info@biomedres.us   +1 (502) 904-2126   One Westbrook Corporate Center, Suite 300, Westchester, IL 60154, USA   Site Map
ISSN: 2574 -1241

Impact Factor : 0.548

  Submit Manuscript

Case ReportOpen Access

Postoperative Analgesia in Total Knee Arthroplasty (Tka)-The Changing Trends Volume 1 - Issue 3

Surjya Prasad Upadhyay1*, Sudhakar Tellicherry1, Sunil Kulkarni2, Partha P SaikiaM3, Piyush N mallick4 and Waleed Elmatite5

  • 1 Department of Anesthesia, NMC Hospital DIP, Dubai
  • 2 Department of Orthopedics, NMC Hospital DIP, Dubai
  • 3 Department of Anesthesia, Life Line hospital Dubai
  • 4 Department of Anesthesia, Al Zahra Hospital, UAE
  • 5 Department of paediatric anesthesia, Children and women Hospital, Buffalo, New york, USA

Received: August 07, 2017;   Published: August 18, 2017

Corresponding author: Surjya Prasad Upadhyay, Specialist Anesthesiologist, NMC Hospital DIP, United Arab Emirates, Dubai

DOI: 10.26717/BJSTR.2017.01.000284

Abstract

Joint replacement surgeries are considered as one of the most painful procedure in orthopedics. Achieving complete and long term pain relief starts from the time of surgery, and perhaps even before the surgery. The traditional approached involved high dose opioid based regimen, though opioid are considered strong analgesic, but are associated with number of unwanted side effects which lead the researcher to sought for alternative techniques. Neuraxial techniques (intrathecal long acting opioid) and continuous epidural analgesia were popular and were accepted by many but they also have limitations and drawback, after epidural analgesia, next popular technique that has evolve major nerve block namely femoral and sciatic, of which femoral nerve block (FNB) seems to provide equianalgesia to epidural without the side effects of epidural. The role of sciatic nerve block in TKA pain is doubtful. FNB still hold its place and many expert consider femoral nerve block as gold standard, however, FNB is associated with quadriceps weakness and risk of fall and sciatic block with foot drop. To overcome these drawback- more distal nerve block techniques has evolved- namely saphenous nerve block in adductor canal, selective tibial which are claimed to provide comparable analgesia to that of femoral and sciatic nerve block. The combination of pre-emptive and multi-modal analgesia and technically well delivered regional nerve blocks and postoperative physical therapy are essential component which not only minimize the side effects of traditional opioid based analgesia but also speed up functional recovery, increases patient satisfaction and reduces overall length of hospitalisation and cost.

Keywords: Postoperative Analgesia; Total Knee Arthroplasty; Multi-Modal Analgesia; Regional Blocks

Introduction

Optimal postoperative analgesia after total knee arthroplasty is the key for earlier recovery and functional outcomes. Joint replacement surgeries are one of the most painful orthopaedic procedure. Inadequate or poorly treated postoperative pain after major joint replacement surgery not only significantly prolongs the rehabilitation process, increased risk of other complications, sometime progress as persistent postoperative pain into chronic pain and it also prolonged the overall length of hospitalization and cost [1]. Achieving complete and long term pain relief starts from the time of surgery, and perhaps even before the surgery. Adequate perioperative analgesia is the key to success after knee arthoplasty surgeries, to maintain long term pain relief and functional recovery after the surgery. Early joint mobilization with initiation of physical therapy is one of the important aspects to achieve successful outcome after total knee arthoplasty [2]. Despite the introduction of newer drugs and techniques and better understanding of postoperative pain mechanism, majority of patients still suffer from extreme pain immediately after surgery that often progress into chronic pain [3-6].

Persistent pain after knee arthoplasty is still an unresolved issue for many patients [7]. Pain is a very subjective phenomenon; everyone has different pain threshold and perception of pain. So there can have individual range of experience and interpretation of pain very differently. It is very difficult to standardise any pain regime for a particular surgery. As per individual perception and requirement, the analgesic regime should be tailored to once need rather than making it fixed regime for all patient. Traditional techniques of pain relief after total joint replacement were primarily relied on opioid, oral or intravenous (IV), patient controlled analgesia (PCA) with IV opioid or epidural infusion [8]. Although opioid are considered strong analgesic, but are associated with number of unwanted side effects notably nausea vomiting, sedation, constipation, confusion, pruritus, urinary retention, respiratory depression, delay ambulation and overall increased length and cost of hospitalization [9,10]. Continuous epidural and PCA limits patient ambulation, requires close monitoring and frequent dose adjustment and may not be appropriate for all patients. One dose regime may not be suitable for every patient in PCA and often leads to under dosing or overdosing with troublesome side effects [11].

With increased understanding of pain patho-physiology, pharmacology of analgesics and their limitations, have led the researchers find alternative approaches for pain management targeting pain at different levels that complements each other in terms of analgesic actions with minimal side effects. The aim of the current article is to provide concise and up to date review on the available analgesics modalities after total knee arthoplasty and to provide evidence based standardized guideline or protocol which is important for both safety and effectiveness for most patients.

Analgesics Options After TKR

Available modalities for the management of postoperative analgesia after total knee arthoplasty are

a. Pre-emptive analgesia

b. Local infiltration

c. Systemic analgesics- opioid, non-opioid, patient controlled analgesia (PCA)

d. Neuraxial analgesia

e. Regional nerve blocks- single shot or continuous

f. Combinations – multi-modal analgesia

Pre-Emptive Analgesia

Pre-incision (at least 1 hour prior to incision) use of analgesics opioid, non-steroidal anti inflammatory drugs (NSAIDs), cyclooxygenase (cox-2) inhibitor, gabapentanoid (gabapentin and pregabalin)) has been shown to reduces the central and peripheral sensitization of pain mechanism and thereby reduces short and long term postoperative pain level and decreases the need of rescue analgesics in postoperative period [12-17]. pre-emptive use of opioid is controversial for fear of opioid related short and long term side effects and many expert do not recommend routine use of opioid even in postoperative period and there is growing trends to exclude opioid from pre-emptive analgesic regime due to risk of opioid related side effects; [16,18] however, opioids should be reserve for rescue analgesia. Non-steroidal anti inflammatory drugs (NSAIDs) or COX-2 inhibitors when given pre-emptively not only has anti-inflammatory effects, they facilitate pain relief and reduce opioid requirements and their related complications.

Local Infiltration Analgesia (LIA)

Intra operative peri-articular (intrarticular and extra-articular) injection of long acting local anaesthetic along with opioid or other adjuvants in varying proportion significantly reduces pain without major side effects specially when such regime is incorporated as part of multi-modal analgesia regimens. There are too heterogeneous techniques in term of drug dosing such as concentration, volume and adjuvants dose. Most commonly used drugs for peri-articular injections are bupivacaine, ropivacine, morphine, clonidine, steroid, keterolac, ephenephrine. So far, we dont have any consensus guideline on optimal drug, and dose - regimens [16,19-23].

Intrathecal Morphine with Local Anesthesia

Intrathecal morphine as an adjunct to local anesthesia provides good postoperative analgesia with parenteral opioid sparing effect for first 24 hours. However, intrathecal morphine is associated with higher incidences of pruritus, nausea-vomiting and urinary retention. Because of heterogeneous study design and dose regime, the dose - response relationship is not clear and there is not enough evidence to provide the optimal dose of intrathecal morphine for postoperative knee arthoplasty [19,23-26]. Low dose intrathecal morphine (100 microgram) has been proven to be more effective and may be safer than single-shot femoral nerve block [27].

Epidural Analgesia

Continuous epidural analgesia is time tested and one of the most effective technique for postoperative analgesia TKA and it is considered by many as gold standard and to which other analgesic techniques are compared. No doubt, it has definite effectiveness and still being widely used in routine clinical practice. However, it has its some drawback or side-effects such as haemodynamic instability, bladder and bowel dysfunction, unintended motor blockade, it makes patient confined to bed, pruritus and risk of respiratory depression, because of these effects its routine use is slowly declining and varieties of other regional analgesic techniques are being evaluated [28,29].

Regional Nerve Block Techniques:

Regional analgesia in the form of peripheral nerves block(s) in total knee arthoplasty is gaining popularity over epidural analgesia as it has not only better analgesic profile, but also has lesser sideeffects. Two main nerves that supply majority of knee joint are femoral for anterior aspect and sciatic nerve through its tibial and common peroneal branches for posterior aspect of knee joint. By blocking these two major nerves can provide almost complete analgesia after unilateral knee arthoplasty, however, complete nerve block results in motor blockade also resulting in paralysis or weakness of the muscles supplied by that particular nerves (quadriceps paralysis in femoral and foot drop in sciatic nerve) and this infect may delay the functional recovery of the patient.

Femoral Nerve Block

Femoral nerve is the main nerve supply the majority of knee joint. Single shot or continuous femoral nerve block has been shown to provide significant reduction in pain score and opioid consumption for up to 24 -48 hours [30-34]. Recent studies comparing epidural versus continuous femoral nerve block has demonstrated comparable postoperative analgesia with preserving the function of non-operative limb that may help in early rehabilitation [33,35]. Since femoral nerve is a branch of lumbar plexus, a lumbar plexus block either single shot or continuous infusion can also provide equivalent analgesia [36]. No doubt, femoral nerve block provide excellent analgesia after knee arthoplasty, the main drawback or concern is associated quadriceps weakness, impaired proprioception and risk of fall [37,38]. As a result, alternative techniques of nerve blocks has been exploredone such technique is motor sparing femoral block; that is blocking the saphenous nerve (terminal branch of femoral nerve after its gives of motor branches).

Adductor Canal Block (ACB)

The adductor canal in middle third of the thigh contain the saphenous nerve and last motor branch of femoral nerve- nerve to vastus medialis, blocking the nerves at this level results in less quadriceps weakness compared with single shot femoral injection. Recently, there are growing publications on the use of adductor canal block after total knee arthoplasty with or without periarticular local anesthetic infiltration. Most of the studies on adductor canal block shows comparable analgesic profile with better preserve quadriceps muscle strength resulting n earlier mobility and functional recovery [39-46]. Single shot adductor canal block provides 24 hours of good analgesia which can be extended for 3-4 days with inserting continuous infusion of local anesthetic through an indwelling catheter. The continuous adductor canal block has been part of standard protocol in many centers [41,44,47]. In a recent meta-analysis of 7 randomised controlled trial (RCT) by Fuqiang G on ACB Versus FNB for TKA found that patient with ACB achieve faster mobilization and functional recovery without a reduction in analgesia in comparison to FNB patients [48].

Sciatic and Selective Tibial nerve block

Though sciatic nerves, through its tibial and common peroneal branches innervates the postero-lateral aspect of knee joint and by blocking the sciatic nerve in addition to femoral or saphenous nerve block, though the role of sciatic nerve block in TKA is disputed by many authors, [49-51] it has undergone a controversial debate on usefulness in patients undergoing TKA. Some studies have proved that it provides superior analgesia after TKA [52-56]. Varieties of techniques of blocking the blocking the posterior knee pain have been described, including blocking sciatic nerve proximally at perigluteal region, distally at popliteal fossa or even isolated selective tibial nerve block [53-56]. So far we don’t have enough evidence to say one technique is superior to other.

Similarly, unlike femoral nerve block with continuous infusion, there is no evidence that continuous sciatic nerve block is superior to single shot sciatic in terms of functional recovery and discharge readiness [57- 59]. There are some additional factors that must be considered before blocking the sciatic nerve in patient undergoing TKA. The TKA related sciatic nerve injury incidence is around 2.4% (0.3-10%) and many surgeons want to evaluate the sciatic nerve function immediately after surgery or after spinal effect wear off [59-62]. Block performance in the immediate postoperative period may be more challenging for both patient and the provider due to postop pain, position difficulty in a narcotized patient, availability of personnel and equipment etc.

some clinician keep the sciatic block as an optional or as rescue block in recovery when the sciatic derived pain is intolerable to the patients [58,60]. Abdallah et al. [61] conducted a systemic review on use of sciatic nerve block in combination with femoral nerve block, use of sciatic nerve blocks (both for single shot or continuous) resulted in analgesic and opioid sparing effects for first 24 hours only and no analgesic benefit beyond 24 hours [61]. So the question arises do we need a separate catheter for continuous sciatic nerve block when the single shot provides equianalgesic effects. Complete sciatic nerve blockade (tibial and common peroneal) results in foot drop due to blockade of common peroneal component of sciatic nerve which carries the motor nerve fibre for dorsiflexion and eversion of the ankle and toe along with sensory innervation along the anterolateral leg and dorsum of foot. Though both common peroneal and tibial nerve innervates the knee joint as they cross the knee, but the sclerotomal distribution from each nerve is still unknown; blocking femoral and selective isolated tibial nerve at popliteal crease provided satisfactory analgesia similar to proximal sciatic + femoral nerve block [56]. The optimal volume and concentration of local anesthetics for selective tibial nerve block has not been estimated yet, generous volume of local anaesthetic at the popliteal crease may result in significant proximal spread and may also block the common peroneal component of sciatic nerve. The spread of local anaesthetic is also depend on the bifurcation point of sciatic nerve. A shorter bifurcation length is associated with greater proximal spread of local anesthetics and potential to at least partial blockade of common peroneal nerve, which is undesirable in patients at risk for peroneal nerve damage after TKA [62,63].

Other Potential Blocks:

4.9.1 Sub-sartorial Compartment Block: This is an ultrasound guided injection of local anaesthetic (LA) below the sartorius muscle distal to the adductor hiatus, 7-10 cm proximal to the knee; aiming to deposit LA around saphenous nerve adjacent to the saphenous branch of the genicular artery [64-66]. At this level, the block work as a pure sensory block and does not produce any motor paralysis. Theoretically this block will likely produce analgesia equivalent to adductor canal block. Unfortunately there are no studies comparing this block with femoral or adductor canal blocks [67,68].

4.9.2 I-Pack Block: (Inter space between the Popliteal Artery and the Capsule of the posterior Knee): First described by SK Sinha in a conference presentation, its an ultrasound guided dilute local anaesthetic infiltration (15-30 ml) in Inter space between the Popliteal Artery and the Capsule of the posterior Knee (I PACK) aiming to provide analgesia of the posterior knee capsule by blocking the terminal articular branches of tibial and peroneal nerves sparing the main nerves. This is relatively newer block and there have not been many studies on this block, some studies and case report reported as added analgesic advantage when combined with adductor canal block [63-65].

Obturator Nerve Block:

The relative contribution of obturator nerve in TKA pain is debatable. It mainly innervates the adductor muscle and skin over the medial aspect of thigh and sends articular branches to the knee joint. The posterior branch and occasionally anterior or accessory obturator nerves follow the popliteal vessels and join with popliteal plexus and may contribute the posterior knee pain TKA patients. Two recent studies has shown conflicting results of obturator nerve block, one study has compared obturator nerve block with sciatic nerve block in addition to femoral nerve blocks in both group found inferior analgesia in obturator group compared to sciatic group [69] whereas, another recent study comparing combined ultrasound guided femoral and obturator nerve block versus femoral nerve block and 3rd group with LIA found a large and significant reduction in the pain and analgesic requirement in patients receiving both femoral and obturator nerve blocks. [70] Further study is needed to defined and map the contribution of obturator nerve in postoperative pain in TKA.

Multimodal Analgesia after TKA:

The combination of two or analgesic drugs and or techniques that act via different mechanism will leads to additive or synergistic analgesia while minimising side effects of each drug [71]. Its a holistic approach for postoperative pain with a goal to maximize the analgesic effect and minimize the side effects of the medications [72-75]. There are varieties of regimen have been described by some international consensus groups [73-75]. typical multimodal analgesia protocol consist of preoperative patient education, preemptive analgesics, preference to regional anaesthesia and nerve blocks, periarticular infiltration of local anaesthetic, round the clock regular analgesics and a standardised programm for postoperative rehabilitation and functional recovery [76-78]. Commonly used drugs in multimodal analgesia regimen are acetaminophen, coxinhibitor or non-steroidal anti-inflammatory drugs, opioid and their derivatives, gabapentinoid, dexamethasone, ketamine etc [79- 85].

Authors Preferred Method

Our practice involve, pre-emptive analgesia with 75 mg pregabalin night before and 2 hour before the surgery along with celecoxib 200 mg orally 2 hr before surgery. Most of our TKA are done under General Anaesthesia with laryngeal mask airway- on spontaneous ventilation. Post-induction before incision- femoral nerve block with dilute short acting local anaesthetic (1% lignocaine 10-15 ml) - this is to cover the tourniquet pain and intra-op analgesia along with femoral nerve block we do selective tibial nerve block with 10 ml of 0.5% levobupivacaine. Single dose of intravenous dexmethasone 8 mg given before incision for both preventing postoperative nausea vomiting and to provide postoperative analgesia.

Maintenance of anaesthesia is done with sevoflurane (0.7-1 MAC) in oxygen with air and low dose remifentanil 200-300 mcg per hour. Intravenous Paracetamol 1 gm along with tramadol 100 mg towards the end of the surgery which are repeated in postoperative period (paracetamol 6th hourly and tramadol 8th hrly). After completion of surgery before extubation -adductor canal block with 20 ml of 0.5% levobupivacaine to provide the prolong postoperative analgesia. As our protocols involve injecting lower concentration and short acting local anaesthetic for femoral nerve block, there is no real femoral block -associated motor weakness and patients are able to begin weight bearing and physical therapy within 6- 8 hours after surgery. Patients are started on oral analgesics therapy in the form of paracetamol, celecoxib, tramadol and are discharged home once pain relief is satisfactory on 2nd postoperative day.

Conclusion

Quality analgesia and early rehabilitation are fundamental for early functional recovery after TKA which are desired by both patient and surgeon. The combination of pre-emptive and multimodal analgesia and technically well delivered regional nerve blocks and postoperative physical therapy are essential component which not only minimize the side effects of traditional opioid based analgesia but also speed up functional recovery, increases patient satisfaction and reduces overall length of hospitalisation and cost.

References

  1. Barrington JW, Halaszynski TM, Sinatra RS (2014) Perioperative pain management in hip and knee replacement surgery. Am J Orthop (Belle Mead NJ) 43(4): S1-S16.
  2. Tekindur Sukru, Yetim Memduh (2016) Postoperative analgesia after total knee arthroplasty. Rev. Bras. Anestesiol 66(4): 437-438.
  3. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS (2009) Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res 467(6): 1418- 423
  4. Parvataneni HK, Ranawat AS, Ranawat CS (2007) The use of local periarticular injections in the management of postoperative pain after total hip and knee replacement: a multimodal approach. Instr Course Lect. 56: 125-131
  5. Sinatra RS, Torres J, Bustos AM (2002) Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg 10: 117-129.
  6. (2012) Korean Knee Society. Guidelines for the Management of Postoperative Pain after Total Knee Arthroplasty. Knee Surgery & Related Research 24(4): 201-207.
  7. Grosu I, lavand’homme P, Thienpont E (2014) Pain after knee arthoplasty: an unresolved issue. Knee Surg Sports Traumatol Arthrosc 22(8): 1744-1758.
  8. Horlocker TT, Kopp SL, Pagnano MW, Hebl JR (2006) Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block. J Am Acad Orthop Surg 14(3): 126-135.
  9. Oderda G (2012) Challenges in the management of acute postsurgical pain. Pharmacotherapy 32(9): 6S-11S.
  10. Barletta JF (2012) Clinical and economic burden of opioid use for postsurgical pain: focus on ventilatory impairment and ileus. Pharmacotherapy 32(9): 12S-18S.
  11. Halawi M, Grant S, Bolognesi M (2015) Multimodal Analgesia for Total Joint Arthroplasty. ORTHOPEDICS 38: e616-e625.
  12. Klasen J, Haas M, Graf S, Harbach H, Quinzio L, et al. (2005) Impact on postoperative pain of long-lasting pre-emptive epidural analgesia before total hip replacement: a prospective, randomised, double-blind study. Anaesthesia 60(2): 118-123.
  13. Ong CK, Lirk P, Seymour RA, Jenkins BJ (2005) The efficacy of preemptive analgesia for acute postoperative pain management: a metaanalysis. Anesth Analg 100: 757-773.
  14. Krych AJ, Horlocker TT, Hebl JR, Pagnano MW (2010) Contemporary pain management strategies for minimally invasive total knee arthroplasty. Instr Course Lect 59: 99-109.
  15. Reuben SS, Buvanendran A, Kroin JS, Raghunathan K (2006) The analgesic efficacy of celecoxib, pregabalin, and their combination for spinal fusion surgery. Anesth Analg 103: 1271-1277
  16. (2012) Korean Knee Society. Guidelines for the Management of Postoperative Pain after Total Knee Arthroplasty. Knee Surgery & Related Research 24(4): 201-207.
  17. Mallory TH, Lombardi AV, Jr Fada RA, Dodds KL, Adams JB (2002) Pain management for joint arthroplasty: preemptive analgesia. J Arthroplasty 17(4): 129-133.
  18. Bromley L (2006) Pre-emptive analgesia and protective premedication. What is the difference? Biomed Pharmacother 60(7): 336-340.
  19. Karlsen APH, Wetterslev M, Hansen SE, Hansen MS, Mathiesen O, et al. (2017) Postoperative pain treatment after total knee arthroplasty: A systematic review 12(3)
  20. Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, et al. (2006) Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. The Journal of bone and joint surgery American volume 88(5): 959-963.
  21. Chinachoti T, Lungnateetape A, Raksakietisak M (2012) Periarticular infiltration of 0.25% bupivacaine on top of femoral nerve block and intrathecal morphine improves quality of pain control after total knee arthroplasty: a randomized double-blind placebo controlled clinical trial. Journal of the Medical Association of Thailand 95(12): 1536-1542.
  22. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, et al. (2010) Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta orthopaedica 81(3): 354-360.
  23. Kim TW, Park SJ, Lim SH, Seong SC, Lee S, et al. (2015) Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? Prospective, randomized, double-blind study. Kneesurgery, sports traumatology, arthroscopy. Knee Surg Sports Traumatol Arthrosc 23(3): 838-845.
  24. Olive DJ, Barrington MJ, Simone SA, Kluger R. (2015) A randomised controlled trial comparing three analgesia regimens following total knee joint replacement: continuous femoral nerve block, intrathecal morphine or both. Anaesthesia and intensive care 43(4): 454-460.
  25. Kunopart M, Chanthong P, Thongpolswat N, Intiyanaravut T, Pethuahong C (2014) Effects of single shot femoral nerve block combined with intrathecal morphine for postoperative analgesia: a randomized, controlled, dose-ranging study after total knee arthroplasty. Journal of the Medical Association of Thailand 97(2): 195-202
  26. Barrington JW, Emerson RH, Lovald ST, Lombardi AV, Berend KR (2016) No Difference in Early Analgesia Between Liposomal Bupivacaine Injection and Intrathecal Morphine After TKA. Clinical Orthopaedics and Related Research 475(1): 94-105.
  27. Frassanito L, Vergari A, Zanghi F, messina A, Bitondo M (2010) Postoperative analgesia following total knee arthroplasty: comparison of low-dose intrathecal morphine and single-shot ultrasound-guided femoral nerve block: a randomized, single blinded, controlled study. European Review for Medical and Pharmacological Sciences 14: 589- 596
  28. Fowler SJ, Symons J, Sabato S, Myles PS (2008) Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Br J Anaesth 100(2): 154-164.
  29. Tekindur Sukru, Yetim Memduh (2016) Postoperative analgesia after total knee arthroplasty. Rev. Bras. Anestesiol 66(4): 437-438.
  30. Chan EY, Fransen M, Sathappan S, Chua NH, Chan YH, et al. (2013) Comparing the analgesia effects of single-injection and continuous femoral nerve blocks with patient controlled analgesia after total knee arthroplasty. The Journal of arthroplasty 28(4): 608-613.
  31. Chan MH, Chen WH, Tung YW, Liu K, Tan PH, et al. (2012) Singleinjection femoral nerve block lacks preemptive effect on postoperative pain and morphine consumption in total knee arthroplasty. Acta anaesthesiologica Taiwanica: official journal of the Taiwan Society of Anesthesiologists 50(2): 54-58.
  32. Jeong MS, Song EK, Seon JK, Byun JW, Lee KJ, et al. (2011) Effectiveness of Pain Relief for Femoral Nerve Block in Multimodal Pain Control Protocols in Total Knee Arthroplasty. Journal of the Korean Orthopaedic Association 46(3): 237-243.
  33. Lee AR, Choi DH, Ko JS, Choi SJ, Hahm TS, et al. (2011) Effect of combined single-injection femoral nerve block and patient-controlled epidural analgesia in patients undergoing total knee replacement. Yonsei medical journal 52(1): 145-150.
  34. Sahin L, Korkmaz HF, Sahin M, Atalan G (2014) Ultrasound-guided single-injection femoral nerve block provides effective analgesia after total knee arthroplasty up to 48 hours. The journal of the Turkish Society of Algology 26(3):113-118.
  35. Barrington MJ, Olive D, Low K, Scott DA, Brittain J, et al. (2005) Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg 101: 1824-1829.
  36. Morin AM, Kratz CD, Eberhart LH, Dinges G, Heider E, et al. (2005) Postoperative analgesia and functional recovery after total-knee replacement: comparison of a continuous posterior lumbar plexus (psoas compartment) block, a continuous femoral nerve block, and the combination of a continuous femoral and sciatic nerve block. Reg Anesth Pain Med 30: 434-45.
  37. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL. (2010) Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 468: 135-140.
  38. Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB (2009) Femoral nerve block for total knee replacement-a word of caution. Knee 16:98-100.
  39. Iang X, Wang Qq, Wu Ca, Tian W (2016) Analgesic Efficacy of Adductor Canal Block in Total Knee Arthroplasty: A Meta-analysis and Systematic Review. Orthop Surg 8: 294-300.
  40. Jæger P, Koscielniak-Nielsen ZJ, Schrøder HM (2014) Adductor canal block for post-operative pain treatment after revision knee arthroplasty: a blinded, randomized, placebo-controlled study.
  41. Hanson NA, Allen CJ, Hostetter LS, Nagy R (2014) Continuous ultrasoundguided adductor canal block for total knee arthroplasty: a randomized, double-blind trial. Anesth Analg 118: 1370-1377.
  42. Rasmussen M, Kim E, Kim T, Howard SK, Mudumbai S, et al. (2015) A retrospective comparative provider workload analysis for femoral nerve and adductor canal catheters following knee arthroplasty. J Anesth 29: 303-307.
  43. Patterson ME, Bland KS, Thomas LC et al (2015) The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty-a retrospective study. J Clin Anesth 27(1): 39-44.
  44. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, et al. (2014) Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 472(5): 1377-1383.
  45. Grevstad U, Mathiesen O, Valentiner LS, Jaeger P, Hilsted KL, et al. (2015) Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: a randomized, blinded study. Reg Anesth Pain Med 40(1): 3-10
  46. Kim DH, Lin Y, Goytizolo EA, Kahn RL, Maalouf DB et al. (2014) Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial. Anesthesiology 120(3): 540- 550
  47. Wiesmann T, Piechowiak K, Duderstadt S, Haupt D, Schmitt J, et al. (2016) Continuous adductor canal block versus continuous femoral nerve block after total knee arthroplasty for mobilisation capability and pain treatment: a randomised and blinded clinical trial. Archives of Orthopaedic and Trauma Surgery 136(3): 397-406.
  48. Fuqiang G, Jinhui M, Wei S, Wanshou G, Zirong L, et al. (2017) Adductor Canal Block Versus Femoral Nerve Block for Analgesia After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. Clinical Journal of Pain 33(4): 356-368
  49. Safa B, Gollish J, Haslam L, Mc Cartney CJ (2014) Comparing the effects of single shot sciatic nerve block versus posterior capsule local anesthetic infiltration on analgesia and functional outcome after total knee arthroplasty: A prospective, randomized, double-blinded, controlled trial. J Arthroplasty 29(6): 1149-1153
  50. Mahadevan D, Walter RP, Minto G, Gale TC, McAllen CJ, et al. (2012) Combined femoral and sciatic nerve block vs combined femoral and periarticular infiltration in total knee arthroplasty: A randomized controlled trial. J Arthroplasty 27: 1806-1811
  51. Cook P, Stevens J, Gaudron C (2003) Comparing the effects of femoral nerve block versus femoral and sciatic nerve block on pain and opiate consumption after total knee arthroplasty. J Arthroplasty 18: 583-586
  52. Yoshinuma H, Hara K, Sugimura K, Makino S, Nakamura K, et al. (2013) Sciatic nerve block provide superior analgesia for popliteal pain after total knee arthroplasty. European Journal of Anaesthesiology 30: 134- 134
  53. Abdallah FW, Chan VWS, Gandhi R, Koshkin A, Abbas S, et al. (2014) The Analgesic Effects of Proximal, Distal, or No Sciatic Nerve Block on Posterior Knee Pain after Total Knee Arthroplasty: A Double-blind Placebo-controlled Randomized Trial. Anesthes 121(6): 1302-1310.
  54. Todkar M (2005) Sciatic Nerve Block After Total Knee Replacement. Medscape General Medicine. 7(4): 4.
  55. Sinha A, Chan VW (2004) Ultrasound imaging for popliteal sciatic nerve block. Reg Anesth Pain Med 29(2): 130-134
  56. Sinha SK, Abrams JH, Arumugam S, D Alessio J, Freitas DG, et al. (2012) 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 115(1): 202-206
  57. Ilfeld BM (2011) Continuous peripheral nerve blocks: a review of thepublished evidence. Anesth Analg 113(4): 904-925.
  58. Ilfed BM, Madison SJ (2011) The Sciatic Nerve and Knee arthoplasty To block, or not to block- that is the question. Regional Anesthesia and Pain Medicine 36(5): 421-423.
  59. Horlocker TT, Cabanela ME, Wedel DJ (1994) Does postoperative epidural analgesia increase the risk of peroneal nerve palsy after total knee arthroplasty? Anesth Analg 79(3): 495-500
  60. Levesque S, Delbos A (2005) Sciatic nerve block for total-knee replacement: is it really necessary in all patients? Reg Anesth Pain Med 30: 410-411.
  61. Abdallah FW, Brull R (2011) Is sciatic nerve block advantageous when combined with femoral nerve block for postoperative analgesia following total knee arthroplasty? A systematic review. Reg Anesth Pain Med 36(5): 493-498.
  62. Nercessian O, Ugwonali O, Park S (2005) Peroneal nerve palsy after total knee arthoplasty. J Arthroplasty 20: 1068-1073.
  63. Eric R Silverman, Amaresh Vydyanathan, Karina Gritsenko, Naum Shaparin, Nair Singh, et al. (2017) The Anatomic Relationship of the Tibial Nerve to the Common Peroneal Nerve in the Popliteal Fossa: Implications for Selective Tibial Nerve Block in Total Knee Arthroplasty, Pain Research and Management pp. 6
  64. Elliot CE, Myers TJ, Soberon JR, K Osteen, D Yuratich, et al. (2015) The adductor canal block combine with IPACK improves physical therapy performance and reduces hospital length of stay. Presented at the 40th annual regional anesthesiology and acute pain medicine meetiing (ASRA) 14-16.
  65. Scimia P, Giordano C, Ricci EB, Budassi P, Petrucci E, et al. (2017) The ultrasound-guided iPACK block with continuous adductor canal block for total knee arthroplasty. Anaesthesia Cases ISSN pp. 2396-8397
  66. Reddy AVG, Jangale A, Reddy RC, Sagi M, Gaikwad A, et al. (2017) To compare effect of combined block of adductor canal block (ACB) with IPACK (interspace between the popliteal artery and capsule of the posterior knee) and adducot canal block (ACB) alone on total knee replacement in immediate postoperative rehabilitation. International Journal of Orthopaedics Sciences 3(2): 141-145
  67. Lundblad M, Kapral S, Marhofer P, Lonnqvist PA (2006) Ultrasoundguided infrapatellar nerve block in human volunteers: description of a novel technique. Br J Anaesth 97(5): 710-714.
  68. Horn JL, Pitsch T, Salinas F, Benninger B (2009) Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Reg Anesth Pain Med 34(5): 486-489.
  69. Runge C, Børglum J, Jensen JM, Kobborg T, Pedersen A, et al. (2016) The analgesic effect of obturator nerve block added to a femoral triangle block after total knee arthroplasty-a randomized controlled trial. Reg Anesth Pain Med 41(4): 445-451.
  70. Sato K, Sai S, Shirai N, Adachi T (2011) Ultrasound Guided Obturator Versus Sciatic Nerve Block in Addition to Continuous Femoral Nerve Block for Analgesia After Total Knee Arthroplasty. Japanese Clinical Medicine 2: 29-34.
  71. Kehlet H, Dahl JB (1993) The value of multimodal or balanced analgesia in postoperative pain treatment. Anesth Analg 77(5): 1048-1056.
  72. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS (2009) Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res 467(6): 1418- 1423.
  73. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, et al. (2008) A preemptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med Dec 33(6): 510-517.
  74. Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, et al. (2005) A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 87(2):63-70.
  75. (2012) American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 116(2): 248-273
  76. Horlocker TT, Kopp SL, Pagnano MW, Hebal JR (2006) Analgesia for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block. J Am Acad Orthop Surg 14(3): 126-135.
  77. Maheshwari AV, Boutary M, Yun AG, Sirianni LE, Dorr LD (2006) Multimodal analgesia without routine parenteral narcotics for total hip arthroplasty. Clin Orthop Relat Res 453: 231-238.
  78. Berend ME, Berend KR, Lombardi AV (2014) Advances in pain management. Game changer in knee arthroplasty. Bone Joint J 96(11): 7-9.
  79. Sinatra RS, Jahr JS, Reynolds LW, Viscusi ER, Groudine SB, et al. (2005) Efficacy and safety of single and repeated administration of 1 gram intravenous acetaminophen injection (paracetamol) for pain management after major orthopedic surgery. Anesthesiology 102(4): 822-831
  80. Alexander R, El-Moalem HE, Gan TJ (2002) Comparison of the morphine sparing effects of diclofenac sodium and ketorolac tromethamine after major orthopedic surgery. J Clin Anesth 14(3):187-192.
  81. Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, et al. (2003) Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial. JAMA 290(18): 2411-2418.
  82. Pulos N, Sheth N (2014) Perioperative pain management following total joint arthroplasty. Ann Orthop Rheumatol 2: 1029.
  83. Backes JR, Bentley JC, Politi JR, Chambers BT (2013) Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. J Arthroplasty 28(8): 11-17.
  84. Mathiesen O, Jacobsen LS, Holm HE, Randall S, Adamiec-Malmstroem L (2008) Pregabalin and dexamethasone for postoperative pain control: a randomized controlled study in hip arthroplasty. Br J Anaesth 101(4): 535-341.
  85. Lee JK, Chung KS, Choi CH (2015) The effect of a single dose of preemptive pregabalin administered with COX-2 inhibitor: a trial in total knee arthroplasty. J Arthroplasty 30(1): 38-42.