Jacques T. YaDeau

Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial.

Background:This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8 h postanesthesia. Methods:Patients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48 h postanesthesia administration. In a joint hypothesis test, noninferiority was first evaluated on the primary outcomes of strength, pain score, and opioid consumption at 6 to 8 h; superiority on each outcome at 6 to 8 h was then assessed only if noninferiority was established. Results:Forty-six patients received ACB; 47 patients received FNB. At 6 to 8 h postanesthesia, ACB patients had significantly higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf [0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5] ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115). At 24 and 48 h postanesthesia, there was no significant statistical difference in dynamometer results, pain scores, or opioid use between the two groups. Conclusion:At 6 to 8 h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps strength and was not inferior in both providing analgesia or opioid intake.This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8 h postanesthesia. Patients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48 h postanesthesia administration. In a joint hypothesis test, noninferiority was first evaluated on the primary outcomes of strength, pain score, and opioid consumption at 6 to 8 h; superiority on each outcome at 6 to 8 h was then assessed only if noninferiority was established. Forty-six patients received ACB; 47 patients received FNB. At 6 to 8 h postanesthesia, ACB patients had significantly higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf [0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5] ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115). At 24 and 48 h postanesthesia, there was no significant statistical difference in dynamometer results, pain scores, or opioid use between the two groups. At 6 to 8 h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps strength and was not inferior in both providing analgesia or opioid intake.

Ultrasound-guided regional anesthesia and analgesia: a qualitative systematic review.

Ultrasound guidance has become popular for performance of regional anesthesia and analgesia. This systematic review summarizes existing evidence for superior risk to benefit profiles for ultrasound versus other techniques. Medline was systematically searched for randomized controlled trials (RCTs) comparing ultrasound to another technique, and for large (n > 100) prospective case series describing experience with ultrasound-guided blocks. Fourteen RCTs and 2 case series were identified for peripheral nerve blocks. No RCTs or case series were identified for perineural catheters. Six RCTs and 1 case series were identified for epidural anesthesia. Overall, the RCTs and case series reported that use of ultrasound significantly reduced time or number of attempts to perform blocks and in some cases significantly improved the quality of sensory block. The included studies reported high incidence of efficacy of blocks with ultrasound (95%-100%) that was not significantly different than most other techniques. No serious complications were reported in included studies. Current evidence does not suggest that use of ultrasound improves success of regional anesthesia versus most other techniques. However, ultrasound was not inferior for efficacy, did not increase risk, and offers other potential patient-oriented benefits. All RCTs are rather small, thus completion of large RCTs and case series are encouraged to confirm findings.

A prospective clinical registry of ultrasound-guided regional anesthesia for ambulatory shoulder surgery.

BACKGROUND: There is a lack of clinical registries to document efficacy and safety of ultrasound-guided regional anesthesia. Interscalene blocks are effective for shoulder arthroscopy, and ultrasound guidance may reduce risk. Furthermore, ultrasound-guided supraclavicular block is a novel approach for shoulder anesthesia that may have less risk for neurological symptoms than interscalene block. METHODS: One thousand one hundred sixty-nine patients undergoing ultrasound-guided regional anesthesia for ambulatory shoulder arthroscopy were enrolled in our prospective registry. Standardized perioperative data were collected including a preoperative neurological screening tool. Either interscalene or supraclavicular block was performed at the discretion of the clinical team. Standardized follow-up was performed in the postanesthesia care unit and at 1 week. Postoperative neurological symptoms (PONS) were assessed at the 1-week follow-up with the same screening tool by a blinded neurologist. RESULTS: Ultrasound-guided interscalene (n = 515) and supraclavicular (n = 654) blocks had excellent anesthetic success (99.8%; 95% confidence interval [CI], 99.4%–99.9%) with 0% (95% CI, 0%–0.3%) incidence of vascular puncture or intravascular injection. The incidence of hoarseness in the postanesthesia care unit was significantly less with supraclavicular (22% with 95% CI, 19%–26%) than interscalene block (31% with 95% CI, 27%–35%). The incidence of dyspnea was similar (7% for supraclavicular vs 10% with interscalene). No patient had a clinically apparent pneumothorax. The incidence of PONS was very low (0.4% with 95% CI, 0.1%–1%), and there was a 0% (95% CI, 0%–0.3%) incidence of permanent nerve injury. CONCLUSIONS: Ultrasound-guided interscalene and supraclavicular blocks are effective and safe for shoulder arthroscopy. Temporary and permanent PONS is uncommon.

The Effects of Femoral Nerve Blockade in Conjunction with Epidural Analgesia After Total Knee Arthroplasty

Either epidural analgesia or femoral nerve blockade improves analgesia and rehabilitation after total knee arthroplasty. No study has evaluated the combination of femoral nerve blockade and epidural analgesia. In this prospective, randomized, blinded study we investigated combining femoral nerve blockade with epidural analgesia. Forty-one patients received a single-injection femoral nerve block with 0.375% bupivacaine and 5 &mgr;g/mL epinephrine; 39 patients served as controls. All patients received combined spinal-epidural anesthesia and patient-controlled epidural analgesia with 0.06% bupivacaine and 10 &mgr;g/mL hydromorphone. Average duration of epidural analgesia was 2 days. All patients received the same standardized physical therapy intervention. Median visual analog scale (VAS) scores with physical therapy were significantly lower for 2 days among patients who received a femoral nerve block versus controls: 3 versus 4 (day 1), 2.5 versus 4 (day 2); P < 0.05. Median VAS pain scores at rest were 0 in both groups on days 1 and 2. Flexion range of motion was improved on postoperative day 2 (70° versus 63°; P < 0.05). No peripheral neuropathies occurred. We conclude that the addition of femoral nerve blockade to epidural analgesia significantly improved analgesia for the first 2 days after total knee arthroplasty.

Nerve localization techniques for interscalene brachial plexus blockade: a prospective, randomized comparison of mechanical paresthesia versus electrical stimulation.

Postoperative neurologic symptoms (PONS) are relatively common after upper extremity orthopedic surgery performed under peripheral neural blockade. In this study, we prospectively compared the incidence of PONS after shoulder surgery under interscalene (IS) block using the electrical stimulation (ES) or mechanical paresthesia (MP) techniques of nerve localization. For patients randomized to the MP group, a 1-in, 23-g long-beveled needle was placed into the IS groove to elicit a paresthesia to the shoulder, arm, elbow, wrist, or hand. For patients randomized to the ES group, a 5-cm, 22-g short-beveled insulated needle was placed into the IS groove to elicit a motor response including flexion or extension of the elbow, wrist, or fingers or deltoid muscle stimulation at a current between 0.2 and 0.5 mA. Each IS block was performed with 50–60 mL of 1.5% mepivacaine containing 1:300,000 epinephrine and 0.1meq/L sodium bicarbonate. Two-hundred-eighteen patients were randomized between the two groups. One patient was lost to follow-up. Twenty-five patients (23%) in the ES group experienced paresthesia during needle insertion. The incidence of PONS using the ES technique was 10.1% (11/109), whereas the incidence with the MP technique was 9.3% (10/108) (not significant). The PONS lasted a median duration of 2 mo, and symptoms in all patients resolved within 12 mo. The success rate, onset time, and patient satisfaction were also comparable between groups. We conclude that the choice of nerve localization technique can be made based on the patient’s and anesthesiologist’s comfort and preferences and not on concern for the development of PONS.

Clonidine and Analgesic Duration After Popliteal Fossa Nerve Blockade: Randomized, Double-blind, Placebo-controlled Study

BACKGROUND:We tested the hypothesis that 100 &mgr;g clonidine added to 0.375% bupivacaine would prolong the duration of analgesia from popliteal fossa nerve blockade. METHODS:Ninety-nine patients scheduled for hospital admission after foot or ankle surgery entered this randomized, double-blind, placebo-controlled trial. Patients received a popliteal fossa block (nerve stimulator technique, via the posterior approach) using 30 mL 0.375% bupivacaine, with epinephrine. Patients were randomized to receive no clonidine, 100 &mgr;g clonidine IM, or 100 &mgr;g clonidine with bupivacaine for the popliteal block. Patients also received a combined spinal-epidural anesthetic, a saphenous nerve block, and postoperative IV patient-controlled analgesia. The primary outcome was patient-reported duration of analgesia. RESULTS:Duration of analgesia was statistically longer in the block clonidine group (18 ± 6 h for clonidine with bupivacaine vs 14 ± 7 h for IM clonidine and 15 ± 7 h for control, P = 0.016 for control vs clonidine with bupivacaine). Pain scores, analgesic use, and side effects attributable to pain management were similar among groups. CONCLUSIONS:Clonidine significantly prolongs the analgesic duration after popliteal fossa nerve blockade with bupivacaine.

Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective, double-blind, randomized controlled trial.

BACKGROUND The perioperative inflammatory response as measured by elevated levels of interleukin-6 (IL-6) has been linked to acute respiratory distress syndrome, postoperative confusion, and fever. Because of the extent of surgery,patients undergoing bilateral total knee arthroplasty may be at high risk of complications. We had found a significant decrease in IL-6 in patients having bilateral total knee replacement who received two doses of 100 mg of hydrocortisone eight hours apart; however, by twenty-four hours, IL-6 levels were equal to those in the group that received a placebo. In the present study, we investigated whether the administration of three doses would reduce IL-6 levels at twenty-four hours and affect other outcomes such as desmosine level, a marker of lung injury. METHODS After institutional review board approval, a total of thirty-four patients (seventeen patients and seventeen control subjects) were enrolled in this double-blind, randomized, placebo-controlled study. Three doses of intravenous hydrocortisone (100 mg) or placebo were given eight hours apart. Urinary desmosine levels were obtained at baseline and at one and three days postoperatively. The level of IL-6 was measured at baseline and at six, ten, twenty-four, and forty-eight hours postoperatively. Pain scores, presence of fever, and functional outcomes were recorded. RESULTS The level of IL-6 increased in both groups, but was significantly higher in the control group, peaking at twenty-four hours (mean and standard deviation, 623.74 ± 610.35 pg/mL versus 148.13 ± 119.35 pg/mL; p = 0.006). Urinary desmosine levels significantly increased by twenty-four hours in the control group, but remained unchanged in the study group (134.75 ± 67.88 pmol/mg and 79.45 ± 46.30 pmol/mg, respectively; p = 0.006). Pain scores at twenty-four hours were significantly lower in the study group (1.4 ± 0.9 versus 2.4 ± 1.2; p = 0.01) as was the presence of fever (11.8%versus 47.1%; p = 0.03). Range of motion at the knee was significantly greater in the study group (81.6 ± 11.6 versus 70.6 ± 14.0 in the right knee [p = 0.02] and 81.4 ± 11.3 versus 73.4 ± 9.4 in the left knee [p = 0.03]). CONCLUSIONS Hydrocortisone (100 mg) given over three doses, each eight hours apart, decreased and maintained a lower degree of inflammation with bilateral total knee replacement as measured by IL-6 level. Corticosteroids decreased the prevalence of fever, lowered visual analog pain scores, and improved knee motion. The significantly lower values of desmosine in the study group suggest that this treatment may be protective against lung injury.

Lumbar plexus blockade reduces pain after hip arthroscopy: a prospective randomized controlled trial.

BACKGROUND:Hip arthroscopy causes moderate to severe postoperative pain. We hypothesized that performance of a lumbar plexus block (LPB) would reduce postoperative pain in the postanesthesia care unit (PACU) for patients discharged home on the day of surgery. METHODS:Patients received a combined spinal epidural with IV sedation, ondansetron, and ketorolac. Half of the patients (n = 42) also underwent a single-injection bupivacaine LPB. Postoperative analgesia (PACU and after discharge) was provided with oral hydrocodone/acetaminophen (5/500 mg) and an oral nonsteroidal antiinflammatory drug. IV hydromorphone was given as needed in the PACU. RESULTS:The LPB reduced pain at rest in the PACU (GEE: &bgr; estimate of the mean on a 0 to 10 scale = −0.9; 95% confidence interval = −1.7 to −0.1; P = 0.037). Mean PACU pain scores at rest were reduced by the LPB from 4.2 to 3.3 (P = 0.048, 95% confidence interval for difference = 0.007–1.8; uncorrected for multiple values per patient, using independent samples t test for preliminary evaluation comparing pain between the groups). There were no statistically significant differences in PACU analgesic usage, PACU pain with movement, and patient satisfaction. No permanent adverse events occurred, but 2 LPB patients fell in the PACU bathroom, without injury. Three unplanned admissions occurred; one LPB patient was admitted for epidural spread and urinary retention. Two control patients were admitted, one for oxygen desaturation and one for pain and nausea. CONCLUSION:LPB resulted in statistically significant reductions in PACU resting pain after hip arthroscopy, but the absence of improvement in most secondary outcomes suggests that assessment of risks and benefits of LPB should be individualized.

Association of Obesity With Inflammation and Pain After Total Hip Arthroplasty

BackgroundThe prevalence of obesity is increasing, and obesity often leads to degenerative joint disease requiring total hip arthroplasty (THA). Obesity is a proinflammatory state associated with an increase in chronic, low-grade inflammatory response. As such, it may augment the postoperative inflammatory response, which has been associated with postoperative pain and complications.Questions/purposesWe determined whether severity of obesity was associated with (1) severity of inflammatory response, as measured by the in vivo circulating levels of cytokines and ex vivo functional reactivity of mononuclear blood cells, and (2) severity of pain, as measured by verbal pain scores and analgesic consumption, in the first 24 hours after THA.MethodsWe studied 60 patients (20 normal weight, 20 overweight, 20 obese) undergoing elective primary unilateral THA in this prospective cross-sectional study. Blood samples were collected for C-reactive protein and cytokine levels, including IL-1β, IL-2, IL-6, IL-8, and tumor necrosis factor α (TNF-α), from patients before and 24 hours after surgery. Cytokine response of whole blood was evaluated ex vivo with or without two standard activators, phorbol-12-myristate-13-acetate and lipopolysaccharide, using standardized blood sample from patients at 24 hours. These standard immune activators are implicated in the inflammatory response to gram-negative infection, translocation of microbial products, pathophysiology of septic shock syndrome in human, and tumor promotion. Pain response was gauged using verbal pain scores (on a 0- to 10-point scale, where 0 = no pain and 10 = worst pain) at rest and with activity at 24 hours after surgery and analgesic consumption of volume of epidural analgesic solution for the first 24 hours after surgery.ResultsNo correlation was found between BMI and postoperative spontaneous circulating cytokine levels. However, after activation of blood leukocytes with lipopolysaccharide, there was a significant positive correlation between the BMI and IL-1β, IL-6, and TNF-α levels (r = 0.26–0.32; p = 0.03, p = 0.03, and p = 0.01, respectively), suggesting priming of the innate immune system in obesity and potential for excessive postoperative inflammatory response. Obesity was not associated with increased pain or analgesic consumption in the first 24 hours after surgery.ConclusionsObesity is associated with a proinflammatory state after THA as demonstrated by enhanced cytokine reactivity. Larger studies exploring the specific impact of obesity and inflammation on surgical outcomes, including pain, are warranted.Level of EvidenceLevel II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Unused Opioid Pills After Outpatient Shoulder Surgeries Given Current Perioperative Prescribing Habits

Background: In the past 16 years, the number of prescription opioids sold in the United States, as well as deaths from prescription opioids, has nearly quadrupled. However, the overall amount of pain reported by patients has not changed significantly. Specific information about opioid prescriptions in the perioperative period is lacking. Of the studies that have been published, investigators have shown that the majority of patients have unused postoperative opioid pills. Moreover, patients appear to lack information about disposal of unused opioid pills. Purpose: To compare the number of pills prescribed versus the numbers left unused after outpatient shoulder surgeries at an orthopaedic surgery institution. Study Design: Case series; Level of evidence, 4. Methods: In this prospective, observational study, 100 patients (age >18 years) undergoing outpatient shoulder surgery (rotator cuff repair, labral repair, stabilization/Bankart repair, debridement) were enrolled. Follow-ups were conducted via surveys on postoperative days (PODs) 7, 14, 28, and 90. The primary outcome was the number of unused pills from the originally prescribed medication. Results: For all procedure types, the median (Q1, Q3) number of prescribed pills was 60 (40, 80). On POD 90, patients reported a median (Q1, Q3) of 13 (0, 32) unused pills; patients who underwent rotator cuff repairs had the lowest number of pills remaining (median [Q1, Q3], 0 [0, 16]), whereas patients who had stabilization/Bankart repairs had the highest number of unused pills (median [Q1, Q3], 37 [29, 50]). Patient satisfaction with pain management ranged from an average of 70% to 90%. Only 25 patients received instructions or education about opioid disposal. Conclusion: Most outpatient shoulder surgery patients who underwent certain operations were prescribed more opioid analgesics than they consumed. Patient education regarding the disposal of opioids was lacking.