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 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 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 A Pilot Randomised Clinical Trial of 3-In-1 Femoral Nerve Block and Intravenous Morphine as Primary Analgesia for Patients Presenting to the Emergency Department with Fractured Hip

2008 ◽  
Vol 15 (4) ◽  
pp. 205-211 ◽  
Author(s):  
CA Graham ◽  
K Baird ◽  
AC McGuffie
Keyword(s):  
Emergency Department ◽  
Pain Score ◽  
Nerve Block ◽  
Femoral Nerve Block ◽  
Femoral Nerve ◽  
Wilcoxon Test ◽  
Block Group ◽  
Pain Scores ◽  
Significant Difference ◽  
Median Pain

Background Fractured neck of femur (NOF) is a leading cause of morbidity and mortality in the elderly. Published clinical guidelines suggest early adequate analgesia as a key management aim. The femoral nerve ‘3-in-1 block’ has previously been shown to provide effective analgesia for these patients in the peri- and post-operative phase of care. The aim of this study was to examine the use of the ‘3-in-1’ femoral nerve block as primary analgesia for patients with a fractured NOF presenting to the emergency department. Methods This was a single centre pragmatic randomised controlled open-label trial comparing femoral nerve block (using a ‘3-in-1’ technique) with intravenous (IV) morphine. A convenience sample of patients presenting to the emergency department of a district general hospital with a clinically or radiologically suspected fractured NOF were recruited. They were randomised to receive either 0.1 mg/kg IV bolus of morphine or a ‘3-in-1’ femoral nerve block with 30 ml of 0.5% plain bupivacaine. Visual analogue pain scores were noted prior to treatment and at 30 minutes, 2 hours, 6 hours and 12 hours after treatment. Immediate complications such as vascular puncture or the requirement for naloxone were noted. Results Forty patients were recruited, 22 patients were randomised to IV morphine and 18 patients were randomised to ‘3-in-1’ femoral nerve block. Complete data were available for 33 patients. There was no significant difference in initial median pain score (p=0.45). Analysis using the Wilcoxon test showed a significant decrease in pain score for the morphine group (p=0.01) and the nerve block group (p<0.01) at 30 minutes compared with baseline. Analysis using the Mann-Whitney U test between median pain scores at each time point showed a significant lower pain score in the nerve block group at 30 minutes (p=0.046). There were no immediate complications in either group. Conclusion Our results suggest that a ‘3-in-1’ femoral nerve block is at least as effective as IV morphine when used as primary analgesia for patients with fractured NOF. Our results suggest that the femoral nerve block may provide better analgesia at 30 minutes. Further larger scale randomised trials are warranted.

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