Adductor canal block combined with local infiltration analgesia versus isolated adductor canal block in reducing pain and opioid consumption after total knee arthroplasty: a systematic review and meta-analysis

Lv, Jianyong; Huang, Cuiyuan; Wang, Zuofeng; Ou, Shan

doi:10.1177/0300060520926075

Cited by 9 publications

(5 citation statements)

References 22 publications

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“…A total of 26 systematic reviews and meta-analyses were identified reporting ACB in TKA [ACB versus FNB (n U 8), [111][112][113][114][115][116][117][118] ACB versus LIA (n ¼ 10), [138][139][140][141][142][143][144][145][146][147] and ACB technique (n ¼ 7)]. [148][149][150][151][152] Five RCTs compared ACB with saline ACB (either bolus or repeated boluses or continuous infusion) (Table S1, http://links.lww.com/ EJA/A701).…”

Section: Adductor Canal Blockmentioning

confidence: 99%

Pain management after total knee arthroplasty

Lavand’homme¹,

Kehlet²,

Rawal³

et al. 2022

European Journal of Anaesthesiology

103

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BACKGROUND The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery. OBJECTIVE To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA.DESIGN A narrative review based on published systematic reviews and meta-analyses, using modified PROSPECT methodology.DATA SOURCES A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA.ELIGIBILITY CRITERIA Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance.RESULTS A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 mg) may be considered in hospitalised patients only in situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified.CONCLUSION The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.

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Section: Adductor Canal Blockmentioning

confidence: 99%

Pain management after total knee arthroplasty

Lavand’homme¹,

Kehlet²,

Rawal³

et al. 2022

European Journal of Anaesthesiology

103

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“…Consistent with previous studies, we also failed to show that the addition of an iPACK block improves functional outcomes or quality of recovery after total knee arthroplasty, irrespective of pain score differences in the first 24 h. 13 Both the study and control groups in the current study received a single IV dexamethasone dose, single-shot adductor canal block, intrathecal morphine (100 μg), and periarticular local anesthesia infiltration for postoperative analgesia (table 1). The synergistic analgesic effect of combining periarticular local anesthesia infiltration and single-dose adductor canal block can significantly delay rescue analgesia, 26 reduce cumulative opioid requirements, 27 and improve range of motion 28 and early discharge after total knee arthroplasty. 29 The addition of intrathecal morphine to adductor canal block and periarticular local anesthesia infiltration can further improve analgesia and reduce postoperative opioid requirements.…”

Section: Multimodal Analgesia For Knee Arthroplastymentioning

confidence: 99%

No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone, and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty

et al. 2022

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Background. An optimal opioid-sparing multimodal analgesic regimen to treat severe pain can enhance recovery after total knee arthroplasty. We hypothesized that adding 5 recently described IV and regional interventions to multimodal analgesic regimen can further reduce opioid consumption. Methods. In a double-blinded fashion, seventy-eight patients undergoing elective total knee arthroplasty were randomized to either (1) a control group (n=39) that received spinal anesthesia with intrathecal morphine, periarticular local anesthesia infiltration, IV dexamethasone and a single injection adductor canal block or (2) a study group (n=39) that received the same set of analgesic treatments plus 5 additional interventions - local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intraoperative IV dexmedetomidine and ketamine, and postoperatively, 1 additional IV dexamethasone bolus, and 2 additional adductor canal block injections. The primary outcome measure was 24-hour cumulative opioid consumption after surgery and secondary outcomes were other analgesic, patient recovery and functional outcomes and adverse events. Results. Opioid consumption was not different between groups at 24 hours (oral morphine equivalents, mean ± SD), study: 23.7 ± 18.0 mg vs. control: 29.3 ± 18.7 mg; mean difference [95% CI], −5.6 mg [-2.7, 13.9]; P = 0.189) and all other time points after surgery. There were no major differences in pain scores, quality of recovery, or time to reach rehabilitation milestones. Hypotensive episodes occurred more frequently in the study group (25/39 (64.1%) vs. 13/39 (33.3%), p= 0.010). Conclusions. In the presence of periarticular local anesthesia infiltration, intrathecal morphine, single shot adductor canal block and dexamethasone, the addition of 5 analgesic interventions – local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, IV dexmedetomidine, IV ketamine, an additional IV dexamethasone dose and repeated adductor canal block injections – failed to further reduce opioid consumption, pain scores or improve functional outcomes after total knee arthroplasty.

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“…It has become clear that periarticular LIA has better pain control with less opioid consumption than ACB alone [1,2]. Although the duration of single-dose LIA may not be long enough to cover the perioperative period, it has been shown that combining ACB with LIA can signi cantly reduce pain scores and morphine consumption compared with LIA alone [3][4][5]. However, this raises concerns about the potential risk of local anesthetic systemic toxicity (LAST), especially with the large doses of local anesthetic used in both LIA and ACB.…”

Section: Introductionmentioning

confidence: 99%

An Observational Study of the Pharmacokinetics of Adductor Canal Block using Liposomal Bupivacaine and Standard Bupivacaine in Total Knee Arthroplasty

Chan

Mak

et al. 2023

Preprint

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Background Periarticular local infiltration of analgesia (LIA) and regional nerve block using adductor canal block (ACB) have been effective in managing postoperative pain for total knee arthroplasty (TKA). It has been shown that combining ACB with LIA can significantly reduce pain scores and morphine consumption compared with LIA alone. However, this raises concerns about the potential risk of local anesthetic systemic toxicity (LAST), especially with the large doses of total local anesthetic used in both LIA and ACB. This study was to evaluate the plasma level of bupivacaine over a 72-hour period following ACB using 66.5 mg of liposomal bupivacaine (LB) in patients undergoing TKA with LIA using 300 mg ropivacaine. Methods This was a prospective observational study. Ten patients undergoing primary, unilateral, simple revision TKA in a tertiary hospital in Hong Kong between December 2020 to February 2022 were included in the study. The primary outcomes were the time to peak plasma concentration (Tmax) of bupivacaine and the peak plasma concentration (Cmax) of bupivacaine. The secondary outcome was the presence of LAST. Results Tmax of bupivacaine was 48 hours while Cmax of bupivacaine was 88 mcg/L, this value was far below 2000 mcg/L, the defined toxic plasma concentration of bupivacaine. Conclusions There is still room for increasing the dose of LB used in ACB for TKA patients, further dose-defining studies with PK data are needed to define the optimal dose that would balance the safety and efficacy of LB. Trial registration The clinical trial was registered at ClinicalTrials.gov with registration number NCT04916392.

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Adductor canal block combined with local infiltration analgesia versus isolated adductor canal block in reducing pain and opioid consumption after total knee arthroplasty: a systematic review and meta-analysis

Cited by 9 publications

References 22 publications

Pain management after total knee arthroplasty

Pain management after total knee arthroplasty

No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone, and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty

An Observational Study of the Pharmacokinetics of Adductor Canal Block using Liposomal Bupivacaine and Standard Bupivacaine in Total Knee Arthroplasty

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