Femoral Block Provides Superior Analgesia Compared With Intra-Articular Ropivacaine After Anterior Cruciate Ligament Reconstruction:

Adductor canal block is similar to femoral nerve block for the quality of rehabilitation after arthroscopic partial meniscectomy

PURPOSE

Adductor canal block (ACB) provides postoperative pain relief as effectively as femoral nerve block (FNB) does, and it preserves the strength of the quadriceps femoris. However, its effect on rehabilitation after arthroscopic partial meniscectomy has not been reported. The purpose of this study was to determine the effect of pre-operative ACB and FNB on the quality of rehabilitation after arthroscopic partial meniscectomy.

METHODS

A total of 150 patients undergoing arthroscopic partial meniscectomy were randomly allocated to the FNB group (receiving 0.3% ropivacaine 30 ml at the thighroot-femoral nerve), the ACB group (receiving 0.3% ropivacaine 30 ml at mid-thigh adductor canal), or the control group. The primary outcome was the Hospital for Special Surgery (HSS) knee score on the 30th postoperative day.

RESULTS

The HSS knee score of the ACB group on the 30th day after the operation was significantly higher than those of the FNB and control groups (88.6 ± 5.3 vs. 85.3 ± 6.9 and 81.2 ± 5.9, respectively; P < 0.05). Both the ACB and FNB groups showed excellent rehabilitation, indicating similar rehabilitation quality for both treatments.

CONCLUSION

ACB is similar to FNB concerning the quality of rehabilitation and pain relief after arthroscopic partial meniscectomy, while ACB has little effect on the strength of the quadriceps femoris.

LEVEL OF EVIDENCE

I TRIAL REGISTRATAION: This trial was registered in the Chinese Clinical Trial Registry (ChiCTR-INC-16008346).

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.

Adductor Canal Block Versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial

BACKGROUND

Femoral nerve block (FNB) is a commonly performed technique that has been proven to provide effective regional analgesia after anterior cruciate ligament (ACL) reconstruction. The adductor canal block (ACB) uses a similar sensory block around the knee while avoiding motor blockade of the quadriceps muscles.

PURPOSE/HYPOTHESIS

The purpose of our study was to compare the efficacy of FNB versus ACB for pain control after ACL reconstruction. It was hypothesized that there would be no difference in pain levels or opioid requirements between the 2 groups.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

We performed a prospective, double-blinded, randomized controlled trial. Sixty patients undergoing primary ACL reconstruction with bone-patellar tendon-bone autograft were randomized to receive either an ACB or an FNB preoperatively. The primary outcomes assessed were pain levels (visual analog scale) and narcotic requirements for 4 days after surgery. Secondary outcomes included ability to perform a straight leg raise in the recovery room and difference in thigh circumference between the operative and nonoperative leg measured at 7 days postoperatively.

RESULTS

Morphine requirements were less in the ACB group in the first 4 hours postoperatively ( P = .02). Aside from this time interval, no differences were found between the 2 groups with regard to opioid requirements and pain scores at any other time. Similarly, no differences were noted in patients' ability to perform a straight leg raise in the recovery room ( P = .13) or in thigh circumference at the first postoperative visit ( P = .09).

CONCLUSION

The results of our study suggest similar efficacy in perioperative pain control with the use of an ACB for ACL reconstruction when compared with FNB. The potential long-term benefit of quadriceps preservation with the ACB is worthy of future study.

REGISTRATION

NCT03033589 (ClinicalTrials.gov identifier).

Long-Term Neurological Complications Associated with Surgery and Peripheral Nerve Blockade: Outcomes after 1065 Consecutive Blocks

Peripheral nerve blockade is gaining popularity as an analgesic option for both upper or lower limb surgery. Published evidence supports the improved efficacy of regional techniques when compared to conventional opioid analgesia. The incidence of neurological deficit after surgery associated with peripheral nerve block is unclear. This paper reports on neurological outcomes occurring after 1065 consecutive peripheral nerve blocks over a one-year period from a single institution. All patients receiving peripheral nerve blocks for surgery were prospectively followed for up to 12 months to determine the incidence and probable cause of any persistent neurological deficit. Formal independent neurological review and testing was undertaken as indicated. Thirteen patients reported symptoms that warranted further investigation. A variety of probable causes were identified, with peripheral nerve block being implicated in two cases (one resolved at nine months and one remaining persistent). Overall incidence of block-related neuropathy was 0.22%.

Persistent postoperative neuropathy is a rare but serious complication of surgery associated with peripheral nerve block. Formal follow-up of all such blocks is recommended to assess causality and allow for early intervention.

The Effect of Femoral Nerve Block on Quadriceps Strength in Anterior Cruciate Ligament Reconstruction: A Systematic Review

PURPOSE

To assess the isokinetic, functional, and patient-reported outcomes of femoral nerve block (FNB) compared with traditional multimodal anesthesia for FNB in anterior cruciate ligament (ACL) reconstruction.

METHODS

A systematic search of PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Reviews, and Google Scholar was conducted according to the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Effects of FNB on quadriceps function were evaluated by isokinetic testing, functional scoring systems, range of motion, and patient self-report questionnaires. Heterogeneous reporting of outcomes precluded a formal meta-analysis. The methodologic merit of all studies included was evaluated by the Coleman Methodology Score.

RESULTS

Six studies were identified with outcome measures reported between 7 days and 6 months postoperatively. At 6 months, 2 of 4 studies that reported isokinetic testing found significantly greater deficits among patients who received a nerve block; one of the remaining studies showed a deficit at 6 weeks but not 6 months. Limited data showed no significant differences in functional or patient-reported outcomes at 6 months after reconstruction, and data regarding the impact of FNB on return to sport were inconclusive. The mean Coleman Methodology Score for the included studies was 53, indicating poor overall methodologic quality of the available literature.

CONCLUSIONS

The limited data available suggest that FNB causes a measurable deficit in quadriceps isokinetic strength during the early postoperative period but has no effect on functional outcomes or return to sport at 6 months after ACL reconstruction. However, current clinical evidence is not sufficient to draw any valid or definitive conclusions regarding the effect of FNB on postoperative outcomes after ACL reconstruction.

LEVEL OF EVIDENCE

Level IV, systemic review of Level I through IV studies.

Adductor canal blockade for moderate to severe pain after arthroscopic knee surgery: a randomized controlled trial

BACKGROUND

The analgesic effect of the adductor canal block (ACB) after knee surgery has been evaluated in a number of trials. We hypothesized that the ACB would provide substantial pain relief to patients responding with moderate to severe pain after arthroscopic knee surgery.

METHODS

Fifty subjects with moderate to severe pain after arthroscopic knee surgery were enrolled in this placebo-controlled, blinded trial. All subjects received two ACBs; an initial ACB with either 30 ml ropivacaine 7.5 mg/ml (n = 25) (R group) or saline (n = 25) (C group) and after 45 min a second ACB with the opposite study medication, according to randomization. Primary outcome was pain during 45 degrees active flexion of the knee at 45 min after the first block, assessed on a 0-100 mm visual analogue scale. Secondary outcome measures were: pain at rest and during flexion of the knee, worst pain experienced during a 5-m walk, patient's evaluation of muscle strength during walk, and amount of sufentanil administered during the 90-min study period.

RESULTS

Regarding primary outcome, mean pain score difference between groups was 34 (95% CI: 25 to 44) mm, P < 0.001, in favour of the R group. At rest, mean pain score difference was 32 (23 to 41) mm, P < 0.001, and during walk: 21 (6 to 36) mm, P = 0.01 in favour of the R group. There were no differences between groups regarding other secondary outcome measures.

CONCLUSION

The ACB is a relevant option for patients with moderate to severe pain after arthroscopic knee surgery.

Review of outcomes in pediatric patients undergoing anterior cruciate ligament repairs with regional nerve blocks

PURPOSE

This article compared the outcomes of pediatric patients undergoing ACL repairs receiving intravenous opioids versus regional nerve blocks for pain management. It was hypothesized that compared to intravenous opioids the use of regional nerve blocks would decrease pain, opioid consumption, and opioid-related side effects.

METHOD

A random retrospective chart review was conducted on a total of 93 pediatric patients who underwent ACL repairs either in 2004 prior to the implementation of regional nerve blocks for pain management [pre-protocol cohort, (n=44)] or in 2009/2010, after the implementation of regional nerve block use [post-protocol cohort, (n=49)].

FINDINGS

The two cohorts were comparable in age, weight and gender. The post-protocol cohort had a significantly lower total opioid consumption (p<0.001). A sensitivity analysis excluding patients who received patient controlled analgesia (PCA) further validated the findings of significantly lower total opioid consumption adjusted for body weight [mg/kg] (p=0.02) and reduction in the highest numerical rating score (NRS) reported on post-operative day (POD) 1 (p=0.01). The cohorts were not significantly different in incidence of common opioid-related side effects or median length of stay (LOS).

CONCLUSIONS

There was evidence that regional nerve blocks reduced opioid consumption and also impacted pain reduction on POD 1 but demonstrated no significant change on opioid-related side effects or readiness for discharge. In view of the retrospective nature of the study the potential benefits of regional nerve blocks suggested a clinical equipoise to conduct a controlled trial in children.

A prospective double blinded randomized study of anterior cruciate ligament reconstruction with hamstrings tendon and spinal anesthesia with or without femoral nerve block

BACKGROUND

Current literature supports the thought that anesthesia and analgesia administered perioperatively for an anterior cruciate ligament (ACL) reconstruction have a great influence on time to effective rehabilitation during the first week after hospital discharge.

PURPOSE

The aim of this study is to answer the research question is there a difference in clinical outcomes between the use of a femoral nerve block with spinal anesthesia versus spinal analgesia alone for people undergoing ACL reconstruction?

METHODS

ACL reconstruction with spinal anesthesia and patient sedation (Group one); and spinal anesthesia with patient sedation and an additional femoral nerve block (Group two). Patients were re-evaluated for pain, range of motion (ROM), active contraction of the quadriceps, and a Functional Independence Measure (FIM) scoring scale.

RESULTS

Spinal anesthesia with a femoral nerve block demonstrates pain relief 6h after surgery (VAS 0.37; p=0.007). From the third (VAS=4.56; p=0.028) to the seventh (VAS=2.87; p=0.05) days after surgery, this same nerve blockage delivered higher pain scores. Patients had a similar progressive improvement on knee joint range of motion with or without femoral nerve block (p<0.002). Group one and two had 23.75 and 24.29° 6h after surgery and 87.81 and 85.36° of knee flexion after 48h post op.

CONCLUSION

Spinal anesthesia associated with a femoral nerve block had no additional benefits on pain control after the third postoperative day. There were no differences between groups concerning ability for knee flexion and to complete daily activities during postoperative period.

LEVEL OF EVIDENCE

Randomized Clinical Trial Level I.

Postoperative Analgesia with Saphenous Block Appears Equivalent to Femoral Nerve Block in ACL Reconstruction

BACKGROUND

Adequate pain control following anterior cruciate ligament reconstruction (ACL) often requires regional nerve block. The femoral nerve block (FNB) has been traditionally employed. Ultrasound application to regional nerve blocks allows for the use of alternatives such as the saphenous nerve block following ACL reconstruction.

QUESTIONS/PURPOSES

This study evaluated postoperative analgesia provided by the subsartorial saphenous nerve block (SSNB) compared to that provided by the traditional FNB for patients undergoing ACL reconstruction with patellar tendon (bone-tendon-bone (BTB)) autografts.

METHODS

A randomized, blinded, controlled clinical trial was conducted using 80 ASA I-III patients, ages 16-65, undergoing ACL reconstruction with BTB. The individuals assessing all outcome measures were blinded to the treatment group. Postoperatively, all patients received cryotherapy and parenteral hydromorphone to achieve numeric rating scale pain scores less than 4. At discharge, patients were given prescriptions for oral opioid analgesics and a scheduled NSAID. Patients were instructed to complete pain diaries and record oral opioid utilization. Patients were contacted on postoperative days (POD) 1 and 2 to ascertain the level of patient satisfaction with the analgesic regimen.

RESULTS

No differences between the two groups were found. Patient demographics and postoperative pain scores at rest were not different. In addition, there was no difference in opioid use, as measured in daily oral morphine equivalents between groups. A small but statistically significant report of higher patient satisfaction with the FNB was found on POD 1 but not on POD 2.

CONCLUSION

These data support our hypothesis that the SSNB provides similar and adequate postoperative analgesia when compared to the FNB, following arthroscopic ACL reconstruction with patellar tendon autograft.

The efficacy of adductor canal blockade after minor arthroscopic knee surgery--a randomised controlled trial

BACKGROUND

Adductor canal blockade (ACB) has been demonstrated to be effective in the treatment of post-operative pain after major knee surgery. We hypothesised that the ACB would reduce pain and analgesic requirements after minor arthroscopic knee surgery.

METHODS

Seventy-two patients scheduled for minor knee surgery were enrolled in this placebo-controlled, blinded trial. The patients were randomised to receive an ACB with either 30 ml ropivacaine 7.5 mg/ml (n = 36) or saline (n = 35) in addition to a basic analgesic regimen with paracetamol and ibuprofen. Primary outcome measure was pain during standing at 2 h after surgery. Secondary outcomes were pain at rest, while standing and after a 5-m walk; opioid consumption and opioid-related side effects 0-24 h after surgery.

RESULTS

Pain scores {median [interquartile range (IQR)]}, regarding primary outcome were 15 (0-26) mm in the ropivacaine vs. 17 (5-28) mm in the control group, 95% confidence interval (CI) (-10 to 4) mm, P = 0.41. Ketobemidone consumption 0-2 h post-operatively [median (IQR)] was lower in the ropivacaine vs. the control group: 0.0 (0.0-2.5) mg vs. 2.5 (0.0-5.0) mg, 95% CI: -2.5 to 0 mg, P = 0.01. No differences were observed for any other outcome.

CONCLUSION

No significant analgesic effect of the ACB could be detected after minor arthroscopic knee surgery with a basic analgesic regimen with acetaminophen and ibuprofen, except from a minor reduction in immediate requirements for supplemental opioids. Clinicaltrials.gov Identifier: NCT01254825.

Local infiltration analgesia is comparable to femoral nerve block after anterior cruciate ligament reconstruction with hamstring tendon graft: a randomised controlled trial

PURPOSE

Arthroscopic anterior cruciate ligament (ACL) reconstruction is a painful procedure requiring intensive postoperative pain management. Femoral nerve block is widely used in ACL surgery. However, femoral nerve block does not cover the donor site of the hamstring tendons. Local infiltration analgesia is a simple technique that has proven effective in postoperative pain management after total knee arthroplasty. Further, local infiltration analgesia covers the donor site and is associated with few complications. It was hypothesised that local infiltration analgesia at the donor site and wounds would decrease pain and opioid consumption after ACL reconstruction with hamstring tendon graft.

METHODS

Sixty patients undergoing primary ACL surgery with hamstring tendon graft were randomised to receive either local infiltration analgesia or femoral nerve block. Pain was scored on the numeric rating scale, and use of opioid, range of motion and adverse effects were assessed at the postoperative recovery unit (0 h), 3, 24 and 48 h, postoperatively.

RESULTS

There were no significant differences between the groups in pain intensity or total opioid consumption at any of the follow-up points. Further, there were no differences between groups concerning side effects and range of motion.

CONCLUSIONS

Local infiltration analgesia and femoral nerve block are similar in the management of postoperative pain after ACL reconstruction with hamstring tendon graft. Until randomised studies have investigated femoral nerve block combined with infiltration at the donor site, we recommend local infiltration analgesia in ACL reconstruction with hamstring tendon graft.

Hospital Charges and Practice Patterns for General and Regional Anesthesia in Arthroscopic Anterior Cruciate Ligament Repair

BACKGROUND

Anesthetic use for arthroscopic anterior cruciate ligament (ACL) reconstruction may display variability in hospital charges and utilization in the United States.

PURPOSE

To evaluate practice patterns and hospital charges for anesthesia in arthroscopic ACL reconstruction.

STUDY TYPE

Cross-sectional study.

METHODS

The PearlDiver Patient Records Database, a national database of insurance billing records, was searched using the current procedural terminology (CPT) codes for arthroscopic ACL reconstruction in combination with different types of anesthesia. The search included the years between 2004 and 2009. Age, sex, number of procedures performed, geographic region, and hospital charges for each type of anesthesia were recorded and compared. Anesthetic types were categorized as general anesthesia (GA) only, GA with concomitant single femoral injection, GA with concomitant other regional anesthesia (RA), single femoral injection only, or other RA only.

RESULTS

Between 2004 and 2009, a total of 53,968 arthroscopic reconstructive procedures were identified. The mean per patient hospital charge for GA alone, GA in combination with single femoral injection, GA in combination with other RA, single femoral injection alone, and RA alone was $1065 (63% of cases), $1614 (29%), $1849 (4%), $630 (3%), and $612 (1%), respectively. The use of GA in combination with RA or single femoral nerve injection significantly increased during this time period (P = .004 and P < .001, respectively).

CONCLUSION

The mean per patient hospital charges for arthroscopic ACL reconstruction varied with the mode of anesthesia utilized, where regional anesthetic techniques alone were least expensive. RA alone was utilized infrequently, and there was a significant increase in the rate of utilization of GA in combination with any form of RA.

CLINICAL RELEVANCE

This study provides information on current trends and hospital charges for anesthesia in arthroscopic ACL reconstruction.

Use of machine learning theory to predict the need for femoral nerve block following ACL repair

OBJECTIVE

We report on a classification approach using machine learning (ML) algorithms for prediction of postoperative femoral nerve block (FNB) requirement following anterior cruciate ligament (ACL) reconstruction.

BACKGROUND

FNBs are commonly performed for ACL reconstruction to control postoperative pain. Ideally, anesthesiologists would target preoperative FNB only to ACL reconstruction patients expected to experience severe postoperative pain. Perioperative factors associated with postoperative FNB placement following ACL reconstruction remain unclear, may differ among separate surgical facilities, and render such predictions difficult.

METHODS

We conducted a chart review of 349 patients who underwent ACL reconstruction at a single outpatient surgical facility. Standard perioperative data commonly available during routine preoperative examination were recorded. ML classifiers based on logistic regression, BayesNet, multilayer perceptron, support vector machine, and alternating decision tree (ADTree) algorithms were then developed to predict which patients would require postoperative FNB.

RESULTS

Each of the ML algorithms outperformed traditional logistic regression using a very limited data set as measured by the area under the receiver operating curve, with ADTree achieving the highest score of 0.7 in the cross-validated sample. Logistic regression outperformed all other classifiers with regard to kappa statistics and percent correctly classified. All models were prone to overfitting in comparisons of training vs cross-validated samples.

CONCLUSION

ML classifiers may offer improved predictive capabilities when analyzing medical data sets compared with traditional statistical methodologies in predicting severe postoperative pain requiring peripheral nerve block.

[Levobupivacaine vs. ropivacaine for continuous femoral analgesia after anterior cruciate ligament reconstruction]

BACKGROUND

Levobupivacaine and ropivacaine are both used for continuous femoral analgesia after anterior cruciate ligament reconstruction; however it is unknown whether both drugs are equally effective regarding pain control, preservation of mobility and patient satisfaction.

METHODS AND MATERIALS

In this randomized, placebo-controlled trial 84 patients undergoing anterior cruciate ligament (ACL) reconstruction with quadruple hamstring tendons were studied. For postoperative pain therapy levobupivacaine 0.125%, ropivacaine 0.2% or placebo control with NaCl 0.9% at a rate of 6 ml/h were used for 48 h using a femoral nerve catheter. All patients also received an i.v. patient-controlled analgesia (IVPCA) pump with piritramide.

RESULTS

Patient satisfaction was significantly higher and night rest was better in both treatment groups compared to the placebo group but there appeared to be no major differences between the two local anesthetics. Opioid consumption was significantly higher in the placebo group compared to the levobupivacaine group but not the ropivacaine group. The pain scores showed a trend towards higher scores in the placebo group throughout but the difference only reached statistical significance on postoperative day 1. No statistical significant differences in motor block were found between the three groups.

CONCLUSION

Postoperative analgesia for ACL reconstruction during the first 48 h using femoral block with a continuous infusion of levobupivacaine 0.125% or ropivacaine 0.2% in combination with an IVPCA is similarly effective and better than a placebo. Both studied drugs seem to be equally appropriate for this purpose.

Hamstring donor-site block: evaluation of pain control after anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to evaluate the effectiveness of using a hamstring donor-site block in controlling postoperative pain levels after anterior cruciate ligament (ACL) reconstruction with autogenous hamstring graft.

METHODS

Over a 5-month period, 27 patients underwent ACL reconstruction with hamstring autograft. All patients received a preoperative femoral nerve block. Intraoperatively, these patients were randomly assigned to groups with and without a hamstring donor-site block. The block group received a 20-mL injection of 0.25% bupivacaine into the hamstring donor site through an arthroscopic shaver sleeve. Both groups received standard postoperative pain medications as needed. Postoperative pain scores were taken by use of a visual analog scale (VAS) and recorded immediately on arrival to the recovery room, at 1 hour after arrival, and at 2 hours after arrival.

RESULTS

There were 15 patients in the hamstring donor-site block group and 12 patients in the standard treatment group. For the block group, mean VAS scores were 3.20 +/- 2.54 on arrival, 2.80 +/- 1.61 at 1 hour, and 2.87 +/- 1.41 at 2 hours. For the standard treatment group, mean VAS scores were 5.50 +/- 1.62 on arrival, 6.08 +/- 1.56 at 1 hour, and 5.33 +/- 2.02 at 2 hours. The hamstring block group had statistically significantly lower mean VAS scores on arrival (P = .0118), at 1 hour (P = .0001), and at 2 hours (P = .0010). There were no complications in either group.

CONCLUSIONS

Injection of the hamstring donor site with local anesthetic through an arthroscopic shaver sleeve showed a statistically significant improvement in postoperative pain levels in patients undergoing autogenous hamstring ACL reconstruction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Femoral nerve block use in anterior cruciate ligament reconstruction surgery

PURPOSE

The goal of this study was to determine whether femoral nerve blocks (FNBs) provide patients undergoing anterior cruciate ligament reconstruction greater pain relief or other benefits compared with more standard pain medication regimens.

METHODS

We searched PubMed, EMBASE, and the Cochrane Database using the following search terms: "ACL or anterior cruciate ligament" and "femoral nerve block or peripheral nerve block" or "regional anesthesia." Thirteen studies were found that fit the inclusion criteria of being randomized controlled trials with a Level of Evidence of I or II, comparing FNB or 3-in-1 blocks with control groups undergoing various multimodal pain regimens.

RESULTS

Only 5 of the 13 studies found a significant difference in pain relief with FNB compared with the control groups; however, the difference in several of the studies may not be clinically relevant. Of the 13 studies, 6 examined parameters other than pain, and only 1 study found a greater incidence of nausea and sedation in its control group. Patient satisfaction was examined in 2 studies, with both finding no difference between groups. Nine studies used a single graft type, and the two studies using multiple graft types accounted for this in their analyses.

CONCLUSIONS

On the basis of the available Level I and II data from randomized controlled trials, there appears to be no evidence that FNBs add additional benefit over multimodal analgesia. FNBs have not been shown to significantly affect patient pain, readiness for discharge, or outcome scores. There is a small but identifiable risk associated with performing FNBs, with potentially catastrophic effects.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II randomized controlled trials with minimal heterogeneity.

Femoral nerve blocks

Femoral nerve blocks and indeed all peripheral nerve blocks have become a popular, safe and effective method of providing postoperative analgesia. The advantages of a femoral nerve block for lower limb surgery include good postoperative analgesia, a reduction in the need for opioids (thus reducing the associated complications of opioids such as nausea, vomiting, itching and confusion (Allen et al 1998, Wang et al 2002)) and the potential for earlier mobilisation and discharge from the hospital (Wang et al 2002, Ilfeld et al 2008).

Pre-emptive intra-articular administration of local anaesthetics/opiates versus postoperative local anaesthetics/opiates or local anaesthetics in arthroscopic surgery of the knee joint: a prospective randomized trial

AIM

Arthroscopic surgery on the knee joint is increasingly being performed as day-case surgery. This necessitates adequate postoperative pain therapy. We performed a study to compare three different intra-articular regimens of pain treatment. The hypothesis was that preoperative intra-articular pain management is superior to postoperative procedures.

METHOD

In this study we compared the preoperative administration of 0.1 mg fentanyl + 5 ml bupivacaine 0.5% with the postoperative administration of either 0.1 mg fentanyl + 5 ml bupivacaine 0.5% or 5 ml bupivacaine 0.5% alone in a total of 564 patients. Participants were randomly assigned to three groups. Each group was subdivided into patients with and without synovitis.

RESULTS

The preoperative administration of fentanyl and bupivacaine significantly decreased the perceived pain. The efficiency increased with major arthroscopic procedures. Postoperative administration of bupivacaine alone had the least effect. There was variation within each group depending on whether synovitis was present or not.

CONCLUSION

This study demonstrated the superiority of the preoperative intra-articular administration of a combination of fentanyl and local anaesthetic over postoperative fentanyl and local anaesthetic or postoperative local anaesthetic alone.

Intra-articular sufentanil in multimodal analgesic management after outpatient arthroscopic anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded study

PURPOSE

This prospective, randomized, blinded study was designed to evaluate the effectiveness of intra-articular sufentanil, ropivacaine, and clonidine compared with that of ropivacaine and clonidine without sufentanil on postoperative pain after arthroscopic reconstruction of the anterior cruciate ligament of the knee.

METHODS

One hundred twenty patients were enrolled and randomly divided into 2 groups. At the end of the operation, the surgeon injected 20 mL of a solution containing 5 microg sufentanil, 100 mg ropivacaine, and 1 microg/kg clonidine in the knees of patients in group A whereas the surgeon injected the same solution without sufentanil in group B. During the postoperative period and for the first 24 hours, we recorded pain intensity using a visual analog scale.

RESULTS

All patients were discharged after a few hours with well-controlled pain. Pain scores were low in both groups both before and after discharge. We did not show any difference in pain scores at any time point. During the first postoperative hour, patients in group B required more rescue analgesic drugs (P < .05).

CONCLUSIONS

In our patients the addition of sufentanil in the intra-articular solution did not provide better control of pain.

LEVEL OF EVIDENCE

Level I, therapeutic randomized controlled trial.

Pre- versus postoperative intraarticular application of local anesthetics and opioids versus femoral nerve block in anterior cruciate ligament repair

BACKGROUND

Often anterior cruciate ligament (ACL) reconstruction is performed as outpatient surgery. This requires a patient friendly postoperative pain management. Three common procedures were compared in this trial.

METHODS

In a prospective, randomized study the effect of postoperative pain management using preoperative intraarticular anesthesia (0.1 mg Fentanyl + 8 ml Bupivacain 0.5%) was compared with postoperative intraarticular anesthesia (0.1 mg Fentanyl + 8 ml Bupivacain 0.5%) and the femoralis 3-in-1 nerve block (20 ml Prilocain 1% + 20 ml Bupivacain 0.5%) in 157 patients who underwent arthroscopic ACL-plasty.

RESULTS

Preoperative intraarticular anesthesia and the femoralis 3-in-1 nerve block showed the same postoperative analgesia and satisfactory pain scores in most cases. Postoperative intraarticular anesthesia was less effective.

CONCLUSION

Our data show that in anterior cruciate ligament reconstruction preoperative intraarticular analgesia with Bupivacain/Fentanyl is satisfactory and equal to the femoralis 3-in-1 nerve block with Bupivacain.

Continuous femoral nerve block versus intra-articular injection for pain control after anterior cruciate ligament reconstruction

BACKGROUND

Continuous femoral nerve blocks have been recommended for postoperative pain control after anterior cruciate ligament reconstruction.

HYPOTHESIS

A pain control protocol involving a continuous ropivacaine femoral nerve block will decrease pain and narcotic use in the first 24 hours after surgery compared with a postoperative pain control protocol involving an intra-articular injection of bupivacaine/morphine.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

Ninety subjects, aged 15 years or older, who were receiving arthroscopically assisted bone-patellar tendon-bone anterior cruciate ligament reconstruction were randomly assigned to 2 groups. The first group received a ropivacaine continuous femoral nerve block and oral hydrocodone (block group). The second group received an intra-articular bupivacaine/morphine injection and oral oxycodone (injection group). Patients in both groups could receive intramuscular injection of hydromorphone for breakthrough pain; most patients in the block group also received bolus doses of ropivacaine through the femoral catheter. Subjects rated their worst, average, and current pain levels using a visual analog scale and category-ratio scale the morning after surgery. Postoperative narcotic pain medication use was converted to morphine-equivalent doses.

RESULTS

Postoperative pain ratings did not differ between the treatment groups. The largest difference in pain ratings between the groups was 0.5 cm for worst pain level (P = .345). Total narcotic use did not differ significantly between groups (1.1 morphine-equivalent doses in both groups; P = .671).

CONCLUSIONS

Continuous femoral block with ropivacaine appeared to have no clinical advantage in the immediate postoperative period after anterior cruciate ligament reconstruction when compared with an intra-articular injection of bupivacaine/morphine. Both methods are effective for pain control after anterior cruciate ligament reconstruction.

Peripheral Nerve Block Techniques for Ambulatory Surgery

Peripheral nerve blocks (PNBs) have an increasingly important role in ambulatory anesthesia and have many characteristics of the ideal outpatient anesthetic: surgical anesthesia, prolonged postoperative analgesia, and facilitated discharge. Critically evaluating the potential benefits and supporting evidence is essential to appropriate technique selection. When PNBs are used for upper extremity procedures, there is consistent opioid sparing and fewer treatment-related side effects when compared with general anesthesia. This has been demonstrated in the immediate perioperative period but has not been extensively investigated after discharge. Lower extremity PNBs are particularly useful for procedures resulting in greater tissue trauma when the benefits of dense analgesia appear to be magnified, as evidenced by less hospital readmission. The majority of current studies do not support the concept that a patient will have difficulty coping with pain when their block resolves at home. Initial investigations of outpatient continuous peripheral nerve blocks demonstrate analgesic potential beyond that obtained with single-injection blocks and offer promise for extending the duration of postoperative analgesia. The encouraging results of these studies will have to be balanced with the resources needed to safely manage catheters at home. Despite supportive data for ambulatory PNBs, most studies have been either case series or relatively small prospective trials, with a narrow focus on analgesia, opioids, and immediate side effects. Ultimately, having larger prospective data with a broader focus on outcome benefits would be more persuasive for anesthesiologists to perform procedures that are still viewed by many as technically challenging.

Intraarticular Bupivacaine-Clonidine-Morphine Versus Femoral-Sciatic Nerve Block in Pediatric Patients Undergoing Anterior Cruciate Ligament Reconstruction

We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 microg/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 microg/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 +/- 40 microg versus 80 +/- 50 microg; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 +/- 3 versus 5.4 +/- 3; P = 0.0002) and during the first 24 h (1.6 +/- 1 versus 2.9 +/- 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 +/- 13 mg versus 21 +/- 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.