Concept: Femoral nerve
Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.
BACKGROUND: /st>Our aim was to estimate the ED(95) of prilocaine 1% w/v for femoral nerve block. METHODS: /st>This two-stage dose-finding sequential clinical trial followed an adaptive design based on the continual reassessment method (CRM). Adult patients undergoing Vastus medialis muscle biopsy under ultrasound-guided femoral nerve block were recruited. Data from previously published studies and our own previous experience were used to set the dose levels and their guesstimate probabilities of response. RESULTS: /st>Forty patients were recruited in the trial (n=26 in the first stage and n=14 in the second stage). Using the CRM, the estimated response probabilities with 13 and 17 ml prilocaine 1% w/v were 90.4% (95% credibility interval: 68-98%) and 99.1% (95% credibility interval: 89-100%), respectively. CONCLUSION: /st>Our study demonstrates that the dose closest to the ED(95) of prilocaine 1% w/v for ultrasound-guided femoral nerve block is 17 ml. The study also illustrates the value of CRM in dose-finding experiments.
Hip fracture is the most common orthopaedic emergency. We investigated the concentration of 30 ml levobupivacaine that provided analgesia to 50% and 95% of patients with a hip fracture when injected around the femoral nerve under ultrasound guidance. We defined analgesia as a ≥ 20-point decrease on a 100-point pain scale with reduced cold sensation in the middle third of the anterior thigh 30 min after the nerve block. We increased the concentration of levobupivacaine if the preceding dose had been ineffective and decreased it if the preceding dose had been effective. Probit regression modelling estimated the effective (95% CI) concentration of 30 ml levobupivacaine in 50% and 95% of patients with a fractured hip to be 0.026 (0.023-0.028)% w/v and 0.036 (0.027-0.047)% w/v, respectively.
This report describes a rare case of femoral nerve paresthesia caused by an acetabular paralabral cyst of the hip joint. A 68-year-old woman presented with a 6-month history of right hip pain and paresthesia along the anterior thigh and radiating down to the anterior aspect of the knee. Radiography showed osteoarthritis with a narrowed joint space in the right hip joint. Magnetic resonance imaging showed a cyst with low T1- and high T2-weighted signal intensity arising from a labral tear at the anterior aspect of the acetabulum. The cyst was connected to the joint space and displaced the femoral nerve to the anteromedial side. The lesion was diagnosed as an acetabular paralabral cyst causing femoral neuropathy. Because the main symptom was femoral nerve paresthesia and the patient desired a less invasive procedure, arthroscopic labral repair was performed to stop synovial fluid flow to the paralabral cyst that was causing the femoral nerve paresthesia. After surgery, the cyst and femoral nerve paresthesia disappeared. At the 18-month follow-up, the patient had no recurrence. There have been several reports of neurovascular compression caused by the cyst around the hip joint. To the authors' knowledge, only 3 cases of acetabular paralabral cysts causing sciatica have been reported. The current patient appears to represent a rare case of an acetabular paralabral cyst causing femoral nerve paresthesia. The authors suggest that arthroscopic labral repair for an acetabular paralabral cyst causing neuropathy can be an option for patients who desire a less invasive procedure.
Total knee arthroplasty (TKA) is a common procedure resulting in significant post-operative pain. Percutaneous cryoneurolysis targeting the infrapatellar branch of the saphenous nerve and anterior femoral cutaneous nerve could relieve post-operative knee pain by temporarily blocking sensory nerve conduction.
Hip and femoral neck fractures are common in elderly patients, who are at an increased risk of complications if their pain is suboptimally managed. This systematic review seeks to determine if regional nerve blocks reduce pain, reduce the need for parenteral opiates, and reduce complications, compared to standard pain management with opiates, acetaminophen, or NSAIDs. Data sources Systematic review of MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials found 401 articles, of which nine were selected for inclusion. Study selection Randomized controlled trials including adult patients with a hip or femoral neck fracture (Population) who had a 3-in-1 femoral nerve block, traditional femoral nerve block, or fascia iliaca compartment block performed preoperatively (Intervention). Comparison must have been made with standard pain management with opiates, acetaminophen, or NSAIDs (Comparison) and outcomes must have included pain score reduction (Outcome). Data synthesis Eight out of nine studies concluded pain scores were improved with the regional nerve block compared to standard pain management. A significant reduction in parenteral opiate use was seen in five out of six studies. No patients suffered life-threatening complications related to the nerve block; however, more minor complications were under-reported. Most of the studies were at a moderate to high risk of bias.
to determine the efficacy of the fascia iliaca block in providing analgesia to patients with a proximal femoral fracture in the emergency department.
Effective analgesia after total knee arthroplasty (TKA) improves patient satisfaction, mobility and expedites discharge. This study assessed whether continuous femoral nerve infusion (CFNI) was superior to a single-shot femoral nerve block in primary TKA surgery completed under subarachnoid blockade including morphine.
Femoral neck fractures are a common and painful injury. Femoral nerve blocks, and a variant of this technique termed the ‘3-in-1’ block, are often used in this patient group, but their effect is variable. The fascia iliaca compartment block (FIB) has been proposed as an alternative, but the relative effectiveness of the two techniques in the early stages of care is unknown. We therefore compared the FIB versus the 3-in-1 block in a randomised trial conducted in two UK emergency departments.
We hypothesized that exercise performance is adjusted during repeated sprints in order to not surpass a critical threshold of peripheral fatigue. Twelve men randomly performed three experimental sessions on different days: one single 10 s all-out sprint and two trials of 10 × 10 s all-out sprint with 30 s of passive recovery in between. One trial was performed in the unfatigued state (CTRL) and one following electrically-induced quadriceps muscle fatigue (FTNMES). Peripheral fatigue was quantified by comparing pre- to post-exercise changes in potentiated quadriceps twitch force (Δ Qtw-pot) evoked by supramaximal magnetic stimulation of the femoral nerve. Central fatigue was estimated by comparing pre- to post-exercise voluntary activation of quadriceps motor units. The RMS of the vastus lateralis and vastus medialis EMG normalized by maximal M-wave amplitude (RMS.Mmax(-1)) was also calculated during sprints. Compared to CTRL, pre-existing quadriceps muscle fatigue in FTNMES (Δ Qtw-pot = - 29 ± 4%) resulted in a significant (P < 0.05) reduction in power output (- 4.0 ± 0.9%) associated with a reduction in RMS.Mmax-1. However, Δ Qtw-pot post-sprints decreased by 51% in both conditions indicating that the level of peripheral fatigue was identical, and independent of the degree of pre-existing fatigue. Our findings showed that power output and cycling EMG are adjusted during exercise for the purpose of limiting the development of peripheral fatigue beyond a constant threshold. We hypothesized that the contribution of peripheral fatigue to exercise limitation involves a reduction in central motor drive in addition to the impairment in muscular function.