The Effect of the Popliteal Plexus Block on Postoperative Opioid Consumption, Pain, Muscle Strength and Mobilization After Total Knee Arthroplasty - a Randomized, Controlled, Blinded Study
Overview
- Phase
- Phase 4
- Intervention
- Marcain 5 mg/ml
- Conditions
- Pain, Acute
- Sponsor
- Regionshospitalet Silkeborg
- Enrollment
- 165
- Locations
- 1
- Primary Endpoint
- Total opioid consumption in each group, A, B and C
- Status
- Completed
- Last Updated
- 2 years ago
Overview
Brief Summary
In this study we wish to investigate the analgesic effect 3 different nerve block regimes in patients following primary total knee arthroplasty (TKA). All nerve blocks were performed as single shot blocks with the administration of Marcain 5 mg/ml.
Regime A: proximal Femoral Triangle Block (FTB) with 10 ml including Intermediate Femoral Cutaneous Nerve Block (IFCNB) with 5 ml + Popliteal Plexus Block (PPB) with 10 ml.
Regime B: proximal FTB with 10 ml including IFCNB with 5 ml.
Regime C: Adductor Canal Block (ACB) with 25 ml.
Detailed Description
The Adductor Canal Block (ACB) is frequently used after TKA, but it is limited to provide anesthesia from the anteromedial part of the knee region. The proximal Femoral Triangle Block (FTB) is also used for TKA, and also limited to provide anesthesia from the anterior medial part of the knee joint. The FTB anesthetize the saphenus nerve, the nerve to vastus medialis, and may anesthetize the medial femoral cutaneous nerve which innervates the distal medial thigh as well as the anteromedial knee region. We included the Intermediate Femoral Cutaneous Nerve block (IFCNB) in the FTB, as the nerves can be targeted in the subcutis on the anterior thigh and easily be anesthetized during the same procedure as FTB. IFCNB anesthetize the distal anterior thigh, which may include the proximal part of the surgical incision for TKA. In the following text the proximal FTB including IFCNB will be refered as "FTB" and the dose of 15 ml will refer to 10 ml for the proximal FTB and 5 ml used for the IFCNB. A new nerve block technique, called Popliteal Plexus Block (PPB), is specifically designed to anaesthetize nerves involved in innervation of the back of the knee joint. The analgesic effect of PPB has not yet been evaluated in randomized, controlled, blinded trials. In order to optimize pain treatment for primary TKA by improving the pain-relieving effect of peripheral nerve blocks, we aim to evaluate the analgesic effects of three different nerve block regimens (FTB + PPB versus FTB versus ACB) after primary unilateral TKA. Our outcomes include postoperative pain scores, opioid consumption, muscle strength and mobilization. Our hypothesis is that the combination of FTB + PPB provides superior postoperative pain treatment after TKA in comparison to both FTB or ACB. The combination of FTB + PPB will reduce opioid consumption (primary outcome) and postoperative pain scores without reducing muscle strength or impairing mobilization.
Investigators
Johan Kløvgaard Sørensen
Specialist Registrar
Regionshospitalet Silkeborg
Eligibility Criteria
Inclusion Criteria
- •Scheduled to undergo primary total knee arthroplasty in spinal anesthesia
- •Able to perform a Timed Up and Go (TUG) test
- •Age \> 50 years old
- •Ability to give their written informed consent to participating in the study after having fully understood the contents of the study
- •American Society of Anesthesiologists (ASA) physical status 1, 2, or 3
Exclusion Criteria
- •Patients who cannot cooperate
- •Patients who cannot understand or speak Danish.
- •Patients with allergy or intolerance to the medicines used in the study
- •Patients with a daily intake of strong opioids (morphine, oxycodone, ketobemidone, methadone, fentanyl)
- •Patients suffering from alcohol and/or drug abuse - based on the investigator's assessment
- •BMI \> 40
- •Diagnosed with chronic central or peripheral neurodegenerative disorders
Arms & Interventions
Group A: Active FTB + Active PPB + Sham ACB
Single shot bolus of 10 ml Marcain 5 mg/ml is used for FTB, 5 ml Marcain 5 mg/ml for IFCN + 10 ml Marcain 5 mg/ml is used for PPB
Intervention: Marcain 5 mg/ml
Group B: Active FTB + Sham PPB + Sham ACB
Single shot bolus of 10 ml Marcain 5 mg/ml is used for FTB, 5 ml Marcain 5 mg/ml is used for IFCN
Intervention: Marcain 5 mg/ml
Group C: Sham FTB + Sham PPB + Active ACB
Single shot bolus of 25 ml Marcain 5 mg/ml is used for ACB
Intervention: Marcain 5 mg/ml
Outcomes
Primary Outcomes
Total opioid consumption in each group, A, B and C
Time Frame: from time of skin closure (end of surgery) until 24 hours postoperative
Total opioid consumption is the aggregate of the opioid administered by the Patient Controlled Analgesia (PCA) pump and any potential rescue opioids administered, calculated as IV morphine equivalents
Secondary Outcomes
- Pain during 90 degrees active flexion of the knee(preoperative (preblock baseline), 2, 5 (prior to TUG test), 7, 20 and 24 hours after time of skin closure (end of surgery))
- Total opioid consumption in each group, A, B and C(from time of skin closure (end of surgery) until 12 hours postoperative)
- Post-block Maximum Voluntary Isometric Contraction (MVIC) by knee extension, calculated as a percentage of the Pre-block baseline value(A 60 minutes interval is between pre-block and post-block MVIC assessments)
- Post-block MVIC by ankle plantarflexion, calculated as a percentage of the Pre-block baseline value(A 60 minutes interval is between pre-block and post-block MVIC assessments)
- Post-block MVIC by ankle dorsiflexion, calculated as a percentage of the Pre-block baseline value(A 60 minutes interval is between pre-block and post-block MVIC assessments)
- Worst pain during TUG(Assessed at the end og the TUG test, 5 hours after time of skin closure (end of surgery))
- Muscle strength of knee extension, graded by Manual Muscle Test (MMT)(Assessed pre-block, post-block (60 minutes after pre-block) and postoperative 5 hours after time of skin closure (end of surgery))
- Muscle strength of ankle plantarflexion, graded by MMT(Assessed pre-block, post-block (60 minutes after pre-block) and postoperative 5 hours after time of skin closure (end of surgery))
- Muscle strength of ankle dorsiflexion, graded by MMT(Assessed pre-block, post-block (60 minutes after pre-block) and postoperative 5 hours after time of skin closure (end of surgery))
- Timed Up and Go (TUG) test postoperative(Assessed 5 hours after time of skin closure (end of surgery))
- Pain at rest(preoperative (preblock baseline), 2, 5 (prior to TUG test), 7, 20 and 24 hours after time of skin closure (end of surgery))