femoral block for ACL repair

[GaseousClay]

In 2018 what are you all doing in terms of block for ACL repair. Most of our surgeons want femoral block and since patients are all going home with knee immobilizers, quad weakness is of no concern. Some surgeons are adamant that femoral blocks delays recovery for ACL repairs, either from personal experience or due to Femoral nerve blocks delay recovery after ACL reconstruction

Adductor canal blocks really just don't work nearly as well for these cases in my experience. thoughts??

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[facted]

Adductor works great. Haven't done a Femoral block in a few years.

We're also doing IPACK blocks per surgeon request, though not sure how effective they are.

 

[Urzuz]

Adductor canal

 

[GaseousClay]

Its hard to convince me that femoral does not have better analgesia, especially in bigger thigh patients where the adductor canal block can be a bit more challenging. Also in a bigger practice the skill level of each provider is different and femoral is just easier plain and simple. So just want to know what reasoning you have for doing only adductor canal here. Do you and the surgeons believe in longer recovery period? Not many studies out there. Most studies showing that long term recovery is equivalent in femoral vs adductor or femoral vs placebo. My old place, the surgeons really just thought since we do adductors for total knees we should just do them for ACLs but no real concrete reason why.

 

[aneftp]

What about chronic pain patients. I’m talking high pain tolerance 350 pounders.

Do u guys find adductor canal blocks work well in those type of patients.

In my experience. The regular femoral
Block works better in the big fat 350 pounders with chronic narcotic use.

 

[deleted697535]

Had my acl done 8 years ago, hamstring graft, no block. Walked the next morning. Threw the oxys in the bin. No physio. Rehabbed myself. full contact sports 4 months later, bit early.
6 months I was 100%

N=1 but Wouldn't dream of doing a block for an ACL.

 

[facted]

What about chronic pain patients. I’m talking high pain tolerance 350 pounders.

Do u guys find adductor canal blocks work well in those type of patients.

In my experience. The regular femoral
Block works better in the big fat 350 pounders with chronic narcotic use.

350 lb patients still have a saphenous nerve in the Adductor canal. If you do the block correctly, it works just fine. Chronic pain issues have concurrent psych issues often. Those patients often do better with dense numbness (ie:femoral) from a psych perspective, imo.

 

[deleted162650]

What about chronic pain patients. I’m talking high pain tolerance 350 pounders.

Do u guys find adductor canal blocks work well in those type of patients.

In my experience. The regular femoral
Block works better in the big fat 350 pounders with chronic narcotic use.

Nothing works in those types of patients. If they’re not apnic, they’re in 9/10 pain.

 

[Planktonmd]

How about some Ibuprofen and no block?
I mean if it hurts it's OK... it is surgery and it does hurt.
It's so funny that people keep talking about the so called "opioid epidemic" and how terrible it is, but at the same time we continue to reinforce the stupid idea that surgery is supposed to be pain free!
I often tell whiny people: "don't worry if it hurts, it's surgery and it's supposed to hurt!"

 

[nimbus]

How about some Ibuprofen and no block?
I mean if it hurts it's OK... it is surgery and it does hurt.
It's so funny that people keep talking about the so called "opioid epidemic" and how terrible it is, but at the same time we continue to reinforce the stupid idea that surgery is supposed to be pain free!
I often tell whiny people: "don't worry if it hurts, it's surgery and it's supposed to hurt!"

Reminds me of this.....

Opinion | After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea

And our pediatric partners have moved away from FNB exactly because of a concern about prolonged quad weakness in young student athletes.

 

[facted]

How about some Ibuprofen and no block?
I mean if it hurts it's OK... it is surgery and it does hurt.
It's so funny that people keep talking about the so called "opioid epidemic" and how terrible it is, but at the same time we continue to reinforce the stupid idea that surgery is supposed to be pain free!
I often tell whiny people: "don't worry if it hurts, it's surgery and it's supposed to hurt!"

Why no block? You help alleviate pain with no addiction side effects, and to boot it helps people avoid opioids. If they should hurt, why even fine ibuprofen?

 

[Hoya11]

In 2018 what are you all doing in terms of block for ACL repair. Most of our surgeons want femoral block and since patients are all going home with knee immobilizers, quad weakness is of no concern. Some surgeons are adamant that femoral blocks delays recovery for ACL repairs, either from personal experience or due to Femoral nerve blocks delay recovery after ACL reconstruction

Adductor canal blocks really just don't work nearly as well for these cases in my experience. thoughts??

Agree with you completely. FNB > ACB . I only do ACB if surgeon if strong surgeon preference and I dont want to deal..

Having reliable pain control for this surgery makes it consistent successful in ASCs which is a big deal, so yes pain is to be expected, but if you have that attitude get ready to be in the hospital for your whole life while another provider gets the ASC contract

 

[Swamp Gas]

In 2018 what are you all doing in terms of block for ACL repair. Most of our surgeons want femoral block and since patients are all going home with knee immobilizers, quad weakness is of no concern. Some surgeons are adamant that femoral blocks delays recovery for ACL repairs, either from personal experience or due to Femoral nerve blocks delay recovery after ACL reconstruction

Adductor canal blocks really just don't work nearly as well for these cases in my experience. thoughts??

I agree with you, femorals are much more reliable and effective. I always ask the surgeon if they’re ok with a femoral. Many insist on adductor. One, however, insists on femorals because he has come to the conclusion that adductors are crap. I don’t know if I’d go that far but given the choice I pick femoral every time.

 

[DrZzZz]

Fem and subgluteal sciatic, plus obturator if they're harvesting the hammy. This is all ortho surg center. I don't think there's anything wrong with being pain free for the early recovery as long as the patient understands there will be pain after they're home and that they don't NEED to rely on oxy for relief.

 

[Planktonmd]

Why no block? You help alleviate pain with no addiction side effects, and to boot it helps people avoid opioids. If they should hurt, why even fine ibuprofen?

What I am trying to say is that by promoting that surgery should be pain free we are contributing to the problem of opioids over prescription because your block will eventually stop working and all that is left is a patient with pain and high expectations.
I am not saying abandon blocks, but you should remember that most of the time these blocks are used to get the patient out of PACU quickly, they don't solve the post-op pain problem they only delay it and they create unrealistic expectations.

 

[facted]

What I am trying to say is that by promoting that surgery should be pain free we are contributing to the problem of opioids over prescription because your block will eventually stop working and all that is left is a patient with pain and high expectations.
I am not saying abandon blocks, but you should remember that most of the time these blocks are used to get the patient out of PACU quickly, they don't solve the post-op pain problem they only delay it and they create unrealistic expectations.

I definitely counsel extensively on expectations after the block wears blocks. And good luck trying to get an ACL out of the PACU without a block, and still breathing.

 

[nimbus]

I definitely counsel extensively on expectations after the block wears blocks. And good luck trying to get an ACL out of the PACU without a block, and still breathing.

I started practice when blocks were rare and they got out of pacu every single time. Blocks have many advantages but they are not even remotely necessary to discharge an ACL repair.

 

[dhb]

It's funny that some people here have no idea of what they're talking about.

If it were for me i'd go with an adductor canal + ipack.

 

[pgg]

And good luck trying to get an ACL out of the PACU without a block, and still breathing.

I know you did a regional fellowship and so every surgery looks like a nail for that hammer but this is crazy talk.

Also ... if I was an athlete competing at the level where my performance was even a little bit important to me, I'm not sure I'd want any block that went near motor fibers. Not just pro athletes, but high school athletes eyeballing an athletic scholarship, or even dedicated amateurs. Of course, that's a pool of people who tend to be motivated to embrace pain and get over little obstacles.

 

[facted]

I know you did a regional fellowship and so every surgery looks like a nail for that hammer but this is crazy talk.

Also ... if I was an athlete competing at the level where my performance was even a little bit important to me, I'm not sure I'd want any block that went near motor fibers. Not just pro athletes, but high school athletes eyeballing an athletic scholarship, or even dedicated amateurs. Of course, that's a pool of people who tend to be motivated to embrace pain and get over little obstacles.

Sure, that's why I do an Adductor that doesn't go anywhere near motor fibers .

Would you get your ACL done without block and no post op narcotics?

 

[pgg]

Sure, that's why I do an Adductor that doesn't go anywhere near motor fibers .

I think adductors are a great option for these surgeries. Still we've got people out there doing femorals and subgluteal sciatics for these cases.

There's no motor-sparing adductor-equivalent for shoulders though. A couple members of my daughter's gymnastics team had surgery in the last year. One had her shoulder done twice. No blocks. At some point that teenage girl got discharged from PACU.

 

[dhb]

Sure, that's why I do an Adductor that doesn't go anywhere near motor fibers .

Well it isn't that far: you can get a patellar snap sometimes if you stimulate

 

[nimbus]

I think adductors are a great option for these surgeries. Still we've got people out there doing femorals and subgluteal sciatics for these cases.

There's no motor-sparing adductor-equivalent for shoulders though. A couple members of my daughter's gymnastics team had surgery in the last year. One had her shoulder done twice. No blocks. At some point that teenage girl got discharged from PACU.

Gymnasts are not average teenage girls. Physical pain is not some novel life altering sensation for them. You could say that for almost all competitive athletes.

 

[crash2500]

Femora block for acl seems like overkill...

 

[GaseousClay]

Femora block for acl seems like overkill...

maybe but patients usually do not receive a single dose of opiate perioperatively and are discharged from pacu ultra fast. last one i had awake while putting the brace on in OR and went home 15 mins later.

 

[sevoflurane]

Absolutely true about the patellar snap with an ACB.

I would probably opt for a FNB if I had to go through an ACL reconstruction.

I could have a good movie night the DOS and let the pain come in POD 1.

It’s not like I would be doing yoga that night anyways. Just have to be aware of the fall precautions.

 

[crash2500]

If your main goal is getting patients out quicker then obviously FNB will be superior, but there are other important measures to consider than just surgicenter times.

Adductor Canal Block Provides Noninferior Analgesia and Superior Quadriceps Strength Compared with Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction | Anesthesiology | ASA Publications

 

[pgg]

While we're on the subject, dense sensory blocks carry other risks.

The worst case of foot drop I've ever seen was only barely improved nearly a year after surgery. That patient got a sciatic block for an ACL and I'm convinced he went home, laid his comfy numb leg up against a coffee table or something, went to sleep, and whacked his peroneal nerve. Talk about snatching defeat from the jaws of victory ...

I posted that case back in 2012 ... Recent Complication

This was a young healthy active duty member of the military. In the end I believe he was med boarded out of the Navy.

 

[sevoflurane]

While we're on the subject, dense sensory blocks carry other risks.

The worst case of foot drop I've ever seen was only barely improved nearly a year after surgery. That patient got a sciatic block for an ACL and I'm convinced he went home, laid his comfy numb leg up against a coffee table or something, went to sleep, and whacked his peroneal nerve. Talk about snatching defeat from the jaws of victory ...

I posted that case back in 2012 ... Recent Complication

This was a young healthy active duty member of the military. In the end I believe he was med boarded out of the Navy.

I remember you posting this. That’s a terrible complication that can happen to any of us. That being said, it is an excessively rare complication.

To your point, the risk isn’t zero.