To compare effect of combined block of adductor canal block (ACB) with IPACK (Interspace between the Popliteal Artery and the Capsule of the posterior Knee) and adductor canal block (ACB) alone on Total knee replacement in immediate postoperative rehabilitation

Abstract

Introduction: Pain management in total knee arthroplasty is aimed to minimize postoperative pain and improve functional outcomes in patients. Although there are many methods used for controlling the pain there has been no consensus on most appropriate or the best protocol. Adductor canal block (ACB) has the unique advantage of providing localized analgesia but it doesn't provide pain relief to the posterior capsule, it has been postulated that IPACK (interspace between the popliteal artery and the capsule of the knee) combined with ACB will provide better pain relief than ACB alone. Materials and Methods: 60 Patients were studied in two groups. Group A had those patients with ACB+ ipack and Group B had ACB. Group A -Patient were subjected to combined ACB block with IPACK. Group B -Patient in this group were given ACB. Patient were studied for pain score VAS on Day 0 and Day 1 morning and evening, range of movement at postoperative Day 1 and distance walked on Day 1. Results: Group B had better outcome as compared to Group A. The mean VAS score for the ACB+IPACK group was less than for ACB alone at end of Day 0 and Day 1 in morning and evening. The ROM for the ACB+IPACK group was better than ACB alone and number of steps walked by patients were more in ACB+IPACK as compared to ACB alone. The statistical difference was significant when Adductor +IPACK group was compared to Adductor group for VAS, ROM and number of steps walked. Conclusion: ACB+IPACK is better mode than ACB for control of postoperative pain in patient undergoing Total knee replacement. IPACK is relatively safe and combined with adductor canal block decreases posterior pain in TKR patients.

Anatomical study of the innervation of posterior knee joint capsule: implication for image-guided intervention

“…The presence of the CFN/SCN, TN, and PON articular branches to the posterior capsule, as demonstrated in this study, highlights the anatomical targets for the iPACK block. Presently, only one randomized trial has been published to show that combined ACB and iPACK block provides superior analgesia to ACB alone 21. Our study also suggests that the injection along the line joining the superior aspect of the two femoral condyles may anesthetize most of the posterior articular branches.…”

Editors’ Note to: Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period

“…The Editor-in-Chief of the European Journal of Orthopaedic Surgery and Traumatology are issuing an Editor's Note for this article [1]. It was brought to our attention that the results overlap with a previously published article by Reddy et al [2]. Despite reporting the same results, differences have been noted in the study design, data collection periods and methodologies described.…”

Evaluation of the iPACK block injectate spread: a cadaveric study

“…Furthermore, combining an iPACK block with ACB and PAI significantly reduced dynamic pain on ambulation and physical therapy when compared with PAI alone 13. Although ropivacaine 0.2% and 0.25% has been used in past clinical studies in varying volumes, 15 mL,12 20 mL,5 25 mL,13 and 30 mL,3 the optimal volume and concentration (dose) of local anesthetic administration has not been determined pending future dose–response and pharmacokinetic studies.…”

“…However, due to the proximity of the tibial and common fibular nerves (CFN) to the targeted region of injection, there is a potential risk of unintentional motor blockade of these somatic nerves. The site of iPACK injection described by Dr Sanjay Sinha is approximately 1 fingerbreadth above the base of patella,4 while Thobhani et al 3 and Reddy et al 5 performed this block more distally at the level of the femoral condyles. Although the iPACK block represents a promising adjunct to FNB or ACB/FTB, little is known about the extent of injectate distribution, articular nerve targets and/or optimal site of injection.…”