A Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique

doi:10.1016/j.arth.2017.11.018

The Journal of Arthroplasty

Volume 33, Issue 4, April 2018, Pages 1045-1051

https://doi.org/10.1016/j.arth.2017.11.018 Get rights and content

Abstract

Background

Adductor canal blocks (ACBs) provide effective analgesia following total knee arthroplasty. We hypothesized that ACB single injection plus intravenous (IV) dexamethasone (Dex) shows non-inferiority to catheter, while ACB single injection does not.

Methods

One hundred eighty patients were randomized and 177 analyzed from among 1 of 3 ACB interventions: (1) 0.5% ropivacaine 20 mL; (2) 0.5% ropivacaine 20 mL plus IV Dex 8 mg; (3) 0.5% ropivacaine 20 mL followed by continuous infusion of 0.2% ropivacaine at 5 mL/h for 48 hours. The primary endpoint was cumulative opioid consumption at 24 hours in oral morphine equivalents, with a non-inferiority limit of 30 mg. Secondary endpoints included opioid consumption at 12 and 48 hours, rest pain scores, quality of recovery survey, length of stay, and anti-emetic usage.

Results

For 24-hour opioid consumption, single injection ACB with and without IV Dex had a mean difference of −24.2 mg (confidence interval [CI] 0.5 to −48.9, P < .001) and −21 mg (CI 3.2 to −45.1, P < .001) relative to catheter, demonstrating non-inferiority. Non-inferiority was also shown at 12 hours by Dex and single injection over catheter with mean difference of −20.4 mg (CI −6.8 to −33.9, P < .001) and −15.1 mg (CI −2.1 to −28.2, P < .001), respectively. No intergroup difference was found for 48-hour opioid consumption. No differences in other secondary outcomes were observed across the 3 groups.

Conclusion

Single injection ACB, with and without IV Dex, is non-inferior to ACB catheters in 24-hour opioid consumption, and may be attractive options for early-discharge, fast-track total knee arthroplasty.

Section snippets

Materials and Methods

This study is a prospective randomized controlled trial conducted at an University affiliated academic hospital. Study approval was obtained from the University Research Ethics board in June 2016 (H16-01058) and the trial registered at ClinicalTrials.gov (NCT02798835). Adults over 18 years of age and with American Society of Anesthesiologists physical status I to III, scheduled to undergo primary unilateral TKA with spinal anesthesia, were eligible for enrolment. Exclusion criteria were

Results

Over a 5-month period (July-November 2016), 226 patients were approached and 180 were randomized into one of the 3 study groups (Fig. 1). Of the remainder, 6 patients were converted to general anesthesia for unsuccessful spinal, 1 refused participation, and 39 did not otherwise meet inclusion criteria. There was 1 protocol violation where a patient randomized into the catheter group was misidentified and received the single injection block instead. This patient remains in the catheter group per

Discussion

This study represents one of the largest prospective studies of ACB on TKA to date, with 177 patients. In accordance to the original hypothesis, single injection ACB with systemic Dex was shown to be non-inferior to a continuous catheter at 12 and 24 hour. Contrary to the hypothesis, the same was also found true for single injection ACB. Remarkably, the catheter group seemed to be the least beneficial modality of the 3 by having the most opioid consumption across all time points. There is a

Acknowledgments

The study authors thank Rebecca Grey, study coordinator, for patient recruitment; Boris Kuzeljevic, statistician, for statistical analysis and interpretation; Nicola Serreqi, anesthetic assistant, for assisting with blocks; and the study surgeons: Drs Bassam Masri, Donald Garbuz, and Nelson Greidanus from the Department of Orthopedics, University of British Columbia.

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A multimodal intraosseous infusion of morphine and ketorolac decreases early postoperative pain and opioid consumption following total knee arthroplasty
2023, Knee
Multimodal pain management regimens and intraosseous infusion of morphine are two novel techniques that show promise in decreasing postoperative pain and opioid consumption following total knee arthroplasty. However, no study has analyzed the intraosseous infusion of a multimodal pain management regimen in this patient population. The purpose of our investigation was to examine the intraosseous administration of a multimodal pain regimen comprised of morphine and ketorolac during total knee arthroplasty with regard to immediate and 2-week postoperative pain, opioid pain medication intake, and nausea levels.
In this prospective cohort study with comparisons to a historical control group, 24 patients were prospectively enrolled to receive an intraosseous infusion of morphine and ketorolac dosed according to age-based protocols while undergoing total knee arthroplasty. Immediate and 2-week postoperative Visual Analog Score (VAS) pain scores, opioid pain medication intake, and nausea levels were recorded and compared against a historical control group that received an intraosseous infusion of morphine alone.
During the first four postoperative hours, patients who received the multimodal intraosseous infusion experienced lower VAS pain scores and required less breakthrough intravenous pain medication than those patients in our historical control group. Following this immediate postoperative period, there were no additional differences between groups in terms of pain levels or opioid consumption, and there were no differences in nausea levels between groups at any time.
Our multimodal intraosseous infusion of morphine and ketorolac dosed according to age-based protocols improved immediate postoperative pain levels and reduced opioid consumption in the immediate postoperative period for patients undergoing total knee arthroplasty.
Liposomal Bupivacaine Versus Continuous Nerve Block: Liposomal Bupivacaine May be Non-inferior and More Cost Effective
2023, Journal of Arthroplasty
Regional anesthesia with adductor canal block has become the standard of care for pain management after total knee arthroplasty (TKA). We hypothesized that liposomal bupivacaine (LB) may be noninferior to continuous nerve block with a pain pump in terms of average pain scores, 30- and 90-day readmissions, and emergency department (ED) visits while reducing cost.
A retrospective chart review was performed on primary TKA patients from 2015 to 2020 by 23 orthopaedic surgeons at a single institution. The inclusion criteria was treatment with LB or a pain pump, and exclusion criteria was receipt of both anesthetics and revision surgery. A total of 2,378 patients met the inclusion criteria with 1,640 patients treated with LB and 738 treated with the pain pump. Demographic differences were not statistically significant. Primary outcomes were average pain scores, 30- and 90-day readmissions, and ED visits. Secondary outcomes were average milligram morphine equivalents per admission, hospital lengths of stay , and costs.
There was no significant difference in pain scores on postoperative days 0, 1, 2, or 3 (P = .77, .86, 0.08, and 0.40, respectively), 30- or 90- day readmissions (P = .527 and P = .374), ED visits (P = .129 and P = .108), milligram morphine equivalents utilizations (P = .194), or average hospital LOS (P = .348). We estimated a potential cost savings of $95 per patient and $155,800 over the course of the study.
LB was found to be noninferior to a pain pump, and the transition to this medication was associated with cost savings.
Management of perioperative pain after TKA
2023, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
On the other hand, a nosocomial infection risk due to 48 hours’ catheterization has not been demonstrated [15,24,47]. There were no significant differences between the two [48,51–53,62]. According to some reports, postoperative pain is less with continuous blocks, but functional recovery is not better [48,50,52,63].
Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.
Continuous vs. single-shot adductor canal block for pain management following primary total knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials
2022, Orthopaedics and Traumatology: Surgery and Research
Citation Excerpt :
For continuous ACB, seven studies [16,18,20–26] used basal rate infusion and four studies [16–18,24–26] used repeated bolus injections. Five studies [16–18,20–26] used intra or periarticular injections as part of their multimodal analgesia regimen for all patients and one study [25] used a block in the interspace between the popliteal artery and the posterior capsule of the knee (IPACK) in addition to single-shot ACB. All studies but one [26] reported opioid consumption.
Adductor canal block (ACB) provides effective analgesia following total knee arthroplasty (TKA). This systematic review aimed to compare continuous and single-shot ACB for pain management and functional recovery following TKA.
MEDLINE, Embase, Web of Science and CENTRAL were searched up to January 5th, 2021. Included studies were randomized controlled trials comparing continuous to single-shot ACB for postoperative pain management after primary TKA. Primary outcome was opioid consumption and secondary outcomes were pain intensity, quadriceps strength, mobility, complications, and length of hospital stay. Meta-analyses were performed using random-effects method.
Eleven studies (910 patients) were included in this systematic review. Continuous ACB did not significantly decrease opioid consumption (8 studies; 642 patients; MD = −5.67; 95% CI: −13.87 to 2.54; I² = 13%) but significantly decreased 48 hours pain scores (10 studies; 852 patients; MD = −0,73; 95% CI: −0.93 to −0.54; I² = 54%). Continuous ACB improved quadriceps strength (4 studies; 250 patients; SMD = 0.59; 95% CI: 0.16 to 1.03; I² = 63%) but not Timed Up and Go test performance (5 studies; 524 patients; MD = 3.99; 95% CI: −8.98 to 1.01; I² = 89%). Type of ACB did not affect nausea and vomiting (5 studies; 357 patients; RR = 1.23; 95% CI: 0.65 to 2.34; I² = 0%) nor length of hospital stay (8 studies; 655 patients; MD = −0.13; 95% CI: −0.28 to 0.01; I² = 36%).
Continuous ACB did not reduce opioid consumption following TKA. Larger trials are required.
Continuous vs. single-shot adductor canal block for pain management following primary total knee arthroplasty: A systematic review and meta-analysis of randomized controlled trials
2022, Revue de Chirurgie Orthopedique et Traumatologique
Le bloc du canal des adducteurs (BCA) est une modalité d’analgésie efficace après une prothèse totale du genou (PTG). Cette revue systématique visait à comparer le BCA en continu et le BCA en injection unique pour la gestion de la douleur et la récupération fonctionnelle après une PTG.
MEDLINE, Embase, Web of Science et CENTRAL ont été recherchées jusqu’au 5 janvier 2021. Les études incluses étaient des essais cliniques randomisés comparant le BCA en continu et le BCA en injection unique pour la gestion de la douleur postopératoire après une PTG primaire. Le critère de jugement principal était la consommation d’opioïdes et les critères de jugement secondaires étaient l’intensité de la douleur, la force du quadriceps, la mobilité, les complications et la durée du séjour hospitalier. Des méta-analyses ont été effectuées en utilisant la méthode des effets aléatoires.
Onze études (910 patients) ont été incluses dans cette revue systématique. Le BCA en continu n’a pas diminué de manière significative la consommation d’opioïdes (8 études ; 642 patients ; DM = −5,67 ; IC95 % : −13,87 à 2,54 ; I² = 13 %) mais a diminué de manière significative les scores de douleur à 48 heures (10 études ; 852 patients ; DM = −0,73 ; IC95 % : −0,93 à −0,54 ; I² = 54 %). Le BCA en continu a amélioré la force du quadriceps (4 études ; 250 patients ; DMS = 0,59 ; IC95 % : 0,16 à 1,03 ; I² = 63 %) mais pas la performance au test chronométré du levé de chaise (5 études ; 524 patients ; DM = 3,99 ; IC95 % : −8,98 à 1,01 ; I² = 89 %). Le type de BCA n’a pas affecté les nausées et les vomissements (5 études ; 357 patients ; RR = 1,23 ; IC95 % : 0,65 à 2,34 ; I² = 0 %) ni la durée d’hospitalisation (8 études ; 655 patients ; DM = −0,13 ; IC95 % : −0,28 à 0,01 ; I² = 36 %).
Le BCA en continu n’a pas réduit la consommation d’opioïdes après une PTG. Des études plus importantes sont nécessaires.
The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis
2022, Journal of Arthroplasty
Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.
We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks.
Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective.
Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.

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: Steven Lee helped in study design, conduct of study, data analysis, manuscript preparation, and final approval; Nirooshan Rooban helped in study design, conduct of study, and manuscript preparation; Himat Vaghadia helped in study design, manuscript preparation, and final approval; Andrew N. Sawka helped in study design, manuscript preparation, and final approval; and Raymond Tang helped in study design, conduct of study, data analysis, manuscript preparation, and final approval.

: Funding: Internal departmental funding from the Department of Anesthesia and Perioperative Care, Vancouver General Hospital, Vancouver, BC, Canada.

: Institutional Review Board Approval: This study is a prospective randomized controlled trial conducted at the University of British Columbia Hospital. Study approval was obtained from the University of British Columbia Research Ethics Board in June 2016 (H16-01058).

: Clinical Trial Number: NCT02798835 (https://clinicaltrials.gov/show/NCT02798835)

: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to https://doi.org/10.1016/j.arth.2017.11.018.

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Primary ArthroplastyA Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique

Abstract

Background

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

J Arthroplasty

J Arthroplasty

Br J Anaesth

Br J Anaesth

Br J Anaesth

J Clin Anesth

Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030

J Bone Joint Surg Am

Prevalence of total hip and knee replacement in the United States

J Bone Joint Surg Am

The role of overweight and obesity in relation to the more rapid growth of total knee arthroplasty volume compared with total hip arthroplasty volume

J Bone Joint Surg Am

The impact of analgesic modality on early ambulation following total knee arthroplasty

Reg Anesth Pain Med

Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials

Anesthesiology

Pain after unilateral total knee arthroplasty: a prospective randomized controlled trial examining the analgesic effectiveness of a combined adductor canal peripheral nerve block with periarticular infiltration versus adductor canal nerve block alone versus periarticular infiltration alone

Anesth Analg

Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: a systematic review and meta-analysis

Int Orthop

Primary Arthroplasty
A Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique