Single-shot Femoral Nerve Block Research Articles

Adductor Canal Block Versus Femoral Nerve Block in Total Knee Arthroplasty: Network Meta-Analysis.

The quality of postoperative analgesia in total knee arthroplasty is crucial for patient recovery, rehabilitation, and hospital stay duration. In line with the above, а single-shot adductor canal block has been considered as an improved method over continuous femoral nerve block. However, continuous adductor canal block and single-shot femoral nerve block have been not adequately addressed in the discussion. This study aimed to compare the effectiveness of various types of adductor and femoral nerve blocks on clinically relevant outcomes in patients following total knee arthroplasty. A systematic review and network meta-analysis were conducted following "PRISMA-NMA" and Cochrane Handbook guidelines. The eligibility criteria included randomized trials and, where these were lacking for a comparison, nonrandomized studies involving adults undergoing primary total knee arthroplasty, comparing single-shot adductor canal block, continuous adductor canal block, single-shot femoral nerve block, and continuous femoral nerve block. A total of 36 studies involving 3308 patients were included. Single-shot adductor canal block showed higher pain scores and opioid consumption but better functional recovery at 24h compared with continuous femoral nerve block. However, this trend vanishes by the 48h assessment postsurgery. Continuous adductor canal block required higher opioid consumption but better functional recovery and shorter hospital stay compared with continuous femoral nerve block. Single-shot adductor canal block showed higher pain scores but comparable opioid consumption and functional recovery to continuous adductor canal block. The shift from continuous femoral nerve block to single-shot adductor canal block as the preferred method for pain relief after total knee arthroplasty may be premature. While the latter improves mobility, it falls short in pain control and does not shorten hospital stays. Continuous adductor canal block shows promise but is currently underappreciated, and single-shot femoral nerve block is often overshadowed by other techniques in regional anesthesia. Further high-quality, multicenter randomized controlled trials are needed to validate these findings.

Pain management after hip fracture repair surgery: a systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Hip fracture is associated with moderate-to-severe postoperative pain, which can influence postoperative recovery and length of stay. The aim of this systematic review was to update the available literature and develop recommendations for optimal pain management after hip fracture. A systematic review utilising procedure specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials, systematic reviews and meta-analysis published in the English language between 04 April 2005 and 12 May 2021, evaluating the effects of analgesic, anaesthetic and surgical interventions were retrieved from MEDLINE, Embase and Cochrane Databases. A total of 60 studies met the inclusion criteria. For patients having hip fracture, pre, intra and postoperative paracetamol and non-steroidal anti-inflammatory drugs or COX-2 inhibitors are recommended. A single shot femoral nerve block or a single shot fascia iliaca compartment block are recommended. Continuous catheter techniques should be used only in specific circumstances. The choice between femoral nerve block or a fascia iliaca compartment block should be made according to local expertise. The postoperative regimen should include regular paracetamol, non-steroidal anti-inflammatory drugs and COX-2 inhibitors with opioids used for rescue. Some of the interventions, although effective, carry risks, and consequentially were omitted from the recommendations, while other interventions were not recommended due to insufficient, inconsistent or lack of evidence.

Single-Shot Versus Continuous Nerve Blocks for Pediatric Anterior Cruciate Ligament Reconstruction: Analgesic Efficacy and Postoperative Outcomes

Background: Regional anesthesia is often used to minimize postoperative pain, enable early mobilization, and improve patient/family satisfaction after ACL reconstruction. Little is known about the effects of nerve blocks on patient-reported outcomes and functional outcomes in pediatric ACL reconstruction. This study was performed to compare analgesic efficacy, isokinetic strength testing, and Patient-Reported Outcomes Measurement Information System (PROMIS) scores between single-shot femoral nerve block (SSNB) and femoral nerve catheter (FNC).Methods: Pediatric patients (<18 years old) who underwent primary ACL reconstruction at a tertiary care children's hospital between January 2018 and August 2019 were included. Patients were grouped based on their anesthesia technique (SSNB or FNC) and compared to identify differences in the occurrence of uncontrolled postoperative pain and opioid refills. PROMIS domain scores, active range of motion (AROM), and isokinetic strength testing at multiple timepoints up to 6 months postoperatively were also collected. Linear regression multiple imputation analysis was performed to account for variable outcome measure availability.Results: A total of 78 patients were included (SSNB:42; FNC:36). The groups had similar pain medication needs and pain scores at 1 week postoperatively. The FNC group had significantly longer in-room to incision times (P<0.001), were less likely to return to school by 1 week after surgery (P=0.03), and had lower mobility scores at the 1-week postoperative visit. Patients in the SSNB group had significantly weaker quadriceps function at 3 months (P=0.02), although this difference resolved by the 6-month visit. There were no cases of infection or neuropathy in either group.Conclusion: Our findings indicate that both FNC and SSNB are viable options with similar efficacy for postoperative pain management in pediatric ACL reconstruction. However, we did not find any evidence of superior analgesia with FNC. Additionally, FNC was associated with lower PROMIS mobility scores at 1 week, delayed return to school, and 30 minutes of additional time spent in the operating room. There were no significant differences between groups in terms of function and PROMIS scores at 6 months postoperatively.Level of Evidence: Level III, retrospective cohort studyKey Concepts•Femoral nerve catheter and single-shot femoral blocks are both viable management options for post-ACL reconstruction pain in children and adolescents.•We found that patients who received a femoral nerve block were less likely to return to school and had lower mobility scores at 1 week postoperatively and spent an additional 30 minutes in the operating room.•Both regional anesthesia techniques had similar PROMIS scores and functional outcomes at 6 months postoperatively.

Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial

(1) Background: The management of postoperative pain after knee replacement is an important clinical problem. The best results in the treatment of postoperative pain are obtained using multimodal therapy principles. Intrathecal morphine (ITM) and single-shot femoral nerve block (SSFNB) are practiced in the treatment of postoperative pain after knee replacement, with the most optimal methods still under debate. The aim of this study was to compare the analgesic efficacy with special consideration of selected side effects of both methods. (2) Materials and methods: Fifty-two consecutive patients undergoing knee arthroplasty surgery at the Department of Orthopedics and Traumatology of the Medical University of Warsaw were included in the study. Patients were randomly allocated to one of two groups. In the ITM group, 100 micrograms of intrathecal morphine were used, and in the SSFNB group, a femoral nerve block in the distal femoral triangle was used as postoperative analgesia. The other elements of anesthesia and surgery did not differ between the groups. (3) Results: The total dose of morphine administered in the postoperative period and the effectiveness of pain management did not differ significantly between the groups (cumulative median morphine dose in 24 h in the ITM group 31 mg vs. SSFNB group 29 mg). The incidence of nausea and pruritus in the postoperative period differed significantly in favor of patients treated with a femoral nerve block. (4) Conclusions: Although intrathecal administration of morphine is similarly effective in the treatment of pain after knee replacement surgery as a single femoral triangle nerve block, it is associated with a higher incidence of cumbersome side effects, primarily nausea and pruritus.

Continuous Femoral Nerve Block Reduces the Need for Manipulation Following Total Knee Arthroplasty.

Background:Peripheral nerve blocks improve both pain control and functional outcomes following total knee arthroplasty (TKA). However, few studies have examined the effects of different peripheral nerve block protocols on postoperative range of motion. The present study assessed the impact of a single-shot femoral nerve block (SFNB) versus continuous femoral nerve block (CFNB) on postoperative range of motion and the need for subsequent manipulation following TKA.Methods:We retrospective reviewed patient charts to identify patients who had undergone primary elective unilateral TKA by 2 surgeons at a high-volume orthopaedic specialty hospital over a 3-year period. A total of 1,091 patients received either SFNB or CFNB and were included in the data analysis. Identical surgical techniques, postoperative oral analgesic regimens, and rehabilitation protocols were used for all patients. Patients with <90° of flexion at 6 weeks postoperatively underwent closed manipulation under anesthesia (MUA).Results:Overall, 608 patients (55.7%) received CFNB and 483 patients (44.3%) received SFNB. Overall, 94 patients (8.6%) required postoperative manipulation for stiffness, including 36 (5.9%) in the CFNB group and 58 (12%) in the SFNB group. The 50% reduction in the need for manipulation in the CFNB group was independent of primary surgeon (p > 0.05). No significant differences were observed between the groups in terms of postoperative range of motion, either at the time of discharge or at 6 weeks postoperatively. A history of knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were significantly associated with the need for further MUA (p = 0.0002, p < 0.0001, and p < 0.0001, respectively).Conclusions:Despite similar final postoperative range of motion between patients in both groups, our results suggest that CFNB may be superior to SFNB for reducing the need for postoperative manipulation after primary TKA. Furthermore, a history of ipsilateral knee surgery, decreased preoperative range of motion, and decreased range of motion at the time of discharge were identified as independent risk factors for postoperative stiffness requiring MUA after primary TKA.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparative analysis of combined spinal epidural and spinal plus single shot femoral nerve block as post-operative analgesia in total knee replacement surgery

Background: Effective anaesthesia is required to overcome complications of epidural anaesthesia and relieve the patients undergoing lower limb surgeries such as total knee replacement from severe pain.&#x0D; Aims and Objective: The current study was aimed to study combined spinal- epidural anaesthesia (CSEA) and spinal plus single shot femoral nerve block (SSFNB) for post-operative analgesia in total knee replacement surgeries.&#x0D; Materials and Methods: This prospective observational and randomized study included 60 subjects undergoing Total knee replacement which were randomized into two groups and administered combined spinal epidural block and single shot femoral nerve block as per standardised protocol for post-operative pain management. Pain as per visual analogue scale and need of rescue analgesia and other haemodynamic parameters were compared between two groups and at different time interval.&#x0D; Result: Two study groups were found to be matched for age, gender, weigh, height and ASA grading. SSFNB group showed significantly high VAS score at 6 Hr, need for rescue analgesia, compared to CSEA group. CSEA group had significantly high number of patients with motor block. significant difference in the variation of pulse rate was observed within both the groups. Significantly higher systolic blood pressure at 6h, 12h, 24h and 36h., diastolic blood pressure at 6h, 24h and 48h and in mean arterial pressure at 6h, 24h and 36 h was observed in SSFNB group compared to CSEA group.&#x0D; Conclusion: We concluded that, patients undergoing total knee replacement show better analgesia and hemodynamic stability with CSEA in comparison to SSFNB, but at the cost of more motor blockade on non-operative limb and delayed recovery.

INTRA-ARTICULAR MORPHINE AND ROPIVACAINE INJECTION PROVIDES EFFICACIOUS ANALGESIA COMPARED TO FEMORAL NERVE BLOCK IN THE FIRST 24 HOURS POST-OPERATIVELY AFTER ACL RECONSTRUCTION WITH BTB IN AN ADOLESCENT COHORT

Background:Opioid consumption and patient satisfaction are influenced by a surgeon’s pain management protocol and the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction include femoral nerve blockade and intra-articular injection; however, debate remains as to the most efficacious methodology.Hypothesis/Purpose:We hypothesize that intra-articular injection with ropivacaine and morphine is as efficacious as a femoral nerve block injection of ropivacaine, dexamethasone, and dexmedetomidine for post-operative pain management in the first 24 hours after bone-patellar tendon-bone (BTB) ACL reconstruction.Methods:Charts were retrospectively reviewed for a single pediatric orthopedic surgeon performing BTB ACL reconstructions from 2013-2019. One hundred sixteen patients were identified, of whom 58 received intra-articular injection and 58 received single shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MME) consumed were tabulated for each patient.Results:Opioid use was 24.3 MMEs in patients treated with intra-articular injection vs 28.5MMEs in those with peripheral block (p=0.108). Consumption of MMEs was greater in the intra-articular group in the 0-4 hours period (7.1 MMEs vs. 4.6 MMEs, p=0.008). There was significantly less MME consumption in patients receiving intra-articular injection compared with peripheral block at 16-20 and 20-24 hours (3.2 MMEs vs. 5.6 MMEs, p=0.01; 3.8 MMEs vs. 6.5 MMEs, p<0.001 respectively). Mean pain scores were not significantly different over the 24-hour period (peripheral block=2.7, intra-articular injection=3.0, p=0.19).Conclusion:Moving away from the use of peripheral nerve block as an analgesic modality may be challenging given the multidisciplinary role of pain management in these patients. However, as Ramlogan et al. succinctly noted in their recent editorial “Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice?” in the British Journal of Anesthesia, both orthopedic and anesthesia colleagues alike are beginning to recognize that it is a change that may benefit our patients. Our study strengthens this argument and shows that there is no significant difference in MME consumption between the femoral nerve block and intra-articular injection groups in the first 24 hours post-operatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require less opioids 16-24 hours post-operatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in pediatric patients undergoing BTB ACL reconstruction.Figure 1.2.Morphine milligram equivalent consumption trend during 24-hour post-operative period. PB=peripheral nerve block; IA=intra-articular injection

ISOKINETIC STRENGTH IS COMPARABLE AMONG ADOLESCENT PATIENTS WHO HAD EITHER A SINGLE INJECTION FEMORAL NERVE BLOCK OR CONTINUOUS FEMORAL NERVE CATHETER DURING ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Background:Single injection femoral nerve blocks or continuous femoral nerve catheters are commonly used during anterior cruciate ligament reconstruction (ACLR). However, both single injection and continuous femoral nerve catheters have been associated with decreased quadriceps strength and function up to 6 months postoperative compared to no regional anesthesiaPurpose/Hypothesis:We compared isokinetic limb asymmetry 5-10 months post-surgery between patients who received either single injection or continuous femoral nerve block during ACLR. We also assessed patient characteristics potentially associated with strength deficits. We hypothesized that patients with continuous femoral nerve catheters would demonstrate decreased quadriceps function due to increased local anesthetic.Methods:We reviewed medical records of patients ages 10-19 years who completed isokinetic testing 5-10 months following quadricep tendon ACLR by a single surgeon. Patients were excluded for previous lower limb surgery. We grouped patients based on whether they received a single injection femoral nerve block (FNB group) or a continuous femoral nerve catheter (FNC group) intraoperatively. Using isokinetic data at 60, 180, and 300 degrees per second, we calculated maximum torque percent deficit of the involved compared to the uninvolved leg, as well as compared peak torque extensor and flexor deficits (% difference between operative/non-operative sides) between groups.Results:Sixty-two patients were included: 50 who received FNC and 12 who received FNB (Table 1). There were no significant differences between continuous femoral nerve block and single-shot femoral nerve block groups for extensor deficits at any speed (Figure 1) or for flexor deficits at any speed (Figure 2). At 60 degrees/s (p=0.006) and 180 degrees/s (p=0.017), longer time since surgery was associated with smaller extensor deficits (Table 2). At 180 degrees/s (p=0.008) older age was associated with greater extensor deficits (Table 2). At 60 degrees/s (p=0.017) skeletal maturity was associated with greater extensor deficits (Table 2). At all speeds, an injured dominant limb was associated with smaller flexor deficits (Table 3). Older age was associated with greater flexor deficits at 60 deg/s (Table 3).Conclusion:No apparent significant isokinetic strength differences were found between groups 5-10 months postoperatively. Longer time from surgery was significantly associated with decreased extensor deficits among both groups at slower isokinetic test speeds. Our data suggest increased isokinetic strength recovery over the 5-10-month timeframe. The surgeon, anesthesia team, and patient should choose the pain management protocol based on resource and patient factors.Tables and Figures:Figure 1.Mean values (error bars represent 95% confidence intervals) for Peak Torque (ft-lb) extensor % deficits (% change between surgically affected and unaffected sides) between continuous femoral nerve block and single-shot femoral nerve block groups at each of the isokinetic test speeds.Figure 2.Mean values (error bars represent 95% confidence intervals) for Peak Torque (ft-lb) flexor % deficits (% change between surgically affected and unaffected sides) between continuous femoral nerve block and single-shot femoral nerve block groups at each of the isokinetic test speeds.

The impact of loco-regional anaesthesia on postoperative opioid use in elderly hip fracture patients: an observational study

PurposeHip fractures are a common health problem among the elderly with an increasing incidence. They are associated with high mortality and morbidity. Optimal pain management remains challenging and inadequate pain control is known for negatively affecting outcomes. Loco-regional anaesthetics (LRA) have been proven to benefit pain management and to lower the risks of opioid use and -related side effects. We aimed to evaluate the use and efficacy of different LRA in elderly hip fracture patients.MethodsSingle-center cohort study of elderly hip fracture patients, who were treated in central Switzerland. We compared patients who received LRA in the form of a femoral nerve block (FNB) or a continuous femoral nerve catheter (CFNC) with patients who did not receive LRA. Primary outcomes were pain—as measured in perioperative morphine use—hospital length of stay (HLOS), postoperative complications, postoperative falls and mortality.Results407 patients were included for analysis. Mean age was 85.2 (SD6.3). There was a significant difference in intraoperative morphine use between the groups (p = 0.007). Postoperative morphine use differed significantly and was lowest in patients with FNB and highest in patients without LRA (p < 0.001). The use of LRA was a significant predictor for postoperative morphine use for postoperative morphine use at the recovery room and for postoperative morphine use 48 h after surgery. No significant differences were found in postoperative complications, a significant difference was found in 1-year mortality.ConclusionsThis article shows that LRA in the form of FNB and CFNC causes a significant decrease in postoperative opioid consumption. Differences between single-shot FNB or CFNC were minimal. There were no significant differences in clinical outcomes such as HLOS, delirium, 30-day and 90-day mortality and postoperative falls. We suggest that use of LRA should be incorporated in the perioperative treatment of elderly patients with a hip fracture. For future research, we recommend evaluating the number of postoperative complications and mortality.

Impact of Intra-Articular Local Anesthesia Infiltration versus Femoral Nerve Block for Postoperative Pain Management in Total Knee Arthroplasty.

Background:Postoperative pain relief after total knee arthroplasty (TKA) can be attained by using several techniques such as intravenous analgesia, epidural analgesia, and peripheral nerve blocks that include femoral nerve and saphenous nerve. Several authors recommended intra-articular injection of local anesthetic (IALA) as a part of multimodal analgesia regimens for TKA instead of other techniques.Aims:The present study compares IALA technique efficacy with single-shot femoral nerve block (FNB) as part of multimodal analgesia regimen in TKA patients for postoperative pain management.Setting and Design:Perioperative care, randomized double-blind comparative study.Subjects and Methods:We recruited a total of 60 patients scheduled for unilateral total knee replacement under spinal anesthesia. Subjects were allocated randomly into two groups FNB and IALA receiving ultrasound-guided FNB and Intra-articular local anesthesia and morphine mix infiltration, respectively. Twenty-four hour postoperative morphine consumption through patient-controlled analgesia was the primary outcome measure in our study. Secondary outcome measures were pain scores, nausea and vomiting.Statistical Analysis:Chi-square test, Mann–Whitney test.Results:The amount of morphine consumed at the end of 24 h was noted to be higher in IALA group as compared to FNB (FNB − 16.03 ± 9.37 mgs; IALA − 23.60 ± 13.73 mgs P = 0.03). Visual analog score at 24 h with knee flexion was better in FNB group (FNB − 1.27 ± 1.43; IALA 2.42 ± 2.54, P = 0.04).Conclusion:FNB technique provides better analgesia in comparison to IALA for postoperative pain management in terms of PCA morphine consumption.

Intra-articular Morphine and Ropivacaine Injection Provides Efficacious Analgesia As Compared With Femoral Nerve Block in the First 24 Hours After ACL Reconstruction: Results From a Bone-Patellar Tendon-Bone Graft in an Adolescent Population.

Background:Opioid consumption and patient satisfaction are influenced by a surgeon’s pain-management protocol as well as the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction are femoral nerve blockade and intra-articular injection; however, debate remains regarding the more efficacious methodology.Hypothesis:We hypothesized that intra-articular injection with ropivacaine and morphine would be found to be as efficacious as a femoral nerve block for postoperative pain management in the first 24 hours after bone–patellar tendon–bone (BTB) ACL reconstruction.Study Design:Cohort study; Level of evidence, 3.Methods:Charts were retrospectively reviewed for BTB ACL reconstructions performed by a single pediatric orthopaedic surgeon from 2013 to 2019. Overall, 116 patients were identified: 58 received intra-articular injection, and 58 received single-shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MMEs) consumed were tabulated for each patient.Results:Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block (P = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; P = .008). There was significantly less MME consumption in patients receiving intra-articular injection versus peripheral block at 16 to 20 hours (3.2 vs 5.6 MMEs; P = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; P < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; P = .19).Conclusion:Within the limitations of this study, we could identify no significant difference in MME consumption between the single-shot femoral nerve block group and intra-articular injection group in the first 24 hours postoperatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require fewer opioids 16 to 24 hours postoperatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction.

Patient-reported outcomes after femoral nerve block versus periarticular injections in patients undergoing total knee arthroplasty: A randomized controlled study

Total Knee Arthroplasty (TKA) is one of the most advanced surgical solutions for pain relief and mobility improvement in patients with end stage osteoarthritis. TKA patients experience severe postoperative pain. Recently, peripheral nerve blockade and Peri or intra-articular injections have been used successfully with fewer side effects when compared to the conventional analgesic techniques. Measuring quality of recovery (QoR) using QoR-15 scale is considered as an accepted and efficient scale for clarification the success of surgery and anaesthesia. One hundred and thirty adult patients scheduled for TKA were randomized into 2 groups: Femoral nerve block (FNB) group and periarticular injections (PAI) group. All patients completed the QoR before or on the day of surgery and at the end of the first post-operative day. Postoperative pain scores, opiod consumption and adverse effects of the drugs and techniques were also measured. Periarticular injectionsresulted in better analgesia at rest and on movement and less postoperative morphine consumption during the first 24 h postoperatively when compared to femoral nerve block. Global QoR-15 score was significantly higher in PAI when compared to FNB group. Periarticular injection of local anesthetics provides better quality of recovery and sufficient level of analgesia than does single shot femoral nerve block for patients undergoing total knee arthroplasty in early postoperative period.

A Randomised Controlled Trial of Local Infiltration Analgesia Versus Femoral Nerve Block for Postoperative Analgesia Following Total Knee Arthroplasty.

BackgroundTotal knee replacement is often associated with significant postoperative pain. Although the use of a femoral nerve block is well-established, local infiltration analgesia has gained popularity in recent years. We compared single-shot local infiltration analgesia with a single-shot femoral nerve block for patients undergoing primary total knee arthroplasty.MethodsA total of 194 patients were randomised to receive either local infiltration analgesia (150 ml bupivacaine 0.067% with adrenaline) or a femoral nerve block (20 ml 0.375% levobupivacaine). Both groups received spinal anaesthesia. The primary outcome measure was the total morphine consumption. Secondary outcome measures included: post-operative pain scores, rehabilitation goals, readiness for discharge, and physical, mental, and functional outcomes, including the Oxford Knee Score (OKS).ResultsA total of 69 patients in the local infiltration analgesia group and 79 patients in the femoral nerve block group were analysed. Median total morphine consumption was significantly greater in the local infiltration analgesia group as compared to the femoral nerve block group (54.67 mg vs 45 mg, respectively, p=0.0388). The post-operative OKS at six weeks was slightly more improved for the femoral nerve block group than for local infiltration analgesia (12.5 vs 9 point median improvements for the femoral nerve block and local infiltration analgesia groups, respectively, p=0.0261). There were no statistically significant differences in other secondary outcome measures.ConclusionA single-shot femoral nerve block significantly reduces the opioid requirement for primary total knee arthroplasty but is otherwise comparable to single-shot local infiltration analgesia.

Analgesic Impact of Single-Shot Versus Continuous Femoral Nerve Block After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

Efficient pain management after total knee arthroplasty will accelerate functional recovery and reduce the length of hospital stay. The femoral nerve block is increasingly used in clinical practice owing to its favorable analgesic efficacy. However, the effect of continuous femoral nerve block compared to single-shot femoral nerve block remains controversial. Three databases (Pubmed, Embase and Cochrane Library) were searched for randomized controlled trials up to April 2019. Seven studies with 525 patients were included in this analysis. The pooled estimates showed that the continuous femoral nerve block could relieve the pain at rest [standardized mean differences with 95% confidence intervals 1.12 (0.63-1.60), I2 = 57%, p < 0.00001] and physical therapy [standardized mean differences with 95% confidence intervals 1.05 (0.47-1.63), I2 = 71%, p = 0.0004] on postoperative day 1 and reduce total morphine consumption on postoperative day 1 [mean differences with 95% confidence intervals 16.15 (13.75-18.54), I2 = 46%, p < 0.00001] and 2 [mean differences with 95% confidence intervals 7.02 (4.82-9.22), I2 = 35%, p < 0.00001]. There is no significant difference in pain scores at rest and physical therapy on postoperative day 2 and 3, in Western Ontario and McMaster University Arthritis Index scores (p = 0.12), the length of hospital stay (p = 0.94) and the incidence of nausea and vomiting (p = 0.09). We conclude that the continuous femoral nerve block is more effective than single-shot femoral nerve block after total knee arthroplasty, which provides objective evidence of pain management for anesthetists.

Evaluating Analgesic Efficacy of Single Femoral Nerve Block versus Combined Femoral-Sciatic Nerve Block Post Total Knee Arthroplasty.

Background:With increasing knee replacement surgeries, there has been a constant search for effective pain control modality.Aims:We compared the analgesic effect of femoral nerve block (FNB) alone with combined femoral and sciatic nerve block (SNB) for postoperative pain management after total knee arthroplasty (TKA).Setting and Design:This was a prospective observational study.Methods:A total of 150 adult patients of American Society of Anesthesiologists physical status class I and II scheduled for elective TKA under spinal anesthesia with 3.4-mL bupivacaine 0.5% and 20-μg fentanyl were randomly allocated to two groups. Group F patients received a single shot FNB with 20 ml 0.375% ropivacaine and Group FS patients received combined FNB with 20 mL of 0.375% ropivacaine and SNB with 40 ml of 0.375% ropivacaine at the end of surgery. The primary outcome was the change in Numeric Rating Scale (NRS) scores between Groups F and FS at 6, 12, 18, 24, and 48 h later. The secondary outcome was total doses of opioid required in both groups.Results:The demographic data were comparable in both groups. The NRS scores were higher and statistically significant in Group F than that in Group FS at all five measured time points (P < 0.00001), and the total pain score with a mean of 15.43 in Group F and a mean of 9.61 in Group FS was statistically significant. Significantly more opioid consumption was seen postoperatively in Group F as compared to Group FS at 12, 18, 24, and 48 h as depicted by P < 0.00001.Conclusions:We conclude that the FNB, when combined with SNB, shows superior results than femoral block alone. SNB reduced pain scores and opiate consumption postoperatively up to 48 h.

Continuous nerve block versus single-shot nerve block for total knee arthroplasty: a meta-analysis from randomized controlled trials.

This meta-analysis aims to determine whether continuous nerve block (CNB) provides better pain relief and functional recovery than single-shot nerve block (SSNB) after total knee arthroplasty (TKA). Embase, PubMed, and the Cochrane Library databases were comprehensively searched. Randomized controlled trials (RCTs) with a modified Jadad Score ≥4 comparing CNB with SSNB in patients after TKA were enrolled in our meta-analysis. The primary outcomes were visual analogue scale (VAS) pain score and morphine consumption. The secondary outcomes were distance able to ambulate, complications and length of hospital stay. Review Manager 5.3 for Windows was used to analyze the extracted data. Two RCTs that compared continuous adductor canal block (ACB) with single-shot ACB, and four RCTs that compared continuous femoral nerve block (FNB) with single-shot FNB were included in our meta-analysis. There were no significant differences in VAS scores at rest for 12 hours (P=0.44), 24 hours (P=0.15) and 48 hours (P=0.16) postoperatively, VAS scores on activity for 24 hours (P=0.15) and 48 hours (P=0.23), total opioid consumption at 12 hours (P=0.20), 24 hours (P=0.25) and 48 hours (P=0.41), distance walked at 24 hours (P=0.58) and 48 hours (P=0.93), nausea and vomiting at 24 hours (P=0.18) and 48 hours (P=0.62), and length of hospital stay (P=0.71) between the CNB and SSNB groups. CNB and SSNB have similar effects on pain relief, complications and functional recovery in patients receiving TKA. The optimal analgesic regimen for patients after TKA needs further identification.

Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis.

Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients. Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence. We included five trials (n= 254), where participants received FNB 30minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty. The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.

Negative Influence of femoral nerve block on quadriceps strength recovery following total knee replacement: A prospective randomized trial

BackgroundPostoperative pain is a major concern after total knee replacement (TKR) and can be relieved using different methods, including femoral nerve block (FNB). Quadriceps strength recovery (QSR) is the most sensitive objective indicator of functional recovery after TKR. The goal of this study was to compare the QSR following TKR between three approaches to analgesia. HypothesisFNB delays QSR at short- and mid-term follow-up. MethodsIn this prospective randomized trial, with single-blind assessment involving 135 patients admitted for TKR in an academic center, the three following groups included were: (A) Continuous FNB 48h+PCA, (B) Single-shot FNB+PCA and (C) PCA alone. No intra-articular local anesthesia was carried out for all patients. Groups were comparable for demographic and surgical data. FNB was carried out and controlled (electric stimulation) by an expert anesthesiologist prior to the surgery. Follow-up was standardized in all groups using blinded assessors. Quadriceps strength was measured using a certified dynamometer at 6 weeks, 6 months and 12 months. Multivariate analysis (Kruskal-Wallis, Mann-Whitney) was used for the main outcome. ResultsA total of 135 patients were included. Two patients in group B were excluded due to a direct fall in the first postoperative week with extensor mechanism rupture and peri-prosthetic femoral fracture. QSR was significantly decreased in patients with FNB at all times (mean±SD): 6 weeks (A: 51.3±23.3%; B: 62.2±21.9%;C: 77.4±19.5%; p<0.01), 6 months (A: 65.4±22.9%; B: 82.1±24.2%;C: 95.7±20.7%; p<0.01) and 12 months (A: 87.8±17.6%; B: 97.8±26.9%;C: 104.8±25.2%; p=0.02). No significant difference between continuous or single-shot FNB was observed. ConclusionFNB has a negative influence on QSR at short- and mid-term follow-up. FNB should not yet be recommended for analgesia after TKR. Level evidenceI High-quality randomized controlled trial with statistically significant difference.

Continuous adductor canal blockade facilitates increased home discharge and decreased opioid consumption after total knee arthroplasty

BackgroundThere is a growing interest in avoiding discharging patients to rehab to maximize outcome and minimize complications after total knee arthroplasty (TKA). In addition, use of postoperative pain pathways that minimize opioid use is critical amidst the current opioid epidemic. However, the ideal pain regimen after TKA has yet to be determined. MethodsFrom July 1, 2013 to October 1, 2014 two perioperative pathways were used to address surgical pain. These included either a single shot femoral nerve block plus liposomal bupivacaine pericapsular injection (FNB + LB-PAI) or adductor canal catheter plus posterior capsule single shot block (ACC + iPACK), each with an oral analgesic protocol. Little modification occurred with regard to surgical technique, postoperative medications, or postoperative physical therapy (PT). ResultsOverall, 264 unilateral, primary TKA patients (146 FNB + LB-PAI, 118 ACC + iPACK) were included. ACC + iPACK patients had a shorter median length of stay (LOS, 2.0 vs 3.0, p < 0.001), more discharges home (79.7% vs 67.8%, p = 0.002), and less median opioid consumption (IV morphine equivalents, IVME, 20.0 vs 44.1, p < 0.001) than the FNB + LB-PAI group. In multivariable analysis, use of ACC + iPACK remained independently associated with shorter LOS, increased discharge home, and less IVME consumed when controlling for confounding variables. ACC + iPACK patients also had fewer opioid related adverse events (0.8 vs 5.5, p = 0.045) and a lower rate of MUA (0.8% vs 6.2%, p = 0.026). ConclusionsWe recommend ACC + iPACK with a multimodal oral analgesic protocol as the primary postoperative analgesia in enhanced recovery TKA protocols. This resulted in an easier recovery with fewer complications. Level of evidenceLevel III.

Application of dexamethasone as an adjuvant to the local anesthetic in the performance of a US-guided femoral block for postoperative analgesia on patients after total knee joint replacement

Introduction: The article discusses the use of dexamethasone as an adjuvant to local anesthetic solution for ultrasound (US)-guided femoral nerve block in patients after total knee joint replacement. A literature review on the clinical use of other adjuvants is also presented. Design: This was a clinical prospective randomized study. Aim: The aim of this article is to investigate the effect of dexamethasone adjuvant on the local anesthetic solution when performing a US-guided femoral block in patients after total knee joint replacement. Methods: The study included 53 patients, randomized into two groups : Group 1: single shot femoral nerve block (FNB) + constant infusion through a perineural catheter 15 mL bolus (ropivacaine 0.5%/levobupivacaine 0.375%) with a subsequent infusion of 5-9 mL per hour, including 20 patients; Group 2: single shot FNB 20 mL bolus (ropivacaine 0.5%/levobupivacaine 0.375%) +/- dexamethasone 4 mg, including 33 patients. In Group 2, 2 subgroups were formed: patients with single shot FNB with chirocain - 10 patients; patients with single shot FNB with ropivacaine - 23 patients. Of these, 15 patients were fasted with single shot FNB with ropivacaine + dexamethasone 4 mg, and 8 patients with pure ropivacaine. Evaluation of effective control of pain relief symptoms was done on 2nd, 4th, 6th, 12th, 18th, 24th, and 36th hours postoperatively according to the Visual Analogue Scale (VAS). Results: No statistically significant difference in VAS scores was observed between the two groups in the 2nd, 6th, 12th, 18th and 36th hours. Such was found only in the 24th hour. We did not detect statistically significant benefits of this adjuvant. We do not have clinically registered adverse drug reactions (ADRs). We have not established a correlation between these occurrences and the use of dexamethasone. Conclusion: Although our results correspond to those of authors who refute the benefits of dexamethasone as an adjuvant to the peripheral nerve block (PNB), we believe, based on clinical observation data, that it actually attenuated reversible hyperalgesia (patients did not report abruptly, acute, sudden onset of pain), therefore prolongation of the analgesic effect was observed until the 18th, 20th postoperative hour.