Continuous Femoral Nerve Blockade Research Articles

Continuous Femoral Nerve Blockade versus Continuous Epidural Analgesia for Postoperative Pain Relief in Knee Surgeries

Abstract Background The progression of osteoarthritis is characteristically slow, occurring over several years or decades. Over this period, the patient can become less and less active and thus more susceptible to morbidities related to decreasing physical activity (including potential weight gain). Early in the disease process, the joints may appear normal. However, the patient’s gait may be antalgic if weight-bearing joints are involved. Objective Compare the benefits of continuous femoral nerve block (CFNB) with those of continuous epidural analgesia CEPA for postoperative pain management after Knee surgeries. Methods This study is a randomized controlled clinical trial was conducted in Ain Shams University Hospitals after obtaining approval from the Research Ethical Committee of Ain Shams University during a period of three months. Patients undergoing primary unilateral TKA for osteoarthritis, were recruited at least one day prior to the scheduled surgery, male and female patients. Results There was significant difference in terms of pain scoring between continuous femoral nerve block (CFNB) and continuous epidural analgesia (CEA) in the first 6 hours, 12 hours, 24 hours, 48 hours, 72 hours but non significant difference in incidence of side effects Conclusion Our study showed that CEA had optimal analgesia and pain control than CFNB in management of post operative pain after total knee replacement.

Comparison of Continuous Epidural Blockade and Continuous Femoral Nerve Block on Postoperative Pain in Total Knee Replacement Surgeries: A Prospective Randomised Controlled Study

Background: The use of epidural analgesia in the management of postoperative pain following orthopedic surgeries has evolved as a critical component of a multimodal approach to achieve the goal of pain relief, early mobilization, and improved compliance with physiotherapy resulting in overall improved outcomes. Aim: The aim of this study is to compare continuous femoral nerve block with continuous epidural block technique for postoperative analgesia in patients undergoing elective total knee replacement surgery.Subjects and Methods:The patients belonging to the ASA I to III scheduled for various knee surgeries under spinal anesthesia were enrolled in this study. They were randomly divided into two equal groups of thirty-three patients each. The Group F patients received continuous femoral nerve blockade and in the Group E patients continuous epidural blocked preoperatively.Results:The analgesic efficacy of both continuous femoral nerve block and continuous epidural nerve block was equal as measured by the visual analogue scores. The incidence of Hypotension was more in the Epidural group. The adverse effects due to the Continuous Femoral Nerve block were lower in comparison with the Continuous Epidural block technique.Conclusion:Continuous femoral nerve blockade provides postoperative analgesia equivalent to that obtained with a continuous epidural blocked but with lesser side effects.

Perioperative pain management and chronic postsurgical pain after elective foot and ankle surgery: a scoping review.

Chronic postsurgical pain (CPSP) can occur after elective mid/hindfoot and ankle surgery. Effective treatment approaches to prevent the development of CPSP in this population have not been extensively investigated. The impact of multimodal strategies to prevent CPSP following elective mid/hindfoot surgery is unknown because of both the heterogeneity of acute pain management and the lack of a recognized definition particular to this surgery. This review aimed to identify and evaluate current pain management strategies after elective mid/hindfoot and ankle surgery. Manual and electronic searches (MEDLINE, Embase, and Cochrane Library) were conducted of literature published between 1990 and July 2017. Comparative studies of adults undergoing elective mid/hindfoot and ankle surgery were included. Two reviewers independently reviewed studies and assessed their methodological quality. We found seven randomized-controlled trials meeting our inclusion criteria. Interventions focused on regional anesthesia techniques such as continuous popliteal sciatic and femoral nerve blockade. Participants were typically followed up to 48 hr postoperatively. Only one study assessed pain six months following elective mid/hindfoot and ankle surgery. There is an overwhelming lack of evidence regarding CPSP and its management for patients undergoing elective mid/hindfoot and ankle surgery. The lack of a recognized and standard definition of CPSP after this group of surgeries precludes accurate and consistent evaluation.

Early Experience with Bilateral Continuous Femoral Nerve Block and Single-Injection Spinal Anesthesia for Bilateral Total Knee Arthroplasty: A Case Series.

Total knee arthroplasty (TKA) is a commonly performed surgery in the United States, with demand for unilateral and simultaneous bilateral TKAs (BTKAs) expected to increase significantly over the coming decades. This study reports the authors' early experience in a consecutive series of simultaneous BTKAs performed under regional anesthesia and mild sedation. In this retrospective case series, the authors examined all simultaneous BTKAs performed over two years by a single surgeon. Only patients receiving bilateral continuous femoral nerve blockade (CFNB) and single-injection sciatic nerve blockade in combination with single-injection subarachnoid block were included in the study. Of the 32 patients who underwent BTKAs during this period, 25 met the inclusion criteria. The patient's anesthesia records, physician notes, nursing notes, pharmacy records, and physical therapy records were then reviewed systematically to create a database of information. Only one of 25 patients required conversion to general anesthesia during surgery. There were no major perioperative complications. The average Defense and Veterans Pain Rating Scale score immediately postoperation was 0.6/10, and the average daily score remained below 3.5/10 throughout the hospital stay. The use of bilateral CFNB did not prevent patients from ambulating during physiotherapy. This early retrospective case series suggests that it is feasible to effectively manage the postoperative pain associated with BTKA with staged bilateral CFNB and single-injection sciatic nerve blockage in combination with single-injection subarachnoid block as the sole anesthetic technique without negatively influencing early ambulation.

Femoral Nerve Catheters Improve Home Disposition and Pain in Hip Fracture Patients Treated With Total Hip Arthroplasty

BackgroundOpioids have been the mainstay of treatment in the physiologically young geriatric hip fracture patient undergoing total hip arthroplasty (THA). However opioid-related side effects increase morbidity. Regional anesthesia may provide better analgesia, while decreasing opioid-related side effects. The goal of this study was to examine the effect of perioperative continuous femoral nerve blockade with regards to pain scores, opioid-related side effects and posthospital disposition in hip fracture patients undergoing THA. MethodsTwenty-nine consecutive geriatric hip fracture patients (22 women/7 men) underwent THA. Average follow-up was 8.3 months (6 weeks-39 months). Fifteen patients were treated with standard analgesia (SA). Fourteen patients received an ultrasound-guided insertion of a femoral nerve catheter after radiographic confirmation of a hip fracture. All complications and readmissions that occurred within 6 weeks of surgery were noted. ResultsContinuous femoral nerve catheter (CFNC) patients were discharged home more frequently than SA patients (43% for CFNC vs 7% for SA; P = .023). CFNC patients reported lower average pain scores preoperatively (P < .0001), on postoperative day 1 (P = .005) and postoperative day 2 (P = .037). Preoperatively, CFNC patients required 61% less morphine equivalent (P = .007). CFNC patients had a lower rate of opioid-related side effects compared with SA patients (7% vs 47%; P = .035). ConclusionCFNC patients were discharged to home more frequently. Use of a CFNC decreased daily average patient-reported pain scores, preoperative opioid usage, and opioid-related side effects after THA for hip fracture. Based on these data, we recommend routine use of perioperative CFNC in hip fracture patients undergoing THA.

Continuous femoral nerve blockade and single-shot sciatic nerve block promotes better analgesia and lower bleeding for total knee arthroplasty compared to intrathecal morphine: a randomized trial

BackgroundKnee arthroplasty leads to postoperative pain. This study compares analgesia and postoperative bleeding achieved by intrathecal morphine with a continuous femoral plus single-shot sciatic nerve block.MethodsA randomized non-blinded clinical trial enrolled patients aged over 18 years old, ASA I to III who underwent total knee arthroplasty. All patients underwent spinal anesthesia with isobaric bupivacaine, 20 mg. One group received 100 mcg of intrathecal morphine (M group), and the other received a femoral nerve block by continuous infusion plus a "single shot" block of the sciatic nerve at the end of the surgery (FI group). Pain score from verbal numeric rating scale (VNRS) and morphine consumption during the first 72 h, as well as motor blockade, adverse effects, and postoperative bleeding were recorded. Analysis of variance of repeated measures with Bonferroni post-test, t-test and Fisher exact test were used for statistical analysis.ResultsThirty nine patients completed the study (M = 20; FI = 19 patients) and were similar except for higher age in the FI group. Motor blockade as well as movement pain during postanesthesia care unit (PACU) staying were not different between the groups, but movement pain was significantly lower in FI group after 24 h. Postoperative bleeding (ml) was lower in FI group.ConclusionsContinuous femoral nerve block combined with sciatic nerve block provides effective for postoperative analgesia in patients undergoing total knee arthroplasty, with lower pain scores after 24 h and a lower incidence of adverse effects and bleeding compared to intrathecal morphine.Trial registrationRetrospectively registered on https://clinicaltrials.gov/ under identifier NCT02882152, 23rd December, 2016.

Continuous Femoral Nerve Blockade versus Epidural Analgesia for Postoperative Pain Relief in Knee Surgeries: A Randomized Controlled Study.

Background:Peripheral neural blockade provides effective analgesia with potentially less side effects than an epidural blockade. The present study was undertaken to compare continuous femoral nerve blockade (CFNB) with continuous epidural analgesia (CEA) for postoperative pain control in knee surgeries.Materials and Methods:The patients belonging to the American Society of Anesthesiologists Class I and II scheduled for various knee surgeries under spinal anesthesia were enrolled in this study. They were randomly divided into two equal groups of thirty patients each. The Group I patients received CFNB and in the Group II patients epidural catheter was placed preoperatively. Postoperatively, continuous infusion with 0.0625% bupivacaine and fentanyl 2 μg/ml started at 5 ml/h for 72 h in both the groups. Data on Visual Analog Scale (VAS) pain scores, hemodynamic changes, side effects at 0, 1, 6, 12, 24, 36, 48, 60, and 72 h and requirement of analgesic doses for the first 24 h of the surgery were noted.Results:In both the groups, pain was well controlled, mean VAS of pain were 0.2, 0.6, 2.47, 2.07, 2.73, 1.5, 1.43, 1.37, and 1.3 for femoral and 0.13, 0.93, 2.57, 2.17, 2.33, 1.6, 1.43, 1.30, and 1.33 for epidural group during 0, 1, 6, 12, 24, 36, 48, 60, and 72 h which was not statistically significant. Hemodynamics were stable throughout in both the groups. The patients in CEA had more incidences of pruritus and urinary retention.Conclusion:CFNB provides postoperative analgesia equivalent to that obtained with a CEA but with fewer side effects.

Postoperative Ultrasound Guided Continuous Femoral Nerve Blockade for Unilateral Total Knee Arthroplasty: A Comparison of 0.125% Bupivacaine and 0.2% Ropivacaine.

Context:Total knee arthroplasty (TKA) is associated with severe postoperative pain which increases morbidity and mortality.Aims:The aim of the study was to compare the analgesic efficacy and motor blockade of continuous infusion of 0.125% bupivacaine and 0.2% ropivacaine in femoral nerve block following unilateral TKA and to assess the effectiveness of femoral nerve block.Settings and Design:One hundred and fifty patients undergoing unilateral total knee replacement surgery were included in this prospective observational comparative study.Subjects and Methods:Patients are divided into two groups of 75 each. Femoral nerve catheter was placed at the end of surgery using ultrasound. Postoperative analgesia and motor blockade were compared for the next 24 h using visual analog scale (VAS) score, additional analgesic requirement, and Bromage scale.Statistical Analysis:Student's t-test and Chi-square test were applied.Results:There was no statistically significant difference in pain between the two groups though VAS score (during rest and movement) and opioid consumption were lower in bupivacaine group. Nearly 28.6% patients experienced pain and required additional analgesics. Seventy-two percent among them complained of pain in the popliteal region supplied by sciatic nerve. Eight patients excluded from the study also had pain in the popliteal fossa. There was a statistically significant difference in motor blockade between the two groups at 12, 18, and 24 h after starting infusion. Bupivacaine group had a higher percentage of type three blocks compared to ropivacaine group.Conclusion:Continuous femoral nerve block (CFNB) with 0.125% bupivacaine infusion provided better analgesia with denser motor blockade compared to 0.2% ropivacaine infusion. CFNB alone is not sufficient to provide adequate analgesia following unilateral TKA.

Cost-benefit evaluation of liposomal bupivacaine in the management of patients undergoing total knee arthroplasty.

Results of a cost-benefit analysis of intraoperative use of liposomal bupivacaine for postsurgical pain management in patients undergoing total knee arthroplasty (TKA) are presented. In a retrospective single-site study, clinical and cost outcomes were compared in a group of 134 consecutive patients who received liposomal bupivacaine (by local infiltration) during TKA and a propensity score-matched historical cohort of 134 patients undergoing TKA who received usual care (continuous femoral nerve blockade with conventional bupivacaine delivered via elastomeric pump). Postsurgical pain scores and opioid use were similar in the two study groups; the mean total amount of nonsteroidal antiinflammatory drugs administered was lower in the liposomal bupivacaine group. Patients who received liposomal bupivacaine typically ambulated earlier than those who received usual care (22% and 3%, respectively, walked on the day of surgery; p < 0.05) and were more likely to be discharged within two days (50% versus 19%, p < 0.001); on average, liposomal bupivacaine- treated patients walked farther on the day of surgery (6.0 m versus 3.1 m, p < 0.001) and the day after surgery (63.7 m versus 25.5 m, p < 0.001) and had a shorter length of stay (LOS) (3.1 days versus 3.6 days, p < 0.03). The mean adjusted total direct hospital cost per patient was significantly lower with liposomal bupivacaine use versus usual care ($8758 versus $9213, p = 0.033). In patients undergoing TKA, intraoperative administration of liposomal bupivacaine for management of postsurgical pain was found to offer advantages over usual care, including decreased time to ambulation and reduced hospital LOS.

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.

The analgesic efficacy of sciatic nerve block (SNB) after total knee arthroplasty (TKA) is unclear. Proximal and distal SNB are each reported to provide posterior knee analgesia, whereas others suggest that posterior knee pain is not important after TKA. This prospective, randomized, double-blind, parallel-arm, placebo-controlled trial examined whether proximal or distal SNB provides superior analgesia in the posterior knee compared with no SNB after TKA. Sixty patients undergoing TKA were randomized to single-shot SNB using either the infragluteal (Proximal group) or popliteal (Distal group) technique, or no SNB (Placebo group). All patients received spinal anesthesia and continuous-femoral nerve blockade. A blinded observer assessed posterior and anterior knee pain at 2, 4, 6, 8, 12, and 24 h postoperatively. The primary outcome was moderate-to-severe posterior knee pain at 4 h postoperatively; secondary outcomes included SNB procedural time, needle passes, and discomfort. Fifty-three patients were analyzed. The proportion of patients (Proximal:Distal:Placebo) who experienced moderate-to-severe posterior knee pain was 18%:22%:89% (P<0.00001) at 2 h, 24%:28%:72% (P<0.01) at 4 h, and 12%:17%:78% (P=0.00003) at 6 h postoperatively. For the anterior knee, the proportion of patients reporting moderate-to-severe pain was 6%:11%:44% (P=0.02) at 2 h, 6%:6%:39% (P=0.012) at 4 h, and 12%:6%:44% (P=0.017) at 6 h postoperatively. Moderate-to-severe pain did not differ between groups beyond 6 h. Both proximal and distal SNB reduced rest pain in the posterior and anterior knee up to 8 h postoperatively compared with no SNB. The popliteal technique required shorter procedural time, fewer needle passes, and produced less discomfort. Proximal and distal SNB each reduce posterior and anterior knee pain after TKA compared with no SNB.

Adverse Effect of Femoral Nerve Blockade on Quadriceps Strength and Function after ACL Reconstruction

The purpose of this study was to determine if quadriceps strength and functional outcomes were similar at 6 months following anterior cruciate ligament [ACL] reconstruction in patients receiving a continuous 48-hour femoral nerve blockade for postoperative analgesia (FNB group) versus patients with no FNB (control group). A retrospective cohort was designed including athletes who underwent primary ACL reconstruction with patellar tendon autograft between 2005 and 2010 at our institution with identical rehabilitation protocols. The FNB group included 96 patients with an average age of 21 years and the control group included 100 patients with an average age of 20 years. At 6 months following ACL reconstruction, isokinetic strength (slow and fast activation) and functional tests including vertical jump, single hop, triple hop, and return to sport were analyzed with an α value < 0.05 as significant. Multivariate regression models were used to compare these outcomes between the FNB and control groups after adjusting for gender and competitive athlete status. At 6 months, fast extension isokinetic strength was inferior in the FNB group (78 vs. 85%; p < 0.01). After adjusting for gender and competitive athlete status, fast (p = 0.002) and slow extension strength (p = 0.01), vertical jump (p = 0.03) and single jump (p = 0.02) were also inferior in the FNB group. There were no significant differences in full return to sport between the two groups (86% at 7.5 months in the FNB group vs. 93% at 7.3 months in the control group). In this retrospective comparative study, the hypothesis that patients treated with continuous FNB for postoperative analgesia following ACL reconstruction with patellar tendon autograft will have inferior knee extension (quadriceps) strength and function at 6 months follow-up was affirmed. However, no differences were observed in return to sport, bringing into question whether these statistical differences translate into meaningful clinical consequences after ACL reconstruction. The level of evidence was level III, retrospective case-control series.

Elective unilateral total knee replacement using continuous femoral nerve blockade versus conventional patient-controlled analgesia: peri-operative patient management based on a multi-disciplinary pathway

OBJECTIVES. To evaluate the effectiveness of our new multidisciplinary pathway for total knee replacement patients and compare outcomes after continuous femoral nerve blockade versus conventional patient-controlled analgesia for postoperative pain. DESIGN. Randomised controlled trial in a routine clinical setting. SETTING. Acute orthopaedic wards and operating theatres, Yan Chai Hospital, Hong Kong. PATIENTS. Sixty patients underwent elective unilateral total knee replacement under spinal anaesthesia from May 2009 to September 2011 and were randomly assigned to continuous femoral nerve blockade or conventional patient-controlled analgesia (30 patients in each group). MAIN OUTCOME MEASURES. Quality of pain control was evaluated by pain scores at rest and during mobilisation, opioid consumption, frequency of side-effects, and patient satisfaction score. Rehabilitation progress was assessed according to the day of first starting weight-bearing exercise, day of independent walking in the ward with aid, Timed Up and Go test, and time elapsing till discharge. Surgical outcome was assessed by the Knee Society score 6 months after discharge, re-admissions, and occurrence of complications. RESULTS. Patients having continuous femoral nerve blockade tended to have less pain on movement and achieved earlier mobilisation than those having patient-controlled analgesia. The former group consumed less opioids, had fewer side-effects, and were more satisfied with their postoperative analgesia. Both groups showed an equally high degree of satisfaction with the new management pathway. Hospital stays, surgical outcomes, and frequency of complications were similar in the two groups. CONCLUSION. Continuous femoral nerve blockade proved to be a feasible and better alternative mode of postoperative analgesia than our conventional patient-controlled analgesia. Our new multidisciplinary management pathway and multimodal analgesic regimen featuring the continuous femoral nerve blockade appeared beneficial to patients and effective in our clinical setting.

The Adverse Effect of Femoral Nerve Blockade on Quadriceps Strength after ACL Reconstruction (SS-13)

The Adverse Effect of Femoral Nerve Blockade on Quadriceps Strength after ACL Reconstruction (SS-13)

Advanced Age, Obesity and Continuous Femoral Nerve Blockade are Independent Risk Factors for Inpatient Falls After Primary Total Knee Arthroplasty

We asked whether femoral nerve blockade (FNB) was an independent risk factor for inpatient post-operative falls after total knee arthroplasty (TKA). Data on 2197 primary TKAs were collected from our institution between 2003 and 2010. Patient demographics, type and duration of blocks were considered predictors of falls in a logistic regression model. Among 60 (2.7%) falls, the odds ratio was 1.04 (1.0–1.07; p=0.008) for each 1year of increased age above the mean (66years), 2.4 (1.3–4.5; p=0.005) for BMI >30kg/m2 and 4.4 (1.04–18.2; p=0.04) for continuous FNB. Single-shot FNB did not increase risk. No fall resulted in operative morbidity. The use of continuous FNB should be cautioned, especially in patients with other risk factors such as obesity and advanced age.

Postoperative Pain Control for Total Knee Arthroplasty: Continuous Femoral Nerve Block Versus Intravenous Patient Controlled Analgesia

Background: Pain after total knee arthroplasty is severe and impacts functional recovery. Objectives: We performed a retrospective study, comparing conventional patient control analgesia (PCA) modalities versus continuous femoral nerve blockade (CFNB) for 1582 post-TKA (total knee arthroplasty) patients. Patients and Methods: Using our electronic acute pain service (APS) database, we reviewed the data of 579 patients who had received CFNBs compared with 1003 patients with intravenous PCA over 4 years. Results: Our results show that the incidence of a severe pain episode was higher in the PCA compared with the CFNB group. Lower pain scores were observed in the CFNB group compared with the PCA group from postoperative day (POD) 1 to 3, primarily due to lower rest pain scores in the CFNB group. Conclusions: Our study shows that there is improvement in pain scores, at rest and on movement, as well as a reduction in incidence of severe pain, in patients who receive CFNB versus those who receive intravenous PCA.

Postoperative pain control for total knee arthroplasty: continuous femoral nerve block versus intravenous patient controlled analgesia.

Background:Pain after total knee arthroplasty is severe and impacts functional recovery.Objectives:We performed a retrospective study, comparing conventional patient control analgesia (PCA) modalities versus continuous femoral nerve blockade (CFNB) for 1582 post-TKA (total knee arthroplasty) patients.Patients and Methods:Using our electronic acute pain service (APS) database, we reviewed the data of 579 patients who had received CFNBs compared with 1003 patients with intravenous PCA over 4 years.Results:Our results show that the incidence of a severe pain episode was higher in the PCA compared with the CFNB group. Lower pain scores were observed in the CFNB group compared with the PCA group from postoperative day (POD) 1 to 3, primarily due to lower rest pain scores in the CFNB group.Conclusions:Our study shows that there is improvement in pain scores, at rest and on movement, as well as a reduction in incidence of severe pain, in patients who receive CFNB versus those who receive intravenous PCA.

Comparative study of ultrasound-guided continuous femoral nerve blockade with continuous epidural analgesia for pain relief following total knee replacement

Background:Regional analgesia is widely used for total knee replacement surgeries (TKR) as it has lesser side-effects and better analgesic efficacy when compared with traditional oral analgesics. Peripheral nerve blockade has also been utilized, including continuous infusion techniques. With the use of ultrasound, the needle and catheter placement can be done accurately under real-time guidance. This may prove a more suitable approach compared with the epidural technique.Aims:Post-operative analgesia in TKR patients was compared between continuous epidural analgesia (CEA) and continuous femoral block (CFB) techniques. VAS scores and use of rescue analgesic were used as parameters. Secondary aims included comparison of rehabilitation scores and side-effects in the form hypotension, vomiting, itching and urinary retention.Settings and Design:Randomised, controlled, non-blinded study done in a tertiary care private hospital.Methods:Forty-two patients fulfilling the study criteria were randomised into the CEA and CFB groups. In total, four patients: three in the CFB group and one in the CEA group, were excluded because of catheter migration.Statistical Analysis:Mean VAS score at 6, 6–24, 24–48 and 48–72 h were considered. Significance was assessed at the 5% level.Results and Conclusion:VAS scores were significantly high (P=0.001) in the femoral group at 6 h, after which there was a declining trend, and scores were essentially similar from 24 h. Common side-effects were more common in the CEA group. Our study shows that CFB gives equivalent analgesia compared with CEA in TKR patients with clinically meaningful decrease in side-effects.

Standardized Multimodal Pain Management Reduces Post-Operative Pain and Length of Stay in Hospital for Total Knee Arthroplasty: A Retrospective Review

Study Objective: To evaluate the utility of multimodal pain management subsequent to general or neuraxial anesthesia following total knee arthroplasty. Design: Retrospective review. Setting: University-affiliated teaching hospital. Patients: 389 patients (ASA physical status I-IV) scheduled for elective total knee replacement surgery over 3 year period. Interventions and Measurements: A total of 218 patients met inclusion criteria: 1) status-post a total knee arthroplasty 2) femoral nerve block with a continuous infusion of 0.1% ropivacaine 3) femoral catheter discontinued on post-op day 3, and 4.) follow-up with acute pain service. The study group (S) (N=105) received multimodal pain management consisting of a continuous femoral nerve blockade, celecoxib 200mg PO Q24 hrs, oxycontin 10mg PO Q12, acetaminophen 1000mg PO TID, and Percocet 5/325 1-2 tabs PO Q4-6 hr PRN (≤3 tabs/24hrs). The control group (NS) (N=113) received a continuous femoral nerve block with a non-standardized pain management regimen as prescribed by the orthopedic service. Outcome measurements included: mode of anesthesia (neuraxial vs. GA); length of surgery; time to ambulation and 90 flexion; pain score, morphine equivalents and length of stay in hospital. Main Results: The study group demonstrated decreased pain scores on the third post-operative day as compared to the control group (S=2.43 vs. NS=3.38, p=0.003, SEM + 0.215). The study group also demonstrated reduced length of stay relative to controls (S=3.64 vs. NS=4.47, p<0.001, SEM + 0.114). Conclusion: Multimodal pain management following total knee arthroplasty improved postoperative outcomes irrespective of opioids requirements or mode of anesthesia. Our results are consistent with previous work demonstrating improved patient care, superior analgesia and reduced length of stay in hospital through implementation of standardized multimodal pain management with standardized discharge criteria.

Is a Patella Motor Response Necessary for Continuous Femoral Nerve Blockade Performed in Conjunction with Ultrasound Guidance?

Successful continuous femoral nerve blockade (CFNB) has been associated with the elicitation of a patella motor response during needle and catheter insertion. We evaluated whether a patella motor response is necessary when CFNB is performed in conjunction with ultrasound (US) guidance. Ninety-eight patients undergoing CFNB (along with sciatic nerve block and spinal anesthetic) for total knee arthroplasty participated in this cohort observational study. Using out-of-plane US guidance alone, the tip of an insulated Tuohy needle was positioned superficial to the midpoint of the femoral nerve visualized in short axis. A nerve stimulator was turned on and the type of motor response (patella versus medial muscle) and minimum stimulating current from the needle were recorded. A stimulating catheter was then inserted and the type of motor response and minimum current from the catheter were recorded. Ten milliliters mepivacaine 2% was injected through the catheter. The primary outcome was sensory block defined as loss of sensation to pinprick on the anterior surface of the distal thigh measured 20 minutes after mepivacaine injection. Forty-three patients demonstrated a patella motor response, 43 demonstrated a medial motor response, and 12 demonstrated no motor response from the catheter. The proportion of patients with sensory block differed according to motor response from the catheter (patella [98%], medial [91%], and no motor response [75%]; P = 0.02), but there was no significant difference between a patella (98%) and medial (91%) motor response from the catheter (P = 0.58). The proportion of patients with motor block 20 minutes after local anesthetic injection also differed according to motor response from the catheter (patella [95%], medial [77%], and no motor response [67%]; P = 0.03). In addition, there was a significant difference between a patella (95%) and medial (77%) motor response from the catheter (P = 0.01). The mean minimum stimulating currents did not differ between patella and medial motor responses elicited from the catheter (P = 0.06). Postoperative pain and analgesic consumption were similar regardless of the type of motor response from the catheter. Based on observational data, a patella or medial motor response from the catheter similarly results in sensory block of the anterior thigh when CFNB is performed in conjunction with out-of-plane US guidance.

Comparing the analgesic efficacy of continuous femoral nerve blockade and continuous intravenous analgesia after total knee arthroplasty

To compare the analgesic efficacy of continuous femoral nerve blockade (CFNB) and continuous intravenous analgesia (CIA) after total knee arthroplasty (TKA). 126 patients undergoing TKA under combined epidural-spinal anesthesia were randomized to receive either a femoral infusion of ropivacaine 0.2% (median infusion rate 5 ml/h) (n = 63) or an intravenous infusion of fentanyl 30 µg/kg (2 ml/h) (n = 63). Adjuvant analgesics were oral celebrex or IM pethidine. In the CFNB group, CFNB was established before combined epidural-spinal anesthesia and 20 ml 0.5%ropivacaine was infused through the catheter placed near femoral nerve. Visual analogue scale (VAS) scores were assessed at rest and on passive mobilization by acute pain service blinded to analgesic treatment. Nausea and vomiting, dizziness, satisfaction and other side-effects were assessed postoperatively. There was significantly less VAS scores in the CFNB group comparing the CIA group at rest 4, 8, 12, 16, 24, 36, 48 h after surgery (P < 0.01). A significant difference in VAS scores was found in CFNB group vs CIA group on passive mobilization 24, 36, 48 h after operation (P < 0.01). There was significantly less dizziness, nausea and vomiting in the CFNB group (P < 0.01). Patient satisfaction was higher in the CFNB group (92.1%) than the CIA group (20.6%) (P < 0.01). CFNA with ropivacaine 0.2% is more effective in controlling postoperative pain than CIA and CFNB is an effective regional component of a multimodal analgesic strategy after TKA.