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The Importance Of Post Surgery Analgesia Using Perineural Catheter After Ligamentous Surgery Of The Knee

H Sbai*, M Khatouf*, M. Harrandou*, A. Elmrini#, N. Kanjaa*, S. Boujraf**

Department of anesthesia and reanimation, University hospital of Fez, Morocco
#Department of orthopedics and traumatology, University hospital of Fez, Morocco
**Department of Biophysics and clinical MRI Methods, Faculty of Medicine and Pharmacy of Fez, Morocco

Address for Correspondence:

Associate Prof. Saïd Boujraf
Department of Biophysics and Clinical MRI Methods
Faculty of Medicine and Pharmacy, University of Fez
BP. 1893; Km 2.200, Sidi Hrazem Road, Fez 30000, Morocco
Phone: 00 212 67 780 442, Fax: 00 212 35 619 321
E-mail:, Web:


During a ligament surgery of the knee, the postoperative analgesia using femoral perineural catheterization allows active program of postoperative rehabilitation by facilitating the premature mobilization and improving the functional outcome of the patients, this allows also a reduced cost and duration of hospitalization.
The use to these techniques allows a decreased postoperative consumption of analgesics (especially morphine); therefore decreasing the incidence of the side effects (pruritis, nausea, vomits and somnolence); this allows also an increased satisfaction of the patients. The flexion gain of the knee is significant this is possible by the first post-surgery day and allows achieving 90° of flexion which is shorter compared to the multimodal analgesia.
The objective of this study was to evaluate the impact of implementing an analgesia using femoral perineural catheter on the rehabilitation at the post surgery stage and to assess duration of hospitalization after ligamentous surgery of the knee.
Key words: analgesia, femoral perineural catheterization, knee surgery

J.Orthopaedics 2007;4(2)e16


The management of the post surgery pain was neglected for a long time in our institution; actually, more and more importance is given after a surgical operation. The analgesia using peripheral perineural catheter is widely recognized as efficient at per and post surgery stages; especially in orthopedic surgery [1]. In recent years, abundant studies showed and clarified the importance of these techniques for fighting against the pain. A targeted analgesia at the posterior stage of ligamento-plasty of the knee should consider anatomical and post surgery rehabilitation requirements. A functional benefit associated to a better articular mobilization outcome using femoral catheter analgesia allows a decreased duration of hospitalization.

The objective of this study was to evaluate the impact of implementing an analgesia using femoral perineural catheter on the rehabilitation at the post surgery stage and to assess duration of hospitalization after ligamentous surgery of the knee.

Material and Methods:

In this study, two stages of ligament surgery of the knee were compared.

In the first stage, orthopedic surgeons supervised a series of 15 patients, and post surgery analgesia was carried out using a combination of analgesic, non-steroidal anti-inflammatory agents, (NSAI) and morphine.

In this second stage, anesthesiologist supervised a series of 20 patients; a post surgery analgesia was carried out using a femoral catheter through anterior veins; intermittent injection of anesthetic agents such as NSAI, buprenorphine at rate of 0.3mg/8 hours; the goal was to achieve a analog visual  scale (AVS)  smaller than 30 % .

The femoral catheter was setup at the pre-surgery stage through anterior vein and using neuron-stimulation for finding the quadriceps response, a motor stimulus used electric stimulation of intensities smaller than 0.6 mA. A dose was 20 ml of bupivacaine at 0.5% was injected in the pre-surgery stage; another dose of 8 ml of bupivacaine at 0.25% was injected at the post-surgery phase each 8 hours by the doctor anesthesiologist. The pain was also evaluated using AVS each 8 hours.

The studied parameters the second stage of the study were as follows: the needed time for the achieving 90° angulations by the knee, the stay duration in the hospital, how were patient satisfied and finally the  side effects or complication.

Results :

The epidemiological profile of the series studied in the second stage was as follows, an average age of (29 ± 5) years old composed of 16 males and 4 females and the average weight was 61 Kg.

The anesthetic approach used wasn’t identical in all patients. So, a general anesthesia was practiced on seven patients, a spinal anesthesia was done in 10 patients, and a tri bloc was realized in 3 patients. In the 24 hours following the surgery, the average morphine administration was 0.8mg of buprenorphine. The angulation of the knee was evaluated on daily basis by physiotherapist; the average value was 50° in second days after surgery and attained 90° by the fifth day (Table I). when comparing series of the both stages of the study, a 90° angulation of the knee achieved in 10 days in the first series while this was reduced to 5 days in the second series (Table II and III).  Evermore, the average hospitalization period was one 15 days in the first series while this was lowered to one week in the second series. All the patients of the second series of the study were satisfied of the pain care at post surgery stage. Neither side effect of the local anesthesia nor consequences of the analgesic technique were observed. However, satisfaction level that considers side effects in the first series wasn’t evaluated.

Stage I
(Multimodal analgesia)
Stage II
(perineural analgesia)
Day 1 33 ± 15 44 ± 15 
Day 2 44 ± 14 60 ± 16 
Day 3 53 ± 17 71 ± 12 
Day 4 62 ± 18 79 ± 12 
Day 5 68 ± 19 88 ± 19 
Day 6 72 ± 15 87 ± 6 
Day 7 73 ± 14 90 ± 4 
Day 8 73 ± 14 90 ± 5 
Day 9 76 ± 11 91 ± 5 
Day 10 88 ± 15 94 ± 5 
Off-hospitalization 89 ± 9 97 ± 4 
6th week 99 ± 12 114 ± 14 

Table I: Flexion of the knee (in degree) in the both stages of the study

The site and the type of the orthopedic surgery At rest (%) At mobilisation (muscles spasme and réflexe) (%) Average duration in days
  Moderate Severe Moderate Severe Moderate
Hip surgery 30-40 40-50 20-30 40-50 3 (2,6) 70-80
Knee surgery 25-30 55-65 30-40 55-65 3 (2,6) 60-70
Elbow and shoulder surgery 25-35 45-60 30-40 45-60 3 (2,6) 60-70

Table II: The pain at rest and at mobilization in en articular surgery [8] 

  Goranson [10] Allen [17] Sbai et al
At the 1st post-surgery day 50 ± 13 52 ± 12 44 ± 15
At the 3rd post-surgery day 82 ± 11 79 ± 12 71 ± 12
At the 5th post-surgery day 93 ± 10 92 ± 11 88 ± 19
By the 6th post-surgery week 105 ± 10 100 ± 10 114 ± 14

Table III: Flexion of the knee (in degrees), comparison of this study outcome and thus reported in the literature

Discussion :

The success of the knee ligament surgery of is well associated to rehabilitation efficiency at the post surgery, the psychotherapy is often started very early [1, 2, 3]. Both passive and active mobilizations allow a limitation of the amyotrophy, a good muscle-tendon adhesions, post surgery hemato- arthrosis and avoiding thromboembolic complications [3, 4, 5]. The analgesia has to be fast efficient at rest and especially in dynamic condition. The pain generated by the mobilization of a joint is often very severe and non morphine analgesic even opianic do not relax enough the patients [4, 6].

The regional analgesia using femoral catheter is mostly used at the preoperative stage and continued during the most painful period that is usually the 72 hours following the surgery, this constitutes the most important stage for managing this type of pain in order since this constitute also the phase of start of the rehabilitation [7, 8, 9], which contribute on its turn to increased pain.

In this stage, the epidural analgesia enough effective; it has higher efficiency when compared to morphine analgesia controlled by the patient (PCA) moreover, it has fewer side effects such as urine retention, low blood pressure, dysesthesia [8, 10]. This work confirms the results reported by the other studies. indeed, a morphine saving was noted and an increase articular angulation amplitude in the early post postoperative stage; even more, the scores of pain at rest and at mobilization was significantly lower in the patients benefiting from an analgesia using femoral perineural catheter when compared with the PCA group [10, 11, 12]. Previous studies of post femoral block of ligament-plasty of the knee reported that related analgesia was of high quality during 29 hours in 79 % of the patients, and only 8 % required additional morphine based analgesia [13, 14]. The follow-up of the degree of flexion of the knee allows appreciating the functional result, this showed profits of the regional analgesia approach; therefore, the maximal amplitudes of this flexion were significantly higher in the fifth day and at the en of the hospitalization [15, 16]. Hence, faster recovery of the articular amplitude and accelerating the post surgery rehabilitation were obtained with the analgesia using femoral perineural catheter; this allowed a reduced duration of hospitalization [16, 17].

These results demonstrated the interest of the choice of analgesia mode for both:  the early post surgery stage and especially enhancing the prognosis realized of the treatment.


During ligament surgery of the knee, the analgesic type used is indispensable for keeping the functional result. The controlled analgesia using femoral catheter allows achieving an early rehabilitation program, to generate a faster recovery of the articular amplitude as well as faster post-operating rehabilitation; these contribute to a decreased duration of a stay at the hospitable.


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This is a peer reviewed paper 

Please cite as :H Sbai :The Importance Of Post Surgery Analgesia Using Perineural Catheter After Ligamentous Surgery Of The Knee

J.Orthopaedics 2007;4(2)e16





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