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Abstract Introduction Total knee arthroplasty (TKA) is accompanied by severe postoperative pain, which is reported to be an important cause of chronic pain. Ultrasound-guided adductor canal block (ACB) combined with infiltration between the popliteal artery and posterior capsular of the knee (IPACK) has been proven to have a better effect on relieving acute pain after TKA. However, whether it has a significant effect on the incidence of chronic pain after TKA has not been reported. This trial was designed to investigate the effect of ultrasound-guided ACB combined with IPACK on the incidence and intensity of chronic pain after TKA. Methods In this prospective, randomized, double-blind, placebo-controlled study, 100 subjects scheduled for TKA were randomly (1:1) divided into two groups: the ropivacaine group and the placebo group. Patients in each group received ultrasound-guided ACB + IPACK procedures with 0.25% ropivacaine or equal volume normal saline. All patients received multimodal analgesia. Pain intensity was assessed using the Numerical Rating Scale (NRS). The primary outcome was the incidence of chronic pain at 3 months after TKA by telephone follow-up. In addition, pain intensity in early resting and mobilized states, chronic pain intensity, the time to first rescue analgesia; opioid consumption; CRP and IL-6 after the operation; length of postoperative hospital stay; and cost of hospitalization and postoperative complications; as well as the function of the knee in the early stage after the operation, were recorded. Results Ninety-one participants were included in the final analysis. At 3 months, the incidence of chronic pain was 30.4% in the ropivacaine group, significantly lower than 51.1% in the placebo group. Compared with the placebo group, the ACB + IPACK with ropivacaine group had significantly lower pain scores at 4 hours, 8 hours, 16 hours, and 24 hours after the operation; increased the knee range of motion at 8 hours and 24 hours after the operation; and a significantly decreased incidence of chronic pain at 3 months after the operation. During the follow-up period, there were no nerve block-related complications in either group. Conclusion In the context of multimodal analgesia protocols, ACB combined with IPACK before surgery decreases the incidence and intensity of chronic pain 3 months after TKA compared with placebo injection. In addition, it reduces the NRS scores, whether at rest or during mobilization, and improves knee function within 24 hours after TKA. Trial registration This trial was registered in the China Clinical Trial Center (registration number ChiCTR2200065300) on November 1, 2022.

Introduction: Total knee arthroplasty (TKA) is accompanied by severe postoperative pain, which is reported to be an important cause of chronic pain. Ultrasound-guided adductor canal block (ACB) combined with infiltration between the popliteal artery and posterior capsular of the knee (IPACK) has been proven to have a better effect on relieving acute pain after TKA. However, whether it has a significant effect on the incidence of chronic pain after TKA has not been reported. This trial was designed to investigate the effect of ultrasound-guided ACB combined with IPACK on the incidence and intensity of chronic pain after TKA. Methods: In this prospective, randomized, double-blind, placebo-controlled study, 100 subjects scheduled for TKA were randomly (1:1) divided into two groups: the ropivacaine group and the placebo group. Patients in each group received ultrasound-guided ACB + IPACK procedures with 0.25% ropivacaine or equal volume normal saline. All patients received multimodal analgesia. Pain intensity was assessed using the Numerical Rating Scale (NRS). The primary outcome was the incidence of chronic pain at 3 months after TKA by telephone follow-up. In addition, pain intensity in early resting and mobilized states, chronic pain intensity, the time to first rescue analgesia; opioid consumption; CRP and IL-6 after the operation; length of postoperative hospital stay; and cost of hospitalization and postoperative complications; as well as the function of the knee in the early stage after the operation, were recorded. Results: Ninety-one participants were included in the final analysis. At 3 months, the incidence of chronic pain was 30.4% in the ropivacaine group, significantly lower than 51.1% in the placebo group. Compared with the placebo group, the ACB + IPACK with ropivacaine group had significantly lower pain scores at 4 hours, 8 hours, 16 hours, and 24 hours after the operation; increased the knee range of motion at 8 hours and 24 hours after the operation; and a significantly decreased incidence of chronic pain at 3 months after the operation. During the follow-up period, there were no nerve block-related complications in either group. Conclusion: In the context of multimodal analgesia protocols, ACB combined with IPACK before surgery decreases the incidence and intensity of chronic pain 3 months after TKA compared with placebo injection. In addition, it reduces the NRS scores, whether at rest or during mobilization, and improves knee function within 24 hours after TKA. Trial registration: This trial was registered in the China Clinical Trial Center (registration number ChiCTR2200065300) on November 1, 2022. [ABSTRACT FROM AUTHOR]

Background & objective: Appropriate perioperative pain management, with multimodal analgesia regimens combining regional anesthesia and systemic analgesics, is crucial for optimum results in individuals undergoing total knee arthroplasty (TKA). We evaluated the efficacy of combined Adductor Canal Block (ACB) and infiltration in the interspace between the popliteal artery and capsule of the knee (IPACK) supplementing against ACB and Periarticular Infiltration (PAI) on postoperative pain scores, use of opioids, and early physical therapy in patients subjected to TKA under spinal anesthesia (SA). Methodology: In the current prospective, randomized, comparative clinical trial, 40 individuals undergoing TKA were arbitrarily distributed in two groups. Group A comprised of patients undergoing ultrasound-guided ACB plus IPACK block; Group B comprised of patients undergoing ACB plus PAI block at the beginning of the surgical procedure. Results: The ACB + IPACK group exhibited notably lower VAS scores (P < 0.05) compared to the ACB plus PAI group. Group A consumed 67.5 ± 21.6 mg of pethidine over the first 48 h, while Group B consumed 87.5 ± 33.9 mg of pethidine. The range of movement of the knee and walking distance also revealed that the values were considerably higher in Group A compared to Group B. Conclusion: The utilization of both adductor canal block and the interspace between the popliteal artery and the knee capsule provides improved analgesia than adductor canal block and periarticular injection, while preserving the knee joint motor power in the postoperative period. [ABSTRACT FROM AUTHOR]

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Copyright of Saudi Medical Journal is the property of Saudi Medical Journal and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

ABSTRACTBackground For successful rehabilitation and optimal functional outcomes after total knee arthroplasty surgery, patients must have effective pain control. Peripheral nerve blocks offer an excellent solution for perioperative multimodal analgesia and are advocated to reduce postoperative opioid consumption.Objectives The objective of this study is to compare the efficacy of combined Femoral-Sciatic nerve block and Adductor- interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block in terms of total rescue analgesia dosage and ambulation on the first postoperative day.Method This is a prospective, randomized, double-blinded trial was conducted at Ain Shams University Hospital. Sixty patients scheduled for total knee arthroplasty (TKA) were randomly divided into two equal groups: one group received a Femoral-Sciatic nerve block, and the other received an Adductor-IPACK block. Both ultrasound-guided blocks were performed by injecting 20 mL of 0.25% bupivacaine immediately after anaesthesia induction. The postoperative opioid requirement in the first 24 hours was assessed using the visual analogue scale (VAS). Motor power, intraoperative fentanyl consumption, intraoperative hemodynamic changes, procedure time, surgery duration, tourniquet time, and technique complications were also recorded.Results Femoral-Sciatic group had lower opioid consumption. The Adductor-IPACK group showed a statistically significant higher Modified Bromage score. However, there was no statistically significant difference between the groups in the postoperative pain score assessed using the VAS.Conclusion Based on our study, we conclude that Femoral-Sciatic blocks required a lower dose of rescue analgesia compared to the Adductor-IPACK group. The Adductor-IPACK group also experienced lesser postoperative muscle power impairment.

ABSTRACTBackground Total knee arthroplasty (TKA) is a major surgical procedure that can be extremely upsetting. There are several methods available for postoperative pain management after knee surgery. One commonly used method is multimodal analgesia based on continuous adductor canal block.Aim of The Work Comparing the effect of the addition of posterior knee block, known as the infiltration between the popliteal artery and capsule of the knee (IPACK) block, to continuous adductor canal block (CACB) after total knee arthroplasty.Patients and Methods A total of 52 patients who underwent total knee arthroplasty were included and randomly divided into two groups receiving ultrasound-guided continuous adductor canal block or a combination of continuous ultrasound guided adductor canal block and the Infiltration between the popliteal artery and capsule of the knee block at the end of the surgery.Results Regarding the criteria for pain control, there was a statistically significant difference between the two groups regarding the postoperative visual analog score at 2, 4, 8, and 12 h after following up, which was not reported at 16 or 24 h postoperatively. The total nalbuphine consumption on the first day postoperative also showed a significant difference. A comparison of the basic demographic data, the onset of ambulation, the Timed Up and Go (TUG) test, and the straight leg raising test revealed no significant difference between the two groups.Conclusion Our study found that the use of continuous ultrasound guided adductor canal block and the Infiltration between the popliteal artery and capsule of the knee block together resulted in better postoperative pain management and reduced the need for nalbuphine. Despite this, there were no significant differences between the groups in terms of motor power or ambulation abilities. Trial registration number: PACTR202301536928551

Background: Total knee arthroplasty (TKA) is a major surgical procedure that can be extremely upsetting. There are several methods available for postoperative pain management after knee surgery. One commonly used method is multimodal analgesia based on continuous adductor canal block. Aim of The Work: Comparing the effect of the addition of posterior knee block, known as the infiltration between the popliteal artery and capsule of the knee (IPACK) block, to continuous adductor canal block (CACB) after total knee arthroplasty. Patients and Methods: A total of 52 patients who underwent total knee arthroplasty were included and randomly divided into two groups receiving ultrasound-guided continuous adductor canal block or a combination of continuous ultrasound guided adductor canal block and the Infiltration between the popliteal artery and capsule of the knee block at the end of the surgery. Results: Regarding the criteria for pain control, there was a statistically significant difference between the two groups regarding the postoperative visual analog score at 2, 4, 8, and 12 h after following up, which was not reported at 16 or 24 h postoperatively. The total nalbuphine consumption on the first day postoperative also showed a significant difference. A comparison of the basic demographic data, the onset of ambulation, the Timed Up and Go (TUG) test, and the straight leg raising test revealed no significant difference between the two groups. Conclusion: Our study found that the use of continuous ultrasound guided adductor canal block and the Infiltration between the popliteal artery and capsule of the knee block together resulted in better postoperative pain management and reduced the need for nalbuphine. Despite this, there were no significant differences between the groups in terms of motor power or ambulation abilities. [ABSTRACT FROM AUTHOR]

Background: For successful rehabilitation and optimal functional outcomes after total knee arthroplasty surgery, patients must have effective pain control. Peripheral nerve blocks offer an excellent solution for perioperative multimodal analgesia and are advocated to reduce postoperative opioid consumption. Objectives: The objective of this study is to compare the efficacy of combined Femoral-Sciatic nerve block and Adductor-interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block in terms of total rescue analgesia dosage and ambulation on the first postoperative day. Method: This is a prospective, randomized, double-blinded trial was conducted at Ain Shams University Hospital. Sixty patients scheduled for total knee arthroplasty (TKA) were randomly divided into two equal groups: one group received a Femoral-Sciatic nerve block, and the other received an Adductor-IPACK block. Both ultrasound-guided blocks were performed by injecting 20 mL of 0.25% bupivacaine immediately after anaesthesia induction. The postoperative opioid requirement in the first 24 hours was assessed using the visual analogue scale (VAS). Motor power, intraoperative fentanyl consumption, intraoperative hemodynamic changes, procedure time, surgery duration, tourniquet time, and technique complications were also recorded. Results: Femoral-Sciatic group had lower opioid consumption. The Adductor-IPACK group showed a statistically significant higher Modified Bromage score. However, there was no statistically significant difference between the groups in the postoperative pain score assessed using the VAS. Conclusion: Based on our study, we conclude that Femoral-Sciatic blocks required a lower dose of rescue analgesia compared to the Adductor-IPACK group. The Adductor-IPACK group also experienced lesser postoperative muscle power impairment. [ABSTRACT FROM AUTHOR]

Background: To investigate if combined single-shot adductor canal blockade (ACB) and infiltration between the popliteal artery and capsule of the knee (IPACK) provide better postoperative pain management compared to ACB alone for patients undergoing unilateral total knee arthroplasty (TKA). Methods: This retrospective cohort study included adult patients who underwent primary, unilateral TKA. Patients were separated into 2 cohorts: single-shot ACB alone (performed with bupivacaine 0.25%) and combined single-shot ACB + IPACK (performed with bupivacaine 0.25%, dexmedetomidine 1 mg/kg, and dexamethasone 4 mg). Patients were propensity-matched 1:1. The primary study outcome was total opioid consumption converted to morphine milligram equivalents (MME) per eight-hour interval and postoperative day. Secondary outcomes included pain scores, length of stay, ambulation distance, return to emergency department, hospital readmission, and 30-day adverse events. Results: One hundred eighty patients were identified, of which propensity matching used 71% to yield 64 patients receiving ACB alone and 64 receiving combined ACB + IPACK. Combined ACB + IPACK had significantly lower total summative MME throughout the entire postoperative stay (P = .002) and cumulatively after the first 24 hours (P < .001). Combined ACB + IPACK also had lower mean pain scores for 0-8 hours (P = .005) and 8-16 hours (P = .009) postoperatively. There were no significant differences in secondary outcomes. Conclusions: Combined single-shot ACB + IPACK block was associated with lower total narcotic intake and mean pain scores during most of the immediate postoperative period following primary, unilateral TKA compared to ACB alone. Implementing longer-acting, single-shot ACB + IPACK for TKA can balance effective and more selective pain management with early rehabilitation.

Introduction: This study aimed to investigate pain management, functional recovery, and stress response expressed by the neutrophile-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) after the popliteal artery and posterior knee capsule infiltration (iPACK) block combined with adductor canal block (ACB) in total knee arthroplasty (TKA). Patients and Methods: This was a prospective, double-blinded, randomised, controlled trial in a tertiary referral hospital. Three hundred and sixty-six patients were randomly allocated into the sham block group and iPACK combined with the ACB group. The primary outcome was postoperative pain scores. The secondary outcomes were opioid consumption, functional recovery expressed by a range of motion, and quadriceps strength. Also, the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were calculated. Results: There were significant differences between the sham block and iPACK + ACB group in pain scores p < 0.0001 at all time points. Therefore, there was a significant difference in opioid consumption (p < 0.0001) and functional recovery (p < 0.0001). Also, NLR and PLR levels 12 h (p < 0.0001) and 24 h (24 h) after surgery (p < 0.0001) were much lower in the iPACK + ACB group. Conclusion: After total knee arthroplasty, the iPACK combined with ACB block group improved pain management, functional recovery, and stress response. Therefore, we strongly recommend this technique as a part of a multimodal analgesia protocol in knee surgery. [ABSTRACT FROM AUTHOR]

Objective: To explore the effects of ultrasound-guided saphenous nerve combine with interspace between the popliteal artery and the posterior capsule of the knee (IPACK) block on stress response, inflammatory cytokines and knee joint range of motion in elderly patients undergoing total knee arthroplasty (TKA) . Methods: According to the random number table method, 102 elderly patients with initial TKA who were admitted to Wuxi Traditional Chinese Medicine Hospital from March 2021 to September 2022 were divided into observation group (treated with analgesia of ultrasound-guided saphenous nerve combined with IPACK block) and control group (treated with analgesia of ultrasound-guided saphenous nerve), 51 cases per group. The pain conditions, inflammatory cytokines, stress response indicators, incidence of adverse reactions and knee joint range of motion were compared between two groups. Results: The visual analogue scale (VAS) scores in observation group were lower than those in control group 6h after operation, 12 h after operation and 24 h after operation (P＜0.05) . The tumor necrosis factor-α (TNF-α), interleukin (IL) -6, IL-1β and β-amyloid (Aβ) in observation group were lower than those in control group 48 h after operation (P＜0.05) . The angiotensin Ⅱ (AngⅡ) and cortisol (COR) in observation group were lower than those in control group 48 h after operation (P＜0.05) . The knee joint range of motion in observation group was higher than that in control group 24 h after operation and 48 h after operation (P＜0.05) . There was no difference in the incidence of adverse reactions between two groups (P＞0.05) . Conclusion: Ultrasound-guided saphenous nerve combine with IPACK block in patients with TKA, which has a good analgesic effect, can alleviate stress response, inhibit excessive secretion of inflammatory cytokines, improve knee joint range of motion, and has a good anesthetic effect. [ABSTRACT FROM AUTHOR]

Background & Objective: Postoperative pain after total knee arthroplasty (TKA) is a significant factor influencing the surgical outcome. Adductor canal block (ACB) has no analgesic effect on the posterior knee capsule, which is innervated by the terminal branches of the tibial nerve and the posterior branch of the obturator nerve. We compared ACB plus IPACK block (infiltration of the interspace between the popliteal artery and the posterior capsule of the knee) versus ACB with selective tibial nerve block (TNB) for pain management after TKA. Methodology: We enrolled 70 patients, aged 40-80 y, body mass index of 18.5-35 kg/m2, scheduled for TKA in the study. Patients were randomly allocated to one of the two equal groups; Group 1 to receive ACB with IPACK block and Group 2 to receive ACB with TNB. Duration of sensory block, motor block, time to first rescue analgesic request, time to ambulation, and hospital length were noted in both groups. The 0-10 numeric rating scale (NRS) was used to measure the pain intensity in the patients. Results: Duration of sensory block, motor block, time to first rescue analgesic request, time to ambulation, and hospital length were significantly increased in Group 2 than in Group 1 (P < 0.001). The numeric rating scale was significantly lower in Group 2 at 8 h only but was comparable in other measurements. Range of motion and the strength of quadriceps were comparable between both groups at 24, 48, and 72 h postoperatively. Conclusions: Adductor canal block with IPACK preserved motor function better and reduced the time to ambulation and hospital stay compared to tibial nerve block with adductor canal block. However, adductor canal block with selective tibial nerve block prolongs sensory block, the time to first analgesia request, and reduces postoperative opioid consumption at first 24 h. Both methods had a comparable effect on quadriceps strength. [ABSTRACT FROM AUTHOR]

Background Knee surgeries are needed in a wide range of patients, from young athletes with anterior cruciate ligament injuries up to old patients with comorbidities presenting for arthroscopy up to total knee replacement procedures. The trend is fast track knee surgery with early ambulation and hospital discharge, so analgesic options of neuraxial blocks and main nerve blocks are less attractive due to the unavoidable muscle weakness. In this study, the benefit of pure sensory nerve block could be reached.Aim of the study To compare the postoperative range of motion and the analgesic efficacy of adductor canal block (ACB) alone against adductor canal with IPACK (interspace between popliteal artery and capsule of the knee) block in knee surgeries.Patients and methods The study is a randomized, prospective, comparative study where 50 patients subjected to knee surgeries were randomized into two groups: Group (A): patients in this group received ultrasound-guided ACB only; Group (AB): under ultrasound guide, patients in this group received a combined ACB and IPACK block at the start of surgery.Results Regarding pain control over the first 24hours following surgery, range of motion and walking distance; there were statistical differences between both groups.When demographic information such age, sex, BMI, and ASA scores were examined between the two groups, there was no statistically significant difference between them (p-value > 0.05).Additionally, there was no statistically significant difference between groups in terms of opioid needs or consumption.Conclusion Regardless of the good analgesic effect of ACB, patients who received a combination of ACB and IPACK blocks have experienced a better pain control, a wider range of motion and a longer walking distance following surgery when compared to patients who received ACB alone.

Knee surgeries are needed in a wide range of patients, from young athletes with anterior cruciate ligament injuries up to old patients with comorbidities presenting for arthroscopy up to total knee replacement procedures. The trend is fast track knee surgery with early ambulation and hospital discharge, so analgesic options of neuraxial blocks and main nerve blocks are less attractive due to the unavoidable muscle weakness. In this study, the benefit of pure sensory nerve block could be reached. To compare the postoperative range of motion and the analgesic efficacy of adductor canal block (ACB) alone against adductor canal with IPACK (interspace between popliteal artery and capsule of the knee) block in knee surgeries. The study is a randomized, prospective, comparative study where 50 patients subjected to knee surgeries were randomized into two groups: Group (A): patients in this group received ultrasound-guided ACB only; Group (AB): under ultrasound guide, patients in this group received a combined ACB and IPACK block at the start of surgery. Regarding pain control over the first 24hours following surgery, range of motion and walking distance; there were statistical differences between both groups. When demographic information such age, sex, BMI, and ASA scores were examined between the two groups, there was no statistically significant difference between them (p-value > 0.05). Additionally, there was no statistically significant difference between groups in terms of opioid needs or consumption. Regardless of the good analgesic effect of ACB, patients who received a combination of ACB and IPACK blocks have experienced a better pain control, a wider range of motion and a longer walking distance following surgery when compared to patients who received ACB alone. [ABSTRACT FROM AUTHOR]

Background: This study aimed to evaluate the impact of Infiltration between the Popliteal Artery and Capsule of the posterior Knee (IPACK) combined with an adductor canal block under the guidance of ultrasound on early motor function after Total Knee Arthroplasty (TKA). Methods: A sample of 60 cases who were scheduled for elective unilateral TKA were divided into two groups using random number table method: a group with IPACK combined with an adductor canal block (I group, n = 30), and a group with femoral nerve block combined with superior popliteal sciatic nerve block (FS group, n = 30). Before anesthesia induction was completed, the patients in I group received an ultrasound-guided adductor canal block with 15 mL of 0.375% ropivacaine and an IPACK block with 25 mL of ropivacaine, and the patients in FS group received a femoral nerve block and a superior popliteal sciatic nerve block with 20 mL of 0.375% ropivacaine under ultrasound guidance. Post-operation, all the patients received patient-controlled intravenous analgesia combined with an oral celecoxib capsule to relieve pain and maintain a visual analogue scale score of ≤ 3. Results: The quadriceps femoris muscle strength score was significantly higher in Ⅰ group than in FS group (p = 0.001), while the modified Bromage score were significantly lower and walking distance results were significantly higher in Ⅰ group than in FS group (both p = 0.000). Conclusion: Compared with femoral nerve block combined with superior popliteal sciatic nerve block, IPACK combined with adductor canal block had a mild impact on early motor functions after TKA.

Background and purpose: The interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block is a novel anesthetic technique for total knee arthroplasty (TKA). Our objective was to compare the effect of IPACK and adductor canal block (ACB) and periarticular injection (PAI), relative to ACB and PAI only, from baseline to postoperative day 3, in patients undergoing unilateral primary TKA. Patients and methods: This was a single-center, double-blinded, randomized controlled trial. Adults over the age of 50 who were scheduled for unilateral primary TKA were enrolled. They were randomly assigned to ACB and PAI block (control group), or ACB, PAI, and IPACK block (IPACK group). The primary outcome was mean pain at rest during 24–48 hours post-operation using a numerical rating scale (0–10). We also investigated opioid use and ambulation pain. Results: 89 patients were evaluated, 45 from the control group and 44 from the IPACK group. Despite slightly higher mean pain score at rest in the control group, no statistically significant difference was found during 0–24 hours (0.13; 95% CI –0.19 to 0.46), 24–48 hours (0.42; CI –0.06 to 0.89), and 48–72 hours (0.35; CI 0.00 to 0.69) postoperatively as well as in maximum pain scores at rest. Neither pain during ambulation nor the number of opioids used differed between the trial groups at any given time point. Conclusion: The addition of the IPACK block to ACB and PAI did not reduce postoperative pain intensity or opioid usage. Therefore, IPACK block may not offer any benefit for pain management in patients undergoing unilateral primary TKA who are already receiving ACB and PAI.

Purpose: To investigate the effect of the combination of remazolam toluenesulfonate and infiltration between the popliteal artery and capsule of the knee (IPACK) on the rehabilitation and sedation of elderly patients undergoing knee arthroplasty. Methods: A total of 84 elderly patients who underwent knee arthroplasty in Quzhou Affiliated Hospital of Wenzhou Medical University between January 2021 and December 2021 were given IPACK in combination with adductor canal block under ultrasound guidance. Forty (40) patients were given anesthesia with propofol + sufentanil + cis-benzene sulfonic acid atracurium (control group), while 44 patients received anesthesia with remazolam toluenesulfonate + sufentanil + cis-benzene sulfonic acid atracurium (study group). Various clinical indices in the patients were assessed. Results: Relative to control, there were significantly lower visual analog scale (VAS) scores at 6 and 12 h after operation, lower frequency of post-operation pumping with PCA pump, lower frequency of remedial analgesia within 48 h after operation (p < 0.05). Moreover, the time taken for spontaneous recovery of breathing, recovery time, and extubation time were similar in the two groups (p > 0.05). The muscle strength of quadriceps femoris of the affected knee joint was higher in the study group than in the control group at 12, 24, and 48 h, after operation (p < 0.05). Conclusion: The combination of remazolam toluenesulfonate with IPACK effectively alleviate pain in elderly patients undergoing knee arthroplasty and improves sedation without increasing cognitive dysfunction. This treatment strategy has potentials for further investigation for possible large-scale application. [ABSTRACT FROM AUTHOR]

Background: ACB is given as single injection or as continuous block or combined with IPACK block (interspace between the popliteal artery and the posterior capsule of knee) to reduce postoperative knee pain after total knee arthroplasty. The aim of this study is to evaluate the technique of ACB that is superior in controlling postoperative pain, decrease opioid consumption and facilitate ambulation in the immediate postoperative period. Methods: A total of 171 patients were analyzed from a group of 180 patients who were randomized into three groups: (1) ACB alone, (2) continuous ACB infusion via catheter (CACB) and (3) ACB combined with IPACK. The primary outcome was pain at rest and after ambulation measured by VAS scale every 8 h till 48 h after surgery. The secondary outcome measures were opioid consumption in morphine equivalents, ambulation distance measured in feet on postoperative day 2, timed up and go test, 30 s chair stand test, sitting active extension lag test and maximal knee flexion at discharge. Results: VAS score at rest and after ambulation, opioid consumption was significantly lower (p < 0.05%) in CACB group compared to other study groups. Similarly, patients in CACB showed significantly (p < 0.05%) better results in the secondary outcome measures. There were no significant differences in the outcomes between ACB and ACB combined with IPACK. Conclusion: CACB allows better pain control and less opioid consumption in the immediate postoperative period after TKA compared to ACB alone or ACB with IPACK resulting in better ambulation and rehabilitation. Clinical Trial Registration Number CTRI/2019/03/018239 registered on March 25, 2019. [ABSTRACT FROM AUTHOR]

Purpose: The infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement. Methods: This double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events. Results: The 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001). Conclusions: The adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay. [ABSTRACT FROM AUTHOR]

El reemplazo total de rodilla (RTR) es un procedimiento quirúrgico, indicado en pacientes que presentan osteoartrosis severa (grado III - IV) de la articulación. Se han desarrollado diversas técnicas de analgesia para disminuir el dolor en el RTR. Objetivo: Evaluar la eficacia del bloqueo capsular versus bloqueo por infiltración entre la arteria poplítea y la cápsula de la rodilla (IPACK) en el manejo del dolor en pacientes tratados con RTR. Materiales y métodos: Se realizó un estudio observacional, analítico, de cohorte prospectivo, durante 10 meses, en 20 pacientes con artrosis severa de rodilla, corroborada por estudio de imágenes. A 10 pacientes se les aplicó el bloqueo IPACK guiado bajo ecografía con levobupivacaína y a los otros 10 pacientes se les aplicó el IPACK con la mezcla de Ranawat luego del cementado de la prótesis durante el acto quirúrgico. En un segundo tiempo, a las 24 y 48 horas del postoperatorio se aplicó un instrumento de evaluación para determinar la funcionalidad de la rodilla considerando los grados de flexión y el nivel de analgesia mediante la escala visual análoga del dolor (EVA). Resultados: No se presentaron diferencias significativas entre ambas técnicas anestésicas, sin embargo los grados de flexión con el bloqueo capsular fueron más altos con respecto al bloqueo IPACK así mismo que con la escala visual análoga del dolor. Conclusión: Los dos bloqueos resultan ser eficientes para el manejo del dolor postoperatorio en pacientes con reemplazo articular de rodilla.

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Abstract Background The aim of this study is to compare the postoperative analgesic effect of infiltration between the popliteal artery and the capsule of the knee (IPACK) and the effect of periarticular multimodal drug injection (PMDI) in addition to adductor canal block (ACB) after total knee arthroplasty. Methods Among patients who received total knee arthroplasty from June 2017 to December 2017, 50 who underwent ACB with additional IPACK and 50 who received ACB with additional PMDI were selected for this study. We compared the postoperative pain numerical rating scale (NRS), the number of times patient-controlled analgesia was administered and the amount administered, the total amount of opioids given, and complications associated with the procedure between the two groups. Results NRS measured at rest and 45° knee flexion at days 1 and 2 after surgery was significantly lower in the IPACK group than in the PMDI group. The resting NRS measured at day 3 after surgery was also significantly lower in the IPACK group than in the PMDI group, and the NRS at 45° knee flexion measured from day 3 to day 5 showed a significant reduction in the IPACK group. No complications relating to the procedure occurred. Conclusions IPACK may be a better option than PMDI for controlling acute phase pain in patients undergoing total knee arthroplasty.

Background The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. Methods With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. Results Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th–90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0–4.3] vs. 2.5 [0–7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. Conclusions Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.

Background: The aim of this study is to evaluate the efficacy of adductor canal block (ACB) combined with additional analgesic methods in total knee arthroplasty (TKA) and investigate whether blocking the sensory nerves that are distributed in the posterior and lateral aspect of knee could improve postoperative pain control.Methods: Two hundred scheduled patients for TKA were randomly allocated into 4 groups: Group A received ACB combined with iPACK (interspace between the popliteal artery and capsule of the knee) block and lateral femoral cutaneous nerve block (LFCNB); Group B received ACB combined with iPACK block; Group C received ACB combined with LFCNB; and Group D received ACB only. Postoperative pain score was the main primary outcome. Secondary outcomes included the morphine consumption and analgesic duration. Other outcomes included knee range of motion, quadriceps strength, ambulation, Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index physical function, timed up and go (TUG) test, and complications.Results: Groups A, B, and C had lower postoperative pain scores within 12 hours at rest and 8 hours with activity than Group D (P < .05). In addition, Group A had lower morphine consumption than both Group C (P < .05) and Group D (P < .01). Group A had the longest analgesic duration (19.21 ± 3.22 hours) among all groups. There were no significant differences among the groups in terms of mobility and complication after surgery.Conclusion: Combining ACB with both iPACK and LFCNB is an effective method for decreasing early postoperative pain in TKA without increasing the complications or affecting the early rehabilitation. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine if infiltration of local anesthetic between the interspace between the popliteal artery and capsule of the knee (IPACK) provides benefit in total knee arthroplasty.Methods: Patients were randomized into continuous adductor canal block with IPACK block or continuous adductor canal block with sham subcutaneous saline injection. Only the anesthesiologist performing the block was aware of randomization status. After surgery, a blinded assessor recorded opioid consumption, pain scores, and gait distance.Results: There were 35 patients in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the postanesthesia care unit (PACU), the average (P = .0122) and worst (P = .0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy (P = .2080). There was no difference in opioid consumption in the PACU (P = .7928), or at 24 hours (P = .7456). There was no difference in pain scores on POD 1 in the AM (P = .4597) or PM (P = .6273), or in the walking distance (P = .5197). There was also no difference in length of stay in the PACU (P = .9426) or hospital (P = .2141).Conclusion: The IPACK group had lower pain scores at rest in the PACU, but this is likely not clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be indications for the use of the IPACK block as a rescue block or in patients who have contraindications to our standard multimodal treatment regimen or in patients with chronic pain or opioid dependence. [ABSTRACT FROM AUTHOR]

Background: The aim of this study is to compare the postoperative analgesic effect of infiltration between the popliteal artery and the capsule of the knee (IPACK) and the effect of periarticular multimodal drug injection (PMDI) in addition to adductor canal block (ACB) after total knee arthroplasty. Methods: Among patients who received total knee arthroplasty from June 2017 to December 2017, 50 who underwent ACB with additional IPACK and 50 who received ACB with additional PMDI were selected for this study. We compared the postoperative pain numerical rating scale (NRS), the number of times patient-controlled analgesia was administered and the amount administered, the total amount of opioids given, and complications associated with the procedure between the two groups. Results: NRS measured at rest and 45° knee flexion at days 1 and 2 after surgery was significantly lower in the IPACK group than in the PMDI group. The resting NRS measured at day 3 after surgery was also significantly lower in the IPACK group than in the PMDI group, and the NRS at 45° knee flexion measured from day 3 to day 5 showed a significant reduction in the IPACK group. No complications relating to the procedure occurred. Conclusions: IPACK may be a better option than PMDI for controlling acute phase pain in patients undergoing total knee arthroplasty. [ABSTRACT FROM AUTHOR]

Background and Objectives: Ultrasound-guided infiltration of the interspace between the popliteal artery and capsule of the knee (iPACK) block, a new regional analgesic technique, is believed to relieve posterior knee pain, after total knee arthroplasty, by targeting the articular branches innervating posterior aspect of the joint. The extent of injectate spread and the number of articular branches affected is currently unknown. This cadaveric study aimed to compare the area of dye spread and frequency of articular branches staining following a proximal versus distal injection technique.Methods: An ultrasound-guided iPACK injection (10 mL of methylene blue dye solution) was performed in 14 lightly embalmed specimens: 7 injected using a proximal injection technique (1 fingerbreadth above base of patella) and 7 using a distal injection technique (at the superior border of the femoral condyles). Following injection, dissection, digitization, and 3D modeling were performed to map the area of dye spread and determine the frequency of nerve staining.Results: Both injection techniques achieved a similar mean area of injectate spread. Of the four articular branches supplying the posterior knee joint capsule, the genicular branch of posterior division of obturator nerve was stained in all specimens. The proximal injection resulted in staining of superior medial genicular nerve, due to dye spread through the adductor hiatus, whereas superior lateral genicular nerve and anterior branch of common fibular nerve were consistently stained following distal injection. Other articular branches were stained with variable frequency.Conclusions: Both proximal and distal iPACK injection techniques provided a similar area of dye spread in the popliteal region and extensive staining of the articular branches supplying the posterior capsule. The proximal injection technique promoted greater anteromedial dye spread, while the distal injection had more anterolateral spread. Further clinical study is required to confirm our cadaveric findings. . [ABSTRACT FROM AUTHOR]

Background: The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist-administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. Methods: With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. Results: Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th-90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0-4.3] vs. 2.5 [0-7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. Conclusions: Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly. [ABSTRACT FROM AUTHOR]

The subspecialty of regional anesthesiology and acute pain medicine (RAAPM) is in a position to lead changes that may impact the current opioid crisis. At the hospital level, RAAPM experts can implement evidence-based multimodal analgesic clinical pathways featuring regional anesthesia. Multimodal analgesia consists of using two or more analgesic modalities targeting pain pathways at various levels to improve pain control, while also aiming to reduce opioid utilization and related adverse effects. These types of pathways or protocols have been widely applied in the joint replacement population. This review focuses on the current state of the evidence regarding individual elements of a multimodal analgesic pathway for patients with total knee arthroplasty including new regional anesthesia techniques like the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block and suggests future research directions to improve the clinical care of this surgical population in the future. [ABSTRACT FROM AUTHOR]

Objectives: Local anesthetic injection into the interspace between the popliteal artery and the posterior capsule of the knee (IPACK) has the potential to provide motor‐sparing analgesia to the posterior knee after total knee arthroplasty. The primary objective of this cadaveric study was to evaluate injectate spread to relevant anatomic structures with IPACK injection. Methods: After receipt of Institutional Review Board Biospecimen Subcommittee approval, IPACK injection was performed on fresh‐frozen cadavers. The popliteal fossa in each specimen was dissected and examined for injectate spread. Results: Ten fresh‐frozen cadaver knees were included in the study. Injectate was observed to spread in the popliteal fossa at a mean ± SD of 6.1 ± 0.7 cm in the medial‐lateral dimension and 10.1 ± 3.2 cm in the proximal‐distal dimension. No injectate was noted to be in contact with the proximal segment of the sciatic nerve, but 3 specimens showed injectate spread to the tibial nerve. In 3 specimens, the injectate showed possible contact with the common peroneal nerve. The middle genicular artery was consistently surrounded by injectate. Conclusions: This cadaver study of IPACK injection demonstrated spread throughout the popliteal fossa without proximal sciatic involvement. However, the potential for injectate to spread to the tibial or common peroneal nerve was demonstrated. Consistent surrounding of the middle genicular artery with injectate suggests a potential mechanism of analgesia for the IPACK block, due to the predictable relationship between articular sensory nerves and this artery. Further study is needed to determine the ideal site of IPACK injection. [ABSTRACT FROM AUTHOR]

Background: Adductor canal block (ACB) is a peripheral nerve blockade technique that provides good pain control in patients undergoing total knee arthroplasty which however does not relieve posterior knee pain. The recent technique of an ultrasound-guided local anesthetic infiltration of the interspace between popliteal artery and the capsule of posterior knee (IPACK) has shown promising results in providing significant posterior knee analgesia without affecting the motor nerves.Materials and methods: A prospective study was conducted from September 2016 to March 2017 in a total of 120 patients undergoing unilateral total knee arthroplasty. The initial 60 consecutive patients received ACB + IPACK (Group 1, n = 60), and the subsequent 60 patients received ACB alone (Group 2, n = 60). All patients were evaluated with VAS score for pain recorded at 8 h, postoperative day (POD) 1 and POD 2 after the surgery. The secondary outcome measures assessed were the range of movement (ROM) and ambulation distance.Results: VAS score showed significantly (p < 0.005) better values in ACB + IPACK group compared to the ACB group. The mean ROM of knee and ambulation distance also showed significantly better values in ACB + IPACK group compared to the ACB group.Conclusion: ACB + IPACK is a promising technique that offers improved pain management in the immediate postoperative period without affecting the motor function around the knee joint resulting in better ROM and ambulation compared to ACB alone. [ABSTRACT FROM AUTHOR]

Background: Our previous study reported that when a respective 20 mL of ropivacaine was used for adductor canal block (ACB) combined with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block for patients undergoing total knee arthroplasty (TKA), the minimum concentration of 0.275% could provide successful block in almost all patients. Based on the results, the primary objective of this study was to investigate the minimum effective volume (MEV 90 , defined as the volume which can provide successful block in 90% of patients) of ACB + IPACK block., Methods: This double-blind, randomized dose-finding trial was based on a biased coin up-and-down sequential design, where the volume of ropivacaine administered to a given patient depended on the previous patient's response. The first patient received 15 mL of 0.275% ropivacaine for ACB and again for IPACK. If the block failed, the next subject received a 1 mL higher volume for ACB and IPACK, respectively; otherwise, the next subject received either a 1 mL lower volume (probability of 0.11) or the same volume (probability of 0.89). The primary outcome was whether the block was successful. Block success was defined as the patient did not suffer significant pain and did not receive rescue analgesia within 6 h after surgery. Then the MEV 90 was estimated by isotonic regression., Results: Based on analysis of 53 patients, the MEV 90 was 17.99 mL (95% CI 17.47-18.61 mL), MEV 95 was 18.48 mL (95% CI 17.45-18.98 mL) and MEV 99 was 18.90 mL (95% CI 17.38-19.07 mL). Patients whose blocks succeeded had significantly lower NRS pain scores, lower morphine consumption, and shorter hospitalization., Conclusion: 0.275% ropivacaine in 17.99 mL respectively can provide successful ACB + IPACK block in 90% of patients undergoing TKA. The minimum effective volume (MEV 90 ) of ACB + IPACK block was 17.99 mL.

Regional anesthesia is an integral component of successful orthopedic surgery. Neuraxial anesthesia is commonly used for surgical anesthesia while peripheral nerve blocks are often used for postoperative analgesia. Patient evaluation for regional anesthesia should include neurological, pulmonary, cardiovascular, and hematological assessments. Neuraxial blocks include spinal, epidural, and combined spinal epidural. Upper extremity peripheral nerve blocks include interscalene, supraclavicular, infraclavicular, and axillary. Lower extremity peripheral nerve blocks include femoral nerve block, saphenous nerve block, sciatic nerve block, iPACK block, ankle block and lumbar plexus block. The choice of regional anesthesia is a unanimous decision made by the surgeon, the anesthesiologist, and the patient based on a risk-benefit assessment. The choice of the regional block depends on patient cooperation, patient positing, operative structures, operative manipulation, tourniquet use and the impact of post-operative motor blockade on initiation of physical therapy. Regional anesthesia is safe but has an inherent risk of failure and a relatively low incidence of complications such as local anesthetic systemic toxicity (LAST), nerve injury, falls, hematoma, infection and allergic reactions. Ultrasound should be used for regional anesthesia procedures to improve the efficacy and minimize complications. LAST treatment guidelines and rescue medications (intralipid) should be readily available during the regional anesthesia administration., Competing Interests: Conflict-of-interest statement: The authors report no conflict of interests., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

This article describes the use of an infiltration between the popliteal artery and capsule of the knee joint (IPACK) to diagnose an entrapment neuropathy of the tibial nerve (TN) in a patient presenting with chronic neuropathic pain in the medial posterior compartment of the left knee, with a previous electromyography showing no evidence of tibial or common peroneal nerve neuropathy. After a positive sciatic nerve block, the patient was evaluated for a TN block, cancelled due to the presence of an abnormal leash of vessels wrapping around the nerve. For this reason, the patient was submitted to a diagnostic IPACK. A negative IPACK suggested that a compression of the TN at the popliteal fossa was the most likely source of the symptoms. After surgical decompression of the TN nerve at the popliteal fossa, the patient's symptoms decreased substantially.

The purpose of this study is to detect geochemical anomalies utilizing a Wavelet-Number (W-N) fractal model based on combination of a two-dimensional Discrete Wavelet Transformation (DWT) signal analysis and a Concentration-Area (C-A) fractal modeling. The DWT was carried by Sym8 as a selected wavelet pattern (by energy matching method) for Zn and Pb based on rock samples collected from the Ipack area, Central Iran. In addition, the DWT was decomposed by continuous wavelet coefficients at five levels and a final image was synthesized. Furthermore, the DWT data were classified using a fractal-wavelet model for delineation of both Zn and Pb anomalies from background levels in this area. Moreover, a Spectrum-Area (S-A) fractal modeling and classical statistics analysis were carried out and their results were compared with the wavelet-fractal modeling. As a result, the main Zn and Pb anomalies are located in the central and southern parts of the Ipack area. The results obtained by the proposed fractal-wavelet modeling are in connection with drilling for Zn and Pb exploration. • Separation of Pb and Zn anomalies by wavelet-fractal method • Comparison between results of S-A and wavelet-fractal methods • Selection of proper wavelet by energy matching methodology [ABSTRACT FROM AUTHOR]

For about twenty years, peripheral nervous blocks have become the gold standard in postoperative analgesia for knee and foot surgery. The development of echography adapted to anesthesia gave anesthesiologists the opportunity to perform distal, mostly sensitive nerve blocks. Proximal nervous blocks associated analgesia used to be better than general (intravenous or oral) analgesia. Most of all it was associated with fewer side effects (nauseas, vomiting, drowsiness…). They reached an analgesia level comparable to central nerve blocks (epidural) with also fewer side effects (hypotension, bradycardia, lateralization...). A main problem with those blocks was that they involved motor blockade, impeding fast revalidation and walking restart. Distal nerve blocks, without motor blockade, offer as efficient analgesia as produced by proximal nerve blocks, without impeding motricity. Using those new techniques, it is now possible, with optimal analgesia, to allow almost immediate walking after a total knee replacement, and to perform most surgical foot operations in a one-day procedure.