VOLUME 26, ISSUE 2
pathways. One of the latest disruptive innovations is the industry of extended release local anesthetics that has resurrected an interest in infiltration and joint injections as the primary postoperative analgesic technique for joint arthroplasty, supplanting some academic and private practice groups current Regional Anesthesia and Acute Pain Programs. Joint injections and joint infusions were traditionally utilized by surgeons in practices where Anesthesiologists were unable or unwilling to perform regional anesthesia. Yet, these techniques were abandonded because of the risk for chondrolysis and subsequent malpractice exposure. Animal studies where bupivacaine was injected into the joint space demonstrated both immediate and delayed destruction of chondrocytes, and human case series confirmed clinical chondrotoxicity for patients receiving bupivacaine joint injections.
The current extended release local anesthetic Liposomal Bupivacaine is over $240/dose (hospital cost to acquire). With few studies, the company producing the product has promised, but not delivered, 72 hours of analgesia ubiquitously. Thus, these agents have been rejected by hospital system formularies including the V.A. This is in contrast to the potential month of continuous titratable analgesia peripheral nerve catheters have demonstrated. Titratability is an invaluable characteristic, but an often overlooked feature of continuous nerve blocks, unlike single shot injections of local anesthesia. If a patient’s motor or sensory function needs to be assessed, an infusion can be discontinued and the patient reassessed within 2 hours. Continuous catheters have demonstrated the ability to turn major inpatient procedures like shoulder arthroplasty into outpatient procedures with interscalene perineural catheters.
Rescue blocks for extended release local anesthetic joint injections appear to be out of the question for 96 hours because of concern by the manufacturer about creating potentially toxic levels of local anesthetic unless the same product is utilized in the rescue block. Naturally, pharmacies are reluctant enough to purchase the intraarticular/local infiltration agent, so much so, that the added cost of a rescue block makes it more prohibitive.
Adductor Canal Blocks for Total Knee Arthroplasty and ACL reconstruction
Anesthesiology practices are constantly being pressured to alter traditional regional techniques like epidurals, femoral, sciatic blocks and catheters to encourage earlier ambulation, regardless of the time and resources required to train an entire department to provide consistent service. Its amazing how the same expectations are not instituted on surgical technique to an entire surgical department.
Enter the en vogue AC (Adductor Canal) aka Transsartorial Saphenous Nerve aka Subsartorial Saphenous Nerve Block. It’s amusing to read and hear from the “Experts” where exactly in the thigh one should perform this block. Too high and there can be motor weakness in the quadriceps, too low and the infrapatellar branches of the saphenous nerve and branches of the obturator will be missed. The utilization of the AC block as an equivalent to the femoral nerve block for ACL repairs and Knee
