Postoperative analgesia after total knee arthroplasty

Dear Editor,

We read with great interest the article of Wang et al.¹ concerning the use of continuous local anesthetic infusion via catheters placed with ultrasound guided and nerve stimulator beside femoral nerve for postoperative analgesia after total knee arthroplasty (TKA). We congratulate them on the presentation of the article. However, we would like to add some comments.

We agree with author that rehabilitation after TKA is an important determinant of post-operative functional reconstruction of knee.¹ Physical therapy with early joint mobilization is also an important aspect to achieve good results. Therefore pain management after TKA is essential and may effect success rate of surgery.

Regional analgesia is commonly used for TKA as it has lesser side-effects and better analgesia when compared with traditional oral analgesics.² Among the regional analgesia techniques, continuous epidural analgesia and continuous femoral block analgesia are preferred to use after TKA.³

Continuous epidural analgesia has definite effectiveness, and a few systemic side effects. It has been widely applied in clinical practice. However, this procedure still causes respiratory depression, hemodynamic instability, intestinal obstruction, urinary retention, pruritus, motor block, and walk limitation.⁴ Continuous femoral nerve block has special advantage for the analgesia in postoperative pain.^5,6 It is that this technique may have less side effects than the others but continuous epidural analgesia may be more successful with postoperative pain management.

Anatomically, the knee joint takes its nerve supply primarily from the femoral nerve; however, there seems to be an important component from the sciatic nerve that evinces as pain related to calf and leg.² Previous studies are inconclusive concerning the necessity of sciatic nerve block and also there are nearly an equal number of studies discussing adequate and inadequate block with femoral nerve block alone.⁷ However a study of Zugliani et al. demonstrated that sciatic nerve block with one single dose associated with continuous femoral nerve block improved significantly the quality of postoperative analgesia in TKA.⁸

We think that sciatic nerve block and femoral nerve block may be performed together or single shot sciatic nerve block may be added for insufficient femoral nerve block and also the use of ultrasound-guided continuous femoral nerve block for postoperative pain control in TKA may be a good alternative to continuous epidural analgesia.

References

• ¹
  Wang F, Liu L, Hu Z, et al. Ultrasound and nerve stimulator guided continuous femoral nerve block analgesia after total knee arthroplasty: a multicenter randomized controlled study. Rev Bras Anestesiol. 2015;65:14-20.
• ²
  Shanthanna H, Huilgol M, Maniar A. Comparative study of ultrasound-guided continuous femoral nerve blockade with continuous epidural analgesia for pain relief following total knee replacement. Indian J Anaesth. 2012;56:270-5.
• ³
  Al-Zahrani T, Doais KS, Aljassir F, et al. Randomized clinical trial of continuous femoral nerve block combined with sciatic nerve block versus epidural analgesia for unilateral total knee arthroplasty. J Arthroplasty. 2015;30:149-54.
• ⁴
  Nora FS. Target-controlled total intravenous anesthesia associated with femoral nerve block for arthroscopic knee meniscectomy. Rev Bras Anestesiol. 2009;59:131-41.
• ⁵
  Guirro U, Tambara E, Munhoz F. Femoral nerve block: assesment of postopratif analgesia in arthroskopic anterior cruciate ligament reconstruction. Br J Anaesth. 2013;63:483-91.
• ⁶
  Aytaç Ş, Atalan G, Gülen G, et al. Comparison of femoral nerve block by neurostimulator accompanied with ultrasound and without ultrasound in knee artroplsty. J Clin Anal Med. 2015;6:208-11.
• ⁷
  Weber A, Fournier R, Van Gessel E, et al. Sciatic nerve block and the improvement of femoral nerve block analgesia after total knee replacement. Eur J Anaesthesiol. 2002;19:834-6.
• ⁸
  Zugliani AH, Verçosa N, Amaral J, et al. Control of postoperative pain following total knee arthroplasty: is it necessary to associate sciatic nerve block to femoral nerve block? Rev Bras Anestesiol. 2007;57:514-24.

Publication Dates

• Publication in this collection
  Jul-Aug 2016