International Orthopaedics

, Volume 39, Issue 4, pp 673–680 | Cite as

Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement

  • Stavros G. MemtsoudisEmail author
  • Daniel Yoo
  • Ottokar Stundner
  • Thomas Danninger
  • Yan Ma
  • Lazaros Poultsides
  • David Kim
  • Mary Chisholm
  • Kethy Jules-Elysee
  • Alejandro Gonzalez Della Valle
  • Thomas P. Sculco
Original Paper



Providing effective analgesia for total knee arthroplasty (TKA) patients remains challenging. Femoral nerve block (FNB) offers targeted pain control; however, its effect on motor function, related fall risk and impact on rehabilitation has been the source of controversy. Adductor canal block (ACB) potentially spares motor fibres of the femoral nerve, but the comparative effect of the two approaches has not yet been well defined due to considerable variability in pain perception. Our study compares both single-shot FNB and ACB, side to side, in the same patients undergoing bilateral TKA.


Sixty patients scheduled for bilateral TKA were randomised to receive ultrasound-guided FNB on one leg and ACB on the other, in addition to combined spinal epidural anaesthesia. The primary outcome was comparative postoperative pain in either extremity at six to eight, 24 and 48 hours postoperatively. Secondary comparative outcomes included motor strength (manually and via dynamometer), physical therapy milestones and patient satisfaction.


While pain levels were lowest at six to eight hours postoperatively and increased thereafter (P < 0.001), no significant differences were seen between extremities at any time point with regard to pain in the quantitative comparison using visual analogue scale (VAS) scores (P = 0.4154), motor strength (P = 0.7548), physical therapy milestones or patient satisfaction. However, in the qualitative comparison, a significant proportion of patients reported the leg receiving ACB to be more painful than that receiving FNB at 24 h [50.9 % (n = 30) vs 25.42 % (n = 15), P = 0.0168)].


Although we could not confirm a benefit in motor function between ACB and FNB, given the equivalent analgesic potency combined with its potentially lower overall impact if neuropraxia should occur, ACB may represent an attractive alternative to FNB.


Adductor canal block Femoral nerve block Total knee replacement Regional anesthesia 



We thank Isabelle Kao and Heather Reel for assisting with data collection and management.


This study was performed with funds from the Hospital for Special Surgery, Department of Anesthesiology, New York, NY, USA, and the Anna-Maria and Stephen Kellen Physician-Scientist Career Development Award, New York, NY, USA (Stavros G. Memtsoudis). Research was supported in part by the Clinical and Translational Science Center (CTSC) at Weill Cornell Medical College through grant no. UL1TR000457-06. Contribution of Dr. Ma on this project was supported in part by the Agency for Healthcare and Quality Research (AHRQ, Rockville, MD) grant no. R01HS021734. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding source, AHRQ, based in Rockville, MD, USA.

Conflicts of interest



  1. 1.
    Grosu I, Lavand'homme P, Thienpont E (2014) Pain after knee arthroplasty: an unresolved issue. Knee Surgery, Sports Traumatology, Arthroscopy. Off J ESSKA 22:1744–1758. doi: 10.1007/s00167-013-2750-2 Google Scholar
  2. 2.
    Kim MH, Nahm FS, Kim TK, Chang MJ, Do SH (2014) Comparison of postoperative pain in the first and second knee in staged bilateral total knee arthroplasty: clinical evidence of enhanced pain sensitivity after surgical injury. Pain 155:22–7. doi: 10.1016/j.pain.2013.08.027 CrossRefPubMedGoogle Scholar
  3. 3.
    Petersen W, Rembitzki IV, Bruggemann GP, Ellermann A, Best R, Koppenburg AG, Liebau C (2014) Anterior knee pain after total knee arthroplasty: a narrative review. Int Orthop 38:319–28. doi: 10.1007/s00264-013-2081-4 CrossRefPubMedCentralPubMedGoogle Scholar
  4. 4.
    Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y (2010) Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology 113:1144–62. doi: 10.1097/ALN.0b013e3181f4b18 CrossRefPubMedGoogle Scholar
  5. 5.
    Ilfeld BM, Mariano ER, Madison SJ et al (2011) Continuous femoral versus posterior lumbar plexus nerve blocks for analgesia after hip arthroplasty: a randomized, controlled study. Anesth Analg 113:897–903. doi: 10.1213/ANE.0b013e318212495b CrossRefPubMedCentralPubMedGoogle Scholar
  6. 6.
    YaDeau JT, Cahill JB, Zawadsky MW (2005) The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty. Anesth Analg 101:891–895, Table of contentsCrossRefPubMedGoogle Scholar
  7. 7.
    Broome CB, Burnikel B (2014) Novel strategies to improve early outcomes following total knee arthroplasty: a case control study of intra articular injection versus femoral nerve block. Int Orthop. doi: 10.1007/s00264-014-2392-0 PubMedGoogle Scholar
  8. 8.
    Kandasami M, Kinninmonth AW, Sarungi M, Baines J, Scott NB (2009) Femoral nerve block for total knee replacement - a word of caution. Knee 16:98–100. doi: 10.1016/j.knee.2008.10.007 CrossRefPubMedGoogle Scholar
  9. 9.
    Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL (2010) Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 468:135–40. doi: 10.1007/s11999-009-1025-1 CrossRefPubMedCentralPubMedGoogle Scholar
  10. 10.
    Wasserstein D, Farlinger C, Brull R, Mahomed N, Gandhi R (2013) Advanced age, obesity and continuous femoral nerve blockade are independent risk factors for inpatient falls after primary total knee arthroplasty. J Arthroplast 28:1121–4. doi: 10.1016/j.arth.2012.08.018 CrossRefGoogle Scholar
  11. 11.
    Horn JL, Pitsch T, Salinas F, Benninger B (2009) Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Reg Anesth Pain Med 34:486–489. doi: 10.1097/AAP.0b013e3181ae11af CrossRefPubMedGoogle Scholar
  12. 12.
    Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R (2009) Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med 34:578–80CrossRefPubMedGoogle Scholar
  13. 13.
    Jaeger P, Grevstad U, Henningsen MH, Gottschau B, Mathiesen O, Dahl JB (2012) Effect of adductor-canal-blockade on established, severe post-operative pain after total knee arthroplasty: a randomised study. Acta Anaesthesiol Scand 56:1013–9. doi: 10.1111/j.1399-6576.2012.02737.x CrossRefPubMedGoogle Scholar
  14. 14.
    Andersen HL, Gyrn J, Moller L, Christensen B, Zaric D (2013) Continuous saphenous nerve block as supplement to single-dose local infiltration analgesia for postoperative pain management after total knee arthroplasty. Reg Anesth Pain Med 38:106–11. doi: 10.1097/AAP.0b013e31827900a9 CrossRefPubMedGoogle Scholar
  15. 15.
    Jaeger P, Nielsen ZJ, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB (2013) Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology 118:409–15. doi: 10.1097/ALN.0b013e318279fa0b CrossRefPubMedGoogle Scholar
  16. 16.
    DeLoach LJ, Higgins MS, Caplan AB, Stiff JL (1998) The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale. Anesth Analg 86:102–6PubMedGoogle Scholar
  17. 17.
    Gerbershagen HJ, Rothaug J, Kalkman CJ, Meissner W (2011) Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods. Br J Anaesth 107:619–26. doi: 10.1093/bja/aer195 CrossRefPubMedGoogle Scholar
  18. 18.
    Urban MK, Chisholm M, Wukovits B (2006) Are postoperative complications more common with single-stage bilateral (SBTKR) than with unilateral knee arthroplasty: guidelines for patients scheduled for SBTKR. HSS Journal. Musculoskelet J Hos Special Surg 2:78–82. doi: 10.1007/s11420-005-0125-z Google Scholar
  19. 19.
    Memtsoudis SG, Hargett M, Russell LA et al (2013) Consensus statement from the consensus conference on bilateral total knee arthroplasty group. Clin Orthop Relat Res 471:2649–57. doi: 10.1007/s11999-013-2976-9 CrossRefPubMedCentralPubMedGoogle Scholar
  20. 20.
    Sapega AA (1990) Muscle performance evaluation in orthopaedic practice. J Bone Joint Surg 72:1562–1574, American VolumePubMedGoogle Scholar
  21. 21.
    Szucs S, Iohom G, O'Donnell B, Sajgalik P, Ahmad I, Salah N, Shorten G. (2012) Analgesic efficacy of continuous femoral nerve block commenced prior to operative fixation of fractured neck of femur. Perioperative Medicine (London, England) 1: 4,0525-1-4. eCollection 2012. doi:  10.1186/2047-0525-1-4
  22. 22.
    Gordon DB, Stevenson KK, Griffie J, Muchka S, Rapp C, Ford-Roberts K (1999) Opioid equianalgesic calculations. J Palliat Med 2:209–18. doi: 10.1089/jpm.1999.2.209 CrossRefPubMedGoogle Scholar
  23. 23.
    Amabile CM, Bowman BJ (2006) Overview of oral modified-release opioid products for the management of chronic pain. Ann Pharmacother 40:1327–1335CrossRefPubMedGoogle Scholar
  24. 24.
    Liu S, Carpenter RL, Mulroy MF, Weissman RM, McGill TJ, Rupp SM, Allen HW (1995) Intravenous versus epidural administration of hydromorphone. Effects on analgesia and recovery after radical retropubic prostatectomy. Anesthesiol 82:682–688CrossRefGoogle Scholar
  25. 25.
    Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG (2009) Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 42:377–81. doi: 10.1016/j.jbi.2008.08.010 CrossRefPubMedCentralPubMedGoogle Scholar
  26. 26.
    Ma Y, Mazumdar M, Memtsoudis SG (2012) Beyond repeated-measures analysis of variance: advanced statistical methods for the analysis of longitudinal data in anesthesia research. Reg AnesthPain Med 37:99–105. doi: 10.1097/AAP.0b013e31823ebc74 CrossRefGoogle Scholar
  27. 27.
    Schulz KF, Altman DG, Moher D, CONSORT Group (2010) CONSORT 2010 statement: updated guidelines for reporting parallel group randomized trials. Ann Intern Med 152:726–32. doi: 10.7326/0003-4819-152-11-201006010-00232 CrossRefGoogle Scholar
  28. 28.
    Hsu LP, Oh S, Nuber GW, Jr Doty R, Kendall MC, Gryzlo S, Nader A (2013) 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 95:1465–1472. doi: 10.2106/JBJS.L.01534, American VolumeCrossRefPubMedGoogle Scholar
  29. 29.
    Ishiguro S, Asano N, Yoshida K et al (2013) Day zero ambulation under modified femoral nerve block after minimally invasive surgery for total knee arthroplasty: preliminary report. J Anesth 27:132–4. doi: 10.1007/s00540-012-1479-2 CrossRefPubMedGoogle Scholar
  30. 30.
    Kim DH, Lin Y, Goytizolo EA et al (2014) Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial. Anesthesiology 120:540–50. doi: 10.1097/ALN.0000000000000119 CrossRefPubMedGoogle Scholar
  31. 31.
    Memtsoudis SG, Ma Y, Gonzalez Della Valle A, Mazumdar M, Gaber-Baylis LK, MacKenzie CR, Sculco TP (2009) Perioperative outcomes after unilateral and bilateral total knee arthroplasty. Anesthesiology 111:1206–16. doi: 10.1097/ALN.0b013e3181bfab7d CrossRefPubMedCentralPubMedGoogle Scholar

Copyright information

© SICOT aisbl 2014

Authors and Affiliations

  • Stavros G. Memtsoudis
    • 1
    Email author
  • Daniel Yoo
    • 1
  • Ottokar Stundner
    • 1
    • 2
  • Thomas Danninger
    • 1
    • 2
  • Yan Ma
    • 3
  • Lazaros Poultsides
    • 4
  • David Kim
    • 1
  • Mary Chisholm
    • 1
  • Kethy Jules-Elysee
    • 1
  • Alejandro Gonzalez Della Valle
    • 4
  • Thomas P. Sculco
    • 4
  1. 1.Department of Anesthesiology, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA
  2. 2.Department of Anesthesiology, Perioperative Medicine and Intensive Care MedicineParacelsus Medical UniversitySalzburgAustria
  3. 3.Division of Biostatics and Epidemiology, Department of Public HealthWeill Medical College of Cornell UniversityNew YorkUSA
  4. 4.Department of Orthopedic Surgery, Hospital for Special SurgeryWeill Medical College of Cornell UniversityNew YorkUSA

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