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Does Patient Perception Differ Following Adductor Canal Block and Femoral Nerve Block in Total Knee Arthroplasty? A Simultaneous Bilateral Randomized Study
The Journal of Arthroplasty 32 (2017) 1856e1861
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Primary Arthroplasty
Does Patient Perception Differ Following Adductor Canal Block and Femoral Nerve Block in Total Knee Arthroplasty? A Simultaneous Bilateral Randomized Study Hyun J. Koh, MD, PhD a, b, In J. Koh, MD, PhD c, d, Man S. Kim, MD c, Keun Y. Choi, MD c, Hyeon U. Jo, MD a, Yong In, MD, PhD c, d, * a
Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, Seoul, Korea Department of Anesthesia and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, Seoul, Korea d Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 September 2016 Received in revised form 31 December 2016 Accepted 18 January 2017 Available online 26 January 2017
Background: Femoral nerve block (FNB) has been used as part of the multimodal analgesia after total knee arthroplasty (TKA), but leads to weakness in the quadriceps muscles. Recently, adductor canal block (ACB) was reported to provide effective pain relief while sparing the strength of the quadriceps. This simultaneous bilateral randomized study investigated whether patients perceived differences between ACB and the FNB after same-day bilateral TKA. Methods: We performed a prospective simultaneous bilateral randomized study in 50 patients scheduled to undergo same-day bilateral TKA. One knee was randomly assigned to ACB and the other knee was assigned to FNB. All ACB and FNB were performed using ultrasound-guided single-shot procedures. These 2 groups were compared for pain visual analogue scale, straight leg raising ability and knee extension while sitting, and motor grade. At postoperative week 1, the peak torque for the quadriceps muscle was measured in both knees with an isokinetic dynamometer. Results: There were no differences in pain levels between ACB and FNB during the entire study period. During the first 48 h after TKA, more of the knees that received ACB could perform straight leg raising and knee extension with greater quadriceps strength compared with FNB. However, no group differences in quadriceps functional recovery were found after postoperative 48 h and isometric quadriceps strength at postoperative 1 week. Conclusion: This simultaneous bilateral randomized study demonstrates that patients did not perceive differences in pain level, but experienced substantial differences in quadriceps strength recovery between knees during the first 48 h (Identifier: NCT02513082). © 2017 Elsevier Inc. All rights reserved.
Keywords: multimodal pain management adductor canal block femoral nerve block same-day bilateral total knee arthroplasty peripheral nerve block
As total knee arthroplasty (TKA) is increasingly recognized as a standard treatment option for end-stage knee disease with widespread acceptance, its use has increased substantially over the past few decades, and future demand is projected to rise rapidly [1-4]. Concerns are emerging about growing socioeconomic burden on the healthcare system [5] and there is a growing emphasis on the establishment of strategies to shorten the length of time spent in
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.01.025. * Reprint requests: Yong In, MD, PhD, Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea. http://dx.doi.org/10.1016/j.arth.2017.01.025 0883-5403/© 2017 Elsevier Inc. All rights reserved.
hospitals by facilitating faster recovery during the early postoperative period [6,7]. Great advances in pain management are well documented to be a major factor in the improvement of postoperative recovery after TKA and the preemptive use of multimodal modalities is currently accepted as a principle of pain management after TKA [8,9]. As peripheral nerve blocks (PNBs) provide effective analgesia, they are considered an essential part of the current multimodal pain management protocol following TKA [9,10]. Given the excellent pain relief and synergistic analgesic effect, femoral nerve block (FNB) is commonly used as an analgesic modality and is considered the standard PNB in patients undergoing TKA [11]. However, FNB is reported to be associated with a significant decrease in quadriceps strength, resulting in delayed rehabilitation, which is associated with the potential risk of falling
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Fig. 1. A flow diagram showing the study design.
[12-15]. A potent pain management modality that preserves motor strength during early rehabilitation is becoming increasingly accepted as part of the current perioperative rehabilitation protocol following TKA. Within this context, a growing body of evidence supports the use of an adductor canal block (ACB), which offers pure sensory block with minimal motor involvement in patients undergoing TKA [16-31]. However, heterogeneities among studies regarding concomitant anesthesia and pain management protocols, infiltration techniques, and outcome variables make it difficult to judge the practical value of ACB in patients after TKA. A comparison between knees that underwent different PNBs in a single patient might be the best method of assessing the difference between ACB and FNB. However, only one previous simultaneous randomized bilateral trial relating to different PNBs has been undertaken [21], and data comparing ACB to FNB in the same patient who underwent same-day bilateral TKA remain limited. However, unfortunately, as previous study used a combined spinal epidural anesthesia and maintained epidural PCA (patient-controlled analgesia) for 2 days after TKA, pain relief and quadriceps recovery might be affected by neuroaxial analgesia. Therefore, pure analgesia and quadriceps recovery between ACB and FNB remain to be determined. Thus, this prospective simultaneous bilateral randomized study was conducted to determine whether patients perceive a difference in pain level, and to investigate how different patients experience functional recovery of the quadriceps muscle with ACB and FNB after undergoing same-day bilateral TKA. Patients and Methods This study included 53 patients scheduled to undergo same-day bilateral TKAs between July 2015 and April 2016. After obtaining
approval from our Institutional Review Board, we randomly assigned one knee to receive ACB and the other knee to receive FNB for each patient. Eligible patients included those aged <75 years, with an American Society of Anesthesiologists (ASA) score of 1 or 2, and who were scheduled for same-day bilateral TKA for primary osteoarthritis. Exclusion criteria included patients who had postoperative complications such as periprosthetic infection, periprosthetic fracture, or venous thromboembolism that could potentially affect the postoperative outcomes. Patients who declined to participate in this trial or who were unable to provide informed consent were also excluded. Of the 53 patients enrolled in this study, 3 were subsequently excluded: 2 patients for a diagnosis other than osteoarthritis (1 rheumatoid arthritis and 1 posttraumatic arthritis) and 1 patient (2 knees) declined to participate. Thus, 50 patients (100 knees) in total were recruited. One knee was randomly assigned to the ACB group, which received the ACB, and the contralateral knee was assigned to the FNB group, which received the FNB. A computer-generated randomization table, permuted into blocks of 4 and 6, was used to randomly assign knees to either the ACB or FNB group. Allocation was assigned at the commencement of surgery by a scrub nurse who was not involved in patient recruitment for this trial. The patients, and an independent investigator who prospectively collected the clinical information, were unaware of group assignments until the final data analyses were complete. Finally, 50 patients (100 knees) were included in the final analyses (Fig. 1). Of these 50 patients, 49 were female and 1 was male. The mean age was 66.9 years, ranging from 51 to 75 years, and the mean body mass index was 27.1 kg/m2, ranging from 20.4 to 34.1. Twelve patients (24%) had ASA scores of 1 and the others (76%) had ASA scores of 2. Final outcome adjudications were completed in July 2016. The study protocol was registered at ClinicalTrials.gov (NCT02513082).
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We performed an a priori power analysis based on the results of a previous study to determine whether our sample size had sufficient statistical power, using the 2-sided hypothesis test at an alpha level of 0.05 and a power of 80% [32]. Thirty-nine knees were required in each group to detect a 2-point visual analogue scale (VAS) difference in pain level, which we considered to be clinically significant for the following reasons. First, the pain levels assessed after same-day bilateral TKA were 3-5 points on a 0 to 10-point VAS in our clinical practice [32-34], and a previous study reported that a 50% reduction in the VAS pain score was clinically meaningful [35]. Second, the mean satisfactory postoperative VAS pain score has been reported to be around 2 VAS points [36]. To allow for exclusions and dropouts, we enrolled 50 patients in the current trial. All operations were performed by a single surgeon (one of the authors) in patients under general anesthesia in a standard fashion. A posterior-stabilized prosthesis (LOSPA; Corentec, Seoul, Korea) was implanted in all patients. The subvastus approach was employed in all cases. The patella was not resurfaced, and cement fixation was used for all components in all cases. An intramedullary alignment system was used for the femoral cuts and an extramedullary system was used for the tibial cut. A pneumatic tourniquet that inflated to 300 mmHg was applied. Meticulous bleeding control was performed after deflation of the tourniquet. An intraarticular suction catheter was inserted and removed within 48 h after the operation. All patients received the same anesthetic and multimodal perioperative management protocol. Two hours before surgery, multimodal oral analgesic drugs (200 mg celecoxib and 150 mg pregabalin) were administered for preemptive analgesia on a call basis. All patients received 1.0 g cefazolin as an antimicrobial prophylaxis, and general anesthesia was administered by a single anesthesiologist (one of the authors). To exclude the confounding factors affecting postoperative pain following TKA, additional pain relieving modalities such as periarticular injection or neuroaxial blockade were not performed in this study. All PNBs were performed immediately after operation in the operating room in an anesthetic state by a single anesthesiologist using S-Nerve ultrasound (Sonosite, Inc, Bothell, WA). For the FNB, the probe was placed parallel to the inguinal ligament and transverse to the femoral artery and vein. The stimulation needle was inserted at the lateral border of the probe and placed 1 cm lateral to the femoral artery just below the inguinal ligament. The placement of the needle was confirmed by injecting a small bolus of local anesthetic, about 1-2 mL. For the ACB, patients were in a supine position with knee slightly flexed and leg externally rotated. In the mid-thigh, the femur was identified and the probe was moved medially until the boat-shaped sartorius muscle was visualized. The femoral artery was also identified underneath the sartorius muscle with the vein. The needle was placed medial to the femoral artery in the adductor canal bordered laterally by the vastus medialis, medially by the sartorius muscle, and inferiorly by the femoral artery. In total, 1-2 mL of the local anesthetic was injected to confirm the proper site. A local anesthetic, 10 cc of 0.75% ropivacaine (150 mg), was used for both PNBs. There were no differences in preoperative conditions and tourniquet time between ACB and FNB groups (Table 1). Postoperatively, all patients received intravenous PCA, which was programmed to deliver 1 mL of a 100-mL solution containing 2000-mg fentanyl when patients depressed a button. A 10-min lockout period without basal flow was in place. The intravenous PCA was typically discontinued on the fourth postoperative day. When patients resumed oral intake, 10-mg oxycodon, 200-mg celecoxib, 37.5-mg tramadol, and 650-mg acetaminophen were administered every 12 h. An intramuscular injection of diclofenac (75 mg) was used as an acute analgesic when a patient reported severe pain greater than level 6 on a 0-10 VAS. All patients received
Table 1 Preoperative Conditions and Tourniquet Time in the ACB and FNB Groups.a Preoperative Conditions
ACB
Pain VAS ROM ( ) Flexion contracture Further flexion Quadriceps function SLR duration (s) Motor grade Tourniquet time (min)
6.3 112.6 9.0 121.6
FNB (1.4) (12.1) (8.4) (12.1)
10 5 43.2 (6.4)
6.5 114.2 9.4 123.6
Significance (1.2) (12.9) (7.5) (9.6)
10 5 42.4 (7.5)
0.589 0.602 0.787 0.363 1.000 1.000 0.576
SD, standard deviation. a Data are presented as means (SD).
40 mg of enoxaparin (Clexane; Sanofi Aventis, Paris, France) subcutaneously for thromboprophylaxis. This treatment was initiated 12 h before the operation and continued for 10 days. All patients wore graduated compression stockings for 4 weeks after the operation. Beginning the day after surgery, patients were allowed to walk using a frame, and began gradually increasing range-ofmotion (ROM) exercises in bed. All patients were admitted for a period of 14 days and followed up at 6 weeks and at 3 months, 6 months, and 1 year postoperatively. The primary outcome variable was pain level, while the secondary outcome variables were the straight leg raising (SLR) ability and knee extension while sitting, duration of SLR, standardized motor strength scale of quadriceps muscle, ROM, isometric quadriceps muscle strength, fall episodes, and the incidence of nerve injury. A clinical investigator (one of the authors) who was blinded to the group assignments assessed all the prospectively collected data. Pain levels were recorded to evaluate the differences in pain relieving effects between ACB and FNB. Pain levels were recorded preoperatively, and at postoperative 12 and 24 h, 2 and 3 days, 1, 2, and 6 weeks, and were estimated using a VAS that ranged from 0 (no pain) to 10 (worst imaginable pain). The ability of SLR and knee extension while sitting, duration of SLR, standardized motor strength scale of the quadriceps muscle using a manual muscle test, ROM, and isometric quadriceps muscle strength at postoperative 1 week was recorded to evaluate the functional recovery of the quadriceps muscle. SLR is the ability to elevate the heel and leg straight upward about 20 cm from the floor in a supine position. Holding the leg for about 10 s was considered normal [37]. Quadriceps strength was evaluated using a manual muscle test in the sitting position with a 0-5 motor strength scale [38]. The patients were asked to extend the knee against gravity while sitting. 0 represents absolutely no muscle contraction and 5 is normal. A grade of 1 means that there is visible contraction but no movement; 2 is active movement of the muscle when gravity is eliminated; 3 is muscle movement against gravity, but not against resistance with additional force; and 4 is less than normal, but more than enough to resist gravity. The ROM was calculated by subtracting the degree of flexion contracture from the degree of maximum flexion using a standard 38-cm goniometer, with the patient lying in the supine position, preoperatively, and at postoperative 12 and 24 h, 2 and 3 days, and 1, 2, and 6 weeks. At postoperative week 1, the peak torque for the quadriceps muscle was measured by a single-blinded rehabilitation physician. Patients were positioned in an isokinetic dynamometer (PrimusRS; BTE Technologies, CO) for maximal isometric contraction. With the knee positioned at 60 of flexion, a set of 2 maximal isometric quadriceps contractions (4 s each) were performed at each measurement time point. The highest peak force was calculated by multiplying the averaged data from the 2 trials, which was then normalized by body mass (Nm/kg). The incidences
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of falls and nerve injury were evaluated during the hospital stay and at each follow-up visit. We compared the primary and secondary outcomes between the ACB and FNB groups. Continuous variables were analyzed using Student's t-test or the Wilcoxon signed-rank test. The chi-squared test or Fisher's exact test was used to determine the statistical significance of differences in the categorical variables. Statistical analyses were performed using SPSS for Windows (version 21.0; IBM Corporation, Armonk, NY). Results Patients did not perceive differences in pain level between the knees that underwent TKAs using different PNBs. The mean pain VAS scores were similar in both knees during the entire study period, including 12 and 24 h, and 2, 3, and 7 days postoperatively (P > .1 in all comparisons with the exception of postoperative 2 days [P ¼ .069]) (Fig. 2). Knees in the ACB group showed superior quadriceps recovery compared to knees in the FNB group during the first 24-48 h after TKA. More knees in the ACB group were able to perform SLR and knee extension while sitting during the first 24 h (P < .01 in all comparisons during the first 24 h) (Fig. 3). In addition, patients in the ACB groups could raise their legs longer with greater quadriceps strength during the first 24-48 h (Table 2). However, ROM during the entire study period (P > .1 in all comparisons) (Table 2) and the maximal isometric quadriceps contraction at postoperative 1 week (92.8 ± 55.9 Nm in ACB vs 99.6 ± 54.9 Nm in FNB, P ¼ .544) were not different. There was no fall episode or nerve injury in both groups during the entire study period. Discussion There has been recent emphasis on faster recovery during the early postoperative period after TKA. Although numerous studies indicate that ACB provides comparable analgesic efficacy and facilitates earlier mobilization by sparing the strength of the quadriceps compared with FNB, the question of whether ACB is more appropriate for the current pain management protocol during TKA remains controversial. Thus, we aimed to determine whether ACB offers superior pain relief and quadriceps recovery for FNB. This study sought to determine whether patients perceived differences in pain level between knees and how different patients experience
Fig. 2. The pain levels according to the VAS during the first 7 days after surgery are shown. No between-group differences were observed during the entire study period. PO, postoperative.
Fig. 3. Bar graph showing the prevalence of knees that was able to perform SLR (A) and extend the knee while sitting (B). A higher proportion of knees in the ACB group performed SLR and knee extension during the first 24 h after TKA. PO, postoperative.
quadriceps recovery with ACB and FNB after undergoing same-day bilateral TKA. Patients did not perceive any difference in pain level between knees that had received either ACB or FNB for TKA. In this study, no between-group differences in pain levels were observed at all time points during the entire study period. The results of this study are in agreement with recent multiple reports of comparable pain levels between ACB and FNB [16-20,22,23,25,27-31,39]. However, our findings do not concur with the only simultaneous bilateral randomized study reporting superior qualitative pain relief in FNB compared with ACB 24 h after TKA [21]. The reasons why FNB provided better qualitative analgesia are unclear, but this finding may be the result of a synergistic effect from neuroaxial analgesia in the previous study. In that study, the authors maintained epidural PCA containing bupivacaine and opioid for 2 days after TKA following a combined spinal-epidural anesthesia, which may affect the quality of analgesia. In contrast, we performed general anesthesia in all patients to avoid such confounding factors. On the other hand, our findings indicate that single-shot ACB can offer satisfactory pain relief after TKA. Although one previous study reported that continuous ACB offered better analgesia compared with single-shot ACB [40], patients experienced tolerable postoperative pain during ambulation without indwelling catheter, which may impair the early postoperative rehabilitation. The findings of this study, together with those of the previous studies, suggest that single-shot ACB can be a reasonable analgesic modality when incorporated into current multimodal pain management protocols.
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Table 2 Duration of SLR, Grade of Motor Strength, and ROM in the ACB and FNB Groups.a Time Points
Duration of SLR (s) ACB
Preoperative PO 6 h PO 12 h PO 24 h PO 2 d PO 3 d PO 1 wk PO 2 wk PO 6 wk
10 2.3 4.8 6.5 9.3 10.0 10 10 10
(3.9) (4.6) (3.3) (1.5) (0.3)
ROM ( )
Grade of Motor Strength
FNB
Significance
ACB
FNB
Significance
ACB
10 0.4 1.0 3.0 8.5 9.9 10 10 10
1.000 <0.01 <0.01 <0.01 0.014 0.383 1.000 1.000 1.000
5 3.2 3.7 4.1 4.9 5 5 5 5
5 2.5 2.8 3.5 4.7 5 5 5 5
1.000 <0.01 <0.01 0.022 0.278 1.000 1.000 1.000 1.000
114.2 84.4 90.0 94.0 103.6 112.2 118.3 122.4 125.1
(1.7) (2.5) (2.9) (1.6) (0.8)
(1.1) (1.3) (1.0) (0.4)
(0.8) (1.1) (1.4) (0.7)
FNB (12.9) (8.1) (7.8) (6.1) (6.9) (8.2) (9.2) (6.3) (4.2)
112.6 84.2 89.8 93.8 103.4 112.4 119.0 123.3 125.9
Significance (17.0) (8.6) (8.0) (6.4) (7.5) (8.2) (9.1) (5.1) (4.2)
0.602 0.908 0.899 0.872 0.89 0.903 0.687 0.425 0.369
PO, postoperative; SD, standard deviation. a Data are presented as means (SD).
Patients experienced superior quadriceps recovery in knees that received ACB during the first 48 h after TKA, but ACB did not have any significant advantage over FNB after postoperative 48 h. In this study, the prevalence of SLR and knee extension while sitting was higher and knees that received ACB performed SLR for longer time and with greater strength compared with those that received FNB during the first 2 days after TKA. However, no between-group differences were observed in the quadriceps recovery 2 days after TKA, in ROM during the entire study period, or in the maximal isometric quadriceps strength at postoperative 1 week. These findings concur with multiple previous reports that ACB provided superior quadriceps recovery within the first 2 days after TKA [16,17,19,22,23,25,27-31,39,41-43]. However, the results of our study do not concur with 2 previous studies reporting comparable functional recovery between ACB and FNB [21,26]. The reason why quadriceps recovery was comparable between ACB, which provides a primary sensory block, and FNB, which provides a motor block, in those studies is unclear, but this may be the result of concomitant anesthetic or analgesic modalities that might affect motor recovery. One of the 2 studies involved sciatic nerve block in all patients, with ACB or FNB added randomly [26], while continuous epidural PCA was maintained in the other study during the first 2 days [21]. The data from this study, together with those of previous studies, suggest that ACB can facilitate postoperative rehabilitation while sparing the quadriceps strength. In addition, ACB seems to be more appropriate for a contemporary postoperative protocol following TKA, especially with same-day bilateral TKA that involves both knees compared with FNB. However, as the functional recovery of the quadriceps may be affected by concomitant pain management modalities, surgeons should take into account the motor involvement of each analgesic modality when establishing postoperative rehabilitation protocols specific to each patient after TKA. This study has several limitations. First, because we evaluated only Korean patients, the demographic characteristics should be noted before extrapolating to other populations. Ninety-eight percent (49/50) of this cohort were women and this female dominance is well documented in Korean patients for an unknown reason [1,44,45]. Second, a control group which received all analgesic modalities except PNB would be helpful to establish a baseline function level and an additional analgesia of PNB. However, as we mainly focused on the patient's perception of the difference between ACB and FNB in a single patient, we could not assess the outcomes of patients who did not receive PNB in this study. In addition, multiple previous studies well documented that each PNB provided a significant additional analgesia in patients who received current multimodal pain management [10,11,25]. Third, this study could not determine whether the difference in PNB affected the length of hospital stay after TKA. Although most patients who undergo TKA are admitted for 1-3 days in the United States, all
patients in this study were admitted for 14 days after surgery, which is the standard practice in our medical system [34,46]. As the length of hospital stay after TKA would be influenced by the overall healthcare system in each country, this finding may not be widely generalizable. However, information in this study would be valuable, because the length of hospital stay would not be a critical factor affecting the pain level after surgery, and 14-day admission can be rather helpful in performing precise evaluation of the pain level in patients. Fourth, although multimodal pain management is considered the standard pain management protocol after TKA, we did not employ epidural anesthesia or additional pain relieving modalities such as periarticular injection, because we wanted to avoid confounding factors that might affect pain relief after TKA. We anticipated that the addition of these modalities would make it more difficult for the patient to perceive the differences between the 2 approaches. However, this should be considered before extrapolating our findings to other postoperative pain management protocols. Fifth, as each patient received ACB or FNB on each knee, we could not determine how much the difference in PNB affected opioid consumption and its related side effects on the timed upand-go test, ambulation distance, and fall episode in this study. Finally, this study could not determine whether the difference in PNB affected patient-reported outcome measures such as patient satisfaction or side preference. However, previous clinical trials and meta-analyses with comparison between ACB and FNB reported that superior pain relief and functional recovery limited to the early postoperative period did not affect patient-reported outcome measures [21,26,30,31]. Despite these limitations, this simultaneous randomized bilateral trial provides valuable information regarding pain relief and functional recovery between ACB and FNB in patients who undergo TKA.
Conclusion This study demonstrates that patients who undergo same-day bilateral TKA do not perceive any difference in pain levels between knees that undergo either ACB or FNB. However, patients experience superior quadriceps recovery during the first 2 days after TKA. Based on current trends in perioperative protocols toward early mobilization following TKA, ACB seems to be a more appropriate PNB option compared with FNB as part of a current multimodal pain management protocol after TKA.
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early functional recovery and pain control: a randomized controlled trial. J Arthroplasty 2014;29(11):2224. Wiesmann T, Piechowiak K, Duderstadt S, et al. Continuous adductor canal block versus continuous femoral nerve block after total knee arthroplasty for mobilisation capability and pain treatment: a randomised and blinded clinical trial. Arch Orthop Trauma Surg 2016;136(3):397. Hussain N, Ferreri TG, Prusick PJ, et al. Adductor canal block versus femoral canal block for total knee arthroplasty: a meta-analysis: what does the evidence suggest? Reg Anesth Pain Med 2016;41(3):314. Kuang MJ, Xu LY, Ma JX, et al. Adductor canal block versus continuous femoral nerve block in primary total knee arthroplasty: a meta-analysis. Int J Surg 2016;31:17. Li D, Ma GG. Analgesic efficacy and quadriceps strength of adductor canal block versus femoral nerve block following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015;24:2614. Li D, Yang Z, Xie X, et al. Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: a systematic review and meta-analysis. Int Orthop 2016;40(5):925. Zhao XQ, Jiang N, Yuan FF, et al. The comparison of adductor canal block with femoral nerve block following total knee arthroplasty: a systematic review with meta-analysis. J Anesth 2016;30:745. Koh IJ, Kang YG, Chang CB, et al. Additional pain relieving effect of intraoperative periarticular injections after simultaneous bilateral TKA: a randomized, controlled study. Knee Surg Sports Traumatol Arthrosc 2010;18(7):916. Koh IJ, Kang YG, Chang CB, et al. Use of reduced-dose periarticular injection for pain management in simultaneous bilateral total knee arthroplasty. J Arthroplasty 2012;27(9):1731. Koh IJ, Kim MW, Kim MS, et al. The patient's perception does not differ following subvastus and medial parapatellar approaches in total knee arthroplasty: a simultaneous bilateral randomized study. J Arthroplasty 2016;31(1): 112. Reuben SS, Steinberg RB, Cohen MA, et al. Intraarticular morphine in the multimodal analgesic management of postoperative pain after ambulatory anterior cruciate ligament repair. Anesth Analg 1998;86(2):374. Myles PS, Urquhart N. The linearity of the visual analogue scale in patients with severe acute pain. Anaesth Intensive Care 2005;33(1):54. Hu H, Meijer OG, Hodges PW, et al. Understanding the active straight leg raise (ASLR): an electromyographic study in healthy subjects. Man Ther 2012;17(6): 531. Sapega AA. Muscle performance evaluation in orthopaedic practice. J Bone Joint Surg Am 1990;72(10):1562. Dong CC, Dong SL, He FC. Comparison of adductor canal block and femoral nerve block for postoperative pain in total knee arthroplasty: a systematic review and meta-analysis. Medicine (Baltimore) 2016;95(12):e2983. Shah NA, Jain NP, Panchal KA. Adductor canal blockade following total knee arthroplastydcontinuous or single shot technique? Role in postoperative analgesia, ambulation ability and early functional recovery: a randomized controlled trial. J Arthroplasty 2015;30(8):1476. Jaeger P, Nielsen ZJ, Henningsen MH, et al. Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebocontrolled, crossover study in healthy volunteers. Anesthesiology 2013;118(2): 409. Ludwigson JL, Tillmans SD, Galgon RE, et al. A comparison of single-shot adductor canal block vs femoral nerve catheter for total knee arthroplasty. J Arthroplasty 2016;31(3):741. Zhang W, Hu Y, Tao Y, et al. Ultrasound-guided continuous adductor canal block for analgesia after total knee replacement. Chin Med J (Engl) 2014;127(23):4077. Koh IJ, Chang CB, Kang YG, et al. Incidence, predictors, and effects of residual flexion contracture on clinical outcomes of total knee arthroplasty. J Arthroplasty 2013;28(4):585. Koh IJ, Cho WS, Choi NY, et al., Kleos Korea Research Group. Causes, risk factors, and trends in failures after TKA in Korea over the past 5 years: a multicenter study. Clin Orthop Relat Res 2014;472(1):316. Koh IJ, Kim GH, Kong CG, et al. The patient's age and American Society of Anesthesiologists Status are reasonable criteria for deciding whether to perform same-day bilateral TKA. J Arthroplasty 2015;30(5):770.
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Primary Arthroplasty
Does Patient Perception Differ Following Adductor Canal Block and Femoral Nerve Block in Total Knee Arthroplasty? A Simultaneous Bilateral Randomized Study Hyun J. Koh, MD, PhD a, b, In J. Koh, MD, PhD c, d, Man S. Kim, MD c, Keun Y. Choi, MD c, Hyeon U. Jo, MD a, Yong In, MD, PhD c, d, * a
Department of Anesthesiology and Pain Medicine, Seoul St. Mary’s Hospital, Seoul, Korea Department of Anesthesia and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, Seoul, Korea d Department of Orthopaedic Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea b c
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 September 2016 Received in revised form 31 December 2016 Accepted 18 January 2017 Available online 26 January 2017
Background: Femoral nerve block (FNB) has been used as part of the multimodal analgesia after total knee arthroplasty (TKA), but leads to weakness in the quadriceps muscles. Recently, adductor canal block (ACB) was reported to provide effective pain relief while sparing the strength of the quadriceps. This simultaneous bilateral randomized study investigated whether patients perceived differences between ACB and the FNB after same-day bilateral TKA. Methods: We performed a prospective simultaneous bilateral randomized study in 50 patients scheduled to undergo same-day bilateral TKA. One knee was randomly assigned to ACB and the other knee was assigned to FNB. All ACB and FNB were performed using ultrasound-guided single-shot procedures. These 2 groups were compared for pain visual analogue scale, straight leg raising ability and knee extension while sitting, and motor grade. At postoperative week 1, the peak torque for the quadriceps muscle was measured in both knees with an isokinetic dynamometer. Results: There were no differences in pain levels between ACB and FNB during the entire study period. During the first 48 h after TKA, more of the knees that received ACB could perform straight leg raising and knee extension with greater quadriceps strength compared with FNB. However, no group differences in quadriceps functional recovery were found after postoperative 48 h and isometric quadriceps strength at postoperative 1 week. Conclusion: This simultaneous bilateral randomized study demonstrates that patients did not perceive differences in pain level, but experienced substantial differences in quadriceps strength recovery between knees during the first 48 h (Identifier: NCT02513082). © 2017 Elsevier Inc. All rights reserved.
Keywords: multimodal pain management adductor canal block femoral nerve block same-day bilateral total knee arthroplasty peripheral nerve block
As total knee arthroplasty (TKA) is increasingly recognized as a standard treatment option for end-stage knee disease with widespread acceptance, its use has increased substantially over the past few decades, and future demand is projected to rise rapidly [1-4]. Concerns are emerging about growing socioeconomic burden on the healthcare system [5] and there is a growing emphasis on the establishment of strategies to shorten the length of time spent in
No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.01.025. * Reprint requests: Yong In, MD, PhD, Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea. http://dx.doi.org/10.1016/j.arth.2017.01.025 0883-5403/© 2017 Elsevier Inc. All rights reserved.
hospitals by facilitating faster recovery during the early postoperative period [6,7]. Great advances in pain management are well documented to be a major factor in the improvement of postoperative recovery after TKA and the preemptive use of multimodal modalities is currently accepted as a principle of pain management after TKA [8,9]. As peripheral nerve blocks (PNBs) provide effective analgesia, they are considered an essential part of the current multimodal pain management protocol following TKA [9,10]. Given the excellent pain relief and synergistic analgesic effect, femoral nerve block (FNB) is commonly used as an analgesic modality and is considered the standard PNB in patients undergoing TKA [11]. However, FNB is reported to be associated with a significant decrease in quadriceps strength, resulting in delayed rehabilitation, which is associated with the potential risk of falling
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Fig. 1. A flow diagram showing the study design.
[12-15]. A potent pain management modality that preserves motor strength during early rehabilitation is becoming increasingly accepted as part of the current perioperative rehabilitation protocol following TKA. Within this context, a growing body of evidence supports the use of an adductor canal block (ACB), which offers pure sensory block with minimal motor involvement in patients undergoing TKA [16-31]. However, heterogeneities among studies regarding concomitant anesthesia and pain management protocols, infiltration techniques, and outcome variables make it difficult to judge the practical value of ACB in patients after TKA. A comparison between knees that underwent different PNBs in a single patient might be the best method of assessing the difference between ACB and FNB. However, only one previous simultaneous randomized bilateral trial relating to different PNBs has been undertaken [21], and data comparing ACB to FNB in the same patient who underwent same-day bilateral TKA remain limited. However, unfortunately, as previous study used a combined spinal epidural anesthesia and maintained epidural PCA (patient-controlled analgesia) for 2 days after TKA, pain relief and quadriceps recovery might be affected by neuroaxial analgesia. Therefore, pure analgesia and quadriceps recovery between ACB and FNB remain to be determined. Thus, this prospective simultaneous bilateral randomized study was conducted to determine whether patients perceive a difference in pain level, and to investigate how different patients experience functional recovery of the quadriceps muscle with ACB and FNB after undergoing same-day bilateral TKA. Patients and Methods This study included 53 patients scheduled to undergo same-day bilateral TKAs between July 2015 and April 2016. After obtaining
approval from our Institutional Review Board, we randomly assigned one knee to receive ACB and the other knee to receive FNB for each patient. Eligible patients included those aged <75 years, with an American Society of Anesthesiologists (ASA) score of 1 or 2, and who were scheduled for same-day bilateral TKA for primary osteoarthritis. Exclusion criteria included patients who had postoperative complications such as periprosthetic infection, periprosthetic fracture, or venous thromboembolism that could potentially affect the postoperative outcomes. Patients who declined to participate in this trial or who were unable to provide informed consent were also excluded. Of the 53 patients enrolled in this study, 3 were subsequently excluded: 2 patients for a diagnosis other than osteoarthritis (1 rheumatoid arthritis and 1 posttraumatic arthritis) and 1 patient (2 knees) declined to participate. Thus, 50 patients (100 knees) in total were recruited. One knee was randomly assigned to the ACB group, which received the ACB, and the contralateral knee was assigned to the FNB group, which received the FNB. A computer-generated randomization table, permuted into blocks of 4 and 6, was used to randomly assign knees to either the ACB or FNB group. Allocation was assigned at the commencement of surgery by a scrub nurse who was not involved in patient recruitment for this trial. The patients, and an independent investigator who prospectively collected the clinical information, were unaware of group assignments until the final data analyses were complete. Finally, 50 patients (100 knees) were included in the final analyses (Fig. 1). Of these 50 patients, 49 were female and 1 was male. The mean age was 66.9 years, ranging from 51 to 75 years, and the mean body mass index was 27.1 kg/m2, ranging from 20.4 to 34.1. Twelve patients (24%) had ASA scores of 1 and the others (76%) had ASA scores of 2. Final outcome adjudications were completed in July 2016. The study protocol was registered at ClinicalTrials.gov (NCT02513082).
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We performed an a priori power analysis based on the results of a previous study to determine whether our sample size had sufficient statistical power, using the 2-sided hypothesis test at an alpha level of 0.05 and a power of 80% [32]. Thirty-nine knees were required in each group to detect a 2-point visual analogue scale (VAS) difference in pain level, which we considered to be clinically significant for the following reasons. First, the pain levels assessed after same-day bilateral TKA were 3-5 points on a 0 to 10-point VAS in our clinical practice [32-34], and a previous study reported that a 50% reduction in the VAS pain score was clinically meaningful [35]. Second, the mean satisfactory postoperative VAS pain score has been reported to be around 2 VAS points [36]. To allow for exclusions and dropouts, we enrolled 50 patients in the current trial. All operations were performed by a single surgeon (one of the authors) in patients under general anesthesia in a standard fashion. A posterior-stabilized prosthesis (LOSPA; Corentec, Seoul, Korea) was implanted in all patients. The subvastus approach was employed in all cases. The patella was not resurfaced, and cement fixation was used for all components in all cases. An intramedullary alignment system was used for the femoral cuts and an extramedullary system was used for the tibial cut. A pneumatic tourniquet that inflated to 300 mmHg was applied. Meticulous bleeding control was performed after deflation of the tourniquet. An intraarticular suction catheter was inserted and removed within 48 h after the operation. All patients received the same anesthetic and multimodal perioperative management protocol. Two hours before surgery, multimodal oral analgesic drugs (200 mg celecoxib and 150 mg pregabalin) were administered for preemptive analgesia on a call basis. All patients received 1.0 g cefazolin as an antimicrobial prophylaxis, and general anesthesia was administered by a single anesthesiologist (one of the authors). To exclude the confounding factors affecting postoperative pain following TKA, additional pain relieving modalities such as periarticular injection or neuroaxial blockade were not performed in this study. All PNBs were performed immediately after operation in the operating room in an anesthetic state by a single anesthesiologist using S-Nerve ultrasound (Sonosite, Inc, Bothell, WA). For the FNB, the probe was placed parallel to the inguinal ligament and transverse to the femoral artery and vein. The stimulation needle was inserted at the lateral border of the probe and placed 1 cm lateral to the femoral artery just below the inguinal ligament. The placement of the needle was confirmed by injecting a small bolus of local anesthetic, about 1-2 mL. For the ACB, patients were in a supine position with knee slightly flexed and leg externally rotated. In the mid-thigh, the femur was identified and the probe was moved medially until the boat-shaped sartorius muscle was visualized. The femoral artery was also identified underneath the sartorius muscle with the vein. The needle was placed medial to the femoral artery in the adductor canal bordered laterally by the vastus medialis, medially by the sartorius muscle, and inferiorly by the femoral artery. In total, 1-2 mL of the local anesthetic was injected to confirm the proper site. A local anesthetic, 10 cc of 0.75% ropivacaine (150 mg), was used for both PNBs. There were no differences in preoperative conditions and tourniquet time between ACB and FNB groups (Table 1). Postoperatively, all patients received intravenous PCA, which was programmed to deliver 1 mL of a 100-mL solution containing 2000-mg fentanyl when patients depressed a button. A 10-min lockout period without basal flow was in place. The intravenous PCA was typically discontinued on the fourth postoperative day. When patients resumed oral intake, 10-mg oxycodon, 200-mg celecoxib, 37.5-mg tramadol, and 650-mg acetaminophen were administered every 12 h. An intramuscular injection of diclofenac (75 mg) was used as an acute analgesic when a patient reported severe pain greater than level 6 on a 0-10 VAS. All patients received
Table 1 Preoperative Conditions and Tourniquet Time in the ACB and FNB Groups.a Preoperative Conditions
ACB
Pain VAS ROM ( ) Flexion contracture Further flexion Quadriceps function SLR duration (s) Motor grade Tourniquet time (min)
6.3 112.6 9.0 121.6
FNB (1.4) (12.1) (8.4) (12.1)
10 5 43.2 (6.4)
6.5 114.2 9.4 123.6
Significance (1.2) (12.9) (7.5) (9.6)
10 5 42.4 (7.5)
0.589 0.602 0.787 0.363 1.000 1.000 0.576
SD, standard deviation. a Data are presented as means (SD).
40 mg of enoxaparin (Clexane; Sanofi Aventis, Paris, France) subcutaneously for thromboprophylaxis. This treatment was initiated 12 h before the operation and continued for 10 days. All patients wore graduated compression stockings for 4 weeks after the operation. Beginning the day after surgery, patients were allowed to walk using a frame, and began gradually increasing range-ofmotion (ROM) exercises in bed. All patients were admitted for a period of 14 days and followed up at 6 weeks and at 3 months, 6 months, and 1 year postoperatively. The primary outcome variable was pain level, while the secondary outcome variables were the straight leg raising (SLR) ability and knee extension while sitting, duration of SLR, standardized motor strength scale of quadriceps muscle, ROM, isometric quadriceps muscle strength, fall episodes, and the incidence of nerve injury. A clinical investigator (one of the authors) who was blinded to the group assignments assessed all the prospectively collected data. Pain levels were recorded to evaluate the differences in pain relieving effects between ACB and FNB. Pain levels were recorded preoperatively, and at postoperative 12 and 24 h, 2 and 3 days, 1, 2, and 6 weeks, and were estimated using a VAS that ranged from 0 (no pain) to 10 (worst imaginable pain). The ability of SLR and knee extension while sitting, duration of SLR, standardized motor strength scale of the quadriceps muscle using a manual muscle test, ROM, and isometric quadriceps muscle strength at postoperative 1 week was recorded to evaluate the functional recovery of the quadriceps muscle. SLR is the ability to elevate the heel and leg straight upward about 20 cm from the floor in a supine position. Holding the leg for about 10 s was considered normal [37]. Quadriceps strength was evaluated using a manual muscle test in the sitting position with a 0-5 motor strength scale [38]. The patients were asked to extend the knee against gravity while sitting. 0 represents absolutely no muscle contraction and 5 is normal. A grade of 1 means that there is visible contraction but no movement; 2 is active movement of the muscle when gravity is eliminated; 3 is muscle movement against gravity, but not against resistance with additional force; and 4 is less than normal, but more than enough to resist gravity. The ROM was calculated by subtracting the degree of flexion contracture from the degree of maximum flexion using a standard 38-cm goniometer, with the patient lying in the supine position, preoperatively, and at postoperative 12 and 24 h, 2 and 3 days, and 1, 2, and 6 weeks. At postoperative week 1, the peak torque for the quadriceps muscle was measured by a single-blinded rehabilitation physician. Patients were positioned in an isokinetic dynamometer (PrimusRS; BTE Technologies, CO) for maximal isometric contraction. With the knee positioned at 60 of flexion, a set of 2 maximal isometric quadriceps contractions (4 s each) were performed at each measurement time point. The highest peak force was calculated by multiplying the averaged data from the 2 trials, which was then normalized by body mass (Nm/kg). The incidences
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of falls and nerve injury were evaluated during the hospital stay and at each follow-up visit. We compared the primary and secondary outcomes between the ACB and FNB groups. Continuous variables were analyzed using Student's t-test or the Wilcoxon signed-rank test. The chi-squared test or Fisher's exact test was used to determine the statistical significance of differences in the categorical variables. Statistical analyses were performed using SPSS for Windows (version 21.0; IBM Corporation, Armonk, NY). Results Patients did not perceive differences in pain level between the knees that underwent TKAs using different PNBs. The mean pain VAS scores were similar in both knees during the entire study period, including 12 and 24 h, and 2, 3, and 7 days postoperatively (P > .1 in all comparisons with the exception of postoperative 2 days [P ¼ .069]) (Fig. 2). Knees in the ACB group showed superior quadriceps recovery compared to knees in the FNB group during the first 24-48 h after TKA. More knees in the ACB group were able to perform SLR and knee extension while sitting during the first 24 h (P < .01 in all comparisons during the first 24 h) (Fig. 3). In addition, patients in the ACB groups could raise their legs longer with greater quadriceps strength during the first 24-48 h (Table 2). However, ROM during the entire study period (P > .1 in all comparisons) (Table 2) and the maximal isometric quadriceps contraction at postoperative 1 week (92.8 ± 55.9 Nm in ACB vs 99.6 ± 54.9 Nm in FNB, P ¼ .544) were not different. There was no fall episode or nerve injury in both groups during the entire study period. Discussion There has been recent emphasis on faster recovery during the early postoperative period after TKA. Although numerous studies indicate that ACB provides comparable analgesic efficacy and facilitates earlier mobilization by sparing the strength of the quadriceps compared with FNB, the question of whether ACB is more appropriate for the current pain management protocol during TKA remains controversial. Thus, we aimed to determine whether ACB offers superior pain relief and quadriceps recovery for FNB. This study sought to determine whether patients perceived differences in pain level between knees and how different patients experience
Fig. 2. The pain levels according to the VAS during the first 7 days after surgery are shown. No between-group differences were observed during the entire study period. PO, postoperative.
Fig. 3. Bar graph showing the prevalence of knees that was able to perform SLR (A) and extend the knee while sitting (B). A higher proportion of knees in the ACB group performed SLR and knee extension during the first 24 h after TKA. PO, postoperative.
quadriceps recovery with ACB and FNB after undergoing same-day bilateral TKA. Patients did not perceive any difference in pain level between knees that had received either ACB or FNB for TKA. In this study, no between-group differences in pain levels were observed at all time points during the entire study period. The results of this study are in agreement with recent multiple reports of comparable pain levels between ACB and FNB [16-20,22,23,25,27-31,39]. However, our findings do not concur with the only simultaneous bilateral randomized study reporting superior qualitative pain relief in FNB compared with ACB 24 h after TKA [21]. The reasons why FNB provided better qualitative analgesia are unclear, but this finding may be the result of a synergistic effect from neuroaxial analgesia in the previous study. In that study, the authors maintained epidural PCA containing bupivacaine and opioid for 2 days after TKA following a combined spinal-epidural anesthesia, which may affect the quality of analgesia. In contrast, we performed general anesthesia in all patients to avoid such confounding factors. On the other hand, our findings indicate that single-shot ACB can offer satisfactory pain relief after TKA. Although one previous study reported that continuous ACB offered better analgesia compared with single-shot ACB [40], patients experienced tolerable postoperative pain during ambulation without indwelling catheter, which may impair the early postoperative rehabilitation. The findings of this study, together with those of the previous studies, suggest that single-shot ACB can be a reasonable analgesic modality when incorporated into current multimodal pain management protocols.
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Table 2 Duration of SLR, Grade of Motor Strength, and ROM in the ACB and FNB Groups.a Time Points
Duration of SLR (s) ACB
Preoperative PO 6 h PO 12 h PO 24 h PO 2 d PO 3 d PO 1 wk PO 2 wk PO 6 wk
10 2.3 4.8 6.5 9.3 10.0 10 10 10
(3.9) (4.6) (3.3) (1.5) (0.3)
ROM ( )
Grade of Motor Strength
FNB
Significance
ACB
FNB
Significance
ACB
10 0.4 1.0 3.0 8.5 9.9 10 10 10
1.000 <0.01 <0.01 <0.01 0.014 0.383 1.000 1.000 1.000
5 3.2 3.7 4.1 4.9 5 5 5 5
5 2.5 2.8 3.5 4.7 5 5 5 5
1.000 <0.01 <0.01 0.022 0.278 1.000 1.000 1.000 1.000
114.2 84.4 90.0 94.0 103.6 112.2 118.3 122.4 125.1
(1.7) (2.5) (2.9) (1.6) (0.8)
(1.1) (1.3) (1.0) (0.4)
(0.8) (1.1) (1.4) (0.7)
FNB (12.9) (8.1) (7.8) (6.1) (6.9) (8.2) (9.2) (6.3) (4.2)
112.6 84.2 89.8 93.8 103.4 112.4 119.0 123.3 125.9
Significance (17.0) (8.6) (8.0) (6.4) (7.5) (8.2) (9.1) (5.1) (4.2)
0.602 0.908 0.899 0.872 0.89 0.903 0.687 0.425 0.369
PO, postoperative; SD, standard deviation. a Data are presented as means (SD).
Patients experienced superior quadriceps recovery in knees that received ACB during the first 48 h after TKA, but ACB did not have any significant advantage over FNB after postoperative 48 h. In this study, the prevalence of SLR and knee extension while sitting was higher and knees that received ACB performed SLR for longer time and with greater strength compared with those that received FNB during the first 2 days after TKA. However, no between-group differences were observed in the quadriceps recovery 2 days after TKA, in ROM during the entire study period, or in the maximal isometric quadriceps strength at postoperative 1 week. These findings concur with multiple previous reports that ACB provided superior quadriceps recovery within the first 2 days after TKA [16,17,19,22,23,25,27-31,39,41-43]. However, the results of our study do not concur with 2 previous studies reporting comparable functional recovery between ACB and FNB [21,26]. The reason why quadriceps recovery was comparable between ACB, which provides a primary sensory block, and FNB, which provides a motor block, in those studies is unclear, but this may be the result of concomitant anesthetic or analgesic modalities that might affect motor recovery. One of the 2 studies involved sciatic nerve block in all patients, with ACB or FNB added randomly [26], while continuous epidural PCA was maintained in the other study during the first 2 days [21]. The data from this study, together with those of previous studies, suggest that ACB can facilitate postoperative rehabilitation while sparing the quadriceps strength. In addition, ACB seems to be more appropriate for a contemporary postoperative protocol following TKA, especially with same-day bilateral TKA that involves both knees compared with FNB. However, as the functional recovery of the quadriceps may be affected by concomitant pain management modalities, surgeons should take into account the motor involvement of each analgesic modality when establishing postoperative rehabilitation protocols specific to each patient after TKA. This study has several limitations. First, because we evaluated only Korean patients, the demographic characteristics should be noted before extrapolating to other populations. Ninety-eight percent (49/50) of this cohort were women and this female dominance is well documented in Korean patients for an unknown reason [1,44,45]. Second, a control group which received all analgesic modalities except PNB would be helpful to establish a baseline function level and an additional analgesia of PNB. However, as we mainly focused on the patient's perception of the difference between ACB and FNB in a single patient, we could not assess the outcomes of patients who did not receive PNB in this study. In addition, multiple previous studies well documented that each PNB provided a significant additional analgesia in patients who received current multimodal pain management [10,11,25]. Third, this study could not determine whether the difference in PNB affected the length of hospital stay after TKA. Although most patients who undergo TKA are admitted for 1-3 days in the United States, all
patients in this study were admitted for 14 days after surgery, which is the standard practice in our medical system [34,46]. As the length of hospital stay after TKA would be influenced by the overall healthcare system in each country, this finding may not be widely generalizable. However, information in this study would be valuable, because the length of hospital stay would not be a critical factor affecting the pain level after surgery, and 14-day admission can be rather helpful in performing precise evaluation of the pain level in patients. Fourth, although multimodal pain management is considered the standard pain management protocol after TKA, we did not employ epidural anesthesia or additional pain relieving modalities such as periarticular injection, because we wanted to avoid confounding factors that might affect pain relief after TKA. We anticipated that the addition of these modalities would make it more difficult for the patient to perceive the differences between the 2 approaches. However, this should be considered before extrapolating our findings to other postoperative pain management protocols. Fifth, as each patient received ACB or FNB on each knee, we could not determine how much the difference in PNB affected opioid consumption and its related side effects on the timed upand-go test, ambulation distance, and fall episode in this study. Finally, this study could not determine whether the difference in PNB affected patient-reported outcome measures such as patient satisfaction or side preference. However, previous clinical trials and meta-analyses with comparison between ACB and FNB reported that superior pain relief and functional recovery limited to the early postoperative period did not affect patient-reported outcome measures [21,26,30,31]. Despite these limitations, this simultaneous randomized bilateral trial provides valuable information regarding pain relief and functional recovery between ACB and FNB in patients who undergo TKA.
Conclusion This study demonstrates that patients who undergo same-day bilateral TKA do not perceive any difference in pain levels between knees that undergo either ACB or FNB. However, patients experience superior quadriceps recovery during the first 2 days after TKA. Based on current trends in perioperative protocols toward early mobilization following TKA, ACB seems to be a more appropriate PNB option compared with FNB as part of a current multimodal pain management protocol after TKA.
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