Ultrasound-Guided Adductor Canal Block Versus Intraoperative Transarticular Saphenous Nerve Block: A Retrospective Analysis

Intraoperative Surgeon-Administered Adductor Canal Block Is a Safe Alternative to Preoperative Anesthesiologist-Administered Adductor Canal Block in Primary Total Knee Arthroplasty

BACKGROUND

The shift toward outpatient total knee arthroplasties (TKAs) has led to a demand for effective perioperative pain control methods. A surgeon-performed "low" adductor canal block ("low-ACB") technique, involving an intraoperative ACB, is gaining popularity due to its efficiency and early pain control potential. This study examined the transition from traditional preoperative anesthesiologist-performed ultrasound-guided adductor canal blocks ("high-ACB") to low-ACB, evaluating pain control, morphine consumption, first physical therapy visit gait distance, hospital length-of-stay, and complications.

METHODS

There were 2,620 patients at a single institution who underwent a primary total knee arthroplasty between January 1, 2019, and December 31, 2022, and received either a low-ACB or high-ACB. Cohorts included 1,248 patients and 1,372 patients in the low-ACB and high-ACB groups, respectively. Demographics and operative times were similar. Patient characteristics and outcomes such as morphine milligram equivalents (MMEs), Visual Analog Scale pain scores, gait distance (feet), length of stay (days), and postoperative complications (30-day readmission and 30-day emergency department visit) were collected.

RESULTS

The low-ACB cohort had higher pain scores over the first 24 hours (5.05 versus 4.86, P < .001) and higher MME at 6 hours (11.49 versus 8.99, P < .001), although this was not clinically significant. There was no difference in pain scores or MME at 12 or 24 hours (20.81 versus 22.07 and 44.67 versus 48.78, respectively). The low-ACB cohort showed longer gait distance at the first physical therapy visit (188.5 versus 165.1 feet, P < .001) and a shorter length of stay (0.88 versus 1.46 days, P < .01), but these were not clinically significant. There were no differences in 30-day complications.

CONCLUSIONS

The low-ACB offers effective pain relief and comparable early recovery without increasing operative time or the complication rate. Low-ACB is an effective, safe, and economical alternative to high-ACB.

LEVEL OF EVIDENCE

Therapeutic study, Level III (retrospective cohort study).

Addition of Surgeon-Administered Adductor Canal Infiltration to the Periarticular Infiltration in Total Knee Arthroplasty: Effect on Pain and Early Outcomes

BACKGROUND

Our aim was to study the additive effect of surgeon-administered adductor canal infiltration (SACI) over routine periarticular infiltration (PAI) on pain control [morphine consumption and pain score by the visual analog scale (VAS)] and early function [flexion and Timed Up and Go (TUG) test] post-total knee arthroplasty (TKA).

METHODS

We prospectively randomized 60 patients into 2 groups. Group I patients received the standard PAI, whereas in Group II, the patients received a SACI in addition to the PAI. The total volume of the injected drug and the postoperative pain management protocol were the same for all. The number of doses of patient-controlled analgesia (PCA) used for breakthrough pain was recorded as PCA consumption. For early function, flexion and the TUG test were used. The VAS score and PCA consumption were compared between the 2 groups by using analyses of variance with post hoc tests as indicated. The TUG test and flexion were compared using Student t tests. The level of significance was set at 0.05.

RESULTS

The PCA consumption in the first 6 hours was significantly higher in Group I (P = .04). The VAS at 6 hours was significantly lower in Group II (P = .042). The TUG test was comparable between the 2 groups preoperatively (P = .72) at 24 hours (P = .60) and 48 hours (P = .60) post-TKA. The flexion was comparable between the 2 groups preoperatively (P = .85) at 24 hours (P = .48) and 48 hours (P = .79) post-TKA.

CONCLUSIONS

Adding a SACI to PAI provides improved pain relief and reduces opioid consumption without affecting early function post-TKA. A SACI avoids the need for an anesthesiologist or specialized equipment with no added operating time and minimal added cost. We recommend routine use of SACI for all patients undergoing TKA.

Surgeon-Performed Intraoperative Peripheral Nerve Blocks and Periarticular Infiltration During Total Hip and Knee Arthroplasty: A Critical Analysis Review

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Surgeon-performed intraoperative peripheral nerve blocks may improve operating room efficiency and reduce hospital resource utilization and, ultimately, costs. Additionally, these blocks can be safely performed intraoperatively by most orthopaedic surgeons, while only specifically trained physicians are able to perform ultrasound-guided peripheral nerve blocks.

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IPACK (infiltration between the popliteal artery and capsule of the knee) blocks are at least noninferior to periarticular infiltration when combined with an adductor canal block for analgesia following total knee arthroplasty.

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Surgeon-performed intraoperative adductor canal blocks are technically feasible and offer reliable anesthesia comparable with ultrasound-guided blocks performed by anesthesiologists. While clinical studies have shown promising results, additional Level-I studies are required.

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A surgeon-performed intraoperative psoas compartment block has been described as a readily available and safe technique, although there is some concern for femoral nerve analgesia, and temporary sensory changes have been reported.