• Mitchell R Klement, W Michael Bullock, Brian T Nickel, Alexander J Lampley, Thorsten M Seyler, Cynthia L Green, Samuel S Wellman, Michael P Bolognesi, and Stuart A Grant.
• Department of Orthopedic Surgery, Duke University Medical Center, Durham, NC 27710, USA; Orthopaedic Associates of Wisconsin, N15W28300 Golf Road, Pewaukee, WI 53072-4800, USA. Electronic address: mklement@orthowisconsin.com.
• Knee. 2019 Jun 1; 26 (3): 679-686.

BackgroundThere is a growing interest in avoiding discharging patients to rehab to maximize outcome and minimize complications after total knee arthroplasty (TKA). In addition, use of postoperative pain pathways that minimize opioid use is critical amidst the current opioid epidemic. However, the ideal pain regimen after TKA has yet to be determined.MethodsFrom July 1, 2013 to October 1, 2014 two perioperative pathways were used to address surgical pain. These included either a single shot femoral nerve block plus liposomal bupivacaine pericapsular injection (FNB + LB-PAI) or adductor canal catheter plus posterior capsule single shot block (ACC + iPACK), each with an oral analgesic protocol. Little modification occurred with regard to surgical technique, postoperative medications, or postoperative physical therapy (PT).ResultsOverall, 264 unilateral, primary TKA patients (146 FNB + LB-PAI, 118 ACC + iPACK) were included. ACC + iPACK patients had a shorter median length of stay (LOS, 2.0 vs 3.0, p < 0.001), more discharges home (79.7% vs 67.8%, p = 0.002), and less median opioid consumption (IV morphine equivalents, IVME, 20.0 vs 44.1, p < 0.001) than the FNB + LB-PAI group. In multivariable analysis, use of ACC + iPACK remained independently associated with shorter LOS, increased discharge home, and less IVME consumed when controlling for confounding variables. ACC + iPACK patients also had fewer opioid related adverse events (0.8 vs 5.5, p = 0.045) and a lower rate of MUA (0.8% vs 6.2%, p = 0.026).ConclusionsWe recommend ACC + iPACK with a multimodal oral analgesic protocol as the primary postoperative analgesia in enhanced recovery TKA protocols. This resulted in an easier recovery with fewer complications.Level Of EvidenceLevel III.Copyright © 2019 Elsevier B.V. All rights reserved.

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