Femoral Catheter Marginally Improves CPM Compliance but Significantly Lowers Opioid Use vs Adductor Canal Catheter with ACL Repair
Aims
•Primary aims: Opioid Use and PainScores
•Secondary aims: Continuous Passive Motion Device (CPM) compliance for 48 hours after surgery andQuality of Recovery (QoR-15) score
Background
•Evidence shown by previous studies:
•Adductor Canal Block catheter(ACB) is non-inferior to Femoral Nerve Block catheter(FNB) analgesia after TotalKnee Arthroplasty [1].
•Single shot ACB is non-inferior to single shot FNB after ACL repair [2].
•ACB shows similar analgesia toFNB, with ACB betterpreserving quadriceps strength[3].
•Some surgeons have requested a FNBcatheter but not an ACB catheter for pain control after ACL reconstructiondue to a subjective impression of (1) better pain control, (2) less call back for poor pain control, and (3) less opioid refill requests.
•Hypothesis: FNB catheter will be superior to an ACB catheter after ACL reconstruction for pain control without negatively affecting the quality of recovery from potential transient quadriceps weakness.
Methods
•Double-blinded, RandomizedControlled Trial comparingFemoral Nerve Catheter with Adductor Canal Catheter.
•Standard ultrasound-guided femoral or adductor canal block catheter with a loading dose of 20mL 0.5% ropivacaine.
•Upon arrival to the recovery room, catheters were connected to portable infusion pump delivering a continuous infusion of 0.2% ropivacaine at 5mL/hr, with 5mL demand bolus and 30-minute lockout.
•Quality of Recovery questionnaire (QoR-15) conducted by phone at 24 and 48 hours after discharge from the recovery room.
Results
•Patients included: FNB = 28, ACB =29
•A significant association (p<0.05) exists between the FNB group and low opioid consumption, while the ACB group is associated with high opioid usage (p<0.05).
•Within the FNB group, there were no patients, 0% (0/28), who had a high opioid consumption level of more than 50 MME/Day.Moreover, there were 50% (14/28) patients who had a low opioid usage level of less than 10 MME/Day in the FNB group.
•In contrast, the ACB group included 17% (5/29) patients with high opioid usage and only 31% (9/29) patients with low opioid usage.
•There were no differences between FNB and ACB catheters for CPMCompliance, pain scores, andQuality of Recovery (QoR-15) score.
Discussion
•No difference in pain scores and quality of recovery partly due to a dedicated team titrating opioids to desirable clinical effects for both groups.
•ACB was placed proximal to the junction of the distal femoral triangle and proximal adductor canal, on average 5 cm above the mid-thigh,measured as the mid-point between the ASIS and the patella.
•Despite the small difference between the 2 groups, the FNB catheterprevents the most severe pain.
•Limitation: No power to assess “fall”risk
References
1. Machi AT, Sztain JF, Kormylo NJ et al. Discharge readiness after tricompartment knee arthroplasty: Adductor canal versus femoral continuous nerve blocks-a dual-center, randomized trial. Anesthesiology 2015;123:444-56.
2. Abdallah FW, Whelan DB, Chan VW et al. Adductor canal block provides noninferior analgesia and superior quadriceps strength compared with femoral nerve block in anterior cruciate ligament reconstruction. Anesthesiology 2016;124:1053-64.
3. Jaeger P, Zaric D, Fomsgaard JS et al. Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: A randomized, double-blind study. Reg Anesth Pain Med 2013;38:526-32.
