The document discusses the anatomy and innervation of the knee joint as it relates to total knee arthroplasty (TKA) pain management. It notes that adopting an adductor canal block (ACB) approach instead of a femoral nerve block (FNB) can help maintain quadriceps strength during physical therapy recovery. The document also emphasizes including regional anesthesia as part of a multimodal postoperative pain management plan for TKA. A better understanding of the anatomy of the ACB provides an opportunity to supplement the traditional FNB approach.

2. Conclusion
• The change from FNB to ACB and the maintenance of
quadriceps strength have the potential to affect
physical therapy outcomes in a massive way.
• There is no question that the “recipe” for TKA
multimodal analgesia should include regional
Anesthesia as part postoperative pain management
plan.
• Better understanding of anatomy of the ACB gives it a
better chance as supplementary to the CALDonian
approach.

5. • The search for the perfect regional analgesic regimen for
TKA patients continued....
• selective local anesthetic that can preferentially
anesthetize sensory nerves while sparing motor
nerves......
• How can an injection of local anesthetic into
the adductor canal by itself possibly provide
enough analgesia for TKA?

6. Anatomy of knee joint

9. Innervation of the knee

13. Medial parpatellar arthrotomy( most common) will evoke
pain thro three terminal nerves:
• 1- infra patellar branch of saphenous nerve.
• 2-medial ratinacular nerve( terminal branch of
nerve to vastus medialis)
• 3-anterior branch of medial femoral cutaneous
nerve.

14. Anatomy of femoral
nerve

16. Adductor canal block
The canal is roughly triangular in cross section
and is bounded by three muscles:
1- quadriceps anterolaterally (specifically
vastusmedialis),
2-sartorius medially and
3-adductor longus & magnus posteriorly.

34. • Recent research defined the contribution of the infra
patellar , medial ratinacular nerve and medial femoral
cutaneous nerve to post TKR Pain with the medial
parapatellar arthrotomy.
• The paralysis from involvement of medial vastal nerve
in the femoral triangle( which extends down to the
middle of the thigh) to some extent , can be spared by
blocking the saphenous nerve in adductor canal
proper .
• Femoral nerve block at any level doesn't alleviate
pain driving from popliteal nerve branches and
obturator nerve innervating the the intraarticular parts .

35. Enhanced recovery for lower limb
arthroplasty
improving
preoperative
care
nursessurgeons
reducing the
physical stress of
the operation
physiotherapistsanaesthetist
decreasing
postoperative
discomfort
improved postoperative
mobility and earlier
supported discharge

37. • Patient selection
• Preoperative preparation.
• Patient selection.

38. Choice of anaesthetic
• Regional vs GA?

40. Postoperative analgesia
Local infiltration

43. Conclusion
• The change from FNB to ACB and the maintenance of
quadriceps strength have the potential to affect
physical therapy outcomes in a massive way.
• There is no question that the “recipe” for TKA
multimodal analgesia should include regional
Anesthesia as part postoperative pain management
plan.
• Better understanding of anatomy of the ACB gives it a
better chance as supplementary to the CALDonian
approach.