Posterior Knee Pain Research Articles

The analgesic effect of continuous adductor canal block combined with popliteal plexus block for total knee arthroplasty: a randomized controlled trial.

This study aimed to confirm the hypothesis that continuous ACB (CACB) combined with a popliteal plexus block (PPB) can improve posterior knee pain, reduce nalbuphine consumption, and shorten the length of hospital stay. Patients who underwent TKA were allocated to the CACB + sham block (SHAM) or CACB + PPB groups. The primary outcome was the maximum pain score originating from the posterior knee within 4h after TKA. Secondary outcomes included the maximum pain score originating from the posterior and anterior knees within 72h after TKA, range of motion on postoperative day (POD) 1-3, postoperative nalbuphine consumption within 72h of surgery, length of hospital stay, and complications. The maximum pain score of the posterior knee was lower in the CACB + PPB group than in the CACB + SHAM group within 0-12h after surgery. Nalbuphine consumption within 24h after surgery was lower in the CACB + PPB group than in the CACB + SHAM group. The range of motion was better in the CACB + PPB group than in the CACB + SHAM group on POD1 and 2. The length of hospital stay was shorter in the CACB + PPB group than in the CACB + SHAM group. The incidence of clinical significant nausea and vomiting was lower in the CACB + PPB group than in the CACB + SHAM group. This study found that PPB combined with CACB could relieve pain in the posterior knee within at least 12h after TKA, reduce nalbuphine consumption within 24h after TKA, improve the range of motion on POD1 and 2, and shorten the length of hospital stay for patients who underwent TKA.

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.

Neuritis ossificans mimicking a malignancy in a child: case report and literature review.

We present the case of a child with neuritis ossificans after acute trauma, treated conservatively. The aim of the review is to compare several parameters in this disease. Emphasis is placed on the clinical-radiological features distinguishing neuritis ossificans from malignancy to avoid unnecessary biopsy and surgery.A literature review was performed. Only 18 cases were described. Except for one, all describe adults, and none had acute trauma. Nearly all were treated surgically.Our 13-year-old patient presented with posterior knee pain after trauma. MRI demonstrated a mass within the tibial nerve with oedema, some lymph nodes and increased avidity on 18fluoro-2-deoxyglucose-positron emission tomography. These findings can be reactive but also associated with malignancy. However, eggshell-like calcifications in the periphery of the mass were seen on CT. Biopsy and resection were proposed. Follow-up visits over the next weeks showed remarkable clinical improvement. Wait-and-scan was advised after international discussion. Follow-up imaging after 2months showed resolution of the oedema and volume reduction of the mass, suggesting a benign pathology. Diagnosis of neuritis ossificans was proposed based on the clinical and radiological features. There was a favorable course with no complaints after twomonths. Imaging after sevenmonths showed an almost complete regression.Neuritis ossificans should be considered within a painfull (mono)neuropathy. The initial inflammatory phase may mimic malignancy, misleading clinicians toward biopsy or surgery with the risk of nerve damage. As seen in our case, neuritis ossificans can be a self-limiting process. Therefore, conservative therapy should be considered with a wait-and-scan approach.

Enlightenment on Knee Flexors Strength Loss in Cases of Posterior Knee Pain After Anterior Cruciate Ligament Reconstruction.

The persistence and the recurrence of posterior medial knee pain (PKP) after anterior cruciate ligament reconstruction (ACLR) using hamstring tendon graft are often overlooked during rehabilitation. Cross-sectional observational study. The study aimed (1)to evaluate the prevalence of these types of PKP before 4months post-ACLR, (2)to measure their consequences on the knee flexors strength, and (3)to evaluate the role of the type of ACLR. From a cohort of patients operated on with hamstring tendon procedures, the persistent and the recurrent PKP were sought at 4months post-ACLR. The evolution of isokinetic muscle strength recovery in PKP subjects was compared with those of nonpainful subjects. The functional deficit was measured at 6/7months post-ACLR by a hop test. Three hundred seventeen subjects (25.8 [6.0]y) were included. At 4months post-ACLR, 2 populations were identified based on the recurrent onset of PKP (PKP+, n = 40) or the absence of knee pain (PKP-, n = 277). The prevalence of PKP was 8.3%. At the fourth month post-ACLR, the PKP+ group had a higher flexor strength deficit compared with the PKP- group (limb symmetry index at 60°/s: 67.2% [12.4%] vs 84.3% [12.6%]; P < .05). At 6/7months, the loss of strength persisted (limb symmetry index at 60°/s: 82.3% [13.4%] vs 87.7% [12.8%]; P < .05). The hop test deficit was comparable, and no difference was shown according to the type of graft. Persistent and recurrent PKP during the rehabilitation period were not uncommon and were associated with a worsening of flexors strength loss on the ACLR side.

Beyond the Baker's Cyst: Pathology and Variant Anatomy in the Popliteal Fossa on Routine Knee MRI

Primary evaluation of the knee focuses on evaluation of cartilaginous degeneration, meniscal injury, ligamentous or tendinous abnormality, and bony lesions, rather than the posterior and extracapsular popliteal fossa. A succinct review of normal popliteal fossa anatomy and normal fat planes is key to recognizing clinically significant pathology and variant anatomy. Abnormal insertion of the medial head of the gastrocnemius, or an accessory head of the gastrocnemius, can increase the risk of popliteal artery entrapment, an underrecognized cause of posterior calf and knee pain. Abnormal branching and course of the popliteal artery can increase risk of surgical vulnerability during multiple knee procedures, including arthroscopy and high tibial osteotomy. Finally, not all masses in the popliteal fossa are Baker's cysts; synovial sarcomas, vascular malformations, and other tumors can present in this anatomic space and can mimic popliteal cysts.

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.

Knee Flexion Range-of-Motion Restriction Following Anterior Cruciate Ligament Reconstruction: A Retrospective Case Report

BACKGROUND: Anterior cruciate ligament tears are a commonly encountered orthopedic knee injury. Only a few studies focus on interventions to restore knee flexion range of motion. The purpose of this case report is to describe the restoration of motion following anterior cruciate ligament reconstruction. CASE PRESENTATION: A 26-year-old man with a traumatic knee injury resulting in a right anterior cruciate ligament tear, joint effusion, decreased knee range of motion (ROM), and decreased strength managed conservatively for 3 months. OUTCOME AND FOLLOW-UP: Restoration of knee flexion ROM was achieved at 16 weeks postoperatively utilizing targeted interventions intended to restore meniscal gliding. The patient maintained knee ROM at 8 months following anterior cruciate ligament reconstruction. DISCUSSION: When a soft end-feel, posterior knee pain, and reduced flexion ROM are present, tibiofemoral joint mobilizations are a targeted intervention to improve meniscal gliding. The utilization of multimodal interventions assisted in the recovery of functional knee ROM and improved pain. JOSPT Cases 2023;3(3):202-205. Epub: 10 July 2023. doi:10.2519/josptcases.2023.11771

The Kneed for Stability: Posterior Knee Pain in a Recreational Soccer Player

The Kneed for Stability: Posterior Knee Pain in a Recreational Soccer Player

Comparison of Analgesic Efficacies of the iPACK (Interspace Between the Popliteal Artery and Capsule of the Posterior Knee) and Genicular Nerve Blocks Used in Combination With the Continuous Adductor Canal Block After Total Knee Arthroplasty: A Randomized Clinical Trial

BackgroundThe interspace between the popliteal artery and capsule of the posterior knee (iPACK) block and the genicular nerve block (GNB) are motor-sparing nerve blocks used for knee pain relief. We compared the analgesic efficacies of ultrasound-guided iPACK block and GNB when combined with continuous adductor canal block after total knee arthroplasty. MethodsIn this randomized control study, 132 total knee arthroplasty patients were assigned to the iPACK, GNB, and iPACK + GNB groups. All patients received combined spinal anesthesia and continuous adductor canal block. The primary outcome was the 8-hour postoperative pain score during movement. Secondary outcomes were pain scores, posterior knee pain, intravenous morphine consumption, and tibial and common peroneal nerve sensorimotor function. All included patients completed the study. ResultsThe 4-hour and 8-hour postoperative pain scores during movement were significantly lower in the iPACK + GNB group than that in the iPACK group (−2.5 [3.6, 1.3]; P < .001 and −2 [-3, −1]; P < .001, respectively). The differences in rating pain scores and posterior knee pain were not clinically relevant. The iPACK group demonstrated a significantly higher intravenous morphine consumption than did the GNB and iPACK + GNB groups during the first 48 hours postoperatively (P < .001) but were not clinically relevant. There was no incidence of complete sensorimotor blockade in any of the groups. ConclusionThe iPACK–GNB combination relieved pain during movement better than the iPACK block alone during the 8 hours postoperatively after total knee arthroplasty in setting of multimodal analgesia such as adductor canal block.

MUCOID DEGENERATION OF THE ANTERIOR CRUCIATE LIGAMENT: REVIEW OF THE LITERATURE

Background:The cases of mucoid degeneration initially described in the 1950s mainly concerned the cardiovascular system. In 1976 Ewing et al (24) reported the first case of mucoid degeneration of striated muscle in the limbs. In 1999 Kumar et al (2) described the first case of mucoid degeneration of the anterior cruciate ligament of the knee Aims: to study the clinical and radiographic semiology of this pathology and the possible therapeutical alternatives. Patients/Methods: Retrospective studies with a case series. The number of cases in each study is greater than or equal to 10 cases.And alldiagnosis of mucoid degeneration of the anterior cruciate ligament is authenticated by magnetic resonance imaging of the knee with Location of the lesion in the anterior cruciate ligament. Results: Our search strategy yielded 42 articles. The abstracts were reviewed to identify articles appropriate for our study resulting in the identification of 18 articles. Ten studies were excluded because they had a limited number of cases (9 articles about one case and 1 article about 5 cases). Another article (17) was also excluded because it included a comparative study with control groups of patients with normal MRI and arthroscopy. Seven articles meeting the inclusion criteria were retained for the final analysis. Conclusions: Mucoid degeneration of the anterior cruciate ligament of the knee is often misunderstood and confused with a partial rupture of the ACL. Its diagnosis must be suspected in front of a stereotyped clinical picture of unusual posterior knee pain and a limitation of flexion. The symptomatology sometimes takes atypical forms because of the frequently associated meniscal and cartilage lesions.

The effect of continuous adductor canal block combined with distal interspace between the popliteal artery and capsule of the posterior knee block for total knee arthroplasty: a randomized, double-blind, controlled trial

BackgroundThe optimal analgesia for total knee arthroplasty (TKA) requires excellent analgesia while preserving muscle strength. This study aimed to determine the hypothesis that continuous adductor canal block (CACB) combined with the distal interspace between the popliteal artery and the posterior capsule of the knee (IPACK) block could effectively alleviate the pain of the posterior knee, decrease opioids consumption, and promote early recovery and discharge.MethodsPatients undergoing unilateral, primary TKA were allocated into group CACB+SHAM (receiving CACB plus sham block) or group CACB+IPACK (receiving CACB plus IPACK block). The primary outcome was cumulative opioid consumption. Secondary outcomes included the incidence of postoperative pain originated from the posterior knee, visual analogue scale (VAS) score, range of motion, ambulation distance, and satisfaction for pain management.ResultsThe incidence of moderate-severe pain of the posterior knee was lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours (17.1% vs. 42.8%; p = 0.019), 8 hours (11.4% vs. 45.7%; p = 0.001), and 24 hours (11.4% vs. 34.3%; p = 0.046) after TKA. The VAS scores of the posterior knee were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [2 (2) vs. 3 (2–4); p = 0.000], 8 hours [1 (1, 2) vs. 3 (2–4); p = 0.001], and 24 hours [1(0–2) vs. 2 (1–4); p = 0.002] after TKA. The overall VAS scores were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [3 (2, 3) vs. 3 (3, 4); p = 0.013] and 8 hours [2 (2, 3) vs. 3 (2–4); p = 0.032] at rest and 4 hours [3 (3, 4) vs. 4 (4, 5); p = 0.001], 8 hours [3 (2–4) vs. 4 (3–5); p = 0.000], 24 hours [2 (2, 3) vs. 3 (2–4); p = 0.001] during active flexion after TKA. The range of motion (59.11 ± 3.90 vs. 53.83 ± 5.86; p = 0.000) and ambulation distance (44.60 ± 4.87 vs. 40.83 ± 6.65; p = 0.009) were superior in group CACB+IPACK than that of the group CACB+SHAM in postoperative day 1. The satisfaction for pain management was higher in group CACB+IPACK than that of the group CACB+SHAM [9 (8, 9) vs. 8 (7–9); p = 0.024]. There was no difference in term of cumulative opioids consumption between group CACB+IPACK and group CACB+SHAM [120(84–135) vs. 120(75–135); p = 0.835].ConclusionThe combination of CACB and distal IPACK block could decrease the incidences of moderate-severe posterior knee pain, improve the postoperative pain over the first 24 hours after TKA, as well as promoting recovery of motor function. However, the opioids consumption was not decreased by adding distal IPACK to CACB.Trial registrationThis study was registered at Chinese Clinical Trial Registry (ChiCTR2200059139; registration date: 26/04/2022; enrollment date: 16/11/2020; http://www.chictr.org.cn).

Ultrasound-guided Aspiration of a Ganglion Cyst of Anterior Cruciate Ligament in Outpatient Clinic

Symptomatic ganglion cysts within the knee joint are rare, and the mainstay of treatment for these cases has been surgical excision. We present a case of a ganglion cyst of the anterior cruciate ligament (ACL) treated with ultrasound-guided aspiration in an outpatient clinic. A 45-year-old woman presented to the hospital with posterior right knee pain after falling down. We were able to identify well circumscribed 2.2cm mass confined to ACL on Magnetic resonance imaging (MRI). We performed percutaneous needle aspiration of the ACL ganglion cyst under ultrasound (US) guidance. The patient's symptoms improved immediately after the procedure and she had no complications. Four weeks later, follow-up revealed that the patient's symptoms had disappeared. Six months later, a recurrence of a ganglion cyst was confirmed on follow-up and was treated in the same way.

Ultrasound-guided pulsed radiofrequency between the popliteal artery and capsule of the knee (R-PACK); a new technique for relief of chronic posterior knee pain

Ultrasound-guided pulsed radiofrequency between the popliteal artery and capsule of the knee (R-PACK); a new technique for relief of chronic posterior knee pain

Management of hypertrophic anterior cruciate ligament mucoid degeneration by arthroscopy

Introduction: Mucoid degeneration of the anterior cruciate ligament (ACL) is a less common entity. The primary pathology is the damage to the functional synovial lining protecting the ACL with no significant preceding trauma. Two types are described i.e., cystic (synovial and mucoid cysts) and infiltrating (mucoid degeneration). These lesions can be asymptomatic. When symptomatic, the patient complained of posterior knee pain with restriction of flexion in the knee. The diagnosis is confirmed by Magnetic Resonance Imaging of the Knee. Recent trends include arthroscopic procedures, including ACL debridement, i.e. partial resection. Total resection can be required in a few cases with ACL reconstruction. Inclusion Criteria: Diagnosed cases of ACL mucoid degeneration on MRI. Exclusion Criteria: Post-traumatic knee injuries-meniscal or ligamentous or bony, ACL synovial or mucoid cysts. Materials and Methods: A total of 18 patients diagnosed with ACL mucoid degeneration were included in the study. The study was conducted from August 2019-August 2021. The patients were assessed clinically with history and clinical examination. MRI was advised in patients with clinical suspicion of ACL mucoid degeneration. Results: The study sample consisted of 18 patients (7 females and 11 males) with ages ranging from 30 to 55 years (mean age, 43.2 years) in males and 35 to 55 years (mean age, 41.5 years) in females. On clinical assessment, exacerbation of pain was more commonly related with terminal flexion in 10 patients (58.8%) as compared to terminal extension (7 patients, 41%). No motion-related exacerbation of pain was seen in 1 case. 17 patients had an extension deficit. No complaint of instability was seen except for 2 cases. Postoperatively an average improvement of the Visual analogue scale by 4 was seen. No flexion or extension deformity was noted. No patient had any major complication. On follow up Anterior Lachman test was grade 1 in 16 cases and in others it was same as opposite non-affected knee. A complete resection of ACL with reconstruction using hamstring graft was done in 1 patient. The same patient showed a pain improvement of 4 scales on VAS. The patient however had episodes of instability. Conclusion: A clinical suspicion of mucoid degeneration of ACL with confirmatory classical appearance on MRI are key to diagnosis. Symptomatic pain relief is better provided with ACL debridement with mild laxity in upcoming future.

Development of an Ultrasound Technique to Evaluate the Popliteal Complex in the Horse.

Simple SummaryThe popliteal tendon and muscle are major stabilizers of the human and dog knee. Injury to this complex causes knee pain, and it is generally associated with other injured structures such as the lateral meniscus and/or the cranial cruciate ligament. The equine popliteal complex is poorly reported. Lameness due to stifle pathology is a serious clinical concern in sport horses, and the roll of the popliteal complex in this is unknown. One of the cardinal diagnostic tools on lameness exams is ultrasonography; however, a comprehensive technique to examine the complete popliteal complex (tendon and muscle) in horses has not been reported. The objective of the study was to develop a detailed ultrasound technique of the equine popliteal complex. We present here a detailed ultrasound technique to clearly evaluate the popliteal tendon, its components and variable insertions, the subpopliteal recess, and muscle. This new ultrasound approach is easy to apply by following clear anatomical landmarks, even by inexperienced operators. The technique presented here can be complementary to a routine stifle ultrasound exam.The popliteal tendon and muscle are major stabilizers of the human and dog knee, more specifically the postero-lateral corner. Injury to this complex causes posterior knee pain, and it is generally associated with other injured structures such as the lateral collateral ligament, lateral meniscus, and/or the cranial cruciate ligament. The popliteal complex is poorly reported in the horse, and its specific function has not been determined. Nevertheless, it is likely that it is similar to that of other species, and that injury to it could have similar clinical repercussions. Lameness due to stifle pathology is a serious clinical entity in sport horses. One of the cardinal diagnostic tools in lameness exams is ultrasonography; however, a comprehensive technique to examine the popliteal complex (tendon and muscle) in the horse has not been reported. The objective of the study was to develop a systematic ultrasound technique of the equine popliteal complex that allows identification of the insertion and variations of the popliteal tendon (PopT), as well as examination of the popliteal muscle (PopM). Comparison between anatomical variants among horses was studied in order to identify possible significant differences. For this, 10 university teaching horses were used, hence 20 stifles were examined, several times. With the ultrasound technique presented here, the PopT and PopM are consistently examined. The developed technique allows reliable examination of the popliteal complex in the horse, and it could be included during standard ultrasound examination of equine stifle.

Effect of soft tissue manipulation of popliteus muscle on quadriceps muscle activity and torque production in athletes with anterior knee pain

Abstract Study aim: Popliteus is majorly associated with posterior knee pain; however, this muscle can also have an impact on anterior knee pain. The purpose of this study was to determine the effect of soft tissue manipulation of popliteus muscle on non-traumatic anterior knee pain in athletes; as the relationship between popliteus and Quadriceps muscle has not been studied/explored much. Materials and methods: In this experimental study, 15 subjects presenting with non-traumatic anterior knee pain were selected. Quadriceps muscle activity, torque production and knee pain were assessed. Followed by a single session of popliteus manipulation all the above parameters were re-assessed immediately and at 24 hours after intervention. Results: Significant reduction in pain (P &lt; 0.005) at 24 hours was observed. There was a significant increase in muscle activity of Vastus Medialis (P &lt; 0.05) and Vastus Lateralis (P &lt; 0.005) immediately after the intervention but not after 24 hours. No significant change was found in the activity of Rectus femoris and Peak torque of Quadriceps immediately after the intervention and at 24 hours. Conclusion: Soft tissue manipulation decreased knee pain and improved muscle activity. Therefore, incorporating popliteus manipulation can be effective in treatment of anterior knee pain.

Comparison of sensory posterior articular nerves of the knee (SPANK) block versus infiltration between the popliteal artery and the capsule of the knee (IPACK) block when added to adductor canal block for pain control and knee rehabilitation after total knee arthroplasty---A prospective randomised trial.

Background and Aims:Adductor canal block (ACB), though an effective procedure for postoperative analgesia in total knee arthroplasty (TKA), does not provide analgesia to the posterior articular aspect of the knee joint. Infiltration between the popliteal artery and the capsule of the knee (IPACK block) and sensory posterior articular nerves of the knee (SPANK block) are two single injection techniques that have been shown to provide effective analgesia in posterior knee pain. This study aims to compare the effect of IPACK block and SPANK block when combined with ACB for analgesia and postoperative rehabilitation in TKA.Methods:A total of 82 patients were randomised into two groups: (1) ACB combined with IPACK, (2) ACB combined with SPANK block. The primary outcome was the pain scores from 6 h to 48 h after surgery and the duration of postoperative analgesia. The secondary outcome measures were 24 h opioid consumption, ambulation parameters like mobilisation ability, quadriceps muscle strength and patient satisfaction score at discharge.Results:Numerical rating scale (NRS) scores at rest and on movement, duration of analgesia, total opioid consumption, and patient satisfaction were significantly better (P < 0.05%) in the IPACK group than in the SPANK block. There were no significant differences in the knee rehabilitation parameters between the blocks.Conclusion:ACB with IPACK block offers better analgesia, less opioid consumption and better patient satisfaction with comparable knee rehabilitation parameters in the immediate postoperative period after TKA compared to ACB with SPANK block.

Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis.

The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: -1.18; 95% confidence interval [CI]: -2.05 to -0.30) and during activity (SMD: -0.26; 95% CI: -0.49 to -0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: -0.295; 95% CI: -0.543 to -0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.

Multimodal Analgesia Plus Intraoperative Hamstring Sheath Injection for Hamstring Autograft Anterior Cruciate Ligament Reconstruction Reduces Postoperative Posterior Knee Pain But Does Not Reduce Postoperative Narcotic Requirements: A Double-Blind Randomized Control Trial (171)

Objectives:This study’s objective was to determine whether multimodal analgesia plus an injection of the hamstring sheath immediately following the harvest of the semitendinosus and gracilis tendons during hamstring autograft anterior cruciate ligament reconstruction (ACLR) reduces postoperative pain. We hypothesized that multimodal analgesia plus a hamstring sheath injection of the harvest site for autograft hamstring ACLR reduces postoperative pain.Methods:The Institutional Review Board approved this study registered with ClinicalTrials.gov and identified by NCT01868425. This study was a single-center, surgeon stratified double-blind, placebo-controlled, randomized study from April 2013 to December 2017. Patients were randomly assigned to one of two groups, in a 1:1 ratio per surgeon, to receive either standard of care analgesia plus intra-operative hamstring sheath saline injection (Placebo group) or standard of care analgesia plus multimodal analgesia plus intraoperative hamstring sheath anesthetic injection (MA group) for patients undergoing ACLR with hamstring autograft. Eligible participants were adults aged 18 years to 55 years old consented for ACLR using hamstring tendon autograft. Contraindication to a femoral nerve block, allergy to protocol medications, nervous system disease, renal or hepatic impairment, history of opioid dependence or current narcotic use, significant psychiatric disease, pregnancy or lactating, a seizure disorder, history of postoperative nausea and vomiting, latex allergy, and clinically significant cardiac or pulmonary disease excluded patients for participation in this study. The primary endpoint was total postoperative opioid administration. Secondary endpoints included the patient’s subjective pain score for the posterior, anterior, and lateral side of the knee, postoperative nausea, sedation, and pruritus scores. Based on our preliminary data, we estimated the mean opioid for standard care will be 6.6 morphine equivalents with a standard deviation of 6.2 morphine equivalents. Testing the ability of multimodal analgesia to reduce opioid usage by at least 50%, a minimal sample size of 45 subjects per group was needed to achieve 80% power based on a one-tailed t-test and a significance level < 0.05. Student’s t-test compared outcomes between groups. Additionally, a linear regression model for was also used for the primary outcome with total opioid administration as the dependent variable in order to control for body mass index (BMI) and sex, providing an adjusted estimate of the difference between groups.Results:A total of 112 patients (Figure 1) met inclusion criteria and were randomized into the placebo group (n = 57) and MA group (n = 55). Demographic data demonstrated no significant differences between groups (Table 1). The primary analysis was postoperative opioid administration and included all patients randomly assigned to either group for opioid administration in the postoperative anesthetic care unit (PACU), however opioid administration in 24 hours after discharge was not recorded for five patients in the MA group, leaving 50 patients remaining for the per-protocol analyses. Secondary outcome data was not recorded for one patient in the placebo group leaving 56 patients remaining for the per-protocol analyses. The mean postoperative opioid needs (Table 2) for patients in the MA group (18.7 ± 13.14) was less than those in the placebo group (22.6 ± 11.15), although this was not statistically significant (p-value = 0.140). Secondary outcomes (Figure 2A) demonstrated a significant reduction in posterior knee pain postoperatively in the MA group (2.84 ± 2.25) compared to Placebo (3.56 ± 1.97; p-value = 0.0362). There were no significant differences in postoperative pain in the front or sides of the knee. Similarly, there were no significant differences in pruritis (MA: 0.26 ± 0.99 vs. Placebo: 0.696 ± 1.73; p-value = 0.2163), sedation (MA: 5.02 ± 2.29 vs. Placebo: 4.61 ± 2.16; p-value = 0.656), and nausea (MA: 1.16 ± 2.28 vs Placebo: 0.714 ± 1.72; p-value = 0.243) scores (Figure 2B).Conclusions:Multimodal analgesia plus hamstring sheath injection reduces postoperative patient reported posterior knee pain compared to placebo for patients undergoing ACLR using hamstring tendon autograft. However, multimodal analgesia plus a hamstring sheath injection does not reduce postoperative opioid requirements.

Mucoïde degeneratie van de voorste kruisband als oorzaak van diepe kniepijn

Mucoid degeneration of the anterior cruciate ligament: a little-known cause of deep knee pain Mucoid degeneration of the anterior cruciate ligament (ACL) is a little-known cause of deep atraumatic knee pain that is relatively frequent. Recent studies have reported a prevalence of 1,8-9,2% on MRI of the knee. Mucoid lesions consist of interstitial deposits of glycosaminoglycan between the collagen bundles. This causes hypertrophy of the ACL, which leads to mechanical impingement at the femoral notch, typically resulting in deep or posterior knee pain in terminal flexion and/or extension. Unlike the often-occurring traumatic ACL ruptures, there are no instability complaints. The gold standard for diagnosing mucoid degeneration of the ACL is MRI. This shows an abnormally thickened and ill-defined ACL with an increased intraligamentary signal on all sequences, but the orientation and continuity are usually maintained. Arthroscopically, the mucoid degeneration can be recognized by a hypertrophic ACL with yellowish to brown substances between the fibers. In addition, an absence of the synovial outline of the ACL is seen regularly. An arthroscopic partial or total ACL resection is the treatment of choice for symptomatic mucoid degeneration of the ACL and results in good post-operative outcomes without development of instability.