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Single Shot Adductor Canal and Selective Tibial Nerve blockade, Multimodal Analgesia, and intraoperative Intra-Articular Liposomal Bupivacaine Allows for Superb Pain Control and Ambulation with Postoperative Discharge on Postoperative Day Two

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Introduction

 

Balancing pain control, while allowing patients to ambulate in the immediate postoperative period has been important to both anesthesiologists and orthopedic surgeons alike.  Proper pain control reduces surgical stress and lessens cardiovascular related adverse events (1).  Maintaining quadriceps strength allows patients to meet ambulation goals, reduces the threat of venous emboli, and increases likelihood of having a successful surgical outcome (2,3).  Many methods have been developed to provide analgesia, such as femoral nerve continuous catheter placement however motor blockade can leave significant quadriceps weakness (4).

 

Recently, the adductor canal block (ACB) has gained popularity because it maintains quadriceps strength (5) while providing equivalent analgesia to the knee as the more traditional femoral nerve blockade (FNB). This is important because the functional impairment seen with FNB has been shown to increase the risk for falls perioperatively (6).  ACB can be performed as either a single injection or continuous infusion (7). The addition of selective tibial nerve block has the advantage of sparing foot drop, while providing effective analgesia for the posterior compartment of the knee joint (8).

 

Periarticular injection of multiple drugs has been shown to improve pain, functional recovery, and patient satisfaction (9,10).  The use of liposomal bupivacaine (Exparel, Pacira Pharmaceuticals Inc., Parsippany, NJ, USA) licensed for infiltration therapy has the advantage of providing duration of local anesthetic of up to 72h (11).  Additionally, scheduled multimodal medical management can, through various mechanisms of action reduce pain and decrease the reliance on narcotics (12).

 

The goal of our study was to examine the effectiveness of single shot peripheral adductor canal and isloted tibial blocks, periarticular injection of Exparel, and scheduled multimodal analgesia on pain control, patient ambulation, and time to meet discharge criteria.

 

Materials and Methods

 

After obtaining institutional permission to undertake a quality improvement study, 30 patients were included in this retrospectively.  Nerve blocks were performed as described (5).  Briefly, all blocks were performed preoperatively using ultrasound guidance with stimuquick needles attached to a nerve stimulator with current set between 0.5-0.8 mA.  Adductor canal and isolated tibial blocks received 30 cc and 10 cc of 0.25% bupivacaine, respectively.  Patients may have been given 0-5 mg intravenous midazolam to facilitate blockade. 

 

Intra articular injection of Exparel was performed intraoperatively.  Patients received 266 mg 0.25% bupivacaine along with up to 133 mg 0.25% plain bupivacaine.

 

Multimodal analgesia consisted of the following drugs given by mouth:  gabapentin 100mg every 8 h; celecoxib 200 mg every 12h; OFIRMEV 1000 mg every 8h; oxycontin 10 mg sustained release every 12h.  Patients had access to  immediate release oxycodone 5-10 mg every 4h and if pain was severe and persisted despite the mulitimodal oral drug regimen intravenous hydromorphone was available 1-2 mg every 2h.

 

Results/Discussion

 

Using this multimodal approach, patients were able to meet ambulation requirements and had minimal need for rescue narcotics (Table 1).  Discharge occurred in the afternoon of postoperative day two (2.9 day average), although 80% patients achieved 200 ft ambulation goal on postoperative day one.  There were no adverse events associated with this study.

 

References

1. Sharrock SE et al. Changes in mortality after total hip and knee arthroplasty over a ten-year period. Anesth Analg. 1995; 80:242-248.

2. Pearse EO, Caldwell BF, Lockwood RJ, Hollard J. Early mobilization after conventional knee replacement may reduce the risk of postoperative venous thromboembolism. J Bone Joint Surg Br. 2007; 89(3):316-322.

3. Munin MC, Rudy TE, Glynn NW, Crossett LS, Rubash HE. Early inpatient rehabilitation after elective hip and knee arthroplasty. JAMA.1998;279(11):847-852.

4. Jaeger P et al. Adductor canal block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology. 2013; 118:409-415.

5.Jaeger P et al. Adductor canal block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013;38(6):526-532.

7. Kim DH et al. Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial. Anesthesiology 2014; 120(3):540-550.

6. Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg. 2010; 111:1552-1554.

8. Sinha SK et al. Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study. Anesth Analg. 2012; 115:202-206.

9. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop. 2008; 79:174-183.

10. Parvataneni HK et al. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty. 2007; 22:33-38.

11. Chahar P and Cummings III, KC. Liposomal bupivacaine: a review of a new bupivacaine formulation. 2012; J Pain Res. 5:257-264.

12. Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol. 2009; 22(5):588-93.

 

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