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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 72-79

Peripheral nerve block (FLOS block) for intraoperative anesthesia in total knee arthroplasty: An observational study


Department of Anaesthesiology and Critical Care, Military Hospital Kirkee, Pune, Maharashtra, India

Date of Submission28-Jul-2020
Date of Acceptance26-Nov-2020
Date of Web Publication09-Feb-2021

Correspondence Address:
Dr. G V Krishna Prasad
Department of Anaesthesiology, Military Hospital Kirkee, Pune - 411 020, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_250_20

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  Abstract 

Background: Peripheral nerve blocks (PNBs) are generally used to provide postoperative analgesia after total knee arthroplasty (TKA) and other lower extremity procedures; these blocks are used rarely for intraoperative anesthesia. We present here, the patients who underwent TKA under PNBs (FLOS Block). FLOS block is nothing but femoral, lateral cutaneous femoral nerve, obturator, and sciatic nerve block.
Materials and Methods: A total of 41 patients participated in the study for TKA using PNB, FLOS block. All the patients received standardized anesthesia and analgesia upon hospitalization. Outcome evaluations included the visual analog scale (VAS) scores during surgery, activity at rest, postoperative blood pressure, and heart rate, also the sedation for femoral, lateral cutaneous femoral nerve obturator and sciatic nerve (FLOS) blocks. Compared with neuraxial (spinal/epidural) anesthesia, PNB (FLOS Block) minimizes hypotension, minimizes urinary retention, improves patient satisfaction, ambulation restrictions, and eliminates the risk of spinal hematoma and infection.
Results: The finding suggests a decreased requirement of opioids in the PNB technique (FLOS Block). Pain scores, assessed by subjective VAS scale, were accurately handled in all the patients reviewed, with good pain control with PNB (FLOS Block). PNB (FLOS Block) provided stable hemodynamic, prolonged, and better postoperative analgesia. Intraoperative anesthesia was very satisfactory for surgery. The requirement of total doses of rescue analgesics, VAS score peroperatively for 48 h, the incidence of side effects, and complications were very few and acceptable.
Conclusion: A femoral, sciatic nerve block with obturator and lateral femoral cutaneous nerve block may be an option to the spinal epidural anesthesia in the patients undergoing TKA. PNB (FLOS Block) showed similar patient satisfaction and postoperative analgesia to spinal-epidural anesthesia.

Keywords: FLOS Block, pain control, peripheral nerve block, total knee arthroplasty


How to cite this article:
Khanna S, Gogoi B, Jaishree SV, Prasad G V. Peripheral nerve block (FLOS block) for intraoperative anesthesia in total knee arthroplasty: An observational study. Indian J Health Sci Biomed Res 2021;14:72-9

How to cite this URL:
Khanna S, Gogoi B, Jaishree SV, Prasad G V. Peripheral nerve block (FLOS block) for intraoperative anesthesia in total knee arthroplasty: An observational study. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Feb 26];14:72-9. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/72/308955




  Introduction Top


Regional anesthesia is the best option for life-saving operations in emergency surgeries where both general and neuraxial anesthesia were risky or contraindicated, since no special preparation, fasting, and preoperative optimization is required.[1] Furthermore, peripheral nerve blocks (PNBs) grant surgical anesthesia with improved cardiorespiratory stability[2] as compared to the central neuraxial blockade which has side effects such as hypotension, bradycardia, coagulation disturbances, sepsis, local infection, immune deficiency, severe spinal deformity, severe decompensated hypovolemia, and shock, meningitis, postdural puncture headache, neurological deficit, hematoma, etc.[3] With the progress of innovative techniques such as peripheral nerve stimulator and ultrasound, the scope of anesthesia has shifted from general anesthesia (GA) and central neuraxial blockade for isolated limb surgery under PNBs.[4] One of the most useful but most neglected anesthetic techniques is the combination of femoral and sciatic nerve block with obturator and lateral femoral cutaneous nerve (LFCN) (3:1) for lower limb surgery?.[5] The combination of femoral and sciatic nerve blocks (FSNBs) with obturator and LFCN has frequently been used for postoperative pain control after total knee replacement (TKR).[6]

Innervation of the anterior knee joint is first and foremost supplied by the femoral nerve. The posterior knee joint is supplied by genicular branches of the sciatic nerve, with input from the obturator nerve supplying the medial portion of the knee joint. The cutaneous innervation of the knee and thigh involves numerous nerve distributions. The LFCN supplies the portions of the lateral and anterior thigh, extending to the knee [Figure 1]. The posterior femoral cutaneous nerve (PFCN) is the pure sensory nerve which in the majority of cases, appears from the greater sciatic foramen under the piriformis muscle. The PFCN then travels medially to the sciatic nerve and lies directly on the deep surface of the gluteus maximus muscle.[7]
Figure 1: Nerve supply of the knee joint

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Recently, PNBs are used widely for lower limb surgeries, but are still not as common as spinal anesthesia, mainly because of increased time and proficiency required as also due to delayed recovery related with their use. The time required to execute PNBs can be decreased by achieving PNBs preoperatively in the block room?.[8]

Transient postoperative neurologic symptoms after PNBs have been reported to occur at rates from 0.0% to 15.0%, with a rate of about 8.0% seen after nerve-stimulation assisted sciatic nerve blockade (SNB).[9],[10] No studies have evaluated the incidence of neurologic sequelae after performing femoral, sciatic, and multiple cutaneous PNBs. The innervation of the knee is highly uneven, mainly cutaneous innervation, which makes surgical anesthesia a challenge using the PNBs alone. No doubt, the femoral nerve blocks provide outstanding analgesia after knee arthroplasty, the main disadvantage or worry is associated with quadriceps weakness, impaired proprioception, and risk of fall.

Regional anesthesia, in specific cases, the use of PNBs, has improved significantly the perioperative pain management of the patients who underwent total knee arthroplasty (TKA). Early rehabilitation and mobilization, improved satisfaction of the patient, and a reduced hospital stay have been accomplished through regional anesthesia and as a result, PNBs are becoming ever more popular. Furthermore, there were very few studies performed on PNB using these four nerve blocks simultaneously, particularly in southern India where there is the scarcity of the studied. Hence, we have chosen to undertake this study for intraoperative anesthesia in TKA. In order to present a focused discussion, this article will only focus on the peripheral blocks in TKR and not employ the field of the neuraxial anesthesia and analgesia.


  Materials and Methods Top


This observational study was designed to evaluate the effectiveness of PNB (FLOS block) for TKA. All patients undergoing TKR in ASA I, II, and III were included in the study. During the period between June 2019 and December 2019, after the ethical committee clearance, patients were enrolled in the study after evaluation at the preoperative anesthesia clinic, and patients who accepted to participate in the study gave informed written consent. Ethical clearance was obtained from institutional ethical committee with reference number ETC/Apr/2019 dated 04 Apr 2019.

  • Study population: Patient undergoing TKA was subjected to PNB (FLOS block)
  • Study design: Observational study
  • Study location: Department of Anesthesiology and Critical Care
  • Study duration: 7 months
  • Sample size: 41 patients.


Inclusion criteria

  • All patients undergoing TKA in ASA I, II, and III.


Exclusion criteria

  • Patients were not included if their body mass index was more than 40, had a history of alcohol or drug abuse, were taking opioid pain medications chronically for more than 6 months or refused to participate, or did not ambulate at baseline, or are allergic to local anesthesia
  • Patients with neurological diseases were excluded.


Screening/survey

A total of 52 patients were screened, 8 were rejected to participate in the study, and 3 were not fit according to inclusion criteria and finally, 41 patients for TKR were found fit according to criteria.



Staff qualification and training

All the patients were examined by an expert physician and orthopedician and after that routine clinical examinations were performed.

Quality control measures to check data completeness and consistency

Local and Hindi language was used to ask questions during the initial screening of the patients with valid identity proof. The data were recorded.

Procedure and methodology

All blocks were performed using ultrasonography (USG) and nerve stimulators. The sciatic nerve block was performed using a curvilinear probe and other nerve blocks were performed using linear probes. Nerve stimulators were used along with this in all blocks.

An ultrasound-guided (curvilinear probe) infragluteal approach was used for SNB. Twenty milliliters of 0.5% bupivacaine with 50 mcg dexmedetomidine was administered deep to the common investing extraneural layer around the sciatic nerve [Figure 2]a and [Figure 2]b.[11]
Figure 2: (a) Sciatic nerve blockade and (b) ultrasound-guided sciatic nerve block[11]

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With the patient supine, the LFCN was identified lateral to the sartorius muscle, anterior to the iliotibial tract, and below fascia lata. Five milliliters of 0.25% bupivacaine was administered at this location [Figure 3]a and [Figure 3]b.
Figure 3: (a) Lateral femoral cutaneous nerve and ultrasound anatomy of the lateral femoral cutaneous nerve. (b) Simulated needle path and local anesthetic spread (blue-shaded area) to anesthetize the lateral femoral cutaneous nerve

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The distal divisions of the obturator nerve were identified between the adductor longus and brevis muscles (anterior division) and between the adductor brevis and magnus (posterior division). A total of 10 mL of 2.0% lignocaine with 1:300,000 epinephrine was used for the obturator nerve block (ONB), 5 mL for each division [Figure 4]a and [Figure 4]b.
Figure 4: (a) Obturator nerve. (b) Ultrasound-guided obturator nerve block

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Femoral nerve block

USG (linear probe), drugs: 10 mL of 2.0% lignocaine, 10 ml of 0.5% bupivacaine, and 10 mL of NS, 4 mg dexamethasone was added to this combination for the femoral block [Figure 5]a and [Figure 5]b.
Figure 5: (a) Femoral nerve block and (b) ultrasound-guided femoral nerve block

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All blocks were done using both the USG machine and nerve stimulator (0.4 mA).

Postoperative analgesia

Injection paracetamol 1 g 8 hourly intravenous (IV) was given as a part of multimodal analgesia and injection tramadol 75 mg IV as rescue analgesia was used when the VAS score was more than 4.

Patient satisfaction with postoperative analgesia was evaluated by the patients themselves with the numerical rating scale (NRS) at 48 h after surgery.

Pain according to VAS scale (0 = no pain, 10 = worst conceivable pain) at rest and on mobilization.

Sedation (0 = awake, 1 = sleepy but awakened by oral order, 2 = sleepy but awakened by nociceptive stimulation, 3 = not awakened), urinary retention (impossible to urinate, requiring a urinary catheter to empty the bladder), nausea, vomiting, and dizziness.

Statistical analysis

The analysis of the categorical data were performed using the Chi-square test or Fisher's exact test. Normally distributed data were statistically tested with the independent t-test. The results were presented as mean ± standard deviation or median with the interquartile range as appropriate. P < 0.05 was considered statistically significant. The data were analyzed using the SPSS (SPSS Inc., IBM, Chicago, IL, USA) version 23.0 software.

Observation

This study was carried out on 41 patients undergoing PNB (FLOS block) for TKA of the age group of 18–65 years with ASA Grades I, II, and III. The duration of surgery (88.5 ± 19.6 min) and for performing the block, the time required was 6.0 ± 0.94 min. Hypertension was the major comorbidity in studied patients (43.9%) [Table 1].
Table 1: Patient's parameters

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Cardiorespiratory parameters such as systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate, and oxygen percent saturation remain stable throughout the surgery and postoperatively as well [Chart 1] and [Chart 2].



Pain score was calculated every hour for the first 4 h then in every 2 h for the next 12 h then in every 4 h up to 24 h and finally at every 6 h up to 48 h. The mean pain score started to rise after a 12 h postoperatively then became almost negligible at 48 h [Chart 3].



No. of patients required rescue analgesia were 8 (19.5%) and mean duration of rescue analgesia was 1470 ± 586.12 minutes [Table 2]. The recovery of sensation of sciatic nerve block was 710.71 ± 220.99 min while that of the femoral nerve block was 467.56 ± 207.84 min [Chart 4] and [Table 3].
Table 2: Rescue analgesia

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Table 3: Sensation parameters

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The complications were observed in very few patients and urinary retention was the major complication that occurred in 9.7% of patients on the day of surgery. Hypotension and pruritus were not seen in any of the patients [Chart 5].



When the criteria of discharge were met, the patients were asked for their satisfaction grade with the applied postoperative analgesia and the majority of patients were highly satisfied by PNB and ambulation restriction after the surgery [Table 4].
Table 4: Patient's parameters. When the discharge criteria were met, the patients were asked to grade their satisfaction with the applied postoperative analgesia using the NRS (10=good, if required, I will repeat it again, to 0=bad, I will never repeat it)

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  Discussion Top


Lower extremity PNBs were hardly ever used routinely for the anesthetic procedure of choice in the past for patients undergoing total joint replacement, primarily because of anesthesiologists' lack of practice in performing such procedures and people thought as time-consuming procedure. These blocks are an exceptional anesthetic option for those who are not the candidates for epidural or spinal anesthesia because anticoagulated or septic patients and may receive peripheral blocks safely. In addition, patients with the disease processes that make the hemodynamically significant sympathectomy seen with the neuraxial anesthesia unsafe may go through a lower extremity nerve block devoid of a significant risk of hemodynamic instability. Further, severe neurological complications (cauda equina syndrome and spinal hematoma) after neuraxial blockade are very rare events[12] but must be considered when opting a secure method for postoperative anesthesia or surgical analgesia. Peripheral nerve damage may occur after PNB, but the consequences are not as grave.[13] These benefits justify PNBs use as substitute anesthesia in the patients undergoing TKA/TKR.

Mean age

In the present study, the majority of patients were of age range between 56 and 70 years with a mean age of 63.41 ± 8.6 years, also the 70.7% of patients were having the ASA score of II, followed by ASA score III (24.04%). Left knee surgery was performed in 51.2% of patients, whereas the right was performed in 48.8% of patients and the mean duration of surgery was 88.5 ± 19.6 min. Hypertension was the major comorbidity in studied patients (43.9%).

The present study is in accordance with the study of Uesugi et al.[14] who has reported the mean age of studied patients as 76.3 ± 6.7 years, 81.9% of patients were having the ASA score of II. Left knee surgery was performed in 50.5% of patients, whereas the right knee was performed in 49.5% of patients and the mean duration of surgery was 89.9 ± 14.4 min. Park e?t al.[15] reported the mean age as 69.51 ± 6.89 years, mean duration of surgery as 107.30 ± 24.40 min similar to the present study. Another study by Kim et al. stated the mean age of the studied patients to be 71.8 ± 1.3 years which suggests that the patients undergoing TKA were mainly in their sixties and seventies. About 90.0% were of ASA score II and the duration of surgery was 135 ± 5.9 min. Furthermore, the duration of surgery reported by Bansal et al. was 87.32 ± 19.01 min exactly similar to that of ours.

Hemodynamic parameters

The hemodynamic parameters (heart rate, systolic, and diastolic blood pressure) were measured both preoperative, intraoperative, and postoperatively of the studied patients at specific intervals, and the same remained stable throughout the surgery and postoperatively as well.

Similar results were quoted by Baddoo[16] who reported that all the 10 patients in their study were cardiovascularly stable throughout the surgery. Bansal et al. in their study stated that cardiorespiratory parameters such as heart rate, respiratory rate, SBP, DBP, and oxygen percent saturation remained stable and comparable in both groups intraoperatively as well as postoperatively.

Pain score

In our study, the pain score was calculated every hour till 4 h then every 2 h till 12 h then every 4 h till 24 h, and finally at every 6 h up to 48 h. The mean pain score started to rise after 12 h postoperatively and reached the maximum that is 2.05 then became almost negligible at 48 h (048). This implies that the pain after the surgery using PNB was far less than any other anesthesia technique.

The similar results were presented by Uesugi et al., postoperative pain in the two groups up to 18 h after surgery was ≤1.5 on the NRS, with good analgesic effectiveness achieved in the early period following TKA. In addition, there were no significant differences in the total number of suppositories used, patient satisfaction, and range of motion of the knee. Earlier studies have revealed that continuous epidural anesthesia and FNB were similarly efficient in relieving the pain after TKA and both reduced the postoperative narcotic usag?e.[17],[18] Because the supplied area by the femoral nerve did not extend to the back of the knee joint, however, the FNB alone does not supply an analgesic effect for the soft posterior tissues of the knee joint. This is achieved by the sciatic nerve block. The joint use of sciatic and femoral nerve blocks is reported to offer a dominant analgesic effect for the surgical site invasion in TKA.[19],[20] If sciatic and femoral nerve blocks are managed continuously rather than individually, this facilitates extended pain relief effect.

The obturator nerve or sciatic nerve supplies the knee joint. Consequently, the sense in the back of the knee can be intact after FNB. The sciatic innervations in the back of the knee offer a comparatively minor contribution to the postoperative pain after TKA.[21]

In the earlier report, the adding of ONB to FNB enhances postoperative analgesia after TKA.[22] In contrast, Bouaziz et al.[23] showed that the efficacy of ONB is not enough as the cutaneous contribution of the obturator nerve was not present in 57.0% of patients.

PNB techniques are now incorporated commonly into multimodal postoperative analgesic strategies. The consequences of prolonged use of PNB included the improvement in postoperative opioid requirements and pain relief, in addition to enhanced postoperative recovery and less opioid-related adverse events by Joshi et al.[24] As an extension of the above benefits, patients are discharged earlier, and surgical procedures can be performed in outpatient settings.[25] Furthermore, Fowler et al.[17] reported that there was no significant difference in pain scores between epidural and PNB at 0–12 h or 12–24 h.

The addition of sciatic nerve blocks can provide better pain relief by reducing posterior knee pain.[26] A study by Park et al. showed that continuous FNB combined with SNB was comparable to epidural analgesia regarding the management of pain, and both provided excellent pain control during knee movement and at rest. In agreement with our findings, earlier studies have also shown that the addition of SNB to FNB reduces the postoperative pain to a level comparable to epidural analgesia after TKR.[27],[28] The main advantage of the FLOS block is that the tourniquet pain is almost nil during the surgery because all four nerves supplied to the thigh, circumferentially. And also helped by addition of Dexmedetomidine in sciatic nerve block which alleviated the pain and provided good sedation which could be due to intramuscular absorption.

Rescue analgesia was given in the form of an injection to the 8 patients out of the total 41 patients and injection tramadol 75 mg slow IV was given as rescue analgesia. The time of demand for the first rescue analgesia was noted and it was more than 14 h postoperatively. Bansal et al. in their study also used tramadol as rescue analgesia. The mean intraoperative sedation score in our study due to the addition of dexmedetomidine in the sciatic block was found to be 1.05 ± 0.78 and the patient was comfortably sedated during the surgery. The patient was very comfortable after the surgery and no adverse effects of dexmedetomidine were noted. In a study conducted by Sathyamoorthy et al.,[29] it was noted that the sedation scores in the dexmedetomidine group were significantly higher than the baseline values and values in the tramadol group (P < 0.0001). Furthermore, Venkatraman et al.[30] reported significantly higher sedation score in the dexmedetomidine group with 70.0% of patients developing a score of 2 and 23.30% of them having a score of 3.

The sedation seen with dexmedetomidine, in the dearth of vomiting and nausea, is advantageous for the anesthetist, surgeon, and the patient. It also provided more relief to the patient, maintained extra cardiorespiratory stability (hemodynamics), improved surgical conditions, and also provided amnesia during surgery.

FLOS block provides several advantages in the perioperative period. These techniques offer the flexibility to prolong intraoperative anesthesia, thereby avoiding the side effects and risks of GA. During surgery, PNBs provide extended postoperative analgesia.

Complications and patient's parameters

The complications were observed in a very few patients and urinary retention and dizziness were the major complications that occurred in 9.76% of patients on the day of surgery and in 4.88 and 2.44% of patients after 2 days of surgery. The incidences of urinary retention may be due to the spread of drug into the sacral plexus during the sciatic nerve block. Hypotension, pruritic, and nerve damage were not seen in any of the patients. There was no single case of nerve injuries due to nerve block. Bansal et al. in their study reported that PNB can be used for lower extremity surgeries devoid of any major complications and drug toxicity. It can also be used in seriously ill patients where both GA and central neuraxial block carry a high risk of mortality. Similarly, Tantry et al.[2] did a study in the anticoagulated patients with valvular disease under combined sciatic and femoral nerve blocks without any complications. Uesugi et al. reported that the mean level of satisfaction in the PNB group was 8.3 ± 1.7, which was similar to the present study. In our institution, early ambulation is advocated, i.e., the next day morning, which was not restricted by the FLOS block.

A large study depicted that long-acting PNBs of the lower limb may be safely performed and is related with a high degree of satisfaction and efficacy.[31] Park et al. found that the number of patients presenting complications was significantly lower in the PNB group than in the epidural group and also the mean patient's satisfaction in the PNB group was 9, whereas that in an epidural group, it was 8 on scale rating from 0 to 10.

Limitations of the study

  • The sample size was perhaps inadequate.
  • The majority of the participants were elderly patients with osteoarthritis undergoing TKA, which represented a relatively homogenous population.


Strengths

  • The data were analyzed on the basis of consent proforma
  • Our use of population-based data allowed us to study the broad range of TKA patients across a universal health-care system.


Recommendations

  • The development of a full understanding of the value attributable to FLOS block for TKA will require a prospective study, for assessing patient-centered outcome measures.
  • Further studies are required to identify the FLOS block as an ideal method of analgesia with long-term persistence.



  Conclusion Top


The combined femoral and sciatic nerve block with obturator and LFCN (FLOS block) using paracetamol IV as one of the most constructive yet most mistreated anesthetic procedures. FLOS (femoral, lateral cutaneous femoral, obturator, and sciatic) Block provides adequate anesthesia for TKA, a PNB can be a good anesthetic candidate for TKA. The incidence of postoperative adverse outcomes was lower and the patient's satisfaction was higher. It is having the least hemodynamic instability and is very effectively used as an alternative to spinal-epidural anesthesia. It is a PNB for TKR/TKA. In high-risk patients with multiple comorbidities where spinal anesthesia is contraindicated, this is safe and useful. Only a few studies have been done using these four nerve blocks simultaneously. It has provided good postoperative analgesia and pain relief also.

When the discharge criteria were met, the patients were asked to grade their satisfaction with the applied postoperative analgesia using the NRS (10 = good, if required, I will repeat it again, to 0 = bad, I will never repeat it).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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