Rheumatology: Current Research
Open Access

Abstract

Fascia Plane Blockade with Dexamethasone Sodium Phosphate and Methylprednisolone Acetate for Knee Arthrodesis in an Opioid Tolerant Patient with Rheumatoid Arthritis

Adrienne B Mejia, Daniel Wiznia and Jinlei Li*

A multimodal strategy for perioperative analgesia after a complex orthopedic surgical course is essential in preventing protracted hospital stays, minimizing opioid requirements and allowing for early return to baseline mobility. Peripheral nerve blocks are beneficial to elderly patients, not only reducing intraoperative opioid use, but also minimizing postoperative opioid consumption. There is a significant gap in literature reporting on perineural administration of corticosteroids in acute pain management perioperatively in patients with rheumatoid arthritis. We present a case of a combination of single injection fascia layer blockade in an octogenarian woman with severe rheumatoid arthritis, total knee arthroplasty and subsequent multiple revisions, presenting for antibiotic spacer removal, bone graft, and joint arthrodesis. By combining single administration ultrasound guided adductor canal, iPACK (infiltration of the interspace between popliteal artery and the capsule of posterior knee) and obturator nerve blocks, with motor sparing local anesthetic low concentration ropivacaine and a combination of adjuvants, hydrophilic dexamethasone sodium phosphate and lipophilic methylprednisolone acetate, the patient had no additional postsurgical opiate requirements and was able to participate in physical therapy on POD 1. Postoperatively her opioid requirement exhibited an inverted “V” shape progression, slowly increased to the peak on POD 4 (comparable to her preoperative baseline), then continued to drop for the remainder of the admission. On POD 7 she was discharged to a rehabilitation facility with a lower opioid regimen than her previous baseline. In summary, the adoption of chronic pain management modality such as lipophilic glucocorticoid in peripheral nerve block is promising and understudied in the perioperative management of acute on chronic pain patients.

Published Date: 2021-08-26; Received Date: 2021-08-05