Postoperatory Analgesia After Total Knee Arthroplasty
Condition: PAIN
Study type: Interventional

Summary: 
      Total knee arthroplasty (TKA) is a worldwide realized procedure, with 600.000 surgeries
      performed per year in the United States, with a 673% increase estimated until 2030.
      Functional and pain management improvement is expected in 90% of patients, with 85% of them
      satisfied after the procedure.

      Immediate postoperatory pain control is an important aspect to be considered. Patients
      submitted to TKA endure pain with variations between 40-80 (according to analog visual scale
      -AVS - which goes from zero to 100) during the immediate postoperatory, with slow decline in
      the first 24 hours. Pain classified as severe occurs in 60% and moderated in 30% of patients
      submitted to TKA during this period of time. Therefore adequate pain management allows an
      earlier rehabilitation, with a higher satisfaction rate and decrease the hospitalization
      period.

      A multimodal control of pain can be reached by using non-steroidal anti-inflammatory, COX-2
      anti-inflammatory inhibitors, peripheral nerve blocks and intra-articular anesthetics
      injections and decrease use of opioids given of potential collateral effects. Peripheral
      blockings are associated to the smallest rate of collateral effects and complications when
      compared to the spinal anesthesia and analgesia controlled by the patients. Studies comparing
      the effects of the femoral and sciatic-femoral blocking guided by ultrasonography for the
      analgesia control after TKA were not found.

      The objective of this article is to evaluate the effect of femoral and sciatic-femoral block
      using ultrasonography by the analog visual scale (AVS) of pain in postoperatory of patients
      submitted to TKA, opioid consumption and complications associated to anesthesics procedures.
    

Detailed description: 
      Inclusion criteria were considered: Patients with TKA indication, aged from 40 to 90 years,
      weight between 50 and 100 kg, body mass index between 18 - 36 and patients classified
      pre-operatory according to the American Anesthesia Association as ASA I or II.
      Non-cooperative patients, with cognitive incapacity to answer pain VAS, neuromuscular or
      peripheral neuropathies, chronically using opioid or who didn´t want to take part of the
      study were taken as exclusion criteria.

      The patients were separated in three groups at randomized by a computer program:

      Group A - control group - spinal anesthesia, Group B - femoral nerve block + procedure
      realized in group A and Group C - femoral and sciatic nerves block + procedure realized in
      group A.

      All the anesthetics procedures were realized by the same anesthetist. The standard anesthesia
      for the procedure was spinal anesthesia with injection of 12 to 15 mg of 0.5% isobaric
      bupivacaine. Patients of the control group (group A) were submitted to spinal anesthesia with
      0.5% isobaric bupivacaine, in isolation. Punctures in the femoral and popliteal areas were
      made to mask the femoral and sciatic block, respectively, with no infusion of any medication.
      The patients of the group B received, furthermore the standard anesthesia, the block of the
      femoral nerve guided by ultrasonography (Nemio 17 - Toshiba Systems Co. - Japan) and
      neurosimulation (Stimuplex HNS 12 - Braun - Germany) with 1 Hz stimulus frequency, 1.2 to 0.5
      mA energy. The technique used was femoral area puncture, at the level of the crural fold of
      skin, with a 0.5% (125mg) ropivacaine associated to 75 mcg of clonidine. For the patients of
      the group C, in addition to the femoral blocking, the anesthesia of the sciatic nerve at the
      top of the popliteal fossae was realized, also guided by ultrasonography (Nemio 17 - Toshiba
      Systems Co. - Japan) and neurosimulation (Stimuplex HNS 12 - Braun - Germany) with 1 Hz
      stimulus frequency, 1.2 to 0.5 mA energy. 0.5% ropivacaine was injected associated to 75mcg
      clonidine. As an adjuvant for analgesia, all the patients received analgesic and
      anti-inflammatory permanently in postoperatory, with availability of opioids for rescue if
      needed. The necessity of its use and eventual complications were registered until hospital
      discharge.

      The pain measurement was realized by the assistant author using a 10 points pain AVS (0,
      absence of pain, and 10 the worst imaginable pain) both ignoring which group the patient was
      part of. This measurement was realized during immediate pre-operatory, within 6, 12, 24, 48
      hours after surgery.

      Details of this study were approved by the Ethical Committee and written informed consent was
      obtained from each participant prior to the commencement of the study.
    

Intervention name(s): Spinal anesthesia; Femoral nerve block; sciatic nerves block
Intervention type(s): Other; Other; Other
Intervention description(s): spinal anesthesia; Femoral nerve block; sciatic nerves block
Intervention MeSH terms: Anesthetics
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Investigator)
Primary purpose: Supportive Care
Keywords: total knee arthroplasty, analgesia, ultrasonography