Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part III: Local Instillation Analgesia—A Systematic Review and Meta-analysis

Yung, Eric M.; Brull, Richard; Albrecht, Éric; Joshi, Girish P.; Abdallah, Faraj W.

doi:10.1213/ane.0000000000002599

Cited by 31 publications

(18 citation statements)

References 52 publications

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“…These meta-analyses were unable to show any analgesic benefit in the immediate postoperative period for the use of femoral nerve block or adductor canal block in ACLR. 35,44,46 SAMBA, however, was able to show a strong recommendation for the use of an intra-articular injection of local anesthetic in addition to an oral regimen of multimodal analgesia. 1…”

Section: Discussionmentioning

confidence: 95%

The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction

et al. 2020

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Background: Patients often have quadriceps or hamstring weakness after anterior cruciate ligament reconstruction (ACLR), despite postoperative physical therapy regimens; however, little evidence exists connecting nerve blocks and ACLR outcomes. Purpose: To compare muscle strength at return to play in patients who received a nerve block with ACLR and determine whether a specific block type affected subjective knee function. Study Design: Cohort study; Level of evidence, 3. Methods: Patients were recruited 5 to 7 months after primary, isolated ACLR and completed bilateral isokinetic strength tests of the knee extensor/flexor groups as a single-session return-to-sport test. Subjective outcomes were assessed with the International Knee Documentation Committee (IKDC) score. Strength was expressed as torque normalized to mass (N·m/kg) and limb symmetry index as involved/uninvolved torque. Chart review was used to determine the type of nerve block and graft used. Nerve block types were classified as knee extensor motor (femoral nerve), knee flexor motor (sciatic nerve), or isolated sensory (adductor canal block/saphenous nerve). A 1-way analysis of covariance controlling for graft type was used. Results: A total of 169 patients were included. Graft type distribution consisted of 102 (60.4%) ipsilateral bone–patellar tendon–bone (BTB) and 67 (39.6%) ipsilateral hamstring tendon. Nerve block type distribution consisted of 38 (22.5%) femoral, 25 (14.8%) saphenous, 45 (26.6%) femoral and sciatic, and 61 (36.1%) saphenous and sciatic. No significant difference was found in knee extensor strength ( P = .113) or symmetry ( P = .860) between patients with knee extensor motor blocks (1.57 ± 0.45 N·m/kg; 70.1% ± 15.3%) and those without (1.47 ± 0.47 N·m/kg; 69.6% ± 18.8%). A significant difference was found between patients with knee flexor motor blocks (0.83 ± 0.26 N·m/kg) and those without (0.92 ± 0.27 N·m/kg) for normalized knee flexor strength ( P = .21) but not knee flexor symmetry ( P = .592). Controlling for graft type, there were no differences in subjective knee function (IKDC score) between all nerve block groups ( P = .57). Conclusion: Our data showed that use of a sciatic nerve block with ACLR in patients with hamstring and BTB grafts influences persistent knee flexor strength deficits at time of return to sports. Although the cause of postoperative muscular weakness is multifactorial, this study adds to the growing body of evidence suggesting that perioperative nerve blocks affect muscle strength and functional rehabilitation after ACLR.

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Section: Discussionmentioning

confidence: 95%

The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction

et al. 2020

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“…Minimising opioid use during the perioperative period is an opportunity to prevent chronic opioid use especially in opioid-naive patients. 11 Opioid minimising anaesthesia techniques have been shown to provide good patient satisfaction while lowering opioid requirements, [12][13][14] and simultaneously avoiding adverse effects (nausea/ vomiting, sedation, ileus, respiratory depression and tolerance).…”

Section: Discussionmentioning

confidence: 99%

Increasing the use of multimodal analgesia during adult surgery in a tertiary academic anaesthesia department

et al. 2021

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ObjectiveMultimodal analgesia pathways have been shown to reduce opioid use and side effects in surgical patients. A quality improvement initiative was implemented to increase the use of multimodal analgesia in adult patients presenting for general anaesthesia at an academic tertiary care centre. The aim of this study was to increase adoption of a perioperative multimodal analgesia protocol across a broad population of surgical patients. The use of multimodal analgesia was tracked as a process metric. Our primary outcome was opioid use normalised to oral morphine equivalents (OME) intraoperatively, in the postanaesthesia care unit (PACU), and 48 hours postoperatively. Pain scores and use of antiemetics were measured as balancing metrics.MethodsWe conducted a quality improvement study of a multimodal analgesia protocol implemented for adult (≥18 and≤70) non-transplant patients undergoing general anaesthesia (≥180 min). Components of multimodal analgesia were defined as (1) preoperative analgesic medication (acetaminophen, celecoxib, diclofenac, gabapentin), (2) regional anaesthesia (peripheral nerve block or catheter, epidural catheter or spinal) or (3) intraoperative analgesic medication (ketamine, ketorolac, lidocaine infusion, magnesium, acetaminophen, dexamethasone ≥8 mg, dexmedetomidine). We compared opioid use, pain scores and antiemetic use for patients 1 year before (baseline group—1 July 2018 to 30 June 2019) and 1 year after (implementation group—1 July 2019 to 30 June 2020) project implementation.ResultsUse of multimodal analgesia improved from 53.9% in the baseline group to 67.5% in the implementation group (p<0.001). There was no significant difference in intraoperative OME use before and after implementation (β0=44.0, β2=0.52, p=0.875). OME decreased after the project implementation in the PACU (β0=34.4, β2=−3.88, p<0.001) and 48 hours postoperatively (β0=184.9, β2=−22.59, p<0.001), while pain scores during those time points were similar.ConclusionA perioperative pragmatic multimodal analgesic intervention was associated with reduced OME use in the PACU and 48 hours postoperatively.

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“…Although ACLR is less invasive in nature than conventional knee surgery, patients can still experience moderate-to-severe postarthroscopic pain. Inadequate postoperative analgesia can delay discharge, increase unplanned admission and readmission after discharge, delay functional recovery, and reduce patient satisfaction with ACLR [1,3,12]. Although opioids have side effects, they still have an important role in postoperative pain management [6].…”

Section: Discussionmentioning

confidence: 99%

“…Repair of the anterior cruciate ligament (ACL) is one of the most commonly performed outpatient arthroscopic procedures [1,2]. Optimal analgesia facilitates early rehabilitation and mobilization, improves functional recovery, reduces postoperative morbidity, and increases patient satisfaction after anterior cruciate ligament reconstruction (ACLR) [1,3]. Multimodal analgesia using opioids and a variety of other analgesics is recommended for the management of acute pain after knee surgery [4].…”

Section: Introductionmentioning

confidence: 99%

The effects of pregabalin and adductor canal block on postoperative pain in arthroscopic anterior cruciate ligament reconstruction

et al. 2020

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Materials and methods: A total of 51 American Society of Anaesthesiologists (ASA) classification I-II patients aged 18-70 years who were scheduled to undergo elective anterior cruciate ligament reconstruction were included in the study. Patients were randomized into groups P, A, and C. Patients in group P (n = 16), received 150 mg of preoperative oral pregabalin, patients in group A (n = 17) received postoperative adductor canal blockade, and patients in group C (n = 18) received neither adductor canal block nor pregabalin. Surgeries were performed under spinal anaesthesia with hyperbaric bupivacaine following monitorization. Demographic data along with block features, hemodynamic data, mean opioid consumption, numerical rating scale score, White's fast-track score, and postoperative adverse effects were recorded. Results: Fifty-seven patients were enrolled in the study, and 6 patients were excluded from the study; the data of 51 patients were included in the final analyses. Demographic characteristics and hemodynamic data were similar between the 3groups. Postoperative opioid consumption was significantly lower in groups A and P compared with group C (group P = 178.75 mg, group C = 318.61 mg, group A = 236.47 mg; P < 0.05). The regression of sensory block was significantly slower in group P (P < 0.05). The first analgesic requirement was earlier in group C than in groups P and A (P < 0.05). Patients in group P had higher fast-track scores at 8 h and 12 h compared with group C (P < 0.05); however, group A fast-track scores were similar to those of the other 2groups (P > 0.05). The rate of postoperative adverse effects was similar between the groups (P > 0.05). Conclusion: Preoperative pregabalin (150 mg) reduced postoperative opioid consumption as much as adductor canal block in patients undergoing anterior cruciate ligament reconstruction. The first analgesic requirement was earlier in group C than in groups P and A. In addition, pregabalin can prolong the duration of spinal sensory block and shorten the time required to achieve high fast-tracking scores. We recommend the use of both methods as a part of multimodal analgesia.

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Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part III: Local Instillation Analgesia—A Systematic Review and Meta-analysis

Cited by 31 publications

References 52 publications

The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction

The Influence of Perioperative Nerve Block on Strength and Functional Return to Sports After Anterior Cruciate Ligament Reconstruction

Increasing the use of multimodal analgesia during adult surgery in a tertiary academic anaesthesia department

The effects of pregabalin and adductor canal block on postoperative pain in arthroscopic anterior cruciate ligament reconstruction

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