Comparative Effects of Periarticular Multimodal Drug Injection and Single-Shot Femoral Nerve Block on Pain Following Total Knee Arthroplasty and Factors Influencing Their Effectiveness

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.

Multimodal Analgesia for Accelerated Rehabilitation after Total Knee Arthroplasty: A Randomized, Double-Blind, Controlled Trial on the Effect of the Co-Application of Local Infiltration Analgesia and Femoral Nerve Block Combined with Dexmedetomidine

Background: Multimodal postoperative pain regimens are widely used following total knee arthroplasty (TKA). However, there are few studies on the rehabilitation of the co-application of local infiltration analgesia (LIA) and femoral nerve block (FNB) combined with dexmedetomidine (DEX) for patients undergoing TKA. This study aimed to investigate the effect of LIA plus FNB and co-application of perioperative DEX on TKA outcomes. Methods: 95 patients were randomized into two groups. Patients in group B (n = 48) received a single preoperative FNB and LIA. Patients in group A (n = 47) received FNB and LIA, as well as continuous intravenous injection of DEX starting from the induction of anesthesia to postoperative day 2. All patients were allowed patient-controlled analgesia postoperatively. Visual analog scale (VAS) scores, knee range of motion (ROM) degrees, narcotic consumption, length of hospital stay (LOS), complications, Hospital for Special Surgery (HSS) scores and Montreal Cognitive Assessment-Basic (MoCA-B) Scores were recorded. Results: In group A, the mean VAS scores at rest and during movement were lower, the amount of rescue analgesia was decreased, first time of ambulation was reduced, ROM was improved, MoCA-B Scores were increased, LOS was shorter, HSS scores were higher postoperatively compared with group B (all p < 0.05). Conclusion: Our study indicated multimodal analgesia involving a single FNB and LIA combined with DEX accelerates rehabilitation for patients undergoing TKA.

Comparison between local infiltration analgesia with combined femoral and sciatic nerve block for pain management after total knee arthroplasty

Background

Total knee arthroplasty (TKA) is usually associated with moderate to severe postoperative pain. Peripheral nerve block (PNB) and local infiltration analgesia (LIA) are two major methods for postoperative analgesia. Femoral nerve block (FNB) leads to residual posterior knee pain; thus, currently sciatic nerve block (SNB) and LIA are two major options for supplementing FNB. However, the efficacy and safety of LIA compared with combined femoral and sciatic nerve block still remain controversial. Here, we conducted a study to analyze the postoperative analgesic efficacy of these two methods.

Method

Two hundred six patients undergoing TKA were enrolled in a retrospective cohort study. The patients received either PNB or LIA. All patients in PNB group were conducted combined femoral and sciatic nerve block. All patients were encouraged to use patient-controlled analgesia (PCA) after surgery. The postoperative visual analog scale (VAS) at rest or with movement during the first 24 h and 48 h was recorded. We analyzed the VAS of 24 h, VAS of 48 h, opioid consumption, and adverse effects between PNB group and LIA group. Chi-square test and nonparametric test were used in this study.

Results

There were 82 patients in the PNB group and 124 patients in the LIA group. The patients’ characteristics such as age, height, weight, and ASA showed no significant difference (P > 0.05). No significant differences were found (P > 0.05) between the two groups regarding VAS score at rest or with movement. The LIA group had less opioid consumption than the PNB group but without significant difference (P > 0.05). In both groups, the most common side effect was nausea, and the side effects showed no significant differences between groups (P > 0.05).

Conclusion

Local infiltration analgesia provided a similar analgesic effect and complications compared with combined femoral and sciatic nerve block in the short term. Considering less opioid consumption with local infiltration analgesia though without significant difference and its convenience, local infiltration analgesia provided better postoperative analgesia.

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.

Opioid-Free Total Knee Arthroplasty? Local Infiltration Analgesia Plus Multimodal Blood-Loss Prevention Make it Possible

Opioids have been widely used in the USA for pain control after total knee arthroplasty (TKA). However, adverse effects, especially the possibility of addiction, have increased interest in opioid-free pain management after surgery. We therefore sought to review current pain management protocols after TKA, focusing especially on opioid-free alternatives. We reviewed the literature on pain management after TKA using Medline (PubMed), through June 30, 2018, using the keywords "TKA" and "analgesia." We found 388 articles but chose to analyze the 34 that presented high-quality (levels I and II) evidence. Local infiltration analgesia (LIA) is a good option for reducing the use of post-operative opioids; many reports have compared LIA against a nerve block or studied the synergies between two protocols of loco-regional anesthesia. Multimodal blood-loss prevention is sometimes recommended in combination with opioid-free analgesia. In most studies, however, no differences are reported or contradictory results exist. Post-operative pain management protocols vary so much that it is difficult to strongly favor a determined pathway.

Comparison of Periarticular Local Infiltration Analgesia With Femoral Nerve Block for Total Knee Arthroplasty: a Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Total knee arthroplasty (TKA) is accompanied by moderate-to-severe postoperative pain. Postoperative pain will hamper functional recovery and lower patients' satisfaction with surgery. Recently, periarticular local infiltration analgesia (LIA) has been widely used in TKA. However, there is no definite answer as to the efficacy and safety of LIA compared with femoral nerve block (FNB).

METHOD

Randomized controlled trials about relevant studies were searched from PubMed (1996 to July 2017), Embase (1980 to July 2017), and Cochrane Library (CENTRAL, July 2017). Ten studies which compared LIA with FNB methods were included in our meta-analysis.

RESULTS

Ten studies containing 950 patients met the inclusion criteria. Our pooled data indicated that LIA was as effective as the FNB in terms of visual analog scale score for pain at 24 hours (P = .52), 48 hours (P = .36), and 72 hours (P = .27), and total morphine consumption (P = .27), range of motion (P = .45), knee society score (P = .51), complications (P = .81), and length of hospital stay (P = .75).

CONCLUSIONS

Our current meta-analysis results demonstrated that there were no differences in efficacy between the FNB and LIA method.

Comparison of local infiltration analgesia and sciatic nerve block as an adjunct to femoral nerve block for pain control after total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

To perform a meta-analysis to assess the efficiency and safety between local infiltration analgesia (LIA) and sciatic nerve block (SNB) when combined with femoral nerve block (FNB) for pain control following total knee arthroplasty (TKA).

METHODS

We systemically searched the following electronic databases for potentially relevant articles: Embase (1980-2017.01), Medline (1966-2017.01), PubMed (1966-2017.01), ScienceDirect (1985-2017.01), web of science (1950-2017.01) and the Cochrane Library. Only studies published in English that were accessible online were considered. Furthermore, we only considered studies that were published from 1966 to 2017. Only studies that met the following inclusion criteria were considered: (a) patients were adult human subjects who were set to undergo TKA; (b) the intervention was either SNB combined with FNB or LIA combined with FNB; (c) the outcomes of the studies, such as visual analog scale (VAS) scores, morphine consumption, length of stay and postoperative adverse effects, including the risk of nausea, vomiting and falls, were reported; (d) studies were either RCTs or non-RCT. Meta-analysis was performed using Stata 11.0 software. Modified Jadad score (7-points scale) which was based on Cochrane Handbook for Systematic Reviews of Interventions is used for assessment of RCTs. The Methodological Index for Nonrandomized Studies (MINORS) scale was used to assess non-RCTs with scores ranging 0 to 24. The synthesis of the outcomes for all studies was calculated as the weighted average rate by using a fixed or random effect model which depends on statistical heterogeneity. Systematic review registration number is CRD42017110661.

RESULTS

Three randomized controlled trials (RCTs) and 2 nonrandomized controlled trials (Non-RCTs), including 240 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of visual analog scale (VAS) score at 12 hours (SMD = -0.337, 95% CI: -0.593 to -0.081, P =.010), VAS score at 24 hours (SMD = -0.337, 95% CI: -0.612 to -0.061, P =.017), morphine equivalent consumption at 24 hours (SMD = -0.371, 95% CI: -0.627 to -0.114, P = .005) and incidence of nausea (RD = 0.215, 95% CI: 0.078 to 0.353, P = .002) and vomiting (RD = 0.143, 95% CI: 0.026 to 0.260, P = .017).

CONCLUSION

FNB combined with SNB provided decreased VAS scores and less morphine consumption at 12 and 24 hours compared with FNB combined with LIA in total knee arthroplasty. In addition, it was associated with lower risks of nausea and vomiting. We assessed the quality of the evidence as low to very low; therefore, our confidence in the effect estimate is limited, and the true effect may be substantially different from our estimates. Further studies should focus on surgeries that are known to be associated with significant postoperative pain, particularly surgeries where improved pain control may deliver significant clinical benefits through reduced morbidity, or cost-effectiveness benefits through faster rehabilitation and discharge. The present meta-analysis has the following limitations: (1) only 5 studies were included in the meta-analysis. Although all of them are recently published studies, the sample sizes are relatively small; (2) Functional outcome is an important parameter; however, owing to the insufficiency of relevant data, we failed to perform a meta-analysis on functional outcome; (3) The doses of anesthetics and the concomitant pain management regimes varied between the studies, which may have influenced the results; (4) The duration of follow-up was relatively short, which might have led to an underestimating of complications; and (5) publication bias present in the meta-analysis may have influenced the results.

Combined femoral and sciatic nerve block versus femoral and local infiltration anesthesia for pain control after total knee arthroplasty: a meta-analysis of randomized controlled trials

Background

The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the effect of combined femoral and sciatic nerve block (SNB) versus femoral and local infiltration anesthesia (LIA) after total knee arthroplasty (TKA).

Methods

The electronic databases PubMed, Embase, Cochrane Library, and Web of Science were searched from their inception to 15 June 2016. Articles comparing combined femoral and SNB versus femoral and LIA for pain control were eligible for this meta-analysis. This systematic review and meta-analysis was performed according to the PRISMA statement criteria. The primary endpoint was the visual analogue scale (VAS) score with rest at 12, 24, and 48 h, which represents the pain control after TKA. Data regarding active knee flexion, length of hospital stay, anesthesia time, and morphine use at 24 and 48 h were also compiled. The complications of postoperative nausea and vomiting (PONV) and fall were also noted to assess the safety of morphine-sparing effects. After testing for publication bias and heterogeneity across studies, the data were aggregated for random-effects modeling when necessary.

Results

Seven clinical trials with 615 patients were included in the meta-analysis. The pooled results indicated that SNB was associated with a lower VAS score at 12 h (MD = −6.96; 95% CI −8.36 to −5.56; P < 0.001) and 48 h (MD = −2.41; 95% CI −3.90 to −0.91; P < 0.001) after TKA. There was no significant difference between the SNB group and the LIA group in terms of the VAS score at 24 h (MD = 0.67; 95% CI −0.31 to 1.66; P = 0.182). The anesthesia time in the LIA group was shorter than in the SNB group, and the difference was statistically significant (MD = 4.31, 95% CI 1.34 to 7.28, P = 0.004). There were no significant differences between the groups in terms of active knee flexion, length of hospital stay, morphine use, PONV, and the occurrence of falls.

Conclusions

SNB may provide earlier anesthesia effects than LIA when combined femoral nerve block (FNB); however, there were no differences in morphine use, active knee flexion, and PONV between the groups. The LIA group spent less time under anesthesia, suggesting that LIA may offer a practical and potentially safer alternative to SNB.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-016-0495-6) contains supplementary material, which is available to authorized users.