Motor-Sparing Effect of Adductor Canal Block for Knee Analgesia: An Updated Review and a Subgroup Analysis of Randomized Controlled Trials Based on a Corrected Classification System

Yu-Hsuan Fan Chiang, Ming-Tse Wang, Shun-Ming Chan, Se-Yi Chen, Man-Ling Wang, Jin-De Hou, Hsiao-Chien Tsai, Jui-An Lin, Yu-Hsuan Fan Chiang, Ming-Tse Wang, Shun-Ming Chan, Se-Yi Chen, Man-Ling Wang, Jin-De Hou, Hsiao-Chien Tsai, Jui-An Lin

Abstract

Objective: Discrepancies in the definition of adductor canal block (ACB) lead to inconsistent results. To investigate the actual analgesic and motor-sparing effects of ACB by anatomically defining femoral triangle block (FTB), proximal ACB (p-ACB), and distal ACB (d-ACB), we re-classified the previously claimed ACB approaches according to the ultrasound findings or descriptions in the corresponding published articles. A meta-analysis with subsequent subgroup analyses based on these corrected results was performed to examine the true impact of ACB on its analgesic effect and motor function (quadriceps muscle strength or mobilization ability). An optimal ACB technique was also suggested based on an updated review of evidence and ultrasound anatomy.

Materials and methods: We systematically searched studies describing the use of ACB for knee surgery. Cochrane Library, PubMed, Web of Science, and Embase were searched with the exclusion of non-English articles from inception to 28 February 2022. The motor-sparing and analgesic aspects in true ACB were evaluated using meta-analyses with subsequent subgroup analyses according to the corrected classification system.

Results: The meta-analysis includes 19 randomized controlled trials. Compared with the femoral nerve block group, the quadriceps muscle strength (standardized mean difference (SMD) = 0.33, 95%-CI [0.01; 0.65]) and mobilization ability (SMD = -22.44, 95%-CI [-35.37; -9.51]) are more preserved in the mixed ACB group at 24 h after knee surgery. Compared with the true ACB group, the FTB group (SMD = 5.59, 95%-CI [3.44; 8.46]) has a significantly decreased mobilization ability at 24 h after knee surgery.

Conclusion: By using the corrected classification system, we proved the motor-sparing effect of true ACB compared to FTB. According to the updated ultrasound anatomy, we suggested proximal ACB to be the analgesic technique of choice for knee surgery. Although a single-shot ACB is limited in duration, it remains the candidate of the analgesic standard for knee surgery on postoperative day 1 or 2 because it induces analgesia with less motor involvement in the era of multimodal analgesia. Furthermore, data from the corrected classification system may provide the basis for future research.

Keywords: analgesia; classification; knee; motor activity: motor-sparing; nerve block: adductor canal block; randomized controlled trial.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Anatomical illustration of the femoral triangle (FT) and the adductor canal (AC). FA, femoral artery (red arrow); FV, femoral vein (blue arrow); STM, sartorius muscle; ALM, adductor longus muscle; AMM, adductor magnus muscle; VMM, vastus medialis muscle; VAM, vastoadductor membrane (purple arrow); NVM, nerve to vastus medialis (cyanide arrow); SN, saphenous nerve (green arrow); FT, femoral triangle; AC, adductor canal; descending genicular artery (orange arrow).
Figure 2
Figure 2
Ergonomic position for proximal adductor canal block. (A) Patient position for mid-thigh localization. The patient is in a supine position with the hip externally rotated and the knee slightly flexed. (B) Operator and ultrasound machine position. Operators stand same side and lateral to the leg, hold the needle with dominant hand, and position the ultrasound machine on the opposite side of the patient. AC, adductor canal; ASIS, anterior superior iliac spine.
Figure 3
Figure 3
Ultrasound identification of the adductor canal. (A) Mark the mid-thigh location midway between the ASIS and base of the patella. Place the probe transversely to obtain short axis view. (B) Identify the femoral vessels. Distinguish the artery by compression sign. (C) Slide the probe medially (red arrow) to visualize (D) the medial borders of the sartorius and adductor longus muscle. (E) Slide the probe caudally (red arrow) along the medial borders of the sartorius muscle and the adductor longus muscle to visualize (F) the point of the start of the adductor canal, intersection of the medial borders of sartorius muscle and adductor longus muscle. (G) Adjust the probe to make the neurovascular bundle on the medial side of the ultrasound screen. Then, slide the probe caudally until (H) the femoral artery goes deep to the adductor hiatus. ASIS, anterior superior iliac spine; pAC, proximal adductor canal; dAC, distal adductor canal; FA, femoral artery; V, femoral vein; STM, sartorius muscle; ALM, adductor longus muscle; VMM, vastus medialis muscle.
Figure 4
Figure 4
The research results and selection procedure.
Figure 5
Figure 5
Forest plot of quadriceps muscle strength between the mixed ACB group and the FNB group “24 h, 48 h”.
Figure 6
Figure 6
Forest plot of Time Up and Go test between the mixed ACB group and the FNB group (24 h, 48 h).
Figure 7
Figure 7
Forest plot of Time Up and Go test between “the ACB group with the exclusion of FTB and studies with undetermined definition” and the FNB group (24 h, 48 h).
Figure 8
Figure 8
Forest plot of pain scores between the FTB group and the true ACB group (24 h).
Figure 9
Figure 9
Forest plot of Time Up and Go test between the FTB group and the true ACB group (24 h).

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Source: PubMed

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