Ropivacaine versus bupivacaine for 3-in-1 block during total knee arthroplasty

Management of Postoperative Pain Following Primary Total Knee Arthroplasty: A Level I Evidence-Based Bayesian Network Meta-Analysis

Background: Postoperative pain management after total knee arthroplasty (TKA) is crucial for promoting early recovery. Advances in pain management techniques have significantly improved outcomes after TKA. Recently, multimodal analgesia has emerged as a key concept in pain management following TKA, using regional anaesthesia to reduce narcotic use and minimise narcotic-related side effects. This Bayesian network meta-analysis compared different treatment options for the management of postoperative pain following primary TKA. Methods: This study was conducted following the 2020 PRISMA statement. In January 2025, all randomised controlled trials (RCTs) related to postoperative pain management following TKA were accessed. Pain reported on postoperative days (PODs) 1-3 was evaluated. Results: Data from 7199 patients were retrieved. Of these, 63.2% (4232 of 6691) were women, and the mean age was 66.7 ± 3.1 years. The mean length of follow-up was 10.2 ± 18.3 weeks. At baseline, comparability was confirmed for age (p = 0.1), BMI (p = 0.8), and visual analogue scale (VAS, p = 0.1). On POD 1, single-shot SNB/three-in-one block was associated with a lower VAS, followed by continuous intra-articular analgesia/local infiltration analgesia (LIA)/posterior capsule infiltration (PCI) and continuous femoral nerve block (FNB)/intermittent SNB. On POD 2, continuous intra-articular analgesia/LIA/PCI was associated with a lower VAS, followed by continuous FNB/PCI and single-shot femoral triangle block (FTB)/single-shot infiltration between the popliteal artery and capsule of the knee (IPACK). On POD 3, continuous ACB was associated with a lower VAS, followed by continuous intra-articular analgesia/LIA/PCI and continuous FNB/PCI. Conclusions: Continuous intra-articular analgesia/LIA/PCI was associated with the best pain control following primary TKA. Multimodal analgesia, which incorporates peripheral nerve blockade and periarticular injections, has become a key concept in contemporary pain management following TKA.

Peripheral Nerve Blocks Outperform General Anesthesia for Pain Control in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

PURPOSE

The purpose of this review is to compare the effectiveness of different peripheral nerve blocks and general anesthesia (GA) in controlling postoperative pain after arthroscopic rotator cuff repair (ARCR).

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review was conducted for the period of January 1, 2005, to February 16, 2021, by searching the following databases: PubMed, Cochrane, Embase, and Arthroscopyjournal.org. The primary outcomes of interest included 1-hour, 24-hour, and 48-hour pain scores on a numeric rating scale or visual analog scale (VAS). Inclusion criteria were English language studies reporting on adults (≥18 years) undergoing ARCR with peripheral nerve blockade. To synthesize subjective pain score data at each evaluation time point across studies, we performed random-effects network meta-regression analyses accounting for baseline pain score as a covariate.

RESULTS

A total of 14 randomized controlled trials with 851 patients were included in the meta-analysis. Data from six different nerve block interventions, single-shot interscalene brachial plexus nerve block (s-ISB; 37.8% [322/851]), single-shot suprascapular nerve block (s-SSNB; 9.9% [84/851]), continuous ISB (c-ISB; 17.5% [149/851]), continuous SSNB (c-SSNB; 6.9% [59/851]), s-ISB combined with SSNB (s-ISB+SSNB; 5.8% [49/851]), s-SSNB combined with axillary nerve block (s-SSNB+ANB; 4.8% [41/851]), as well as GA (17.3% [147/851]) were included. Our meta-analysis demonstrated that c-ISB block had a significant reduction in pain score relative to GA at 1-hour postoperation (mean difference [MD]: -1.8; 95% credible interval [CrI] = -3.4, -.08). There were no significant differences in VAS pain scores relative to GA at 24 and 48 hours postoperatively. However, s-ISB+SSNB had a significant reduction in 48-hour pain score compared to s-ISB (MD = -1.07; 95% CrI = -1.92, -.22).

CONCLUSIONS

It remains unclear which peripheral nerve block strategy is optimal for ARCR. However, peripheral nerve blocks are highly effective at attenuating postoperative ARCR pain and should be more widely considered as an alternative over general anesthesia alone.

LEVEL OF EVIDENCE

Level II Systematic review and meta-analysis of Level I and II studies.

Liposomal Bupivacaine vs Ropivacaine for Adductor Canal Blocks in Total Knee Arthroplasty: A Prospective Randomized Trial

BACKGROUND

The purpose of this study is to determine the benefit of the analgesic liposomal bupivacaine compared to ropivacaine, by assessing pain and joint stiffness, and total oral opioid consumption by milligram morphine equivalent (MME) after total knee arthroplasty.

METHODS

Patients were randomized to receive either the study drug (liposomal bupivacaine admixed with bupivacaine) or the control drug (ropivacaine) in an adductor canal block. Only the anesthesiologist performing the block was aware of which arm of the study the patient was randomized to. MME, pain, Knee injury and Osteoarthritis Outcome Score Joint Replacement, and overall benefit of analgesia scores were recorded 24, 48, and 72 hours post-surgery either face-to-face or via telephone depending on patient discharge status.

RESULTS

One hundred patients were enrolled into the study and analyzed: 54 in the control group and 46 in the experimental group. Primary outcomes measured were pain as a numerical rating scale, MME, and length of stay in hours. Secondary outcomes were joint pain and stiffness recorded as Knee injury and Osteoarthritis Outcome Score Joint Replacement outcome and overall benefit of analgesia score. No statistically significant between-group differences were observed for any measured outcome.

CONCLUSION

We did not find any supporting evidence that liposomal bupivacaine yields increased pain relief following total knee arthroplasty compared to the control drug, ropivacaine.

Multimodal nerve injection provides noninferior analgesic efficacy compared with interscalene nerve block after arthroscopic rotator cuff repair

PURPOSE

This randomized noninferiority trial aimed to evaluate whether combined suprascapular, axillary nerve, and the articular branch of lateral pectoral nerve block (3NB) is noninferior to interscalene nerve block (ISB) for pain control after arthroscopic rotator cuff repair (ASRCR).

MATERIALS AND METHODS

Eighty-five patients undergoing ASRCR were randomized to either 3NB (n = 43) or ISB (n = 42) group. We used 5 and 15 ml of 0.2% ropivacaine for each nerve in the 3NB and ISB groups, respectively. The primary outcome was the visual analog scale (VAS) pain score at 4 h postoperatively measured assessed on an 11-point scale (ranging from 0 = no pain to 10 = worst pain) that was analyzed using noninferiority testing. The secondary outcome was VAS pain scores in the recovery room and at 8, 12, 24, 36, 48, and 72 h postoperatively. Rebound pain, IV-PCA usage during 48 h, dyspnea, muscle weakness, and satisfaction were evaluated.

RESULTS

Regarding the primary outcome, the mean difference in VAS pain scores between the 3NB (2.5 ± 1.6) and ISB (2.2 ± 2.3) groups at 4 h postoperatively was 0.3, with a 95% confidence interval (CI) of -0.56 to 1.11. The upper limit of 95% CI is lower than the noninferiority margin of 1.3 (p < 0.001). At all other time points, except in the recovery room, 3NB showed noninferior to ISB. Rebound pain, IV-PCA usage during the second 24 h, and muscle weakness were lower in the 3NB group (all p < 0.005). The satisfaction was similar in both groups (p = 0.815).

CONCLUSION

Combined 3NB is noninferior to ISB in terms of pain control after ASRCR; and is associated with low levels of rebound pain, IV-PCA usage, and muscle weakness.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Evaluating Analgesic Efficacy of Single Femoral Nerve Block versus Combined Femoral-Sciatic Nerve Block Post Total Knee Arthroplasty

Background

With increasing knee replacement surgeries, there has been a constant search for effective pain control modality.

Aims

We compared the analgesic effect of femoral nerve block (FNB) alone with combined femoral and sciatic nerve block (SNB) for postoperative pain management after total knee arthroplasty (TKA).

Setting and Design

This was a prospective observational study.

Methods

A total of 150 adult patients of American Society of Anesthesiologists physical status class I and II scheduled for elective TKA under spinal anesthesia with 3.4-mL bupivacaine 0.5% and 20-μg fentanyl were randomly allocated to two groups. Group F patients received a single shot FNB with 20 ml 0.375% ropivacaine and Group FS patients received combined FNB with 20 mL of 0.375% ropivacaine and SNB with 40 ml of 0.375% ropivacaine at the end of surgery. The primary outcome was the change in Numeric Rating Scale (NRS) scores between Groups F and FS at 6, 12, 18, 24, and 48 h later. The secondary outcome was total doses of opioid required in both groups.

Results

The demographic data were comparable in both groups. The NRS scores were higher and statistically significant in Group F than that in Group FS at all five measured time points (P < 0.00001), and the total pain score with a mean of 15.43 in Group F and a mean of 9.61 in Group FS was statistically significant. Significantly more opioid consumption was seen postoperatively in Group F as compared to Group FS at 12, 18, 24, and 48 h as depicted by P < 0.00001.

Conclusions

We conclude that the FNB, when combined with SNB, shows superior results than femoral block alone. SNB reduced pain scores and opiate consumption postoperatively up to 48 h.

Suprascapular Nerve Block Versus Interscalene Block as Analgesia After Arthroscopic Rotator Cuff Repair: A Randomized Controlled Noninferiority Trial

PURPOSE

To compare the efficacy of suprascapular nerve block (SSB) and interscalene block (ISB) as postoperative analgesia within the first 24 hours after arthroscopic supraspinatus and/or infraspinatus tendon repair.

METHODS

A single-blind, randomized controlled study was performed between 2013 and 2014. The inclusion criteria were arthroscopic supraspinatus and/or infraspinatus tendon repair confirmed intraoperatively, with or without associated procedures, and informed consent. The exclusion criteria were a previously operated shoulder, repair of the subscapularis tendon, and an allergy to local anesthetics. ISB was performed under ultrasound guidance by an anesthesiologist, whereas SSB was performed based on specific anatomic landmarks by a surgeon. The primary evaluation criterion was mean shoulder pain score during the first postoperative 24 hours assessed on a visual analog scale by the patient. The secondary criteria were complications of locoregional anesthesia, the use of analgesics in the recovery room (the first 2 hours) until postoperative day 7, and pain (visual analog scale) during the first week. Forty-four patients were needed for this noninferiority study. An institutional review board approved the study.

RESULTS

Seventy-four patients were randomized, and 59 met the intraoperative inclusion criteria. Six patients were excluded (1 for pneumothorax after ISB, 1 for unsuccessful SSB, and 4 for incomplete questionnaires). None of the patients were lost to follow-up. There was no significant difference between the SSB and ISB groups in mean pain score for the first 24 hours (P = .92) or the first 7 days (P = .05). However, there was significantly less pain in the ISB group in the recovery room (P = .01). Consumption of analgesics was comparable between the groups, but the SSB group took significantly more morphine in the recovery room.

CONCLUSIONS

In this prospective, randomized controlled study, SSB was as effective as ISB for mean pain control within the first 24 hours but ISB was more effective in relieving pain in the recovery room after arthroscopic supraspinatus and/or infraspinatus tendon repair.

LEVEL OF EVIDENCE

Level I, therapeutic, randomized controlled study.

Lower limb surgeries under combined femoral and sciatic nerve block

Introduction:

Peripheral nerve blocks are gaining popularity for many infraumblical surgeries with the development of new techniques such as ultrasound and peripheral nerve stimulator. It provides stable hemodynamic, better, and prolonged postoperative analgesia. This study was carried out to see the effectiveness of combined femoral and sciatic nerve block with ropivacaine alone and by adding fentanyl.

Materials and Methods:

The study was carried out on 100 patients scheduled for lower limb surgeries and were randomly divided into two groups of 50 each. In Group A, patients received 20 ml of 0.5% ropivacaine for femoral nerve block and same dose for sciatic nerve block and in Group B, 25 μg fentanyl was added each for femoral nerve and sciatic nerve block along with ropivacaine. All hemodynamic parameters, onset and duration of sensory and motor blocks were noted. The patient characteristics were analyzed using the “Chi-square tests” and the intergroup comparison of the parametric data was carried out using the unpaired t-test using software IBM SPSS 17.0.

Results:

Combined femoral and sciatic nerve block provide longer duration of postoperative analgesia of about 12–13 h. All the above-mentioned parameters were statistically non-significant.

Conclusion:

Hence in this study, onset and duration of sensory and motor block was comparable in both groups. However postoperative analgesia was prolonged as compared to neuraxial blockade without any hemodynamic instability.

Endogenous opiates and behavior: 2014

This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants). This paper is the thirty-seventh consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2014 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (endogenous opioids and receptors), and the roles of these opioid peptides and receptors in pain and analgesia (pain and analgesia); stress and social status (human studies); tolerance and dependence (opioid mediation of other analgesic responses); learning and memory (stress and social status); eating and drinking (stress-induced analgesia); alcohol and drugs of abuse (emotional responses in opioid-mediated behaviors); sexual activity and hormones, pregnancy, development and endocrinology (opioid involvement in stress response regulation); mental illness and mood (tolerance and dependence); seizures and neurologic disorders (learning and memory); electrical-related activity and neurophysiology (opiates and conditioned place preferences (CPP)); general activity and locomotion (eating and drinking); gastrointestinal, renal and hepatic functions (alcohol and drugs of abuse); cardiovascular responses (opiates and ethanol); respiration and thermoregulation (opiates and THC); and immunological responses (opiates and stimulants).

Continuous postoperative pain control using a multiple-hole catheter after iliac bone grafting: comparison between ropivacaine and levobupivacaine

The aim of this study was to compare the analgesic effects of ropivacaine and levobupivacaine in continuous infiltration anaesthesia delivered via a multiple-hole catheter for the purpose of postoperative analgesia after iliac bone grafting. Thirty-four patients scheduled for iliac bone grafting in the maxillofacial region participated in this study. The patients were randomized to a ropivacaine group (Ropi group) and a levobupivacaine group (Levo group). After harvesting the iliac bone for grafting, a multiple-hole catheter was placed on the periosteum of the iliac bone. When surgery was completed, continuous administration was started at 4 ml/h of 0.2% ropivacaine (Ropi group) or 0.25% levobupivacaine (Levo group). Pain was evaluated in the recovery room and at 4h after surgery, as well as at 9:00 and 18:00 on postoperative days 1, 2, and 3, using a visual analogue scale. Side effects were also recorded. No significant difference in the visual analogue scale scores at rest or in motion was observed between the two groups. In addition, there were no side effects in the two groups. Both 0.2% ropivacaine and 0.25% levobupivacaine provided comparable analgesic effects in continuous infiltration anaesthesia delivered via a multiple-hole catheter after iliac bone grafting.

Analgesia for total knee arthroplasty: a meta-analysis comparing local infiltration and femoral nerve block

Patients frequently experience postoperative pain after a total knee arthroplasty; such pain is always challenging to treat and may delay the patient's recovery. It is unclear whether local infiltration or a femoral nerve block offers a better analgesic effect after total knee arthroplasty.We performed a systematic review and meta-analysis of randomized controlled trials to compare local infiltration with a femoral nerve block in patients who underwent a primary unilateral total knee arthroplasty. We searched Pubmed, EMBASE, and the Cochrane Library through December 2014. Two reviewers scanned abstracts and extracted data. The data collected included numeric rating scale values for pain at rest and pain upon movement and opioid consumption in the first 24 hours. Mean differences with 95% confidence intervals were calculated for each end point. A sensitivity analysis was conducted to evaluate potential sources of heterogeneity.While the numeric rating scale values for pain upon movement (MD-0.62; 95%CI: -1.13 to -0.12; p=0.02) in the first 24 hours differed significantly between the patients who received local infiltration and those who received a femoral nerve block, there were no differences in the numeric rating scale results for pain at rest (MD-0.42; 95%CI:-1.32 to 0.47; p=0.35) or opioid consumption (MD 2.92; 95%CI:-1.32 to 7.16; p=0.18) in the first 24 hours.Local infiltration and femoral nerve block showed no significant differences in pain intensity at rest or opioid consumption after total knee arthroplasty, but the femoral nerve block was associated with reduced pain upon movement.