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Soffin EM, Abdallah FW, Mariano ER. Unwarranted variation in perioperative pain management for pediatric anterior cruciate ligament reconstruction: a call to improve the quality of quality improvement. Reg Anesth Pain Med 2024:rapm-2024-105637. [PMID: 38925709 DOI: 10.1136/rapm-2024-105637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Edward R Mariano
- Anesthesiology, Perioperative and Pain Medicine Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
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Chen B, Tan M, Li Q, Wang S, Chen D, Zhao M, Cao J. Application of ultrasound-guided single femoral triangle and adductor canal block in arthroscopic knee surgery: a prospective, double-blind, randomized clinical study. BMC Anesthesiol 2024; 24:182. [PMID: 38783177 PMCID: PMC11112763 DOI: 10.1186/s12871-024-02555-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE To compare the difference in analgesic effect between femoral triangle block (FTB) and adductor canal block (ACB) during arthroscopic knee surgery. METHODS Patients who underwent arthroscopic knee surgery were randomized preoperatively to FTB group or ACB group. For each group, 20 mL of 0.1% ropivacaine was injected. PRIMARY OUTCOMES The numeric rating score (NRS) at 12 h after surgery at rest and during movement. SECONDARY OUTCOME (1) The NRS at post anesthesia care unit (PACU) and 2, 24 h after surgery at rest and during movement; (2) The quadriceps muscle strength at PACU and 2, 12, 24 h after surgery; (3) Consumption of Rescue analgesia; (4) Incidence of adverse reactions. RESULTS The NRS at 12 h after surgery at rest and during movement of ACB group were higher than FTB group. Among secondary outcomes, the NRS at PACU at rest and during movement, 2 h after surgery during movement of FTB group lower than ACB group; the quadriceps muscle strength at 2 h after surgery of FTB group stronger than ACB group. After multiple linear regression model analysis, the data showed additional statistically significant reduction NRS at 24 h after surgery at rest (0.757, p = 0.037) in FTB group. Other outcomes were similar between two groups. CONCLUSIONS The FTB appears to provide superior pain control after knee arthroscopy than ACB, the FTB is superior to the ACB in quadriceps muscle strength at 2 h after surgery. TRIAL REGISTRATION The trial was registered in the Chinese Clinical Trial Registry (ChiCTR2300068765). Registration date: 28/02/2023.
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Affiliation(s)
- Baizhou Chen
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Minghe Tan
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Qingshu Li
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Siqi Wang
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Daiyu Chen
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Maoji Zhao
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Jun Cao
- The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.
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Sadacharam K, Furstein JS, Staffa SJ, Li G, Karroum R, Booth JM, Kim E, McCahan SM, Muhly WT, Chidambaran V. Multisite prospective study of perioperative pain management practices for anterior cruciate ligament reconstruction in adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report. Reg Anesth Pain Med 2024:rapm-2024-105381. [PMID: 38637132 DOI: 10.1136/rapm-2024-105381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 04/03/2024] [Indexed: 04/20/2024]
Abstract
INTRODUCTION Although 200 000 adolescents undergo anterior cruciate ligament reconstruction (ACLR) surgery annually, no benchmarks for pediatric post-ACLR pain management exist. We created a multicenter, prospective, observational registry to describe pain practices, pain, and functional recovery after pediatric ACLR. METHODS Participants (n=519; 12-17.5 years) were enrolled from 15 sites over 2 years. Data on perioperative management and surgical factors were collected. Pain/opioid use and Lysholm scores were assessed preoperatively, on postoperative day 1 (POD1), POD3, week 6, and month 6. Descriptive statistics and trends for opioid use, pain, and function are presented. RESULTS Regional analgesia was performed in 447/519 (86%) subjects; of these, adductor canal single shot was most frequent (54%), nerve catheters placed in 24%, and perineural adjuvants used in 43%. On POD1, POD3, week 6, and month 6, survey response rates were 73%, 71%, 61%, and 45%, respectively. Over these respective time points, pain score >3/10 was reported by 64% (95% CI: 59% to 69%), 46% (95% CI: 41% to 52%), 5% (95% CI: 3% to 8%), and 3% (95% CI: 1% to 6%); the number of daily oxycodone doses used was 2.8 (SD 0.19), 1.8 (SD 0.13), 0, and 0. There was considerable variability in timing and tests for postdischarge functional assessments. Numbness and weakness were reported by 11% and 4% at week 6 (n=315) and 16% and 2% at month 6 (n=233), respectively. CONCLUSION We found substantial variability in the use of blocks to manage post-ACLR pain in children, with a small percentage experiencing long-term pain and neurological symptoms. Studies are needed to determine best practices for regional anesthesia and functional assessments in this patient population.
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Affiliation(s)
| | - James S Furstein
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Galaxy Li
- Nemours Children's Health System, Jacksonville, Florida, USA
| | - Rami Karroum
- Department of Anesthesiology and Pain Medicine, Akron Children's Hospital, Akron, Ohio, USA
| | - Jocelyn M Booth
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Eugene Kim
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Los Angeles, California, USA
| | | | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Vidya Chidambaran
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Kaur J, Pham NS, Cahan E, Halvorsen KC, Langner JL, Bryson XM, Chan CM, Vorhies JS. Use of Peripheral Nerve Blocks Is Not Associated With Decreased Postoperative Opioid Prescription After ACL Reconstruction in Adolescents. Orthopedics 2024; 47:83-88. [PMID: 37341565 DOI: 10.3928/01477447-20230616-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
The rate of anterior cruciate ligament (ACL) injuries and reconstruction in pediatric patients is increasing. Perioperative peripheral nerve blocks (PNBs) are widely used for pain management in this population. We used a multi-state administrative claims database to describe the effect of PNB after ACL reconstruction on postoperative opioid consumption. We identified patients 10 to 18 years old undergoing primary ACL reconstruction between 2014 and 2016 in an administrative claims database. Patients filling an outpatient perioperative prescription for opioids with at least 1 year of follow-up were included. We stratified patients based on PNB. Our primary outcome was opioid prescription patterns (in morphine milligram equivalents [MMEs]) and incidence of opioid represcription. Of the 4459 cases, 2432 (54.5%) of the patients were given a PNB during ACL reconstruction while 2027 (45.5%) were not. Patients with PNB were prescribed more MMEs per day (76.1±41.7 vs 62.7±35.7 MMEs, P<.001), more pills (63.6±53.1 vs 54.4±40.6 pills, P<.001), higher MMEs per pill (10.0±9.5 vs 8.3±5.0 MMEs, P<.001), and more total MMEs (460.6±259.4 vs 355.7±215.1 MMEs, P<.001) than patients without PNB. Adjusting for prescription patterns and demographic variables with logistic regression, PNBs were associated with a 60% increase in the odds of opioid represcription within 30 days and a 32% increase in the odds of opioid represcription within 90 days. We demonstrated an increase in postoperative opioid prescription rates with PNB after ACL reconstruction. [Orthopedics. 2024;47(2):83-88.].
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ten Hoope W, Admiraal M, Hermanides J, Hermanns H, Hollmann MW, Lirk P, Kerkhoffs GMMW, Steens J, van Beek R. The Effectiveness of Adductor Canal Block Compared to Femoral Nerve Block on Readiness for Discharge in Patients Undergoing Outpatient Anterior Cruciate Ligament Reconstruction: A Multi-Center Randomized Clinical Trial. J Clin Med 2023; 12:6019. [PMID: 37762959 PMCID: PMC10531554 DOI: 10.3390/jcm12186019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/03/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
This study evaluated the effect of adductor canal block (ACB) versus femoral nerve block (FNB) on readiness for discharge in patients undergoing outpatient anterior cruciate ligament (ACL) reconstruction. We hypothesized that ACB would provide sufficient pain relief while maintaining motor strength and safety, thus allowing for earlier discharge. This was a randomized, multi-center, superiority trial. From March 2014 to July 2017, patients undergoing ACL reconstruction were enrolled. The primary outcome was the difference in readiness for discharge, defined as Post-Anesthetic Discharge Scoring System score ≥ 9. Twenty-six patients were allocated to FNB and twenty-seven to ACB. No difference in readiness for discharge was found (FNB median 1.8 (95% CI 1.0 to 3.5) vs. ACB 2.9 (1.5 to 4.7) hours, p = 0.3). Motor blocks and (near) falls were more frequently reported in patients with FNB vs. ACB (20 (76.9%) vs. 1 (3.7%), p < 0.001, and 7 (29.2%) vs. 1 (4.0%), p = 0.023. However, less opioids were consumed in the post-anesthesia care unit for FNB (median 3 [0, 21] vs. 15 [12, 42.5] oral morphine milligram equivalents, p = 0.004) for ACB. Between patients with FNB or ACB, no difference concerning readiness for discharge was found. Despite a slight reduction in opioid consumption immediately after surgery, FNB demonstrates a less favorable safety profile compared to ACB, with more motor blocks and (near) falls.
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Affiliation(s)
- Werner ten Hoope
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Manouk Admiraal
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Henning Hermanns
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Markus W. Hollmann
- Department of Anesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Gino M. M. W. Kerkhoffs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam Movement Sciences, Amsterdam University Medical Centers, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen Steens
- Department of Orthopedics, Dijklander Ziekenhuis, Maelsonstraat 3, 1624 NP Hoorn, The Netherlands
| | - Rienk van Beek
- Department of Anesthesiology, Dijklander Ziekenhuis, Maelsonstraat 3, 1624 NP Hoorn, The Netherlands
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Meade PJ, Matzko CN, Stamm MA, Mulcahey MK. Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction. Arthrosc Sports Med Rehabil 2023; 5:100758. [PMID: 37645396 PMCID: PMC10461209 DOI: 10.1016/j.asmr.2023.100758] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/25/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR). Methods Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users. Results Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively. Conclusions This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use. Level of Evidence Level III, retrospective cohort study.
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Affiliation(s)
- Patrick J. Meade
- Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | | | - Michaela A. Stamm
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
| | - Mary K. Mulcahey
- Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A
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Moussa MK, Lefevre N, Valentin E, Meyer A, Grimaud O, Bohu Y, Gerometta A, Khiami F, Hardy A. Dynamic intermittent compression cryotherapy with intravenous nefopam results in faster pain recovery than static compression cryotherapy with oral nefopam: post-anterior cruciate ligament reconstruction. J Exp Orthop 2023; 10:72. [PMID: 37486444 PMCID: PMC10366045 DOI: 10.1186/s40634-023-00639-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023] Open
Abstract
PURPOSE To evaluate the effectiveness of dynamic intermittent compression cryotherapy (DICC) (CryoNov®) with an intravenous nefopam-based pain management protocol (DCIVNPP) in reducing post-operative pain following anterior cruciate ligament reconstruction (ACLR) compared to static compression cryotherapy (SCC) (Igloo®) and oral Nefopam. METHODS This was a retrospective analysis of prospectively collected data including 676 patients who underwent primary ACLR in 2022. Patients were either in the DCIVNPP group or in the SCC (control group), and were matched for age, sex, and Lysholm and Tegner scores (338 per arm). The primary outcome was pain on the visual analogue scale (VAS), analyzed in relation to the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) thresholds for VAS. The secondary outcome was side effects. RESULTS Postoperative pain in the DCIVNPP group was less severe on the VAS than in the control group (p < 0.05). The maximum difference in the VAS between groups was 0.57, which is less than the MCID threshold for VAS. The DCIVNPP group crossed the PASS threshold for VAS on Day 3, sooner than the control group. The side effect profiles were similar in both groups except for higher rates of dizziness and malaise in the DCIVNPP group, and higher rates of abdominal pain in the control group. Most of the side effects decreased over time in both groups, with no significant side effects after Day 3. CONCLUSION DCIVNPP effectively allows for faster pain recovery than in the control group. The difference in side effects between the protocols may be due to mode of administration of nefopam. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Mohamad K Moussa
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France.
| | - Nicolas Lefevre
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France
| | - Eugenie Valentin
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France
| | - Alain Meyer
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France
| | - Olivier Grimaud
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France
| | - Yoan Bohu
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France
| | | | - Frederic Khiami
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France
| | - Alexandre Hardy
- Department of Sports Surgery, Clinique du Sport, 75005, Paris, France
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Xie Y, Sun Y, Lu Y. Effect of Adductor Canal Block Combined with Local Infiltration Analgesia on Postoperative Pain of Knee Arthroscopy Under General Anesthesia: A Randomized Controlled Trial. Pain Ther 2023; 12:543-552. [PMID: 36790542 PMCID: PMC10036701 DOI: 10.1007/s40122-023-00482-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/02/2023] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Postoperative pain in knee arthroscopy (KA) is a common and troublesome problem. The best local analgesic technique for relieving postoperative pain in patients with KA has not been well studied. This prospective trial aimed to observe whether adductor canal block (ACB) combined with local infiltration analgesia (LIA) could further decrease the incidence of postoperative pain undergoing KA. METHODS This randomized controlled study recruited 60 patients aged 18-65 years, ASA I-II, who received KA, and randomly divided them into ACB + LIA group and LIA group. The primary outcome was the incidence of postoperative pain 24 h after surgery. The secondary outcomes included the incidence of quadriceps femoris weakness, and the consumption of opioids during operation. RESULTS A total of 60 participants completed the trial. The incidence of postoperative pain 24 h after surgery in ACB + LIA group was lower than that in the LIA group (10% [3 of 30] vs. 33% [10 of 30]; P = 0.028). There was no difference in the incidence of quadriceps muscle weakness 24 h after surgery between the two groups. The consumption of remifentanil and sufentanil in ACB + LIA group was significantly lower than that in LIA group (P = 0.006, P < 0.001). CONCLUSIONS Compared with patients receiving LIA alone, ACB combined with LIA could reduce the incidence of postoperative pain while retaining the strength of the quadriceps femoris in patients undergoing KA and reduce the consumption of opioids during surgery. CLINICAL TRIAL NUMBER AND REGISTRY URL This study was registered at the Chinese Clinical Trial Registry with the registration number ChiCTR1800018463 on September 20, 2018. ( http://www.chictr.org.cn/showproj.aspx?proj=31192 ).
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Affiliation(s)
- Yaping Xie
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, 230022, China
| | - Yue Sun
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, 230022, China
| | - Yao Lu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, 230022, China.
- Ambulatory Surgery Center, The First Affiliated Hospital of Anhui Medical University, Hefei, 230022, China.
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Hussain N, Brull R, Vannabouathong C, Speer J, Lagnese C, McCartney CJL, Abdallah FW. Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction. Anaesthesia 2023; 78:207-224. [PMID: 36326047 DOI: 10.1111/anae.15873] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- N Hussain
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - R Brull
- Department of Anesthesiology and Pain Medicine, Women's College Hospital, University of Toronto, ON, Canada
| | - C Vannabouathong
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - J Speer
- Department of Anesthesiology, Ohio State University, Wexner Medical Center, Columbus, OH, USA
| | - C Lagnese
- Department of Anesthesiology, Cleveland Clinic Akron General, Akron, OH, USA
| | - C J L McCartney
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, ON, Canada
| | - F W Abdallah
- Department of Anesthesiology and Pain Medicine, and the Ottawa Hospital Research Institute, University of Ottawa, ON, Canada.,Department of Anesthesia, and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, ON, Canada
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Motor-Sparing Effect of Adductor Canal Block for Knee Analgesia: An Updated Review and a Subgroup Analysis of Randomized Controlled Trials Based on a Corrected Classification System. Healthcare (Basel) 2023; 11:healthcare11020210. [PMID: 36673579 PMCID: PMC9859112 DOI: 10.3390/healthcare11020210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/28/2022] [Accepted: 12/31/2022] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE Discrepancies in the definition of adductor canal block (ACB) lead to inconsistent results. To investigate the actual analgesic and motor-sparing effects of ACB by anatomically defining femoral triangle block (FTB), proximal ACB (p-ACB), and distal ACB (d-ACB), we re-classified the previously claimed ACB approaches according to the ultrasound findings or descriptions in the corresponding published articles. A meta-analysis with subsequent subgroup analyses based on these corrected results was performed to examine the true impact of ACB on its analgesic effect and motor function (quadriceps muscle strength or mobilization ability). An optimal ACB technique was also suggested based on an updated review of evidence and ultrasound anatomy. MATERIALS AND METHODS We systematically searched studies describing the use of ACB for knee surgery. Cochrane Library, PubMed, Web of Science, and Embase were searched with the exclusion of non-English articles from inception to 28 February 2022. The motor-sparing and analgesic aspects in true ACB were evaluated using meta-analyses with subsequent subgroup analyses according to the corrected classification system. RESULTS The meta-analysis includes 19 randomized controlled trials. Compared with the femoral nerve block group, the quadriceps muscle strength (standardized mean difference (SMD) = 0.33, 95%-CI [0.01; 0.65]) and mobilization ability (SMD = -22.44, 95%-CI [-35.37; -9.51]) are more preserved in the mixed ACB group at 24 h after knee surgery. Compared with the true ACB group, the FTB group (SMD = 5.59, 95%-CI [3.44; 8.46]) has a significantly decreased mobilization ability at 24 h after knee surgery. CONCLUSION By using the corrected classification system, we proved the motor-sparing effect of true ACB compared to FTB. According to the updated ultrasound anatomy, we suggested proximal ACB to be the analgesic technique of choice for knee surgery. Although a single-shot ACB is limited in duration, it remains the candidate of the analgesic standard for knee surgery on postoperative day 1 or 2 because it induces analgesia with less motor involvement in the era of multimodal analgesia. Furthermore, data from the corrected classification system may provide the basis for future research.
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Le plexus lombal et ses branches. ANESTHÉSIE & RÉANIMATION 2023. [DOI: 10.1016/j.anrea.2022.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Han C, Hashimoto Y, Nakagawa S, Takahashi S, Nishida Y, Yamasaki S, Takigami J, Nakamura H. The effect and safety of periarticular multimodal drug injection without morphine and epinephrine in anterior cruciate ligament reconstruction. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2022. [DOI: 10.1177/22104917221136285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Periarticular multimodal drug injection (PMDI) is a safe and effective pain management technique after anterior cruciate ligament reconstruction (ACLR); however, adding morphine and epinephrine sometimes causes adverse effects. Therefore, we evaluated the efficacy of PMDI without morphine and epinephrine after ACLR. Methods This retrospective matched case-control study included patients who had undergone primary double-bundle ACLR with PMDI and were then matched one-to-one with a control group without PMDI based on sex, age, and body mass index using propensity-matched analysis. The following clinical outcomes were compared between the groups: visual analog scale (VAS) score, C-reactive protein (CRP) concentration, number of times the patients used additional analgesics, complication rate, and postoperative time to achieve straight leg raise (SLR). Results Twenty-nine patients with PMDI and 29 controls were enrolled. The VAS score at 1 day postoperatively was lower in the PMDI than the control group (1.93 ± 1.44 vs. 3.41 ± 1.75, respectively; P < 0.001). The CRP concentration at 1 and 3 days was lower in the PMDI than the control group (0.46 ± 0.47 vs. 1.00 ± 0.69 mg/dL, P < 0.001; and 1.93 ± 1.71 vs. 4.01 ± 2.55 mg/dL, P < 0.001, respectively). The average number of additional analgesics used was significantly lower in the PMDI than the control group. There were no significant differences in the frequency of occurrence of postoperative complications between the two groups. The number of patients who could achieve SLR within 1 day was 27/29 (93%) in PMDI group, which was significantly higher than the control group (12/29, 41%) ( P < 0.001). Conclusion PMDI without morphine and epinephrine after ACLR reduced patients’ subjective pain level, objective inflammatory response without complications and enabled patients to achieve early functional recovery.
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Affiliation(s)
- Changhun Han
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Yusuke Hashimoto
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Sunao Nakagawa
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Shinji Takahashi
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Yohei Nishida
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
| | - Shinya Yamasaki
- Department of Orthopaedic Surgery, Osaka City General Hospital, Osaka, Japan
| | - Junsei Takigami
- Department of Orthopaedic Surgery, Shimada Hospital, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka Metropolitan University, Graduate School of Medicine, Osaka, Japan
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Wang J, Chu T, Sun R, Xu A. Analgesic Efficacy of Quadratus Lumborum Block in Patients Undergoing Nephrectomy: A Systematic Review and Meta-Analysis. PAIN MEDICINE 2022; 24:476-487. [PMID: 36321993 DOI: 10.1093/pm/pnac166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/30/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022]
Abstract
Abstract
Objective
To evaluate the analgesic efficacy of quadratus lumborum block (QLB) in adults undergoing nephrectomy.
Design
Systematic review and meta-analysis.
Patients
Adult patients (≥18 years of age) received nephrectomy under general anesthesia.
Methods
We searched PubMed, Embase, the Cochrane Library, and Web of Science on January 10, 2022, including randomized controlled trials that evaluated the analgesic efficacy of QLB for patients undergoing nephrectomy.
Results
A total of 12 randomized controlled trials (N = 821 patients) were included in the study. Compared with the non-block, single-shot QLB reduced postoperative opioid consumption (mean difference [MD], −8.37 mg intravenous morphine equivalent; 95% confidence interval [CI], −12.19 to −4.54 mg) and pain scores at 2 hours, 6 hours, 12 hours, and 24 hours at rest and during movement after nephrectomy. Single-shot QLB also prolonged the time to first analgesic request (MD, 6.44 hours; 95% CI, 2.23 to 10.65 hours), shortened the length of hospital stay (MD, −0.32 day; 95% CI, −0.55 to −0.09 day), and decreased the incidence of postoperative nausea and vomiting (risk ratio, 0.48; 95% CI, 0.36 to 0.65). Compared with continuous epidural anesthesia, repeated QLB could provide comparable postoperative analgesic benefits.
Conclusions
Single-shot QLB provided a statistically significant but clinically small improvement in postoperative analgesia and recovery for patients undergoing nephrectomy. The QLB would be beneficial as part of multimodal analgesia. Future research might need to determine which approach of QLB is superior for postoperative analgesia after nephrectomy.
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Affiliation(s)
- Jinxu Wang
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Huazhong University of Science and Technology , Wuhan, China
| | - Tiantian Chu
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Huazhong University of Science and Technology , Wuhan, China
| | - Rao Sun
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Huazhong University of Science and Technology , Wuhan, China
| | - Aijun Xu
- Department of Anesthesiology and Pain Medicine, Tongji Hospital, Huazhong University of Science and Technology , Wuhan, China
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Hampton H, Torre M, Satalich J, Pershad P, Gammon L, O’Connell R, Brusilovsky I, Vap A. Benefits of Implementing an Enhanced Recovery After Surgery Protocol in Ambulatory Surgery. Orthop J Sports Med 2022; 10:23259671221133412. [PMID: 36452342 PMCID: PMC9703544 DOI: 10.1177/23259671221133412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/12/2022] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols in orthopaedic surgery have garnered significant focus due to their ability to control pain adequately in the immediate postoperative window, allowing for earlier mobilization, shorter hospital stays, and fewer complications. Virginia Commonwealth University created a multimodal pain management approach in which patients receive a preoperative femoral nerve block followed by periarticular intraoperative local injection anesthesia consisting of bupivacaine, ketamine, and ketorolac. HYPOTHESIS We hypothesized that implementation of the ERAS protocol will decrease postoperative pain scores, decrease recovery time in the postanesthesia care unit (PACU), and decrease opioid use in anterior cruciate ligament (ACL) reconstruction. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Two patient cohorts were involved: before ERAS implementation (pre-ERAS) and after (post-ERAS). Patients with ACL reconstruction only and patients with ACL reconstruction with meniscal repair were analyzed separately. Post-ERAS patients received an intraoperative periarticular injection of bupivacaine, ketamine, and ketorolac and a postoperative multimodal pain regimen. Outcomes included time spent in the PACU, short-term and long-term opioid consumption, and pain score at discharge from the PACU. RESULTS Compared with pre-ERAS patients, post-ERAS patients had decreased pain (2.1 vs 0.84 out of 10, respectively), spent less time in the PACU (79.4 vs 62.8 minutes, respectively), and had less opioid consumption in the immediate postoperative period (4.55 vs 2.26 total morphine milligram equivalents [MMEs], respectively) (P < .001 for all). After ERAS implementation, long-term MME use decreased from 410 to 321 between 0 and 2 weeks postoperatively, 92.6 to 1.69 between 2 and 6 weeks, and 494.5 to 323 between 0 and 6 weeks (P < .001 for all). All domains showed significant improvements for both the ACL and the ACL plus meniscal repair cohorts, with the exception of pain at discharge in the ACL plus meniscal repair group. CONCLUSION The study findings suggest that an enhanced recovery pathways protocol that includes a standardized intraoperative periarticular bupivacaine, ketamine, and ketorolac injection improves pain scores in the immediate postoperative window, decreases opioid consumption, and reduces recovery time in the PACU for patients undergoing ACL reconstruction.
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Affiliation(s)
- Hailey Hampton
- Virginia Commonwealth University Medical School, Richmond, Virginia, USA
| | - Matthew Torre
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - James Satalich
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Prayag Pershad
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Lee Gammon
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Robert O’Connell
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Ilia Brusilovsky
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - Alexander Vap
- Department of Orthopedic Surgery, Virginia Commonwealth University Health System, Richmond, Virginia, USA
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Calixto NE, Saldanha U. Perineural Adductor Canal Catheter Placement for Prevention of Complex Regional Pain Syndrome-I Exacerbation After Knee Arthroscopy: A Case Report. A A Pract 2022; 16:e01579. [PMID: 35404910 DOI: 10.1213/xaa.0000000000001579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Arthroscopic knee surgery is a common trigger for lower extremity complex regional pain syndrome (CRPS). Few studies assess nerve block catheters for CRPS treatment; they do not appear to be studies of regional anesthesia to treat CRPS that occurs after knee surgery. We present a case of CRPS-I triggered by knee surgery on multiple prior occasions but finally prevented by perineural adductor canal catheter placement. The literature presents only moderate evidence supporting interventions such as intravenous regional anesthesia and sympathetic blockade; continuous nerve blockade may be an effective treatment of CRPS-I and in particular postoperative CRPS-I.
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Affiliation(s)
- Nathaniel E Calixto
- From the Department of Anesthesiology and Pain Medicine, University of California, Davis Medical Center, Sacramento, California
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Schaver AL, Glass NA, Duchman KR, Wolf BR, Westermann RW. Periarticular Local Infiltrative Anesthesia and Regional Adductor Canal Block Provide Equivalent Pain Relief After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2022; 38:1217-1223. [PMID: 34808250 DOI: 10.1016/j.arthro.2021.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare postoperative pain and recovery after anterior cruciate ligament reconstruction (ACLR) in patients who received an adductor canal block (ACB) or periarticular local infiltrative anesthesia (LIA). METHODS A retrospective review of a prospectively collected ACL registry was performed. Patients underwent ACLR at a single institution between January 2015 and September 2020 and received long-acting local anesthesia with a preoperative ultrasound-guided ACB or periarticular LIA after surgery. Visual analog scale (VAS) pain scores, milligram morphine equivalents (MME) consumed in the post-anesthesia care unit (PACU), and total hospital recovery time were compared. Univariate analysis was used to compare VAS pain and MME totals between overall groups and groups propensity score matched for age, sex, body mass index, graft type, and meniscal treatment. Results are presented as mean (95%CI) unless otherwise indicated. RESULTS There were 265 knees (253 patients) included (LIA, 157 knees; ACB, 108 knees). Overall, VAS pain scores before hospital discharge (LIA: 2.6 [2.4-2.8] vs ACB: 2.4 [2.1-2.7]; P = .334) and total MMEs were similar (LIA: 17.6 [16.4-18.8] vs ACB: 18.5 [17.2-19.8] (MME); P =.134). Median time to discharge also did not significantly differ (LIA: 137.5 [IQR: 116-178] vs. ACB: 147 [IQR: 123-183] (min); P = .118). Matched subanalysis (LIA and ACB; n = 94) did not reveal significant differences in VAS pain before discharge (LIA: 2.4 [2.1-2.7] vs ACB: 2.7 [2.4-3.0]; P = .134) or total MMEs (LIA: 18.6 (17.2-20.0) vs ACB: 17.9 (16.4-19.4); P = .520). CONCLUSION The use of ACB or LIA resulted in similar early pain levels, opioid consumption, and hospital recovery times after ACLR surgery. LEVEL OF EVIDENCE III, retrospective comparison study.
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Affiliation(s)
- Andrew L Schaver
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, U.S.A
| | - Natalie A Glass
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, U.S.A
| | - Kyle R Duchman
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, U.S.A
| | - Brian R Wolf
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, U.S.A
| | - Robert W Westermann
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa, U.S.A..
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Markiewitz ND, Swarup I, Talwar D, Muhly WT, Wells L, Williams BA. Perioperative Pain Management Practices Vary Across Time and Setting for Pediatric ACL Reconstruction: Trends From a National Database in the United States. Orthop J Sports Med 2022; 10:23259671211068831. [PMID: 35071660 PMCID: PMC8777349 DOI: 10.1177/23259671211068831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Surgical and anesthetic techniques have enabled a shift to the ambulatory
setting for the majority of patients with anterior cruciate ligament (ACL)
tears. While this change likely reflects improvements in acute pain
management, little is known about national trends in pediatric perioperative
pain management after ACL reconstruction (ACLR). Purpose: To describe recent trends in the United States in perioperative pain
management for pediatric ACLR. Study Design: Cross-sectional study; Level of evidence, 3. Methods: Pediatric patients (age, ≤18 years) who underwent ACLR with peripheral nerve
blocks between January 2008 and December 2017 were identified in the
Pediatric Health Information System database. We modeled the use of oral and
intravenous analgesic medications over time using Bayesian logistic mixed
models. Models were adjusted for patient age, sex, race, primary payer, and
treatment setting (ambulatory, observation, or inpatient). Results: The study criteria produced a sample of 18,605 patients. Older children were
more likely to receive intravenous acetaminophen, intravenous ketorolac, and
oral and intravenous opioids. Younger children were more likely to receive
ibuprofen. In our adjusted logistic model, treatment setting was found to be
an independent predictor of the utilization of all medications. We found an
increase in the overall utilization of oral acetaminophen (adjusted odds
ratio [adj OR], 1.14 [95% CI, 1.04-1.23]), intravenous acetaminophen (adj
OR, 1.42 [95% CI, 1.22-1.65]), and oral opioids (adj OR, 1.16 [95% CI,
1.06-1.28]) over the study period at a typical hospital. We found
significant heterogeneity in medication use across hospitals, with the most
heterogeneity in intravenous acetaminophen. Other studied descriptive
variables did not appear to predict practices. Conclusion: After adjusting for patient characteristics and treatment settings, pain
management strategies varied among hospitals and over time. Patient age and
treatment setting predicted practices. Regional anesthesia, opioid
medications, and intravenous ketorolac remained the mainstays of treatment,
while intravenous acetaminophen emerged in use over the course of the study
period. The variability in the pain management of pediatric patients
undergoing ACLR suggests that further study is necessary to establish the
most effective means of perioperative pain management in these patients.
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Affiliation(s)
- Nathan D. Markiewitz
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Divya Talwar
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Wallis T. Muhly
- Division of Anesthesia, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lawrence Wells
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brendan A. Williams
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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18
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Nair A, Fultambkar G, Kasetty S, Vijayanand B. Dexmedetomidine and clonidine as adjuvants to ropivacaine in adductor canal block for postoperative analgesia in patients undergoing arthroscopic anterior cruciate ligament reconstruction: A prospective, randomized, double-blind study. BALI JOURNAL OF ANESTHESIOLOGY 2022. [DOI: 10.4103/bjoa.bjoa_88_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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19
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Juncker RB, Mirza FM, Gagnier JJ. Reduction in opioid use with perioperative non-pharmacologic analgesia in total knee arthroplasty and ACL reconstruction: a systematic review. SICOT J 2021; 7:63. [PMID: 34928208 PMCID: PMC8686827 DOI: 10.1051/sicotj/2021063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: The world’s opioid epidemic has gotten increasingly severe over the last several decades and projects to continue worsening. Orthopedic surgery is the largest contributor to this epidemic, accounting for 8.8% of postoperative opioid dependence cases. Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction are commonly performed orthopedic operations heavily reliant on opioids as the primary analgesic in the peri- and immediate postoperative period. These downfalls highlight the pressing need for an alternate, non-pharmacologic analgesic to reduce postoperative opioid use in orthopedic patients. The presented systematic review aimed to analyze and compare the most promising non-pharmacologic analgesic interventions in the available literature to guide future research in such a novel field. Methods: A systematic search of PubMed, MEDLINE, Embase, Cochrane, and Web of Science was performed for studies published before July 2020 based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, and the obtained manuscripts were evaluated for inclusion or exclusion against strict, pre-determined criteria. Risk-of-bias and GRADE (grades of recommendation, assessment, development, and evaluation) assessments were then performed on all included studies. Results: Six studies were deemed fit for inclusion, investigating three non-pharmacologic analgesics: percutaneous peripheral nerve stimulation, cryoneurolysis, and auricular acupressure. All three successfully reduced postoperative opioid use while simultaneously maintaining the safety and efficacy of the procedure. Discussion: The results indicate that all three presented non-pharmacologic analgesic interventions are viable and warrant future research. That said, because of its slight advantages in postoperative pain control and operational outcomes, cryoneurolysis seems to be the most promising. Further research and eventual clinical implementation of these analgesics is not only warranted but should be a priority because of their vast potential to reduce orthopedics surgeries’ contribution to the opioid epidemic.
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Affiliation(s)
- Ryan B Juncker
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles (UCLA), 615 Charles E Young Dr S, Rm. 410, Los Angeles, CA 90095, USA
| | - Faisal M Mirza
- Coastal Health Partners, 65 Nielson St #102, Watsonville, CA 95076, USA
| | - Joel J Gagnier
- Department of Orthopaedic Surgery, Department of Epidemiology, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109, USA
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20
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Procedure-specific and patient-specific pain management for ambulatory surgery with emphasis on the opioid crisis. Curr Opin Anaesthesiol 2020; 33:753-759. [PMID: 33027075 DOI: 10.1097/aco.0000000000000922] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Postoperative pain is frequent while, on the other hand, there is a grooving general concern on using effective opioid pain killers in view of the opioid crisis and significant incidence of opioid abuse. The present review aims at describing nonopioid measures in order to optimize and tailor perioperative pain management in ambulatory surgery. RECENT FINDINGS Postoperative pain should be addressed both preoperatively, intraoperatively and postoperatively. The management should basically be multimodal, nonopioid and procedure-specific. Opioids should only be used when needed on top of multimodal nonopioid prophylaxis, and then limited to a few days at maximum, unless strict control is applied. The individual patient should be screened preoperatively for any risk factors for severe postoperative pain and/or any abuse potential. SUMMARY Basic multimodal analgesia should start preoperatively or peroperatively and include paracetamol, cyclo-oxygenase (COX)-2 specific inhibitor or conventional nonsteroidal anti-inflammatory drug (NSAID) and in most cases dexamethasone and local anaesthetic wound infiltration. If any of these basic analgesics are contraindicated or there is an extra risk of severe postoperative pain, further measures may be considered: nerve-blocks or interfascial plane blocks, gabapentinnoids, clonidine, intravenous lidocaine infusion or ketamine infusion. In the abuse-prone patient, a preferably nonopioid perioperative approach should be aimed at.
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Kew ME, Bodkin SG, Diduch DR, Smith MK, Wiggins A, Brockmeier SF, Werner BC, Gwathmey FW, Miller MD, Hart JM. The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2020; 48:1689-1695. [PMID: 32343596 DOI: 10.1177/0363546520914615] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients often have quadriceps or hamstring weakness after anterior cruciate ligament reconstruction (ACLR), despite postoperative physical therapy regimens; however, little evidence exists connecting nerve blocks and ACLR outcomes. PURPOSE To compare muscle strength at return to play in patients who received a nerve block with ACLR and determine whether a specific block type affected subjective knee function. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients were recruited 5 to 7 months after primary, isolated ACLR and completed bilateral isokinetic strength tests of the knee extensor/flexor groups as a single-session return-to-sport test. Subjective outcomes were assessed with the International Knee Documentation Committee (IKDC) score. Strength was expressed as torque normalized to mass (N·m/kg) and limb symmetry index as involved/uninvolved torque. Chart review was used to determine the type of nerve block and graft used. Nerve block types were classified as knee extensor motor (femoral nerve), knee flexor motor (sciatic nerve), or isolated sensory (adductor canal block/saphenous nerve). A 1-way analysis of covariance controlling for graft type was used. RESULTS A total of 169 patients were included. Graft type distribution consisted of 102 (60.4%) ipsilateral bone-patellar tendon-bone (BTB) and 67 (39.6%) ipsilateral hamstring tendon. Nerve block type distribution consisted of 38 (22.5%) femoral, 25 (14.8%) saphenous, 45 (26.6%) femoral and sciatic, and 61 (36.1%) saphenous and sciatic. No significant difference was found in knee extensor strength (P = .113) or symmetry (P = .860) between patients with knee extensor motor blocks (1.57 ± 0.45 N·m/kg; 70.1% ± 15.3%) and those without (1.47 ± 0.47 N·m/kg; 69.6% ± 18.8%). A significant difference was found between patients with knee flexor motor blocks (0.83 ± 0.26 N·m/kg) and those without (0.92 ± 0.27 N·m/kg) for normalized knee flexor strength (P = .21) but not knee flexor symmetry (P = .592). Controlling for graft type, there were no differences in subjective knee function (IKDC score) between all nerve block groups (P = .57). CONCLUSION Our data showed that use of a sciatic nerve block with ACLR in patients with hamstring and BTB grafts influences persistent knee flexor strength deficits at time of return to sports. Although the cause of postoperative muscular weakness is multifactorial, this study adds to the growing body of evidence suggesting that perioperative nerve blocks affect muscle strength and functional rehabilitation after ACLR.
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Affiliation(s)
- Michelle E Kew
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - Stephan G Bodkin
- Kinesiology Department, University of Virginia, Charlottesville, Virginia, USA
| | - David R Diduch
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - Marvin K Smith
- Memorial Healthcare System, Department of Orthopaedics, Hollywood, Florida, USA
| | - Anthony Wiggins
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Stephen F Brockmeier
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - F Winston Gwathmey
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - Mark D Miller
- Department of Orthopaedics, University of Virginia, Charlottesville, Virginia, USA
| | - Joseph M Hart
- Kinesiology Department, University of Virginia, Charlottesville, Virginia, USA
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Nguyen KT, Marcelino R, Jagannathan N, Suresh S, Sawardekar A. Infiltration Between Popliteal Artery and Capsule of the Knee Block to Augment Continuous Femoral Nerve Catheter for Adolescent Anterior Cruciate Ligament Reconstruction: A Case Series. A A Pract 2020; 14:37-39. [DOI: 10.1213/xaa.0000000000001135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Joshi GP, Kehlet H, Rawal N. Surgeon-administered regional analgesia to replace anaesthetist-administered regional analgesia: need for communication and collaboration. Br J Anaesth 2019; 123:707-709. [DOI: 10.1016/j.bja.2019.08.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 01/04/2023] Open
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The Effect of Perioperative Pregabalin on Pain after Arthroscopic Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial. J Clin Med 2019; 8:jcm8091426. [PMID: 31510032 PMCID: PMC6780650 DOI: 10.3390/jcm8091426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 01/31/2023] Open
Abstract
Pain after anterior cruciate ligament (ACL) reconstruction is usually intense in the early postoperative period, but the efficacy of a multimodal analgesia approach remains controversial. This study aimed to investigate the analgesic efficacy of pregabalin in multimodal analgesia after ACL reconstruction. Patients who underwent ACL reconstruction under spinal anesthesia and agreed to use intravenous patient-controlled analgesia (IV-PCA) were randomly administered placebo (control group, n = 47) or pregabalin 150 mg (pregabalin group, n = 46) 1 h before surgery and 12 h after initial treatment. Pain by verbal numerical rating scale (VNRS) at rest and with passive flexion of knee was assessed at postoperative 12, 24, and 36 h and 2 weeks. IV-PCA consumption, rescue analgesic use, and side effects were also evaluated. Lower scores of VNRS were obtained with passive flexion of knee in the pregabalin group than in the control group at postoperative 24 (7(4-8) vs. 8(6-9), p = 0.043) and 36 h (4(3-7) vs. 5(4-9), p = 0.042), and lower value of VNRS at rest was observed in the pregabalin group [0(0-1)] than in the control group [1(0-2)] at postoperative 2 weeks (p < 0.001). No differences were obtained for IV-PCA consumption, rescue analgesic use, and side effects except for dizziness for postoperative 12 h. Pregabalin as an adjuvant to multimodal analgesic regimen significantly reduced early postoperative pain in patients undergoing ACL reconstruction.
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Abdallah FW, Brull R, Joshi GP. In Response. Anesth Analg 2019; 129:e106. [PMID: 31425243 DOI: 10.1213/ane.0000000000004280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada Department of Anesthesia, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas,
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