Continuous Saphenous Nerve Block as Supplement to Single-Dose Local Infiltration Analgesia for Postoperative Pain Management After Total Knee Arthroplasty:

A randomized controlled trial on the effectiveness of laparoscopic-guided transversus abdominis plane block in patients undergoing laparoscopic IPOM plus

INTRODUCTION

Ventral hernia repairs, particularly laparoscopic ventral hernia repair (LVHR), have become common procedures among general surgeons worldwide. Despite the benefits of LVHR, acute postoperative pain remains a significant concern. Transversus abdominis plane (TAP) blocks have been employed to alleviate postoperative pain in various laparoscopic procedures. This study aimed to assess the effectiveness of laparoscopic-guided TAP block in laparoscopic IPOM plus and its impact on postoperative pain and analgesic requirements.

MATERIALS AND METHODS

A randomized controlled trial was conducted at a tertiary care center in India involving 72 patients undergoing laparoscopic IPOM plus. Patients were randomized into two groups: Group I received laparoscopic-guided TAP block, while Group II received standard general anesthesia without TAP block. Pain scores were assessed at 6, 12, and 24 h postoperatively using the numerical rating scale. Postoperative analgesic requirements were also recorded.

RESULTS

Group I demonstrated significantly lower pain scores at 6 and 24 h postoperatively compared to Group II. The need for additional analgesics was significantly lower in Group I (13.8%) compared to Group II (72.2%). There were no significant differences in age, BMI, duration of surgery, or other demographic characteristics between the two groups.

CONCLUSION

The findings of this randomized controlled trial demonstrate the effectiveness of laparoscopic-guided TAP blocks in reducing postoperative pain and analgesic requirements after laparoscopic IPOM plus.

The Effect of Postoperative Single-Injection Adductor Canal Block in Total Knee Arthroplasty Under Spinal Anesthesia With Intraoperative Dexmedetomidine Infusion

Background

Single-injection adductor canal block (SACB) is one of the multimodal pain managements in total knee arthroplasty. The effect of an intrathecal local anesthetic is prolonged with an intraoperative dexmedetomidine infusion. Currently, SACB's effect along with the prolonged spinal anesthesia effect by dexmedetomidine has not been studied elsewhere.

Methods

Seventy-eight patients were randomized to either the SACB group (n = 39) or the control group (n = 39). Spinal anesthesia and continuous infusion of dexmedetomidine were performed intraoperatively. The SACB was performed using 15 mL of either 0.5% ropivacaine or normal saline in postanesthesia care unit postoperatively. Primary endpoint examined the average numerical rating scale (NRS) pain scores at 2, 6, 12, and 24 hours after SACB while resting or moving. The secondary outcomes were the morphine equivalent, postoperative nausea and vomiting score, quadriceps strength, and overall satisfaction score.

Results

The SACB group showed a lower average NRS pain score until 24 hours than the control group (2.4 vs 3.3 resting, 3.4 vs 4.1 moving). Resting and moving NRS scores at 6 and 12 hours were significantly lower in the SACB group, whereas no difference was found at 2, 24, and 48 hours, regardless of movement. The satisfaction score was higher in the SACB group than in the control group (9 [7.3-10.0] vs 7 [5.3-8.8]), and morphine equivalent at 2 hours was lower in the SACB group (2 [1-3]) than in the control group (2.9 [1.6-4]).

Conclusions

SACB provided an additional analgesic effect in patients undergoing total knee arthroplasty under spinal anesthesia with continuous dexmedetomidine intravenous infusion.

Does Proximal Adductor Canal Block Provide Better Analgesic Efficacy than Distal Adductor Canal Block in Patients Undergoing Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

To compare the analgesic efficacy and adverse events of proximal versus distal ACB for adults undergoing knee arthroplasty, we searched PubMed, Cochrane, Web of Science, and Embase to identify all eligible randomized controlled trials (RCTs). The study quality of the RCTs was evaluated using the Cochrane risk of bias assessment tool. Heterogeneity among studies was examined by Cochrane Q test. Our primary outcomes were pain intensity at rest/during movement and morphine consumption. Statistical analyses were conducted by RevMan Software. Seven eligible studies involving 400 subjects were included in this meta-analysis with 202 participants in the proximal ACB group and 198 participants in the distal ACB group. The results demonstrated that proximal ACB provided significantly better pain relief at rest at 2 h (SMD -0.27, 95% CI -0.54 to -0.01, four trials, 222 participants, I2 = 0, p = 0.04) and 24 h (SMD -0.28, 95% CI -0.48 to -0.08, seven trials, 400 participants, I2 = 0, p = 0.006) following the surgery. We found no evidence of a difference in postoperative pain intensity at other timepoints. Furthermore, we noted no evidence of a difference in cumulative morphine consumption and occurrence of adverse events. Proximal ACB provides better pain relief and comparable adverse effects profile compared with distal ACB. The analgesic benefit offered by proximal ACB, however, did not appear to extend beyond the first 24 h. The overall evidence level was mostly low or very low, which requires more well-organized multicenter randomized trials in the future.

A Network Meta-Analysis of Randomized Controlled Trials Assessing Intraoperative Anesthetic Therapies for Analgesic Efficacy and Morphine Consumption Following Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to compare intraoperative anesthetic therapies for total knee arthroplasty (TKA) regarding postoperative analgesic efficacy and morphine consumption by conducting a systematic literature search.

METHODS

Randomized controlled trials of TKA using various anesthetic therapies were identified from various databases from conception through December 31, 2021. A network meta-analysis of relevant literature was performed to investigate which treatment showed better outcomes. In total, 40 trials were included in this study.

RESULTS

Surface under the cumulative ranking curve showed local infiltration anesthesia (LIA) with saphenous nerve block (SNB) to produce the best pain relief on postoperative days (PODs) 1 and 2 and the best reduction of morphine consumption on PODs 1 and 3. However, femoral nerve block showed the largest effect on pain relief on POD 3, and liposomal bupivacaine showed the largest effect on reduction of morphine consumption on POD 2.

CONCLUSIONS

According to this network meta-analysis, surface under the cumulative ranking curve percentage showed that LIA with SNB provided the best analgesic effect after TKA. Furthermore, patients receiving LIA with SNB had the lowest consumption of morphine. Although femoral nerve block resulted in better pain relief on POD 3, LIA with SNB could be selected first when trying to reduce morphine consumption or increase early ambulation.

Peripheral regional anaesthesia and outcomes: a narrative review of the literature from 2013 to 2023

The use of peripheral regional anaesthesia continues to increase, yet the evidence supporting its use and impact on relevant outcomes often lacks scientific rigour, especially when considering the use of specific blocks for a particular surgical indication. In this narrative review, we consider the relevant literature in a 10-yr period from 2013. We performed a literature search (MEDLINE and EMBASE) for articles reporting randomised controlled trials and other comparative trials of peripheral regional anaesthetic blocks vs systemic analgesia in adult patients undergoing surgery. We evaluated measures of effective treatment and complications. A total of 128 studies met our inclusion criteria. There remains variability in the technical conduct of blocks and the outcomes used to evaluate them. There is a considerable body of evidence to support the use of interscalene blocks for shoulder surgery. Saphenous nerve (motor-sparing) blocks provide satisfactory analgesia after knee surgery and are preferred to femoral nerve blocks which are associated with falls when patients are mobilised early as part of enhanced recovery programmes. There are additional surgical indications where the efficacy of cervical plexus, intercostal nerve, and ilioinguinal/iliohypogastric nerve blocks have been demonstrated. In the past 10 yr, there has been a consolidation of the evidence indicating benefit of peripheral nerve blocks for specific indications. There remains great scope for rigorous, multicentre, randomised controlled trials of many peripheral nerve blocks. These would benefit from an agreed set of patient-centred outcomes.

Efficacy of Supplemental Ultrasound-Guided Pericapsular Nerve Group (PENG) Block Combined with Lateral Femoral Cutaneous Nerve Block in Patients Receiving Local Infiltration Analgesia after Hip Fracture Surgery: A Prospective Randomized Controlled Trial

Background and Objectives: Local infiltration analgesia (LIA) represents a potential approach to reducing pain in patients undergoing total hip arthroplasty (THA). The pericapsular nerve group (PENG) block also provides adequate analgesia for fractures and THA. As most hip surgeries use a lateral incision, affecting the cutaneous supply by branches of the lateral femoral cutaneous nerve (LFCN), the LFCN block can contribute to postoperative analgesia. However, no studies have investigated the effectiveness of supplemental PENG block combined with LFCN block in patients undergoing LIA after hip fracture surgery. Our study aimed to assess the effectiveness of PENG combined with LFCN block following hip fracture surgery in patients who underwent LIA. Materials and Methods: Forty-six patients were randomly assigned to LIA or PENG + LFCN + LIA groups. The primary outcome was the pain score at rest and during movement at 2, 6, 12, 24, and 48 h postoperatively. The total opioid dose for postoperative analgesia was also measured at the same time points. Secondary outcomes included postoperative cognitive function assessment. Results: The median pain scores at rest and during movement were lower in the PENG + LFCN + LIA group throughout the study periods compared to the LIA group, except at 2 h (at rest) and 48 h (during movement) after surgery. The total fentanyl dose was lower in the PENG + LFCN + LIA group at all time points after surgery when compared to the LIA group. Postoperative delirium incidence and the median abbreviated mental test scores were not significantly different between the two groups. Conclusions: The combination of PENG and LFCN blocks may contribute to enhanced recovery for patients undergoing LIA after hip fracture surgery. However, further well-controlled research is necessary to determine the effectiveness of supplemental PENG combined with LFCN block in addressing cognitive deficits in these patients.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

EDITOR’S PERSPECTIVE

Integrating IPACK (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) Block in an Enhanced Recovery after Surgery Pathway for Total Knee Arthroplasty-A Prospective Triple-Blinded Randomized Controlled Trial

We explored the efficacy of an interspace between the popliteal artery and capsule of the posterior knee (IPACK) block when added to an established enhanced recovery after surgery (ERAS) pathway to assist with posterior knee analgesia and functional mobility after total knee arthroplasty (TKA). We recruited participants undergoing TKA in our prospective, randomized, triple-blinded controlled trial. All study patients participated in our ERAS pathway consisting of a primary spinal anesthetic, adductor canal nerve catheter, and periarticular joint infiltration. Patients were randomized to receive an IPACK block or no block. The primary outcome was total postoperative opioid consumption. Secondary outcomes included pain scores, recovery unit length of stay, time to first opioid use, the incidence of posterior knee pain, ambulation distance and activities of daily living on postoperative day 1, and hospital length of stay. A total of 96 patients were randomized to the control and IPACK groups. There were no statistical differences in primary or majority of secondary outcomes. There was a lower incidence of posterior knee pain (39%) in the IPACK group when compared with controls (8.7%), p < 0.01. In terms of opioid consumption and a majority of functional outcomes, our study demonstrates no overall benefits of adding an IPACK block in this ERAS pathway in TKA. Nevertheless, IPACK may have the potential of mitigating posterior knee pain after TKA.

LEVEL OF EVIDENCE

level 1.

CLINICAL TRIAL NUMBER AND REGISTRY URL

NCT03653416. www.

CLINICALTRIALS

gov.

Total joint replacement in ambulatory surgery

Total joint arthroplasty is one of the most commonly performed surgical procedures in the United States, and projected numbers are expected to double in the next ten years. From 2018 to 2020, total hip and knee arthroplasty were removed from the United States' Center for Medicare and Medicaid Services "inpatient-only" list, accelerating this migration to the ambulatory setting. Appropriate patient selection, including age, body mass index, comorbidities, and adequate social support, is critical for successful ambulatory total joint arthroplasty. General anesthesia and neuraxial anesthesia are both safe and effective anesthetic choices, and recent studies in this population have found no difference in outcomes. Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, local infiltration analgesia, and peripheral nerve blocks, is the foundation for adequate pain control. Common reasons for "failure to launch" include postoperative urinary retention, postoperative nausea and vomiting, inadequate analgesia, and hypotension.

Effects of a Continuous Adductor Canal Block After Total Knee Arthroplasty

This retrospective cohort study analyzed the short-term outcomes of patients undergoing total knee arthroplasty receiving periarticular anesthetic injections (PAIs) with and without continuous adductor canal blocks (CACBs) regarding early postoperative narcotic use, pain scores, and range of motion with otherwise similar postoperative regimens. Two hundred ninety-four patients were included: 120 received PAIs with CACBs, and 174 received PAIs only. Matched analysis was performed for type of anesthesia. There were substantial decreases in early inpatient narcotic use with the addition of CACBs to PAIs with general and spinal anesthesia without an adverse effect on pain, knee range of motion, or length of stay. [Orthopedics. 2023;46(3):185-191.].

Reevaluation of the topographical anatomy of the mid-thigh: A magnetic resonance and ultrasound imaging study

Adductor canal (AC) and sciatic nerve (SN) blockades are commonly used during total knee arthroplasties for postoperative pain control. Medical professionals have begun to utilize single injection combined regional anesthesia methods due to increased patient comfort. In this study, we examined the topographical anatomy of the mid-thigh, which is recommended as the appropriate intervention level for combined AC and SN blockades, in order to provide a safe approach for clinicians. We examined 184 thigh magnetic resonance images (MRI) from 98 patients. We measured the diameter of the mid-thigh, anterior thigh muscle thickness, subcutaneous adipose tissue thickness, and SN depth on the MRIs. We obtained ultrasound (US) images of the vastoadductor membranes (VAM) of 26 volunteers, and measured the vertical distances between the greater trochanter and the adductor tubercle (A) and the greater trochanter and the upper edge of the VAM (B). We then proportioned B to A in order to determine in which part of the thigh the AC was located. The AC was in the distal third of the thigh, and the SN's depth was located in the third quarter of the thigh's diameter. Only the adductor magnus, and no neurovascular structure, was at risk of injury between the AC and the SN. The upper edge of the VAM was 6.5 cm below the mid-thigh, therefore it is not appropriate to suggest performing an AC blockade at mid-thigh. We think that it is safe to perform a combined AC and SN blockade in a single injection in selected patients.

Surgeon-Performed Intraoperative Peripheral Nerve Blocks and Periarticular Infiltration During Total Hip and Knee Arthroplasty: A Critical Analysis Review

➢

Surgeon-performed intraoperative peripheral nerve blocks may improve operating room efficiency and reduce hospital resource utilization and, ultimately, costs. Additionally, these blocks can be safely performed intraoperatively by most orthopaedic surgeons, while only specifically trained physicians are able to perform ultrasound-guided peripheral nerve blocks.

➢

IPACK (infiltration between the popliteal artery and capsule of the knee) blocks are at least noninferior to periarticular infiltration when combined with an adductor canal block for analgesia following total knee arthroplasty.

➢

Surgeon-performed intraoperative adductor canal blocks are technically feasible and offer reliable anesthesia comparable with ultrasound-guided blocks performed by anesthesiologists. While clinical studies have shown promising results, additional Level-I studies are required.

➢

A surgeon-performed intraoperative psoas compartment block has been described as a readily available and safe technique, although there is some concern for femoral nerve analgesia, and temporary sensory changes have been reported.

The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis

BACKGROUND

Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.

METHODS

We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks.

RESULTS

Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective.

CONCLUSION

Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

DATA SOURCES

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

ELIGIBILITY CRITERIA

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

RESULTS

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

CONCLUSION

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

Single shot adductor canal block combined with intravenous patient-controlled analgesia can be effective as continuous adductor canal block in reducing opioid consumption and breakthrough pain after total knee arthroplasty

PURPOSE

The aim of this study was to compare the following three analgesic methods after Total knee arthroplasty (TKA): intravenous patient-controlled analgesia (IV-PCA), continuous adductor canal block (C-ACB), and intravenous patient-controlled analgesia combined with single shot adductor canal block (PCA + sACB).

METHODS

Records of 482 patients undergoing primary TKA from September 2019 to September 2020 were analyzed. Patients were divided into three pain control groups: IV-PCA (n = 180), C-ACB (n = 173) and PCA + sACB (n = 129). Single shot adductor canal block was performed 24 h after surgery in the PCA + sACB group. Rescue opioid consumption, breakthrough pain, pain numerical rating scale (NRS), and anti-emetics administration were measured from postoperative day (POD) 1 to POD 5.

RESULTS

Rescue opioid consumption was less in C-ACB or PCA + sACB group than in the IV-PCA group at POD1 (p < 0.001 and p = 0.002, respectively). Patients in C-ACB and PCA + sACB groups had less breakthrough pain (NRS > 5) than the IV-PCA group at POD1 (p = 0.007). On POD2, C-ACB was statistically superior to IV-PCA (p = 0.011) in terms of breakthrough pain. Postoperative pain NRS was lower in the C-ACB and PCA + sACB groups than in the IV-PCA group (p = 0.025 and p = 0.019, respectively). The total number of anti-emetics consumption was lower in C-ACB and PCA + sACB groups than in the IV-PCA group (p = 0.003 and p = 0.002, respectively).

CONCLUSION

PCA + sACB not only reduced patients' need for rescue opioids, but also decreased the number of breakthrough pain and anti-emetics compared to IV-PCA in early postoperative days after TKA. However, C-ACB and PCA + sACB did not differ significantly in analgesic efficacy or opioid-related side effects. PCA + sACB can be as effective as C-ACB for patients undergoing TKA.

LEVEL OF EVIDENCE

Retrospective cohort study, level III.

Combined application of adductor canal block and local infiltration anesthesia in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials

BACKGROUND

Perioperative pain after total knee arthroplasty (TKA) may seriously affect the rapid recovery of patients. The purpose of this study was to assess whether the combined use of adductor canal block (ACB) and local infiltration anesthesia (LIA) can further reduce postoperative pain and improve early functional recovery.

MATERIALS AND METHODS

PubMed, Web of Science, EMBASE, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) comparing ACB + LIA and LIA alone in primary TKA. The primary outcomes were visual analog scale (VAS) scores at rest and walking, morphine consumption, range of motion (ROM) at 24 and 48 h postoperatively and distance walked. The secondary outcomes were the length of stay, the incidence of nausea and vomiting, and the total complications. Subgroup analyses were performed on the VAS at rest and walking, morphine consumption, and distance walked at 24, 48, and 72 h postoperatively.

RESULTS

A total of 10 RCTs involving 797 patients were enrolled in this meta-analysis. The results demonstrated that the combined application of ACB + LIA had a lower resting VAS at 24 h postoperatively (p = 0.02) and the walking score at 24 (p = 0.0002) and 48 h (p = 0.02) postoperatively compared with LIA alone. Similarly, the combined ACB + LIA group also had less morphine consumption at 48 h postoperatively (p = 0.0005) and had a higher ROM score at 24 h (p = 0.01) postoperatively compared to the LIA group. There were no statistical differences in length of stay, distance walked, and incidence of nausea and vomiting.

CONCLUSION

The current meta-analysis showed that ACB + LIA significantly reduced postoperative walking pain and morphine consumption and promoted rapid recovery in the early postoperative period. There is no statistical difference in the length of stay and ROM after 72 h in the two groups.

Pain and Opioid Consumption and Mobilization after Surgery: Post Hoc Analysis of Two Randomized Trials

BACKGROUND

Early mobilization is incorporated into many enhanced recovery pathways. Inadequate analgesia or excessive opioids may restrict postoperative mobilization. The authors tested the hypotheses that in adults recovering from abdominal surgery, postoperative pain and opioid consumption are inversely related to postoperative mobilization, and that postoperative mobilization is associated with fewer potentially related complications.

METHODS

The authors conducted a subanalysis of two trials that enrolled adults recovering from abdominal surgery. Posture and movement were continuously monitored for 48 postoperative hours using noninvasive untethered monitors. Mobilization was defined as the fraction of monitored time spent sitting or standing.

RESULTS

A total of 673 patients spent a median [interquartile range] of 7% [3 to 13%] of monitored time sitting or standing. Mobilization time was 1.9 [1.0 to 3.6] h/day for patients with average pain scores 3 or lower, but only 1.2 [0.5 to 2.6] h/day in those with average scores 6 or greater. Each unit increase in average pain score was associated with a decrease in mobilization time of 0.12 (97.5% CI, 0.02 to 0.24; P = 0.009) h/day. In contrast, there was no association between postoperative opioid consumption and mobilization time. The incidence of the composite of postoperative complications was 6.0% (10 of 168) in the lower mobilization quartile, 4.2% (7 of 168) in the second quartile, and 0% among 337 patients in the highest two quartiles (P = 0.009).

CONCLUSIONS

Patients recovering from abdominal surgery spent only 7% of their time mobilized, which is considerably less than recommended. Lower pain scores are associated with increased mobility, independently of opioid consumption. Complications were more common in patients who mobilized poorly.

EDITOR’S PERSPECTIVE

Analgesic efficacy of single-shot adductor canal block versus adductor canal block combined with intra-articular ropivacaine infusion after total knee arthroplasty

Aims

Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone.

Methods

This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain.

Results

The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014).

Conclusion

Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA.

Cite this article: Bone Jt Open 2021;2(12):1082–1088.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison between Local Infiltration Analgesia and Ultrasound Guided Single Shot Adductor Canal Block Post Total Knee Replacement Surgery - A Randomized Controlled Trial

Context:

Good quality analgesia posttotal knee arthroplasty (TKA) contributes majorly to early mobilization and shorter hospital stay.

Aim:

To compare adductor canal block (ACB) versus local infiltration analgesia (LIA) for postoperative pain relief in patients undergoing TKA.

Settings and Design:

This prospective, single-blind, randomized controlled trial was undertaken at a tertiary care university hospital.

Materials and Methods:

Sixty patients of American Society of Anesthesiologists physical status Classes I, II, and III, who received spinal anesthesia for TKA were randomly allocated to two groups. Group A patients had LIA of the knee joint using a mixture of 50 mL of 0.25% bupivacaine, 10 mg morphine (1 mL) and 99 mL of normal saline. Group B patients received ACB using 25 mL of 0.5% bupivacaine under ultrasound guidance. All patients received multimodal analgesia comprising of paracetamol, diclofenac, and patient controlled analgesia with morphine in the first 24 h' postoperative period. The primary outcome measures were first 24 h' morphine consumption and pain scores at 4, 6, 8, 12, and 24 h. The secondary outcome measures were nausea/vomiting, sedation, and patient satisfaction scores.

Statistical Analysis:

Statistical analysis was performed using the Student's t-test, Mann–Whitney test, and Chi-square test.

Results:

The 24 h morphine consumption was 11.97 ± 7.97 and 10.83 ± 6.41 mg in the LIA group and ACB group, respectively (P = 0.54). No significant differences were noted either in the pain scores at rest and flexion or secondary outcome measures between both groups in the first 24 h.

Conclusion:

Single-shot ACB is equally effective as LIA as postoperative analgesia for TKA.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature

BACKGROUND

Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery.

METHODS

A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations.

RESULTS

Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92).

CONCLUSIONS

Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes.

RECOMMENDATION

PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

The impact of ultrasound-guided transmuscular quadratus lumborum block combined with local infiltration analgesia for arthroplasty on postoperative pain relief

STUDY OBJECTIVE

This study aimed to evaluate the efficacy of ultrasound-guided transmuscular quadratus lumborum block (QLB) combined with local infiltration analgesia (LIA) for pain management and recovery in patients who have undergone total hip arthroplasty (THA) via a posterolateral approach.

DESIGN

This was a prospective, randomized controlled trial.

SETTING

We collected data in the preoperative area, operating room, and bed ward.

PATIENTS

A total of 80 patients with American Society of Anesthesiology functional status scores of II-III were included and assigned to two groups, and all 80 patients were included in the final analysis.

INTERVENTIONS

All included patients were randomly assigned to the nerve block (group N) or the control group (group C). Patients in the group N received transmuscular QLB combined with LIA, while patients in the group C received only LIA.

MEASUREMENTS

The primary outcome was postoperative pain during the first active motion: it was measured at six hours after surgery and assessed using a visual analog scale (VAS). Secondary outcomes were the resting VAS scores in the post-anesthesia care unit (PACU) and at 2, 6, 12, 24, 48, and 72 h after surgery; VAS scores during motion at 12, 24, 48, and 72 h after surgery; intraoperative consumption of opioids; postoperative consumption of morphine hydrochloride; frequency of sleep interruption due to pain on the night of surgery; time until the first "walk out of the bed" after surgery; muscle strength of the quadriceps femoris; and postoperative adverse effects.

MAIN RESULTS

Compared to the group C, patients in the group N had significantly lower VAS scores during motion at 6, 12, and 24 h after surgery, as well as lower resting VAS scores in the PACU and at 2, 6, 12, and 24 h after surgery. Patients in the group N also consumed significantly smaller amounts of intraoperative opioids and morphine after surgery. Patients in the group N reported significantly fewer interruptions in sleep due to pain on the night of surgery and were able to "walk out of the bed" significantly earlier than those in the group C. There was no significant difference between the two groups in muscle strength of the quadriceps femoris or incidence of postoperative adverse effects.

CONCLUSIONS

Compared to treatment with LIA alone, ultrasound-guided transmuscular QLB combined with LIA can provide better postoperative pain relief and enhance the recovery of THA patients, since it does not cause quadriceps femoris muscle weakness and is associated with significantly lower need for intraoperative opioids.

Retrospective Analysis of Pain Relief in Total Knee Replacement Surgeries

Background and Aims

The aim of the study is to measure the postoperative adequacy of pain relief and functional recovery after unilateral primary total knee arthroplasty or total knee replacement (TKR) with a multimodal approach.

Settings and Design

This was a retrospective observational study done in a tertiary care center.

Materials and Methods

Eighty patients aged 18-65 years (yrs) with ASA Physical Status Classes I, II, and III operated for unilateral primary TKR surgery under suitable Anaesthesia and was administered ultrasound-guided adductor canal block + periarticular infiltration (PI) from January 2018 to January 2019 were included. Thereafter, the patients visual analog scale (VAS) scores at rest, 45° knee flexion, and mobilization as well as additional analgesia given were noted after going through the records at following time points: 12 hourly for 24 h and thereafter on postoperative day 1 (POD1) and POD2. Level of block, adverse events, and functional recovery (time up and go [TUG] test, 10 s walk test) on POD1 and POD2 were also noted.

Statistical Analysis and Results

The statistical software namely SPSS 18.0 were used for the analysis of the data. The mean VAS score at 12 h was 4.33 ± 1.3 which worsened at 24 h with steady improvement over the next 2 days. Similarly, the case with a mean VAS score at 45° flexion and on mobilization showed a similar trend. At 12 h postadductor block, besides intravenous (i.v.) paracetamol, 32.6% of patients were given tramadol 50 mg i.v. whereas one patient was given a buprenorphine patch in addition to tramadol. The number of patients requiring additional tramadol and buprenorphine patch steadily increased over the next 2 days. The average time taken for the TUG test at 24 h was 30.98 ± 4.77 s, and the average time taken for the 10 s walk test at 24 h was 6.16 ± 1.10 steps with improvement in performance over the next 2 days.

Conclusion

In our study, our multimodal analgesia model did not provide satisfactory analgesia though mobilization was not hampered.

Adductor canal block with or without added magnesium sulfate following total knee arthroplasty: a multi-arm randomized controlled trial

PURPOSE

Postoperative analgesia following total knee arthroplasty (TKA) often includes intrathecal opioids, periarticular injection (PAI) of local anesthetic, systemic multimodal analgesia, and/or peripheral nerve blockade. The adductor canal block (ACB) provides analgesia without muscle weakness and magnesium sulphate (MgSO₄) may extend its duration. The purpose of this trial was to compare the duration and quality of early post-TKA analgesia in patients receiving postoperative ACB (± MgSO₄) in addition to standard care.

METHODS

Elective TKA patients were randomized to: 1) sham ACB, 2) ropivacaine ACB, or 3) ropivacaine ACB with added MgSO₄. All received spinal anesthesia with intrathecal morphine, intraoperative PAI, and multimodal systemic analgesia. Patients and assessors remained blinded to allocation. Anesthesiologists knew whether patients had received sham or ACB but were blinded to MgSO_4. The primary outcome was time to first analgesic (via patient-controlled analgesia [PCA] with iv morphine) following ACB. Secondary outcomes were morphine consumption, side effects, visual analogue scale pain scores, satisfaction until 24 hr postoperatively, and length of stay.

RESULTS

Of 130 patients, 121 were included. Nine were excluded post randomization: four were protocol violations, three did not meet inclusion criteria, and two had severe pain requiring open label blockade. There were no differences in the median [interquartile range] time to first PCA request: sham, 310 min [165-550]; ropivacaine ACB, 298 min [120-776]; and ropivacaine ACB with MgSO₄, 270 min [113-780] (P = 0.96). Similarly, we detected no differences in resting pain, opioid consumption, length of stay, or associated side effects until 24 hr postoperatively.

CONCLUSION

We found no analgesic benefit of a postoperative ACB, with or without added MgSO₄, in TKA patients undergoing spinal anesthesia and receiving intrathecal morphine, an intraoperative PAI, and multimodal systemic analgesia.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT02581683); registered 21 October 2015.

Clinical efficacy of adductor canal block in medial open wedge high tibial osteotomy

BACKGROUND

To evaluate the effect of adductor canal block (ACB) on short-term postoperative outcomes in patients who underwent medial open-wedge high tibial osteotomy (MOWHTO) compared to that of a placebo.

METHODS

35 patients who underwent unilateral MOWHTO between 2017 and 2019 were prospectively reviewed and randomly divided into two groups: 19 patients who received a single-shot ACB and 16 patients who received a saline injection (a placebo group). Primary outcomes were (1) pain measured using the visual analog scale and range of motion, (2) patient satisfaction, (3) postoperative need for additional opioids, (3) quadriceps strength (the time to straight leg raising [SLR]), (4) clinical outcomes, and (5) complications.

RESULTS

The pain score was lower in the ACB group than in the placebo group in the first 12 h (p = 0.04). ACB did not exhibit significantly less quadriceps strength weakness postoperatively. There was no statistical difference in the time to SLR (23.5 ± 17.7 h in ACB vs. 27.6 ± 11.4 in placebo, p = 0.520). The opioid consumption rate within postoperative 12 h was significantly decreased after ACB (16.7% in ACB, 70% in placebo, p = 0.017). The proportion of patients with more than 5 opioid injections within 72 h postoperatively was lower in the ACB group (8.3% in ACB, 50% in placebo, p = 0.043). Both groups did not show any localized and systemic complications.

CONCLUSION

ACB following MOWHTO exhibited better outcomes than a placebo with respect to opioid consumption with no changes in the quadriceps strength and complications.

LEVEL OF EVIDENCE

II, Prospectively comparative study.

Similar early functional recovery after total knee replacement comparing single shot versus continuous saphenous nerve block: A randomised, double-blind trial

PURPOSE

Total knee replacement (TKR) is associated with post-operative pain. Femoral nerve block can relieve the pain but also affects the post-operative mobility. Saphenous nerve block (SNB) can improve analgesia without interfering mobilisation. However, there is no consensus on the ideal mode of administration of SNB. We aim to compare the effects of single shot versus continuous SNB on patients undergoing TKR.

METHODS

Patients were randomised into two groups: single shot and continuous SNB groups. Post-operative rehabilitation and mobilisation were assessed by blinded physiotherapists, and preoperative and post-operative American knee scores were recorded by blinded specialised nurse. Post-operative analgesics usage was recorded by blinded pain nurses and anaesthetists.

RESULTS

Sixty-four patients were recruited; 6 patients withdrew with 29 patients in each group. There is no significant difference in early mobilisation and rehabilitation comparing both groups. The mean of the range gained on day 2 when compared to day 1 in single-shot SNB group was 17.41 ± 19.67° versus continuous SNB group was 23.45 ± 19.18° (p = 0.149). The mean of the range gained on day 3 when compared to day 1 in single-shot group was 27.24 ± 22.66° versus continuous SNB group was 29.31 ± 21.57° (p = 0.6). The mean of maximum flexion achieved by day 3 in single-shot SNB group was 92.41 ± 9.6° versus continuous SNB was 91.90 ± 7.95° (p = 0.84). The day of reaching maximum flexion and the goal of 40 m showed no significant difference. Length of stay (LOS), difference in post-operative American Knee Society knee score at 3 months and analgesics usage showed no significant difference.

CONCLUSION

There is no significant difference in comparing the effect on mobilisation, LOS, early clinical outcome, analgesics usage in the single-shot group and the continuous SNB group.

Adductor Canal Block Combined With iPACK (Interspace Between the Popliteal Artery and the Capsule of the Posterior Knee) Block vs Periarticular Injection for Analgesia After Total Knee Arthroplasty: A Randomized Noninferiority Trial

BACKGROUND

The combination of adductor canal block (ACB) and infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block may provide sufficient motor-sparing anterior and posterior knee analgesia after total knee arthroplasty. This study aimed to determine if ACB with iPACK block was noninferior to ACB with periarticular injection (PAI) when combined with postoperative multimodal analgesia regimen.

METHODS

Seventy-six patients were randomized to receive either ACB + iPACK block and continuous ACB (CACB) (ACB + iPACK group) or PAI and CACB (ACB + PAI group). Noninferiority was concluded for the primary outcome if the adjusted mean between-group difference in pain on movement at 12 postoperative hours was within 1.3 points on a visual analog pain scale. Pain scores, morphine consumption, functional performance, and adverse events were the secondary outcome measures assessed for superiority.

RESULTS

Adjusted mean differences, (ACB + iPACK) - (ACB + PAI), in anterior and posterior knee pain scores on movement at 12 postoperative hours were -0.66 (-1.86, 0.54) and -0.19 (-1.36, 0.99), respectively. The upper limit of 95% confident interval was lower than the prespecified noninferiority limit. The mean visual analog scale pain scores were low and no clinically significant differences between groups. However, morphine requirement at 48 postoperative hours was significantly higher (P < .05) and showed greater reduced quadriceps strength at 0 and 45 degrees on postoperative day 0 (P = .006 and .04, respectively) in the ACB + iPACK group.

CONCLUSIONS

ACB with iPACK block provides a noninferior analgesia compared with PAI when combined with CACB. However, patients who received ACB + iPACK block may require higher amounts of opioids and have worse immediate functional performance.

LEVEL OF EVIDENCE

Therapeutic level I.

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

STUDY OBJECTIVE

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

DESIGN

Systematic review and network meta-analysis of RCTs.

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS

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

RESULTS

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

CONCLUSION

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

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD 42020168102).

Motor-sparing nerve blocks for total knee replacement: A scoping review

STUDY OBJECTIVE

This scoping review investigates the optimal combination of motor-sparing analgesic interventions for patients undergoing total knee replacement (TKR).

DESIGN

Scoping review.

INTERVENTION

MEDLINE, EMBASE and CINAHL databases were searched (inception-last week of May 2020). Only trials including motor-sparing interventions were included. Randomized controlled trials lacking prospective registration and blinded assessment were excluded.

MAIN RESULTS

The cumulative evidence suggests that femoral triangle blocks outperform placebo and periarticular infiltration. When combined with the latter, femoral triangle blocks are associated with improved pain control, higher patient satisfaction and decreased opioid consumption. Continuous femoral triangle blocks provide superior postoperative analgesia compared with their single-injection counterparts. However, these benefits seem less pronounced when perineural adjuvants are used. Combined femoral triangle-obturator blocks result in improved analgesia and swifter discharge compared with femoral triangle blocks alone.

CONCLUSIONS

The optimal analgesic strategy for TKR may include a combination of different analgesic modalities (periarticular infiltration, femoral triangle blocks, obturator nerve block). Future trials are required to investigate the incremental benefits provided by local anesthetic infiltration between the popliteal artery and the capsule of the knee (IPACK), popliteal plexus block and genicular nerve block.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparative study of the influence of adductor canal block plus multimodal periarticular infiltration versus combined adductor canal block, multimodal periarticular infiltration and intra-articular epidural catheter ropivacaine infiltration on pain relief after total knee arthroplasty: a prospective study

BACKGROUND

A combined regimen of adductor canal block (ACB) and multimodal periarticular infiltration (MPI) with local anesthetic (ropivacaine) is a known effective method of controlling pain in the first 6-8 h after total knee arthroplasty (TKA); however, managing breakthrough pain after their combined effect wears off can be challenging. We hypothesized that, by additionally leaving an intra-articular epidural catheter (IAEC) inside the knee with intermittent infiltration of local anesthetic in conjunction with ACB and MPI, it would help manage the breakthrough pain when their combined effect wears off.

METHODS

We did a prospective study in our institution between December 2015 and August 2016 on a total of 206 patients undergoing primary unilateral TKA. The initial consecutive 106 patients received ACB + MPI (Group 1, n = 106), and the subsequent 100 patients received ACB + MPI + IAEC (Group 2, n = 100). The primary outcome measure was pain using visual analogue scale (VAS) recorded at 6, 12, 24 and 48 h, and the secondary outcome measures were requirement for rescue analgesics and repeat adductor canal block and length of hospital stay.

RESULTS

There was no statistically significant difference in VAS scores between the two groups at 6 h but at 12, 24 and 48 h; there was a statistically significant difference between the two groups in terms of VAS scores, rescue analgesic requirements, repeat adductor canal block and shorter hospital stay favoring the ACB + MPI + IAEC group.

CONCLUSION

Intermittent knee infiltration with ropivacaine is a safe, reproducible and effective method to control pain in the first 48 h postoperative period after TKA.

A prospective comparative study of local infiltration versus adductor block versus combined use of the two techniques following knee arthroplasty

BACKGROUND

Pain management after total knee arthroplasty (TKA) is important as acute postoperative pain can affect patient's ability to walk and participate in rehabilitation required for good functional outcome. This is achieved by effective intra-operative and post-operative analgesia to facilitate early recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) are analgesic regimens and commonly used for effective post-operative analgesia after TKA. Our aim was to compare the efficacy and outcomes of these two methods, combined and independently.

METHODS

Our study included 120 patients undergoing unilateral TKA, who were randomized into three groups: LIA (Group I), ACB (Group II) and combined LIA + ACB (Group III). Patients were operated by a single surgeon. The outcome was defined by post-operative analgesia achieved by the three techniques (measured by the NPRS) and amount of fentanyl consumed postoperatively. Secondary outcome was evaluated based on postoperative functional outcomes in terms of ability to stand, distance covered, range of motion of knee on the 1st post-operative day, complications and WOMAC (Western Ontario & McMaster Universities Osteoarthritis Index) scores.

RESULTS

All patients were available for analysis. Numerical Pain Rating Scale for pain showed significant differences at 24 h between Group I and Group II, with a p value of 0.018 (GroupI was better), significant differences were found at 24 h between Group III and Group II, with p values being 0.023 and 0.004 (GroupIII was better). No significant differences were found between Group I and Group III at 24 h. Total fentanyl consumption was significantly less in Group III than in Group I and Group II, with p value being 0.042 and 0.005, respectively (Group III was better and consumed less fentanyl). No significant differences were found in WOMAC scores between the three groups at baseline, 2 and 6 weeks after operation.

CONCLUSION

In patients undergoing TKA, analgesic effect of combined ACB and LIA was superior, as indicated by reduced opioid consumption and no differences in functional outcomes and complications were observed as compared to separate use of the two techniques.

Is continuous catheter adductor canal block better than single-shot canal adductor canal block in primary total knee arthroplasty?: A GRADE analysis of the evidence through a systematic review and meta-analysis

BACKGROUND

The adductor canal block (ACB) has emerged as an alternative to the femoral nerve block (FNB) after total knee arthroplasty. This meta-analysis was conducted to investigate which ACB method provides better pain relief and functional recovery after total knee arthroplasty METHODS:: We conducted a meta-analysis to identify randomized controlled trials involving single-shot adductor canal block (SACB) and continuous catheter ACB (CACB) after TKA up to December 2019 by searching databases including the PubMed, Web of Science, Embase, Cochrane Controlled Trials Register, Cochrane Library, CBM, CNKI, VIP, and Wanfang databases. Finally, we included 8 randomized controlled trials involving 702 knees in our study. We used Review Manager Software and Grading of Recommendations Assessment, Development, and Evaluation profiler to perform the meta-analysis.

RESULTS

Compared with SACB, CACB can achieve better postoperative pain relief at 24 and 48 h both at rest and after mobilization, lower amount of opioid consumption at 72 h, a shorter length of hospital stay (LOH) and larger range of motion (ROM). In addition, the Timed Up and Go (TUG) test results; quadriceps strength; and incidence of complications, including postoperative nausea and vomiting, DVT, catheter-related infections, catheter dislodgement and neurologic deficits, showed no significant difference between the two ACB methods.

CONCLUSION

The results of this study demonstrate that CACB is an effective alternative to SACB and can provide better pain relief, a shorter LOH, more degrees of maximum flexion and a lower amount of opioid consumption over time, but it provides a comparable level of recovery of quadriceps strength and mobility with a similar risk of catheter-related complications. Thus, CACB may be a better analgesia strategy than SACB after TKA at present.

Effectiveness of continuous adductor canal block versus continuous femoral nerve block in patients with total knee arthroplasty: A PRISMA guided systematic review and meta-analysis

BACKGROUND

This study aimed to evaluate the effectiveness of continuous adductor canal block (CACB) versus continuous femoral nerve block (CFNB) in postoperative analgesia and early rehabilitation of patients with total knee arthroplasty (TKA).

METHODS

The Cochrane Library, PubMed, and EMbase were systematically searched to retrieve literature comparing efficacy of CACB versus CFNB on pain relief and functional recovery in knee replacement patients until December 2018, without language limitation. Meta-analysis was performed using RevMan 5.3 software.

RESULTS

A total of 7 clinical randomized controlled trials and 4 retrospective studies were included, involving 484 cases in the CACB group and 491 in the CFNB group. The results of the meta-analysis showed that the visual analogue scores (VAS) at rest were similar between the CACB group and the CFNB group at 8 hours (standard mean difference(SMD) = -0.26, 95% confidence interval(CI): -0.62, 0.11), 12 hours (SMD = -0.02, 95%CI: -0.50, 0.47), 24 hours (SMD = 0.05, 95%CI: -0.22, 0.33), and 48 hours (SMD = -0.10, 95%CI: -0.29, 0.09) after TKA (P > .05 for all). The muscle strength of patients in the CACB group post-operation was significantly improved than those of the CFNB group (SMD = 0.81; 95% CI: 0.35, 1.26; P = .0005). There were no significant differences in the amount of opioids consumption and the incidence of postoperative fall between CACB and CFNB (P > .05).

CONCLUSION

The analgesic effects of CACB versus CFNB are equivalent after TKA. CACB has less effect on the quadriceps muscle strength, which is beneficial to the early postoperative activities and functional rehabilitation.

Adductor canal blocks for postoperative pain treatment in adults undergoing knee surgery

BACKGROUND

Peripheral regional anaesthesia techniques are well established for postoperative pain treatment following knee surgery. The adductor canal block (ACB) is a new technique, which can be applied as a single shot or by catheter for continuous regional analgesia.

OBJECTIVES

To compare the analgesic efficacy and adverse events of ACB versus other regional analgesic techniques or systemic analgesic treatment for adults undergoing knee surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase, five other databases, and one trial register on 19 September 2018; we checked references, searched citations, and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) comparing single or continuous ACB versus other regional analgesic techniques or systemic analgesic treatment. Inclusion was independent of the technique used (landmarks, peripheral nerve stimulator, or ultrasound) and the level of training of providers.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. Our primary outcomes were pain intensity at rest and during movement; rate of accidental falls; and rates of opioid-related adverse events. We used GRADE to assess the quality of evidence for primary outcomes.

MAIN RESULTS

We included 25 RCTs (1688 participants) in this review (23 trials combined within meta-analyses). In 18 studies, participants underwent total knee arthroplasty (TKA), whereas seven trials investigated patients undergoing arthroscopic knee surgery. We identified 11 studies awaiting classification and 11 ongoing studies. We investigated the following comparisons. ACB versus sham treatment We included eight trials for this comparison. We found no significant differences in postoperative pain intensity at rest (2 hours: standardized mean difference (SMD) -0.56, 95% confidence interval (CI) -1.20 to 0.07, 4 trials, 208 participants, low-quality evidence; 24 hours: SMD -0.49, 95% CI -1.05 to 0.07, 6 trials, 272 participants, low-quality evidence) or during movement (2 hours: SMD -0.59, 95% CI -1.5 to 0.33; 3 trials, 160 participants, very low-quality evidence; 24 hours: SMD 0.03, 95% CI -0.26 to 0.32, 4 trials, 184 participants, low-quality evidence). Furthermore, they noted no evidence of a difference in postoperative nausea between groups (24 hours: risk ratio (RR) 1.91, 95% CI 0.48 to 7.58, 3 trials, 121 participants, low-quality evidence). One trial reported that no accidental falls occurred 24 hours postoperatively (low-quality evidence). ACB versus femoral nerve block We included 15 RCTs for this comparison. We found no evidence of a difference in postoperative pain intensity at rest (2 hours: SMD -0.74, 95% CI -1.76 to 0.28, 5 trials, 298 participants, low-quality evidence; 24 hours: SMD 0.04, 95% CI -0.09 to 0.18, 12 trials, 868 participants, high-quality evidence) or during movement (2 hours: SMD -0.47, 95% CI -1.86 to 0.93, 2 trials, 88 participants, very low-quality evidence; 24 hours: SMD 0.56, 95% CI -0.00 to 1.12, 9 trials, 576 participants, very low-quality evidence). They noted no evidence of a difference in postoperative nausea (24 hours: RR 1.22, 95% CI 0.42 to 3.54, 2 trials, 138 participants, low-quality evidence) and no evidence that the rate of accidental falls during postoperative care was significantly different between groups (24 hours: RR 0.20, 95% CI 0.04 to 1.15, 3 trials, 172 participants, low-quality evidence).

AUTHORS' CONCLUSIONS

We are currently uncertain whether patients treated with ACB suffer from lower pain intensity at rest and during movement, fewer opioid-related adverse events, and fewer accidental falls during postoperative care compared to patients receiving sham treatment. The same holds true for the comparison of ACB versus femoral nerve block focusing on postoperative pain intensity. The overall evidence level was mostly low or very low, so further research might change the conclusion. The 11 studies awaiting classification and the 11 ongoing studies, once assessed, may alter the conclusions of this review.

Randomized Prospective Comparative Study of Adductor Canal Block vs Periarticular Infiltration on Early Functional Outcome After Unilateral Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is associated with significant postoperative pain. Effective pain relief is essential for early postoperative rehabilitation. Periarticular infiltration (PAI) and adductor canal block (ACB) have become popular modes of pain management after TKA. Our aim is to compare their efficacy and impact on early functional outcome in patients undergoing TKA.

METHODS

A single-blinded randomized controlled trial, 100 patients undergoing unilateral primary TKA for symptomatic osteoarthritis were allocated to either of the 2 groups (50 in each arm): postoperative ultrasound-guided single shot of ACB (group A) or intraoperative PAI (group B). All patients underwent TKA without patella resurfacing under spinal anesthesia. Preoperative workup, surgical technique, and postoperative management were standardized for all the patients. Patients were assessed for pain using visual analogue scale at 6, 12, and 24 hours after surgery; hemoglobin level preoperatively and postoperatively on day 1 to calculate blood loss; hospital stay; tourniquet time; operative time; and postoperative complications by an independent observer blinded to the group allocation.

RESULTS

Patients were matched for age, gender, American Society of Anesthesiologists grade, and deformity. Visual analogue scale (scale 0-10) between PAI and ACB at 6, 12, and 24 hours were significantly different (P < .05) with higher scores seen in patients with ACB at all time points. Tourniquet time and operative time were significantly longer in the PAI than ACB. No significant difference in hospital stay was observed. No complications occurred during the study.

CONCLUSION

PAI achieves better pain control as compared to ACB in patients undergoing unilateral TKA.

Peripheral nerve catheters: A critical review of the efficacy

Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.

Continuous Adductor Canal Block used for postoperative pain relief after medial Unicondylar Knee Arthroplasty: a randomized, double-blind, placebo-controlled trial

Background

Peripheral nerve block and local infiltration analgesia (LIA) provide good analgesia after knee replacement. This study evaluated the additional analgesic efficacy of continuous adductor canal block (ACB) added to single-dose LIA after medial unicondylar knee arthroplasty (UKA). We hypothesized ACB would lower pain scores and facilitate postoperative ambulation.

Methods

Forty-six patients were enrolled into this double-blind, randomized, placebo-controlled trial. UKA was performed and all patients received single-dose LIA intraoperatively. Patients were randomized into two groups: Group RP receiving 0.2% ropivacaine or Group Con receiving normal saline. A flow at 6 mL/h was administered for 48 h through a catheter in the adductor canal. Primary outcome was movement pain score at 24 h using the numeric rating scale (NRS-11). Secondary outcomes included serial postoperative pain scores, rate of patients with NRS>3 at rest and movement within 24 and 48 h postoperatively, time to breakthrough pain, quadriceps motor strength, ambulated distance, catheter related infection and patient satisfaction.

Results

Forty-two patients were analyzed. Pain scores with movement at 24 h postoperatively were significantly lower in Group RP than that in Group Con (3 vs. 5 NRS, P<0.001). Compared with Group Con, breakthrough pain occurred later in Group RP (18.5 vs 10.0 h, P = 0.002), serial pain scores at rest and with movement and rate of patients with NRS>3 with movement after surgery were significantly lower. Quadriceps motor strength was equivalent, however, ambulated distance on postoperative day 1 and 2 in Group Con was significant less (19.7 vs 37.3 m, P = 0.046; 33.4 vs 59.5 m, P = 0.002).

Conclusions

Continuous adductor canal block added to single-dose LIA offered better analgesia and facilitated ambulation without motor weakness after medial UKA.

Trial registration

Clinical Trial Registration: ChiCTR-IOR-16008720; Registered 25 June 2016.

Addition of Adductor Canal Block to Periarticular Injection for Total Knee Replacement: A Randomized Trial

BACKGROUND

Periarticular injection is a popular method to control postoperative pain after total knee replacement. An adductor canal block is a sensory block that can also help to alleviate pain after total knee replacement. We hypothesized that the combination of adductor canal block and periarticular injection would allow patients to reach discharge criteria 0.5 day faster than with periarticular injection alone.

METHODS

This prospective trial enrolled 56 patients to receive a periarticular injection and 55 patients to receive an adductor canal block and periarticular injection. Both groups received intraoperative neuraxial anesthesia and multiple different types of pharmaceutical analgesics. The primary outcome was time to reach discharge criteria. Secondary outcomes, collected on postoperative days 1 and 2, included numeric rating scale pain scores, the PAIN OUT questionnaire, opioid consumption, and opioid-related side effects.

RESULTS

There was no difference in time to reach discharge criteria between the groups with and without an adductor canal block. The Wilcoxon-Mann-Whitney odds ratio was 0.87 (95% confidence interval [CI], 0.55 to 1.33; p = 0.518). The median time to achieve discharge criteria (and interquartile range) was 25.8 hours (23.4 hours, 44.3 hours) in the adductor canal block and periarticular injection group compared with 26.4 hours (22.9 hours, 46.2 hours) in the periarticular injection group. Patients who received an adductor canal block and periarticular injection reported lower worst pain (difference in means, -1.4 [99% CI, -2.7 to 0]; adjusted p = 0.041) and more pain relief (difference in means, 12% [99% CI, 0% to 24%]; adjusted p = 0.048) at 24 hours after anesthesia. There was no difference in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores).

CONCLUSIONS

The time to meet the discharge criteria was not significantly different between the groups. In the adductor canal block and periarticular injection group, the patients had lower worst pain and greater pain relief at 24 hours after anesthesia. No difference was noted in any other secondary outcome measure (e.g., opioid consumption, opioid-related side effects, numeric rating scale pain scores).

LEVEL OF EVIDENCE

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

Hybrid Blocks for Total Knee Arthroplasty: A Technical Description

INTRODUCTION

This narrative review article aims to examine current evidence of knee innervation in order to develop a technique of targeting pure sensory innervation of the knee joint without compromising motor function.

METHODS

A literature review of knee innervation was performed to gain an anatomic understanding of terminal sensory branches of the relevant target nerves (femoral, obturator, sciatic, and lateral femoral cutaneous).

RESULTS

Pure sensory block of the knee joint is challenging due to important contributions from themuscular innervation close to the joint and the variability of nerves afferents contained within and around the adductor canal.

CONCLUSION

On the basis of this anatomic knowledge we describe an ultrasound-guided 3-injection hybrid technique that represents a balance between preserving adequate motor power while still providing analgesia in a simple method.

Lower extremity regional anesthesia: essentials of our current understanding

The advent of ultrasound guidance has led to a renewed interest in regional anesthesia of the lower limb. In keeping with the American Society of Regional Anesthesia and Pain Medicine's ongoing commitment to provide intensive evidence-based education, this article presents a complete update of the 2005 comprehensive review on lower extremity peripheral nerve blocks. The current review article strives to (1) summarize the pertinent anatomy of the lumbar and sacral plexuses, (2) discuss the optimal approaches and techniques for lower limb regional anesthesia, (3) present evidence to guide the selection of pharmacological agents and adjuvants, (4) describe potential complications associated with lower extremity nerve blocks, and (5) identify informational gaps pertaining to outcomes, which warrant further investigation.

The efficacy of combined adductor canal block with local infiltration analgesia for pain control after total knee arthroplasty: A meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the efficiency and safety of the combined adductor canal block (ACB) with local infiltration anesthesia (LIA) versus LIA alone for pain control after total knee arthroplasty (TKA).

METHODS

We searched PubMed, Medline, Embase, Web of Science, the Cochrane Library and Google databases from inception to August 2017 to selected studies that comparing the combined ACB with LIA and LIA alone for pain control after TKA. Only randomized controlled trials (RCTs) were included. Outcomes included visual analogue scale (VAS) with rest or mobilization at 8 h, 24 h and 48 h, total morphine consumption at 6 h, 24 h and 48 h, distance walked at 24 h and 48 h and the length of hospital stay.

RESULTS

Seven randomized controlled trial (RCTs) were finally included in this meta-analysis. The present meta-analysis indicated that, compared with LIA alone, combined ACB with LIA was associated with a reduction of VAS with rest at 24 h and 48 h and VAS with mobilization at 24 h. Additionally, combined ACB with LIA was associated with an increase of the distance walked at 24 h and a reduction of the length of hospital stay.

CONCLUSION

Combined ACB with LIA could significantly reduce pain scores and morphine consumption compared LIA alone after TKA. Further multimodal large sample RCTs are needed to identify the optimal drug of ACB and LIA.

A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine

Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.