Saphenous Nerve Block From Within the Knee Is Feasible for TKA: MRI and Cadaveric Study

Kavolus, Joseph J.; Sia, David; Potter, Hollis G.; Attarian, David E.; Lachiewicz, Paul F.

doi:10.1007/s11999.0000000000000006

Cited by 18 publications

(17 citation statements)

References 29 publications

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“…A recent MRI and cadaveric study seems to show that saphenous nerve block is feasible from within the knee, and thus could be performed by the surgeon. 228 It was observed that administration of basic analgesics (NSAIDs or COX-2-specific inhibitors combined with paracetamol) was missing in a significant number of RCTs, which precludes an objective evaluation of the benefits of the analgesic intervention studied. 229 There was considerable heterogeneity between studies with regards to anaesthetic and analgesic techniques as well as variability in outcomes assessed.…”

Section: Discussionmentioning

confidence: 99%

Pain management after total knee arthroplasty

Lavand’homme¹,

Kehlet²,

Rawal³

et al. 2022

European Journal of Anaesthesiology

105

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BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA.DESIGN A narrative review based on published systematic reviews and meta-analyses, using modified PROSPECT methodology.DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA.ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance.RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 mg) may be considered in hospitalised patients only in situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified.CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.

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Section: Discussionmentioning

confidence: 99%

Pain management after total knee arthroplasty

Lavand’homme¹,

Kehlet²,

Rawal³

et al. 2022

European Journal of Anaesthesiology

105

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“…In line with them, we found AMR was an independent predictor of PROMS (KSS total-post score and HSS-post score) in elderly OA patients following TKA in our study (Tables 3 and 4 ). Meanwhile, the current use of MRI was becoming more and more widespread in process of diagnosis and treatment [ 42 – 45 ]. These results to some extent supported the feasibility of AMR in the knee joint to be a predictor of functional outcomes in elderly OA patients after TKA.…”

Section: Discussionmentioning

confidence: 99%

Predictive value of adipose to muscle area ratio based on MRI at knee joint for postoperative functional outcomes in elderly osteoarthritis patients following total knee arthroplasty

et al. 2020

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Background The current research used a new index—adipose to muscle area ratio (AMR)—to measure fatness compared with body mass index (BMI) in elderly osteoarthritis (OA) patients following total knee arthroplasty. Our study aimed to test the relationship between the two indexes (AMR and BMI) and to examine whether AMR was a predictive factor of patient-reported outcome measures (PROMS) for elderly OA patients following total knee arthroplasty (TKA). Methods The retrospective data of 78 OA patients (older than 60 years) following TKA was included in our study. Clinical features of patients included age, BMI, sex, AMR, side of the implant, time of follow-up, complications, the Knee Society Score (KSS score), and the Hospital for Special Surgery knee score (HSS score). The area of adipose tissue and muscle tissue was measured on the cross section (supra-patella, midline of the patella, joint line of the knee) of the knee magnetic resonance imaging (MRI). AMR was calculated as the average of adipose to muscle area ratio at the three levels. The Pearson correlation analysis, simple linear regression, and multiple linear regression were used to study the relationship between BMI, AMR, and PROMS (KSS total-post score and HSS-post score) in the study. Results Of all patients, the mean (± standard deviations (SD)) of age was 67.78 ± 4.91 years. For BMI and AMR, the mean (± SD) were 26.90 ± 2.11 and 2.36 ± 0.69, respectively. In Pearson correlation analysis, BMI had a good correlation with AMR (r = 0.56, p = 0.000), and AMR (r = − 0.37, p = 0.001, HSS-post score; r = − 0.43, p = 0.000, KSS total-post score) had better correlations with PROMS postoperatively compared with BMI (r = − 0.27, p = 0.019, HSS-post score; r = − 0.33, p = 0.003, KSS total-post score). In multivariate linear regression analysis, AMR was negatively correlated with KSS total-post score as well as HSS-post score, while BMI was not. As for patients with complications, AMR values were between the 3rd quartile and 4th quartile of the AMR value in the entire study cohort. Conclusions In this study, the new obesity evaluation indicator—AMR, which was well related with BMI, was found to be a predictor of PROMS (KSS total-post score and HSS-post score) in elderly OA patients following TKA.

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“…Pepper et al described an ACB which they performed in 11 cadavers with an accuracy of 86%, but they did not describe the anatomical landmarks for the injection [16]. Kavolus et al used the femoral transepicondylar axis as their anatomical landmark to perform the ACB in cadavers with an accuracy of 72% [17]. Our study uses the superior pole of the patellar and medial epicondyle as the anatomical landmarks to estimate the location of the adductor tubercle.…”

Section: Discussionmentioning

confidence: 98%

“…Kavolus et al. used the femoral transepicondylar axis as their anatomical landmark to perform the ACB in cadavers with an accuracy of 72% [ 17 ]. Our study uses the superior pole of the patellar and medial epicondyle as the anatomical landmarks to estimate the location of the adductor tubercle.…”

Section: Discussionmentioning

confidence: 99%

Anatomical Landmarks for Intraoperative Adductor Canal Block in Total Knee Arthroplasty: A Cadaveric Feasibility Assessment

2021

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Background: Postoperative analgesia after knee arthroplasty forms a basis for an optimal range of motion after surgery. Femoral nerve blocks are established as a sensory nerve blockade but at the expense of quadriceps weakness delaying postoperative mobilization. The adductor canal block (ACB) similarly provides sensory blockade but preserves quadriceps function. If ACB is performed intraoperatively, it would reduce the time and cost needed for ACBs. This study aimed at investigating possible landmarks making it feasible to perform ACB intraoperatively. Material and methods: Twenty-seven knees were used. The superior pole of the patella, medial epicondyle, and adductor tubercle was proposed as landmarks to perform the ACB through a medial parapatellar approach. A needle was directed toward the adductor tubercle until a tactile feedback was felt. Ten to 15 mL India ink were injected using this technique. The adductor canal was dissected to visualize the ink spread and determine whether the saphenous nerve and the nerve to vastus medialis were exposed to the ink. Results: The anatomic landmarks were easily identified in all knees. The ACB resulted in the saphenous nerve and nerve to vastus medialis being bathed in ink consistently. A volumetric relationship was noted with the injectate. No injury to the neurovascular structures was observed. Conclusions: An accurate and safe technique with reliable anatomic landmarks was presented to perform an ACB. In addition, an increase in injected ink volume correlated to an increase in the spread of ink; thus, we postulate that 10 mL of local anesthetic may be sufficient for an adequate regional block.

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Saphenous Nerve Block From Within the Knee Is Feasible for TKA: MRI and Cadaveric Study

Abstract: This technique may be a useful alternative to an ultrasound-guided block. A trial comparing surgeon- and anesthesiologist-performed nerve block should be considered to determine the clinical efficacy of this procedure.

Cited by 18 publications

References 29 publications

Pain management after total knee arthroplasty

Pain management after total knee arthroplasty

Predictive value of adipose to muscle area ratio based on MRI at knee joint for postoperative functional outcomes in elderly osteoarthritis patients following total knee arthroplasty

Anatomical Landmarks for Intraoperative Adductor Canal Block in Total Knee Arthroplasty: A Cadaveric Feasibility Assessment

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