A Comparative Analysis of Bupivacaine Concentrations in Adductor Canal Block for Pain Management Post-unilateral Knee Arthroplasty.

What's New in Adult Reconstructive Knee Surgery.

What's New in Adult Reconstructive Knee Surgery.

Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice?

Effect of adductor canal block on pain in patients with severe pain after total knee arthroplasty: a randomized study with individual patient analysis

Background: After total knee arthroplasty, regional anaesthetic methods such as femoral nerve and adductor canal blocks are frequently used to ease the pain. Objective: To assess how femoral nerve and adductor canal blocks affect post-operative mobility, healing time, and pain management following total knee arthroplasty. Methodology: From October 8, 2023, to September 25, 2024, a tertiary care hospital hosted this cross-sectional study. We randomly assigned 160 patients receiving unilateral primary total knee replacement to either the adductor canal or femoral nerve block (80 in each group). Before surgery, each group had their nerve block. Postoperative pain was measured at 6, 12, 18, and 24 hours using the numeric rating scale. Mobility on postoperative days 1–7 and the time until straight leg raise were recovery markers. Results: Age (femoral nerve block: 65.4±8.3 years; ACB: 64.8±7.9 years), gender distribution, body mass index, and ASA physical state did not significantly differ across groups. At every time point, the femoral nerve block group's pain scores were significantly lower: at 6 hours, this score was 3.8±1.2, compared to the adductor canal block's 4.2±1.3 (p=0.04). These tendencies continued at later evaluations (p<0.03). About 35% of the femoral nerve block group and 67.5% of the ACB group, respectively, attained straight leg raise greater than 30° on Day 1 (p<0.001). By Day 7, 93.75% of the femoral nerve block group and 100% of the ACB group had pain-free straight leg raise (p=0.05). According to multiple regression analysis, femoral nerve block was substantially linked to quicker recovery and lower pain scores (B=-0.5, p=0.001). Conclusion: After total knee arthroplasty, femoral nerve block provides better postoperative pain management and a faster recovery than adductor canal block, although adductor canal block allows for earlier leg mobilization and improves straight leg raise recovery.

Objective To compare the analgesic effect of continuous adductor canal block(ACB) and continuous femoral nerve block(FNB) after total knee arthroplasty(TKA). Methods Sixty patients scheduled for unilateral TKA were randomly assigned into two groups, receiving continuous ACB(group A) or continuous FNB(group F). Intravenous anesthesia was applied throughout the operation. The adductor canal and the femoral nerve were catheterized for block under the guidance of sonography before induction of general anesthesia. Patient-controlled analgesia was provided immediately after surgery with 0.2% ropivacaine through the perineural catheter. The pain severity at rest and upon movement (passive knee flexion of 45 degrees) with a 0-10 numeric rating scale (NRS), the Lovett score of muscle strength of the quadriceps femoris, and the modified Bromage score of the motor block of the affected extremity were assessed 4, 8, 12, 24, 48 h after surgery. The maximal range of active/passive motion of the knee joint was recorded 1, 2, 3, 14 d after surgery. The number of effective patient-controlled bolus of ropivacaine and the number of need for opioid rescue within 48 h after surgery, the first time of out-of-bed activity, the time of active knee flexion reaching 90 degrees, and the hospital for special surgery(HSS) score of knee function 14 d after surgery were also recorded. Results There was no difference between group A and group F in terms of the NRS scores at rest and upon movement, the number of effective patient-controlled bolus of ropivacaine and the number of need for opioid rescue (P>0.05). Patients in group A had a higher Lovett score of muscle strength of the quadriceps femoris and a lower modified Bromage score of the motor block than those in group F within 12 h after surgery (P 0.05). Conclusions An equal postoperative analgesic efficacy was observed in patients receiving continuous ACB and continuous FNB. Furthermore, continuous ACB did not provide a superior effect on early rehabilitation than continuous FNB. Key words: Adductor canal block; Femoral nerve block; Total knee arthroplasty; Postoperative analgesia; Rehabilitation

Addition of buprenorphine to local anesthetic in adductor canal blocks after total knee arthroplasty improves postoperative pain relief: a randomized controlled trial

In the last decade, the widespread use of regional anesthesia in total knee arthroplasty has led to improvements in pain control, more rapid functional recovery, and reductions in the length of the hospital stay. The aim of this study was to compare the efficacy of adductor canal blocks (ACB) and periarticular anesthetic injections (PAI), both with bupivacaine, for pain management in total knee arthroplasty. One hundred and fifty-five patients undergoing primary total knee arthroplasty under spinal anesthesia were randomized to 1 of 3 groups: ACB alone (15 mL of 0.5% bupivacaine), PAI alone (50 mL of 0.25% bupivacaine with epinephrine), and ACB+PAI. The primary outcome in this study was the visual analog scale (VAS) pain score in the immediate postoperative period. Secondary outcomes included postoperative opioid use, activity level during physical therapy, length of hospital stay, and knee range of motion. The mean VAS pain score was significantly higher after use of ACB alone, compared with the score after use of ACB+PAI, on postoperative day 1 (POD1) (3.9 versus 3.0, p = 0.04) and POD3 (4.2 versus 2.0, p = 0.02). Total opioid consumption through POD3 was significantly higher when ACB alone had been used (131 morphine equivalents [ME]) compared with PAI alone (100 ME, p = 0.02) and ACB+PAI (98 ME, p = 0.02). Opioid consumption in the ACB-alone group was significantly higher than that in the ACB+PAI group on POD2 and POD3 and significantly higher than that in the PAI-alone group on POD2. There was no significant difference in opioid consumption between the patients treated with PAI alone and those who received ACB+PAI. The activity level during physical therapy on POD0 was significantly lower after use of ACB alone (26 steps) than after use of PAI alone (68 steps, p < 0.001) or ACB+PAI (65 steps, p < 0.001). This randomized controlled clinical trial demonstrated significantly higher pain scores and opioid consumption after total knee arthroplasty done with an ACB and without PAI, suggesting that ACB alone is inferior for perioperative pain control. There were no significant differences between PAI alone and ACB+PAI with regard to pain or opioid consumption. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Acute postoperative pain after total knee arthroplasty (TKA) is so severe to the degree that necessitates proper analgesia which is one of the patients' human rights and prevents the drawbacks of pain on various body systems. Local anesthetic Infiltration between the Popliteal Artery and the Capsule of the Knee (IPACK) can represent a promising technique for management of postoperative pain in combination with adductor canal block (ACB) after TKA. Methods: Patients received an ACB (Group I) or ACB plus IPACK (Group II) as a component of a multimodal analgesic for TKA. Visual analogue scale (VAS) for postoperative pain assessment were assessed as the primary outcome and opioid consumption, time to first rescue analgesia, and patient satisfaction were assessed as secondary outcomes. Results: Regarding VAS, there were nonsignificant differences between both groups in the first 8hrs postoperative, while after 8hrs postoperative and up to 48hr postoperative, VAS scores were lower in Group II. Total morphine consumption was less in Group II which had a longer time to first rescue analgesia than Group I. Patient satisfaction 48hr postoperative was higher in Group II than in Group I. Conclusion: The combination of IPACK block with ACB has the potential of being an adequate technique for management of acute postoperative pain after TKA but this needs more researches of larger samples and use of other types of local anesthetics with different volumes and concentrations.

ObjectiveThe aim of this study compare the effectiveness of the space between the popliteal artery and the posterior knee capsule (iPACK) and posterior capsule injection (PCI) in patients with primary end stage knee osteoarthritis treated with total knee arthroplasty (TKA).MethodsThis was a double-blind, prospective, randomised trial. A total of 195 participants were randomly assigned to one of three groups: Group 1 with an adductor canal block (ACB) plus iPACK. Group 2 with ACB + PCI and a final control group with ACB only. All participants underwent primary total knee arthroplasty. Outcome measures comprised pain assessment using the Visual Analog Scale (VAS) and monitoring opioid analgesic consumption. VAS measurements were taken at the 1st, 6th, 12th, 24th, 48th, and 72nd hours, followed by the 10th day and the 12th week.ResultsAge, sex, BMI and side of surgery were analyzed and no significant differences were found. Groups ACB + iPACK and ACB + PCI exhibited significantly lower VAS scores compared to the control group at 3, 6, and 12 h after surgery, with group ACB + iPACK showing the lowest VAS scores among all groups. No significant difference in VAS values between groups was detected after 24 h postoperatively and after that. Significant differences were observed between groups in opioid consumption. The values for the first hour, first day, second day, and total consumption exhibited statistically significant differences between the groups.ConclusionOur study has shown that PCI in combination with ACB is not inferior to the iPACK technique. It is our belief that these combination techniques can be used in accordance with the surgeon’s experience and preference. It is important to remember that PCI is quicker and easier to perform without using ultrasonography.

Background: Individuals exhibit variations in pain perception and pain threshold, and these differences exist between the right and left limbs, resulting in biases related to inter-cerebral pain variability and inter-patient pain variability. Currently, there is limited available data comparing adductor canal block (ACB) with femoral nerve block (FNB) in individuals who have undergone bilateral total knee arthroplasty (TKA). Methods: We conducted a prospective, non-randomized, controlled study involving patients scheduled for bilateral total knee arthroplasty (TKA) under central neuraxial anesthesia. Following surgery, patients received intermittent 12-hourly boluses of 15 mL ropivacaine 0.5% through two distinct peripheral nerve blocks (adductor canal block - ACB and femoral nerve block - FNB) in either of the lower limbs. The primary objective was to evaluate the postoperative Visual Analog Scale (VAS) score, while the secondary outcomes included the assessment of quadriceps muscle strength and the degree of flexion at the knee joint. Results: Out of the 70 patients evaluated for eligibility, 63 were enrolled, and 60 were included in the final analysis. Visual Analog Scale (VAS) scores after both blocks during periods of rest at 30 minutes, 6 hours, 12 hours, and 48 hours post-operatively did not exhibit any significant differences. However, VAS scores during rest at 24 hours and during exercise at 24 hours and 48 hours demonstrated a notable disparity. Furthermore, there was a significant difference in favour of adductor canal block (ACB) over femoral nerve block (FNB) regarding quadriceps muscle strength and the degree of knee flexion at 24 hours and 48 hours post-operatively. Conclusions: Adductor canal block (ACB) delivers comparable pain relief to femoral nerve block (FNB) both at rest and during passive exercise for up to 48 hours after surgery. ACB notably maintains the motor strength of quadriceps muscles when contrasted with FNB, and this preservation comes without introducing any additional complications.

Background: The aim of the study was to compare the study of continuous epidural and continuous adductor canal block for postoperative pain management in total knee arthroplasty (TKA). Materials and Methods: A total of 150 cases were recruited with 75 cases in each group; patients participated in the study were divided into the adductor canal block (ACB) group and continued epidural group. All the patients received the standardized anesthesia and analgesia on hospitalization. Outcome evaluations included the visual analog scale (VAS) scores during activity and at rest, range of motion, quadriceps strength, complication occurrence, total opioid consumption and sleep disruptions caused by pain, postoperative hospital stay, and postoperative nausea and vomiting (PONV) before discharge in all groups. Results: The lateral VAS scores of the knee were lower in the continuous epidural group at rest and during activity as compared with the ACB group. However, the overall knee VAS score, complication occurrence, total opioid consumption and sleep disruptions caused by pain, and PONV were similar between ACB and epidural groups. The urinary retention in patients receiving continuous epidural was common compared to no retention in the adductor group, early mobilization in the adductor group, and no muscle weakness in the ACB group. Conclusion: The ACB does not relieve the lateral knee pain at an early stage but offers comparable analgesic effect and enhanced effectiveness of the early rehabilitation compared to an epidural in patients who underwent TKA.

Background Total knee arthroplasty (TKA) is a highly distressful major surgery, with a significant potential for complications, not only because of the surgical and anesthetic impact of the procedure, but also because of the demographic and clinical characteristics of the target population. Careful pain management is necessary post-operative to achieve early post-operative mobilization while ensuring patient comfort throughout and preventing post-operative complications. Objective we aim to compare postoperative pain management and post- operative analgesic consumption between IPACK block and Adductor canal block in total knee arthroplasty cases. Methods After obtaining approval from the medical ethical committee in Ain Shams University, this Prospective randomized controlled double-blind clinical trial study was conducted in the operating theatres of Ain shams University Hospitals. Study period March 2022 to August 2022. Physical status: ASA 1 or 2 and candidates for spinal anaesthesia undergoing total knee arthroplasty. Age group: 40-65 years. Sample sizes of 30 patients in total; 15 in group I (group I) and 15 in group II (group A). Results As for the comparison between effect of IPACK block and Adductor canal block as regard post-operative pain in total knee arthroplasty, it showed that there is significance regarding the numeric version of the visual analogue scale (VAS) that was used to assess postoperative pain and its intensity with range 1-3 for Adductor canal block and 2-4 for IPACK block. Conclusion The comparison between effect of IPACK block and Adductor canal block as regard post-operative pain in total knee arthroplasty showed significant difference regarding the numeric version of the visual analogue scale (VAS) that was used to assess postoperative pain and its intensity with range 1-3 for Adductor canal block and 2-4 for IPACK block. These findings with our study primary and secondary outcomes showed that Adductor canal block has more analgesic effect with respect to IPACK block regarding pain assessment but with no significant difference regarding the by the time till first analgesia postoperative and Total analgesics consumption (in mg.) over 24-hour period post-operative.

Context Femoral nerve block (FNB) provides effective analgesia after total knee arthroplasty (TKA) but has been associated with delayed ambulation due to quadriceps muscle weakness. Adductor canal block (ACB) may be a promising alternative, with less effect on the quadriceps muscle and comparable analgesic efficacy. Aim The aim of the study was to compare ACB with FNB regarding the quadriceps muscle strength and its analgesic efficacy in patients following TKA. Settings and design This was a prospective, randomized, controlled, double-blinded study. Patients and methods The patients were randomized to receive either ACB or FNB. The primary outcome was the effect on quadriceps muscle and early ambulation as determined by the timed up and go test and 10-min walk test. The secondary outcome was to compare the analgesic efficacy as determined by numeric rating scale, opioid consumption, and hospital length of stay. Results We enrolled 110 patients, of whom 107 were analyzed. The timed up and go test and the 10-m walk test were significantly shorter in the ACB group than in the FNB group on the postoperative day 1 with P-value of 0.002 and 0.005, respectively, whereas the difference between both study groups was statistically nonsignificant on the postoperative day 2. There was no significant difference between the study groups regarding the numeric rating scale, morphine consumption, or length of stay. Conclusion ACB may promote early ambulation after TKA without a reduction in analgesia when compared with FNB.

There is no consensus on whether adductor canal block (ACB) combined with infiltration between the popliteal artery and capsule of the posterior knee (IPACK) block can further increase analgesia and reduce opioid consumption after total knee arthroplasty (TKA) compared with ACB and periarticular infiltration analgesia (PIA). This study aimed to evaluate the effectiveness of combining ACB and PACK block on analgesia and functional recovery following TKA. A retrospective cohort study was conducted involving 386 patients who underwent primary unilateral TKA at our institution from January 2020 to October 2022. Patients were divided into 3 groups and treated with PIA, ACB, or ACB combined with IPACK block, respectively. Primary outcomes were postoperative morphine consumption and visual analogue scale (VAS) pain scores. Secondary outcomes included functional recovery, evaluated by knee range of motion, quadriceps strength, daily mobilization distance, and postoperative length of stay. Other outcomes included incidence of complications. Patients in the ACB + IPACK group had significantly less morphine consumption on postoperative day 1 and during hospitalization than patients in the PIA and ACB groups. Furthermore, the ACB + IPACK group had significantly lower VAS scores at rest and during motion at 6, 12, and 24 hours postoperatively (but not at other time points), better knee range of motion on postoperative days 1 and 2 (but not day 3), and a greater daily mobilization distance on postoperative day 1 (but not days 2 and 3). The ACB + IPACK group had significantly lower incidences of postoperative nausea and vomiting than the PIA and ACB groups. This retrospective cohort study suggests that a combination of ACB and IPACK block may have a greater effect than PIA or ACB alone on analgesia following TKA, while providing better functional recovery. Further study is warranted.