IPACK block: emerging complementary analgesic technique for total knee arthroplasty
Keywords:
Analgesia, Nerve block, Femoral artery, Arthroplasty, Knee
Abstract
Introduction:
Pain control in total knee arthroplasty (TKA) is a determining factor in the patient's rehabilitation process. With conventional peripheral blocking techniques for the posterior compartment, foot drop, and distal motor deficit have been reported. The infiltration between popliteal artery and capsule of the knee (IPACK) block is a promising emerging analgesic technique.
Objective:
To describe analgesic control, opioid consumption, and mobility of patients scheduled for TKA using IPACK block as adjunct analgesic to the femoral block.
Methods:
We conducted a prospective observational cohort study over a 6-month period in adults taken to TKA. Sociodemographic and anthropometric characteristics, laterality, postoperative pain, and opioid consumption, patient and surgeon satisfaction (Likert), postoperative nausea and vomiting, and walk in the first 24hours, were evaluated and reported with a descriptive analysis.
Results:
Twenty-seven patients taken to TKA received an IPACK block. The pain score remained in a mild level during the 48 hours of evaluation. In 73% of the cases, an opioid rescue dose was not required; 81% of the patients managed to walk in the first 24 hours.
Conclusion:
The IPACK block, combined with femoral block and neuraxial anesthesia, turn out to be an excellent analgesic strategy for TKA, achieving adequate pain management, prompt rehabilitation, and early ambulation of the patient.
References
1. O’Donnell R, Dolan J. Anaesthesia and analgesia for knee joint arthroplasty. BJA Educ 2018;18:8-15.
2. Guild GN, Galindo RP, Marino J, et al. Periarticular regional analgesia in total knee arthroplasty. A review of the neuroanatomy and injection technique. Orthop Clin North Am 2015;46:1-8.
3. Srikandarajah S, Gilron I. Systematic review of movement-evoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: a fundamental distinction requiring standardized measurement. Pain 2011;152:1734-1739.
4. Xu J, Chen XM, Ma CK, et al. Peripheral nerve blocks for postoperative pain after major knee surgery. Cochrane Database Syst Rev 2014;2014:1-8.
5. Grosu I, Lavand’homme P, Thienpont E. Pain after knee arthroplasty: an unresolved issue. Knee Surg Sport Traumatol Arthrosc 2014;22:1744-1758.
6. Alves WM, Migon EZ, Zabeu JLA. Pain following total knee arthroplasty-a systematic approach. Rev Bras Ortop 2015;45:384-391.
7. Angers M, Belzile ÉL, Vachon J, et al. Negative influence of femoral nerve block on quadriceps strength recovery following total knee replacement: a prospective randomized trial. Orthop Traumatol Surg Res 2019;105:633-637.
8. Baratta JL, Gandhi K, Viscusi ER. Perioperative pain management for total knee arthroplasty. J Surg Orthop Adv 2014;23:22-36.
9. Elliott CE, Thobhani S. The adductor canal catheter and interspace between the popliteal artery and the posterior capsule of the knee for total knee arthroplasty. Tech Reg Anesth Pain Manag 2014;18:126-129.
10. Thobhani S, Scalercio L, Elliott CE, et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: An analysis of 106 patients. Ochsner J 2017;17:233-238.
11. Mejía-Terrazas GE, Zaragoza-Lemus G, Gaspar-Carrillo SP. Analgesia postoperatoria para cirugía de rodilla, estudio comparativo. Rev Mex Anestesiol 2007;30:197-200.
12. Grape S, Kirkham KR, Baeriswyl M, et al. The analgesic efficacy of sciatic nerve block in addition to femoral nerve block in patients undergoing total knee arthroplasty: a systematic review and meta-analysis. Anaesthesia 2016;71:1198-1209.
13. Scimia P, Giordano C, Ricci EB, et al. The ultrasound-guided iPACK block with continuous adductor canal block for total knee arthroplasty. Anaesth reports 2017;5:74-78.
14. Spring 2015 Abstract. ASRA 40th Annual Regional Anesthesia and Acute Pain Medicine Meeting May 14Y16, 2015 Las Vegas, NV. Regional Anesthesia & Pain Medicine 2015;40:642-662.
15. Kim DH, Beathe JC, Lin Y, et al. Addition of infiltration between the popliteal artery and the capsule of the posterior knee and adductor canal block to periarticular injection enhances postoperative pain control in total knee arthroplasty. Anesth Analg 2018;129:1.
16. Thobhani S, Thomas L, Osteen K. Effectiveness of local anesthetic infiltration between popliteal artery and capsule of knee (iPACK) for attenuation of knee pain in patients undergoing total knee arthroplasty. 40th Annu Reg Anesthesiol Acute Pain Med Meet (ASRA) Las Vegas. 2015; May 14-16: Abstract 165.
17. Prieto-Requeijo P, Mayo-Moldes M, Corujeira-Rivera M, et al. Bloqueo del nervio femoral en postoperatorio de artroplastia total de rodilla: comparación de bupivacaína 0.25% con mezcla de bupivacaína 0.25% years mepivacaína 2%. Rev Esp Cir Ortop Traumatol 2009;53:300-304.
18. Jacob AK, Harris DJ, Smith HM, et al. Interspace between Popliteal artery and posterior capsule of the knee (IPACK) injectate spread: A cadaver study. J Ultrasound Med 2019;38:741-745.
19. Sánchez Freytes S. Regional anaesthesia techniques for post-operative pain control in total knee replacement surgery. Review article. Rev Argentina Anestesiol 2016;74:57-63.
20. Jiang X, Wang QQ Wu CAI, et al. Analgesic efficacy of adductor canal block in total knee arthroplasty: a meta-analysis and systematic review. Orthop Surg 2016;8:294-300.
21. Reddy DAG, Jangale DA, Reddy DR, et al. To compare effect of combined block of adductor canal block (ACB) with IPACK (Interspace between the Popliteal Artery and the Capsule of the posterior Knee) and adductor canal block (ACB) alone on Total knee replacement in immediate postoperative rehabili. Int J Orthop Sci 2017;3:141-145.
22. Ohgoshi Y, Matsutani M, Kubo EN. Use of IPACK block with continuous femoral triangle block for total knee arthroplasty: a clinical experience. J Clin Anesth 2019;54 (September 2018): 52-54.
23. Kandarian B, Indelli PF, Sinha S, et al. Implementation of the IPACK (infiltration between the popliteal artery and capsule of the knee) block into a multimodal analgesic pathway for total knee replacement. Korean J Anesthesiol 2019;72:238-244.
24. Mejía-Terrazas GE, Peña-Riveron A, Unzueta-Navarro D. Analgesia postoperatoria en cirugía de reemplazo articular. Acta Ortop Mex 2013;27:273-278.
25. González JL, Campos MD, Miramontes GI, et al. Analysis of the efficiency and safety of the ileofascial block for postoperatory pain after total knee arthroplasty. Rev Soc Esp Dolor 2012;19: 231-238.
2. Guild GN, Galindo RP, Marino J, et al. Periarticular regional analgesia in total knee arthroplasty. A review of the neuroanatomy and injection technique. Orthop Clin North Am 2015;46:1-8.
3. Srikandarajah S, Gilron I. Systematic review of movement-evoked pain versus pain at rest in postsurgical clinical trials and meta-analyses: a fundamental distinction requiring standardized measurement. Pain 2011;152:1734-1739.
4. Xu J, Chen XM, Ma CK, et al. Peripheral nerve blocks for postoperative pain after major knee surgery. Cochrane Database Syst Rev 2014;2014:1-8.
5. Grosu I, Lavand’homme P, Thienpont E. Pain after knee arthroplasty: an unresolved issue. Knee Surg Sport Traumatol Arthrosc 2014;22:1744-1758.
6. Alves WM, Migon EZ, Zabeu JLA. Pain following total knee arthroplasty-a systematic approach. Rev Bras Ortop 2015;45:384-391.
7. Angers M, Belzile ÉL, Vachon J, et al. Negative influence of femoral nerve block on quadriceps strength recovery following total knee replacement: a prospective randomized trial. Orthop Traumatol Surg Res 2019;105:633-637.
8. Baratta JL, Gandhi K, Viscusi ER. Perioperative pain management for total knee arthroplasty. J Surg Orthop Adv 2014;23:22-36.
9. Elliott CE, Thobhani S. The adductor canal catheter and interspace between the popliteal artery and the posterior capsule of the knee for total knee arthroplasty. Tech Reg Anesth Pain Manag 2014;18:126-129.
10. Thobhani S, Scalercio L, Elliott CE, et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: An analysis of 106 patients. Ochsner J 2017;17:233-238.
11. Mejía-Terrazas GE, Zaragoza-Lemus G, Gaspar-Carrillo SP. Analgesia postoperatoria para cirugía de rodilla, estudio comparativo. Rev Mex Anestesiol 2007;30:197-200.
12. Grape S, Kirkham KR, Baeriswyl M, et al. The analgesic efficacy of sciatic nerve block in addition to femoral nerve block in patients undergoing total knee arthroplasty: a systematic review and meta-analysis. Anaesthesia 2016;71:1198-1209.
13. Scimia P, Giordano C, Ricci EB, et al. The ultrasound-guided iPACK block with continuous adductor canal block for total knee arthroplasty. Anaesth reports 2017;5:74-78.
14. Spring 2015 Abstract. ASRA 40th Annual Regional Anesthesia and Acute Pain Medicine Meeting May 14Y16, 2015 Las Vegas, NV. Regional Anesthesia & Pain Medicine 2015;40:642-662.
15. Kim DH, Beathe JC, Lin Y, et al. Addition of infiltration between the popliteal artery and the capsule of the posterior knee and adductor canal block to periarticular injection enhances postoperative pain control in total knee arthroplasty. Anesth Analg 2018;129:1.
16. Thobhani S, Thomas L, Osteen K. Effectiveness of local anesthetic infiltration between popliteal artery and capsule of knee (iPACK) for attenuation of knee pain in patients undergoing total knee arthroplasty. 40th Annu Reg Anesthesiol Acute Pain Med Meet (ASRA) Las Vegas. 2015; May 14-16: Abstract 165.
17. Prieto-Requeijo P, Mayo-Moldes M, Corujeira-Rivera M, et al. Bloqueo del nervio femoral en postoperatorio de artroplastia total de rodilla: comparación de bupivacaína 0.25% con mezcla de bupivacaína 0.25% years mepivacaína 2%. Rev Esp Cir Ortop Traumatol 2009;53:300-304.
18. Jacob AK, Harris DJ, Smith HM, et al. Interspace between Popliteal artery and posterior capsule of the knee (IPACK) injectate spread: A cadaver study. J Ultrasound Med 2019;38:741-745.
19. Sánchez Freytes S. Regional anaesthesia techniques for post-operative pain control in total knee replacement surgery. Review article. Rev Argentina Anestesiol 2016;74:57-63.
20. Jiang X, Wang QQ Wu CAI, et al. Analgesic efficacy of adductor canal block in total knee arthroplasty: a meta-analysis and systematic review. Orthop Surg 2016;8:294-300.
21. Reddy DAG, Jangale DA, Reddy DR, et al. To compare effect of combined block of adductor canal block (ACB) with IPACK (Interspace between the Popliteal Artery and the Capsule of the posterior Knee) and adductor canal block (ACB) alone on Total knee replacement in immediate postoperative rehabili. Int J Orthop Sci 2017;3:141-145.
22. Ohgoshi Y, Matsutani M, Kubo EN. Use of IPACK block with continuous femoral triangle block for total knee arthroplasty: a clinical experience. J Clin Anesth 2019;54 (September 2018): 52-54.
23. Kandarian B, Indelli PF, Sinha S, et al. Implementation of the IPACK (infiltration between the popliteal artery and capsule of the knee) block into a multimodal analgesic pathway for total knee replacement. Korean J Anesthesiol 2019;72:238-244.
24. Mejía-Terrazas GE, Peña-Riveron A, Unzueta-Navarro D. Analgesia postoperatoria en cirugía de reemplazo articular. Acta Ortop Mex 2013;27:273-278.
25. González JL, Campos MD, Miramontes GI, et al. Analysis of the efficiency and safety of the ileofascial block for postoperatory pain after total knee arthroplasty. Rev Soc Esp Dolor 2012;19: 231-238.
How to Cite
1.
Caballero-Lozada AF, Gómez JM, Ramírez JA, Posso M, Zorrilla-Vaca A, Lasso LF. IPACK block: emerging complementary analgesic technique for total knee arthroplasty. Colomb. J. Anesthesiol. [Internet]. 2020 Apr. 1 [cited 2024 Apr. 25];48(2):78-84. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/133
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How to Cite
1.
Caballero-Lozada AF, Gómez JM, Ramírez JA, Posso M, Zorrilla-Vaca A, Lasso LF. IPACK block: emerging complementary analgesic technique for total knee arthroplasty. Colomb. J. Anesthesiol. [Internet]. 2020 Apr. 1 [cited 2024 Apr. 25];48(2):78-84. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/133
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