Impact of Adductor Canal Block on Functional Recovery

Assiut University

Status: Unknown

Conditions: Total Knee Replacement

Treatments: Procedure: Adductor Canal block; Procedure: Peri-articular Infilteration; Procedure: Intrathecal morphine

Study type: Interventional

Funder types: Other

Identifiers

NCT04814303

Adductor canal block in TKR

Details and patient eligibility

About

TKA involves extensive bone resection as well as soft tissue excision and therefore is associated with profound postoperative pain. Adequate analgesia after TKA is therefore considered paramount to facilitate early hospital discharge and effective functional recovery.

Full description

Osteoarthritis (OA) of the knee has become a major public health issue and imposes a significant healthcare burden and accounts for high annual hospitalizations. Chronic OA of the knee may lead to reduced physical fitness, mobility disability with a resultant increased risk of cardio-metabolic comorbidity and early mortality. Total knee arthroplasty (TKA) is indicated in severe cases to improve long-term pain and function. (1) TKA involves extensive bone resection as well as soft tissue excision and therefore is associated with profound postoperative pain. (2) Inadequate perioperative pain control may prolong hospitalization, hinder early rehabilitation, and is also a strong predictor of persistent pain beyond 3 months. (3) Adequate analgesia after TKA is therefore considered paramount to facilitate early hospital discharge and effective functional recovery. (4) The recently introduced adductor canal block (ACB) typically covers the anterio-medial aspect of the knee and preserves quadriceps function, which presumably enhances postoperative rehabilitation by allowing patients to actively participate in knee movement. The relative effectiveness of this ACB technique added to intrathecal morphine is limited to a single study (1) in which assessment of short-term functional recovery was done and dexamethasone was neither included in the LIA solution nor perineurally in the ACB. Thus, we hypothesize that adductor canal block as an adjunct to intrathecal morphine will have a better impact on functional recovery than peri-articular infiltration.

Enrollment: 200 estimated patients

Sex: All

Ages: 45 to 85 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• American Society of Anesthesiologist class ( ASA) I - III
• BMI 18-35 kg/m2
• Scheduled for primary unilateral TKR

Exclusion criteria

• Known allergy to local anesthetics
• Contraindication to adductor canal block e.g. infection at the site of injection
• Contraindication to spinal anesthesia e.g. coagulopathy.
• Patients with pre-existing motor or sensory deficits in lower extremities.
• Patients who are morbidly obese (BMI≥35) because ultrasound-guided regional anesthesia could be technically difficult.
• Bilateral or revision total knee replacement
• Insulin or noninsulin-dependent diabetes mellitus.
• systemic corticosteroid use within 30-days of surgery

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Triple Blind

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200 participants in 3 patient groups

ITM

Active Comparator group

Description:

spinal anesthesia will be induced with heavy bupivacaine 0.5% 12.5-15 mg (2.5-3 mL) at L3-4 or L4-5 inter-vertebral and Intrathecal morphine 150 μg will be added.

Treatment:

Procedure: Intrathecal morphine

ACB

Active Comparator group

Description:

spinal anesthesia will be induced with heavy bupivacaine 0.5% 12.5-15 mg (2.5-3 mL) at L3-4 or L4-5 inter-vertebral and Intrathecal morphine 150 μg will be added. The block will be performed in the mid adductor canal to block both the saphenous and the nerve to vastus medialis. After skin infiltration with 1 to 2 mL of 2% lidocaine, an 80-mm, 22-gauge, the short-bevel echogenic needle is advanced in-plane with the ultrasound beam in an anterior-to-posterior direction until the tip is located within the adductor canal deep to the vastoadductor membrane. After negative aspiration, 1-2 mL of local anesthetic is injected to confirm the proper injection plane. The study solution will be injected within the canal adjacent to the femoral artery. Patients in this group received 30 mL of 0.25% bupivacaine with 1:400,000 epinephrine and 4 mg dexamethasone.

Treatment:

Procedure: Intrathecal morphine

Procedure: Adductor Canal block

PAI

Active Comparator group

Description:

spinal anesthesia will be induced with heavy bupivacaine 0.5% 12.5-15 mg (2.5-3 mL) at L3-4 or L4-5 inter-vertebral and Intrathecal morphine 150 μg will be added. PAI intra-operatively will be performed with 150 mL of 0.25% bupivacaine with 1:400,000 epinephrine, 30 mg of ketorolac, and 8 mg dexamethasone.

Treatment:

Procedure: Intrathecal morphine

Procedure: Peri-articular Infilteration