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Govender-Davies S, Davies L, Pillay-Addinall S. A cadaveric study investigating the spread of injectate following an interspace between the popliteal artery and the capsule of the posterior knee block in a neonatal sample: a pilot study. Anat Cell Biol 2024; 57:229-237. [PMID: 38551026 DOI: 10.5115/acb.23.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/22/2024] [Accepted: 02/21/2024] [Indexed: 06/14/2024] Open
Abstract
The infiltration of the interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block, is a novel ultrasound-guided technique used for postoperative pain management of the knee. The success of the block is attributed to the spread of injectate between the capsule of the knee and the popliteal artery. This novel technique is believed to target the articular branches of the tibial, common fibular (peroneal) and obturator nerves. However, the extent of the spread in a paediatric population is unknown. Therefore, this study aims to evaluate the spread of the IPACK block. Using ultrasound guidance, the IPACK block was replicated bilaterally in neonatal cadavers. Methylene blue dye (0.3 ml/kg) was injected proximally and distally. Subsequently, cadavers were dissected to determine the injectate spread. Proximal injections resulted in staining of some of the articular branches, while the distal injections resulted in staining of all four articular branches. Additional staining of the superior lateral and medial genicular nerves was noted irrespective of the technique. Overall, both injections resulted in posterior, anterolateral spread with limited medial spread. Results from this study reveal preservation of the main nerve trunks following the proximal technique, while the distal technique displayed greater staining of the articular branches. We believe that the block can be seen as a more holistic and viable alternative to lower limb blocks for the paediatric population, as it allows for a wider spread in the posterior and medial-lateral compartments of the knee.
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Affiliation(s)
- Sabashnee Govender-Davies
- Department of Anatomy and Histology, School of Medicine, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
| | - Llewellyn Davies
- Department of Anaesthesia, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Sashrika Pillay-Addinall
- Department of Anatomy and Histology, School of Medicine, Sefako Makgatho Health Sciences University, Ga-Rankuwa, South Africa
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2
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Kim J, Kim SH, Shin HY, Kim IB, Kim BW, Lee UY, Park HJ. Investigation of Optimal Needle Position for Radiofrequency Ablation-Based Blockade of Interspace between the Popliteal Artery and the Posterior Capsule of the Knee: A Cadaveric Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:689. [PMID: 38792872 PMCID: PMC11122841 DOI: 10.3390/medicina60050689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/20/2024] [Accepted: 04/21/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: The interspace between the popliteal artery and the posterior capsule of the knee (iPACK) block has been widely used in perioperative settings to control posterior knee pain and can additionally be used for chronic knee pain. In this cadaveric study, we aimed to investigate the needle tip position and its proximity to the articular branch of the tibial nerve (ABTN) during an iPACK-targeted radiofrequency procedure. Materials and Methods: An ultrasound-guided iPACK block was performed on 20 knees of 10 cadavers. We injected 0.1 mL each of blue and green gelatinous dye near the tibial artery (point A) and posterior knee capsule (point B), respectively, and evaluated the spread of both around the ABTN. For a hypothetical conventional radiofrequency ablation (RFA) lesion (diameter, 2.95 mm) and cooled RFA lesion (diameter, 4.9 mm), we counted the number of specimens in which the ABTNs would be captured. Results: The percentage of specimens in which the ABTN would be captured by a cooled RFA lesion was 64.71% at point A and 43.75% at point B (p = 0.334). Meanwhile, the percentage of specimens in which the ABTN would be captured by a conventional RFA lesion was 58.82% from point A and 25% from point B (p = 0.065). Conclusions: When performing an RFA-based iPACK block, the needle tip may be positioned either lateral to the tibial artery or in the space between the posterior knee capsule and the tibial artery. However, more studies with larger samples are needed to verify these results before the clinical use of this procedure can be recommended.
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Affiliation(s)
- Jiyoung Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Republic of Korea; (J.K.); (H.Y.S.)
| | - Sang Hyun Kim
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.H.K.); (I.-B.K.)
| | - Hwa Yong Shin
- Department of Anesthesiology and Pain Medicine, College of Medicine, Chung-Ang University, Seoul 06973, Republic of Korea; (J.K.); (H.Y.S.)
| | - In-Beom Kim
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.H.K.); (I.-B.K.)
| | - Bae Wook Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - U-Young Lee
- Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (S.H.K.); (I.-B.K.)
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
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3
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Liu X, Xiao Y, Yang H. A new attempt at the popliteal artery and knee posterior capsule space block. Asian J Surg 2023; 46:5489-5490. [PMID: 37544780 DOI: 10.1016/j.asjsur.2023.07.126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/24/2023] [Indexed: 08/08/2023] Open
Affiliation(s)
- Xinzhe Liu
- Department of Anesthesiology, The Second Hospital of Dalian Medical University, 467 Zhong Shan Road, Dalian, 116023, People's Republic of China
| | - Yu Xiao
- Department of Anesthesiology, The Second Hospital of Dalian Medical University, 467 Zhong Shan Road, Dalian, 116023, People's Republic of China
| | - Haitao Yang
- Department of Anesthesiology, The Second Hospital of Dalian Medical University, 467 Zhong Shan Road, Dalian, 116023, People's Republic of China.
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Bh PP, Jinadu S, Okunlola O, Darkzali H, Lin HM, Lai YH. Integrating IPACK (Interspace between the Popliteal Artery and Capsule of the Posterior Knee) Block in an Enhanced Recovery after Surgery Pathway for Total Knee Arthroplasty-A Prospective Triple-Blinded Randomized Controlled Trial. J Knee Surg 2023; 36:1289-1296. [PMID: 35944566 DOI: 10.1055/s-0042-1755355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We explored the efficacy of an interspace between the popliteal artery and capsule of the posterior knee (IPACK) block when added to an established enhanced recovery after surgery (ERAS) pathway to assist with posterior knee analgesia and functional mobility after total knee arthroplasty (TKA). We recruited participants undergoing TKA in our prospective, randomized, triple-blinded controlled trial. All study patients participated in our ERAS pathway consisting of a primary spinal anesthetic, adductor canal nerve catheter, and periarticular joint infiltration. Patients were randomized to receive an IPACK block or no block. The primary outcome was total postoperative opioid consumption. Secondary outcomes included pain scores, recovery unit length of stay, time to first opioid use, the incidence of posterior knee pain, ambulation distance and activities of daily living on postoperative day 1, and hospital length of stay. A total of 96 patients were randomized to the control and IPACK groups. There were no statistical differences in primary or majority of secondary outcomes. There was a lower incidence of posterior knee pain (39%) in the IPACK group when compared with controls (8.7%), p < 0.01. In terms of opioid consumption and a majority of functional outcomes, our study demonstrates no overall benefits of adding an IPACK block in this ERAS pathway in TKA. Nevertheless, IPACK may have the potential of mitigating posterior knee pain after TKA. LEVEL OF EVIDENCE level 1. CLINICAL TRIAL NUMBER AND REGISTRY URL NCT03653416. www. CLINICALTRIALS gov.
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Affiliation(s)
- Poonam Pai Bh
- Department of Anesthesiology, Mount Sinai Health System, New York, New York
| | - Samiat Jinadu
- Department of Anesthesiology, Mount Sinai Health System, New York, New York
| | - Olubunmi Okunlola
- Department of Anesthesiology, Mount Sinai Health System, New York, New York
| | - Haider Darkzali
- Department of Anesthesiology, University of Iowa, Iowa City, Iowa
| | - Hung Mo Lin
- Department of Anesthesiology, Mount Sinai Health System, New York, New York
| | - Yan H Lai
- Department of Anesthesiology, Mount Sinai Health System, New York, New York
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5
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Wang JH, Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis. J Knee Surg 2023; 36:345-353. [PMID: 34600437 DOI: 10.1055/s-0041-1733882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: -1.18; 95% confidence interval [CI]: -2.05 to -0.30) and during activity (SMD: -0.26; 95% CI: -0.49 to -0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: -0.295; 95% CI: -0.543 to -0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.
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Affiliation(s)
- Jou-Hua Wang
- Department of Orthopedics, National Cheng Kung University, Tainan, Taiwan
| | - Hsuan-Hsiao Ma
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Te-Feng Arthur Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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De-Arriba-Agre JI, García-Mulas C, Grigelmo-Hernández S, Jiménez-Rejano JJ, Fernández-Carnero S, Naranjo-Cinto F, Pecos-Martín D, Nunez-Nagy S. Dry Needling of the Popliteus Muscle Validation by Ultrasound Imaging: A Cross-Sectional Observational Study. J Clin Med 2022; 11:6409. [PMID: 36362636 PMCID: PMC9658522 DOI: 10.3390/jcm11216409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/18/2022] [Accepted: 10/27/2022] [Indexed: 09/17/2023] Open
Abstract
Dry needling is a widely used technique for the treatment of painful syndromes in the musculature, however, its usefulness is of greater relevance in deep structures, such as the popliteus muscle, as it is more difficult to access. This muscle is heavily involved in knee pathology, being a source of pain and functional impairment, especially secondary to underlying pathologies. The method selected for the observation and study of the soft tissues, by means of imaging tests that do not use ionising radiation, is ultrasound. A cross-sectional observational study is proposed. It will be carried out in a healthy population, during the years 2021 and 2022, observing, by ultrasound, the results of the popliteal puncture technique, recorded by Mayoral del Moral et al. A popliteus muscle needle reach of 92% was achieved with this technique, in 48 of 50 patients. The results of the present cross-sectional observational study in living subjects, support that the popliteal puncture, described by Mayoral et al. is a reliable and safe approach, when performed with a 0.30 × 50 mm needle, and no adverse reactions or punctures of the vascular-nerve structures have been reported during the interventions.
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Affiliation(s)
- José-Ignacio De-Arriba-Agre
- Universidad de Alcalá, Facultad de Enfermería y Fisioterapia, Departamento de Fisioterapia, Grupo de 6 Investigación en Fisioterapia y Dolor, 28801 Alcalá de Alcalá, Spain
| | - Carmen García-Mulas
- Universidad de Alcalá, Facultad de Enfermería y Fisioterapia, Departamento de Fisioterapia, Grupo de 6 Investigación en Fisioterapia y Dolor, 28801 Alcalá de Alcalá, Spain
| | - Sara Grigelmo-Hernández
- Universidad de Alcalá, Facultad de Enfermería y Fisioterapia, Departamento de Fisioterapia, Grupo de 6 Investigación en Fisioterapia y Dolor, 28801 Alcalá de Alcalá, Spain
| | | | - Samuel Fernández-Carnero
- Universidad de Alcalá, Facultad de Enfermería y Fisioterapia, Departamento de Fisioterapia, Grupo de 6 Investigación en Fisioterapia y Dolor, 28801 Alcalá de Alcalá, Spain
| | - Fermin Naranjo-Cinto
- Universidad de Alcalá, Facultad de Enfermería y Fisioterapia, Departamento de Fisioterapia, Grupo de 6 Investigación en Fisioterapia y Dolor, 28801 Alcalá de Alcalá, Spain
| | - Daniel Pecos-Martín
- Universidad de Alcalá, Facultad de Enfermería y Fisioterapia, Departamento de Fisioterapia, Grupo de 6 Investigación en Fisioterapia y Dolor, 28801 Alcalá de Alcalá, Spain
| | - Susana Nunez-Nagy
- Universidad de Alcalá, Facultad de Enfermería y Fisioterapia, Departamento de Fisioterapia, Grupo de 6 Investigación en Fisioterapia y Dolor, 28801 Alcalá de Alcalá, Spain
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7
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Guo J, Hou M, Shi G, Bai N, Huo M. iPACK block (local anesthetic infiltration of the interspace between the popliteal artery and the posterior knee capsule) added to the adductor canal blocks versus the adductor canal blocks in the pain management after total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:387. [PMID: 35962410 PMCID: PMC9373358 DOI: 10.1186/s13018-022-03272-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/19/2022] [Indexed: 12/02/2022] Open
Abstract
Background Several studies have suggested that the addition of iPACK block (the popliteal artery and the posterior knee capsule have been given interspace local anesthetic infiltration) might get better analgesia than adductor canal block (ACB) only after total knee arthroplasty (TKA). This paper compiles all available evidence on the effect of two analgesia regimens (ACB and iPACK + ACB) involving all sides. Methods We searched in eight major databases for all clinical trials discussing the effect of two analgesia regimens after TKA. Statistical analyses were conducted by Stata and RevMan Software. In addition, we performed GOSH analysis, subgroup analysis, meta-regression analysis to study the source of heterogeneity. Publication bias was checked using Egger’s test. Trim-and-fill analysis was applied in terms of sensitivity analysis of the results. Results There are fourteen eligible studies for our meta-analysis. There are significant differences between the two groups in VAS score at rest and with activity, and the VAS scores were lower in the ACB + iPACK Group (VAS scores at rest: 95%CI [− 0.96, − 0.53], P < 0.00001. VAS scores with activity: 95%CI [− 0.79, − 0.43], P < 0.00001). A differential was discovered to support the ACB + iPACK Group when comparing the two groups on postoperative cumulative morphine consumption (95%CI: [− 0.52, − 0.14], P: 0.0007). The patients in the group of ACB + iPACK performed better in the postoperative range of knee movement (95%CI: [5.18, 10.21], P < 0.00001) and walking distance (95%CI: [0.15, 0.41], P < 0.00001). There were significant differences between the patients in the ACB + iPACK Group and ACB Group on the TUG test of POD1 and POD2. We found that patients' hospital stays in the ACB + iPACK Group were significantly shorter than in the ACB Group (95%CI: [− 0.78, − 0.16], P: 0.003). No difference was found between the patients in the ACB + iPACK Group and ACB Group on postoperative quadriceps muscle strength and the incidence of PONV. Conclusion The addition of iPACK lowers postoperative VAS scores, cumulative morphine consumption, and hospital stays. Meanwhile, the addition of iPACK improves postoperative patients’ activity performance without extra side effects. iPACK combined with ACB proves to be a suitable pain management technique after TKA.
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Affiliation(s)
- Jiao Guo
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China
| | - Minna Hou
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China
| | - Gaixia Shi
- Department of Nursing, Shaanxi Provincial People's Hospital, Xi'an, China
| | - Ning Bai
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China
| | - Miao Huo
- Department of Anesthesiology, Shaanxi Provincial People's Hospital, No. 256 Youyi Xi Road, Xi'an, China.
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Marty P, Chassery C, Rontes O, Vuillaume C, Basset B, Merouani M, Marquis C, De Lussy A, Ferré F, Naudin C, Joshi GP, Delbos A. Combined proximal or distal nerve blocks for postoperative analgesia after total knee arthroplasty: a randomised controlled trial. Br J Anaesth 2022; 129:427-434. [DOI: 10.1016/j.bja.2022.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/20/2022] [Accepted: 05/11/2022] [Indexed: 11/02/2022] Open
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Mou P, Wang D, Tang XM, Zeng WN, Zeng Y, Yang J, Zhou ZK. Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia and Function Recovery Following Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study. J Arthroplasty 2022; 37:259-266. [PMID: 34653576 DOI: 10.1016/j.arth.2021.10.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND This study aimed to explore the analgesic effect among adductor canal block (ACB) combined with infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block, ACB, and IPACK block following total knee arthroplasty (TKA). METHODS One hundred twenty patients were randomly allocated into 3 groups including group A (ACB + IPACK block), group B (ACB), and group C (IPACK block). The primary outcome was postoperative pain score. The secondary outcome was opioid consumption. Other outcomes included functional evaluation and postoperative complications. RESULTS Group A showed the lowest pain scores within 8 hours at rest and with knee maximum flexion (P < .001). From 12 to 24 hours, group C showed the highest pain scores, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups 24 hours postoperatively. Group C showed the most opioid consumption within the first 24 hours and during the hospitalization, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups including function evaluation and postoperative complications. CONCLUSION ACB + IPACK block can improve early analgesia when compared with ACB. However, the small statistical benefit to the addition of IPACK block to ACB may be unlikely to be clinically significant. Further studies may focus on patient selection and how to prolong the effect of IPACK block.
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Affiliation(s)
- Ping Mou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Duan Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xiu-Mei Tang
- Department of Orthopedics, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Wei-Nan Zeng
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China; Department of Orthopedics, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yan Zeng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jing Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Zong-Ke Zhou
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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10
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Kim J, Lee K, Kim Y, Lee H, Park HJ. Using the iPACK block to reduce chronic pain in a patient with knee osteoarthritis: A case report. J Clin Anesth 2021; 74:110476. [PMID: 34364189 DOI: 10.1016/j.jclinane.2021.110476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
Infiltration between the popliteal artery and capsule of the knee (iPACK) block is an emerging modality to control perioperative knee joint pain. This case report describes the successful control of chronic knee joint pain using iPACK block in a patient with knee osteoarthritis. We suggest that iPACK block could be applied in the fields of both pain medicine and perioperative analgesia. In addition, by placing the needle closely to the popliteal plexus, iPACK block could serve as an intervention for pain related to procedures such as radiofrequency ablation.
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Affiliation(s)
- Jiyoung Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kusang Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Youngchan Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - HyunHwa Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hue Jung Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
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11
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Kim DH, Kim SJ, Liu J, Beathe J, Memtsoudis SG. Fascial plane blocks: a narrative review of the literature. Reg Anesth Pain Med 2021; 46:600-617. [PMID: 34145072 DOI: 10.1136/rapm-2020-101909] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 12/16/2022]
Abstract
Fascial plane blocks (FPBs) are increasingly numerous and are often touted as effective solutions to many perioperative challenges facing anesthesiologists. As 'new' FPBs are being described, questions regarding their effectiveness remain unanswered as appropriate studies are lacking and publications are often limited to case discussions or technical reports. It is often unclear if newly named FPBs truly represent a novel intervention with new indications, or if these new publications describe mere ultrasound facilitated modifications of existing techniques. Here, we present broad concepts and potential mechanisms of FPB. In addition, we discuss major FPBs of (1) the extremities (2) the posterior torso and (3) the anterior torso. The characteristics, indications and a brief summary of the literature on these blocks is included. Finally, we provide an estimate of the overall level of evidence currently supporting individual approaches as FPBs continue to rapidly evolve.
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Affiliation(s)
- David H Kim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Sang Jo Kim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jiabin Liu
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jonathan Beathe
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Stavros G Memtsoudis
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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12
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Wang F, Ma W, Huang Z. Analgesia effects of IPACK block added to multimodal analgesia regiments after total knee replacement: A systematic review of the literature and meta-analysis of 5 randomized controlled trials. Medicine (Baltimore) 2021; 100:e25884. [PMID: 34087830 PMCID: PMC8183733 DOI: 10.1097/md.0000000000025884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/21/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Currently, no meta-analysis exists elucidate the analgesic effect of adding IPACK block to our current multimodal analgesia regimen after total knee replacement (TKR). The purpose of this study is to systematically review the level I evidence in the literature to ascertain whether IPACK block can bring additional analgesic benefits to existing multimodal analgesia regimens. METHODS The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Only level I randomized controlled trials (RCTs) were included in our study. The primary outcome was the pain scores with rest and activity. Secondary outcomes included cumulative opioid consumption, cumulative distance ambulated, and length of stay (LOS). RESULTS Five RCTs with a total of 467 patients were included. The most important finding in our study was that although IPACK block supplementation improved pain scores at 12 hours with rest or activity after surgery, no such benefit was observed at subsequent time points during the postoperative period. Interestingly, IPACK supplementation did not reduce opioid consumption, especially in the first 24 hours after surgery. Furthermore, other postoperative outcomes, including cumulative distance ambulated and LOS, were also not improved by the addition of an IPACK. CONCLUSIONS The addition of an IPACK block to multimodal analgesia regiments does not reduce the postoperative opioid consumption nor improve functional performance. However, it may be an appropriate method to improve immediate analgesic effects after TKR.
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Chan E, Howle R, Onwochei D, Desai N. Infiltration between the popliteal artery and the capsule of the knee (IPACK) block in knee surgery: a narrative review. Reg Anesth Pain Med 2021; 46:784-805. [PMID: 33990439 DOI: 10.1136/rapm-2021-102681] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/29/2021] [Accepted: 04/29/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The infiltration between the popliteal artery and the capsule of the knee (IPACK) block has been described as an alternative analgesic strategy for knee pain. OBJECTIVE Our aim was to perform a narrative review to examine the place and value that the IPACK block has in comparison to and in conjunction with other regional anesthesia modalities. EVIDENCE REVIEW Following an extensive search of electronic databases, we included anatomical studies, letters, comparative observational studies, and non-randomized and randomized controlled trials that examined the IPACK block in relation to surgery on the knee under general or neuraxial anesthesia. FINDINGS In all, 35 articles were included. Cadaveric studies demonstrated the potential for injected dye to spread to the nerves responsible for the innervation of the posterior as well as anteromedial and anterolateral aspects of the knee. Of the comparative observational studies (n=15) and non-randomized (n=1) and randomized controlled trials (n=13), 2 and 27 were conducted in the context of anterior cruciate ligament reconstruction and knee replacement surgery, respectively. The role of the IPACK block with each different permutation of regional anesthesia techniques was investigated by a small number of studies. Clinical studies, in the setting of knee replacement surgery, revealed variation in the manner in which the IPACK block was performed, and indicated the possible superiority of distal injection at the level of the femoral condyles for the management of posterior knee pain. Evidence suggested the following: the IPACK block in combination with single shot adductor canal block (ACB) may be beneficial for analgesic and functional outcomes; in conjunction with single shot or continuous ACB, the IPACK block might be superior to local infiltration analgesia (LIA); and functional outcomes may be improved with the supplementation of continuous ACB and LIA with the IPACK block. The IPACK block did not commonly result in the occurrence of foot drop. Relative to tibial nerve block (TNB), the IPACK block reduced the occurrence of foot drop and increased the proportion of patients who were able to be discharged on the third postoperative day. CONCLUSIONS The IPACK block was potentially complementary to the ACB and might be preferable to the TNB as a motor-sparing regional anesthesia technique in knee surgery. Definitive recommendations were not reached in the presence of the heterogeneous and limited evidence base.
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Affiliation(s)
- Edmund Chan
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ryan Howle
- Department of Anaesthesia, St Vincent's University Hospital, Dublin, Ireland
| | - Desire Onwochei
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Honorary Senior Clinical Lecturer, King's College London, London, UK
| | - Neel Desai
- Department of Anaesthesia, Guy's and St Thomas' NHS Foundation Trust, London, UK .,Honorary Senior Clinical Lecturer, King's College London, London, UK
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D'Souza RS, Langford BJ, Olsen DA, Johnson RL. Ultrasound-Guided Local Anesthetic Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (IPACK) Block for Primary Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials. Local Reg Anesth 2021; 14:85-98. [PMID: 34012290 PMCID: PMC8126972 DOI: 10.2147/lra.s303827] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/13/2021] [Indexed: 11/23/2022] Open
Abstract
Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; low-quality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Brendan J Langford
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - David A Olsen
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Hospital, Rochester, MN, USA
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Zheng FY, Liu YB, Huang H, Xu S, Ma XJ, Liu YZ, Chu HC. The impact of IPACK combined with adductor canal block under ultrasound guidance on early motor function after total knee arthroplasty. Braz J Anesthesiol 2021; 72:110-114. [PMID: 33915199 PMCID: PMC9373452 DOI: 10.1016/j.bjane.2021.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 04/01/2021] [Accepted: 04/14/2021] [Indexed: 11/19/2022] Open
Abstract
Background This study aimed to evaluate the impact of Infiltration between the Popliteal Artery and Capsule of the posterior Knee (IPACK) combined with an adductor canal block under the guidance of ultrasound on early motor function after Total Knee Arthroplasty (TKA). Methods A sample of 60 cases who were scheduled for elective unilateral TKA were divided into two groups using random number table method: a group with IPACK combined with an adductor canal block (I group, n = 30), and a group with femoral nerve block combined with superior popliteal sciatic nerve block (FS group, n = 30). Before anesthesia induction was completed, the patients in I group received an ultrasound-guided adductor canal block with 15 mL of 0.375% ropivacaine and an IPACK block with 25 mL of ropivacaine, and the patients in FS group received a femoral nerve block and a superior popliteal sciatic nerve block with 20 mL of 0.375% ropivacaine under ultrasound guidance. Post-operation, all the patients received patient-controlled intravenous analgesia combined with an oral celecoxib capsule to relieve pain and maintain a visual analogue scale score of ≤ 3. Results The quadriceps femoris muscle strength score was significantly higher in Ⅰ group than in FS group (p = 0.001), while the modified Bromage score were significantly lower and walking distance results were significantly higher in Ⅰ group than in FS group (both p = 0.000). Conclusion Compared with femoral nerve block combined with superior popliteal sciatic nerve block, IPACK combined with adductor canal block had a mild impact on early motor functions after TKA.
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Affiliation(s)
- Fang-Yu Zheng
- The Affiliated Hospital of Qingdao University, Department of Anesthesiology, Qingdao, China; Women and Children's Hospital, Qingdao University, Department of Anesthesiology, Qingdao, China
| | - Yong-Bo Liu
- The Affiliated Hospital of Qingdao University, Department of Operating Room, Qingdao, China
| | - Hui Huang
- The Affiliated Hospital of Qingdao University, Department of Anesthesiology, Qingdao, China
| | - Shuai Xu
- The Affiliated Hospital of Qingdao University, Department of Cardiovascular Surgery Intensive Care Unit, Qingdao, China
| | - Xiao-Jun Ma
- The Affiliated Hospital of Qingdao University, Department of Anesthesiology, Qingdao, China
| | - Ying-Zhi Liu
- The Affiliated Hospital of Qingdao University, Department of Anesthesiology, Qingdao, China.
| | - Hai-Chen Chu
- The Affiliated Hospital of Qingdao University, Department of Anesthesiology, Qingdao, China
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Nakase J, Shimozaki K, Asai K, Yoshimizu R, Kimura M, Tsuchiya H. Usefulness of lateral femoral cutaneous nerve block in combination with femoral nerve block for anterior cruciate ligament reconstruction: a prospective trial. Arch Orthop Trauma Surg 2021; 141:455-460. [PMID: 33386977 DOI: 10.1007/s00402-020-03724-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 12/06/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The study aimed to compare the combination of femoral nerve block (FNB) with interspace between the popliteal artery and the capsule of posterior knee (IPACK) block (IPACK group) with the combination of FNB with lateral femoral cutaneous nerve (LFCN) block (LFCN group) for postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction. We hypothesized that the lower pain scores and decreased suppository use would be noted in patients administered a combination of FNB and IPACK block. MATERIALS AND METHODS A non-randomized prospective controlled clinical trial was conducted. The IPACK and LFCN groups included 40 patients each. The patients received IPACK block and LFCN block alternately. Thirty minutes prior to the surgery and after administration of general anesthesia, patients received an ultrasound-guided FNB and IPACK block or LFCN block. After ACL reconstruction, the visual analog scale pain scores were recorded at 30 min, 4 h, 8 h, 12 h, 24 h, 48 h, and 72 h after the surgery. The administration and use of analgesic suppositories were assessed. These measures were compared among the treatment types at each time-point using the Welch's t-test. RESULTS Suppository use was significantly less in the LFCN group than in the IPACK group. The pain scores were significantly lower in the LFCN group at 30 min, 4 h, 48 h, and 72 h after the surgery. CONCLUSION The combination of FNB with LFCN block during ACL reconstruction significantly reduces pain in the early postoperative period compared to a combination of FNB with IPACK block. LEVEL OF EVIDENCE Prospective control trial, Level II.
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Affiliation(s)
- Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-0934, Japan.
| | - Kengo Shimozaki
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-0934, Japan
| | - Kazuki Asai
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-0934, Japan
| | - Rikuto Yoshimizu
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-0934, Japan
| | - Mitsuhiro Kimura
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-0934, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takaramachi, Kanazawa, 920-0934, Japan
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Kertkiatkachorn W, Kampitak W, Tanavalee A, Ngarmukos S. Adductor Canal Block Combined With iPACK (Interspace Between the Popliteal Artery and the Capsule of the Posterior Knee) Block vs Periarticular Injection for Analgesia After Total Knee Arthroplasty: A Randomized Noninferiority Trial. J Arthroplasty 2021; 36:122-129.e1. [PMID: 32694032 DOI: 10.1016/j.arth.2020.06.086] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 06/20/2020] [Accepted: 06/29/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The combination of adductor canal block (ACB) and infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block may provide sufficient motor-sparing anterior and posterior knee analgesia after total knee arthroplasty. This study aimed to determine if ACB with iPACK block was noninferior to ACB with periarticular injection (PAI) when combined with postoperative multimodal analgesia regimen. METHODS Seventy-six patients were randomized to receive either ACB + iPACK block and continuous ACB (CACB) (ACB + iPACK group) or PAI and CACB (ACB + PAI group). Noninferiority was concluded for the primary outcome if the adjusted mean between-group difference in pain on movement at 12 postoperative hours was within 1.3 points on a visual analog pain scale. Pain scores, morphine consumption, functional performance, and adverse events were the secondary outcome measures assessed for superiority. RESULTS Adjusted mean differences, (ACB + iPACK) - (ACB + PAI), in anterior and posterior knee pain scores on movement at 12 postoperative hours were -0.66 (-1.86, 0.54) and -0.19 (-1.36, 0.99), respectively. The upper limit of 95% confident interval was lower than the prespecified noninferiority limit. The mean visual analog scale pain scores were low and no clinically significant differences between groups. However, morphine requirement at 48 postoperative hours was significantly higher (P < .05) and showed greater reduced quadriceps strength at 0 and 45 degrees on postoperative day 0 (P = .006 and .04, respectively) in the ACB + iPACK group. CONCLUSIONS ACB with iPACK block provides a noninferior analgesia compared with PAI when combined with CACB. However, patients who received ACB + iPACK block may require higher amounts of opioids and have worse immediate functional performance. LEVEL OF EVIDENCE Therapeutic level I.
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Affiliation(s)
- Wannida Kertkiatkachorn
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aree Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srihatach Ngarmukos
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Kar A, Padhy S, Patki A, Durga P, Sireesha L. Comparison of sensory posterior articular nerves of the knee (SPANK) block versus infiltration between the popliteal artery and the capsule of the knee (IPACK) block when added to adductor canal block for pain control and knee rehabilitation after total knee arthroplasty---A prospective randomised trial. Indian J Anaesth 2021; 65:792-797. [PMID: 35001951 PMCID: PMC8680422 DOI: 10.4103/ija.ija_682_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/03/2021] [Accepted: 11/03/2021] [Indexed: 11/08/2022] Open
Abstract
Background and Aims: Adductor canal block (ACB), though an effective procedure for postoperative analgesia in total knee arthroplasty (TKA), does not provide analgesia to the posterior articular aspect of the knee joint. Infiltration between the popliteal artery and the capsule of the knee (IPACK block) and sensory posterior articular nerves of the knee (SPANK block) are two single injection techniques that have been shown to provide effective analgesia in posterior knee pain. This study aims to compare the effect of IPACK block and SPANK block when combined with ACB for analgesia and postoperative rehabilitation in TKA. Methods: A total of 82 patients were randomised into two groups: (1) ACB combined with IPACK, (2) ACB combined with SPANK block. The primary outcome was the pain scores from 6 h to 48 h after surgery and the duration of postoperative analgesia. The secondary outcome measures were 24 h opioid consumption, ambulation parameters like mobilisation ability, quadriceps muscle strength and patient satisfaction score at discharge. Results: Numerical rating scale (NRS) scores at rest and on movement, duration of analgesia, total opioid consumption, and patient satisfaction were significantly better (P < 0.05%) in the IPACK group than in the SPANK block. There were no significant differences in the knee rehabilitation parameters between the blocks. Conclusion: ACB with IPACK block offers better analgesia, less opioid consumption and better patient satisfaction with comparable knee rehabilitation parameters in the immediate postoperative period after TKA compared to ACB with SPANK block.
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Li D, Alqwbani M, Wang Q, Liao R, Yang J, Kang P. Efficacy of Adductor Canal Block Combined With Additional Analgesic Methods for Postoperative Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study. J Arthroplasty 2020; 35:3554-3562. [PMID: 32680754 DOI: 10.1016/j.arth.2020.06.060] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 06/17/2020] [Accepted: 06/19/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study is to evaluate the efficacy of adductor canal block (ACB) combined with additional analgesic methods in total knee arthroplasty (TKA) and investigate whether blocking the sensory nerves that are distributed in the posterior and lateral aspect of knee could improve postoperative pain control. METHODS Two hundred scheduled patients for TKA were randomly allocated into 4 groups: Group A received ACB combined with iPACK (interspace between the popliteal artery and capsule of the knee) block and lateral femoral cutaneous nerve block (LFCNB); Group B received ACB combined with iPACK block; Group C received ACB combined with LFCNB; and Group D received ACB only. Postoperative pain score was the main primary outcome. Secondary outcomes included the morphine consumption and analgesic duration. Other outcomes included knee range of motion, quadriceps strength, ambulation, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index physical function, timed up and go (TUG) test, and complications. RESULTS Groups A, B, and C had lower postoperative pain scores within 12 hours at rest and 8 hours with activity than Group D (P < .05). In addition, Group A had lower morphine consumption than both Group C (P < .05) and Group D (P < .01). Group A had the longest analgesic duration (19.21 ± 3.22 hours) among all groups. There were no significant differences among the groups in terms of mobility and complication after surgery. CONCLUSION Combining ACB with both iPACK and LFCNB is an effective method for decreasing early postoperative pain in TKA without increasing the complications or affecting the early rehabilitation.
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Affiliation(s)
- Donghai Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Mohammed Alqwbani
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qiuru Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ren Liao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jing Yang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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Kampitak W, Tanavalee A, Ngarmukos S, Tantavisut S. Motor-sparing effect of iPACK (interspace between the popliteal artery and capsule of the posterior knee) block versus tibial nerve block after total knee arthroplasty: a randomized controlled trial. Reg Anesth Pain Med 2020; 45:267-276. [DOI: 10.1136/rapm-2019-100895] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 01/29/2023]
Abstract
Background and objectiveAn ultrasound-guided anesthetic technique targeting the interspace between the popliteal artery and capsule of the posterior knee (iPACK) can provide posterior knee analgesia with preserved motor function after total knee arthroplasty (TKA). This study compared the peroneal nerve motor-sparing effects of iPACK block and tibial nerve block (TNB) when combined with local infiltration analgesia (LIA) and continuous adductor canal block (CACB).MethodsIn this study, 105 patients scheduled for elective TKA were randomized to receive proximal iPACK block (iPACK1), distal iPACK block (iPACK2), or TNB, along with spinal anesthesia, modified LIA, and CACB. The primary outcome was the incidence of common peroneal nerve (CPN) motor blockade. Secondary outcomes included CPN sensory function, tibial sensorimotor function, posterior knee pain, pain score, intravenous morphine requirement, timed up-and-go test, quadriceps muscle strength, range of motion, length of hospital stay, patient satisfaction, and adverse events.ResultsThe incidence of CPN motor blockade was significantly higher in the TNB group than in the iPACK1 (p=0.001) and iPACK2 (p=0.001) groups, but was not significant between the iPACK1 and iPACK2 groups (p=0.76). Tibial nerve motor function was more preserved in the iPACK1 and iPACK2 groups than in the TNB group (p<0.001 and p<0.001, respectively). Complete CPN and tibial sensorimotor blockade were not observed in the iPACK2 group. Posterior knee pain score was significantly higher in the iPACK1 group than in other groups during the 24-hour postoperative period (p=0.001).ConclusionsCompared with TNB, iPACK1 and iPACK2 preserved CPN and tibial nerve motor function to a greater extent. However, iPACK2 did not demonstrate complete CPN and tibial nerve motor blockade while maintaining effective posterior knee pain relief.Trial registration numberTCTR20180206002.
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