Adductor Canal Block for Total Knee Arthroplasty

The Perfect Recipe or Just One Ingredient?

Edward R. Mariano, M.D., M.A.S. (Clinical Research), Anahi Perlas, M.D., F.R.C.P.C.

anesthetic infusions in particular may not be considered viable

options despite providing effective
analgesia and decreasing the time
to meet discharge criteria.6
The search for the perfect
regional analgesic regimen for
TKA patients continues. Although
we anxiously await the selective
local anesthetic that can preferentially anesthetize sensory nerves
while sparing motor nerves,9 we
need to make the most of our
imperfect nonselective local anesthetics in the perioperative management of pain. The innervation
of the knee is complex, with contributions from both the lumbar
and sacral plexuses. Thus, continuous neuraxial analgesia and
femoral and sciatic nerve blocks,
in single dose or continuous
infusions, have all been used for
postoperative pain management
after TKA.10,11 Although enthusiasm for ACB with TKA is fairly
recent, the technique itself is not.
A similar approach has been used
to anesthetize the saphenous nerve
in the adductor canal to provide
analgesia to the medial aspect of
the ankle.1114 For TKA, however, the real question in many
anesthesiologists minds is: How can an injection of local anesthetic into the adductor canal by itself possibly provide enough
analgesia for TKA?
The short answer is: it does not have to. Integrated multimodal analgesic protocols, as defined by the American Society of Anesthesiologists practice guidelines on perioperative
pain management, use two or more analgesic modalities with
different mechanisms of action to provide superior analgesia
and limit side effects and adverse events.12 Regional analgesic techniques are usually at the center of these multimodal

N this issue of Anesthesiology,

Kim et al.1 compare the motor
and analgesic effects of adductor
canal block (ACB) and femoral
nerve block (FNB) for total knee
arthroplasty (TKA) in the context
of an established clinical pathway
using multimodal analgesia. The
management of postoperative pain
after TKA remains challenging.
Postoperative pain can be moderate to severe; yet, patients are
expected to start physical therapy
and ambulate as soon as possible
after surgery because early rehabilitation may translate into longerterm functional achievements.2
Recent interest in ACB as a
regional analgesic technique for
TKA3 coincides with the negative light cast on FNB due to
previously reported claims that
it increases fall risk.46 Another
article published in this issue of
Anesthesiology by Memtsoudis
et al.7 (including E.R.M.) provides compelling evidence to
refute these claims and identifies many other factors associated
with increased fall risk other than
anesthetic and analgesic selection.
However, no one can argue against the need to reduce fall
risk; in our study, TKA patients who fell were more likely to
go on to suffer additional major cardiac, pulmonary, thromboembolic, or other organ-system complications with higher
30-day mortality compared with TKA patients who did not
fall.7 Inpatient falls leading to injury are considered hospitalacquired conditions and never events by the Center for
Medicare and Medicaid Services (http://www.cms.gov). In
some practice settings,4 especially those that may not have
comprehensive multicomponent fall prevention programs
in place,8 FNB and continuous femoral perineural local

Although we do not yet

have sufficient evidence to
support a universal change
from [femoral nerve block
to adductor canal block for
total knee arthroplasty] patients within a multimodal
analgesic protocol, perhaps
the time is coming.

Image: Thinkstock.
Corresponding articles on page 540 and page 551.
Accepted for publication October 25, 2013. From the Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health
Care System, Palo Alto, California; Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine,
Stanford, California (E.R.M.); Department of Anesthesia and Pain Management, University Health Network, Toronto, Ontario, Canada; and
Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada (A.P.).
Copyright 2014, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:530-2

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March 2014

EDITORIAL VIEWS

protocols in a background of nonsteroidal anti-inflammatory drugs, acetaminophen, and low-dose opioids.12 There is
a nascent but growing case being made in the contemporary
literature to support ACB as the most appropriate regional
analgesic technique to be the core of a multimodal analgesic
protocol for TKA due to its decreased potential for quadriceps weakness.13,14
The efficacy of ACB for TKA in the setting of oral multimodal analgesia has been previously demonstrated in a
proof-of-concept study.15 Similarly, the addition of ACB to
a multimodal protocol including local infiltration analgesia
provides further improvement in pain scores and ambulation
compared with placebo injection.16 Retrospective cohort
studies further suggest that the combination of ACB and
local infiltration analgesia is associated with enhanced early
postoperative ambulation compared with femoral nerve
perineural infusions.17,18
The current study1 is one of the first randomized clinical trials to compare the effectiveness of ACBs to FNBs
for TKA patients within a multimodal analgesic protocol.
All subjects received preoperative and postoperative nonsteroidal anti-inflammatory drugs, acetaminophen, and
systemic opioids; all but three subjects received low-dose
epidural patient-controlled analgesia with bupivacaine
and hydromorphone postoperatively. Subjects were randomly assigned to receive an ACB or FNB preoperatively
followed by intraoperative neuraxial anesthesia with local
anesthetic only. Quadriceps muscle strength was assessed
at 6 to 8h postoperatively, whereas pain and opioid consumption were monitored for the first 48h. The ACB
group demonstrated greater quadriceps muscle strength at
6 to 8h (an advantage of 5.2 kgf over the FNB) and was
found to be noninferior in terms of pain scores and opioid consumption up to 48h.1 Although the difference in
muscle strength is statistically significant, the clinical relevance of this outcome is still questionable; a recent study
comparing ACB with FNB also demonstrated a quadriceps strength advantage postoperatively in TKA patients,
but no benefits in mobilization ability.19 Furthermore, the
epidural analgesia provided to both groups may have been
a confounder in the noninferiority hypothesis testing. We
can conclude that ACB does not provide inferior analgesia compared with FNB within this institutions multimodal
protocol, but we do not know whether or not a quadriceps
strength advantage at 6 to 8h postoperatively translates
into actual rehabilitative benefits for TKA patients in the
short or long term or whether these results can be reproduced in other practice models.
The study by Kim et al. does not report any in-hospital
rehabilitation metrics such as ambulation distance, range of
motion, ability to perform straight leg raise, time to meet
functional independence and discharge eligibility, or shortor long-term functional outcomes. The effects of ACB on
these parameters, if any, remain unknown. At the authors
institution, patients are only dangled at the bedside on
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the day of surgery and begin ambulation on postoperative

day 1.1 The physical therapy regimen (i.e., knee immobilizer for the operative extremity, use of a front-wheel walker,
number of assistants during ambulation) is not specified. At
institutions that brace the operative extremity with a knee
immobilizer and provide sufficient assistance, a decrease in
quadriceps strength from FNB may not necessarily be a hindrance to ambulation.6,20
The issue of context is an important one as clinical
pathways integrating pain management, physical therapy,
nursing, and surgical care are often specific to individual
institutions. Multimodal analgesia should be interpreted
and applied differently based on the practice model, just as
there can be many different recipes for the same dish. There is
no question that the recipe for TKA multimodal analgesia
should include regional anesthesia, opioids, and nonopioid
analgesic medications, but there may be some latitude with
regard to choosing the individual ingredients.
The change from FNB to ACB and the maintenance
of quadriceps strength have the potential to affect physical
therapy outcomes in a way that we have not previously seen.
Although the study by Kim et al. provides us with important new information, there is a great deal of work to be
done to quantify these potential benefits within the context
of different practice models, and many prospective studies
are currently underway to evaluate ACB in comparison with
FNB. In a recent search of ClinicalTrials.gov using the search
terms adductor canal, femoral, and knee arthroplasty,
the output generated nine studiestwo completed (the current study1 and the study by Jger et al.19), one terminated,
four recruiting but not completed, and two that have not
started recruiting. Although we do not yet have sufficient
evidence to support a universal change from FNB to ACB
for TKA patients within a multimodal analgesic protocol,
perhaps the time is coming.

Competing Interests
Dr. Mariano has received an unrestricted educational funding (paid to his institution) for teaching programs from
I-Flow Corporation/Kimberly-Clark (Lake Forest, California) and B Braun (Bethlehem, Pennsylvania). These companies had absolutely no input into any aspect of article
preparation. Dr. Perlas declares no competing interests.

Correspondence
Address correspondence to Dr. Mariano: emariano@stanford.edu

References
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Editorial Views

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