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Li Q, Zhuang Z, Chen D, Tang S, Jiang Q. Does Proximal Adductor Canal Block Provide Better Analgesic Efficacy than Distal Adductor Canal Block in Patients Undergoing Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Orthop Surg 2024; 16:1019-1033. [PMID: 38506184 PMCID: PMC11062875 DOI: 10.1111/os.14027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 03/21/2024] Open
Abstract
To compare the analgesic efficacy and adverse events of proximal versus distal ACB for adults undergoing knee arthroplasty, we searched PubMed, Cochrane, Web of Science, and Embase to identify all eligible randomized controlled trials (RCTs). The study quality of the RCTs was evaluated using the Cochrane risk of bias assessment tool. Heterogeneity among studies was examined by Cochrane Q test. Our primary outcomes were pain intensity at rest/during movement and morphine consumption. Statistical analyses were conducted by RevMan Software. Seven eligible studies involving 400 subjects were included in this meta-analysis with 202 participants in the proximal ACB group and 198 participants in the distal ACB group. The results demonstrated that proximal ACB provided significantly better pain relief at rest at 2 h (SMD -0.27, 95% CI -0.54 to -0.01, four trials, 222 participants, I2 = 0, p = 0.04) and 24 h (SMD -0.28, 95% CI -0.48 to -0.08, seven trials, 400 participants, I2 = 0, p = 0.006) following the surgery. We found no evidence of a difference in postoperative pain intensity at other timepoints. Furthermore, we noted no evidence of a difference in cumulative morphine consumption and occurrence of adverse events. Proximal ACB provides better pain relief and comparable adverse effects profile compared with distal ACB. The analgesic benefit offered by proximal ACB, however, did not appear to extend beyond the first 24 h. The overall evidence level was mostly low or very low, which requires more well-organized multicenter randomized trials in the future.
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Affiliation(s)
- Qiangqiang Li
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing UniversityNanjingPeople's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and RehabilitationNanjingPeople's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing Medical UniversityNanjingPeople's Republic of China
| | - Zaikai Zhuang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing UniversityNanjingPeople's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and RehabilitationNanjingPeople's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing Medical UniversityNanjingPeople's Republic of China
| | - Dongyang Chen
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing UniversityNanjingPeople's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and RehabilitationNanjingPeople's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing Medical UniversityNanjingPeople's Republic of China
| | - Shaowen Tang
- Department of EpidemiologySchool of Public Health, Nanjing Medical UniversityNanjingChina
| | - Qing Jiang
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing UniversityNanjingPeople's Republic of China
- Branch of National Clinical Research Center for Orthopedics, Sports Medicine and RehabilitationNanjingPeople's Republic of China
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic SurgeryNanjing Drum Tower Hospital Clinical College of Nanjing Medical UniversityNanjingPeople's Republic of China
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Swenson JD, Conrad KM, Pace NL, Phillips K, Saltzman CL. Scheduled, Simultaneous Dosing of Pregabalin, Celecoxib, and Acetaminophen Markedly Reduces or Eliminates Opioid Use After ACL Reconstruction Using Allograft or Hamstring Tendon Autograft: A Randomized Clinical Trial. Orthop J Sports Med 2022; 10:23259671221140837. [PMID: 36518729 PMCID: PMC9743025 DOI: 10.1177/23259671221140837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/13/2022] [Indexed: 09/05/2023] Open
Abstract
BACKGROUND Opioid analgesics continue to be prescribed after ambulatory surgery despite untoward adverse effects, risk of overdose, and association with substance use disorder. PURPOSE/HYPOTHESIS The purpose was to investigate the use of a novel system to provide scheduled and simultaneous dosing of acetaminophen, celecoxib, and pregabalin after anterior cruciate ligament reconstruction (ACLR). It was hypothesized that this system would markedly reduce pain and opioid use compared with existing best practice. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS Included were 100 patients scheduled for elective, primary ACLR using allograft or hamstring tendon autograft. Selection criteria included age between 18 and 65 years and weight between 65 and 120 kg. Exclusion criteria were a known allergy to any drug used in the study or the use of opioid analgesics before surgery. Patients in the intervention group received a blister pack with scheduled, simultaneous doses of acetaminophen, celecoxib, and pregabalin; patients were also given oxycodone 5 mg as needed for breakthrough pain. Patients in the control group were prescribed ibuprofen and oxycodone 5 mg/acetaminophen 325 mg as needed for pain. The primary outcome measure was pain. Secondary outcomes were nausea, itching, and daily oxycodone use. Patients were asked to quantify their average pain at rest, nausea, and itching on an 11-point verbal scale (from 0 to 10). These data were recorded for 6 days during daily telephone contacts with patients after hospital discharge. RESULTS Cumulative results for 6 days showed significantly lower values in the intervention group compared with the control group for pain (median [interquartile range], 28 [14-35] vs 35 [28-41], respectively; P = .009) and oxycodone use (median [interquartile range] number of tablets, 0 [0-2] vs 8 [1.25-16], respectively; P < .001). Based on these data, the upper tolerance limits for the number of oxycodone tablets required by 90% of patients in the intervention and control groups were 8 tablets and 30 tablets, respectively. Cumulative results for nausea and itching were also significantly lower for the intervention group. Most patients in the intervention group used no opioids during recovery. CONCLUSION Simultaneous dosing of 3 nonopioid analgesics resulted in reduced postoperative pain and markedly lower opioid use. REGISTRATION NCT04015908 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Jeffrey D. Swenson
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Kevin M. Conrad
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Nathan L. Pace
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah, USA
| | - Kathleen Phillips
- Department of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Charles L. Saltzman
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah, USA
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Desai RG, de Guzman KD, van Helmond N, Patel KM. Computer-Assisted Instrument Guidance to Improve Adductor Canal Block Performance for Total Knee Arthroplasty: A Pilot Randomized Controlled Trial. Cureus 2021; 13:e14300. [PMID: 33968512 PMCID: PMC8099000 DOI: 10.7759/cureus.14300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Postoperative pain associated with total knee arthroplasties (TKAs) is routinely managed with ultrasound-guided adductor canal blocks (ACBs). Computer-assisted instrument guidance (CAIG) systems can supplement the existing ultrasound machinery and block needles. CAIG systems allow the operator to navigate the needle in real time while displaying a projected trajectory of its path onto the ultrasound monitor. This study explored how ACBs performed with CAIG compare with conventional ultrasound-only ACBs in terms of block efficiency, success, and potential tissue damage for patients undergoing TKA. Methodology A total of 26 patients undergoing TKA under spinal anesthesia with an ACB were randomized to ACB utilizing conventional real-time ultrasound or to ACB utilizing real-time ultrasound supplemented with CAIG. The primary outcome measure was time to block completion. The secondary outcome measures included number of needle insertions, postoperative pain scores until postoperative day three, postoperative muscle weakness, opioid requirements on postoperative day zero, length of stay, and patient satisfaction with pain management. Results The time required to complete the block as well as the number of needle insertion attempts were similar between the CAIG and conventional ACB groups. Postoperative outcomes such as pain scores up to postoperative day three, postoperative muscle weakness, opioid requirements on postoperative day zero, length of stay, and patient satisfaction with perioperative pain management were comparable between the CAIG and conventional ACB groups. Conclusions CAIG does not reduce ACB performance times or patient outcomes when performed by experienced anesthesiologists.
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Affiliation(s)
- Ronak G Desai
- Anesthesiology, Cooper University Hospital, Camden, USA
| | - Kiana D de Guzman
- Anesthesiology, Cooper Medical School of Rowan University, Camden, USA
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Layera S, Aliste J, Bravo D, Saadawi M, Salinas FV, Tran DQ. Motor-sparing nerve blocks for total knee replacement: A scoping review. J Clin Anesth 2020; 68:110076. [PMID: 33035871 DOI: 10.1016/j.jclinane.2020.110076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/24/2020] [Accepted: 09/20/2020] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE This scoping review investigates the optimal combination of motor-sparing analgesic interventions for patients undergoing total knee replacement (TKR). DESIGN Scoping review. INTERVENTION MEDLINE, EMBASE and CINAHL databases were searched (inception-last week of May 2020). Only trials including motor-sparing interventions were included. Randomized controlled trials lacking prospective registration and blinded assessment were excluded. MAIN RESULTS The cumulative evidence suggests that femoral triangle blocks outperform placebo and periarticular infiltration. When combined with the latter, femoral triangle blocks are associated with improved pain control, higher patient satisfaction and decreased opioid consumption. Continuous femoral triangle blocks provide superior postoperative analgesia compared with their single-injection counterparts. However, these benefits seem less pronounced when perineural adjuvants are used. Combined femoral triangle-obturator blocks result in improved analgesia and swifter discharge compared with femoral triangle blocks alone. CONCLUSIONS The optimal analgesic strategy for TKR may include a combination of different analgesic modalities (periarticular infiltration, femoral triangle blocks, obturator nerve block). Future trials are required to investigate the incremental benefits provided by local anesthetic infiltration between the popliteal artery and the capsule of the knee (IPACK), popliteal plexus block and genicular nerve block.
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Affiliation(s)
- Sebastián Layera
- Hospital Clínico Universidad de Chile, Department of Anesthesiology and Perioperative Medicine, University of Chile, Office B222 2nd Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile.
| | - Julián Aliste
- Hospital Clínico Universidad de Chile, Department of Anesthesiology and Perioperative Medicine, University of Chile, Office B222 2nd Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile
| | - Daniela Bravo
- Hospital Clínico Universidad de Chile, Department of Anesthesiology and Perioperative Medicine, University of Chile, Office B222 2nd Floor, Sector B, 999 Santos Dumont, Independencia, Santiago 8380456, Chile
| | - Mohammed Saadawi
- St. Mary's Hospital, Department of Anesthesiology, McGill University, 3830 Ave Lacombe, Montreal, Quebec H3T-1M5, Canada
| | - Francis V Salinas
- US Anesthesia Partners-Washington, Swedish Medical Center, Department of Anesthesiology, Seattle, WA, USA
| | - De Q Tran
- St. Mary's Hospital, Department of Anesthesiology, McGill University, 3830 Ave Lacombe, Montreal, Quebec H3T-1M5, Canada
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Hamilton DL. Increasing patient safety during adductor canal block. Reg Anesth Pain Med 2020; 45:394. [PMID: 32122973 DOI: 10.1136/rapm-2019-101015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 09/28/2019] [Accepted: 10/01/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Duncan Lee Hamilton
- Anaesthesia, James Cook University Hospital, Middlesbrough, UK .,Hull York University School of Medicine, York, UK
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Lansdown AK, Yong DB, Chuan A. Not so fast! The argument for a simplified adductor canal block might not be so simple after all…. Reg Anesth Pain Med 2019; 44:rapm-2019-100595. [PMID: 31101733 DOI: 10.1136/rapm-2019-100595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Andrew Kenneth Lansdown
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - David Benjamin Yong
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Alwin Chuan
- University of New South Wales Faculty of Medicine, Putney, New South Wales, Australia
- Department of Anaesthesia, Liverpool Hospital, Liverpool, New South Wales, Australia
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Gleicher Y, Peacock S. Local anesthetic systemic toxicity following adductor canal block. Reg Anesth Pain Med 2019; 44:rapm-2019-100610. [PMID: 31023933 DOI: 10.1136/rapm-2019-100610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
| | - Shaorn Peacock
- Anesthesia, University of Toronto, Toronto, Ontario, Canada
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