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

Abstract

Background: Anterior cruciate ligament reconstruction (ACLR) is associated with moderate to severe pain in the immediate postoperative period. The optimal individual preemptive or intraoperative anesthetic modality on postoperative pain control is not well-known. Purpose: To systematically review and perform a meta-analysis comparing postoperative pain scores (visual analog scale [VAS]), opioid consumption, and incidence of complications during the first 24 hours after primary ACLR in patients receiving spinal anesthetic, adjunct regional nerve blocks, or local analgesics. Study Design: Systematic review and meta-analysis. Methods: PubMed, Embase, MEDLINE, Biosis Previews, SPORTDiscus, Ovid, PEDRO, and the Cochrane Library databases were systematically searched from inception to March 2020 for human studies, using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Inclusion criteria consisted of (1) level 1 studies reporting on the use of spinal anesthesia, adjunct regional anesthesia (femoral nerve block [FNB] or adductor canal block [ACB]), or local analgesia in patients undergoing primary ACLR and (2) studies reporting on patient-reported VAS, opioid consumption, and incidence of complications related to anesthesia within the first 24 hours after surgery. Non–level 1 studies, studies utilizing a combination of anesthetic modalities, and those not reporting outcomes during the first 24 hours were excluded. Data were synthesized, and a random effects meta-analysis was performed to determine postoperative pain, opioid use, and complications based on anesthetic modality at multiple time points (0-4, 4-8, 8-12, 12-24 hours). Results: A total of 263 studies were screened, of which 27 level 1 studies (n = 16 regional blocks; n = 12 local; n = 4 spinal) met the inclusion criteria and were included in the meta-analysis. VAS scores were significantly lower in patients receiving a regional block as compared with spinal anesthesia 8 to 12 hours after surgery ( P < .01), patients receiving an FNB versus ACB at 12 to 24 hours ( P < .01), and those treated with a continuous FNB rather than single-shot regional blocks (FNB, ACB) at 12 to 24 hours ( P < .01). No significant difference in VAS was appreciated when spinal, regional, and local anesthesia groups were compared. Conclusion: Based on evidence from level 1 studies, pain control after primary ACLR based on VAS was significantly improved at 8 to 12 hours in patients receiving regional anesthesia as compared with spinal anesthesia. Pain scores were significantly lower at 12 to 24 hours in patients receiving FNB versus ACB and those treated with continuous FNB rather than single-shot regional anesthetic.

Do Continuous Peripheral Nerve Blocks Decrease Home Opioid Use Following Anterior Cruciate Ligament Reconstruction in Children and Adolescents? The Envelope Please

“…The VAS on POD #1 in the CPNB group was 6 in our study compared with 2.72 (range: 1.00 to 5.70) in the pooled metanalysis and 5.5 in the SPNB group compared with 4.28 (3.70 to 5.70) in the pooled metanalysis. 16 We attribute this difference to our preoperative opioid education. Since patients/parents were instructed to only use the opioids in the case of uncontrolled breakthrough pain, they likely did not use the medication unless the pain level reached a severe level (7+).…”

“…This does illustrate the powerful effect the surgeon can have on reducing opioid usage postoperative. A recent metanalysis by Maheshwer et al 16 compared VAS scores from studies that had used a continuous femoral nerve block compared with different studies that had used any type of single-shot regional block. The metanalysis found improved VAS 12 hours after surgery to 24 hours after surgery.…”

Overprescribing and Undereducating: a Survey of Pre- and Postoperative Pain Protocols for Pediatric Anterior Cruciate Ligament Surgery

“…Although postoperative analgesia use aside from opioids was not analyzed in this study, surgeons and patients must be cautious of the associated prolonged motor paralysis and muscle weakness associated with sciatic and femoral nerve blocks. 11 , 12 Micalizzi et al. 13 speculated that the lack of studies analyzing pediatric pain management following ACL surgery is secondary to physicians treating pediatric patients using the same standard of care used for adult patients and the challenges in performing research in pediatric patients due to variations in growth rates and size affecting study populations and pharmacokinetics.…”

Effect of Perioperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Oral and Maxillofacial Surgery: A Randomized Controlled Clinical Trial

“… 32 Continuous infusion of dexmedetomidine from 10 min before induction of anesthesia to half an hour before the end of surgery, combined with opioids during surgery, may play a multi-mode analgesic effect, thereby reducing postoperative pain score. 33 There was no significant difference in the number of postoperative analgesic pump presses between the two groups, which may be because surgeons tend to use salvage analgesia of flurbiprofen axetil after surgery, thus reducing the number of patients pressing analgesic pump.…”