Efficacy of Adding Adductor Canal Block to Sciatic Nerve Block in Hallux Valgus Surgery

doi:10.21203/rs.3.rs-4864183/v1

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Efficacy of Adding Adductor Canal Block to Sciatic Nerve Block in Hallux Valgus Surgery

https://doi.org/10.21203/rs.3.rs-4864183/v1

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Background

Optimal postoperative multimodal analgesia strategies were still under investigation in many orthopedic surgeries. The aims of this study were to determine the effects of adding the adductor canal block to the popliteal sciatic nerve block on sedation need, tourniquet pain, postoperative pain, and patient-surgeon satisfaction in patients operated for hallux valgus correction.

Methods

In this prospective, randomized, and controlled clinical trial, group S patients were performed only popliteal sciatic nerve block with 10 ml 0,5% bupivacaine and 10 ml 2% prilocaine in the prone position, group S + A were performed adductor canal block with 10 ml of 0,5% bupivacaine and 10 ml of 2% prilocaine with popliteal sciatic nerve block.

Results

Demographic data, duration of surgery, tourniquet time, surgeon satisfaction, complication rate, motor block time, time to first pain, first analgesic administration time and opioid consumption were similar between the two groups. Sensory and motor block onset time, tourniquet pain and additional sedation need rate were statistically significantly lower and patient satisfaction was significantly higher in Group S + A.

Conclusion

Adding the adductor canal block to the popliteal sciatic nerve block increases the quality of the peripheral nerve block and patient satisfaction with decreasing tourniquet pain and sedation need in hallux valgus correction surgery.

Health sciences/Anatomy

Health sciences/Diseases

Health sciences/Medical research

Regional anesthesia

Sciatic nerve

Femoral nerve

Nerve block

Hallux Valgus

Hallux valgus is one of the most common chronic foot deformities in women, with lateral deviation of the forefoot toe and medial deviation of the first metatarsal (1, 2). Surgical correction is the preferred method in the treatment of this deformity. While it can be performed with local, general or regional anesthesia, regional anesthesia techniques provide excellent analgesia without general anesthesia side effects (3). Regional anesthesia has important advantages such as the patient's wakefulness to be able to express their complaints, preservation of spontaneous breathing and better respiratory reflexes, better perioperative pain management, and early mobilization. By performing the peripheral nerve blocks as part of the regional anesthesia techniques, the duration of hospitalization is shortened, the mobilization time is shortened, and the postoperative complications are also reduced (3, 4).

Popliteal sciatic nerve block (PSNB) provides both motor and sensory block of the leg below the knee, except for the region located medial to the leg and foot that is innervated by the saphenous nerve (5). Saphenous nerve block is recommended in addition to popliteal nerve block in the medial aspect of the foot surgeries and/or using a tourniquet (6). Adductor canal block (ACB) is the blockage of the saphenous nerve in the adductor canal and is predominantly a sensory nerve block (7, 8).

Considering the benefits of ACB in the correction of hallux valgus, which is an operation involving the medial aspect of the foot, it was aimed to investigate the possible effects of adding ACB to PSNB on intraoperative sedation need, tourniquet pain, postoperative pain, period of recovery from the motor block and patient-surgeon satisfaction in this study.

Our study was approved by the XXX Ethics Committee on patients who underwent surgery for hallux valgus deformity (Ethical Committee: Istanbul Medeniyet University Goztepe Education and Research Hospital Ethical Committee; Approval No. 2021/0419.). The study was carried out in accordance with relevant regulations and informed consent was obtained from all participants and/or their legal guardians. Clinical trial number and registry URL: Clinical Trials.gov; Trial registration number: NCT05960422; Date of first trial registration: 17/07/2023, First posted date: 25/07/2023. Written consent was obtained from ASA I-III patients aged between 18 and 80, after providing detailed information about the preoperative peripheral nerve block. Patients with coagulopathy, wounds or infections in the block region, allergies to local anesthetic drugs, significantly impaired peripheral neuropathy and neurogenic disorders affecting the lower extremity, peripheral arterial disease, mental retardation, and patients who did not provide consent were not included in the study. Gender, age, body mass index (BMI), and ASA scores of all patients were recorded. The patients were divided into two groups, the group S (n = 26), and the group S + A (n = 26), by using a computer program for randomization. The hallux valgus deformities of the patients participating in the study were corrected by applying the chevron osteotomy surgical technique by the same surgeon.

In the preoperative preparation room, patients were subjected to standard monitoring including electrocardiography (ECG), peripheral oxygen saturation (SpO₂), and arterial blood pressure measured non-invasively. Mean arterial pressure (MAP), SpO₂, and heart rate (HR) values were recorded at 15-minute intervals. Sedation was achieved using midazolam 1–2 mg and fentanyl 50 µg to maintain a Ramsay Sedation Scale score of 2 before block procedures. Patients with a preoperative SpO₂ value below 92% were planned for oxygen insufflation with a mask at a rate of 2–3 lit/min. Blocks were administered by the same investigator and perioperative data were recorded by another investigator.

For patients undergoing PSNB (Group S) in the prone position, the anode (+) of the nerve stimulator (Plexygon Nerve Stimulator, VYGON, 7501.31, Ecouen, FRANCE) was connected to the ECG electrode placed on the foot. A 21-gauge 100-mm block needle (Vygon Echoplex, Vygon, Ecouen, France) was connected to the cathode (-) pole of the stimulator. The high-frequency linear probe of ultrasound (Samsung Ultrasound H60; Hampshire, Korea) was prepared in a sterile manner. After visualizing the popliteal artery in the popliteal fossa with the probe it was advanced proximally in a horizontal and minimally lateral position to determine the point of separation of the tibia and peroneal nerves. Before the stimulator needle was advanced towards the sciatic nerve with in-plane approach, local anesthesia was injected subcutaneously. While passing through the skin and subcutaneous tissue, the nerve stimulator was opened up to 1 mA. After observing dorsiflexion or plantar flexion of the foot, the stimulator was reduced to 0.3–0.5 mA until disappearing the movement. When making sure that the movement has disappeared at the point where the needle is located, bupivacaine (Bustesin 0.5%, VEM Pharmaceuticals Industry and Trade Ltd.Co., Istanbul, Türkiye) 10 ml and prilocaine (Pricain 0.2%, Polifarma Pharmaceutical JSC. Tekirdag,Türkiye) 10 ml were administered to the target tissue (Fig. 1).

The patients in group S + A were given in supine position with the extremity to be blocked slightly externally rotated. The femoral artery was visualized by advancing the ultrasound probe distally, and the saphenous nerve was identified just lateral to the femoral artery, beneath the sartorius muscle at the anterior part of the thigh. At the junction of the Sartorius muscle and vastus medialis, bupivacaine 0.5% 10 ml and prilocaine 2% 10 ml were applied around the saphenous nerve. Then the popliteal sciatic block as mentioned above was performed (Fig. 2).

The medial, lateral, and sole of the foot were tested with a pinprick test to evaluate the sensory block of the tibial nerve. The anterior of the distal part of the leg and lateral and back of the foot were tested to evaluate the sensory block of the peroneal nerve. Internal malleolus sensation was tested for evaluating the sensory block of the saphenous nerve. The patients with pinprick test 2 were evaluated as successful blocks. Motor block efficiency was evaluated with the Modified Bromage Scale, and the scale below 3 was also considered an unsuccessful block. Modified Bromage Scale and pinprick test were evaluated by the same investigator.

When additional sedation was needed during the intraoperative period it was provided with midazolam 1 mg i.v. and ketamine 50 mg i.v. Postoperative pain control was achieved with 50 mg dexketoprofen. It was planned to give 0.5 mg/kg morphine as rescue analgesic.

Onset times of sensory and motor block, tourniquet and surgery durations, tourniquet pain as numerical rate pain scores (NPRS), and sedation needs were recorded intraoperatively. Motor block return times, the times of first analgesic administration, and the amounts of opioid-NSAID used were recorded postoperatively. Complications such as nausea and vomiting, and local anesthetics toxicity were recorded. Patient-surgeon satisfaction was evaluated with the Likert satisfaction rating scale.

Statistical Analysis

Power analysis was performed using the G*Power (v3.1.9.2) program to determine the number of samples. A pilot study was carried out with 15 people in each group at the beginning of the study. The mean NRPS for pain in the groups was 0.17 for group S + A and 0.80 group S. The effect size was calculated as W = 0.836, and there should be at least 24 people in the groups to achieve 80% power at α = 0.05 level. For statistical analysis, the NCSS (Number Cruncher Statistical System) 2007 software program from Kaysville, Utah, USA was used. Descriptive statistical methods such as mean, standard deviation, median, frequency, percentage, minimum, and maximum were used for data evaluation. The normal distribution of quantitative variables was tested using the Shapiro-Wilk test and graphical examinations. Independent samples t-test was used for the comparison of quantitative variables with a normal distribution between two groups, while the Mann-Whitney U test was used for the comparison of quantitative variables without a normal distribution between two groups. For within-group comparisons of quantitative variables with a normal distribution repeated measures analysis of variance (ANOVA) was performed, and Bonferroni-corrected pairwise comparisons were used for the evaluation of individual comparisons. Friedman test was used for within-group comparisons of quantitative variables without a normal distribution, and Bonferroni-corrected Wilcoxon signed-ranks test was used for evaluating individual comparisons. Pearson chi-square test, Fisher's exact test, and Fisher-Freeman-Halton exact test were employed for comparing qualitative data. Spearman correlation analysis was used for assessing the relationships between quantitative variables. Statistical significance was considered at p < 0.05.

The study was completed with 54 patients, and since the blocks in 2 patients were unsuccessful the statistical analysis was performed with 52 patients. There were no statistically significant differences in terms of gender, age, BMI, and ASA scores between the groups (p > 0.05) (Table 1). There was no statistically significant difference in terms of baseline hemodynamic parameters between the groups (p > 0.05). While the MAP values of the group P + S at 15th min were found to be significantly higher than those of the group S (p = 0.016), there were no statistically significant differences in the other MAP values between the groups (p > 0.05). There were no statistically significant differences in HR values at all times between the groups (p > 0.05). Although the SpO₂ values of group S at 30th, 45th, and 60th min were significantly higher compared with group S + A (p = 0,001, p = 0,001, p = 0,009), these values were not clinically significant.

Table 1

Demographic Data
			Block		p^*
		Total	GROUP S + A	GROUP S	p^*
Gender	Female	40 (76,9)	20 (76,9)	20 (76,9)	^a0,542
Gender	Male	12 (23,1)	6 (23,1)	6 (23,1)
Age	Mean	43,69 ± 16,18	45,77 ± 17,33	41,62 ± 14,99	^b0,234
Age	Median (Min-Max)	38,5 (18–78)	48,5 (18–78)	34 (22–70)
BMI	Mean	25,9 ± 4,74	26,54 ± 5,43	25,27 ± 3,94	^c0,230
BMI	Median (Min-Max)	25,1 (17,2–39,1)	25,9 (17,2–39,1)	24,7 (20,4–38,1)
ASA	I	14 (26,9)	7 (26,9)	7 (26,9)	^d1,000
	II	37 (71,2)	18 (69,2)	19 (73,1)
	III	1 (1,9)	1 (3,8)	0 (0)
^aPearson Chi Square Test, ^bMann Whitney U Test, ^dFisher Freeman Halton Test, ^eFisher’s Exact Test. p^: Evaluation between groups*

The sensory block and motor block onset times of the group S patients were found to be statistically significantly longer compared to those in the group S + A (p = 0,002, p = 0,003). The tourniquet pain scores and rates of additional sedation need were also found to be statistically significantly higher in the group S (p = 0,004, p = 0,020). There were no statistically significant differences between the groups in terms of tourniquet duration, surgical duration, motor block duration, time to first pain sensation (p > 0.05). As for incidence of complication, there were no statistical differences in patients with nausea and vomiting (Table 2). Local anesthetic toxicity has not been seen in any patient.

Table 2

Distribition of data by groups
		BLOCK		P^*
		GROUP S + A	GROUP S	P^*
Sensory block onset time	Meant ± SD	3,58 ± 1,42	5,00 ± 2,23	^b0,002
Sensory block onset time	Median (Min-Max)	3 (2–6)	5 (1–10)
Motor block onset time	Meant ± SD	7,58 ± 2,00	10,04 ± 4,40	^b0,003
Motor block onset time	Median (Min-Max)	7 (5–11)	10 (2–20)
Tourniquet duration (min)	Meant ± SD	55,15 ± 29,6	45,58 ± 20,92	^b0,198
Tourniquet duration (min)	Median (Min-Max)	46 (20–125)	43 (15–93)
Surgery duration (min)	Meant ± SD	64,77 ± 31,57	58,04 ± 21,98	^b0,923
Surgery duration (min)	Median (Min-Max)	55 (30–141)	55 (20–110)
NRPS pain (tourniquet)	Meant ± SD	0,19 ± 0,57	0,88 ± 0,99	^b0,004
NRPS pain (tourniquet)	Median (Min-Max)	0 (0–2)	0 (0–2)
Additional sedation		4 (15,4)	10(38,5)	^a0,020
Motor block duration	Meant ± SD	467,85 ± 113,56	530,92 ± 276,59	^b0,956
Motor block duration	Median (Min-Max)	482 (292–703)	465 (165–1235)
Nausea/Vomiting		3 (11,5)	4 (15,4)	^e1,000
^aPearson Chi Square Test, ^bMann Whitney U Test, ^dFisher Freeman Halton Test, ^eFisher’s Exact Test.

While first dose administration times in pain treatment and choice of first-second analgesic drug were statistically the same between groups (p > 0.05) (Table 3).

Table 3

Distribution of postoperative analgesia outcomes by groups.
		BLOCK		P^*
		GROUP S + A	GROUP S	P^*
Time of first pain	Meant ± SD Median (Min-Max)	611,77 ± 139,99	683 ± 305,99	^b0,596
Time of first pain	Meant ± SD Median (Min-Max)	603,5 (380–877)	642 (180–1422)	^b0,596
Time of first dose administration	Meant ± SD	683,33 ± 142,25	669,48 ± 215,49	^c0,807
Time of first dose administration	Median (Min-Max)	675 (400–907)	675 (217–1051)	^c0,807
1.Dose Drugs	None	5 (19,2)	5 (19,2)	^d0,641
	Morphine	0 (0)	2 (7,7)
	NSAID	21 (80,8)	19 (73,1)
2. Dose Drugs	None	13 (61,9)	7 (33,3)	^d0,083
	Morphine	0 (0)	1 (4,8)
	NSAID	7 (33,3)	13 (61,9)
	Morphine + NSAID	1 (4,8)	0 (0)
^cStudent T Test, ^dFisher Freeman Halton Test. p^: Evaluation between groups*

Patient satisfaction was found to be significantly higher in the group S + A compared to the group S (p = 0,009). However, no statistically significant difference was detected in surgeon satisfaction between the groups (p > 0.05) (Table 4).

Table 4

Distribution of patient and surgeon satisfaction by groups.
		Block		P^*
		GROUP S + A	GROUP S	P^*
Patient satisfaction	Medium	2 (7,7)	0 (0)	^d0,009
	Good	4 (15,4)	13 (50,0)
	Great	20 (76,9)	13 (50,0)
Surgeon satisfaction	Medium	0 (0)	1 (3,8)	^d1,000
	Good	3 (11,5)	3 (11,5)
	Great	23 (88,5)	22 (84,6)
^dFisher Freeman Halton Test. p^: Evaluation between groups*

Peripheral nerve blocks are increasingly being preferred in patients undergoing orthopedic procedures to reduce postoperative pain and opioid consumption. While the popliteal sciatic nerve block is suitable for anesthesia and analgesia in foot surgery, a more proximal block is required for surgeries on the posterior aspect of the foot and medial ankle with the tourniquet applied distal to the thigh. In ACB, the strength of the quadriceps muscle is largely preserved by staying distal to the efferent branches of the quadriceps muscle and affecting the two largest sensory branches of the femoral nerve, the saphenous nerve, and the vastus medialis, as well as the branches of the obturator nerve that innervate the joint (9). Chen et al. (6) presented two cases for demonstrating the applicability of proximal saphenous nerve block (ACB) in foot and ankle surgery despite the absence of a medial incision. The saphenous nerve innervates the distal tibial periosteum, medial and ventral capsules of the ankle joint, and in some cases, the medial aspect of the talocalcaneonavicular joint, indicating the important role of ACB in patients undergoing ankle surgery. Considering all these factors, the addition of ACB to PSNB may become an appropriate technique for hallux valgus correction surgery.

As in previous studies, it was expected that there would be more female patients in this study (1). The absence of differences in demographic data and baseline hemodynamic parameters may suggest the homogeneity of our study groups. The higher MAP values at the 15th minute in the group S + A compared to the group that received only PSNB can be attributed to the increased anxiety resulting from the two separate interventions performed in the group S + A.

Inadequate postoperative pain management is known to reduce patient satisfaction and function, as well as delay hospital discharge and rehabilitation (10). In a study conducted by Li et al. (11) comparing the control group with the group S performed with ropivacaine 0.5% 20 ml in patients operated for calcaneus fracture surgery, they found that the time to first analgesic administration (15.57 hours) was longer, the duration of patient-controlled analgesia use was shorter, and the number of weight-bearing steps was lesser in group S. The reason for the earlier onset of pain, unlike the study of Li et al., may be the use of long-acting drug bupivacaine in a lower volume in our study. In a study comparing the addition of femoral nerve block (FNB) or ACB to PSNB in patients operated for lower limb surgery, Sertcakacılar et al. (12) found that the motor block duration was 10.84 hours and the sensory block recovery time was 8.44 hours in the group S + A. The motor block duration in the group S + A was measured 7.79 ± 1.89 hours, and the time to first pain sensation was recorded as 10.19 ± 2.33 hours. In a study by Fanelli et al. (13) comparing equal volume of ropivacaine 0.75%, bupivacaine 0.5%, and mepivacaine 2% for sciatic and femoral nerve blockade together for hallux valgus repair surgery with tourniquet, they found the motor block duration of 788 minutes and an analgesic duration of 880 minutes in bupivacaine group. In a study by Dabir et al. (14), the onset time of anesthetic effect in the group receiving peripheral nerve block was determined as 11.83 ± 2.45 minutes. The times found in these studies were similar to the times we found. In the study by Migues et al. (15), the block formation time was 8.6 ± 5 minutes for ankle block and 10.48 ± 6 minutes for PSNB without statistically significant and the block formation time was recorded as 10.04 ± 4.40 minutes in our study. The pain scores were similar at 6, 12, 18, and 24 hours, and the average analgesic duration was 10.96 ± 7.56 hours for the ankle block group and 14.32 ± 7.73 hours for the group S in the study. The time from block administration to the first analgesic application in the group S was recorded as 11.92 ± 6.46 hours. While the time of the first analgesic application was similar in both groups, the time of the second analgesic application needed more in the group S. However, the amount of drug administered as a second dose of analgesic was found similar in both groups. In our study, after the block procedures, the patients in the group S + A had first pain after 10,18 ± 2.3 hours, while it was 11,38 ± 5 hours in the group S, but it was not statistically significant. Besides the frequency of second-dose analgesic use, 61.9% of patients in the group S + A and 33.3% of patients in the group S did not receive analgesics and the addition of ACB reduced analgesic consumption.

While popliteal sciatic nerve block provides sufficient anesthesia and analgesia for foot surgery, we believe that ACB is highly beneficial for patients who undergo thigh-level tourniquet application during the surgery. While pneumatic tourniquet usage is preferred during below-knee orthopedic surgery to provide a bloodless surgical field and reduce intraoperative blood loss, it is associated with certain side effects. Pain and discomfort in the tourniquet area during regional anesthesia is a common complication of tourniquet application. Patients may experience a localized progressive dull or burning pain in the tourniquet area (16). It has been shown that the source of tourniquet pain is ischemia of the compressed nerves and compression of the tissues under the tourniquet (17). To alleviate discomfort related to the tourniquet, we believe that ACB is appropriate because proximal ACB at the mid-thigh level may affect the saphenous nerve and several other sensory nerves that innervate the anterior surface of the knee and the proximal tibia (18). While the average tourniquet duration was similar between groups, the group S had higher tourniquet pain scores in our study and this result may cause high patient satisfaction scores and lower pain scores in the group S + A. In the study by Li et al. (11) patient, surgeon, and nurse satisfaction were better in patients in the group S compared to the control group.

On the other hand; in a study by Joe et al. (19) that included patients undergoing foot and ankle surgery with PSNB + FNB and PSNB + ACB blocks, they found no significant difference in VAS scores, while quadriceps muscle strength was preserved mostly in the ACB group; additional analgesic use, patient satisfaction, surgical and recovery times were similar in both groups.

Migues et al. (15) found that the success rate was 92.5% in the ankle block and 96% in the PSNB and our success rate of PSNB was 96.29% similar to this study. Tsai et al. (20), performed subsartorial saphenous nerve block and sciatic nerve block in lower extremity surgery and found that the success rate of all blocks was 77%. Two failures occurred in the blocks applied to the patients during our study.

In a study conducted by Tian et al. (21) the most common side effect in both groups was nausea (13%), and there was no difference in side effects between the FNB + PSNB group and local infiltration analgesia (LIA) group performed in the patients operated for total knee arthroplasty. Similarly, Sehmbi et al.²¹ examined ACB with placebo or FNB and they reported that there were similar results in postoperative nausea and vomiting risk, antiemetic use, or postoperative sedation in groups. There was no difference in nausea and vomiting between the groups in our study.

There were some limitations in this study. Since nerves can be reached from different regions in the group S + A, the patients of this group underwent two separate invasive procedures. Because the observation period was limited to 24 hours postoperatively, we could not assess the longer effects of the applied blocks. The dosage adjustments could not be done for local anesthetics according to their weight, and a standard medication regimen was used for all patients. However the average BMI levels were similar between groups.

In conclusion, based on our observations, adding ACB to PSNB block in patients undergoing hallux valgus surgery has shown beneficial effects; it shortens the onset of motor and sensory block, reduces tourniquet pain, increases patient satisfaction, and reduces the need for sedation. Therefore, we conclude that adding ACB to the PSNB block is advantageous in patients undergoing hallux valgus surgery.

Acknowledgement

The authors acknowledge Alper Gulluoglu M.D., Seyit Ibrahim Solcan M.D. and Ayda Turkoz M.D. for preparing this manuscript and providing language help.

Conflict of interest

The authors declare no conflicts of interest.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

Research data declarations:

Data is provided within the supplementary information files.

The use of AI and AI-assisted technologies in scientific writing

The authors declare that they did not use AI and AI-assisted technologies in the writing process.

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No competing interests reported.

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Efficacy of Adding Adductor Canal Block to Sciatic Nerve Block in Hallux Valgus Surgery

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