Perioperative Pain and Swelling Control in Anterior Cruciate Ligament Reconstruction

Early postoperative practices following anterior cruciate ligament reconstruction in France

INTRODUCTION

The early postoperative period after anterior cruciate ligament reconstruction (ACL) is critical for optimal functional recovery. Despite an abundance of literature, there is no consensus regarding good practices. This period is often under-considered by orthopedic surgeons. The aim of this study was to identify early postoperative practices after ACL reconstruction in France.

HYPOTHESIS

The hypothesis was that there was a discrepancy between validated data in the literature and the current practices of orthopedic surgeons in France.

MATERIAL AND METHODS

In 2019, a questionnaire was sent to all the members of the French Arthroscopy Society to investigate their postoperative practices after ACL reconstruction. Two hundred sixty-nine members responded. Surgeons were divided into two groups of experienced (n=137) and less experienced (n=132) surgeons, according to the number of ACL reconstructions performed per year (<or≥50/year). Outpatient management, effusion prevention measures, and rehabilitation instructions and goals were collected. Overall responses were analyzed after multiple linear logistic regression and the responses of the two groups were compared.

RESULTS

ACL reconstruction was performed as an outpatient procedure in 72.9% of cases. This rate increased with surgical experience (p=0.009×10^-3). Among measures to prevent effusion, cryotherapy was recommended in 97.8% of cases. The experienced group more often used compressive cryotherapy devices (p=0.004). Rehabilitation was started immediately in 75.5% of cases, with as main objective recovery of full extension (89.6%). Weight-bearing was allowed in 98.5% of cases and a brace was prescribed in 69.9% of cases. In the experienced group, braces were less frequent (p=0.02) and self-rehabilitation was preferred (p=0.0006).

CONCLUSION

Early postoperative practices after ACL reconstruction in France are related to surgical experience. The greater the surgical experience, the greater the role of joint effusion prevention and self-rehabilitation. Despite recommendations in the literature, a quarter of the French orthopedic surgeons who responded to this survey did not perform this procedure on an outpatient basis and more than two-thirds prescribed braces.

LEVEL OF EVIDENCE

IV.

Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part I-Femoral Nerve Block

The optimal management of pain after ambulatory anterior cruciate ligament reconstruction (ACLR) is unclear. Femoral nerve block (FNB) is purported to enhance postoperative analgesia, but its effectiveness in the setting of modern multimodal analgesia is unclear. This systematic review examines the effect of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, whether or not the analgesic regimen used included local instillation analgesia (LIA). We retrieved randomized controlled trials evaluating the effects of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, compared to multimodal analgesia alone (control). We designated postoperative opioid consumption at 24 hours as our primary outcome. Secondary outcomes included postoperative opioid consumption at 24-48 hours, rest, and dynamic pain severity between 0 and 48 hours, time to analgesic request, postanesthesia care unit and hospital stay durations, patient satisfaction, postoperative nausea and vomiting, functional outcomes, and long-term (>1 month) quadriceps strength. Eight randomized controlled trials (716 patients) were identified. Five trials compared FNB administration to control, and another 3 compared the combination of FNB and LIA to LIA alone. Compared to control, adding FNB resulted in modest reductions in 24-hour opioid consumption in 2 of 3 trials, and improvements in rest pain at 1 hour in 1 trial and up to 24 hours in another. In contrast, the combination of FNB and LIA, compared to LIA alone, did not reduce opioid consumption in any of the trials, but it did improve pain scores at 20 minutes only in 1 trial. The effect of FNB on long-term quadriceps strength or function after ACLR was not evaluated in the reviewed trials. Contemporary evidence suggests that the benefits of adding FNB to multimodal analgesia for ACLR are modest and conflicting, but there is no incremental analgesic benefit if the multimodal analgesic regimen included LIA. Our findings do not support the routine use of FNB for analgesia in patients having ACLR.