International Orthopaedics (SICOT) DOI 10.1007/s00264-014-2527-3

ORIGINAL PAPER

Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement Stavros G. Memtsoudis & Daniel Yoo & Ottokar Stundner & Thomas Danninger & Yan Ma & Lazaros Poultsides & David Kim & Mary Chisholm & Kethy Jules-Elysee & Alejandro Gonzalez Della Valle & Thomas P. Sculco

Received: 15 August 2014 / Accepted: 1 September 2014 # SICOT aisbl 2014

Abstract Purpose Providing effective analgesia for total knee arthroplasty (TKA) patients remains challenging. Femoral nerve block (FNB) offers targeted pain control; however, its effect on motor function, related fall risk and impact on rehabilitation has been the source of controversy. Adductor canal block (ACB) potentially spares motor fibres of the femoral nerve, but the comparative effect of the two approaches has not yet been well defined due to considerable variability in pain perception. Our study compares both single-shot FNB and ACB, side to side, in the same patients undergoing bilateral TKA. Methods Sixty patients scheduled for bilateral TKA were randomised to receive ultrasound-guided FNB on one leg and ACB on the other, in addition to combined spinal epidural anaesthesia. The primary outcome was comparative S. G. Memtsoudis (*) : D. Yoo : O. Stundner : T. Danninger : D. Kim : M. Chisholm : K. Jules-Elysee Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, USA e-mail: [email protected] O. Stundner : T. Danninger Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, 5020 Salzburg, Austria Y. Ma Division of Biostatics and Epidemiology, Department of Public Health, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, USA L. Poultsides : A. G. D. Valle : T. P. Sculco Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th Street, New York, NY, USA

postoperative pain in either extremity at six to eight, 24 and 48 hours postoperatively. Secondary comparative outcomes included motor strength (manually and via dynamometer), physical therapy milestones and patient satisfaction. Results While pain levels were lowest at six to eight hours postoperatively and increased thereafter (Pthree months, had a history of peripheral neuropathy and/or neurologic deficits, had contraindications (infection at the site of injections, coagulopathies) to surgery or refused the use of peripheral nerve blocks, contraindications to spinal or epidural anaesthesia and allergies or contraindications to standard medications used as part of the protocol. Patients for bilateral TKA were screened for eligibility according to institutional guidelines [18, 19]. In brief, appropriate candidates with no significant cardiopulmonary disease were classified as 1 or 2 according to the American Society of Anesthesiologists (ASA) Physical Status Classification1 and had a body mass index (BMI) >40 kg/m2. Patients provided written informed consent and were given 6 mg dexamethasone and 7.5 or 15 mg meloxicam (weightadjusted) pre-operatively, as per institutional protocol. In the operating room, standard ASA monitors and nasal oxygen at 3 l/min via cannula were applied, and sedation with midazolam 5 mg IV in divided doses was induced. The two extremities were randomised to receive either US guided subsartorial ACB or FNB using blinded envelopes prepared by a independent research assistant and only visible to the attending anaesthesiologist assigned. Patients, surgeons, physical therapists and research assistants performing the follow-up were blinded to the randomisation. Subsequently, blocks were performed as randomised using a sterile technique. US-guided blocks were performed using a 13–6 MHz linear probe (SonoSite, Bothell, WA, USA) and a 22-gauge Chiba type needle of either 6 cm or 10 cm length depending on patient habitus and anaesthesiologist preference. FNBs were performed using an in-plane technique, advancing the needle tip under the fascia lata approximately 1 cm lateral to the femoral nerve and injecting 30 ml of bupivacaine 0.25 %. ACBs also used an in-plane technique and were performed by injecting 15 ml bupivacaine 0.25 %. Approaches were carried out following common institutional practice on the basis of previous descriptions [6, 12]. Following nerve block, patients received a combined spinal epidural anaesthetic in the lumbar region of 2.5 ml bupivacaine 0.5 % intrathecal injection. An epidural catheter was placed in the lumbar region and used for postoperative pain control. A radial arterial line was placed as per institutional protocol. Sequential surgery commenced under tourniquet inflation using a posteriorly stabilised knee implant. After surgery, patients were transferred to the recovery room where they were observed as per routine for the first postoperative night. Pain management via epidural catheter was started at the earliest sign of neuraxial anaesthetic resolution and consisted of patient-controlled analgesia containing bupivacaine 0.06 %/hydromorphone 10 mcg/ml at 4 ml/h basal rate, 4 ml bolus every ten minutes and a 20-ml maximum hourly dose. In 1 http://www.asahq.org/Home/For-Members/Clinical-Information/ASAPhysical-Status-Classification-System.

International Orthopaedics (SICOT)

addition, one to two pills of hydrocodone 5 mg with 325 mg acetaminophen were made available orally every four hours, as needed. The basal epidural rate was reduced to 2 ml/h on the morning of postoperative day (POD) 1 and discontinued on POD 2 before the catheter was removed later that day. Data recorded included patient demographics (age, gender, height, weight, ASA classification, individual comorbidities) and intraoperative events (tourniquet times, estimated blood loss, IV fluids). Patients were approached six to eight hours, 24 hours and 48 hours postoperatively and assessed for pain, sensory recovery and motor strength. Pain was evaluated by asking the patient to rate which extremity was more painful, with options being left, right and the same. The visual analogue (VAS) scale was used at rest and while performing a standardised exercise using a continuous passive motion (CPM) machine. Pinprick tests were conducted at the dermatomes of the saphenous nerve and assessed for no, partial or complete sensory recovery. Motor strength was evaluated using a Lafayette Manual Muscle Test System (Lafayette Instrument Company, Lafayette, IN, USA). Quadriceps strength was assessed with the patient supine, knees flexed on a foam roller at 34–40°, bed angle between 14–27° and knee extension against the Lafayette dynamometer placed over the base of the tibia. Strength readings were recorded as kilograms of force. Quadriceps strength was estimated using a manual muscle test with a standardised 0–5 motor-strength scale [20]. Motor strength was measured before surgery to establish a reference. All motor-strength evaluations were performed three times at each time point and the results averaged. Patient satisfaction with either block was assessed using a standardised scale from 0–10 [21]. Further, we collected data on the attainment of physical therapy milestones as defined by the ability to extend the knee independently to within

Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement.

Providing effective analgesia for total knee arthroplasty (TKA) patients remains challenging. Femoral nerve block (FNB) offers targeted pain control; ...
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