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

Postoperative Pain and Opioid Usage With Combined Adductor Canal and IPACK Block Versus Isolated Adductor Canal Block After Anterior Cruciate Ligament Reconstruction With a Bone-Patellar Tendon-Bone Autograft: A Single-Center Randomized Controlled Trial

BACKGROUND

Efforts to decrease pain, improve early rehabilitation, and reduce opioid consumption have prompted a focus on peripheral nerve blocks for pain management after anterior cruciate ligament reconstruction (ACLR). The commonly used adductor canal block (ACB) might not provide sufficient postoperative pain control because of its lack of coverage of the posterior aspect of the knee. The addition of the IPACK (interspace between the popliteal artery and the capsule of the posterior knee) block, which targets this area, to the standard ACB could potentially provide better pain control after ACLR over the current standard of care.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare and analyze postoperative pain, satisfaction, and opioid demand between the standard ACB and a combination of an ACB and IPACK block in patients undergoing ACLR with a bone-patellar tendon-bone (BTB) autograft. It was hypothesized was that the addition of the IPACK block would substantially improve early postoperative pain control and minimize opioid use.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

A total of 102 patients undergoing ACLR with a BTB autograft at a single institution were recruited. Patients were randomly assigned to receive either the ACB alone or the ACB plus IPACK block. Patients were contacted at 24 hours (postoperative day [POD] 1), 48 hours (POD 2), 72 hours (POD 3), and 1 week to assess postoperative pain scores, opioid consumption, and satisfaction with their postoperative pain control. Intergroup comparative analysis was performed using a t test or nonparametric test for continuous variables and the chi-square test for categorical variables. Opioid usage was reported as morphine milligram equivalents (MME).

RESULTS

The final analysis included 96 patients, with 47 in the control group (ACB) who received only the ACB and 49 in the experimental group (IPACK) who received the ACB and an additional IPACK block. The cohort was composed of 60.4% male patients with a mean age of 28.40 ± 7.51 years (range, 18-55 years) and a mean body mass index of 25.67 ± 4.84 kg/m2. There were no statistically significant differences between the groups with respect to age, body mass index, or sex (P > .05). Patients in the IPACK group reported significantly lower opioid usage than those in the ACB group on POD 1 (mean, 6.1 [interquartile range (IQR), 4.5-7.7] vs 10.7 [IQR, 8.6-13.0] MME, respectively; P < .001), POD 2 (mean, 7.3 [IQR, 5.2-9.5] vs 12.5 [IQR, 10.0-15.0] MME, respectively; P = .001), and POD 3 (mean, 4.2 [IQR, 2.8-5.5] vs 9.4 [IQR, 7.1-12.0] MME, respectively; P < .001). The visual analog scale for pain score on POD 1 (mean, 67.7 [IQR, 62.0-73.0] vs 55.2 [IQR, 48.0-63.0], respectively; P = .024) and POD 3 (mean, 54.9 [IQR, 48.0-63.0] vs 44.4 [IQR, 37.0-51.0], respectively; P = .037) was statistically higher in the ACB group compared with the IPACK group. On POD 1, patient satisfaction was higher in the IPACK group than in the ACB group (mean, 7.3 [IQR, 6.6-8.0] vs 5.6 [IQR, 4.8-6.4], respectively; P = .001). No statistically significant differences were observed between groups on POD 7. On regression analysis, IPACK block (β = -13.0; P = .03) and male sex (β = -9.9; P = .024) were significant negative predictors for opioid use on POD 1. The association of reduced opioid use in the IPACK group persisted on POD 2 (β = -12.0; P = .019) and POD 3 (β = -15.0; P < .001).

CONCLUSION

The results of this study suggest that the addition of an IPACK block to an ACB leads to reduced opioid consumption, improved pain control, and higher satisfaction with pain control acutely after ACLR with a BTB autograft.

REGISTRATION

NCT05286307 (ClinicalTrials.gov).

Dexamethasone as an additive to bupivacaine in an ultrasound-guided adductor canal block for the management of persistent pain after arthroscopic reconstruction of the anterior cruciate ligament: a randomized, double-blind study

BACKGROUND

Pain is a protective response to noxious stimuli to prevent further damage. The surgical incision results in several events that lead to pain that outlasts its benefits. Persistent postsurgical pain (PPSP) is defined as "pain that persists for three months after surgical intervention.

OBJECTIVES

To investigate the effect of dexamethasone as an adjuvant to adductor canal block on persistent postsurgical pain after ACL reconstruction.

PATIENTS AND METHODS

Ninety patients who underwent arthroscopic reconstruction of the anterior cruciate ligament and who completed the study were randomly allocated into two groups. Forty-five patients in each group received ultrasound-guided adductor canal block at the end of surgery. G I (Dexa group): Forty-five patients received a 20 ml mixture of 0.25% bupivacaine and 8 mg dexamethasone (2 ml). G II (control group): Patients received a 20 ml mixture of 0.25% bupivacaine and 2 ml of normal saline.

RESULTS

No significant differences in demographic data, intraoperative hemodynamics or surgery duration were detected between the two groups. The duration of postoperative analgesia was significantly longer in the dexamethasone group (10 h ± 3 vs. 6 h ± 1) than in the control group. Additionally, 24 h postoperative consumption of meperidine was significantly lower in the dexamethasone group (65 ± 23 vs. 104 ± 27) than in the control group. Postoperative VAS scores at 6 and 12 h were also lower in the dexamethasone group than in the control group. Three-month follow-up revealed a significantly lower incidence of PPSP in the dexamethasone group (20% versus 33% in the control group). Moreover, the severity of PPSP was significantly lower in the dexamethasone group than in the control group. Additionally, Codeine consumption was significantly lower in the dexamethasone group than in the control group.

CONCLUSION

Perineural dexamethasone in ultrasound-guided adductor canal block reduced the severity of PPSP and opioid analgesia consumption in the first three months following arthroscopic reconstruction of the ACL.

CLINICAL TRIAL REGISTRATION

The study was registered on clinical trial registration (NCT04631822) in October 2020.

Local Infiltration Analgesia Versus Adductor Canal Block for Managing Pain After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis

Background

Adductor canal block (ACB) and local infiltration analgesia (LIA) are frequently used to manage pain in patients after anterior cruciate ligament reconstruction (ACLR).

Purpose

To compare the difference in pain scores and opioid consumption between ACB and LIA for ancillary pain management in patients after ACLR.

Study Design

Systematic review; Level of evidence, 3.

Methods

A literature search was conducted using PubMed, MEDLINE, and Embase databases according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies that compared pain scores at 2, 6, 12, or 24 hours after ACLR or provided information on 24-hour opioid consumption were included. Of 240 publications initially screened by abstract and title, 4 studies were included, and data related to participant characteristics, anesthetic technique, and pain-related outcomes were extracted. The standardized mean difference (MD) in pain scores and morphine milligram equivalents consumed in 24 hours was compared using a random-effects model.

Results

In all studies, ropivacaine was the primary anesthetic used for LIA and ACB, with 1 study also employing bupivacaine as an alternative. The difference in pain scores between LIA and ACB was not significant at 2 hours (MD, 0.04 [95% CI, -0.22 to 0.29]; P = .79), 6 hours (MD, 0.16 [95% CI, -0.20 to 0.52]; P = .39), 12 hours (MD, 0.54 [95% CI, -0.49 to 1.56]; P = .31), or 24 hours (MD, 0.12 [95% CI, -0.10 to 0.34]; P = .28). The difference in morphine milligram equivalents was also not statistically significant (MD, -0.07 [95% CI, -0.25 to 0.11]; P = .68).

Conclusion

From this review, the authors suggest considering LIA over ACB because of its potential to offer comparable pain relief and opioid consumption while being less time intensive. However, the study results should be interpreted with caution, given the limited number of studies included.

Postoperative Multimodal Approach to Pain Control in Anterior Cruciate Ligament Autograft Surgery: A Single-Center Series

Background: Anterior cruciate ligament (ACL) injuries are prevalent and represent a significant socioeconomic burden, as ACL injuries account for nearly 60% of all knees joint traumas. The purpose of this study is to emphasize the role of arthroscopic ACL reconstruction and the challenges in postoperative pain management. Methods: This study involved 90 patients undergoing ACL reconstruction, categorized into three groups receiving different pain management protocols. The focus was on evaluating the efficacy of multimodal analgesia using lidocaine and magnesium sulfate. The main outcome was pain assessment using the Visual Analog Scale (VAS). Results: Patients receiving fentanyl, lidocaine, and magnesium sulfate (FLM) reported significantly lower pain scores in the postoperative period. Minimal use of additional opioids was observed, suggesting effective pain management with the multimodal analgesia regimen. Conclusions: The study showed that multimodal analgesia, including FLM, effectively manages postoperative pain following ACL reconstruction. This study showed significantly lower pain scores with FLM, highlighting its potential in early postoperative pain relief. Future research should consider long-term outcomes and cost-effectiveness, emphasizing the need for more comprehensive evaluations of multimodal analgesia’s impact.

ChatGPT Provides Unsatisfactory Responses to Frequently Asked Questions Regarding Anterior Cruciate Ligament Reconstruction

PURPOSE

To determine whether the free online artificial intelligence platform ChatGPT could accurately, adequately, and appropriately answer questions regarding anterior cruciate ligament (ACL) reconstruction surgery.

METHODS

A list of 10 questions about ACL surgery was created based on a review of frequently asked questions that appeared on websites of various orthopaedic institutions. Each question was separately entered into ChatGPT (version 3.5), and responses were recorded, scored, and graded independently by 3 authors. The reading level of the ChatGPT response was calculated using the WordCalc software package, and readability was assessed using the Flesch-Kincaid grade level, Simple Measure of Gobbledygook index, Coleman-Liau index, Gunning fog index, and automated readability index.

RESULTS

Of the 10 frequently asked questions entered into ChatGPT, 6 were deemed as unsatisfactory and requiring substantial clarification; 1, as adequate and requiring moderate clarification; 1, as adequate and requiring minor clarification; and 2, as satisfactory and requiring minimal clarification. The mean DISCERN score was 41 (inter-rater reliability, 0.721), indicating the responses to the questions were average. According to the readability assessments, a full understanding of the ChatGPT responses required 13.4 years of education, which corresponds to the reading level of a college sophomore.

CONCLUSIONS

Most of the ChatGPT-generated responses were outdated and failed to provide an adequate foundation for patients' understanding regarding their injury and treatment options. The reading level required to understand the responses was too advanced for some patients, leading to potential misunderstanding and misinterpretation of information. ChatGPT lacks the ability to differentiate and prioritize information that is presented to patients.

CLINICAL RELEVANCE

Recognizing the shortcomings in artificial intelligence platforms may equip surgeons to better set expectations and provide support for patients considering and preparing for ACL reconstruction.

Infiltration of local anesthetic in the Interspace between the popliteal artery and capsule of the posterior knee "IPACK block" versus adductor canal block "ACB" for pain relief after open wedge high tibial osteotomy: a randomized clinical trial

BACKGROUND

A high tibial osteotomy is usually associated with severe postoperative pain. Both adductor canal block (ACB) and interspace between the popliteal artery and capsule of the posterior knee (IPACK) have been described as effective block techniques for providing analgesia after knee surgeries, with few comparisons in wedge osteotomy cases. We aim to compare the postoperative analgesic profile of the previously mentioned two block techniques in patients undergoing tibial osteotomies.

METHODS

Sixty patients were enrolled in this randomized prospective trial (30 received IPACK and 30 received ACB). Both blocks were installed before the spinal anesthesia after infiltration of 2 mL lidocaine 2%. Twenty mL of bupivacaine 0.25% mixed with dexamethasone as anesthetic adjuvant were used for both blocks. The postoperative analgesic profiles were compared between the two groups.

RESULTS

Postoperative pain scores were lower in the IPACK group, and that decrease was evident throughout the first 10 hours postoperatively. Additionally, the duration of analgesia was much prolonged with the same block (487.50±82.39 vs. 301.93±92.06 minutes with ACB). There was a significant decline in postoperative analgesic consumption (1.27±0.45 vs. 1.8±0.61 gm, P=0.000), and a significant increase in the ambulation distance (19.10±0.60 vs. 17.73±0.45 m, P=0.000) with a significant decline in the duration of hospitalization (43.27±7.61 vs. 54±8.35 hours) in the IPACK group compared to the ACB group.

CONCLUSIONS

IPACK is a superior block technique compared to ACB in patients undergoing high tibial osteotomy regarding postoperative analgesia, ambulation distance, and patient satisfaction with little rate of adverse events in both groups.

Adenosine, lidocaine, and magnesium therapy augments joint tissue healing following experimental anterior cruciate ligament rupture and reconstruction

Aims

Adenosine, lidocaine, and Mg2+ (ALM) therapy exerts differential immuno-inflammatory responses in males and females early after anterior cruciate ligament (ACL) reconstruction (ACLR). Our aim was to investigate sex-specific effects of ALM therapy on joint tissue repair and recovery 28 days after surgery.

Methods

Male (n = 21) and female (n = 21) adult Sprague-Dawley rats were randomly divided into ALM or Saline control treatment groups. Three days after ACL rupture, animals underwent ACLR. An ALM or saline intravenous infusion was commenced prior to skin incision, and continued for one hour. An intra-articular bolus of ALM or saline was also administered prior to skin closure. Animals were monitored to 28 days, and joint function, pain, inflammatory markers, histopathology, and tissue repair markers were assessed.

Results

Despite comparable knee function, ALM-treated males had reduced systemic inflammation, synovial fluid angiogenic and pro-inflammatory mediators, synovitis, and fat pad fibrotic changes, compared to controls. Within the ACL graft, ALM-treated males had increased expression of tissue repair markers, decreased inflammation, increased collagen organization, and improved graft-bone healing. In contrast to males, females had no evidence of persistent systemic inflammation. Compared to controls, ALM-treated females had improved knee extension, gait biomechanics, and elevated synovial macrophage inflammatory protein-1 alpha (MIP-1α). Within the ACL graft, ALM-treated females had decreased inflammation, increased collagen organization, and improved graft-bone healing. In articular cartilage of ALM-treated animals, matrix metalloproteinase (MMP)-13 expression was blunted in males, while in females repair markers were increased.

Conclusion

At 28 days, ALM therapy reduces inflammation, augments tissue repair patterns, and improves joint function in a sex-specific manner. The study supports transition to human safety trials.

Comparison of genicular nerve block with adductor canal block for postoperative pain management in patients undergoing arthroscopic knee ligament reconstruction: A randomised controlled trial

Background and Aims

Genicular nerve block (GNB) is beneficial in early ambulation and faster patient discharge since it selectively blocks articular branches and is motor-sparing. This study aimed to compare the analgesic efficacy of ultrasound (US)-guided GNB with adductor canal block (ACB) in patients undergoing arthroscopic anterior cruciate ligament reconstruction (ACLR).

Methods

This randomised, double-blind study was conducted on 38 adults undergoing arthroscopic ACLR. Patients in Group GNB (n = 19) received US-guided GNB with 3 ml of 0.25% bupivacaine and 2 mg dexamethasone. Patients in Group ACB (n = 19) received US-guided ACB with 20 ml of 0.25% bupivacaine with 6 mg dexamethasone. Postoperative rescue analgesia was provided by intravenous Patient Controlled Analgesia (PCA) with morphine. The primary outcome was Numerical Rating Scale (NRS) pain scores over 24 h. The secondary outcome was the duration of analgesia and 24-h morphine consumption. The Chi-square test was used to test the statistical significance between categorical variables. Independent t-test or Mann-Whitney U test was used to compare continuous variables.

Results

NRS scores at rest and physical activity at 24 h were similar in both the groups (P = 0.429 and P = 0.101, respectively). The mean time to rescue analgesia was comparable in both groups (Group GNB: 820.79 [483.65] min [95% confidence interval {CI}: 603.31-1038.27] and Group ACB: 858.95 [460.06] min [95% CI: 652.08, 1065.82], P = 0.805), and the mean 24-h morphine consumption was also comparable in both groups (P = 1.000).

Conclusion

US-guided GNB has an analgesic efficacy similar to US-guided ACB for patients undergoing arthroscopic ACLR.

Mental Health in the Youth Athlete

Though research is inconclusive in being able to determine if young athletes are more or less likely to suffer from mental health disorders compared with their non-athlete peers, there are important psychological considerations that are unique to the athletic population. This includes depression in the context of overtraining and burnout, performance anxiety, perfectionism, psychological sequalae of concussion, and injury as an independent risk factor for depression, anxiety, post-traumatic stress, and high-risk behaviors. Optimization of mental health care in youth athletes requires continued efforts to improve mental health literacy, decrease stigma, encourage help-seeking behaviors, and advance the routine implementation of effective screening practices.

Femoral nerve block using lower concentration ropivacaine preserves quadriceps strength while providing similar analgesic effects after knee arthroscopy

PURPOSE

Femoral nerve block (FNB) is widely used in patients undergoing knee arthroscopy. However, the most commonly used concentration of ropivacaine (0.2% or above) may cause an unexpected decrease in the muscle strength of the quadriceps. Therefore, a lower concentration of ropivacaine (0.1%) for FNB was administered to investigate the effect on quadriceps strength and postoperative pain after knee arthroscopy.

METHODS

This was a double-blind, randomized, controlled trial (ChiCTR2000041404). A total of 83 patients scheduled for elective knee arthroscopy were randomized to receive 0.1% or 0.2% ropivacaine for FNB under ultrasound guidance. The primary outcomes were quadriceps strength and numerical rating scale (NRS) pain score. Quadriceps strength was measured before surgery and 6 h and 24 h after surgery, while NRS score was recorded before surgery, at the postanaesthesia care unit (PACU), and 6 h and 24 h after surgery. Multiple linear regression tests were used to compare the differences in quadriceps strength and NRS score between the two groups. Two-factor analysis of variance, using the factors group and time of measurement, was used for repeated NRS scores. Secondary outcomes included knee mobility, side effects, patient satisfaction, and length of hospital stay.

RESULTS

The mean (SD) quadriceps strength at 6 h after surgery was 7.5 (5.7) kg for the 0.1% ropivacaine group and 3.0 (4.4) kg for the 0.2% ropivacaine group. The mean difference adjusted for baseline characteristics was - 5.2 (95% CI - 7.2 to - 3.1) kg (P < 0.001). There was no significant difference between the two groups in quadriceps strength at 24 h after surgery. The mean differences in the average NRS score and maximum NRS score in the PACU were - 0.6 (P = 0.008) and - 1.0 (P < 0.001), respectively. There was no significant difference in NRS score at 6 h or 24 h after surgery. Two-factor analysis of variance showed no significant difference in the interaction factors of time and group for average NRS score and maximum NRS score.

CONCLUSIONS

Compared with 0.2% ropivacaine, 0.1% ropivacaine for FNB preserved quadriceps strength at 6 h after knee arthroscopy while providing similar analgesic effects.

LEVEL OF EVIDENCE

I.

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

Background

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

Method

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

Result

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

Conclusion

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

Females Are More Likely Than Males to Fill an Opioid Prescription in the Year After Anterior Cruciate Ligament Reconstruction

Purpose

To report rates of preoperative and postoperative opioid use between male and female patients and to identify risk factors for extended opioid use following anterior cruciate ligament reconstruction (ACLR).

Methods

Patients undergoing ACLR between 2011 and 2018 were identified from the PearlDiver database. The opioid refill rates for males vs females were compared at monthly intervals for 1 year after ACLR. Patients who filled an opioid prescription <3 months before surgery were classified as opioid users, while those who had never filled one were classified as nonopioid users.

Results

Of 106,995 ACLR patients, 37,890 (35.4%) were opioid users <3 months before surgery, and 37,554 (35.1%) had never filled an opioid prescription. Of the preoperative opioid users, 20,413 (53.9%) were female and 17,477 (46.1%) were male (P < .001). Postoperatively, females were at higher risk of filling an opioid prescription at each monthly interval, except for the first month after surgery. The refill rate for opioid users was also higher than that for nonopioid users at each monthly interval after ACLR. In addition to patient sex, a preoperative diagnosis of anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use increased a patient's risk of filling an opioid prescription postoperatively.

Conclusions

This study demonstrated that females are significantly more likely to be opioid users than males prior to ACLR and are more likely to continue to refill an opioid prescription in the year following surgery. Multiple risk factors were associated with prolonged postoperative opioid utilization, including female sex, anxiety/depression, low back pain, myalgia, a history of drug dependence, alcohol abuse, and tobacco use.

Level of Evidence

Level III, retrospective cohort study.

Benefits of Implementing an Enhanced Recovery After Surgery Protocol in Ambulatory Surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols in orthopaedic surgery have garnered significant focus due to their ability to control pain adequately in the immediate postoperative window, allowing for earlier mobilization, shorter hospital stays, and fewer complications. Virginia Commonwealth University created a multimodal pain management approach in which patients receive a preoperative femoral nerve block followed by periarticular intraoperative local injection anesthesia consisting of bupivacaine, ketamine, and ketorolac.

HYPOTHESIS

We hypothesized that implementation of the ERAS protocol will decrease postoperative pain scores, decrease recovery time in the postanesthesia care unit (PACU), and decrease opioid use in anterior cruciate ligament (ACL) reconstruction.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Two patient cohorts were involved: before ERAS implementation (pre-ERAS) and after (post-ERAS). Patients with ACL reconstruction only and patients with ACL reconstruction with meniscal repair were analyzed separately. Post-ERAS patients received an intraoperative periarticular injection of bupivacaine, ketamine, and ketorolac and a postoperative multimodal pain regimen. Outcomes included time spent in the PACU, short-term and long-term opioid consumption, and pain score at discharge from the PACU.

RESULTS

Compared with pre-ERAS patients, post-ERAS patients had decreased pain (2.1 vs 0.84 out of 10, respectively), spent less time in the PACU (79.4 vs 62.8 minutes, respectively), and had less opioid consumption in the immediate postoperative period (4.55 vs 2.26 total morphine milligram equivalents [MMEs], respectively) (P < .001 for all). After ERAS implementation, long-term MME use decreased from 410 to 321 between 0 and 2 weeks postoperatively, 92.6 to 1.69 between 2 and 6 weeks, and 494.5 to 323 between 0 and 6 weeks (P < .001 for all). All domains showed significant improvements for both the ACL and the ACL plus meniscal repair cohorts, with the exception of pain at discharge in the ACL plus meniscal repair group.

CONCLUSION

The study findings suggest that an enhanced recovery pathways protocol that includes a standardized intraoperative periarticular bupivacaine, ketamine, and ketorolac injection improves pain scores in the immediate postoperative window, decreases opioid consumption, and reduces recovery time in the PACU for patients undergoing ACL reconstruction.