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Jebmh.com Original Research Article

Comparison of Analgesic Outcome of Ultrasound Guided Distal Adductor Canal Block with Proximal Adductor Canal Block for Patients Undergoing Unilateral Total Knee Replacement- A Prospective Single Blinded Study

Manasa Vijay1, B. Girija Kumari2, Subashree Jayaraman3

1Assistant Professor, Department of Anaesthesia, Balaji Institute of Surgery, Research and Rehabilitation for Disabled, Tirupati, Andhra Pradesh. 2Assistant Professor, Department of Anaesthesia, Balaji Institute of Surgery, Research and Rehabilitation for Disabled, Tirupati, Andhra Pradesh. 3Assistant Professor, Department of Anaesthesia, Balaji Institute of Surgery, Research and Rehabilitation for Disabled, Tirupati, Andhra Pradesh.

ABSTRACT

BACKGROUND Continuous epidural analgesia is the gold standard for postoperative analgesia for Corresponding Author: lower limb surgeries. But it needs strict patient monitoring as it can cause Dr. B. Girija Kumari, Department of Anaesthesia, hypotension, opioid induced bradycardia, delayed mobility due to dense motor Balaji Institute of Surgery, Research and block, leading to long hospital stay which in turn makes the patient prone for Rehabilitation for Disabled, nosocomial infections and DVT. Other modes of analgesia include Tirupati- 517501, Andhra Pradesh. block but this leads to quadriceps weakness leading to delayed mobility and patient E-mail: [email protected] discharge. DOI: 10.18410/jebmh/2019/615

Financial or Other Competing Interests: METHODS None. We describe two different sites of injections of drug into adductor canal that is upper adductor canal and lower adductor canal to evaluate adequate analgesia. How to Cite This Article: 100 patients posted for unilateral TKR was selected randomly. Block was Manasa V, Girija Kumari B, Subashree J. performed post-operatively. Group A patients received distal adductor canal block Comparison of analgesic outcome of and group B patients received proximal adductor canal block. Both the groups of ultrasound guided distal adductor canal block with proximal adductor canal block patients received 0.25% bupivacaine 40 ml. Painless time after giving block was for patients undergoing unilateral total noted by the ICU staff who was blinded and the total amount of analgesia required knee replacement a prospective single in 24 hours was noted along with the VAS score at 12 Hrs and 24 Hrs after surgery. blinded study. J. Evid. Based Med. Healthc. 2019; 6(46), 2950-2954. DOI: RESULTS 10.18410/jebmh/2019/615 Lower adductor canal block provided better analgesia with a VAS score significantly Submission 28-10-2019, less at 12 hrs and 24 hrs and also the painless time in hours was significantly more Peer Review 01-11-2019, in group A patients. We also noticed that the analgesic requirement in group A Acceptance 06-11-2019, patients was less compared to group B at 0.01 level 99% sign. Published 18-11-2019.

CONCLUSIONS

Lower adductor canal block provided better analgesic outcome in patients undergoing unilateral TKR in the acute postoperative period.

KEYWORDS Adductor Canal, , Femoral Nerve,

J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 46/Nov. 18, 2019 Page 2950

Jebmh.com Original Research Article

BACKGROUND VAS score was noted at 12th Hours and 24 Hours after

surgery. Total dose of opioid that is Butrum and Paracetamol Regional anaesthesia techniques used for knee and below required up to 24 Hours was noted. knee surgeries have been extensively studied and have provided excellent options for perioperative care for every age group of patients.1 Various studies have confirmed the early recovery with adductor canal block over femoral nerve block, with motor sparing effect for knee surgeries.1 The combination of the femoral nerve block with sciatic nerve block has provided adequate analgesia with lower consumption of perioperative opioids and rescue analgesia, 1 for knee and below knee surgeries. The superior efficacy of the combined adductor canal block with the sciatic nerve Figure 1. Ultrasound Description of Anatomy. Point of block comes with associated technical difficulties including Injection is on the Superficial Femoral Artery. Division of positioning of patients differently for both the blocks. Studies Femoral Artery into Descending Genicular Artery have shown that block given at Lower Adductor canal

successfully has blocked saphenous nerve, obturator nerve, nerve to and sciatic nerve through a single RESULTS

injection point.1 Groups N Mean ± S.D. Range t-value p Group 1 50 9.35±3.36 4.3-15.20 Hrs 0.000 Group 2 50 5.19±1.25 2.15 – 8.20 Hrs METHODS **significant at 0.01 level (P<0.001)

Table 1 100 patients undergoing unilateral TKR ASA grade 1 and Group A grade 2 selected randomly in BIRRD Hospital, Tirupati. Pain Group A Group B Total (n=100) Patients with bleeding and clotting disorders, patients with Surgical Pain 42 (84.0) 38 (76.0) 80 (80.0) stenotic lesions, patient refusal, patients allergic to Other Site Back Pain 8 (16.0) 0 (0.0) 8 (8.0) bupivacaine were taken into exclusion criteria. The Table 2. Distribution of Painless Time in Hours Institutional ethical committee clearance was obtained. Informed consent was obtained from each of the patients Group A N Mean ± S.D. Range t-value p-value VAS Score Group A 50 3.50±2.197 0.10.0 1.604 0.112 posted for unilateral knee replacement. All standard ASA (12 Hrs) Group B 50 4.08±1.307 0.-7.0 minimum mandatory monitoring attached. An intravenous Group A 50 1.22±1.516 0-5.0 6.302 0.000 line secured with a running intravenous fluid. The patient Group B 50 2.92±1.158 0-7.0 **significant at 0.001 level; (p<0.001) received subarachnoid block with 0.5% bupivacaine heavy Table 3. Distribution of VAS Score using 25-gauge Quincke Babcock spinal needle in sitting position. After the surgery in the post-operative ICU Supine Group A position was maintained with the ipsilateral leg kept in Group A Group B Total Narcotics No. of No. of No. of external rotation, slight abduction and knees slightly flexed % % % (frog leg position). A linear high frequency ultrasound probe Patients Patients Patients No 20 40.0 0 .0 20 20.0 (6-13 Hz) was used. The probe was placed and vastus Once 19 38.0 0 .0 19 19.0 medialis muscle was identified and scanned proximally. The 1 mg 11 22.0 19 19 30 30.0 vastus and sartorius intersection (antero-medial 2 mg 0 .0 31 31 31 31.0 Total 50 100.0 50 50 100 100.0 intermuscular septum) was identified and the probe was slid Table 4. Requirement of Narcotics proximally till the superficial femoral artery appeared in the (Figure 1). The probe was slid slowly Group A proximally till the descending genicular artery branching Group A Group B Total NSAIDS No. of No. of No. of from superficial femoral artery was visualized in the hiatus. % % % This point was the injection point. (Figure 1) The point was Patients Patients Patients No 4 8.0 0 .0 4 4.0 8-10 cm above the femoral condyle. Under all aseptic Once 13 26.0 0 .0 13 13.0 precautions, the needle was guided in plane from lateral to Twice 5 10.0 0 .0 5 5.0 medial side under USG guidance to reach perivascular region Thrice 4 8.0 0 .0 4 4.0 1 Mg 3 6.0 0 .0 3 3.0 and after negative aspiration 0.25% bupivacaine 40 ml was 2 Mg 12 24.0 19 38.0 31 31.0 injected, visualized to push the femoral artery posteriorly. 3 Mg 8 16.0 30 60.0 28 38.0 Group A patients were given with 0.25% of bupivacaine 40 4 Mg 1 2.0 1 2.0 2 2.0 Total 50 100.0 50 100.0 100 100.0 ml at lower part of adductor canal that is where the division Chi- X2 Value = 43.317 df = 7; p= 0.000 of descending genicular artery was identified. Group B square (significant at 0.01 level) (p<0.01) patients were given 0.25%, 40 ml of bupivacaine at upper Table 4. Distribution of Requirement of NSAID part of canal that is at mid-. Postoperatively patients

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Jebmh.com Original Research Article

There was a significant difference in painless time in hours between the 2 groups (table 6). It was noted that the mean value for group A was 9 hrs. 35 min (mean) and for group B was 5 hrs. 19 min. This indicates that painless time in group A was greater than group B since t value is 8.208 and significance is 0.00 which is less than 0.01 (at 99% level of confidence) which indicates significant difference We also noticed that the VAS sore for 12 hrs. was 3.50 in group A and 4.08 in group B. VAS score at 24 hrs. in group A was 1.22 and group B was 2.92. Which indicates significantly less VAS score in group A patients. We also noticed that the analgesic requirement in group A patients was less compared to group B at 0.01 level 99% sign. Figure 5. Schematic Description of Contents and

Relationships in Adductor Canal- Upper Part of Canal Relevant Anatomy Runs Behind the Femoral Artery in Lower Part of Canal Vein is Lateral to the Artery, Saphenous Nerve Runs Anterior to The Artery in The Upper Part and Then It Becomes Medial to the Femoral Artery in The Lower Part

Figure 2. Cross Section of Adductor Canal Figure 6. Schematic Description of Popliteal Fossa

Figure 3. Boundaries of Adductor Canal- Floor of Upper Part of Adductor Canal is Formed by Adductor Longus and Lower

Part is Formed by Adductor Magnus Figure 7. Schematic Description Course of Obturator Nerve, Saphenous Nerve in Distal Part of Adductor Canal

The adductor canal is a musculo-aponeurotic tunnel extending from the apex of the to the adductor hiatus below. It is divided into upper and lower adductor canal. It is triangle in cross section (Figure 2). Roof is also known as medial wall it is formed by strong fibrous membrane, sub Sartorius plexus derived from medial cutaneous nerve of thigh, saphenous nerve, anterior division of obturator nerve and . Posterior wall is Figure 4. Course of Obturator Nerve- Posterior Division of also known as floor of canal which is formed by adductor Obturator Nerve Runs Over Anterior Surface of Adductor canal in upper part and adductor magnus in lower part of Magnus in Lower Part of Canal canal (Figure 3). Anterior wall is formed by vastus medialis.

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Jebmh.com Original Research Article

The upper part of canal contains the femoral artery, femoral femoral nerve block in providing analgesia and also provides vein posterior to femoral artery along with the femoral nerve better quadriceps strength Runge C, Moriggl B, Borglum J, behind the femoral artery, saphenous nerve anterior to the Bendtsen TF.6 The analgesia for knee and below knee femoral artery, nerve to vastus medialis lateral to the surgeries can be achieved by combining adductor canal femoral artery (Figure 2) lower part of the canal contains block and sciatic nerve block. Combining these two blocks femoral nerve lateral to the femoral artery, descending needs a lateral position or change of position, from supine genicular artery giving branches that is saphenous artery to prone or lateral position, causing discomfort and technical which is a superficial branch accompanies saphenous nerve difficulties in patients. A single injection technique 1 to block and muscular branch pierces vastus medialis supplies knee all these nerves can provide ease of practice and better joint and terminates. Saphenous nerve crosses anterior postoperative care.1 Runge et al6 in 2017, performed a aspect of artery from lateral to medial side, nerve to vastus cadaver study where they described the spread of drug to medialis is not found in lower part of canal, anterior division sciatic nerve when injected in the adductor canal. Wan Yi of obturator nerve ends in the canal by supplying femoral Wong, Siska Bjørn, Jennie Maria Christin Strid, Jens artery. Posterior division of obturator nerve runs behind the Børglum.11 The dye injected in the distal part of adductor femoral artery over the anterior surfaces of adductor canal was seen to spread in the popliteal fossa staining the magnus (Figure 4). The posterior division of the obturator sciatic nerve, the genicular branches of the posterior division nerve along with femoral vessels enters the popliteal fossa of the obturator nerve and the saphenous nerve and the through the adductor hiatus.2 The medial part of knee is nerve to vastus medialis in the adductor canal.12 A cadaveric supplied by the intramuscular, extra muscular and the study conducted by Thiayagarajan et al13 in 2019 proved genicular branches from the nerve to vastus medialis. The that adductor canal is arround 8.5 cms in females and 10.5 saphenous nerve gives off the superficial patellar, posterior cms in male. Wong et al11 also compared the cadaver studies and the deep genicular nerves Bendtsen TF, Moriggl B, Chan and analyzed the location of adductor canal using ultrasound V, Pedersen EM.3 The lateral part of the knee is supplied by and concluded that the true adductor canal lies distal to the the genicular branches from the sciatic nerve division of mid-thigh level and also injection of drug in the distal part common peroneal nerve. The posterior part of the knee and of the adductor canal spreads drug into the popliteal fossa the capsule is supplied by the popliteal plexus formed by the blocking the sciatic nerve also.1 Giving block at lower part of genicular nerves from the posterior division of obturator adductor canal blocked all the four important nerves nerve and tibial division of sciatic nerve.4 The skin around supplying the knee, leg and .1 the knee is supplied by the cutaneous branches from the femoral nerve and the saphenous nerve.5 The nerve supply Limitations of the leg and foot is from the sciatic nerve (tibial nerve and This technique remains safe and easy to perform the early peroneal nerves), except the skin on the medial aspect is rehabilitation potential has to be documented. The need for supplied by the sensory saphenous nerve.6,7,4 the injection to be given in a relatively vascular area requires repeated aspiration and a watchful eye on the ultrasound screen to see the drug spread. In the 100 cases performed DISCUSSION we have not faced any complications, but a larger study is needed to validate such findings.

The epidural analgesia has been considered gold standard

for postoperative analgesia for lower limb surgeries. But CONCLUSIONS

epidural analgesia needs constant monitoring due to hypotension, bradycardia, opioids induced respiratory Sciatic nerve block combined with femoral nerve and depression. However, different peripheral nerve blocks have obturator nerve block, have better outcome in knee and given comparable analgesia to epidural analgesia with lower below knee surgeries. Hence, distal adductor canal block side effects. Morin et al8 have compared the continuous overcomes the positional and technical difficulties described lumbar plexus block, continuous femoral nerve block, and and blocks all 4 nerves and provides better analgesia combined femoral and sciatic nerve block and concluded compared to proximal adductor canal block. that the combination of femoral and sciatic nerve block is required for complete analgesia for knee surgeries Ganapathy S, Wasserman RA, Watson JT, Bennett J, REFERENCES Armstrong KP, Stockall CA, et al.9 Pham et al10 have studied the combination of femoral and sciatic nerve block reduces [1] Roy R, Agarwal G, Pradhan C, et al. Ultrasound guided the postoperative opioid requirement significantly, Morin 4 in 1 block – a newer, single injection technique for AM, Kratz CD, Eberhart LH, Dinges G, Heider E, Schwarz N, complete postoperative analgesia for knee and below et al.8 Various studies have concluded that the combination knee surgeries. Anaesth Pain & Intensive Care of sciatic with femoral nerve block improves the 2018;22(1):87-93. postoperative analgesia significantly Burckett-St Laurant D, [2] Dellon AL. Partial knee joint denervation for knee pain: Peng P, Giron Arango L, Niazi AU, Chan VW, Agur A, et al.5 a review. Orthop & Muscul Syst 2014;3:167. The adductor canal block has been proven to be superior to

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[3] Bendtsen TF, Moriggl B, Chan V, et al. Defining adductor femoral nerve block, and the combination of a canal block. Reg Anesth Pain Med 2014;39(3):253-254. continuous femoral and sciatic nerve block. Reg Anesth [4] De Souza RR, De Carvalho CA, Konig B Jr. Pain Med 2005;30(5):434-445. Topographical anatomy of adductor canal: form, limits [9] Ganapathy S, Wasserman RA, Watson JT, et al. and constitution of its walls. Rev Paul Med 1978;92(1- Modified continuous femoral three-in-one block for 2):6-9. postoperative pain after total knee arthroplasty. Anesth [5] Burckett-St Laurant D, Peng P, Arango GL, et al. The Analg 1999;89(5):1197-1202. nerves of the adductor canal and the innervations of the [10] Dang PC, Gautheron E, Guilley J, et al. The value of knee: an anatomic study. Reg Anesth Pain Med adding sciatic block to continuous femoral block for 2016;41(3):321-327. analgesia after total knee replacement. Reg Anesth Pain [6] Runge C, Moriggl B, Borglum J, et al. The spread of Med 2005;30(2):128-133. ultrasound-guided injectate from the adductor canal to [11] Wong WY, Bjørn S, Strid JMC, et al. Defining the the genicular branch of the posterior obturator nerve location of the adductor canal using ultrasound. Reg and the popliteal plexus –a cadaveric study. Reg Anest Anesth Pain Med 2017;42(2):241-245. Pain Med 2017;42(6):725-730. [12] Hayek SM, Ritchey RM, Sessler D, et al. Continuous [7] Sigirci A. Pain management in total knee arthroplasty by femoral nerve analgesia after unilateral total knee intraoperative local anesthetic application and one-shot arthroplasty: stimulating versus non-stimulating femoral block. Indian J Orthop 2017;51(3):280-285. catheters. Anesth Analg 2006;103(6):1565-1570. [8] Morin AM, Kratz CD, Eberhart LH, et al. Postoperative [13] Thiayagarajan MK, Kumar SV, Venkatesh S. An exact analgesia and functional recovery after total-knee localization of adductor canal and its clinical replacement: comparison of a continuous posterior significance: a cadaveric study. Anesth Essays Res lumbar plexus (psoas compartment) block, a continuous 2019;13(2):284-286.

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