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Proximal versus distal adductor canal catheters for total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials

Cathéters proximaux ou distaux du canal adducteur pour l’arthroplastie totale du genou : revue systématique et méta-analyse d’études randomisées contrôlées

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Abstract

Purpose

Total knee arthroplasty (TKA) is associated with severe postoperative pain. Continuous adductor canal blockade provides analgesia while preserving quadriceps muscle strength. Nevertheless, uncertainty still exists as to the optimal adductor canal catheter placement approach. We sought to conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the analgesic effects of proximal vs distal adductor canal catheters in patients undergoing TKA.

Source

We systematically searched PubMed, EMBASE, and Cochrane for RCTs comparing distal and proximal adductor canal catheters for TKA regarding critical clinical outcomes in adult patients. Statistical analysis was performed using R version 4.1.2 (R Foundation for Statistical Computing, Vienna, Austria). Heterogeneity was assessed using the Cochran Q test and I2 statistics. Trial sequential analysis (TSA) was performed to evaluate the risk of random errors and the uncertainty of our results. The risk of bias was appraised according to the RoB-2 tool.

Principal findings

Six RCTs and 352 patients were included, of whom 151 (42.9%) were male, and 175 (49.7%) were randomized to undergo proximal adductor canal catheter placement. Due to the randomized nature of the studies, baseline characteristics were similar between groups. There were no statistical differences between proximal and distal adductor canal catheters regarding cumulative opioid consumption in the first 24 hr (mean difference [MD], −4.86; 95% confidence interval [CI], −15.19 to 5.47; P = 0.36; four RCTs; 240 patients); pain scores at rest (MD, 0.41; 95% CI, −1.23 to 0.40; P = 0.32; six RCTs; 350 patients); and pain scores with movement for the first 24 hr (MD, −0.25; 95% CI, −0.85 to 0.35; P = 0.42; four RCTs; 246 patients). In the TSA, the required information size was not reached, and the Z-curve did not cross the monitoring boundaries in any of the endpoints.

Conclusion

These findings suggest that proximal vs distal adductor canal catheter placement in patients undergoing TKA may be equally effective for the outcomes of opioid consumption in the first 24 hr, pain scores at rest, and pain scores with movement in the first 24 hr. Nevertheless, TSA findings suggest insufficient power to definitively conclude no differences between the two techniques.

Study registration

PROSPERO (CRD42022353576); registered 25 August 2022.

Résumé

Objectif

L’arthroplastie totale du genou (ATG) est associée à une douleur postopératoire majeure. Le bloc continu du canal adducteur procure une analgésie tout en préservant la force musculaire du quadriceps. Néanmoins, il existe encore des incertitudes quant à l’approche optimale de positionnement du cathéter du canal adducteur. Nous avons cherché à réaliser une revue systématique et une méta-analyse d’études randomisées contrôlées (ERC) comparant les effets analgésiques de cathéters proximaux et distaux du canal adducteur chez la patientèle bénéficiant d’une ATG.

Sources

Nous avons réalisé des recherches systématiques dans les bases de données PubMed, EMBASE et Cochrane pour en tirer les ERC comparant les cathéters distaux et proximaux du canal adducteur pour l’ATG touchant aux critères d’évaluation cliniques critiques chez les patient·es adultes. L’analyse statistique a été réalisée à l’aide de la version R 4.1.2 (R Foundation for Statistical Computing, Vienne, Autriche). L’hétérogénéité a été évaluée à l’aide du test Q de Cochran et des statistiques I2. Une analyse séquentielle des études a été réalisée pour évaluer le risque d’erreurs aléatoires et l’incertitude de nos résultats. Le risque de biais a été évalué selon l’outil RoB-2.

Constatations principales

Six ERC et 352 patient·es ont été inclus·es, dont 151 (42,9 %) hommes, et 175 (49,7 %) ont été randomisé·es pour bénéficier d’une pose proximale d’un cathéter du canal adducteur. En raison de la nature randomisée des études, les caractéristiques initiales étaient similaires entre les groupes. Il n’y avait aucune différence statistique entre les cathéters proximaux et distaux du canal adducteur en ce qui concerne la consommation cumulative d’opioïdes au cours des premières 24 heures (différence moyenne [DM], −4,86; intervalle de confiance [IC] à 95 %, −15,19 à 5,47; P = 0,36; quatre ERC; 240 patient·es); les scores de douleur au repos (DM, −0,41; IC 95 %, −1,23 à 0,40; P = 0,32; six ERC ; 350 patient·es); et les scores de douleur en mouvement pendant les premières 24 heures (DM, −0,25; IC 95 %, −0,85 à 0,35; P = 0,42; quatre ERC; 246 patient·es). Dans l’analyse séquentielle des études, la taille d’information requise n’a pas été atteinte et la courbe en Z n’a franchi les limites de surveillance dans aucun des paramètres.

Conclusion

Ces résultats suggèrent que le positionnement proximal ou distal d’un cathéter du canal adducteur chez les personnes subissant une ATG peut être tout aussi efficace en ce qui touche aux critères de consommation d’opioïdes au cours des premières 24 heures, de scores de douleur au repos et de scores de douleur en mouvement au cours des premières 24 heures. Néanmoins, les résultats de l’analyse séquentielle suggèrent une puissance insuffisante pour conclure de manière définitive à l’absence de différences entre les deux techniques.

Enregistrement de l’étude

PROSPERO (CRD42022353576); enregistrée le 25 août 2022.

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Author contributions

All authors contributed to the study conception and design. Rafael Lombardi, Isabela Marques, Pedro E. P. Carvalho, Gabriela R. Brandão, Jasmeen Kaur, and Ashish Sakharpe performed material preparation, data collection, and analysis. Rafael Lombardi, Isabela Marques, Pedro E. P. Carvalho, Gabriela R. Brandão, Jasmeen Kaur, and Ashish Sakharpe wrote the first draft of the manuscript. All authors critically reviewed previous versions of the manuscript. All authors agree to be accountable for all aspects of the work.

Acknowledgements

The authors would like to thank Dr. Rhanderson Cardoso, MD, for his review of the manuscript.

Disclosures

The authors have no relevant financial or nonfinancial interests to disclose.

Funding statement

The authors did not receive support from any organization for the submitted work.

Prior conference presentations

Presented at the American Academy of Pain Medicine 2023 meeting (23–26 March 2023, Fort Lauderdale, FL, USA).

Data availability

Because this meta-analysis was based on data extracted from previously published research, all the data and study materials are available in the public domain. The authors of this meta-analysis do not have access to patient-level data of the individual studies. Researchers interested in individual-level data from the studies included in this meta-analysis are encouraged to contact the corresponding author from each study for such requests.

Editorial responsibility

This submission was handled by Dr. Vishal Uppal, Associate Editor, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Authors and Affiliations

  1. Department of Anesthesiology, University of Nebraska Medical Center, 984455 Nebraska Medical Center, Omaha, NE, 68198, USA

    Rafael A. Lombardi MD & Nicholas E. Heiser MD

  2. Division of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain

    Isabela R. Marques MD

  3. Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil

    Pedro E. P. Carvalho MD

  4. Federal University of Health Sciences of Porto Alegre, Porto Alegra, Brazil

    Gabriela R. Brandao MD

  5. Department of Anesthesiology, Augusta University Medical Center, Augusta, GA, USA

    Jasmeen Kaur MD & Ashish Sakharpe MD

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  1. Rafael A. Lombardi MD
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Correspondence to Rafael A. Lombardi MD.

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Lombardi, R.A., Marques, I.R., Carvalho, P.E.P. et al. Proximal versus distal adductor canal catheters for total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. Can J Anesth/J Can Anesth (2023). https://doi.org/10.1007/s12630-023-02552-w

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