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

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.

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.

Contribution of Multimodal Analgesia to Postoperative Pain Outcomes Immediately After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Level 1 Randomized Clinical Trials

BACKGROUND

Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe pain in the immediate postoperative period. The optimal individual preemptive or intraoperative anesthetic modality on postoperative pain control is not well-known.

PURPOSE

To systematically review and perform a meta-analysis comparing postoperative pain scores (visual analog scale [VAS]), opioid consumption, and incidence of complications during the first 24 hours after primary ACLR in patients receiving spinal anesthetic, adjunct regional nerve blocks, or local analgesics.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

PubMed, Embase, MEDLINE, Biosis Previews, SPORTDiscus, Ovid, PEDRO, and the Cochrane Library databases were systematically searched from inception to March 2020 for human studies, using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Inclusion criteria consisted of (1) level 1 studies reporting on the use of spinal anesthesia, adjunct regional anesthesia (femoral nerve block [FNB] or adductor canal block [ACB]), or local analgesia in patients undergoing primary ACLR and (2) studies reporting on patient-reported VAS, opioid consumption, and incidence of complications related to anesthesia within the first 24 hours after surgery. Non-level 1 studies, studies utilizing a combination of anesthetic modalities, and those not reporting outcomes during the first 24 hours were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine postoperative pain, opioid use, and complications based on anesthetic modality at multiple time points (0-4, 4-8, 8-12, 12-24 hours).

RESULTS

A total of 263 studies were screened, of which 27 level 1 studies (n = 16 regional blocks; n = 12 local; n = 4 spinal) met the inclusion criteria and were included in the meta-analysis. VAS scores were significantly lower in patients receiving a regional block as compared with spinal anesthesia 8 to 12 hours after surgery (P < .01), patients receiving an FNB versus ACB at 12 to 24 hours (P < .01), and those treated with a continuous FNB rather than single-shot regional blocks (FNB, ACB) at 12 to 24 hours (P < .01). No significant difference in VAS was appreciated when spinal, regional, and local anesthesia groups were compared.

CONCLUSION

Based on evidence from level 1 studies, pain control after primary ACLR based on VAS was significantly improved at 8 to 12 hours in patients receiving regional anesthesia as compared with spinal anesthesia. Pain scores were significantly lower at 12 to 24 hours in patients receiving FNB versus ACB and those treated with continuous FNB rather than single-shot regional anesthetic.

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.

Intra-articular Morphine and Ropivacaine Injection Provides Efficacious Analgesia As Compared With Femoral Nerve Block in the First 24 Hours After ACL Reconstruction: Results From a Bone-Patellar Tendon-Bone Graft in an Adolescent Population

Background:

Opioid consumption and patient satisfaction are influenced by a surgeon’s pain-management protocol as well as the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction are femoral nerve blockade and intra-articular injection; however, debate remains regarding the more efficacious methodology.

Hypothesis:

We hypothesized that intra-articular injection with ropivacaine and morphine would be found to be as efficacious as a femoral nerve block for postoperative pain management in the first 24 hours after bone–patellar tendon–bone (BTB) ACL reconstruction.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Charts were retrospectively reviewed for BTB ACL reconstructions performed by a single pediatric orthopaedic surgeon from 2013 to 2019. Overall, 116 patients were identified: 58 received intra-articular injection, and 58 received single-shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MMEs) consumed were tabulated for each patient.

Results:

Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block (P = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; P = .008). There was significantly less MME consumption in patients receiving intra-articular injection versus peripheral block at 16 to 20 hours (3.2 vs 5.6 MMEs; P = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; P < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; P = .19).

Conclusion:

Within the limitations of this study, we could identify no significant difference in MME consumption between the single-shot femoral nerve block group and intra-articular injection group in the first 24 hours postoperatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require fewer opioids 16 to 24 hours postoperatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction.

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.

Neurological structures and mediators of pain sensation in anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) tears is a devastating injury and one of the most common knee injuries experienced by athletes in the United States. Although patients reach maximal subjective improvement by one-year following ACL reconstruction, many patients often experience moderate to severe post-operative pain. Opioids, intra-articular injections, and regional anesthesia have been previously implemented to mediate post-operative pain. However, chronic opioid usage has become an epidemic in the United States. Alternative analgesic modalities, such as nerve blocks, have been implemented in clinical practice to provide adequate pain relief and minimize opioid usage. Periarticular injections targeted towards local neurological structures performed concomitantly with nerve blocks provides superior pain relief and satisfaction than isolated nerve blocks. Therefore, it is imperative for physicians to understand local neurological anatomy around the knee joint in order to provide adequate analgesia while minimizing opioid consumption. This purpose of this investigation is to summarize (1) neurogenic origins of pain generators and mediators in sites affected by ACL reconstruction and autograft harvest sites and (2) analgesia utilized in ACL reconstruction.

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).

Efficacy of the Adductor Canal Approach to Saphenous Nerve Block for Anterior Cruciate Ligament Reconstruction With Hamstring Autograft: A Randomized Controlled Trial

Background

For reconstruction of the anterior cruciate ligament (ACL) with hamstring autograft, perioperative analgesia can be achieved with multimodal analgesia and intra-articular local anesthesia infiltration with or without additional regional blocks. Saphenous nerve block (SNB) via the adductor canal is commonly used in our practice, but its benefit has not been well established in the literature.

Purpose

To assess the efficacy of SNB in ACL reconstruction with hamstring autograft.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Consecutive patients undergoing arthroscopic ACL reconstruction with hamstring autograft were randomized into a control group (no SNB) and an intervention group (SNB). All patients received standardized anesthetic induction and maintenance agents with perioperative analgesia, per study protocol, with local anesthetic infiltration of the graft harvest site and intra-articular infiltration.

Results

Sixty patients were randomized into the 2 groups (n = 30 each). There was no statistically significant difference in total opiate consumption between the groups (control, 34 mg; SNB, 31 mg; P = .40). There was no statistically significant difference in visual analog scale scores for pain at 0, 8, and 24 hours postsurgery, and no difference in overall satisfaction score. The control group had a significantly higher visual analog scale score at 4 hours postsurgery (3.0 vs 1.9, P = .04).

Conclusion

SNB has a minimal effect on postsurgical care for ACL reconstruction with hamstring autograft in the presence of multimodal analgesia and local anesthetic infiltration.

Quadriceps Strength Deficits After a Femoral Nerve Block Versus Adductor Canal Block for Anterior Cruciate Ligament Reconstruction: A Prospective, Single-Blinded, Randomized Trial

Background:

Peripheral nerve blocks, particularly femoral nerve blocks (FNBs), are commonly performed for anterior cruciate ligament (ACL) reconstruction. However, associated quadriceps muscle weakness after FNBs is well described and may occur for up to 6 months postoperatively. The adductor canal block (ACB) has emerged as a viable alternative to the FNB, theoretically causing less quadriceps weakness during the immediate postoperative period, as it bypasses the majority of the motor fibers of the femoral nerve that branch off proximal to the adductor canal.

Purpose/Hypothesis:

This study sought to identify if a difference in quadriceps strength exists after an ACB or FNB for ACL reconstruction beyond the immediate postoperative period. Beyond the immediate postoperative period, we anticipated no difference in quadriceps strength between patients who received ACBs or FNBs for ACL reconstruction.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 102 patients undergoing primary ACL reconstruction using a variety of graft types were enrolled between November 2015 and April 2016. All patients were randomized to receive an ACB or FNB before surgery, and the surgeon was blinded to the block type. All patients underwent aggressive rehabilitation without functional bracing postoperatively. The time to the first straight-leg raise was reported by the patient. Isokinetic strength testing was performed at 3 and 6 months postoperatively.

Results:

Data for 73 patients were analyzed. There was no significant difference in patient demographics of age, body mass index, sex, or tourniquet time between the FNB (n = 35) and ACB (n = 38) groups. The mean time to the first straight-leg raise was similar, at 13.1 ± 1.0 hours for the FNB group and 15.5 ± 1.2 hours for the ACB group (P = .134). The mean extension torque at 60 deg/s increased significantly for both the ACB (53.7% ± 3.4% to 68.3% ± 2.9%; P = .008) and the FNB (53.3% ± 3.3% to 68.5% ± 4.1%; P = .006) groups from 3 to 6 months postoperatively. There was also no significant difference in mean extension torque at 60 deg/s or 180 deg/s between the FNB and ACB groups at 3 and 6 months. There were no significant differences in postoperative complications (infection, arthrofibrosis, retear) between groups.

Conclusion:

Although prior studies have shown immediate postoperative benefits of ACBs compared with FNBs, with a faster return of quadriceps strength, in the current study there was no statistically or clinically significant difference in quadriceps strength at 3 and 6 months postoperatively in patients who received ACBs or FNBs for ACL reconstruction.

Single-Shot Femoral Nerve Block Does Not Cause Long-Term Strength and Functional Deficits Following Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine if patients treated with a single-shot femoral nerve block have strength and functional deficits at 9-month follow-up.

METHODS

Forty-three patients who underwent primary anterior cruciate ligament reconstructions were randomized to receive either a preoperative single-shot femoral nerve block or local infiltration anesthesia for primary pain control. All patients underwent a standardized comprehensive rehabilitation program postoperatively. Isokinetic strength and function was tested using a Biodex machine at 9 months or more postoperatively comparing the operative and nonoperative extremity.

RESULTS

No significant difference in strength was found at an average of 10.6 months postoperatively (range, 9-15 months) between the femoral nerve block and control groups. In comparing strength deficits, we found no difference in slow isokinetic extension strength (22.4% vs 27.8%, P = .51), fast isokinetic extension strength (18.5% vs 12.5%, P = .41), slow isokinetic flexion strength (11.0% vs 15.1%, P = .55), and fast isokinetic flexion strength (8.2% vs 4.9%, P = .56) in the femoral nerve block versus control groups, respectively. In terms of functional outcomes, there also was no difference in deficits for single-leg hop distance (P = .12), timed single-leg hop (P = .74), and single-leg triple hop distance (P = .94). Maximal strength noted to be within 15% of the contralateral limb was achieved in 40% of patients and maximal function in 63% of patients at an average of 10.6 months postoperatively. A 13% complication rate was found in patients who received a femoral nerve block (1 with prolonged quadriceps inhibition and 2 with prolonged sensory disturbances).

CONCLUSIONS

Our study found a 13% motor/sensory complication rate in patients who underwent femoral nerve block for pain control after anterior cruciate ligament reconstruction. Although these deficits may persist, they are not permanent and are not different when compared with controls at 9-month follow-up. However, maximal strength and function are not fully restored at normal return to play time and rehabilitation should continue long term to maximize recovery.

LEVEL OF EVIDENCE

Level I, prospective randomized trial.

Pain Management After Outpatient Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Effective pain management after anterior cruciate ligament (ACL) reconstruction improves patient satisfaction and function.

PURPOSE

To collect and evaluate the available evidence from randomized controlled trials (RCTs) on pain control after ACL reconstruction.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature review was performed using PubMed, Medline, Google Scholar, UpToDate, Cochrane Reviews, CINAHL, and Scopus following PRISMA guidelines (July 2014). Only RCTs comparing a method of postoperative pain control to another method or placebo were included.

RESULTS

A total of 77 RCTs met inclusion criteria: 14 on regional nerve blocks, 21 on intra-articular injections, 4 on intramuscular/intravenous injections, 12 on multimodal regimens, 6 on oral medications, 10 on cryotherapy/compression, 6 on mobilization, and 5 on intraoperative techniques. Single-injection femoral nerve blocks provided superior analgesia to placebo for up to 24 hours postoperatively; however, this also resulted in a quadriceps motor deficit. Indwelling femoral catheters utilized for 2 days postoperatively provided superior analgesia to a single-injection femoral nerve block. Local anesthetic injections at the surgical wound site or intra-articularly provided equivalent analgesia to regional nerve blocks. Continuous-infusion catheters of a local anesthetic provided adequate pain relief but have been shown to cause chondrolysis. Cryotherapy improved analgesia compared to no cryotherapy in 4 trials, while in 4 trials, ice water and water at room temperature provided equivalent analgesic effects. Early weightbearing decreased pain compared to delayed weightbearing. Oral gabapentin given preoperatively and oral zolpidem given for the first week postoperatively each decreased opioid consumption as compared to placebo. Ibuprofen reduced pain compared to acetaminophen. Oral ketorolac reduced pain compared to hydrocodone-acetaminophen.

CONCLUSION

Regional nerve blocks and intra-articular injections are both effective forms of analgesia. Cryotherapy-compression appears to be beneficial, provided that intra-articular temperatures are sufficiently decreased. Early mobilization reduces pain symptoms. Gabapentin, zolpidem, ketorolac, and ibuprofen decrease opioid consumption. Despite the vast amount of high-quality evidence on this topic, further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption.

CLINICAL RELEVANCE

These results provide the best available evidence from RCTs on pain control regimens after ACL reconstruction.

Immediate post-operative pain in anterior cruciate ligament reconstruction surgery with bone patellar tendon bone graft versus hamstring graft

Background

Pain in the immediate post-operative period after anterior cruciate ligament (ACL) surgery, apart from an unpleasant experience for the patient, can act as a barrier for static quadriceps contractions and optimum execution of the initial rehabilitation protocol resulting in slow recovery and a later return to full function for a sportsperson. There is no report in the literature comparing pain in the immediate post-operative period after using the two most widely used autografts, bone patellar tendon bone (BPTB) graft and hamstring graft.

Methods

The present study compared the visual analogue scale (VAS) pain score in the immediate post-operative period after arthroscopic ACL reconstruction with the BPTB and hamstring autografts. Both groups consisted of 50 patients each. The mean age of the BPTB and hamstring cohorts was 26.9 ± 7.3 years (age range 18–59 years) and 26.7 ± 9.0 years (age range 17–52 years), respectively. Unpaired t test was applied to compare pain scores between the BPTB and hamstring cohorts.

Results

In the present study, patients in the BPTB cohort showed higher mean pain scores across all the post-operative time intervals except at 6 h. However, the difference in the mean VAS pain score at post-operative 6, 12,18, 24, 36 and 48 h in the two groups was statistically not significant (p value of 1, 0.665, 0.798, 0.377, 0.651 and 0.215 at 6, 12, 18, 24, 36 and 48 h, respectively).

Conclusions

Our study concludes that the arthroscopic ACL reconstruction with BPTB autograft and hamstring autograft is associated with similar pain in the immediate post-operative period. As a result, aggressive physiotherapy regime is not affected by the type of graft being used for ACL reconstruction, as the pain scores in the immediate post-operative period are similar for both techniques.

Trial registration

Clinical Trials Registry-India, CTRI/2016/01/006502

Comparison of intraarticular bupivacaine and levobupivacaine with morphine and epinephrine for knee arthroscopy

OBJECTIVE

To compare the efficacy of intraarticularly injected bupivacaine with levobupivacaine when administered in combination with morphine and adrenaline for post-operative analgesia and functional recovery after knee surgery.

MATERIALS AND METHODS

Sixty American Society of Anesthesiologists physical status I-II patients were randomized into three groups: Group B was administered 30 mL isobaric 0.5% bupivacaine, 2 mg morphine and 100 μg adrenaline, Group L was administered 30 mL 0.5% levobupivacaine, 2 mg morphine and 100 μg adrenaline, and Group C was administered 30 mL 0.9% NaCl solution into the knee joint by the surgeon at the end of surgery. The morphine usage and visual analog pain scores were recorded regularly afterwards. We also recorded the time that elapsed before each patients' first mobilization, positive response to straight leg raising, tolerance to 30-50° knee flexion, recovery of quadriceps reflexes and discharge from the hospital. We also recorded patient and surgeon satisfaction.

RESULTS

The pain scale values were lower in Groups B and L than in Group C at 2, 4, 6, 8, 12 and 24 hours post-operatively (all p<0.001). In Groups B and L, the time for first analgesic request was longer (p<0.01), the morphine consumption was lower (p<0.001), and the duration of morphine usage was shorter (p<0.001). The times to positive response to straight leg raising, tolerance to 30-50° knee flexion and the first mobilization were shorter in Groups B and L (p<0.001 for all).

CONCLUSION

After arthroscopic knee surgery, intraarticular levobupivacaine combined with morphine and adrenaline decreases analgesic requirements, shortens the postoperative duration of analgesic use and hastens mobilization as effectively as bupivacaine.

Analgesic effect of hamstring block after anterior cruciate ligament reconstruction compared with placebo: a prospective randomized trial

PURPOSE

To evaluate the effect of a hamstring block for postoperative pain management using 20 mL of 0.25% bupivacaine compared with placebo after anterior cruciate ligament (ACL) reconstruction with a hamstring autograft.

METHODS

In a 3-month period, 45 patients undergoing ACL reconstruction with a hamstring autograft who all received a femoral nerve block were randomized to receive either 20 mL of 0.25% bupivacaine or 20 mL of saline water administered through a catheter into the donor-site space. The patients and recovery staff were blinded to the treatment. Postoperative donor-site pain was evaluated subjectively by the patients using a pain score (Likert scale from 0 to 10). The pain was registered for each hour in the first 6 hours and thereafter once daily for 8 days. Furthermore, the requirement for postoperative analgesic medicine was registered.

RESULTS

The hamstring block group (n = 23) had significantly less pain for each of the first 6 postoperative hours. The pain score was reduced from 4.2 to 2.3 (95% confidence interval, 1.3 to 3.3) (P = .01) in the first hour and from 2.8 to 1.3 (95% confidence interval, 0.6 to 1.9) in the sixth hour, and there was a significantly lower overall requirement for early postoperative fentanyl, reduced from a mean of 58 to 35 μg (P = .02), and morphine, reduced from a mean of 10 to 6 mg (P = .04). After 6 hours, there was no difference in the pain level and use of analgesics between the 2 groups.

CONCLUSIONS

With the use of a donor-site block in hamstring ACL reconstruction, the donor-site pain level, as well as the overall requirement for fentanyl and morphine, was significantly reduced in the first 6 postoperative hours. No effect of the donor-site block was seen after 6 hours.

LEVEL OF EVIDENCE

Level I, therapeutic, randomized controlled study.

Pain management after total knee arthroplasty: a case–control study of continuous nerve block therapy

BACKGROUND

Continuous femoral nerve block infusions (CFNBIs) have been found to both decrease patient postoperative pain and improve postoperative joint mobilization, both of which impact patient satisfaction, outcome, and length of stay. When we began the use of CFNBIs, we needed to create a policy, process, standing order form, and staff education plan as well as a means to maximize therapy efficacy and believed that a research study would best meet those needs.

PURPOSE

To evaluate the patient response to the institution of CFNBI therapy, identify process improvement areas, and suggest areas for future study.

METHODS

Through retrospective chart review, using a case–control research design with 27 pairs of patients matched by body mass index, American Society of Anesthesiologists patient physical status classification, and age, we examined whether patients receiving CFNBI therapy after total knee arthroplasty would report less postoperative pain, require less narcotics, and achieve mobilization goals earlier than patients receiving traditional narcotic analgesia only.

RESULTS

The CFNBI case group reported significantly less pain over the fi rst three postoperative days ( p = .05), but findings revealed no significant differences between case and control groups in total narcotic use or achievement of mobility goals. On the basis of this study, we increased the CFNBI drug concentration and expect that this will allow us to meet all 3 patient goals.

CONCLUSION

This study has added to previous research that supports CFNBI as a proven therapy to decrease postoperative pain in patients undergoing total knee arthroplasty. The structure of a research project facilitates the implementation, evaluation, and improvement of such new therapies. Evaluating patient data allows identification of process improvement areas—in our case, the change in drug concentration—as well as the need for staff education aimed at facilitating their active participation in CFNBI therapy.

Utility of multimodal analgesia with fascia iliaca blockade for acute pain management following hip arthroscopy

PURPOSE

The purpose of this study was to evaluate the utility of multimodal analgesia with fascia iliaca blockade and for acute pain control in patients undergoing hip arthroscopy.

METHODS

Thirty consecutive patients undergoing primary hip arthroscopy were prospectively studied. All patients were treated preoperatively with ultrasound-guided single injection fascia iliaca blockade and multimodal analgesia. Data collected included post-operative nausea, numeric rating scale (NRS) pain scores during rest and activity, opioid consumption during the first five days (recorded as tablets of 5 mg hydrocodone/500 mg acetaminophen) and overall patient satisfaction with analgesia.

RESULTS

This study included 23 female and 7 male patients with a median age of 35 years (range 14-58). No patient required medication for post-operative nausea. The overall NRS scores were an average of 3.9 on day 0, 3.6 on day 1, 3.4 on day 2, 2.9 on day 3, 3.0 on day 4 and 2.7 on day 5. The average tablets of opioid taken were 1.5 on day 0, 1.2 on day 1, 1.3 on day 2, 1.0 on day 3, 1.1 on day 4 and 0.9 on day 5. Overall, 20 patients rated their post-operative pain control as very satisfied (67 %), and 10 patients as satisfied (33 %). There were no complications or side effects from the fascia iliaca blockade.

CONCLUSION

In this prospective study, multimodal analgesia with fascia iliaca blockade following hip arthroscopy was safe and effective. The quality of early post-operative analgesia provided by the fascia iliaca blockade was excellent and resulted in low opioid consumption, high quality of pain relief and high overall patient satisfaction.

Intra-articular morphine versus bupivacaine for postoperative pain management

The purpose of this study was to determine whether morphine would be as effective as bupivacaine for postoperative pain control after knee arthroscopy with no worsening of the side effect profile. Eighty-two patients who underwent partial meniscectomy, chondral debridement, or both were prospectively randomized to receive 10 mg of morphine (10-cc volume) or 10 cc of .5% bupivacaine immediately postoperatively. Visual analog scale scores and side effect profiles were recorded in the postanesthesia care unit, in the transitional care unit, and then every 4 hours postoperatively until 24 hours. In-hospital data were available for all 82 patients, but postdischarge data were available for only 64 patients. Visual analog scale scores in the postanesthesia care unit decreased from 3.4 on admission to 2.4 on discharge for the morphine group and from 2.6 to 2.4 for the bupivacaine group (P>.217, all time points). Medication use was the same for both groups in the hospital (62% and 78%, respectively) with no statistical difference. Visual analog scale scores decreased from 3.0 to 1.5 for the morphine group and from 2.8 to 1.8 for the bupivacaine group between 4 and 24 hours postoperatively (P>.376, all time points). Medication use decreased between 4 and 24 hours postoperatively for both groups, from 71.7% to 52.9%, respectively, with no statistical difference at all time points. Four patients in the morphine group and 1 patient in the bupivacaine group experienced side effects. This study indicates that 10 mg of intra-articular morphine is as effective as 10 cc of .5% bupivacaine for postoperative pain control for partial meniscectomy and chondral debridement of the knee. It minimally increases side effects initially and circumvents the issue of chondral toxicity of bupivacaine.

Advanced age, obesity and continuous femoral nerve blockade are independent risk factors for inpatient falls after primary total knee arthroplasty

We asked whether femoral nerve blockade (FNB) was an independent risk factor for inpatient post-operative falls after total knee arthroplasty (TKA). Data on 2197 primary TKAs were collected from our institution between 2003 and 2010. Patient demographics, type and duration of blocks were considered predictors of falls in a logistic regression model. Among 60 (2.7%) falls, the odds ratio was 1.04 (1.0-1.07; p=0.008) for each 1 year of increased age above the mean (66 years), 2.4 (1.3-4.5; p=0.005) for BMI >30 kg/m(2) and 4.4 (1.04-18.2; p=0.04) for continuous FNB. Single-shot FNB did not increase risk. No fall resulted in operative morbidity. The use of continuous FNB should be cautioned, especially in patients with other risk factors such as obesity and advanced age.

[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.

Intra-articular morphine enhances analgesic efficacy of ropivacaine for knee arthroscopy in ambulatory patients

The aim of this double-blind, randomized control trial was to compare the effectiveness of intra-articular ropivacaine alone or with morphine or ketoprofen for controlling pain after arthroscopic knee surgery. One hundred fifty-six patients scheduled for elective knee arthroscopy were recruited. All patients received general anesthesia and were randomly assigned to 4 groups to receive intra-articular ropivacaine 40 mg (group R), ropivacaine 24 mg plus morphine 8 mg (group R+M), ropivacaine 36 mg plus ketoprofen 100 mg (group R+K), or normal saline (group N/S). Pain, sedation, orientation, nausea, vomiting, and urine retention were recorded at 0, 1, 2, 4, 8, 12, and 24 hours postoperatively. Pain was evaluated by a 10-cm visual analog scale (VAS). When the pain was >2, a suppository of 400 mg paracetamol plus 10 mg codeine plus 50 mg caffeine was given. Results showed that at 4 hours postoperatively, pain differed significantly among the 4 groups (P<.001), with less pain recorded in the R+M group. Similarly, the number of suppositories administered postoperatively to the R+M group was significantly less (P<.001) vs the other groups. Patients who received ropivacaine and morphine or normal saline had a higher incidence of nausea and vomiting vs the other groups (P=.001 and P=.036, respectively). The combination of intra-articular ropivacaine and morphine is associated with less pain after knee arthroscopy during early recovery but with a higher incidence of nausea and vomiting. However, the addition of ketoprofen to ropivacaine provides relatively satisfactory pain relief, but with fewer side effects compared to morphine.

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.

Intra-articular morphine and bupivicaine for post-operative analgesia in anterior cruciate ligament reconstruction: a prospective randomised controlled trial

Anterior cruciate ligament reconstruction (ACLR) has the potential for significant post-operative pain. Conventional systemic opiate treatment may cause nausea and drowsiness, which may delay recovery. The use of intra-articular local anaesthesia has been shown to be effective. We wished to examine the additional effect of intra-articular morphine. This is a prospective, randomised, double-blind trial. Sixty patients were randomised to receive 20 ml 0.5% bupivicaine (group L, n = 30) or bupivicaine with 10 mg morphine (group M, n = 30) by intra-articular injection at the end of the operation. Visual analogue scores (VAS) were recorded before ACLR (expected pain) and repeated at 6 and 24 h after surgery. Time to first analgesic request and total systemic opiate and other analgesic use in the first 24 h was recorded. Pre-operative VAS measurements did not predict pain or analgesic use post-operatively. There were no significant differences between groups L and M with regard post-operative VAS or time to first analgesic request. Group M required less opiate analgesic post-operatively (oral morphine equivalent 50 mg for group L and 27 mg for group M, P < 0.007). There were no complications associated with the intra-articular analgesic. The simple addition of morphine to the intra-articular injection of bupivicaine gives a significant reduction in opiate analgesic requirement after ACLR.

Wound infiltration for surgery

Wound infiltration with local anaesthetics is a simple, effective and inexpensive means of providing good analgesia for a variety of surgical procedures without any major side-effects. In particular, local anaesthetic toxicity, wound infection and healing do not appear to be major considerations. The purpose of this review is to outline the existing literature on a procedure-specific basis and to encourage a more widespread acceptance of the technique, ensuring that all layers are infiltrated in a controlled and meticulous manner.

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.

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.