Conventional teaching advises against using adrenaline with local anaesthetic near end-arteries due to risks of irreversible vasospasm, however there are benefits of adjunctive adrenaline including enhanced anaesthetic effect, prolonged duration and temporary haemostasis. Retrospective analysis was undertaken for all elective finger and distal palmar surgery using digital nerve or field blocks performed by four orthopaedic hand surgeons, during a two-year period in a large teaching hospital. Data collected from theatre databases and clinical notes included procedure type, anaesthetic agent, adrenaline use, tourniquet use and evidence of post-operative digital ischaemia or wound complications. 230 procedures (mean age 59 years) were performed, including 158 cases with plain anaesthetic only (2%, 1% Lidocaine or 0.25% Bupivicaine in 150, 4 and 4 cases respectively) and 72 cases with 0.25% Bupivicaine and adrenaline (1:200,000.) Mean anaesthetic volume was 7.5ml (7.2ml vs 8.0ml without and with adrenaline respectively.) Tourniquet was used in all cases without adrenaline but was not used in 21 (29%) of cases with adrenaline. Mean tourniquet time in each group was 16 minutes. Two post-operative infections occurred in the group without adrenaline with none in the adrenaline group and there were no cases of digital necrosis in either group. In the elective setting, adjunctive adrenaline with local anaesthetic does not increase the risk of post-operative infections or digital ischaemia. For proximal finger surgery, where digital tourniquets are often restrictive, using adrenaline can prevent the need for painful arm tourniquets

Lower-extremity orthopaedic procedures may be performed under either regional or general anaesthesia, or a combination of both techniques. There is a growing body of evidence supporting the benefits of regional anaesthesia, with meta-analyses of randomised controlled trials and registry data suggesting decreases in deep surgical site infections, thromboembolic events, cardiopulmonary complications and length of stay associated with use of regional anaesthesia. In patients undergoing foot and ankle surgery specifically, there is evidence demonstrating decreased post-operative pain, nausea, vomiting, opioid use and unplanned hospital admission. This supports an increased role for the use in regional anaesthesia in patients undergoing foot and ankle surgery. However, the type of anaesthetic used is dependent on surgeon, patient, anaesthesiologist and institutional factors. The purpose of this study is to investigate pre-operative factors that predict the type of anaesthetic used in patients undergoing foot and ankle surgery. Data was collected prospectively on 888 patients undergoing foot or ankle surgery at a single institution. The primary method of anaesthesia for each procedure was recorded. Ten additional variables were recorded and analysed: age, BMI, gender, diabetes, ASA status, procedure length, procedure start time, elective vs. trauma procedure, primary vs. revision procedure and preoperative anticoagulation. Logistic regression modelling was performed to identify factors that independently predict the type of anaesthetic used. General anaesthetic was employed in 280 patients (32%), and regional anaesthesia was the primary anaesthetic type used in 608 (68%). Logistic regression modelling demonstrated that factors that independently predict use of general anaesthetic include younger age (p<0.0001; Odds Ratio 0.97/year), male sex (0.0033; 1.618), procedure start time (0.0319; 1.066/hour) and length of procedure (<0.0001; 1.520/hour). Patients who underwent general anaesthetic had a mean length of procedure of 108 +/− 77 minutes, whereas patients provided with regional anaesthesia had a mean length of procedure 83 +/− 64 minutes. With increasing evidence supporting the benefits of regional anaesthesia in patients undergoing lower extremity surgery, it is important to identify modifiable factors that contribute to patients receiving alternative treatments. Since later procedure start time was identified as an independent predictor of general anaesthetic use, there may be a role for identifying patients at increased risk of complications associated with general anaesthesia and scheduling earlier start times. Furthermore, while it is logical that extended length of procedure may be a contraindication to regional anaesthesia, the mean procedure time of 108 minutes in the general anaesthesia group indicates that many of these patients should still be considered candidates for regional anaesthesia

Introduction. Local anaesthetic has been reported to have a detrimental effect on human chondrocytes both in vitro and in vivo. Magnesium, an NMDA-receptor antagonist, may be an alternative intra-articular analgesic agent following arthroscopy. We aimed to report the dose response effect of commonly used local anaesthteitc on chondrocyte viability and also report on the effect of adding magnesium to local anaesthetic. Methods. Human chondrocytes were grown under standard conditions. Cells were exposed to either lignocaine (0.5, 1, 2%), levobupivacaine (0.125, 0.25, 0.5%), bupivacaine (0.125, −.25, 0.5%) or ropivacaine (0.1875, 0.375, 0.75%) for 15 minutes. Cells were also exposed to a local anesthetic agent with the addition of magnesium (10, 20, or 50%). Cells exposed to media or saline served as controls. The MTS assay was used to assess cell viability 24-hours after exposure. Results. One-way ANOVA showed an expected dose response in all local anaesthetic groups with the exception of lignocaine. Magnesium alone was no more toxic than normal saline (P>0.3). 50% magnesium showed similar effect on cell viability to the least toxic local anaesthetic (lignocaine 1%, P=0.31). The addition of magnesium to the local anesthetic agents resulted in greater cell viability than when cells were treated with the respective local anaesthetic alone (lignocaine (P=0.033), levobupivacaine (P=0.007), bupivacaine (P<0.001), ropivacaine (P<0.001)). Conclusion. We have shown that cell viability is greater in the presence of magnesium than selected local anaesthetics and also with the addition of magnesium to local anaesthetic compared to the local anesthetic agent alone. We believe that these findings offer support to an alternative intra-articular analgesia following arthroscopy

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again

It has been reported that some of the local anaesthetic agents possess antimicrobial activity against clinically-significant bacteria. Although bupivacaine exhibits a bacteriostatic effect at concentrations above 0.25% there are concerns that it might interact with some of the other antibiotics administered to patients. Whilst these interactions may be potentially benign, the risk is that they are antagonistic and that local bupivacaine might predispose the patient to a higher risk of infection. Bupivacaine is commonly administered as a local anaesthetic following knee arthroplasy; the purpose of this study was to assess its potential interactions with gentamicin eluting from the cement used to fix the device. A strain of Saphylococcus aureus (29213) with established susceptible Minimal Inhibition Concentration (MIC) and Minimal Bactericidal Concentration (MBC) for gentamicin was used. This organism was inoculated into four types of broth; Mueller-Hinton broth (MH), MH with different concentrations of gentamicin, MH with 0.25% and 0.125% bupivacaine and MH with various combinations of gentamicin and bupivacaine. The broths were incubated at 37C and at 0.5, 1, 2, 3, 6 and 24 hours post inoculation the number of bacteria remaining were counted. From these data kill-curves were generated describing the absolute and individual rates of killing seen with bupivacaine and gentamicin alone and when in combination. Bupivacaine showed a bacteriostatic effect only at concentrations of 0.25% and higher. All concentrations of gentamicin above or equal to the expected MBC showed bactericidal effect. However, in combination with both strengths of Bupivacaine (0.25 and 0.125%) the bacteriocidal effect of gentamicin was seen at a lower concentration and the rate of killing of bacteria was enhanced. Bupivacaine has bacteriostatic effect at concentrations above 0.25% in line with published data. In these experiments we have shown that the use of bupivacaine together with gentamicin does not reduce the bactericidal property of the antibiotic and that the bactericidal effect of gentamicin appears to be enhanced by bupivacaine. This would suggest that the local use of bupivacaine is unlikely to increase the risk of infection in patients undergoing knee arthroplasty and may actually be beneficial

Background. Continuous post-operative infusion of local anaesthetic solutions has been implicated as the causative factor in many cases of chondrolysis. Recent in-vitro studies have shown that even a single exposure to local anaesthetic can cause apoptosis and mitochondrial dysfunction leading to chondrocyte death. Glucosamine has been shown to have a protective and reparative effect on articular cartilage. Aims. To compare the effect of a single exposure of different local anaesthetic solutions on human articular cartilage and to investigate the protective and reparative effects of Glucosamine on articular cartilage exposed to 0.5% Bupivacaine. Methods. Chondral explants (n=354) were obtained from femoral heads of hip fracture patients undergoing hemiarthroplasty. Each specimen was exposed to one of 8 test solutions for one hour. The specimens were then incubated in culture medium containing radio-labelled 35-sulphur for 16 hours. The uptake of 35-S by each specimen was measured to give an estimate of proteoglycan metabolism. Test solutions. 1. 1% Lidocaine 2. 2% Lidocaine 3. 0.25% Bupivacaine, 4. 0.5% Bupivacaine, 5. 0.5% Levo-Bupivacaine 6. Control solution of M199 culture medium. 7. To investigate its protective effect, 100 micrograms of Glucosamine was added along with 0.5% Bupivacaine 8. To investigate its reparative effect, Glucosamine was added after exposure to Bupivacaine for an hour. Results. Compared to the control solution, the inhibition of proteoglycan metabolism was 64% with 1% Lidocaine(p< 0.001), 79% with 2% Lidocaine(p< 0.001), 61% with 0.25% Bupivacaine(p< 0.001), 85% with 0.5% Bupivacaine(p< 0.001) and 77% with 0.5% Levo-Bupivacaine(p< 0.001). Adding Glucosamine reduced Bupivacaine toxicity to 43%(p< 0.001). Glucosamine marginally repaired the damage caused by Bupivacaine, with inhibition of proteoglycan metabolism at 70%(p=0.004). Conclusion. All local anaesthetic solutions were toxic to articular cartilage. The addition of Glucosamine to 0.5% Bupivacaine protected against its toxicity to articular cartilage

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

Introduction. Pneumatic tourniquets (PTs) are commonly used in local anaesthetic cases in the upper limb to provide a bloodless operating field. They give excellent efficacy however their limitations have prompted the introduction of a new single-use sterile silicone ring tourniquet (SRT). The evidence of use of the SRT over the standard PT is limited. Aim. To compare the level of perceived pain, and therefore tolerance, of the Silicone Ring and Pneumatic tourniquets when applied to the upper arm and to evaluate whether there was a clear benefit of use of either tourniquet in local anaesthetic procedures of the upper limb. Materials and methods. 30 volunteers, 15 male and 15 female, with a median age of 42 were recruited to compare the two tourniquets. Pain was measured using a VAS pain scale on application and at 1, 5 and 10 minutes. Results. Volunteers experienced significantly more pain on application and at 1 and 5 minutes with the SRT. This difference in pain perceived was most marked upon application. Two volunteers could not tolerate application of the SRT. Three volunteers experienced bruising of the arm and/or forearm following use of the SRT. There was no difference in pain scores at 10 minutes. Conclusion. Due to the severe pain experienced on application of the SRT it would not be suitable for local anaesthetic procedures in the upper limb. In addition the degree of pain may reduce the patients confidence and adversely affect their experience of the procedure. The PT is more suitable for local procedures. However the SRT may have a role in procedures performed under general anaesthetic

Urinary catheterization in the postoperative period is known to increase the risk of deep joint infection following arthroplasty. A number of studies have attempted to elucidate the individual patient factors and surgical procedural factors which predispose patients to postoperative urinary retention. We conducted a retrospective observational study of three hundred patients to specifically determine the effect of the anaesthetic technique on the incidence of urinary retention following elective lower limb arthroplasty. One hundred consecutive patients were surveyed in each of three groups differing by the type of the anaesthetic technique and the drug administered; 1) general anaesthesia with femoral nerve block, 2) spinal anaesthesia with intrathecal fentanyl, and 3) spinal anaesthesia with intrathecal morphine. The incidence of urinary retention requiring catheterisation in male patients receiving intrathecal morphine was 58% compared with 10% and 6% for those who had general anaesthesia with femoral nerve block and intrathecal fentanyl, respectively. This difference was statistically significant (p<0.01). The incidence of urinary retention in females across all groups was =2%. The average residual volume of urine following catheterisation was 750ml (460-1500ml). Our findings show that the use of intrathecal morphine greatly increases the risk of postoperative urinary retention in male patients, whereas no significant increase was found amongst female patients. This risk should be carefully considered when choosing the type of intraoperative anaesthetic/analgesic combination employed in male patients and be rationalised against the intended benefits to the patient

Introduction. It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinico-radiological features and concomitant hip and lumbar spine arthritis. It has been hypothesized that an anaesthetic hip arthrogram can help identify the source of pain in these cases. The purpose of this study is to analyze our experience with this technique in order to verify its accuracy. Methods. We undertook a retrospective analysis of 204 patients who underwent a hip anesthetic-steroid arthrogram for diagnostic purposes matching our inclusion criteria. Patient charts were scrutinized carefully for outcomes of arthrogram and treatment. Harris Hip Score was used to quantify outcome. Results. The results show that out of 204, 162 patients had positive and 42 had negative response to arthrogram. Of the positive responders (N=162), 76 underwent uncemented Total Hip Arthroplasty (THA), all with good results, and the rest are being treated conservatively. From the negative responder group (N=42), 33 were successfully treated for spinal and other disorders, 8 underwent successful THA and 1 had an unsuccessful THA. Conclusion. Our findings suggest that the relief of symptoms following instillation of local anaesthetic and steroid into the hip joint has a positive predictive value and specificity of 100%, sensitivity of 95% and negative predictive value of 89.5%. We thereby believe that this is useful and reliable test with low morbidity for distinguishing between pain arising from the hip and other sources and can predict the potential benefit of THA in this diagnostic challenging group of patients

The last decade has seen a rise in the use of the gamma nail for managing inter-trochanteric and subtrochanteric hip fractures. Patients with multiple co-morbidities are under high anaesthetic risk of mortality and are usually not suitable for general or regional anaesthesia. However, there can be a strong case for fixing these fractures despite these risks. Apart from aiming to return patients to their pre-morbid mobility, other advantages include pain relief and reducing the complications of being bed bound (e.g. pressure ulcers, psychosocial factors). While operative use of local anaesthesia and sedation has been documented for insertion of extra-medullary femoral implants such as the sliding hip screw, currently no literature is present for the insertion of the gamma nail. We studied intra-operative and post-operative outcomes of three patients aged between 64 and 83 with right inter-trochanteric hip fractures and American Society of Anesthesiologists (ASA) scores of 4 or more. Consent for each case was obtained after discussion with the patient and family, or conducted with the patient's best interests in mind. All patients received a short unlocked gamma nail, and were operated on within 24 hours of admission. Each patient underwent local injections of Bupivacaine or Lignocaine or both, with Epinephrine, and with one patient receiving nerve block of the fascia iliaca. Each patient received a combination of sedatives under the discretion of the anaesthetist including Midazolam, Ketamine, Propofol, Fentanyl, and/or Haloperidol. Operating time ranged from 30–90 minutes. Patients were managed post-operatively with analgesia based on the WHO pain ladder and physiotherapy. Our results showed no intra-operative complications in any of the cases. All patients noted improvement in their pain and comfort post-operatively without complications of the operation site. Two patients achieved their pre-morbid level of mobility after undergoing physiotherapy and were subsequently discharged from the orthopaedic team. One patient with ongoing pre-operative medical complications died 5 days after the operation. This study provides a glimpse into the use of local anaesthetic and sedation on high operative risk patients, and this may be a viable alternative to extra-medullary implants or non-operation. Further research is needed to quantify the risks and benefits of operating within this patient group

Purpose. To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure. Methods. Prospective analysis of patients who required MUA post TKA performed by two surgeons using the same prosthesis from 2003 to 2008. Compared to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. Risk factors were identified including warfarin and statin use, diabetes and body mass index. Results. Seventy-two patients required an MUA out of 1313 TKAs (5.5%) compared to a control group of 50 patients. The mean arc of motion preoperatively was 89.0° (MUA group) vs 92.2° (control) (p=0.47), at discharge 71.0° vs 76.8° (p< 0.05) and 6 weeks follow-up 64.0° vs 97.3° (p< 0.0001). Post manipulation the mean arc of motion was 108° on table, 83.1° at 3 months follow-up and 81.9° at 12 months. Patients whose manipulation was within 3 months of TKA (23 patients) improved their mean arc of motion from 53.6° to 78.0° (p< 0.0025), those 3–12 months (42 patients) from 67° to 83.0° (p< 0.0001) and those >12 months (7 patients) 81° to 89° (p=0.32). Mean increase of extension was 3.7° on table and 3.6° at 12 months. Mean flexion increase was 40.5° on table and 15.7° at 12 months. The relative risk factor for requiring an MUA was 6.97 warfarin (p< 0.05), 1.58 statins, 2.85 diabetes and 1.17 obesity. Conclusions. MUA following primary TKA improves their range of motion if done within 12 months, however only 50% improvement is maintained. Patients with less than 75° flexion at discharge or those on warfarin therapy are likely to require a manipulation to improve their range of movement

Introduction. The conservative management of Sub-Acromial Impingement Syndrome (SAIS) of the shoulder includes both physiotherapy treatment and subacromial injection with local anaesthetic and steroids. The outcome from injection treatment has rarely been evaluated scientifically. Methods. Patients attending a designated shoulder clinic and diagnosed by an experienced shoulder surgeon as having a SAIS between January 2009 and December 2011 were considered for inclusion in the study. 67 of 86 patients screened completed the study (3 did not meet inclusion criteria; 9 declined to participate; 3 lost to follow-up; 4 developed frozen shoulder syndrome). Each patient had a pre-injection Oxford Shoulder Score (OSS) and was given one subacromial injection of 10ml 0.25% levobupivacaine(Chirocaine) + 40 mg triamcinolone(Kenalog) through the posterior route. Radiograph imaging was also assessed. Follow-up was carried out at 6 to 12 weeks post injection when OSS was repeated. A 6 month follow-up assessment to assess if the patient's improvement in functionality and absence of symptoms indicated that a subacromial decompression operation was not necessary. The percentage of patients showing improvement in OSS was calculated and the difference in OSS pre- and post-injection assessed using a Wilcoxon Signed Rank test. Results. The median OSS pre-injection was 29 (range 2–43) and post-injection was 40 (range 2–48) (p=< 0.001; z=−6.0; r=−0.5). 45/69 (71%) of patients benefited significantly from subacromial injection at 6 to 12 weeks post-injection. However only 28/53 (53%) benefited significantly from injection by 6 months post-injection. These results support the continued use of sub-acromial corticosteroid injections in the treatment of SAIS. 31% of these patients were subsequently treated with an arthroscopic subacromial decompression operation. Previous injection history had no impact on the results. Conclusions. We recommend that all patients with SAIS should be offered at least one subacromial injection before being considered for an arthroscopic subacromial decompression operation

Manipulation under anaesthetic (MUA) is an established treatment for frozen shoulder. Frozen shoulder may coexist with other shoulder conditions, whose treatment may differ from MUA. One such condition is calcific tendonitis. Only one study to date documents treatment of patients with frozen shoulder and concurrent calcific tendinitis. The objective was to demonstrate that MUA and injection is a satisfactory treatment for concurrent diagnosis of frozen shoulder and calcific tendinitis. Patients with a clinical diagnosis of frozen shoulder and radiological evidence of calcific tendinitis were prospectively recruited from Jan 1999 – Jan 2009. Treatment by MUA and injection was performed. Clinical examination, Oxford Shoulder Scores and need for further treatment were used as outcome measures. Fourteen patients (median age 53.5 years) were identified with frozen shoulder and concurrent calcific tendinitis. Significant improvement in both Oxford Shoulder Score and range of movement was achieved following MUA (P values < 0.001). Two patients required further treatment (not for calcific tendinitis). This improvement was maintained in the long term (median 107 wks). It is our belief that MUA and injection is a safe and effective treatment, addressing the frozen shoulder with MUA takes priority, and as such frozen shoulder “trumps” other pathologies occurring simultaneously

We carried out a comparison of the analgesic requirements, length of stay in hospital, complications and cost effectiveness of patients who had either a continuous disposable infusion pump or standard treatment for unicompartmental knee replacement.

This study began as an audit. We completed the audit loop with a prospective study after implementing our recommendations. The device is a single use disposable elastometric pump, set immediately after surgery to deliver a continuous flow of 0.5% bupivacaine at a rate of 2mls per hour for 48 hrs into the knee joint via a fine catheter with a fenestrated tip.

The case notes of all patients in the study were analysed to establish their total analgesic requirements for 48hrs following surgery. Complications and length of stay in hospital were recorded This has changed our clinical practice. Results of our study of 50 patients, 25 in each group (age and sex matched) confirmed that there was a significant reduction in opiate requirements after introduction of the pain pump. Length of stay in hospital was reduced from 5.7 to 3.9 days. Patients' requirements for NSAIDs were reduced. There were no significant complications in the pain pump group. The costs of the pump (£40) were offset by the reduction in analgesic requirements and shortened length of stay in hospital.

We conclude this form of analgesia is safe, effective and cost effective. Our department has now changed to using the pump for all unicompartmental knee replacements.

Paediatric wrist fractures are routinely managed with closed reduction and a molded cast. Gap(GI) and Cast indices(CI) are useful in predicting re-displacement following application of cast. Over 6 months we audited the efficacy of molded cast application following closed reduction of distal radial fractures in paediatric patients. The standard was that proposed by Malviya et al where GI >0.15 and CI >0.8 indicate an increased risk of re-displacement. Age, date and time of operation and surgeon's grade were collected. Pre-op displacement, post-reduction GI and CI and subsequent re-displacement were measured using imaging. Post audit intended changes to practice were presented to all surgeons, a “one-pager” was placed above scrub sinks. Re-audit was conducted at 1 year. The audit and re-audit included 28 and 24 patients respectively. Cast molding (CI) improved minimally following intervention (32% to 29%). Cast padding (GI) improved significantly (82% to 63%). Loss of reduction decreased slightly (14% to 12%), this was not accurately predicted by GI and CI in the re-audit. Audit demonstrated that casts were loose, over-padded and did not hold reduction adequately. Re-audit demonstrated that tighter, less padded but still inadequately molded casts were being applied with minimal change in loss of reduction.

Introduction

This study was performed to investigate the efficacy of steroid and local anaesthesia (LA) in reducing post-operative pain in lumbar discectomy.

Aims. As the world continues to fight successive waves of COVID-19 variants, we have seen worldwide infections surpass 100 million. London, UK, has been severely affected throughout the pandemic, and the resulting impact on the NHS has been profound. The aim of this study is to evaluate the impact of COVID-19 on theatre productivity across London’s four major trauma centres (MTCs), and to assess how the changes to normal protocols and working patterns impacted trauma theatre efficiency. Methods. This was a collaborative study across London’s MTCs. A two-month period was selected from 5 March to 5 May 2020. The same two-month period in 2019 was used to provide baseline data for comparison. Demographic information was collected, as well as surgical speciality, procedure, time to surgery, type of anaesthesia, and various time points throughout the patient journey to theatre. Results. In total, 1,243 theatre visits were analyzed as part of the study. Of these, 834 patients presented in 2019 and 409 in 2020. Fewer open reduction and internal fixations were performed in 2020 (33.5% vs 38.2%), and there was an increase in the number of orthoplastic cases in 2020 (8.3% vs 2.2%), both statistically significant results (p < 0.000). There was a statistically significant increase in median time from 2019 to 2020, between sending for a patient and their arrival to the anaesthetic room (29 vs 35 minutes; p = 0.000). Median time between arrival in the anaesthetic room and commencement of anaesthetic increased (7 to 9 minutes; p = 0.104). Conclusion. Changes in working practices necessitated by COVID-19 led to modest delays to all aspects of theatre use, and consequently theatre efficiency. However, the reality is that the major concerns of impact of service did not occur to the levels that were expected. Cite this article: Bone Jt Open 2021;2(10):886–892

Objective. Carpal tunnel release surgery is a commonly performed procedure for alleviating symptoms of median nerve compression and restoring hand function. With pressure on theatre time these procedures are now commonly performed in a step-down out-patient facility under local anaesthetic. The choice of suture for skin closure in this procedure can impact the quality of wound healing, patient outcomes and the follow-up required however the question of the best type of suture remains unanswered. The purpose of this study was to compare the outcomes of absorbable and non-absorbable sutures using a randomised control trial design. Methods. Eighty patients diagnosed with bilateral carpal tunnel syndrome were enrolled and underwent outpatient carpal tunnel release surgery under local anaesthetic in a staged fashion. Random number generation was used to assign each hand to receive interrupted nylon or Vicryl Rapide sutures. Pre-operative data collection included patient demographics, ASA, inflammatory conditions, smoking status as well as a Boston Carpal Tunnel Questionnaire (BCTQ) for each hand. Patients were followed up at 2 and 6 weeks after each operation and the BCTQ was repeated along with the Patient and Observer Scar Assessment Scale and the VAS score for wound discomfort. This study has approval from the DHB ethics committee, Local Iwi, HDC and ANZ Clinical Trials:ACTRN12623000100695. Results. Statistical analysis assessed patient preference and the scores between the groups. Multi-variate analysis was performed to assess the factors that may be contributing to patient choice. Conclusion. Insights into patient preference and clinical outcomes associated with absorbable sutures and non-absorbable sutures in the setting of out-patient surgery are discussed

Introduction. This study aimed to assess the relationship between preparation times and operative procedures for elective orthopaedic surgery. A clearer understanding of these relationships may facilitate list organisation and thereby contribute to improved operating theatre efficiency. Methods. Two years of elective orthopaedic theatre data was retrospectively analysed. The hospital medical information unit provided de- identified data for 2015 and 2016 elective orthopaedic cases, from which were selected seven categories of procedures with sufficient numbers to allow further analysis - primary hip and knee replacement, spinal surgery, shoulder surgery (excluding shoulder replacement), knee surgery, foot and ankle surgery (excluding ankle replacement), Dupuytrens surgery and general orthopaedic surgery. The data analysed included patient age, ASA grade, operation, operation time, and preparation time (calculated as the time from the start of the anaesthetic proceedings to the patient's admission to Recovery, with the operating time [skin incision to skin closure] subtracted). Statistical analysis of the data was undertaken. Results. A total of 1596 procedures performed over the two year period were analysed. Preparation times for the different procedures were assessed, along with the relationship to the procedure complexity. Neither age nor ASA correlated strongly with preparation times. Spine procedures had greater preparation times than hip and knee arthroplasty. Greater uniformity in preparation times for hip and knee arthroplasty was seen across the anaesthetic group than operative times across the surgeon group. Discussion. Preparation times are just one aspect that may be evaluated with regard to theatre utilisation. This study did not address the theatre turn-over time between cases, which includes transfer of the patient from the admitting/pre-operative area into the theatre. Conclusion. Preparation times for elective procedures follow a pattern which may be used to inform list planning, with the potential for greater theatre efficiencies with regard to list utilisation and staff allocation