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

Introduction. We hereby present results of controlled randomized trial of use of popliteal block for pain relief in ankle and hind foot surgery. Materials and methods. We have studied 63 patients over period of 9 months. Patients who needed ankle or hind foot procedure were selected for trial. Patients were explained about the trial and popliteal block along with leaflets at preoperative clinics. Patients were randomized on the day of surgery. A sealed envelop stating whether patient will go to block group (A) or no block group (B) was opened in the anaesthetic room before the patient was anaesthetized. Patients were evaluated for subjective pain scores at 30 min, 6 hrs, 12 hrs and 24 hrs after surgery. Amount of anaelgesic required and time to first dose was documented. Popliteal blocks were given by one foot and ankle consultant and one trained fellow. The block was administered in lateral position at 0.8 mA stimulus to detect the nerve. The data was compared statistically between group A and B. Results. The average pain scores in Group A (33 pts) were 0.72, 1.60, 1.51 and 1.03 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. While in Group B (30 pts) it was 2.73, 5.5, 6.03 and 3.33 at 30 min, 6 hrs, 12 hrs and 24 hrs respectively. There was statistically significant difference in pain scores at 6 and 12 hrs. There was no statistically significant difference in pain scores at 30 min and 24 hrs. Time to the request for first analgesic was statistically longer in Group A. Conclusion. Popliteal block offers an effective way of pain relief in ankle and hind foot surgery. We believe that it may reduce amount of anaesthetic or anaelgesic drug requirement as well

Purpose

Total and partial joint arthroplasty has been clinically proven to successfully relieve pain and improve function in patients with hip and knee degenerative arthrosis. It has been shown that early return to ambulation correlates well with functional scores. Moreover, the benefits of reduced narcotic use are multi-fold and range from reduced risk of addiction, gastrointenstinal and cardiopulmonary side effects. Establishing realistic pre-operative expectations regarding functional improvement and pain control will nevertheless impact patient satisfaction. Thus, the purpose of this study was to establish safe, achievable and data-driven benchmarks for post-operative ambulation and pain control in patients undergoing elective total joint arthroplasty.

Ilizarov frame removal often occurs in the outpatient setting, and previous data has shown it can be a painful experience. Frames with a total of four or more olive wires or half-pins in combination yielded increased pain scores at frame removal.

Sublingual fentanyl provides rapid onset, short acting analgesia for painful procedures such as dressing changes in burns patients. We hypothesised that administration of sublingual fentanyl, prior to frame removal would improve patients' pain scores.

Twenty-one patients were given 100 mcg sublingual fentanyl prior to frame removal. Their pain scores were documented on an 11-point (0–10) numeric visual scale before, immediately after, 15 and 30 minutes after frame removal, and the following day. The same nurse specialist removed all the frames. Nitrous oxide was available for patients if they needed further analgesia.

The majority of frames were removed from tibia. The average patient age was 40.8 years. Each frame had a median of 9 wires (range 2–17), and 4 olives (2–8). Eight frames had half pins (range 1–4, median 2). Fourteen patients used nitrous oxide in addition to fentanyl.

Overall, the average pain score was 3.1. This peaked at 7.5 immediately after frame removal, but 15 minutes following removal the average was 2.5. Patients who had supplementary nitrous oxide had higher pain scores throughout (though not beforehand), although these differences were not statistically significant.

Four patients (19%) reported adverse effects following administration, but none required medical intervention.

Patients' pain scores averaged 2.52 within 15 minutes of removal, compared with 5.25 from our previous review. This suggests that fentanyl may be beneficial in frame removal, but our sample size was small, and more research is needed in this area.

The aim of our study was to assess the outcome of caudal epidural injection for patients with low back pain in relation to fatty infiltration of spinal muscle. This is a prospective study. The spinal muscles were graded on sagittal section T1 MRI at the lower border of lumber 4 vertebra from 3 to 12 depending on the severity of fatty infiltration. The outcome of the intervention was assessed by improvement in pre and post intervention oswestry disability index score as well as visual analog pain score. Patients with significant fatty changes don't respond well to the caudal epidural injection.

Introduction

Acetabular revision surgery remains a technically demanding procedure with higher failure rates than primary total hip arthroplasty (THA). An acetabular component with three dimensional porous titanium and anatomic screw holes (Figure 1) was designed to allow the cup to be positioned anatomically and provide reliable fixation.

Abstract. Background. We know that tears of the Triangular fibrocartilage complex (TFCC) can cause DRUJ instability and ulnar sided wrist pain. This study shows the clinical result of patients who had arthroscopic transosseous repair of the TFCC tear with DRUJ instability. Arthroscopic repair of TFCC tear is a promising, minimally invasive surgical technique especially in patients with DRUJ instability. Materials and methods. Fifteen patients who underwent TFCC one tunnel repair form 2018–2021 were reviewed retrospectively in hospital. The proximal component of TFCC was repaired through arthroscopic one- tunnel transosseous suture technique. VAS score for pain, wrist range of motion, grip strength and post operative complications were evaluated and each patient was rated according to the DASH score. Results. The patients had a TFCC tear confirmed on MRI and was confirmed on arthroscopy by doing a hook test. The patients were followed up for 6 months. Twelve patients had normal stability of DRUJ and three patients showed mild laxity compared with the contralateral side. The mean VAS score reduced from 4.7 to 0.8 (P=0.001) and grip strength increased significantly. The quick DASH score (P=0.001)also showed significant functional improvement. No surgical related complications occurred. Conclusions. Arthroscopic one tunnel transosseous TFCC foveal repair can be an excellent and safe method for repair of TFCC tear with DRUJ instability. Its a good treatment option in terms of reliable pain relief, functional improvement and reestablishment of DRUJ stability

Introduction. Methoxyflurane can cause hepatotoxicity and nephrotoxicity at anaesthetic doses but has excellent analgesic properties and no nephrotoxic effects in patients without preexisting disease. Approved for use in the UK and Ireland in 2015, it is currently being used in emergency departments for analgesia during fracture reduction. During the Covid emergency, with theatre access severely restricted and many patients unwilling to use inhaled Nitrous oxide, Penthrox had the potential to provide adequate pain relief to aid frame removals and minor procedures in the clinic. Materials and Methods. Patients presenting to the Limb Reconstruction Unit Elective clinic and requiring frame removal or minor procedures were included in the study. Patients with renal, cardiac or hepatic disease, history of sensitivity to fluorinated anaesthetic agents and those on any nephrotoxic or enzyme inducing drugs were excluded. Verbal consent was obtained, the risks and benefits explained and the procedure was done in a side room in the clinic. Besides patient and procedure details, the Visual Analog Score and Richmond Agitation Scale was noted and patient's satisfaction documented. The results were presented as numbers, means and averages. Results. A total of 39 patients were included in the study of which 17 had Ilizarov frames removed, 10 had Hexapod Removals, 9 had heel rings removed and 3 others had an ex fix removed. Eleven patients required/ requested extra pain relief in the form of oral analgesia. All patients were satisfied or very satisfied with the experience. One patient had a wire jam during removal and required a GA for removal. Conclusions. Patient satisfaction was very high (>95%) with good results and allowed frame removals and minor procedures to be done in the clinic during the Covid pandemic. It also cut expenses and has potential for regular future use

Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) with the flexor carpi radialis (FCR) tendon is one of the most common procedures for the treatment of thumb carpometacarpal (CMC) arthritis. An alternative method involves trapeziectomy alone (TA). The trapeziectomy with LRTI procedure was developed to theoretically improve biomechanical strength and hand function when compared to TA, which leaves an anatomical void proximal to the first metacarpal. The LRTI procedure takes longer to perform and includes an autologous tendon graft. The goal of this retrospective cohort study was to evaluate the clinical outcomes of trapeziectomy with or without LRTI at a minimum follow-up of 1 year. A total of 43 adult patients who had underwent a total of 58 (TA=36, LRTI=22) surgical procedures for CMC arthritis participated in the study. This single surgeon retrospective cohort study sampled patients who underwent CMC arthroplasty with either TA or LRTI techniques between 2008 and 2020 with a minimum time of 1 year post-operatively. The patients were evaluated subjectively (The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire) and objectively (hand/thumb strength, pre/post-operative hand radiographs). Both the TA and LRTI procedures provided good pain relief, motion, strength, and stability without any severe complications. There was no statistically significant difference in hand or thumb strength between the two groups. Radiography showed that compared to the preoperative status, the trapezial space decreased similarly between the two groups. There was no difference in size of collapse between TA and LRTI post-operatively. The TA procedure had similar outcomes to LRTI and has the advantages of shorter surgical time, less incision length, and lower surgical complexity. TA provided equivalent trapezial space to LRTI after the operation. Future study should investigate these two procedures in a head-to-head comparison rather than longitudinally where both surgeon experience and time since procedure at follow-up may have impacted results

Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori. A retrospective cohort study from January 1. st. , 2015, to December 31. st. 2020 inclusive. Eligible patients were 16–65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriate. No statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004). Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori. The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area

Introduction. Day stay surgery for anterior cruciate ligament (ACL) reconstructions is an increasingly common practice and has driven clinicians to come up with postoperative pain regimes that allow same day mobilisation and a safe and timely discharge. There is a paucity of literature surrounding the use of intraosseous (IO) ropivacaine used as a Bier's block to provide both intraoperative and postoperative analgesia in lower limb surgery. Methods. This patient blinded, pilot study randomised 15 patients undergoing ACL reconstruction to receive either IO ropivacaine 1.5 or 2.0 mg/kg; or 300 mg of ropivacaine as local infiltration (standard of care). Toxic plasma levels of ropivacaine have been defined in the literature and therefore the primary outcome for this study was arterial plasma concentration of ropivacaine as a means to determine its safety profile. Samples were taken via an arterial line at prespecified times after tourniquet deflation. Secondary outcomes that we were interested in included immediate postoperative pain scores using the visual analogue scale (VAS) and perioperative opioid equivalent consumption. Results. Participants had a mean age of 27.8 (SD 9.2) years and 87% (13/15) were male. All patients in the intervention group receiving IO ropivacaine had plasma concentrations well below the threshold for central nervous system (CNS) toxicity (0.60 µg/ml). The highest plasma concentration was achieved in the intervention group receiving 1.5 mg/kg dose of ropivacaine reaching 3.59 mg/ml. This would equate to 0.22 µg/ml of free plasma ropivacaine. There were no differences across the three groups regarding pain scores or perioperative opioid consumption. Conclusions. This study demonstrates that IO administration of 0.2% ropivacaine is both safe and effective in reducing perioperative pain in patients undergoing ACL reconstruction. There may be scope to increase the IO dose further or utilise other analgesics via the IO regional route to improve perioperative pain relief

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

Introduction. 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

Significance. In spite of evidence that total knee replacement (TKR) surgery is effective, numerous studies have demonstrated that approximately 20 percent of patients who have undergone TKR surgery are not satisfied. This relatively high rate of patients who are not satisfied is the result of unmet patient expectations. The strongest predictor of dissatisfaction after TKR is unmet expectations (RR = 10.7, Bourne, Chesworth, et al, 2010). This is confirmed by Dunbar, Richardson, and Robertsson (2013): “Unmet expectation seems to be a major cause of unsatisfactory outcomes and satisfaction is most strongly correlated with relief of pain, followed by improvement in physical function.” Objective: To develop patient reported outcome (PRO) recovery graphs for knee function, activity level, and pain relief to be used as a shared decision making tool for total knee replacement surgery. Methods. A proprietary joint arthroplasty database of patient reported outcomes (PROs) was analyzed to determine the recovery curve means and standard deviations of four PROs at six time points: pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years post-operatively for total knee replacement surgery. The recovery graphs are stratified by percentile (10%, 26%, 50%, 75%, and 90%) The PROs analyzed were: (1) European quality of life (EQ-5D); Oxford Knee Score (OKS); (3) Lower Extremity Activity Scale (LEAS); and (4) Likert Pain Scale (LPS). The minimum clinically important difference (MCID) was calculated using a distribution method where the MCID equals one half the standard deviation of the score change, MCID = σΔ/2. The LEAS and LPS are used to measure patients’ expectations for pain relief and activity improvement. Prior to discussing surgery, patients are asked to report their pre-operative pain and activity levels and to specify their expected pain relief and activity improvement one year after surgery. Results. EQ-5D: MCID 0.086, mean pre-op 0.695, 1 year post op 0.845, mean change 0.150 (1.74 MCIDs). Oxford Knee Score: MCID 4.55, mean pre-op 25.7, 1 year post op 39.7, mean change 14.0 (3.08 MCIDs). Lower Extremity Activity Scale: MCID 1.61, mean pre-op 9.08, 1 year post op 10.82, mean change 1.74 (1.08 MCIDs). Likert Pain Scale: MCID 1.26, mean pre-op 5.98, 1 year post op 1.41, mean change −4.57 (3.63 MCIDs). Stratified recovery graphs for Oxford Knee Score, Lower Extremity Activity Scale, and Likert Pain Scale are attached. Conclusions. Pain relief (3.63 MCIDs) and improved knee function (3.08 MCIDs) will be the most dramatic improvements for patients undergoing total knee replacement surgery. Stratified recovery graphs can be used as a shared decision making tool to manage both realistic and unrealistic expectations. The recovery graphs delineate the time course for rehabilitation. Patients typically do not exceed their pre-operative activity level until three months after surgery

[Purpose]. There have been only a few reports about the efficacy of postoperative cryotherapy following total hip arthroplasty (THA), and past studies have described that local cooling is efficacy for pain relief. The purpose of this study is whether the continuous local cooling following THA is effective for pain relief and the reduction of blood loss, swelling, and the duration of hospital stay. [Materials and Methods]. Thirty-eight patients (39 hips) underwent primary cementless THA for osteoarthritis and were divided into a cryotherapy group (30 subjects; from Apr. 2013 to Oct. 2013) and a control group (9 subjects; from Nov. 2012 to Mar. 2013). In the cryotherapy group, a continuous cooling pad was applied on the surgical wound and the thigh with a cloth anchor band (CF-3000, Sigmax, Japan) with the cooling temperature set to a constant 5°C for 72 hours immediately after surgery. Blood was collected on postoperative days 1,4,7,14, and 21 to determine Hb, CK, and CRP levels. Postoperative pain of the hip was scored by using a visual analog scale questionnaire on postoperative days 1 to 28. Total doses of selecoxib and dicrofenac sodium used for pain relief were measured. The circumference of patellar superior border was measured on postoperative days 4,7,14, and 28. The unpaired t-test was used for blood tests as well as for comparisons between the cryotherapy and control groups, and the Mann-Whitney U test was used for the analysis of age, BMI, approach of the surgery, analgesic use, pain scores, the circumference of the thigh and the duration of hospital stay. [Results]. There were no significant differences in age (p = 0.605), BMI (p = 0.790), approach of the surgery (p = 0.572), duration of the surgery (p = 0.117), blood loss during surgery (p = 0.739), or hospital stay (p = 0.169) between the cryotherapy and the control. There were no significant differences between the 2 groups in CK, CRP levels, or pain scores. However, Hb levels measured postoperatively in only day 4 and the total dose of selecoxib was used for pain relief were significantly lower for the cryotherapy group than for the control group, respectively (p = 0.028, p = 0.003), and the total dose of dicrofenac sodium was tend to be significant lower for the cryotherapy group. (p = 0.070). The circumference of patellar superior border measured postoperatively in only day 4 was significantly lower for the cryotherapy group than for the control group (p = 0.010). No complications such as skin problems or neuroparalysis were observed. [Discussion]. This study found the reduction of blood loss, swelling on the patellar superior border, and the total dose of selecoxib for the patients undergoing cryotherapy. However, the pain-relief efficacy of postoperative cryotherapy has not been recognized. Postoperative continuous cryotheraapy is a simple, noninvasive, and effective approach for the reduction of blood loss and swelling following THA

Arthrosis of the hip joint can be a significant source of pain and dysfunction. While hip replacement surgery has emerged as the gold standard for the treatment of end stage coxarthrosis, there are several non-arthroplasty management options that can help patients with mild and moderate hip arthritis. Therefore, the purpose of this paper is to review early prophylactic interventions that may help defer or avoid hip arthroplasty. Nonoperative management for the symptomatic hip involves minimizing joint inflammation and maximizing joint mobility through intra-articular joint injections and exercise therapy. While weight loss, activity modifications, and low impact exercises is generally recommended for patients with arthritis, the effects of these modalities on joint strength and mobility are highly variable. Intra-articular steroid injections tended to offer reliable short-term pain relief (3–4 weeks) but provided unreliable long-term efficacy. Additionally, injections of hyaluronic acid do not appear to provide improved pain relief compared to other modalities. Finally, platelet rich plasma injections do not perform better than HA injections for patients with moderate hip joint arthrosis. Primary hip joint arthrosis is rare, and therefore treatment such as peri-acetabular osteotomies, surgical dislocations, and hip arthroscopy and related procedures are aimed to minimise symptoms but potentially aim to alter the natural history of hip diseases. The state of the articular cartilage at the time of surgery is critical to the success or failure of any joint preservation procedures. Lech et al. reported in a series of dysplastic patients undergoing periacetabular osteotomies that one third of hips survived 30 years without progression of arthritis or conversion to THA. Similarly, surgical dislocation of the hip, while effective for treatment of femoroacetabular impingement, carries a high re-operation rate at 7 years follow up. Finally, as the prevalence of hip arthroscopic procedures continues to rise, it is important to recognise that failure to address the underlying structural pathologies can lead to failure and rapid joint destruction. In summary, several treatment modalities are available for the management of hip pain and dysfunction in patients with a preserved joint space. While joint preservation procedures can help improve pain and function, they rarely alter the natural history of hip disease. The status of the articular cartilage at the time of surgery is the most important predictor of treatment success or failure

Revision surgery for pelvic discontinuity in the presence of bone loss is challenging. The cup-cage reconstruction option has become popular for the management of pelvic discontinuity in the recent years. The aim of this study was to review the clinical, radiological and patient reported outcomes with the use of cup cage construct for pelvic discontinuity at our institution. Twenty-seven patients (27 cup-cage reconstructions) were identified at median 6-year (minimum 2 year, maximum 10 years) follow up. Eight were female patients. The median age was 77 years [mean 72, range 37–90, SD 13.6]. There were 5 deaths and 2 were lost to follow up. Two patients were converted to excision arthroplasty; one for infection and one for failure of the construct. A further 3 patients required revision for instability but the cup cage construct was not revised (2 revisions of cemented cups to a constrained cup and one revision of proximal modular component of the femoral prosthesis). Revision of the cup cage construct was not necessary in any of these cases. We noted excellent pain relief (mean WOMAC pain 85.6) and good functional outcome (mean WOMAC function 78.2, mean UCLA 5, mean OHS 78.6). Patient satisfaction with regards pain relief; function and return to activities were noted to be excellent. Radiological changes were noted in further 4 patients (cup migration in one case; fracture of ischial spike in one case and breakage of the cage screws in 2 patients). No migration of the construct was noted in any of the cases. In conclusion, the cup cage construct is an excellent method of dealing with complex pelvic discontinuity. Our study suggests a low failure rate; high patient satisfaction and pain relief and moderate functional outcome at median 6 year follow up

Over the past fifteen years, the average length of stay for total knee arthroplasty (TKA) has gradually decreased from several days to overnight. The most logical and safest next step is outpatient arthroplasty. Through the era of so-called minimally invasive surgery, perhaps the most intriguing advancements are not related to the surgery itself, but instead the areas of rapid recovery techniques and perioperative protocols. Rapid recovery techniques and perioperative protocols have been refined to allow for same-day discharge with improved outcomes. As mentioned, the single most important outcome from the minimally invasive movement has been the multi-modal approach to pain management of patients undergoing arthroplasty. Along with blood loss management, using tranexamic acid and hypotensive anesthetic techniques, this multi-modal program is the most important variable in reducing or avoiding side-effects. In any arthroplasty procedure, side-effects that need to be addressed include the negative effects of narcotics and blood loss. Anesthetic techniques, utilizing local nerve blocks, such as the adductor canal block and sciatic blocks for knee arthroplasty augment intraoperative anesthesia and provide postoperative pain relief and quicker mobilization. Additionally, pericapsular injection with a cocktail of local anesthetic helps significantly with pain relief and recovery reducing the amount of oral narcotic utilised in the early postoperative period. Many have utilised liposomal bupivacaine in these cocktails to successfully increase the period of pain relief. The use of multi-modal perioperative protocols can help avoid narcotics and helps avoid the side-effects of nausea. We also utilise an aggressive prophylactic antiemetic program with dexamethasone, ondansetron and a scopolamine patch. Patients without any significant cardiovascular history are given celecoxib preoperatively, which is continued for approximately two weeks postoperatively. Immediately postoperative, acetaminophen and additional dexamethasone are administered intravenously. The multi-modal protocols to address fear, risk, and side-effects will increase the eligibility for outpatient surgery and decrease the need for overnight hospitalization. By focusing on the patient and avoiding over-treatment, outpatient arthroplasty is quickly becoming the standard of care for total hip replacement in the same way other procedures transitioned from hospital in-patient surgeries to ambulatory procedures

Significance. In spite of evidence that total knee replacement (TKR) surgery is effective, numerous studies have demonstrated that approximately 20 percent of patients who have undergone TKR surgery are not satisfied. This relatively high rate of patients who are not satisfied is the result of unmet patient expectations. The strongest predictor of dissatisfaction after TKR is unmet expectations (RR = 10.7, Bourne, Chesworth, et al, 2010). This is confirmed by Dunbar, Richardson, and Robertsson (2013): “Unmet expectation seems to be a major cause of unsatisfactory outcomes and satisfaction is most strongly correlated with relief of pain, followed by improvement in physical function.” Hypothesis: One year post-operative pain relief and activity level expectations can be measured pre-operatively and used for shared decision making. Methods. A web–based system for prospectively collecting patient reported outcomes (PROs) has been developed. The data set for total hip/knee replacement surgery includes: (1) European quality of life, EQ-5D; Oxford Hip Score/Oxford Knee Score; (3) Lower Extremity Activity Scale (LEAS); and (4) Pain Likert Scale (PLS). The EQ-5D was selected as the health related quality of life (HRQL) general outcome measure because it has been adopted by multiple international joint replacement registries (Swedish Hip Arthroplasty Register, Norwegian Arthroplasty Register, United Kingdom National Joint Registry). The EQ-5D can be used to calculate quality adjusted life years (QALYs) for economic and/or comparative effectiveness analyses. The OHS/OKS questionnaires are used by the United Kingdom National Joint Registry and the New Zealand Joint Registry. The LEAS and PLS are used to measure patient's expectations for pain relief and functional improvement by asking patients to report their pre-operative pain and activity level before surgery and asking patients to report their pain and activity level expectations one year after surgery. Results. The LEAS change (one-year post-operative activity level minus pre-operative activity level) mean and standard deviation are 1.45 and 3.18. The LEAS minimum clinically important difference (MCID) is 1.59. The mean LEAS change is 0.91 MCIDs. The PLS change (one-year post-operative pain score minus pre-operative pain score) mean and standard deviation are −4.57 and 2.85. The PLS MCID is 1.43. The mean PLS change is −3.2 MCIDs. The z statistic for expected change is z = (Δ. expect. – μ. Δ. )/σ. Δ. The probability of realizing an expected activity level change greater than or equal to 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 is 68%, 56%, 43%, 31%, 21%, 13%, 7.6%, 4.0%, 2.0%, 0.9%, and 0.4%, respectively. The probability of realizing an expected pain change greater than or equal to 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 is 95%, 90%, 82%, 71%, 58%, 44%, 31%, 20%, 11%, 6.0%, and 2.8%, respectively. Conclusions. Dramatic improvement in activity level is unlikely. However, 86 percent of patients can expect clinically significant pain relief defined by pain relief greater than the MCID. Shared decision making should discuss unrealistic expectations prior to proceeding with surgery

Introduction. Circular frames in the lower limbs have been removed by Specialist nurses in our clinics for the past 20 years using Entonox. This standard of care has helped reduce the burden of health care cost by avoiding removal of frames in theatres. We have recently started using Penthrox and present our encouraging initial data suggestive of superior efficacy when compared to Entonox. Materials and Methods. We included in this study the last ten patients on whom Entonox was used during frame removal and the first ten patients on whom Penthrox was used. Visual analogue pain scale was used to quantify pain at the beginning, middle and at the end of frame removal in both groups. The data was found to be normally distributed and Unpaired T test was used to analyse it. Confidence interval of 95% and p-value 0.05 deemed significant. Results. At the beginning of frame removal the Entonox group had a mean VAS score of 5.3 and Penthrox group had 3 (p-value 0.1194). During the middle of frame removal the Entonox group had a mean VAS score of 7.3 and Penthrox group had 4.5 (p-value 0.0379, statistically significant). At the end of frame removal the Entonox group had a mean VAS score of 4.2 and Penthrox group had 2.3 (p-value 0.1734). Penthrox group showed a statistically significant improvement in the mean VAS pain score when assessed in the middle of frame removal. The mean VAS score of both groups were not statistically significant at the beginning and end of frame removal. Conclusions. We found Penthrox to offer better pain relief when compared to Entonox during circular frame removal. This will encourage more patients to choose the option of frame removal in the clinic thereby reducing health care cost to the NHS. This pilot study will be followed by a multicentre comparative study where Entonox is in use in comparison to patients at Salford where the practice has shifted to Penthrox