Purpose. The purposes of this study are as follows; 1) to compare postoperative blood loss between general anesthesia(GA) and spinal anesthesia(SA) and 2) to analyze the affecting factors of postoperative blood loss through the subgroup analysis. METHODS. A retrospective analysis was made on the clinical data of 122 patients with osteoarthritis undergoing primary TKA between January 2012 and December 2013. According to different anesthetic method, the patients were divided into the General Anesthesia group (73 cases) and the Spinal Anesthesia group (49 cases). Each group was divided subgroup as age, BMI, Preoperative blood pressure, Surgery time, Torniquet time, INR. The total blood loss, Post Operation 1 day blood loss, hidden blood loss, and the percentage of hidden blood loss were compared between 2 groups. For the analysis of postoperative blood loss, each group was compared postoperative blood loss using hemovac drainage per day and total blood loss. In preoperative blood pressure, Higher than 140 mmHg in systolic blood pressure and higher than 90 mmHg in diastolic blood pressure were employed as a cut-off value to group the well-controlled hypertension group(n=42) and uncontrolled hypertension group(n=29). RESULTS. One day after the surgery blood loss(p=0.322) and total blood loss(p=0.560) showed no significant differences between two group. But in the uncontrolled hypertension group showed a large amount of bleeding one day after the surgery(p=0.003) and total blood loss(p=0.004) in the spinal anesthesia. CONCLUSION. It seems that, general anesthesia is effective method to reduce postoperative blood loss. Preoperative blood pressure control is one of the important affecting factor of postoperative blood loss

The purpose of this study is to determine whether the mode of anaesthesia chosen for patients undergoing lumbar microdiscectomy surgery has any significant influence on the immediate outcome in terms of safety, efficacy or patient satisfaction. This prospective randomised study compared safety, efficacy and satisfaction levels in patients having spinal versus general anaesthesia for single level lumbar microdiscectomy. Fifty consecutive healthy and cooperative patients were recruited and prospectively randomised into two equal groups; half the patients received a spinal anaesthetic (SA), the remainder a general anaesthetic (GA). Each specific mode of anaesthesia was standardised. Comprehensive post-operative evaluation concentrated on documenting any complications specific to the particular mode of anaesthesia, recording the pace at which the various milestones of physiological and functional recovery were reached, and the level of patient satisfaction with the type of anaesthesia used. The results showed no serious complication specific to their particular mode of anaesthesia in either group. Thirteen out of 25 SA patients required temporary urinary catheterisation (9 males, 4 females) while among the GA group 4 patients required urinary catheterisation (4 males and 1 female). Post-operative pain perception was significantly lower in the SA group. The SA patients achieved the milestones of physiological and functional recovery more rapidly. While both groups were satisfied with their procedure, the level of satisfaction was significantly higher in the SA group. In conclusion, lumbar spinal microdiscectomy can be carried out with equal safety, employing either spinal or general anaesthesia. While they require more temporary urinary catheterisation associated with the previous use of intrathecal morphine, patients undergoing SA suffer less pain in association with their procedure and recover more rapidly. Blinded to an extent by not having experienced the alternative, both groups appeared satisfied with their anaesthetic. However, the level of satisfaction was significantly higher in the SA group

Purpose. The pros and cons of general anesthesia versus spinal anesthesia in total hip arthroplasty has been a long debated topic. The purpose of this study was to compare the surgical times, blood loss and transfusion requirements between anesthetic types in patients undergoing primary total hip arthroplasty. Method. A consecutive series of 1600 THA procedures with complete preoperative and postoperative data were evaluated. Twenty eight percent of procedures were performed with a general anesthetic (GA), 67% with a spinal anesthetic (SP) and 5% with a combination of the two. Outcomes were compared and tested for significance using the Independent Samples Kruskal Wallis or Pearson Chi-Square analysis. Results. Comparing GA and SP respectively, there was a statistically significant difference in patient age between the groups (age 63.73 14.5 vs 66.6 12.8, p<0.05), but not in ASA scores and distribution, or preoperative hemoglobin levels (131.74 32.5 vs 133.21 28.9). There was a statistically significant difference in length of time proceeding surgical procedure favoring Generals (SP: 35 mins (10 72) vs GA: 30 mins (8 65), p<0.05), however overall time in room was longer in Generals (GA: 132.83 29.0 vs SP: 127.15 22.5). There was a statistically significant difference in discharge hemoglobin favoring Spinals (SP: 97.9 14.2 vs GA: 94.9 16.4, p<0.05), lower transfusion rates (SP: 8.4% vs GA: 14.0%, p<0.05) and shorter length of stay (SP: 4.9 days vs GA: 5.3 days, p<0.05). The patients receiving a combination of anesthetic had a significantly greater length of time prior to proceeding the surgical procedure (43 mins (20 145)) and overall time in room (142.85 27.2) compared to both GA and SP, however were similar in all other outcomes. Conclusion. In this consecutive series of patients undergoing general anesthesia, spinal anesthesia and a combination for total hip arthroplasty, the general anesthesia cohort demonstrated advantages in statistically significantly shorter time proceeding the surgical procedure, however the overall procedure time was significantly longer. The spinal group had less blood loss and lower transfusion rates and the combination group had statistically longer procedure times compared to both GA and SP

Objective. Compare the safety and effectiveness of different anesthetic technique used in the simultaneous bilateral total knee arthroplasty (BTKA). Methods. Medical records of patients admitted for simultaneous BTKA between January 1, 2014 and September 1, 2015 in ‘The safety and effect evaluation of joint arthroplasty’ database were analyzed. The general anesthesia (GA) and neuraxial anesthesia (NA) group were identified. Patient preoperative characteristics were compared. Perioperative outcomes measured included operating time, blood loss, transfusion requirement, length of hospitalization, joint range of motion at discharge, complications. Results. A total of 1191 patients from 25 hospitals were identified, 802 (67.34%) patients were performed under GA, and 389 (32.66%) patients were performed under NA. Patients characteristics were similar between the two groups (P<0.05), except that patients operated under NA were older than those under GA (P<0.01). NA was associated with significantly less overall complications and infection complications, and reduction of length of hospitalization (P<0.05). But operating time, blood loss, transfusion requirement, joint range of motion at discharge were similar between the two groups (P<0.05). Conclusion. Patients who underwent simultaneous BTKA under NA had shorter hospitalization, lower overall complication and infection complication rate than GA. And, it could have an important medical and economic impact on health-care practice

Introduction

Methoxyflurane can cause hepatotoxicity and nephrotoxicity at anaesthetic doses but has excellent analgesic properties and no nephrotoxic effects in patients without preexisting disease. Approved for use in the UK and Ireland in 2015, it is currently being used in emergency departments for analgesia during fracture reduction. During the Covid emergency, with theatre access severely restricted and many patients unwilling to use inhaled Nitrous oxide, Penthrox had the potential to provide adequate pain relief to aid frame removals and minor procedures in the clinic.

This study was designed to compare length of hospital stay, and 30-day major and minor complications between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal or epidural anesthesia with or without regional nerve blocks. Patients 18 years and older undergoing TKA between the years of 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient demographics, anesthesia type, length of operation and hospital stay, as well as 30-day major and minor complications were collected from the database. Patients with “primary anesthesia technique” codes for either spinal or epidural anesthesia along with “other anesthesia technique” codes for regional anesthesia were assumed to have been given a regional nerve block. Chi square tests, and analysis of variance were utilized to evaluate unadjusted differences in demographics and outcomes between anesthesia types. Multivariable regression was utilized to compare outcomes (length of stay and complications) between anesthesia types, while adjusting for age, American Society of Anesthesiologist (ASA) class, comorbidities, sex, steroid/immunosuppressant use, body mass index (BMI), diabetes, length of operation and smoking status. A total of 214,665 TKA patients were identified (average age 67 ± 10 years). Of these, 257 (0.12%) underwent epidural anesthesia with a nerve block (EB), while 2,318 (1.08%) underwent epidural anesthesia with no block (E), 14,468 (1.08%) underwent spinal anesthesia with a block (SB), and 85,243 (39.7%) underwent spinal anesthesia with no block (S), and 112,377 (52.4%) underwent general anesthesia (G). The unadjusted length of stay (LOS) was significantly longer in the E group (3.67 ± 5 days) compared to the G group (3.1 ± 3.9 days), while the unadjusted LOS was significantly shorter in the EB group (2.6 ± 1.2), and both SB and S groups (2.6 ± 3 and 2.9 ± 3, respectively), compared to the G group p < 0 .001. Following covariable adjustment, anesthesia type remained an independent predictor of length of stay. Compared to the G group, patients in the E group stayed 0.56 days longer (95% Confidence interval [95%CI] 0.42 – 0.71 days), while patients in the SB were discharged 0.28 days (95%CI 0.21 – 0.35 days) earlier, and those in the S group were discharged 0.06 days earlier (95%CI 0.02–0.09), (p < 0 .0001). While the unadjusted rates of major complications were not significantly different between groups, the unadjusted rates of minor complications were higher in the E, EB, and G groups compared to the S and SB groups. Following covariable adjustment, there were no differences between groups in the risk of minor complications. In conclusion, these data indicate that anesthesia type following TKA is associated with length of hospital stay, but not with 30-day complications. After adjusting for relevant covariables, patients who received epidural anesthesia without a nerve block for TKA were discharged later, while patients who received spinal anesthesia, both with and without a nerve block for TKA were discharged earlier, compared to patients who received general anesthesia for TKA

Anesthetic peripheral nerve blocks (PNB) have been shown to be more advantageous than general anesthesia in a variety of surgical operations. In comparison to conventional methods of general anesthesia, the choice of regional localized infiltration has been shown to shorten hospital stays, decrease hospital readmissions, allow early mobilization, and reduce narcotic use. Perioperative complications of PNBs have been reported at varying rates in literature. Thus, the purpose of this study was to provide a review on the clinical evidence of PNB complications associated with foot and ankle surgeries. A systematic review of the literature was completed using PubMed search terms: “lower extremity”, “foot and ankle”, “nerve block”, and “complications”. All studies reporting minor and major complications were considered along with their acute management, treatments, and postoperative follow up timelines. The range of complications was reported for Sensory Abnormalities, Motor Deficits, Skin and systemic complications (local anesthetic systemic toxicity & intravascular injections). A designation of the scientific quality (Level I-IV) of all papers was assigned then a summary evidence grade was determined. The search strategy extracted 378 studies of which 38 studies were included after criteria review. Block complications were reported in 20 studies while 18 studies had no complications to report. The quality of evidence reviewed ranged from Level I to Level IV studies with follow up ranging from twenty four hours to one-three year timelines. The range of complications for all studies reporting sensory abnormalities was 0.53 to 45.00%, motor deficits 0.05 to 16.22% and skin and systemic complications 0.05 to 6.67%. Sensory abnormalities that persisted at last follow up occurred in six studies with incidence ranging from 0.23 to 1.57%. Two studies reported motor complications of a foot drop with an incidence of 0.05% and 0.12%. When considering only the highest quality studies (Level 1) that had complications to report, the complications rate was 10.00% to 45.00% for sensory abnormalities, 7.81 to 16.22% for motor deficits, 6.67% for skin complications and 2.50% for systemic complications. High quality studies (Level I providing Summary Grade A Evidence) reporting all complications with a range of incidence from 0 to 45%. While most of these complications were not serious and permanent, some were significant including sensory abnormalities, foot drop and CRPS. Based on this systematic review of the current literature, the authors emphasize a significant rate of complications with PNB and recommend that patients are appropriately informed prior to consenting to these procedures

Objectives. Although most joint surgeons have reached a consensus that preoperative risk assessment and appropriate medical intervention for elderly patients of primary total hip arthrplasty (PTHA) could significantly reduce postoperative complications and mortality, there is still lack of a detailed and comprehensive approach for risk stratifying and a systematic method for risk allaying. We aimed to explore the risk factors related to the aggravation of preoperative complications and the appearance of complications post-operation of primary total hip arthrplasty (PTHA) in elderly patients for hip fracture. Patients and methods. We retrospectively reviewed the demographic and clinical data of 156 patients who underwent PTHA for hip fracture from January 2014 to December 2016, of which there were 61 male (39.1%) and 95 female (60.9%) patients; 111 patients aged 60–79 years (71.2%) and 45 patients ≥ 80 years old (28.8%); 125 patients of femoral neck fracture (80.1%) and 31 patients of inter-trochanteric fracture (19.9%); 109 patients of spinal anesthesia (69.9%) and 48 patients of general anesthesia (30.1%); 85 patients undergoing surgery within 3 days (54.5%) and 71 patients operated ≥ 4 days (45.5%) since admission. We evaluated the correlations among gender, age, type of fracture, methods of anesthesia, time of operation since admission, the aggravation of preoperative complications and the appearance of postoperative complications post PTHA using the IBM SPSS Statistics (version 21) and the Exce1 2016. Results. The appearance of postoperative complications were statistically correlated with age, time of operation since admission, and type of anesthesia. The appearance of postoperative complication were significantly more in patients operated ≥ 4 days since admission (P < 0.05), and patients with general anesthesia (P < 0.05). Age ≥ 80 years old was not only statistically correlated with the aggravation of three kind of preoperative complications, hypertension, heart disease and respiratory tract infection (P < 0.05), also statistically correlated with the postoperative exacerbation of respiratory tract infection (P < 0.01), the appearance of anemia (P < 0.01), hypoalbuminemia (P < 0.01), water and electrolyte balance disorder (P < 0.05), and gastrointestinal reaction (P < 0.05). Age ≥ 80 years old was neither significantly correlated with postoperative aggravation of diabetes mellitus, urinary tract infection and abnormal liver and kidney function (P > 0.05), nor with postoperative urinary retention (P > 0.05). Conclusion. The occurrence of postoperative complications of elderly patients post PTHA for hip fracture was correlated with age ≥ 80 years old, delayed surgery longer than 4 days since admission, and general anesthesia. Much more attention should be paid to the patients with preoperative diseases of hypertension, heart diseases, and respiratory tract infection, especially age ≥ 80 years patients with respiratory tract infection. Specific postoperative attention should be paid to correct anemia, supplement albumin, regulate the imbalance of water and electrolyte, and treat the digestive tract response for PTHA patients aged ≥ 80 years

Lower-extremity orthopaedic procedures may be performed under either regional or general anaesthesia, or a combination of both techniques. There is a growing body of evidence supporting the benefits of regional anaesthesia, with meta-analyses of randomised controlled trials and registry data suggesting decreases in deep surgical site infections, thromboembolic events, cardiopulmonary complications and length of stay associated with use of regional anaesthesia. In patients undergoing foot and ankle surgery specifically, there is evidence demonstrating decreased post-operative pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports an increased role for the use in regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict the type of anaesthetic used in patients undergoing foot and ankle surgery. Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analysed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used. General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p<0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure (<0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 +/− 77 minutes, whereas patients provided with regional anaesthesia had a mean length of procedure 83 +/− 64 minutes. With increasing evidence supporting the benefits of regional anaesthesia in patients undergoing lower extremity surgery, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure may be a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be considered candidates for regional anaesthesia

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis. The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts. Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care). General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates

Prosthetic joint infection (PJI) is a complex disease that causes significant damage to the peri-implant tissue. Developing an animal model that is clinically relevant in depicting this disease process is an important step towards developing novel successful therapies. In this study, we have performed a thorough histologic analysis of peri-implant tissue harvested post Staphylococcus aureus (S. aureus) infection of a cemented 3D-printed titanium hip implant in rats. Sprague-Dawley rats underwent left hip cemented 3D-printed titanium hemiarthroplasty via posterior approach under general anesthesia. Four surgeries were performed for the control group and another four for the infected group. The hip joint was inoculated with 5×10. 9. CFU/mL of S. aureus Xen36 prior to capsule closure. The animals were scarified 3 weeks after infection. The femur was harvested and underwent micro-CT and histologic analysis. Hematoxylin and eosin (H&E), as well as Masson's trichrome (MT) stains were performed. Immunohistochemistry (IHC) using rabbit antibody for S. aureus was also used to localize bacterial presence within femur and acetabulum tissue . The histologic analysis revealed strong resemblance to tissue changes in the clinical setting of chronic PJI. IHC demonstrated the extent of bacterial spread within the peri-implant tissue away from the site of infection. The H&E and MT stains showed 5 main features in infected bone: 1) increased PMNs, 2) fibrovascular inflammation, 3) bone necrosis, and 4) increased osteoclasts 5) fibrosis of muscular tissue and cartilage. Micro CT data showed significantly more osteolysis present around the infected prosthesis compared to control (surgery with no infection). This is the first clinically relevant PJI animal model with detailed histologic analysis that strongly resembles the clinical tissue pathology of chronic PJI. This model can provide a better understanding of how various PJI therapies can halt or reverse peri-implant tissue damage caused by infection

Fragility fractures are an emerging healthcare problem in Sub-Saharan Africa and hip fractures (HFs) are associated with high levels of morbidity, prolonged hospital stays, increased healthcare resources utilization, and mortality. The worldwide average healthcare cost in the first-year post HF was US$43,669 per patient in a 2017 systematic review, however there are no studies quantifying fracture-associated costs within SSA. We estimated direct healthcare costs of HF management in the South African public healthcare system. We conducted a prospective ingredients-based costing study in 200 consecutive consenting HF patients to estimate costs per patient across five regional public sector hospitals in KwaZulu-Natal (KZN). Resource use including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by relevant unit costs, estimated from KZN Department of Health hospital fees manual 2019/20, in local currency (South African Rand, ZAR). Generalised linear models were used to estimate total covariate adjusted costs and cost predictors. The mean unadjusted cost for HF management was ZAR114,179 (95% CI; ZAR105,468–125,335). The major cost driver was orthopaedics/surgical ward costs ZAR 106.68, contributing to 85% of total cost. The covariate adjusted cost for HF management was ZAR114,696 (95% CI; ZAR111,745–117,931). After covariate adjustment, total costs were higher in patients operated under general anaesthesia compared to surgery under spinal anaesthesia and no surgery. Direct healthcare costs following a HF are substantial: 58% of the gross domestic per capita (US$12,096 in 2020), and six-times greater than per capita spending on health (US$1,187 in 2019) in SA. As the population ages, this significant economic burden to the health system will increase. Further research is required to evaluate direct non-medical, and the indirect costs incurred post HF

Purpose. We compared visible blood loss and calculated blood loss after bipolar hemiarthroplasty in femoral neck fracture, and evaluated correlation between blood loss and its risk factors. Materials and Methods: A total of 356 patients who underwent bipolar hemiarthroplasty in femoral neck fracture between 2004 and 2010 were enrolled in this study. The total blood loss was calculated using the formula reported by Mercuiali and Brecher. We analyzed several factors, including gender, age, body mass index (BMI), anesthesia method, cardiovascular and cerebrovascular disease, preoperative anemia, American Society of Anesthesiologists (ASA) score, use of cement, and use of antithrombotic agents. Results: Total calculated blood loss (1,408±72 ml) differed significantly from visible blood loss(980±102 ml). In addition, calculated blood loss differed between risk factors (1,526±369 ml in cardiovascular disease, 1,588±279 ml in general anesthesia, 1,645±920 ml in obesity, and 1,605±439 ml in use of antithrombotic agents). Conclusion: Total calculated blood loss was much greater than visible blood loss. Patients with risk factors such as cardiovascular disease, obesity, use of antithrombotic agents, and general anesthesia should be treated with care in order to reduce blood loss

Total hip arthroplasty (THA) is reliable and reproducible in relieving pain and improving function in patients with end-stage arthritis of the hip joint. With improvements in surgical technique and advances in implant and instrument design, there has been a shift in focus from the technical aspects of the surgical procedure to improving the overall patient experience. In addition, shifts in medico-economic trends placed a premium on early patient mobilization, early discharge, and maximizing patient satisfaction. Arguably, a single most important advance in arthroplasty over the past 2 decades has been the development of multimodal pain protocols that form the foundation of many of the rapid recovery protocols today. The principal concept of multimodal analgesia is pain reduction through the utilization of multiple agents that synergistically act at various nodes of the pain pathway, thus, minimizing patient exposure to each individual agent and opioids in order to prevent opioid related adverse events (ORAE). Regional anesthesia has been shown to reduce post-operative pain, morphine consumption, and nausea and vomiting compared to general anesthesia but not length of stay. Additionally, general anesthesia has been shown to be associated with increased rates of post-operative adverse events, The use of peripheral nerve blocks in the form of sciatic, femoral or fascia iliaca blocks have not been shown to significantly reduce post-operative pain compared to controls. Periarticular infiltration of local anesthetics has been shown in some settings to reduce pain during the immediate post-operative period (<24 h). However, no significant differences were noted in terms of early recovery or complications. The use of liposomal bupivacaine (LB) local infiltration decreased pain and shortened length of stay comparable to patients receiving a fascia iliaca compartment block, and has been shown in relatively few randomised trials to provide improved pain relief at 24 hours only compared to conventional bupivacaine. Continuous intra-articular infusion of bupivacaine after THA did not significantly further reduce post-operative pain compared to placebo. In summary, the use of regional anesthesia when appropriate along with local anesthetic infiltration in the setting of a robust multimodal pain protocol minimises pain and complications while maximizing patient satisfaction following THA

Introduction. In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated. Methods. All paediatric patients (≤ 16 years) treated in our institution during the six-week peak period of the pandemic were included. Prospective data for all paediatric trauma and urgent elective admissions and retrospective data for all sarcoma admissions were collected. Telephone interviews were conducted with all patients and families to assess COVID-19 related morbidity at 14 days post-discharge. Results. Overall, 100 children underwent surgery or interventional radiological procedures under GA between 20 March and 8 May 2020. There were 35 trauma cases, 20 urgent elective orthopaedic cases, two spinal emergency cases, 25 admissions for interventional radiology procedures, and 18 tumour cases. 78% of trauma cases were performed within 24 hours of referral. In the 97% who responded at two weeks following discharge, there were no cases of symptomatic COVID-19 in any patient or member of their households. Conclusion. Despite the extensive restructuring of services and the widespread concerns over the surgical and anaesthetic management of paediatric patients during this period, we treated 100 asymptomatic patients across different orthopaedic subspecialties without apparent COVID-19 or unexpected respiratory complications in the early postoperative period. The data provides assurance for health care professionals and families and informs the consenting process. Cite this article: Bone Joint Open 2020;1-6:287–292

Simultaneous bilateral total hip arthroplasty (THA) in patients with bilateral hip osteoarthritis is gradually becoming attractive, as it requires a single anesthesia and hospitalization. However, there are concerns about the potential complications following this surgical option. The purpose of this study is to compare the short-term major and minor complications and assess the readmission rate, between patients treated with same-day bilateral THA and those with staged procedures within a year. We retrospectively reviewed the charts of all patients with bilateral hip osteoarthritis that underwent simultaneous or staged (within a year) bilateral total THA in our institution, between 2016-2020. Preoperative patient variables between the two groups were compared using the 2-sample t-test for continuous variables, the Fisher's exact test for binary variables, or the chi-square test for multiple categorical variables. Similarly, differences in the 30-day major and minor complications and readmission rates were assessed. A logistic regression model was also developed to identify potential risk factors. A total of 160 patients (mean age: 64.3 years, SD: ±11.7) that underwent bilateral THA was identified. Seventy-nine patients were treated with simultaneous and eighty-one patients with staged procedures. There were no differences in terms of preoperative laboratory values, gender, age, Body Mass Index (BMI), or American Society of Anesthesiologists Scores (ASA) (p>0.05) between the two groups. Patients in the simultaneous group were more likely to receive general anesthesia (43% vs 9.9%, p0.05). After controlling for potential confounders, the multivariable logistic regression analysis showed similar odds of having a major (odds ratio 0.29, 95% confidence interval [0.30-2.88], p=0.29) or minor (odds ratio 1.714, 95% confidence interval [0.66-4.46], p=0.27) complication after simultaneous compared to staged bilateral THA. No differences in emergency department visits or readmission for reasons related to the procedure were recorded (p>0.05). This study shows that similar complication and readmission rates are expected after simultaneous and staged THAs. Simultaneous bilateral THA is a safe and effective procedure, that should be sought actively and counselled by surgeons, for patients that present with radiologic and clinical bilateral hip disease

Total hip arthroplasty (THA) is performed under general anesthesia (GA) or spinal anesthesia (SA). The first objective of this study was to determine which patient factors are associated with receiving SA versus GA. The second objective was to discern the effect of anesthesia type on short-term postoperative complications and readmission. The third objective was to elucidate factors that impact the effect of anesthesia type on outcome following arthroplasty. This retrospective cohort study included 108,905 patients (median age, 66 years; IQR 60-73 years; 56.0% females) who underwent primary THA for treatment of primary osteoarthritis in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database during the period of 2013-2018. Multivariable logistic regression analysis was performed to evaluate variables associated with anesthesia type and outcomes following arthroplasty. Anesthesia type administered during THA was significantly associated with race. Specifically, Black and Hispanic patients were less likely to receive SA compared to White patients (White: OR 1.00; Black: OR 0.73; 95% confidence interval [CI] 0.71-0.75; Hispanic: OR 0.81; CI, 0.75-0.88), while Asian patients were more likely to receive SA (OR 1.44, CI 1.31-1.59). Spinal anesthesia was associated with increased age (OR 1.01; CI 1.00-1.01). Patients with less frailty and lower comorbidity were more likely to receive SA based on the modified frailty index ([mFI-5]=0: OR 1.00; mFI-5=1: OR 0.90, CI 0.88-0.93; mFI-5=2 or greater: OR 0.86, CI 0.83-0.90) and American Society of Anesthesiologists (ASA) class (ASA=1: OR 1.00; ASA=2: OR 0.85, CI 0.79-0.91; ASA=3: OR 0.64, CI 0.59-0.69; ASA=4-5: OR 0.47; CI 0.41-0.53). With increased BMI, patients were less likely to be treated with SA (OR 0.99; CI 0.98-0.99). Patients treated with SA had less post-operative complications than GA (OR 0.74; CI 0.67-0.81) and a lower risk of readmission than GA (OR 0.88; CI 0.82-0.95) following THA. Race, age, BMI, and ASA class were found to affect the impact of anesthesia type on post-operative complications. Stratified analysis demonstrated that the reduced risk of complications following arthroplasty noted in patients treated with SA compared to GA was more pronounced in Black, Asian, and Hispanic patients compared to White patients. Furthermore, the positive effect of SA compared to GA was stronger in patients who had reduced age, elevated BMI, and lower ASA class. Among patients undergoing THA for management of primary osteoarthritis, factors including race, BMI, and frailty appear to have impacted the type of anesthesia received. Patients treated with SA had a significantly lower risk of readmission to hospital and adverse events within 30 days of surgery compared to those treated with GA. Furthermore, the positive effect on outcome afforded by SA was different between patients depending on race, age, BMI, and ASA class. These findings may help to guide selection of anesthesia type in subpopulations of patients undergoing primary THA

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

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

Introduction. Early rehabilitation and discharge following minimally-invasive total hip arthroplasty has potential risks including the possibility that patients may become progressively anemic at home. The current study assess the use of pre-emptive autologous blood transfusion on the length of stay, readmission, and allogenous transfusion. Methods. Patients treated by primary total hip arthroplasty using the superior capsulotomy technique were studied. Patients were divided into two groups. Group 1 were patients who did donate autologous blood and received an intra-operative pre-emptive transfusion. There were 283 patients in Group 1. Group 2 were patients who were medically capable of donating autologous blood but did not for non-medical reasons. There were 71 patients in Group 2. Patients who did not donate autologous blood for medical reasons (preoperative Hgb less than 11.5, age over 80) were excluded. All patients received general anesthesia. Length of stay, allogenous transfusion and readmission were compared. Results. The mean length of stay after surgery for the Group 1 patients who received autologous blood donation during primary THA was 1.56 days (SD 78 days, range 0–4). The mean length of stay for the Group 2 patients who did not donate or receive autologous blood during primary THA was 1.87 days (SD 84 days, range 1–4). Patients who received autologous blood donation had a significantly shorter post-surgical length of stay than patients who did not (p = .002, Mann-Whitney test). Patients who did not donate and preemptively receive autologous blood received significantly more allogenous blood (Mann-Whitney, p=.0004). Moreover 15% of those who auto-donated were given allogenic transfusions, while 37% of those who did not auto-donate were given allogeneic transfusions. One patient who did receive autologous transfusion and was discharged on day 2 sustained an NSAID induced GI-bleed 3 weeks postop and was admitted for transfusion and treatment. There were no other readmissions in either group. Conclusions. Patients who receive pre-emptive autologous blood transfusion intra-operatively when treated specifically by total hip arthroplasty using the superior capsulotomy technique under general anesthesia have shorter hospital stays and lower allogenous transfusion rates than a matched cohort of patients that did not donate and receive autogenous blood