International Journal of Orthopaedics Sciences 2017; 3(2): 141-145
ISSN: 2395-1958
IJOS 2017; 3(2): 141-145
© 2017 IJOS
www.orthopaper.com
Received: 21-02-2017
Accepted: 22-03-2017
Dr. AV Gururva Reddy
Sunshine Hospitals Penderghast
Road, Opposite Parsi
Dharamsala, Behind Paradise
Hotel, Secunderabad, Telangana
India
Dr. Ajit Jangale
Sunshine Hospitals Penderghast
Road, Opposite Parsi
Dharamsala, Behind Paradise
Hotel, Secunderabad, Telangana
India
Dr. RC Reddy
Sunshine Hospitals Penderghast
Road, Opposite Parsi
Dharamsala, Behind Paradise
Hotel, Secunderabad, Telangana
India
Dr. Murlidhar Sagi
Sunshine Hospitals Penderghast
Road, Opposite Parsi
Dharamsala, Behind Paradise
Hotel, Secunderabad, Telangana
India
Dr. Arshaj Gaikwad
Sunshine Hospitals Penderghast
Road, Opposite Parsi
Dharamsala, Behind Paradise
Hotel, Secunderabad, Telangana
India
Dr. Adarsh Reddy
Sunshine Hospitals Penderghast
Road, Opposite Parsi
Dharamsala, Behind Paradise
Hotel, Secunderabad, Telangana
India
Correspondence
Dr. AV Gururva Reddy
Sunshine Hospitals Penderghast
Road, Opposite Parsi
Dharamsala, Behind Paradise
Hotel, Secunderabad, Telangana
India
To compare effect of combined block of adductor canal
block (ACB) with IPACK (Interspace between the
Popliteal Artery and the Capsule of the posterior Knee)
and adductor canal block (ACB) alone on Total knee
replacement in immediate postoperative rehabilitation
Dr. AV Gururva Reddy, Dr. Ajit Jangale, Dr. RC Reddy, Dr. Murlidhar
Sagi, Dr. Arshaj Gaikwad and Dr. Adarsh Reddy
DOI: http://dx.doi.org/10.22271/ortho.2017.v3.i2c.21
Abstract
Introduction: Pain management in total knee arthroplasty is aimed to minimize postoperative pain and
improve functional outcomes in patients. Although there are many methods used for controlling the pain
there has been no consensus on most appropriate or the best protocol. Adductor canal block (ACB) has
the unique advantage of providing localized analgesia but it doesn’t provide pain relief to the posterior
capsule, it has been postulated that IPACK (interspace between the popliteal artery and the capsule of the
knee) combined with ACB will provide better pain relief than ACB alone.
Materials and Methods: 60 Patients were studied in two groups. Group A had those patients with
ACB+ ipack and Group B had ACB.
Group A -Patient were subjected to combined ACB block with IPACK.
Group B –Patient in this group were given ACB.
Patient were studied for pain score VAS on Day 0 and Day 1 morning and evening, range of movement
at postoperative Day 1 and distance walked on Day 1.
Results: Group B had better outcome as compared to Group A. The mean VAS score for the
ACB+IPACK group was less than for ACB alone at end of Day 0 and Day 1 in morning and evening.
The ROM for the ACB+IPACK group was better than ACB alone and number of steps walked by
patients were more in ACB+IPACK as compared to ACB alone. The statistical difference was significant
when Adductor +IPACK group was compared to Adductor group for VAS, ROM and number of steps
walked.
Conclusion: ACB+IPACK is better mode than ACB for control of postoperative pain in patient
undergoing Total knee replacement. IPACK is relatively safe and combined with adductor canal block
decreases posterior pain in TKR patients.
Keywords: IPACK, Adductor canal block, Genicular block, Pain control, Total knee arthroplasty
1. Introduction
The total knee arthroplasty has become a standard successful modality for treatment of
advance osteoarthritis of knee joint. Total knee arthroplasty (TKA) has proven to be a
successful treatment to improve mobility, pain and quality of life for patients suffering from
osteoarthritis. Though there have been advances in technologies and instrumentations in TKR,
pain management after the operation is still evolving [1, 2]. Pain management in total knee
arthroplasty is aimed to minimize postoperative pain and improve functional outcomes in
patients. Proper pain management in perioperative period is important for faster recovery and
rehabilitation which influences the desired outcome [3, 4]. Various methods described for pain
management after TKR are epidural anesthesia, femoral nerve block, adductor canal block,
intra articular cocktail, intraarticular epidural catheter (Caledonion protocol) along with I.V
analgesics and combinations of these modalities. Although there are many methods used for
controlling the pain there has been no consensus on most appropriate or the best protocol. [5, 6].
Femoral nerve block (FNB) is one of the most commonly used pain-relief methods, which has
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been proven to be effective on relieving the pain, reducing the
usage of opoid painkiller, and shortening the hospital stays [7,
8],
but FNB may lead to post-operative quadriceps weakness,
which not only limits the patients ambulation and early
physical rehabilitation, but also increases the risk of falling [9,
10]
. These deficiencies make the rehabilitation results
unsatisfactory [11, 12]. Adductor canal block (ACB) is the other
analgesia for TKA and has been developed gradually in recent
years. ACB attracted extensive attention due to its lower
complication of reducing quadriceps strength and similar
outcomes of opioid consumption, pain management, opioid
adverse events, and ambulation ability when compared with
FNB [13-16]. There are studies in literature which compare FNB
with ACB and have concluded that ACB is better than FNB
also ACB have been combined with intra articular and
periarticular local anaesthetist injections intraoperatively.
Adductor canal block (ACB) has the unique advantage of
providing localized analgesia to the peripatellar and intraarticular aspects of the knee joint without reducing the
patient's ability to perform a straight leg raise but ACB does
not provide analgesia to the posterior aspect of the knee, which
is commonly moderate to severe after surgery. This pain may
be decreased by addition of the genicular block, also known as
the iPACK block (interspace between the popliteal artery and
the capsule of the knee). The aim of this study was to compare
effect of combined block of adductor canal block with IPACK
(Interspace between the Popliteal Artery and the Capsule of
the posterior Knee) and adductor canal block on Total knee
replacement in immediate postoperative rehabilitation. It has
been postulated that ultrasound-guided local anesthetic
infiltration of the Interspace between the Popliteal Artery and
the Capsule of the posterior Knee (IPACK) provides posterior
knee analgesia and the iPACK would spare the main trunk of
the tibial and peroneal nerves and block only the terminal
branches innervating the posterior knee joint. IPACK was
proposed by research team at St. Francis Hospital and Medical
Center in Hartford, Conn., It is an ultrasound-guided
infiltration of the interspace between the popliteal artery and
the capsule of the knee with a local anesthetic solution that
provides an alternative analgesic when combined with a
femoral nerve block [17].
2. Materials and Methods
This study was conducted at Sunshine hospital from July 2016
to December 2016. This study was conducted as a single blind
randomized controlled trial (RCT) at a single institution.
Approval was provided by a human research ethics committee.
The study included patients from single arthroplasty surgeon.
This was a prospective study with sample size of 60 patients in
each group. Patients undergoing primary unilateral TKA were
invited to take part in the study and informed consent was
obtained from patients willing to participate. Inclusion criteria
was unilateral cases, Serum Creatinine below 1.5.Exclusion
criteria were Bilateral cases (same sitting as well as staggered
cases) Rheumatoid arthritis, inflammatory arthroplasty,
revision cases, Bedridden/ non ambulatory after the surgery
were excluded. Preliminary statistical analysis showed that a
minimum of 60 patients in each group.
Sealed opaque envelopes were made based upon random
numbers generated by computer. These envelopes were only
accessible to the anesthesiologist who provided the Block
injection material for each participant patients and the data
collection team was blinded to the group to which the patients
were randomized. The anesthesiologist who prepared the
treatment solution was aware of the allocation and surgeon
was not aware of the treatment and both were not involved in
data collection or data analysis. Randomization was not
stratified by surgeon. The anesthesiologist also informed the
scrub nurse of the group allocation, who then prepared the
appropriate solution to be given. Post-operatively, patients and
the Data collection team were blinded to the treatment
administered in operation theatre.
Group A -Patient undergoing total knee replacement unilateral
were subjected to combined Adductor canal block (ACB) with
IPACK. All cases of adductor canal block were given 20 ml of
0.2% ropivacaine and for IPACK 20 ml of 0.2% ropivacaine.
Group B –Patient in this group were given adductor canal
block which comprised of 20 ml of 0.2% ropivacaine.
Adductor canal block was given by standard method described
in literature.
2.1 Technique for IPACK: The knee was bent in 90 degreee
flexion and needle was inserted from medial aspect, though
one can give from lateral aspect also, our Anesthetist was
comfortable to give medially. (Picture 1) With the
Ultrasonography the popliteal vessels were identified and and
Needle was inserted in the space between the vessels and the
posterior capsule. (Picture 2) The needle is inserted along the
entire space between the vessels and capsule and 20 ml of
0.2% ropivacaine is given along the entire space and
simultaneously the needle is withdrawn while the local
anaesthesia is still being given. (Picture 3)
Needle is inserted from the
medial aspect of thigh just above
the knee joint line
Picture 1
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International Journal of Orthopaedics Sciences
Popliteal vessels
Knee joint capsule
Picture 2
Popliteal vessels
Needle-Ropivacaine given
Knee Capsule
Picture 3
Table 2: Descriptive Statistics
All patients undergoing the study were subjected to same
amount of I.V NSAIDS, I.V paracetamol, and Tramadol in
perioperative period.
IPACS +ACB Age
ACB age
ACB Female
ACB male
IPACS+ACB Female
IPACS +ACB male
2.2 Surgical Technique
Total knee arthroplasty was performed under spinal anesthesia
combined with sedation and by a medial parapatellar approach
in all cases. Single surgeon operated all cases. Tourniquet was
used in all cases and released before closure.
The patella was debulked and denervated in all patients.
Surgical drains were not used in any patient.
N
60
61
42
18
38
22
Mean
66.6000
63.3279
62.3488
65.6667
66.1842
67.3182
Table 3:
P
Value
60
2.9167±0.64550
3.1833±0.72467
3.4500±0.67460
62.2500± 8.25
Adductor+
IPACK
60
1.4333±0.6474
2.05±0.4323
2.55±0.7274
71.8333 ± 9.52
7.1333±1.434
8.51±1.85
0.000
Adductor
2.3 Measurement of Outcome
Outcome was measured with VAS score at 8 pm night same
day of operation and next day again in morning 8 am and night
8 pm and on day 2 mornings.
Range of movement was measured on Day 1 after the dressing
in morning along with VAS score.
Number of steps walked by the patient on Day 1 morning was
recorded.
2.4 Statistical analysis
Outcome was compared statistically by student T test
3. Observation and Results
Table 1: Sample Size
Male
Female
IPACS+adductor
22
38
60
Adductor
18
42
60
Standard Deviation
±8.82254
±6.24959
±6.71489
±4.27028
±8.98303
±8.69804
N
VAS Day 0
VAS Day 1 -8 am
VAS Day 1-8 pm
ROM Day 1
Distance walked
Day 1
0.000
0.000
0.000
0.000
The total patients included in each group were 60 (Table 1)
and baseline variables of Age and sex were comparable in both
groups. The mean VAS score for Adductor block group was
2.91, 3.18, 3.45 at end of Day 0 and Day 1 in morning and
evening whereas the Adductor +IPACK group the mean VAS
score was 1.433,2.05,2.55 at end of Day 0 and Day 1 in
morning and evening. (Table 2) The ROM for Adductor group
was 62.25 degrees and distance walked in steps was 7.13 steps
whereas the Adductor +IPACK group has mean ROM of
71.833 and steps walked was 8.51. (Table 2).
The statistical difference was significant (P value < 0.0001)
when Adductor +IPACK group was compared to Adductor
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group for VAS, ROM and number of steps walked. (Table 3)
Statistics tool: SPSS 16.0
4. Discussion
Pain management is integral part of postoperative management
of Total knee arthroplasty (TKA) patients. There are different
modalities of pain management for postoperative TKA
patients.
There is only one study in literature by Elliot et al showing
ACB+IPACK reduces the stay as well as improves the
physical therapy response. Pain scores, opioid consumption,
physical therapy performance, and time to discharge were
recorded in this study and they concluded that, ACB/iPACK
group had non-inferior VAS scores with slightly higher opioid
consumption compared with the FNB/iPACK group. However,
the ACB/iPACK group had significantly better ambulation
distance and the group also had more discharges on POD1 and
POD2, and all patients in this group were discharged by POD
[18]
.
In our study of 2 groups adductor block (ACB) against
ACB+IPACK, we found that ACB+IPACK had significant
more ROM and better ambulatory distance as compared with
adductor alone. In our study VAS score of ACB+IPACK was
better on day 0 as well as day one as compared to adductor
alone.
Intraarticular injections were not in both groups to avoid any
bias due to site of injection, the variation in the needle
diameter. The main complain of patients with only adductor
block on Day 1 was pain in posterior region of knee joint.
There are multiple other modalities for pain management after
knee replacement. Also there is no consensus on the best
method to control pain management. According to previous
studies, some studies suggest local infiltration of injection
(LIA) is superior to Femoral nerve block on pain management
[19]
some studies report an equal outcome between the two
methods [20,21] while other studies demonstrate LIA is inferior
to FNB on pain control [22,23].Ashraf et al [24] conducted a RCT
to compare intra-articular analgesia with single shot FNB after
TKA and they demonstrated better pain control and less opiate
consumption in patients that received LIA. While, Ali et al [25]
suggest that continuous intra-articular analgesia after TKA has
no relevant clinical effect on VAS pain and does not affect
analgesic consumption, ROM, or leg-raising ability. A study
presented by Jaeger et al [26] comparing ACB with FNB in
patients undergoing TKA, demonstrated that both groups
showed preserved quadriceps strength, similar pain scores and
opioid consumption. A recent study comparing continuous
ACB with placebo infusion following TKA demonstrated
reduced opioid consumption in the first 48h with ACB [27].
In our study we had better pain control as well as better ROM
and ambulatory distance for ACB+IPACK as compared to
ACB alone on Day 1. As the adductor canal block gives relief
from pain of knee joint anteriorly and medially but it doesn’t
cover the posterior capsule as the deep small genicular nerves
are not covered by adductor alone. The benefit of adding
IPACK is the entire posterior space between capsule and
popliteal vessels can be given the local anaesthesia of 15 ml
and it adds up to the pain relief of the posterior capsule
significantly. As it is given under Ultrasound guidance it
avoids any injury to popliteal vessels which may happen while
local infiltration of cocktail used theoretically.
The drawback of our study was that obese patient were
excluded and patient having creatinine above 1.5 were
excluded so that we could follow our post-operative protocals
of analegisa for all the patients in the both groups (opiods,
Paracetamol and NASID were given to all patients at the
particular time).The study follow up was only for short term
till day 1 evening.
Authors opinion is that combined multimodal approach of pain
management should be done to have effective pain
management in perioperative period. It should include the
adductor block with IPACK combined with some form of intra
articular injections or epidural catheter insertion.
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