Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
J Arthroplasty. 2021 Jan;36(1):122-129.e1. doi: 10.1016/j.arth.2020.06.086. Epub 2020 Jul 2.
The combination of adductor canal block (ACB) and infiltration between the popliteal artery and the posterior capsule of the knee (iPACK) block may provide sufficient motor-sparing anterior and posterior knee analgesia after total knee arthroplasty. This study aimed to determine if ACB with iPACK block was noninferior to ACB with periarticular injection (PAI) when combined with postoperative multimodal analgesia regimen.
Seventy-six patients were randomized to receive either ACB + iPACK block and continuous ACB (CACB) (ACB + iPACK group) or PAI and CACB (ACB + PAI group). Noninferiority was concluded for the primary outcome if the adjusted mean between-group difference in pain on movement at 12 postoperative hours was within 1.3 points on a visual analog pain scale. Pain scores, morphine consumption, functional performance, and adverse events were the secondary outcome measures assessed for superiority.
Adjusted mean differences, (ACB + iPACK) - (ACB + PAI), in anterior and posterior knee pain scores on movement at 12 postoperative hours were -0.66 (-1.86, 0.54) and -0.19 (-1.36, 0.99), respectively. The upper limit of 95% confident interval was lower than the prespecified noninferiority limit. The mean visual analog scale pain scores were low and no clinically significant differences between groups. However, morphine requirement at 48 postoperative hours was significantly higher (P < .05) and showed greater reduced quadriceps strength at 0 and 45 degrees on postoperative day 0 (P = .006 and .04, respectively) in the ACB + iPACK group.
ACB with iPACK block provides a noninferior analgesia compared with PAI when combined with CACB. However, patients who received ACB + iPACK block may require higher amounts of opioids and have worse immediate functional performance.
Therapeutic level I.
隐动脉阻滞（ACB）联合膝关节后囊与腘动脉之间浸润（iPACK）阻滞可能为全膝关节置换术后提供充分的膝关节前、后运动镇痛。本研究旨在确定 ACB 联合 iPACK 阻滞与关节周围注射（PAI）相比，联合术后多模式镇痛方案是否具有非劣效性。
76 例患者随机分为接受 ACB+iPACK 阻滞联合持续 ACB（CACB）（ACB+iPACK 组）或 PAI 联合 CACB（ACB+PAI 组）。如果组间差异的调整后均值在术后 12 小时运动时的视觉模拟疼痛评分上相差 1.3 分以内，则认为主要结局具有非劣效性。疼痛评分、吗啡消耗量、功能表现和不良事件为次要结局评估指标。
调整后的平均差值（ACB+iPACK）-（ACB+PAI），术后 12 小时膝关节前、后运动时疼痛评分分别为-0.66（-1.86，0.54）和-0.19（-1.36，0.99）。95%置信区间上限低于预设的非劣效性界限。平均视觉模拟评分较低，两组间无明显差异。然而，术后 48 小时吗啡需求显著增加（P<.05），术后第 0 天和第 45 度时股四头肌力量明显降低（P=.006 和 P=.04）。
ACB 联合 iPACK 阻滞与 PAI 联合 CACB 相比，提供了非劣效的镇痛效果。然而，接受 ACB+iPACK 阻滞的患者可能需要更多的阿片类药物，并且在术后即刻功能表现更差。
治疗水平 I。
