Femoral nerve block for total knee replacement — A word of caution

Background Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.Questions/purposes We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. Methods Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. Results The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p \ 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.

Section: Introductionmentioning

confidence: 99%

Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA: A Randomized, Double-blind Trial

Reinhardt

Duggal

Umunna

et al. 2014

“…However, concerns remain that femoral nerve block will prevent early ambulation and increase the number of patient falls after surgery [1,7,10,12]. In our cohort, all patients were able to ambulate by postoperative Day 1 and 45% (35 of 77) of patients were able to ambulate on the day of surgery.…”

Section: Discussionmentioning

confidence: 87%

“…For example, Seet et al [16] reported no ambulation until at least 60 hours after surgery. Similarly, Kandasami et al [10] reported that 70% of their patients were unable to mobilize until postoperative Day 2 ( Table 2). An important component of our treatment protocol facilitating ambulation is the use of dilute bupivacaine with the intention of preserving motor function.…”

Section: Discussionmentioning

confidence: 88%

“…These blocks have also been shown to decrease length of stay and complications and increase early knee flexion [3,5,6,8,14,15,18]. However, several studies have raised the concern that continuous femoral nerve block may delay patient ambulation and increase the risk of falls during the postoperative period [10,16]. To date, few studies specifically address the effect of continuous femoral nerve block on early ambulation after TKA [4,14,15].…”

Section: Introductionmentioning

confidence: 99%

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Continuous Femoral Nerve Block Using 0.125% Bupivacaine Does Not Prevent Early Ambulation After Total Knee Arthroplasty

Beebe

Allen

Anderson

et al. 2014

Background Continuous femoral nerve block has been shown to decrease opioid use, improve postoperative pain scores, and decrease length of stay. However, several studies have raised the concern that continuous femoral nerve block may delay patient ambulation and increase the risk of falls during the postoperative period. Questions/purposes This study sought to determine whether continuous femoral nerve block with a single-shot sciatic block prevented early ambulation after total knee arthroplasty (TKA) and whether the technique was associated with adverse effects.

“…These postoperative falls represent a major source of potential morbidity for the patient, as well as regulatory and financial liability for the institution; therefore, substantial resources have been expended to understand which patients are at risk for falling and when these falls occur [2,4,10,12,15,16]. Numerous factors associated with falls have been identified, some of which are intrinsic to the patient, such as age and cognitive impairment, while other factors are related to the procedures and treatments that they undergo, such as medication side effects and muscle weakness from peripheral nerve blocks [3,9,10,13,17]. External factors may also play a role, including room design, bed height, and staff-to-patient ratios [19,20].…”

Section: Introductionmentioning

confidence: 99%

Preoperative Patient Education Reduces In-hospital Falls After Total Knee Arthroplasty

Clarke

Timm

Goldberg

et al. 2012

Background Inpatient hospital falls after orthopaedic surgery represent a major problem, with rates of about one to three falls per 1000 patient days. These falls result in substantial morbidity for the patient and liability for the institution. Questions/purposes We determined whether preoperative patient education reduced the rate of in-hospital falls after primary TKA and documented the circumstances and the injuries resulting from the falls. Patients and MethodsWe reviewed data from all 244 patients who underwent primary TKA at a single institution between March and November 2009. Seventytwo patients of one surgeon were enrolled in a preoperative nurse-led education program. This group was compared with a control group of 172 patients who concurrently underwent TKA at the same institution but did not receive preoperative education. Results More control patients had in-hospital falls than those in the education group: seven (one of whom had two falls) of 172 (4%) versus none of 72 (0%), respectively.