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Slightly better pain relief but more frequently motor blockade with combined nerve block analgesia compared to continuous intraarticular analgesia after total knee arthroplasty.

ABSTRACT: PURPOSE:Pain management after total knee arthroplasty (TKA) is still under debate. Continuous peripheral nerve blocks (PNB) can provide long pain relief but impair muscle function. Continuous intraarticular analgesia could result in longer pain relief than local infiltration analgesia without negative effects on muscle function. This study investigated the efficacy of pain control between PNB's and continuous intraarticular analgesia after TKA. METHODS:A prospective randomized study on 140 patients undergoing TKA was performed. Patients received either a combination of continuous femoral nerve block, continuous sciatic nerve block and single-shot obturator nerve block (group R) or a local infiltration analgesia and a continuous intraarticular catheter with ropivacaine (group L). Primary outcome was pain measured on a numerical rating scale. Knee function, patient-reported outcome (PRO) and adverse events were assessed until 1 year after surgery. RESULTS:Pain at rest was lower in group R on the day of surgery (mean NRS 3.0 vs. 4.2) and the morning of postoperative day 1 (mean NRS 3.4 vs. 4.4). Motor blockade longer than postoperative day 3 occurred more often in group R compared to group L (15.3% vs. 1.5%). Pain levels, PRO and satisfaction 3-month and 1-year after surgery were similar. CONCLUSION:Continuous PNB's were slightly more effective in the first 24 h after surgery but were associated more often with motor blockade which should be avoided. It must be balanced if the small amount of better pain relief immediately after surgery justifies the risks associated with motor blockade following PNB's. LEVEL OF EVIDENCE:I.

SUBMITTER: Lutzner J

PROVIDER: S-EPMC7148269 | biostudies-literature | 2020 Apr

REPOSITORIES: biostudies-literature

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Slightly better pain relief but more frequently motor blockade with combined nerve block analgesia compared to continuous intraarticular analgesia after total knee arthroplasty.

Lützner Jörg J Gehring Richard R Beyer Franziska F

Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA 20200228 4

<h4>Purpose</h4>Pain management after total knee arthroplasty (TKA) is still under debate. Continuous peripheral nerve blocks (PNB) can provide long pain relief but impair muscle function. Continuous intraarticular analgesia could result in longer pain relief than local infiltration analgesia without negative effects on muscle function. This study investigated the efficacy of pain control between PNB's and continuous intraarticular analgesia after TKA.<h4>Methods</h4>A prospective randomized stu ...[more]

PMID: 32112126

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Project description:BACKGROUND:The optimal position for continuous adductor canal block (ACB) for analgesia after total knee anthroplasty (TKA) remians controversial, mainly due to high variability in the localization of the the adductor canal (AC). Latest neuroanatomy studies show that the nerve to vastus medialis plays an important role in innervating the anteromedial aspect of the knee and dives outside of the exact AC at the proximal end of the AC. Therefore, we hypothesized that continuous ACB at the proximal end of the exact AC could provide a better analgesic effect after TKA compared with that at the middle of the AC (which appeared to only block the saphenous nerve). METHODS:Sixty-two adult patients who were scheduled for a unilateral TKA were randomized to receive continuous ACB at the proximal end or middle of the AC. All patients received patient-controlled intravenous analgesia with sufentanil postoperatively. The primary outcome measure was cumulative sufentanil consumption within 24?h after the surgery, which was analyzed using Mann-Whitney U tests. P-values <?0.05 (two-sided) were considered statistically significant. The secondary outcomes included postoperative sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. RESULTS:Sixty patients eventually completed the study (30/group). The 24-h sufentanil consumption was 0.22??g/kg (interquartile range [IQR]: 0.15-0.40??g/kg) and 0.39??g/kg (IQR: 0.23-0.52??g/kg) in the proximal end and middle groups (P?=?0.026), respectively. There were no significant inter-group differences in sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. CONCLUSIONS:Continuous ACB at the proximal end of the AC has a better opioid-sparing effect without a significant influence on quadriceps motor strength compared to that at the middle of the AC after TKA. These findings indicates that a true ACB may not produce the effective analgesia, instead, the proximal end AC might be a more suitable block to alleviate pain after TKA. TRIAL REGISTRATION:This study was registered at ClinicalTrials.gov ( NCT03942133 ; registration date: May 06, 2019; enrollment date: May 11, 2019).

Project description:Unsatisfactory analgesia for major knee surgery with femoral nerve block (FNB) alone was reported and the additional benefit of sciatic block to continuous femoral nerve block (CFNB) was not conclusive. The aim of the present study was to find the benefit of the additional mini-dose spinal morphine (0.035 mg) to CFNB for postoperative pain control and to compare their associated side effects after total knee arthroplasty (TKA).After written informed consent and with Institutional Ethics Committee approval, 68 American Society of Anesthesiologists (ASA) Physical Status I-III patients scheduled for elective unilateral TKA under spinal anesthesia (SA) were included in the present prospective, randomized controlled study. The patients were allocated into two groups. CFNB was placed in all patients by the inguinal paravascular approach with 20 ml of 0.25 % levobupivacaine. Group I (named CFNB/SA group), SA was administered with 2.8 ml levobupivacaine and Group II (named CFNB/SAMO group), SA with 2.8 ml levobupivacaine plus morphine 0.035 mg. At Post Anesthesia Care Unit (PACU), pain and other adverse effects were recorded. Pain was assessed by visual analog scale (VAS) 0-10. Tramadol 50 mg intravenous (IV) was given if the VAS > 4. In the ward, all patients were maintained by continuous femoral infusion of 0.125 % levobupivacaine rate 7 ml/hr and then reduced to 5 ml/hr if VAS ≤3.Patient's demographics data in each group were not different. At post-operative (PO) 12-24 h, the VAS scores were significantly lesser in the CFNB/SAMO group. Cumulative tramadol IV requirement for PO48h were also significantly lesser in the CFNB/SAMO group. Nausea, vomiting and numbness were significantly greater in the CFNB/SAMO group during early postoperative period (PO1-6 h).Though in some patients CFNB was inadequate, a mini-dose of intrathecal morphine (0.035 mg) in addition to CFNB was found to be effective with minimal side effects.Thai Clinical Trial Registry (identifier: TCTR20150609003 , date of registration: 6 June 2015).

Project description:The ideal local anesthetic regime for femoral nerve block that balances analgesia with mobility after total knee arthroplasty (TKA) remains undefined.We compared two volumes and concentrations of a fixed dose of ropivacaine for continuous femoral nerve block after TKA to a single injection femoral nerve block with ropivacaine to determine (1) time to discharge readiness; (2) early pain scores and analgesic consumption; and (3) functional outcomes, including range of motion and WOMAC scores at the time of recovery.Ninety-nine patients were allocated to one of three continuous femoral nerve block groups for this randomized, placebo-controlled, double-blind trial: a high concentration group (ropivacaine 0.2% infusion), a low concentration group (ropivacaine 0.1% infusion), or a placebo infusion group (saline 0.9% infusion). Infusions were discontinued on postoperative Day (POD) 2. The primary outcome was time to discharge readiness. Secondary outcomes included opioid consumption, pain, and functional outcomes. Ninety-three patients completed the study protocol; the study was halted early because of unanticipated changes to pain protocols at the host institution, by which time only 61% of the required number of patients had been enrolled.With the numbers available, the mean time to discharge readiness was not different between groups (high concentration group, 62 hours [95% confidence interval [CI], 51-72 hours]; low concentration group, 73 hours [95% CI, 63-83 hours]; placebo infusion group 65 hours [95% CI, 56-75 hours]; p = 0.27). Patients in the low concentration group consumed significantly less morphine during the period of infusion (POD 1, high concentration group, 56 mg [95% CI, 42-70 mg]; low concentration group, 35 mg [95% CI, 27-43 mg]; placebo infusion group, 48 mg [95% CI, 38-59 mg], p = 0.02; POD 2, high concentration group, 50 mg [95% CI, 41-60 mg]; low concentration group, 33 mg [95% CI, 24-42 mg]; placebo infusion group, 39 mg [95% CI, 30-48 mg], p = 0.04); however, there were no important differences in pain scores or opioid-related side effects with the numbers available. Likewise, there were no important differences in functional outcomes between groups.Based on this study, which was terminated prematurely before the desired sample size could be achieved, we were unable to demonstrate that varying the concentration and volume of a fixed-dose ropivacaine infusion for continuous femoral nerve block influences time to discharge readiness when compared with a conventional single-injection femoral nerve block after TKA. A low concentration of ropivacaine infusion can reduce postoperative opioid consumption but without any important differences in pain scores, side effects, or functional outcomes. These pilot data may be used to inform the statistical power of future randomized trials.Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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Slightly better pain relief but more frequently motor blockade with combined nerve block analgesia compared to continuous intraarticular analgesia after total knee arthroplasty.

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Slightly better pain relief but more frequently motor blockade with combined nerve block analgesia compared to continuous intraarticular analgesia after total knee arthroplasty.

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