FEMORAL NERVE BLOCK VERSUS ADDUCTOR CANAL BLOCK FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN PEDIATRIC AND ADOLESCENT PATIENTS

Orlando D. Sabbag; Heath P. Melugin; Brian T. Samuelsen; Nancy M. Cummings; Diane L. Dahm; Bruce A. Levy; Aaron J. Krych; Michael J. Stuart; Todd A. Milbrandt

摘要

Background Adductor canal block (ACB) is an alternative method to femoral nerve block (FNB) for post-operative analgesia for anterior cruciate ligament reconstruction (ACLR) in pediatric and adolescent patients. Prior studies have suggested that FNB is associated with persistent strength deficits at 6 months after ACLR in this population. Proponents of the ACB consider that this method may result in a decreased incidence of quadriceps strength deficits during post-operative rehabilitation. The purpose of this study was to compare knee strength and function at 6 and 9 months after ACLR in pediatric and adolescent patients who received FNB versus ACB peri-operatively. Methods Patients 18 years or younger who underwent primary ACLR between 2002 and 2017 at a single institution were identified. ACLR was performed with either a patellar tendon autograft or hamstring autograft. A transphyseal ACLR was performed in patients with open physes. All patients participated in a comprehensive rehabilitation program which included isokinetic strength testing and functional testing at 6 and/or 9 months postoperatively. Patients were excluded if they underwent multiligamentous knee reconstruction, concomitant cartilage restoration procedures, did not receive perioperative FNB or ACB, or if they did not complete isokinetic strength and functional testing at 6 or 9 months. The included cohort was separated into FNB group and ACB group for comparison. Isokinetic extension and flexion strength deficits and functional deficits in vertical jump, single hop, and triple hop between the two groups were compared at both time points. A strength deficit of 15% or less and a functional deficit of 10% or less compared to the contralateral side were considered satisfactory. Univariate analysis was performed to assess for differences in patient demographics and surgical variables. A 1:1 matched subgroup analysis between the two groups was performed to account for possible differences in outcomes associated to graft types, concomitant meniscus repair, and BMI. Results Of the 240 patients identified, 85 patients (64 FNB, 21 ACB) with a mean age of 15.9 years (Range: 11-18) met inclusion criteria for comparison at 6 months and 76 patients (40 FNB, 36 ACB) with a mean age of 15.5 years (Range: 12-17) met inclusion criteria for comparison at 9 months. Univariate analysis showed significantly greater deficits at 6 months in the FNB with respect to fast isokinetic flexion strength (7.7% vs. -4.9%; p = .03). There were no differences in slow isokinetic flexion (10.5% vs. 6.8%; p = .79) and fast isokinetic extension (11.9% vs. 13.9%; p = .68) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (19.3% vs. 12.0%; p = .24), but this did not reach statistical significance. This clinical difference in satisfactory scores between the groups with respect to slow isokinetic extension was accentuated with the 1:1 matched outcome trial (23.9% vs. 12.1%; p = .20). With respect to function, there were no differences in deficits for vertical jump (8.4% vs. 4.3%; p = .55), single hop (7.4% vs. 9.3%; p = .65), or triple hop (6.0% vs. 7.1%; p = .77) between the two groups. Univariate analysis showed significant greater deficits at 9 months in the FNB with respect to slow isokinetic flexion strength (9.6% vs. 0.4%; p = .01). There were no differences in fast isokinetic flexion (-0.2% vs. 0.7%; p = .87) and fast isokinetic extension (6.0% vs. 2.7%; p = .51) strength deficits between the groups. There were clinically relevant greater deficits in the FNB group with respect to slow isokinetic extension (17.3% vs -14.0%, p = .19), but this did not reach statistical significance. With respect to function, there were no differences in deficits for vertical jump (5.2% vs. 6.5%, p = .85), single hop (7.7% vs. 6.2%; p = .79), or triple hop (1.9% vs. 3.9%; p = .35) between the two groups. Conclusion Because previous studies have shown a significant delay in return of strength with FNB, ACB began to be employed at our center for post-operative pain control following ACLR in pediatric and adolescent patients. This study showed that pediatric and adolescent patients treated with FNB as a method of post-operative analgesia after ACLR had significantly greater deficits in fast isokinetic flexion at 6 months and slow isokinetic flexion at 9 months compared to those who received ACB. These differences may or may not have clear clinical relevance. However, patients treated with FNB showed clinically relevant greater deficits in slow isokinetic extension strength at 6 and 9 months postoperatively compared to those who received ACB if 85% strength return is used as criteria to return to sport. Pediatric and adolescent patients could benefit from undergoing perioperative analgesia with ACB instead of FNB, but comparison between these two methods of regional anesthesia may require a prospective

机译：背景引言管阻滞（ACB）是股神经阻滞（FNB）替代方法，用于小儿和青少年患者的前交叉韧带重建（ACLR）术后镇痛。先前的研究表明，FNB与该人群ACLR后6个月持续的力量不足有关。 ACB的支持者认为，这种方法可能导致术后康复过程中股四头肌力量不足的发生率降低。这项研究的目的是比较围手术期接受FNB与ACB的儿童和青少年患者ACLR后6个月和9个月的膝盖力量和功能。方法确定2002年至2017年间在单一机构接受过原发性ACLR的18岁以下的患者。 ACLR用tend腱自体移植或auto绳肌自体移植进行。开放性植检患者经phy骨ACLR。所有患者均参加了全面的康复计划，其中包括术后6个月和/或9个月的等速肌力测试和功能测试。如果患者进行了多韧带膝关节重建，伴随的软骨修复程序，未接受围手术期FNB或ACB或在6或9个月未完成等速肌力和功能测试，则将其排除在外。将纳入的队列分为FNB组和ACB组进行比较。在两个时间点比较了两组之间的垂直跳，单跳和三跳等速运动的伸肌和屈肌力量缺陷和功能缺陷。与对侧相比，强度不足15％或更少，功能不足10％或更少。进行单因素分析以评估患者人口统计学和手术变量的差异。两组之间进行了1：1匹配的亚组分析，以解释与移植物类型，伴随的半月板修复和BMI相关的结局可能存在的差异。结果在确定的240例患者中，85例（64 FNB，21 ACB）的平均年龄为15.9岁（范围：11-18岁）符合纳入标准，进行了6个月的比较，76例（40 FNB，36 ACB）符合纳入标准。平均年龄为15.5岁（范围：12-17岁），符合纳入标准，可在9个月时进行比较。单变量分析显示，FNB在6个月时的快速等速屈曲强度明显更大（7.7％vs -4.9％; p = .03）。两组之间的慢速等速屈曲（10.5％vs. 6.8％; p = .79）和快速等速屈伸（11.9％vs. 13.9％; p = 0.68）没有差异。 FNB组在慢速等速运动方面存在临床相关的更大缺陷（19.3％比12.0％; p = 0.24），但这没有统计学意义。在1：1等比结局试验中，两组在慢速等速运动扩展方面令人满意的评分之间的临床差异得到了加强（23.9％对12.1％; p = 0.20）。在功能方面，垂直跳跃（8.4％vs. 4.3％; p = .55），单跳（7.4％vs. 9.3％; p = .65）或三跳（6.0％）的赤字没有差异。两组之间的差异为7.1％; p = 0.77）。单变量分析显示，在9个月时，FNB的慢速等速屈曲强度明显更大（9.6％vs. 0.4％; p = 0.01）。两组之间的快速等速屈曲（-0.2％vs. 0.7％; p = .87）和快速等速屈伸（6.0％vs. 2.7％; p = .51）没有差异。 FNB组在慢速等速运动方面存在临床相关的更大缺陷（17.3％对-14.0％，p = .19），但这没有统计学意义。在功能方面，垂直跳跃（5.2％vs. 6.5％，p = .85），单跳（7.7％vs. 6.2％; p = .79）或三跳（1.9％）的赤字没有差异。两组之间的差异为3.9％; p = 0.35）。结论由于以前的研究表明FNB的力量恢复明显延迟，因此ACB开始在我们的中心用于小儿和青少年患者ACLR术后疼痛的控制。这项研究表明，与接受ACB的患者相比，接受ACLR术后FNB作为手术后镇痛方法的儿童和青少年患者在6个月时快速等速屈曲和9个月时缓慢等速屈曲的缺陷明显更大。这些差异可能或可能不具有明确的临床相关性。但是，与使用ACB的患者相比，如果将85％的力量恢复作为恢复运动的标准，则接受FNB治疗的患者在术后6个月和9个月时，在慢速等速运动时的力量表现出与临床相关的更大缺陷。小儿和青少年患者可以从围手术期使用ACB代替FNB进行镇痛，但是这两种局部麻醉方法的比较可能需要前瞻性

FEMORAL NERVE BLOCK VERSUS ADDUCTOR CANAL BLOCK FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION IN PEDIATRIC AND ADOLESCENT PATIENTS

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