الفهرس 
IntroductionOnly 14 pages are availabe for public view
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Abstract
Postoperative pain management after total knee arthroplasty (TKA) continues to evolve with better treatment strategies being formulated to improve patient satisfaction, clinical outcomes and reduce opioid use in the immediate postoperative period. Appropriate perioperative pain management has been shown to result in faster recovery and rehabilitation leading to better functional outcome in patients undergoing TKA. Multimodal analgesia is incorporated into most clinical pathways to facilitate earlier ambulation, improve patient comfort, and enhance patient satisfaction. By utilizing a number of analgesic strategies, including ―motorsparing‖ peripheral nerve blocks and peri-articular injections (PAIs), patients’ recoveries may be enhanced by promoting early postoperative ambulation, improving pain scores, and reducing opioid consumption. Adductor canal block (ACB) is a popular peripheral nerve block that has been shown to decrease pain significantly and thereby opioid consumption with minimal effect on quadriceps function. Though ACB provides analgesia to the peri-patellar and intra-articular aspect of knee joint, it does not relieve posterior knee pain which is moderate to severe in intensity. The PAI technique is based on the systematic infiltration of a mixture of a local anesthetic drug, usually combined with a non-steroidal antiinflammatory drug, and adrenaline around all knee joint structures, constituting a simple blind technique that is performed by orthopedic surgeons, relieving postoperative knee pain without quadricep muscle strength weakness. Ultrasound-guided infiltration of local anesthetic in the interspace between the popliteal artery and posterior capsule of the knee (IPACK) is a regional anesthetic modality for posterior knee analgesia. The IPACK block targets the medial and lateral genicular nerves, and other articular branches innervating the posterior aspect of the knee joint which in theory has less motor and sensory blockade below the knee than the more proximal sciatic nerve block. This prospective randomized study was carried out in Tanta University Hospitals in Anesthesia Department for one year after approval from ethical committee of faculty of medicine of Tanta university from june 2020 to july2021. In this study, 69 patients were assessed for eligibility, 5 patient did not meet the inclusion criteria (1 patient had skin infection at the site of block, 2 morbid obese patients, 1 patient had history of chronic use of analgesics, 1 patient was ASA IV, 1 patient showed coagulopathy) and 3 patients refused to participate .The remaining 60 patient were randomly allocated into three groups(20 in each ). All patients were followed up and analyzed statistically. group I (n: 20) : patients recieved adductor block alone. group II (n: 20): Patients received peri-articular injection alone. group III (n: 20) : Patients received adductor block (ACB) and infiltration of interspace between popliteal artery and posterior knee capsule block (IPACK). Results were summarized, compared and analyzed Demographic data includes, age, sex, BMI, ASA physical status and weight were insignificantly different among the three groups. Measurements of our study include, NRS at rest and physiotherapy, time of first analgesic requirement, total dose of morphine consumption, motor assessment using TUG, MRC scores, patient satisfaction and recorded side effects. The main aim of this study was to investigate the post-operative analgesic effect of combined adductor canal block and infiltration of the interspace between popliteal artery and the capsule of posterior knee block (IPACK) compared to adductor canal block (ACB) only and peri-articular injection (PAIs) in patient undergoing total knee arthroplasty. The primary outcome of this study was the post-operative numeric rating score (NRS) while the secondary outcome was the postoperative analgesic consumption. Our result showed that there is no statistical difference regarding the demographic data among the three studied groups. Concerning postoperative pain assessment at the rest and during the physiotherapy in this study, it was evaluated using NRS, There is no significant difference among the three studied groups at 0h, 2hrs while NRS score in PAIs group was significantly lower at 4hrs, 6hrs, 12hrs compared to combined (ACB+IPACK) group and ACB group and also significantly lower in combined (ACB+IPACK) group than ACB group. Also, we found that the total dose of post-operative morphine consumption was significantly lower in PAIs group than combined (ACB+IPACK) group and ACB group and also significantly lower in combined (ACB+IPACK) group than ACB group. Meanwhile, no significant difference between the three studied groups at 18hrs, 24hrs, 2nd, and 3rd post-operative days. But regarding the mean time to the first rescue analgesia, It was significantly longer in PAIs than both combined (ACB+IPACK) group and ACB group and significantly longer in combined (ACB+IPACK) than ACB group. While concerning the motor block assessment using the Timed Upand Go test (TUG), it was significantly higher in PAIs group than ACB group, but it showed insignificant difference between PAIs group and combined (ACB+IPACK ) group. Also, the Medical Research council (MRC) score was statistically significant at 12hrs and 24hrs in PAIs group compared to combined (ACB+IPACK) block and ACB group, and also was significantly higher in combined (ACB +IPACK) group than ACB group. As regard patient satisfaction score in the studied groups, it was significantly higher in in PAIs group than ACB group, but it showed insignificant difference in PAIs group and combined (ACB+IPACK) group. The incidence of hypotension and bradycardia was 10%in ACB group, 5% in combined (ACB+IPACK) group and 5% in PAIs group which showed insignificant difference between all studied groups.