The management of postoperative analgesia in total knee arthroplasty (TKA) has undergone significant advancements. A variety of nerve blocks, including femoral nerve block (FNB) and combined femoral-tibial block (FTB), have been studied for their efficacy in pain relief and functional outcomes. This review highlights key findings from recent studies and meta-analyses in this field.

Continuous Femoral Infusion and Peripheral Nerve Blocks

Jaques et al. (2001) demonstrated the effectiveness of continuous femoral infusion (CFI), showing a 74% reduction in morphine use compared to patient-controlled analgesia (PCA) and better recovery outcomes. CFI was also associated with a 72% reduction in postoperative bleeding and improved rehabilitation measures​. Similarly, Davies et al. (2004) found that combining femoral and sciatic nerve blocks achieved comparable results to epidural analgesia, with lower visual analog scale (VAS) scores and equivalent perioperative blood loss​.

Comparative Analyses of Nerve Blocks

Morin et al. (2005) explored the efficacy of continuous femoral nerve blocks (FNB), femoral-sciatic combinations, and continuous psoas compartment blocks, finding that the femoral-sciatic combination reduced analgesic requirements without improving long-term outcomes. Richman et al. (2006) corroborated these findings, noting that perineural analgesia outperformed opioids across all measured parameters, including VAS scores and opioid-related side effects​.

Combined Nerve Block Techniques

Studies like Hunt (2009) and Zorrilla-Vaca (2018) emphasized the benefits of combining femoral and sciatic nerve blocks. Hunt observed lower morphine consumption and better pain scores in patients receiving these combined blocks​. Zorrilla-Vaca’s meta-analysis supported the combined use of sciatic and femoral nerve blocks as an optimal strategy for reducing postoperative pain and opioid consumption​.

Innovations in Sciatic and Tibial Nerve Blocks

Sanjay Sinha (2012) compared sciatic nerve blocks with selective tibial nerve blocks, concluding that tibial nerve blocks minimized motor block complications while maintaining effective analgesia. Germain et al. (2012) and Faiz (2017) further refined techniques for sciatic nerve blocks, showing superior outcomes with caudal injections near the tibial nerve​.

Meta-Analytic Evidence and Clinical Trials

Chan et al. (2014) and Gerrard et al. (2017) conducted comprehensive meta-analyses on the role of FNB. Both studies highlighted the effectiveness of FNB over PCA and epidural analgesia, with lower rates of complications like nausea and urinary retention​. Moreover, Gerrard’s analysis suggested adductor canal blocks as a viable alternative to FNB with equivalent analgesic benefits​.

Study Methodology:

The aim of this study was to compare the effects of Femoral Nerve Block with Combined Femoral and selective Tibial Nerve Block for postoperative analgesia in Total Knee Arthroplasty under ultrasound guidance.

Study Site:

This study was conducted in the Department of Anaesthesiology at Yashoda Superspeciality hospital, Secunderabad over a period from August 2017 to April 2018 after obtaining approval from the ethical clearance committee.

Study Population

A total of 60 patients belonging to ASA grade I, II and III randomly allocated to group I (Femoral group) & Group II (Femoral + Tibial nerve group) of 30 each undergoing elective total knee replacements under spinal block were studied.

Study Design

A prospective, double-blind, randomized, controlled study

Randomization

A computer-generated random number list was used to randomize patients into 2 groups: Group I was given Femoral Nerve block and Group II was given Femoral and tibial nerve block after giving spinal anaesthesia.

Allocation

Group allocation was concealed.

Blinding

Blinding was done at two levels. Neither the patient nor the investigator assessing the patient post-operatively knew which drug the patient was getting.

Sample Size

As we were unable to find relevant previous studies with required statistical data to calculate sample size, we decided to conduct a pilot study after obtaining ethical committee clearance.

The 20 patients were divided into group I (Femoral group) & Group II (Femoral + Tibial nerve group). We performed femoral block on them after TKA. Demographic data were recorded in 53 both study groups with age, sex, weight, height. We calculated the sample size, based on the mean duration of sensory block in both groups. The results obtained from Pilot Study were extrapolated to find out the Optimum Sample Size of the study using the following formula

Where alpha= 1.9608

Where (1-aplha) ( beta ) = 0.8416

sd1=std. dev of group 1

sd2=std. dev of group 2

μ1=mean of group 1

μ2=mean of group 2

Based on the results of the Pilot Study and after discussion with a Biostatistician, the sample size with a 95% Confidence Interval was found out to be 14. We decided to take 60 patients as sample size to account for drop outs and because TKA is a very routinely performed surgery in our institute. It was decided in consultation with a statistician. 60 patients were included in Study with 30 patients receiving femoral nerve Block and the other 30 patients receiving combined femoral nerve Block with Selective Tibial Nerve Block.

Inclusion criteria: -

Patients who are

• Adult subjects with ASA grade I – III.
• Age between 18-70 years.
• Weighing between 40-85kgs.
• Patients who are competent to understand the study protocol and provide voluntary, written informed consent.

Exclusion Criteria:-

• Patients will be excluded if they are
• ASA IV,V
• Younger than 18yrs
• Age more than 70 yrs.
• BMI >35kg/m2.
• Inability to provide informed consent.
• Cognitive or psychiatric history that may interfere in assessment
• Refusal of spinal, femoral or tibial nerve blocks.
• Pre-existing Neuropathy or Neurological deficit.
• Pre-existing chronic pain conditions requiring use of analgesics daily.
• Local site infection.
• Patients with coagulation disorder / bleeding diathesis.
• Pregnant or lactating mother.

 Patients with history of potential for adverse reactions to Local Anesthetic or Steroid.

Pre an aesthetic evaluation

A Pre-anaesthetic evaluation comprising of history of previous medical and surgical illnesses, previous anaesthetic exposures, drug allergies, and baseline airway examination was done.

Investigations

The following investigation will be done:

1. Blood investigations: Hemoglobin %, BT, CT, blood sugar, blood group and cross matching.
2. ECG and Chest x-ray PA view depending on the age & associated co- morbidities.

Preliminaries

1. Written informed consent
2. Premedication was standardized with Tab Pantoprazole 40mg PO night before surgery and 2 hours before surgery, Tab Ondansetron 4mg PO night before surgery and 2 hours before surgery and Tab Alprazolam 0.5mg PO night before surgery. Patients were kept nil by mouth for at least 6 hours prior to surgery.
3. Intravenous access – starting of an intravenous line with 20G intravenous cannula under aseptic techniques.

Preoperative vital parameters in the form of baseline pulse, blood pressure and oxygen saturation were recorded. Patients were explained the procedure of spinal anaesthesia, selective tibial nerve block and continuous femoral nerve block for postoperative pain control at the time of pre anaesthetic evaluation and instructed about the numeric rating scale and informed consent obtained. Patient is then taken inside the operation theatre.

Pre-medication

Injection midazolam 1- 2mg and/or up to 100 μg of intravenous fentanyl titrated to maintain constant verbal communication with the patient.

Monitoring

Pulse oximetry, Non-invasive blood pressure monitor, respiratory rate, electrocardiography.

Procedure

After obtaining informed written consent and institutional approval, adult patients of both gender, between ages of 18-70years, ASA grade –I, II, III will be selected. After taking history, physical examination and all routine investigations will be done. Before performing the procedure routine monitors like pulse oximetry, non invasive blood pressure, electrocardiogram will be attached. All observations will be carried out by a single investigator who will be also blinded to the treatment group. Spinal anesthesia with 0.5%

Bupivacaine (heavy) will be given in subarachnoid space after free flow of CSF present.

In group 1, an ultrasound guided femoral canal block (FCB) will be performed after surgery in post anesthesia care unit(PACU).The femoral canal block will be performed in supine position with the limb rotated externally. Landmarks will be identified. The femoral nerve is located just below the inguinal ligament in upper medial portion of thigh. Locate the anterior superior iliac spine and the pubic tubercle. A line between these two structures is where the inguinal ligament is located. Next locate the pulsation of the femoral artery. The site for needle insertion is approximately 2 cm lateral to the pulsation. From medial to lateral the structures are femoral vein, femoral artery, and femoral nerve .An 10-12 MHz transducer probe placed in transverse orientation to visualize the femoral artery in short axis deep to the Sartorius muscle .Under aseptic precautions, the skin will be infiltrated with 2-3 ml of 2% lignocaine with a 26G 1⁄2 inch hypodermic needle. The block will be performed in plane to the ultrasound beam with Contiplex needle to position needle tip anterolateral to the artery and just deep to posterior fascia of Sartorius muscles, whenever necessary 0.5-1 ml of D5W(dextrose 5% in water) will be used for hydro location of needle tip. Once in position a total volume of 10 ml of 0.75% ropivacaine will be deposited adjacent to femoral artery and deep Sartorius muscle with intermittent aspiration. Contiplex catheter will be fixed at 10 cms.

After completion of procedure, a sterile dressing will be placed over insertion site. Post op infusion of 0.2% ropivacaine 5-6 ml/hr. will be continued for 3 days.

In group 2, after the spinal anesthesia, the patients were positioned in the lateral decubitus position with the operative leg nondependent. Using sterile prep and sheath, a 13 to 6 MHz linear transducer (HFL38, Sonosite TM, and Bothell, WA) was placed at the popliteal crease to visualize the popliteal vessels in short axis, and the tibial nerve was visualized as a hyperechoic oval structure posterior to the popliteal vessels. Following the tibial nerve cephalad, the convergence of the common peroneal nerve and tibial nerve was identified .The block needle was advanced in a medial to anterolateral direction toward the target nerve using an in-plane approach. Inject sufficient ropivacaine 0.75% to encircle the target nerve, up to 10 ml. The block needle position was adjusted, if necessary, to achieve circumneural spread of the local anaesthetic. After the surgery in the post anesthesia care unit (PACU), as described in group 1, Contiplex femoral nerve catheter is fixed at 10 cms. Subsequently, the catheter was injected incrementally with 10 mL of ropivacaine 0.75%. Post op femoral catheter infusion of 0.2% ropivacine 5-6 ml/hr will be continued for 3 days.

Methods of measurement of Outcomes of interest

Patient demographic data was recorded in both groups. Age, weight, height, time for first request of analgesics, cumulative opioid requirement for 24hrs duration, post-operative pain relief by NRS score, motor blockade by MBS score at PACU, 6 hrs,12 hrs,18 hrs, 24 hrs, first request, complications.

After the block is administered, a pain nurse who had undergone prior education in assessment of sensory and motor anesthesia and who is unaware of group assignment will collect data on each patient.

Study Parameters:

• Time for first request of analgesics is the duration after the block when the patient first complains of pain and requests for analgesics. It is determined in minutes after block.
• Cumulative opioid requirement is the total amount of fentanyl in micrograms administered to the patient in 24hrs duration.
• The postoperative pain was assessed a using 0-10 numerical rating scale (NRS). The NRS scores were assessed at PACU, 6hrs, 12hrs, 18hrs, 24hrs, and first request by a blinded investigator. Patients rate their pain on 0-10 NRS pain scale.

Fig - NRS Scale ¹⁰²

• Motor blockade was tested using MODIFIED BROMAGE SCALE (MBS). The MBS scores were assessed at PACU, 6hrs, 12 hrs, 18 hrs, 24 hrs, and first request.

Fig Modified Bromage Scale¹⁰³

• Complications – Foot drop is the complication of interest which occurs due to proximal spread of local anesthetic and blockade of common peroneal nerve. Patients were observed for any discomfort, nausea, vomiting, shivering, bradycardia, pain and other side effects.
• Totally effective/no analgesia- when there is no need of supplementation / analgesia.

Outcome Measures

The following parameters were studied in both the groups.

1. Time for first request of analgesics.
2. Post-operative pain relief by NRS score.
3. Motor blockade by MBS score.
4. Cumulative Fentanyl requirement.
5. Complications- Number of patients having foot drop.

• Results were expressed as mean±SD.
• Demographic and haemodynamic data were subjected to statistical analysis by using two sample t-tests.
• P-value <0.05 was considered statistically significant.

Statistical Methods

The following methods of statistical analysis have been used in this study. Data were

expressed as mean values ± standard deviation/ standard error, percentages (%), and

numbers (n). The statistical analysis was performed by a statistician using Windostat

Version 9.2 in Hyderabad; Telangana. Significance is assessed at 5 % level of

significance. Significance levels (ascending order): p<0.05.

1. The student ‘t’ test was used to determine whether there was a statistical difference

between two treatments groups in the parameters measured.

2. One way Analysis of Variance (Anova):

Differences in parameters such as demographic data, time to 1st request of analgesia, NRS score, cumulative opioid requirement and adverse effects over time were analysed using ANOVA (analysis of variance)

In the entire above test, the “p” value of less than 0.05 was accepted as indicating

statistical significance. Data analysis was carried out using MS EXCEL and Statistical Package for Social Science (SPSS) package software. 

Sixty patients were included in this study and were randomized into two groups of thirty patients each.

GROUP I – FEMORAL GROUP

GROUP II – FEMORAL + TIBIAL NERVE GROUP

In the group I the age of the patients selected for the study ranged between 47-68 years with a mean age of 58.50 and a standard deviation of 5.82. In the group II the age of the patients ranged between 44 – 74 years with a mean age of 61.46 and a standard deviation of 7.63. The difference of proportion of subjects observed between the study groups with

respect to age was not statistically significant.

In the group I the mean height of 165.30 cms and a standard deviation of 6.19 and in the group II the mean height of 162.53 cms with a standard deviation of 7.87 was seen. The difference of proportion of subjects observed between the study groups with respect to height was statistically not significant.

In the group I the mean body weight was 68.90 and a standard deviation of 10.6. In the group II mean body weight was 68.73 and a standard deviation of 12.14. The difference of proportion of subjects observed between the study groups with respect to weight was not statistically significant.

60 patients of either the sex participated in the study. Femoral group has 17 males and 13 females while Femoral + Tibial group has 16 males and 14 females. Both groups were statistically insignificant. Comparison of time to 1st request of Analgesia in the two groups:

In group I, mean value was 958.33 with a standard deviation of 4.81 and in group II the mean value was 1556.03 with a standard deviation of 6.61, p value was 0.000 and it was statistically significant.

Comparison of postoperative NRS scores in the two groups:

At PACU, the mean NRS pain scores were 0.467with a standard deviation of 0.629 in group I and 0.300 with a standard deviation of 0.466 in group II. The difference in the two groups was statistically not significant (p value =0.140).

At the end of 6 hrs, the mean NRS pain scores were 0.621with a standard deviation of 0.622in group I and 0.500 with a standard deviation of 0.509in group II. The difference in the two groups was statistically not significant (p value =0.207).

At the end of 12 hrs, the mean NRS pain scores were 1.800with a standard deviation of 0.761 in group I and 0.833with a standard deviation of 0.461 in group II and the difference in the two groups was statistically significant (p value =0.000).

At the end of 18hrs, the mean NRS pain scores were 4.533with a standard deviation of 0.629 in group I and 1.700with a standard deviation of 0.466in group II and there was statistically significant difference between the groups (p value =0.000).

At the end of 24 hrs, the mean NRS pain scores were 3.700with a standard deviation of 0.702 in group I and 3.333with a standard deviation of 0.479 in group II. The difference in the two groups was statistically not significant (p value =0.065).

At the time of 1st request, the mean NRS pain scores were 4.533 with a standard deviation of 0.629 in group I and 4.333 with a standard deviation of 0.479 in group II. The difference in the two groups was statistically not significant (p value =0.266).

Comparison of postoperative NRS pain Scores in 24 hours Duration

Comparison of postoperative NRS Score at Various time Intervals in both Groups

Distribution of postoperative NRS Score over time in both Groups

Comparison of Cumulative opioid (Fentanyl) requirement in the two groups for 24 hours duration:

In group I, mean value was 154.000with a SD of 26.077 and in group II the mean value was 123.333with a SD of 18.257, p value was 0.000and it was statistically significant but clinically not much difference was noted.

Comparison of postoperative MBS scores in the two groups:

Modified Bromage Scores were found statistically significant at 6 hours and 12 hours post operatively. At the end of 6 hrs, the mean MBS scores were 5.700with a standard deviation of 0.466 in group Femoral and 2.600 with a standard deviation of 1.404 in group Femoral+Tibial. The difference in the two groups was statistically significant (p value =0.000).

At the end of 12 hrs, the mean MBS scores were 6.000 with a standard deviation of 0.000 in group Femoral and 5.367with a standard deviation of 0.890 in group Femoral+Tibial. The difference in the two groups was statistically significant (p value =0.000).

Comparison of postoperative MBS in 24 Hour Duration:

Comparison of postoperative MBS at Various time intervals in both Groups:

Quantity degree of MBS in relation to number of cases in both groups at 6hrs &12hrs

In PACU, the MBS scores were 1/6 for all patients in both groups. At 6 hrs, 21(70%) patients had a MBS score of 6/6 and 9 patients had a score of 5/6 in Femoral group whereas in Femoral +Tibial group, 13 patients had a score of 4/6, 4 patients had a score of 3/6, 1 patient had a score of 2/6, 12 patients had a score of 1/6. 

At 12 hrs, in femoral group, all 30 patients had a MBS score of 6/6 where as in femoral+ tibial group, 18(60%) patients had a score of 6/6. At 18 hrs, 24 hrs, 1st request, MBS score was 6/6 for all patients in both groups.

Duration of motor blockade:

In Femoral group: 70 % of patients recovered from motor blockade by 6 hrs. 100 % patients recovered from motor blockade by 12 hrs.

In Femoral + Tibial group: 60 % of patients recovered from motor blockade by 12 hrs. 100 % patients recovered from motor blockade by 18 hrs.

Pie diagram showing complications in both groups

The duration of analgesia was considered till the time to first request of Analgesia. In our study it was shown that the mean time for first request of analgesic was 958.33 mins with a standard deviation of 4.81 in Femoral group and in 1556.03 mins with a standard deviation of 6.61in Femoral+Tibial nerve group, which was statistically significant( p = 0.000).

Femoral in addition with Selective Tibial nerve block provided longer duration of analgesia compared to femoral block. The mean Cumulative opioid (Fentanyl) requirement in group I was 154.000with a SD of 26.077 micrograms and in group II the mean value was 123.333 micrograms with a SD of 18.257, which was statistically significant (p = 0.000).There was significant reduction in Intravenous Fentanyl requirement in Femoral +Tibial nerve group than the Femoral group.

The assessment of pain was done using NRS scores in both the groups. The mean postoperative NRS scores for 24 hrs time duration in group I was 2.606 with a standard deviation of 0.138 whereas in group II was 1.833 with a standard deviation of 0.118. NRS scores were statistically significant at the end of 12 hrs and 18 hrs where the p-value is 0.000.This proves that better pain control was achieved with Femoral+Tibial nerve group than with femoral group.

The motor blockade assessment was done by MBS score in both the groups. The mean postoperative MBS scores for 24 hrs time duration in group I was 5.117 with a standard deviation of 0.139 whereas in group II was 4.494 with a standard deviation of 0.156.MBS scores were statistically significant at the end of 6 hrs and 12 hrs where the p-value is 0.000.This proves that early ambulation was achieved with Femoral nerve group than with Femoral + Tibial nerve group.

Complications

13 patients out of total 30 patients in Femoral + Tibial nerve group developed Foot drop, presumably due to proximal spread of local anaesthetic.

Pain is the most unpleasant, undesired and unfortunately an inevitable companion to most surgeries. Inadequate control of postoperative pain leads to several adverse events ranging from patient’s discomfort, prolonged immobilization and pulmonary complications.

Total knee arthroplasty (TKA) is a common surgery to help improve mobility and quality of  life. The pain after TKA is severe and does not fade noticeably for 48–72 h after the surgery.¹⁰⁴ Effective pain control allows for earlier ambulation and initiation of physiotherapy, which hastens recovery, reduces the length of stay in the hospital, and lowers the risk of postoperative complications, such as thromboembolic disease or nosocomial infections.^{105, 106}

Patient-controlled analgesia (PCA) - opioids and epidural and femoral nerve block (FNB) are commonly used analgesic options for TKA. PCA- morphine or other opioids are frequently used as the primary analgesic for TKA. The use of opioids is associated with side effects such as nausea, vomiting, pruritus, and sedation.107These side effects can have negative effects on patient comfort and safety as well as delaying the start of physiotherapy, which will negatively impact functional rehabilitation. 108 Lumbar epidural analgesia is another common method of analgesia for TKA, and some physicians state that it provides better pain relief than other postoperative analgesic options.¹⁰⁵ There are, however, many adverse effects associated with epidural analgesia, including significant perioperative hypotension, urinary retention, pruritus, and respiratory depression.^{105, 109, 110}

In addition, sensation and ambulation are affected in the non-operative leg. These adverse effects may limit the early initiation of physiotherapy after TKA. The use of epidural analgesia may interfere with the commencement of anticoagulation therapy to prevent thromboembolic events due to the risk of epidural hematoma. Without the use of anticoagulant prophylaxis, knee replacements are associated with a 40–70% risk of deep vein thrombosis and 1–2% risk of fatal pulmonary embolism.¹⁰⁵

Peripheral nerve blocks for total knee arthroplasty (TKA) are effective for postoperative pain management and may hasten the recovery process. ¹¹¹There are a number of regional techniques that have been used for TKA. FNB is a common method of analgesia for postoperative pain control after TKA. FNB does not provide a motor blockade to the non-operative leg, which may encourage earlier ambulation. The femoral nerve alone only provides sensation to the anteromedial aspect of the knee, whereas the sciatic nerve innervates the posterior aspect of the knee. A combination of the femoral nerve (FN) block and sciatic nerve (SN) block is an accepted technique for the postoperative pain management after TKA. Although the evidence for adding the SN block to FN block is controversial, it is commonly performed for TKA in many institutions.^{12, 21, 112, 113, 114} Addition of the SN block may provide superior analgesia but can produce foot-drop or weakness of the tibialis anterior muscle due to blockade of the common peroneal nerve (CPN), which may mask surgically induced CPN injury.22 Potential risk factors for CPN injury include severe valgus deformity, pre-existing neuropathy, rheumatoid arthritis, prolonged tourniquet time, and constrictive dressings. However, no single risk factor has been consistently shown to be associated with CPN.

The present study a prospective, randomized controlled, double blinded study comparing the effects of femoral nerve block with combined femoral and selective tibial nerve block for postoperative analgesia was carried out in patients undergoing Total Knee Arthroplasty at Yashoda Hospitals–Secunderabad. It was prospective, randomized and comparative study. The study included total 60 patients belonging to ASA I, II, III posted for Total Knee arthroplasty.

Sample size was decided based on a pilot study after Ethical Committee clearance and in consultation with a statistician. A computer-generated random number list was used to randomize patients into two groups. Both the groups, after giving spinal anaesthesia were divided into two groups.

GROUP FEMORAL: Femoral nerve blockade with 10 ml of 0.75% Ropivacaine in PACU followed by continuous femoral catheter infusion with 0.2% Ropivacaine at a rate of 5-6ml/hr for 3 days.

GROUP FEMORAL + TIBIAL: Selective Tibial nerve blockade with 10 ml of 0.75% Ropivacaine before surgery followed by femoral nerve blockade in PACU with 10 ml of 0.75% Ropivacaine followed by continuous femoral catheter infusion with 0.2% Ropivacaine at a rate of 5-6 ml/hr for 3 days.

Hypothesis

The study hypothesized that combining femoral and selective tibial nerve blocks as part of a multimodal analgesic regimen, compared to using a femoral nerve block alone under ultrasound guidance, would improve postoperative analgesia for total knee arthroplasty (TKA).

Study Comparisons and Outcomes

Both groups were similar in demographic parameters such as age (58.50 ± 5.82 vs. 61.46 ± 7.63 years), height (165.30 ± 6.19 cm vs. 162.53 ± 7.87 cm), weight (68.90 ± 10.6 kg vs. 68.73 ± 12.14 kg), and sex distribution (17/13 vs. 16/14), with no statistically significant differences.

Duration of Analgesia

The time until the first request for rescue analgesics, indicating the duration of pain relief, was significantly longer in the femoral + tibial group (1556.03 ± 6.61 minutes) compared to the femoral group (958.33 ± 4.81 minutes). This highlights a prolonged pain-free period in the combined nerve block group.

Studies by Faraj W. Abdallah and others support these findings, showing that blocking the sciatic nerve at the distal level (popliteal fossa) extends analgesic duration.

Postoperative Pain Relief

Pain was assessed using NRS scores. The femoral + tibial group exhibited significantly lower pain scores (mean NRS: 1.833) compared to the femoral group (mean NRS: 2.606) within the first 24 hours. The differences were particularly significant at 12 and 18 hours post-surgery. Similar results were reported by studies such as those by Davies AF, which highlighted the superiority of combined nerve blocks over epidural analgesia.

Motor Blockade

Motor recovery, assessed via the Modified Bromage Score (MBS), revealed earlier ambulation in the femoral group compared to the femoral + tibial group. By 6 hours, 70% of patients in the femoral group had recovered, with full recovery by 12 hours. In contrast, 60% of the femoral + tibial group recovered by 12 hours, and all by 18 hours. This indicates a delay in motor recovery associated with the addition of tibial nerve block.

Opioid Requirement

Cumulative opioid use was significantly lower in the femoral + tibial group (123.33 ± 18.257 µg) than the femoral group (154.000 ± 26.077 µg). Although statistically significant, the clinical difference was minimal. Previous research, such as that by Hunt KJ and Zorrilla-Vaca A, supports the efficacy of combining sciatic and femoral nerve blocks in reducing opioid consumption.

Complications

No complications were observed in the femoral group, whereas 13 patients in the femoral + tibial group developed foot drop, likely due to proximal anesthetic spread affecting the common peroneal nerve. Studies by Sanjay K. Sinha and Eric R. Silverman suggest that modifying the tibial nerve block technique can mitigate these risks.

Summary

The combined femoral and selective tibial nerve block provides superior analgesia but delays motor recovery and increases the risk of complications such as foot drop. While effective, its use should be weighed against the potential for motor impairment and tailored to individual patient needs.

There was no significant difference in both the groups with respect to demographic data (age, weight, height, gender)

We conclude that Combined Femoral and Selective Tibial nerve block provides better quality of postoperative analgesia compared with femoral block in patients undergoing Total Knee Arthroplasty. However, the higher incidence of motor weakness may be a hindrance for early ambulation & physiotherapy.

1. Adding a selective tibial nerve block to a femoral block enhances the quality and prolongs the duration of analgesia following total knee arthroplasty (TKA). However, due to the higher risk of motor weakness associated with tibial nerve blocks, continuous femoral nerve block alone is recommended for postoperative pain management in TKA.
2. A continuous femoral nerve block using 0.2% ropivacaine effectively provides adequate pain relief, maintaining pain scores within the mild to moderate range throughout the study period without causing motor weakness.
3. Continuous femoral nerve block is associated with fewer complications and side effects compared to other analgesic techniques. Over time, combining femoral and selective tibial nerve blocks may become a valuable method for postoperative pain relief in knee surgeries.
4. The failure rate of combined femoral and selective tibial nerve blocks can be significantly reduced with the use of ultrasound guidance.
5. Performing combined femoral and selective tibial nerve blocks is straightforward, and it is recommended that all anesthesiologists receive proper training in performing continuous femoral nerve blocks.

An assessment of postoperative physiotherapy goals was not done.

However, in our study we found that high quality analgesia may prevent early ambulation after Total knee arthroplasty. Mean duration of motor blockade was not observed.

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