The Efficacy Of Ultrasound-Guided Adductor Canal Block for Arthroscopic Knee Surgery
Condition: Knee Arthropathy
MeSH terms: Joint Diseases
Study type: Interventional

Summary: 
      The ultrasound-guided selective blockade of the saphenous nerve in the adductor canal
      provides effective analgesia and reduces postoperative pain in patients undergoing
      arthroscopic medial meniscectomy. Selective blockade of the saphenous nerve in the adductor
      canal provides effective analgesia without quadriceps muscle weakness. It has been shown that
      usage of tourniquet during performing the adductor canal block (ACB) block increases the
      spread of local anesthetics in a distal and proximal way. Therefore, the proximal spread of
      local anesthetics may cause possible quadriceps weakness. The distal spread of local
      anesthetics may increase analgesic effect via sciatic nerve. The timing of the tourniquet
      inflation for ACB is a topic of discussion.The aim of this study is to compare the different
      times of US-guided ACB performing for postoperative analgesia management after arthroscopic
      knee surgery.
    

Detailed description: 
      Knee arthroscopy is one of the most common orthopedic procedures. Knee arthroscopy is
      commonly used for the repairement of meniscus tears, debridement and reshaping of cartilage
      flaps, and ligament reconstruction. Knee arthroscopy is a minimally invasive procedure,
      however patients may complain severe pain due to the port-site incisions and the ligaments in
      the knee joint. Opioid agents are commonly used for analgesia management. However, opioids
      have adverse effects such as nausea, vomiting, sedation and respiratory depression.
      Peripheral nerve blocks such as femoral block, adductor canal block (ACB) may be performed to
      reduce opioid consumption and opioid-related side effects.

      Selective blockadge of the saphenous nerve in the adductor canal for knee surgery provides
      effective analgesia without quadriceps muscle weakness. This is an important advantage of ACB
      since it there is no motor blockadge in the postoperative period. Blocking of the motor
      branches leads to delaying of the mobilization and it increases the patient's falling risk.
      ACB, targets the saphenous nerve and the vastus medialis branch which are the two largest
      sensorial nerves of the femoral nerve that innervates the knee. ACB blocks the articular
      branches of the obturator nerve at the same time. Since the ACB is performed at the distal
      site of thigh it does not target majority of the efferent branches of the quadriceps muscle,
      therefore the strength of this muscle may not be affected.

      ACB is an effective and safely block. It has been shown that usage of the tourniquet during
      performing the ACB block increases the spread of local anesthetics in a distal and proximal
      way. There are two questions in this issue. Firstly, the proximal spread of local anesthetics
      may cause possible quadriceps weakness. Secondly the distal spread of local anesthetics may
      increase analgesic effect via sciatic nerve blockade. In the routine surgical procedure, at
      the beginning of the surgery a tourniquet is attached to the thigh and inflated following the
      induction of anesthesia. Then at the end of the procedure the tourniquet is deinflated and
      the patient is extubated. ACB may be performed preoperatively or postoperatively. It may be
      performed before or after the inflation of the tourniquet.

      The aim of this study is to compare the different performing times of US-guided ACB for
      postoperative analgesia management after arthroscopic knee surgery. The primary aim is to
      compare postoperative opioid consumption and the secondary aim is to evaluate postoperative
      pain scores (VAS), and adverse effects related with opioids (allergic reaction, nausea,
      vomiting).
    

Intervention name(s): Group Preoperatively Adductor Canal Block; Group Preoperatively Tourniquet Adductor Canal Block; Group Postoperatively Adductor Canal Block
Intervention type(s): Other; Other; Other
Intervention description(s): The ACB will be performed preoperatively before inflation of the tourniquet. After identifing the adductor canal, by using the in-plane technique, the probe will be placed at the mid-thigh, half the distance between the inguinal crease and the patella, for block location. The superficial femoral artery will be visualized dorsal to the sartorius muscle. Then, the probe will be remowed to distally. At this level, the hyperechoic view of the saphenous nerve will be visualized lateral and anterior to the artery in the subsartorial region. 5 mL of saline will be injected to confirm the proper injection site, and then a dose of 0.25% bupivacaine 30 mL will be injected here.; The ACB will be performed preoperatively after inflation of the tourniquet. After identifing the adductor canal, by using the in-plane technique, the probe will be placed at the mid-thigh, half the distance between the inguinal crease and the patella, for block location. The superficial femoral artery will be visualized dorsal to the sartorius muscle. Then, the probe will be remowed to distally. At this level, the hyperechoic view of the saphenous nerve will be visualized lateral and anterior to the artery in the subsartorial region. 5 mL of saline will be injected to confirm the proper injection site, and then a dose of 0.25% bupivacaine 30 mL will be injected here.; The ACB will be performed postoperatively. After identifing the adductor canal, by using the in-plane technique, the probe will be placed at the mid-thigh, half the distance between the inguinal crease and the patella, for block location. The superficial femoral artery will be visualized dorsal to the sartorius muscle. Then, the probe will be remowed to distally. At this level, the hyperechoic view of the saphenous nerve will be visualized lateral and anterior to the artery in the subsartorial region. 5 mL of saline will be injected to confirm the proper injection site, and then a dose of 0.25% bupivacaine 30 mL will be injected here.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Ninety patients aged 18-65 years old with American Society of Anesthesiologists (ASA) classification I-II and scheduled for arthroscopic knee surgery will be included in the study. Patients will be randomly divided into three groups (Group Pre = preoperatively before inflation of the tourniquet group, Group Pre-T = preoperatively after inflation of the tourniquet group, Group Post = Postoperatively group) including 30 patients each, before entering the operating room.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Postoperative analgesia; Adductor canal block; Knee arthroscopy