Journal of Clinical Anesthesia (2016) 35, 404410

Original Contribution

Postoperative analgesic efcacy of fascia iliaca

block versus periarticular injection for total
knee arthroplasty
Cagla Bali MD (Specialist)a,b,, Ozlem Ozmete MD (Specialist)a,b,1 ,
H. Evren Eker MD (Assoc. Prof)a,b,2 , Murat A. Hersekli MD (Prof)b,c,3 ,
Anis Aribogan MD (Prof)a,b,4
a
Baskent University School of Medicine, Anesthesiology and Reanimation Department, Adana Teaching and Research Center,
Adana, Turkey
b
Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh.39. Sk. No.6 01250, Yuregir, Adana,
Turkiye
c
Baskent University School of Medicine, Department of Orthopedics and Traumatology, Adana Teaching and Research Center,
Adana, Turkey

Received 23 January 2016; revised 1 August 2016; accepted 9 August 2016

Keywords:
Abstract
Fascia iliaca block;
Study objective: This study evaluated the postoperative analgesic efcacies of fascia iliaca block and peri-
Periarticular drug injection;
articular drug injection techniques after TKA (total knee arthroplasty) surgeries.
Total knee arthroplasty
Design: Prospective, randomized clinical trial.
Setting: University Teaching and Research Center.
Patients: Seventy-one American Society of Anesthesiologists (ASA) I-III patients between 48 and 70 years
of age who underwent total knee arthroplasty were randomized.
Interventions: Tenoxicam (20 mg) was administered intramuscularly to both groups of patients 30 minutes
before surgery. Patients were randomized into two groups to receive fascia iliaca block before the induction
of anesthesia (Group FI) or periarticular drug injection during the surgery (Group PI). All surgeries were per-
formed under general anesthesia using standard techniques. Postoperative analgesia was provided with
patient-controlled intravenous morphine.
Measurements: Total morphine consumption was the primary outcome measure and was recorded postop-
eratively at 1, 2, 6, 12 and 24 hours. Pain levels at rest and on movement (knee exion) were evaluated using
the Visual Analogue Scale (VAS) and recorded at the same time points. Patients' demographics, rescue an-
algesic demands, side effects, hemodynamics, and satisfaction scores were also recorded.

Clinical Trials.gov Identifier: NCT02047331.
Corresponding author at: Baskent Universitesi Tip Fakultesi Adana Uygulama ve Arastirma Merkezi Dadaloglu, Mh. 39. Sk. No.6 01250, Yuregir, Adana,
Turkey. Tel.: +90 322 3272727x1472, +90 532 0613026 (Mobile); fax: +90 322 3271273.
E-mail address: caglaetike@hotmail.com (C. Bali).
1
Tel: +90 322 3 272 727, +90 536 6 965 114 (Mobile); fax: +90 322 3 271 273.
2
Tel.: +90 322 3272727x1469, +90 505 748 20 38 (Mobile); fax: +90 322 3 271 273.
3
Tel.: +90 322 3 272 727, +90 532 354 44 15 (Mobile); fax: +90 322 3 271 273.
4
Tel.: +90 322 3 272 727, +90 532 2 148 661 (Mobile); fax: +90 322 3 271 273.

http://dx.doi.org/10.1016/j.jclinane.2016.08.030
0952-8180/ 2016 Elsevier Inc. All rights reserved.
Fascia Block versus periarticular injection for knee 405

Main results: The groups had similar VAS scores both at rest and on movement (P N .05). However, the
amount of cumulative morphine and use at each follow-up period was higher in Group PI (P b .0001).
The groups did not differ signicantly in rescue analgesic use or side effects, such as nausea/vomiting, he-
modynamic variables, and patient satisfaction scores (P N .05).
Conclusions: Fascia iliaca block may be used as an alternative method to periarticular injection, and it effec-
tively reduces the amount of morphine used to relieve post-TKA pain.
2016 Elsevier Inc. All rights reserved.

1. Introduction 2.1. Intervention

Total knee arthroplasty (TKA) is commonly performed in

geriatric patients to relieve pain and movement restrictions
caused by degenerative disorders, but it may cause severe
postoperative pain [1].
Effective postoperative analgesia improves patient out-
comes by allowing early ambulation and rehabilitation in this
population [2-4]. Parenteral opioids, nonsteroidal anti-
inammatory drugs (NSAIDs), and epidural techniques are
widely used for this purpose [5,6].
Peripheral nerve blocks are also frequently performed for
postoperative analgesia in TKA. Fascia iliaca compartment block
is used for postoperative analgesia in knee and hip surgery. This
block is considered safe because of the long distance between the
needle entry point and vascular and neural structures [7].
Periarticular drug injection is an intervention in which a
high-volume, low-concentration local anesthetic solution is
administered into the joint capsule and periarticular surround-
ing tissues to achieve a satisfactory level of postoperative anal-
gesia [8].
In this study, we compared the postoperative analgesic ef-
cacies of fascia iliaca block and periarticular drug injection
techniques after TKA surgery.
2. Materials and methods
This prospective, randomized study was approved by The
Baskent University Institutional Review Board and Ethics
Committee (Project No: KA12/269) and supported by the
Baskent University Research Fund. Patients undergoing
TKA were included in the study. The following exclusion cri-
teria were used: 18 years of age, coagulation disorder, heart
failure, renal impairment (creatinine level 1.4 mg/dL), hepat-
ic failure (history of cirrhosis, chronic liver disease or unex-
plained/undiagnosed possible hepatic dysfunction [total
bilirubin 1.5 mg/dL, AST, ALT 2 upper limit of nor-
mal]), morbid obesity (Body Mass Index [BMI] N35 kg/m2),
history of severe allergic reaction, such as anaphylaxis, angio-
edema, or urticaria, to drugs used in the protocol, previous sur-
gery or infection in the region of the block, sensorial or motor
disorder of the operated leg, use of NSAIDs, opioids or other
analgesic agents in the week prior the surgery, or refusal to en-
roll in the study.
Patients were informed of the study during the preoperative ex-
amination. Written informed consent was obtained from all patients.
The randomization scheme was automatically created using
a computer and was kept in sealed envelopes. An anesthesiol-
ogist who was not part of the study prepared these envelopes.
Patients were assigned to Group FI (n = 36) or Group PI (n =
35) before surgery, according to the randomization scheme.
Group FI received fascia iliaca block before the induction of
anesthesia, and Group PI received a periarticular injection dur-
ing the surgery by the surgeon.
Tenoxicam 20 mg (Tilcotil 20 mg/2 ml acon, Deva, Istan-
bul, Turkey) was administered intramuscularly to both groups
of patients in the preoperative period, 30 minutes before sur-
gery. Patients were transferred to the operating room and mon-
itored using pulse oximetry, electrocardiography, and
noninvasive blood pressure. The fascia iliaca block in Group
FI was performed prior to the induction of anesthesia using
the following technique [9]. Patients were placed in a supine
position, and the skin was cleaned aseptically. The inguinal
ligament from the anterior superior iliac spine to the pubic tu-
bercle was drawn on the skin and divided into 3 parts. The in-
jection point was 1 cm caudally from the point where the
lateral and middle part of the inguinal ligament met. The skin
and deep tissues were inltrated with 1% lidocaine. A 21G
nerve block needle (Stimuplex A 0.80 100 mm, 30 bevel,
Melsungen, Germany) was inserted into the skin perpendicu-
larly until the rst (fascia lata) and second loss of resistance
(fascia iliaca) was felt. Following aspiration to exclude
intravascular injection, 40 mL of 0.25% bupivacaine (11.5
mg/kg), which was prepared under aseptic conditions, was
injected. Sensorial block was evaluated using the pinprick test
20 minutes after injection for areas of the thigh innervated by
the femoral, lateral cutaneous and obturator nerves. The senso-
ry block of the area innervated by the femoral and lateral cuta-
neous nerves (anterior and lateral aspects of the thigh) was
accepted as a successful block. Sensory block was classied
into one of three grades: 0 (normal sensation); 1 (decreased
sensation); and 2 (absent sensation). Motor block was evaluat-
ed simultaneously using the Bromage scale: Grade 1: No mo-
tor block; Grade 2: Inability to raise extended leg, able to move
knees and feet; Grade 3: Inability to raise extended leg and
move knee, able to move feet; and Grade 4: Complete block
of motor limb.
406
All surgeries were performed under general anesthesia using
standard techniques after block evaluations. Intravenous propo-
fol (2 mg/kg) and fentanyl (0.5 g/kg) were used for induction,
and intravenous rocuronium was used as a muscle relaxant
(0.6 mg/kg). Following endotracheal intubation, anesthesia
was maintained using sevourane (1%-2%) and a mixture of
nitrous oxide and oxygen (50% + 50%). No other opioids
were used during surgery. Patients received 0.1 mg/kg intrave-
nous morphine after the induction of general anesthesia if the
blocks were unsuccessful and morphine PCA after the surgery.
The same surgeon performed all surgeries using an anterior
midline incision and medial parapatellar approach under a
pneumatic tourniquet. Group PI received a periarticular injec-
tion intraoperatively by the surgeon. Before the placement of
the prosthesis, 20 mL of a solution was inltrated into the
posterior capsule, and another 30 mL of this solution [a total
of 50 mL solution, including 35 mL 0.5% bupivacaine, 0.5
mL adrenaline (1 mg/mL) and 14.5 mL isotonic sodium]
was inltrated into the periarticular soft tissues. An addi-
tional 10 mL of this solution without adrenaline (5 mL
0.5% bupivacaine and 5 mL isotonic sodium) was inltrated
into the skin during closure of the incision. The periarticular
injection solution was also prepared under aseptic conditions.
Neuromuscular blockade was reversed at the end of surgery
using neostigmine (0.05 mg/kg) and atropine (0.015 mg/kg). Pa-
tients were then extubated and transferred to the recovery room.
Intravenous morphine was administered via PCA in the re-
covery room (1 mg bolus, with a lockout of 7 minutes, no basal
infusion) for all patients. PCA was continued for 48 hours after
surgery, and 24-hour morphine consumption was evaluated.
Additional doses of morphine were administered as a rescue
analgesic to a maximum 0.1 mg/kg after consultation with a
physician who was also blinded to the study when patients
had VAS scores 4. An intramuscular diclofenac sodium
(Diclomec ampoule 75 mg/3 mL, Abdi Ibrahim, Istanbul,
Turkey) was administered as a second rescue analgesic twice
daily if the patients had VAS scores 4 despite morphine
PCA and additional intravenous morphine doses. Metoclo-
pramide (10 mg, three times daily) was routinely prescribed
as the rescue antiemetic.
Anesthesia technicians who were blinded to the study re-
corded all data, including total morphine consumption, pain
scores, rescue analgesic demand, side effects, such as
nausea/vomiting, and hemodynamic data. Postoperative pain
levels at rest and on movement (knee exion) were evaluated
using the VAS and recorded at 1, 2, 6, 12, and 24 hours post-
operatively. Hemodynamic data (heart rate, systolic, diastolic,
and mean blood pressure) and peripheral oxygen saturation
were recorded before anesthesia, at 5-minute intervals during
surgery, and at 1, 2, 6, 12, and 24 hours postoperatively. Pa-
tients' overall satisfaction related to pain management, includ-
ing the method used for them in the study (i.e., block or
periarticular injection), and PCA were also recorded and
scored as 1 = good, 2 = satisfactory, 3 = poor at the end of
the rst 24 hours. Infection in the region of the block or joint
was recorded 2 weeks after surgery.
C. Bali et al.
2.2. Statistical analysis
The primary outcome parameter of this study was mor-
phine consumption during the rst postoperative 24 hours.
Power analysis of the study was based on a study by Carli
et al. [10] with a 40% difference in morphine consumption be-
tween the groups. Win-Epi 2.0 was used for sample size calcu-
lation. A total of 66 patients with 33 patients in each group was
considered an appropriate number following sample size cal-
culations for a 95% condence interval and power of 80%.
This study was designed to include a total of 72 patients to ac-
count for possible patient losses to follow-up. A per protocol
analysis was performed.
The compact program SPSS 17.0 (SPSS Inc., Chicago, IL,
USA) was used for statistical analyses of the data. Categorical
variables are expressed as numbers and percentages, and
numerical variables are expressed as the means and standard
deviation or as medians and minimummaximum when nec-
essary. Intergroup comparisons of numerical variables were
performed using Student t test when the assumptions were ful-
lled and the MannWhitney U test when the assumptions
were not fullled. For parameters with normal distribution, re-
peated measures analysis and the paired t test were used to
compare dependent variables, and the Wilcoxon test or Fried-
man test were used otherwise. P b .05 were considered signif-
icant for all comparisons.
3. Results
One patient refused to participate in the study, and 71 pa-
tients were randomized. Three patients from Group FI were
excluded from the study because of an unsuccessful block at-
tempt, and the remaining 68 patients were included in the nal
analyses (Fig. 1). The 2 groups had similar demographic char-
acteristics, operation and tourniquet times, and durations of
hospital stay (Table 1).
The groups had similar VAS scores both at rest and on
movement (Tables 2 and 3). However, the amount of PCA
morphine used, both cumulatively and at each follow-up peri-
od, was higher in Group PI (P b .0001) (Fig. 2). The 2 groups
did not signicantly differ in rescue analgesic use (both addi-
tional morphine doses and diclofenac sodium). The amount
of rst rescue analgesic (additional morphine) was 4.11
2.21 mg in Group PI and 3.93 1.83 in Group FI (P N .05).
The number of patients who used the second rescue analgesic
(diclofenac sodium) once and twice were 22 and 7, respective-
ly, in Group PI and 18 and 5, respectively, in Group FI. Grade
4 motor block was observed in 15 patients in Group FI. The 2
groups did not differ signicantly in intraoperative or postop-
erative hemodynamic variables.
The rates of nausea and vomiting of the two groups were al-
so similar; 6 patients in Group PI and 4 patients in Group FI
suffered from vomiting. One patient in Group PI developed
urinary retention. None of the patients developed neurological
Fascia Block versus periarticular injection for knee 407

Enrollment Assessed for eligibility (n=72)

Excluded (n= 1)
Not meeting inclusion criteria
(n=0)
Declined to participate (n=1)

Randomized (n=71)

Allocation
Allocated to Group PI (n=35) Allocated to Group FI (n=36)
Received Periarticular injection (n=35) Received Fascia iliaca block (n=33)
Did not receive Periarticular injection (n=0) Did not receive Fascia iliaca block
(Failed block)(n=3)

Follow-Up
Lost to follow-up (n=0) Lost to follow-up (n=0)
Discontinued Periarticular injection (n=0) Discontinued Fascia iliaca block
(n= 0)

Analysis

Analysed (n=35) Analysed (n=33)

Excluded from analysis (n=0) Excluded from analysis (n=0)

Fig. 1 Study ow chart.

symptoms or infection in the region of the block or joint. The described it as poor. Sixteen patients in Group FI described
groups also reported similar satisfaction from pain manage- pain management as good, 16 patients described it as satisfac-
ment. Fifteen patients in Group PI described pain management tory, and 1 patient described it as poor.
as good, 18 patients described it as satisfactory, and 2 patients

Table 1 Demographic variables for patients in the study.

4. Discussion
Periarticular injection (PI) Fascia block (FI)
n = 35 n = 33
This study revealed that VAS scores were similar in both
Age (yr) 61,74 6,72 63,30 5,51 groups, but morphine use was signicantly higher at each
Weight (kg) 83,60 7,62 84,09 7,79
Height (cm) 163,48 7,84 163,15 7,38
Sex (F/M) 21/14 18/15 Table 2 Visual Analogue pain scores at rest.
ASA a (I/II/III) 2/25/8 5/21/7
Postoperative Periarticular injection Fascia block
Side (L/R) 18/17 12/21
Times (PI) (FI)
Surgery 108,62 11,59 111,03 13,28
Time(min) b median median p
Tourniquet 95,14 10,89 95,45 13,10 (min-max) a
(min-max)
time (min)
Hospital length 35 35 1h 2 (13) 2 (13) NS b
of stay (day) 2h 2 (24) 2 (14) NS
6h 4 (25) 3 (25) NS
Data presented as numbers for sex, ASA and operated side of knee, as
12 h 3 (24) 3 (24) NS
minumum and maximum for hospital length of stay and as mean stan-
dard deviation otherwise.
24 h 2 (13) 2 (13) NS
a a
American Society of Anesthesiologists. Minimum-maximum.
b b
Minute. Not signicant.
408 C. Bali et al.

Table 3 Visual Analogue pain scores on movement. block acted more rapidly and was more efcacious for the si-
Postoperative Periarticular injection Fascia block multaneous blockade of lateral femoral cutaneous and femoral
Times (PI) (FI) nerves [15].
Femoral nerve block is also frequently performed for post-
Median Median p
operative pain relief after major knee surgery [11]. However,
a
(min-max) (min-max) femoral nerve block has notable incidences of temporary and
1h 3 (24) 3 (14) NS b permanent neurological complications [16,17]. One study
2h 4 (25) 4 (27) NS compared fascia iliaca block with femoral nerve block and
6h 5 (38) 5 (37) NS found that both techniques had similar analgesic efcacies
12 h 4 (37) 4 (36) NS and were associated with the use of similar amounts of analge-
24 h 2 (24) 2 (14) NS sic, but the authors concluded that neurological complications
a
Minimum-maximum. may develop with femoral block [11]. Kong et al [18] com-
b
Not signicant. pared the analgesic efcacy of fascia iliaca block with femoral
block under ultrasound guidance and found no differences in
VAS scores and opioid consumption. However, 3 of the fem-
measurement point in Group PI than Group FI. This result in- oral block patients experienced dysesthesia, which was not ob-
dicates that fascia iliaca block provides the same level of anal- served in the fascia iliaca group. On the other hand only a few
gesia with the use of less morphine in the rst 24 hours after cases related to neurological complications due to fascia iliaca
TKA compared to periarticular injection. block were reported to our knowledge [19,20]. In one study,
Conventional methods, such as parenteral opioids, epidural fascia iliaca block was performed under spinal anesthesia
analgesia, and femoral blocks, are commonly used to eliminate [19], but the performing of a nerve block in an anesthetized pa-
TKA-associated pain [5]. Fascia iliaca block has gained popu- tient is controversial.
larity recently for reducing TKA-associated pain [11]. The pri- Administration of high volumes of local anesthetic is need-
mary advantages of this block include the long distance ed because of the large interfascial volume of distribution. The
between the injection point and vascular and neural structures, application of a proximally directed massage is also needed to
the lack of need for a nerve stimulator, and the ability to per- facilitate the proximal spread of local anesthetic. Despite the
form the block with any blunt needle, such as Tuohy and spi- simple application of fascia iliaca block, the transition between
nal needles, in addition to peripheral nerve block needles fascias may not be clearly discerned, and the procedure may
[7,9,12]. Unfortunately, fascia iliaca block requires a volume fail in patients with a high BMI or a large amount of lipoidosis
as large as 4050 mL to obtain an effective result because it at the intended region of the block. The intervention failed in
is a compartment block [13]. three patients with BMIs near 30 in our study. However, ultra-
One study that compared fascia iliaca block with epidural sound guidance may be used to increase the rate of success in
analgesia in TKA found that both techniques exhibited similar these patients.
analgesia and early rehabilitation, but the epidural technique Motor weakness and fall risk following peripheral nerve
was associated with more hemodynamic side effects, includ- blocks after TKA are major problems. We observed a Brom-
ing hypotension [14]. Another study compared fascia iliaca age score of grade 4 motor block in 15 patients, but patients
block with three-in-one block and reported that fascia iliaca who undergo TKA are not mobilized during the rst 24 hours
at our institution. Patients begin walking and physiotherapy on
the next day. Therefore, we did not observe any falls, and mo-
Fascia Block Periarticular Injection tor block did not affect patient care on the rst day.
PCA Morphine Consumption (mg)

40
*
Periarticular drug injection is the administration of a solu-
35 tion containing large volumes of different medications into
*
30 the intraarticular area and periarticular soft tissues. It is a sim-
25
* ple, effective, and safe method [5,21,22]. Many studies dem-
20
onstrated that it reduces postoperative pain and opioid use
15 *
10
after TKA [23-25]. This procedure also allows early mobiliza-
5 * tion, which reduces the duration of hospital stay and costs [21].
0 Previous studies commonly used local anesthetics, NSAIDs,
1.Hour 2.Hour 6.Hour 12.Hour 24.Hour
steroids, and opioid combinations [21,23]. Since nociceptive
Postoperative time
receptors in the articular area are the aim of the block, adequate
analgesia can be achieved by a combination of analgesics act-
Data presented are means ing through separate pain pathways.
*: p< 0.0001 The present study compared two different methods. Only
bupivacaine was injected and it was concluded that periarticu-
PCA: Patient controlled analgesia
lar bupivacaine led to the use of a larger amount of morphine.
Fig. 2 Cumulative PCA morphine consumption. Adrenaline was added to the solution in an attempt to reduce
Fascia Block versus periarticular injection for knee
systemic absorption and prolong its duration of effect, but the
need for additional analgesics could not be reduced. Catheter
application may be used to increase efcacy, but this use
should be carefully considered because of the risk of infection.
In TKA procedures, nociceptive pain occurs as a result of
surgical trauma [26]. Inammatory mechanisms play a role
in pain pathogenesis, and multiple receptors in articular and
periarticular areas are responsible for pain transmission
[27-29]. Systemic NSAIDs alone do not suppress the inam-
matory response to surgical trauma, as indicated in the present
study. A larger amount of morphine use associated with stand-
alone sodium channel blockade via local anesthetic injection
suggests that it is necessary to block many of the receptors in
the articular area that are responsible for pain conduction, in-
cluding opioid and NMDA receptors. Hence, the success of
the method was demonstrated in studies in which solutions
were prepared with drug combinations, particularly opioids
[23,30]. This study compared two different techniques and
used bupivacaine alone to achieve standardization, which
may be responsible for the use of a larger amount of morphine
for periarticular application.
Blockade of the nerves responsible for the innervation of
the knee region using a fascia iliaca block provided a grade 2
sensorineural block and inhibited nociceptive conduction.
This result is clinically reected in reduced use of postopera-
tive morphine.
There are several limitations in the present study. First, pa-
tients were not blinded to the group allocation because we per-
formed the fascia iliaca block before anesthesia induction for
safety reasons. Future studies could blind the patients with
the use of sham techniques, but we designed the present study
protocol to avoid the increased infection risk associated with
the use of double interventions to each patient.
The second limitation of the study was our inability to use
an ultrasound device. We did not have an ultrasound device
in our department during the study period. The use of an ultra-
sound device would aid the visualization of the local anesthetic
spread below the fascia iliaca and the management of failed
blocks. The choice of a 24-hour end time point may be another
limitation, but we used a single-shot technique. The use of
continuing techniques would allow evaluations of the patients
during a longer period and functional outcome measures of the
joint. Fall risk after peripheral nerve blocks is an important is-
sue after TKA, but we could not measure fall risk because of
our institutional protocol. Despite these limitations, this study
increased our block-performing skills, and the authors of this
study routinely use both techniques, especially fascia iliaca
block, in their daily practice.
5. Conclusion
Fascia iliaca block may be used as an alternative method to
periarticular injection to effectively reduce the amount of mor-
phine used to relieve post-TKA pain during the rst 24 hours.
409
Conicts of interest
The authors declare no conicts of interest.
Acknowledgement
This study was supported by Baskent University Research
Fund (Project number: KA12-269).
References
[1] McCartney CJL, Nelligan K. Postoperative pain management after total
knee arthroplasty in elderly patients: treatment options. Drugs Aging
2014;31:83-91.
[2] Strassels SA, Chen C, Carr DB. Postoperative analgesia: economics, re-
source use, and patient satisfaction in an urban teaching hospital. Anesth
Analg 2002;94:130-7.
[3] Kroll MA, Otis JC, Sculco TP, Lee AC, Paget SA, Bruckenstein R, et al.
The relationship of stride characteristics to pain before and after total
knee arthroplasty. Clin Orthop Relat Res 1989:191-5.
[4] Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects
of intravenous patient-controlled analgesia with morphine, continuous
epidural analgesia, and continuous three-in-one block on postoperative
pain and knee rehabilitation after unilateral total knee arthroplasty.
Anesth Analg 1998;87:88-92.
[5] Galimba J. Promoting the use of periarticular multimodal drug injection
for total knee arthroplasty. Orthop Nurs 2009;28:250-4 [quiz 255].
[6] Horlocker TT, Kopp SL, Pagnano MW, Hebl JR. Analgesia for total hip
and knee arthroplasty: a multimodal pathway featuring peripheral nerve
block. J Am Acad Orthop Surg 2006;14:126-35.
[7] Wambold D, Carter C, Rosenberg AD. The fascia iliaca block for postop-
erative pain relief after knee surgery. Pain Pract 2001;1:274-7.
[8] Ng FY, Ng JKF, Chiu KY, Yan CH, Chan CW. Multimodal periarticular
injection vs continuous femoral nerve block after total knee arthroplasty:
a prospective, crossover, randomized clinical trial. J Arthroplasty 2012;
27:1234-8.
[9] Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca
compartment block with the 3-in-1 block in children. Anesth Analg
1989;69:705-13.
[10] Carli F, Clemente A, Asenjo JF, Kim DJ, Mistraletti G, Gomarasca M,
et al. Analgesia and functional outcome after total knee arthroplasty: peri-
articular inltration vs continuous femoral nerve block. Br J Anaesth
2010;105:185-95.
[11] Brisbane Orthopaedic & Sports Medicine Centre Writing Committee,
McMeniman TJ, McMeniman PJ, Myers PT, Hayes DA, Cavdarski A,
et al. Femoral nerve block vs fascia iliaca block for total knee arthroplasty
postoperative pain control: a prospective, randomized controlled trial. J
Arthroplasty 2010;25:1246-9.
[12] Diwan S. Fascia Iliaca block - an anatomical and technical description. J
Anaesth Crit Care Case Rep 2015;1:27-30.
[13] Range C, Egeler C. Fascia Iliaca compartment block: landmark and ultra-
sound approach. http://www.frca.co.uk/Documents/193%20Fascia%
20Iliaca%20compartment%20block.pdf.
[14] Gallardo J, Contreras-Domnguez V, Begazo H, Chvez J, Rodrguez R,
Monardes A. Efcacy of the fascia iliaca compartment block vs continu-
ous epidural infusion for analgesia following total knee replacement sur-
gery. Rev Esp Anestesiol Reanim 2011;58:493-8.
[15] Capdevila X, Biboulet P, Bouregba M, Barthelet Y, Rubenovitch J,
d'Athis F. Comparison of the three-in-one and fascia iliaca compartment
blocks in adults: clinical and radiographic analysis. Anesth Analg 1998;
86:1039-44.
410
[16] Auroy Y, Narchi P, Messiah A, Litt L, Rouvier B, Samii K. Serious com-
plications related to regional anesthesia: results of a prospective survey in
France. Anesthesiology 1997;87:479-86.
[17] Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier FJ,
et al. Major complications of regional anesthesia in France: the SOS re-
gional anesthesia hotline service. Anesthesiology 2002;97:1274-80.
[18] Kong M, Guo R, Chen J, Li P, Wu Z. A randomized study to compare the
analgesic efcacy of ultrasound-guided block of fascia Iliaca compart-
ment or femoral nerve after patella fracture surgery. Cell Biochem Bio-
phys 2015;72:567-70.
[19] Atchabahian A, Brown AR. Postoperative neuropathy following fascia
iliaca compartment blockade. Anesthesiology 2001;94:534-6.
[20] Gros T, Bassoul B, Dareau S, Delire V, Roche B, Eledjam JJ. Postoper-
ative neuropathy following fascia iliaca compartment blockade. Ann Fr
Anesth Reanim 2006;25:216-7.
[21] Kerr DR, Kohan L. Local inltration analgesia: a technique for the con-
trol of acute postoperative pain following knee and hip surgery: a case
study of 325 patients. Acta Orthop 2008;79:174-83.
[22] Andersen L, Husted H, Otte KS, Kristensen BB, Kehlet H. High-
volume inltration analgesia in total knee arthroplasty: a randomized,
double-blind, placebo-controlled trial. Acta Anaesthesiol Scand 2008;
52:1331-5.
C. Bali et al.
[23] Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne
RB, et al. Efcacy of periarticular multimodal drug injection in total knee
arthroplasty. A randomized trial. J Bone Joint Surg Am 2006;88:959-63.
[24] Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC,
et al. A multimodal analgesia protocol for total knee arthroplasty. A ran-
domized, controlled study. J Bone Joint Surg Am 2006;88:282-9.
[25] Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat
CS. Controlling pain after total hip and knee arthroplasty using a multi-
modal protocol with local periarticular injections: a prospective random-
ized study. J Arthroplasty 2007;22:33-8.
[26] Voscopoulos C, Lema M. When does acute pain become chronic? Br J
Anaesth 2010;105(Suppl. 1):i69-85.
[27] Durieux ME. Peripheral analgesic receptor systems. Br J Anaesth 2006;
97:273-4.
[28] Stein C, Yassouridis A. Peripheral morphine analgesia. Pain 1997;71:
119-21.
[29] Stein C. Opioid receptors on peripheral sensory neurons. Adv Exp Med
Biol 2003;521:69-76.
[30] Mullaji A, Kanna R, Shetty GM, Chavda V, Singh DP. Efcacy of peri-
articular injection of bupivacaine, fentanyl, and methylprednisolone in
total knee arthroplasty:a prospective, randomized trial. J Arthroplasty
2010;25:851-7.