesia, though they cause quadriceps weakness which limits PT (4). An alternative is the adductor canal block (ACB) which provides analgesia while limiting quadriceps weakness (4). The adductor canal is an aponeurotic structure in the middle third of the thigh containing the femoral artery and vein, and several nerves innervating the knee joint including the saphenous nerve, nerve to the vastus medialis, medial femoral cutaneous nerve, posterior branch and occasionally the anterior branch of the obturator nerve (5). In a multi-modal approach with Orthopedic Surgery, Regional Anesthesia, and PT departments, an early goal directed plan of care was developed to study ACB in UKA with a focus on analgesia effectiveness and PT compliance rates. Methods. Following IRB approval, we performed a case series including 29 patients who received a single shot ACB. Primary outcomes were distance walked with PT on postoperative day (POD) 0 and 1 and discharge day. Our secondary outcomes included Visual Analog Scale (VAS) scores in the post-anesthesia care unit (PACU), 8 and 24 hours postoperatively and oral morphine equivalents required for breakthrough pain. Results. All patients received PT prior to discharge. With respect to distance walked, the median distance on POD 0 was 26 feet (IQR 9–66), and on POD 1 was 128 feet (IQR of 80–200), and the median day of discharge was POD 1 (IQR 0–2). In this study, the patients’ median age was 64 (IQR 59–69) and the median BMI was 31 kg/m2 (IQR 22–41). The median VAS score in the PACU was 1 (IQR 0–7). The VAS scores for 8 and 24 hours were 5 (IQR 2–7) and 5 (IQR 2.7–7). Median oral morphine equivalents required for breakthrough pain were 99.5 mg (IQR 67.5–150.5 mg) (Figure 3). Conclusion. This case series supports that a single shot ACB facilitates early PT and hospital discharge in patients post UKA

Background. Exparel (Pacira Pharmaceuticals, Parsippany, NJ, USA) is a long-acting liposomal Bupivacaine extended release compound that can be used as peri-articular injection (PAI) or regional nerve block. The purpose of this study was to compare the post-operative analgesic efficacy of Exparel as a single administration adductor canal block (ACB) varsus PAI. Methods. From May 2016 to June of 2017, 70 patients with primary knee osteoarthritis undergoing unilateral knee replacement were prospectively randomized into two cohorts: 1) PAI (Exparel 266 mg (20 ml vial) with 20 ml of 0.5% bupivacaine HCl, and normal saline to a total volume of 120 ml); 2) ACB (Subsartorial saphenous nerve using Exparel 266 mg in 20 ml vial). All patents underwent spinal anesthesia with comprehensive pre-emptive and postoperative multimodal pain protocol. All opioids given were converted to morphine equivalents. Pain was recorded at 4 – 12 hrs (day of surgery), post-operative day (POD) 1, 2, and 3 after surgery. Results. There was no statistical significance between the pain scores during the first 12 hrs (day 0) after surgery. We found a trend towards a significance on POD # 1, as PAI group had less pain (5.3 vs 4.2, p=0.09). The mean pain score in ACB group increased on POD # 3 while in PAI continued a decrease (4.8 vs 1.8, p=0.03). There was no statistical significance between the 2 groups regarding the accumulative daily converted Morphine equivalent consumption or total consumption. Conclusion. We found similar results between PAI and ACB using Exparel after TKA up to 48 hours

BACKGROUND. Acetabular defects are encountered in both primary total hip arthroplasty (THA) in patients with developmental dysplasia of the hip (DDH) and in revision THA. The purpose of this study was to evaluate the clinical and radiographic results of one method of acetabular reconstruction for THA using a hydroxyapatite (HA) block with either an autogenous graft or allograft of impacted morsellized bone in conjunction with a cemented socket. METHODS. Fourteen hips in 14 patients (all female; average age, 64 years) were treated with the above technique in primary (11 DDH) or revision THA (three loosened sockets). All patients were followed clinically in a prospective fashion, and radiographs were analyzed retrospectively. One initial patient had 16-year follow-up, whereas the remaining 13 patients had follow-up between four and 5.5 years. RESULTS. No acetabular components were revised, including the socket of 16-year postoperative case which remains rigidly fixed and supported by the graft and HA block with only mild polyethylene wear and minor osteolysis. The mean Japanese Orthopaedic Association (JOA) score for the hips improved from 37 points preoperatively to 90 points postoperatively. CONCLUSIONS. The authors report very good results of acetabular reconstruction with the use of these biomaterials in conjunction with impaction morsellized bone graft in THA. Osteointegration and good clinical outcome were achieved in all of cases. However longer-term outcome should be the subject of further investigation, as the majority of these patients had only mid-term follow-up of 4 to 5.5 years

BACKGROUND. There is no report of additional type of bulk bone grafting (Ad-BG) method with impaction morselized bone graft for reconstruction of shallow dysplastic hip in total hip arthroplasty. The purpose of this study was to define the shallow acetabulum and to evaluate the clinical and radiographic results of primary total hip arthroplasty (THA) with Ad-BG method. MATERIALS and METHODS. With modification of Crowe's classification, shallow dysplasia was defined and classified (Fig. 1). Between October 1999 and August 2008, 120 hips of 302 THAs for dysplastic hip were defined as shallow and Ad-BG was done in 96 hips (80% of shallow hips). For 24 hips with shallow dysplasia, THA were performed by using conventional type of interpositional bulk bone graft (Ip-BG) (8 hips) or without bone graft by using rigid lateral osteophyte. All patients were followed clinically using the Japanese Orthopaedic Association (JOA) score and also Merle d'Aubigne and Postel (M&P) scores in a prospective fashion, and radiographs were analyzed retrospectively. The criteria used for determining loosening were migration or total radiolucent zone between the prosthesis (or bone cement) and host bone. The mean follow-up periods were 8.0 ± 2.3 (5.0–13.5) years. Operative technique. Resected femoral head was sliced with thickness of 1–2 cm, and then a suitable size of the bulk bone block was placed on the lateral cortex of the ilium and fixed by polylactate absorbable screws. Autogenous impaction morselized bone grafting with or without hydroxyapatite granules was performed in conjunction with a cemented socket (Fig. 2). The same surgeon assisted by his colleagues operated all of the cases. RESULTS. No acetabular components were revised except for a case with shallow and Crowe type IV acetabulum. The mean JOA and M&P score for the hips improved from preoperative 39 and 6 points to postoperative 93 and 17 points respectively. Radiographically, the Ad-BGs in most of the cases were remodeled and recognized reorientation within 2 years postoperatively. CONCLUSIONS. The authors report good results of acetabular reconstruction with the use of Ad-BG technique in conjunction with impaction morselized bone graft for shallow dysplastic hip in primary THA. Osteointegration and good clinical outcome were achieved in most of cases. However longer term outcome should be the subject of further investigation

Purpose

Correct sizing of prostheses is a considerable factor regarding function and successful rate of total knee arthroplasty (TKA). Patient-specific guide (PSG), using CT preoperative planning for sizing, alignment and bone cutting, has been developed to improve the accuracy and reproducibility of TKA. The purpose of this study is comparing the accuracy of CT-based preoperative sizing in PSG with the conventional femoral sizing instrument.

Background. Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anaesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anaesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block technique (SV). Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions. Methods. A single-centre prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anaesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anaesthesia along with the anaesthesia onset time. Results. A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5] vs. 3 [2, 4], respectively, P = 0.006). However, anaesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anaesthesia was more predictable in the dorsal block compared to the volar block. Conclusion. The single-injection volar subcutaneous blocks are less painful with a similar anaesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anaesthesia of the region

Introduction. The regionalisation of major trauma in the UK has significantly improved outcomes for patients with severe, lower limb injuries. Chronic pain after complex lower limb injuries is well documented, but seems to remain a problem despite better clinical and radiological outcomes. We hypothesised that pain was mediated through the saphenous nerve, especially as most tibial injuries affected the soft tissues medially. As a proof of concept, we undertook adductor canal blocks to understand pain aetiology. Materials & Methods. Patients with chronic pain following complex lower limb trauma or congenital deformity correction have been selected and underwent an adductor canal block by one of our trauma anaesthetist that specialises in this procedure. Their outcomes were recorded in their clinical records and patients were contacted by phone to document their experiences. Results. 14 patients with chronic, treatment refractory lower limb pain who were being managed in our orthoplastics clinic following complex, lower limb trauma were identified. Six of those patients had required plastic coverage. Of these 14 patients, all stated their pain completely resolved after the procedure and then returned between 24 hours and 4 weeks after the procedure. Two patients underwent a saphenous nerve diversion after conduction of the blocks, reporting subsequent resolution of their complaints. Conclusions. As a proof of concept, we report that the saphenous nerve underlies chronic pain in patients with complex lower limb injuries. An adductor canal block is an effective diagnostic tool for these patients. Saphenous diversion may offer a permanent solution in patients who respond well to saphenous nerve block. A prospective study is planned to objectively measure pain and quality of life scores after treatment of complex injuries and pre and post adductor canal block