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Sørensen JK, Grevstad U, Jaeger P, Nikolajsen L, Runge C. Effects of popliteal plexus block after total knee arthroplasty: a randomized clinical trial. Reg Anesth Pain Med 2024:rapm-2024-105747. [PMID: 39019501 DOI: 10.1136/rapm-2024-105747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Accepted: 07/02/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND AND OBJECTIVES Motor-sparing peripheral nerve blocks enhance multimodal opioid-sparing strategies after total knee arthroplasty. We hypothesized that adding a popliteal plexus block to a femoral triangle block could reduce 24-hour opioid consumption after total knee arthroplasty, compared with standalone femoral triangle block or adductor canal block. METHODS This patient- and assessor-blinded, randomized controlled trial allocated 165 patients into three equally sized parallel groups, receiving either 1) popliteal plexus block+femoral triangle block, 2) femoral triangle block, or 3) adductor canal block. Intravenous oxycodone was administered via patient-controlled analgesia pumps. The primary outcome was 24-hour postoperative opioid consumption. Secondary outcomes were preoperative maximum voluntary isometric contraction and manual muscle tests of knee and ankle movement assessed before and after the nerve block procedure together with postoperative pain scores, mobilization, and 12-hour opioid consumption. RESULTS 24-hour postoperative intravenous oxycodone consumption varied significantly between groups (p<0.01), with medians (IQR) of 6 mg (2-12) in the popliteal plexus block+femoral triangle block group, 10 mg (8-16) in the femoral triangle block group, and 12 mg (6-18) in the adductor canal block group. Median consumption in the popliteal plexus block+femoral triangle block group was reduced by -4 mg (95% CI -7.4 to -1.0, p<0.01) and -6 mg (95% CI -8.3 to -1.3, p=0.01) compared with groups of femoral triangle block and adductor canal block, respectively. No differences were found in pain scores, mobilization, or changes in preoperative muscle strength. Post hoc analysis revealed successful 24-hour opioid-free postoperative care among 12 patients with popliteal plexus block+femoral triangle block, as compared with two with femoral triangle block and six with adductor canal block. CONCLUSION Adding a popliteal plexus block to a femoral triangle block resulted in a statistically significant reduction of 24-hour postoperative opioid consumption after total knee arthroplasty. However, no differences were found in pain scores. Popliteal plexus block did not impair the lower leg muscles.
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Affiliation(s)
- Johan Kløvgaard Sørensen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Ulrik Grevstad
- Department of Anesthesiology, Gentofte Hospital, Hellerup, Hovedstaden, Denmark
| | - Pia Jaeger
- The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark
| | - Lone Nikolajsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Charlotte Runge
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Elective Surgery Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
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Han Z, Zhang Y, Xue C, Jin S, Chen Q, Zhang Y. Comparison of the Effects of Adductor Canal and Femoral Nerve Blocks on Postoperative Opioid Consumption and Inflammatory Factor Levels in Elderly Patients After Total Knee Arthroplasty: A Prospective Observational Study. J Pain Res 2024; 17:2375-2391. [PMID: 39011277 PMCID: PMC11249107 DOI: 10.2147/jpr.s463097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/28/2024] [Indexed: 07/17/2024] Open
Abstract
Purpose Total Knee Arthroplasty (TKA) is a highly invasive procedure causing severe postoperative pain, which hampers early mobility. Effective pain management is crucial for optimal recovery. This study aimed to evaluate how adductor canal block (ACB) and femoral nerve block (FNB) affect opioid use and inflammation factor levels in elderly TKA patients. Methods This prospective observational study included 120 patients who received TKA, and divided them into three groups, based on the different nerve block technique: ACB, FNB, and no intervention before general anesthesia (CON). Postoperative opioid consumption, pain assessment, inflammation factor, knee function recovery and other clinical indicators were recorded. Results The CON group had significantly higher cumulative sufentanil consumption compared to the ACB and FNB groups at both 12 h and 48h postoperative (P<0.001). Compared with the CON group, the ACB and FNB groups persistently had lower pain scores until 12 h at rest and 24 h during motion after surgery. The ACB group showed significantly lower serum concentrations of C-reactive protein (CRP) and interleukin-6 (IL-6) compared to the CON group at 24 h postoperative (P=0.017, P=0.009), and IL-6 levels remained significantly lower at 72 h postoperative (P=0.005). Both ACB and FNB groups achieved earlier ambulation compared to the CON group (P=0.002). On the first day postoperative, both the ACB and FNB groups showed significantly better knee motion (P<0.001), quadriceps strength (P<0.001), and daily mobilization (P<0.001) compared to the CON group. Additionally, the ACB group exhibited superior quadriceps strength (P<0.001) and daily mobilization (P<0.001) compared to the FNB group. Conclusion The ACB and FNB groups exhibited comparable clinical efficacy outcomes in terms of pain scores and opioid consumption. However, the ACB group experienced reduced postoperative inflammation and improved knee recovery, especially in quadriceps strength.
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Affiliation(s)
- Zhengyi Han
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China
| | - Yangyang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China
| | - Chenxi Xue
- Department of Orthopedics, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, People’s Republic of China
| | - Shiyun Jin
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China
| | - Qi Chen
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China
| | - Ye Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, People’s Republic of China
- Key Laboratory of Anesthesiology and Perioperative Medicine of Anhui Higher Education Institutes, Anhui Medical University, Hefei, 230601, People’s Republic of China
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Lombardi RA, Marques IR, Carvalho PEP, Brandao GR, Kaur J, Sakharpe A, Heiser NE. Proximal versus distal adductor canal catheters for total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 2024; 71:834-848. [PMID: 37821677 DOI: 10.1007/s12630-023-02552-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/09/2023] [Accepted: 03/23/2023] [Indexed: 10/13/2023] Open
Abstract
PURPOSE Total knee arthroplasty (TKA) is associated with severe postoperative pain. Continuous adductor canal blockade provides analgesia while preserving quadriceps muscle strength. Nevertheless, uncertainty still exists as to the optimal adductor canal catheter placement approach. We sought to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the analgesic effects of proximal vs distal adductor canal catheters in patients undergoing TKA. SOURCE We systematically searched PubMed, EMBASE, and Cochrane for RCTs comparing distal and proximal adductor canal catheters for TKA regarding critical clinical outcomes in adult patients. Statistical analysis was performed using R version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Heterogeneity was assessed using the Cochran Q test and I2 statistics. Trial sequential analysis (TSA) was performed to evaluate the risk of random errors and the uncertainty of our results. The risk of bias was appraised according to the RoB-2 tool. PRINCIPAL FINDINGS Six RCTs and 352 patients were included, of whom 151 (42.9%) were male, and 175 (49.7%) were randomized to undergo proximal adductor canal catheter placement. Due to the randomized nature of the studies, baseline characteristics were similar between groups. There were no statistical differences between proximal and distal adductor canal catheters regarding cumulative opioid consumption in the first 24 hr (mean difference [MD], -4.86; 95% confidence interval [CI], -15.19 to 5.47; P = 0.36; four RCTs; 240 patients); pain scores at rest (MD, 0.41; 95% CI, -1.23 to 0.40; P = 0.32; six RCTs; 350 patients); and pain scores with movement for the first 24 hr (MD, -0.25; 95% CI, -0.85 to 0.35; P = 0.42; four RCTs; 246 patients). In the TSA, the required information size was not reached, and the Z-curve did not cross the monitoring boundaries in any of the endpoints. CONCLUSION These findings suggest that proximal vs distal adductor canal catheter placement in patients undergoing TKA may be equally effective for the outcomes of opioid consumption in the first 24 hr, pain scores at rest, and pain scores with movement in the first 24 hr. Nevertheless, TSA findings suggest insufficient power to definitively conclude no differences between the two techniques. STUDY REGISTRATION PROSPERO (CRD42022353576); registered 25 August 2022.
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Affiliation(s)
- Rafael A Lombardi
- Department of Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE, 68198, USA.
| | - Isabela R Marques
- Division of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Pedro E P Carvalho
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Gabriela R Brandao
- Federal University of Health Sciences of Porto Alegre, Porto Alegra, Brazil
| | - Jasmeen Kaur
- Department of Anesthesiology, Augusta University Medical Center, Augusta, GA, USA
| | - Ashish Sakharpe
- Department of Anesthesiology, Augusta University Medical Center, Augusta, GA, USA
| | - Nicholas E Heiser
- Department of Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE, 68198, USA
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Tan M, Chen B, Li Q, Wang S, Chen D, Zhao M, Cao J. Comparison of Analgesic Effects of Continuous Femoral Nerve Block, Femoral Triangle Block, and Adductor Block After Total Knee Arthroplasty: A Randomized Clinical Trial. Clin J Pain 2024; 40:373-382. [PMID: 38506437 PMCID: PMC11081475 DOI: 10.1097/ajp.0000000000001211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 02/20/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVES This study aimed to compare the analgesic effects of continuous femoral nerve block (FNB), femoral triangle block (FTB), and adductor canal block (ACB) following total knee arthroplasty (TKA). The goal was to identify the most effective nerve block technique among these. METHODS Patients undergoing TKA were randomly assigned to 1 of 3 groups: FNB, FTB, or ACB. Nerve blocks were administered preoperatively, with catheters placed for patient-controlled nerve analgesia (PCNA). The primary end point was the Numeric Rating Scale (NRS) score at movement at 24 hours postsurgery. Secondary end points included NRS scores at rest and movement, quadriceps strength, Timed Up and Go (TUG) test performance, range of motion, effective PCNA utilization, and opioid consumption at various postsurgery time points. RESULTS Of the 94 valid data sets analyzed (FNB: 31, FTB: 31, ACB: 32), significant differences were observed in the primary end point (H=7.003, P =0.03). Post hoc analysis with Bonferroni correction showed that the FNB group had a significantly lower median pain score (3 [2 to 4]) compared with the ACB group (4 [3 to 5], Bonferroni-adjusted P =0.03). Regarding secondary end points, both the FNB and FTB groups had significantly lower NRS scores than the ACB group at various time points after surgery. Quadriceps strength and TUG completion were better in the FTB and ACB groups. There were no statistically significant differences among the groups for the other end points. DISCUSSION Continuous FTB provides postoperative analgesia comparable to FNB but with the advantage of significantly less impact on quadriceps muscle strength, a benefit not seen with FNB. Both FTB and ACB are effective in preserving quadriceps strength postoperatively.
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Affiliation(s)
- Minghe Tan
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University
| | - Bozhou Chen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University
| | - Qingshu Li
- Department of Pathology, College of Basic Medicine, Chongqing Medical University, Chongqing, China
| | - Siqi Wang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University
| | - Daiyu Chen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University
| | - Maoji Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University
| | - Jun Cao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University
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Heo Y, Yang M, Nam SM, Lee HS, Kim YD, Won HS. New insight into the vasto-adductor membrane for safer adductor canal blockade. Korean J Pain 2024; 37:132-140. [PMID: 38433475 PMCID: PMC10985484 DOI: 10.3344/kjp.23292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 11/23/2023] [Accepted: 12/16/2023] [Indexed: 03/05/2024] Open
Abstract
Background : This study aimed to identify exact anatomical landmarks and ideal injection volumes for safe adductor canal blocks (ACB). Methods : Fifty thighs from 25 embalmed adult Korean cadavers were used. The measurement baseline was the line connecting the anterior superior iliac spine (ASIS) to the midpoint of the patellar base. All target points were measured perpendicular to the baseline. The relevant cadaveric structures were observed using ultrasound (US) and confirmed in living individuals. US-guided dye injection was performed to determine the ideal volume. Results : The apex of the femoral triangle was 25.3 ± 2.2 cm distal to the ASIS on the baseline and 5.3 ± 1.0 cm perpendicular to that point. The midpoint of the superior border of the vasto-adductor membrane (VAM) was 27.4 ± 2.0 cm distal to the ASIS on the baseline and 5.0 ± 1.1 cm perpendicular to that point. The VAM had a trapezoidal shape and was connected as an aponeurosis between the medial edge of the vastus medialis muscle and lateral edge of the adductor magnus muscle. The nerve to the vastus medialis penetrated the muscle proximal to the superior border of the VAM in 70% of specimens. The VAM appeared on US as a hyperechoic area connecting the vastus medialis and adductor magnus muscles between the sartorius muscle and femoral artery. Conclusions : Confirming the crucial landmark, the VAM, is beneficial when performing ACB. It is advisable to insert the needle obliquely below the superior VAM border, and a 5 mL injection is considered sufficient.
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Affiliation(s)
- Yanguk Heo
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Miyoung Yang
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
- Sarcopenia Total Solution Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Sung Min Nam
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
| | - Hyun Seung Lee
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Yeon-Dong Kim
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
- Department of Anesthesiology and Pain Medicine, Wonkwang University School of Medicine, Wonkwang University Hospital, Iksan, Korea
| | - Hyung-Sun Won
- Department of Anatomy, Wonkwang University School of Medicine, Iksan, Korea
- Jesaeng-Euise Clinical Anatomy Center, Wonkwang University School of Medicine, Iksan, Korea
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Kanayama T, Nakase J, Yoshimizu R, Ishida Y, Yanatori Y, Arima Y, Takemoto N. Periarticular cocktail injection is more useful than nerve blocks for pain management after anterior cruciate ligament reconstruction. Asia Pac J Sports Med Arthrosc Rehabil Technol 2024; 36:45-49. [PMID: 38584974 PMCID: PMC10995970 DOI: 10.1016/j.asmart.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/12/2024] [Accepted: 03/17/2024] [Indexed: 04/09/2024] Open
Abstract
Background Anterior cruciate ligament (ACL) reconstruction is commonly associated with moderate-to-severe postoperative pain. Notably, various pain control strategies, a femoral nerve block (FNB) with a lateral femoral cutaneous nerve block (LFCNB), adductor canal block (ACB) with LFCNB, or periarticular cocktail injection (PI), have been investigated. However, no studies compare the effects of FNB with LFCNB, ACB with LFCNB, and PI for pain control after ACL reconstruction. This study aimed to evaluate the impact of FNB with LFCNB, ACB with LFCNB, and PI for pain relief in the early postoperative period after ACL reconstruction. Methods This retrospective controlled clinical trial enrolled 299 patients who underwent primary ACL reconstruction at our hospital between April 2016 and October 2022. We categorized these cases into groups based on the use of PI (PI group), FNB with LFCNB (FNB group), and ACB with LFCNB (ACB group) for pain management. We selected 40 cases each, with matched age, sex, and body mass index (BMI) from each group, resulting in 120 cases for analysis. In the FNB and ACB groups, 0.75% ropivacaine 15 ml was injected under ultrasound guidance preoperatively. In the PI group, a mixture of 0.75% ropivacaine 20 ml, normal saline 20 ml, and dexamethasone 6.6 mg was injected half at the start of surgery and the rest just before wound closure. Patient demographics (age, sex, height, body weight, and BMI) and surgical data (the requirement for meniscal repair, operative time, and tourniquet inflation time) were analyzed. After ACL reconstruction, patients' numerical rating scale pain scores (NRS) (0-10) were recorded at 30 min and 4, 8, 12, 24, 48, and 72 h postoperatively. NRS were then compared among the three groups using analysis of variance. In addition, within each group, these data were compared between the NRS ≥7 and NRS ≤6 groups using a t-test. Results There were no significant differences in patient demographics and surgical data. Pain scores were significantly higher in the PI group than in the FCB and ACB groups 30 min postoperatively, but they were lower at 12, 24, 48, and 72 h postoperatively. In the FNB group, there were no significant differences in the demographic and surgical data by NRS pain score. In the ACB group, the number of men was significantly higher in the NRS ≥7 group than in the NRS ≤6 group (p = 0.015). In the PI group, tourniquet inflation time was significantly longer in the NRS ≥7 group than in the NRS ≤6 group (p = 0.008). Conclusions Following ACL reconstruction using a hamstring autograft, periarticular cocktail significantly reduced early postoperative pain compared with nerve block combinations.
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Affiliation(s)
- Tomoyuki Kanayama
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Junsuke Nakase
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Rikuto Yoshimizu
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yoshihiro Ishida
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yusuke Yanatori
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yu Arima
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Naoki Takemoto
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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Smulders PS, Ten Hoope W, Baumann HM, Hermanides J, Hemke R, Beenen LFM, Oostra RJ, Marhofer P, Lirk P, Hollmann MW. Adductor canal block techniques do not lead to involvement of sciatic nerve branches: a radiological cadaveric study. Reg Anesth Pain Med 2024; 49:174-178. [PMID: 37399253 DOI: 10.1136/rapm-2022-104227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Low and high volume mid-thigh (ie, distal femoral triangle) and distal adductor canal block approaches are frequently applied for knee surgical procedures. Although these techniques aim to contain the injectate within the adductor canal, spillage into the popliteal fossa has been reported. While in theory this could improve analgesia, it might also result in motor blockade due to coverage of motor branches of the sciatic nerve. This radiological cadaveric study, therefore, investigated the incidence of coverage of sciatic nerve divisions after various adductor canal block techniques. METHODS Eighteen fresh, unfrozen and unembalmed human cadavers were randomized to receive ultrasound-guided distal femoral triangle or distal adductor canal injections, with 2 mL or 30 mL injectate volume, on both sides (36 blocks in total). The injectate was a 1:10 dilution of contrast medium in local anesthetic. Injectate spread was assessed using whole-body CT with reconstructions in axial, sagittal and coronal planes. RESULTS No coverage of the sciatic nerve or its main divisions was found. The contrast mixture spread to the popliteal fossa in three of 36 nerve blocks. Contrast reached the saphenous nerve after all injections, whereas the femoral nerve was always spared. CONCLUSIONS Adductor canal block techniques are unlikely, even when using larger volumes, to block the sciatic nerve, or its main branches. Furthermore, injectate reached the popliteal fossa in a small minority of cases, yet if a clinical analgesic effect is achieved by this mechanism is still unknown.
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Affiliation(s)
- Pascal Sh Smulders
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Werner Ten Hoope
- Department of Anesthesiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Holger M Baumann
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Robert Hemke
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Roelof-Jan Oostra
- Department of Medical Biology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Peter Marhofer
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Philipp Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Markus W Hollmann
- Department of Anesthesiology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
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Wan D, Wang R, Wei J, Zan Q, Shang L, Ma J, Yao S, Xu C. Bibliometric and visual analysis of research on analgesia and total knee arthroplasty from 1990 to 2022. Heliyon 2024; 10:e25153. [PMID: 38322956 PMCID: PMC10844279 DOI: 10.1016/j.heliyon.2024.e25153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 02/08/2024] Open
Abstract
Background In recent decades, there have been notable advancements in the field of analgesia and total knee arthroplasty (TKA). This study aims to employ bibliometric analysis to elucidate the prevailing research focal points and trends within analgesia and TKA from 1990 to 2022. Material and methods Relevant publications were retrieved from the Web of Science Core Collection. CiteSpace, VOSviewer, and Scimago Graphica were used for visualization and bibliometric analysis of countries, institutions, authors, journals, references, and keywords. Results A total of 2776 publications on analgesia and TKA were identified, with the United States having the highest number of publications. The University of Copenhagen was the most productive institution, and Kehlet, Henrik was the most prolific author. The Journal of Arthroplasty had the most publications and citations. The most common keywords were "TKA," "pain management," "postoperative pain," "Total hip arthroplasty (THA)," and "postoperative management." Keyword burst detection demonstrated that adductor canal block (ACB) was a recent research hotspot. Conclusion Our study revealed a sharp increase in global publications on analgesia and TKA, and this trend is expected to continue. Further research is necessary to determine the optimal regimen for multimodal analgesia, the ideal location and volume of ACB, and their clinical significance.
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Affiliation(s)
- Dongping Wan
- Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
- The First Clinical Medical College, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Rui Wang
- The First Clinical Medical College, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Jie Wei
- State Key Laboratory of Cancer Biology, Department of Pathology, The First Affiliated Hospital of Air Force Military Medical University, Xi’an, China
| | - Qiang Zan
- The First Clinical Medical College, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Lei Shang
- Department of Health Statistics, Faculty of Preventive Medicine, The Air Force Military Medical University, Xi’an, China
| | - Jianbing Ma
- Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Shuxin Yao
- Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
| | - Chao Xu
- Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi Province, China
- Department of Health Statistics, Faculty of Preventive Medicine, The Air Force Military Medical University, Xi’an, China
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Jensen AE, Bjørn S, Nielsen TD, Moriggl B, Hoermann R, Vaeggemose M, Bendtsen TF. Distal subsartorial compartment block of the saphenous nerve - A dissection study and a patient case series. J Clin Anesth 2024; 92:111315. [PMID: 37926063 DOI: 10.1016/j.jclinane.2023.111315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/05/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
STUDY OBJECTIVE A saphenous nerve block is an important tool for analgesia after foot and ankle surgery. The conventional midthigh approach to saphenous nerve block in the femoral triangle may impede ambulation by impairing quadriceps motor function. PRIMARY OBJECTIVE Developing a selective saphenous nerve block targeting the nerve distal to its emergence from the adductor canal in the subsartorial compartment. DESIGN This study consists of A) a dissection study and B) Data from a clinical case series. SETTING A) Medical University of Innsbruck, Austria (dissection of 15 cadaver sides) and. B) Aarhus University Hospital, Denmark (5 patients). INTERVENTIONS A) Five mL of methylene blue was injected into the subsartorial compartment distal to the intersection of the saphenous nerve and the tendon of the adductor magnus guided by ultrasound. B) Five patients undergoing major hindfoot and ankle surgery had a subsartorial compartment block with 10 mL of local anesthetic in addition to a popliteal sciatic nerve block. MEASUREMENT A) The frequencies of staining the saphenous and medial vastus nerves. B) Assessment of postoperative pain by NRS score (0-10) and success rate of saphenous nerve block by presence of cutaneous anesthesia in the anteromedial lower leg, and motor impairment by ability to ambulate. MAIN RESULTS A) The saphenous nerve was stained in 15/15 cadaver sides. A terminal branch of the medial vastus nerve was stained in 2/15 cadaver sides. B) All patients were fully able to ambulate without support. No patients had any post-surgical pain from the anteromedial aspect of the ankle and foot (NRS score 0). The success rate of saphenous nerve block was 100%. CONCLUSION The saphenous nerve can be targeted in the subsartorial compartment distal to the intersection of the nerve and the tendon of the adductor magnus. The subsartorial compartment block provided efficient analgesia without quadriceps motor impairment.
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Affiliation(s)
- Anne E Jensen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Siska Bjørn
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas D Nielsen
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bernhard Moriggl
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Romed Hoermann
- Institute of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Vaeggemose
- GE Healthcare, Brøndby, Denmark; MR Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Thomas F Bendtsen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark.
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de Arzuaga CIS, Miguel M, Biarnés A, García M, Naya J, Khoudeir A, Minguell J, Pujol O. Single-injection nerve blocks for total knee arthroplasty: femoral nerve block versus femoral triangle block versus adductor canal block-a randomized controlled double-blinded trial. Arch Orthop Trauma Surg 2023; 143:6763-6771. [PMID: 37391523 PMCID: PMC10542711 DOI: 10.1007/s00402-023-04960-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/22/2023] [Indexed: 07/02/2023]
Abstract
INTRODUCTION Femoral nerve block (FNB) is a well-established analgesic technique for TKA. However, it associates quadriceps weakness. Therefore, femoral triangle block (FTB) and adductor canal block (ACB) were proposed as effective alternative motor-spearing techniques. The primary objective was to compare quadriceps muscle strength preservation between FNB, FTB and ACB in TKA. The secondary objective was to analyze pain control and functional outcomes. METHODS This is a prospective, double-blinded RCT. From April 2018 to April 2019, patients who undergo a primary TKA were randomized into three experimental groups: FNB-G1/FTB-G2/ACB-G3. Quadriceps strength preservation was measured as the difference in maximum voluntary isometric contraction (MVIC) preoperatively and postoperatively. RESULTS Seventy-eight patients (G1, n = 22; G2, n = 26; G3, n = 30) met our inclusion/exclusion criteria. Patients with FNB retained significantly lower baseline MVIC at 6 h postoperatively (p = 0.001), but there were no differences at 24 and 48 h. There were no differences between the groups in functional outcomes at any time point. Patients in the FNB-G1 presented significant lower pain scores at 6 h (p = 0.01), 24 h (p = 0.005) and 48 h (p = 0.01). The highest cumulative opioid requirement was reported in ACB-G3. CONCLUSION For patients undergoing TKA, FTB and ACB preserve quadriceps strength better than FNB at 6 h postoperatively, but there are no differences at 24 and 48 h. Moreover, this early inferiority does not translate to worse functional outcomes at any time point. FNB is associated with better pain control at 6, 24 and 48 h after surgery, while ACB presents the highest cumulative opioid requirement. CLINICAL TRIAL REGISTRATION This study was registered in clinicaltrials.gov (NCT03518450; https://clinicaltrials.gov/ct2/show/NCT03518450 ; submitted March 17, 2018).
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Affiliation(s)
- Carlos I Salvadores de Arzuaga
- Anesthesiology and Reanimation Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcos Miguel
- Anesthesiology and Reanimation Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alfons Biarnés
- Anesthesiology and Reanimation Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marcelo García
- Anesthesiology and Reanimation Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Naya
- Anesthesiology and Reanimation Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Andrea Khoudeir
- Physical Medicine and Rehabilitation Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Minguell
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Pujol
- Orthopaedic Surgery Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Coviello A, Iacovazzo C, Cirillo D, Diglio P, Bernasconi A, D’Abrunzo A, Barone MS, Posillipo C, Vargas M, Servillo G. The Twenty-Five Most Cited Articles About Adductor Canal Block: A Bibliometric Analysis from 1980 to 2022. J Pain Res 2023; 16:3353-3365. [PMID: 37808463 PMCID: PMC10557973 DOI: 10.2147/jpr.s415184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 08/07/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Loco-regional anesthesia role is increasingly important in surgery, especially in postoperative pain control. Using ultrasound-guided techniques has made the loco-regional approach increasingly safe and manageable, guaranteeing excellent analgesic results and patient compliance. This bibliometric research aimed to identify the most influential papers on the adductor canal blocks and outline their characteristics. Methods All articles published from 1980 to 2022 were included in the Web of Science, PubMed, and Scopus databases and found using the keywords "Adductor canal block" or "Saphenous nerve block" or "Peripheral nerve block" or "Hunter canal block" or "Subsartorial canal block" or "ACB" or "Knee" or "TKR" or "TKA" or "Analgesia" or "Arthroplasty" or "Replacement" in the title section had bibliometric analysis performed. The first 25 papers were selected and analyzed by the number of citations. The correlation between numerical variables was evaluated using the Pearson Correlation coefficient. Results Literature screening found 252 publications. One hundred ten were only about the adductor canal block. Of these, 25 articles were selected for our bibliometric study, published in 8 different journals and with a total number of citations equal to 1.457. "Regional Anesthesia and pain medicine" journal - with 9 articles - was the one that produced the most. There was a significant strong correlation between the n. of citations and the citation rate (R = 0.84, p < 0.001). Conclusion The purpose of this study is to be a guide on regional anesthesia and, particularly, on adductor canal block, making the most effective as well as the most cited articles available to anesthesiologists or other researchers interested in this topic.
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Affiliation(s)
- Antonio Coviello
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Carmine Iacovazzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Dario Cirillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Pasquale Diglio
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Alessio Bernasconi
- Department of Public Health, School of Medicine, “Federico II” University of Naples, Unit of Orthopedics and Traumatology, Naples, Italy
| | - Anella D’Abrunzo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Maria Silvia Barone
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Concetta Posillipo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, “Federico II” University of Naples, Naples, Italy
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Hannig KE, Hauritz RW, Bjørn S, Jensen HI, Henriksen CW, Jessen C, Bendtsen TF. Pain relief after major ankle and hindfoot surgery with repetitive peripheral nerve blocks: A feasibility study. Acta Anaesthesiol Scand 2023; 67:1266-1272. [PMID: 37280182 DOI: 10.1111/aas.14289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/12/2023] [Accepted: 05/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Major ankle and hindfoot surgery (e.g., ankle, triple and subtalar arthrodesis) typically causes severe postoperative pain, especially the first two postoperative days. Current modalities of postoperative analgesic treatment often include continuous peripheral nerve blocks of the saphenous and sciatic nerves via catheters in order to extend the duration of pain- and opioid-free nerve blockade to 48 h. Unfortunately, the 48 h-efficacy of continuous infusion via a catheter is reduced by a high displacement rate. We hypothesised that one-time repetition of the single injection peripheral nerve blocks would provide effective analgesia with a low opioid consumption the first 48 postoperative hours. METHODS Eleven subjects preoperatively received a popliteal sciatic and a saphenous single injection nerve block with a protracted local anaesthetic mixture. Surgery was performed under general anaesthesia. The one-time repetition of the single injection nerve block was carried out approximately 24 h after the primary nerve block. The main outcomes were pain and cumulative opioid consumption during the first 48 postoperative hours. RESULTS Nine of the 11 (82%) patients had effective analgesia without opioids during the first 48 postoperative hours. Two patients each required a single dose of 7.5 mg of oral morphine equivalents after 43 h. CONCLUSION One-time repetition of single injection saphenous and sciatic nerve blocks consistently provided effective analgesia practically without opioids for 48 h after major elective ankle and hindfoot surgery.
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Affiliation(s)
- Kjartan E Hannig
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Anaesthesiology, Vejle Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Rasmus W Hauritz
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Siska Bjørn
- Institute of Clinical Medicine, Health, Aarhus University, Aarhus, Denmark
| | - Hanne Irene Jensen
- Department of Anaesthesiology, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
- Department of Anaesthesiology, Vejle Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | - Claus W Henriksen
- Department of Orthopaedic Surgery, Kolding Hospital, a part of Lillebaelt Hospital, University Hospital of Southern Denmark, Denmark
| | | | - Thomas F Bendtsen
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
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13
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Watanabe T, Mera H, Seino Y. Identifying nerve to vastus medialis at adductor canal entry. J Anesth 2023; 37:813-814. [PMID: 37358672 DOI: 10.1007/s00540-023-03213-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/31/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Tatsunori Watanabe
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Niigata, Japan.
- Department of Anesthesiology, Uonuma Kikan Hospital, Minami-Uonuma, Niigata, Japan.
| | - Hisashi Mera
- Department of Orthopedics, Uonuma Kikan Hospital, Minami-Uonuma, Niigata, Japan
| | - Yutaka Seino
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Niigata, Japan
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14
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Fujino T, Yoshida T, Kawagoe I, Hinotsume A, Hiratsuka T, Nakamoto T. Migration rate of proximal adductor canal block catheters placed parallel versus perpendicular to the nerve after total knee arthroplasty: a randomized controlled study. Reg Anesth Pain Med 2023; 48:420-424. [PMID: 36977526 PMCID: PMC10359574 DOI: 10.1136/rapm-2022-104303] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Perineural catheters placed parallel to the nerve course are reported to have lower migration rates than those placed perpendicular to it. However, catheter migration rates for a continuous adductor canal block (ACB) remain unknown. This study compared postoperative migration rates of proximal ACB catheters placed parallel and perpendicular to the saphenous nerve. METHODS Seventy participants scheduled for unilateral primary total knee arthroplasty were randomly assigned for parallel or perpendicular placement of the ACB catheter. The primary outcome was the migration rate of the ACB catheter on postoperative day (POD) 2. Catheter migration was defined as being unable to confirm saline administration via the catheter around the saphenous nerve at the mid-thigh level under ultrasound guidance. Secondary outcomes included active and passive range of motion (ROM) of the knee on postoperative rehabilitation. RESULTS Sixty-seven participants were included in the final analyses. The catheter migrated significantly less often in the parallel group (5 of 34 (14.7%)) than in the perpendicular group (24 of 33 (72.7%)) (p<0.001). The mean (SD) active and passive knee flexion ROM (degrees) improved significantly in the parallel than in the perpendicular group (POD 1: active, 88.4 (13.2) vs 80.0 (12.4), p=0.011; passive, 95.6 (12.8) vs 85.7 (13.6), p=0.004; POD 2: active, 88.7 (13.4) vs 82.2 (11.5), p=0.036; passive, 97.2 (12.8) vs 91.0 (12.0), p=0.045). CONCLUSION Parallel placement of the ACB catheter provided a lower postoperative catheter migration rate than perpendicular placement of the ACB catheter along with corresponding improvements in ROM and secondary analgesic outcomes. TRIAL REGISTRATION NUMBER UMIN000045374.
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Affiliation(s)
- Takashi Fujino
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
- Department of Anesthesiology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Takayuki Yoshida
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Department of Anesthesiology, Kansai Medical University Medical Center, Moriguchi, Osaka, Japan
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Akinori Hinotsume
- Department of Anesthesiology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tsuyoshi Hiratsuka
- Department of Anesthesiology, Kansai Medical University, Hirakata, Osaka, Japan
| | - Tatsuo Nakamoto
- Department of Anesthesiology, Kansai Medical University, Hirakata, Osaka, Japan
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Oshima T, Nakase J, Kanayama T, Yanatori Y, Ishida T, Tsuchiya H. Ultrasound-guided adductor canal block is superior to femoral nerve block for early postoperative pain relief after single-bundle anterior cruciate ligament reconstruction with hamstring autograft. J Med Ultrason (2001) 2023; 50:433-439. [PMID: 37106246 DOI: 10.1007/s10396-023-01309-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/22/2023] [Indexed: 04/29/2023]
Abstract
PURPOSE This study aimed to compare the combination of a lateral femoral cutaneous nerve (LFCN) block with a femoral nerve block (FNB) and an adductor canal block (ACB) for postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring autograft. METHODS A non-randomized, prospective, controlled clinical trial was conducted. The FNB and ACB groups consisted of 41 and 40 patients, respectively. Thirty minutes prior to surgery, the patients received an ultrasound-guided LFCN block either with FNB or ACB. The following values were recorded and compared between the two groups: duration of surgery, pain management during surgery (including total amount of fentanyl administered), and numerical rating scale (NRS) scores at 30 min and 4, 8, 12, 24, 48, and 72 h after surgery. Factors affecting pain relief (NRS < 2) were evaluated, including block type, total amount of fentanyl administered, duration of surgery, age, sex, body mass index, and postoperative suppository use. Significant factors predicting pain relief were determined using the Cox proportional hazard regression model. RESULTS There were no significant differences in pain management during the surgery. Pain scores were significantly lower in the ACB group at 30 min, 4 h, 24 h, and 48 h after surgery. The Cox proportional hazard regression model identified ACB as a significant factor for pain relief (hazard ratio: 1.88; 95% confidence interval: 1.12-3.13; p = 0.018). CONCLUSION The combination of ACB with LFCN block during ACL reconstruction significantly reduced pain in the early postoperative period compared to FNB with LFCN block.
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Affiliation(s)
- Takeshi Oshima
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazaw, Ishikawa, 920-8641, Japan
- Asanogawa General Hospital, Kanazawa, Ishikawa, Japan
| | - Junsuke Nakase
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazaw, Ishikawa, 920-8641, Japan.
| | - Tomoyuki Kanayama
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazaw, Ishikawa, 920-8641, Japan
| | - Yusuke Yanatori
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazaw, Ishikawa, 920-8641, Japan
| | - Toshihiro Ishida
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazaw, Ishikawa, 920-8641, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi, Kanazaw, Ishikawa, 920-8641, Japan
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Matthews D, Rella RT. Surgeon-placed peripheral nerve block and continuous non-opioid analgesia in total knee arthroplasty is accessible intraoperatively: A cadaveric study. J ISAKOS 2023; 8:204-209. [PMID: 36935063 DOI: 10.1016/j.jisako.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 02/26/2023] [Accepted: 03/11/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Pain management in TKA patients is challenged by a postoperative requirement for early ambulation along with the concurrent goal of reducing opioid consumption while simultaneously reducing the length of hospital stay. Peripheral nerve blocks (PNB) address these concerns to some degree, with femoral nerve and adductor canal blocks being the most-used regional nerve blocks for surgeries performed around the knee joint. PURPOSE The authors hypothesized that placing a catheter between the muscles that make up the adductor canal during a standard surgical approach for a Total Knee Arthroplasty would provide equitable or superior access for a peripheral nerve block in the adductor canal. The nerves that are located between the muscles that make up the adductor canal transmit the majority of the pain after TKA. METHODS This cadaveric study was conducted in 12 fresh-frozen human cadaveric lower limbs, comparing the standard technique of adductor canal block, placed under ultrasound guidance, to this experimental technique. Using colored indicator dyes to locate the site of surrogate peripheral nerves, the techniques were compared. RESULTS Through a standard anterior surgical approach to the knee, an intraoperative catheter placement technique can be performed to provide a peripheral nerve block to the saphenous nerve for patients undergoing TKA that is comparable to standard ultrasound guided anesthesia block techniques. CONCLUSIONS This cadaveric study demonstrates the availability for the surgeon to place a catheter between the muscles that form the adductor canal during a standard surgical approach for TKA. This novel technique can provide equivalent coverage of the nerves for an ACB when compared to a standard ultrasound guided ACB.
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Affiliation(s)
- Daniel Matthews
- Alabama Orthopedic Sports Medicine, Daphne, AL 36526, USA; University of South Alabama Department of Orthopedic Surgery, 36617, USA.
| | - Robert T Rella
- University of South Alabama Frederick P. Whiddon College of Medicine, 36688, USA.
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Lee SH, Kim HJ, Kim SH, Cho TH, Kwon HJ, O J, Hong JE, Nam SH, Hwang YI, Yang HM. Anatomical study of the adductor canal: three-dimensional micro-computed tomography, histological, and immunofluorescence findings relevant to neural blockade. Korean J Anesthesiol 2023; 76:252-260. [PMID: 36245345 DOI: 10.4097/kja.22499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/06/2022] [Indexed: 06/02/2023] Open
Abstract
BACKGROUND A precise anatomical understanding of the adductor canal (AC) and its neural components is essential for discerning the action mechanism of the AC block. We therefore aimed to clarify the detailed anatomy of the AC using micro-computed tomography (micro-CT), histological evaluation, and immunofluorescence (IF) assays. METHODS Gross dissections of 39 thighs provided morphometric data relevant to injection landmarks. Serial sectional images of the AC were defined using micro-CT and ultrasonography. The fascial and neural structures of the AC proper were histologically evaluated using Masson's trichrome and Verhoeff-Van Gieson staining, and double IF staining using choline acetyltransferase (ChAT) and neurofilament 200 antibodies. RESULTS The posteromedial branch insertion of the nerve to vastus medialis (NVM) into the lateral border of the AC proper was lower (14.5 ± 2.4 cm [mean ± SD] above the base of the patella) than the origin of the proximal AC. The AC consists of a thin subsartorial fascia in the proximal region and a thick aponeurosis-like vastoadductor membrane in the distal region. In the proximal AC, the posteromedial branch of the NVM (pmNVM) consistently contained both sensory and motor fibers, and more ChAT-positive fibers were observed than in the saphenous nerve (27.5 ± 11.2 / 104 vs. 4.2 ± 2.6 / 104 [counts/µm2], P < 0.001). CONCLUSIONS Anatomical differences in fascial structures between the proximal and distal AC and a mixed neural component of the neighboring pmNVM have been visualized using micro-CT images, histological evaluation, and IF assays.
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Affiliation(s)
- Shin Hyo Lee
- Department of Anatomy, Yonsei University College of Medicine, Seoul, Korea
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seoul, Korea
| | - Hee Jung Kim
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Hyung Kim
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hyeon Cho
- Department of Anatomy, Yonsei University College of Medicine, Seoul, Korea
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun-Jin Kwon
- Department of Anatomy, Yonsei University College of Medicine, Seoul, Korea
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seoul, Korea
| | - Jehoon O
- Center of Biohealth Convergence and Open Sharing System, Hongik University, Seoul, Korea
| | - Ju Eun Hong
- Department of Biomedical Laboratory Science, College of Software and Digital Healthcare Convergence, Yonsei University MIRAE Campus, Wonju, Korea
| | - Seung Hyun Nam
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Il Hwang
- Department of Anatomy and Cell Biology, Seoul National University College of Medicine, Seoul, Korea
| | - Hun-Mu Yang
- Department of Anatomy, Yonsei University College of Medicine, Seoul, Korea
- Translational Research Unit for Anatomy and Analgesia, Yonsei University College of Medicine, Seoul, Korea
- Surgical Anatomy Education Center, Yonsei University College of Medicine, Seoul, Korea
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18
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Torun BI, Balaban M, Hatipoglu SC. Reevaluation of the topographical anatomy of the mid-thigh: A magnetic resonance and ultrasound imaging study. Clin Anat 2023; 36:350-359. [PMID: 35790028 DOI: 10.1002/ca.23927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/04/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022]
Abstract
Adductor canal (AC) and sciatic nerve (SN) blockades are commonly used during total knee arthroplasties for postoperative pain control. Medical professionals have begun to utilize single injection combined regional anesthesia methods due to increased patient comfort. In this study, we examined the topographical anatomy of the mid-thigh, which is recommended as the appropriate intervention level for combined AC and SN blockades, in order to provide a safe approach for clinicians. We examined 184 thigh magnetic resonance images (MRI) from 98 patients. We measured the diameter of the mid-thigh, anterior thigh muscle thickness, subcutaneous adipose tissue thickness, and SN depth on the MRIs. We obtained ultrasound (US) images of the vastoadductor membranes (VAM) of 26 volunteers, and measured the vertical distances between the greater trochanter and the adductor tubercle (A) and the greater trochanter and the upper edge of the VAM (B). We then proportioned B to A in order to determine in which part of the thigh the AC was located. The AC was in the distal third of the thigh, and the SN's depth was located in the third quarter of the thigh's diameter. Only the adductor magnus, and no neurovascular structure, was at risk of injury between the AC and the SN. The upper edge of the VAM was 6.5 cm below the mid-thigh, therefore it is not appropriate to suggest performing an AC blockade at mid-thigh. We think that it is safe to perform a combined AC and SN blockade in a single injection in selected patients.
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Affiliation(s)
- Bilge Ipek Torun
- Faculty of Medicine, Department of Anatomy, Ankara Yildirim Beyazit University, Ankara, Turkey
| | - Mehtap Balaban
- Faculty of Medicine, Department of Radiology, Ankara Yildirim Beyazit University, Ankara, Turkey
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Orebaugh SL, Barrington M. Anatomy for the Adductor Canal Block: Does Location Really Matter? Anesth Analg 2023; 136:455-457. [PMID: 36806232 DOI: 10.1213/ane.0000000000006378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Affiliation(s)
- Steven L Orebaugh
- From the Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael Barrington
- School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Woodworth GE, Arner A, Nelsen S, Nada E, Elkassabany NM. Pro and Con: How Important Is the Exact Location of Adductor Canal and Femoral Triangle Blocks? Anesth Analg 2023; 136:458-469. [PMID: 36806233 DOI: 10.1213/ane.0000000000006234] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
In this Pro-Con commentary article, we debate the importance of anterior thigh block locations for analgesia following total knee arthroplasty. The debate is based on the current literature, our understanding of the relevant anatomy, and a clinical perspective. We review the anatomy of the different fascial compartments, the course of different nerves with respect to the fascia, and the anatomy of the nerve supply to the knee joint. The Pro side of the debate supports the view that more distal block locations in the anterior thigh increase the risk of excluding the medial and intermediate cutaneous nerves of the thigh and the nerve to the vastus medialis, while increasing the risk of spread to the popliteal fossa, making distal femoral triangle block the preferred location. The Con side of the debate adopts the view that while the exact location of local anesthetic injection appears anatomically important, it has not been proven to be clinically relevant.
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Affiliation(s)
- Glenn E Woodworth
- From the Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Andrew Arner
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, Oregon
| | - Sylvia Nelsen
- Department of Biomedical and Diagnostic Sciences, School of Dentistry, Oregon Health & Science University, Portland, Oregon
| | - Eman Nada
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
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Fan Chiang YH, Wang MT, Chan SM, Chen SY, Wang ML, Hou JD, Tsai HC, Lin JA. Motor-Sparing Effect of Adductor Canal Block for Knee Analgesia: An Updated Review and a Subgroup Analysis of Randomized Controlled Trials Based on a Corrected Classification System. Healthcare (Basel) 2023; 11:210. [PMID: 36673579 PMCID: PMC9859112 DOI: 10.3390/healthcare11020210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Discrepancies in the definition of adductor canal block (ACB) lead to inconsistent results. To investigate the actual analgesic and motor-sparing effects of ACB by anatomically defining femoral triangle block (FTB), proximal ACB (p-ACB), and distal ACB (d-ACB), we re-classified the previously claimed ACB approaches according to the ultrasound findings or descriptions in the corresponding published articles. A meta-analysis with subsequent subgroup analyses based on these corrected results was performed to examine the true impact of ACB on its analgesic effect and motor function (quadriceps muscle strength or mobilization ability). An optimal ACB technique was also suggested based on an updated review of evidence and ultrasound anatomy. MATERIALS AND METHODS We systematically searched studies describing the use of ACB for knee surgery. Cochrane Library, PubMed, Web of Science, and Embase were searched with the exclusion of non-English articles from inception to 28 February 2022. The motor-sparing and analgesic aspects in true ACB were evaluated using meta-analyses with subsequent subgroup analyses according to the corrected classification system. RESULTS The meta-analysis includes 19 randomized controlled trials. Compared with the femoral nerve block group, the quadriceps muscle strength (standardized mean difference (SMD) = 0.33, 95%-CI [0.01; 0.65]) and mobilization ability (SMD = -22.44, 95%-CI [-35.37; -9.51]) are more preserved in the mixed ACB group at 24 h after knee surgery. Compared with the true ACB group, the FTB group (SMD = 5.59, 95%-CI [3.44; 8.46]) has a significantly decreased mobilization ability at 24 h after knee surgery. CONCLUSION By using the corrected classification system, we proved the motor-sparing effect of true ACB compared to FTB. According to the updated ultrasound anatomy, we suggested proximal ACB to be the analgesic technique of choice for knee surgery. Although a single-shot ACB is limited in duration, it remains the candidate of the analgesic standard for knee surgery on postoperative day 1 or 2 because it induces analgesia with less motor involvement in the era of multimodal analgesia. Furthermore, data from the corrected classification system may provide the basis for future research.
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Affiliation(s)
- Yu-Hsuan Fan Chiang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Ming-Tse Wang
- Department of Anesthesiology, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Shun-Ming Chan
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei 11490, Taiwan
| | - Se-Yi Chen
- Department of Neurosurgery, Chung-Shan Medical University Hospital, Taichung 40201, Taiwan
- School of Medicine, Chung-Shan Medical University, Taichung 40201, Taiwan
| | - Man-Ling Wang
- Department of Anesthesiology, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Jin-De Hou
- Division of Anesthesiology, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
- Department of Anesthesiology, School of Medicine, National Defense Medical Center, Taipei 11490, Taiwan
| | - Hsiao-Chien Tsai
- Dianthus MFM Clinic Taoyuan, Dianthus MFM Center, Taoyuan 33083, Taiwan
| | - Jui-An Lin
- Department of Anesthesiology, School of Medicine, National Defense Medical Center, Taipei 11490, Taiwan
- Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan
- Center for Regional Anesthesia and Pain Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Department of Anesthesiology, School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Anesthesiology, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
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[Research progress on analgesic effect of adductor canal block after knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:106-114. [PMID: 36708123 PMCID: PMC9883644 DOI: 10.7507/1002-1892.202210066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Objective To summarize the research progress of the analgesic effect of adductor canal block (ACB) applied to knee arthroplasty, in order to find the ACB mode that can obtain better effectiveness. Methods The research progress of the analgesic effect of ACB after knee arthroplasty was reviewed by widely consulting the related literature on ACB at home and abroad in recent years. Results In recent years, multimodal analgesia has become the mainstay of postoperative pain management after knee arthroplasty. Among these, ACB replaces the once "gold standard" femoral nerve block (FNB) by offering comparable and effective analgesia with better preservation of quadriceps function. It is generally safe and efficient to use 0.2% ropivacaine ACB with initial loading doses of 15-30 mL and continual loading doses of less than 8 mL/hour to give analgesia comparable to FNB with minimal impact on lower extremity muscular strength. However, the risk of patient falls must still be taken into consideration by medical staff. Adjuvants like dexmedetomidine and dexamethasone used in ACB can increase the analgesic duration and postoperative analgesic impact. As a perineural adjunct for ACB, 1 µg/kg dexmedetomidine may strike a balance between safety and analgesic efficacy. Conclusion ACB is a safe and effective analgesia method after knee arthroplasty. The adductor canal anatomy, the optimum blocking strategy and blocking site of ACB are all hotly debated and still require additional study due to the significant variety of the nerve structures in adductor canal.
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Drapeau-Zgoralski V, Bourget-Murray J, Hall B, Horton I, Dervin G, Duncan K, Addy K, Garceau S. Surgeon-Performed Intraoperative Peripheral Nerve Blocks and Periarticular Infiltration During Total Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2022; 10:01874474-202211000-00006. [PMID: 36574407 DOI: 10.2106/jbjs.rvw.22.00105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
➢ 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. ➢ 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. ➢ 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. ➢ 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.
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Affiliation(s)
| | | | - Brandon Hall
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Isabel Horton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Geoffrey Dervin
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Kenneth Duncan
- Division of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Keith Addy
- Division of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Valera-Calero JA, Varol U, Plaza-Manzano G, Fernández-de-las-Peñas C, Agudo-Aguado A. Regression Model Decreasing the Risk of Femoral Neurovascular Bundle Accidental Puncture. Tomography 2022; 8:2498-2507. [PMID: 36287807 PMCID: PMC9611046 DOI: 10.3390/tomography8050208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 11/07/2022] Open
Abstract
Although most of the adverse events derived from dry needling are minor, avoiding potential hazards for patients including accidental invasion of vessels, ganglia, and nerves is essential to ensure patients’ safety. We aimed to investigate the contribution of predictors explaining the variance of sartorius muscle depth limit at proximal third and middle thigh as these locations lead to an augmented risk of neurovascular bundle invasion during dry needling application. A diagnostic study was conducted on 84 subjects to calculate the accuracy of a prediction model for sartorius depth, as assessed with ultrasound imaging, based on sex, age, height, weight, body mass index (BMI), thigh perimeter, and length. After calculating a correlation matrix, a multiple linear regression analysis was performed to detect those variables contributing to the sartorius deep limit in both locations. Although males showed greater thigh perimeter than women (p < 0.001), the deep limit of the sartorius muscle was significantly more superficial for both the proximal third (p = 0.003) and the mid-third (p = 0.004) points. No side-to-side anthropometric differences were found (p > 0.05). In addition, we found sartorius muscle depth to be associated with the proximal and mid-third girth, gender, height, and BMI (all, p < 0.01). Gender, proximal-third girth, and BMI explained 51.1% and 42.6% of the variance for the sartorius deep limit at the proximal and the mid-third, respectively. This study analyzed whether anthropometric features could predict sartorius muscle depth in healthy participants for assisting clinicians in choosing the optimal needle length to avoid accidental femoral bundle puncture.
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Affiliation(s)
- Juan Antonio Valera-Calero
- Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela, 28692 Madrid, Spain
- VALTRADOFI Research Group, Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela, 28692 Madrid, Spain
| | - Umut Varol
- VALTRADOFI Research Group, Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela, 28692 Madrid, Spain
| | - Gustavo Plaza-Manzano
- Department of Radiology, Rehabilitation and Physiotherapy, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria San Carlos (IdISSC), 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-913-941-545
| | - César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
- Cátedra Institucional en Docencia, Clínica e Investigación en Fisioterapia: Terapia Manual, Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, 28922 Alcorcón, Spain
| | - Adolfo Agudo-Aguado
- Department of Physiotherapy, Faculty of Health, Universidad Camilo José Cela, 28692 Madrid, Spain
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Fujita Y, Mera H, Watanabe T, Furutani K, Kondo HO, Wakai T, Kawashima H, Ogose A. Significantly earlier ambulation and reduced risk of near-falls with continuous infusion nerve blocks: a retrospective pilot study of adductor canal block compared to femoral nerve block in total knee arthroplasty. BMC Musculoskelet Disord 2022; 23:768. [PMID: 35953812 PMCID: PMC9373377 DOI: 10.1186/s12891-022-05735-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 07/29/2022] [Indexed: 12/14/2022] Open
Abstract
Background Near-falls should be detected to prevent falls related to the earlier ambulation after Total knee arthroplasty (TKA). The quadriceps weakness with femoral nerve block (FNB) has led to a focus on adductor canal block (ACB). We purposed to examine the risk of falls and the earlier ambulation in each continuous infusion nerve block. Methods Continuous infusion nerve block (FNB or ACB) was performed until postoperative day (POD) 2 or 3. Pain levels and falls/near-falls with knee-buckling were monitored from POD 1 to POD 3. The score on the manual muscle test, MMT (0 to 5, 5 being normal), of the patients who could ambulate on POD 1, was investigated. Results A total of 73 TKA cases, 36 FNB and 37 ACB, met the inclusion criteria. No falls were noted. But episodes of near-falls with knee-buckling were witnessed in 14 (39%) cases in the FNB group and in 4 (11%) in the ACB group (p = 0.0068). In the ACB group, 81.1% of patients could ambulate with parallel bars on POD 1, while only 44.4% of FNB patients could do so (p = 0.0019). The quadriceps MMT values in the ACB group was 2.82, significantly higher than 1.97 in the FNB group (p = 0.0035). There were no significant differences in pain as measured with a numerical rating scale (NRS) and rescue analgesia through POD 3. Conclusion ACB was associated with significantly less knee-buckling and earlier ambulation post-TKA, with better quadriceps strength. Our study indicated the incidence of falls and near-falls with continuous infusion nerve blocks, and support the use of ACB to reduce the risk of falls after TKA. It is suggested that a certain number of the patients even with continuous ACB infusion should be considered with the effect of motor branch to prevent falls. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05735-6.
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Affiliation(s)
- Yutaka Fujita
- Department of Orthopedic Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan.,Present Address: Department of Orthopedic Surgery, Nagaoka Chuo General Hospital, 2041, Kawasaki-machi, Nagaoka City, Niigata, 940-8653, Japan
| | - Hisashi Mera
- Department of Orthopedic Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan.
| | - Tatsunori Watanabe
- Department of Anesthesiology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan
| | - Kenta Furutani
- Department of Anesthesiology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan.,Present Address: Department of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, 754, Ichibancho, Asahimachidori, Chuo-ku, Niigata, 951-8211, Japan
| | - Haruna O Kondo
- Division of Rehabilitation, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan
| | - Takao Wakai
- Division of Rehabilitation, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan
| | - Hiroyuki Kawashima
- Division of Orthopedic Surgery, Niigata University Graduate School of Medical and Dental Sciences, 754, Ichibancho, Asahimachidori, Chuo-ku, Niigata, 951-8211, Japan
| | - Akira Ogose
- Department of Orthopedic Surgery, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Uonuma Kikan Hospital, 4132 Urasa, Minami-Uonuma, Niigata, 949-7302, Japan
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Marty P, Chassery C, Rontes O, Vuillaume C, Basset B, Merouani M, Marquis C, De Lussy A, Ferré F, Naudin C, Joshi GP, Delbos A. Combined proximal or distal nerve blocks for postoperative analgesia after total knee arthroplasty: a randomised controlled trial. Br J Anaesth 2022; 129:427-434. [DOI: 10.1016/j.bja.2022.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/20/2022] [Accepted: 05/11/2022] [Indexed: 11/02/2022] Open
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Morishige S, Yamaguchi Y, Nakajima K, Tsuboi S, Sugawara Y, Hayami H, Tobias JD, Inagawa G. Ultrasound-Guided Placement of a Hemodialysis Catheter into the Distal Femoral Vein in a Patient with Multiple Catheters: A Case Report. Int Med Case Rep J 2022; 15:209-212. [PMID: 35469269 PMCID: PMC9034840 DOI: 10.2147/imcrj.s359258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/08/2022] [Indexed: 11/23/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury may require postoperative renal replacement therapy. Although the right internal jugular vein and femoral veins are generally the preferred insertion sites for the hemodialysis catheter for continuous renal replacement therapy, the presence of other indwelling catheters or prior thrombotic events from previous catheters may preclude use of these sites. We present a case in which the hemodialysis catheter was inserted into the distal femoral vein using point-of-care ultrasound in a patient with multiple catheter insertions after coronary artery bypass grafting. Although the tip of the dialysis catheter was more distal than the classic femoral approach, renal replacement therapy was performed without problems. Moreover, it was easier for the nurses to keep the insertion site clean and to change the patient’s position.
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Affiliation(s)
- Shuta Morishige
- Department of Anesthesiology, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
| | - Yoshikazu Yamaguchi
- Department of Anesthesiology, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
- Correspondence: Yoshikazu Yamaguchi, Department of Anesthesiology, Yokohama Municipal Citizen’s Hospital, 1-1 Mitsuzawanishimachi, Kanagawa-ku, Yokohama-shi, Kanagawa, 221-0855, Japan, Tel +81-45-316-4580, Fax +81-45-316-6580, Email
| | - Kei Nakajima
- Department of Anesthesiology, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
| | - Sayaka Tsuboi
- Department of Anesthesiology, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
| | - Yoh Sugawara
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Hajime Hayami
- Department of Anesthesiology, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital and The Ohio State University, Columbus, OH, USA
| | - Gaku Inagawa
- Department of Anesthesiology, Yokohama Municipal Citizen’s Hospital, Yokohama, Japan
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Sonawane K, Dixit H, Mistry T, Balavenkatasubramanian J. Comparing Analgesic Efficacy of a Novel Dual Subsartorial Block Using Two Different Volumes in Patients Undergoing Total Knee Arthroplasty: A Prospective, Double-Blind, Monocentric, Randomised Trial. Cureus 2021; 13:e20488. [PMID: 34934599 PMCID: PMC8683700 DOI: 10.7759/cureus.20488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: Total knee arthroplasty (TKA) is a life-changing joint surgery that improves health-related quality of life and functional status. Patients in need of this surgery mostly belong to the geriatric age group with limited functional reserves and multiple co-morbidities requiring utmost perioperative care with the most suitable analgesic modalities. Regional analgesia (RA) should provide effective analgesia while allowing early mobility, reduced opioid consumption, and early discharge. Dual subsartorial block (DSB) is a novel procedure-specific, motor-sparing, and opioid-sparing RA technique for TKA surgeries. Our study compared the analgesic efficacy of the two different combinations of volumes used in DSB. Methods: This prospective randomized comparative study included patients between 25-75 years of age of American Society of Anesthesiology (ASA) I-II grades who underwent an elective cemented unilateral total knee replacement performed via medial approaches under neuraxial anesthesia. A total of 104 patients were divided into two equal groups based on the local anesthetic (LA) volumes (Group A 10/20 ml and Group B 20/10 ml) used in the DSB. Postoperative pain scores (using a visual analog scale) and quadriceps strengths (using neurological exam), and opioid consumption were measured at regular intervals till discharge. Results: Most patients (71.2%) remained pain-free and comfortable until discharge, while 28.8% complained of pain within 12 hours of DSB. Mean quadriceps strength remained almost normal (4-5/5) until the discharge with no incidences of buckling or fall in either group. Over time, the postoperative trend between the groups showed a significant difference for dynamic pain (p = 0.002) and quadriceps strength (p = <0.001). There was an insignificant difference (p = 0.161) between the groups regarding opioid consumption, with the median oral morphine equivalent of zero in both groups. Discussion: The effective analgesic coverage of DSB is based on the involvement of all innervations of the procedure-specific pain generators of TKR surgeries. The specific focus on selective sensory innervations and the type/volume of the LA used makes DSB a motor-sparing RA alternative that facilitates early mobility and discharge. It can provide effective postoperative analgesia without compromising the motor strength of the quadriceps muscle when administered in either 10/20 or 20/10 volumes.
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Affiliation(s)
- Kartik Sonawane
- Anesthesiology, Ganga Medical Centre and Hospitals, Pvt. Ltd, Coimbatore, IND
| | - Hrudini Dixit
- Anesthesiology, Ganga Medical Centre and Hospitals, Pvt. Ltd, Coimbatore, IND
| | - Tuhin Mistry
- Anesthesiology, Ganga Medical Centre and Hospitals, Pvt. Ltd, Coimbatore, IND
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Lipo Definition in Thighs: Volumizing and Defining the Vastus Muscles by Fat Transfer. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3945. [PMID: 34849318 PMCID: PMC8615436 DOI: 10.1097/gox.0000000000003945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/24/2021] [Indexed: 11/26/2022]
Abstract
Volumizing muscles in the thighs by fat grafting to complement body contouring surgeries has not been adequately investigated. Our objective was to describe a technique (VDVFAT) that defines and volumizes thigh muscles by lipotransfer in the vastus medialis and vastus lateralis muscles. Methods VDVFAT was performed in 52 patients by the same surgeon at a private clinic in Lima, Peru, between 2018 and 2019. All patients were aged between 18 and 60 years, had no cutaneous flaccidity of the thighs, had a body mass index less than 28, and had Goldman surgical risk below Class II. Results A total of 45 women aged 19-41 years (mean: 29.2 years) and seven men aged 24-41 years (mean: 33 years) were included. A mean of 173.36 cm3 of intramuscular fat was grafted to the vastus lateralis, resulting in increased muscle thickness of 21.09 mm, which is equivalent to 88.31% of the initial size of the muscle (P < 0.0001). An intramuscular fat mass of 123.53 cm3 was grafted into the vastus medialis, resulting in increased muscle thickness of 30 mm, which is equivalent to 87.02% of the initial size of the muscle (P < 0.0001). Conclusions Volumizing and defining the vastus muscles by fat transfer is a safe and reproducible method for defining and volumizing muscles. However, further studies are necessary to determine the durability of fat grafts.
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Rodriguez-Patarroyo FA, Cuello N, Molloy R, Krebs V, Turan A, Piuzzi NS. A guide to regional analgesia for Total Knee Arthroplasty. EFORT Open Rev 2021; 6:1181-1192. [PMID: 35839095 PMCID: PMC8693230 DOI: 10.1302/2058-5241.6.210045] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Regional analgesia has been introduced successfully into the postoperative pain management after total knee arthroplasty, reducing pain scores, opioid use and adverse effects. Combination of regional analgesia techniques is associated with better pain management and lower side effects than single regional techniques. Adductor canal block provides good analgesia and considerably lower detrimental effect in muscular strength than femoral nerve block, enhancing surgical recovery. Infiltration techniques may have equivalent analgesic effect than epidural analgesia and peripheral nerve blocks, however there should be awareness of dose dependent toxicity. Novel long-acting local anesthetics role for regional analgesia is still to be determined, and will require larger randomized trials to support its advantage over traditional local anesthetics.
Cite this article: EFORT Open Rev 2021;6:1181-1192. DOI: 10.1302/2058-5241.6.210045
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Affiliation(s)
| | - Nadin Cuello
- Department of Orthopaedic and Trauma Surgery, Hospital Interzonal General de Agudos Eva Perón, San Martín, Buenos Aires, Argentina
| | - Robert Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Viktor Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- Outcomes Research Department, Anesthesiology Institute, Cleveland Clinic Ohio, USA
- Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Drudis R, Colomina J, Torra M, Sabate S, Villalba P, Marco G, Triquell X, Del Pozo D, Palliso F, Montero A. Adductor canal block performed 20 hours after total knee arthroplasty to improve postoperative analgesia and functional recovery: a double-blind randomized controlled clinical trial. Minerva Anestesiol 2021; 88:238-247. [PMID: 34709013 DOI: 10.23736/s0375-9393.21.15838-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The goal of postoperative pain protocols in total knee arthroplasty (TKA) is to get pain free patients throughout severe pain period without impairing walking ability. The aim of the study was to investigate if an adductor canal block performed 20 hours after TKA, in patients treated with systemic analgesia and intraoperative local infiltration anaesthesia (LIA), improves postoperative pain and functional outcomes. METHODS A prospective randomized, double blinded controlled study was conducted. One hundred eighty-three patients undergoing primary TKA were randomized to receive either a sham block or an adductor canal block with 20 ml of ropivacaine 0.5%. The primary outcome was resting and dynamic pain scores using the numerical pain rating scale (NPRS). Secondary outcomes included opioid rescue requirements, quadriceps and adductor muscle strength, patient ability for ambulation and complications. RESULTS Two hours after the block, in adductor canal block group NPRS was significantly lower at rest (1[0-2] vs. 3[2-5], P<0.001) and with mobilization (5[3-6] vs. 6[5-8], P<0.001), and quadriceps strength was significantly higher (3.7[2.7-6] vs. 3(1.7-4.9), P=0.023). The differences were not maintained beyond 24 hours post-block. In the first 24 hours the percentage of patients with tramadol requirements was lower in the adductor canal block group (36[38.3] vs 52[58,4], P =0.006). Other secondary outcomes were similar between groups. There were no patient falls. CONCLUSIONS An adductor canal block done 20 hours after total knee arthroplasty reduces pain and opioid requirements without increasing the risk of falls. An optimal pain control, especially at movement was not achieved.
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Affiliation(s)
- Reis Drudis
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain -
| | - Jordi Colomina
- Department of Orthopaedic Surgery, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Montserrat Torra
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Sergi Sabate
- Department of Anaesthesiology, Hospital Universitari Santa Creu i Sant Pau, Fundació Puigvert, Barcelona, Spain
| | - Paz Villalba
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Gregorio Marco
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Xenia Triquell
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Dolors Del Pozo
- Department of Anaesthesiology, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Francesc Palliso
- Department of Orthopaedic Surgery, Hospital Universitari de Santa Maria, Lleida, Spain
| | - Antonio Montero
- Department of Anaesthesiology, Hospital Universitari Arnau de Vilanova, Av. Lleida, Spain
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Jaremko I, Lukaševič K, Tarasevičius Š, Zeniauskas L, Macas A, Gelmanas A. Comparison of 2 Peripheral Nerve Blocks Techniques for Functional Recovery and Postoperative Pain Management After Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Trial. Med Sci Monit 2021; 27:e932848. [PMID: 34629461 PMCID: PMC8518512 DOI: 10.12659/msm.932848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Methods of pain management that have less effect on motor function after total knee arthroplasty (TKA) are needed to ensure early mobilization. We investigated whether the distal femoral triangle and distal adductor canal blocks are superior to the femoral nerve block regarding motor blockade at early postoperative hours. MATERIAL AND METHODS Patients scheduled for TKA under spinal anesthesia were blindly assigned into 2 groups. One group received the distal femoral triangle and distal adductor canal blocks and the other group received the femoral nerve block. In both groups, at 3, 6, 24, and 48 h after surgery motor blockade was evaluated with the Bromage scale. Secondary outcomes such as pain control efficacy and patient satisfaction were evaluated at 6, 24, and 48 h postoperatively using either the VAS scale or a 10-point scale. RESULTS We analyzed the outcomes of 77 patients. Better motor function at 3 and 6 h after TKA was observed in the distal femoral triangle and the distal adductor canal blocks group (37.7% vs 23.4%, p=0.032 and 49.4% vs 32.5%, p=0.002, respectively). At 24 h after the surgery, patients from the femoral nerve block group consumed significantly more rescue opioid analgesics (p=0.016). We found no significant differences in pain intensity and patient satisfaction at any timepoints after the surgery. CONCLUSIONS The distal femoral triangle and distal adductor canal blocks resulted in significantly better motor function at the first 3 and 6 h after total knee arthroplasty. At 24 h after surgery, rescue opioid doses in the femoral nerve block group were significantly higher.
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Affiliation(s)
- Inna Jaremko
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Karina Lukaševič
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Šarūnas Tarasevičius
- Department of Orthopaedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Linas Zeniauskas
- Department of Orthopaedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Andrius Macas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Arūnas Gelmanas
- Department of Anesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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AbdelRady MM, Ali WN, Younes KT, Talaat EA, AboElfadl GM. Analgesic efficacy of single- shot adductor canal block with levobupivacaine and dexmedetomidine in total knee arthroplasty: A randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.1968713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Marwa Mahmoud AbdelRady
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Wesam Nashat Ali
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Khaled Tolba Younes
- Anesthesia and Intensive Care Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esraa Ahmed Talaat
- Rheumatology & Rehabilitation Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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Kampitak W, Tanavalee A, Tansatit T, Ngarmukos S, Songborassamee N, Vichainarong C. The analgesic efficacy of anterior femoral cutaneous nerve block in combination with femoral triangle block in total knee arthroplasty: a randomized control trial. Korean J Anesthesiol 2021; 74:496-505. [PMID: 34182749 PMCID: PMC8648511 DOI: 10.4097/kja.21120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/27/2021] [Indexed: 11/10/2022] Open
Abstract
Background Ultrasound-guided femoral triangle block (FTB) can provide motor-sparing anterior knee analgesia. However, it may not completely anesthetize the anterior femoral cutaneous nerve (AFCN). We hypothesized that an AFCN block (AFCNB) in combination with a FTB would decrease pain during movement in the immediate 12-hour postoperative compared with a FTB alone. Methods Eighty patients scheduled to undergo total knee arthroplasty (TKA) were randomized to receive either FTB alone (FTB group) or AFCNB with FTB (AFCNB + FTB group) as a part of the multimodal analgesic regimen. The primary outcome was pain during movement 12 hours postoperatively. Secondary outcomes included numeric rating scale (NRS) pain scores, incidence of surgical incision site pain, intravenous morphine consumption, immediate functional performance, patient satisfaction, and length of hospital stay. Results The NRS pain scores on movement 12 hours postoperatively were significantly lower in patients of AFCNB + FTB group compared to those in patients of FTB group (mean difference, -2.02 [95% confidence interval: -3.14, -0.89], P < 0.001). Incidence of pain at the site of surgical incision in 24 hours postoperatively and morphine consumption in 48 hours postoperatively were significantly lower (P < 0.001) and quadriceps muscle strength at 0 degree immediately after the surgery was significantly greater in patients of AFCNB + FTB group (P = 0.04). Conclusions The addition of ultrasound-guided AFCNB to FTB provided more effective analgesia and decreased opioid requirement compared to FTB alone after TKA and may enhance immediate functional performance on the day of surgery.
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Affiliation(s)
- Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Aree Tanavalee
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Tanvaa Tansatit
- Department of Anatomy, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Srihatach Ngarmukos
- Department of Orthopedics, King Chulalongkorn Memorial Hospital and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattaporn Songborassamee
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chutikant Vichainarong
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society and Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Sonawane K, Dixit H, Mistry T, Gurumoorthi P. A high-volume proximal adductor canal (Hi-PAC) block - an indirect anterior approach of the popliteal sciatic nerve block. J Clin Anesth 2021; 73:110348. [PMID: 34062476 DOI: 10.1016/j.jclinane.2021.110348] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/15/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Kartik Sonawane
- Dept. of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India.
| | - Hrudini Dixit
- Dept. of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India
| | - Tuhin Mistry
- Dept. of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India
| | - Palanichamy Gurumoorthi
- Dept. of Anesthesiology, Ganga Medical Centre & Hospitals, Pvt. Ltd., Coimbatore, Tamil Nadu, India
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Martin R, Kirkham KR, Ngo THN, Gonvers E, Lambert J, Albrecht E. Combination of femoral triangle block and infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) versus local infiltration analgesia for analgesia after anterior cruciate ligament reconstruction: a randomized controlled triple-blinded trial. Reg Anesth Pain Med 2021; 46:763-768. [PMID: 34039734 DOI: 10.1136/rapm-2021-102631] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/15/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Femoral triangle block and local infiltration analgesia are two effective analgesic techniques after anterior cruciate ligament reconstruction. Recently, the iPACK block (infiltration between the popliteal artery and the capsule of the posterior knee) has been described to relieve posterior knee pain. This randomized controlled triple-blinded trial tested the hypothesis that the combination of femoral triangle block and iPACK provides superior analgesia to local infiltration analgesia after anterior cruciate ligament reconstruction. METHODS Sixty patients undergoing anterior cruciate ligament reconstruction received general anesthesia and were randomly allocated to two groups: femoral triangle block and iPACK under ultrasound guidance or local infiltration analgesia. For each group, a total of 160 mg of ropivacaine was injected. Postoperative pain treatment followed a predefined protocol with intravenous morphine patient-controlled analgesia, acetaminophen, and ibuprofen. The primary outcome was cumulative intravenous morphine consumption at 24 hours postoperatively. Secondary pain-related outcomes included pain scores (Numeric Rating Scale out of 10) measured at 2 and 24 hours postoperatively. Functional outcomes, such as range of motion and quadriceps strength, were also recorded at 24 postoperative hours, and at 4 and 8 postoperative months. RESULTS Cumulative intravenous morphine consumption at 24 hours postoperatively was significantly reduced in the femoral triangle block and iPACK group (femoral triangle block and iPACK: 9.7 mg (95% CI: 6.7 to 12.7); local infiltration analgesia: 17.0 mg (95% CI: 11.1 to 23.0), p=0.03). Other pain-related and functional-related outcomes were similar between groups. CONCLUSIONS The combination of femoral triangle block and iPACK reduces intravenous morphine consumption during the first 24 hours after anterior cruciate ligament reconstruction, when compared with local infiltration analgesia, without effect on other pain-related, early, or late functional-related outcomes. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03680716).
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Affiliation(s)
- Robin Martin
- Department of Orthopaedic Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Kyle Robert Kirkham
- Department of Anaesthesia, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Trieu Hoai Nam Ngo
- Department of Orthopaedic Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Erin Gonvers
- Department of Anaesthesia, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Jean Lambert
- Department of Orthopaedic Surgery, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Eric Albrecht
- Department of Anaesthesia, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Krishna V, Govil N, Tripathi M, Jain G, Goyal T, Aggarwal S. Comparison of adductor canal block with femoral nerve block for post-operative pain relief after bilateral total knee arthroplasty: A non-randomised controlled trial. Indian J Anaesth 2021; 65:S80-S85. [PMID: 34188260 PMCID: PMC8191188 DOI: 10.4103/ija.ija_1317_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 03/13/2021] [Accepted: 04/03/2021] [Indexed: 01/05/2023] Open
Abstract
Background and Aims Pain perception and pain threshold vary from one individual to another and also differ in the right and left limbs leading to an inter-cerebral pain variability bias and inter-patient pain variability bias. To date, data comparing adductor canal block (ACB) with femoral nerve block (FNB) in the same patient who underwent bilateral total knee arthroplasty (TKA) remain limited. Methods We performed a prospective, non-randomised, controlled study. Patients scheduled for bilateral TKA with central neuraxial anaesthesia received every 12-hourly intermittent boluses of 15 mL of ropivacaine 0.5% in two different peripheral nerve blocks (ACB and FNB) in either of the lower limbs postoperatively. The primary outcome was to assess postoperative VAS score, and the secondary outcomes were muscle strength of the quadriceps muscle and degree of flexion at the knee joint. Results Among the 80 patients assessed for eligibility, 72 patients were enroled, and 69 were included in the final analysis. VAS scores after the two blocks during rest at 30 minutes, 6 hours, 12 hours and 48 hours post-operatively had no significant difference. VAS scores during rest at 24 hours and on doing exercise at 24 hours and 48 hours showed a significant difference. Quadriceps muscle strength and degree of flexion of knee at 24 hours and 48 hours post-operatively did show a significant difference in favour of the ACB over FNB. Conclusion ACB provides equivalent analgesia in comparison with FNB at rest and during passive exercise up to 48 hours post-operatively. ACB significantly preserved motor power of quadriceps muscles when compared with FNB with no added complications.
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Affiliation(s)
- Vamshi Krishna
- Department of Anaesthesiology All India Institute of Medical Sciences, Rishikesh, India
| | - Nishith Govil
- Department of Anaesthesiology Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
| | | | - Gaurav Jain
- Department of Anaesthesiology All India Institute of Medical Sciences, Rishikesh, India
| | - Tarun Goyal
- Department of Orthopaedics All India Institute of Medical Sciences, Bhatinda, India
| | - Shantanu Aggarwal
- Department of Community Medicine Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, Uttarakhand, India
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Layera S, Saadawi M, Tran DQ, Salinas FV. Motor-Sparing Peripheral Nerve Blocks for Shoulder, Knee, and Hip Surgery. Adv Anesth 2020; 38:189-207. [PMID: 34106834 DOI: 10.1016/j.aan.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Sebastián Layera
- Department of Anesthesiology and Perioperative Medicine, Hospital Clínico Universidad de Chile, University of Chile, Office B222 Second Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile
| | - Mohammed Saadawi
- Department of Anesthesiology, St. Mary's Hospital, McGill University, 3830 Avenue Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - De Q Tran
- Department of Anesthesiology, St. Mary's Hospital, McGill University, 3830 Avenue Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - Francis V Salinas
- Department of Anesthesiology, US Anesthesia Partners-Washington, 600 Broadway, Suite 270, Seattle, WA 98122, USA.
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Fei Y, Cui X, Chen S, Peng H, Feng B, Qian W, Lin J, Weng X, Huang Y. Continuous block at the proximal end of the adductor canal provides better analgesia compared to that at the middle of the canal after total knee arthroplasty: a randomized, double-blind, controlled trial. BMC Anesthesiol 2020; 20:260. [PMID: 33036554 PMCID: PMC7545931 DOI: 10.1186/s12871-020-01165-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background The optimal position for continuous adductor canal block (ACB) for analgesia after total knee anthroplasty (TKA) remians controversial, mainly due to high variability in the localization of the the adductor canal (AC). Latest neuroanatomy studies show that the nerve to vastus medialis plays an important role in innervating the anteromedial aspect of the knee and dives outside of the exact AC at the proximal end of the AC. Therefore, we hypothesized that continuous ACB at the proximal end of the exact AC could provide a better analgesic effect after TKA compared with that at the middle of the AC (which appeared to only block the saphenous nerve). Methods Sixty-two adult patients who were scheduled for a unilateral TKA were randomized to receive continuous ACB at the proximal end or middle of the AC. All patients received patient-controlled intravenous analgesia with sufentanil postoperatively. The primary outcome measure was cumulative sufentanil consumption within 24 h after the surgery, which was analyzed using Mann-Whitney U tests. P-values < 0.05 (two-sided) were considered statistically significant. The secondary outcomes included postoperative sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. Results Sixty patients eventually completed the study (30/group). The 24-h sufentanil consumption was 0.22 μg/kg (interquartile range [IQR]: 0.15–0.40 μg/kg) and 0.39 μg/kg (IQR: 0.23–0.52 μg/kg) in the proximal end and middle groups (P = 0.026), respectively. There were no significant inter-group differences in sufentanil consumption at other time points, pain at rest and during passive knee flexion, quadriceps motor strength, and other recovery related paramaters. Conclusions Continuous ACB at the proximal end of the AC has a better opioid-sparing effect without a significant influence on quadriceps motor strength compared to that at the middle of the AC after TKA. These findings indicates that a true ACB may not produce the effective analgesia, instead, the proximal end AC might be a more suitable block to alleviate pain after TKA. Trial registration This study was registered at ClinicalTrials.gov (NCT03942133; registration date: May 06, 2019; enrollment date: May 11, 2019).
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Affiliation(s)
- Yuda Fei
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Xulei Cui
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China.
| | - Shaohui Chen
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Huiming Peng
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Bin Feng
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Wenwei Qian
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Jin Lin
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Xisheng Weng
- Orthopaedic Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
| | - Yuguang Huang
- Anesthesiology Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, Beijing, 100730, China
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Vichainarong C, Kampitak W, Tanavalee A, Ngarmukos S, Songborassamee N. Analgesic efficacy of infiltration between the popliteal artery and capsule of the knee (iPACK) block added to local infiltration analgesia and continuous adductor canal block after total knee arthroplasty: a randomized clinical trial. Reg Anesth Pain Med 2020; 45:872-879. [DOI: 10.1136/rapm-2020-101396] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/15/2020] [Accepted: 07/06/2020] [Indexed: 12/21/2022]
Abstract
BackgroundA combination of motor-sparing analgesia with local infiltration analgesia (LIA) and continuous adductor canal block (CACB) may improve postoperative pain and functional recovery for total knee arthroplasty (TKA). We hypothesized that the addition of a novel technique for posterior knee block, known as the infiltration between the popliteal artery and capsule of the knee (iPACK) block, to LIA with CACB would reduce opioid requirements.MethodsIn this double-blinded randomized controlled trial, 72 patients were assigned to receive either LIA with CACB (LIA+CACB group) or iPACK block with LIA and CACB (iPACK+LIA+CACB group). The primary outcome was cumulative postoperative intravenous morphine consumption within 24 hours. The secondary outcomes included numerical rating scale pain scores, incidence of posterior knee pain, performance test results, patient satisfaction, length of stay, and adverse events.ResultsMorphine consumption within 24 hours postoperatively showed no significant intergroup difference (LIA+CACB; 1.31±1.85 mg vs iPACK+LIA+CACB; 0.61±1.25 mg, p=0.08). There were no clinically significant differences in the overall pain scores between the groups. The lower Timed Up and Go test scores on postoperative days 1 and 2, along with a shorter duration of hospitalization, were found in the iPACK+LIA+CACB group (p<0.05).ConclusionThe addition of an iPACK block to the LIA and CACB does not reduce the postoperative opioid consumption nor improve analgesia. However, it may improve immediate functional performance and reduce the length of hospitalization after TKA.Trial registration numberTCTR20180702001.
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Pascarella G, Costa F, Del Buono R, Strumia A, Agrò FE. Adductor canal or femoral triangle block: not a conundrum but a continuum. Comment on Br J Anaesth 2020; 124: e194-5. Br J Anaesth 2020; 125:e233-e234. [PMID: 32386821 DOI: 10.1016/j.bja.2020.04.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/02/2020] [Accepted: 04/04/2020] [Indexed: 10/24/2022] Open
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Comparison of the ultrasound-guided single-injection femoral triangle block versus adductor canal block for analgesia following total knee arthroplasty: a randomized, double-blind trial. J Anesth 2020; 34:702-711. [PMID: 32533332 DOI: 10.1007/s00540-020-02813-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 06/06/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of the study is to compare the femoral triangle (FT) and adductor canal (AC) blocks in terms of the analgesic efficacy and ambulatory outcomes in the context of multimodal analgesia following total knee arthroplasty (TKA). METHODS Patients presenting for TKA were assigned to a preoperative ultrasound-guided single-injection FT or AC block. Combined spinal and epidural anesthesia with bupivacaine was administered for TKA. Perioperatively a multimodal analgesic regimen was applied up to 48 h after surgery. The primary outcome was the average pain score during movement in the first 24 h postoperatively. The secondary outcomes included pain scores at rest and during movement at postoperative predetermined time points, cumulative opioid consumption in oral morphine equivalents, functional mobility measured by the timed "Up and Go" (TUG) test and muscle strength in the lower extremity. RESULTS Ninety-eight patients completed the study. Patients in the FT group had lower median pain scores during movement in the first 24 h postoperatively than those in the AC group (1.3 [1.0-3.3] vs. 3.0 [1.7-4.3]; median difference: - 1.0, adjusted 95% CI from - 1.7 to - 0.3, P = 0.010). There were significant differences in the pain scores at rest and during movement at 12 and 24 h postoperatively between the two groups (P = 0.008 and 0.005, respectively). Cumulative oral morphine equivalent consumption in the first and second 24 h postoperatively, Functional mobility reflected by the TUG test and muscle strength in the lower extremity showed no significantly statistically differences between the two groups. CONCLUSIONS The preoperative FT block provided improved analgesic outcomes without compromising functional mobility in the context of multimodal analgesia following TKA compared with the AC block. TRIAL REGISTRATION https://www.chictr.org.cn . Identifier: ChiCTR-INR-17012716.
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Impact of leg movement on skin-adductor canal distance: a potential cause for catheter tip displacement? Can J Anaesth 2020; 67:936-941. [DOI: 10.1007/s12630-020-01693-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 01/31/2020] [Accepted: 02/13/2020] [Indexed: 10/24/2022] Open
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Comparison of Adductor Canal Block and Femoral Triangle Block for Total Knee Arthroplasty. Clin J Pain 2020; 36:558-561. [DOI: 10.1097/ajp.0000000000000833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tran J, Chan VWS, Peng PWH, Agur AMR. Evaluation of the proximal adductor canal block injectate spread: a cadaveric study. Reg Anesth Pain Med 2019; 45:rapm-2019-101091. [PMID: 31879373 DOI: 10.1136/rapm-2019-101091] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/30/2019] [Accepted: 12/03/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES Quadriceps sparing adductor canal block has emerged as a viable intervention to manage pain after total knee arthroplasty. Recent studies have defined ultrasound (US) landmarks to localize the proximal and distal adductor canal. US-guided proximal adductor canal injection has not been investigated using these sonographic landmarks. The objectives of this cadaveric study were to evaluate dye injectate spread and quantify the capture rates of nerves supplying articular branches to the knee joint capsule using a proximal adductor canal injection technique. METHODS A US-guided proximal adductor canal injection with 10 mL of dye was performed in seven lightly embalmed specimens. Following injection, specimens were dissected to document dye spread and frequency of nerve staining. RESULTS Following proximal adductor canal injection, dye spread consistently stained the deep surface of sartorius, vastoadductor membrane, aponeurosis of the vastus medialis obliquus, and adductor canal. The saphenous nerve, posteromedial branch of nerve to vastus medialis, superior medial genicular nerve and genicular branch of obturator nerve were captured in all specimens at the proximal adductor canal. There was minimal to no dye spread to the distal femoral triangle, anterior division of the obturator nerve and anterior branches of nerve to vastus medialis. CONCLUSIONS This anatomical study provides some insights into the mechanism of analgesia to the knee following a proximal adductor canal injection and its motor sparing properties. Further clinical investigation is required to confirm cadaveric findings.
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Affiliation(s)
- John Tran
- Division of Anatomy, Department of Surgery, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Vincent W S Chan
- Department of Anesthesia, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Philip W H Peng
- Department of Anesthesia, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Anne M R Agur
- Division of Anatomy, Department of Surgery, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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Bjørn S, Nielsen TD, Moriggl B, Hoermann R, Bendtsen TF. Anesthesia of the anterior femoral cutaneous nerves for total knee arthroplasty incision: randomized volunteer trial. Reg Anesth Pain Med 2019; 45:rapm-2019-100904. [PMID: 31826920 DOI: 10.1136/rapm-2019-100904] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 10/18/2019] [Accepted: 11/18/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES For pain relief after total knee arthroplasty (TKA), an injection at the midthigh level may produce analgesia inferior to that of a femoral nerve block as the anterior femoral cutaneous nerves (intermediate femoral cutaneous nerve (IFCN) and medial femoral cutaneous nerve (MFCN)) are not anesthetized. The IFCN can be selectively anesthetized in the subcutaneous tissue above the sartorius muscle and the MFCN by an injection in the proximal part of the femoral triangle (FT). The primary aim was to investigate the area of cutaneous anesthesia in relation to the surgical incision for TKA and anteromedial knee area after intermediate femoral cutaneous nerve blockade (IFCNB) in combination with an injection in the proximal or distal part of the FT (proximal vs distal femoral triangle block (FTB)). METHODS The study was carried out as two separate investigations: first, dissection of nine cadaver sides to verify a technique for IFCNB; second, a volunteer study with 40 healthy volunteers. The surgical midline incision for TKA was drawn bilaterally. All volunteers received an active distal FTB combined with a placebo proximal FTB on one side and vice versa on the other side. All volunteers were randomized to an active IFCNB on one side and placebo IFCNB on the contralateral side. RESULTS Identification of IFCN was successful in all cadaver sides. Fifteen out of 20 volunteers had complete anesthesia of the incision line after IFCNB combined with proximal FTB, which was significantly higher compared with proximal FTB alone and with distal FTB+IFCNB. A gap at the anteromedial knee area was present in 2/20 volunteers with proximal FTB compared with 17/20 with distal FTB when all volunteers had active IFCNB. CONCLUSION Ultrasound-guided blockade of the IFCN and MFCN anesthetize the surgical midline incision and the anteromedial area of the knee relevant for TKA. In contrast, an injection at the midthigh level produces insufficient cutaneous anesthesia not covering the areas of interest. TRIAL REGISTRATION NUMBER EudraCT: 2018-004986-15.
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Affiliation(s)
- Siska Bjørn
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Bernhard Moriggl
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | - Romed Hoermann
- Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
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Chuan A, Lansdown A, Brick K, Bourgeois A, Pencheva L, Hue B, Goddard S, Lennon M, Walters A, Auyong D, Youlden D, Osborne I, Chin S, Gabriel G, Jackson S, Darlow J, Cameron A, Francis C, Lightfoot N. Adductor canal versus femoral triangle anatomical locations for continuous catheter analgesia after total knee arthroplasty: a multicentre randomised controlled study. Br J Anaesth 2019; 123:360-367. [DOI: 10.1016/j.bja.2019.03.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/20/2019] [Accepted: 03/21/2019] [Indexed: 02/03/2023] Open
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Opioid- and Motor-sparing with Proximal, Mid-, and Distal Locations for Adductor Canal Block in Anterior Cruciate Ligament Reconstruction. Anesthesiology 2019; 131:619-629. [DOI: 10.1097/aln.0000000000002817] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
The ideal location for single-injection adductor canal block that maximizes analgesia while minimizing quadriceps weakness after painful knee surgery is unclear. This triple-blind trial compares ultrasound-guided adductor canal block injection locations with the femoral artery positioned medial (proximal adductor canal), inferior (mid-adductor canal), and lateral (distal adductor canal) to the sartorius muscle to determine the location that optimizes postoperative analgesia and motor function. The hypothesis was that distal adductor block has (1) a superior opioid-sparing effect and (2) preserved quadriceps strength, compared with proximal and mid-locations for anterior cruciate ligament reconstruction.
Methods
For the study, 108 patients were randomized to proximal, mid-, or distal adductor canal injection locations for adductor canal block. Cumulative 24-h oral morphine equivalent consumption and percentage quadriceps strength decrease (maximum voluntary isometric contraction) at 30 min postinjection were coprimary outcomes. The time to first analgesic request, pain scores, postoperative nausea/vomiting at least once within the first 24 h, and block-related complications at 2 weeks were also evaluated.
Results
All patients completed the study. Contrary to the hypothesis, proximal adductor canal block decreased 24-h morphine consumption to a mean ± SD of 34.3 ± 19.1 mg, (P < 0.0001) compared to 64.0 ± 33.6 and 65.7 ± 22.9 mg for the mid- and distal locations, respectively, with differences [95% CI] of 29.7 mg [17.2, 42.2] and 31.4 mg [21.5, 41.3], respectively, mostly in the postanesthesia care unit. Quadriceps strength was similar, with 16.7%:13.4%:15.3% decreases for proximal:mid:distal adductor canal blocks. The nausea/vomiting risk was also lower with proximal adductor canal block (10 of 34, 29.4%) compared to distal location (23 of 36, 63.9%; P = 0.005). The time to first analgesic request was longer, and postoperative pain was improved up to 6 h for proximal adductor canal block, compared to mid- and distal locations.
Conclusions
A proximal adductor canal injection location decreases opioid consumption and opioid-related side effects without compromising quadriceps strength compared to mid- and distal locations for adductor canal block in patients undergoing anterior cruciate ligament reconstruction.
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Li J, Lam D, King H, Credaroli E, Harmon E, Vadivelu N. Novel Regional Anesthesia for Outpatient Surgery. Curr Pain Headache Rep 2019; 23:69. [PMID: 31372836 DOI: 10.1007/s11916-019-0809-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW Peripheral nerve blocks are effective and safe modalities for perioperative analgesia. But it remains unclear what blocks are adequate for ambulatory surgeries, as well as the proper patient management before and after discharge. RECENT FINDINGS Emerging nerve blocks have sparked interests due to ease to perform under ultrasound guidance and lower risks of adverse events. Some of these novel blocks are particularly suitable for ambulatory procedures, including but not limited to motor-sparing lower extremity nerve blocks and phrenic-sparing nerve blocks for shoulder surgeries. The adoption of peripheral nerve block into outpatient surgery is a multidisciplinary effort that encompasses appropriate patient choice, careful selection of nerve blocks that minimize potential adverse events after discharge, and proper patient follow-up until block effects resolve.
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Affiliation(s)
- Jinlei Li
- Department of Anesthesiology, Yale University, New Haven, CT, USA.
| | - David Lam
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Hanna King
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | | | - Emily Harmon
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University, New Haven, CT, USA
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Hauritz RW, Hannig KE, Balocco AL, Peeters G, Hadzic A, Børglum J, Bendtsen TF. Peripheral nerve catheters: A critical review of the efficacy. Best Pract Res Clin Anaesthesiol 2019; 33:325-339. [PMID: 31785718 DOI: 10.1016/j.bpa.2019.07.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
Continuous peripheral nerve blocks are commonly used for postoperative analgesia after surgery. However, catheter failure may occur due to either primary (incorrect insertion) or secondary reasons (displacement, obstruction, disconnection). Catheter failure results in unanticipated pain, need for opioid use, and risk of readmission or delay in hospital discharge. This review aimed to assess definition and frequency of catheter failure, and discuss the alternatives to prolong duration of single-shot nerve blocks. A literature search was performed on peripheral catheters reporting failure as the main outcome measure. Thirty-three studies met the selection criteria, comprising 2711 catheters. Literature review suggests that peripheral nerve catheters have clinically significant failure rate when the assessment is performed using an objective (imaging) method. Subjective methods of assessment (without imaging) may underestimate the incidence of catheter failure.
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Affiliation(s)
- Rasmus W Hauritz
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Kjartan E Hannig
- Department of Anesthesia and Intensive Care Medicine, Kolding Hospital, Denmark
| | - Angela Lucia Balocco
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Gwendolyne Peeters
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Admir Hadzic
- Department of Anesthesiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
| | - Jens Børglum
- Department of Anesthesia and Intensive Care Medicine, Zealand University Hospital, Denmark
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