Clinical Study Of Adductor Canal Combined With IPACK Block For Multimodal Analgesia After Total Knee Arthroplasty

Background:Total knee arthroplasty（TKA）is the preferred surgical approach for osteoarthritis or rheumatoid arthritis because it can effectively improve the pain around the knee joint and improve the quality of life.Early research has shown that IPACK（interspace between the popliteal artery and the capsule of the posterior knee,IPACK）anesthesia combined with adductor tube block（adductor canal block,ACB）can be used as the first selection of TKA surgery analgesia,but Single nerve block has short effective block time,nerve block accompanied with a high incidence of rebound pain,therefore increased the dosage of opioids and reduced the effective time of functional exercise after the operation.Some studies have shown that the addition of adjuvant to local anesthetic drugs can prolong the effective time of block,but there are few reports on the pain outbreak after nerve block.Therefore,IPACK block combined with continuous ACB after knee surgery,combined with dexamethasone injection as an adjuvant in local anesthetics,is the focus of this study.Objective:To evaluate the efficacy of continuous adductor canal block combined with IPACK block as a multimodal analgesic program after total knee arthroplasty.Method:108 patients with optional unilateral total knee arthroplasty under combined spinal-epidural anesthesia were selected,regardless of gender and age ranging from49 to 82 years old.Patients were classified into three groups by ASA grade I-III by random number table method（n=36）.Nerve block was divided into:single ACB combined IPACK group（SAI group）,continuous ACB combined IPACK group（CAI group）and continuous ACB combined IPACK combined dexamethasone group（CAD group）.Prevention and multi-mode analgesia were used in all patients.Before anesthesia,50 mg of flurbiprofen was injected intravenously,and 200 mg of Crecoxib was taken orally after surgery,twice per day,to inhibit inflammatory pain.Postoperative NRS scores were observed at 8,12,24,36,and 48 h at rest,and at 24,36,and 48 h at active functional exercise.The area under the curve(AUC _{s NRS} and AUC _{m NRS})of the static NRS and the motor NRS of the 48 h postoperatively was calculated.The occurrence times of outbreak pain and oxycodone to remedy analgesia were recorded.The Angle of active knee bending and the number of steps were recorded.The incidence of never block-related adverse events and postoperative rehabilitation related adverse events and the average length of hospital stay were recorded.Result:In the resting state,the difference of effective time of IPACK block between CAI group and CAD group was statistically significant（P<0.05）.NRS scores in the CAD group at 24 h after surgery were lower than those in the other two groups,and the difference was statistically significant（P<0.05）.NRS scores of the SAI group were higher than those of the other two groups 48 h after the operation at rest,and the difference was statistically significant（P<0.05）.The number of cases of CAD pain outbreak was less than CAI group and SAI group,and the difference was statistically significant（P<0.05）.NRS scores of CAI group and CAD group were better than SAI group 24 h after operation,and the difference was statistically significant（P<0.05）.The SAI group was smaller than CAI group and CAD group 24 h after operation,and the difference was statistically significant（P<0.05）.The number of steps in SAI group was less than that in CAI group and CAD group,and the difference was statistically significant（P<0.05）.Compared with SAI group and CAI group,both static and motor AUC _NRS of the CAD group were reduced（P<0.05）,oxycodone dosage was the least,and the length of hospital stay and other secondary observation indexes were not statistically significant（P>0.05）.There were no adverse events related to nerve block anesthesia and postoperative motor rehabilitation in the three groups.Conclusion:Multimode analgesia regimens with continuous adductor canal blockade combined with IPACK block and dexamethasone as a local anesthetic adjuvant after total knee arthroplasty provide improved analgesia and contribute to patient rehabilitation.