IPACK Block Research Articles

The Effect of the Application of Adductor and Infiltration of Local Anesthetic Between the Popliteal Artery and Capsule of the Knee (IPACK) Block to Patients on Postoperative Recovery and Sleep Quality Following Total Knee Arthroplasty: a Randomized, Controlled Study

Aim: The adductor canal block (ACB) and IPACK (Infiltration of local anesthetic between the popliteal artery and capsule of the knee) block are motor protective blocks that provide effective analgesia and allow early ambulation. The aim of this study was to investigate the effect on postoperative recovery and sleep quality of patients applied with ACB and IPACK for total knee arthroplasty (TKA). Material and Method: This prospective, double-blinded, randomized, controlled study included 80 patients who underwent unilateral TKA under spinal anesthesia. The patients were separated as those applied with ACB+IPACK (Group ACB+IPACK, n=40) and a control group (Group C, n=40). The primary outcome was the postoperative first-day quality of recovery scale (QoR-15). Secondary outcomes were postoperative first and second-day Timed-Up-and-Go (TUG) test and range of motion (ROM), the total amount of rescue opioid drugs required, pain scales at different time points in the first 48 hours postoperatively, sleep evaluation on the postoperative and 6 following nights, and evaluation of sleep quality for 1 month using the Pittsburgh Sleep Quality Index (PSQI). Results: The QoR on postoperative days 1 and 7 were better in the ACB+ IPACK group than in the control group (p= 0.001, p= 0.002, respectively). On postoperative days 1 and 2, the TUG (p= 0.035, p= 0.019, respectively) and ROM (p=0.003, p=0.000) values were higher in the ACB+ IPCAK group. Postoperative opioid consumption was lower in the ACB+IPACK group (p= 0.012). The PSQI values at 1 month postoperatively were similar in both groups (p =0.095). Conclusion: The study results demonstrated that ACB+IPACK applied with ultrasound for TKA postoperative analgesia provided effective analgesia, higher QoR and physical performance, and reduced postoperative opioid consumption. However, there was no effect on postoperative sleep quality.

Comparison between Ultrasound Guided Femoral Nerve Block versus IPACK Block (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) in Patients Undergoing Total Knee Replacement on Postoperative Ambulation and Pain

Abstract Background Total knee replacement (TKR) is a well-known popular surgical procedure for knee diseases, including end-stage knee osteoarthritis that causes severe postoperative pain and prolonged immobility. TKR is associated with significant postoperative pain. The need for effective analgesia without compromising function is a priority. Aim of the Work The current study aims to assess the IPACK block concerning postoperative ambulation as a primary outcome and analgesic efficacy as a secondary outcome when compared with femoral nerve block following TKR. Patients and Methods This study is a randomized controlled clinical trial was conducted on 40 random patients who were scheduled to undergo total knee replacement and were divided into 2 equal groups: Group A: Patients in group A (n = 20) received spinal anesthesia followed by FNB block at the beginning of the operation with 20ml bupivacaine (0.25%) under complete aseptic conditions, Group B: Patients in group B (n = 20) received spinal anesthesia followed by IPACK at the beginning of the operation with 20ml bupivacaine (0.25%) under complete aseptic conditions. Results As for the comparison between effect of the IPACK block and FNB regarding ambulation and postoperative pain in TKR, it showed that there is significance regarding ambulation that was delayed in FNB than IPACK using TUG test and 10-min walk test, but regarding VAS score that was used to assess postoperative pain and its intensity, it showed that FNB has more analgesic effect concerning IPACK block with less total analgesics consumption (in mg.) over 24-hour period post-operative. Conclusion Our study showed that there was delayed ambulation in FNB than in IPACK using the TUG test and 10-min walk test, but regarding the VAS score that was used to assess postoperative pain and its intensity, it showed that FNB has more analgesic effect concerning IPACK block with less total analgesics consumption (in mg.) over 24-hour period post-operative.

Comparison between Ultrasound Guided IPACK Block (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) and Adductor Canal Block in Patients Undergoing Total Knee Replacement in Postoperative Pain

Abstract Background Total knee replacement (TKR) is associated with significant postoperative pain. The need for effective analgesia without compromising function is a priority. Aim of the Work The aim of the study is to compare postoperative pain management and post-operative analgesia between IPACK block and Adductor canal block in total knee replacement cases. Patients and Methods The study was conducted on 60 patients who were scheduled to undergo total knee replacement and were divided into 2 equal groups: group 1: Patients in group 1 (n = 30) will receive IPACK block at the beginning of operation with 20 ml bupivacaine (0.25%) under complete aseptic conditions, group 2: patients in group 2 (n = 30) will receive Adductor canal block at the beginning of the operation with 20 ml bupivacaine (0.25%) under complete aseptic conditions. Results The two groups were adequately monitored and assessed post-operatively for 24 hours and they were compared regarding analgesic outcome by recording time for first for analgesic need, total consumption of opioid and pain score during walking and climbing stairs. Side effects were also monitored and compared. Conclusion The comparison between effect of IPACK block and adductor canal block as regard post- operative pain in total knee replacement showed significant difference regarding the numeric version of the visual analogue scale (VAS) that was used to assess postoperative pain and its intensity with range 1-3 for adductor canal block and 2-4 for IPACK block.

IPACK Block and Adductor Canal Catheter vs Adductor Canal Catheter for Total Knee Arthroplasty: A Randomized Controlled Trial

Background: Regional anesthetic techniques including the adductor canal catheter (ACC) have aided management of post-operative pain for total knee arthroplasty (TKA). The interspace between the popliteal artery and posterior capsule of the knee (iPACK), has been introduced to address posterior knee pain that is not well covered by the ACC. Studies have looked at the addition of the iPACK block to subjects who received an ACC with and without periarticular local infiltration with varying results. We hypothesized that adding the iPACK block to subjects who also received an ACC and periarticular injection (PAI) would significantly decrease opioid consumption compared to the ACC alone in TKA. Methods: Sixty subjects were randomized to receive an ACC alone (control group) or ACC plus single shot iPACK block (iPACK group) for TKA. All subjects were operated on by the same surgeon and received the same PAI. For the primary outcome of postoperative pain, we used opioid consumption as measured by morphine milligram equivalent (MME). Secondary outcomes included pain scores determined by the visual analog scale (VAS), distance ambulated, time to physical therapy (PT) and length of hospital stay. Results: We did not observe a significant difference between groups for opioid consumption, pain scores, distance ambulated (p > 0.05 across all time points), length of hospital stay (p = 0.64), or time to PT (p = 0.32). Conclusion: When combined with an ACC and PAI, the iPACK block did not significantly decrease opioid consumption, pain scores, time to first PT session or increase distance ambulated.

A comparative study of adductor canal block with infiltration of the interspace between popliteal artery and the capsule of posterior knee or with periarticular infiltration after total knee arthroplasty

Background & objective: Appropriate perioperative pain management, with multimodal analgesia regimens combining regional anesthesia and systemic analgesics, is crucial for optimum results in individuals undergoing total knee arthroplasty (TKA). We evaluated the efficacy of combined Adductor Canal Block (ACB) and infiltration in the interspace between the popliteal artery and capsule of the knee (IPACK) supplementing against ACB and Periarticular Infiltration (PAI) on postoperative pain scores, use of opioids, and early physical therapy in patients subjected to TKA under spinal anesthesia (SA). Methodology: In the current prospective, randomized, comparative clinical trial, 40 individuals undergoing TKA were arbitrarily distributed in two groups. Group A comprised of patients undergoing ultrasound-guided ACB plus IPACK block; Group B comprised of patients undergoing ACB plus PAI block at the beginning of the surgical procedure. Results: The ACB + IPACK group exhibited notably lower VAS scores (P < 0.05) compared to the ACB plus PAI group. Group A consumed 67.5 ± 21.6 mg of pethidine over the first 48 h, while Group B consumed 87.5 ± 33.9 mg of pethidine. The range of movement of the knee and walking distance also revealed that the values were considerably higher in Group A compared to Group B. Conclusion: The utilization of both adductor canal block and the interspace between the popliteal artery and the knee capsule provides improved analgesia than adductor canal block and periarticular injection, while preserving the knee joint motor power in the postoperative period. Keywords: Adductor canal block; IPACK; Local anesthetic; Multimodal analgesia; Pain, Postoperative; Arthroplasty Citation: Hassan HA, Elzahaby HM, Elagamy AE, Rashed MM, Hussein MM. A comparative study of adductor canal block with infiltration of the interspace between popliteal artery and the capsule of posterior knee or with periarticular infiltration after total knee arthroplasty. Anaesth. pain intensive care 2024;28(4):620−625; DOI: 10.35975/apic.v28i4.2503 Received: February 10, 2024; Reviewed: March 13, 2024; Accepted: March 18, 2024

I Pack Block versus Adductor Canal Block for Post-Operative Pain Management in Total Knee Arthroplasty

Abstract Background Total knee arthroplasty (TKA) is a highly distressful major surgery, with a significant potential for complications, not only because of the surgical and anesthetic impact of the procedure, but also because of the demographic and clinical characteristics of the target population. Careful pain management is necessary post-operative to achieve early post-operative mobilization while ensuring patient comfort throughout and preventing post-operative complications. Objective we aim to compare postoperative pain management and post- operative analgesic consumption between IPACK block and Adductor canal block in total knee arthroplasty cases. Methods After obtaining approval from the medical ethical committee in Ain Shams University, this Prospective randomized controlled double-blind clinical trial study was conducted in the operating theatres of Ain shams University Hospitals. Study period March 2022 to August 2022. Physical status: ASA 1 or 2 and candidates for spinal anaesthesia undergoing total knee arthroplasty. Age group: 40-65 years. Sample sizes of 30 patients in total; 15 in group I (group I) and 15 in group II (group A). Results As for the comparison between effect of IPACK block and Adductor canal block as regard post-operative pain in total knee arthroplasty, it showed that there is significance regarding the numeric version of the visual analogue scale (VAS) that was used to assess postoperative pain and its intensity with range 1-3 for Adductor canal block and 2-4 for IPACK block. Conclusion The comparison between effect of IPACK block and Adductor canal block as regard post-operative pain in total knee arthroplasty showed significant difference regarding the numeric version of the visual analogue scale (VAS) that was used to assess postoperative pain and its intensity with range 1-3 for Adductor canal block and 2-4 for IPACK block. These findings with our study primary and secondary outcomes showed that Adductor canal block has more analgesic effect with respect to IPACK block regarding pain assessment but with no significant difference regarding the by the time till first analgesia postoperative and Total analgesics consumption (in mg.) over 24-hour period post-operative.

Comparison between Ultrasound Guided Femoral Nerve Block versus IPACK Block in Patients Undergoing Total Knee Replacement on Postoperative Ambulation and Pain: A randomised controlled clinical trial

Background: Total knee replacement (TKR) is a widely used surgical technique for knee disorders. The study is aimed to assess the interspace between the popliteal artery and capsule of the posterior knee (IPACK) block concerning postoperative ambulation as a primary outcome and analgesic efficacy as a secondary outcome when compared to the femoral nerve block (FNB) following TKR. Methods: Under spinal anaesthesia, forty patients undergoing elective unilateral TKR were divided into two groups: FNB, receiving ultrasound-guided FNB, and IPACK Block, receiving ultrasound-guided IPACK block. Ambulation was assessed with the timed up-and-go (TUG) and 10-meter walk tests. Post-surgery, pethidine consumption in 24 hours and VAS scores were recorded. Results: After 24 hours postoperative, TUG showed a mean value of 4.8±1.2 seconds in the IPACK group compared with 8.7±2.1 seconds in the FNB group (p < 0.001). The time needed for a 10-meter walk test was significantly longer in the FNB group (12.1±2.1 seconds) than in the IPACK group (8.3±1.2 seconds) in the first 12 hours postoperative. Similarly, 24 hours postoperatively, values were 6.4±1.2 seconds Vs 10.4±2.1 seconds respectively (p < 0.001). Using the VAS score, the FNB group demonstrated a greater analgesic effect than the IPACK group, while taking less total pethidine (73.8±17.2 mg) compared to 110.0±29.7 mg in the IBACK group. Conclusion: There was delayed ambulation in FNB than in IPACK. The FNB has a better analgesic profile compared to the IPACK block with less total analgesics consumption over 24 hours post-operatively.

Enhanced Postoperative Pain Management and Mobility Following Arthroscopic Knee Surgery: A Comparative Study of Adductor Canal Block with and without IPACK Block.

BACKGROUND Arthroscopic knee surgery (AKS) is minimally invasive, reducing hospital stay compared to traditional surgery, but postoperative pain remains a significant issue. This study compared the analgesic and functional outcomes following AKS following anesthesia using adductor canal block (ACB) with and without anesthesia using the interspace between the popliteal artery and posterior capsule of the knee (IPACK) block under spinal anesthesia (SA). MATERIAL AND METHODS We randomly allocated 120 patients into 3 groups: IPACK+ACB+SA for Group A (n=40), ACB+SA for Group B (n=40), and SA for Group C (n=40). The outcome was the visual analog scale (VAS) score evaluated at rest and during activity at 3 h, 6 h, 12 h, 24 h, and 48 h postoperatively, the frequency of administration of postoperative rescue analgesic, and the maximal walking distance at 24 h and 48 h postoperatively. RESULTS Compared with Group C, the VAS scores in Group A were significantly lower at 48 h postoperatively (P<0.05). There was a significant difference in the frequency of postoperative rescue analgesia use among the 3 groups (P=0.001). In a subgroup analysis of meniscus shaping under arthroscopy, the resting VAS score in Group A was lower than that in Group B and Group C at 48 h postoperatively (P<0.05). The maximum walking distance of Group A was longer than that of Group B and Group C at 24 h and 48 h postoperatively (P<0.01). CONCLUSIONS The effect of postoperative analgesia in the group receiving IPACK combined with ACB after AKS was obviously superior. In arthroscopic meniscus repair surgery, the duration of analgesia was longer, and the maximum walking distance at 48 h postoperatively was longer.

Investigation of Optimal Needle Position for Radiofrequency Ablation-Based Blockade of Interspace between the Popliteal Artery and the Posterior Capsule of the Knee: A Cadaveric Study.

Background and Objectives: The interspace between the popliteal artery and the posterior capsule of the knee (iPACK) block has been widely used in perioperative settings to control posterior knee pain and can additionally be used for chronic knee pain. In this cadaveric study, we aimed to investigate the needle tip position and its proximity to the articular branch of the tibial nerve (ABTN) during an iPACK-targeted radiofrequency procedure. Materials and Methods: An ultrasound-guided iPACK block was performed on 20 knees of 10 cadavers. We injected 0.1 mL each of blue and green gelatinous dye near the tibial artery (point A) and posterior knee capsule (point B), respectively, and evaluated the spread of both around the ABTN. For a hypothetical conventional radiofrequency ablation (RFA) lesion (diameter, 2.95 mm) and cooled RFA lesion (diameter, 4.9 mm), we counted the number of specimens in which the ABTNs would be captured. Results: The percentage of specimens in which the ABTN would be captured by a cooled RFA lesion was 64.71% at point A and 43.75% at point B (p = 0.334). Meanwhile, the percentage of specimens in which the ABTN would be captured by a conventional RFA lesion was 58.82% from point A and 25% from point B (p = 0.065). Conclusions: When performing an RFA-based iPACK block, the needle tip may be positioned either lateral to the tibial artery or in the space between the posterior knee capsule and the tibial artery. However, more studies with larger samples are needed to verify these results before the clinical use of this procedure can be recommended.

IPACK Block Efficacy for Acute Pain Management after Total Knee Replacement: A Review.

Patients often experience a significant degree of knee pain following total knee replacement (TKR). To alleviate this pain, nerve blocks may be performed such as the adductor canal block (ACB). However, ACBs are unable to relieve pain originating from the posterior region of the knee. A new type of nerve block known as the IPACK block may be used in conjunction with ACBs as it is designed to inhibit nerve branches innervating this area. In this article, we examine the rationale behind the IPACK procedure, how it is performed, and clinical trials examining its efficacy. 5 of the 7 clinical trials examined in this article showed the IPACK + ACB block to show superior efficacy in treating pain following TKR compared to other blocks. These blocks included PMDI+ACB, SPANK+ACB, PAI+ACB, ACB alone, and SCAB. 2 of the 7 clinical trials showed the IPACK + ACB to be less effective in managing patients pain following TKR compared to other blocks which included the CACB and 4 in 1 block. In most instances, the IPACK + ACB showed superior efficacy in managing patients' pain following TKR when compared to other types of nerve blocks. This was determined by measuring usage of opioids, reported postoperative pain, and length of hospital stays following TKR. Thus, we suppose the IPACK block may be used in conjunction with the ACB to effectively reduce patient's pain following TKR.

Infiltration of local anesthetic in the Interspace between the popliteal artery and capsule of the posterior knee "IPACK block" versus adductor canal block "ACB" for pain relief after open wedge high tibial osteotomy: a randomized clinical trial.

A high tibial osteotomy is usually associated with severe postoperative pain. Both adductor canal block (ACB) and interspace between the popliteal artery and capsule of the posterior knee (IPACK) have been described as effective block techniques for providing analgesia after knee surgeries, with few comparisons in wedge osteotomy cases. We aim to compare the postoperative analgesic profile of the previously mentioned two block techniques in patients undergoing tibial osteotomies. Sixty patients were enrolled in this randomized prospective trial (30 received IPACK and 30 received ACB). Both blocks were installed before the spinal anesthesia after infiltration of 2 mL lidocaine 2%. Twenty mL of bupivacaine 0.25% mixed with dexamethasone as anesthetic adjuvant were used for both blocks. The postoperative analgesic profiles were compared between the two groups. Postoperative pain scores were lower in the IPACK group, and that decrease was evident throughout the first 10 hours postoperatively. Additionally, the duration of analgesia was much prolonged with the same block (487.50±82.39 vs. 301.93±92.06 minutes with ACB). There was a significant decline in postoperative analgesic consumption (1.27±0.45 vs. 1.8±0.61 gm, P=0.000), and a significant increase in the ambulation distance (19.10±0.60 vs. 17.73±0.45 m, P=0.000) with a significant decline in the duration of hospitalization (43.27±7.61 vs. 54±8.35 hours) in the IPACK group compared to the ACB group. IPACK is a superior block technique compared to ACB in patients undergoing high tibial osteotomy regarding postoperative analgesia, ambulation distance, and patient satisfaction with little rate of adverse events in both groups.

Diz Artroplasti Hastalarında Epidural Anestezi ile Adduktor Kanal ve IPACK Blok Kombinasyonunun Karşılaştırılması

Objective: Motor function-preserving peripheral nerve blocks have begun to play an important role in multimodal analgesic approaches of the patients with total knee arthroplasty (TKA). The aim of this study is to compare the effects of anesthesia methods on postoperative analgesia and early rehabilitation of patients after total knee arthroplasty. Methods: In this retrospective study, in which patients with unilateral TKA were screened, two groups were formed from selected patients. Group EA was administered 0.03 mg kg-1 of morphine with 10 cc saline through the epidural catheter in the postoperative period. In Group Adductor Canal Block (ACB)+ infiltration of local anesthetic between the popliteal artery and capsule of the knee block (IPACK), 10 mL 0.5% bupivacaine, 10 mL 2% lidocaine and 20 mL local anesthetic mixtures were made separately for ACB and IPACK blocks at one time. Primary postoperative outcome was Visual Analogue Scale (VAS), secondary outcomes were physical therapy ambulation test results. Results: In this study, postoperative pain score rates as the primary outcome were measured as follows: VAS8: 5 / 4 (p=0.041); VAS12: 5 / 4 (p=0.004) and VAS24: 4 / 3 (p=0.001) and lower pain scores were obtained in the ACB + IPACK group. In timed up to go (TUG) tests, TUG24 was 36/34 (p=0.001), TUG48 32.5/30 (p=0.012) and TUG72 20/12. Better ROM measurements were recorded in group ACB+IPACK at both 24 and 48 hours. Conclusion: In the ACB + IPACK group, better pain scores, more significant ambulation values, and less side-effect profile were obtained. Keywords: Adductor canal block, analgesia, epidural analgesia, total knee arthroplasty

Chronic post-surgical pain after knee arthroplasty: a role of peripheral nerve blocks.

Peripheral nerve blocks are an efficient method of pain control after total knee arthroplasty (TKA), but there is no report of their impact on chronic post-surgical pain (CPSP). This prospective observational study aimed to assess adductor canal block (ACB) and IPACK block (blocks vs. no blocks) on opioid consumption, postoperative pain score, chronic post-surgical pain 2 years after TKA. 166 patients (82 vs. 84) were analyzed. Opioid consumption was less in the group with blocks (9.74 ± 3.87 mg vs. 30.63 ± 11.52 mg) (p < 0.001). CPSP was present in 20.24% of patients in the group without blocks and 6.1% of patients with blocks (p = 0.011). Predictor variables of CPSP included pain before surgery (cut-off of 5.5), pain at rest (cut-off of 2.35), pain during active movement (cut-off: 2.5), and opioid consumption (cut-off: 8 mg). Peripheral nerve blocks provide adequate analgesia, significantly decrease opioid consumption, improve functional outcomes, and reduce CPSP 2 years after surgery.

Comparative Efficacy of iPACK vs Popliteal Sciatic Nerve Block for Pain Management Following Total Knee Arthroplasty: A Retrospective Analysis.

Introduction Total knee arthroplasty (TKA) is associated with severe acute postoperative pain. The use of tourniquets and drains (T/D) is common in TKA but may have an influence on postoperative pain and muscular strength. The infiltration of local anesthetic between the popliteal artery and capsule of the knee (iPACK block) is a motor-sparing block that provides analgesia to the posterior aspect of the knee. However, evidence regarding its efficacy is scarce.This study aims to assess the effectiveness of iPACK block and the impact of T/D use on pain and muscular strength after TKA. Material and methods A retrospective study was carried out including patients who underwent TKA from January 2020 to April 2023. Patients were allocated into groups according to the peripheral nerve block performed and T/D use. Results We included 415 patients in this study. No differences were found in pain at rest or the need for rescue analgesia between patients who received an iPACK block or sciatic nerve block (SNB) with T/D applied. Patients who received a SNB reported lower pain scores on movement (p= 0.019), but with a higher prevalence of motor block (p < 0.001). Patients who underwent surgery without using T/D reported lower pain scores on movement (p= 0.021) and reduced need for rescue analgesia (p= 0.041). Conclusion These findings indicate that iPACK block can facilitate early mobilization after TKA without significant impact on postoperative muscle strength. Furthermore, the use of a T/D may be a source of postoperative pain that could compromise early rehabilitation.

Uticaj perifernih nervnih blokova na inflamatorni odgovor posle artroplastike kolena

Introduction: The increased inflammatory response after knee arthroplasty (TKA) is a result of bone and soft tissue trauma whose extensive reactions contribute to postoperative morbidity and mortality. Methods: After elective TKA, 200 patients were included in this prospective cohort study. In one group of patients the adductor block and IPACK block were applied, while in the second group there were no blocks. Results: In the group with blocks fewer patients experienced pain at rest with lower intensity (1.18±0.76 vs. 3.35±1.18 p&lt;0.001). In the group without blocks, pain was more intense when coughing (1.7±0.52 vs. 3.72±1.61 p&lt;0.001) and during active movements of the operated leg (1.67±0.83 vs. 3.78±1.94 p&lt;0.001). In the first 24 hours after surgery, in the group with blocks, 22% of patients needed opioids in a dose of 9.64±3.21, while all patients in the group without blocks needed opioids in a dose of 30.94±11.47. Postoperatively, a statistically significant difference between the groups was observed in WBC, CRP, ESR, and albumin levels on the 1st, 3rd, and 5th days. Three months after TKA, the KOOS score was statistically higher in the group with blocks (92.6±11.73 vs 85.65±17.49 p&lt;0.001). Conclusion: The combination of nerve blocks provides adequate postoperative analgesia enabling early rehabilitation, reducing morphine consumption, reducing the count of WBC, CRP, ESR, and albumin (1st, 3rd, and 5th day postoperatively), and positively affecting the functional status three months after surgery. Identification and influence on factors that reduce the local and systemic inflammatory response is vital in improving recovery after TKA.

Pain Management, Functional Recovery, and Stress Response Expressed by NLR and PLR after the iPACK Block Combined with Adductor Canal Block for Total Knee Arthroplasty-A Prospective, Randomised, Double-Blinded Clinical Trial.

This study aimed to investigate pain management, functional recovery, and stress response expressed by the neutrophile-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) after the popliteal artery and posterior knee capsule infiltration (iPACK) block combined with adductor canal block (ACB) in total knee arthroplasty (TKA). This was a prospective, double-blinded, randomised, controlled trial in a tertiary referral hospital. Three hundred and sixty-six patients were randomly allocated into the sham block group and iPACK combined with the ACB group. The primary outcome was postoperative pain scores. The secondary outcomes were opioid consumption, functional recovery expressed by a range of motion, and quadriceps strength. Also, the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were calculated. There were significant differences between the sham block and iPACK + ACB group in pain scores p < 0.0001 at all time points. Therefore, there was a significant difference in opioid consumption (p < 0.0001) and functional recovery (p < 0.0001). Also, NLR and PLR levels 12 h (p < 0.0001) and 24 h (24 h) after surgery (p < 0.0001) were much lower in the iPACK + ACB group. After total knee arthroplasty, the iPACK combined with ACB block group improved pain management, functional recovery, and stress response. Therefore, we strongly recommend this technique as a part of a multimodal analgesia protocol in knee surgery.

Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia After Total Knee Arthroplasty: A Retrospective Cohort Study

Background: There is no consensus on whether adductor canal block (ACB) combined with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block can further increase analgesia and reduce opioid consumption after total knee arthroplasty (TKA) compared with ACB and periarticular infiltration analgesia (PIA). Purpose: This study aimed to evaluate the effectiveness of combining ACB and PACK block on analgesia and functional recovery following TKA. Methods: A retrospective cohort study was conducted involving 386 patients who underwent primary unilateral TKA at our institution from January 2020 to October 2022. Patients were divided into 3 groups and treated with PIA, ACB, or ACB combined with IPACK block, respectively. Primary outcomes were postoperative morphine consumption and visual analogue scale (VAS) pain scores. Secondary outcomes included functional recovery, evaluated by knee range of motion, quadriceps strength, daily mobilization distance, and postoperative length of stay. Other outcomes included incidence of complications. Results: Patients in the ACB + IPACK group had significantly less morphine consumption on postoperative day 1 and during hospitalization than patients in the PIA and ACB groups. Furthermore, the ACB + IPACK group had significantly lower VAS scores at rest and during motion at 6, 12, and 24 hours postoperatively (but not at other time points), better knee range of motion on postoperative days 1 and 2 (but not day 3), and a greater daily mobilization distance on postoperative day 1 (but not days 2 and 3). The ACB + IPACK group had significantly lower incidences of postoperative nausea and vomiting than the PIA and ACB groups. Conclusion: This retrospective cohort study suggests that a combination of ACB and IPACK block may have a greater effect than PIA or ACB alone on analgesia following TKA, while providing better functional recovery. Further study is warranted.

Does Adding an IPACK Block to the Suprainguinal Fascia Iliaca Block Improve the Quality of Analgesia in Patients Undergoing Knee Arthroplasty under Spinal Anesthesia? A Retrospective Cohort Study.

Background and Objectives: Total knee arthroplasty (TKA) is a commonly performed orthopedic procedure, and is often accompanied by significant postoperative pain. The supra-inguinal fascia iliaca block (SIFIB), similar to an anterior lumbar plexus block, is frequently used in hip surgeries. The interspace between the popliteal artery and capsule of the posterior knee (IPACK) block is a regional anesthesia technique that targets the posterior innervation of the knee capsule. This retrospective study aimed to compare the analgesic effects of SIFIB and SIFIB + IPACK on patients undergoing TKA under spinal anesthesia. Materials and Methods: This retrospective study revealed the data collected from a tertiary hospital. Patient data were gathered for individuals who underwent unilateral TKA under spinal anesthesia during the period between 1 January 2023 and 1 September 2023. Inclusion criteria comprised patients falling within ASA class I-III, those following a standardized perioperative analgesia regimen, and individuals receiving opioids via a patient-controlled analgesia device (PCA) as part of their postoperative pain management strategy. Patients were grouped as SIFIB and SIFIB + IPACK according to the performed regional anesthesia technique. Results: In the study, the data of 88 patients in total, 61 in the SIFIB group and 27 in the IPACK group, were analyzed. The 24 h cumulative morphine consumption was similar in the SIFIB and SIFIB + IPACK groups (10.62 ± 6.58 mg vs. 12.55 ± 8.84 mg, respectively; p: 0.258). The NRS scores of the groups were similar in all time frames. Conclusions: Our study reveals that combining IPACK with SIFIB in the multimodal analgesia plan does not provide additional benefits in terms of postoperative opioid consumption and pain scores in patients undergoing unilateral THA under spinal anesthesia.

Infiltration Between Popliteal Artery and Capsule of the Knee Combined with Adductor Canal Block as Analgesic Adjuvant During and Postoperative in Total Knee Replacement Surgery

Background: Infiltration between the popliteal artery and capsule of the knee (iPACK) is one method that has been proposed in recent years as a potential alternative to peripheral nerve block as analgesia in total knee replacement (TKR) procedures. This study presents anesthetic management using spinal anesthesia combined with iPACK and adductor canal block (ACB) in patients with grade IV osteoarthritis who underwent TKR of the right knee.&#x0D; Case presentation: A woman, a housewife aged 50 years, was planning to undergo TKR surgery. The patient came with complaints of pain in the right knee 1 year before entering the hospital. The patient was given supplemental oxygen with a nasal cannula at 3 liters per minute. Prior to spinal anesthesia, the patient was given fentanyl 25 mcg iv, ketamine 10 mg iv, and midazolam 1.5 mg IV as premedication. The patient was positioned on the right side, and a 27G Quincke needle was inserted at the level of L3-L4 and given bupivacaine heavy 0.5% 7.5 mg, then lateralized for 15 minutes. After lateralization, the patient was positioned supine and used ultrasound to direct ACB action with a regimen of ropivacaine 0.25% + dexamethasone 5 mg a volume of 20 ml, then iPACK was performed with a regimen of Ropivacaine 0.375% + dexamethasone 5 mg a volume of 20 ml. After surgery, the patient is treated in the recovery room for 1 hour until bromage score is 0. The patient received the PCA Morphine analgesic demand only 1 mg/mL, 1 mg per dose, max 5 mg over 4 hours, lockout interval 6 minutes; Paracetamol 500 mg every 6 hours PO; Ibuprofen 400 mg every 8 hours PO.&#x0D; Conclusion: TKR patients who were given analgesia using the ACB peripheral nerve block technique combined with iPACK experienced a decrease in pain levels and lower use of postoperative morphine so that patient mobilization was faster and reduced the patient's length of stay.

IPACK block with spinal anesthesia compared to fentanyl-based spinal anesthesia for postoperative analgesia following arthroscopic meniscectomy: a randomized, prospective study

BackgroundLocal anesthesia and intrathecal narcotics are utilized to provide postoperative analgesia. IPACK (infiltration between the knee capsule and popliteal artery) is a new localized analgesic approach for knee surgery. This randomized study aimed to compare fentanyl-based spinal anesthesia and IPACK block-based spinal anesthesia for postoperative analgesia in patients undergoing arthroscopic meniscectomy.ResultsIn group F, the VAS (visual analog scale) was higher than in group I, whereas the total amount of morphine was lower in group I (P < .05). In group F (3.92 ± 1.54), the initial painkiller request occurred earlier than in group I (8.82 ± 0.44). In addition, total morphine administrated in group F (20.81 ± 0.69) was significantly higher than in group I (9.54 ± 0.73) (P < .05). Group I had a higher level of patient satisfaction 24 h after surgery than group F (P < .05). In the current study, there were no significant adverse effects linked to the use of fentanyl. Moreover, no complications associated with the IPACK block were detected.ConclusionsThe combination of IPACK block and hyperbaric bupivacaine spinal anesthesia is an effective treatment for initial postoperative pain following arthroscopic meniscectomy, according to the findings of this study. IPACK block prolongs postoperative analgesia more than intrathecal fentanyl.Trial registrationThis study was registered with Clinical Trials Registry (NCT05833776).