Femoral nerve block is a reliable and effective method of providing anaesthesia and analgesia in the peri-operative period but there remains a small but serious risk of neurological complication. We aimed to determine incidence and outcome of neurological complications following femoral nerve block in patients who had major knee surgery. During the period January 2003 to August 2008, medical records of all patients undergoing knee surgery by Dr Myles Coolican and Dr David Parker, who had been administered femoral block for peri-operative analgesia, were evaluated. Patients with a neurological complication were invited take part in the study. A detailed physical examination including sensory responses, motor response and reflexes in both limbs was performed by an independent orthopaedic surgeon. Subjective outcome and pain specific questionnaires as well as clinical measurements were also collected. Out of 1393 patients administered with femoral nerve block anaesthesia during this period, 28 subjects (M:F= 5:23) were identified on the basis of persistent symptoms (more than three months) of femoral nerve dysfunction. All the patients had sensory dysfunction in the autonomous zone of femoral nerve sensory distribution. The incidence of neurological complications was 2.01%. One patient was deceased of unrelated causes and five patients declined to participate in the study. 14 patients out of the 22 have been examined so far. Nine cases had a one shot nerve block and five had continuous peripheral nerve block catheter. Areas of hypoesthesia/anaesthesia involving femoral nerve distribution occurred in 7 subjects and hyperaesthesia/paresthesia occurred in four. One subject had a combination of hypoesthesia and hyperesthesia in different areas of the femoral nerve distribution. Three subjects had bilateral symptoms following bilateral simultaneous nerve blocks. Dysesthesias in the affected dermatomes were found in seven cases and paresthesias were found in eight cases. Douleur Neuropathique en 4 questions (DN4) score of ï. 3. 4 was found in all the patients (average value: 5.55). The average scores for tingling, pins and needles and burning sensation (in a scale from 0 to 10) are 3.8, 3.1 and 2.9 respectively. The incidence of persistent neurological complication after femoral nerve block in our series is much higher compared to the reported incidence in the contemporary literature (Auroy Y. et al. Major complications of regional anesthesia in France: Anesthesiology 2002; 97:1274 80). The symptoms significantly influence the quality of life in the affected cases and question the value of the femoral nerve block in knee surgery

Objectives. The goal of this retrospective study was to compare two different processes of pain control after total knee arthroplasty (TKA): local anesthesia versus femoral nerve block. The tested hypothesis was that the patient's ability to be discharged was obtained sooner with the local anesthesia process. Methods. 110 patients consecutively operated on for TKA by a single surgeon without any selection criterion were included. The study group included 58 patients operated on under general anesthesia with infiltration of the surgical field with local anesthesia. The control group included 52 patients operated on under general anesthesia and continuous femoral nerve block. In the study group, 200 ml of ropivacaïne 5% were injected into the surgical field, and an intra-articular catheter was left to allow continuous infusion of ropivacaïne (20 ml/h during 24 hours). The control group was treated by a femoral nerve block with ropivacaïne during 24 hours. Discharge was considered allowed when the patient was able to walk independently, go upstairs and downstairs independently, when the knee flexed over 90° and if the subjective pain assessment (VAS) was under 3/10. Results. Discharge allowance was obtained sooner (mean 2 days) in the study group (p<0.01). 40 patients of the study group (69%) and 2 patients of the control group (4%) were able to stand up on the day of implantation (p<0.001). Deambulation was possible at D1 in the study group and D2 in the control group (p<0.001). Gait was possible at D4 in the study group and D6 in the control group (p<0.05). Discharge was possible 2 days earlier in the study group (p<0.01). Active quadriceps function was recovered 2 days earlier in the study group (p<0.001). Knee flexion exceeded 90° 2 days earlier in the study group (p<0.001). There was a faster decrease of the pain VAS in the study group, but the total consumption of analgesic was not different in the two groups. The complication rate was not different in the two groups. Conclusion. The process using local anesthesia may allow a better pain control after TKA, and consequently a faster rehabilitation and an earlier discharge

We performed a randomized feasibility trial to examine the impact of preoperative femoral nerve block (FNB) on elderly patients with hip fractures, including those with mild to moderate cognitive impairment. We evaluated the impact of preoperative FNB on the following outcomes within 5 days of surgical fixation: 1. Pain levels, 2. Total narcotic consumption, 3. Postoperative mobilization. Randomized allocation of 73 patients in a 2:1 intervention:control ratio. To allow comparison between the 2 groups as well as sub- analysis of the intervention group to examine treatment fidelity (i.e. the ability to deliver the intervention as planned). Inclusion criteria: Patient age≥ 65 years admitted with a low energy hip fracture, ambulatory preinjury, Mini Mental State Exam MMSE score≥13 (moderate dementia), Able to provide direct or proxy consent. Exclusion criteria: Admission ≥ 30 hours after injury, prior regular use of opiates. Potential participants were identified and either participants or proxy respondents provided signed informed consent. Participants allocated to the intervention group received a FNB administered by the UAH acute pain service (APS) within 20 hours of admission to hospital in addition to the usual care. Participants in the control group received usual care. Participants were followed for 5 days postoperatively with daily assessment of pain, narcotic consumption, delirium and mobility. Main outcome measure: (1) Pain at rest and activity (2) Preoperative and postoperative opioid consumption, (3) Mobilization in POD#1. Overall, 73 participants were enrolled (23 Control: 50 FNB). The FNB group was slightly older (mean [SD] 80.1 [8.7] vs. 76.2 [9.2], p=0.09) and had more males (21 [42%] vs. 5 [22%], p=0.09) than the Control group. The mean MMSE score for both groups was >24 (p=0.35 for group comparison), suggesting minimal cognitive impairment of participants. The FNB group reported significantly less pain at rest and activity than the control group over time (p < 0 .001 for both). Opioid consumption were non-significantly higher and more variable in the control group preoperatively (Median [25, 75 quartile] 10.6 [0, 398] vs 7.5 [0, 125], p=0.26) and postoperatively (13.1 [0, 950] vs 10 [0, 260], p=0.31). 41 (85%) of FNB participants mobilized on day 1 vs. 16 (73%) of control participants (p=0.21). Preoperative FNB significantly reduced pain. Opioid consumption was not significantly different, but more variable in the control group. Although not significant, more FNB patients successfully mobilized on day 1 postoperatively. Participants with cognitive impairment were not enrolled due to difficulty in obtaining proxy consent. A definitive randomized trial would be feasible and add valuable information about pain management following hip fracture

Background:. Total knee replacement (TKR) is a frequent and effective surgery for knee osteoarthritis. Postoperative pain is under concern and can be relieved by different methods, including femoral nerve block (FNB). The efficacy of FNB on pain relief was associated with the absence of clinical impact when measured with the range of motion (ROM). Recent studies suggest that the quadriceps strength is the best indicator of functional recovery after TKR. The goal of this study is to compare the quadriceps strength recovery after TKR according to the kind of analgesia (patient control analgesia (PCA) with or without FNB) Hypothesis: the FNB delays the QSR at short and mid-term follow-up. Methods:. Prospective randomized trial with single-blind assessment involving 135 patients admitted for TKR in an academic center. Randomization into one of the three following groups: A) Continuous FNB 48h + PCA B) Single-shot FNB and PCA C) PCA alone. Groups were comparable for demographic and surgical data. The FNB was realised and controlled (electric stimulation) by an expert anesthesiologist before the surgery. Follow-up standardised in all groups with blinded assessors. Quadriceps strength measured with a validated dynamometer at 6 weeks, 6 and 12 months. Secondary outcomes included clinical evaluation (ROM, pain, stability) and functional scores (SF-36 v2, WOMAC). Multivariate analysis (Kruskal-Wallis, Mann-Whitney) for main outcomes and Spearman factor for correlation. Sample size calculated for alpha 5% and study power 80%. Results:. 111 patients available for 6 weeks follow-up (A-B-C:40-38-33) and 104 (36-36-32) at 6 and 12 months. Two patients in group B excluded for direct fall in the first postoperative week with extensor mechanism rupture and peri-prosthetic femoral fracture. QSR is significantly decreased in patients with FNB at all times (mean, 95% IC): 6 weeks (A 51.3%, 44.1–58.5; B 62.2%, 55.2–69.2; C 77.4%, 70.7–84.1; p < 0,05), 6 months (A 65.4%, 57.9–72.9; B 82.1%, 74.2–90; C 95.7%, 88.5–102.9; p < 0,05) and 12 months (A 87.8%, 82.1–93.5; B 97.8%, 89–106.6; C 104.8%, 96.1–113.5; p < 0,05). No significant difference between continuous or single-shot FNB. Higher ROM in group C at all times (p 6 weeks = 0,046; p 6 months = 0,159; p 12 months = 0,026). No correlation between ROM and QSR (rho = 0,07; p = 0,23). Better functional results in the group C at all times (p < 0,05), with good correlation to QSR (rho = 0,177; p = 0,032). Slight difference in analgesic effect of FNB (p = 0,14). Conclusion:. Femoral nerve block has a negative influence on QSR at short and mid-term follow-up and delays the rehabilitation after TKR. QSR is actually the most sensitive indicator of functional recovery after TKR and is better related to functional tests than ROM. This can explain the harmlessness of FNB in previous studies. FNB should not yet be recommended for analgesia after TKR

Our study is still in progress. The results mentioned in the abstract are preliminary results. The final results will be provided at the time of presentation. Over the past decade, the widespread availability of high-resolution ultrasonography coupled with advances in regional anaesthesia have popularised peripheral nerve blocks for anterior cruciate ligament reconstructions (ACLRs). The aim of this study is to investigate whether the femoral nerve block (FNB) administered at the time of ACLR has any long-term impact on the quadriceps strength as compared to patients who did not receive a FNB. This is a retrospective study. Four hundred charts of patients who underwent ACLR at our institution and had subsequent Biodex testing (an isokinetic rehabilitation test that provides objective information about muscle strength deficits and imbalances of the operated leg compared to the non-operated leg) from 2004 to 2015 were reviewed. Patients who had prior ipsilateral knee surgery, multi-ligament knee injury or at extreme ages were excluded from the study. The following baseline patient characteristics was recorded for each reviewed chart: age, sex, medical comorbidities, the date of the injury, date of the surgery, surgery technical notes and associated procedures, the surgeon, the hospital were the patient was operated, the Biodex test date and the Biodex test results. Data extraction assessed any association between the ACLR patients' who received FNB with the results of the Biodex test after completing the rehabilitation protocol. Descriptive statistics were used to compare the type of anaesthesia, mode of pain control and the results of the Biodex tests between patients grouped by the mode of anaesthesia used at the time of surgery (FNB versus no FNB). A multivariate regression model then compared quadriceps strength (inferred by Biodex test results) between groups while controlling for baseline differences between groups. Fifty five percent of the ACLR patients received FNB compared to 45% that did not receive FNB over the last 11 years of performing ACLRs (2004–2015) at our institute. Fifty percent of the patients that received FNB failed to achieve more than or equal to 80% quadriceps strength (compared to the contralateral non-operated leg) at 6 months on Biodex test. On the other hand, only 20% of the non-FNB group failed to achieve more than or equal to 80% quadriceps strength. This study lead us to think that ACLR patients that received FNB are significantly weaker in quadriceps strength at 6 months post ACLR in comparison to non-FNB ACLR patients. This finding subsequently might affect the time needed to return to sports and might indicate a considerable clinical consequence of the FNB on ACL-reconstruction patients

Background. Total knee arthroplasty is associated with early postoperative pain. Appropriate pain management is important to facilitate postoperative rehabilitation and positive functional outcomes. This study compares outcomes in TKA with three techniques; local infiltration analgesia, single shot femoral nerve block and intrathecal morphine. Methods. Forty-five patients undergoing elective primary Total Knee Arthroplasty (TKA) with were randomized into one of three groups in a double blind proof of concept study. Study arm 1 received local infiltration analgesia ropivacaine intra-operatively, an elastomeric device of ropivacaine for 24 hours post-op. Study arm 2 received a femoral nerve block of ropivacaine with placebo local infiltration analgesia and placebo intrathecal morphine. Study arm 3 received intrathecal morphine, placebo femoral nerve block and placebo local infiltration analgesia. All patients received standardized pre-operative, intraoperative and Post-operative analgesic medication. Participants were mobilized at 4 hrs, 24hrs and 48 hrs post operation. Range of Motion, Visual Analogue Scale (VAS) pain intensity scores and two minute walk test and Timed Up and Go test were performed. Postoperative use of analgesic drugs was recorded. Knee Society Score (KSS), Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were completed at preoperative and 6 weeks post op. Results. Assessment of the efficacy of analgesia will be conducted using VAS pain scores collected preoperatively, 0–24hrs and 24–48 hours postoperatively between the three randomized groups. Frequency of use of other analgesia and need for PCA will be compared between groups at 0–24hr and 24–48hrs post operatively. The assessment of functional outcomes will be measured between the three groups by comparing the ability to mobilize the first 4 hrs after surgery, maximal flexion and extension, two minute walk test and timed up-and-go preoperatively, on postoperative day 1 and 2 and 6 weeks. Patient reported outcome measures KSS, Oxford Knee score and KOOS will be compared for the three study arms. Conclusion. Results from the study will provide important information for the management of TKA in the hospital setting. The comparison of the three commonly used analgesic techniques and mobilization outcomes are pertinent for physiotherapy and rehabilitation management, anaesthetic specialists, nursing staff, orthopaedic surgeons and patients

Total knee arthroplasty is associated with early postoperative pain. Appropriate pain management is important to facilitate postoperative rehabilitation and positive functional outcomes. This study compares outcomes in TKA with three techniques; local infiltration analgesia, single shot femoral nerve block and intrathecal morphine. Methods. Forty-five patients undergoing elective primary Total Knee Arthroplasty (TKA) with were randomized into one of three groups in a double blind proof of concept study. Study arm 1 received local infiltration analgesia ropivacaine intra-operatively, an elastomeric device of ropivacaine for 24 hours post-op. Study arm 2 received a femoral nerve block of ropivacaine with placebo local infiltration analgesia and placebo intrathecal morphine. Study arm 3 received intrathecal morphine, placebo femoral nerve block and placebo local infiltration analgesia. All patients received standardized pre-operative, intraoperative and Post-operative analgesic medication. Participants were mobilized at 4 hrs, 24hrs and 48 hrs post operation. Range of Motion, Visual Analogue Scale (VAS) pain intensity scores and two minute walk test and Timed Up and Go test were performed. Postoperative use of analgesic drugs was recorded. Knee Society Score (KSS), Oxford Knee Score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were completed at preoperative and 6 weeks post op. Results. Preliminary results of 32 participants convey the positive outcomes after total knee replacement demonstrated by the improvement in Oxford Knee Score and Knee Osteoarthritis Outcome score. There are marked improvements in the 2-minute walk tests at the six week time-point. At day one post-operative only 5 participants were unable to walk. Patient-controlled analgesia was used on 5 occasions on day one, 2 of which continued on day two. Sedation scores were recorded in six participants on day one and 2 on day two. Nausea was reported in 5 cases on day one and 9 on day two. Urinary catheter was needed in 5 cases on day one. Importantly the study remains blinded, therefore an analysis of the three study arms is not available and is therefore currently difficult to report on the statistical significance. There will be further assessment of the efficacy of analgesia using VAS pain scores, analgesia consumption and side effects collected preoperatively, 0–24hrs and 24–48 hours postoperatively between the three randomized groups. The assessment of functional outcomes will be measured between the three groups by comparing the ability to mobilize the first 4 hrs after surgery, maximal flexion and extension, two minute walk test and timed up-and-go preoperatively, on postoperative day 1 and 2 and 6 weeks. Conclusion. Results from the study will provide important information for the management of TKA in the hospital setting. We anticipate completion of all 45 surgeries in the next 2 months. The Blinding codes with be broken thereafter and full data analysis performed. The comparison of the three commonly used analgesic techniques and mobilization outcomes will allow enhanced management of patient's post-operative pain with earlier discharge from hospital an lower complication rates

Purpose. To evaluate the effectiveness of post-operative pain management using the intra-operative peri-articular injection(PAI) and/or electromyography (EMG)-guided preoperative femoral nerve block (FNB) in total knee arthroplasty(TKA). Materials and Methods. From March 2013 to February 2014, 90 knees which underwent primary TKA by one surgeon were included in our study. The patients were classified into three groups; a single injection FNB with an EMG guide (Group I, 30 knees), intra-operative PAI (Group II, 30 knees) and both FNB and PAI (Group III, 30 knees). Pain at rest and moving was evaluated by Visual Analogue Scale (VAS) at postoperative 0, 4, 8, 24 and 48 hours. Postoperative range of motion, time to walking, total blood loss, amount of opioid consumption and complications were compared in each group. Results. VAS immediately after surgery was 67.9 in group I, 54.6 in group II and 54.7 in group III. VAS was significantly higher in group I than group II and III (p=0.005), but was not significantly different between group II and III (p>0.05). VAS at postoperative 4 and 8hr showed similar results. VAS at postoperative 24 hr was 49.6 in group I, 56.4 in group II and 46.7 in group III, which was significantly higher in group II than group I and III (p=0.043). After postoperative 48hr, there were no differences in group I, II and III. The total amount of opioid consumption in group III was smaller than that in group I and II (p=0.017). There were no differences in postoperative range of motion, time to walking and total blood loss. There was one case with temporary peroneal nerve palsy in group II and no infection in all cases. Conclusion. PAI was more effective than FNB for early (0∼8hr) postoperative period after TKA. However, PAI showed rebound pain at 24hr after TKA. PAI in combination with FNB could enhance the effect of postoperative pain management from immediate postoperative period to 24hr

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

Introduction. Many determinants of the length of stay (LOS) for primary total knee arthroplasty (TKA) have been described. Multimodal, pre-emptive analgesia, age, walking aid score and stair score are some of them. Single shot peripheral nerve block is a popular method to provide prolonged analgesia in immediate post operative period after TKA. Delayed recovery from the nerve block can delay the rehabilitation programme and subsequently lengthen the LOS when the multi disciplinary team discharge criteria are well defined and standardized. The aim of this study is to calculate the incidence of delayed recovery from the sciatic and femoral nerve block administered in cases of primary TKA and its influence on LOS. Methods. All the patients undergoing primary TKA and receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block since April 2010 till January 2011 have been included in the study. Patients demographics, date and day of operation, time of nerve block, complete recovery from the nerve block post operatively and date of discharge were recorded prospectively. Results. Total 34 patients were included in the study. 24 patients recovered from the effect of peripheral nerve block on the post operative day one and 10 patients recovered on the post operative day two. Mean LOS of patients recovered on post operative day one is 4.8 days and mean LOS of those who recovered on post operative day 2 is 5.6 days. Conclusion. Almost one third of the patients receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block recovered late. Delayed recovery from nerve block seems to increase the duration to achieve the discharge criteria after primary TKA. This information can be used favorably to influence the outcome by altering the concentration and amount of anaesthetic agent used

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

Peri-articular injections (PAI) have become an important component in many multimodal pain protocols after total knee arthroplasty (TKA). Liposomal bupivacaine has emerged as a highly marketed and touted ingredient for PAI. However, the true efficacy of this material, particularly compared with less expensive PAI “cocktails” such as traditional bupivacaine or ropivacaine, has not been proven to date. Ropivacaine is considered a long-active local analgesic and in combination with epinephrine, ketorolac and clonidine has been shown to be a very effective PAI in a multimodal pain program. Liposomal bupivacaine has been similarly touted as a long-acting PAI. Initial reports provided support for liposomal bupivacaine PAI's providing similar pain relief as epidurals or femoral nerve blocks. The authors of these studies tout comparable pain control with decreased length of stay attributable to avoiding the side effects of epidurals and regional blocks. However, the ultimate clinical issue relates to how liposomal bupivacaine PAI's compares to traditional PAI cocktail ingredients such as bupivacaine and ropivacaine, which also avoid deleterious effects of regional analgesia, and at a much cheaper price point. Fortunately the highest quality research to date, which includes randomised prospective trials and retrospective controlled cohort studies, have reported consistent results. In a retrospective cohort study comparing a traditional ropivacaine and epinephrine versus liposomal bupivacaine PAI demonstrated no difference between the two groups in inpatient pain scores when used in a comprehensive multimodal pain control program. Further, two prospective randomised trials reported no difference in liposomal bupivacaine PAI compared to a traditional PAI of either bupivacaine or ropivacaine, epinephrine, ketorolac and clonidine. Finally, there have been some authors who contend the efficacy of liposomal bupivacaine PAI's is entirely dependent on a meticulous injection technique, however, comparative studies against traditional PAI ingredients with this recommended technique do not exist. In summary, the existing data supports that liposomal bupivacaine is an effective PAI that can be used to provide comparable pain relief to that achieved by regional blocks. However, liposomal bupivacaine has not been shown to provide superior pain relief when compared to traditional ropivacaine or bupivacaine PAI's in multimodal pain protocols after TKA. Further, liposomal bupivacaine is prohibitively priced at approximately six times that of ropivacaine-based PAI cocktails. Therefore, the “game changer” is likely the implementation of peri-articular injections as an essential component of multimodal pain control programs and NOT liposomal bupivacaine

Introduction. Pain control following total knee arthroplasty (TKA) heavily influences timing of mobilization and rehabilitation postoperatively as well as length of hospital stay. Recently, periarticular injection of liposomal bupivacaine (EXPAREL®; Pacira Pharmaceuticals, Inc., San Diego, California) has demonstrated pain relief comparable to femoral nerve block for postoperative analgesia in TKA with earlier mobilization and shortened hospital stay. In order to better explore the use of EXPAREL® in TKA, we standardized the postoperative analgesia to intraoperative periarticular injection of multimodal pain management, which is a recommended postoperative method of pain control in TKA. We studied the effectiveness of periarticular EXPAREL® in TKA postoperative pain control, including impact on early mobilization and length of hospital stay, compared to another local analgesic (Ropivacaine) when both are used as part of a multimodal pain management approach. Methods. We performed a double blind, randomized, controlled, prospective, IRB-approved study that enrolled 96 participants who underwent a unilateral TKA by one surgeon between May 2014 and March 2015. The two randomized groups were as follows: group 1 (control group) was given the standard intra-articular “pain cocktail” injection, consisting of ropivacaine, ketorolac, morphine, and epinephrine mixed with saline into a 100cc preparation and group 2 (study group) was given a similar intra-articular injection consisting of bupivacaine, ketorolac, morphine, and epinephrine mixed with saline into an 80cc preparation as well as an injection of EXPAREL®, 20cc of 1.3% EXPAREL®, to total 100cc. All patients included in the study were determined to be opioid naïve as described by the Food and Drug Administration criteria. Patients were treated with the same postoperative pain management protocol as well as the same post-operative physical therapy program. The consumption of oral and intravenous narcotics at specific time points as well as total use was recorded during hospital stay. We recorded Visual Analog Pain scores, hours to ambulate 100 feet and length of hospital stay (hours). Both the investigator and the patient were blinded as to which group the patient was randomized, making this a double blind study. Results. On a per hour basis, the mean use of narcotics of the two groups differed by only 0.1mg. For total narcotic use during hospital stay, the weighted sum used by patients in the EXPAREL® group, 97.7mg of hydrocodone ±42.84 mg, exceeded the weighted sum, 89.6 mg of hydrocodone ± 58.57 mg, used by patients in the control group. The difference between the two groups was not significant. The means for length of stay differed by only 26 minutes and the difference was not significant. Similarly insignificant, the means for the time to ambulate 100 feet differed by 53 minutes, with the EXPAREL® group actually taking the longer time. The two groups did not differ for Visual Analog Score for pain on day 1 or day 2 post-operatively. Conclusion. When comparing the use of EXPAREL® to another multimodal pain management approach using ropivacaine, there is no difference in post-operative opioid consumption, Visual Analong Scores for pain, amount of time to ambulate or length of hospital stay

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

Pain control is critical in the management of TKA patients and is crucial to allow for early ambulation and accelerated physical therapy. Currently data suggests that 19% of patients are not satisfied with their results following TKA, and failure to control pain may result in prolonged hospitalization, worse outcomes, and increased patient dissatisfaction. Studies suggest that local analgesics coupled with both pre- and post-operative multimodal pain management may result in improved pain control and increased patient satisfaction. Minimization of opioid use is helpful in decreasing complications, accelerating physical therapy milestones, minimizing length of stay and increasing discharge to home. Femoral nerve blocks (FNB) can reduce pain scores for up to 48 hours post-operatively, but may delay ambulation and result in an increased rate of falls. Periarticular injection (PAI) with local analgesics can provide significant short term relief comparable to FNB and can also facilitate decreased opioid consumption. One commonly used local anesthetic is bupivacaine, but the average half-life of this drug is only 2.7 hours. An alternative to this for PAI during TKA is liposomal bupivacaine (LB). LB is a multivesicular drug designed for rapid absorption, prolonged release of bupivacaine, and analgesia that is maintained for up to 72 hours with a single injection. LB exhibits a bimodal peak of distribution, one immediate associated with extra-liposomal bupivacaine, and a second 10–36 hours later associated with the release of liposomal encapsulated bupivacaine. The safety profile of LB has been investigated and adverse events are similar to standard bupivacaine and demonstrate acceptable tolerability. Multiple studies have demonstrated efficacy of this drug compared to other pain control modalities. LB is highly technique dependent and only one piece of a multimodal pain management protocol. Our study consisted of 1808 consecutive primary TKA patients from Sept 2013 to Sept 2015. Three patient cohorts were compiled by date, from Sept 2013 to May 2014 was cohort 1, consisting of FNB and PCA. Department wide adoption of LB began in May 2014 and became routinely used in all patients undergoing total joint arthroplasty at our institution. Cohort 2 entailed a PCA along with LB injection from May 2014 through Feb 2015. Cohort 3 consisted of LB injection only and was from Feb 2015 through Sept 2015. All patients undergoing TKA were eligible and there were no exclusion criteria as long as the protocols were followed. The standard multi-modal analgesia protocol was provided to all patients in all three cohorts. Prior to entering the operating room, patients received preemptive oral analgesics, consisting of: 200 mg celecoxib, 1000 mg acetaminophen, and 50 mg pregabalin. Intra-operative analgesia was chosen at the discretion of the anesthesiologist and preferentially consisted of spinal anesthesia with general anesthesia as an alternate. For all three cohorts, a peri-incisional analgesic cocktail was injected prior to closure consisting of: 40 cc 0.25% Marcaine, 5 cc of (1 mg/cc) morphine, and 1 cc of (30 mg/cc) ketorolac. Cohorts 1 and 2 received PCA post-operatively for pain control post-operatively with prn oral narcotic administration as well. Cohort 3 did not receive a PCA. The cohort treated without FNB and without a PCA using a multimodal pain management protocol including a short acting periarticular injection and a longer acting periarticular injection with LB, had equivalent pain control, less narcotic use, faster achievement of physical therapy milestones, earlier and more frequent discharge home, less complications and a lower cost of the episode of care

Background. Continuous epidural anesthesia or femoral nerve block has decreased postoperative pain after total knee arthroplasty to some extent. Although the established efficacy of these pain relief method, some adverse events such as hematoma or muscle weakness are still problematic. Intraoperative local infiltration of analgesia (LIA) has accepted as a promising pain control method after total knee arthroplasty. The safety and efficacy of LIA has been reported, although there are still limited evidence about the effect of LIA on quadriceps function and recovery of range of motion in early post-operative phase. The purpose of this study is to compare the quadriceps function and range of motion after TKA between the LIA with continuous epidural anesthesia and continuous epidural anesthesia alone. Methods. Thirty patients with knee osteoarthritis who underwent primary TKA were included in this study. Patients who took anticoagulants were treated continuous epidural anesthesia alone (n=11) and the other patients were treated with LIA with continuous epidural anesthesia (n=19). A single surgeon at our department performed all surgeries. Surgical procedure and rehabilitation process was identical between two groups. Before the implantation, analgesic drugs consisting of 20 ml of 0.75 % ropivacaine and 6.6 mg of dexamethasone were injected into the peri-articular tissues. In each group, fentanyl continuous epidural patient-controlled analgesia (PCA) was also used during 48-h post-operative period. Knee flexion and extension angle were evaluated before surgery, post-op day 3, 7, 10 and 14. The quadriceps function was evaluated by quadriceps peak torque at 30° and 60° flexion using VIODEX. The peak torque was recorded preoperatively, day 14 and 3 month after surgery. The difference between two groups was analyzed by Mann Whitney U-test using Prism 6, a statistical software. Results. LIA group showed better postoperative flexion angle until day 7 (Fig. 1). Then the discrepancy became smaller and came to the same degree at day14. The peak torque at 30° and 60° flex is higher in LIA group compared to epidural anesthesia alone. The LIA group showed less peak torque decrease at 2 weeks after surgery than epidural anesthesia alone group (Fig. 2, 3). No adverse events such as were observed in each group. Discussion. This paper demonstrated that LIA in addition to the continuous epidural anesthesia after TKA provides better quadriceps function and early recovery in knee range of motion. In this study we also used continuous epidural anesthesia, thus this study can not evaluate the stand alone LIA effects on quadriceps function and range of motion recovery. Furthermore the patients were not randomly assigned in this study, this might be another limitation of this study. In conclusion, LIA provide better quadriceps function and early recovery of range of motion in addition to the pain relief. To view tables/figures, please contact authors directly

Introduction. In Japan, edoxaban has been used for the prevention of venous thromboembolism (VTE) after total knee arthroplasty (TKA) since June 2011. Edoxaban is an oral direct factor Xa inhibitor, expected to be more convenient for the postoperative treatment of TKA. Enoxaparin, a II and Xa inhibitor, was approved in Japan for the prevention of VTE in patients undergoing orthopedics surgery from 2008. In this study, the effect for the prevention of VTE after TKA was compared between these two drugs in Japanese patients. Patients and Methods. We studied 42 Japanese patients who underwent TKA from May 2011 to April 2012. The operations were performed under general anesthesia, continuous femoral nerve block, an air tourniquet, and using cements for implant fixation. These patients were divided in two groups, use of 30 mg edoxaban once daily (ED group), and use of 1000 IU of enoxaparin twice daily (EN group). The initial dose was administered between 12 and 21 hours after surgery. We compared the incidence of VTE, bleeding complications, D dimer levels, and hemoglobin (Hb) loss. The screening of VTE was performed by enhanced CT scan screening from the chest to the foot on postoperative day 5 or 6 in all patients. The bleeding complication was divided into major bleeding and minor bleeding with Japanese guideline for the prevention of VTE. D dimer levels and Hb levels were preoperatively and postoperative day 1, 3, 5, 7, and 14. The loss of Hb was calculated from preoperative Hb level minus lowest postoperative Hb level. Results. The following results is showed in the order as ED group, EN group. The incidence of VTE was 45%, 32%, that was higher in ED group (see figure 1). There were almost no differences between both groups about D dimer levels and Hb loss in follow up period (see figure 2, 3). There were no major bleeding in both groups. The incidence of minor bleeding were 20%, 32%, that was higher in EN group (see figure 4). Discussion. We compared the effect of edoxaban and enoxaparin for the prevention of VTE. These two drugs are different way of administration. Edoxaban is administered orally, on the other enoxaparin requires with hypodermic injection. Therefore edoxaban is expected to be more convenient and less complaints than enoxaparin for the prevention of VTE. However our study showed that the use of 30 mg edoxaban once daily was less efficacy than the use of enoxaparin 1000 IU twice daily. The bleeding complication was lower incidence in the edoxaban, thus consideration should be given to the administration dosage of edoxaban to Japanese patients

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

Purpose. Femoral nerve block (FNB) following total knee arthroplasty (TKA) has had mixed results with some studies reporting improvement in pain and reduced narcotic exposure while others have not shown substantial differences. The effect of a FNB on rehabilitation indices (quadriceps strength, knee flexion) is also unclear. The study purpose was to compare the effect of FNB+ a multimodal analgesic protocol (MMA) to MMA only on the 1) development of a complete quadriceps motor block and 2) knee flexion during the first two postoperative days and 3) knee flexion out to 12 weeks after primary TKA. Secondarily, we compared hospital length of stay (LOS), postoperative pain, analgesic use and the incidence of nausea/vomiting. Method. This was a controlled clinical trial undertaken at two tertiary hospitals that do high annual TJA volumes (>200 cases). Both hospitals followed the same regional clinical pathway for preoperative, perioperative and postoperative care. The pathway started mobilization on the day of surgery with a goal for discharge home on the third postoperative day. At one site, FNB was used for the first two postoperative days in addition to MMA as needed (FNB group [n=19]) while the other site used standardized MMA (MMA group [n=20]) only. The presence of a complete quadriceps block, knee flexion, pain, analgesic use, incidence of nausea and vomiting were recorded daily in hospital. Hospital LOS was also recorded and knee flexion and pain were assessed at two, six and 12 weeks post discharge. Results. The groups were similar preoperatively in terms of age (p=0.27), gender (p=0.34), preoperative function (p=0.63) and knee flexion (p=0.83). In the FNB group, 10 (52%) had a complete quadriceps motor block on the day of surgery and 13 (68%) on the first postoperative day compared with no complete motor blocks in the MMA group (p<0.001). Pain and analgesic use was similar between groups (p>0.21) as was the incidence of nausea/vomiting (p>0.66). Knee flexion was similar at discharge(p=0.87) and at all post-discharge visits (p>0.14). Median LOS was 4(Interquartile range [IQR] 4,5) days and 3.5(3,4) days in the FNB and MMA groups respectively (p=0.04). Conclusion. The addition of a FNB to a MMA regimen did not confer advantages in pain control, analgesic use, nausea/vomiting or knee flexion. FNB significantly increased the likelihood of a complete quadriceps motor block in the initial postoperative period. Hospital LOS was also increased in the FNB group. These results are inconsistent with previous reports of FNB benefits, but may reflect the heterogeneous nature of clinical practice among centres, evolution of pain management into MMA techniques (+/− FNB) and the trend to shorter LOS and more aggressive postoperative rehabilitation. Further, multiple practitioners with varying experience performed the FNB. A randomized trial is needed to compare current MMA protocols to controlled FNB technique when an accelerated postoperative rehabilitation program is utilized

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