Lower Extremity Surgical Procedures Research Articles

Tone management: An environmental scan of current management practices across Canada.

Currently, there are no standardized approaches to care or evaluation for tone dysfunction in Canada. The study authors hypothesize that there is significant practice variation across the country. This environmental scan is aimed to describe the current practice for management of paediatric patients with hypertonia across Canada. A web-based survey was developed by the authors with a multi-disciplinary approach and sent to representative paediatric rehabilitation sites in each province in Canada. Disciplines at the rehabilitation sites surveyed included all or some of the following disciplines: physiatry, neurology, neurosurgery, plastic surgery, orthopaedic surgery, physiotherapy and occupational therapy. All statistical analyses were performed using the R statistical software version 4.0. Fifteen rehabilitation sites were contacted, and 12 sites were used for the final analysis. Cerebral palsy was found to be the most common diagnosis for tone dysfunction, with 58% of sites diagnosing greater than 20 new patients per year. In 67% of sites, patients were seen within a formal multidisciplinary clinic to manage hypertonia. All 12 sites utilized oral baclofen and gabapentin, and 92% of sites utilized trihexyphenidyl. Botulinum toxin injections were offered at 50% of sites. Upper and lower extremity surgical procedures were offered in 83% of the sites. The information gained from this study provides some insight into the current practice across Canada for children with hypertonia. This study may assist in the development of a national, standardized strategy to tone management, potentially facilitating more equitable access to care for patients.

Manual Palpation versus Ultrasound to Identify the Intervertebral Space for Spinal Anesthesia in Infants.

Awake spinal anesthesia continues as an alternative to general anesthesia for infants. Standard clinical practice includes the manual palpation of surface landmarks to identify the desired intervertebral space for lumbar puncture (LP). The current study investigates the accuracy of manual palpation for identifying the intended intervertebral site for LP, using ultrasonography for confirmation and to determine the interspace where the conus medullaris ends. After informed parental consent, patients less than one year of age undergoing spinal anesthesia for lower abdominal, urologic, or lower extremity surgical procedures were included. Patients were held in the seated position and an attending pediatric anesthesiologist or pediatric anesthesiology fellow declared the vertebral interspace intended for needle insertion, palpated surface landmarks, and placed a mark at the site. A research anesthesiologist then determined the actual vertebral interspace of the marked site and the location of the conus medullaris using ultrasonography. The time to complete both techniques (manual palpation and ultrasonography) was recorded. The study cohort included 50 infants (median age of 7 months). Sixteen vertebral interspaces (32%) were inaccurately marked. One was marked two spaces higher than intended, ten were marked one space higher than intended, and five were marked one space lower than intended. In one patient, the intended vertebral interspace for the lumbar puncture overlaid the conus medullaris. The median time required was 25 seconds (IQR 14.3, 32) for palpation and 39 seconds (IQR 29, 63.8) for ultrasonography. Manual palpation of surface landmarks to determine the correct interspace for LP for spinal anesthesia in infants is inaccurate. The time required to perform spinal ultrasonography in infants for determination of the optimal site for LP is brief and may be useful in ensuring accurate identification of the correct interspace and the location of the conus medullaris.

The Use of Amniotic Membrane for Peripheral Nerve Injury in Lower Extremity Surgical Procedures

Category: Basic Sciences/Biologics; Other Introduction/Purpose: Patients undergoing nerve decompression surgery often report persistent symptoms. Some have suggested that wrapping the affected nerve with amniotic membrane may improve outcomes if the nerve is wrapped with amniotic membrane at the time of surgery, possibly related to anti-inflammatory, antifibrotic, or pro-regenerative effects. There is little in the foot and ankle literature to support such approaches. The aim of this preliminary study was to assess the initial safety of amniotic membrane use outcomes in foot and ankle surgery during nerve decompression procedures as an initial study in anticipation of a randomized, prospective trial. Methods: We retrospectively reviewed outcomes among 22 patients, >=18 years old, who had undergone amniotic membrane neurorrhaphy for lower extremity nerves including sural, saphenous, superficial peroneal, common peroneal, deep peroneal, digital (Morton's neuroma), Baxter's and posterior tibial nerve. Patients may have had multiple nerves wrapped and have had other procedures done. All patients had failed conservative treatments including cortisone injections, orthotics, nonsteroidal anti- inflammatory drugs, and physical therapy. Patients' demographics, postoperative complications, patient reported outcome measures (PROMs), and preoperative/postoperative Visual Analog Scores (VAS) for pain was collected. Data were reported in a descriptive manner. Results: Twenty-two patients, 16 females and 6 males averaging 51 years of age were assessed. Only one patient of the twenty- two reported a higher postoperative VAS compared to the preoperative VAS. There were no post-operative infections or reactions to the amniotic membrane. No patient required repeat surgery. The average pre- and post-operative VAS were 6.36 and 2.77, respectively. The average PROMs Pain Interference and Pain Intensity (Short Form 4a and 3a, respectively) were 42.02 and 35.94, respectively, that were within the normal range. Conclusion: The use of amniotic membrane wrap in lower extremity nerve decompression procedures was shown to be safe regarding post-operative short-term complications in this series of patients. However, in order to prove the usefulness of this technique for pain and function improvement, further studies with larger populations, particularly randomized clinical trials with long term follow up are necessary.

Microangiopathy in Inflammatory Diseases-Strategies in Surgery of the Lower Extremity.

Background: Patients with an inflammatory disease frequently develop chronic angiopathy of the capillaries. Due to this pathology, there is an increased rate of complications in lower extremity surgical procedures. It is not uncommon for microangiopathic wound healing disorders to cause deep infections and fistulas, which lead to prolonged courses and hospitalizations. In addition, adhesions and ossifications of the contractile elements occur regularly. This sometimes results in serious limitations of the mobility of the patients. The study aims to present the results of a combination of vacuum and physical therapy. Patient and methods: A retrospective study of six patients with systemic sclerosis undergoing joint-related procedures of the lower extremity between 2015 and 2020 was performed. In addition to characterization of the patients and therapy, special attention was paid to cutaneous wound healing, affection of the fascia and displacement layers, and sclerosis of the muscle and tendon insertion. Results: The characterized structures (skin, tendon, fascia) show pathological changes at the microangiopathic level, which are associated with delayed healing and less physical capacity. Early suture removal regularly results in secondary scar dehiscence. With a stage-adapted vacuum therapy with sanitation of the deep structures and later on a dermal vacuum system, healing with simultaneous mobilization of the patients could be achieved in our patient cohort. Conclusion: In the case of necessary interventions on the lower extremity, such as trauma surgery, additional decongestive measures in the sense of regular and sustained lymphatic therapy and adapted physiotherapy are indispensable.

Peripheral Nerve Blocks for the Lower Extremity

Lower extremity peripheral nerve blocks (PNBs) are often used for surgical anesthesia and postoperative pain management. The use of PNB provides improved analgesia, reduced opioid consumption, and improved patient satisfaction and can facilitate earlier rehabilitation and discharge. As the number of lower extremity total joint arthroplasties is projected to increase significantly, the role of peripheral nerve blocks can be expected to grow in similar fashion. With the growing number of procedures and the increasing focus on patient experience and expeditious hospital discharge, PNBs are increasingly recognized as a powerful tool to improve patient care and facilitate recovery after lower extremity surgery. We provide a basic review of regional anesthesia for lower extremity surgical procedures. The widespread availability of ultrasonography has improved the performance and efficacy of PNBs; thus, we focus on ultrasonography-guided procedures. In this review, we discuss pertinent lower extremity anatomy and sonoanatomy, indications, patient outcome measures, techniques, and complications of the most commonly used blocks. This review contains 35 figures, 11 tables, 5 videos, and 103 references. Key words: adductor canal block, analgesia, ankle block, clinical applications of peripheral nerve blocks, complications of peripheral nerve blocks, continuous peripheral nerve catheter, early ambulation, fascia iliaca compartment block, femoral nerve block, lower extremity nerve blocks, lower extremity regional anesthesia, lumbar plexus block, obturator nerve block, peripheral nerve block, peripheral nerve catheter, popliteal block, psoas compartment block, regional anesthesia, regional anesthesia techniques, saphenous nerve block, sciatic nerve block, ultrasonography guided

Peripheral Nerve Blocks for the Lower Extremity

Lower extremity peripheral nerve blocks (PNBs) are often used for surgical anesthesia and postoperative pain management. The use of PNB provides improved analgesia, reduced opioid consumption, and improved patient satisfaction and can facilitate earlier rehabilitation and discharge. As the number of lower extremity total joint arthroplasties is projected to increase significantly, the role of peripheral nerve blocks can be expected to grow in similar fashion. With the growing number of procedures and the increasing focus on patient experience and expeditious hospital discharge, PNBs are increasingly recognized as a powerful tool to improve patient care and facilitate recovery after lower extremity surgery. We provide a basic review of regional anesthesia for lower extremity surgical procedures. The widespread availability of ultrasonography has improved the performance and efficacy of PNBs; thus, we focus on ultrasonography-guided procedures. In this review, we discuss pertinent lower extremity anatomy and sonoanatomy, indications, patient outcome measures, techniques, and complications of the most commonly used blocks. This review contains 35 figures, 11 tables, 5 videos, and 103 references. Key words: adductor canal block, analgesia, ankle block, clinical applications of peripheral nerve blocks, complications of peripheral nerve blocks, continuous peripheral nerve catheter, early ambulation, fascia iliaca compartment block, femoral nerve block, lower extremity nerve blocks, lower extremity regional anesthesia, lumbar plexus block, obturator nerve block, peripheral nerve block, peripheral nerve catheter, popliteal block, psoas compartment block, regional anesthesia, regional anesthesia techniques, saphenous nerve block, sciatic nerve block, ultrasonography guided

A Complex Forefoot Malunion in a Patient with Werner’s Syndrome: A Case Report

Lower extremity surgical procedures in patients with Werner’s syndrome are uncommon, and for this reason they are rarely reported in the literature. In this report, we present the case of a 39-year-old man with a history of Werner’s syndrome, and a malunited right hallux varus and first ray insufficiency after previous bunionectomy performed 4 years earlier. Further reconstructive surgery involved forefoot osteotomy and arthrodesis with internal fixation, and the patient ultimately healed the soft tissues and bones, despite delayed wound healing.

Epidural versus intravenous clonidine for postoperative patient controlled analgesia

unlike most other sedative drugs, 2 adrenoceptor agonists e.g (clonidine) are capable of producing both sedation and analgesia with little if any, respiratory change. The aim of this study was to evaluate the analgesic efficacy, the respiratory and the endocrine effects of epidural versus intravenous clonidine for postoperative pain. Forty adult patients ASA I and II of both sexes were scheduled for elective lower abdominal or lower extremity surgical procedures. For postoperative pain relief , the patients were randomly divided into two groups, twenty patient of each. In (Group I) patients received intravenous clonidine through patient-controlled analgesia pump (IPCA). In (Group II) patients received epidural clonidine through patient-controlled analgesia pump (EPCA). A standard anaesthetic technique was employed to all patients and anaesthesia was maintained with gas oxygen halothane and muscle relaxant. Serial arterial and venous blood samples were taken to measure blood gases and endorphin level. After surgery patients with visual analogue scale ( VAS ) >4 were given clonidine initial dose 4µg/kg intravenous or epidural infusion over a period of 30 minutes then they were allowed to self administer clonidine using PCA pump which delivered a bolus dose of 0.5µg/kg with a 15 minute lockout interval to the corresponding route. Self-administered doses were (124.2±34.637µg) in intravenous group and (100.6±31.406µg) in epidural group. The total clonidine dose was (424. ±38.138µg) in intravenous group versus (399.8±47.371µg) in epidural group. Pain scores were lower after than before clonidine administration in both groups . No significant difference in pain scores were found between the two groups. There was also no significant changes in respiratory rate, arterial PH, Pa Co2 or Pa o2 in each studied group and no significant difference between the two groups. Forced vital capacity ( FVC ) and Forced expiratory volume in one second ( FEV1 ) were significantly reduced before clonidine injection in both groups. The beta endorphin level was increased after one hour of clonidine administration and there was no significant difference between the two groups. In conclusion Clonidine proves to be adequate alternative to opiates without their side effects and the dose of clonidine is lower by the epidural route.

Epidural versus intravenous clonidine for postoperative patient controlled analgesia

unlike most other sedative drugs, 2 adrenoceptor agonists e.g (clonidine) are capable of producing both sedation and analgesia with little if any, respiratory change. The aim of this study was to evaluate the analgesic efficacy, the respiratory and the endocrine effects of epidural versus intravenous clonidine for postoperative pain. Forty adult patients ASA I and II of both sexes were scheduled for elective lower abdominal or lower extremity surgical procedures. For postoperative pain relief , the patients were randomly divided into two groups, twenty patient of each. In (Group I) patients received intravenous clonidine through patient-controlled analgesia pump (IPCA). In (Group II) patients received epidural clonidine through patient-controlled analgesia pump (EPCA). A standard anaesthetic technique was employed to all patients and anaesthesia was maintained with gas oxygen halothane and muscle relaxant. Serial arterial and venous blood samples were taken to measure blood gases and endorphin level. After surgery patients with visual analogue scale ( VAS ) >4 were given clonidine initial dose 4µg/kg intravenous or epidural infusion over a period of 30 minutes then they were allowed to self administer clonidine using PCA pump which delivered a bolus dose of 0.5µg/kg with a 15 minute lockout interval to the corresponding route. Self-administered doses were (124.2±34.637µg) in intravenous group and (100.6±31.406µg) in epidural group. The total clonidine dose was (424. ±38.138µg) in intravenous group versus (399.8±47.371µg) in epidural group. Pain scores were lower after than before clonidine administration in both groups . No significant difference in pain scores were found between the two groups. There was also no significant changes in respiratory rate, arterial PH, Pa Co2 or Pa o2 in each studied group and no significant difference between the two groups. Forced vital capacity ( FVC ) and Forced expiratory volume in one second ( FEV1 ) were significantly reduced before clonidine injection in both groups. The beta endorphin level was increased after one hour of clonidine administration and there was no significant difference between the two groups. In conclusion Clonidine proves to be adequate alternative to opiates without their side effects and the dose of clonidine is lower by the epidural route.

Optimizing spinal anesthesia for ambulatory surgery.

Spinal anesthesia is used for ambulatory surgical procedures. We provide an overview of the use of local anesthetics, use of continuous techniques, and use of adjuncts for optimization of spinal anesthesia for ambulatory surgery. Review of current literature and critical analysis of selected manuscripts. Small doses of lidocaine (approximately 40 mg) and bupivacaine (approximately 7.5 mg) are appropriate for ambulatory surgery. Increasing concentration of local anesthetic solution may result in increased duration of anesthesia and recovery. While use of hyperbaric solutions consistently produce more cephalad sensory block, use of isobaric solutions provide adequate sensory and motor block for lower extremity surgical procedures. The use of continuous techniques may provide valuable anesthetic titration, as small doses of spinal anesthetics may produce highly variable results. Epinephrine is not recommended as an adjunct due to prolongation of recovery time. In contrast, intrathecal fentanyl may prolong surgical anesthesia without prolonging recovery. Ambulatory spinal anesthesia may be optimized by selection of dose, concentration, and baricity of local anesthetic. Use of a continuous technique or an intrathecal adjunct may also be valuable means to optimize spinal anesthesia for ambulatory surgery.