The purpose of this study is to compare the analgesic outcomes (time to first analgesic request, total amount of analgesic consumption, and pain scores) following total knee arthroplasty by either combined biceps femoris short head block and adductor canal block or genicular nerve block in elderly patients.
patient acceptance
Physical status: ASA I, II and Ⅲ.
Body mass index (BMI): 18.5 - 35 kg/m2.
Type of operations: total knee arthroplasty.
Known hypersensitivity to dexamethasone or bupivacaine.
Coagulation disorders or taking drugs affect surgical hemostasis.
Patients with pre-existing neurological deficits.
Uncooperative patient or with altered mental status.
Parallel
Combined biceps femoris short head block and adductor canal block
Other interventionAdductor Canal Block high-frequency probe will be placed transversely on the anterior thigh midpoint between inguinal crease and medial condyle (depth 3-5 cm). The needle will be advanced in-plane from lateral to medial through sartorius or vastus medialis muscle toward the femoral artery. Then (10 ml of 0.25% bupivacaine and 2 mg dexamethasone) will be injected after negative aspiration, with confirming spread around the artery without vascular puncture. Biceps femoris short head block The probe will be placed on the distal posterior thigh to visualize biceps femoris muscle near the lateral supracondylar line of the femur. The needle will be inserted to the interface between biceps femoris and femur cortex. Then (25 ml of 0.25% bupivacaine and 2 mg dexamethasone), with observing muscle lift and circumferential spread along the bone surface .
Genicular nerve block
Other interventionPosition the patient will be placed in supine position with the knee slightly flexed via a pillow in the popliteal fossa. Use a high-frequency linear ultrasound transducer. Superolateral genicular nerve (SLGN): the transducer will be placed coronally over lateral femoral epicondyle, with sliding proximally to femur metaphysis; identifying artery between vastus lateralis fascia and bone. Superomedial genicular nerve (SMGN): the transducer will be placed coronally over medial femoral epicondyle, proximal to adductor tubercle at femur metaphysis; artery between vastus medialis fascia and bone. Inferomedial genicular nerve (IMGN): the transducer will be placed coronally over medial tibial condyle, distal to metaphysis; artery beneath medial collateral ligament. • Inferolateral genicular nerve (ILGN, optional): the transducer will be placed coronally over lateral tibial epicondyle to fibula head; artery between collateral ligament and tibia
Time of first rescue analgesia (naluphine)
to the duration from the block to the moment when the patient first requires or requests supplemental nalbuphine due to breakthrough pain
block performance time
time refers to the duration required to prepare, image (e.g., via ultrasound), insert the needle, and inject local anesthetic to complete a regional nerve block procedure.
Pain intensity
10-point NRS \[(0 = no pain, 10 = worst imaginable pain), 1-3: Mild pain (nagging, annoying, slightly interfering with activities of daily living (ADLs), 4 - 6: Moderate pain (significantly interfering with ADLs, 7 - 10: Severe pain (disabling, unable to perform ADLs)
Total amount of rescue analgesia (nalbuphine)
the cumulative dose of nalbuphine administered as supplemental pain relief during a defined postoperative observation period, typically when pain scores exceed a predefined threshold like NRS ≥4
assess functional recovery
(knee range of motion active flexion /extension,
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