Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study.
01 Nov 2013-Regional Anesthesia and Pain Medicine (BMJ Publishing Group Ltd)-Vol. 38, Iss: 6, pp 526-532
TL;DR: Adductor canal block preserved quadriceps muscle strength better than FNB, without a significant difference in postoperative pain.
About: This article is published in Regional Anesthesia and Pain Medicine.The article was published on 2013-11-01. It has received 300 citations till now. The article focuses on the topics: Adductor canal & Ropivacaine.
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TL;DR: The current review article strives to summarize the pertinent anatomy of the lumbar and sacral plexuses, discuss the optimal approaches and techniques for lower limb regional anesthesia, and identify informational gaps pertaining to outcomes, which warrant further investigation.
290 citations
TL;DR: This narrative review presents a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty, and identifies interventions lacking high-quality evidence.
Abstract: Enhanced recovery after surgery (ERAS) protocols produce significant clinical and economic benefits in a range of surgical subspecialties. There is a long tradition of applying clinical pathways to the perioperative care of joint arthroplasty patients. Enhanced recovery after surgery represents the next step in the evolution of standardized care. To date, reports of full ERAS pathways for hip or knee arthroplasty are lacking. In this narrative review, we present the evidence base that can be usefully applied to constructing ERAS pathways for hip or knee arthroplasty. The history and rationale for applying ERAS to joint arthroplasty are explained. Evidence demonstrates improved outcomes after joint arthroplasty when a standardized approach to care is implemented. The efficacy of individual ERAS components in hip or knee replacement is considered, including preoperative education, intraoperative anaesthetic techniques, postoperative analgesia, and early mobilization after joint arthroplasty. Interventions lacking high-quality evidence are identified, together with recommendations for future research. Based on currently available evidence, we present a model ERAS pathway that can be applied to perioperative care of patients undergoing hip or knee arthroplasty.
219 citations
TL;DR: It is demonstrated that the incidence and/or severity of chronic, persistent postsurgical pain may, at times, be decreased with a short-term postoperative CPNB, and a number of novel, alternative analgesic modalities are under development/investigation.
Abstract: A continuous peripheral nerve block (CPNB) consists of a percutaneously inserted catheter with its tip adjacent to a target nerve/plexus through which local anesthetic may be administered, providing a prolonged block that may be titrated to the desired effect. In the decades after its first report in 1946, a plethora of data relating to CPNB was published, much of which was examined in a 2011 Anesthesia & Analgesia article. The current update is an evidence-based review of the CPNB literature published in the interim. Novel insertion sites include the adductor canal, interpectoral, quadratus lumborum, lesser palatine, ulnar, superficial, and deep peroneal nerves. Noteworthy new indications include providing analgesia after traumatic rib/femur fracture, manipulation for adhesive capsulitis, and treating abdominal wall pain during pregnancy. The preponderance of recently published evidence suggests benefits nearly exclusively in favor of catheter insertion using ultrasound guidance compared with electrical stimulation, although little new data are available to help guide practitioners regarding the specifics of ultrasound-guided catheter insertion (eg, optimal needle-nerve orientation). After some previous suggestions that automated, repeated bolus doses could provide benefits over a basal infusion, there is a dearth of supporting data published in the past few years. An increasing number of disposable infusion pumps does now allow a similar ability to adjust basal rates, bolus volume, and lockout times compared with their electronic, programmable counterparts, and a promising area of research is communicating with and controlling pumps remotely via the Internet. Large, prospective studies now document the relatively few major complications during ambulatory CPNB, although randomized, controlled studies demonstrating an actual shortening of hospitalization duration are few. Recent evidence suggests that, compared with femoral infusion, adductor canal catheters both induce less quadriceps femoris weakness and improve mobilization/ambulation, although the relative analgesia afforded by each remains in dispute. Newly published data demonstrate that the incidence and/or severity of chronic, persistent postsurgical pain may, at times, be decreased with a short-term postoperative CPNB. Few new CPNB-related complications have been identified, although large, prospective trials provide additional data regarding the incidence of adverse events. Lastly, a number of novel, alternative analgesic modalities are under development/investigation. Four such techniques are described and contrasted with CPNB, including single-injection peripheral nerve blocks with newer adjuvants, liposome bupivacaine used in wound infiltration and peripheral nerve blocks, cryoanalgesia with cryoneurolysis, and percutaneous peripheral nerve stimulation.
200 citations
TL;DR: Adductor canal block provides a clinically relevant and statistically significant increase in quadriceps muscle strength for patients in severe pain after TKA.
182 citations
TL;DR: Adductor canal block provided better ambulation and early functional recovery but without superior analgesia than femoral nerve block post TKA, while pain scores, opioid consumption showed no significant difference.
Abstract: Total knee arthroplasty is associated with intense, early post-operative pain. Femoral nerve block is known to provide optimal pain relief but reduces the strength of the quadriceps muscle and associated with the risk of falling. Adductor canal block is almost pure sensory blockade with minimal effect on quadriceps muscle strength. We prospectively randomized 100 patients in two groups' continuous adductor and femoral block group. Ambulation ability (Timed up go, 10-m walk, 30s chair test), time to active SLR, quadsticks, staircase competency, ambulation distance was significantly better ( P value
147 citations
References
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TL;DR: The data from both nursing home and community-dwelling subjects indicate a strong relationship of lower extremity strength to balance and gait, and an association between these functions and the occurrence of falls.
Abstract: We studied the effects of lower extremity strength as well as gait and balance on the occurrence of falls in nursing home residents. Nursing home residents with a history of falls had less than half of the knee and ankle strength of nonfalling subjects residing in the same home. The differences were more prominent at the ankle than the knee, and were most pronounced in the ankle dorsiflexors, where they were one-tenth that of controls. Also of note was the fact that this same group of fallers had slowed gait velocity (58% of control) as well as an impaired response to postural perturbation as determined on the Postural Stress Test (55% of control). In a recently completed study we measured strength as balance (EquiTest balance platform) of community-dwelling subjects. The occurrence of loss of balance during the sensory organization test was correlated with diminished lower extremity (Pearson R = -.36, p = .001) as well as ankle dorsi and plantar flexion moments (Pearson R = -.37, p = .001). Using a logistic regression model, we demonstrated an independent effect of strength on the odds ratio of an SOT-LOB; for each newtonmeter per kg increase in strength there was a 20% decrease (95% CI, .74-87) in the odds ratio. The data from both nursing home and community-dwelling subjects indicate a strong relationship of lower extremity strength to balance and gait. The nursing home studies demonstrated an association between these functions and the occurrence of falls.(ABSTRACT TRUNCATED AT 250 WORDS)
659 citations
"Adductor canal block versus femoral..." refers result in this paper
...Although we were not able to demonstrate an effect on ability to mobilize 24 hours after surgery, other studies have shown that quadriceps weakness leads to functional impairment,(23) to lower points on the falls efficacy scale,(24) and to an increased risk of falls.(25) There were no fall episodes in this study population, but peripheral nerve blocks...
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TL;DR: To examine the current evidence regarding the reliability and validity of hand‐held dynamometry for assessment of muscle strength in the clinical setting, a large number of studies using this method have found it to be reliable.
Abstract: Objective To examine the current evidence regarding the reliability and validity of hand-held dynamometry for assessment of muscle strength in the clinical setting. Data Sources A search was conducted of the following databases: Cochrane, MEDLINE, PubMed, PEDro, OTseeker, Index to Chiropractic Literature (ICL), and MANTIS, from inception until January 29, 2010. Study Selection The MeSH subject heading "muscle strength dynamometer" was searched, in isolation and in combination with the text word phrases "hand-held dynamometer" and "isokinetic." Four hundred fifty-four different studies met this search and were reviewed for possible inclusion. Data Extraction Two independent reviewers assessed the quality of the included manuscripts. The PEDro data collection system was used in conjunction with the Cochrane Diagnostic Test Accuracy Description. A third reviewer was used when there was disagreement between the primary reviewers. Data Synthesis Seventeen manuscripts met the inclusion criteria for this review, with a total of 19 studies (2 of the manuscripts involved 2 separate studies) that compared hand-held dynamometry with an identified reference standard (isokinetic muscle strength testing). The results demonstrated minimal differences between hand-held dynamometry and isokinetic testing. Conclusions Considering hand-held dynamometry's ease of use, portability, cost, and compact size, compared with isokinetic devices this instrument can be regarded as a reliable and valid instrument for muscle strength assessment in a clinical setting.
557 citations
TL;DR: Lower extremity strength gain is associated with gains in chair rise performance, gait speed, and in mobility tasks such as gait, transfers, stooping, and stair climbing, but not with improved endurance, balance, or disability.
475 citations
TL;DR: Patients who are managed with total knee arthroplasty have profound impairment of quadriceps strength one month after surgery, predominantly due to failure of voluntary muscle activation, and it is also influenced, to a lesser degree, by muscle atrophy.
Abstract: Background: While total knee arthroplasty reduces pain and provides a functional range of motion of the knee,
quadriceps weakness and reduced functional capacity typically are still present one year after surgery. The purpose of
the present investigation was to determine the role of failure of voluntary muscle activation and muscle atrophy in the
early loss of quadriceps strength after surgery.
Methods: Twenty patients with unilateral knee osteoarthritis were tested an average of ten days before and twentyseven
days after primary total knee arthroplasty. Quadriceps strength and voluntary muscle activation were measured
with use of a burst-superimposition technique in which a supramaximal burst of electrical stimulation is superimposed
on a maximum voluntary isometric contraction. Maximal quadriceps cross-sectional area was assessed with
use of magnetic resonance imaging.
Results: Postoperatively, quadriceps strength was decreased by 62%, voluntary activation was decreased by 17%,
and maximal cross-sectional area was decreased by 10% in comparison with the preoperative values; these differences
were significant (p < 0.01). Collectively, failure of voluntary muscle activation and atrophy explained 85% of the
loss of quadriceps strength (p < 0.001). Multiple linear regression analysis revealed that failure of voluntary activation
contributed nearly twice as much as atrophy did to the loss of quadriceps strength. The severity of knee pain with
muscle contraction did not change significantly compared with the preoperative level (p = 0.31). Changes in knee
pain during strength-testing did not account for a significant amount of the change in voluntary activation (p = 0.14).
Conclusions: Patients who are managed with total knee arthroplasty have profound impairment of quadriceps
strength one month after surgery. This impairment is predominantly due to failure of voluntary muscle activation, and
it is also influenced, to a lesser degree, by muscle atrophy. Knee pain with muscle contraction played a surprisingly
small role in the reduction of muscle activation.
431 citations
"Adductor canal block versus femoral..." refers background or result in this paper
...At 4 weeks postoperative, quadriceps strength was reduced by 60% to 64%.(21,22) Strength loss was mainly due to a central inability to fully activate the muscle, with pain accounting for less than 25% of the change in voluntary activation....
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...Although reducing the volume for bolus injection may further spare quadriceps strength, the 48% reduction from baseline seen with the ACB at 24 hours postoperative in the current study is actually less than reported in previous studies.(17,21,22) At 4 weeks postoperative, quadriceps strength was reduced by 60% to 64%....
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...Strength loss was mainly due to a central inability to fully activate the muscle, with pain accounting for less than 25% of the change in voluntary activation.(21,22) In a third study,(17) quadriceps strength was reduced by 83% at discharge (mean, 2....
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TL;DR: Standardized strength assessment procedures of hip ABD, ER, IR, FLEX, with test–retest measurement variation below 5%, hip ADD below 6% and hip EXT below 8%, make it possible to determine even small changes in hip strength at the individual level.
Abstract: Hip strength assessment plays an important role in the clinical examination of the hip and groin region. The primary aim of this study was to examine the absolute test-retest measurement variation concerning standardized strength assessments of hip abduction (ABD), adduction (ADD), external rotation (ER), internal rotation (IR), flexion (FLEX) and extension (EXT) using a hand-held dynamometer. Nine subjects (five males, four females), physically active for at least 2.5 h a week, were included. Twelve standardized isometric strength tests were performed twice with a 1-week interval in between by the same examiner. The test order was randomized to avoid systematic bias. Measurement variation between sessions was 3-12%. When the maximum value of four measurements was used, test-retest measurement variation was below 10% in 11 of the 12 individual hip strength tests and below 5% in five of the 12 tests. No systematic differences were present. Standardized strength assessment procedures of hip ABD, ER, IR, FLEX, with test-retest measurement variation below 5%, hip ADD below 6% and hip EXT below 8%, make it possible to determine even small changes in hip strength at the individual level.
375 citations