Combined femoral and popliteal nerve block is superior to local periarticular infiltration anaesthesia for postoperative pain control after total knee arthroplasty

Abstract

Introduction After primary total knee arthroplasty (TKA), local periarticular infiltration anaesthesia (LIA) is a fast and safe method for postoperative pain control. Moreover, ultrasound-guided regional anaesthesia (USRA) with femoral and popliteal block is a standard procedure in perioperative care. Two analgesic regimens for TKA—LIA versus URSA with dexmedetomidine—were compared as an additive to ropivacaine. We hypothesised that the use of URSA provides a superior opioid sparing effect for TKA compared with LIA. Methods Fifty patients (planned 188 participants; safety analysis was performed after examining the first 50 participants) were randomised. These patients received LIA into the knee capsule during surgery with 60 ml of ropivacaine 0.5% and 1 ml of dexmedetomidine (100 µg ml−1) or two single-shot URSA blocks (femoral and popliteal block) before surgery with 15 ml of ropivacaine 0.5% and 0.5 ml of dexmedetomidine for each block. Postoperative opioid consumption in the first 48 h, pain assessment and complications were analysed. Results In the safety analysis, there was a significantly higher need for opioids in the LIA group, with a median oral morphine equivalent of 42.0 [interquartile range (IQR) 23.5–57.0] mg versus 27.0 [IQR 0.0–33.5] mg (P = 0.022). Due to this finding, the study was terminated for ethical considerations according to the protocol. Conclusion This is the first study presenting data on LIA application in combination with dexmedetomidine. A superior opioid-sparing effect of URSA was observed when compared with LIA in TKA when dexmedetomidine is added to local anaesthetics. Also, a longer lasting opioid-sparing effect in the LIA group was observed when compared with the recently published literature; this difference could be attributed to the addition of dexmedetomidine. Therefore, multimodal analgesia regimens could be further improved when LIA or USRA techniques are combined with dexmedetomidine.

Local Periarticular Infiltration with Dexmedetomidine Results in Superior Patient Well-Being after Total Knee Arthroplasty Compared with Peripheral Nerve Blocks: A Randomized Controlled Clinical Trial with a Follow-Up of Two Years

“…The study's cohort was based on a previous study [18] that examined two novel analgesic regimens for TKA using dexmedetomidine additionally in LIA and USRA, focusing on opioid consumption, postoperative pain, and complications, but was terminated due to ethical considerations. With a minimum follow-up of two years in this study population, we aimed to gain new insights into the effects of the described analgesic regimens on patients' clinical outcomes and well-being up to two years postoperatively.…”

“…Among peripheral nerve blocks (PNBs), the femoral, sciatic, and obturator nerves are the most common targets for postoperative analgesia by ultrasound-guided regional anesthesia (USRA) in TKA [18]. Furthermore, the combination of a femoral (FNB) and sciatic nerve block (SNB), which contributes to additional improved pain relief compared to FNB alone [19,20], is described by a recent meta-analysis as one of the best options when it comes to early pain relief [21].…”

“…This is one of the reasons that LIA has been the subject of increasing interest in recent years [23]. Besides its advantages regarding lower complication rates and reduced systemic toxicity, the application of LIA in TKA is simple and fast [15,18,24]. Moreover, the analgesic effect of both approaches is reported to be comparable, with no significant difference in the short-term, making LIA a feasible alternative to combined femoral and sciatic nerve blocks [25].…”

“…Concerning regional anesthesia and analgesia, it has shown superiority over fentanyl in elective cesarean sections by increasing the time to first rescue analgesia and prolonging the duration of the sensory block [29]. Additionally, a study by Schittek et al provided data on TKA patients who received USRA with FNB and SNB as well as LIA with dexmedetomidine as an adjuvant in both groups [18]. The authors observed significantly more pain in the USRA group than in the LIA group at rest and exercise one day after surgery, with no meaningful difference between the study groups until the sixth postoperative day [18].…”

“…Additionally, a study by Schittek et al provided data on TKA patients who received USRA with FNB and SNB as well as LIA with dexmedetomidine as an adjuvant in both groups [18]. The authors observed significantly more pain in the USRA group than in the LIA group at rest and exercise one day after surgery, with no meaningful difference between the study groups until the sixth postoperative day [18]. Furthermore, they detected a longer-lasting opioid-sparing effect in both groups, which they attributed to the addition of dexmedetomidine.…”