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

Dynamic intermittent compression cryotherapy with intravenous nefopam results in faster pain recovery than static compression cryotherapy with oral nefopam: post-anterior cruciate ligament reconstruction

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.

The effect and safety of periarticular multimodal drug injection without morphine and epinephrine in anterior cruciate ligament reconstruction

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.

Periarticular injection and hamstring block versus placebo for pain control in anterior cruciate ligament reconstruction: A randomized controlled trial

PURPOSE

To study the effectiveness of periarticular infiltration (PI), including the proximal donor site vs. placebo in anterior cruciate ligament (ACL) reconstruction.

METHOD

A total of 44 patients were randomized in two groups assigned to receive PI or placebo. The perioperative protocol was the same for both groups. The principal outcome was pain measured at 8 and 24 h by a visual analog scale (VAS). The pain was registered in the knee and the proximal donor site. Pain scores were also assessed to determine whether the VAS improvement would reach the threshold values reported for the minimal clinically significant difference. The secondary outcome was the need for opioid rescue medication.

RESULTS

Patients receiving PI exhibited lower pain values in the knee at 8 h (mean PI 35.00 ± 5.76 vs. placebo 60.23 ± 4.52 p = 0.01) and at 24 h (mean PI 37.23 ± 5.62 vs. placebo 55.55 ± 3.41 p = 0.008). These results were above the threshold for clinical significance. No improvements were found in proximal donor site pain and consumption of opioid rescue medication. Complications were comparable between the two groups.

CONCLUSION

PI significantly reduced pain in the knee vs. placebo after ACL reconstruction with hamstring autograft at 8 and 24 h after surgery. The instillation of part of the mixture in the proximal hamstring stump did not result in any improvement LEVEL OF EVIDENCE I: Level I, randomized controlled trial.

Local Infiltration Analgesia Versus Femoral Nerve Block for Pain Control in Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis

Background:

Anterior cruciate ligament reconstruction (ACLR) is often performed on an outpatient basis; thus, effective pain management is essential to improving patient satisfaction and function. Local infiltration analgesia (LIA) and femoral nerve block (FNB) have been commonly used for pain management in ACLR. However, the comparative efficacy and safety between the 2 techniques remains a topic of controversy.

Purpose:

To compare pain reduction, opioid consumption, and side effects of LIA and FNB after ACLR.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed to identify studies comparing pain on the visual analog scale (a 100-mm scale), total morphine-equivalent consumption, and side effects between the 2 techniques after ACLR at the early postoperative period. The LIA was categorized into intra-articular injection and periarticular injection, and subgroup analyses were performed comparing either intra-articular injection or periarticular injection with FNB. Two reviewers performed study selection, risk-of-bias assessment, and data extraction.

Results:

A total of 10 studies were included in this systematic review and meta-analysis. In terms of VAS pain scores, our pooled analysis indicated that FNB was significantly more effective at 2 hours postoperatively compared with LIA (mean difference, 8.19 [95% confidence interval (CI), 0.75 to 15.63]; P = .03), with no significant difference between the 2 techniques at 4, 8, and 12 hours postoperatively; however, LIA was significantly more effective at 24 hours postoperatively compared with FNB (mean difference, 5.61 [95% CI, −10.43 to −0.79]; P = .02). Moreover, periarticular injection showed a significant improved VAS pain score compared with FNB at 24 hours postoperatively (mean difference, 11.44 [95% CI, −20.08 to −2.80]; P = .009), and the improvement reached the threshold of minimal clinically important difference of 9.9. Total morphine-equivalent consumption showed no difference between the 2 techniques, and side effects were unable to be quantified for the meta-analysis because of a lack of data.

Conclusion:

Compared with FNB, LIA was not as effective at 2 hours, comparable within 12 hours, and significantly more effective at 24 hours postoperatively for reducing pain after ACLR. Total morphine-equivalent consumption showed no significant differences between the 2 techniques.

The efficacy and safety of local infiltration analgesia vs femoral nerve block after anterior cruciate ligament reconstruction: A retrospective trial protocol

BACKGROUND

Several previous trials have attempted to compare the efficacy of femoral nerve block (FNB) and local infiltrative analgesia (LIA) for patients received anterior cruciate ligament (ACL) reconstruction, but reached inconsistent conclusions. The primary purpose of this present research was to compare the FNB and LIA in the reconstruction of ACL.

METHODS

This investigation was conducted and then reported on the basis of Strengthening the Reporting of Observational studies in the Epidemiology checklist. From our registry database, we retrospectively determined 688 patients who received the primary reconstruction of ACL from 2016 to 2019 at our academic institutions. This current retrospective cohort study was approved through the institutional review committee at our hospital. Inclusion criteria contained the primary or autograft bone-patellar tendine-bone reconstruction of ACL in the patients over 16 years of age. Patients in the LIA group underwent intraoperative infiltration at the harvested site after tendon harvest, with use of 2 mg/mL of ropivacaine 20 mL and 5 mg/mL of epinephrine, respectively. After the reconstruction of ACL, 5 Lg/mL of epinephrine, and 20 mL of ropivacaine (2 mg/mL) were injected at the site of surgical trauma. The patient in FNB group was given 40 mL of ropivacaine (2 mg/mL), and the ropivacaine was injected into femoral nerve sheath at femoral triangle level. The primary outcome was the consumption of morphine 24 h after the operation. And the secondary results involved the complications, functional results, and the scores of pain.

RESULTS

It is assumed that the efficacy of LIA in the early postoperative pain is no less than that of FNB. For our study, the major limitation is the lack of randomization. Nevertheless, these data were prospectively harvested, with high response rate of patient.

TRIAL REGISTRATION

This study protocol was registered in Research Registry (researchregistry6277).

Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial

Background and objectives

There are no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia.

Method

Randomized and controlled clinical trial of patients undergoing reconstruction of the Anterior Cruciate Ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The groups C, M, R0,375 and R0,25 was compared with only the previously described technique, subarachnoid morphine (100░μg), or Femoral Nerve Block (BNF) with 25░mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24░hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated.

Results

Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24░hours. There was a higher incidence of urinary retention in the M group (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 group (30%) than in the M and C groups (0%), with statistical significance (p░<░0.05).

Conclusion

There was no difference in the intensity of postoperative pain in patients submitted to ACL reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M group and motor block in the R0,375 group.

[Comparison between subarachnoid morphine and femoral nerve block for analgesia after knee ligament reconstruction: a randomized clinical trial]

BACKGROUND AND OBJECTIVES

There is no consensus of the ideal technique to provide analgesia in knee ligament reconstructions. The aim of this study was to compare the intensity of postoperative pain in these patients under different modalities of analgesia.

METHOD

Randomized and controlled clinical trial of patients undergoing reconstruction of the anterior cruciate ligament (ACL) with flexor tendons between December 2013 and 2014. All patients underwent spinal anesthesia and rescue analgesia with tramadol. The Groups C, M, R0,375 and R0,25 were compared with only the previously described technique, subarachnoid morphine (100 μg) or femoral nerve block with 25 mL of 0.375% ropivacaine and 0.25%, respectively. Pain intensity at 6, 12 and 24hours, age, sex, rescue analgesia, adverse reactions and satisfaction were evaluated.

RESULTS

Among the 83 eligible patients, a predominance of males (85.7%) was observed, between 28 and 31 years. The Group C requested more opioid (27.3%) than the other groups, without significance when compared. There were no significant differences in pain intensity at 6, 12 and 24hours. There was a higher incidence of urinary retention in the Group M (23.8%) than in the R0,375 (0%) and prolonged quadriceps motor block in the R0,375 Group (30%) than in the M and C Groups (0%), with statistical significance (p < 0.05).

CONCLUSION

There was no difference in the intensity of postoperative pain in patients submitted to anterior cruciate ligament reconstruction with flexor tendons under the analgesic modalities evaluated, despite the predominance of urinary retention in the M Group and motor block in the R0,375 Group.

Local Infiltration Analgesia with Ropivacaine Improves Postoperative Pain Control in Ankle Fracture Patients: A Retrospective Cohort Study

Purpose

The study aimed at investigating the effect of local infiltration analgesia (LIA) with ropivacaine on postoperative analgesia for patients undergoing ankle fracture surgery.

Methods

Consecutive patients were retrospectively included and analysed according to their medical records from July 2014 to August 2018 in a tertiary hospital. Inclusion criteria were patients undergoing open reduction and internal fixation (ORIF) for ankle fractures under general anaesthesia. Moreover, patients should have received intravenous patient-controlled analgesia (iPCA) or LIA + iPCA for postoperative pain relief. The primary outcome indicator was visual analogue scale (VAS) from 8 hours to 48 hours after surgery. Secondary outcomes included postoperative opioid requirement, need for rescue medication, opioid-related adverse effects, and wound complications.

Results

In total, 89 consecutive patients were included in the study. There were 48 males and 41 females. The average age was 44.6 ± 7.0 years, and VAS scores were significantly lower in the LIA + iPCA group at 8 hours after surgery (1.51 ± 0.58 cm vs 4.77 ± 1.83 cm, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes,

Conclusions

The retrospective cohort study indicates that LIA with ropivacaine can provide better early postoperative pain management with a reduction of VAS scores for ankle fracture surgery. Patients receiving wound infiltration also experience decreased opioid consumption, a lower rate of analgesia-related side effects, and comparable wound complication rate.

Local Anesthetics' Toxicity toward Human Cultured Chondrocytes: A Comparative Study between Lidocaine, Bupivacaine, and Ropivacaine

OBJECTIVE

In orthopedic joint injection, the most frequently used local anesthetics are ropivacaine, bupivacaine, and 1% or 2% lidocaine. The aim of this study was to examine effects of these various anesthetics on the viability of human chondrocytes. Our hypothesis was that all local anesthetics tested damage human chondrocytes in vitro.

METHODS

Primary human chondrocytes were isolated and cultured from 6 donated human knee joints (mean age of donors 61.2 years). Local anesthetics were added to these cultures. Toxicity analysis was performed by visualization of cell structure using light microscopy. Determination of vital chondrocytes was performed by use of a Casy cell counter. Chondrocytes' cell death was examined by fluorescence microscopy and an XTT ELISA assay.

RESULTS

Light microscope and fluorescence microscope data revealed a defect cell structure and increased number of dead cells after addition of 1% or 2% lidocaine and bupivacaine but not ropivacaine. We were able to show an increased level of XTT activity after treatment with bupivacaine, 2% lidocaine or ropivacaine. The count of vital chondrocytes was significantly decreased after treatment with bupivacaine, 1% or 2% lidocaine, and ropivacaine.

CONCLUSIONS

The data show that treatment with local anesthetics induces cell damage of human chondrocytes in vitro. Ropivacaine seems to be a local anesthetic with the lowest toxic potential on human chondrocytes, a feature that may favor its preference for use in joint injection.

Periarticular Injection Versus Femoral Nerve Block for Pain Relief After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

PURPOSE

To compare the effectiveness and safety of periarticular injection (PI) with those of femoral nerve block (FNB) after anterior cruciate ligament (ACL) reconstruction.

METHODS

A total of 129 patients scheduled for ACL reconstruction were randomly assigned to receive PI or FNB. Other perioperative interventions were identical for all patients. The primary outcome was the postoperative pain score 24 hours after surgery, which was measured using a 100-mm visual analog scale (VAS). The pain scores were also assessed to determine whether the VAS score would reach the threshold values reported for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS).

RESULTS

The PI group had significantly lower VAS scores 24 hours after ACL reconstruction than the FNB group (21 mm vs 39 mm; P < .0001). Consequently, the primary outcome reached the level of clinical significance as indicated by the threshold values of an MCID of 9.9 and a PASS of 33. The PI group also had a significantly lower VAS score at rest at 4 hours, 8 hours, and 2 days after surgery (30 mm vs 39 mm [P = .025], 25 mm vs 33 mm [P = .022], and 22 mm vs 32 mm [P = .0022], respectively). The opioid consumption during the initial 24 hours was significantly lower in the PI group (354 μg vs 503 μg; P = .0003). The complication rate, including opioid-related complications, was not significantly different between groups.

CONCLUSION

The patients treated with PI had significantly better pain scores and lower opioid consumption than those treated with FNB without elevating the complication rate.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

The effect of midazolam on pain control after knee arthroscopy: a systematic review and meta-analysis

BACKGROUND

Midazolam has some potential in pain control of patients undergoing knee arthroscopy. However, the results remain controversial. We conduct a systematic review and meta-analysis to explore the effect of midazolam on pain control after knee arthroscopy.

METHODS

PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched. Randomized controlled trials (RCTs) assessing the effect of midazolam on pain management after knee arthroscopy are included. Two investigators have independently searched articles, extracted the data, and assessed the quality of the included studies. This meta-analysis is performed using the random-effect model.

RESULTS

Six RCTs are included in this meta-analysis. Compared with control intervention after knee arthroscopy, midazolam intervention can significantly reduce the pain scores (standard mean difference (Std. MD) = - 3.70; 95% confidence interval (CI) = - 6.81 to - 0.60; P = 0.02), the number of patients requiring analgesics (risk ratio (RR) = 0.66; 95% CI = 0.49 to 0.88; P = 0.005), and analgesic consumption (Std. MD = -1.62; 95% CI = - 3.04 to - 0.19; P = 0.03), as well as increase the time to first analgesic requirement (Std. MD = 1.58; 95% CI = 0.17 to 2.99; P = 0.03). In addition, midazolam intervention results in no increase in adverse events following knee arthroscopy (RR = 0.74; 95% CI = 0.18 to 2.98; P = 0.67).

CONCLUSIONS

Midazolam intervention is revealed to substantially reduce the pain scores, the number of patients requiring analgesics, and analgesic consumption, as well as improve the time to first analgesic requirement after knee arthroscopy.

Comparison of periarticular anesthesia with liposomal bupivacaine with femoral nerve block for pain control after total knee arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

Periarticular anesthesia (PAI) with liposomal bupivacaine (LB) and femoral nerve block (FNB) were 2 common type of pain management after total knee arthroplasty (TKA). There is no consensus about PAI with LB shows better clinical outcome than FNB. Thus, we performed a systematic review and meta-analysis to compare the efficacy and safety of PAI with LB and FNB for patients prepared for TKA.

METHODS

Randomized controlled trials (RCTs) and non-RCTs from PubMed (1966-2017.2), EMBASE (1980-2017.2), and the Cochrane Central Register of Controlled Trials (CENTRAL, 2017.2), Web of Science (1966-2017.2), and Chinese Wanfang database (1980-2017.2) were searched. Continuous outcomes including visual analogue scale (VAS) at 24, 48, and 72 hours, total morphine consumption, length of hospital, and range of motion (ROM) were reported as the weighted mean difference with 95% and confidence interval (CI) and discontinuous outcomes (the occurrence of postoperative nausea and vomiting [PONV]) were presented as relative risk with 95% CI. Random-effects model was adopted to analyze the relevant data.

RESULTS

According to the inclusion and exclusion criteria, 8 studies with 2407 patients were eligible and finally included in this meta-analysis (LB = 1114, FNB = 1293). There was no significant difference between VAS at 24, 4, and 72 hours, ROM, and the occurrence of PONV between PAI with LB group versus FNB group (P > 0.05). Compared with the FNB group, PAI with LB was associated with a significant decrease in length of hospital stay by 0.43 day (MD = -0.43; 95% CI -0.60 to -0.27; P = 0.001) and the total dose of total morphine consumption by (MD = -29.32; 95% CI -57.55 to -1.09; P = 0.042).

CONCLUSIONS

The review of trials found that PAI with LB provided a significant beneficial effect over FNB in improving the pain or decreased the total morphine consumption in patients who underwent TKA. However, PAI with LB associated with less LOS than FNB. More high quality RCTs are still needed to identify the effects and optimal dose of LB for pain management after TKA.