Introduction. A recent paper suggested implanting an uncemented acetabular shell which is 6mm or greater than the native femoral head in total hip arthroplasty (THA) significantly increased the risk of postoperative pain. We retrospectively analyzed 265 Delta ceramic-on-ceramic (DCoC) THA comparing the native femoral head size to the implanted shell and reviewing if the patient suffered with post-operative pain (POP). Methods. 265 consecutive THAs were performed using the Corail and Pinnacle prostheses with DCoC bearing. Native femoral head size was calculated retrospectively on pre-operative radiographs using TraumaCad software. All patients were sent questionnaires requesting information on satisfaction, sounds, postoperative pain and complications. Statistical analysis was then undertaken on the data. Results. Questionnaires were returned by 169 patients (189 hips). 42 patients reported postoperative pain. Patients suffering with pain had an average difference between native head and implanted shell of +6.8mm, compared to those without of +5.4mm. A shell of +6mm larger than the native head was associated with a statistically significant increase in the risk of postoperative pain (P=0.01). Patients with groin pain were more likely to have a smaller native head (46.1 Vs 47.3mm (P=0.046)). Patients with pain were more likely to complain of noisy hips (P=0.001). 70% of patients described being satisfied to the point where they forgot they had a THA. The dislocation rate was 1.1%. Discussion. A +6mm difference between native head and implanted shell was found to be a significant predictor of postoperative pain. We propose that to reduce the risk of postoperative pain, a limit of +4mm should be used. Overall complications were low and patients were very satisfied with their THA

Patients overestimate pain following hip and knee replacement. Ninety two patients awaiting hip or knee replacement were asked at their pre-operative assessment to estimate the level of pain they expected following their surgery on a 10cm visual analogue scale. Note was made of their age, gender, previous surgeries, Amsterdam anxiety score as regards the anaesthetic and surgery and an information score relating to their anaesthetic and surgery. Seventy nine patients had pain scores collected on a daily basis post surgery. Mean (std dev) age of the group was 68 (11) years and with a female to male ratio of 1.57. Females were significantly more anxious about the surgery than males (t-test, p< 0.007). Patients were more anxious about the anaesthetic and the surgery with hip replacement compared to knee replacement although this did not reach significance (t-test p=0.07). The mean (std dev) pain score pre-operatively was 7.5 (1.6). The mean (std dev) pain score expected was 7.0 (2.2) on the first post operative day and 4.3 (2.2) on the sixth post operative day. Forty four per cent of patients expected to have pain greater than their arthritis pain on the day following surgery. The level of pain experienced post-operatively was significantly lower than expected. Mean (std dev) pain score was 5.1 (2.7) on day 1 post op and 3.3 (2.4) on day 6 (t-test, p< 0.05 for both). There was no correlation between age, gender, number of previous surgeries, anxiety or information scores and the expected level of pain. The majority of patients, whatever their age, gender or level of anxiety over estimate their level of post-operative pain after joint replacement. Studies are needed to assess whether educating patients about pain post surgery will be of benefit, particularly in their early rehabilitation

Aims. The purpose of the present study was to evaluate the impact of intravenous tranexamic acid on the reduction of blood loss, transfusion rate, and early post-operative clinical outcome in total shoulder arthroplasty. Patients and Methods. A randomised, placebo-controlled trial which included 54 patients undergoing unilateral primary stemless anatomical or stemmed reverse total shoulder arthroplasty was undertaken. Patients received either 100 ml saline (placebo, n = 27), or 100 ml saline together with 1000 mg of tranexamic acid (TXA, n = 27) intravenously prior to skin incision and during wound closure. Peri-operative blood loss via an intra-articular drain was recorded and total blood loss was calculated. The post-operative transfusion rate was documented. Assessment of early clinical parameters included the visual analogue scale for pain (VAS), documentation of haematoma formation and adverse events. Results. Mean peri-operative blood drainage (placebo: 170 ml versus TXA: 50 ml, p = 0.001) and calculated mean total blood loss (placebo: 1248.2 ml versus TXA: 871.0 ml, p = 0.009) were significantly lower in the TXA group. No transfusions were necessary during the study period in either group. Mean VAS for pain significantly decreased from pre-operative (VAS 7) to the early post-operative period (VAS 1.7, p < 0.001). Significant differences regarding mean post-operative pain between placebo (VAS 2.0) and TXA (VAS 1.3) were detected (p = 0.05). The occurrence of haematomas was significantly more frequent in the placebo (59.3%, n = 16) than in the TXA group (25.9%, n = 6, p = 0.027). Whereas only mild haematomas developed in the TXA group, in the placebo group a total of 22.2% (n = 6) developed either moderate or severe haematomas. No adverse events associated with administration of TXA occurred. Conclusion. Intravenous administration of TXA successfully reduced mean peri-operative blood drainage, total estimated blood loss, pain during the first post-operative days, and haematoma formation in total shoulder arthroplasty. Cite this article: Bone Joint J 2017;99-B:1073–9

Aims: Intra-bursal versus inter-scalene post-operative effective pain control for Arthroscopic Shoulder Surgery. Methods: We prospectively collected data over a consecutive two year period, the first year patients (n=65) all having inter-scalene and the second year patients (n=79) having intra-bursal catheters. The interscalene 16F catheters were placed with the patient anaesthetised and an electrical Touhy needle. The intra-bursal 16F catheters were placed at the end of the arthroscopic shoulder operation, under direct vision, exiting from the posterior portal. Pain parameters collected were pain scores, visual analogue scales, analgesia usage, and whether or not the patients were comfortably able to go home the same day as surgery. Results: Pain and visual analogue scores showed no statistical differences between the two groups. Analgesia usage was greater in the inter-scalene group than the intra-bursal group, but was not statistically different. 32/65 (49%) of patients with inter-scalene catheters and 75/79 (95%) of patients with intra-bursal catheters were able to comfortably go home on the day of surgery, 28/33 (84%) of the inter-scalene patients were hospitalised due to post-operative pain, and 5/33 (15%) due to anaesthetic or medical problems. 2/4 (50%) of hospitalised intra-bursal patients had post-anaesthetic complications, and 2/4(50%) had pre-operative medical problems. Conclusions: Inter-scalene analgesia is widely published as the most effective for post-shoulder surgery pain control. Our data does not support this view, intra-bursal analgesia administration was found to be more effective at returning a comfortable patient home on the day of surgery. Our practice now routinely utilises intra-bursal catheters for either bolus analgesia or continuous pumps

Navigation in total knee replacement is now used more frequently. The proven benefits in comparison to a conventional knee replacement include reduced hospital stay, reduced blood loss, and improved component alignment. A retrospective study was carried out to evaluate the difference in post-operative pain outcomes between conventional and computer-assisted navigation knee arthroplasty in a high volume setting. Computer-assisted surgery may be more painful because of the extra pin holes required for the navigation. The amount of anti-emetic use between the two groups was also looked at as evidence exists that greater anti-emetic is used if pain levels are greater. All the navigated arthroplasty operations were performed by one of two surgeons in a single hospital using a uniform surgical approach and navigation system. A single type of prosthesis was used in the conventional group. In the first part of the study, the navigated group consisted of 87 patients and the conventional group of 40 patients (total = 127 cases). In the second ‘antiemetic use’ study, the navigated group consisted of 71 patients and the conventional group of 39 (total = 110). The analgesic and anti-emetic use was collated for the 72-hour post-operative period. This was chosen so that any analgesic influence of the anesthetic would have been negated over this period. Pain scores were measured over the 72 hour period at regular intervals using a visual analogue scale. Patients in the navigated group seemed to report less pain in the first 24 hours but this was later reversed. Interestingly, their pain scores were more constant during this period, whilst the conventional group exhibited greater variability. The actual difference in pain scores between the two groups was however not significant (p=0.33). The amount of opioid used by patients in each group was the primary factor used to see if a difference exists between the two procedures. The assumption was made that a correlation exists between opioid usage and pain. The total opioid usage was calculated by using referenced opioid conversion calculations for intravenous and oral forms of morphine including weaker opioids such as codeine and tramadol. The average opioid used in the conventional group was 164.8 mg whilst in the navigated it was 173.7mg. However using the Student’s t-test this difference was not significant with a p value = 0.69. The percentage of patients requiring opioid greater than 300mg in 72 hours was actually greater in the conventional group (15% vs 12.6%). The average antiemetic use looking initially at cyclizine was 57.7mg in conventional and 50.4mg in the navigated. This difference was also not significant (p=0.59). On analysis of the tourniquet times between the groups it was noted that the average time for a conventional operation was 89.6 minutes whilst it was 88.6 minutes in the other. This is in contrast to previous findings and it seems that the learning curve is improving at least in this high volume setting. This paper suggests that there is no difference between the two groups with respect to pain experienced in the post-operative period

Background Various methods of analgesia have been described for shoulder surgery, and we routinely used inter-scalene analgesia. We hypothesised that inter-scalene analgesia provided better pain control than intra-bursal analgesia. Methods We prospectively collected data over a consecutive two year period, with the first year patients (n=65) all having inter-scalene and the second year patients (n=79) having intra-bursal catheters. The interscalene 16F catheters were placed with the patient anaesthetised and an electrical Touhy needle. The intra-bursal 16F catheters were placed at the end of the arthroscopic shoulder operation, under direct vision, exiting from the posterior portal. Pain parameters collected were pain scores, visual analogue scales, analgesia useage, and whether or not the patients were comfortably able to go home the same day as surgery. Results Pain and visual analogue scores showed no statistical differences between the two groups. Analgesia useage was greater in the inter-scalene group than the intra-bursal group, but was not statistically different. 32/65 (49%) of patients with inter-scalene catheters and 75/79 (95%) of patients with intra-bursal catheters were able to comfortably go home on the day of surgery, 28/33 (84%) of the inter-scalene patients were hospitalised due to post-operative pain, and 5/33 (15%) due to anaesthetic or medical problems. 2/4 (50%) of hospitalised intra-bursal patients had post-anaesthetic complications, and 2/4(50%) had pre-operative medical problems. Discussion Inter-scalene analgesia is widely published as the most-effective route for post-shoulder surgery pain control. Our data does not support this view, and intra-bursal analgesia administration was found to be more effective at returning a comfortable patient home on the day of surgery. Our practice now routinely utilises intra-bursal catheters for either bolus analgesia or continuous pumps

The purpose of this prospective audit was to assess the efficacy of local infiltration analgesia in relieving postoperative pain following knee replacement surgery. Methods and materials: Data was collected on 61 consecutive patients undergoing knee replacement. They formed 2 groups. Patients in Group I (n=33) had 30 mls of Bupivacaine 0.5%, Ketoralac 30 mg, 0.75ml of adrenaline 1:1000 concentration made up to100mls with normal saline while patients in Group II (n=28) had either patient controlled analgesia (PCA) or regional nerve blocks. The group I patients had the local analgesia cocktail infiltrated into the soft tissues before wound closure. Majority of these patients had spinal anaesthesia supplemented with sedation while some had general anaesthesia supplemented with regional nerve blocks. All the patients were prescribed morphine as rescue analgesia and patacetamol/co-codamol and/or naproxene as supplemental analgesia. Pain was assessed with Numerical Rating Scale (NRS 0 – 10) at 1 hr, 3 hr, 6 hr and 8 hrs post-operatively. Results: The two groups were well matched for age, sex, ASA grade and body mass index. Pain control was generally satisfactory for group I (NRS range 0 – 2) compared to group II (NRS range 0 – 7). Most patients did not require morphine for post-operative pain control in group I (18/27 pts) while additional analgesics were not needed until 6 hours in this group. They were able to mobilise with assistance earlier compared to the other group. Moreover the pain levels as assessed by pain scores were lower with group I patients compared to group II patients. The nursing level of intensity was lower in group I patients as monitoring of PCA was not required compared to group II patients. Conclusion: Local infiltration analgesia is practical, simple and safe procedure with good efficacy in relieving pain after knee surgery. Moreover monitoring levels are reduced relieving nursing staff to concentrate on other duties

Purpose

Factors contributing to chronic postoperative pain (CPOP) are poorly defined in young people and developmental considerations are poorly understood. With over 5 million children undergoing surgery yearly and 25% of adults referred to chronic pain clinics identifying surgery as the antecedent, there is a need to elucidate factors that contribute to CPOP in young people. The present study includes patients undergoing hip preservation surgery at a children's hospital.

Previous authors have suggested that the analgesic effects of intra-articular morphine may be beneficial. Clonidine has been found to potentiate the analgesic effect of morphine. Following knee arthroscopy, morphine has demonstrated equivocal effect in comparison to bupivicaine for analgesia while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine following hip arthroscopy. The purpose of this study was to evaluate the efficacy of intra-articular morphine in combination with clonidine on pain and narcotic consumption following hip arthroscopy surgery for femoroacetabular impingement.

A retrospective review was performed on 43 patients that underwent hip arthroscopy between September 2014 and May 2015 at our institution for femoroacetabular impingement. All patients received preoperative Celebrex and Tylenol per our anesthesia protocol, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 mcg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the two groups.

We found that patients who received intra-articular morphine and clonidine used significantly less opioid analgesic in the PACU, with 23 mEq of morphine equivalents required in the intra-articular morphine and clonidine group compared to 40 mEq of opiod equivalents in the non-injection group (p=0.0259). There were no statistically significant differences in time spent in recovery prior to discharge or in VAS pain scores recorded immediately post-operatively and at one hour following surgery.

In conclusion, we found that an intraoperative intra-articular injection of morphine and clonidine significantly reduced the amount of narcotic requirement following hip arthroscopy. We do believe that there may be significant benefits to this, including less systemic effects from overall narcotic usage in the perioperative period. Our study demonstrated a beneficial effect of intra-articular morphine that may help with overall pain improvement, less narcotic consumption, and improved patient satisfaction following outpatient hip arthroscopy. This study provides the foundation for future research currently being conducted in a randomised-control setting.

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.

Introduction and Aims: Cold therapy is known to reduce pain and swelling after surgical procedures on the knee. We hypothesised that if cold therapy is started earlier, then there would be a reduction in pain and swelling in patients undergoing arthroscopic anterior cruciate ligament [ACL] reconstruction.

Method: We prospectively randomised 40 patients undergoing arthroscopic ACL reconstruction with hamstring autograft, to receive either room temperature [19° C] or cold [4° C] arthroscopy irrigation fluid. Patients were then assessed over the following seven days, with regard to pain [measured on a visual analogue scale], and swelling [measured with limb girth at four points around the knee].

Results: Pain scores were consistently reduced in the cold fluid group compared to the room temperature group throughout the post-operative period, and this difference was significant [p< =0.05] from six hours until seven days post-operatively. At day seven, the swelling measured at 5cm below the joint and 5cm above the joint were significantly lower in the cold group compared with the room temperature group. Drainage from the intra-articular drain was significantly lower in the cold group.

Conclusion: The use of cold irrigation fluid is a simple and safe measure by which pain and swelling (at day 7) can be reduced in the early post-operative period for arthroscopic ACL reconstruction.

Introduction Cold therapy is known to reduce pain and swelling after surgical procedures on the knee. We hypothesised that if cold therapy is started earlier, then there would be a reduction in pain and swelling in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction

Methods We prospectively randomised 40 patients undergoing arthroscopic ACL reconstruction with hamstring autograft, to receive either room temperature (19°C) or cold (4°C) arthroscopy irrigation fluid.Patients were then assessed over the following 7 days, with regard to pain (measured on a visual analogue scale), and swelling (measured with limb girth at 4 points around the knee).

Results Pain scores were consistently reduced in the cold fluid group compared to the room temperature group throughout the post operative period, and this difference was significant (p< =0.05) from 6 hours until 7 days post-operatively

At day 7 the swelling measured at 5cm below the joint and 5cm above the joint were significantly lower in the cold group compared with the room temperature group.

Drainage from the intra-articular drain was significantly lower in the cold group.

Conclusion The use of cold irrigation fluid is a simple and safe measure by which pain and swelling (at day 7), can be reduced in the early post-operative period for arthroscopic ACL reconstruction.

The use of tourniquet in lower limb orthopaedic surgery is well established, however, it does have associated risks and complications and its use has been previously questioned. The purpose of this study was to compare postoperative pain scores, analgesic requirements and time to discharge in patients undergoing tourniquet assisted and non-tourniquet assisted routine knee arthroscopy.

A total of 40 patients were randomised to tourniquet assisted and non-tourniquet assisted groups. Arthroscopy was performed using a standardised local anaesthetic infiltration in the non-tourniquet assisted group. All patients completed a postoperative pain score.

Findings demonstrated that the incidence and mean scores for postoperative pain were significantly lower in the non-tourniquet group. Additionally postoperative analgesic requirements of patients in the non-tourniquet group were also found to be significantly lower and time spent in recovery and on the ward postoperatively was also lower in the non-tourniquet group compared to the tourniquet group.

On the basis of the results in our study we recommend abolishing the use of tourniquet in routine knee arthroscopies in the virgin knee.

Background: The use of psoas compartment block provides good analgesia but poor surgical anaesthesia. In Ortho-geriatric care different nerve blockade had been used to avoid the systemic adverse effect of centrally acting agents and provide long duration of unilateral limb analgesia after arthroplasty.

Aim: The aim of the study is to establish the quality of pain control, incidence of side effects and complications achieved with a psoas compartment block (PCB) following surgery for fractured neck of femur.

Study design: Prospective, Non randomised, longitudinal, Cohort. A Pilot Study period January 2003 -December 2004

Materials & Method: 10 patients of mean age 74.8 years (Range 23–93), 3 males and 9 females had unilateral hip surgery with general or a spinal (with no intrathecal opiate administration) as the main anaesthesia and a psoas Compartment Block for continuous infusion of bupivacaine for postoperative pain control (a total dose of 2mg/kg given in theatre and received a continuous infusion of bupivacaine 0.1% at a rate of 25ml/hour for 48 hours) and assessed by nurse led pain team.

Result & analysis: All the patients in this study group had excellent pain control. On the first post operative day only one patient had mild pain, and another had moderate pain. On the second day 3 patients had mild pain [chart 1].

Conclusion: These patients had excellent to good post operative pain control without having any adverse side effects. This study will help us to treat pain among elderly geriatric patients particularly in the demented group in immediate post-operative period. We need randomised comparative study to advocate this practice.

Purpose: To determine if patients randomized to a knee immobilizer following a primary hamstring tendon anterior cruciate ligament (ACL) reconstruction have lower visual analog scale (VAS) pain scores at day two postoperative than patients who do not wear a knee immobilizer.

Method: Patients aged 18–40 with symptomatic ACL deficiency as determined by MRI or physical exam who met the study inclusion criteria were eligible. Patients meeting intra-operative inclusion critiera were randomized (immobilizer or no immobilizer) during wound closure. The immobilizer used was a soft unhinged brace with velcro straps and three metal bars (Breg). Pre, intra and post operative protocols were standardized. Analgesic use and VAS scores were recorded at: one hour after surgery, 8am and 8pm for the first two days postoperative, and 5pm for days 3–14 postoperative. Patients were examined by the surgeon within 14–28 days postoperative. Based on a published survey and the literature, the primary outcome was patient self-assessed pain using a 0–100mm VAS (no pain-worst pain) at day 2 postoperative. Secondary outcomes included: analgesic use, complications, and range of motion. A sample size estimate was calculated resulting in 44 patients per group. A total of 102 patients were enrolled; 88 randomized and 14 excluded intra-operatively. Recruitment was achieved within 11 months.

Results: There was no difference in mean VAS pain scores at 2 days post-operative between immobilized and non-immobilized patients (32.6 and 35.2, respectively; p=0.59, 95% CI −6.99, 12.3). Regardless of group allocation, the greatest pain reported was on the evening of day 1 post-operative. Throughout the first week, patients medicated to a pain level of approximately 30/100. There were no differences between groups in medication consumed, range of motion or complications. At 2 days post-operative all patients randomized to the immobilizer group reported that they worn their brace 76–100% of the time.

Conclusion: No differences in pain were detected between immobilized and non-immobilized patients at any point during 14 days post ACL reconstruction. Based on these findings, a knee immobilizer is not recommended post-operatively for pain control. This study does not address other reasons for immobilizer use such as graft protection or range of motion.

Painful OA is linked to CNS changes in pain processing. Temporal summation of pain (TSP) is a measure of one such CNS change, central sensitization. TSP is defined using a series (≥0.33Hz) of painful stimuli and is a predictor of postoperative pain, experienced by 20% of patients after total knee replacement (TKR) surgery. This study has developed a protocol to use functional MRI to assess CNS changes in OA pain processing.

This pilot includes 3 participants with chronic knee OA pain awaiting TKR (62 ± 4.4) and 5 healthy volunteers (50 ± 13.6). 3-Tesla BOLD fMRI brain scans were recorded during short series of one second painful stimuli, applied using an automated inflatable cuff to the calf muscle of the leg with the affected knee or left side in healthy volunteers. The pain intensity at onset and during the 10 painful stimuli were recorded using a numerical rating scale. The pattern of brain activation was averaged across noxious stimuli, and the differential activation compared the 1st vs. 10th (last) stimulus. Bone marrow lesions (BMLs), synovitis and effusion size were scored from 3-Tesla knee MRI's using MOAKS scoring.

TSP was raised in OA patients compared to control group (p=0.023). TSP brain activity in the chronic OA patients displayed higher signal within the subgenual anterior cingulate (sgACC) compared to healthy volunteers. Knee MRI identified OA patient's exhibited higher BML scores (p=0.038) and more knee effusion (p=0.018), but the lack of synovitis did not differ from control group (p=0.107).

Enhanced TSP in chronic knee OA pain may be linked with augmented responses in emotional circuitry. BMLs and effusion size appear to contribute more with pain than synovitis. These results may help understand sensitization to improve outcomes for patients with knee OA undergoing TKR surgery.

In a randomised controlled pragmatic trial we investigated whether local infiltration analgesia would result in earlier readiness for discharge from hospital after total knee replacement (TKR) than patient-controlled epidural analgesia (PCEA) plus femoral nerve block. A total of 45 patients with a mean age of 65 years (49 to 81) received a local infiltration with a peri-articular injection of bupivacaine, morphine and methylprednisolone, as well as adjuvant analgesics. In 45 PCEA+femoral nerve blockade patients with a mean age of 67 years (50 to 84), analgesia included a bupivacaine nerve block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics. The mean time until ready for discharge was 3.2 days (1 to 14) in the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral nerve blockade group. The mean pain scores for patients receiving local infiltration were higher when walking (p = 0.0084), but there were no statistically significant differences at rest. The mean opioid consumption was higher in those receiving local infiltration.

The choice between these two analgesic pathways should not be made on the basis of time to discharge after surgery. Most secondary outcomes were similar, but PCEA+femoral nerve blockade patients had lower pain scores when walking and during continuous passive movement. If PCEA+femoral nerve blockade is not readily available, local infiltration provides similar length of stay and similar pain scores at rest following TKR.

Cite this article: Bone Joint J 2013;95-B:629–35.

Introduction. Recent advances in minimally invasive surgery and improved post-operative pain management make it possible to perform major foot/ankle operations as day-case. This could have significant impact on length of stay, saving resources and is in keeping with government policy. However, there are theoretical concerns about complications and low patient satisfaction due to pain. Methods. The survey was developed following review of the literature and was approved for distribution by the BOFAS (British Orthopaedic Foot & Ankle Society) scientific committee. An online survey (19 questions) was sent to UK foot and ankle surgeons via the BOFAS membership list. Major foot/ ankle procedures were defined as surgery that is usually performed as an inpatient in majority of centres and day-case as same day discharge, with day surgery as the intended pathway. Results. A total of 132 surgeons responded, 80% from Acute NHS Trusts. The majority (78%) thought that more procedures could be performed as day-case at their centre. Currently 45% of respondents perform less than 100 day-case surgeries per year for these procedures. Despite post-operative pain and patient satisfaction being theoretical concerns for day-case surgery in this population; these outcomes were only measured by 34% and 10% of respondents respectively. The top perceived barriers to performing more major foot and ankle procedures as day-case were: Lack of physiotherapy input pre/post-operatively (23%), Lack of out of hours support (21%). Conclusions. There is consensus among surgeons to do more major foot/ ankle procedures as day-case. Despite theoretical concerns about post-operative pain and satisfaction this was only measured by a third of those surveyed. Out of hours support and physiotherapy input pre/ post-op were perceived as the main barriers. There is a need to scope the provision of physiotherapy pre/post-operatively and out of hours support at sites where this is a perceived barrier

Hallux valgus surgery can result in moderate to severe post-operative pain requiring the use of narcotic medication. The percutaneous distal metatarsal osteotomy is a minimally invasive approach which offers many advantages including minimal scarring, immediate weight bearing and decreased post-operative pain. The goal of this study is to determine whether the use of narcotics can be eliminated using an approach combining multimodal analgesia, ankle block anesthesia and a minimally invasive surgical approach. Following ethics board approval, a total of 160 ambulatory patients between the ages of 18-70 with BMI ≤ 40 undergoing percutaneous hallux valgus surgery are to be recruited and randomized into Narcotic-free (NF) or Standard (S) groups. To date, 72 patients have been recruited (38 NF and 34 S). The NF group received acetaminophen, naproxen, pregabalin 75mg and 100mg Ralivia (tramadol extended release) before surgery and acetaminophen, naproxen, pregabalin 150mg one dose and Ralivia 100mg BID for five days, as well as a rescue narcotic (hydromorphone, 1mg pills) after surgery. The S group received acetaminophen and naproxen prior to surgery and acetaminophen, naproxen and hydromorphone (1mg pills) post-operatively, our current standard. Visual analog scales (VAS) were used to assess pain and narcotic consumption was recorded at 6, 12, 24, 36, 48, 72 hours and seven days post-operatively. Patients wore a smart watch to record the number of daily steps and sleep hours. A two-sided t-test was used to compare the VAS scores and narcotic consumption. During the first post-operative week, the NF group consumed in total an average of 6.5 pills while the S group consumed in total an average of 16 pills and this difference was statistically significant (p-value=0.001). Importantly, 19 patients (50%) in the NF group and four patients (12%) in the S group did not consume any narcotics post-operatively. For the VAS scores at 24, 48, 72 hours and seven days the NF group's average scores were 2.17, 3.17, 2.92, 2.06 respectively and the S group's average scores were 3.97, 4.2, 3.23, 1.97. There was a statistically significant difference between the groups at 24 and 48hours (the NF group scored lower on the VAS) with a p-value of 0.0008 and 0.04 respectively, but this difference is not considered clinically significant as the minimal clinically important difference reported in the literature is a two-point differential. The NF group walked an average of 1985.75 steps/day and slept an average of 8h01 minute/night, while the S group walked an average of 1898.26 steps/day and slept an average of 8h26 minutes/night in the first post-operative week. Hallux valgus remains a common orthopedic foot problem for which surgical treatment results in moderate to severe post-operative pain. This study demonstrates that with the use of multimodal analgesia, ultrasound guided ankle blocks and a percutaneous surgical technique, narcotic requirements decreased post-operatively. The use of long-acting tramadol further decreased the need for narcotic consumption. Despite decreased use of narcotics, this combined novel approach to hallux valgus surgery allows for early mobilization and excellent pain control

Total Knee Arthroplasty (TKA) is a successful treatment for end stage osteoarthritis of the knee joint. However, post-operative pain can lead to patient dissatisfaction and poorer outcomes. Cooled radiofrequency nerve ablation (CRNA) has reportedly been effective at treating pain osteoarthritic knee pain by targeting the periarticular nerves of the knee. We undertook a prospective, controlled pilot study to determine if CRNA provides effective post-operative analgesia when utilised intra-operatively during total knee arthroplasty. Participants were recruited from January 2019 to February 2020. Those meeting inclusion criteria underwent TKA with intraoperative CRNA to 6 target sites prior to the cementing of implants. The primary outcomes were pain scores and opiate usage in the first 4 days post-operatively, then weekly up to 6 weeks. A total of 62 patients were screened and allocated sequentially; 18 were recruited to the control group and 12 recruited to the study group. The two groups did not have any significant difference in demographics. There were no clinically significant differences between the two groups in terms of pain scores nor opiate usage. There were complications as a result of the intervention. This study demonstrated no benefit of using intraoperative CRNA for improving post-operative pain scores or reducing opiate use after TKA