Abstract
Total knee arthroplasty (TKA) is among the most commonly performed orthopedic procedures. Controlling the pain of this patient population is essential in improving outcomes such as opioid consumption, hospital length of stay, overall function, and rehabilitation participation following their procedure. Local anesthetic infiltration of the interspace between the popliteal artery and capsule of the posterior knee, known as the IPACK block, combined with an adductor canal block (ACB) can be used to reduce pain in the challenging area of the posterior knee after knee surgery without compromising motor function of the quadriceps muscles. One limiting factor to this combination of techniques is the duration of analgesia provided. This case series demonstrates the combination of dexmedetomidine and dexamethasone (Dex-Dex) as local anesthetic adjuvants to significantly prolong the analgesic duration of ACB (in addition to IPACK block) in three patients undergoing TKA. Preoperative ACB and IPACK blocks were performed for postoperative analgesia in three TKA patients. The anesthetic mixture was 10 cc 0.2% ropivacaine combined with 25 mcg of dexmedetomidine and 5-mg preservative-free dexamethasone for the ACB, and 0.2% ropivacaine combined with 5-mg preservative-free dexamethasone was utilized for the IPACK block. Two of the patients reported experiencing four days of analgesia and one patient reported five days of analgesia following the ACB + IPACK block. Two of the patients required no opioid analgesics postoperatively. An ACB utilizing 0.75% ropivacaine has been demonstrated to provide approximately 10.8 hours of analgesia. Our series demonstrates a significantly prolonged duration of analgesia from this injectate combination. Few studies have utilized the Dex-Dex combination. The combination, however, was previously proven to safely increase the analgesic duration of a caudal block prior to hypospadias surgeries in pediatrics. More studies are needed to understand a potential synergistic effect of Dex-Dex, which could have a substantial impact on postoperative analgesia for TKA patients.
Highlights
Total knee arthroplasty (TKA) is among the most commonly performed orthopedic procedures, with an expected increase of up to 3.5 million procedures performed by 2030 [1]
This case series demonstrates the combination of dexmedetomidine and dexamethasone (Dex-Dex) as local anesthetic adjuvants to significantly prolong the analgesic duration of adductor canal block (ACB) in three patients undergoing TKA
The anesthetic mixture was 10 cc 0.2% ropivacaine combined with 25 mcg of dexmedetomidine and 5-mg preservative-free dexamethasone for the ACB, and 0.2% ropivacaine combined with 5-mg preservative-free dexamethasone was utilized for the IPACK block
Summary
Total knee arthroplasty (TKA) is among the most commonly performed orthopedic procedures, with an expected increase of up to 3.5 million procedures performed by 2030 [1]. ACB in combination with an IPACK block is a favorable technique to control the postoperative pain following a TKA procedure and is growing in popularity. Following discharge from the hospital, the patient reported analgesic efficacy lasting four days with progressively mild increase in pain on postoperative day 5 He subsequently did not require the use of opioid analgesics and used over-the-counter ibuprofen and acetamenophen to control his 5/10 pain once the effect of the blocks did subside. The only opioid used during this patient’s general anesthetic was 100 mcg of fentanyl during the induction of anesthesia The patient rated his pain as a 5/10 following her procedure, she did not take any opioid analgesics. He subsequently required 5 mg of oxycodone twice at night and once in the morning for two days until switching to acetaminophen for pain relief thereafter
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