Tourniquets and Adductor Canal Blocks in Total Knee Arthroplasty: Is There a Synergistic Effect on Postoperative Pain and Quadriceps Weakness?

Background and Hypothesis: Adequate pain control and avoidance of falls are crucial for successful early recovery following total knee arthroplasty (TKA). Studies have shown an increase in postoperative quadriceps weakness (QW) and pain associated with tourniquet use during TKA. Additionally, increasing doses of adductor canal block (ACB) anesthetic per unit of BMI are associated with QW after TKA. This retrospective cohort study examined whether tourniquets and ACBs have a synergistic effect on postoperative QW and pain. Experimental Design or Project Methods: 348 TKAs in 319 patients performed by a single surgeon between October 2015 and May 2018 were retrospectively reviewed. Outcomes included QW as documented in the physical therapy evaluation, average pain score during the first 24 hours after PACU discharge, average pain score during the remainder of the hospital stay, and final pain score prior to discharge. Results: Sex, age, and BMI did not differ in patients with ACBs with (n=177) and without (n=168) tourniquet use (p≥0.330). The overall prevalence of QW in the sample was 8.7%. Proportionally more patients with ACBs and tourniquets (11.6%) had QW compared to patients with ACBs without tourniquets (6.1%), but the difference was not statistically significant with the numbers available. Patient-reported pain scores at the three time points did not differ significantly between patients who received ACBs with or without tourniquets. Conclusion and Potential Impact: There appears to be no synergistic effect of ACBs and tourniquet use on postoperative pain. However, due to the effect size and number of cases in each group, the synergistic effect of ACBs and tourniquet use on QW deserves additional study with a larger sample size as these results may impact functional recovery and postoperative complications among patients undergoing primary TKA.

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Efficacy of Liposomal Bupivacaine versus Ropivacaine in Adductor Canal Block for Total Knee Arthroplasty

The Journal of Knee Surgery ◽

10.1055/s-0040-1713114 ◽

2020 ◽

Author(s):

Chang-Hwa Mary Chen ◽

Andrew G. Yun ◽

Teresa Fan

Keyword(s):

Total Knee Arthroplasty ◽

Pain Score ◽

Knee Arthroplasty ◽

Opioid Use ◽

Adductor Canal Block ◽

Liposomal Bupivacaine ◽

Adductor Canal ◽

Pain Scores ◽

Average Pain ◽

Total Knee

AbstractAdductor canal block (ACB) is advantageous for postoperative analgesia in total knee arthroplasty (TKA) because it results in minimal motor block. Liposomal bupivacaine (LB) is Food and Drug Administration-approved extended-release formulation of bupivacaine for interscalene peripheral nerve blocks. Its use is increasing in the TKA setting, mainly as a local infiltration agent. We compared the efficacy of ACB using LB versus ropivacaine in TKA. Two cohorts of patients were retrospectively analyzed at a single institution receiving ropivacaine and LB ACB for TKA. Duration of LB ACB, time to first opioid use postrecovery room, amount of opioid use postrecovery room, length of stay (LOS), and average and highest pain scores were collected. A total of 91 and 142 TKA patients received ropivacaine and LB for ACB, respectively. At 8 hours postrecovery room, more patients in the LB group required no opioids compared with the ropivacaine group (p = 0.026). Mean opioid consumption was lower in the LB group than in the ropivacaine group at 8 and 24 hours postrecovery room, although statistical significance was only observed at 8 hours (p = 0.022). The highest pain score for patients in the two groups was not statistically different. The average pain score for patients with a 2-day LOS was higher in the LB group, but average pain scores were similar for patients with 1- and 3-day LOS. Median LOS for the LB and ropivacaine groups was 1 and 2 days, respectively (p < 0.0001). Significantly lower opioid use at 8 hours postrecovery room was seen in the LB group compared with the ropivacaine group. There was no difference in opioid use at 24 and 48 hours. There was also no advantage with LB ACB in decreasing pain scores. However, the LB ACB group demonstrated a significantly shorter LOS compared with the ropivacaine ACB group.

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Tranexamic Acid Increases Early Postoperative Pain and Decreases Time to First Opioid Following Total Knee Arthroplasty

Proceedings of IMPRS ◽

10.18060/23580 ◽

2019 ◽

Vol 2 (1) ◽

Author(s):

Sachin Seetharam ◽

Sydney Keller ◽

Mary Ziemba-Davis ◽

R. Michael Meneghini MD

Keyword(s):

Total Knee Arthroplasty ◽

Postoperative Pain ◽

Blood Loss ◽

Tranexamic Acid ◽

Knee Arthroplasty ◽

Ex Vivo ◽

Pain Scores ◽

Average Pain ◽

Total Knee

Background and Hypothesis: Tranexamic acid (TXA) decreases blood loss in total knee arthroplasty (TKA). However, TXA evoked pain in rats by inhibiting GABA and glycine receptors in the spinal dorsal horn, and caused cellular death in ex vivo and in vitro human periarticular tissues exposed to clinical concentrations of TXA. We evaluated inpatient postoperative pain and blood loss in TKA performed with and without TXA. Project Methods: 105 consecutive cemented TKAs without TXA were compared to 72 consecutive cemented TKAs with TXA. Procedures were performed by a single surgeon using identical perioperative medical and pain-control protocols. Outcomes included: average of q2-4 hour pain scores during the first 24 hours after PACU discharge, average pain during remainder of stay, final pain score prior to discharge, time in minutes to first opioid after PACU discharge, total opioids in morphine equivalents (MEQs) during the first 24 hours after PACU discharge, average MEQs per remaining days of stay, and mean g/dL pre- to postoperative decrease in hemoglobin. Multivariate analyses accounted for 15 demographics and covariates. Results: The sex (p=0.393), age (p=0.784), and BMI (p=0.930) of the two cohorts were similar. Mean pain during the first 24 hours was greater (4.1 vs. 3.2, p=0.001), MEQs consumed during the first 24 hours were greater (45 vs. 37, p=0.069), and time to first opioid medication was shorter (326 vs. 414, p=0.023) in patients who received TXA. The decrease in hemoglobin was less in patients who received TXA (-2.2 vs. -2.7, p<0.001). Conclusion and Potential Impact: Our hypothesis based on animal and laboratory studies that TXA may increase early postoperative pain was confirmed by three metrics. Consistent with the effective life of TXA, pain and opioid consumption after 24 hours did not differ based on TXA use. Further work is warranted to investigate the nature consequences associated with TXA, relative to its demonstrated benefits for blood conservation.

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Does the addition of iPACK to adductor canal block in the presence or absence of periarticular local anesthetic infiltration improve analgesic and functional outcomes following total knee arthroplasty? A systematic review and meta-analysis

Regional Anesthesia and Pain Medicine ◽

10.1136/rapm-2021-102705 ◽

2021 ◽

pp. rapm-2021-102705

Author(s):

Nasir Hussain ◽

Richard Brull ◽

Brendan Sheehy ◽

Michael Dasu ◽

Tristan Weaver ◽

...

Keyword(s):

Total Knee Arthroplasty ◽

Postoperative Pain ◽

Functional Recovery ◽

Knee Arthroplasty ◽

Meta Analysis ◽

Opioid Consumption ◽

Adductor Canal Block ◽

Adductor Canal ◽

Total Knee ◽

Local Anesthetic Infiltration

BackgroundWhen combined with adductor canal block (ACB), local anesthetic infiltration between popliteal artery and capsule of knee (iPACK) is purported to improve pain following total knee arthroplasty (TKA). However, the analgesic benefits of adding iPACK to ACB in the setting of surgeon-administered periarticular local infiltration analgesia (LIA) are unclear.ObjectivesTo evaluate the analgesic benefits of adding iPACK to ACB, compared with ACB alone, in the setting of LIA following TKA.Evidence reviewWe conducted a meta-analysis of randomized trials comparing the effects of adding iPACK block to ACB versus ACB alone on pain severity at 6 hours postoperatively in adult patients undergoing TKA. We a priori planned to stratify analysis for use of LIA. Opioid consumption at 24 hours, functional recovery, and iPACK-related complications were secondary outcomes.FindingsFourteen trials (1044 patients) were analyzed. For the primary outcome comparison in the presence of LIA (four trials, 273 patients), adding iPACK to ACB did not improve postoperative pain at 6 hours. However, in the absence of LIA (eight trials, 631 patients), adding iPACK to ACB reduced pain by a weighted mean difference (WMD) (95% CI) of −1.33 cm (−1.57 to –1.09) (p<0.00001). For the secondary outcome comparisons in the presence of LIA, adding iPACK to ACB did not improve postoperative pain at all other time points, opioid consumption or functional recovery. In contrast, in the absence of LIA, adding iPACK to ACB reduced pain at 12 hours, and 24 hours by a WMD (95% CI) of −0.98 (−1.79 to –0.17) (p=0.02) and −0.69 (−1.18 to –0.20) (p=0.006), respectively, when compared with ACB alone, but did not reduce opioid consumption. Functional recovery was also improved by a log(odds ratio) (95% CI) of 1.28 (0.45 to 2.11) (p=0.003). No iPACK-related complications were reported.ConclusionAdding iPACK to ACB in the setting of periarticular LIA does not improve analgesic outcomes following TKA. In the absence of LIA, adding iPACK to ACB reduces pain up to 24 hours and enhances functional recovery. Our findings do not support the addition of iPACK to ACB when LIA is routinely administered.

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Comparative study between continuous adductor canal block and intravenous morphine for postoperative analgesia in total knee arthroplasty

Ain-Shams Journal of Anesthesiology ◽

10.1186/s42077-020-00112-8 ◽

2020 ◽

Vol 12 (1) ◽

Author(s):

Hithem Mohammed Gamil Mohammed Ali ◽

Bassel Mohammed Essam Nour Eldin ◽

Heba Abd Elazim Labib Ahmed ◽

Ramy Mounir Wahba Gobran ◽

Diaa Eldin Mahmoud Heiba

Keyword(s):

Total Knee Arthroplasty ◽

Postoperative Pain ◽

Knee Arthroplasty ◽

Quadriceps Muscle ◽

Saphenous Nerve ◽

Adductor Canal Block ◽

Adductor Canal ◽

Intravenous Morphine ◽

Group A ◽

Total Knee

Abstract Background Postoperative pain after total knee arthroplasty (TKA) is known to range from moderate (30% of patients) to severe (60% of patients). Inadequate management for postoperative pain may induce various immobility-related complications, muscle weakness, and chronic pain. Therefore, post-TKA analgesia is crucial, not only for patients’ satisfaction, but for improving surgical outcomes and reducing complications. The present study aims to compare the effect of ultrasound-guided adductor canal block ACB (saphenous nerve block) versus incremental dose of intravenous morphine after total knee arthroplasty surgery. Results The results of this study revealed no difference between group A and group B as regards postoperative quadriceps muscle strength; maximal knee flexion, total distance ambulated, and postoperative vital data (heart rate per minute and respiratory rate per minute). However, group A showed better postoperative pain control, lower doses of intravenous morphine consumption and lower incidence of nausea and vomiting. Conclusion Continuous adductor canal block (saphenous nerve block) is superior to intravenous morphine in decreasing postoperative pain and decreasing total morphine consumption and adverse effects as nausea and vomiting, but both are equivalent in preserving quadriceps muscle power.

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