Lower Extremity Surgery Research Articles

Modified Battlefield Acupuncture Does Not Reduce Pain or Improve Quality of Life in Patients with Lower Extremity Surgery.

This study seeks to determine if modified Battlefield Acupuncture is more effective at relieving acute extremity pain, reducing medication use, and improving quality of life than placebo acupuncture or standard care after lower extremity surgery. We conducted a multi-site 3-arm randomized, double-blind controlled trial of standard care alone versus standard care + placebo auricular acupuncture with semi-permanent needles versus standard care + modified battlefield acupuncture with semi-permanent needles for lower extremity surgery at two Air Force hospitals. Subjects reported pain level immediately after acupuncture, 24, 48, 168, and 720 hours later to a blinded research associate. Additionally, subjects completed a PIQ-6 30 days post-operatively, and opioid use was tracked for 30 days post-operatively. Two hundred thiry-three subjects >18 years old (92 females and 141 males) with a mean age of 44.5 years were randomized with 81 randomized to modified BFA, 74 randomized to placebo acupuncture, and 78 randomized to standard care. Overall pain levels were unchanged at each time point between groups. Outcomes showed unchanged pain, opioid and quality of life between groups. The use of modified battlefield acupuncture protocol does not change pain opioid use or quality of life in those with lower extremity surgery.

Etiology and Treatment Outcomes for Sural Neuroma.

Neuroma results from disorganized regeneration following nerve injury and may be symptomatic. The aim of this study was to investigate the causes, treatment, and outcomes of operatively treated sural neuromas, and to describe the factors associated with persistent or unchanged postoperative pain symptoms. Consecutive patients with surgically treated sural neuromas in a 14-year period were identified using Current Procedural Terminology (CPT) codes ( n = 49), followed by a chart review to collect patient and treatment characteristics. Postoperative pain symptoms were categorized as complete resolution of pain, improvement of pain, no change in pain, or worse pain. The median patient age was 46.5 years (interquartile range [IQR], 39.1-51.3), and median follow-up was 4.0 years (IQR, 1.9-9.2). Ninety percent of symptomatic sural neuromas developed as a result of previous lower extremity surgery. Initial surgery of sural neuroma led to improvement in pain in 63% of patients, and an additional 8.2% of the patients had improvement after secondary neuroma surgery. Pain relief after diagnostic injection showed a trend toward an association with postoperative pain improvement. Neuroma excision and implantation in muscle was the most common surgical technique used (67%). Four of the 7 patients that underwent a second neuroma operation reported symptom improvement. Sural neuromas may arise from prior surgery or trauma to the lower extremity. Surgical intervention resulted in either improvement or complete resolution of pain symptoms in 71% of patients, although occasionally more than one procedure was required to obtain symptomatic relief. Preoperative anesthetic injection may help identify patients that benefit from neuroma surgery. Level of Evidence: Level IV, retrospective case series.

An Assessment of Long-Term Opioid Use Following Tibial Plateau Fracture Repair

Objectives: Is there a difference in percentage of opioid use at 3 and 6 months among different races/ethnicities following tibial plateau fracture repair after controlling for potential confounders? Methods: Retrospective secondary data analysis of 18- to 65-year-old patients with operative tibial plateau fractures between 2006 and 2015 at a level-I trauma center. Exclusion criteria included preinjury opioid use or history of opioid dependence, American Society of Anesthesiologists class ≥3, renal or lower extremity neurological impairment, and/or rheumatoid arthritis. Three hundred fifteen operative tibial plateau fractures were identified and, following application of our exclusion criteria, final sample size was 211. Intervention included single-shot peripheral nerve block (PNB) vs. no PNB. Main outcome measurements were opioid use at 3 or 6 months compared among all race/ethnicities. Results: Black patients were less likely to be on prescription opioids than whites at both 3 months (p = 0.015, odds ratio [OR] = 0.396 [0.188 to 0.835]) and 6 months (p = 0.027, OR = 0.239 [0.067 to 0.852]). Hispanic patients did not differ statistically from white patients in having an opioid prescription at 3 or 6 months. Smokers were independently more likely to be on prescription opioids than nonsmokers at 6 months (p = 0.013, OR = 2.874 [1.245 to 6.635]). Conclusions: Disparities exist with regard to opioid use among white and black patients following lower extremity surgery, regardless of PNB status. White patients are at risk for long-term opioid use following tibial plateau fracture repair and black patients may not be receiving adequate pain control postoperatively. Smoking was found to be associated with long-term opioid use.

不同浓度布比卡因腰麻联合B超指导限制性输液策略在下肢小手术中的应用

不同浓度布比卡因腰麻联合B超指导限制性输液策略在下肢小手术中的应用

CSM 2019 American Academy of Sports Physical Therapy Poster Presentations (Abstracts SPO1–SPO132)

CSM 2019 American Academy of Sports Physical Therapy Poster Presentations (Abstracts SPO1–SPO132)

ULTRASOUND SKILLS IN LOWER EXTREMITY TRAUMATOLOGY AND ORTHOPEDICS - REGIONAL ANESTHESIA AND BEYOND.

SUMMARYDuring the last two decades ultrasound guidance has been established as an invaluable tool for performing peripheral nerve blocks. Ultrasound guidance reduces block performance time, volume of local anesthetic, risk of intravascular injection and need for opioid rescue analgesia compared to landmark based and neurostimulator guided techniques. The use of ultrasound guidance must not be understood as a surrogate to, but should complement a thorough understanding of anatomy. The purpose of this overview is to present ultrasound guided techniques for performing basic lower extremity blocks, as well as to discuss more recent trends in providing regional analgesia for patients undergoing lower extremity surgery.

Combined Psoas Compartment Block and Sciatic Nerve Block for Elective Lower Limb Surgeries

AIM AND OBJECTIVE OF THE STUDY : This study was aimed at evaluation of the motor and sensory blockade and post operative analgesia using both psoas compartment block and sciatic nerve block in elective lower extremity surgeries. PRIMARY OBJECTIVE : To assess the effectiveness of the lower limb block based on 1. Sensory block. 2. Motor block. 3. Post operative analgesia. SECONDARY OBJECTIVE : To assess the onset of block, total duration of block, and the time taken for the first dose of rescue analgesia and to look for complications if any MATERIAL AND METHOD : DESIGN OF THE STUDY: Randomized Prospective study. Selection of Subjects : • Study involves adult patients between 18 to 60 years ofASAps I- II posted for elective lower limb surgeries. • Sample size 60. • Randomization – computer generated random numbers. PSOAS COMPARTMENT BLOCK AND SCIATIC NERVE BLOCK : Sixty patients subjected to psoas compartment block followed by sciatic nerve block using nerve stimulator 0.25% bupivacaine over 30 ml for psoas compartment block and 0.25% of 20ml bupivacaine for sciatic nerve block was administered. Under strict aseptic precautions, psoas compartment block performed by winnes technique and and sciatic nerve block by labat’s technique using peripheral nerve stimulator after obtaining twitch of quadriceps and calf muscle contraction and dorsiflexion of foot. Results are based on following parameters. • Time of onset of sensory blockade. • Time taken for onset of motor blockade. • From the time of block, visual analogue scale noted for every 30 minutes 1hour, 2 hour by 4, 6, and 8 hours • From the time of block Bromage score noted for 2, 6,and 8 hours. • Time elapsed till first rescue analgesia dose. • The incidence of first dose of rescue analgesia at 9 to 10 hours is 48.3 % (29 out of 60 patients) and at 10 to 11 hours is 51.7 % (31 out of 60 patients). • Sensory blockade by visual analogue scale reveals no pain upto 8 hours and almost complete block upto 6 hours in 73.3% of patients and good analgesic effect upto 9 to 10 hours in 48.3 % (29 out of 60 patients) and at 10 to 11 hours is 51.7 % (31 out of 60 patients). • So overall combined psoas comapartment block and sciatic nerve block provides effective sensoryblockade, motor blockade and good postoperative analgesic effect. CONCLUSION : This study concluded that skillful application of psoas compartment block by posterior approach [WINNIES APPROACH] and proximal sciatic nerve blockv [LABATS APPROACH] provides adequate intraoperative analgesia for major lower extremity procedures and maintains prolonged postoperative analgesia with significantly lower consumption of opioid analgesics. It also provides, early ambulation, short hospital stay and far less side effects when compared with neuroaxial blocks such as hemodynamic instability, meningeal irritation, introduction of infections, neurological complications and others. Finally, both patient and surgeon satisfaction were achieved successfully with psoas compartment block and sciatic nerve block. Combined psoas compartment block and sciatic nerve block is a safe and effective alternative for analgesia for lower limb surgeries.

Co-administration of dexmedetomidine and levobupivacaine results in better onset and duration of epidural anesthesia in lower extremity orthopedic surgery

Background: The goal of this study is to know the efficacy of the addition of 0.5 mcg/kg dexmedetomidine to 15 mL isobaric 0.5% levobupivacaine on the onset and duration of sensory and motor blockade of epidural anesthesia in lower extremity orthopedic surgery. Methods: Randomized clinical double-blind trials were conducted in Dr. Mohammad Hoesin Hospital Palembang. A total of 34 patients underwent lower extremity surgery met the inclusion and exclusion criteria. Data were analyzed by independent t-test and Mann-Whitney test using SPSS 22.0 software. Result: The onset of sensory block in group D was 5.41±1.84 minutes compared to 17.59± 2.65 in Group C (p <0.001), as seen in [Table 2]. The sensory block duration was 362.41±25.66 minutes in Group D compared to 215.82±15.69 in Group C (p <0.001). The onset of the motoric block in group D was 16.53±1.81 minutes compared to 26.12±2.78 in Group C (p <0.001), while the motoric block duration was 301.29±20.55 minutes in Group D compared to 167.35±17.24 in Group C (p <0.001). Conclusion: The addition of 0.5mcg/kg dexmedetomidine to 15 ml isobaric 0.5% levobupivacaine in epidural anesthesia provide faster onset and prolonged duration in both motoric and sensory block in patients undergoing lower extremity surgery.

Reliability of the Modified Clavien-Dindo-Sink Complication Classification System in Pediatric Orthopaedic Surgery.

Background:There is no standardized complication classification system that has been evaluated for use in pediatric or general orthopaedic surgery. Instead, subjective terms such as major and minor are commonly used. The Clavien-Dindo-Sink complication classification system has demonstrated high interrater and intrarater reliability for hip-preservation surgery and has increasingly been used within other orthopaedic subspecialties. This classification system is based on the magnitude of treatment required and the potential for each complication to result in long-term morbidity. The purpose of the current study was to modify the Clavien-Dindo-Sink system for application to all orthopaedic procedures (including those involving the spine and the upper and lower extremity) and to determine interrater and intrarater reliability of this modified system in pediatric orthopaedic surgery cases.Methods:The Clavien-Dindo-Sink complication classification system was modified for use with general orthopaedic procedures. Forty-five pediatric orthopaedic surgical scenarios were presented to 7 local fellowship-trained pediatric orthopaedic surgeons at 1 center to test internal reliability, and 48 scenarios were then presented to 15 pediatric orthopaedic surgeons across the United States and Canada to test external reliability. Surgeons were trained to use the system and graded the scenarios in a random order on 2 occasions. Fleiss and Cohen kappa (κ) statistics were used to determine interrater and intrarater reliabilities, respectively.Results:The Fleiss κ value for interrater reliability (and standard error) was 0.76 ± 0.01 (p < 0.0001) and 0.74 ± 0.01 (p < 0.0001) for the internal and external groups, respectively. For each grade, interrater reliability was good to excellent for both groups, with an overall range of 0.53 for Grade I to 1 for Grade V. The Cohen κ value for intrarater reliability was excellent for both groups, ranging from 0.83 (95% confidence interval [CI], 0.71 to 0.95) to 0.98 (95% CI, 0.94 to 1.00) for the internal test group and from 0.83 (95% CI, 0.73 to 0.93) to 0.99 (95% CI, 0.97 to 1.00) for the external test group.Conclusions:The modified Clavien-Dindo-Sink classification system has good interrater and excellent intrarater reliability for the evaluation of complications following pediatric orthopaedic upper extremity, lower extremity, and spine surgery. Adoption of this reproducible, reliable system as a standard of reporting complications in pediatric orthopaedic surgery, and other orthopaedic subspecialties, could be a valuable tool for improving surgical practices and patient outcomes.

The role of newly diagnosed diabetes mellitus for poor in-hospital prognosis of coronary artery bypass grafting

Background: The management of coronary artery disease in patients with type 2 diabetes (T2DM) who need myocardial revascularization is a great challenge.&#x0D; Aims: To study the role of newly diagnosed T2DM in the development of in-hospital adverse outcomes after coronary artery surgery (CABG).&#x0D; Methods: 708 consecutive patients underwent CABG were included. All patients without history of T2DM and with border fasting hyperglycemia underwent an oral glucose tolerance test.&#x0D; Results: The screening allowed to diagnose T2DM in 8.9% and prediabetes in 10.4% of the study population. The the number of patients with T2DM increased from 15.2% to 24.1%, and with prediabetes from 3.0% to 13.4%. The total number of patients with carbohydrate metabolism disorders increased from 18.2% to 37.5%. The trend towards higher rate of in-hospital complications after CABG was defined among patients with newly diagnosed and previously diagnosed T2DM. The regression analysis demonstrated the presence of the relationships between the previously diagnosed T2DM and the total number of significant complications (odds ratio (OR) 1.350, 95% confidence interval (CI): 1.0571.723, p=0.020) and prolonged in-hospital stay (OR 1.609, 95%CI 1.2022.155, p=0.001). The significance of these relationships increased with the addition of newly diagnosed T2DM to the regression model (for in-hospital complications: OR 1.731, 95% CI 1.1312.626, p=0.012; for prolonged in-hospital stay: OR 2.229, 95%CI 1.4123.519, p0.001). Moreover, additional associations between T2DM and the risk of developing multiple organ dysfunction (OR 2.911, 95% CI 1.0727.901, p=0.039), urgent lower extremity surgery (OR 1.638, 95%CI 1.00915.213, p=0.020) and the need for extracorporeal correction of hemostasis (OR 3.472, 95%CI 1.04211.556, p=0.044) have been defined. Importantly, the presence of these associations would not have been identified without including newly diagnosed DM in the regression model.&#x0D; Conclusion: The newly diagnosed T2DM affects the prognosis of CABG as well as the previously diagnosed T2DM. The obtained results suggest the importance of active preoperative T2DM screening.

Y-Balance test asymmetry is greater in collegiate athletes with a history of concussion

Athletes with a history of concussion (HC) are at an increased risk of sustaining lower extremity injuries. It is unclear if these individuals exhibit dynamic postural control deficits associated with lower extremity injury risk. The purpose of this study was to determine if collegiate athletes with a HC demonstrate differences in Y-Balance Test (YBT) performance compared to athletes with no history of concussion (NHC). A total of 116 varsity and club athletes from a Division-I university participated. Forty participants reported a HC (female/male: 31/9, age: 20.0 ± 1.4 years, height: 169.3 ± 13.1 cm, mass: 68.4 ± 14.0 kg) while 76 reported NHC (female/male: 60/16, age: 20.0 ± 1.7 years, height: 168.5 ± 12.9 cm, mass: 68.7 ± 14.6 kg). Individuals with a current concussion or lower extremity injury, or a history of lower extremity surgery were excluded. Participants completed the YBT anterior reach direction barefoot on both limbs. The YBT was completed by maximally reaching anteriorly, maintaining balance, and returning to the starting position without errors. Participants completed 4 practice trials and 3 test trials. Reach distances were averaged and normalized to leg length. Between-limb asymmetry was calculated as the absolute difference between the left and right limbs. Separate independent t-tests examined group differences in normalized reach distances and asymmetry. The proportion of participants in each group with &gt;4 cm of asymmetry was compared using a χ2 test. Alpha was set at 0.05 for all analyses. No group differences were identified in normalized reach distances for the left (HC: 61.4% ± 9.2%, NHC: 60.8% ± 6.2%, p = 0.88, ES = 0.08) or right (HC: 61.4% ± 6.2%, NHC: 60.2% ± 6.8%, p = 0.51, ES = 0.17) limbs. However, a greater proportion of HC participants demonstrated &gt;4 cm asymmetry (HC: 40.0%, NHC: 19.7%; p = 0.02) and these participants exhibited greater asymmetry (HC: 3.87 ± 3.69 cm, NHC: 2.40 ± 2.13 cm, p = 0.03; ES = 0.53). Athletes with a HC exhibited greater asymmetry compared to athletes with NHC. Anterior reach asymmetries of &gt;4 cm are associated with greater lower extremity injury risk. The YBT may provide a clinical technique to further explore the relationship between concussion and lower extremity injury.

Driving after Upper or Lower Extremity Orthopaedic Surgery.

Orthopaedic procedures can affect patients' ability to perform activities of daily living, such as driving automobiles or other vehicles that require coordinated use of the upper and lower extremities. Many variables affect the time needed before a patient can drive competently after undergoing orthopaedic surgery to the extremities. These variables include whether the patient underwent upper or lower extremity surgery, the country in which the patient resides, whether the right or left lower extremity is involved, whether the dominant arm is involved, whether the extremity is in a cast or brace, whether the patient has adequate strength to control the steering wheel, and whether the patient is taking pain medication. The type and complexity of the procedure also influence the speed of return of driving ability. Few studies provide definitive data on driving ability after upper or lower extremity surgery. Patients should be counseled not to drive until they can control the steering wheel and the pedals competently and can drive well enough to prevent further harm to themselves or to others. This review discusses the limited recommendations in the literature regarding driving motorized vehicles after upper or lower extremity orthopaedic surgery.

The influence of high-dose intraoperative remifentanil on postoperative sore throat: a prospective randomized study: A CONSORT compliant article.

Background:Endotracheal intubation for general anesthesia causes postoperative sore throat (POST). This study is designed to evaluate the effect of high-dose remifentanil on the incidence of POST in patients after general anesthesia.Methods:Ninety-two patients scheduled for orthopedic lower extremity surgery under general anesthesia were randomly assigned into 1 of 2 groups. In the high-dose remifentanil (HR) group (n = 46), remifentanil was infused at a rate of 0.25 μg/kg/min and subsequently increased or decreased by 0.05 μg/kg/min per clinical demand. In the low-dose remifentanil (LR) group (n = 46), remifentanil was infused at a rate of 0.05 μg/kg/min. The incidence of POST was monitored at 0, 2, 4, and 24 hours postoperatively. Complications regarding opioids were compared between groups.Results:The overall incidence of POST was higher in the HR group compared with that in the LR group [33 (72%) vs 18 (39%), P = .022]. The incidence of POST at 0, 2, and 24 hours after surgery was higher in the HR group compared with that in the LR group (P < .001, P = .001, and P = .001, respectively). The incidence of postoperative nausea, vomiting, drowsiness, and headache was similar between the groups. The incidence of postoperative shivering was higher in the HR group than in the LR group [10 (22%) vs 2 (4%), difference 17%, 95% CI 2%–33%, P = .027].Conclusion:A relatively large dose of intraoperative remifentanil increased the incidence of POST in patients for orthopedic surgery under general anesthesia.Trial Registration:Clinicaltrials.gov Identifier: NCT03173339.

Does Tourniquet Time or Pressure Contribute to Intracranial Pressure Increase following Tourniquet Application?

Objective: The aim of this study was to determine whether an early increase in intracranial pressure (ICP) following the deflation of a tourniquet is related to the tourniquet time (TT) or tourniquet pressure (TP) and to identify a safe cut-off value for TT or TP. Materials and Methods: Patients who underwent elective orthopedic lower-extremity surgery under general anesthesia were randomized into 2 groups: group A (inflation with a pneumatic TP of systolic blood pressure + 100 mm Hg; n = 30) and group B (inflation using the arterial occlusion pressure formula; n = 30). The initial and maximum TPs, TT, and sonographic measurements of optic-nerve sheath diameter (ONSD) and end-tidal CO₂ values were taken at specific time points (15 min before the induction of anesthesia, just before, and 5, 10, and 15 min after the tourniquet was deflated). Results: The initial and maximum TPs were found to be significantly higher in group A than in group B. At 5 min after the tourniquet deflation, there was a significant positive correlation between TT and ONSD (r = 0.57, p = 0.0001). When ONSD ≥5 mm was taken as a standard criterion, the safe cut-off value for the optimal TT was found to be < 67.5 min (sensitivity 87% and specificity 59.5%). Conclusion: The ICP increase in the early period after tourniquet deflation was well correlated with TT but not with TP. TT of ≥67.5 min was found to be the cut-off value and is considered the starting point of the increase in ICP after tourniquet deflation.

Effects of tourniquet usage in lower extremity surgery on optic nerve sheath diameter

Background/aim: The aim of this study was to evaluate changes in intracranial pressure following tourniquet deflation using noninvasive ultrasonographic optic nerve sheath diameter (ONSD) measurements. Materials and methods: Our study included 59 adult patients between the ages of 18 and 65 years from the American Society of Anesthesiologists (ASA) I/II risk groups who were scheduled to undergo elective orthopedic surgery of the lower extremities using a tourniquet under general anesthesia. ONSD and end-tidal CO2 (ETCO2) were measured 5 times: 15 min prior to the anesthesia induction; just prior to the deflation of the tourniquet; and at 5, 10, and 15 min after the deflation. Additionally, age, sex, weight, height, ASA score, and duration of operation and tourniquet usage were recorded. Results: The ONSD value measured 5 min after the deflation was significantly higher than all of the remaining measurements. There was a significant correlation between the ONSD and ETCO2 measurements at 5 and 10 min after deflation (r = 0.61, 95% CI 0.42-0.75, P < 0.0001 and r = 0.30, 95% CI 0.04-0.51, P < 0.05, respectively). Conclusion: The ultrasonographic ONSD measurements, which were obtained using a simple and noninvasive approach, increased significantly following tourniquet deflation, and this increase was correlated with an increase in ETCO2.

Data analysis of 8 113 cases of limb deformities corrected by external fixation

To analyze the data of external fixation instruments (including Ilizarov instruments) used by QIN Sihe orthopaedic surgical team in the treatment of limb deformities in the past 30 years, and to explore the indications for the application of modern external fixation techniques in the correction of limb deformities and individual device configuration selection strategy. According to QIN Sihe orthopaedic surgical team, the use of external fixator between January 1988 and December 2017 was analyzed retrospectively. The total use of external fixation and the proportion of different external fixators were analyzed in gender, different operation time, different age, different parts, and different diseases. External fixators were used in 8 113 patients, 69 of them were used simultaneously in both lower extremity surgery, so 8 182 external fixators were used. Among them, there were 4 725 (57.74%) combined external fixators, 3 388 (41.41%) Ilizarov circle fixators, 64 (0.78%) single arm external fixators (including Orthofix), 5 (0.06%) Taylor space external fixators. There were 4 487 males (55.31%) and 3 626 females (44.69%). According to the analysis of different time periods, the number of external fixators increased year by year, and the number of applications increased after 2000. The main age of the patients was 11-30 years old, of which 1 819 sets (22.23%) were used at the age of 21-25 years. The use of the external fixator covered almost all parts of the limbs, with the ankle and toe areas being the most common, reaching 4 664 sets (57.00%), and the upper extremities the least, with 152 sets (1.86%). The 8 113 cases covered more than a dozen disciplines and more than 150 kinds of diseases. The top 5 diseases were poliomyelitis sequelae, cerebral palsy, deformity of lower extremity after spina bifida, traumatic sequelae, and congenital equinovarus foot. Ilizarov technique has been widely used in extremity deformity, disability, and complicated orthopedic diseases caused by vascular, lymphoid, nerve, skin, endocrine, and other diseases. The indication of operation is far beyond the scope of orthopedics. The domestic external fixator and its mounting tools can basically meet the requirements of various treatments. The technique of external fixation has entered a new era of tension tissue regeneration under stress control, natural repair of tissue trauma and deformity, and reconstruction of limb function.

Comparative Study between Intrathecal and Caudal Epidural Anesthesia in Children for Lower Abdominal Surgery

Background: regional anaesthesia techniques are now established in the practice of pediatric anaesthesia. it is one of the most common techniques used for post-operative pain management in pediatric patients especially for urogenital, rectal, inguinal and lower extremity surgeries. Objective: to compare caudal and spinal anaesthesia in paediatrics regarding haemodynamics, efficacy (sensory block characteristics, motor block characteristics) post operative analgesia, surgeon’s satisfaction, parents’ satisfaction and complications incidence. Material and Methods: the present study was carried on100 patients, with age ranging from (6-12) and of ASA (american society of anaesthesia.) I, II classes undergoing infraubmliclal pediatric surgeries, patients in each group were randomly assigned to receive spinal or caudal epidural anaesthesia. Results: the demographic data of patients as regard age, sex and ASA classification showed no statistical significant difference between the two groups, where the study was designed to compare between the effectiveness of spinal anaesthesia with bupivacaine 0.3mg/kg and caudal anaesthesia with bupivacaine 2mg/kg(1ml/kg vol.) as a sole anaesthetic technique adequate for infraumblical pediatric surgeries below T10 as regard the sensory and motor block characteristics, perioperative haemodynamic effects, pain assessment, analgesic requirements, and both the surgeon ad parents satisfaction was assessed.the results showed the superiority of subarachnoid on achieving rapid onset of sensory blockade, intense motor blockade, on the other hand the caudal epidural had the advantage of longer post operative analgesic effect and lower post operative analgesic consumption, furthermore both techniques gained good degree of parent and surgeon satisfaction. Conclusion: if both techniques are correctly used and the anatomy of the patient is normal there is minimal risk of complications.

Incidence of pediatric venous thromboembolism after elective spine and lower extremity surgery in children with neuromuscular complex chronic conditions: do we need prophylaxis?

Incidence of pediatric venous thromboembolism after elective spine and lower extremity surgery in children with neuromuscular complex chronic conditions: do we need prophylaxis?

New blocks for the same old joints.

New block techniques are being constantly developed or old techniques modified to improve outcomes after surgery. This review discusses the reasons why new block techniques need to be developed to match the needs of contemporary anesthetic practice. New block techniques have been developed for joint surgeries of both upper and lower extremities. New upper extremity blocks focus on decreasing the risk of complications like diaphragmatic paresis and improving the quality of blocks. Techniques for lower extremity surgeries are being performed distally, closer to the joints, to minimize weakness of the extremity. A review of the available evidence for these techniques is undertaken to get an understanding of the indications and limitations of these techniques. Future studies need to be undertaken to further refine these techniques and produce evidence of support for analgesic efficacy, safety, and reliability.

2D Video Analysis of the Effects of TheraBand® CLX Neuromuscular Exercises on Overhead Deep Squat: An Observational Cohort Study

**Background:** Overhead deep squat (OHDS) is used in both Functional Movement Screen (FMSTM) and other systems to examine movement competency during squatting. There is little evidence examining the effective- ness of exercises in improving OHDS performance in individuals with stability dysfunctions. **Purpose:** The purpose of this study is to determine the effect of low-level corrective exercises using TheraBand® CLX bands on OHDS performance in subjects with identified stability dysfunction during squatting. **Study Design:** This is an observational cohort study. **Methods:** In total, 59 healthy subjects (age, 18–40 years), participated in this study. Subjects were included if they demonstrated stability dysfunction during squatting and were excluded if they had a history of spinal or lower extremity injury or surgery and/or neurological or balance issues. Two-dimensional (2D) videos were used to record a preintervention (pre) OHDS in the frontal and sagittal views. Corrective exercises using TheraBand CLX were assigned on the basis of OHDS deficits. Subjects performed 3 sets of 15 repetitions of the assigned corrective exercises at a nonfatiguing workload, and postintervention (post) 2D videos were repeated. All videos were analyzed using Dartfish® Software to measure trunk angle, knee separation distance, and squat depth. **Results:** Statistically significant differences were observed between pre and post measures of knee separation at 0° of knee flexion (P = 0.013) and 60° of knee flexion (P = 0.039), as well as trunk-to-floor angle at 60° of knee flexion (P = 0.020) and at full depth (P = 0.000). Pre and post measures of full squat depth and knee separation at full depth were not significantly different. The effect sizes of the measured variables were small to medium, ranging from 0.02 to 0.67. **Discussion:** Corrective exercises using TheraBand CLX had several positive short-term statistically significant effects on OHDS mechanics. Small effect sizes were associated with knee separation (0° and 60°) and trunk angle at 60°, and a medium effect size was associated with trunk angle at full depth. Thus, movement changes observed in the postintervention squat cannot be fully attributed to the interventions. **Conclusion:** Significant short-term changes with small-to-medium effect sizes were found in multiple outcome measures; however, it is questionable whether these changes would be clinically observable in a physical therapy or sports performance setting without the use of video analysis.