Journal of Anesthesia & Clinical

Research

Karnawat et al., J Anesth Clin Res 2015, 6:10

http://dx.doi.org/10.4172/2155-6148.1000578

Review

Open Access

Adductor Canal Block for Post-Operative Pain Relief in Knee Surgeries: A

Review Article
Rakesh Karnawat*, Monika Gupta and Om Prakash Suthar
Department of Anesthesia & Critical Care Medicine, Dr. SN Medical College, Jodhpur, Rajasthan 342003, India
*Corresponding

author: Rakesh Karnawat, Professor, Department of Anesthesia & Critical Care Medicine, Dr. SN Medical College, Jodhpur, Rajasthan 342003, India,
Tel: +919828033321; E-mail: dr.rakeshkarnawat@yahoo.com

Received date: September 28, 2015; Accepted date: October 27, 2015; Published date: October 30, 2015
Copyright: 2015 Karnawat R et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract
The adductor canal block (ACB) is newer compartment block of the saphenous nerve, which is a branch of
femoral nerve, performed at the level of lower third of the thigh so that much of the motor innervation of the
quadriceps group is spared, thus preserving much of the quadriceps strength making early ambulation and
rehabilitation safer. The most significant advantage of the ACB over femoral nerve block and other techniques is that
it is predominantly a sensory block and reduces the incidence of fall after knee surgeries.

analgesia;

motor function. PMDI is periarticular injection of a mixture of

medications during surgery, usually consisting of ropivacaine,
ketorolac and adrenaline delivers drugs directly to the source of pain,
particularly the posterior capsule of the knee or hip joint [11,12].

Postoperative pain is an important consequence of knee surgeries

that can affect early ambulation, range of motion and duration of stay
in hospital. Advance surgical techniques like arthroscopies and early
mobilization after surgery have made knee surgeries more patients
friendly.

Adductor canal block (ACB) is a highly successful approach to the

saphenous nerve (also k/a saphenous nerve block), that was first
described by Vander Wal [13]. Compared with FNB, ACB results in
less reduction in the quadriceps muscle strength [14] as only the motor
nerve to the vastus medialis of the quadriceps muscle traverses the
adductor canal [15].

Keywords: Adductor canal block;

Quadriceps strength; Knee surgery

Post-operative

Introduction

As we know pain is considered as fifth vital sign. Unrelieved

postoperative pain may result in clinical and psychological changes
that increase morbidity and mortality as well as costs and that decrease
quality of life [1]. Inadequate pain control can lead to secondary
medical sequela such as venous thromboembolic and cardiac events.
Adequate control of pain is therefore paramount to a successful
outcome and to patient satisfaction [2].
Adequate analgesia with motor preservation has become the prime
goal after orthopedic surgeries to enable shorter hospital stay, early
physiotherapy and faster recovery.
Many options are available for the treatment of postoperative pain,
including systemic (i.e., opioid and nonopioid) analgesics and regional
(i.e., neuraxial and peripheral) analgesic techniques. Multimodal
analgesia is achieved by combining different analgesics that act by
different mechanisms and at different sites in the nervous system,
resulting in additive or synergistic analgesia with lowered adverse
effects of sole administration of individual analgesics [3].
In knee surgeries, epidural analgesia faces a relatively high failure
rate [4] and can produce adverse effects such as urinary retention and
motor block [5], the latter potentially hindering early mobilization.
Femoral nerve block (FNB) is a well-established treatment for
postoperative pain, however, invariably followed by reduced
quadriceps muscle strength [6,7] and associated with the risk of falling
[8-10].
Periarticular multimodal drug injection (PMDI) and adductor canal
block (ACB) are associated with good analgesia and preservation of

J Anesth Clin Res

ISSN:2155-6148 JACR, an open access journal

Relevant Anatomy
The adductor canal (also known as Hunters canal or subsartorial
canal) is bordered by 3 muscles: anterolaterally the quadriceps muscle
(specifically vastus medialis); posteriorly adductor magnus, and
medially the sartorius muscle. It extends from the upper/anterior thigh
femoral structures to the lower/medial thigh adductor hiatus the
distal opening in the adductor magnus muscle approx. 13 cm proximal
to the knee. The femoral vessels leave the canal at the adductor hiatus,
where they dive deeply, and this abrupt change in femoral artery depth
is a useful indicator of the distal limit of the canal, and therefore the
optimal level for LA placement. The surrounding muscles and in
particular the artery, is useful landmark to guide LA placement [16].
The sensory saphenous nerve, the nerve to the vastus medialis, the
medial femoral cutaneous nerve, the medial retinacular nerve, and the
articular branches from the obturator nerve travel within the adductor
canal [17]. In addition, the femoral artery and vein also travels within
the canal.
Cadaver studies have shown that 15 ml of LA is sufficient to fill the
adductor canal although an MRI study supported the use of 30 ml
volume [18] (Figure 1).

Technique
Adductor canal block does not provide complete surgical anesthesia.
So, surgery is carried out under general anesthesia or spinal anesthesia

Volume 6 Issue 10 1000578

Citation:

Karnawat R, Gupta M, Suthar OP (2015) Adductor Canal Block for Post-Operative Pain Relief in Knee Surgeries: A Review Article. J
Anesth Clin Res 6: 578. doi:10.4172/2155-6148.1000578

Page 2 of 4
and for providing post-operative analgesia, block is administered at the
end of the surgery.

Indications
Adductor canal block (ACB) is used as postoperative analgesia in
low volume (5-10 ml) after knee arthroscopy, anterior cruciate
ligament reconstruction (ACLR), lower leg, foot and ankle surgery
involving areas of skin supplied by the saphenous nerve and in high
volume (20-30 ml) after total and uni-compartmental knee
replacement.

Contraindications
Absolute

Patient refusal
Inflammation or infection over injection site
Allergy to local anesthetics

Relative

Figure 1: Applied anatomical view of thigh.

Patient is placed in supine position. The operative leg is slightly
flexed at the knee and externally rotated into a stable position (frog leg
position). After draping the leg, sterile ultrasound gel is applied on the
medial aspect about midway down the thigh. An 8-14 mHz linear
ultrasound transducer is placed transversely on the medial part of the
thigh, halfway between the superior anterior iliac spine and the patella.
Femoral artery is identified. The femoral vein will be just beneath the
artery and will be easily compressed by downward pressure on the
ultrasound probe.
After identifying the femoral artery, the femoral nerves will be seen
on either side of the artery as bright, echodensities. An 18-gauge,
Contiplex tuohy needle is inserted in-plane from the lateral side of the
transducer. The local anesthetic solution is injected on each side of the
artery at the points of the bright densities. A 20-gauge catheter can be
placed to enhance the duration of the block which is generally
advanced 1-2 cm beyond the tip of the needle (Figure 2).

Anticoagulation or bleeding disorders

Pre-existing peripheral neuropathies

Complications
These are the same as for any regional anesthetic technique like
block failure, bleeding/bruising, infection, local anesthetic toxicity,
nerve injury, etc.

Pharmacological Considerations
Adductor canal block can be performed using variety of short and
long acting local anesthetics in varying concentrations. In general, the
duration of action is affected by the concentration of the local
anesthetic as well as the volume injected. Duration of action can also
be prolonged with additives such as epinephrine or a corticosteroid,
typically dexamethasone [19]. Bupivacaine and ropivacaine are most
commonly used long-acting local anesthetic agents. Bupivacaine has
the risk of cardiotoxicity causing hypotension, arrhythmias and even
cardiac arrest. Ropivacaine has very close pharmacodynamic profile to
equipotent doses of bupivacaine. They have similar anesthetic and
analgesic effects. The benefit of ropivacaine is its lower risk of
cardiotoxicity in the event of inadvertent intravascular injection,
significantly faster onset time and higher therapeutic index leading to
an improved safety profile [20]. So, ropivacaine can be preferred over
bupivacaine.
Differential sensory and motor block with ropivacaine is only
apparent at low concentrations (0.2% and less). The 0.20% or higher
doses provided satisfactory postoperative analgesia, but a significantly
higher rate of motor blockade is seen with concentrations above 0.50%
[21]. Thus, for adductor canal block 15 to 30 ml of 0.20-0.50 %
ropivacaine is optimal for achieving adequate analgesia with preserved
motor power.

Figure 2: Sono-view showing contents of adductor canal.

J Anesth Clin Res

ISSN:2155-6148 JACR, an open access journal

Numerous studies compared adductor canal block with femoral

nerve block in terms of motor power and analgesia. Kwofie et al. [22]
used 15 ml of 3% chloroprocaine to compare ACB with FNB on
volunteers and found ACB results in significant quadriceps motor
sparing and significantly preserved balance but they did not compared
analgesia by above techniques. Patterson et al. [23] used 15-30 ml
bupivacaine and found adductor canal block provides equally effective
analgesia when compared with a femoral nerve block and improves

Volume 6 Issue 10 1000578

Citation:

Karnawat R, Gupta M, Suthar OP (2015) Adductor Canal Block for Post-Operative Pain Relief in Knee Surgeries: A Review Article. J
Anesth Clin Res 6: 578. doi:10.4172/2155-6148.1000578

Page 3 of 4
postoperative physical therapy performance. Kim et al. [24] used same
volume of 0.5% bupivacaine with epinephrine 5 ug/ml and found
analgesia and strength were both satisfactory. Sayed El Ahl [25] also
used 15 ml of 0.5% ropivacaine and found that quadriceps strength is
maintained with ACB but it provides inferior analgesia as compared to
FNB.
Higher volumes have also been used by some authors like Jaeger et
al. [26] used 30 ml of 0.5% ropivacaine and found that adductor canal
block preserved quadriceps muscle strength better than FNB, without a
significant difference in postoperative pain. Jenstrup et al. [27] also
used 30 ml of 0.75% ropivacaine and found reduction in morphine
consumption and pain scores but this large dose if used in higher
concentration can cause quadriceps weakness from proximal spread.

Continuous Versus Single Dosing

quadriceps group has already departed the nerve, well above the
position of the local anesthetic. This preserves much of the quadriceps
strength making early ambulation and rehabilitation safer. The most
significant advantage of the ACB is that it is predominantly a sensory
block [18].

Limitations
The sensory innervations of the knee joint is not only from nerves
passing through the adductor canal, but also from articular filaments
arising from the nerves to the vastus lateralis and intermedius, which
both arise from the posterior division of the femoral nerve proximal to
the adductor canal, and in fact only just distal to the inguinal ligament.
Therefore, ACB may not provide post knee surgery analgesia as
effective as that produced by a combined femoral and obturator block
[16].

Postsurgical pain lasts for many days whereas the action of local
anesthetic lasts for 18 to 24 hours after a single shot injection. So,
alternate delivery methods were developed for continued postsurgical
pain management. Indwelling nerve block catheters can be placed
adjacent to the nerve and a local anesthetic is infused through an
infusion pump [2]. Perineural nerve blocks may be continued
following hospital discharge on an ambulatory basis using a portable
infusion pump [28,29] (Ambulatory pump). These have shown to
decrease the time to reach discharge criteria, provide adequate
analgesia, reduce intravenous opioid consumption and facilitate early
ambulation.

Being a compartment block, it is likely that intermittent boluses are

required to block all nerves within the canal. This will necessitate
either nurse administered boluses or a pump enabling relatively high
bolus volumes. As the site of catheter placement is close to the knee,
there is increased risk of catheter displacement [35].

Patient controlled analgesia (PCA) through catheter can also be

used to maintain peripheral nerve block like ACB. PCA provides
superior postoperative analgesia and enhances patient satisfaction. It
can be programmed for several variables like bolus dose, lock-out
interval and continuous or basal infusion. In a study, Mudumbai et al.
[30] used an infusion of ropivacaine 0.2% with basal rate of 6 ml/hour,
patient-controlled bolus of 5 ml and 30-minute lockout interval and
found early post-operative ambulation without reduction in analgesia.

References

Advantages over Other Techniques

The use of peripheral nerve blocks in the lower extremity has not
been as widespread as in the upper extremity. This is due to anatomic
considerations as well as the predominance of neuraxial anesthesia
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Femoral nerve block is the most common peripheral nerve block
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The adductor canal block is another block of the femoral nerve
further down the thigh so that much of the motor innervation of the

J Anesth Clin Res

ISSN:2155-6148 JACR, an open access journal

Conclusion
Adductor canal block is a new technique for postoperative analgesia
after knee surgeries with promising results and can be developed as a
routine part of anesthesia technique for these surgical procedures.

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Karnawat R, Gupta M, Suthar OP (2015) Adductor Canal Block for Post-Operative Pain Relief in Knee Surgeries: A Review Article. J
Anesth Clin Res 6: 578. doi:10.4172/2155-6148.1000578

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