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      Comparison of Intra-articular Analgesia and Femoral Nerve Block for Postoperative Pain Relief in Unilateral Total Knee Arthroplasty: A Randomized Clinical Study

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          Abstract

          Background and Aims:

          Femoral nerve block (FNB) and intra-articular analgesia (IAA) are used for postoperative analgesia after total knee arthroplasty (TKA).

          Aims and Objectives:

          We aimed to determine the better technique among the two, with regard to duration and quality of postoperative analgesia along with 24-h rescue analgesic consumption. The functional recovery in the early postoperative period was also assessed.

          Settings and Design:

          This was a prospective double-blind study comprising 40 American Society of Anesthesiologists I–III patients undergoing elective TKA who were randomly assigned to two groups ( n = 20).

          Methodology:

          In Group A, 20 mL ropivacaine 0.5%, containing dexmedetomidine (1 μg.kg − 1), was given by FNB, and in Group B, intra-articular administration of the same drug was done. Analgesic effect was evaluated by measuring the Visual Analog Scale (VAS) and duration of analgesia. Quadriceps muscle strength was noted.

          Statistical Analysis:

          Observation data obtained were reported as mean value and analyzed using Student's t-test or Wilcoxon/Mann–Whitney rank test.

          Results:

          The mean VAS on passive movement at the 2 nd, 6 th, and 16 th h postoperatively was 1.75 ± 0.44, 2.90 ± 0.72, and 2.75 ± 0.44 in Group A as compared to 2.25 ± 0.72, 4.30 ± 2.05, and 2.20 ± 0.77 in Group B ( P = 0.026, 0.043, and 0.014, respectively). In Group A, the first request for analgesic (rescue analgesic) was at 637 ± 119 min and the total consumption of tramadol was 50.00 mg. In Group B, the first request for analgesic was at 404.44 ± 136 min, with a total dose of 63.89 mg. The Pvalue for the time of rescue analgesic was <0.001, while for total drug consumption, it was 0.018.

          Conclusion:

          We concluded that the duration and quality of analgesia (VAS) were significantly superior and rescue analgesic requirement less in patients who received FNB as compared to IAA.

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          Most cited references12

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          Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial.

          Postoperative pain after total knee arthroplasty (TKA) can be difficult to manage and may delay recovery. Recent studies have suggested that periarticular infiltration with local anesthetics may improve outcome. 80 patients undergoing TKA under spinal anesthesia were randomized to receive continuous femoral nerve block (group F) or peri- and intraarticular infiltration and injection (group I). Group I received a solution of 300 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine by infiltration of the knee at the end of surgery, and 2 postoperative injections of these substances through an intraarticular catheter. More patients in group I than in group F could walk < 3 m on the first postoperative day (29/39 vs. 7/37, p < 0.001). Group I also had significantly lower pain scores during activity and lower consumption of opioids on the first postoperative day. No differences between groups were seen regarding side effects or length of stay. Peri- and intraarticular application of analgesics by infiltration and bolus injections can improve early analgesia and mobilization for patients undergoing TKA. Further studies of optimal drugs, dosage, and duration of this treatment are warranted.
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            Total knee replacement in young, active patients. Long-term follow-up and functional outcome.

            We reviewed our experience with total knee arthroplasties performed between 1977 and 1992 in patients who were fifty-five years old or less to determine the appropriate management for younger patients who have severe osteoarthrosis. One hundred and fourteen knee replacements were performed in eighty-eight patients who were an average of fifty-one years old (range, twenty-two to fifty-five years old). All of the operations were performed by one of the two senior ones of us (J. N. I. or W. N. S.) with the use of cementing techniques. A posterior stabilized, posterior cruciate-substituting design was used for all but one replacement, for which a semiconstrained total condylar prosthesis was used. Six knees (four patients) were lost to follow-up. Follow-up data for the remaining 108 knees (eighty-four patients) were used to perform the survivorship analysis. One hundred and three unrevised knees (eighty patients) were available for clinical evaluation with the scoring systems of The Hospital for Special Surgery and the Knee Society at an average of eight years (range, three to eighteen years) postoperatively; thirty-six knees were followed for more than ten years. In addition, the activity levels of the patients were assessed with the activity score of Tegner and Lysholm. Radiographs were examined for evidence of loosening of the component. At the latest follow-up examination, the average knee score according to the system of The Hospital for Special Surgery had improved from 55 points preoperatively to 92 points. According to the system of the Knee Society, the average knee score was 94 points and the average functional score was 89 points. The result for all 103 knees was good or excellent according to the knee scores of The Hospital for Special Surgery and the Knee Society. Ninety-seven knees (94 per cent) had good or excellent function according to the functional score of the Knee Society. The average activity score of Tegner and, Lysholm improved from 1.3 points (range, 0 to 4 points) preoperatively to 3.5 points (range, 1 to 6 points) at the latest follow-up examination. All but two patients had improvement in the activity score postoperatively, and nineteen (24 per cent) of the eighty patients had an activity score of at least 5 points, indicating regular participation in activities such as tennis, skiing, bicycling, or strenuous farm or construction work. Nine (9 per cent) of the 103 knees had non-progressive tibial radiolucent lines. Two patients had a revision because of late infection, and one patient had revision of a well fixed tibial component because of wear of the polyethylene. In addition, three patellar components were revised for loosening, and one spacer was exchanged to treat instability. With failure defined as revision of either the femoral or the tibial component, the over-all rate of survival was 94 per cent at eighteen years. When the three patellar revisions were included in the failures, the survival rate was 90 per cent at eighteen years. When the exchange of the spacer was also included in the failures, the survival rate was 87 per cent at eighteen years. We consider arthroplasty with cementing of a posterior stabilized total knee prosthesis to be effective operative treatment with durable results for osteoarthrosis in younger patients when other, less invasive measures have failed. Within the average eight-year follow-up interval of this study, polyethylene wear, osteolysis, and loosening of the conforming posterior cruciate-substituting prosthesis were not major problems for these younger, active patients, although it is possible that this observation could change with an even longer duration of follow-up.
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              The pain visual analog scale: is it linear or nonlinear?

              The visual analog scale (VAS) is a tool widely used to measure pain, yet controversy surrounds whether the VAS score is ratio or ordinal data. We studied 52 postoperative patients and measured their pain intensity using the VAS. We then asked them to consider different amounts of pain (conceptually twice as much and then half as much) and asked them to repeat their VAS rating after each consideration (VAS2 and VAS3, respectively). Patients with unrelieved pain had their pain treated with IV fentanyl and were then asked to rate their pain intensity when they considered they had half as much pain. We compared the baseline VAS (VAS1) with VAS2 and VAS3. The mean (95% confidence interval) for VAS2:1 was 2.12 (1.81-2.43) and VAS3:1 was 0.45 (0.38-0.52). We conclude that the VAS is linear for mild-to-moderate pain, and the VAS score can be treated as ratio data. A change in the visual analog scale score represents a relative change in the magnitude of pain sensation. Use of the VAS in comparative analgesic trials can now meaningfully quantify differences in potency and efficacy.
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                Author and article information

                Journal
                Anesth Essays Res
                Anesth Essays Res
                AER
                Anesthesia, Essays and Researches
                Wolters Kluwer - Medknow (India )
                0259-1162
                2229-7685
                Apr-Jun 2020
                12 October 2020
                : 14
                : 2
                : 321-325
                Affiliations
                [1 ]Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India
                [2 ]Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
                [3 ]Department of Intensive Care, Dayanand Medical College and Hospital, Ludhiana, Punjab, India
                Author notes
                Address for correspondence: Dr. Neeru Luthra, Department of Anaesthesia, Dayanand Medical College and Hospital, Ludhiana, Punjab, India. E-mail: drneeru1977@ 123456yahoo.co.in
                Article
                AER-14-321
                10.4103/aer.AER_56_20
                7819411
                90d9bf05-fdc7-46ca-9c47-9ad6dad75738
                Copyright: © 2020 Anesthesia: Essays and Researches

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

                History
                : 18 June 2020
                : 29 June 2020
                : 30 June 2020
                Categories
                Original Article

                ambulation,analgesia,dexmedetomidine,femoral nerve block,pain,ropivacaine,total knee arthroplasty

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