The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty—a retrospective study

doi:10.1016/j.jclinane.2014.08.005

Journal of Clinical Anesthesia

Volume 27, Issue 1, February 2015, Pages 39-44

https://doi.org/10.1016/j.jclinane.2014.08.005 Get rights and content

Highlights

•
Total knee arthroplasty is associated with significant postoperative pain.
•
An adductor canal block can provide analgesia similar to a femoral nerve block following a total knee arthroplasty.
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The adductor canal block allows improved physical therapy performance compared with a femoral nerve block.

Abstract

Study Objective

To determine the ability of an ultrasound-guided single-shot adductor canal block to provide adequate analgesia and improve performance during physical therapy.

Design

A retrospective chart review.

Setting

All procedures were performed at Ochsner Medical Center.

Measurements

Patient demographics as well as the type of peripheral nerve block performed. Pain scores and opioid consumption were recorded at postanesthesia care unit discharge and again at 8 ± 3, 16 ± 3, and 24 ± 3 hours. In addition, physical therapy performance was analyzed.

Main Results

There were no significant differences in pain scores or cumulative hydromorphone requirements between the adductor canal block group and the femoral nerve block group at any of the time points analyzed. Gait distance measured during physical therapy sessions in the adductor canal block group was superior compared with the femoral nerve block group.

Conclusion

Within the first 24 hours, a single-shot adductor canal block provides equally effective analgesia when compared with a femoral nerve block and improves postoperative physical therapy performance.

Introduction

Patients undergoing a total knee arthroplasty (TKA) experience significant postoperative pain [1], [2], [3], [4]. A continuous femoral nerve block (FNB) via a femoral nerve catheter (FNC) provides excellent postoperative analgesia, decreases opioid consumption, and reduces the incidence of postoperative nausea [4], [5], [6]. Although effective in controlling postoperative pain, FNB produces quadriceps muscle weakness that impairs early postoperative mobilization and physical therapy and increases the risk of falling [2], [7]. Improvements in regional analgesia after a TKA with minimal quadriceps muscle weakness may facilitate postoperative rehabilitation.

There has been recent interest in the adductor canal block (ACB) as a peripheral nerve block that may provide analgesia after knee surgery. The adductor canal is an aponeurotic structure in the middle third of the thigh, which contains several nerves involved in the innervation of the knee [8], [9], [10], [11], [12], [13]. Injection of local anesthetic into the adductor canal results in sensory changes in the medial, anterior, and lateral aspects of the knee [14]. In addition, ACB also results in significantly less quadriceps weakness when compared with FNB in healthy volunteers [15]. Therefore, ACB shows potential as a primarily sensory block with limited motor involvement. Indeed, the ACB provides analgesia after arthroscopic medial meniscectomy [16] and surgical repair of the anterior cruciate ligament [17]. Furthermore, previous studies demonstrated that ACB improved reported pain scores and reduced opioid requirements when compared with placebo in patients undergoing TKA [18], [19], [20], [21].

Evidence comparing ACB to FNB in patients undergoing TKA is still limited. Therefore, the objective of the current study was to determine the ability of an ultrasound-guided single-shot ACB to provide adequate analgesia and improve performance during physical therapy when compared with the FNB in patients undergoing TKA.

Section snippets

Materials and methods

After Ochsner Medical Center Institutional Review Board approval, a retrospective examination of the medical records of all patients who underwent a primary unilateral TKA between July 1, 2012, and October 31, 2012, was performed. Perioperative data collected included age, body mass index, gender, American Society of Anesthesiologists classification, type of regional anesthetic for postoperative pain, pain scores, cumulative opioid consumption, and gait distance during physical therapy.

All

Results

Although a sample size of 26 patients in each group was the minimum number of patients required for data abstraction, many additional patients were found to have undergone a primary unilateral TKA during the study period. All patients in both groups were analyzed to lessen the chance of sample bias in the study. During the study period, 114 patients underwent a primary unilateral TKA. Of these patients, 63 patients received ACB and 51 patients received FNB (Figure). Multiple patients in both

Discussion

A single-shot ultrasound-guided ACB provides analgesia equivalent to FNB in patients undergoing TKA during the first 24 hours after surgery. We did not find any differences in pain scores or cumulative opioid consumption in patients who received ACB compared with patients who received FNB. These findings are supported by previous studies that have demonstrated the analgesic effect of the ACB in patients after a TKA [18], [19], [20], [21]. However, many previous studies compared ACB to placebo

Acknowledgments

We would like to thank Miranda McGoffin, PT, for her assistance with collecting the physical therapy data, Heather Porter for serving as our research coordinator, and Jill Donegan and Pat Brandon for their assistance on the Acute Pain Service. We would also like to thank Kathleen McFadden for her assistance in the preparation of this manuscript, including the design of the tables and figures.

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Cited by (62)

Peripheral Nerve Block Utilization is Associated With Decreased Postoperative Opioid Consumption and Shorter Length of Stay Following Total Knee Arthroplasty
2023, Arthroplasty Today
This study aims to examine differences in postoperative complications and opioid consumption associated with perioperative peripheral nerve block (PNB) utilization during primary total knee arthroplasty (TKA).
The Premier Healthcare Database was queried for adult patients who underwent primary, elective TKA from 2015 to 2020. Patients who received a femoral or adductor canal PNB were compared to patients who did not. PNB utilization was trended from 2015 to 2020. Univariate and multivariate regression analyses were performed to assess differences in the 90-day risk of postoperative complications between groups. The average inpatient opioid consumption in morphine milligram equivalents was assessed as a function of length of stay.
Overall, 609,991 patients were included. PNB utilization increased from 9.29% in 2015 to 30.3% in 2020. After controlling for confounders, the PNB cohort was more likely to have same-day discharge (adjusted odds ratio [aOR] 1.88) and had a decreased risk of periprosthetic joint infection (aOR 0.87), pulmonary embolism (aOR 0.81), and respiratory failure (aOR 0.78). However, there was an increased risk of seroma (aOR 1.75) and hematoma (aOR 1.22) associated with PNB utilization. Lower average overall opioid exposure was seen in the PNB cohort vs no-PNB cohort (82.1 ± 194.7 vs 89.4 ± 214.1 morphine milligram equivalents, P < .001).
PNB utilization during primary TKA is associated with a shorter length of stay and decreased risk of multiple postoperative complications, as well as reduced postoperative opioid consumption. These data provide evidence in support of the safety and efficacy of this emerging practice. However, the clinical relevance of an increased risk of seroma and hematoma formation may warrant further investigation.
Synergistic effects of robotic surgery and IPACK nerve block on reduction of opioid consumption in total knee arthroplasty
2022, Journal of Orthopaedics
There are numerous strategies to combat postoperative analgesia and expedite recovery after total knee arthroplasty (TKA). The purpose of this study was to determine opioid consumption, length of stay, and functional outcomes after robotic versus standard TKA in the setting of various regional pain modalities.
A consecutive series of patients treated with unilateral primary robotic or standard TKA from January 2018–February 2021 were retrospectively identified. Regional pain modalities included peri-articular injection (PAI), adductor canal block (ACB), and infiltration between popliteal artery and capsule of knee (IPACK). Patient demographics, operative/perioperative variables, and postoperative function were recorded. Daily opiate consumption was calculated as morphine milligram equivalents (MME). Multivariate regression was performed to control for age, sex, and race.
After review, 283 patients (177 Females; 106 Males) were included. Robotic TKA patients received IPACK + ACB (36), while standard TKA patients received either ACB (45), IPACK + ACB (167), or PAI (35). Daily inpatient opioid consumption in the standard IPACK + ACB (p = 0.02) and robotic IPACK + ACB groups (p = 0.0001) was significantly lower compared to standard ACB. When combined with IPACK block, robotic procedures synergistically lowered opiate consumption (p = 0.004) compared to standard procedures and led to earlier discharge (p = 0.003). The robotic IPACK + ACB cohort also demonstrated improved early ambulation compared to standard ACB, (p = 0.05), whereas the same benefit was not seen for patients who received IPACK during standard TKA.
The utilization of IPACK block decreases inpatient postoperative opioid requirements following TKA. Robotic TKA and IPACK block appeared to have a synergistic effect on opioid consumption and postoperative recovery.
Anatomical Landmarks for Intraoperative Adductor Canal Block in Total Knee Arthroplasty: A Cadaveric Feasibility Assessment
2021, Arthroplasty Today
Citation Excerpt :
Mudumbai et al. have shown that patients with ACB, when compared to FCB, had earlier ambulation postoperatively and were also able to ambulate longer distances at 24 hours [5,6]. Hence, ACB has become an increasingly popular choice for peripheral analgesia after TKA, as it is predominantly a sensory nerve blockade preserving quadriceps motor function [5–10]. Periarticular local anesthetic injection performed intraoperatively by the surgeon has been established to be effective in managing postoperative pain after TKA [11].
Postoperative analgesia after knee arthroplasty forms a basis for an optimal range of motion after surgery. Femoral nerve blocks are established as a sensory nerve blockade but at the expense of quadriceps weakness delaying postoperative mobilization. The adductor canal block (ACB) similarly provides sensory blockade but preserves quadriceps function. If ACB is performed intraoperatively, it would reduce the time and cost needed for ACBs. This study aimed at investigating possible landmarks making it feasible to perform ACB intraoperatively.
Twenty-seven knees were used. The superior pole of the patella, medial epicondyle, and adductor tubercle was proposed as landmarks to perform the ACB through a medial parapatellar approach. A needle was directed toward the adductor tubercle until a tactile feedback was felt. Ten to 15 mL India ink were injected using this technique. The adductor canal was dissected to visualize the ink spread and determine whether the saphenous nerve and the nerve to vastus medialis were exposed to the ink.
The anatomic landmarks were easily identified in all knees. The ACB resulted in the saphenous nerve and nerve to vastus medialis being bathed in ink consistently. A volumetric relationship was noted with the injectate. No injury to the neurovascular structures was observed.
An accurate and safe technique with reliable anatomic landmarks was presented to perform an ACB. In addition, an increase in injected ink volume correlated to an increase in the spread of ink; thus, we postulate that 10 mL of local anesthetic may be sufficient for an adequate regional block.
Editorial Commentary: Femoral Nerve Block: Don't Kill the Motor Branch
2020, Arthroscopy - Journal of Arthroscopic and Related Surgery
Femoral nerve block is commonly used for pain control after knee surgery and helps to reduce the need for opioids in the early postoperative period. The potential disadvantage is blockage of the motor branch of the femoral nerve, resulting in quadriceps weakness and reduced strength by up to 50%. Adductor canal nerve block is a possible alternative resulting in less muscle weakness. The rationale behind adductor canal nerve block is blockage of the saphenous nerve and part of the obturator nerve, providing reliable and adequate pain relief.
The Effect of the IPACK Block on Pain After Primary TKA: A Double-Blinded, Prospective, Randomized Trial
2020, Journal of Arthroplasty
The purpose of this study was to determine if infiltration of local anesthetic between the interspace between the popliteal artery and capsule of the knee (IPACK) provides benefit in total knee arthroplasty.
Patients were randomized into continuous adductor canal block with IPACK block or continuous adductor canal block with sham subcutaneous saline injection. Only the anesthesiologist performing the block was aware of randomization status. After surgery, a blinded assessor recorded opioid consumption, pain scores, and gait distance.
There were 35 patients in the IPACK group and 34 in the NO IPACK group. There was no difference demographically between the groups. In the postanesthesia care unit (PACU), the average (P = .0122) and worst (P = .0168) pain scores at rest were statistically lower in the IPACK group. There was no difference in the pain scores during physical therapy (P = .2080). There was no difference in opioid consumption in the PACU (P = .7928), or at 24 hours (P = .7456). There was no difference in pain scores on POD 1 in the AM (P = .4597) or PM (P = .6273), or in the walking distance (P = .5197). There was also no difference in length of stay in the PACU (P = .9426) or hospital (P = .2141).
The IPACK group had lower pain scores at rest in the PACU, but this is likely not clinically significant. The routine use of the IPACK is not supported by the results of this study. There may be indications for the use of the IPACK block as a rescue block or in patients who have contraindications to our standard multimodal treatment regimen or in patients with chronic pain or opioid dependence.
Triple injection peri-sartorius (TIPS) block for postoperative analgesia after total knee arthroplasty: Randomised controlled study
2024, Indian Journal of Anaesthesia

View all citing articles on Scopus

^☆: A portion of this data was presented during a poster session at the annual American Society of Regional Anesthesia and Pain Medicine Meeting, May 2-5, 2013, in Boston, Massachusetts.

View full text

Original ContributionThe adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty—a retrospective study☆

Highlights

Abstract

Study Objective

Design

Setting

Measurements

Main Results

Conclusion

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgments

Knee

Reg Anesth Pain Med

Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery

Anesth Analg

Continuous femoral nerve blocks: decreasing local anesthetic concentration to minimize quadriceps femoris weakness

Anesthesiology

The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty

Anesth Analg

The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway

Anesth Analg

Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials

Anesthesiology

Peripheral nerve blocks improve analgesia after total knee replacement surgery

Anesth Analg

The connective tissue of the adductor canal—a morphological study in fetal and adult specimens

J Anat

Clinical anatomy for medical students

Gray's anatomy: the anatomical basis of clinical practice

Grant's atlas of anatomy

The innervation of the knee joint

Anat Rec

Original Contribution
The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty—a retrospective study☆