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Zhang H, Deng Y, Zhao Y, Wang F. Efficacy of adductor canal and popliteal plexus block combined with local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee and local infiltrative analgesia for postoperative pain and functional outcome after total knee arthroplasty: A randomized controlled study. Knee 2024; 50:107-114. [PMID: 39153415 DOI: 10.1016/j.knee.2024.07.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 06/26/2024] [Accepted: 07/23/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Adductor canal block and periarticular infiltration analgesia (PIA) have been shown to relieve pain in total knee arthroplasty (TKA) effectively. However, their analgesic effectiveness has some limitations. Thus, we considered a novel blocking site that could achieve analgesia without affecting the muscle strength of the lower limbs. METHODS Seventy-two patients undergoing primary unilateral total knee arthroplasty were randomized into two groups. One group was treated with adductor canal and popliteal plexus (APB) combined with interspace between the popliteal artery and posterior capsule of the knee (iPACK) and local infiltration anesthesia (LIA) and the other was treated with PIA. The primary outcomes included postoperative pain, as assessed by the visual analog scale (VAS), and the consumption of oral tramadol. Secondary outcomes included functional recovery and daily ambulation distance. Tertiary outcomes included postoperative adverse effects. RESULTS The APB group had lower VAS scores after surgery at rest and during motion. Compared with the PIA group, the walking distance of the APB group on the second day was greater. The muscle strength of the APB group was lower than that of the PIA group at the early stage. Patients in the APB group also consumed less tramadol than those in the PIA group. There was no difference in the incidence of adverse events between the two groups. CONCLUSIONS APB combined with iPACK and LIA is a novel block for TKA, and it can reduce postoperative pain sooner after TKA without affecting postoperative functional recovery or increasing complications.
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Affiliation(s)
- Han Zhang
- Department of Anesthesiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yanan Deng
- Department of Anesthesiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Yongbin Zhao
- Department of Anesthesiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Fang Wang
- Department of Anesthesiology, Honghui Hospital, Xi'an Jiaotong University, Xi'an, China.
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Koczian O, Winkler H, Zental N, Innmann MM, Westhauser F, Walker T, Fischer D, Weigand MA, Decker SO. Comparing Different Multimodal Analgesia Protocols for Primary Total Knee Arthroplasty-A Retrospective Cohort Analysis. J Clin Med 2024; 13:4079. [PMID: 39064119 PMCID: PMC11277639 DOI: 10.3390/jcm13144079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
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.
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Affiliation(s)
- Otto Koczian
- Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (O.K.); (H.W.); (N.Z.); (D.F.); (M.A.W.)
| | - Harald Winkler
- Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (O.K.); (H.W.); (N.Z.); (D.F.); (M.A.W.)
| | - Nelly Zental
- Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (O.K.); (H.W.); (N.Z.); (D.F.); (M.A.W.)
| | - Moritz M. Innmann
- Medical Faculty Heidelberg, Department of Orthopedics, Heidelberg University, Schlierbacher Landstrasse 200A, 69118 Heidelberg, Germany; (M.M.I.); (F.W.); (T.W.)
| | - Fabian Westhauser
- Medical Faculty Heidelberg, Department of Orthopedics, Heidelberg University, Schlierbacher Landstrasse 200A, 69118 Heidelberg, Germany; (M.M.I.); (F.W.); (T.W.)
| | - Tilman Walker
- Medical Faculty Heidelberg, Department of Orthopedics, Heidelberg University, Schlierbacher Landstrasse 200A, 69118 Heidelberg, Germany; (M.M.I.); (F.W.); (T.W.)
| | - Dania Fischer
- Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (O.K.); (H.W.); (N.Z.); (D.F.); (M.A.W.)
| | - Markus A. Weigand
- Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (O.K.); (H.W.); (N.Z.); (D.F.); (M.A.W.)
| | - Sebastian O. Decker
- Medical Faculty Heidelberg, Department of Anesthesiology, Heidelberg University, Im Neuenheimer Feld 420, 69120 Heidelberg, Germany; (O.K.); (H.W.); (N.Z.); (D.F.); (M.A.W.)
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D'Souza RS, Barrington MJ, Sen A, Mascha EJ, Kelley GA. Systematic reviews and meta-analyses in regional anesthesia and pain medicine (Part II): guidelines for performing the systematic review. Reg Anesth Pain Med 2024; 49:403-422. [PMID: 37945064 DOI: 10.1136/rapm-2023-104802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 06/26/2023] [Indexed: 11/12/2023]
Abstract
In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota, USA
| | - Michael J Barrington
- Department of Anesthesia and Perioperative Pain Medicine, Oregon Health & Sciences University, Portland, Oregon, USA
| | - Ananda Sen
- Departments of Biostatistics and Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - George A Kelley
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, West Virginia, USA
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Zhao D, Li P. Efficacy of adding infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) to adductor canal block and local infiltration analgesia in total knee arthroplasty: A retrospective cohort study. J Orthop Surg (Hong Kong) 2024; 32:10225536241265445. [PMID: 38896879 DOI: 10.1177/10225536241265445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVE Local infiltration analgesia (LIA), adductor canal block (ACB), and infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) are popular multimodal analgesia techniques used during total knee arthroplasty (TKA). This study aimed to explore the efficacy of adding the IPACK technique to ACB and LIA in patients undergoing TKA. METHODS In this retrospective cohort study, patients who underwent primary unilateral TKA were divided into two groups based on their date of admission. Sixty-three patients underwent IPACK, ACB and LIA (IPACK group) during surgery, while 60 patients underwent ACB and LIA (control group). The primary outcome was the postoperative administration of morphine hydrochloride as a rescue analgesic. Secondary outcomes included time to first rescue analgesia, postoperative pain assessed using the visual analog scale (VAS), functional recovery assessed by knee range of motion and ambulation distance, time until hospital discharge, and complication rates. RESULTS The two groups were similar in average postoperative 0-to-24-h morphine consumption (11.8 mg for the control group vs 12.7 mg for the IPACK group, p = .428) and average total morphine consumption (18.2 mg vs 18.0 mg, p = .983) during hospitalization. There were also no significant differences in the secondary outcomes. CONCLUSIONS The addition of IPACK to ACB and LIA did not provide any clinical analgesic benefits. Orthopedic surgeons and anesthesiologists are justified in using ACB and LIA without IPACK for TKA.
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Affiliation(s)
- Dongmei Zhao
- Sports Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China
- Department of Orthopedics and Orthopedic Research Institute West China Hospital, Sichuan University, Chengdu 610041, China
| | - Pengcheng Li
- Sports Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China
- Department of Orthopedics and Orthopedic Research Institute West China Hospital, Sichuan University, Chengdu 610041, China
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Lawrence KW, Link L, Lavin P, Schwarzkopf R, Rozell JC. Characterizing patient factors, perioperative interventions, and outcomes associated with inpatients falls after total knee arthroplasty. Knee Surg Relat Res 2024; 36:11. [PMID: 38459532 PMCID: PMC10924359 DOI: 10.1186/s43019-024-00215-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 02/20/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION Mechanical falls represent a potential adverse event after total knee arthroplasty (TKA) and may introduce further injury and delay postoperative recovery. This study aimed to identify patient characteristics associated with inpatient falls, to determine the impact of inpatient falls on surgical outcomes following TKA, and to describe the relationship between tourniquet and/or adductor canal block (ACB) use and fall rates. METHODS Patients undergoing primary, elective TKA at a single institution between 2018 and 2022 were retrospectively analyzed. Patients were stratified into groups based on whether they sustained a postoperative inpatient fall or not. Perioperative characteristics, lengths of stay (LOS), rates of 90-day readmissions, and revisions were compared, and fall characteristics were described. Subanalysis was conducted comparing fall incidence based on tourniquet and/or ACB use. RESULTS In total 6472 patients were included with 39 (0.6%) sustaining falls. Falls most commonly occurred on postoperative days one (43.6%) and two (30.8%), and were most commonly due to loss of balance (41.9%) or buckling (35.5%). Six (15.4%) fall patients sustained minor injuries, and one (2.6%) sustained major injury (malleolar fracture requiring non-operative orthopaedic management). The LOS (3.0 ± 1.5 vs 2.3 ± 1.5 days, p = 0.002) and all-cause revision rates at latest follow-up (10.3% vs. 2.0%, p = 0.008) were significantly higher in the fall group. Falls were comparable across subgroups based on tourniquet and/or ACB use (p = 0.429). CONCLUSION Patients who fell had a longer LOS and higher revision rate postoperatively. Rates of inpatient falls were comparable regardless of tourniquet and/or ACB use. Concern for inpatient falls should not influence surgeons when considering the use of tourniquets and/or ACBs, though well-designed, large-volume, prospective randomized studies are warranted to better understand this relationship.
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Affiliation(s)
- Kyle W Lawrence
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Lauren Link
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Patricia Lavin
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Fl Suite 1518, New York, NY, 10003, USA.
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D'Souza RS, Barrington MJ, Sen A, Mascha EJ, Kelley GA. Systematic Reviews and Meta-analyses in Regional Anesthesia and Pain Medicine (Part II): Guidelines for Performing the Systematic Review. Anesth Analg 2024; 138:395-419. [PMID: 37942964 DOI: 10.1213/ane.0000000000006607] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
In Part I of this series, we provide guidance for preparing a systematic review protocol. In this article, we highlight important steps and supplement with exemplars on conducting and reporting the results of a systematic review. We suggest how authors can manage protocol violations, multiplicity of outcomes and analyses, and heterogeneity. The quality (certainty) of the evidence and strength of recommendations should follow the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. It is our goal that Part II of this series provides valid guidance to authors and peer reviewers who conduct systematic reviews to adhere to important constructs of transparency, structure, reproducibility, and accountability. This will likely result in more rigorous systematic reviews being submitted for publication to the journals like Regional Anesthesia & Pain Medicine and Anesthesia & Analgesia .
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Affiliation(s)
- Ryan S D'Souza
- From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, Minnesota
| | - Michael J Barrington
- Department of Anesthesia and Perioperative Pain Medicine, Oregon Health & Sciences University, Portland, Oregon
| | - Ananda Sen
- Departments of Biostatistics and Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Edward J Mascha
- Departments of Quantitative Health Sciences and Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - George A Kelley
- Department of Epidemiology and Biostatistics, West Virginia University, Morgantown, West Virginia
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Abdo HMA, Abd Elaziz MS, Elhamid AEEA, Kassem AA, Haiba DM. Effect of Adding Infiltration between The Popliteal Artery and Capsule of The Knee Block (IPACK) to Continuous Adductor Canal Block after Total Knee Arthroplasty. EGYPTIAN JOURNAL OF ANAESTHESIA 2023; 39:680-686. [DOI: 10.1080/11101849.2023.2246732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/25/2023] [Accepted: 08/07/2023] [Indexed: 09/01/2023] Open
Affiliation(s)
- Hatem Mohammed Ahmed Abdo
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Saeed Abd Elaziz
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amr Essam Eldin Abd Elhamid
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amr Ahmed Kassem
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Diaaeldein Mahmoud Haiba
- Department of Anesthesiology, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Domagalska M, Wieczorowska-Tobis K, Reysner T, Kowalski G. Periarticular injection, iPACK block, and peripheral nerve block in pain management after total knee arthroplasty: a structured narrative review. Perioper Med (Lond) 2023; 12:59. [PMID: 37968690 PMCID: PMC10652613 DOI: 10.1186/s13741-023-00346-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/25/2023] [Indexed: 11/17/2023] Open
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is commonly performed in patients with end-stage osteoarthritis or rheumatoid arthritis of the knee to reduce joint pain, increase mobility, and improve quality of life. However, TKA is associated with moderate to severe postoperative pain, which remains a significant clinical challenge. Surgeon-administered PAI and anesthesiologist-administered iPACK have proven viable alternatives to conventional peripheral nerve blocks. This review aims to discuss which IPACK block or periarticular injection, combined or not with different peripheral nerve blocks, has better effects on postoperative rehabilitation, patient satisfaction, and overall outcome. MATERIAL AND METHODS The literature review was performed on standards of care, current therapeutic options, a pain management protocol, and innovative treatment options for patients undergoing total knee arthroplasty. The literature was reviewed through four electronic databases: PubMed, Cochrane Library, Google Scholar, and Embase. RESULTS The initial search yielded 694 articles. Fifty relevant articles were selected based on relevance, recentness, search quality, and citations. Six studies compared PAI to peripheral nerve block (PNB), and eight studies checked the effectiveness of adding PNB to PAI. Three studies compared iPACK to PNB, and ten reviewed the point of adding PNB to iPACK. CONCLUSIONS The literature review indicates that the best analgesic effect is obtained by combining PAI or iPACK with a peripheral nerve block, particularly with ACB, due to its analgesic, motor-sparing effect, and satisfactory analgesia.
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Affiliation(s)
- Małgorzata Domagalska
- Chair and Department of Palliative Medicine, University of Medical Sciences, Os.Rusa 55 61-245, Poznań, Poland.
| | | | - Tomasz Reysner
- Chair and Department of Palliative Medicine, University of Medical Sciences, Os.Rusa 55 61-245, Poznań, Poland
| | - Grzegorz Kowalski
- Chair and Department of Palliative Medicine, University of Medical Sciences, Os.Rusa 55 61-245, Poznań, Poland
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Wang Q, Hu J, Ma T, Zhao D, Yang J, Kang P. Comparison of Different Concentrations of Ropivacaine Used for Ultrasound-Guided Adductor Canal Block + IPACK Block in Total Knee Arthroplasty. J Knee Surg 2023; 36:1273-1282. [PMID: 35944570 DOI: 10.1055/s-0042-1755368] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This study aimed to compare the analgesic efficacy of different concentrations of ropivacaine used for the combination of ultrasound-guided adductor canal block (ACB) and infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block in total knee arthroplasty (TKA). Before general anesthesia, 90 patients undergoing TKA were randomized to receive ACB + IPACK block with ropivacaine 0.2, 0.25, or 0.3% (defined as group A, B, and C, respectively). Primary outcome was the reported visual analog scale (VAS) pain scores at rest 30 minutes following arrival to the postanesthesia care unit (PACU). Secondary outcomes were postoperative VAS pain scores, postoperative morphine consumption, the time to first rescue analgesia, functional recovery of knee (including the range of motion and quadriceps strength), and postoperative complications. Compared with group A, group B and group C had significantly lower VAS scores 30 minutes following arrival to the PACU (p < 0.001 and p < 0.001, respectively). These two groups also had significantly lower VAS pain scores at postoperative 2 hours (at rest: p = 0.037 and 0.002; during motion: p = 0.035 and 0.001, respectively) and 6 hour (at rest: p = 0.033 and 0.002; during motion: p < 0.001 and p < 0.001, respectively), lower postoperative morphine consumption (p = 0.001 and 0.002, respectively), longer time to first rescue analgesia (p = 0.010 and 0.009, respectively), and better range of knee motion on the day of surgery (p = 0.008 and 0.002, respectively). Group B and group C showed no significant differences in these outcomes between each other (p > 0.05). The three groups did not show a significant difference in postoperative quadriceps strength and complication rates (p > 0.05). Compared with ropivacaine 0.2%, ropivacaine 0.25 and 0.3% can provide early pain relief in the first 6 hours after surgery. Ropivacaine 0.25 and 0.3% may provide more clinical benefits for patients undergoing outpatient TKA.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jian Hu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ting Ma
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Dongmei Zhao
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jing Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Hussain N, Brull R, Vannabouathong C, Robinson C, Zhou S, D'Souza RS, Sawyer T, Terkawi AS, Abdallah FW. Analgesic Effectiveness of Motor-sparing Nerve Blocks for Total Knee Arthroplasty: A Network Meta-analysis. Anesthesiology 2023; 139:444-461. [PMID: 37364292 DOI: 10.1097/aln.0000000000004667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Abstract
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
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Affiliation(s)
- Nasir Hussain
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Chris Vannabouathong
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Christopher Robinson
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard, Boston, Massachusetts
| | - Steven Zhou
- Department of Anesthesiology, The Ohio State University, Wexner Medical Center, Columbus, Ohio
| | - Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Tamara Sawyer
- College of Medicine, Central Michigan University, Saginaw, Michigan
| | - Abdullah Sulieman Terkawi
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, California
| | - Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Kampitak W, Kertkiatkachorn W, Ngarmukos S, Tanavalee A, Tanavalee C, Tangkittithaworn C. Comparison of Analgesic Efficacies of the iPACK (Interspace Between the Popliteal Artery and Capsule of the Posterior Knee) and Genicular Nerve Blocks Used in Combination With the Continuous Adductor Canal Block After Total Knee Arthroplasty: A Randomized Clinical Trial. J Arthroplasty 2023; 38:1734-1741.e2. [PMID: 36931354 DOI: 10.1016/j.arth.2023.03.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 03/19/2023] Open
Abstract
BACKGROUND The interspace between the popliteal artery and capsule of the posterior knee (iPACK) block and the genicular nerve block (GNB) are motor-sparing nerve blocks used for knee pain relief. We compared the analgesic efficacies of ultrasound-guided iPACK block and GNB when combined with continuous adductor canal block after total knee arthroplasty. METHODS In this randomized control study, 132 total knee arthroplasty patients were assigned to the iPACK, GNB, and iPACK + GNB groups. All patients received combined spinal anesthesia and continuous adductor canal block. The primary outcome was the 8-hour postoperative pain score during movement. Secondary outcomes were pain scores, posterior knee pain, intravenous morphine consumption, and tibial and common peroneal nerve sensorimotor function. All included patients completed the study. RESULTS The 4-hour and 8-hour postoperative pain scores during movement were significantly lower in the iPACK + GNB group than that in the iPACK group (-2.5 [3.6, 1.3]; P < .001 and -2 [-3, -1]; P < .001, respectively). The differences in rating pain scores and posterior knee pain were not clinically relevant. The iPACK group demonstrated a significantly higher intravenous morphine consumption than did the GNB and iPACK + GNB groups during the first 48 hours postoperatively (P < .001) but were not clinically relevant. There was no incidence of complete sensorimotor blockade in any of the groups. CONCLUSION The iPACK-GNB combination relieved pain during movement better than the iPACK block alone during the 8 hours postoperatively after total knee arthroplasty in setting of multimodal analgesia such as adductor canal block.
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Affiliation(s)
- Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wannida Kertkiatkachorn
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srihatach Ngarmukos
- Department of Orthopedics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aree Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chotetawan Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chonruethai Tangkittithaworn
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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12
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Qiao Y, Li F, Zhang L, Song X, Yu X, Yang W, Zhou S, Zhang H. Clinical effects of interspace between the popliteal artery and capsule of the posterior knee block with multimodal analgesia for total knee arthroplasty: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023; 143:5815-5832. [PMID: 36790543 PMCID: PMC10449984 DOI: 10.1007/s00402-023-04798-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/22/2023] [Indexed: 02/16/2023]
Abstract
PURPOSE Combination of regional anaesthesia technique that is most effective in analgesia and postoperative functional outcome with the fewest complications needs investigation. Interspace between the popliteal artery and the capsule of the posterior knee block (IPACK) has been introduced clinically. We evaluated the efficacy of IPACK in combination with other nerve blocks after total knee arthroplasty. METHODS Data were obtained from PubMed, Cochrane Library, Web of Science, and Sciencedirect. Studies that compared outcomes using IPACK combined with other regional nerve blocks after total knee arthroplasty with other analgesic modalities and those which used pain scores or opioid consumption as primary or secondary outcomes were included. RESULTS Seventeen articles (20 trials, 1652 patients) were included. IPACK supplementation significantly reduced rest pain scores after total knee arthroplasty at postoperative hours 8-12(95%CI - 0.85 [- 1.36, - 0.34], I2 = 94%, p = 0.001), postoperative day 1 (95% CI - 0.49 [- 0.85, - 0.14], I2 = 87%, p = 0.006), and postoperative day 2 (95% CI - 0.28 [- 0.51, -0.05], I2 = 72%, p = 0.02); there was no significant difference at postoperative day 3 or discharge (95% CI - 0.14 [- 0.33, 0.05], I2 = 0%, p = 0.14). Combination treatment resulted in reduced dynamic pain scores at postoperative hours 8-12 (95%CI - 0.52 [- 0.92, - 0.12], I2 = 86%, p = 0.01) and postoperative day 1(95% CI - 0.49 [- 0.87, - 0.11], I2 = 88%, p = 0.01). There was no difference between postoperative day 2(95% CI - 0.29 [- 0.63, 0.05], I2 = 80%, p = 0.09), postoperative day 3 or discharge (95% CI - 0.45 [- 0.92, 0.02], I2 = 83%, p = 0.06). In addition, it strongly reduced postoperative opioid consumption within 24 H (95% CI - 0.76 [- 1.13, - 0.39], I2 = 85%, p < 0.00001), 24-48 H (95% CI - 0.43 [- 0.85, - 0.01], I2 = 83%, p = 0.04), and total opioid use (95% CI - 0.64 [- 1.07, - 0.22], I2 = 86%, p = 0.003). Although IPACK supplementation improved timed up and go test and walking distance at postoperative day 2, there was no statistically significant difference at other time periods or obvious improvement in knee range of motion and quadriceps strength. IPACK block supplementation could shorten the length of stay (LOS) (95% CI - 0.40 [- 0.64, - 0.15], I2 = 70%, p = 0.001) and improve patient satisfaction (95% CI 0.43 [0.01, 0.84], I2 = 87%, p = 0.04). CONCLUSION Based on these results, IPACK supplementation, in addition to standard postoperative analgesia, can be used effectively and safely to relieve early postoperative pain after total knee arthroplasty.
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Affiliation(s)
- Yongjie Qiao
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, No. 333, Nanbinghe Road, Qilihe District, Lanzhou, 730050, Gansu, China
| | - Feng Li
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, No. 333, Nanbinghe Road, Qilihe District, Lanzhou, 730050, Gansu, China
- Department of Orthopedics, The 943rd Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Wuwei, Gansu, China
| | - Lvdan Zhang
- Department of Respiratory Medicine, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, Lanzhou, Gansu, China
| | - Xiaoyang Song
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, No. 333, Nanbinghe Road, Qilihe District, Lanzhou, 730050, Gansu, China
| | - Xinyuan Yu
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, No. 333, Nanbinghe Road, Qilihe District, Lanzhou, 730050, Gansu, China
| | - Wenbin Yang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, No. 333, Nanbinghe Road, Qilihe District, Lanzhou, 730050, Gansu, China
| | - Shenghu Zhou
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, No. 333, Nanbinghe Road, Qilihe District, Lanzhou, 730050, Gansu, China
| | - Haoqiang Zhang
- Department of Joint Surgery, The 940th Hospital of Joint Logistic Support Force of Chinese People's Liberation Army, No. 333, Nanbinghe Road, Qilihe District, Lanzhou, 730050, Gansu, China.
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13
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Zhao C, Wang L, Chen L, Wang Q, Kang P. Effects of magnesium sulfate on periarticular infiltration analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled trial. J Orthop Surg Res 2023; 18:301. [PMID: 37060089 PMCID: PMC10105472 DOI: 10.1186/s13018-023-03790-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 04/10/2023] [Indexed: 04/16/2023] Open
Abstract
BACKGROUND To investigate whether adding magnesium sulfate to a periarticular infiltration analgesia (PIA) cocktail could improve pain control and functional outcomes in patients undergoing total knee arthroplasty (TKA). METHODS Ninety patients were randomly assigned to the magnesium sulfate and control groups, with 45 patients in each group. In the magnesium sulfate group, patients were given a periarticular infusion of a cocktail of analgesics consisting of epinephrine, ropivacaine, magnesium sulfate, and dexamethasone. The control group received no magnesium sulfate. The primary outcomes consisted of visual analogue scale (VAS) pain scores, postoperative morphine hydrochloride consumption for rescue analgesia, and time to first rescue analgesia. Secondary outcomes were postoperative inflammatory biomarkers (IL-6 and CRP), postoperative length of stay, and knee functional recovery (assessed by knee range of motion, quadriceps strength, daily mobilization distance, and time to first straight-leg raising). Tertiary outcomes included the postoperative swelling ratio and complication rates. RESULTS Within 24 h of surgery, patients in the magnesium sulfate group had markedly lower VAS pain scores during motion and at rest. After the addition of magnesium sulfate, the analgesic effect was dramatically prolonged, leading to a reduction in morphine dosage within 24 h and the total morphine dosage postoperatively. Postoperative inflammatory biomarker levels were significantly reduced in the magnesium sulfate group compared with the control. There were no considerable differences between the groups in terms of the postoperative length of stay and knee functional recovery. Both groups had similar postoperative swelling ratios and incidences of complications. CONCLUSIONS The addition of magnesium sulfate to the analgesic cocktail for PIA can prolong postoperative analgesia, decrease the consumption of opioids, and effectively alleviate early postoperative pain after TKA. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR2200056549. Registered on 7 February 2022, https://www.chictr.org.cn/showproj.aspx?proj=151489 .
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Affiliation(s)
- Chengcheng Zhao
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Liying Wang
- Department of Operating Room, West China Hospital, Sichuan University, Chengdu, China
- West China School of Nursing, Sichuan University, Chengdu, China
| | - Liyile Chen
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Qiuru Wang
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China
| | - Pengde Kang
- Department of Orthopaedics, Orthopaedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, 610041, Sichuan, China.
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14
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Wang JH, Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis. J Knee Surg 2023; 36:345-353. [PMID: 34600437 DOI: 10.1055/s-0041-1733882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: -1.18; 95% confidence interval [CI]: -2.05 to -0.30) and during activity (SMD: -0.26; 95% CI: -0.49 to -0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: -0.295; 95% CI: -0.543 to -0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.
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Affiliation(s)
- Jou-Hua Wang
- Department of Orthopedics, National Cheng Kung University, Tainan, Taiwan
| | - Hsuan-Hsiao Ma
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Te-Feng Arthur Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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15
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Tang X, Wang D, Mou P, Lei L, Ning N, Chen J, Zhou Z. 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. J Arthroplasty 2023:S0883-5403(23)00010-4. [PMID: 36690189 DOI: 10.1016/j.arth.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 01/04/2023] [Accepted: 01/15/2023] [Indexed: 01/21/2023] Open
Abstract
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.
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Affiliation(s)
- Xiumei Tang
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Duan Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ping Mou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Lei Lei
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ning Ning
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
| | - Jiali Chen
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
| | - Zongke Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
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16
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Motor-Sparing Effect of Adductor Canal Block for Knee Analgesia: An Updated Review and a Subgroup Analysis of Randomized Controlled Trials Based on a Corrected Classification System. Healthcare (Basel) 2023; 11:healthcare11020210. [PMID: 36673579 PMCID: PMC9859112 DOI: 10.3390/healthcare11020210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Discrepancies in the definition of adductor canal block (ACB) lead to inconsistent results. To investigate the actual analgesic and motor-sparing effects of ACB by anatomically defining femoral triangle block (FTB), proximal ACB (p-ACB), and distal ACB (d-ACB), we re-classified the previously claimed ACB approaches according to the ultrasound findings or descriptions in the corresponding published articles. A meta-analysis with subsequent subgroup analyses based on these corrected results was performed to examine the true impact of ACB on its analgesic effect and motor function (quadriceps muscle strength or mobilization ability). An optimal ACB technique was also suggested based on an updated review of evidence and ultrasound anatomy. MATERIALS AND METHODS We systematically searched studies describing the use of ACB for knee surgery. Cochrane Library, PubMed, Web of Science, and Embase were searched with the exclusion of non-English articles from inception to 28 February 2022. The motor-sparing and analgesic aspects in true ACB were evaluated using meta-analyses with subsequent subgroup analyses according to the corrected classification system. RESULTS The meta-analysis includes 19 randomized controlled trials. Compared with the femoral nerve block group, the quadriceps muscle strength (standardized mean difference (SMD) = 0.33, 95%-CI [0.01; 0.65]) and mobilization ability (SMD = -22.44, 95%-CI [-35.37; -9.51]) are more preserved in the mixed ACB group at 24 h after knee surgery. Compared with the true ACB group, the FTB group (SMD = 5.59, 95%-CI [3.44; 8.46]) has a significantly decreased mobilization ability at 24 h after knee surgery. CONCLUSION By using the corrected classification system, we proved the motor-sparing effect of true ACB compared to FTB. According to the updated ultrasound anatomy, we suggested proximal ACB to be the analgesic technique of choice for knee surgery. Although a single-shot ACB is limited in duration, it remains the candidate of the analgesic standard for knee surgery on postoperative day 1 or 2 because it induces analgesia with less motor involvement in the era of multimodal analgesia. Furthermore, data from the corrected classification system may provide the basis for future research.
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17
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Wang Q, Ma T, Hu J, Yang J, Kang P. Minimum effective volume of ropivacaine for ultrasound-guided adductor canal + IPACK block in total knee arthroplasty: A double-blind, randomized dose-finding trial. J Orthop Surg (Hong Kong) 2023; 31:10225536231161873. [PMID: 36862143 DOI: 10.1177/10225536231161873] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Our previous study reported that when a respective 20 mL of ropivacaine was used for adductor canal block (ACB) combined with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block for patients undergoing total knee arthroplasty (TKA), the minimum concentration of 0.275% could provide successful block in almost all patients. Based on the results, the primary objective of this study was to investigate the minimum effective volume (MEV90, defined as the volume which can provide successful block in 90% of patients) of ACB + IPACK block. METHODS This double-blind, randomized dose-finding trial was based on a biased coin up-and-down sequential design, where the volume of ropivacaine administered to a given patient depended on the previous patient's response. The first patient received 15 mL of 0.275% ropivacaine for ACB and again for IPACK. If the block failed, the next subject received a 1 mL higher volume for ACB and IPACK, respectively; otherwise, the next subject received either a 1 mL lower volume (probability of 0.11) or the same volume (probability of 0.89). The primary outcome was whether the block was successful. Block success was defined as the patient did not suffer significant pain and did not receive rescue analgesia within 6 h after surgery. Then the MEV90 was estimated by isotonic regression. RESULTS Based on analysis of 53 patients, the MEV90 was 17.99 mL (95% CI 17.47-18.61 mL), MEV95 was 18.48 mL (95% CI 17.45-18.98 mL) and MEV99 was 18.90 mL (95% CI 17.38-19.07 mL). Patients whose blocks succeeded had significantly lower NRS pain scores, lower morphine consumption, and shorter hospitalization. CONCLUSION 0.275% ropivacaine in 17.99 mL respectively can provide successful ACB + IPACK block in 90% of patients undergoing TKA. The minimum effective volume (MEV90) of ACB + IPACK block was 17.99 mL.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedics surgery, 34753West China Hospital, Sichuan University, China
| | - Ting Ma
- Anesthesia and Surgery Center, 34753West China Hospital, Sichuan University, China.,Department of Anesthesiology, 34753West China Hospital, Sichuan University, China
| | - Jian Hu
- Department of Anesthesiology, 34753West China Hospital, Sichuan University, China
| | - Jing Yang
- Anesthesia and Surgery Center, 34753West China Hospital, Sichuan University, China.,Department of Anesthesiology, 34753West China Hospital, Sichuan University, China
| | - Pengde Kang
- Department of Orthopaedics surgery, 34753West China Hospital, Sichuan University, China.,Anesthesia and Surgery Center, 34753West China Hospital, Sichuan University, China
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18
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Shabayek MI, Eskandar FSL, Hasanin SMK, Moussa Ahmad AH. Comparative study between the analgesic efficacy of adductor canal block alone and adductor canal with IPACK (interspace between popliteal artery and capsule of the knee) block for knee surgeries. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2124787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
- Mohamed Ibrahim Shabayek
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Fahmy Saad Latif Eskandar
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sahar Mohamed Kamal Hasanin
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Aya Hisham Moussa Ahmad
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Tang X, Lai Y, Du S, Ning N. Analgesic efficacy of adding the IPACK block to multimodal analgesia protocol for primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2022; 17:429. [PMID: 36175927 PMCID: PMC9523917 DOI: 10.1186/s13018-022-03266-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/26/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a standard treatment for end-stage degenerative knee disease. Most patients will experience moderate-to-severe postoperative knee pain, significantly affecting rehabilitation. However, controversy remains regarding the efficacy of adding the interspace between the popliteal artery and capsule of the knee (IPACK) into multimodal analgesia protocol. METHODS PubMed, Medline, Embase, Cochrane Library, and other databases were searched from inception to February 1, 2021. Studies comparing patients receiving IPACK to patients not receiving IPACK were included. The primary outcome was the ambulation pain score on a visual analogue scale (VAS) of 0-10. Secondary outcomes included pain score at rest, morphine usage, functional recovery, clinical outcomes, and complications. RESULTS Thirteen RCTs involving 1347 knees were included. IPACK was associated with lower ambulation pain scores (weight mean difference [WMD] - 0.49, 95% confidence interval [CI] - 0.72 to - 0.26). The benefits were observed from 2 to 4 h, 6 to 12 h, and beyond one week. IPACK also significantly reduced rest pain scores (WMD - 0.49, 95% CI - 0.74 to - 0.24), and the benefits were observed from 6 to 12 h and beyond one week. IPACK reduced the overall morphine consumption (WMD - 2.56, 95% CI - 4.63 to - 0.49). Subgroup analysis found reduced oral morphine consumption from 24 to 48 h (WMD - 2.98, 95% CI - 5.71 to - 0.24) and reduced rate of morphine requirement from 12 to 24 h (relative risk [RR] = 0.51, 95% CI 0.31 to 0.83). Functional recovery outcomes regarding ambulation distances (on the second postoperative day [POD2]) (WMD = 1.74, 95% CI 0.34 to 3.15) and quadriceps muscle strength (at 0 degree) (WMD = 0.41, 95% CI 0.04 to 0.77) favored IPACK. And IPACK reduced the rate of sleep disturbance (on POD 1) (RR = 0.39, 95% CI 0.19 to 0.81). There was no significant difference in the other outcomes. CONCLUSIONS Moderate-level evidence confirmed that IPACK was related to better results in pain scores, morphine usage, and functional recovery without increasing the risk of complications. REGISTRATION CRD42021252156.
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Affiliation(s)
- Xiumei Tang
- grid.13291.380000 0001 0807 1581West China School of Nursing, Sichuan University, #37 Guoxue Road, Chengdu, 610041 People’s Republic of China ,grid.13291.380000 0001 0807 1581Department of Orthopedics, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041 People’s Republic of China
| | - Yahao Lai
- grid.13291.380000 0001 0807 1581Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041 People’s Republic of China
| | - Siwei Du
- grid.13291.380000 0001 0807 1581West China School of Nursing, Sichuan University, #37 Guoxue Road, Chengdu, 610041 People’s Republic of China ,grid.13291.380000 0001 0807 1581Department of Orthopedics, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041 People’s Republic of China
| | - Ning Ning
- grid.13291.380000 0001 0807 1581West China School of Nursing, Sichuan University, #37 Guoxue Road, Chengdu, 610041 People’s Republic of China ,grid.13291.380000 0001 0807 1581Department of Orthopedics, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041 People’s Republic of China
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20
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Tang X, Jiang X, Lei L, Zhu W, Fu Z, Wang D, Chen J, Ning N, Zhou Z. 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. Orthop Surg 2022; 14:2809-2821. [PMID: 36125191 DOI: 10.1111/os.13263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Xiumei Tang
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Xile Jiang
- Department of Clinical Nutrition, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Lei Lei
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Weitao Zhu
- Department of Computer Science and Technology, Sichuan University, Chengdu, P.R. China
| | - Zhongmin Fu
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Duan Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Jiali Chen
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Ning Ning
- West China School of Nursing, Sichuan University/Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, P.R. China
| | - Zongke Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, P.R. China
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Su C, Liu Y, Wu P, Lang J, Chen L. Comparison Between Periarticular Analgesia Versus Intraarticular Injection for Effectiveness and Safety After Total Knee Arthroplasty. J Perianesth Nurs 2022; 37:952-955. [PMID: 36123240 DOI: 10.1016/j.jopan.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/08/2022] [Accepted: 04/24/2022] [Indexed: 10/14/2022]
Abstract
PURPOSE In most studies, local infiltration analgesia (LIA) can provide better analgesic effect in the early postoperative period, but the optimal technique is unknown. Our study was designed to evaluated the early clinical efficacy and safety of periarticular analgesia versus intraarticular injection in Total knee arthroplasty (TKA). DESIGN A prospective study was conducted on 100 patients admitted for TKA. Subjects were divided into two groups: 50 in group A, 50 in Group B. METHODS Patients in group A received periarticular analgesia with ropivacaine 300 mg and morphine 5 mg (the drugs were diluted with saline to 50 ml) in the periosteal borders, posterior capsule and extensor apparatus and subcutaneous tissues during surgery. After stitching of joint capsule, tranexamic acid (TXA) 2 g (20 ml) was injected into the articular cavity. Group B patients had all of the 70 mL mixture (ropivacaine 300 mg, morphine 5 mg and TXA 2 g) injected intraarticularly after stitching of the joint capsule. We assessed postoperative length of stay (LOS), knee functional outcome, pain, and complications after surgery. FINDINGS There was no statistical difference in visual analog scale (VAS) scores for knee pain between the two groups on postoperative day (POD)1, 3, or 30 (P > .05). Mean postoperative LOS was 7.40 ± 1.98 days in Group A, compared to 8.02 ± 2.09 days in Group B (P > .05). No significant differences between groups were seen in the mean swelling ratio (P > .05), and no significant differences were found in the Hospital for Special Surgery (HSS) knee score and range of motion (ROM) at 30 days follow-up (P > .05). There was also no statistical difference in the incidence of complications (such as superficial wound infection, deep vein thrombosis (DVT) and nausea and vomiting) between the Group A and the Group B. CONCLUSIONS In conclusion, it seems that intraarticular injection had a similar analgesic effect compared with periarticular injection when adopting a multi-modal analgesia regimen. Our results suggest that there is no obvious advantage with the use of periarticular injections compared to intraarticular injection. The authors believe that intraarticular injection may be a better technique compared with periarticular injections in the absence of a drainage tube because intraarticular injection can reduce the number of surgical steps and have similar postoperative outcomes.
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Affiliation(s)
- Chenxian Su
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yangbo Liu
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peng Wu
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Junzhe Lang
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lei Chen
- Department of Orthopedics, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China.
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Wang Q, Hu J, Cai L, Bahete A, Yang J, Kang P. Minimum effective concentration of ropivacaine for ultrasound-guided adductor canal + IPACK block in total knee arthroplasty. J Orthop Surg (Hong Kong) 2022; 30:10225536221122339. [PMID: 35975643 DOI: 10.1177/10225536221122339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the minimum effective concentration (MEC90, defined as effective in 90% of patients) of ropivacaine during the combined procedure of adductor canal block (ACB) and infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block for patients undergoing total knee arthroplasty. METHODS This double-blind, randomized dose-finding trial was based on a biased coin up-and-down sequential design, where the concentration of ropivacaine administered to a given patient depended on the previous patient's response. Before surgery, the first patient received 20 mL of 0.2% ropivacaine for ACB and again for IPACK. If the block failed, the next subject received a 0.025% higher ropivacaine concentration; otherwise, the next subject received either a 0.025% smaller dose (probability of 0.11) or the same dose (probability of 0.89). The primary outcome was whether the block was successful. Block success was defined as the patient did not suffer significant pain and did not receive rescue analgesia within 6 h after surgery. MEC90 was estimated by isotonic regression, and the 95% confidence interval (CI) was calculated by bootstrapping. Secondary outcomes were numerical rating scale (NRS) pain scores at postoperative 24 h and 48 h, postoperative morphine consumption, and time to hospital discharge. Secondary outcomes were compared between patients whose blocks succeeded with those which failed. RESULTS Based on analysis of 52 patients, the MEC90 was 0.247% (95% CI 0.227-0.271%), MEC95 was 0.260% (95% CI 0.244-0.282%) and MEC99 was 0.272% (95% CI 0.260-0.291%). In contrast, four of nine trials in a recent systematic review reported ropivacaine concentrations below 0.247%. Patients whose blocks succeeded (n = 45) had significantly lower NRS pain scores, lower morphine consumption, and shorter hospitalization than patients whose blocks failed (n = 7). CONCLUSIONS Our small trial suggests that 0.247% ropivacaine in 20 mL respectively can provide successful ACB + IPACK block in 90% of patients. However, given that many published trials have used lower concentrations, our findings should be verified in larger studies.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedics surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Jian Hu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lijun Cai
- Department of Orthopaedics surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Aergen Bahete
- Department of Orthopaedics surgery, West China Hospital, 34753Sichuan University, Chengdu, China
| | - Jing Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Pengde Kang
- Department of Orthopaedics surgery, West China Hospital, 34753Sichuan University, Chengdu, China
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Guo J, Hou M, Shi G, Bai N, Huo M. iPACK block (local anesthetic infiltration of the interspace between the popliteal artery and the posterior knee capsule) added to the adductor canal blocks versus the adductor canal blocks in the pain management after total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:387. [PMID: 35962410 PMCID: PMC9373358 DOI: 10.1186/s13018-022-03272-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/19/2022] [Indexed: 12/02/2022] Open
Abstract
Background Several studies have suggested that the addition of iPACK block (the popliteal artery and the posterior knee capsule have been given interspace local anesthetic infiltration) might get better analgesia than adductor canal block (ACB) only after total knee arthroplasty (TKA). This paper compiles all available evidence on the effect of two analgesia regimens (ACB and iPACK + ACB) involving all sides. Methods We searched in eight major databases for all clinical trials discussing the effect of two analgesia regimens after TKA. Statistical analyses were conducted by Stata and RevMan Software. In addition, we performed GOSH analysis, subgroup analysis, meta-regression analysis to study the source of heterogeneity. Publication bias was checked using Egger’s test. Trim-and-fill analysis was applied in terms of sensitivity analysis of the results. Results There are fourteen eligible studies for our meta-analysis. There are significant differences between the two groups in VAS score at rest and with activity, and the VAS scores were lower in the ACB + iPACK Group (VAS scores at rest: 95%CI [− 0.96, − 0.53], P < 0.00001. VAS scores with activity: 95%CI [− 0.79, − 0.43], P < 0.00001). A differential was discovered to support the ACB + iPACK Group when comparing the two groups on postoperative cumulative morphine consumption (95%CI: [− 0.52, − 0.14], P: 0.0007). The patients in the group of ACB + iPACK performed better in the postoperative range of knee movement (95%CI: [5.18, 10.21], P < 0.00001) and walking distance (95%CI: [0.15, 0.41], P < 0.00001). There were significant differences between the patients in the ACB + iPACK Group and ACB Group on the TUG test of POD1 and POD2. We found that patients' hospital stays in the ACB + iPACK Group were significantly shorter than in the ACB Group (95%CI: [− 0.78, − 0.16], P: 0.003). No difference was found between the patients in the ACB + iPACK Group and ACB Group on postoperative quadriceps muscle strength and the incidence of PONV. Conclusion The addition of iPACK lowers postoperative VAS scores, cumulative morphine consumption, and hospital stays. Meanwhile, the addition of iPACK improves postoperative patients’ activity performance without extra side effects. iPACK combined with ACB proves to be a suitable pain management technique after TKA.
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Affiliation(s)
- Jiao Guo
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China
| | - Minna Hou
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China
| | - Gaixia Shi
- Department of Nursing, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Ning Bai
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China
| | - Miao Huo
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China.
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Liposomal Bupivacaine in Adductor Canal Blocks Before Total Knee Arthroplasty Leads to Improved Postoperative Outcomes: A Randomized Controlled Trial. J Arthroplasty 2022; 37:1549-1556. [PMID: 35351553 DOI: 10.1016/j.arth.2022.03.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/07/2022] [Accepted: 03/22/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND This study compares the use of liposomal bupivacaine (Exparel) versus ropivacaine in adductor canal blocks (ACB) before total knee arthroplasties (TKAs). METHODS From the months of April 2020 to September 2021, 147 patients undergoing unilateral primary TKA were asked to participate in this prospective, double-blinded randomized controlled trial. Each patient received an iPACK block utilizing ropivacaine and was additionally randomized to receive an ACB with Exparel or Ropivacaine. For each patient, demographic information, inpatient hospital information, postoperative opioid use, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire scores were collected. RESULTS Overall, 100 patients were included (50 in each cohort). The Exparel group had a lower hospital length of stay compared to the Control group (36.3 vs 49.7 hours, P < .01). Patients in the Exparel group reported an increased amount of Numerical Rating Scale pain score improvement at all postoperative timepoints. These patients also used a lower amount of inpatient opioids (40.9 vs 47.3 MME/d, P = .04) but a similar amount of outpatient opioids (33.4 vs 32.1 MME/d, P = .351). Finally, the Exparel group had increased improvements in all WOMAC subscores and total scores at most timepoints compared to the Control group (P < .05). CONCLUSION Exparel peripheral regional nerve blocks lead to decreases in pain levels, shorter hospital lengths of stay, inpatient opioid usage, and improved WOMAC scores. Exparel can be safely used in ACB blocks before TKA to help in controlling postoperative pain and decrease length of stay.
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The effect of continuous adductor canal block combined with distal interspace between the popliteal artery and capsule of the posterior knee block for total knee arthroplasty: a randomized, double-blind, controlled trial. BMC Anesthesiol 2022; 22:175. [PMID: 35668348 PMCID: PMC9169338 DOI: 10.1186/s12871-022-01712-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 05/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The optimal analgesia for total knee arthroplasty (TKA) requires excellent analgesia while preserving muscle strength. This study aimed to determine the hypothesis that continuous adductor canal block (CACB) combined with the distal interspace between the popliteal artery and the posterior capsule of the knee (IPACK) block could effectively alleviate the pain of the posterior knee, decrease opioids consumption, and promote early recovery and discharge. METHODS Patients undergoing unilateral, primary TKA were allocated into group CACB+SHAM (receiving CACB plus sham block) or group CACB+IPACK (receiving CACB plus IPACK block). The primary outcome was cumulative opioid consumption. Secondary outcomes included the incidence of postoperative pain originated from the posterior knee, visual analogue scale (VAS) score, range of motion, ambulation distance, and satisfaction for pain management. RESULTS The incidence of moderate-severe pain of the posterior knee was lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours (17.1% vs. 42.8%; p = 0.019), 8 hours (11.4% vs. 45.7%; p = 0.001), and 24 hours (11.4% vs. 34.3%; p = 0.046) after TKA. The VAS scores of the posterior knee were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [2 (2) vs. 3 (2-4); p = 0.000], 8 hours [1 (1, 2) vs. 3 (2-4); p = 0.001], and 24 hours [1(0-2) vs. 2 (1-4); p = 0.002] after TKA. The overall VAS scores were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [3 (2, 3) vs. 3 (3, 4); p = 0.013] and 8 hours [2 (2, 3) vs. 3 (2-4); p = 0.032] at rest and 4 hours [3 (3, 4) vs. 4 (4, 5); p = 0.001], 8 hours [3 (2-4) vs. 4 (3-5); p = 0.000], 24 hours [2 (2, 3) vs. 3 (2-4); p = 0.001] during active flexion after TKA. The range of motion (59.11 ± 3.90 vs. 53.83 ± 5.86; p = 0.000) and ambulation distance (44.60 ± 4.87 vs. 40.83 ± 6.65; p = 0.009) were superior in group CACB+IPACK than that of the group CACB+SHAM in postoperative day 1. The satisfaction for pain management was higher in group CACB+IPACK than that of the group CACB+SHAM [9 (8, 9) vs. 8 (7-9); p = 0.024]. There was no difference in term of cumulative opioids consumption between group CACB+IPACK and group CACB+SHAM [120(84-135) vs. 120(75-135); p = 0.835]. CONCLUSION The combination of CACB and distal IPACK block could decrease the incidences of moderate-severe posterior knee pain, improve the postoperative pain over the first 24 hours after TKA, as well as promoting recovery of motor function. However, the opioids consumption was not decreased by adding distal IPACK to CACB. TRIAL REGISTRATION This study was registered at Chinese Clinical Trial Registry ( ChiCTR2200059139 ; registration date: 26/04/2022; enrollment date: 16/11/2020; http://www.chictr.org.cn ).
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Mou P, Wang D, Tang XM, Zeng WN, Zeng Y, Yang J, Zhou ZK. Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia and Function Recovery Following Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study. J Arthroplasty 2022; 37:259-266. [PMID: 34653576 DOI: 10.1016/j.arth.2021.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND This study aimed to explore the analgesic effect among adductor canal block (ACB) combined with infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block, ACB, and IPACK block following total knee arthroplasty (TKA). METHODS One hundred twenty patients were randomly allocated into 3 groups including group A (ACB + IPACK block), group B (ACB), and group C (IPACK block). The primary outcome was postoperative pain score. The secondary outcome was opioid consumption. Other outcomes included functional evaluation and postoperative complications. RESULTS Group A showed the lowest pain scores within 8 hours at rest and with knee maximum flexion (P < .001). From 12 to 24 hours, group C showed the highest pain scores, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups 24 hours postoperatively. Group C showed the most opioid consumption within the first 24 hours and during the hospitalization, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups including function evaluation and postoperative complications. CONCLUSION ACB + IPACK block can improve early analgesia when compared with ACB. However, the small statistical benefit to the addition of IPACK block to ACB may be unlikely to be clinically significant. Further studies may focus on patient selection and how to prolong the effect of IPACK block.
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Affiliation(s)
- Ping Mou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Duan Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xiu-Mei Tang
- Department of Orthopedics, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Wei-Nan Zeng
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China; Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yan Zeng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jing Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zong-Ke Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Villa JM, Pannu TS, Higuera-Rueda CA. What's New in Adult Reconstructive Knee Surgery. J Bone Joint Surg Am 2022; 104:97-106. [PMID: 34780387 DOI: 10.2106/jbjs.21.01080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesus M Villa
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
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Kamel I, Ahmed MF, Sethi A. Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know. World J Orthop 2022; 13:11-35. [PMID: 35096534 PMCID: PMC8771411 DOI: 10.5312/wjo.v13.i1.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/20/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.
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Affiliation(s)
- Ihab Kamel
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Muhammad F Ahmed
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Anish Sethi
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
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Li Q, Hu Q, Alqwbani M, Li D, Yang Z, Wang Q, Kang P. Additional nerve blocks are not superior to multiple-site infiltration analgesia in total knee arthroplasty under adductor canal block. J Orthop Surg Res 2021; 16:591. [PMID: 34645496 PMCID: PMC8513222 DOI: 10.1186/s13018-021-02769-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/04/2021] [Indexed: 02/08/2023] Open
Abstract
Background Adductor canal block (ACB) with additional nerve blocks (ANBs) is reported to provide adequate analgesia and enhanced functional rehabilitation in total knee arthroplasty (TKA). The present study aims to evaluate whether ANBs are superior to multiple-site infiltration analgesia (MIA) in patients undergoing TKA under ACB. Methods We enrolled 530 patients undergoing primary TKA from 2015 to 2019 at our institution in this retrospective cohort study. Patients were divided into two groups: Group A was treated with ANBs + ACB; Group B was treated with MIA + ACB. Primary outcomes were pain scores and morphine consumption. Functional recovery was the secondary outcome. Other outcomes included satisfaction score, cost-effectiveness, adverse events, and length of hospital stay (LOS). Results Pain scores at rest and morphine consumption were slightly lower in the ANBs + ACB group than in the MIA + ACB group. No significant difference was found in functional recovery, post-operative complications or LOS between the groups. Meanwhile, the cost of analgesic intervention in the MIA + ACB group was less than that in the ANBs + ACB group. Conclusion The present study suggests that ANBs do not provide superior pain relief compared to MIA for patients undergoing TKA under ACB. Trial registration Chinese Clinical Trial Registry, ChiCTR2100043227. Registered 9 February 2021, https://www.chictr.org.cn/showproj.aspx?proj=121745.
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Affiliation(s)
- Qianhao Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qinsheng Hu
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Mohammed Alqwbani
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Donghai Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Zhouyuan Yang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Qiuru Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan, People's Republic of China.
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Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study. J Arthroplasty 2021; 36:3421-3431. [PMID: 34090689 DOI: 10.1016/j.arth.2021.05.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA). METHODS Patients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications. RESULTS Compared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates. CONCLUSION Adding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.
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Wang F, Ma W, Huang Z. Analgesia effects of IPACK block added to multimodal analgesia regiments after total knee replacement: A systematic review of the literature and meta-analysis of 5 randomized controlled trials. Medicine (Baltimore) 2021; 100:e25884. [PMID: 34087830 PMCID: PMC8183733 DOI: 10.1097/md.0000000000025884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/21/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Currently, no meta-analysis exists elucidate the analgesic effect of adding IPACK block to our current multimodal analgesia regimen after total knee replacement (TKR). The purpose of this study is to systematically review the level I evidence in the literature to ascertain whether IPACK block can bring additional analgesic benefits to existing multimodal analgesia regimens. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Only level I randomized controlled trials (RCTs) were included in our study. The primary outcome was the pain scores with rest and activity. Secondary outcomes included cumulative opioid consumption, cumulative distance ambulated, and length of stay (LOS). RESULTS Five RCTs with a total of 467 patients were included. The most important finding in our study was that although IPACK block supplementation improved pain scores at 12 hours with rest or activity after surgery, no such benefit was observed at subsequent time points during the postoperative period. Interestingly, IPACK supplementation did not reduce opioid consumption, especially in the first 24 hours after surgery. Furthermore, other postoperative outcomes, including cumulative distance ambulated and LOS, were also not improved by the addition of an IPACK. CONCLUSIONS The addition of an IPACK block to multimodal analgesia regiments does not reduce the postoperative opioid consumption nor improve functional performance. However, it may be an appropriate method to improve immediate analgesic effects after TKR.
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Chan E, Howle R, Onwochei D, Desai N. Infiltration between the popliteal artery and the capsule of the knee (IPACK) block in knee surgery: a narrative review. Reg Anesth Pain Med 2021; 46:784-805. [PMID: 33990439 DOI: 10.1136/rapm-2021-102681] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The infiltration between the popliteal artery and the capsule of the knee (IPACK) block has been described as an alternative analgesic strategy for knee pain. OBJECTIVE Our aim was to perform a narrative review to examine the place and value that the IPACK block has in comparison to and in conjunction with other regional anesthesia modalities. EVIDENCE REVIEW Following an extensive search of electronic databases, we included anatomical studies, letters, comparative observational studies, and non-randomized and randomized controlled trials that examined the IPACK block in relation to surgery on the knee under general or neuraxial anesthesia. FINDINGS In all, 35 articles were included. Cadaveric studies demonstrated the potential for injected dye to spread to the nerves responsible for the innervation of the posterior as well as anteromedial and anterolateral aspects of the knee. Of the comparative observational studies (n=15) and non-randomized (n=1) and randomized controlled trials (n=13), 2 and 27 were conducted in the context of anterior cruciate ligament reconstruction and knee replacement surgery, respectively. The role of the IPACK block with each different permutation of regional anesthesia techniques was investigated by a small number of studies. Clinical studies, in the setting of knee replacement surgery, revealed variation in the manner in which the IPACK block was performed, and indicated the possible superiority of distal injection at the level of the femoral condyles for the management of posterior knee pain. Evidence suggested the following: the IPACK block in combination with single shot adductor canal block (ACB) may be beneficial for analgesic and functional outcomes; in conjunction with single shot or continuous ACB, the IPACK block might be superior to local infiltration analgesia (LIA); and functional outcomes may be improved with the supplementation of continuous ACB and LIA with the IPACK block. The IPACK block did not commonly result in the occurrence of foot drop. Relative to tibial nerve block (TNB), the IPACK block reduced the occurrence of foot drop and increased the proportion of patients who were able to be discharged on the third postoperative day. CONCLUSIONS The IPACK block was potentially complementary to the ACB and might be preferable to the TNB as a motor-sparing regional anesthesia technique in knee surgery. Definitive recommendations were not reached in the presence of the heterogeneous and limited evidence base.
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Affiliation(s)
- Edmund Chan
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ryan Howle
- Department of Anaesthesia, St Vincent's University Hospital, Dublin, Ireland
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Honorary Senior Clinical Lecturer, King's College London, London, UK
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Honorary Senior Clinical Lecturer, King's College London, London, UK
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Hussain N, Brull R, Sheehy B, Dasu M, Weaver T, Abdallah FW. Does the addition of iPACK to adductor canal block in the presence or absence of periarticular local anesthetic infiltration improve analgesic and functional outcomes following total knee arthroplasty? A systematic review and meta-analysis. Reg Anesth Pain Med 2021; 46:713-721. [PMID: 33990436 DOI: 10.1136/rapm-2021-102705] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/10/2021] [Accepted: 04/14/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND When combined with adductor canal block (ACB), local anesthetic infiltration between popliteal artery and capsule of knee (iPACK) is purported to improve pain following total knee arthroplasty (TKA). However, the analgesic benefits of adding iPACK to ACB in the setting of surgeon-administered periarticular local infiltration analgesia (LIA) are unclear. OBJECTIVES To evaluate the analgesic benefits of adding iPACK to ACB, compared with ACB alone, in the setting of LIA following TKA. EVIDENCE REVIEW We conducted a meta-analysis of randomized trials comparing the effects of adding iPACK block to ACB versus ACB alone on pain severity at 6 hours postoperatively in adult patients undergoing TKA. We a priori planned to stratify analysis for use of LIA. Opioid consumption at 24 hours, functional recovery, and iPACK-related complications were secondary outcomes. FINDINGS Fourteen trials (1044 patients) were analyzed. For the primary outcome comparison in the presence of LIA (four trials, 273 patients), adding iPACK to ACB did not improve postoperative pain at 6 hours. However, in the absence of LIA (eight trials, 631 patients), adding iPACK to ACB reduced pain by a weighted mean difference (WMD) (95% CI) of -1.33 cm (-1.57 to -1.09) (p<0.00001). For the secondary outcome comparisons in the presence of LIA, adding iPACK to ACB did not improve postoperative pain at all other time points, opioid consumption or functional recovery. In contrast, in the absence of LIA, adding iPACK to ACB reduced pain at 12 hours, and 24 hours by a WMD (95% CI) of -0.98 (-1.79 to -0.17) (p=0.02) and -0.69 (-1.18 to -0.20) (p=0.006), respectively, when compared with ACB alone, but did not reduce opioid consumption. Functional recovery was also improved by a log(odds ratio) (95% CI) of 1.28 (0.45 to 2.11) (p=0.003). No iPACK-related complications were reported. CONCLUSION Adding iPACK to ACB in the setting of periarticular LIA does not improve analgesic outcomes following TKA. In the absence of LIA, adding iPACK to ACB reduces pain up to 24 hours and enhances functional recovery. Our findings do not support the addition of iPACK to ACB when LIA is routinely administered.
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Affiliation(s)
- Nasir Hussain
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Richard Brull
- Department of Anesthesiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Brendan Sheehy
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael Dasu
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Tristan Weaver
- Department of Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Faraj W Abdallah
- Faculty of Medicine, Anesthesia, University of Ottawa, Ottawa, Ontario, Canada
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D'Souza RS, Langford BJ, Olsen DA, Johnson RL. Ultrasound-Guided Local Anesthetic Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (IPACK) Block for Primary Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials. Local Reg Anesth 2021; 14:85-98. [PMID: 34012290 PMCID: PMC8126972 DOI: 10.2147/lra.s303827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; low-quality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brendan J Langford
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - David A Olsen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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Li D, Wang Q, Zhao X, Luo Y, Kang P. Comparison of Intravenous and Topical Dexamethasone for Total Knee Arthroplasty: A Randomized Double-Blinded Controlled Study of Effects on Dexamethasone Administration Route and Enhanced Recovery. J Arthroplasty 2021; 36:1599-1606. [PMID: 33293172 DOI: 10.1016/j.arth.2020.11.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/26/2020] [Accepted: 11/10/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The optimal route for dexamethasone (DEX) administration regimen for patients undergoing primary TKA has not been investigated. This study aims to determine whether intravenous and topical DEX provide different clinical effects in patients with TKA. METHODS In this double-blinded, placebo-controlled trial, 90 patients undergoing primary TKA were randomized to intravenous DEX group (n = 45) or topical DEX group (n = 45, DEX applied in anesthetic cocktail for periarticular injection). The primary outcome was postoperative VAS pain score and morphine consumption. Secondary outcomes were included knee swelling, knee flexion, and extension angle, Knee Society Score (KSS), and postoperative hospital stays. Tertiary outcomes assessed the blood-related metrics, including inflammatory biomarkers and fibrinolysis parameters. Finally, nausea and vomiting and other adverse events were compared. RESULTS The topical administration of DEX provide lower pain score at 2h, 8h, 12h at rest (P < .05) and 12h, 24h with activity (P < .05), and less knee swelling in the first postoperative day (P < .05), while intravenous DEX was more effective in decreasing blood inflammatory biomarkers, including C-reactive protein (CRP) at postoperative 24h (P < .05) and interleukin-6 (IL-6) at postoperative 24h, 48h (P < .05), and reducing postoperative nausea (P < .05) for patients receiving TKA. However, there was no significant difference in knee flexion and extension angle, KSS, postoperative hospital stays, and complications occurrence (P > .05) between intravenous and topical DEX after TKA. CONCLUSION Topical administration of DEX provided better clinical outcomes on postoperative pain management and knee swelling early after TKA, while intravenous DEX was more effective in decreasing blood inflammatory biomarkers and preventing postoperative nausea.
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Affiliation(s)
- Donghai Li
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qiuru Wang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xin Zhao
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yue Luo
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedics surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Albrecht E, Wegrzyn J, Dabetic A, El-Boghdadly K. The analgesic efficacy of iPACK after knee surgery: A systematic review and meta-analysis with trial sequential analysis. J Clin Anesth 2021; 72:110305. [PMID: 33930796 DOI: 10.1016/j.jclinane.2021.110305] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/01/2021] [Accepted: 04/01/2021] [Indexed: 12/18/2022]
Abstract
STUDY OBJECTIVE The novel infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to relieve posterior knee pain after knee surgery. The study objective is to determine whether iPACK provides analgesia after knee surgery when compared with a control group. DESIGN Systematic review, meta-analysis and trial sequential analysis. SETTING Operating room, postoperative recovery area and ward, up to 24 postoperative hours. PATIENTS Patients scheduled for knee surgery under general or spinal anaesthesia. INTERVENTIONS We searched five electronic databases for randomized controlled trials comparing iPACK with a control group. MEASUREMENTS The primary outcome was rest pain score scores on a visual analogue scale (VAS) of 0-10 at 12 h postoperatively, analysed according to the nature of surgery (total knee arthroplasty vs. anterior cruciate ligament reconstruction) and the use of multimodal analgesia. Secondary outcomes included rest and dynamic pain scores, intravenous morphine-equivalent consumption at 2 h and 24 h, and functional outcomes including ambulation distance and range of motion at discharge. MAIN RESULTS Six trials involving 687 patients were included, all of which received total knee arthroplasty only. When compared with a control group, iPACK significantly reduced rest pain scores at 12 h, with a mean difference (95% CI) of -1.0 (-1.5 to -0.5), I2 = 93%, p = 0.0003, without subgroup differences for postoperative multimodal analgesia (p = 0.15). Secondary pain outcomes were inconsistently improved with iPACK. Functional outcomes were either similar between groups or had clinically unimportant differences. The overall quality of evidence was moderate. CONCLUSIONS There is moderate level evidence that iPACK might provide analgesia for posterior pain after total knee arthroplasty when compared with a control group at 12 h, but was not associated with any other meaningful benefits. Based on these results, there is currently limited evidence supporting the use of iPACK as a complement to adductor canal block for analgesia after total knee arthroplasty.
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Affiliation(s)
- Eric Albrecht
- Program Director of Regional Anaesthesia, Department of Anaesthesia, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland.
| | - Julien Wegrzyn
- Professor, Department of Orthopaedic, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Aleksandar Dabetic
- Resident, Department of Anaesthesia, University Hospital of Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Kariem El-Boghdadly
- Consultant, Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Honourary Senior Lecturer, King's College London, London, United Kingdom
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