Femoral Block vs Adductor Canal Block

Regional Analgesia For Total Knee Arthroplasty

Jared Pearson, MD Stanford Anesthesiology

Anatomy of the Femoral Nerve

Innervation of the Knee

Anatomical Basis for AC Block

-The saphenous nerve (SN) is a sensory branch of the posterior division of the femoral nerve -Motor branches of the femoral nerve branch distal to the inguinal ligament but proximal to adductor canal (AC) - AC is an aponeurotic space, volume and spread of a local anesthetic injection in patients may contribute to the extent of blockade. - The Vasus Medialis (VM) is one of four muscles comprising the quadriceps femoris and contributes to extension of the knee joint and stabilization of the patella. - Cadaveric Studies: 72.5% of the 40 total specimens observed that the distal most branch of the NVM innervated the VM more proximal to the site where the SN crosses over the SFA to become medial to the vessel.

Anatomic Basis for AC Block

- Cadaveric injection of femoral nerve at the adductor canal with dye - The femoral nerve was successfully dyed in all cases of the cadaver study, - The muscular branch to the sartorius muscle and 3/4 quadriceps muscle was dyed - The vastus medialis muscle, evaded dyeing.

Adductor Canal vs placebo

Effects of Adductor-Canal-Blockade on pain and ambulation after total knee arthroplasty: a randomized study
Design: Double blinded, placebo controlled. spinal MAC + post op adductor canal block morphine PCA 2.5 mg q10 min, ibuprofen 400 mg and tylenol 1g Q6 30 ml 0.75% ropi (n=34) vs saline bolus (n=37). 24 hrs post op: Both groups 15 cc bolus of 0.75% ropivicaine End Points: First 24 hrs: morphine: 40 mg vs 56 mg (p=.006) in first 24 hrs pain at rest: lower (but not statistically significant) pain at 45 degrees: lower (statistically significant), PONV: the same in both groups, but less zofran in ACB group First 24-72 hrs: pain at rest: lower in placebo -> ropivicaine group (statistically significant) pain at 45 degrees: lower in placebo -> ropivicaine group (statistically significant)

Adductor Canal: Rescue Block

Effect of adductor-canal-blockade on established, severe post-operative pain after total knee arthroplasty
--morphine PCA 2.5 mg q10 min, ibuprofen 400 mg and tylenol 1g Q6 with fent/morphine PRN --30 ml of 0.75% ropivicaine (n=20) vs saline (n=21)injected 30 min postoperatively.

VAS pain scores at rest: 56 vs 68, but not statistically significant VAS scores at flexion: -12 scores less on average (statistically significant) morphine consumption: 18mg vs 28 mg 6 hrs post op nausea: statistically less TUG (Time up and Go) Test: 36 secs vs 50 seconds

Adductor vs Femoral compared to PCA alone

Reduced opioid consumption in 24 hrs: Insignificant decrease in pain at rest: Significant decrease in pain with activity: Decreased nausea: ACB - 16 mg X X X FNB - 19 mg X X X

Adductor Canal Block Summary

Adductor Canal Block:
- reduces opioid consumption during perioperative period similar to FNB - reduces pain at 45 degrees flexion - may reduce pain scores at rest - Offers motor sparing of the quadriceps muscle vs femoral n block

The Future:
Does adductor canal block increase qaud strength and reduce fall risk?

References
1) The saphenous nerve and its relationship to the nerve to the vastus medialis in and around the adductor canal: an anatomical study Acta Anaesthesiol Scand 2012; 56: 365367 2) Ishiguro et al. [Epub ahead of print]Anatomy and Clinical Implications of Ultrasound-Guided Selective Femoral Nerve Block. Anesth Analg. 2012 Aug 10. 3) Jaeger P et al. Effect of adductor-canal-blockade on established, severe post-operative pain after total kneearthroplasty: a randomised study. Acta Anaesthesiol Scand. 2012 Sep;56(8):1013-9. Epub 2012 Jul 26. 4) Jenstrup et al. Effects of Adductor-Canal-Blockade on pain and ambulation after total knee arthroplasty: a randomized study Acta Anaesthesiol Scand 2012; 56: 357364 5) Paul JE et al. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010 Nov;113(5):1144-62.