scholarly journals A reduced concentration femoral nerve block is effective for perioperative pain control following ACL reconstruction: a retrospective review

2021 ◽  
Author(s):  
Lukas N. Muench ◽  
Megan Wolf ◽  
Cameron Kia ◽  
Daniel P. Berthold ◽  
Mark P. Cote ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Nerve Block ◽  
Femoral Nerve Block ◽  
Standard Dose ◽  
Cruciate Ligament ◽  
Femoral Nerve ◽  
Retrospective Chart Review ◽  
Single Shot ◽  
Level Of Evidence ◽  
Low Concentration

Abstract Introduction Femoral nerve block (FNB) is a routinely used regional analgesic technique for anterior cruciate ligament (ACL) reconstruction. One method to balance the analgesic effect and functional impairment of FNBs may be to control the concentration of local anesthetics utilized for the block. Materials and methods Retrospective chart review was performed on 390 consecutive patients who underwent ACL reconstruction between June 2014 and May 2017. Patients were divided into those who received a standard (0.5%-bupivacaine) or low (0.1–0.125%-bupivacaine) concentration single-shot FNB performed with ultrasound guidance. Maximum postoperative VAS, Post-Anaesthesia Care Unit (PACU) time prior to discharge, need for additional ‘rescue’ block, and intravenous postoperative narcotic requirements were recorded. Results A total of 268 patients (28.4 ± 11.9 years) were included for final analysis, with 72 patients in the low-concentration FNB group and 196 patients receiving the standard concentration. There were no differences in the maximum postoperative VAS between the low (6.4 ± 2.5) and standard (5.7 ± 2.9) concentration groups (P = 0.08). Similarly, the time from PACU arrival to discharge was not different between groups (P = 0.64). A sciatic rescue block was needed in 22% of patients with standard-dose FNB compared to 30% of patients receiving the low-concentration FNB (P = 0.20). Patients with a hamstring autograft harvest were more likely to undergo a postoperative sciatic rescue block compared to a bone-patellar tendon autograft (P = 0.005), regardless of preoperative block concentration. Quadriceps activation was preserved with low-concentration blocks. Conclusions Using 1/5th to 1/4th the standard local anesthetic concentration for preoperative femoral nerve block in ACL reconstruction did not significantly differ in peri-operative outcomes, PACU time, need for rescue blockade, or additional immediate opioid requirements. Level of Evidence III.

scholarly journals Intra-articular Morphine and Ropivacaine Injection Provides Efficacious Analgesia As Compared With Femoral Nerve Block in the First 24 Hours After ACL Reconstruction: Results From a Bone–Patellar Tendon–Bone Graft in an Adolescent Population

2021 ◽  
Vol 9 (3) ◽  
pp. 232596712098590
Author(s):  
Brendon C. Mitchell ◽  
Matthew Y. Siow ◽  
Andrew T. Pennock ◽  
Eric W. Edmonds ◽  
Tracey P. Bastrom ◽  
...  
Keyword(s):  
Pain Management ◽  
Acl Reconstruction ◽  
Patellar Tendon ◽  
Nerve Block ◽  
Femoral Nerve Block ◽  
Femoral Nerve ◽  
Single Shot ◽  
Pain Scores ◽  
Peripheral Block ◽  
Bone Patellar Tendon

Background: Opioid consumption and patient satisfaction are influenced by a surgeon’s pain-management protocol as well as the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction are femoral nerve blockade and intra-articular injection; however, debate remains regarding the more efficacious methodology. Hypothesis: We hypothesized that intra-articular injection with ropivacaine and morphine would be found to be as efficacious as a femoral nerve block for postoperative pain management in the first 24 hours after bone–patellar tendon–bone (BTB) ACL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: Charts were retrospectively reviewed for BTB ACL reconstructions performed by a single pediatric orthopaedic surgeon from 2013 to 2019. Overall, 116 patients were identified: 58 received intra-articular injection, and 58 received single-shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MMEs) consumed were tabulated for each patient. Results: Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block ( P = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; P = .008). There was significantly less MME consumption in patients receiving intra-articular injection versus peripheral block at 16 to 20 hours (3.2 vs 5.6 MMEs; P = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; P < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; P = .19). Conclusion: Within the limitations of this study, we could identify no significant difference in MME consumption between the single-shot femoral nerve block group and intra-articular injection group in the first 24 hours postoperatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require fewer opioids 16 to 24 hours postoperatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in adolescent patients undergoing BTB ACL reconstruction.

scholarly journals Effects of the addition of dexamethasone on postoperative analgesia after anterior cruciate ligament reconstruction surgery under quadruple nerve blocks

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Yuki Aoyama ◽  
Shinichi Sakura ◽  
Shoko Abe ◽  
Erika Uchimura ◽  
Yoji Saito
Keyword(s):  
Sciatic Nerve ◽  
Acl Reconstruction ◽  
Nerve Block ◽  
Femoral Nerve Block ◽  
Cruciate Ligament ◽  
Femoral Nerve ◽  
Hamstring Tendon ◽  
Sciatic Nerve Block ◽  
University Hospital ◽  
Nerve Blocks

Abstract Background Anterior cruciate ligament (ACL) reconstruction is an invasive surgical procedure for the knee. Quadruple nerve blocks including continuous femoral nerve block and single-injection sciatic, obturator, and lateral femoral cutaneous nerve blocks can provide effective intraoperative anesthesia and analgesia in the early postoperative period. However, severe pain often appears after the effect of single-injection nerve blocks resolves and that is why we conducted two studies. The first study was to determine whether dexamethasone administered along with local anesthetic for sciatic nerve block could prolong the duration of analgesia in patients given quadruple nerve blocks, including continuous femoral nerve block, for ACL reconstruction using a hamstring tendon autograft. The second study was designed to evaluate any difference in effects from dexamethasone administered perineurally versus intravenously. Methods Patients undergoing unilateral arthroscopic ACL reconstruction using a hamstring tendon autograft were enrolled into two studies. The first study was prospectively conducted to see if dexamethasone 4 mg could prolong the duration of analgesia when administered perineurally to the subgluteal sciatic nerve with 0.5% ropivacaine. In the second study, we retrospectively evaluated the effects of intravenous dexamethasone 4 mg as compared with those of perineural dexamethasone to the sciatic nerve block and effects with no dexamethasone. Results In the first study, perineural dexamethasone prolonged the duration of analgesia by 9.5 h (median duration: 22.5 and 13.0 h with and without perineural dexamethasone, respectively, P = 0.011). In the second study, the duration of analgesia was similarly prolonged for intravenous and perineural dexamethasone compared with no dexamethasone. Conclusion Perineural dexamethasone administered along with local anesthetic for single sciatic nerve block prolonged the duration of analgesia of quadruple nerve blocks for ACL reconstruction, however the effects were not different from those of intravenous dexamethasone. Trial registration The protocols of both studies were approved by the Institutional Review Board of Shimane University Hospital, Japan (study number 2821 and 3390 for study 1 and study 2, respectively). Study 1 was registered in University Hospital Medical Information Network Clinical Trials Registry (UMIN000028930). Study 2, which was a retrospective study, was not registered.

Liposomal Bupivacaine for Pain Control After Anterior Cruciate Ligament Reconstruction

2016 ◽  
Vol 44 (7) ◽  
pp. 1680-1686 ◽  
Author(s):  
Ajay Premkumar ◽  
Heather Samady ◽  
Harris Slone ◽  
Regina Hash ◽  
Spero Karas ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Acl Reconstruction ◽  
Nerve Block ◽  
Pain Control ◽  
Femoral Nerve Block ◽  
Cruciate Ligament ◽  
Femoral Nerve ◽  
Liposomal Bupivacaine ◽  
Postoperative Hematoma ◽  
Anterior Cruciate

Background: Local anesthetics are commonly administered into surgical sites as a part of multimodal pain control regimens. Liposomal bupivacaine is a novel formulation of bupivacaine designed for slow diffusion of a single dose of local anesthetic over a 72-hour period. While early results are promising in various settings, no studies have compared pain management regimens containing liposomal bupivacaine to traditional regimens in patients undergoing anterior cruciate ligament (ACL) reconstruction. Purpose: To evaluate liposomal bupivacaine in comparison with 0.25% bupivacaine hydrochloride (HCl) for pain control after ACL reconstruction. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: A total of 32 adult patients undergoing primary ACL reconstruction with a soft tissue quadriceps tendon autograft between July 2014 and March 2015 were enrolled. All patients received a femoral nerve block immediately before surgery. Patients then received either a 40-mL suspension of 20 mL Exparel (1 vial of bupivacaine liposome injectable suspension) and 20 mL 0.9% injectable saline or 20 mL 0.5% bupivacaine HCl and 20 mL 0.9% injectable saline, which was administered into the graft harvest site and portal sites during surgery. Patients were given either a postoperative smartphone application or paper-based journal to record data for 1 week after ACL reconstruction. Results: Of the 32 patients recruited, 29 patients were analyzed (90.6%). Two patients were lost to follow-up, and 1 was excluded because of a postoperative hematoma. There were no statistically significant differences in postoperative pain, medication use, pain location, recovery room time, or mobility between the 2 study groups. Conclusion: There were comparable outcomes with 0.25% bupivacaine HCl at a 200-fold lower cost than liposomal bupivacaine. This study does not support the widespread use of liposomal bupivacaine for pain control after ACL reconstruction in the setting of a femoral nerve block. Registration: ClinicalTrials.gov NCT02189317

scholarly journals INTRA-ARTICULAR MORPHINE AND ROPIVACAINE INJECTION PROVIDES EFFICACIOUS ANALGESIA COMPARED TO FEMORAL NERVE BLOCK IN THE FIRST 24 HOURS POST-OPERATIVELY AFTER ACL RECONSTRUCTION WITH BTB IN AN ADOLESCENT COHORT

2021 ◽  
Vol 9 (7_suppl3) ◽  
pp. 2325967121S0002
Author(s):  
Brendon C. Mitchell ◽  
Matthew Y. Siow ◽  
Andrew T. Pennock ◽  
Eric W. Edmonds ◽  
Tracey P. Bastrom ◽  
...  
Keyword(s):  
Anterior Cruciate Ligament ◽  
Pain Management ◽  
Acl Reconstruction ◽  
Nerve Block ◽  
Femoral Nerve Block ◽  
Cruciate Ligament ◽  
Femoral Nerve ◽  
Pain Scores ◽  
Anterior Cruciate ◽  
Peripheral Block

Background: Opioid consumption and patient satisfaction are influenced by a surgeon’s pain management protocol and the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction include femoral nerve blockade and intra-articular injection; however, debate remains as to the most efficacious methodology. Hypothesis/Purpose: We hypothesize that intra-articular injection with ropivacaine and morphine is as efficacious as a femoral nerve block injection of ropivacaine, dexamethasone, and dexmedetomidine for post-operative pain management in the first 24 hours after bone-patellar tendon-bone (BTB) ACL reconstruction. Methods: Charts were retrospectively reviewed for a single pediatric orthopedic surgeon performing BTB ACL reconstructions from 2013-2019. One hundred sixteen patients were identified, of whom 58 received intra-articular injection and 58 received single shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MME) consumed were tabulated for each patient. Results: Opioid use was 24.3 MMEs in patients treated with intra-articular injection vs 28.5MMEs in those with peripheral block (p=0.108). Consumption of MMEs was greater in the intra-articular group in the 0-4 hours period (7.1 MMEs vs. 4.6 MMEs, p=0.008). There was significantly less MME consumption in patients receiving intra-articular injection compared with peripheral block at 16-20 and 20-24 hours (3.2 MMEs vs. 5.6 MMEs, p=0.01; 3.8 MMEs vs. 6.5 MMEs, p<0.001 respectively). Mean pain scores were not significantly different over the 24-hour period (peripheral block=2.7, intra-articular injection=3.0, p=0.19). Conclusion: Moving away from the use of peripheral nerve block as an analgesic modality may be challenging given the multidisciplinary role of pain management in these patients. However, as Ramlogan et al. succinctly noted in their recent editorial “Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice?” in the British Journal of Anesthesia, both orthopedic and anesthesia colleagues alike are beginning to recognize that it is a change that may benefit our patients. Our study strengthens this argument and shows that there is no significant difference in MME consumption between the femoral nerve block and intra-articular injection groups in the first 24 hours post-operatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require less opioids 16-24 hours post-operatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in pediatric patients undergoing BTB ACL reconstruction. [Table: see text][Figure: see text]

scholarly journals Adductor Canal Block versus Femoral Nerve Block for Pain Control After Anterior Cruciate Ligament Reconstruction: A Prospective Randomized Trial

2019 ◽  
Vol 7 (7_suppl5) ◽  
pp. 2325967119S0025
Author(s):  
Kelechi R. Okoroha ◽  
Jonathan Lynch ◽  
Vincent Lizzio ◽  
Charles Cong Yu ◽  
Toufic Raja Jildeh ◽  
...  
Keyword(s):  
Acl Reconstruction ◽  
Nerve Block ◽  
Pain Control ◽  
Femoral Nerve Block ◽  
Cruciate Ligament ◽  
Femoral Nerve ◽  
Thigh Circumference ◽  
Adductor Canal ◽  
Anterior Cruciate ◽  
Straight Leg Raise

Objectives: Regional anesthesia in the form of a femoral nerve block (FNB) is a commonly performed technique that has been proven to provide effective analgesia following anterior cruciate ligament (ACL) reconstruction. The adductor canal nerve block (ANB) employs a similar sensory block around the knee while avoiding motor blockade of the quadriceps. The purpose of our study was to compare the efficacy of FNB versus ANB for pain control following ACL reconstruction. Our hypothesis was that there would be no difference in pain levels or opioid requirements between the two groups. Methods: We performed a prospective, double-blinded, randomized controlled trial. Sixty patients undergoing primary ACL reconstruction using bone-tendon-bone autograft were randomized to receive either an ANB or FNB preoperatively. The primary outcomes assessed were pain levels (visual analog scale) and narcotic requirements for 4 days following surgery. Secondary outcomes included ability to perform a straight leg raise in the recovery room and difference in thigh circumference between the operative and nonoperative leg measured at 7 days postoperatively. Results: Morphine requirements were less in ACB in the first 4 hours postoperatively (p = .02). Aside from this time interval, there were no differences between the 2 groups with regard to opioid requirements and pain scores at any other time. Similarly, no differences were noted in the patient’s ability to perform a straight leg raise in the recovery room (p = .13) or in thigh circumference at the first postoperative visit (p = .09) Conclusion: The results of our study suggest similar efficacy in perioperative pain control with the use of an ANB for ACL reconstruction when compared to FNB. The potential long-term benefit of quadriceps preservation with the ACB is worthy of future study.

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