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

Indications for Surgery, Activities After Surgery, and Pain Are the Most Commonly Asked Questions in Anterior Cruciate Ligament Injury and Reconstruction

Purpose

To leverage Google's search algorithms to summarize the most commonly asked questions regarding anterior cruciate ligament (ACL) injuries and surgery.

Methods

Six terms related to ACL tear and/or surgery were searched on a clean-installed Google Chrome browser. The list of questions and their associated websites on the Google search page were extracted after multiple search iterations performed in January of 2022. Questions and websites were categorized according to Rothwell's criteria. The Journal of the American Medical Association (JAMA) Benchmark criteria were used to grade website quality and transparency. Descriptive statistics were provided. χ2 and Student t-tests identified for categorical differences and differences in JAMA score, respectively (significance set at P < .05).

Results

A total of 273 unique questions associated with 204 websites were identified. The most frequently asked questions involved Indications/Management (20.2%), Specific Activities (15.8%), and Pain (10.3%). The most common websites were Medical Practice (27.9%), Academic (23.5%), and Commercial (19.5%). In Academic websites, questions regarding Specific Activities were seldom included (4.7%) whereas questions regarding Pain were frequently addressed (39.3%, P = .027). Although average JAMA score was relatively high for Academic websites, the average combined score for medical and governmental websites was lower (P < .001) than nonmedical websites.

Conclusions

The most searched questions on Google regarding ACL tears or surgery related to indications for surgery, pain, and activities postoperatively. Health information resources stemmed from Medical Practice (27.9%) followed by Academic (23.5%) and Commercial (19.5%) websites. Medical websites had lower JAMA quality scores compared with nonmedical websites.

Clinical Relevance

These findings presented may assist physicians in addressing the most frequently searched questions while also guiding their patients to greater-quality resources regarding ACL injuries and surgery.

Prospective Comparison of Postoperative Pain and Opioid Consumption Between Primary Repair and Reconstruction of the Anterior Cruciate Ligament

Background

Anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with postoperative pain and necessitates using perioperative nerve blocks and multimodal analgesic plans.

Purpose

To assess postoperative pain and daily opioid use after ACL repair versus ACLR and to assess whether ACL repair could be performed successfully without using long-acting nerve blocks.

Study Design

Cohort study; Level of evidence, 2.

Methods

All eligible patients who underwent ACL surgery between 2019 and 2022 were prospectively enrolled. Patients were treated with primary repair if proximal tears with sufficient tissue quality were present; otherwise, they underwent single-bundle ACLR with either hamstring tendon or quadriceps tendon autograft. The patients were divided into 3 groups: ACLR with adductor canal nerve block (up to 20 mL of 0.25% bupivacaine with 2 mg dexamethasone), primary repair with nerve block, and primary repair without nerve block. Pain visual analog scale and number of opioids used were recorded during the first 14 postoperative days (PODs). Furthermore, patients completed the Quality of Recovery-15 (QoR-15) survey, and range of motion was assessed. Group differences were compared using Mann-Whitney U test and chi-square test.

Results

Seventy-eight patients were included: 30 (39%) underwent ACLR, 19 (24%) ACL repair with nerve block, and 29 (37%) ACL repair without nerve block. Overall, the ACL repair group used significantly fewer opioids than the ACLR group on POD 1 (1 vs 3, P = .027) and POD 2 (1 vs 3, P = .014) while also using fewer opioids in total (3 vs 8, P = .038). This difference was even more marked when only analyzing those patients who received postoperative nerve blocks (1 vs 8, P = .029). Repair patients had significantly higher QoR-15 scores throughout the first postoperative week, and they had greater range of motion (all P < .05). There were no significant differences in pain scores, opioid usage, or QoR-15 scores between patients who underwent repair with versus without nerve block.

Conclusion

The ACL repair group experienced less postoperative pain during the first 2 weeks after surgery and used significantly fewer opioids than the ACLR group. Furthermore, they had improved knee function and higher recovery quality than patients who underwent ACLR during the initial postoperative period. Postoperative nerve blocks may not be necessary after ACL repair.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

I, Systematic review of Level I studies.

Effects of General Anesthesia Plus Multimodal Analgesia on Immediate Perioperative Outcomes of Hamstring Tendon Autograft ACL Reconstruction

Anterior cruciate ligament reconstruction with hamstring tendon autograft (H-ACLR) is a standard ambulatory procedure with the potential for considerable postoperative pain. We hypothesized that general anesthesia combined with a multimodal analgesia regimen would reduce postoperative opioid use associated with H-ACLR.

Methods

This study was a single-center, surgeon-stratified, double-blinded, placebo-controlled, randomized clinical trial. The primary end point was the total postoperative opioid use during the immediate postoperative period, and secondary outcomes included postoperative knee pain, adverse events, and ambulatory discharge efficiency.

Results

One hundred and twelve subjects, 18 to 52 years of age, were randomized to placebo (57 subjects) or combination multimodal analgesia (MA) (55 subjects). The MA group required fewer opioids postoperatively (mean ± standard deviation, 9.81 ± 7.58 versus 13.88 ± 8.49 morphine milligram equivalents; p = 0.010; effect size = -0.51). Similarly, the MA group required fewer opioids within the first 24 hours postoperatively (mean ± standard deviation, 16.56 ± 10.77 versus 22.13 ± 10.66 morphine milligram equivalents; p = 0.008; effect size = -0.52). The subjects in the MA group reported lower posteromedial knee pain (median [interquartile range, IQR]: 3.0 [0.0 to 5.0] versus 4.0 [2.0 to 5.0]; p = 0.027) at 1 hour postoperatively. Nausea medication was required for 10.5% of the subjects receiving the placebo versus 14.5% of the subjects receiving MA (p = 0.577). Pruritis was reported for 17.5% of subjects receiving the placebo versus 14.5% receiving MA (p = 0.798). The median time to discharge was 177 minutes (IQR, 150.5 to 201.0 minutes) for subjects receiving placebo versus 188 minutes (IQR, 160.0 to 222.0 minutes) for those receiving MA (p = 0.271).

Conclusions

A combination of general anesthesia and local, regional, oral, and intravenous multimodal analgesia appears to reduce postoperative opioid requirements after H-ACLR compared with placebo. Adding preoperative patient education and focusing on donor-site analgesia may maximize perioperative outcomes.

Level of Evidence

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

General, spinal or regional anaesthesia does not affect strength performance 6 months after ACL reconstruction

PURPOSE

The recovery of strength is a key element in successfully returning to sports after ACL reconstruction. The type of anaesthesia has been suspected an influential factor in the post-operative recovery of muscle function.

METHODS

In this retrospective analysis, n = 442 consecutive patients undergoing primary isolated ACL reconstruction using a hamstring autograft were analysed by pre- and post-operative isokinetic tests in a single orthopaedic centre. These were subdivided into four cohorts: (1) general anaesthesia (n = 47), (2) general anaesthesia with prolonged (48 h) on-demand femoral nerve block (n = 37), (3) spinal anaesthesia (n = 169) and (4) spinal anaesthesia with prolonged (48 h) on-demand femoral nerve block (n = 185). Primary outcome was the change from pre- to post-operative isokinetic strength during knee extension and flexion.

RESULTS

Using one-way ANOVA, there was no significant influence of the type of anaesthesia. The main effect of anaesthesia on change in extension forces was not significant, and effect sizes were very small (n.s.). Similarly, the main effect of anaesthesia on change in flexion forces was statistically not significant (n.s.).

CONCLUSIONS

The findings of this study support the interpretation that the type of anaesthesia has no significant effect on the ability to recover thigh muscle strength 6 months after isolated hamstring ACL reconstruction. With regard to the recovery of athletic performance and return-to-sports testing criteria, there is no reason to avoid regional anaesthesia.

LEVEL OF EVIDENCE

III.

Perioperative Gabapentin May Reduce Opioid Requirement for Early Postoperative Pain in Patients Undergoing Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials

PURPOSE

To evaluate the efficacy of perioperative gabapentin or pregabalin treatment on postoperative pain and opioid requirement reduction in patients undergoing anterior cruciate ligament reconstruction (ACLR).

METHODS

A systematic review of randomized control trials was conducted evaluating the effect of gabapentin or pregabalin on postoperative pain and opioid requirement for patients undergoing ACLR. The primary outcomes assessed were postoperative pain scores and opioid requirements. Secondary outcomes were complications, side effects, dosage, and timing of intervention.

RESULTS

The initial search query identified 151 studies and 6 studies were included after full-text articles were reviewed. Three studies investigated the use of gabapentin and three studies investigated pregabalin. All three gabapentin studies reported significantly decreased or equivalent pain scores while also significantly reducing or removing total opioid consumption compared to control groups. Pregabalin demonstrated inconsistent efficacy for pain control and opioid consumption parameters across three studies. One study (pregabalin, n = 1) reported significantly increased incidence of dizziness with pregabalin compared to placebo.

CONCLUSION

There is moderate evidence demonstrating that preoperative gabapentin may be safe and effective in reducing postoperative pain and opioid consumption after ACLR. Gabapentin may be considered when employed as part of a multimodal analgesia regimen; however, the optimal protocol has yet to be determined. Currently, there is limited evidence demonstrating the efficacy of pregabalin on pain and opioid consumption in the setting of ACLR.

LEVEL OF EVIDENCE

Systematic Review of Level I Studies.

Combined femoral-obturator-sciatic nerve block has superior postoperative pain score and earlier ambulation as compared to spinal anaesthesia for arthroscopic anterior cruciate ligament reconstruction

PURPOSE

Peripheral nerve blocks can be a suitable alternative to central neuraxial blockage, as the sole anaesthetic agent for better early postoperative outcomes, decreased hospital stay and earlier mobilisation after anterior cruciate ligament reconstruction (ACLR) surgery. The purpose of this study was to compare consciousness during the procedure, pain during early postoperative period (< 7 days), and perioperative outcomes following ACLR using combined sciatic, femoral, and obturator nerve blocks compared to the spinal anaesthesia.

METHODS

This was a prospective case-control study including patients between 18 and 55 years of age, with anterior cruciate ligament (ACL) injury confirmed clinically and radiologically and undergoing ACLR. Patients were allocated in the two groups alternatively, group 1 included patients who received combined nerve blocks, and group 2 included patients who received spinal anaesthesia for the surgery. The sensory effect, motor effect, adequacy of anaesthesia, perioperative analgesic use, duration of stay, postoperative pain (visual analogue scale 0-10 cm) and functional outcomes were noted.

RESULTS

There were 60 patients in each group. A total of seven patients in group 1 (11%) and two patients in group 2 (3%) needed conversion to general anaesthesia (n.s.). In group 1, out of 53 patients who underwent surgery, 26 patients had no perception of surgery in the joint, 17 patients had perception of manipulation of the knee joint, 4 patients had sense of touch, and 6 patients had sensation of pain in the knee (VAS scale less than 3). In group 2, out of 58 patients, 42 patients had no perception of surgery, 12 had a perception of manipulation of the knee joint, 2 had sense of touch, and 2 had sensation of pain in the knee. Blockage of sensory effect was significantly better in group 2 (p = 0.0001). However, the motor effect was comparable between the two groups (n.s.). Group 1 had significantly better pain scores 6, 12, and 18 h after the surgery. Moreover, patients in group 1 also had faster ambulation (mean difference of 5.5 h, p = 0.0001) and reduced hospital stay (mean difference of 8.4 h, p = 0.0001).

CONCLUSION

Combined sciatic, femoral, and adductor canal block is an effective sole anaesthetic modality for ACLR. The sensory effect was inferior when compared to spinal anaesthesia but sufficient for the procedure without the need for supplementation with any other anaesthetic modality. Patients receiving this combined nerve block had lesser early postoperative pain scores, earlier ambulation, and shorter hospital stay as compared to the spinal anaesthesia.

LEVEL OF EVIDENCE

Level 3.

Effect of Perioperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Oral and Maxillofacial Surgery: A Randomized Controlled Clinical Trial

Purpose

The aim of the study was to determine whether perioperative dexmedetomidine administration can improve postoperative delirium in elderly patients undergoing oral and maxillofacial surgery.

Patients and Methods

This was a prospective double-blind randomized controlled clinical trial conducted in Cangzhou Central Hospital from December 2021 to March 2022. Patients aged 65 and older underwent oral and maxillofacial surgery under general anesthesia. Eligible patients were randomly assigned to dexmedetomidine or control group. Dexmedetomidine was injected intravenously from 10 min before induction of anesthesia to 30 min before the end of surgery in dexmedetomidine group, while patients in the control group were given normal saline at the same rate during the same time period. The primary measurement indicators were the incidence and duration of delirium in the first five days after surgery. The secondary measurement indicators were Visual Analogue Score (VAS) for the first 24 hours following surgery, subjective sleep quality score within 24 hours postoperatively and intraoperative adverse reactions.

Results

One hundred and twenty patients were randomly assigned. Baseline characteristics were similar between two groups. The incidence and duration of postoperative delirium did not differ statistically between two groups (all P > 0.05). Compared with control group, VAS scores in dexmedetomidine group were significantly lower at 6, 12, and 24 hours after surgery (all P < 0.05); moreover, Richards-Campbell Sleep Questionnaire (RCSQ) results were significantly improved 1 day after surgery in dexmedetomidine group (P < 0.05). Dexmedetomidine-related adverse reactions were similar in both groups (P > 0.05).

Conclusion

Intravenous infusion of dexmedetomidine 10 min before induction of anesthesia to half an hour before the end of surgery did not improve postoperative delirium in elderly patients undergoing oral and maxillofacial surgery; however, dexmedetomidine may be associated with decreased postoperative pain and improved postoperative sleep quality.

Do Continuous Peripheral Nerve Blocks Decrease Home Opioid Use Following Anterior Cruciate Ligament Reconstruction in Children and Adolescents? The Envelope Please

BACKGROUND

Levels of opioid misuse and addiction among children and adolescents have reached alarming proportions. Exposure to opioids after surgery for anterior cruciate ligament reconstruction (ACLR), which is commonly performed in young athletes, increases this risk. This study was designed to evaluate whether continuous peripheral nerve block (CPNB) with placement of an elastomeric reservoir ball, compared with single-shot peripheral nerve block (SPNB), would decrease the need for home opioid analgesia and improve pain control after ACLR in children and adolescents.

METHODS

Prospectively collected data from a consecutive cohort that underwent ACLR by a single surgeon were retrospectively reviewed. Patients who received ACLR with 72-hour CPNB were assigned to Group 1. Patients who received ACLR with SPNB were assigned to Group 2. Postoperative pain management included cryotherapy, oral acetaminophen, and ibuprofen. A prescription for 10 doses of hydrocodone/acetaminophen (5/325 mg) was provided in a sealed envelope with instructions that the prescription should only be used in the case of uncontrolled pain. Reports of no opioid use were corroborated by the unopened envelope and unfilled prescription.

RESULTS

One hundred and ninety-six patients were enrolled in the study (SPNB=114 patients, CPNB=82 patients). Average age was 15±1.5 years (115 female). A total of 138 patients (70%) did not need home opioid analgesia after surgery. Of the 58 patients (30%) that did there were 35 (30.7%) in the SPNB group and 23 (28.0%) in the CPNB group (P=0.659). There were no differences between groups in demographics, operative data, or visual analog scale scores on any postoperative day.

CONCLUSION

The findings of this study demonstrate equivalent pain control and opioid consumption in children and adolescents undergoing ACLR treated with either a CPNB or a SPNB. At-home opioid analgesia use can be negated after ACLR in 70% of children and adolescents. For the patients in this study who required opioids, average use was only 2 pills of 5 mg hydrocodone/325 mg acetaminophen, with no child using more than 10 pills.

LEVEL OF EVIDENCE

Level II-therapeutic.

Overprescribing and Undereducating: a Survey of Pre- and Postoperative Pain Protocols for Pediatric Anterior Cruciate Ligament Surgery

Purpose

To establish a better understanding of the variations in pain management protocols and prescribing patterns for pediatric patients undergoing anterior cruciate ligament (ACL) reconstruction or repair.

Methods

A 20-question multiple-choice survey was distributed to 3 professional orthopaedic societies to assess the pre-emptive and postoperative pain management prescribing patterns for pediatric patients undergoing ACL reconstruction or repair. Clinical agreement (defined as agreement between >80% of participants) and general agreement (defined as agreement between >60% of participants) were calculated based on responses as previously reported.

Results

Clinical agreement was observed among the 68 respondents in use of a single shot nerve block before induction of anesthesia versus continuous use when a peripheral nerve block was used, “always” counseling patients on postoperative pain control, the prescribing of opioids postoperatively, and a lack of change in postoperative protocol when concomitant meniscal repair or meniscectomy was performed. General agreement was observed in the use of a peripheral nerve block, some pre-emptive analgesia practices, and the lack of counseling patients with regard to disposal of unused opioid pain medication postoperatively. Opioids were prescribed by 88% of participants postoperatively, with 48% prescribing 11 to 19 pills and 15% prescribing ≥20 pills.

Conclusions

While pain management practices before and following ACL reconstruction and repair in the pediatric population remain varied, opioids are frequently prescribed postoperatively with many providers neglecting to provide instruction on excess opioid disposal.

Clinical Relevance

ACL reconstruction and repair is becoming increasingly common in the pediatric population. Clinical guidelines that establish pre-emptive and postoperative pain-control protocols should be considered to determine safe and optimal pain control throughout the duration of care while minimizing opioid prescribing and consumption.