Does Combination Therapy of Popliteal Sciatic Nerve Block and Adductor Canal Block Effectively Control Early Postoperative Pain after Total Knee Arthroplasty?

Anesthesia for the Patient Undergoing Knee Procedures

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.

A phase 3 active-controlled trial of liposomal bupivacaine via sciatic nerve block in the popliteal fossa after bunionectomy

STUDY OBJECTIVE

To investigate the efficacy, safety, pharmacodynamics, and pharmacokinetics of liposomal bupivacaine (LB) administered via ultrasound-guided sciatic nerve block in the popliteal fossa in participants undergoing bunionectomy.

DESIGN

Two-part, randomized, double-blind, active-controlled trial (NCT05157841).

SETTING

Operating room, postanesthesia care unit, and health care facility (6 sites).

PATIENTS

Adults with American Society of Anesthesiologists physical status classification ≤3 and body mass index ≥18 to <40 kg/m2 undergoing elective distal metaphyseal osteotomy.

INTERVENTIONS

Part A participants were randomized 1:1:1 to LB 266 mg, LB 133 mg, or bupivacaine hydrochloride 50 mg (BUPI). Part B participants were randomized 1:1 to LB (at the dose established by part A) or BUPI.

MEASUREMENTS

The primary endpoint was area under the curve (AUC) of numerical rating scale (NRS) pain intensity scores 0-96 h after surgery. Secondary endpoints included total postsurgical opioid consumption, opioid-free status 0-96 h after surgery, and pharmacokinetic endpoints.

MAIN RESULTS

Part A enrolled 22 participants per group. In part B, additional participants were randomized to LB 133 mg (n = 59) and BUPI (n = 60) (185 total). LB 133 mg had significant reductions versus BUPI in the AUC of NRS pain intensity score (least squares mean [LSM], 207.4 vs 371.4; P < 0.00001) and total opioid consumption 0-96 h after surgery (LSM, 17.7 [95% confidence interval (CI), 13.7, 22.8] morphine milligram equivalents [MMEs] vs 45.3 [95% CI, 35.1, 58.5] MMEs; P < 0.00001) and an increased proportion of opioid-free participants (24.4% vs 6%; odds ratio, 5.04 [95% CI, 2.01, 12.62]; P = 0.0003) in parts A + B. Adverse events were similar across groups.

CONCLUSIONS

LB 133 mg administered via sciatic nerve block in the popliteal fossa after bunionectomy demonstrated superior and long-lasting postsurgical pain control versus BUPI. The clinical relevance of these findings is supported by concurrent reductions in pain and opioid consumption over 4 days after surgery and a significantly greater percentage of participants remaining opioid-free.

A Retrospective Comparison of Clinical Efficacy between Multimodal Analgesia and Patient-Controlled Epidural Analgesia in Patients Undergoing Total Knee Arthroplasty

Background and Objectives: Adequate pain management during early rehabilitation is mandatory for improving the outcomes of patients undergoing total knee arthroplasty (TKA). Conventional pain management, mainly comprising opioids and epidural analgesia, may result in certain adverse effects such as dizziness, nausea, and motor blockade. We proposed a multimodal analgesic (MA) strategy involving the use of peripheral nerve block (NB), periarticular injection (PAI), and intravenous patient-controlled analgesia (IVPCA). This study compared the clinical efficacy and adverse effects of the proposed MA strategy and patient-controlled epidural analgesia (PCEA). Materials and Methods: We enrolled 118 patients who underwent TKA under spinal anesthesia. The patients followed either the MA protocol or received PCEA after surgery. The analgesic effect was examined using a numerical rating scale (NRS). The adverse effects experienced by the patients were recorded. Results: A lower proportion of patients in the MA group experienced motor blockade (6.45% vs. 22.98%) compared to those in the PCEA group on the first postoperative day. Furthermore, a lower proportion of patients in the MA group experienced numbness (18.52% vs. 43.33%) than those in the PCEA group on the first postoperative day. Conclusions: The MA strategy can be recommended for reducing the occurrence of motor blockade and numbness in patients following TKA. Therefore, the MA strategy ensures early rehabilitation while maintaining adequate pain relief.

Early Postoperative Pain Control and Inflammation for Total Knee Arthroplasty: A Retrospective Comparison of Continuous Adductor Canal Block versus Single-Shot Adductor Canal Block Combined with Patient-Controlled Intravenous Analgesia

Objective

The aim of this study was to compare pain control and inflammation among patients who received a continuous adductor canal block (CACB) versus single-shot adductor canal block (SACB) combined with patient-controlled intravenous analgesia (PCIA) for total knee arthroplasty (TKA) analgesia in the first two days after surgery.

Design

Matched cohort retrospective study. Setting. University hospital. Patients. One hundred fifty-six patient charts were included in this study: 78 patients with CACB in Group A and 78 patients with SACB combined with PCIA in Group B. Patients were matched according to age, body mass index, and American Society of Anesthesiologists class. Measurements. The primary outcome of the study was Visual Analogue Scale (VAS) pain scores before operation (Pre) and at postoperative 6 (POH6), 12 (POH12), 24 (POH24), 30 (POH30), 36 (POH36), and 48 hours (POH48). Secondary outcomes included patient-controlled bolus, time of first postoperative ambulation, range of knee flexion and extension, inflammation cytokines on Pre and POH48, percentage of remedial analgesics treatment, incidence of adverse events and complications, hospital stay and cost, and Numerical Rating Scale (NRS) satisfaction scores at discharge. Main Results. Mean VAS scores at rest and with motion were lower in Group B than in Group A on all postoperative hours. At POH30, compared with Group A (1.1 ± 0.6), mean VAS scores at rest in Group B (0.9 ± 0.4) were lower (P=0.048), and compared with Group A (2.6 ± 0.7), mean VAS scores with motion in Group B (2.2 ± 0.8) were lower (P=0.001). The number of patient-controlled bolus was 4.3 ± 1.6 (95% CI 3.9-4.6) in Group A and 3.1 ± 1.3 (95% CI 2.8-3.4) in Group B, respectively (P < 0.001). Patients in Group B displayed better functional recovery and inflammation results at POH48 than Group A with respect to range of knee flexion and extension (117.8 ± 10.9° vs. 125.2 ± 9.4°, P < 0.001) and inflammation cytokines, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and interleukin-6 (IL-6) ((43.8 ± 16.1) vs. (36.8 ± 13.2), P=0.003; (34.9 ± 9.4 mg/L) vs. (29.6 ± 10.6 mg/L), P=0.001; (21.3 ± 8.7 pg/ml) vs. (14.0 ± 7.0 pg/ml), P < 0.001)).

Conclusion

SACB combined with PCIA in the first two days of patients undergoing TKA has better analgesic and beneficial effects on functional recovery and inflammation.

Anesthesia for the Patient Undergoing Knee Procedures

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.

A guide to regional analgesia for Total Knee Arthroplasty

Regional analgesia has been introduced successfully into the postoperative pain management after total knee arthroplasty, reducing pain scores, opioid use and adverse effects.

Combination of regional analgesia techniques is associated with better pain management and lower side effects than single regional techniques.

Adductor canal block provides good analgesia and considerably lower detrimental effect in muscular strength than femoral nerve block, enhancing surgical recovery.

Infiltration techniques may have equivalent analgesic effect than epidural analgesia and peripheral nerve blocks, however there should be awareness of dose dependent toxicity.

Novel long-acting local anesthetics role for regional analgesia is still to be determined, and will require larger randomized trials to support its advantage over traditional local anesthetics.

Cite this article: EFORT Open Rev 2021;6:1181-1192. DOI: 10.1302/2058-5241.6.210045

Reducing opioid usage in total knee arthroplasty postoperative pain management: a literature review and future directions

Total knee arthroplasty (TKA) is a common orthopedic surgery performed with a projected 3.5 million procedures to be done by 2030. Current postoperative pain management for TKA is insufficient, as it results in extensive opioid consumption and functional decline postoperatively. This study identifies the best practices for postoperative TKA pain management through a literature review of the last three years. Studies utilizing interventional techniques (local infiltration analgesia, nerve blocks) and pharmacologic options were reviewed on PubMed, Embase, Ovid Medline and Scopus. Primary outcomes analyzed were the effect of different analgesic approaches on pain reduction, opioid use reduction and improvements in functional mobility or quadriceps strength postoperatively. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.

The impact of individualized care after artificial knee replacement surgery for patients with valgus deformity of the knee†

Objective

To evaluate the perioperative nursing of total knee arthroplasty for patients with valgus deformity of the knee.

Methods

Seventy-six patients who underwent surgical treatment were enrolled in the study from March 2014 to March 2018. The patients in the control group were treated with routine nursing. The experimental group was treated not only with routine nursing but also with health education, psychological care, family social support, and other nursing intervention. Hospital for special surgery and Pittsburgh sleep quality index were used to evaluate the effect of nursing intervention on patients after operation.

Results

All the index scores of the experimental group were lower than those of the control group (P < 0.05), indicating that the function of the diseased limb and the patient's sleep status improved significantly after the intervention.

Conclusions

Individualized nursing can improve the recovery of limb function and improve the patients’ quality of life. It is very effective for nurses to implement individualized nursing measures for patients after surgery.

The role of ultrasound-guided single-shot femoral and sciatic nerve blocks on pain management after total knee arthroplasty

BACKGROUND

Peripheral nerve blocks reduce postoperative pain and opioid consumption after total knee arthroplasty (TKA). The aim of this study was to evaluate the effects of single-shot femoral nerve and sciatic nerve blocks on postoperative pain management and opioid consumption after TKA.

METHODS

This study included 100 patients who underwent TKA between July 2015 and September 2017. Fifty patients received pre-operative, single-injection, ultrasound-guided femoral and sciatic nerve blocks (Group 1) and 50 did not (Group 2). Multimodal analgesia was otherwise identical, and oxycodone was administered either intravenously or orally if the patients complained of postoperative pain ≥6 on the visual analog scale (VAS). Postoperative VAS scores, opioid consumption, and the fear of future TKA were compared between the groups.

RESULTS

The mean VAS in the first 18 postoperative hours was significantly lower in Group 1 (P ≤ 0.002). The mean amount of oxycodone taken in the first three postoperative days was significantly lower in Group 1 (P = 0.001). Patient fear of future TKA at 14 days postoperatively was significantly lower in Group 1 (P = 0.027).

CONCLUSIONS

Pre-operative ultrasound-guided, single-shot femoral and sciatic nerve blocks afforded effective pain control in the first 18 h after TKA, and significantly reduced oxycodone consumption in the first three postoperative days.

Optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK) for posterior knee pain after total knee arthroplasty: an anatomical and clinical study

Background

This study aimed to determine the optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK), using the anatomical pattern of the articular branch of tibial nerve (ABTN). We hypothesized that injection at the level of ABTN forming a popliteal plexus would mainly spread throughout the popliteal fossa without contacting the tibial or peroneal nerves.

Methods

The anatomical study included 30 soft cadavers. Ultrasound-guided dye injection was performed in legs of 10 cadavers after identifying the position of the ABTN and surrounding structures, followed by dissection to assess its spread. Clinical study was conducted in 15 patients undergoing total knee arthroplasty (TKA) with ultrasound-guided injection in the iPACK. All patients also received continuous adductor canal block. Sensorimotor function of the tibial and common peroneal nerves was determined.

Results

In the distal portion of the popliteal fossa, the tibial nerve and popliteal vessels ran superficially and closely together. The trajectory of ABTN ran lateral to the popliteal vasculature, forming a plexus towards the posterior capsule of the knee below the medial side of the upper edge of lateral femoral condyle. In cadavers, the ABTN and surrounding area of the popliteal plexus were stained with dye after injection. In the clinical study, no patients experienced complete motor or sensory blocks.

Conclusions

We described a modified iPACK technique injection at the level of the ABTN forming the popliteal plexus, and it may constitute an optional anesthetic regimen to promote early ambulation following TKA.

Association between perioperative statin use and postoperative pain after total knee arthroplasty

BACKGROUND AND OBJECTIVES

Data is insufficient to determine whether perioperative statin use increases or decreases postoperative pain. This study aimed to investigate the association between perioperative statin use and pain outcomes after total knee arthroplasty performed under spinal anesthesia.

METHODS

This is a retrospective, observational study based on medical records from a tertiary hospital between January 2005 and October 2017. Medical records of patients who underwent elective total knee arthroplasty under spinal anesthesia as inpatients were analyzed. Pain outcomes were compared through postoperative day (POD) 3 in patients who were taking statins perioperatively versus patients who were not taking statins.

RESULTS

A total of 1088 propensity-matched participants were included in the final analysis (544 patients in the statin group and 544 patients in the non-statin group). The total morphine equivalent consumption through POD 3 was higher in the statin group than in the non-statin group (mean (SD), statin group: 525.4 (119.7) vs non-statin group: 495.3 (115.3), 95% CI of the difference: 15.9 to 44.4, p<0.001). In the linear regression analysis, the total morphine equivalent consumption through POD 3 was 30.14 mg higher in the statin group compared with the non-statin group (95% CI 15.93 to 44.35; p<0.001).

CONCLUSIONS

Perioperative statin use is associated with a significant increase in postoperative opioid consumption after total knee arthroplasty performed under spinal anesthesia; however, this increase was so marginal that its clinical importance remains controversial.