BASIC SCIENCE
Regional analgesia and
orthopaedic surgery
Andrew T Wilson
Abstract
Regional anaesthesia and analgesia is a growing subspeciality which
impacts on all orthopaedic procedures. Advances continue to be
made in techniques which will influence patient outcomes. It is there-
fore essential that all practising anaesthetists and orthopaedic sur-
geons understand the background principles and practices of
regional anaesthesia to aid in the team treatment plan decision mak-
ing. All regional procedures have potential to facilitate postoperative
recovery however all have inherent risks and if “overdone” may inhibit
early rehabilitation. Only with the understanding of the techniques
available can an informed choice be made.
This review examines pharmacology of current local anaesthetics
and additives, the pros and cons of central axial blocks and differing
techniques including LIA local infiltration analgesia and ultrasound
guided blocks for major joint surgery in the upper and lower limbs. It
is not intended as a literature review of all the latest esoteric tech-
niques but as a background essential reading of what is currently
happening in orthopaedic anaesthesia.
Keywords orthopaedic surgery; regional analgesia
Introduction
It is 130 years since Koller1 first described the use of cocaine to
produce local anaesthesia for an ophthalmic surgical proce-
dure. Following on from this 1884 landmark case was a decade
of trials whereby cocaine was applied topically, injected sub-
cutaneously, around specific nerves and then centrally most
notably by Bier2 in 1899. Techniques have all developed
around this basic principle of bathing the nerves supplying the
surgical site with Local Anaesthetic (LA). Has the speciality
moved on? The answer is of course yes. Over the last century
advances have been made in LA potency, safety and efficacy,
nerve localization techniques, central axial blockade, ultra-
sound guided regional analgesia and more recently liposomal
LA. There is now a greater understanding as to how Regional
anaesthesia/analgesia (RA) affects surgical outcome and may
even reduce cancer recurrence.
A basic knowledge of these principles, practices and de-
velopments is not only a requirement for the anaesthetic trainee
but also for any practising surgeon as there is no surgical site that
is not amenable to RA.
Unfortunately there are practices continuing which have no
evidence base and in deed, some which continue despite
Dr Andrew T Wilson MBChB FRCA FICM Consultant Anaesthetist and
Intensivist, United Leeds Teaching Hospitals Trust, Leeds, UK.
Conflict of interest: none declared.
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evidence that potentially cause harm with no benefit at all.
Surgeons and Anaesthetists continue to add drugs to long
acting local anaesthetic agents, continue to give epidurals for
lower limb arthroplasty surgery and continue to refuse regional
techniques because of perceived but disproven risks of
complications.
Pharmacokinetics
An in depth knowledge of LA pharmacology is not essential,
however the basic principles are required to understand the
mechanism of action of LA, toxicity, choice of agent and future
developments.
Regional anaesthesia and regional analgesia can be consid-
ered the same entity, anaesthesia being a more profound and
denser block than analgesia. Regional anaesthesia makes the
operative site insensate for the duration of the surgery and is
influenced by LA concentration. Regional analgesia decreases the
operative site pain for a period well beyond the operative period.
This duration of action is influenced by choice, concentration
and volume of LA, additives and/or continuous catheter
techniques.
With the exception of the ultra short acting chloroprocaine
(Procaine) all local anaesthetic agents now in use are amides, the
original ester agents having high incidences of allergic reactions.
All local anaesthetics produce their effects by blocking
voltage-gated sodium channels. Unfortunately, this is true of all
types of nerve fibres and to date no LA is available which can
truly differentiate between motor and sensory fibres. Agents such
as ropivacaine had been suggested to produce less motor block3
than other equipotent agents such as bupivacaine but motor
block still occurs and so the clinical significance of this remains
small if at all. More recent developments may allow the goal of
specific sensory fibre sodium channels to be selected4 but despite
this being a reality no agent is as yet clinically available.
This motor block is now of greater relevance than previous
reviews because of the pressures, both economic and medical,
to get patients mobilized and discharged as quickly as possible.
It must be recognized that all regional techniques have a risk
benefit ratio. In deed it is this risk benefit ratio which has
resulted in the adoption of the new surgical technique of Local
Infiltration Arthroplasty5 surgery (LIA) because of the previous
over reliance of epidural analgesia in lower limb arthroplasty
surgery. This technique will be discussed in greater detail later
in the review.
The choice of LA to use is often dictated by the duration of
action as differing surgical procedures have differing intra and
postoperative analgesic requirements. For example the pain after
a surgical procedure on the shoulder compared with the hand is
generally more intense and of a greater duration. The choice for
hand units is often therefore for shorter acting agents even
though both shoulder and hand surgery may of the same oper-
ative duration and both are day case procedures under regional
alone.
The duration of action is dependent on both the protein
binding and the clearance from the injection site. Both of these
elements can be manipulated pharmacologically to increase the
longevity of the block but clinically only clearance can be
altered. Protein binding of the longer acting agents such as
bupiviacaine and ropivicaine is approximately 95% whereas
254 Ó 2016 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE
that of the shorter acting lidocaine is only 65%. The clearance
from the injection site is dependent upon local blood flow and
some LA, such as lidocaine; also have intrinsic vasodilator
properties that potentiate this. This flow can be manipulated by
vasopressors such as adrenaline or felypressin but since the
protein binding of the longer acting agents is so high local blood
flow has little if any effect on the duration of action on these
agents. However, the practice of adding adrenaline to these long
acting agents unfortunately continues despite the lack of any
pharmacological basis.
The onset time of local anaesthetics is dependent upon three
factors; molecular weight (all are similar), pKa and diffusibility.
Only pKa can be manipulated. A detailed understanding of
molecular pKa is not required save to say the further the pKa of
the molecule from the acid pH solution (all LA pKa are alkaline)
the more ionized it is and therefore the less able it is to cross
the lipid membrane. Again however, only the shorter acting
agents are amenable to manipulation as the very high pKa of
the longer agents makes a small increase in non-ionized mol-
ecules (by warming or alkalinization with bicarbonate) of little
significance. pKa is not therefore routinely manipulated as the
short acting agents already have a quick onset time.
It should be noted that the agents with quickest onset time
tend to be the same as those with the shortest duration of action
and lowest potency.
Additive agents and phospholipid encapsulation
(liposomal)
Adrenaline
The use of vasopressors, as noted above, is only of use with short
acting agents. They increase duration of action by decreasing
clearance secondary to local blood flow. The addition of a vaso-
pressor will also allow an increased dose of the non-potent short
acting drugs to be used before reaching toxic levels as plasma
levels will not peak rapidly. This has little or no influence on
plasma levels of the longer agents, in deed ropivacaine has been
shown to have an intrinsic vasoconstrictor action of its own.
There is some evidence that adrenaline may have specific
analgesic properties acting on alpha 2 receptors but the signifi-
cance of this is again minor in long acting blocks. Putting it
simply; if a long duration of action is required a long acting agent
without an additive should be used not a short acting one with
adrenaline added. Vasopressors are not without their potential
complications as they may reduce blood flow to the target nerves
which may potentiate any risk of axonotmesis.
Of course superficial infiltration with adrenaline containing
LA is given for local vasoconstrictor actions to decrease blood
loss and nothing to do with duration of block but unfortunately
this practice continues for nerve blocks as well.
Mixing two agents, one short acting but rapid onset (such
as Lidocaine or Prilocaine) and one long acting slow onset
(such as Bupivacaine or Ropivacaine), is common place but
has little pharmacological basis. However, ultrasound has
allowed specific nerves to be targeted for postoperative
analgesia with long acting agents whilst anaesthesia of the
whole limb is produced with short acting agents to the
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remaining plexus. This has been given the term differential
blockade.
Other additives
For peripheral nerve blocks there have been many agents added
to an LA to increase its effectiveness but few until now have
been shown to be of significant benefit.6 Even those that have
previously been shown to be beneficial have additional side
effects. As with the addition of vasopressors it does not make
good clinical sense to try and add any additive to a short
duration LA to improve its duration of action when longer
acting agents are freely available. Likewise in peripheral nerve
blocks the general rule was not to add any additive to an
already long acting agent although this rule was often ignored
with many centres routinely adding opioids or clonidine (and to
a less frequent extent NSAIDs, midazolam, ketamine, neostig-
mine and relaxants) to agents such as bupivicaine and ropi-
vacaine despite the lack of evidence. Until recently the alpha-2
receptor agonist clonidine was the only adjuvant to be used
routinely in the UK but there are as many papers refuting its
benefits as there are showing it to improve quality and duration
of block. It is likely that it does improve the duration and
quality of short acting plexus blocks but has no significant ef-
fect on longer acting LA.
More recently two more adjuvants have not only suggested an
increase in length of block but for the first time these are in long
acting local anaesthetics. Both dexamethasone7 and dexmedeta-
tomidine8 have significant promise but only the former has
become routinely used. Dexamethasone has been shown to
significantly increase the duration of both sensory and motor
block of long acting LA by up to 90%9 although some authors
have questioned its superiority over systemic dexamethasone.10
There are still some concerns regarding potential nerve toxicity
but clinically there have been no adverse side effects.11
For central axial blocks the addition of opioids or cloni-
dine is far more evidence based. They produce prolonged
analgesia or an improvement in block quality because of their
direct action on the dorsal and ventral horns, respectively.
The addition of diamorphine or morphine to a spinal anaes-
thetic is a now a routine procedure to provide excellent
analgesia for up to 24 hours without the residual motor
block. Side effects such as pruritis are common but also
include the far more serious late respiratory depression. Late
respiratory depression is far more common in the hydrophilic
long acting agents such as morphine compared with the short
acting lipophilic agents such as fentanyl. Many centres insist
on an HDU bed postoperatively or at least a ratio of nurses to
patient infrequently found on a busy orthopaedic ward and
this often precludes their use.
Liposomal LA
The idea of encapsulating LA in a phospholipid barrier to prolong
duration of action and reduce toxicity is not new12 and has been
researched for more than 25 years. Recent publications have
been favourable in wound infiltration techniques looking at
safety and tolerability13 as well as effect on wound healing14 but
not RCTs comparing analgesia scores with non-liposomal
255 Ó 2016 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE
Key points in pharmacology
C All local anaesthetics, with the exception of chloroprocaine, are
Amides.
C To date all LA produce motor block as well as sensory.
C Adrenaline does not increase the duration of action of long acting
LA.
C The alpha 2 agonists clonidine and dexmedetomidine and steroid
dexamethasone have been shown to significantly improve the
duration or quality of analgesia in peripheral blocks.
C The duration and quality of spinal/epidural analgesia can be
significantly improved by opioids and clonidine but both have
significant side effects especially in the elderly.
C There is insufficient evidence to date to recommend the use of
Liposomal LA.
bupivacaine. To date there is little evidence that it will prolong
most regional nerve block techniques but phase 2 and 3 trials are
continuing so it is too early to say whether there is enough evi-
dence to use liposomal LA.
Regional techniques
An outline of the basic principles of central axial (spinal and
epidural), plexus (brachial and lumbar) and peripheral nerve
blocks as well as local infiltration will aid background under-
standing when it comes to discussing RA for specific sites and
procedures.
Central neuraxial block, CNB
We now have more than 100 years experience in CNB and the
basic principle of bathing the cord in LA has not changed.
Spinal: single shot spinal (subdural) anaesthesia remains a
popular choice as it remains a safe and easy alternative to general
anaesthesia with the added advantage of providing excellent
analgesia in the very early postoperative phase. Spinal catheters
can be used to prolong spinal blocks but their necessarily small
size has limited their popularity. Extending the analgesia beyond
the very early postoperative period has proved more problem-
atical and attempts to do this with epidural catheters (combined
epispinal) have potentially set back the rehabilitation phase
because of the prolonged motor block. There is now a general
consensus that postoperative epidurals in routine lower limb
surgery should not be used. However it is also true to say that
lower limb arthroplasty surgery is painful well beyond the first
few postoperative hours and unless analgesia is effective, which
is difficult to achieve with the standard analgesics such as
morphine, rehabilitation will equally be set back. Therefore the
addition of multi-drug analgesic regimens, LA infiltration or
other regional techniques and/or spinal opiates is an essential
part of the spinal anaesthesia protocol.
Spinal needle: the major drive for change in needle design has
been from obstetric RA where the high incidence of post dural
puncture headache (PDPH) led to research to find the least
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Figure 1 Quinke and Sprotte pencil point needle.
traumatic needle. The incidence of PDPH is secondary to
continuing CSF leak and can be influenced principally by needle
size but also needle tip design with PDPH being more common
with the older large gauge needles. The standard bevelled cutting
needle (Quincke) has largely been replace by a blunter pencil
point needle (Sprotte) however variations on both themes are
still in use particularly in orthopaedic anaesthesia (Figure 1).
PDPH is most common in the younger population and those that
ambulate early postoperatively. Fortunately, PDPH is rarely seen
therefore following joint replacement surgery where the firmer
larger gauge cutting needle may be required to facilitate place-
ment beyond the osteoarthritic spine.
Choice of LA: the duration of block is largely determined by the
agent used. Whilst there is renewed interest in shorter acting
agents such as preservative free chloroprocaine for outpatient
surgery, lidocaine has an unacceptable high incidence of tran-
sient neurological symptoms and is no longer used. The majority
of spinal anaesthetics are now with bupivicaine 0.5%. This agent
gives the most predictable block of approximately 120 minutes
duration although a relatively slow onset time. Most bupivacaine
is administered as hyperbaric or “heavy” bupivicaine. With this
hyperbaric solution the height of the block is less influenced by
other factors and therefore is more predictable than with hypo or
normo-baric solutions. Hypobaric solutions are far less predict-
able but do have the benefit of inducing some unilateral anaes-
thesia in a nondependent limb such as fractured neck of femur
patients. Height of block is further influenced by position at time
of block and the pre-fixed first ten minutes after and to a lesser
predictable degree by age, site of injection and obesity.
Epidural: the indications and popularity of epidurals for ortho-
paedic procedures have declined in recent years. There has been
recognition that the best analgesia does not necessarily produce
the best outcomes and it may not be too long before this is also
shown for general surgical procedures.
The advantage of an epidural, where the LA is placed in the
space extra-durally with a Tuohy needle between the liga-
mentum flavum and the dura, is that using a catheter technique
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 BASIC SCIENCE
the block can be established incrementally to achieve the desired
height and also kept topped up well beyond the few hours of a
single shot. The disadvantages though are potential patchy
blocks with “missed segments”, time to achieve adequate block
height and misplacement of the catheter. Epidurals are therefore
rarely used for anaesthesia but more as a method of achieving
excellent intra and postoperative analgesia. Unfortunately it is
this excellent postoperative analgesia with its concomitant motor
block which often produces a pain free but relatively immobile
patient with a potential subsequent delay in discharge. Other
secondary effects include the requirement of urinary catheteri-
zation and a potential increase in DVT and chest infections sec-
ondary to immobility.
Hyperbaric solutions are not used in epidural blocks as
altering baricity has no influence on epidural spread. As with
spinal anaesthesia, block height can be influenced and the
greatest influences of epidural spread and height of block are site
of injection and volume of injectate used. For orthopaedic
anaesthesia a lumbar epidural will always suffice for lower limb
and pelvic surgery as height of block does not need to extend
beyond the lower thoracic dermatomes. Further influences are
similar to those in spinal anaesthesia.
Safety and adverse effects: there is a common misconception
that CNB is safer than general anaesthesia but this is not sup-
ported in the literature. There are specific examples of periop
survival being influenced positively by spinal anaesthesia but
survival rates beyond the immediate operative period are
comparable. Whilst it may appear intuitive that avoidance of
general anaesthesia must be advantageous this does not take
into account both the adverse effects of regional anaesthesia
and the overall stress effects of surgery. There has been a lot of
recent literature regarding best practice in fracture neck of
femur patients. Whilst most authors recommend spinal anaes-
thesia plus or minus a fascia iliaca block, all recommend the
avoidance of significant and prolonged hypotension. Hypoten-
sion secondary to sympathetic block is the biggest drawback to
spinal anaesthesia and is compounded by the addition of gen-
eral anaesthesia. This combination is therefore best avoided but
this is not always possible in the agitated disorientated patient.
The commonest adverse effect of a central axial block is hy-
potension because when a block extends above T10 a sympa-
thetic block occurs with subsequent vasodilatation. Height of
block is the greatest influence of how much sympathectomy
occurs but the degree of cardiovascular compromise is further
influenced by pre-existing hypovolaemia, hypotension, treated
hypertension, age and the addition of general anaesthesia. Pre-
existing hypovolaemia is therefore an absolute contraindication
to central axial blockade.
Normal respiratory function is not affected by a normal low
spinal anaesthetic however patients with severe obstructive lung
disease who rely on accessory muscles of respiration may well be
compromised. The risk benefit ratio of spinal versus general
anaesthesia in patients with severe pulmonary disease will usu-
ally still come down on the side of spinal.
Cardiovascular function is however affected by spinal anaes-
thesia as already mentioned and therefore patients with signifi-
cant cardiac disease may well do better with general anaesthesia
if the height of block is such that significant sympathetic block is
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inevitable. If subsequent hypotension is well controlled (or no
sympathectomy occurs) central axial blocks, particularly low
blocks, are a very safe alternative to general anaesthesia in the
presence of cardiovascular disease. Significant aortic stenosis is a
relative contraindication to spinal anaesthesia as the fixed car-
diac output will not respond well in the presence of
vasodilatation.
It can be seen therefore that spinal or epidural anaesthesia are
ideal for patients with respiratory disease but less so for those
with significant cardiac disease. Of course many patients pre-
senting for orthopaedic procedures have both lung and cardiac
disease and therefore the decision is usually not quite so clear
cut.
Major complications of CNB have recently been the subject
of a UK national audit15 the results of which were that per-
manent nerve injury was approx three per 100 000 spinals and
paraplegia or death was approximately one per 100 000 spinal
anaesthetics. Notably two-thirds of initially disabling injuries
resolved fully.
Anticoagulants: postoperative thromboprophylaxis for major
orthopaedic surgery is now standard therapy because of the high
risk of DVT and PE following this type of surgery in an already at
risk group.
However because of the cohort of patients for arthroplasty
surgery many preoperatively are already on anticoagulants or
antiplatelet therapy secondary to comorbidities. Unfortunately
with central axial blocks and deep peripheral nerve blocks this
increases the risk of local/spinal haematoma with subsequent
risk of neurological deficit. AAGBI (UK)16 European and
American17 guidelines have been published, differing slightly,
principally because of the differing techniques of administering
thromboprophylaxis. Most regional centres have adopted their
own adaptation of these national guidelines but aspirin is never
a contraindication to RA. The choice of whether to still do a
regional technique on a patient who is anticoagulated or on
antiplatelet therapy such as clopidogrel becomes a risk benefit
analysis. If the patient’s anticoagulation does not preclude
surgery it is unlikely to preclude regional anaesthesia but
medico-legally it becomes difficult to justify as it is rarely
essential.
Compartment syndrome: acute compartment syndrome (ACS)
requires prompt recognition, diagnosis and treatment. The
question is does RA influence time of diagnosis and subsequent
outcome? A recent systematic review18 examined whether
modern acute pain management techniques contributed to a
delay in diagnosis. They found no good evidence of any adverse
influence of RA on compartment syndrome diagnosis but did
acknowledge that under-reporting is common and no compara-
tive trials have been published. There is evidence to the contrary
in that in the presence of RA if significant break through pain
occurs ACS must be considered and may aid diagnosis.
A note of caution however; a dense block of either a CNB or
PNB will delay diagnosis with its complete sensory and motor
block. Anaesthesia with long acting agents or analgesia with high
concentration LA should therefore be avoided. Withholding
analgesia (PCA or RA) has no evidence of benefit and is
inhumane.
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 BASIC SCIENCE
Spinal/epidural key points
C Most spinal anaesthetics are single shot with bupivicaine and last
approximately 120 minutes.
C Spinal but not epidural spread is influenced by LA baricity and
patient position.
C The commonest side effect is hypotension secondary to sympa-
thetic block and this makes pre-existing hypovolaemia a
contraindication.
C They are excellent for patients with respiratory disease but must
be used with caution in patients with cardiac disease.
C Unlike peripheral blocks, central block analgesia can be extended
without motor block by the use of opioids or clonidine.
C Delay in central block after thromboprophylaxis or antiplatelet
therapy is essential to avoid a spinal haematoma.
C In emergency cases an individual risk benefit analysis on such
patients needs to be done but RA is rarely essential.
C No evidence of influence on Compartment syndrome but dense
blocks must be avoided.
Local infiltration and LIA
“Fast track surgery programmes” are not new and are not
confined to orthopaedic surgery with Henrik Kehlet describing
multimodal strategies to improve surgical outcome in 200219 and
evidence of major enhancements with fast track surgery in
2008.20 The concept of local infiltration analgesia, LIA, in
arthroplasty surgery however warrants further detailed
discussion.
Kohan and Kerr,21 from Sydney Australia, have been credited
with the introduction of a fast track programme for lower limb
arthroplasty surgery, the central tenant of which is early ambu-
lation. This early ambulation, in the first few hours of the im-
mediate postoperative period, is possible because of excellent
postoperative analgesia with no motor block achieved by the
combination of local infiltration and a multimodal postoperative
analgesic regimen. It includes no epidural or peripheral nerve
blockade thereby minimizing postoperative motor blockade. The
technique involves a spinal anaesthetic for the procedure and
infiltration of all tissue planes with a mixture of ropivacaine and
two adjuvant, ketorolac and adrenaline. Initially an intra-
articular catheter was placed and used for reinjection 15e20
hours postoperatively. Most are able to walk with assistance less
than six hours postoperatively and within 22 hours
independently.
Whilst it is true to say their early reported but unpublished
results (usually personal communications) of discharge after
only one postoperative day have not been reliably replicated, it
was this innovative programme which has driven research.
Kohan and Kerr’s subsequent published results of between 41%
(total hip replacement, THR) and 51% (total knee replacement,
TKR) discharge after a single overnight hospital stay are a still a
target to achieve. The percentage of THR who stayed more than
three nights in hospital however was still 33%. This is often
overlooked and perhaps reflects the understandable bias of sur-
geons wishing to achieve early discharge with excellent patient
analgesia and satisfaction rates. It is still a target bench mark. For
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early users of the technique, three days also seemed to be the
ideal target to aim for as few centres in the UK had the ability to
provide physiotherapy and occupational therapy outside of the
hospital adequate enough to allow discharge before this period.
Over the last half decade however, many centres are now
achieving even earlier discharge rates in the straight forward
primary arthroplasty patients. Most centres are no longer using
postoperative intra-articular or wound catheters to continue the
LIA as standardized parenteral analgesic regimens have
improved.
Why then has this not become the sole standard and why do a
third of THR patients stay more than three days? The answer is
that what Kerr and Kohan have achieved is not the perfect
analgesic regimen but an understanding that a rethink of the
whole postoperative programme was required as per Kehlet’s
ideology. It is no longer necessary or desirable to have patients
rehabilitate when they are ready or when a motor block dictates
and that outcome may well improve if early mobilization and
subsequent discharge is sort. What ever analgesic regimen is
chosen, for patients to ambulate early they must be adequately
analgized with no residual motor block. Despite the hype it is
probably not the immediate (within four hours) mobilization that
is important, however impressive this appears, but the emphasis
on excellent analgesia and early mobilization and the setting of a
programme that facilitates physiotherapy and occupational
therapy in the early postoperative phase. Regional anaesthesia by
any technique must therefore be adapted to allow this early
mobilization and this therefore precludes the use of a post-
operative epidural and long lasting dense nerve blocks. Stand-
ardised postoperative analgesia must be regular and not PRN and
it must be multi-faceted (i.e. not opiates alone). There is some
evidence that the use of a spinal anaesthetic followed by a multi-
modal regular analgesic regimen without LIA provides the same
analgesic scores as with LIA in hip arthroplasties and may
eventually preclude the use of LIA in THRs.
LIA key points
C Should not be considered just a regional anaesthetic technique
but part of a whole fast track programme.
C Early mobilization achieved because of excellent analgesia
without motor block.
C Technique involves infiltrating the whole operative area with
ropivacaine, ketorolac and adrenaline.
C The efficacy and use of intra-articular catheters for top ups has
been questioned.
C The target may be that approximately 50% of arthroplasty pa-
tients can be discharged after only 1 overnight hospital stay.
Nerve and plexus blocks
The practice of peripheral nerve blocks has grown exponentially
in the last two decades. This is principally because of the drive to
day-case surgery but also because orthopaedic anaesthesia has
become a subspecialty in its own right with the availability of
ultrasound. Their opiate sparing effect increases patient satis-
faction rates and for day-case surgery decreases inpatient
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 BASIC SCIENCE
admission rates. There is evidence that peripheral nerve blocks
improve surgical outcome both in upper and lower limb surgery
principally on the range of movement achieved. At first glance,
peripheral nerve blocks appear to be the ideal method of anal-
gesia and they remain so for upper limb procedures. However as
previously discussed, if motor block is allowed to persist, reha-
bilitation for lower limb surgery may be inhibited. This does not
mean peripheral blocks are no longer the ideal for knee surgery
in particular but that care has to be taken to ensure a dose and
concentration of LA minimizes long lasting motor block.
There are too many nerve blocks to go into any detail but
individual blocks will be considered under specific surgical
procedures below. The general practice of nerve blocks including
localization, safety and efficacy and needles used will be
described.
Efficacy and safety: the greatest influence on efficacy is experi-
ence of the operator what ever technique of localization is used.
Different studies are therefore difficult to compare but in general
a failure rate of 5e10% is the norm with approximation to but
not reaching 100% success in very experienced hands. Some
techniques which are still practised such as single shot axillary
brachial plexus blocks, will always produce a low success rate
(approx. 60%) because of a failure to realize the technique’s
limitations.
The two major safety complications are LA toxicity and nerve
damage. All peripheral nerve blocks have complications which
can be reduced but not eliminated by basic practices.
There are two types of nerve damage which may occur,
temporary neuropraxia or the potentially permanent axonotm-
esis. The former is very common and usually caused by direct
needle trauma. This can be reduced by not eliciting parasthesia,
not searching for a low threshold current and possibly by using
ultrasound as the needle can be directed away from the nerve.
The latter, axonotmesis, is usually caused by intrafascicular in-
jection with a pressure effect causing ischaemia. This is a rare
complication in the order of one in 10 000 regional blocks
although this may be significantly higher in the smaller nerves
such as the roots of the brachial plexus. This can be reduced
again by avoiding direct nerve contact, not using approaches
where the nerve is already stretched, not injecting under pressure
and not injecting if the awake patient complains of pain. With
ultrasound it is easy to see the margins of nerves and aim away
from them. Unfortunately however many anaesthetists insist on
placing their needle tip immediately adjacent to the nerve with
an in plane technique and recent articles have shown that intra
nerve injection is subsequently and unnecessarily common.22 It
is likely that in large nerves with a lot of connective tissue,
intraneural injection, i.e. sub epineurium, is common but actual
intrafascicular injection is fortunately very rare.
The second important complication is toxic levels of LA pro-
ducing CNS and CVS collapse (Table 1). Toxic levels can either
be achieved because of an overdose of drug or more commonly
by rapid level increases secondary to intravascular injection. It is
therefore a minimal standard to have reliable venous access
before any peripheral nerve block is performed.
The degree and length of CNS and CVS collapse is dependent
on the LA used. Although maximum doses are quoted they are
only a guideline as the absorption rate is dependent on site of
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Maximum recommended doses of LA
LA Max dose without Max dose
adrenaline with adrenaline
mg/kg (mg) mg/kg (mg)
Lidocaine 3 (300) 7 (500)
Bupivacainea 2 (150) 2 (150)
Ropivacaine 3 (200) 3 (200)
a
Includes levo-bupivacaine.
Table 1
injection. It is not the maximum dose that is important but the
maximum plasma level of drug with drugs rapidly absorbed from
the pleura (and of course intravascular) for example compared
with intra-articular. Most maxima quoted are by the manufac-
turers and not based on clinical trials and quoted maxima vary.
There has been an increase in use of the newer and safer long
acting agents such as levobupivicaine and ropivacaine in pref-
erence to bupivicaine. However these agents may still produce
collapse and there is some evidence that the use of intralipid
during cardiac resuscitation is beneficial. CNS collapse usually
precedes CVS collapse and may have warning signs such as
circum-oral tingling but this is rapidly followed by a seizure if
levels continue to rise. It is this initial warning sign that is lost if
the patient has already been anaesthetized or heavily sedated but
this knowledge has not been translated into any evidence of
more frequent toxicity in the anesthetised patient.
Nerve localization: peripheral nerve stimulation was the main
stay of mixed nerve localization for the last 30 years. This
involved the application of a stimulating current of the order of
1.0 mA applied via an insulated needle so that only the tip is
exposed maximizing current density. A reduction in the applied
current to a threshold current required to stimulate muscle
contraction allowed approximation to the nerve (Coulomb’s
law). This threshold has been taken a little further to suggest a
very low stimulating current, i.e. <0.3 mA, may indicate nerve
epineurium penetration and possibly an increase in risk of axo-
notmesis but this has little clinical evidence base. Unfortunately
even with a low threshold current and the needle tip in close
proximity to the target nerve, the needle tip and therefore spread
of LA may be in the wrong tissue plane and block failure the
result.
Over the last 15 years there has been an increase in the use of
ultrasound for nerve localization and in the UK this has become
the norm. Ultrasound has the benefit that both the target nerve
and the needle can be visualized. Whilst this may suggest it to be
a safer technique because nerves and vessels can be identified
there have still been reports of both nerve damage and intra-
vascular injection occurring with ultrasound. Fortunately both
complications, although catastrophic, are rare and it cannot
therefore be shown that one technique is statistically safer than
the other however obvious it may appear.
Ultrasound does allow visualization of tissue planes and the
spread of LA. This has led to a change in practice from aiming the
259 Ó 2016 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE

needle directly towards a nerve and placing it as close as It should be noted that because of a series of five serious
possible, to now aiming next to nerves but in to the same tissue untoward incidents in the United States, the ISB is the only block
plane. This will improve block success rates and enable better that the ASRA guidelines say must be done on awake patients.
teaching of techniques and therefore risk benefit ratio should There is no such consensus in Europe and these guidelines did
improve. Ultrasound has also allowed new techniques and ap- not take in to account ultrasound.
proaches to be described. There is some evidence that a suprascapular nerve block
alone provides analgesia of the shoulder but it is inferior to the
Upper limb interscalene block and cannot therefore be recommended. Intra-
articular or subacromial LA appears to have little benefit over
All regional anaesthesia requires a detailed knowledge of the
placebo.
nerve distribution of the limb and this is especially true of the
The ISB will not block the lower trunk (C8 and T1) and its
upper limb. There is no blanket block which is all encompassing
divisions. It cannot therefore be used alone for surgery of the
and so the regional anaesthetist has to have a detailed knowledge
hand or elbow (Figure 2a and b).
of the brachial plexus and its surrounding anatomy.
The brachial plexus and its terminal branches are easy to Elbow and distal arm
visualize and identify with ultrasound and this is therefore For surgery below the shoulder a supra-clavicular, SCB, or
becoming the gold standard for brachial plexus blockade. axillary brachial plexus block, ABPB, are ideal and again are
aided by ultrasound. The infra-clavicular approach is now less
The shoulder
commonly used because of its proximity to the pleura but is
The innervation of the shoulder is from the axillary and supra-
similar to the SCB. The SCB has been named the “spinal of the
scapular nerves derived from the upper trunk of the brachial
arm” as it is the only site where all of the trunks and divisions are
plexus. The area medial to deltoid is however innervated by the
in close proximity lying superior lateral to the subclavian artery.
supra-clavicular branches of the superficial cervical plexus and
Even here it is a two injection technique. The C8/T1 lower trunk
will require additional LA if the surgical site extends medial to
has to be identified separately as it begins its descent behind the
the delto-pectoral groove.
1st rib by passing behind the subclavian artery to become the
For shoulder surgery there is only one block that will reli-
medial cord (and subsequently the ulna nerve).
ably anaesthetize/analgize the shoulder and that is the inter-
The SCB does carry a small risk of pneumothorax and
scalene, ISB. C5 and 6 roots are blocked as the upper trunk lies
vascular puncture and this makes ultrasound an invaluable aid.
between the middle and anterior scalene muscles in the neck.
Because of ultrasound, the use of the SCB has become much
Lower brachial plexus blocks near the clavicle are possible but
more popular in hand units where previously it was out of favour
do not reliably block the suprascapular nerve as it arises from
(Figure 3a and b).
the upper trunk fairly high in the neck and gives a sensory
The axillary block has become at least a three if not four in-
innervation to the posterior capsule of the shoulder. A single
jection technique because of the unacceptable levels of missed
shot nerve block gives up to 17 hours analgesia and is therefore
terminal branches with the original single shot technique. LA is
excellent for many day case procedures. Unfortunately shoul-
placed around the ulna, median and radial nerves separately as
der surgery is particularly painful and this pain often exceeds
well as the musculo-cutaneous nerve as it lies away from the
24 hours.23 This has led to the development of interscalene
artery between the biceps and coracobrachialis muscles. Recent
catheters which, providing there is robust support in the com-
studies have refuted this suggestion however, and single shot
munity, are safe to be continued out of hospital following early
blocks deep to the artery have been shown to be as successful as
discharge.24 However this level of support has proved difficult
multi injection techniques albeit with large volumes.
to obtain in the UK and may not now be necessary as the
A recent development with ultrasound is the selective block-
addition of dexamethasone has been shown to extend the block
ing of nerves supplying the operative site with long acting LA,
to more than 24 hours.

Figure 2 (a and b) Ultrasound image of interscalene space using Sonosite S nerve portable ultrasound machine.

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 BASIC SCIENCE
Figure 3 (a and b) Ultrasound image of supraclavicular region using Sonosite S nerve portable ultrasound
machine.
such as the ulna and median nerves for hand surgery, and
blocking the remaining nerves with short acting LA to cover the
period of operation and tourniquet only.
Rescue blocks of peripheral nerves are easy to achieve at or
below the elbow if a partial brachial plexus block is insufficient
for surgery.
Key points in upper limb RA
C All approaches are aided by Ultrasound.
C All carry the risk of vascular puncture.
Shoulder
C Interscalene is the only reliable block but area medial to deltoid is
innervated by cervical plexus.
C Significant postoperative pain extends beyond the duration of
single shot block (consider interscalene catheter or
dexamethasone).
Elbow and distal arm/hand
C Supra-clavicular or axillary blocks are suitable.
C SCB is a two injection technique because of lack of spread of LA
to the lower trunk.
C ABPB is a multiple injection technique as a single injection does
not reliably spread around all terminal branches.
Lower limb
The sensory innervation of the lower limb arises from both the
lumbar and sacral plexus which though joined, are impossible to
anaesthetize with a single plexus block. It is for this reason that
central neuraxial block became the principal anaesthetic tech-
nique for lower limb surgery and until recently epidural catheters
for postoperative analgesia were common. There is little evi-
dence however that the preconception of CNB being safer or
more effective than GA has any basis as per a 2016 review.25
It is now more commonly the practice to provide anaesthesia
with CNB or GA but postoperative analgesia with spinal opiates
and/or peripheral nerve blocks or LIA, i.e. no epidural. As
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mentioned above the principle problem with any lower limb RA
is the associated motor block preventing early mobilization.
However peripheral nerve blocks have been shown to improve
perioperative outcomes after lower limb arthroplasty surgery so
should not be totally excluded.26 This lack of ambulation is far
less of a problem with soft tissue knee surgery such as ACL
repairs and indeed peripheral nerve blocks may facilitate early
discharge by minimizing parenteral opiates and their associated
side effects of postoperative nausea and vomiting.
Bilateral lower limb procedures are a particular problem for
RA as even single side procedures require near maximum LA
doses. CNB therefore remains the mode of analgesia most
commonly used for bilateral lower limb arthroplasty.
The femoral nerve block, FNB: is easy to achieve and success
rates have improved with the use of ultrasound. With ultrasound
the fascial plane between the fascia iliaca and the iliacus muscle
is easy to visualize and lateral spread of LA towards the lateral
cutaneous nerve confirms that a large volume FNB is a two in
one block not three in one. There is little difference between a
“fascia Iliaca block” and a femoral nerve block, the former being
used in the preoperative setting of fractured neck of femur pa-
tients. In some centres catheters have been placed in this fascial
plane to prolong the block. Despite the use of low concentration
LA, motor block is still a potential problem with catheters but
discharge home only one day post TKR has been achieved with a
catheter in situ.27 It is true to say that because of the mobilization
issue, femoral nerve blocks are becoming confined to soft tissue
surgery only in many centres(Figure 4a and b).
The adductor canal block, ACB: is a recently popularized block
that is still finding its place in regional analgesia for orthopaedic
surgery. After the femoral nerve splits the saphenous nerve fol-
lows the superficial femoral artery in to the adductor canal and is
visualized with ultrasound. The advantage of this block, which is
predominantly a saphenous nerve block, is that if done with
small volumes (less than 10 ml) little or no motor block occurs.
Of course only the medial and anterior knee (as well as antero-
medial lower leg) is analgized but the advantage of no motor
block may outweigh the disadvantage of less analgesia in knee
surgery.
261 Ó 2016 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE
Figure 4 (a and b) Ultrasound image using a GE LOGIQ E machine of in plane femoral nerve block showing LA
spread under the fascia Iliaca.
The sciatic nerve block, SNB: is less easy to achieve in inex-
perienced hands. Above the popliteal fossa it is less easy to
define using ultrasound and access to the nerve can be difficult.
Despite its significant innervation of the posterior capsule of the
knee and the tibial plateau, most studies have failed to show its
efficacy following TKR perhaps because of the high failure rate of
this block. It is not therefore recommended in the PROSPECT
review.28 However in experienced hands the SNB is an excellent
block for analgesia for a large area of the lower limb. In combi-
nation with a FNB, complete knee analgesia is achieved with no
opiate requirement. Again the prolonged nature of this block
makes early mobilization difficult if high concentration long
acting LA is used. The combination of a relatively high failure
rate, the lack of evidence of efficacy and the inevitable delay in
mobilization has virtually led to the abandonment of this pro-
cedure for surgery at or above the knee except for amputations.
A distal SNB at the popliteal fossa causes far less problems
with mobilization is easier to visualize and do with ultrasound
and it therefore remains the main stay for analgesia for major
foot and ankle surgery.
The hip
The innervation of the hip joint is from the sciatic, obturator and
femoral nerves and the overlying skin lateral to the joint the
lateral cutaneous nerve of the thigh (LCN). Because of this,
multiple innervation peripheral nerve blocks are not ideal for hip
surgery although significant analgesia is achieved with a lumbar
plexus block when combined with a high sciatic nerve block.
The lumbar plexus block is a facial plane block of the lumbar
plexus roots within the confines of the psoas muscle. It has the
advantage of being a single shot block for femoral, obturator and
LCN. However it has the significant disadvantages of high vol-
ume of LA required and unpredictable epidural spread.
Spinal anaesthesia, with or without LIA, when combined with
spinal opiates is likely to become the gold standard for hip sur-
gery analgesia as it provides excellent analgesia without pro-
longed motor block. However similar results for fast track
surgery with discharge on day one have been achieved with short
term epidural analgesia in hip arthroplasty surgery.29 It is quite
possible therefore that early mobilization and discharge can be
achieved in hip surgery what ever technique is employed as long
as long acting motor block is avoided.
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The knee
The innervation of the knee is from the femoral and the sciatic
nerves. Historically it is believed that the obturator nerve gives a
variable sensory innervation to the medial knee however the
clinical evidence for this is poor. Unlike the hip, complete anal-
gesia of the knee is possible with just two peripheral nerve blocks
although the addition of a sciatic nerve block to a femoral nerve
block remains contentious as discussed above. The PROSPECT
working group review, published in 2008, supported the use of
GA plus a single shot femoral nerve block or spinal anaesthesia
plus spinal opiates. Unfortunately, this group has not considered
LIA in their review.
Total knee replacement surgery generally is more painful than
total hip arthroplasty. The dose of intrathecal morphine required
is significantly higher than for hip surgery and as the concomi-
tant side effects increase so does the risk benefit ratio.
It does appear that analgesia is more difficult to obtain with
knee arthroplasty and hence the continued popularity of pe-
ripheral nerve blocks (femoral or adductor canal) for this type of
surgery. For the anaesthetist it is a balancing act between
adequate analgesia to allow mobilization and too much analgesia
preventing it. The concept of no pain after major joint surgery
should perhaps be replaced with pain control adequate enough to
facilitate early ambulation in relative comfort rather than the
search for zero pain.
Analgesia and early discharge for soft tissue knee recon-
structive surgery can be facilitated by a femoral nerve block
alone. Some centres in the US discharge ACL patients with
femoral catheters but in the UK a single shot femoral block is the
norm and this does not prevent discharge on day of surgery
despite the loss of motor function.
Foot and ankle surgery
The innervation of the foot and ankle is predominantly from the
terminal branches of the sciatic nerve. There is a small variable
but never the less significant supply from the saphenous branch
of the femoral nerve from the medial malleolus to the base of the
first metatarsal. Excellent analgesia is therefore achieved either
by blocking the sciatic nerve in the popliteal fossa or for foot
surgery by blocking the terminal branches at the ankle. The
popliteal block is amenable to catheter placement to prolong
analgesia. The saphenous nerve can be blocked medial to the
262 Ó 2016 Elsevier Ltd. All rights reserved.
 BASIC SCIENCE
knee or at the ankle adjacent to the saphenous vein and more
recently by ultrasound in the adductor canal. Major foot surgery
can therefore be achieved as day case procedures and can be
done under block alone with little motor block delaying
discharge.
Key points in lower limb RA
C All procedure possible under GA or central neuraxial block.
C Innervation of all major joints is from lumbar and sacral plexus
making single plexus block inadequate.
Hip
C Because of multiple innervation spinal anaesthesia  opiates 
LIA is the preferred technique by many.
C Alternatives include lumbar plexus block.
C Early ambulation and discharge possible in most cases if long
acting LA avoided.
Knee
C TKR generally more painful than THR.
C RA presents a more difficult balance between adequate analgesia
to facilitate mobilization and too much motor block inhibiting it.
C Adductor canal block has the advantage over a femoral block of
no motor block despite significant knee analgesia.
Conclusion
RA in orthopaedic surgery has moved to become more efficient,
safer and evidence based. There is now a realization that simply
giving a general anaesthetic is no longer the best technique for
the vast majority of major orthopaedic procedures as regional
analgesia will improve surgical outcome as well as patient
satisfaction. However, particularly in lower limb surgery, long
acting RA may well be detrimental to the patient if early post-
operative mobilization is inhibited by a dense regional block. RA
must therefore be considered a balance both by the surgeon and
anaesthetist. It therefore is essential that both members of the
team have a treatment plan that includes intra- and post-
operative needs and aims and neither is blinded to the other’s
requirements. A
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