Comparison of 4 in 1 block with modified 4 in 1 block using ultrasound for postoperative analgesia in cruciate ligament reconstruction in knee surgeries.

Total knee arthroplasty or replacement (TKA), arthroscopic knee surgeries are one of the most commonly performed, life-changing surgical procedures, leading to improved health-related quality of life and functional status, therefore these surgeries demand better outcomes with minimal morbidity and mortality and early mobilisation and discharge. The central neuraxial blocks were associated with higher complications, morbidity and delayed ambulation. The regional techniques provide a better and early outcome as compared to the central neuraxial techniques. Regional analgesia (RA) is an important component of multimodal analgesia to deal with perioperative pain. Regional anaesthesia includes epidural analgesia, femoral nerve block, adductor canal block, sciatic nerve block, IPACK, etc. But these blocks have many drawbacks. Femoral nerve block is associated with quadriceps muscle weakness leading to delay in patient’s mobility. Sciatic nerve block also causes foot drop. The Adductor canal block does not cover the skin on the back of the knee. Surgeons refuse IPACK because of diffusion of local anaesthetics disturbs the anatomy of the surgical field. 70 Patients between the age group of 20 to 50 years old of either sex belonging to ASA I and II will included in the study. Using computer generated randomisation, patients will be allotted in to two groups of 35 each. One group will receive the newly developed regional technique Modified 4 in 1 block with the addition of USG and PNS guided Vastus medialis nerve block. The patients in this block will receive 20ml injection bupivacaine 0.25% and 2ml of injection dexamethasone 8mg added as adjuvant (total volume of drug 22ml). The second group will receive the 4 in 1 block. In this technique , the vastus and sartorius intersection (antero medial intermuscular septum) will be identified and the probe will be slide proximally till the superficial femoral artery appearing in the adductor hiatus. The probe will slide slowly proximally till the descending genicular artery branching from superficial femoral artery will be visualized in the hiatus. This point will be the point of interest. The point will be 8–10 cm above the femoral condyle. At this point, 20 mL of 0.25% Bupivacaine and 2ml (8mg) dexamethasone will be injected after confirmation of negative aspiration of blood and no excess pressure upon injection. The needle was guided further in plane from lateral to medial side under USG guidance to reach perivascular region and after negative aspiration 22ml of total drug will be injected, visualized to push the femoral artery posteriorly ( total amount of drug given is 22ml). The patient’s vitals, VAS score, total analgesic consumption and quadriceps muscle strength will be noted at regular intervals for 48 hours post operatively and the data will be compiled and will be send for statistical analysis.