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

Introduction. Many determinants of the length of stay (LOS) for primary total knee arthroplasty (TKA) have been described. Multimodal, pre-emptive analgesia, age, walking aid score and stair score are some of them. Single shot peripheral nerve block is a popular method to provide prolonged analgesia in immediate post operative period after TKA. Delayed recovery from the nerve block can delay the rehabilitation programme and subsequently lengthen the LOS when the multi disciplinary team discharge criteria are well defined and standardized. The aim of this study is to calculate the incidence of delayed recovery from the sciatic and femoral nerve block administered in cases of primary TKA and its influence on LOS. Methods. All the patients undergoing primary TKA and receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block since April 2010 till January 2011 have been included in the study. Patients demographics, date and day of operation, time of nerve block, complete recovery from the nerve block post operatively and date of discharge were recorded prospectively. Results. Total 34 patients were included in the study. 24 patients recovered from the effect of peripheral nerve block on the post operative day one and 10 patients recovered on the post operative day two. Mean LOS of patients recovered on post operative day one is 4.8 days and mean LOS of those who recovered on post operative day 2 is 5.6 days. Conclusion. Almost one third of the patients receiving forty milliliters of 0.375% of Bupivacaine for sciatic and femoral nerve block recovered late. Delayed recovery from nerve block seems to increase the duration to achieve the discharge criteria after primary TKA. This information can be used favorably to influence the outcome by altering the concentration and amount of anaesthetic agent used

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

Introduction. Hindfoot surgery is assumed to be more painful than midfoot/forefoot procedures with the former often requiring an inpatient stay for pain relief. Poorly controlled pain is associated with adverse patient outcomes and consequently, peripheral nerve blocks (PNB) have become popular for their effective pain control. Aim. To investigate whether hindfoot procedures are more painful than forefoot/midfoot procedures by measuring pain scores, assessing effectiveness of PNBs and patient satisfaction in foot and ankle surgery. Method. In total 140 patients were prospectively studied. Inclusion criteria: Adults undergoing elective foot and ankle surgery. Exclusion criteria: Paediatric patients 16 years and under, those with alternate sources of pain, peripheral neuropathy or incomplete pain scores. Pain was measured via the Visual Analog Scale (VAS) at 3 intervals; immediately, 6 hours and at 24 hours post-operatively. A Johnson patient satisfaction assessment was conducted at 2 weeks. Statistical analysis was performed using SPSS v.18.0. Results. Forefoot/midfoot surgery vs. hindfoot surgery pain scores showed that there was no significant difference at any post-operative interval. PNB vs. no PNB pain scores showed that there was no significant difference at the first two intervals, except at 24 hours post-operatively, p = 0.024. Patients' who had a PNB experienced rebound pain at 24 hours. Overall 94% of patients were satisfied with their experience and anaesthetic. Conclusion. Hindfoot surgery is not more painful than forefoot/midfoot surgery when PNBs are used. Additionally, patients who have a PNB experience rebound pain at 24 hours post-operatively, a finding that requires further research

Dexmedetomidine, an alpha 2 agonist, has been approved for providing sedation in the intensive care unit. Along with sedative properties, it has analgesic activity through its highly selective action on alpha 2 receptors. Recent studies have examined the use of dexmedetomidine as an adjuvant to prolong the duration of peripheral nerve blocks. Studies showing effectiveness of dexmedetomidine for adductor canal block in knee surgery are small. Also, its effectiveness has not been compared to Epinephrine which is a strong alpha and beta receptor agonist. In a previous study, we showed that motor sparing knee blocks significantly increased the duration of analgesia compared with periarticular knee infiltration using local anesthetic mixture containing Epinephrine following total knee arthroplasty (TKA). In this study, we compared two local anesthetic mixtures: one containing Dexmedetomidine and the other Epinephrine for prolongation of motor sparing knee block in primary TKA patients. After local ethics board approval and gaining Notice of Compliance (NOC) from Health Canada for use of Dexmedetomidine perineurally, 70 patients between the ages 18 – 95 of ASA class I to III undergoing unilateral primary total knee arthroplasty were enrolled. Motor sparing knee block − 1) Adductor canal continuous catheter 2) Single shot Lateral Femoral Cutaneous Nerve block 3) Single shot posterior knee infiltration was performed in all patients using 60 ml mixture of 0.5% Ropivacaine, 10 mg Morphine, 30 mg Ketorolac. Patients randomized into the Dexmedetomidine group (D) received, in addition to the mixture, 1mcg/kg Dexmedetomidine and the Epinephrine (E) group received 200mcg in the mixture. The primary outcome was time to first rescue analgesia as a surrogate for duration of analgesia and secondary outcomes were NRS pain scores up to 24 hours and opioid consumption. The time to first rescue analgesia was not significantly different between Epinephrine and dexmedetomidine groups, Mean and SD 18.45 ± 12.98 hours vs 16.63 ± 11.80 hours with a mean difference of 1.82 hours (95% CI −4.54 to 8.18 hours) and p value of 0.57. Pain scores at 4, 6, 12, 18 and 24 hours were comparable between groups. Mean NRS pain scores Epinephrine vs Dexmedetomidine groups were 1.03 vs 0.80 at 4 hours, 1.48 vs 3.03 at 6 hours, 3.97 vs 4.93 at 12 hours, 5.31 vs 6.18 and 6.59 v 6.12 at 24 hours. Opioid consumption was also not statistically significant between both groups at 6, 12 18, 24 hours (p values 0.18, 0.88, 0.09, 0.64 respectively). Dexmedetomidine does not prolong the duration of knee motor sparing blocks when compared to Epinephrine for total knee arthroplasty. Pain scores and opioid consumption was also comparable in both groups. Further studies using higher dose of dexmedetomidine are warranted

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

The entirety of the patient experience after contemporary total knee and total hip replacements in 2017 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to pro-actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some include gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

Introduction. Regional anesthesia is commonly utilized to minimize postoperative pain, improve function, and allow earlier rehabilitation following Total Knee Arthroplasty (TKA). The adductor canal block (ACB) provides effective analgesia of the anterior knee. However, patients will often experience posterior pain not covered by the ACB requiring supplemental opioid medications. A technique involving infiltration of local anesthetic between the popliteal artery and capsule of knee (IPACK) targets the terminal branches of the sciatic nerve, providing an alternative for controlling posterior knee pain following TKA. Materials and Methods. IRB approval was obtained, a power analysis was performed, and all patients gave informed consent. Eligible patients were those scheduled for an elective unilateral, primary TKA, who were ≥ 18 years old, English speaking, American Society of Anesthesiologists physical status (ASA PS) classification I-III. Exclusion criteria included contraindication to regional anesthesia or peripheral nerve blocks, allergy to local anesthetics, allergy to nonsteroidal anti-inflammatory drugs (NSAIDs), chronic renal insufficiency with GFR < 60, chronic pain not related to the operative joint, chronic (> 3 month) opioid use, pre-existing peripheral neuropathy involving the operative limb, and body mass index (BMI) ≥ 40 kg/m. 2. . Patients were randomized into one of two treatment arms: Continuous ACB with IPACK (IPACK Group) block or Continuous ACB with sham subcutaneous saline injection (No IPACK Group). IPACK Group received single injection of 20 mL 0.25% Ropivacaine. Postoperatively, all patients received a standardized multimodal analgesic regimen. The study followed a double-blinded format. Only the anesthesiologist performing the block was aware of randomization status. Following surgery, a blinded medical assessor recorded cumulative opioid consumption, average and worst pain scores, and gait distance. Results. 72 people were enrolled in the study and three withdrew. There were 35 people in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the Post Anesthesia Care Unit (PACU), the average (P=0.0122) and worst (P=0.0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy. (P=0.2080) There was no difference in opioid consumption in the PACU (P=0.7928), at 8 hours (P=0.2867), 16 hours (P=0.2387), 24 hours (P=0.7456), or 30 hours (P=0.8029). There was no difference in pain scores on POD 1 in the AM (P=0.4597) or PM (P=0.6273), nor was there any difference in walking distance (P=0.5197). There was also no difference in length of stay in the PACU (P=0.9426) or hospital (P=0.2141) between the two groups. Discussion/Conclusion. Overall, pain was well controlled between the two groups. The IPACK group had lower pain scores at rest in the PACU, but this may not be clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be use of the IPACK block as a rescue block or in patients whom have contraindications to our standard multimodal treatment regimen, or in patients with chronic pain or opioid dependence

There has been a widespread appreciation on the part of both patients and surgeons that pain control following total knee replacement is an important goal. The concepts of both preemptive analgesia and multimodal pain protocols have become increasingly popular. In addition to these ideas, surgeons continue to utilise adjunctive treatments such as peripheral nerve blocks and periarticular injections. Multiple studies demonstrate the efficacy of these therapies. Several authors have published different “cocktails” for their periarticular injections in an attempt to help delineate which components of the cocktail are most important. In addition to deciding on a correct cocktail, how it is delivered is important. This video will demonstrate a technique that increases the likelihood that the injected solution is placed in the appropriate areas and does not simply bath the tissues. Important components of the technique include the use of a small gauge needle (22) and a control syringe to insure proper placement as well as an aim to target the injections into the periosteum of the femur and tibia and the posterior capsule primarily

The entirety of the patient experience after contemporary total knee and total hip replacements in 2016 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilisation therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to pro-actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some included gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

The entirety of the patient experience after contemporary total knee and total hip replacements in 2016 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to proactively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anaesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some included gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

Our study is still in progress. The results mentioned in the abstract are preliminary results. The final results will be provided at the time of presentation. Over the past decade, the widespread availability of high-resolution ultrasonography coupled with advances in regional anaesthesia have popularised peripheral nerve blocks for anterior cruciate ligament reconstructions (ACLRs). The aim of this study is to investigate whether the femoral nerve block (FNB) administered at the time of ACLR has any long-term impact on the quadriceps strength as compared to patients who did not receive a FNB. This is a retrospective study. Four hundred charts of patients who underwent ACLR at our institution and had subsequent Biodex testing (an isokinetic rehabilitation test that provides objective information about muscle strength deficits and imbalances of the operated leg compared to the non-operated leg) from 2004 to 2015 were reviewed. Patients who had prior ipsilateral knee surgery, multi-ligament knee injury or at extreme ages were excluded from the study. The following baseline patient characteristics was recorded for each reviewed chart: age, sex, medical comorbidities, the date of the injury, date of the surgery, surgery technical notes and associated procedures, the surgeon, the hospital were the patient was operated, the Biodex test date and the Biodex test results. Data extraction assessed any association between the ACLR patients' who received FNB with the results of the Biodex test after completing the rehabilitation protocol. Descriptive statistics were used to compare the type of anaesthesia, mode of pain control and the results of the Biodex tests between patients grouped by the mode of anaesthesia used at the time of surgery (FNB versus no FNB). A multivariate regression model then compared quadriceps strength (inferred by Biodex test results) between groups while controlling for baseline differences between groups. Fifty five percent of the ACLR patients received FNB compared to 45% that did not receive FNB over the last 11 years of performing ACLRs (2004–2015) at our institute. Fifty percent of the patients that received FNB failed to achieve more than or equal to 80% quadriceps strength (compared to the contralateral non-operated leg) at 6 months on Biodex test. On the other hand, only 20% of the non-FNB group failed to achieve more than or equal to 80% quadriceps strength. This study lead us to think that ACLR patients that received FNB are significantly weaker in quadriceps strength at 6 months post ACLR in comparison to non-FNB ACLR patients. This finding subsequently might affect the time needed to return to sports and might indicate a considerable clinical consequence of the FNB on ACL-reconstruction patients

Purpose. Pain and stiffness from elbow arthritides can be reliably improved with arthroscopic osteocapsular ulnohumeral arthroplasty (OUA) in selected patients. Post-operative continuous passive motion (CPM) may be helpful in reducing hemarthrosis, improving soft-tissue compliance and maintaining the range of motion (ROM) established intra-operatively. There is only one published series of arthroscopic OUA and CPM was used in a minority of those patients. We hypothesized that a standardized surgical and post-operative CPM protocol would lead to rapid recovery and sustained improvement in ROM. Method. Thirty patients with painful elbow contractures underwent limited open ulnar nerve decompression and arthroscopic OUA at our institution by a single fellowship trained upper limb reconstruction surgeon. All patients underwent CPM for three days in-hospital with a continuous peripheral nerve block, followed by gradual weaning of CPM at home over two weeks. ROM using a goniometer was assessed at discharge, cessation of CPM (2 weeks) and final follow-up. The main outcome was elbow flexion, extension and total arc of motion. Paired students t-test was used to compare pre and post-operative ROM. Results. The median age was 45 (14–68) years, 77% were male, 73% had the dominant side affected and the most common pre-operative diagnosis was arthritis (50% post-traumatic, 30% primary osteoarthritis). Mean last follow-up was 7 months (range 2 weeks to 2 years). The mean pre-operative range of motion was 119 flexion, −32 extension and a total arc of 8719. At cessation of CPM, the mean flexion was 135, extension −7 and total arc 12711. At last follow-up flexion was maintained at a mean of 134 (p=0.6) but some extension was lost (mean −15, p<0.05) and total arc of motion decreased to 11820 (p<0.05). However, only two patients failed to maintain a functional arc of >100 and the amount of pre-operative contracture was correlated (r=0.73) with final arc of motion. Complications included only two transient ulnar neuropraxias. Only three patients required post-CPM bracing or physiotherapy. Conclusion. We present excellent improvement in short-term ROM following arthroscopic OUA using a standardized post-operative CPM protocol. These results are equal or better than open and non-CPM results published in the literature and alleviate the need for lengthy post-operative physiotherapy and splinting protocols in the majority of patients. A comparative study of CPM and non-CPM post-operative regimens after arthroscopic OUA is warranted to determine the true influence of CPM

Femoral nerve block is a reliable and effective method of providing anaesthesia and analgesia in the peri-operative period but there remains a small but serious risk of neurological complication. We aimed to determine incidence and outcome of neurological complications following femoral nerve block in patients who had major knee surgery. During the period January 2003 to August 2008, medical records of all patients undergoing knee surgery by Dr Myles Coolican and Dr David Parker, who had been administered femoral block for peri-operative analgesia, were evaluated. Patients with a neurological complication were invited take part in the study. A detailed physical examination including sensory responses, motor response and reflexes in both limbs was performed by an independent orthopaedic surgeon. Subjective outcome and pain specific questionnaires as well as clinical measurements were also collected. Out of 1393 patients administered with femoral nerve block anaesthesia during this period, 28 subjects (M:F= 5:23) were identified on the basis of persistent symptoms (more than three months) of femoral nerve dysfunction. All the patients had sensory dysfunction in the autonomous zone of femoral nerve sensory distribution. The incidence of neurological complications was 2.01%. One patient was deceased of unrelated causes and five patients declined to participate in the study. 14 patients out of the 22 have been examined so far. Nine cases had a one shot nerve block and five had continuous peripheral nerve block catheter. Areas of hypoesthesia/anaesthesia involving femoral nerve distribution occurred in 7 subjects and hyperaesthesia/paresthesia occurred in four. One subject had a combination of hypoesthesia and hyperesthesia in different areas of the femoral nerve distribution. Three subjects had bilateral symptoms following bilateral simultaneous nerve blocks. Dysesthesias in the affected dermatomes were found in seven cases and paresthesias were found in eight cases. Douleur Neuropathique en 4 questions (DN4) score of ï. 3. 4 was found in all the patients (average value: 5.55). The average scores for tingling, pins and needles and burning sensation (in a scale from 0 to 10) are 3.8, 3.1 and 2.9 respectively. The incidence of persistent neurological complication after femoral nerve block in our series is much higher compared to the reported incidence in the contemporary literature (Auroy Y. et al. Major complications of regional anesthesia in France: Anesthesiology 2002; 97:1274 80). The symptoms significantly influence the quality of life in the affected cases and question the value of the femoral nerve block in knee surgery