Anesthesia: Essays and Researches  Login  | Users Online: 781 Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Home | About us | Editorial board | Ahead of print | Search | Current Issue | Archives | Submit article | Instructions | Copyright form | Subscribe | Advertise | Contacts

Table of Contents  
Year : 2018  |  Volume : 12  |  Issue : 4  |  Page : 774-777  

Comparison between multisite infiltration analgesia versus adductor canal block for pain management in total knee arthroplasty: A prospective study

1 Department of Orthopaedics, Sunshine Hospital, Secunderabad, Telangana, India
2 Department of Anaesthesia, Sunshine Hospital, Secunderabad, Telangana, India
3 Department of Orthopaedics, Maxcure Hospital, Hyderabad, Telangana, India

Date of Web Publication18-Dec-2018

Correspondence Address:
Dr. Sukesh Rao Sankineani
Department of Orthopaedics, Sunshine Hospital, P. G. Road, Secunderabad - 500 003, Telangana
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_124_18

Rights and Permissions

Background: Severe acute postoperative pain after total knee arthroplasty (TKA) may cause significant morbidity to patients. Recent techniques such as peripheral nerve blocks have shown promising hope in providing appropriate pain control without systemic side effects. Adductor canal block (ACB) and multisite infiltration analgesia (MIA) are two techniques that are proven to be effective individually. Aim: This study aims to compare the efficacy of ACB versus MIA in postoperative analgesia and functional recovery after unilateral knee arthroplasty. Settings and Design: A prospective study was conducted between July 2016 and December 2016 involving 200 patients undergoing unilateral TKA. Materials and Methods: Patients were either administered MIA (Group I, n = 100 patients) or ACB (Group II, n = 100 patients). All the patients were assessed for severity of pain by visual analog scale (VAS) at 8, 24, and 48 h postoperatively and knee range of motion (ROM) at 48 h after surgery. Statistical Analysis: The Statistical Package for the Social Sciences (SPSS 19.0, SPSS Inc., Chicago, IL, USA) was used for descriptive and inferential analysis. Results: Patients who received MIA showed significantly better VAS scores 8, 24, and 48 h after surgery. Furthermore, this subset of patients showed a marginally better ROM postoperatively. However, there was no difference number of patients requiring rescue analgesia for breakthrough pain or technique-related problems between both groups. Conclusion: This study demonstrates that MIA is a safe technique that provides effective analgesia at 8, 24, and 48 h postoperatively. This leads to faster rehabilitation compared to ACB in patients undergoing TKA.

Keywords: Adductor canal block, knee arthroplasty, multisite infiltration analgesia

How to cite this article:
Gurava Reddy A V, Shafeekh M, Sankineani SR, Jhakotia K, Sagi M, Daultani D, Khanna V, Eachempati KK. Comparison between multisite infiltration analgesia versus adductor canal block for pain management in total knee arthroplasty: A prospective study. Anesth Essays Res 2018;12:774-7

How to cite this URL:
Gurava Reddy A V, Shafeekh M, Sankineani SR, Jhakotia K, Sagi M, Daultani D, Khanna V, Eachempati KK. Comparison between multisite infiltration analgesia versus adductor canal block for pain management in total knee arthroplasty: A prospective study. Anesth Essays Res [serial online] 2018 [cited 2019 Oct 18];12:774-7. Available from:

   Introduction Top

Total knee arthroplasty (TKA) is a highly rewarding procedure for treating patients with advanced osteoarthritis (OA) of the knee.[1] The number of patients undergoing TKA is projected to increase six-fold in the coming two decades owing to an increase in life expectancy.[2] Severe acute postoperative pain may interfere with patients' ability to sleep, walk, and actively participate in rehabilitation activities.[3] Results from studies indicate that inadequate pain management during hospitalization may fail to achieve functional outcomes leading to further complications pneumonia, deep vein thrombosis, or pulmonary embolus.[4],[5]

Conventionally, analgesia techniques such as patient-controlled analgesia (PCA), continuous epidural analgesia, lumbar plexus block (LPB), and femoral nerve blocks (FNBs) have been performed to reduce pain during the immediate postoperative period. PCA using intravenous opioids and continuous epidural poses the risk of side effects such as nausea, pruritus, vomiting, dizziness, urinary retention, sedation, poor muscle control, and constipation.[6],[7],[8] LPBs require advanced skills and FNBs cause quadriceps weakness that increase the risk of inpatient falls.[9],[10],[11]

In the recent past, adductor canal blocks (ACBs) and multisite infiltration analgesia (MIA) have become popular because they can preserve quadriceps strength while providing similar postoperative analgesia, comparable to the conventional FNB.[12],[13],[14],[15] One drawback to ACBs is that they do not provide analgesia to the posterior aspect of the knee. MIA allows pain control at the source, maximizes muscle control, facilitates rehabilitation, and prevents venous stasis and has lower pain scores in the postoperative care unit.[16] About one-fifth of a 100 ml mixture of ropivacaine, ketorolac, morphine, and epinephrine with normal saline is injected, before component implantation, into the posterior capsule and collateral ligaments. The quadriceps, retinacula, and fat receive the remainder. Such infiltration with periarticular MIA has shown superior outcomes when compared to patients not receiving them.[16] MIA during TKA has thus been recommended for routine application in light of effective pain relief and smoother rehabilitation.

The present study compares the efficacy of ACB versus MIA in postoperative analgesia and functional recovery after unilateral TKA in a high-volume arthroplasty center.

   Materials and Methods Top

The entire treatment protocol was approved by the Institute Ethics Committee and was conducted according to the principles established in the Declaration of Helsinki. Consent for the publication of clinical details, radiographs, and photographs was obtained from the patients. A prospective study was conducted between July 2016 and December 2016 in our institute on a total of 200 patients who underwent unilateral TKA. The patients either received MIA (Group I, n = 100) or ACB (Group II, n = 100) along with spinal anesthesia. Patients undergoing bilateral or revision TKA surgery, having a history of bleeding diathesis, severe renal insufficiency, history of arrhythmia or seizures, sepsis, preexisting lower extremity neurological abnormality, and difficulties in comprehending visual analog scale (VAS) pain scores, were excluded from the study.

All patients were given spinal anesthesia with 2.5 ml 0.5% hyperbaric bupivacaine at the L3/4 interspaces (alternatively at the L2/3 or L4/5 interspaces). In Group I patients, a periarticular cocktail was prepared with 30 ml of 0.2% ropivacaine, 40 mg ketorolac, 0.5 ml of adrenaline, 4 mg of morphine sulfate, and 30 ml of distilled water (total solution volume 60 ml). The first injection is done after bone surfaces have been prepared before implantation to ensure access to the posterior joint capsule. Approximately 30 ml is injected into the tissues around the posterior joint capsule, using a systematic sequence from one side to the other to ensure uniform delivery. The second injection (30–35 ml) is done after component insertion. This injection is into the deep tissues around the medial and lateral collateral ligaments and wound edges. Group II patients received ultrasound (US)-guided ACB 4 h after spinal anesthesia. After sterile preparation and draping, approximately halfway between the anterior superior iliac spine and the patella, at the midthigh level, adductor canal was visualized using a high-frequency linear US transducer (S-Nerve US, SonoSite Inc., Bothell, WA 98021, USA). The transducer was placed transverse to the longitudinal axis of the extremity to identify the adductor canal underneath the sartorius muscle. The femoral artery was first identified as a visible pulsatile structure, with the vein just inferior and the saphenous nerve just lateral to the artery. From the lateral side of the transducer, a 22G 50-mm length, short-beveled regional block needle (Stimuplex® insulated B Braun Medical Germany) was inserted in the plane, through the sartorius muscle. With the tip of the needle placed just lateral to the artery and the saphenous nerve, 20 ml of 0.75% ropivacaine was injected to expand the adductor canal. All the patients had a uniform postoperative analgesia regimen which involved the use of paracetamol 1 g intravenously every 8 h, pregabalin 75 mg given orally once daily, and buprenorphine patch for 4 weeks. Intravenous morphine was considered in the form of rescue analgesia in patients having breakthrough pain. All the patients underwent a uniform rehabilitation protocol and were discharged from the hospital 3 days after the surgery.

Outcome measures

The primary outcome measure was postoperative pain score at rest using VAS (scale 0–10, where 0 = no pain, and 10 = worst imaginable pain). At the time of enrolment, all the patients were explained and taught about the VAS scale for self-assessment. Patients were assessed for pain at 8 h postoperatively, pain at rest on the 1st postoperative day (POD1) and on the 2nd POD. Secondary outcome measure included active knee range of motion (ROM) measured using a goniometer on the POD2.

Statistical methods

Descriptive and inferential statistical analysis has been carried out in the present study. The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Continuous variables are presented as mean ± SD or with medians and 10th–90th percentiles as appropriate and ordinal and nominal variables as n. Independent samples t- test was used to compare the groups if the assumption of normality was met, and the Mann–Whitney U-test was used for unpaired data. Categorical data were analyzed using the Chi-square test or by Fisher's exact test, as appropriate. The nature of the hypothesis testing was two-tailed, and P < 0.05 was considered statistically significant.

   Results Top

A total of 200 patients met the inclusion criteria and were included in the analysis. Hundred eligible patients were included in Group I (MIA) and other and another 100 eligible patients were included in Group II (ACB). Three patients each in both the groups required rescue analgesia between 8 h and 24 h after surgery with intravenous morphine.

Visual analog scale score – 8 h postoperatively

Patients in Group I (MIA) recorded a mean VAS score of 5.53 ± 1.185 8 h postoperatively while patients in Group II (ACB) recorded a mean VAS score 5.98 ± 1.263 which was statistically significant (P = 0.004 and t = 2.960) [Table 1] and [Figure 1].
Table 1: Comparison of study variables in two groups

Click here to view
Figure 1: Comparison of visual analog scale scores in Groups I and II

Click here to view

Visual analog scale score – 24 h postoperatively

Recorded 24-h VAS scores of Groups I and II were 3.75 ± 1.019 and 4.16 ± 1.098 (P = 0.005 and t = 2.898), respectively [Table 1] and [Figure 1].

Visual analog scale score-48 h postoperatively

Similarly, mean VAS scores 48 h after injections in Groups I and II were 2.14 ± 0.865 and 2.51 ± 0.847, respectively, which were also statistically significant (P = 0.005 and t = 2.863) [Table 1] and [Figure 1].

Clinical outcome – range of motion

Patients in Group I (MIA) recorded a mean ROM of 74.10 ± 13.416 48 h postoperatively while patients in Group II (ACB) recorded a mean ROM of 70.20 ± 12.711 which was statistically significant (P = 0.047 and t = 2. 007) [Table 1].

   Discussion Top

This study evaluated the efficacy of two modalities of pain management following TKA-MIA and ACB. Our results show that MIA is marginally better at controlling pain thereby allowing better knee movement in the immediate postoperative period compared to ACB. Furthermore, MIA shows significantly better pain control at 24 h of surgery when patients start to perceive more pain. Both the treatment modalities did not show any technique specific adverse effects. Pain requiring breakthrough analgesia was reported in both the groups equally between 8 h and 24 h postoperatively.

Pain following TKA is a significant hurdle to successful mobilization and rehabilitation of the patients. Consequently, it may increase the eventual risk of knee stiffness, reduction in knee scores and outcomes of a successful TKA. An FNB is effective in pain control post-TKA.[17] However, it results in quadriceps weakness, and thus, we have to compromise between the goals of adequate pain relief and muscle strength. An ideal nerve block must provide effective analgesia and at the same time, accelerate the mobilization by preserving motor function. Therefore, the ACB, which does not have the setbacks of FNB, came into the picture. MIA is another modality of pain management, which has gained a lot of popularity nowadays. This involves infiltration of a mixture of drugs at a correct dose around periarticular tissues to reduce the postoperative pain and to improve rehabilitation. This MIA does not interfere with motor function, thereby promoting immediate postoperative rehabilitation. Both ACBs performed preoperatively and periarticular infiltration performed intraoperatively are effective in reducing pain following TKA without causing quadriceps motor weakness which can impede mobilization.

Numerous studies have been published comparing the efficacy of local infiltration analgesia (LIA) with nerve blocks. Kurosaka et al.[18] conducted a prospective randomized control trial in 145 patients comparing LIA with FNB and reported better pain control and lower opioid consumption in LIA on day 1 after surgery. In another randomized control trial by Ashraf et al.,[19] forty patients were evaluated comparing LIA with FNB, which reported better pain control in LIA group in the first 24 h after surgery. Multiple studies have shown that ACB provides good performance in preserving the quadriceps strength to FNB while providing similar pain control leading to a preference for ACB for pain control.[20],[21] Our study shows that MIA is not inferior compared to ACB in preserving muscle strength while providing better pain control. Li et al.[22] compared the pain control and rehabilitation in patients undergoing TKA between MIA, FNB, and ACB. They concluded that MIA was more effective on pain control at rest and had better efficacy on rehabilitation when compared with the other two nerve blocks.

This study has some limitations. We could not evaluate the length of hospital stay as all our patients were discharged 72 h after the study according to our discharge protocol. Furthermore, we could not calculate the opioid consumption in our patients as our postoperative pain protocol uses only nonopioid analgesics and anti-inflammatory agents. We accept that lack of randomization would have introduced an element of bias in our study even though both the groups are comparable regarding patient profile and number.

   Conclusion Top

This study concludes that MIA provides better pain control while preserving quadriceps function leading to early rehabilitation and reduced complications in patients undergoing TKA compared to ACB.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Memtsoudis SG, Yoo D, Stundner O, Danninger T, Ma Y, Poultsides L, et al. Subsartorial adductor canal vs. femoral nerve block for analgesia after total knee replacement. Int Orthop 2015;39:673-80.  Back to cited text no. 1
Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, et al. Perioperative comparative effectiveness of anesthetic technique in orthopedic patients. Anesthesiology 2013;118:1046-58.  Back to cited text no. 2
Chaumeron A, Audy D, Drolet P, Lavigne M, Vendittoli PA. Periarticular injection in knee arthroplasty improves quadriceps function. Clin Orthop Relat Res 2013;471:2284-95.  Back to cited text no. 3
Chavis SW, Duncan LH. Pain management – Continuum of care for surgical patients. AORN J 2003;78:382-6, 389-99.  Back to cited text no. 4
Hawker G, Wright J, Coyte P, Paul J, Dittus R, Croxford R, et al. Health-related quality of life after knee replacement. J Bone Joint Surg Am 1998;80:163-73.  Back to cited text no. 5
Ganapathy S. Wound/intra-articular infiltration or peripheral nerve blocks for orthopedic joint surgery: Efficacy and safety issues. Curr Opin Anaesthesiol 2012;25:615-20.  Back to cited text no. 6
Sinatra R, Chung KS, Silverman DG, Brull SJ, Chung J, Harrison DM, et al. An evaluation of morphine and oxymorphone administered via patient-controlled analgesia (PCA) or PCA plus basal infusion in postcesarean-delivery patients. Anesthesiology 1989;71:502-7.  Back to cited text no. 7
Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the ranawat orthopaedic center. Clin Orthop Relat Res 2009;467:1418-23.  Back to cited text no. 8
Kwofie MK, Shastri UD, Gadsden JC, Sinha SK, Abrams JH, Xu D, et al. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: A blinded, randomized trial of volunteers. Reg Anesth Pain Med 2013;38:321-5.  Back to cited text no. 9
Danninger T, Opperer M, Memtsoudis SG. Perioperative pain control after total knee arthroplasty: An evidence based review of the role of peripheral nerve blocks. World J Orthop 2014;5:225-32.  Back to cited text no. 10
Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg 2010;111:1552-4.  Back to cited text no. 11
Grevstad U, Mathiesen O, Valentiner LS, Jaeger P, Hilsted KL, Dahl JB, et al. Effect of adductor canal block versus femoral nerve block on quadriceps strength, mobilization, and pain after total knee arthroplasty: A randomized, blinded study. Reg Anesth Pain Med 2015;40:3-10.  Back to cited text no. 12
Patterson ME, Bland KS, Thomas LC, Elliott CE, Soberon JR Jr., Nossaman BD, et al. The adductor canal block provides effective analgesia similar to a femoral nerve block in patients undergoing total knee arthroplasty – A retrospective study. J Clin Anesth 2015;27:39-44.  Back to cited text no. 13
Kim DH, Lin Y, Goytizolo EA, Kahn RL, Maalouf DB, Manohar A, et al. Adductor canal block versus femoral nerve block for total knee arthroplasty: A prospective, randomized, controlled trial. Anesthesiology 2014;120:540-50.  Back to cited text no. 14
Shah NA, Jain NP. Is continuous adductor canal block better than continuous femoral nerve block after total knee arthroplasty? Effect on ambulation ability, early functional recovery and pain control: A randomized controlled trial. J Arthroplasty 2014;29:2224-9.  Back to cited text no. 15
Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am 2006;88:959-63.  Back to cited text no. 16
Affas F, Nygårds EB, Stiller CO, Wretenberg P, Olofsson C. Pain control after total knee arthroplasty: A randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthop 2011;82:441-7.  Back to cited text no. 17
Kurosaka K, Tsukada S, Seino D, Morooka T, Nakayama H, Yoshiya S, et al. Local infiltration analgesia versus continuous femoral nerve block in pain relief after total knee arthroplasty: A randomized controlled trial. J Arthroplasty 2016;31:913-7.  Back to cited text no. 18
Ashraf A, Raut VV, Canty SJ, McLauchlan GJ. Pain control after primary total knee replacement. A prospective randomised controlled trial of local infiltration versus single shot femoral nerve block. Knee 2013;20:324-7.  Back to cited text no. 19
Li D, Yang Z, Xie X, Zhao J, Kang P. Adductor canal block provides better performance after total knee arthroplasty compared with femoral nerve block: A systematic review and meta-analysis. Int Orthop 2016;40:925-33.  Back to cited text no. 20
Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014;472:1377-83.  Back to cited text no. 21
Li D, Tan Z, Kang P, Shen B, Pei F. Effects of multi-site infiltration analgesia on pain management and early rehabilitation compared with femoral nerve or adductor canal block for patients undergoing total knee arthroplasty: A prospective randomized controlled trial. Int Orthop 2017;41:75-83.  Back to cited text no. 22


  [Figure 1]

  [Table 1]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Materials and Me...
    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded62    
    Comments [Add]    

Recommend this journal