Ultrasound guided hamstring block to reduce autologous graft site pain in hamstring

INTERVENTION: Does the addition of ultrasound guided hamstrings block result in improved post‐op analgesia compared to adductor canal block alone after autologous hamstring graft ACL reconstruction. Patients will be given an information sheet and consent form outlining the purpose of the study, what the study involves and commonly asked questions. Induction of anaesthesia will be performed with 1‐2mcg/kg of fentanyl and propofol titrated to effect. Anaesthesia will be maintained with sevoflurane in air: oxygen to achieve an age adjusted MAC (minimum alveolar concentration) of 1.0. An Fi02 of 0.5 will be administered and ventilation managed to achieve tidal volumes of 7‐10ml/kg prior to the establishment of spontaneous ventilation. Ventilation will be either spontaneous or pressure supported and fentanyl will be titrated to achieve a respiratory rate of 10‐16/min. Once general anaesthesia has been established the nerve blocks will be preformed. Intervention blocks: o Standard Care Plus Hamstring block – in addition to adductor canal block a hamstring block will also be performed via ultrasound guidance using the same 100mm 22g Stimuplex needle to inject: 20ml 0.2% Ropivacaine (40mg Ropivacaine) with placed posterior to the belly of gracilis at the level of the adductor canal (mid‐thigh) 20ml 0.2% Ropivacaine (40mg Ropivacaine) is placed either side of semitendinosus in the mid‐thigh Blocks will be performed by consultant anaesthetists or regional anaesthesia fellows under direct supervision. Blocks will be preformed around the Saphaneous nerve in the adductor canal and hamstring fascial planes via ultrasound guidance. Blocks wil be preformed once only after general anaesthesia has been established in the operating theatre. CONDITION: ACL rupture;Pain relief;Anaesthesia; ; ACL rupture ; Pain relief ; Anaesthesia Anaesthesiology ‐ Pain management Musculoskeletal ‐ Other muscular and skeletal disorders Surgery ‐ Other surgery PRIMARY OUTCOME: Oral Morphine equivalent at 24H following ACL reconstruction. This will be recorded by reviewing analytics from patient‐controlled analgesia machine as well as cumulative recording of opioids from the patients medication chart.[24 hours following surgery] SECONDARY OUTCOME: Numerical pain scores via the numerical pain rating scale.[6 and 24 hours following surgery] Presence of post‐operative nausea or vomiting ‐ composite outcome ; ; o Motor blockade will be tested by power of the extensor hallucus longus, with comparison to the non‐operative side. If there is a difference then motor blockade will be recorded as yes. ; [15‐30 Minutes after arrival in PACU post operatively.] Presence of sciatic nerve motor blockade – blockade of the sensory will be examined for by clinical examination. ; o Sensory blockade will be tested by reduced sensation to ice on the lateral side of the foot of the operative/blocked side compared to the non‐operative side. If there is a difference then sensory blockade will be recorded as yes. [15‐30 Minutes after arrival in PACU post operatively.] Quality of Recovery 15 Score [At 24 hours post ACL reconstruction] Time to first opioid dose. Obtained from reviewing the first opioid dose recorded on the medication chart in PACU or the ward. [Following ACL reconstruction the time from arrival in PACU to the first given dose of opioid in PACU or the ward will be calculated.] INCLUSION CRITERIA: Inclusion criteria 1. Patients undergoing ACL reconstruction with ipsilateral hamstrings graft 2. Age between 18 and 65 3. Operation performed under general anaesthesia ; The presence of nausea or vomiting that requires anti emetic administration will be recorded immediately post operatively, 1 hour, 6 hour and 24 hour post operatively. PACU nurses will question patients during recovery.[Immediately post operatively, 1 hour, 6 hour and 24 hours post ACL reconstruction] Presence of saphenous nerve blockade – blockade of the sensory nerve will be examined for by clinical examination. This will be tested by reduced sensation to ice on the medial malleolus of the ankle of the operative/blocked side compared to the non‐operative side. If there is a difference then a sensory blockade will be recorded as yes. This will signify that an effective adductor canal block has been placed. [Following ACL reconstruction] Presence of sciatic nerve motor blockade – blockade of the motor components will be examined for by clinical examination.