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EDITORIAL
Year : 2022  |  Volume : 23  |  Issue : 2  |  Page : 81-82
 

Sensory blocks for knee surgery: The dawn of a new era


Department of Anesthesiology, All India Institute of Medical Sciences, Guntur, Andhra Pradesh, India

Date of Submission15-Sep-2022
Date of Decision15-Sep-2022
Date of Acceptance15-Sep-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Dr. Rajasekhar Metta
Department of Anesthesiology, All India Institute of Medical Sciences, 425, 4th Floor, OPD Building, Mangalagiri, Guntur - 522 503, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_95_22

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How to cite this article:
Biyani G, Metta R. Sensory blocks for knee surgery: The dawn of a new era. Indian Anaesth Forum 2022;23:81-2

How to cite this URL:
Biyani G, Metta R. Sensory blocks for knee surgery: The dawn of a new era. Indian Anaesth Forum [serial online] 2022 [cited 2023 Jan 30];23:81-2. Available from: http://www.theiaforum.org/text.asp?2022/23/2/81/359851




An ideal sensory block should provide complete analgesia with no motor weakness. However, in clinical practice, finding such blocks is a rarity, and hence we aim for an optimal balance between adequate analgesia and preserving motor function. Analgesia for knee surgeries can be provided by performing proximal blocks such as lumbar and sacral plexus, or combination of femoral, obturator, and sciatic nerves. Although they provide excellent analgesia, motor weakness is common.[1] Over the past two decades, selective sensory blocks for knee joint like adductor canal block (ACB) and infiltration between the popliteal artery and capsule of the knee joint (IPACK) have emerged. By preserving the motor function, they allow early mobilization of the patient and thereby the advantages of ambulation.

Selective blockade of articular branches of the femoral, obturator, and sciatic nerves supplying the knee joint is the target of interest for the abovementioned blocks. The anterior capsule of the knee joint is supplied by the articular branches from nerve to vastus lateralis and nerve to vastus intermedius, superomedial genicular branch from nerve to vastus medialis, infrapatellar branch from the saphenous nerve, inferolateral and recurrent branches from the common peroneal nerve.[2] The posterior capsule is entirely supplied by the branches of tibial nerve with a small contribution from the posterior division of the obturator nerve and common peroneal nerve in the superomedial and superolateral aspects, respectively.[3]

The ACB was first described by Manickam et al. in 2009.[4] The adductor canal (Hunter's canal or subsartorial canal), is a musculoaponeurotic tunnel extending from the femoral triangle proximally to the adductor hiatus distally. It is bound superiorly by sartorius, anterolaterally by vastus medialis, and anteromedially by adductor longus or magnus muscles.[5] Its contents are femoral vessels, saphenous nerve, nerve to vastus medialis, and occasionally branches of the obturator nerve. While performing ACB, we aim to target only the sensory (articular) branches of these nerves innervating the anterior capsule, thereby preserving the motor power. In a recent meta-analysis by Hasabo et al.,[6] the researchers have found that ACB largely preserves the strength of quadriceps muscle, and its analgesic efficacy is equal to femoral nerve block. However, case reports of quadriceps weakness have been reported,[7] questioning the ideal site of injection within the adductor canal. It has been postulated that motor-sparing effect is more obvious with an injection in the distal adductor canal compared to the proximal or mid adductor canal, but large-scale studies have failed to confirm the same.[8]

IPACK block was first described by Sinha et al. in 2012,[9] with the aim to block the articular branches of the sciatic nerve supplying the posterior capsule of knee joint. The injection is made between the popliteal vessels and capsule of the knee joint where these sensory branches run. In a study by Kandarian et al.,[10] the authors found that the addition of IPACK to the existing multimodal analgesic protocol significantly reduces the pain scores in the immediate postoperative period. Similarly, in a meta-analysis by Guo et al.,[11] the authors found that the addition of IPACK to the ACB is a good technique for pain management following total knee arthroplasties. However, in other studies, the block is found to have no effect on opioid consumption, length of stay, and adverse events within 30 days.[12],[13] Moreover, due to its close proximity to the surgical site, the block should be performed under strict aseptic precautions.

Selective sensory blocks are the need of the hour, but in reality, we are still in search of the one. In addition to ACB and IPACK blocks, other sensory blocks such as selective blockade of nerve to vastus lateralis, and nerve to vastus intermedius are described in the literature, but the evidence is lacking to recommend their routine use. Future research must be aimed at modifying the present techniques, finding newer sensory blocks, and throwing more light in determining the role of such motor-sparing sensory blocks in the present multimodal analgesic regimen.



 
  References Top

1.
Marty P, Chassery C, Rontes O, Vuillaume C, Basset B, Merouani M, et al. Combined proximal or distal nerve blocks for postoperative analgesia after total knee arthroplasty: A randomised controlled trial. Br J Anaesth 2022;129:427-34.  Back to cited text no. 1
    
2.
Franco CD, Buvanendran A, Petersohn JD, Menzies RD, Menzies LP. Innervation of the anterior capsule of the human knee: Implications for radiofrequency ablation. Reg Anesth Pain Med 2015;40:363-8.  Back to cited text no. 2
    
3.
Tran J, Peng PW, Gofeld M, Chan V, Agur AM. Anatomical study of the innervation of posterior knee joint capsule: Implication for image-guided intervention. Reg Anesth Pain Med 2019;44:234-8.  Back to cited text no. 3
    
4.
Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R. Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med 2009;34:578-80.  Back to cited text no. 4
    
5.
Ghassemi J. Adductor canal block. In: Andrew T, editor. Gray, Atlas of Ultrasound-Guided Regional Anesthesia. 3rd ed., Ch. 42. Philadelphia: Elsevier 2019; 169-73.  Back to cited text no. 5
    
6.
Hasabo EA, Assar A, Mahmoud MM, Abdalrahman HA, Ibrahim EA, Hasanin MA, et al. Adductor canal block versus femoral nerve block for pain control after total knee arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2022;101:e30110.  Back to cited text no. 6
    
7.
Chen J, Lesser JB, Hadzic A, Reiss W, Resta-Flarer F. Adductor canal block can result in motor block of the quadriceps muscle. Reg Anesth Pain Med 2014;39:170-1.  Back to cited text no. 7
    
8.
Lee B, Park SJ, Park KK, Kim HJ, Lee YS, Choi YS. Optimal location for continuous catheter analgesia among the femoral triangle, proximal, or distal adductor canal after total knee arthroplasty: A randomized double-blind controlled trial. Reg Anesth Pain Med 2022;47:353-8.  Back to cited text no. 8
    
9.
Sinha S, Abras J, Sivasenthil A, Freitas D, D'Alessio J, Barnett J, et al. Spring 2012 use of ultrasound guided popliteal fossa infiltration to control pain after total knee arthroplasty: A prospective, randomized, observer-blinded study. ASRA 37th Annual regional Anesthesia meeting and workshops march 15-18, 2012 San Diego, CA. Reg Anesth Pain Med 2012;37:665-75.  Back to cited text no. 9
    
10.
Kandarian B, Indelli PF, Sinha S, Hunter OO, Wang RR, Kim TE, et al. Implementation of the IPACK Infiltration between the popliteal artery and capsule of the knee block into a multimodal analgesic pathway for total knee replacement. Korean J Anesthesiol 2019;72:238-44.  Back to cited text no. 10
    
11.
Guo J, Hou M, Shi G, Bai N, Huo M. iPACK block local anesthetic infiltration of the interspace between the popliteal artery and the posterior knee capsule added to the adductor canal blocks versus the adductor canal blocks in the pain management after total knee arthroplasty: A systematic review and meta-analysis. J Orthop Surg Res 2022;17:387.  Back to cited text no. 11
    
12.
Thobhani S, Scalercio L, Elliott CE, Nossaman BD, Thomas LC, Yuratich D, et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: An analysis of 106 patients. Ochsner J 2017;17:233-8.  Back to cited text no. 12
    
13.
Wang F, Ma W, Huang Z. Analgesia effects of IPACK block added to multimodal analgesia regiments after total knee replacement: A systematic review of the literature and meta-analysis of 5 randomized controlled trials. Medicine (Baltimore) 2021;100:e25884.  Back to cited text no. 13
    




 

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