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Journal of Anesthesia & Clinical

Research

Karnawat et al., J Anesth Clin Res 2015, 6:10
http://dx.doi.org/10.4172/2155-6148.1000578

Review

Open Access

Adductor Canal Block for Post-Operative Pain Relief in Knee Surgeries: A
Review Article
Rakesh Karnawat*, Monika Gupta and Om Prakash Suthar
Department of Anesthesia & Critical Care Medicine, Dr. SN Medical College, Jodhpur, Rajasthan 342003, India
*Corresponding

author: Rakesh Karnawat, Professor, Department of Anesthesia & Critical Care Medicine, Dr. SN Medical College, Jodhpur, Rajasthan 342003, India,
Tel: +919828033321; E-mail: dr.rakeshkarnawat@yahoo.com

Received date: September 28, 2015; Accepted date: October 27, 2015; Published date: October 30, 2015
Copyright: © 2015 Karnawat R et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract
The adductor canal block (ACB) is newer compartment block of the saphenous nerve, which is a branch of
femoral nerve, performed at the level of lower third of the thigh so that much of the motor innervation of the
quadriceps group is spared, thus preserving much of the quadriceps strength making early ambulation and
rehabilitation safer. The most significant advantage of the ACB over femoral nerve block and other techniques is that
it is predominantly a sensory block and reduces the incidence of fall after knee surgeries.

analgesia;

motor function. PMDI is periarticular injection of a mixture of
medications during surgery, usually consisting of ropivacaine,
ketorolac and adrenaline delivers drugs directly to the source of pain,
particularly the posterior capsule of the knee or hip joint [11,12].

Postoperative pain is an important consequence of knee surgeries
that can affect early ambulation, range of motion and duration of stay
in hospital. Advance surgical techniques like arthroscopies and early
mobilization after surgery have made knee surgeries more patients
friendly.

Adductor canal block (ACB) is a highly successful approach to the
saphenous nerve (also k/a saphenous nerve block), that was first
described by Vander Wal [13]. Compared with FNB, ACB results in
less reduction in the quadriceps muscle strength [14] as only the motor
nerve to the vastus medialis of the quadriceps muscle traverses the
adductor canal [15].

Keywords: Adductor canal block;
Quadriceps strength; Knee surgery

Post-operative

Introduction

As we know pain is considered as fifth vital sign. Unrelieved
postoperative pain may result in clinical and psychological changes
that increase morbidity and mortality as well as costs and that decrease
quality of life [1]. Inadequate pain control can lead to secondary
medical sequela such as venous thromboembolic and cardiac events.
Adequate control of pain is therefore paramount to a successful
outcome and to patient satisfaction [2].
Adequate analgesia with motor preservation has become the prime
goal after orthopedic surgeries to enable shorter hospital stay, early
physiotherapy and faster recovery.
Many options are available for the treatment of postoperative pain,
including systemic (i.e., opioid and nonopioid) analgesics and regional
(i.e., neuraxial and peripheral) analgesic techniques. Multimodal
analgesia is achieved by combining different analgesics that act by
different mechanisms and at different sites in the nervous system,
resulting in additive or synergistic analgesia with lowered adverse
effects of sole administration of individual analgesics [3].
In knee surgeries, epidural analgesia faces a relatively high failure
rate [4] and can produce adverse effects such as urinary retention and
motor block [5], the latter potentially hindering early mobilization.
Femoral nerve block (FNB) is a well-established treatment for
postoperative pain, however, invariably followed by reduced
quadriceps muscle strength [6,7] and associated with the risk of falling
[8-10].
Periarticular multimodal drug injection (PMDI) and adductor canal
block (ACB) are associated with good analgesia and preservation of

J Anesth Clin Res
ISSN:2155-6148 JACR, an open access journal

Relevant Anatomy
The adductor canal (also known as Hunter’s canal or “subsartorial
canal”) is bordered by 3 muscles: anterolaterally the quadriceps muscle
(specifically vastus medialis); posteriorly adductor magnus, and
medially the sartorius muscle. It extends from the upper/anterior thigh
femoral structures to the lower/medial thigh adductor hiatus – the
distal opening in the adductor magnus muscle approx. 13 cm proximal
to the knee. The femoral vessels leave the canal at the adductor hiatus,
where they dive deeply, and this abrupt change in femoral artery depth
is a useful indicator of the distal limit of the canal, and therefore the
optimal level for LA placement. The surrounding muscles and in
particular the artery, is useful landmark to guide LA placement [16].
The sensory saphenous nerve, the nerve to the vastus medialis, the
medial femoral cutaneous nerve, the medial retinacular nerve, and the
articular branches from the obturator nerve travel within the adductor
canal [17]. In addition, the femoral artery and vein also travels within
the canal.
Cadaver studies have shown that 15 ml of LA is sufficient to fill the
adductor canal although an MRI study supported the use of 30 ml
volume [18] (Figure 1).

Technique
Adductor canal block does not provide complete surgical anesthesia.
So, surgery is carried out under general anesthesia or spinal anesthesia

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The benefit of ropivacaine is its lower risk of cardiotoxicity in the event of inadvertent intravascular injection. nerve injury.1000578 Page 2 of 4 and for providing post-operative analgesia. Duration of action can also be prolonged with additives such as epinephrine or a corticosteroid. halfway between the superior anterior iliac spine and the patella. The femoral vein will be just beneath the artery and will be easily compressed by downward pressure on the ultrasound probe. significantly faster onset time and higher therapeutic index leading to an improved safety profile [20]. Bupivacaine and ropivacaine are most commonly used long-acting local anesthetic agents. arrhythmias and even cardiac arrest.2% and less). infection. After identifying the femoral artery. [22] used 15 ml of 3% chloroprocaine to compare ACB with FNB on volunteers and found ACB results in significant quadriceps motor sparing and significantly preserved balance but they did not compared analgesia by above techniques. Anticoagulation or bleeding disorders Pre-existing peripheral neuropathies Complications These are the same as for any regional anesthetic technique like block failure. J Anesth Clin Res 6: 578. Patient is placed in supine position. ropivacaine can be preferred over bupivacaine. local anesthetic toxicity. block is administered at the end of the surgery. foot and ankle surgery involving areas of skin supplied by the saphenous nerve and in high volume (20-30 ml) after total and uni-compartmental knee replacement. The operative leg is slightly flexed at the knee and externally rotated into a stable position (frog leg position). echodensities. Patterson et al. An 18-gauge.20-0. typically dexamethasone [19]. Ropivacaine has very close pharmacodynamic profile to equipotent doses of bupivacaine. an open access journal Numerous studies compared adductor canal block with femoral nerve block in terms of motor power and analgesia. anterior cruciate ligament reconstruction (ACLR).20% or higher doses provided satisfactory postoperative analgesia. Bupivacaine has the risk of cardiotoxicity causing hypotension. Thus. Suthar OP (2015) Adductor Canal Block for Post-Operative Pain Relief in Knee Surgeries: A Review Article.50 % ropivacaine is optimal for achieving adequate analgesia with preserved motor power. Gupta M.50% [21]. A 20-gauge catheter can be placed to enhance the duration of the block which is generally advanced 1-2 cm beyond the tip of the needle (Figure 2). Kwofie et al. Indications Adductor canal block (ACB) is used as postoperative analgesia in low volume (5-10 ml) after knee arthroscopy. but a significantly higher rate of motor blockade is seen with concentrations above 0.Citation: Karnawat R. The 0. J Anesth Clin Res ISSN:2155-6148 JACR. the duration of action is affected by the concentration of the local anesthetic as well as the volume injected. etc. lower leg. bleeding/bruising. So.4172/2155-6148. In general. After draping the leg. The local anesthetic solution is injected on each side of the artery at the points of the bright densities. Contiplex tuohy needle is inserted in-plane from the lateral side of the transducer. Differential sensory and motor block with ropivacaine is only apparent at low concentrations (0. Femoral artery is identified. doi:10. [23] used 15-30 ml bupivacaine and found adductor canal block provides equally effective analgesia when compared with a femoral nerve block and improves Volume 6 • Issue 10 • 1000578 . An 8-14 mHz linear ultrasound transducer is placed transversely on the medial part of the thigh. Pharmacological Considerations Adductor canal block can be performed using variety of short and long acting local anesthetics in varying concentrations. Figure 2: Sono-view showing contents of adductor canal. the femoral nerves will be seen on either side of the artery as bright. for adductor canal block 15 to 30 ml of 0. sterile ultrasound gel is applied on the medial aspect about midway down the thigh. They have similar anesthetic and analgesic effects. Contraindications Absolute • • • Patient refusal Inflammation or infection over injection site Allergy to local anesthetics Relative • • Figure 1: Applied anatomical view of thigh.

patient-controlled bolus of 5 ml and 30-minute lockout interval and found early post-operative ambulation without reduction in analgesia. But advances in needles.5% bupivacaine with epinephrine 5 ug/ml and found analgesia and strength were both satisfactory.2% with basal rate of 6 ml/hour.a word of caution. Cole N. 12. Ann Orthop Rheumatol 2: 1026. and a 0. large retrospective outcome database study by Memtsoudis et al. including ligamentous rupture. References Advantages over Other Techniques The use of peripheral nerve blocks in the lower extremity has not been as widespread as in the upper extremity. Myles PS (2008) Epidural analgesia compared with peripheral nerve blockade after major knee surgery: a systematic review and meta-analysis of randomized trials. Unlike brachial plexus. Limitations The sensory innervations of the knee joint is not only from nerves passing through the adductor canal. Umeh U (2014) Modern Anesthesia for Total Joint Arthroplasty. Gupta M. Mantilla CB (2013) Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis. Shah VP. [30] used an infusion of ropivacaine 0. Lancet 353: 2051-2058. Postsurgical pain lasts for many days whereas the action of local anesthetic lasts for 18 to 24 hours after a single shot injection.1000578 Page 3 of 4 postoperative physical therapy performance. Symons J. Loland VJ. Ilfeld BM. lock-out interval and continuous or basal infusion. [26] used 30 ml of 0. Johnson RL. [34] found no association between elevated fall risk and peripheral nerve block. Charous MT. 4. This preserves much of the quadriceps strength making early ambulation and rehabilitation safer. femoral neuritis (0. Ilfeld BM. well above the position of the local anesthetic. Anesthesiology 115: 774-781. hematoma.2% risk of permanent nerve injury [33]. 1. 3. Br J Anaesth 109: 144-154. (2010) Continuous peripheral nerve blocks: is local anesthetic dose the only factor. Sandhu NS. Perineural nerve blocks may be continued following hospital discharge on an ambulatory basis using a portable infusion pump [28. an open access journal Conclusion Adductor canal block is a new technique for postoperative analgesia after knee surgeries with promising results and can be developed as a routine part of anesthesia technique for these surgical procedures. catheters. ACB may not provide post knee surgery analgesia as effective as that produced by a combined femoral and obturator block [16]. the nerves supplying lower extremity are not clustered where they can be easily blocked with a relatively superficial injection of local anesthetic. Payne A.5% ropivacaine and found that adductor canal block preserved quadriceps muscle strength better than FNB. Acta Orthop 79: 174-183. 10. Kandasami M. Hermanides J. The adductor canal block is another block of the femoral nerve further down the thigh so that much of the motor innervation of the J Anesth Clin Res ISSN:2155-6148 JACR. Slover J. The most significant advantage of the ACB is that it is predominantly a sensory block [18]. Anesth Analg 111: 1552-4. Fowler SJ. Kinninmonth AW. Being a compartment block. This will necessitate either nurse administered boluses or a pump enabling relatively high bolus volumes. Therefore. there is increased risk of catheter displacement [35]. Mariano ER. provide adequate analgesia. As the site of catheter placement is close to the knee. Hollmann MW. Donohue MC (2010) The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. or do concentration and volume influence infusion effects as well? Anesthesiology 112: 347-354. Kopp SL. Scott NB (2009) Femoral nerve block for total knee replacement . and in fact only just distal to the inguinal ligament. Br J Anaesth 100: 154-164. Erwin PJ. J Anesth Clin Res 6: 578. et al. Ranawat AS. 8. Additional complications of FNB include vascular injury. Br J Anaesth 110: 518-528. Hebl JR. Anesth Analg 77: 1048-1056. alternate delivery methods were developed for continued postsurgical pain management. Parvataneni HK. Kim et al. 5. These have shown to decrease the time to reach discharge criteria. Riesgo A. Mudumbai et al. Loland VJ. without a significant difference in postoperative pain.75% ropivacaine and found reduction in morphine consumption and pain scores but this large dose if used in higher concentration can cause quadriceps weakness from proximal spread. Moeller LK.5% ropivacaine and found that quadriceps strength is maintained with ACB but it provides inferior analgesia as compared to FNB. which both arise from the posterior division of the femoral nerve proximal to the adductor canal. Sayed El Ahl [25] also used 15 ml of 0. Patient controlled analgesia (PCA) through catheter can also be used to maintain peripheral nerve block like ACB. Indwelling nerve block catheters can be placed adjacent to the nerve and a local anesthetic is infused through an infusion pump [2]. 9. Howard H. Stevens MF. Kerr DR. nerve stimulator and ultrasound technology have facilitated localization of neural structures and improved success rates [2]. wound dehiscence. Jenstrup et al. fracture. Baines J. et al. Madison SJ. 7.29] (Ambulatory pump). Dahl JB (1993) The value of "multimodal" or "balanced analgesia" in postoperative pain treatment. 6. So. 11. 2. Carr DB. Goudas LC (1999) Acute pain. The most noted complication of FNB is decreased quadriceps strength [32] which might increase the fall risk. Suresh PJ. However. et al. Sarungi M. [27] also used 30 ml of 0. This is due to anatomic considerations as well as the predominance of neuraxial anesthesia [31]. Femoral nerve block is the most common peripheral nerve block used for providing post-operative analgesia in lower limb surgeries nowadays. (2007) Controlling pain after total hip and knee arthroplasty using a multimodal Volume 6 • Issue 10 • 1000578 .4172/2155-6148. [24] used same volume of 0.4% incidence [32]. PCA provides superior postoperative analgesia and enhances patient satisfaction. Such incidences may need reoperation for injuries. Lirk P (2012) Failed epidural: causes and management. Suthar OP (2015) Adductor Canal Block for Post-Operative Pain Relief in Knee Surgeries: A Review Article. Continuous Versus Single Dosing quadriceps group has already departed the nerve. Duke KB.Citation: Karnawat R. and mobile-bearing dislocation have a 0. but also from articular filaments arising from the nerves to the vastus lateralis and intermedius. reduce intravenous opioid consumption and facilitate early ambulation. Kohan L (2008) Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Stevens-Lapsley JE. In a study. 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