Comparison of Femoral Nerve Catheter,Adductor Canal Catheter,and Periarticular Liposomal Bupivacaine Infiltration for Postoperative Analgesia After Primary Total Knee Arthroplasty

BackgroundPeripheral nerve catheters are used to provide analgesia after total knee arthroplasty (TKA) and have been shown to decrease pain and opioid use, to facilitate participation with physical therapy (PT), and to hasten discharge. More recently, pericapsular infiltration using liposomal bupivacaine (LB) has been employed as an alternative analgesic approach.MethodsThis retrospective study compared outcomes for three analgesic approaches: femoral nerve catheter (FNC), adductor canal catheter (ACC), and intraoperative LB infiltration. The primary outcome was numeric rating scale (NRS) pain scores at 24 hours. Secondary outcomes included pain scores at 12, 36, and 48 hours, time-to-first opioid, cumulative opioid use, distance walked, and time-to-discharge.ResultsPain scores at 24 hours were significantly lower in both the ACC and FNC cohorts when compared to the LB cohort (3.1 versus 4.6 [P = .017] and 2.4 versus 4.6 [P < .0001]). The ACC and FNC groups did not differ significantly at that timepoint (P = .27). Similar comparisons were found at 12 and 36 hours, while at 48 hours the FNC group was superior. Time to first opioid and opioid consumption favored the ACC and FNC groups. Walking distance favored the ACC group. Both the ACC and LB groups had a faster time-to-discharge than the FNC group.ConclusionBoth ACCs and FNCs provided superior analgesia at 24 hours compared to LB, while being equivalent to each other. Pain scores at 12 hours and 36 hours as well as opioid consumption through 48 hours mirrored this finding. Although various differences were found between groups in terms of time-to-first analgesic, walking distance and time-to-discharge, the ACC approach appeared to optimally balance analgesia, ambulation, and time-to-discharge.     

Periarticular Knee Injection With Liposomal Bupivacaine and Continuous Femoral Nerve Block for Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial

Background

Local periarticular infiltration (PAI) analgesia has emerged as an important component of multimodal approaches to treat total knee arthroplasty postoperative pain. Liposomal bupivacaine may provide prolonged analgesic duration when injected into the surrounding tissues. The purpose of this study was to compare the analgesic efficacy and serum bupivacaine levels of a continuous femoral nerve block (CFNB) with bupivacaine to PAI with liposomal bupivacaine.

Liposomal Bupivacaine Versus Standard Periarticular Injection in Total Knee Arthroplasty With Regional Anesthesia: A Prospective Randomized Controlled Trial

Background

Liposomal bupivacaine (Exparel) is a long-acting local anesthetic preparation with demonstrated efficacy over placebo in reducing postoperative pain and opioid requirement. Limited comparative efficacy and cost-effectiveness data exist for its use in total knee arthroplasty (TKA) when used in a multimodal, opioid-sparing analgesic and anesthetic approach. We hypothesized that liposomal bupivacaine offers no clinical advantage over our standard of care but carries significant economic impact.

Adductor Canal Block Combined With iPACK (Interspace Between the Popliteal Artery and the Capsule of the Posterior Knee) Block vs Periarticular Injection for Analgesia After Total Knee Arthroplasty: A Randomized Noninferiority Trial

BackgroundThe combination of adductor canal block (ACB) and infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block may provide sufficient motor-sparing anterior and posterior knee analgesia after total knee arthroplasty. This study aimed to determine if ACB with iPACK block was noninferior to ACB with periarticular injection (PAI) when combined with postoperative multimodal analgesia regimen.MethodsSeventy-six patients were randomized to receive either ACB + iPACK block and continuous ACB (CACB) (ACB + iPACK group) or PAI and CACB (ACB + PAI group). Noninferiority was concluded for the primary outcome if the adjusted mean between-group difference in pain on movement at 12 postoperative hours was within 1.3 points on a visual analog pain scale. Pain scores, morphine consumption, functional performance, and adverse events were the secondary outcome measures assessed for superiority.ResultsAdjusted mean differences, (ACB + iPACK) ? (ACB + PAI), in anterior and posterior knee pain scores on movement at 12 postoperative hours were ?0.66 (?1.86, 0.54) and ?0.19 (?1.36, 0.99), respectively. The upper limit of 95% confident interval was lower than the prespecified noninferiority limit. The mean visual analog scale pain scores were low and no clinically significant differences between groups. However, morphine requirement at 48 postoperative hours was significantly higher (P < .05) and showed greater reduced quadriceps strength at 0 and 45 degrees on postoperative day 0 (P = .006 and .04, respectively) in the ACB + iPACK group.ConclusionsACB with iPACK block provides a noninferior analgesia compared with PAI when combined with CACB. However, patients who received ACB + iPACK block may require higher amounts of opioids and have worse immediate functional performance.Level of evidenceTherapeutic level I.     

Prospective Randomized Trial Comparing Femoral Nerve Block With Intraoperative Local Anesthetic Injection of Liposomal Bupivacaine in Total Knee Arthroplasty

Background

Postoperative pain after total knee arthroplasty (TKA) may impact long-term results and incidence of complications. Femoral nerve block (FNB) provides excellent pain relief after TKA, although associated risks include weakness, delayed participation in therapy, and nerve injury. Liposomal bupivacaine (LB) is a potentially longer acting local anesthetic that may reduce postoperative pain.

Intraoperative Surgeon Administered Adductor Canal Blockade Is Not Inferior to Anesthesiologist Administered Adductor Canal Blockade: A Prospective Randomized Trial

BackgroundControlling postoperative pain and reducing opioid requirements after total knee arthroplasty remain a challenge, particularly in an era stressing rapid recovery protocols and early discharge. A single-shot adductor canal blockade (ACB) has been shown to be effective in decreasing postoperative pain. The purpose of the present study is to compare the efficacy of an anesthesiologist administered ACB and a surgeon administered intraoperative ACB.MethodsPatients undergoing primary total knee arthroplasty were prospectively randomized to receive either an anesthesiologist administered (group 1) or surgeon administered (group 2) ACB using 15 mL of ropivacaine 0.5%. Primary outcomes were pain visual analog scale, range of motion, and opioid consumption.ResultsThirty-four patients were randomized to group 1 and 29 to group 2. Opioid equivalents consumed were equal on postoperative day (POD) 0, 1, and 2. Patients in group 1 had statistically less pain on POD 0, but this did not reach clinical significance and there was no difference in pain on POD 1 or 2. Patients in group 1 had significantly increased active flexion POD 1, but there was no difference in active flexion on POD 0 or 6 weeks postop. There was no difference in patient satisfaction with pain control or short-term functional outcomes.ConclusionSurgeon administered ACB is not inferior to anesthesiologist administered ACB with respect to pain, opioid consumption, range of motion, patient satisfaction, or short-term functional outcomes. Surgeon administered ACB is an effective alternative to anesthesiologist administered ACB.     

Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia and Function Recovery Following Total Knee Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Study

BackgroundThis study aimed to explore the analgesic effect among adductor canal block (ACB) combined with infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block, ACB, and IPACK block following total knee arthroplasty (TKA).MethodsOne hundred twenty patients were randomly allocated into 3 groups including group A (ACB + IPACK block), group B (ACB), and group C (IPACK block). The primary outcome was postoperative pain score. The secondary outcome was opioid consumption. Other outcomes included functional evaluation and postoperative complications.ResultsGroup A showed the lowest pain scores within 8 hours at rest and with knee maximum flexion (P < .001). From 12 to 24 hours, group C showed the highest pain scores, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups 24 hours postoperatively. Group C showed the most opioid consumption within the first 24 hours and during the hospitalization, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups including function evaluation and postoperative complications.ConclusionACB + IPACK block can improve early analgesia when compared with ACB. However, the small statistical benefit to the addition of IPACK block to ACB may be unlikely to be clinically significant. Further studies may focus on patient selection and how to prolong the effect of IPACK block.     

Liposomal Bupivacaine Versus Traditional Periarticular Injection for Pain Control After Total Knee Arthroplasty

The purpose of this study was to compare a novel liposomal bupivacaine to traditional peri-articular injection (PAI) in a multi-modal pain protocol for total knee arthroplasty (TKA). A retrospective cohort study compared 85 consecutive patients undergoing TKA with a traditional PAI of ropivacaine, epinephrine and morphine to 65 patients with a liposomal bupivacaine PAI. After the initial 24 h, inpatient self-reported pain scores were higher in the liposomal bupivacaine group compared to the traditional PAI group (P = 0.04) and a smaller percentage (16.9%) of patients in the liposomal bupivacaine group rated their pain as “mild” compared to the traditional group (47.6%). Liposomal bupivacaine PAI provided inferior pain control compared to the less expensive traditional PAI in a multi-modal pain control program in patients undergoing TKA.     

The Efficacy of Liposomal Bupivacaine Using Periarticular Injection in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Background

Total knee arthroplasty (TKA) is gradually emerging as the treatment of choice for end-stage osteoarthritis. In the past, the method of liposomal bupivacaine by periarticular injection (PAI) showed better effects on pain reduction and opioid consumption after surgery. However, some recent studies have reported that liposomal bupivacaine by PAI did not improve pain control and functional recovery in patients undergoing TKA. Therefore, this meta-analysis was conducted to determine whether liposomal bupivacaine provides better pain relief and functional recovery after TKA.

Efficacy of Adductor Canal Block Combined With Additional Analgesic Methods for Postoperative Analgesia in Total Knee Arthroplasty: A Prospective,Double-Blind,Randomized Controlled Study

BackgroundThe aim of this study is to evaluate the efficacy of adductor canal block (ACB) combined with additional analgesic methods in total knee arthroplasty (TKA) and investigate whether blocking the sensory nerves that are distributed in the posterior and lateral aspect of knee could improve postoperative pain control.MethodsTwo hundred scheduled patients for TKA were randomly allocated into 4 groups: Group A received ACB combined with iPACK (interspace between the popliteal artery and capsule of the knee) block and lateral femoral cutaneous nerve block (LFCNB); Group B received ACB combined with iPACK block; Group C received ACB combined with LFCNB; and Group D received ACB only. Postoperative pain score was the main primary outcome. Secondary outcomes included the morphine consumption and analgesic duration. Other outcomes included knee range of motion, quadriceps strength, ambulation, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index physical function, timed up and go (TUG) test, and complications.ResultsGroups A, B, and C had lower postoperative pain scores within 12 hours at rest and 8 hours with activity than Group D (P < .05). In addition, Group A had lower morphine consumption than both Group C (P < .05) and Group D (P < .01). Group A had the longest analgesic duration (19.21 ± 3.22 hours) among all groups. There were no significant differences among the groups in terms of mobility and complication after surgery.ConclusionCombining ACB with both iPACK and LFCNB is an effective method for decreasing early postoperative pain in TKA without increasing the complications or affecting the early rehabilitation.     

单次股神经阻滞联合关节腔周围注射在膝关节置换术后镇痛的研究

目的观察单次股神经阻滞联合关节腔周围注射在全膝关节置换术后的镇痛效果。方法选取2017年1月至2018年5月于我院拟行全膝关节置换术的患者共50例,其中男22例,女28例;年龄60~80岁,平均为(69.90±9.46)岁。50例患者随机分为实验组(单次股神经阻滞联合关节腔周围注射组)和对照组(单次股神经阻滞组),每组各25例。比较两组患者术后静息和运动状态视觉模拟评分(visual analogue scale,VAS)、术后膝关节活动度(range of motion,ROM)及不良反应发生情况。结果实验组在术后6 h、12 h、24 h、48 h静息及运动状态VAS评分均比对照组同期VAS评分低,差异有统计学意义(P<0.05);实验组术后1 d、2 d膝关节活动度比对照组同期膝关节活动度高(P<0.05),但术后3 d、7 d两组患者术后膝关节活动度比较差异无统计学意义(P>0.05)。两组患者术后并发症发生率比较差异无统计学意义(P>0.05)。结论对于膝关节置换患者,单次股神经阻滞联合关节腔周围注射比单纯单次股神经阻滞更能缓解患者术后早期的疼痛,有助于患者术后早期行功能锻炼,且不增加术后并发症发生,但对于患者远期功能恢复并无明显优势。     

Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty

In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.     

Adductor Canal Block or Local Infiltrate Analgesia for Pain Control After Total Knee Arthroplasty? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Total knee arthroplasty is a treatment option for debilitating arthritis. In the postoperative period, patients experience moderate to severe pain affecting the rehabilitation, hospital stay, and patient satisfaction. This study aims at utilizing current best evidence to determine whether adductor canal block (ACB) or periarticular injection (PAI) is a better modality for managing short-term postoperative pain and opioid consumption.

Liposomal Bupivacaine in Adductor Canal Blocks Before Total Knee Arthroplasty Leads to Improved Postoperative Outcomes: A Randomized Controlled Trial

BackgroundThis study compares the use of liposomal bupivacaine (Exparel) versus ropivacaine in adductor canal blocks (ACB) before total knee arthroplasties (TKAs).MethodsFrom the months of April 2020 to September 2021, 147 patients undergoing unilateral primary TKA were asked to participate in this prospective, double-blinded randomized controlled trial. Each patient received an iPACK block utilizing ropivacaine and was additionally randomized to receive an ACB with Exparel or Ropivacaine. For each patient, demographic information, inpatient hospital information, postoperative opioid use, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire scores were collected.ResultsOverall, 100 patients were included (50 in each cohort). The Exparel group had a lower hospital length of stay compared to the Control group (36.3 vs 49.7 hours, P < .01). Patients in the Exparel group reported an increased amount of Numerical Rating Scale pain score improvement at all postoperative timepoints. These patients also used a lower amount of inpatient opioids (40.9 vs 47.3 MME/d, P = .04) but a similar amount of outpatient opioids (33.4 vs 32.1 MME/d, P = .351). Finally, the Exparel group had increased improvements in all WOMAC subscores and total scores at most timepoints compared to the Control group (P < .05).ConclusionExparel peripheral regional nerve blocks lead to decreases in pain levels, shorter hospital lengths of stay, inpatient opioid usage, and improved WOMAC scores. Exparel can be safely used in ACB blocks before TKA to help in controlling postoperative pain and decrease length of stay.     

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

BackgroundThe purpose of this study is to determine the benefit of the analgesic liposomal bupivacaine compared to ropivacaine, by assessing pain and joint stiffness, and total oral opioid consumption by milligram morphine equivalent (MME) after total knee arthroplasty.MethodsPatients were randomized to receive either the study drug (liposomal bupivacaine admixed with bupivacaine) or the control drug (ropivacaine) in an adductor canal block. Only the anesthesiologist performing the block was aware of which arm of the study the patient was randomized to. MME, pain, Knee injury and Osteoarthritis Outcome Score Joint Replacement, and overall benefit of analgesia scores were recorded 24, 48, and 72 hours post-surgery either face-to-face or via telephone depending on patient discharge status.ResultsOne hundred patients were enrolled into the study and analyzed: 54 in the control group and 46 in the experimental group. Primary outcomes measured were pain as a numerical rating scale, MME, and length of stay in hours. Secondary outcomes were joint pain and stiffness recorded as Knee injury and Osteoarthritis Outcome Score Joint Replacement outcome and overall benefit of analgesia score. No statistically significant between-group differences were observed for any measured outcome.ConclusionWe did not find any supporting evidence that liposomal bupivacaine yields increased pain relief following total knee arthroplasty compared to the control drug, ropivacaine.     

Systemic Safety of Liposomal Bupivacaine in Simultaneous Bilateral Total Knee Arthroplasty

Background

Intraoperative periarticular injections (PAIs) with local anesthetic are an important component of multimodal pain control in total joint arthroplasty. Liposomal bupivacaine is an extended-release formulation of bupivacaine designed to provide extended pain relief, approved for use in a single surgical site. The systemic safety profile for use in simultaneous bilateral TKA (bTKA) with a full dose in each knee has not been evaluated. The purpose of this study was to determine the safety and pharmacokinetics of bilateral full-dose PAI liposomal bupivacaine in the blood collected in patients undergoing simultaneous bTKA.

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).

Three-in-One Nerve Block With Different Concentrations of Bupivacaine in Total Knee Arthroplasty : Randomized,Placebo-Controlled,Double-Blind Trial

Pain after total knee arthroplasty may be severe and lead to adverse outcomes. Using 2 concentrations of bupivacaine, we investigated 3-in-1 nerve block's effect on pain control, narcotic use, sedation, and patient satisfaction. One hundred five patients undergoing unilateral total knee arthroplasty were randomized into 3 groups: low-dose or high-dose bupivacaine or placebo. Ninety-nine patients completed the study. Three-in-1 nerve block reduced patient-controlled opioid analgesia usage and improved pain relief in the early postoperative period but had little effect beyond postoperative day 1. There were no significant differences among groups with respect to nausea or sedation. Patients in each group exhibited high overall satisfaction. Low-dose bupivacaine was superior to high-dose bupivacaine for pain relief, narcotic consumption, and patient satisfaction in the early postoperative period.     

A Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique

Background

Adductor canal blocks (ACBs) provide effective analgesia following total knee arthroplasty. We hypothesized that ACB single injection plus intravenous (IV) dexamethasone (Dex) shows non-inferiority to catheter, while ACB single injection does not.