Surgeon-performed periarticular injection and anesthesiologist-performed femoral nerve or adductor canal block with local anesthetic have been used in multimodal pain management for total knee arthroplasty (TKA) patients. Anesthesiologist-performed adductor canal blocks are costly, time consuming, and may be unreliable. We investigated the feasibility of a surgeon-performed saphenous nerve (“adductor-canal”) block from within the knee joint.

A retrospective analysis of 94 thigh-knee MRI studies was performed to determine the relationship between the width of the distal femur at the epicondylar axis and the proximal location of the saphenous nerve after its exit from the adductor canal and separation from the superficial femoral artery. After obtaining these data, TKA resections and trial component implantation were performed, using a medial parapatellar approach, in 11 fresh cadaveric lower extremity specimens. Using a blunt tip 1.5cm needle, we injected 10 ml each of two different colored solutions at two different intra-articular medial injection locations, and after 30 minutes, dissected the femoral and saphenous nerve and femoral artery from the hip to the knee to determine the location of the injections.

Based upon the MRI analysis, the saphenous nerve was located (and had exited the adductor canal) at a mean of 1.5 times the epicondylar width in females, and mean 1.3 times the epicondylar width in males, proximal to the medial epicondyle. After placement of TKA trial components and injection, the proximal injection site solution bathed the saphenous nerve in 8 of 11 specimens. The proximal blunt needle and solution was adjacent, but did not puncture, the femoral artery and vein in only one specimen. This study suggests that a surgeon-performed injection of the saphenous nerve from within the knee is a feasible procedure. This technique may be a useful alternative to ultrasound guided block. A trial comparing surgeon and anesthesiologist-performed nerve block should be considered to determine the clinical efficacy of this procedure. Our anecdotal use of this intra-articular injection over the past year has been favorable. Newer, extended release anesthetic agents should be investigated with this technique.

Abstract. Background. During COVID-19 pandemic, there has been worldwide cancellation of elective surgeries to protect patients from nosocomial transmission and peri-operative complications. With unfolding situation, there is definite need for exit strategy to reinstate elective services. Therefore, more literature evidence supporting exit plan to elective surgical services is imperative to adopt a safe working principle. This study aims to provide evidence for safe elective surgical practice during pandemic. Methods. This single centre, prospective, observational study included adult patients who were admitted and underwent elective surgical procedures in the trust's COVID-Free environment at Birmingham Treatment Centre between 19th May and 14th July’2020. Data collected on demographic parameters, peri-operative variables, surgical specialities, COVID-19 RT-PCR testing results, post-operative complications and mortality. The study also highlighted the protocols it followed for the elective services during pandemic. Results. 303 patients were included with mean age of 49.9 years (SD 16.5) comprising of 59% (178) female and 41% (125) male. They were classified according to American Society of Anaesthesiologist Grade, different surgical specialities and types of anaesthesia used. 96% patients were discharged on the same day. 100% compliance to pre-operative COVID-19 testing was maintained. There was no 30-day mortality or major respiratory complications. Conclusion. Careful patient selection, simultaneous involvement of the pre-assessment and anaesthetic team, strict adherence to peri-operative protocols and delivering vigilant post-operative care for COVID-19 infection can help providing safe elective surgical services if the community transmission under reasonable control. However, it is particularly important to maintain COVID-free safe environment for such procedures

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

Wound complications are common in patients with soft tissue sarcomas (STS) treated with surgical excision. Limited data is available on predictive factors for wound complications beyond the relationship to neo-adjuvant or adjuvant radiotherapy. Likewise, the association between blood transfusion, patient comorbidities and post-operative outcomes is not well described. In the present study we identified the predictive factors for blood transfusion and wound complications in patients undergoing surgical resection of soft tissue sarcoma from a national cohort. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent surgical resection of a STS from 2005 to 2013. Primary malignant soft tissue neoplasms were identified using the following ICD-9 codes: 171.2, 171.3 and 171.6. Patients treated with both wide excision and amputation were identified using the current procedural terminology (CPT) codes. Prolonged operative time was defined as greater than 90th percentile of time required per procedure. A multivariable logistic regression model was used to identify associations between patient factors and post-operative wound complications (superficial and deep surgical site infections (SSI), and wound dehiscence). A similar regression model sought to identify prognostic factors for blood transfusion and associations with post-operative outcomes. A total of 788 patients met our inclusion criteria. Of theses, 64.2% had tumours in the lower limb, 23.1% patients had tumours in the upper limb, and 12.7% patients had pelvic tumours. Six hundred and forty patients (81.2%) underwent surgical excision; 148 (18.8%) patients had an amputation. Multivariable logistic regression modeling identified American Society of Anaesthesiologist (ASA) class 3 and 4 (OR=2.3, P=0.03; OR=8.3, P=0.001, respectively), amputation (OR=14.0, P<0.001) and prolonged operative time (OR=4.6, P<0.001) as significant predictors of blood transfusion. Radiotherapy (OR=2.6, P=0.01) and amputation (OR=2.6, P=0.01) were identified as predictors of superficial SSI, whereas ASA class 4 (OR=6.2, P=0.03), prolonged operative time (OR=3.9, P=0.012) and return to the operating room (OR=10.5, P<0.001) were associated with deep SSI. Male gender (OR=1.8, P=0.03), diabetes (OR=2.3, P=0.03), ASA class 3 (OR=2.4, P=0.003), amputation (OR=3.8, P<0.001) and steroids (OR=4.5, P=0.03) were identified as predictors for wound dehiscence and open SSI. A national cohort demonstrates that male gender, diabetes, chronic steroid use, higher ASA score and radiotherapy are associated with an increased incidence of wound complications. One in twenty-three patients undergoing resection of an STS will require a blood transfusion, and this risk is correlated with amputation, prolonged operative time and increased ASA score. Strategies to decrease the risk of blood transfusion and wound complication should be considered for these patient groups

The main purpose of preoperative blood tests is to provide information to reduce the possible harm or increase the benefit to patients by altering their clinical management if necessary. This information may help clinicians assess the risk to the patient, predict postoperative complications and establish a baseline measurement for later reference. National Institute of Clinical Excellence (NICE) has issued guidelines around the need for pre-operative blood tests related to the age of the patient, comorbidities and the complexity of the procedure they will undergo. We decided to retrospectively review the pre-operative blood requests for patients under the age of 65 who were admitted at our institution over a 2 month period for open reduction and internal fixation of the ankle or tibial plateau and manipulation under anaesthesia of the lower limb. Patients were divided into 2 groups, under the age of 40 and between 40-65 years old. Patients under the age of 18 were excluded. These surgical procedures were classified as ‘intermediate complexity’. Admission clerkings of our 63 patient cohort were reviewed to ascertain if any patients had a significant co-morbidity or past medical history. The pre operative blood tests requested for each patient were audited against the NICE recommendations. None of the patients under the age of 40 had any significant comorbidites, whilst 8 patients above the age of 40 suffered with hypertension. 95% of patients had at least one blood test carried out. All patients over the age of 40 had at least one blood test. Tests requested included full blood count (91%), urea and electrolytes (91%), coagulation (66%), liver function tests (67%), group and save (69%), CRP (70%), ESR (2%), thyroid function tests (5%) and CK (2%). Only 5 patients (5%) followed the guidelines correctly. The clinical value of testing healthy individuals before an operation is debatable. The possible benefits of routine preoperative investigations include identification of unsuspected conditions that may require treatment before surgery or a change in surgical or anaesthetic management. The American Society of Anaesthesiologists has stated that ‘routine preoperative tests (i.e. tests intended to discover a disease or disorder in an asymptomatic patient) do not make an important contribution to the process of perioperative assessment and management of the patient by the anaesthesiologist.’. The overzealous requesting of preoperative blood tests also has a financial burden upon individual institutions. Our study also showed that some blood tests, such as inflammatory markers and thyroid function tests, were inappropriately requested. Adherence to the NICE guidelines would have resulted in a significant financial saving. This review has shown that adopting the NICE guidelines may result in a decrease in the amount of unnecessary blood tests patients undergo when they attend hospital for routine, minor or intermediate surgical procedures. If these guidelines were implemented for all surgical procedures, this would undoubtedly result in a significant financial saving for the institution and the NHS as a whole. At our institution we have implemented surgical and anaesthetic team awareness and education around these guidelines in a bid to reduce the use of unnecessary testing

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.