Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually. In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting. This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain. The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated.

1. The Best AnalgesicThe Best Analgesic
Regimen for Total KneeRegimen for Total Knee
Arthroplasty PatientsArthroplasty Patients
Edward R. Mariano, M.D., M.A.S.Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative and Pain MedicineProfessor of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of MedicineStanford University School of Medicine
Chief, Anesthesiology and Perioperative CareChief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care SystemVeterans Affairs Palo Alto Health Care System
@EMARIANOMD@EMARIANOMD

2. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Financial DisclosuresFinancial Disclosures
 Halyard Health, B Braun – UnrestrictedHalyard Health, B Braun – Unrestricted
educational program funding paid to myeducational program funding paid to my
institutioninstitution
The contents of the following presentationThe contents of the following presentation
are solely the responsibility of the speakerare solely the responsibility of the speaker
without input from any of the abovewithout input from any of the above
companies.companies.

3. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
#1: One Size Does Not Fit All#1: One Size Does Not Fit All
REGIONAL ANESTHESIOLOGIST

4. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
#2: Use Multi-Modal Analgesia#2: Use Multi-Modal Analgesia
Hebl JR, et al. JBJS 2005;87 Suppl 2:63Hebl JR, et al. JBJS 2005;87 Suppl 2:63

5. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
#3: Deliver a Consistent Product#3: Deliver a Consistent Product

6. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Sensory Innervation of the KneeSensory Innervation of the Knee
Obturator

7. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Epidural Analgesia for TKAEpidural Analgesia for TKA
 BupivBupiv 0.25% at 6-15 ml/h0.25% at 6-15 ml/h vs. opioidsvs. opioids11
– Epid group had lower pain scores but highEpid group had lower pain scores but high
proportion hadproportion had complete motor blockcomplete motor block
 Epid bupiv+MS vs. epid MS vs. IV opioidsEpid bupiv+MS vs. epid MS vs. IV opioids22
– Bupiv+MS: shorter time to achieve ambulationBupiv+MS: shorter time to achieve ambulation
distance and range of motion goalsdistance and range of motion goals
– Shorter hospital length of stayShorter hospital length of stay
1. Raj PP, et al. A&A 1987;66:4011. Raj PP, et al. A&A 1987;66:401
2. Mahoney OM, et al. CORR 1990;Nov:302. Mahoney OM, et al. CORR 1990;Nov:30

8. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
““Evolution” of Regional AnalgesiaEvolution” of Regional Analgesia
Spinal & Epidural -> Nerve Block -> Continuous Nerve BlockSpinal & Epidural -> Nerve Block -> Continuous Nerve Block
Anticoagulation

9. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
CFNB vs. Epidural for TKACFNB vs. Epidural for TKA
 Comparable analgesiaComparable analgesia
 Better side effect profile with CFNBBetter side effect profile with CFNB
– Less nausea and vomitingLess nausea and vomiting
– Less urinary retention (no need for foley)Less urinary retention (no need for foley)
– Sparing of non-operative limbSparing of non-operative limb
– No epidural hematoma (anticoagulation)No epidural hematoma (anticoagulation)
 Epidurals require hospitalizationEpidurals require hospitalization
Barrington MJ, et al. A&A 2005;101:1824Barrington MJ, et al. A&A 2005;101:1824
Zaric D, et al. A&A 2006;102:1240Zaric D, et al. A&A 2006;102:1240

10. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Effect of CFNB on Knee ROMEffect of CFNB on Knee ROM
Knee Flexion (Degrees)Knee Flexion (Degrees)
PCAPCA CFNBCFNB P ValueP Value
POD #1POD #1 3333 ± 15± 15 5656 ± 22± 22 0.0090.009
POD #3POD #3 5353 ± 17± 17 7474 ± 11± 11 <0.001<0.001
6 weeks6 weeks 103103 ± 12± 12 116116 ± 12± 12 0.030.03
3 months3 months 116116 ± 11± 11 124124 ± 12± 12 NSNS
Singelyn FJ, et al. A&A 1998;87:88Singelyn FJ, et al. A&A 1998;87:88

11. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Ropi
v
Saline
““Single-Injection” vs. CFNB for TKASingle-Injection” vs. CFNB for TKA
 50 subjects50 subjects, tricompartment TKA, tricompartment TKA
 CFNB with 1 night infusion of ropivacaine:CFNB with 1 night infusion of ropivacaine:
randomized to ropiv vs. saline on POD1randomized to ropiv vs. saline on POD1
Ilfeld BM, et al. Anesth 2008;108:703Ilfeld BM, et al. Anesth 2008;108:703
3 Discharge Criteria:
1. NRS (pain) < 4
2. IV opioid-free x 12 hours
3. Ambulating > 30 meters

12. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Sciatic Nerve Block: Yes or No?Sciatic Nerve Block: Yes or No?
 TKA patients (n=16) received CFNB onlyTKA patients (n=16) received CFNB only
0
2
4
6
8
10
12
14
16
18
0 1 2 3 4
Postoperative Day
IVMorphine(mg)
Placebo Ropivacaine
randomizedrandomized
Ilfeld BM, et al. Anesth 2005;103:A1013Ilfeld BM, et al. Anesth 2005;103:A1013

13. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Sciatic Nerve Block: Yes or No?Sciatic Nerve Block: Yes or No?
Wegener JT, et al. RAPM 2011;36:481Wegener JT, et al. RAPM 2011;36:481
Ilfeld and Madison. RAPM 2011;36:421Ilfeld and Madison. RAPM 2011;36:421
Pham-Dang C, et al. RAPM 2005;30:128Pham-Dang C, et al. RAPM 2005;30:128
Abdallah and Brull. RAPM 2011;36:493Abdallah and Brull. RAPM 2011;36:493
Yes
No
Maybe

14. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Lower Extremity CPNB andLower Extremity CPNB and
FallsFalls
 Pooled analysis of 3 published RCTsPooled analysis of 3 published RCTs
(knee and hip arthroplasty) with CPNB x 4(knee and hip arthroplasty) with CPNB x 4
daysdays
– 85 subjects received ropivacaine 0.2%85 subjects received ropivacaine 0.2%
– 86 subjects received saline86 subjects received saline
 NoNo falls in the saline group vs.falls in the saline group vs. 77 falls infalls in
the ropiv group (P=0.013)the ropiv group (P=0.013)
Ilfeld BM, et al. A&A 2010;111:1552Ilfeld BM, et al. A&A 2010;111:1552
Memtsoudis & Mariano, et al. Anesthesiology 2014;120:551Memtsoudis & Mariano, et al. Anesthesiology 2014;120:551
Premier Perspective Database; n=191,570Premier Perspective Database; n=191,570
PNB in 12.1% of cases; no association with fallsPNB in 12.1% of cases; no association with falls
Risk factors=higher age, greater comorbidity burdenRisk factors=higher age, greater comorbidity burden

15. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Local Infiltration AnalgesiaLocal Infiltration Analgesia
 Ropivacaine ≥300 mg + ketorolac +Ropivacaine ≥300 mg + ketorolac +
epinephrine ± opioidepinephrine ± opioid
– vs. control (blinding issues): lower painvs. control (blinding issues): lower pain
scores, less opioid consumptionscores, less opioid consumption
– vs. CFNB (blinding issues, mixed results):vs. CFNB (blinding issues, mixed results):
 LIA: better early function but more complications?LIA: better early function but more complications?
 CFNB: possibly better late functional benefits?CFNB: possibly better late functional benefits?
 Benefits may be limited to 6-12 hoursBenefits may be limited to 6-12 hours
Toftdahl K, et al. Acta Ortho 2007;78:172Toftdahl K, et al. Acta Ortho 2007;78:172
Carli F, et al. BJA 2010;105:185Carli F, et al. BJA 2010;105:185
Kehlet and Andersen. Acta Anaes 2011;55:778Kehlet and Andersen. Acta Anaes 2011;55:778
Ventittoli PA, et al. JBJS 2006;88:282Ventittoli PA, et al. JBJS 2006;88:282
Busch CA, et al. JBJS 2006;88:959Busch CA, et al. JBJS 2006;88:959
McCartney and McLeod. BJA 2011;107:487McCartney and McLeod. BJA 2011;107:487

16. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Can We Increase Selectivity?Can We Increase Selectivity?
 Injectate administeredInjectate administered
distal to the femoraldistal to the femoral
triangle intriangle in adductor canaladductor canal
 Many variations onMany variations on
techniquetechnique
 Effective vs. placeboEffective vs. placebo
injectioninjection
 Decreases quad strengthDecreases quad strength
but less than FNBbut less than FNBTsui & Ozelsel. RAPM 2009;34:178Tsui & Ozelsel. RAPM 2009;34:178
Ishiguro S, et al. A&A 2012;115:1467Ishiguro S, et al. A&A 2012;115:1467
Jaeger P, et al. Acta AnaesJaeger P, et al. Acta Anaes
2012;56:10132012;56:1013
Lund J, et al. Acta Anaes 2011;55:14Lund J, et al. Acta Anaes 2011;55:14
Manickam B, et al. RAPM 2009;34:578Manickam B, et al. RAPM 2009;34:578
Krombach & Gray. RAPM 2007;32:369Krombach & Gray. RAPM 2007;32:369
LATERAL
SF
A
N
SARTORIUS

17. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Introducing ACB for TKAIntroducing ACB for TKA
Perlas A, et al. RAPM 2013;38:334Perlas A, et al. RAPM 2013;38:334

18. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
We Changed Our Clinical PathwayWe Changed Our Clinical Pathway
 In April 2012, clinical pathway changedIn April 2012, clinical pathway changed
from CFNB to continuous adductor canalfrom CFNB to continuous adductor canal
blocks due to concern over quad weaknessblocks due to concern over quad weakness
 Hypothesis for retrospective cohort study:Hypothesis for retrospective cohort study:
patients with continuous adductor canalpatients with continuous adductor canal
blocksblocks ambulate furtherambulate further than those withthan those with
continuous femoral nerve blocks oncontinuous femoral nerve blocks on
postoperative day (POD) 1 withoutpostoperative day (POD) 1 without
reduction in analgesiareduction in analgesia
Mudumbai & Mariano, et al. CORR 2014;472:1377Mudumbai & Mariano, et al. CORR 2014;472:1377

19. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
 Patients in thePatients in the
adductor canal groupadductor canal group
walkedwalked 3737 (0-90)(0-90)
meters vs.meters vs. 66 (0-51)(0-51)
meters in the femoralmeters in the femoral
catheter groupcatheter group
((p=0.003p=0.003).).
 Pain scores, opioidPain scores, opioid
consumption, andconsumption, and
hospital length of stayhospital length of stay
were similar.were similar.
ResultsResults
Mudumbai & Mariano, et al. CORR 2014;472:1377Mudumbai & Mariano, et al. CORR 2014;472:1377

20. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Evidence from RCTsEvidence from RCTs
 TKA: continuous ACB vs. FNBTKA: continuous ACB vs. FNB11
– Greater preservation of quad MVIC in ACBGreater preservation of quad MVIC in ACB
group (median 52% vs. 18%)group (median 52% vs. 18%)
– No differences in pain, opioids, flexion, TUGNo differences in pain, opioids, flexion, TUG
 TKA: repeated bolus ACB vs. FNBTKA: repeated bolus ACB vs. FNB22
– ACB had better TUG, 10 meter walk time, andACB had better TUG, 10 meter walk time, and
30 sec chair test30 sec chair test
– No differences in pain, opioidsNo differences in pain, opioids
1. Jaeger P, et al. RAPM 2013;38:5261. Jaeger P, et al. RAPM 2013;38:526
2. Shah NA and Jain NP. J Arthro2. Shah NA and Jain NP. J Arthro

21. Best Multimodal Analgesia for TKABest Multimodal Analgesia for TKA
Our Problems Are Solved!Our Problems Are Solved!

22. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
……Or Maybe NotOr Maybe Not

23. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Anesth Clinics 2014;32:853

24. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Use Multimodal AnalgesiaUse Multimodal Analgesia
Anesthesiology 2012;116:248Anesthesiology 2012;116:248

25. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Add Non-Opioid AnalgesicsAdd Non-Opioid Analgesics
 Non-steroidal anti-inflammatory drugsNon-steroidal anti-inflammatory drugs
 Gabapentin and pregabalin preoperativelyGabapentin and pregabalin preoperatively
– Gabapentin 300-1200 mg 1-2.5 hrs preopGabapentin 300-1200 mg 1-2.5 hrs preop
– Pregabalin 150-300 mg 1-2 hrs preopPregabalin 150-300 mg 1-2 hrs preop
 Ketamine intraoperativelyKetamine intraoperatively
– 0.5 mg/kg IV bolus + 0.25 mg/kg/h infusion0.5 mg/kg IV bolus + 0.25 mg/kg/h infusion
– RCT in opioid-tolerant patients undergoingRCT in opioid-tolerant patients undergoing
spine surgery: decreased pain/opioids for wksspine surgery: decreased pain/opioids for wks
Loftus RW, et al. Anesth 2010;113:639Loftus RW, et al. Anesth 2010;113:639
Hadi I, et al. CJA 2006;53:1190Hadi I, et al. CJA 2006;53:1190
Dahl JB, et al. Acta Anaes 2004;48:1130Dahl JB, et al. Acta Anaes 2004;48:1130
De Kock M, et al. Pain 2001;92:373De Kock M, et al. Pain 2001;92:373

26. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
Clinical Pathway (VA Palo Alto)Clinical Pathway (VA Palo Alto)
PreopPreop Adductor canal catheter insertionAdductor canal catheter insertion
IntraopIntraop Periarticular local anesthetic infiltration:Periarticular local anesthetic infiltration:
ropivacaine 0.2% (150 ml) with ketorolacropivacaine 0.2% (150 ml) with ketorolac
30 mg and epinephrine30 mg and epinephrine
PostopPostop 1.1. Perineural infusion of ropivacainePerineural infusion of ropivacaine
2.2. Scheduled meds: oral oxycodone,Scheduled meds: oral oxycodone,
acetaminophen, and diclofenacacetaminophen, and diclofenac
3.3. PRN meds: oxycodone (PO) andPRN meds: oxycodone (PO) and
morphine (IV) for breakthrough pain morphine (IV) for breakthrough pain
No IV PCA

27. Perioperative Analgesia for TKAPerioperative Analgesia for TKA
SummarySummary
 We discussed:We discussed:
– Possible analgesic options for developing aPossible analgesic options for developing a
multimodal plan for the patient undergoingmultimodal plan for the patient undergoing
total knee arthroplasty;total knee arthroplasty;
– Merits and demerits of the femoral nerveMerits and demerits of the femoral nerve
block; andblock; and
– The growing body of evidence favoringThe growing body of evidence favoring
adductor canal blocks in certain situations.adductor canal blocks in certain situations.