A Comparative study between ultrasound guided four in one block versus femoral nerve block versus adductor canal block in enhanced recovery after knee replacement surgery

Abstract

ltrasound guided 4-in-1 block is a novel technique used to achieve postoperative analgesia for knee and below knee surgeries. This study aimed to compare between the three regional techniques ultrasound guided; 4-in-1 block, femoral nerve block (FNB), adductor canal block (ACB) following total knee replacement (TKR) surgeries as regard pain scores, opioid consumption, quadriceps muscle strength and early ambulation. Pain scores measured using Visual Analogue Scale VAS score at intervals (2 h, 4 h, 8 h, 12 h ,16 h and 24 h) postoperatively, showed lower scores in patients received 4-in-1 block compared to patients received FNB or ACB. 4-in-1 block group; 0 (0-1), 0 (0-1), 1 (1-2), 3 (2-3), 3 (3-4), 3 (3-4) versus FNB group; 1 (0-1), 2 (1-3), 3 (2-4), 3 (3-3), 3 (3-4), 4 (3-4) versus ACB group; 1 (0-1), 2 (2-3), 3 (3-3.75), 3 (3-3), 3 (3-3), 4 (3-4) with a p-value 0.16, <0.001, <0.001, 0.003, 0.67, 0.19. Also, as regard to the cumulative Nalbuphine consumption in the first 24 hours postoperatively; the 4-in-1 block group showed less Nalbuphine consumption compared to FNB and ACB groups (7.6 ± 5.1 for 4-in-1 block group versus 11.9 ± 5.3 for FNB group versus 11.8 ± 9 for ACB group with a p-value of 0.018). Quadriceps muscle strength and early ambulation assessed using Straight Leg Raise (SLR) test and Timed Up-and-Go (TUG) test 24 hours postoperative. SLR test percentages are significantly higher in 4-in-1 block and ACB groups compared to FNB group