Background: The aim of this study was to compare the postoperative analgesic efficacy when a tibial nerve block was added to the femoral nerve block for total knee arthroplasty (TKA). Methods: A total of 60 patients were randomly assigned to the experimental group (EG) or the control group (CG) in a 1:1 ratio. The thirty patients who formed the CG underwent an ultrasound-guided femoral nerve block together with neuraxial anaesthesia and the administration of opioids and NSAIDs through an intravenous elastomeric pump for the management of the postoperative pain; the other thirty, who formed the EG, underwent neuraxial anaesthesia together with femoral and tibial nerve blocks. The efficacy of the analgesic effect was evaluated based on the numerical pain rating scale (NPRS) and on the need for analgesic rescue at different time intervals within 48 h after surgery. Results: At 24 h, the mean NPRS score in the EG and CG at rest was 1.50 ± 1.19 and 1.63 ± 1.60 [U = 443.5, p = 0.113], respectively. With joint movement, the mean NPRS score was 2.80 ± 1.49 and 3.57 ± 1.79 [U = 345, p = 0.113], respectively. Ten patients in the EG [33.3%] and 24 in the CG [80%] required rescue analgesia [Phi = 0.471, p < 0.001]. At 48 h, the mean NPRS score in the EG and CG at rest was 0.33 ± 0.60 and 0.43 ± 0.72 [U = 428, p = 0.681], respectively. With movement, the mean NPRS score was 1.03 ± 0.99 in the EG and 1.60 ± 1.07 in the CG [U = 315, p = 0.038]. No patient in the EG group required rescue analgesia, while three patients in the CG [10%] did [Phi = 0.229, p = 0.076]. The mean opioid dosage in the CG was 300 mg, whereas in the EG it was 40 mg ± 62.14 [U < 0.05, p < 0.001]. Conclusions: Adding a tibial nerve block to the femoral nerve block in TKA may achieve the same analgesic efficacy within 48 h after surgery and would reduce the systematic use of opioids.

BACKGROUND: The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the accuracy and efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged behind in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. The objective of this study was to compare the accuracy of traditional anatomical landmark-guided technique with an ultrasound-guided approach for ankle block by assessing the spread of injectate along the posterior tibial nerve (PTN) in cadaver models.
METHODS: Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo anatomical landmark-guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The anatomical landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN, with the needle subsequently advanced in-plane with a posterior to anterior trajectory until the tip was adjacent to the nerve. Each specimen was injected with 2 mL of acrylic dye. All the specimens were dissected following injection to determine which nerves had been successfully coated with dye.
RESULTS: The PTN was successfully coated with dye in all five (100%) ultrasound-guided blocks. In the anatomical landmark group, two (40%) PTN were successfully coated with dye. Of the three unsuccessful attempts, two specimens were noted to have dye injected posterior to the PTN; dye was injected into the flexor digitorum longus tendon in one.
CONCLUSIONS: The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate of delivering a simulated nerve block to the correct anatomic location.

An ultrasound-guided anesthetic technique targeting the interspace between the popliteal artery and capsule of the posterior knee (iPACK) can provide posterior knee analgesia with preserved motor function after total knee arthroplasty (TKA). This study compared the peroneal nerve motor-sparing effects of iPACK block and tibial nerve block (TNB) when combined with local infiltration analgesia (LIA) and continuous adductor canal block (CACB).
In this study, 105 patients scheduled for elective TKA were randomized to receive proximal iPACK block (iPACK1), distal iPACK block (iPACK2), or TNB, along with spinal anesthesia, modified LIA, and CACB. The primary outcome was the incidence of common peroneal nerve (CPN) motor blockade. Secondary outcomes included CPN sensory function, tibial sensorimotor function, posterior knee pain, pain score, intravenous morphine requirement, timed up-and-go test, quadriceps muscle strength, range of motion, length of hospital stay, patient satisfaction, and adverse events.
The incidence of CPN motor blockade was significantly higher in the TNB group than in the iPACK1 (p=0.001) and iPACK2 (p=0.001) groups, but was not significant between the iPACK1 and iPACK2 groups (p=0.76). Tibial nerve motor function was more preserved in the iPACK1 and iPACK2 groups than in the TNB group (p<0.001 and p<0.001, respectively). Complete CPN and tibial sensorimotor blockade were not observed in the iPACK2 group. Posterior knee pain score was significantly higher in the iPACK1 group than in other groups during the 24-hour postoperative period (p=0.001).
Compared with TNB, iPACK1 and iPACK2 preserved CPN and tibial nerve motor function to a greater extent. However, iPACK2 did not demonstrate complete CPN and tibial nerve motor blockade while maintaining effective posterior knee pain relief.
TCTR20180206002.

Following forefoot surgery, compared to the traditional multimodal approach, regional anesthesia and analgesia provides high quality pain relief, decreases opioids consumption and leads to very high satisfaction scores. Traditional regional techniques relied either on wound infiltration, landmark technique ankle blocks or popliteal sciatic nerve block. Numerous anatomic variations of the different nerves might lead to failure following a blind technique. The current evolution towards ambulatory care will push surgical teams to favor techniques that simplify postoperative treatment and encourages immediate ambulation. The development of Ultrasound Guided Blocks has enabled us to perform very selective and precise nerve blocks. Ankle blocks provide excellent intraoperative anesthesia as well as long postoperative pain relief. Complications are rare using regional anesthesia for postoperative analgesia even after extensive foot surgery. Revival of ankle blocks is a perfect example of the high impact of new technological advances in improving ambulatory surgical care after foot surgery.

Peripheral nerve block and local infiltration analgesia (LIA) have an increasing role as part of multimodal analgesia for enhanced recovery after total knee arthroplasty (TKA). We hypothesized that the combination of obturator nerve block (ONB) and tibial nerve block (TNB) would reduce pain and opioid consumption more than ONB or TNB alone when combined with continuous adductor canal block and LIA.
Ninety patients were recruited into the study and received spinal anesthesia, LIA, and continuous adductor canal block. They were further randomized to receive either an ONB (group 1), a TNB (group 2), or both (group 3). The primary outcome was total morphine consumption over the postoperative 24 hours. The secondary outcomes included visual analog scale scores, time to first and total dosage of rescue analgesia, Timed Up and Go test, range of motion, muscle strength test, hospital stay, and patient satisfaction.
Eighty-nine patients completed analysis. The median total morphine consumption during the first 24 postoperative hours was 2 mg (interquartile range [IQR] 0-4) in group 3, 4 mg (IQR 2-8) in group 2, and 6 mg (IQR 6-14) in group 1 (P < .001). Posterior knee pain during the first 24 hours postoperatively was significantly lower in group 3 than in group 1 (P = .006). The ability to ambulate and quadriceps strength were significantly better in group 3 than in the other groups.
The combination of triple nerve block was superior to double nerve block in improving analgesia and functional outcomes in the immediate postoperative period after total knee arthroplasty, when combined with LIA.

The increasing scope and complexity of foot and ankle procedures performed in an outpatient setting require more intensive perioperative analgesia. Regional anesthesia (popliteal and saphenous nerve blocks) has been proven to provide satisfactory pain management, decreased postoperative opioid use, and earlier patient discharge. This can be further augmented with the placement of a continuous-flow catheter, typically inserted into the popliteal nerve region. This study investigated the use of a combined popliteal and saphenous continuous-flow catheter nerve block compared to a single popliteal catheter and single-injection saphenous nerve block in postoperative pain management after ambulatory foot and ankle surgery.
A prospective study was conducted using 60 patients who underwent foot and ankle surgery performed in an outpatient setting. Demographic data, degree of medial operative involvement, American Society of Anesthesiologists physical classification system, anesthesia time, and postanesthesia care unit time were recorded. Outcome measures included pain satisfaction, numeric pain scores (NPS) at rest and with activity, and opioid intake. Patients were also classified by degree of saphenous nerve involvement in the operative procedure, by the surgeon who was blinded to the anesthesia randomization.
Patients in the dual-catheter group took significantly less opioid medication on the day of surgery and postoperative day 1 (POD 1) compared to the single-catheter group ( P = .02). The dual-catheter group reported significantly greater satisfaction with pain at POD 1 and POD 3 and a significantly lower NPS at POD 1, 2, and 3. This trend was observed in all 3 subgroups of medial operative involvement.
Patients in the single-catheter group reported more pain, less satisfaction with pain control, and increased opioid use on POD 1, suggesting dual-catheter use was superior to single-injection nerve blocks with regard to managing early postoperative pain in outpatient foot and ankle surgery.
Level II, prospective cohort study.