An Evaluation of Ultrasound-Guided Adductor Canal Blockade for Postoperative Analgesia After Medial Unicondylar Knee Arthroplasty

Anterior Quadratus Lumborum Block and Quadriceps Strength: A Prospective Cohort Study

The decrease in quadriceps strength after anterior quadratus lumborum block (AQLB) has not been quantified. This prospective cohort study investigated the incidence of quadriceps weakness after AQLB. We enrolled patients undergoing robot-assisted partial nephrectomy, and AQLB was performed at the L2 level with 30 mL of 0.375% ropivacaine. We evaluated each quadriceps' maximal voluntary isometric contraction using a handheld dynamometer preoperatively and postoperatively at 1 and 4 days. The incidence of muscle weakness was defined as a 25% reduction in muscle strength compared with the preoperative baseline, and "muscle weakness possibly caused by nerve block" was defined as a 25% reduction compared with the non-block side. We also assessed the numerical rating scale and quality of recovery-15 scores. Thirty participants were analyzed. The incidence of muscle weakness compared with preoperative baseline and the non-block side was 13.3% and 30.0%, respectively. Patients with a numerical rating scale ≥ 4 or quality of recovery-15 score < 122, which was classified as moderate or poor, had decreased muscle strength with relative risks of 1.75 and 2.33, respectively. All patients ambulated within 24 h after surgery. The incidence of quadriceps weakness possibly caused by nerve block was 13.3%; however, all patients could ambulate after 1 day.

Evaluation of ultrasound-guided adductor canal block with two different concentration of bupivacaine in arthroscopic knee surgery: A feasibility study

STUDY OBJECTIVE

The application of regional anaesthesia techniques as a component of multimodal analgesia in knee arthroscopic surgeries increases the quality of postoperative analgesia. Adductor canal block (ACB) is an effective "motor sparing" analgesia technique used in knee surgeries. This study aimed to evaluate the efficacy of ACB using two different concentrations of local anaesthetic in terms of analgesic requirements and pain density in patients undergoing knee arthroscopy.

DESIGN

Prospective, randomised, controlled.

SETTING

Tertiary hospital.

PATIENTS

A total of 60 patients (ASA I-II) were evaluated in three groups, with 20 patients in each group.

INTERVENTIONS

Standardised postoperative analgesia was performed in all groups. In addition, ultrasound-guided ACB (same volume/two different concentrations of bupivacaine: 0.25% vs 0.16%) was applied to the experimental groups.

MEASUREMENTS

Tramadol consumption, rescue analgesic requirement and Numeric Rating Scores (NRS).

MAIN RESULTS

Tramadol requirement in the first 24 hours was significantly higher in the control group (209.5 ± 23.27 mg) (P < .001), and there was no difference between the experimental groups (63 ± 42.06 mg vs 80.5 ± 36.63 mg). Although the mean NRS scores in the first three hours were higher in the control group when compared with both block groups, it was similar in all groups in the following measurements.

CONCLUSION

In arthroscopic knee surgery, ACB interventions with 0.25% and 0.16% concentrations of bupivacaine were similar in terms of postoperative analgesic efficacy, and they increased the quality of multimodal analgesics when compared with the control group.

A comparison of analgesic techniques for total knee arthroplasty: A network meta-analysis

STUDY OBJECTIVE

There is no established analgesic method for postoperative total knee arthroplasty. We comprehensively compared the analgesic methods for postoperative total knee arthroplasty.

DESIGN

A network meta-analysis of randomised controlled trials was used to compare 18 interventions, which were ranked by six outcome indices, to select the best modality.

SETTING

Postoperative recovery room and inpatient ward.

PATIENTS

98 randomised controlled trials involving 7452 patients (ASA I-III) were included in the final analysis.

INTERVENTIONS

Studies that included the use of at least one of the following 12 nerve block(fascia iliaca compartment block (FIB), FNB, cFNB, single femoral nerve block (sFNB), adductor canal block (ACB), sciatic nerve block (SNB), obturator nerve block (ONB), continuous posterior lumbar plexus block (PSOAS), FNB + SNB, ACB + LIA, FNB + LIA, PCA + FNB).

MEASUREMENTS

Pain intensity was compared using Visual Analogue Scale (VAS). Also, postoperative complications, function score, hospital length of stay, morphine consumption and patient satisfaction were measured.

MAIN RESULTS

For visual analogue scale scores, continuous femoral nerve block (FNB) and FNB + sciatic nerve block (SNB) were the the most effective interventions. For reducing postoperative complications, fascia iliaca compartment block, FNB, SNB, and obturator nerve block showed the best results. For reducing postoperative morphine consumption, adductor canal block (ACB) + local infiltration analgesia (LIA) and FNB + SNB were preferred. For function scores (range of motion, Timed-Up-and-Go test), ACB and LIA were optimal choices. For reducing hospital length of stay and patient satisfaction, ACB + LIA and FNB + LIA were best, respectively.

CONCLUSIONS

Peripheral nerve block, especially FNB and ACB, is a better option than other analgesic methods, and its combination with other methods can be beneficial. Peripheral nerve block is a safe and effective postoperative analgesia method. However, our findings can only provide objective evidence. Clinicians should choose the treatment course based on the individual patient's condition and clinical situation.

Perineural Dexmedetomidine Reduces the Median Effective Concentration of Ropivacaine for Adductor Canal Block

BACKGROUND Multimodal analgesic regimens are well known as the best option for total knee arthroplasty. They include the adductor canal block, combined with local infiltration analgesia and a block of the interspace between the popliteal artery and the capsule of the posterior knee. However, these analgesic techniques all require a large amount of local anesthetics. In this study, we explored whether the quantity of local anesthetics could be decreased by using dexmedetomidine for the adductor canal block. MATERIAL AND METHODS Fifty-four patients scheduled for unilateral, primary total knee arthroplasty were allocated into 2 groups: the ropivacaine group (group R) and the dexmedetomidine group (group RD). Ropivacaine 0.5% was chosen as the initial concentration, and the concentration was decreased or increased according to the response of the previous participant. Based on Dixon's up-and-down method, the median effective concentration was calculated. RESULTS The quadriceps strength was similar between the 2 groups, both at 30 min after adductor canal block and during recovery from general anesthesia in the Postanesthesia Care Unit. None of the patients in this study exhibited bradycardia or hypotension. The median effective concentration of ropivacaine for adductor canal block was 0.29% (95% confidence interval [CI], 0.28-0.31%) in group RD, which was lower than that in group R (0.38% [95% CI, 0.36-0.41%]). CONCLUSIONS This study found perineural dexmedetomidine 1 μg/kg could reduce the median effective concentration of ropivacaine for the adductor canal block.

Evaluation of 'spin' in the abstracts and articles of randomized controlled trials in pain literature and general anesthesia

Aim: To evaluate the abstracts and articles of randomized controlled trials (RCTs) in pain literature and general anesthesia for the evidence of spin. Materials & methods: Following a priori protocol, we used a PubMed search for RCTs from a 2-year period. Data extracted using the Boutron spin definition for criteria. Results: A total of 163 articles were identified as RCTs with clear primary and secondary end points. A total of 33 trials were identified with nonsignificant primary end points. An 18/33 were found to have spin (54.5%). The spin was identified in the results, title and conclusion 12/18, 3/18 and 3/18, respectively. Conclusion: Spin was found in 54% of pain RCTs. With sensitive clinical concerns, such as chronic pain, any misrepresentation of validity could prove to have significant clinical consequences.

Adductor canal blocks for postoperative pain treatment in adults undergoing knee surgery

BACKGROUND

Peripheral regional anaesthesia techniques are well established for postoperative pain treatment following knee surgery. The adductor canal block (ACB) is a new technique, which can be applied as a single shot or by catheter for continuous regional analgesia.

OBJECTIVES

To compare the analgesic efficacy and adverse events of ACB versus other regional analgesic techniques or systemic analgesic treatment for adults undergoing knee surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase, five other databases, and one trial register on 19 September 2018; we checked references, searched citations, and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) comparing single or continuous ACB versus other regional analgesic techniques or systemic analgesic treatment. Inclusion was independent of the technique used (landmarks, peripheral nerve stimulator, or ultrasound) and the level of training of providers.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. Our primary outcomes were pain intensity at rest and during movement; rate of accidental falls; and rates of opioid-related adverse events. We used GRADE to assess the quality of evidence for primary outcomes.

MAIN RESULTS

We included 25 RCTs (1688 participants) in this review (23 trials combined within meta-analyses). In 18 studies, participants underwent total knee arthroplasty (TKA), whereas seven trials investigated patients undergoing arthroscopic knee surgery. We identified 11 studies awaiting classification and 11 ongoing studies. We investigated the following comparisons. ACB versus sham treatment We included eight trials for this comparison. We found no significant differences in postoperative pain intensity at rest (2 hours: standardized mean difference (SMD) -0.56, 95% confidence interval (CI) -1.20 to 0.07, 4 trials, 208 participants, low-quality evidence; 24 hours: SMD -0.49, 95% CI -1.05 to 0.07, 6 trials, 272 participants, low-quality evidence) or during movement (2 hours: SMD -0.59, 95% CI -1.5 to 0.33; 3 trials, 160 participants, very low-quality evidence; 24 hours: SMD 0.03, 95% CI -0.26 to 0.32, 4 trials, 184 participants, low-quality evidence). Furthermore, they noted no evidence of a difference in postoperative nausea between groups (24 hours: risk ratio (RR) 1.91, 95% CI 0.48 to 7.58, 3 trials, 121 participants, low-quality evidence). One trial reported that no accidental falls occurred 24 hours postoperatively (low-quality evidence). ACB versus femoral nerve block We included 15 RCTs for this comparison. We found no evidence of a difference in postoperative pain intensity at rest (2 hours: SMD -0.74, 95% CI -1.76 to 0.28, 5 trials, 298 participants, low-quality evidence; 24 hours: SMD 0.04, 95% CI -0.09 to 0.18, 12 trials, 868 participants, high-quality evidence) or during movement (2 hours: SMD -0.47, 95% CI -1.86 to 0.93, 2 trials, 88 participants, very low-quality evidence; 24 hours: SMD 0.56, 95% CI -0.00 to 1.12, 9 trials, 576 participants, very low-quality evidence). They noted no evidence of a difference in postoperative nausea (24 hours: RR 1.22, 95% CI 0.42 to 3.54, 2 trials, 138 participants, low-quality evidence) and no evidence that the rate of accidental falls during postoperative care was significantly different between groups (24 hours: RR 0.20, 95% CI 0.04 to 1.15, 3 trials, 172 participants, low-quality evidence).

AUTHORS' CONCLUSIONS

We are currently uncertain whether patients treated with ACB suffer from lower pain intensity at rest and during movement, fewer opioid-related adverse events, and fewer accidental falls during postoperative care compared to patients receiving sham treatment. The same holds true for the comparison of ACB versus femoral nerve block focusing on postoperative pain intensity. The overall evidence level was mostly low or very low, so further research might change the conclusion. The 11 studies awaiting classification and the 11 ongoing studies, once assessed, may alter the conclusions of this review.

Continuous Adductor Canal Block used for postoperative pain relief after medial Unicondylar Knee Arthroplasty: a randomized, double-blind, placebo-controlled trial

Background

Peripheral nerve block and local infiltration analgesia (LIA) provide good analgesia after knee replacement. This study evaluated the additional analgesic efficacy of continuous adductor canal block (ACB) added to single-dose LIA after medial unicondylar knee arthroplasty (UKA). We hypothesized ACB would lower pain scores and facilitate postoperative ambulation.

Methods

Forty-six patients were enrolled into this double-blind, randomized, placebo-controlled trial. UKA was performed and all patients received single-dose LIA intraoperatively. Patients were randomized into two groups: Group RP receiving 0.2% ropivacaine or Group Con receiving normal saline. A flow at 6 mL/h was administered for 48 h through a catheter in the adductor canal. Primary outcome was movement pain score at 24 h using the numeric rating scale (NRS-11). Secondary outcomes included serial postoperative pain scores, rate of patients with NRS>3 at rest and movement within 24 and 48 h postoperatively, time to breakthrough pain, quadriceps motor strength, ambulated distance, catheter related infection and patient satisfaction.

Results

Forty-two patients were analyzed. Pain scores with movement at 24 h postoperatively were significantly lower in Group RP than that in Group Con (3 vs. 5 NRS, P<0.001). Compared with Group Con, breakthrough pain occurred later in Group RP (18.5 vs 10.0 h, P = 0.002), serial pain scores at rest and with movement and rate of patients with NRS>3 with movement after surgery were significantly lower. Quadriceps motor strength was equivalent, however, ambulated distance on postoperative day 1 and 2 in Group Con was significant less (19.7 vs 37.3 m, P = 0.046; 33.4 vs 59.5 m, P = 0.002).

Conclusions

Continuous adductor canal block added to single-dose LIA offered better analgesia and facilitated ambulation without motor weakness after medial UKA.

Trial registration

Clinical Trial Registration: ChiCTR-IOR-16008720; Registered 25 June 2016.

Single-Injection Adductor Canal Block With Multiple Adjuvants Provides Equivalent Analgesia When Compared With Continuous Adductor Canal Blockade for Primary Total Knee Arthroplasty: A Double-Blinded, Randomized, Controlled, Equivalency Trial

BACKGROUND

Peripheral nerve blockade is used to provide analgesia for patients undergoing total knee arthroplasty. This study compared a single-injection adductor canal block (SACB) with adjuvants to continuous adductor canal blockade (CACB). The hypothesis was that the 2 groups would have equivalent analgesia at 30 hours after neural blockade.

METHODS

This was a double-blinded, randomized, controlled, equivalency trial. Sixty patients were randomized to either the SACB group (20 mL of 0.25% bupivacaine, 1.67 mcg/mL of clonidine, 2 mg of dexamethasone, 150 mcg of buprenorphine, and 2.5 mcg/mL of epinephrine) or the CACB group (20 mL 0.25% of bupivacaine injection with 2.5 mcg/mL of epinephrine followed by an 8 mL/h infusion of 0.125% bupivacaine continued through postoperative day 2). The primary outcome was movement pain scores at 30 hours using the numeric rating scale (NRS). The secondary outcomes included serial postoperative NRS pain scores (rest and movement every 6 hours), opioid consumption, time to first opioid administration, ability to straight leg raise, patient satisfaction, length of stay, and the incidence of nausea/vomiting.

RESULTS

An intention-to-treat analysis included 59 patients. The NRS pain scores with movement were equivalent at 30 hours (SACB 5.5 ± 2.8 vs CACB 5.7 ± 2.9 [mean NRS ± standard deviation]; mean difference 0.2 [-1.5 to 1.0 {90% confidence interval}]). All NRS pain scores were equivalent until 42 hours (rest) and 48 hours (rest and movement) with the CACB group having lower pain scores. Other secondary outcomes were not statistically different.

CONCLUSION

An SACB provides equivalent analgesia for up to 36 hours after block placement when compared with a CACB for patients undergoing total knee arthroplasty, though a CACB was favored at 42 hours and beyond.

Sevoflurane versus isoflurane in shoulder arthroscopy in beach chair position in patients with prior interscalene brachial plexus block: A prospective randomised equivalency-based haemodynamic evaluation trial

Background and Aims:

There is a paucity of literature on comparative effects of different inhalational anaesthetics in beach chair position (BCP) for shoulder arthroscopy. We aimed to investigate and compare the haemodynamic effects, anaesthetic and surgical outcomes between two inhalational agents.

Methods:

In this randomised study, patients of age 18–60 years, were allotted to two groups (29, sevoflurane and 28, isoflurane) and received protocol-based anaesthesia. Intraoperatively, different haemodynamic and other data were recorded.

Results:

All mean of averages of individual subject's vitals were comparable between the groups [P = 0.681, 0.325, 0.803, and 0.051, respectively for systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure (MBP) and heart rate (HR)]. Higher mean HR was recorded for maximum readings of isoflurane (P = 0.028). Equivalency was observed for SBP, MBP, and DBP (P = 0.000, 002, and 0.027, respectively). Process capability indices indicated that sevoflurane had better values (Pp: 0.55 versus 0.41, Ppk: 0.35 versus 0.22) for SBP as with MBP (Pp: 0.62 versus 0.51, Ppk: 0.36 versus 0.33). For achieving optimal vision, higher pump pressures (PPs) were demanded by surgeon (P = 0.025) and higher differences observed between initial and highest PPs (P = 0.027), in isoflurane subjects. Multivariable analysis revealed that no continuous predictor was able to predict the quality of vision except additional pump flow factor, for both groups.

Conclusion:

Both inhalational agents demonstrated equivalent haemodynamic effects. Increased arthroscopic PP requirements were observed with isoflurane anaesthesia. Sevoflurane may be superior to isoflurane during BCP arthroscopy.