J Knee Surg 2024; 37(03): 220-226
DOI: 10.1055/a-2037-6418
Original Article

Adductor Canal Nerve Block versus Intra-articular Anesthetic in Knee Arthroscopy: A Single-Blinded Prospective Randomized Trial

Michael Perry
1   Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
,
Ryan LeDuc
1   Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
,
Steven Stakenas
1   Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
,
Amy Wozniak
1   Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
,
Audrice Francois
1   Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
,
Douglas Evans
1   Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
› Author Affiliations
Funding None.

Abstract

Effective perioperative pain control following knee arthroscopy allows patients to reduce narcotic intake, avoid side effects of these medications, and recover more quickly. Adductor canal nerve blockade (ACB) and intra-articular injection of local anesthetic have been described as adjuvant treatments for postoperative pain control following surgery of the knee. This study directly compares the effect of each of these treatment modalities. Patients undergoing knee arthroscopy were blinded and randomized to receive either an ACB (n = 60) or intra-articular injection of local anesthetic (IAB, n = 64). Outcome measures included patient reported visual analog scale (VAS) scores at 1, 2, 4, 8, 16, 24, 36, 48 hours and 1 week and total narcotic consumption at 12, 24, and 48 hours postoperatively. Student's t-tests were used to compare unadjusted VAS scores at each time point and use of postoperative pain medication between treatment groups. Adjusted VAS scores were estimated in a multivariable general linear model with interaction of time and treatment group and other relevant covariates. There were no statistically significant differences between the two groups in terms of gender, age, body mass index, and insurance type. ACB patients had significantly higher pain scores than IAB patients at hours 1 and 2 (hour 1: 4.02 [2.99] vs. 2.59 [3.00], p = 0.009; hour 2: 3.12 [2.44] vs. 2.17 [2.62], p = 0.040). ACB patients had higher pain scores than IAB patients up to hour 16, though hours 4 to 16 were not significantly different. Adjusted covariate analyses demonstrate an additional statistically significant reduction in pain score in the IAB group at hour 4. There were no differences in narcotic consumption. Intraoperative local anesthetic and regional ACB each provides adequate pain control following knee arthroscopy, and intraoperative local anesthetic may provide enhanced pain control for up to 4 hours postoperatively.

Level of Evidence: Level 1 evidence, randomized control trial.

Note

This project received approval by our institutional review board.


Supplementary Material



Publication History

Received: 01 October 2022

Accepted: 12 February 2023

Accepted Manuscript online:
17 February 2023

Article published online:
01 April 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Shah NV, Solow M, Kelly JJ. et al. Demographics and rates of surgical arthroscopy and postoperative rehabilitative preferences of arthroscopists from the Arthroscopy Association of North America (AANA). J Orthop 2018; 15 (02) 591-595
  • 2 Rubenstein WJ, Lansdown DA, Feeley BT, Ma CB, Zhang AL. Body mass index screening in knee arthroscopy: an analysis using the national surgical quality improvement database. Arthroscopy 2019; 35 (12) 3289-3294
  • 3 Armellin G, Nardacchione R, Ori C. Intra-articular sufentanil in multimodal analgesic management after outpatient arthroscopic anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded study. Arthroscopy 2008; 24 (08) 909-913
  • 4 Dauri M, Fabbi E, Mariani P. et al. Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular and wound infusion after anterior cruciate ligament reconstruction. Reg Anesth Pain Med 2009; 34 (02) 95-99
  • 5 McGrath B, Elgendy H, Chung F, Kamming D, Curti B, King S. Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth 2004; 51 (09) 886-891
  • 6 Aasbø V, Raeder JC, Grøgaard B, Røise O. No additional analgesic effect of intra-articular morphine or bupivacaine compared with placebo after elective knee arthroscopy. Acta Anaesthesiol Scand 1996; 40 (05) 585-588
  • 7 Solheim N, Rosseland LA, Stubhaug A. Intra-articular morphine 5 mg after knee arthroscopy does not produce significant pain relief when administered to patients with moderate to severe pain via an intra-articular catheter. Reg Anesth Pain Med 2006; 31 (06) 506-513
  • 8 Sites BD, Beach ML, Davis MA. Increases in the use of prescription opioid analgesics and the lack of improvement in disability metrics among users. Reg Anesth Pain Med 2014; 39 (01) 6-12
  • 9 van Amsterdam J, van den Brink W. The misuse of prescription opioids: a threat for Europe?. Curr Drug Abuse Rev 2015; 8 (01) 3-14
  • 10 Hamilton DF, Lane JV, Gaston P. et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open 2013; 3 (04) e002525
  • 11 Steiner SRH, Cancienne JM, Werner BC. Narcotics and knee arthroscopy: trends in use and factors associated with prolonged use and postoperative complications. Arthroscopy 2018; 34 (06) 1931-1939
  • 12 Gatewood CT, Tran AA, Dragoo JL. The efficacy of post-operative devices following knee arthroscopic surgery: a systematic review. Knee Surg Sports Traumatol Arthrosc 2017; 25 (02) 501-516
  • 13 Hanson NA, Derby RE, Auyong DB. et al. Ultrasound-guided adductor canal block for arthroscopic medial meniscectomy: a randomized, double-blind trial. Can J Anaesth 2013; 60 (09) 874-880
  • 14 Grevstad U, Mathiesen O, Valentiner LS, Jaeger P, Hilsted KL, Dahl JB. 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 (01) 3-10
  • 15 Jaeger P, Nielsen ZJK, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB. Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology 2013; 118 (02) 409-415
  • 16 Zhou Y, Yang T-B, Wei J. et al. Single-dose intra-articular ropivacaine after arthroscopic knee surgery decreases post-operative pain without increasing side effects: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2016; 24 (05) 1651-1659
  • 17 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 (02) 377-381
  • 18 Harris PA, Taylor R, Minor BL. et al; REDCap Consortium. The REDCap consortium: building an international community of software platform partners. J Biomed Inform 2019; 95: 103208
  • 19 Myles PS, Myles DB, Galagher W. et al. Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state. Br J Anaesth 2017; 118 (03) 424-429
  • 20 Sun Q-B, Liu S-D, Meng Q-J, Qu H-Z, Zhang Z. Single administration of intra-articular bupivacaine in arthroscopic knee surgery: a systematic review and meta-analysis. BMC Musculoskelet Disord 2015; 16 (01) 21-11
  • 21 Wei J, Yang H-B, Qin J-B, Kong F-J, Yang T-B. Single-dose intra-articular bupivacaine after knee arthroscopic surgery: a meta-analysis of randomized placebo-controlled studies. Knee Surg Sports Traumatol Arthrosc 2014; 22 (07) 1517-1528
  • 22 Jacobson E, Assareh H, Cannerfelt R, Anderson RE, Jakobsson JG. The postoperative analgesic effects of intra-articular levobupivacaine in elective day-case arthroscopy of the knee: a prospective, randomized, double-blind clinical study. Knee Surg Sports Traumatol Arthrosc 2006; 14 (02) 120-124
  • 23 Yang Y, Zeng C, Wei J. et al. Single-dose intra-articular bupivacaine plus morphine versus bupivacaine alone after arthroscopic knee surgery: a meta-analysis of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc 2017; 25 (03) 966-979
  • 24 Zeidan A, Kassem R, Nahleh N. et al. Intraarticular tramadol-bupivacaine combination prolongs the duration of postoperative analgesia after outpatient arthroscopic knee surgery. Anesth Analg 2008; 107 (01) 292-299
  • 25 Sayın P, Dobrucalı H, Türk HŞ, Totoz T, Işıl CT, Hancı A. Effects of intra-articular levobupivacaine, fentanyl-levobupivacaine and tramadol-levobupivacaine for postoperative pain in arthroscopic knee surgery. Acta Orthop Traumatol Turc 2015; 49 (03) 267-273
  • 26 Mitra S, Kaushal H, Gupta RK. Evaluation of analgesic efficacy of intra-articular bupivacaine, bupivacaine plus fentanyl, and bupivacaine plus tramadol after arthroscopic knee surgery. Arthroscopy 2011; 27 (12) 1637-1643
  • 27 Vora MU, Nicholas TA, Kassel CA, Grant SA. Adductor canal block for knee surgical procedures: review article. J Clin Anesth 2016; 35: 295-303
  • 28 Espelund M, Fomsgaard JS, Haraszuk J, Dahl JB, Mathiesen O. The efficacy of adductor canal blockade after minor arthroscopic knee surgery–a randomised controlled trial. Acta Anaesthesiol Scand 2014; 58 (03) 273-280
  • 29 Hsu LP, Oh S, Nuber GW. et al. 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 Am 2013; 95 (16) 1465-1472
  • 30 Akkaya T, Ersan O, Ozkan D. et al. Saphenous nerve block is an effective regional technique for post-menisectomy pain. Knee Surg Sports Traumatol Arthrosc 2008; 16 (09) 855-858
  • 31 Westergaard B, Jensen K, Lenz K. et al. A randomised controlled trial of ultrasound-guided blockade of the saphenous nerve and the posterior branch of the obturator nerve for postoperative analgesia after day-case knee arthroscopy. Anaesthesia 2014; 69 (12) 1337-1344
  • 32 Fan L, Yu X, Zan P, Liu J, Ji T, Li G. Comparison of local infiltration analgesia with femoral nerve block for total knee arthroplasty: a prospective, randomized clinical trial. J Arthroplasty 2016; 31 (06) 1361-1365
  • 33 Jiménez-Almonte JH, Wyles CC, Wyles SP. et al. Is local infiltration analgesia superior to peripheral nerve blockade for pain management after THA: a network meta-analysis. Clin Orthop Relat Res 2016; 474 (02) 495-516
  • 34 Bailey L, Griffin J, Elliott M. et al. Adductor canal nerve versus femoral nerve blockade for pain control and quadriceps function following anterior cruciate ligament reconstruction with patellar tendon autograft: a prospective randomized trial. Arthroscopy 2019; 35 (03) 921-929
  • 35 Kristensen PK, Pfeiffer-Jensen M, Storm JO, Thillemann TM. Local infiltration analgesia is comparable to femoral nerve block after anterior cruciate ligament reconstruction with hamstring tendon graft: a randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 2014; 22 (02) 317-323