Comparison Of The Analgesic Efficacy Of IPACK (Interspace Between The Popliteal Artery And Capsule Of The Posterior Knee) Block Alone And IPACK Block Combined With Genicular Block In Patients Planned For Total Knee Arthroplasty
Condition: Pain, Joint; Knee Arthropathy; Anesthesia; Orthopedic Disorder
MeSH terms: Musculoskeletal Diseases; Arthralgia
Study type: Interventional

Summary: 
      The IPACK (interspace between the popliteal artery and capsule of the posterior knee) block
      is a regional anesthesia technique in which a local anesthetic is infiltrated under
      ultrasound guidance between the popliteal artery and the capsule of the posterior knee. This
      technique blocks the branches of the obturator nerve, the common peroneal nerve, and the
      tibial nerve in the popliteal region. In the context of knee arthroplasty, the application of
      the IPACK block has been associated with lower scores for ambulatory pain, lower scores for
      resting pain, and reduced morphine consumption .

      The genicular nerves, including the superomedial, inferomedial, superolateral, inferolateral
      genicular nerves, and the infrapatellar branch of the saphenous nerve, comprise the five main
      innervation branches of the knee. Clinically, they play an important role in the anterior
      sensory innervation of the knee.

      In the study, the investigators aimed to prospectively, double-blind, and randomly compare
      the postoperative analgesic efficacy of combined IPACK block and genicular block with the
      sole application of IPACK block in patients undergoing total knee arthroplasty (TKA). The
      investigators hypothesized that in blocks performed with equal volumes, there might be a
      spread of the local anesthetic solution from the IPACK block area to the genicular block
      area, and the investigators investigated this hypothesis.
    

Detailed description: 
      Chronic knee pain, observed in the range of 7-33% in the society, is often caused by
      osteoarthritis. The knee joint consists of four bones: the femur, tibia, the largest sesamoid
      bone called the patella, and the fibula, although it does not directly join the joint. It is
      divided into three compartments called the medial tibiofemoral, lateral tibiofemoral, and
      patellofemoral, which share a common synovial cavity. Additionally, the knee joint is
      composed of the patellofemoral and tibiofemoral joints. The knee joint is supported by
      ligaments that provide stability and muscles and tendons that maintain its dynamic structure.

      The superomedial quarter of the anteromedial aspect of the knee joint is innervated by the
      nervus vastus medialis, the medial branch of the nervus vastus intermedius, and the superior
      medial genicular nerve. The inferomedial quarter is innervated by the infrapatellar branch of
      the saphenous nerve and the inferior medial genicular nerve. The superolateral quarter of the
      anterolateral aspect is innervated by the nervus vastus lateralis, the lateral branch of the
      nervus vastus intermedius, the superior lateral genicular nerve, and the articular branches
      of the common fibular nerve. The inferolateral portion is innervated by the inferior lateral
      genicular nerve and the recurrent fibular nerve. The posterior sensation of the knee is
      provided by the popliteal plexus. Due to the dense innervation of the knee joint,
      approximately 60% of patients undergoing knee prostheses experience severe pain, while 30%
      describe a moderate level of pain.

      The IPACK (interspace between the popliteal artery and capsule of the posterior knee) block
      is a regional anesthesia technique in which a local anesthetic is infiltrated under
      ultrasound guidance between the popliteal artery and the capsule of the posterior knee. This
      technique blocks the branches of the obturator nerve, the common peroneal nerve, and the
      tibial nerve in the popliteal region. In the context of knee arthroplasty, the application of
      the IPACK block has been associated with lower scores for ambulatory pain, lower scores for
      resting pain, and reduced morphine consumption .

      The genicular nerves, including the superomedial, inferomedial, superolateral, inferolateral
      genicular nerves, and the infrapatellar branch of the saphenous nerve, comprise the five main
      innervation branches of the knee. Clinically, they play an important role in the anterior
      sensory innervation of the knee. GNB (genicular nerve block) and radiofrequency ablation
      techniques are utilized in the treatment of chronic osteoarthritis and have recently gained
      popularity in postoperative pain management following knee surgeries.

      In our study, the investigators aimed to prospectively, double-blind, and randomly compare
      the postoperative analgesic efficacy of combined IPACK block and genicular block with the
      sole application of IPACK block in patients undergoing total knee arthroplasty (TKA). The
      investigators hypothesized that in blocks performed with equal volumes, there might be a
      spread of the local anesthetic solution from the IPACK block area to the genicular block
      area, and the investigators investigated this hypothesis.
    

Intervention name(s): IPACK + Genicular Nerve Block
Intervention type(s): Procedure
Intervention description(s): IPACK and Genicular Nerve block were applied with the same total volume of local anesthetic as the control group.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: IPACK Block; Genicular Nerve Block; Total Knee Arthroplasty