The Effect of Femoral Nerve Block Versus Adductor Canal Block on the Quality of early Recovery after Revision Total Knee Arthroplasty, a retrospective Study

Background Multimodal pain analgesia strategies are common in perioperative management of total knee arthroplasty (TKA), although the role of adductor canal blocks (ACB) versus femoral nerve block on early postoperative recovery for revision knee surgery is not investigated. Aim The purpose of this study is to independently evaluate the effect of ACB on short-term postoperative outcomes including (1) length of stay (LOS), (2) postoperative narcotic utilization, and (3) function with physical therapy in revision TKA. Methods We retrospectively identified a cohort study of consecutive 40 patients from January 2021 to July 2021 who had undergone unilateral revision TKA using a single-shot ACB (19 patients) vs femoral nerve block (21 patients) under spinal anesthesia ( hyperbaric 0.5% Marcaine 2.5 ml and 20 microgram fentanyl) in addition to a standardized multimodal pain analgesia protocol. These 2 groups were compared using independent sample t-tests with primary end points of interest being distance ambulated after surgery, and inpatient narcotic use. Results Quadriceps strength was better preserved in adductor group than in femoral group. Walking meters and going upstairs were better results in adductor group. IV morphine consumption within the first 48 hours period were less in adductor group comparing to femoral group. Conclusion Adductor nerve block showed better early recovery in revision TKA when comparing to femoral nerve block (FNB).

Analgesic Impact of a Popliteal Plexus Block to Standard Adductor Canal Block in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Randomized Blind Clinical Trial

Background. Damage to the anterior cruciate ligament (ACL) is crippling and often requires an arthroscopic outpatient surgery. Nevertheless, many patients experience severe pain during the first day after ACL reconstruction (ACLR). The adductor canal block (ACB) has yielded conflicting results for post-ACLR pain relief. This research investigated the effect of a supplemental popliteal plexus block on postoperative pain outcomes compared to a sole ACB. Methods. Following a randomized design, 60 cases scheduled for knee arthroscopy with ACLR using an ipsilateral hamstring graft were separated into two categories. Subjects in group A (n = 30) received an ACB only, while subjects in group B (n = 30) received combined ACB and popliteal plexus block (PPB). Results. We found significant differences between the two groups. The time of the first analgesic request (TFR) was later for the combined ACB and PPB (median 8 h) compared to the ACB only group (median 0.5 h). Morphine consumption was lower for patients who received combined ACB and PPB (median 12 mg) compared to ACB only (median 30 mg). The number of the requested doses was lower for the combined ACB and PPB group (median 3 doses) compared to the ACB only group (median 7 doses). Conclusions. The addition of PPB to ACB was associated with improved analgesia and a reduced need for opioid-based sedatives following ACLR with an ipsilateral hamstring graft (https://clinicaltrials.gov/ct2/show/NCT04020133).

Comparative Study between Adductor Canal Block, Femoral Nerve Block and Epidural Analgesia for Management of Post-Operative Pain in Total Knee Replacement

Background: Total knee arthroplasty (TKA) is a common surgery that is associated with moderate to severe pain. Early ambulation and physical therapy are essential for functional recovery and long-term functional outcome after TKA as well as for reducing the immobility related complications. Hence, optimal pain relief while maintaining the motor function remains the mainstay in postoperative pain management after TKA. ‎Patients and Methods: This prospective randomized controlled open-labelled study was carried out at Tanta University Hospital, Orthopedic Surgery Department from January 2020 to February 2021. Results: Heart rate was significantly increased at 12 and 18 hours postoperatively in group I and II compared to group III and there was insignificant change between group I and group II. Mean arterial blood pressure was significantly increased at 12 and 18 hours postoperatively in group I and II compared to group III and was insignificant change between group I and group II.NRS was significantly increased at 12 and 18 hours postoperatively in group I and II compared to group III and was insignificant change between group I and group II. Patient satisfaction was significantly higher in group III compared to group I and group II on the second postoperative day. Conclusion: Adductor canal nerve block provide better postoperative pain relieve with lower NRS after TKA than femoral and epidural blocks. It provides more stability of hemodynamic parameter and longer time for the 1st time of analgesic request. Also, total consumption of morphine in 1st postoperative day is lower than femoral and epidural blocks.

Analgesic efficacy of single-shot adductor canal block versus adductor canal block combined with intra-articular ropivacaine infusion after total knee arthroplasty

Aims Single-shot adductor canal block (ACB) after total knee arthroplasty (TKA) for postoperative analgesia is a common modality. Patients can experience breakthrough pain when the effect of ACB wears off. Local anaesthetic infusion through an intra-articular catheter (IAC) can help manage breakthrough pain after TKA. We hypothesized that combined ACB with ropivacaine infusion through IAC is associated with better pain relief compared to ACB used alone. Methods This study was a prospective double-blinded placebo-controlled randomized controlled trial to compare the efficacy of combined ACB+ IAC-ropivacaine infusion (study group, n = 68) versus single-shot ACB+ intra-articular normal saline placebo (control group, n = 66) after primary TKA. The primary outcome was assessment of pain, using the visual analogue scale (VAS) recorded at 6, 12, 24, and 48 hours after surgery. Secondary outcomes included active knee ROM 48 hours after surgery and additional requirement of analgesia for breakthrough pain. Results The study group (mean visual analogue scale (VAS) pain score of 5.5 (SD 0.889)) experienced significant reduction in pain 12 hours after surgery compared to the control group (mean VAS 6.62 (SD 1.356); mean difference = 1.12, 95% confidence interval (CI) -1.46 to 0.67; p < 0.001), and pain scores on postoperative day (POD) 1 and POD-2 were lower in the study group compared to the control group (mean difference in VAS pain = 1.04 (-1.39 to -0.68, 95% CI, p < 0.001). Fewer patients in the study group (0 vs 3 in the control group) required additional analgesia for breakthrough pain, but this was not statistically significant. The study group had significantly increased active knee flexion (mean flexion 86.4° (SD 7.22°)), compared to the control group (mean 73.86° (SD 7.88°), mean difference = 12.54, 95% CI 9.97 to 15.1; p < 0.014). Conclusion Combined ACB+ ropivacaine infusion via IAC is a safe, reproducible analgesic modality after primary TKA, with superior analgesia compared to ACB alone. Further large volume trials are warranted to generate evidence on clinical significance on analgesia after TKA. Cite this article: Bone Jt Open 2021;2(12):1082–1088.

Significantly Earlier Ambulation and Reduced Risk of Near-Falls with Continuous Infusion Nerve Blocks: A Retrospective Pilot Study of Adductor Canal Block Compared to Femoral Nerve Block in Total Knee Arthroplasty

Background: One option in total knee arthroplasty (TKA) perioperative pain management is femoral nerve block (FNB). Its association with quadriceps weakness has led to a focus on adductor canal block (ACB), with the aim of avoiding weakness in adjacent muscles. This study reviewed cases at our institution. Methods: In this pilot non-blinded study, nerve block (FNB or ACB) was performed under ultrasonic guidance after induction of general anesthesia, with an initial bolus followed by continuous levobupivacaine infusion into the perineurium as needed until postoperative day (POD) 2 or 3. Pain levels and falls/near-falls with knee-buckling were monitored from POD 1 to POD 3. The score on the manual muscle test, MMT (0 to 5, 5 being normal), of the patients who had been able to ambulate on POD 1, was investigated. Results: A total of 73 TKA cases, 37 FNB and 36 ACB, met the inclusion criteria. Episodes of near-falls in the form of knee-buckling were witnessed in 14 (38%) cases in the FNB group and in 4 (11%) in the ACB group (p = 0.0068). In the ACB group, 81.1% of patients were able to ambulate with parallel bars on POD 1, while only 44.4% of FNB patients could do so (p = 0.0019). The quadriceps MMT values of patients able to ambulate with parallel bars on POD 1 in the ACB group was 2.82, significantly higher than 1.97 in the FNB group (p = 0.0035). There were no significant differences in pain as measured with a numerical rating scale (NRS) through POD 3. Conclusion: Compared to FNB, ACB was associated with significantly less knee-buckling and earlier initiation of ambulation post-TKA, with better quadriceps muscle strength. These findings support the use of ACB as the anesthesia method of choice for TKA.