Postoperative Nerve Injury After Adductor Canal Block for TKA

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jope

jope

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At my shop, we've run into a few of our surgeons suddenly requesting that their patients not get adductor canal blocks afterwards because they have had a few cases of postoperative persistent paresthesias in their total knees. For many of these cases, the surgeons mention that EMG is often not helpful since there the contralateral comparison leg can be abnormal as well. While this most likely a coincidence and surgical factors are more likely to blame, I was wondering what percentage of total knees at your hospital receive adductor canal blocks?

At our hospital, 90%+ of patients get a spinal for their TKA, then receive a single shot adductor canal block in the PACU. Most people use either 20 cc of 0.5% ropivicaine or bupivicaine but some do some combination of 2-4 mg of preservative-free dexamethasone, 50-100 mcg epinephrine, and 30-50 mcg dexmedetomidine. Interestingly, in the most recent 7 paresthesias in the past 8 months, 6 of these patients had dexmedetomidine and the blocks were done by 6 different anesthesiologists. Our departments had a meeting and a proposed compromise at this time to only use plain local anesthestic and to consider avoiding blocks in patients with diabetes or preexisting neuropathies.

In my opinion, the chance of us causing injury via direct trauma is fairly low. When I perform this block, I find it's often difficult to see the saphenous vein and I often just inject local anesthetic on either side of the femoral artery to get a collection around it and hope that catches the saphenous nerve. It usually does from my experience.
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Why are you guys doing them post-operatively rather than preop? I can't remember an incidence of a reported nerve injury attributed to an adductor canal block at our place and we do like 30-40 Total knees a week. Likely its the surgeon and not the block unless the 6 diff anesthesiologists are just terrible and stab around blindly.
 
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Which nerve was damaged? The saphenous or nerve to the vastus? For the latter, I’m now using a nerve stim at low current. If I get a twitch, I slightly move my needle till it disappears. For the former, I don’t know the incidence of nerve damage for this nerve due to the surgery itself. I do wonder , since the block is in PACU after SAB if the patients might still be numb and unable to give feedback with an intraneural injection of the saphenous.
We do these blocks Preop before the SAB.
 
We also do these blocks preoperatively and have started adding an ipack. No stim, US only, don't use epi but do use dex and clonidine. No injuries reported.
 
We do the adductor in preop, plain 0.5% ropiv, with a catheter. Nimbus or qball pump that can go home with patient. Surgeons here like GA (unless strong reasons to avoid it). They also add a lot of periarticular local cocktail (bupiv, ketorac, something else I can’t remember). We do probably 15-20/wk, haven’t heard of any nerve injuries in the last year from this.
 
Do they use a tourniquet? How long and what pressure?

Persistent parasthesia is far more likely to be from the tourniquet than the block.

We do them postop because patient has a spinal so we want it to kick in as the spinal wears off. And its logistically more efficient.
 
You'll never get "nerve damage" if you do what I do....don't do nerve blocks. It's all about risk management....at this point in my career, I try to do as little as possible. Basically, I've figured out what degree of inactivity will get me fired and do JUST a little bit of work above that.
 
There is a reason I’ll never let anyone do a block on me.
 
You wouldnt be able to be put in any ortho rooms in my practice without a willingness to do blocks. So you would be missing out on substantial amounts of revenue over the life of your career...and likely wouldnt be hired at most groups for that reason as well.

If you are somewhere where nobody does them or you can do the cataract room all day..then it may work.

Again...the tourniquet and surgery itself are far more likely to cause nerve injuries than any competent block. Most injuries are temporary anyways
 
I have always been less than thrilled with doing a block which can cause some transient nerve injury and then almost immediately inflating a tourniquet at that spot and adding pressure/ischemia on top of it.
 
jope said:
At my shop, we've run into a few of our surgeons suddenly requesting that their patients not get adductor canal blocks afterwards because they have had a few cases of postoperative persistent paresthesias in their total knees. For many of these cases, the surgeons mention that EMG is often not helpful since there the contralateral comparison leg can be abnormal as well. While this most likely a coincidence and surgical factors are more likely to blame, I was wondering what percentage of total knees at your hospital receive adductor canal blocks?

At our hospital, 90%+ of patients get a spinal for their TKA, then receive a single shot adductor canal block in the PACU. Most people use either 20 cc of 0.5% ropivicaine or bupivicaine but some do some combination of 2-4 mg of preservative-free dexamethasone, 50-100 mcg epinephrine, and 30-50 mcg dexmedetomidine. Interestingly, in the most recent 7 paresthesias in the past 8 months, 6 of these patients had dexmedetomidine and the blocks were done by 6 different anesthesiologists. Our departments had a meeting and a proposed compromise at this time to only use plain local anesthestic and to consider avoiding blocks in patients with diabetes or preexisting neuropathies.

In my opinion, the chance of us causing injury via direct trauma is fairly low. When I perform this block, I find it's often difficult to see the saphenous vein and I often just inject local anesthetic on either side of the femoral artery to get a collection around it and hope that catches the saphenous nerve. It usually does from my experience.
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How long were the tourniquet times for the TKAs? I would not place a block in a knee that was ischemic from a tourniquet without an intact neuro exam. Medicolegaly doing essentially all postoperative blocks is too high risk. Also blocking a patient with a spinal too is high risk. Systems level problem.
 
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Are all these pain management blocks really needed? Does the temporary pain relief they afford outweigh the risk of permanent nerve injury? Even for young patients that might live with a nerve injury for 50 years?
 
Consigliere said:
You'll never get "nerve damage" if you do what I do....don't do nerve blocks. It's all about risk management....at this point in my career, I try to do as little as possible. Basically, I've figured out what degree of inactivity will get me fired and do JUST a little bit of work above that.
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Especially when you have surgeons unwilling to take any responsibility and will throw you under the bus for anything
 
narcusprince said:
How long were the tourniquet times for the TKAs? I would not place a block in a knee that was ischemic from a tourniquet without an intact neuro exam. Medicolegaly doing essentially all postoperative blocks is too high risk. Also blocking a patient with a spinal too is high risk. Systems level problem.
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???
 
Something doesn’t sound right.
We don’t have big volume, but I haven’t heard any “nerve damage”. We started with adductor catheter, now transitioned to ipack and adductor with exparel. Spinal unless patients stopped their anticoagulants late. None of us are “regional trained”, but we get decent results; we haven’t had any vs you have 8 within the last year? Something doesn’t sound right.

Different anesthesiologists?
Different surgeons?
Tourniquet time?
Mixture composition?
I am sure you’ve looked into it.

Preop, postop? I dont think it makes much different. If the surgeon wants to pin it on us, they can say whatever they want. Unless you get perfectly clear picture every single time showing needle placement, you’re s**t out of luck if they want to say this is on you, regardless when you place the block. Some of my attendings in training will only do adductor (nothing sciatic distribution) place the block after spinal wore off (so moving with sensation intact), postop just to avoid any damages pinned on blocks. I am sure it’s not 100%, but probably as risk adverse as it can be.

If I were an amc or hospital employee.... I would say the hell with it too. Since I do get “something” for every blocks I do, hey, if I need to do TAP all day long and generate revenues for us. Why the hell not?
 
urge said:
Are all these pain management blocks really needed? Does the temporary pain relief they afford outweigh the risk of permanent nerve injury? Even for young patients that might live with a nerve injury for 50 years?
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No epidural then for your family?
 
IMGASMD said:
if I need to do TAP all day long and generate revenues for us. Why the hell not?
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TAP is not a real nerve block.

I’m not opposed to fascial “blocks”.
 
Surprised some of you guys are so risk averse when it comes to blocks. The expectation from our orthopods is that the vast majority of patients will get blocks (RCRs, TSAs, TKAs, ACLs, etc). They would complain loudly and publicly (to hospital admin) if we didn’t do them. Besides, they are fun, they pay well, and they improve patient satisfaction.

I will say this: if a patient or family member with patient expresses ANY hesitation, I will quickly shift gears and actively dissuade them from the block. Setup for a problem IMO.
 
Back to the original post..so I mentioned that our group has not had problems with AC blocks. Most of us are using either plain ropi/bupi or adding PF decadron only (not the laundry list of additives you guys are using). Most of our surgeons do not use tourniquets. Those that do use them for 40-50 min max.

Food for thought.
 
urge said:
They can make their own decisions.
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How about your wife/daughter? (If you’re a man) will you not say anything?
Only wondering.

urge said:
TAP is not a real nerve block.

I’m not opposed to fascial “blocks”.
Click to expand...

Some people don’t consider these “real blocks”, and don’t want to be bothered to do them, pretty much the flip side of what you’re saying.

At the end of the day, is the group being “fairly” compensated for time and effort and/or result. That’s all.
 
Consigliere said:
You'll never get "nerve damage" if you do what I do....don't do nerve blocks. It's all about risk management....at this point in my career, I try to do as little as possible. Basically, I've figured out what degree of inactivity will get me fired and do JUST a little bit of work above that.
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Brilliant!
 
eikenhein said:
Especially when you have surgeons unwilling to take any responsibility and will throw you under the bus for anything
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I still have to see a surgeon willing to take responsibility for any complications, but I only have been in this business for 22 years.
 
okayplayer said:
Back to the original post..so I mentioned that our group has not had problems with AC blocks. Most of us are using either plain ropi/bupi or adding PF decadron only (not the laundry list of additives you guys are using). Most of our surgeons do not use tourniquets. Those that do use them for 40-50 min max.

Food for thought.
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The guys who are adding epinephrine to Bupivacaine or Ropivacaine need to stop that nonsense.
 
Just wanted to add a bit more information.

The most recent issues involved 7 patients that were operated on by three different surgeons. They all used tourniqets and one was actually a very slick fast new surgeon that had been doing TKAs here for 4 years with no issues then suddenly go 2 cases within a couple months. The other two were slower surgeons. The paresthesias were in the saphenous distribution in these cases.

As for adding epinephrine, it makes sense to possibly avoid since there isn’t much proven benefit for prolongation kf blocks.
 
Perhaps consider changing your work flow such that the block is a preop block done before SAB. That way if the patient notes paresthesia during the block (never seen this with an AC block, but whatever) you can do something about it. Doing it after the SAB is active I would think is more medicolegally treacherous.

Just my 2 cents.
 
okayplayer said:
Perhaps consider changing your work flow such that the block is a preop block done before SAB. That way if the patient notes paresthesia during the block (never seen this with an AC block, but whatever) you can do something about it. Doing it after the SAB is active I would think is more medicolegally treacherous.

Just my 2 cents.
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Agree with this. ASRA recommendations are that blocks shouldn't routinely be done in an insensate patient. From a medicolegal perspective, would be wise to do the block preop.

I've prob done 300-400 TKA with adductor block and never had an issue. Bunch of different surgeons. The issue is not the block.

For what it's worth, I use 20ml 0.5% bupi and 4mg decadron.
 
Planktonmd said:
I still have to see a surgeon willing to take responsibility for any complications, but I only have been in this business for 22 years.
Click to expand...


I’ve had several surgeons own complications they could have blamed on me. Guess I’m lucky.
 
IMGASMD said:
How about your wife/daughter? (If you’re a man) will you not say anything?
Only wondering.
Click to expand...

are you talking about for labor? he already answered you - why are you pressing the issue? they can make their own decision. while I would never deny a woman requesting one for labor, I certainly wouldn't encourage any woman in my family to get one. the pain of childbirth isn't a pathological pain and many women (and nearly 100% of them before 100 years ago) did just fine the natural way. but again, each woman can make that decision on her own: the wimps will get epidurals, the strong ones won't.
 
leaverus said:
are you talking about for labor? he already answered you - why are you pressing the issue? they can make their own decision. while I would never deny a woman requesting one for labor, I certainly wouldn't encourage any woman in my family to get one. the pain of childbirth isn't a pathological pain and many women (and nearly 100% of them before 100 years ago) did just fine the natural way. but again, each woman can make that decision on her own: the wimps will get epidurals, the strong ones won't.
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Of course. Just want to see how people treat or assess pain. But by your last sentence, you’ve certainly made up your mind.
Then is there a real role for regional anesthesia for pain control, in your opinion? Or the chance of nerve damage is too high?
 
There is a very good series of articles in RAPM called "Neurological complications after elective orthopedic procedures". Its pretty clear from the data that the incidence of neurological complications after surgery is pretty much INDEPENDENT of the use of regional anesthesia, and in some groups of patients the use of blocks actually reduce their incidence (better surgical conditions?).

For those that say "Why do blocks just for better pain relief?", consider that the chance of developing a long term opioid abuse problem is about 5% postoperatively, and TKA has the highest risk among all surgeries (doi: 10.1213/ANE.0000000000002458). Compared with the incredibly low incidence of severe neurological complications attributable to blocks, the balance clearly tips in favor of doing them.

Just grab a bunch of patients and do a quick telephone follow–up 12–24–48 hrs. We are currently doing Femoral Triangle and iPACK for TKA and the results speak for themselves. With perineural dexamethasone and dexmedetomidine, you usually have VAS of 0–3 the first 24 hrs.
 
facted said:
Agree with this. ASRA recommendations are that blocks shouldn't routinely be done in an insensate patient. From a medicolegal perspective, would be wise to do the block preop.

I've prob done 300-400 TKA with adductor block and never had an issue. Bunch of different surgeons. The issue is not the block.

For what it's worth, I use 20ml 0.5% bupi and 4mg decadron.
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the evidence from paediatric anaesthesia is that doing blocks asleep has equivalent safety.
agree with the medico-legal benefit, disagree that their is any clinical benefit!
 
FFP said:
Exactly. Epi should be enough.
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Now when I was reading another thread where you were pretty much saying you found no comedians on the planet funny I figured you had your sense of humor surgically removed. But this.... this is funny!
 
leaverus said:
are you talking about for labor? he already answered you - why are you pressing the issue? they can make their own decision. while I would never deny a woman requesting one for labor, I certainly wouldn't encourage any woman in my family to get one. the pain of childbirth isn't a pathological pain and many women (and nearly 100% of them before 100 years ago) did just fine the natural way. but again, each woman can make that decision on her own: the wimps will get epidurals, the strong ones won't.
Click to expand...

:corny:🤣
 
My advice for the OP is to use the safest cocktail possible when performing the Adductor Canal Block. That means 0.5% Ropivacaine with PF decadron 2 mg total volume of 20 ml. Forget the other stuff and stick with the safest cocktail which will deliver about 20 hours of postop analgesia.

The other alternative is PF 0.5% Ropivacaine 20 ml with no adjuvants. This will last 12-16 hours postop. Perhaps, you guys need to do 50 of these blocks without any adjuvants to shows the surgeons you are back on track in terms of complications.

I do think the "double crush" injury is the explanation for these complications. The extra PF decadron combined with the Epi plus the tourniquet are all contributing to the outcome. Since the saphenous nerve can be difficult to visualize completely (we only see a portion of it near the femoral artery) it is possible some of the local is being injected intraneural.
 
, the adductor canal is bounded by intermuscular compartments. Although no published report currently exists, leaking of local anesthetic from the potentially fenestrated vastoadductor membrane or the migration of catheter tip outside of the adductor canal can result in possible delayed myositis or even local anesthetic systemic toxicity[14]. There has been one report of a patient developing a hematoma around the adductor canal injection site after catheter removal, who subsequently developed saphenous distribution neuropathy that required 4 months of gabapentin treatment before resolution of symptoms[36].
 
DM27 said:
I initially thought this was a repost of the NFL player's injury blamed on an adductor canal block.

www.si.com

Diving Into Sharrif Floyd's $180M suit vs. Dr. Andrews

Sharrif Floyd's lawsuit against Dr. James Andrews won’t be an easy case to settle, riddled with challenges in proving $180 million in damages.
www.si.com www.si.com
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Sounds like the lawyer and patient are just blaming everyone for everything. I am supposed to believe that the patient was scheduled for surgery before an exam and didnt consent for any surgical procedure..and then only consented for a small procedure...and then didn't consent for nerve block either??

Sounds like the patient had pretty significant knee issues and didnt recover well. Plain and simple
 
UscGhost said:
Sounds like the lawyer and patient are just blaming everyone for everything. I am supposed to believe that the patient was scheduled for surgery before an exam and didnt consent for any surgical procedure..and then only consented for a small procedure...and then didn't consent for nerve block either??

Sounds like the patient had pretty significant knee issues and didnt recover well. Plain and simple
Click to expand...

It sounds like he was consented for an arthroscopic meniscus repair (and the always present "all other indicated procedures" on the consent form) and then woke up having receiving a chondroplasty which is a significantly bigger recovery. Probably also was not expected to need a nerve block for the planned procedure but then got something much more painful and got a nerve block in recovery. Potential issue for anesthesiologist is did he consent for a nerve block before the procedure that probably would not have needed it? And when the surgery changed, who did he get consent from for the nerve block since the patient cannot consent in PACU.
 
So, the only reported case of permanent saphenous nerve damage secondary to an Adductor Canal block just happens to occur in the super-athlete suing for $180 million dollars? I'm not buying it. I bet the athlete had a prolonged nerve block with some paresthesias/vastus weaknesss which may have persisted for several months, even a year, but "permanent" is highly unlikely.
 
What's confusing about it is that it does not appear to even be saphenous damage that the suit hinges on, but also some degree of motor impairment. The whole case was very confusing from the medical end. The not mentioned subtext is that this guy did not have the most robust NFL career leading into this so this may have been the best case end scenario for him.
 
In my experience, my partners that say regional blocks are unnecessary are the ones that just don't know how to perform the blocks. I think it's just an excuse.
 
Just be prepared to answer post op numbness/weakness questions with every block you do
 
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