The Effect of Perioperative Pregabalin on Pain after Arthroscopic Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

Current Evidence-based Approaches to Multimodal Pain Control and Opioid Minimization After Arthroscopic and Knee Preservation Surgery

Nonarthroplasty knee procedures are common and may cause a wide spectrum of postoperative pain, ranging from minimal to severe, depending on the patient, pathology, and procedure. Procedures include ligament repair and reconstruction, especially anterior cruciate ligament reconstruction, meniscal débridement, repair and transplant, periarticular osteotomy, and cartilage restoration. Multimodal analgesia regimens have been implemented successfully, but notable variation characterizes current protocols. Increased public and physician awareness of the burden of opioid usage in the United States has encouraged the medical community to embrace opioid-minimizing and nonopioid techniques to mitigate the deleterious effects of these medications. Nonopioid medications; anesthesia techniques; surgical techniques; and postoperative nonmedication strategies, including physical therapy, transcutaneous electrical nerve stimulation, cryotherapy, cognitive techniques, and non-Western interventions, can form part of an effective multimodal approach. A multimodal approach can facilitate adequate analgesia without compromising patient satisfaction or outcome.

Pregabalin does not reduce postoperative pain after outpatient ACL surgery: A case-control study

INTRODUCTION

In France, prescribing pregabalin requires a secure prescription valid for 6 months since the decree of 12 February 2021, based on recommendations of the French Centre for Evaluation and Information on Pharmacodependence and Addiction vigilance (CEIP-A). This led to discontinuation of this treatment as a postoperative analgesic in the French ACL Study (FAST) cohort. We aimed to evaluate the impact of this change on early postoperative pain.

HYPOTHESIS

Pregabalin is an important analgesic for reducing early postoperative pain after anterior cruciate ligament (ACL) repair.

METHODS

At our healthcare facility, 584 patients from the FAST cohort who underwent primary isolated ACL reconstruction were included: 292 patients operated before June 1, 2021 who received pregabalin postoperatively and 292 patients operated after June 1, 2021 who did not receive pregabalin. The patients were matched based on age, sex, preoperative Lysholm and Tegner scores. Pain was evaluated on a visual analog scale (VAS) on D0 in the evening, D0 at night, D1, D2 and D3.

RESULTS

The patients who did not receive pregabalin had more severe pain at night on D0: 5.21 vs 5.68 (p=.048). There was no difference between groups in the postoperative pain at rest during the evening of D0 (p=.89), D1 (p=.33), D2 (p=.37) and D3 (p=.21).

CONCLUSION

In the context of outpatient arthroscopic ACL reconstruction, pregabalin does not reduce early postoperative pain in a clinically significant manner.

LEVEL OF EVIDENCE

IV; case-control study.

The effect of pregabalin on postoperative pain after anterior cruciate ligament reconstruction: A systematic review of randomized clinical trials

Background

Despite the enormous success of anterior cruciate ligament (ACL) reconstruction, acute neuropathic pain can develop postoperatively and is both distressing and difficult to treat once established. Pregabalin, an anticonvulsant agent that selectively affects the nociceptive process, has been used as a pain relief agent. The purpose of this systematic review of randomized controlled trials (RCTs) was to evaluate the pain control effect of pregabalin versus placebo after ACL reconstruction.

Method

A search of the literature was performed from inception to June 2022, using PubMed, Scopus, Google Scholar, Web of Science, Cochrane and EBSCO. Studies considered for inclusion were RCTs that reported relevant outcomes (postoperative pain scores, cumulative opioid consumption, adverse events) following administration of pregabalin in patients undergoing ACL reconstruction.

Result

Five placebo-controlled RCTs involving 272 participants met the inclusion criteria. 75 mg and 150 mg oral pregabalin was used in included trials. Two studies used a single dose of pregabalin one hour before anesthesia induction. Two studies used pregabalin 1 hour before anesthesia induction and 12 hours after. One study used daily pregabalin 7 days before and 7 days after surgery. Out of five papers, three papers found significantly lower pain intensity and cumulative opioid consumption in pregabalin group compared with placebo group. However, a decrease in pain scores was found in all trials. Pregabalin administration was associated with dizziness and nausea.

Conclusion

The use of pregabalin may be a valuable asset in pain management after ACL reconstruction. However, future studies with larger sample size and longer follow-up period are required.

Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction

This guideline was developed to inform clinical practice on rehabilitation after anterior cruciate ligament reconstruction (ACLR) and was performed in accordance with the Appraisal of Guidelines for REsearch & Evaluation II (AGREE II) instrument and used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. A Guideline Development Group systematically searched and reviewed evidence using randomised clinical trials and systematic reviews to evaluate the effectiveness of rehabilitation interventions and guide clinicians and patients on the content of the optimal rehabilitation protocol after ACLR.The guideline targets patients during rehabilitation after ACLR and investigates the effectiveness of the available interventions to the physiotherapist, alone or in combination (eg, exercise, modalities, objective progression criteria). Exercise interventions should be considered the mainstay of ACLR rehabilitation. However, there is little evidence on the dose-response relationship between volume and/or intensity of exercise and outcomes. Physical therapy modalities can be helpful as an adjunct in the early phase of rehabilitation when pain, swelling and limitations in range of motion are present. Adding modalities in the early phase may allow earlier pain-free commencement of exercise rehabilitation. Return to running and return to training/activity are key milestones for rehabilitation after ACLR. However, there is no evidence on which progression or discharge criteria should be used.While there is a very low level of certainty for most components of rehabilitation, most of the recommendations provided in this guideline were agreed to by expert clinicians. This guideline also highlights several new elements of ACLR management not reported previously.

The Effect of Pregabalin Levels on Pain and Substance P Level Post-Cesarean Section

BACKGROUND: Post-operative pain is a very important problem faced by post-operative patients. Antihyperalgesia is caused by the inhibition of the neurotransmitter glutamate and substance P (SP) by pregabalin. This study aimed to compare the effect of preventive administration of 50 mg oral pregabalin and 1 g paracetamol with 75 mg oral pregabalin and 1 g intravenous paracetamol on Numeric Rating Scale (NRS) scores and SP levels after cesarean section with spinal anesthesia. AIM: The objective of the study was to compare the effect of preventive administration of 50 mg oral pregabalin and 1 g paracetamol with 75 mg oral pregabalin and 1 g intravenous paracetamol on NRS scores and SP levels after cesarean section with spinal anesthesia. METHODS: This study used a double-blind randomized trial design. Samples were selected randomly and consecutively from the entire population that met the inclusion criteria. There were a total of 30 samples. SP levels were measured 2 h before cesarean section. The study drug was administered by mouth with a sip of water 1 h before the expected time of the surgical incision. SP levels were checked at the 4th h (SP 1) and 6th h (SP 2) postoperatively. The assessment of the degree of pain using the NRS was carried out at 2 h, 4 h, 6 h, 12 h, and 24 h postoperatively. This study used the Mann–Whitney U-test to compare both the levels of SP and NRS between the two groups. RESULTS: The results of this study showed that there was a significant difference in the NRS scores between the 50 mg and 75 mg pregabalin groups (p < 0.05). In the 75 mg pregabalin group, the NRS scores were lower than in the 50 mg pregabalin group in patients undergoing CS surgery under spinal anesthesia. There was a significant difference in SP levels between the 50 mg and 75 mg pregabalin groups (p < 0.05). SP levels in the 50 mg pregabalin group increased at 4 h and 6 h postoperatively, while in the 75 mg pregabalin group, it tended to decrease at 4 h and 6 h postoperatively. CONCLUSION: The quiescent and mobile NRS scores in the 75 mg pregabalin group were lower than the 50 mg pregabalin group with a combination of 1 g intravenous paracetamol after SC surgery. SP levels in the 75 mg pregabalin group decreased compared to the 50 mg pregabalin group with a 1 g intravenous paracetamol combination which experienced an increase after CS surgery. Pregabalin 75 mg is recommended for preventive use in CS surgery.

Intravenous diclofenac and orphenadrine for the treatment of postoperative pain after remifentanil-based anesthesia : A double-blinded, randomized, placebo-controlled study

BACKGROUND

Postoperative intravenous diclofenac reduces patient opioid demand and is commonly used in surgical units. Orphenadrine is mainly used in combination with diclofenac for musculoskeletal injuries and postoperative pain control. The objective of this study was to compare the analgesic efficacy of diclofenac-orphenadrine, diclofenac alone and saline.

METHODS

We performed a double-blind, randomized, placebo-controlled, parallel-group, single-center clinical study investigating the opioid-sparing effect of a combination of diclofenac and orphenadrine versus diclofenac alone versus isotonic saline solution. Initially 72 patients were included and received total intravenous anesthesia during cruciate ligament surgery. All patients were postoperatively treated with a patient-controlled analgesia (PCA) device containing hydromorphone. Pharmacological safety was assessed by laboratory parameters, vital signs, and delirium detection scores.

RESULTS

There was no significant difference between the groups in cumulative dose of PCA analgesics required after 24 h postsurgery, with 5.90 mg (SD ± 2.90 mg) in the placebo group, 5.73 mg (SD ± 4.75 mg) in the diclofenac group, and 4.13 mg (SD ± 2.57 mg) in the diclofenac-orphenadrine group. Furthermore, there was no significant difference between the groups in cumulative dose of PCA analgesics required 2 h postsurgery (n = 65). Mean dose of hydromorphone required after 2 h was 1.54 mg (SD ± 0.57 mg) in the placebo group, 1.56 mg (SD ± 1.19 mg) in the diclofenac-only group, and 1.37 mg (SD ± 0.78 mg) in the diclofenac-orphenadrine group. However, when comparing the diclofenac-orphenadrine group and the diclofenac group combined to placebo there was a significant reduction in PCA usage in the first 24 h postsurgery. In total, there were 25 adverse events reported, none of which were rated as severe.

CONCLUSION

Orphenadrine-diclofenac failed to significantly reduce postoperative opioid requirements. However, in an exploratory post hoc analysis the diclofenac-orphenadrine and the diclofenac group combined versus placebo showed a tendency to reduce opioid demand in postoperative pain control. Further research is required to determine the value of orphenadrine as an adjuvant in a multimodal approach for postoperative pain management.

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.

Liposomal Bupivacaine Decreases Post-Operative Opioid Use after Anterior Cruciate Ligament Reconstruction: A Review of Level I Evidence

INTRODUCTION

Anterior Cruciate Ligament tears are common after a non-contact injury and several thousand reconstructions (ACLR) occur yearly in the United States. Multimodal pain management has evolved greatly to include nerve blocks to minimize physical therapy losses post-operatively, pericapsular and wound injections, and other adjunctive measures. However, there is a surprisingly high use of opioid use after ACLR.

OBJECTIVE

The purpose of present investigation is to summarize the current state of knowledge regarding opioid use after ACLR and to synthesize the literature regarding the use of liposomal bupivacaine and its potential to reduce post-operative opioid use in ACLR patients.

METHODS

The literature search was performed in Mendeley. Search fields were varied until redundant. All articles were screened by title and abstract and a preliminary decision to include an article was made. A full-text screening was performed on the selected articles. Any question regarding the inclusion of an article was discussed by three authors until an agreement was reached.

RESULTS

Eighteen articles summarized the literature around the opioid epidemic in ACL surgery and the current context of multimodal pain strategies in ACLR. Five primary articles directly studied the use of liposomal bupivacaine as compared to reasonable control options. There remains to be over prescription of opioids within orthopedic surgery. Patient and prescriber education are effective methods at decreasing opioid prescriptions. Many opioid pills prescribed for ACLR are not used for the correct purpose. Several risk factors have been identified for opioid overuse in ACLR: American Society of Anesthesiologists score, concurrent meniscal/cartilage injury, preoperative opioid use, age < 50, COPD, and substance abuse disorder. Liposomal bupivacaine is effective in decreasing post-operative opioid use and reducing post-operative pain scores as compared to traditional bupivacaine. LB may also be effective as a nerve block, though the data on this is more limited and the effects on post-operative therapy need to be weighed against the potential therapeutic benefit. LB is associated with significantly greater costs than traditional bupivacaine.

DISCUSSION

The role for opioid medications in ACLR should continue to decrease over time. Liposomal bupivacaine is a powerful tool that can reduce post-operative opioid consumption in ACLR.

Managing Perioperative Pain After Anterior Cruciate Ligament (ACL) Reconstruction: Perspectives from a Sports Medicine Surgeon

Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.

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.

Evaluation of the Efficacy of Prolonged Pregabalin Administration Before and After Surgery in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Repair: A Prospective, Randomized, Double-blind Study

CONTEXT AND OBJECTIVE

Reconstruction of the knee ligament causes postoperative pain and delayed rehabilitation.

OBJECTIVE

The primary objective of this study was to evaluate the effect of a prolonged preoperative and postoperative pregabalin use for arthroscopic anterior cruciate ligament repair.

MATERIALS AND METHODS

Group 1 (N=25) patients received pregabalin 75 mg/d, and group 2 (N=25) received placebo, 7 days before and 7 days after surgery. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (15 mg). The following were evaluated: pain intensity immediately after the surgery, and 12 hours, 24 hours, 1 week, 2 weeks, 1 month, and 2 months after the surgery using a Numerical Rating Scale; dose of postoperative supplementary analgesic for 2 months; time to first analgesic requirement; and side effects during 2 months. For supplementation, the participants received 1 g dipyrone; if there was no pain control, 100 mg ketoprofen was administered; if there was no effect, 100 mg tramadol was administered; and if there was no pain control, 5 mg intravenous morphine was administered until pain control.

RESULTS

There was no difference between the groups with regard to pain intensity (P=0.077). In the pregabalin group, morphine consumption was lower at 12 hours (P=0.039) and 24 hours (P=0.044) after surgery, and the consumption of tramadol and ketoprofen was lower 24 hours after surgery. There was no significant difference in the incidence of nausea and vomiting. Dizziness was higher in the pregabalin group (group 1=12 patients; group 2=3 patients; P=0.005).

DISCUSSION

A prolonged preoperative and postoperative pregabalin prescription for anterior cruciate ligament repair decreased the need for supplementary analgesics during the first 24 postoperative hours but increased dizziness.