S1:E5 "Hip-Op-Hooray! (Nerve blocks for hip surgery and hip fracture)"

Is a painting your thing, or are you more sci fi with Luke and Leia? I'm Amit Pawa. From lumbar plexus to, well, virtually nothing, there are plenty of ways to say hip hop hooray. I'm Jeff Gadsden, and this is Block It Like It's Hot. Hey, Jeff. 

You know what? It's a great time to be alive as we are here recording episode five. We're gonna be dropping some tips on what you can do for your hips. You ready for hip hop hooray? Nice. 

Wow. That instant rhymes at the very beginning. Yeah. Love the rhymes and the title. Hip hop hooray. 

Kinda works on two levels. Right? That celebratory vibe. Hey. We we're excited about hips. 

We love we love hips. Naughty by nature, callback, love it. Well, I was gonna say hip hop hooray, Sean, but then I was thinking that was too complicated. Hip array, Sean. Yeah. 

Yeah. Yeah. That's that's sort of next level. Let's wait let's wait for season two before we start getting too complicated with the titles. Listen. 

I'm happy that I'm happy you like the title. That was that was my inspiration. You're right, on both levels. So listen, man. It's been a couple of weeks since our, last podcast. 

Tell me what you've been up to. I'm curious to know. That lots has happened. It's, always busy. I I was just got back this morning from Las Vegas. 

Wow. Yeah. I had a meeting about orthopedic value based care. Real lot of really cool ideas and people actually. There's a there's a good showing of anesthesiologists, but what I like about this meeting is there are mostly orthopedic surgeons administrators and some other stakeholders who are, you know, all kind of like shooting for the same goal, but it's it's different ask answering questions on a panel when your audience is not blockers like me. 

Right? But that but that's but that must be a really great opportunity to get our voice heard by, by that group, by that population. It's really important that they know what's what's available because as I've heard, as I've been looking into regional anesthesia in The United States, there's a great variety, of levels of regional anesthesia at practice depending upon where you are. So it must be a great opportunity to talk about what can be done. Right? 

Well, totally. And, you know, I I shared with that audience at at one of one of the talks I gave, kind of the recipe we talked about with the knees. And Mhmm. And and actually share with them your story about your surgeon, how he came back so impressed that first day. And it resonated. 

Like, lot of people came up afterwards and said, hey. I I need to get our anesthesia group doing all this stuff. Can we use you as a resource? And that that sort of thing. So that was it was cool. 

It was cool. That sounds very, very exciting actually. Vegas Vegas is a a trip though. I mean, we I went for I went for a run with a friend on Saturday morning, and he's a bit of a nut. We he said, meet me in the lobby at 05:45. 

I'm like, oh, come on. And so but what was neat about it was, okay, the strip to ourselves. We ran up the strip and back, and, you see some you see some things, man, at 06:00 in the morning on the Las Vegas Strip. I can only imagine, but I'm kind of guessing they're not necessarily things we wanna share on here. Well, there's there's there's, all range of of PGR rated stuff going at least. 

You know, you might see a couple of homeless guys fighting. Okay. Dead body. I I wasn't sure. Maybe. 

Oh my goodness. No. But it was cool. Start I started to run out with all the lights. Yeah. 

Lights are flashing, and it it felt like you were at, you know, it's nighttime in Vegas, and then the sun came up on the run, and we came back and arrived back at daytime. So it was fun. Very, very cool. What have you been doing? Well, actually, my my I think my couple of weeks has not been quite as exciting as that, but I've had some great opportunities, and they were exciting. 

So we had a local teaching and training day for our registrars in the region. So I actually managed to get together with some of my colleagues from Guy's and St. Thomas's, someone called Megan Smith, who's a consultant and a barrister. So she does law and regional anesthesia. She was talking about legal aspects of regional anesthesia. 

Desire on Wochay, who is massive into, obstetrics and regional. She talked to ambulatory spinals at this study day. Nice. And Toby Ashkin, one of our REUK board members, was actually talking about regional anesthesia in patients on anticoagulant medication. So that was really fascinating. 

But the reason the meeting was so exciting was that we got a chance to focus on some of those core, as we call them, REUK plan a blocks, and infuse them and teach them about that. So it was a cool it was a cool day. I managed to recruit, I hope, a few, regional anesthetists. I also had a couple more free trainee free days. I didn't have trainees with me. 

So, again, I had to do all the the blocks. You know? I had to see the patients, draw up the the drugs, and talk to myself as we said last time. Yeah. And I I got caught out by a well, I nearly got caught out by a cheeky tibial nerve when I was doing an ankle block the the other day. 

Cheeky tibial nerve. Cheeky tibial nerve. They these guys can be cheeky. We Like, wasn't in the right spot? Completely wasn't. 

You know you know, sometimes the flexalisis longus Most cheeky tibial nerves. Tendon can can masquerade as a tibial nerve. And this time, the tibial nerve was anterior The cheek. To the posterior tibial artery, and that was naughty. But thankfully, I followed some of our basic rules, and I managed to find I managed to find it. 

Oh, I hope you taught that nerve a lesson. I did. Yeah. Good. I surrounded it. 

With local anesthesia. Oh, that fine. Alright, man. So what do our listeners have to look forward to today? Well, you know, Jeff, we've had some Twitter follower feedback, and they wanted us to cover the same style of discussion that we did for our knee episode, episode, but this time talking about hip arthroplasty surgery. 

So, you know, we set the precedent with knees. We better not, disappoint. So we're gonna be talking about hips. But you know what, Jeff? Before we get stuck in, we've had some great questions and interaction online. 

Shall we do some shout outs? Oh, foe show. We we have Foe show. Oh, foe show. We have had some questions from Twitter regarding, guess what, ESP. 

First from Stefan van Herweig from Belgium and Batul Basaran from Turkey. So Stefan says he stopped performing lumbar ESP after an episode of lower limb paralysis. And after reading some studies showing no benefit over multimodal analgesia. And Batool quotes the varying study outcomes as well and thinks that, like, ESP might help, but wonders about a T lip block and what if it might be better. And so what do we think about that? 

Well, listen. Just help me out here because I know so I'm definitely no TLIP expert. So TLIP is thoracolumbar what is the IP? Internet protocol? I don't even Yeah. 

Intellectual property? No. I think the it's it's Thoracolumbar Insert interfacial Yeah. I think that's it. I think it's Thoracolumbar interfacial play. 

Now listen. I I I've heard Kijin Chin talk about this. He's got some great videos on that. I I I've yet to I I don't do them. I've done lumbar ESPs. 

And as yet, so far, I have not had an issue with lower limb paralysis. I'm just trying to think, that must be really quite bad luck with a lumbar ESP to get lower I would have to think so. I mean, we've we've done three years now of this, lumbar ESPs for spine surgery regularly and have not had a problem with epidural spread or interference with neuro monitoring or patients waking up and, ugh, it looks like we got, you know, we we got the ventral roots, and they've got a lumbar plexus block. So because that's gotta be quite hard, Jeff. Right? 

You know, we gotta get deep to that fascia. That fascia is quite thick in the lumbar region. Right? So you gotta get deep to it and into the posterior aspect to the psoas muscle and inject quite a lot like doing an intertransverse process block but in a lumbar region. Yeah. 

I think that's it. Right? So I think as we talked about it on the ESP episode, in contrast to what I'm trying to do and what you're trying to do with your Yeah. Pepper pot the the fascial plane and get get stuff you know, but get get stuff in front of the, you know, that fascial plane. So it's almost like an MTP. 

I'm not trying to do that for any of the spine stuff. I'm I'm truly hitting the dorsal surface of the transverse process and keeping it in in the ESP muscle and lifting. In terms of TLIP, I have tried it. I'm not sure if it's just our patient population, or maybe I'm just not very good at ultrasound. I think, you know, I have a hard time finding a fascial plane in a lot of people in that muscle group. 

Like, I put the probe on, and I'm like, okay. Well, there's the ESP muscle, but whether I can find the iliocostalis versus the longissimus or, you know, I I'm like, dude, hit the bone and just put your local there. Plus, it it's so much easier to teach a trainee just to hit the bone. Right? And now I'm now I'm confused again because if I can't even remember what the acronym's supposed to stand for, there's literally no way I'm gonna be able do the block. 

But I so it could be something thor thoracis, longissim. Anyway, I yeah. I agree. When I stick the probe on the back, I have not, with confidence, been able to to regularly identify them. But it may be a, you know, a product of the fact that I I don't I haven't tried hard enough. 

I haven't practiced hard enough. So I think, you know, we're we're both of us are intrigued by the low limb weakness, that Stefan has had. But, I'm not definitely not a TLIP expert, and you'd probably say you're not either. Right? No. 

And the other thing I will say in response to that question, and I'm thinking about it, is there are anatomic, obviously, differences. And some patients show up with previous spine surgery and, you know, local contract to places where you don't expect it. So it's not I I I hesitate. I don't wanna imply that there is a technique issue with Stefan's approach or anything. No. 

Sometimes the patient's body does weird things with local. Completely. And I think I think that's a I think that's very fair. Well, listen. I'm moving on. 

Tanya Selak, who is known on Twitter as Gong Gas Girl, from Australia, but, originally in New Zealand, was shocked. She was shocked by the Gadsden self ESP block and was surprised about my block failure when I when I sort of fessed up to having a a block that didn't work. So we're both delighted that Tanya has listened in, and is supporting us down under. Yeah. Totally. 

Tanya, if you only knew half of the shenanigans that go on at the duke wrap block suite. I'm trying to work out if I could say shenanigans in a naughty accent. I I think he just did. I mean, check. Alright. 

On you, mate. Sorry. That was the accident. One more shout out from Teresa Pereira from Portugal who loves the show. Thanks, Teresa. 

And is also a Star Wars fan. Her cats are called Luke and Leia. Yeah. And she says despite having watched the Duke videos that are translated into Portuguese, she's gonna go back to the originals just for the sound effects. I love that. 

Thanks, Theresa. I, you know, I really am so fortunate to have an amazing team of Portuguese anesthesiologists that have done that done those translations. I'm really so grateful, and, I'm glad that it's be it's a resource for all the Portuguese speaking people around the world. Alright, Jeff, man. Let's get into the main episode. 

What do reckon? Let's do it. In the same way that we started off the knee episode, what I want to know is if you were having your hip replaced, what would you want? Let's start off first. Would you want a GA or would you want a spinal? 

This is so I I'm team spinal for me. Yeah. And and I think that more so even more so than knees, the evidence supporting a safer procedure under spinal is is robust enough in in in Uh-huh. Hips that I have no there. Right? 

And when talking about SAFE, you're talking about complications. You're talking about mortality. Are you looking at the the stuff that came out of Stavros MEMSUDA's work? Or what what are you referring to exactly? Yeah. 

There's another there's a number of of big data studies looking back at, you know, tens and tens of thousands of patients and Yeah. Things like respiratory complications, bleeding, DVT, cardiac complications, big time morbidity that you you care about. Right? It's not just, well, pain scores were two versus three. Okay. 

So so so your your team's spinal. And, you know, I'm again, I'll tell you the one thing that that's confused me about hips, and I'm I'm very happy to say and to to own up to the fact I'm I'm confused. I have seen so many variations in practice when it comes to anesthesia for, for hip surgery that I I'm not convinced that there's an optimal or an ideal way because I've I've worked with some surgeons who are absolutely adamant that we're not allowed to put any blocks in, and they can do everything with, with their own local infiltration. And I've worked with other surgeons to say, I don't mind. Do what you want. 

Put in a fascial iliaca. And I've seen some surgeons actually ask for a GA plus a spinal. They definitely don't want the patient to be awake. They want monitored anesthesia care. They want the patient to be asleep, but they want the benefit of having a spinal. 

So this is where I'm totally confused. So I think if I my head is telling me that I should ask for a spinal, and I think I probably would. Okay. I'm I'm slightly nervous about the additive effect of a g a general anesthetic plus a spinal from a cardiovascular point of view. So, I think I'm probably I I am team spinal, but I I do wanna get up and about straight afterwards. 

So I think I'd much rather get up and about and reduce my risk of, thromboembolic events afterwards. So, you know, I this is coming down to that whole analgesia versus mobility Uh-huh. Right here. Yeah. Because there are things that we can do that can make people feel really comfortable, but then maybe they won't mobilize afterwards. 

What's important to you, do you think? Do you yeah. I'm just gonna have you go back. Did you just say a a spinal plus general anesthesia? Is that an option that people are doing? 

Oh my goodness. Yeah. They may be a minority, but there are definitely some surgeons that are asking for the combined approach of a spinal anesthetic plus a GA. Okay. Interesting. 

I mean and to be fair to be fair, do To be fair. We we do our spinalists with hips with propofol sedation such that the patients are not we're not engaging in sparkling conversation with them. So I you you can you can say that's a general, but there's no airway device and etcetera, etcetera. Are you is that what you're talking about? Or No. 

No. No. So I so I think we could probably have a whole episode on monitored anesthesia care and the difference in practices between the the, you know, North America and and and The UK. Now I'm talking about people are doing a proper general anesthesia. So an endotracheal tube or a supraglottic airway in addition to the spinal. 

And that may be due to the fact that the whole concept of GAWA, g a, without an airway, is not something that we that we're very big on here because of the potential risk of complications. So we don't do a lot of I think is it GAWA g general anesthesia without airway? Power no like GAWA. Yeah. Power definitely no like GAWA. 

Okay. No. And listen. And that I think that's that is a factor that we should touch on is that if this procedure ends up outlasting the spinal, now I have to deal with an airway in the lateral position, in an obese patient, under the drapes, etcetera, etcetera. And so this adds a layer of complexity. 

That that does become a a consideration preoperatively in terms of my thinking. I think that's cool. Let's let's shelve that. We'll chamber that and use that as a as a a topic for later. Yeah. 

Analgesia versus mobility. Well, you know my feelings on short acting spinals. And so if if I can do a lidocaine or mepivacaine Do you mean ambulatory spinal? Ambulatory. See, again, it just sounds better with the British accent. 

Ambulatory spinal. Yes. Okay. Yeah. No. 

I'm a total fan. And so that is that is, again, our our now our default. So lidocaine or Mepi But, again but let but let me get my head around this. So if you're gonna do that, you have got to ensure that your surgery is gonna be a a fixed duration. Right? 

So you gotta get the spinal in the right time. Gotta get into the OR or to the anus or to the Operating Theater, and their surgery's gotta start right on time, and it can't outlast the the the duration of action of the medication. That makes me nervous. A big part of my day now is texting. Get on a text thread with both ORs, and there's the circulating nurse and the either the resident or the CRNA in the room and my block team. 

So it's a big big text chain. Alright. We're closing, on skin, rolling, and that gives us our cue to do, you know, do the spinal for the next one. And so the totally fair comment though because has it failed there? Of course. 

And then, you know, a tray is opened up in the OR that's like got a dirty instrument or something. And now we're eating it at the spinal time while we get that tray replaced. So What about now do you do that irrespective of who's operating? So will you always have the senior most surgeon doing the operating? So I guess what I'm asking is we we work in teaching hospitals, and we have, consultants doing the operations, and we also have fellows or senior registrars doing the operations, which can affect the operative time. 

So this is presumably, you have similar issues, and do you have to have these discussions and make plans accordingly? Well, it similar. But, I mean, like, between you and me and, I guess, all of our listeners now, we are there are surgeons who may not routinely get the job done in a hundred and twenty minutes. And so Yep. They we do have a cohort of colleagues, orthopedic colleagues I work with that will still get a bupivacaine spinal. 

Okay. Well, listen. Kind of on the same talk topic now. So I so so far, GADS has gone spinal, mobility, ambulatory spinal. So I know the answer to this, but I'm gonna ask it because, again, I don't think it's clear. 

Intrathecal opioids or not? And I know the answer, but tell say it to me. Tell it to me. No. No. 

No. I I don't like them. No. No. No. 

No. No. We can provide analgesia in different ways that don't have the side effect profile. Okay. And likewise, the same same, argument. 

I'm kind of guessing we're gonna get into what you're gonna do at the end. We're gonna get the Gansden recipe for, for hips right at end. So stay right to the end of the podcast to hear all that. I'm guessing you don't catheterize them because you get them to come in and take, go to the washroom or the bathroom and empty the bladder before you do your anesthesia. Right? 

Yeah. Exactly. Unless it's a planned big long revision that we expected to be, like, four hours. Yeah. It was this time when a part of our order set for the PACU patients were, after total joints was straight cath, the bladder, you know, at will. 

Yeah. And and so they were all getting and they're all getting a straight cath, which is, you know, part of the drive here is to avoid potential urinary tract infections. And so that's why we didn't get but got away from catheterizing them in the OR. So so that that rate has plummeted with the short acting spinal. That's really interesting. 

Now I don't want to give me the answers as to what you do, but I wanna know, number one, in addition to the spinal, do you addition do you deliver some additional peripheral regional anesthesia? That's question one. Yes. Uh-huh. This is gonna be exciting. 

And do you deliver the same peripheral regional anesthesia irrespective if they're having a spinal or GA? Because presumably, there must be some of your patients that get a GA. Of course. Yeah. I mean, there's some that come in on novel anticoagulants or refuse this bottle, and that so we have to have a a plan b. 

Yeah. Largely. Yes. Okay. Yep. 

Because I'm really excited about hearing all of this because I do a whole mix of things. I haven't got a fixed recipe, which is kind of why I'm hoping I can get some answers here. Like, come on, Jeff. Why isn't local anesthetic infiltration good enough? I've told you that there are some of my surgical colleagues that say, don't worry about blocks. 

I'll just do the local. So why isn't that good enough? Or is it? I don't know that it that it isn't, honestly. Like, if you have a so I our issue not our issue, I think a lot the issue at a lot of places is one of consistency. 

So if I hand an orthopedic surgeon a syringe and say, infiltrate the joint to your satisfaction and and I do it six different times, I'll see it six different ways of doing it. And so there are good infiltrators and there are what's the right word here? Orthopedic surgeons aren't patient creatures by nature. Right? So there's a lot of Mhmm. 

Squirty squirty, you know, or here and there and then inconsistent results. Where if if you do a ultrasound guided block of whatever type you wanna do Yes. Each and every time, I I'd be shocked if your blocks don't work the same way each and every time. Right? Mhmm. 

Mhmm. Okay. We have this back and forth with our surgeons sometimes because they'll they'll wanna go back to using infiltration with some sort of cocktail and and we'll have to sort of talk them off a ledge. It it ends up becoming a discussion about, well, how much okay. Let's if we're gonna do both, how much local are you gonna use and not Yes. 

We're gonna use and that sort of thing. Cocktails. I could use a cocktail right now, actually. I'd love a cocktail. Do you like yeah. 

Do you like cocktails? I do. Do you know who makes the best cocktails in my house? Tell me. Your wife. 

No. 10 year old son. Yeah. He he hold. He learned how he learned. 

I think he watched he watched a movie. I forget the name of the movie. Was some, like, action adventure movie where the one of the characters was a was a bartender. And then he he went went to his room, came back with a white shirt and a little apron on and Oh my started to started to, like, Google, how do I make a Manhattan? So he makes a mean Manhattan, man. 

Like, when you when when you come visit us Yeah. I'll get a hold to and Negronis. Those are his two. Manhattan, Negronis. My goodness. 

Wow. So he'll he'll, I'll sometimes get a message from him, somehow. I'm already back from work. And he said, dad, what do you want? I'll make you a cocktail for when you get home. 

You want a Manhattan or a Negroni? Oh my goodness. That sounds amazing. And and and he's self taught? Wow. 

Okay. We we our filters are obviously too good in our, on our YouTube at home. I don't think my kids will be able to get to get access to that, but maybe I need to relax the filters to allow them to do that. Well, listen. Seeing as we're kind of just changing topic for a second, I think it would be a good time. 

We last time, we forgot to have the competition question for winning a mug. So Oh, yeah. I think we're gonna run this competition now, and I've got a good question which will really work out who's been listening or not. So to be in with a chance of winning a Block It Like It's Hot Mug, we need to know, in episode two, to be in with a chance of winning a mug, where did Jeff say he just returned from where he was teaching cervical ESP blocks? So if you wanna answer that, they they gotta give us some answers. 

So how can they get these answers to us, Jeff? You can DM us to our Twitter account at Block It underscore hot underscore pod or the Instagram account, block it like it's hot, all underscores in between, or email us at block it like it's hot podcast, no apostrophes, at Gmail. Absolutely. So perfect. And what we'll do is we'll collect all of the names, put them in a hat or a a virtual hat, and we will pick a winner. 

So please please do get on with that and hope we love look forward to giving away some more merchandise. Awesome. Okay, man. Let's get back to let's get back to this this content. We hear a lot about anterior approaches versus the minimally invasive approach versus standard approaches, so MIS. 

So do you think that the type of approach has an impact on the regional anesthesia requirements? Yeah. To a degree, for sure. I mean, the tissue trauma and where it's happening, where it's occurring in in the soft tissues at least is is gonna be different. And and so, you know, so I think it's one of the whole drivers of the interior approach is that muscle splitting get down sort of with as little trauma as possible Yep. 

Get to the joint. But then once you get to the joint, though, then the joint's a joint. You're opening up the capsule. You're sawing out the bone, and you're putting in components. So, so that's still gonna hurt. 

It does have a a bit of an effect on our our block choice, but not as much as you'd think. I mean, I just told you we we do the same blocks every time, mostly. Yeah. Okay. Well, listen. 

Talking about blocks because we've got the option to sort of work out what, you know, what the gold standard is, and then we're gonna say, well, what's minimum? So let's assume that you're gonna give the patient a spinal anesthetic because we're kind of going along with that vibe. And I'll from my point of view, I'll be thinking that I'm doing a general anesthesia just to kind of give give, breadth here. What is the first block that you might add? We'll do a pang block. 

That's that's our that's now our go to. We were and we've gone through, like, the knees. I mean, the same story. We've gone through an evolution of how we're doing this. So What did you start with? 

Did you start with femoral or fascia aliaca, Or did you not you just skip those? No. No. No. We used we used both of those. 

Okay. Femoral, early on. Fascia aliaceae was fairly recent, actually. Uh-huh. Like a super inguinal fasciae. 

Yeah. I I I'm a fan of that block. I I think it's it's fun to do and it gets you great results. Of course, the issue is you're aiming to achieve a block of the femoral nerve. So, again, when our surgeons were really interested in getting them out the same day and mobilizing and doing rehab in the recovery room, that became inconsistent with, with that practice. 

So, so that's why we changed to the ping block. There were you know, I've done lumbar plexus blocks for these. Well, you know, it's interesting you should say that I remember watching the one and only Sandy Kopp, who was giving a lecture many years ago talking about her history or her experience in regional season. She was talking about how, at one of the institutes that she was working at, there was a variation in practice for hip arthroplasty, and she introduced lumbar plexus catheters as the gold standard that everybody got. And actually standardizing the care with the way that all patients were treated, way that the infusion rate was dropped at a certain point or stopped at a certain point to get patients moving, by the time they did ward rounds, etcetera, in the morning. 

It was fascinating. So I can see why lumbar plexus is was a was a great block. And in fact, during my regional anesthesia fellowship, the the guy who was running is a a a very, a very, incredible guy, a chap called Winston Cotino. So he was running the fellowship when I when I did it. He used to do nerve stimulator guided lumbar plexus blocks for every patient having hips. 

Oh, yeah. And in fact, he used to say yeah. And he said to me, you know what? Don't worry if you use muscle relaxant to intubate them. Just turn the current up and it will still work. 

And, actually, we intubate the patient. He'd then do a lumbar plexus block. He'd just crank up. I'm not saying this is the right thing to do. He'd crank up the current, and, actually, we'd still get twitches, and he never failed. 

He never failed. But having looked with ultrasound, I can't believe that I did it landmark with, with a needle now. I don't think I'd ever go that way, and I certainly wouldn't advocate necessarily doing, what what what he was doing back then. We'll do we'll do it every once in a while, lumbar plexus. Not not so much for our outpatient elective hips because, again, we we want them to get up and moving, more like big operations where they're gonna stay in hospital for a couple of days, and it's largely for MFB. 

Do you know MFB? F b. I I can only think of rude things. Oh. Well, I know your mind goes there. 

Maximum fellow benefit. So we we could do ephemeral, but, hey. You're a you're a Duke fellow. You're getting maximum fellow benefit today, buddy. Let's let's do a lumbar plexus. 

I like that. So let you know what I think we should do? We've just assumed that everybody knows what Peng stands for, and you said that's your goatee block. So Peng stands for the pericapsular nerve group. So that was a group that described this initial block. 

Right? And the whole idea of this block was to catch the articular branches for the anterior aspects of the hip joint. Right? Exactly. Yeah. 

So, pericapsular nerve group, but, I mean, this is one of the one of my favorite store. Phil Peng was the guy who innovated this. And so That's right. Man, to be able to get your your your surname as as an acronym that works for that. I'm trying to find something that works for Gadsden. 

It's just it's just I'm coming up blank, man. Gen genicular, anterior, direct It can be GA doesn't seem Oh. Oh, something like that. Would Now you got it. That's a that is it. 

Okay. The Gadsden approach. So, yeah. So, again, it represents a very similar journey or philosophy that we've been seeing with other blocks. Mhmm. 

Find an area where you can hit a bone, layer out some local there, and you're getting a motor sparing approach to the area they're interested in. So you get the articular fibers of the femoral nerve, the obturator, and the accessory obturator nerve as they come over the pubic ramus or under the pubic ramus as in the case of the obturator. So does a great job. We found that when we transitioned from supraginglinal fascia latae to pain Yep. Our surgeons didn't even know. 

They didn't notice the difference. In terms of in terms of the patient's Is that right? Responses. Yeah. They had the same same analgesic experience. 

But that that literally blows my mind because the next question I was gonna ask you was, now hold on. I is your surgeon doing local anesthetic infiltration as well? If you're so you're or are they letting you like the previous discussion we had about, you know, we're gonna do all the local. Are you guys mainly doing all of the local? Yes. 

Correct. Okay. So what about the lateral femoral cutaneous nerve distribution? So, you know, where you may be having an incision. Because for me, when I look at that diagram, that cross sectional view, when you when you weigh in and aim your needle down on the ileopubic eminence, you got out of the way. 

You got a femoral arch in the femoral nerve. But on your way in, potentially at risk of needle puncture, if you're not careful, is the lateral femoral cutaneous nerve. So what's to stop you from dropping a couple of mils by that bad boy on the way down to being pangtastic? Oh, pangtastic. You read my mind, man. 

That's exactly what we do. So we put we take a twenty mil we take a twenty mil syringe of point two percent rupivacaine with, one to four hundred thousand epi or 2.5, and we put 15 of that on the pang. I don't think you need much more than 15, to be honest, and then, save five for that, LFCN. That's your recipe, is it? That's our recipe. 

Yeah. That is really interesting. Of course, the the the beauty about the pang is you should be getting, as you said, articular femoral and obturation accessory obturator. You're adding in the lateral femoral for, for cutaneous issues with regards to the incision. So the only thing we're not dealing with, which may not be a not be relevant for hip arthroplasty is all the posterior innervation. 

Right? So we got sciatic. We got superior and inferior gluteal. And it does it matter that we're not getting those? Well, it didn't seem like it did matter. 

And then I I found a article that characterized the density of innervation of the hip capsule, and there's just so much more on the anterior, portion of it. The back is not that richly innervated as I I compared to the front. So so I think that's what that's why it works. So but I think we've we've just literally jumped and landed on the the the Ganzan recipe almost prematurely. Right? 

So paying an LFCN is your standard in addition to a spinal. Yeah. But I I need to broaden this out a bit because here's the bit that kind of really blows my mind because I'm hearing people using either the ESP block or the quadratus lumborum block for hip arthroplasty surgery, and I don't get it. I don't get it. So ESP, I I kind of do because, you know, for the reasons that we're talking about. 

But only really any really makes sense to me if that local anesthetic is really going across that thick fascia and and and getting down towards the lumbar plexus. Otherwise, why would you do an ESP, for hip arthroplasty surgery? But we know there's data on there because Ed Mariano, he's done some work, and they've changed their whole, hip arthroplasty pathway to ESP blocks. And quadratheclumbarum now listen. We're gonna talk about this in another episode. 

QL isn't a sole entity. I think Yeah. Depending upon where you put your local answer, you can get a different block. But I'm thinking if you're doing a quadracelumbarum block, set certainly a a transmuscular or an anterior caudate slum boring block. The whole reason we do that is to get abdominal analgesia. 

We don't wanna get so so so help me out. What do you think about this? I'm with you. I the ESP, I I think if you're getting any benefit out of that, it's one of two things. Either your local is getting ventral, and you're getting you're doing a weak lumbar plexus block, which should work. 

Right? I I think that would that would that would do it. Or there's there's something to and we talked about this in the ESP episode. There's there's a feeling that just anesthetizing the fascia of the thoracolumbar fascia may provide analgesia in some way, shape or form. So one of those and so I don't doubt that it works for some people. 

I just I it seems like a very indirect approach. Whereas the Hapeng seems to be, like, the most targeted distal approach to to this conundrum. But QL, don't get it also. To me, that's an abdominal block. And, yeah, you'll get you'll get t 12 and l one for sure, but that's just only part of it. 

Right? So I think if you're if you're using if you're calling it a QL and getting benefit for, for hip arthroplasty, what you're really doing is a lumbar plexus block. So therefore, you should call it a lumbar plexus block, but I might be being slightly controversial there. Daring discourse here. I like it. 

Yeah. Yeah. Well, I was gonna say, if you think I was being controversial there, just you wait. Just you wait. I think that we might be making this all too complicated. 

So I wanna tell you about three of my friends. In fact, one of them, I met the surgeon of this friend last I was at a party, and I met the surgeon of this friend last night. So I spoke to the surgeon thoroughly, but so we'll speak about friend number one who's the only person whose identity I'm gonna reveal. Friend number one is Alan McFarlane. Oh, nice. 

Very good friend of mine, current president of REUK. He works in Glasgow, and his colleagues have there have developed a day case total hip arthroplasty pathway. And so he's, they've developed it, and he's practicing it. And I'm gonna talk about what he does. So they use a spinal. 

They don't give any intrathecal opioid. They don't use any local anesthetic infiltration, and they get most of their patients out on the day case. The only thing they do do as part of their pathway, and this happened when they removed the intrathecal morphine, is they give three doses of modified release oxycodone. One pre op, one on the night of surgery, and one on the morning after. That's it. 

Three doses. But they do day case hip arthroplasty just with spinal and this multimodal analgesia. They also give Dex and and try to examine So that's patient's friend one. Okay? But I'm gonna give you the full sequence because I want I want you to hear the full progression the term we're working. 

Alright. I'll be really fast. Friend number two uses ambulatory spinal intrathecal pro prima king, no opioid, and that's it. So literally, that's it. Ambulatory spinal and nothing else. 

I've got another friend, and this is a surgeon I met yesterday. And this surgeon can do his arthroplasty skin to skin in forty minutes. And he uses intrathecal, parodycaine, but he uses a magic mix kind of fitting with your cocktail of ropivacaine, morphine, clonidine, adrenaline, and a steroid. So we got three approaches. Let are we making this too complicated, man? 

Just do a spinal and that's it. Or spinal local anesthetic or nothing. Tell me. Yeah. I agree. 

I think that you're you yes. We are we could be making this more complicated, but it all depends on a, the goal. Yeah. Is this is this ambulatory? Yeah. 

I think there's some patient selection, maybe patient coaching factors in there as well. Right? So I think that's the key. Right? I think there's a lot of patients, and this may be a UK versus US thing, but I think a lot of our patients really desire and expect to be as analgesed as possible afterwards and not put up with a lot of discomfort. 

Whereas I can imagine Alan and his team saying to their patients, alright, love. Here's a wee dose of oxycodone, and then you're gonna go down to the lobby and then the door, and you're gonna be great. That is I think that was brilliant. I think that was I think that was your best accent today. Oh. 

To be clear, I'm not imitating Alan MacFarlane, and that's just my that's a generic Scottish accent. No. No. No. No. 

No. That that that was a generic that was a generic Scottish accent. Wasn't Alan, but, actually, that was your best accent today. That was brilliant. No. 

But I think there's a lot to that. Right? I think we miss this sometimes as you say Yeah. Is the coaching and then saying, man, you are you're getting your hip replaced. There's gonna be some discomfort and this is this is what it's gonna look like. 

Day one's gonna be your most challenging day, day two's gonna be a little bit better, day three a little bit better, and then so on and so forth. Given that sort of trajectory to look forward to, people can get through that, I I think. Yeah. Well, see so the thing that and I think we'll we'll conclude on on what we you and I both have kind of arrived and think is a is a great recipe. The thing that's blowing my mind is that there is one of my friends who does a spinal, no local, no blocks, and the patients get up and mobilize. 

I don't get it, but you must have a slick and efficient surgeon who goes in minimal tissue disruption, gets in there, does the work. The patients know they're gonna be getting up and walking. They've got their standard multimodal prescription written up and ready for them to go as they get out here. They've got physiotherapy ready to show them how to walk. The only way these processes of ambulatory, surgery can work with with all of that work that goes in the background. 

Yeah. So I'm so and I think that's not easy to set up. And I think, you know, we would love to achieve, ambulatory, hip replacements at my place, and there have been some situations where we've done it. But I think to get all of those pieces lined up, that's a lot of work. There's a lot of work to make that work. 

So, and the other thing so what we what we do have, is an inconsistency in what happens with discharge medication. We call them TTAs or to take away or the orders that patients get sent home with. I don't think there's a consistent way in working out what is enough to give somebody and what do you give them. And I I remember, Ed Mariano's group in fact, it was one of the the junior residents or somebody who was even a student at that stage presented a paper at one of the ASRA meetings I went to where they looked at the opioid use within the previous twenty four hours, and they worked out a tailored dose for the patient to go home with a with strict instructions on how to taper it. Yeah. 

I remember that. That was a great project. Again, getting to that sort of directed recovery instructions. Here's what you're gonna do rather than just giving someone a bottle of pills and a good luck to you, sir. Yeah. 

Yeah. That kind of thing. I like that. So, Jeff, give you an idea. I think we're gonna close-up here, on exactly how you do what you do. 

So let's have a patient, and let's call this patient Henry. So Henry's coming to you for a total hip arthroplasty. Tell me what you do to Henry, and you've got two minutes to do this. Okay. Not to not to actually do the blocks, but to tell me about it. 

Oh, I could do it though. Oh, okay. Henry's in. He's getting changed. He uses the restroom on the way back to the block area. 

He's, gets checked in. He's sitting on the edge of the bed. We do a short acting spinal with eighty milligrams of lidocaine or fifty two and a half milligrams of mepivacaine. So that would be four mils of two percent lidocaine. Correct. 

Yep. That's our that's our go to now. And lay gets laid down and we'll take a ultrasound probe, put it over an inguinal crease, do our peng block with fifteen mils of low concentration ropivacaine with a bit of epinephrine in it and then do save five mils of that for the LFCN. And then Henry is off to the OR. Bob's your uncle. 

And you go, alright, Henry. Off you go. Right, Henry. So so that's it. That's it's that simple. 

Yeah. Again, I I think your comment about Well. Overcomplicating hips is is on the money. I think you we go through contortion sometimes to get all these things, and it's just not necessary. Well, listen. 

I'm fascinated. I and I think I think that's gonna be what I do. I'm gonna I'm gonna finish up with one comment. I've started working or occasionally done some some work with a surgeon at my at my hospital at Guy's in Saint Thomas'. And the first time I did a list with him, the first thing he said to me was, can you do pain blocks? 

Really? I said, yes. I can. And the reason he said that was one of my previous fellows, a chap called Ganesh Nair, he'd done a list, an operating list with this surgeon and said, I can do a motor sparing block. And this is a surgeon who hadn't normally accepted any blocks of any kind. 

So Ganesh said to him, I could do a motor sparing block. Let me know what you think. So he did pain blocks, and when the surgeon went to follow-up the patients the next day, he noticed a difference. Oh, cool. So he was now saying, I don't want any any if you if you could do a pain block, please do it. 

And that's actually something and then, you know, that's the surgeon accepting. So I think we're onto something really interesting here. So I I'm really happy. I've really enjoyed this episode. Thank you, Jeff. 

Yeah. My question. Complicated, but we keep we keep it simple. Right? Yep. 

Totally. The other thing we haven't mentioned yet, I'm just saying that in the last thirty seconds is we've talked today about arthroplasty, but we do a fair number of hip scopes as well. And Oh. Also a fairly painful operation, especially intra op. And so we found a pang block is quite effective for that too. 

Because I mean, jamming that scope Mhmm. Maybe jamming is not the right verb there, but inserting the scope into into the capsule and doing a lot of manipulation and that sort of thing. So we paying I I think interested to hear other people's thoughts on that, but paying seems great for that too. So, guys, let us know if you are using a a paying block for your hip arthroplasty and or your hip scopes. We'd be really interested to hear that. 

So, Jeff, I guess we're kind of there. That that all all that's left is for us to wrap up. Right? Yeah. We've already mentioned where they can they can get us, the Twitter Yes. 

And the the YouTube. YouTube is at block it like it's hot, no apostrophe. Yes. Yes. And please, yeah, hit us up. 

Use the hashtag block it like it's hot. Let us know your feedback. Send out your questions. Oh, I I've been loving the social media interaction and following the conversations afterwards, and I am learning so much, through this process. A 100%. 

Yeah. A 100%. So please carry on doing that, guys. And all that leads us to say, until the next episode, we hope you Block it like it's hot.