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Addition of Periarticular Injection to Adductor Canal and IPACK Blocks Does Not Affect Pain Relief After Total Knee Arthroplasty

In a study conducted by researchers at Hospital for Special Surgery (HSS), the addition of periarticular injection (PAI) of local anesthetic by surgeons did not appear to reduce pain during ambulation after total knee arthroplasty, nor did it reduce opioid use, in patients who underwent a multimodal analgesia protocol that included an adductor canal block (ACB) and Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block. These findings were presented at the 2022 Spring American Society of Regional Anesthesia and Pain Medicine (ASRA) Annual Meeting.1

“If not properly treated, pain after TKA can be severe. Currently, in addition to other analgesic medications (multimodal analgesia), many patients receive two long-lasting nerve blocks (ACB and IPACK) as well as PAI by the surgical staff,” said HSS anesthesiologist Jacques Ya Deau, MD, PhD. “Previous studies have shown that patients with a PAI do better when the nerve blocks are added to their pain management therapy.”

However, “we thought that it may not be necessary to do the PAI, given the theoretically nearly-complete analgesia provided by the two nerve blocks. It's best to avoid unnecessary procedures,” Dr. Ya Deau added.

The researchers randomized 94 patients undergoing primary TKA into either a PAI group or a placebo group. Patients in the PAI group received a deep injection consisting of: 

  • 30 mL of bupivacaine 0.25%, with 1:200,000 epinephrine
  • 8 mg of Morphine
  • 40 mg of Methylprednisolone
  • 500 mg of Cefazolin
  • Normal saline to bring total volume to 64 mL

They also received a superficial injection of 20 mL of bupivacaine, 0.25%.

Both groups received the standardized multimodal analgesia protocol of intraoperative sedation consisting of: 

  • midazolam and propofol
  • a mepivacaine spinal (60 mg)
  • adductor canal block (comprised of 15 mL bupivacaine 0.25%, with 1 mg of preservative-free dexamethasone)
  • IPACK block (comprised of 25 mL bupivacaine 0.25%, with 2 mg of preservative-free dexamethasone)
  • intraoperative ketamine (50 mg)
  • ketorolac (15 mg)

Postsurgical pain relief included:

  • IV ketorolac, followed by oral meloxicam
  • IV, then oral acetaminophen
  • 60 mg of oral duloxetine daily
  • 5-10 mg of oral oxycodone by mouth every 4 hours as needed. Opioids were adjusted according to patient needs. 
  • In the recovery room, IV hydromorphone was available for breakthrough pain. 

The researchers examined numerical rating score (NRS) pain with movement and opioid consumption. They found no significant difference between the PAI and placebo groups. NRS pain with movement the day after surgery in the ACB/IPACK/No PAI group was noninferior to the ACB/IPACK/PAI group, and there was no significant difference in cumulative opioid consumption from the PACU to postop day 2 between the groups. 

These results indicate that PAI may not provide a benefit in patients undergoing TKA with a multimodal pain relief plan that already includes ACB and IPACK blocks. “In the context of multimodal analgesia, the two nerve blocks provided excellent pain relief. There was no additional benefit from adding a PAI,” Dr. Ya Deau said. 

The researchers noted that these results may not be generalizable to different surgeries or to patients with different underlying conditions or baseline characteristics. 

Dr. Ya Deau added that looking towards future research, it is important to investigate how to improve pain relief after the nerve blocks wear off a few days after surgery.

“Currently, most TKA patients have excellent pain relief during the first few days. This is the acute pain phase, when otherwise pain would be most severe,” Dr. Ya Deau said. “Unfortunately, some of these patients have more pain than is desirable once discharged. We need to continue trying to improve pain management on days 3-14 after surgery,” he concluded.


1. Justas Lauzadis, PhD; Douglas Padgett, MD; Geoffrey Westrich, MD; Ejiro Gbaje, MPH; Fred Cushner, MD; Richard L. Kahn, MD; Yi Li n, MD; Enrique A. Goytizolo, MD; David J Mayman, MD; David H. Kim, MD; Kethy M. Jules Elysee, MD; Jacques T. YaDeau , MD, PhD. “Does Periarticular Injection reduce pain after knee arthroplasty among patients receiving peripheral nerve blocks?” Presented at: 47th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), March 31-April 2, 2021; Las Vegas, NV.

About HSS

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 14th consecutive year), No. 2 in rheumatology by U.S. News & World Report (2023-2024), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2023-2024). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a fourth consecutive year (2023). Founded in 1863, the Hospital has the lowest readmission rates in the nation for orthopedics, and among the lowest infection and complication rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. In addition, more than 200 HSS clinical investigators are working to improve patient outcomes through better ways to prevent, diagnose, and treat orthopedic, rheumatic and musculoskeletal diseases. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 165 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.