Relative Contributions of Adductor Canal Block and Intrathecal Morphine to Analgesia and Functional Recovery After Total Knee Arthroplasty

Biswas, Abhijit; Perlas, Anahi; Ghosh, Meela; Chin, Ki-Jinn; Niazi, Ahtsham U.; Pandher, Barjind; Chan, Vincent

doi:10.1097/aap.0000000000000724

Cited by 21 publications

(46 citation statements)

References 28 publications

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“…Though the ACB results in less quadriceps weakness than FNB, it needs to be administered under ultrasound by an anaesthesiologist [19]. But, Biswas et al and Nader et al showed that ACB had better pain scores and lower opioid consumption than PAI alone [20,21]. Goytizolo et al also showed that combining PAI and ACB resulted in better pain scores [22].…”

Section: Discussionmentioning

confidence: 99%

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty

Bagaria

Kulkarni

Valavi

et al. 2020

Knee Surg & Relat Res

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Background Adductor canal block (ACB) is one of the preferred methods of analgesia in total knee arthroplasty (TKA). However, conventionally its use is time-consuming, requires ultrasound guidance, a trained anaesthesia team and adherence to strict asepsis by members of the allied teams. This study was done to assess the feasibility and safety of direct adductor canal block (DACB) as a part of surgeon-administered periarticular infiltration. Materials and methods Thirty computed tomography (CT) angiography films of the patients were retrospectively reviewed. The trajectory of the needle placement for a DACB in relation to the target region of the adductor block was determined. Fourteen knees in seven cadavers, were dissected through a medial parapatellar approach to perform TKA. After administering the DACB using the technique based on CT data, dissection was carried out to ascertain the correct placement of the dye by visualising the stained areas. Results The angle of approach in the coronal plane from the entry point to the medial high point and to the adductor hiatus was 10.2° (8−14°) and 6° (3.8−11°), respectively. The angle of approach in the sagittal plane from the entry point to the medial high point and to the adductor hiatus was 7° (5−10.5°) and 29° (19−43°), respectively. In all the 14 cadaveric knees, we confirmed the correct placement of the methylene blue dye as demonstrated by the staining of the adductor canal. Conclusion The study demonstrates the feasibility of the DACB. This surgeon-driven technique is likely to reduce the cost of the procedure, reduce operating room time and also eliminate the risks of surgical-site contamination.

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Section: Discussionmentioning

confidence: 99%

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty

Bagaria

Kulkarni

Valavi

et al. 2020

Knee Surg & Relat Res

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“…Cheah et al 30 conducted a retrospective study, which suggested that intrathecal morphine could still be considered for its benefits in the setting of modern multimodal analgesia for total joint arthroplasty. Biswas et al 31 recently conducted a randomized study to evaluate whether intrathecal morphine could offer any additional advantages in the context of multimodal analgesia. However, there has been no clinical study to investigate the role of intrathecal opioids in the setting of intravenous dexmedetomidine infusion and multimodal analgesia.…”

Section: Discussionmentioning

confidence: 99%

Comparison of bupivacaine plus intrathecal fentanyl and bupivacaine alone for spinal anesthesia with intravenous dexmedetomidine sedation: a randomized, double-blind, noninferiority trial

Park

Lee

Yoo

et al. 2019

Reg Anesth Pain Med

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Background and objectivesFentanyl is widely used as an intrathecal adjuvant to local anesthetics to enhance the duration of spinal anesthesia. Recent evidence suggests that intravenous dexmedetomidine prolongs the duration of spinal anesthesia. This noninferiority study evaluated whether bupivacaine alone could provide a noninferior duration of block compared with bupivacaine and fentanyl when intravenous dexmedetomidine was administered intraoperatively.MethodsFifty-six patients scheduled for total knee arthroplasty under spinal anesthesia were randomly allocated to receive either bupivacaine 13 mg with intrathecal fentanyl 20 µg (Group BF) or bupivacaine 13 mg (Group B). Both groups underwent intravenous dexmedetomidine sedation throughout the surgery (1 µg kg–1 for 10 min, followed by 0.5 µg kg–1 h–1). The primary outcome was the time to two-segment regression of the sensory block. The noninferiority margin for the mean difference was predefined as −10 min. Secondary outcomes included postoperative pain scores, analgesics consumptions, and the incidences of pruritus, nausea, and vomiting.ResultsThere was no significant difference in the two-segment regression time of sensory block (Group B 109.1±25.0 min vs Group BF 104.3±25.9 min; p=0.484). The mean difference in the two-segment regression time between the 2 groups was 4.8 min (95 % CI −8.9 to 18.6), demonstrating the noninferiority of bupivacaine alone. Secondary outcomes showed no significant differences between the two groups.ConclusionsThe duration of spinal anesthesia with bupivacaine alone is noninferior to that of bupivacaine plus fentanyl in patients receiving intravenous dexmedetomidine intraoperatively. Our results suggest that intrathecal fentanyl may not be required when intravenous dexmedetomidine is administered.Trial registration number NCT03105115.

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“…Case reports, retrospective studies, cadaveric studies, non-English articles, review articles and meta-analyses were excluded (N = 69) (Included articles are listed in Supplemental Digital Content). The points of needle entry were grouped into 3 different regions ( Figures 4A and 4B): i) proximal blocks, 20,21 including block entry points that target the SFA after it has just beneath the medial border of the sartorius muscle, or the proximal-thigh approach by Meier et al involving the needle insertion at a location where the SFA is underneath the medial third of the sartorius muscle; ii) mid-thigh blocks, 3,10,20,22 including blocks performed at the midthigh level (between ASIS and base of patella), and the distal approach described Meier et al where the SFA lies underneath the middle third of sartorius; and iii) distal blocks, 11,22,23 including blocks performed at the dACB and other true AC blocks . Figure 4A shows the anatomical locations and Figure 4B shows the corresponding ultrasound image of the levels of these blocks.…”

Section: Discussionmentioning

confidence: 99%

Adductor Canal Blocks: An Observational Ultrasound Study in Volunteers to Identify the Relationship of the True Adductor Canal to Commonly Described Block Approaches and a Review of the Literature

Ranganath¹,

Yap²,

Wong³

et al. 2019

Preprint

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Background There is controversy over the site at which the ultrasound-guided adductor canal blocks (ACB) should be performed, and the anatomic relationship of these sites to the true adductor canal (AC). Most studies describe performing the ACB at the anatomical mid-point of the thigh (mid-thigh ACB, mtACB), or 2-3 cm above the inferior border of AC (distal ACB, dACB). The aim of the study was to determine the relationship of these approaches to the true anatomical AC in volunteers. Methods Using ultrasonography and surface landmarks, we characterized the AC anatomy of both lower limbs in 60 adult volunteers (30 males, 30 females). The primary outcome variable was the distance from the mid-thigh approach to the superior border of AC. Calculated secondary measurements were the distance between the 2 approaches and the length of AC. Results The (median [IQR]) needle entry point for mtACB was above the superior border of the AC in both males (5.5 cm [4.6-7.0]) and females (6.6 cm [5.8-7.3]) (P = 0.045 [95% CI of the difference in medians, -1.63 to 0.00 cm]). The median distance between the needle entry points of mtACB and dACB in males vs females were not different (median difference: 0.63 cm; 95% CI, -0.25 to 1.50). The length of the adductor canal was 1.5 cm longer in males compared to females (95% CI, 1.00 to 2.25 cm) Conclusions AC blocks performed at mid-thigh or more proximal are outside the anatomical adductor canal. A review of recent literature shows 3 different sites where AC blocks are performed; the majority of the blocks are performed in the mid-thigh region and hence outside of the true adductor canal.

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Relative Contributions of Adductor Canal Block and Intrathecal Morphine to Analgesia and Functional Recovery After Total Knee Arthroplasty

Abstract: This study was registered at ClinicalTrials.gov, identifier NCT02411149.

Cited by 21 publications

References 28 publications

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty

Comparison of bupivacaine plus intrathecal fentanyl and bupivacaine alone for spinal anesthesia with intravenous dexmedetomidine sedation: a randomized, double-blind, noninferiority trial

Adductor Canal Blocks: An Observational Ultrasound Study in Volunteers to Identify the Relationship of the True Adductor Canal to Commonly Described Block Approaches and a Review of the Literature

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