Download Selecting the Right Regional Analgesic Technique for Knee Surgery

Selecting the Right Regional Analgesic Technique for Knee Surgery
Edward R. Mariano, MD, MAS
University of California, San Diego
A great deal of research is currently underway to determine the optimal analgesic
regimens for all types of surgery. Since the pain experience is specific to the individual, not all
patients will neatly fit into predefined postoperative pain categories. Beware the patient who
says, “I have a high pain threshold.” To further complicate the issue, not all surgeons or surgical
approaches are created equally. However, various knee surgeries can be expected to generate
differing levels of pain, and therefore, I base my recommendations on the best available evidence
presented below with the caveat that every analgesic regimen should be personalized to the
individual patient’s needs.
Total Knee Arthroplasty (TKA)
Very few knee surgeries will produce as much postoperative pain as tricompartment TKA. In
addition to the surgical insult and associated stress response, expectations of early and rapid
rehabilitation contribute significantly to the pain experience.
There is compelling evidence to support the use of continuous femoral nerve blocks (cFNB) for
postoperative analgesia following TKA.1-3 Compared to subjects who receive a one-day infusion
of ropivacaine (representing single-injection blocks) followed by systemic analgesia alone,
subjects receiving a 4-day cFNB achieve predetermined criteria for hospital discharge faster.3
How do cFNB compare to alternative regional anesthesia techniques for TKA?
Since the femoral nerve is a terminal branch of the lumbar plexus, a lumbar plexus catheter, or
psoas compartment catheter, may provide effective analgesia following TKA. A study
comparing these two continuous nerve block techniques for TKA did not demonstrate a
difference in analgesia although this was not the primary outcome.4 Potential complications
from lumbar plexus blocks include epidural spread, hypotension, intrathecal or intravascular
injection, and hematomas of the psoas compartment, retroperitoneum, and renal capsule.5
Arguably, continuous epidural analgesia can be considered the gold standard for pain
management following lower extremity joint replacement. However, recent studies have
demonstrated comparable analgesia produced by cFNB.6,7 More importantly, subjects who
received cFNB suffered fewer side effects such as nausea/vomiting, pruritus, and hypotension
compared to subjects who received epidurals.6,7 In addition, the selectivity of cFNB preserves
function in the non-operative limb, which may aid in early rehabilitation. In our experience,
patients also report satisfaction from early removal of urinary catheters when placed
intraoperatively since they are not indicated for cFNB. A major complication that can be
avoided when cFNB are used instead of epidural catheters for TKA is the dreaded epidural
hematoma. Due to the serious potential consequences, the American Society of Regional
Anesthesia recommends removal of epidural catheters prior to commencing twice-daily dosing
of low molecular weight heparin thromboprophylaxis.8 Given the effective analgesia provided
by cFNB and relative safety profile, cFNB are the ideal choice for TKA.
Are sciatic nerve blocks necessary for TKA in addition to cFNB?
I have heard many practitioners comment that the time required to place a sciatic nerve block in
addition to cFNB preoperatively may not be feasible in a busy surgery center. Patients who
receive cFNB alone will experience pain and require intravenous opioids, particularly on the day
of surgery through postoperative day 1.3,9-11 In contrast, sciatic nerve blocks added to cFNB
provide near-complete analgesia for tricompartment TKA.9,11 However, the decision to add
sciatic nerve blocks should be institution-specific and take into account the physical therapy
goals for the individual patient and surgical factors (tricompartment vs. unicompartment or
minimally-invasive TKA). For example, a patient on a minimally-invasive TKA clinical
pathway may be expected to ambulate on the day of surgery, and anesthesia in the sciatic nerve
distribution (foot and ankle) may actually be a hindrance. Multimodal analgesia with long-acting
opioids (sustained-release oxycodone, methadone, or sustained-release oral morphine), shortacting opioids (oxycodone or hydrocodone) and nonopioid analgesics (nonsteroidal antiinflammatory agents such as celecoxib, acetaminophen, and/or gabapentin) in addition to cFNB
may decrease the need for sciatic nerve blocks following less-invasive TKA. Depending on the
clinical pathway and regional anesthesia practice model, it may be prudent to place cFNB
preoperatively and assess the need for a “rescue” sciatic nerve block postoperatively in the case
of significant breakthrough pain in postanesthesia recovery.
Anterior Cruciate Ligament Reconstruction (ACLR)
For complex outpatient knee surgeries such as ACLR, peripheral nerve blocks (femoral nerve
blocks with or without sciatic nerve blocks) are associated with less pain and lower odds of
unplanned hospital admission compared to systemic analgesia.12 The decision regarding
continuous vs. single-injection and whether or not to add a sciatic nerve block depends on the
expected surgical trauma and patient factors. When a cadaveric allograft is used for ACLR, a
single-injection femoral nerve block provides superior pain control compared to placebo, and
cFNB may not offer significant advantages.13 However, patients who undergo autograft ACLR
with cFNB report lower pain scores for the first 4 days after surgery compared to single-injection
femoral nerve block and placebo groups.13 Patients with opioid intolerance and/or increased pain
sensitivity may benefit from cFNB for ACLR regardless of graft type. In order to ensure patient
safety at home, patients with continuous lower extremity blocks should be non-weightbearing,
and outpatients with cFNB should be discharged home with a knee immobilizer. A singleinjection sciatic nerve block added to femoral blockade provides complete analgesia following
ACLR14 and should be considered, especially when an autograft harvest of hamstring or Achilles
tendon is planned. Intraarticular local anesthetics do not offer advantages over peripheral nerve
blockade for ACLR.14,15
Knee Arthroscopy
For knee arthroscopy not involving ligamentous reconstruction, patient disposition and
weightbearing status are important considerations. Despite the seemingly complex list of
procedures associated with knee arthroscopy (e.g. chondroplasty, meniscectomy, loose body
removal), patients are routinely discharged home with no weightbearing restriction. In these
situations, peripheral nerve blocks for analgesia may not be indicated, and intraarticular
injections offer an alternative for minimally-invasive surgeries expected to generate only mild
pain. The mixture of 0.25% bupivacaine 30 ml with morphine 3 mg and clonidine 1 mcg/kg
injected into the knee joint provides better pain relief than local anesthetic alone.16 Other
adjuvant medications that may be added to local anesthetics for intraarticular injection include
neostigmine,17 ketorolac,18 steroids,19,20 and tramadol.21
In summary, optimal regional analgesia for knee surgery depends on many factors including type
of surgery, postoperative management goals, and patient preferences. Peripheral nerve blockade
should not be the only analgesic, and multi-modal pain control has proven advantages. Although
there are many recommended strategies (Table 1), the ideal plan will always be tailored to the
individual patient.
Table 1: Recommended
regional analgesic
techniques for knee
surgery
Surgical Procedure
Femoral Nerve Block
Sciatic Nerve Block
TKA (tricompartment)
TKA (unicompartment)
ACLR with autograft
ACLR with allograft
Knee arthroscopy
Continuous
Continuous
Continuous
Single or Continuous
No
Single or Continuous
+/- Single
Single
+/- Single
No
TKA – total knee arthroplasty; ACLR – anterior cruciate ligament reconstruction
References:
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