- Email: [email protected]
Is Adductor Canal Block Better Than Femoral Nerve Block in Primary Total Knee Arthroplasty? A GRADE Analysis of the Evidence Through a Systematic Review and Meta-Analysis
Accepted Manuscript Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis Ming-jie Kuang, Jian-xiong Ma, Lin Fu, Wei-wei He, Jie Zhao, Xin-long Ma PII:
S0883-5403(17)30421-7
DOI:
10.1016/j.arth.2017.05.015
Reference:
YARTH 55882
To appear in:
The Journal of Arthroplasty
Received Date: 22 December 2016 Revised Date:
26 April 2017
Accepted Date: 8 May 2017
Please cite this article as: Kuang M-j, Ma J-x, Fu L, He W-w, Zhao J, Ma X-l, Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis, The Journal of Arthroplasty (2017), doi: 10.1016/ j.arth.2017.05.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis
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Ming-jie Kuanga,b, *, Jian-xiong Ma a, *, Lin Fu a,b,*, Wei-wei Hea,b, Jie Zhaoa, Xin-long Maa,b *These authors contributed equally to this work. a
Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin 300050, People's
Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052,
People's Republic of China
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Republic of China
Corresponding author: Xin-long Ma, Tianjin Hospital, Tianjin 300211, China, e-mail ： [email protected], phone number: +86-13602179865. Email
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Name
[email protected]
Jian-xiong Ma
[email protected]
Jie Zhao
[email protected]
[email protected]
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Weiwei He
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Ming-jie Kuang
Lin Fu
[email protected]
Xin-long Ma
[email protected]
ACCEPTED MANUSCRIPT Abstract: Background: Total knee arthroplasty (TKA) is associated with intense postoperative pain with a need for early ambulation to gain function and prevent postoperative
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complications. Compared with femoral nerve block (FNB), adductor canal block (ACB) can relieve postoperative pain and preserve quadriceps muscle strength. This
pain relief and function recovery following TKA.
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meta-analysis was conducted to investigate which analgesic method provides better
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Method: We conducted a meta-analysis to identify relevant randomized controlled trials (RCTs) involving ACB and FNB after TKA in electronic databases, including Web of Science, Embase, PubMed, and the Cochrane Library, up to November 2016. Finally, nine RCTs involving 609 patients (668 knees) were included in our study.
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Review Manager Software and GRADE (Grading of Recommendations Assessment, Development and Evaluation) profiler were used to perform the meta-analysis. Results: Compared with FNB, ACB resulted in better quadriceps muscle strength and
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mobilization ability. There were no significant differences in the visual analogue scale
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(VAS) at rest, VAS with mobilization, rescue opioid consumption, patient satisfaction, and length of hospital stay. Conclusions: Compared with FNB, ACB shows similar pain control after TKA. However, ACB can better preserve quadriceps muscle strength and improve mobilization ability. In conclusion, ACB showed better functional recovery after TKA without compromising pain control. Therefore, ACB is recommended as an alternative analgesic method for early ambulation after TKA.
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Keywords: adductor canal block, femoral nerve block, total knee arthroplasty
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Is adductor canal block better than femoral nerve block in primary total knee
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arthroplasty? A GRADE analysis of the evidence through a systematic
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review and meta-analysis
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Abstract:
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Background: Total knee arthroplasty (TKA) is associated with intense
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postoperative pain with a need for early ambulation to gain function and
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prevent postoperative complications. Compared with femoral nerve block
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(FNB), adductor canal block (ACB) can relieve postoperative pain and
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preserve quadriceps muscle strength. This meta-analysis was conducted to
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investigate which analgesic method provides better pain relief and function
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recovery following TKA.
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Method: We conducted a meta-analysis to identify relevant randomized
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controlled trials (RCTs) involving ACB and FNB after TKA in electronic
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databases, including Web of Science, Embase, PubMed, and the Cochrane
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Library, up to November 2016. Finally, nine RCTs involving 609 patients
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(668 knees) were included in our study. Review Manager Software and
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GRADE (Grading of Recommendations Assessment, Development and
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Evaluation) profiler were used to perform the meta-analysis.
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Results: Compared with FNB, ACB resulted in better quadriceps muscle
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strength and mobilization ability. There were no significant differences in the
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visual analogue scale (VAS) at rest, VAS with mobilization, rescue opioid
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consumption, patient satisfaction, and length of hospital stay.
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Conclusions: Compared with FNB, ACB shows similar pain control after
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TKA. However, ACB can better preserve quadriceps muscle strength and
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improve mobilization ability. In conclusion, ACB showed better functional
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recovery after TKA without compromising pain control. Therefore, ACB is
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recommended as an alternative analgesic method for early ambulation after
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TKA.
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Keywords: adductor canal block, femoral nerve block, total knee
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arthroplasty
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Introduction
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An increasing number of total knee arthroplasties (TKAs) are performed
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because of end-stage knee osteoarthritis and rheumatoid arthritis [1]. Usually,
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TKA is associated with intense early postoperative pain and a need for early
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ambulation to regain function and prevent postoperative complications [2].
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Femoral nerve block (FNB) techniques are considered preferred methods to
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deliver post-operative analgesia and to minimize postoperative pain in TKA
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patients [3]. However, some recent studies reported that continuous blockade
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of the femoral nerve may result in weakness of the quadriceps muscle and
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therefore increases the risk of falling during early ambulation [4-6]. Thus far,
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the management of early postoperative pain following TKA has not been
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optimized to improve quadriceps muscle strength without compromising
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analgesia dosage [7].
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Adductor canal block (ACB) is a relatively new technique that has been
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successfully used for early postoperative pain control after TKA without
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weakening quadriceps muscle strength [8]. Recently, an anatomical study of
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the adductor canal showed that both the saphenous nerve and the nerve to the
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vastus medialis contribute to the innervation of the knee joint and are distal
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to the quadriceps motor branches [9]. Thus, ACB can relieve postoperative
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pain while preserving quadriceps muscle strength.
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double-blind randomized controlled trial (RCT) in healthy volunteers
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A prospective
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demonstrated that ACB reduced quadriceps strength by only 8% compared
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with 49% using FNB [8]. In addition, several studies reported that ACB
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preserved quadriceps muscle strength better than FNB in patients undergoing
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TKA [10-13]. However, there are no consistent conclusions on which of the
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two techniques leads to better function recovery after TKA. Some studies [12,
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14] showed that ACB improve postoperative motor function after TKA;
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however, others drew different conclusions and reported that ACB provides
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equivalent ambulation ability compared with FNB [15, 16]. A meta-analysis
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conducted by Li et al[17] showed that ACB provided better ambulation
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ability, faster functional recovery and better pain control at rest after TKA
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than FNB. However, the authors included a wide variety of studies that were
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not applicable to the meta-analysis. For example, the meta-analysis included
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reports by Kwofie et al [18] and Jaeger et al [19], which focus on the
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influences to the quadriceps strength of health volunteers without TKAs.
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Therefore, the results of meta-analysis were limited and inaccurate.
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To achieve a fast functional recovery and early ambulation after TKA, it is
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necessary to choose an optimal anesthetic technique. Therefore, to
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investigate which anesthetic technique provided better pain relief, we
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performed a meta-analysis to evaluate evidence from all available RCTs that
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compared ACB with FNB for patients undergoing primary TKA and to
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propose recommendations for clinicians using the GRADE (Grading of
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Recommendations, Assessment, Development and Evaluation) system.
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Materials and methods
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Search strategy
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This systematic review and meta-analysis was prospectively registered on
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PROSPERO (International prospective register of systematic reviews) and
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the registration number was CRD42016051316 (Supplemental PDF). The
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PRISMA guidelines[20], GRADE system[21] and Cochrane Handbook[22]
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were applied to assess the quality of the results published in all included
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studies to make sure the results of our meta-analysis reliable and veritable.
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We conducted a meta-analysis to identify relevant RCTs involving ACB and
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FNB after TKA in electronic databases including Web of Science, Embase,
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PubMed, the Cochrane Controlled Trials Register, and the Cochrane Library
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up to November 2016. Only RCTs performed on human beings is included.
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The search strategy was presented in Supplemental table 2. Flow chart of
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the trial selection process was presented in Fig 1. In addition, we also
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conducted other databases according to the Cochrane Collaboration
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guidelines.
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Inclusion criteria
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Included studies were considered eligible if they met the PICOS criteria as
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follows:
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Population: Patients were scheduled for primary TKA;
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Intervention: ACB;
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Comparator: FNB;
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Outcomes: The primary outcomes included the following: visual analogue
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scale [23] (VAS) pain score at rest and VAS pain score after mobilization (8
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h, 24 h, 48 h). VAS pain score, which consisted of a scale from 0 (no pain) to
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10 (worst imaginable pain), was used to evaluate pain control. Secondary
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outcomes contained the following: timed up and go (TUG) test [24], which is
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a method to evaluate mobilization ability; quadriceps muscle strength;
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adductor muscle strength; opioid consumption (all opioids given were
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converted to morphine equivalents at 8, 24 and 48 h); the length of the
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hospital stay (days) and patient satisfaction. Patient satisfaction was
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evaluated using a ten-point scale from 0 (completely unsatisfied) to 10
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(totally satisfied) [16]
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Study design: Interventional studies (RCTs);
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Only published clinical studies were included; the included studies were
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required to contain at least one outcome. Only studies published in English
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were included. The studies must have had a follow up rate of at least 80%,
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and at least two main patient-important outcomes had to be included. Two
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authors had to have assessed the eligible studies independently. In cases of
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disagreement, a consensus was reached through discussion between two
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authors.
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Exclusion criteria included observational studies, non-RCTs, review articles,
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studies with a sample size < 50 and studies with insufficient outcome data.
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Data extraction
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We used a standard data extraction form to retrieve the relevant data from
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eligible articles. The extracted data included authors, study location, sample
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size, study design, publishing date, gender, population, age, duration of
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follow-up, interventions, dosages and type of anaesthesia, and outcomes. If
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necessary, we contacted the corresponding authors of the included RCTs to
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make sure the information was integrated and to get any missing data. Two
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reviewers extracted the data independently. If there were disagreements
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between two authors, consensus were reached through discussion.
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Risk of bias and quality assessment
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According to the Cochrane Handbook for Systematic Reviews of
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Interventions, the methodological quality and basis of the included literature
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were assessed as follows: randomization, allocation concealment, blind
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method, selective reporting, group similarity at baseline, incomplete outcome
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data, compliance, timing of outcome assessments, and intention-to-treat
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analysis (Fig 2 and Fig 3).
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Assessment of reporting bias
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A funnel plot was used to assess the existence of reporting bias. We
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evaluated whether asymmetry was due to publication bias or to a relationship
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between trial size and effect size.
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Dealing with missing data
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In cases of incomplete and missing data, we contacted the corresponding
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authors of the included studies to make sure the information integrated. All
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the data was presented as the form of mean ± standard deviation (SD) in our
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meta-analysis. If the data were reported as median and interquartile range
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(IQR), we assumed that the median was equivalent to the mean and that the
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width of the IQR was equivalent to 1.35 times the SD. When data were
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reported in a graph, means ± SD was estimated by Get Data software. All the
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methods mentioned above to calculate the means ± SD on the basis of the
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Cochrane Handbook for Systematic Reviews.
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Statistical analysis and data synthesis
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Meta-analyses was performed with Review Manager Software for Windows
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(Version 5.3. Copenhagen: The Nordic Cochrane Centre, the Cochrane
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Collaboration, 2014). The mean difference (MD) or standard mean
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difference (SMD) was used to assess continuous outcomes such as VAS
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score, rescue opioid consumption, TUG test, and quadriceps muscle strength,
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with a 95% confidence interval [CI]. Relative risks (RR) with a 95% CI were
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used to assess dichotomous outcomes. The inverse variance and Mantel–
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Haenszel methods were used to combine separate statistics. If P values were
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less than 0.05, the results were considered statistically significant.
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GRADE the evidence
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GRADE system was used to evaluate the quality of the evidence for each
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outcome [21]. GRADE profiler (Version 3.6.1) was used to evaluate the
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evidence regarding included outcomes. Initially, RCTs were considered as
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being of high confidence in estimating an effect, and observational studies
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were considered as being of low confidence in estimating an effect. Reasons
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that may decrease the level of confidence include risk of bias, inconsistency,
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indirectness, imprecision, and publication bias. Reasons that may raise the
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level of confidence include large effect, dose response, and all plausible
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residual confounding and bias. The GRADE evidence was divided into the
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following categories: (1) High-quality evidence, which indicated that further
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research was unlikely to change the confidence in an estimate of effect; (2)
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Moderate-quality evidence, which indicated that further research was likely
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to have an important impact on confidence in an estimate of effect and may
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change the estimate; (3) Low-quality evidence, which indicated that further
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research was likely to have an important impact on confidence in an estimate
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of effect and was likely to change the estimate; (4) Very low-quality
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evidence, which indicated that we were very uncertain about the results. The
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results of the GRADE analysis are presented in Supplemental table 2.
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Investigation of heterogeneity
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Statistical heterogeneity of the included studies was evaluated using
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chi-square test in accordance with the values of P and I2. If the I2 < 50% and
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P > 0.1, the heterogeneity might not be important. A fixed-effects model was
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used to assess the outcomes. If I2 was between 50% to 100%, it may
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represent substantial heterogeneity. We used random-effects model to
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evaluate these outcomes. Thresholds for the interpretation of I2 can be
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misleading, since the importance of inconsistency depends on several factors.
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Therefore, subgroup analysis was performed to interpret the potential source
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of heterogeneity.
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Results
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Excluded studies and search results
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Initially, a total of 212 citations were identified from electronic journals
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databases, of which 137 records were removed by primary screening
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according to the title and abstract. After reading the full text of 75 remaining
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studies in detail, 63 studies that did not meet the inclusion criteria were
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excluded. Among 12 RCTs, two studies [18, 19] focused on the influences to
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the quadriceps strength of health volunteers rather than TKAs. The control
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group was placebo rather than FNB in another study [25]. Finally, 9 RCTs
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[10-13, 15, 16, 26-28] with 609 patients (668 knees) that compared ACB
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with FNB were included in our meta-analysis. All the included studies were
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published between 2013 and 2016. The characteristics of 9 included studies
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were summarised in Table 1.
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The sample size of each RCT ranged from 42 to 98. The American Society of
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Anesthesiologists grade[29] was presented in three studies[11, 12, 15]. The
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proportion and combination of anaesthetics were different in included studies
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(Table 1). Only two studies [11, 15] used bupivacaine as the study
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medication, and ropivacaine was used in other articles. Two studies [10, 26]
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reported that outcome assessors and clinical personnel were blinded. All
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articles except Zhang[27] reported the random sequence generation. All
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included studies reported outcomes of more than 95% of participants.
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Risk of bias in included studies
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Randomization
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Eight included studies[10-13, 15, 16, 26, 28] clearly reported the random
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sequence generation, which indicated that a low risk of selection bias in
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these studies. Only one study[27] did not describe the randomization process.
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Therefore, the selection bias in this study was unclear.
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Allocation concealment
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Allocation concealment was considered to be adequate in eight studies[10-13,
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15, 16, 26, 28], and unclear in the other study [27], given that authors did not
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provide the allocation information in this study.
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Blinding method
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The blinding method can be divided into two parts: blinding of outcome
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assessment (detection bias) and blinding of the participants and personnel
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(performance bias). Seven studies[10, 11, 13, 15, 16, 26, 28] were
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double-blinded and were rated as having low-risk detection and performance
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bias. One study[12] did not report the blinding method and was rated as
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having high-risk detection and performance bias. Zhang et al[27] reported
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that only blind outcome assessment was used but did not clearly describe the
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method used. Therefore, the study was rated as having unclear-risk detection
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bias and high-risk performance bias [27].
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Selective reporting
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All nine included studies[10-13, 15, 16, 26-28] showed that all main
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outcomes were presented in the protocol and were considered at low risk of
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reporting bias.
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Group similarity at baseline
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Results (e.g. age, weight, male/female etc.) of ACB and FNB were similar at
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baseline for each study.
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Intention-to-treat analysis (ITT)
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Only five included studies reported the ITT [10, 11, 15, 16, 28]. The
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remaining studies showed an unclear[12, 13, 26] and high[27] risk of bias.
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Incomplete outcome data
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All the studies presented complete data and was considered at a low risk bias
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for this criterion.
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Compliance
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Risk of bias was unclear in all included studies because compliance was not
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monitored in the control group.
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Timing of outcome assessments
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Risk of bias was low because all important outcome assessments for all
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intervention groups were measured at the same time.
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Publication bias
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Publication bias was also evaluated using a funnel plot diagram
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(Supplemental Fig 1). The diagram was symmetrical, indicating low risk of
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publication bias.
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Other bias
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Further risks of bias was found in included studies. However, we cannot
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ignore other potential risk of biases. Therefore, we rated as having
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unclear-risk of other bias.
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Results of meta-analysis
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Primary outcomes
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(1) VAS score at rest
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Five studies assessing 418 knees reported VAS scores at rest within 8 hours
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post-operatively. There was no significant difference between the ACB and
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FNB groups (MD=0.13, 95%CI: [-0.15, 0.41], P=0.35; Fig 4). VAS score at
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24 hours post-operatively was reported in seven studies, and a total of 521
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knees were involved in the meta-analysis. No significant differences were
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found between the two groups (MD=-0.01, 95%CI: [-0.55, 0.53], P=0.97;
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Fig 4). Six studies involving 473 knees reported the VAS score at 48 hours.
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Meta-analysis showed no significant differences between the ACB and FNB
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groups (MD=-0.06, 95%CI: [-0.15, 0.03], P=0.23; Fig 4).
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(2) VAS score with mobilization
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Data from three studies assessing 227 knees reported the VAS score with
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mobilization within 8 hours. The ACB group reported a similar pain score
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with mobilization within 8 hours compared to the FNB group (MD=-0.15,
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95%CI: [-0.39, -0.09], P=0.21; Fig 4). A meta-analysis was conducted of
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seven studies involving a total of 511 knees to evaluate the VAS score with
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mobilization at 24 and 48 hours post-operatively. However, the results of the
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meta-analysis revealed no significant differences between ACB and FNB
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groups at 24 hours (MD=0.23, 95%CI: [-0.20, 0.66], P=0.30; Fig 4) and 48
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hours (MD=-0.07, 95%CI: [-0.17, 0.03], P=0.18; Fig 4) post-operatively.
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Secondary outcomes
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Two methods were used to evaluate quadriceps muscle strength. Three
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authors[10, 13, 28] evaluated quadriceps muscle strength as maximum
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voluntary isometric contraction[30] (MVIC) using a handheld dynamometer.
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A manual muscle test[31] (MMT) with a standardised 0–5 motor strength
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scale was used in four studies[15, 16, 26, 27].
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(1) Quadriceps muscle strength (MMT)
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Four studies involving 282 knees reported the quadriceps muscle strength as
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measured by MMT at 8 hours, 24 hours and 48 hours. The pooled data
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showed significant differences at 8 hours (MD=0.71, 95%CI: [0.05, 1.37],
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P=0.04; Fig 5), at 24 hours (MD=0.68, 95%CI: [0.05, 1.31], P=0.03; Fig 5)
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and 48 hours (MD=0.67, 95%CI: [0.03, 1.31], P=0.04; Fig 5).
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(2) Quadriceps muscle strength (MVIC)
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Meta-analysis showed that the quadriceps muscle strength measured by
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MVIC at 24 hours in the ACB group was much greater than that in the FNB
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group (MD=75.65, 95%CI: [28.49, 122.81], P=0.002; Fig 5).
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(3) Adductors muscle strength (MVIC)
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MVIC was also used to evaluate adductor muscle strength. Two studies
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assessing 97 knees reported adductor muscle strength at 24 hours
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post-operatively. There was no significant difference between the ACB and
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FNB groups (MD=-19.2, 95%CI: [-44.67, 6.26], P=0.14; Fig 5).
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(4) TUG test
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The TUG test was conducted in four studies involving a total of 348 knees to
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evaluate mobilization ability. Significant differences were found between the
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ACB and FNB groups at 24 hours (MD=-11.63, 95%CI: [-21.72, -1.53],
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P=0.02; Fig 5) and 48 hours (MD=-9.63, 95%CI: [-18.3, -0.96], P=0.03; Fig
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5).
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(5) Opioid consumption
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Opioid consumption was reported in four of the included studies, and a total
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of 252 knees were involved in the meta-analysis. The pooled data showed no
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significant difference between ACB and FNB groups at 8 hours (MD=1.64,
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95%CI: [-2.66, 5.94], P=0.45; Fig 6), 24 hours (MD=0.13, 95%CI: [-5.32,
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5.57], P=0.96; Fig 6) and 48 hours (MD=5.19, 95%CI: [-1.94, 12.33],
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P=0.15; Fig 6).
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(6) Patient satisfaction
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A meta-analysis examined four studies (315 knees) to assess post-operative
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patient satisfaction. No significant differences were discovered between
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ACB and FNB groups at 8 hours (MD=0.17, 95%CI: [-0.09, 0.43], P=0.20;
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Fig 6), 24 hours (MD=-0.41, 95%CI: [-0.90, 0.08], P=0.10; Fig 6) and 48
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hours (MD=0.02, 95%CI: [-1.84, 1.88], P=0.98; Fig 6).
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(7) Length of hospital stay
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Two studies with 191 patients reported the length of hospital stay. There
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were no significant differences between the ACB and FNB groups
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(MD=-0.38, 95%CI: [-1.30, 0.54], P=0.42; Fig 6).
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Discussion
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TKA is one of the most commonly treated osteoarthritis in older adults, and
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the prevalence of this operation will continue to rise as the population ages.
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The pain following TKA may be a major concern despite the successful
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recovery of function in the patient. Yet, to date, no clear standard is known
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for pain control after TKA. An optimal analgesic technique for TKA should
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be based on early ambulation and lasting symptom improvement without
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severe complications, including muscle weakness, nerve damage, and
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infection. Both ACB and FNB have proven to be safe and effective technique
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for pain management after TKA. Some recent published studies have
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reported that FNB is associated with delayed ambulation [10] and risk of
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falling [32]. However, Elkassabany et al did not detect a significant reduction
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in fall risk when comparing ACB with FNB [26]. Therefore, the aim of the
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present systematic review and meta-analysis was to evaluate the efficacy of
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ACB and FNB in postoperative pain control and recovering ambulation
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ability. Our findings demonstrated that ACB presents similar pain control
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compared with FNB. However, ACB can better preserve quadriceps muscle
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strength and improve mobility. In conclusion, ACB showed better functional
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recovery after TKA without compromising pain control.
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A previous meta-analysis demonstrated that their ACB group had lower VAS
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at rest during the early post-operative period compared to their FNB group
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[17]. However, according to our meta-analysis, ACB groups present similar
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VAS scores at rest after TKA compared with FNB groups, at 8 hours, 24
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hours and 48 hours. Several RCTs [10, 13, 15] also reported that VAS scores
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at rest were similar between ACB and FNB groups. This result was
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consistent with our findings. In the included studies, statistical heterogeneity
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was found in VAS at 8 hours and 24 hours. Thus, a random-effects model
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was performed to evaluate the results. Subgroup analysis was carried out for
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the VAS score at rest to determine the source of heterogeneity (Table 2).
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Factors such as local anesthetic volume, race, tourniquet use, age, and type
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of catheter caused significant heterogeneity. Because of the inconsistency
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caused by very serious heterogeneity, the quality of evidence regarding VAS
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at rest with 8 hours and 24 hours was low. However, the evidence regarding
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VAS at rest at 48 hours was of high quality. Furthermore, all the included
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studies were RCTs of high quality. Therefore, the overall quality of evidence
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and effect estimate regarding VAS at rest was reliable.
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In addition, our meta-analysis failed to find any significant difference for
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VAS score with mobilization at 8 hours, 24 hours and 48 hours between the
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ACB and FNB groups. However, the VAS score with mobilization at 8 hours
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was found to be slightly lower in the ACB group than in the FNB group.
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Several recent published studies reported that the VAS score with
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mobilization was similar between both groups during post-operative days 0
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to 2 [13, 15, 16, 26]. These findings are consistent with our meta-analysis.
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Therefore, ACB provides equally effective pain relief for patients after TKA
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compared with FNB.
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Opioid analgesics are often used to relieve postoperative pain for patients
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who have undergone TKA. Usually, rescue opioids are used for breakthrough
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postoperative pain based on patients’ reported VAS scores (VAS>7 points)
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[33]. In our meta-analysis, rescue opioid consumption also did no differ
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between the two groups within 48 hours. A retrospective study showed that
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opioid consumption in patients with ACB was not significantly different
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from patients receiving FNB within 48 hours [34]. A study presented by
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Shah et al[12] also reported the same conclusions. Because of the small
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sample size, the validity of the results regarding rescue opioid use in the
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ACB and FNB groups is limited. However, the quality of evidence was
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moderate, and the conclusion was reasonable.
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Quadriceps muscle strength has a great impact on the ability to ambulate.
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The results of our meta-analysis showed that quadriceps muscle strength was
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much greater in the ACB group than in the FNB group. However, the quality
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of evidence was low according to the GRADE system, and we could not
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confidently draw conclusions about this result. Several prospective studies
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comparing ACB and FNB in healthy volunteers [8, 35] and TKA patients[16,
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26] have suggested that the loss of quadriceps muscle strength in ACB
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groups is significantly lower than placebo or that in FNB groups. Moreover,
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Grevstad et al[36] reported that no statistically significant differences were
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found between local anesthetic volume (ACB) and effects on quadriceps
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muscle strength in healthy volunteers. Together, these findings demonstrated
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that ACB can preserve quadriceps strength. More RCTs with larger sample
388
sizes are needed to verify our conclusions. Our meta-analysis failed to find
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any significant difference between ACB and FNB groups regarding adductor
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muscle strength, indicating that ACB does not reduce adductor muscle
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strength. However, Jenstrup et al[37] reported that ACB may block the nerve
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to the vastus medialis and thereby affect muscle strength. Grevstad et al
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demonstrated a positive correlation between local anesthetic volume and
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effects on the vastus medialis muscle [36]. Meanwhile, because of the small
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sample size and heterogeneity, the quality of evidence was very low. The
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effect estimate was uncertain and had a lower GRADE recommendation
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strength. The TUG test evaluates ambulation ability by measuring the time a
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patient takes to stand up from a chair, walk a distance of three meters without
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any support, and return to the chair [12]. The results of our meta-analysis
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reported that the TUG test result in the ACB group was better than that in the
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FNB group at 24 hours and 48 hours. Hanson et al [25] reported that ACB
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for TKA resulted in better ambulation ability than placebo during the first 48
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hours.
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significant differences were found in motor function between ACB and FNB
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groups. Therefore, we confirmed that ACB was better than FNB in terms of
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enhancing mobilization ability after TKA.
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According to the results of our meta-analysis, patient satisfaction score
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within 48 hours and length of the hospital stay in the two groups were similar.
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Similarly, a study presented by Memtsoudis[15] showed that
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Since patient satisfaction is a subjective scale, it can easily be affected by
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subjective factors. Length of hospital stay was affected by multiple factors,
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including sex, age, and the physiological status of the patients. Prolonged
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hospitalization may cause serious complications, including urinary system
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infection, muscle atrophy, and deep vein thrombosis. Furthermore, cost
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increases greatly with prolonged hospitalization. Kim et al[11] reported side
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effects of pain management, such as nausea, vomiting and pruritis; however,
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there were no significant differences between their ACB and FNB groups.
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Our systematic review and meta-analysis has the following limitations: (1)
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Only nine studies were included in our meta-analysis; if more RCTs had
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been included, the test power for our analysis would have been greater. (2)
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We evaluated only the immediate effects within 48 hours after TKA; the
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included studies tell us nothing about the duration of the effects or whether
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these effects lead to better long-term functional outcomes. Therefore, a
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long-term follow-up study is needed to investigate functional outcomes. (3)
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Only English publications were included in our meta-analysis. (4)
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Heterogeneity among the included studies was unavoidable because of racial
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differences, age differences, and differences in the tourniquet use, mode of
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anesthesia, and type of catheter used.
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Conclusions
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Compared with FNB, ACB shows similar pain control after TKA. ACB can
430
better preserve quadriceps muscle strength and improve mobilization ability.
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In conclusion, ACB resulted in better functional recovery after TKA without
432
compromising pain control. Therefore, concerning the early ambulation after
433
TKA, ACB is recommended as an alternative analgesic method.
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Conflict of interest
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No conflict of interest exits in the submission of the manuscript, and the
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manuscript has been approved for publication by all authors.
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Williams R, Hughes C, Mariano ER, Liu J. The Risk of Falls After Total Knee Arthroplasty with the Use of a Femoral Nerve Block Versus an Adductor Canal Block: A Double-Blinded Randomized Controlled Study. Anesth Analg, 2016 27. Zhang W, Hu Y, Tao Y, Liu X, Wang G. Ultrasound-guided continuous adductor canal
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29. Owens WD, Felts JA, Spitznagel EL, Jr. ASA physical status classifications: a study of 30. Stark T, Walker B, Phillips JK, Fejer R, Beck R. Hand-held dynamometry correlation
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31. Sapega AA. Muscle performance evaluation in orthopaedic practice. J Bone Joint Surg Am 72(10): 1562, 1990
32. Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth
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Analg 111(6): 1552, 2010
33. Huskisson EC. Measurement of pain. Lancet 2(7889): 1127, 1974 34. Ardon AE, Clendenen SR, Porter SB, Robards CB, Greengrass RA. Opioid consumption in total knee arthroplasty patients: a retrospective comparison of adductor canal and femoral nerve continuous infusions in the presence of a sciatic nerve catheter. J Clin Anesth 31: 19,
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35. Kwofie MK, Shastri UD, Gadsden JC, Sinha SK, Abrams JH, Xu D, Salviz EA. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps
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36. Grevstad U, Jaeger P, Sorensen JK, Gottschau B, Ilfeld B, Ballegaard M, Hagelskjaer M, Dahl JB. The Effect of Local Anesthetic Volume Within the Adductor Canal on Quadriceps Femoris Function Evaluated by Electromyography: A Randomized, Observer- and Subject-Blinded, Placebo-Controlled Study in Volunteers. Anesth Analg, 2016 37.
Lund
J,
Jenstrup
MT,
Jaeger
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JB.
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adductor-canal-blockade for adjuvant post-operative analgesia after major knee surgery: preliminary results. Acta Anaesthesiol Scand 55(1): 14, 2011
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Table 1 . The characteristics of included studies ACB group/FNB group
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(mean)
(% male)
63/65
71/61
ASA grade(cases) Ⅰ
Ⅱ
N/A
N/A
Ⅲ
Anesthesia
ACB group
11/14
Spinal or general anesthesia
revstad 2015
25/24
65/54
28/33
N/A
N/A
N/A
Spinal or general anesthesia
Jæger 2013
22/26
70/66
22/52
N/A
N/A
N/A
Spinal anesthesia
46/47
68/67.6
48/38
2/3
38/36
6/8
Spinal anesthesia
Memtsoudis 2015
30/29
64.4
26
7
52
0
Spinal anesthesia
Shah 2014
48/50
68/66
27/28
13/14
35/33
RCT
30 ml of 0.2% ropivacaine
30 ml of 0.2% ropivacaine
RCT
30ml of 0.5 % ropivacaine , 0.2 % ropivacaine 8ml/h
30ml of 0.5 % ropivacaine , 0.2 % ropivacaine 8ml/h
RCT
15ml of 0.5 % bupivacaine with 5 ug/ml epinephrine
30ml of 0.25 % bupivacaine with 5 ug/ml epinephrine
RCT
15 ml bupivacaine 0.25 %
30 ml of 0.25 % bupivacaine
RCT RCT RCT
Spinal anesthesia
20 ml of 0.75% ropivacaine
General anaesthesia
15 ml of 0.375 % ropivacaine
15 ml of 0.375 % ropivacaine
Spinal anesthesia General anaesthesia
20 ml of 0.33% ropivacaine 30mL, 100 mg of Bupivacaine hydrochloride
20 ml of 0.33% ropivacaine 30mL, 100 mg of Bupivacaine hydrochloride
43/43
N/A
N/A
N/A
Zhang 2014
30/30
64/62
20/26
N/A
N/A
N/A
Macrinici 2016
49/49
67/67
39/37
N/A
N/A
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72/66
N/A
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FNB: Femoral Nerve Block
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A bolus of 20 ml of 0.5% ropivacaine
0/3
21/21
ACB: Adductor Canal Block
A bolus of 20 ml of 0.5% ropivacaine
30ml of 0.25 % bupivacaine at an interval of 4 h
Wiesmann 2016
RCT: Randomized Controlled Trial
Reference type
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Kim 2014
FNB group
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Elkassabany 2016
Cases
Gender
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Study(year)
Age
ASA: American Society of Anesthesiologists
N/A: not applicable
RCT RCT
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Table 2.
Subgroup analysis Effect estimate
Subgroup or Outcomes Studies χ MD and 95%CI I2 (%) P Spinal anesthesia 6 56.44 -0.09 (-0.65, 0.46) 91 0.74 Apply tourniquet 3 0.03 0.36 (-0.11, 0.82) 0 0.13 Ropivacaine usage 5 54.51 -0.13(-0.77, 0.52) 93 0.70 2 2 MD: Mean Difference, CI: Confidence Interval, χ : Chi-square test, I : Heterogeneity Test
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S0883-5403(17)30421-7
DOI:
10.1016/j.arth.2017.05.015
Reference:
YARTH 55882
To appear in:
The Journal of Arthroplasty
Received Date: 22 December 2016 Revised Date:
26 April 2017
Accepted Date: 8 May 2017
Please cite this article as: Kuang M-j, Ma J-x, Fu L, He W-w, Zhao J, Ma X-l, Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis, The Journal of Arthroplasty (2017), doi: 10.1016/ j.arth.2017.05.015. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis
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Ming-jie Kuanga,b, *, Jian-xiong Ma a, *, Lin Fu a,b,*, Wei-wei Hea,b, Jie Zhaoa, Xin-long Maa,b *These authors contributed equally to this work. a
Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital, Tianjin 300050, People's
Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin 300052,
People's Republic of China
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b
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Republic of China
Corresponding author: Xin-long Ma, Tianjin Hospital, Tianjin 300211, China, e-mail ： [email protected], phone number: +86-13602179865. Email
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Name
[email protected]
Jian-xiong Ma
[email protected]
Jie Zhao
[email protected]
[email protected]
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Weiwei He
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Ming-jie Kuang
Lin Fu
[email protected]
Xin-long Ma
[email protected]
ACCEPTED MANUSCRIPT Abstract: Background: Total knee arthroplasty (TKA) is associated with intense postoperative pain with a need for early ambulation to gain function and prevent postoperative
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complications. Compared with femoral nerve block (FNB), adductor canal block (ACB) can relieve postoperative pain and preserve quadriceps muscle strength. This
pain relief and function recovery following TKA.
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meta-analysis was conducted to investigate which analgesic method provides better
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Method: We conducted a meta-analysis to identify relevant randomized controlled trials (RCTs) involving ACB and FNB after TKA in electronic databases, including Web of Science, Embase, PubMed, and the Cochrane Library, up to November 2016. Finally, nine RCTs involving 609 patients (668 knees) were included in our study.
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Review Manager Software and GRADE (Grading of Recommendations Assessment, Development and Evaluation) profiler were used to perform the meta-analysis. Results: Compared with FNB, ACB resulted in better quadriceps muscle strength and
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mobilization ability. There were no significant differences in the visual analogue scale
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(VAS) at rest, VAS with mobilization, rescue opioid consumption, patient satisfaction, and length of hospital stay. Conclusions: Compared with FNB, ACB shows similar pain control after TKA. However, ACB can better preserve quadriceps muscle strength and improve mobilization ability. In conclusion, ACB showed better functional recovery after TKA without compromising pain control. Therefore, ACB is recommended as an alternative analgesic method for early ambulation after TKA.
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Keywords: adductor canal block, femoral nerve block, total knee arthroplasty
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Is adductor canal block better than femoral nerve block in primary total knee
2
arthroplasty? A GRADE analysis of the evidence through a systematic
3
review and meta-analysis
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1
Abstract:
5
Background: Total knee arthroplasty (TKA) is associated with intense
6
postoperative pain with a need for early ambulation to gain function and
7
prevent postoperative complications. Compared with femoral nerve block
8
(FNB), adductor canal block (ACB) can relieve postoperative pain and
9
preserve quadriceps muscle strength. This meta-analysis was conducted to
10
investigate which analgesic method provides better pain relief and function
11
recovery following TKA.
12
Method: We conducted a meta-analysis to identify relevant randomized
13
controlled trials (RCTs) involving ACB and FNB after TKA in electronic
14
databases, including Web of Science, Embase, PubMed, and the Cochrane
15
Library, up to November 2016. Finally, nine RCTs involving 609 patients
16
(668 knees) were included in our study. Review Manager Software and
17
GRADE (Grading of Recommendations Assessment, Development and
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4
1
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Evaluation) profiler were used to perform the meta-analysis.
19
Results: Compared with FNB, ACB resulted in better quadriceps muscle
20
strength and mobilization ability. There were no significant differences in the
21
visual analogue scale (VAS) at rest, VAS with mobilization, rescue opioid
22
consumption, patient satisfaction, and length of hospital stay.
23
Conclusions: Compared with FNB, ACB shows similar pain control after
24
TKA. However, ACB can better preserve quadriceps muscle strength and
25
improve mobilization ability. In conclusion, ACB showed better functional
26
recovery after TKA without compromising pain control. Therefore, ACB is
27
recommended as an alternative analgesic method for early ambulation after
28
TKA.
29
Keywords: adductor canal block, femoral nerve block, total knee
30
arthroplasty
31
Introduction
32
An increasing number of total knee arthroplasties (TKAs) are performed
33
because of end-stage knee osteoarthritis and rheumatoid arthritis [1]. Usually,
34
TKA is associated with intense early postoperative pain and a need for early
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ambulation to regain function and prevent postoperative complications [2].
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Femoral nerve block (FNB) techniques are considered preferred methods to
37
deliver post-operative analgesia and to minimize postoperative pain in TKA
38
patients [3]. However, some recent studies reported that continuous blockade
39
of the femoral nerve may result in weakness of the quadriceps muscle and
40
therefore increases the risk of falling during early ambulation [4-6]. Thus far,
41
the management of early postoperative pain following TKA has not been
42
optimized to improve quadriceps muscle strength without compromising
43
analgesia dosage [7].
44
Adductor canal block (ACB) is a relatively new technique that has been
45
successfully used for early postoperative pain control after TKA without
46
weakening quadriceps muscle strength [8]. Recently, an anatomical study of
47
the adductor canal showed that both the saphenous nerve and the nerve to the
48
vastus medialis contribute to the innervation of the knee joint and are distal
49
to the quadriceps motor branches [9]. Thus, ACB can relieve postoperative
50
pain while preserving quadriceps muscle strength.
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double-blind randomized controlled trial (RCT) in healthy volunteers
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A prospective
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demonstrated that ACB reduced quadriceps strength by only 8% compared
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with 49% using FNB [8]. In addition, several studies reported that ACB
54
preserved quadriceps muscle strength better than FNB in patients undergoing
55
TKA [10-13]. However, there are no consistent conclusions on which of the
56
two techniques leads to better function recovery after TKA. Some studies [12,
57
14] showed that ACB improve postoperative motor function after TKA;
58
however, others drew different conclusions and reported that ACB provides
59
equivalent ambulation ability compared with FNB [15, 16]. A meta-analysis
60
conducted by Li et al[17] showed that ACB provided better ambulation
61
ability, faster functional recovery and better pain control at rest after TKA
62
than FNB. However, the authors included a wide variety of studies that were
63
not applicable to the meta-analysis. For example, the meta-analysis included
64
reports by Kwofie et al [18] and Jaeger et al [19], which focus on the
65
influences to the quadriceps strength of health volunteers without TKAs.
66
Therefore, the results of meta-analysis were limited and inaccurate.
67
To achieve a fast functional recovery and early ambulation after TKA, it is
68
necessary to choose an optimal anesthetic technique. Therefore, to
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investigate which anesthetic technique provided better pain relief, we
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performed a meta-analysis to evaluate evidence from all available RCTs that
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compared ACB with FNB for patients undergoing primary TKA and to
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propose recommendations for clinicians using the GRADE (Grading of
73
Recommendations, Assessment, Development and Evaluation) system.
74
Materials and methods
75
Search strategy
76
This systematic review and meta-analysis was prospectively registered on
77
PROSPERO (International prospective register of systematic reviews) and
78
the registration number was CRD42016051316 (Supplemental PDF). The
79
PRISMA guidelines[20], GRADE system[21] and Cochrane Handbook[22]
80
were applied to assess the quality of the results published in all included
81
studies to make sure the results of our meta-analysis reliable and veritable.
82
We conducted a meta-analysis to identify relevant RCTs involving ACB and
83
FNB after TKA in electronic databases including Web of Science, Embase,
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PubMed, the Cochrane Controlled Trials Register, and the Cochrane Library
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up to November 2016. Only RCTs performed on human beings is included.
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The search strategy was presented in Supplemental table 2. Flow chart of
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the trial selection process was presented in Fig 1. In addition, we also
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conducted other databases according to the Cochrane Collaboration
89
guidelines.
90
Inclusion criteria
91
Included studies were considered eligible if they met the PICOS criteria as
92
follows:
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Population: Patients were scheduled for primary TKA;
94
Intervention: ACB;
95
Comparator: FNB;
96
Outcomes: The primary outcomes included the following: visual analogue
97
scale [23] (VAS) pain score at rest and VAS pain score after mobilization (8
98
h, 24 h, 48 h). VAS pain score, which consisted of a scale from 0 (no pain) to
99
10 (worst imaginable pain), was used to evaluate pain control. Secondary
100
outcomes contained the following: timed up and go (TUG) test [24], which is
101
a method to evaluate mobilization ability; quadriceps muscle strength;
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adductor muscle strength; opioid consumption (all opioids given were
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converted to morphine equivalents at 8, 24 and 48 h); the length of the
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hospital stay (days) and patient satisfaction. Patient satisfaction was
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evaluated using a ten-point scale from 0 (completely unsatisfied) to 10
106
(totally satisfied) [16]
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Study design: Interventional studies (RCTs);
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Only published clinical studies were included; the included studies were
109
required to contain at least one outcome. Only studies published in English
110
were included. The studies must have had a follow up rate of at least 80%,
111
and at least two main patient-important outcomes had to be included. Two
112
authors had to have assessed the eligible studies independently. In cases of
113
disagreement, a consensus was reached through discussion between two
114
authors.
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Exclusion criteria included observational studies, non-RCTs, review articles,
116
studies with a sample size < 50 and studies with insufficient outcome data.
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Data extraction
118
We used a standard data extraction form to retrieve the relevant data from
119
eligible articles. The extracted data included authors, study location, sample
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size, study design, publishing date, gender, population, age, duration of
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follow-up, interventions, dosages and type of anaesthesia, and outcomes. If
122
necessary, we contacted the corresponding authors of the included RCTs to
123
make sure the information was integrated and to get any missing data. Two
124
reviewers extracted the data independently. If there were disagreements
125
between two authors, consensus were reached through discussion.
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Risk of bias and quality assessment
127
According to the Cochrane Handbook for Systematic Reviews of
128
Interventions, the methodological quality and basis of the included literature
129
were assessed as follows: randomization, allocation concealment, blind
130
method, selective reporting, group similarity at baseline, incomplete outcome
131
data, compliance, timing of outcome assessments, and intention-to-treat
132
analysis (Fig 2 and Fig 3).
133
Assessment of reporting bias
134
A funnel plot was used to assess the existence of reporting bias. We
135
evaluated whether asymmetry was due to publication bias or to a relationship
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between trial size and effect size.
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Dealing with missing data
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In cases of incomplete and missing data, we contacted the corresponding
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authors of the included studies to make sure the information integrated. All
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the data was presented as the form of mean ± standard deviation (SD) in our
141
meta-analysis. If the data were reported as median and interquartile range
142
(IQR), we assumed that the median was equivalent to the mean and that the
143
width of the IQR was equivalent to 1.35 times the SD. When data were
144
reported in a graph, means ± SD was estimated by Get Data software. All the
145
methods mentioned above to calculate the means ± SD on the basis of the
146
Cochrane Handbook for Systematic Reviews.
147
Statistical analysis and data synthesis
148
Meta-analyses was performed with Review Manager Software for Windows
149
(Version 5.3. Copenhagen: The Nordic Cochrane Centre, the Cochrane
150
Collaboration, 2014). The mean difference (MD) or standard mean
151
difference (SMD) was used to assess continuous outcomes such as VAS
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score, rescue opioid consumption, TUG test, and quadriceps muscle strength,
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with a 95% confidence interval [CI]. Relative risks (RR) with a 95% CI were
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used to assess dichotomous outcomes. The inverse variance and Mantel–
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Haenszel methods were used to combine separate statistics. If P values were
156
less than 0.05, the results were considered statistically significant.
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GRADE the evidence
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GRADE system was used to evaluate the quality of the evidence for each
159
outcome [21]. GRADE profiler (Version 3.6.1) was used to evaluate the
160
evidence regarding included outcomes. Initially, RCTs were considered as
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being of high confidence in estimating an effect, and observational studies
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were considered as being of low confidence in estimating an effect. Reasons
163
that may decrease the level of confidence include risk of bias, inconsistency,
164
indirectness, imprecision, and publication bias. Reasons that may raise the
165
level of confidence include large effect, dose response, and all plausible
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residual confounding and bias. The GRADE evidence was divided into the
167
following categories: (1) High-quality evidence, which indicated that further
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research was unlikely to change the confidence in an estimate of effect; (2)
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Moderate-quality evidence, which indicated that further research was likely
170
to have an important impact on confidence in an estimate of effect and may
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change the estimate; (3) Low-quality evidence, which indicated that further
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research was likely to have an important impact on confidence in an estimate
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of effect and was likely to change the estimate; (4) Very low-quality
174
evidence, which indicated that we were very uncertain about the results. The
175
results of the GRADE analysis are presented in Supplemental table 2.
176
Investigation of heterogeneity
177
Statistical heterogeneity of the included studies was evaluated using
178
chi-square test in accordance with the values of P and I2. If the I2 < 50% and
179
P > 0.1, the heterogeneity might not be important. A fixed-effects model was
180
used to assess the outcomes. If I2 was between 50% to 100%, it may
181
represent substantial heterogeneity. We used random-effects model to
182
evaluate these outcomes. Thresholds for the interpretation of I2 can be
183
misleading, since the importance of inconsistency depends on several factors.
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Therefore, subgroup analysis was performed to interpret the potential source
185
of heterogeneity.
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Results
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Excluded studies and search results
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Initially, a total of 212 citations were identified from electronic journals
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databases, of which 137 records were removed by primary screening
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according to the title and abstract. After reading the full text of 75 remaining
191
studies in detail, 63 studies that did not meet the inclusion criteria were
192
excluded. Among 12 RCTs, two studies [18, 19] focused on the influences to
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the quadriceps strength of health volunteers rather than TKAs. The control
194
group was placebo rather than FNB in another study [25]. Finally, 9 RCTs
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[10-13, 15, 16, 26-28] with 609 patients (668 knees) that compared ACB
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with FNB were included in our meta-analysis. All the included studies were
197
published between 2013 and 2016. The characteristics of 9 included studies
198
were summarised in Table 1.
199
The sample size of each RCT ranged from 42 to 98. The American Society of
200
Anesthesiologists grade[29] was presented in three studies[11, 12, 15]. The
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proportion and combination of anaesthetics were different in included studies
202
(Table 1). Only two studies [11, 15] used bupivacaine as the study
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medication, and ropivacaine was used in other articles. Two studies [10, 26]
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reported that outcome assessors and clinical personnel were blinded. All
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articles except Zhang[27] reported the random sequence generation. All
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included studies reported outcomes of more than 95% of participants.
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Risk of bias in included studies
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Randomization
209
Eight included studies[10-13, 15, 16, 26, 28] clearly reported the random
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sequence generation, which indicated that a low risk of selection bias in
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these studies. Only one study[27] did not describe the randomization process.
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Therefore, the selection bias in this study was unclear.
213
Allocation concealment
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Allocation concealment was considered to be adequate in eight studies[10-13,
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15, 16, 26, 28], and unclear in the other study [27], given that authors did not
216
provide the allocation information in this study.
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Blinding method
218
The blinding method can be divided into two parts: blinding of outcome
219
assessment (detection bias) and blinding of the participants and personnel
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(performance bias). Seven studies[10, 11, 13, 15, 16, 26, 28] were
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double-blinded and were rated as having low-risk detection and performance
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bias. One study[12] did not report the blinding method and was rated as
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having high-risk detection and performance bias. Zhang et al[27] reported
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that only blind outcome assessment was used but did not clearly describe the
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method used. Therefore, the study was rated as having unclear-risk detection
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bias and high-risk performance bias [27].
227
Selective reporting
228
All nine included studies[10-13, 15, 16, 26-28] showed that all main
229
outcomes were presented in the protocol and were considered at low risk of
230
reporting bias.
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Group similarity at baseline
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Results (e.g. age, weight, male/female etc.) of ACB and FNB were similar at
233
baseline for each study.
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Intention-to-treat analysis (ITT)
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Only five included studies reported the ITT [10, 11, 15, 16, 28]. The
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remaining studies showed an unclear[12, 13, 26] and high[27] risk of bias.
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Incomplete outcome data
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All the studies presented complete data and was considered at a low risk bias
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for this criterion.
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Compliance
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Risk of bias was unclear in all included studies because compliance was not
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monitored in the control group.
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Timing of outcome assessments
244
Risk of bias was low because all important outcome assessments for all
245
intervention groups were measured at the same time.
246
Publication bias
247
Publication bias was also evaluated using a funnel plot diagram
248
(Supplemental Fig 1). The diagram was symmetrical, indicating low risk of
249
publication bias.
250
Other bias
251
Further risks of bias was found in included studies. However, we cannot
252
ignore other potential risk of biases. Therefore, we rated as having
253
unclear-risk of other bias.
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Results of meta-analysis
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Primary outcomes
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(1) VAS score at rest
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Five studies assessing 418 knees reported VAS scores at rest within 8 hours
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post-operatively. There was no significant difference between the ACB and
259
FNB groups (MD=0.13, 95%CI: [-0.15, 0.41], P=0.35; Fig 4). VAS score at
260
24 hours post-operatively was reported in seven studies, and a total of 521
261
knees were involved in the meta-analysis. No significant differences were
262
found between the two groups (MD=-0.01, 95%CI: [-0.55, 0.53], P=0.97;
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Fig 4). Six studies involving 473 knees reported the VAS score at 48 hours.
264
Meta-analysis showed no significant differences between the ACB and FNB
265
groups (MD=-0.06, 95%CI: [-0.15, 0.03], P=0.23; Fig 4).
266
(2) VAS score with mobilization
267
Data from three studies assessing 227 knees reported the VAS score with
268
mobilization within 8 hours. The ACB group reported a similar pain score
269
with mobilization within 8 hours compared to the FNB group (MD=-0.15,
270
95%CI: [-0.39, -0.09], P=0.21; Fig 4). A meta-analysis was conducted of
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seven studies involving a total of 511 knees to evaluate the VAS score with
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mobilization at 24 and 48 hours post-operatively. However, the results of the
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meta-analysis revealed no significant differences between ACB and FNB
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groups at 24 hours (MD=0.23, 95%CI: [-0.20, 0.66], P=0.30; Fig 4) and 48
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hours (MD=-0.07, 95%CI: [-0.17, 0.03], P=0.18; Fig 4) post-operatively.
276
Secondary outcomes
277
Two methods were used to evaluate quadriceps muscle strength. Three
278
authors[10, 13, 28] evaluated quadriceps muscle strength as maximum
279
voluntary isometric contraction[30] (MVIC) using a handheld dynamometer.
280
A manual muscle test[31] (MMT) with a standardised 0–5 motor strength
281
scale was used in four studies[15, 16, 26, 27].
282
(1) Quadriceps muscle strength (MMT)
283
Four studies involving 282 knees reported the quadriceps muscle strength as
284
measured by MMT at 8 hours, 24 hours and 48 hours. The pooled data
285
showed significant differences at 8 hours (MD=0.71, 95%CI: [0.05, 1.37],
286
P=0.04; Fig 5), at 24 hours (MD=0.68, 95%CI: [0.05, 1.31], P=0.03; Fig 5)
287
and 48 hours (MD=0.67, 95%CI: [0.03, 1.31], P=0.04; Fig 5).
288
(2) Quadriceps muscle strength (MVIC)
289
Meta-analysis showed that the quadriceps muscle strength measured by
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MVIC at 24 hours in the ACB group was much greater than that in the FNB
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group (MD=75.65, 95%CI: [28.49, 122.81], P=0.002; Fig 5).
292
(3) Adductors muscle strength (MVIC)
293
MVIC was also used to evaluate adductor muscle strength. Two studies
294
assessing 97 knees reported adductor muscle strength at 24 hours
295
post-operatively. There was no significant difference between the ACB and
296
FNB groups (MD=-19.2, 95%CI: [-44.67, 6.26], P=0.14; Fig 5).
297
(4) TUG test
298
The TUG test was conducted in four studies involving a total of 348 knees to
299
evaluate mobilization ability. Significant differences were found between the
300
ACB and FNB groups at 24 hours (MD=-11.63, 95%CI: [-21.72, -1.53],
301
P=0.02; Fig 5) and 48 hours (MD=-9.63, 95%CI: [-18.3, -0.96], P=0.03; Fig
302
5).
303
(5) Opioid consumption
304
Opioid consumption was reported in four of the included studies, and a total
305
of 252 knees were involved in the meta-analysis. The pooled data showed no
306
significant difference between ACB and FNB groups at 8 hours (MD=1.64,
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95%CI: [-2.66, 5.94], P=0.45; Fig 6), 24 hours (MD=0.13, 95%CI: [-5.32,
308
5.57], P=0.96; Fig 6) and 48 hours (MD=5.19, 95%CI: [-1.94, 12.33],
309
P=0.15; Fig 6).
310
(6) Patient satisfaction
311
A meta-analysis examined four studies (315 knees) to assess post-operative
312
patient satisfaction. No significant differences were discovered between
313
ACB and FNB groups at 8 hours (MD=0.17, 95%CI: [-0.09, 0.43], P=0.20;
314
Fig 6), 24 hours (MD=-0.41, 95%CI: [-0.90, 0.08], P=0.10; Fig 6) and 48
315
hours (MD=0.02, 95%CI: [-1.84, 1.88], P=0.98; Fig 6).
316
(7) Length of hospital stay
317
Two studies with 191 patients reported the length of hospital stay. There
318
were no significant differences between the ACB and FNB groups
319
(MD=-0.38, 95%CI: [-1.30, 0.54], P=0.42; Fig 6).
320
Discussion
321
TKA is one of the most commonly treated osteoarthritis in older adults, and
322
the prevalence of this operation will continue to rise as the population ages.
323
The pain following TKA may be a major concern despite the successful
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recovery of function in the patient. Yet, to date, no clear standard is known
325
for pain control after TKA. An optimal analgesic technique for TKA should
326
be based on early ambulation and lasting symptom improvement without
327
severe complications, including muscle weakness, nerve damage, and
328
infection. Both ACB and FNB have proven to be safe and effective technique
329
for pain management after TKA. Some recent published studies have
330
reported that FNB is associated with delayed ambulation [10] and risk of
331
falling [32]. However, Elkassabany et al did not detect a significant reduction
332
in fall risk when comparing ACB with FNB [26]. Therefore, the aim of the
333
present systematic review and meta-analysis was to evaluate the efficacy of
334
ACB and FNB in postoperative pain control and recovering ambulation
335
ability. Our findings demonstrated that ACB presents similar pain control
336
compared with FNB. However, ACB can better preserve quadriceps muscle
337
strength and improve mobility. In conclusion, ACB showed better functional
338
recovery after TKA without compromising pain control.
339
A previous meta-analysis demonstrated that their ACB group had lower VAS
340
at rest during the early post-operative period compared to their FNB group
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[17]. However, according to our meta-analysis, ACB groups present similar
342
VAS scores at rest after TKA compared with FNB groups, at 8 hours, 24
343
hours and 48 hours. Several RCTs [10, 13, 15] also reported that VAS scores
344
at rest were similar between ACB and FNB groups. This result was
345
consistent with our findings. In the included studies, statistical heterogeneity
346
was found in VAS at 8 hours and 24 hours. Thus, a random-effects model
347
was performed to evaluate the results. Subgroup analysis was carried out for
348
the VAS score at rest to determine the source of heterogeneity (Table 2).
349
Factors such as local anesthetic volume, race, tourniquet use, age, and type
350
of catheter caused significant heterogeneity. Because of the inconsistency
351
caused by very serious heterogeneity, the quality of evidence regarding VAS
352
at rest with 8 hours and 24 hours was low. However, the evidence regarding
353
VAS at rest at 48 hours was of high quality. Furthermore, all the included
354
studies were RCTs of high quality. Therefore, the overall quality of evidence
355
and effect estimate regarding VAS at rest was reliable.
356
In addition, our meta-analysis failed to find any significant difference for
357
VAS score with mobilization at 8 hours, 24 hours and 48 hours between the
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ACB and FNB groups. However, the VAS score with mobilization at 8 hours
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was found to be slightly lower in the ACB group than in the FNB group.
360
Several recent published studies reported that the VAS score with
361
mobilization was similar between both groups during post-operative days 0
362
to 2 [13, 15, 16, 26]. These findings are consistent with our meta-analysis.
363
Therefore, ACB provides equally effective pain relief for patients after TKA
364
compared with FNB.
365
Opioid analgesics are often used to relieve postoperative pain for patients
366
who have undergone TKA. Usually, rescue opioids are used for breakthrough
367
postoperative pain based on patients’ reported VAS scores (VAS>7 points)
368
[33]. In our meta-analysis, rescue opioid consumption also did no differ
369
between the two groups within 48 hours. A retrospective study showed that
370
opioid consumption in patients with ACB was not significantly different
371
from patients receiving FNB within 48 hours [34]. A study presented by
372
Shah et al[12] also reported the same conclusions. Because of the small
373
sample size, the validity of the results regarding rescue opioid use in the
374
ACB and FNB groups is limited. However, the quality of evidence was
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moderate, and the conclusion was reasonable.
376
Quadriceps muscle strength has a great impact on the ability to ambulate.
377
The results of our meta-analysis showed that quadriceps muscle strength was
378
much greater in the ACB group than in the FNB group. However, the quality
379
of evidence was low according to the GRADE system, and we could not
380
confidently draw conclusions about this result. Several prospective studies
381
comparing ACB and FNB in healthy volunteers [8, 35] and TKA patients[16,
382
26] have suggested that the loss of quadriceps muscle strength in ACB
383
groups is significantly lower than placebo or that in FNB groups. Moreover,
384
Grevstad et al[36] reported that no statistically significant differences were
385
found between local anesthetic volume (ACB) and effects on quadriceps
386
muscle strength in healthy volunteers. Together, these findings demonstrated
387
that ACB can preserve quadriceps strength. More RCTs with larger sample
388
sizes are needed to verify our conclusions. Our meta-analysis failed to find
389
any significant difference between ACB and FNB groups regarding adductor
390
muscle strength, indicating that ACB does not reduce adductor muscle
391
strength. However, Jenstrup et al[37] reported that ACB may block the nerve
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to the vastus medialis and thereby affect muscle strength. Grevstad et al
393
demonstrated a positive correlation between local anesthetic volume and
394
effects on the vastus medialis muscle [36]. Meanwhile, because of the small
395
sample size and heterogeneity, the quality of evidence was very low. The
396
effect estimate was uncertain and had a lower GRADE recommendation
397
strength. The TUG test evaluates ambulation ability by measuring the time a
398
patient takes to stand up from a chair, walk a distance of three meters without
399
any support, and return to the chair [12]. The results of our meta-analysis
400
reported that the TUG test result in the ACB group was better than that in the
401
FNB group at 24 hours and 48 hours. Hanson et al [25] reported that ACB
402
for TKA resulted in better ambulation ability than placebo during the first 48
403
hours.
404
significant differences were found in motor function between ACB and FNB
405
groups. Therefore, we confirmed that ACB was better than FNB in terms of
406
enhancing mobilization ability after TKA.
407
According to the results of our meta-analysis, patient satisfaction score
408
within 48 hours and length of the hospital stay in the two groups were similar.
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Since patient satisfaction is a subjective scale, it can easily be affected by
410
subjective factors. Length of hospital stay was affected by multiple factors,
411
including sex, age, and the physiological status of the patients. Prolonged
412
hospitalization may cause serious complications, including urinary system
413
infection, muscle atrophy, and deep vein thrombosis. Furthermore, cost
414
increases greatly with prolonged hospitalization. Kim et al[11] reported side
415
effects of pain management, such as nausea, vomiting and pruritis; however,
416
there were no significant differences between their ACB and FNB groups.
417
Our systematic review and meta-analysis has the following limitations: (1)
418
Only nine studies were included in our meta-analysis; if more RCTs had
419
been included, the test power for our analysis would have been greater. (2)
420
We evaluated only the immediate effects within 48 hours after TKA; the
421
included studies tell us nothing about the duration of the effects or whether
422
these effects lead to better long-term functional outcomes. Therefore, a
423
long-term follow-up study is needed to investigate functional outcomes. (3)
424
Only English publications were included in our meta-analysis. (4)
425
Heterogeneity among the included studies was unavoidable because of racial
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differences, age differences, and differences in the tourniquet use, mode of
427
anesthesia, and type of catheter used.
428
Conclusions
429
Compared with FNB, ACB shows similar pain control after TKA. ACB can
430
better preserve quadriceps muscle strength and improve mobilization ability.
431
In conclusion, ACB resulted in better functional recovery after TKA without
432
compromising pain control. Therefore, concerning the early ambulation after
433
TKA, ACB is recommended as an alternative analgesic method.
434
Conflict of interest
435
No conflict of interest exits in the submission of the manuscript, and the
436
manuscript has been approved for publication by all authors.
437
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Table 1 . The characteristics of included studies ACB group/FNB group
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(mean)
(% male)
63/65
71/61
ASA grade(cases) Ⅰ
Ⅱ
N/A
N/A
Ⅲ
Anesthesia
ACB group
11/14
Spinal or general anesthesia
revstad 2015
25/24
65/54
28/33
N/A
N/A
N/A
Spinal or general anesthesia
Jæger 2013
22/26
70/66
22/52
N/A
N/A
N/A
Spinal anesthesia
46/47
68/67.6
48/38
2/3
38/36
6/8
Spinal anesthesia
Memtsoudis 2015
30/29
64.4
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7
52
0
Spinal anesthesia
Shah 2014
48/50
68/66
27/28
13/14
35/33
RCT
30 ml of 0.2% ropivacaine
30 ml of 0.2% ropivacaine
RCT
30ml of 0.5 % ropivacaine , 0.2 % ropivacaine 8ml/h
30ml of 0.5 % ropivacaine , 0.2 % ropivacaine 8ml/h
RCT
15ml of 0.5 % bupivacaine with 5 ug/ml epinephrine
30ml of 0.25 % bupivacaine with 5 ug/ml epinephrine
RCT
15 ml bupivacaine 0.25 %
30 ml of 0.25 % bupivacaine
RCT RCT RCT
Spinal anesthesia
20 ml of 0.75% ropivacaine
General anaesthesia
15 ml of 0.375 % ropivacaine
15 ml of 0.375 % ropivacaine
Spinal anesthesia General anaesthesia
20 ml of 0.33% ropivacaine 30mL, 100 mg of Bupivacaine hydrochloride
20 ml of 0.33% ropivacaine 30mL, 100 mg of Bupivacaine hydrochloride
43/43
N/A
N/A
N/A
Zhang 2014
30/30
64/62
20/26
N/A
N/A
N/A
Macrinici 2016
49/49
67/67
39/37
N/A
N/A
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N/A
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FNB: Femoral Nerve Block
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0/3
21/21
ACB: Adductor Canal Block
A bolus of 20 ml of 0.5% ropivacaine
30ml of 0.25 % bupivacaine at an interval of 4 h
Wiesmann 2016
RCT: Randomized Controlled Trial
Reference type
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FNB group
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Cases
Gender
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Study(year)
Age
ASA: American Society of Anesthesiologists
N/A: not applicable
RCT RCT
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Table 2.
Subgroup analysis Effect estimate
Subgroup or Outcomes Studies χ MD and 95%CI I2 (%) P Spinal anesthesia 6 56.44 -0.09 (-0.65, 0.46) 91 0.74 Apply tourniquet 3 0.03 0.36 (-0.11, 0.82) 0 0.13 Ropivacaine usage 5 54.51 -0.13(-0.77, 0.52) 93 0.70 2 2 MD: Mean Difference, CI: Confidence Interval, χ : Chi-square test, I : Heterogeneity Test
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