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Gui YK, Xiao R, Luo YR, Liu Y, Da X, Zhu SH, Shi DW, Hu XD, Xu GH. Analgesic Effects of Different Local Infiltration Anesthesia Techniques Combined with Femoral Nerve Block in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Clinical Trial. Local Reg Anesth 2023; 16:183-192. [PMID: 38148969 PMCID: PMC10750774 DOI: 10.2147/lra.s436767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/29/2023] [Indexed: 12/28/2023] Open
Abstract
Objective Pain after total knee arthroplasty (TKA) remains an unresolved problem. Femoral nerve block (FNB) could relieve pain; however, it alone is insufficient. The local infiltration anesthesia technique (LIA) has been suggested as a supplement to FNB. This study aimed to evaluate the analgesic effects of different LIA combined with FNB in TKA patients. Methods The femoral nerve was blocked with 0.375% ropivacaine 20mL, and all patients routinely received general anesthesia. The primary indicator was the proportion of patients who did not receive post-operative remedial analgesia. Seventy-eight patients were randomly assigned to PAI (periarticular injection combined with FNB), IAI (intra-articular injection combined with FNB), or control (FNB alone) groups. All patients underwent FNB under general anesthesia. The primary outcome was the proportion of patients who did not receive additional postoperative analgesia within the first 48 h after surgery. Results Compared with the PAI and control groups, the IAI group had a higher proportion (69.23%) of patients who did not receive remedial analgesia within 48 hours after surgery (P = 0.009; P = 0.009), a lower consumption of diclofenac sodium lidocaine (P = 0.021; P < 0.001), and an earlier time of walking with a walker (P < 0.001; P < 0.001). The time of first need for remedial analgesia postoperatively in IAI group was longer than the PAI group (P = 0.008) and IAI group has a shorter hospital stay than the control group (P = 0.008). The maximum NRS during the first 48 hours postoperatively and NRS 24 hours after surgery in the IAI group were lower than those in the control and PAI groups. The incidences of POD and PONV were similar among the three groups (P = 0.610; P = 0.264). Conclusion When combined with FNB, intra-articular injection offers a superior analgesic effect and favorable recovery compared to periarticular injection and separate application of FNB.
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Affiliation(s)
- Yong-Kang Gui
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
| | - Rui Xiao
- Fuyang Hospital of Anhui Medical University, Fuyang, Anhui, 230022, People’s Republic of China
| | - Ya-Ru Luo
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
| | - Yang Liu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
| | - Xin Da
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
| | - Si-Hui Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
| | - De-Wen Shi
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
| | - Xu-Dong Hu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
| | - Guang-Hong Xu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230022, People’s Republic of China
- Key Laboratory of Anesthesia and Perioperative Medicine of Anhui Higher Education Institutes, Hefei, Anhui, 230022, People’s Republic of China
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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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Perka C, von Heymann C, Lier H, Kaufner L, Treskatsch S. Die perioperative Gabe von Tranexamsäure. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2023; 161:532-537. [PMID: 37336245 DOI: 10.1055/a-2055-8178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
The application of tranexamic acid (TXA) during endoprosthetic surgical procedures has significantly increased in recent years. Due its ability to reduce perioperative blood loss and avert the need for blood transfusions as well as wound drainage, TXA is becoming part of a 'standard practice'. However, TXA is currently not approved for the application during endoprosthetic procedures and therefore, a benefit-risk analysis should always be conducted. Prophylactic administration of TXA without prior patient consent is only justified if fibrinolytic bleeding is expected and there are no contraindications or relevant risk factors for thromboembolic complications. Respectively, no patient consent is required when a therapeutic dose of TXA is administered in the context of fibrinolytic bleeding. The following guidelines provide updated recommendations based on the current state of knowledge on TXA optimal timing, routes of administration and dosing regimen.
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Affiliation(s)
- Carsten Perka
- Klinik für Orthopädie, Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Christian von Heymann
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Berlin, Deutschland
| | - Heiko Lier
- Klinik für Anästhesiologie und Operative Intensivmedizin, Medizinische Fakultät und Uniklinik Köln, Köln, Deutschland
| | - Lutz Kaufner
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité ‒ Universitätsmedizin Berlin, Berlin, Deutschland
| | - Sascha Treskatsch
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité ‒ Universitätsmedizin Berlin, Berlin, Deutschland
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Reinbacher P, Schittek GA, Draschl A, Hecker A, Leithner A, Klim SM, Brunnader K, Koutp A, Hauer G, Sadoghi P. Local Periarticular Infiltration with Dexmedetomidine Results in Superior Patient Well-Being after Total Knee Arthroplasty Compared with Peripheral Nerve Blocks: A Randomized Controlled Clinical Trial with a Follow-Up of Two Years. J Clin Med 2023; 12:5088. [PMID: 37568489 PMCID: PMC10420252 DOI: 10.3390/jcm12155088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND This study aimed to compare local periarticular infiltration (LIA) with ultra-sound guided regional anesthesia (USRA) with ropivacaine and dexmedetomidine as an additive agent in primary total knee arthroplasty (TKA). METHODS Fifty patients were randomized into two groups in a 1:1 ratio. Patients in the LIA group received local periarticular infiltration into the knee joint. The USRA group received two single-shot USRA blocks. Functional outcomes and satisfaction (range of movement, Knee Society Knee Score, Western Ontario and McMaster Universities Osteoarthritis Index, Oxford Knee Score, and Forgotten Joint Score), including well-being, were analyzed preoperatively and at five days, six weeks, and one and two years postoperatively. RESULTS Functional outcomes did not significantly differ between the two groups at six weeks and one and two years after the implementation of TKA. A moderate correlation was observed in the LIA group regarding well-being and pain on day five. Six weeks postoperatively, the LIA group showed significantly superior well-being but worse pain scores. No differences between the groups in well-being and functional outcomes could be observed one and two years postoperatively. CONCLUSION Patients treated with LIA had superior postoperative well-being in the early postoperative phase of up to six weeks. Furthermore, LIA patients had similar functionality compared to patients treated with USRA but experienced significantly more pain six weeks postoperatively. LIA leads to improved short-term well-being, which is potentially beneficial for faster knee recovery. We believe that LIA benefits fast-track knee recovery with respect to improved short-term well-being, higher practicability, and faster application.
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Affiliation(s)
- Patrick Reinbacher
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
| | - Gregor A. Schittek
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, 8036 Graz, Austria
| | - Alexander Draschl
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
| | - Andrzej Hecker
- Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, 8036 Graz, Austria
- COREMED—Centre for Regenerative Medicine and Precision Medicine, Joanneum Research Forschungsgesellschaft mbH, 8010 Graz, Austria
| | - Andreas Leithner
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
| | - Sebastian Martin Klim
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
| | - Kevin Brunnader
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
| | - Amir Koutp
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
| | - Georg Hauer
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
| | - Patrick Sadoghi
- Department of Orthopaedics & Traumatology, Medical University of Graz, 8036 Graz, Austria; (P.R.); (P.S.)
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Pic C, Macabeo C, Waissi E, Lasselin P, Raffin M, Pradat P, Lalande L, Lustig S, Aubrun F, Dziadzko M. No Benefit of Adductor Canal Block Compared with Anterior Local Infiltration Analgesia in Primary Total Knee Arthroplasty: A Single-Blinded Randomized Controlled Clinical Trial. J Bone Joint Surg Am 2023; 105:231-238. [PMID: 36723467 DOI: 10.2106/jbjs.22.00745] [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: 02/02/2023]
Abstract
BACKGROUND An adductor canal block (ACB) performed by an anesthesiologist is an established component of analgesia after total knee arthroplasty. Alternatively, surgeons may perform periarticular local infiltration analgesia (LIA) intraoperatively. We hypothesized that ACB would be superior to anterior LIA in terms of morphine consumption in the first 48 hours after primary total knee arthroplasty under spinal anesthesia. METHODS This prospective controlled and blinded trial included 98 patients; 48 received an ACB plus sham (saline solution) anterior LIA, and 50 received a sham (saline solution) ACB plus anterior LIA. Both groups received posterior LIA with local anesthetic. The primary outcome was cumulative morphine consumption at 48 hours after surgery. Secondary outcomes were pain while resting, standing, and walking, rehabilitation scores, opioid-related side effects, and patient satisfaction. RESULTS No difference in the primary outcome was found, and the 48-hour morphine consumption was low in both arms (28.8 ± 17.6 mg with ACB, 26.8 ± 19.2 mg with anterior LIA; p = 0.443). Pain scores were significantly better in the anterior LIA arm, but the differences were not clinically relevant. There were no differences in any other secondary outcome measures. CONCLUSIONS LIA may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Caroline Pic
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Caroline Macabeo
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Emran Waissi
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Philippe Lasselin
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Mahé Raffin
- Centre de Recherche Clinique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Pierre Pradat
- Centre de Recherche Clinique, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Laure Lalande
- Service de Pharmacie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France
| | - Sebastien Lustig
- Département de Chirurgie Orthopédique et Médecine de Sport, Centre d'Excellence FIFA Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France.,IFSTTAR, LBMC UMR_T9406, Université Claude Bernard, Lyon, France
| | - Frederic Aubrun
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France.,Research on Healthcare Performance Lab (RESHAPE INSERM U1290), Université Claude Bernard, Lyon, France
| | - Mikhail Dziadzko
- Département d'Anesthésie-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard, Lyon, France.,Research on Healthcare Performance Lab (RESHAPE INSERM U1290), Université Claude Bernard, Lyon, France
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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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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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Borck M, Wandrey JD, Höft M, Kastelik J, Perka C, Tafelski S, Treskatsch S. Local infiltration analgesia versus peripheral nerve block anaesthesia in total knee arthroplasty: a pharmaco-economic comparison. BMC Anesthesiol 2022; 22:80. [PMID: 35337268 PMCID: PMC8953132 DOI: 10.1186/s12871-022-01620-w] [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: 01/09/2022] [Accepted: 03/14/2022] [Indexed: 11/22/2022] Open
Abstract
Background A superior analgesic method in perioperative pain-management of patients receiving total knee arthroplasty is the subject of controversial debate. Although higher cost-efficiency is claimed for the local infiltration analgesia (LIA), there is a lack of data on its costs compared to peripheral nerve block anaesthesia (PNBA). The goal of this study was to investigate the differences in immediate perioperative costs between the LIA and PNBA in treatment of patients receiving total knee arthroplasty. Methods The comparison was conducted based on a randomized controlled clinical trial examining 40 patients with elective, primary total knee arthroplasty (TKA, 20 patients with LIA and 20 patients with PNBA). The analysis included surgical case costs, anaesthesiological case costs, material, costs of postoperative opioid requirements and catheter review visits for patients receiving PNBA. Results The overall mean costs for the LIA-group were 4328.72€ and 4368.12€ for the PNBA (p = 0.851). While there was no statistically significant difference in surgical case costs, the anaesthesiological costs were lower with the LIA procedure (1370.26€ vs. 1542.45€, p = 0.048). Material costs in the LIA group were 4.18€/patient and 94.64€/patient with the PNBA. Costs for postoperative opioid requirements showed no statistically significant difference between the two procedures. Conclusions There is no relevant difference in immediate perioperative costs between LIA and PNBA. Shorter induction times lead to lower anaesthesiological case costs with the LIA. Overall economic aspects seem to play a less important role for determining an adequate procedure for perioperative pain management. Trial registration The study was approved by the ethics-review-board of Charité Hospital Berlin (Ethikausschuss 4, Charité – Universitätsmedizin Berlin, on 16th February 2017) and registered with data safety authorities. Study patients provided written informed consent to participate in the trial. Study registry: ClinicalTrials.gov, NCT03114306.
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Affiliation(s)
- Michael Borck
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health , Charitéplatz 1, 10117, Berlin, Germany.,Department of Anaesthesiology and Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jan D Wandrey
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health , Charitéplatz 1, 10117, Berlin, Germany.,Department of Anaesthesiology and Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Moritz Höft
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health , Charitéplatz 1, 10117, Berlin, Germany.,Department of Anaesthesiology and Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Joanna Kastelik
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health , Charitéplatz 1, 10117, Berlin, Germany.,Department of Anaesthesiology and Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Carsten Perka
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health , Charitéplatz 1, 10117, Berlin, Germany.,Centre for Musculoskeletal Surgery, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Germany
| | - Sascha Tafelski
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany.,Berlin Institute of Health , Charitéplatz 1, 10117, Berlin, Germany.,Department of Anaesthesiology and Intensive Care, Campus Charité Mitte and Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Sascha Treskatsch
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Berlin Institute of Health , Charitéplatz 1, 10117, Berlin, Germany. .,Department of Anaesthesiology and Intensive Care, Charité Campus Benjamin Franklin (CBF), Hindenburgdamm 30, 12203, Berlin, Germany.
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Combined femoral and popliteal nerve block is superior to local periarticular infiltration anaesthesia for postoperative pain control after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:4046-4053. [PMID: 35112178 PMCID: PMC9668930 DOI: 10.1007/s00167-022-06868-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION After primary total knee arthroplasty (TKA), local periarticular infiltration anaesthesia (LIA) is a fast and safe method for postoperative pain control. Moreover, ultrasound-guided regional anaesthesia (USRA) with femoral and popliteal block is a standard procedure in perioperative care. Two analgesic regimens for TKA-LIA versus URSA with dexmedetomidine-were compared as an additive to ropivacaine. We hypothesised that the use of URSA provides a superior opioid sparing effect for TKA compared with LIA. METHODS Fifty patients (planned 188 participants; safety analysis was performed after examining the first 50 participants) were randomised. These patients received LIA into the knee capsule during surgery with 60 ml of ropivacaine 0.5% and 1 ml of dexmedetomidine (100 µg ml-1) or two single-shot URSA blocks (femoral and popliteal block) before surgery with 15 ml of ropivacaine 0.5% and 0.5 ml of dexmedetomidine for each block. Postoperative opioid consumption in the first 48 h, pain assessment and complications were analysed. RESULTS In the safety analysis, there was a significantly higher need for opioids in the LIA group, with a median oral morphine equivalent of 42.0 [interquartile range (IQR) 23.5-57.0] mg versus 27.0 [IQR 0.0-33.5] mg (P = 0.022). Due to this finding, the study was terminated for ethical considerations according to the protocol. CONCLUSION This is the first study presenting data on LIA application in combination with dexmedetomidine. A superior opioid-sparing effect of URSA was observed when compared with LIA in TKA when dexmedetomidine is added to local anaesthetics. Also, a longer lasting opioid-sparing effect in the LIA group was observed when compared with the recently published literature; this difference could be attributed to the addition of dexmedetomidine. Therefore, multimodal analgesia regimens could be further improved when LIA or USRA techniques are combined with dexmedetomidine.
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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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Li D, Alqwbani M, Wang Q, Yang Z, Liao R, Kang P. Ultrasound-guided adductor canal block combined with lateral femoral cutaneous nerve block for post-operative analgesia following total knee arthroplasty: a prospective, double-blind, randomized controlled study. INTERNATIONAL ORTHOPAEDICS 2020; 45:1421-1429. [PMID: 33200245 DOI: 10.1007/s00264-020-04549-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 03/26/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE The purpose of this study was to investigate whether adductor canal block (ACB) combined with lateral femoral cutaneous nerve block (LFCNB) could improve the efficacy of post-operative analgesia in a comparison with a standard peri-articular infiltration analgesia (PIA) after a total knee arthroplasty (TKA). METHODS One hundred and sixty patients of scheduled unilateral primary TKA were randomly allocated into two groups for post-operative analgesia. Eighty cases were treated with ACB combined with LFCNB and the other eighty treated with PIA. The primary outcomes were pain visual analogue scale (VAS) and rescue pain killer consumption, and the secondary outcomes were knee active range of motion (ROM), quadriceps strength, patients' ambulation ability, Knee Society Score (KSS), length of hospital stay, and adverse events. RESULTS We found that ACB combined with LFCNB was better on decreasing the post-operative pain score within 12 hours at rest and 8 h with activity (p < 0.05) and provided longer duration of analgesia (19.91 ± 5.09 VS 12.06 ± 3.67 h, p < 0.01) and less rescue morphine consumption (13.63 ± 9.84 vs 18.00 ± 11.52 mg, p = 0.011) than the PIA. There was no significant difference between the two groups (p > 0.05) in terms of knee ROM, quadriceps strength, daily mobilization distance, KSS, and complication occurrence. CONCLUSIONS ACB combined with LFCNB provides a significantly better pain control, less opioid consumption, and longer duration of analgesia than peri-articular infiltration while preserving muscle function without affecting knee functional recovery nor the length of stay or side effects occurrence.
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Affiliation(s)
- Donghai Li
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Mohammed Alqwbani
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Qiuru Wang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zhouyuan Yang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Ren Liao
- Department of Anesthesiology, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, Sichuan Province, China
| | - Pengde Kang
- Department of Orthopaedics Surgery, West China Hospital, Sichuan University, 37# Guoxue Road, Chengdu, 610041, People's Republic of China.
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Calvo A, Gómez Tarradas JM, Sala X, Basora M, Lozano L, Erdoes G. Local infiltration analgesia for total knee arthroplasty: Does a mixture of ropivacaine and epinephrine have an impact on hemodynamics? An observational cohort study. Saudi J Anaesth 2020; 14:335-342. [PMID: 32934626 PMCID: PMC7458011 DOI: 10.4103/sja.sja_86_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 02/17/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose: High doses of local anesthetic administered intra-articularly and peri-articularly during local infiltration analgesia (LIA) for total knee arthroplasty (TKA) may have potential effects on patient hemodynamics. The aim of this study was to know if hemodynamic changes are associated with LIA in patients undergoing TKA. Methods: In a prospective observational design, elective patients undergoing orthopedic surgery for TKA and treated with LIA consisting of a mixture of ropivacaine (300 mg) and epinephrine (1 mg) were investigated for changes in selected hemodynamic parameters: heart rate (HR), non-invasively registered mean arterial blood pressure (MAP), and incidence of arrhythmias during the perioperative course, consisting of the following periods: period 1. from establishment of spinal anesthesia to prior to LIA administration, period 2. from administration of LIA to before release of ischemia tourniquet, period 3. from release ischemia tourniquet to end of surgery, and period 4. from transfer to the post anesthesia care unit to the ward. Statistical analysis was done with ANOVA-RM for the difference in means in repeated measurements, and with the Tukey Test between pairs. Data are presented as mean ± standard deviation. A P value <0.05 was considered significant. Results: Ninety-nine patients (mean age 77 ± 8 years) were included. HR increased from period 2 to period 3 up to 16% (67 ± 14 to 77 ± 13 bpm, P < 0.001), and from period 2 to period 4 up to 21% (67 ± 14 to 81 ± 12 bpm, P < 0.001). MAP showed no significant changes from period 2 to period 3 (89 ± 13 to 87 ± 13 mmHg, P > 0.50), and from period 2 to period 4 (89 ± 13 to 91 ± 11 mmHg, P > 0.50). No arrhythmias were detected during follow-up. Conclusions: A mixture of ropivacaine and epinephrine for LIA, despite the high doses administered, does not have a negative impact on hemodynamics.
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Affiliation(s)
- Andrea Calvo
- Department of Anesthesiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - José M Gómez Tarradas
- Department of Anesthesiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Xavier Sala
- Department of Anesthesiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Misericordia Basora
- Department of Anesthesiology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Luis Lozano
- Knee Unit, Department of Orthopedics, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, University of Bern, Bern, Switzerland
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Comparison of Adductor Canal Block and Femoral Triangle Block for Total Knee Arthroplasty. Clin J Pain 2020; 36:558-561. [DOI: 10.1097/ajp.0000000000000833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Römer R, Komann M, Weinmann C, Meißner W. [Postoperative pain therapy after total knee arthroplasty : Is the local infiltration anesthesia the best therapy?]. Schmerz 2019; 34:33-40. [PMID: 31578650 DOI: 10.1007/s00482-019-00419-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Optimal perioperative pain management after total knee arthroplasty is necessary to promote mobilization and achieve early rehabilitation. The aim of this study was to determine whether local infiltration anesthesia (LIA) is the better postoperative pain therapy compared to a femoral nerve block (FNB) or a sciatic nerve block (SNB) using routine data. METHODS Data from the acute pain registry "Qualitätsverbesserung in der postoperativen Schmerztherapie" (QUIPS) were analyzed. The endpoints included postoperative maximal pain, frequency of pain-related movement impairment, nausea, and number of patients requesting opioids postoperatively. The influence of regional anesthesia in addition to general anesthesia was analyzed in 5 groups. RESULTS In total, the data of 8754 patients could be examined. It was found that the addition of LIA (β = -0.087 p = 0.000) or FNB (β = -0.137 p = 0.000) to general anesthesia is associated with a small but significant reduction of postoperative maximum pain. Between LIA, FNB, and SNB no relevant differences could be detected. DISCUSSION The pain reduction achieved by adding LIA or FNB in patients after total knee arthroplasty is relatively small. Comparison of techniques is hindered as there exists no widely accepted standard for performing LIAs yet.
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Affiliation(s)
- Robert Römer
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Schmerztherapie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
| | - Marcus Komann
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Schmerztherapie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - Claudia Weinmann
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Schmerztherapie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - Winfried Meißner
- Klinik für Anästhesiologie und Intensivmedizin, Sektion Schmerztherapie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
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