Contemporary Perioperative Analgesia in Total Knee Arthroplasty: Multimodal Protocols, Regional Anesthesia, and Peripheral Nerve Blockade

AbstractPerioperative care of the total knee arthroplasty (TKA) patient has evolved considerably over the past decade. Among the changes driving this evolution toward shorter hospitalization and accelerated rehabilitation have been regional anesthesia, peripheral nerve blockade, and multimodal analgesia protocols. These complementary techniques are increasingly supported by scientific evidence, though considerable uncertainty persists regarding the optimal combination of strategies. Continued refinement of technique and critical evaluation is trending toward greater characterization of the comparative effectiveness of myriad options. Contemporary interdisciplinary arthroplasty care teams have the opportunity to individualize the TKA patient's perioperative pain control to optimize not only the clinical outcome but also patient satisfaction.

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Peripheral Nerve Blockade for Total Knee Arthroplasty: An Evidence-Based Review

Current Anesthesiology Reports ◽

10.1007/s40140-015-0104-y ◽

2015 ◽

Vol 5 (2) ◽

pp. 225-234

Author(s):

Lloyd Turbitt ◽

Stephen Choi ◽

Colin J. L. McCartney

Keyword(s):

Total Knee Arthroplasty ◽

Peripheral Nerve ◽

Knee Arthroplasty ◽

Evidence Based ◽

Nerve Blockade ◽

Peripheral Nerve Blockade ◽

Total Knee

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Perioperative Nerve Injury after Total Knee Arthroplasty

Anesthesiology ◽

10.1097/aln.0b013e3182039f5d ◽

2011 ◽

Vol 114 (2) ◽

pp. 311-317 ◽

Cited By ~ 54

Author(s):

Adam K. Jacob ◽

Carlos B. Mantilla ◽

Hans P. Sviggum ◽

Darrell R. Schroeder ◽

Mark W. Pagnano ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Peripheral Nerve ◽

Nerve Injury ◽

Knee Arthroplasty ◽

Outcome Variable ◽

Tourniquet Time ◽

Nerve Blockade ◽

Neurologic Recovery ◽

Peripheral Nerve Blockade ◽

Total Knee

Background Perioperative nerve injury (PNI) is one of the most debilitating complications after total knee arthroplasty (TKA). Although regional anesthesia (RA) techniques reduce pain and improve functional outcomes after TKA, they may also contribute to PNI. The objective of this study was to test the hypothesis that PNI risk differs among patients according to RA use during TKA. Methods All patients aged at least 18 yr who underwent elective TKA from January 1988 to July 2007 were retrospectively identified. The primary outcome variable was the presence of a new PNI documented within 3 months of the procedural date. Age, sex, body mass index, type of procedure, tourniquet time, type of anesthesia, and use of peripheral nerve blockade were evaluated as potential risk factors for PNI using multivariable logistic regression. Results Ninety-seven cases of PNI were identified among 12,329 patients. Overall incidence of PNI was 0.79% (95% CI, 0.64-0.96%). PNI was not associated with peripheral nerve blockade (odds ratio [OR], 0.97) or type of anesthesia (OR, 1.10 [neuraxial vs. general]; OR, 1.82 [combined vs. general]). Risk for PNI decreased with age (OR, 0.68 [per decade]; P < 0.001) but increased with tourniquet time (OR, 1.28 [per 30-min increase]; P = 0.003) and bilateral procedures (OR, 2.51; P < 0.001). Patients with PNI who underwent peripheral nerve blockade were less likely to have complete neurologic recovery (OR, 0.37; P = 0.03). Conclusions Risk for PNI after TKA was unchanged by the use of RA techniques. This finding supports the notion that the known benefits of RA for patients undergoing TKA can be achieved without increasing risk of neurologic injury. However, in rare situations when PNI occurs, complete recovery may be less likely if it develops after peripheral nerve blockade.

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Evidence-based Review of Periarticular Injections and Peripheral Nerve Blocks in Total Knee Arthroplasty

The Open Orthopaedics Journal ◽

10.2174/1874325002014010069 ◽

2020 ◽

Vol 14 (1) ◽

pp. 69-72

Author(s):

Alexander Gaukhman ◽

Simon Garceau ◽

Ran Schwarzkopf ◽

James Slover

Keyword(s):

Total Knee Arthroplasty ◽

Pain Management ◽

Peripheral Nerve ◽

Regional Anesthesia ◽

Knee Arthroplasty ◽

Motor Blockade ◽

Nerve Blocks ◽

Peripheral Nerve Blocks ◽

Post Operative Pain ◽

Total Knee

Background: Recently, post-operative pain management after Total Knee Arthroplasty (TKA) has focused on a multimodal approach for reducing opioid requirements, promoting early rehabilitation, and expediting discharge from hospital. Regional anesthesia, in the form of Periarticular Injections (PAI) and Peripheral Nerve Blocks (PNB), has shown promise as adjunctive therapy to oral analgesics. Objective: To review the current literature surrounding regional anesthesia for TKA. Discussion: PNBs provide effective analgesia after TKA. Historically, femoral nerve blocks (FNB) have been commonly employed. FNBs, however, lead to the significant motor blockade to the quadriceps musculature, which can dampen early rehabilitation efforts and increase the risk of post-operative falls. Adductor Canal Blocks (ACB) have shown excellent results in reducing post-operative pain while minimizing motor blockade. Periarticular injections (PAI), and infiltration between the popliteal Artery and Capsule of the Knee (IPACK) have similarly helped in reducing patient discomfort after TKA and providing analgesia to the posterior capsular region of the knee. Conclusion: PAIs, and PNBs are important elements in many multimodal postoperative pain management protocols after TKA. Current evidence appears to suggest that a combination of an ACB supplemented by posterior capsular analgesic coverage through PAI or IPACK may provide optimal results.

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