Peri-articular local infiltration analgesia versus femoral nerve block for postoperative pain control following anterior cruciate ligament reconstruction: Prospective, comparative, non-inferiority study

INTRODUCTION

Femoral nerve block (FNB) is considered as a major advance in anterior cruciate ligament (ACL) reconstruction as it reduces the need for parenteral opioids. However, the incidence of transient or even permanent neurological deficits due to the FNB is estimated at 1.94% after knee surgery. The primary objective of this study was to compare local infiltration analgesia (LIA) to FNB during ACL reconstruction procedures. The study hypothesis was that LIA was not less effective than FNB on early postoperative pain.

PATIENTS AND METHODS

A retrospective analysis of data collected prospectively in the FAST cohort included a series of continuous patients who underwent primary repair for isolated ACL with a hamstring graft in 2013-2014. Changes in our anesthesia practices over time allowed us to form three successive groups: Group 1 - FNB, Group 2 - FNB+LIA, Group 3 - LIA only. Ultrasound-guided FNB was done pre-operatively. The LIA was done at the end of the procedure by the surgeon with systematic infiltration of all skin incisions and the hamstring donor site; no intra-articular injections were performed. The primary endpoint was the average early postoperative pain (Days 0-3) described by the patient on a visual analogue scale (0-10). Sample size calculation pointed to 36 subjects being needed per group for a non-inferiority study.

RESULTS

The study involved 126 patients: G1=42, G2=38, G3=46. The patients were comparable at enrolment. The average early postoperative pain levels were 3.1±2.4, 2.8±2.0 and 2.5±2.2, respectively (P=0.66). A trend toward higher intake of tramadol was noted in the LIA group on D0 to D3, with a significant trend test on Day 1 (P=0.03) and Day 2 (P=0.02).

CONCLUSION

After reconstruction of isolated ACL tears with a hamstring graft, FNB is not more effective than LIA on patients' early postoperative pain. Patients who received a FNB consumed significantly less opioid-like analgesics.

LEVEL OF EVIDENCE

III - Prospective, comparative, non-randomized study.

Postoperative discomfort after outpatient anterior cruciate ligament reconstruction: a prospective comparative study

INTRODUCTION

The principal objective of the present study was to compare rates of postoperative discomfort after anterior cruciate ligament (ACL) reconstruction between inpatient (In) and outpatient (Out) management.

PATIENTS AND METHOD

A single-surgeon non-randomized prospective comparative study included patients undergoing primary surgery for isolated ACL tear by short hamstring graft in 2012-13. The Out group comprised patients eligible for and consenting to outpatient surgery and the In group, those not eligible or not consenting. The principal assessment criterion was onset of at least 1 symptom of postoperative discomfort (SPD): anxiety, nausea and vomiting, malaise, vertigo or stomach pain, between postoperative days 0 and 3. Secondary assessment criteria were difficulty in getting to sleep, getting up during the night, regular walking or going out, number of episodes of knee pain and waking because of pain. All criteria were assessed on-line by the patient.

RESULTS

One hundred and thirty-three patients filled out the questionnaire, 70 in the Out group and 63 in the In group; 42 females, 91 males; mean age, 30±9 years. Between D0 and D3, the proportion of patients with ≥l SPD was comparable between groups (Out 37% vs In 41%, P=0.62). Out-group patients had significantly less difficulty sleeping the first postoperative night (P=0.01), got up significantly more often during the first night after surgery (P<0.0001), more often walked regularly on day 1 (P=0.03), and were significantly less often woken by pain during the first night (P=0.003). Risk factors for SPD were female gender (OR=4.8±1.9) and postoperative complications (OR=3.8±2.5).

CONCLUSION

Patients undergoing ACL reconstruction on an outpatient basis did not show more symptoms of postoperative discomfort than those managed as conventional inpatients.

LEVEL OF EVIDENCE

IV; prospective comparative study.

Outpatient surgery feasibility in anterior cruciate ligament reconstruction: a prospective comparative assessment

INTRODUCTION

The main objective of this study was to assess the feasibility of outpatient surgery in anterior cruciate ligament (ACL) reconstruction. We hypothesized that if the patient underwent the procedure within a dedicated organization, safety would be ensured.

PATIENTS AND METHODS

A non-randomized, prospective, comparative, single-operator study conducted in 2012-2013 included all patients undergoing first-line surgery for ACL arthroscopic reconstruction using a short hamstring graft. The outpatient group (OP) included patients who were eligible for outpatient surgery and provided consent; the conventional hospitalization group (CH) comprised those patients not suitable for outpatient surgery and those who refused it. The main evaluation criterion was failure of the admission modality defined as hospitalization of a patient who had undergone outpatient surgery or rehospitalization in the first week after discharge. The secondary evaluation criteria were the rate of postoperative complications, postoperative pain, use of analgesics, and patient satisfaction. A total of 138 patients were included: 71 in the OP group and 67 in the CH group, with a mean age of 29.6±9 years. Twenty-nine percent of the patients refused outpatient surgery. In the CH group, the mean hospital stay lasted 2.7±0.8 days.

RESULTS

One patient in the OP group was hospitalized with localized bleeding and there were no rehospitalizations. Six early postoperative complications were noted in each group. The mean postoperative pain on D0-D4 and patient satisfaction were similar in the two groups.

CONCLUSION

This prospective study encountered no serious events after outpatient ACL reconstruction surgery. In a selected population, the risks are comparable to those in conventional hospitalization.

LEVEL OF EVIDENCE

Level III, comparative study.

Prognosis of valve replacement for aortic stenosis with or without coexisting coronary heart disease: a comparative study

Between January 1978 and June 1992, 798 patients underwent isolated AVR for hemodynamically significant calcific aortic stenosis. Preoperative coronary angiography was performed in 687 patients, of whom 229 had coronary stenosis > 40% and were divided into three (I, IIa and IIb) groups. Group I consisted of 144 patients undergoing AVR plus coronary artery bypass grafts (CABG); 39 patients in Group IIa had AVR only in the presence of coronary stenoses < 60%, and 46 patients in Group IIb had AVR only in the presence of coronary stenoses > 60%. Group III consisted of 144 matched patients selected from the remaining 458 patients with no coronary disease, or stenoses less than 40%, according to five matching criteria (age, sex, functional status, ejection fraction and year of surgery) with patients in Group I. Early mortality was 10.4% in Group I, 7.7% in Group IIa, 13% in Group IIb and 4.9% in Group III. Although the differences in operative mortality are apparent, they did not reach statistical significance. A difference in long term survival could only be detected between Groups I and III (actuarial survival at nine years 66% and 78.9%, respectively, p < 0.01). Similarly, late coronary events were more frequent in Group I than in Group III (13.9% vs. 5.1%, p < 0.03). It is concluded that revascularization should be as complete as possible for severe coronary stenoses coexisting with significant calcific aortic stenosis. However, bypassing of moderate coronary lesions (stenoses in the order of 50%) in association with AVR does not appear justified on current evidence. Further studies on this important aspect are clearly required.

[Prognosis after aortic valve replacement for aortic valve stenosis with or without associated coronary lesions]

With the increasing age of patients and the progression of degenerative pathologies, the management of aortic stenosis (AS) with coronary artery disease is becoming more frequent. Reported results of combined valve and coronary surgery are equivocal especially with respect to the increased risk compared with aortic valve replacement without coronary surgery. The authors assessed the results of combined surgery by comparing two groups of patients with AS operated between 1979 and 1991: 122 patients with coronary lesions undergoing combined valve and coronary surgery (Group I) and 122 patients without coronary artery disease undergoing isolated aortic valve replacement (Group II) and paired with Group I patients for 5 prognostic factors (age, sex, functional status, date of surgery and left ventricular ejection fraction). Pairing the patients provided comparable populations for these 5 factors. The average age was high (68 years in Group I with over 50% of patients over 70 years of age) and most patients were in functional classes III or IV (67% in Group I). In Group I, 67% of patients had multivessel disease (average 2 vessel disease). Aortic valve replacement was associated with an average of 1.7 coronary bypass grafts per patient. Myocardial protection was the same in all cases using cold potassium enriched cardioplegic solutions. Operative mortality was 10.6% in Group I compared with 4.9% in Group II (NS) and the respective perioperative infarction rates were 6.6% and 0.8% (p < 0.02). Seven year actuarial survival rates were 71.8% in Group I and 74.9% in Group II (NS) without any increased late mortality in Group II.(ABSTRACT TRUNCATED AT 250 WORDS)