Targeting Safe Analgesia of the Posterior Knee Capsule

Integrating IPACK (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) Block in an Enhanced Recovery after Surgery Pathway for Total Knee Arthroplasty—A Prospective Triple-Blinded Randomized Controlled Trial

We read the article “Integrating IPACK (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) Block in an Enhanced Recovery after Surgery Pathway for Total Knee Arthroplasty—A Prospective Triple-Blinded Randomized Controlled Trial” by Poonam Pai et al in the Journal for Knee Surgery (2023) with great interest.[1] We applaud the authors in finding that when added to an enhanced recovery after surgery pathway consisting of a spinal anesthetic, adductor canal nerve catheter, and surgeon-administered periarticular joint infiltration (PAI), the interspace between the popliteal artery and capsule of the posterior knee (IPACK) block did not significantly impact postoperative opioid consumption or measured functional outcomes on postoperative day 1. Interestingly, the authors found that addition of the IPACK block did significantly decrease posterior knee pain. We found this notable as both the IPACK block and PAI target the posterior knee capsule.

Innervation of the posterior knee capsule is complex and includes branches of the obturator, sciatic, common fibular, and tibial nerves.[2] PAI has variable effectiveness in this anatomical area.[3] Prior studies have shown that addition of the IPACK and adductor canal blocks to PAI provides superior analgesia and decreases opioid consumption in total knee arthroplasty.[4] This study found that the IPACK block resulted in improved posterior knee analgesia compared with PAI. This could signify that an ultrasound-guided approach may be more consistent in targeting the posterior knee capsule.

The authors also astutely mention concern for local anesthetic toxicity (LAST). Peripheral nerve blocks, especially in the lower extremity, have a decreased risk of LAST compared with PAI.[5] Further study of the effectiveness of the IPACK block compared with PAI may show that the IPACK is a reasonable replacement of PAI while also potentially decreasing the risk of LAST. We greatly appreciate the work Dr. Poonam Pai and team performed to further our understanding of posterior knee analgesia and its contribution toward the creation of patient care pathways that target analgesia and prioritize patient safety.

Publication History

Received: 27 September 2022

Accepted: 18 October 2022

Accepted Manuscript online:
21 October 2022

Article published online:
19 January 2023

• References

• 1 Poonam Pai Bh, Jinadu S, Okunlola O, Darkzali H, Lin HM, Lai YH. Integrating IPACK (interspace between the popliteal artery and capsule of the posterior knee) block in an enhanced recovery after surgery pathway for total knee arthroplasty-a prospective triple-blinded randomized controlled trial. J Knee Surg 2023; 36 (12) 1289-1296
• 2 Tran J, Peng PWH, Gofeld M, Chan V, Agur AMR. Anatomical study of the innervation of posterior knee joint capsule: implication for image-guided intervention. Reg Anesth Pain Med 2019; 44 (02) 234-238
• 3 Guild III GN, Galindo RP, Marino J, Cushner FD, Scuderi GR. Periarticular regional analgesia in total knee arthroplasty: a review of the neuroanatomy and injection technique. Orthop Clin North Am 2015; 46 (01) 1-8
• 4 Kim DH, Beathe JC, Lin Y. et al. Addition of infiltration between the popliteal artery and the capsule of the posterior knee and adductor canal block to periarticular injection enhances postoperative pain control in total knee arthroplasty: a randomized controlled trial. Anesth Analg 2019; 129 (02) 526-535
• 5 Gitman M, Barrington MJ. Local anesthetic systemic toxicity: a review of recent case reports and registries. Reg Anesth Pain Med 2018; 43 (02) 124-130