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 femoral nerve 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, Saphenous Nerve, Femoral Nerve, Femoral Artery 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 vastus medialis and sciatic nerve through a single RESULTS 1 injection point. 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 adductor hiatus (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-thigh. Postoperatively patients J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 6/Issue 46/Nov. 18, 2019 Page 2951 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 Femoral Vein 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.