Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA
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Femoral continuous peripheral nerve blocks (CPNBs) provide effective analgesia after TKA but have been associated with quadriceps weakness and delayed ambulation. A promising alternative is adductor canal CPNB that delivers a primarily sensory blockade; however, the differential effects of these two techniques on functional outcomes after TKA are not well established.
We determined whether, after TKA, patients with adductor canal CPNB versus patients with femoral CPNB demonstrated (1) greater total ambulation distance on Postoperative Day (POD) 1 and 2 and (2) decreased daily opioid consumption, pain scores, and hospital length of stay.
Between October 2011 and October 2012, 180 patients underwent primary TKA at our practice site, of whom 93% (n = 168) had CPNBs. In this sequential series, the first 102 patients had femoral CPNBs, and the next 66 had adductor canal CPNBs. The change resulted from a modification to our clinical pathway, which involved only a change to the block. An evaluator not involved in the patients’ care reviewed their medical records to record the parameters noted above.
Ambulation distances were higher in the adductor canal group than in the femoral group on POD 1 (median [10th–90th percentiles]: 37 m [0–90 m] versus 6 m [0–51 m]; p < 0.001) and POD 2 (60 m [0–120 m] versus 21 m [0–78 m]; p = 0.003). Adjusted linear regression confirmed the association between adductor canal catheter use and ambulation distance on POD 1 (B = 23; 95% CI = 14–33; p < 0.001) and POD 2 (B = 19; 95% CI = 5–33; p = 0.008). Pain scores, daily opioid consumption, and hospital length of stay were similar between groups.
Adductor canal CPNB may promote greater early postoperative ambulation compared to femoral CPNB after TKA without a reduction in analgesia. Future randomized studies are needed to validate our major findings.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
KeywordsRopivacaine Clinical Pathway Femoral Nerve Femoral Nerve Block Adductor Canal
The authors thank Dr. Ronald Pearl, Chair, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, for his general support of this research and Dr. Todd Wagner, Associate Director, Center for Health Care Evaluation, Veterans Affairs Palo Alto Health Care System, for his guidance on statistical methods.
- 3.Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM. Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology. 2011;115:774–781.PubMedCentralPubMedCrossRefGoogle Scholar
- 12.Ilfeld BM, Ball ST, Gearen PF, Le LT, Mariano ER, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Meyer RS. Ambulatory continuous posterior lumbar plexus nerve blocks after hip arthroplasty: a dual-center, randomized, triple-masked, placebo-controlled trial. Anesthesiology. 2008;109:491–501.PubMedCentralPubMedCrossRefGoogle Scholar
- 14.Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW, Sessler DI, Enneking FK, Shuster JJ, Theriaque DW, Berry LF, Spadoni EH, Gearen PF. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study. Anesthesiology. 2008;108:703–713.PubMedCentralPubMedCrossRefGoogle Scholar
- 15.Ilfeld BM, Mariano ER, Girard PJ, Loland VJ, Meyer RS, Donovan JF, Pugh GA, Le LT, Sessler DI, Shuster JJ, Theriaque DW, Ball ST. A multicenter, randomized, triple-masked, placebo-controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge-readiness following total knee arthroplasty in patients on general orthopaedic wards. Pain. 2010;150:477–484.PubMedCentralPubMedCrossRefGoogle Scholar
- 16.Ilfeld BM, Moeller LK, Mariano ER, Loland VJ, Stevens-Lapsley JE, Fleisher AS, Girard PJ, Donohue MC, Ferguson EJ, Ball ST. Continuous peripheral nerve blocks: is local anesthetic dose the only factor, or do concentration and volume influence infusion effects as well? Anesthesiology. 2010;112:347–354.PubMedCrossRefGoogle Scholar
- 17.Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Continuous interscalene brachial plexus block for postoperative pain control at home: a randomized, double-blinded, placebo-controlled study. Anesth Analg. 2003;96:1089–1095.Google Scholar
- 27.Memtsoudis SG, Dy CJ, Ma Y, Chiu YL, Della Valle AG, Mazumdar M. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. J Arthroplasty. 2012;27:823–828.e1.Google Scholar
- 28.Napier RJ, Spence D, Diamond O, O’Brien S, Walsh T, Beverland DE. Modifiable factors delaying early discharge following primary joint arthroplasty. Eur J Orthop Surg Traumatol. 2012 July 22 [Epub ahead of print].Google Scholar
- 29.NIH Consensus Statement on total knee replacement. NIH Consens State Sci Statements. 2003;20:1–34.Google Scholar
- 31.Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway. Anesth Analg. 2006;102:1234–1239.PubMedCrossRefGoogle Scholar