Analgesic Impact of a Popliteal Plexus Block to Standard Adductor Canal Block in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Randomized Blind Clinical Trial

Atef Mahmoud, Maged Boules, Joseph Botros, Mohamed Mostafa, Safaa Ragab, Mohammed Alsaeid, Atef Mahmoud, Maged Boules, Joseph Botros, Mohamed Mostafa, Safaa Ragab, Mohammed Alsaeid

Abstract

Background: Damage to the anterior cruciate ligament (ACL) is crippling and often requires an arthroscopic outpatient surgery. Nevertheless, many patients experience severe pain during the first day after ACL reconstruction (ACLR). The adductor canal block (ACB) has yielded conflicting results for post-ACLR pain relief. This research investigated the effect of a supplemental popliteal plexus block on postoperative pain outcomes compared to a sole ACB.

Methods: Following a randomized design, 60 cases scheduled for knee arthroscopy with ACLR using an ipsilateral hamstring graft were separated into two categories. Subjects in group A (n = 30) received an ACB only, while subjects in group B (n = 30) received combined ACB and popliteal plexus block (PPB).

Results: We found significant differences between the two groups. The time of the first analgesic request (TFR) was later for the combined ACB and PPB (median 8 h) compared to the ACB only group (median 0.5 h). Morphine consumption was lower for patients who received combined ACB and PPB (median 12 mg) compared to ACB only (median 30 mg). The number of the requested doses was lower for the combined ACB and PPB group (median 3 doses) compared to the ACB only group (median 7 doses).

Conclusions: The addition of PPB to ACB was associated with improved analgesia and a reduced need for opioid-based sedatives following ACLR with an ipsilateral hamstring graft (https://ichgcp.net/clinical-trials-registry/NCT04020133).

Conflict of interest statement

All authors declare that there are no conflicts of interest.

Copyright © 2021 Atef Mahmoud et al.

Figures

Figure 1
Figure 1
CONSORT flow diagram.
Figure 2
Figure 2
Comparison of postoperative pain scores between groups.
Figure 3
Figure 3
Comparison of postoperative nausea and vomiting.
Figure 4
Figure 4
Comparison of postoperative patient satisfaction level.

References

    1. Akova B. ACL surgery: how to get it right the first time and what to do if it fails. Journal of Sports Science and Medicine . 2010;9(3):527–528.
    1. Barnett S., Murray M. M., Liu S., et al. Resolution of pain and predictors of postoperative opioid use after bridge-enhanced anterior cruciate ligament repair and anterior cruciate ligament reconstruction. Arthroscopy, Sports Medicine, and Rehabilitation . 2020;2(3):e219–e228. doi: 10.1016/j.asmr.2020.02.004.
    1. Filbay S. R., Ackerman I. N., Russell T. G., Macri E. M., Crossley K. M. Health-related quality of life after anterior cruciate ligament reconstruction. The American Journal of Sports Medicine . 2014;42(5):1247–1255. doi: 10.1177/0363546513512774.
    1. Secrist E. S., Freedman K. B., Ciccotti M. G., Mazur D. W., Hammoud S. Pain management after outpatient Anterior cruciate ligament reconstruction. The American Journal of Sports Medicine . 2016;44(9):2435–2447. doi: 10.1177/0363546515617737.
    1. Fanton G. S., Dillingham M. F., Wall M. S., et al. Novel drug product to improve joint motion and function and reduce pain after arthroscopic anterior cruciate ligament reconstruction. Arthroscopy: The Journal of Arthroscopic & Related Surgery . 2008;24(6):625–636. doi: 10.1016/j.arthro.2008.02.003.
    1. Chmielewski T. L., Jones D., Day T., Tillman S. M., Lentz T. A., George S. Z. The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. Journal of Orthopaedic & Sports Physical Therapy . 2008;38(12):746–753. doi: 10.2519/jospt.2008.2887.
    1. Terkawi A. S., Mavridis D., Sessler D. I., et al. Pain management modalities after total knee arthroplasty. Anesthesiology . 2017;126(5):923–937. doi: 10.1097/aln.0000000000001607.
    1. Okoroha K. R., Keller R. A., Jung E. K., et al. Pain assessment after anterior cruciate ligament reconstruction. Orthopaedic Journal of Sports Medicine . 2016;4(12):232596711667492–232596711667496. doi: 10.1177/2325967116674924.
    1. Ward B. D., Lubowitz J. H. Basic knee arthroscopy part 2: surface anatomy and portal placement. Arthroscopy Techniques . 2013;2(4):e501–e502. doi: 10.1016/j.eats.2013.07.013.
    1. Tifford C. D., Spero L., Luke T., Plancher K. D. The relationship of the infrapatellar branches of the saphenous nerve to arthroscopy portals and incisions for anterior cruciate ligament surgery: an anatomic study. The American Journal of Sports Medicine . 2000;28(4):562–567. doi: 10.1177/03635465000280042001.
    1. Sehmbi H., Brull R., Shah U. J., et al. Evidence basis for regional anesthesia in ambulatory arthroscopic knee surgery and anterior cruciate ligament reconstruction. Anesthesia & Analgesia . 2019;128(2):223–238. doi: 10.1213/ane.0000000000002570.
    1. Burckett-St Laurant D., Peng P., Girón Arango L., et al. The nerves of the adductor canal and the innervation of the knee. Regional Anesthesia and Pain Medicine . 2016;41(3):321–327. doi: 10.1097/AAP.0000000000000389.
    1. Abdallah F. W., Whelan D. B., Chan V. W., et al. Adductor canal block provides noninferior analgesia and superior quadriceps strength compared with femoral nerve block in anterior cruciate ligament reconstruction. Anesthesiology . 2016;124(5):1053–1064. doi: 10.1097/ALN.0000000000001045.
    1. Vora M. U., Nicholas T. A., Kassel C. A., Grant S. A. Adductor canal block for knee surgical procedures: review article. Journal of Clinical Anesthesia . 2016;35:295–303. doi: 10.1016/j.jclinane.2016.08.021.
    1. Kolli S., Malik M. F. The adductor canal block: a clinical review. Current Anesthesiology Reports . 2019;9(3):291–294. doi: 10.1007/s40140-019-00335-y.
    1. Mcewen A., Quemby D. Ultrasound guided adductor canal block (saphenous nerve block) anaesthesia tutorial of the week 301 13th january 2014 Dr daniel quemby, specialist trainee anaesthesia torbay hospital, torquay. Anaesthesia Tutor Week . 2014;301:1–11.
    1. Saad A. H., Gad El-Rab N. A., Aly M. G., Said H. G. Review article: ultrasound-guided adductor canal block for post-operative analgesia in knee arthroscopy. The Medical Journal of Cairo University . 2018;86(9):2141–2148. doi: 10.21608/mjcu.2018.57492.
    1. Rasouli M. R., Viscusi E. R. Adductor canal block for knee surgeries: an emerging analgesic technique. The archives of bone and joint surgery . 2017;5(3):131–132. doi: 10.22038/abjs.2017.8433.
    1. Espelund M., Grevstad U., Jaeger P., et al. Adductor canal blockade for moderate to severe pain after arthroscopic knee surgery: a randomized controlled trial. Acta Anaesthesiologica Scandinavica . 2014;58(10):1220–1227. doi: 10.1111/aas.12407.
    1. Stebler K., Martin R., Kirkham K. R., Lambert J., De Sede A., Albrecht E. Adductor canal block versus local infiltration analgesia for postoperative pain after anterior cruciate ligament reconstruction: a single centre randomised controlled triple-blinded trial. British Journal of Anaesthesia . 2019;123(2):e343–e349. doi: 10.1016/j.bja.2019.04.053.
    1. Kejriwal R., Cooper J., Legg A., Stanley J., Rosenfeldt M. P., Walsh S. J. Efficacy of the adductor canal approach to saphenous nerve block for anterior cruciate ligament reconstruction with hamstring autograft: a randomized controlled trial. Orthopaedic Journal of Sports Medicine . 2018;6(10):232596711880094–232596711880095. doi: 10.1177/2325967118800948.
    1. Ramlogan R., Tierney S., McCartney C. J. L. Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice? British Journal of Anaesthesia . 2019;123(2):e186–e188. doi: 10.1016/j.bja.2019.05.028.
    1. Sztain J. F., Khatibi B., Monahan A. M., et al. Proximal versus distal continuous adductor canal blocks. Anesthesia & Analgesia . 2018;127(1):240–246. doi: 10.1213/ANE.0000000000003422.
    1. Abdallah F. W., Mejia J., Prasad G. A., et al. Opioid- and motor-sparing with proximal, mid-, and distal locations for adductor canal block in anterior cruciate ligament reconstruction. Anesthesiology . 2019;131(3):619–629. doi: 10.1097/ALN.0000000000002817.
    1. Johnston D. F., Sondekoppam R. V., Uppal V., Litchfield R., Giffin R., Ganapathy S. Effect of combining peri-hamstring injection or anterior obturator nerve block on the analgesic efficacy of adductor canal block for anterior cruciate ligament reconstruction: a randomised controlled trial. British Journal of Anaesthesia . 2020;124(3):299–307. doi: 10.1016/j.bja.2019.11.032.
    1. Zorrilla-Vaca A., Li J. The role of sciatic nerve block to complement femoral nerve block in total knee arthroplasty: a meta-analysis of randomized controlled trials. Journal of Anesthesia . 2018;32(3):341–350. doi: 10.1007/s00540-018-2480-1.
    1. Manickam B., Perlas A., Duggan E., Brull R., Chan V. W. S., Ramlogan R. Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Regional Anesthesia and Pain Medicine . 2009;34(6):578–580. doi: 10.1097/aap.0b013e3181bfbf84.
    1. Runge C., Moriggl B., Børglum J., Bendtsen T. F. The spread of ultrasound-guided injectate from the adductor canal to the genicular branch of the posterior obturator nerve and the popliteal plexus. Regional Anesthesia and Pain Medicine . 2017;42(6):725–730. doi: 10.1097/aap.0000000000000675.
    1. Sessler C. N., Grap M. J., Ramsay M. A. Evaluating and monitoring analgesia and sedation in the intensive care unit. Critical Care . 2008;12(3):p. S2. doi: 10.1186/cc6148.
    1. Goffin P., Lecoq J.-P., Ninane V., et al. Interfascial spread of injectate after adductor canal injection in fresh human cadavers. Anesthesia & Analgesia . 2016;123(2):501–503. doi: 10.1213/ANE.0000000000001441.
    1. Gautier P. E., Hadzic A., Lecoq J.-P., Brichant J. F., Kuroda M. M., Vandepitte C. Distribution of injectate and sensory-motor blockade after adductor canal block. Anesthesia & Analgesia . 2016;122(1):279–282. doi: 10.1213/ANE.0000000000001025.
    1. Runge C., Bjørn S., Jensen J. M., et al. The analgesic effect of a popliteal plexus blockade after total knee arthroplasty: a feasibility study. Acta Anaesthesiologica Scandinavica . 2018;62(8):1127–1132. doi: 10.1111/aas.13145.
    1. Thobhani S., Scalercio L., Elliott C. E., et al. Novel regional techniques for total knee arthroplasty promote reduced hospital length of stay: an analysis of 106 patients. The Ochsner Journal . 2017;17(3):233–238. doi: 10.1043/1524-5012-17.3.233.
    1. Sankineani S. R., Reddy A. R. C., Eachempati K. K., Jangale A., Gurava Reddy A. V. Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period. European Journal of Orthopaedic Surgery and Traumatology . 2018;28(7):1391–1395. doi: 10.1007/s00590-018-2218-7.
    1. Lundblad M., Forssblad M., Eksborg S., Lönnqvist P.-A. Ultrasound-guided infrapatellar nerve block for anterior cruciate ligament repair: a prospective, randomised, double-blind, placebo-controlled clinical trial. European Journal of Anaesthesiology . 2011;28(7):511–518. doi: 10.1097/eja.0b013e32834515ba.
    1. Chisholm M. F., Bang H., Maalouf D. B., et al. Postoperative analgesia with saphenous block appears equivalent to femoral nerve block in ACL reconstruction. HSS Journal . 2014;10(3):245–251. doi: 10.1007/s11420-014-9392-x.
    1. El Ahl M. Femoral nerve block versus adductor canal block for postoperative pain control after anterior cruciate ligament reconstruction: a randomized controlled double blind study. Saudi Journal of Anaesthesia . 2015;9(3):279–282. doi: 10.4103/1658-354X.154708.
    1. Mall N. A., Wright R. W. Femoral nerve block use in anterior cruciate ligament reconstruction surgery. Arthroscopy: The Journal of Arthroscopic & Related Surgery . 2010;26(3):404–416. doi: 10.1016/j.arthro.2009.08.014.

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