Comparison of adductor canal block and local infiltration analgesia techniques for postoperative analgesia in gonarthrosis patients receiving a total knee prosthesis

Amac: Total dizartroplastisi(TDA) major bir ortopedik cerrahidir ve hastalar postoperatif donemde ciddi agri cekmektedir. Lokal infiltrasyon analjezisi ve / veya periferik sinir bloklari  TDA sonrasi analjezi amacli siklikla kullanilir. Bu calismanin amaci TDA sonrasi postoperatif ilk 24 saat icerisinde lokal infiltrasyon analjezisi ve addutor kanal blok tekniginin etkinligini karsilastirmaktir. Gerec ve Yontemler : 40-80 yas arasi, ASA I-III grup ve TDA yapilacak 60 hasta lokal etik komite onayi alindiktan sonra bu calismaya dahil edildi. Tum hastalara 15 mg 0.5% heavy bupivacaine ile spinal anestezi uygulandi. I. Gruba sinir blokaji amacli ultrasonografi esliginde 20 mL 0.25% bupivacaine uygulandi. II. Gruba periartikuler alan ve subkutan dokuya 60 mL kokteyl enjekte edildi. Vizuel analogskalasi(VAS) ile postoperatif 0,1,2,8,12 ve 24. saatlerde agri skorlari degerlendirildi. VAS skoru 4 uzerinde olan ve agrisinin giderilmesine ihtiyaci oldugunu belirten hastalara intravenoz analjezikler uygulandi ve analjezi gereksinim zamani olarak kaydedildi. Istatistiksel analiz IBM SPSS 23.0 software ile yapildi. p 0.05). I. Gruptaki hastalarin tamaminin ortalama 10.0±4.9. saatlerde ve II. Gruptaki hastalarin 28’inin ise 8.7±6.02. saatlerde  ek analjezi ihtiyaci oldugu gozlendi. Bu fark istatistiksel olarak anlamli bulunmadi (p>0.05). Sonuc : Bu calismada; TDA operasyonu sonrasindaki ilk 24 saatte multimodal analjezi methodu olarak her iki yontemin de yeterli analjezi sagladigi ve kullanilabilecegi gosterilmistir.


Introduction
Total knee arthroplasty (TKA) is a major orthopaedic surgical procedure, and almost half of all patients experience severe postoperative pain. One of the most important factors in ensuring the success of the treatment process and patient comfort is the control of postoperative pain. In providing postoperative analgesia after TKA operations, local infiltration anaesthesia and/or peripheral nerve blocks are often used. [1,2] Adductor canal blocks provide effective analgesia after TKA surgery and accelerate the recovery process. When postoperative analgesia is provided in the early stage, early pain-free mobilization of the patient can be achieved, thereby shortening the length of hospital stay. [3] Local infiltration anaesthesia has been shown to provide effective analgesia in the postoperative period. [4] The aim of this study was to compare the analgesic efficacy of local infiltration anaesthesia and adductor canal block techniques in the first postoperative 24 hours after the TKA procedure. Patients were evaluated with respect to demographic characteristics, postoperative pain scores, the need and time of requirement for additional analgesics and side effects.

Materials and Methods
This study was planned as a single-centre, randomized, double-blind, controlled study. Informed consent was obtained from all the patients participating in the study, and all the researchers signed the Declaration of Helsinki. Approval for the study was granted by the local ethics committee.
The study was planned with a total of 60 patients of both sexes aged 40-80 years who were in the ASA I-II-III physical risk group and were undergoing TKA for primary or secondary osteoarthritis. The exclusion criteria were defined as patients with a previous TKA surgery on the same side, an infection in the application area, neuropathy, a local anaesthetic allergy, cerebrovascular disease, bleeding diathesis, neuromuscular disease, a renal implant, heart failure (American Heart Association Grade 3), pulmonary failure, or a mental status impairment that can create difficulties in understanding a numerical scale and patients who were in the ASA IV-V physical risk group, reported long-term use of analgesics such as NSAIDs and opioids, or exhibited unwillingness to participate.
The patients were randomly allocated to one of two groups using the sealed envelope method of randomization.

Anaesthesia Technique
In both patient groups, 0.03 mg/kg midazolam IV and 1 µg/ kg fentanyl IV were applied. Then, with entry into the spinal space, the spinal anaesthesia technique was used with 15 mg 0.5% heavy bupivacaine.

Adductor Canal Block (Saphenous Nerve Block) (Group I)
All the nerve blocks were applied under ultrasonography (USG) guidance by the same anaesthetist who was experienced in peripheral nerve blocks. The application area was prepared by the appropriate sepsis-antisepsis preparation procedure in the Group I patients, and the procedure was performed using a 6-13 mHz linear ultrasound probe (Logiqe, General Electric, USA). With the patient in the supine position, the thigh was abducted and externally rotated. The probe was placed transversely at the anteromedial site at the middle third of the thigh. Once the femoral artery was identified under the sartorius muscle, the 5 cm peripheral nerve block needle (Stimuplex D. B., Braun, Melsungen, Germany) was inserted in-plane in a lateral-to-medial direction. When the needle tip was visualized medial to the artery, aspiration was performed, 1 to 2 mL of the local anaesthetic was injected to confirm the injection site, and the remaining local anaesthetic volume was administered (0.25% bupivacaine 20 mL in total) under USG guidance to the surroundings of the nerve in the adductor canal.

Local Infiltration Anaesthesia Group (Group II)
For the patients in Group II, a 60 mL mixture was injected by the surgical team during the surgical procedure from the periarticular area to the subcutaneous tissue (posterior capsule, collateral ligament, quadriceps muscle). The local anaesthetic cocktail was composed of 200 mg 0.5% bupivacaine, 40 mg methylprednisolone, 0.15 mg adrenaline, 750 mf cefazolin and 8 mg morphine (Table 1).

Surgical Technique
All the surgical procedures were applied by the same orthopaedist. Routine cemented total knee prosthesis surgery was performed with a mid-vastus approach using a 250 mmHg pressure tourniquet. A drain was applied to the surgical field.

Postoperative Follow-Up
Postoperative pain was evaluated at regular intervals in the first 48 hours (at 0, 1, 2, 8, 12, 24 hours) with a visual analogue scale (VAS) marked on a ruler from 0-10 cm (0=no pain, 10=the most severe pain). Any time at which the VAS score was >4 or the patient reported a need for pain relief, the appropriate IV analgesic combination was administered (tramadol hcl 100 mcg, paracetamol 1 gr IV inf ). The time of requirement for the first dose of analgesics was recorded.
During the follow-up period, nausea, vomiting, hypotension, bleeding, bradycardia, and signs of local anaesthesia toxicity (dizziness, ringing in the ears, numbness of the tongue, spasm, arrythmia) were monitored.

Statistical Analysis
Analyses of the study data were performed using IBM SPSS 23.0 statistics software. Descriptive statistical methods were used (number (n), percentage (%), mean, standard deviation (SD), median, minimum-maximum) when evaluating the study data, and in the comparison of qualitative data, the

Results
The study included a total of 60 patients, with 30 in each group, for evaluation. The patient characteristics are shown in Table   2. No statistically significant differences were determined between the groups with respect to age, sex, height, weight, BMI, ASA or operating time (p>0.05). No procedure-related side effects were observed in any patient in either group (Table 3).
No statistically significant differences were found between the groups with respect to the VAS values at any of the measured times (p>0.05) ( Table 4).
The mean VAS values of both groups were <4 at all the measured times ( Figure 1).
There was a need for additional analgesics in all the patients (100%) in the ACB group and in 28 (93.3%) patients in the LIA group. The time of requirement for additional analgesics was recorded as 10.0±4.9 hours in the ACB group and 8.7±6.02 hours in the LIA group (Table 5). These differences were not statistically significant (p>0.05).   canal block. [11,12] For these anatomic reasons, ACBs made with a saphenous nerve block in the adductor canal have become more preferred than FNBs because ACBs cause less weakness in the quadriceps; weakness in the quadriceps can result in a delay to begin rehabilitation, a risk for falls and a prolonged stay in the hospital. [13][14][15] The primary advantage of the adductor canal block is the sparing of the motor branches to the quadriceps muscles, resulting in earlier patient mobility following TKA. [16] Many studies have shown that the use of a cocktail for LIA anaesthesia provides effective anaesthesia, has a low sideeffect profile and improves patient rehabilitation. [4,6,7] Several studies have compared LIA with femoral nerve blocks and the epidural analgesia method, and it is thought that in both methods, there is a larger risk for falls and quadriceps muscle weakness than in LIA. [1,17] In the current study, there were no differences between the groups with respect to the demographic data, and the majority of patients were obese and female. No statistically significant differences were found between the groups with respect to adverse events.  [13], the use of 20 ml of local anaesthetic solution in the ACB has been shown to provide effective analgesia and minimal quadriceps muscle weakness.
The results of the current study support the findings of these two studies of the analgesic effect created in the ACB group.

Conclusion
From the results of this study, it can be concluded that these two techniques can be used interchangeably as a part of a multimodal analgesia method postoperatively in the first 24 hours after TKA operations. In this study, we did not compare the early postoperative mobilization of patients. Therefore, we did not record early motion pain. We also recommend well-structured clinical trials with appropriate protocols to compare early motion pain.