Intraoperative Surgeon-Performed versus Conventional Anesthesiologist-Performed Continuous Adductor Canal Block in Total Knee Arthroplasty: A Randomized Controlled Trial

Abstract

A continuous adductor canal block (cACB) for pain control in total knee arthroplasty (TKA) is always performed by an anesthesiologist. A surgeon-performed cACB during surgery is somewhat questionable in terms of feasibility, reproducibility, and efficacy. This study was divided into two phases. In Phase 1 study, an experimental dissection of 16 cadaveric knees to expose the saphenous nerve and related muscles around the adductor canal was conducted. The extent of dye after injection via a catheter inserted into the adductor canal at the time of TKA was evaluated. In Phase II, a randomized controlled trial study comparing clinical outcomes between surgeon-performed (Group 1) and anesthesiologist-performed cACB (Group 2) during TKA in 63 patients was evaluated. The visual analogue scale (VAS) at rest and during movement at several time points and functional outcomes during hospitalization were compared. The Phase I study demonstrated surgeon-performed cACB during surgery feasible and reproducible with consistent dye extension into the adductor canal after injection via a catheter. In the Phase II study, 29 patients of Group 1 and 30 patients of Group 2 completed the evaluation with no differences in baseline parameters. The VAS during movement at 24 and 36 hours, quadriceps strength, time up and go test, and knee motion at different time points, and total morphine consumption showed no differences between both groups. There were no procedure-related complications. The surgeon-performed cACB during surgery was feasible and reproducible with similar VAS scores and functional outcomes during hospitalization to anesthesiologist cACB. Level of evidence is Level I, prospective randomized trial.

Keywords

adductor canal block - peripheral nerve block - total knee arthroplasty - surgeon-performed ACB

• References

• 1 Karlsen AP, Wetterslev M, Hansen SE, Hansen MS, Mathiesen O, Dahl JB. Postoperative pain treatment after total knee arthroplasty: a systematic review. PLoS One 2017; 12 (03) e0173107
• 2 Hannon CP, Keating TC, Lange JK, Ricciardi BF, Waddell BS, Della Valle CJ. Anesthesia and analgesia practices in total joint arthroplasty: a survey of the American Association of Hip and Knee Surgeons Membership. J Arthroplasty 2019; 34 (12) 2872-2877.e2
• 3 Lo LWT, Suh J, Chen JY. et al. Early postoperative pain after total knee arthroplasty is associated with subsequent poorer functional outcomes and lower satisfaction. J Arthroplasty 2021; 36 (07) 2466-2472
• 4 Li JW, Ma YS, Xiao LK. Postoperative pain management in total knee arthroplasty. Orthop Surg 2019; 11 (05) 755-761
• 5 Karpetas GZ, Spyraki MK, Giakoumakis SI. et al. Multimodal analgesia protocol for pain management after total knee arthroplasty: comparison of three different regional analgesic techniques. J Musculoskelet Neuronal Interact 2021; 21 (01) 104-112
• 6 Li D, Yang Z, Xie X, Zhao J, Kang P. Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: a systematic review and meta-analysis. Int Orthop 2016; 40 (05) 925-933
• 7 Kukreja P, Bevinetto C, Brooks B. et al. Comparison of adductor canal block and femoral nerve block for early ambulation after primary total knee arthroplasty: a randomized controlled trial. Cureus 2019; 11 (12) e6331
• 8 Schnabel A, Reichl SU, Weibel S. et al. Adductor canal blocks for postoperative pain treatment in adults undergoing knee surgery. Cochrane Database Syst Rev 2019; 2019 (10) CD012262
• 9 Agarwala S, Bhadiyadra R, Menon A. Analgesic effectiveness of local infiltrative analgesia alone versus combined single dose adductor canal block with local infiltrative analgesia: a single centre case control study. J Clin Orthop Trauma 2020; 11 (Suppl. 05) S717-S721
• 10 Kwofie MK, Shastri UD, Gadsden JC. et al. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med 2013; 38 (04) 321-325
• 11 Johns N, Noye N, Wall C, Martin G, Loch A. Efficacy of adductor canal blocks in total knee arthroplasty. J Knee Surg 2022; 35 (13) 1491-1494
• 12 Yu R, Wang H, Zhuo Y, Liu D, Wu C, Zhang Y. Continuous adductor canal block provides better performance after total knee arthroplasty compared with the single-shot adductor canal block? An updated meta-analysis of randomized controlled trials. Medicine (Baltimore) 2020; 99 (43) e22762
• 13 Bagaria V, Kulkarni RV, Valavi A, Choudhury H, Dhamangaonkar A, Sahu D. The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty. Knee Surg Relat Res 2020; 32 (01) 48
• 14 Greenky MR, McGrath ME, Levicoff EA. et al. Intraoperative surgeon administered adductor canal blockade is not inferior to anesthesiologist administered adductor canal blockade: a prospective randomized trial. J Arthroplasty 2020; 35 (05) 1228-1232
• 15 Kampitak W, Tanavalee A, Ngarmukos S, Amarase C. Opioid-sparing analgesia and enhanced recovery after total knee arthroplasty using combined triple nerve blocks with local infiltration analgesia. J Arthroplasty 2019; 34 (02) 295-302
• 16 Kertkiatkachorn W, Kampitak W, Tanavalee A, Ngarmukos S. Adductor canal block combined with iPACK (interspace between the popliteal artery and the capsule of the posterior knee) block vs periarticular injection for analgesia after total knee arthroplasty: a randomized noninferiority trial. J Arthroplasty 2021; 36 (01) 122-129.e1
• 17 Kampitak W, Tanavalee A, Tansatit T, Ngarmukos S, Songborassamee N, Vichainarong C. The analgesic efficacy of anterior femoral cutaneous nerve block in combination with femoral triangle block in total knee arthroplasty: a randomized controlled trial. Korean J Anesthesiol 2021; 74 (06) 496-505