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This study compares analgesic effect between two techniques of adductor canal nerve block after total knee arthroplasty. The first group of the patients will receive intraoperative adductor canal nerve block; and the other group post operative ultrasound guided adductor canal nerve block. Investigators will measure postoperative opioid consumption, pain management and rehabilitation goals.
Total knee arthroplasty (TKA) is a successful alternative to treat late stage knee osteoarthritis (OA). Pain management has been one of the main focuses of postoperative care. Most surgeons prefer a comprehensive multimodal approach including preoperative pharmacological treatment, intraoperative infiltration with complex drug mixes and postoperative peripheral nerve block.
The most common postoperative nerve block alternative is the proximal femoral nerve block (FNB) which has shown improvements on postoperative pain measured by reduced opioid consumption and decreased pain at rest. Its main detractors argue that the motor nerve block effect is deleterious to early ambulation and have promoted adductor canal nerve blocks (ACB). Described by Lund et al in 2011, ACB block main femoral pain sensory contributors to the knee (articular branches of obturator nerve, vastus medialis branch and saphenous nerve) but is more distal to most motor branches to the quadriceps allowing near to normal quadriceps strength.
Standard ACB block is performed under ultrasound guidance after surgery completion, still in the operating room (OR). Recent literature has shown the anatomic feasibility of intraoperative ACB via blunt suprapatellar dissection in standard medial parapatellar TKA approaches. The study seeks to determine the effectiveness of standard ultrasound guidance ACB compared with intraoperative ACB.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intraoperative Block | Experimental | Before skin closure, blunt suprapatellar dissection proximal to medial femoral condyle towards adductor canal. Nerve block at this level with 20ml of Bupivacaine 0.25%. Postoperatively, mid-thigh ultrasound guided standard adductor canal nerve block with 20ml of saline solution (NaCl 0.9%). |
|
| Ultrasound Block | Active Comparator | Before skin closure, blunt suprapatellar dissection proximal to medial femoral condyle towards adductor canal. Nerve block at this level with 20ml of of saline solution (NaCl 0.9%). Postoperatively, mid-thigh ultrasound guided standard adductor canal nerve block with 20ml Bupivacaine 0.25%. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Intraoperative Block | Procedure | One shot adductor canal nerve block with 20ml of bupivacaine 0.25% through surgical incision |
|
| Measure | Description | Time Frame |
|---|---|---|
| 24 hour opioid consumption | Opioid consumption by patient controlled analgesia (PCA) and any other oral or IV analgesics | First 24 hours after surgery |
| Measure | Description | Time Frame |
|---|---|---|
| 24 patient reported pain | Patient reported pain scale using visual analog scale (VAS) every 6 hours after surgery (0 hours, 6 hours, 12 hours, 18 hours and 24 hours) | First 24 hours after surgery |
| Time up and go Test |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Pablo Besa | Pontificia Universidad Catolica de Chile | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Pontificia Universidad Católica de Chile | Santiago | Santiago Metropolitan | 8330024 | Chile |
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Two arm, randomly assigned
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Total blind (patient, physicians, outcome assessors and statistician) Closed envelope by independent randomizer is given to physician assistant. The assistant prepares randomly allocated placebo or local anesthetic. Group is coded so that statistician is also blind
| Ultrasound Block | Procedure | One shot adductor canal nerve block with 20ml of bupivacaine 0.25% mid-thigh |
|
| Intraoperative Placebo | Procedure | One shot adductor canal nerve infusion with 20ml of saline solution through surgical incision |
|
| Ultrasound Placebo | Procedure | One shot adductor canal nerve infusion with 20ml of saline solution mid-thigh |
|
Standardised test to determine patients ability to walk 24 hours after surgery
| 24 hours after surgery |
| Time to Discharge | Time between surgery and patient in conditions for discharge: no IV requirements, basic walking capability and VAS pain score equal or below 3 | 7 days |
| Range of motion | Active and passive knee range of motion | 24 hours after surgery |
| ID | Term |
|---|---|
| D020370 | Osteoarthritis, Knee |
| ID | Term |
|---|---|
| D010003 | Osteoarthritis |
| D001168 | Arthritis |
| D007592 | Joint Diseases |
| D009140 | Musculoskeletal Diseases |
| D012216 | Rheumatic Diseases |
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