Comparison of Analgesic Effects of Continuous Femoral Nerve Block, Femoral Triangle Block, and Adductor Block After Total Knee Arthroplasty: A Randomized Clinical Trial.

OBJECTIVES: This study aimed to compare the analgesic effects of continuous femoral nerve block (FNB), femoral triangle block (FTB), and adductor canal block (ACB) following total knee arthroplasty (TKA). The goal was to identify the most effective nerve block technique among these. METHODS: Patients undergoing TKA were randomly assigned to 1 of 3 groups: FNB, FTB, or ACB. Nerve blocks were administered preoperatively, with catheters placed for patient-controlled nerve analgesia (PCNA). The primary end point was the Numeric Rating Scale (NRS) score at movement at 24 hours postsurgery. Secondary end points included NRS scores at rest and movement, quadriceps strength, Timed Up and Go (TUG) test performance, range of motion, effective PCNA utilization, and opioid consumption at various postsurgery time points. RESULTS: Of the 94 valid data sets analyzed (FNB: 31, FTB: 31, ACB: 32), significant differences were observed in the primary end point (H=7.003, P =0.03). Post hoc analysis with Bonferroni correction showed that the FNB group had a significantly lower median pain score (3 [2 to 4]) compared with the ACB group (4 [3 to 5], Bonferroni-adjusted P =0.03). Regarding secondary end points, both the FNB and FTB groups had significantly lower NRS scores than the ACB group at various time points after surgery. Quadriceps strength and TUG completion were better in the FTB and ACB groups. There were no statistically significant differences among the groups for the other end points. DISCUSSION: Continuous FTB provides postoperative analgesia comparable to FNB but with the advantage of significantly less impact on quadriceps muscle strength, a benefit not seen with FNB. Both FTB and ACB are effective in preserving quadriceps strength postoperatively.

Effect of Perineural or Intravenous Betamethasone on Femoral Nerve Block Outcomes in Knee Arthroplasty: A Randomized, Controlled Study.

OBJECTIVES: Despite the use of multimodal analgesia, patients undergoing knee arthroplasty still encounter residual moderate pain. The addition of betamethasone to local anesthetic has been shown to improve postoperative pain. However, it remains uncertain whether the positive effects of perineural or intravenous administration of betamethasone on analgesia outcomes lead to better early mobility and postoperative recovery. METHODS: Between June 2022 and February 2023, a total of 159 patients who were undergoing knee arthroplasty were included in this study. These patients were allocated randomly into three groups: (i) the NS group, received ropivacaine 0.375% and intravenous 3mL 0.9% normal saline; (ii) the PNB group, received ropivacaine 0.375% plus perineural betamethasone (12mg) 3mL and intravenous 3mL 0.9% normal saline; and (iii) the IVB group, received ropivacaine 0.375% and intravenous betamethasone (12mg) 3mL. RESULTS: Both perineural and intravenous administration of betamethasone led to improved median (IQR) numeric rating scale (NRS) scores on the 6-meter walk test, with a score of 1.0 (1.0-2.0) for both groups, compared with 2.0 (1.0-2.0) for the NS group (p = 0.003). Compared to the NS group, both the PNB and IVB groups showed significant reductions in NRS scores at 24 and 36 h after surgery, along with a significant increase in ROM at 24, 36, and 48 h post-operation. Additionally, it exhibited lower levels of cytokine IL-1ß and TNF-α in fluid samples, as well as lower level of HS-CRP in blood samples in the PNB and IVB groups compared to the NS group. CONCLUSION: The administration of perineural and intravenous betamethasone demonstrated an enhanced analgesic effect following knee arthroplasty. Furthermore, it was associated with reduced levels of IL-1ß, TNF-α, and HS-CRP, as well as enhanced knee ROM, which is conducive to early ambulation and postoperative rehabilitation after knee arthroplasty.

Reduction of leakage from insertion site during continuous femoral nerve block with catheter-through-needle versus catheter-over-needle technique for postoperative analgesia after total knee arthroplasty: a randomized controlled trial.

BACKGROUND: Continuous femoral nerve block (CFNB) is a common procedure used for postoperative analgesia in total knee arthroplasty. Continuous nerve block using a conventional needle (catheter-through-needle/CTN) is complicated by leakage of the anesthetic from the catheter insertion site. A different type of needle (catheter-over-needle/ CON) is now available, which is believed to reduce leakage as the diameter of the catheter is larger than that of the needle. The purpose of this study was to compare the incidence of leakage from the catheter insertion site during CFNB while using CTN and CON for postoperative analgesia after total knee arthroplasty (TKA). METHODS: This prospective, randomized, single-blinded controlled study included 60 patients who were scheduled for TKA at our facility between May 2016 and November 2017. Patients were randomly allocated to the CTN or CON groups. All patients in both groups received CFNB and sciatic nerve block for postoperative analgesia. The administration of 0.16% levobupivacaine mixed with 6 mg of indigo carmine (a dye added to easily identify leakage) was started at 6 ml/h at the end of surgery. The primary outcome was the incidence of leakage from the catheter insertion site. We further investigated the degree of leakage, the incidence of catheter migration, pain scores using the numerical rating scale at 48 h postoperatively, and the number of days until the operated knee could be flexed 120 degrees postoperatively in both groups. RESULTS: The CON group had a significantly lower incidence and degree of leakage from the catheter insertion site. There were no significant differences in other measurement outcomes. CONCLUSIONS: Use of CON reduces the incidence of leakage from the catheter insertion site during CFNB in the use of postoperative analgesia for total knee arthroplasty. Future research is needed to determine additional benefits of using CON related to decreased leakage. TRIAL REGISTRATION: The study was registered in the University Hospital Medical Information Network (UMIN) Clinical Trials Registry ( UMIN000021537 ), prospectively registered on 18 March 2016.

Perineural Dexmedetomidine Reduces the Median Effective Concentration of Ropivacaine for Adductor Canal Block.

BACKGROUND Multimodal analgesic regimens are well known as the best option for total knee arthroplasty. They include the adductor canal block, combined with local infiltration analgesia and a block of the interspace between the popliteal artery and the capsule of the posterior knee. However, these analgesic techniques all require a large amount of local anesthetics. In this study, we explored whether the quantity of local anesthetics could be decreased by using dexmedetomidine for the adductor canal block. MATERIAL AND METHODS Fifty-four patients scheduled for unilateral, primary total knee arthroplasty were allocated into 2 groups: the ropivacaine group (group R) and the dexmedetomidine group (group RD). Ropivacaine 0.5% was chosen as the initial concentration, and the concentration was decreased or increased according to the response of the previous participant. Based on Dixon's up-and-down method, the median effective concentration was calculated. RESULTS The quadriceps strength was similar between the 2 groups, both at 30 min after adductor canal block and during recovery from general anesthesia in the Postanesthesia Care Unit. None of the patients in this study exhibited bradycardia or hypotension. The median effective concentration of ropivacaine for adductor canal block was 0.29% (95% confidence interval [CI], 0.28-0.31%) in group RD, which was lower than that in group R (0.38% [95% CI, 0.36-0.41%]). CONCLUSIONS This study found perineural dexmedetomidine 1 µg/kg could reduce the median effective concentration of ropivacaine for the adductor canal block.

Multimodal analgesia protocol for pain management after total knee arthroplasty: comparison of three different regional analgesic techniques.

OBJECTIVES: To evaluate three different analgesic techniques, continuous epidural analgesia (EA), continuous intra-articular (IA) infusion analgesia and continuous femoral nerve block (FNB) in postoperative pain management, length of hospital stay (LOS), and time of patient mobilization after total knee arthroplasty (TKA). METHODS: Seventy-two patients undergoing TKA were randomly allocated into three groups according to the analgesic technique used for postoperative pain management. Group EA patients received epidural analgesia (control group), group IA received intra-articular infusion and group FNB received femoral nerve block. RESULTS: Upon analyzing the Numerical Rating Scale (NRS) scores at rest, at passive and active movement, up to 3 days postoperatively, we observed no statistically significant differences at any time point among the three groups. Similarly, no association among these analgesic techniques (EA, IA, FNB) was revealed regarding LOS. However, significant differences emerged concerning the time of mobilization. Patients who received IA achieved earlier mobilization compared to FNB and EA. CONCLUSIONS: Both IA and FNB generate similar analgesic effect with EA for postoperative pain management after TKA. However, IA appears to be significantly more effective in early mobilization compared to EA and FNB. Finally, no clinically important differences could be detected regarding LOS among the techniques studied.

Was femoral nerve block effective for pain control of medial opening-wedge high tibial osteotomy?: A single blinded randomized controlled study.

BACKGROUND AND PURPOSE: Medial compartment femoro-tibial osteoarthritis (OA) is a common disease and opening-wedge high tibial osteotomy (OWHTO) is the common surgical procedure carried out for these patients. While most researchers are focusing on the surgical techniques during operation, the aim of this study is to evaluate the pain control effect of femoral nerve block (FNB) for OWHTO patients. METHODS: In this prospective, single-center, randomized controlled trial (RCT) study, 41 patients were operated on by OWHTO for OA during 2017 to 2018. Twenty of them (group A) accepted epidural anesthesia with FNB and 21 patients (group B) only had their single epidural anesthesia. All blocks were successful and all the 41 patients recruited were included in the analysis and there was no loss to follow-up or withdrawal. Systematic records of visual analog scores (VAS), quadriceps strength, mean number of times of patient-controlled intravenous analgesia (PCIA), using of additional opioids or nonsteroidal anti-inflammatory drugs (NSAIDs), and complications were done after hospitalization. The Student t test and Chi-Squared test was used and all P values ≤.05 were considered statistically significant. RESULTS: VAS scores at rest (3.48 ±â€Š1.0 vs 4.68 ±â€Š1.1) and on movemment (4.51 ±â€Š0.6 vs 4.97 ±â€Š0.8) decreased more in group A than group B with significance at follow-up of 12 hours. The quadriceps strength, consumption of additional opioids or NSAID injections and mean number of times that the patients pushed the PCIA button didnot differ significantly within each group. CONCLUSION: This RCT study shows that FNB in patients undergoing OWHTO for unicompartmental osteoarthritis of the knee could result in significant reduction in VAS scores at 12 hours postoperatively.Research registry, Researchregistry4792. Registered April 7, 2019 - Retrospectively registered, http://www.researchregistry.com.

A Low Dose of Naloxone Added to Ropivacaine Prolongs Femoral Nerve Blockade: A Randomized Clinical Trial.

Femoral nerve blocks (FNBs) are used as safe and useful procedures to control severe postoperative pain from total knee arthroplasty (TKA). Various adjuvants have been used to prolong the duration of the local anesthetic blockade. This study evaluated whether a low dose of naloxone administered with local anesthetics prolongs the duration of FNB. A prospective, randomized double-blind controlled study was conducted with 74 patients undergoing unilateral TKA. Through a single-bolus administration guided by ultrasound, the control group (group C) received 20 mL of 0.375% ropivacaine, while the naloxone group (group N) received 20 mL of 0.375% ropivacaine with 100 ng of naloxone. The time elapsed before the first analgesia request, the total amount of opioids consumed at 24 h postoperatively, the onset time of the sensory blockade, the visual analog pain scale (VAS) scores after arriving at the recovery room, after 6, 12, 18, and 24 h at rest and after 12, 18, and 24 h of activity, the quadricep strength before the FNB procedure and at 12 and 24 h postoperatively, the quality of sleep on the first night after surgery, the satisfaction score, and the incidence of postoperative complications were recorded. The time elapsed before the first analgesia request was significantly longer in group N (735.5 ± 187.2 min) than that in group C (602.6 ± 210.4 min) (P=0.003). The total dose of supplementary opioids consumed at 24 h postoperatively was significantly lower in group N (312.4 ± 141.7 µg) than that in group C (456.5 ± 279.5 µg) (P=0.007). Lower VAS scores were recorded in group N than that in group C at rest and during knee activity (rest, 12 h, P=0.001, 18 h, P=0.043; activity, 12 h, P=0.001). The addition of a low dose of naloxone to ropivacaine for FNB significantly delayed the first request for rescue analgesia and decreased the opioid consumption within 24 h, without significant complications.

Methylene blue induces an analgesic effect by significantly decreasing neural firing rates and improves pain behaviors in rats.

Methylene blue (MB) is a blue cationic thiazine dye and currently used in different medical settings. Notably, there have been several attempts to introduce MB for attenuating pain in the last decade. Some clinical studies reported remarkable results, which, however, have been much debated. In addition, accumulating evidence have revealed that MB diminishes voltage-gated sodium channel currents. Accordingly, in the present study, we conducted in vivo experiments, including in vivo single nerve recording and behavioral test, to investigate whether MB dampens neural firing rates and ultimately contributes to pain relief. As a result, neural firing rates significantly decreased and finally converged to zero after MB administration. This event lasted longer than that of lidocaine and was dose-dependently modulated. Furthermore, there was a marked improvement in pain behaviors. The withdrawal threshold and latency of hind paws significantly rose post-MB administration. Therefore, these results demonstrate that MB lessens pain by significantly weakening neural excitability, which implies a strong possibility that this dye may be developed as a pain-relieving medication in the future. This is the first in vivo study to elucidate the effect of MB on nerves and pain relief.

Effect of Vitamin B Complex Treatment on Macrophages to Schwann Cells Association during Neuroinflammation after Peripheral Nerve Injury.

Peripheral nerve injury (PNI) triggers a complex multi-cellular response involving the injured neurons, Schwann cells (SCs), and immune cells, often resulting in poor functional recovery. The aim of this study was to investigate the effects of the treatment with vitamin B (B1, B2, B3, B5, B6, and B12) complex on the interaction between macrophages and SCs during the recovery period after PNI. Transection of the motor branch of the femoral nerve followed by reconstruction by termino-terminal anastomosis was used as an experimental model. Isolated nerves from the sham (S), operated (O), and operated groups treated with the B vitamins (OT group) were used for immunofluorescence analysis. The obtained data indicated that PNI modulates interactions between macrophages and SCs in a time-dependent manner. The treatment with B vitamins complex promoted the M1-to M2-macrophage polarization and accelerated the transition from the non-myelin to myelin-forming SCs, an indicative of SCs maturation. The effect of B vitamins complex on both cell types was accompanied with an increase in macrophage/SC interactions, all of which correlated with the regeneration of the injured nerve. Clearly, the capacity of B vitamins to modulate macrophages-SCs interaction may be promising for the treatment of PNI.

The relative analgesic value of a femoral nerve block versus adductor canal block following total knee arthroplasty: a randomized, controlled, double-blinded study.

BACKGROUND: Multiple comparative studies report that adductor canal blocks provide similar pain relief to femoral nerve blocks following total knee arthroplasty. However, adductor canal blockade fails to anesthetize several important femoral nerve branches that contribute to knee innervation. We sought to clarify this anatomic discrepancy by performing both blocks in sequence, using patients as their own controls. We hypothesized that patients would experience additional pain relief following a superimposed femoral nerve block, demonstrating that these techniques are not equivalent. METHODS: Sixteen patients received continuous adductor canal block before undergoing knee arthroplasty under general anesthesia. In the recovery room, patients reported their pain score on a numeric scale of 0-10. Once a patient reached a score of five or greater, he/she was randomized to receive an additional femoral nerve block using 2% chloroprocaine or saline sham, and pain scores recorded every 5 min for 30 min. Patients received opioid rescue as needed. Anesthesiologists performing and assessing block efficacy were blinded to group allocation. RESULTS: Patients randomized to chloroprocaine versus saline reported significantly improved median pain scores 30 min after the femoral block (2.0 vs. 5.5, P = 0.0001). Patients receiving chloroprocaine also required significantly fewer morphine equivalents during the 30 min post-femoral block (1.0 vs. 4.5 mg, P = 0.03). CONCLUSIONS: Adductor canal block is a useful technique for postoperative pain following total knee arthroplasty, but it does not provide equivalent analgesic efficacy to femoral nerve block. Future studies comparing efficacy between various block sites along the thigh are warranted.

Similar early functional recovery after total knee replacement comparing single shot versus continuous saphenous nerve block: A randomised, double-blind trial.

PURPOSE: Total knee replacement (TKR) is associated with post-operative pain. Femoral nerve block can relieve the pain but also affects the post-operative mobility. Saphenous nerve block (SNB) can improve analgesia without interfering mobilisation. However, there is no consensus on the ideal mode of administration of SNB. We aim to compare the effects of single shot versus continuous SNB on patients undergoing TKR. METHODS: Patients were randomised into two groups: single shot and continuous SNB groups. Post-operative rehabilitation and mobilisation were assessed by blinded physiotherapists, and preoperative and post-operative American knee scores were recorded by blinded specialised nurse. Post-operative analgesics usage was recorded by blinded pain nurses and anaesthetists. RESULTS: Sixty-four patients were recruited; 6 patients withdrew with 29 patients in each group. There is no significant difference in early mobilisation and rehabilitation comparing both groups. The mean of the range gained on day 2 when compared to day 1 in single-shot SNB group was 17.41 ± 19.67° versus continuous SNB group was 23.45 ± 19.18° (p = 0.149). The mean of the range gained on day 3 when compared to day 1 in single-shot group was 27.24 ± 22.66° versus continuous SNB group was 29.31 ± 21.57° (p = 0.6). The mean of maximum flexion achieved by day 3 in single-shot SNB group was 92.41 ± 9.6° versus continuous SNB was 91.90 ± 7.95° (p = 0.84). The day of reaching maximum flexion and the goal of 40 m showed no significant difference. Length of stay (LOS), difference in post-operative American Knee Society knee score at 3 months and analgesics usage showed no significant difference. CONCLUSION: There is no significant difference in comparing the effect on mobilisation, LOS, early clinical outcome, analgesics usage in the single-shot group and the continuous SNB group.

Femoral nerve blocks for the treatment of acute pre-hospital pain: A systematic review with meta-analysis.

BACKGROUND: Pain management is one of the most important interventions in the emergency medical services. The femoral nerve block (FNB) is, among other things, indicated for pre- and post-operative pain management for patients with femoral fractures but its role in the pre-hospital setting has not been determined. The aim of this review was to assess the effect and safety of the FNB in comparison to other forms of analgesia (or no treatment) for managing acute lower extremity pain in adult patients in the pre-hospital setting. METHODS: A systematic review (PROSPERO registration (CRD42018114399)) was conducted. The Cochrane and GRADE methods were used to assess outcomes. Two authors independently reviewed each study for eligibility, extracted the data and performed risk of bias assessments. RESULTS: Four studies with a total of 252 patients were included. Two RCTs (114 patients) showed that FNB may reduce pain more effectively than metamizole (mean difference 32 mm on a 100 mm VAS (95% CI 24 to 40)). One RCT (48 patients) compared the FNB with lidocaine and magnesium sulphate to FNB with lidocaine alone and was only included here for information regarding adverse effects. One case series included 90 patients. Few adverse events were reported in the included studies. The certainty of evidence was very low. We found no studies comparing FNB to inhaled analgesics, opioids or ketamine. CONCLUSIONS: Evidence regarding the effectiveness and adverse effects of pre-hospital FNB is limited. Studies comparing pre-hospital FNB to inhaled analgesics, opioids or ketamine are lacking.

Meralgia paresthetica: Nerve stimulator-guided injection with methylprednisolone/lidocaine, a double-blind randomized placebo-controlled study.

BACKGROUND: Meralgia paresthetica is a mononeuropathy of the lateral femoral cutaneous nerve. A common therapy is injection with corticosteroids. The goal of this study was to analyze the effect of injection with methylprednisolone/lidocaine vs placebo. METHODS: After randomization, 10 patients received a nerve stimulator-guided injection with methylprednisolone/lidocaine, and 10 patients received saline. The primary outcome measure was pain (visual analogue scale, VAS). RESULTS: In the placebo group, there was a significant pain reduction (baseline VAS, 6.8; VAS week 12, 4.3; P = .014). The VAS score in the methylprednisolone group did not show a significant reduction (baseline VAS, 7.4; VAS week 12, 4.8; P = .053). There was no significant difference in pain reduction between the groups. CONCLUSIONS: We found no objective evidence for benefit from nerve stimulator-guided injection with corticosteroids in meralgia paresthetica, although this study is limited by a small sample size. Future placebo-controlled studies using ultrasound-guided injection are warranted.

Immunohistochemical Femoral Nerve Study Following Bisphosphonates Administration.

Background and objectives: Bisphosphonates represent selective inhibitors of excess osteoblastic bone resorption that characterizes all osteopathies, targeting osteoclasts and their precursors. Their long-term administration in postmenopausal women suffering from osteoporosis has resulted in neural adverse effects. The current study focuses on the research of possible alterations in the femoral nerve, caused by bisphosphonates. We hypothesized that bisphosphonates, taken orally (per os), may produce degenerative changes to the femoral nerve, affecting lower-limb posture and walking neuronal commands. Materials and Methods: In order to support our hypothesis, femoral nerve specimens were extracted from ten female 12-month-old Wistar rats given 0.05 milligrams (mg) per kilogram (kg) of body weight (b.w.) per week alendronate per os for 13 weeks and from ten female 12-month-old Wistar rats given normal saline that were used as a control group. Specimens were studied using immunohistochemistry for selected antibodies NeuN (Neuronal Nuclear Protein), a protein located within mature, postmitotic neural nucleus, and cytosol and Sox10 (Sex-determining Region Y (SRY) - High-Motility Group (HMG) - box 10). The latter marker is fundamental for myelination of peripheral nerves. Obtained slides were examined under a light microscope. Results: Samples extracted from rats given alendronate were more Sox10 positive compared to samples of the control group, where the marker's expression was not so intense. Both groups were equally NeuN positive. Our results are in agreement with previous studies conducted under a transmission electron microscope. Conclusions: The suggested pathophysiological mechanism linked to histological alterations described above is possibly related to toxic drug effects on Schwann and neuronal cells. Our hypothesis enhances the existing scientific evidence of degenerative changes present on femoral nerve following bisphosphonates administration, indicating a possible relationship between alendronate use and neuronal function.

The efficacy of continuous versus single-injection femoral nerve block in Total knee Arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Continuous femoral nerve block (cFNB) has been developed to extend the analgesic effect since the efficacy of single-injection femoral nerve block (sFNB) is often limited to approximately 16-24 h. The aim of this meta-analysis was to validate the add-on effect of cFNB in the setting of a multimodal analgesic protocol. METHODS: We performed a comprehensive literature review on Web of Science, Embase, the Cochrane Library and PubMed. Eight randomized controlled trials (N = 626) that compared the efficacy of cFNB with sFNB were included. The primary outcome domains consist of visual analog scale (VAS) score at postoperative 24 and 48 h. The secondary outcome domains include opioid consumption, length of hospital stay and incidence of nausea. RESULTS: Our analysis revealed that cFNB was associated with a lower VAS score at 24 h (SMD: -0.277;95% CI - 0.503 to - 0.05). However, the difference of VAS score did not meet the minimal clinically importance difference for total knee arthroplasty (TKA). VAS score at 48 h was similar between the cFNB and sFNB group. The cFNB group was associated with less amount of opioids consumed at both 24(SMD: -1.056;95% CI - 1.737 to - 0.375) and 48 h(SMD: -1.040;95% CI - 1.790 to - 0.289). Length of hospital stay and incidence of nausea were similar between the two groups. CONCLUSION: In the setting of a multimodal analgesic protocol, patients might benefit from cFNB with regards to a reduced need of opioids in the early postoperative period. However, we did not find a clinically significant difference in pain scores at different time points between the cFNB and sFNB group. LEVEL OF EVIDENCE: I; meta-analysis.

Comparison between local infiltration analgesia with combined femoral and sciatic nerve block for pain management after total knee arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is usually associated with moderate to severe postoperative pain. Peripheral nerve block (PNB) and local infiltration analgesia (LIA) are two major methods for postoperative analgesia. Femoral nerve block (FNB) leads to residual posterior knee pain; thus, currently sciatic nerve block (SNB) and LIA are two major options for supplementing FNB. However, the efficacy and safety of LIA compared with combined femoral and sciatic nerve block still remain controversial. Here, we conducted a study to analyze the postoperative analgesic efficacy of these two methods. METHOD: Two hundred six patients undergoing TKA were enrolled in a retrospective cohort study. The patients received either PNB or LIA. All patients in PNB group were conducted combined femoral and sciatic nerve block. All patients were encouraged to use patient-controlled analgesia (PCA) after surgery. The postoperative visual analog scale (VAS) at rest or with movement during the first 24 h and 48 h was recorded. We analyzed the VAS of 24 h, VAS of 48 h, opioid consumption, and adverse effects between PNB group and LIA group. Chi-square test and nonparametric test were used in this study. RESULTS: There were 82 patients in the PNB group and 124 patients in the LIA group. The patients' characteristics such as age, height, weight, and ASA showed no significant difference (P > 0.05). No significant differences were found (P > 0.05) between the two groups regarding VAS score at rest or with movement. The LIA group had less opioid consumption than the PNB group but without significant difference (P > 0.05). In both groups, the most common side effect was nausea, and the side effects showed no significant differences between groups (P > 0.05). CONCLUSION: Local infiltration analgesia provided a similar analgesic effect and complications compared with combined femoral and sciatic nerve block in the short term. Considering less opioid consumption with local infiltration analgesia though without significant difference and its convenience, local infiltration analgesia provided better postoperative analgesia.

Analgesic Impact of Single-Shot Versus Continuous Femoral Nerve Block After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis.

INTRODUCTION: Efficient pain management after total knee arthroplasty will accelerate functional recovery and reduce the length of hospital stay. The femoral nerve block is increasingly used in clinical practice owing to its favorable analgesic efficacy. However, the effect of continuous femoral nerve block compared to single-shot femoral nerve block remains controversial. METHODS: Three databases (Pubmed, Embase and Cochrane Library) were searched for randomized controlled trials up to April 2019. Seven studies with 525 patients were included in this analysis. RESULTS: The pooled estimates showed that the continuous femoral nerve block could relieve the pain at rest [standardized mean differences with 95% confidence intervals 1.12 (0.63-1.60), I2 = 57%, p < 0.00001] and physical therapy [standardized mean differences with 95% confidence intervals 1.05 (0.47-1.63), I2 = 71%, p = 0.0004] on postoperative day 1 and reduce total morphine consumption on postoperative day 1 [mean differences with 95% confidence intervals 16.15 (13.75-18.54), I2 = 46%, p < 0.00001] and 2 [mean differences with 95% confidence intervals 7.02 (4.82-9.22), I2 = 35%, p < 0.00001]. There is no significant difference in pain scores at rest and physical therapy on postoperative day 2 and 3, in Western Ontario and McMaster University Arthritis Index scores (p = 0.12), the length of hospital stay (p = 0.94) and the incidence of nausea and vomiting (p = 0.09). CONCLUSION: We conclude that the continuous femoral nerve block is more effective than single-shot femoral nerve block after total knee arthroplasty, which provides objective evidence of pain management for anesthetists.

Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis.

BACKGROUND: Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients. METHODS: Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence. RESULTS: We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty. CONCLUSIONS: The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.

Chemical Hip Denervation for Inoperable Hip Fracture.

BACKGROUND: Hip fracture is a challenging geriatric problem for the health care professionals, especially in patients with multiple comorbidities. In patients with inoperable hip fracture secondary to severe comorbid conditions, the pain can lead to significant challenges in nursing care. With the current understanding of the innervation of hip joint, we are now able to perform selective chemical denervation of the articular branches of femoral and obturator nerves to manage the pain associated with inoperable hip fracture. METHODS: In this retrospective case series, we analyzed 20 consecutive patients with inoperable hip fracture who received chemical denervation and examined the effect of the denervation on pain and functional outcomes, including the maximally tolerable hip flexion and the ability to sit during their hospital stay. We also assessed the likelihood of being ambulatory as a long-term outcome. RESULTS: The movement-related pain was significantly reduced at 10 minutes postprocedure, on postintervention days 1 and 5 (P values of <.001), and the degree of maximally tolerable hip flexion was doubled at the same time points (P values of <.001, .003, and .002, respectively). Fifty percent of the patients managed to sit within the first 5 days after procedure, and 3 of them managed to walk with aid 4 months after hip denervation. No procedural adverse event was noted. CONCLUSIONS: We concluded that this chemical hip denervation could be a safe and effective measure to handle the pain-related and rehabilitation-related challenges as a result of inoperable hip fracture.