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Periarticular injection plus ACB, IPACK improves pain control in TKA
Patients undergoing total knee arthroplasty who received periarticular injection plus interspace between the popliteal artery and capsule of the posterior knee block and adductor canal block had significantly better pain control, and had significantly less opioid use, according to results presented at the World Congress on Regional Anesthesia & Pain Medicine.
“The addition of [interspace between the popliteal artery and capsule of the posterior knee block] IPACK and [adductor canal block] ACB are shown to be an extremely valuable modality to add to a multimodal pathway,” David H. Kim, MD, anesthesiologist at Hospital for Special Surgery and co-author of the study, told Healio.com/Orthopedics.
Kim and colleagues randomly assigned 86 patients undergoing TKA to receive either a periarticular injection (control group) or an IPACK with an ACB and modified periarticular injection (intervention group). The investigators defined the primary outcome as pain on ambulation on postoperative day 1. Secondary outcomes included numeric rating scale pain scores, pain outcomes and opioid consumption.
Results showed lower numeric rating scale pain score on ambulation among the intervention group on postoperative days 0, 1 and 2 vs. the control group. Researchers also found significantly lower pain scores in the intervention group after physical therapy on postoperative days 0 and 1. Compared with the control group, patients in the intervention group reported more satisfaction, significantly less pain, less interference from pain when walking, better sleep, less severe pain in a 24 hour period and no desire for more pain treatments than offered, according to results from the PainOUT questionnaire. The findings also showed less opioid consumption, less IV opioids and less IV patient-controlled analgesia among the intervention group. Although researchers found no differences in hospital length of stay between the two groups, more patients in the intervention group vs. the control group were discharged on postoperative days 0 and 1. – by Casey Tingle
Reference:
Kim D, et al. Paper 4886. Presented at: World Congress on Regional Anesthesia & Pain Medicine; April 19-21, 2018; New York.
Disclosure: Kim reports no relevant financial disclosures.
Perspective
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Pain control after TKA is of renewed interest with the popularity of periarticular injections (PAIs) that are simple, reliable and surgeon-directed. Further, their motor-sparing nature supports the concentrated efforts to decrease length of stay (LOS) and eliminate in-hospital falls. However, recent innovations in motor-sparing peripheral nerve block such as the adductor canal block (ACB) and interspace between the popliteal artery and capsule of the posterior knee (IPACK) offer alternatives. In this excellent randomized clinical trial from Kim et al, the authors evaluated PAI vs. a modified PAI with an IPACK and an ACB in 86 patients. The primary outcome was pain (via numeric rating scale) on ambulation on postoperative day 1. With that primary outcome, the authors found a significant decrease in the intervention group (1.7 vs. 5; P < .001). However, there was no difference in LOS. As such, the additional costs and time of completing two peripheral nerve blocks must be balanced by the incremental benefits. Future studies with larger numbers powered to look at PAI vs. PAI and ACB or IPACK will help provide clarity.