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.     

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta-analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid-related adverse effects and functional recovery. Network meta-analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft-donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single-injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid-related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single-injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction.     

Regional anesthesia in knee arthroscopy: A new technique involving femoral and sciatic nerve blocks in knee arthroscopy

We describe a new anesthetic technique of femoral and sciatic nerve blocks in knee arthroscopy. The sciatic nerve block is administered through a posterior approach, and the block of the femoral and lateral femoral cutaneous nerves in a single anterior approach. This type of regional anesthesia is safe and effective, providing excellent intraoperative and postoperative analgesia as well as minimizing postoperative complications.     

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.     

Post-operative analgesia following total knee replacement: an evaluation of the addition of an obturator nerve block to combined femoral and sciatic nerve block

BACKGROUND: Femoral and sciatic nerve block may not provide complete post-operative analgesia following total knee replacement. This study was designed to evaluate whether the addition of an obturator nerve block to combined femoral and sciatic nerve block improves the quality of post-operative analgesia following primary total knee replacement. METHODS: Sixty patients were randomised into one of two groups: combined femoral and sciatic nerve block with 15 ml 0.75% ropivacaine to each nerve or combined femoral and sciatic nerve block with 15 ml 0.75% ropivacaine to each nerve and an obturator nerve block with 5 ml 0.75% ropivacaine. RESULTS: Peripheral nerve blocks were successful in 85% of patients. The group which received the obturator nerve block showed a significant increase in the time until their first request for analgesia (mean 257.0 vs. 433.6 min) and a significant reduction in the total requirements for morphine throughout the study period (mean 83.8 vs. 63.0 mg) (P<0.05). There were no systemic or neurological sequelae in any of the groups. CONCLUSIONS: The addition of an obturator nerve block to femoral and sciatic blockade improved post-operative analgesia following total knee replacement.     

Comparing the Effects of Single Shot Sciatic Nerve Block Versus Posterior Capsule Local Anesthetic Infiltration on Analgesia and Functional Outcome After Total Knee Arthroplasty : A Prospective,Randomized, Double-Blinded,Controlled Trial

Peripheral nerve blocks appear to provide effective analgesia for patients undergoing total knee arthroplasty. Although the literature supports the use of femoral nerve block, addition of sciatic nerve block is controversial. In this study we investigated the value of sciatic nerve block and an alternative technique of posterior capsule local anesthetic infiltration analgesia. 100 patients were prospectively randomized into three groups. Group 1: sciatic nerve block; Group 2: posterior local anesthetic infiltration; Group 3: control. All patients received a femoral nerve block and spinal anesthesia. There were no differences in pain scores between groups. Sciatic nerve block provided a brief clinically insignificant opioid sparing effect. We conclude that sciatic nerve block and posterior local anesthetic infiltration do not provide significant analgesic benefits.     

Sciatic nerve block by the lateral route at the level of the popliteal fossa with 0.75% ropivacine: advantages of a more proximal approach

OBJECTIVES: To assess the efficacy of a sciatic nerve block using a lateral approach 11 cm cephalad to the lateral femoral epicondyle for providing surgical anesthesia and postoperative analgesia in scheduled foot surgery (hallux valgus) after a single injection of 30 mL of 0.75% ropivacaine. METHODS: A block was performed in 30 patients using a point of puncture 11 cm cephalad to the most prominent point of the lateral femoral epicondyle in the groove between the biceps femoris and vastus lateralis muscles. Once the nerve had been located with a stimulator (2 Hz, 0.5 mA), 30 mL of 0.75% ropivacaine was injected. Data recorded were time until block, number of attempts, depth at which the nerve was found, sciatic nerve response obtained, and time until the sensory block was complete. We evaluated quality of anesthesia during surgery, duration of postoperative analgesia, and patient discomfort during performance of the block. RESULTS: Time required to perform the block was 4.3 +/- 1.2 minutes and only one puncture attempt was needed in 27 patients. The nerve was located at 5.5 +/- 0.4 cm, with response located in the common peroneal nerve in 18 patients and in the posterior tibial nerve in 12. The time needed to achieve a full sensory block was 19.3 +/- 5.1 minutes. Twenty-six patients (86%) were very satisfied with the anesthetic quality of the block, 2 were moderately satisfied, and 2 were dissatisfied. Postoperative analgesia lasted 19 +/- 3.4 hours. Four patients reported minimal discomfort during performance of the block. No complications were observed. CONCLUSIONS: The sciatic nerve block from a lateral approach 11 cm cephalad to the lateral femoral epidondyle is an appropriate anesthetic technique for foot surgery. It is safe, effective and easy to perform. Infusion of 30 mL of 0.75% ropivacaine provided adequate anesthesia and long-lasting postoperative analgesia for our patients.     

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.     

Combined sciatic and femoral nerve block for knee arthroscopy: 4 years’ experience

Selective block of the femoral and sciatic nerves was performed on 601 patients undergoing knee arthroscopy. The results were good in 87%, adequate in 12%, and poor in 1%. The whole knee surface was covered by the nerve blockade. The duration of anesthesia was 152 ± 21 min and that of analgesia, was 336 ± 18 min. No correlation was observed between the effectiveness of the anesthesia and type of surgery performed. The technique described thus proved adequate for knee arthroscopic surgery, reproducibility was excellent, costs and hospital stays were reduced with respect to general anesthesia, and surgeon and patient satisfaction was high. Received: 25 May 1998     

Experience of ultrasound-guided popliteal sciatic nerve block and femoral nerve perineural catheter placement in a morbidly obese patient undergoing total knee arthroplasty

A 60-year-old morbidly obese woman (150 cm, 112 kg, BMI 49.8) underwent total knee replacement under general anesthesia combined with sciatic nerve block and continuous femoral nerve block. Following induction of general anesthesia and tracheal intubation, the sciatic nerve was blocked using the popliteal approach with the patient in the supine position. Then the femoral nerve block was performed, followed by perineural catheter placement for postoperative continuous local anesthetic infusion. For both procedures, real-time ultrasound imaging was used to facilitate needle placement and confirm the adequate local anesthetic deposition. Twenty-five and 30 ml of 0.375% ropivacaine was injected around the sciatic and femoral nerves, respectively. Postoperatively 0.15% ropivacaine was infused at the rate of 5 ml x hr(-1) for 60 hours through the femoral catheter, which provided satisfactory pain relief in combination with scheduled loxoprofen administration. No block-related complications were noted. Our experience suggests that the ultrasound-guided technique may prove useful to facilitate safe and accurate block when technical difficulties are anticipated with anatomic landmark-based approaches.     

Postoperative analgesia and functional recovery after total-knee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block

BACKGROUND AND OBJECTIVES: Continuous femoral nerve block is a well-accepted technique for regional analgesia after total-knee replacement. However, many patients still experience considerable pain at the popliteal space and at the medial aspect of the knee. The goal of this study is to evaluate whether a psoas compartment catheter provides better postoperative analgesia than a femoral nerve catheter does and whether it is as effective as the combination of a femoral and a sciatic nerve catheter and, thus, improves functional outcome. METHODS: Ninety patients who underwent total-knee replacement under standardized general anesthesia participated in this prospective randomized study. Group FEM received a continuous femoral nerve block, group FEM/SCI received a combination of a femoral and a sciatic continuous nerve block, and group PSOAS received a continuous psoas compartment block. Patient-controlled analgesia with piritramide was available for 48 hours. Maximal bending and extending of the knee and walking distance was assessed during the first 7 days. A standardized telephone survey was conducted after 9 to 12 months to evaluate residual pain and functional outcome. RESULTS: Postoperative opioid consumption during 48 hours was significantly less in the FEM/SCI group (median: 18 mg; 25th/75th percentile: 6/40) compared with the FEM group (49 mg; 25/66) and the PSOAS group (44 mg; 30/62) (P =.002). Postoperative pain scores were not different, and no differences occurred with respect to short-term or long-term functional outcome. CONCLUSION: The FEM/SCI catheter is superior to FEM and PSOAS catheter with respect to reduced analgesic requirements after total-knee replacement, but functional outcome does not differ with those 3 continuous regional analgesia techniques.     

Postoperative analgesia with continuous sciatic nerve block after foot surgery: a prospective, randomized comparison between the popliteal and subgluteal approaches

To compare the posterior popliteal and subgluteal continuous sciatic nerve block for anesthesia and acute postoperative pain management after foot surgery, 60 ASA physical status I and II patients undergoing elective orthopedic foot surgery were randomly assigned to either a Subgluteal group (n = 30) or Popliteal group (n = 30). Before surgery and after performing a femoral nerve block with 15 mL of 2% mepivacaine, we performed the sciatic nerve block with 20 mL of 0.75% ropivacaine using either a subgluteal or posterior popliteal approach, and the placement of a catheter came afterward. In the recovery room, the catheter was connected to a patient-controlled analgesia pump to infuse 0.2% ropivacaine (basal infusion rate of 5 mL/h, incremental bolus of 10 mL, and a lockout time of 60 min). There were no technical problems in catheter placement. Intraoperative efficacy of nerve block was similar in the two groups. Postoperative catheter displacement and occlusion were recorded in four patients in the Popliteal group and two patients in the Subgluteal group (P = 0.67). Both approaches provided similar postoperative analgesia. We conclude that the subgluteal approach is as effective and safe as the previously described posterior popliteal approach for continuous sciatic block and can be considered a useful alternative to anesthesia and acute postoperative analgesia after foot procedures. IMPLICATIONS: Comparing two different approaches for continuous sciatic nerve block after orthopedic foot surgery, this prospective, randomized study demonstrated that the subgluteal approach is as effective and safe as the previously described posterior popliteal approach, and can be considered a useful alternative to anesthesia and acute postoperative analgesia after foot procedures.     

Patient satisfaction and effectiveness of lumbar plexus and sciatic nerve block for total knee arthroplasty

The purpose of this study was to evaluate the efficacy of combined lumbar plexus block techniques for total knee arthroplasty. Long-acting local anesthetics were used to ensure adequate intraoperative and postoperative anesthesia and analgesia. All patients undergoing total knee arthroplasty at our institution were offered lumbar plexus block after obtaining informed consent. Patients for study were a continuous group of 87 patients over a 1-year period. A subset of 40 patients was studied for postoperative analgesia effect. All patients were contacted by phone for a satisfaction survey. There were 87 patients who received initial lumbar plexus and sciatic nerve blocks, 78% (68 of 87) of whom had adequate initial blocks. Sixteen patients (22%) required conversion to general anesthesia intraoperatively because of inadequate anesthesia. A subset of patients studied for postoperative analgesia revealed an average time of 13 hours before the first request for supplemental narcotics. There were no complications related to the lumbar plexus block in our study group of patients. There was a 92% overall satisfaction rate with the anesthesia provided by the lumbar plexus block. Lumbar plexus block can be used successfully for total knee arthroplasty. Lumbar plexus block appears to have advantages for early postoperative analgesia, leading to increased patient comfort and satisfaction.     

神经刺激器指导实施下肢神经联合阻滞的麻醉效果

目的比较在神经刺激器指导下实施不同下肢神经联合阻滞的麻醉效果。方法选择ASAⅠ或Ⅱ级18~58岁股骨下段以下的下肢手术患者80例,随机均分为:坐骨神经加股神经阻滞组(N1组)、坐骨神经加股神经加股外侧皮神经阻滞组(N2组)、坐骨神经加腰大肌肌间沟阻滞组(N3组)与脊麻组(S组)。用不同电流强度刺激指导穿刺,比较神经阻滞的起效和持续时间、阻滞的效果以及患者满意度评分和不良反应。结果N2、N3组止血带反应明显轻于N1与S组。N1、N2和N3组的感觉与运动阻滞时间均明显长于S组(P<0.01)。电流的强度与起效时间呈正相关。结论神经刺激器电流强度在0.25~0.30mA时麻醉效果满意。坐骨神经加股神经加股外侧皮神经阻滞和坐骨神经腰大肌肌间沟阻滞用于股骨下段以下的下肢手术是一种安全可靠的麻醉方法,坐骨神经加股神经阻滞适用于股骨下段以下短小手术,效果可靠。     

The value of adding sciatic block to continuous femoral block for analgesia after total knee replacement

BACKGROUND AND OBJECTIVES: The benefit of adding a sciatic nerve block to the femoral block to improve analgesia after total knee replacement is controversial. The aim of this study is to address this controversy in a prospective, comparative, and randomized study. METHODS: Patients were allocated randomly to receive a continuous femoral nerve block or continuous blocks of both the femoral and sciatic nerves. Stimulating catheters were used in all cases. A loading dose of 15 mL ropivacaine 0.75% was injected into each catheter, followed by administration of ropivacaine 0.2% (2-5 mL/h infusion via the femoral catheter; bolus 10 mL repeated every 12 hours in the sciatic catheter). The primary outcome was visual analog scale (VAS) scores (0 = no pain, 100 mm = worst pain) in postanesthesia care unit and in the 48-hour period after surgery. The secondary outcomes were amplitude of knee flexion, morphine consumption, and occurrence of postoperative nausea and vomiting (PONV). RESULTS: The VAS scores at rest were significantly higher when there was only continuous femoral nerve block than when there was both continuous femoral and sciatic nerve blocks. This difference progressively decreased and disappeared at 36 hours after surgery. The combined femoral and sciatic blocks decreased the morphine consumption by 81% and significantly decreased the occurrence of PONV. CONCLUSION: During the 36 hours immediately after total knee replacement, the combination of continuous femoral and sciatic nerve blocks improves analgesia while decreasing morphine consumption and PONV.     

Regional anesthesia for orthopedic procedures: What orthopedic surgeons need to know

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration.     

Local or regional anesthesia in knee arthroscopic surgery--patients satisfaction]

There is no doubt, that local anesthesia for knee arthroscopic surgery is rather simple, reliable, well tolerated, cost-effective and safe procedure acceptable also for one-day-surgery and outpatients. Patient's acceptance and satisfaction are behind those measurable data and could be predicted only after the question if the patients would prefer intraarticular analgesia when they should need to have another arthroscopy performed. The aim of the investigation was to compare this prediction with real patients feeling. Comparison was made between the types of anesthesia (regional, intraarticular) used for knee surgery, twice the same knee and patient. The retrospective data (mean 9 months after the last surgery) showed higher patients satisfaction (93.5%) with local anesthesia if compare with regional (2.6%) and femoral nerve block (3.9%).     

Femoral nerve injury complicating continuous psoas compartment block

OBJECTIVES: The objective of this case report is to describe a femoral nerve injury after a psoas compartment block (PCB) and to discuss the probable mechanisms of injury and neuron regeneration. To date, this is the first report of severe femoral nerve injury after PCB. CASE REPORT: A 60-year-old, American Society of Anesthesiologists II woman underwent right total knee replacement under general anesthesia and continuous PCB for postoperative analgesia. Postoperatively, she showed signs of severe femoral nerve injury. A physical therapy program and muscle electrical stimulation were instituted and continued for 6 months. The patient recovered completely with no residual motor or sensory deficit and had no other complication. CONCLUSIONS: Severe nerve injuries after regional anesthesia techniques remain infrequent and probably unreported. Our case report suggests that severe femoral nerve injury should be added to the list of reported complications during PCB. This case report is also encouraging because it shows the possibility of a good recovery after such injury.     

Skin temperature during regional anesthesia of the lower extremity

Increase in skin temperature (Ts) occurs early during neuraxial blocks. However, the reliability of Ts to predict successful peripheral block is unknown. Therefore, we investigated whether an increase in Ts more than 1 degrees C precedes or follows an impairment of sensation after combined femoral and sciatic nerve block as well as after epidural anesthesia. In this prospective, nonrandomized study we determined Ts changes in 33 patients undergoing knee or foot surgery under femoral and sciatic nerve block and 10 patients undergoing epidural anesthesia. Perception and motor function were assessed every 5 min. An increase in Ts (> or =1 degrees C) at the foot occurred later after sciatic nerve block than after epidural anesthesia (10.3 +/- 2.8 versus 5.0 min; P < 0.01). Alterations of Ts at skin innervated by the femoral nerve were <1 degrees C. Ts increase preceded sensory block after sciatic nerve block in 6.6% of patients but indicated a successful block (sensitivity, specificity, and accuracy = 100%). We conclude that an increase of Ts is a reliable, but late, sign of successful sciatic nerve block. Therefore it is of limited clinical value. Ts changes after femoral nerve block are negligible and late.     

股神经联合坐骨神经阻滞应用在踝关节镜手术中的效果评价

目的 比较两种不同的麻醉方式在踝关节镜手术中的应用效果。方法 选择2018年1月至2019年12月在中山大学孙逸仙纪念医院行踝关节镜手术的患者60例,随机分为股神经组和腰丛组,每组各30例,股神经组实施股神经联合坐骨神经阻滞,腰丛组实施腰丛联合坐骨神经阻滞。比较两组患者术中和术后的麻醉和镇痛效果、麻醉操作时间、不同时间的心率及平均血压和麻醉并发症及不良反应。结果 两组患者术中额外使用局麻药和麻醉性镇痛药人数、术后24小时内静息或运动的VAS评分及额外使用镇痛药的人数和使用时间差异均无统计学意义;股神经组麻醉操作时间显著少于腰丛组;股神经组在麻醉操作过程中的心率和平均血压显著低于腰丛组;两组患者术后不良反应比较差异无统计学意义。结论 股神经联合坐骨神经阻滞与腰丛联合坐骨神经阻滞在踝关节镜手术中的麻醉和术后镇痛效果无显著差别,但前者麻醉操作时间更短,围术期生命体征更平稳。