Analgesic Efficacy of Adductor Canal Block in Total Knee Arthroplasty: A Meta-analysis and Systematic Review

Postoperative pain relief after total knee arthroplasty: A Bayesian network meta-analysis and systematic review of analgesic strategies based on nerve blocks

STUDY OBJECTIVE

A Bayesian network meta-analysis was performed to compare the analgesic efficacy of the following nerve block techniques: femoral nerve block (FNB), adductor canal block (ACB), infiltration between the popliteal artery and the capsule of the posterior knee (iPACK), and genicular nerve block (GNB) following total knee arthroplasty (TKA).

DESIGN

Systematic review and network meta-analysis (NMA).

PATIENTS AND MEASUREMENTS

We searched the Web of Science, PubMed, EMBASE, and Cochrane Library databases until September 20, 2022. Patients who were treated by any of the above four nerve block techniques (alone or in combination) after TKA were included. Patients who underwent minimally invasive knee surgery were excluded. The indicators included pain scores during rest and mobilization, opioid consumption after surgery, postsurgical mobilization function (ROM [range of motion], TUG [Timed-Up-and-Go] test) at 24 h and 48 h, and length of hospital stay. The risk of bias was assessed by the Cochrane risk of bias tool.

RESULTS

Forty-two studies involving 2857 patients were eligible for this study. This NMA suggested that ACB + iPACK was the most efficacious option for improving ambulation ability and shortening the length of hospital stay. Furthermore, ACB + iPACK was the best regimen for resting-pain and movement-pain relief (78% and 87%, respectively) and for reducing opioid consumption (90%) at 48 h. However, FNB + iPACK was the most efficacious option for relief of resting pain (42%) and reducing opioid consumption (68%) at 24 h; GNB was the most efficacious option for movement pain relief at 24 h (94%).

CONCLUSION

Considering both pain control and knee functional recovery, ACB + iPACK may be the optimal analgesic regimen for patients after TKA. At the same time, it significantly reduces pain and opioid consumption at 48 h. However, ACB + iPACK is not the recommended technique for short-term (24 h) pain control.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD42022362322).

Periarticular Infiltration Compared to Single Femoral Nerve Block in Total Knee Arthroplasty: A Prospective Randomized Study

Objective  To compare patients undergoing total knee arthroplasty (TKA) under spinal anesthesia and single femoral nerve block (FNB) with subjects undergoing TKA under spinal anesthesia and periarticular infiltration (PAI). Materials and Methods  A total of 100 patients undergoing primary TKA were randomized into two groups. Group 1 included patients undergoing surgery under FNB associated with spinal anesthesia, while group 2 included patients undergoing TKA under IPA and spinal anesthesia. The assessment of these subjects in the early postoperative period included pain, active flexion, active extension, elevation of the extended limb, and morphine use. Results  There was no significant difference in the types of analgesia concerning pain, the elevation of the extended limb, and morphine use. Active flexion and extension were better in the PAI group ( p  = 0.04 and p  = 0.02 respectively). Conclusion  We conclude that the techniques are similar regarding pain control, limb elevation, and morphine use. The use of IPA provided better active flexion and extension during the hospital stay compared to single FNB in patients undergoing TKA.

A prospective, randomized trial of liposomal bupivacaine compared to conventional bupivacaine on pain control and postoperative opioid use in adults receiving adductor canal blocks for total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a commonly performed procedure to alleviate pain and improve functional limitations caused by end-stage joint damage. Effective management of postoperative pain following TKA is crucial to the prevention of complications and enhancement of recovery. Adductor canal blocks (ACB) with conventional bupivacaine (CB) provide adequate analgesia after TKA, but carry a risk of rebound pain following block resolution. Liposomal bupivacaine (LB) is an extended-release local anesthetic that can provide up to 72 h of pain relief. The objective of this study was to compare postoperative outcomes between ACBs using LB and CB after TKA.

METHODS

This single institution, prospective, randomized, clinical trial enrolled patients scheduled for TKA. Participants were randomized to receive ACB with either LB or CB. Pain scores up to 72 h postoperatively were assessed as the primary outcome. Opioid consumption and length of stay were evaluated as secondary outcomes.

RESULTS

A total of 80 patients were enrolled. Demographic and clinical characteristics were similar between the two groups. LB group showed significantly lower cumulative opioid use during the 72 h evaluated (P = 0.016). There were no differences in pain scores or length of stay between the groups.

CONCLUSION

The study demonstrated that LB ACBs led to significantly lower opioid consumption in the days following TKA without affecting pain scores or length of stay. This finding has important implications for improving postoperative outcomes and reducing opioid use in TKA patients. Previous studies have reported inconsistent results regarding the benefits of LB, highlighting the need for further research.

TRIAL REGISTRATION

This project was retrospectively registered with clinicaltrials.gov ( NCT05635916 ) on 2 December 2022.

Pain Management, Functional Recovery, and Stress Response Expressed by NLR and PLR after the iPACK Block Combined with Adductor Canal Block for Total Knee Arthroplasty-A Prospective, Randomised, Double-Blinded Clinical Trial

INTRODUCTION

This study aimed to investigate pain management, functional recovery, and stress response expressed by the neutrophile-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) after the popliteal artery and posterior knee capsule infiltration (iPACK) block combined with adductor canal block (ACB) in total knee arthroplasty (TKA).

PATIENTS AND METHODS

This was a prospective, double-blinded, randomised, controlled trial in a tertiary referral hospital. Three hundred and sixty-six patients were randomly allocated into the sham block group and iPACK combined with the ACB group. The primary outcome was postoperative pain scores. The secondary outcomes were opioid consumption, functional recovery expressed by a range of motion, and quadriceps strength. Also, the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were calculated.

RESULTS

There were significant differences between the sham block and iPACK + ACB group in pain scores p < 0.0001 at all time points. Therefore, there was a significant difference in opioid consumption (p < 0.0001) and functional recovery (p < 0.0001). Also, NLR and PLR levels 12 h (p < 0.0001) and 24 h (24 h) after surgery (p < 0.0001) were much lower in the iPACK + ACB group.

CONCLUSION

After total knee arthroplasty, the iPACK combined with ACB block group improved pain management, functional recovery, and stress response. Therefore, we strongly recommend this technique as a part of a multimodal analgesia protocol in knee surgery.

The effects of continuous catheter adductor canal block for pain management in knee replacement therapy: a meta-analysis

PURPOSE

Adductor canal block has emerged as a favourable element of multimodal analgesia regimens for total knee arthroplasty, due to the exclusive sensory blockade it provides. However, it is controversial as to whether a single shot or continuous technique adductor canal block is superior. This meta-analysis examined the effect of both these techniques on pain management associated with total knee arthroplasty.

METHODS

All randomised controlled trials published on Cochrane Library, PubMed, and EMBASE, Scopus, and PsychINFO were systematically searched. The PEDro scale was used to assess the quality of studies. A total of 8 articles, 2 of which were split by subgroup analyses to create 10 studies, with 828 adults were selected for inclusion in the analysis. The mean difference and effect size with a 95% confidence interval (CI) were analysed for the pooled results.

RESULTS

Statistically significant pooled effects of analgesia technique in favour of catheter use were found in the reduction of pain scores and VAS scores, and total rescue analgesia dosage. No significant changes were observed in the hospital stay time. Subgroup analysis revealed that patients with BMI 30 or more reported higher pain scores than those with BMI below 30.

CONCLUSION

Based upon studies that are currently available, our meta-analysis appears to demonstrate that continuous administration of analgesia through an adductor canal catheter provides greater pain reduction in total knee arthroplasty than single shot analgesia. Despite these current findings, future studies with larger sample sizes and greater control of study parameters are required to confirm the current findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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

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.

Adductor Canal Blocks Are Not Associated With Improved Early Postoperative Outcomes in Patients Undergoing Total Knee Arthroplasty

Background: As length of stay after total knee arthroplasty (TKA) continues to shorten, interventions that may reduce early postoperative pain and complications must be studied. Peripheral nerve block is being explored as a potential means of improving pain management. The purpose of this study was to evaluate the impact of adductor canal block (ACB) on postoperative outcomes for patients undergoing TKA. Methods: We conducted a retrospective review of 565 patients who received unilateral TKA under spinal anesthesia with a periarticular anesthetic injection. Patients were divided by ACB status. Univariate comparisons and multivariate regression were used to compare outcomes for patients receiving ACBs vs those who did not. Results: Of the 565 patients, 167 received an ACB, and 398 did not. Patients who received an ACB were less likely to require nausea medication during the immediate postoperative period. Length of stay, narcotic consumption, rate of discharge to home, postanesthesia care unit recovery time, urinary retention, ability to complete physical therapy, and 30-day readmission rate did not differ significantly between groups. After risk adjustment, the only significant finding was decreased likelihood of nausea in patients receiving an ACB. Conclusion: ACBs appear to have little to no significant impact on early clinical outcomes in patients having TKA under spinal anesthesia with a periarticular anesthetic injection. Further study of larger patient cohorts is required to validate these findings.

Efficacy of Adductor Canal Block on Medial Knee Pain in Patients with Knee Osteoarthritis: A Randomized Single-Blind Placebo-Controlled Study

BACKGROUND

This study aimed to confirm the efficacy of ultrasound-guided adductor canal block (ACB) as a treatment option for medial knee pain caused by knee osteoarthritis (KOA).

METHODS

In total, 31 participants with medial knee pain due to KOA were randomized to either the ACB (ultrasound-guided ACB, n = 15) or placebo group (1 mL of 1% lidocaine, n = 16). The primary outcome was a numerical rating scale (NRS) for knee pain intensity comparing before and 4 weeks after injection. The secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), average daily number of analgesics consumed, average daily opioid consumption, and Timed Up and Go (TUG) test results before and 4 weeks after injection.

RESULTS

Participants' baseline characteristics were not significantly different between the groups, except for age. At 4 weeks post-injection, the NRS score in the ACB group significantly improved compared to that in the placebo group (p = 0.009). However, the WOMAC, average daily number of analgesics consumed, average daily opioid consumption, and TUG test results did not show significant differences.

CONCLUSION

ACB can be an effective treatment for reducing medial knee pain in patients with KOA.

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.

Significantly earlier ambulation and reduced risk of near-falls with continuous infusion nerve blocks: a retrospective pilot study of adductor canal block compared to femoral nerve block in total knee arthroplasty

Background

Near-falls should be detected to prevent falls related to the earlier ambulation after Total knee arthroplasty (TKA). The quadriceps weakness with femoral nerve block (FNB) has led to a focus on adductor canal block (ACB). We purposed to examine the risk of falls and the earlier ambulation in each continuous infusion nerve block.

Methods

Continuous infusion nerve block (FNB or ACB) was performed until postoperative day (POD) 2 or 3. Pain levels and falls/near-falls with knee-buckling were monitored from POD 1 to POD 3. The score on the manual muscle test, MMT (0 to 5, 5 being normal), of the patients who could ambulate on POD 1, was investigated.

Results

A total of 73 TKA cases, 36 FNB and 37 ACB, met the inclusion criteria. No falls were noted. But episodes of near-falls with knee-buckling were witnessed in 14 (39%) cases in the FNB group and in 4 (11%) in the ACB group (p = 0.0068). In the ACB group, 81.1% of patients could ambulate with parallel bars on POD 1, while only 44.4% of FNB patients could do so (p = 0.0019). The quadriceps MMT values in the ACB group was 2.82, significantly higher than 1.97 in the FNB group (p = 0.0035). There were no significant differences in pain as measured with a numerical rating scale (NRS) and rescue analgesia through POD 3.

Conclusion

ACB was associated with significantly less knee-buckling and earlier ambulation post-TKA, with better quadriceps strength. Our study indicated the incidence of falls and near-falls with continuous infusion nerve blocks, and support the use of ACB to reduce the risk of falls after TKA. It is suggested that a certain number of the patients even with continuous ACB infusion should be considered with the effect of motor branch to prevent falls.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05735-6.

Adductor Canal Blocks With Bupivacaine and Magnesium After Same-day Discharge Total Knee Arthroplasty Improve Postoperative Pain Relief and Decrease Opioid Consumption: A Prospective Randomized Controlled Trial

OBJECTIVES

Adequate pain management is a critical component of facilitating same-day discharge for total knee arthroplasty (TKA). Adductor canal blocks (ACB) have been shown to be an effective technique for managing pain after TKA. The objective of this study was to investigate the impact of adding magnesium to local anesthetic in ACB on postoperative pain, opioid consumption, nausea, and overall patient satisfaction.

MATERIALS AND METHODS

A sample of 119 adults undergoing elective unilateral TKA were included. Patients were randomly assigned to receive ACB with magnesium and bupivacaine (n=56) or with bupivacaine only (n=63). Primary outcomes were total opioid consumption in the first 48 hours after surgery and pain scores. Secondary outcomes were the incidence of nausea in the first 48 hours after surgery and total overall satisfaction.

RESULTS

Opioid consumption decreased significantly in the Mg group compared with the no-Mg group over the first 24 hours (33.2±3.0 vs. 21.3±2.4, P=0.003), the second 24 hours (35.4±2.7 vs. 27.3±2.3, P=0.026), and the first 48 hours total after surgery (68.6±5.1 vs. 48.6±4.3, P=0.004). Pain scores were reduced in the Mg group (24 h: 5.1±2.3 vs. 3.5±2.0, P=0.000; 48 h: 5.1±1.6 vs. 3.9±1.6, P=0.000). Secondary outcomes showed no difference in the incidence of nausea over the first 48 hours and overall satisfaction.

CONCLUSION

The addition of magnesium to local anesthetic in ACB decreases pain scores and opioid consumption, without increasing nausea, when compared with ACB with local anesthetic alone.

Peripheral Nerve Blockade for Medial Patellofemoral Ligament Reconstruction in Pediatric Patients: The Addition of a Proximal Single-Injection Sciatic Nerve Block Provides Improved Analgesia

Purpose

We tested the hypothesis that the addition of a single-injection proximal sciatic nerve block to an adductor canal block would significantly reduce pain scores and opioid requirements compared to a group of patients that received only an adductor canal or femoral nerve block for medial patellofemoral ligament reconstruction in pediatric patients. The primary end-point is the number of patients achieving a Patient Acceptable Symptom State (PASS) (pain score less than four) for the entire 24-hour postoperative period in patients with and without a proximal sciatic block.

Patients and Methods

This is a retrospective cohort study of 144 consecutive pediatric patients, ages 10 to 18 years, undergoing medial patellofemoral ligament reconstruction with peripheral nerve blockade for postoperative analgesia from 2016–2020 at a pediatric orthopedics children’s hospital. Patients were divided into 2 cohorts with and without a proximal sciatic nerve block: group A/F: adductor canal or femoral CPNB and group AS: adductor canal CPNB and a proximal single-injection sciatic nerve block.

Results

There was strong evidence for an increase in the number of patients who reported a pain score less than four for the entire 24-hour postoperative period in the group that received the additional proximal sciatic block. (PASS: A/F 13/62 (21%) vs AS 43/82 (52%), p<0.001) There was strong evidence for a reduction in mean and maximum pain scores and opioid requirements in the first 24-hours after surgery in the proximal sciatic group.

Conclusion

The addition of a proximal sciatic nerve block was associated with significantly reduced mean and maximum pain scores and opioid requirements after medial patellofemoral ligament reconstruction in pediatric patients and supports a randomized clinical trial to confirm these findings. Based on the results of this study we recommend the addition of a proximal sciatic nerve block, anterior or posterior, to an adductor canal block to provide improved analgesia and reduced opioid requirements in the 24-hours after MPFLR in pediatric patients.

Liposomal Bupivacaine vs Ropivacaine for Adductor Canal Blocks in Total Knee Arthroplasty: A Prospective Randomized Trial

BACKGROUND

The purpose of this study is to determine the benefit of the analgesic liposomal bupivacaine compared to ropivacaine, by assessing pain and joint stiffness, and total oral opioid consumption by milligram morphine equivalent (MME) after total knee arthroplasty.

METHODS

Patients were randomized to receive either the study drug (liposomal bupivacaine admixed with bupivacaine) or the control drug (ropivacaine) in an adductor canal block. Only the anesthesiologist performing the block was aware of which arm of the study the patient was randomized to. MME, pain, Knee injury and Osteoarthritis Outcome Score Joint Replacement, and overall benefit of analgesia scores were recorded 24, 48, and 72 hours post-surgery either face-to-face or via telephone depending on patient discharge status.

RESULTS

One hundred patients were enrolled into the study and analyzed: 54 in the control group and 46 in the experimental group. Primary outcomes measured were pain as a numerical rating scale, MME, and length of stay in hours. Secondary outcomes were joint pain and stiffness recorded as Knee injury and Osteoarthritis Outcome Score Joint Replacement outcome and overall benefit of analgesia score. No statistically significant between-group differences were observed for any measured outcome.

CONCLUSION

We did not find any supporting evidence that liposomal bupivacaine yields increased pain relief following total knee arthroplasty compared to the control drug, ropivacaine.

Is There an Optimal Timing of Adductor Canal Block for Total Knee Arthroplasty?-A Retrospective Cohort Study

Adductor canal block (ACB) has gained popularity for postoperative pain control after total knee arthroplasty (TKA). However, its role in TKA has been questioned recently. Our study aimed to clarify the role of ACB in reducing postoperative pain after TKA and to elucidate an optimal timing to perform ACB for better outcomes. We conducted a comprehensive review of the perioperative records of 652 patients undergoing primary TKA from January 2019 to December 2019. Patients were divided into three groups: Group A received general anesthesia without ACB, Group B received ACB before inducing general anesthesia, and Group C received ACB at the post-anesthesia recovery unit (PACU). Patients in Groups B and C had lower pain visual analogue scale (VAS) scores than patients in Group A at the PACU. Opioid consumption was similar among the three groups; however, a slightly higher dose was required by Group A patients. Higher VAS scores were recorded in the ward in Group A than in Groups B and C with the leg at rest. In addition, higher VAS scores were recorded in Group A than in Groups B and C with the leg in continuous passive motion (CPM) training. More patients in Group A (34.9%) quit their first CPM training after a few cycles than those in Groups B (27.0%) and C (20.1%). Group A patients required a higher per kg dose of opioids in the ward than Groups B and C patients. Additionally, the hourly consumption of sevoflurane was similar among the three groups of patients, while Group A and C patients required a higher hourly per kg dose of intraoperative opioids than Group B patients. More patients in Group A (67.6%) and C (61.7%) developed intraoperative hypertension than patients in Group B (52.7%). There was no significant difference in PON (postoperative nausea), POV (postoperative vomiting), postoperative dizziness, or patient satisfaction among the three groups of patients. Group A patients had a longer length of hospital stay compared to Group B and C patients. In conclusion, preoperative ACB could be a better choice for patients undergoing TKA as it decreases intraoperative opioid consumption and facilitates a stable hemodynamic state during surgery.

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.

A comparison of adductor canal block before and after thigh tourniquet during knee arthroscopy: A randomized, blinded study

Background

Adductor canal block (ACB) provides effective analgesia after arthroscopic knee surgery. However, there is insufficient data regarding whether ACB should be performed before or after inflation of a thigh tourniquet. We aimed to investigate the efficacy of ACB performed before and after placement of a thigh tourniquet and evaluate associated quadriceps motor weakness.

Methods

ACB was performed before tourniquet inflation in the PreT group, and it was performed after inflation in the PostT group. In the PO group, ACB was performed at the end of surgery after deflation of the tourniquet.

Results

There were no statistically significant differences between the groups in terms of demographic data. There was no statistically significant difference among the three groups in terms of total postoperative opioid consumption (P = 0.513). Patient satisfaction and the amount of rescue analgesia administered were also not significantly different between the groups. There was no significant difference in terms of static and dynamic visual analog scale scores between the groups (for 24 h: P = 0.306 and P = 0.271, respectively). The incidence of motor block was higher in the PreT group (eight patients) than in the PostT group (no patients) and the PO group (one patient) (P = 0.005).

Conclusions

Using a tourniquet before or after ACB did not result in differences in terms of analgesia quality; however, applying a tourniquet immediately after ACB may lead to quadriceps weakness.

Developing a business case for a regional anesthesia block room: up with efficiency, down with costs

BACKGROUND

Regional anesthesia techniques offer many benefits for total joint arthroplasty (TJA) patients. However, they require personnel and equipment resources, as well as valuable operating room (OR) time. A block room offers a dedicated environment to perform regional anesthesia procedures while potentially offsetting costs.

METHODS

The goal of this prospective quality improvement study was to develop a business case for implementation of a regional anesthesia block room and to demonstrate the cost-effectiveness of this program in decreasing OR time for TJA. All elective TJA patients presenting between January 2019 and March 2020 were included in our analysis.

RESULTS

Our detailed business plan was approved by the hospital leadership. 561 patients in the preintervention group and 432 in the postintervention group were included for data analysis. Mean total OR time per surgical case decreased from 166 to 143 min for a difference of 23 min (95% CI 17 to 29). Similarly, anesthesia controlled OR time decreased from 46 min to 26 min for a difference of 20 min (95% CI 17 to 22). The block room resulted in an additional primary TJA case per daily OR list. The percentage of TJA patients receiving a peripheral nerve block increased from 63.1% to 87.0% (p<0.001). No safety events or block room associated OR delays were observed.

CONCLUSION

Implementing a regional anesthesia block room required a comprehensive business plan for securing the necessary resources to support the program. The regional anesthesia block room is a cost-effective method to improve patient care and OR efficiency.

Quadriceps muscle group function and after total knee arthroplasty-asystematic narrative update

BACKGROUND

This article systematically summarizes the present evidences, published in the last 20 years, regarding the pre- and post-operative factors, which may influence recovery of the function of the quadriceps muscle group following total knee arthroplasty (TKA). We following the PRISMA methodology, including meta-analyses and high-level evidence studies (prospective trials, and, when unavailable, retrospective studies).

SOURCES OF DATA

Pubmed and Cochrane databases: 582 articles were identified and 54 of them were selected.

AREAS OF AGREEMENT

Tourniquets inflated at high pressure exert a detrimental effect on the quadriceps muscle group. Faster quadriceps recovery takes place using mini-invasive approaches, an eight-week rehabilitation period including balance training and the use of nutraceuticals.

AREAS OF DISAGREEMENT

Pre-habilitation and pre-operative factors, analgesic methods and different TKA implants.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

Telerehabilitation seems a cost-effective tool for rehabilitation after TKA. Patients' optimization protocols before TKA should include standardized nutraceuticals intake.

Comparison of Periarticular Injection and Intra-articular Injection for Pain Management After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

PURPOSE

Local infiltration analgesia, an essential component of multimodal analgesia after total knee arthroplasty (TKA), can be classified into periarticular injection (PAI) and intra-articular injection (IAI) as per administration techniques. Currently, there is no definite answer of the optimal choice between the two techniques. This meta-analysis aims to determine whether PAI provides superiority of pain relief and functional recovery than IAI after TKA.

DESIGN

Systematic review and meta-analysis.

METHODS

Comparative studies that compared PAI and IAI in patients after TKA were searched in the Embase, PubMed, MEDLINE, and the Cochrane Library databases. The primary outcomes were visual analog scale scores for pain and opioid consumption. The secondary outcomes were complications, function of recovery, and length of hospital stay.

FINDINGS

Four randomized controlled trials and two case-controlled studies with a total of 769 patients were enrolled. There were no significant differences in mean visual analog scale scores at postoperative day 0 (P = .17) and day 1 (P = .27), maximum visual analog scale scores at day 0 (P = .89) and day 1 (P = .82), total opioid consumption at day 1 (P = .96), opioid complications (P = .15), and length of hospital stay (P = .84) between PAI and IAI.

CONCLUSIONS

Based on the available evidence, PAI does not offer superior effects at pain control and discharge than IAI after TKA. However, owing to the limited sample size and heterogeneity of the included studies, further large well-designed randomized controlled trials are still needed to validate this conclusion.

REGISTRATION

The protocol has been registered in the PROSPERO international database under number CRD42020165138.

Quadriceps Weakness After Single-Shot Adductor Canal Block: A Multivariate Analysis of 1,083 Primary Total Knee Arthroplasties

BACKGROUND

Adductor canal blocks (ACBs) are commonly employed in multimodal pain control for total knee arthroplasty (TKA) and minimize motor blockade compared with femoral nerve blocks. Quadriceps weakness may be associated with ACBs. The purpose of this study was to quantify the prevalence of clinically relevant quadriceps weakness after a single-shot ACB and to identify the factors that are associated with its diagnosis.

METHODS

The study group consisted of 1,083 retrospectively reviewed consecutive TKAs that were performed with ACBs at an academic hip and knee center. Quadriceps weakness was quantified with a standardized rating system during the initial physical therapy evaluation, and 23 potential covariates were analyzed.

RESULTS

The prevalence of quadriceps weakness was 9%. Increasing the dose of the ACB anesthetic per unit of body mass index (BMI) increased the probability of quadriceps weakness by 5.0 times (95% confidence interval [CI], 1.9 to 13.3; p = 0.001). The highest probability of quadriceps weakness (52.9%) was associated with women who received the highest anesthetic dose per unit of BMI and an epinephrine extender but no corticosteroid extender.

CONCLUSIONS

The optimal volume of local anesthetic in ACBs to maintain pain control while minimizing quadriceps weakness has not yet been defined. Our observation that quadriceps weakness was associated with increasing doses of ACB anesthetic per unit of BMI suggests that more than traditional structural canal-fill parameters (i.e., filling the distal aspect of the adductor canal without spreading to the femoral triangle) should be considered when choosing injectates and injectate volumes for ACBs.

LEVEL OF EVIDENCE

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

Analgesic efficacy of infiltration between the popliteal artery and capsule of the knee (iPACK) block added to local infiltration analgesia and continuous adductor canal block after total knee arthroplasty: a randomized clinical trial

Background

A combination of motor-sparing analgesia with local infiltration analgesia (LIA) and continuous adductor canal block (CACB) may improve postoperative pain and functional recovery for total knee arthroplasty (TKA). We hypothesized that the addition of a novel technique for posterior knee block, known as the infiltration between the popliteal artery and capsule of the knee (iPACK) block, to LIA with CACB would reduce opioid requirements.

Methods

In this double-blinded randomized controlled trial, 72 patients were assigned to receive either LIA with CACB (LIA+CACB group) or iPACK block with LIA and CACB (iPACK+LIA+CACB group). The primary outcome was cumulative postoperative intravenous morphine consumption within 24 hours. The secondary outcomes included numerical rating scale pain scores, incidence of posterior knee pain, performance test results, patient satisfaction, length of stay, and adverse events.

Results

Morphine consumption within 24 hours postoperatively showed no significant intergroup difference (LIA+CACB; 1.31±1.85 mg vs iPACK+LIA+CACB; 0.61±1.25 mg, p=0.08). There were no clinically significant differences in the overall pain scores between the groups. The lower Timed Up and Go test scores on postoperative days 1 and 2, along with a shorter duration of hospitalization, were found in the iPACK+LIA+CACB group (p<0.05).

Conclusion

The addition of an iPACK block to the LIA and CACB does not reduce the postoperative opioid consumption nor improve analgesia. However, it may improve immediate functional performance and reduce the length of hospitalization after TKA.

Trial registration number

TCTR20180702001.

The Effect of the IPACK Block on Pain After Primary TKA: A Double-Blinded, Prospective, Randomized Trial

BACKGROUND

The purpose of this study was to determine if infiltration of local anesthetic between the interspace between the popliteal artery and capsule of the knee (IPACK) provides benefit in total knee arthroplasty.

METHODS

Patients were randomized into continuous adductor canal block with IPACK block or continuous adductor canal block with sham subcutaneous saline injection. Only the anesthesiologist performing the block was aware of randomization status. After surgery, a blinded assessor recorded opioid consumption, pain scores, and gait distance.

RESULTS

There were 35 patients in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the postanesthesia care unit (PACU), the average (P = .0122) and worst (P = .0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy (P = .2080). There was no difference in opioid consumption in the PACU (P = .7928), or at 24 hours (P = .7456). There was no difference in pain scores on POD 1 in the AM (P = .4597) or PM (P = .6273), or in the walking distance (P = .5197). There was also no difference in length of stay in the PACU (P = .9426) or hospital (P = .2141).

CONCLUSION

The IPACK group had lower pain scores at rest in the PACU, but this is likely not clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be indications for the use of the IPACK block as a rescue block or in patients who have contraindications to our standard multimodal treatment regimen or in patients with chronic pain or opioid dependence.

Anesthesia of the anterior femoral cutaneous nerves for total knee arthroplasty incision: randomized volunteer trial

BACKGROUND AND OBJECTIVES

For pain relief after total knee arthroplasty (TKA), an injection at the midthigh level may produce analgesia inferior to that of a femoral nerve block as the anterior femoral cutaneous nerves (intermediate femoral cutaneous nerve (IFCN) and medial femoral cutaneous nerve (MFCN)) are not anesthetized. The IFCN can be selectively anesthetized in the subcutaneous tissue above the sartorius muscle and the MFCN by an injection in the proximal part of the femoral triangle (FT). The primary aim was to investigate the area of cutaneous anesthesia in relation to the surgical incision for TKA and anteromedial knee area after intermediate femoral cutaneous nerve blockade (IFCNB) in combination with an injection in the proximal or distal part of the FT (proximal vs distal femoral triangle block (FTB)).

METHODS

The study was carried out as two separate investigations: first, dissection of nine cadaver sides to verify a technique for IFCNB; second, a volunteer study with 40 healthy volunteers. The surgical midline incision for TKA was drawn bilaterally. All volunteers received an active distal FTB combined with a placebo proximal FTB on one side and vice versa on the other side. All volunteers were randomized to an active IFCNB on one side and placebo IFCNB on the contralateral side.

RESULTS

Identification of IFCN was successful in all cadaver sides. Fifteen out of 20 volunteers had complete anesthesia of the incision line after IFCNB combined with proximal FTB, which was significantly higher compared with proximal FTB alone and with distal FTB+IFCNB. A gap at the anteromedial knee area was present in 2/20 volunteers with proximal FTB compared with 17/20 with distal FTB when all volunteers had active IFCNB.

CONCLUSION

Ultrasound-guided blockade of the IFCN and MFCN anesthetize the surgical midline incision and the anteromedial area of the knee relevant for TKA. In contrast, an injection at the midthigh level produces insufficient cutaneous anesthesia not covering the areas of interest.

TRIAL REGISTRATION NUMBER

EudraCT: 2018-004986-15.

Ketamine reduces pain and opioid consumption after total knee arthroplasty: A meta-analysis of randomized controlled studies

OBJECTIVE

To examine the analgesic efficacy and safety of ketamine after total knee arthroplasty.

METHODS

We searched for all articles on ketamine in patients with total knee arthroplasty in electronic databases, including PubMed, Embase, Ovid, Cochrane Library, Web of Science, CNKI, Wanfang Data, and VIP, up to the February 2019. Randomized controlled trials comparing ketamine and the placebo for pain management after total knee arthroplasty were utilized. The outcome measurements consist of the pain score, opioid consumption, length of hospitalization and postoperative complications. All data analyses were conducted using STATA 13.0. Cochrane Collaboration's tool was adopted to assess the risk of bias.

RESULTS

A total of six randomized controlled trials were included in the meta-analysis. The present meta-analysis demonstrated that there were significant differences between the two groups regarding the pain score within the first 24 postoperative hours. Ketamine was associated with a significant reduction of cumulative morphine consumption. Notably, ketamine could significantly decrease the incidence of nausea and vomiting without increasing the risk of thrombosis.

CONCLUSION

Ketamine is effective in reducing pain and cumulative morphine consumption during the early post-operative period after total knee arthroplasty. In addition, the use of ketamine is associated with a lower incidence of adverse effects.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Opioid Minimization in Opioid-Naïve Patients

Surgical care episodes place opioid-naïve patients at risk for transitioning to new persistent postoperative opioid use. With one of the central principles being the application of multimodal pain interventions to reduce the reliance on opioid-based medications, enhanced recovery pathways provide a framework that decreases perioperative opioid use. The fourth Perioperative Quality Initiative brought together a group of international experts representing anesthesiology, surgery, and nursing with the objective of providing consensus recommendations on this important topic. Fourth Perioperative Quality Initiative was a consensus-building conference designed around a modified Delphi process in which the group alternately convened for plenary discussion sessions in between small group discussions. The process included several iterative steps including a literature review of the topics, building consensus around the important questions related to the topic, and sequential steps of content building and refinement until agreement was achieved and a consensus document was produced. During the fourth Perioperative Quality Initiative conference and thereafter as a writing group, reference applicability to the topic was discussed in any area where there was disagreement. For this manuscript, the questions answered included (1) What are the potential strategies for preventing persistent postoperative opioid use? (2) Is opioid-free anesthesia and analgesia feasible and appropriate for routine operations? and (3) Is opioid-free (intraoperative) anesthesia associated with equivalent or superior outcomes compared to an opioid minimization in the perioperative period? We will discuss the relevant literature for each questions, emphasize what we do not know, and prioritize the areas for future research.

Continuous adductor canal blockade facilitates increased home discharge and decreased opioid consumption after total knee arthroplasty

BACKGROUND

There is a growing interest in avoiding discharging patients to rehab to maximize outcome and minimize complications after total knee arthroplasty (TKA). In addition, use of postoperative pain pathways that minimize opioid use is critical amidst the current opioid epidemic. However, the ideal pain regimen after TKA has yet to be determined.

METHODS

From July 1, 2013 to October 1, 2014 two perioperative pathways were used to address surgical pain. These included either a single shot femoral nerve block plus liposomal bupivacaine pericapsular injection (FNB + LB-PAI) or adductor canal catheter plus posterior capsule single shot block (ACC + iPACK), each with an oral analgesic protocol. Little modification occurred with regard to surgical technique, postoperative medications, or postoperative physical therapy (PT).

RESULTS

Overall, 264 unilateral, primary TKA patients (146 FNB + LB-PAI, 118 ACC + iPACK) were included. ACC + iPACK patients had a shorter median length of stay (LOS, 2.0 vs 3.0, p < 0.001), more discharges home (79.7% vs 67.8%, p = 0.002), and less median opioid consumption (IV morphine equivalents, IVME, 20.0 vs 44.1, p < 0.001) than the FNB + LB-PAI group. In multivariable analysis, use of ACC + iPACK remained independently associated with shorter LOS, increased discharge home, and less IVME consumed when controlling for confounding variables. ACC + iPACK patients also had fewer opioid related adverse events (0.8 vs 5.5, p = 0.045) and a lower rate of MUA (0.8% vs 6.2%, p = 0.026).

CONCLUSIONS

We recommend ACC + iPACK with a multimodal oral analgesic protocol as the primary postoperative analgesia in enhanced recovery TKA protocols. This resulted in an easier recovery with fewer complications.

LEVEL OF EVIDENCE

Level III.

Is continuous proximal adductor canal analgesia with a periarticular injection comparable to continuous epidural analgesia for postoperative pain after Total Knee Arthroplasty? A retrospective study

Background

The classic adductor canal block (ACB) is a regional technique that aims to introduce local anesthetic to the saphenous nerve as it traverses the adductor canal. It offers the benefit of preserved quadriceps strength, and is ideal for rehabilitation. Proximal ACB (PACB) allows the operator to place the block away from the surgical site, permitting preoperative placement. Our primary outcome was total opioid consumption; secondary outcomes included the highest numerical rating scale scores and total gait distance at the indicated time intervals.

Questions/purposes

We asked: 1) Does a Continuous Proximal ACB block with Periarticular knee injection (PACB) provide better analgesia than a Continuous Epidural (CSE)?; 2) Do PACB catheter patients do better with physical therapy compared to CSE patients?; 3) Are PACB patients discharged earlier than CSE patients?

Methods

With IRB approval we performed a retrospective chart review of patients who had underwent primary total knee arthroplasty between October 2015 and September 2016. The selected patients (n = 151) were divided into two groups: CSE group, 72 patients who received a continuous epidural catheter and the PACB group, 79 patients who received at PACB with Periarticular injection. The CSE group received a single-segment combined spinal epidural (CSE) in the operating room. The epidural catheter infusion was started with 0.1% ropivacaine at 8 mL/hour to 14 mL/hour during the post-operative period. The PACB group received a proximal adductor canal catheter with 20 ml of 0.5 % ropivacaine and maintained with ropivacaine 0.2% at 8 ml to 14 ml post operatively. Total opioid consumption, highest numeric rating scores and total gait distance travelled were recorded upon discharge from the PACU and completion of postoperative day (POD) 0, 1, and 2.

Results

We found that the median cumulative morphine consumption was significantly higher in the CSE group compared to the PACB group (194 (0-498) versus 126 (0-354) mg, p = 0.012), a difference that was most notable on POD 1 (84 (16-243) versus 60 (5-370) mg, p = 0.0001). Mean hospital length of stay was also shorter in the PACB group (2.6 ± 0.67 versus 3.0 ± 1.08 days, p = 0.01).

Conclusion

PACB group used significantly lower morphine consumption compared to the CSE group; they were better participants during physical therapy and achieved longer gait distances. The mean hospital length of stay was also shorter in the PACB group.

Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review

BACKGROUND

Elective total joint arthroplasty may be a gateway to long-term opioid use.

QUESTIONS/PURPOSE

We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies.

RESULTS

Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA.

CONCLUSIONS

The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.

Perioperative Pain Management in Hip and Knee Arthroplasty

Total hip and knee arthroplasty is associated with significant perioperative pain, which can adversely affect recovery by increasing risk of complications, length of stay, and cost. Historically, opioids were the mainstay of perioperative pain control. However, opioids are associated with significant downsides. Preemptive use of a multimodal pain management approach has become the standard of care to manage pain after hip and knee arthroplasty. Multimodal pain management uses oral medicines, peripheral nerve blocks, intra-articular injections, and other tools to reduce the need for opioids. Use of a multimodal approach promises to decrease complications, improve outcomes, and increase patient satisfaction after hip and knee arthroplasty.