Pain Management, Functional Recovery, and Stress Response Expressed by NLR and PLR after the iPACK Block Combined with Adductor Canal Block for Total Knee Arthroplasty—A Prospective, Randomised, Double-Blinded Clinical Trial
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SUBMITTER: Domagalska M
PROVIDER: S-EPMC10672046 | biostudies-literature | 2023 Nov
REPOSITORIES: biostudies-literature
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Project description:BackgroundThere is no consensus on whether adductor canal block (ACB) combined with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block can further increase analgesia and reduce opioid consumption after total knee arthroplasty (TKA) compared with ACB and periarticular infiltration analgesia (PIA).PurposeThis study aimed to evaluate the effectiveness of combining ACB and PACK block on analgesia and functional recovery following TKA.MethodsA retrospective cohort study was conducted involving 386 patients who underwent primary unilateral TKA at our institution from January 2020 to October 2022. Patients were divided into 3 groups and treated with PIA, ACB, or ACB combined with IPACK block, respectively. Primary outcomes were postoperative morphine consumption and visual analogue scale (VAS) pain scores. Secondary outcomes included functional recovery, evaluated by knee range of motion, quadriceps strength, daily mobilization distance, and postoperative length of stay. Other outcomes included incidence of complications.ResultsPatients in the ACB + IPACK group had significantly less morphine consumption on postoperative day 1 and during hospitalization than patients in the PIA and ACB groups. Furthermore, the ACB + IPACK group had significantly lower VAS scores at rest and during motion at 6, 12, and 24 hours postoperatively (but not at other time points), better knee range of motion on postoperative days 1 and 2 (but not day 3), and a greater daily mobilization distance on postoperative day 1 (but not days 2 and 3). The ACB + IPACK group had significantly lower incidences of postoperative nausea and vomiting than the PIA and ACB groups.ConclusionThis retrospective cohort study suggests that a combination of ACB and IPACK block may have a greater effect than PIA or ACB alone on analgesia following TKA, while providing better functional recovery. Further study is warranted.
| S-EPMC11748369 | biostudies-literature
Project description:BackgroundRevision knee arthroplasty is assumed to be even more painful than primary knee arthroplasty and predominantly performed in chronic pain patients, which challenges postoperative pain treatment. We hypothesized that the adductor canal block, effective for pain relief after primary total knee arthroplasty, may reduce pain during knee flexion (primary endpoint: at 4 h) compared with placebo after revision total knee arthroplasty. Secondary endpoints were pain at rest, morphine consumption and morphine-related side effects.MethodsWe included patients scheduled for revision knee arthroplasty in general anesthesia into this blinded, placebo-controlled, randomized trial. Patients were allocated to an adductor canal block via a catheter with either ropivacaine or placebo; bolus of 0.75% ropivacaine/saline, followed by infusion of 0.2% ropivacaine/saline. Clinicaltrials.gov ID: NCT01191593.ResultsWe enrolled 36 patients, of which 30 were analyzed. Mean pain scores during knee flexion at 4 h (primary endpoint) were: 52 ± 22 versus 71 ± 25 mm (mean difference 19, 95% CI: 1 to 37, P = 0.04), ropivacaine and placebo group respectively. When calculated as area under the curve (1-8 h/7 h) pain scores were 55 ± 21 versus 69 ± 21 mm during knee flexion (P = 0.11) and 39 ± 18 versus 45 ± 23 mm at rest (P = 0.43), ropivacaine and placebo group respectively. Groups were similar regarding morphine consumption and morphine-related side effects (P > 0.05).ConclusionsThe only statistically significant difference found between groups was in the primary endpoint: pain during knee flexion at 4 h. However, due to a larger than anticipated dropout rate and heterogeneous study population, the study was underpowered.Trial registrationClinicaltrials.gov NCT01191593.
| S-EPMC4227669 | biostudies-literature
Project description:PurposeThe infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement.MethodsThis double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events.ResultsThe 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001).ConclusionsThe adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay.
| S-EPMC8853355 | biostudies-literature
Project description:ObjectivesTo evaluate the combination of the infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block and single adductor canal block (SACB) versus SACB for motor-sparing knee analgesia effects after total knee arthroplasty (TKA).MethodsPubMed, Ovid, Cochrane Library, and other databases were searched from the inception to January 2021. Randomized controlled trials (RCTs) comparing patients receiving iPACK plus SACB with patients receiving SACB after TKA were included. The included studies were assessed by two reviewers according to the Cochrane risk of bias criteria. Meta-analysis was performed with STATA 13.0 software, the risk ratios (RR) and mean differences (MD) were used to compare dichotomous and continuous variables. The primary outcome was ambulation pain and secondary outcomes were rest pain, opioid consumption, function ability, clinical outcomes, and complications.ResultsSeven RCTs (304 knees in iPACK + SACB group; 305 knees in SACB group) were included. The follow-up periods ranged from 2 days to 3 months. Pooled data indicated lower pain scores at ambulation (p < 0.0001) for iPACK + SACB. When comparing the pain scores of subgroups analyzed at specific periods, lower scores in subgroups within 12 h (at rest and ambulation) and after 48 h (at ambulation) were observed in the iPACK + SACB group. Analysis demonstrated greater reduction in morphine consumption (p = 0.007) in the iPACK + SACB group. The iPACK + SACB group is also superior to the SACB group regarding function ability, which included range of motion (ROM) (p = 0.001), time up to go (TUG) test (p = 0.030), and ambulation distance (p < 0.0001). No difference was found in clinical outcomes or complications.ConclusionsWith the iPACK added to SACB, pain scores, morphine consumption, functional ability were improved. Additional high-quality studies are required to further address this topic.
| S-EPMC9627073 | biostudies-literature
Project description:IntroductionAdductor canal block (ACB) is hypothesised to provide superior analgesia to femoral nerve block (FNB) for total knee arthroplasty (TKA) while preserving quadriceps strength.Methods30 patients undergoing TKA were randomised to receive either ACB or FNB. Baseline tests of quadriceps strength were performed. Ultrasound-guided blocks with 30 mL of 0.5% ropivacaine were administered before induction of general anaesthesia. Patient-controlled analgesia (morphine) was prescribed for postoperative analgesia. The primary outcome of this prospective, double-blinded, randomised controlled trial was morphine consumption (mean ± standard deviation) in the first 24 hours. Secondary outcomes were pain scores using a numeric rating scale (median and interquartile range [IQR]), quadriceps strength (% of baseline) and functional outcomes at 24 hours and 48 hours postoperatively.ResultsThere was no statistically significant difference in morphine consumption at 24 hours between the ACB and FNB groups (21 ± 11 mg vs. 20 ± 12 mg; p = 0.85). No statistically significant differences were observed between the ACB and FNB groups in pain scores at 24 hours (at rest: 0 [IQR 0-2] vs. 0 [IQR 0-2]; on movement: 5 [IQR 4-8] vs. 5 [IQR 3-8]) and quadriceps strength (24 hours: 28.8% ± 26.1% vs. 26.8% ± 19.6% of baseline; 48 hours: 31.5 ± 23.1% vs. 33.7% ± 20.1% of baseline). There were also no statistically significant differences in functional outcomes and length of stay.ConclusionWe found no statistically significant differences in analgesic effects, quadriceps strength or functional recovery postoperatively between ACB and FNB.
| S-EPMC6441689 | biostudies-literature
Project description:BackgroundMultiple comparative studies report that adductor canal blocks provide similar pain relief to femoral nerve blocks following total knee arthroplasty. However, adductor canal blockade fails to anesthetize several important femoral nerve branches that contribute to knee innervation. We sought to clarify this anatomic discrepancy by performing both blocks in sequence, using patients as their own controls. We hypothesized that patients would experience additional pain relief following a superimposed femoral nerve block, demonstrating that these techniques are not equivalent.MethodsSixteen patients received continuous adductor canal block before undergoing knee arthroplasty under general anesthesia. In the recovery room, patients reported their pain score on a numeric scale of 0-10. Once a patient reached a score of five or greater, he/she was randomized to receive an additional femoral nerve block using 2% chloroprocaine or saline sham, and pain scores recorded every 5 min for 30 min. Patients received opioid rescue as needed. Anesthesiologists performing and assessing block efficacy were blinded to group allocation.ResultsPatients randomized to chloroprocaine versus saline reported significantly improved median pain scores 30 min after the femoral block (2.0 vs. 5.5, P = 0.0001). Patients receiving chloroprocaine also required significantly fewer morphine equivalents during the 30 min post-femoral block (1.0 vs. 4.5 mg, P = 0.03).ConclusionsAdductor canal block is a useful technique for postoperative pain following total knee arthroplasty, but it does not provide equivalent analgesic efficacy to femoral nerve block. Future studies comparing efficacy between various block sites along the thigh are warranted.
| S-EPMC7533174 | biostudies-literature
Project description:IntroductionFemoral nerve block (FNB) is a well-established analgesic technique for TKA. However, it associates quadriceps weakness. Therefore, femoral triangle block (FTB) and adductor canal block (ACB) were proposed as effective alternative motor-spearing techniques. The primary objective was to compare quadriceps muscle strength preservation between FNB, FTB and ACB in TKA. The secondary objective was to analyze pain control and functional outcomes.MethodsThis is a prospective, double-blinded RCT. From April 2018 to April 2019, patients who undergo a primary TKA were randomized into three experimental groups: FNB-G1/FTB-G2/ACB-G3. Quadriceps strength preservation was measured as the difference in maximum voluntary isometric contraction (MVIC) preoperatively and postoperatively.ResultsSeventy-eight patients (G1, n = 22; G2, n = 26; G3, n = 30) met our inclusion/exclusion criteria. Patients with FNB retained significantly lower baseline MVIC at 6 h postoperatively (p = 0.001), but there were no differences at 24 and 48 h. There were no differences between the groups in functional outcomes at any time point. Patients in the FNB-G1 presented significant lower pain scores at 6 h (p = 0.01), 24 h (p = 0.005) and 48 h (p = 0.01). The highest cumulative opioid requirement was reported in ACB-G3.ConclusionFor patients undergoing TKA, FTB and ACB preserve quadriceps strength better than FNB at 6 h postoperatively, but there are no differences at 24 and 48 h. Moreover, this early inferiority does not translate to worse functional outcomes at any time point. FNB is associated with better pain control at 6, 24 and 48 h after surgery, while ACB presents the highest cumulative opioid requirement.Clinical trial registrationThis study was registered in clinicaltrials.gov (NCT03518450; https://clinicaltrials.gov/ct2/show/NCT03518450 ; submitted March 17, 2018).
| S-EPMC10542711 | biostudies-literature
Project description:BackgroundThe shivering effect after spinal anesthesia in total knee arthroplasty (TKA) is challenging for anesthesiologists. This study aimed to compare two administration routes of dexmedetomidine as a post-neuraxial shivering prevention measure and an adjunctive analgesic and sedative agent.MethodsFifty-six patients were randomly allocated into two equal groups. The intravenous dexmedetomidine (IV dex) group received an IV infusion of 0.5 µg/kg dexmedetomidine diluted in 20 ml saline and an adductor canal block (ACB) consisting of 20 ml of 0.25% levobupivacaine and 1 ml saline. The adductor canal block dexmedetomidine (ACB dex) group received a 20 ml IV infusion of saline and an ACB consisting of 20 ml 0.25% levobupivacaine and 1 ml of 0.5 µg/kg dexmedetomidine.ResultsThe incidence of shivering 1 h post spinal anesthesia was equal in both groups (50%); however, the shivering grade was significantly lower in the IV dex group 1 h postoperatively. The onset of sensory block was significantly later in the IV dex group (22.14 ± 2.52 min) than in the ACB dex group (12 ± 3.31 min). Postoperative analgesic duration (h) was significantly longer in the ACB dex group (12.28 ± 4.47) compared to the IV dex group (9.28 ± 1.90). The sedation scores were also significantly higher in the IV dex group in the preoperative, intraoperative, and immediate postoperative periods.ConclusionsWhile perineural ACB dexmedetomidine had similar intraoperative anti-shivering with less sedative effects as IV dexmedetomidine, it was associated with both less shivering control and superior analgesia post-TKA under spinal anesthesia.
| S-EPMC10391069 | biostudies-literature
Project description:BackgroundPostoperative analgesia after knee arthroplasty forms a basis for an optimal range of motion after surgery. Femoral nerve blocks are established as a sensory nerve blockade but at the expense of quadriceps weakness delaying postoperative mobilization. The adductor canal block (ACB) similarly provides sensory blockade but preserves quadriceps function. If ACB is performed intraoperatively, it would reduce the time and cost needed for ACBs. This study aimed at investigating possible landmarks making it feasible to perform ACB intraoperatively.Material and methodsTwenty-seven knees were used. The superior pole of the patella, medial epicondyle, and adductor tubercle was proposed as landmarks to perform the ACB through a medial parapatellar approach. A needle was directed toward the adductor tubercle until a tactile feedback was felt. Ten to 15 mL India ink were injected using this technique. The adductor canal was dissected to visualize the ink spread and determine whether the saphenous nerve and the nerve to vastus medialis were exposed to the ink.ResultsThe anatomic landmarks were easily identified in all knees. The ACB resulted in the saphenous nerve and nerve to vastus medialis being bathed in ink consistently. A volumetric relationship was noted with the injectate. No injury to the neurovascular structures was observed.ConclusionsAn accurate and safe technique with reliable anatomic landmarks was presented to perform an ACB. In addition, an increase in injected ink volume correlated to an increase in the spread of ink; thus, we postulate that 10 mL of local anesthetic may be sufficient for an adequate regional block.
| S-EPMC8280478 | biostudies-literature
Project description:Multimodal analgesia featuring peripheral nerve blocks decreases postoperative pain for patients undergoing primary total knee arthroplasty (TKA). Many anesthesiologists and surgeons advocate for the use of adductor canal blocks (ACBs) for analgesia, which result in less weakness compared to femoral nerve blocks. Few data exist to guide analgesic management in total knee revision (TKR), considered to be more painful than primary TKA. We hypothesized that TKR patients with a continuous ACB would use more opioids than primary TKA patients who received the same analgesic regimen.A retrospective study of 58 TKA and TKR patients who received ACBs in a multimodal protocol was conducted from 1/2014 to 3/2016. Exclusion criteria included patients who took ≥ 20 mg of morphine daily preoperatively. The primary outcome was 48-hour opioid consumption. Secondary outcomes included pain ratings, catheter boluses, and catheter infusion rate changes over 48 hours.For the primary outcome of 48-hour opioid consumption, there was no significant difference between groups. Postoperative pain ratings were not significantly different during the overall 48-hour time period. There were also no significant differences in catheter boluses and infusion rate changes. Least squares regression analysis revealed a positive correlation between number of previous knee surgeries and postoperative pain level.Patients who underwent TKR with continuous ACB experienced a similar postoperative analgesic course as primary TKA patients. Within the TKR cohort, the number of previous revisions was positively associated with pain level. Larger prospective studies with TKR are needed to confirm these findings.
| S-EPMC5559700 | biostudies-other