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

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests two anesthesia techniques to determine which aids recovery better after knee replacement surgery. The Adductor Canal Block with sham catheter involves a single injection to numb the knee area, while the Continuous Adductor Canal Catheter (ACC) provides continuous numbing. The trial seeks participants with osteoarthritis who are scheduled for knee replacement surgery with specific doctors, live near the hospital, and have a smartphone. The goal is to identify which method reduces pain and improves recovery. As an unphased trial, it offers participants the chance to contribute to valuable research that could enhance recovery techniques for future patients.

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 prior data suggests that these anesthesia techniques are safe for knee surgery recovery?

Research shows that the adductor canal block, a type of pain relief, is generally safe for reducing pain after knee surgery. Studies indicate that a continuous adductor canal catheter (ACC) can manage pain while still allowing movement. This method has been successfully used in outpatient settings, often enabling patients to go home the same day after surgery.

The main safety concerns include falls, infections, nerve injury, and muscle weakness. However, reports suggest these issues are rare. Most patients tolerate the ACC well and can move around soon after surgery. The continuous catheter method appears to improve recovery, making it a promising option for managing pain in knee surgeries. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about these anesthesia techniques for knee surgery recovery because they aim to enhance pain management and speed up recovery. The Continuous Adductor Canal Catheter (ACC) is unique as it continuously delivers local anesthetic to the adductor canal, potentially improving pain control over traditional single-shot blocks. Meanwhile, the Adductor Canal block with a sham catheter is designed to assess the effectiveness of continuous delivery compared to a standard block, providing valuable insights into optimal pain management strategies. These approaches could revolutionize post-operative care by improving comfort and reducing reliance on systemic pain medications.

What evidence suggests that this trial's anesthetic techniques could be effective for knee surgery recovery?

Research has shown that a continuous adductor canal catheter (ACC), which participants in this trial may receive, can reduce pain after knee surgery. This method provides better pain relief than single injections, which wear off more quickly. Additionally, patients using the ACC often regain knee movement faster after surgery. One study found that the ACC improved knee movement by about 11.77 degrees, a significant improvement. Overall, the continuous method aids in both pain management and quicker physical recovery after knee surgery. Another group in this trial will receive an adductor canal block with a sham catheter for comparison. ^{2 3 6 7 8}

Who Is on the Research Team?

David Kim, MD

Principal Investigator

Hospital for Special Surgery, New York

Are You a Good Fit for This Trial?

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 for a Trial Participant

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

What Are the Treatments Tested in This Trial?

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.

How Is the Trial Designed?

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+

Published Research Related to This Trial

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]

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 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 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]

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 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 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 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]

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 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]

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]

Citations

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Postoperative continuous adductor canal block for total ... Paired outcomes at 6 weeks compared to baseline ROM, showed significant improvement in knee ROM with a cACB (mean difference 11.77°, 95% CI: 3.1–20.5°, P = 0.01) ...

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Review Article Adductor canal block in total knee arthroplasty Important safety outcomes were falls, infection, nerve injury, and quadriceps weakness. ... Song, et al. Is continuous catheter adductor canal block better than ...