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

Abstract

Summary 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.

Application of ultrasound-guided single femoral triangle and adductor canal block in arthroscopic knee surgery: a prospective, double-blind, randomized clinical study

“…However, a case report suggested that the ACB may lead to impaired sciatic nerve function [ 19 ]. In other studies, the analgesic effect of the ACB were modest and clinically unimportant [ 2 , 20 , 21 ], Therefore, we believe that a single ACB may have limitations in the clinical setting.…”

“…Several studies have reported that block combined with obturator nerve or infiltration between popliteal artery and posterior genicular capsule results in better analgesia without affecting quadriceps muscle strength compared with single FTB [ 27 , 28 ]. In addition, Hussain N et al have shown that compared with other block techniques, regional anesthesia techniques targeting the distribution of femoral and sciatic nerves can provide the most consistent analgesic benefits [ 2 ]. This is also the direction of future research.…”

“…Adverse pain feedback after knee arthroscopy can seriously slow down the speed of early rehabilitation of patients, hinder the development of day surgery and significantly reduce patient satisfaction [ 1 ]. Arthroscopic knee surgery has been reported to cause moderate to severe pain [ 2 ], the presence of preoperative opioid use in such patients is a major risk factor for long-term opioid use after surgery. The opioid crisis has made research on optimizing analgesia in orthopedic surgery more important [ 3 ].…”

The Effectiveness of Adductor Canal Block Compared to Femoral Nerve Block on Readiness for Discharge in Patients Undergoing Outpatient Anterior Cruciate Ligament Reconstruction: A Multi-Center Randomized Clinical Trial

“…Patients with FNB consumed less opioids in the PACU compared to patients allocated to ACB (median 3 [0, 21] vs. 15 [12, 42.5] oral MME, p = 0.004). However, on postoperative day 1, opioid consumption was similar between groups (median 2.5 [2, 4.8] vs. 2 [1,4] oral MME, p = 0.527. The OBAS score was comparable between groups on POD 0 and POD 1.…”

“…The Society for Ambulatory Anesthesia advocates for the utilization of local installation analgesia as the primary approach, suggesting the adoption of adductor canal block or femoral nerve block only when local installation is not a feasible option [ 3 ]. In contrast, a recent published network analysis, suggests the consideration of a single injection femoral nerve block combined with a sciatic nerve block, or local infiltration analgesia [ 4 ].…”