Continuous adductor canal block for TKA

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sevoflurane

sevoflurane

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Not sure if any of you are doing continuous adductor canal blocks for TKA's. It has caught my interest and I am debating running a side to side comparison... 35 in ea. arm. The MAJOR advantage of the adductor canal catheter is that it is presumably entirely sensory... avoiding the biggest draw back of femoral nerve blocks- that being motor block/weakness.

My major issue with this block is that it is done mid thigh and as we know, the femoral nerve divides (sometimes extensively) as you cross the inguinal ligament. Therefore, you may miss important sensory contributions to the knee with the adductor canal blocks.

I would like to encourage any of you doing TKA's on a regular basis to read through this article and post your thoughts.

http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2010.02333.x/full

Again, it's no silver bullet but the lack of s/e of the block and the reduction of narcotic consumption is certainly a plus and something we all want.
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So I tried doing one of these for a ACL....

It was awesome, it worked great.. awesome...

Let's try it for something else....

Partial knee arthroplasty (uni-compartmental)....

It was ok, it worked ok... pt still hurt post op....

Total Knee.... in combination with a sciatic nerve block

it sucked.. 10/10 pain...

So.. maybe in my hands at least.. and in my N=1... this block was definitely inferior to my usual TKA anesthesia (FNB/SNB)....

I might keep doing them for my ACLs.. but honestly.. a femoral nerve block is associated with much less uncertainty..

drccw
 
Thanks for your input drccw. Did you place a catheter or single shot for your TKA?

Once you are mid-thigh, the fem nerve has already given off a lot of it's branches. That is for sure. If you are comparing pain scores only... fnb will win every single time. If you are comparing distance walked POD 0 and POD #1, adductor canal might win (def. on POD 0)

I would argue that correct placement of LA by the orthopod (especially laterally and posteriorly) AND adductor cannal infiltration might be useful to both decrease systemic opiods AND get some good distance on POD 0.

FNB + SNB is what I do routinely for my TKA's. My dosage has come down quite a bit with the addition of PF decadron. I still get some motor block/weakness.

Trying to fine tune my practice. Our goal is to D/C our patients the morning of POD #3. This saves the hospital $$$$ yet requires early and effective PT on POD # 0.
 
proman said:
I don't think it's that good of a block.
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Me neither... at least for TKA's. I'll do it for tibial plates that will get a medial incision. Works great for those cases.

A competing orthopedic hospital about an hour away from where I am located is using them for all their TKA's. :eek: .... hooking them up to an on-Q pump and letting them ride for 48 hours. Apparently they have good results... but I remain skeptical.
 
sevoflurane said:
Thanks for your input drccw. Did you place a catheter or single shot for your TKA?

Once you are mid-thigh, the fem nerve has already given off a lot of it's branches. That is for sure. If you are comparing pain scores only... fnb will win every single time. If you are comparing distance walked POD 0 and POD #1, adductor canal might win (def. on POD 0)

I would argue that correct placement of LA by the orthopod (especially laterally and posteriorly) AND adductor cannal infiltration might be useful to both decrease systemic opiods AND get some good distance on POD 0.

FNB + SNB is what I do routinely for my TKA's. My dosage has come down quite a bit with the addition of PF decadron. I still get some motor block/weakness.

Trying to fine tune my practice. Our goal is to D/C our patients the morning of POD #3. This saves the hospital $$$$ yet requires early and effective PT on POD # 0.
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Single shot abductor canal.... catheters are a pain for us.....

Our FNB+SNB is working well. We use lower doses (10-15 ml of 0.5% ropivicaine) and have very low incidence of muscle weakness on POD#1.... POD# 0 our folks are just dangling at bedside..

drccw
 
drccw said:
Single shot abductor canal.... catheters are a pain for us.....

Our FNB+SNB is working well. We use lower doses (10-15 ml of 0.5% ropivicaine) and have very low incidence of muscle weakness on POD#1.... POD# 0 our folks are just dangling at bedside..

drccw
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This is great place to block the saphenous nerve for ankle /foot surgery but we bolused TKA's w/ 0.5 rop and post op infusion of 0.1 rop fem/sci. catheters which allowed patient to PT adequately
 
I've done quite a few in combination with popliteal sciatic blocks for ankle surgery. In my experience, a significant percentage still get some motor block in the quads. Not totally knocked out, but you can usually get motor stimulus if you stimulate while placing it.

I'm also leary of placing a block at the same spot where a tourniquet was on the leg for any prolonged period of time. I think it has to increase the chance of a nerve injury.
 
Mman said:
I've done quite a few in combination with popliteal sciatic blocks for ankle surgery. In my experience, a significant percentage still get some motor block in the quads. Not totally knocked out, but you can usually get motor stimulus if you stimulate while placing it.

I'm also leary of placing a block at the same spot where a tourniquet was on the leg for any prolonged period of time. I think it has to increase the chance of a nerve injury.
Click to expand...

I've done a few with a nerve stimulater.. I kept marching lower and lower till I couldn't get any motor response... this was mainly for ACLs...

I think that that's a good point about the tourniquet.....

drccw
 
YouTube blockjocks
Videos 21-23
It's the Duke guys. They say 80% success with saph for ACL informally
 
Mman said:
I've done quite a few in combination with popliteal sciatic blocks for ankle surgery.
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OFFTOPIC -

I'm looking to add more of this (saphenous at adductor canal) to my repertoire for ankle surgery; Group's current practice is solely distal sciatic (popliteal) block and the surgeon adds the saphenous down lower. I've been queried why not add a femoral, and informed the surgeons of the quadriceps weakness that might prove a problem post-op for outpatients. In investigating this I've also come across Nysora mentioning low 10mL femoral blocks to reliably get the saphenous yet not be hampered by quadriceps weakness. I'm not certain which I'll try first, but I'm leaning towards saphenous block in add to distal sciatic.
 
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Jay K said:
OFFTOPIC -

I'm looking to add more of this to my repertoire for ankle surgery; Group's current practice is solely distal sciatic (popliteal) block and the surgeon adds the saphenous down lower. I've been queried why not add a femoral, and informed the surgeons of the quadriceps weakness that might prove a problem post-op for outpatients. In investigating this I've also come across Nysora mentioning low 10mL femoral blocks to reliably get the saphenous yet not be hampered by quadriceps weakness. I'm not certain which I'll try first, but I'm leaning towards saphenous block in add to distal sciatic.
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Why not just infiltrate the saphenous at the tibial tuberosity? It's a fieldblock that works reasonably well, takes less than a minute, and requires no skill whatsoever. You can even do it asleep if you want to. If you really wanna be slick try blocking the saphenous under USG. Google it and you'll find some really good resources to teach you how to block it. It's not a very hard block to do as long as you are comfortable with an ultrasound. Combine it w/a popliteal and you should get a complete block for ankle/foot surgery.

Fem block is overkill for ankle surgery IMO
 
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1. I think I misquoted the Duke video - I don't think they mentioned a success rate for adductor canal saph block for ACL.
2. I would guess that you can't guarantee quad strength after a low dose fem blk. Do a saphenous block and bill for it.
 
ssmallz said:
If you really wanna be slick try blocking the saphenous under USG. Google it and you'll find some really good resources to teach you how to block it. It's not a very hard block to do as long as you are comfortable with an ultrasound. Combine it w/a popliteal and you should get a complete block for ankle/foot surgery.
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USG saphenous (at adductor canal) IS what I'm talking about in addition to popliteal. I like Auyong's technique here:

http://www.youtube.com/watch?v=E1tmS9Lv1bU
 
I've been using this one w/pretty good results. Still not an expert but so far so good

http://neuraxiom.com/html/saphenous.html

Once you see 2 vessels they point to the saphenous. I like it more than the canal block b/c the nerve is farther away from the artery giving me a greater margin of safety.
 
sevoflurane said:
Me neither... at least for TKA's. I'll do it for tibial plates that will get a medial incision. Works great for those cases.

A competing orthopedic hospital about an hour away from where I am located is using them for all their TKA's. :eek: .... hooking them up to an on-Q pump and letting them ride for 48 hours. Apparently they have good results... but I remain skeptical.
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I've always just felt like to get any good pain relief in the anterior aspect of the knee you are going to have to sacrifice motor to some extent, I'd be curious when their patients are walking and what the pain scores are.
 
Idiopathic said:
I've always just felt like to get any good pain relief in the anterior aspect of the knee you are going to have to sacrifice motor to some extent, I'd be curious when their patients are walking and what the pain scores are.
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That is the silver bullet I'm looking for. I think you can possibly get good pain relief with the adductor canal block (which may pick off the obturator as well) + local infiltration by the surgeon. This combo MAY (not sure) give you good (not perfect) pain relief with intact quads/hamstrings.... allowing for early PT and early discharge = good reimbursement if d/c'd w/in 3 days and good patient satisfaction.

I'm just not sure at this point in time.
 
I've done a few mid thigh saphenous nerve blocks as described by the Duke guys and www.blockjocks.com

About midway between the inguinal crease and knee pace the probe (transverse). Move the probe towards the knee until the femoral artery disappears. In addition, you should see the tail end of the sartorius muscle. Some of you block the saphenous nerve here ( sartorius meets the vastus medialus medially).

I simply move the probe back up the thigh until the femoral artery reappears. This is usually in the middle region of the sartorius muscle which lies next to the femoral artery. At this area the saphenous nerve is located near the femoral artery. Some think 0900 is the most common location; that said, I simply inject local 5-8 mls anterior to the artery and 5-8 mls posterior to the artery. This is fairly easy to do and reliably gets the saphenous nerve.

If you want to place a saphenous catheter then try and place some catheter at 1000/1100 to the artery and push some catheter posterior or 700 position to the artery while removing the needle.

The block works for ACL, ankle and foot surgery. I doubt it works well for total knee but blockjocks add the vastus medialus nerve block as well so it may indeed provide good relief in that combo.
 
With all this talk of double crush injury why would you do a saphenous nerve block and popliteal
Nerve block for a surgeon who uses a tourniquet regularly? Why not do a femoral nerve block with 0.2 percent Rop and a Labat/Raj sciatic block? Yes, ambulation and motor block are better preserved with a saphenous/popliteal block but what about tourniquet induced nerve injury?

If tourniquet induced nerve injury is not an issue then why do we block the MC nerve high up in the axilla when this nerve is easier and larger to see in the body of the biceps muscle in the middle of the arm?

Why is okay to use a tourniquet for popliteal/saphenous/vastus medialus nerve blocks but not okay to use a tourniquet for a distal MC nerve block?
 
http://www.youtube.com/watch?v=YXQ2PDK3wq8&feature=youtube_gdata_player

This is an easy technique. Midthigh saphenous nerve block. Scan the thigh from midthigh towards the knee. Use the artery as your guide. Look for the saphenous nerve next to the artery. If you can't see the nerve then assume the saphenous nerve is above/below the artery and place local around the vessel.

In the link above the saphenous nerve is clearly seen via u/s.
 
When I had my ACL done I totally lost my quadriceps function post-op. This is an expected phenomena, and the first thing that they did in PT was to retrain me to contract my Quad.

My question is that if the quads are already out completely (mine sure were) with an ACL (and then for sure they will be out with a TKR), why is there so much worry about the effect of the High Femoral nerve block on the quadriceps?

Thanks!
 
Conclusion
We found no indications of saphenous nerve injury caused by the adductor-canal-blockade at the mid-thigh level. However, 84% of the patients had signs of injury to the infrapatellar branch of the saphenous nerve in the operated leg. Such findings are well-known complications to the surgical procedure.


http://onlinelibrary.wiley.com/doi/10.1111/j.1399-6576.2012.02792.x/abstract
 
How long does a single shot adductor canal saphenous block last? I'd be using 0.5% bupiv to get more duration. I don't have PF decadron yet
 
Oggg said:
How long does a single shot adductor canal saphenous block last? I'd be using 0.5% bupiv to get more duration. I don't have PF decadron yet
Click to expand...

14-16 hours at best without the Decadron. You get 20 hours or more (usually 24) if you add the PF decadron. Maybe, it is time for the Exparel?:naughty:

Why not just add 2 mg of regular Dedacron for non diabetic patients? That small amount of preservative is likely harmless.
 
Anybody stimulating their Adductor Canal Blocks?

I've been doing it for the heck of it since I often hit a lateral high pop with stimulation first (TKA's).

I've been getting quite a few patellar snaps with the AC block. Just reinforces the fact that the coverage of this block is better than I originally thought.

Figured I'd share that with you guys that are not stimulating (which is completely not necessary) or are not doing ACB's.
 
BTW, I've completely abandoned femoral nerve blocks for TKA's.
 
dhb said:
changed your mind? ;)
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You bet. Big time.

The benefit of little to no motor loss with a little less analgesia is what I've been looking for. It's been over a year since this thread was started and the above statements were made. I've done a good 200 hundred of these in a year and now have changed my practice.

Changed my mind? Evolution more like it. ;)
 
sevoflurane said:
You bet. Big time.

The benefit of little to no motor loss with a little less analgesia is what I've been looking for. It's been over a year since this thread was started and the above statements were made. I've done a good 200 hundred of these in a year and now have changed my practice.

Changed my mind? Evolution more like it. ;)
Click to expand...

Darwin would be proud of you

Dang you're right 1 year ago, time flies
 
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sevoflurane said:
You bet. Big time.

The benefit of little to no motor loss with a little less analgesia is what I've been looking for. It's been over a year since this thread was started and the above statements were made. I've done a good 200 hundred of these in a year and now have changed my practice.

Changed my mind? Evolution more like it. ;)
Click to expand...

Mind saying what you are using and the results you are getting from it? Starting to do these and a little dosage and expectation guidance would be helpful. Just curious on "real life" application vs academic.
 
Since it's entirely a sensory block, I'm using 15cc's of.5% marcaine with 4mg of dexamethasone + 5cc's of exparel. I dissect the saphenous nerve off of the femoral artery- usually on both sides of the artery (you often see the saphenous hugging the femoral artery at 11 o'clock and 3 o'clock positions).

The one case that really opened my eyes was a bilateral TKA. This patient did not get a block from me pre-op as the surgeons were going to approach toxicity levels with LIA. Hours later, however, I was called by the ortho service and asked to help out. We brought her down from the floor and I placed bilateral ACBs. The results were stunning and the patient was extremely grateful. It was like walking out of the OB room after placing an epidural on a patient that was 8cm dilated, on mag and pushing.

Try it out... and see for yourself. :)

Heck, stimulate it and see if you get a patellar snap!
I've seen that more than once on ACBs!
 
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I know. Surprised me too the first time I saw it. Goes to show the variability of fiber pathways. As far as I know, the peri patellar plexus has no motor fibers and shouldn't produce a snap. A patellar snap is def. not the norm. But if you do enough of them, you will see it happen.
 
sevoflurane said:
I know. Surprised me too the first time I saw it. Goes to show the variability of fiber pathways. As far as I know, the peri patellar plexus has no motor fibers and shouldn't produce a snap. A patellar snap is def. not the norm. But if you do enough of them, you will see it happen.
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It's because you are still blocking motor branches from the femoral nerve and not just the saphenous nerve. Complete take off of the saphenous nerve from the femoral is variable. It's what you still can get quad weakness from the block.
 
That is correct. In my experience, the rare instances you pick off a branch, it is the one to the vastus medialis. Clinically, it is not significant as the rest of the quads compensate. ACBs is a sensory block 95% of the time. The times that it is not, it has little clinical relevance.
 
Solid 2 days. By the third, I'd say it's largely gone.
 
Sorry to bring this old topic up, but what are people doing to protect the operative limb after an adductor canal catheter for a TKA? Do you routinely place a knee immobilizer? wait for PT to evaluate quad strength and if adequate, no immobilizer? immobilizer only when patient is alone?

I am concerned of increased motor block with infusion and or confounding factors that may lead to fall and then the blame on the catheter.
 
ambulatory with PT only. No motor block. If they blame you, there are multiple studies of no motor block with CACB. And multiple studies of quad weakness from TKA surgery alone. No immobilizer.
 
I still think femoral is superior for knee :)
 
Our surgeons want us to do adductor catheters for tar using OnQ. I wrote up orders and discharge instructions (patients would go home with these). Pharmacy calculated the cost at $600 per patient. They would like to see a study showing decreased LOS with this vs our current infiltration to approve this. . I can't find anything. Do any of you know of anything?
 
kmurp said:
Our surgeons want us to do adductor catheters for tar using OnQ. I wrote up orders and discharge instructions (patients would go home with these). Pharmacy calculated the cost at $600 per patient. They would like to see a study showing decreased LOS with this vs our current infiltration to approve this. . I can't find anything. Do any of you know of anything?
Click to expand...

Why would you spend $600 when a bottle of Exparel is $320 and you don't need a catheter? Why not compare both groups for pain scores and LOS? One group gets the OnQ while the other gets a single shot Adductor canal with Exparel.
 
kmurp said:
Our surgeons want us to do adductor catheters for tar using OnQ. I wrote up orders and discharge instructions (patients would go home with these). Pharmacy calculated the cost at $600 per patient. They would like to see a study showing decreased LOS with this vs our current infiltration to approve this. . I can't find anything. Do any of you know of anything?
Click to expand...
Do your own study. That's what we did. We had a know-it-all new grad joint fellowship orthopod come in claiming he wanted Exparel for all of his TKA's. We designed a study at our site. We went back and looked at the last 50 TKA's and started collecting data on his next 50 with Exparel. We measured LOS, narcotic use and when requested, PT participation, falls and Pain scores. We stopped the study early because our FNB/Snb combo was far superior. These new grads come out and think that the way they trained is the cats meow. They are brainwashed every single time. It takes time to convince them differently.
Recent Anesthesiology News reported that FNB/SNB combo was the most effective.
 
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