The combined treatment of entrapped Infrapatellar Branch of the Saphenous Nerve after ACL reconstruction: Ultrasound-guided perineural injection and acupotomy

BACKGROUND: The anterior cruciate ligament (ACL) reconstruction (ACLR) under the arthroscopy is a widespread procedure for ACL rupture, which could stabilize knee and promote recovery. However, one of its complications is the injury of infrapatellar branch of saphenous nerve (IBSN). In traditional Chinese medicine, acupotomy functions via releasing and stripping adhesion tissues. Accordingly, acupotomy is suitable for the treatment of entrapped nerve injury and tissues adhesion. CASE DESCRIPTION: A 14-year-old man, who had ACLR before and returned to normal activity, presented with severe pain after a mild strain two weeks ago. The physical and imaging examinations revealed the compression injury of IBSN. METHODS: We provided the ultrasound-guided perineural injection of 0.4% lidocaine, while it only alleviates the symptoms temporally and partially. Acupotomy using a small needle knife (0.4*40 mm) was performed. RESULTS: The severe pain was immediately resolved. The visual analog pain scale (VAS) decreased from 10 to 1 and return to normal walking. The diameter of IBSN became smaller and the signal of peripheral soft tissue became hypoechoic in ultrasound. CONCLUSION : In this case, the combined treatments of ultrasound-guided perineural injection and acupotomy are thought to be innovative procedures for IBSN entrapment with relative long-lasting therapeutic effects.

Combined popliteal and saphenous nerve block vs NSAIDS for post operative analgesia in below knee surgery patients: A cross-sectional study

Peripheral nerve blocks are becoming increasingly popular to control postoperative pain in orthopaedic limb surgeries. An outstanding feature of nerve block is its lack of adverse effects, reduced requirement of analgesics and better patient satisfaction. To compare the efficacy of combined popliteal and saphenous nerve block with NSAIDS for postoperative pain relief in below knee surgery patients. We performed a prospective randomized study involving seventy patients. All patients underwent an elective orthopaedic procedure below knee under spinal anaesthesia. Thirty five patients had received a combined popliteal and saphenous nerve block and the rest thirty-five received intravenous NSAIDS at the end of surgical procedure. Post operative VAS Score, time for first rescue analgesia, total diclofenac requirement, total anti-emetic requirement and complications if any were noted.: The statistical power of sample was 80% and type I error (α) of 0.05. The distribution of the data was evaluated using the Shapiro-Wilk test. For data with a non-normal distribution, the Mann-Whitney U test was used in intergroup comparisons. The data were expressed as the median, minimum and maximum (min-max). For comparison of postoperative analgesic use, the chi-square test was used, and complication rates were compared using a cross-ratio test. P-values less than 0.05 were considered to be statistically significant in all the analyses.: Patients with a combined popliteal and saphenous nerve block had significantly less pain at six hours, twelve hours and twenty four hours (p value <0.001) postoperatively. Time for request of rescue analgesia was prolonged. Total diclofenac and anti emetic requirement was also reduced. Also higher level of satisfaction was achieved among this group of patients. : A combined popliteal and saphenous nerve block provides significantly better postoperative pain relief than NSAIDS in patients who underwent below knee surgeries.

Comparative Study Between Ultrasound Guided Femoral Nerve Block Versus Ultrasound Guided Saphenous Nerve Block After Total Knee Replacement

Background Total knee arthroplasty (TKA) is one of the most commonly performed operations in our daily practice. It is indicated in all patients with severe osteoarthritis and it needs early postoperative ambulation to improve postoperative outcomes and to reduce immobility related complications. Providing adequate analgesic control is very important to achieve functional recovery, facilitates rehabilitation and attenuates the progression from acute to chronic postsurgical pain, aiming to maximize non-opioid analgesics in addition to regional analgesic techniques. It is estimated that the majority of patients experience either severe pain (60% of patients) or moderate pain (30% of patients) following TKA surgeries. With the emergence of enhanced recovery after surgery ERAS clinical pathways, many surgical specialties are adopting multimodal analgesic regimens to improve patient outcomes. Objective This study aimed at shedding lights on the value of preserving the motor function in the immediate postoperative period after total knee replacement. That was illustrated by comparing femoral nerve block (mixed motor and sensory nerve) versus saphenous nerve block (pure sensory nerve) in the adductor canal, and the effect of either blocks on the analgesia and ambulation of the patients postoperatively. Patients and Methods After approval of the departmental ethical committee, from September 2017 to September 2019, this Prospective double armed interventional randomized clinical study was conducted at Ain Shams University Hospitals, operating theatre department on 40 adult patients of ASA physical status classification I-II, admitted to Ain Shams university hospital, scheduled for elective primary unilateral total knee replacement surgery. The patients were subdivided into 2 groups A and B, (20) patients for each group. Results In our study we performed a prospective randomized trial to compare between saphenous nerve block (adductor canal block ACB) versus femoral nerve block FNB regarding postoperative analgesic efficacy in terms of pain scores using visual analogue scale VAS during rest and during 45 degree passive flexion of the knee joint, both were measured at 6, 12, 24 and 48 hours postoperatively. Total nalufen consumption in the first 24 hours postoperative was measured in milligrams. Also postoperative Quadriceps muscle strength clinical testing by using a Timed Up-and-Go test (TUG test) at 24 hours postoperative and (10 minutes walking test) at 24 hours postoperative. We found that analgesic efficacy of both groups in the terms of VAS pain scores and cumulative 1st 24 hours Nalufin consumption are equivalent but there is a statistically significant difference in quadriceps muscle strength being higher in adductor canal block group than femoral nerve block group. TUG test results were lower in ACB group compared to FNB group, and results of 10-minutes walking test were significantly higher in ACB group compared to FNB group. Also incidence of postoperative nausea, vomiting and Sedation was assessed and it was found no statistically significant differences in nausea, vomiting and Sedation between the two groups. Conclusion Saphenous nerve block (adductor canal block) is equivalent to femoral nerve block in achieving postoperative pain but it's superior to femoral nerve block in preserving quadriceps muscle power. So it's competent to be chosen as postoperative analgesic modality after Total knee replacement surgeries.

Effect of perineural dexamethasone as an adjuvant to levobupivacaine in saphenous nerve block for knee arthroplasty

Background Total knee arthroplasty (TKA) is a major surgery where postoperative pain management not only aims for patients comfort but also is crucial to achieve post-operative ambulation leading to better outcome and preventing post-operative complications. Femoral nerve block is commonly used following Total knee arthroplasty for post-operative pain control but affects the quadriceps muscle strength increasing the risk of falls. Meanwhile, Adductor canal block has only sensory effect while preserving the motor power allowing for functional recovery within the first 24 hours post‑total knee arthroplasty. However, single injection nerve block is limited by its short duration. Adding adjuvants to the local anesthetic has shown prominent results in prolongation of the duration of the nerve block with dexamethasone being the most effective one. Aim of the Work to assess the efficacy of perineural dexamethasone as an adjuvant on duration of sensory blockage of Saphenous nerve block - performed by levobupivacaine -after knee arthroplasty surgery. Patients and Methods This randomized clinical trial study was carried at Ain Shams university hospitals, starting from March 2019 to August 2019. It included forty adult patients undergoing unilateral total knee arthroplasty who were randomly divided into 2 groups. A group received spinal anaesthesia followed by adductor canal block (ACB) with 19ml levobupivacaine plus 1ml normal saline and the other received spinal anesthesia followed by ACB with 19ml levobupivacaine injection plus 1ml (4mg) dexamethasone. The two groups were adequately monitored and assessed post-operatively for 24 hours and they were compared regarding analgesic outcome by recording time for first for analgesic need, total consumption of opioid and pain score during walking and climbing stairs. Side effects were also monitored and compared. Results prolongation of ACB when adding dexamethasone perineurally as an adjuvant to levobupivacaine, evident by prolongation of time for first analgesic requirement, decrease in total consumption of opioid in first 24 hours and lower pain score during walking and climbing stairs. Conclusion Adding dexamethasone as an adjuvant to ACB showed that it prolonged its duration with decrease in the post-operative pain scores and total morphine consumption.