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The effect of adductor-canal-blockade on outcome after medial unicondylar knee arthroplasty: a preliminary study.

Unicondylar knee arthroplasty (UKA) fell into disfavor after reports published in the 1970s and 1980s demonstrated discouraging survivorship data for UKA. (1-3) Over the past two decades, improved surgical technique and implant design have led to improved survivorship (4-10) and resurrected UKA in the arthroplasty surgeon's armamentarium. UKA shows improved functional outcomes (11-14) and better replicates native knee kinematics (15,16) compared to total knee arthroplasty (TKA). Patients prefer UKA to TKA (13) and are more likely to return to sports following UKA. (17) The literature also suggests decreased postoperative morbidity (18,19) and a faster recovery after UKA compared to TKA. (18) Finally, in the modern era with equivalent survivorship, UKA appears to provide potential cost advantages compared to TKA. (20-22)

Postoperative pain management and early rehabilitation are paramount to achieving high patient satisfaction and excellent functional outcomes following knee arthroplasty. (23-25) Opioids provide excellent analgesia and have been considered the gold-standard for management of postoperative pain following joint arthroplasty. Unfortunately, opioids may delay postoperative recovery due to numerous side effects, including nausea, somnolence, altered balance, urinary retention, ileus, hypotension, and respiratory depression. (25-28) Multimodal analgesia protocols were developed and have proven effective to reduce postoperative opioid usage while providing adequate pain relief after joint arthroplasty, including UKA. (23-29-32) Peripheral nerve blockade (PNB) is a crucial component of most multimodal analgesia protocols. PNBs are provided as either a single shot or continuous infusion. Different PNBs have been investigated for use in arthroplasty patients, with lumbar plexus block (LPB) and femoral nerve block (FNB) being most common. LPB anesthetizes three major peripheral nerves within the psoas compartment of interest to the knee surgeon, including the femoral, obturator, and lateral femoral cutaneous nerves. (33,36) LPB has been used successfully in multimodal analgesia after TKA. (30,31,37) FNB affects the femoral nerve but does not reliably anesthetize the obturator or lateral femoral cutaneous nerves. (38) FNB has been used as a single-shot for TKA (39,40) and UKA (41) and as a continuous infusion for TKA (29,42) and UKA. (32,43) While LPB and FNB have both been used successfully to perform knee arthroplasty, which technique provides the optimal regional anesthesia for knee surgery is controversial. (33) LPB and FNB both result in postoperative quadriceps weakness, (29,44-47) which compromises patients' ability to ambulate safely and to participate in physical therapy. Thus, practitioners have sought an alternative PNB capable of providing similar postoperative analgesia while minimizing the morbidity associated with quadriceps weakness that accompanies LPB and FNB.

Adductor canal blockade (ACB) was first described by van der Wal as a more reliable and robust blockade of the saphenous nerve. (48) The technique involved transsartorial injection approximately one finger width proximal to the superior pole of the patella. Subsequent work demonstrated that a more proximal blockade, approximately midway between the anterior superior iliac spine (ASIS) and the patella, may block other nerves known to traverse the adductor (Hunter's) canal in addition to the saphenous nerve, including the posterior branch of the obturator nerve, medial femoral cutaneous nerve, anterior branch of obturator nerve, and the nerve to vastus medialis muscle. (49) At this level, all but the nerve to the vastus medialis muscle are thought to be sensory nerves with contributions to the knee joint. (50) ACB preserves extensor mechanism function better than other PNB techniques. (43-45,51,52) Ultrasound-guided techniques have made ACB both reliable and safe. (53,54) Thus, ACB appears to offer a useful technique to anesthetize the superficial and deeper structures of the medial knee while preserving a majority of the knee's extensor mechanism.

UKA offers decreased morbidity, faster recovery, better functional outcomes, and equivalent survivorship compared to TKA for certain patients. In order for individual patients and the health care system to fully capture the benefits offered by UKA, regional anesthesia techniques must facilitate rather than compromise patients ability for early postoperative mobilization and safe discharge.

The main purpose of our study was to test the hypothesis that the predominantly sensory adductor canal blockade (ACB) would facilitate shorter hospital stay after medial unicompartmental knee arthroplasty (mUKA). Secondary endpoints were narcotic consumption, steps walked during PT sessions, and total PT sessions required prior to discharge.

Material and Methods

Twelve patients scheduled for elective mUKA received spinal anesthesia and single-shot ACB. Prior to this pilot study the standard of care for mUKA at our institution was spinal anesthesia and single-shot LPB. All PNBs were performed preoperatively with the patient sedated. An ultrasound machine (M-turbo, SonoSite, Inc., Bothell, Washington, USA) and a linear HFL38x 13-6 MHz probe were utilized for all ACBs.

ACB patients were matched by age, gender, body mass index (BMI), and Charlson Comorbidity Index in a 1:2 ratio to 24 LPB patients. Time to hospital discharge, number of physical therapy (PT) sessions required for safe discharge, and steps taken during PT sessions were retrospectively abstracted from each patient's medical record. Total daily narcotic consumption was recorded for each patient and then converted to oral morphine equivalents as described in the literature. (55-57) The following conversion factors were used to obtain oral morphine equivalence: morphine IV (3x), hydromorphone IV (12x), hydromorphone orally (6x), oxycodone orally (1.5x), and hydrocodone orally (1x). Criteria for safe hospital discharge were: 1. pain sufficiently controlled with oral agents, 2. ability to ambulate safely as evaluated by a physical therapist, 3. ability to eat and drink, and 4. no surgical complications. House officers, mid-level providers, nursing staff, and physical therapists involved in postoperative patient care were blinded to the PNB used for each patient's surgery.

Patients in both the ACB and LPB cohorts received preoperative and postoperative multimodal adjuvant analgesics as deemed appropriate by the attending anesthesiologist and unless contraindicated. Preoperatively, these routinely consisted of acetaminophen 1,000 mg orally or intravenously, celecoxib 400 mg orally, and pregabalin 150 mg orally. The postoperative analgesic regimen was managed by the acute pain service (APS) at our institution, and all patients had oral and intravenous opioids available as needed for breakthrough pain control. Additionally, multimodal adjuvant analgesics were routinely continued or prescribed as directed by the APS and typically included 1,000 mg acetaminophen orally every 6 hours, celebrex 200 mg twice daily, and pre-gabalin 75 mg twice daily, unless contraindicated. There was no change to the preoperative or postoperative multimodal adjuvant analgesia protocol during the time of this study.

ACBs were performed with the patient supine and the leg of interest externally rotated at the hip. The ultrasound probe was placed at the mid-thigh level, approximately halfway between the ASIS and the patella, to obtain a transverse cross-sectional view of the sartorius muscle and the adductor canal. Underneath the sartorius muscle, the superficial femoral artery was identified in short-axis. The saphenous nerve could often be identified anterior to the artery using anatomical position to define direction, but visualization of the nerve was not necessary for block success. A 21 gauge short bevel needle (Arrow[R] StimuQuik[R]) was inserted in-plane from anterior and advanced through the sartorius muscle and the fascia separating it from the adductor canal. The needle was then directed to the anterior side of the artery adjacent to the saphenous nerve. After negative aspiration and with incremental dosing, 12 to 15 mL of 0.25% bupivacaine (containing 1:200,000 epinephrine and clonidine 50 pg/30 ml) was injected once the spread of local anesthetic was visualized to be within the adductor canal on ultrasound.

LPBs were consistently performed with nerve stimulation using Capdevila's approach to the lumbar plexus. (34) With the patient in the lateral decubitus position with hips flexed, a marking pen was used to draw the intercristal line connecting the iliac crests. The midline was also identified using manual palpation, and the point at which the intercristal line crossed the midline was used to define the L4-L5 interspace. The posterior superior iliac spine (PSIS) was identified, and a second line was drawn from this point parallel to the midline. The distance from this second line to the midline along the intercristal line was then divided into thirds, and the needle insertion site for the LPB was at the intersection of the lateral and medial thirds. The needle was inserted perpendicular to the patient's back and advanced to contact the L4 transverse process. It was then redirected caudally and advanced 2 cm deep to the transverse process to locate the lumbar plexus. Stimulation of the quadriceps muscles at a current between 0.2 mA and 0.8 mA defined adequate needle to nerve approximation. After negative aspiration and with incremental dosing 25 cc of 0.25% bupivacaine (containing 1:200,000 epinephrine and clonidine 50 [micro]g/30 ml) was injected.

Patient demographic and endpoint data were compared between the ACB and LPB cohorts using a two-tailed, unpaired, Student's t-test for continuous data and chi-square analysis for categorical data (Prism 5, GraphPad Software Inc., La Jolla, CA). Alpha was set to 0.05 to determine statistical significance. All data are presented as mean and standard deviation.

Results

Patient demographics, including sex, age, BMI, and Charlson Comorbidity Index, were similar for ACB and LPB groups (Table 1). Patients who received ACB had a significantly shorter hospital stay (27.8 [+ or -] 3.9 hours) compared with patients who received LPB (39.7 [+ or -] 18.5 hours, p = 0.025) (Table 2). Patients treated with ACB required significantly fewer PT sessions (1.3 [+ or -] 0.6 sessions) compared to patients who received LPB (2.4 [+ or -] 1.5 sessions, p = 0.007). Nine of 12 (75%) patients treated with ACB required only one PT session prior to safe discharge compared to only 6 of 24 (25%) patients treated with LPB, which was significantly different (p = 0.032). Patients treated with ACB walked significantly more steps during their first PT session (225.0 [+ or -] 156.6 steps) compared with patients treated with LPB (107.4 [+ or -] 170.0, p = 0.045). There was no statistical difference in steps walked during the second PT session between groups. There was a trend toward more patients being able to ambulate during the first PT session following ACB (83%) compared with LPB (54%, p = 0.143). Finally, there was a trend towards decreased narcotic requirements in the ACB group compared to the LPB group, but the differences were not significant on either postoperative day 1 or 2.

Discussion

UKA offers patients the potential for decreased postoperative morbidity, (18,19) faster recovery, (18) more normal knee kinematics, (15,16) and improved function (11-14,17) while providing equivalent survivorship to TKA. (4-10) UKA has also been demonstrated to be a cost-effective alternative to TKA, (20-22) which is an important consideration for patients, payors, providers, and institutions in the current healthcare environment. Multimodal anesthesia protocols are important for achieving patient satisfaction and good clinical outcomes after joint arthroplasty. PNBs play an important role in these protocols, and the ACB is a relatively new PNB designed to exert predominantly sensory effects while minimizing quadriceps weakness that appears well suited to mUKA. (48-50) In this present preliminary study, we compare ACB to LPB in terms of length of hospital stay, several measures of postoperative ambulatory ability, and postoperative opioid consumption.

Our data suggests that ACB significantly shortened patients' hospital stays following mUKA compared to LPB (27.8 versus 39.7 hours, p = 0.025). Enhanced ambulation following mUKA was observed in the ACB cohort, with a three-fold increase in patients safely discharged after only one PT session (ACB:75% versus LPB:25%, p = 0.032), and more steps taken during the initial PT session (ACB :225 steps versus LPB: 108 steps, p = 0.045). Patients treated with ACB showed a trend toward reduced postoperative narcotic requirement following mUKA compared to LPB.

Minimizing the length of stay after knee arthroplasty may be desirable from the perspectives of improved outcomes, decreased postoperative morbidity, and cost-effectiveness. (58,59) The feasibility of outpatient or same day UKA has been shown. Cross and coworkers reported a 100% success rate discharging patients home on the day of surgery in a cohort of 105 patients indicated for outpatient UKA. (60) A multimodal analgesia protocol was utilized that included premedicating patient with opioids and anti-emetics, epidural anesthesia intraoperatively without intravenous narcotics, transfusion of one unit of autologous blood, use of a suction-reinfusion drain system, postoperative intravenous fluid therapy to prevent hypotension, an indwelling bladder catheter to minimize bladder distension, postoperative analgesia with oral opioids, and PT. (60) The investigators' protocol did not include a PNB. Gondusky and colleagues reported a 99% success rate discharging patients home on the day of surgery in a cohort of 160 patients. (41) All patients were prescribed oral narcotics, antibiotics, and a sleep aid at a preoperative appointment, and selected patients were prescribed a scopolamine patch. Preoperatively patients were administered a histamine H2 antagonist, a short-acting benzodiazepine, and a single-shot FNB. (41) Surgery was performed under general anesthesia, and intravenous narcotics were administered as needed. Ropivicaine 0.2% was injected periarticularly in all patients. (41) All patients were discharged with a knee-immobilizer that they were instructed to wear with all weightbearing activities until they could perform five normal straight leg raises. (41) Patients were also discharged with a front-wheel walker or crutches and home health PT was arranged. (41) The investigators reported five postoperative complications, including two patients requiring reoperation and one patient each with hematoma, wound drainage, and readmission (POD9 for fatigue and UTI). (41) Although the investigators reported zero falls as postoperative complications, the number of patient falls may be underreported. Dervin and associates reported on their experience with same day UKA. (32) These investigators described inclusion and exclusion criteria to identify patients thought suitable for same day UKA. (32) An initial cohort of 91 patients were screened, and 40 patients were offered same day UKA; 16 of 40 patients declined same day UKA secondary to apprehension related to same day surgery, which left a cohort of 24 patients who underwent UKA with the intention of day of surgery discharge. (32) Preoperative prescriptions were provided for acetaminophen, celecoxib, pregabalin, and oral hydromorphone, and these medications were also administered preoperatively. (32) A continuous FNB was administered, prior to which patients were sedated using midazolam, fentanyl, and ketamine. Surgeries were performed under spinal anesthesia and pericapsular injection of ropivicaine, morphine, and ketorolac was administered. (32) Postoperatively patients received oral acetaminophen, celecoxib, pregabalin, and hydromorphone as needed. (32) The FNB was fitted with a disposable pump system, and patients were discharged with a continuous FNB. (32) Intensive postoperative home nursing services were arranged. (32) The investigators reported two complications, one prolonged wound drainage that required revision arthrotomy and one bearing dislocation that required revision. (32) Although the two protocols that utilized a FNB reported low rates of falls, both groups relied heavily on knee immobilizers, assistive devices, and home health PT and nursing services, which may impede rehabilitation and require additional resources to coordinate and administer. These reports demonstrate early hospital discharge following UKA is both feasible and relatively safe. However, the protocols underscore the problems inherent to LPB or FNB. Cross and coworkers elected not to utilize any PNB, and while both Gondusky and colleagues and Dervin and associates utilized FNB in their protocols, they directed significant resources towards minimizing fall risk. Beebe and coworkers reinforce this concept, reporting the early ambulation is possible with a FNB following TKA but only with a knee immobilizer and front-wheeled walker. (42) A RCT will be required to determine whether early ambulation requiring a knee immobilizer compared to early ambulation without a knee immobilizer makes a clinical difference. There is a significant financial cost associated with impaired quadriceps function, including durable medical equipment, professional services, and potential liability and possible readmission if a patient fell.

A Danish group has investigated ACB as an alternative PNB to provide similar analgesia while avoiding extensor mechanism weakness that is the major drawback of both LPB and FNB. In a preliminary study, ACB was associated with low pain scores and morphine requirement following TKA when qualitatively referenced against historical controls treated with FNB. (49) In a subsequent randomized controlled trial (RCT), the investigators reported that continuous ACB decreased morphine requirements, reduced pain during knee range of motion, and improved ambulatory ability compared to placebo in patients undergoing TKA. (50) The same investigators performed another RCT to compare ACB to FNB and concluded that ACB better preserved quadriceps strength but resulted in no significant differences in pain or morphine requirements after TKA compared to FNB. (51) In a study of healthy volunteers, the investigators demonstrated ACB was significantly better at preserving quadriceps strength and ambulatory ability compared to FNB. (44) These investigators also conducted a safety study and reported no saphenous nerve injuries following ACB in a cohort of 97 patients. (54) Other investigators have confirmed the Danish groups' results. Mudumbai and colleagues demonstrated significantly increased postoperative ambulation following TKA in patients treated with continuous ACB compared to continuous FNB and noted equivalent pain scores, opioid consumption, and length of hospitalization between groups. (43) Kim and coworkers conducted a RCT comparing single-shot ACB to single-shot FNB and reported that ACB resulted in increased extensor mechanism strength and was non-inferior in pain control and opioid consumption compared to FNB. (52) Kwofie and colleagues administered single-shot ACB and FNB to healthy volunteers and found no decrease from baseline in extensor mechanism strength or balance after ACB but found significant decrement in both parameters following FNB. (45) Another recent prospective study reported a 100% success rate of ACB in 20 consecutive patients. (53)

Our data provides further support for the above findings and suggests that the benefits of ACB extend to UKA. Our data does not directly measure quadriceps strength but demonstrates that ACB allows patients to participate earlier and more vigorously in PT and to clear PT sooner compared to LPB, indirectly suggesting relative preservation of quadriceps strength and similar analgesic effects. The trend towards decreased opioid consumption in the ACB cohort compared to the LPB group suggests that ACB provides similar pain control following UKA. It is important to note that much of the above work compares ACB to FNB while our work compares ACB to LPB. At our institution, we use continuous FNB for TKA but elected to use single-shot LPB rather than FNB for mUKA because of sporadic postoperative patient complaints of pain following UKA, which was managed at our institution by administration of a single-shot obturator nerve block. For this reason, the protocol was changed so all UKA patients received LPB.

Our preliminary study was limited by its retrospective case-control design. We utilized a two-to-one matching process to identify control patients with similar comorbidities to ACB patients; however, the retrospective nature and matching process cannot eliminate possible selection bias. The relatively small number of patients may limit the power of our study to detect significant differences in selected endpoints. Finally, we could not formally compare muscle strength, balance, proprioception, fall risk, or patient satisfaction because these endpoints were not obtained for control patients.

Conclusion

Multimodal analgesia protocols for knee arthroplasty may be improved by substituting ACB for LPB or FNB given the ability of ACB to provide equivalent analgesia while better preserving quadriceps function. Data from our study suggests that ACB may permit earlier hospital discharge and better participation in PT without compromising the quality of perioperative analgesia and may represent a promising option for mUKA. These encouraging initial results suggest that a prospective, randomized trial to provide Level I evidence regarding the utility of ACB in the setting of mUKA would be valuable.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.

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Matthew L. Brown, M.D., Thorsten M. Seyler, M.D., John Allen, B.S., Johannes F. Plate, M.D., Daryl S. Henshaw, M.D., and Jason E. Lang, M.D.

Matthew L. Brown, M.D., Thorsten M. Seyler, M.D., John Allen, B.S., Johannes F. Plate, M.D., and Jason E. Lang, M.D., Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, North Carolina. Daryl S. Henshaw, M.D., Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina.

Correspondence: Jason E. Lang, M.D., Residency Program Director, Chief of the Division of Adult Reconstruction, Department of Orthopaedic Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157; jlang@ wakehealth.edu.
Table 1 Patient Demographics

                  ACB                  LPB                  P value

Patients          12                   24
Male              5 (42%)              10 (42%)
Age               59.8 [+ or -] 7.5    59.5 [+ or -] 7.3    0.250
Body Mass Index   31.2 [+ or -] 5.6    31.6 [+ or -] 5.4    0.801
Charlson          0.83 [+ or -] 0.55   0.83 [+ or -] 0.56   0.984
  Comorbidity
  Index

ACB, adductor canal block; LPB, lumbar plexus block.

Table 2 Outcome Measures Following mUKA

                         ACB                    LPB

Time to hospital         27.8 [+ or -] 3.9      39.7 [+ or -] 18.5
  discharge (hours)
Mean Number of           1.3 [+ or -] 0.6       2.4 [+ or -] 1.5
  PT sessions
Number of PT
  sessions to
  discharge:
  1                      9 (75%)                6 (25%)
  2                      2 (17%)                11 (45%)
  3                      1 (8%)                 3 (13%)
  >3                     0 (0%)                 4 (17%)
Patient walked           10 (83%)               13 (54%)
  during 1st
  PT session
Steps taken during PT:
  First session          225.0 [+ or -] 156.6   107.4 [+ or -] 170.0
  Second session         233.3 [+ or -] 117.9   184.3 [+ or -] 133.5
Opioid use (oral MEQ)
  POD#1                  66.8 [+ or -] 37.8     78.2 [+ or -] 50.3
  POD#2                  9.6 [+ or -] 22.2      37.8 [+ or -] 60.9

                         P value

Time to hospital         0.025
  discharge (hours)
Mean Number of           0.007
  PT sessions
Number of PT             0.032
  sessions to
  discharge:
  1
  2
  3
  >3
Patient walked           0.143
  during 1st
  PT session
Steps taken during PT:
  First session          0.045
  Second session         0.566
Opioid use (oral MEQ)
  POD#1                  0.452
  POD#2                  0.052

ACB, adductor canal block; LPB, lumbar plexus block;
PT, physical therapy; POD, postoperative day;
MEQ, morphine equivalent dose.
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Author:Brown, Matthew L.; Seyler, Thorsten M.; Allen, John; Plate, Johannes F.; Henshaw, Daryl S.; Lang, Ja
Publication:Bulletin of the NYU Hospital for Joint Diseases
Article Type:Report
Date:Jan 1, 2015
Words:5449
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