Femoral nerve block with 0.25% or 0.5% bupivacaine improves postoperative analgesia following outpatient arthroscopic anterior cruciate ligament repair

BACKGROUND AND OBJECTIVES: Femoral nerve block is effective in reducing postoperative pain after inpatient knee surgery. We studied its efficacy compared with standard analgesia following outpatient anterior cruciate ligament repair, including the duration of analgesia and the effect of different concentrations of bupivacaine. METHODS: After Institutional Review Board approval and informed consent, we prospectively randomized patients to receive, in a blinded fashion, either a sham block, a femoral nerve block with 25 mL 0.25% bupivacaine, or with 25 mL 0.5% bupivacaine after anterior cruciate ligament repair under epidural anesthesia. Verbal analog pain scores were evaluated by a blinded observer at 20 and 40 minutes after injection. Patients with pain >4 (out of 10) were assessed for the presence of a block and offered a supplemental block if no anesthesia was present at either evaluation. By prospective agreement, any study group with 6 failures was excluded from further recruitment. After discharge, patients recorded pain scores and analgesic consumption in a diary, and estimated the time at which they perceived that analgesia and sensory block from the femoral nerve block resolved, based on an increase in pain, sensation, and strength in the leg. RESULTS: In the sham block group, 6 of 12 patients reported inadequate analgesia in the postanesthesia care unit (4 at 20 minutes, 2 at 40 minutes; greater than other groups, P <.003) and were excluded from further study. Patients with sham blocks had higher pain scores 20 minutes after the block, and requested intravenous analgesia more often. Bupivacaine 0.25% and 0.5% provided 23.2 +/- 7 and 25.7 +/- 11 hours of analgesia, respectively. CONCLUSIONS: Femoral nerve block with 0.25% bupivacaine contributes significantly to multimodal postoperative analgesia in the immediate postoperative period following outpatient anterior cruciate ligament repair. Both doses of bupivacaine studied provided analgesia for the first night after surgery.     

Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty

BACKGROUND AND OBJECTIVES: Regional analgesic techniques allow better postoperative rehabilitation and shorter hospital stay after major knee surgery. The authors tested the hypothesis that similar results could be obtained after total-hip arthroplasty. METHODS: Forty-five patients scheduled for THA under general anesthesia were randomly divided into 3 groups. Postoperative analgesia was provided during the first 48 hours, with intravenous patient-controlled analgesia (IV PCA) induced by morphine (dose, 1.5 mg; lockout interval, 8 min) in group IV, continuous femoral nerve sheath block in group FNB, and continuous epidural analgesia in group EPI. The day after surgery, the 3 groups started identical physical therapy regimens. Pain scores at rest and on movement, supplemental analgesia, side effects, daily degree of maximal hip flexion and abduction, day of first walk, and duration of hospital stay were recorded. RESULTS: Population data, quality of pain relief, postoperative hip rehabilitation, and duration of hospital stay were comparable in the 3 groups. When compared with the two other techniques, continuous FNB was associated with a lower incidence of side effects (no nausea/vomiting, urinary retention, arterial hypotension, or catheter problem during the first 48 hours in 20%, 60%, and 13% of patients in groups IV, FNB, and EPI, respectively). CONCLUSIONS: This study suggests that IV PCA with morphine, continuous FNB, and continuous epidural analgesia provide similar pain relief and allow comparable hip rehabilitation and duration of hospital stay after total-hip arthroplasty (THA). As continuous FNB is associated with less side effects, it appears to offer the best option of the three.     

Is sciatic nerve block advantageous when combined with femoral nerve block for postoperative analgesia following total knee arthroplasty? A systematic review

Sciatic nerve block (SNB) is commonly performed in combination with femoral nerve block (FNB) for postoperative analgesia following total knee arthroplasty (TKA). This systematic review examines the effects of adding SNB to FNB for TKA compared with FNB alone on acute pain and related outcomes. Four intermediate-quality randomized and 3 observational trials, including a total of 391 patients, were identified. Three of 4 trials investigating the addition of single-shot SNB and 2 of 3 trials investigating continuous SNB reported improved early analgesia at rest and reduced early opioid consumption. Only 2 trials specifically assessed posterior knee pain. We were unable to uncover any clinically important analgesic advantages for SNB beyond 24 hours postoperatively. At present, there is inconclusive evidence in the literature to define the effect of adding SNB to FNB on acute pain and related outcomes compared with FNB alone for TKA.     

Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement.

We have investigated the value of a 3-in-1 nerve block, followed by a continuous low-dose infusion of bupivacaine into the femoral nerve sheath for postoperative analgesia after total knee replacement. Thirty-seven patients were randomly allocated to either a control group or a study group. The study group had a catheter placed in the ipsilateral femoral nerve sheath. A 3-in-1 nerve block was then performed in the study group with injection of 30 mL of 0.25% bupivacaine through the catheter. This was followed by a continuous infusion of 0.125% bupivacaine at 6 mL/h. The study group had significantly lower pain scores 4 and 24 h postoperatively (P less than 0.01) and required less postoperative opioid analgesic medication (P less than 0.01) than the control group. The authors conclude that a continuous low-dose infusion into the femoral nerve sheath results in better pain relief than conventional intramuscularly administered narcotics after total knee arthroplasty.     

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.     

Comparison of Local Infiltration of Analgesia and Sciatic Nerve Block in Addition to Femoral Nerve Block for Total Knee Arthroplasty

We conducted a prospective randomized controlled trial to test the null hypothesis that there is no difference between sciatic nerve block (SNB) and local infiltration of analgesia (LIA) regarding postoperative analgesia after total knee arthroplasty (TKA), when administrated in addition to femoral nerve block (FNB). Forty-six patients scheduled for TKA were randomized into two groups: concomitant administration of FNB and SNB or FNB and LIA. Average pain scores during the first 21 days after surgery were similar in the two groups and remained at low level. There was no significant difference in the need for adjuvant analgesics, patient satisfaction level, the time to achieve rehabilitation goals, and length of hospital stay. The LIA offers a potentially safer alternative to SNB as an adjunct to FNB.     

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.     

A comparison of the analgesic effects of femoral nerve block and intra-articular bupivicaine in day case operative knee arthroscopy

A double blind prospective study of 50 patients undergoing operative day case knee arthroscopy was performed. Each patient received either intra-articular bupivicaine or a femoral nerve block (FNB) after the operative procedure. Pain scores were recorded pre- and post-operatively at rest and found to be reduced in the FNB group. Time to first dose of analgesia was also prolonged in the FNB group. No major complications were recorded and no patient required overnight stay.     

Femoral nerve block and ketorolac in patients undergoing anterior cruciate ligament reconstruction

PURPOSE: The primary objective was to evaluate the analgesic effectiveness of femoral nerve block and ketorolac following ACL reconstruction. The secondary objective was to examine their effects on recovery milestones. METHODS: Prior to standard general anesthesia, 90 patients were randomized into three groups of preoperative treatment: 1) femoral nerve block (15 mL bupivacaine 0.5%) and 1 mL normal saline i.v. (FNB group); 2) placebo femoral nerve block (15 mL normal saline) and 30 mg (1 mL) ketorolac i.v. (KT group); 3) placebo femoral nerve block (15 mL normal saline) and 1 mL normal saline i.v. (PL group). Postoperatively, pain was assessed by visual analogue score, demand and consumption of morphine via patient-controlled analgesia pump. The times for patients to tolerate oral fluid, food, sit up, ambulate and void were also noted. RESULTS: Morphine consumption within one hour, three hours and until POD 1 in the FNB group was lower than the PL group (7 +/- 6, 11 +/- 9, 27 +/- 23 mg vs 13 +/- 5, 20 +/- 9, 49 +/- 28 mg respectively), whereas only that within one hour in the KT group was lower than the PL group. Pain score was lower in FNB and KT groups in the first postoperative hour than in the PL group (P < 0.05). There were no differences among the three groups in the times to meet recovery milestone and discharge criteria. CONCLUSION: Femoral nerve block provides superior analgesia than placebo for ACL reconstruction but was insufficient to facilitate early recovery.     

Comparison of two regional anesthetic techniques for knee arthroscopy

This study compares the efficacy of “3-in-1 block” versus femoral nerve block for knee arthroscopy. One-hundred patients had a 3-in-1 block; 180 patients had a femoral nerve block. The 3-in-1 block provided anesthesia in 75 patients; 20 patients needed supplementary local anesthesia. Five patients required a general anesthesia to complete the operation. The femoral nerve block was effective in 88 patients; 90 patients needed intravenous flunitrazepam and/or fentanyl; 2 patients needed general anesthesia. The 3-in-1 block provided more satisfactory muscle relaxation and a longer postoperative analgesia than femoral nerve block. No side effects were recorded in either group. Our results suggest that the 3-in-1 block is the most effective technique of regional anesthesia for knee arthroscopy.     

Femoral block provides superior analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction

BACKGROUND AND OBJECTIVES: Arthroscopic anterior cruciate ligament (ACL) reconstruction of the knee is a painful procedure requiring intensive postoperative pain management. This prospective study investigates analgesic quality after a femoral block as compared with intra-articular injection of local anesthetic. METHODS: Eighty patients scheduled for elective ACL repair under general anesthesia were included in our study. Upon completion of surgery, the patients were randomly assigned into 1 of 2 groups: femoral group (n = 40) received a femoral block with 20 mL 1% ropivacaine; intra-articular group (n = 40) received 20 mL 1% ropivacaine injected intra-articularly. During the first 24 hours after surgery, all patients received 2 g propacetamol and 100 mg ketoprofen, intravenously. Additional postoperative analgesia was available with parenteral morphine if required. Analgesic duration was defined as the time from end of surgery to the first requirement for a supplemental analgesic. Data collection included patient demographics, visual analog scale (VAS) scores, analgesic duration, and morphine use. Analysis of variance (ANOVA) test was used to compare the 2 groups. RESULTS: VAS score in the recovery room and during rehabilitation was higher in the intra-articular group than in the femoral group (P <.001). Morphine use was lower in the femoral group than in the intra-articular group (P <.001). Similarly, analgesic duration was longer in the femoral group than the intra-articular group (P <.0001). CONCLUSIONS: Compared with intra-articular injection of local anesthetic, femoral nerve block (FNB) provides better analgesia and allows a significant morphine-sparing effect after ACL repair.     

Postoperative analgesia after total-hip arthroplasty: Comparison of intravenous patient-controlled analgesia with morphine and single injection of femoral nerve or psoas compartment block. a prospective, randomized, double-blind study

BACKGROUND: The authors compared the analgesic effects and quality of rehabilitation of three analgesic techniques after total-hip arthroplasty in a double-blind, randomized trial. METHODS: Forty-five patients were assigned to 1 of 3 groups, patient-controlled analgesia with morphine (PCA), femoral nerve block (FNB), or psoas compartment block (PCB). At the end of the procedure performed under general anesthesia, nerve blocks using 2 mg/kg of 0.375% bupivacaine and 2 microg/kg of clonidine were performed in the FNB (n = 16) and PCB (n = 15) groups. In the recovery room, all 3 groups received initial intravenous morphine titration if their pain score was higher than 30 on a 100-mm visual analog scale (VAS), and then a PCA device was initiated. Morphine consumption was the primary end point to assess postoperative analgesia. RESULTS: After extubation (H0), morphine titration was higher in the PCA group (P <.05). During the first 4 postoperative hours (H0 to H4), morphine consumption per hour and VAS pain score were lower in the PCB group (P <.05). After H4, there was no difference in morphine consumption and VAS among groups, either at rest or during mobilization. After H4, morphine consumption remained lower than 0.5 mg/h, and VAS remained lower than 30 mm in the 3 groups. In 4 patients of the PCB group, an epidural diffusion was noted. Hip mobility and length of stay in the rehabilitation center were not different among the groups. CONCLUSIONS: PCA is an efficient and safe analgesia technique. FNB and PCB should not be used routinely after total-hip arthroplasty.     

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.     

Multimodal periarticular injection vs continuous femoral nerve block after total knee arthroplasty: a prospective, crossover, randomized clinical trial

This study compares the efficacy of pain control using continuous femoral nerve block (FNB) and multimodal periarticular soft tissue injection. This is a randomized, crossover, clinical trial. Sixteen patients having bilateral osteoarthritis of the knee scheduled for staged total knee arthroplasty were randomized to receive either FNB (0.2% ropivacaine), via indwelling catheter for 72 hours, or multimodal periarticular soft tissue injection in the first stage. In the second stage, they received the opposite treatment. The primary outcome measure was morphine consumption by patient-controlled analgesia in the first 72 hours postoperatively. Cumulative morphine consumption as well as rest pain and motion pain in the first 72 hours was comparable between the 2 groups. The functional outcomes did not differ significantly. We conclude that multimodal periarticular soft tissue injection provides comparable analgesia to continuous FNB after total knee arthroplasty.     

Postoperative analgesia after total knee replacement: the effect of an obturator nerve block added to the femoral 3-in-1 nerve block

Femoral nerve block (FNB) does not consistently produce anesthesia of the obturator nerve. In this single-blind, randomized, controlled study we added a selective obturator nerve block (ONB) to FNB to analyze its influence on postoperative analgesia after total knee replacement (TKR). Before general anesthesia, 90 patients undergoing TKR received FNB (Group 1), FNB and selective ONB (Group 2), or placebo FNB (Group 3). Postoperative analgesia was further provided by morphine IV via patient-controlled analgesia. Analgesic efficacy and side effects were recorded in the first 6 h after surgery. Adductor strength decreased by 18% +/- 9% in Group 1 and by 78% +/- 22% in Group 2 (P < 0.0001). Total morphine consumption was reduced in Group 2 compared with Groups 1 and 3 (P < or = 0.0001). Patients in Group 2 reported lower pain scores than those in Groups 1 and 3 (P = 0.0003). The incidence of nausea was more frequent in Groups 1 and 3 (P = 0.01). We conclude that FNB does not produce complete anesthesia of the obturator nerve. Single-shot FNB does not provide additional benefits on pain at rest over opioids alone in the early postoperative period. The addition of an ONB to FNB improves postoperative analgesia after TKR.     

Intraoperative single-shot “3-in-1” femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement

PURPOSE: To compare analgesia after intraoperative single shot "3-in-1" femoral nerve block (FNB) in combination with general anesthesia using ropivacaine 0.25%, ropivacaine 0.5% with bupivacaine 0.25% for total knee replacement (TKR). METHODS: We performed a randomized, double-blind study in 48 patients for elective TKR under general anesthesia. Patients were randomized to one of four groups (C: sham block, R1: "3-in-1" FNB using 30 mL of ropivacaine 0.25%, R2: "3-in-1" FNB using 30 mL of ropivacaine 0.5%, B: "3-in-1" FNB using 30 mL of bupivacaine 0.25%). Verbal pain score (VPS) both at rest and movement were assessed for 48 hr after TKR (0=none; 1=mild; 2=moderate; 3=severe). Total morphine consumption and its associated side effects, duration of hospitalization after operation were also compared. RESULTS: There were no differences in patients' physical characteristics, intraoperative morphine usage, operation time, tourniquet time or length of hospitalization between the four groups. When compared with group C, the VPS was significantly lower in groups R1, R2 and B at one, four, eight, 24 and 48 hr after TKR (P <0.05). The morphine requirement of groups R1, R2 and B were also significantly lower when comparing with group C up to 48 hr postoperatively (P <0.05). There were no significant differences in VPS and postoperative morphine requirement at any time between groups R1, R2 and B. CONCLUSION: "3-in-1" FNB with ropivacaine provided analgesia that was clinically comparable to that of bupivacaine up to 48 hr after TKR. Increasing the concentration of ropivacaine from 0.25% to 0.5% failed to improve the postoperative analgesia of "3-in-1" FNB.     

Epidural fentanyl in labour

In a randomized double-blind trial in the first stage of labour, 20 patients given fentanyl 80 micrograms in the epidural test dose of bupivacaine, were compared with 20 patients receiving an intravenous infusion designed to produce comparable plasma fentanyl concentrations, at the same time as their epidural test dose. Despite slightly higher plasma fentanyl concentrations in the intravenous fentanyl group, epidural fentanyl produced analgesia which was more complete, more rapid in onset and slightly longer lasting. Supplementary doses of bupivacaine were needed to produce analgesia in 75% of the intravenous and 30% of the epidural fentanyl group. It is clear that epidural fentanyl produces satisfactory pain relief when added to the epidural test dose, but that the presence of fentanyl in the systemic circulation makes a negligible contribution to analgesia.     

Femoral nerve block as an alternative to parenteral narcotics for pain control after anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) reconstruction is associated with significant postoperative pain, usually requiring parenteral narcotics. A prospective study of arthroscopically assisted autograft patellar tendon ACLR was initiated using Winnie's “three-in-one” femoral nerve block (FNB) as the primary means of postoperative pain control. Patient satisfaction and absence of parenteral narcotic use indicated clinical success. Of 24 patients studied, 92% had no parenteral narcotics administered following FNB. Ninety-five percent of patients believed FNB was beneficial and would request another. The average duration of pain control was 29 hours and the majority of patients (79%) believed discharge was possible within 23 hours. There were two patients who failed to respond to FNBs (8%) and no major complications. FNB is a safe, reliable, and effective form of analgesia following ACLR, eliminating the need for parenteral narcotics.     

Sciatic nerve blockade improves early postoperative analgesia after open repair of calcaneus fractures

OBJECTIVE: To determine the effectiveness of analgesia, with or without sciatic nerve blockade, after open repair of calcaneus fracture. DESIGN: Randomized, prospective trial involving 30 patients divided into 3 groups of 10, all having open repair of calcaneus fractures. Group 1 used morphine patient-controlled analgesia alone. Groups 2 and 3 had morphine patient-controlled analgesia and a "one-shot" bupivacaine sciatic nerve blockade, either presurgically (group 2) or postsurgically (group 3). SETTING: Harborview Medical Center operating rooms and orthopedic floors. OUTCOME MEASURES: Morphine use over 24 hours, visual analogue scale pain scores, and sciatic nerve blockade duration. RESULTS: In the absence of sciatic nerve blockade, initial postoperative pain was marked, even with a mean recovery room dose of intravenous morphine more than 30 mg. Sciatic nerve blockade with bupivacaine had a mean duration of 14 hours and substantially reduced pain for the first 24 postoperative hours. Presurgical blockade confers no advantage over postsurgical blockade. CONCLUSION: Sciatic nerve blockade confers significant benefit over morphine alone for analgesia after open repair of calcaneus fractures. Postsurgical sciatic nerve blockade provides the longest possible postoperative block duration.     

A single injection ultrasound-assisted femoral nerve block provides side effect-sparing analgesia when compared with intrathecal morphine in patients undergoing total knee arthroplasty

Postoperative pain after total knee arthroplasty (TKA) is severe, and achieving adequate analgesia remains a clinical challenge. We tested the hypothesis that, in patients having unilateral TKA under intrathecal (IT) anesthesia, the addition of a femoral nerve block would provide superior analgesia when compared with IT morphine and demonstrate fewer adverse side effects. In a single-blinded and controlled trial, 41 ASA I-III patients undergoing unilateral TKA were randomized into 2 groups. Both groups received 15 mg of IT hyperbaric bupivacaine for the surgical anesthetic. Group ITM received 250 microg of IT morphine and group FNB received an ultrasound-assisted femoral nerve block with 40 mL of 0.5% ropivacaine, 5 microg/mL of epinephrine, and 75 microg of clonidine. At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales for pain, cumulative IV morphine consumption, hemodynamics, and side effects. There were no statistically significant differences in morphine consumption, pain at rest, or pain with movement. However, group FNB had fewer perioperative side effects including nausea, vomiting, and pruritus (P < 0.05 for each event). This corresponded to a decrease in patient satisfaction in group ITM, in which 20% of the patients rated their experience as "unsatisfactory" (P < 0.05). We conclude that, in comparison with IT morphine, a single injection femoral nerve block provides equivalent analgesia but with a significant reduction in side effects for patients having TKA under bupivacaine intrathecal anesthesia.