Knee Capsule Research Articles

Survival and functional outcomes after hemiarthroplasty in children with proximal tibial osteosarcoma

BackgroundTreatment options for correcting limb-length discrepancy after limb-salvage reconstruction for proximal tibial osteosarcoma in children have several limitations. Therefore, we aimed to evaluate the feasibility, complications, prognosis, and clinical outcomes of reconstruction using hemiarthroplasty after tumor resection in pediatric patients with proximal tibial osteosarcoma.MethodsWe conducted a comprehensive retrospective analysis of the data of pediatric patients with osteosarcoma of the proximal tibia who underwent surgery between December 2008 and November 2018 at our center. We enrolled 49 consecutive patients who underwent hemiarthroplasty. The cruciate ligaments of all patients were reconstructed using special spacers, and the medial and lateral collateral ligaments of the knee and joint capsule were reconstructed using a mesh. Postoperatively, if the unequal length of both lower limbs exceeded 4 cm or knee instability occurred, a second-stage surgery was performed for limb lengthening and replacing the distal femoral prosthesis. We analyzed the oncological prognosis, complications of hemiarthroplasty, postoperative stability, and postoperative function.ResultsThe follow-up period ranged between 11 and 159 months, with a median of 84 (62, 129) months. The overall 5-year survival rate was 83.2%. Thirty-nine patients survived at the end of the follow-up period with 34 prostheses (87.2%). The overall prosthesis survival rate was 87.4% after 5 years, indicating the long-term benefits of the procedure. Limb length was measured in 28 adult patients. The average limb-length discrepancy was 33 ± 15 mm with a median of 33 mm (21, 47); the femur and tibia caused a discrepancy of 8.5 ± 9.9 mm and 24.8 ± 15.5 mm, respectively. The patients had 30–135° of knee motion, with a mean of 82 ± 24°. The femoral tibial angle was greater on the affected side than on the healthy side, with a mean difference of 4.5°±3.6°. The Musculoskeletal Tumor Society (MSTS) score was 25 ± 3. Five patients underwent second-stage distal femoral prosthesis replacement, with mean MSTS scores of 24 ± 2 and 28 ± 1 before and after second-stage surgery, respectively.ConclusionsHemiarthroplasty in children reduces limb-length discrepancy in adulthood by rebuilding cruciate ligaments, lateral collateral ligaments, and the joint capsule, thereby improving knee stability.

The role of iPACK (interspace between the popliteal artery and the posterior knee capsule) radiofrequency for pain management following meniscus repair- a case report

The role of iPACK (interspace between the popliteal artery and the posterior knee capsule) radiofrequency for pain management following meniscus repair- a case report

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

Large Human Fabella Bone

Fabella bone is identified as an accessory and evolutionary sesamoid bone in humans. It was noticed as an irregular shape located within the lateral head of gastrocnemius in the posterolateral capsule of the left knee of a 55-year-old male. Another smaller fabella was noted and both were kept in a safe place Measurements were taken after a week and their length was 2.7 cm and 1.8 cm respectively. The size of fabella usually ranges from 5mm-20mm in diameter, but in this study, the length of the larger one was 2.7 cm. Fabella originated as a small cartilaginous nodule and underwent endochondral ossification. It helps to reduce resistance within tendons and redirect muscle forces. In humans, gastrocnemius acts to flex the knee and plantar flex the foot. Fabella function was thought to stabilize the femoral complex and medial femoral condyle. Patients with fabella pain syndrome usually complain of increased posterolateral pain during the full extension of the knee joint. Fabella pain syndrome could be treated with physical therapy, local anaesthetics injection, radial extracorporeal shock wave therapy or fabellectomy. It has been observed that there has been an increase in the prevalence of fabella in recent years. Larger moments acting on the knee and increasing muscle or tendon strain could produce stimuli essential to encourage fabella formation.

Investigating the anti-inflammatory and immune-modulatory effects of “Gola” guava fruit and leaf extract in alleviating papain-induced knee osteoarthritis

IntroductionThis present research was designed to investigate the anti-inflammatory and immune-modulatory effects of a 50% hydroethanolic extract of “Gola” guava fruit (GF50%) and guava leaf (GL50%) against papain-induced knee osteoarthritis (KOA).MethodsSixty Sprague–Dawley rats were divided into five groups (10 rats/ group): T0 (negative control), T1 (positive control), T2 (200 mg/kg GF50%), T3 (400 mg/kg GF50%), T4 (200 mg/kg GL50%), and T5 (400 mg/kg GL50%). Physical parameters were evaluated throughout the trial, while biochemical, histopathological, and radiographic analyses were performed at 0, 15, and 30 days. The histopathological and radiographic analyses were evaluated using the Osteoarthritis Research Society International (OARSI) score and Kellgren–Lawrence (KL) classification systems, respectively.Results and discussionThe T1 group demonstrated a significant increase in knee diameter, confirming successful OA induction. The T5 group maintained a significantly lower body weight at day 30, and the T3 group exhibited the highest weight gain. The high dose of GL50% (400 mg/ kg) effectively reduced knee inflammation and significantly downregulated myeloperoxidase (MPO), interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α). In contrast, it significantly (p < 0.001) upregulated the serum and knee capsule tissue superoxide dismutase (SOD), catalase (CAT), and glutathione peroxidase (GPx). In addition, histopathological and X-ray examinations also confirmed the chondroprotective potential of GL50% extract against OA. Consequently, 400 mg/kg GL50% exhibited anti-inflammatory and chondroprotective potential by lowering oxidative stress and pro-inflammatory cytokines and elevating antioxidant status. These findings could provide a theoretical basis for understanding the mechanism and potential medicinal value of guava fruit and leaf in treating KOA.

Comparing Different Multimodal Analgesia Protocols for Primary Total Knee Arthroplasty-A Retrospective Cohort Analysis.

Background: Several local regional anesthesia regimes have been described in the literature to reduce post-surgical pain following total knee arthroplasty (TKA), but it is unclear which regime has the best analgetic effect combined with the best motor function. The aim of this study was to determine if patients with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) combined with an adductor canal block (SACB) had less pain, better motor function, and less opioid consumption after TKA than patients with a femoral nerve block (FNB) combined with a popliteal sciatic nerve block (PSB). Methods: In a retrospective cohort analysis, 342 patients following primary TKA were examined; 175 patients were treated with an IPACK combined with a SACB, and 167 patients with a femoral FNB combined with a PSB. The outcome parameters postoperative pain (visual analogue scale (VAS) for mobilization and at rest, functional recovery, opioid consumption, hospital discharge, and complications were analyzed and compared between both groups. Results: The IPACK/SACB group had a higher postoperative need for opioids despite higher doses of ropivacaine compared to the FNB/PSB group, accompanied by higher VAS scores. Patients' satisfaction was equal between the groups. Both groups showed comparable mobilization rates and walking distances following TKA. Conclusions: IPACK/SACB showed equal results compared to FNB/PSB for mobilization rates and patients' satisfaction following TKA without a reduction in opioid consumption.

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.

Comparison between Combination of Proximal Adductor Canal Block and Infiltration between Popliteal Artery and Capsule of Knee (iPACK) with Large-Volume Distal Adductor Canal Block in Facilitating Early Mobilization after Total Knee Replacement: A Randomized, Single-Blind Study

Abstract Background: Adductor canal block (ACB) and infiltration between popliteal artery and capsule of knee (iPACK) are popular block methods for analgesia after total knee replacement (TKR), covering both the anterior and posterior knee. This study aimed to compare the performance of the combination of ACB and iPACK with large-volume distal ACB in facilitating early mobilization after TKR. Patients and Methods: This study was a single-blind, randomized, controlled trial of 30 subjects who underwent TKR. Subjects were randomly assigned to either Group A (the large-volume distal ACB) or Group B (the combination of proximal ACB and iPACK). Outcome variables included postoperative time up and go (TUG) test, numeric rating scale (NRS), postoperative morphine consumption, block-performing time, time to first opioid rescue analgesia, and side effects. Results: This study found that the block-performing time was significantly shorter in Group A compared to Group B (230.67 vs. 509.67, P < 0.001). The mean postoperative TUG test (67 vs. 64, P = 0.78), NRS at all-time points, and postoperative morphine consumption (3 vs. 3 mg, P = 0.85) did not differ significantly. No block-related side effects were found in either group. Conclusion: Large-volume distal ACB is not superior to the combination of proximal ACB and iPACK in facilitating early mobilization after TKR. Block-performing time of distal ACB was shorter compared to the combination of proximal ACB and iPACK.

Efficacy of adding infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) to adductor canal block and local infiltration analgesia in total knee arthroplasty: A retrospective cohort study.

Local infiltration analgesia (LIA), adductor canal block (ACB), and infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) are popular multimodal analgesia techniques used during total knee arthroplasty (TKA). This study aimed to explore the efficacy of adding the IPACK technique to ACB and LIA in patients undergoing TKA. In this retrospective cohort study, patients who underwent primary unilateral TKA were divided into two groups based on their date of admission. Sixty-three patients underwent IPACK, ACB and LIA (IPACK group) during surgery, while 60 patients underwent ACB and LIA (control group). The primary outcome was the postoperative administration of morphine hydrochloride as a rescue analgesic. Secondary outcomes included time to first rescue analgesia, postoperative pain assessed using the visual analog scale (VAS), functional recovery assessed by knee range of motion and ambulation distance, time until hospital discharge, and complication rates. The two groups were similar in average postoperative 0-to-24-h morphine consumption (11.8mg for the control group vs 12.7mg for the IPACK group, p = .428) and average total morphine consumption (18.2mg vs 18.0mg, p = .983) during hospitalization. There were also no significant differences in the secondary outcomes. The addition of IPACK to ACB and LIA did not provide any clinical analgesic benefits. Orthopedic surgeons and anesthesiologists are justified in using ACB and LIA without IPACK for TKA.

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.

A Recess Is Observed Between the Posterior Knee Capsule and the Meniscotibial Ligament Complex in Pediatric Specimens

To define the surgical anatomy of the meniscotibial ligament complex of the pediatric medial and lateral menisci and their relation to the proximal tibial physis and posterior joint capsule. Fourteen pediatric cadaveric knee specimens (aged 3 months to 11 years) were dissected to clarify the relation of the posterior knee capsule, the meniscus, and the meniscotibial ligament complex. Metallic markers were placed marking the meniscotibial ligament capsular attachment on the proximal tibia. Specimens underwent computed tomography scanning to evaluate pin placement and relation to the physis. A digital measurement tool was used to measure the distances between the proximal tibial physis and the pins (placed at 5 points on both the lateral and medial menisci). In each specimen, clear separation was noted between the posterior joint capsule from the meniscus and meniscotibial ligament complex in the medial and lateral compartments. There was an increase in the distance between the proximal tibial physis and the insertion points of the meniscotibial ligament complex with increasing specimen age. For both the medical and lateral menisci in group 1, the median meniscotibial ligament insertion points were often less than 7 mm (interquartile range, 0.00-7.8 mm) away from the physis. The median meniscotibial ligament insertion points in group 2 tended to be farther from the physis but always less than 20 mm (interquartile range, 2.5-17.5 mm)-and as close as less than 5 mm (lateral posterior root). In this anatomic study of pediatric knees, we observed a distinct recess/cul-de-sac space between the posterior knee capsule and meniscal attachments in all specimens. This defines a distinct plane between the posterior knee capsule and the meniscotibial ligament complex, with a distance between the physis and meniscotibial ligament capsular attachments that increases with age. The anatomic parameters evaluated in our study should be considered as future meniscal repair and transplantation techniques aim to restore the meniscal anatomy, stability, and mobility provided by the meniscotibial ligament complex and capsule structures.

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.

Arthritis or an Adjacent Fascial Response? A Case Report of Combined Pyomyositis and Aseptic Arthritis

Pyomyositis, accompanied by aseptic arthritis, has been previously documented in several publications. However, none of the authors in the mentioned case reports offered a pathophysiological explanation for this unusual phenomenon or proposed a treatment protocol. We present a case of a healthy, 70‐year‐old male who was presented to the emergency department 4 days after tripping over a pile of wooden planks and getting stabbed by a nail to his thigh. The right thigh was swollen. Unproportional pain was produced by a light touch to the thigh. A laboratory test and a CT scan were obtained. The working diagnosis was pyomyositis of the thigh and septic arthritis of the ipsilateral knee. The patient underwent urgent debridement and irrigation of his right thigh. An arthroscopic knee lavage was performed as well. Intraoperative cultures from the thigh revealed the growth of Streptococcus pyogenes and Staphylococcus aureus. Cultures from synovial fluid were sterile; thus, septic arthritis was very unlikely. The source of the knee effusion might have been an aseptic inflammatory response due to the proximity of the thigh infection. Anatomically, the quadriceps muscle inserts on the patella, and its tendon fuses with the knee capsule, creating a direct fascial track from the thigh to the knee. The inflammatory response surrounding the infection may have followed this track, creating a domino effect, affecting adjacent capillaries within the joint capsule, and causing plasma leakage into the synovial space, leading to joint effusion. Our suggested treatment is addressing the primary infection with antibiotics and considering adding anti‐inflammatory therapy, given our suspicion that this process has an inflammatory component.

The anatomical description of the pericruciate fat pad (PCFP) – a brief report of cadaveric dissection

Introduction. Fat pads of the human knee joint are relatively well-known structures except for the pericruciate fat pad (PCFP). Aim. The study aimed to describe (1) the anatomy of the pericruciate fat pad (PCFP) and (2) its relation to the middle genicular artery (MGA). Materials and methods. Four male cadaveric lower limbs were dissected. PCFP was excised, and its horizontal and vertical lengths and volume were measured. The presence of MGA was assessed, and its internal diameter was registered. Results. PCFP was located in the intercondylar fossa. Its superior, inferior, medial&lateral and posterior borders were the intercondylar roof, tibial plateau, femoral condyles, and posterior knee capsule, respectively. The anterior part of the PCFP enveloped the posterior cruciate ligament (PCL). PCFP had a homogenous appearance of adipose tissue with small lobules. It was connected to the PCL with a fibrous process. The mean horizontal&vertical length and volume were 56.85±3.4 mm (range 52.1-60.2 mm), 42.8±5.8 mm (range 34.2-46.1 mm) and 43.75±4.79 ml (range 40-50 ml), respectively. The MGA penetrated the PCFP in all four examined limbs; its mean diameter was 1.18±0.33 mm (range 0.8-1.55 mm). Conclusions. PCFP is a relatively large structure, with MGA present within all examined cases. Care must be taken when performing surgeries involving the posterior intra-articular part of the knee because the PCFP may present an underestimated potential for oedema and bleeding.

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.

The Anterolateral Ligament of the Knee Is a Nonisometric Thin Ligament With High Prevalence and Almost Constant Attachment to the Lateral Meniscus: A Systematic Review With Meta-analysis

To provide comprehensive information about the anterolateral ligament (ALL) prevalence, morphometry, isometry, insertions, histology, and its relationship with the lateral meniscus (LM). The study was performed, according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Eligible cadaveric studies investigating the frequency of the ALL presence, and anatomical features were identified through an online search of the PubMed, Scopus, and Cochrane Central databases from inception to June 2022. Statistical analysis was conducted with the open-source R programming language using the "meta" package. The Higgins I2 statistic was used for quantifying heterogeneity. Thirty-three studies (1,478 cadaveric knees) were included. The ALL had a 79% prevalence. It was attached to the LM periphery in 97% of studies. Most studies reported a femoral insertion of the ALL, just proximal and posterior to the lateral epicondyle. Tibial attachment is constant at the midpoint between Gerdy's tubercle and fibular head. The mean ALL thickness at the joint line was 1.6 [1.2; 2.0] mm. The ALL length was found to significantly change across the knee flexion (P < .01). It was increased from 0° to 60° and decreased after 60° flexion. Seven histological studies demonstrated a typical ligamentous microstructure. The ALL is a thin ligament, distinct to the knee capsule, which may be found in 79% of the knees having an almost constant attachment to the LM. The ALL is not isometric. It becomes tense during internal rotation and between 30° and 60° knee flexion. Pooled results should be interpreted with caution due to the high heterogeneity among the included studies. This study sheds light on controversial issues and provides comprehensive and accurate information about the essential anatomical knowledge on ALL, which may contribute to optimizing ALL reconstruction surgical techniques and biomechanical settings.

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).

Ultrasound Guided Infiltration of Popliteal Artery and Capsule of Knee [IPACK] versus IPACK with Adductor Canal Block [ACB] for Postoperative Knee Surgery Analgesia: A Comparative Study

Ultrasound Guided Infiltration of Popliteal Artery and Capsule of Knee [IPACK] versus IPACK with Adductor Canal Block [ACB] for Postoperative Knee Surgery Analgesia: A Comparative Study