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Postoperative Fall after the Use of the 3-in-1 Femoral Nerve Block for Knee Surgery: A Report of Four Cases



We present a serious postoperative complication related to the use of femoral nerve block in 4 patients, each of whom fell and sustained further injury. Preoperatively, all patients underwent a 3-in-1 femoral nerve block with 30 to 35 ml of 0.25% levobupivacaine with 1:200,000 epinephrine, with guidance by a nerve stimulator. After the falls, neurological examination of the operated legs revealed reduced 2-point discrimination, pain, and/or light touch sensation. All patients underwent further operation for the fall injury and had delayed full weight bearing. We recommend that, after having a femoral nerve block, patients should undergo enhanced postoperative evaluation of blockade and proprioceptive function to ensure safe neurological function before mobilisation.
We present a serious postoperative complication
related to the use of femoral nerve block in 4 patients,
each of whom fell and sustained further injury.
Preoperatively, all patients underwent a 3-in-1 femoral
nerve block with 30 to 35 ml of 0.25% levobupivacaine
with 1:200 000 epinephrine, with guidance by a nerve
stimulator. After the falls, neurological examination
of the operated legs revealed reduced 2-point
discrimination, pain, and/or light touch sensation. All
patients underwent further operation for the fall injury
and had delayed full weight bearing. We recommend
that, after having a femoral nerve block, patients
should undergo enhanced postoperative evaluation
Postoperative fall after the use of the 3-in-1
femoral nerve block for knee surgery: a report
of four cases
HDE Atkinson,1 I Hamid,2 CM Gupte,3 RC Russell,1 JM Handy4
1 DepartmentofTraumaandOrthopaedics,ImperialCollegeSchoolofMedicine,StMary’sHospital,London,United
2 TheHillingdonHospital,Uxbridge,Middlesex,UnitedKingdom
3 Department of Orthopaedics andTraumatology, Imperial College School of Medicine, Chelsea and Westminster
4 DepartmentofAnaesthetics,ImperialCollegeSchoolofMedicine,ChelseaandWestminsterHospital,London,United
Journal of Orthopaedic Surgery 2008;16(3):381-4
of blockade and proprioceptive function to ensure
safe neurological function before mobilisation.
Key words: accidental falls; arthroplasty, replacement, knee;
autonomic nerve block; femoral nerve
The number of surgical procedures performed on a
day-case or short-stay basis has increased considerably
over the past decade.1 Anaesthetic techniques have
evolved to facilitate early recovery and postoperative
mobilisation. Early mobilisation improves both short-
and long-term functional outcomes, decreases the risk
of respiratory tract infections, and shortens the length
of hospital stay.2
382 HDEAtkinsonetal. Journal of Orthopaedic Surgery
Femoral nerve block (FNB), rst described in
1973,3 is used either as a single-nerve or 3-in-1 block
(including the femoral nerve, the lateral cutaneous
nerve of the thigh, and the obturator nerve), both
as an independent anaesthetic modality and as an
analgesic adjunct to other anaesthetic techniques.
Common indications include knee arthroplasty,
arthroscopy, ligament reconstruction, foot and ankle
surgery, and management of femoral fractures.4–6
The use of a FNB together with general anaesthesia
reduces the required doses of general anaesthetic
agents, and hence its side-effects, including nausea,
vomiting, drowsiness, and respiratory depression.
The FNB also confers superior pain control,
decreases opioid requirement, and enables earlier
ambulation and hospital discharge.7–9 Compared
with neuraxial (spinal/epidural) anaesthesia, FNB
minimises hypotension, urinary retention, pruritus,
and eliminates the risks of spinal haematoma and
The common complications of FNB include
incomplete nerve blockade, direct nerve trauma
with potential quadriceps wasting, local haematoma
and subsequent ischaemic injury, infection, and the
risks of systemic intravenous injection of the local
anaesthetic agent.11
We present a serious postoperative complication
related to the use of FNB in 4 patients, each of whom
fell and sustained further injury.
Case 1
In March 2004, a 79-year-old osteoporotic woman
underwent an elective right primary total knee
replacement. Prior to the operation, she underwent
a 3-in-1 FNB with 32 ml of 0.25% levobupivacaine
with 1:200 000 epinephrine, with guidance by a nerve
stimulator. The operation was performed under
general anaesthesia with the use of a tourniquet. At
20.5 hours following the blockade, the patient was
mobilised with the assistance of physiotherapists.
She had minimal pain when moved from her bed
to a chair. She stood up and on attempting to take
a step on her operated leg, the knee gave way. She
fell and sustained a supracondylar periprosthetic
fracture. A neurological examination of the operated
leg revealed reduced 2-point discrimination (using
an aesthesiometer), pain (using needle pin-prick),
and light touch sensation (using Semmes-Weinstein
monolaments), when compared with the other
leg. Proprioception and power were not tested.
She underwent further xation and regained full
weight bearing 13 weeks later. Her hospital stay was
prolonged by 16 days. At 6-month follow-up, her
0º to 80º despite having normal neurological status.
Case 2
In November 2004, a 77-year-old woman underwent
an elective left primary total knee replacement under
general anaesthesia without the use of a tourniquet.
Preoperatively, she had a 3-in-1 FNB with 35 ml of
0.25% levobupivacaine with 1:200 000 epinephrine,
with guidance by a nerve stimulator. At 21.5 hours after
the blockade, she had minimal pain and was mobilised
with assistance by physiotherapists. The operated
knee gave way and the patient fell and sustained a
displaced bimalleolar ankle fracture. Neurological
examination revealed normal quadriceps power,
but reduced 2-point discrimination and light-touch
sensation, compared to the other leg. She underwent
further operation and remained non–weight bearing
for 6 weeks. At 3-month follow-up, her range of knee
movement was poor (0º–90º) despite physiotherapy
and mobilisation.
Case 3
In May 2005, a 67-year-old woman with bilateral mild
knee osteoarthritis and a degenerated left medial
meniscus underwent arthroscopy of the left knee
under general anaesthesia with the use of a tourniquet.
An overnight hospital stay was anticipated and thus
preoperatively she was given a nerve-stimulator
guided 3-in-1 FNB with 30 ml of 0.25% levobupivacaine
with 1:200 000 epinephrine. While ambulating to the
toilet independently 19 hours later, her operated knee
gave way and she fell. She inverted her left ankle and
sustained a trimalleolar ankle fracture. Neurological
examination revealed normal leg power, but reduced
great-toe proprioception, proximal tibial vibration
sense, 2-point discrimination, and light-touch
sensation. She underwent further surgery and was
kept non–weight bearing in a plaster cast for 6 weeks.
At 6-month follow-up, her ankle remained stiff, with
reduced range of movement, despite having good
radiological healing.
Case 4
In October 2005, an obese 38-year-old woman
underwent a day-case right knee hamstring anterior
cruciate ligament (ACL) reconstruction under
Vol. 16 No. 3, December 2008 Postoperativefallaftertheuseofthe3-in-1femoralnerveblockforkneesurgery 383
general anaesthesia with the use of a tourniquet.
Preoperatively, a 3-in-1 FNB with 30 ml of 0.25%
levobupivacaine with 1:200 000 epinephrine was
used, with guidance by a nerve stimulator. The ACL
graft was xed securely. At 6.25 hours following
the blockade, the patient was mobilised with the
aid of crutches and physiotherapists. With no pain
inhibition, the patient bore her full weight on the
operated leg which gave way, causing her to fall
and the knee to hyperex to 140º. Neurological
examination revealed very poor quadriceps control,
with inability to perform full straight leg raise against
resistance (Grade 4 Medical Research Council motor
power) and reduced pain and light-touch sensation.
She was kept in hospital overnight for observation,
and regained normal neurological function 23 hours
later. She was discharged and continued rehabilitation.
Four months later, the operated knee began to give
way because of graft failure. At 9-month follow-
up, her knee remained clinically and radiologically
unstable. After revision surgery, she recovered well,
with a stable knee.
These patients underwent surgery at 3 different
hospitals, were anaesthetised by 4 different
anaesthetists, and operated on by 3 different
orthopaedic surgeons. Each patient received a 3-in-1
FNB with 30 to 35 ml of 0.25% levobupivacaine and
1:200 000 epinephrine, which alleviated postoperative
pain and enabled early mobilisation. Typically, up to
40 ml of 0.25 to 0.5% levobupivacaine can be instilled
in 3-in-1 blocks. Although the proportion of patients
with a complete sensory block is smaller with the lower
0.25% concentration, the analgesic quality or the onset
of blockade between the 2 different levobupivacaine
Epinephrine 1:200 000 is commonly given in FNBs, as
it reduces the risk of toxicity, plasma absorption, and
enables larger volumes to be given, but its use is not
Although FNB provides good postoperative
analgesia, the extended duration of sensory and
proprioceptive decit is a ‘double-edged sword’
with respect to early mobilisation and related falls,
as muscle, skin and joint proprioception from the
legs are the dominant sensory input determining
safe ambulation and balance.14 The normal duration
of levobupivacaine 3-in-1 femoral nerve blockade is
reported to range from 3 to 12 hours and even up to 17
hours for 0.5% levobupivacaine concentrations,12,15,16
while duration is shorter in neuraxial use.17 The
addition of epinephrine 1:200 000 may increase the
duration of peripheral nerve blockade (range, 4–12
hours),15,16 but this is controversial.17 Prolonged nerve
blockade of up to 30 hours is a well-documented
risk18,19; the precise aetiology (including intraneural
injection or local anaesthetics overdose) is often
speculative.18,19 Three of our patients had blockades
lasting longer than 19 hours. None had normal
sensory neurology on examination following their
falls, despite 2 having regained full quadriceps
Although the cause of these falls may be
multifactorial, and 3 of our patients were over 65
years of age, these cases highlight a complication
related to the use of FNB and early mobilisation.
Multidisciplinary research by anaesthetists,
orthopaedic surgeons, and physiotherapists is
We recommend that, after having a FNB, patients
should undergo enhanced postoperative evaluation of
blockade and proprioceptive function (in particular
2-point discrimination, light touch, and vibration
sense) to ensure safe neurological function before
mobilisation. Some centres have already introduced
this in the context of outpatient laparoscopy under
spinal anaesthesia.14
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... Moreover, multiple clinical studies and several meta-analyses (7)(8)(9) showed that ACB could preserve quadriceps muscle strength, better early ambulation with good analgesic effects and less morphine consumption when compared to FNB in patients after TKA (11)(12)(13)(14)(15)(16)(17)(18). Understanding of adductor canal anatomy, including nerves related to ACL reconstruction, is still not clear but the assumption of analgesic effectiveness of the ACB is less. ...
... A novel nerve block technique with ultrasound (US)-guided local anesthetic injection between the popliteal artery and the capsule of the knee (IPACK). (17)(18)(19) By targeting only, the sensory branches of the sciatic nerve, the IPACK block provides an alternative for decreasing posterior knee pain following TKA and greatly avoid foot drop. (18)(19)(20)(21) However, clinical evidence comparing the effectiveness of analgesia, postoperative physical rehabilitation, and opioids reduction with the addition of an iPACK block to ACB is still limited. ...
... (17)(18)(19) By targeting only, the sensory branches of the sciatic nerve, the IPACK block provides an alternative for decreasing posterior knee pain following TKA and greatly avoid foot drop. (18)(19)(20)(21) However, clinical evidence comparing the effectiveness of analgesia, postoperative physical rehabilitation, and opioids reduction with the addition of an iPACK block to ACB is still limited. The objective of this study was to evaluate the effect of an iPACK block along with ACB block on postoperative pain scores, opioid consumption, and during early physical physiotherapy. ...
Full-text available
BACKGROUND: Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the knee (IPACK) and the adductor canal block (ACB), are promising analgesic pathways but supporting literature remains rare. Periarticular injections (PAIs) are becoming an essential multimodal joint analgesia. We hypothesized that ACB and IPACK would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone. METHODS: This double-blinded randomized controlled trial included 50 patients undergoing ACL repair. Patients either received (1) a PAI (control group, n = 26) or (2) an iPACK with an ACB (intervention group, n = 24). The primary outcome was pain on ambulation on POD 1. Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption. RESULTS: The intervention group reported significantly lower pain scores on ambulation than the control group on POD 1 (difference in means [95% confidence interval]; P < .001). In addition, pain scores on ambulation on POD 2 for group B (3.5 [-4.3 to -2.7]) and POD 2 for group A (1.0 [1.9 to 0.1]; with P = .033) were significantly lower. Patients in the intervention group were more satisfied, had less intravenous opioid consumption (post anesthesia care unit, P = .028), and reduced need for intravenous patient-controlled analgesia for the first 24 hours (P = .037). CONCLUSIONS: The addition of iPACK and ACB significantly improves analgesia and reduces opioid consumption after ACL repair compared to PAI alone. This study strongly supports iPACK and ACB use within a multimodal analgesic pathway.
... FNBs have been used as an effective method of pain control after ACLR but involve a combined blockage of motor and sensory nerves and are associated with decreased quadriceps strength postoperatively with an increased risk of falls. 5,7,8 Meanwhile, blocks targeting the saphenous nerve provide the opportunity for sensory blockage without the accompanying weakness and fall-risk associated with FNB. Conflicting results have been reported with ACB, with one study reporting equivalent pain relief and improved strength as compared with FNB following patellar tendon autograft ACLR, 9 and other studies reporting worse postoperative pain relief compared to FNB and no improvement compared to placebo block following hamstring autograft ACLR. ...
Full-text available
Regional anesthetic blockade of the adductor canal following anterior cruciate ligament reconstruction has gained popularity due to theoretical benefit of improved patient experience, decreased requirement for pain medication and maintained motor function. However, this block does not cover the anterior and lateral genicular innervation to the knee, which may lead to persistent pain postoperatively. The following Technical Note details the genicular nervous system and provides rationale and technique for performing a simple surgeon-administered regional anesthetic at the completion of anterior cruciate ligament reconstruction to address the anterior and lateral genicular nervous system.
... FNB has been widely used due to its ease of application and its excellent pain relief after TKA [6][7][8][9][10][11][12]. However, some studies have shown that FNB weakens quadriceps strength [13,14], which may result in an increased risk of falls during rehabilitation [15][16][17][18][19][20][21][22]. FNB is focused on the proximal femoral nerve, which contains both motor and sensory bers [23]. ...
Full-text available
Background: One option in total knee arthroplasty (TKA) perioperative pain management is femoral nerve block (FNB). Its association with quadriceps weakness has led to a focus on adductor canal block (ACB), with the aim of avoiding weakness in adjacent muscles. This study reviewed cases at our institution. Methods: In this pilot non-blinded study, nerve block (FNB or ACB) was performed under ultrasonic guidance after induction of general anesthesia, with an initial bolus followed by continuous levobupivacaine infusion into the perineurium as needed until postoperative day (POD) 2 or 3. Pain levels and falls/near-falls with knee-buckling were monitored from POD 1 to POD 3. The score on the manual muscle test, MMT (0 to 5, 5 being normal), of the patients who had been able to ambulate on POD 1, was investigated. Results: A total of 73 TKA cases, 37 FNB and 36 ACB, met the inclusion criteria. Episodes of near-falls in the form of knee-buckling were witnessed in 14 (38%) cases in the FNB group and in 4 (11%) in the ACB group (p = 0.0068). In the ACB group, 81.1% of patients were able to ambulate with parallel bars on POD 1, while only 44.4% of FNB patients could do so (p = 0.0019). The quadriceps MMT values of patients able to ambulate with parallel bars on POD 1 in the ACB group was 2.82, significantly higher than 1.97 in the FNB group (p = 0.0035). There were no significant differences in pain as measured with a numerical rating scale (NRS) through POD 3. Conclusion: Compared to FNB, ACB was associated with significantly less knee-buckling and earlier initiation of ambulation post-TKA, with better quadriceps muscle strength. These findings support the use of ACB as the anesthesia method of choice for TKA.
... 11 This might be particularly useful in outpatient ACLR reconstruction which requires short stay and immediate mobilization. 10,12 Our hypothesis was that cACB would result in improved analgesia for knee arthroscopic surgeries, without any increase in adverse effects. The primary outcome was time of first analgesic requirement. ...
Background and objectives: Anterior cruciate ligament reconstruction (ACLR) is one of the most frequently performed orthopedic procedures. The ability to perform ACLR on an outpatient basis is largely dependent on an effective analgesic regimen. The aim of the study was to compare the analgesic effect between continuous adductor canal block (cACB) and femoral nerve block (cFNB) during arthroscopy guided ACLR. Method: In this prospective, randomized controlled clinical trial, 60 ASA I/II patients for arthroscopic ACLR were recruited. Patients in Group I received cACB and those in Group II cFNB. A bolus dose of 20 cc 0.5% levobupivacaine followed by 0.125% 5 mL.h-1 was started for 24 hours. Rescue analgesia in the form of paracetamol 1 g intravenous (IV) was given. Parameters assessed like time of first rescue analgesia, total analgesic requirement in 24 hours, and painless range of motion of the knee (15 degrees of flexion to further painless flexion). Results: The time-to-first postoperative analgesic request (hours) was earlier in Group II (14.40 ± 4.32) than Group I (16.90 ± 3.37) and this difference was statistically significant (p < 0.05). The cumulative 24-h analgesic consumption (paracetamol in g) was 0.70 ± 0.47 in Group I and 1.70 ± 0.65 in Group II (p < 0.001). The painless range of motion (degree) was 55.67 ± 10.40 in Group I and 40.00 ± 11.37 in Group II (p < 0.001). Conclusion: The findings of this study suggest that continuous adductor canal block provides superior analgesia in patients undergoing arthroscopic ACLR when compared to continuous femoral nerve block.
... [17] Furthermore, FNB may possess better pain-relieving functions compared to patient-controlled analgesia (opioids). [18,19] As a peripheral nerve block, FNB is a well-established analgesia strategy and is considered to be the standard in postoperative TKA pain management. [15,20,21] However, patients that receive FNB usually suffer from a marked reduction in quadriceps muscle strength, [22,23] increasing their risk for postoperative fall. ...
Full-text available
Background: Adductor canal block (ACB) has emerged as an attractive alternative for femoral nerve blocks (FNB) as the peripheral nerve block of choice for total knee arthroplasty (TKA), preserving quadriceps motor function while providing analgesia comparable to FNB. However, its optimal application for TKA remains controversial. The objective of this meta-analysis was to compare continuous-injection ACB (CACB) vs single-injection ACB (SACB) for postoperative pain control in patients undergoing TKA. Methods: This study attempts to identify the available and relevant randomized controlled trials (RCTs) regarding the analgesic effects of CACB compared to SACB in patients undergoing TKA according to electronic databases, including PubMed, Medline, Web of Science, EMbase, and the Cochrane Library, up to September 2019. Primary outcomes in this regard included the use of a visual analogue scale (VAS) pain score with rest or activity, while secondary outcomes were cumulative opioid consumption, length of hospital stay (LOS), complications of vomiting and nausea, and rescue analgesia. The corresponding data were analyzed using RevMan v5.3. Ethical review: Because all of the data used in this systematic review and meta-analysis has been published, the ethical approval was not necessary RESULTS:: This research included 9 studies comprised of 739 patients. The analyzed outcomes demonstrated that patients who received CACB had a better at rest-VAS scores at 4 hours (P = .007), 8 hors (P < .0001), 12 hours (P < .0001), 24 hours (P = .02), mobilization-VAS score at 48 hours (P < .0001), and rescue analgesia (P = .03) than those who underwent SACB. Nevertheless, no significant differences were present between the 2 strategies in terms of pain VAS scores 48 hours at rest (P = .23) and 24 hours at mobilization (P = .10), complications of vomiting and nausea (P = .42), and length of hospital stay (P = .09). Conclusion: This meta-analysis indicated that CACB is superior to SACB in regard to analgesic effect following TKA. However, due to the variation of the included studies, no firm conclusions can be drawn. Further investigations into RCT are required for verification.
... The American Journal of Sports Medicine 1-7 DOI: 10.1177/0363546520914615 Ó 2020 The Author(s) muscle activation noted. 2,8,14,40,42,45 Adductor canal blocks, however, have not been shown to affect motor activation of the quadriceps. 15 Multiple regional anesthetic block options have been described for use in ACLR, including the sciatic nerve, adductor canal, femoral nerve, and combinations of these pathways. ...
Background Patients often have quadriceps or hamstring weakness after anterior cruciate ligament reconstruction (ACLR), despite postoperative physical therapy regimens; however, little evidence exists connecting nerve blocks and ACLR outcomes. Purpose To compare muscle strength at return to play in patients who received a nerve block with ACLR and determine whether a specific block type affected subjective knee function. Study Design Cohort study; Level of evidence, 3. Methods Patients were recruited 5 to 7 months after primary, isolated ACLR and completed bilateral isokinetic strength tests of the knee extensor/flexor groups as a single-session return-to-sport test. Subjective outcomes were assessed with the International Knee Documentation Committee (IKDC) score. Strength was expressed as torque normalized to mass (N·m/kg) and limb symmetry index as involved/uninvolved torque. Chart review was used to determine the type of nerve block and graft used. Nerve block types were classified as knee extensor motor (femoral nerve), knee flexor motor (sciatic nerve), or isolated sensory (adductor canal block/saphenous nerve). A 1-way analysis of covariance controlling for graft type was used. Results A total of 169 patients were included. Graft type distribution consisted of 102 (60.4%) ipsilateral bone–patellar tendon–bone (BTB) and 67 (39.6%) ipsilateral hamstring tendon. Nerve block type distribution consisted of 38 (22.5%) femoral, 25 (14.8%) saphenous, 45 (26.6%) femoral and sciatic, and 61 (36.1%) saphenous and sciatic. No significant difference was found in knee extensor strength ( P = .113) or symmetry ( P = .860) between patients with knee extensor motor blocks (1.57 ± 0.45 N·m/kg; 70.1% ± 15.3%) and those without (1.47 ± 0.47 N·m/kg; 69.6% ± 18.8%). A significant difference was found between patients with knee flexor motor blocks (0.83 ± 0.26 N·m/kg) and those without (0.92 ± 0.27 N·m/kg) for normalized knee flexor strength ( P = .21) but not knee flexor symmetry ( P = .592). Controlling for graft type, there were no differences in subjective knee function (IKDC score) between all nerve block groups ( P = .57). Conclusion Our data showed that use of a sciatic nerve block with ACLR in patients with hamstring and BTB grafts influences persistent knee flexor strength deficits at time of return to sports. Although the cause of postoperative muscular weakness is multifactorial, this study adds to the growing body of evidence suggesting that perioperative nerve blocks affect muscle strength and functional rehabilitation after ACLR.
... The Femoral Nerve Block (FNB) is one of the easiest peripheral nerve blocks to master because the landmarks are generally easy to identify and the nerve is usually found at a superficial depth. However, prolonged motor blockade from FNB is associated with a small but clinically important risk of fall [6,7] . ...
Objective: To compare the efficacy of adductor canal block and femoral nerve block for pain management in patients with anterior cruciate ligament reconstruction. Methods: A computerized search was performed in the database of PubMed, Embase, Web of Science and Cochrane Library for randomized controlled trials. The outcome measures included visual analog scale, morphine consumption, quadriceps strength, length of hospitalization and postoperative adverse events. The risk of bias of randomized controlled trials was assessed according to the Cochrane Risk of Bias Tool. All quantitative syntheses were completed using STATA version 14. Results: Seven randomized controlled trials involving a total of 643 patients were included in our meta-analysis. The present meta-analysis indicated that there were no significant differences between the 2 groups in terms of postoperative pain score, opioid consumption, length of hospitalization or adverse effects after anterior cruciate ligament reconstruction. However, adductor canal block showed superior quadriceps strength and range of motion in the early postoperative period. Conclusion: Adductor canal block shows similar and adequate analgesia compared to the femoral nerve block in anterior cruciate ligament reconstruction and adductor canal block can preserve a higher quadriceps strength and better range of motion.
Background Both adductor canal block (ACB) and of Local Infiltrative Analgesia (LIA) have been shown to reduce pain after total knee arthroplasty (TKA). The efficacy of combining ACB and LIA remains controversial. The objective of this study is to analyse the effect of LIA + single dose ACB compared to LIA alone on early post-operative pain and mobilization in TKA. Methods This Cohort Prospective study analyses the Visual Analogue Score (VAS) pain scores and rehabilitation milestones at 24 h between LIA alone and LIA + single dose ACB in unilateral TKA operated by a single surgeon between August 2014 and February 2019. Results VAS at rest and on movement were significantly better in the combined LIA + ACB group (n = 151) compared to LIA (n = 120) alone at 24 h. All patients were able to achieve the desired milestones of sitting, standing by the bedside and walking with the help of a walker within 24 h of the surgery. Conclusion Though the VAS scores were statistically significant, the actual scores at rest and on movement in both groups were significantly better than preoperative scores with excellent pain relief. All patients in both groups were able to ambulate within 24 h. LIA alone significantly improved the pain scores and enabled early mobilization. Addition of single dose ACB to LIA did not significantly alter the milestones.
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ABSTRACT Introduction: Femoral Nerve Block (FNB) is used as an adjunct to postoperative analgesia in Anterior Cruciate Ligament (ACL) reconstruction surgeries. However, it causes a reduction in quadriceps strength following use. To mitigate the loss in muscle function and patient safety, surgeons and anaesthesiologists have recently been exploring the potential benefits of a motor sparing Adductor Canal Nerve Blockade (ACB). To date, few comparative studies exist to determine its clinical utility. Aim: To compare the efficacy of femoral nerve block versus ACB for postoperative pain and functional outcome in patients undergoing ACL reconstruction. Materials and Methods: This prospective, randomised controlled trial was done after approval from Institutional Ethics Committee, Kasturba Medical College, Mangalore, Karnataka, India, 76 ASA Class 1 and 2 patients posted for ACL reconstruction, aged 18-60 years were chosen after consent and were randomised into two groups using computer-generated block randomisation. Group F received femoral nerve block and Group A received adductor canal block postoperatively. Visual analogue scale score at 0, 12 and 24 hours and Medical Research Council grading at 2, 12 and 24 hours post-block were measured and compared between both groups. Data analysis was done using student unpaired t-test, student paired t-test and chi-square test. Results: Visual analogue scale scores at 0, 12 and 24 hours postoperative was 2.29, 3.26 and 3.86 in Group A and 2.59, 3.61 and 4.49 in Group F (statistically non significant). Average time for rescue analgesia was 1 hour and 8 hours in Group A and F respectively. Medical research council grading 2, 12 and 24 hours postoperative was 2.6, 4.09 and 4.77 in Group A and 2.8, 3.15 and 4.05 in Group F (statistically significant). Conclusion: Compared with femoral nerve block, the study suggests that adductor canal block preserves quadriceps strength but is equianalgesic for patients undergoing anterior cruciate ligament reconstruction.
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Twenty-two patients undergoing total knee arthroplasty received combined sciatic plus femoral “3 in 1” blocks as adjuncts to general anaesthesia. Eleven patients received 0.375% bupivacaine 45 ml (168.75 mg) with adrenaline 1 in 200000 and the remaining 11 received plain solution according to a previously prepared, randomized list. The mean maximum plasma bupivacaine concentration was significantly greater with plain solution than when adrenaline was added (1.66 μg ml−1 compared with 0.98 μg ml−1) (P < 0.05). Bupivacaine concentrations were greater at all times in the plain group compared with the group receiving adrenaline. These differences were statistically significant at 10, 15 and 20 min (P < 0.05). The greatest peak concentration recorded was 3.13 μg ml−1 in one patient receiving plain bupivacaine. No patient developed signs of systemic toxic effects. Peak plasma concentrations were related inversely to body weight in patients receiving solution containing adrenaline (P < 0.005), but no relationship existed in patients who received plain solution.
Long saphenous vein stripping (LSVS) surgery is often used to treat varicose veins.We tested the hypothesis that femoral nerve block (FNB) with genitofemoral nerve infiltration provides sufficient analgesia and superior recovery characteristics to spinal anesthesia for LSVS procedures in the ambulatory setting. Thirty-six patients were randomized to receive FNB with 30 mL of 3% alkalinized chloroprocaine, and 32 patients received spinal anesthesia with 65 mg of 5% hyperbaric lidocaine. Data collected included patient demographics, time required for induction of and recovery from anesthesia, postoperative anesthesia complications, and patient report of pain severity after the operation. During a follow-up call, a blinded observer noted the onset of any complications, the requirement for analgesics, and the patients' satisfaction with the anesthetic technique. Patients in the FNB group had significantly faster recovery (P < 0.01) and lower incidences of pain (P < 0.05) and complications (P < 0.05) than the patients in the spinal group. All patients who received FNB indicated that they would choose this type of anesthesia in the future, whereas five (15%) patients in the spinal group would refuse spinal anesthesia in the future (P < 0.01). We conclude that FNB is an excellent anesthetic choice for LSVS. (Anesth Analg 1997;84:749-52)
Purpose: To compare two small-dose solutions (with and without: epinephrine) for spinal anesthesia during outpatient laparoscopy and to determine spinal cord function with these low-dose solutions. Method: Twenty outpatients undergoing gynecological laparoscopy were randomly assigned to receive spinal anesthesia with one of two low dose solutions. Group LS- 10 mg lidocaine plus 10 mug sufentanil; Group LSE- 10 mg lidocaine plus 10 mug sufentanil plus epinephrine 50 mug. Solutions were diluted to three millilitres with sterile water for injection. A 27-gauge Whitacre needle was inserted at L2-3 or L3-4 in the sitting position. Operating conditions and spinal cord function (spinothalamic, dorsal column and motor) were assessed. Results: Operating conditions were good - excellent in both groups. The incidence of shoulder tip discomfort, pruritus and nausea, and the amount of supplementation with alfentanil and midazolam was not different between groups. Most patients in both groups had preserved dorsal column function and normal motor power on arrival in PACU and were able to satisfy 'walk out' criteria. Recovery of pinprick sensation and discharge times were not different. Mild pruritus (VAS score less than or equal to 5)was present in both groups. Conclusion: For short duration laparoscopy, addition of 50 mug epinephrine to a small dose of spinal 10 mg lidocaine with 10 mug sufentanil did not provide additional benefit in terms of intraoperative analgesia or operating conditions. Spinal cord function was preserved with small-dose techniques.
Based on findings that the cardiotoxicity infrequently observed with racemic bupivacaine shows enantioselectivity, i.e. it is more pronounced with the R(+)-enantiomer, the S(−)-enantiomer (levobupivacaine) has been developed for clinical use as a long acting local anaesthetic. The majority of in vitro, in vivo and human pharmacodynamic studies of nerve block indicate that levobupivacaine has similar potency to bupivacaine. However, levobupivacaine had a lower risk of cardiovascular and CNS toxicity than bupivacaine in animal studies. In human volunteers, levobupivacaine had less of a negative inotropic effect and, at intravenous doses >75mg, produced less prolongation of the QTc interval than bupivacaine. Fewer changes indicative of CNS depression on EEG were evident with levobupivacaine. Levobupivacaine is long acting with a dose-dependent duration of anaesthesia. The onset of action is ≤15 minutes with various anaesthetic techniques. In studies of surgical anaesthesia in adults, levobupivacaine provided sensory block for up to 9 hours after epidural administration of ≤202.5mg, 6.5 hours after intrathecal 15mg, and 17 hours after brachial plexus block with 2 mg/kg. Randomised, double-blind clinical studies established that the anaesthetic and/or analgesic effects of levobupivacaine were largely similar to those of bupivacaine at the same dose. Sensory block tended to be longer with levobupivacaine than bupivacaine, amounting to a difference of 23 to 45 minutes with epidural administration and approximately 2 hours with peripheral nerve block. With epidural administration, levobupivacaine produced less prolonged motor block than sensory block. This differential was not seen with peripheral nerve block. Conditions satisfactory for surgery and good pain management were achieved by use of local infiltration or peribulbar administration of levobupivacaine. Levobupivacaine was generally as effective as bupivacaine for pain management during labour, and was effective for the management of postoperative pain, especially when combined with clonidine, morphine or fentanyl. The tolerability profiles of levobupivacaine and bupivacaine were very similar in clinical trials. No clinically significant ECG abnormalities or serious CNS events occurred with the doses used. The most common adverse event associated with levobupivacaine treatment was hypotension (31%). Conclusions: Levobupivacaine is a long acting local anaesthetic with a clinical profile closely resembling that of bupivacaine. However, current preclinical safety and toxicity data show an advantage for levobupivacaine over bupivacaine. Clinical data comparing levobupivacaine with ropivacaine are needed before the role of the drug can be fully established. Excluding pharmacoeconomic considerations, levobupivacaine is an appropriate choice for use in place of bupivacaine. Pharmacodynamics Levobupivacaine is a long acting, amide-type local anaesthetic that is the S(−) \3- isomer of the racemate bupivacaine. In general, in vitro, in vivo and human volunteer studies of nerve block indicate that levobupivacaine is as potent as bupivacaine and produces similar sensory and motor block. A trend towards a longer sensory block with levobupivacaine was seen in some studies, and may be related to the greater vasoconstrictive activity of levobupivacaine than that of the R(+)-enantiomer (dexbupivacaine) at lower doses. The minimum local analgesic concentration was 0.083% for epidural levobupivacaine 20ml and 0.081% for bupivacaine 20ml in women in the first stage of labour. Levobupivacaine has been consistently less toxic than bupivacaine in animal models. The lethal dose of levobupivacaine was 1.3- to 1.6-fold higher than that of bupivacaine in most animal studies, providing supportive evidence for a safety advantage over bupivacaine. In vitro findings indicating a lower risk of cardiotoxicity with levobupivacaine compared with dexbupivacaine and/or bupivacaine have included lesser effects or lower potency in: blocking cardiac sodium channels in the inactivated state; blocking cardiac potassium channels; reducing the maximal rate of depolarisation; prolonging atrioventricular conduction; and prolonging QRS interval duration. Differences between the agents with regards to effects on contractility seem to be less consistent, but levobupivacaine also appears to be less detrimental in this regard. In animal studies, levobupivacaine was associated with fewer and less severe cardiac disturbances, especially ventricular arrhythmias. In human volunteers, intravenous levobupivacaine (mean dose 56mg) produced less of a negative inotropic effect than bupivacaine (48mg). In another study of intravenous administration, the mean maximum increase in QTc interval was significantly less with levobupivacaine than with bupivacaine (3 vs 24 msec) in volunteers receiving >75mg. A lower risk of CNS toxicity with levobupivacaine compared with dexbupivacaine and/or bupivacaine has also been reported, including less propensity to cause apnoea and higher convulsive doses (levobupivacaine 103mg vs bupivacaine 85mg) in animal studies. In human volunteers, 64% of intravenous bupivacaine recipients (mean dose 65.5mg) compared with 36% of levobupivacaine (67.7mg) recipients experienced central or peripheral nervous system disorders. Intravenous levobupivacaine 40mg produced fewer changes indicative of CNS depression on EEG than bupivacaine 40mg in volunteers. When compared with ropivacaine in animals, levobupivacaine had similar or more pronounced nerve blocking effects, depending on the concentration and model. Levobupivacaine and ropivacaine had generally similar cardiovascular effects in in vitro and animal studies, although some studies reported greater QRS interval prolongation and/or arrhythmogenic risk with levobupivacaine at some concentrations, but no difference in mortality rates. However, cardiotoxicity has not been compared at established equipotent anaesthetic doses. Pharmacokinetics Only limited pharmacokinetic data are available for levobupivacaine. The plasma concentrations of levobupivacaine are dependent on dose and route of administration. Maximum plasma concentrations were 0.58 to 1.02 mg/L after epidural administration of 75 to 150mg, and 0.47 and 0.96 mg/L after brachial plexus block with 1 and 2 mg/kg, respectively, in patients. The elimination half-life after intravenous administration of 40mg in volunteers was 1.3 hours and the volume of distribution was 67L. Levobupivacaine is highly protein bound (>97%). The drug is extensively metabolised by the cytochrome P450 (CYP) system, primarily CYP1A2 and CYP3A4 isoforms, and then excreted in the urine (71% within 48 hours) and faeces (24%). Levobupivacaine crosses the placenta, with an umbilical vein/maternal vein drug concentration ratio of 0.3 after epidural levobupivacaine 0.5% (150mg) in women undergoing Caesarean section. After administration of racemic bupivacaine, it appears that systemic disposition is enantioselective, particularly with regards to plasma protein binding, which is higher with levobupivacaine than dexbupivacaine. Levobupivacaine does not undergo racaemisation in vivo. Therapeutic Use Most trials of levobupivacaine have been randomised and double-blind and have involved 20 to 137 patients. All but 1 trial were in adults. Surgical Anaesthesia: Levobupivacaine is long acting with an onset of action ≤15 minutes. The duration of action is dose-dependent and varies according to the anaesthetic technique. Adequate sensory and motor block for surgery was achieved in ≥90% of adult patients receiving adequate doses of levobupivacaine with satisfactory anaesthetic technique in most of the 10 available clinical trials. The anaesthetic and/or analgesic effects of levobupivacaine were largely similar to those with bupivacaine at the same dose in all comparative studies, including those of epidural, peripheral nerve block (supraclavicular or axillary brachial plexus nerve block), local infiltration and peribulbar administration. The duration of sensory block tended to be longer with levobupivacaine, although the difference was not statistically significant compared with bupivacaine in most cases. After epidural administration, the duration of sensory block with levobupivacaine was 8 to 9 hours with 0.75% (112.5 to 202.5mg), 7.5 hours with 0.5% (150mg) and 6 hours with 0.5% (75mg), and was 23 to 45 minutes longer than with bupivacaine at the same dose. The duration of sensory block after intrathecal levobupivacaine 15mg was 6.5 hours. With peripheral nerve block, the duration of sensory block was 17 hours with levobupivacaine 0.5% (2 mg/kg) versus 15 hours with bupivacaine 0.5% (2 mg/kg) or levobupivacaine 0.25% (1 mg/kg). With epidural administration, levobupivacaine produced less prolonged motor block than sensory block. This differential was not seen with peripheral nerve block. Pain Management: Analgesia attained with epidural levobupivacaine was generally similar to that with bupivacaine in women in labour in the 2 available studies. The median time to onset of pain relief was 12 minutes and the duration of pain relief was approximately 50 minutes with levobupivacaine or bupivacaine 0.25% (25mg). With another regimen (mean dose of levobupivacaine 28 mg/h, bupivacaine 27 mg/h), 43% of the first stage of labour was pain free in both groups. Effective postoperative pain relief was attained by combining epidural levobupivacaine 0.125% (7.5 mg/h) with clonidine, levobupivacaine 0.25% (10 mg/h) with morphine or levobupivacaine 0.125% (5 mg/h) with fentanyl or using higher doses of levobupivacaine 0.25% (15 mg/h). The time to first request for rescue analgesia was 10 to 17 hours. The combined regimens were more effective than any of the comparator agents alone, and the higher dose was more effective than lower doses of levobupivacaine. Ilioinguinal/iliohypogastric nerve block with levobupivacaine 0.5% (1.25 mg/kg per operated side) at the conclusion of surgery provided better pain relief than placebo in children. When used at the lower doses needed for pain management, most patients did not have significant motor block. Tolerability The tolerability profiles of levobupivacaine and bupivacaine were very similar in clinical trials. The most common adverse events associated with levobupivacaine anaesthesia in 1141 patients in phase II/III trails (regardless of causality to the drug; route not stated) were: hypotension (31%), nausea (21%), postoperative pain (18%), fever (17%), vomiting (14%), anaemia (12%), pruritus (9%), pain (8%), headache (7%), constipation (7%), dizziness (6%) and fetal distress (5%). Levobupivacaine and bupivacaine generally exerted similar effects on blood pressure and heart rate. No clinically significant ECG abnormalities occurred in clinical trials. No serious adverse CNS events were caused by levobupivacaine at the doses used; a small number of patients reported transient hypoaesthesia or paraesthesia, but these effects may have been operation-related. When levobupivacaine was used in obstetric indications, fetal outcome was not significantly different with levobupivacaine and bupivacaine. No significant CNS toxicity or cardiotoxicity was seen in a patient who received prompt treatment following an unintentional intravascular injection of levobupivacaine 142.5mg. Dosage and Administration Indications and recommended dosages for levobupivacaine differ markedly between Europe and the US. The indications for levobupivacaine in Europe include epidural, intrathecal, peripheral nerve block, peribulbar administration and local infiltration for surgical anaesthesia in adults. Levobupivacaine is also indicated for epidural use for the management of pain, including labour and postoperative pain in adults. In children, levobupivacaine is indicated for ilioinguinal/iliohypogastric nerve block. The recommended maximum single dose for surgical anaesthesia in adults (other than for intrathecal administration) is generally 150mg. Additional doses may be required for a prolonged procedure. The recommended maximum single dose for intrathecal administration is 15mg. The recommended maximum epidural dose for labour analgesia is a 0.125% infusion of 12.5 mg/h or epidural injections of 0.25% up to 25mg at ≥15-minute intervals. For postoperative pain management in adults, the dose should not exceed 18.75 mg/h. The maximum dose for children undergoing ilioinguinal/iliohypogastric block is 1.25 mg/kg/ side. In the US, levobupivacaine is indicated for epidural, peripheral nerve block, peribulbar administration and local infiltration for surgical anaesthesia in adults. Levobupivacaine is also indicated for epidural use for the management of pain, including labour and postoperative pain in adults. The drug is not currently indicated in the US for intrathecal administration or use in children. Surgical anaesthesia doses are similar to those in Europe, but doses of up to 50mg can be given for labour analgesia and up to 25 mg/h for postoperative pain management. According to European prescribing information, the use of 0.75% (7.5 mg/ml) of levobupivacaine is contraindicated in obstetric patients; this is based on experience with bupivacaine and the 0.75% concentration of levobupivacaine has not been studied in obstetric patients. Concentrations up to 0.5% (150mg) can be used for Caesarean section. The drug is contraindicated for paracervical block in obstetrics and intravenous regional anaesthesia (Bier’s block) as well as in patients with severe hypotension or known hypersensitivity to local anaesthetics of the amide type. US product labelling carries warnings against the use of levobupivacaine in obstetric patients at the 0.75% concentration, obstetrical paracervical block, and intravenous regional anaesthesia. Use of levobupivacaine in patients with known hypersensitivity to amide-type local anaesthetics is contraindicated. Levobupivacaine should be used with caution in patients with impaired cardiovascular function or liver disease or reduced liver blood flow. As with all local anaesthetics, epidural levobupivacaine can cause hypotension, bradycardia and possibly cardiac arrest. Appropriate treatments, equipment and personnel should be readily available in the event that a serious adverse event occurs. The toxic effects of other local anaesthetics, antiarrhythmic agents with local anaesthetic activity or class III antiarrhythmic agents may be additive to those of levobupivacaine.
Anterior cruciate ligament reconstruction is performed routinely as an outpatient surgical procedure despite few studies of patient acceptance or postoperative patient analgesia. This study reports the first series of postoperative femoral nerve blocks as analgesia for outpatient anterior cruciate ligament reconstruction. The authors retrospectively reviewed 161 patients undergoing two incision arthroscopically assisted autograft middle 1/3 patellar tendon anterior cruciate ligament reconstruction on an out-patient basis at the authors' institution during a period of 30 months. Hospital and anesthesia records were reviewed, and 83% of patients were contacted retrospectively to survey their perceptions of the procedure and its outcome. Ninety-eight percent of the patients were discharged from the ambulatory surgery center, with 51% discharged the same day as the surgery and 47% discharged by 7:00 AM the next day. As the study progressed, the number of patients staying overnight was reduced by 50%. Ninety-eight percent of patients surveyed found femoral nerve block to be beneficial, and the same percentage thought the discharge time was appropriate. However, 69% of patients staying overnight cited reasons other than pain as factors in their stay. No significant complications were reported. Based on these results, the administration of a femoral nerve block is recommended for patients undergoing outpatient anterior cruciate ligament reconstruction because it is a highly effective form of analgesia with an excellent degree of patient satisfaction.
Besides various methods of general anaesthesia, regional anaesthetic procedures are well suited for the surgical care of traumatological patients. For operations on patients with lesions of the lower leg, we have been using for 3 years a combination of dorsolateral blockade of the sciatic nerve according to Winnie with a "3 in 1-block". Our experiences with 80 patients show that a complete anaesthesia of the operation field holds for about 100 minutes with a blockade using 1.5% lidocaine with adrenaline. Main indications of this method are operations on lesions of the fibular ligament, leg fractures, ankle joint fractures, removal of osteosynthesis metal and other operations on the leg or foot. Partial or complete failures were registered in 12% of the cases. Severe complications did not occur.
While femoral and sciatic blocks have been used effectively to provide anesthesia for operations on the lower leg and foot, block anesthesia for procedures on or above the knee has not been used extensively because of the necessity to also block the obturator and lateral femoral cutaneous nerves. Even in experienced hands, if blockade of all four nerves is attempted, it requires a large number of injections and large volumes of local anesthetic; thus, not only may the failure rate be high but the complication rate as well. A reexamination of the anatomy would seem to indicate that the three nerves to the leg arising from the lumbar plexus can be blocked by a single injection, for the lumbar plexus arises in a fascial envelope, from which an extension accompanies the femoral nerve. Thus, if this fascial extension is identified by the production of a paresthesia of the femoral nerve and if a sufficient volume of anesthetic solution is injected to reach the plexus, anesthesia of all three nerves does result. Clinical experience has shown such a technic to be extremely effective, safe, and simple; and volume anesthesia studies have indicated that to block all three nerves consistently a minimum of 20 ml. of anesthetic must be utilized. On the other hand, additional studies showed that even with the use of volumes two or three times this minimum volume, anesthesia over the distribution of the sciatic nerve did not result; this nerve had to be blocked separately if anesthesia in that distribution was necessary.
Assessment is made of the effectiveness of femoral nerve block, administered either before or after surgery, in supplementing postoperative analgesia for knee joint (anterior cruciate) reconstruction surgery. Femoral nerve block, performed before surgery, with Bupivacaine 0.5%, reduced intramuscular opiate ad ministration by 80% in the recovery room and 40% in the first 24 postoperative hours. An effective and rapidly performed technique for fem oral nerve block is described.
We describe a new anesthetic technique of femoral and sciatic nerve blocks in knee arthroscopy. The sciatic nerve block is administered through a posterior approach, and the block of the femoral and lateral femoral cutaneous nerves in a single anterior approach. This type of regional anesthesia is safe and effective, providing excellent intraoperative and postoperative analgesia as well as minimizing postoperative complications.