Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: a randomized controlled clinical trial

Femoral Nerve Block and Local Instillation Analgesia Associated With More Reliable Efficacy in Regional Anesthesia Interventions Within 24 Hours Following Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis

PURPOSE

To assess the relative effectiveness of different regional anesthetic techniques (peripheral nerve blocks, local instillation analgesia, including intra-articular, subcutaneous, and periarticular infiltration) in patients undergoing anterior cruciate ligament reconstruction (ACLR).

METHODS

PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception to December 31, 2020. The search was supplemented by manual review of relevant reference lists. Randomized controlled trials of participants after ACLR that compared regional anesthesia interventions were selected. The 2 coprimary outcomes were (1) rest pain scores and (2) cumulative oral morphine equivalent consumption on day 1 (24 hours) post-ACLR. Data were pooled using a Bayesian framework.

RESULTS

Of 759 records identified, 46 trials were eligible, evaluating 9 interventions in 3,171 patients. Local instillation analgesia (LIA), including intra-articular, subcutaneous, and periarticular infiltration, had significant improvement in pain relief as compared with placebo (-0.91; 95% CrI -1.45 to -0.37). Femoral nerve block (FNB) also showed significant effects in relieving pain as compared with placebo (-0.70; 95% 95% credible interval [CrI] -1.28 to -0.12). Compared with placebo, a significant reduction in opioid consumption was found in LIA (mean difference -13.29 mg; 95% CrI -21.77 to -4.91) and FNB (mean difference -13.97 mg; 95% CrI -24.71 to -3.04). Femoral and sciatic nerve block showed the greatest ranking for pain relief and opioid consumption without significant evidence (P > .05) to support superiority in comparison with placebo, respectively.

CONCLUSIONS

Our meta-analysis shows that FNB and LIA can significantly diminish postoperative pain and reduce opioid consumption following ACLR compared with placebo in the setting of regional anesthesia, and femoral and sciatic nerve block may be the number 1 top-ranked analgesic technique despite high uncertainty.

LEVEL OF EVIDENCE

I, Systematic review of Level I studies.

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction can cause moderate to severe acute postoperative pain. Despite advances in our understanding of knee innervation, consensus regarding the most effective regional anaesthesia techniques for this surgical population is lacking. This network meta-analysis compared effectiveness of regional anaesthesia techniques used to provide analgesia for anterior cruciate ligament reconstruction. Randomised trials examining regional anaesthesia techniques for analgesia following anterior cruciate ligament reconstruction were sought. The primary outcome was opioid consumption during the first 24 h postoperatively. Secondary outcomes were: rest pain at 0, 6, 12 and 24 h; area under the curve of pain over 24 h; and opioid-related adverse effects and functional recovery. Network meta-analysis was conducted using a frequentist approach. A total of 57 trials (4069 patients) investigating femoral nerve block, sciatic nerve block, adductor canal block, local anaesthetic infiltration, graft-donor site infiltration and systemic analgesia alone (control) were included. For opioid consumption, all regional anaesthesia techniques were superior to systemic analgesia alone, but differences between regional techniques were not significant. Single-injection femoral nerve block combined with sciatic nerve block had the highest p value probability for reducing postoperative opioid consumption and area under the curve for pain severity over 24 h (78% and 90%, respectively). Continuous femoral nerve block had the highest probability (87%) of reducing opioid-related adverse effects, while local infiltration analgesia had the highest probability (88%) of optimising functional recovery. In contrast, systemic analgesia, local infiltration analgesia and adductor canal block were each poor performers across all analgesic outcomes. Regional anaesthesia techniques that target both the femoral and sciatic nerve distributions, namely a combination of single-injection nerve blocks, provide the most consistent analgesic benefits for anterior cruciate ligament reconstruction compared with all other techniques but will most likely impair postoperative function. Importantly, adductor canal block, local infiltration analgesia and systemic analgesia alone each perform poorly for acute pain management following anterior cruciate ligament reconstruction.

The effect and safety of periarticular multimodal drug injection without morphine and epinephrine in anterior cruciate ligament reconstruction

Background

Periarticular multimodal drug injection (PMDI) is a safe and effective pain management technique after anterior cruciate ligament reconstruction (ACLR); however, adding morphine and epinephrine sometimes causes adverse effects. Therefore, we evaluated the efficacy of PMDI without morphine and epinephrine after ACLR.

Methods

This retrospective matched case-control study included patients who had undergone primary double-bundle ACLR with PMDI and were then matched one-to-one with a control group without PMDI based on sex, age, and body mass index using propensity-matched analysis. The following clinical outcomes were compared between the groups: visual analog scale (VAS) score, C-reactive protein (CRP) concentration, number of times the patients used additional analgesics, complication rate, and postoperative time to achieve straight leg raise (SLR).

Results

Twenty-nine patients with PMDI and 29 controls were enrolled. The VAS score at 1 day postoperatively was lower in the PMDI than the control group (1.93  ±  1.44 vs. 3.41  ±  1.75, respectively; P < 0.001). The CRP concentration at 1 and 3 days was lower in the PMDI than the control group (0.46  ±  0.47 vs. 1.00  ±  0.69 mg/dL, P < 0.001; and 1.93  ±  1.71 vs. 4.01  ±  2.55 mg/dL, P < 0.001, respectively). The average number of additional analgesics used was significantly lower in the PMDI than the control group. There were no significant differences in the frequency of occurrence of postoperative complications between the two groups. The number of patients who could achieve SLR within 1 day was 27/29 (93%) in PMDI group, which was significantly higher than the control group (12/29, 41%) ( P < 0.001).

Conclusion

PMDI without morphine and epinephrine after ACLR reduced patients’ subjective pain level, objective inflammatory response without complications and enabled patients to achieve early functional recovery.

A quadruple peripheral nerve block outside the OR for anterior cruciate ligament reconstruction reduces the OR occupancy time

PURPOSE

The use of regional anesthesia (RA) for anterior cruciate ligament (ACL) reconstruction reduces morphine consumption, the time spent in the post-anesthesia care unit (PACU) and the hospital readmission rate. However, RA failures due to delays in the induction of anesthesia and its unpredictable success rate (Cuvillon et al. Ann Fr Anesth 29:710-715, 2010; Jankowski et al. Anesth Analg 10.1213/01.ANE.0000081798.89853.E7) can lead to disorganization of the operating room (OR) schedule. The hypothesis is that performing RA outside the OR will significantly reduce the OR occupancy time relative to using general anesthesia (GA). The primary objective was to compare the OR occupancy time between RA and GA when performing ACL reconstruction.

METHODS

This was a retrospective, single-center study of data collected prospectively from consecutive patients operated by a single surgeon between January 2019 and December 2020. The patients undergoing ACL reconstruction were divided into two groups based on the type of anesthesia they received (GA, RA). RA consisted of a quadruple peripheral nerve block (femoral, sciatic, obturator and lateral femoral cutaneous nerves). The durations of the perioperative stages of the patient's journey in the OR suite were compared between these two groups.

RESULTS

The analysis involved 469 ACL reconstructions: 356 GA and 113 RA. The two groups were comparable in age, gender and ASA score (American Society of Anesthesiologists). The OR occupancy time for ACL reconstruction with RA was reduced by a mean of 13 min (70 ± 12 SD vs. 83 ± 14 SD; P < 0.0001) and the PACU time by 41 min relative to GA (P < 0.0001). The entry-incision time was reduced by an average of 8 min and the end-exit time by 3 min (P < 0.0001). The care time in the PACU was reduced from 84 ± 35 to 46 ± 26 min (P < 0.0001). However, performing anesthesia outside the OR (i.e., in a RA block room) did not reduce the turnover time (n.s).

CONCLUSION

Performing RA outside the OR reduced the OR occupancy time by nearly 20% relative to using GA for ACL reconstructions.

LEVEL OF EVIDENCE

Level IV.

Peripheral Nerve Blockade for Medial Patellofemoral Ligament Reconstruction in Pediatric Patients: The Addition of a Proximal Single-Injection Sciatic Nerve Block Provides Improved Analgesia

Purpose

We tested the hypothesis that the addition of a single-injection proximal sciatic nerve block to an adductor canal block would significantly reduce pain scores and opioid requirements compared to a group of patients that received only an adductor canal or femoral nerve block for medial patellofemoral ligament reconstruction in pediatric patients. The primary end-point is the number of patients achieving a Patient Acceptable Symptom State (PASS) (pain score less than four) for the entire 24-hour postoperative period in patients with and without a proximal sciatic block.

Patients and Methods

This is a retrospective cohort study of 144 consecutive pediatric patients, ages 10 to 18 years, undergoing medial patellofemoral ligament reconstruction with peripheral nerve blockade for postoperative analgesia from 2016–2020 at a pediatric orthopedics children’s hospital. Patients were divided into 2 cohorts with and without a proximal sciatic nerve block: group A/F: adductor canal or femoral CPNB and group AS: adductor canal CPNB and a proximal single-injection sciatic nerve block.

Results

There was strong evidence for an increase in the number of patients who reported a pain score less than four for the entire 24-hour postoperative period in the group that received the additional proximal sciatic block. (PASS: A/F 13/62 (21%) vs AS 43/82 (52%), p<0.001) There was strong evidence for a reduction in mean and maximum pain scores and opioid requirements in the first 24-hours after surgery in the proximal sciatic group.

Conclusion

The addition of a proximal sciatic nerve block was associated with significantly reduced mean and maximum pain scores and opioid requirements after medial patellofemoral ligament reconstruction in pediatric patients and supports a randomized clinical trial to confirm these findings. Based on the results of this study we recommend the addition of a proximal sciatic nerve block, anterior or posterior, to an adductor canal block to provide improved analgesia and reduced opioid requirements in the 24-hours after MPFLR in pediatric patients.

Most Analgesia Treatments Have No Clinical Significance for Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis of 66 Randomized Controlled Trials

PURPOSE

To assess the relative efficacy of several clinical treatments for postoperative analgesia of anterior cruciate ligament reconstruction through network meta-analysis based on multiple published randomized controlled trials.

METHODS

We searched PubMed, the Cochrane library, EMBASE, and Web of Science, each from inception until February 15, 2021. Outcomes including pain scores at rest (visual analog scale, numerical rating scales, and other scales, which were converted to a standardized 0-10 scale), morphine consumption, and complications were meta-analyzed. Quality of the included studies was assessed using the Cochrane risk-of-bias tool. The authors defined the best choice for postoperative analgesia as the one that had significant difference in pain scores, morphine consumption, and had no significant difference in the risk of complications compared with placebo in the initial 48 postoperative hours.

RESULTS

In total, 66 studies with 4,168 patients were included in this network meta-analysis. Only periarticular infiltration was significantly superior to placebo in pain scores and morphine consumption (pain at 2 hours: mean difference [MD] -0.74, 95% confidence interval [CI] -1.36 to -0.12; pain at 6 hours: MD -0.81, 95% CI -1.42 to -0.21; pain at 12 hours: MD -0.85, 95% CI -1.53 to -0.17; pain at 24 hours: MD -0.80, 95% CI -1.19 to -0.40; morphine consumption at 24 hours: MD -10.12, 95% CI -14.31 to -5.93; morphine consumption at 48 hours: MD -5.62, 95% CI -6.74 to -4.51). Periarticular infiltration did not increase the risk of complications compared with placebo (nausea and vomiting: odds ratio [OR] 0.63, 95% CI 0.34-1.16; pruritus: OR 0.74, 95% CI 0.35-1.58; urinary retention: OR 0.55, 95% CI 0.25-1.23). In addition, There was no significant difference between adductor canal block and femoral nerve block in pain scores and morphine consumption (pain at 2 hours: MD -0.01, 95% CI -1.44 to 1.42; pain at 6 hours: MD 0.29, 95% CI -0.28 to 0.86; pain at 12 hours: MD 0.36, 95% CI -0.44 to 1.16; pain at 24 hours: MD 0.26, 95% CI -0.22 to 0.75; pain at 48 hours: MD -0.36, 95% CI -0.97 to 0.24; morphine at 24 hours: MD 1.04, 95% CI -4.70 to 6.79; morphine at 48 hours: MD -0.32, 95% CI -0.70 to 0.07; postoperative nausea and vomiting: OR 1.07, 95% CI 0.55-2.09; pruritus: OR 1.36, 95% CI 0.66-2.79; urinary retention: OR 1.41, 95% CI 0.37-5.29).

CONCLUSIONS

Based on current evidence, most analgesic methods could result in lower pain scores and decrease morphine consumption when compared with placebo; however, differences between methods were small and inconsistent. There seemed to be no significant difference between adductor canal block and femoral nerve block in pain score, morphine consumption and complications.

LEVEL OF EVIDENCE

Level I, meta-analysis of Level I RCTs.

Perioperative opioid use and Press Ganey patient satisfaction scores after anterior cruciate ligament reconstruction

Background

Satisfaction measures such as Press Ganey (PG) scores are increasingly used to determine reimbursement.

Purpose

To investigate the relationship between PG satisfaction scores and perioperative opioid use in patients undergoing anterior cruciate ligament reconstruction (ACLR).

Methods

Patients undergoing ACLR were retrospectively identified. Perioperative opioid prescription data were collected using the electronic medical record.

Results

Positive correlations existed between immediate preoperative total morphine equivalents (TMEs) and PG scores. There was a negative correlation between "Pain Control" and preoperative TMEs.

Conclusion

PG scores were correlated with preoperative and intraoperative opioid administration but not postoperative opioid administration.

Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis

PURPOSE

To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes.

METHODS

A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable.

RESULTS

Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use.

CONCLUSIONS

Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of RCTs.

Usefulness of lateral femoral cutaneous nerve block in combination with femoral nerve block for anterior cruciate ligament reconstruction: a prospective trial

INTRODUCTION

The study aimed to compare the combination of femoral nerve block (FNB) with interspace between the popliteal artery and the capsule of posterior knee (IPACK) block (IPACK group) with the combination of FNB with lateral femoral cutaneous nerve (LFCN) block (LFCN group) for postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction. We hypothesized that the lower pain scores and decreased suppository use would be noted in patients administered a combination of FNB and IPACK block.

MATERIALS AND METHODS

A non-randomized prospective controlled clinical trial was conducted. The IPACK and LFCN groups included 40 patients each. The patients received IPACK block and LFCN block alternately. Thirty minutes prior to the surgery and after administration of general anesthesia, patients received an ultrasound-guided FNB and IPACK block or LFCN block. After ACL reconstruction, the visual analog scale pain scores were recorded at 30 min, 4 h, 8 h, 12 h, 24 h, 48 h, and 72 h after the surgery. The administration and use of analgesic suppositories were assessed. These measures were compared among the treatment types at each time-point using the Welch's t-test.

RESULTS

Suppository use was significantly less in the LFCN group than in the IPACK group. The pain scores were significantly lower in the LFCN group at 30 min, 4 h, 48 h, and 72 h after the surgery.

CONCLUSION

The combination of FNB with LFCN block during ACL reconstruction significantly reduces pain in the early postoperative period compared to a combination of FNB with IPACK block.

LEVEL OF EVIDENCE

Prospective control trial, Level II.

Extraplexus versus intraplexus ultrasound-guided interscalene brachial plexus block for ambulatory arthroscopic shoulder surgery: A randomized controlled trial

Background

This randomized study compared the efficacy and safety of extraplexus and intraplexus injection of local anesthetic for interscalene brachial plexus block.

Methods

208 ASA I-II patients scheduled for elective shoulder arthroscopy under general anesthesia and ultrasound-guided interscalene brachial plexus block were randomly allocated to receive an injection of 25mL ropivacaine 0.5% either between C5-C6 nerve roots (intraplexus), or anterior and posterior to the brachial plexus into the plane between the perineural sheath and scalene muscles (extraplexus). The primary outcome was time to loss of shoulder abduction. Secondary outcomes included block duration, perioperative opioid consumption, pain scores, block performance time, number of needle passes, onset of sensory blockade, paresthesia, recovery room length of stay, patient satisfaction, incidence of Horner’s syndrome, dyspnea, hoarseness, and post-operative nausea and vomiting.

Results

Time to loss of shoulder abduction was faster in the intraplexus group (log-rank p-value<0.0005; median [interquartile range]: 4 min [2–6] vs. 6 min [4–10]; p-value <0.0005). Although the intraplexus group required fewer needle passes (2 vs. 3, p<0.0005), it resulted in more transient paresthesia (35.9% vs. 14.5%, p = 0.0004) with no difference in any other secondary outcome.

Conclusion

The intraplexus approach to the interscalene brachial plexus block results in a faster onset of motor block, as well as sensory block. Both intraplexus and extraplexus approaches to interscalene brachial plexus block provide effective analgesia. Given the increased incidence of paresthesia with an intraplexus approach, an extraplexus approach to interscalene brachial plexus block is likely a more appropriate choice.

Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial

Background and objectives

There are no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia.

Method

Randomized and controlled clinical trial of patients undergoing reconstruction of the Anterior Cruciate Ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The groups C, M, R0,375 and R0,25 was compared with only the previously described technique, subarachnoid morphine (100░μg), or Femoral Nerve Block (BNF) with 25░mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24░hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated.

Results

Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24░hours. There was a higher incidence of urinary retention in the M group (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 group (30%) than in the M and C groups (0%), with statistical significance (p░<░0.05).

Conclusion

There was no difference in the intensity of postoperative pain in patients submitted to ACL reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M group and motor block in the R0,375 group.

[Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial]

BACKGROUND AND OBJECTIVES

There is no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia.

METHOD

Randomized and controlled clinical trial of patients undergoing reconstruction of the anterior cruciate ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The Groups C, M, R0,375 and R0,25 were compared with only the previously described technique, subarachnoid morphine (100 μg) or femoral nerve block with 25 mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated.

RESULTS

Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The Group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24hours. There was a higher incidence of urinary retention in the Group M (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 Group (30%) than in the M and C Groups (0%), with statistical significance (p < 0.05).

CONCLUSION

There was no difference in the intensity of postoperative pain in patients submitted to anterior cruciate ligament reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M Group and motor block in the R0,375 Group.

Femoral nerve catheters and limb strength asymmetry at 6 months after primary anterior cruciate ligament reconstruction in pediatric patients

BACKGROUND

The postoperative implications of single-injection femoral nerve blockade and femoral nerve catheter placement for anterior cruciate ligament reconstruction are not well defined among pediatric patients. Femoral nerve blockade may be associated with deficits in quadriceps symmetry at 6 months postoperative.

AIMS

We compared outcomes after primary anterior cruciate ligament reconstruction surgery in pediatric patients who received either a single-injection femoral nerve block or femoral nerve catheter and a single-injection popliteal nerve block.

METHODS

We conducted a retrospective chart review of patients 10-19 years of age who underwent anterior cruciate ligament reconstruction with quadriceps tendon-patellar bone autograft by a single orthopedic surgeon at two of our locations. Of 88 patients analyzed, 31 received single-injection femoral nerve blockade (52% female, mean age = 15.6 ± 1.8 years) and 57 received femoral nerve catheter (53% female, mean age = 15.6 ± 1.7 years). Time from surgery to return-to-sport clearance and movement symmetry were compared between groups at approximately 6 months postoperatively.

RESULTS

The single-injection femoral nerve blockade group exhibited significantly greater single-leg squat symmetry than did the femoral nerve catheter group (95.5 ± 6.7% vs 88.3 ± 9.3%; P = 0.02; mean difference = 7.2%, 95% CI = -1.1, 13.3) 6 months postoperatively. There was no difference in time from surgery to return-to-sport clearance between groups (median = 247 [interquartile range = 218-295] days vs 268 [241-331] days; P = 0.22; mean difference = 40 days; 95% CI = -23, 102).

CONCLUSION

Though time to return to sport did not differ, patients in the femoral nerve catheter group exhibited greater single-leg squat asymmetry than did those in the femoral nerve blockade group approximately 6 months postoperatively. Persistent functional deficits may be important to consider when treating pediatric patients undergoing anterior cruciate ligament reconstruction.

The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction

BACKGROUND

Patients often have quadriceps or hamstring weakness after anterior cruciate ligament reconstruction (ACLR), despite postoperative physical therapy regimens; however, little evidence exists connecting nerve blocks and ACLR outcomes.

PURPOSE

To compare muscle strength at return to play in patients who received a nerve block with ACLR and determine whether a specific block type affected subjective knee function.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were recruited 5 to 7 months after primary, isolated ACLR and completed bilateral isokinetic strength tests of the knee extensor/flexor groups as a single-session return-to-sport test. Subjective outcomes were assessed with the International Knee Documentation Committee (IKDC) score. Strength was expressed as torque normalized to mass (N·m/kg) and limb symmetry index as involved/uninvolved torque. Chart review was used to determine the type of nerve block and graft used. Nerve block types were classified as knee extensor motor (femoral nerve), knee flexor motor (sciatic nerve), or isolated sensory (adductor canal block/saphenous nerve). A 1-way analysis of covariance controlling for graft type was used.

RESULTS

A total of 169 patients were included. Graft type distribution consisted of 102 (60.4%) ipsilateral bone-patellar tendon-bone (BTB) and 67 (39.6%) ipsilateral hamstring tendon. Nerve block type distribution consisted of 38 (22.5%) femoral, 25 (14.8%) saphenous, 45 (26.6%) femoral and sciatic, and 61 (36.1%) saphenous and sciatic. No significant difference was found in knee extensor strength (P = .113) or symmetry (P = .860) between patients with knee extensor motor blocks (1.57 ± 0.45 N·m/kg; 70.1% ± 15.3%) and those without (1.47 ± 0.47 N·m/kg; 69.6% ± 18.8%). A significant difference was found between patients with knee flexor motor blocks (0.83 ± 0.26 N·m/kg) and those without (0.92 ± 0.27 N·m/kg) for normalized knee flexor strength (P = .21) but not knee flexor symmetry (P = .592). Controlling for graft type, there were no differences in subjective knee function (IKDC score) between all nerve block groups (P = .57).

CONCLUSION

Our data showed that use of a sciatic nerve block with ACLR in patients with hamstring and BTB grafts influences persistent knee flexor strength deficits at time of return to sports. Although the cause of postoperative muscular weakness is multifactorial, this study adds to the growing body of evidence suggesting that perioperative nerve blocks affect muscle strength and functional rehabilitation after ACLR.

Effects of the nontourniquet combined with controlled hypotension technique on pain and long-term prognosis in elderly patients after total knee arthroplasty: a randomized controlled study

PURPOSE

The aim of this study was to confirm the alleviating effects of the nontourniquet technique on the postoperative acute and chronic pain of patients after total knee arthroplasty (TKA).

METHODS

122 elderly patients undergoing TKA were randomly divided into two groups: group T (n = 58) and group H (n = 64). An electronic inflatable tourniquet was used during TKA in group T. The patients in group H received controlled hypotension but without tourniquet use during the operation. The numeric rating scale (NRS) score was used to evaluate pain level on day 1, day 2, day 3 and day 7 after the operation, and the incidence of chronic pain was judged at 3-month and 1-year follow-ups, and functional recovery of the knee joint was estimated by the active range of knee joint motion (AROM) at the same time points. Cognitive function was assessed by the montreal cognitive assessment scale (MoCA) for 7 days after operation.

RESULTS

There were no significant differences in the NRS scores and AROM for 7 days after surgery. The incidence rate of chronic pain in group H (25.0%) was lower than that in group T (41.4%) and the AROM in group H was greater at one year follow-up. The MoCA score in group H was lower than that in group T on day 1 and day 2.

CONCLUSION

The nontourniquet combined with controlled hypotension technique can alleviate chronic pain and promote the long-term rehabilitation of patients after TKA.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

Liposome Bupivacaine Compared to Plain Local Anesthetics to Reduce Postsurgical Pain: An Updated Meta-Analysis of Randomized Controlled Trials

Objective

Peripheral nerve blocks for postoperative analgesia have improved block success, but analgesia efficacy has been limited by the short duration of traditional local anesthetics. The results of randomized trials comparing liposome bupivacaine with conventional local anesthetic formulations (e.g., plain bupivacaine and ropivacaine) have generated conflicting results. This study was conducted to systematically review the effectiveness of analgesic efficacy of liposome bupivacaine infiltration at the surgical site versus plain local anesthetic bupivacaine or ropivacaine in patients undergoing surgery.

Methods

PRISMA statement guidelines were followed. A search of electronic databases National Library of Medicine's PubMed database, Cochrane Database of Systematic Reviews, Embase, and Google Scholar from January 2012 to September 2017 was performed. Among the 1,612 records identified, 9 randomized controlled trials involving 779 patients were eligible for data extraction and meta-analysis.

Results

Liposome bupivacaine did not reduce postsurgical pain at rest compared to plain local anesthetics at 24 and 48 hours after surgery. Moreover, liposome bupivacaine did not reduce postoperative opioid consumption at 24, 48, or 72 hours when compared to plain local anesthetics. Liposome bupivacaine did reduce postoperative nausea when compared to plain local anesthetics (P =<0.3). There was no significant difference in hospital length of stay between study groups, the use of plain bupivacaine or ropivacaine, or among orthopedic or nonorthopedic procedures. No manifestations of local anesthetic toxicity were reported.

Conclusions

Our results suggest that liposome bupivacaine does not have an analgesic advantage when compared to plain local anesthetics at the surgical site for patients undergoing surgical procedures.

Short-term Outcomes in Pediatric Patients Managed with Peripheral Nerve Blockade for Arthroscopic Anterior Cruciate Ligament Reconstruction and/or Meniscus Surgeries

Introduction

Peripheral nerve blockade (PNB) can be a useful component of a multimodal analgesia approach in managing pain after knee arthroscopy. However, the impact of PNB and short-term recovery in pediatric patients, particularly adolescents, who underwent knee arthroscopy for anterior cruciate ligament (ACL) reconstruction and/or meniscus surgery (repair or resection) has not been well characterized. This prospective study presents observational data on short-term patient outcomes and side effects for 72 hours following discharging home of pediatric patients who underwent arthroscopic ACL and/or meniscus procedures with PNB.

Methods

This is a single-center, single-surgeon prospective observational study conducted over a three-year period. We characterized 72-hour postoperative outcomes including pain scores, return of sensation to the affected limb, analgesic use [nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids], readmission rate, and activities of daily living (ADL) via telephone survey. In addition, retrospective chart review was conducted to obtain perioperative and anesthesia details. Results for surgery groups were analyzed using descriptive and Pearson correlations using the SPSS version 24 (IBM Corp. Released 2016. IBM SPSS Statistics for Mac, Version 24.0. Armonk, NY, USA).

Results

We collected data on 47 patients undergoing ACL reconstruction with or without meniscus surgery (18/47, 38.3%) or meniscus surgery only (29/47, 61.7%). At 72 hours postsurgery, there were no readmissions or complications related to pain. Median-reported pain scores were 2.5 and 5.0 for the ACL and meniscus groups, respectively. A majority of patients continued to require opioids (45/47, 95.7%) and NSAIDs (46/47, 97.9%) at 72 hours postsurgery, but the number of daily opioid doses taken decreased with each day postoperatively. Over 93% of the patients could ambulate and shower at 72 hours postsurgery.

Conclusions

Regional nerve block appears to be an effective and safe analgesic strategy for pediatric arthroscopic ACL and meniscus procedures, with no short-term complications or readmissions related to pain in our cohort. Future prospective investigation is needed to characterize long-term pain outcomes in this surgical population.