I'd like to thank everyone for coming to my talk today. I'd like to apologize for not being able to be there in person, but I look forward to any comments or discussion about this topic because I think it's a very important one we need to discuss and address. My talk today is gonna be on to block or not to block, the pros and cons of regional anesthesia for knee surgery. I have no disclosures for this talk except for I will be talking about two research projects that I've been specifically involved in. As surgeons, one of our jobs is to manage the perioperative pain process that starts when the patient even walks in the door for their surgery, interoperatively while the patient is on the table, and postoperatively to help make sure that the patient gets home as safe and comfortably as possible. Our goal is a safe surgery as well as a patient that tolerates the procedure as best as possible. With having as few phone calls and complications as we possibly can get. We all know about the opioid crisis and the abuse and misuse of opioids and our desire to decrease their utilization as much as possible in the perioperative period. Thusly, multimodal anesthesia and perioperative pain management really has increased and improved, and that has really popularized the use of regional anesthesia for knee surgery. In 2012, an AOS exhibit selection really talked about the pros and cons of regional anesthesia as it was gaining popularity. As you can see from this graph, some of the things as the pros that were described were improvement in patient satisfaction, decrease in pain, decrease adverse events, potential decreased length of surgery, and the ability to reduce the amount of time that the patient has to be in the operating room. As you can see from this graph, some of the things as the pros that were described were improvement in patient satisfaction, potential decreased length of stay in the hospital, and potential improved rehabilitation in the post-operative period. This exhibit also did address some of the complications that were seen in the previous reports up to this 2012 time period, which include local spread of medication, hematoma formation, vascular puncture, persistent neuropathy at 0.5% in one study for femoral and sciatic regional anesthesia, as well as falls and quad weakness as potential complications after regional anesthesia. Since this time, a wide variety of reports have come out trying to determine if regional anesthesia is efficacious for our patients after lower extremity surgery. This is one example of a study that looked at peripheral nerve blocks after hip arthroscopy and really showed no difference between regional anesthesia or multimodal anesthesia. I think the most important thing is to treat each patient as an individual and really ask yourself a set of questions when you're considering a block and the regional team has come up to you asking if you want a block and what type of block you would like. So here's some general questions to consider. So does the patient have any medication allergies? Do they have any GI or kidney sensitivities? What about their ability to swallow and take medications and compliance with those medications? Do they have any history of any chronic regional pain or pain syndromes? And really, what's their risk of opioid complications, abuse, or misuse? When you're thinking about exact pain medications to give the patient, really you need to think about past, current, and future pain levels, as well as what their non-narcotic pain medication use has been, what their narcotic pain medication use has been, and any other types of non-medication pain modalities that they may really benefit from and utilize. We all know there's a lot of studies out there showing the more narcotics patients take preoperatively means the more narcotics they're gonna take postoperatively and this should be addressed at the preoperative visit. We wanna reiterate the goal of this is having as safe a surgery as possible with the patient tolerating the procedure as possible. I really think it's not realistic to think it's gonna be a zero pain surgery, but we wanna minimize any pain and complications they may have. Keeping in mind that an upwardly mobile patient able to do their rehab and physical therapy while having minimal side effects such as sedation, GI upset, or severe chronic pain or acute pain is really our goal. So I wanna talk quickly about two studies that I've been involved with. I think we all know the pros of blocks and the potential pros. Our anesthesia colleagues have done a good job trying to show really any sort of pros that they could have in regards to the improved in rehab, the decreased pain utilization, potentially shorter stay, but we really don't talk much about complications from blocks. You can see they've had several medical students who are coming to the orthopedic residency review process in the near future. So keep these names in mind as they're all stellar, but they did a great job looking at a systematic review of block complications. Really what we looked at was a review of the literature to determine any reporting of long-term complications. So something greater than six weeks after the surgery in regards to these regional anesthesia. Using our standard PRISMA guidelines, we found that only 1% of the literature even commented for positive or negative on complications after regional anesthesia. Of the 158 studies we found that looked at outcomes of regional anesthesia, only 16 of them even commented or reported on complications either for the positive or for the negative. You can see the three block types that were included in this. Femoral and adductor canal commonly lumped together, popliteal and sciatic regional anesthesia were all included. You can see the number of studies that talked about complications with the largest number being in femoral and adductor canals, followed by sciatic and lastly popliteal. And varying number reported that they did see long-term complications versus no complications. When we look specifically at the complications that were reported for each of the blocks, we can see here the femoral and adductor canal block complications included return to sport strength deficits, greater extension loss, neuropathic pain, prolonged quad inhibition, a specific antirefemoral cutaneous nerve parasitia and several with sensory complications lasting greater than three months postoperatively. When we look at the complications reported from popliteal and sciatic regional anesthesia, parasitias that lasted greater than one year postoperatively were reported after both of these types of blocks. In the sciatic population, 2% of their population had this parasitias that lasted six months or greater. And also for that sciatic, there was a report of decreased strength at one year postoperatively. When we put all this together, we can report that about 1% of studies on block outcomes even mentioned complications and both motor and sensory complications rarely occur but are reported. And this manuscript and data is submitted for publication and review. I'd also like to report on some findings from the SCORE database, which is the Sports Cohort Outcomes Registry, which is over the 20 centers in pediatric sports medicine, prospectively collected data specifically on a few procedures in pediatric sports medicine. The data is prospectively collected and specific to only a few procedures. ACL reconstructions with or without meniscus repair, discoid meniscus with or without repair, tibial spine fixation with or without repair. You can see here the numbers of cases that at the time of data collection, there were almost 5,000 cases in this database. When we looked at the utilization of regional anesthesia amongst these procedures, you can see that there was similarly 4,790 cases of regional anesthesia in this over 5,000 cases. I'd like to highlight this very interesting finding on our motor loss. And you can see here that we had five patients with reported motor loss after an adductor canal regional anesthesia, as well as the number of sensory losses we had in both adductor and femoral regional anesthesia. When we look at all of our sensory loss complications, we had 21 of them to try and determine was there any causative factors for these sensory loss. We can see that the numbness in the sensory loss lasted greater than 120 days in eight patients. The average time to the numbness being resolved was 106 days, and there was no association with age, sex, height, weight, or tourniquet time with the development of a sensory loss. There was a variety of blocks that had a result in sensory loss. Ultrasound was used in the majority of these cases, and this was across numerous procedures of ACL reconstructions, tibial spine fixation, and meniscus repair. You can see overall, 14 of them did resolve, but there were two permanent sensory losses which were considered greater than one year, and at the time of data collection, six of them were still ongoing. When we look collectively at our motor losses in this database, we had seven motor loss complications. When we look specifically at contributing factors, there was no association with age, sex, height and weight, or tourniquet time. There was a variety of block types that had a result in motor loss. Similarly, ultrasound was used commonly in these motor losses. The procedures consisted of ACL reconstructions, tibial spine, as well as meniscus repair, and at the time of data collections, four of them were resolved, but three of them were ongoing greater than 100 days with motor loss. So the conclusions from this database was that less than 1% complication rate, including motor and sensory loss in this prospectively collected data. Sensory loss was more common than motor loss. Adductor canal blocks can result in a motor loss and was the predominant one in our database. Sensory loss can take months to resolve if it is present, and permanent motor loss is possible after regional anesthesia. So in conclusion, I would advocate that we take every patient as an individual, weighing the risks and benefits of different types of medications, as well as the risks and benefits of regional anesthesia. For some patients, that 1% risk of motor loss may be worth the chance of decreasing their opioid abuse rate, but in a professional athlete or some heavy laborer, that 1% motor loss may dramatically affect their life and may not be worth the risk. So really, it should be a shared decision-making process as to whether you're gonna utilize regional anesthesia in your patients. I'd like to thank everyone for coming to this session today. Very proud to be a forum member. And here's my email should there be any questions or further discussion on this topic. I think it's something we can do a lot better with really talking with our patients about the pros and cons of regional anesthesia.

regional anesthesia

knee surgery

pain management

complications

patient satisfaction