Selective Tibial Nerve Block vs Local Infiltration Analgesia After Prothetic Knee Surgery

Overview

Patient suffer from moderate posterior knee pain after TKA despite injection of local anesthetic around the femoral or saphenous nerves. Indeed, the posterior part of the knee is innervated by the sciatic nerve. This nerve is not routinely blocked as clinicians fear to produce a motor block of the leg that might impair the postoperative assessment. An analgesic alternative is the infiltration of the knee with local anesthetics performed by the surgeon. Recently a trial(1) demonstrated that a selective tibial nerve block provides an effective analgesia without a motor blockage when compared with a sciatic nerve block. The objective of this randomized controlled double-blinded trial is to assess whether a tibial nerve block is more effective for the postoperative pain than local infiltration analgesia when there are combined with an adductor canal block, without decreasing the functional parameters.

Full Title of Study: “Optimal Pain Control After Prothetic Knee Surgery Either by Selective Tibial Nerve Block Versus Local Infiltration Analgesia”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Treatment
    • Masking: Triple (Participant, Investigator, Outcomes Assessor)
  • Study Primary Completion Date: January 31, 2023

Interventions

  • Drug: Ropivacaine 0.5% Injectable Solution
    • Tibial nerve block with 10ml of Ropivacaine 0.5%
  • Drug: Ropivacaine 0.2% Injectable Solution
    • Infiltration with 25ml of Ropivacaine 0.2% in the posterior knee capsule

Arms, Groups and Cohorts

  • Experimental: Tibial nerve block
    • Adductor canal and tibial nerve blocks performed by the anesthetist under ultrasound guidance before spinal block.
  • Active Comparator: Local infiltration analgesia
    • Adductor canal block by the anesthetist under ultrasound guidance before spinal block. Infiltration of the knee by the surgeon with local anesthetic at the end of the surgery.

Clinical Trial Outcome Measures

Primary Measures

  • Total morphine consumption (mg)
    • Time Frame: 24 hours postoperatively

Secondary Measures

  • Total morphine consumption (mg)
    • Time Frame: 2 hours, 48 hours and 72 hours postoperatively
  • Analgesic duration (minutes)
    • Time Frame: Postoperative day 0
    • Time from the block to the first analgesic request
  • Pain scores (numeric rating scale, 0-10) at rest and on movement
    • Time Frame: 2 hours, 24 hours, 48 hours and 72 hours postoperatively
    • 0= no pain, 10=the worst pain imaginable
  • Rate of postoperative nausea and vomiting
    • Time Frame: 2 hours, 24 hours, 48 hours and 72 hours postoperatively
    • Yes/No
  • Rate of prurit
    • Time Frame: 2 hours, 24 hours, 48 hours and 72 hours postoperatively
    • Yes/No
  • Active flexion
    • Time Frame: 24hours, 48hours and 72hours postoperatively
    • Flexion of the knee by the patient measured in degrees
  • Passive flexion
    • Time Frame: 24hours, 48hours and 72hours postoperatively
    • Flexion of the knee by physiotherapist measured in degrees
  • Quadriceps muscle strength (numeric scale, 1-5)
    • Time Frame: 24hours, 48hours and 72hours postoperatively
    • 1=no contraction, 5=normal strength
  • Distance walked (meters)
    • Time Frame: 24hours, 48hours and 72hours postoperatively
  • Complication of tibial nerve block
    • Time Frame: up to 1 week
    • Intravascular injection/hematoma/infection/Common peroneal nerve block
  • Length of stay in hospital
    • Time Frame: up to 14 days
    • Days

Participating in This Clinical Trial

Inclusion Criteria

  • Patient scheduled for a total knee arthroplasty under spinal block. – Patient with a weight above 40kg. Exclusion Criteria:

  • Patient with ASA IV status. – Contraindication to spinal block, or peripheral nerve blocks. – Neurological deficit of the lower limb. – Patient with renal dysfunction. – Patient with chronic pain, opioid consumption or alcohol consumption. – Pregnancy.

Gender Eligibility: All

Minimum Age: 18 Years

Maximum Age: N/A

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Centre Hospitalier Universitaire Vaudois
  • Provider of Information About this Clinical Study
    • Principal Investigator: Eric Albrecht, Program director of regional anaesthesia – Centre Hospitalier Universitaire Vaudois
  • Overall Contact(s)
    • Eric Albrecht, PD Dr, +41 79 556 63 41, eric.albrecht@chuv.ch

References

Sinha SK, Abrams JH, Arumugam S, D'Alessio J, Freitas DG, Barnett JT, Weller RS. Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study. Anesth Analg. 2012 Jul;115(1):202-6. doi: 10.1213/ANE.0b013e3182536193. Epub 2012 Apr 27.

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