ERAS Anesthesia Techniques for Knee Surgery Recovery

(EKAT-TeleTPS Trial)

Overseen By George Birch, BS

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Hospital for Special Surgery, New York

Must not be taking: Gabapentin, Pregabalin

Disqualifiers: Hepatic insufficiency, Renal insufficiency, Diabetes, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 1

Duration: 1 day

94 Participants Needed

Trial Summary

What is the purpose of this trial?

A comparison of two anesthetic techniques for total knee replacements: (1) Peri-Articular Injection (PAI), local infiltration between the popliteal artery and capsule of the knee block (IPACK) and single-shot adductor canal block (ACB) vs. (2) PAI, IPACK and continuous adductor canal block catheter (ACC).

Will I have to stop taking my current medications?

The trial does not specify if you need to stop taking your current medications, but it excludes people who regularly use gabapentin or pregabalin. It's best to discuss your specific medications with the trial team.

What data supports the effectiveness of the treatment Adductor Canal Block (ACB) for knee surgery recovery?

Research shows that Adductor Canal Block (ACB) is effective in reducing pain after knee surgeries, such as total knee arthroplasty, by providing good pain control without affecting muscle strength. It has been found to reduce the need for additional pain medication like morphine in the first 24 hours after surgery. ^{1 2 3 4 5}

Is the adductor canal block (ACB) safe for use in knee surgery recovery?

The adductor canal block (ACB) is considered safe for use in knee surgery, as it is a preferred method of pain relief in total knee arthroplasty (knee replacement surgery). However, it requires careful administration by a trained team to ensure safety. ^{6 7 8 9 10}

How is the treatment Adductor Canal block with sham catheter, Continuous Adductor Canal Catheter (ACC) different from other treatments for knee surgery recovery?

The Continuous Adductor Canal Catheter (ACC) is unique because it provides continuous pain relief while allowing better mobility compared to other methods like epidural analgesia, which can cause more leg weakness. This technique focuses on blocking specific nerves in the adductor canal, minimizing muscle weakness and improving recovery after knee surgery. ^{3 4 11 12 13}

Research Team

David Kim, MD

Principal Investigator

Hospital for Special Surgery, New York

Eligibility Criteria

This trial is for English-speaking adults aged 18-65 with osteoarthritis, scheduled for knee replacement surgery using regional anesthesia. They must live within an hour of the hospital, be able to follow the study protocol, have a smartphone, and have home caregivers if needed. Excluded are those with diabetes, chronic pain or high pain catastrophizing scores, severe knee deformities, no home caregivers for catheter care, ASA status III/IV patients, those unable to manage a catheter at home or going to rehab facilities post-surgery.

Inclusion Criteria

Has a smart phone

Patients with osteoarthritis scheduled for a primary total knee arthroplasty with a participating surgeon

You are scheduled to receive regional anesthesia during the study.

Exclusion Criteria

You have a severe bending or twisting problem in your joints.

Patients undergoing general anesthesia

Diabetes

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo total knee arthroplasty with either a continuous adductor canal catheter or a single-shot adductor canal block

1 day

1 visit (in-person, day of surgery)

Post-operative Monitoring

Participants' opioid consumption is monitored during the post-anesthesia care unit stay and the 24-48 hour period post spinal induction

2 days

In-patient monitoring

Follow-up

Participants are monitored for safety and effectiveness after treatment

4 weeks

Treatment Details

Interventions

• Adductor Canal block with sham catheter
• Continuous Adductor Canal Catheter (ACC)

Trial Overview The trial compares two anesthesia techniques in knee replacements: one uses a single-shot nerve block plus local injections (PAI & IPACK), while the other adds a continuous nerve block through a catheter (ACC). The goal is to see which method provides better pain control during recovery.

Participant Groups

Group I: Continuous Adductor Canal Catheter (ACC) Active Control 1 Intervention

Patients will receive a combined spinal epidural, PAI, IPACK, and a continuous adductor canal catheter

Group II: Adductor Canal block with sham catheter Placebo Group 1 Intervention

Patients will receive a combined spinal epidural, PAI, IPACK, and an adductor canal block. The patient will also receive a sham catheter.

Adductor Canal block with sham catheter is already approved in European Union, United States, Canada for the following indications:

Approved in European Union as Adductor Canal Block for:

• Postoperative pain management for knee surgery

Approved in United States as Adductor Canal Block for:

• Postoperative pain management for knee surgery

Approved in Canada as Adductor Canal Block for:

• Postoperative pain management for knee surgery

Who Is Running the Clinical Trial?

Hospital for Special Surgery, New York

Lead Sponsor

Trials

257

Recruited

61,800+

Findings from Research

In a study of 120 patients undergoing total knee arthroplasty, the combination of adductor canal block (ACB) and interspace between popliteal artery and capsule of posterior knee block (IPACK) provided significantly better pain relief compared to ACB alone, as measured by VAS scores.

Patients receiving the ACB+IPACK technique also demonstrated improved range of motion and ambulation distance post-surgery, indicating that this method enhances recovery without compromising motor function.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period. Sankineani, SR., Reddy, ARC., Eachempati, KK., et al.[2022]

In a study of 70 patients undergoing arthroscopic knee surgeries under spinal anesthesia, those who received an adductor canal block (ACB) experienced significantly lower morphine consumption (8.63 mg) compared to those who did not receive the block (21.91 mg), indicating ACB's effectiveness in pain management.

The ACB not only prolonged the duration of analgesia (approximately 366 minutes vs. 150 minutes) but also resulted in lower pain scores during rest and knee flexion, while maintaining better hemodynamic stability and showing no complications.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Evaluation of Analgesic Efficacy of Ultrasound-Guided Adductor Canal Block With 20 mL of 0.5% Ropivacaine in Patients Undergoing Knee Surgeries-A Randomized Control Trial. Arumugam, P., Ravi, S., Ln, S., et al.[2023]

In a study of 57 total knee arthroplasty patients, both proximal and distal adductor canal blocks (ACBs) provided similar levels of postoperative pain relief, as indicated by comparable opioid consumption and pain scores.

While the proximal ACB group showed a trend towards better functional mobility (measured by the 'Up and Go' test), this difference was not statistically significant, suggesting that both techniques are equally effective for pain management post-surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A Randomized Comparison of Pain Control and Functional Mobility between Proximal and Distal Adductor Canal Blocks for Total Knee Replacement. Romano, C., Lloyd, A., Nair, S., et al.[2022]

In a study of 180 patients undergoing total knee arthroplasty, a single injection of adductor canal block (ACB) with or without intravenous dexamethasone was found to be non-inferior to a continuous catheter in terms of opioid consumption at 24 hours post-surgery.

Both the single injection ACB with and without dexamethasone significantly reduced opioid use compared to the catheter method, suggesting that these options could facilitate faster recovery and earlier discharge for patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique. Lee, S., Rooban, N., Vaghadia, H., et al.[2022]

In a study of 30 patients undergoing total knee arthroplasty, both adductor canal block (ACB) and femoral nerve block (FNB) provided similar levels of pain relief, with no significant difference in morphine consumption in the first 24 hours post-surgery.

Both techniques also preserved quadriceps strength equally well, showing no significant differences in muscle strength or functional recovery at 24 and 48 hours after the procedure.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A randomised controlled trial comparing adductor canal block and femoral nerve block for knee arthroplasty. Lim, YC., Quek, HYK., Phoo, WHJ., et al.[2020]

The study confirms that the direct adductor canal block (DACB) is a feasible technique for pain management in total knee arthroplasty, as demonstrated by successful dye placement in all 14 cadaveric knees examined.

DACB, being a surgeon-administered method, could potentially lower costs, reduce operating room time, and minimize the risk of surgical-site contamination compared to traditional ultrasound-guided methods.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty. Bagaria, V., Kulkarni, RV., Valavi, A., et al.[2020]

The Clancy anatomic endoscopic ACL reconstruction technique aims to improve knee stability by achieving more anatomically correct graft placement, which may better restore normal knee function compared to traditional methods.

While current techniques provide functional stability, they often fail to fully restore normal knee kinematics, particularly in rotational stability, but early results from the new technique show promise for improved outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Anatomic endoscopic anterior cruciate ligament reconstruction with patella tendon autograft. Cain, EL., Clancy, WG.[2022]

In a study of 109 patients undergoing anterior cruciate ligament (ACL) reconstruction, the average distance from the apex of the deep cartilage margin (ADC) to the femoral tunnel center was found to be consistent across both arthroscopy and CT measurements, indicating reliable landmark usage during surgery.

The results showed that while overall clinical outcomes improved post-surgery, better stability was associated with more proximally located femoral tunnels, suggesting that precise tunnel placement at the proximal corner of the ACL remnant enhances stability in remnant-preserving ACL reconstruction.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Femoral tunnel placement in single-bundle, remnant-preserving anterior cruciate ligament reconstruction using a posterior trans-septal portal. Lee, SH., Lee, ES., Ko, TW., et al.[2019]

The SAMBBA technique preserves the anterior cruciate ligament (ACL) remnant during reconstruction, which may enhance graft tendon vascularity and improve healing outcomes.

This method also maintains the semitendinosus tibial insertion, utilizing standard surgical portals and equipment, potentially simplifying the procedure while maximizing biological benefits.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Anterior Cruciate Ligament Reconstruction and Preservation: The Single-Anteromedial Bundle Biological Augmentation (SAMBBA) Technique. Sonnery-Cottet, B., Freychet, B., Murphy, CG., et al.[2022]

In a study of 40 patients undergoing anatomic ACL reconstruction, the tibial tunnel was often placed inaccurately, with a mean deviation of 2.14 mm medial and 5.11 mm posterior to the native ACL footprint, indicating a significant positioning error.

Only 18 out of 40 patients had more than 50% overlap of the reconstructed tunnel with the native ACL footprint, highlighting challenges in achieving precise graft placement despite modern surgical techniques.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. Pedneault, C., Laverdière, C., Hart, A., et al.[2020]

In a study of 60 patients undergoing knee arthroscopy, the use of adductor canal block (ACB) with either 0.25% or 0.16% bupivacaine significantly reduced the need for tramadol compared to a control group, highlighting its effectiveness in postoperative pain management.

Both concentrations of bupivacaine provided similar analgesic efficacy, suggesting that ACB is a reliable 'motor sparing' technique that enhances multimodal analgesia in knee surgeries.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Evaluation of ultrasound-guided adductor canal block with two different concentration of bupivacaine in arthroscopic knee surgery: A feasibility study. Guven Kose, S., Kose, HC., Arslan, G., et al.[2022]

Bupivacaine liposome provided significantly better pain control than ropivacaine pain ball (RPB) in the first 36 hours after total knee arthroplasty, with a mean pain score of 3.1 compared to 4.0 (P < 0.001).

Overall, bupivacaine liposome was not only effective in managing pain but also resulted in lower total costs per patient case ($20,919.53) compared to RPB ($22,574.17), indicating a cost-effective option for postoperative pain management.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adductor Canal Block With Bupivacaine Liposome Versus Ropivacaine Pain Ball for Pain Control in Total Knee Arthroplasty: A Retrospective Cohort Study. Wang, Y., Klein, MS., Mathis, S., et al.[2022]

In a study of 145 patients undergoing total knee arthroplasty, continuous adductor canal blocks (CACB) resulted in better ambulation and lower pain scores compared to epidural analgesia, indicating enhanced postoperative recovery.

Patients receiving CACB reported higher satisfaction rates (68% in general + CACB and 63% in spinal + CACB) compared to those receiving combined spinal-epidural analgesia (36%), suggesting that CACB may be a more favorable option for pain management in knee surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Continuous Adductor Canal Blocks Provide Superior Ambulation and Pain Control Compared to Epidural Analgesia for Primary Knee Arthroplasty: A Randomized, Controlled Trial. Kayupov, E., Okroj, K., Young, AC., et al.[2022]

References

1. France pubmed.ncbi.nlm.nih.gov

Comparison of adductor canal block and IPACK block (interspace between the popliteal artery and the capsule of the posterior knee) with adductor canal block alone after total knee arthroplasty: a prospective control trial on pain and knee function in immediate postoperative period. [2022]

2. China (Republic : 1949- ) pubmed.ncbi.nlm.nih.gov

Evaluation of Analgesic Efficacy of Ultrasound-Guided Adductor Canal Block With 20 mL of 0.5% Ropivacaine in Patients Undergoing Knee Surgeries-A Randomized Control Trial. [2023]

3. India pubmed.ncbi.nlm.nih.gov

A Randomized Comparison of Pain Control and Functional Mobility between Proximal and Distal Adductor Canal Blocks for Total Knee Replacement. [2022]

4. United States pubmed.ncbi.nlm.nih.gov

A Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique. [2022]

5. India pubmed.ncbi.nlm.nih.gov

A randomised controlled trial comparing adductor canal block and femoral nerve block for knee arthroplasty. [2020]

6. England pubmed.ncbi.nlm.nih.gov

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty. [2020]

7. United States pubmed.ncbi.nlm.nih.gov

Anatomic endoscopic anterior cruciate ligament reconstruction with patella tendon autograft. [2022]

8. Netherlands pubmed.ncbi.nlm.nih.gov

Femoral tunnel placement in single-bundle, remnant-preserving anterior cruciate ligament reconstruction using a posterior trans-septal portal. [2019]

9. Netherlands pubmed.ncbi.nlm.nih.gov

Anterior Cruciate Ligament Reconstruction and Preservation: The Single-Anteromedial Bundle Biological Augmentation (SAMBBA) Technique. [2022]

10. United States pubmed.ncbi.nlm.nih.gov

Evaluating the Accuracy of Tibial Tunnel Placement After Anatomic Single-Bundle Anterior Cruciate Ligament Reconstruction. [2020]

11. India pubmed.ncbi.nlm.nih.gov

Evaluation of ultrasound-guided adductor canal block with two different concentration of bupivacaine in arthroscopic knee surgery: A feasibility study. [2022]

12. United States pubmed.ncbi.nlm.nih.gov

Adductor Canal Block With Bupivacaine Liposome Versus Ropivacaine Pain Ball for Pain Control in Total Knee Arthroplasty: A Retrospective Cohort Study. [2022]

13. United States pubmed.ncbi.nlm.nih.gov

Continuous Adductor Canal Blocks Provide Superior Ambulation and Pain Control Compared to Epidural Analgesia for Primary Knee Arthroplasty: A Randomized, Controlled Trial. [2022]