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• W4232974232 abstract "On behalf of the Prospect group I would like to thank Drs Morfey and Brull for their interest in, and their kind comments about, our recent systematic review [1]. While our review is specifically limited to procedure-specific postoperative analgesia, we agree that analgesia may additionally have an impact on rehabilitation and length of stay after different surgical procedures. To date, there are little data about how effective analgesia can be used to directly influence predetermined outcome targets. Indeed there is some evidence that the provision of effective, continuous, peripheral nerve analgesia for knee arthroplasty does not improve hospital length of stay or other postoperative rehabilitation targets [2]. In this study, to which Morfey and Brull refer, there was no improvement in hospital length of stay, early rehabilitation goals or long-term functional recovery when continuous femoral nerve infusion was compared to single-injection femoral nerve block. While perineural analgesia avoids the unwanted adverse effects of systemic opioid analgesia and provides excellent analgesia, there is a trade-off in early mobility until the block(s) have fully regressed. This becomes more pronounced if continuous perineural infusions are used beyond 24 h because even dilute concentrations of long acting local anaesthetics will produce evidence of muscle weakness and proprioceptive dysfunction. In turn, the risks of a fall will increase and such falls have been recorded [3]. Morfey and Brull draw our attention to the study by Morin et al.[4], which demonstrates improved analgesia when a sciatic nerve block is combined with a femoral nerve block. We could not include it in our review as it was published just after the cut-off for the literature review. While this study confirms the opioid-sparing effects of combined femoral and sciatic blocks compared to either a sole lumbar plexus block or femoral block in the early recovery period it also shows that there was no difference between the groups for range of movement or residual pain scores at 7 days or 12 months. Thus the benefits of adding a sciatic nerve block to a femoral block are unclear in terms of improvement in outcome goals. While a reduction in postoperative pain visual analogue scores has been shown in a number of studies, others have failed to show a benefit, as referred to in our review. In clinical practice, a single injection sciatic nerve block will often outlast a single-injection femoral nerve block leading to continuing immobility even though quadriceps power has returned. Dang et al. [5] demonstrated that it is possible to provide very low pain visual analogue scores for prolonged periods with continuous femoral nerve infusions and intermittent sciatic catheter boluses. However, partial sensorimotor dysfunction is an inevitable consequence of these prolonged blocks (up to 54 h in this study) and there were no improvements in functional recovery. In a systematic review comparing peripheral nerve blocks with lumbar epidurals for lower limb surgery [6], Butler et al. confirmed the lack of good data and of consensus about whether sciatic nerve block adds any value to a femoral block. Consequently, whilst a combination of femoral and sciatic nerve blocks may be a popular current clinical practice this combination cannot yet be recommended for improving other outcome targets from knee arthroplasty. Currently we remain uncertain about the role of effective analgesia in achieving any predetermined goals of functional recovery. However, we are not short of topics for future research, as Morfey and Brull suggest. New areas of interest such as local infiltration analgesia [7] are promising but we need more published data. We also need more focussed research with currently available analgesic techniques/drugs. While effective analgesia is an important outcome in its own right, if regional analgesia is to make a contribution to other functional outcomes future research needs to be targeted differently. Mobility goals and length of stay may depend on factors completely divorced from effective analgesia (provision of rehabilitation resources, traditional ward routines, staff and patient expectations). We need to identify those aspects of early mobilisation and return of function, which depend on effective analgesia, and target these for specific investigation. The quality of analgesia required to enable patients to meet specific outcome goals certainly requires regional anaesthesia as a component part, to avoid the need for strong opioids in the early recovery but whether continuous perineural infusions add any further benefit is not yet clear. Evidence from multimodal peri-operative analgesic regimens [8, 9] suggests that peripheral nerve blocks have an important role in providing effective analgesia when combined with the other elements of protocols specifically designed to improve functional recovery and other outcome goals. However, continuous peripheral nerve infusions are technically demanding, require a significant investment of time and effort in setting up appropriate care pathways, and are associated with rare but significant adverse events. Currently, their use is confined to a relatively small number of specialist centres and if they are to be used effectively and safely in larger numbers of patients, their role in improving outcome, over and above the quality of analgesia they provide, must be more clearly defined." @default.
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• W4232974232 date "2009-03-01" @default.
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• W4232974232 title "A reply" @default.
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• W4232974232 doi "https://doi.org/10.1111/j.1365-2044.2009.05878_2.x" @default.
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