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Adductor Canal Block versus Femoral Nerve Block for


Total Knee Arthroplasty
A Prospective, Randomized, Controlled Trial
David H. Kim, M.D., Yi Lin, M.D., Ph.D., Enrique A. Goytizolo, M.D., Richard L. Kahn, M.D.,
Daniel B. Maalouf, M.D., M.P.H., Asha Manohar, M.D., Minda L. Patt, M.D.,
Amanda K. Goon, B.A., Yuo-yu Lee, M.S., Yan Ma, Ph.D., Jacques T. YaDeau, M.D., Ph.D.
ABSTRACT
Background: This prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femoral nerve block (FNB) in patients undergoing total knee arthroplasty. The authors hypothesized that ACB, compared with
FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8h
postanesthesia.
Methods: Patients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and
opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48h postanesthesia administration. In a
joint hypothesis test, noninferiority was first evaluated on the primary outcomes of strength, pain score, and opioid consumption at 6 to 8h; superiority on each outcome at 6 to 8h was then assessed only if noninferiority was established.
Results: Forty-six patients received ACB; 47 patients received FNB. At 6 to 8h postanesthesia, ACB patients had significantly
higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf
[0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5]
ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115).
At 24 and 48h postanesthesia, there was no significant statistical difference in dynamometer results, pain scores, or opioid use
between the two groups.
Conclusion: At 6 to 8h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps
strength and was not inferior in both providing analgesia or opioid intake. (Anesthesiology 2014; 120:540-50)

PTIMAL pain relief is essential for functional recovery after


total knee arthroplasty (TKA).1 Addition of femoral nerve
block (FNB) to an analgesic regimen provides superior pain control2,3 and shortens hospital stay,4 in comparison with epidural or
intravenous patient-controlled analgesia (PCA) alone.1,5,6 However, prolonged motor blockade from FNB is associated with
a small (2%) but clinically important risk of fall.7,8 With FNB
there will always be a compromise between the goals of adequate
pain relief and muscle strength. An ideal nerve block would provide effective analgesia, minimize opioid use and side effects, and
hasten mobilization by preserving motor strength. Fast-track
total joint replacements are gaining popularity. Motor preservation with adequate analgesia has become the optimal postoperative pain goal in orthopedic surgeries to enable earlier physical
therapy, faster recovery, and shorter hospital stays.

What We Already Know about This Topic


Despite the improved analgesia and shortened hospital stays
provided by the use of femoral nerve blockade after total knee
arthroplasty, these blocks can cause significant motor weakness, delaying mobilization and increasing the risk of falls

What This Article Tells Us That Is New


The results of this randomized, blinded trial suggest that adductor canal block results in less motor impairment after surgery, but provides a comparable level of pain relief

With the advent of ultrasonography, the adductor canal can


be easily visualized at the mid-thigh level, allowing performance
of adductor canal block (ACB) with a high success rate.9,10 In
recent years, ACB has been successfully used for postoperative
pain control after knee surgery.9,11 Anatomical study of the

This article is featured in This Month in Anesthesiology, page 1A. Corresponding article on page 530.
Presented in part at the American Society of Regional Anesthesia Annual Meeting, San Diego, California, March 1518, 2012. Submitted for
publication January 10, 2013. Accepted for publication September 30, 2013. From the Department of Anesthesiology, Hospital for Special Surgery, New York, New York (D.H.K., Y.L., E.A.G., R.L.K., D.B.M., A.K.G., and J.T.Y.); Department of Anesthesiology and Critical Care Medicine,
The Johns Hopkins University, Baltimore, Maryland (A.M.); Department of Anesthesiology, Weill-Cornell Medical Center, New York, New
York (M.L.P.); and Department of Epidemiology and Biostatistics Core, Hospital for Special Surgery, New York, New York (Y.-y.L. and Y.M.).
Presented in part at the American Society of Regional Anesthesia Annual Meeting, San Diego, CA, March 1518, 2012.
Copyright 2014, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:540-50

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March 2014

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adductor canal demonstrated that the adductor canal may serve


as a conduit for more than just the saphenous nerve, possibly
including the vastus medialis nerve, medial femoral cutaneous
nerve, articular branches from the obturator nerve, as well as
the medial retinacular nerve.1012 Thus, the sensory changes are
not limited to the distribution of the saphenous nerve,13 but
includes the medial and anterior aspects of the knee from the
superior pole of the patella to the proximal tibia.
There has not been a randomized control study comparing
ACB with FNB after TKA. This prospective, d
ouble-blinded,
randomized, controlled study tested the hypothesis that ACB
would be associated with less quadriceps motor weakness than
FNB and provide analgesia that is not inferior as determined
by Numeric Rating Scale (NRS) pain scores and opioid use.
Using a joint hypothesis test with three primary outcomes,
we hypothesize that the ACB is superior in strength but not
inferior in pain score and opioid use at 6 to 8h postanesthesia.

Materials and Methods


This study was approved by the Institutional Review Board
of Hospital for Special Surgery, New York, New York. The
study was registered with ClinicalTrials.gov, Identifier
NCT01333943. All patients gave informed written consent.
Ninety-four patients scheduled to undergo elective TKA
were enrolled in the presurgical area by an anesthesiologist.
They were assigned to either ACB or FNB (1:1 allocation,
parallel trial design), based on a computer-generated randomization list created by an independent researcher. Group
assignment was concealed via opaque envelopes that were
opened only after enrollment. Eligibility criteria included
elective unilateral TKA, planned combined spinal epidural
anesthetic, age 18 to 90 yr, ability to follow study protocol, and American Society of Anesthesiologists class 1 to 3.
Exclusion criteria included contraindication for neuraxial
anesthetic, chronic opioid use (defined as daily or almost
daily use of opioids for >3 months), hypersensitivity and/
or allergies to local anesthetics, intraoperative use of volatile
anesthetics, preexisting neuropathy on the operative limb,
contraindications to a femoral or ACB, allergy to any of the
study medications, aged younger than 18 or older than 90
yr, and American Society of Anesthesiologists class 4 or 5.
A research assistant recorded baseline patient demographics
and medical history in the presurgical area. Patients were then
placed supine with a cushion underneath their knee, resulting
in a 45-degree angle at the knee. Quadriceps strength of both
legs was assessed by placing the dynamometer on the anterior
of the ankle, between the malleoli. Patients were instructed to
extend their legs three times each, with a 30-s pause between
each attempt (Lafayette Manual Muscle Test System; Lafayette Instrument Company, Lafayette, IN; as described by
Maffiuletti14). After each attempt, patients rated their pain
using NRS. The patients quadriceps were also assessed by a
neurologic exam, based on a 12-point scale as described by
Bohannon.15 Sensory function along the distribution of the
saphenous nerve (medial side of leg above the ankle) was

assessed by pinprick and temperature discrimination using


the jagged edges of a broken tongue depressor and an alcohol
swab in comparison with the nonoperative side.
Patients were randomized to receive either an ACB or
FNB. The anesthesiologist performing the block was aware of
the treatment, but the patient and the research assistant were
blinded to group assignment. An ultrasound-guided ACB
(15 cc of 0.5% of bupivacaine with 5 g/ml epinephrine,
via a 21-gauge 4-inch Stimuplex A needle; B. Braun Medical
Inc., Melsungen, Germany) was performed at mid-thigh level
using a high-frequency linear ultrasound transducer (1012
Hz; SonoSite Turbo; SonoSite Inc., Bothell, WA), as described
by Manickam.10 Ultrasound-guided FNB (30 cc of 0.25% of
bupivacaine with 5 g/ml epinephrine, via a 22-gauge 2-inch
Stimuplex A needle; B. Braun Medical Inc.) with nerve stimulator confirmation were performed below the inguinal ligament. The type of motor response (e.g., quadriceps, patellar)
and the minimum current needed were recorded. Ultrasound
pictures (preinjection and postinjection) were obtained to
verify proper local anesthetic placement.
All patients received a standardized anesthetic and analgesic. Preoperative oral meloxicam (7.5 or 15mg based on
age; 7.5mg was given to patients >74 yr) and dexamethasone
(6mg) were given in the holding area. Patients were sedated
with intravenously administered midazolam and propofol
before performance of the nerve block and epidural placement
(opioids and ketamine were not used). Combined spinal epidural anesthesia was administered, with 2.5 cc of 0.5% bupivacaine as the spinal agent. Epidural local anesthetic, if needed,
consisted of 2% lidocaine. Ondansetron (4mg IV) was given
during the operation. Intraoperative data included total time
to perform the block (starting from needle insertion to exit),
surgery time, tourniquet pressure, and total tourniquet time.
Oral postoperative pain medications were oxycodone/
acetaminophen (5/325mg q 4h as needed) and daily meloxicam (7.5 or 15mg based on age; 7.5mg was given to patients
>74 yr). Epidural PCA (10 g/ml hydromorphone, 0.06%
bupivacaine) was used for postoperative days (PODs) 0 to
2. Initial settings were 4ml/h of continuous infusion, 4-ml
bolus on demand every 10min as needed, maximum total of
20ml/h. At 7 am the following day (POD 1), the continuous infusion was lowered to 2ml/h, and at 5 pm on POD
1 the continuous infusion was set to 0. At noon on POD
2, the epidural was discontinued. Additional postoperative
antiemetics were metoclopramide (10mg IV every 6h as
needed), and/or ondansetron (4mg IV every 8h as needed).
At the discretion of the acute pain service, patients oral regimens were tailored to address the patients pain needs.
Quadriceps motor strength, as well as sensory exam (leg
pinprick and temperature discrimination) was assessed for
both legs at 6 to 8, 24, and 48h after anesthesia administration. The 6 to 8h assessment was done in the postanesthesia
care unit, whereas the 24- and 48-h assessments were done
in the inpatient unit. Block success was verified by testing
for pinprick sensation in the saphenous nerve distribution.

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Adductor Canal Block versus Femoral Nerve Block for TKA

Physical therapists dangled patients (i.e., placed in sitting position with legs on the side of the bed) on POD 0
regardless of block status and patient readiness to ambulate. On POD 1 and afterward, patients were assessed and
encouraged to ambulate with assistance.
Noninferior analgesia was assessed by measuring both
NRS pain scores and opioid consumption, data collected
included: (1) NRS pain scores (determined by patient interview, using the standard NRS of 0 to 10, at 6 to 8, 24, and
48h); and (2) total morphine consumption (converting oral,
intravenous, and epidural opioid to morphine equivalent on
PODs 0, 1, and 2). To strengthen the claim that the ACB
was noninferior in analgesia to the FNB, we decided to conduct a joint hypothesis test using both pain score and opioid
consumption as primary outcomes.
Additional data collected included: (1) patient satisfaction (patient interviewed, using a scale of 010, 10 being the
most satisfied, at 68 and 24h); (2) postoperative nausea and
vomiting (present or absent, determined by patient interview
at 68, 24, and 48h); (3) pruritis, (present or absent, determined by patient interview at 68, 24, and 48h); (4) incidence of complications (if any), including falls, neurologic
symptoms, and local anesthetic toxicity; (5) length of hospital
stay (days); (6) success of blinding (by asking patients before
discharge which treatment they thought they had received.
Statistical Analysis
Standardized difference was calculated to compare patient
demographics and baseline characteristics including age,
sex, race, American Society of Anesthesiologists, length of
hospital stay, and body mass index between ACB and FNB.
An absolute difference greater than 0.2 was considered to be
clinically important.16,17 To reduce the chance of confounding, the clinically important variables were adjusted in multiple regression analysis.
The primary outcomes included quadriceps muscle
strength as measured by dynamometer reading, NRS pain
scores, and total opioid consumption. We hypothesized that
ACB would be preferred if (1) ACB was noninferior to FNB
on all primary outcomes and (2) ACB was superior to FNB at
least on quadriceps muscle strength. Therefore we conducted
a joint hypothesis testing as described by Mascha and Turan.18
A two-step sequential testing procedure18 was followed
for the joint hypothesis testing of (1) and (2), both at 6 to
8h postanesthesia administration. First, noninferiority was
assessed on each individual outcome. Specifically, the following noninferiority was defined for ACB as compared with
FNB: (1) the mean dynamometer readings not less than 3 kgf
(equivalent to a clinically relevant difference of 20% points as
described in Ilfeld etal.19) lower than FNB (2) the mean NRS
pain score not more than 1.6 higher than FNB,20 and (3) the
mean opioid consumption not more than 50% greater than
FNB.2 Second, we evaluated the superiority on each outcome
if noninferiority was confirmed on all outcomes. Noninferiority hypotheses were evaluated against a one-sided significance

criterion of 0.025 and superiority hypotheses were evaluated


against a one-sided significance criterion of 0.008 (adjusting
for the three outcomes, 0.025/3 = 0.008). In addition to the
joint hypothesis testing, all primary outcomes were also compared between ACB and FNB at each specific time (baseline,
68h after anesthesia administration, and at PODs 1 and 2).
The HolmBonferroni stepdown procedure21 was used to
control the familywise error rate.
The primary outcomes were further studied using multiple regression based on the generalized estimating equation
(GEE) method,22,23 adjusting for any clinically important
differences that were identified in the baseline variables. In
addition, an interaction effect between treatment group and
time was also incorporated in the regression analysis. Treatment effect was further assessed at each time point if the
interaction effect was significant. For each primary outcome,
data collected at baseline (no baseline opioid consumption),
6 to 8, 24, and 48h postanesthesia were included in the
GEE analysis. To reflect the observed correlation structure
between repeated measurements, an autoregressive(1) correlation matrix was considered in GEE. The autoregressive
correlation structure assumes that measurements closer in
time have a higher correlation than those that are further
apart.22 The GEE method is able to take into account correlations between repeated measures and does not require a
particular distribution for data, leading to robust parameter
estimation.
Secondary outcomes included side effects (nausea, vomiting) and patient satisfaction. Chi-square test or Fisher exact
test was performed to compare the incidence of side effects.
Patient satisfaction was analyzed using t test or nonparametric alternative according to the distribution of the data.
We powered the study to detect a 50% difference in
motor strength as measured by the dynamometer at postanesthesia care unit between the ACB and FNB groups. This
was the difference found from an earlier pilot study (unpublished data: The unpublished data were a pilot study done
by David Kim, M.D., New York, New York, primarily to
estimate the number of patients needed for the study. It was
done in August 2010 at the Hospital for Special Surgery. By
looking at 10 patients who underwent a total knee replacement under either saphenous nerve block or a FNB (nonrandomized, five patients in each group), motor strength
estimates were extrapolated. Quadriceps strength was measured at 68h after the block. From the pilot study, it was
estimated that the FNB group would result in at least 50%
decrease in motor strength in comparison with the saphenous nerve block.). The mean (61.3 N) and SD (30 N) of
dynamometer readings for the FNB group from the pilot
study served as reference values for the power analysis. On
the basis of a type I error rate of 5% and a power of 80%,
and taking into account potential protocol violations and
dropouts, we set the target sample size at 47 per group.
All analyses used an intention-to-treat approach, in
which patients were evaluated in the groups to which they

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were originally randomly assigned, regardless of the treatment they actually received. SAS version 9.3 (SAS Institute,
Cary, NC) was used for all analyses.

Results
Patients were enrolled from March 2011 to November
2011. Patient recruitment and flow through the protocol are
described in the CONSORT (Consolidated Standards Of
Reporting Trials) diagram. Of the 94 patients enrolled, one
patient was excluded for inappropriate enrollment (fig.1).
The patient had a profound preexisting neurological condition (significant quadriceps weakness and numbness at baseline) and should not have been enrolled. Four patients were
noted to have failed blocks (i.e., no loss of sensation in the
saphenous distribution). Success rates for the ACB and FNB
were 93.6 and 97.9%, respectively. Three patients did not
have an epidural PCA postoperatively (1 intrathecal catheter, 2 spinals only) but an intravenous PCA. Four patients
withdrew from the study on POD 0 or 1, but all available
data were included in the intention-to-treat analysis. Three
patients were not assessed by the research assistant at either
the postanesthesia care unit, PODs 1 and/or 2 time points,
but all other available data were included in the intentionto-treat analysis. After the exclusion, 46 patients received
ACB; 47 patients received FNB. Baseline values were similar
between the two groups (table1), with the exception of the

age group between 60 to 70 yr, Asian race, and obese class I


(body mass index between 30 to 35).
A joint hypothesis test was performed using all three
outcomes as primary (table2) at the endpoint of 6 to 8h
postanesthesia. All outcomes were found to be noninferior.
Specifically, the lower confidence limit of dynamometer readings was greater than the delta (P < 0.0001); the upper confidence limits of NRS pain scores and opioid use were less
than their respective deltas (NRS pain scores, P = 0.019; opioid use, P = 0.012). Therefore the ACB was found to not be
weaker than the FNB or have higher pain scores or more opioid use. Next, we conducted a superiority test and found only
the dynamometer readings for the ACB to be superior to the
readings for the FNB (difference ACB-FNB kgf [98.3% CI],
5.2 [2.77.7]; P < 0.0001). Therefore, the joint hypothesis
test demonstrates that the ACB is superior to the FNB with
regard to strength and not inferior with regard to pain score
and opioid consumption at 6 to 8h postanesthesia.
We further compared dynamometer readings, NRS pain
score, and opioid use between groups at each specific time.
At 6 to 8h postanesthesia, mean strength during extension
of the knee from a starting position of 45-degree flexion was
significantly higher for the ACB versus the FNB (table3,
difference ACB-FNB kgf [95% CI], 5.2 [3.17.2]; P <
0.0001). At 24 and 48h, the ACB and FNB groups were not
statistically significantly different with a P value of 0.9999 at

Assessed for eligibility


(n = 231)

Excluded (n = 137)
Did not meet inclusion criteria (n = 82)
Declined to participate (n = 55)
Randomized (n = 94)

FEMORAL NERVE BLOCK


Allocated to intervention (n = 47)

ADDUCTOR CANAL BLOCK


Allocated to intervention (n = 47)

Excluded from analysis


Known neuropathy (n = 1)

Analyzed (n = 47)

Analyzed (n = 46)

Fig. 1. CONSORT (Consolidated Standards Of Reporting Trials) diagram. Flow of patients through the protocol.

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Adductor Canal Block versus Femoral Nerve Block for TKA

Table 1. Demographics

Status, N (%)
Included in per-protocol
analysis
Excluded
Age, mean SD
Age, N (%)
Age group 1: age 50
Age group 2: 50 < age 60
Age group 3: 60 < age 70
Age group 4: 70 < age 80
Age group 5: 80 < age
Sex, N (%)
Male
Female
Race, N (%)
Asian
Black
Hispanic
White
Other/unknown
ASA, N (%)
1
2
3
Hospital stay, mean SD
BMI, mean SD
BMI, N (%)
Normal: 18.5 < BMI < 25
Overweight: 25 BMI < 30
Obese class I: 30 BMI < 35
Obese class II: 35 BMI < 40
Obese class III: 40 BMI

ACB

FNB

N = 46

N = 47

Standardized Difference

40 (87.0)

39 (83.0)

0.111

6 (13.0)
68.09.4

8 (17.0)
67.611.3

3 (6.5)
6 (13.0)
20 (43.5)
13 (28.3)
4 (8.7)

4 (8.5)
8 (17.0)
14 (29.8)
16 (34.0)
5 (10.6)

22 (47.8)
24 (52.2)

18 (38.3)
29 (61.7)

0
3 (6.5)
2 (4.3)
40 (87.0)
1 (2.2)

1 (2.1)
5 (10.6)
1 (2.1)
39 (83.0)
1 (2.1)

2 (4.3)
38 (82.6)
6 (13.0)
3.70.8
29.96.4

3 (6.4)
36 (76.6)
8 (17.0)
3.60.8
30.35.8

13 (28.3)
17 (37.0)
5 (10.9)
6 (13.0)
5 (10.9)

10 (21.3)
16 (34.0)
9 (19.1)
9 (19.1)
3 (6.4)

0.043

0.075
0.111
0.287
0.125
0.066
0.193

0.209
0.147
0.126
0.111
0.003

0.09
0.15
0.111
0.07
0.072

0.162
0.061
0.233
0.167
0.16

A standardized difference >0.2 is considered to be clinically important.


ACB = adductor canal block; ASA = American Society of Anesthesiologists; BMI = body mass index; FNB = femoral nerve block.

Table 2. Joint Hypothesis Testing for Outcomes at Postanesthesia 68 h


Noninferiority One-tailed Test
Outcome at
Postanesthesia
68 h
Dynamometer
readings
NRS pain scores
at rest
Opioids (oral opioids + PCA)

ACB

FNB

Difference

N = 46

N = 47

ACB-FNB
(95% CI)*

7.35.4
6.1 [3.5, 10.9]
1.71.9
1.0 [0.0, 3.5]
36.617.9
32.2 [22.4, 47.5]

2.23.8
0.0 [0.0, 3.9]
0.91.8
0.0 [0.0, 1.0]
35.820.7
26.6 [19.6, 49.0]

Superiority One-tailed Test


Difference
ACB-FNB
(98.3% CI)

P Value
(HolmBonferroni)

Delta

P Value

<0.0001

0.75 (0.06, 1.55)

1.6

0.019

0.75 (0.24, 1.74)

0.9999

1.05 (0.83, 1.32)

1.5

0.0115

1.05 (0.79, 1.39)

0.9999

5.2 (3.1, 7.2)

5.2 (2.7, 7.7)

<0.0001

Results presented as mean SD, median [first, third quartiles]. Overall alpha is 0.025 for both noninferiority and superiority tests. Noninferiority was found
on all three outcomes with the given deltas (P < 0.025) and superiority on dynamometer readings (P < 0.008).
* Noninferiority test is significant for dynamometer readings (NRS, opioids) if the lower (upper) confidence limit is greater (less) than delta. Superiority test
is significant for dynamometer readings (NRS) if lower (upper) confidence limit is greater (less) than zero; superiority test is significant for opioids use if the
upper confidence limit is <1. Ratio of ACB/FNB.
ACB = adductor canal block; FNB = femoral nerve block; NRS = Numeric Rating Scale; PCA = patient-controlled analgesia.

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each time point. Strength was not statistically significantly


different between groups on the nonoperative leg throughout all time measurements (e.g., preoperative, 68, 24, and
48h). Of note, the operative knees of three patients in the
FNB group buckled during their physical therapy session
on POD 1. No patients in the ACB buckled.
When comparing the NRS pain scores at rest between
groups (table4), it was found that the ACB group was not
inferior to the FNB group at 6 to 8h postanesthesia (difference: ACB-FNB [95% CI], 0.7 [0.1 to 1.55]; P = 0.0190).
At 24 and 48h, there were no statistically significant difference between groups, noninferiority P = 0.0103 and
P = 0.0005, respectively. The upper limits of the CIs at all
time measurements were less than the delta of 1.6, suggesting

that ACB was not inferior to FNB with regard to the NRS
pain scores at rest throughout the first 48h.
The ACB group had a cumulative opioid intake that
was not inferior to the FNB group at 6 to 8h postanesthesia (table5, ratio: ACB/FNB [95% CI], 1.05 [0.81.3];
P = 0.0029). Similarly, ACB was not inferior to FNB with regard
to opioid use throughout the first 48h (noninferiority P value of
0.0115, and 0.0029 at 24 and 48h, respectively). The upper CI
limits at all times were less than the delta of 1.5. All patients analyzed had a bupivacaine/hydromorphone epidural PCA or an
intravenous hydromorphone PCA (n = 3), which was discontinued on POD 2. Even after the patient-controlled epidural analgesia was discontinued on POD 2, there was no difference in
oral consumption between the two groups by discharge (fig.2).

Table 3. Dynamometer Readings over Time

Time of Follow-up
Operative leg
Preoperative, kgf
Postanesthesia 68 h, kgf
Postanesthesia 24 h, kgf
Postanesthesia 48 h, kgf
Nonoperative leg
Preoperative, kgf
Postanesthesia 68 h, kgf
Postanesthesia 24 h, kgf
Postanesthesia 48 h, kgf

ACB

FNB

N = 46

N = 47

15.68.5
12.3 [9.6, 20.2]
7.35.4
6.1 [3.5, 10.9]
3.94.2
3.5 [1.1, 4.4]
2.22.9
1.8 [0.0, 3.3]

14.88.2
11.6 [8.3, 20.1]
2.23.8
0.0 [0.0, 3.9]
4.04.0
2.8 [1.1, 6.8]
2.83.2
1.7 [0.0, 4.1]

18.59.1
16.7 [11.6, 24.4]
15.87.6
14.4 [9.9, 21.3]
16.77.4
15.7 [10.2, 22.6]
16.77.8
15.1 [12.0, 22.0]

18.39.2
16.9 [10.7, 27.4]
16.210.3
13.9 [8.1, 25.4]
17.89.0
16.9 [10.1, 25.4]
18.511.8
16.4 [9.2, 26.3]

Difference:
ACB-FNB (95% CI)

Test of Equal
Medians:
P Value
(HolmBonferroni)*

0.8 (2.7 to 4.2)


5.2 (3.17.2)

0.9999
<0.0001

0.1 (1.9 to 1.6)

0.9999

0.6 (1.9 to 0.7)

0.9999

0.2 (3.6 to 4.0)

0.9999

0.4 (4.4 to 3.6)

0.9999

1.1 (4.6 to 2.5)

0.9999

1.8 (6.2 to 2.6)

0.9999

Results presented as mean SD, median [first, third quartiles].


* HolmBonferroni adjusted P < 0.05 is considered statistically significant.
ACB = adductor canal block; FNB = femoral nerve block; kgf = kilogram-force unit.

Table 4. NRS Pain Scores at Rest over Time

Time of Follow-up
Preoperative
Postanesthesia 68 h
Postanesthesia 24 h
Postanesthesia 48 h

ACB

FNB

N = 46

N = 47

3.03.2
2.0 [0.0, 6.0]
1.71.9
1.0 [0.0, 3.5]
3.12.3
3.0 [1.5, 5.0]
4.32.2
4.0 [3.0, 6.0]

3.43.1
3.0 [0.0, 5.0]
0.91.8
0.0 [0.0, 1.0]
2.82.3
3.0 [1.0, 4.0]
4.83.0
4.8 [3.0, 7.3]

Difference:
ACB-FNB (95% CI)

Noninferiority
One-tailed
Test*: P Value
(HolmBonferroni)

0.3 (1.7 to 1.0)

0.0075

0.7 (0.1 to 1.55)

0.0190

0.3 (0.7 to 1.3)

0.0103

0.6 (1.7 to 0.6)

0.0005

Results presented as mean SD, median [first, third quartiles]. HolmBonferroni adjusted P < 0.025 is considered statistically significant.
* Delta = 1.6 for the noninferiority test.
ACB = adductor canal block; FNB = femoral nerve block; NRS = Numeric Rating Scale.

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Adductor Canal Block versus Femoral Nerve Block for TKA

Table6 summarized the results from regression analysis


using GEE approach for each outcome. In all GEE analyses, the clinically important variables shown in table 1 were
included to adjust for potential confounding effects.
Significant treatment by time interaction effect was
found for dynamometer readings (P < 0.0001). We then
further compared the treatment effect at each specific time.
The ACB group was found to have significant higher motor
strength at postanesthesia 6 to 8h (P < 0.0001). Among
the adjusted covariates, older age groups (i.e., 5060, 60
70, 7080) were found to have significantly higher dynamometer motor strength readings than the youngest age
group (age <50, P = 0.0093, P = 0.0014, and P = 0.0002).
Male patients demonstrated greater dynamometer motor
strength than females (P = 0.0264). Compared with White,

Hispanics were associated with significant higher motor


strength (P = 0.011), while Other patients (unknown ethnicity) were associated with significantly lower motor strength
(P = 0.015). Nonoperative legs had significantly higher
motor strength than operative legs (P < 0.0001).
No significant interaction effect between time and treatment was found for NRS pain scores and opioids use. Therefore, ACB and FNB had similar effects on NRS and opioids
use over time. Specifically, compared with baseline both
groups had significantly lower NRS at 6 to 8h postanesthesia (P < 0.001), and higher NRS at 48h (P = 0.0005). Both
groups had significantly higher opioids use at postanesthesia
24 and 48h compared with baseline (24h, P < 0.0001; 48h,
P < 0.0001). In addition, older patients (age 7080 yr, >80
yr) had significantly lower opioids use compared with those

Fig. 2. Total opioid use over time. The plus sign represents the femoral nerve block group and the triangle represents the adductor canal block group.

Table 5. Opioid Use (Oral Opioids + PCA)


ACB
Time of Follow-up
Postanesthesia 68 h
Postanesthesia 24 h
Postanesthesia 48 h

FNB

N = 46

N = 47

36.617.9
32.2 [22.4, 47.5]
50.330.8
46.8 [30.0, 60.6]
60.732.3
62.4 [41.0, 76.2]

35.820.7
26.6 [19.6, 49.0]
50.433.1
40.2 [29.7, 70.5]
62.839.1
57.8 [35.0, 77.4]

Ratio: ACB/FNB
(95% CI)

Noninferiority
One-tailed Test*: P Value
(HolmBonferroni)

1.05 (0.81.3)

0.0029

1.03 (0.71.4)

0.0115

0.95 (0.71.3)

0.0029

Results presented as mean SD, median [first, third quartiles]. HolmBonferroni adjusted P < 0.025 is considered statistically significant.
* Delta = 1.5 for the noninferiority test.
ACB = adductor canal block; FNB = femoral nerve block; PCA = patient-controlled analgesia.

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PERIOPERATIVE MEDICINE

younger than 50 yr of age (age 7080 yr: P = 0.048; age >80


yr: 0.0331).
Other postoperative outcomes were measured in the
study (table7). There were no significant differences in the
incidence of nausea and vomiting, pruritus, satisfaction, and
length of stay (3.70.8 days, ACB vs. 3.60.8 days, FNB,
P = 0.7346). There were no complications noted/reported to
the Institutional Review Board. Though three patients with
a FNB buckled, none of the patients fell. There was no local
anesthetic toxicity or neurologic complications.
Blinding was successful (table8). Bang Blinding Index24
was 0.08 for ACB, and 0 for FNB (table 8 for percentages).

Discussion
This prospective study demonstrated that the ACB is an effective alternative to the FNB for patients undergoing TKA.
The ACB exhibited significant sparing of the quadriceps

strength at 6 to 8h and was not inferior to the FNB regarding pain scores and opioid consumption.
Several studies validated the ACB as an effective analgesic
method, but most studied arthroscopic knee surgery.2 This
study compared ACB with FNB in patients undergoing
TKA, a more painful procedure that requires optimal pain
relief to hasten mobilization. Jenstrup etal.25 demonstrated
effectiveness of the ACB on pain and ambulation after TKA,
compared with placebo. Strength was not objectively measured and the study involved a high dose of local anesthetic
(30ml of 0.75% ropivacaine, 225mg). This large dose of
local anesthetic could cause quadriceps weakness from proximal spread. The current study used a lower dose of anesthetic
(75mg bupivacaine) and directly compared ACB with FNB.
At 6 to 8h postanesthesia, median strength for ACB
patients was reduced compared with baseline. One explanation could be blockade of the nerve going to the vastus

Table 6. The Estimated Covariate-adjusted Treatment Effects and Differences between Treatments from the Regression Analysis
Based on GEE
Covariates

Coefficient Estimate (95% CI)

Dynamometer readings
Difference in dynamometer readings between ACB and FNB at each time point:
Preoperative
0.33 (3.14 to 3.79)
Postanesthesia 68 h
4.91 (1.798.03)
Postanesthesia 24 h
0.24 (2.46 to 1.98)
Postanesthesia 48 h
0.17 (2.67 to 2.34)
Nonoperative leg
0.35 (0.290.42)
2.18 (0.543.82)
50 < age 60 vs. age 50
3.13 (1.215.05)
60 < age 70 vs. age 50
3.18 (1.494.86)
70 < age 80 vs. age 50
1.77 (0.40 to 3.93)
80 < age vs. age 50
Male vs. female
1.05 (0.121.98)
Asian vs. White
0.60 (1.78 to 0.58)
Black vs. White
0.50 (1.61 to 0.61)
Hispanic vs. White
4.36 (0.997.72)
Others vs. White
1.95 (3.51 to 0.39)
Overall NRS pain scores at rest
Postanesthesia 68 h vs. preoperative
1.89 (2.66 to 1.12)
Postanesthesia 24 h vs. preoperative
0.23 (0.96 to 0.51)
Postanesthesia 48 h vs. preoperative
1.36 (0.602.12)
ACB vs. FNB
0.08 (0.56 to 0.71)
0.27 (1.75 to 1.21)
50 < age 60 vs. age 50
1.07 (2.45 to 0.30)
60 < age 70 vs. age 50
0.58 (1.99 to 0.84)
70 < age 80 vs. age 50
0.27 (2.31 to 1.77)
80 < age vs. age 50
Overall opioids (oral opioids + PCA)
Postanesthesia 24 h vs. preoperative
14.11 (8.5519.68)
Postanesthesia 48 h vs. preoperative
25.56 (19.0232.09)
ACB vs. FNB
0.35 (9.69 to 8.99)
20.72 (52.75 to 11.30)
50 < age 60 vs. age 50
25.46 (54.85 to 3.93)
60 < age 70 vs. age 50
29.68 (59.12 to 0.24)
70 < age 80 vs. age 50
33.31 (63.94 to 2.68)
80 < age vs. age 50

P Value

0.7689
<0.0001
0.7356
0.8345
<0.0001
0.0093
0.0014
0.0002
0.1099
0.0264
0.3160
0.3748
0.0112
0.0145
<0.0001
0.5500
0.0005
0.8144
0.7208
0.1267
0.4238
0.7964
<0.0001
<0.0001
0.9415
0.2047
0.0896
0.0482
0.0331

P < 0.05 is considered significant.


ACB = adductor canal block; FNB = femoral nerve block; GEE = generalized estimating equations; NRS = Numeric Rating Scale; PCA = patient-controlled
analgesia.

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Adductor Canal Block versus Femoral Nerve Block for TKA

Table 7. Side Effects and Patient Satisfaction


ACB
N = 46
N (%)

FNB
N = 47
N (%)

2 (4.5)
15 (35.7)
13 (29.6)
6 (14.3)
22 (52.4)
19 (43.2)
9.80.6
10.0 [10.0, 10.0]
8.81.9
10.0 [8.0, 10.0]
3.70.8
3.5 [3.0, 4.0]

5 (11.1)
16 (35.6)
11 (23.9)
7 (15.6)
19 (42.2)
15 (33.3)
9.60.9
10.0 [10.0, 10.0]
9.11.7
10.0 [8.5, 10.0]
3.60.8
4 [3.0, 4.0]

Time of Follow-up
Nausea or vomiting

Pruritis

Patient satisfaction

Postanesthesia 628 h
Postanesthesia 24 h
Postanesthesia 48 h
Postanesthesia 68 h
Postanesthesia 24 h
Postanesthesia 48 h
Postanesthesia 68 h
Postanesthesia 24 h

Hospital stay

P Value
(HolmBonferroni)
0.9999
0.9999
0.9999
0.9999
0.9999
0.9999
0.6439
0.5041
0.7346

Results presented as frequency (percentage) for discrete outcomes and mean SD, median [first, third quartiles] for continuous outcomes. HolmBonferroni adjusted P < 0.05 is considered statistically significant.
ACB = adductor canal block; FNB = femoral nerve block.

medialis. Alternatively, pain could limit forceful extension of


the leg. Effects of surgery and tourniquet use on quadriceps
strength also deserve consideration.
It is interesting to note that as the block wore off, ACB
group median quadriceps strength diminished from 6.1 kgf
(68h) to 3.5 kgf (24h). In contrast, FNB group median
quadriceps strength improved as the FNB wore off, rising
from 0 kgf (68h) to 2.8 kgf (24h), supporting the idea that
pain limited ACB group strength at 24h but muscle weakness limited FNB group strength at 6 to 8h. At 24 and 48h,
both ACB and FNB groups had quadriceps weakness that
was probably not due to the block, based on the expected
duration of a bupivacaine nerve block. This quadriceps weakness was not caused by the epidural, as demonstrated by preserved strength on the nonoperative leg. It seems more likely
that the decreased quadriceps strength was due to either pain
or surgical factors, including the use of a tourniquet.
The primary outcome was measured by determining
the patients ability to actively extend the knee while it was
passively flexed at 45 degrees, with the patient supine during the assessment. It is presumed that improved strength
facilitates progress through physical therapy, but it has not
been shown that the relative preservation of motor strength
by ACB correlated with improved ability to ambulate. At
our institution, physical therapists do not routinely assess
ambulation on POD 0, but limit the session to dangling and
standing. On POD 1, patients are encouraged to ambulate
Table 8. Blinding

ACB
FNB

Guessed
ACB

Guessed
FNB

Do Not
Know

N (%)

N (%)

N (%)

Total
Assessed

9 (24)
10 (27)

6 (16)
10 (27)

22 (60)
17 (46)

37
37

ACB = adductor canal block; FNB = femoral nerve block.

with assistance. Future studies could investigate the relationship between improved early quadriceps strength and time
of achievement of physical therapy milestones.
No falls were noted in this study. However, three patients
in the FNB group were noted to buckle due to quadriceps
weakness on POD 1. No patients in the ACB group were
noted to be weak on POD 1. However, given the small sample
size of this study (n = 94), it would be difficult to assess fall risk
reduction. Other secondary outcomes like nausea and vomiting, pruritus, patient satisfaction, length of stay, and complications showed no significant difference. This can be attributed
to the ACB providing analgesia that is no different than that of
FNB, thus limiting the known side effects of opioid use (e.g.,
nausea, pruritus). Patients were blinded successfully, which
further strengthens the argument that the ACB provided
adequate analgesia to blind the patients regarding which block
was performed. However, the successful pain relief can also be
attributed in part to the postoperative use of an epidural PCA
and further studies could limit the use of an epidural (i.e., no
continuous infusion) or use an intravenous PCA.
Though we powered the study using a 50% difference
in motor strength between the two groups, we performed a
power analysis for NRS pain score and opioid consumption
at 6 to 8h. A difference of 1.6 and an increase of 50% (ACB
vs. FNB) were considered clinically significant for NRS pain
score and opioid consumption, respectively. With the given
sample size (n = 46 for ACB and n = 47 for FNB), we were
able to detect clinical significance with a power of 98.4 and
97.9% for pain score and opioid consumption, respectively.
The sample size, however, was underpowered to detect significant difference in the complications, for example, falls,
neuropraxia, and nausea and vomiting.
A major concern among practitioners is whether an ACB
provides enough sensory coverage for a TKA. It is important
to note that the ACB performed at the level of the midthigh involves not only the saphenous nerve but several

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PERIOPERATIVE MEDICINE

other sensory nerves that innervate the medial, lateral, and


anterior aspects of the knee, encompassing the superior pole
of the patella to the proximal tibia. The ACB groups NRS
pain scores and opioid consumption demonstrate that it is
not inferior to the FNB. However, it should be noted that
the epidural PCA may have confounded the NRS and opioid consumption results. There was no control (no block)
group because it is the standard at our institution to provide
a regional block and epidural for postoperative pain management. Nevertheless, future studies may want to either have
a control (no block) group, or have all patients receive an
intravenous PCA for postoperative pain control.
Opioid consumption was no different in both groups.
The incidence of postoperative nausea and vomiting was low
in both groups. This is most likely due to the prophylactic administration of dexamethasone and ondansetron, as
well as the avoidance of intraoperative opioids and volatile
agents. However, the effective postoperative blockade of
both groups minimized the use of oral opioids and thus limited their notable side effects of nausea and vomiting.
There are several limitations to the study. The duration of
analgesia from the ACB block is unclear and was not measured. Other studies have addressed this issue by placing
peripheral nerve catheters. Future studies may want to investigate the use of additives such as clonidine and dexamethasone.
By prolonging a mostly sensory block, theoretically, patients
will ambulate quicker and be discharged sooner. Though our
study confirms the ACB to be an effective alternative to the
FNB, other future studies may want to compare the ACB
with the FNB on the same patient, by performing both blocks
for bilateral knee arthroplasty. Also, a large follow-up study is
needed to investigate whether ACB improves rehabilitation,
incidence of falls, and/or length of hospital stay.
Thus, the ACB provides adequate analgesia but significantly spares motor strength in comparison with the FNB.
As expected, patients pain scores incrementally increased as
both blocks receded and patients epidurals were weaned, as
observed on POD 1 and 2. Theoretically, the ACB should
hasten mobilization and facilitate rehabilitation, preventing
notable complications from immobilization, such as deep
vein thrombosis and pulmonary emboli, and possibly shortening hospital length of stay.

Acknowledgments
The authors thank Dorothy Marcello, B.A., Department of
Anesthesiology, Hospital for Special Surgery, New York,
New York, for assistance with patient enrollment and data
entry.
Study funded by the Hospital for Special Surgery Anesthesiology Department (New York, New York)Research
and Education Fund. The Agency for Healthcare Research
and Quality (Rockville, Maryland) grant R01HS021734 supported Dr. Mas research.

Competing Interests
The authors declare no competing interests.

Correspondence
Address correspondence to Dr. Kim: Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street,
New York, New York 10021. kimd@hss.edu. This article may
be accessed for personal use at no charge through the Journal Web site, www.anesthesiology.org.

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ANESTHESIOLOGY REFLECTIONS FROM THE WOOD LIBRARY-MUSEUM

Dr. Paul Woods Academy of Anesthesiology Active Membership


Certificate

On Ether Days Eve, October 15, 1958, Dr. Paul M. Wood received Active Membership Certificate No. 21 (above)
from The Academy of Anesthesiology. Founded by Mayo Clinics John S. Lundy, M.D., in 1929, as the Anaesthetists
Travel Club, this organization of leading North American anesthesiologists met annually to update each other on
advances in the art and science of anesthesiology. The Travel Club was resurrected, after a brief wartime lapse, as
The Academy of Anesthesiology in 1952. The Academy continues today with active membership limited to 75
anesthesiologists. (Copyright the American Society of Anesthesiologists, Inc.)
George S. Bause, M.D., M.P.H., Honorary Curator, ASAs Wood Library-Museum of Anesthesiology, Park Ridge,
Illinois, and Clinical Associate Professor, Case Western Reserve University, Cleveland, Ohio. UJYC@aol.com.

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