RU2645936C1 - Method for geniculate nerves blockade during knee joint surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: anaesthesia of the upper-lateral, upper-medial and lower-medial geniculate nerves is carried out under external control. Optional anaesthesia of the lower-lateral geniculate nerve is performed, with 5 ml of 0.75% ropivacaine injected per each nerve, and the external control is exercised by ultrasonic method, visualizing blood vessels accompanying the nerves branches.

EFFECT: method does not cause motor blockade and allows early activation of patients, prevents afferent nociception in the central nervous system, allows to avoid intravascular direction of the needle tip, does not require X-ray navigation.

3 ex, 3 dwg

Description

The invention relates to medicine, more specifically to anesthesiology, namely to methods of conduction anesthesia of peripheral nerves during open and arthroscopic surgical interventions on the knee joint intraoperatively, as a component of combined anesthesia, as well as in the early postoperative period with the aim of stopping the postoperative pain syndrome. The invention can also be used for therapeutic and diagnostic and diagnostic and prognostic blockades in the complex conservative treatment of chronic pain in patients with gonarthrosis, or after a knee arthroplasty operation in the long term in the presence of persisting pain.

Currently, surgical interventions on the knee joint offer methods based on the blockade of the femoral and sciatic nerves. The methods can be based on a single (so-called “single shot”) blockade by a local anesthetic of long-acting femoral and sciatic nerves, the use of prolonged techniques based on the installation of catheters to the femoral and sciatic nerves. The blockade technique may involve the use of neurostimulation control or ultrasound navigation.

The method based on a single blockade with a local anesthetic of long-term action of the femoral and sciatic nerves includes the following actions. (Peripheral Regional Anaesthesia: An Atlas of Anatomy and Techniques. G. Meier and J. Buettner, published by Thieme Verlag, Stuttgart, Germany, pp. 117-132). For the blockade of the femoral nerve, the patient is laid in the supine position, the thigh is slightly retracted and rotated outwards. After treating the skin with an antiseptic, 3 cm down from the inguinal ligament (or 1 cm below the inguinal fold) and 1.5 cm lateral to the artery, a needle is injected and intradermal or superficial subcutaneous local anesthesia is performed. An 18G needle with a short 45 ° cut is advanced in the cranial and dorsal direction at an angle of 30 ° to the skin and parallel to the artery until it senses the stiff resistance of the broad fascia of the thigh, then overcome this resistance by slightly increasing the pressure of the needle. After that, the tip of the needle is lowered and further advanced in the proximal direction, parallel to the artery under the control of peripheral neurostimulation. Contraction of the quadriceps femoris muscle and the symptom of the “dancing patella” with a current strength of 0.4 mA and a pulse duration of 0.1 ms indicate the correct position of the needle tip in the immediate vicinity of the femoral nerve. After a negative aspiration test result, 10-20 ml of long-acting local anesthetic is administered (for example, ropivacaine solution 0.75%). Finger pressure distal to the tip of the needle can contribute to the distribution of the local anesthetic solution in the cranial direction.

After that, the sciatic nerve is blocked. The patient is in a supine position, the thigh is slightly retracted without rotation along the axis. The puncture point is located at the intersection of two lines: the perpendicular to the line connecting the anterior superior iliac spine and the pubic tubercle (inguinal ligament) drawn from the point at the border of its medial and middle thirds, and the line drawn through the large trochanter of the femur parallel to the which the perpendicular was delayed. The 22G needle 12-15 cm long is advanced from the puncture point slightly in the lateral direction to the medial side of the femur until it feels contact with it, while paying attention to the distance to the femur, which is usually 4.5-6 cm. Then the needle is pulled up to the subcutaneous layer is further advanced in the vertical direction by 5 cm in depth, bypassing the femur. The motor reaction to stimulation of the sciatic nerve - contraction of the muscles of the shin or foot movement (tibial nerve - plantar flexion; peroneal nerve - dorsiflexion) indicates that the tip of the needle is near the sciatic nerve. The position of the needle is optimized so that a motor reaction occurs at a current strength of 0.3-0.4 mA and a pulse duration of 0.1 ms. Then, 20 ml of long-acting local anesthetic is administered (for example, ropivacaine solution 0.75%).

Also, the blockade of the femoral and sciatic nerves can be carried out under the control of ultrasonic navigation.

A feature of the methods based on the blockade of the femoral and sciatic nerves is the ability to block all types of sensitivity (but also blockade of motor fibers) in the area of innervation of the corresponding nerves, an adequate level of postoperative analgesia with little effect on hemodynamics.

However, the method of anesthesia prevents early activation. Since the femoral and sciatic nerves are mixed nerves and their blockade causes, along with sensory nerves, a comparable “duration” and motor “shutdown”, which excludes support of the limb until the blockade regresses completely.

The method, based on the level of blockade, is not acceptable for performing neurodestructive procedures in patients with chronic pain without the likelihood of invalidating the patient with loss of limb supportability (even using radiofrequency pulsed neurodestruction).

There are methods that relate to local infiltration anesthesia (MIA) methods and do not apply to conduction anesthesia methods. MIA is one of the effective methods of postoperative analgesia. This technique uses a local anesthetic (ropivacaine, bupivacaine, prolonged lipoform bupivacaine-EXPAREL®) or a mixture of local anesthetic with adjuvants.

The mixture contains local anesthetic solutions: ropivacin hydrochloride and bupivacaine hydrochloride. Adjuvants: adrenomimetic - adrenaline, opioid analgesic - morphine hydrochloride, central-α-adrenomimetic - clonidine, NSAIDs - ketorolac, ketoprofen, glucocorticoids - betamethasone, dexamethasone. There are many modifications of the MIA presented in the review article D.M.R. Gibbs et al. The local infiltration of analgesia following total knee replacement. A REVIEW OF CURRENT LITERATURE. J Bone Joint Surg Br. 2012; 94-B: 1154-9.

One method for local infiltration analgesia (Dennis R Kerr & Lawrence Kohan (2008) Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients, Acta Orthopedic, 79: 2, 174 -183; DMR Gibbsetal. The local infiltration of analgesia following total knee replacement .; J Bone Joint Surg Br. 2012; 94-B: 1154-9), is that the PCA mixture is infiltrated (ropivacaine, ketoprofen, adrenaline ) Ropivacaine hydrochloride (Naropin ^® ) is taken at a rate of 3 mg / kg, but not more than 300 mg - 0.2% solution (recommended concentration for manufacturer's infiltration analgesia), adrenaline 100 μg for patients weighing <80 kg and 200 μg for patients with a body weight> 80 kg, ketoprofen 5% - 2 ml.

Infiltration is carried out intraoperatively by the operating surgeon in 3 stages. The first injection is carried out after processing the bone before installing the components of the endoprosthesis, 30-50 ml is injected into the posterior capsule to a depth of 3 mm and the intercondylar region. The second stage, after the installation of the endoprosthesis, is injected 30-50 ml into the anterior capsule, in the area of the collateral ligaments, and along the femur and tibia. The remaining amount of the solution infiltrates the subcutaneous adipose tissue after closing the capsule. The positive features of the method include its ability to provide effective postoperative analgesia in the early postoperative period, which allows to refuse / reduce the dosage of narcotic and non-narcotic analgesics, does not affect the support function of the lower limb, which does not limit the possibility of early activation of patients.

The method, however, is not without drawbacks. Infiltration is performed after applying traumatic stimuli (providing access, preparing surfaces for implantation) before installing the components of the endoprosthesis, which does not protect against afferent nociceptive effects of the first stage of the operation. MIA must be used as a component of combined anesthesia. The method is associated with the likelihood of toxic effects of local anesthetic used in submaximal dosages. Relatively higher consumption of local anesthetic compared with the methods of blocking the femoral and sciatic nerves and the one we offer, gives a relatively lesser duration of pain relief. The method characterizes the inability to clearly trace the technique of infiltration by the surgeon, and the potential likelihood of intravascular administration (blind technique). The method cannot be used in the treatment of chronic pain syndrome.

Closest to the technical nature of the claimed is a method consisting in the blockade of three genicular nerves under x-ray navigation [Choi et al. Radiofrequency treatment relieves chronic knee osteoarthritis pain: A double-blind randomized controlled trial. Pain 2011; 152: 481-7], during which they performed a diagnostic blockade of the upper lateral, upper medial and lower medial genicular nerves. Using X-ray navigation, the points of anesthetic administration were determined by positioning the needle tip periostally in the area of transition of the femoral diaphysis to the lateral and medial epicondyle and in the region of the transition of the tibial diaphysis to the medial epicondyle. A solution of lidocaine 2% - 2 ml per each nerve was injected. A 50% reduction in pain within 24 hours was regarded as a positive test. After positive tests, the possibility of performing ablation (neurodegradation) was considered.

Since the method is based on selective blockade of the genicular branches, which are sensory and do not contain motor fibers, its use allows anesthesia of the knee joint without loss of motor function of the lower limb.

The disadvantage of this method is that the method is based on the blockade / ablation of 3 out of 6 genicular branches, which is likely to create a pain relief. The method was used in a clinic for patients with chronic pain and its clinical value is not clear in the category of patients with acute pain (in the early postoperative period). The method is essentially a diagnostic and prognostic blockade using lidocaine as a local anesthetic. A positive test requires the implementation of neurodestructive ablation for a longer “off” sensitivity. The method is performed under X-ray navigation, which carries a radiation dose for the patient and for the staff, and the doctor performing the procedure with a large "flow" of patients, radiation exposure may exceed the maximum permissible. X-ray navigation allows you to visualize bone structures and does not allow to visualize the passage of blood vessels, nerve trunks. X-ray navigation limits the possibilities of implementation by requirements for premises, licensing, etc., which does not allow manipulation outside a specially equipped operating room - reduces the "bandwidth" of the operating room. X-ray navigation requires an “assistant” (X-ray technician), etc.

The aim of the present invention is to expand the range of anesthesia methods used in surgery on the knee joint by creating a more reliable and safe method.

The technical task is to develop a method that provides more reliable anesthesia under safer external control.

The technical result is achieved as a result of blockade, in addition to the upper lateral, upper medial and lower medial nerves, in addition, the blockade of the lower lateral nerve by introducing anesthetic on each nerve, and anesthesia is performed under ultrasonic navigation.

As an analgesic, a solution of 0.75% ropivacaine in a total dose of 150 mg (total volume of 20 ml) is used.

The use, in contrast to the infiltration methods, of smaller volumes (20 ml versus 100-150 ml), but with a higher concentration, solutions of local anesthetic ropivacaine (0.75% versus 0.2%), with a decrease in the total dosage administered (150 mg versus 200- 300 mg) allows you to increase the duration of the sensory action of the blockade by 2-3 times (12-18 hours versus 5-6 hours). At the same time, blockade of 4 nerves allows for a better blockade and is used to treat acute pain in the perioperative period.

The use of ultrasound navigation during anesthesia provides the ability to visualize the blood vessels that accompany the branches of the nerves, which avoids the intravascular conduction of the needle tip; it can be used to treat acute pain in the perioperative period, it does not require the use of X-ray navigation (X-ray technicians are not required, a room that meets safety requirements for protection against X-ray radiation is not required, it can be performed outside the operating room, thereby increasing its “throughput”)

Anesthesia is performed using an ultrasound device with a linear transducer (8-18 MHz) and a 20 ml syringe with a solution of ropivacaine 0.75% -20 ml with a 22G needle, 50 mm long, sequentially as follows:

Blockade technique of the superior medial genicular nerve:

- The position of the patient lying on his back with a supinated lower limb.

- The position of the sensor is longitudinal with respect to the lower limb (in the frontal plane), on the medial surface of the inner condyle of the femur, 0.5 cm proximal and ventral to the leading tubercle.

- Landmarks: the transition of the medial condyle of the femur to the diaphysis, periostally located superior medial genicular artery.

- Purpose: to visualize the superior medial genicular artery.

- The artery is visualized as a round, anechoic, periosteal formation.

- After verification of the artery, bring a needle to it (injections of the in-plane needle), with a negative aspiration test, inject 3-5 ml of 0.75% ropivacaine paravasally.

- If there is a failure in the identification of the artery, move the sensor ventrally or dorsally, consider using a color doppler. If there is no effect from these actions, enter the anesthetic at the site of transition of the medial condyle of the thigh into the diaphysis, periosteally.

Technique of blockade of the lower medial genicular nerve:

- Patient supine position with supinated lower limb

- The position of the sensor is longitudinal with respect to the limb (in the frontal plane), on the medial surface of the inner condyle of the tibia 0.5-1 cm ventral

- Landmarks: transition of the medial condyle of the tibia to the diaphysis, periostally located lower medial genicular artery

- Purpose: to visualize the lower medial genicular artery

- The artery is visualized as a round, anechoic, periosteal formation

- After verification of the artery, bring a needle to it (needle in-plane needle), with a negative aspiration test, inject 3-5 ml of 0.75% ropivacaine paravasally

- If there is a failure in the identification of the artery, move the sensor ventrally or dorsally, consider using a color doppler. If there is no effect from these actions, introduce an anesthetic at the site of transition of the medial condyle of the tibia to the diaphysis, periosteally

Blockade technique of the superior lateral genicular nerve:

- The position of the patient lying on his back with a pronounced lower limb

- The position of the sensor is longitudinal, on the lateral surface of the external condyle of the femur 0.5-1 cm ventral

- Landmarks: transition of the lateral condyle of the femur to the diaphysis, periostally located superior lateral genicular artery

- Purpose: to visualize the superior lateral genicular artery

- The artery is visualized as a round, anechoic, periosteal formation

- After verification of the artery, bring a needle to it (needle in-plane needle), with a negative aspiration test, inject 3-5 ml of 0.75% ropivacaine paravasally

- If there is a failure in the identification of the artery, move the sensor ventrally or dorsally, consider using a color doppler. Or, inject the anesthetic periostally at the site of transition of the diaphysis into the lateral condyle of the femur.

Blockade technique of the lower lateral genicular nerve:

- The position of the patient lying on his back with a pronounced lower limb

- The position of the sensor is longitudinal, on the lateral surface of the lower leg above the head of the fibula.

- Landmarks: transition of the head of the fibula to its diaphysis, with a sensor to slide ventrally to the tibia into the cusp of the tuberosity, but not reaching it, a periostally located lower lateral genicular artery is sought

- Purpose: to visualize the inferior lateral genicular artery

- The artery is visualized as a round, anechoic, periosteal formation

- After verification of the artery, bring a needle to it (needle in-plane needle), with a negative aspiration test, inject 3-5 ml of 0.75% ropivacaine paravasally

- If there is a failure in the identification of the artery, move the sensor ventrally or dorsally, consider using a color doppler. Or inject the anesthetic periostally. Avoid introducing or spreading the anesthetic to the site of transition of the diaphysis into the head of the fibula - risk of blocking the common fibula (refers to mixed, motor block - violation of the dorsiflexion of the foot).

The method is illustrated by the following pictures:

In FIG. Figure 1 shows the anesthesia for the closest analogue - an x-ray of the knee with installed needles for radiofrequency denervation of the upper medial, lower lateral, lower medial genicular nerves.

In FIG. 2 shows a general view of the knee joint in an unbent position (in the position for holding the blockade according to the described method), where the numbers indicate: 1 - the scan area to search for the blockade point of the superior medial genicular nerve, 2 - the scan area for search of the blockade point of the superior lateral genicular nerve, 3 - scan area for finding the blockade point of the lower medial genicular nerve; 4 - scan area for searching the blockade point of the lower lateral genicular nerve (Sensor location in front flax plane, longitudinal scan).

In FIG. 3 (3 photos) shows the implementation of the blockade of the superior lateral genicular nerve. The numbers denote: 5 - the femur, 6 - the nerve, 7 - the artery, 8 - the needle, 9 - local anesthetic.

The industrial applicability of the method is illustrated by clinical examples of combined anesthesia in patients with gonarthrosis with knee replacement.

Example 1. Patient S., 71 years old, was admitted to planned surgical treatment for gonarthrosis with complaints of pain at rest and with exercise, decreased range of motion in the right knee joint. Assessment of pain in the preoperative period on a digital analogue scale from 0-10 (CRS): - 7 points.

When collecting anamnesis, the following concomitant diseases were identified: salivary gland oncocytoma from 2000 g, relapse from 2011 of cholelithiasis, cholecystectomy (1997), sectoral resection of the right mammary gland due to mastitis (1994).

The severity of the somatic state according to ASA II.

Anesthesiological aid. Monitoring (NIAD, heart rate, Sp02). Monitoring Depth of Anesthesia: BIS. After catheterization of the peripheral vein with the aim of intra- and postoperative pain relief, the block of the upper medial, upper lateral, lower medial, lower lateral genicular nerves on the right was performed under ultrasound control. After carrying out aspiration tests, 5 ml of 0.75% ropivacaine solution was administered perineurally to each of the nerves. No complications were noted. After the blockade, the pain level in the central nervous system: 0 points.

Premedication: Fentanyl 200 mcg, Dexamethasone 8 mg. Preoxygenate a 8 liter stream with FiO ₂ 1.0 for 5 min. Induction of anesthesia: Propofol 150 mg, myoplegia: Arduan 1 mg (precurarization) succinylcholine 100 mg. After the onset of myoplegia, laryngoscopy and orotracheal intubation of the trachea with transfer of the patient to mechanical ventilation in VCV mode with ventilation parameters: flow 2 liters, FiO ₂ 0.4, TV 6-7 ml / kg, BH 8-12, PEEP 5 cm / N ₂ O with moderate hyperventilation P _ET CO2 32-34.

Maintenance of anesthesia: Sevoflurane 1.0-1.3 MAK (minimum alveolar concentration), fentanyl 200 μg before a skin incision. Monitoring the depth of anesthesia: BIS with target values of 40-50.

For hemostatic purpose, 1250 mg of tranex was administered intraoperatively.

Beginning of surgery 13.00 - end 14.40 At the stages of surgical intervention, hemodynamic parameters are stable. Heart rate 60-68 / min, blood pressure 72-86 mm Hg SpO ₂ - 99-100%. Infusion therapy: 1750 ml injected, blood loss - 250 ml.

After the operation, a sufficient level of consciousness, muscle tone, spontaneous breathing were restored. Transfer to auxiliary ventilation was carried out through an endotracheal tube with a BH of 10-12 min, EtCO ₂ 32-36 mmHq, SpO ₂ - 98%. No decourage. The patient is extubated without complications. Reconstruction of the oropharynx has been performed. Adequate breathing through the natural airways (BH 12-14 per min, SpO ₂ 98-99%, without inhalation O ₂ ). Hemodynamics is stable: HELL 107/68 mm Hg pulse of 70 per minute, rhythmic.

Pain level after 30 minutes according to the Central Researcher: 3 points. The patient was transferred to the specialized department. Assessment of the level of pain 12 hours after the end of the operation: 1 point. Narcotic analgesics for postoperative analgesia were not used. In the evening after the operation, activation within the ward (verticalization, visiting the bathroom).

Example 2. Patient K., 76 years old, was admitted to planned surgical treatment for gonarthrosis with complaints of pain during exercise, decreased range of motion in the right knee joint.

Assessment of pain in the preoperative period on a digital rating scale from 0-10: 5 points.

When collecting anamnesis, the following concomitant diseases were identified: hypertension 2 stages, arterial hypertension 1 tbsp., Paresis of the facial nerve on the right of traumatic origin.

The severity of the somatic state according to ASAIII.

Anesthesiological aid. Monitoring (NIAD, heart rate, SpO2). Monitoring Depth of Anesthesia: BIS. After catheterization of the peripheral vein with the aim of intra- and postoperative pain relief, the block of the upper medial, upper lateral, lower medial, lower lateral genicular nerves on the right was performed under ultrasound control. After carrying out aspiration tests, 5 ml of 0.75% ropivacaine solution was administered perineurally to each of the nerves. No complications were noted. After the blockade, the pain level in the central nervous system: 1 point.

Premedication: Fentanyl 100 mcg, Dexamethasone 8 mg. Preoxygenate a 10 liter stream with FiO ₂ 1.0 for 5 min. Induction of anesthesia: Propofol 150 mg, myoplegia: Nimbex 6 mg. After the onset of myoplegia, laryngoscopy and orotracheal intubation of the trachea with transfer of the patient to mechanical ventilation in VCV mode with ventilation parameters: flow 2 liters, FiO ₂ 0.4, TV 6-7 ml / kg, BH 8-12, PEEP 5 cm / N ₂ O with moderate hyperventilation P _ET CO2 32-34. Maintenance of anesthesia: Sevoflurane 1,0-1,3 MAK, fentanyl 200 mcg before a skin incision. Monitoring the depth of anesthesia: BIS with target values of 40-50. For hemostatic purpose, 1250 mg of tranex was administered intraoperatively.

Start of operation 10.10 - end 12.20. At the stages of surgical intervention, hemodynamic parameters are stable. Heart rate 50-57 / min, blood pressure 70-86 mm Hg SpO2 - 99-100%. Infusion therapy: 1750 ml injected, blood loss - 250 ml.

After the operation, a sufficient level of consciousness, muscle tone, spontaneous breathing were restored. Transfer to VIVL was performed through an endotracheal tube with a BH of 12-14 per min, EtCO ₂ 32-36 mmHq, SpO ₂ - 98%. No decourage. The patient is extubated without complications. Reconstruction of the oropharynx has been performed. Adequate breathing through the natural airways (BH 12-14 per min, SpO ₂ 98-99%, without inhalation O ₂ ). Hemodynamics is stable: HELL 118/62 mm Hg pulse 72 per minute, rhythmic.

Pain level after 30 minutes according to the Central Researcher: 2 points. The patient was transferred to the specialized department. Assessment of the level of pain 12 hours after the end of the operation: 1 point. Narcotic analgesics for postoperative analgesia were not used. In the evening after the operation, it is activated within the chamber (verticalization, visiting the bathroom).

Example 3. Patient K., 58 years old, was admitted for planned surgical treatment for gonarthrosis with complaints of pain at rest and with exercise, decreased range of motion in the right knee joint.

Assessment of pain in the preoperative period on a digital rating scale from 0-10: 5 points.

When collecting anamnesis revealed the following concomitant diseases: obesity 2 tbsp. (BMI 39), grade II hypertension, type 2 diabetes mellitus, subcompensated, condition after extended interlaminophasetectomy L4-L5 from 2 sides from 2013, endoprosthetics of the right knee joint from 2014

The severity of the somatic state according to ASAIII.

Anesthesiological aid. Monitoring (NIAD, heart rate, SpO2). Monitoring Depth of Anesthesia: BIS. After catheterization of the peripheral vein for the purpose of intra- and postoperative analgesia, the block of the upper medial, upper lateral, lower medial, lower lateral genic nerves on the right was performed under the U3 control. After carrying out aspiration tests, 5 ml of 0.75% ropivacaine solution was administered perineurally to each of the nerves. No complications were noted. After the blockade, the pain level for the central nervous system: 0 points

Premedication: Fentanyl 200 mcg, Dexamethasone 8 mg. Preoxygenate a 10 liter stream with FiO ₂ 1.0 for 5 min. Induction of anesthesia: Propofol 180 mg, myoplegia: Nimbex 6 mg. After the onset of myoplegia, laryngoscopy and orotracheal intubation of the trachea with transfer of the patient to mechanical ventilation in VCV mode with ventilation parameters: flow 2 liters, FiO ₂ 0.4, TV 6-7 ml / kg, BH 8-12, PEEP 5 cm / N ₂ O with moderate hyperventilation P _ET CO2 32-34. Maintenance of anesthesia: Sevoflurane 1,0-1,3 MAK, fentanyl 200 mcg before a skin incision. Monitoring the depth of anesthesia: BIS with target values of 40-50. For hemostatic purpose, 1250 mg of tranex was administered intraoperatively.

Start of operation 12.10 - end of 14.10. At the stages of surgical intervention, hemodynamic parameters are stable. Heart rate 57-65 / min, blood pressure 77-95 mm Hg SpO ₂ - 99-100%. Infusion therapy: 1850 ml injected, blood loss - 250 ml, diuresis - 200 ml.

After the operation, a sufficient level of consciousness, muscle tone, spontaneous breathing were restored. Transfer to VIVL was carried out through an endotracheal tube with a BH of 12-14 per min, EtCO ₂ 34-37 mmHq, SpO ₂ - 98%. No decourage. The patient is extubated without complications. Reconstruction of the oropharynx has been performed. Adequate breathing through the natural airways (BH 12-14 per min, SpO ₂ 98-99%, without inhalation O ₂ ). Hemodynamics is stable: BP 115/72 pulse 60 per minute, rhythmic. The level of pain after 30 minutes according to the central nervous system: 0 point. The patient was transferred to the specialized department. Assessment of the level of pain 12 hours after the end of the operation: 1 point. Narcotic analgesics for postoperative analgesia were not used. In the evening after the operation, it is activated within the chamber (verticalization, visiting the bathroom). The advantages of the proposed method compared to analogues are as follows:

- unlike methods of analgesia based on the blockade of the femoral and sciatic nerves, the proposed method does not cause motor blockade and allows for early activation of patients;

- unlike the infiltration techniques that begin to be performed before installing the femoral and tibial components, that is, after the most traumatic stages of the operation, blockade is performed before the operation, preventing afferent nociception in the central nervous system; this reduces the risk of intravascular administration;

- in contrast to the closest analogue, the inventive method provides the ability to visualize the blood vessels accompanying the branches of the nerves, which avoids the intravascular conduction of the needle tip; it can be used to treat acute pain in the perioperative period, it does not require the use of X-ray navigation (X-ray technicians are not required, a room that meets safety requirements for protection against X-ray radiation is not required, it can be performed outside the operating room, thereby increasing its effective use and “throughput”);

- the method has been successfully tested in patients with both acute pain and chronic pain syndrome and can be recommended for use in the perioperative period as part of combined anesthesia and multimodal postoperative analgesia. It can also be recommended for the treatment of chronic pain as a prognostic block before deciding on the implementation of neurodestructive techniques.

Claims (1)

The method of blockade of the genicular nerves during surgery on the knee joint, including anesthesia of the upper lateral, upper medial and lower medial genicular nerves, carried out under external control, characterized in that they additionally conduct anesthesia of the lower lateral genic nerve, while each nerve is injected with 5 ml of 0.75% ropivacaine, and external control is carried out by the ultrasonic method, visualizing the blood vessels that accompany the branches of the nerves.

Images