Introduction. Manipulation under anesthesia (MUA) remains the gold standard to address restricted range of motion (ROM) within 3–6 months after primary total knee arthroplasty (TKA). However, there is little data on the outcomes of MUA with different types of anesthesia. We sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 413 neuraxial anesthesia) at a single institution from 2016–2019. Mean age was 62 years and 349 patients (64%) were female. Mean body mass index was 32 kg/m. 2. The mean time from primary TKA to MUA was 10 weeks. Mean pre-MUA ROM was similar between each group; mean pre-MUA extension was 4.2° (p=0.35) and mean pre-MUA flexion was 77° (p=0.56). Patient demographics were statistically similar between both groups. We compared immediate complications, including fracture, extensor mechanism disruptions, and wound complications, Visual analogue pain scores (VAS), length of stay (LOS), and immediate and 3 month follow-up ROM between these groups. Results. No patients in either group sustained an immediate post-MUA complication. Patients undergoing MUA with IV sedation had significantly higher day of MUA average VAS of 5.1 compared to 4.1 in the neuraxial group (p<0.001). The average LOS was shorter in patients that received IV sedation (9 hours) compared to neuraxial anesthesia (12 hours) (p=0.009). Immediate-post MUA ROM was 1° – 121° in the IV sedation group and 0.9° – 123° in the neuraxial anesthesia group (p=0.21). Three month follow-up ROM was 2° – 108° in the IV sedation group and 1.9° – 110° in the neuraxial anesthesia group. Conclusion. IV sedation and neuraxial anesthesia are both effective anesthetic methods for patients undergoing MUA after primary TKA with minimal perioperative differences. Surgeons and anesthesiologists should cater anesthetic technique to patient specific needs as the orthopedic outcomes are similar for both methods; however, IV sedation resulted in a shorter LOS

Aims. Spinal anaesthesia has seen increased use in contemporary primary total knee arthroplasties (TKAs). However, controversy exists about the benefits of spinal in comparison to general anaesthesia in primary TKAs. This study aimed to investigate the pain control, length of stay (LOS), and complications associated with spinal versus general anaesthesia in primary TKAs from a single, high-volume academic centre. Methods. We retrospectively identified 17,690 primary TKAs (13,297 patients) from 2001 to 2016 using our institutional total joint registry, where 52% had general anaesthesia and 48% had spinal anaesthesia. Baseline characteristics were similar between cohorts with a mean age of 68 years (SD 10), 58% female (n = 7,669), and mean BMI of 32 kg/m. 2. (SD 7). Pain was evaluated using oral morphine equivalents (OMEs) and numerical pain rating scale (NPRS) data. Complications including 30- and 90-day readmissions were studied. Data were analyzed using an inverse probability of treatment weighted model based on propensity score that included many patient and surgical factors. Mean follow-up was seven years (2 to 18). Results. Patients treated with spinal anaesthesia required fewer postoperative OMEs (p < 0.001) and had lower NPRS scores (p < 0.001). Spinal anaesthesia also had fewer cases of altered mental status (AMS; odds ratio (OR) 1.3; p = 0.044), as well as 30-day (OR 1.4; p < 0.001) and 90-day readmissions (OR 1.5; p < 0.001). General anaesthesia was associated with increased risk of any revision (OR 1.2; p = 0.021) and any reoperation (1.3; p < 0.001). Conclusion. In the largest single institutional report to date, we found that spinal anaesthesia was associated with significantly lower OME use, lower risk of AMS, and lower overall 30- and 90-day readmissions following primary TKAs. Additionally, spinal anaesthesia was associated with reduced risk of any revision and any reoperation after accounting for numerous patient and operative factors. When possible and safe, spinal anaesthesia should be considered in primary TKAs. Cite this article: Bone Joint J 2022;104-B(11):1209–1214

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

Aims. Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. Methods. We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m. 2. (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. Results. Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. Conclusion. IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126–130

Purpose. The purposes of this study are as follows; 1) to compare postoperative blood loss between general anesthesia(GA) and spinal anesthesia(SA) and 2) to analyze the affecting factors of postoperative blood loss through the subgroup analysis. METHODS. A retrospective analysis was made on the clinical data of 122 patients with osteoarthritis undergoing primary TKA between January 2012 and December 2013. According to different anesthetic method, the patients were divided into the General Anesthesia group (73 cases) and the Spinal Anesthesia group (49 cases). Each group was divided subgroup as age, BMI, Preoperative blood pressure, Surgery time, Torniquet time, INR. The total blood loss, Post Operation 1 day blood loss, hidden blood loss, and the percentage of hidden blood loss were compared between 2 groups. For the analysis of postoperative blood loss, each group was compared postoperative blood loss using hemovac drainage per day and total blood loss. In preoperative blood pressure, Higher than 140 mmHg in systolic blood pressure and higher than 90 mmHg in diastolic blood pressure were employed as a cut-off value to group the well-controlled hypertension group(n=42) and uncontrolled hypertension group(n=29). RESULTS. One day after the surgery blood loss(p=0.322) and total blood loss(p=0.560) showed no significant differences between two group. But in the uncontrolled hypertension group showed a large amount of bleeding one day after the surgery(p=0.003) and total blood loss(p=0.004) in the spinal anesthesia. CONCLUSION. It seems that, general anesthesia is effective method to reduce postoperative blood loss. Preoperative blood pressure control is one of the important affecting factor of postoperative blood loss

Background. It is unclear which form of anaesthesia is the most favourable in primary total hip replacement (THR) surgery. A recently published systematic review of modern anaesthesia techniques in primary THR surgery (Macfarlane 2009) was not able to show any convincing benefit of regional or general anaesthesia. One retrospective study that examined anaesthesia and leg length (Sathappan 2008), found an increased incidence of leg length difference > 5 mm in those patients who were operated with regional anaesthesia. Our department used a mini invasive approach in supine as standard procedure in THR. The type of anaesthesia that is chosen is up to the individual anaesthetist. Purpose. We wanted to see if there was any correlation between type of anaesthesia and leg length, total time spent in theatre and recovery room, postoperative hospital stay, blood loss or operating time in primary THR surgery with a mini invasive approach in supine. Materials and Methods. Our study was a retrospective study of 170 primary THR patients. All patients received an uncemented Corail stem and a cemented Marathon cup. Patients with abnormal anatomy, BMI > 46, simultaneous removal of internal fixation or incomplete data were excluded in the analysis. Radiograpic leg length was measured using the inter teardrop line and the lesser trochanter. Results. 99 patients were operated on with spinal anaesthesia and 71 with total intravenous anaesthesia (TIVA). There were 65% women in both groups. Average age was 74 years (32–95) in the spinal anaesthesia group and 67 years (38–93) in the TIVA group. We found no significant difference in the average operating time (spinal 65 min, TIVA 64 min), drop in haemoglobin to the first postoperative day (spinal 16%, TIVA 16%), postoperative hospital stay (Spinal 1.4 days, TIVA 1.4) or in transfusion rate (spinal 1%, TIVA 1.4%). We found a significant difference in the proportion of patients with a leg length difference of more than 7 mm (Spinal 22%, TIVA 6%, p = 0.02) and the average total time spent in theatre and post-operative department (spinal 325 min, TIVA 293 min, p < 001). Discussion. The study is retrospective and is therefore fettered by the limitations inherent in such a study. Our study seems to confirm the earlier findings that the type of anaesthesia can affect leg length in primary THR. It is speculated that spinal anaesthesia has a more unpredictable effect on muscular tension which could explain this

Aim: Supine lateral bending radiographs are the standard methods of evaluating curve flexibility before surgery in idiopathic scoliosis. Supine traction radiographs have also been used at the authors’ institution in addition to the supine lateral bending radiographs before surgery, believing that it is usually more helpful to analyze the response of the main and compensatory curves to corrective forces. The purpose of this prospective study was to use and evaluate the results of traction radiographs taken before general anesthesia (BGA) and under general anesthesia (UGA). Material and Method: 25 patients required surgical treatment with idiopathic scoliosis were evaluated prospectively. Thirteen were female. The average age was 12.87 years. We designed a new electronic traction table in order to take the longitudinal traction and three-points lateral pressure radiographs. We situated the patient on the table and measured the patient’s weight. Then we made a longitudinal and lateral traction while asking the possible neurologic symptoms. If there was not any symptom we stopped at the seventy percent of the patient’s weight for the longitudinal and at the fifty percent for the lateral pressure. These radiographs had been taken before and under general anesthesia (UGA). The influence of the traction radiographies on the decision for surgery and its correlation with postoperative result was examined. Results: Longitudinal traction radiographs taken consciously provided the best amount of flexibility, with no significant difference from traction with the patient UGA (p = 0.17) but with significant difference from bending radiographs (p < 0.002). No significant difference was demonstrated between the traction radiographies taken before and under general anesthesia and postoperative correction (P = 0.14). Conclusion: The curve flexibility in supine traction films taken with the patient BGA was nearly equal to the curve flexibility in supine traction films taken with the patient UGA in all patients and all types of curves. Thus, there is no need to obtain a normal supine traction film for flexibility analysis under general anesthesia. By this way; the surgeons will be able to give the patient a definitive plan before surgery because the decision can be finalized after seeing the traction radiographs with the patient before the general anesthesia and operation time will be shorter

Total hip arthroplasty (THA) is performed under general anesthesia (GA) or spinal anesthesia (SA). The first objective of this study was to determine which patient factors are associated with receiving SA versus GA. The second objective was to discern the effect of anesthesia type on short-term postoperative complications and readmission. The third objective was to elucidate factors that impact the effect of anesthesia type on outcome following arthroplasty. This retrospective cohort study included 108,905 patients (median age, 66 years; IQR 60-73 years; 56.0% females) who underwent primary THA for treatment of primary osteoarthritis in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database during the period of 2013-2018. Multivariable logistic regression analysis was performed to evaluate variables associated with anesthesia type and outcomes following arthroplasty. Anesthesia type administered during THA was significantly associated with race. Specifically, Black and Hispanic patients were less likely to receive SA compared to White patients (White: OR 1.00; Black: OR 0.73; 95% confidence interval [CI] 0.71-0.75; Hispanic: OR 0.81; CI, 0.75-0.88), while Asian patients were more likely to receive SA (OR 1.44, CI 1.31-1.59). Spinal anesthesia was associated with increased age (OR 1.01; CI 1.00-1.01). Patients with less frailty and lower comorbidity were more likely to receive SA based on the modified frailty index ([mFI-5]=0: OR 1.00; mFI-5=1: OR 0.90, CI 0.88-0.93; mFI-5=2 or greater: OR 0.86, CI 0.83-0.90) and American Society of Anesthesiologists (ASA) class (ASA=1: OR 1.00; ASA=2: OR 0.85, CI 0.79-0.91; ASA=3: OR 0.64, CI 0.59-0.69; ASA=4-5: OR 0.47; CI 0.41-0.53). With increased BMI, patients were less likely to be treated with SA (OR 0.99; CI 0.98-0.99). Patients treated with SA had less post-operative complications than GA (OR 0.74; CI 0.67-0.81) and a lower risk of readmission than GA (OR 0.88; CI 0.82-0.95) following THA. Race, age, BMI, and ASA class were found to affect the impact of anesthesia type on post-operative complications. Stratified analysis demonstrated that the reduced risk of complications following arthroplasty noted in patients treated with SA compared to GA was more pronounced in Black, Asian, and Hispanic patients compared to White patients. Furthermore, the positive effect of SA compared to GA was stronger in patients who had reduced age, elevated BMI, and lower ASA class. Among patients undergoing THA for management of primary osteoarthritis, factors including race, BMI, and frailty appear to have impacted the type of anesthesia received. Patients treated with SA had a significantly lower risk of readmission to hospital and adverse events within 30 days of surgery compared to those treated with GA. Furthermore, the positive effect on outcome afforded by SA was different between patients depending on race, age, BMI, and ASA class. These findings may help to guide selection of anesthesia type in subpopulations of patients undergoing primary THA

Background. Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anaesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anaesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block technique (SV). Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions. Methods. A single-centre prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anaesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anaesthesia along with the anaesthesia onset time. Results. A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5] vs. 3 [2, 4], respectively, P = 0.006). However, anaesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anaesthesia was more predictable in the dorsal block compared to the volar block. Conclusion. The single-injection volar subcutaneous blocks are less painful with a similar anaesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anaesthesia of the region

Radial head fractures are among the most common fractures around the elbow. Radial head arthroplasty is one of the surgical treatment options after complex radial head fractures. This surgery is usually done under general anaesthesia. However, there is a recent anaesthetic technique - wide awake local anaesthesia no tourniquet (WALANT) - that has proven useful in different surgical settings, such as in distal radius or olecranon fractures. It allows a good haemostatic control without the use of a tourniquet and allows the patient to actively collaborate during the surgical procedure. Furthermore, there are no side effects or complications caused by the general anaesthesia and there's an earlier patient discharge. The authors present the case of a seventy-six-year-old woman who presented to the emergency department after a fall from standing height with direct trauma to the left elbow. The radiological examination revealed a complete intra-articular comminuted fracture of the radial head (Mason III). Clinical management: The patient was submitted to surgery with radial head arthroplasty, using WALANT. The surgery was successfully completed without pain. There were no intra or immediate post-operative complications and the patient was discharged on the same day. Six weeks after surgery, the patient had almost full range of motion and was very pleased with the functional outcome, with no limitations on her activities of daily living. The use of WALANT has been expanded beyond the hand and wrist surgery. It is a safe and simple option for patients at high risk of general anaesthesia, allowing similar surgical outcomes without the intraoperative and postoperative complications of general anaesthesia and permitting an earlier hospital discharge. Furthermore, it allows the patient to actively collaborate during the surgery, providing the surgeons the opportunity to evaluate active mobility and stability, permitting final corrections before closing the incision

Introduction. External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting. Materials & Methods. This prospective case series evaluated the first 20 consecutive cases of EF removal in the outpatient clinic between 10/06/22 to 16/09/22. Regional anaesthesia using ultrasound-guided blockade of peripheral nerves was administered using 1% lidocaine due to its rapid onset and short half-life. Patients were assessed for additional analgesia requirement, asked to evaluate their experience and perceived pain using the Visual Analogue Scale (VAS). Results. Twenty patients were included in the study. The mean age was 46.6 years (range 21–85 years). Two thirds were male patients (N=13). Post procedure all patients indicated positive satisfaction ratings, each participant responding as either ‘satisfied’ (N=4), ‘very satisfied’ (N=15) or ‘highly satisfied’ (N=1). In addition, 85% of participants reported they would opt for this method of EF removal in future should it be necessary. VAS for pain immediately following completion of the procedure was low, with an average score of 0.45 (range 0–4), where a score of 0= ‘No pain’, and 10 = ‘worst pain possible’. Conclusions. We present the first description of outpatient EF removal using sole regional anaesthesia, with a prospective case series of 20 EF removed in fully awake patients. This novel technique is cost-effective, reproducible, and safe. This not only reduces the burden of these surgical cases on an operating list but also improves patient experience when compared to other forms of conscious sedation. By eliminating the use of Entonox and methoxyflurane for sedation and analgesia, this project demonstrates a method of improving environmental sustainability of surgery, anaesthesia and operating theatres

Aims. We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue. Methods. This was a randomized control trial of 169 patients who required surgery for closed isolated distal radius fractures. The study was performed between March 2016 and April 2019 at a public sector level 1 trauma centre. General anaesthesia was used in 56 patients, Bier’s block in 58 patients, and WALANT in 55 patients. Data were collected on pre-, peri-, and postoperative parameters, clinical outcome, hospital costs, and patient satisfaction. One-way analysis of variance (ANOVA) was used with a p-value of 0.05 being significant. Results. Operations with WALANT proceeded sooner, and patients recovered faster, resulting in mean fewer missed working days (7.8 (SD 1.67)) compared with general anaesthesia (20.1 (SD 7.37)) or Bier’s block (14.1 (SD 7.65)) (p < 0.001). The WALANT patients did not develop complications, while the other patients did (p < 0.04). Clinical outcomes did not differ, nor did surgeon qualification affect clinical outcomes. Mean hospital costs were lower for WALANT ($428.50 (SD 77.71)) than for general anaesthesia ($630.63 (SD 114.77)) or Bier’s block ($734.00 (SD 37.54)) (p < 0.001). Patient satisfaction was also higher (p < 0.001). Conclusion. WALANT for distal radius fractures results in a faster recovery, is more cost-effective, has similar clinical outcomes, and has fewer complications than general anaesthesia or Bier's block. This makes WALANT an attractive technique in any setting, but especially in middle- and low-income countries. Cite this article: Bone Joint Res 2020;9(7):429–439

Aims. The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining. Methods. A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires. Results. Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections. Conclusion. Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902–907

This study was designed to compare length of hospital stay, and 30-day major and minor complications between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal or epidural anesthesia with or without regional nerve blocks. Patients 18 years and older undergoing TKA between the years of 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). Patient demographics, anesthesia type, length of operation and hospital stay, as well as 30-day major and minor complications were collected from the database. Patients with “primary anesthesia technique” codes for either spinal or epidural anesthesia along with “other anesthesia technique” codes for regional anesthesia were assumed to have been given a regional nerve block. Chi square tests, and analysis of variance were utilized to evaluate unadjusted differences in demographics and outcomes between anesthesia types. Multivariable regression was utilized to compare outcomes (length of stay and complications) between anesthesia types, while adjusting for age, American Society of Anesthesiologist (ASA) class, comorbidities, sex, steroid/immunosuppressant use, body mass index (BMI), diabetes, length of operation and smoking status. A total of 214,665 TKA patients were identified (average age 67 ± 10 years). Of these, 257 (0.12%) underwent epidural anesthesia with a nerve block (EB), while 2,318 (1.08%) underwent epidural anesthesia with no block (E), 14,468 (1.08%) underwent spinal anesthesia with a block (SB), and 85,243 (39.7%) underwent spinal anesthesia with no block (S), and 112,377 (52.4%) underwent general anesthesia (G). The unadjusted length of stay (LOS) was significantly longer in the E group (3.67 ± 5 days) compared to the G group (3.1 ± 3.9 days), while the unadjusted LOS was significantly shorter in the EB group (2.6 ± 1.2), and both SB and S groups (2.6 ± 3 and 2.9 ± 3, respectively), compared to the G group p < 0 .001. Following covariable adjustment, anesthesia type remained an independent predictor of length of stay. Compared to the G group, patients in the E group stayed 0.56 days longer (95% Confidence interval [95%CI] 0.42 – 0.71 days), while patients in the SB were discharged 0.28 days (95%CI 0.21 – 0.35 days) earlier, and those in the S group were discharged 0.06 days earlier (95%CI 0.02–0.09), (p < 0 .0001). While the unadjusted rates of major complications were not significantly different between groups, the unadjusted rates of minor complications were higher in the E, EB, and G groups compared to the S and SB groups. Following covariable adjustment, there were no differences between groups in the risk of minor complications. In conclusion, these data indicate that anesthesia type following TKA is associated with length of hospital stay, but not with 30-day complications. After adjusting for relevant covariables, patients who received epidural anesthesia without a nerve block for TKA were discharged later, while patients who received spinal anesthesia, both with and without a nerve block for TKA were discharged earlier, compared to patients who received general anesthesia for TKA

The optimal timing of when to perform manipulation under anesthesia (MUA) for stiffness following total knee arthroplasty (TKA) is unclear. This study aimed to identify the risk factors for MUA following primary TKA and whether performing an “early” MUA within 3 months results in a greater improvement in range of motion. Primary TKAs performed between January 2013 and December 2018 at three tertiary New Zealand hospitals were reviewed. International Classification of Diseases discharge coding was used to identify patients who underwent an MUA. Multivariate Cox regression was performed to identify patient and surgical risk factors for MUA. Pre- and post-MUA knee flexion angles were identified through manual review of operation notes. Multivariate linear regression was performed to compare the mean flexion angles pre- and post-MUA, as well as the mean gain in flexion, between patients undergoing “early” (<3 months) versus “late” MUA (>3 months). 7386 primary TKAs were analyzed in which 131 underwent subsequent MUA (1.8%). Patients aged <65 years were two times more likely to undergo MUA compared to patients aged ≥65 years (2.5% versus 1.3%, adjusted hazard ratio = 2.1, p<0.001). Gender, body mass index, patient comorbidities or a history of cancer were not associated with the risk of MUA. There was no difference in the final post-MUA flexion angle between patients who underwent early versus late MUA (104.7 versus 104.1 degrees, p = 0.819). However, patients who underwent early MUA had poorer pre-MUA flexion (72.3 versus 79.6 degrees, p = 0.012), and subsequently had a greater overall gain in flexion compared to patients who underwent late MUA (mean gain 33.1 versus 24.3 degrees, p<0.001). Younger age was the only patient risk factor for MUA. A greater overall gain in flexion was achieved in patients who underwent early MUA within 3 months

Introduction. With resumption of non-urgent surgery in May 2020, standard anesthesia for hip arthroscopy switched from general with endotracheal intubation (GA) to spinal (SA) in response to COVID-19 implications; reducing potential aerosolized exposure for patient and staff and reducing consumption of personal protective equipment (PPE). There are no studies that compare the attributes for these two anesthesia methods for hip arthroscopy; and thus, this was viewed as an opportunity to perform a comparative observational study on SA to a recent matched group of GA. Methods. Beginning in May 2020, SA became the standard for hip arthroscopy. GA was used if the patient refused SA or had a history of previous lumbar spinal surgery, or body mass index (BMI) greater than 35. SA patients were carefully matched for age, gender and procedure to a recent previous GA population and compared for recovery room (RR) length of stay, entry and discharge visual analog scores (VAS), morphine mg equivalent (MME) usage, and untoward events. Additionally, SA and GA cases performed since May 2020 were compared for the length of time from entry to the operating room (OR) until the surgeon was able to perform an examination under anesthesia (EUA). Results. Statistical analysis determined that these groups are too small (46 in each group) to establish significant differences, but the authors felt that an opportunity to explore this, based on a recent change out of necessity (COVID-!9), was worth presenting as a novel study to compare two accepted methods of anesthesia for hip arthroscopy. SA patients required fewer regional blocks (7 vs 1) and needed less narcotics (99 vs 153). As a potential advantage of SA, continued investigation to see if this reaches statistical significance is meaningful. SA patients did spend more time in the PACU (136 vs 133); and had more problems with urinary retention, requiring catheterization (5 vs 0); but most of these occurred early in the experience and was corrected by having the patient void immediately prior to transfer to the OR and avoiding anticholinergic medications. SA seemed to add only slightly to the length of time until the surgeon could perform an EUA and begin positioning for the procedure (9 vs 8). Conclusion. Hip arthroscopy can be effectively performed with either GA or SA. Of particular interest with further studies will be whether choice of anesthesia affects early postoperative rehabilitation

Botulinum toxin A (BoNT-A) is a substance that requires repeated application due to its effectiveness being lost 12–16 weeks post application. Performing these intra-muscular injections under anesthesia reduces pain and distress during applications, ensuring effective and successful functional results. This study evaluates motor development of patients undergoing 3 or more repeated BoNT-A application in a tertiary pediatric hospital and the safety as well as effect of 3 different types of anesthesia. 75 children with cerebral palsy who underwent BoNT-A application at least three times consecutively with 6-month intervals and a total of 320 procedures admitted between January 2008 and January 2018 were retrospectively examined. Gross Motor Function Classification System (GMFCS) was employed in motor development evaluation. To observe the improvement in motor development, those with 2-1-0 level decreases in GMFCS classes were grouped and compared in terms of birth time, birth weight, cerebral palsy type and first BoNT-A application age. The 3 types of anesthesia methods (sedation analgesia, larengeal mask anesthesia (LMA) and inhalation mask anesthesia) applied during the procedures were compared in terms of sedation, procedure, recovery and total operation room time. The mean age of the children for all procedures was 45.51 ± 22.40 months. As a result of procedures, significant motor development was observed in 60 (80%) patients (p <0,000∗). No significant difference was observed when the children with cerebral palsy whose GMFCS declined in the form of level 2, 1 and unchanged were compared in terms of first application age, birth weight and gestational age. It was found that 106 (33.1%) were applied sevoflurane with anesthesia mask, 103 (32.1%) were administered sevoflurane with laryngeal mask, and 111 (34.6%) were sedation-analgesia. Only 10 out of 320 procedures were seen to develop side effects (8 vomiting, 2 bronchospasm). In the patients who underwent sedation analgesia during the first 3 BoNT-A procedures, the duration of recovery and total operating room time was seen to be significantly shorter than the others, while there was no difference between the anesthesia methods in the 4th and subsequent procedures. Regardless of the type of anesthesia, the recovery and total operating room times of those having undergone 6 or more procedures were longer than those with less than 6 procedures (p <0.009, p <0.016, respectively). As conclusion, repeated BoNT-A applications in children with CP provides progress in motor steps, it can be applied safely and effectively under anesthesia. Sedation analgesia application provides easier recovery compared to general anesthesia with LMA and mask only in the first three applications. However, recovery time increases with 4 and more repeated applications as the number of applications increases

Introduction. We designed this study to compare 30-day complications and length of hospital stay between patients undergoing total knee arthroplasty (TKA) with general anesthesia, to those undergoing TKA with spinal, epidural anesthesia, or Monitored Anesthesia Care (MAC, a combination of local anesthesia with sedation and analgesia provided by an anesthesiologist) with or without regional nerve blocks. Methods. We identified patients ≥18 years undergoing TKA between the years of 2006 and 2017 from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). We collected patient demographics, anesthesia type, 30-day complications, length of operation and hospital stay from the database. We used multivariable regression to compare complications and length of stay (LOS) between anesthesia types, while adjusting for relevant covariables. Results. We identified 265,325 TKA patients. Of these, 91 (0.03%) underwent epidural anesthesia with a nerve block, while 1,855 (0.70%) underwent epidural anesthesia with no block, 12,800 (4.82%) underwent MAC with a block, 25,643 (9.66%) underwent MAC with no block, 13,575 (5.12%) underwent spinal anesthesia with a block, 80,803 (30.45%) underwent spinal anesthesia with no block, and 130,558 (49.21%) underwent general anesthesia. The rate of complications was not associated with the presence of a block, while the unadjusted LOS was significantly lower with the use of a block in patients treated with spinal anesthesia (2.54±2.07 vs. 2.84±2.25), epidural anesthesia (2.87±1.81 vs. 3.88± 4.67), and MAC (2.51±2.14 vs. 2.68±2.11), p<0.0001. The unadjusted rate of major complications was significantly lower in patients who underwent spinal anesthesia (2.10%), and MAC (1.91%) compared to general anesthesia (2.31%), p<0.0001. Similarly, the unadjusted rate of minor complications was significantly lower for patients treated with spinal anesthesia(1.86%) and MAC (1.78%) compared to general anesthesia (2.11%), p<0.0001. The unadjusted LOS was significantly longer in patients treated with epidural (3.83±4.58), compared to general (2.94±3.64) anesthesia, p<0.0001. In contrast, the unadjusted LOS was significantly lower for patients treated with spinal anesthesia (2.80±2.23), and MAC (2.62±2.12) compared to general anesthesia, p<0.0001. Following covariable adjustment, spinal anesthesia and MAC were associated with a 0.93 (0.87–0.98), and 0.84 (0.78–0.91), odds of major complications compared to general anesthesia. Similarly, spinal anesthesia and MAC were associated with a 0.92 (0.87–0.98) and 0.89 (0.82–0.97) odds of minor complications compared to general anesthesia. Following covariable adjustment, epidural anesthesia increased the LOS by 0.25 (0.27–0.28) days compared to general, while spinal anesthesia and MAC decreased the LOS by 0.04 (95%CI 0.05–0.04), and 0.10 (0.11–0.09) days, compared to general. In patients treated with spinal anesthesia, epidural anesthesia, and MAC, the use of a block was independently associated with a decreased LOS by 0.10 (0.12–0.90), 0.24 (0.39–0.09), and 0.07 (0.08–0.05). Conclusion. Patients who undergo TKA with spinal anesthetic, and MAC appear to have superior outcomes compared to those who undergo TKA with general anesthesia. In addition, the use of a regional nerve block appears to be independently associated with a shorter LOS in patients who undergo TKA with neuraxial (spinal and epidural) anesthetic, and MAC. For figures, tables, or references, please contact authors directly

Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation. Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions. Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient. The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort

Background. Frozen Shoulder is a common condition which causes significant morbidity in people of working age. The 2 most popular forms of surgical treatment for this condition are Manipulation under Anaesthesia (MUA) or MUA plus Arthroscopic Capsular Release (ACR). Both treatment modalities are known to give good results, but no-one has compared the two to see which is better. Aim. To compare the outcome in patients with primary frozen shoulder, who are treated by either MUA or MUA plus ACR. Methods. 56 patients with primary frozen shoulder were treated by either MUA or MUA plus ACR. Each patient had their American Shoulder and Elbow Score (ASES), and their Oxford Shoulder Score (OSS) measured pre- and post-operatively. Results. The patients who had MUA plus ACR had a mean ASES of 19.6 pre-operatively, 78.3 at 6 months, and a mean of 80.1 at 12 months. The mean OSS was 32.5 pre-operatively, 53.6 at 6 months and 53.8 at 12 months. The patients who had a MUA had a mean ASES of 28.7 pre-operatively, 57.9 at 6 months and 58 at 12 months. The mean OSS was 33 pre-operatively, 42.5 at 6 months and 48 at 12 months. Conclusions. Both treatments give good results; MUA plus ACR give significantly superior results at 6 to 12 months post-operatively. However, there is no significant difference beyond 12 months