Johnson, Rebecca L.

Intraoperative tourniquet-related pain is well recognized by anesthesiologists, but postoperative tourniquet-related pain has received little attention. We present a patient who underwent a total knee arthroplasty under general anesthesia and an adductor canal nerve block. She complained of intractable thigh pain postoperatively. Lidocaine 5% patches completely resolved her postoperative tourniquet-related pain.

ObjectivesTo identify any anatomic barriers to local anesthetic spread between the sciatic nerve (SN) and the posterior femoral cutaneous nerve (PFCN) at the level of the infragluteal crease and to describe a potential technique for an ultrasound (US)‐guided subgluteal PFCN block in a cadaveric model.MethodsBilateral US‐guided subgluteal injections of a colored latex solution were performed around the SN (15 mL) and PFCN (10 mL) in 4 unembalmed cadavers, for a total of 8 cadaver thighs. The specimens were dissected after latex polymerization to observe the spread of the latex solutions.ResultsWith US guidance, the PFCN was visualized deep to the gluteus maximus and slightly superficial or lateral to the SN at the level of the infragluteal crease. The SN and PFCN were found on dissection to be coated with their respective colored latex in all 8 thighs. The SN and PFCN were consistently separated by the deep investing muscular fascia of the thigh, with only 2 thighs showing substantial mixing of latex injectates.ConclusionsThe deep investing muscular fascia of the thigh appears to impede the spread of injectate between the SN and PFCN in a most unembalmed cadaver specimens. A US‐guided subgluteal PFCN blockade may be a feasible technique to complement an SN block when complete anesthesia of the posterior thigh is required.

Abstract Background Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. Methods This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. Results One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection ( P = 0.016; Hodges–Lehmann median difference [95% CI] = −1 [−2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal −2 [−3 to −1]; P < 0.001; average −0.8 [−1.3 to −0.2]; P = 0.003; and liposomal bupivacaine: maximal −3 [−4 to −2]; P < 0.001; average −1.4 [−2.0 to −0.8]; P < 0.001). Conclusions Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.

Positioning‐related injuries caused during surgery under anesthesia are most likely multifactorial. Pathologic mechanical forces alone (overstretching and/or ischemia from direct compression) may not fully explain postsurgical neuropathy with recent evidence implicating patient‐specific factors or perioperative inflammatory responses spatially and even temporally divorced from the anatomical region of injury. The aim of this introductory article is to provide an overview of anatomic considerations of these mechanical forces on soft and nervous tissues along with factors that may compound compression or stretch injury. Three subsequent articles will address specific positioning‐related anatomic considerations of the (1) upper extremities, (2) lower extremities, and (3) central nervous system and soft tissues. Clin. Anat. 28:678–682, 2015. © 2015 Wiley Periodicals, Inc.

AbstractPurposeThe purpose of this study was to evaluate the utility of multimodal analgesia with fascia iliaca blockade and for acute pain control in patients undergoing hip arthroscopy.MethodsThirty consecutive patients undergoing primary hip arthroscopy were prospectively studied. All patients were treated preoperatively with ultrasound‐guided single injection fascia iliaca blockade and multimodal analgesia. Data collected included post‐operative nausea, numeric rating scale (NRS) pain scores during rest and activity, opioid consumption during the first five days (recorded as tablets of 5 mg hydrocodone/500 mg acetaminophen) and overall patient satisfaction with analgesia.ResultsThis study included 23 female and 7 male patients with a median age of 35 years (range 14–58). No patient required medication for post‐operative nausea. The overall NRS scores were an average of 3.9 on day 0, 3.6 on day 1, 3.4 on day 2, 2.9 on day 3, 3.0 on day 4 and 2.7 on day 5. The average tablets of opioid taken were 1.5 on day 0, 1.2 on day 1, 1.3 on day 2, 1.0 on day 3, 1.1 on day 4 and 0.9 on day 5. Overall, 20 patients rated their post‐operative pain control as very satisfied (67 %), and 10 patients as satisfied (33 %). There were no complications or side effects from the fascia iliaca blockade.ConclusionIn this prospective study, multimodal analgesia with fascia iliaca blockade following hip arthroscopy was safe and effective. The quality of early post‐operative analgesia provided by the fascia iliaca blockade was excellent and resulted in low opioid consumption, high quality of pain relief and high overall patient satisfaction.Level of evidenceProspective case series, Level II.