Femoral Nerve Block vs Fascia Iliaca Block for Total Knee Arthroplasty Postoperative Pain Control: A Prospective, Randomized Controlled Trial

doi:10.1016/j.arth.2009.11.018

The Journal of Arthroplasty

Volume 25, Issue 8, December 2010, Pages 1246-1249

https://doi.org/10.1016/j.arth.2009.11.018 Get rights and content

Abstract

Femoral nerve block (FNB) is an accepted mode of analgesia for lower limb procedures but has a documented complication rate. This study compared femoral nerve and fascia iliaca regional anesthesia for total knee arthroplasty (TKA), using fentanyl consumption as the primary outcome measure. Ninety-eight primary unilateral TKA patients were blinded and randomized into fascia iliaca block (FIB) (n = 51) or FNB (n = 47) groups. No significant differences were found in analgesia use (fentanyl and tramadol) at 12 and 36 hours in pain, nausea and range of motion between the groups. There was one case of paresthesia in the femoral nerve in the FNB group. Fascia iliaca block is as effective as FNB as part of a multimodal anesthetic regimen for TKA.

Section snippets

Methods

Approval of the research protocol was obtained through the institutional ethics committee. One hundred four consecutive primary TKA patients with primary diagnosis of osteoarthritis were recruited into the study. Patients were excluded if they had a stated allergy to local anesthetic or medications used in the protocol or had undergone previous surgery in the region of the block. Informed consent was obtained, and the patients were blinded and allocated by block randomization using sealed

Results

The quantities of fentanyl administered via the PCA at 12 and 36 hours and tramadol use at 12 and 36 hours were not significantly different between the FNB and FIB groups (Fig. 1, Fig. 2; Table 2). The VAS pain, postoperative nausea and vomiting, and range of motion (flexion and extension) data showed no statistical difference between the groups (Table 3). Subcutaneous morphine was used in 10 patients (4 in FIB, 6 in FNB) with a mean total dosage of 32.8 mg ± 4.2 mg for FIB and 32.4 mg ± 7.1 mg

Discussion

Multimodal techniques featuring peripheral nerve blocks have demonstrated a significant advantage in perioperative pain relief for TKA patients [1]. The FNB has previously demonstrated adequate perioperative pain relief as well as rapid rehabilitation in the postoperative period 8, 9, 10, 11, 12. In addition, FNB has been found to be superior when compared to PCA administered morphine [3] and provides equivalent analgesia to epidural anesthesia without the risk of severe neuraxial compression 13

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Cited by (29)

A comparison of analgesic techniques for total knee arthroplasty: A network meta-analysis
2021, Journal of Clinical Anesthesia
There is no established analgesic method for postoperative total knee arthroplasty. We comprehensively compared the analgesic methods for postoperative total knee arthroplasty.
A network meta-analysis of randomised controlled trials was used to compare 18 interventions, which were ranked by six outcome indices, to select the best modality.
Postoperative recovery room and inpatient ward.
98 randomised controlled trials involving 7452 patients (ASA I-III) were included in the final analysis.
Studies that included the use of at least one of the following 12 nerve block(fascia iliaca compartment block (FIB), FNB, cFNB, single femoral nerve block (sFNB), adductor canal block (ACB), sciatic nerve block (SNB), obturator nerve block (ONB), continuous posterior lumbar plexus block (PSOAS), FNB + SNB, ACB + LIA, FNB + LIA, PCA + FNB).
Pain intensity was compared using Visual Analogue Scale (VAS). Also, postoperative complications, function score, hospital length of stay, morphine consumption and patient satisfaction were measured.
For visual analogue scale scores, continuous femoral nerve block (FNB) and FNB + sciatic nerve block (SNB) were the the most effective interventions. For reducing postoperative complications, fascia iliaca compartment block, FNB, SNB, and obturator nerve block showed the best results. For reducing postoperative morphine consumption, adductor canal block (ACB) + local infiltration analgesia (LIA) and FNB + SNB were preferred. For function scores (range of motion, Timed-Up-and-Go test), ACB and LIA were optimal choices. For reducing hospital length of stay and patient satisfaction, ACB + LIA and FNB + LIA were best, respectively.
Peripheral nerve block, especially FNB and ACB, is a better option than other analgesic methods, and its combination with other methods can be beneficial. Peripheral nerve block is a safe and effective postoperative analgesia method. However, our findings can only provide objective evidence. Clinicians should choose the treatment course based on the individual patient's condition and clinical situation.
Fascia iliaca compartment block reduces pain and opioid consumption after total hip arthroplasty: A systematic review and meta-analysis
2019, International Journal of Surgery
Citation Excerpt :
Foss et al. supported the use of FICB in acute management of hip fracture pain because it is an effective, easily learned procedure that also may reduce opioid side effects in this fragile, elderly group of patients. Watts et al. [28] showed that FICB is as effective as femoral nerve block as part of a multimodal anesthetic regimen for total knee replacement. Currently, there was no reliable evidence regarding the morphine-sparing effect for FICB in THA.
Optimal pain management after total hip arthroplasty (THA) remains controversial. We perform a meta-analysis from randomized controlled trials (RCTs) to evaluate the efficacy and safety of fascia iliaca compartment block (FICB) in THA.
In this meta-analysis, we conducted electronic searches of Pubmed, Medline, Cochrane library, and Web of Science before February 2019. We collected RCTs to compare FICB and placebo for pain control after THA. The outcome measurements consisted of pain score, opioid consumption, length of hospitalization and postoperative complications. All data analyses were conducted using STATA 13.0. Cochrane Collaboration's tool was adopted to assess the risk of bias.
Seven RCTs met our inclusion criteria with 165 patients in the FICB groups, and 160 patients in the placebo groups. The present meta-analysis indicated that there were significant differences between the groups in terms of pain score at postoperative 12 h (WMD = −0.285, 95% CI [-0.460, −0.109], P = 0.002) and 24 h (WMD = −0.391, 95% CI [-0.723, −0.059], P = 0.021). FICB was associated with significant superior in opioid consumption at postoperative 12 h (WMD = −5.394, 95% CI [-8.772, −2.016], P = 0.002) and 24 h (WMD = −6.376, 95% CI [-10.737, −2.016], P = 0.004) compared with placebo. No significant difference was identified regarding length of hospitalization (WMD = 0.112, 95% CI [-0.125, 0.350], P = 0.354).
Fascia iliaca compartment block was effective for pain relief during the early post-operative period after total hip arthroplasty. Meanwhile, it reduced the cumulative morphine consumption and the risk of opioid-related adverse effects.
Fascia iliaca compartment blocks: Different techniques and review of the literature
2019, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
However, in this study, 60 mL of LA were injected in both groups as a loading dose. With these large volumes, it is highly unlikely to detect a clinical difference between the blocks as both blocks have similar injection points [25]. A small study in children scheduled for anterior cruciate ligament repair could not demonstrate a difference between FICB and FNB in terms of VAS scores and morphine consumption [26].
The fascia iliaca compartment block has been promoted as a valuable regional anesthesia and analgesia technique for lower limb surgery. Numerous studies have been performed, but the evidence on the true benefits of the fascia iliaca compartment block is still limited. Recent anatomical, radiological, and clinical research has demonstrated the limitations of the landmark infrainguinal technique. Nevertheless, this technique is still valuable in situations where ultrasound cannot be used because of lack of equipment or training. With the introduction of ultrasound, a new suprainguinal approach of the fascia iliaca has been described. Research has demonstrated that this technique leads to a more reliable block of the target nerves than the infrainguinal techniques. However, more research is needed to determine the place of this technique in clinical practice.
Postoperative analgesic efficacy of fascia iliaca block versus periarticular injection for total knee arthroplasty
2016, Journal of Clinical Anesthesia
Citation Excerpt :
Another study compared fascia iliaca block with three-in-one block and reported that fascia iliaca block acted more rapidly and was more efficacious for the simultaneous blockade of lateral femoral cutaneous and femoral nerves [15]. Femoral nerve block is also frequently performed for postoperative pain relief after major knee surgery [11]. However, femoral nerve block has notable incidences of temporary and permanent neurological complications [16,17].
This study evaluated the postoperative analgesic efficacies of fascia iliaca block and periarticular drug injection techniques after TKA (total knee arthroplasty) surgeries.
Prospective, randomized clinical trial.
University Teaching and Research Center.
Seventy-one American Society of Anesthesiologists (ASA) I-III patients between 48 and 70 years of age who underwent total knee arthroplasty were randomized.
Tenoxicam (20 mg) was administered intramuscularly to both groups of patients 30 minutes before surgery. Patients were randomized into two groups to receive fascia iliaca block before the induction of anesthesia (Group FI) or periarticular drug injection during the surgery (Group PI). All surgeries were performed under general anesthesia using standard techniques. Postoperative analgesia was provided with patient-controlled intravenous morphine.
Total morphine consumption was the primary outcome measure and was recorded postoperatively at 1, 2, 6, 12 and 24 hours. Pain levels at rest and on movement (knee flexion) were evaluated using the Visual Analogue Scale (VAS) and recorded at the same time points. Patients' demographics, rescue analgesic demands, side effects, hemodynamics, and satisfaction scores were also recorded.
The groups had similar VAS scores both at rest and on movement (P > .05). However, the amount of cumulative morphine and use at each follow-up period was higher in Group PI (P < .0001). The groups did not differ significantly in rescue analgesic use or side effects, such as nausea/vomiting, hemodynamic variables, and patient satisfaction scores (P > .05).
Fascia iliaca block may be used as an alternative method to periarticular injection, and it effectively reduces the amount of morphine used to relieve post-TKA pain.
Multimodal therapy in perioperative analgesia
2014, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
This consecutive randomized study revealed no difference in analgesic outcomes between the intrathecal and general/multimodal groups [77]. Probably the most recent emphasis in the literature is on the peripheral nerve blocks (e.g., femoral, fascia iliaca, adductor canal, sciatic, and tibial blocks); significant evidence supports utilization of regional anesthesia as part of a successful multimodal analgesic regimen [78–80]. An entire review can be conducted on all of the regional anesthesia peripheral nerve block and catheter options, which can provide additional detailed information on positive outcomes.
This article reviews the current evidence for multimodal analgesic options for common surgical procedures. As perioperative physicians, we have come a long way from using only opioids for postoperative pain to combinations of acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), selective Cyclo-oxygenase (COX-2) inhibitors, local anesthetics, N-methyl-d-aspartate (NMDA) receptor antagonists, and regional anesthetics. As discussed in this article, many of these agents have decreased narcotic requirements, improved patient satisfaction, and decreased postanesthesia care unit (PACU) times, as well as morbidity in the perioperative period.
What's new in adult reconstructive knee surgery
2012, Journal of Bone and Joint Surgery
Citation Excerpt :
Although peripheral blocks can be effective, there remain concerns regarding the possibility of nerve-related complications, including paresthesias, weakness, and, potentially, palsies. McMeniman et al.17 specifically compared femoral nerve and fascia iliaca anesthesia in a blinded, randomized study of ninety-eight primary total knee arthroplasties. They found no differences between groups in terms of the use of fentanyl after surgery and concluded that the fascia iliaca block is as effective as a femoral nerve block.

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: No benefits or funds were received in support of the study.

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Femoral Nerve Block vs Fascia Iliaca Block for Total Knee Arthroplasty Postoperative Pain Control: A Prospective, Randomized Controlled Trial

Abstract

Section snippets

Methods

Results

Discussion

Contin Educ Anaesth Crit Care Pain

Reg Anesth Pain Med

J Arthroplasty

J Arthroplasty

Reg Anesth Pain Med

Br J Anaesth

Ann Emerg Med

Injury

Reg Anesth Pain Med

Reg Anesth Pain Med

Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery

Anesthesiology