Adductor Canal Block or Local Infiltrate Analgesia for Pain Control After Total Knee Arthroplasty? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The analgesic effect of continuous adductor canal block combined with popliteal plexus block for total knee arthroplasty: a randomized controlled trial

This study aimed to confirm the hypothesis that continuous ACB (CACB) combined with a popliteal plexus block (PPB) can improve posterior knee pain, reduce nalbuphine consumption, and shorten the length of hospital stay. Patients who underwent TKA were allocated to the CACB + sham block (SHAM) or CACB + PPB groups. The primary outcome was the maximum pain score originating from the posterior knee within 4 h after TKA. Secondary outcomes included the maximum pain score originating from the posterior and anterior knees within 72 h after TKA, range of motion on postoperative day (POD) 1-3, postoperative nalbuphine consumption within 72 h of surgery, length of hospital stay, and complications. The maximum pain score of the posterior knee was lower in the CACB + PPB group than in the CACB + SHAM group within 0-12 h after surgery. Nalbuphine consumption within 24 h after surgery was lower in the CACB + PPB group than in the CACB + SHAM group. The range of motion was better in the CACB + PPB group than in the CACB + SHAM group on POD1 and 2. The length of hospital stay was shorter in the CACB + PPB group than in the CACB + SHAM group. The incidence of clinical significant nausea and vomiting was lower in the CACB + PPB group than in the CACB + SHAM group. This study found that PPB combined with CACB could relieve pain in the posterior knee within at least 12 h after TKA, reduce nalbuphine consumption within 24 h after TKA, improve the range of motion on POD1 and 2, and shorten the length of hospital stay for patients who underwent TKA.

Driving Forces for Outpatient Total Hip and Knee Arthroplasty with Enhanced Recovery After Surgery Protocols: A Narrative Review

PURPOSE OF REVIEW

To explore the recent developments and trends in the anesthetic and surgical practices for total hip and total knee arthroplasty and discuss the implications for further outpatient total joint arthroplasty procedures.

RECENT FINDINGS

Between 2012 and 2017 there was an 18.9% increase in the annual primary total joint arthroplasty volume. Payments to physicians falling by 7.5% (14.9% when adjusted for inflations), whereas hospital reimbursements and charges increased by 0.3% and 18.6%, respectively. Total knee arthroplasty and total hip arthroplasty surgeries were removed from the Medicare Inpatient Only in January 2018 and January 2020, respectively leading to same-day TKA surgeries increases from 1.2% in January 2016 to 62.4% by December 2020 Same-day volumes for THA surgery increased from 2% in January 2016 to 54.5% by December 2020. Enhanced Recovery After Surgery (ERAS) protocols have revolutionized modern anesthesia and surgery practices. Centers for Medicare Services officially removed total joint arthroplasty from the inpatient only services list, opening a new door for improved cost savings to patients and the healthcare system alike. In the post-COVID healthcare system numerous factors have pushed increasing numbers of total joint arthroplasties into the outpatient, ambulatory surgery center setting. Improved anesthesia and surgical practices in the preoperative, intraoperative, and postoperative settings have revolutionized pain control, blood loss, and ambulatory status, rendering costly hospital stays obsolete in many cases. As the population ages and more total joint procedures are performed, the door is opening for more orthopedic procedures to exit the inpatient only setting in favor of the ambulatory setting.

Comparing Different Multimodal Analgesia Protocols for Primary Total Knee Arthroplasty-A Retrospective Cohort Analysis

Background: Several local regional anesthesia regimes have been described in the literature to reduce post-surgical pain following total knee arthroplasty (TKA), but it is unclear which regime has the best analgetic effect combined with the best motor function. The aim of this study was to determine if patients with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) combined with an adductor canal block (SACB) had less pain, better motor function, and less opioid consumption after TKA than patients with a femoral nerve block (FNB) combined with a popliteal sciatic nerve block (PSB). Methods: In a retrospective cohort analysis, 342 patients following primary TKA were examined; 175 patients were treated with an IPACK combined with a SACB, and 167 patients with a femoral FNB combined with a PSB. The outcome parameters postoperative pain (visual analogue scale (VAS) for mobilization and at rest, functional recovery, opioid consumption, hospital discharge, and complications were analyzed and compared between both groups. Results: The IPACK/SACB group had a higher postoperative need for opioids despite higher doses of ropivacaine compared to the FNB/PSB group, accompanied by higher VAS scores. Patients' satisfaction was equal between the groups. Both groups showed comparable mobilization rates and walking distances following TKA. Conclusions: IPACK/SACB showed equal results compared to FNB/PSB for mobilization rates and patients' satisfaction following TKA without a reduction in opioid consumption.

What Is the Role of a Periarticular Injection for Knee Arthroplasty Patients Receiving a Multimodal Analgesia Regimen Incorporating Adductor Canal and Infiltration Between the Popliteal Artery and Capsule of the Knee Blocks? A Randomized Blinded Placebo-Controlled Noninferiority Trial

BACKGROUND

Optimal analgesic protocols for total knee arthroplasty (TKA) patients remain controversial. Multimodal analgesia is advocated, often including peripheral nerve blocks and/or periarticular injections (PAIs). If 2 blocks (adductor canal block [ACB] plus infiltration between the popliteal artery and capsule of the knee [IPACK]) are used, also performing PAI may not be necessary. This noninferiority trial hypothesized that TKA patients with ACB + IPACK + saline PAI (sham infiltration) would have pain scores that were no worse than those of patients with ACB + IPACK + active PAI with local anesthetic.

METHODS

A multimodal analgesic protocol of spinal anesthesia, ACB and IPACK blocks, intraoperative ketamine and ketorolac, postoperative ketorolac followed by meloxicam, acetaminophen, duloxetine, and oral opioids was used. Patients undergoing primary unilateral TKA were randomized to receive either active PAI or control PAI. The active PAI included a deep injection, performed before cementation, of bupivacaine 0.25% with epinephrine, 30 mL; morphine; methylprednisolone; cefazolin; with normal saline to bring total volume to 64 mL. A superficial injection of 20 mL bupivacaine, 0.25%, was administered before closure. Control injections were normal saline injected with the same injection technique and volumes. The primary outcome was numeric rating scale pain with ambulation on postoperative day 1. A noninferiority margin of 1.0 was used.

RESULTS

Ninety-four patients were randomized. NRS pain with ambulation at POD1 in the ACB + IPACK + saline PAI group was not found to be noninferior to that of the ACB + IPACK + active PAI group (difference = 0.3, 95% confidence interval [CI], [-0.9 to 1.5], P = .120). Pain scores at rest did not differ significantly among groups. No significant difference was observed in opioid consumption between groups. Cumulative oral morphine equivalents through postoperative day 2 were 89 ± 40 mg (mean ± standard deviation), saline PAI, vs 73 ± 52, active PAI, P = .1. No significant differences were observed for worst pain, fraction of time in severe pain, pain interference, side-effects (nausea, drowsiness, itching, dizziness), quality of recovery, satisfaction, length of stay, chronic pain, and orthopedic outcomes.

CONCLUSIONS

For TKA patients given a comprehensive analgesic protocol, use of saline PAI did not demonstrate noninferiority compared to active PAI. Neither the primary nor any secondary outcomes demonstrated superiority for active PAI, however. As we cannot claim either technique to be better or worse, there remains flexibility for use of either technique.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations

PURPOSE

Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways.

SOURCE

We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature.

PRINCIPAL FINDINGS

Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen.

CONCLUSION

Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

Analgesic Effectiveness of Motor-sparing Nerve Blocks for Total Knee Arthroplasty: A Network Meta-analysis

BACKGROUND

The analgesic effectiveness of contemporary motor-sparing nerve blocks used in combination for analgesia in total knee arthroplasty is unclear. This network meta-analysis was conducted to evaluate the analgesic effectiveness of adding single-injection or continuous adductor canal block (ACB) with or without infiltration of the interspace between the popliteal artery and the capsule of the posterior knee (iPACK) to intraoperative local infiltration analgesia (LIA), compared to LIA alone, after total knee arthroplasty.

METHODS

Randomized trials examining the addition of single-injection or continuous ACB with or without single-injection block at the iPACK to LIA for total knee arthroplasty were considered. The two primary outcomes were area-under-the-curve pain scores over 24 to 48 h and postoperative function at greater than 24 h. Secondary outcomes included rest pain scores at 0, 6, 12, and 24 h; opioid consumption (from 0 to 24 h and from 25 to 48 h); and incidence of nausea/vomiting. Network meta-analysis was conducted using a frequentist approach.

RESULTS

A total of 27 studies (2,317 patients) investigating the addition of (1) single-injection ACB, (2) continuous ACB, (3) single-injection ACB and single-injection block at the iPACK, and (4) continuous ACB and single-injection block at the iPACK to LIA, as compared to LIA alone, were included. For area-under-the-curve 24- to 48-h pain, the addition of continuous ACB with single-injection block at the iPACK displayed the highest P-score probability (89%) of being most effective for pain control. The addition of continuous ACB without single-injection block at the iPACK displayed the highest P-score probability (87%) of being most effective for postoperative function.

CONCLUSIONS

The results suggest that continuous ACB, but not single-injection ACB and/or single-injection block at the iPACK, provides statistically superior analgesia when added to LIA for total knee arthroplasty compared to LIA alone. However, the magnitude of these additional analgesic benefits is clinically questionable.

EDITOR’S PERSPECTIVE

Does an Adductor Canal Block Influence Patient-Reported Outcomes at One Year Following Total Knee Arthroplasty?

Introduction Total knee arthroplasty (TKA) for osteoarthritis is performed to improve knee function and quality of life. Adductor canal block (ACB) (with posterior capsule local anaesthetic) and periarticular local anaesthetic infiltration (LA) alone are common methods used for post-operative pain control following TKA. The primary aim of this study was to investigate the influence of ACB compared to LA alone on knee function at one year in patients undergoing primary TKA. The secondary aims were to investigate the influence on health-related quality of life (HRQoL), patient satisfaction at one year, and length of stay (LOS) in hospital following TKA. Methods During a three-year period, 1396 patients who underwent TKA at the study centre completed pre-operative and one-year post-operative questionnaires. Data collected included patient demographics, co-morbidities, LOS, Oxford Knee Score (OKS), EuroQol 5-Dimension (EQ-5D) and satisfaction scores. Patients who had a spinal anaesthetic (n=1096) with either ACB (with posterior capsule local anaesthetic) (n=224) and LA infiltration alone (n=872) were compared. Results There was a significant improvement in pre-operative to one-year post-operative knee function as measured by OKS overall (15.1, p<0.001), however there was no significant difference between ACB and LA groups (p=0.37). There was no significant difference in change (p=0.43) or one-year post-operative (p=0.70) HRQoL, as measured by EQ-5D. There was also no significant difference in one-year patient satisfaction between groups (p=0.57). There was no significant difference in median LOS between groups (four days with ACB, four days with LA), although patients younger than 55 years undergoing ACB had a statistically significant median of one day reduced LOS compared with the LA group (p=0.01). Conclusions ACB when compared with LA alone was not associated with a difference in change in knee function, HRQoL, or patient satisfaction at one year following TKA. There was also no difference between groups in length of stay post-operatively. However, ACB was associated with a shorter length of stay in patients younger than 55, and this may be a group that would benefit from this intervention.

Peripheral Nerve Block Utilization is Associated With Decreased Postoperative Opioid Consumption and Shorter Length of Stay Following Total Knee Arthroplasty

Background

This study aims to examine differences in postoperative complications and opioid consumption associated with perioperative peripheral nerve block (PNB) utilization during primary total knee arthroplasty (TKA).

Methods

The Premier Healthcare Database was queried for adult patients who underwent primary, elective TKA from 2015 to 2020. Patients who received a femoral or adductor canal PNB were compared to patients who did not. PNB utilization was trended from 2015 to 2020. Univariate and multivariate regression analyses were performed to assess differences in the 90-day risk of postoperative complications between groups. The average inpatient opioid consumption in morphine milligram equivalents was assessed as a function of length of stay.

Results

Overall, 609,991 patients were included. PNB utilization increased from 9.29% in 2015 to 30.3% in 2020. After controlling for confounders, the PNB cohort was more likely to have same-day discharge (adjusted odds ratio [aOR] 1.88) and had a decreased risk of periprosthetic joint infection (aOR 0.87), pulmonary embolism (aOR 0.81), and respiratory failure (aOR 0.78). However, there was an increased risk of seroma (aOR 1.75) and hematoma (aOR 1.22) associated with PNB utilization. Lower average overall opioid exposure was seen in the PNB cohort vs no-PNB cohort (82.1 ± 194.7 vs 89.4 ± 214.1 morphine milligram equivalents, P < .001).

Conclusions

PNB utilization during primary TKA is associated with a shorter length of stay and decreased risk of multiple postoperative complications, as well as reduced postoperative opioid consumption. These data provide evidence in support of the safety and efficacy of this emerging practice. However, the clinical relevance of an increased risk of seroma and hematoma formation may warrant further investigation.

No Benefit of Adductor Canal Block Compared with Anterior Local Infiltration Analgesia in Primary Total Knee Arthroplasty: A Single-Blinded Randomized Controlled Clinical Trial

BACKGROUND

An adductor canal block (ACB) performed by an anesthesiologist is an established component of analgesia after total knee arthroplasty. Alternatively, surgeons may perform periarticular local infiltration analgesia (LIA) intraoperatively. We hypothesized that ACB would be superior to anterior LIA in terms of morphine consumption in the first 48 hours after primary total knee arthroplasty under spinal anesthesia.

METHODS

This prospective controlled and blinded trial included 98 patients; 48 received an ACB plus sham (saline solution) anterior LIA, and 50 received a sham (saline solution) ACB plus anterior LIA. Both groups received posterior LIA with local anesthetic. The primary outcome was cumulative morphine consumption at 48 hours after surgery. Secondary outcomes were pain while resting, standing, and walking, rehabilitation scores, opioid-related side effects, and patient satisfaction.

RESULTS

No difference in the primary outcome was found, and the 48-hour morphine consumption was low in both arms (28.8 ± 17.6 mg with ACB, 26.8 ± 19.2 mg with anterior LIA; p = 0.443). Pain scores were significantly better in the anterior LIA arm, but the differences were not clinically relevant. There were no differences in any other secondary outcome measures.

CONCLUSIONS

LIA may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Addition of infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) to local infiltration analgesia for total knee arthroplasty: a prospective randomized controlled trial

BACKGROUND

Local infiltration analgesia (LIA) is a popular analgesic technique commonly administered during total knee arthroplasty (TKA). Recent studies have demonstrated that the infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) can be complementary to analgesic modalities. However, the combined and relative efficacy of LIA and IPACK is unclear. We aimed to evaluate the analgesic and functional outcomes among LIA, IPACK, and LIA+IPACK.

MATERIALS AND METHODS

A total of 120 patients undergoing primary TKA were randomly allocated to 1 of 3 groups: LIA (50 mL of 0.25% ropivacaine and 2.0 μg/mL epinephrine); IPACK (20 mL of 0.25% ropivacaine and 2.0 μg/mL epinephrine); and LIA+IPACK. The primary outcome was the visual analog scale (VAS) pain score. Secondary outcomes were opioid use, knee range of motion (ROM), quadriceps muscle strength, mobilization distance, timed up and go (TUG) test, and postoperative complications.

RESULTS

The mean VAS pain scores were significantly higher after using IPACK alone than after using LIA+IPACK and LIA within 24 hours (all p＜0.05). LIA+IPACK had lower mean VAS pain scores than LIA when the knees were at rest (within 12 hours, p < 0.05) and flexion (within 8 hours, p＜0.05). Patients receiving LIA+IPACK and LIA had significantly lower morphine equivalents (ME) than those receiving IPACK alone within 24 hours (26.3, 28.9 versus 47.8, both p＜0.05) and during hospitalization (98, 101.6, versus 128.4 both p＜0.05). Both LIA+IPACK and LIA had higher ROM (within two days), higher level of muscle strength (within 12 hours), longer mobilization distances (within one day), and shorter TUG time (till discharge) compared with IPACK alone (all p＜0.05), while LIA+IPACK only had a higher knee ROM than LIA on the first postoperative day (p＜0.05). There was no significant difference in any other outcomes.

CONCLUSIONS

This randomized controlled trial demonstrated that there were significantly lower pain scores, less opioid consumption, and better functional results with LIA+IPACK and LIA when compared with IPACK alone, suggesting that IPACK alone was inferior for pain control.

Positioning the Catheter Tip Anterior or Posterior to the Saphenous Nerve in Continuous Adductor Canal Block: A Mono-Centric Retrospective Comparative Study

Background and Aim

Ultrasound-guided continuous adductor canal block (cACB) is a conventional choice in patients undergoing total knee arthroplasty (TKA) for the management of the postoperative pain. This study aims to compare different catheter tip locations for cACB relative to the saphenous nerve (anteriorly vs posteriorly) in terms of efficacy and complications.

Methods

At the department of Surgical Sciences, Orthopedic Trauma and Emergencies of the University of Naples Federico II (Naples, Italy), between January 2020 and November 2021, retrospective comparative study was executed. Patients planned for TKA were included in the study if they met the follow inclusion criteria: patients undergone TKA; aged 50-85 years; body mass index (BMI) of 18-35 kg/m2; American Society of Anesthesiologists (ASA) physical status classification from I to III; subarachnoid technique for anesthesiology plane; continuous adductor canal block performed by an anesthetist with considerable experience. Patients were assigned to receive cACB with the catheter tip located anteriorly (Group 1, G1) or posteriorly to the saphenous nerve (Group 2, G2). Postoperative pain, ambulation ability, episodes of pump block and rate of catheter dislodgement and leakage were evaluated and analyzed.

Results

Altogether, 102 patients were admitted to the study (48 in G1 and 54 in G2). After the first 8 postoperative hours, in G1 17 patients (35.4%) had a VAS greater than 4, while in group 2 only 3 patients (5.6%) had a VAS greater than 4 (p-value <0.01). All patients of both groups showed ambulation ability in the postoperative period. No episode of leakage was recorded. While the catheter displacement rate was similar in the two groups (2.1% for G1 vs 3.7% for G2; p-value >0.05), the episodes of pump block were significantly less in G2 than in G1 (3.7% vs 20.8%; p-value <0.01).

Conclusion

In cACB for TKA, we found that positioning the catheter tip posteriorly to the saphenous nerve may lead to a greater postoperative analgesia and reduce the risk of pump block compared to placing the catheter tip anteriorly to the nerve.

Multimodal Analgesia for Accelerated Rehabilitation after Total Knee Arthroplasty: A Randomized, Double-Blind, Controlled Trial on the Effect of the Co-Application of Local Infiltration Analgesia and Femoral Nerve Block Combined with Dexmedetomidine

Background: Multimodal postoperative pain regimens are widely used following total knee arthroplasty (TKA). However, there are few studies on the rehabilitation of the co-application of local infiltration analgesia (LIA) and femoral nerve block (FNB) combined with dexmedetomidine (DEX) for patients undergoing TKA. This study aimed to investigate the effect of LIA plus FNB and co-application of perioperative DEX on TKA outcomes. Methods: 95 patients were randomized into two groups. Patients in group B (n = 48) received a single preoperative FNB and LIA. Patients in group A (n = 47) received FNB and LIA, as well as continuous intravenous injection of DEX starting from the induction of anesthesia to postoperative day 2. All patients were allowed patient-controlled analgesia postoperatively. Visual analog scale (VAS) scores, knee range of motion (ROM) degrees, narcotic consumption, length of hospital stay (LOS), complications, Hospital for Special Surgery (HSS) scores and Montreal Cognitive Assessment-Basic (MoCA-B) Scores were recorded. Results: In group A, the mean VAS scores at rest and during movement were lower, the amount of rescue analgesia was decreased, first time of ambulation was reduced, ROM was improved, MoCA-B Scores were increased, LOS was shorter, HSS scores were higher postoperatively compared with group B (all p < 0.05). Conclusion: Our study indicated multimodal analgesia involving a single FNB and LIA combined with DEX accelerates rehabilitation for patients undergoing TKA.

Efficacy of Adductor Canal Blocks in Total Knee Arthroplasty

Total knee arthroplasty (TKA) is associated with significant postoperative pain. The population receiving TKA is generally elderly and often have multiple comorbidities that can present a challenge to postoperative management. Safe and effective multimodal pain management has led to improved outcomes while minimizing complications and side effects. The objective of this study was to investigate the efficacy of adductor canal blocks (ACB) in patients receiving TKA within a regional Queensland population. We performed a retrospective comparative cohort analysis of 458 patients who received TKA at a regional private hospital between January 2016 and December 2018. Inclusion criteria included body mass index (BMI) <50 kg/m² and unilateral TKA. Using the patients' hospital records, age, gender, American Society of Anesthesiologists' score (ASA), BMI, diabetic status, length of stay (LOS), opioid requirement on discharge, range of motion (ROM) on discharge, return to theater, and readmission within 12 months were recorded. One hundred and thirty-eight patients received ACB and 263 did not. The two groups were comparable for age, gender, diabetic status, and ASA. Patients who received an ACB had an 18-hour longer LOS (p < 0.0001), but were discharged on lower dosages of opioids equivalent to 7.9 oral morphine milligram equivalent (MME; p < 0.0001). Patients who had an ACB had a similar ROM on discharge and did not have an increased rate of readmission or return to theater. This study demonstrates that ACB are efficacious when used as part of a multimodal analgesia regime for TKA.

IPACK (Interspace between the Popliteal Artery and the Capsule of the Posterior Knee) Block Combined with SACB (Single Adductor Canal Block) Versus SACB for Analgesia after Total Knee Arthroplasty

OBJECTIVES

To evaluate the combination of the infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block and single adductor canal block (SACB) versus SACB for motor-sparing knee analgesia effects after total knee arthroplasty (TKA).

METHODS

PubMed, Ovid, Cochrane Library, and other databases were searched from the inception to January 2021. Randomized controlled trials (RCTs) comparing patients receiving iPACK plus SACB with patients receiving SACB after TKA were included. The included studies were assessed by two reviewers according to the Cochrane risk of bias criteria. Meta-analysis was performed with STATA 13.0 software, the risk ratios (RR) and mean differences (MD) were used to compare dichotomous and continuous variables. The primary outcome was ambulation pain and secondary outcomes were rest pain, opioid consumption, function ability, clinical outcomes, and complications.

RESULTS

Seven RCTs (304 knees in iPACK + SACB group; 305 knees in SACB group) were included. The follow-up periods ranged from 2 days to 3 months. Pooled data indicated lower pain scores at ambulation (p < 0.0001) for iPACK + SACB. When comparing the pain scores of subgroups analyzed at specific periods, lower scores in subgroups within 12 h (at rest and ambulation) and after 48 h (at ambulation) were observed in the iPACK + SACB group. Analysis demonstrated greater reduction in morphine consumption (p = 0.007) in the iPACK + SACB group. The iPACK + SACB group is also superior to the SACB group regarding function ability, which included range of motion (ROM) (p = 0.001), time up to go (TUG) test (p = 0.030), and ambulation distance (p < 0.0001). No difference was found in clinical outcomes or complications.

CONCLUSIONS

With the iPACK added to SACB, pain scores, morphine consumption, functional ability were improved. Additional high-quality studies are required to further address this topic.

Multimodal Analgesia

Perioperative pain management is one of the domains in which Anesthesiologists are intricately involved, and which is immensely important. Adequate postoperative analgesia is central to avoid both the acute as well as chronic complications of uncontrolled postoperative pain. Preventive analgesia has been identified as an approach to mitigate the phenomenon of central sensitization, which plays an important role in the development of chronic pain after surgery. As an over-reliance on opioids for peri- and postoperative pain control is associated with opioid dependence and hyperalgesia, multimodal analgesia has taken center stage. Multimodal analgesia, in theory, will optimize perioperative pain control, reduce the chance of central sensitization, and avoid the detrimental effects of opioid overuse. Multiple classes of systemic analgesic medications have been used to accomplish these tasks, and the aim of this article is to outline these medications, their mechanisms of action, as well as the evidence behind their individual roles in multimodal analgesia. Regional anesthesia has also been embraced as a key component of multimodal analgesia in orthopedic surgery; however, over the past several years, local infiltration analgesia (LIA) emerged as a viable alternative, particularly in total knee arthroplasty.

Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations

BACKGROUND

The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery.

OBJECTIVE

To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA.

DESIGN

A narrative review based on published systematic reviews, using modified PROSPECT methodology.

DATA SOURCES

A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA.

ELIGIBILITY CRITERIA

Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance.

RESULTS

A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified.

CONCLUSION

The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.

Periarticular Injection of Ketorolac Augmenting Intravenous Administration of Ketorolac for Postoperative Pain Control: A Randomized Controlled Trial in Simultaneous Bilateral Total Knee Arthroplasty

Adequate postoperative pain control with minimal side effects is necessary for patients undergoing total knee arthroplasty (TKA). Ketorolac is a frequently used nonsteroidal anti-inflammatory drug due to its excellent disposition in all administration routes; however, it possesses an "analgesic ceiling," which means that higher doses of the drug have no additional analgesic effect. Alternatively, increasing the local concentration of ketorolac via periarticular injection may provide additional pain relief to parenteral administration of ketorolac, but evidence demonstrating the benefits and safety of this approach is limited. Therefore, this study assesses whether local ketorolac injection could yield additional pain reduction to intravenous administration of ketorolac. A total of 54 patients who underwent simultaneous bilateral TKA were enrolled. Randomization was performed to determine whether 50 mg of bupivacaine plus 30 mg of ketorolac (ketorolac group), or only 50 mg bupivacaine (bupivacaine group) would be periarticularly injected into the first knee operated on (more painful), and then the contralateral knee would receive another mixture. Ketorolac (30 mg) was intravenously given every 8 hours for the first 48 hours. Visual analog scales (VASs) were used to assess pain, knee recovery function, and patients' preferred knee. Postoperative VAS pain scores in the ketorolac group were lower than those in the bupivacaine group 6 to 96 hours postoperatively and reached statistical significance 12 (4.25 ± 2.38 vs. 5.06 ± 2.48, respectively; p = 0.04) and 24 hours (4.22 ± 1.94 vs. 5.30 ± 2.12, respectively; p < 0.01) postoperatively. The ketorolac group had higher degrees of knee flexion and straight leg raise. No patient experienced adverse effects of ketorolac. On the day of discharge, 61.11% of the patients favored the knee that received local ketorolac injection (p < 0.01). Adjunct local ketorolac injection to systemic administration is well tolerated and may improve its analgesic effect as determined by the patients' perception.

Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty

BACKGROUND

Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB.

METHODS

This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI).

RESULTS

In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003).

CONCLUSION

Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.

Adductor canal block versus intra-articular steroid and lidocaine injection for knee osteoarthritis: a randomized controlled study

Background

This study aimed to assess the efficacy of the adductor canal block (ACB) in comparison to intra-articular steroid-lidocaine injection (IASLI) to control chronic knee osteoarthritis (KOA) pain.

Methods

A randomized, single-blinded trial in an outpatient rehabilitation clinic recruiting chronic KOA with pain ≥ 6 months over one year. Following randomization, subjects received either a single ACB or IASLI under ultrasound guidance. Numerical rating scale (NRS) scores for pain, and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were recorded at baseline, 1 hour, 1 month, and 3 months post-injection.

Results

Sixty-six knees were recruited; 2 were lost to follow-up. Age was normally distributed (P = 0.463), with more female subjects in both arms (P = 0.564). NRS scores improved significantly for both arms at 1 hour, with better pain scores for the IASLI arm (P = 0.416) at 1st month and ACB arm at 3rd month (P = 0.077) with larger effect size (Cohen’s d = 1.085). Lower limb function improved significantly in the IASLI arm at 1 month; the ACB subjects showed greater functional improvement at 3 months (Cohen’s d = 0.3, P = 0.346). Quality of life (QoL) improvement mirrored the functional scores whereby the IASLI group fared better at the 1st month (P = 0.071) but at the 3rd month the ACB group scored better (Cohen’s d = 0.08, P = 0.710).

Conclusions

ACB provides longer lasting analgesia which improves function and QoL in chronic KOA patients up to 3 months without any significant side effects.

Effect of Local Infiltration Analgesia on Functional Outcomes in Total Knee Arthroplasty: A Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Local infiltration analgesia (LIA) is a simple, surgeon-administered technique for the treatment of postoperative pain after total knee arthroplasty (TKA). The aim of the study was to investigate the efficacy of LIA and its effects on functional outcomes in TKA. A total of 135 patients with primary TKA were recruited and randomized either to receive LIA or to receive placebo injection (PI). Pain, active range of motion (ROM), knee function score, functional activities, and hospital length of stay (LOS) were assessed before surgery and from postoperative day (POD) 1 to at discharge. Lower pain scores at rest were recorded on POD1 and POD2 in the LIA group (p = 0.027 and p = 0.020, respectively). Lower pain score on walking was recorded on POD1 in the LIA group (p = 0.002). There was a statistically significant difference in active knee flexion between groups on POD1 (p = 0.038). There was a significant difference in LOS between LIA and PI groups. Shorter stay was seen in LIA group. There were no statistically significant differences between the groups in terms of knee function score and functional outcomes. LIA technique is effective for pain management in the early postoperative period. LIA added benefit for knee function in terms of active knee flexion ROM after TKA. A shorter hospital LOS was observed in LIA group. However, we did not find any differences in groups in terms of functional assessment such as ability to rise from a chair and walking capacity.The level of evidence is randomized controlled trial, level I.

The effects of local infiltration anesthesia and femoral nerve block analgesia after total knee arthroplasty: a systematic review and meta-analysis

Background

Local infiltration anesthesia (LIA) and femoral nerve block (FNB) are commonly used analgesia methods after total knee arthroplasty (TKA). However, there is no definitive conclusion about which of these two analgesia modes is superior. Therefore, this study aimed to systematically evaluate the analgesic effects of LIA and FNB after TKA.

Methods

We used the terms “total knee replacement, knee replacement, total knee arthroplasty, knee arthroplasty, local infiltration analgesia, periarticular infiltration, periarticular injection, intra-articular infiltration, intra-articular injection, peripheral nerve block, femoral nerve block” to search the PubMed, Cochrane Central Register of Controlled Trials, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and Weipu databases. The search period was set from the date of establishment of the database to September 2021. The Cochrane risk of bias tool was used to evaluate the quality of the included studies, and network meta-analysis was performed using Stata14.0 and RevMan 5.30 software.

Results

Nine articles were included for analysis. The results of meta-analysis showed that compared with LIA and FNB, the difference in opioid use [mean difference (MD) −4.35, 95% confidence interval (CI): −7.26 to −1.45] was statistically significant. However, there was no significant difference between the static visual analogue score at 24 hours postoperatively (MD 0.20, 95% CI: −0.91 to 1.31), the visual analogue score for exercise visual analogy at 24 hours after surgery (MD 0.10, 95% CI: −0.12 to 0.32), and the length of hospital stay (MD 0.05, 95% CI: −0.40 to 0.50).

Discussion

LIA and FNB have similar effects on pain relief after TKA, but LIA can reduce the use of analgesic drugs and is easy to operate. Therefore, LIA can be used as the priority analgesic method for patients with TKA. However, multi-center, large-sample, high-quality, randomized controlled trials are still needed for further verification.

Adductor canal catheter block after total knee arthroplasty in patients with severe osteoarthritis and limited mobility. A single center study in Riyadh, Saudi Arabia

Purpose:

Total knee arthroplasty (TKA) is one of the most performed procedures. Postoperative pain control is an important factor for the improvement of patient's quality of life. The aim of this study is to report pain control results and functional outcome scores associated with adductor canal blockade (ACB) usage post-TKA.

Methods:

A prospective case series study of patients who underwent TKA for degenerative osteoarthritis with ACB postoperatively from 2018 to 2019 in a single center in Saudi Arabia, Riyadh. Assessment of functional outcome scores and pain level were measured preoperatively and postoperatively respectively using Knee injury and Osteoarthritis Outcome Score (KOOS) and the Visual Analog Scale (VAS).

Results:

Average KOOS score preoperatively for all 5 domains showed a marked improvement at 3 months compared to preoperative values. Pain score postoperatively was measured at 12, 24, and 48 h with an average of 0.7, 1.2, and 0.6 out of 10 on the VAS scale, respectively. The incidence of associated common side effects with the use of analgesic use was included as an add-on in the postoperative questionnaire.

Conclusion:

In conclusion, by comparing preoperative and postoperative pain levels and functional outcome scores, our study showed a significant pain control and improved functional outcome scores following TKA using ACB.

Additional Peripheral Nerve Block to Periarticular Injection Has No Benefit for Patients Undergoing TKA: A Factorial Propensity Score-Matched Analysis Comparing Four Multimodal Analgesic Techniques

BACKGROUND

Controversy remains over what and how many analgesic techniques are required as the most effective multimodal pain regimen in total knee arthroplasty (TKA). This study aimed to evaluate the effect of additional analgesic methods combined with periarticular injection (PAI) analgesia for TKA.

METHODS

Using retrospective cohort data, patients undergoing TKA with spinal anesthesia and PAI were divided into 4 groups. Group A (control) comprised 66 patients; group B (73 patients) had additional adductor canal block; group C (70 patients) obtained additional femoral nerve block, and group D (73 patients) received additional adductor canal block and intrathecal morphine. Propensity score matching was applied to compare visual analog scale (VAS) for pain intensity, cumulative morphine use (CMU), knee flexion angle, straight leg raise, length of hospital stay, and postoperative nausea and vomiting.

RESULTS

There was no significant difference regarding VAS and morphine use, when either group B or C was compared with group A. Group D had significantly lower VAS than groups A, B, and C during the first 24 hours after surgery and required significantly less CMU than groups A and B. However, the pain score of group D increased afterward, with significantly longer length of hospital stay than groups A and B. There was no difference in straight leg raise among the groups.

CONCLUSION

Additional peripheral nerve block to PAI provides no benefit for patients undergoing TKA. Adjuvant intrathecal morphine could significantly reduce the VAS and CMU in the acute postoperative period; however, rebound pain with prolonged hospital stays was observed.

Effect of ultrasound-guided selective sensory nerve blockade of the knee on pain management compared with periarticular injection for patients undergoing total knee arthroplasty: A prospective randomized controlled trial

BACKGROUND

Ultrasound-guided selective sensory nerve blockade (SSNB) of the knee, including an adductor canal block (ACB), anterior femoral cutaneous nerve block, and infiltration between the popliteal artery and posterior capsule of the knee may provide effective motor-sparing knee analgesia for total knee arthroplasty (TKA). We hypothesized that the SSNB would manage pain better on ambulation 24 hours postoperatively compared to periarticular infiltration (PAI), when combined with postoperative continuous ACB.

METHODS

Seventy-two patients undergoing elective TKA under spinal anesthesia were randomly assigned to either SSNB (SSNB group) or intraoperative PAI (PAI group). All patients received postoperative multimodal analgesia, including continuous ACB. The primary outcome was pain on ambulation 24 hours postoperatively. Secondary outcomes included rest and dynamic numerical rating scale pain score, intravenous morphine requirement, functional performance measures, adverse events, satisfaction, and length of stay.

RESULTS

There was no difference in pain score during movement between the groups (mean difference -0.48 [-1.38 to 0.42], p = 0.3) and other immediate overall pain scores 24 hours postoperatively. Patients in the SSNB group had significantly lower intravenous morphine requirement than the PAI group for 48 hours postoperatively (0 [0, 0] vs. 0 [0, 2]; p = 0.008). There was no intergroup difference in the performance-based measures, satisfaction, and length of stay.

CONCLUSIONS

The SSNB did not provide superior postoperative analgesia, or improvement in immediate functional performance. However, it may result in lower opioid consumption postoperatively when compared with the intraoperative PAI.

Comparison of Efficacy of Adductor Canal Block, Local Infiltration Analgesia and Both Combined in Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial

PURPOSE

The aim of our study is to compare the efficacy of adductor canal block (ACB), periarticular local infiltration (PLI) and both combined (ACB + PLI) in multimodal pain management after TKA.

METHODS

This is a prospective, randomized controlled double-blinded study undergoing primary unilateral TKA. They were randomized into three groups with fifty patients in each group: ACB alone (30 ml of 0.2% ropivacaine), PLI alone (30 ml 0.5% ropivacaine in 20 ml of normal saline), and both combined (ACB + PLI). The primary outcome studied was pain using visual analog score (VAS) in postoperative days (POD) 1 and 2. The secondary outcomes estimated were the ambulation capacity, the knee range of motion, need for rescue analgesia and length of hospital stay.

RESULTS

The mean VAS score was significantly lower at rest and after mobilization in the combined group (3.51 at POD 1, 2.04 at POD 2), compared with either alone group (ACB = 4.70, 2.86 versus PLI = 4.39, 3.41 at POD 1 and 2 respectively after mobilization, p < 0.001). The ambulation capacity (combined = 103.3 steps versus ACB = 98.1 and PLI = 95.2 steps, p = 0.04) and the knee range of motion (arc of motion 106.7 degrees versus ACB = 104.9 and PLI = 102.2 degrees, p = 0.004) were significantly higher in the combined group compared to the other groups. There was no significant difference in the length of stay between the groups (p = 0.12).

CONCLUSION

Adductor canal block combined with periarticular local infiltration provides better pain relief, good range of motion, quicker rehabilitation, and reduced opioid consumption.

Reducing opioid usage in total knee arthroplasty postoperative pain management: a literature review and future directions

Total knee arthroplasty (TKA) is a common orthopedic surgery performed with a projected 3.5 million procedures to be done by 2030. Current postoperative pain management for TKA is insufficient, as it results in extensive opioid consumption and functional decline postoperatively. This study identifies the best practices for postoperative TKA pain management through a literature review of the last three years. Studies utilizing interventional techniques (local infiltration analgesia, nerve blocks) and pharmacologic options were reviewed on PubMed, Embase, Ovid Medline and Scopus. Primary outcomes analyzed were the effect of different analgesic approaches on pain reduction, opioid use reduction and improvements in functional mobility or quadriceps strength postoperatively. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.

An Update on Multimodal Pain Management After Total Joint Arthroplasty

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Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols.

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Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty.

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Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge.

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There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.

Fascial plane blocks: a narrative review of the literature

Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.

Efficacy of Adductor Canal Block Combined With Additional Analgesic Methods for Postoperative Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BACKGROUND

The aim of this study is to evaluate the efficacy of adductor canal block (ACB) combined with additional analgesic methods in total knee arthroplasty (TKA) and investigate whether blocking the sensory nerves that are distributed in the posterior and lateral aspect of knee could improve postoperative pain control.

METHODS

Two hundred scheduled patients for TKA were randomly allocated into 4 groups: Group A received ACB combined with iPACK (interspace between the popliteal artery and capsule of the knee) block and lateral femoral cutaneous nerve block (LFCNB); Group B received ACB combined with iPACK block; Group C received ACB combined with LFCNB; and Group D received ACB only. Postoperative pain score was the main primary outcome. Secondary outcomes included the morphine consumption and analgesic duration. Other outcomes included knee range of motion, quadriceps strength, ambulation, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index physical function, timed up and go (TUG) test, and complications.

RESULTS

Groups A, B, and C had lower postoperative pain scores within 12 hours at rest and 8 hours with activity than Group D (P < .05). In addition, Group A had lower morphine consumption than both Group C (P < .05) and Group D (P < .01). Group A had the longest analgesic duration (19.21 ± 3.22 hours) among all groups. There were no significant differences among the groups in terms of mobility and complication after surgery.

CONCLUSION

Combining ACB with both iPACK and LFCNB is an effective method for decreasing early postoperative pain in TKA without increasing the complications or affecting the early rehabilitation.

Which is the best analgesia treatment for total knee arthroplasty: Adductor canal block, periarticular infiltration, or liposomal bupivacaine? A network meta-analysis

STUDY OBJECTIVE

To review all randomized controlled trials (RCTs) comparing the analgesic efficacy of adductor canal block (ACB), periarticular infiltration (PAI), and any other mode of these treatments in analgesia, such as PAI with liposomal bupivacaine (LB), continuous adductor canal block (cACB) or ACB + PAI, after total knee arthroplasty (TKA).

DESIGN

Systematic review and network meta-analysis of RCTs.

PATIENTS

We searched PubMed, Embase, and the Cochrane database to detect all relevant RCTs on investigating the analgesic effects of ACB, PAI and LB for TKA published until April 2020.

INTERVENTIONS

Use of different analgesic methods of ACB, PAI, cACB, ACB + PAI and LB.

MEASUREMENTS

The primary endpoint was visual analog scale (VAS) score at rest and movement. The secondary endpoints were opioids consumption, length of hospitalization and knee range of motion (ROM). We used Cochrane risk of bias to assess the quality of evidence for outcomes.

RESULTS

Forty-two studies involving 3785 patients with 5 different methods containing ACB, PAI, ACB + PAI, continuous ACB (cACB), LB, were evaluated. According to surface under the cumulative ranking curve value, 24 h resting VAS score was the lowest the ACB + PAI (88.4%), followed by cACB (73.4%); Resting VAS score at 48 h and movement VAS score at 24 h and 48 h was the lowest in the cACB (99.9%, 92% and 100%). Total opioids consumption was the least in LB (81.4%) before cACB (60.8%). ROM was the largest in the ACB + PAI (84.1%) before cACB (78.8%).

CONCLUSION

Although all analgesic methods available were not evaluated, and further studies are needed to establish our results, the 24 h resting VAS score was lowest in ACB + PAI and 48 h resting and movement VAS score was lowest in cACB.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD 42020168102).

Continuous adductor canal block provides better performance after total knee arthroplasty compared with the single-shot adductor canal block?: An updated meta-analysis of randomized controlled trials

BACKGROUND

Adductor canal block (ACB) has emerged as an attractive alternative for femoral nerve blocks (FNB) as the peripheral nerve block of choice for total knee arthroplasty (TKA), preserving quadriceps motor function while providing analgesia comparable to FNB. However, its optimal application for TKA remains controversial. The objective of this meta-analysis was to compare continuous-injection ACB (CACB) vs single-injection ACB (SACB) for postoperative pain control in patients undergoing TKA.

METHODS

This study attempts to identify the available and relevant randomized controlled trials (RCTs) regarding the analgesic effects of CACB compared to SACB in patients undergoing TKA according to electronic databases, including PubMed, Medline, Web of Science, EMbase, and the Cochrane Library, up to September 2019. Primary outcomes in this regard included the use of a visual analogue scale (VAS) pain score with rest or activity, while secondary outcomes were cumulative opioid consumption, length of hospital stay (LOS), complications of vomiting and nausea, and rescue analgesia. The corresponding data were analyzed using RevMan v5.3.

ETHICAL REVIEW

Because all of the data used in this systematic review and meta-analysis has been published, the ethical approval was not necessary RESULTS:: This research included 9 studies comprised of 739 patients. The analyzed outcomes demonstrated that patients who received CACB had a better at rest-VAS scores at 4 hours (P = .007), 8 hors (P < .0001), 12 hours (P < .0001), 24 hours (P = .02), mobilization-VAS score at 48 hours (P < .0001), and rescue analgesia (P = .03) than those who underwent SACB. Nevertheless, no significant differences were present between the 2 strategies in terms of pain VAS scores 48 hours at rest (P = .23) and 24 hours at mobilization (P = .10), complications of vomiting and nausea (P = .42), and length of hospital stay (P = .09).

CONCLUSION

This meta-analysis indicated that CACB is superior to SACB in regard to analgesic effect following TKA. However, due to the variation of the included studies, no firm conclusions can be drawn. Further investigations into RCT are required for verification.

HTX-011 Reduced Pain and Opioid Use After Primary Total Knee Arthroplasty: Results of a Randomized Phase 2b Trial

BACKGROUND

HTX-011 is an extended-release, dual-acting local anesthetic consisting of bupivacaine and low-dose meloxicam in a novel polymer that is administered by needle-free application during surgery. The active ingredients are released from the polymer by controlled diffusion over 72 hours.

METHODS

This phase 2b, double-blind, placebo-controlled and active-controlled trial enrolled patients undergoing primary unilateral total knee arthroplasty under general anesthesia. Two hundred thirty-two patients were randomized into 4 groups: HTX-011 400 mg bupivacaine/12 mg meloxicam, applied without a needle into the surgical site, the same dose of HTX-011 with a separate 50 mg ropivacaine injection into the posterior capsule, bupivacaine hydrochloride (HCl) 125 mg injection, and saline placebo injection. Only opioids were permitted for postoperative pain rescue. Primary and key secondary endpoints were mean area under the curve of pain intensity scores over 48 hours and 72 hours, respectively, for HTX-011 groups vs placebo.

RESULTS

Both HTX-011 groups had significantly reduced mean pain intensity vs placebo through 48 and 72 hours (both P < .001). Ropivacaine added a small initial benefit in the first 12 hours. Both HTX-011 groups also had decreased mean pain intensity vs bupivacaine HCl alone through 48 and 72 hours (P < .05). The HTX-011 groups had significantly earlier discharge readiness along with lower opioid consumption through 72 hours. HTX-011 alone or with ropivacaine was well-tolerated with a safety profile similar to controls.

CONCLUSION

Needle-free application of HTX-011 400 mg bupivacaine/12 mg meloxicam provided superior pain reduction through 72 hours after total knee arthroplasty compared with placebo and bupivacaine HCl alone.

Analgesic effectiveness of Local Infiltrative Analgesia alone versus combined single dose adductor canal block with Local Infiltrative Analgesia: A single centre case control study

BACKGROUND

Both adductor canal block (ACB) and of Local Infiltrative Analgesia (LIA) have been shown to reduce pain after total knee arthroplasty (TKA). The efficacy of combining ACB and LIA remains controversial. The objective of this study is to analyse the effect of LIA + single dose ACB compared to LIA alone on early post-operative pain and mobilization in TKA.

METHODS

This Cohort Prospective study analyses the Visual Analogue Score (VAS) pain scores and rehabilitation milestones at 24 h between LIA alone and LIA + single dose ACB in unilateral TKA operated by a single surgeon between August 2014 and February 2019.

RESULTS

VAS at rest and on movement were significantly better in the combined LIA + ACB group (n = 151) compared to LIA (n = 120) alone at 24 h. All patients were able to achieve the desired milestones of sitting, standing by the bedside and walking with the help of a walker within 24 h of the surgery.

CONCLUSION

Though the VAS scores were statistically significant, the actual scores at rest and on movement in both groups were significantly better than preoperative scores with excellent pain relief. All patients in both groups were able to ambulate within 24 h. LIA alone significantly improved the pain scores and enabled early mobilization. Addition of single dose ACB to LIA did not significantly alter the milestones.

Evidence-based Review of Periarticular Injections and Peripheral Nerve Blocks in Total Knee Arthroplasty

Background:

Recently, post-operative pain management after Total Knee Arthroplasty (TKA) has focused on a multimodal approach for reducing opioid requirements, promoting early rehabilitation, and expediting discharge from hospital. Regional anesthesia, in the form of Periarticular Injections (PAI) and Peripheral Nerve Blocks (PNB), has shown promise as adjunctive therapy to oral analgesics.

Objective:

To review the current literature surrounding regional anesthesia for TKA.

Discussion:

PNBs provide effective analgesia after TKA. Historically, femoral nerve blocks (FNB) have been commonly employed. FNBs, however, lead to the significant motor blockade to the quadriceps musculature, which can dampen early rehabilitation efforts and increase the risk of post-operative falls. Adductor Canal Blocks (ACB) have shown excellent results in reducing post-operative pain while minimizing motor blockade. Periarticular injections (PAI), and infiltration between the popliteal Artery and Capsule of the Knee (IPACK) have similarly helped in reducing patient discomfort after TKA and providing analgesia to the posterior capsular region of the knee.

Conclusion:

PAIs, and PNBs are important elements in many multimodal postoperative pain management protocols after TKA. Current evidence appears to suggest that a combination of an ACB supplemented by posterior capsular analgesic coverage through PAI or IPACK may provide optimal results.

Surgeon-Performed High-Dose Bupivacaine Periarticular Injection With Intra-Articular Saphenous Nerve Block Is Not Inferior to Adductor Canal Block in Total Knee Arthroplasty

BACKGROUND

Periarticular injection or anesthesiologist-performed adductor canal block are commonly used for pain management after total knee arthroplasty. A surgeon-performed, intra-articular saphenous nerve block has been recently described. There is insufficient data comparing the efficacy and safety of these methods.

METHODS

This is a retrospective two-surgeon cohort study comparing short-term perioperative outcomes after primary total knee arthroplasty, in 50 consecutive patients with surgeon-performed high-dose periarticular injection and intra-articular saphenous nerve block (60 mL 0.5% bupivacaine, 30 mL saline, 30mg ketorolac) and 50 consecutive patients with anesthesiologist-performed adductor canal catheter (0.25% bupivacaine 6 mL/h infusion pump placed postoperatively with ultrasound guidance). Chart review assessed pain scores through POD #1, opioid use, length of stay, and short-term complications, including local anesthetic systemic toxicity. Statistical analysis was performed with two-tailed Student's T-test.

RESULTS

The high-dose periarticular injection cohort had significantly lower pain scores in the postanesthesia care unit (mean difference 1.4, P = .035), on arrival to the inpatient ward (mean difference 1.7, P = .013), and required less IV narcotics on the day of surgery (mean difference 6.5 MME, P = .0004). There was no significant difference in pain scores on POD #1, total opioid use, day of discharge, or short-term complications. There were no adverse events related to the high dose of bupivacaine.

CONCLUSION

Compared with postoperative adductor canal block catheter, an intraoperative high-dose periarticular block demonstrated lower pain scores and less IV narcotic use on the day of surgery. No difference was noted in pain scores on POD #1, time to discharge, or complications. There were no cardiovascular complications (local anesthetic systemic toxicity) despite the high dose of bupivacaine injected.

LEVEL OF EVIDENCE

III.

Postoperative Pain Management in Total Knee Arthroplasty

Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end‐stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient‐controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.

Decreasing hospital length of stay and enhancing recovery in Total Knee Arthroplasty

BACKGROUND

Patients undergoing Total Knee Arthroplasty (TKA) typically have early postoperative pain and decreased mobility, especially so in the first 24 h. Achieving a pain free knee in the immediate postoperative period and reducing complications using multimodal pain and blood management protocols forms a keystone in early mobilization and functional recovery. Enhanced Recovery after Surgery pathways (ERASp) since their inception, have significantly improved perioperative care and functional outcomes, thereby reducing the average length of stay (ALOS), complications and overall healthcare costs. ERASp modified suitably for TKA have had encouraging results. We have retrospectively analyzed the outcomes of the ERASp for TKA at our tertiary care centre with equal emphasis on pre-hospital preparations, in-hospital care, and post-hospital discharge.

METHODS

All TKA patients operated by the senior author between July 2016 and January 2018 with a minimum one year follow up were included. The outcomes measured were: Visual Analogue Score (VAS) for pain at rest and on movement, milestones, transfusion requirements, postoperative complications, ALOS and functional scores at one year follow-up.

RESULTS

775 patients (392 unilateral TKA {UTKA} and 383 bilateral {BTKA}) met our inclusion criteria. Both groups were comparable demographically. Mean VAS pain scores at rest were 3.15 ± 2.15 on the day of surgery, 2.5 ± 1.86 on the first postoperative day and 2.08 ± 1.81 on the second day, and 6.2 ± 2.38, 5.77 ± 2.34 and 4.71 ± 2.48 on movement respectively in the UTKA group. In the BTKA group, the mean VAS pain scores at rest were 4.39 ± 2.25 on the day of surgery, 3.98 ± 2.36 on the first postoperative day and 3.05 ± 2.12 on the second day and 6.21 ± 2.38, 5.77 ± 2.34 and 4.71 ± 2.48 on movement respectively. 85.49% of UTKA and 77.22% of BTKA patients walked on the day of surgery. Decrease in haemoglobin and transfusion rates were 1.25 ± 0.41 g% and 0.5%, 1.85 ± 0.62 and 3.9% in the UTKA and BTKA groups respectively.The average length of hospital stay (LOS) was 3.98 days. LOS was 3.17 and 4.78 days with 1.55% and 6.05% major complications in the UTKA and BTKA groups respectively.There was a significant improvement in Oxford Knee and WOMAC scores at 3, 6 and 12 months in both groups.

CONCLUSIONS

Pain following TKA is a major deterrent in early mobilization thereby delaying functional recovery and increasing ALOS. We recommend our multimodal interdisciplinary protocol to achieve early mobilization, better pain scores and minimize complications, resulting in overall reduced LOS.

Effect of Adductor Canal Block on Acute Perioperative Pain and Function in Total Knee Arthroplasty

BACKGROUND

Multimodal pain management strategies are commonplace in perioperative management of total knee arthroplasty (TKA), although controversy remains regarding the role of adductor canal blocks (ACB) in this algorithm. The purpose of this study is to independently evaluate the effect of ACB on short-term postoperative outcomes including (1) length of stay (LOS), (2) postoperative narcotic utilization, and (3) function with physical therapy in the era of modern TKA.

METHODS

We retrospectively identified a cohort of consecutive patients from January 2014 to January 2018 who had undergone unilateral primary TKA using a single-shot ACB in addition to a standardized multimodal pain regimen vs those who only received a multimodal pain regimen. These 2 groups were compared using independent sample t-tests with primary end points of interest being LOS, distance ambulated with therapy, and inpatient narcotic use.

RESULTS

There were 624 patients in the ACB group, with a mean age of 64.5 years. The group without ACB consisted of 69 patients, with a mean age of 67.2 years. We observed no significant difference in narcotic utilization postoperatively (2.361 vs 2.097, P = .088). The ACB group ambulated significantly further with therapy (75.8 vs 59.9 ft, P = .008) and had a shorter LOS in both total hours and percentage of postoperative day 1 (%POD1) discharges (34.8 vs 40.6 hours, P = .01, 83% vs 66.6%, P = .01).

CONCLUSION

ACB did not decrease postoperative pain medication utilization. The modest improvement in distance ambulated with therapy on POD1 (16 ft) and LOS (16% greater POD1 discharges) may not support the cost-effectiveness of this intervention.

LEVEL OF EVIDENCE

III, Retrospective Cohort.