Background and purpose - There is a large volume of heterogeneous studies across all Enhanced Recovery After Surgery (ERAS®) components within total hip and total knee replacement surgery. This multidisciplinary consensus review summarizes the literature, and proposes recommendations for the perioperative care of patients undergoing total hip replacement and total knee replacement with an ERAS program.Methods - Studies were selected with particular attention being paid to meta-analyses, randomized controlled trials, and large prospective cohort studies that evaluated the efficacy of individual items of the perioperative treatment pathway to expedite the achievement of discharge criteria. A consensus recommendation was reached by the group after critical appraisal of the literature.Results - This consensus statement includes 17 topic areas. Best practice includes optimizing preoperative patient education, anesthetic technique, and transfusion strategy, in combination with an opioid-sparing multimodal analgesic approach and early mobilization. There is insufficient evidence to recommend that one surgical technique (type of approach, use of a minimally invasive technique, prosthesis choice, or use of computer-assisted surgery) over another will independently effect achievement of discharge criteria.Interpretation - Based on the evidence available for each element of perioperative care pathways, the ERAS® Society presents a comprehensive consensus review, for the perioperative care of patients undergoing total hip replacement and total knee replacement surgery within an ERAS® program. This unified protocol should now be further evaluated in order to refine the protocol and verify the strength of these recommendations.

https://www.tandfonline.com/doi/pdf/10.1080/17453674.2019.1683790

Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS ®) Society recommendations

https://rapm.bmj.com/content/rapm/38/6/526.full.pdf

Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study.

https://rapm.bmj.com/content/rapm/34/2/134-170.full.pdf

Lower extremity regional anesthesia: essentials of our current understanding.

Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: a randomized, blinded study

Purpose
Despite the recent advances in the understanding of pain mechanisms and the introduction of new drugs and new techniques in the postoperative management, pain after total knee arthroplasty (TKA) is still an unresolved issue. It affects the quality of life and rehabilitation of an important percentage of patients undergoing TKA. The aim of this narrative review was to give an overview on pain mechanisms and multimodal pain management.

Pain after knee arthroplasty: an unresolved issue.

Background:The authors hypothesized that the adductor canal block (ACB), a predominant sensory blockade, reduces quadriceps strength compared with placebo (primary endpoint, area under the curve, 0.5–6 h), but less than the femoral nerve block (FNB; secondary endpoint). Other secondary endpoints wer

Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers.

Adductor Canal Block Versus Femoral Nerve Block and Quadriceps Strength: A Randomized, Double-blind, Placebo-Controlled, Crossover Study in Healthy Volunteers

Background:Dexmedetomidine used as an adjuvant to local anesthetics may prolong the duration of peripheral nerve blocks Whether this is mediated by a perineural or systemic mechanism remains unknown The authors hypothesized that dexmedetomidine has a peripheral mechanism of actionMethods:The auth

Does Dexmedetomidine Have a Perineural Mechanism of Action When Used as an Adjuvant to Ropivacaine?: A Paired, Blinded, Randomized Trial in Healthy Volunteers.

Researchers sought to determine the volume of local anesthetic used for adductor canal block (ACB) that would achieve sufficient filling of the canal without proximal spread to the femoral triangle. The anticipated minimum successful outcome was gauged at 95% of patients in the study, represented as ED95. Forty subjects received anACB of lidocaine 1% in sequential intervals between 5 up to 20mL. Usingmagnetic resonance imaging, researchers assessed distal filling of the adductor canal, as well as the secondary outcome of volume on proximal spread to the femoral triangle. Other secondary outcomes measured were quadriceps muscle weakness, as determined by a 25% or greater decrease from the baseline, and sensory block. It was determined that 20 mL of lidocaine had the greatest probability of filling the canal at ED95. Proximal spread to the femoral triangle was highest in the group receiving 10 mL (7/12 subjects, at 58%), whereas the 15and 20-mL groups showed half the patients with spread (4/8 and 8/16, respectively). The group receiving 5 mL recorded no spread in each of 4 subjects. Regarding the secondary outcome of muscle weakness, 7 subjects in total reported a reduction in muscle strength, with no data indicating any difference per sequential grouping in this regard.

Optimal Volume of Local Anesthetic for Adductor Canal Block: Using the Continual Reassessment Method to Estimate ED95

Background: The authors hypothesized that both perineural and systemic dexamethasone as adjuncts to bupivacaine increase the duration of an ulnar nerve block compared with bupivacaine alone, and that systemic dexamethasone is noninferior to perineural dexamethasone. Methods: The authors performed bilateral ulnar nerve blocks with 3 ml bupivacaine 5 mg/ml in 16 healthy volunteers on two trial days. According to randomization, subjects received adjunct treatment with 1 ml dexamethasone 4 mg/ml + 1 ml of saline (perineural condition) in one arm and 2 ml saline in the other arm (systemic condition, through absorption and redistribution of the contralaterally administered perineural dexamethasone) on one trial day; and 2 ml saline in one arm (placebo condition) and 2 ml of lidocaine in the other arm (lidocaine condition) on the other trial day. The primary outcome was the duration of the sensory nerve block assessed by temperature discrimination. Results: Mean sensory block duration was 706 ± 94 min for the perineural condition, 677 ± 112 min for the systemic condition, and 640 ± 121 min for the placebo condition. The duration of the sensory nerve block was greater with perineural dexamethasone versus placebo (mean difference 66 min (95% CI, 23 to 108). Block duration was similar between systemic dexamethasone and placebo (mean difference 36 min; 95% CI, –30 to 103). Conclusions: Perineural dexamethasone as an adjunct to bupivacaine in healthy volunteers resulted in a greater duration of an ulnar nerve block when compared with placebo. Systemic dexamethasone resulted in a similar duration as placebo. When carefully controlling for the effects of systemic dexamethasone, perineural administered dexamethasone prolongs a peripheral nerve block. Under carefully controlled conditions in healthy volunteers, systemic dexamethasone does not appear to prolong nerve block duration.

Pia Jæger

Papers

Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers.

Adductor Canal Block Versus Femoral Nerve Block and Quadriceps Strength: A Randomized, Double-blind, Placebo-Controlled, Crossover Study in Healthy Volunteers

Does Dexmedetomidine Have a Perineural Mechanism of Action When Used as an Adjuvant to Ropivacaine?: A Paired, Blinded, Randomized Trial in Healthy Volunteers.

Optimal Volume of Local Anesthetic for Adductor Canal Block: Using the Continual Reassessment Method to Estimate ED95

Perineural and Systemic Dexamethasone and Ulnar Nerve Block Duration: A Randomized, Blinded, Placebo-controlled Trial in Healthy Volunteers