Comparing the effects of femoral nerve block versus femoral and sciatic nerve block on pain and opiate consumption after total knee arthroplasty

The goal of this study was to compare femoral and femoral plus sciatic nerve blocks in the postoperative pain management of patients undergoing total knee arthroplasty (TKA). A total of 97 patients participated in a convenience sample, comparative study. Patients who received femoral nerve block only (n = 30) reported statistically higher pain scores (P <.05) and showed 61% higher opiate consumption than those who received femoral and sciatic nerve blocks (n = 67) in the first 24 hours after surgery. The results suggest that the combined femoral and sciatic nerve block provides superior pain management in the early postoperative period after TKA.     

The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty

Either epidural analgesia or femoral nerve blockade improves analgesia and rehabilitation after total knee arthroplasty. No study has evaluated the combination of femoral nerve blockade and epidural analgesia. In this prospective, randomized, blinded study we investigated combining femoral nerve blockade with epidural analgesia. Forty-one patients received a single-injection femoral nerve block with 0.375% bupivacaine and 5 microg/mL epinephrine; 39 patients served as controls. All patients received combined spinal-epidural anesthesia and patient-controlled epidural analgesia with 0.06% bupivacaine and 10 microg/mL hydromorphone. Average duration of epidural analgesia was 2 days. All patients received the same standardized physical therapy intervention. Median visual analog scale (VAS) scores with physical therapy were significantly lower for 2 days among patients who received a femoral nerve block versus controls: 3 versus 4 (day 1), 2.5 versus 4 (day 2); P < 0.05. Median VAS pain scores at rest were 0 in both groups on days 1 and 2. Flexion range of motion was improved on postoperative day 2 (70 degrees versus 63 degrees ; P < 0.05). No peripheral neuropathies occurred. We conclude that the addition of femoral nerve blockade to epidural analgesia significantly improved analgesia for the first 2 days after total knee arthroplasty.     

Single-Injection Femoral and Sciatic Nerve Blocks for Pain Control After Total Knee Arthroplasty

This study was designed to evaluate the addition of a single-injection sciatic nerve block to a femoral nerve block for analgesia after total knee arthroplasty. Fifty-seven patients undergoing primary total knee arthroplasty were randomized to receive femoral nerve blockade or a sham block. A subsequent 31 patients received both femoral and sciatic nerve blocks (FSNBs) before general anesthesia. Intravenous morphine use and visual analog pain scale scores were recorded at regular intervals. Femoral and sciatic nerve blocks were placed in less than five minutes, on average. Lower visual analog pain scale scores were noted in both femoral nerve blockade and FSNB groups compared to shams through 48 hours. Morphine use was significantly lower in the FSNB group. Femoral and sciatic nerve block can be placed quickly and consistently in the operating room with improved postoperative pain relief and reduced narcotic consumption.     

Bedside femoral block performed on the first postoperative day after unilateral total knee arthroplasty: a randomized study of 49 patients

This randomized study compared the effectiveness of a femoral nerve block with other methods of pain control on the first postoperative day after total knee arthroplasty. The femoral block consisted of a single injection administered at patients' bedside during the surgeon's hospital rounds. Compared with control group patients, femoral block patients reported less pain on a visual analog scale and required one half the amount of oxycodone (P = .021). Additional femoral block or continued epidural analgesia was required more frequently by control group patients. Thus, pain management with femoral blocks resulted in less work for nursing staff (P = .004). Performing a femoral nerve block as needed during the surgeon's hospital rounds is quick and requires minimal additional time without any special equipment. Bedside femoral block is a useful adjunct to other pain control methods following primary total knee arthroplasty.     

Minimally invasive total knee arthroplasty

Currently, minimally invasive total knee arthroplasty is defined as an incision length of < 14 cm. However, the length of the incision is not the primary influence on potential postoperative benefits to the patient and should not be the only characteristic of the minimally invasive approach for knee arthroplasty. Some other factors that should also be included in this definition are: 1. The amount of soft-tissue dissection (including muscle, ligament, and capsular damage). 2. Patellar retraction or eversion. 3. Tibiofemoral dislocation. Minimally invasive surgery should not be considered to be a cosmetic procedure but rather one that addresses patients' concerns with regard to postoperative pain and slow rehabilitation. Standard total knee arthroplasties provide pain relief, but returning to activities of daily living remains a challenge for some individuals, who may take several weeks to recover. Several studies have demonstrated long-term success (at more than ten years) of standard total knee arthroplasties. However, many patients remain unsatisfied with the results of the surgery. In a study of functional limitations of patients with a Knee Society score of > or = 90 points after total knee arthroplasty, only 35% of patients stated that they had no limitations. This finding was highlighted in a study by Dickstein et al., in which one-third of the elderly patients who underwent knee replacement were unhappy with the outcome at six and twelve months postoperatively. Although many surgeons utilize objective functional scoring systems to evaluate outcome, it is likely that the criteria for a successful result of total knee arthroplasty differ between the patient and the surgeon. This was evident in a report by Bullens et al., who concluded that surgeons are more satisfied with the results of total knee arthroplasty than are their patients. Trousdale et al. showed that, in addition to concerns about long-term functional outcome, patients' major concerns were postoperative pain and the time required for recovery. Patients undergoing total knee arthroplasty have specific functional goals, such as climbing stairs, squatting, kneeling, and returning to some level of low-impact sports after surgery. Our clinical investigations demonstrated that the minimally invasive surgical approach reduces hospital stays, decreases postoperative pain, and decreases rehabilitation needs as well as enables patients to return to normal function more quickly. It is important for surgeons to take an evolutionary, rather than a revolutionary, approach when performing minimally invasive total knee arthroplasty. The surgeon should downsize incisions progressively to prevent severe damage to the quadriceps mechanism. Extensive open exposure, prolonged patellar eversion, and dislocation of the tibiofemoral joint should evolve into a vastus medialis muscle split with patellar subluxation, retraction but not dislocation of the patella, and avoidance of gross dislocation of the tibiofemoral joint. Developing the techniques of minimally invasive total knee arthroplasty may be difficult and time-consuming, but patient benefits and satisfaction should outweigh the extra effort required. These changes require well-designed clinical studies to further document their effectiveness.     

The analgesic efficacy of sciatic nerve block in addition to femoral nerve block in patients undergoing total knee arthroplasty: a systematic review and meta‐analysis

The aim of this meta‐analysis was to assess the postoperative analgesic efficacy of sciatic nerve block when combined with femoral nerve block after total knee arthroplasty. Outcomes included resting pain scores (analogue scale, 0–100), intravenous morphine consumption at 12 h, 24 h and 48 h postoperatively, and functional outcomes comprising knee flexion, distance walked, and length of stay. Twelve randomised controlled trials were included, with a total of 600 patients. When combined with femoral nerve block, sciatic nerve block significantly reduced resting pain scores at 12 h postoperatively with a mean difference of 10 (95% CI: ?15 to ?5; p < 0.00001). Resting pain scores at 24 h, and intravenous morphine consumption at 12 h, 24 h and 48 h postoperatively were also significantly reduced, but without clinical significance beyond 12 h and without affecting functional outcomes. In conclusion, sciatic nerve block confers additional postoperative analgesia within the first 12 postoperative hours compared with femoral nerve block alone for patients undergoing total knee arthroplasty.     

超声联合神经刺激器引导连续股神经阻滞用于全膝关节置换术后镇痛的对比研究

目的探讨超声联合神经刺激器引导连续股神经阻滞的临床效果。方法 2010年9月对全膝关节置换术后镇痛22例采用超声联合神经刺激器引导连续股神经阻滞（C＋S组）,23例采用单纯神经刺激器引导连续股神经阻滞（S组）,比较2组镇痛效果及穿刺并发症。结果 C＋S组操作时间（6.3±3.0）min,明显短于S组（11.5±7.0）min（t=-3.212,P=0.002）。经股神经管推注0.25%罗哌卡因20 ml后15 min麻醉效果差异无显著性（Z=-0.462,P=0.644）。术后静态VAS评分（RVAS）、主动功能训练VAS评分（IVAS）和持续被动功能训练VAS评分（PVAS）差异无显著性（P〉0.05）。术后S组5例穿刺部位皮下淤血,C＋S组无皮下淤血病例（P=0.049）。术后C＋S组需要单次推注利多卡因4例,S组为5例,差异无显著性（χ2=0.000,P=1.000）。术后72 h哌替啶用量C＋S组与S组差异无显著性（Z=-0.069,P=0.945）。结论超声联合神经刺激器引导连续股神经阻滞操作时间明显缩短,同时可以减少穿刺导致的术后皮下淤血。     

Continuous femoral nerve block in total knee arthroplasty: immediate and two-year outcomes

We conducted a prospective study to investigate the immediate and 2-year outcomes of total knee arthroplasty patients who received continuous femoral nerve block (FNB) for analgesia. Sixty patients undergoing unilateral total knee arthroplasty were randomized into 3 groups and received high-dose continuous FNB, low-dose continuous FNB, or no FNB. In the immediate postoperative period, we studied their pain scores, cumulative morphine use, any FNB-related complications, time of first ambulation, and patient satisfaction. At 2 years, we assessed their functional outcomes with Oxford knee questionnaire and Knee Society clinical rating system. Immediately after surgery, there was less pain, higher satisfaction, and lower morphine use among patients on continuous FNB regardless of ropivacaine dosage used. At 2 years, there were no significant differences in functional outcomes.     

Effects of a preoperative femoral nerve block on pain management and rehabilitation after total knee arthroplasty

The objective of this prospective, randomized, double-blind study was to determine if preoperative administration of a femoral nerve block reduces the amount of morphine needed for postoperative analgesia after total knee arthroplasty (TKA). Forty-two patients undergoing TKA were randomly assigned to receive either a femoral nerve block (0.50% bupivacaine hydrochloride with epinephrine 1:200,000) or matching placebo. Results showed postoperative morphine use was significantly lower in patients who received the nerve block (25.5 vs 37.5 mg, P = .016); however, the 2 groups had similar pain scores and rehabilitative outcomes. In general, a preoperative femoral nerve block is a safe and effective adjunct for decreasing morphine use for post-TKA analgesia.     

Femoral nerve block using ropivacaine 0.025%, 0.05% and 0.1%: effects on the rehabilitation programme following total knee arthroplasty: a pilot study

Femoral nerve blockade is recommended for analgesia following total knee arthroplasty. Following implementation of this type of postoperative analgesia in our hospital we found that active mobilization the day after surgery, may be difficult due to insufficient quadriceps muscle strength. We therefore designed a pilot study comparing the effect of ropivacaine 0.1%, 0.05% or 0.025% on the patient's postoperative rehabilitation and analgesia. Three groups of 12 patients received bolus doses of ropivacaine via their femoral nerve catheters for postoperative analgesia. The ability to actively mobilize, quadriceps muscle strength, pain VAS-scores and patient's satisfaction were measured during in the first three postoperative days. There were no significant differences in the patient's ability to actively mobilize and the pain VAS-scores. The overall satisfaction of the patients with the pain treatment was significantly better (p =   0.049) in the 0.1% compared with the 0.025% group. This pilot-study demonstrated no advantage associated with the use of a ropivacaine concentration less than 0.1%.     

Effects of a preoperative femoral nerve block on pain management and rehabilitation after total knee arthroplasty.

The objective of this prospective, randomized, double-blind study was to determine if preoperative administration of a femoral nerve block reduces the amount of morphine needed for postoperative analgesia after total knee arthroplasty (TKA). Forty-two patients undergoing TKA were randomly assigned to receive either a femoral nerve block (0.50% bupivacaine hydrochloride with epinephrine 1:200,000) or matching placebo. Results showed postoperative morphine use was significantly lower in patients who received the nerve block (25.5 vs 37.5 mg, P = .016); however, the 2 groups had similar pain scores and rehabilitative outcomes. In general, a preoperative femoral nerve block is a safe and effective adjunct for decreasing morphine use for post-TKA analgesia.     

围术期帕瑞昔布钠对全膝关节置换术后疼痛和功能恢复的影响

目的本研究评估帕瑞昔布钠对全膝关节置换术后疼痛和功能恢复的影响。方法择期行全膝关节置换术的患者30例。所有患者均于麻醉前行股神经置管,然后于L3～4间隙穿刺行腰-硬联合麻醉。患者被随机分为两组:帕瑞昔布钠联合连续股神经镇痛组(PF组)和连续股神经镇痛组(F组),其中PF组于切皮前15min和术后12h给予帕瑞昔布钠40mg,F组给予生理盐水。术后对两组患者的静息和运动时的VAS评分以及膝关节主动活动度进行评估。结果术后静息时两组VAS评分相似;而运动时的各时点VAS评分PF组显著低于F组(P<0.05),同时膝关节的主动活动度PF组显著高于F组(P<0.05)。结论联合应用帕瑞昔布钠的多模式镇痛提高了全膝关节置换术后股神经镇痛的效果,有利于患者运动功能的恢复,对出血无明显影响。     

Continuous versus single-dose sciatic nerve block to complement a femoral block after total knee replacement surgery: a randomized clinical trial

INTRODUCTION: Performing a sciatic nerve block to complement a continuous femoral nerve block for analgesia after total knee arthroplasty is a subject of controversy. We compared the efficacy of a continuous sciatic nerve block to that of a single-dose block of the same nerve combined with a continuous femoral nerve block. MATERIAL AND METHODS: Patients received a continuous femoral nerve block by infusion of 0.2% ropivacaine, 0.4 mL x kg(-1), plus patient controlled analgesia and were randomized to receive a sciatic nerve block either by continuous infusion (0.5% ropivacaine, 20 mL, plus continuous infusion of 5 mh(-1)) or by a single 20 mL dose of 0.5% ropivacaine. The stimulating catheters remained indwelling for 72 hours after the operation. The main outcome measure was assessment of postoperative pain on a verbal numerical scale from 0 (no pain) to 10 (greatest pain) at rest and upon movement. RESULTS: The pain assessments upon movement of the operated joint were significantly greater after 24 hours in the group receiving a single dose of ropivacaine to block the sciatic nerve. The back of the knee was most often named as the location of pain. No adverse effects related to the analgesic technique were recorded, and the level of satisfaction was higher among patients receiving the continuous sciatic nerve block. CONCLUSION: Twenty-four hours after total knee replacement surgery, better analgesia was achieved with a continuous sciatic nerve block than with a single-dose block combined with a continuous femoral nerve block.     

静脉注射帕瑞昔布联合股神经阻滞用于老年病人膝关节置换术后镇痛及膝关节功能康复的效果

目的 评价静脉注射帕瑞昔布联合股神经阻滞用于老年病人膝关节置换术后镇痛及膝关节功能康复的效果.方法 拟在全身麻醉下行单侧膝关节置换术老年病人40例,ASA分级Ⅱ级,年龄65～74岁,体重45～90 kg,采用随机数字表法,将其随机分为2组:单纯股神经阻滞组(FNB组,n＝20)和股神经阻滞联合间断静脉注射帕瑞昔布组(FNB-Pa组,n＝20).FNB组术毕时通过股神经阻滞导管注入0.25％罗哌卡因25 ml镇痛,每8h给药1次,至术后72 h;FNB-Pa组在术毕前30 min、术后12、24、48 h分别静脉注射帕瑞昔布40 mg;股神经阻滞用药同FNB组,至术后72 h.于术后2、12、24、36、48及72 h时记录静态时VAS评分,并于术后36、48及72 h时记录动态时VAS评分.于术前、术后24、48及72 h对患膝关节功能进行评分(HSS评分);并记录有关不良反应的发生情况.结果 FNB-Pa组术后静态、动态时VAS评分均比FNB组明显降低(P<0.05).与术前比较,术后两组病人HSS评分均明显提高(P<0.05或0.01);FNB- Pa组术后48、72 h HSS评分明显高于FNB组(P<0.05).两组均未见有关不良反应发生.结论 股神经阻滞联合间断静脉注射帕瑞昔布,可安全、有效地缓解老年病人膝关节置换术后静态和动态时疼痛,有助于术后关节功能的康复.     

Femoral-sciatic nerve blocks for complex outpatient knee surgery are associated with less postoperative pain before same-day discharge: a review of 1,200 consecutive cases from the period 1996-1999

BACKGROUND: Outpatient knee surgery has come to involve increasingly complex procedures. The authors present observational data from a nerve block algorithm designed for the care of outpatients undergoing knee surgery. The aim of this report is to demonstrate differences in pain and unplanned hospital admission associated with surgical complexity and nerve blocks used. METHODS: Day-of-surgery outcomes were studied for 1,200 consecutive outpatients undergoing routine arthroscopy or one of six complex outpatient knee procedures. Nerve blocks were administered on the basis of anticipated pain from open incisions in the femoral and sciatic nerve distributions. Regression analysis was used to determine factors associated with postoperative pain and unplanned hospital admissions, and patients were categorized as having received femoral and sciatic nerve blocks (FSB), femoral nerve block only (FNB), or no nerve blocks. RESULTS: Patients undergoing more complex (vs. less invasive) knee surgery were at greater risk for pain (P 相似文献   

Femoral-Sciatic Nerve Blocks for Complex Outpatient Knee Surgery Are Associated with Less Postoperative Pain Before Same-day Discharge: A Review of 1,200 Consecutive Cases from the Period 1996-1999

Background: Outpatient knee surgery has come to involve increasingly complex procedures. The authors present observational data from a nerve block algorithm designed for the care of outpatients undergoing knee surgery. The aim of this report is to demonstrate differences in pain and unplanned hospital admission associated with surgical complexity and nerve blocks used.

Methods: Day-of-surgery outcomes were studied for 1,200 consecutive outpatients undergoing routine arthroscopy or one of six complex outpatient knee procedures. Nerve blocks were administered on the basis of anticipated pain from open incisions in the femoral and sciatic nerve distributions. Regression analysis was used to determine factors associated with postoperative pain and unplanned hospital admissions, and patients were categorized as having received femoral and sciatic nerve blocks (FSB), femoral nerve block only (FNB), or no nerve blocks.

Results: Patients undergoing more complex (vs. less invasive) knee surgery were at greater risk for pain (P <= 0.004), whereas the use of FSB (vs. FNB or no block) was associated with less pain (P < 0.01). When no nerve blocks were used, more complex (vs. less invasive) knee surgery was associated with a 10-fold greater risk of hospital admission (P = 0.001). In the regression analyses, more complex surgery (P < 0.001) was associated with increased risk of admission, and the use of FNB or FSB (vs. no block) was associated with a 2.5-fold reduction in unplanned admissions (P = 0.009).     

Lumbar paravertebral nerve block in the management of pain after total hip and knee arthroplasty: a randomized controlled clinical trial

The accepted mode of pain management after total hip or knee arthroplasty is patient-controlled analgesia. This study evaluates the efficacy of lumbar paravertebral nerve block in diminishing postoperative pain when used as an adjunct to patient-controlled analgesia. A total of 115 arthroplasty patients received postoperatively a lumbar paravertebral nerve block (block, n = 57) or a sham procedure (control, n = 58). The block group required approximately 10 mg less morphine for pain control than the control group during the first 4 hours postoperatively (P<.001). There were no significant differences in morphine use between the groups 4 to 24 hours postoperatively. Visual analog scale pain score measurements at 4, 8, and 24 hours did not differ significantly between the groups. Paravertebral nerve block of the lumbar plexus is an invasive procedure with some risk. Considering the added risk and minimal benefits, routine use of this procedure is not supported.     

不同剂量氨酚羟考酮对膝关节置换术后镇痛效果的研究

目的观察口服氨酚羟考酮片在膝关节置换术后患者中的镇痛疗效和安全性,选择最佳的给药剂量。方法选择行单侧全膝关节置换患者50例,随机分为氨酚羟考酮10mg组和5mg组,均为Q8H给药,同时使用股神经阻滞（0.2%罗哌卡因）,两组患者均维持镇痛5 d。术后记录静息痛、康复锻炼疼痛最重时、康复锻炼结束时疼痛评分、膝关节被动活动度、膝关节主动活动度,记录功能活动时疼痛：下床、行走、即刻松拐疼痛评分,以及药物相关的并发症。结果氨酚羟考酮10mg组患者在术后1 d、3 d的静息痛VAS评分及膝关节主动活动优于5mg组,不良反应发生率10mg组为26.7%,5mg组为10%。结论氨酚羟考酮用于全膝关节置换术后康复镇痛效果良好,建议在术后早期（1～3天）使用10mg,Q8H给药,以缓解患者的静息痛、锻炼痛,之后可以减药量为5mg,Q8H,也可以达到满意的功能表现,同时减少药物的副作用。