Abstract
Background:
Pain after total knee arthroplasty is severe and impacts functional recovery.Objectives:
We performed a retrospective study, comparing conventional patient control analgesia (PCA) modalities versus continuous femoral nerve blockade (CFNB) for 1582 post-TKA (total knee arthroplasty) patients.Patients and Methods:
Using our electronic acute pain service (APS) database, we reviewed the data of 579 patients who had received CFNBs compared with 1003 patients with intravenous PCA over 4 years.Results:
Our results show that the incidence of a severe pain episode was higher in the PCA compared with the CFNB group. Lower pain scores were observed in the CFNB group compared with the PCA group from postoperative day (POD) 1 to 3, primarily due to lower rest pain scores in the CFNB group.Conclusions:
Our study shows that there is improvement in pain scores, at rest and on movement, as well as a reduction in incidence of severe pain, in patients who receive CFNB versus those who receive intravenous PCA.1. Background
Severe postoperative pain is a major complaint in patients who have undergone total knee arthroplasty (TKA). In addition, post-TKA pain directly impacts postoperative physiotherapy and mobilization, which can result in stiffness and poor joint function (1–3). Post-TKA pain peaks up to 48 hours after surgery (4).
Effective postoperative pain control is important, especially with the initiation of physiotherapy and early ambulation, which hastens recovery and reduces hospital length of stay (5). The risk of postoperative complications, such as venous thromboembolism and nosocomial infections (6), has also been shown to decrease with early mobilization.
Pain control modalities for post-TKA include intravenous patient-controlled analgesia (PCA), peripheral nerve blockade, and continuous epidural analgesic techniques. All methods have been shown to be efficacious in relieving postoperative pain. However, conventional techniques that use intravenous PCA with morphine and fentanyl are associated with side effects, such as respiratory depression, sedation, pruritus, nausea and vomiting, hypotension, constipation, and urinary retention (7); epidural analgesia is associated with hypotension and bilateral motor blockade if local anesthetics are used (8, 9).
2. Objectives
We performed a retrospective study, comparing conventional PCA modalities versus continuous femoral nerve blockade (CFNB) for 1582 post-TKA patients.
5. Discussion
Our study shows that there is improvement in pain scores, at rest and on movement, as well as a reduction in the incidence of severe pain in patients who receive CFNB versus those who receive intravenous PCA. There were no documented adverse events in the CFNB group, whereas an incident of hypotension and respiratory depression was noted in the PCA group. We did not record common side effects, such as pruritus, nausea, and vomiting. To our knowledge, this is the largest single-center retrospective study of CFNB alone versus PCA.
Severe pain after total knee arthroplasty has been shown to impact functional recovery (10). Various studies have demonstrated the effectiveness of femoral nerve blocks in reducing pain post-total knee arthroplasty compared with intravenous PCA (3, 7, 8, 11–17). A systematic review of 112 studies between 1996 and 2005 by the PROSPECT working group supports the use of femoral nerve blocks for postoperative analgesia for primary TKA, based on the reduction in pain scores and supplemental analgesia (10). Of the 112 studies, 5 investigated the use of continuous infusion femoral nerve block versus placebo (8, 18–21), all of which noted reduced pain scores at rest and with motion at 24 and 48 hours with CFNB.
Similarly, a recent meta-analysis by Paul et al. (6) found that single-shot and continuous FNB was superior (lower opioid consumption) to PCA alone. In particular, continuous FNB with intravenous PCA was clearly superior to PCA alone with regard to reduced morphine consumption at 24 and 48 hours, pain scores, and nausea. Currently, there is a paucity of evidence to support the use of single-shot femoral nerve block as opposed to continuous nerve block technique. In 2 studies (20, 22), however, the authors showed significant improvements in analgesic use at rest and on movement, as well as opioid-sparing benefits, with single shot nerve blocks.
Because our report was a retrospective case review, there are inherent limitations. The data were obtained from an electronic database; thus, details, such as the method of insertion of the femoral nerve catheter, mode of anesthesia, and surgical technique, were unavailable. For future studies, it might be useful to perform continuous FNB, which allows one to control the concentration of the local anesthetic dose, type of local anesthetic, and infusion regimen, which preserves the quadriceps function better, resulting in earlier mobilization (23).
In total knee arthroplasty, postoperative pain control is imperative in facilitating physical therapy and rehabilitation. Our study demonstrated a significant reduction in the incidence of severe pain with CFNB versus PCA, with lower pain scores to Day 3 post-TKA. In addition, we did not observe any adverse effects from CFNB, such as hypotension and respiratory depression. Thus, CFNB is a safe alternative for post-TKA pain control.
Acknowledgements
References
-
1.
Kehlet H. The stress response to surgery: release mechanisms and the modifying effect of pain relief. Acta Chir Scand Suppl. 1989;550:22-8.
-
2.
Kehlet H. Surgical stress: the role of pain and analgesia. Br J Anaesth. 1989;63(2):189-95.
-
3.
Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d’Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91(1):8-15.
-
4.
Frassanito L, Vergari A, Zanghi F, Messina A, Bitondo M, Antonelli M. Post-operative 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. Eur Rev Med Pharmacol Sci. 2010;14(7):589-96.
-
5.
Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2008;108(4):703-13.
-
6.
Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A. Femoral Nerve Block Improves Analgesia Outcomes after Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials. Anesthesiology. 2010.
-
7.
Chelly JE, Greger J, Gebhard R, Coupe K, Clyburn TA, Buckle R. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty. 2001;16(4):436-45.
-
8.
Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. 1998;87(1):88-92.
-
9.
Fowler S.J, JS, Sabato S, Myles PS. Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. British Journal of Anaesthesia. [Meta analysis]. 2008;100(2):154-64.
-
10.
Fischer HB, Simanski CJ, Sharp C, Bonnet F, Camu F, Neugebauer EA. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia. 2008;63(10):1105-23.
-
11.
Shum CF, Lo NN, Yeo SJ, Yang KY, Chong HC, Yeo SN. Continuous femoral nerve block in total knee arthroplasty: immediate and two-year outcomes. J Arthroplasty. 2009;24(2):204-9.
-
12.
Kadic L, Boonstra MC, D. E. Waal Malefijt MC, Lako SJ, VAN Egmond J, Driessen JJ. Continuous femoral nerve block after total knee arthroplasty? Acta Anaesthesiol Scand. 2009;53(7):914-20.
-
13.
Ilfeld BM, Meyer RS, Le LT, Mariano ER, Williams BA, Vandenborne K. Health-related quality of life after tricompartment knee arthroplasty with and without an extended-duration continuous femoral nerve block: a prospective, 1-year follow-up of a randomized, triple-masked, placebo-controlled study. Anesth Analg. 2009;108(4):1320-5.
-
14.
Seet E, Leong WL, Yeo AS, Fook-Chong S. Effectiveness of 3-in-1 continuous femoral block of differing concentrations compared to patient controlled intravenous morphine for post total knee arthroplasty analgesia and knee rehabilitation. Anaesth Intensive Care. 2006;34(1):25-30.
-
15.
Ozen M, Inan N, Tumer F, Uyar A, Baltaci B. The effect of 3-in-1 femoral nerve block with ropivacaine 0.375% on postoperative morphine consumption in elderly patients after total knee replacement surgery. Agri. 2006;18(4):44-50.
-
16.
De Ruyter ML, Brueilly KE, Harrison BA, Greengrass RA, Putzke JD, Brodersen MP. A pilot study on continuous femoral perineural catheter for analgesia after total knee arthroplasty: the effect on physical rehabilitation and outcomes. J Arthroplasty. 2006;21(8):1111-7.
-
17.
Singelyn FJ, Gouverneur JM. Extended “three-in-one” block after total knee arthroplasty: continuous versus patient-controlled techniques. Anesth Analg. 2000;91(1):176-80.
-
18.
Kaloul I, Guay J, Cote C, Fallaha M. The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement. Can J Anaesth. 2004;51(1):45-51.
-
19.
Ganapathy S, Wasserman RA, Watson JT, Bennett J, Armstrong KP, Stockall CA. Modified continuous femoral three-in-one block for postoperative pain after total knee arthroplasty. Anesth Analg. 1999;89(5):1197-202.
-
20.
Hirst GC, Lang SA, Dust WN, Cassidy JD, Yip RW. Femoral nerve block. Single injection versus continuous infusion for total knee arthroplasty. Reg Anesth. 1996;21(4):292-7.
-
21.
Edwards ND, Wright EM. Continuous low-dose 3-in-1 nerve blockade for postoperative pain relief after total knee replacement. Anesth Analg. 1992;75(2):265-7.
-
22.
Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway. Anesth Analg. 2006;102(4):1234-9.
-
23.
Hadzic A, Houle TT, Capdevila X, Ilfeld BM. Femoral Nerve Block for Analgesia in Patients Having Knee Arthroplasty. Anaesthesiology. 2010;113(5):1014-5.
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