Background and Aims Periarticular injections (PAIs) are becoming a component of multimodal joint pathways. Motor-sparing peripheral nerve blocks, such as the infiltration between the popliteal artery and capsule of the knee (IPACK) and the adductor canal block (ACB), may augment PAI in multimodal analgesic pathways for knee surgery, but supporting literature remains rare. We hypothesized that t ACB and IPACK would lower pain on ambulation on postoperative day (POD) 1 compared to PAI alone.

Methods This triple-blinded randomized controlled trial included 50 patients undergoing ACL repair. Patients either received (1) a PAI (control group, n = 26) or (2) an iPACK with an ACB (intervention group, n = 24). The primary outcome was pain on ambulation on POD .Secondary outcomes included numeric rating scale (NRS) pain scores, patient satisfaction, and opioid consumption

Results Opioid consumption was different in both groups. Highly significant difference was also observed comparing the two groups concerning the total morphine consumption (mg) in the first 24 postoperative hours 6 mg in iPACK group compared to 11 mg in PAI group (p value=0.037). Pain upon ambulation was significantly less in iPACK group ( P value=0.01).The occurrence of postoperative nausea and vomiting was low in both groups with no statistical difference, this is most likely due to the prophylactic administration of dexamethasone and ondansetron given routinely to all patients

Conclusions The addition of iPACK and ACB significantly improves analgesia and reduces opioid consumption after ACL repair compared to PAI alone. This study strongly supports iPACK and ACB use within a multimodal analgesic pathway