الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Regional anaesthesia (RA) results in more rapid recovery with earlier mobilization, better pain relief and less nausea and vomiting and so earlier oral intake than GA. Also, RA decreases and even abolishes the catabolic hormonal response to surgery with a resultant decrease in glucose mobilization.
Total knee arthroplasty (TKA) is a painful and common orthopaedic procedure amongst elderly patients that frequently results in moderate to severe pain in the immediate postoperative period as well as chronic pain in up to 35 % of patients. An exaggerated pain response will make the patient unable to tolerate physiotherapy of the knee. Good postoperative pain control is important to facilitate rehabilitation and may also decrease the likelihood of developing chronic pain. It is also generally believed that joint splinting and relative immobilization lead to joint stiffness. Moreover, severe postoperative pain is a common reason for delays in hospital discharge and unanticipated hospital admissions. So the target is always effective pain relief after surgery or acute injury that increases mobility and expedite a patient’s return to normal function with earlier return to work and better psychological benefits.
Peripheral nerve blocks are now considered the gold standard for pain management. Peripheral nerve blocks (PNB) being associated with minimal hemodynamic disturbances are ideal for high risk surgical patients who cannot tolerate the adverse haemodynamic consequences. Major potential benefits of PNB techniques may include postoperative analgesia, less physiologic derangements, more rapid postoperative recovery, avoidance of airway instrumentation, and reduced incidence of potential complications associated with GA.
The addition of a sciatic nerve block to a femoral nerve block after total knee arthroplasty (TKA) may provide superior analgesia by reducing posterior knee pain. The sciatic nerve block may, however, cause an inability to dorsiflex the foot due to blockade of the common peroneal nerve (CPN), and some surgeons request no preoperative sciatic nerve block be performed for fear of masking a surgical injury to the peroneal nerve with a reported incidence of 0.3% to 10%.
The aim of the present study is to compare between ultrasound guided sciatic nerve block and tibial nerve block in addition to femoral nerve block for total knee arthroplasty as regard the incidence of postoperative peroneal motor block, duration of analgesia and the incidence of adverse events.
The present study was done on 80 patients ASA physical status I- II , scheduled to undergo elective total knee arthroplasty divided into two equal groups, each group received ultrasound guided femoral nerve block, in addition; group I received ultrasound guided sciatic nerve block and group II received ultrasound guided selective tibial nerve block.
Patients of each group received 25 ml of 0.25% bupivacaine for femoral nerve block, in addition, patients of group I received 25 ml of 0.25% bupivacaine for sciatic nerve block and patients of group II received 15 ml of 0.25 % bupivacaine for selective tibial nerve block.
Assessment of the block by loss of sensation to cold was done every 5 minutes. After onset of the block, all patients received general anaesthesia with a laryngeal mask airway for surgery. General anaesthesia was induced with propofol (2mg/kg) and was maintained with isoflurane (MAC 1.15%), air (50%) and oxygen (50%) with spontaneous breathing.
The following parameters were measured for all patients:
• Demographic data: Age (yrs), weight (Kgs) and sex.
• Vital signs: Heart rate (beats per minute), mean arterial blood pressure (mmHg), peripheral oxygen saturation (SPO2 %). All parameters were continuously monitored before the block and till 24 hours postoperatively.
• Pain scoring: The visual analog scale was assessed every 1 hour at the ward for the first 24 hours post operatively and was recorded at 6, 12, 18, and 24 h.
• Duration of analgesia (minutes).
• Total dose of rescue analgesia in 24 hours.
• Score of the sensory block: Cold sensation was tested using an alcohol swab compared to the non operative foot.
• Onset of the sensory block (in minutes).
• Duration of the sensory block (in minutes).
• Score of the motor block: Femoral nerve motor block by Manual Muscle Testing for Quadriceps Femoris muscle group and Timed Up and Go (TUG) test, Tibial nerve motor block by plantar flexion of the foot and Common peroneal nerve motor block by dorsiflexion of the foot