Download PDF
J Knee Surg 2021; 34(07): 705-711
DOI: 10.1055/s-0039-1700840
Original Article

Decreased Opioid Consumption and Length of Stay Using an IPACK and Adductor Canal Nerve Block following Total Knee Arthroplasty

Christian J. Eccles
1   Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
,
Andrew M. Swiergosz
1   Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
,
Austin F. Smith
1   Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
,
Samrath J. Bhimani
1   Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
,
Langan S. Smith
2   Orthopedic Associates, KentuckyOne Health Medical Group, Louisville, Kentucky
,
Arthur L. Malkani 
1   Department of Orthopaedic Surgery, University of Louisville, Louisville, Kentucky
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Peripheral nerve blocks such as a femoral + sciatic block have demonstrated significant pain relief following TKA. However, these nerve blocks have residual motor deficits which prevent immediate postoperative ambulation. The purpose of this study was to compare outcomes in patients undergoing primary TKA with femoral and sciatic (Fem + Sci) motor nerve blocks versus an adductor canal and the interspace between the popliteal artery and the capsule of the posterior knee and adductor canal block (IPACK + ACB) sensory nerve blocks. A total of 100 consecutive patients were reviewed, 50 received Fem + Sci nerve blocks and 50 received IPACK + ACB blocks preoperatively. There were no differences in the two groups with respect to surgical technique, implant type, postoperative pain, and physical therapy protocols. Differences in opioid requirements, length of stay (LOS), distance walked, and common knee scoring systems were analyzed. Among them, 62% IPACK + ACB patients were discharged on postoperative day 1 compared with 14% in the Fem + Sci group (p < 0.0001). The IPACK + ACB patients had a shorter LOS (mean 1.48 days vs. 2.02 days, p < 0.001), ambulated further on postoperative day 0 (mean 21.4 feet vs. 5.3 feet, p < 0.001), and required less narcotics the day after surgery (mean, 15.7 vs. 24.0 morphine equivalents p < 0.0001) and at 2 weeks (mean, 6.2 vs. 9.3 morphine equivalents, p = 0.025). The use of this combination IPACK and ACB demonstrated improved early ambulation with a decrease in opioid use and length of stay compared with a femoral and sciatic motor nerve block in patients undergoing primary TKA.

Keywords

primary TKA - opioid use - length of stay - femoral sciatic nerve block - adductor canal block - IPACK block


Publication History

Received: 07 May 2019

Accepted: 18 September 2019

Article published online:
04 November 2019

© 2019. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009; 467 (10) 2606-2612
    CrossrefPubMedGoogle Scholar
  • 2 Grosu I, Lavand'homme P, Thienpont E. Pain after knee arthroplasty: an unresolved issue. Knee Surg Sports Traumatol Arthrosc 2014; 22 (08) 1744-1758
    CrossrefPubMedGoogle Scholar
  • 3 Horner G, Dellon AL. Innervation of the human knee joint and implications for surgery. Clin Orthop Relat Res 1994; (301) 221-226
    PubMedGoogle Scholar
  • 4 Macfarlane AJR, Prasad GA, Chan VWS, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty?. Clin Orthop Relat Res 2009; 467 (09) 2379-2402
    CrossrefPubMedGoogle Scholar
  • 5 Chan E-Y, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev 2014; (05) CD009941
    PubMedGoogle Scholar
  • 6 Moucha CS, Weiser MC, Levin EJ. Current strategies in anesthesia and analgesia for total knee arthroplasty. J Am Acad Orthop Surg 2016; 24 (02) 60-73
    CrossrefPubMedGoogle Scholar
  • 7 Xu J, Chen XM, Ma CK, Wang XR. Peripheral nerve blocks for postoperative pain after major knee surgery. Cochrane Database Syst Rev 2014; (12) CD010937
    PubMedGoogle Scholar
  • 8 Perlas A, Kirkham KR, Billing R. et al. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med 2013; 38 (04) 334-339
    CrossrefPubMedGoogle Scholar
  • 9 Cullom C, Weed JT. Anesthetic and analgesic management for outpatient knee arthroplasty. Curr Pain Headache Rep 2017; 21 (05) 23
    CrossrefPubMedGoogle Scholar
  • 10 Baratta JL, Gandhi K, Viscusi ER. Perioperative pain management for total knee arthroplasty. J Surg Orthop Adv 2014; 23 (01) 22-36
    CrossrefPubMedGoogle Scholar
  • 11 Hsia H-L, Takemoto S, van de Ven T. et al. Acute pain is associated with chronic opioid use after total knee arthroplasty. Reg Anesth Pain Med 2018; 43 (07) 705-711
    PubMedGoogle Scholar
  • 12 Nickel BT, Klement MR, Byrd WA, Attarian DE, Seyler TM, Wellman SS. The James A. Rand young investigator's award: battling the opioid epidemic with prospective pain threshold measurement. J Arthroplasty 2018; 33 (7S): S3-S7
    CrossrefPubMedGoogle Scholar
  • 13 Jæger P, Zaric D, Fomsgaard JS. et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 2013; 38 (06) 526-532
    CrossrefPubMedGoogle Scholar
  • 14 Zorrilla-Vaca A, Li J. The role of sciatic nerve block to complement femoral nerve block in total knee arthroplasty: a meta-analysis of randomized controlled trials. J Anesth 2018; 32 (03) 341-350
    CrossrefPubMedGoogle Scholar
  • 15 Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 2010; 468 (01) 135-140
    CrossrefPubMedGoogle Scholar
  • 16 Thacher RR, Hickernell TR, Grosso MJ. et al. Decreased risk of knee buckling with adductor canal block versus femoral nerve block in total knee arthroplasty: a retrospective cohort study. Arthroplast Today 2017; 3 (04) 281-285
    CrossrefPubMedGoogle Scholar
  • 17 Patterson ME, Bland KS, Thomas LC. et al. The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study. J Clin Anesth 2015; 27 (01) 39-44
    CrossrefPubMedGoogle Scholar
  • 18 Kuang M-J, Ma J-X, Fu L, He W-W, Zhao J, Ma X-L. Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A grade analysis of the evidence through a systematic review and meta-analysis. J Arthroplasty 2017; 32 (10) 3238-3248.e3
    CrossrefPubMedGoogle Scholar
  • 19 Mudumbai SC, Kim TE, Howard SK. et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472 (05) 1377-1383
    CrossrefPubMedGoogle Scholar
  • 20 Abdallah FW, Chan VWS, Gandhi R, Koshkin A, Abbas S, Brull R. The analgesic effects of proximal, distal, or no sciatic nerve block on posterior knee pain after total knee arthroplasty: a double-blind placebo-controlled randomized trial. Anesthesiology 2014; 121 (06) 1302-1310
    CrossrefPubMedGoogle Scholar
  • 21 Elliott CE, Thobhani S. The adductor canal catheter and interspace between the popliteal artery and the posterior capsule of the knee for total knee arthroplasty. Tech Reg Anesth Pain Manage 2014; 18 (04) 126-129
    CrossrefPubMedGoogle Scholar
  • 22 Sinha SK, Abrams JH, Arumugam S. et al. Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study. Anesth Analg 2012; 115 (01) 202-206
    CrossrefPubMedGoogle Scholar
  • 23 Sankineani SR, Reddy ARC, Eachempati KK, Jangale A, Gurava Reddy AV. 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. Eur J Orthop Surg Traumatol 2018; 28 (07) 1391-1395
    CrossrefPubMedGoogle Scholar
  • 24 Thobhani S, Scalercio L, Elliott CE. et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: an analysis of 106 patients. Ochsner J 2017; 17 (03) 233-238
    Google Scholar
  • 25 Reddy DAG, Jangale DA, Reddy DR, Sagi DM, Gaikwad DA, Reddy DA. 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. Int J Orthop Sci 2017; 3 (Suppl. 02) 141-145
    CrossrefPubMedGoogle Scholar
  • 26 Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States - an alternative projection model. Osteoarthritis Cartilage 2017; 25 (11) 1797-1803
    CrossrefPubMedGoogle Scholar
  • 27 Backstein D, Thiagarajah S, Halawi MJ, Mont MA. Outpatient total knee arthroplasty-the new reality and how can it be achieved?. J Arthroplasty 2018; 33 (12) 3595-3598
    CrossrefPubMedGoogle Scholar
  • 28 Meneghini RM, Ziemba-Davis M, Ishmael MK, Kuzma AL, Caccavallo P. Safe selection of outpatient joint arthroplasty patients with medical risk stratification: the “outpatient arthroplasty risk assessment score”. J Arthroplasty 2017; 32 (08) 2325-2331
    CrossrefPubMedGoogle Scholar
  • 29 Terkawi AS, Mavridis D, Sessler DI. et al. Pain management modalities after total knee arthroplasty: a network meta-analysis of 170 randomized controlled trials. Anesthesiology 2017; 126 (05) 923-937
    CrossrefPubMedGoogle Scholar
  • 30 Theisen K, Jacobs B, Macleod L, Davies B. The United States opioid epidemic: a review of the surgeon's contribution to it and health policy initiatives. BJU Int 2018; 122 (05) 754-759
    CrossrefPubMedGoogle Scholar