We present a case of unexpectedly prolonged motor and sensory block following a successful single injection ultrasound-guided infraclavicular block with bupivacaine (0.25%) and dexamethasone (8 mg). ultrasound guidance and safety measurement such as injection of the local anaesthetic at a slow rate and verifying that usual resistance was felt throughout the injection, has been applied. It took 42 hours for the block to go away. Although there was no evidence of neurologic injury but we should always be prepared to consider the possibility of nerve injury and take appropriate measures.

Dear Editor: In the treatment of unilateral total limbal stem cell deficiency (LSCD), conjunctival limbal autograft (CLAU) surgery taken from the healthy fellow eye with or without amniotic membrane transplantation (AMT) is one of the main therapeutic alternatives. There are some controversies regarding the optimal size of the limbal graft necessary for complete and stable epithelialization of the cornea. Traditionally, two 60o limbal grafts have been used.

Background: Pain is one of the major concerns of patients underwent Total Knee Arthroplasty (TKA), appropriate pain management is a key factor in patient's early physical fitness to move, physiotherapy, and most importantly, patient satisfaction.Objectives: In this study the analgesic effect of single injection femoral nerve block (SFNB) was compared with local infiltration analgesia (LIA).Patients and Methods: Forty patients who underwent TKA under spinal anesthesia were randomized to receive single femoral nerve block (group F) or intra-periarticular infiltration (group I). Group F received single injection 20cc ropivacaine (10mg/cc) and in group I, a combination of 300mg ropivacaine, 30mg ketorolac and 0.5mg epinephrine diluted to a volume of 150cc and locally injected in and around the knee joint in 3 stages. Postoperative pain intensity measured by Visual Analog Scale (VAS). Morphine consumption, mobilization time and patients’ satisfaction evaluated as well.Results: Group I had significantly lower morphine consumption in the first postoperative day (10 vs.12.5mg, P-value<0.05). Within 6 hours postoperatively, VAS score was statistically lower in group I compared to group F (3 vs.4, P-value<0.05). However, within 12 hours it was statistically higher in group I than group F (6 vs.5, P-value<0.05). Other parameters were not statistically different in two groups.Conclusions: Both methods LIA and SFNB provided excellent pain relief and lower morphine consumption following TKA. LIA is a surgeon-controlled analgesic technique, which can be used to enhance patients’ satisfaction and reduce the pain in the very early postoperative period by surgeon independently.

Unilateral temporomandibular joint (TMJ) dislocation is a rare condition often triggered by yawning, vomiting, or other activities involving wide opening of the mouth, resulting from the forward movement of the condylar head. This case report highlights a longstanding unilateral TMJ dislocation managed by the single injection of local anesthetics into the deep temporal and masseteric nerve peripheries, alleviating muscle spasm and pain to restore TMJ function.

Background: Round block technique (RBT) is a versatile technique for the excision of benign and malignant breast lesions with oncologic safety. Although a technically challenging procedure, it has the benefit of an inconspicuous scar and desirable aesthetic outcomes and wider exposure for tissue resection and remodelling. This study discusses the utility of RBT for the excision of different pathologies, complications, and cosmetic outcomes as it is underutilized in the developing countries. Methods: The study was conducted at the breast surgery clinic, at Liaquat National Hospital. All patients with benign (fibroadenomas, benign phyllodes) or malignant (carcinoma, malignant phyllodes) lesions undergoing the round block technique were included. The clinical size, site, distance from the nipple, pathology, pathological size, and margin status were recorded. Early and late complications were documented during the follow-up. At the time of the final study analysis, patients were interviewed for cosmetic outcome satisfaction using the Harvard scale (4-point Likert score) Results: Overall, 49 patients were included in the study over 2.5 years. The mean clinical tumor size was 4.72cm, of which 63% were in the upper quadrant, and the average distance from the areolar margin was 1.71cm. The pathology included 21 fibroadenomas and 18 carcinomas, with the mean size of 4.14cm. Early complications were seen in 12 cases, and late complications were observed in 2 cases which were all managed conservatively. The cosmetic outcome was found to be fair by 6.1% of the patients, good by 87%, and excellent by the 6.1% of them. Conclusion: RBT is a technically challenging procedure but is easily adaptable. It provides good exposure for excision of both benign and malignant tumors of the breast while maintaining the oncologic safety margin and good cosmesis, especially for young patients with large lesion in the upper inner quadrant.