This is the final submission of National University's Jonathan Gardner's Scholarly Project. He is a Nurse Anesthesia Resident at National University.
By the year 2030 the demand for primary total knee arthroplasty (TKA) is projected to grow by 673% to 3.48 million procedures. The anesthetic management for TKA has profound and distinct effects on recovery and rehabilitation, with multiple anesthetic options available for perioperative management. We set out to answer the question “In adult patients undergoing total knee arthroplasty how does the adductor canal block as compared to the femoral nerve block effect postoperative morbidity?”
A comprehensive review of the literature was conducted for comparing adductor canal block (ACB) to femoral nerve block. One meta-analysis, 8 randomized controlled trials and 3 retrospective cohort studies were included with a date range from 2013-2015. Current literature demonstrates that adductor canal blocks are equal to, if not superior to femoral nerve block for TKA patients as evidenced by: less morbidity and equivalent or even superior analgesia noted in ACB patients. An adductor canal block allows for improved range of motion and ambulation times postoperatively, resulting in increased success and engagement in physical therapy. Adductor canal blocks can reduce hospital stays, potentially saving the patient and hospital thousands of dollars. The ACB is a viable and superior anesthetic technique to the femoral nerve block for management of TKA.
The aging and increasingly overweight population in the United States (US) has a high incidence of osteoarthritis.1 Major weight bearing joints, in particular, the knees and hips are primarily affected by the constant physiologic stress and tissue trauma that leads to primary osteoarthritis. Weinstein et al. provides evidence that over half the adults in the US diagnosed with osteoarthritis of the knee will progress to a total knee replacement.2 Currently in the US approximately 4 to 6.7 million adults have undergone a total knee replacement surgery.2,3
A total knee arthroplasty (TKA) involves removing arthritic cartilage and underlying bone of the distal femur and proximal tibia. These are replaced with metal implants on the femur and tibia with a plastic spacer placed in between the implants. The posterior portion of the patella is resurfaced to glide smoothly over the new joint. With the growing need for TKA surgeries in the US, an optimal anesthetic is essential to improve postoperative morbidity, patient safety, financial efficacy, and patient satisfaction.2
Suboptimal postoperative recovery has far reaching effects beyond the obvious safety and satisfaction of the patient. Patients experiencing an adverse reactions to opioid administration including fall risk, respiratory depression, and episodic hypotension have an overall increased cost, longer hospitalization, and increased likelihood of readmission.7,9 By the year 2030 the demand for primary TKAs is projected to grow by 673% to 3.48 million procedures.10 The estimated hospital expenditures for TKA procedures will equal $28.5 billion annually.11 With an average increase in cost of $4,707 per patient experiencing an opioid related adverse event, it is clearly evident the importance of utilizing the safest and most effective anesthetic and analgesic regimen to decrease overall morbidity, cost, and increase patient satisfaction.9
Background and Significance
There are a variety of different anesthetic options for TKA surgery: general anesthesia, general anesthesia combined with subarachnoid or epidural block, general anesthesia with peripheral nerve block, and regional anesthesia with monitored anesthesia care. Regional anesthetic options can be further delineated into different types of peripheral nerve blockades available: femoral nerve block, femoral nerve block with a sciatic block, fascia iliaca block, fascia iliaca block with a sciatic block and the adductor canal block. Each of these anesthetic options have their respective positive and negative attributes. The optimal anesthetic plan for the patient should be driven by outcome data and evidenced based research.
The anesthetic management for TKA has profound and distinct effects on recovery and rehabilitation. The current practice of general anesthesia alone without the addition of neuraxial or peripheral nerve blockade is dependent on opioid analgesia for the management of postoperative pain. Large or sequential opioid consumption increases episodes of hypotension, respiratory depression and unsafe ambulation.6 These morbidity issues related to opioid analgesia can impede recovery and increase negative patient outcomes.4 The prolonged immobility due to extensive pain from inadequate analgesia or over consumption of opioids leads to decreased participation in rehabilitation due to sedation and overall general weakness.7 This predisposes the patient to sedentary patterns and the increased risk of deep vein thrombosis formation.8 Current and continuing research invariably proves the integration of a regional anesthetic in the analgesic perioperative course decreases overall opioid consumption by as much as 50%.4,5
Anesthesia providers, surgeons and patients collaborate to decide on the most appropriate type of anesthetic for the individual patient and planned surgery. Two common regional anesthesia techniques for TKA are the femoral nerve block (FNB) and the adductor canal block (ACB). Single shot and continuous femoral nerve blocks are commonly used for analgesia after total knee arthroplasty with great success. With the increased availability and efficacy of ultrasound guided peripheral nerve blocks, the adductor canal block is a viable and arguably a better alternative for post-op analgesia in TKA patients regarding functional outcomes and decreased morbidity and mortality.
Femoral Nerve Block
The regional anesthetic technique of interrupting the pain sensation transmitted along the femoral nerve via femoral nerve block was first described in medical literature in 1952.12 Since then, the femoral nerve block has become a primary adjunctive anesthetic option for TKA patients.13 The femoral nerve supplies motor innervation to the quadriceps and is the primary afferent/sensory nerve of the knee and thigh. The traditional approach for placing a femoral nerve block involves injecting local anesthetic in the fascial sheath of femoral nerve at the femoral crease.14 At this location the femoral nerve has not divided into distinctive afferent or efferent branches. Local anesthetic infiltration at this level of the femoral nerve produces both motor and sensory nerve blockade of the skin and anterior thigh muscles and most of the femur and knee joint.14
The term ‘single shot’ FNB refers to a one time injection of local anesthetic which can be performed pre- or postoperatively. Another option is a continuous catheter inserted at the location of the single shot FNB and threaded into fascial compartment surrounding the femoral nerve and covers the same distribution of the femoral nerve at that location. The catheter allows for continuous infusion and the option of bolus dosing of anesthetics and analgesics.
Adductor Canal Block
The adductor canal is a triangular shaped fascial tunnel containing the femoral artery, femoral vein and the distal afferent branch of the femoral nerve named the saphenous nerve and another distal branch of the femoral nerve that provides motor innervation to vastus medialis muscle. The obturator nerve is contained within the canal as well and provides sensory innervation of the medial aspect of the thigh and motor innervation of the adductor muscles of the thigh. Notably, the nerves contained within the adductor canal do not innervate the major quadriceps muscles of the thigh. Therefore the adductor canal block (ACB) is primarily a sensory block and may offer a favorable alternative to the continuous femoral nerve block as quadriceps function is largely preserved. Thus the patient with an ACB can participate in rehabilitation sooner and more effectively than a patient with a FNB.
The traditional non-ultrasound guided peripheral nerve block technique of using landmarks with verification of location by stimulation of efferent nerves with predictable motor response is not possible, as the ACB is an isolated sensory fiber block. It was first described in the medical literature in 1993 using a landmark approach on cadavers. An ultrasound guided approach was documented in medical literature in 2009.15 It wasn’t until 2011 that the anesthetic community acknowledged and reported its efficacy in providing adequate postoperative analgesia in TKA patients.16,17 Similar to the continuous FNB catheter, an indwelling catheter is also a viable option for the ACB allowing for postoperative infusions of analgesics and or anesthetics.
Review of Evidence
A comprehensive review of the current literature was performed utilizing search terms of: adductor canal block, femoral nerve block, saphenous nerve block, postoperative pain after TKA, and ambulation after TKA. Preference was given to evidence within the last 10 years. 1 meta-analysis, 8 RCTs, and 3 cohort studies were included in this evidence review focusing on the efficacy and therapeutic benefits of an adductor canal block when compared to a femoral nerve block.
Complications of TKA Surgery
In healthcare today, major orthopedic surgery is commonplace in most hospitals throughout the US. Orthopedic surgeries, including the TKA, come with a distinct and equally as commonplace set of complications. Venous thrombosis, falls, and arthrofibrosis, are common complications that delay recovery and contribute to increased hospital length of stay. It is in the patients’ and healthcare providers’ best interest to minimize the incidence of these injuries and insults by implementing the safest and most effective perioperative anesthetic and recovery plan.
Venous thromboembolism (VTE) caused by venous stasis, vascular insult and hyper coagulability is a known complication of TKA surgery.18 Its prevalence has been reported as high as 48% with general anesthesia.19 Another study found 47% incidence of deep venous thromboembolism (DVT) in TKA surgeries with 87% percent of the “positive for thrombus" occurring in the first 24 hour period postoperatively.20 The odds of developing a thromboemoblic complication is significantly reduced by the greater distance that the patient mobilizes within the first 24 hours postoperatively.21 This level of iatrogenic insult is surprisingly high, but early ambulation, a benefit of an ACB versus FNB, decreases this incidence even more.
The American Academy of Orthopedic Surgeons has issued a consensus based recommendation to promote early ambulation after TKA to reduce the incidence or severity of VTE.22 In a meta-analysis by Li et al. including 434 patients, the ACB was proven to increase postoperative mobility and functional recovery compared to the FNB.23 A study by Mudumbai evaluated the effectiveness of a continuous ACB compared to a continuous FNB in promoting early ambulation as measured on post-op day 1 and post-op day 2 defined by the sum of the distances ambulated in 2 physical therapy sessions. Preoperatively both groups had ultrasound guided catheter placement and postoperatively both groups had a portable continuous infusion device that delivered an infusion of local anesthetic. Results of the study showed a significantly greater ambulation distance in ACB group of 37 meters on post op day 1 versus FNB group of 6 meters. On post op day 2 it was 60 meters for ACB versus 21 meters ambulated for the FNB group.24 All of the research reviewed comparing ACB to FNB shows increased ambulation and quadriceps strength in the patients who received the ACB.6,23-29
A key element of recovery, healing, and return to functional mobility is the reduction of arthrofibrosis. In post TKA patients, early ambulation and range of motion ability is key to preventing and minimizing arthrofibrosis.30 Patients’ satisfaction scores after knee replacement surgery mainly depend on the amount of physical activity the patient can resume once they have recovered from surgery .This directly correlates to the post operative TKA range of motion.31
Fall prevention campaigns are omnipresent in healthcare facilities nationwide and for good measure. A patient fall can cost the hospital anywhere from $3,500 to $27,000 based on the severity of the fall. Additionally, the Center for Medicare and Medicaid Services has deemed falls a preventable event and will accordingly not reimburse the hospital.32 Pelt et al. found in their study of 707 TKAs with a femoral nerve catheter 19 out 707 patients sustained a fall (2.7%) and they noted this was their most common postoperative complication of TKAs.33 The profound motor nerve blockade of a femoral nerve block causes quadriceps weakness, predisposing a post TKA patient to increased fall risk whereas an adductor canal block, as stated previously, is motor blockade sparing.30,34
In Mudumbai’s study of 167 patients comparing continuous ACB to continuous FNB after TKA, 4 FNB patients sustained falls while 0 ACB sustained falls.24 Multiple studies have proven that ACBs are associated with increased quadriceps motor strength, mobility and faster ambulation times, which bolsters the argument that the ACB leads to a decrease in fall risk.6,23, 24, 26-28, 34-36
In Jaegers study of 12 healthy male volunteer subjects, assessing quadriceps motor impairment was assessed between an ACB and a FNB, with secondary outcomes measuring adductor strength and ability to ambulate in the 6-hour period subsequent to the block.27 Eleven patients were analyzed. One subject dropped out of the study because he sustained a fall after the FNB when measuring his ability to ambulate. Each subject on day 1 of their study had either an active single shot ultrasound guided ACB or FNB. They received both blocks; one leg had an ACB that was active (30ml 0.1% Ropivacaine) or placebo (30 ml normal saline) and the other leg had a FNB that was active or placebo with only one leg being actively blocked. The same subject at least 72 hours later received the opposite blockade of what they had previously. This reliably measured the effect of the blockade of ACB vs FNB when compared against the subjects’ baseline quadriceps strength. Both the investigator and study subjects were blinded to the treatment. Various tests and exercises were administered to the subjects to determine mobility and quadriceps strength. The results of the study showed that in the 6-hour post intervention period mean quadricep strength reduction was 8% in the ACB group and 49% in the FNB group. Performance in mobility tests were significantly better in the ACB group compared to the FNB group.
The ideal anesthetic for TKA is one that promotes the most rapid recovery with the least amount of pain. Insufficient postoperative analgesia has been correlated with poor functional recovery in the TKA patient.37 The most influential factor in patient participation in post operative physical therapy and mobilization is the presence of pain.38 Severe pain is present in 60% of patient undergoing TKA while 30% of patients describe it as moderate.38 The traditional approach to severe to moderate pain relief is to mitigate and alleviate the pain with a narcotic regimen. Narcotics are not benign, with the most common side effects being post-operative nausea and vomiting, ventilatory depression, sedation and impairment of bladder and bowel function. These side effects create unnecessary complications and discomfort, unless the amount of narcotic pain management can be reduced.39
It is well described in the literature the effectiveness of the FNB in reducing both postoperative pain and the concomitant need for large doses of narcotics.40 The ACB offers at least equivalent postoperative pain reduction to the FNB6,24-26,28,35 and some studies have even shown the ACB is superior in pain relief postoperatively.23 In a meta-analysis including 8 RCTS, Li et al. concluded that post operative TKA pain relief from an ACB showed statistically significant decreases in pain scores when compared to a FNB within 8 hours and at the 24 hour mark postoperatively, and there was no degradation in efficacy in comparison to the FNB beyond the 24 hour period.23 The adequate relief from pain encourages a more active recovery and decreases unproductive physical therapy .
In Grevstad’s study comparing ACB to FNB to determine if pain relief from the ACB improved functional quadriceps strength and pain scores, a sample of 50 patients undergoing TKA was divided equally into 2 groups, an ACB group (n=25) and a FNB group (n=25). Both groups received a standardized multimodal analgesic regimen. Surgery was performed under general anesthesia with propofol and remifentanil or with spinal anesthesia of 10-15mg 0.5% Bupivacaine. The study period was 2 hours immediately post-operative. Baseline pain scores and quadriceps strength were measured before receiving peripheral nerve blockade. The individual patient received both an ACB and a FNB injection. The patient and the anesthesia provider were blinded to which actual block the patient received by having the provider inject 30ml of either saline or 0.2% Ropivacaine to both the adductor canal and the femoral nerve area with pharmacy ensuring the different injectates were indistinguishable. The ACB group received the ropivacaine in the adductor and 30 ml of saline in the femoral nerve area with the opposite being true for the FNB group. Results of the study show a 20% increase in quadriceps strength in the ACB group and similar pain scores and opioid consumption between the groups. In a timed test to measure safe mobility (TUG test) 7/25 patients who received the FNB were not able to perform the test where all 25 of the ACB were able to engage in the test after the nerve blockade.25
Hospital Length of Stay
Healthcare fiscal responsibility affects consumers and providers of surgical and anesthetic services simultaneously. It is the goal to reduce anesthetic perioperative complications and provide a service that decreases known risk factors with unnecessary side effects that can increase morbidity and hospital length of stay. In Ludwigson’s cohort study of 297 patients comparing single shot ACB to a FNB catheter, the ACB patient’s length of stay was 2.5 days compared to FNB catheter of length of stay of 3 days. Although the length of stay was longer for the FNB group, the study was limited by the fact that the two groups received different modalities. The FNB catheter allowed for continuous infusion or bolus dosing to cover breakthrough pain if required. The ACB group was a one-time administration.28
A more balanced randomized control trial of 97 TKA patients by Shah et al compared continuous catheter ACB to a continuous catheter FNB and found the ACB length of hospital stay at 3.08 days versus FNB 3.92 days which amounts to almost a full day difference.26 In terms of hospital dollars this can amount to approximately $1760-$2150 per day on US national average.40,41 When confounding factors such as falls, thrombosis, or the negative sequelae of increased opioid consumption are included, these costs increase exponentially, with some of them potentially not being reimbursed by insurance providers.
Any changes made to clinical management of a patient needs to be agreed upon by the patient, surgeon and anesthesia provider. Many of the institutions in the research had protocols for patients that had received a FNB or ACB including the nurses and physical therapists involved in the patient’s care and rehabilitation. These protocols served to educate the patient and the staff involved in their care of limitations, expectations and any safety concerns (ambulation, loss of sensation, etc). Possible negative post-operative ramifications to the institution and care providers of substituting an adductor canal block for a femoral nerve block are very minimal. As illustrated earlier, the changes are favorable for all parties involved; shorter hospital stay, equal analgesic properties and decreased incidence of falls.
A possible barrier to administering an adductor canal block is the availability of an ultrasound machine, and competently trained providers. The adductor canal block is a sensory nerve block and, without motor nerve fibers present a nerve simulation technique is not possible, and ultrasound guidance is necessary. Conversely, some practitioners may still utilize a nerve stimulation/anatomical landmark approach to a femoral nerve block where an ultrasound machine is not necessarily required. As technology and standards improve it may be legally challenging to defend against the omission of ultrasound guidance when performing peripheral nerve blocks.
The common and recommended technique for performing an ACB found in literature is positioning the patient supine with the thigh externally rotated and abducted for ultrasound probe placement on the medial thigh to locate the femoral nerve and saphenous artery in the adductor canal space. The saphenous nerve is located subsartorius, bounded medially and superiorly by the vastus medialus and inferiorly by the adductor longus in the adductor canal. Needle placement technique either in plane or out of plane may be utilized to deposit the local anesthetic in the adductor canal space anterior to the femoral artery so that the anesthetic envelops the artery and subsequently the saphenous nerve runs which runs parallel to it. Most studies have used larger doses of up to 30ml of 0.75% Ropivicaine for up to 24 hours of analgesia.14,25,29 It is this author’s recommendation after the culmination of research, the effective and safe amount of local anesthetic is 25-30 ml of 0.5% Ropivicaine. According to NYSORA there have not been any prospective studies on peripheral nerve blocks in anticoagulated patients and the American Society of Regional Anesthesia at this time does not delineate a peripheral nerve block from neuraxial anesthesia in regards to recommendations on needle or catheter placement in anticoagulated patients. Therefore, it is recommended to follow the established guidelines when placing a peripheral nerve block in a patient as if they were receiving neuraxial anesthesia. NYSORA does state that many clinicians opt for applying those guidelines when the peripheral nerve block is in a highly vascularized area and or non-compressible.
It is imperative to minimize the incidence of falls, excessive opioid use, delayed recovery and insults by implementing the safest and most effective perioperative anesthetic and recovery plan. Current literature provides substantial evidence to support the utilization of an adductor canal block rather than a femoral nerve block whether utilizing single shot or catheter administration. Early improved range of motion and ambulation times are recommended to decrease the incidence of venous thromboembolism and arthrofibrosis. An ACB allows for improved range of motion and ambulation times postoperatively. The motor sparing effect of an ACB has decreased the incidence of falls in the post TKA population compared to a FNB; while in the studies to date it is shown that patients receiving a FNB have an increased incidence of falls. Finally, hospital length of stay has been shown to be decreased by up almost a full day in the ACB patients.26 ACBs are superior to FNB for TKA patients as evidenced by: less negative sequelae and equivalent or even superior analgesia noted in ACB patients, and with improved ambulation and early recovery, it benefits the patient, surgeon, hospital and anesthetic providers to utilize an ACB block versus a femoral nerve block in TKA patients.
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6. Patterson ME, Bland KS, Thomas LC, et al. The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study. J Clin Anesth. February 2015;27(1):39-44.
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13. Capdevila X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis F. Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999 Jul;91(1):8-15
14. Femoral Nerve Block. New York School of Regional Anesthesia http://www.nysora.com/techniques/ner...rve-block.html Accessed September 16th, 2015
15. 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(5):486-9.
16. Lund J, Jenstrup T, Jaeger P, et al. Continuous adductorcanal-blockade for adjuvant post-oper tive analgesia after major knee surgery: preliminary results. Acta Anaesthesiol
17. Saranteas T, Anagnostis G, Paraskeuopoulos T, et al. Anatomy and clinical implications of the ultrasound-guided subsartorial saphenous nerve block. Reg Anesth Pain Med. 2011;36(4):399-402.
18. Izumi M, Ikeuchi M, Aso K, et al. Less deep vein thrombosis due to transcutaneous fibular nerve stimulation in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2015;23(11):3317-23.
19. Williams-russo P, Sharrock NE, Haas SB, et al. Randomized trial of epidural versus general anesthesia: outcomes after primary total knee replacement. Clin Orthop Relat Res. 1996;(331):199-208.
20. Maynard MJ, Sculco TP, Ghelman B. Progression and regression of deep vein thrombosis after total knee arthroplasty. Clin Orthop Relat Res. 1991;(273):125-30.
21. Chandrasekaran S, Ariaretnam SK, Tsung J, Dickison D. Early mobilization after total knee replacement reduces the incidence of deep venous thrombosis. ANZ J Surg. 2009;79(7-8):526-9.
22. AAOS. Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty http:// www.aaos.org/research/ guidelines/VTE/VTE_guideline.asp. Accessed November 11, 2015.
23. 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. 2015;
24. Mudumbai S, Kim T, Mariano E, et al. Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical Orthopaedics & Related Research. May 2014;472(5):1377-1383.
25. Grevstad U, Mathiesen O, Lind T, Dahl JB. Effect of adductor canal block on pain in patients with severe pain after total knee arthroplasty: a randomized study with individual patient analysis. Br J Anaesth. 2014;112(5):912-9.
26. Shah N, Jain N. 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. The Journal Of Arthroplasty. November 1, 2014;29(11):2224-2229.
27. Jæger P, Nielsen Z, Henningsen M, Hilsted K, Mathiesen O, Dahl J. Adductor Canal Block versus Femoral Nerve Block and Quadriceps Strength: A Randomized, Double-blind, Placebo-controlled, Crossover Study in Healthy Volunteers. Anesthesiology. February 2013;118(2):409-415.
28. Ludwigson JL, Tillmans SD, Galgon RE, Chambers TA, Heiner JP, Schroeder KM. A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty. J Arthroplasty. 2015;30(9 Suppl):68-71.
29. Jenstrup MT, Jæger P, Lund J, et al. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand. 2012;56(3):357-64.
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33. Pelt CE, Anderson AW, Anderson MB, Van dine C, Peters CL. Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter: can we reduce the incidence?. J Arthroplasty. 2014;29(6):1154-7.
34. 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. July -August 2013;38(4):321-5.
35. Kim D, Lin Y, Yadeau J, et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. Anesthesiology. March 2014;120(3):540-550.
36. Jæger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013;38(6):526-32.
37. Wang H, Boctor B, Verner J. The effect of single-injection femoral nerve block on rehabilitation and length of hospital stay after total knee replacement. Reg Anesth Pain Med. 2002;27(2):139-44.
38. Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Anesth Analg. 1998;87(1):88-92.
39. Good RP, Snedden MH, Schieber FC, Polachek A. Effects of a preoperative femoral nerve block on pain management and rehabilitation after total knee arthroplasty. Am J Orthop. 2007;36:554–557.
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42. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev. 2014;5:CD009941.
43. Mitchell D, Friedman RJ, Baker JD, Cooke JE, Darcy MD, Miller MC. Prevention of thromboembolic disease following total knee arthroplasty. Epidural versus general anesthesia. Clin Orthop Relat Res. 1991;(269):109-12.
44. Peng L, Ren L, Qin P, et al. Continuous Femoral Nerve Block versus Intravenous Patient Controlled Analgesia for Knee Mobility and Long-Term Pain in Patients Receiving Total Knee Replacement: A Randomized Controlled Trial. Evid Based Complement Alternat Med. 2014;2014:569107.
45. The Evolution of the Adductor Canal Block: The Emerging Technique for
Motor-Sparing Analgesia to the Knee Adductor Canal John Kline CRNA
|Purpose of Study||Sample size||Study Type||Conclusion||Title|
|A meta-analysis to try to find out if ACB is better than FNB in pain treatment and joint functional recovery after TKA.||434 patients
|Meta Analysis||ACB provide better ambulation ability, faster functional recovery and better pain control at rest after TKA compared to FNB.||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. 2015;|
|Prove efficacy of ACB post op TKA on total morphine consumption, pain measures and early ambulation||71||RCT||CACB Cath vs Placebo-
Decreased pain, faster ambulation, decreased morphine requirement with ACB Cath
|Jenstrup MT, Jæger P, Lund J, et al. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand. 2012;56(3):357-64.|
|Prove efficacy of ACB in established pain after TKA||41||RCT, double blind||ACB required 10mg less morphine in immediate 6 hour post op period.||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(8):1013-9.|
|Prove ACB is as effective as FNB for TKA||80||Cohort, Retrospective||ACB single shot compared to Continuous FNB in 24 hour postoperative period showed ACB able to ambulate further and had equal opioid consumption||Patterson ME, Bland KS, Thomas LC, et al. The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty--a retrospective study. J Clin Anesth. February 2015;27(1):39-44.|
|Compare ACB to FNB for TKA||93||RCT||No significant difference in opioid consumption between the groups and a significant difference with increased motor strength of the ACB group compared to the FNB group||Kim D, Lin Y, Yadeau J, et al. Adductor Canal Block versus Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized, Controlled Trial. Anesthesiology. March 2014;120(3):540-550.|
|Compare ACB to FNB for TKA||48||RCT, Double Blind||ACB group had significantly higher percentage of quadriceps strength and there was no statistically significant difference between ACB and FNB in pain scores, opioid consumption, adductor strength, mobility or morphine related adverse effects||Jæger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med. 2013;38(6):526-32.|
|Compare continuous ACB to continuous FNB after TKA to show that ACB would be associated with greater postoperative ambulation without a reduction in analgesia||168||Cohort, Retrospective||Greater ambulation distance in ACB group on POD 1 of 37meters versus and 6 meters for FNB. On POD 2 it was 60 meters for ACB versus 21meters. No significant difference between the groups in all items measured except that the FNB group had four falls and the ACB group had zero falls||Mudumbai S, Kim T, Mariano E, et al. Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical Orthopaedics & Related Research. May 2014;472(5):1377-1383.|
|Compare ACB to FNB to determine if pain relief from the ACB improved functional quadriceps strength and pain scores||50||RCT, Blinded||20% increase in quadriceps strength in the ACB group, similar pain scores, opioid consumption between the groups. In a timed test to measure safe mobility (TUG test) 7/25 FNB were not able to perform the test where all 25 of the ACB were able to engage in the test after the nerve blockade||Grevstad U, Mathiesen O, Valentiner L, Jaeger P, Hilsted K, Dahl J. Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: a randomized, blinded study. Regional Anesthesia & Pain Medicine. Jan-Feb 2015;40(1):3-10.|
|ACB compared to FNB if ACB produced less quadricep strength impairment. Secondary outcomes measured were adductor strength and ability to ambulate.||11||RCT, Blinded, Crossover Study||In the 6 hour post intervention period mean quadricep strength reduction was 8% in ACB group and 49% in FNB group. Performance in mobility tests was better in the ACB group compared to the FNB group||Jæger P, Nielsen Z, Henningsen M, Hilsted K, Mathiesen O, Dahl J. Adductor Canal Block versus Femoral Nerve Block and Quadriceps Strength: A Randomized, Double-blind, Placebo-controlled, Crossover Study in Healthy Volunteers. Anesthesiology. February 2013;118(2):409-415|
|Compare ACB as opposed to continuous FNB on ambulation ability, pain scores and opioid consumption||98||RCT||Ambulation and mobility was significantly improved in the ACB versus the FNB group. There was no significant intergroup difference in pain scores or opioid requirements. Length of hospital stay was ACB 3.08 vs FNB 3.92 which amounts to almost a full day difference.||Shah N, Jain N. 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. The Journal Of Arthroplasty. November 1, 2014;29(11):2224-2229.|
|Compare effect on quadricep strength of single shot ACB to single shot FNB.||16||RCT, Blinded||Statistical significant motor strength and balance were maintained in the ACB group compared to the FNB group||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. July -August 2013;38(4):321-5.|
|Compare sngle shot adductor canal block to femoral nerve catheter for TKA||297||Cohort, Retrospective||ACB had shorter length of stay by half day, further ambulatory distances(POD1 and 2) similar pain control and earlier discharge when compared to FNC. undergoing TKA.||Ludwigson JL, Tillmans SD, Galgon RE, Chambers TA, Heiner JP, Schroeder KM. A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty. J Arthroplasty. 2015;30(9 Suppl):68-71.|