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.
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.
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