patients able to get up and move, and how much pain are they hav-
ing? Do they need supplemental blocks? I think it's an evolving ques-
tion that the literature is still teasing out."
There is new thinking in regional anesthesia with the potential to
move the needle:
• Periarticular injections. For total knees, a periarticular injection
combined with an adductor canal block allows for a very rapid dis-
charge and controls pain safely, says orthopedic surgeon R. Michael
Meneghini, MD, director of the Indiana University Hip and Knee
Center.
"The combination has really improved our ability to get patients out
of the hospital quickly or to do them in a surgery center," he says.
The periarticular injection, directed at the local peripheral nerves
around the knee, can be a combination of a "pretty inexpensive
dosage of ropivacaine, clonidine and epinephrine that has really been
shown to improve pain scores in multiple studies," says Dr.
Meneghini, who adds that Exparel (liposomal bupivacaine), on the
other hand, significantly increases costs without having a commensu-
rate effect on pain.
• Adductor canal blocks. These blocks are increasingly preferred
over femoral blocks for total knees because they allow for greater
mobility after surgery. "They don't shut down your quadricep strength
the way femoral blocks do," says Dr. Meneghini, "but you still have to
pay attention, because they can have proximal spread and produce
quad weakness. Patients can still be at a risk for falls."
Stavros G. Memtsoudis, MD, PhD, FCCP, echoes both the enthusi-
asm and the concern. With adductor canal blocks, "care needs to be
taken to limit the volume of anesthetic, so as to not cause inadvertent
upward spread, which can affect femoral nerve fibers and cause
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