The Effect of the IPACK Block on Pain After Primary TKA: A Double-Blinded, Prospective, Randomized Trial.

BACKGROUND: The purpose of this study was to determine if infiltration of local anesthetic between the interspace between the popliteal artery and capsule of the knee (IPACK) provides benefit in total knee arthroplasty. METHODS: Patients were randomized into continuous adductor canal block with IPACK block or continuous adductor canal block with sham subcutaneous saline injection. Only the anesthesiologist performing the block was aware of randomization status. After surgery, a blinded assessor recorded opioid consumption, pain scores, and gait distance. RESULTS: There were 35 patients in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the postanesthesia care unit (PACU), the average (P = .0122) and worst (P = .0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy (P = .2080). There was no difference in opioid consumption in the PACU (P = .7928), or at 24 hours (P = .7456). There was no difference in pain scores on POD 1 in the AM (P = .4597) or PM (P = .6273), or in the walking distance (P = .5197). There was also no difference in length of stay in the PACU (P = .9426) or hospital (P = .2141). CONCLUSION: The IPACK group had lower pain scores at rest in the PACU, but this is likely not clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be indications for the use of the IPACK block as a rescue block or in patients who have contraindications to our standard multimodal treatment regimen or in patients with chronic pain or opioid dependence.

The Effects of Peri-Operative Dexamethasone on Patients Undergoing Total Hip or Knee Arthroplasty: Is It Safe for Diabetics?

BACKGROUND: Peri-operative dexamethasone has been shown to effectively reduce post-operative nausea and vomiting and aide in analgesia after total joint arthroplasty (TJA); however, systemic glucocorticoid therapy has many adverse effects. The purpose of this study is to determine the effects of dexamethasone on prosthetic joint infection (PJI) and blood glucose levels in patients undergoing TJA. METHODS: A retrospective chart review of all patients receiving primary TJA from 2011 to 2015 (n = 2317) was conducted. Patients were divided into 2 cohorts: dexamethasone (n = 1426) and no dexamethasone (n = 891); these groups were subdivided into diabetic and non-diabetic patients. The primary outcome was PJI; secondary measures included glucose levels and pre-operative hemoglobin A1c (A1c) values. Statistics were carried out using logistic and regression models. RESULTS: Of the 2317 joints, 1.12% developed PJI; this was not affected by dexamethasone (P = .166). Diabetics were found to have higher rate of infection (P < .001); however, diabetics who received dexamethasone were not found to have a significantly higher infection rate that non-diabetics (P = .646). Blood glucose levels were found to increase post-operatively, and dexamethasone did not increase this change (P = .537). Diabetes (P < .001) and increasing hemoglobin A1c (P < .001) were also associated with increased serum glucose levels; however, this was not influenced by dexamethasone (P = .595). CONCLUSION: Although diabetic patients were found to have a higher infection rate overall, this was not affected by administration of intravenous dexamethasone, nor was the post-operative elevation in serum glucose levels. In this study population, peri-operative intravenous dexamethasone did not increase the rate of PJI and was safe to administer in patients undergoing TJA.

Novel Regional Techniques for Total Knee Arthroplasty Promote Reduced Hospital Length of Stay: An Analysis of 106 Patients.

BACKGROUND: Novel regional techniques, including the adductor canal block (ACB) and the local anesthetic infiltration between the popliteal artery and capsule of the knee (IPACK) block, provide an alternative approach for controlling pain following total knee arthroplasty (TKA). This study compared 3 regional techniques (femoral nerve catheter [FNC] block alone, FNC block with IPACK, and ACB with IPACK) on pain scores, opioid consumption, performance during physical therapy, and hospital length of stay in patients undergoing TKA. METHODS: All patients had a continuous perineural infusion, either FNC block or ACB. Patients in the IPACK block groups also received a single injection 30-mL IPACK block of 0.25% ropivacaine. Pain scores and opioid consumption were recorded at postanesthesia care unit discharge and again at 8-hour intervals for 48 hours. Physical therapy performance was measured on postoperative days (POD) 1 and 2, and hospital length of stay was recorded. RESULTS: We found no significant differences in the 3 groups with regard to baseline patient demographics. Although we observed no differences in pain scores between the 3 groups, opioid consumption was significantly reduced in the FNC with IPACK group. Physical therapy performance was significantly better on POD 1 in the ACB with IPACK group compared to the other 2 groups. Hospital length of stay was significantly shorter in the ACB with IPACK group. CONCLUSION: This study demonstrated that an IPACK block reduced opioid consumption by providing effective supplemental analgesia following TKA compared to the FNC-only technique. ACB with IPACK provided equivalent analgesia and improved physical therapy performance, allowing earlier hospital discharge.

The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement.

PURPOSE OF REVIEW: The perioperative surgical home (PSH) is a patient-centered, physician-led, multidisciplinary care pathway developed to deliver value-based care based on shared decision-making. Physician and hospital reimbursement will be tied to providing quality care at lower cost, and the PSH model has been used in providing care to patients undergoing lower extremity arthroplasty. The purpose of this review is to discuss the rationale, definition, development, current state, and future direction of the PSH. RECENT FINDINGS: The PSH model guides the patient throughout the pre and perioperative process and into the postoperative phase. It has been shown in multiple studies to decrease length of stay, improve functional outcomes, allow more home discharges, and lower costs. There is no increase in complications or readmission rates. The PSH pathway is a safe and effective method of providing value-based care to patients undergoing hip and knee arthroplasty.

The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study.

STUDY OBJECTIVE: To determine the ability of an ultrasound-guided single-shot adductor canal block to provide adequate analgesia and improve performance during physical therapy. DESIGN: A retrospective chart review. SETTING: All procedures were performed at Ochsner Medical Center. MEASUREMENTS: Patient demographics as well as the type of peripheral nerve block performed. Pain scores and opioid consumption were recorded at postanesthesia care unit discharge and again at 8 ± 3, 16 ± 3, and 24 ± 3 hours. In addition, physical therapy performance was analyzed. MAIN RESULTS: There were no significant differences in pain scores or cumulative hydromorphone requirements between the adductor canal block group and the femoral nerve block group at any of the time points analyzed. Gait distance measured during physical therapy sessions in the adductor canal block group was superior compared with the femoral nerve block group. CONCLUSION: Within the first 24 hours, a single-shot adductor canal block provides equally effective analgesia when compared with a femoral nerve block and improves postoperative physical therapy performance.

Comparison of ultrasound and nerve stimulation techniques for interscalene brachial plexus block for shoulder surgery in a residency training environment: a randomized, controlled, observer-blinded trial.

BACKGROUND: The ability to provide adequate intraoperative anesthesia and postoperative analgesia for orthopedic shoulder surgery continues to be a procedural challenge. Anesthesiology training programs constantly balance the time needed for procedural education versus associated costs. The administration of brachial plexus anesthesia can be facilitated through nerve stimulation or by ultrasound guidance. The benefits of using a nerve stimulator include a high incidence of success and less cost when compared to ultrasonography. Recent studies with ultrasonography suggest high success rates and decreased procedural times, but less is known about the comparison of these procedural times in training programs. We conducted a prospective, randomized, observer-blinded study with inexperienced clinical anesthesia (CA) residents-CA-1 to CA-3-to compare differences in these 2 guidance techniques in patients undergoing interscalene brachial plexus block for orthopedic surgery. METHODS: In this study, 41 patients scheduled for orthopedic shoulder surgery were randomly assigned to receive an interscalene brachial plexus block guided by either ultrasound (US group) or nerve stimulation (NS group). Preoperative analgesics and sedatives were controlled in both groups. RESULTS: The US group required significantly less time to conduct the block (4.3 ± 1.5 minutes) than the NS group (10 ± 1.5 minutes), P â€Š=  .009. Moreover, the US group achieved a significantly faster onset of sensory block (US group, 12 ± 2 minutes; NS group, 19 ± 2 minutes; P â€Š=  .02) and motor block (US group, 13.5 ± 2.3 minutes; NS group, 20.2 ± 2.1 minutes; P â€Š=  .03). Success rates were high for both techniques and were not statistically different (US group, 95%; NS group, 91%). No differences were found in operative times, postoperative pain scores, need for rescue analgesics, or incidences of perioperative or postdischarge side effects. CONCLUSION: On the basis of our results with inexperienced residents, we found that using US in guiding the interscalene approach to the brachial plexus significantly shortened the duration of intervals in conduction of the block and onset of anesthesia when compared with NS; moreover, these times could have significant cost savings for the institution. Finally, the use of US technology in an academic medical center facilitates safe, cost-effective, quality care.

Comparison of extended-release epidural morphine with femoral nerve block to patient-controlled epidural analgesia for postoperative pain control of total knee arthroplasty: a case-controlled study.

BACKGROUND: Because newer anticoagulation strategies for total knee replacement present potentially increased risk of neuraxial analgesia, there is movement away from using patient-controlled epidural analgesia (PCEA) for pain control. This concern opens the door for other regional modalities in postoperative analgesia, including the use of extended-release epidural morphine (EREM) combined with a femoral nerve block (FNB). METHODS: This study was a prospective observational chart review with the use of recent historical controls in patients undergoing unilateral total knee replacement. Outcomes of interest were 0-, 24-, and 48-hour postoperative pain scores using the visual analog scale (VAS); incidence of side effects; and time spent in the postanesthesia care unit (PACU). RESULTS: Postoperative pain scores at 24 and 48 hours in the EREM and FNB group (n â€Š=  14; 2.6 ± 0.6 and 5.0 ± 0.9, respectively) were comparable to the PCEA group (n â€Š=  14; 3.8 ± 0.6 and 4.2 ± 0.9). The PACU time was shorter in the EREM and FNB group (2.4 ± 0.3 hours) compared with PCEA (3.6 ± 0.3 hours, P â€Š=  .02). No statistically significant difference was found in the incidence of side effects between the 2 groups. CONCLUSIONS: The VAS scores at 24 and 48 hours indicate that EREM and FNB provide comparable analgesia to PCEA. The trend toward shorter PACU times represents an opportunity for cost-identification analysis. The study data are limited by their observational nature and the small number of patients involved; nevertheless, this study demonstrates a therapeutic equivalence to PCEA that may be more cost effective.