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Efficacy of adductor canal block in total knee

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(Acta Anaesth. Belg., 2017, 68, 63-71)

Efficacy of adductor canal block in total knee arthroplasty: a

systematic review
D. F. Hoogma (*), S. Rex (**), M. Van de Velde (**) and S. Coppens (*)

Summary : Total knee arthroplasty (TKA) is associated popularity for knee surgery, despite limited
with significant postoperative pain, frequently im- evidence for its efficacy and efficiency. Two studies
pairing recovery and delaying discharge from the compared the quadriceps muscle strength in healthy
hospital. Adductor canal block (ACB) could enhance volunteers after FNB or ACB and found that FNB
postoperative recovery. This systematic review highlights decreased quadriceps muscle strength by 48-89%,
that the evidence for ACB use in TKA is sparse. ACB is
as compared to only 5-8% for ACB (7, 8).
associated with adequate analgesia. Although evidence
Recently, a meta-analysis comparing ACB
suggests that ambulation ability with an ACB is better
preserved as compared to placebo, it remains unclear as to FNB has concluded that ACB is superior to
compared to a femoral nerve block. FNB regarding pain control and ambulation
ability (9). This meta-analysis has however been
Keywords : Anesthesia, Conduction ; Arthroplasties, heavily criticized for methodological issues (10).
Replacement, Knee ; Nerve block. To overcome these limitations, we performed a
systematic review of the available literature, in order
to assess whether ACB for primary TKA is effective
during the postoperative in terms of morphine
Introduction consumption, muscle strength, ambulation ability,
and hospital LOS.

Total knee arthroplasty (TKA) is associated Materials and Methods

with moderate to severe postoperative pain, delaying
early mobilization and prolonging hospital length The authors performed a systematic review
of stay (LOS) (1). Postoperative analgesia aims at according to the instructions of the Cochrane
facilitating early mobilization and rehabilitation, handbook for systematic reviews of interventional
thereby enhancing recovery and minimizing post- studies (11) and the PRISMA guidelines (12). On
operative morbidity. A major challenge is to provide October 6th, 2016, we conducted a literature search
sufficient analgesia while preserving muscle func- in the following databases: US National Library of
tion and strength. While central neuraxial blocks Medicine database (MEDLINE), Excerpta Medica
have been traditionally used for perioperative database (EMBASE), Scopus and Trip (without any
anesthesia and analgesia in TKA (2), the advances date limitation). We used the following keywords
in ultrasound-guided regional anesthesia have made in all four databases: (total knee arthroplasty AND
peripheral nerve blocks (PNB) increasingly popular saphenous nerve block) OR (total knee replacement
(3).
The femoral nerve block (FNB) causes
quadriceps muscle weakness and can therefore
cause functional impairment, thereby potentially Danny Feike Hoogma, Steffen Rex, Marc Van de Velde, Steve
Coppens
increasing the risk of postoperative falls (4). (*) Department of Anesthesiology, University Hospitals
However, a recent large retrospective review found Leuven, Belgium.
no association between peripheral nerve blocks (**) Departments of Cardiovascular Sciences, KU Leuven,
and Department of Anesthesiology, University Hospitals
and in-hospital falls (5). In contrast, the adductor Leuven, Belgium.
canal block (ACB) is predominantly a sensory Correspondence address : Dr. Danny Hoogma, Department
block, with the theoretical advantage of preserving of Anesthesiology, University Hospitals Leuven, Herestraat
quadriceps muscle strength and therefore promoting 49, 3000 Leuven, Belgium. Tel. +32 16 34 42 70. Fax +32
16 34 42 45
ambulation ability to a greater extent than FNB E-mail : [email protected]
(6). In recent years, ACB has gained increasing Protocol registration : PROSPERO register: CRD4201603614

© Acta Anæsthesiologica Belgica, 2017, 68, n° 2

64 d. f. hoogma et al.
AND saphenous nerve block) OR (total knee The Jadad scale, also known as the Oxford
replacement AND adductor canal block) OR (total quality scoring system, was used to assess the
knee arthroplasty AND adductor canal block)). We methodological quality of randomization, blinding,
included only randomized controlled trials (RCTs). and withdrawal of the included studies (Table 1)
The protocol has been registered in the PROSPERO (13).
register: CRD42016036149.
Each abstract was then screened to identify Results
studies in which patients were randomized to
receive either ACB or other analgesic techniques Study selection and characteristics
for primary TKA. In addition, the references of
these RCTs were searched for any relevant articles The literature search yielded a total of 431
not identified in our primary search. The specific citations. After excluding duplicates and non-
outcomes sought in each article were morphine pertinent titles or abstracts, only 11 citations were
consumption, quadriceps muscle strength and eligible. The large number of duplicates was due
hospital LOS. to a considerable overlap between the databases.
We excluded studies if surgery was other than Moreover, a large number of clinical trial protocols
primary TKA. Moreover, studies were excluded if was found in one database. One prospective,
the PNB was administered as rescue therapy. The randomized study was retrieved from the search,
flowchart of the literature search is illustrated in insofar as, in this study, the ACB was placed only
Figure 1. on the first postoperative day (POD) (Fig. 1).
A self-designed form for extraction of the trial Hence, ten studies could be included in our
characteristics and the aforementioned outcomes analysis (Table 1), with two studies analyzing
was used to assist in data collection. Data extracted single shot ACB and 8 studies testing continuous/
for analysis included author, number of patients, intermittent ACB (CACB). In 6 studies, ACB was
study design, additional analgesia, systemic opioid compared with FNB (6, 14-18), while in 2 studies
equivalents, quadriceps muscle strength, gait aids the control group received placebo injections in
used during ambulation ability testing, hospital the adductor canal (19, 20). One study used a sham
LOS, and the primary outcome parameter of each catheter as control intervention (21) and the last one
study. compared single shot ACB to CACB (22).

Quality
Quality assessment for randomization,
blinding, and withdrawal was performed using
the Jadad scale (13). This yielded 8 studies with a
maximum score of 5/5 and 2 studies with a score
of 3/5 due to inadequate blinding. Primary and
secondary outcome measures were clearly defined
-
in 9 out of 10 studies (Table 1).

- Retrospective Opioid consumption

- Redo surgery
- Rescue block
- No TKA/TKR Opioid consumption was recorded in 8 out of 10
-
-
Incomplete data
Clinical trial protocols studies, but only in 3 studies as primary outcome
(Table 1, 2). Due to different control groups and
adjuvant analgesia techniques, the results were not
entirely uniform.
Testing ACB against placebo in the control group
resulted in a significant difference in total morphine
consumption (20). The comparison of ACB with
a sham-block resulted in a reduced IV morphine
equivalent consumption at 48 h in the group with
ACB. After adjustment for baseline covariates,
Fig. 1. — Flow diagram of the study selection
reduced morphine consumption was still in favor of
(last updated October 2016) ACB (21).

© Acta Anæsthesiologica Belgica, 2017, 68, n° 2

 efficacy of adductor canal block in total knee arthroplasty 65
Table 1:
Detailed information on study features. CACB, continuous adductor canal block; ASIS, anterior superior iliac spine; CFNB, continuous
femoral nerve block; POD, postoperative day; NRS, numerical rating scale; ACB, adductor canal block; FNB, femoral nerve block;
SSACB, single shot adductor canal block; TUG, timed up and go; MIA, multi-site infiltration analgesia

Author Number Study groups Jadad Primary outcome

of pa- score
tients
Jenstrup (20) 75 CACB (halfway between ASIS and patella) with 5 Morphine consumption
initial bolus of 30 ml ropivacaine 0.75% and
intermittent boluses (15 ml/6 h) ropivacaine 0.75%
compared to placebo, until 18 h postoperative.
24 h postoperative 15 ml bolus ropivacaine 0.75%
in both groups.
Andersen (19) 40 CACB (halfway between base patella and ASIS) 5 Worst pain on movement
with initial bolus of 15 ml ropivacaine 0.75%
and intermittent boluses (15 ml/12 h) ropivacaine
0.75% compared to placebo, until POD 2: 8pm.
Jaeger (6) 54 CACB (halfway between ASIS and patella) com- 5 Maximum voluntary isometric con-
pared to CFNB traction of the quadriceps
Bolus of 30 ml ropivacaine 0.5% followed by an
infusion ropivacaine 0.2% 8 ml/h during 24 h.
Sham-catheter on the other puncture site.
Hanson (21) 80 CACB (halfway between inguinal crease and pa- 5 Morphine consumption
tella) 8 ml/h ropivacaine 0.2% compared to sham
catheter, until POD 2.
Kim (14) 94 ACB (distal third of the thigh) bupivacaine 0.5% 5 Not clearly defined: dynamometer,
15 ml compared to FNB bupivacaine 0.25% 30 ml. numerical rating scale for pain (non-
inferiority) and morphine consumption
(non-inferiority)
Shah and Jain (15) 100 CACB (halfway between ASIS and patella) com- 3 Visual analog pain scale and
pared to CFNB mobilization ability
Bolus of 30 ml ropivacaine 0.75% followed by
intermittent boluses ropivacaine 0.25% 30 ml/4h,
until POD 2: 8am.
Wiesmann (16) 46 CACB (distal thigh) compared to CFNB 5 Mobilisation (TUG)
Bolus of 15 ml ropivacaine 0.375% followed by
an infusion ropivacaine 0.2% 6 ml/h, during 48h.
Shah (22) 90 CACB compared to SSACB (halfway between 5 Visual analog pain scale
ASIS and patella)
Bolus of 30 ml ropivacaine 0.75%, followed with
intermittent boluses ropivacaine 0.25% 30 ml/4 h
compared to placebo, until POD 2: 8am.
Machi (17) 84 CACB (midpoint between ASIS and cephalad mar- 3 Time to attain 4 discharge criteria
gin of the patella) compared to CFNB (adequate analgesia; intravenous
opioid independence; ability to stand,
Bolus of 30 ml lidocaine 2% followed by an in- walk 3 m, return, and sit down; and
fusion ropivacaine 0.2% 6 ml/h with boluses 4 ambulate 30 m)
ml/30min, during 72 h.
Li (18) 90 MIA compared to FNB and/or ACB (middle or dis- 5 Numerical rating score (NRS) at rest
tal thigh level) and with activity and change of vital
signs
FNB and ACB: Bolus of 20 ml ropivacaine 0.5%
with epinephrine 0.1 mg.
MIA: 70 ml ropivacaine 0.25% with epinephrine
0.3 mg

© Acta Anæsthesiologica Belgica, 2017, 68, n° 2

66 d. f. hoogma et al.
When comparing ACB to FNB, cumulative in TUG testing 24 hours postoperatively (22). This
total morphine consumption 6-8, 24 and 48 hours was also true in another study comparing ACB to
postoperatively was comparable between groups. FNB (18). In contrast, one RCT found a significant
ACB was therefore described as not being inferior difference in favour of patients receiving CACB
to FNB (6,14,18). In two other studies, there with ropivacaine when compared to placebo at
was no difference in systemic opioid equivalent 24 h postoperatively (20). Others found CACB
requirements, even up to 72 h after surgery, although to be superior with respect to the TUG test when
the FNB group reported superior analgesia during compared to CFNB (15). Likewise, Machi and
physical therapy (16, 17). colleagues detected a significant difference in
Adding an AC with ropivacaine to a single ambulation ability in favor of CACB, with 97% of
dose local infiltration analgesia (LIA) resulted in a the patients being able to fulfill the TUG test 24 h
reduced total morphine IV equivalents consumption postoperatively, as compared to 56% in the CFNB
on the day of surgery, when compared to LIA group. Patients of the latter group had significantly
alone. This difference disappeared on the third less pain during physical therapy (17).
postoperative day (19). Opioid consumption was
even higher in the group with ACB as compared to Hospital length of stay
multi-site infiltration analgesia (MIA), which is a
Hospital LOS was recorded in 6 out of 10
combination of 3 local infiltrations sites, intra- and
studies (Table 2). In 5 studies, it was recorded as
peri-articular with wound infiltration (18).
a secondary outcome. Only one RCT reported a
decrease in hospital LOS for the CACB group when
Muscle strength and ambulation
compared to CFNB (15). Four RCT’s reported that
hospital LOS was not different for the two groups
Muscle strength was evaluated in 9 out of
when comparing CACB to placebo, CACB to single
10 studies by analyzing the maximum voluntary
shot ACB, CACB to CFNB, or ACB to FNB. There
isometric contraction using dynamometry or the
were no difference in the incidence of adverse
“Timed Up-and-Go” (TUG) test as parameter
effects (14, 18, 19, 22).
for ambulation (Table 2). Three studies analyzed
One study defined the time until achievement
muscle strength as the primary outcome parameter
of 4 discharge criteria as the primary outcome:
(6,14,16), while the remaining 6 studies assessed
adequate analgesia, independence from IV opioids,
muscle strength as a secondary outcome (15,17,18,
ability to stand, walk 3 m, return, and sit down,
20-22).
and ambulate 30 m. Patients with a CACB reached
Single shot ACB was found to be non-inferior
all four criteria within a median time of 55 h as
to FNB with respect to absolute force of the
compared to 61 h for those with a CFNB. This
quadriceps muscle. This effect was even superior
difference did not reach statistical significance (17).
for strength with significantly higher median
dynamometer readings at 6-8 h postoperatively with
Discussion
non superior pain scores during physical therapy
in the ACB group. Dynamometer readings were Effective treatment of postoperative pain
however not superior at 12 h, 24 h and 48 h (14, and enhancing early rehabilitation is important to
18). Another RCT found that patients with CACB facilitate early discharge from the hospital (23).
had significantly higher quadriceps strength as The ACB is apparently associated with adequate
compared to patients with continuous FNB (CFNB) analgesia and with maintenance of quadriceps
at 24 h postoperatively (6). strength. Whether the effects contribute to enhanced
The comparison of CACB with a sham catheter ambulation ability, or a reduction in hospital LOS
showed stronger absolute quadriceps force on remains uncertain.
the second postoperative day but not on the first TKA is associated with moderate to severe
postoperative day. Pain scores during these physical postoperative pain, for which most often multimodal
therapy sessions were significantly lower in the systemic analgesia is used. Postoperative morphine
CACB group (21). consumption is one of the most frequently used
Seven studies reported TUG as the ambulation surrogate markers for the relatively objective
parameter. In two studies, there was no difference assessment of postoperative pain (24). Eight out
between CACB and CFNB regarding the TUG test of 10 studies included in our systematic review
and pain scores (6, 16). Also, CACB compared to reported the postoperative use of opioids, with
single shot ACB showed no significant difference only 2 studies showing a reduction in morphine

© Acta Anæsthesiologica Belgica, 2017, 68, n° 2

 Table 2.
Studies comparing morphine consumption, quadriceps muscle strength, ambulation ability and hospital length of stay as outcome parameter. CACB, continuous adductor canal block; PCA, patient
controlled analgesia; LIA, local infiltration analgesia; CFNB, continuous femoral nerve block; SD, standard deviation; FNB, femoral nerve block; ACB, adductor canal block; CSE, combined
spinal epidural anesthesia; MIA, mutli-site infiltration analgesia; CI, confidence interval; TUG, timed up and go; POD, postoperative day; MVIC, maximum voluntary isometric contraction; CSE,
combined spinal epidural anesthesia; IQR, interquartile range; SSACB, single shot adductor canal block; PACU, postanesthesia care unit, SR, sustained release.

Author Study groups Additional analgesia Morphine consumption ( mg) Quadriceps muscle strength Hospital length of stay (LOS)
Jenstrup (20) CACB Spinal anesthesia (10 mg hyperbaric 40 ± 21 vs 56 ± 26 (Mean ± SD, TUG na
compared to bupivacaine) P = 0.006) at 24h 36 ± 17 vs 50 ± 29 s (Mean ± SD) at 24h
placebo Morphine-PCA 33 ± 20 vs 41 ± 27 s (Mean ± SD) at 26h
Acetaminophen 1g/6 h orally
Ibuprofen 400 mg/6 h orally
Andersen CACB Spinal anesthesia (12.5-15 mg hyperbaric 67 (22-159) vs 68 (20-163) na 3.1 (2.4-5) vs 3.1 (1.8-5.2) days
(19) compared to bupivacaine) (Median + range) on the 3th (Median, range) P = 0.68
placebo LIA (100 ml ropivacaine 2 mg/ ml + POD
epinephrine 10 µg/ ml)
Morphine-PCA
Acetaminophen 1g q 6 h orally
Morphine ER 10 mg q 12 h orally
Jaeger (6) CACB Spinal anesthesia (10-15 mg hyperbaric 22 ± 9 vs 22 ± 21 (Mean ± SD) MVIC at 24 h postoperatively (% of na
compared to bupivacaine) P = 0.94) at 24 h baseline value):
CFNB Morphine-PCA 52 (9-92) vs 18 (0-69) % (Median, 95%
Acetaminophen 1g q 6 h orally CI), P = 0.004
Ibuprofen 400 mg q 6 h orally
TUG at 24 h postoperatively
37 ± 22 vs 39 ± 16 s (Mean ± SD)
Hanson (21) CACB Orally Acetaminophen 975 mg, celecoxib 46.7 (95% CI, 34.86-58.5) vs Quadriceps strength (maximum pounds na
compared to 400 mg and gabapentin 900 mg 63.4 (95% CI, 51.89-74.83) of force)
placebo Sedation with 0-250 µg fentanyl and 0-5 mg (Least-square mean) at 48 h (Mean ± SD)
midazolam IV POD1: 24.9 ± 20.5 vs 23.3 ± 20.1, P =
FNB with ropivacaine 0.5% 20 ml + 0.746
epinephrine 1/40.000 POD2: 34.3 ± 25.3 vs 21.2 ± 17, P =
Spinal anesthesia (12.5 mg plain bupivacaine) 0.01
Varied practice: LIA (30 ml bupivacaine
0.25% + morphine 10 mg)
Morphine-PCA
Kim (14) ACB Meloxicam 7.5 mg or 15 mg orally 6-8 h: 36.5 ± 17,9 vs 35.8 ± 20.7 Dynamometer readings (Mean ± SD) 3.7 ± 0.8 vs 3.6 ± 0.8 days
compared to preoperatively (Mean ± SD) 6-8h: 7.3 ± 5.4 vs 2.2 ± 3.8 (kilogram- (Mean ± SD) P = 0.73
FNB CSE (spinal anesthesia 12.5 mg hyperbaric 24 h: 50.3 ± 30.8 vs 50.4 ± 33.1 force unit)
bupivacaine, epidural top-ups with lidocaine (Mean ± SD) 24h: 3.9 ± 4.2 vs 4.0 ± 4.0 (kilogram-
2%) force unit)
Epidural-PCA No difference of the non-operatively leg
Oxycodone/acetaminophen 5/325 mg q 4 h at any given time
orally as needed
Meloxicam 7.5 mg/d or 15 mg/d orally

© Acta Anæsthesiologica Belgica, 2017, 68, n° 2

efficacy of adductor canal block in total knee arthroplasty 67
 Author Study groups Additional analgesia Morphine consumption ( mg) Quadriceps muscle strength Hospital length of stay (LOS)
68
Shah and CACB Spinal anesthesia (12.5 mg hyperbaric na TUG at 24h postoperatively 3.08 ± 0.4 vs 3.92 ± 0.44 days
Jain (15) compared to bupivacaine) 51.81 ± 7.93 vs 180 ± 68.4 s (Mean ± (Mean ± SD) P < 0.001
CFNB Intra-articular infiltration (20 ml 0,25 SD)
bupivacaine + 250 mg cefuroxime + 40 mg
triamcinolone acetonide)
Diclofenac sodium 75 mg q 8 h IV or
paracetamol 1000 mg q 8 h IV
Acetaminophen 500 mg q 6 h orally
Tramadol 50 mg IV (rescue)
Wiesmann CACB General anesthesia Intraoperative fentanyl (mg) TUG median (25th-75th IQR): na
(16) compared to Anterior sciatic nerve block median (25th-75th IQR): POD 2: 45 (35-80) vs 64.5 (56-91) s
CFNB Ibuprofen 400-600 mg q 8 h orally 0.4 (0.25-0.5) vs 0.4 (0.4-0.5). POD 3: 51 (37-65) vs 45 (37-70) s
Piritramide IV 3.75-7.5 mg (rescue) P = 0.11
PACU piritramide median

© Acta Anæsthesiologica Belgica, 2017, 68, n° 2

(25th-75th IQR):
1.0 (0-7.5) vs 0.0 (0-7.5). P =
0.74
Shah (22) CACB Spinal anesthesia (15 mg hyperbaric na TUG at 24h postoperatively (Mean ± 3.08 ± 0.35 vs 3.2 ± 0.4 days
compared to bupivacaine) SD) (Mean ± SD) P = 0.157
SSACB Intra-articular infiltration (20 ml 0.5 57.95 ± 8.46 vs 60.3 ± 3.82 s
bupivacaine + 250 mg cefuroxime + 40 mg
triamcinolone acetonide)
Diclofenac sodium 75 mg q 8 h IV or
d. f. hoogma

paracetamol 1000 mg q 8 h IV
Acetaminophen 500 mg q 6 h orally
Tramadol 50 mg IV (rescue)
et al.

Machi (17) CACB Spinal anesthesia (10-15 mg hyperbaric Similar intravenous opioid TUG (% of treatment group) Discharge readiness criteria as
compared to bupivacaine) or general anesthesia) requirements POD1 morning: 79 vs 31% median (25th-75th IQR)
CFNB LIA (30 ml ropivacaine 0.5%, epinephrine POD1 afternoon: 100 vs 65% POD1: 55 (42-63) vs 61 (49-
10 μg/ml, ketolorac 30 mg and tranexamic 69) h
acid 2g) Hospital LOS as median
Lidocaine 2% 10 ml perineural or SR (25th-75th IQR):
oxycodone 5-10 mg orally on PACU if 74 (69-76) vs 73 (70-77) h. P
needed = 0.97
Acetaminophen 975 mg q 6h orally
Celecoxib 200 mg q 12 h orally
SR oxycodone 10 mg q 12 h orall
Li (18) MIA Celecoxib 200 mg q 12 h orally 3 days Opioid consumption (Mean ± TUG POD 1 and 2: Postoperative hospital days
compared to preoperative SD): ACB = FNB, P > 0.05 (mean ± SD):
FNB and Diclofenac 50 mg q 12 h orally MIA: 32.5 ± 21.7 MIA: 3.6 ± 0.8
ACB SR oxycodone 10 mg q 12 h orally FNB: 38.3 ± 22.6 FNB: 5.2 ± 1.0
Parecoxib q 12 h intramuscular ACB: 37.9 ± 20.6 ACB: 4.9 ± 0.8
Pethidine 50 mg intramuscular on PACU if P < 0.05 P < 0.05
needed
 efficacy of adductor canal block in total knee arthroplasty 69
consumption for the ACB, but only when compared motoric effects highly vulnerable to bias. Second,
to placebo (20,21). The other 6 studies showed no the limited number of RCTs, their non-homogenous
benefit of the ACB as compared to the respective designs, and a lack of uniform outcome parameters
control group (Table 2). also precluded a statistical meta-analysis of the
It is difficult to draw valid conclusions from aggregated data. Third, the studies included in our
these data as, concomitant analgesia protocols review had sample sizes varying from 40 to 100
varied widely in each individual study. Moreover, patients. As a consequence, the studies clearly
the studies lack a uniform control group, making lacked power to detect differences in most of the
quantification and comparison of the effects secondary outcome parameters (25).
nearly impossible. As least common denominator, Forth, the individual studies included in
the studies suggest that ACB decreases opioid our systematic review suffer from a lack in con-
requirements when compared to placebo. When sensus regarding the exact anatomical location
added to LIA, it is equipotent when compared to of the adductor canal (Table 1). A recent meta-
FNB, but might be inferior to MIA. analysis from Hussain et al. also highlights this
Nine out of 10 studies reported muscle strength limiting factor, suggesting a better definition of its
and/or ambulation ability, albeit using different anatomical location (26). Some authors recommend
outcome parameters. All studies assessing muscle to use a subsartorial approach with blockade of
strength found ACB to be superior to the control the vastus medialis branches of the femoral nerve,
group (6,14,21). When assessing ambulation ability together with the saphenous nerve (27). Others have
with a TUG test, three studies found ACB to be suggested that the real ACB is located in the Hunters
superior to the control group (15,17,20) while four canal, beneath the vastoadductor membrane, hence
other studies showed no benefit of ACB as compared much lower than the position that can be reached
to the control group (6,16,18,22). Compared to by the mid-thigh approach (28). It has been brought
placebo, an ACB seems to enhance ambulation, forward that only at this location, there is dispersion
possibly due to lower pain scores (19-21). of the injectate into the popliteal fossa (29). How-
Again, the unambiguous interpretation of these ever, the efficacy of ACB close to the hiatus may
results is difficult, as endpoints were not unifor result in a lower success rate when compared to the
mly assessed. Every single trial used a different more traditional subsartorial mid-thigh ACB (27,
method to study ambulation ability. Data suggest 30).
that ACB preserves muscle strength better than the In conclusion, the use of ACB in TKA is
comparators. This is especially true in volunteer apparently associated with adequate analgesia
studies (8). Whether this translates into better and maintenance of quadriceps strength, without
ambulation ability in a postoperative setting, where conclusive evidence of enhanced ambulation ability.
surgery and the use of a tourniquet also causes The data show a trend toward ACB being superior
quadriceps dysfunction, has still to be unequivocally as compared to placebo and at least non-inferior
demonstrated. as compared to FNB. Based on the heterogeneity
A total of 6 studies report hospital LOS with of the available data, it is impossible to exactly
only 1 study finding ACB to be superior to the quantify these effects. Further adequately powered
control group (15) and 1 study showing that ACB is clinical trials with uniform outcome parameters and
inferior to MIA in that respect (18). The remaining definitions are warranted.
4 studies found ACB to be equivalent to the control
group (14,19,22). Of note, the only study that was
specifically powered for the assessment of LOS did References
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