Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study.

BACKGROUND: Sciatic nerve block when combined with femoral nerve block for total knee arthroplasty may provide superior analgesia but can produce footdrop, which may mask surgically induced peroneal nerve injury. In this prospective, randomized, observer-blinded study, we evaluated whether performing a selective tibial nerve block in the popliteal fossa would avoid complete peroneal motor block. METHODS: Eighty patients scheduled for primary total knee arthroplasty were randomized to receive either a tibial nerve block in the popliteal fossa or a sciatic nerve block proximal to its bifurcation in combination with femoral nerve block as part of a multimodal analgesia regimen. Local anesthetic solution of sufficient volume to encircle the target nerve was administered for the block, up to a maximum of 20 mL. General anesthesia was administered for surgery. After emergence from anesthesia, in the recovery room, the presence or absence of peroneal sensory and motor block was noted. Pain scores and opioid consumption were recorded for 24 hours after surgery. RESULTS: The tibial nerve block and sciatic nerve block were performed 1.7 cm (99% CI, 1.3 to 2.1) and 9.4 cm (99% CI, 8.3 to 10.5) proximal to the popliteal crease, respectively (99% CI for difference between means: 6.4 to 9.0; P < 0.001). A lower volume of ropivacaine 0.5% was used for the tibial nerve block, 8.7 mL (99% CI, 7.9 to 9.4) versus 15.2 mL (99% CI, 14.9 to 15.5), respectively (99% CI for difference between means, 5.6 to 7.3; P < 0.001). No patient receiving a tibial nerve block developed complete peroneal motor block compared to 82.5% of patients with sciatic nerve block (P < 0.001). There were no significant differences in the pain scores and opioid consumption between the groups. CONCLUSIONS: Tibial nerve block performed in the popliteal fossa in close proximity to the popliteal crease avoided complete peroneal motor block and provided similar postoperative analgesia compared to sciatic nerve block when combined with femoral nerve block for patients undergoing total knee arthroplasty.

Spinal Anesthesia Using Ropivacaine Leads to Earlier Ambulation After Total Hip Arthroplasty.

Spinal anesthesia has grown in popularity for total hip arthroplasty (THA) due to its documented low complications. However, the use of a local anesthetic agent dictates the recovery of neuraxial blockade. Bupivacaine has emerged as the most popular choice, but its relatively long-acting effect limits its use with rapid recovery. Although not well studied, ropivacaine may offer a viable alternative with shorter-acting properties. Primary unilateral THA patients who received either ropivacaine or bupivacaine spinal anesthesia were retrospectively reviewed. These groups were compared for common demographics, such as age, sex, and body mass index. The primary outcomes included postoperative ambulation time and distance, post-anesthesia care unit transition time, and selective complications. Five hundred three patients were included. Of these, 227 received ropivacaine and 276 received bupivacaine. The ropivacaine group showed superior ambulation time and distance, quicker post-anesthesia care unit transition, and equivalent complications compared with the bupivacaine group. Ropivacaine shows a clear advantage over bupivacaine for spinal anesthesia during THA when considering rapid recovery. Its use should be strongly considered, especially in the ambulatory setting. [Orthopedics. 2021;44(3):e343-e346.].

Ultrasound-guided interscalene needle placement produces successful anesthesia regardless of motor stimulation above or below 0.5 mA.

BACKGROUND: We quantified the motor response after ultrasound (U-S)-guided needle placement for interscalene block (ISB). We then compared block characteristics based on motor response above or below 0.5 mA. METHODS: Sixty-one patients scheduled for ambulatory shoulder surgery under ISB and general anesthesia were included in this prospective, observational study. Preoperatively, an insulated needle was positioned by U-S in the interscalene groove. The lowest current producing motor response was determined, and 30 mL 0.5% bupivacaine with epinephrine was injected. Motor and sensory block were tested in the upper trunk distribution for 15 min until general anesthesia was induced. Postoperatively, the success of upper trunk block, pain score in the postanesthesia care unit and block duration, and analgesic tablet consumption overnight were recorded. Patients were divided a priori into Group A (current < or =0.5 mA) and Group B (current >0.5 mA), and results were compared between groups. RESULTS: The observed current range was 0.14-1.7 mA, with current < or =0.5 mA in 42% of patients (Group A). All patients had complete sensorimotor upper trunk block and none required narcotics in the postanesthesia care unit. Block duration (both groups: 17.8 +/- 4.9 h, mean +/- sd) and home analgesic use were equivalent. Sensory block onset was equivalent between groups, but incomplete motor block at 15 min was more likely in Group B: 37% vs 12% in Group A (P = 0.03). CONCLUSION: During U-S-guided ISB using nerve stimulation, the observed motor response below or above 0.5 mA had no impact on success or duration of upper trunk block.

C-reactive protein, inflammation, and coronary risk: an update.

The recognition that inflammation is closely related to atherothrombosis, diabetes, and the metabolic syndrome, represents an enormously important advance in medical science. The prevention community initially took a very cautious approach to recommending CRP measurements, in part because of the variable quality of assays; the advent of high sensitivity CRP measurements and the remarkable research output from Ridker's lab and many others, has demonstrated that this inflammatory marker can provide useful prognostic information, and has contributed a great deal to our understanding of pathobiology. Normal values have been established, and high sensitivity CRP assays are widely available; it is likely that CRP measurements will become increasingly used by physicians to assess vascular risk and potentially to guide therapy. Measurements of CRP in active clinical syndromes, such as coronary artery disease patients with vascular disease or congestive heart failure, would appear at this time to have little useful purpose outside of clinical research studies. We must remember that CRP is but one of many inflammatory markers; nevertheless, the database supporting CRP measurements is far greater than for any of the other markers, and the widely available hs-CRP assay makes it extremely attractive to pursue the conundrum of inflammation and athersclerosis with vigor.

The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers.

BACKGROUND AND OBJECTIVES: Adductor canal block (ACB) has been suggested as an analgesic alternative to femoral nerve block (FNB) for procedures on the knee, but its effect on quadriceps motor function is unclear. We performed a randomized, blinded study to compare quadriceps strength following adductor canal versus FNB in volunteers. Our hypothesis was that quadriceps strength would be preserved following ACB, but not FNB. Secondary outcomes included relative preservation of hip adduction and degree of balance impairment. METHODS: The ACB was performed in one leg and the FNB in the contralateral leg in 16 volunteers using a randomized block sequence. For all blocks, 15 mL of 3% chloroprocaine was injected under ultrasonographic guidance. Maximal voluntary isometric contraction of knee extension and hip adduction was measured at baseline and at 30 and 60 minutes after block. After 60-minute assessments were complete, the second block was placed. A test of balance (Berg Balance Scale) was performed 30 minutes after the first block only. RESULTS: Quadriceps strength and balance scores were similar to baseline following ACB. Following FNB, there was a significant reduction in quadriceps strength (95.1% ± 17.1% vs 11.1% ± 14.0%; P < 0.0001) and balance scores (56 ± 0 vs 37 ± 17.2; P = 0.02) compared with baseline. There was no difference in hip adductor strength (97.0% ± 10.8% vs 91.8% ± 9.6%; P = 0.17). CONCLUSIONS: Compared with FNB, ACB results in significant quadriceps motor sparing and significantly preserved balance.

Local infiltration analgesia followed by continuous infusion of local anesthetic solution for total hip arthroplasty: a prospective, randomized, double-blind, placebo-controlled study.

BACKGROUND: We studied the efficacy of local infiltration analgesia in surgical wounds with 0.2% ropivacaine (50 mL), ketorolac (15 mg), and adrenaline (0.5 mg) compared with that of local infiltration analgesia combined with continuous infusion of 0.2% ropivacaine as a method of pain control after total hip arthroplasty. We hypothesized that as a component of multimodal analgesia, local infiltration analgesia followed by continuous infusion of ropivacaine would result in reduced postoperative opioid consumption and lower pain scores compared with infiltration alone, and that both of these techniques would be superior to placebo. METHODS: In this prospective, double-blind, placebo-controlled study, 105 patients were randomized into three groups: Group I, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of 0.2% ropivacaine at 5 mL/hr; Group II, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of saline solution at 5 mL/hr; and Group III, in which patients received infiltration with saline solution followed by continuous infusion of saline solution at 5 mL/hr.All patients received celecoxib, pregabalin, and acetaminophen perioperatively and patient-controlled analgesia; surgery was performed under general anesthesia. Before wound closure, the tissues and periarticular space were infiltrated with ropivacaine, ketorolac, and adrenaline or saline solution and a fenestrated catheter was placed. The catheter was attached to a pump prefilled with either 0.2% ropivacaine or saline solution set to infuse at 5 mL/hr.The primary outcome measure was postoperative opioid consumption and the secondary outcome measures were pain scores, adverse side effects, and patient satisfaction. RESULTS: There were no differences between groups in the administration of opioids in the operating room, in the recovery room, or on the surgical floor. The pain scores on recovery room admission and discharge and the floor were low and similar between groups. There were no differences in the incidence of adverse side effects among groups. Patient satisfaction with pain management was similar in all groups. CONCLUSIONS: Local infiltration analgesia alone or followed by continuous infusion of ropivacaine as part of multimodal analgesia provides no additional analgesic benefit or reduction in opioid consumption compared with placebo following total hip arthroplasty. LEVEL OF EVIDENCE: Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Decreasing the local anesthetic volume from 20 to 10 mL for ultrasound-guided interscalene block at the cricoid level does not reduce the incidence of hemidiaphragmatic paresis.

BACKGROUND AND OBJECTIVES: This prospective, randomized, double blind study was designed to determine whether reduction in volume from 20 to 10 mL of ropivacaine 0.5% for ultrasound-guided interscalene block might decrease the incidence of diaphragmatic paresis and preserve pulmonary function. METHOD: Thirty patients scheduled for arthroscopic shoulder surgery were randomized to receive either 10 or 20 mL of ropivacaine 0.5% for interscalene block at the level of the cricoid cartilage. General anesthesia was administered for surgery, and the surgeon infiltrated lidocaine at the port sites. Hemidiaphragmatic excursion and pulmonary function tests were measured before block, 15 mins after block, and at the time of discharge from recovery room. Onset and duration of sensory dermatomal spread, motor block, pain scores, and analgesic consumption were recorded. RESULTS: Hemidiaphragmatic paresis occurred 15 mins after block performance in 14 of 15 patients in each group. At postanesthesia care unit discharge, 13 of 15 patients in each group continued to demonstrate hemidiaphragmatic paresis. Significant reduction of spirometric values(forced vital capacity, forced expiratory volume at 1 sec, and peak expiratory flow) occurred to a similar degree in both groups after block.Sensory dermatomal spread, motor block, pain scores, and analgesic consumption were not significantly different between groups. CONCLUSIONS: Decreasing the volume for interscalene block from 20 to 10 mL did not reduce the incidence of hemidiaphragmatic paresis or impairment in pulmonary function, which persisted at discharge from recovery room. No significant differences in quality or duration of analgesia were observed.