Application Of Different Local Infiltration Techniques Combined With Femoral Nerve Block In Total Knee Arthroplasty

Background and Objectives: Total knee arthroplasty(TKA)is a severe traumatic procedure,and patients often experience severe PAIn after surgery.Severe postoperative pain can obviously influence the early postoperative functional rehabilitation exercise,prolongs the length of hospital stay,and increases various postoperative complications and the financial burden of patients.In recent years,with the popularization of ultrasound in clinical anesthesia,nerve block is more and more widely used in clinical anesthesia.The femoral nerve and sciatic nerve are the main innervating nerves of lower limbs.And the femoral nerve block(FNB)combined with sciatic nerve block(SNB)is also widely used in TKA.However,due to the deep location of the sciatic nerve and its unclear ultrasonic imaging,irreversible sciatic nerve injury after SNB has been reported in the past,which seriously affects the quality of life of patients and increases the economic burden of patients.However,if TKA patients only receive FNB alone,a large number of them will still experience moderate to severe pain after surgery.Our previous study showed that FNB combined with other analgesic methods,such as dexmedetomidine,as an adjuvant of nerve block,can significantly improve the postoperative analgesic effect.Local infiltration analgesia technique(LIA)has been widely used in clinical practice,and relevant studies have shown that LIA can be used as a supplement of FNB for postoperative analgesia of TKA.But up to now,the effect of FNB combined with different LIA on postoperative analgesia of TKA remains unclear.Therefore,we designed this study to observe whether there are differences in the analgesic effects of different LIA combined FNB with on postoperative TKA,so as to provide reference for clinical application.Methods: Seventy-eight patients undergoing TKA were included and randomly divided into three groups:(1)Control group(C group FNB alone): FNB(20ml 0.375%ropivacaine);(2)IAI group(intra-articular injection combined with FNB): FNB(20ml0.375% ropivacaine)+IAI(50ml drug solution);(3)PAI group(periarticular injection combined with FNB): FNB(20ml 0.375% ropivacaine)+PAI(20ml drug solution).All patients received general anesthesia and multimodal analgesia routinely.The primary indicator was the proportion of patients without postoperative rescue analgesia in the first 48 hours after surgery,while the duration of analgesia(the duration from the completion of FNB to the first postoperative rescue analgesia);the resting VAS at postoperative 6h,12 h,24h,48h;the motorial VAS at postoperative 12 h,24h,48h;the maximum VAS during postoperative 48 hours;the dosage of postoperative rescue analgesics during postoperative 48 hours;the occurrence of postoperative nausea and vomiting(PONV)and postoperative delirium(POD)assessed by CAM-ICU scale during postoperative 72 hours;the first time to walk with a walker;and the dosage of sufentanil during operation were recorded as secondary indicators.Results: The proportion of patients without postoperative rescue analgesia within48 hours after operation in the IAI group was significantly higher than that in the C group and PAI group(69% VS 27% VS 27%,P=0.002).Using Kaplan-Meier survival analysis,the duration of analgesia for patients without remedial analgesia was calculated as 48 hours and the duration of analgesia in the IAI group was significantly longer than that in the C group and PAI group(P=0.003,P=0.006).There was no statistically significant difference in the duration of analgesia between the C group and the PAI group(log-rank test: P =0.483).Within 48 hours after operation there were significant differences in the dosage of diclofenac sodium lidocaine among the three groups(P<0.05).the dosage of diclofenac sodium lidocaine in the IAI group was significantly lower than that in the C group and PAI group(P=0.017).There was no statistically significant difference in the dose of diclofenac sodium lidocaine between the C group and the PAI group(P=0.072).The resting PAIn score of the IAI group at 12 hours postoperative was significantly lower than that of the C group(P =0.014).The resting and motor VAS within 24 hours after surgery and the max VAS within 48 hours after surgery in the IAI group were significantly lower than those in the PAI group and C group(P =0.001,P <0.05,P <0.05),while there was no statistical difference between the PAI group and the C group.In addition,VAS scores were similar in all three groups at other time points.The incidence of POD and PONV was similar among the three groups(P>0.05).Patients in the IAI group had the earliest postoperative walk after surgery with the help of a walker earlier than those in the PAI and C groups(P<0.05),while the time of walk in the C group and the PAI group is similar.None of the three groups reported the occurrence of common peroneal nerve injury,deep vein thrombosis,or fall after getting out of bed.There was no significant difference in the duration of surgery and the total consumption of intra-operative analgesics in the three groups.Conclusions: The intra-articular injection combined with FNB could offer a superior postoperative analgesic effect and early postoperative rehabilitation exercise compared with the periarticular injection combined with FNB and FBN alone.However,there was no significant difference between periarticular injection combined with FNB and FBN alone.