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Subsartorial adductor canal vs femoral nerve block for analgesia after total
knee replacement

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DOI: 10.1007/s00264-014-2527-3 · Source: PubMed

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International Orthopaedics (SICOT) (2015) 39:673–680
DOI 10.1007/s00264-014-2527-3

ORIGINAL PAPER

Subsartorial adductor canal vs femoral nerve block for analgesia

after total knee replacement
Stavros G. Memtsoudis & Daniel Yoo & Ottokar Stundner & Thomas Danninger &
Yan Ma & Lazaros Poultsides & David Kim & Mary Chisholm & Kethy Jules-Elysee &
Alejandro Gonzalez Della Valle & Thomas P. Sculco

Received: 15 August 2014 / Accepted: 1 September 2014 / Published online: 9 October 2014
# SICOT aisbl 2014

Abstract postoperative pain in either extremity at six to eight, 24 and

Purpose Providing effective analgesia for total knee
arthroplasty (TKA) patients remains challenging. Femoral
nerve block (FNB) offers targeted pain control; however, its
effect on motor function, related fall risk and impact on
rehabilitation has been the source of controversy. Adductor
canal block (ACB) potentially spares motor fibres of the
femoral nerve, but the comparative effect of the two ap-
proaches has not yet been well defined due to considerable
variability in pain perception. Our study compares both
single-shot FNB and ACB, side to side, in the same patients
undergoing bilateral TKA.
Methods Sixty patients scheduled for bilateral TKA were
randomised to receive ultrasound-guided FNB on one leg
and ACB on the other, in addition to combined spinal epidural
anaesthesia. The primary outcome was comparative
S. G. Memtsoudis (*) : D. Yoo : O. Stundner : T. Danninger :
D. Kim : M. Chisholm : K. Jules-Elysee
Department of Anesthesiology, Hospital for Special Surgery, Weill
Medical College of Cornell University, 535 East 70th Street, New
York, NY, USA
e-mail: memtsoudiss@hss.edu
O. Stundner : T. Danninger
Department of Anesthesiology, Perioperative Medicine and Intensive
Care Medicine, Paracelsus Medical University, Muellner
Hauptstrasse 48, 5020 Salzburg, Austria
48 hours postoperatively. Secondary comparative outcomes
included motor strength (manually and via dynamometer),
physical therapy milestones and patient satisfaction.
Results While pain levels were lowest at six to eight hours
postoperatively and increased thereafter (P<0.001), no signif-
icant differences were seen between extremities at any time
point with regard to pain in the quantitative comparison using
visual analogue scale (VAS) scores (P = 0.4154), motor
strength (P=0.7548), physical therapy milestones or patient
satisfaction. However, in the qualitative comparison, a signif-
icant proportion of patients reported the leg receiving ACB to
be more painful than that receiving FNB at 24 h [50.9 % (n=
30) vs 25.42 % (n=15), P=0.0168)].
Conclusions Although we could not confirm a benefit in
motor function between ACB and FNB, given the equivalent
analgesic potency combined with its potentially lower overall
impact if neuropraxia should occur, ACB may represent an
attractive alternative to FNB.
Keywords Adductor canal block . Femoral nerve block .
Total knee replacement . Regional anesthesia
Introduction

Y. Ma
Division of Biostatics and Epidemiology, Department of Public
Health, Weill Medical College of Cornell University, 535 East 70th
Street, New York, NY, USA
L. Poultsides : A. G. D. Valle : T. P. Sculco
Department of Orthopedic Surgery, Hospital for Special Surgery,
Weill Medical College of Cornell University, 535 East 70th Street,
New York, NY, USA
Total knee arthroplasty (TKA) is associated with significant
postoperative pain [1–3]. To alleviate discomfort and facilitate
recovery, many practitioners perform peripheral nerve blocks
to provide targeted pain control. Traditionally, a femoral nerve
block (FNB) has been viewed as the appropriate intervention
to achieve this goal in the patient undergoing TKA, and
various approaches have been described [4–6]. Alternative
674
approaches, such as intra-articular injections of local anes-
thetics, have been investigated as well [7].
Despite having established the FNB as an effective analge-
sic intervention,[4] considerable controversy persists regard-
ing the effect of FNBs on motor function and thus their
potential role in reducing the patient’s ability to participate
in rehabilitation,[8] in causing prolonged quadriceps dysfunc-
tion and its contribution to fall risk [9, 10]. Partially facilitated
by the expansion in the use of ultrasound (US), a more
targeted attempt to block only the sensory fibres of the femoral
nerve supplying the operative site has been propagated, thus
leading a number of researchers to study the feasibility of
performing an adductor canal block (ACB) [11–15]. This
approach underlies the hypothesis that ACB can provide
analgesia with significantly less effect on motor function.
Thus far, only a small number of studies have comparatively
evaluated the ACB vs the FNB approach in a clinical setting
involving TKA patients. While results suggest that motor
function may be spared to a higher degree,[15] many practi-
tioners question the analgesic equivalence of ACB and its
comparable effect on patient satisfaction. A major problem
performing such a comparison lies in the fact that pain per-
ception is highly dependent on the individual, and large
interpatient variability therefore exists [16, 17]. Thus, studies
targeted to show equivalence between two approaches are
difficult to design, especially because of the large number of
patients needed to achieve adequate power.
In order to address this issue, we used a novel method that
would allow comparison of either type of nerve block within
the same individual by enrolling patients undergoing bilateral
TKA. By allowing each patient and assessors to directly
compare their experience between nerve blocks, bias infused
by interpatient variability may thus be minimised.
The primary outcome of the study was differential quanti-
tative and qualitative pain postoperatively after TKA. Second-
ary outcomes included assessment of motor strength, achieve-
ment in physical therapy milestones and patient satisfaction.
With this approach, we hypothesised that patients would
report similar pain with an ACB compared with the extremity
receiving an FNB. We further hypothesised that patients
would have improved motor strength with an ACB but similar
satisfaction scores when comparing FNB to ACB.
Materials and methods
This study w as registered at ClinicalTrials.gov
(NCT01505374) and received approval after review by the
Institutional Review Board at the Hospital for Special Surgery.
Sixty patients scheduled for primary bilateral TKA were en-
rolled between April 2012 and September 2013. Patients were
excluded from the study if they had a history of chronic pain
defined as daily or almost daily (most days of a week) use of
International Orthopaedics (SICOT) (2015) 39:673–680
opioids for >three months, had a history of peripheral neuropa-
thy and/or neurologic deficits, had contraindications (infection at
the site of injections, coagulopathies) to surgery or refused the
use of peripheral nerve blocks, contraindications to spinal or
epidural anaesthesia and allergies or contraindications to stan-
dard medications used as part of the protocol.
Patients for bilateral TKA were screened for eligibility
according to institutional guidelines [18, 19]. In brief, appro-
priate candidates with no significant cardiopulmonary disease
were classified as 1 or 2 according to the American Society of
Anesthesiologists (ASA) Physical Status Classification1 and
had a body mass index (BMI) >40 kg/m2.
Patients provided written informed consent and were given
6 mg dexamethasone and 7.5 or 15 mg meloxicam (weight-
adjusted) pre-operatively, as per institutional protocol. In the
operating room, standard ASA monitors and nasal oxygen at 3
l/min via cannula were applied, and sedation with midazolam
5 mg IV in divided doses was induced. The two extremities
were randomised to receive either US guided subsartorial
ACB or FNB using blinded envelopes prepared by a indepen-
dent research assistant and only visible to the attending anaes-
thesiologist assigned. Patients, surgeons, physical therapists
and research assistants performing the follow-up were blinded
to the randomisation. Subsequently, blocks were performed as
randomised using a sterile technique. US-guided blocks were
performed using a 13–6 MHz linear probe (SonoSite, Bothell,
WA, USA) and a 22-gauge Chiba type needle of either 6 cm or
10 cm length depending on patient habitus and anaesthesiolo-
gist preference. FNBs were performed using an in-plane tech-
nique, advancing the needle tip under the fascia lata approxi-
mately 1 cm lateral to the femoral nerve and injecting 30 ml of
bupivacaine 0.25 %. ACBs also used an in-plane technique
and were performed by injecting 15 ml bupivacaine 0.25 %.
Approaches were carried out following common institutional
practice on the basis of previous descriptions [6, 12].
Following nerve block, patients received a combined spinal
epidural anaesthetic in the lumbar region of 2.5 ml
bupivacaine 0.5 % intrathecal injection. An epidural catheter
was placed in the lumbar region and used for postoperative
pain control. A radial arterial line was placed as per institu-
tional protocol. Sequential surgery commenced under tourni-
quet inflation using a posteriorly stabilised knee implant. After
surgery, patients were transferred to the recovery room where
they were observed as per routine for the first postoperative
night.
Pain management via epidural catheter was started at the
earliest sign of neuraxial anaesthetic resolution and consisted
of patient-controlled analgesia containing bupivacaine
0.06 %/hydromorphone 10 mcg/ml at 4 ml/h basal rate, 4 ml
bolus every ten minutes and a 20-ml maximum hourly dose. In
1
http://www.asahq.org/Home/For-Members/Clinical-Information/ASA-
Physical-Status-Classification-System.
International Orthopaedics (SICOT) (2015) 39:673–680
addition, one to two pills of hydrocodone 5 mg with 325 mg
acetaminophen were made available orally every four hours, as
needed. The basal epidural rate was reduced to 2 ml/h on the
morning of postoperative day (POD) 1 and discontinued on
POD 2 before the catheter was removed later that day. Data
recorded included patient demographics (age, gender, height,
weight, ASA classification, individual comorbidities) and in-
traoperative events (tourniquet times, estimated blood loss, IV
fluids). Patients were approached six to eight hours, 24 hours
and 48 hours postoperatively and assessed for pain, sensory
recovery and motor strength. Pain was evaluated by asking the
patient to rate which extremity was more painful, with options
being left, right and the same. The visual analogue (VAS) scale
was used at rest and while performing a standardised exercise
using a continuous passive motion (CPM) machine. Pinprick
tests were conducted at the dermatomes of the saphenous nerve
and assessed for no, partial or complete sensory recovery.
Motor strength was evaluated using a Lafayette Manual Mus-
cle Test System (Lafayette Instrument Company, Lafayette,
IN, USA). Quadriceps strength was assessed with the patient
supine, knees flexed on a foam roller at 34–40°, bed angle
between 14–27° and knee extension against the Lafayette
dynamometer placed over the base of the tibia. Strength
readings were recorded as kilograms of force. Quadriceps
strength was estimated using a manual muscle test with a
standardised 0–5 motor-strength scale [20]. Motor strength
was measured before surgery to establish a reference. All
motor-strength evaluations were performed three times at
each time point and the results averaged. Patient satisfaction
with either block was assessed using a standardised scale
from 0–10 [21].
Further, we collected data on the attainment of physical
therapy milestones as defined by the ability to extend the knee
independently to within <10° of maximal extension. Although
not allowing for comparative evaluation in respect to the
primary goal of the study, we recorded the overall consump-
tion of opioids and epidural volume use, which was converted
and reported as morphine equivalents [22–24]. All study data
were collected and managed by using REDCap electronic data
capture tools through the Clinical and Translational Science
Center at Weill Cornell Medical College [25].
Statistical analysis
Continuous variables are presented as mean [standard deviation
(SD)], and median and categorical variables are described as
frequency and percentage. Univariate analysis for determina-
tion of differences between FNBs and ACBs was conducted by
Wilcoxon signed rank-sum test for continuous and chi-square/
Fisher’s exact test for categorical variables. Pain scores and
motor strength were further studied using multiple regression
based on the generalised estimating equations method (GEE),
adjusting for age, gender, BMI, ASA classification, and
675
tourniquet time [26]. In addition, an interaction effect between
nerve block and time was also incorporated into the regression
analysis. Nerve blocks were further compared at each time
point if the interaction effect was significant. For each outcome,
data collected at baseline (no baseline pain score), six to eight
hours, 24 hours and 48 hours postanesthesia at each time point
were included in the GEE analysis. This method takes into
account correlations between repeated measures and does not
require a particular data distribution, thus providing a robust
parameter estimation.
We powered the study to detect a mean difference of 1.2
(SD=2.4) in median pain scores between the two nerve blocks
at any time point based on previous observations of pain levels
after bilateral TKA and the assumption that a difference of
30 % would be clinically relevant [2]. On the basis of a type I
error rate of 5 % and a power of 80 %, we set the target sample
size at 60 patients. All analyses were performed using SAS
version 9.3 (SAS Institute, Cary, NC, USA).
Results
Fifty-nine patients concluded the study as per protocol. Figure 1
displays the Consolidated Standards of Reporting Trials
(CONSORT) flow diagram [27]. One patient allocated to the
ACB group was excluded from analysis, as the postoperative
pain management protocol was changed due to epidural failure.
Table 1 details patient demographics and intraoperative events,
such as fluid balances and tourniquet times. There was no differ-
ence in mean tourniquet times for joints receiving an ACB vs
FNB (49.24±14.11 minutes vs 49.34±12.49 minutes, P=0.655).
Average opioid consumption was at 10.09 mg±21.06 mg on
POD 0, 49.02 mg±47.36 mg on POD 1 and 73.99 mg±
58.3 mg on POD 2, for a total of 133.11 mg±114.53 mg. Average
patient-controlled epidural analgesia (PCEA) consumption was
9.11 mg±5.95 mg on POD 0, 35.70 mg±17.40 mg on POD 1
and 9.09 mg±11.21 mg on POD 2, for a total of 53.90 mg±
27.76 mg. Table 2 shows results of the sensory exam over time. A
higher proportion of patients had a return of sensory function at
24 hours after ACB than after FNB (P=0.035).
At six to eight hours postoperatively, 8.5 % (n=5) of patients
reported that the extremity receiving the FNB was more pain-
ful, 11.9 % (n=7) expressed that the side receiving the ACB
had more pain and 79.7 % (n=47) that both extremities were
equally painful (P<0.0001). At 24 and 48 hours, these propor-
tions were 25.4 % (n=15), 50.9 % (n=30) and 23.7 % (n=14)
(P=0.0168) as well as 25.4 % (n=15), 47.5 % (n=28) and
27.1 % (n=16) (P=0.0699), respectively. Table 3 details infor-
mation on motor strength over time as measured by dynamom-
etry and physical therapy assessment. While a significant and
profound decrease in motor strength from baseline of >80 %
was seen at six to eight hours postoperatively, no significant
676
Fig. 1 Consolidated Standards of
Reporting Trials (CONSORT)
diagram
difference between nerve-block modalities was found in the
average strength measured (P=0.7548). When evaluating the
achievement of physical therapy milestones in terms of ability
to extend the knee within 10° of full extension, there was no
difference in the time in which this was achieved (1.7±1.2 days
for ACB vs 1.9±1.4 days for FNB).
Table 4 shows quantitative pain scores in either extremity
over time both at rest and with exercise. Average pain levels at
rest and with standardised exercise were lowest at six to eight
hours postoperatively and increased thereafter (P<0.001), but
no significant differences were seen between extremities at
any time point (P=0.4154).
Patient satisfaction was similar for both nerve blocks, with
an average score of 9.4±1.1 for ACB vs 9.3±1.6 for FNB at
six to eight hours, respectively (P=0.8387), 8±2.4 vs 8.4±
2.3 at 24 hours, respectively (P=0.3157) and at 48 hours 7.4±
2.8 vs 8.3±2.3, respectively (P=0.0596).
Discussion
In this study of patients undergoing bilateral knee arthroplasty,
we directly compared the impact of a single-shot ACB vs an
International Orthopaedics (SICOT) (2015) 39:673–680
FNB on postoperative quantitative and qualitative measures of
pain, motor strength and patient satisfaction. While both types of
blocks were associated with similar results for all outcomes, in
direct comparison between approaches, more patients reported
better pain control with the femoral vs the saphenous approach at
24 hours. However, when evaluating absolute pain levels, they
were statistically—and probably clinically—insignificantly dif-
ferent. Given a similar impact on motor function and satisfaction
beyond the immediate postoperative period, the single-shot ACB
may thus represent a viable alternative to the femoral approach.
We found that patients had similar overall pain scores at
rest and during exercise when comparing blocks. This is in
line with previous reports supporting the effectiveness of ACB
in knee arthroplasty and arthroscopy patients [14, 28, 29]. A
study by Andersen et al., which compared the use of a con-
tinuous saphenous nerve catheter in addition to a local infil-
tration technique with the latter approach alone found superior
pain relieve in patients treated with ACB [14]. In a smaller
study by Ishiguro et al, the authors reported observational
results in a cohort of patients receiving an ACB and reported
satisfactory results in respect to pain control, motor function
and mobility. However, a control group including patients
with an FNB was absent [29].
International Orthopaedics (SICOT) (2015) 39:673–680 677

Table 1 Patient demographics receiving either FNB or ACB, which found similar pain
Parameter Value control between both blocks, with superior preserved strength
in the ACB group. However, pain was only a secondary
Age Mean (SD) 64.41 (7.36) outcome, as this study was designed to detect an advantage
Median (min, max) 65.49 (42.83, 76.25) of ACBs over the femoral approach in terms of motor function
Body mass index Mean (SD) 28.43 (4.42) [30]. Irrespectively, this is the first study to describe a direct
(kg/m2) Median (min, max) 27.81 (17.53, 38.80) comparison of multiple outcomes by assessing outcomes
Gender n (%) Male 26 (44.1) head-to-head in the same patients, thus vastly reducing the
Female 33 (55.9) issue of interpatient variability.
Total 59 (100) A commonly discussed advantage associated with an ACB
ASAa n (%) 1 7 (11.9) compared with the femoral technique is the potential sparing
2 52 (88.1) of motor fibres. This, at least in theory, may lead to better
Surgery time (min) Mean (SD) 137.03 (27.98) ability of patients to participate actively in physical therapy
Median (min, max) 136 (91, 200) and reduce the risk of falling. Indeed, Jaeger et al. documented
Anesthesia time (min) Mean (SD) 210.63 (33.27) that when comparing the effect of an FNB to an ACB in 11
Median (min, max) 205 (153, 289) healthy volunteers, motor strength was reduced by a mean of
Opioid consumption Mean (SD) 133.11 (114.53) 49 % vs 8 % compared with baseline [15]. However, while
morphine equivalents Median (min, max) 114.53 (15.50, 825) proving the concept, their study was not able to take into
(mg) account the effects of peri-operative insults, such as pain,
PCEA consumption Mean (SD) 53.9 (27.76)
swelling and tourniquet associated quadriceps dysfunction,
morphine equivalent Median (min, max) 48.54 (19.01, 191.2)
(mg) on the ability of patients to move their extremities. However,
Crystalloid infusion (ml) Mean (SD) 2,615.42 (555.97) this assumption was confirmed in patients receiving continu-
Median (min, max) 2,600 (1,600, 4,000) ous catheter-guided ACB vs FNB with values for median
Estimated blood loss (ml) Mean (SD) 447.31 (142.61) strength at 52 % and 18 % of baseline, respectively. In con-
Median (min, max) 400 (200, 1,000) trast, we observed a steeper decline in motor strength >80 %
compared with baseline. This may be explained by the impact
FNBfemoral nerve block, ACBadductor canal block, BMI body mass of other perisurgical factors in bilateral vs unilateral TKA
index, PCEA patient-controlled epidural analgesia, SD standard deviation
a
patients, i.e. two procedures vs one [31], and thus may be
American Society of Anesthesiologists Physical Status Classification
influenced in their ability to generate adequate force during
physical therapy. Further, differences in technique using a
Studies directly comparing ACB and FNB are rare. Indeed, single-shot approach vs a catheter technique have to be con-
the only published data, by Jaeger et al., compare continuous, sidered. Indeed, not only was motor strength profoundly de-
catheter-facilitated ACB vs FNB, showing similar levels of pressed but remained so beyond the expected time of action of
pain control and superior muscle strength in the ACB cohort, either nerve block. Thus, while of theoretical advantage, the
without allowing conclusions to be drawn in the setting of differential effect of single-shot ACBs vs FNBs may be neg-
single-shot administration of these modalities [15]. Address- ligible, at least in the setting of bilateral TKA. However, this is
ing the latter scenario is an unpublished study performed at not to say that a saphenous approach may provide a certain
our institution in unilateral knee arthroplasty patients safety aspect. In the rare event of neurapraxia related to the

Table 2 Results of sensory

examination Time point Sensory examination result Nerve block P value

Adductor canal block Femoral nerve block

6–8 h postop No sensation n (%) 18 (30.5) 13 (22) 0.500

Partially intact n (%) 22 (37.3) 22 (37.3)
Completely intact n (%) 19 (32.2) 24 (40.7)
24 h postop No sensation n (%) 0 (0) 0 (0) 0.035
Partially intact n (%) 10 (16.9) 20 (33.9)
Completely intact n (%) 49 (83.1) 39 (66.1)
48 h postop No sensation n (%) 0 (0) 0 (0) 1.000
Partially intact n (%) 4 (6.8) 4 (6.8)
Completely intact n (%) 55 (93.2) 55 (93.2)
678 International Orthopaedics (SICOT) (2015) 39:673–680

Table 3 Physical exam–Lafa-

yette Manual Muscle Tester Time point Parameters Nerve block P value
(LMMT): muscle strength and
strength grades (1–5) ACB FNB

Baseline Mean (SD) 17.06 (10.65) 17.24 (14.37) 0.944

Median (min, max) 14.4 (4.6, 49.47) 14.37 (3.57, 56.4)
Mean grades (SD) 4.78 (0.46) 4.83 (0.42) 0.418
Median grades (min, max) 5 (3, 5) 5 (3, 5)
6–8 h postoperative Mean (SD) 2.86 (3.55) 2.45 (3.31) 0.511
Median (min, max) 1.82 (0, 14.43) 1.27 (0, 14.6)
Mean grades (SD) 1.61 (1.59) 1.33 (1.45) 0.444
Median grades (min, max) 2 (0, 5) 1 (0, 5)
24 h postoperative Mean (SD) 5.00 (3.68) 5.08 (4.06) 0.939
Median (min, max) 3.87 (0.8, 19.87) 3.57 (0.83, 19.53)
Mean grades (SD) 2.8 (1.06) 2.57 (1.15) 0.34
Median grades (min, max) 3 (0, 5) 3 (1, 5)
Mean and median strength in ki- 48 h postoperative Mean (SD) 3.35 (2.62) 3.76 (3.35) 0.435
lograms of force (kgF) Median (min, max) 2.77 (0.27, 12.53) 3.3 (0, 20)
ACB adductor canal block, FNB Mean grades (SD) 2.42 (1.32) 2.42 (1.25) 0.974
femoral nerve block, SD standard Median grades (min, max) 3 (0, 5) 2 (0, 5)
deviation

actual nerve block, detrimental effect might be more limited if pain scores, motor strength and patient satisfaction. However,
only saphenous fibres of the femoral nerve are involved as in the direct comparison between the two approaches, more
opposed to the entire femoral nerve. patients had better pain control with an FNB at 24 hours
Our study has a number of limitations. First, it was conduct- postoperatively, which may raise questions regarding differ-
ed in the setting of our practice, which employs epidural ential block duration but may be of limited clinical signifi-
analgesia postoperatively, thus not allowing for assessment of cance if interpreting data in their entirety. In the setting of
the independent impact of the respective nerve blocks on bilateral TKA surgery, motor function was significantly and
outcomes. However, the comparative impact of either block similarly reduced in both extremities, suggesting that the use
studied should be equally affected by such an approach, and of a particular nerve block, at least early in the postoperative
thus, bias may be minimised. Given our study design of bilat- period, may have only limited overall differential impact on
eral knee arthroplasty patients, we were unable to study the quadriceps strength. Given the potential for rare but signifi-
independent impact on outcomes such as opioid consumption cant neurapraxias and—in the setting of likely equivalence to
and associated side effects or length of hospital stay. However,
our unique design allowed us to reduce interpatient variability
for our primary outcome, which can be a significant problem Table 4 Average postoperative pain scores
with studies assessing pain outcomes. Further, our observation Time point Parameters Nerve blocks P value
period was limited to 48 hours postoperatively, and conclusions
and potential complications detected thereafter were not ACB FNB
accounted for. However, we are not aware of any untoward
events associated with the use of either block in any of our 6–8 h rest Mean (SD) 0.81 (2.13) 0.9 (2.4) 0.746
Median (min, max) 0 (0, 10) 0 (0, 10)
patients. Finally, doses and local anesthetics used represent
6–8 h exercise Mean (SD) 0.69 (1.88) 0.79 (2.1) 0.839
common practice at our hospital, and while standardised for Median (min, max) 0 (0, 10) 0 (0,10)
the study, different approaches, such as the use of additives or 24 h rest Mean (SD) 2.81 (2.42) 2.47 (2.42) 0.368
catheters, may have yielded different results; these alternative Median (min, max) 3 (0, 9) 2 (0, 8)
interventions therefore require further study. Finally, our data 24 h exercise Mean (SD) 3.8 (2.6) 2.82 (2.46) 0.026
should be interpreted in the context of bilateral TKA, which Median (min, max) 4 (0, 10) 3 (0, 10)
may be associated with different and, likely, more profound 48 h rest Mean (SD) 4.12 (2.72) 3.88 (2.52) 0.679
physiologic changes compared with unilateral TKA patients, Median (min, max) 4 (0, 10) 4 (0,10)
which in turn may influence outcomes studied differentially 48 h exercise Mean (SD) 5.51 (2.76) 5.37 (2.58) 0.479
Median (min, max) 5 (0, 10) 5 (0, 10)
from those seen in unilateral joint surgery.
In conclusion, we found that the use of ACBs vs FNBs in ACB adductor canal block, FNB femoral nerve block, SD standard
knee arthroplasty patients yielded similar results in absolute deviation
International Orthopaedics (SICOT) (2015) 39:673–680
control pain, affect motor function and achieve satisfaction—
the ACB may represent an attractive alternative as an analge-
sic technique in knee arthroplasty patients.
Acknowledgments We thank Isabelle Kao and Heather Reel for
assisting with data collection and management.
Funding This study was performed with funds from the Hospital for
Special Surgery, Department of Anesthesiology, New York, NY, USA,
and the Anna-Maria and Stephen Kellen Physician-Scientist Career De-
velopment Award, New York, NY, USA (Stavros G. Memtsoudis). Re-
search was supported in part by the Clinical and Translational Science
Center (CTSC) at Weill Cornell Medical College through grant no.
UL1TR000457-06. Contribution of Dr. Ma on this project was supported
in part by the Agency for Healthcare and Quality Research (AHRQ,
Rockville, MD) grant no. R01HS021734. The content is solely the
responsibility of the authors and does not necessarily represent the official
views of the funding source, AHRQ, based in Rockville, MD, USA.
Conflicts of interest None.
References
1. Grosu I, Lavand'homme P, Thienpont E (2014) Pain after knee
arthroplasty: an unresolved issue. Knee Surgery, Sports
Traumatology, Arthroscopy. Off J ESSKA 22:1744–1758. doi:10.
1007/s00167-013-2750-2
2. Kim MH, Nahm FS, Kim TK, Chang MJ, Do SH (2014) Comparison
of postoperative pain in the first and second knee in staged bilateral
total knee arthroplasty: clinical evidence of enhanced pain sensitivity
after surgical injury. Pain 155:22–7. doi:10.1016/j.pain.2013.08.027
3. Petersen W, Rembitzki IV, Bruggemann GP, Ellermann A, Best R,
Koppenburg AG, Liebau C (2014) Anterior knee pain after total knee
arthroplasty: a narrative review. Int Orthop 38:319–28. doi:10.1007/
s00264-013-2081-4
4. Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y
(2010) Femoral nerve block improves analgesia outcomes after total
knee arthroplasty: a meta-analysis of randomized controlled trials.
Anesthesiology 113:1144–62. doi:10.1097/ALN.0b013e3181f4b18
5. Ilfeld BM, Mariano ER, Madison SJ et al (2011) Continuous femoral
versus posterior lumbar plexus nerve blocks for analgesia after hip
arthroplasty: a randomized, controlled study. Anesth Analg 113:897–
903. doi:10.1213/ANE.0b013e318212495b
6. YaDeau JT, Cahill JB, Zawadsky MW (2005) The effects of femoral
nerve blockade in conjunction with epidural analgesia after total knee
arthroplasty. Anesth Analg 101:891–895, Table of contents
7. Broome CB, Burnikel B (2014) Novel strategies to improve early
outcomes following total knee arthroplasty: a case control study of
intra articular injection versus femoral nerve block. Int Orthop. doi:
10.1007/s00264-014-2392-0
8. Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB
(2009) Femoral nerve block for total knee replacement - a word of
caution. Knee 16:98–100. doi:10.1016/j.knee.2008.10.007
9. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL (2010)
Complications of femoral nerve block for total knee arthroplasty. Clin
Orthop Relat Res 468:135–40. doi:10.1007/s11999-009-1025-1
10. Wasserstein D, Farlinger C, Brull R, Mahomed N, Gandhi R (2013)
Advanced age, obesity and continuous femoral nerve blockade are
independent risk factors for inpatient falls after primary total knee
arthroplasty. J Arthroplast 28:1121–4. doi:10.1016/j.arth.2012.08.
018
679
11. Horn JL, Pitsch T, Salinas F, Benninger B (2009) Anatomic basis to
the ultrasound-guided approach for saphenous nerve blockade. Reg
Anesth Pain Med 34:486–489. doi:10.1097/AAP.0b013e3181ae11af
12. Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R
(2009) Feasibility and efficacy of ultrasound-guided block of the
saphenous nerve in the adductor canal. Reg Anesth Pain Med 34:
578–80
13. Jaeger P, Grevstad U, Henningsen MH, Gottschau B, Mathiesen O,
Dahl JB (2012) Effect of adductor-canal-blockade on established,
severe post-operative pain after total knee arthroplasty: a randomised
study. Acta Anaesthesiol Scand 56:1013–9. doi:10.1111/j.1399-
6576.2012.02737.x
14. Andersen HL, Gyrn J, Moller L, Christensen B, Zaric D (2013)
Continuous saphenous nerve block as supplement to single-dose
local infiltration analgesia for postoperative pain management after
total knee arthroplasty. Reg Anesth Pain Med 38:106–11. doi:10.
1097/AAP.0b013e31827900a9
15. Jaeger P, Nielsen ZJ, Henningsen MH, Hilsted KL, Mathiesen O,
Dahl JB (2013) Adductor canal block versus femoral nerve block and
quadriceps strength: a randomized, double-blind, placebo-controlled,
crossover study in healthy volunteers. Anesthesiology 118:409–15.
doi:10.1097/ALN.0b013e318279fa0b
16. DeLoach LJ, Higgins MS, Caplan AB, Stiff JL (1998) The visual
analog scale in the immediate postoperative period: intrasubject vari-
ability and correlation with a numeric scale. Anesth Analg 86:102–6
17. Gerbershagen HJ, Rothaug J, Kalkman CJ, Meissner W (2011)
Determination of moderate-to-severe postoperative pain on the nu-
meric rating scale: a cut-off point analysis applying four different
methods. Br J Anaesth 107:619–26. doi:10.1093/bja/aer195
18. Urban MK, Chisholm M, Wukovits B (2006) Are postoperative
complications more common with single-stage bilateral (SBTKR)
than with unilateral knee arthroplasty: guidelines for patients sched-
uled for SBTKR. HSS Journal. Musculoskelet J Hos Special Surg 2:
78–82. doi:10.1007/s11420-005-0125-z
19. Memtsoudis SG, Hargett M, Russell LA et al (2013) Consensus
statement from the consensus conference on bilateral total knee
arthroplasty group. Clin Orthop Relat Res 471:2649–57. doi:10.
1007/s11999-013-2976-9
20. Sapega AA (1990) Muscle performance evaluation in orthopaedic
practice. J Bone Joint Surg 72:1562–1574, American Volume
21. Szucs S, Iohom G, O'Donnell B, Sajgalik P, Ahmad I, Salah N,
Shorten G. (2012) Analgesic efficacy of continuous femoral nerve
block commenced prior to operative fixation of fractured neck of
femur. Perioperative Medicine (London, England) 1: 4,0525-1-4.
eCollection 2012. doi: 10.1186/2047-0525-1-4
22. Gordon DB, Stevenson KK, Griffie J, Muchka S, Rapp C, Ford-
Roberts K (1999) Opioid equianalgesic calculations. J Palliat Med 2:
209–18. doi:10.1089/jpm.1999.2.209
23. Amabile CM, Bowman BJ (2006) Overview of oral modified-release
opioid products for the management of chronic pain. Ann
Pharmacother 40:1327–1335
24. Liu S, Carpenter RL, Mulroy MF, Weissman RM, McGill TJ, Rupp
SM, Allen HW (1995) Intravenous versus epidural administration of
hydromorphone. Effects on analgesia and recovery after radical
retropubic prostatectomy. Anesthesiol 82:682–688
25. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG
(2009) Research electronic data capture (REDCap)–a metadata-
driven methodology and workflow process for providing translation-
al research informatics support. J Biomed Inform 42:377–81. doi:10.
1016/j.jbi.2008.08.010
26. Ma Y, Mazumdar M, Memtsoudis SG (2012) Beyond repeated-
measures analysis of variance: advanced statistical methods for the
analysis of longitudinal data in anesthesia research. Reg AnesthPain
Med 37:99–105. doi:10.1097/AAP.0b013e31823ebc74
27. Schulz KF, Altman DG, Moher D, CONSORT Group (2010)
CONSORT 2010 statement: updated guidelines for reporting parallel
680
group randomized trials. Ann Intern Med 152:726–32. doi:10.7326/
0003-4819-152-11-201006010-00232
28. Hsu LP, Oh S, Nuber GW, Jr Doty R, Kendall MC, Gryzlo S,
Nader A (2013) Nerve block of the infrapatellar branch of the
saphenous nerve in knee arthroscopy: a prospective, double-
blinded, randomized, placebo-controlled trial. J Bone Joint
Surg 95:1465–1472. doi:10.2106/JBJS.L.01534, American
Volume
29. Ishiguro S, Asano N, Yoshida K et al (2013) Day zero ambulation
under modified femoral nerve block after minimally invasive surgery
View publication stats
International Orthopaedics (SICOT) (2015) 39:673–680
for total knee arthroplasty: preliminary report. J Anesth 27:132–4.
doi:10.1007/s00540-012-1479-2
30. Kim DH, Lin Y, Goytizolo EA et al (2014) Adductor canal block
versus femoral nerve block for total knee arthroplasty: a prospective,
randomized, controlled trial. Anesthesiology 120:540–50. doi:10.
1097/ALN.0000000000000119
31. Memtsoudis SG, Ma Y, Gonzalez Della Valle A, Mazumdar M,
Gaber-Baylis LK, MacKenzie CR, Sculco TP (2009) Perioperative
outcomes after unilateral and bilateral total knee arthroplasty.
Anesthesiology 111:1206–16. doi:10.1097/ALN.0b013e3181bfab7d