How Does the Addition of Adductor Canal Block to Local Infiltration Affect Recovery in Patients Undergoing Total Knee Arthroplasty? A Feasibility Study.

Study Overview
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Brief Summary
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The use of periarticular injection and adductor canal block are well-established techniques used both in combination or in isolation in the management of postoperative pain for patients undergoing total knee arthroplasty. The aim of this study is to investigate whether combining these two techniques have an added benefit, compared to periarticular injection alone, with respect to quality of recovery, functional return, discharge readiness, and short and long term post-operative narcotic use.

Detailed Description
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This study is a double blinded, randomized control trial. In order to create a blinded study, each participant will receive two injections; a single shot adductor canal block (ACB) and a periarticular injection (PI). All syringes will be non-identifiable to the surgeon, anesthetist and the patient. Specifically, the two arms are: Arm 1: PI (Ropivacaine + Ketorolac + Epinepherine) + ACB (Ropivacaine) Arm 2: PI (Ropivacaine + Ketorolac + Epinepherine) + ACB (Normal Saline) The aim of this study is to investigate whether combining these two techniques have an added benefit, compared to periarticular injection alone. The investigators hypothesize that the addition of an adductor canal block will translate to a superior quality of recovery, as well as an improvement in functional return, discharge readiness and less short-term and long-term post-operative narcotic use.

Official Title
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Total Regional Anesthesia Techniques Resulting in up and Early Discharge Following Knee Surgery: An Opioid Reduction Plan for Transitional Pain at Home.

Conditions
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Knee Osteoarthritis, Arthritis Knee, Knee Disease, Opioid Use

Intervention / Treatment
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* Procedure: Adductor Canal Block
* Procedure: Periarticular Injection


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients requiring primary total knee arthroplasty Patients interested in being part of the study Eligible to receive spinal anesthesia Exclusion Criteria: Age < 18 years BMI > 40 kg/m2 Deemed unsuitable for regional anesthesia Planned general anesthesia Hepatic insufficiency/Intolerance to acetaminophen Renal insufficiency (defined by eGFR <60) Chronic opioid use (individuals requiring the equivalent of 1 mg or more of intravenous morphine, or 3 mg or more of oral morphine, per hour for greater than 1 month) Sulpha allergy Allergy or intolerance to trial medications Clinical Frailty Scale Score > 4 Surgery scheduled on a weekend

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized control trial. Two arms of 30 participants will be included in this study. The experimental arm will receive both the periarticular injection and the adductor canal block with local anesthetic, while the control group will receive the periarticular injection and a sham adductor canal block with normal saline.
Masking: Quadruple


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Periarticular Injection + Adductor Canal Block (Local Anesthestic)<br>The experimental arm with receive both the periarticular injection and the adductor canal block. The periarticular injection will be performed by the surgeon and will consist of 100 mL of injectate being distributed in the following manner: 30 mL to the posterior capsule, 10 mL to the medial collateral ligament, 10mL to the lateral collateral ligament (ensuring not to infiltrate common peroneal nerve), 20mL to the quadriceps and anterior capsule, and 30 mL to the subcutaneous tissue. The periarticular injection will consist of 250 mg of ropivacaine, 30 mg of ketorolac, and 0.5 mg of epinephrine. The adductor canal block will be completed by the anesthesiologist after spinal anesthesia has been initiated, but before the surgery commences. The block will be completed using an aseptic technique under dynamic, in-plane US guidance. 20 mL of injectate consisting of 100mg of ropivicaine and 50 mcg of epinephrine will be injected around the hyperechoic saphenous nerve. | Procedure: Adductor Canal Block<br>* As previously described.<br>Procedure: Periarticular Injection<br>* As previously described.<br>|
| Placebo Comparator: Periarticular Injection + Adductor Canal Block (Normal Saline)<br>The control arm with receive a periarticular injection and a sham adductor canal block. The periarticular injection will be carried out in the same manner as described for the experimental group. The technical aspects of the sham adductor canal block will be the same as for the experimental arm; however, the injectate will consist of 20 mL of normal saline. | Procedure: Adductor Canal Block<br>* As previously described.<br>Procedure: Periarticular Injection<br>* As previously described.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Scoring on the Quality of Recovery-15 Survey | The Quality of Recovery-15 Survey is a validated patient-reported outcome questionnaire that measures the quality of recovery after surgery and anaesthesia. The 11-point numerical rating scale leads to a minimum score of 0 (very poor recovery) and a maximum score of 150 (excellent recovery). To be completed pre-operatively, and on POD#1, POD#10, and POD#28. | Up to 4 weeks post-operatively. | 
| Feasibility Outcomes | Defined by eligibility, recruitment rate, adherence to intervention protocol, percentage of completed outcome measures, participant retention | End of project | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Postoperative Pain | Pain will be assessed using the numeric rating scale (NRS) - an eleven point scale from 0 (no pain) to 10 (worst pain imaginable) - at rest and with movement. To be completed twice daily while in hospital. | Throughout hospital stay, an average of 1-2 days. | 
| Range of Motion | To be assessed by physiotherapy personnel twice daily while in hospital. | Throughout hospital stay, an average of 1-2 days. | 
| Time to Meet Discharge Criteria | Discharge criteria will be assessed by physiotherapy personnel and will include the ability to transfer in and out of bed independently, the ability to transfer on and off the toilet independently, the ability to ambulate independently with or without an assistive device for 50 meters, and the ability to do stairs if they are present in the patient's home environment. Time to meet discharge will be reported in half days. To be completed twice daily while in hospital. | Throughout hospital stay, an average of 1-2 days. | 
| Narcotic Consumption | In hospital opioid consumption will be recorded and tracked by nursing personnel and will be assessed twice daily while in hospital. Post-discharge opioid consumption will be assessed using a questionnaire that will be administered by the Research Assistant over the phone. Corroboration of patient report will be completed by the Pharmacy Department. Post-discharge opioid consumption will be tracked on POD #10 and POD#28. | Up to 4 weeks post-operatively. | 
| Timed Up and Go (TUG) Test | To be assessed by physiotherapy personnel twice daily while in hospital. | Throughout hospital stay, an average of 1-2 days. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Orthopedics, Quality of Recovery-15 Survey, Peripheral Nerve Block, Local Infiltration, Adductor Canal Block, Periarticular Injection, Regional Anesthesia, Total Knee Arthroplasty, Total Knee Replacement