Regional Nerve Blocks for Primary Total Knee Arthroplasty in Chronic Opioid Patients

Abstract

Postoperative pain control after total knee arthroplasty (TKA) remains challenging, particularly in patients utilizing chronic opioids preoperatively. Our study aimed to evaluate the effect of regional nerve blockade on perioperative pain control outcomes after TKA in patients using or not using chronic preoperative opioids. A retrospective review of our institutional database identified 434 chronic opioid patients defined as documented ongoing use greater than 3 months prior to contemporary TKA. Patients were 1:1 matched to nonopioid users based upon age, sex, body mass index, and regional block type (single-shot adductor canal block [ACB, 29%], 3-day ACB catheter [31%], or no block [41%]). All patients underwent primary TKA using periarticular injections and contemporary multimodal pain management. Immediate and 90-day postoperative outcomes, including Knee Osteoarthritis Outcome Score, Junior (KOOS, Jr), were compared via univariate analysis among the matched cohort and regional block type among chronic opioid patients. Chronic opioid patients demonstrated higher inpatient opioid use than controls (90 vs. 65 oral morphine equivalents [OMEs], respectively, p < 0.01), but no significant differences existed in length of stay (LOS), discharge pain scores, 90-day readmission or KOOS, Jr (all p ≥ 0.05). When comparing chronic opioid patients according to block type, those receiving no block had the highest LOS (1.6 days, p < 0.01), discharge pain score (5.0, p < 0.01), and inpatient opioid use (80 OMEs, p < 0.01) compared with either ACB. The subgroup receiving an ACB catheter demonstrated a significantly higher 90-day readmission rate (9%, p < 0.05). Patients utilizing chronic opioids preoperatively require more opioids in the immediate postoperative period after TKA compared with nonopioid users despite contemporary modalities. Nonetheless, the use of any type of ACB provides improved pain control in these patients.

Keywords

adductor canal block - regional nerve block catheter - chronic opioid user - total knee replacement - multimodal analgesia

Note

Investigation performed at the Mayo Clinic, Jacksonville, Florida.

Publication History

Received: 30 March 2025

Accepted: 30 July 2025

Accepted Manuscript online:
30 July 2025

Article published online:
12 August 2025

• References

• 1 Brander VA, Stulberg SD, Adams AD. et al. Predicting total knee replacement pain: a prospective, observational study. Clin Orthop Relat Res 2003; (416) 27-36
• 2 Chalmers BP, Puri S, Chiu YF. et al. Patients undergoing primary, cementless TKA had similar pain, opioid utilization, and functional outcomes compared to matched patients with cemented fixation. J Arthroplasty 2023; 38 (10) 2131-2136
• 3 Lewis GN, Rice DA, McNair PJ, Kluger M. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesth 2015; 114 (04) 551-561
• 4 Young PF, Roberts C, Shi GG. et al. Total knee arthroplasty with and without schedule II opioids: a randomized, double-blinded, placebo-controlled trial. Cureus 2024; 16 (03) e56150
• 5 Wilke BK, Foster DT, Roberts CA. et al. Early in-hospital pain control is a stronger predictor for patients requiring a refill of narcotic pain medication compared to the amount of narcotics given at discharge. J Arthroplasty 2019; 34 (07) 1354-1358
• 6 Sing DC, Barry JJ, Cheah JW, Vail TP, Hansen EN. Long-acting opioid use independently predicts perioperative complication in total joint arthroplasty. J Arthroplasty 2016; 31 (09) 170-174.e1
• 7 Kim K, Chen K, Anoushiravani AA, Roof M, Long WJ, Schwarzkopf R. Preoperative chronic opioid use and its effects on total knee arthroplasty outcomes. J Knee Surg 2020; 33 (03) 306-313
• 8 Alsheikh KA, Alkhelaifi AS, Alharbi MK. et al. Adductor canal blockade versus continuous epidural analgesia after total knee joint replacement: a retrospective cohort study. Saudi J Anaesth 2020; 14 (01) 38-43
• 9 Smith RL, Doyle R. Femoral nerve block vs adductor canal block for total knee arthroplasty. Br J Hosp Med (Lond) 2018; 79 (03) 178
• 10 Yue DB, Wang BL, Liu KP, Guo WS. Efficacy of multimodal cocktail periarticular injection with or without steroid in total knee arthroplasty. Chin Med J (Engl) 2013; 126 (20) 3851-3855
• 11 Fillingham YA, Hannon CP, Austin MS. et al; AAHKS Anesthesia & Analgesia Clinical Practice Guideline Workgroup. Regional nerve blocks in primary total knee arthroplasty: the Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37 (09) 1691-1696
• 12 Pagan DN, Hernandez VH, Reddy GB, D'Apuzzo MR. Chronic opioid use independently increases complications and resource utilization after primary total joint arthroplasty. J Arthroplasty 2023; 38 (06) 1004-1009
• 13 Chan EY, Fransen M, Sathappan S, Chua NH, Chan YH, Chua N. Comparing the analgesia effects of single-injection and continuous femoral nerve blocks with patient controlled analgesia after total knee arthroplasty. J Arthroplasty 2013; 28 (04) 608-613
• 14 Bedard NA, Pugely AJ, Westermann RW, Duchman KR, Glass NA, Callaghan JJ. Opioid use after total knee arthroplasty: trends and risk factors for prolonged use. J Arthroplasty 2017; 32 (08) 2390-2394
• 15 Dong CC, Dong SL, He FC. Comparison of adductor canal block and femoral nerve block for postoperative pain in total knee arthroplasty: a systematic review and meta-analysis. Medicine (Baltimore) 2016; 95 (12) e2983
• 16 Kuang MJ, Ma JX, Fu L, He WW, Zhao J, Ma XL. Is adductor canal block better than femoral nerve block in primary total knee arthroplasty? A GRADE analysis of the evidence through a systematic review and meta-analysis. J Arthroplasty 2017; 32 (10) 3238-3248.e3
• 17 Tang Y, Tang X, Wei Q, Zhang H. Intrathecal morphine versus femoral nerve block for pain control after total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2017; 12 (01) 125
• 18 Zhang LK, Ma JX, Kuang MJ, Ma XL. Comparison of periarticular local infiltration analgesia with femoral nerve block for total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty 2018; 33 (06) 1972-1978.e4
• 19 Tan Z, Kang P, Pei F, Shen B, Zhou Z, Yang J. A comparison of adductor canal block and femoral nerve block after total-knee arthroplasty regarding analgesic effect, effectiveness of early rehabilitation, and lateral knee pain relief in the early stage. Medicine (Baltimore) 2018; 97 (48) e13391
• 20 Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain - United States, 2022. MMWR Recomm Rep 2022; 71 (03) 1-95