Is continuous proximal adductor canal analgesia with a periarticular injection comparable to continuous epidural analgesia for postoperative pain after Total Knee Arthroplasty? A retrospective study


Background. The classic adductor canal block (ACB) is a regional technique that aims to introduce local anesthetic to the saphenous nerve as it traverses the adductor canal. It offers the benefit of preserved quadriceps strength, and is ideal for rehabilitation. Proximal ACB (PACB) allows the operator to place the block away from the surgical site, permitting preoperative placement. Our primary outcome was total opioid consumption; secondary outcomes included the highest numerical rating scale scores and total gait distance at the indicated time intervals.

Questions/purposes. We asked: 1) Does a Continuous Proximal ACB block with Periarticular knee injection (PACB) provide better analgesia than a Continuous Epidural (CSE)?; 2) Do PACB catheter patients do better with physical therapy compared to CSE patients?; 3) Are PACB patients discharged earlier than CSE patients?

Methods. With IRB approval we performed a retrospective chart review of patients who had underwent primary total knee arthroplasty between October 2015 and September 2016. The selected patients (n = 151) were divided into two groups: CSE group, 72 patients who received a continuous epidural catheter and the PACB group, 79 patients who received at PACB with Periarticular injection. The CSE group received a single-segment combined spinal epidural (CSE) in the operating room. The epidural catheter infusion was started with 0.1% ropivacaine at 8 mL/hour to 14 mL/hour during the post-operative period. The PACB group received a proximal adductor canal catheter with 20 ml of 0.5 % ropivacaine and maintained with ropivacaine 0.2% at 8 ml to 14 ml post operatively. Total opioid consumption, highest numeric rating scores and total gait distance travelled were recorded upon discharge from the PACU and completion of postoperative day (POD) 0, 1, and 2.

Results: We found that the median cumulative morphine consumption was significantly higher in the CSE group compared to the PACB group (194 (0-498) versus 126 (0-354) mg, p = 0.012), a difference that was most notable on POD 1 (84 (16-243) versus 60 (5-370) mg, p = 0.0001). Mean hospital length of stay was also shorter in the PACB group (2.6 ± 0.67 versus 3.0 ± 1.08 days, p = 0.01).

Conclusion: PACB group used significantly lower morphine consumption compared to the CSE group; they were better participants during physical therapy and achieved longer gait distances. The mean hospital length of stay was also shorter in the PACB group

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  • 1. Jaeger P, Grevstad U, Henningsen MH, Gottschau B, Mathiesen O, Dahl JB. Effect of adductor-canal-blockade on established, severe post-operative pain after total knee arthroplasty: a randomised study. Acta Anaesthesiol Scand 2012. 56:1013-1019. doi: 10.1111/j.1399-6576.2012.02737.x

  • 2. Mariano ER, Kim TE, Wagner MJ, Funck N, Harrison TK, Walters T, et al. A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty. J Ultrasound Med 2014; 33: 1653-1662. doi: 10.7863/ultra.33.9.1653

  • 3. Ishiguro S, Yokochi A, Yoshioka K, Asano N, Deguchi A, Iwasaki Y, et al. Technical communication: anatomy and clinical implications of ultrasound-guided selective femoral nerve block. Anesth Analg 2012; 115: 1467-1470. doi: 10.1213/ANE.0b013e31826af956

  • 4. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, et al. Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011; 115: 774-781. doi: 10.1097/ALN.0b013e3182124dc6

  • 5. Ackerman DB, Trousdale RT, Bieber P, Henely J, Pagnano MW, Berry DJ. Postoperative patient falls on an orthopedic inpatient unit. J Arthroplasty 2010; 25: 10-14. doi: 10.1016/j.arth.2008.09.025

  • 6. Hitcho EB, Krauss MJ, Birge S, Claiborne Dunagan W, Fischer I, Johnson S, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med 2004; 19: 732-739. doi: 10.1111/j.1525-1497.2004.30387.x

  • 7. Krombach J, Gray AT. Sonography for saphenous nerve block near the adductor canal. Reg Anesth Pain Med 2007; 32: 369-370. doi: 10.1016/j.rapm.2007.04.006

  • 8. Tsui BC, Ozelsel T. Ultrasound-guided transsartorial perifemoral artery approach for saphenous nerve block. Reg Anesth Pain Med 2009; 34: 177-178; author reply 178. doi: 10.1097/AAP.0b013e31819a273e

  • 9. Horn JL, Pitsch T, Salinas F, Benninger B. Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Reg Anesth Pain Med 2009; 34: 486-489. doi: 10.1097/AAP.0b013e3181ae11af

  • 10. Lund J, Jenstrup MT, Jaeger P, Sørensen AM, Dahl JB. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand 2011; 55: 14-19. doi: 10.1111/j.1399-6576.2010.02333.x

  • 11. Kirkpatrick JD, Sites BD, Antonakakis JG. Preliminary experience with a new approach to performing an ultrasound-guided saphenous nerve block in the mid to proximal femur. Reg Anesth Pain Med 2010; 35: 222-223. doi: 10.1097/AAP.0b013e3181d24589

  • 12. Kuang MJ, Ma JX, Fu L, He WW, Zhao J, Ma XL. Is Adductor Canal Block Better than Femoral Nerve Block in Primary Total Knee Arthroplasty? A GRADE Analysis of the Evidence Through a Systematic Review and Meta-Analysis. J Arthroplasty 2017; 32: 3238-3248. e3. doi: 10.1016/j.arth.2017.05.015

  • 13. Jiang X, Wang QQ, Wu CA, Tian W. Analgesic Efficacy of Adductor Canal Block in Total Knee Arthroplasty: A Meta-analysis and Systematic Review. Orthop Surg 2016; 8: 294-300. doi: 10.1111/os.12268.

  • 14. Kayupov E, Okroj K, Young AC, Moric M, Luchetti TJ, Zisman, et al. Continuous Adductor Canal Blocks Provide Superior Ambulation and Pain Control Compared to Epidural Analgesia for Primary Knee Arthroplasty: A Randomized, Controlled Trial. J Arthroplasty 2018; 33: 1040-1044. e1. doi: 10.1016/j.arth.2017.11.013

  • 15. Joshi GP, Bonnet F, Shah R, Wilkinson RC, Camu F, Fischer B, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008; 107: 1026-1040. doi: 10.1213/01.ane.0000333274.63501.ff

  • 16. Tiwari AK, Prasad A. In response to “Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty? Effect on ambulation ability, early functional recovery and pain control: a randomized controlled trial”. J Arthroplasty 2015; 30: 515. doi: 10.1016/j.arth.2014.10.012

  • 17. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014; 472: 1377-1383. doi: 10.1007/s11999-013-3197-y

  • 18. Jaeger P, Nielsen ZJ, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB. Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology 2013; 118: 409-415. doi: 10.1097/ALN.0b013e318279fa0b

  • 19. Jenstrup MT, Jæger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, et al. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 2012; 56: 357-364. doi: 10.1111/j.1399-6576.2011.02621.x

  • 20. Ishiguro S, Asano N, Yoshida K, Nishimura A, Wakabayashi H, Yokochi A, et al. Day zero ambulation under modified femoral nerve block after minimally invasive surgery for total knee arthroplasty: preliminary report. J Anesth 2013; 27: 132-134. doi: 10.1007/s00540-012-1479-2

  • 21. Gi E, Yamauchi M, Yamakage M, Kikuchi C, Shimizu H, Okada Y, et al. Effects of local infiltration analgesia for posterior knee pain after total knee arthroplasty: comparison with sciatic nerve block. J Anesth 2014; 28: 696-701. doi: 10.1007/s00540-014-1793-y

  • 22. Zhang LK, Ma JX, Kuang MJ, Ma XL. Comparison of Periarticular Local Infiltration Analgesia With Femoral Nerve Block for Total Knee Arthroplasty: a Meta-Analysis of Randomized Controlled Trials. J Arthroplasty 2018; 33: 1972-1978. e4 doi: 10.1016/j.arth.2017.12.042

  • 23. Singh PM, Borle A, Trikha A, Michos L, Sinha A, Goudra B. Role of Periarticular Liposomal Bupivacaine Infiltration in Patients Undergoing Total Knee Arthroplasty – A Meta-analysis of Comparative Trials. J Arthroplasty 2017; 32: 675-688.e1. doi: 10.1016/j.arth.2016.09.042

  • 24. Aikawa K, Hashimoto T, Itosu Y, Fujii T, Horiguchi T, Amenomori H, et al. Comparison of the Effect of Periarticular Infiltration Analgesia versus Sciatic Nerve Block for Total Knee Arthroplasty. Masui 2016; 65: 50-55

  • 25. Kovalak E, Dogan AT, Üzümcügil O, Obut A, Yildiz AS, Kanay E, et al. A comparison of continuous femoral nerve block and periarticular local infiltration analgesia in the management of early period pain developing after total knee arthroplasty. Acta Orthop Traumatol Turc 2015; 49: 260-266. doi: 10.3944/AOTT.2015.14.0263


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