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Benzon HT, Elmofty D, Shankar H, Rana M, Chadwick AL, Shah S, Souza D, Nagpal AS, Abdi S, Rafla C, Abd-Elsayed A, Doshi TL, Eckmann MS, Hoang TD, Hunt C, Pino CA, Rivera J, Schneider BJ, Stout A, Stengel A, Mina M, FitzGerald JD, Hirsch JA, Wasan AD, Manchikanti L, Provenzano DA, Narouze S, Cohen SP, Maus TP, Nelson AM, Shanthanna H. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections - guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society. Reg Anesth Pain Med 2024:rapm-2024-105593. [PMID: 39019502 DOI: 10.1136/rapm-2024-105593] [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: 04/23/2024] [Accepted: 06/14/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND There is potential for adverse events from corticosteroid injections, including increase in blood glucose, decrease in bone mineral density and suppression of the hypothalamic-pituitary axis. Published studies note that doses lower than those commonly injected provide similar benefit. METHODS Development of the practice guideline was approved by the Board of Directors of American Society of Regional Anesthesia and Pain Medicine with several other societies agreeing to participate. The scope of guidelines was agreed on to include safety of the injection technique (landmark-guided, ultrasound or radiology-aided injections); effect of the addition of the corticosteroid on the efficacy of the injectate (local anesthetic or saline); and adverse events related to the injection. Based on preliminary discussions, it was decided to structure the topics into three separate guidelines as follows: (1) sympathetic, peripheral nerve blocks and trigger point injections; (2) joints; and (3) neuraxial, facet, sacroiliac joints and related topics (vaccine and anticoagulants). Experts were assigned topics to perform a comprehensive review of the literature and to draft statements and recommendations, which were refined and voted for consensus (≥75% agreement) using a modified Delphi process. The United States Preventive Services Task Force grading of evidence and strength of recommendation was followed. RESULTS This guideline deals with the use and safety of corticosteroid injections for sympathetic, peripheral nerve blocks and trigger point injections for adult chronic pain conditions. All the statements and recommendations were approved by all participants after four rounds of discussion. The Practice Guidelines Committees and Board of Directors of the participating societies also approved all the statements and recommendations. The safety of some procedures, including stellate blocks, lower extremity peripheral nerve blocks and some sites of trigger point injections, is improved by imaging guidance. The addition of non-particulate corticosteroid to the local anesthetic is beneficial in cluster headaches but not in other types of headaches. Corticosteroid may provide additional benefit in transverse abdominal plane blocks and ilioinguinal/iliohypogastric nerve blocks in postherniorrhaphy pain but there is no evidence for pudendal nerve blocks. There is minimal benefit for the use of corticosteroids in trigger point injections. CONCLUSIONS In this practice guideline, we provided recommendations on the use of corticosteroids in sympathetic blocks, peripheral nerve blocks, and trigger point injections to assist clinicians in making informed decisions.
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Affiliation(s)
- Honorio T Benzon
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dalia Elmofty
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Maunak Rana
- Department of Anesthesia, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Andrea L Chadwick
- Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shalini Shah
- University of California Irvine, Orange, California, USA
| | - Dmitri Souza
- Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Ameet S Nagpal
- Orthopaedics and PM&R, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salahadin Abdi
- Pain Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - Christian Rafla
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Alaa Abd-Elsayed
- University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Tina L Doshi
- Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Maxim S Eckmann
- Anesthesiology, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Thanh D Hoang
- Endocrinology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Carlos A Pino
- Anesthesiology, Naval Medical Center San Diego, San Diego, California, USA
| | | | - Byron J Schneider
- PM&R, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Angela Stengel
- American Society of Regional Anesthesia and Pain Medicine, Pittsburgh, Pennsylvania, USA
| | - Maged Mina
- Anesthesiology, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | | | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ajay D Wasan
- University of Pittsburgh Health Sciences, Pittsburgh, Pennsylvania, USA
| | | | | | - Samer Narouze
- Anesthesia, Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven P Cohen
- Anesthesiology, Feinberg School of Medicine, Chicago, Illinois, USA
- Anesthesiology, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | | | - Ariana M Nelson
- Department of Anesthesiology and Perioperative Medicine, University of California Irvine, Irvine, California, USA
- Department of Aerospace Medicine, Exploration Medical Capability, Johnson Space Center
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Anderson ND, Shaner JL, Braunecker S, Potter LG. Regional Anesthesia in the Austere Environment: Lessons Learned from Current Out-of-Hospital Practice. Wilderness Environ Med 2024; 35:234-242. [PMID: 38380990 DOI: 10.1177/10806032241231257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Pain management for trauma in the extreme environment is vital for both casualty comfort and aiding safe extrication. However, adequate pain management in a resource-limited environment can be challenging and is often limited. We conducted a scoping review of the use of regional anesthesia in the prehospital environment, evaluating which regional anesthetic procedure was performed for various indications, their efficacy, and the type of healthcare provider delivering the anesthetic. METHODS A PRISMA-guided systematic literature review was conducted of Medline, Embase, and Cochrane databases for studies reporting the use of regional anesthesia in the prehospital environment published before June 30, 2022. RESULTS Thirty studies met the criteria and were included in the review. The most common types of regional anesthesia were fascia-iliaca compartment block (n = 317, from 12 studies) and femoral nerve block (n = 210, from 8 studies), along with various other blocks for a range of indications. These blocks had good efficacy and a low-risk profile and could be delivered by a wide range of healthcare providers. CONCLUSIONS Regional anesthesia is an effective and non-resource-heavy pain management tool in prehospital environments, which may be applicable to austere settings. It can cover a wide range of injuries and can avoid systemic complications for casualties that may already be challenging to manage in out-of-hospital settings. Additionally, regional anesthesia can be effectively delivered by a wide range of providers. This review provides a holistic summary of pain management using regional anesthesia in the prehospital environment, with a discussion on its potential use in more extreme settings.
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Affiliation(s)
| | - Julie L Shaner
- Department of Orthopaedic Surgery, University of Florida, College of Medicine, Jacksonville, FL
| | - Stefan Braunecker
- Department of Anesthesiology, University of Florida, College of Medicine, Jacksonville, FL
| | - Lydia G Potter
- Emergency Medicine Academic Centre, Cardiff University, Cardiff, UK
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Neely G, Hollis N, Mozingo C. Anesthesia for the Patient Undergoing Knee Procedures. Anesthesiol Clin 2024; 42:247-261. [PMID: 38705674 DOI: 10.1016/j.anclin.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Anesthesia for patients undergoing knee procedures encompasses a large patient population with significant variation in patient age, comorbidities, and type of surgery. In addition, these procedures are performed in vastly different surgical environments, including large academic hospitals, private hospitals, and out-patient surgical centers. These variabilities require a thoughtful and individualized anesthetic approach tailored toward the medical and surgical needs of each patient. This article discusses anesthetic approaches to patients with acute, subacute, and chronic knee-related pathology requiring surgery. We will also review pertinent knee anatomy and innervation and discuss regional nerve blocks and their applications to knee-related surgical procedures.
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Affiliation(s)
- Grant Neely
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA.
| | - Nicole Hollis
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
| | - Cy Mozingo
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
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Genc C, Tulgar S, Unal M, Genc AS, Kehribar L, Erdivanli B, Vermeylen K, Koksal E. The minimum effective concentration (MEC90) of bupivacaine for an ultrasound-guided suprainguinal fascia iliaca compartment block for analgesia in knee surgery: a dose-finding study. Korean J Anesthesiol 2024; 77:364-373. [PMID: 38480982 PMCID: PMC11150113 DOI: 10.4097/kja.23710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND In recent years, the suprainguinal fascia iliaca compartment block (SFICB) has become more common in clinical practice. This assessor-blinded dose-finding study aimed to determine the minimum effective concentration (MEC90, MEC95) of bupivacaine for a single-injection SFICB in patients undergoing arthroscopic anterior cruciate ligament repair. METHODS This prospective study was conducted at a tertiary hospital (postoperative recovery room and ward). The SFICB was performed as a postsurgical intervention after spinal anesthesia. Seventy patients were allocated using the biased-coin design up-and-down sequential method. The ultrasound-guided SFICB was performed using different bupivacaine concentrations, and standard multimodal analgesia was administered to all patients. Block success was defined as the absence of pain or presence of only tactile sensation during the pinprick test conducted on the anterior and lateral regions of the mid-thigh six hours postoperatively. RESULTS According to isotonic regression and bootstrap CIs, the MEC90 value of bupivacaine for a successful SFICB was 0.123% (95% CI [0.098, 0.191]) and the MEC95 value was 0.188% (95% CI [0.113, 0.223]). CONCLUSIONS Our study showed that the MEC90 and MEC95 values for bupivacaine administered via an SFICB for analgesia were 0.123% and 0.188%, respectively. One advantage of using lower concentrations of bupivacaine is the associated reduction in quadriceps weakness.
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Affiliation(s)
- Caner Genc
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Serkan Tulgar
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Murat Unal
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Ahmet Serhat Genc
- Department of Orthopedics and Traumatology, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Lokman Kehribar
- Department of Orthopedics and Traumatology, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
| | - Basar Erdivanli
- Department of Anesthesiology and Reanimation, Recep Tayyip Erdogan University Faculty of Medicine, Rize, Turkey
| | - Kris Vermeylen
- Department of Anesthesia, AZ Turnhout, Turnhout, Belgium
| | - Ersin Koksal
- Department of Anesthesiology and Reanimation, Samsun University Faculty of Medicine, Samsun Training and Research Hospital, Samsun, Turkey
- Department of Anesthesiology and Reanimation, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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Kull C, Martin R, Rossel JB, Nguyen A, Albrecht E. Femoral vs sciatic nerve block to provide analgesia after medial open wedge high tibial osteotomy in the setting of multimodal analgesia: A randomized, controlled, single-blinded trial. J Clin Anesth 2024; 93:111355. [PMID: 38134484 DOI: 10.1016/j.jclinane.2023.111355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 10/14/2023] [Accepted: 11/22/2023] [Indexed: 12/24/2023]
Abstract
STUDY OBJECTIVE Medial open wedge high tibial osteotomy (MOW HTO) is associated with moderate to severe postoperative pain. The proximal part of the tibia is innervated by branches from the femoral nerve anteriorly and the sciatic nerve posteriorly. There is a paucity of information regarding the optimal peripheral nerve block for postoperative analgesia with minimal impact on motor function. This study tested the hypothesis that a femoral nerve block provides superior analgesia to a sciatic nerve block after MOW HTO in the setting of multimodal analgesia. DESIGN Randomized controlled single-blind trial. SETTING Operating room, postoperative recovery area and ward, up to 6 postoperative months. PATIENTS Fifty patients undergoing MOW HTO. INTERVENTIONS Interventions were femoral or sciatic nerve block under ultrasound guidance. For each intervention, a total of 100 mg of ropivacaine was injected. Postoperative pain treatment followed a pre-defined protocol with intravenous patient-controlled analgesia of morphine, paracetamol, and ibuprofen. MEASUREMENTS The primary outcome was intravenous morphine consumption at 24 h postoperatively. Secondary outcomes included rest and dynamic pain scores (on a numeric rating scale out of 10) at 2, 24 and 48 h postoperatively. Functional outcomes included the Short Form-12, Knee injury and Osteoarthritis Outcome Score, and International Knee Documentation Committee (IKDC) scores measured at 6 months postoperatively. MAIN RESULTS Mean [95% confidence interval] i.v. morphine consumption at 24 postoperative hours were 24 mg [15 mg,33 mg] in the femoral nerve block group and 24 mg [16 mg,32 mg] in the sciatic nerve block group (p = 0.98). There were no significant differences in the secondary outcomes between groups. CONCLUSIONS This trial failed to demonstrate that a femoral nerve block provides superior analgesia to a sciatic nerve block after MOW HTO under general anesthesia in the setting of multimodal analgesia. There was no significant difference in quality of life and functional outcomes at 6 months postoperatively between groups. Trial registry number:Clinicaltrials.com - NCT05728294; Kofam.ch - SNCTP000003048 | BASEC2018-01774.
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Affiliation(s)
- Corey Kull
- Department of Anaesthesia, University Hospital of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Robin Martin
- Consultant, Department of Orthopedic surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jean-Benoit Rossel
- Statistician, Centre for Primary Care and Public Health (Unisanté), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Alexandre Nguyen
- Research assistant, University Hospital of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Eric Albrecht
- Program director of Regional Anesthesia, Department of Anesthesia, University Hospital of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland.
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Pai P, Amor D, Lai YH, Echevarria GC. Use and Clinical Relevancy of Pericapsular Nerve Block (PENG) in Total Hip Arthroplasty: A Systematic Review and Meta-analysis. Clin J Pain 2024; 40:320-332. [PMID: 38268183 DOI: 10.1097/ajp.0000000000001196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 01/08/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND Ultrasound-guided pericapsular nerve group (PENG) block is an emerging regional anesthesia technique that may provide analgesia for patients undergoing total hip arthroplasties (THA). There are clinical studies comparing this fascial plane block to other established methods; however, evidence on the actual efficacy of this block for THA continues to evolve. OBJECTIVE Available clinical studies conducted over the past 4 years were reviewed to evaluate the analgesic efficacy and effectiveness of PENG block in patients undergoing THAs. METHODS A meta-analysis of randomized controlled trials (RCTs) in patients undergoing THA, where PENG block was compared to no block, placebo/sham block (injection with saline), or other analgesic techniques including suprainguinal fascia iliaca block (FIB), or periarticular infiltration (PAI) was performed. Our primary outcome was opioid consumption during the first 24 hours. Secondary outcomes were postoperative rest and dynamic pain scores at 6-12, 24 and 48 hours, block performance time, sensory-motor assessment, quadriceps weakness, the incidence of postoperative falls, first analgesic request, block and opioid-related complications, surgical complications, patient satisfaction scores, postanesthesia care unit length of stay, hospital length of stay, and functional and quality of life outcomes. RESULTS We included 12 RCTs with a total of 705 patients. Data showed that PENG block decreased 24-hour oral morphine milligram equivalent consumption by a mean difference (MD) of 3.75 mg (95% CI: -5.96,-1.54; P =0.0009). No statistically significant differences in rest or dynamic pain were found, except for a modest MD reduction in dynamic pain score of 0.55 points (95% CI: -0.98, -0.12; P =0.01), measured 24 hours after surgery in favor of PENG block. CONCLUSIONS Our systematic review and meta-analysis suggest that PENG block provides better analgesia, measured as MME use, in the first 24 hours after THA, with no real impact on postoperative VAS scores. Despite statistical significance, the high heterogeneity across RCTs implies that PENG's benefits may not surpass the minimal clinically important difference threshold for us to recommend PENG as best practice in THA.
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Affiliation(s)
- Poonam Pai
- Icahn School Of Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Mount Sinai West and Morningside Hospitals, NY
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Shabani M, Beye SA, Traore A, Echave P, Raingeval X, Coulibaly D, Crespo S. The Gluteus Deep Investing Fascia Compartment Block: A Novel Technique for Posterior Femoral Cutaneous Nerve Block. Local Reg Anesth 2024; 17:55-65. [PMID: 38699287 PMCID: PMC11064292 DOI: 10.2147/lra.s455702] [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: 12/27/2023] [Accepted: 04/11/2024] [Indexed: 05/05/2024] Open
Abstract
Purpose The posterior femoral cutaneous nerve (PFCN) block is used in regional anesthesia for lower extremity surgery. This study introduces a new ultrasound-guided technique called the "Gluteus-Deep Investing Fascia compartment Block (GDIF block)" for blocking the PFCN. This approach involves injecting local anesthetic into the potential space between the gluteus maximus muscle and the deep investing fascia, named the 'Gluteus Deep Investing Fascia Compartment'. The study discusses the anatomical and sonographic features crucial for identifying this compartment and explores the potential benefits of this approach for achieving effective PFCN block. Additionally, it examines the clinical application of the GDIF block for PFCN block as part of the Complete Lower Extremity Fascia Tri-compartment Block technique, named "CLEFT Block." This technique combines the suprainguinal fascia iliaca block with GDIF compartment block for PFCN and a sciatic nerve block as exclusive anesthesia technique. Patients and Methods Nine patients with weapon-related lower limb injuries underwent surgery at district hospitals supported by the International Committee of the Red Cross. Between October and December 2023, seventeen above-knee procedures were performed for the nine patients using the GDIF block as part of a CLEFT block technique. Anesthesia was performed with a CLEFT block technique using a volume ratio of 1:1 of 1% lidocaine and 0.5% levobupivacaine. Results The GDIF block technique for PFCN blockade was performed successfully in all patients without complications, achieving complete PFCN blockade. The CLEFT block technique proved effective as the sole anesthetic technique for seventeen above-knee procedures. All surgeries were completed successfully without additional pain medication or conversion to general anesthesia. Conclusion The GDIF block appears to be a promising technique for anesthetic management, alone or as part of the CLEFT block. Further research with a larger patient population is necessary to validate these findings.
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Affiliation(s)
- Majaliwa Shabani
- Health_unit, International Committee of the Red Cross, Bamako, Mali
| | | | - Abdoulaye Traore
- Anesthesia Department, Hôpital Somine Dolo de Mopti, Mopti, Mali
| | - Pablo Echave
- Anesthesia Department, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Xavier Raingeval
- Association de Développement et de Recherche en Anesthésie Locorégionale Echoguidée (ADRALE), Paris, France
| | - Daouda Coulibaly
- Surgery Department, Centre de Santé de Référence de Kidal, Kidal, Mali
| | - Sophie Crespo
- Health Unit, International Committee of the Red Cross, Geneva, Switzerland
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Leyba E, Harris H, Gallardo O, Morgan W, Cornelius B. Pericapsular Nerve Group (PENG) Block Results in Significant Opioid Reduction in Total Hip Arthroplasty: A Retrospective Analysis. J Perianesth Nurs 2024; 39:270-273. [PMID: 38206217 DOI: 10.1016/j.jopan.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/26/2023] [Accepted: 08/07/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE The purpose of this retrospective study was to determine the effectiveness of pericapsular nerve group (PENG) block for pain control intraoperatively in patients undergoing total hip arthroplasty (primary-27130) (THA), compared to opioid based analgesia. The PENG block is an emerging regional anesthesia technique that aims to provide hip analgesia with preservation of motor function offering benefit over existing regional techniques while reducing overall opioid requirements. DESIGN A retrospective cohort chart review and analysis. METHODS A single-site, retrospective chart review was performed for individuals undergoing THAs at a community hospital from 2019 to 2022 (N = 123). Anesthesia records were collected and observed for multiple data points including peripheral nerve block provided, micrograms of fentanyl administered before and during the case, additional medications given, and additional nerve blocks performed. The demographic data included birth date, sex, and procedure date. FINDINGS For statistical analysis only, patients receiving PENG (59) were compared to those receiving only intravenous analgesia (No Block-57). Statistically and clinically significant reductions in fentanyl administration and morphine equivalents were found in the population receiving PENG blocks. The mean intraoperative fentanyl given to the No Block group was 292.98 mcg versus 50.42 mcg in the PENG group (P < .05). Mean morphine equivalents given in the No Block group was 23.51 mg versus 11.21 mg in the PENG group (P < .05). CONCLUSIONS Receiving a PENG block preoperatively resulted in clinically and statistically significant opioid reduction during the perioperative period when compared with patients who did not receive a regional block.
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Affiliation(s)
- Evan Leyba
- Graduate Program of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Holly Harris
- Graduate Program of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | - Olana Gallardo
- Graduate Program of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX
| | | | - Brian Cornelius
- Graduate Program of Nurse Anesthesia, Texas Wesleyan University, Fort Worth, TX.
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Bareka M, Ntalouka MP, Angelis F, Mermiri M, Tsiaka A, Hantes M, Arnaoutoglou E. Femoral-Obturator-Sciatic (FOS) Nerve Block as an Anesthetic Triad for Arthroscopic ACL Reconstruction: Is This the Magic Trick We Were Missing? J Clin Med 2024; 13:1054. [PMID: 38398367 PMCID: PMC10889400 DOI: 10.3390/jcm13041054] [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: 12/22/2023] [Revised: 01/25/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024] Open
Abstract
Arthroscopic anterior cruciate ligament (ACL) reconstruction with hamstring grafting is a common orthopedic procedure that is associated with moderate-to-severe pain. Peripheral nerve blockade as an anesthetic technique is an appealing option in the era of modern anesthesia. The aim of this narrative review is to document the efficacy and safety of the combination of femoral, obturator, and sciatic (FOS) nerve blocks as an exclusive method for anesthesia in patients undergoing ACL reconstruction. An electronic search of the literature published up to October 2023 was conducted in the Medline, Embase, Cochrane, Web of Science, and Google Scholar databases to find studies on ACL reconstruction and peripheral obturator nerve block. Overall, 8 prospective studies-with a total of 315 patients-published between 2007 and 2022 were included in this review. Ultrasound-guided peripheral FOS nerve blockade is an effective anesthetic technique for ACL reconstruction, offering good perioperative pain management, minimal opioid consumption, and an excellent safety profile. Further well-designed prospective studies are needed to determine the best approach for obturator nerve blockade and the appropriate type and dosage of local anesthetic.
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Affiliation(s)
- Metaxia Bareka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, 41110 Larissa, Greece; (M.B.); (M.P.N.)
| | - Maria P. Ntalouka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, 41110 Larissa, Greece; (M.B.); (M.P.N.)
| | - Fragkiskos Angelis
- Department of Orthopaedic Surgery and Musculoskelatal Trauma, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, 41110 Larissa, Greece
| | - Maria Mermiri
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, 41110 Larissa, Greece; (M.B.); (M.P.N.)
| | - Aikaterini Tsiaka
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, 41110 Larissa, Greece; (M.B.); (M.P.N.)
| | - Michael Hantes
- Department of Orthopaedic Surgery and Musculoskelatal Trauma, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, 41110 Larissa, Greece
| | - Eleni Arnaoutoglou
- Department of Anaesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, 41110 Larissa, Greece; (M.B.); (M.P.N.)
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Silva J, Shehata P, Sehmbi H, Abd-Elsayed A. Radiofrequency ablation and pulsed radiofrequency of the lower extremities. RADIOFREQUENCY ABLATION TECHNIQUES 2024:140-168. [DOI: 10.1016/b978-0-323-87063-4.00023-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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11
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Et T, Korkusuz M. Comparison of the pericapsular nerve group block with the intra-articular and quadratus lumborum blocks in primary total hip arthroplasty: a randomized controlled trial. Korean J Anesthesiol 2023; 76:575-585. [PMID: 37013389 PMCID: PMC10718628 DOI: 10.4097/kja.23064] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND The pericapsular nerve group (PENG) block, quadratus lumborum block (QLB), and intra-articular (IA) local anesthetic injection have been shown to provide effective analgesia in total hip arthroplasty (THA). This randomized study aimed to compare the analgesic efficacy, motor protection, and quality of recovery associated with the PENG block, QLB, and IA injection. METHODS Eighty-nine patients who underwent a unilateral primary THA under spinal anesthesia were randomly assigned to the PENG (n=30), QLB (n=30), or IA (n=29) group. The primary outcome was the numerical rating scale (NRS) score over the first 48 h postoperatively. The secondary outcomes were postoperative opioid consumption, quadriceps and adductor muscle strength, and quality of recovery (QoR-40). RESULTS The dynamic (with movement) NRS scores at 3 and 6 h postoperatively were significantly lower in the PENG and QLB groups compared to the IA group (P = 0.002 and P < 0.001, respectively). The time to first opioid analgesia requirement was longer in the PENG and QLB groups than in the IA group (P = 0.009 and P = 0.016, respectively). A provided better preservation was found in the the PENG group than in the QLB group in terms of quadriceps muscle strength at 3 h postoperatively (P = 0.007) and time to mobilization (P = 0.003). No significant differences in the QoR-40 scores were seen. CONCLUSIONS The PENG and QLB groups showed similar analgesic effects and both showed more effective analgesia 6 h postoperatively than the IA group. All the groups showed similar postoperative quality of recovery.
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Affiliation(s)
- Tayfun Et
- Department of Anesthesiology and Intensive Care Medicine, Karamanoğlu Mehmetbey University Faculty of Medicine, Karaman, Turkey
| | - Muhammet Korkusuz
- Department of Anesthesiology and Intensive Care Medicine, Karamanoğlu Mehmetbey University Faculty of Medicine, Karaman, Turkey
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Kusderci HS, Genc C, Canikli Adiguzel Ş, Güzel N, Tulgar S, Suren M, Koksal E. Does Adding an IPACK Block to the Suprainguinal Fascia Iliaca Block Improve the Quality of Analgesia in Patients Undergoing Knee Arthroplasty under Spinal Anesthesia? A Retrospective Cohort Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1870. [PMID: 37893588 PMCID: PMC10608291 DOI: 10.3390/medicina59101870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/16/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Total knee arthroplasty (TKA) is a commonly performed orthopedic procedure, and is often accompanied by significant postoperative pain. The supra-inguinal fascia iliaca block (SIFIB), similar to an anterior lumbar plexus block, is frequently used in hip surgeries. The interspace between the popliteal artery and capsule of the posterior knee (IPACK) block is a regional anesthesia technique that targets the posterior innervation of the knee capsule. This retrospective study aimed to compare the analgesic effects of SIFIB and SIFIB + IPACK on patients undergoing TKA under spinal anesthesia. Materials and Methods: This retrospective study revealed the data collected from a tertiary hospital. Patient data were gathered for individuals who underwent unilateral TKA under spinal anesthesia during the period between 1 January 2023 and 1 September 2023. Inclusion criteria comprised patients falling within ASA class I-III, those following a standardized perioperative analgesia regimen, and individuals receiving opioids via a patient-controlled analgesia device (PCA) as part of their postoperative pain management strategy. Patients were grouped as SIFIB and SIFIB + IPACK according to the performed regional anesthesia technique. Results: In the study, the data of 88 patients in total, 61 in the SIFIB group and 27 in the IPACK group, were analyzed. The 24 h cumulative morphine consumption was similar in the SIFIB and SIFIB + IPACK groups (10.62 ± 6.58 mg vs. 12.55 ± 8.84 mg, respectively; p: 0.258). The NRS scores of the groups were similar in all time frames. Conclusions: Our study reveals that combining IPACK with SIFIB in the multimodal analgesia plan does not provide additional benefits in terms of postoperative opioid consumption and pain scores in patients undergoing unilateral THA under spinal anesthesia.
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Affiliation(s)
- Hatice Selcuk Kusderci
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Samsun Education and Research Hospital, Samsun University, Barış Bulvarı No. 199, 55090 Samsun, Turkey; (H.S.K.); (C.G.); (Ş.C.A.); (M.S.)
| | - Caner Genc
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Samsun Education and Research Hospital, Samsun University, Barış Bulvarı No. 199, 55090 Samsun, Turkey; (H.S.K.); (C.G.); (Ş.C.A.); (M.S.)
| | - Şenay Canikli Adiguzel
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Samsun Education and Research Hospital, Samsun University, Barış Bulvarı No. 199, 55090 Samsun, Turkey; (H.S.K.); (C.G.); (Ş.C.A.); (M.S.)
| | - Nizamettin Güzel
- Department of Orthopedics and Traumatology, Samsun Education and Research Hospital, Barış Bulvarı No. 199, 55090 Samsun, Turkey;
| | - Serkan Tulgar
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Samsun Education and Research Hospital, Samsun University, Barış Bulvarı No. 199, 55090 Samsun, Turkey; (H.S.K.); (C.G.); (Ş.C.A.); (M.S.)
| | - Mustafa Suren
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Samsun Education and Research Hospital, Samsun University, Barış Bulvarı No. 199, 55090 Samsun, Turkey; (H.S.K.); (C.G.); (Ş.C.A.); (M.S.)
| | - Ersin Koksal
- Department of Anesthesiology and Reanimation, Ondokuzmayıs University Faculty of Medicine, 55280 Samsun, Turkey;
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Medhat MM, Kamel AAF, Salem DAE, Alagamy SA, Fathi HM. The Analgesic Effects of Preemptive Ultrasound-Guided Pericapsular Nerve Group Block in Comparison with Erector Spinae Plane Block in Elderly Undergoing Hip Arthroplasty: A Randomized Controlled Trial. Anesth Pain Med 2023; 13:e138623. [PMID: 38028113 PMCID: PMC10664163 DOI: 10.5812/aapm-138623] [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: 06/26/2023] [Revised: 07/21/2023] [Accepted: 07/28/2023] [Indexed: 12/01/2023] Open
Abstract
Background Perioperative pain management strategies in the elderly undergoing hip arthroplasty need special and safe preemptive care. Objectives The primary aim of this study was to compare the analgesic effects of preemptive ultrasound-guided pericapsular nerve group (PENG) block and lumbar erector spinae plane block (L-ESPB) in the elderly undergoing hip arthroplasty. The time to the first postoperative rescue analgesia was measured. The secondary aim was to assess the ease of spinal positioning (EOSP), onset of sensory block, block performance time, and patient satisfaction. Methods Before positioning for spinal anesthesia, 69 elderly patients undergoing hip arthroplasty were randomized into three groups (n = 23 per group). The first intervention group received ultrasound-guided PENG block with 20 mL bupivacaine 0.25%; the second intervention group received ultrasound-guided L-ESPB using the same dose of bupivacaine. In the control group, patients received spinal anesthesia without any block. Results The time to first postoperative rescue analgesic (morphine) was significantly prolonged in the PENG group (13.3 ± 3.5 h) compared to the L-ESPB (9.5 ± 2.3 h) and control (2.6 ± 0.4 h) groups. The EOSP score was significantly higher in the PENG group compared to the L-ESPB and control groups (P < 0.001). The block performance time and oneset of the sensory block were significantly shorter in the PENG group compared to the L-ESPB group. The highest patient satisfaction scores were observed in the PENG group. Conclusions Preemptive pericapsular nerve group block postponed the need for postoperative analgesia and eased spinal positioning compared to L-ESPB in the elderly undergoing hip arthroplasty.
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Affiliation(s)
- Marwa Mohamed Medhat
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
| | - Alshaimaa Abdel Fattah Kamel
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
| | | | - Sherif A. Alagamy
- Department of orthopedic, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
| | - Heba M Fathi
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
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Bravo D, Aliste J, Layera S, Fernández D, Erpel H, Aguilera G, Arancibia H, Barrientos C, Wulf R, León S, Brañes J, Finlayson RJ, Tran DQ. Randomized clinical trial comparing pericapsular nerve group (PENG) block and periarticular local anesthetic infiltration for total hip arthroplasty. Reg Anesth Pain Med 2023; 48:489-494. [PMID: 36797036 DOI: 10.1136/rapm-2023-104332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/09/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND This randomized trial compared pericapsular nerve group block and periarticular local anesthetic infiltration in patients undergoing primary total hip arthroplasty. We hypothesized that, compared with pericapsular nerve group block, periarticular local anesthetic infiltration would decrease the postoperative incidence of quadriceps weakness at 3 hours fivefold (ie, from 45% to 9%). METHODS Sixty patients undergoing primary total hip arthroplasty under spinal anesthesia were randomly allocated to receive a pericapsular nerve group block (n=30) using 20 mL of adrenalized bupivacaine 0.50%, or periarticular local anesthetic infiltration (n=30) using 60 mL of adrenalized bupivacaine 0.25%. Both groups also received 30 mg of ketorolac, either intravenously (pericapsular nerve group block) or periarticularly (periarticular local anesthetic infiltration), as well as 4 mg of intravenous dexamethasone.Postoperatively, a blinded evaluator carried out sensory assessment and motor assessment (knee extension and hip adduction) at 3, 6 and 24 hours. Furthermore, the blinded observer also recorded static and dynamic pain scores at 3, 6, 12, 18, 24, 36 and 48 hours; time to first opioid request; cumulative breakthrough morphine consumption at 24 hours and 48 hours; opioid-related side effects; ability to perform physiotherapy at 6, 24 and 48 hours; as well as length of stay. RESULTS There were no differences in quadriceps weakness at 3 hours between pericapsular nerve group block and periarticular local anesthetic infiltration (20% vs 33%; p=0.469). Furthermore, no intergroup differences were found in terms of sensory block or motor block at other time intervals; time to first opioid request; cumulative breakthrough morphine consumption; opioid-related side effects; ability to perform physiotherapy; and length of stay. Compared with pericapsular nerve group block, periarticular local anesthetic infiltration resulted in lower static pain scores (at all measurement intervals) and dynamic pain scores (at 3 and 6 hours). CONCLUSION For primary total hip arthroplasty, pericapsular nerve group block and periarticular local anesthetic infiltration result in comparable rates of quadriceps weakness. However, periarticular local anesthetic infiltration is associated with lower static pain scores (especially during the first 24 hours) and dynamic pain scores (first 6 hours). Further investigation is required to determine the optimal technique and local anesthetic admixture for periarticular local anesthetic infiltration. TRIAL REGISTRATION NUMBER NCT05087862.
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Affiliation(s)
- Daniela Bravo
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Julián Aliste
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Sebastián Layera
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Diego Fernández
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Hans Erpel
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Germán Aguilera
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | - Hernán Arancibia
- Anesthesiology and Perioperative Medicine, University of Chile, Santiago de Chile, Chile
| | | | - Rodrigo Wulf
- Orthopedic Surgery, University of Chile, Santiago de Chile, Chile
| | - Sebastián León
- Orthopedic Surgery, University of Chile, Santiago de Chile, Chile
| | - Julián Brañes
- Orthopedic Surgery, University of Chile, Santiago de Chile, Chile
| | - Roderick J Finlayson
- Pain and Research, The University of British Columbia, Vancouver, British Columbia, Canada
| | - De Q Tran
- Anesthesiology, McGill University, Montreal, Québec, Canada
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15
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Kim JY, Kim J, Kim DH, Han DW, Kim SH, Kim D, Chung S, Yu S, Lee UY, Park HJ. Anatomical and Radiological Assessments of Injectate Spread Stratified by the Volume of the Pericapsular Nerve Group Block. Anesth Analg 2023; 136:597-604. [PMID: 36727847 DOI: 10.1213/ane.0000000000006364] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The pericapsular nerve group (PENG) block was recently suggested as a regional technique for managing acute pain after hip surgery. However, few anatomical studies have confirmed the spread of injectate during the PENG block. This cadaver study aimed to analyze injectate spread to the target nerves during single-injection ultrasound-guided PENG block. METHODS Ultrasound-guided PENG block with 3 different injectate volumes (10, 20, or 30 mL) was performed in 18 cadavers. Injectate spread by the volume was first evaluated on computed tomography, followed by cadaver dissection. The spread of the dye over the pelvis and lower limb was evaluated. RESULTS The articular branches of the femoral nerve were stained nearly sufficiently with 20- and 30-mL specimens. The femoral nerve itself was stained simultaneously in six of 12 (50%) 20-mL specimens and 12 of 12 (100%) 30-mL specimens. The accessory obturator nerve was observed only in three (9%) of 36 specimens. The articular branches of the obturator nerve were rarely affected, regardless of injectate volume (1/12, 10 mL specimens; 2/12, 20 mL specimens; 1/12, 30 mL specimens; P > .999). Rather, the obturator nerve was affected. However, the obturator nerve was not stained consistently even with 30 mL of injectate (50%). CONCLUSIONS After combining the dissection and radiological findings, the single-injection ultrasound-guided PENG blocks with volumes of 10, 20, and 30 mL do not support motor sparing or selective anterior hip capsule innervation in a clinical setting. If early rehabilitation is needed, high-volume PENG block might not be the ideal option, and persisting pain after PENG block might be attributed in part to the lack of obturator nerve articular branches blockade.
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Affiliation(s)
- Ji Yeong Kim
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Jiyoung Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do-Hyeong Kim
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Dong Woo Han
- From the Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Korea
| | - Sang Hyun Kim
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Donghyun Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Siwook Chung
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sanghyuck Yu
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - U-Young Lee
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Vermeylen K, Van Aken D, Versyck B, Casaer S, Bleys R, Bracke P, Groen G. Deep posterior gluteal compartment block for regional anaesthesia of the posterior hip: a proof-of-concept pilot study. BJA OPEN 2023; 5:100127. [PMID: 37587997 PMCID: PMC10430842 DOI: 10.1016/j.bjao.2023.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/11/2023] [Accepted: 01/23/2023] [Indexed: 08/18/2023]
Abstract
Background Various regional anaesthesia approaches to branches of the anterior lumbar plexus have been proved effective in providing analgesia in hip surgery. However, some patients still experience significant residual posterior hip pain attributed to the posterior nerve supply of the hip. This not only suggests that anterior approaches may not always provide sufficient pain relief, but also that the blocking of major nerves supplying the posterior pericapsular region is needed. Methods We present an ultrasound-guided technique to block all major nerves supplying the posterior capsule of the hip joint. The optimal target area was determined by ultrasound imaging, cross-sectional digitised anatomy, and cadaver research, and was found in the deep gluteal compartment. Furthermore, this posterior pericapsular deep-gluteal block was evaluated in two patients. Results The spread of dye in the cadaver was observed deep to the gluteus maximus and in between the quadratus femoris and piriformis muscles, and conformed to the presumed location during the ultrasound procedure. It included all major supplying nerves to the posterior hip capsule, that is the superior gluteal nerve, nerve to quadratus femoris and sciatic nerve. In both patients where this posterior pericapsular deep-gluteal block was applied the pain was substantially reduced (numeric rating scale: 4 to 1 and 7 to 1). Conclusion We present a successful ultrasound-guided technique targeting the deep gluteal compartment to block all major nerves supplying the hip joint's posterior capsule. This posterior pericapsular deep-gluteal block can be applied as an additional block in hip surgery, with also a possible role in chronic hip pathology.
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Affiliation(s)
- Kris Vermeylen
- Department of Anaesthesia, AZ Turnhout, Turnhout, Belgium
| | - David Van Aken
- Department of Anaesthesia, Department of Radiology, AZ Klina, Brasschaat, Belgium
| | - Barbara Versyck
- Department of Anaesthesia, AZ Turnhout, Turnhout, Belgium
- Department of Anaesthesia, Catharina Hospital, Eindhoven, the Netherlands
| | - Sari Casaer
- Department of Anaesthesia, Gasthuiszusters Antwerpen, Antwerp, Belgium
| | - Ronald Bleys
- Department of Functional Anatomy, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Bracke
- Department of Radiology, AZ Klina, Brasschaat, Belgium
| | - Gerbrand Groen
- Anesthesiology Pain Center, Department of Anesthesiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Rugg CM, Ginder JH, Bharadwaj A, Vomer R, Dale GA, Ketterly J, Zarzour H, Amendola A, Lau BC. Perioperative Management in the Collegiate Athlete: An Integrated Approach. Sports Med Int Open 2023; 7:E1-E8. [PMID: 37101550 PMCID: PMC10125641 DOI: 10.1055/a-2051-7756] [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: 11/03/2022] [Accepted: 01/26/2023] [Indexed: 04/28/2023] Open
Abstract
Collegiate athletes face rigorous physical, academic, and emotional demands. While significant attention has been paid to injury prevention among young athletes in the past two decades, orthopedic injury rates remain high among collegiate athletes, and a significant number will undergo surgical management for injuries each year. In this narrative review, we describe techniques for perioperative management of pain and stress after surgery in collegiate athletes. In particular, we outline pharmacologic and non-pharmacologic management of surgical pain, with a goal of minimizing opiate consumption. We emphasize a multi-disciplinary approach to optimizing post-operative recovery in collegiate athletes help minimize reliance on opiate pain medication. Additionally, we recommend that institutional resources should be harnessed to support athletes in their well-being, from a nutritional, psychological and sleep standpoint. Critical to success in perioperative pain management is the communication among the athletic medicine team members and with the athlete and family to address pain and stress management and encourage timely, safe return to play.
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Affiliation(s)
| | | | | | - Rock Vomer
- Orthopedics, Division of Sports Medicine, Duke University, Durham,
United States
- Correspondence Dr. Rock Vomer Duke
UniversityOrthopedics, Division of Sports
Medicine3475 Erwin
Road27708–0187
DurhamUnited States919 668n
1400
| | | | | | - Hap Zarzour
- Athletics, Duke University, Durham, United States
| | | | - Brian C. Lau
- Orthopedics, Duke University, Durham, United States
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Crutchfield CR, Schweppe EA, Padaki AS, Steinl GK, Roller BA, Brown AR, Lynch TS. A Practical Guide to Lower Extremity Nerve Blocks for the Sports Medicine Surgeon. Am J Sports Med 2023; 51:279-297. [PMID: 35437023 DOI: 10.1177/03635465211051757] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) are vital in the administration of surgical analgesia and have grown in popularity for use in lower extremity arthroscopic procedures because of their capacity to safely and effectively control pain. The number and specificity of PNBs, however, have made choosing the best option for a procedure nebulous for orthopaedic surgeons. PURPOSE To present a narrative literature review of the PNBs available for arthroscopic hip and knee procedures that is adapted to an audience of orthopaedic surgeons. STUDY DESIGN Narrative literature review. METHODS A combination of the names of various lower extremity PNBs AND "hip arthroscopy" OR "knee arthroscopy" was used to search the English medical literature including PubMed, Cochrane Library, ScienceDirect, Embase, and Scopus. Placement technique, specificity of blockade, efficacy, and complications were assessed. Searches were performed through May 2, 2021. RESULTS A total of 157 studies were included in this review of lower extremity PNBs. Femoral nerve, lumbar plexus, sciatic nerve, and fascia iliaca compartment blocks were most commonly used in arthroscopic hip surgery, while femoral nerve, 3-in-1, and adductor canal blocks were preferred for arthroscopic knee surgery. Each block demonstrated a significant benefit (P > .05) in ≥1 of the following outcomes: intraoperative morphine, pain scores, nausea, and/or opioid consumption. Combination blocks including the lateral femoral cutaneous nerve block, obturator nerve block, quadratus lumborum block, and L1 and L2 paravertebral block have also been described. Complication rates ranged from 0% to 4.8% in those administered with ultrasound guidance. The most commonly reported complications included muscular weakness, postoperative falls, neuropathy, intravascular and intraneural injections, and hematomas. CONCLUSION When administered properly, PNBs were a safe and effective adjuvant method of pain control with a significant potential to limit postoperative narcotic use. While blockade choice varies by surgeon preference and procedure, all PNBs should be administered with ultrasound guidance, and vigilant protocols for the risk of postoperative falls should be exercised in patients who receive them.
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Affiliation(s)
| | - Eric A Schweppe
- Columbia University Irving Medical Center, New York, New York, USA
| | - Ajay S Padaki
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Brian A Roller
- Columbia University Irving Medical Center, New York, New York, USA
| | - Anthony R Brown
- Columbia University Irving Medical Center, New York, New York, USA
| | - T Sean Lynch
- Columbia University Irving Medical Center, New York, New York, USA
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James M, Bentley RA, Womack J, Goodman BA. Safety profile and outcome after ultrasound-guided suprainguinal fascia iliaca catheters for hip fracture: a single-centre propensity-matched historical cohort study. Can J Anaesth 2022; 69:1139-1150. [PMID: 35819630 DOI: 10.1007/s12630-022-02279-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 01/12/2022] [Accepted: 02/14/2022] [Indexed: 10/17/2022] Open
Abstract
PURPOSE Peripheral nerve blocks improve analgesia following hip fracture; however, there are little published data on safety and outcomes of continuous regional anesthetic techniques. Our institution offers pre- and perioperative, anesthesiologist-delivered ultrasound-guided suprainguinal fascia iliaca catheters (FICs) to patients with hip fracture. We aimed to document the safety profile of this technique and establish whether there are any significant clinical benefits in outcomes measured by the UK National Hip Fracture Database. METHODS We performed a single-centre historical cohort study of 2,187 patients admitted to our institution with hip fracture over a 5.75-year period. Of these, 915 were treated with FIC and 1,272 received standard care (single-shot block). To control for baseline differences between these two cohorts, we used propensity score matching and exact matching, resulting in two well-matched groups of 728 patients treated with an FIC and standard care. RESULTS No serious complications were observed as a result of an FIC. Unplanned removal occurred in 146/852 (17.1%) patients with documented data. No differences in 30-day mortality, pressure ulcer rates, or hospital length of stay were observed between the matched groups. The percentage of patients who were discharged to their usual residence was 79.3% in the FIC cohort vs 75.1% in the standard care cohort (difference, 4.2%; 95% confidence interval, -0.1 to 8.4; P = 0.06). DISCUSSION Our single-centre propensity-matched historical cohort study suggests that ultrasound-guided suprainguinal fascia iliaca catheterization is a safe technique for patients with hip fracture and that our service is deliverable and sustainable within the UK's National Health Service. This study did not show statistically significant differences in outcomes between patients treated with FIC and standard care. An adequately powered multicentre randomized controlled trial comparing these approaches is warranted.
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Affiliation(s)
- Michael James
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | | - Jonathan Womack
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Ben A Goodman
- Department of Anaesthesia, Royal Victoria Infirmary, Newcastle upon Tyne, UK.
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK.
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Kitcharanant N, Leurcharusmee P, Wangtapun P, Kantakam P, Maikong N, Mahakkanukrauh P, Tran DQ. Surgeon-performed pericapsular nerve group (PENG) block for total hip arthroplasty using the direct anterior approach: a cadaveric study. Reg Anesth Pain Med 2022; 47:359-363. [DOI: 10.1136/rapm-2022-103482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/02/2022] [Indexed: 01/04/2023]
Abstract
BackgroundDuring total hip arthroplasty (THA) using the direct anterior approach, orthopaedic surgeons can identify all anatomical landmarks required for pericapsular nerve group (PENG) blocks and carry out the latter under direct vision. This cadaveric study investigated the success of surgeon-performed PENG block. Success was defined as dye staining of the articular branches of the femoral and accessory obturator nerves.Methods11 cadavers (18 hip specimens) were included in the current study. To simulate THA in live patients, an orthopaedic surgeon inserted trial prostheses using the direct anterior approach. Subsequently, a block needle was advanced until contact with the bone (between the anterior inferior iliac spine and iliopubic eminence). 20 mL of 0.1% methylene blue was injected. Cadavers were then dissected to document the presence and dye staining of the femoral, lateral femoral cutaneous, obturator and accessory obturator nerves as well as the articular branches of the femoral, obturator and accessory obturator nerves.ResultsMethylene blue stained the articular branches of the femoral nerve and the articular branches of the accessory obturator nerve (when present) in all hip specimens. Therefore, surgical PENG block achieved a 100% success rate. Dye stained the femoral and obturator nerve in one (5.6%) and two (11.1%) hip specimens, respectively. No dye staining was observed over the accessory obturator nerve in the pelvis nor the lateral femoral cutaneous nerve.ConclusionSurgeon-performed PENG block during direct anterior THA reliably targets the articular branches of the femoral and accessory obturator nerves. Future trials are required to compare surgeon-performed PENG block with anaesthesiologist-performed, ultrasound-guided PENG block, and surgeon-performed periarticular local anaesthetic infiltration.
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Neely G, Hollis N, Mozingo C. Anesthesia for the Patient Undergoing Knee Procedures. Clin Sports Med 2022; 41:247-261. [PMID: 35300838 DOI: 10.1016/j.csm.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Anesthesia for patients undergoing knee procedures encompasses a large patient population with significant variation in patient age, comorbidities, and type of surgery. In addition, these procedures are performed in vastly different surgical environments, including large academic hospitals, private hospitals, and out-patient surgical centers. These variabilities require a thoughtful and individualized anesthetic approach tailored toward the medical and surgical needs of each patient. This article discusses anesthetic approaches to patients with acute, subacute, and chronic knee-related pathology requiring surgery. We will also review pertinent knee anatomy and innervation and discuss regional nerve blocks and their applications to knee-related surgical procedures.
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Affiliation(s)
- Grant Neely
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA.
| | - Nicole Hollis
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
| | - Cy Mozingo
- West Virginia University Department of Anesthesiology, 1 Medical Center Drive, PO Box 8255, Morgantown, WV 26508, USA
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22
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Kamel I, Ahmed MF, Sethi A. Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know. World J Orthop 2022; 13:11-35. [PMID: 35096534 PMCID: PMC8771411 DOI: 10.5312/wjo.v13.i1.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/20/2021] [Accepted: 01/10/2022] [Indexed: 02/06/2023] Open
Abstract
Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.
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Affiliation(s)
- Ihab Kamel
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Muhammad F Ahmed
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
| | - Anish Sethi
- Department of Anesthesiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, United States
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23
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Pascarella G, Costa F, Del Buono R, Pulitanò R, Strumia A, Piliego C, De Quattro E, Cataldo R, Agrò FE, Carassiti M. Impact of the pericapsular nerve group (PENG) block on postoperative analgesia and functional recovery following total hip arthroplasty: a randomised, observer-masked, controlled trial. Anaesthesia 2021; 76:1492-1498. [PMID: 34196965 PMCID: PMC8519088 DOI: 10.1111/anae.15536] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2021] [Indexed: 12/01/2022]
Abstract
The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that aims to provide hip analgesia with preservation of motor function, although evidence is currently lacking. In this single-centre, observer-masked, randomised controlled trial, patients undergoing total hip arthroplasty received pericapsular nerve group block or no block (control group). Primary outcome measure was maximum pain scores (0-10 numeric rating scale) measured in the first 48 h after surgery. Secondary outcomes included postoperative opioid consumption; patient mobilisation assessments; and length of hospital stay. Sixty patients were randomly allocated equally between groups. The maximum pain score of patients receiving the pericapsular nerve group block was significantly lower than in the control group at all time-points, with a median (IQR [range]) of 2.5 (2.0-3.7 [0-7]) vs. 5.5 (5.0-7.0 [2-8]) at 12 h; 3 (2.0-4.0 [0-7]) vs. 6 (5.0-6.0 [2-8]) at 24 h; and 2.0 (2.0-4.0 [0-5]) vs. 3.0 (2.0-4.7 [0-6]) at 48 h; all p < 0.001. Moreover, the pericapsular nerve group showed a significant reduction in opioid consumption, better range of hip motion and shorter time to ambulation. Although no significant difference in hospital length of stay was detected, our results suggest improved postoperative functional recovery following total hip arthroplasty in patients who received pericapsular nerve group block.
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Affiliation(s)
- G. Pascarella
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
| | - F. Costa
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
| | - R. Del Buono
- Unit of AnesthesiaIntensive Care and Pain ManagementASST Gaetano PiniMilanItaly
| | - R. Pulitanò
- Unit of AnesthesiaIntensive Care and Pain ManagementAzienda Ospedaliera San Giovanni AddolorataRomeItaly
| | - A. Strumia
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
| | - C. Piliego
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
| | - E. De Quattro
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
| | - R. Cataldo
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
| | - F. E. Agrò
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
| | - M. Carassiti
- Unit of AnesthesiaIntensive Care and Pain ManagementDepartment of MedicineCampus Bio‐Medico UniversityRomeItaly
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24
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Jaremko I, Lukaševič K, Tarasevičius Š, Zeniauskas L, Macas A, Gelmanas A. Comparison of 2 Peripheral Nerve Blocks Techniques for Functional Recovery and Postoperative Pain Management After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Trial. Med Sci Monit 2021; 27:e932848. [PMID: 34629461 PMCID: PMC8518512 DOI: 10.12659/msm.932848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Methods of pain management that have less effect on motor function after total knee arthroplasty (TKA) are needed to ensure early mobilization. We investigated whether the distal femoral triangle and distal adductor canal blocks are superior to the femoral nerve block regarding motor blockade at early postoperative hours. MATERIAL AND METHODS Patients scheduled for TKA under spinal anesthesia were blindly assigned into 2 groups. One group received the distal femoral triangle and distal adductor canal blocks and the other group received the femoral nerve block. In both groups, at 3, 6, 24, and 48 h after surgery motor blockade was evaluated with the Bromage scale. Secondary outcomes such as pain control efficacy and patient satisfaction were evaluated at 6, 24, and 48 h postoperatively using either the VAS scale or a 10-point scale. RESULTS We analyzed the outcomes of 77 patients. Better motor function at 3 and 6 h after TKA was observed in the distal femoral triangle and the distal adductor canal blocks group (37.7% vs 23.4%, p=0.032 and 49.4% vs 32.5%, p=0.002, respectively). At 24 h after the surgery, patients from the femoral nerve block group consumed significantly more rescue opioid analgesics (p=0.016). We found no significant differences in pain intensity and patient satisfaction at any timepoints after the surgery. CONCLUSIONS The distal femoral triangle and distal adductor canal blocks resulted in significantly better motor function at the first 3 and 6 h after total knee arthroplasty. At 24 h after surgery, rescue opioid doses in the femoral nerve block group were significantly higher.
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Affiliation(s)
- Inna Jaremko
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Karina Lukaševič
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Šarūnas Tarasevičius
- Department of Orthopaedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Linas Zeniauskas
- Department of Orthopaedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Arūnas Gelmanas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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25
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Aliste J, Layera S, Bravo D, Jara Á, Muñoz G, Barrientos C, Wulf R, Brañes J, Finlayson RJ, Tran DQ. Reply to Dr Pascarella and colleagues. Reg Anesth Pain Med 2021; 47:201. [PMID: 34518370 DOI: 10.1136/rapm-2021-103125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 08/23/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Julián Aliste
- Anesthesiology and Perioperative Medicine, University of Chile School of Medicine, Santiago, Chile
| | - Sebastián Layera
- Anesthesiology and Perioperative Medicine, University of Chile School of Medicine, Santiago, Chile
| | - Daniela Bravo
- Anesthesiology and Perioperative Medicine, University of Chile School of Medicine, Santiago, Chile
| | - Álvaro Jara
- Anesthesiology and Perioperative Medicine, University of Chile School of Medicine, Santiago, Chile
| | - Gonzalo Muñoz
- Anesthesiology and Perioperative Medicine, University of Chile School of Medicine, Santiago, Chile
| | | | - Rodrigo Wulf
- Orthopedic Surgery, University of Chile, Santiago, Chile
| | - Julián Brañes
- Orthopedic Surgery, University of Chile, Santiago, Chile
| | - Roderick J Finlayson
- Pain and Research, The University of British Columbia, Kelowna, Columbia, Canada
| | - De Q Tran
- Anesthesiology, McGill University, Montreal, Quebec, Canada
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26
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Kantakam P, Maikong N, Sinthubua A, Mahakkanukrauh P, Tran DQ, Leurcharusmee P. Cadaveric investigation of the minimum effective volume for ultrasound-guided suprainguinal fascia iliaca block. Reg Anesth Pain Med 2021; 46:757-762. [PMID: 33911024 DOI: 10.1136/rapm-2021-102563] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/06/2021] [Accepted: 03/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND This cadaveric dose-finding study investigated the minimum effective volume of dye in 90% of cases (MEV90), required to stain the femoral, lateral femoral cutaneous and obturator nerves for ultrasound-guided suprainguinal fascia iliaca block (SIFIB). METHODS In cadaveric specimens of the lower limb, the block needle was advanced, medial to the anterosuperior iliac spine, until its tip was positioned between the internal oblique and iliacus muscles underneath the fascia iliaca. The dye was injected inside the fascia iliaca compartment. Volume assignment was carried out using a biased coin design, whereby the volume of dye administered to each cadaveric specimen depended on the response of the previous one. In case of failure, the next one received a higher volume (defined as the previous volume with an increment of 2.5 mL). If the previous cadaveric specimen had a successful block, the next one was randomized to a lower volume (defined as the previous volume with a decrement of 2.5 mL), with a probability of b=0.11, or the same volume, with a probability of 1-b=0.89. Success was defined as the staining of the femoral, lateral femoral cutaneous, and obturator nerves on dissection. RESULTS Thirty-six cadavers (60 cadaveric specimens) were included in the study. Using isotonic regression and bootstrap CI, the MEV90 for ultrasound-guided SIFIB was estimated to be 62.5 mL (95% CI 60 to 65). CONCLUSION For ultrasound-guided SIFIB, the MEV90 of dye required to stain the femoral, lateral femoral cutaneous and obturator nerves is 62.5 mL. Further studies are required to correlate this finding with the MEV90 of local anesthetic in human subjects.
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Affiliation(s)
- Perada Kantakam
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Naraporn Maikong
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Sinthubua
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pasuk Mahakkanukrauh
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Excellence in Osteology Research and Training Center (ORTC), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - De Q Tran
- Department of Anesthesiology, St Mary's Hospital, McGill University, Montreal, Québec, Canada
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27
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Tran DQ, Kantakam P, Maikong N, Sinthubua A, Mahakkanukrauh P, Leurcharusmee P. Reply to Dr Bendtsen and colleagues. Reg Anesth Pain Med 2021; 46:832-833. [PMID: 33911026 DOI: 10.1136/rapm-2021-102782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022]
Affiliation(s)
- De Q Tran
- Department of Anesthesiology, St.Mary's Hospital, McGill University, Montreal, Quebec, Canada
| | - Perada Kantakam
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Naraporn Maikong
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apichat Sinthubua
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Pasuk Mahakkanukrauh
- Department of Anatomy, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Excellence in Osteology Research and Training Center (ORTC), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Prangmalee Leurcharusmee
- Excellence in Osteology Research and Training Center (ORTC), Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand .,Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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28
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Stebler K, Choquet O, Bernard N, Biboulet P, Capdevila X. An uncommon cause of nerve stimulator's malfunction during a dual guidance lumbar plexus block: A technical brief report and an algorithm for prevention of complications. Anaesth Crit Care Pain Med 2021; 40:100832. [PMID: 33744494 DOI: 10.1016/j.accpm.2021.100832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/25/2022]
Abstract
Posterior Lumbar plexus block (PLPB) combined with an ipsilateral sacral plexus block is a valuable anaesthetic technique in patients undergoing hip fracture surgery. PLPB is performed through the acoustic window of the lumbar ultrasound trident and the position of the needle tip, before injection of LA, was confirmed by observing quadriceps femoris muscle contraction to peripheral nerve stimulation (i.e., dual guidance). We report an uncommon cause of nerve stimulator malfunction that might impair block performance and promote complications. We add an algorithm to limit the risk of complications.
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Affiliation(s)
- Kevin Stebler
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Olivier Choquet
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Nathalie Bernard
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Philippe Biboulet
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France
| | - Xavier Capdevila
- Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital, 34295 Montpellier Cedex 5, France.
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29
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Hyland SJ, Brockhaus KK, Vincent WR, Spence NZ, Lucki MM, Howkins MJ, Cleary RK. Perioperative Pain Management and Opioid Stewardship: A Practical Guide. Healthcare (Basel) 2021; 9:333. [PMID: 33809571 PMCID: PMC8001960 DOI: 10.3390/healthcare9030333] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/20/2022] Open
Abstract
Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.
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Affiliation(s)
- Sara J. Hyland
- Department of Pharmacy, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA
| | - Kara K. Brockhaus
- Department of Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
| | | | - Nicole Z. Spence
- Department of Anesthesiology, Boston University School of Medicine, Boston Medical Center, Boston, MA 02118, USA;
| | - Michelle M. Lucki
- Department of Orthopedics, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Michael J. Howkins
- Department of Addiction Medicine, Grant Medical Center (OhioHealth), Columbus, OH 43215, USA;
| | - Robert K. Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, Ypsilanti, MI 48197, USA;
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30
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Layera S, Saadawi M, Tran DQ, Salinas FV. Motor-Sparing Peripheral Nerve Blocks for Shoulder, Knee, and Hip Surgery. Adv Anesth 2020; 38:189-207. [PMID: 34106834 DOI: 10.1016/j.aan.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Sebastián Layera
- Department of Anesthesiology and Perioperative Medicine, Hospital Clínico Universidad de Chile, University of Chile, Office B222 Second Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile
| | - Mohammed Saadawi
- Department of Anesthesiology, St. Mary's Hospital, McGill University, 3830 Avenue Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - De Q Tran
- Department of Anesthesiology, St. Mary's Hospital, McGill University, 3830 Avenue Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - Francis V Salinas
- Department of Anesthesiology, US Anesthesia Partners-Washington, 600 Broadway, Suite 270, Seattle, WA 98122, USA.
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31
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Bravo D, Layera S, Aliste J, Jara Á, Fernández D, Barrientos C, Wulf R, Muñoz G, Finlayson RJ, Tran DQ. Lumbar plexus block versus suprainguinal fascia iliaca block for total hip arthroplasty: A single-blinded, randomized trial. J Clin Anesth 2020; 66:109907. [DOI: 10.1016/j.jclinane.2020.109907] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/30/2020] [Accepted: 05/21/2020] [Indexed: 11/28/2022]
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32
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Layera S, Aliste J, Bravo D, Saadawi M, Salinas FV, Tran DQ. Motor-sparing nerve blocks for total knee replacement: A scoping review. J Clin Anesth 2020; 68:110076. [PMID: 33035871 DOI: 10.1016/j.jclinane.2020.110076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/24/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE This scoping review investigates the optimal combination of motor-sparing analgesic interventions for patients undergoing total knee replacement (TKR). DESIGN Scoping review. INTERVENTION MEDLINE, EMBASE and CINAHL databases were searched (inception-last week of May 2020). Only trials including motor-sparing interventions were included. Randomized controlled trials lacking prospective registration and blinded assessment were excluded. MAIN RESULTS The cumulative evidence suggests that femoral triangle blocks outperform placebo and periarticular infiltration. When combined with the latter, femoral triangle blocks are associated with improved pain control, higher patient satisfaction and decreased opioid consumption. Continuous femoral triangle blocks provide superior postoperative analgesia compared with their single-injection counterparts. However, these benefits seem less pronounced when perineural adjuvants are used. Combined femoral triangle-obturator blocks result in improved analgesia and swifter discharge compared with femoral triangle blocks alone. CONCLUSIONS The optimal analgesic strategy for TKR may include a combination of different analgesic modalities (periarticular infiltration, femoral triangle blocks, obturator nerve block). Future trials are required to investigate the incremental benefits provided by local anesthetic infiltration between the popliteal artery and the capsule of the knee (IPACK), popliteal plexus block and genicular nerve block.
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Affiliation(s)
- Sebastián Layera
- Hospital Clínico Universidad de Chile, Department of Anesthesiology and Perioperative Medicine, University of Chile, Office B222 2nd Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile.
| | - Julián Aliste
- Hospital Clínico Universidad de Chile, Department of Anesthesiology and Perioperative Medicine, University of Chile, Office B222 2nd Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile
| | - Daniela Bravo
- Hospital Clínico Universidad de Chile, Department of Anesthesiology and Perioperative Medicine, University of Chile, Office B222 2nd Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile
| | - Mohammed Saadawi
- St. Mary's Hospital, Department of Anesthesiology, McGill University, 3830 Ave Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - Francis V Salinas
- US Anesthesia Partners-Washington, Swedish Medical Center, Department of Anesthesiology, Seattle, WA, USA
| | - De Q Tran
- St. Mary's Hospital, Department of Anesthesiology, McGill University, 3830 Ave Lacombe, Montreal, Quebec H3T-1M5, Canada
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33
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Ireland E, Womack J, Foley E. Sacral plexus catheter analgesia in a patient with traumatic sacral fractures and Tarlov cysts. Anaesth Rep 2020; 7:76-78. [PMID: 32051956 DOI: 10.1002/anr3.12023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2019] [Indexed: 11/05/2022] Open
Abstract
We report the use of a sacral plexus catheter for continuous local anaesthetic infusion in a patient with a unilateral sacral ala fracture following a fall from a horse. Although sacral plexus blockade has been well described for lower limb surgery, an ultrasound-guided continuous catheter technique for conservatively managed fractures has not been described. Despite appropriate oral analgesia, the patient reported severe pain, particularly in the right gluteal region, which meant she was unable to sit upright or take deep breaths. A sacral plexus catheter was inserted with ultrasound guidance and an initial bolus of 30 ml levobupivicaine 0.25% was delivered followed by infusion of 8 ml.h-1 levobupivicaine 0.125%. Daily follow-up and assessment were provided by the acute pain team. We judged the procedure to be a success as measured by an improvement in mobilisation, deep breathing, cough and patient satisfaction.
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Affiliation(s)
- E Ireland
- Royal Victoria Infirmary Newcastle Upon Tyne UK
| | - J Womack
- Royal Victoria Infirmary Newcastle Upon Tyne UK
| | - E Foley
- Royal Victoria Infirmary Newcastle Upon Tyne UK
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34
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Editorial: Regional anesthesiology and acute pain medicine in 2020 and beyond. Curr Opin Anaesthesiol 2020; 32:635-637. [PMID: 31460942 DOI: 10.1097/aco.0000000000000788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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35
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Bjørn S, Nielsen TD, Moriggl B, Hoermann R, Bendtsen TF. Anesthesia of the anterior femoral cutaneous nerves for total knee arthroplasty incision: randomized volunteer trial. Reg Anesth Pain Med 2019; 45:rapm-2019-100904. [PMID: 31826920 DOI: 10.1136/rapm-2019-100904] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/18/2019] [Accepted: 11/18/2019] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Siska Bjørn
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Bernhard Moriggl
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Romed Hoermann
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
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