Femoral nerve versus adductor canal block for early postoperative pain control and knee function after anterior cruciate ligament reconstruction with hamstring autografts: a prospective single-blind randomised controlled trial

Abstract

Introduction

The optimal pain management strategy for postoperative pain after anterior cruciate ligament reconstruction (ACLR) remains unclear. This study compared femoral nerve block (FNB) and adductor canal block (ACB) for pain management of early postoperative pain, knee function, and recovery of activity of daily living (ADL) after ACLR using hamstring autografts.

Material and methods

In this prospective, single-blind, randomised controlled trial, 64 patients aged 12–56 years who underwent anatomical double-bundle ACLR with a hamstring autograft between August 2019 and May 2020 were randomised to undergo preoperative FNB (n = 32) or ACB (n = 32). The peripheral nerve block was performed by a single experienced anaesthesiologist under ultrasound guidance. The primary outcomes were postoperative pain as evaluated using the visual analogue scale (VAS) at 3, 6, 12, 24, and 48 h postoperatively and the need for pain relief. The secondary outcome was knee function, including the recovery of range of motion, contraction of the vastus medialis, and stable walking with a double-crutch (ADL), as evaluated by blinded physical therapists.

Results

There were no significant differences in patient demographics between the two groups. The VAS scores, need for pain relief, knee function, and ADL did not significantly differ between the groups.

Conclusion

FNB and ACB provided comparable outcomes related to early postoperative pain, knee function, and ADL after double-bundle ACLR using hamstring autografts. Further research is necessary to evaluate the mid- to long-term effect of each block on recovery of knee function and ADL.

Level of evidence

I.

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References

  1. 1.

    Abdallah FW, Mejia J, Prasad GA, Moga R, Chahal J, Theodoropulos J et al (2019) Opioid- and motor-sparing with proximal, mid-, and distal locations for adductor canal block in anterior cruciate ligament reconstruction: a randomized clinical trial. Anesthesiology 131:619–629

    PubMed  Article  PubMed Central  Google Scholar 

  2. 2.

    Abdallah FW, Whelan DB, Chan VW, Prasad GA, Endersby RV, Theodoropolous J et al (2016) Adductor canal block provides noninferior analgesia and superior quadriceps strength compared with femoral nerve block in anterior cruciate ligament reconstruction. Anesthesiology 124:1053–1064

    CAS  PubMed  Article  Google Scholar 

  3. 3.

    Adoni A, Paraskeuopoulos T, Saranteas T, Sidiropoulou T, Mastrokalos D, Kostopanagiotou G (2014) Prospective randomized comparison between ultrasound-guided saphenous nerve block within and distal to the adductor canal with low volume of local anesthetic. J Anaesthesiol Clin Pharmacol 30:378–382

    PubMed  PubMed Central  Article  Google Scholar 

  4. 4.

    Akinci SB, Saricaoğlu F, Atay OA, Doral MN, Kanbak M (2005) Analgesic effect of intra-articular tramadol compared with morphine after arthroscopic knee surgery. Arthroscopy 21:1060–1065

    PubMed  Article  Google Scholar 

  5. 5.

    Apfelbaum JL, Chen C, Mehta SS, Gan TJ (2003) Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 97:534–540 (table of contents)

    PubMed  Article  PubMed Central  Google Scholar 

  6. 6.

    Astur DC, Aleluia V, Veronese C, Astur N, Oliveira SG, Arliani GG et al (2014) A prospective double blinded randomized study of anterior cruciate ligament reconstruction with hamstrings tendon and spinal anesthesia with or without femoral nerve block. Knee 21:911–915

    PubMed  Article  Google Scholar 

  7. 7.

    Bailey L, Griffin J, Elliott M, Wu J, Papavasiliou T, Harner C et al (2019) Adductor canal nerve versus femoral nerve blockade for pain control and quadriceps function following anterior cruciate ligament reconstruction with patellar tendon autograft: a prospective randomized trial. Arthroscopy 35:921–929

    PubMed  Article  PubMed Central  Google Scholar 

  8. 8.

    Bushnell BD, Sakryd G, Noonan TJ (2010) Hamstring donor-site block: evaluation of pain control after anterior cruciate ligament reconstruction. Arthroscopy 26:894–900

    PubMed  Article  PubMed Central  Google Scholar 

  9. 9.

    Carbone A, Rodeo S (2017) Review of current understanding of post-traumatic osteoarthritis resulting from sports injuries. J Orthop Res 35:397–405

    PubMed  Article  PubMed Central  Google Scholar 

  10. 10.

    Chew HF, Evans NA, Stanish WD (2003) Patient-controlled bupivacaine infusion into the infrapatellar fat pad after anterior cruciate ligament reconstruction. Arthroscopy 19:500–505

    PubMed  Article  Google Scholar 

  11. 11.

    Chisholm MF, Bang H, Maalouf DB, Marcello D, Lotano MA, Marx RG et al (2014) Postoperative analgesia with saphenous block appears equivalent to femoral nerve block in ACL reconstruction. HSS J 10:245–251

    PubMed  PubMed Central  Article  Google Scholar 

  12. 12.

    Chmielewski TL, Jones D, Day T, Tillman SM, Lentz TA, George SZ (2008) The association of pain and fear of movement/reinjury with function during anterior cruciate ligament reconstruction rehabilitation. J Orthop Sports Phys Ther 38:746–753

    PubMed  Article  Google Scholar 

  13. 13.

    El Ahl MS (2015) Femoral nerve block versus adductor canal block for postoperative pain control after anterior cruciate ligament reconstruction: a randomized controlled double blind study. Saudi J Anaesth 9:279–282

    PubMed  PubMed Central  Article  Google Scholar 

  14. 14.

    Espelund M, Fomsgaard JS, Haraszuk J, Mathiesen O, Dahl JB (2013) Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction: a randomised controlled trial. Eur J Anaesthesiol 30:422–428

    CAS  PubMed  Article  Google Scholar 

  15. 15.

    FAiAz AF, KAmAth SS, (2019) Randomised controlled trial between ultrasound guided femoral nerve block and adductor canal block for postoperative pain and functional outcome in anterior cruciate ligament reconstruction. J Clin Diagn Res 13:11–14

    Google Scholar 

  16. 16.

    Faunø P, Lund B, Christiansen SE, Gjøderum O, Lind M (2015) Analgesic effect of hamstring block after anterior cruciate ligament reconstruction compared with placebo: a prospective randomized trial. Arthroscopy 31:63–68

    PubMed  Article  Google Scholar 

  17. 17.

    Filbay SR, Ackerman IN, Russell TG, Macri EM, Crossley KM (2014) Health-related quality of life after anterior cruciate ligament reconstruction: a systematic review. Am J Sports Med 42:1247–1255

    PubMed  Article  Google Scholar 

  18. 18.

    Frost S, Grossfeld S, Kirkley A, Litchfield B, Fowler P, Amendola A (2000) The efficacy of femoral nerve block in pain reduction for outpatient hamstring anterior cruciate ligament reconstruction: a double-blind, prospective, randomized trial. Arthroscopy 16:243–248

    CAS  PubMed  Article  Google Scholar 

  19. 19.

    Ghodki PS, Shalu PS, Sardesai SP (2018) Ultrasound-guided adductor canal block versus femoral nerve block for arthroscopic anterior cruciate ligament repair under general anesthesia. J Anaesthesiol Clin Pharmacol 34:242–246

    CAS  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Hewett TE, Di Stasi SL, Myer GD (2013) Current concepts for injury prevention in athletes after anterior cruciate ligament reconstruction. Am J Sports Med 41:216–224

    PubMed  Article  PubMed Central  Google Scholar 

  21. 21.

    Iskandar H, Benard A, Ruel-Raymond J, Cochard G, Manaud B (2003) Femoral block provides superior analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction. Reg Anesth Pain Med 28:29–32

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  22. 22.

    Jæger P, Zaric D, Fomsgaard JS, Hilsted KL, Bjerregaard J, Gyrn J et al (2013) Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 38:526–532

    PubMed  Article  CAS  PubMed Central  Google Scholar 

  23. 23.

    Karst GM, Jewett PD (1993) Electromyographic analysis of exercises proposed for differential activation of medial and lateral quadriceps femoris muscle components. Phys Ther 73:286–295 (discussion 295–289)

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  24. 24.

    Kocher MS, Steadman JR, Briggs K, Zurakowski D, Sterett WI, Hawkins RJ (2002) Determinants of patient satisfaction with outcome after anterior cruciate ligament reconstruction. J Bone Jt Surg Am 84:1560–1572

    Article  Google Scholar 

  25. 25.

    Koh IJ, Chang CB, Seo ES, Kim SJ, Seong SC, Kim TK (2012) Pain management by periarticular multimodal drug injection after anterior cruciate ligament reconstruction: a randomized, controlled study. Arthroscopy 28:649–657

    PubMed  Article  PubMed Central  Google Scholar 

  26. 26.

    Kristensen PK, Pfeiffer-Jensen M, Storm JO, Thillemann TM (2014) Local infiltration analgesia is comparable to femoral nerve block after anterior cruciate ligament reconstruction with hamstring tendon graft: a randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 22:317–323

    PubMed  Article  PubMed Central  Google Scholar 

  27. 27.

    Kurosaka K, Tsukada S, Nakayama H, Iseki T, Kanto R, Sugama R et al (2018) Periarticular injection versus femoral nerve block for pain relief after anterior cruciate ligament reconstruction: a randomized controlled trial. Arthroscopy 34:182–188

    PubMed  Article  PubMed Central  Google Scholar 

  28. 28.

    Lentz TA, Tillman SM, Indelicato PA, Moser MW, George SZ, Chmielewski TL (2009) Factors associated with function after anterior cruciate ligament reconstruction. Sports Health 1:47–53

    PubMed  PubMed Central  Article  Google Scholar 

  29. 29.

    Lundblad M, Kapral S, Marhofer P, Lönnqvist PA (2006) Ultrasound-guided infrapatellar nerve block in human volunteers: description of a novel technique. Br J Anaesth 97:710–714

    CAS  PubMed  Article  PubMed Central  Google Scholar 

  30. 30.

    Lynch JR, Okoroha KR, Lizzio V, Yu CC, Jildeh TR, Moutzouros V (2019) Adductor canal block versus femoral nerve block for pain control after anterior cruciate ligament reconstruction: a prospective randomized trial. Am J Sports Med 47:355–363

    PubMed  Article  Google Scholar 

  31. 31.

    Macdonald SA, Heard SM, Hiemstra LA, Buchko GM, Kerslake S, Sasyniuk TM (2014) A comparison of pain scores and medication use in patients undergoing single-bundle or double-bundle anterior cruciate ligament reconstruction. Can J Surg 57:E98-104

    PubMed  PubMed Central  Article  Google Scholar 

  32. 32.

    Majewski M, Susanne H, Klaus S (2006) Epidemiology of athletic knee injuries: a 10-year study. Knee 13:184–188

    CAS  PubMed  Article  Google Scholar 

  33. 33.

    Mall NA, Wright RW (2010) Femoral nerve block use in anterior cruciate ligament reconstruction surgery. Arthroscopy 26:404–416

    PubMed  Article  Google Scholar 

  34. 34.

    Malone T, Davies G, Walsh WM (2002) Muscular control of the patella. Clin Sports Med 21:349–362

    PubMed  Article  Google Scholar 

  35. 35.

    Manickam B, Perlas A, Duggan E, Brull R, Chan VW, Ramlogan R (2009) Feasibility and efficacy of ultrasound-guided block of the saphenous nerve in the adductor canal. Reg Anesth Pain Med 34:578–580

    PubMed  Article  Google Scholar 

  36. 36.

    Mayr HO, Entholzner E, Hube R, Hein W, Weig TG (2007) Pre- versus postoperative intraarticular application of local anesthetics and opioids versus femoral nerve block in anterior cruciate ligament repair. Arch Orthop Trauma Surg 127:241–244

    PubMed  Article  Google Scholar 

  37. 37.

    Nakase J, Shimozaki K, Asai K, Yoshimizu R, Kimura M, Tsuchiya H (2021) Usefulness of lateral femoral cutaneous nerve block in combination with femoral nerve block for anterior cruciate ligament reconstruction: a prospective trial. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03724-9

    Article  PubMed  Google Scholar 

  38. 38.

    Okoroha KR, Keller RA, Jung EK, Khalil L, Marshall N, Kolowich PA et al (2016) Pain assessment after anterior cruciate ligament reconstruction: bone-patellar tendon-bone versus hamstring tendon autograft. Orthop J Sports Med 4:2325967116674924

    PubMed  PubMed Central  Article  Google Scholar 

  39. 39.

    Reid N, Stella J, Ryan M, Ragg M (2009) Use of ultrasound to facilitate accurate femoral nerve block in the emergency department. Emerg Med Australas 21:124–130

    PubMed  Google Scholar 

  40. 40.

    Runner RP, Boden SA, Godfrey WS, Premkumar A, Samady H, Gottschalk MB et al (2018) Quadriceps strength deficits after a femoral nerve block versus adductor canal block for anterior cruciate ligament reconstruction: a prospective, single-blinded, randomized trial. Orthop J Sports Med 6:2325967118797990

    PubMed  PubMed Central  Article  Google Scholar 

  41. 41.

    Secrist ES, Freedman KB, Ciccotti MG, Mazur DW, Hammoud S (2016) Pain management after outpatient anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Am J Sports Med 44:2435–2447

    PubMed  Article  PubMed Central  Google Scholar 

  42. 42.

    Sehmbi H, Brull R, Shah UJ, El-Boghdadly K, Nguyen D, Joshi GP et al (2019) Evidence basis for regional anesthesia in ambulatory arthroscopic knee surgery and anterior cruciate ligament reconstruction: part II: adductor canal nerve block—a systematic review and meta-analysis. Anesth Analg 128:223–238

    PubMed  Article  PubMed Central  Google Scholar 

  43. 43.

    Shino K, Horibe S, Hamada M, Nakamura N, Nakata K, Toritsuka Y et al (2002) Allograft anterior cruciate ligament reconstruction. Tech Knee Surg 1:78–85

    Article  Google Scholar 

  44. 44.

    Sousa PL, Krych AJ, Cates RA, Levy BA, Stuart MJ, Dahm DL (2017) Return to sport: does excellent 6-month strength and function following ACL reconstruction predict midterm outcomes? Knee Surg Sports Traumatol Arthrosc 25:1356–1363

    PubMed  Article  PubMed Central  Google Scholar 

  45. 45.

    Vorobeichik L, Brull R, Joshi GP, Abdallah FW (2019) Evidence basis for regional anesthesia in ambulatory anterior cruciate ligament reconstruction: part I—femoral nerve block. Anesth Analg 128:58–65

    PubMed  Article  PubMed Central  Google Scholar 

  46. 46.

    Wessel J (1994) Straight leg raise: an overused exercise. Physiother Can 46:17–19

    Google Scholar 

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Correspondence to Takahiro Ogura.

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Ogura, T., Omatsu, H., Fukuda, H. et al. Femoral nerve versus adductor canal block for early postoperative pain control and knee function after anterior cruciate ligament reconstruction with hamstring autografts: a prospective single-blind randomised controlled trial. Arch Orthop Trauma Surg (2021). https://doi.org/10.1007/s00402-021-03823-1

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Keywords

  • Femoral nerve block
  • Adductor canal block
  • Anterior cruciate ligament reconstruction
  • Hamstring autograft