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.

A randomized comparative evaluation of local infiltration analgesia, extended nerve blocks, and conventional analgesia in pain management after total knee arthroplasty

“…[11] A recently conducted study compared the continuous intraarticular administration of ropivacaine with the combined continuous femoral, sciatic, and single-shot obturator nerve block. [12] A slightly better pain relief, but more frequent motor blockade, and even persisting quadriceps weakness were observed in the perineural catheter group.…”

“…A couple of studies employed local anesthetic administered to only femoral nerve, [3][4][5][6][7][8][9][10] only in two studies provided blockade each of the three the nerves supplied the joint of the knee. [11,12] A systematic review reported less overall pain scores, opioid consumption, and more extended overall range on motion in the first 72 h after TKA, when femoral nerve block was combined with sciatic or obturator nerve block or with both. [18] In one of these studies, the femoral and sciatic nerve were blocked with or without obturator nerve blockade.…”

“…[3][4][5][6][7][8][9][10] To the best of our knowledge, there are only few studies using blockade of all the three nerves, where posterior approach was used to perform sciatic block. [11,12] Objectives: The aim of this study was to analyze the postoperative effects of extended nerve blocks and local infiltration analgesia (LIA) on postoperative pain control, muscle weakness, and blood loss after total knee arthroplasty (TKA). Patients and methods: Between February 24 th 2020 and July 10 th 2020, a total of 161 patients (55 males, 106 females; median age: 69.0 years [IQR 63.0-75.0], range, 41 to 81 years) who underwent primary TKA were randomly allocated into three parallel groups according to their concomitant procedure in a double-blind fashion: (i) those to whom nerve blockade was performed after competition of surgery under the duration of spinal anesthesia (n=50); (ii) those to whom LIA was performed during surgery (n=52), and (iii) control group (n=59).…”

Pain management in total knee arthroplasty. A comprehensive review

“…That is why recent studies emphasize continuous PNB, especially ACB [72] because continuous FNB impaired mobilization capability due to the weakness of the quadricep muscle. [73][74][75].…”

iPACK block vs. periarticular injection for total knee arthroplasty. A comprehensive review

“…In addition, Runge et al (28) randomized 82 patients combined with triangular femoral block to reduce morphine use over LIA after TKA (6 vs. 20; p < 0,001). Finally, Lützner et al(29) found that a…”