The Journal of Arthroplasty 30 Suppl. 1 (2015) 68–71

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A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty Jordan L. Ludwigson, BS a, Samuel D. Tillmans, BS a, Richard E. Galgon, MD b, Tamara A. Chambers, RN, MSN b, John P. Heiner, MD c, Kristopher M. Schroeder, MD b a b c

University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin

a r t i c l e

i n f o

Article history: Received 21 January 2015 Accepted 30 March 2015 Keywords: anesthesiology analgesia physical therapy total knee arthroplasty pain

a b s t r a c t The aim of this study was to compare perioperative analgesia provided by single-injection adductor canal block (ACB) to continuous femoral nerve catheter (FNC) when used in a multimodal pain protocol for total knee arthroplasty (TKA). A retrospective cohort study compared outcome data for 148 patients receiving a single-injection ACB to 149 patients receiving an FNC. The mean length of stay (LOS) in the ACB group was 2.67 (±0.56) and 3.01 days (±0.57) in the FNC group (P b 0.0001). The median ambulatory distances for the adductor group were further than the femoral group for postoperative days 1 (P b 0.0001) and 2 (P = 0.01). Single-injection ACB offered similar pain control and earlier discharge compared to continuous FNC in patients undergoing TKA. © 2015 Elsevier Inc. All rights reserved.

Total knee arthroplasty (TKA) is variably associated with significant postoperative pain. Therefore, multimodal analgesic protocols are used to achieve optimal pain relief, shorten length of stay (LOS), and reduce healthcare costs [1,2]. In the setting of TKA, multimodal analgesia regimens increase patient satisfaction and allow for earlier ambulation when compared to oral and intravenous opioid interventions alone [3,4]. Peripheral nerve blocks are included in many TKA pain management plans and have demonstrated superior postoperative analgesia and overall patient outcomes [2,5–10]. Evidence also suggests the utilization of continuous femoral nerve catheters (FNC) for postoperative pain control following TKA provides superior pain control relative to epidural anesthetics and opioid administration alone [11]. However, FNCs may reduce quadriceps muscle strength and have been associated with an increased risk of postoperative falls [12,13], catheter site infection, and limited ability to ambulate until postoperative day (POD) 2 [14]. In addition, mixed evidence exists to definitively state that the additional time, efforts, and cost associated with placing and managing a continuous FNC provides postoperative benefits beyond those linked to traditional single-injection femoral nerve blocks [15,16]. Therefore, adequate pain control, along with quadriceps muscle preservation, has become a goal among orthopedic departments following TKA [17].

No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to doi: http://dx.doi.org/10.1016/j.arth.2015.03.044. Reprint requests: Jordan L. Ludwigson, BS, University of Wisconsin School of Medicine and Public Health, W1694 County Road S, Alma, WI 54610. http://dx.doi.org/10.1016/j.arth.2015.03.044 0883-5403/© 2015 Elsevier Inc. All rights reserved.

With the exception of some variable motor fibers to the vastus medialis, the saphenous and obturator nerves traveling in the adductor canal are sensory in nature [2]. Recent studies provide evidence that continuous ACBs compared to continuous FNCs following TKA spare quadriceps motor strength [18], while achieving similar pain scores [17,19]. Thus, attention in the literature focused on evaluating the use of continuous ACBs for TKA instead of continuous FNC [17,19–22]. Postoperative outcomes for single-injection ACBs following TKA have not, however, been compared to continuous FNCs. The aim of this study was to compare single-injection ACB to continuous FNC with respect to perioperative pain, opioid administration, rehabilitation, and hospital LOS. We hypothesized that single-injection ACB achieves adequate postoperative analgesia while facilitating earlier completion of rehabilitation requirements.

Methods Following protocol approval by the institutional review board, we performed a retrospective review of medical records for consecutive patients who underwent unilateral TKA at our institution between August 1, 2012 and March 31, 2014. All study records were contained in the electronic medical record used at our institution. Of the 297 eligible patients, 148 patients received single-injection ACBs, while 149 patients underwent continuous FNC placement. The following demographic, perioperative, and physical therapy data were extracted and compared: age, gender, body mass index (BMI), length of stay (LOS), baseline opioid consumption, American Society of Anesthesiologists (ASA) physical status score, pain scores, opioid administration, anti-emetic

J.L. Ludwigson et al. / The Journal of Arthroplasty 30 Suppl. 1 (2015) 68–71

administration, and chemical characteristics of the peripheral nerve block (0.5% ropivacaine or 0.5% bupivacaine), and physical therapy data for postoperative day (POD) 0 through 3. Patients preoperatively received either a single-injection ACB or a continuous FNC following sterile skin preparation with chlorhexidine gluconate and lidocaine skin analgesia. Both peripheral nerve blocks were performed by the regional block team, consisting of a resident or fellow supervised by a faculty anesthesiologist with specific training in regional anesthesia, and placed under ultrasound guidance. Sedation with intravenous midazolam and fentanyl was given as needed to facilitate block placement. The adductor canal blocks were positioned on the medial thigh halfway between the inguinal ligament and patella under the sartorius muscle just lateral and superficial to the femoral artery. The femoral nerve catheters were positioned deep to the fascia iliaca approximately 1.0 cm lateral and superficial to the femoral nerve. Following negative aspiration, all patients in both groups received an injection of either ropivacaine or bupivacaine (0.5%, 20 ml). The femoral nerve group also received a continuous infusion of 0.2% bupivacaine until the morning of POD one and 0.1% until discontinued on POD 2 at a continuous rate of 5 ml per hour. Patients underwent either spinal or general anesthesia as their primary anesthetic at the discretion of the in-room anesthesia provider. Those patients managed with general anesthesia were induced with propofol, opioids, and muscle relaxants followed by airway securement. Generally, inhaled agents were used to maintain an appropriate depth of anesthesia. Individual patient hemodynamic and respiratory response to the surgery were used to determine appropriate intraoperative anesthesia maintenance with anesthesia and opioids at the discretion of the anesthesia team caring for the patient. Postanesthesia care unit (PACU) nurses administered anti-emetics and opioids as deemed appropriate based on patient complaints of nausea and pain. All surgical procedures were performed using a medial parapatellar approach through a standard-length incision with the patient in the supine position and a tourniquet about the proximal thigh. All operations were performed with the same technique and implant design (Zimmer NexGen, Warsaw, IN, USA). A bolus of 0.25% bupivacaine and 1:200,000-epinephrine was injected during surgery posterior to the capsule after components of the knee joint were removed. Following the procedure, a sterile dressing was applied and all patients were placed in a knee immobilizer for 12–24 hours postoperatively when out of bed and standing or walking. Time spent with a knee immobilizer was dependent on patient demonstration of strength and ambulation ability during physical therapy sessions. Throughout each patient's hospital stay, self-rated pain scores were taken every 2–6 hours as part of standard nursing practice on the orthopedic inpatient floor. Median and peak pain scores from post-operative day 0 through discharge were obtained from the EMR. Categorical pain scores were defined as: none 0; mild 0.01–2.99; moderate 3.00–6.99; severe 7.00–10.0. Oral and intravenous opioids were administered postoperatively per protocol without standardization between comparison groups. The postoperative pain regimen included oxycodone and morphine as needed, acetaminophen every 6–8 hours, and ketorolac in selected patients. In order to comparatively assess total oral and intravenous opioid administration throughout length of stay, all opioids given were converted to intravenous morphine equivalents (Meq) with the following formula: 1/3 [mg PO morphine] + 1/2 [mg PO oxycodone] + 1/3 [mg PO hydrocodone] + 1/20 [mg PO codeine] + 10/7.5 [mg PO hydromorphone] + [mg IV morphine] + 10/1.5 [mg IV hydromorphone] + 1/10 [mcg IV fentanyl]. Rehabilitation through physical therapy was performed by patients under stable medical conditions on postoperative days 0 through 3. Ambulation distances from both morning and evening sessions were combined into a total ambulatory distance for comparative purposes. Active surgical knee range of motion data was normalized into degrees of flexion in supine (0°–90°) and degrees from complete extension (90°–0°) while seated. Physical therapy data were obtained from physical therapy notes. Patients were encouraged to ambulate within 24 hours after procedure completion. Standard hospital rehabilitation protocol for discharge

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was followed. Barring medical complications, patients were discharged once both pain control and physical therapy requirements were complete. Data were initially analyzed for normality with a D’Agostino & Pearson omnibus test. For normally distributed data, intergroup comparisons were performed using the Student's t-test and reported with a mean and standard error. For data not normally distributed, the Mann–Whitney U test was used for intergroup comparisons. These data are reported with a median and interquartile range (IQR). All statistical analyses were performed using Prism Version 6 (GraphPad Software, La Jolla, CA, USA). P values less than 0.05 were considered statistically significant. Results During the study period, 297 patients underwent unilateral TKA. One hundred forty-eight patients received a single injection ACB, while 149 patients received a continuous FNC. Baseline characteristics, including age, gender, BMI, ASA physical score, anesthesia type, and baseline pain score, were similar between the groups (Table 1). There was no statistical difference between groups for mean perioperative opioid usage, in intravenous morphine equivalents, at any time frame when preoperative chronic and naïve opioid usage was taken into consideration (Table 2). More patients in the ACB group were administered anti-emetics on postoperative day 0 with a percentage of 39.86% in comparison to 24.83% in the FNC group (P = 0.006). Antiemetics administration during the remaining stay did not reach statistical significance (P = 0.72). With respect to median self-rated pain scores during physical therapy, there was no statistical difference on postoperative day 0 (P = 0.56) or throughout the remaining stay (P = 0.23) between comparison groups. Physical therapy data suggest statistically significant differences in rehabilitation capabilities between the ACB and FNC groups on both postoperative days 1 and 2 (Table 3). Most notably, the median ambulatory distances for the adductor group were further compared to the femoral group for postoperative day (POD) 1 with a distance for the ACB group at 175 feet (95.0–250.0) and the FNC group at 90 feet (31.5–202.5) (P b 0.0001). Similar results on POD 2 ambulatory distances were reported with median distance for the ACB group at 260 feet (174.0–357.0) and the FNC group at 207 feet (120.0–329.5) (P = 0.01). Similarly, postsurgical mean knee flexion for the adductor group were greater than the femoral group on both POD 1 (P b 0.0001) and POD 2 (P = 0.001). Additionally, our data suggest a statistically significant difference in the mean hospital length of stay with a time of 2.67 days (± 0.56) for the adductor group compared to 3.01 days (±0.57) in the femoral group (P b 0.0001) (Fig. 1). Discussion The primary finding of this study is that patients receiving a singleinjection ACB for postoperative pain control following TKA demonstrated improvements in ambulation distance and knee flexion on both PODs 1 and 2, and were discharged home sooner when compared to those receiving a continuous FNC. While the improvements in ambulation distance and hospital discharge time likely represent expected increased quadriceps strength, it is surprising that there exists no difference in self-rated pain scores or opioid administration between a block of limited duration versus a continuous catheter technique. The sensory innervation to the articular surfaces and surrounding cutaneous regions of the knee are complex and variable [2]. Redundant afferent nerve fibers travel with the sciatic, femoral, and obturator nerves [23]. Often considered the gold standard for nerve blockade following TKA, the posterior division of the femoral nerve provides the primary motor innervation to the sartorious and quadriceps femoris muscles. A study of twelve healthy volunteer men demonstrated that femoral nerve blocks with ropivacaine reduce quadriceps strength by 49% from baseline [18]. The saphenous nerve, a branch of the posterior

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J.L. Ludwigson et al. / The Journal of Arthroplasty 30 Suppl. 1 (2015) 68–71

Table 1 Patient Demographics.

Table 3 Physical Therapy Outcome Measurements. ACB Mean (±SE) or Median (IQR)

Age Gender (% male) BMI, kg/m2 ASA Anesthesia type (% general) Baseline pain score

FNC Mean (±SE) or Median (IQR)

n = 148

n = 149

64.09 (±9.21) 45.95% 31.29 (±6.21) 2.00 (2.00–2.00) 4.73% 0.00 (0.00–3.00)

64.74 (±9.21) 44.97% 31.48 (±5.87) 2.00 (2.00–2.00) 4.03% 0.00 (0.00–3.00)

P Value 0.54 0.87 0.78 0.06 0.77 0.89

femoral nerve, and the anterior branch of the obturator nerve found within the adductor canal are primarily sensory to both the articular surfaces and cutaneous areas surrounding the knee [2]. Blockade at the level of the adductor canal has emerged as an enticing strategy to provide analgesia without producing quadriceps weakness [17–19]. The results from this retrospective study suggest that single-injection ACB provides similar pain relief to a continuous FNC on POD 0 (P = 0.56) and the remaining stay (P = 0.23). In fact, opioid administration following surgery for both preoperative chronic and naïve users trended toward greater consumption in the femoral group compared to the adductor group, yet this trend did not reach statistical significance. Single bolus injection into the adductor canal is notably easier to perform by anesthetic providers than femoral nerve catheters, potentially leading to more optimal bolus placement [17]. A study of 298 TKA patients examining analgesic outcomes of 48-hour continuous FNC, local infiltration analgesia, or local infiltration analgesia plus ACB found that the additional ACB was associated with lower pain scores at rest and during movement for the first 24 hours than a continuous FNC [24]. Several previous TKA studies have found that opioid consumption and pain scores between patients receiving continuous adductor canal catheters and those with continuous femoral nerve catheters are similar [17–19]. Anti-emetic administration was unexpectedly higher in the adductor group on POD 0 (P = 0.006). While not statistically significant, the adductor group had a higher percent of naïve opioid users (77.4%) compared to the femoral group (66.9%), which may account for the difference in nausea presence. A study of 75 patients demonstrated that postoperative ambulation ability (up to 24 hours), assessed with a Timed-Up-and-Go (TUG) test, in a continuous adductor canal blockade group is greater when compared to a placebo group following TKA. A similar study of 98 knee arthroplasty patients (48 adductor catheters and 50 femoral catheters) indicated greater ambulation distance in a single physical therapy session directly before discharge in the adductor group (92 meters vs. 38 meters) [21]. Physical therapy data from our study suggest that ambulation ability, evaluated by distance traveled (feet), is greater for the

Ambulatory distance (ft.) Postop day 0 Postop day 1 Postop day 2 Knee flexion (degrees) Postop day 0 Postop day 1 Postop day 2 Knee extension (degrees) Postop day 0 Postop day 1 Postop day 2

ACB Mean (±SE) or Median (IQR)

FNC Mean (±SE) or Median (IQR)

P Value

45.0 (17.0–82.5) 175.0 (95.0–250.0) 260.0 (174.0–357.0)

24.00 (10.00–70.00) 90.0 (31.5–202.5) 207.0 (120.0–329.5)

0.34 b0.0001 0.01

62.67 (±7.51) 66.31 (±1.58) 74.36 (±3.02)

53.10 (±4.09) 51.27 (±1.47) 61.45 (±1.60)

0.28 b0.0001 0.001

9.89 (±1.02) 8.97 (±0.58) 6.89 (±0.75)

9.00 (±0.85) 8.46 (±0.41) 7.36 (±0.45)

0.51 0.48 0.61

single-injection ACB group on both PODs 1 and 2 (P b 0.0001 and P = 0.01, respectively). Similarly, pooled data from POD 0 through POD 2 found that knee flexion (0°–90°) averaged 67.40° (±1.41) in the adductor group and 54.75° (±1.17) in the femoral group (P b 0.0001). Timely progression with physical therapy with the single-injection ACB may lead to more desirable outcomes in TKA populations. A retrospective analysis of 1509 TKA patients demonstrated greater functional ambulation with statistically relevant shorter length of stay, lower hospitalization costs, and improved knee function in follow-up visits [25]. An additional prospective study of 86 patients undergoing either total hip or total knee arthroplasty found early ambulation was associated with improved functional independence goals and lower total hospital costs [26]. Notably, our data suggest that mean hospital LOS is less in the ACB group (2.67 days ± 0.56) than the FNC group (3.01 days ± 0.57). Length of stay after TKA, however, is affected by multiple factors including age, cardiovascular disease, BMI, ASA status, and hospital volume and may not be an unbiased postoperational outcomes determinant [27]. This study does have certain limitations. First of all, there are many variables that are not completely standardized or accounted for in a retrospective chart review including lack of standardization in the multimodal pain regime and anesthesia type provided between comparison groups. Second, while there is little variation in technique possible with adductor canal blockade and femoral nerve catheter insertion, variability between providers or trainees may have impacted the results. Third, non-protocolled opioid administration and self-reported pain scores could be affected by the various pain specialists working on the orthopedic inpatient floor. We do, however, believe that consistent surgical technique and discharge requirements strengthen the results and

Table 2 Patient Pain and Drug Outcome Measures.

Self-rated pain Postop day 0 Remaining stay Preop opioid use (% chronic) Opioid usage (preop naive) Postop day 0 Remaining stay Opioid usage (preop chronic) Postop day 0 Remaining stay Nausea present (%) Postop day 0 Remaining stay

ACB Median (IQR)

FNC Median (IQR)

P Value

3.75 (1.63–5.25) 4.00 (3.00–5.00) 23.65%

3.75 (3.00–6.00) 4.00 (3.00–6.00) 33.11%

0.56 0.23 0.07

30.00 (20.00–40.00) 47.50 (30.00–77.50)

32.50 (25.00–42.59) 55.00 (35.17–84.17)

0.16 0.19

27.67 (18.67–42.50) 70.00 (40.00–107.9)

35.25 (25.21–53.75) 99.59 (51.88–155.5)

0.06 0.09

39.86% 25.68%

24.83% 27.52%

0.006 0.72

Fig. 1. A chart of mean hospital LOS between comparison groups.

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validate methodology used throughout the study's duration. In addition, using chronologically continuous patients in each study group reduces potential selection bias associated with chart reviews. In conclusion, this novel study demonstrates that single-injection adductor canal blockades compared to a continuous femoral nerve catheter infusion in TKA patients may be superior for postoperative ambulation, knee flexion, and LOS while providing similar pain control and opioid requirements. Femoral nerve catheters, associated with additional costs upwards of $600 through POD 2 per patient, management requirements, risk of infection, and risk of fall, did not appear to offer any outcome benefits when utilized as part of multimodal analgesia protocols. Based on the results of the study, we conclude that TKA pain management protocols should consider utilizing single-injection adductor canal blocks for total knee arthroplasties. Further research comparing single-injection adductor canal blocks to continuous femoral nerve catheters and continuous adductor canal catheters is warranted. References 1. Fischer J, Simanski P, Bonnet F, et al. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Br J Anaesth 2008;63:1105. 2. Lund J, Jenstrup MT, Jaeger P, et al. Continuous adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. J Anaesth Scand 2010;55(1):14. 3. Andersen HL, Gyrn J, Moller L, et al. Continuous saphenous nerve block as supplement to single-dose local infiltration analgesia for postoperative pain management after total knee arthroplasty. Reg Anesth Pain Med 2013;38(2):106. 4. Charous MT, Madison SJ, Preetham JS, et al. Varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011;115(4):774. 5. Bergeron SG, Kardash J, Huk OL, et al. Functional outcome of femoral versus obturator nerve block after total knee arthroplasty. Clin Orthop Relat Res 2009;467(1):1458. 6. Kardash K, Hickey D, Tessler M, et al. Obturator versus femoral nerve block for analgesia after total knee arthroplasty. Anesth Analg 2007;105(3):853. 7. Macalou D, Trueck S, Meuret P, et al. Postoperative analgesia after total knee replacement: the effect of an obturator nerve block added to the femoral 3-in-1 nerve block. Anesth Analg 2004;99(4):251. 8. Mcnamee DA, Parks L, Milligan KR. Post-operative analgesia following total knee replacement: an evaluation of the addition of an obturator nerve block to combined femoral and sciatic nerve block. J Anaesth Scand 2002;46(1):95.

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9. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block improves analgesia outcomes after total knee arthroplasty. Pain 2010;113(5):1144. 10. Sato K, Sai S, Shirai N, et al. Ultrasound guided obturator versus sciatic nerve block in addition to continuous femoral nerve block for analgesia after total knee arthroplasty. Jap Clin Med 2011;2(1):33. 11. Barrington MJ, Olive D, Low K, et al. Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg 2005;101(6):1824. 12. Pelt CE, Anthony AW, Anderson MB, et al. Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter: can we reduce the incidence? J Arthroplasty 2014;29(1):1154. 13. Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg 2010;111(6):1552. 14. Kandasami M, Kinninmonth AW, Sarungi M, et al. Femoral nerve block for total knee replacement: a word of caution. Knee 2009;16(1):98. 15. Albrecht E, Morfey D, Chan V, et al. Single-injection or continuous femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 2014;472(5):1384. 16. Salinas FV, Liu SS, Mulroy MF, et al. 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 2006;102(6):1234. 17. Jenstrup MT, Jaeger P, Lund J, et al. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. J Anaesth Scand 2012;56(1):357. 18. Jaeger P, Nielsen ZJ, Henningsen MH, et al. Adductor canal block versus femoral nerve block and quadriceps strength. Anesthesiology 2013;118(2):409. 19. Kim DH, Lin Y, Goytizolo EA, et al. Adductor canal block versus femoral nerve block for total knee arthroplasty. Anesthesiology 2014;120(3):540. 20. Jaeger P, Zaric D, Fomsgaard JS, et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty. Reg Anesth Pain Med 2013;38(6):526. 21. Shah NA, Jain NP. 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 control trial. J Arthroplasty 2014;29(11):2224. 22. Ping H, Cheong KF, Lim A, et al. Intraoperative single-shot “3-in-1” femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement. Can J Anesth 2001; 48(11):1102. 23. Gardner E. The innervation of the knee joint. Anat Rec 1948;101:109. 24. Perlas A, Kirkham KR, Billing R, et al. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med 2013;38(4):334. 25. Pau YH, Ong PH. Association of early ambulation with length of stay and costs in total knee arthroplasty. Am J Phys Med Rehabil 2014;00(00):1. 26. Munin MC, Rudy TE, Glynn NW, et al. Early inpatient rehabilitation after elective hip and knee arthroplasty. J Am Med Assoc 1998;279(11):847. 27. Jonas SC, Smith HK, Blair PS. Factors influencing length of stay following primary total knee replacement in a UK specialist orthopaedic centre. Knee 2013;20(1):310.

A Comparison of Single Shot Adductor Canal Block Versus Femoral Nerve Catheter for Total Knee Arthroplasty.

The aim of this study was to compare perioperative analgesia provided by single-injection adductor canal block (ACB) to continuous femoral nerve cathe...
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