COMPARATIVE EVALUATION OF ULTRASOUND-GUIDED iPACK COMBINED WITH ADDUCTOR CANAL BLOCK VERSUS LUMBAR ERECTOR SPINAE PLANE BLOCK FOR MULTIMODAL ANALGESIA FOLLOWING TOTAL KNEE ARTHROPLASTY: A PROSPECTIVE RANDOMIZED DOUBLE-BLIND CONTROLLED STUDY
Keywords:
Total knee arthroplasty, iPACK block, Adductor canal block, Lumbar erector spinae plane block, Regional anesthesia, Postoperative analgesia, Opioid consumption, Enhanced recovery after surgery, Ultrasound-guided nerve block, Multimodal analgesiaAbstract
ackground: ETotal knee arthroplasty (TKA) is one of the vascularly indicated and commonly done orthopedic surgeries for osteoarthritis of the knee at terminal stages because of the surgical pain related to it. Therefore, perioperative analgesia must be provided to ensure early mobilization, reduce the patients' needs for postoperative opioids, improve functional recovery in a short period, and enhance satisfaction of the patients. Among all possible regional motor-sparing techniques of analgesia, infiltration between the knee joint capsule and popliteal artery (iPACK) block use along with adductor canal nerve block (ACB) and lumbar erector spinae plane block (L-ESPB) techniques has been shown to provide good analgesia following TKA. However, research data comparing the two techniques with respect to postoperative pain control, total quantity of opioid consumption, inflammatory biomarker levels, and early rehabilitation is limited. Aim: The purpose of this research study is to evaluate the difference in analgesic effectiveness, opioid-sparing effect, functional recovery, inflammatory response, and postoperative outcome variables between ultrasound-guided iPACK combined with adductor canal block compared to lumbar erector spinae plane block for elective total knee arthroplasty under spinal anesthesia.
Materials and Methods: This trial was a prospective, randomized, double-blind controlled clinical research study undertaken over a period of 18 months within the Department of Anesthesiology in a tertiary care institution. The study consisted of ninety adult subjects (ASA Physical Status I-III) aged from 60 to 85 years who were scheduled for unilateral primary total knee arthroplasty under spinal anesthesia, which was randomly divided into three*(3) equal groups. Group IA was subjected to ultrasound-guided iPACK in conjunction with adductor canal block, Group LE was subject to ultrasound-guided erector spinae lumbar block, and Group C was administered clinical multimodal analgesia without the employment of additional regional block. The primary outcome measures included cumulative opioid usage in the first fort-eight (48) postoperative hours. The secondary outcome measures included postoperative pain scale to be measured at rest and in motion, rescue analgesia administration time measurement, quadriceps strength, early ambulation, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio and postoperative complication, patient satisfaction, and hospital stay. A statistical analysis for the data obtained was carried out using appropriate nonparametric tests.
Results: The results showed that patients treated via iPACK with adductor canal block had significantly lower total opioid consumption throughout the first 48 hours as compared to both lumbar ESP block treated group and the control group. In addition, for the patients treated via iPACK with adductor canal block, pain scores were lower at rest and upon degree mobilization and those treated via iPACK with adductor canal block had much longer time before the first use of rescue analgesia was required. The patients also experienced preservation of quadriceps muscle strength and were able to ambulate independently earlier. Following the surgery, all the patients treated via both regional anesthesia techniques had lower levels of pain and utilized opioids at a lesser amount than patients who underwent multimodal analgesia. While both groups treated by the two regional anesthetic techniques showed improvement in postoperative inflammatory markers such as NLR and PLR as compared to preoperative levels, there was no statistically significant difference between both interventions provided to the patients. The incidences of postoperative nausea and vomiting and other adverse opioid effects were less for the patients in the regional nerve block group. All in all, the procedure involving co-administration of iPACK followed by a standard adductor canal block is more advantageous in providing multimodal analgesia and accelerated recovery following total knee arthroplasty.
Conclusion: The combination of ultrasound-guided iPACK and the adductor canal block technique is a viable and safe technique that provides motor-sparing analgesic management for patients undergoing total knee arhtroplasty. It provides high-quality postoperative analgesia compared to lumbar erector spinae plane block, reduces opioid consumption significantly, prolongs the time before the use of rescue analgesia postoperatively, enhances rehabilitation, and increases patient satisfaction while providing the same level of safety as other techniques. Therefore, regional anesthesia techniques within standardized ERAS protocols can provide improved management both during the perioperative period and in recovery after primary total knee arthroplasty.
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