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The posterior lumbar plexus (psoas compartment) block and the three-in-one femoral nerve block provide similar postoperative analgesia after total knee replacement

  • Ismaïl Kaloul
  • Joanne GuayEmail author
  • Christiane Côté
  • Michel Fallaha
Regional Anesthesia and Pain

Abstract

Purpose

To compare the efficacy of a continuous posterior lumbar plexus (PSOAS) block to a continuous three-in-one femoral nerve (FEM) block in patients undergoing primary total knee replacement (TKR).

Methods

Sixty patients were randomly allocated to receiveiv patient-controlled morphine analgesia (PCA), PCA plus a continuous FEM block with 30 mL ropivacaine 0.5% and epinephrine 1:200,000 bolus followed by an infusion of ropivacaine 0.2% at 12 mL · hr−1 for 48 hr, or PCA plus a continuous PSOAS block with the same bolus and infusion regimen as the FEM group. Postoperative morphine consumption, verbal analogue scale pain scores at rest and during physiotherapy and evidence of sensory and motor blockades were noted.

Results

Both regional techniques significantly reduced 48 hr morphine consumption (FEM 37.3 ± 34.7 mg,P = 0.0002; PSOAS 36.1 ± 25.8 mg,P < 0.0001) compared to PCA (72.2 ± 26.6 mg). Pain scores at rest, six and 24 hr after TKR were lower in the FEM and PSOAS groups compared to the PCA group (P < 0.0001). Although sensory and motor blockades of the obturator nerve were achieved more often in the PSOAS group than in the FEM group (P < 0.0001), morphine consumption and pain scores did not differ between the two groups.

Conclusion

Both continuous PSOAS block and continous threein-one FEM block provided better analgesia than PCA but no differences were seen between the two regional techniques.

Keywords

Total Knee Arthroplasty Ropivacaine Total Knee Replacement Morphine Consumption Femoral Nerve Block 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Le bloc du plexus lombaire par voie postérieure (loge du psoas) et le bloc du nerf fémoral trois-en-un produisent une analgésie similaire après une arthroscopie totale du genou

Résumé

Objectif

Comparer l’efficacité d’un bloc continu du plexus lombaire par voie postérieure (PSOAS) à celle d’un bloc trois- en- un du nerf fémoral (FEM) pour l’analgésie postopératoire des patients subissant une arthroplastie totale du genou (ATG).

Méthode

Soixante patients ont été divisés au hasard en trois groupes égaux et ont reçu l’analgésie iv auto- contrôlée (AAC) avec morphine, l’AAC plus un bloc FEM avec 30 mL de ropivacaïne 0,5 % et adrénalinée à 1:200 000 suivi d’une perfusion de ropivacaïne 0,2 %à 12 mL · h−1 pour 48 h, ou l’AAC plus un bloc PSOAS continu. La consommation de morphine, le score de douleur par l’échelle verbale analogique (EVA) au repos et durant la kinésithérapie, et les blocs sensitifs et moteurs ont été notés.

Résultats

Les deux types de bloc, comparés à l’AAC, réduisent la consommation totale (48 h) de morphine (AAC 72,2 ± 26,6 mg; FEM 37,3 ± 34,7 mg, P = 0,0002; PSOAS 36,1 ± 25,8 mg, P < 0,0001) et les scores de douleur au repos, à six et 24 h après l’ATG ont été plus bas dans les groupes FEM et PSOAS comparés au groupe d’AAC (P < 0,0001). Le blocage du nerf obturateur (sensitif et moteur) est plus constant avec le bloc PSOAS qu’avec le bloc FEM (P < 0,0001) mais les deux techniques ont un effet similaire sur la consommation de morphine et les ÉVA.

Conclusion

Comparativement à l’AAC, les deux blocs continus du plexus lombaire offrent une meilleure analgésie postopératoire mais il n’y a pas de différence entre les deux types de bloc quant à la consommation de morphine et aux ÉVA.

References

  1. 1.
    Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop 1990; 260: 30–7.PubMedGoogle Scholar
  2. 2.
    Singelyn FJ, Deyaert M, Joris D, Pendeville ES, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg 1998; 87: 88–92.PubMedCrossRefGoogle Scholar
  3. 3.
    Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, D’Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology 1999; 91: 8–15.PubMedCrossRefGoogle Scholar
  4. 4.
    Chelly JE, Greger J, Gebhard R, et al. Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty. J Arthroplasty 2001; 16: 436–45.PubMedCrossRefGoogle Scholar
  5. 5.
    Wang H, Boctor B, Verner J. The effect of single-injec- tion femoral nerve block on rehabilitation and length of hospital stay after total knee replacement. Reg Anesth Pain Med 2002; 27: 139–44.PubMedCrossRefGoogle Scholar
  6. 6.
    Edwards ND, Wright EM. Continuous low-dose 3-in-l nerve blockade for postoperative pain relief after total knee replacement. Anesth Analg 1992; 75: 265–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Ng HP, Cheong KF, Lim A, Lim J, Puhaindran ME. Intraoperative single-shot “3-in-l” femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement. Can J Anesth 2001; 48: 1102–8.PubMedGoogle Scholar
  8. 8.
    American Society of Regional Anesthesia and Pain Medicine. Regional anesthesia in the anticoagulated patient — defining the risks. 2002 [cited 17 May 2003]. Available from: URL: http://www.asra.com/ items_of_interest/consensus_statements/index.iphtml.Google Scholar
  9. 9.
    Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD. Peripheral nerve blocks improve analgesia after total knee replacement surgery. Anesth Analg 1998; 87: 93–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Marhofer P, Nasel C, Sitzwohl C, Kapral S. Magnetic resonance imaging of the distribution of local anesthetic during the three-in-one block. Anesth Analg 2000; 90: 119–24.PubMedCrossRefGoogle Scholar
  11. 11.
    McNamee DA, Parks L, Milligan KR. Post-operative analgesia following total knee replacement: an evaluation of the addition of an obturator nerve block to combined femoral and sciatic nerve block. Acta Anaesthesiol Scand 2002; 46: 95–9.PubMedCrossRefGoogle Scholar
  12. 12.
    Parkinson SK, Mueller JB, Little WL, Bailey SL. Extent of blockade with various approaches to the lumbar plexus. Anesth Analg 1989; 68: 243–8.PubMedGoogle Scholar
  13. 13.
    Winnie AP, Ramamurthy S, Durrani Z, Radonjic R. Plexus blocks for lower extremity surgery. new answers to old problems. Anesthesiology 1974; 1: 11–6.Google Scholar
  14. 14.
    Bouaziz H, Vial F, Jochum D, et al. An evaluation of the cutaneous distribution after obturator nerve block. Anesth Analg 2002; 94: 445–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Gentili M, Aveline C, Bonnet F. Total spinal anesthesia after posterior lumbar plexus block (French). Ann Fr Anesth Réanim 1998; 17: 740–2.PubMedGoogle Scholar
  16. 16.
    Pham-Dang C, Beaumont S, Floch H, Bodin J, Winer A, Pinaua M. Acute toxic accident following lumbar plexus block with bupivacaine (French). Ann Fr Anesth Réanim 2000; 19: 356–9.PubMedCrossRefGoogle Scholar
  17. 17.
    Klein SM, D’Ercole F, Greengrass RA, Warner DS. Enoxaparin associated with psoas hematoma and lumbar plexopathy after lumbar plexus block. Anesthesiology 1997; 87: 1576–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Aida S, Takahashi H, Shimoji K. Renal subcapsular hematoma after lumbar plexus block. Anesthesiology 1996; 84: 452–5.PubMedCrossRefGoogle Scholar
  19. 19.
    Weller RS, Gerancher JC, Crews JC, Wade KL. Extensive retroperitoneal hematoma without neurologic deficit in two patients who underwent lumbar plexus block and were later anticoagulated. Anesthesiology 2003; 98: 581–5.PubMedCrossRefGoogle Scholar
  20. 20.
    Capogna G, Celleno D, Fusco P, Lyons G, Columb M. Relative potencies of bupivacaine and ropivicaine for analgesia in labour. Br J Anaesth 1999; 82: 371–3.PubMedGoogle Scholar
  21. 21.
    Bernard JM, Macaire P. Dose-range effects of clonidine added to lidocaine for brachial plexus block. Anesthesiology 1997; 87: 277–84.PubMedCrossRefGoogle Scholar
  22. 22.
    Hiippala S, Strid L, Wennerstrand M, et al. Tranexamic acid (Cyklokapron) reduces perioperative blood loss associated with total knee arthroplasty. Br J Anaesth 1995; 74: 534–7.PubMedCrossRefGoogle Scholar
  23. 23.
    Synthèse: quels blocs tronculaires du membre pelvien choisir?Ln: Gaertner E, Choquet O, Macaire P, Zetlaoui PJ (Eds.). Anesthésie Régionale : Anesthésie Tronculaire et Plexique de L’adulte. Reuil-Malmaison: Arnette; 2001: 191.Google Scholar
  24. 24.
    Bernard N, Pirat P, Branchereau S, Gaertner E, Capdevila X. Continuous peripheral nerve blocks in 1416 patients: a prospective multicenter study measur- ing incidences and characteristics of infectious adverse events. Anesthesiology 2002; 96: 882 (abstract).Google Scholar
  25. 25.
    Kaloul I, Guay J, Côté C, Halwagi A, Varin F. Ropivacaine plasma concentrations are similar during continuous lumbar plexus blockade: using the anterior three-in-one and the posterior psoas compartment techniques? Can J Anesth 2004; 51: 52–6.PubMedCrossRefGoogle Scholar
  26. 26.
    Hirst GC, Lang SA, Dust WN, Cassidy JD, Yip RW. Femoral nerve block. Single injection versus continuous infusion for total knee arthroplasty. Reg Anesth 1996; 21: 292–7.PubMedGoogle Scholar

Copyright information

© Canadian Anesthesiologists 2004

Authors and Affiliations

  • Ismaïl Kaloul
    • 1
  • Joanne Guay
    • 1
    Email author
  • Christiane Côté
    • 1
  • Michel Fallaha
    • 2
  1. 1.Department of AnesthesiologyHôpital Maisonneuve-Rosemont, Université de MontréalMontréalCanada
  2. 2.Department of SurgeryHôpital Maisonneuve-Rosemont, Université de MontréalMontréalCanada

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