|Year : 2021 | Volume
| Issue : 2 | Page : 33-36
Comparative study of clinical effects of ultrasonography-guided adductor canal block versus femoral nerve block for postoperative analgesia in total knee replacement surgery under spinal anesthesia
Indradip Sanyal1, Dipasri Bhattacharya1, Amit Kumar Ray2
1 Department of Anaesthesiology, Critical Care and Pain, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India
2 Department of Anaesthesiology, Critical Care and Pain, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
|Date of Submission||14-Nov-2022|
|Date of Acceptance||06-Dec-2022|
|Date of Web Publication||08-Mar-2023|
B26/10, Abhyudoy Housing, EKTP Phase IV, P.O.EKT, Kolkata - 700 107, West Bengal
Source of Support: None, Conflict of Interest: None
Prevention of postoperative pain and preservation of Quadriceps muscle strength is essential for mobilization after total knee replacement (TKR) surgery. Peripheral nerve blocks are important modalities of pain management. We have compared adductor canal block (ACB) versus femoral nerve block (FNB) for assessment of the intensity of pain, duration of analgesia, consumption of tablet paracetamol as rescue analgesic, and Quadriceps range of motion following TKR. A double-blind randomized prospective study was carried out on 74 patients scheduled for TKR under spinal anesthesia. Patients were divided into two equal groups. Group ACB (n = 37) received ACB and Group FNB (n = 37) received FNB at the end of the operation. The intensity of postoperative pain was assessed by the Visual Analog Scale (VAS) score. Duration of analgesia and Quadriceps range of motion were assessed postoperatively. Group ACB showed low cumulative VAS, increased duration of analgesia, and increased Quadriceps range of motion (P ≤ 0.5) compared to Group FNB. Ultrasound-guided ACB is a better alternative to FNB for postoperative analgesia and better Quadriceps function in patients undergoing TKR under spinal anesthesia.
Keywords: Adductor canal block, femoral nerve block, quadriceps range of motion, total knee replacement, Visual Analog Scale
|How to cite this article:|
Sanyal I, Bhattacharya D, Ray AK. Comparative study of clinical effects of ultrasonography-guided adductor canal block versus femoral nerve block for postoperative analgesia in total knee replacement surgery under spinal anesthesia. J Recent Adv Pain 2021;7:33-6
|How to cite this URL:|
Sanyal I, Bhattacharya D, Ray AK. Comparative study of clinical effects of ultrasonography-guided adductor canal block versus femoral nerve block for postoperative analgesia in total knee replacement surgery under spinal anesthesia. J Recent Adv Pain [serial online] 2021 [cited 2023 Mar 31];7:33-6. Available from: http://www.jorapain.com/text.asp?2021/7/2/33/371252
| Introduction|| |
Total knee replacement (TKR) is associated with severe postoperative pain and reduced Quadriceps power. Effective postoperative analgesia is a challenge after TKR. The incidence of moderate-to-severe pain after TKR is reported to be about 50% and it can contribute to immobility-related complications, delay in hospital discharge, and may interfere with functional outcomes. Multimodal approaches to its relief have been tried, which include neuraxial blockade, systemic nonsteroidal analgesics injection, local infiltration analgesia, and peripheral nerve blockade (PNB).
Early mobilization is required after TKR for better outcomes after surgery. Despite comprehensive multimodal analgesic regimen, TKR is often associated with intense postoperative pain. Epidural analgesia being a viable alternative however may result in side effects such as urinary retention and motor block, with the latter potentially hindering mobilization.
PNBs are commonly used to relieve pain and to reduce analgesic requirements. Femoral Nerve Block (FNB) is one of the most commonly used nerve block, has been shown to be effective in reducing the requirement of rescue analgesics and shortening hospital stays following TKR. FNB has some disadvantages. It leads to Quadriceps muscle weakness as it is a mixed nerve containing both motor and sensory component. Quadriceps weakness results in functional impairment and delays mobilization.,
Adductor canal block (ACB) blocks the largest sensory branch of the femoral nerve to the knee, the saphenous nerve, which is a component of the Adductor canal. ACB thus provides analgesia with only sensory blockade and is as effective as FNB in reducing postoperative pain. As it has no motor component, it does not affect Quadriceps power. When compared with FNB, ACB has been reported to be associated with almost similar pain scores but better quadriceps strength postoperatively, ensuring better ambulation after TKR.,, The advantage of ultrasonography (USG) guided block is that it gives real-time image, helps to visualize the tip of the needle and deposition of drugs accurately.,
Hence, we have undertaken this study of USG-guided ACB versus FNB for postoperative pain management and assessment of Quadriceps range of motion in patients undergoing TKR under spinal anesthesia.
The aim of the study was to assess analgesic efficacy in terms of intensity of pain using the Visual Analgesic Scale score, duration of analgesia, and functional recovery of Quadriceps muscle between ACB and FNB in postoperative patients of TKR.
| Methods|| |
After approval from the Ethics committee and informed consent from the patients, the study was undertaken on 74 patients undergoing TKR under spinal anesthesia according to a standard protocol. Inclusion criteria were the American Society of Anesthesiologist (ASA) physical status 1, 2, age 50 to 80 years, and patients with Body Mass Index (BMI) <30. Exclusion criteria were any non-TKR patient, uncooperative patients, cardiac or neurological diseases, uncontrolled diabetes, hypertension, patient on psychiatric medications, known allergy to the drugs used, chronic opioid use (defined as daily or almost daily use of opioids for more than 3 months), BMI >30 or <20 and ASA Class 4 or 5.
The patients were divided into two groups; 37 in each, one group was ACB and the other was FNB. Both groups were given spinal anesthesia with 26 gauge Quincke's needle along with co-loading of Ringer's lactate solution @10 ml per kg body weight, with 3 ml of bupivacaine heavy (0.5%) at L 34 intervertebral space under strict asepsis using routine ASA monitoring standards. At the end of operation, 10 ml of 0.25% bupivacaine was injected in each group after locating the respective nerve under ultrasound guidance with high-frequency linear transducer (1012 Hz). In the ACB group, under USG guidance, boat-shaped Sartorius muscle was identified, then the femoral artery, femoral vein, and femoral nerve from medial to the lateral side and the injection was given distally along the Saphenous nerve under the Sartorius muscle. In the FNB group, after locating the femoral nerve on the hypoechoic Ilio Psoas muscle, the needle tip was placed in the layer of the femoral nerve so that the injection lifts the nerve toward the surface.The study was done in Orthopedic operation theatre of R G Kar Medical College, Kolkata.
The sample size was calculated following the formula: Group A = ACB, Group B = FNB, n = 37 (no of patients).
Primary variables are the duration of analgesia from the time of administration of nerve block to the requirement of rescue analgesics, the intensity of pain by Visual Analog Scale (0 = no pain, and 10 unbearable pain), the requirement of rescue analgesics (1000 mg of Tablet PCM) when Visual Analog Scale (VAS) was >3.The range of motion of the Quadriceps was assessed by Goniometer by Straight Leg Raising (SLR) test.
SPSS version was used for statistical analysis, P < 0.05 was considered statistically significant.
| Results|| |
Demographic variables based on age, sex, BMI, and duration of operation, in between the two groups are given in [Table 1]. The comparative duration of analgesia (mean ± standard deviation [s.d.]) of patients in both groups is given in [Table 2].
|Table 1: Demographic variables based on age, sex, body mass index, duration of operation, in between two groups|
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In Group A, the mean pain score at 0 min (mean ± s.d.) of patients was 2.05 ± 0.77. In Group B, the mean pain score at 0 min (mean ± s.d.) of patients was 3.37 ± 1.34 (P < 0.0001). In Group A, the mean pain score at 1 h (mean ± s.d.) of patients was 1.75 ± 0.59. In Group B, the mean pain score at 1 h (mean ± s.d.) of patients was 2.81 ± 1.15 (P < 0.0001). In Group A, the mean pain score at 3 h (mean ± s.d.) of patients was 1.32 ± .47. In Group B, the mean pain score at 3 h (mean ± s.d.) of patients was 2.21 ± .85 (P < 0.0001). In Group A, the mean pain score at 6 h (mean ± s.d.) of patients was 0.43 ± .50. In Group B, the mean pain score at 6 h (mean ± s.d.) of patients was 1.54 ± .69 (P < 0.0001). In Group A, the mean pain score at 9 h (mean ± s.d.) of patients was 0.35 ± .48. In Group B, the mean pain score at 9 h (mean ± s.d.) of patients was 0.86 ± .82 (P = 0.0016). In Group A, the mean pain score at 12 h (mean ± s.d.) of patients was 0.18 ± .39. In GroupB, the mean pain score at 12 h (mean ± s.d.) of patients was 0.59 ± .49 (P = 0.0002). The cumulative VAS scores at various time period in both groups is given in [Figure 1]. The range of motion at various time periods is given in [Table 3].
|Figure 1: Cumulative VAS Score in between two groups. VAS: Visual analog scale|
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| Discussion|| |
TKR is associated with moderate-to-severe postoperative pain, thereby effective analgesia is of extreme importance. The ideal analgesia regime that balances optimal postoperative pain control and early mobilization by preserving motor function is essential for early recovery after TKR. ACB after TKR is better due to effective analgesia and motor preservation compared with FNB.,, The results of the study showed the duration of analgesia was higher in the ACB Group compared to the FNB Group, low cumulative pain scores in terms of VAS in the ACB group, better range of motion of Quadriceps as measured by SLR in the ACB Group compared to FNB Group. This fact is supported by Grevstad et al., Koh J, Dong C. and Dong S. Studies by Pia Jaeger et al. showed Quadriceps weakness after FNB using Dynamometer (placed between the malleoli on the anterior aspect to the ankle and asking the patients to extend their legs three times with a 30 s pause between each attempt). The greater preservation of quadriceps strength and early ambulation in patients with ACB is an attribute of the anatomy of the block. ACB mainly targets Saphenous nerve, which is purely sensory in nature. ACB results in sensory blockade of the anteromedial aspect of the knee, and spares most of the motor innervations of the Quadriceps group.,, The femoral nerve, on the other hand, is encountered at or below the level of the inguinal ligament. Injection at this site causes neural blockade in the entire front of the upper thigh down to and including the patella, and the medial side of the lower leg to nearly the medial malleolus of the femur., The importance of this muscle power preservation in ACB as compared to FNB is reflected in a new composite score called “discharge readiness” which includes four parameters: adequate analgesia, intravenous opioid dependence, ability to stand, walk 3 m and sit down, and ability to ambulate 30 m., Moreover, lesser hospital stay has economic benefits from all aspects and lesser rescue analgesics consumption has fewer adverse effects in the ACB group also.,,, Our study showed similar results as the study of Christensen et al., Sakai et al. and Kurtz et al.,, All our patients who received ACB had early mobilization.
This study had many limitations as a relatively larger sample size would have been more convenient, lack of high-quality evidence in several outcomes, and heterogeneity may come from risk factors such as age, gender, dose, and concentration of local anesthetics, also anesthesia methods may influence postoperative pain scores.
To conclude, both ACB and FNB are effective modalities of pain management after TKR, but ACB, however, has better analgesic efficacy, better quadriceps function, and early ambulation in comparison to FNB. Hence, ACB may be a preferred option for postoperative analgesia after TKR.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]