Introduction. Peri-articular local anesthetic injections reduce post-operative pain in total knee arthroplasty and assist recovery. It is inconclusive whether intra-operative injection of peri-articular morphine is locally effective. The aim of this study is whether the addition of morphine to peri-articular injections in only unilateral knee improves post-operative pain, range of motion, swelling in patients with simultaneous bilateral total knee arthroplasty. Materials and Methods. A prospective single-center double-blinded randomized controlled trial was undertaken to assess the local efficacy of adding morphine to intra-operative, peri-articular anesthesia in simultaneous bilateral total knee arthroplasty. Twenty eight patients with 56 TKAs were randomly divided into 2 groups, unilateral TKA with intraoperative peri-articular injection with adding morphine and the other side TKA without adding morphine. The morphine group received an intraoperative, peri-articular injection of local anesthetic (Ropivacaine 150mg), epinephrine (50μg), ketoprofen (25mg) and methylpredonisolone sodium (20mg) plus 0.1mg/kg of morphine. The no-morphine group received the same amount of local anesthetic, epinephrine, ketoprofen and methylpredonisolone sodium without morphine. The operating surgeon, operating staff, patients, physiotherapists, ward nursing staff and data collectors remained blinded for the duration of study. All surgeries were performed by the same operating team. A standard medial parapatellar approach was used in all operations. Post-operative analgesia was standardized to all participants with celecoxib daily for 3 weeks. Primary outcomes included visual analog pain scores (VAS), ROM and swelling of the thigh. Secondary outcomes included WOMAC and adverse outcomes. Result. There were no significant differences between two groups for pre-operative ROM, pre-operative pain VAS or the circumference of the thigh. There were no statistically significant differences in primary and secondary outcomes between two groups (Figure 1, 2, 3). Discussion. Multiple studies have demonstrated the clinical efficacy of multimodal peri-articular injection of analgesics in TKA for pain relief. However, the opioids often lead to nausea as an adverse effect, which is reported from 25% to 56%. The mechanism of pain relief by morphine is mainly the efficacy through the opioid receptor in central nerve system, and the other mechanism through local opioid receptor (μ-receptor) is rarely revealed for pain relief. Our study used morphine in unilateral TKA and no-morphine in the other side TKA and showed no significant difference in primary and secondary outcomes. These results revealed that the efficacy for pain relief in peri-articular injection without morphine is the same as that in no-morphine group. In conclusion, adding morphine in peri-articular injection could not be locally effective for pain relief

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

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

Intrathecal morphine (IM) is a common adjunct in paediatric spinal deformity surgery. We previously demonstrated with idiopathic scoliosis it provides safe and effective analgesia in the immediate postoperative period. This study represents our 25 year experience with IM in all diagnostic groups. Our prospective Pediatric Orthopaedic Spine Database (1993–2018) was reviewed to identify all patients undergoing spinal deformity surgery who received IM and who did not. Patients 21 years of age or less who had a posterior spinal fusion (PSF) with segmental spinal instrumentation (SSI), and received 9–19 mcg/kg (up to 1 mg) of IM were included. Early onset scoliosis surgical patients were excluded. We assessed demographics, pain scores, time to first dose of opioids, diagnoses, surgical time, paediatric intensive care unit (PICU) admission and IM complications (respiratory depression, pruritus, nausea/ vomiting). There were 986 patients who met inclusion criteria. This included 760 patients who received IM and 226 who did not. IM was not used for short procedures (< 3 hrs), respiratory concerns, unsuccessful access of intrathecal space, paraplegia, and anesthesiologist decision. Both groups followed the same strict perioperative care path. The patients were divided into 5 diagnostic groups (IM / non IM patients): idiopathic (578/28), neuromuscular (100/151), syndromic (36/17), and congenital scoliosis (32/21) and kyphosis (14/9). Females predominated over males (697/289). The first dose of opioids after surgery was delayed for a mean of 10.6 hrs in IM group compared to 2.3 hrs in the non-IM group (p=0.001). The postoperative pain scores were significantly lower in the IM groups in the Post Anesthesia Care Unite (p=0.001). Only 17 IM patients (2%) were admitted to the PICU for observation secondary to respiratory depression, none required re-intubation. None of the IM group were re-intubated. Forty-nine patients (6%) experienced pruritus in the IM group compared to 4 of 226 patients (2%) in the non IM group. There were 169 patients (22%) of the IM patients and 21 patients (9%) of the non IM had nausea and vomiting postoperatively. Three patients (0.39%) had a dural leak from the administration of IM but did not require surgical repair. There were no other perioperative complications related to the use of IM. There were no significant group differences. Pre-incision IM is a safe and effective adjunct for pain management in all diagnostic groups undergoing spinal surgery. The IM patients had lower pain scores and a longer time to first administration of post-operative opioids. Although there is an increased frequency of respiratory depression, pruritus, and nausea/vomiting in the IM group, there were no serious complications

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

Regional anaesthesia is integral to best practice analgesia for patients with neck of femur fractures (NOFFs). These patients are generally frail and are vulnerable to side effects of opioid analgesia. Femoral nerve block (FNB) or fascia-iliaca block (FIB) can reduce opioid requirement. Literature supports good efficacy for extra-capsular NOFFs however it is acknowledged to be suboptimal for intracapsular fractures. We present a novel technique, using point of care ultrasound guidance to perform hip ultrasound guided haematoma (HUSH) aspiration, and injection of local anaesthetic (block) for intracapsular NOFFs. This a case control series. A consecutive series of cognitively intact patients, with an isolated intra-capsular NOFF, received a HUSH block using 10mls of 0.75% Ropivicaine. Haematoma was aspirated and volume recorded. This was performed in addition to standard NOFF pathway analgesia that includes a FIB and multimodal analgesia including opioids. Visual Analogue Scale (VAS)pain scores at rest and on movement were recorded pre and post procedure as well as combined morphine equivalent units administered post HUSH block. The control arm was a retrospective group of similar patients who followed the routine care pathway including a FIB. VAS pain scores from observation charts and usage of morphine equivalent units were calculated. Ten patients consented to receive HUSH blocks and we included thirty-eight patients in our control series. The HUSH block group showed mean VAS pain score of 4.2/10 at rest and 8.6 on movement prior to block. In the time after the block, VAS pain scores reduced to 1.5 at rest (p=0.007) and 3.1 on movement (p=0.0001) with a mean total morphine equivalent use of 8.75mg. This is significantly different from the control group's mean VAS pain at rest score 6.9 (p=0.0001) and 24.1mg total morphine equivalent (p=0.07). HUSH Block in addition to fascia iliaca block appears to significantly better pain relief in intracapsular neck of femur fracture patients when compared to fascia iliaca block alone. We believe it is relatively easy to perform with readily available ultrasound scanners in emergency departments

Excessive postoperative opioid prescribing is a significant contributor to the opioid crisis. Prescribing in orthopaedic surgery is often further complicated by high use of opioid-based preoperative analgesia. ‘Opioid PrEscRiptions and usage After Surgery’ (OPERAS) is an international multicentre prospective student- and trainee-led collaborative study which aims to quantify the amount of opioids prescribed at discharge after common orthopaedic surgeries against what is consumed by patients at 7-days, and assess the impact of opioids on patient-reported outcomes. Data is being collected over 6 14-day periods on consecutive adult patients undergoing shoulder arthroplasty, rotator cuff repair, shoulder labral repair, anterior cruciate ligament repair, hip arthroplasty, and knee arthroplasty, with follow-up via telephone call at 7-days after discharge. The primary outcome is the proportion of oral morphine equivalents (OME) of prescribed opioids versus consumed opioids at 7-days post-discharge. This ongoing study is actively recruiting in over 20 countries. Globally, 65 centres are collecting orthopaedic, including 10 New Zealand centres and 17 Australian centres. To date, 284 orthopaedic patients have been prospectively enrolled with complete data (mean age 59.6 ± 16.7 years; 51.6% female). Overall, 77% and 89% of patients were prescribed opioids on discharge in New Zealand and Australia respectively. On average, 60% of prescribed opioids were consumed at 7-days post-discharge globally (150 OME (75-500) vs. 90 OME (15-200); p<0.01). In New Zealand and Australia, 42.1% (285 OME (150-584) vs. 120 OME (6-210); p<0.01) and 63.3% (150 OME (86-503) vs. 95 OME (28-221); p<0.01) of prescribed opioids were consumed at 7-days, respectively. OPERAS will provide the first high-quality global data on opioid prescription and consumption patterns with patient perspectives. These data can inform prescribing practice and inform guidelines. The growing interest in New Zealand and Australia in student- and trainee-led orthopaedic collaborative research, as evidenced by this study should be actively encouraged and fostered

Introduction. A 6cm femoral gain requires 5-Y during normal growth, but only 6–8-W surgically (x30–40 faster). In lengthening surgery, losses of muscle force (MF) and circumferences (MC) are major. Recovery is long, preventing sports till bone fusion. Can we maintain MC and strength throughout the entire lengthening and how?. We monitored for over 30 years patients for muscle force (isokinetic), circumferences, activities (including sports) and food intake, and acted on the 5 principles of the Osteostasis. Materials & Methods. Over 750 femoral lengthening with Full WB Nails (FWBN) got Isokinetic testing (≧1991), circumferences measurements (≧2012; 20-15-10-5-0cm above patella, max-calf, mini/max-ankle), food intake (≧2012), using MyFitnessPal App (≧2016), gradually enforced. Preoperative training along with a daily post-operative training are supervised by our trainers. Recommendations for food intake and activities were provided. Patients noted on a specific App all parameters. Compliance was noted. Results. Instead of a traditional 7–9cm circumference loss for 8–10cm gains using Ex-fix or nails, with FWBN and our protocols, no MC loss could be noted in compliant pre-trained patients, intensive early post-op resistance training, high calory intake (M:>4200, F:>3000; 20–25% Proteins) and supplements (no fat pad increase). Bone fusion could be obtained at the end of lengthening or within short weeks (Healing Index down to 8D/cm). Non-compliant patients (or using morphine), lost weight and MC. Conclusions. Increasing by 8–10cm muscle length, even bilaterally, and maintaining MC during lengthening, is possible, with very fast bone fusion. It requires building up several hundred of grams of muscles. The ‘building up equation’ associating resistance bike from the early post-operative phase with sports, strong food intake with increased protein intake, and added supplements with no morphine medication, proved to boost circumferences and bone fusion. It induced fast recovery, walking and sports capacities

Introduction. Frame HI is the #Days for device removal/cm. IM Nail HI is less relevant (31–45 D/cm). Albizzia HI was 33 D/cm (1991–2003). Patients felt fine approximately 1M after end of lengthening (EoL), resuming normal life and sports. This sometimes resulted in implants fractures (e.g. skying before bone fusion). Ideally, the full fusion should occur at the EoL. We decided to shorten the HI to reach this target, optimising all parameters. Materials & Methods. The evolution of care has been monitored over a 32-year clinical experience with a fully weight-bearing nails (Albizzia then G-nail). Monitoring was with X-rays, DEXA, blood bone activity, and in London with special 5G CBCT Scans. We implemented several changes in the Care of patients and measured them according to the ‘Five Principles’ (stability, function, ‘Roads-vascular supply’, ‘Materials-calories’ and ‘Workers-BFC’, with actions on food intake, activity levels and on muscle and bone vascular growths. Results. Preop: training (vascularity, muscle force). Op & Postop: spine morphine, IM sawing preserving BFC, controlled hypo-pressure, low hydration, 50 cm leg elevation, walking, resistance bike, full motion (drainage, muscle reactivation), discharge 3–4h postop (including bilateral). Postop daily intense gym training. POD07-21: Distraction increased to fight non-linear hyper-ossification (44–50 mm gain at POD30) +/- aided by NSAIDs. HI decreased to 12–20D/cm, sometimes 8D/cm with some ‘soft fusion’ during lengthening, hardening within 1W after EoL. Conclusions. The surgeon is not a passive X-rays observer, but has an active role in changing the healing speed and decreasing HI for patient safety. Electro/Magnetic nails (torque 1 Nm) may be clocked by bone fusion, which does not occur with the G-Nail (19 Nm). An holistic vision for patients and treatments at several levels is essential to accelerate bone healing, and to return fast to full normal life, after a short ‘lengthening parenthesis’

Interscalene brachial plexus block is the standard regional analgesic technique for shoulder surgery. Given its adverse effects, alternative techniques have been explored. Reports suggest that the erector spinae plane block may potentially provide effective analgesia following shoulder surgery. However, its analgesic efficacy for shoulder surgery compared with placebo or local anaesthetic infiltration has never been established. We conducted a randomised controlled trial to compare the analgesic efficacy of pre-operative T2 erector spinae plane block with peri-articular infiltration at the end of surgery. Sixty-two patients undergoing arthroscopic shoulder repair were randomly assigned to receive active erector spinae plane block with saline peri-articular injection (n = 31) or active peri-articular injection with saline erector spinae plane block (n = 31) in a blinded double-dummy design. Primary outcome was resting pain score in recovery. Secondary outcomes included pain scores with movement; opioid use; patient satisfaction; adverse effects in hospital; and outcomes at 24 h and 1 month. There was no difference in pain scores in recovery, with a median difference (95%CI) of 0.6 (-1.9-3.1), p = 0.65. Median postoperative oral morphine equivalent utilisation was significantly higher in the erector spinae plane group (21 mg vs. 12 mg; p = 0.028). Itching was observed in 10% of patients who received erector spinae plane block and there was no difference in the incidence of significant nausea and vomiting. Patient satisfaction scores, and pain scores and opioid use at 24 h were similar. At 1 month, six (peri-articular injection) and eight (erector spinae plane block) patients reported persistent pain. Erector spinae plane block was not superior to peri-articular injection for arthroscopic shoulder surgery

Abstract. Objectives. To determine the effectiveness of LIA compared to ACB in providing pain relief and reducing opiates usage in hamstring graft ACL reconstructions. Materials and Methods. In a consecutive series of hamstring graft ACL reconstructions, patients received three different regional and/or anaesthetic techniques for pain relief. Three groups were studied: group 1: general anaesthetic (GA)+ ACB (n=38); group 2: GA + ACB + LIA (n=31) and group 3: GA+LIA (n=36). ACB was given under ultrasound guidance. LIA involved infiltration at skin incision site, capsule, periosteum and in the hamstring harvest tunnel. Analgesic medications were similar between the three groups as per standard multimodal analgesia (MMA). Patients were similar in demographics distribution and surgical technique. The postoperative pain and total morphine requirements were evaluated and recorded. The postoperative pain was assessed using the visual analogue scores (VAS) at 0hrs, 2hrs, 4hrs, weight bearing (WB) and discharge (DC). Results. There was no statistically significant difference in opiates intake amongst the three groups. When comparing VAS scores; there were no statistical difference between the groups at any of the time intervals that VAS was measured. However, the GA+LIA group hospital's LOS (m=2.31hrs, SD=0.75) was almost half that of GA+ACB group (m=4.24hrs, SD=1.08); (conditions t(72)=8.88; p=0.000). There was no statistical significance in the incidence of adverse effects amongst the groups. Conclusion. The LIA technique provided equally good pain relief following hamstring graft ACL reconstructions when compared to ACB, while allowing for earlier rehabilitation, mobilisation and discharge

Orthopaedic surgeons prescribe more opioids than any other surgical speciality. Opioids remain the analgesic of choice following arthroscopic knee and shoulder surgery. There is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients’ pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. The objective of the current randomized controlled trial (RCT) was to evaluate the efficacy of a multi-modal, opioid-sparing approach to postoperative pain management in patients undergoing arthroscopic shoulder and knee surgery. The NO PAin trial is a pragmatic, definitive RCT (NCT04566250) enrolling 200 adult patients undergoing outpatient shoulder or knee arthroscopy. Patients are randomly assigned in a 1:1 ratio to an opioid-sparing group or standard of care. The opioid-sparing group receives a three-pronged prescription package consisting of 1) a non-opioid prescription: naproxen, acetaminophen and pantoprazole, 2) a limited opioid “rescue prescription” of hydromorphone, and 3) a patient education infographic. The control group is the current standard of care as per the treating surgeon, which consists of an opioid analgesic. The primary outcome of interest is oral morphine equivalent (OME) consumption up to 6 weeks postoperatively. The secondary outcomes are postoperative pain scores, patient satisfaction, quantity of OMEs prescribed and number of opioid refills. Patients are followed at both 2 and 6 weeks postoperatively. Data analysts and outcome assessors are blinded to the treatment groups. As of December 1, 2021 we have enrolled 166 patients, reaching 83% of target enrolment. Based on the current recruitment rate, we anticipate that enrolment will be completed by the end of January 2022 with final follow-up and study close out completed by March of 2022. The final results will be released at the Canadian Orthopaedic Association Meeting in June 2022 and be presented as follows. The mean difference in OME consumption was XX (95%CI: YY-YY, p=X). The mean difference in OMEs prescribed was XX (95%CI: YY-YY, p=X). The mean difference in Visual Analogue Pain Scores (VAS) and patient satisfaction are XX (95%CI: YY-YY, p=X). The absolute difference in opioid refills was XX (95%CI: YY-YY, p=X). The results of the current study will demonstrate whether an opioid sparing approach to postoperative outpatient pain management is effective at reducing opioid consumption while adequately addressing postoperative pain in patients undergoing outpatient shoulder and knee arthroscopy. This study is novel in the field of arthroscopic surgery, and its results will help to guide appropriate postoperative analgesic management following these widely performed procedures

Orthopaedic surgeons prescribe more opioids than any other surgical speciality. Opioids remain the analgesic of choice following arthroscopic knee and shoulder surgery. There is growing evidence that opioid-sparing protocols may reduce postoperative opioid consumption while adequately addressing patients’ pain. However, there are a lack of prospective, comparative trials evaluating their effectiveness. The objective of the current randomized controlled trial (RCT) was to evaluate the efficacy of a multi-modal, opioid-sparing approach to postoperative pain management in patients undergoing arthroscopic shoulder and knee surgery. The NO PAin trial is a pragmatic, definitive RCT (NCT04566250) enrolling 200 adult patients undergoing outpatient shoulder or knee arthroscopy. Patients are randomly assigned in a 1:1 ratio to an opioid-sparing group or standard of care. The opioid-sparing group receives a three-pronged prescription package consisting of 1) a non-opioid prescription: naproxen, acetaminophen and pantoprazole, 2) a limited opioid “rescue prescription” of hydromorphone, and 3) a patient education infographic. The control group is the current standard of care as per the treating surgeon, which consists of an opioid analgesic. The primary outcome of interest is oral morphine equivalent (OME) consumption up to 6 weeks postoperatively. The secondary outcomes are postoperative pain scores, patient satisfaction, quantity of OMEs prescribed and number of opioid refills. Patients are followed at both 2 and 6 weeks postoperatively. Data analysts and outcome assessors are blinded to the treatment groups. As of December 1, 2021 we have enrolled 166 patients, reaching 83% of target enrolment. Based on the current recruitment rate, we anticipate that enrolment will be completed by the end of January 2022 with final follow-up and study close out completed by March of 2022. The final results will be released at the Canadian Orthopaedic Association Meeting in June 2022 and be presented as follows. The mean difference in OME consumption was XX (95%CI: YY-YY, p=X). The mean difference in OMEs prescribed was XX (95%CI: YY-YY, p=X). The mean difference in Visual Analogue Pain Scores (VAS) and patient satisfaction are XX (95%CI: YY-YY, p=X). The absolute difference in opioid refills was XX (95%CI: YY-YY, p=X). The results of the current study will demonstrate whether an opioid sparing approach to postoperative outpatient pain management is effective at reducing opioid consumption while adequately addressing postoperative pain in patients undergoing outpatient shoulder and knee arthroscopy. This study is novel in the field of arthroscopic surgery, and its results will help to guide appropriate postoperative analgesic management following these widely performed procedures

Ankle fractures are common orthopedic injuries, often requiring operative intervention to restore joint stability, improve alignment, and reduce the risk of post-traumatic ankle arthritis. However, ankle fracture surgeries (AFSs) are associated with significant postoperative pain, typically requiring postoperative opioid analgesics. In addition to putting patients at risk of opioid dependence, the adverse effects of opioids include nausea, vomiting, and altered mental status which may delay recovery. Peripheral nerve blocks (PNBs) offer notable benefits to the postoperative pain profile when compared to general or spinal anaesthesia alone and may help improve recovery. The primary objective of this quality improvement (QI) study was to increase PNB administration for AFS at our institution to above 50% by January 2021. A root cause analysis was performed by a multidisciplinary team to identify barriers for PNB administration. Four interventions were chosen & implemented: recruitment and training of expert anesthesiologists in regional anesthesia techniques, procurement of additional ultrasound machines, implementation of a dedicated block room with training to create an enhanced learning environment, and the development of an educational pamphlet for patients outlining strategies to manage rebound pain, instructions around the use of oral multimodal analgesia, and the potential for transient motor block of the leg. The primary outcome was the percentage of patients who received PNB for AFS. Secondary outcome measures included total hospitalization length of stay (LOS), post-anesthesia care unit (PACU) and 24-hour postoperative opioid consumption (mean oral morphine equivalent [OME]), proportion of patients requiring opioid analgesic in PACU, and proportion of patients experiencing post-operative nausea and/or vomiting (PONV) requiring antiemetic in PACU. Thirty-day post-operative emergency department (ED) visits were collected as a balance measure. The groups receiving PNB and not receiving PNB included 78 & 157 patients, respectively, with no significant differences in age, gender, or ASA class between groups. PNB administration increased from less than 10% to 53% following implementation of the improvement bundle. Mean total hospital LOS did not vary significantly across the PNB and no PNB groups (1.04 days vs. 1.42 days, P = 0.410). Both mean PACU and mean 24-hour postoperative opioid analgesic consumption was significantly lower in the PNB group compared to the no PNB group (OME in PACU 38.96mg vs. 55.42mg [P = 0.001]; 24-hour OME 44.74mg vs. 37.71mg [P = .008]). A greater proportion of patients in the PNB group did not require any PACU opioid analgesics compared to those in the no PNB group (62.8% vs. 27.4%, P < 0.001). The proportion of patients experiencing PONV and requiring antiemetic both in the PACU did not vary significantly across groups. Thirty-day postoperative ED visits did not vary significantly across groups. By performing a root cause analysis and implementing a multidisciplinary, patient-centered QI bundle, we achieved significant increases in PNB administration for AFS. As a result, there were significant improvements in the recovery of patients following AFS, specifically reduced use of postoperative opioid analgesia. This multi-faceted approach provides a framework for an individualized QI approach to increase PNB administration and achieve improved patient outcomes following AFS

Chronic postoperative pain (CPP) can occur in elective mid/hindfoot and ankle surgery patients. Multimodal pain management has been reported to reduce postoperative pain and opioid use, which may prevent the development of CPP. However, few studies have examined the impact of multimodal pain management strategies on CPP following complex elective mid/hindfoot and ankle surgery. The purpose of this study was to 1) evaluate current pain management strategies and 2) determine current definitions, incidence, and prevalence of CPP after elective mid/hindfoot and ankle surgery. Three databases (MEDLINE, Embase and Cochrane Library) were manually and electronically searched for English language studies published between 1990 and July 2017. For the first aim, we included comparative studies of adults undergoing elective mid/hindfoot and ankle surgery that investigated pre-, peri- or postoperative pain management. For the second aim, we included observational studies examining CPP definition, incidence, and prevalence. Two reviewers independently screened titles and abstracts, followed by full texts. Conflicts were resolved through discussion with a third reviewer. Reviewers also independently assessed the quality of studies meeting inclusion criteria using the Joanna Briggs Institute Critical Appraisal Checklist. For the first aim, 1159 studies were identified by the primary search, and seven high quality randomized controlled trials were included. Ankle arthroplasty or fusion and calcaneal osteotomy were the most common procedures performed. The heterogeneity of study interventions, though all regional anesthesia techniques, precluded meta-analysis. Most investigated continuous popliteal, sciatic and/or femoral nerve blockade. Participants were typically followed up to 48 hours postoperatively to examine postoperative pain levels and morphine consumption in hospital. Interventions effective at reducing postoperative pain and/or morphine consumption included inserting popliteal catheters using ultrasound instead of nerve stimulation guidance, perineural dexamethasone, and adding continuous femoral blockade to continuous popliteal blockade. Using more than one analgesic was generally more effective than using a single agent. Only two studies examined longer term pain management. One found no difference in pain levels and opioid consumption at two weeks with perineural or systemic dexamethasone use. The other found that pain with activity was significantly reduced at six months postoperatively with the addition of a femoral catheter infusion to a popliteal catheter infusion. For the second aim, only two studies of the 747 identified were selected. One prospective observational study defined CPP as moderate-to-severe pain at one year after foot and ankle surgery, and reported 21% and 43% of patients as meeting their definition at rest and with activity, respectively. The other study was a systematic review that reported 23–60% of patients experienced residual pain after total ankle arthroplasty. There is no standardized definition of CPP in this population, and incidence and prevalence are rarely reported and vary largely based on definition. Although regional anesthesia may be effective at reducing in-hospital pain and opioid consumption, evidence is very limited regarding longer-term pain management and associated outcomes following elective mid/hindfoot and ankle surgery

Introduction. Liposomal bupivacaine has been shown to be effective in managing post-operative pain in hallux valgus and hemorrhoid surgery. However, non-industry-supported and well-powered randomized studies evaluating its efficacy in Total Knee Arthroplasty (TKA) are lacking. Our hypothesis was that liposomal bupivacaine would not decrease post-operative visual analog pain scores (VAS) or narcotic consumption in the acute post-operative period. Methodology. Two hundred seven consecutive patients were enrolled into a single-blinded prospective randomized study. We included patients undergoing unilateral TKA by five fellowship-trained surgeons with a diagnosis of osteoarthritis, rheumatoid arthritis, or post-traumatic arthritis. Patients were excluded for any other diagnosis necessitating TKA, allergy to the medications, or pre-operative opiate use. Participants received standardized pain management, anesthesia, and physical therapy. Patients were randomized intra-operatively to one of three groups: an intra-articular (IA) injection of bupivacaine and morphine at the conclusion of the procedure, a peri-articular (PA) injection of a bupivacaine and morphine, or a PA injection of liposomal bupivacaine. Post-operative pain VAS and mean morphine equivalents (MME) consumed were recorded and compared utilizing analysis of variance (ANOVA). A power analysis demonstrated that 159 patients were needed for 80% power to detect a 25% difference in VAS or MME. Results. Patients in each study group had a mean VAS score of 3.95 (SD 2.1), 3.97 (SD 1.9). and 3.86 (SD 1.8) (p=0.94), respectively. MME consumed per day in each group was 100.7 (SD 48.4), 100.1 (SD 42.2), and 98.9 (SD 41.6) (p=0.97). Conclusion. Liposomal bupivacaine does not alter mean pain scores or post-operative narcotic consumption in patients undergoing unilateral TKA. Further, no difference was noted in comparing patients who received a single IA injection versus a PA injection. To our knowledge, this is the first reported study to evaluate post-operative pain control between identical IA and PA injections in patients undergoing unilateral TKA

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

Background. Post operative analgesia is an important part of Total Knee Arthroplasty (TKA) to facilitate early mobilisation and patient satisfaction. We investigated the effect of periarticular infiltration of the joint with chirocaine local anaesthetic (LA) on the requirement of analgesic in the first 24 hrs period post op. Methods. Retrospective analysis of case notes was carried out on 28 patients, who underwent TKA by two different surgeons. They were divided into two groups of 14 each; who did and did not receive the LA infiltration respectively. All patients were given spinal morphine (162 mcg r: 150-200). Analgesic requirement was assessed in terms of the amount of paracetamol, morphine, diclofenac, oxynorm and tramadol administered in 24hrs post op including the operating time. Results. Following results were obtained from patients receiving LA infiltration vs no infiltration: Morphine; 70 mg vs 200 mg, Paracetamol; 60 gm vs 58 gms, Diclofenac; 1650 mg vs 1050 mg, Oxynorm; 40 mg vs 80 mg, Tramadol; 200 mg vs 400 mg. Average length of stay (LOS) was 6 days (r: 3-8) in both groups. Conclusion. From this study it may be concluded that periarticular LA infiltration reduces the requirement of morphine in first 24 hrs by almost 1/3rd. The amount of tramadol and oxynorm was also halved in LA infiltrated group although the requirement of paracetamol remained the same. LA infiltrated group received almost 1.5 times more Diclofenac as compared to the non infiltrated group. The LOS was not affected by the administration of LA

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

INTRODUCTION. The benefits of combining enhanced recovery after surgery (ERAS) interventions with an outpatient THA/TKA program are uncertain. The primary objective was to compare adverse event rate and secondly to compare pain management, functional recovery, PROMs and patients' satisfaction. METHODS. We conducted an ambidirectional single subject cohort study on 48 consecutive patients who experienced both a standard-inpatient and an ERAS-outpatient THA/TKA (contralaterally). We compared complications according to Clavien-Dindo scale and Comprehensive Complications Index (CCI), and unplanned episodes of care. Postoperative pain assessed with a numeric rating scale, opioid consumption in morphine milligram equivalents, functional recovery, patient-reported outcome measures (WOMAC, KOOS, HOOS, Forgotten Joint Score and Patient Joint Perception) and patients' satisfaction were also evaluated. RESULTS. Following the ERAS-outpatient surgery, complication rates were reduced by more than 50% (2.1 vs 4.4, p<0.001), CCI was significantly lower (12.3 vs 19.1, p<0.001), and similar unplanned episodes of care were observed (p>0.999). In the first 8 postoperative hours, perceived pain was similar (p>0.805) while opioid consumption was significantly reduced with ERAS-outpatient care (9.3 vs 26.5 MME, p<0.001). Patients walked, climbed stairs, showered, performed activities of daily living, practised sports, went back to work sooner after ERAS-outpatient surgery (p<0.001), but PROMs were similar between groups at the last follow-up (p> 0.188). Patients were more satisfied with hospital stay, pain management, functional recovery, wound management, and overall experience of the ERAS-outpatient pathway and recommended it significantly more (p <0.002). DISCUSSION. Most studies comparing outpatient to inpatient programs conclude that outpatient surgeries did not increase complication or readmission rates, and, overall, were not inferior. We found that compared to std-inpatient practice, ERAS-outpatient program reduced complications by half while not resulting in more unplanned episodes of care. Moreover, it resulted in similar pain relief with fewer opioids, faster early functional recovery and higher satisfaction. Patients were significantly more inclined to recommend the ERAS-outpatient pathway after having personally experienced both outpatient and inpatient protocols. These finding are likely multifactorial and linked to the specific ERAS interventions. CONCLUSION. Results of this study highlight the importance of following ERAS principles when implementing an outpatient THA/TKA program