# Supra-Sartorial Subcutaneous Infiltration (SSSI) for Anterior Femoral Cutaneous Nerve Coverage in Total Knee Arthroplasty: A Preliminary Clinical Study

## TL;DR

This study explores a new method to improve pain control after knee replacement surgery by combining a specific nerve coverage technique with existing pain management strategies.

## Contribution

The study introduces a simpler alternative to targeted anterior femoral cutaneous nerve blocks using supra-sartorial subcutaneous infiltration.

## Key findings

- SSSI combined with PC-LIA provided clinically meaningful analgesia in 58% of patients after TKA.
- Pain scores were maintained at acceptable levels for over 9 hours in some patients without rescue analgesia.
- The study highlights variability in effectiveness, suggesting the need for further controlled trials.

## Abstract

Background: Multimodal analgesia, combining adductor canal block (ACB) and local infiltration analgesia (LIA), is commonly used for pain control after total knee arthroplasty (TKA). However, ACB alone may not fully cover the anteromedial knee, a region extensively disrupted by TKA. Recent studies suggest that blocking branches of the anterior femoral cutaneous nerve (AFCN) could enhance analgesia, but targeted AFCN blocks are technically challenging. We evaluated supra-sartorial subcutaneous infiltration (SSSI) at the femoral triangle apex as a simpler alternative to AFCN blocks. Methods: We retrospectively reviewed 19 patients undergoing TKA with a standardized multimodal analgesic protocol, including intraoperative LIA limited to posterior capsule (PC-LIA), postoperative SSSI, and delayed intermittent ACB via catheter. SSSI involved infiltrating 20 mL of 0.3% ropivacaine into the subcutaneous plane above the sartorius muscle at the level of femoral triangle apex. Pain was assessed using Numerical Rating Scale (NRS) scores at rest and during movement at 9:00 PM on postoperative day 0 (POD 0) and 9:00 AM on POD 1, with scheduled ACB doses administered at the time of NRS pain score assessments. Rescue ACB boluses were given for intolerable pain before the first scheduled dose. Results: Eleven patients (58%) required no rescue analgesia before the first scheduled ACB, maintaining NRS scores ≤ 4 at rest and with movement for a minimum of 575–785 min post-spinal anesthesia. Eight patients needed rescue ACB, with variable pain relief. Conclusions: SSSI, when combined with PC-LIA, provided clinically meaningful analgesia in 58% of our patient cohort following TKA, though the variability observed suggests limited consistency. As a practical alternative to targeted AFCN blocks, SSSI could potentially complement ACB in multimodal pain management, but its efficacy remains uncertain due to the retrospective, non-controlled study design without a comparator group. Further investigation through prospective randomized controlled trials is warranted to validate these preliminary findings.