Abstract：
The optimal analgesia for total knee arthroplasty (TKA) requires excellent analgesia while preserving muscle strength. This study aimed to determine the hypothesis that continuous adductor canal block (CACB) combined with the distal interspace between the popliteal artery and the posterior capsule of the knee (IPACK) block could effectively alleviate the pain of the posterior knee, decrease opioids consumption, and promote early recovery and discharge.
Patients undergoing unilateral, primary TKA were allocated into group CACB+SHAM (receiving CACB plus sham block) or group CACB+IPACK (receiving CACB plus IPACK block). The primary outcome was cumulative opioid consumption. Secondary outcomes included the incidence of postoperative pain originated from the posterior knee, visual analogue scale (VAS) score, range of motion, ambulation distance, and satisfaction for pain management.
The incidence of moderate-severe pain of the posterior knee was lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours (17.1% vs. 42.8%; p = 0.019), 8 hours (11.4% vs. 45.7%; p = 0.001), and 24 hours (11.4% vs. 34.3%; p = 0.046) after TKA. The VAS scores of the posterior knee were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [2 (2) vs. 3 (2-4); p = 0.000], 8 hours [1 (1, 2) vs. 3 (2-4); p = 0.001], and 24 hours [1(0-2) vs. 2 (1-4); p = 0.002] after TKA. The overall VAS scores were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [3 (2, 3) vs. 3 (3, 4); p = 0.013] and 8 hours [2 (2, 3) vs. 3 (2-4); p = 0.032] at rest and 4 hours [3 (3, 4) vs. 4 (4, 5); p = 0.001], 8 hours [3 (2-4) vs. 4 (3-5); p = 0.000], 24 hours [2 (2, 3) vs. 3 (2-4); p = 0.001] during active flexion after TKA. The range of motion (59.11 ± 3.90 vs. 53.83 ± 5.86; p = 0.000) and ambulation distance (44.60 ± 4.87 vs. 40.83 ± 6.65; p = 0.009) were superior in group CACB+IPACK than that of the group CACB+SHAM in postoperative day 1. The satisfaction for pain management was higher in group CACB+IPACK than that of the group CACB+SHAM [9 (8, 9) vs. 8 (7-9); p = 0.024]. There was no difference in term of cumulative opioids consumption between group CACB+IPACK and group CACB+SHAM [120(84-135) vs. 120(75-135); p = 0.835].
The combination of CACB and distal IPACK block could decrease the incidences of moderate-severe posterior knee pain, improve the postoperative pain over the first 24 hours after TKA, as well as promoting recovery of motor function. However, the opioids consumption was not decreased by adding distal IPACK to CACB.
This study was registered at Chinese Clinical Trial Registry ( ChiCTR2200059139 ; registration date: 26/04/2022; enrollment date: 16/11/2020; http://www.chictr.org.cn ).
Patients undergoing unilateral, primary TKA were allocated into group CACB+SHAM (receiving CACB plus sham block) or group CACB+IPACK (receiving CACB plus IPACK block). The primary outcome was cumulative opioid consumption. Secondary outcomes included the incidence of postoperative pain originated from the posterior knee, visual analogue scale (VAS) score, range of motion, ambulation distance, and satisfaction for pain management.
The incidence of moderate-severe pain of the posterior knee was lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours (17.1% vs. 42.8%; p = 0.019), 8 hours (11.4% vs. 45.7%; p = 0.001), and 24 hours (11.4% vs. 34.3%; p = 0.046) after TKA. The VAS scores of the posterior knee were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [2 (2) vs. 3 (2-4); p = 0.000], 8 hours [1 (1, 2) vs. 3 (2-4); p = 0.001], and 24 hours [1(0-2) vs. 2 (1-4); p = 0.002] after TKA. The overall VAS scores were lower in group CACB+IPACK than that of the group CACB+SHAM at 4 hours [3 (2, 3) vs. 3 (3, 4); p = 0.013] and 8 hours [2 (2, 3) vs. 3 (2-4); p = 0.032] at rest and 4 hours [3 (3, 4) vs. 4 (4, 5); p = 0.001], 8 hours [3 (2-4) vs. 4 (3-5); p = 0.000], 24 hours [2 (2, 3) vs. 3 (2-4); p = 0.001] during active flexion after TKA. The range of motion (59.11 ± 3.90 vs. 53.83 ± 5.86; p = 0.000) and ambulation distance (44.60 ± 4.87 vs. 40.83 ± 6.65; p = 0.009) were superior in group CACB+IPACK than that of the group CACB+SHAM in postoperative day 1. The satisfaction for pain management was higher in group CACB+IPACK than that of the group CACB+SHAM [9 (8, 9) vs. 8 (7-9); p = 0.024]. There was no difference in term of cumulative opioids consumption between group CACB+IPACK and group CACB+SHAM [120(84-135) vs. 120(75-135); p = 0.835].
The combination of CACB and distal IPACK block could decrease the incidences of moderate-severe posterior knee pain, improve the postoperative pain over the first 24 hours after TKA, as well as promoting recovery of motor function. However, the opioids consumption was not decreased by adding distal IPACK to CACB.
This study was registered at Chinese Clinical Trial Registry ( ChiCTR2200059139 ; registration date: 26/04/2022; enrollment date: 16/11/2020; http://www.chictr.org.cn ).
摘要：
全膝关节置换术（TKA）的最佳镇痛需要出色的镇痛，同时保持肌肉力量。本研究旨在确定以下假设：连续内收肌管阻滞（CACB）结合the动脉和膝关节后囊之间的远端间隙（IPACK）阻滞可以有效缓解膝关节后端的疼痛。减少阿片类药物的消费，促进早期康复和出院。
接受单侧治疗的患者，主要TKA分为CACB+SHAM组(接受CACB+假阻断)或CACB+IPACK组(接受CACB+IPACK阻断).主要结果是累积阿片类药物消耗。次要结果包括源自膝关节后端的术后疼痛发生率，视觉模拟量表（VAS）评分，运动范围,步行距离,以及疼痛管理的满意度。
在4小时时，CACB+IPACK组的后膝中重度疼痛发生率低于CACB+SHAM组（17.1%vs.42.8%；p=0.019)，8小时（11.4%vs.45.7%；p=0.001)，和24小时(11.4%vs.34.3%；p=0.046）TKA后。4小时时CACB+IPACK组膝关节后端VAS评分低于CACB+SHAM组[2(2)vs.3（2-4）；p=0.000]，8小时[1(1,2)vs.3（2-4）；p=0.001]，和24小时[1（0-2）vs.2（1-4）；TKA后p=0.002。在4小时时，CACB+IPACK组的总体VAS评分低于CACB+SHAM组[3（2，3）vs.3（3，4）;p=0.013]和8小时[2（2，3）与3（2-4）;p=0.032]在休息和4小时[3（3，4）vs.4(4，5)；p=0.001]，8小时[3（2-4）vs.4（3-5）；p=0.000]，24小时[2（2，3）vs.3（2-4）；TKA后主动屈曲期间p=0.001]。运动范围(59.11±3.90vs.53.83±5.86；p=0.000）和步行距离（44.60±4.87vs.40.83±6.65；p=0.009）在术后第1天，CACBIPACK组优于CACBSHAM组。CACB+IPACK组对疼痛管理的满意度高于CACB+SHAM组[9（8，9）vs.8（7-9）；p=0.024]。CACB+IPACK组和CACB+SHAM组[120(84-135)vs.120（75-135）；p=0.835]。
联合应用CACB和远端IPACK阻滞可以降低中重度膝关节后疼痛的发生率，改善TKA术后24小时的术后疼痛，以及促进电机功能的恢复。然而,向CACB中添加远端IPACK并没有减少阿片类药物的消耗量.
本研究在中国临床试验注册中心（ChiCTR2200059139；注册日期：26/04/2022；注册日期：16/11/2020；http://www。chictr.org.cn)。
接受单侧治疗的患者，主要TKA分为CACB+SHAM组(接受CACB+假阻断)或CACB+IPACK组(接受CACB+IPACK阻断).主要结果是累积阿片类药物消耗。次要结果包括源自膝关节后端的术后疼痛发生率，视觉模拟量表（VAS）评分，运动范围,步行距离,以及疼痛管理的满意度。
在4小时时，CACB+IPACK组的后膝中重度疼痛发生率低于CACB+SHAM组（17.1%vs.42.8%；p=0.019)，8小时（11.4%vs.45.7%；p=0.001)，和24小时(11.4%vs.34.3%；p=0.046）TKA后。4小时时CACB+IPACK组膝关节后端VAS评分低于CACB+SHAM组[2(2)vs.3（2-4）；p=0.000]，8小时[1(1,2)vs.3（2-4）；p=0.001]，和24小时[1（0-2）vs.2（1-4）；TKA后p=0.002。在4小时时，CACB+IPACK组的总体VAS评分低于CACB+SHAM组[3（2，3）vs.3（3，4）;p=0.013]和8小时[2（2，3）与3（2-4）;p=0.032]在休息和4小时[3（3，4）vs.4(4，5)；p=0.001]，8小时[3（2-4）vs.4（3-5）；p=0.000]，24小时[2（2，3）vs.3（2-4）；TKA后主动屈曲期间p=0.001]。运动范围(59.11±3.90vs.53.83±5.86；p=0.000）和步行距离（44.60±4.87vs.40.83±6.65；p=0.009）在术后第1天，CACBIPACK组优于CACBSHAM组。CACB+IPACK组对疼痛管理的满意度高于CACB+SHAM组[9（8，9）vs.8（7-9）；p=0.024]。CACB+IPACK组和CACB+SHAM组[120(84-135)vs.120（75-135）；p=0.835]。
联合应用CACB和远端IPACK阻滞可以降低中重度膝关节后疼痛的发生率，改善TKA术后24小时的术后疼痛，以及促进电机功能的恢复。然而,向CACB中添加远端IPACK并没有减少阿片类药物的消耗量.
本研究在中国临床试验注册中心（ChiCTR2200059139；注册日期：26/04/2022；注册日期：16/11/2020；http://www。chictr.org.cn)。
