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Relative Contributions of Adductor Canal Block and Intrathecal Morphine to Analgesia and Functional Recovery After Total Knee Arthroplasty: A Randomized Controlled Trial
  1. Abhijit Biswas, MBBS, FCARCSI, MSc, EDRA,
  2. Anahi Perlas, MD, FRCPC,
  3. Meela Ghosh, MBBS, BSc, FRCA,
  4. KiJinn Chin, MD, FRCPC,
  5. Ahtsham Niazi, MD, FCARCSI, FRCPC,
  6. Barjind Pandher, BSc and
  7. Vincent Chan, MD, FRCPC, FRCA
  1. Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, Canada
  1. Address correspondence to: Anahi Perlas, MD, FRCPC, Department of Anesthesia and Pain Medicine, Toronto Western Hospital, 399 Bathurst St, Toronto, Ontario, Canada M5T2S8 (e-mail: Anahi.perlas{at}uhn.ca).

Abstract

Background and Objectives Effective postoperative analgesia may enhance early rehabilitation after orthopedic surgery. This randomized double-blind trial investigates the relative contributions of adductor canal block and low-dose intrathecal morphine (ITM) to postoperative analgesia and functional recovery after total knee arthroplasty.

Methods Two-hundred one patients undergoing elective unilateral total knee arthroplasty under spinal anesthesia were randomized to 3 groups. All patients received standardized intraoperative local infiltration analgesia and postoperative oral analgesics. Patients in group 1 received a “sham” adductor canal block with 30 mL of normal saline. Patients in group 2 received an adductor canal block with 30 mL of ropivacaine 0.5% with 1:400,000 epinephrine, whereas patients in group 3 received the adductor canal block with the active drug and 100 μg of ITM. The primary outcome measure was the Timed Up and Go (TUG) test on the second postoperative day. Secondary outcomes included postoperative pain scores and opioid requirements, distance walked, time to hospital discharge, and self-reported functional outcomes at 3 months.

Results All 3 groups had similar values of TUG test on postoperative day (POD) 2 (46 [36–62], 45 [33–61], and 52 [41–69]; P = 0.166) as well as other short-term and 3-month functional outcomes. Patients in group 3 showed a favorable analgesic profile as evidenced by 3 positive secondary outcomes. These positive outcomes were lower pain scores 12 hours postoperatively both at rest (4 [2–6.3], 4 [2.3–6], and 3 [1–4]; P = 0.007) and on movement (6 [4–8], 6 [3–8], and 4 [2–6]; P = 0.002), a lower incidence of “rescue” intravenous patient-controlled analgesia (42%, 34%, and 20%; P = 0.031), and the lowest cumulative opioid requirements for the first 48 hours postoperatively (86 ± 71, 68 ± 46, and 59 ± 39; P < 0.005, group 3 compared with group 1).

Conclusions Our data suggest that there is no difference in either the primary outcome of TUG test on POD 2, other immediate functional secondary outcomes, or in global functional outcome at 3 months postoperatively across all 3 groups. Our data also suggest an improved analgesic profile in the first 48 hours postoperatively when both adductor canal block and low-dose ITM (100 μg) are added to local infiltration analgesia as evidenced by several positive secondary outcomes of lower pain scores and opioid requirements.

Clinical Trial Registration This study was registered at ClinicalTrials.gov, identifier NCT02411149.

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Footnotes

  • V.C. has received honoraria from SonoSite, Braun, and Aspen Pharma. He is also a member of the Medical Advisory Board for Smiths Medical. The authors declare no conflict of interest.

    Presented at the 42nd Annual Regional Anesthesia and Acute Pain Medicine Meeting, American Society of Regional Anesthesia and Pain Medicine, April 7, 2017, San Francisco, CA.

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