Reconstruction of the anterior cruciate ligament: comparison of analgesia using intrathecal morphine, intra-articular morphine and intra-articular levobupivacaine

Abstract

ObjectiveTo compare the analgesic effect of intra-articular administration of morphine and levobupivacaine (separately or in combination) with intrathecal administration of morphine in patients undergoing anterior cruciate ligament (ACL) reconstruction using autologous grafts from the patellar tendon.MethodsThis was a retrospective analysis on data gathered from the medical files of 60 patients aged 20 to 50 years who underwent knee video arthroscopy for ACL reconstruction. The patients were divided into four groups of 15 individuals (A, B, C and D) according to the agent administered into the joint and around the incision: 20 mL of saline solution with 5 mg of morphine in A; 20 mL of 0.5% levobupivacaine solution in B; 10 mL of solution with 2.5 mg of morphine plus 10 mL of 0.5% levobupivacaine solution in C; and morphine administered intrathecally in D.ResultsAll the groups presented low pain scores during the first 12 h after the surgery. Groups B and C presented significantly greater pain scores than shown by group D (control), 24 h after the surgery. There was no statistical difference in pain scores between group A and group D.ConclusionThe patients in group A presented analgesia comparable to that of the patients in group D, whereas the procedure of group C was no capable of reproducing the analgesic effect observed in group D, as observed 24 h after the surgery. Further studies are needed in order to show the exact mechanism of action, along with the ideal dose and concentration for applying opioids to joints.

Contribution of Multimodal Analgesia to Postoperative Pain Outcomes Immediately After Primary Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-analysis of Level 1 Randomized Clinical Trials

“…ACLRs are associated with moderate to severe pain in the immediate postoperative period, with pain reportedly greatest during the first days after surgery. 31,40 Despite providing pain control, postoperative opioid consumption carries the risk for respiratory depression, excessive sedation, urinary retention, and mental alterations, leading to increased hospital length of stay and hospital costs. 29,37,39 Given the recent increase in consumption and abuse of opioid pain medications, the Centers for Disease Control and Prevention have labeled the current opioid crisis an epidemic.…”

“…ACLRs are associated with moderate to severe pain in the immediate postoperative period, with pain reportedly greatest during the first days after surgery. 31,40 Despite providing pain control, postoperative opioid consumption carries the risk for respiratory depression, excessive sedation, urinary retention, and mental alterations, leading to Figure 8. Forest plot reporting postoperative VAS scores at 12 to 24 hours in regional studies, local studies, and spinal studies, including the individual study estimates (gray squares), summary estimate (center of diamond), and 95% CI (width of diamond).…”

Posterior capsule injection of local anesthetic for post-operative pain control after ACL reconstruction: a prospective, randomized trial

“…Current strategies to limit pain after ACLR include: cryotherapy, systemic oral opioid analgesic and antiinflammatory medications, intrathecal and regional blockade of peripheral nerves, as well as local and intra-articular injections [3,[9][10][11]13]. Each technique has been studied at length with mixed but overall favorable results [9][10][11]13].…”

“…Current strategies to limit pain after ACLR include: cryotherapy, systemic oral opioid analgesic and antiinflammatory medications, intrathecal and regional blockade of peripheral nerves, as well as local and intra-articular injections [3,[9][10][11]13]. Each technique has been studied at length with mixed but overall favorable results [9][10][11]13]. Over the past two decades, blockade of the femoral nerve via femoral nerve blocks (FNB) as well as adductor canal blocks have been found to provide adequate pain control in orthopedic studies [2,7,13].…”