Pain medicine

Adductor Canal Block versus Femoral Nerve Block and

Quadriceps Strength
A Randomized, Double-blind, Placebo-controlled,
Crossover Study in Healthy Volunteers
Pia Jger, M.D.,* Zbigniew J.K. Nielsen, M.D., D.M.Sci., Maria H. Henningsen, M.B., R.N.,
Karen Lisa Hilsted, R.N., Ole Mathiesen, M.D., Ph.D., Jrgen B. Dahl, M.D., DMSci., M.B.A.#

ABSTRACT
Background: The authors hypothesized that the adductor
canal block (ACB), a predominant sensory blockade, reduces
quadriceps strength compared with placebo (primary endpoint, area under the curve, 0.56h), but less than the femo-ral
nerve block (FNB; secondary endpoint). Other secondary
endpoints were adductor strength and ability to ambulate.

Methods: The authors enrolled healthy young men into this

double blind, placebo-controlled, randomized, crossover
study. On two separate study days, subjects received either
ACB or FNB with ropivacaine, and placebo in the opposite limb. Strength was assessed as maximum voluntary
iso-metric contraction for quadriceps and adductor muscles.
In addition, subjects performed three standardized
ambulation
tests.
Clinicaltrials.gov
Identifier:
NCT01449097.
Results: Twelve subjects were randomized, 11 analyzed.
Quadriceps strength (area under the curve, 0.56h) was
significantly reduced when comparing ACB with placebo (5.0
1.0 vs. 5.90.6, P = 0.02, CI: 1.5 to 0.2), FNB with
placebo (P = 0.0004), and when comparing FNB with ACB (P
= 0.002). The mean reduction from baseline was 8% with

* Research Assistant, Associate Professor, Medical Student,

Research Nurse, Chief Physician, Section of Acute Pain Management, # Professor, Department of Anaesthesia, Centre of Head and
Orthopaedics, Copenhagen University Hospital, Rigshospitalet,
Copenhagen, Denmark.

Received from the Department of Anaesthesia, Centre of Head and

Orthopaedics, Copenhagen University Hospital, Rigshospi-talet,
Copenhagen, Denmark. Submitted for publication March 23, 2012.
Accepted for publication September 12, 2012. Supported by the Fund
of 17-12-1981, Copenhagen, Denmark, which cov-ered the expenses
of the hand held dynamometer. All other sup-port was provided solely
from institutional and/or departmental sources. Dr. Neilsen
occasionally receives speakers honoraria from B.Braun Medical,
Melsungen, Germany. No other author has any conflict of interest.
Address correspondence to Dr. Jger: Department of Anaesthe-sia
4231, Centre of Head and Orthopaedics, Rigshospitalet, Blegda-msvej
9, DK-2100 Copenhagen , Denmark. pia.jaeger@rh.regionh. dk.
This article may be accessed for personal use at no charge through the
Journal Web site, www.anesthesiology.org.
Copyright 2013, the American Society of Anesthesiologists, Inc. Lippincott
Williams & Wilkins. Anesthesiology 2013; 118:409-15

What We Already Know about This Topic

Continuous femoral nerve block is commonly used for

post-operative analgesia after knee surgery, but results in
quadri-ceps weakness and an increased risk of falling

Adductor canal block has been advocated as an

alternative with perhaps less risk of motor weakness

What This Article Tells Us That Is New

In healthy volunteers, adductor canal block reduced quadriceps strength by only 8% compared with 49% with femoral
nerve block, suggesting that both risk of weakness and falling
might be reduced in patients with adductor canal block

ACB and 49% with FNB. The only statistically significant

difference in adductor strength was between placebo and
FNB (P = 0.007). Performance in all mobilization tests was
reduced after an FNB compared with an ACB (P < 0.05).
Conclusions: As compared with placebo ACB statistically
significantly reduced quadriceps strength, but the reduction was only 8% from baseline. ACB preserved quadriceps strength and ability to ambulate better than FNB did.
Future studies are needed to compare the analgesic effect of
the ACB with the FNB in a clinical setting.

he femoral nerve block (FNB) is often considered as

the gold standard for postoperative pain treatment after
total knee arthroplasty. Continuous FNBs, however, have
been shown to reduce quadriceps muscle strength1 and are
associated with an increased risk of falling postoperatively.2
Efforts have been made to optimize the continuous FNBs
by comparing basal infusion with repeated hourly bolus
doses,1 by investigating the effect of continuous infusions
with dif-ferent concentrations and basal rates, but at
equivalent total

This article is featured in This Month in

Anesthesiology. Please see this issue of Anesthesiology, page
9A.

This article is accompanied by an Editorial View. Please

see: Ilfeld BM, Hadzic A: Walking the tightrope after knee
surgery: Optimizing postoperative analgesia while minimizing
quadri-ceps weakness. Anesthesiology 2013; 118: 24850.

Anesthesiology, V 118 No 2
2013

409

February

Adductor Canal Block and Muscle Strength

nerve enters the

canal.
In
comparison,
the
doses,3 and by FNB affects all four
of
the
reducing the total parts
dose of local quadriceps muscle,
the
pec-tineus
anesthetic
4
muscle
and,
injected. None of
although
rarely,
it
these
attempts
were successful in might also block the
reduc-ing
the obturator nerve (as
degree
of part of a 3-in-1quadriceps
block).
muscle block, and Due
to
the
reducing the total affection of the
dose of local vastus
medialis
anesthetic
was
muscle
the
ACB is
followed
by
expected
to
reduce
insufficient pain
4
the
quadriceps
relief.
strength
Jenstrup et al.5 muscle
compared
with
reported
a
placebo,
but
to
a
favorable effect of
limited
extent
the adductor canal
block (ACB) on compared with the
pain
during FNB. The ACB and
activity
and the FNB can also be
morphine
expected to reduce
consumption
adductor strength:
comparable with the
ACB
by
the results of the blocking the posFNB, as presented terior branch of the
in a recent meta- obturator nerve, and
analysis.6
In the FNB by blockaddition, the ACB ing the pectineus
enhanced
muscle
and
a
mobilization
possibly
ability compared
involvement of the
with
placebo,
assessed with the obturator nerve. No
Timed-Up-and-Go study to date has
investigated
the
(TUG) test.5 The
effect
of
ACB
on
ACB theoretically
muscle
strength.
affects
mainly

sensory
nerves. We aimed to
the
The only motor investigate
nerve
traversing effect of the ACB
healthy
the adductor canal in
is the nerve to the volunteers
on
and
vastus medialis.7 quadriceps
In addition, the adductor
muscle
posterior branch of strength, and the
the obturator nerve ability to ambulate.
enters the distal We hypothesized
part of the canal,7 that
the
ACB
but as the upper reduces quadriceps
part
of
the strength to some
adductor magnus extent
compared
is the most distal
with placebo (primuscle inner-vated
mary
endpoint).
by this nerve,8 it
Secondary
seems likely that
endpoints included
the motor fibers
the effect of the
depart before the

ACB
on www.clinicaltrials.gov.
Accessed September 24,
quadriceps
2012.
strength
compared
with Anesthesiology 2013;
the FNB as an 118:409-15
active
control,
and the effect on
adductor strength
and ability to
ambulate.

Materials and
Methods
This prospective,
randomized,
double
blind,
placebo-controlled, crossover
study
was
approved by the
local
Regional
Ethics Committee
(H-4-2011-057),
the
Danish
Medicines Agency
(2011-004285-15),
and the Danish
Data Protec-tion
Agency. The trial
was
registered
(NCT01449097)**
and monitored by
the
Copenhagen
University
Hospital
Good
Clinical Practice
unit. The study
was conducted at
the
Copenhagen
University
Hospital,
Rigshospitalet, in
accor-dance with
the guidelines for
Good
Clinical
Practice and the
Helsinki
Declarations. Data
are presented in
accordance with
the
CONSORT
statement.

After obtaining
written informed
consent, 12 male
volunteers were
included into the
study
from
October to
**

November
2011.
Men
aged 1830 yr,
with a body
mass index of
1825,
and
American
Society
of
Anesthesiologi
sts status I
were
considered
eligible.
Exclusion
criteria were:
intense
exercise 24h
before
the
tests,
consumption
of opi-oids or
steroids
(except
oral
inhalation)
within the last
4 weeks, any
drug
intake
within the last
48h,
pathology or
previous
surgery
or
trauma to the
lower
limb,
diabetes mellitus, inability
to cooperate,
inability
to
speak
or
understand
Danish,
alcohol
or
drug abuse, or
allergy to any
drug used in
the study.

Intervention
s
Each
subject
was
investigated on
2
separate
study days. At
least 72h had
to
elapse
between
2
experiments in
a
single

subject. On the
first day of the
study, subjects
received an FNB
in one limb and
an ACB in the
other limb. In a
double-masked
fashion
and
according
to
randomization
30ml of 0.1%
ropivacaine was
given in one
block
and
isotonic saline in
the other. This
was reversed on
the second day
of the study (see
Randomization
and Blinding).
The FNB was
performed first
(T = 0), shortly
followed by the
ACB. Subjects
were placed in a
supine position,
with the leg to be
blocked
abducted
45
degrees in the
hip and the knee
flexed, so that
the heel touched
the contralateral
knee. Venue 40
ultrasound
machine
(GE
Medical
Systems, Wuxi,
China) equipped
with linear 12L
probe was used
in all blocks for
needle guidance.
No
other
medication was
given during the
study period.
Femoral Nerve
Block.
We
employed
the
technique
presented
by
Murray et al.9
for the FNB. The
femoral
nerve
was
clearly
visible in all
subjects, as was

the
blocking
needle, which
was inserted in
plane. Hence, it
was
not
necessary
to
use a nerve
stimulator.
Thirty
milliliters
of
either
local
anesthetic
or
saline
was
slowly injected
with repeated
aspiration. The
needle tip was
repositioned
when necessary
during injection
to assure full
spread of the
solution around
the nerve.

Melsungen,
Germany) was
inserted
in
plane of the
probe
from
lateral direction.
The
sartorius
muscle
was
transfixed and
the needle tip
was
placed
under it just
lateral
and
superficial
to
the
artery.
Thirty
milliliters of either
local anesthetic
or saline was
then
slowly
injected
with
repeated
aspiration.

All subjects

Adductor
received both
Canal Block.
active
ACB
The
linear
and
FNB
probe
was
during
the
2
placed on the
days of the
medial part of
study, but only
the thigh half
one
active
way between
block
at
the
the
inguinal
time.
Placebo
liga-ment and
treatment
the
patella.
consisted
of
The femoral
saline
injected
artery
was
in the block in
visualized in
the
opposite
short
axis
limb.
immediately
under
the
sartorius
Outcomes
muscle. After
The
primary
skin
endpoint was the
preparation
difference
in
with
quadriceps
chlorhexidine
strength
gluconate and
isopropyl
(calculated
as
alcohol a 22area under the
gauge, 80-mm
curve for the
long insulated
interval 0.56h)
needle (Stimuin
plex D Plus;
B.
Braun
Medical,
410
Jger et al

PAIN MEDICINE

limbs
recei
ving
ACB
comp
ared
with
place
bo.
Seco
ndary
endpoint
s
inclu
ded
the
differ
ence
in
quadr
iceps
stren
gth in
limbs
recei
ving
FNB
comp
ared
with
ACB
and
place
bo,
the
differ
ence
in
adduc
tor
stren
gth
betwe
en
the
differ
ent
treat
ments
, and
the
differ
ence
betwe
en

ACB
and
FNB
in
mobil
izatio
n
tests
at 1
and 6
h
(TUG
test,
the
10-m
walk
test
and
the
30-s
Chair
Stand
test).

Ass
ess
men
t of
Out
com
es
Musc
le
stren
gth
was
asses
sed
as
maxi
mum
volu
ntary
isometri
c
contr
actio
n
(MV
IC)
with
a
hand
held
dyna
mom
eter
(HH
D,
Lafa
yette

Instr
umen
t,
Lafa
yette,
IN).
The
HHD
is
consi
dered
a
relia
ble
and
valid
instr
umen
t for
meas
uring
musc
le
stren
gth.10
We
appli
ed
stand
ardiz
ed
and
reco
mmend
ed
proce
dures
to
assur
e
valid
meas
urem
ents.1
1

Q
uadri
ceps
stren
gth
was
meas
ured
with
the
subje
cts
place
d in a
seate
d
positi

on
with
the
knees
flexe
d 90
degre
es
and
the
lower
legs
hangi
ng
free.1
2

Altho
ugh
excell
ent
intraclass
correl
ation
coeffi
cients
have
been
show
n
with
this
setup
for
quadr
iceps
evalu
ation
in
some
studie
s,12,13
other
studie
s
have
show
n that
when
meas
uring
the
stren
gth of
the
knee
exten
sors,
interr
ater
reliab
ility
can

be
reduc
ed if
the
stren
gth of
the
subje
ct
overc
omes
the
stren
gth of
the
tester.
1417

To
elimi
nate
interr
ater
varia
bility,
a
blind
ed,
singl
e
exam
iner
(Ms.
Hilst
ed)
perfo
rmed
all
asses
smen
ts. In
additi
on,
we
used
a
setup
descr
ibed
earlie
r,18
using
nonel
astic
strap
with
Velcr
o
closu
res to
fix
the
dyna
mom
eter

for
quadr
iceps
evaluatio
n.
The
Velcr
o
strap
was
attach
ed to
the
exam
inatio
n
couch
and
aroun
d the
patie
nts
ankle
,
perpe
ndicu
lar to
the
lower
leg.
The
HHD
was
place
d
under
the
Velcr
o
strap
on
the
anteri
or
tibia,
5cm
proxi
mal
to the
trans
malle
olar
axis.

F
or
addu
ctor
stren
gth
eval
uatio
n,
we

appli
ed a
valid
ated
proc
edur
e19
with
the
subje
cts
place
d in
supi
ne
posit
ion
and
the
ipsil
atera
l leg
abdu
cted
30
degr
ees
from
the
sagit
tal
plan
e.
The
HH
D
was
place
d on
the
medi
al
tibia
5cm
proxi
mal
to
the
medi
al
mall
eolus
. A
mark
er
was
used
to
mark
the
corre
ct
place

ment
of
the
HH
D
and
to
assur
e the
same
place
ment
throu
ghou
t the
day.
W
e
perfo
rmed
three
conse
cutiv
e
quadr
iceps
and
adduc
tor
muscl
e
practi
ce
contr
actio
ns to
famili
arize
the
subje
ct
with
the
proce
dure.
Subje
cts
were
instru
cted
to
take
2 s to
reach
the
maxi
mal
effort
,
maint
ain
this

force
for
appro
ximat
ely 3
s and
then
relax.
A
stand
ardiz
ed
verba
l
com
mand
was
issue
d
durin
g the
trials
(pus
hpushpushpause
).
The
subje
cts
perfo
rmed
three
conse
cutiv
e
trials
separ
ated
by
30-s
rest
perio
ds,
for
each
musc
le at
each
time
point.
The
mean
value
was
used
for
calculati
ons.
Musc

le
stren
gths
was
asses
sed
prebl
ock,
at 30
min,
45
min,
and
1, 2,
3, 4,
5,
and 6
h
postb
lock.
M
obiliz
ation
abilit
y was
asses
sed
with
the
TUG
test,
the
10-m
walk
test
and
the
30-s
Chair
Stand
test,
prebl
ock
and
at 1
and 6
h
postb
lock.
The
TUG
test
meas
ures
the
time
it
takes
a
perso

n to
stand
up
from
a
chair,
walk
a
dista
nce
of 3
m,
and
retur
n to
the
chair.
The
10-m
walk
test
meas
ures
the
time
it
takes
to
walk
a
dista
nce
of 10
m as
quick
ly as
possi
ble.
The
30-s
Chair
Stand
test
asses
ses
how
many
times
a
perso
n is
able
to
rise
from
a
chair
and
sit
down

again
in 30
s,
with

the
arms
kept
cross
ed
over
the
chest.
The
mobil
izatio
n
tests
have
been
valid
ated
in
previ
ous
studi
es.20
22

No
gait
aids
were
allow
ed
durin
g the
tests.
The
tests
were
only
perfo
rmed
if the
subje
ct felt
that it
was
possi
ble
rise
witho
ut the
risk
of
fallin
g.
Statis
tical
handl
ing of
result
s
from
subje
cts
who

could
not
be
mobil
ized
is
descri
bed
in the
Statis
tical
Anal
ysis
sectio
n.

W
e
teste
d
musc
le
stren
gth
and
abilit
y to
amb
ulate
in all
subje
cts at
24h
post
bloc
k.
Thes
e
tests
were
only
mad
e as
a
clini
cal
contr
ol
and
the
data
were
not
inclu
ded
in
the
statis
tical
anal
yses.
If
full

stren
gth
was
not
regai
ned
at
24h,
anot
her
contr
ol
was
sche
dule
d
until
the
bloc
k
had
subsi
ded
com
plete
ly.
A
fter
comp
letio
n of
all
asses
smen
ts at
6-h
postb
lock
a
blind
ed
obser
ver,
not
other
wise
invol
ved
in the
study
,
teste
d all
subje
cts
for
loss
of
cold
sensa

tion
in the
saph
enou
s
nerve
inner
vatio
n
area,
on
the
medi
al
part
of
the
lowe
r leg.

Ran
dom
izati
on
and
Blin
ding
The
subje
cts
were
assig
ned
conse
cutiv
e
numb
ers
upon
inclusion
into
the
study.
The
phar
macy
prepa
red
two
prepa
cked
boxes
for
each
study
partic
ipant,
one
for
each

study
day.
Each
prepa
cked
box
was
label
ed
with
the
corre
spon
ding
study
day
and
conta
ined
two
identi
cal
20ml
conta
iners;
one
with
0.2%
ropiv
acain
e the
other
with
isoto
nic
saline
. The
two
20ml
conta
iners
were
label
ed
ACB
and
FNB,
accor
ding
to
rando
mizat
ion.
Ropi
vacai
ne
and
isoto
nic
saline

are
both
trans
paren
t
liquid
s and
were
packe
d in
conta
iners
identi
cal in
appea
rance
. To
obtai
n a
conce
ntrati
on of
0.1%
ropiv
acaine,
each
20-ml
conta
iner
of
study
medi
catio
n was
dilute
d
with
20ml
of
isoto
nic
saline
in a
syrin
ge.
Thirt
y
millil
iters
of
dilute
d
study
medi
catio
n was
inject
ed in
each
block
.

T
he
subje
cts
recei
ved
two
block
s on
each
day
of the
study,
one
in
each
limb.
The
rando
mizat
ion
proce
ss
assur
ed
that
all
subje
cts
recei
ved
both
an
activ
e
ACB
and
an
FNB
during
the 2
days
of the
study,
but
only
one
activ
e
block
at the
time,
with
a
place
bo
block
in the
oppo
site
limb.

All
ACB
s
were
place
d in
the
right
limb
and
all
FNBs
in the
left
limb
on
day 1
of the
study,
with
the
oppos
ite
place
ment
on
day
2.
This
assur
ed
that
for
each
partic
ipant
the
active
block
s
were
place
d in
the
same
limb
on
days
1 and
2 of
the
study
(eithe
r
right
or
left
accor
ding
to
rando
mizat

ion)
and
that
the
placebo
block
s
were
in the
oppo
site
limb
both
days
of the
study.

A
ll
inves
tigat
ors
and
subje
cts
were
blind
ed to
treat
ment
. The
rand
omiz
ation
key
was
first
brok
en
once
enrol
ment
of all
subje
cts
was
com
plete
d.
Sa
mpl
e
Size
A
25%
reduc
tion
from
baseli

ne in
quadr
iceps
MVI
C
was
consi
dered
clinic
ally
relev
ant,
becau
se a
sidetoside
differ
-ence
of
10%
is
norm
al in
healt
hy
indivi
duals
witho
ut
functional
impor
tance.
23,24

On
the
basis
of a
previ
ous
study,
1

we
estim
ated
that
the
SD of
the
perce
nt
chang
e
from
baseli
ne
woul
d be
18.
With
=

0.05
and a
powe
r of
80%,
10
subjects
woul
d be
requi
red in
this
cross
over
study.

To
comp
ensate
for
dropo
uts,
we
plann
ed for
an
inclus
ion of
12
subje
cts.

Anesthesiology
2013;118:409-15
411
Jger et al.

Adductor Canal Block and Muscle Strength

Statistical
Analysis
Data
were
analyzed using
SAS version 9.1
(SAS
Institute
Inc., Cary, NC).
Data
are
presented
as
mean with SD.
The sample size
of this study was
12
(less
1
secondary
to
subject falling),
thus limiting the
precision
with
which distributional
characteristics
can be assessed.
Parametric tests
were
chosen
under
the
assumption that
muscle strength
and mobilization
are physiological
parameters that
usually
are
normally
distributed.
A
two-sample t test
for paired data
was used for
comparisons
between
the
placebo
and
ACB,
placebo
and FNB, and
ACB and FNB
treatments.
At
each time point,
we used the mean
value from the
three
consecutive trials to
calculate
the
percentile change
in MVIC from
baseline.
For
limbs receiving
placebo, we used
the mean value of
days 1 and 2. For
comparison
of
MVIC
(in
percentage
of
baseline values)

between
the
treatments,
we
calculated
the
area under the
curve for the
interval 0.56h
postblock.
We
calculated
the
area under the
curve by add-ing
the areas under
the
curve
between
each
pair
of consecutive
observations [(t2
t1) (y 1 +
y2
)/2].
Comparisons of
MVIC between
the
treatments
were
only
performed as area
under the curve
for the interval
0.56h.
Compari-sons of
the ability to
ambulate with an
ACB versus an
FNB
were
performed at 1
and
6h
postblock.
Subjects
who
were unable to
perform
the
mobilization tests
obtained a value
of zero in the 30s Chair Stand
test, whereas for
the TUG and 10m walk tests we
used the highest
test score value
obtained
with
each
treatment
and added 1 s to
this score. The
nature of the
hypothesis
testing was twotailed, and a P
value of less than
0.05
was
considered
significant. The
24-h assessments
were not part of
the
statistical

analyses.
All
planned
statistical
analyses
were
reported** before
inclu-sion
into
the study.

Results
Twelve subjects
were included
and randomized,
11
ana-lyzed.
One
subject
(receiving active
FNB) withdrew
his
con-sent
after
a
fall
episode at 10h
postblock
on
day 1. The fall
resulted in brief
involuntary
contractions of
the muscles of
the thigh, which
resolved without
treatment
and
sequelae.
For
subjects
characteristics,
see table 1.
The
mean
quadriceps
MVIC (0.56h
postblock) was
92% of baseline
values in limbs
receiving ACB,
compared with
51% in limbs
receiving FNB,
and
exceeded
baseline values
by 6% in limbs
receiving placebo
(fig. 1). When
cal-culated
as
area under the
curve for the
same interval, the
quadriceps
MVIC
was
statistically
significantly
reduced in
Table 1.
Subjects
Characteristics

No. of subjects
Age, yr
Height, cm
Weight, kg
Values are
reported as
number of subjects
or mean SD.

limbs receiving
ACB compared
with
placebo
(5.01.0
vs.
5.90.6, P =
0.02, CI: 1.5 to
0.2).
Additionally, the
quadriceps
MVIC
was
reduced in limbs
receiving FNB
com-pared with
both ACB (2.5
2.3 vs. 5.0
1.0, P = 0.002,
CI: 1.33.9) and
placebo (2.5
2.3 vs. 5.90.6,
P = 0.0004, CI:
1.94.8) (fig. 1).
The
mean
adductor MVIC
(0.56h
postblock) was
95% of baseline
values in limbs
receiving ACB,
compared with
90% and 99% in
limbs receiving
FNB
and
placebo,
respectively (fig.
2). On the basis
of calculations of
area under the
curve, there were
no differences in
adductor MVIC
between
limbs
receiving ACB
versus placebo
(5.20.8 vs. 5.5
0.5, P = 0.29)
or ACB versus
FNB (5.20.8
vs. 4.90.6, P =
0.37). However,
there
was
a
statistically
significant
difference
between
limbs
receiving FNB
and placebo (4.9
0.6 vs. 5.5
0.5, P = 0.007).
All subjects
could
be

mobilized after
receiving
an
ACB (ACB in
one limb, placebo
in the opposite
limb).
Conversely,
after
receiving an FNB
(FNB in one
limb, placebo in
the
opposite
limb) only 6 of
11 subjects could
perform the TUG
test at 1 and 6h
postblock
(fig.
3), 5 of 11 and 6
of
11
could
perform the 10-m
walk test (1 and
6h, respectively,
fig. 4), and 6 of
11 and 7 of 11
could
perform
the 30- s Chair
Stand test (1 and
6h, respectively,
fig. 5). Results
are presented in
table 2. The
subjects
performed
the
TUG and the 10m walk test at 1
and 6h postblock
faster
after
receiving
an
ACB compared
with an FNB
(TUG: P = 0.002
and P = 0.008, 1
and
6h,
respectively; and
10-m walk test:
P = 0.005 and P
= 0.002, 1 and 6
h, respec-tively).
Additionally, the
number of times
the subject was

Fig. 1. Effects of
the ACB, FNB
and placebo on
quadriceps
muscle strength.
Muscle strength
was assessed as
MVIC calculated
as area under the
curve for the
interval
0.56h
postblock (mean

SD).
Quadriceps MVIC
was significantly
reduced
when
comparing
placebo with ACB
(P = 0.02), and
FNB
(P
=
0.0004),
and
when comparing
ACB with FNB (P
= 0.002). ACB =
adductor
canal
block; FNB =
femoral
nerve
block; MVIC =
maximum
voluntary
isometric
contraction.

Anesthesiology 2013; 118:409-15

412
Jger et al

PAIN MEDICINE

Fig.
2.
Effec
ts of
the
ACB,
FNB
and
place
bo on
addu
ctor
musc
le
stren
gth.
Musc
le
stren
gth
was
asse
ssed
as
MVIC
calcu
lated
as
area
unde
r the
curve
for
the
interv
al
0.5
6h
postb
lock
(mea
n
SD).
The
differ
ence

in
addu
ctor
musc
le
stren
gth
betw
een
place
bo
and
FNB
was
statis
tically
signif
i-cant
(P =
0.007
) but
not
clinic
ally
impor
tant.
ACB
=
addu
ctor
canal
block
;
FNB
=
femo
ral
nerve
block
;
MVIC
=
maxi
mum
volun
tary
isom
etric
contr
actio
n.

Fig.
4.
Effec
ts of
the
ACB
and
FNB
on
mobil
izatio
n, assess
ed
with
the
10-m
walk
test.
Data
are
expre
ssed
as
mean
SD.
Subj
ects
who
could
not
be
mobil
ized
were
assig
ned
the
highe
st
test

able
to
rise
and
sit

score
value
obtai
ned
with
each
treat
ment
and 1
s
was
adde
d to
this
score
. The
subje
cts
perfo
rmed
the
10-m
walk
test
at 1
and
6h
signif
icantl
y
faster
after
recei
ving
an
ACB
comp
ared
with
an
FNB
(P =
0.005
and
P =
0.002
,
respe
ctivel
y).
ACB
=
addu
ctor
canal
block
;
FNB
=
femo
ral
nerve
block
.

durin
g the
30-s
Chai
r
Stan

d test
was
redu
ced
after
the
FNB
com
pare
d
with
the
ACB
(P =
0.00
7
and
P =
0.02,
1
and
6h,
respe
ctive
ly).

Fig.
3.
Effec

In
all
limb
s
recei
ving
activ
e
bloc
ks,
the
subje
cts
had
complete
loss
of
cold
temp
eratu
re
discr
imin
ation
,
whic
h
indicated
that
there
were
no
bloc
k
failu
res.
ts of
the
ACB
and
FNB
on
mobil
izatio
n,
asse
ssed
with
the
TUG
test.
Data
are
expre
ssed
as
mean
SD.
Subjects
who
could

not
be
mobil
ized
were
assig
ned
the
highe
st
test
score
value
obtai
ned
with
each
treat
ment
and 1
s
was
adde
d to
this
score
. The
subje
cts
perfo
rmed
the
TUG
test
at 1
and
6h
signif
icantl
y
faster
after
recei
ving
an
ACB
comp
ared
with
an
FNB
(P =
0.002
and
P =
0.008
,
respe
ctivel
y).
ACB
=
addu
ctor
canal
block
;
FNB
=
femo
ral

nerve
block
;
TUG
=
Time
d-UpandGo.

Fig.
5.
Effect
s of
the
ACB
and
FNB
on
mobili
zation
,
asses
sed
with
the
30-s
Chair
Stand
test.
Data
are
expre
ssed
as
mean
SD.
Subje
cts
who
could
not
be
mobili
zed
were
assig
ned a

value
of 0
for
the
test.
The
numb
er of
times
the
subje
ct
was
able
to
rise
and
sit
durin
g the
30-s
Chair
Stand
test
at 1
and
6h
was
signifi
cantly
reduc
ed
after
the
FNB
comp
ared
with
the
ACB
(P =
0.007
and
P =
0.02,
respe
ctivel
y).
ACB
=
addu
ctor
canal
block;
FNB
=
femor
al
nerve
block.

Anesthesiology
2013;118:409-15
413
Jger et al.

Table
2.
Mobil
izatio
n

Tests

s
musc
30-s le
Chair
Timedstren
Up- gth
10-mby
Stand8%
Test
and-Go
comTest (s)
Walkpared
with
Test (s)
(No. basel
of
Rises)
ine.
Such
Preblock
reduc
ACB
tion
FNB
may
1h postblock
not
ACB
be
FNB

funct
6h postblock
ional
ACB
ly
FNB
24h postblock
impo
ACB
rtant
FNB
in
patie
Value
nts,
s are
report
as a
ed as
sidemean
to SD.
ACB
side
=
differ
addu
ence
ctor
of
canal
block;
10%
FNB
in
=
healt
femor
al
hy
nerve
indiv
block.
idual
s is a
norm
Disc
al
ussi
varia
on
nce.2
The
3,24
In
most
comp
impo
ariso
rtant
n, the
findi
FNB
ng of
reduc
this
ed
study
the
was
quad
that
ricep
the
s
ACB
stren
only
gth
reduc
by
ed
49%
the
comp
quad
ared
ricep

to
basel
ine.
Furth
ermo
re,
the
ACB
prese
rved
the
abilit
y to
ambu
late
bette
r
than
the
FNB.

T
here
was
no
diffe
renc
e in
addu
ctor
musc
le
stren
gth
betw
een
limb
s
recei
ving
ACB
and
place
bo
(P =
0.29)
. The
ACB
theor
etica
lly
bloc
ks
the
artic
ular
bran
ch
from
the
poste
rior
bran

ch of
the
obtur
ator
nerv
e, as
it
enter
s the
dista
l part
of
the
addu
ctor
canal
. 25
The
litera
ture
does
not
repor
t
whet
her
the
moto
r
fiber
s to
the
addu
ctor
mag
nus
musc
le
are
retai
ned
or
give
n off
befor
e the
poste
rior
bran
ch
enter
s the
canal
.
Pr
eviou
s
studi
es
have
show
n that

the
obtur
ator
nerve
is
almo
st
alwa
ys
spare
d
when
perfo
rmin
g an
FNB.
26

How
ever,
the
femo
ral
nerve
suppl
ies
the
pecti
neus
musc
le,8
whic
h is a
part
of
the
addu
ctor
musc
les.
The
10%
reduc
tion
from
basel
ine in
the
addu
ctor
musc
le
stren
gth
after
the
FNB
and
the
statis
ticall
y
signi
fican
t

differ
ence
comp
ared
with
place
bo
(P =
0.007
) are
prob
ably
cause
d by
weak
ness
of
the
pecti
neus
musc
le.
How
ever,
this
reduc
tion
may
not
lead
to
funct
ional
impo
rtanc
e.23,24
T
he
49%
reduc
tion
in
quad
ricep
s
stren
gth
after
the
FNB,
as
foun
d in
our
study
, is
less
than
what
is
repor
ted

by
Char
ous
et
al.1
They
recen
tly
made
a
study
in
healt
hy
volu
nteer
s
comp
aring
the
effect
of
FNB
with
basal
infus
ion
vers
us
repea
ted
hourl
y
bolus
doses
on
quad
ricep
s
musc
le
stren
gth.
They
used
the
same
conc
entra
tion
of
ropiv
acain
e
(0.1
%)
and
the
same
total
volu

me
as we
did
(30
ml,
altho
ugh
infus
ed
over
6h
via a
perin
eural

Adductor
ry
Canal effect
Block
and Muscle
of
Strength

cathe
ter),
but
they
foun
d a
reduc
tion
of
more
than
80%
with
eithe
r
meth
od.
How
ever,
Char
ous
et
al.1
exclu
ded 4
of 15
subje
cts as
nonr
espo
nders
in
their
prim
ary
analy
ses,
beca
use
they
had
less
than
20%
chan
ge
from
basel
ine in
quad
ricep
s
stren
gth
or no
senso

the
FNB.
In
our
study
, 3 of
11
subje
cts
had
no or
limit
ed
effect
of
the
FNB
on
quad
ricep
s
musc
le
stren
gth.
Beca
use
we
were
blind
ed to
what
block
the
subje
cts
recei
ved,
we
could
not
exclu
de
patie
nts
with
an
insuf
ficie
nt
moto
r
block
ade
after
FNB.
If we
had
used
the

same
exclu
sion
criter
ion
as
Char
ous
et
al.,1
the
quad
ricep
s
musc
le
stren
gth
woul
d
have
been
reduc
ed
with
69%,
whic
h is
close
r to
the
result
of
their
study
. We
did,
howe
ver,
asses
s for
senso
ry
loss
of
cold
in the
saph
enou
s
area
at 6h
postb
lock,
and
using
this
criter
ion
we
had
neith

er
ACB
nor
FNB
failur
es.
T
he
comp
ariso
ns of
three
differ
ent
treat
ment
s
may
be
consi
dered
a
limit
ation
to the
study
.
How
ever,
the
prim
ary
endp
oint
was
clearl
y
defin
ed
and
regist
ered*
*
befor
e
inclu
-sion
into
the
study
. It
shoul
d be
noted
that
no
attem
pts
have
been
made
to

adjus
t the
seco
ndar
y
comp
ariso
ns
for
multi
plicit
y, but
exact
P
value
s are
repor
ted
so
that
the
reade
r can
perfo
rm
post
hoc
adjus
tmen
ts.
S
urpri
singl
y, 3
of 11
subje
cts
had a
reduc
tion
in
quad
riceps
stren
gth
after
recei
ving
ACB
.
This
laste
d for
appr
oximatel
y 3h,
had a
delay
ed

onset
, and
with
full
moto
r
stren
gth
regai
ned
in all
subje
cts at
24- h
postb
lock.
Whet
her
this
is a
result
of a
block
of
the
nerve
to the
vastu
s
medi
alis
or a
result
of
diffu
sion
from
the
addu
ctor
canal
to
other
branc
hes
of
the
femo
ral
nerve
, or
alter
nativ
ely
diffu
sion
to the
neigh
borin
g
musc
les,

is
uncer
tain.
Beca
use
the
nerve
to the
vastu
s
medi
alis
trave
rses
the
addu
ctor
canal
, we
woul
d
expe
ct
this
nerve
to be
block
ed in
all
subje
cts,
and
woul
d not
expe
ct a
delay
ed
and
transi
ent
respo
nse.
A
previous
study
of
the
ACB
with
magn
etic
reson
ance
imag
ing7
show
ed
that
30ml
inject

ed
throu
gh a
cathe
ter
fills
out
the
entir
e
addu
ctor
canal
. It is
possi
ble
that
this
large
volu
me
can
result
in
diffu
sion
to the
moto
r
fiber
s of
the
femo
ral
nerve
outsi
de of
the
addu
ctor
canal
. This
could
expla
in the
delay
ed
and
transi
ent
respo
nse
seen
with
the
ACB
in
this
study
.
Futur
e

studi
es
are
need
ed to
inves
tigate
how
much
volu
me
suffi
cientl
y
fills
the
addu
ctor
canal
, and
whet
her
the
reduc
tion
in
quad
ricep
s
musc
le
stren
gth
obser
ved
in
this
study
could
be
avoid
ed
with
a
small
er
volu
me,
with
out
comp
romi
sing
the
effect
on
pain.
In
concl
usion
, the
ACB

reduc
ed
quad
ricep
s
musc
le
stren
gth
comp
ared
with
place
bo.
How
ever,
the
ACB
only
reduc
ed
quad
ricep
s
stren
gth
by
8%
comp
ared
with
basel
ine
and
such
reduc
tion
is not
consi
dered
funct
ional
ly
impo
rtant
in
patie
nts.
In
comp
ariso
n, the
FNB
reduc
ed
quad
ricep
s
stren
gth
by
49%

comp
ared
with
basel
ine.
N
one
of
the
block
s
reduc
ed
addu
ctor
musc
le
stren
gth
to a
degre
e of
funct
ional
impo
rtanc
e.
Impo
rtantl
y, all
subje
cts
could
be
mobi

lized
with
an
ACB
, and
the
abilit
y to
ambu
-late
was
bette
r
prese
rved
with
an
ACB
comp
ared
with
an
FNB.
This
study
confi
rms
that
the
ACB
is
main
ly a
senso
ry

Anesthesiology
2013; 118:40915
414
Jger et al

PAIN MEDICINE
The
authors
thank
block, Copenh
which agen
Univers
may be ity
a
Hospita
useful l Good
analge Clinical
Practic
sic
e Unit,
adjuva Bispebj
nt for erg
acute Hospita
l,
pain Copenh
manag agen,
ement Denma
rk, for
after
monitor
knee ing the
surgery study.

.
Howev
Refer
er, the
ences
block
1. Char
will
ous
only be
MT,
of use
Madi
son
if
it
SJ,
provid
Sure
sh
es
PJ,
adequa
San
te/equi
dhu
NS,
valent
Lola
analnd
VJ,
gesia
Mari
to FNB
ano
ER,
after
Don
major
ohue
knee
MC,
Dutt
surgery
on
and
PH,
Ferg
conseq
uson
uently,
EJ,
future
Ilfel
d
studies
BM:
are
Con
tinu
needed
ous
to
fem
oral
compa
nerv
re the
e
analge
bloc
ks:
sic
Vary
effect
ing
local
of the
ane
ACB
stheti
with
c
the
deliv
FNB in
ery
met
a
hod
clinical
(bol
us
setting.

ver
sus
bas
al)
to
min
imiz
e
qua
dric
eps
mot
or
blo
ck
whil
e
mai
ntai
nin
g
sen
sor
y
blo
ck.
Anest

hesiolo
gy

201
1;
115
:77
4
81

2. Ilfel

d
BM,
Duk
e
KB,
Do
noh
ue
MC
:
The
ass
oci
atio
n
bet
we
en
low
er
extr
emi
ty
con
tinu
ous
peri
phe
ral
ner
ve
blo
cks
and
pati
ent
falls
afte
r
kne
e
and
hip
arth
ropl
asty.
Ane
sth
Ana
lg

201
0;
111:
155
24

3. Bau

er
M,
Wan
g L,
Oni
bon
oje
OK,
Parr
ett
C,
Ses
sler
DI,
Mou
nirSoli
man
L,
Zak
y S,
Kre
bs
V,
Bull
er
LT,
Don
ohu
e
MC,
Stev
ensLap
sley
JE,
Ilfel
d
BM:
Con
tinu
ous
fem
oral
nerv
e
bloc
ks:
Dec
reas
ing
local
ane
sthe
tic
con
cent
ratio
n to
mini
miz
e
qua
dric
eps
fem
oris
wea
kne
ss.
Anesthe
siology

201
2;
116:
665
72

4. Bro

dner

G,
Bue
rkle
H,
Van
Ake
n
H,
La
mb
ert
R,
Sch
we
ppe
Har
ten
aue
r
ML,
We
mp
e
C,
Go
gart
en
W:
Pos
top
erat
ive
ana
lges
ia
afte
r
kne
e
sur
ger
y: A
co
mp
aris
on
of
thre
e
diff
ere
nt
con
cen
trati
ons
of
ropi
vac
ain
e
for
con
tinu
ous
fem
oral
ner
ve
blo
cka
de.
Ane
sth
Ana
lg
200
7;
105
:25
6
62

5. Jen

stru
p
MT,
Jg
er P,
Lun
d J,
Fom
sga
ard
JS,
Bac
he
S,
Mat
hies
en
O,
Lars
en
TK,
Dahl
JB:
Effe
cts
of
add
ucto
rcan
albloc
kad
e on
pain
and
amb
ulati
on
after
total
kne
e
arthr
opla
sty:
A
rand
omi
zed
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Acta
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esth
esiol
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6. Paul

JE,
Arya
A,
Hurl
burt
L,
Che
ng
J,
Tha
ban
e L,
Tidy
A,
Murt
hy
Y:
Fem
oral
nerv

e
blo
ck
imp
rov
es
ana
lge
sia
out
co
me
s
afte
r
tota
l
kne
e
arth
ropl
ast
y: A
met
aana
lysi
s of
ran
do
miz
ed
cont
roll
ed
trial
s.
Anest

hesiolo
gy

201
0;
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62

7. Lun

d J,
Jen
stru
p
MT,
Jae
ger
P,
Sr
ens
en
AM,
Da
hl
JB:
Co
ntin
uou
s
add
uct
orcan
alblo
cka
de
for
adj
uva
nt
pos
tope
rativ
e
ana
lge

sia
after
maj
or
kne
e
surg
ery:
Preli
min
ary
resu
lts.
Acta
Ana
esth
esiol
Sca
nd
201
1;
55:1
49

8. Sta

ndri
ng
S:
Gra
ys
Ana
tom
y:
The
Ana
tomi
cal
Basi
s of
Clini
cal
Pra
ctic
e.
Edi
nbu
rgh,
Sco
tlan
d,
Else
vier/
Chu
rchil
l
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ngst
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bys
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S,
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MO:
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esth
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201
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pl

1:5
7
66
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11.
Sta
rk
T,
Wal
ker
B,
Phil
lips
JK,
Fej
er
R,
Bec
k R:
Ha
ndhel
d
dyn
am
om
etry
corr
elat
ion
with
the
gol
d
sta
nda
rd
isok
inet
ic
dyn
am
om
etry
: A
syst
em
atic 12.
revi
ew.
PM
R
201
1;
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72
9

Anesth
esiolog
y
2013;11
8:40915

Maf
fiul
etti
NA:
Ass
ess
me
nt
of
hip
and
kne
e
mu
scle
fun
ctio
n in
orth
opa
edi
c
pra
ctic
e
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res
ear
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J
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Am
201
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220
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Roy
MA,
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y
TJ:
Reli
abili
ty
of
han
dhel
d
dyn
am
om
etry
in
ass
ess
me
nt
of
kne
e
ext
ens
or
stre
ngt
h
afte
r
hip
frac
ture
.
Am
J

Ph
ys
Me
d
Re
ha
bil
20
04;
83:
81
3
8

W,
Hs
u
HC
,
Ch
ang
LY,
Ch
en
HL:
En
han
cin
13.
g
Kw
the
oh
exa
CK
m,
ine
Pet
rs
ric
resi
k
stin
MA
g
,
forc
Mu
e
nin
imp
M
rov
C:
es
Int
the
erreli
rat
abil
er
ity
reli
of
abi
ma
lity
nua
for
l
fun
mu
cti
scl
on
e
an
stre
d
ngt
str
h
en
me
gth
asu
me
re
as
me
ure
nts:
me
Co
nts
mp
in
aris
the
on
ac
of a
ute
ne
car
w
e
dev
ho
ice
spi
wit
-tal
h
aft
han
er
dele
hel
ctiv
d
e
dyn
hip
am
an
om
d
etry
kn
. J
ee
Re
art
hab
hro
il
pla
Me
sty.
d
Art
200
hrit
7;
is
39:
Ca
679
re
84
Re
s 15. Lu
19
YM,
97;
Lin
10:
JH,
12
Hsi
8
ao
34
SF,
Liu
14. Lu
MF,
T

16.

Ch
en
SM
,
Lu
e
YJ:
Th
e
rel
ativ
e
an
d
ab
sol
ute
reli
abi
lity
of
leg
mu
scl
e
str
en
gth
tes
tin
g
by
a
ha
nd
hel
d
dy
na
mo
me
ter.
J
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en
gth
Co
nd
Re
s
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11;
25:
10
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71 17.
Rei
nki
ng
MF
,
Bo
ckr
ath
Pu
gli
es
e
K,
Wo
rrel
l T,
Ke
ger
rei
s
RL
,
Mill
erSa
yer

s K,
Far
r J:
Ass
ess
me
nt
of
qua
dric
eps
mu
scle
perfor
ma
nce
by
han
dhel
d,
iso
met
ric,
and
isok
inet
ic
dyn
am
ometry
in
pati
ent
s
with
kne
e
dys
fun
ctio
n. J
Ort
hop
Spo
rts
Phy
s
The
r
199
6;
24:
154
9
Kell
n
BM,
Mc
Keo
n
PO,
Go
ntk
of
LM,
Her
tel
J:
Ha
ndhel
d
dyn
am
om
etry
:
Reli
abili
ty
of
low

er
swe
ext
lling
re
afte
mit
r
y
tota
mu
l
scl
kne
e
e
tes
arth
tin
ropl
g
asty
in
.
he
Arc
alt
h
hy,
Phy
ph
s
ysi
Me
call
d
y
Re
act
hab
ive
il
,
201
yo
0;
un
91:
g
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ad
06
ult 19.
s.
Tho
J
rbor
Sp
g K,
ort
Pet
Re
ers
ha
en
bil
J,
20
Ma
08;
gnu
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sso
16
n
0
SP,
70
Hl
18.
mic
Hol
h P:
m
Clin
B,
ical
Kri
ass
ste
ess
ns
me
en
nt
MT
of
,
hip
Be
stre
nc
ngt
ke
h
J,
usi
Hu
ng
ste
a
d
han
H,
dKe
hel
hle
d
t
dyn
H,
am
Ba
om
nd
eter
hol
is
m
reli
T:
abl
Lo
e.
ss
Sca
of
nd
kn
J
eeMe
ext
d
en
Sci
sio
Spo
n
rts
str
201
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0;
gth
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ate
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d 20.
to
Yeu
kn
ng
ee
TS,

We
F,
ss
Lau
el
ren
J,
za
Str
L,
atf
Foti
ord
C,
P,
Ditu
Ma
nno
cd
JF,
er
Mol
mi
inar
d
i M:
J:
Vali
Rel
dity
iab
and
ility
reli
,
abili
vali
ty
dity
of
,
the
an
10d
m
res
wal
po
k
nsi
test
ve
and
ne
the
ss
6of
min
the
wal
low
k
er
test
ext
in
re
spi
mit
nal
y
cor
fun
d
cinju
tio
ry
nal
pati
sca
ent
le
s.
for
Spi
inp
nal
atie
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nts
d
of
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1;
ort
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hop
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aed
40
ic 22.
reh
Rikl
abil
i
itat
RE:
ion
Rel
wa
iabi
rd.
lity,
J
vali
Ort
dity
ho
,
p
and
Sp
met
ort
hod
s
olo
Ph
gic
ys
al
Th
iss
er
ues
20
in
09;
ass
39:
ess
46
ing
8
phy
77
sic
al
21.
acti
Sci
vity
vol
in
ett
old
o
er
G,
adu
Ta
lts.
mb
Re
ure
s Q
lla

Ex
erc
Sp
ort
20
00;
71
(2
Su
ppl
):S
89

96

23.

N:
Ev
oke
d
teta
nic
tor
que
and
acti
vation
lev
el
exp
lain
stre
ngt
h
diff
ere
nce
s
by
sid
e.
Eur
J
Ap
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Ph
ysi
ol
200
9;
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74

Ostenb
erg
A,
Ro
os
E,
Ek
dah
l C,
Ro
os
H:
Iso
kin
etic
kne
e
ext
ensor
stre
ngt
h 25.
and
Hor
fun
ner
ctio
G,
nal
Dell
on
per
AL:
for
Inn
ma
erv
nce
atio
in
n of
hea
the
lthy
hu
fem
ma
ale
n
soc
kne
e
cer
join
pla
t
yer
and
s.
imp
Sc
licat
and
ion
J
s
Me
for
sur
d
ger
Sci
y.
Sp
Clin
orts
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8;
Rel
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at
Pt
Res
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199
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24.

Apr
(30
1):2
21
6

Kri
sh
na
n
26.
C,
Lan
Wil
g
lia
SA,
ms
Yip
G
RW

,
Ane
Ch
sth
an
199
g
3;
PC
5:2
,
92
Ge
6
rar
d
MA
:
Th
e
fe
mo
ral
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n