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How Can We Best Balance Pain Control and Rehabilitation After Knee Replacement?

McCartney, Colin J. L. MBChB, PhD, FRCA, FRCPC; Wong, Patrick MD, FRCPC

doi: 10.1213/ANE.0000000000001311
Editorials: Editorial

From the Department of Anesthesiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada.

Accepted for publication March 1, 2016.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Colin J. L. McCartney, MBChB, PhD, FRCA, FRCPC, Department of Anesthesiology, The Ottawa Hospital and University of Ottawa, 1053 Carling Ave., Room B311, Ottawa, Ontario, Canada K1Y 4E9. Address e-mail to

Total knee arthroplasty (TKA) is a common, painful surgical procedure that requires high-quality anesthesia and postoperative pain control to facilitate early rehabilitation. In the past, common barriers to early rehabilitation after TKA included pain, nausea, and dizziness, which often were related to basic analgesic methods that used opioid analgesics alone. The more recent use of multimodal analgesic techniques and peripheral regional anesthesia has allowed significant reduction in opioid requirements and improved pain control while reducing major side effects.1

Commonly used peripheral regional anesthesia techniques for TKA include femoral and sciatic nerve blocks (both single-injection and continuous techniques). These techniques provide profound pain control after major knee surgery but require careful titration to avoid impairment of motor function.2,3 In addition, their use requires extra training and resources and can provide a significant barrier to use in many institutions.

More recently, periarticular infiltration and local infiltration analgesia (LIA) have demonstrated promise as simple, surgically administered methods of providing pain relief that do not impair motor function.4 Since the initial description, LIA has been investigated against various analgesic modalities (Table 1).5–26 Many of these studies have confirmed the analgesic benefit of LIA, but comparisons against methods such as femoral and/or sciatic nerve block have been less conclusive.5,19,27,28 Persisting concern about exacerbating motor weakness and impairment of rehabilitation has led many practitioners to evaluate more distal techniques such as blocks of the saphenous nerve in the adductor canal (adductor canal block [ACB])29 or tibial nerve block in the popliteal fossa.30 Studies on the ACB to date have demonstrated similar analgesic benefits without motor impairment compared with both single-injection and continuous femoral nerve block techniques.31–36 In 2013, Andersen et al.25 demonstrated that the addition of ACB to LIA led to better analgesia and earlier ambulation over LIA alone. For that reason, many practitioners are moving to the use of the ACB in preference to femoral nerve block to avoid motor impairment.

Table 1

Table 1

In this issue of Anesthesia & Analgesia, Sawhney et al.26 further our knowledge of the ACB by comparing, in a randomized and blinded fashion, the combination of ACB and local infiltration to either technique alone for patients having TKA. Although they found no difference in pain control with the addition of ACB to LIA for pain at rest, there was a significant reduction in pain in walking when the 2 techniques were used together. There was also a significant reduction in IV hydromorphone consumption in the combination group. Reassuringly, the addition of ACB did not cause any impairment in distance walked compared with LIA alone. Finally, the use of ACB alone (without LIA) led to poor pain control compared with the other 2 groups, suggesting that the use of ACB alone (without LIA) should be avoided. Disappointingly but not surprisingly, the beneficial effects of adding a single-shot ACB to LIA disappeared by postoperative day 2.

The results of this study add to previous findings that demonstrate the analgesic benefits of the ACB when added to LIA. The lack of negative impact of the ACB on ability to ambulate should facilitate early recovery. Moreover, reduction in opioid consumption with the addition of ACB to LIA will lead to reduction in opioid-related adverse effects, further improving the ability to ambulate. Sawhney et al.26 advance our knowledge of the field by further demonstrating the analgesic benefit of the ACB when added to LIA alone for TKA. Use of the ACB should therefore be strongly considered for patients having TKA because of the benefits to pain control and reduction in opioid consumption without impact on rehabilitation.

Although Sawhney et al.26 are to be commended for this advance in knowledge, further studies are required to continue to evaluate the place of ACB for early recovery after knee surgery. Few studies have evaluated ACB for knee procedures other than TKA.37–39 Because Sawhney et al.26 were unable to show any benefits of adding ACB to LIA beyond postoperative day 1, a continuous ACB technique should be the focus of further future investigations to examine whether benefit can be extended.36 The impact of these advanced peripheral nerve blocks on discharge readiness40 and ability to manage TKA patients at home needs further evaluation. Furthermore, the safety of additional multiple local anesthetic techniques with regard to local anesthetic toxicity needs to be examined.

In summary, TKA is a painful procedure that requires good pain relief for optimal recovery. Sawhney et al.26 demonstrate that ACB is a useful addition to LIA alone for improving pain control and reducing opioid consumption without causing significant impact to early rehabilitation. This study adds to a growing body of literature demonstrating the analgesic benefits of ACB without impairing the all-important analgesic “balance” that is vital for successful recovery after TKA.

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Name: Colin J. L. McCartney, MBChB, PhD, FRCA, FRCPC.

Contribution: This author conducted literature review and wrote the manuscript.

Attestation: Colin J. L. McCartney approved the final manuscript.

Name: Patrick Wong, MD, FRCPC.

Contribution: This author conducted literature review and wrote the manuscript.

Attestation: Patrick Wong approved the final manuscript.

This manuscript was handled by: Terese T. Horlocker, MD.

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1. McCartney CJ, Nelligan K. Postoperative pain management after total knee arthroplasty in elderly patients: treatment options. Drugs Aging 2014;31:83–91.
2. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM. Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011;115:774–81.
3. Brodner G, Buerkle H, Van Aken H, Lambert R, Schweppe-Hartenauer ML, Wempe C, Gogarten W. Postoperative analgesia after knee surgery: a comparison of three different concentrations of ropivacaine for continuous femoral nerve blockade. Anesth Analg 2007;105:256–62.
4. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 2008;79:174–83.
5. Marques EM, Jones HE, Elvers KT, Pyke M, Blom AW, Beswick AD. Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness. BMC Musculoskelet Disord 2014;15:220.
6. Han CD, Lee DH, Yang IH. Intra-synovial ropivacaine and morphine for pain relief after total knee arthroplasty: a prospective, randomized, double blind study. Yonsei Med J 2007;48:295–300.
7. Zhang J, Jiang Y, Shao J, Shen H, Wang Q, Zhang X. Effect of periarticular multimodal drug injection on pain after total knee arthroplasty. J Clin Rehabil Tissue Eng Res 2007;11:8678–82.
8. Fu P, Wu Y, Wu H, Li X, Qian Q, Zhu Y. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty—a randomized controlled trial. Knee 2009;16:280–4.
9. Fu PL, Xiao J, Zhu YL, Wu HS, Li XH, Wu YL, Qian QR. Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial. J Int Med Res 2010;38:1404–12.
10. Chen Y, Zhang Y, Zhu YL, Fu PL. Efficacy and safety of an intra-operative intra-articular magnesium/ropivacaine injection for pain control following total knee arthroplasty. J Int Med Res 2012;40:2032–40.
11. Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, Varin F. A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Joint Surg Am 2006;88:282–9.
12. Andersen KV, Bak M, Christensen BV, Harazuk J, Pedersen NA, Søballe K. A randomized, controlled trial comparing local infiltration analgesia with epidural infusion for total knee arthroplasty. Acta Orthop 2010;81:606–10.
13. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010;81:354–60.
14. Spreng UJ, Dahl V, Hjall A, Fagerland MW, Ræder J. High-volume local infiltration analgesia combined with intravenous or local ketorolac+morphine compared with epidural analgesia after total knee arthroplasty. Br J Anaesth 2010;105:675–82.
15. Essving P, Axelsson K, Åberg E, Spännar H, Gupta A, Lundin A. Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial. Anesth Analg 2011;113:926–33.
16. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty 2007;22:33–8.
17. Meftah M, Wong AC, Nawabi DH, Yun RJ, Ranawat AS, Ranawat CS. Pain management after total knee arthroplasty using a multimodal approach. Orthopedics 2012;35:e660–4.
18. Ng FY, Ng JK, Chiu KY, Yan CH, Chan CW. Multimodal periarticular injection vs continuous femoral nerve block after total knee arthroplasty: a prospective, crossover, randomized clinical trial. J Arthroplasty 2012;27:1234–8.
19. Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK, Søballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop 2007;78:172–9.
20. Carli F, Clemente A, Asenjo JF, Kim DJ, Mistraletti G, Gomarasca M, Morabito A, Tanzer M. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth 2010;105:185–95.
21. Affas F, Nygårds EB, Stiller CO, Wretenberg P, Olofsson C. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthop 2011;82:441–7.
22. Krenzel BA, Cook C, Martin GN, Vail TP, Attarian DE, Bolognesi MP. Posterior capsular injections of ropivacaine during total knee arthroplasty: a randomized, double-blind, placebo-controlled study. J Arthroplasty 2009;24:138–43.
23. Koh IJ, Kang YG, Chang CB, Do SH, Seong SC, Kim TK. Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA? A randomised, controlled study. Knee 2012;19:253–9.
24. Mahadevan D, Walter RP, Minto G, Gale TC, McAllen CJ, Oldman M. Combined femoral and sciatic nerve block vs combined femoral and periarticular infiltration in total knee arthroplasty: a randomized controlled trial. J Arthroplasty 2012;27:1806–11.
25. Andersen HL, Gyrn J, Møller L, Christensen B, Zaric D. Continuous saphenous nerve block as supplement to single-dose local infiltration analgesia for postoperative pain management after total knee arthroplasty. Reg Anesth Pain Med 2013;38:106–11.
26. Sawhney M, Mehdian H, Kashin B, Ip G, Bent M, Choy J, McPherson M, Bowry R. Pain after unilateral total knee arthroplasty: a prospective randomized controlled trial examining the analgesic effectiveness of a combined adductor-canal peripheral nerve block with periarticular infiltration versus adductor-canal nerve block alone versus periarticular infiltration alone. Anesth Analg 2016;122:2040–6.
27. Fowler SJ, Christelis N. High volume local infiltration analgesia compared to peripheral nerve block for hip and knee arthroplasty—what is the evidence? Anaesth Intensive Care 2013;41:458–62.
28. Spangehl MJ, Clarke HD, Hentz JG, Misra L, Blocher JL, Seamans DP. The Chitranjan Ranawat Award: periarticular injections and femoral and sciatic blocks provide similar pain relief after TKA: a randomized clinical trial. Clin Orthop Relat Res 2015;473:45–53.
29. Jenstrup MT, Jæger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, Larsen TK, Dahl JB. Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 2012;56:357–64.
30. Sinha SK, Abrams JH, Arumugam S, D’Alessio J, Freitas DG, Barnett JT, Weller RS. Femoral nerve block with selective tibial nerve block provides effective analgesia without foot drop after total knee arthroplasty: a prospective, randomized, observer-blinded study. Anesth Analg 2012;115:202–6.
31. Kim DH, Lin Y, Goytizolo EA, Kahn RL, Maalouf DB, Manohar A, Patt ML, Goon AK, Lee YY, Ma Y, Yadeau JT. Adductor canal block versus femoral nerve block for total knee arthroplasty: a prospective, randomized, controlled trial. Anesthesiology 2014;120:540–50.
32. Hanson NA, Allen CJ, Hostetter LS, Nagy R, Derby RE, Slee AE, Arslan A, Auyong DB. Continuous ultrasound-guided adductor canal block for total knee arthroplasty: a randomized, double-blind trial. Anesth Analg 2014;118:1370–7.
33. Shah NA, Jain NP. Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty? Effect on ambulation ability, early functional recovery and pain control: a randomized controlled trial. J Arthroplasty 2014;29:2224–9.
34. Grevstad U, Mathiesen O, Valentiner LS, Jaeger P, Hilsted KL, Dahl JB. Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: a randomized, blinded study. Reg Anesth Pain Med 2015;40:3–10.
35. Zhang W, Hu Y, Tao Y, Liu X, Wang G. Ultrasound-guided continuous adductor canal block for analgesia after total knee replacement. Chin Med J (Engl) 2014;127:4077–81.
36. Shah NA, Jain NP, Panchal KA. Adductor canal blockade following total knee arthroplasty-continuous or single shot technique? Role in postoperative analgesia, ambulation ability and early functional recovery: a randomized controlled trial. J Arthroplasty 2015;30:1476–81.
37. Chen JY, Li N, Xu YQ. Single shot adductor canal block for postoperative analgesia of pediatric patellar dislocation surgery: a case-series report. Medicine (Baltimore) 2015;94:e2217.
38. Ahl El MS. Femoral nerve block versus adductor canal block for postoperative pain control after anterior cruciate ligament reconstruction: a randomized controlled double blind study. Saudi J Anaesth 2015;9:279–82.
39. Espelund M, Grevstad U, Jaeger P, Hölmich P, Kjeldsen L, Mathiesen O, Dahl JB. Adductor canal blockade for moderate to severe pain after arthroscopic knee surgery: a randomized controlled trial. Acta Anaesthesiol Scand 2014;58:1220–7.
40. Machi AT, Sztain JF, Kormylo NJ, Madison SJ, Abramson WB, Monahan AM, Khatibi B, Ball ST, Gonzales FB, Sessler DI, Mascha EJ, You J, Nakanote KA, Ilfeld BM. Discharge readiness after tricompartment knee arthroplasty: adductor canal versus femoral continuous nerve blocks—a dual-center, randomized trial. Anesthesiology 2015;123:444–56.
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