Ultrasound-Guided Single Injection Adductor Canal Block with Intrathecal Morphine for Analgesia after Total Knee Arthroplasty

Main Article Content

Sophit Lhoawcha

Abstract

Background: Total knee arthroplasty (TKA) is an operation associated with moderate to severe postoperative pain. Adductor canal block (ACB) is a peripheral nerve blockade technique that provides good pain control in patients undergoing TKA when combined with multimodal analgesia. Objectives: To compare the outcomes of the ACB with no block (NB) in patients who have received intrathecal morphine as multimodal analgesia. Methods: We performed a double-blind, randomized, controlled study of eighty patients scheduled for TKA with spinal anesthesia and 0.2 mg of intrathecal morphine. After the operation, the patients were randomized to either the ACB group (ACB with 20 ml of bupivacaine 0.5% with 1: 200,000 epinephrine) or the NB group (no block). The primary outcome was the comparative postoperative pain score at rest and during movement in 6, 12, and 24 hours postoperatively. Secondary comparative outcomes included quadriceps and adductor muscle strength, opioid-related side effects, hospital length of stay, and patient satisfaction. Results: The pain scores at rest and during movement in 6, 12, and 24 hours were no significant difference. However, there was a tendency of numbers of patients with no pain (NRS=0) in the ACB group than the NB group, especially during knee motion. When controlling the factor of preoperative quadriceps strength, operation time, and periarticular block by a surgeon, the results showed that there were significant differences in the pain on movement between both groups (Odds ratio 0.35; 95%CI 0.13-0.89, p=0.028). Conclusions: ACB is a peripheral nerve blockade technique that provides good pain control, particularly pain during movement in patients undergoing TKA when combined with intrathecal morphine as multimodal analgesia.

Downloads

Download data is not yet available.

Article Details

Section
Original articles

References

1.Strassels SA, Chen C, Carr DB. Postoperative analgesia:
economics, resource use, and patient satisfaction in an
urban teaching hospital. Anesth Analg 2002;94:130-7.
2. Wu CL, Richman JM. Postoperative pain and quality of
recovery. Curr Opin Anaesthesiol 2004;17:455-60.
3. Fischer HB, Simanski CJ, Sharp C, et al. A procedure-specific
systematic review and consensus recommendations for
postoperative analgesia following total knee arthroplasty.
Anaesthesia 2008;63:1105-23.
4. Andersen LO, Gaarn-Larsen L, Kristensen BB, et al.
Subacute pain and function after fast-track hip and knee
arthroplasty. Anaesthesia 2009;64:508-13.
5. Sinatra RS, Torres J, Bustos AM. Pain management after
major orthopaedic surgery: current strategies and new
concepts. J Am Acad Orthop Surg 2002;10:117-29.
6. Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty.
J Am Acad Orthop Surg 2004;12:164-71.
7. Ragucci MV, Leali A, Moroz A, Fetto J. Comprehensive deep
venous thrombosis prevention strategy after total-knee
arthroplasty. Am J Phys Med Rehabil 2003;82:164-8.
8. Puolakka PA, Rorarius MG, Roviola M, et al. Persistent pain
following knee arthroplasty. Eur J Anaesthesiol 2010;27:
455-60.
9. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block
improves analgesia outcomes after total knee arthroplasty:
a meta-analysis of randomized controlled trials. Anesthesiology
2010;113:1144-62.
10. Ilfeld BM, Duke KB, Donohue MC. The association between
lower extremity continuous peripheral nerve blocks and
patient falls after knee and hip arthroplasty. Anesth Analg
2010;111:1552-4.
11. Burckett-St Laurant D, Peng P, Giron Arango L, et al. The
Nerves of the Adductor Canal and the Innervation of the
Knee: An Anatomic Study. Reg Anesth Pain Med 2016;41:
321-7.
12. Anagnostopoulou S, Kostopanagiotou G, Paraskeuopoulos
T, et al. Anatomic variations of the obturator nerve in the
inguinal region: implications in conventional and ultrasound
regional anesthesia techniques. Reg Anesth Pain Med
2009;34:33-9.
13. Grevstad U, Mathiesen O, Valentiner LS, et al. Effect of
adductor canal block versus femoral nerve block on
quadriceps strength, mobilization, and pain after total knee
arthroplasty: a randomized, blinded study. Reg Anesth Pain
Med 2015;40:3-10.
14. Kwofie MK, Shastri UD, Gadsden JC, et al. The effects of
ultrasound-guided adductor canal block versus femoral
nerve block on quadriceps strength and fall risk: a blinded,
randomized trial of volunteers. Reg Anesth Pain Med
2013;38:321-5.
15. Kim DH, Lin Y, Goytizolo EA, et al. Adductor canal block
versus femoral nerve block for total knee arthroplasty: a
prospective, randomized, controlled trial. Anesthesiology
2014;120:540-50.
16. Wang D, Yang Y, Li Q, et al. Adductor canal block versus
femoral nerve block for total knee arthroplasty: a metaanalysis of randomized controlled trials. Sci Rep 2017;7:
40721.
17. Mariano ER, Perlas A. Adductor canal block for total knee
arthroplasty: the perfect recipe or just one ingredient?
Anesthesiology 2014;120:530-2.
18. Biswas A, Perlas A, Ghosh M, et al. Relative Contributions
of Adductor Canal Block and Intrathecal Morphine to
Analgesia and Functional Recovery After Total Knee
Arthroplasty: A Randomized Controlled Trial. Reg Anesth
Pain Med 2018;43:154-60.
19. Jaeger P, Zaric D, Fomsgaard JS, et al. Adductor canal block
versus femoral nerve block for analgesia after total knee
arthroplasty: a randomized, double-blind study. Reg Anesth
Pain Med 2013;38:526-32.
20. Zhang X-l, Cheng T, Zeng B-f, Chinese Medical A, Chinese
Orthopaedic A. Experts’ consensus on minimally invasive
surgery for total joint arthroplasty. Orthop Surg 2011;3:147-51.
21. Safa B, Gollish J, Haslam L, McCartney CJ. Comparing the
effects of single shot sciatic nerve block versus posterior
capsule local anesthetic infiltration on analgesia and functional
outcome after total knee arthroplasty: a prospective, randomized, double-blinded, controlled trial. J Arthroplasty
2014;29:1149-53.
22. Lund J, Jenstrup MT, Jaeger P, Sorensen AM, Dahl JB.
Continuous adductor-canal-blockade for adjuvant
post-operative analgesia after major knee surgery:
preliminary results. Acta Anaesthesiol Scand 2011;55:14-9.
23. Kampitak W, Tanavalee A, Ngarmukos S, et al. Does
Adductor Canal Block Have a Synergistic Effect with Local
Infiltration Analgesia for Enhancing Ambulation and
Improving Analgesia after Total Knee Arthroplasty? Knee
Surg Relat Res 2018;30:133-41.
24. Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD. Peripheral
nerve blocks improve analgesia after total knee replacement
surgery. Anesth Analg 1998;87:93-7.
25. Szczukowski MJ, Jr., Hines JA, Snell JA, Sisca TS. Femoral
nerve block for total knee arthroplasty patients: a method to
control postoperative pain. J Arthroplasty 2004;19:720-5.
26. Ng HP, Cheong KF, Lim A, Lim J, Puhaindran ME. Intraoperative
single-shot “3-in-1” femoral nerve block with ropivacaine
0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides
comparable 48-hr analgesia after unilateral total knee
replacement. Can J Anaesth 2001;48:1102-8.
27. Jaeger P, Nielsen ZJ, Henningsen MH, et al. Adductor canal
block versus femoral nerve block and quadriceps strength:
a randomized, double-blind, placebo-controlled, crossover
study in healthy volunteers. Anesthesiology 2013;118:409-15.
28. Mudumbai SC, Kim TE, Howard SK, et al. Continuous
adductor canal blocks are superior to continuous femoral
nerve blocks in promoting early ambulation after TKA. Clin
Orthop Relat Res 2014;472:1377-83.
29. Rathmell JP, Pino CA, Taylor R, Patrin T, Viani BA. Intrathecal
morphine for postoperative analgesia: a randomized,
controlled, dose-ranging study after hip and knee arthroplasty.
Anesth Analg 2003;97:1452-7.
30. Murphy PM, Stack D, Kinirons B, Laffey JG. Optimizing the
dose of intrathecal morphine in older patients undergoing
hip arthroplasty. Anesth Analg 2003;97:1709-15.
31. Gehling M, Tryba M. Risks and side-effects of intrathecal
morphine combined with spinal anaesthesia: a meta-analysis.
Anaesthesia 2009;64:643-51.