The efficacy of femoral nerve block in pain reduction for outpatient hamstring anterior cruciate ligament reconstruction: a double-blind, prospective, randomized trial

Periarticular cocktail injection is more useful than nerve blocks for pain management after anterior cruciate ligament reconstruction

Background

Anterior cruciate ligament (ACL) reconstruction is commonly associated with moderate-to-severe postoperative pain. Notably, various pain control strategies, a femoral nerve block (FNB) with a lateral femoral cutaneous nerve block (LFCNB), adductor canal block (ACB) with LFCNB, or periarticular cocktail injection (PI), have been investigated. However, no studies compare the effects of FNB with LFCNB, ACB with LFCNB, and PI for pain control after ACL reconstruction. This study aimed to evaluate the impact of FNB with LFCNB, ACB with LFCNB, and PI for pain relief in the early postoperative period after ACL reconstruction.

Methods

This retrospective controlled clinical trial enrolled 299 patients who underwent primary ACL reconstruction at our hospital between April 2016 and October 2022. We categorized these cases into groups based on the use of PI (PI group), FNB with LFCNB (FNB group), and ACB with LFCNB (ACB group) for pain management. We selected 40 cases each, with matched age, sex, and body mass index (BMI) from each group, resulting in 120 cases for analysis. In the FNB and ACB groups, 0.75% ropivacaine 15 ml was injected under ultrasound guidance preoperatively. In the PI group, a mixture of 0.75% ropivacaine 20 ml, normal saline 20 ml, and dexamethasone 6.6 mg was injected half at the start of surgery and the rest just before wound closure. Patient demographics (age, sex, height, body weight, and BMI) and surgical data (the requirement for meniscal repair, operative time, and tourniquet inflation time) were analyzed. After ACL reconstruction, patients' numerical rating scale pain scores (NRS) (0-10) were recorded at 30 min and 4, 8, 12, 24, 48, and 72 h postoperatively. NRS were then compared among the three groups using analysis of variance. In addition, within each group, these data were compared between the NRS ≥7 and NRS ≤6 groups using a t-test.

Results

There were no significant differences in patient demographics and surgical data. Pain scores were significantly higher in the PI group than in the FCB and ACB groups 30 min postoperatively, but they were lower at 12, 24, 48, and 72 h postoperatively. In the FNB group, there were no significant differences in the demographic and surgical data by NRS pain score. In the ACB group, the number of men was significantly higher in the NRS ≥7 group than in the NRS ≤6 group (p = 0.015). In the PI group, tourniquet inflation time was significantly longer in the NRS ≥7 group than in the NRS ≤6 group (p = 0.008).

Conclusions

Following ACL reconstruction using a hamstring autograft, periarticular cocktail significantly reduced early postoperative pain compared with nerve block combinations.

Ultrasound-guided adductor canal block is superior to femoral nerve block for early postoperative pain relief after single-bundle anterior cruciate ligament reconstruction with hamstring autograft

PURPOSE

This study aimed to compare the combination of a lateral femoral cutaneous nerve (LFCN) block with a femoral nerve block (FNB) and an adductor canal block (ACB) for postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction with hamstring autograft.

METHODS

A non-randomized, prospective, controlled clinical trial was conducted. The FNB and ACB groups consisted of 41 and 40 patients, respectively. Thirty minutes prior to surgery, the patients received an ultrasound-guided LFCN block either with FNB or ACB. The following values were recorded and compared between the two groups: duration of surgery, pain management during surgery (including total amount of fentanyl administered), and numerical rating scale (NRS) scores at 30 min and 4, 8, 12, 24, 48, and 72 h after surgery. Factors affecting pain relief (NRS < 2) were evaluated, including block type, total amount of fentanyl administered, duration of surgery, age, sex, body mass index, and postoperative suppository use. Significant factors predicting pain relief were determined using the Cox proportional hazard regression model.

RESULTS

There were no significant differences in pain management during the surgery. Pain scores were significantly lower in the ACB group at 30 min, 4 h, 24 h, and 48 h after surgery. The Cox proportional hazard regression model identified ACB as a significant factor for pain relief (hazard ratio: 1.88; 95% confidence interval: 1.12-3.13; p = 0.018).

CONCLUSION

The combination of ACB with LFCN block during ACL reconstruction significantly reduced pain in the early postoperative period compared to FNB with LFCN block.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

I, Systematic review of Level I studies.

Network meta-analysis of the analgesic effectiveness of regional anaesthesia techniques for anterior cruciate ligament reconstruction

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.

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

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

Methods

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

Results

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

Conclusions

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

Level of Evidence

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

The Median Effective Analgesic Concentration of Ropivacaine in Sciatic Nerve Block Guided by Ultrasound After Arthroscopic Anterior Cruciate Ligament Reconstruction: A Double-Blind Up-Down Concentration-Finding Study

Background

The median effective analgesic concentration (MEAC; EC50 = effective concentration in 50% patients) of ropivacaine in sciatic nerve block guided by ultrasound (US) required for effective postoperative analgesia following arthroscopic anterior cruciate ligament (ACL) reconstruction has not yet been found. This study aimed to determine the effectiveness of MEAC of 20 ml ropivacaine of postoperative anesthesia for patients after ACL reconstruction.

Methods

In total, 29 patients who underwent elective arthroscopic ACL reconstruction were enrolled in this study. All the subjects were given 20 ml of 0.2% ropivacaine for femoral nerve block. A concentration of 20 ml ropivacaine administered to the sciatic nerve was measured by applying the up-and-down sequential method (UDM). The starting concentration was 0.2% in the first patient, and the next patient received decremented 0.025% ropivacaine if the prior patient's postoperative visual analog pain score was <4 in the initial 8 h. Otherwise, the participant was given an incremental dose of 0.025% ropivacaine. The EC50 of ropivacaine was determined by using centered isotonic, linear-logarithmic, exponential regressions, and linear regression. The “goodness of fit” was compared among various models by calculating the residual standard errors.

Results

The concentration of ropivacaine administered ranged from 0.1 to 0.2%. The EC50 [95% confidence interval (CI)] determined by four statistical methods (centered isotonic, exponential regressions, linear-logarithmic, and linear regression) was 0.115, 0.113% (0.108, 0.343%), 0.142% (0.112, 0.347%), and 0.129% (0.103, 0.359%), respectively. Among all models, the residual standard error was the smallest for the exponential regression (0.2243).

Conclusion

The EC50 of ropivacaine in US-guided sciatic nerve block was 0.113–0.142%, and exponential regression model best matched the data.

A reduced concentration femoral nerve block is effective for perioperative pain control following ACL reconstruction: a retrospective review

INTRODUCTION

Femoral nerve block (FNB) is a routinely used regional analgesic technique for anterior cruciate ligament (ACL) reconstruction. One method to balance the analgesic effect and functional impairment of FNBs may be to control the concentration of local anesthetics utilized for the block.

MATERIALS AND METHODS

Retrospective chart review was performed on 390 consecutive patients who underwent ACL reconstruction between June 2014 and May 2017. Patients were divided into those who received a standard (0.5%-bupivacaine) or low (0.1-0.125%-bupivacaine) concentration single-shot FNB performed with ultrasound guidance. Maximum postoperative VAS, Post-Anaesthesia Care Unit (PACU) time prior to discharge, need for additional 'rescue' block, and intravenous postoperative narcotic requirements were recorded.

RESULTS

A total of 268 patients (28.4 ± 11.9 years) were included for final analysis, with 72 patients in the low-concentration FNB group and 196 patients receiving the standard concentration. There were no differences in the maximum postoperative VAS between the low (6.4 ± 2.5) and standard (5.7 ± 2.9) concentration groups (P = 0.08). Similarly, the time from PACU arrival to discharge was not different between groups (P = 0.64). A sciatic rescue block was needed in 22% of patients with standard-dose FNB compared to 30% of patients receiving the low-concentration FNB (P = 0.20). Patients with a hamstring autograft harvest were more likely to undergo a postoperative sciatic rescue block compared to a bone-patellar tendon autograft (P = 0.005), regardless of preoperative block concentration. Quadriceps activation was preserved with low-concentration blocks.

CONCLUSIONS

Using 1/5th to 1/4th the standard local anesthetic concentration for preoperative femoral nerve block in ACL reconstruction did not significantly differ in peri-operative outcomes, PACU time, need for rescue blockade, or additional immediate opioid requirements.

LEVEL OF EVIDENCE

III.

Anterior cruciate ligament reconstruction with ultrasound-guided femoral nerve block does not adversely affect knee extensor strength beyond that seen with intravenous patient-controlled analgesia at 3 and 6 months postoperatively

BACKGROUND

This study aimed to investigate the effect of anterior cruciate ligament (ACL) reconstruction with an ultrasound-guided femoral nerve block (FNB) on knee extensor strength weakness 3 and 6 months, and graft rupture in the 1 year following ACL reconstruction.

METHODS

One hundred and seven patients who underwent ACL reconstruction were included in this retrospective study. The patients were divided into two groups stratified by the method of postoperative pain management. The FNB group included 66 patients, and there were 41 patients in the intravenous patient-controlled analgesia (iv-PCA) group. The isokinetic peak torque of knee flexor and extensor was measured preoperative, 3 and 6 months after ACL reconstruction. Muscle strength measurements were performed using the BIODEX dynamometer at a velocity of 60°/s and 180°/s. Peak torque of knee extensor and flexor strength, estimated pre-injury capacity (EPIC), body weight ratio (BW), and graft rupture incidence were compared between the two groups.

RESULTS

There were no statistically significant differences in the knee extensor and flexor strength for all items at 3 and 6 months after ACL reconstruction. There was also not a statistically significant difference in the graft rupture incidence between the two groups: FNB group was two patients, 3.0% vs. iv-PCA group was one patient, 2.4% (p = 0.86).

CONCLUSION

ACL reconstruction with ultrasound-guided FNB does not affect knee extensor strength at 6 months, nor graft rupture at 1 year postoperatively.

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.

Femoral nerve versus adductor canal block for early postoperative pain control and knee function after anterior cruciate ligament reconstruction with hamstring autografts: a prospective single-blind randomised controlled trial

INTRODUCTION

The optimal pain management strategy for postoperative pain after anterior cruciate ligament reconstruction (ACLR) remains unclear. This study compared femoral nerve block (FNB) and adductor canal block (ACB) for pain management of early postoperative pain, knee function, and recovery of activity of daily living (ADL) after ACLR using hamstring autografts.

MATERIAL AND METHODS

In this prospective, single-blind, randomised controlled trial, 64 patients aged 12-56 years who underwent anatomical double-bundle ACLR with a hamstring autograft between August 2019 and May 2020 were randomised to undergo preoperative FNB (n = 32) or ACB (n = 32). The peripheral nerve block was performed by a single experienced anaesthesiologist under ultrasound guidance. The primary outcomes were postoperative pain as evaluated using the visual analogue scale (VAS) at 3, 6, 12, 24, and 48 h postoperatively and the need for pain relief. The secondary outcome was knee function, including the recovery of range of motion, contraction of the vastus medialis, and stable walking with a double-crutch (ADL), as evaluated by blinded physical therapists.

RESULTS

There were no significant differences in patient demographics between the two groups. The VAS scores, need for pain relief, knee function, and ADL did not significantly differ between the groups.

CONCLUSION

FNB and ACB provided comparable outcomes related to early postoperative pain, knee function, and ADL after double-bundle ACLR using hamstring autografts. Further research is necessary to evaluate the mid- to long-term effect of each block on recovery of knee function and ADL.

LEVEL OF EVIDENCE

I.

Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis

PURPOSE

To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes.

METHODS

A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable.

RESULTS

Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use.

CONCLUSIONS

Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis of RCTs.

Usefulness of lateral femoral cutaneous nerve block in combination with femoral nerve block for anterior cruciate ligament reconstruction: a prospective trial

INTRODUCTION

The study aimed to compare the combination of femoral nerve block (FNB) with interspace between the popliteal artery and the capsule of posterior knee (IPACK) block (IPACK group) with the combination of FNB with lateral femoral cutaneous nerve (LFCN) block (LFCN group) for postoperative pain control in patients undergoing anterior cruciate ligament (ACL) reconstruction. We hypothesized that the lower pain scores and decreased suppository use would be noted in patients administered a combination of FNB and IPACK block.

MATERIALS AND METHODS

A non-randomized prospective controlled clinical trial was conducted. The IPACK and LFCN groups included 40 patients each. The patients received IPACK block and LFCN block alternately. Thirty minutes prior to the surgery and after administration of general anesthesia, patients received an ultrasound-guided FNB and IPACK block or LFCN block. After ACL reconstruction, the visual analog scale pain scores were recorded at 30 min, 4 h, 8 h, 12 h, 24 h, 48 h, and 72 h after the surgery. The administration and use of analgesic suppositories were assessed. These measures were compared among the treatment types at each time-point using the Welch's t-test.

RESULTS

Suppository use was significantly less in the LFCN group than in the IPACK group. The pain scores were significantly lower in the LFCN group at 30 min, 4 h, 48 h, and 72 h after the surgery.

CONCLUSION

The combination of FNB with LFCN block during ACL reconstruction significantly reduces pain in the early postoperative period compared to a combination of FNB with IPACK block.

LEVEL OF EVIDENCE

Prospective control trial, Level II.

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.

Prospective Study of Acute Opioid Use After Adolescent Anterior Cruciate Ligament Reconstruction Shows No Effect From Patient- or Surgical-Related Factors

INTRODUCTION

Patient-reported pain scores and opioid use have not been quantified after outpatient adolescent anterior cruciate ligament reconstruction (ACLR).

METHODS

Patients aged 12 to 18 years undergoing primary isolated ACLR, with or without meniscal treatment, were prospectively recruited. Patients actively taking opioids or with previous extended use of opioids were excluded. Two orthopaedic surgeons performed ACLR and determined the use of a hamstring or bone-patellar tendon-bone autograft. For postoperative pain management, patients were prescribed 40 tablets of hydrocodone/acetaminophen 5/325 mg. Patients were instructed to document daily pill consumption and side effects through a daily log for 6 weeks. Patients completed the American Pain Society Patient Outcome Questionnaire at the end of weeks 1 and 6.

RESULTS

One hundred three patients were enrolled, with age: 12.5 to 18.9 years (mean 16.2 y ± 1.3), weight: 41.3 to 113.6 kg (mean 72.4 kg ± 17.2), and body mass index: 17.8 to 40.1 (mean 25.9 ± 4.9). Sixty-nine patients received a hamstring autograft, and 34 received a bone-patellar tendon-bone autograft. Fifty-six received additional meniscal procedures. The median number of postoperative opioids taken by patients was 17 (range 0 to 40). No notable differences were found in total pill consumption with regard to age, weight, body mass index, sex, block type, autograft type, or meniscal treatment at 1 week post-op or 6 weeks post-op. No correlation was found between the self-reported "worst pain in the past 24 hours" at the end of the first postoperative week or after 6 weeks (r = 0.112, P = 0.26, and r = 0.093, P = 0.36). No correlation was found between the level of satisfaction with pain treatment and total number of pills taken during the first postoperative week or at the end of 6 weeks (r = -0.090, P = 0.37, and r = -0.172, P = 0.08).

CONCLUSION

Patients take most pain medication during the first postoperative week after adolescent ACLR, although patient and surgical variables had no notable influence on pill consumption.

LEVEL OF EVIDENCE

Level IV, case series.

Effect of combining peri-hamstring injection or anterior obturator nerve block on the analgesic efficacy of adductor canal block for anterior cruciate ligament reconstruction: a randomised controlled trial

BACKGROUND

Pain after anterior cruciate ligament reconstruction (ACLR) with autologous hamstring graft can be attributed to both arthroscopic surgery and the graft donor site. This study investigated whether donor site pain control was superior with the addition of either peri-hamstring injection or anterior division obturator nerve block in comparison with adductor canal block (ACB) alone.

METHODS

Patients scheduled to undergo knee arthroscopy with ACLR using a graft from the ipsilateral hamstring were randomised to one of three groups. All patients received ACB and multimodal analgesia. Subjects in Group H received peri-hamstring local anaesthetic injection while subjects in Group O received an anterior division of the obturator nerve block, and subjects in Group C served as a control group (ACB alone).

RESULTS

In 105 subjects undergoing ACLR, there was no significant difference between groups H, O, and C for the primary outcome of pain on movement as assessed by numerical rating scale (NRS) on knee flexion at 2 h after operation (P=0.11). There was no difference in NRS at any time point in the first 48 h after operation, nor was there a difference in oxycodone consumption between the three groups at 24 h (P=0.2). Worst knee pain was initially at the graft donor site in all three groups, which transitioned to anterior knee pain after 12 h.

CONCLUSIONS

The addition of ultrasound-guided peri-hamstring injection or anterior division of obturator nerve block to ACB did not result in a significant reduction in pain or opioid consumption after ACLR with ipsilateral hamstring graft.

CLINICAL TRIAL REGISTRATION

NCT01868282.

Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part I-Femoral Nerve Block

The optimal management of pain after ambulatory anterior cruciate ligament reconstruction (ACLR) is unclear. Femoral nerve block (FNB) is purported to enhance postoperative analgesia, but its effectiveness in the setting of modern multimodal analgesia is unclear. This systematic review examines the effect of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, whether or not the analgesic regimen used included local instillation analgesia (LIA). We retrieved randomized controlled trials evaluating the effects of adding FNB to multimodal analgesia on analgesic outcomes after ACLR, compared to multimodal analgesia alone (control). We designated postoperative opioid consumption at 24 hours as our primary outcome. Secondary outcomes included postoperative opioid consumption at 24-48 hours, rest, and dynamic pain severity between 0 and 48 hours, time to analgesic request, postanesthesia care unit and hospital stay durations, patient satisfaction, postoperative nausea and vomiting, functional outcomes, and long-term (>1 month) quadriceps strength. Eight randomized controlled trials (716 patients) were identified. Five trials compared FNB administration to control, and another 3 compared the combination of FNB and LIA to LIA alone. Compared to control, adding FNB resulted in modest reductions in 24-hour opioid consumption in 2 of 3 trials, and improvements in rest pain at 1 hour in 1 trial and up to 24 hours in another. In contrast, the combination of FNB and LIA, compared to LIA alone, did not reduce opioid consumption in any of the trials, but it did improve pain scores at 20 minutes only in 1 trial. The effect of FNB on long-term quadriceps strength or function after ACLR was not evaluated in the reviewed trials. Contemporary evidence suggests that the benefits of adding FNB to multimodal analgesia for ACLR are modest and conflicting, but there is no incremental analgesic benefit if the multimodal analgesic regimen included LIA. Our findings do not support the routine use of FNB for analgesia in patients having ACLR.

Reduced Opioid Use After Surgeon-Administered Genicular Nerve Block for Anterior Cruciate Ligament Reconstruction in Adults and Adolescents

BACKGROUND

Pain management after anterior cruciate ligament reconstruction (ACLR) may pose a risk of prolonged opioid use.

QUESTIONS/PURPOSES

The purposes of this study in ACLR were to investigate the efficacy of a surgeon-administered local-regional block of specific genicular nerves on post-operative analgesia following ACLR and to quantify the outpatient opioid consumption and duration through the complete post-operative course.

METHODS

Prospectively, all patients undergoing primary ACLR by a single surgeon were studied over a 10-month period. Exclusion criteria consisted of history of pre-operative opioid use, revision surgery, multi-ligament surgery, allergy to oral opioids, and allergy to local anesthetic. ACLR was performed using autograft or allograft patellar tendon bone (PTB) graft under general anesthesia. At the conclusion of the procedure, all patients received a local anesthetic (bupivacaine 0.25%) injection by the surgeon including a unique circumferential genicular nerve and fat pad block performed based on anatomic landmarks without use of image guidance. Post-operatively, the quantity and duration of opioid use (hydrocodone 5 mg) and pain scores were recorded for 4 months prospectively. Statistical analysis was performed to evaluate risk factors for increased opioid use.

RESULTS

A single surgeon performed 75 ACLRs. After exclusions, a total of 70 patients were enrolled and followed prospectively. None were lost to follow-up. Total opioid consumption ranged from 0 to 30 tablets. The average number of opioid tablets used over the 4-month post-operative course was 5.5 (± 6.7). After surgery, 84% of patients took between 0 and 10 tablets and 21% of patients took no opioids throughout their entire post-operative course. The average duration of consumption was 2.6 days (± 3.1). No patients were taking opioids at the 6-week or 4-month follow-up. There were no refills required. No statistically significant differences were seen in regard to graft choice of autograft PTB (n = 48) vs allograft PTB (n = 22) in total opioid consumption or duration of use. In comparing adolescent (n = 31) versus adult (n = 39), no significant difference was seen in total opioid consumption or duration of use. All patients were satisfied with the post-operative pain management protocol.

CONCLUSION

Opioid use was unexpectedly low among patients undergoing ACLR after a surgeon-administered circumferential genicular nerve block and fat pad infiltration. With this protocol, the graft choice and patient age did not correlate with increased opioid use. These results could be useful in guiding post-operative opioid prescribing after ACLR.

Adductor Canal Block Versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial

BACKGROUND

Femoral nerve block (FNB) is a commonly performed technique that has been proven to provide effective regional analgesia after anterior cruciate ligament (ACL) reconstruction. The adductor canal block (ACB) uses a similar sensory block around the knee while avoiding motor blockade of the quadriceps muscles.

PURPOSE/HYPOTHESIS

The purpose of our study was to compare the efficacy of FNB versus ACB for pain control after ACL reconstruction. It was hypothesized that there would be no difference in pain levels or opioid requirements between the 2 groups.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

We performed a prospective, double-blinded, randomized controlled trial. Sixty patients undergoing primary ACL reconstruction with bone-patellar tendon-bone autograft were randomized to receive either an ACB or an FNB preoperatively. The primary outcomes assessed were pain levels (visual analog scale) and narcotic requirements for 4 days after surgery. Secondary outcomes included ability to perform a straight leg raise in the recovery room and difference in thigh circumference between the operative and nonoperative leg measured at 7 days postoperatively.

RESULTS

Morphine requirements were less in the ACB group in the first 4 hours postoperatively ( P = .02). Aside from this time interval, no differences were found between the 2 groups with regard to opioid requirements and pain scores at any other time. Similarly, no differences were noted in patients' ability to perform a straight leg raise in the recovery room ( P = .13) or in thigh circumference at the first postoperative visit ( P = .09).

CONCLUSION

The results of our study suggest similar efficacy in perioperative pain control with the use of an ACB for ACL reconstruction when compared with FNB. The potential long-term benefit of quadriceps preservation with the ACB is worthy of future study.

REGISTRATION

NCT03033589 (ClinicalTrials.gov identifier).

Efficacy of the Adductor Canal Approach to Saphenous Nerve Block for Anterior Cruciate Ligament Reconstruction With Hamstring Autograft: A Randomized Controlled Trial

Background

For reconstruction of the anterior cruciate ligament (ACL) with hamstring autograft, perioperative analgesia can be achieved with multimodal analgesia and intra-articular local anesthesia infiltration with or without additional regional blocks. Saphenous nerve block (SNB) via the adductor canal is commonly used in our practice, but its benefit has not been well established in the literature.

Purpose

To assess the efficacy of SNB in ACL reconstruction with hamstring autograft.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

Consecutive patients undergoing arthroscopic ACL reconstruction with hamstring autograft were randomized into a control group (no SNB) and an intervention group (SNB). All patients received standardized anesthetic induction and maintenance agents with perioperative analgesia, per study protocol, with local anesthetic infiltration of the graft harvest site and intra-articular infiltration.

Results

Sixty patients were randomized into the 2 groups (n = 30 each). There was no statistically significant difference in total opiate consumption between the groups (control, 34 mg; SNB, 31 mg; P = .40). There was no statistically significant difference in visual analog scale scores for pain at 0, 8, and 24 hours postsurgery, and no difference in overall satisfaction score. The control group had a significantly higher visual analog scale score at 4 hours postsurgery (3.0 vs 1.9, P = .04).

Conclusion

SNB has a minimal effect on postsurgical care for ACL reconstruction with hamstring autograft in the presence of multimodal analgesia and local anesthetic infiltration.

Quadriceps Strength Deficits After a Femoral Nerve Block Versus Adductor Canal Block for Anterior Cruciate Ligament Reconstruction: A Prospective, Single-Blinded, Randomized Trial

Background:

Peripheral nerve blocks, particularly femoral nerve blocks (FNBs), are commonly performed for anterior cruciate ligament (ACL) reconstruction. However, associated quadriceps muscle weakness after FNBs is well described and may occur for up to 6 months postoperatively. The adductor canal block (ACB) has emerged as a viable alternative to the FNB, theoretically causing less quadriceps weakness during the immediate postoperative period, as it bypasses the majority of the motor fibers of the femoral nerve that branch off proximal to the adductor canal.

Purpose/Hypothesis:

This study sought to identify if a difference in quadriceps strength exists after an ACB or FNB for ACL reconstruction beyond the immediate postoperative period. Beyond the immediate postoperative period, we anticipated no difference in quadriceps strength between patients who received ACBs or FNBs for ACL reconstruction.

Study Design:

Randomized controlled trial; Level of evidence, 1.

Methods:

A total of 102 patients undergoing primary ACL reconstruction using a variety of graft types were enrolled between November 2015 and April 2016. All patients were randomized to receive an ACB or FNB before surgery, and the surgeon was blinded to the block type. All patients underwent aggressive rehabilitation without functional bracing postoperatively. The time to the first straight-leg raise was reported by the patient. Isokinetic strength testing was performed at 3 and 6 months postoperatively.

Results:

Data for 73 patients were analyzed. There was no significant difference in patient demographics of age, body mass index, sex, or tourniquet time between the FNB (n = 35) and ACB (n = 38) groups. The mean time to the first straight-leg raise was similar, at 13.1 ± 1.0 hours for the FNB group and 15.5 ± 1.2 hours for the ACB group (P = .134). The mean extension torque at 60 deg/s increased significantly for both the ACB (53.7% ± 3.4% to 68.3% ± 2.9%; P = .008) and the FNB (53.3% ± 3.3% to 68.5% ± 4.1%; P = .006) groups from 3 to 6 months postoperatively. There was also no significant difference in mean extension torque at 60 deg/s or 180 deg/s between the FNB and ACB groups at 3 and 6 months. There were no significant differences in postoperative complications (infection, arthrofibrosis, retear) between groups.

Conclusion:

Although prior studies have shown immediate postoperative benefits of ACBs compared with FNBs, with a faster return of quadriceps strength, in the current study there was no statistically or clinically significant difference in quadriceps strength at 3 and 6 months postoperatively in patients who received ACBs or FNBs for ACL reconstruction.

Analgesia after ACL reconstruction: Hamstring donor-site injection versus intra-articular local anaesthetic injection

BACKGROUND

The purpose of this study was to compare hamstring donor-site injection versus intra-articular injection of a local anaesthetic for analgesia after anterior cruciate ligament (ACL) reconstruction.

HYPOTHESIS

The two methods provide similar pain relief.

MATERIAL AND METHODS

158 consecutive patients undergoing ACL hamstring tendon graft reconstruction (semi-tendinosus/gracilis [STG] or four-stranded semi-tendinosus [ST4]) during two periods in 2015 were included. Peripheral nerve block was not performed. At the end of surgery, 20mL of ropivacaine 7.5mg/mL was injected, intra-articularly during the early period (n=79) and into the hamstring donor site during the second period (n=79). Post-operative pain was evaluated subjectively by the patients using a visual analogue scale (VAS). We recorded patient demographics, concomitant surgical procedures, VAS pain scores, rescue analgesic use, time to discharge, and patient satisfaction. VAS pain score, side effects, and patient satisfaction were also recorded during a phone interview on the day after surgery (D1).

RESULTS

Mean VAS pain scores were not significantly different between the two groups immediately after surgery (D0) or on D1 (D0: intra-articular, 2.08 and donor site, 1.88; Mann-Whitney P=0.6). Neither were the groups significantly different for rescue analgesic use, patient satisfaction, or quadriceps activation.

CONCLUSION

The same local anaesthetic provides similar pain relief when injected intra-articularly or into the hamstring donor site after hamstring tendon ACL reconstruction (STG or ST4).

LEVEL OF EVIDENCE

III, prospective case-control study.

Anesthesia and analgesia methods for outpatient anterior cruciate ligament reconstruction

INTRODUCTION

More and more anterior cruciate ligament (ACL) reconstructions are being performed as outpatient surgery in France, because of economic considerations. Postoperative pain is the most common reason for delayed discharge that could require hospitalization, and the main reason for unanticipated hospital admission. The purpose of this study was to define the best anesthesia and analgesia methods for ACL reconstruction.

MATERIALS AND METHODS

This was a prospective, multicenter, comparative study performed between January 2014 and April 2015. Inclusion criteria were ACL reconstruction in patients above 15 years of age performed as an outpatient surgical procedure. The anesthesia techniques analyzed were general anesthesia, spinal anesthesia and quadruple nerve blockade. The analgesic methods studied were single-shot nerve blocks, continuous nerve blocks, peri-articular and intra-articular local infiltration analgesia (LIA), non-steroidal anti-inflammatory agents (NSAIDs) and intravenous corticosteroids. The main outcome criterion was pain on a visual analog scale (VAS). The secondary outcome criteria were delayed discharge of a patient who had undergone outpatient surgery, consumption of opioids and complications for the various anesthesia techniques and analgesia methods.

RESULTS

In all, 680 patients were included in this study, which was 63% of the ACL reconstruction procedures performed during this period. The study population was 69% male and 31% female, with an average age of 30 years. Twenty-three patients (3.4%) could not be discharged on the day of surgery. No correlation was found with the anesthesia technique used. NSAID treatment was protective relative to delayed discharge (P=0.009), while opioid consumption was a risk factor (P<0.01). There were no differences in the pain levels related to the type of anesthesia. Peri-articular LIA of the hamstring tendon harvest site was effective. Intra-articular LIA did not provide better analgesia. Continuous nerve block had complication rates above 13%.

DISCUSSION

All types of anesthesia were compatible with outpatient ACL reconstruction. No gold standard analgesia method can be defined based on this study's findings. However, we recommend multimodal analgesia associating peri-articular LIA or one-shot sensory saphenous nerve block, NSAIDs and corticosteroid treatment, and cryotherapy.

LEVEL OF EVIDENCE

II, prospective comparative non-randomized study.

Pain Management After Outpatient Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Effective pain management after anterior cruciate ligament (ACL) reconstruction improves patient satisfaction and function.

PURPOSE

To collect and evaluate the available evidence from randomized controlled trials (RCTs) on pain control after ACL reconstruction.

STUDY DESIGN

Systematic review.

METHODS

A systematic literature review was performed using PubMed, Medline, Google Scholar, UpToDate, Cochrane Reviews, CINAHL, and Scopus following PRISMA guidelines (July 2014). Only RCTs comparing a method of postoperative pain control to another method or placebo were included.

RESULTS

A total of 77 RCTs met inclusion criteria: 14 on regional nerve blocks, 21 on intra-articular injections, 4 on intramuscular/intravenous injections, 12 on multimodal regimens, 6 on oral medications, 10 on cryotherapy/compression, 6 on mobilization, and 5 on intraoperative techniques. Single-injection femoral nerve blocks provided superior analgesia to placebo for up to 24 hours postoperatively; however, this also resulted in a quadriceps motor deficit. Indwelling femoral catheters utilized for 2 days postoperatively provided superior analgesia to a single-injection femoral nerve block. Local anesthetic injections at the surgical wound site or intra-articularly provided equivalent analgesia to regional nerve blocks. Continuous-infusion catheters of a local anesthetic provided adequate pain relief but have been shown to cause chondrolysis. Cryotherapy improved analgesia compared to no cryotherapy in 4 trials, while in 4 trials, ice water and water at room temperature provided equivalent analgesic effects. Early weightbearing decreased pain compared to delayed weightbearing. Oral gabapentin given preoperatively and oral zolpidem given for the first week postoperatively each decreased opioid consumption as compared to placebo. Ibuprofen reduced pain compared to acetaminophen. Oral ketorolac reduced pain compared to hydrocodone-acetaminophen.

CONCLUSION

Regional nerve blocks and intra-articular injections are both effective forms of analgesia. Cryotherapy-compression appears to be beneficial, provided that intra-articular temperatures are sufficiently decreased. Early mobilization reduces pain symptoms. Gabapentin, zolpidem, ketorolac, and ibuprofen decrease opioid consumption. Despite the vast amount of high-quality evidence on this topic, further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption.

CLINICAL RELEVANCE

These results provide the best available evidence from RCTs on pain control regimens after ACL reconstruction.

Adductor Canal Block Provides Noninferior Analgesia and Superior Quadriceps Strength Compared with Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction

BACKGROUND

By targeting the distal branches of the femoral nerve in the mid-thigh, the adductor canal block (ACB) can preserve quadriceps muscle strength while providing analgesia similar to a conventional femoral nerve block (FNB) for inpatients undergoing major knee surgery. In this randomized, double-blind, noninferiority trial, the authors hypothesized that ACB provides postoperative analgesia that is at least as good as FNB while preserving quadriceps strength after outpatient anterior cruciate ligament reconstruction.

METHODS

A total of 100 patients were randomized to receive ACB or FNB with 20 ml ropivacaine 0.5% (with epinephrine). The authors sequentially tested the joint hypothesis that ACB is noninferior to FNB for cumulative oral morphine equivalent consumption and area under the curve for pain scores during the first 24 h postoperatively and also superior to FNB for postblock quadriceps maximal voluntary isometric contraction.

RESULTS

The authors analyzed 52 and 48 patients who received ACB and FNB, respectively. Compared with preset noninferiority margins, the ACB-FNB difference (95% CI) in morphine consumption and area under the curve for pain scores were -4.8 mg (-12.3 to 2.7) (P = 0.03) and -71 mm h (-148 to 6) (P < 0.00001), respectively, indicating noninferiority of ACB for both outcomes. The maximal voluntary isometric contraction for ACB and FNB at 45 min were 26.6 pound-force (24.7-28.6) and 10.6 pound-force (8.3-13.0) (P < 0.00001), respectively, indicating superiority of ACB.

CONCLUSION

Compared with FNB, the study findings suggest that ACB preserves quadriceps strength and provides noninferior postoperative analgesia for outpatients undergoing anterior cruciate ligament reconstruction.

Ultrasound-guided femoro-sciatic nerve block for post-operative analgesia after below knee orthopaedic surgeries under subarachnoid block: Comparison between clonidine and dexmedetomidine as adjuvants to levobupivacaine

Background and Aims:

The advent of ultrasonographic-guided techniques has led to increased interest in femoro-sciatic nerve block (FSNB) for lower limb surgeries. α₂-agonists have been used recently as adjuvants to local anaesthetics in nerve blocks. We aimed to compare equal doses of clonidine or dexmedetomidine as an adjuvant to levobupivacaine in FSNB for post-operative analgesia.

Methods:

Ninety patients scheduled to undergo below knee orthopaedic surgeries under subarachnoid block were divided into three groups: Group LL (n = 30) patients received 38 mL of 0.125% levobupivacaine with 2 mL normal saline, Group LD (n = 30) patients received 38 mL of 0.125% levobupivacaine with 0.5 μg/kg dexmedetomidine and Group LC (n = 30) received 38 mL of 0.125% levobupivacaine with 0.5 μg/kg clonidine in saline to make total drug volume of 40 mL. The primary and secondary outcome variables were duration of analgesia and rescue analgesic requirement, verbal rating score respectively. Continuous variables were analysed with analysis of variance or the Kruskal–Wallis test on the basis of data distribution. Categorical variables were analysed with the contingency table analysis and the Fisher's exact test.

Results:

Duration of analgesia was prolonged with dexmedetomidine (10.17 ± 2.40 h) and clonidine (7.31 ± 1.76 h) as compared to control (4.16 ± 1.04 h, P = 0.00). Significantly lower pain scores were observed in dexmedetomidine group as compared to clonidine up to 8 h post-operatively.

Conclusion:

Equal doses of clonidine or dexmedetomidine added to levobupivacaine prolonged the duration of analgesia, decreased requirement of rescue analgesia. Dexmedetomidine delays the requirement of rescue analgesics with better pain scores as compared to clonidine.

Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: a randomized controlled clinical trial

STUDY OBJECTIVE

To compare preoperative femoral (FNB) with combined femoral and sciatic nerve block (CFSNB) in patients undergoing arthroscopic anterior cruciate ligament (ACL) reconstruction.

DESIGN

Prospective, randomized clinical trial.

SETTING

Ambulatory surgery center affiliated with an academic medical center.

PATIENTS

Sixty-eight American Society of Anesthesiology physical status I and II patients undergoing arthroscopic ACL reconstruction.

INTERVENTIONS

Subjects randomized to the CFSNB group received combined femoral and sciatic nerve blocks preoperatively, whereas patients randomized to the FNB group only received femoral nerve block preoperatively. Both groups then received a standardized general anesthetic with a propofol induction followed by sevoflurane or desflurane maintenance. Intraoperative pain was treated with fentanyl. Pain in the postanesthesia care unit (PACU) was treated with ketorolac and opiates. Patients with significant pain despite ketorolac and opiates could receive a rescue nerve block.

MEASUREMENTS

Our primary outcome variable was highest Numeric Rating Scale (NRS) pain score in PACU. NRS pain scores, opioid consumption, opioid adverse effects, and patient satisfaction were assessed perioperatively until postoperative day 3.

MAIN RESULTS

The highest PACU NRS pain score was significantly higher in the FNB group compared with the CFSNB group (7 [3-10] vs 5 [0-10], P=.002). The FNB group required significantly larger doses of opioids perioperatively (31.8 vs 19.8mg intravenous morphine equivalents, P<.001). PACU length of stay was significantly longer in the FNB group (128.2 vs 103.1minutes, P=.006). There was no significant difference in opioid consumption, pain scores, or patient satisfaction on postoperative days 1-3 between groups.

CONCLUSIONS

Preoperative CFSNB for arthroscopic ACL reconstruction improves analgesia, decreases opioid consumption perioperatively, and decreases PACU length of stay when compared with FNB alone.

Preoperative Femoral Nerve Block for Hip Arthroscopy: A Randomized, Triple-Masked Controlled Trial

BACKGROUND

Arthroscopy has become a standard method of treatment for a variety of intra-articular hip disorders. While most arthroscopic hip procedures are performed as outpatient surgeries, patients can still experience significant postoperative pain and opioid-associated side effects.

PURPOSE

The potential benefits of a preoperative femoral nerve block (FNB) in hip arthroscopy were explored in a previous retrospective review. The study objective was to confirm these findings in a prospective randomized study.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Fifty patients undergoing hip arthroscopy were included in this prospective, single-center, randomized controlled trial that was patient-, operator-, and assessor-blinded. Patients received either a preoperative ultrasound-guided FNB with 20 mL of 0.5% bupivacaine (FNB group) or normal saline (control group). Nerve blockade was confirmed via standardized sensory testing before the induction of general anesthesia. The primary endpoint was cumulative consumption of oral morphine equivalent at 24 hours after discharge. Secondary endpoints included opioid use at various time points, pain scores, Quality of Recovery (QoR-27) score, incidence of nausea and vomiting, time to discharge, block-related complications, falls at 24 hours, and patient satisfaction.

RESULTS

Fifty patients completed the study, including 27 in the FNB group and 23 in the control group. Most patient characteristics were statistically similar between groups except for operative time, which was longer in the control group. Cumulative oral morphine consumption was lower in the FNB group at 48 hours; there was no difference at 24 hours or 7 days postoperatively. Pain scores were significantly lower up to 6 hours postoperatively in the FNB group compared with control; however, rebound pain was observed at 24 hours after discharge in patients who received FNB. There was no difference in most secondary outcomes. Importantly, a total of 6 patients in the FNB group reported falls (without injury) within the first 24 hours postoperatively compared with none in the control group. Patient satisfaction with pain control was high in both groups at all time points.

CONCLUSION

Preoperative FNB may improve early pain control after hip arthroscopy. However, given the observed risk of falls, the routine use of FNB for outpatient hip arthroscopy cannot be recommended.

Analgesic effect of hamstring block after anterior cruciate ligament reconstruction compared with placebo: a prospective randomized trial

PURPOSE

To evaluate the effect of a hamstring block for postoperative pain management using 20 mL of 0.25% bupivacaine compared with placebo after anterior cruciate ligament (ACL) reconstruction with a hamstring autograft.

METHODS

In a 3-month period, 45 patients undergoing ACL reconstruction with a hamstring autograft who all received a femoral nerve block were randomized to receive either 20 mL of 0.25% bupivacaine or 20 mL of saline water administered through a catheter into the donor-site space. The patients and recovery staff were blinded to the treatment. Postoperative donor-site pain was evaluated subjectively by the patients using a pain score (Likert scale from 0 to 10). The pain was registered for each hour in the first 6 hours and thereafter once daily for 8 days. Furthermore, the requirement for postoperative analgesic medicine was registered.

RESULTS

The hamstring block group (n = 23) had significantly less pain for each of the first 6 postoperative hours. The pain score was reduced from 4.2 to 2.3 (95% confidence interval, 1.3 to 3.3) (P = .01) in the first hour and from 2.8 to 1.3 (95% confidence interval, 0.6 to 1.9) in the sixth hour, and there was a significantly lower overall requirement for early postoperative fentanyl, reduced from a mean of 58 to 35 μg (P = .02), and morphine, reduced from a mean of 10 to 6 mg (P = .04). After 6 hours, there was no difference in the pain level and use of analgesics between the 2 groups.

CONCLUSIONS

With the use of a donor-site block in hamstring ACL reconstruction, the donor-site pain level, as well as the overall requirement for fentanyl and morphine, was significantly reduced in the first 6 postoperative hours. No effect of the donor-site block was seen after 6 hours.

LEVEL OF EVIDENCE

Level I, therapeutic, randomized controlled study.

Review of outcomes in pediatric patients undergoing anterior cruciate ligament repairs with regional nerve blocks

PURPOSE

This article compared the outcomes of pediatric patients undergoing ACL repairs receiving intravenous opioids versus regional nerve blocks for pain management. It was hypothesized that compared to intravenous opioids the use of regional nerve blocks would decrease pain, opioid consumption, and opioid-related side effects.

METHOD

A random retrospective chart review was conducted on a total of 93 pediatric patients who underwent ACL repairs either in 2004 prior to the implementation of regional nerve blocks for pain management [pre-protocol cohort, (n=44)] or in 2009/2010, after the implementation of regional nerve block use [post-protocol cohort, (n=49)].

FINDINGS

The two cohorts were comparable in age, weight and gender. The post-protocol cohort had a significantly lower total opioid consumption (p<0.001). A sensitivity analysis excluding patients who received patient controlled analgesia (PCA) further validated the findings of significantly lower total opioid consumption adjusted for body weight [mg/kg] (p=0.02) and reduction in the highest numerical rating score (NRS) reported on post-operative day (POD) 1 (p=0.01). The cohorts were not significantly different in incidence of common opioid-related side effects or median length of stay (LOS).

CONCLUSIONS

There was evidence that regional nerve blocks reduced opioid consumption and also impacted pain reduction on POD 1 but demonstrated no significant change on opioid-related side effects or readiness for discharge. In view of the retrospective nature of the study the potential benefits of regional nerve blocks suggested a clinical equipoise to conduct a controlled trial in children.

A prospective double blinded randomized study of anterior cruciate ligament reconstruction with hamstrings tendon and spinal anesthesia with or without femoral nerve block

BACKGROUND

Current literature supports the thought that anesthesia and analgesia administered perioperatively for an anterior cruciate ligament (ACL) reconstruction have a great influence on time to effective rehabilitation during the first week after hospital discharge.

PURPOSE

The aim of this study is to answer the research question is there a difference in clinical outcomes between the use of a femoral nerve block with spinal anesthesia versus spinal analgesia alone for people undergoing ACL reconstruction?

METHODS

ACL reconstruction with spinal anesthesia and patient sedation (Group one); and spinal anesthesia with patient sedation and an additional femoral nerve block (Group two). Patients were re-evaluated for pain, range of motion (ROM), active contraction of the quadriceps, and a Functional Independence Measure (FIM) scoring scale.

RESULTS

Spinal anesthesia with a femoral nerve block demonstrates pain relief 6h after surgery (VAS 0.37; p=0.007). From the third (VAS=4.56; p=0.028) to the seventh (VAS=2.87; p=0.05) days after surgery, this same nerve blockage delivered higher pain scores. Patients had a similar progressive improvement on knee joint range of motion with or without femoral nerve block (p<0.002). Group one and two had 23.75 and 24.29° 6h after surgery and 87.81 and 85.36° of knee flexion after 48h post op.

CONCLUSION

Spinal anesthesia associated with a femoral nerve block had no additional benefits on pain control after the third postoperative day. There were no differences between groups concerning ability for knee flexion and to complete daily activities during postoperative period.

LEVEL OF EVIDENCE

Randomized Clinical Trial Level I.

Femoral nerve block: Assessment of postoperative analgesia in arthroscopic anterior cruciate ligament reconstruction

BACKGROUND AND OBJECTIVES

Knee anterior cruciate ligament reconstruction (ACLR) may be painful in the postoperative period. The primary objective of this study was to evaluate whether the use of femoral nerve block (FNB) associated with spinal anesthesia would improve the postoperative pain treatment in ACLR and the secondary objectives were to evaluate tramadol request and adverse events.

METHOD

53 patients were randomly divided into two groups: GA (n =26) received spinal anesthesia and GB (n = 27) received spinal anesthesia and FNB. All patients received multimodal analgesia and rescue analgesics could be requested anytime. Assessments were performed at 6, 12 and 24 hours.

RESULTS

There was no difference between both groups regarding demographic and clinical- surgical variables. There was no difference between groups regarding pain intensity. Mean pain scores were higher at 12 hours in GA and there was no change in GB; 55.6% of patients reported moderate pain in GA and 53.8% mild pain in GB. There was no difference regarding tramadol request. There were no serious adverse events: 80.8% of patients in GB had motor block of the thigh and two fell.

CONCLUSIONS

Analgesia was more effective with the combination of spinal and FNB, which allowed better control of postoperative pain, assessed 12 hours after anesthesia. There was no difference in tramadol request. Patients in this study had no serious adverse events; however, one must be attentive to motor paralysis and the possibility of falling when FNB is performed.

Hospital Charges and Practice Patterns for General and Regional Anesthesia in Arthroscopic Anterior Cruciate Ligament Repair

BACKGROUND

Anesthetic use for arthroscopic anterior cruciate ligament (ACL) reconstruction may display variability in hospital charges and utilization in the United States.

PURPOSE

To evaluate practice patterns and hospital charges for anesthesia in arthroscopic ACL reconstruction.

STUDY TYPE

Cross-sectional study.

METHODS

The PearlDiver Patient Records Database, a national database of insurance billing records, was searched using the current procedural terminology (CPT) codes for arthroscopic ACL reconstruction in combination with different types of anesthesia. The search included the years between 2004 and 2009. Age, sex, number of procedures performed, geographic region, and hospital charges for each type of anesthesia were recorded and compared. Anesthetic types were categorized as general anesthesia (GA) only, GA with concomitant single femoral injection, GA with concomitant other regional anesthesia (RA), single femoral injection only, or other RA only.

RESULTS

Between 2004 and 2009, a total of 53,968 arthroscopic reconstructive procedures were identified. The mean per patient hospital charge for GA alone, GA in combination with single femoral injection, GA in combination with other RA, single femoral injection alone, and RA alone was $1065 (63% of cases), $1614 (29%), $1849 (4%), $630 (3%), and $612 (1%), respectively. The use of GA in combination with RA or single femoral nerve injection significantly increased during this time period (P = .004 and P < .001, respectively).

CONCLUSION

The mean per patient hospital charges for arthroscopic ACL reconstruction varied with the mode of anesthesia utilized, where regional anesthetic techniques alone were least expensive. RA alone was utilized infrequently, and there was a significant increase in the rate of utilization of GA in combination with any form of RA.

CLINICAL RELEVANCE

This study provides information on current trends and hospital charges for anesthesia in arthroscopic ACL reconstruction.

Validity of four pain intensity rating scales

The Visual Analogue Scale (VAS), Numerical Rating Scale (NRS), Verbal Rating Scale (VRS), and the Faces Pain Scale-Revised (FPS-R) are among the most commonly used measures of pain intensity in clinical and research settings. Although evidence supports their validity as measures of pain intensity, few studies have compared them with respect to the critical validity criteria of responsivity, and no experiment has directly compared all 4 measures in the same study. The current study compared the relative validity of VAS, NRS, VRS, and FPS-R for detecting differences in painful stimulus intensity and differences between men and women in response to experimentally induced pain. One hundred twenty-seven subjects underwent four 20-second cold pressor trials with temperature order counterbalanced across 1°C, 3°C, 5°C, and 7°C and rated pain intensity using all 4 scales. Results showed statistically significant differences in pain intensity between temperatures for each scale, with lower temperatures resulting in higher pain intensity. The order of responsivity was as follows: NRS, VAS, VRS, and FPS-R. However, there were relatively small differences in the responsivity between scales. A statistically significant sex main effect was also found for the NRS, VRS, and FPS-R. The findings are consistent with previous studies supporting the validity of each scale. The most support emerged for the NRS as being both (1) most responsive and (2) able to detect sex differences in pain intensity. The results also provide support for the validity of the scales for use in Portuguese samples.

Hamstring donor-site block: evaluation of pain control after anterior cruciate ligament reconstruction

PURPOSE

The purpose of this study was to evaluate the effectiveness of using a hamstring donor-site block in controlling postoperative pain levels after anterior cruciate ligament (ACL) reconstruction with autogenous hamstring graft.

METHODS

Over a 5-month period, 27 patients underwent ACL reconstruction with hamstring autograft. All patients received a preoperative femoral nerve block. Intraoperatively, these patients were randomly assigned to groups with and without a hamstring donor-site block. The block group received a 20-mL injection of 0.25% bupivacaine into the hamstring donor site through an arthroscopic shaver sleeve. Both groups received standard postoperative pain medications as needed. Postoperative pain scores were taken by use of a visual analog scale (VAS) and recorded immediately on arrival to the recovery room, at 1 hour after arrival, and at 2 hours after arrival.

RESULTS

There were 15 patients in the hamstring donor-site block group and 12 patients in the standard treatment group. For the block group, mean VAS scores were 3.20 +/- 2.54 on arrival, 2.80 +/- 1.61 at 1 hour, and 2.87 +/- 1.41 at 2 hours. For the standard treatment group, mean VAS scores were 5.50 +/- 1.62 on arrival, 6.08 +/- 1.56 at 1 hour, and 5.33 +/- 2.02 at 2 hours. The hamstring block group had statistically significantly lower mean VAS scores on arrival (P = .0118), at 1 hour (P = .0001), and at 2 hours (P = .0010). There were no complications in either group.

CONCLUSIONS

Injection of the hamstring donor site with local anesthetic through an arthroscopic shaver sleeve showed a statistically significant improvement in postoperative pain levels in patients undergoing autogenous hamstring ACL reconstruction.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Femoral nerve block use in anterior cruciate ligament reconstruction surgery

PURPOSE

The goal of this study was to determine whether femoral nerve blocks (FNBs) provide patients undergoing anterior cruciate ligament reconstruction greater pain relief or other benefits compared with more standard pain medication regimens.

METHODS

We searched PubMed, EMBASE, and the Cochrane Database using the following search terms: "ACL or anterior cruciate ligament" and "femoral nerve block or peripheral nerve block" or "regional anesthesia." Thirteen studies were found that fit the inclusion criteria of being randomized controlled trials with a Level of Evidence of I or II, comparing FNB or 3-in-1 blocks with control groups undergoing various multimodal pain regimens.

RESULTS

Only 5 of the 13 studies found a significant difference in pain relief with FNB compared with the control groups; however, the difference in several of the studies may not be clinically relevant. Of the 13 studies, 6 examined parameters other than pain, and only 1 study found a greater incidence of nausea and sedation in its control group. Patient satisfaction was examined in 2 studies, with both finding no difference between groups. Nine studies used a single graft type, and the two studies using multiple graft types accounted for this in their analyses.

CONCLUSIONS

On the basis of the available Level I and II data from randomized controlled trials, there appears to be no evidence that FNBs add additional benefit over multimodal analgesia. FNBs have not been shown to significantly affect patient pain, readiness for discharge, or outcome scores. There is a small but identifiable risk associated with performing FNBs, with potentially catastrophic effects.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II randomized controlled trials with minimal heterogeneity.

Femoral nerve blockade as a preemptive anesthetic in patients undergoing anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded, placebo-controlled study

BACKGROUND

Femoral nerve blockade has been purported to be an effective regional anesthetic in patients undergoing various procedures to lower extremities.

HYPOTHESIS

Femoral nerve blockade will provide improved postoperative pain control over a local anesthetic in the knee joint alone in patients undergoing endoscopic patellar tendon anterior cruciate ligament reconstruction.

STUDY DESIGN

Randomized, controlled trial; Level of evidence, 1.

METHODS

Fifty-six adult patients undergoing an endoscopic patellar tendon anterior cruciate ligament reconstruction under general anesthesia were prospectively randomized to receive either a bupivacaine femoral nerve blockade (block) or a saline placebo injection (control). Both groups received local bupivacaine injection and intravenous ketorolac at wound closure. Outcomes included postoperative pain measured on a validated visual analog scale at postoperative intervals for 72 hours, intraoperative and postoperative narcotic consumption, admission rates, hospital charges, patient satisfaction, and complications related to the femoral nerve block.

RESULTS

There were 31 block patients and 25 control patients. No significant differences between groups for postoperative pain scores, intraoperative or postoperative narcotic consumption, readiness for discharge, duration of hospitalization, admission rates, hospital charges, or patient satisfaction were observed. There were no complications related to the femoral nerve block.

CONCLUSION

A preemptive femoral nerve blockade, although safe, does not provide significant clinical benefit in this patient population to justify its routine use.

Randomized double blind comparison between sciatic-femoral nerve block and propofol-remifentanil, propofol-alfentanil general anesthetics in out-patient knee arthroscopy

The aim of this study is the evaluation preparation and discharge times as well as the side-effects, patient satisfaction and costs after out-patient knee arthroscopy performed with a combined sciatic-femoral nerve block or a propofol-remifentanil, propofol-alfentanil general anesthetics. Sixty patients, (remifentanil group 1, n = 20), (alfentanil group 2, n = 20) and a combined sciatic-femoral nerve block (PNB group 3, n = 20). In group 1, anesthesia was induced with remifentanil (1 mic kg(-1) followed by 0.5 mic kg(-1) min(-1) i.v), in group 2 alfentanil (20 mic kg(-1) followed by 2 mic kg(-1) min(-1) i.v, in both groups (group 1, 2) propofol was given 2 mg kg(-1) i.v followed by 9 mg kg(-1) h(-1) i.v. Patients then received atracurium 0.6 mg kg(-1) i.v. to facilitate endotracheal intubation. In the PNB group (group 3), patients received a sciatic-femoral nerve block with ropivacaine 25 mL 0.75 mg using a multiple injection technique aided by a nerve stimulator and a short, bevelled, Teflon-coated stimulating needle. There was no significant difference in the duration of stay in the post anesthesia care unit and day surgery unit between groups, there was significant increase in the time to first urination in PNB group than the other two groups. Also there was no significant difference in the stay in delay surgery. The cost of disposal materials, preoperative and post operative times were higher in PNB group. The cost of drugs was higher in remifentanil and alfentanil groups than PNB group; the total cost was insignificant in the three groups. In conclusion, this prospective randomized study suggests that in patients undergoing out-patient arthroscopy, a combined sciatic-femoral nerve block (using a small volume of ropivacaine 0.75%) compared with a propofol-remifentanil or propofol-alfentanil general anesthetics techniques may provide similar intraoperative analgesic efficacy, a shorter length of stay in the PACU and an increased likelihood of bypassing the first phase of postoperative recovery.

Lateral trans-biceps popliteal block for elective foot and ankle surgery performed after induction of general anesthesia

BACKGROUND

The purpose of this study was to determine safety and efficacy of lateral transtendinous popliteal blocks performed after induction of general anesthesia for intraoperative and postoperative pain control in elective foot and ankle surgery.

METHODS

The charts of 475 consecutive patients were retrospectively reviewed. The technique was a lateral transtendinous popliteal block under nerve stimulator direction (described in the text). Patient records were retrospectively evaluated from the postanesthesia care unit, as well as at followup on postoperative day 1 and weeks 2, 6, and 12.

RESULTS

The block was complete in 398 patients (83.7%). An incomplete block was found in 77 patients (16.2 %). In the incomplete category, 21 patients (4.4%) had no pain but some motor function, 32 patients (6.5%) reported mild to moderate pain, and 24 patients (5.3%) had severe pain. The average block duration was 16.5 hours. There were no adverse effects documented in any patient at followup.

CONCLUSIONS

Lateral popliteal nerve block after induction of general anesthesia appears to be safe and effective for intraoperative and postoperative pain control in elective foot and ankle surgery.

Continuous femoral nerve block versus intra-articular injection for pain control after anterior cruciate ligament reconstruction

BACKGROUND

Continuous femoral nerve blocks have been recommended for postoperative pain control after anterior cruciate ligament reconstruction.

HYPOTHESIS

A pain control protocol involving a continuous ropivacaine femoral nerve block will decrease pain and narcotic use in the first 24 hours after surgery compared with a postoperative pain control protocol involving an intra-articular injection of bupivacaine/morphine.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

Ninety subjects, aged 15 years or older, who were receiving arthroscopically assisted bone-patellar tendon-bone anterior cruciate ligament reconstruction were randomly assigned to 2 groups. The first group received a ropivacaine continuous femoral nerve block and oral hydrocodone (block group). The second group received an intra-articular bupivacaine/morphine injection and oral oxycodone (injection group). Patients in both groups could receive intramuscular injection of hydromorphone for breakthrough pain; most patients in the block group also received bolus doses of ropivacaine through the femoral catheter. Subjects rated their worst, average, and current pain levels using a visual analog scale and category-ratio scale the morning after surgery. Postoperative narcotic pain medication use was converted to morphine-equivalent doses.

RESULTS

Postoperative pain ratings did not differ between the treatment groups. The largest difference in pain ratings between the groups was 0.5 cm for worst pain level (P = .345). Total narcotic use did not differ significantly between groups (1.1 morphine-equivalent doses in both groups; P = .671).

CONCLUSIONS

Continuous femoral block with ropivacaine appeared to have no clinical advantage in the immediate postoperative period after anterior cruciate ligament reconstruction when compared with an intra-articular injection of bupivacaine/morphine. Both methods are effective for pain control after anterior cruciate ligament reconstruction.

Peripheral Nerve Block Techniques for Ambulatory Surgery

Peripheral nerve blocks (PNBs) have an increasingly important role in ambulatory anesthesia and have many characteristics of the ideal outpatient anesthetic: surgical anesthesia, prolonged postoperative analgesia, and facilitated discharge. Critically evaluating the potential benefits and supporting evidence is essential to appropriate technique selection. When PNBs are used for upper extremity procedures, there is consistent opioid sparing and fewer treatment-related side effects when compared with general anesthesia. This has been demonstrated in the immediate perioperative period but has not been extensively investigated after discharge. Lower extremity PNBs are particularly useful for procedures resulting in greater tissue trauma when the benefits of dense analgesia appear to be magnified, as evidenced by less hospital readmission. The majority of current studies do not support the concept that a patient will have difficulty coping with pain when their block resolves at home. Initial investigations of outpatient continuous peripheral nerve blocks demonstrate analgesic potential beyond that obtained with single-injection blocks and offer promise for extending the duration of postoperative analgesia. The encouraging results of these studies will have to be balanced with the resources needed to safely manage catheters at home. Despite supportive data for ambulatory PNBs, most studies have been either case series or relatively small prospective trials, with a narrow focus on analgesia, opioids, and immediate side effects. Ultimately, having larger prospective data with a broader focus on outcome benefits would be more persuasive for anesthesiologists to perform procedures that are still viewed by many as technically challenging.

Intraarticular Bupivacaine-Clonidine-Morphine Versus Femoral-Sciatic Nerve Block in Pediatric Patients Undergoing Anterior Cruciate Ligament Reconstruction

We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 microg/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 microg/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 +/- 40 microg versus 80 +/- 50 microg; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 +/- 3 versus 5.4 +/- 3; P = 0.0002) and during the first 24 h (1.6 +/- 1 versus 2.9 +/- 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 +/- 13 mg versus 21 +/- 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.

Daystay hamstring ACL reconstruction performed under regional anaesthesia

Daycase ACL reconstruction is commonly performed under general anaesthesia with a patella tendon graft. We report our experience with hamstring reconstruction under regional anaesthesia. Over a 14-month period, 104 daycase arthroscopic ACL reconstructions were performed by one surgeon and one anaesthetist. All operations were performed under spinal anaesthesia with a femoral nerve block. Patients were discharged with oral analgesia, brace and a cryocuff. One hundred and two patients were prospectively evaluated with a visual analogue pain score (0-10) and a patient satisfaction questionnaire. Of these 102 patients, 101 (99%) were happy to be discharged on the same day. One patient was admitted from the daycase unit, and one patient was re-admitted. Patients were very satisfied with the pain relief provided. The mean visual analogue pain score was 1.0 at discharge, 1.8 in the middle of the first night, and 2.1 on the first post-op day. Patients experienced significantly more pain the day after surgery than the evening of surgery (p=0.04). We conclude that hamstring ACL reconstruction under regional anaesthesia is well tolerated by patients as a daycase procedure.

Peripheral Nerve Blocks and Continuous Catheter Techniques

Peripheral nerve blocks provide intense, site-specific analgesia and are associated with a lower incidence of side effects when compared with many other modalities of postoperative analgesia. Continuous catheter techniques further prolong these benefits. These advantages can facilitate a prompt recovery and discharge and achieve significant perioperative cost savings. This is of tremendous value in a modern health care system that stresses cost-effective use of resources and a continued shift toward shorter hospital stay as well as outpatient surgery.