Adductor canal block versus femoral nerve block for total knee arthroplasty: a meta-analysis of randomized controlled trials

Duan Wang, Yang Yang, Qi Li, Shen-Li Tang, Wei-Nan Zeng, Jin Xu, Tian-Hang Xie, Fu-Xing Pei, Liu Yang, Ling-Li Li, Zong-Ke Zhou, Duan Wang, Yang Yang, Qi Li, Shen-Li Tang, Wei-Nan Zeng, Jin Xu, Tian-Hang Xie, Fu-Xing Pei, Liu Yang, Ling-Li Li, Zong-Ke Zhou

Abstract

Femoral nerve blocks (FNB) can provide effective pain relief but result in quadriceps weakness with increased risk of falls following total knee arthroplasty (TKA). Adductor canal block (ACB) is a relatively new alternative providing pure sensory blockade with minimal effect on quadriceps strength. The meta-analysis was designed to evaluate whether ACB exhibited better outcomes with respect to quadriceps strength, pain control, ambulation ability, and complications. PubMed, Embase, Web of Science, Wan Fang, China National Knowledge Internet (CNKI) and the Cochrane Database were searched for RCTs comparing ACB with FNB after TKAs. Of 309 citations identified by our search strategy, 12 RCTs met the inclusion criteria. Compared to FNB, quadriceps maximum voluntary isometric contraction (MVIC) was significantly higher for ACB, which was consistent with the results regarding quadriceps strength assessed with manual muscle strength scale. Moreover, ACB had significantly higher risk of falling versus FNB. At any follow-up time, ACB was not inferior to FNB regarding pain control or opioid consumption, and showed better range of motion in comparison with FNB. ACB is superior to the FNB regarding sparing of quadriceps strength and faster knee function recovery. It provides pain relief and opioid consumption comparable to FNB and is associated with decreased risk of falls.

Figures

Figure 1. Flow chart showing study identification,…
Figure 1. Flow chart showing study identification, inclusion and exclusion.
Figure 2
Figure 2
(A) Risk of bias graph; (B) for Risk of bias summary (“+” indicates a low risk of bias, “−” indicates a high risk of bias, “?” indicates unclear or unknown risk of bias).
Figure 3. Forest plot of quadriceps and…
Figure 3. Forest plot of quadriceps and adductor MVIC between ACB and FNB.
(MVIC, maximum voluntary isometric contraction).
Figure 4. Forest plot of pain score…
Figure 4. Forest plot of pain score at rest between ACB and FNB.
Figure 5. Forest plot of pain score…
Figure 5. Forest plot of pain score at activity between ACB and FNB.
Figure 6
Figure 6
(A) Forest plot of opioid consumption between ACB and FNB; (B) Forest plot of risk of falls between ACB and FNB.
Figure 7. Funnel plots of primary outcomes.
Figure 7. Funnel plots of primary outcomes.
(A) For pain score at rest; (B) for pain score at activity; (C) for quadriceps and adductor strength measured by MVIC; (D) for quadriceps strength measured by manual 5-grade motor-strength scale.

References

    1. Carr A. J. et al.. Knee replacement. Lancet 379, 1331–1340 (2012).
    1. Wang D. et al.. Closed Suction Drainage Is Not Associated with Faster Recovery after Total Knee Arthroplasty: A Prospective Randomized Controlled Study of 80 Patients. Orthop Surg 8, 226–233 (2016).
    1. Singh J. A. et al.. A population-based study of trends in the use of total hip and total knee arthroplasty, 1969–2008. Mayo Clin Proc 85, 898–904 (2010).
    1. Grosu I., Lavand’homme P. & Thienpont E. Pain after knee arthroplasty: an unresolved issue. Knee Surg Sports Traumatol Arthrosc 22, 1744–1758 (2014).
    1. Ilfeld B. M. et al.. A multicenter, randomized, triple-masked, placebo-controlled trial of the effect of ambulatory continuous femoral nerve blocks on discharge-readiness following total knee arthroplasty in patients on general orthopaedic wards. Pain 150, 477–484 (2010).
    1. Hebl J. R. et al.. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 87 Suppl 2, 63–70 (2005).
    1. YaDeau J. T. et al.. The effects of femoral nerve blockade in conjunction with epidural analgesia after total knee arthroplasty. Anesth Analg 101, 891–895, table of contents (2005).
    1. Johnson R. L., Kopp S. L., Hebl J. R. & Erwin P. J. & Mantilla, C. B. Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis. Br J Anaesth 110, 518–528 (2013).
    1. Kandasami M., Kinninmonth A. W., Sarungi M., Baines J. & Scott N. B. Femoral nerve block for total knee replacement - a word of caution. Knee 16, 98–100 (2009).
    1. Ackerman D. B. et al.. Postoperative patient falls on an orthopedic inpatient unit. J Arthroplasty 25, 10–14 (2010).
    1. Pelt C. E., Anderson A. W., Anderson M. B., Van Dine C. & Peters C. L. Postoperative falls after total knee arthroplasty in patients with a femoral nerve catheter: can we reduce the incidence? J Arthroplasty 29, 1154–1157 (2014).
    1. Davis J. J., Bond T. S. & Swenson J. D. Adductor canal block: more than just the saphenous nerve? Reg Anesth Pain Med 34, 618–619 (2009).
    1. Horn J. L., Pitsch T., Salinas F. & Benninger B. Anatomic basis to the ultrasound-guided approach for saphenous nerve blockade. Reg Anesth Pain Med 34, 486–489 (2009).
    1. Manickam B. et al.. Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med 34, 578–580 (2009).
    1. Zhang W., Hu Y., Tao Y., Liu X. & Wang G. Ultrasound-guided continuous adductor canal block for analgesia after total knee replacement. Chin Med J (Engl) 127, 4077–4081 (2014).
    1. Grevstad U. et al.. Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: a randomized, blinded study. Reg Anesth Pain Med 40, 3–10 (2015).
    1. Jaeger P. et al.. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 38, 526–532 (2013).
    1. Liu Y., Zhang Y. Z., Tan Z., Liao R. & T. Y. Z. Comparison of Postoperative Analgesia between Ultrasound Guided Adductor Canal Block and Femoral Nerve Block in Patients after Total Knee Arthroplasty (chinese). West China Medical Journal 29 (2014).
    1. Memtsoudis S. G. et al.. Subsartorial adductor canal vs femoral nerve block for analgesia after total knee replacement. Int Orthop 39, 673–680 (2015).
    1. Wiesmann T. et al.. Continuous adductor canal block versus continuous femoral nerve block after total knee arthroplasty for mobilisation capability and pain treatment: a randomised and blinded clinical trial. Arch Orthop Trauma Surg (2016).
    1. Dong C. C., Dong S. L. & He F. C. Comparison of Adductor Canal Block and Femoral Nerve Block for Postoperative Pain in Total Knee Arthroplasty: A Systematic Review and Meta-analysis. Medicine (Baltimore) 95, e2983 (2016).
    1. Li D. & Ma G. G. Analgesic efficacy and quadriceps strength of adductor canal block versus femoral nerve block following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc (2015).
    1. Elkassabany N. M. et al.. 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).
    1. Zhang Y. W., Yue D. M., Liu Q. R. & Ji Y. The effect of continuous adductor canal blocks on early ambulation after total knee arthroplasty J clin Anesthesiol 31, 966–968 (2015).
    1. Tan Z. et al.. The effect of adductor canal block and femoral nerve block under multimodal analgesia for early analgesic effect and re-habilitation after total knee replacement (chinese). Chin J Orthop 35 (2015).
    1. Li D., Yang Z., Xie X., Zhao J. & Kang P. Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: a systematic review and meta-analysis. Int Orthop (2015).
    1. Moher D., Liberati A., Tetzlaff J. & Altman D. G. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Annals of internal medicine 151, 264–269 (2009).
    1. Higgins J. P. et al.. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. Bmj 343, d5928 (2011).
    1. Wang D. et al.. Genetic association between NFKB1 -94 ins/del ATTG Promoter Polymorphism and cancer risk: a meta-analysis of 42 case-control studies. Sci Rep 6, 30220 (2016).
    1. Balshem H. et al.. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 64, 401–406 (2011).
    1. Kim D. H. et al.. Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial. Anesthesiology 120, 540–550 (2014).
    1. Machi A. T. et al.. Discharge Readiness after Tricompartment Knee Arthroplasty: Adductor Canal versus Femoral Continuous Nerve Blocks-A Dual-center, Randomized Trial. Anesthesiology 123, 444–456 (2015).
    1. Shah N. A. & Jain N. P. Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty? Effect on ambulation ability, early functional recovery and pain control: a randomized controlled trial. J Arthroplasty 29, 2224–2229 (2014).
    1. Jaeger P. et al.. Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double-blind, placebo-controlled, crossover study in healthy volunteers. Anesthesiology 118, 409–415 (2013).
    1. Kwofie M. K. et al.. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med 38, 321–325 (2013).
    1. Higgins J. (2013).
    1. Kuang M. J. et al.. Adductor canal block versus continuous femoral nerve block in primary total knee arthroplasty: A meta-analysis. Int J Surg 31, 17–24 (2016).
    1. Jenstrup M. T. et al.. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 56, 357–364 (2012).
    1. Mudumbai S. C. et al.. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 472, 1377–1383 (2014).

Source: PubMed

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