Anesthesiology, V 120 No 3 540 March 2014

O
PTIMAL pain relief is essential for functional recovery after
total knee arthroplasty (TKA).
1
Addition of femoral nerve
block (FNB) to an analgesic regimen provides superior pain con-
trol
2,3
and shortens hospital stay,
4
in comparison with epidural or
intravenous patient-controlled analgesia (PCA) alone.
1,5,6
How-
ever, prolonged motor blockade from FNB is associated with
a small (2%) but clinically important risk of fall.
7,8
With FNB
there will always be a compromise between the goals of adequate
pain relief and muscle strength. An ideal nerve block would pro-
vide eective analgesia, minimize opioid use and side eects, and
hasten mobilization by preserving motor strength. Fast-track
total joint replacements are gaining popularity. Motor preserva-
tion with adequate analgesia has become the optimal postopera-
tive pain goal in orthopedic surgeries to enable earlier physical
therapy, faster recovery, and shorter hospital stays.
With the advent of ultrasonography, the adductor canal can
be easily visualized at the mid-thigh level, allowing performance
of adductor canal block (ACB) with a high success rate.
9,10
In
recent years, ACB has been successfully used for postoperative
pain control after knee surgery.
9,11
Anatomical study of the
What We Already Know about This Topic
Despite the improved analgesia and shortened hospital stays
provided by the use of femoral nerve blockade after total knee
arthroplasty, these blocks can cause signifcant motor weak-
ness, delaying mobilization and increasing the risk of falls
What This Article Tells Us That Is New
The results of this randomized, blinded trial suggest that ad-
ductor canal block results in less motor impairment after sur-
gery, but provides a comparable level of pain relief
Copyright 2014, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins. Anesthesiology 2014; 120:540-50
ABSTRACT
Background: Tis prospective double-blinded, randomized controlled trial compared adductor canal block (ACB) with femo-
ral nerve block (FNB) in patients undergoing total knee arthroplasty. Te authors hypothesized that ACB, compared with
FNB, would exhibit less quadriceps weakness and demonstrate noninferior pain score and opioid consumption at 6 to 8 h
postanesthesia.
Methods: Patients received an ACB or FNB as a component of a multimodal analgesic. Quadriceps strength, pain score, and
opioid consumption were assessed on both legs preoperatively and at 6 to 8, 24, and 48 h postanesthesia administration. In a
joint hypothesis test, noninferiority was rst evaluated on the primary outcomes of strength, pain score, and opioid consump-
tion at 6 to 8 h; superiority on each outcome at 6 to 8 h was then assessed only if noninferiority was established.
Results: Forty-six patients received ACB; 47 patients received FNB. At 6 to 8 h postanesthesia, ACB patients had signicantly
higher median dynamometer readings versus FNB patients (median [interquartile range], 6.1 kgf [3.5, 10.9] (ACB) vs. 0 kgf
[0.0, 3.9] (FNB); P < 0.0001), but was not inferior to FNB with regard to Numeric Rating Scale pain scores (1.0 [0.0, 3.5]
ACB vs. 0.0 [0.0, 1.0] FNB; P = 0.019), or to opioid consumption (32.2 [22.4, 47.5] ACB vs. 26.6 [19.6, 49.0]; P = 0.0115).
At 24 and 48 h postanesthesia, there was no signicant statistical dierence in dynamometer results, pain scores, or opioid use
between the two groups.
Conclusion: At 6 to 8 h postanesthesia, the ACB, compared with the FNB, exhibited early relative sparing of quadriceps
strength and was not inferior in both providing analgesia or opioid intake. (ANESTHESIOLOGY 2014; 120:540-50)
This article is featured in This Month in Anesthesiology, page 1A. Corresponding article on page 530.
Presented in part at the American Society of Regional Anesthesia Annual Meeting, San Diego, California, March 1518, 2012. Submitted for
publication January 10, 2013. Accepted for publication September 30, 2013. From the Department of Anesthesiology, Hospital for Special Sur-
gery, New York, New York (D.H.K., Y.L., E.A.G., R.L.K., D.B.M., A.K.G., and J.T.Y.); Department of Anesthesiology and Critical Care Medicine,
The Johns Hopkins University, Baltimore, Maryland (A.M.); Department of Anesthesiology, Weill-Cornell Medical Center, New York, New
York (M.L.P.); and Department of Epidemiology and Biostatistics Core, Hospital for Special Surgery, New York, New York (Y.-y.L. and Y.M.).
Presented in part at the American Society of Regional Anesthesia Annual Meeting, San Diego, CA, March 1518, 2012.
Adductor Canal Block versus Femoral Nerve Block for
Total Knee Arthroplasty
A Prospective, Randomized, Controlled Trial
David H. Kim, M.D., Yi Lin, M.D., Ph.D., Enrique A. Goytizolo, M.D., Richard L. Kahn, M.D.,
Daniel B. Maalouf, M.D., M.P.H., Asha Manohar, M.D., Minda L. Patt, M.D.,
Amanda K. Goon, B.A., Yuo-yu Lee, M.S., Yan Ma, Ph.D., Jacques T. YaDeau, M.D., Ph.D.
PERIOPERATIVE MEDICINE
Anesthesiology 2014; 120:540-50 541 Kim et al.
PERIOPERATIVE MEDICINE
adductor canal demonstrated that the adductor canal may serve
as a conduit for more than just the saphenous nerve, possibly
including the vastus medialis nerve, medial femoral cutaneous
nerve, articular branches from the obturator nerve, as well as
the medial retinacular nerve.
1012
Tus, the sensory changes are
not limited to the distribution of the saphenous nerve,
13
but
includes the medial and anterior aspects of the knee from the
superior pole of the patella to the proximal tibia.
Tere has not been a randomized control study comparing
ACB with FNB after TKA. Tis prospective, double-blinded,
randomized, controlled study tested the hypothesis that ACB
would be associated with less quadriceps motor weakness than
FNB and provide analgesia that is not inferior as determined
by Numeric Rating Scale (NRS) pain scores and opioid use.
Using a joint hypothesis test with three primary outcomes,
we hypothesize that the ACB is superior in strength but not
inferior in pain score and opioid use at 6 to 8 h postanesthesia.
Materials and Methods
Tis study was approved by the Institutional Review Board
of Hospital for Special Surgery, New York, New York. Te
study was registered with ClinicalTrials.gov, Identier
NCT01333943. All patients gave informed written consent.
Ninety-four patients scheduled to undergo elective TKA
were enrolled in the presurgical area by an anesthesiologist.
Tey were assigned to either ACB or FNB (1:1 allocation,
parallel trial design), based on a computer-generated ran-
domization list created by an independent researcher. Group
assignment was concealed via opaque envelopes that were
opened only after enrollment. Eligibility criteria included
elective unilateral TKA, planned combined spinal epidural
anesthetic, age 18 to 90 yr, ability to follow study proto-
col, and American Society of Anesthesiologists class 1 to 3.
Exclusion criteria included contraindication for neuraxial
anesthetic, chronic opioid use (dened as daily or almost
daily use of opioids for >3 months), hypersensitivity and/
or allergies to local anesthetics, intraoperative use of volatile
anesthetics, preexisting neuropathy on the operative limb,
contraindications to a femoral or ACB, allergy to any of the
study medications, aged younger than 18 or older than 90
yr, and American Society of Anesthesiologists class 4 or 5.
A research assistant recorded baseline patient demographics
and medical history in the presurgical area. Patients were then
placed supine with a cushion underneath their knee, resulting
in a 45-degree angle at the knee. Quadriceps strength of both
legs was assessed by placing the dynamometer on the anterior
of the ankle, between the malleoli. Patients were instructed to
extend their legs three times each, with a 30-s pause between
each attempt (Lafayette Manual Muscle Test System; Lafay-
ette Instrument Company, Lafayette, IN; as described by
Mauletti
14
). After each attempt, patients rated their pain
using NRS. Te patients quadriceps were also assessed by a
neurologic exam, based on a 12-point scale as described by
Bohannon.
15
Sensory function along the distribution of the
saphenous nerve (medial side of leg above the ankle) was
assessed by pinprick and temperature discrimination using
the jagged edges of a broken tongue depressor and an alcohol
swab in comparison with the nonoperative side.
Patients were randomized to receive either an ACB or
FNB. Te anesthesiologist performing the block was aware of
the treatment, but the patient and the research assistant were
blinded to group assignment. An ultrasound-guided ACB
(15 cc of 0.5% of bupivacaine with 5 g/ml epinephrine,
via a 21-gauge 4-inch Stimuplex A needle; B. Braun Medical
Inc., Melsungen, Germany) was performed at mid-thigh level
using a high-frequency linear ultrasound transducer (1012
Hz; SonoSite Turbo; SonoSite Inc., Bothell, WA), as described
by Manickam.
10
Ultrasound-guided FNB (30 cc of 0.25% of
bupivacaine with 5 g/ml epinephrine, via a 22-gauge 2-inch
Stimuplex A needle; B. Braun Medical Inc.) with nerve stim-
ulator conrmation were performed below the inguinal liga-
ment. Te type of motor response (e.g., quadriceps, patellar)
and the minimum current needed were recorded. Ultrasound
pictures (preinjection and postinjection) were obtained to
verify proper local anesthetic placement.
All patients received a standardized anesthetic and anal-
gesic. Preoperative oral meloxicam (7.5 or 15 mg based on
age; 7.5 mg was given to patients >74 yr) and dexamethasone
(6 mg) were given in the holding area. Patients were sedated
with intravenously administered midazolam and propofol
before performance of the nerve block and epidural placement
(opioids and ketamine were not used). Combined spinal epi-
dural anesthesia was administered, with 2.5 cc of 0.5% bupi-
vacaine as the spinal agent. Epidural local anesthetic, if needed,
consisted of 2% lidocaine. Ondansetron (4 mg IV) was given
during the operation. Intraoperative data included total time
to perform the block (starting from needle insertion to exit),
surgery time, tourniquet pressure, and total tourniquet time.
Oral postoperative pain medications were oxycodone/
acetaminophen (5/325 mg q 4 h as needed) and daily meloxi-
cam (7.5 or 15 mg based on age; 7.5 mg was given to patients
>74 yr). Epidural PCA (10 g/ml hydromorphone, 0.06%
bupivacaine) was used for postoperative days (PODs) 0 to
2. Initial settings were 4 ml/h of continuous infusion, 4-ml
bolus on demand every 10 min as needed, maximum total of
20 ml/h. At 7 AM the following day (POD 1), the continu-
ous infusion was lowered to 2 ml/h, and at 5 PM on POD
1 the continuous infusion was set to 0. At noon on POD
2, the epidural was discontinued. Additional postoperative
antiemetics were metoclopramide (10 mg IV every 6 h as
needed), and/or ondansetron (4 mg IV every 8 h as needed).
At the discretion of the acute pain service, patients oral regi-
mens were tailored to address the patients pain needs.
Quadriceps motor strength, as well as sensory exam (leg
pinprick and temperature discrimination) was assessed for
both legs at 6 to 8, 24, and 48 h after anesthesia administra-
tion. Te 6 to 8 h assessment was done in the postanesthesia
care unit, whereas the 24- and 48-h assessments were done
in the inpatient unit. Block success was veried by testing
for pinprick sensation in the saphenous nerve distribution.
Anesthesiology 2014; 120:540-50 542 Kim et al.
Adductor Canal Block versus Femoral Nerve Block for TKA
Physical therapists dangled patients (i.e., placed in sit-
ting position with legs on the side of the bed) on POD 0
regardless of block status and patient readiness to ambu-
late. On POD 1 and afterward, patients were assessed and
encouraged to ambulate with assistance.
Noninferior analgesia was assessed by measuring both
NRS pain scores and opioid consumption, data collected
included: (1) NRS pain scores (determined by patient inter-
view, using the standard NRS of 0 to 10, at 6 to 8, 24, and
48 h); and (2) total morphine consumption (converting oral,
intravenous, and epidural opioid to morphine equivalent on
PODs 0, 1, and 2). To strengthen the claim that the ACB
was noninferior in analgesia to the FNB, we decided to con-
duct a joint hypothesis test using both pain score and opioid
consumption as primary outcomes.
Additional data collected included: (1) patient satisfac-
tion (patient interviewed, using a scale of 010, 10 being the
most satised, at 68 and 24 h); (2) postoperative nausea and
vomiting (present or absent, determined by patient interview
at 68, 24, and 48 h); (3) pruritis, (present or absent, deter-
mined by patient interview at 68, 24, and 48 h); (4) inci-
dence of complications (if any), including falls, neurologic
symptoms, and local anesthetic toxicity; (5) length of hospital
stay (days); (6) success of blinding (by asking patients before
discharge which treatment they thought they had received.
Statistical Analysis
Standardized dierence was calculated to compare patient
demographics and baseline characteristics including age,
sex, race, American Society of Anesthesiologists, length of
hospital stay, and body mass index between ACB and FNB.
An absolute dierence greater than 0.2 was considered to be
clinically important.
16,17
To reduce the chance of confound-
ing, the clinically important variables were adjusted in mul-
tiple regression analysis.
Te primary outcomes included quadriceps muscle
strength as measured by dynamometer reading, NRS pain
scores, and total opioid consumption. We hypothesized that
ACB would be preferred if (1) ACB was noninferior to FNB
on all primary outcomes and (2) ACB was superior to FNB at
least on quadriceps muscle strength. Terefore we conducted
a joint hypothesis testing as described by Mascha and Turan.
18
A two-step sequential testing procedure
18
was followed
for the joint hypothesis testing of (1) and (2), both at 6 to
8 h postanesthesia administration. First, noninferiority was
assessed on each individual outcome. Specically, the follow-
ing noninferiority was dened for ACB as compared with
FNB: (1) the mean dynamometer readings not less than 3 kgf
(equivalent to a clinically relevant dierence of 20% points as
described in Ilfeld et al.
19
) lower than FNB (2) the mean NRS
pain score not more than 1.6 higher than FNB,
20
and (3) the
mean opioid consumption not more than 50% greater than
FNB.
2
Second, we evaluated the superiority on each outcome
if noninferiority was conrmed on all outcomes. Noninferior-
ity hypotheses were evaluated against a one-sided signicance
criterion of 0.025 and superiority hypotheses were evaluated
against a one-sided signicance criterion of 0.008 (adjusting
for the three outcomes, 0.025/3 = 0.008). In addition to the
joint hypothesis testing, all primary outcomes were also com-
pared between ACB and FNB at each specic time (baseline,
68 h after anesthesia administration, and at PODs 1 and 2).
Te HolmBonferroni stepdown procedure
21
was used to
control the familywise error rate.
Te primary outcomes were further studied using mul-
tiple regression based on the generalized estimating equation
(GEE) method,
22,23
adjusting for any clinically important
dierences that were identied in the baseline variables. In
addition, an interaction eect between treatment group and
time was also incorporated in the regression analysis. Treat-
ment eect was further assessed at each time point if the
interaction eect was signicant. For each primary outcome,
data collected at baseline (no baseline opioid consumption),
6 to 8, 24, and 48 h postanesthesia were included in the
GEE analysis. To reect the observed correlation structure
between repeated measurements, an autoregressive(1) cor-
relation matrix was considered in GEE. Te autoregressive
correlation structure assumes that measurements closer in
time have a higher correlation than those that are further
apart.
22
Te GEE method is able to take into account cor-
relations between repeated measures and does not require a
particular distribution for data, leading to robust parameter
estimation.
Secondary outcomes included side eects (nausea, vomit-
ing) and patient satisfaction. Chi-square test or Fisher exact
test was performed to compare the incidence of side eects.
Patient satisfaction was analyzed using t test or nonparamet-
ric alternative according to the distribution of the data.
We powered the study to detect a 50% dierence in
motor strength as measured by the dynamometer at postan-
esthesia care unit between the ACB and FNB groups. Tis
was the dierence found from an earlier pilot study (unpub-
lished data: Te unpublished data were a pilot study done
by David Kim, M.D., New York, New York, primarily to
estimate the number of patients needed for the study. It was
done in August 2010 at the Hospital for Special Surgery. By
looking at 10 patients who underwent a total knee replace-
ment under either saphenous nerve block or a FNB (non-
randomized, ve patients in each group), motor strength
estimates were extrapolated. Quadriceps strength was mea-
sured at 68 h after the block. From the pilot study, it was
estimated that the FNB group would result in at least 50%
decrease in motor strength in comparison with the saphe-
nous nerve block.). Te mean (61.3 N) and SD (30 N) of
dynamometer readings for the FNB group from the pilot
study served as reference values for the power analysis. On
the basis of a type I error rate of 5% and a power of 80%,
and taking into account potential protocol violations and
dropouts, we set the target sample size at 47 per group.
All analyses used an intention-to-treat approach, in
which patients were evaluated in the groups to which they
Anesthesiology 2014; 120:540-50 543 Kim et al.
PERIOPERATIVE MEDICINE
were originally randomly assigned, regardless of the treat-
ment they actually received. SAS version 9.3 (SAS Institute,
Cary, NC) was used for all analyses.
Results
Patients were enrolled from March 2011 to November
2011. Patient recruitment and ow through the protocol are
described in the CONSORT (Consolidated Standards Of
Reporting Trials) diagram. Of the 94 patients enrolled, one
patient was excluded for inappropriate enrollment (g. 1).
Te patient had a profound preexisting neurological condi-
tion (signicant quadriceps weakness and numbness at base-
line) and should not have been enrolled. Four patients were
noted to have failed blocks (i.e., no loss of sensation in the
saphenous distribution). Success rates for the ACB and FNB
were 93.6 and 97.9%, respectively. Tree patients did not
have an epidural PCA postoperatively (1 intrathecal cath-
eter, 2 spinals only) but an intravenous PCA. Four patients
withdrew from the study on POD 0 or 1, but all available
data were included in the intention-to-treat analysis. Tree
patients were not assessed by the research assistant at either
the postanesthesia care unit, PODs 1 and/or 2 time points,
but all other available data were included in the intention-
to-treat analysis. After the exclusion, 46 patients received
ACB; 47 patients received FNB. Baseline values were similar
between the two groups (table 1), with the exception of the
age group between 60 to 70 yr, Asian race, and obese class I
(body mass index between 30 to 35).
A joint hypothesis test was performed using all three
outcomes as primary (table 2) at the endpoint of 6 to 8 h
postanesthesia. All outcomes were found to be noninferior.
Specically, the lower condence limit of dynamometer read-
ings was greater than the delta (P < 0.0001); the upper con-
dence limits of NRS pain scores and opioid use were less
than their respective deltas (NRS pain scores, P = 0.019; opi-
oid use, P = 0.012). Terefore the ACB was found to not be
weaker than the FNB or have higher pain scores or more opi-
oid use. Next, we conducted a superiority test and found only
the dynamometer readings for the ACB to be superior to the
readings for the FNB (dierence ACB-FNB kgf [98.3% CI],
5.2 [2.77.7]; P < 0.0001). Terefore, the joint hypothesis
test demonstrates that the ACB is superior to the FNB with
regard to strength and not inferior with regard to pain score
and opioid consumption at 6 to 8 h postanesthesia.
We further compared dynamometer readings, NRS pain
score, and opioid use between groups at each specic time.
At 6 to 8 h postanesthesia, mean strength during extension
of the knee from a starting position of 45-degree exion was
signicantly higher for the ACB versus the FNB (table 3,
dierence ACB-FNB kgf [95% CI], 5.2 [3.17.2]; P <
0.0001). At 24 and 48 h, the ACB and FNB groups were not
statistically signicantly dierent with a P value of 0.9999 at
Fig. 1. CONSORT (Consolidated Standards Of Reporting Trials) diagram. Flow of patients through the protocol.
Assessed for eligibility
(n = 231)
Randomized (n = 94)
Excluded (n = 137)
Did not meet inclusion criteria (n = 82)
Declined to participate (n = 55)
FEMORAL NERVE BLOCK
Allocated to intervention (n = 47)
ADDUCTOR CANAL BLOCK
Allocated to intervention (n = 47)
Analyzed (n = 47)
Analyzed (n = 46)
Excluded from analysis
Known neuropathy (n = 1)
Anesthesiology 2014; 120:540-50 544 Kim et al.
Adductor Canal Block versus Femoral Nerve Block for TKA
Table 1. Demographics
ACB FNB
Standardized Difference N = 46 N = 47
Status, N (%) 0.111
Included in per-protocol
analysis
40 (87.0) 39 (83.0)
Excluded 6 (13.0) 8 (17.0)
Age, mean SD 68.0 9.4 67.6 11.3 0.043
Age, N (%)
Age group 1: age 50 3 (6.5) 4 (8.5) 0.075
Age group 2: 50 < age 60 6 (13.0) 8 (17.0) 0.111
Age group 3: 60 < age 70 20 (43.5) 14 (29.8) 0.287
Age group 4: 70 < age 80 13 (28.3) 16 (34.0) 0.125
Age group 5: 80 < age 4 (8.7) 5 (10.6) 0.066
Sex, N (%) 0.193
Male 22 (47.8) 18 (38.3)
Female 24 (52.2) 29 (61.7)
Race, N (%)
Asian 0 1 (2.1) 0.209
Black 3 (6.5) 5 (10.6) 0.147
Hispanic 2 (4.3) 1 (2.1) 0.126
White 40 (87.0) 39 (83.0) 0.111
Other/unknown 1 (2.2) 1 (2.1) 0.003
ASA, N (%)
1 2 (4.3) 3 (6.4) 0.09
2 38 (82.6) 36 (76.6) 0.15
3 6 (13.0) 8 (17.0) 0.111
Hospital stay, mean SD 3.7 0.8 3.6 0.8 0.07
BMI, mean SD 29.9 6.4 30.3 5.8 0.072
BMI, N (%)
Normal: 18.5 < BMI < 25 13 (28.3) 10 (21.3) 0.162
Overweight: 25 BMI < 30 17 (37.0) 16 (34.0) 0.061
Obese class I: 30 BMI < 35 5 (10.9) 9 (19.1) 0.233
Obese class II: 35 BMI < 40 6 (13.0) 9 (19.1) 0.167
Obese class III: 40 BMI 5 (10.9) 3 (6.4) 0.16
A standardized difference >0.2 is considered to be clinically important.
ACB = adductor canal block; ASA = American Society of Anesthesiologists; BMI = body mass index; FNB = femoral nerve block.
Table 2. Joint Hypothesis Testing for Outcomes at Postanesthesia 68 h
Outcome at
Postanesthesia
68 h
ACB FNB
Noninferiority One-tailed Test Superiority One-tailed Test
Difference Difference
N = 46 N = 47
ACB-FNB
(95% CI)* Delta P Value
ACB-FNB
(98.3% CI)
P Value
(HolmBonferroni)
Dynamometer
readings
7.3 5.4 2.2 3.8
6.1 [3.5, 10.9] 0.0 [0.0, 3.9] 5.2 (3.1, 7.2) 3 <0.0001 5.2 (2.7, 7.7) <0.0001
NRS pain scores
at rest
1.7 1.9 0.9 1.8
1.0 [0.0, 3.5] 0.0 [0.0, 1.0] 0.75 (0.06, 1.55) 1.6 0.019 0.75 (0.24, 1.74) 0.9999
Opioids (oral opi-
oids + PCA)
36.6 17.9 35.8 20.7
32.2 [22.4, 47.5] 26.6 [19.6, 49.0] 1.05 (0.83, 1.32) 1.5 0.0115 1.05 (0.79, 1.39) 0.9999
Results presented as mean SD, median [frst, third quartiles]. Overall alpha is 0.025 for both noninferiority and superiority tests. Noninferiority was found
on all three outcomes with the given deltas (P < 0.025) and superiority on dynamometer readings (P < 0.008).
* Noninferiority test is signifcant for dynamometer readings (NRS, opioids) if the lower (upper) confdence limit is greater (less) than delta. Superiority test
is signifcant for dynamometer readings (NRS) if lower (upper) confdence limit is greater (less) than zero; superiority test is signifcant for opioids use if the
upper confdence limit is <1. Ratio of ACB/FNB.
ACB = adductor canal block; FNB = femoral nerve block; NRS = Numeric Rating Scale; PCA = patient-controlled analgesia.
Anesthesiology 2014; 120:540-50 545 Kim et al.
PERIOPERATIVE MEDICINE
each time point. Strength was not statistically signicantly
dierent between groups on the nonoperative leg through-
out all time measurements (e.g., preoperative, 68, 24, and
48 h). Of note, the operative knees of three patients in the
FNB group buckled during their physical therapy session
on POD 1. No patients in the ACB buckled.
When comparing the NRS pain scores at rest between
groups (table 4), it was found that the ACB group was not
inferior to the FNB group at 6 to 8 h postanesthesia (dier-
ence: ACB-FNB [95% CI], 0.7 [0.1 to 1.55]; P = 0.0190).
At 24 and 48 h, there were no statistically signicant dif-
ference between groups, noninferiority P = 0.0103 and
P = 0.0005, respectively. Te upper limits of the CIs at all
time measurements were less than the delta of 1.6, suggesting
that ACB was not inferior to FNB with regard to the NRS
pain scores at rest throughout the rst 48 h.
Te ACB group had a cumulative opioid intake that
was not inferior to the FNB group at 6 to 8 h postanesthe-
sia (table 5, ratio: ACB/FNB [95% CI], 1.05 [0.81.3];
P = 0.0029). Similarly, ACB was not inferior to FNB with regard
to opioid use throughout the rst 48 h (noninferiority P value of
0.0115, and 0.0029 at 24 and 48 h, respectively). Te upper CI
limits at all times were less than the delta of 1.5. All patients ana-
lyzed had a bupivacaine/hydromorphone epidural PCA or an
intravenous hydromorphone PCA (n = 3), which was discontin-
ued on POD 2. Even after the patient-controlled epidural anal-
gesia was discontinued on POD 2, there was no dierence in
oral consumption between the two groups by discharge (g. 2).
Table 3. Dynamometer Readings over Time
Time of Follow-up
ACB FNB
Difference:
ACB-FNB (95% CI)
Test of Equal
Medians:
P Value
(HolmBonferroni)* N = 46 N = 47
Operative leg
Preoperative, kgf 15.6 8.5 14.8 8.2 0.8 (2.7 to 4.2) 0.9999
12.3 [9.6, 20.2] 11.6 [8.3, 20.1]
Postanesthesia 68 h, kgf 7.3 5.4 2.2 3.8 5.2 (3.17.2) <0.0001
6.1 [3.5, 10.9] 0.0 [0.0, 3.9]
Postanesthesia 24 h, kgf 3.9 4.2 4.0 4.0 0.1 (1.9 to 1.6) 0.9999
3.5 [1.1, 4.4] 2.8 [1.1, 6.8]
Postanesthesia 48 h, kgf 2.2 2.9 2.8 3.2 0.6 (1.9 to 0.7) 0.9999
1.8 [0.0, 3.3] 1.7 [0.0, 4.1]
Nonoperative leg
Preoperative, kgf 18.5 9.1 18.3 9.2 0.2 (3.6 to 4.0) 0.9999
16.7 [11.6, 24.4] 16.9 [10.7, 27.4]
Postanesthesia 68 h, kgf 15.8 7.6 16.2 10.3 0.4 (4.4 to 3.6) 0.9999
14.4 [9.9, 21.3] 13.9 [8.1, 25.4]
Postanesthesia 24 h, kgf 16.7 7.4 17.8 9.0 1.1 (4.6 to 2.5) 0.9999
15.7 [10.2, 22.6] 16.9 [10.1, 25.4]
Postanesthesia 48 h, kgf 16.7 7.8 18.5 11.8 1.8 (6.2 to 2.6) 0.9999
15.1 [12.0, 22.0] 16.4 [9.2, 26.3]
Results presented as mean SD, median [frst, third quartiles].
* HolmBonferroni adjusted P < 0.05 is considered statistically signifcant.
ACB = adductor canal block; FNB = femoral nerve block; kgf = kilogram-force unit.
Table 4. NRS Pain Scores at Rest over Time
Time of Follow-up
ACB FNB
Difference:
ACB-FNB (95% CI)
Noninferiority
One-tailed
Test*: P Value
(HolmBonferroni) N = 46 N = 47
Preoperative 3.0 3.2 3.4 3.1 0.3 (1.7 to 1.0) 0.0075
2.0 [0.0, 6.0] 3.0 [0.0, 5.0]
Postanesthesia 68 h 1.7 1.9 0.9 1.8 0.7 (0.1 to 1.55) 0.0190
1.0 [0.0, 3.5] 0.0 [0.0, 1.0]
Postanesthesia 24 h 3.1 2.3 2.8 2.3 0.3 (0.7 to 1.3) 0.0103
3.0 [1.5, 5.0] 3.0 [1.0, 4.0]
Postanesthesia 48 h 4.3 2.2 4.8 3.0 0.6 (1.7 to 0.6) 0.0005
4.0 [3.0, 6.0] 4.8 [3.0, 7.3]
Results presented as mean SD, median [frst, third quartiles]. HolmBonferroni adjusted P < 0.025 is considered statistically signifcant.
* Delta = 1.6 for the noninferiority test.
ACB = adductor canal block; FNB = femoral nerve block; NRS = Numeric Rating Scale.
Anesthesiology 2014; 120:540-50 546 Kim et al.
Adductor Canal Block versus Femoral Nerve Block for TKA
Table 6 summarized the results from regression analysis
using GEE approach for each outcome. In all GEE analy-
ses, the clinically important variables shown in table 1 were
included to adjust for potential confounding eects.
Signicant treatment by time interaction eect was
found for dynamometer readings (P < 0.0001). We then
further compared the treatment eect at each specic time.
Te ACB group was found to have signicant higher motor
strength at postanesthesia 6 to 8 h (P < 0.0001). Among
the adjusted covariates, older age groups (i.e., 5060, 60
70, 7080) were found to have signicantly higher dyna-
mometer motor strength readings than the youngest age
group (age <50, P = 0.0093, P = 0.0014, and P = 0.0002).
Male patients demonstrated greater dynamometer motor
strength than females (P = 0.0264). Compared with White,
Hispanics were associated with signicant higher motor
strength (P = 0.011), while Other patients (unknown ethnic-
ity) were associated with signicantly lower motor strength
(P = 0.015). Nonoperative legs had signicantly higher
motor strength than operative legs (P < 0.0001).
No signicant interaction eect between time and treat-
ment was found for NRS pain scores and opioids use. Tere-
fore, ACB and FNB had similar eects on NRS and opioids
use over time. Specically, compared with baseline both
groups had signicantly lower NRS at 6 to 8 h postanesthe-
sia (P < 0.001), and higher NRS at 48 h (P = 0.0005). Both
groups had signicantly higher opioids use at postanesthesia
24 and 48 h compared with baseline (24 h, P < 0.0001; 48 h,
P < 0.0001). In addition, older patients (age 7080 yr, >80
yr) had signicantly lower opioids use compared with those
Table 5. Opioid Use (Oral Opioids + PCA)
Time of Follow-up
ACB FNB
Ratio: ACB/FNB
(95% CI)
Noninferiority
One-tailed Test*: P Value
(HolmBonferroni) N = 46 N = 47
Postanesthesia 68 h 36.6 17.9 35.8 20.7 1.05 (0.81.3) 0.0029
32.2 [22.4, 47.5] 26.6 [19.6, 49.0]
Postanesthesia 24 h 50.3 30.8 50.4 33.1 1.03 (0.71.4) 0.0115
46.8 [30.0, 60.6] 40.2 [29.7, 70.5]
Postanesthesia 48 h 60.7 32.3 62.8 39.1 0.95 (0.71.3) 0.0029
62.4 [41.0, 76.2] 57.8 [35.0, 77.4]
Results presented as mean SD, median [frst, third quartiles]. HolmBonferroni adjusted P < 0.025 is considered statistically signifcant.
* Delta = 1.5 for the noninferiority test.
ACB = adductor canal block; FNB = femoral nerve block; PCA = patient-controlled analgesia.
Fig. 2. Total opioid use over time. The plus sign represents the femoral nerve block group and the triangle represents the ad-
ductor canal block group.
Anesthesiology 2014; 120:540-50 547 Kim et al.
PERIOPERATIVE MEDICINE
younger than 50 yr of age (age 7080 yr: P = 0.048; age >80
yr: 0.0331).
Other postoperative outcomes were measured in the
study (table 7). Tere were no signicant dierences in the
incidence of nausea and vomiting, pruritus, satisfaction, and
length of stay (3.7 0.8 days, ACB vs. 3.6 0.8 days, FNB,
P = 0.7346). Tere were no complications noted/reported to
the Institutional Review Board. Tough three patients with
a FNB buckled, none of the patients fell. Tere was no local
anesthetic toxicity or neurologic complications.
Blinding was successful (table 8). Bang Blinding Index
24

was 0.08 for ACB, and 0 for FNB (table 8 for percentages).
Discussion
Tis prospective study demonstrated that the ACB is an eec-
tive alternative to the FNB for patients undergoing TKA.
Te ACB exhibited signicant sparing of the quadriceps
strength at 6 to 8 h and was not inferior to the FNB regard-
ing pain scores and opioid consumption.
Several studies validated the ACB as an eective analgesic
method, but most studied arthroscopic knee surgery.
2
Tis
study compared ACB with FNB in patients undergoing
TKA, a more painful procedure that requires optimal pain
relief to hasten mobilization. Jenstrup et al.
25
demonstrated
eectiveness of the ACB on pain and ambulation after TKA,
compared with placebo. Strength was not objectively mea-
sured and the study involved a high dose of local anesthetic
(30 ml of 0.75% ropivacaine, 225 mg). Tis large dose of
local anesthetic could cause quadriceps weakness from proxi-
mal spread. Te current study used a lower dose of anesthetic
(75 mg bupivacaine) and directly compared ACB with FNB.
At 6 to 8 h postanesthesia, median strength for ACB
patients was reduced compared with baseline. One expla-
nation could be blockade of the nerve going to the vastus
Table 6. The Estimated Covariate-adjusted Treatment Effects and Differences between Treatments from the Regression Analysis
Based on GEE
Covariates Coeffcient Estimate (95% CI) P Value
Dynamometer readings
Difference in dynamometer readings between ACB and FNB at each time point:
Preoperative 0.33 (3.14 to 3.79) 0.7689
Postanesthesia 68 h 4.91 (1.798.03) <0.0001
Postanesthesia 24 h 0.24 (2.46 to 1.98) 0.7356
Postanesthesia 48 h 0.17 (2.67 to 2.34) 0.8345
Nonoperative leg 0.35 (0.290.42) <0.0001
50 < age 60 vs. age 50 2.18 (0.543.82) 0.0093
60 < age 70 vs. age 50 3.13 (1.215.05) 0.0014
70 < age 80 vs. age 50 3.18 (1.494.86) 0.0002
80 < age vs. age 50 1.77 (0.40 to 3.93) 0.1099
Male vs. female 1.05 (0.121.98) 0.0264
Asian vs. White 0.60 (1.78 to 0.58) 0.3160
Black vs. White 0.50 (1.61 to 0.61) 0.3748
Hispanic vs. White 4.36 (0.997.72) 0.0112
Others vs. White 1.95 (3.51 to 0.39) 0.0145
Overall NRS pain scores at rest
Postanesthesia 68 h vs. preoperative 1.89 (2.66 to 1.12) <0.0001
Postanesthesia 24 h vs. preoperative 0.23 (0.96 to 0.51) 0.5500
Postanesthesia 48 h vs. preoperative 1.36 (0.602.12) 0.0005
ACB vs. FNB 0.08 (0.56 to 0.71) 0.8144
50 < age 60 vs. age 50 0.27 (1.75 to 1.21) 0.7208
60 < age 70 vs. age 50 1.07 (2.45 to 0.30) 0.1267
70 < age 80 vs. age 50 0.58 (1.99 to 0.84) 0.4238
80 < age vs. age 50 0.27 (2.31 to 1.77) 0.7964
Overall opioids (oral opioids + PCA)
Postanesthesia 24 h vs. preoperative 14.11 (8.5519.68) <0.0001
Postanesthesia 48 h vs. preoperative 25.56 (19.0232.09) <0.0001
ACB vs. FNB 0.35 (9.69 to 8.99) 0.9415
50 < age 60 vs. age 50 20.72 (52.75 to 11.30) 0.2047
60 < age 70 vs. age 50 25.46 (54.85 to 3.93) 0.0896
70 < age 80 vs. age 50 29.68 (59.12 to 0.24) 0.0482
80 < age vs. age 50 33.31 (63.94 to 2.68) 0.0331
P < 0.05 is considered signifcant.
ACB = adductor canal block; FNB = femoral nerve block; GEE = generalized estimating equations; NRS = Numeric Rating Scale; PCA = patient-controlled
analgesia.
Anesthesiology 2014; 120:540-50 548 Kim et al.
Adductor Canal Block versus Femoral Nerve Block for TKA
medialis. Alternatively, pain could limit forceful extension of
the leg. Eects of surgery and tourniquet use on quadriceps
strength also deserve consideration.
It is interesting to note that as the block wore o, ACB
group median quadriceps strength diminished from 6.1 kgf
(68 h) to 3.5 kgf (24 h). In contrast, FNB group median
quadriceps strength improved as the FNB wore o, rising
from 0 kgf (68 h) to 2.8 kgf (24 h), supporting the idea that
pain limited ACB group strength at 24 h but muscle weak-
ness limited FNB group strength at 6 to 8 h. At 24 and 48 h,
both ACB and FNB groups had quadriceps weakness that
was probably not due to the block, based on the expected
duration of a bupivacaine nerve block. Tis quadriceps weak-
ness was not caused by the epidural, as demonstrated by pre-
served strength on the nonoperative leg. It seems more likely
that the decreased quadriceps strength was due to either pain
or surgical factors, including the use of a tourniquet.
Te primary outcome was measured by determining
the patients ability to actively extend the knee while it was
passively exed at 45 degrees, with the patient supine dur-
ing the assessment. It is presumed that improved strength
facilitates progress through physical therapy, but it has not
been shown that the relative preservation of motor strength
by ACB correlated with improved ability to ambulate. At
our institution, physical therapists do not routinely assess
ambulation on POD 0, but limit the session to dangling and
standing. On POD 1, patients are encouraged to ambulate
with assistance. Future studies could investigate the relation-
ship between improved early quadriceps strength and time
of achievement of physical therapy milestones.
No falls were noted in this study. However, three patients
in the FNB group were noted to buckle due to quadriceps
weakness on POD 1. No patients in the ACB group were
noted to be weak on POD 1. However, given the small sample
size of this study (n = 94), it would be dicult to assess fall risk
reduction. Other secondary outcomes like nausea and vomit-
ing, pruritus, patient satisfaction, length of stay, and complica-
tions showed no signicant dierence. Tis can be attributed
to the ACB providing analgesia that is no dierent than that of
FNB, thus limiting the known side eects of opioid use (e.g.,
nausea, pruritus). Patients were blinded successfully, which
further strengthens the argument that the ACB provided
adequate analgesia to blind the patients regarding which block
was performed. However, the successful pain relief can also be
attributed in part to the postoperative use of an epidural PCA
and further studies could limit the use of an epidural (i.e., no
continuous infusion) or use an intravenous PCA.
Tough we powered the study using a 50% dierence
in motor strength between the two groups, we performed a
power analysis for NRS pain score and opioid consumption
at 6 to 8 h. A dierence of 1.6 and an increase of 50% (ACB
vs. FNB) were considered clinically signicant for NRS pain
score and opioid consumption, respectively. With the given
sample size (n = 46 for ACB and n = 47 for FNB), we were
able to detect clinical signicance with a power of 98.4 and
97.9% for pain score and opioid consumption, respectively.
Te sample size, however, was underpowered to detect sig-
nicant dierence in the complications, for example, falls,
neuropraxia, and nausea and vomiting.
A major concern among practitioners is whether an ACB
provides enough sensory coverage for a TKA. It is important
to note that the ACB performed at the level of the mid-
thigh involves not only the saphenous nerve but several
Table 8. Blinding
Guessed
ACB
Guessed
FNB
Do Not
Know
Total
Assessed N (%) N (%) N (%)
ACB 9 (24) 6 (16) 22 (60) 37
FNB 10 (27) 10 (27) 17 (46) 37
ACB = adductor canal block; FNB = femoral nerve block.
Table 7. Side Effects and Patient Satisfaction
Time of Follow-up
ACB
N = 46
N (%)
FNB
N = 47
N (%)
P Value
(HolmBonferroni)
Nausea or vomiting Postanesthesia 628 h 2 (4.5) 5 (11.1) 0.9999
Postanesthesia 24 h 15 (35.7) 16 (35.6) 0.9999
Postanesthesia 48 h 13 (29.6) 11 (23.9) 0.9999
Pruritis Postanesthesia 68 h 6 (14.3) 7 (15.6) 0.9999
Postanesthesia 24 h 22 (52.4) 19 (42.2) 0.9999
Postanesthesia 48 h 19 (43.2) 15 (33.3) 0.9999
Patient satisfaction Postanesthesia 68 h 9.8 0.6 9.6 0.9 0.6439
10.0 [10.0, 10.0] 10.0 [10.0, 10.0]
Postanesthesia 24 h 8.8 1.9 9.1 1.7 0.5041
10.0 [8.0, 10.0] 10.0 [8.5, 10.0]
Hospital stay 3.7 0.8 3.6 0.8 0.7346
3.5 [3.0, 4.0] 4 [3.0, 4.0]
Results presented as frequency (percentage) for discrete outcomes and mean SD, median [frst, third quartiles] for continuous outcomes. HolmBonfer-
roni adjusted P < 0.05 is considered statistically signifcant.
ACB = adductor canal block; FNB = femoral nerve block.
Anesthesiology 2014; 120:540-50 549 Kim et al.
PERIOPERATIVE MEDICINE
other sensory nerves that innervate the medial, lateral, and
anterior aspects of the knee, encompassing the superior pole
of the patella to the proximal tibia. Te ACB groups NRS
pain scores and opioid consumption demonstrate that it is
not inferior to the FNB. However, it should be noted that
the epidural PCA may have confounded the NRS and opi-
oid consumption results. Tere was no control (no block)
group because it is the standard at our institution to provide
a regional block and epidural for postoperative pain manage-
ment. Nevertheless, future studies may want to either have
a control (no block) group, or have all patients receive an
intravenous PCA for postoperative pain control.
Opioid consumption was no dierent in both groups.
Te incidence of postoperative nausea and vomiting was low
in both groups. Tis is most likely due to the prophylac-
tic administration of dexamethasone and ondansetron, as
well as the avoidance of intraoperative opioids and volatile
agents. However, the eective postoperative blockade of
both groups minimized the use of oral opioids and thus lim-
ited their notable side eects of nausea and vomiting.
Tere are several limitations to the study. Te duration of
analgesia from the ACB block is unclear and was not mea-
sured. Other studies have addressed this issue by placing
peripheral nerve catheters. Future studies may want to investi-
gate the use of additives such as clonidine and dexamethasone.
By prolonging a mostly sensory block, theoretically, patients
will ambulate quicker and be discharged sooner. Tough our
study conrms the ACB to be an eective alternative to the
FNB, other future studies may want to compare the ACB
with the FNB on the same patient, by performing both blocks
for bilateral knee arthroplasty. Also, a large follow-up study is
needed to investigate whether ACB improves rehabilitation,
incidence of falls, and/or length of hospital stay.
Tus, the ACB provides adequate analgesia but signi-
cantly spares motor strength in comparison with the FNB.
As expected, patients pain scores incrementally increased as
both blocks receded and patients epidurals were weaned, as
observed on POD 1 and 2. Teoretically, the ACB should
hasten mobilization and facilitate rehabilitation, preventing
notable complications from immobilization, such as deep
vein thrombosis and pulmonary emboli, and possibly short-
ening hospital length of stay.
Acknowledgments
The authors thank Dorothy Marcello, B.A., Department of
Anesthesiology, Hospital for Special Surgery, New York,
New York, for assistance with patient enrollment and data
entry.
Study funded by the Hospital for Special Surgery Anes-
thesiology Department (New York, New York)Research
and Education Fund. The Agency for Healthcare Research
and Quality (Rockville, Maryland) grant R01HS021734 sup-
ported Dr. Mas research.
Competing Interests
The authors declare no competing interests.
Correspondence
Address correspondence to Dr. Kim: Department of Anes-
thesiology, Hospital for Special Surgery, 535 East 70th Street,
New York, New York 10021. kimd@hss.edu. This article may
be accessed for personal use at no charge through the Jour-
nal Web site, www.anesthesiology.org.
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ANESTHESIOLOGY REFLECTIONS FROM THE WOOD LIBRARY-MUSEUM
Dr. Paul Woods Academy of Anesthesiology Active Membership
Certifcate
On Ether Days Eve, October 15, 1958, Dr. Paul M. Wood received Active Membership Certicate No. 21 (above)
from The Academy of Anesthesiology. Founded by Mayo Clinics John S. Lundy, M.D., in 1929, as the Anaesthetists
Travel Club, this organization of leading North American anesthesiologists met annually to update each other on
advances in the art and science of anesthesiology. The Travel Club was resurrected, after a brief wartime lapse, as
The Academy of Anesthesiology in 1952. The Academy continues today with active membership limited to 75
anesthesiologists. (Copyright the American Society of Anesthesiologists, Inc.)
George S. Bause, M.D., M.P.H., Honorary Curator, ASAs Wood Library-Museum of Anesthesiology, Park Ridge,
Illinois, and Clinical Associate Professor, Case Western Reserve University, Cleveland, Ohio. UJYC@aol.com.