JOA - 2026-07-28 - Journal Article
Periarticular Injection Alone Provides Comparable Early Recovery to Combined Adductor Canal and Infiltration between the Popliteal Artery and Capsule of the Knee Blocks Following Total Knee Arthroplasty: A Prospective Randomized Trial.
Schneider AM, Granger C, King J, Riegler V, Bartosiak KA, Bendich I, Barrack RL
Topics
Key Takeaway
PAI alone produced outcomes equivalent to combined ACB+IPACK+PAI in primary TKA, with the only statistically significant difference being a 0.6-point lower VAS on POD1 in the PAI-only group—below the pre-specified 1.0-point threshold for clinical significance.
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Summary
This prospective, patient-blinded RCT randomized 140 primary TKA patients to PAI alone versus ACB+IPACK+PAI, with identical total local anesthetic dose (80 mL 0.25% bupivacaine with epinephrine plus 30 mg ketorolac) across groups. VAS pain, MME opioid consumption, Oxford Knee Score, step counts, and patient satisfaction were monitored daily via remote patient monitoring for 14 postoperative days. No clinically significant between-group differences were identified; the sole statistically significant finding (POD1 VAS 3.3 vs. 3.9, p=0.025) did not meet the pre-specified 1.0-point minimum clinically important difference.
Key Limitation
Follow-up limited to 14 postoperative days, precluding assessment of whether block strategy influences functional recovery milestones such as discharge readiness, 6-week ROM, or return to activity.
Original Abstract
INTRODUCTION
The relative effectiveness of commonly used regional anesthesia techniques, including adductor canal block (ACB) and infiltration between the popliteal artery and capsule of the knee (IPACK), compared with periarticular injection (PAI) alone in total knee arthroplasty (TKA) remains unclear.
MATERIALS AND METHODS
In this prospective, randomized, patient-blinded trial, 140 patients undergoing primary TKA were randomized to receive either preoperative regional blocks (ACB plus IPACK) combined with intraoperative PAI (n = 70) or intraoperative PAI alone (n = 70). All patients received an identical total dose and composition of local anesthetic (80 mL of 0.25% bupivacaine with epinephrine and 30 mg ketorolac). Daily remote patient monitoring was performed for two weeks preoperatively and two weeks postoperatively to assess visual analog scale (VAS) pain scores, opioid consumption (morphine milligram equivalents [MME]), Oxford Knee Scores (OKS), step counts, and patient satisfaction. Linear mixed models and appropriate comparative tests were used for analysis. An a priori power analysis determined that 70 patients per group were required to detect a VAS pain difference of greater than 1.0.
RESULTS
Pain scores peaked on postoperative day three in both groups and declined thereafter. The PAI-only group reported slightly lower VAS pain on postoperative day 1 (3.3 versus 3.9; mean difference -0.6; P = 0.025), although this difference did not meet the threshold for clinical significance; no other between-group differences were observed. Opioid consumption, OKS, step counts, and patient satisfaction with pain control, activity level, and range of motion were similar between groups throughout the study period.
DISCUSSION
In patients undergoing primary TKA, intraoperative PAI alone produced outcomes comparable to combined ACB plus IPACK and PAI through the first fourteen postoperative days. These Level I findings, captured using high-frequency remote patient monitoring, suggest that routine use of multiple regional blocks may not provide clinically meaningful additional benefit within contemporary multimodal pathways.