Reduction of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block: a randomized clinical trial

BACKGROUND: Single-injection femoral nerve block analgesia and spinal anesthesia have been associated with fewer postoperative nursing interventions and successful same-day discharge after anterior cruciate ligament reconstruction. In the current study, the authors prospectively determined the effect of continuous femoral nerve block on a numeric rating scale (NRS) of pain intensity with movement for 7 postoperative days. METHODS: Patients undergoing this surgery with no history of previous invasive surgery on the same knee were recruited for this study. After standardized spinal anesthesia, intravenous sedation, and perioperative multimodal analgesia, patients received a femoral nerve catheter with (1) saline bolus (30 ml) plus saline infusion (270 ml at 5 ml/h, placebo group); (2) levobupivacaine (0.25%) bolus with saline infusion (group I), or (3) levobupivacaine (0.25%) bolus and infusion (group II). Patients were surveyed preoperatively and on postoperative days 1-4 and 7 to determine NRS scores (scale 0-10). RESULTS: Data from 233 participants were analyzed. On days 1-2, 50% of placebo patients had NRS scores of 5 or above, whereas among group II patients, only 25% had scores of 5 or above (P < 0.001). In regression models for NRS scores during days 1-4, group II was the only factor predicting lower pain scores (odds ratios, 0.3-0.5; P = 0.001-0.03). Overall, patients with preoperative NRS scores greater than 2 were likely to report higher NRS scores during days 1-7 (odds ratios, 3.3-5.2; P < 0.001). CONCLUSIONS: Femoral nerve block catheters reliably keep NRS scores below the moderate-to-severe pain threshold for the first 4 days after anterior cruciate ligament reconstruction.     

Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial

Because postoperative pain after total knee replacement (TKR) can be severe, we compared the analgesic efficacy of continuous femoral nerve blockade (CFNB) and continuous epidural analgesia (CEA) after TKR in this prospective randomized trial. Patients undergoing TKR under spinal anesthesia were randomized to receive either a femoral infusion of bupivacaine 0.2% (median infusion rate 9.3 mL/h) (n = 53) or an epidural infusion of ropivacaine 0.2% with fentanyl 4 microg/mL (median infusion rate 7.6 mL/h) (n = 55). Adjuvant analgesics were oral rofecoxib and oxycodone and IV morphine. Pain, nausea and vomiting, hypotensive episodes, motor block, range of knee movement, and rehabilitation milestones were assessed postoperatively. There were equivalent pain scores, range of movement, and rehabilitation in both groups. There was significantly less nausea and vomiting in the CFNB group (P < 0.002). The CFNB group received more rofecoxib (P < 0.04) and oxycodone (P < 0.005) than the CEA group. The operative limb displayed more motor block than the nonoperative limb in both groups at the level of the hip and knee for up to 48 h (P < 0.05, Mann-Whitney U-test), but there was no difference between groups in the nonoperative limb. CFNB is an effective regional component of a multimodal analgesic strategy after TKR.     

Rebound pain scores as a function of femoral nerve block duration after anterior cruciate ligament reconstruction: retrospective analysis of a prospective, randomized clinical trial

BACKGROUND AND OBJECTIVES: Continuous perineural femoral analgesia has been reported to reduce numeric rating pain scores (NRS, scale 0-10) after anterior cruciate ligament reconstruction (ACLR). In the current study, we determined rebound pain scores in autograft ACLR outpatients after nerve block analgesia resolved. METHODS: After standardized spinal anesthesia and perioperative multimodal analgesia, patients received a femoral perineural catheter and 50 hours of saline or levobupivacaine. All patients received levobupivacaine (30 mL of 0.25% as a bolus) before the infusion. Patients completed a pain diary for 6 days, indicating serial NRS scores and perceptions of when nerve block analgesia resolved. Block duration and rebound pain scores were computed. RESULTS: Data from 84 participants' pain diaries were analyzed. Patients receiving saline infusion reported mean nerve block duration of 37 hours versus 59 hours for patients receiving the levobupivacaine infusion (P < .001). Mean rebound pain scores increased by 2.0 (95% confidence interval, 1.6-2.4). Based on the computations used to derive block duration and rebound pain scores, each hour of additional block duration was predictive of a 0.03-unit reduction in rebound pain scores. CONCLUSIONS: In an anesthesia care protocol consisting of spinal anesthesia and multimodal analgesia during and after autograft ACL reconstruction, approximately 33 hours of additional nerve block duration were required to reduce rebound pain scores by one unit. Further study is required to determine rebound pain score differences when other local anesthetics and anesthetic/analgesic plans are being used and when other surgeries are being performed.     

Analgesia with femoral nerve block for anterior cruciate ligament reconstruction

Anterior cruciate ligament reconstruction is performed routinely as an outpatient surgical procedure despite few studies of patient acceptance or postoperative patient analgesia. This study reports the first series of postoperative femoral nerve blocks as analgesia for outpatient anterior cruciate ligament reconstruction. The authors retrospectively reviewed 161 patients undergoing two incision arthroscopically assisted autograft middle 1/3 patellar tendon anterior cruciate ligament reconstruction on an out-patient basis at the authors' institution during a period of 30 months. Hospital and anesthesia records were reviewed, and 83% of patients were contacted retrospectively to survey their perceptions of the procedure and its outcome. Ninety-eight percent of the patients were discharged from the ambulatory surgery center, with 51% discharged the same day as the surgery and 47% discharged by 7:00 AM the next day. As the study progressed, the number of patients staying overnight was reduced by 50%. Ninety-eight percent of patients surveyed found femoral nerve block to be beneficial, and the same percentage thought the discharge time was appropriate. However, 69% of patients staying overnight cited reasons other than pain as factors in their stay. No significant complications were reported. Based on these results, the administration of a femoral nerve block is recommended for patients undergoing outpatient anterior cruciate ligament reconstruction because it is a highly effective form of analgesia with an excellent degree of patient satisfaction.     

Comparison of epidural,continuous femoral block and intraarticular analgesia after anterior cruciate ligament reconstruction

BACKGROUND: The purpose of this study was to compare three locoregional techniques of pain management after arthroscopic anterior cruciate ligament reconstruction (ACLR). METHODS: Sixty ASA I-II subjects were enrolled after obtaining written informed consent. Patients were randomly allocated to three groups of 20 subjects. The first group (EPI) received epidural ropivacaine 0.2% plus sufentanil 0.2 micro g ml-1, at 5 ml h-1. Patients in the second group (CFB) were given a continuous infusion of the same analgesic mixture through a femoral catheter. The third group (IA) received a continuous intraarticular infusion of ropivacaine 0.2% plus sufentanil 0.2 micro g ml-1, at 5 ml h-1. All subjects were allowed PCA boluses of 5 ml of local anesthetic. Analgesia was assessed for 36 h after the end of surgery by means of a visual analog scale (VAS) and a verbal scale (VS), as well as the number of PCA boluses administered and the amount of supplementary i.v. ketorolac, if given. RESULTS: The VAS and VS scores were significantly higher in group IA during the 24 h following surgery. Ketorolac requirement was higher in group IA throughout the postoperative observation. Adverse effects were similar in all groups except for urinary retention, which was significantly more frequent in group EPI. CONCLUSIONS: We conclude that either epidural or continuous femoral nerve block provide adequate pain relief in patients who undergo ACLR, whereas intraarticular analgesia seems unable to cope satisfactorily with the analgesic requirements of this surgical procedure.     

Comparing etoricoxib and celecoxib for preemptive analgesia for acute postoperative pain in patients undergoing arthroscopic anterior cruciate ligament reconstruction: a randomized controlled trial

Background  

The efficacy of selective cox-2 inhibitors in postoperative pain reduction were usually compared with conventional non-selective conventional NSAIDs or other types of medicine. Previous studies also used selective cox-2 inhibitors as single postoperative dose, in continued mode, or in combination with other modalities. The purpose of this study was to compare analgesic efficacy of single preoperative administration of etoricoxib versus celecoxib for post-operative pain relief after arthroscopic anterior cruciate ligament reconstruction.     

Lateral femoral condyle fracture after endoscopic anterior cruciate ligament reconstruction

A case is described in which a coronal plane fracture of the lateral femoral condyle propagated through the femoral tunnel 2 months after endoscopic anterior cruciate ligament reconstruction     

Femoral tunnel position in chronic anterior cruciate ligament rupture reconstruction: randomized controlled trial comparing anatomic,biomechanical and clinical outcomes

Purpose

The aim of this study was to compare the outcomes between anteromedial (AM) and transtibial (TT) femoral tunnel positioning techniques for the reconstruction of chronic anterior cruciate ligament (ACL) rupture.

Materials and methods

It is a randomized prospective study of 106 patients who underwent ACL reconstruction because of a chronic ACL rupture (55 AMT, 51 TT). Minimum follow-up was 2 years. Demographic, clinical and radiological data, including MRI grafts’ anatomy and biomechanics intraoperative navigation system evaluation, were analyzed. Also, International Knee Documentation Committee score, Tegner Knee score, Lysholm Knee Score, Short-Form Health Survey and 4-point Likert Scale were evaluated.

Results

The AM technique achieves a more anatomic graft than TT technique in both sagittal and coronal plane (6° approximately). Immediate postoperative biomechanical evaluation of the graft showed both techniques significantly improved translational and rotational laxity (p = 0.000). AMT showed superiority only in controlling internal rotation (p = 0.016). Both techniques reported significant improvement in all evaluated score scales, without differences between techniques. Independently of the femoral tunnel positioning technique, patients with cartilage lesion had worse clinical outcomes.

Conclusions

Our findings suggest that AMT achieves a more anatomical and biomechanically accurate graft allowing better control over internal rotation laxity; however, this does not lead to better clinical outcomes if we compare with TT in the reconstruction of chronic ACL rupture. Patients with chronic ACL rupture and cartilage lesion had worse clinical outcomes, independently the femoral tunnel positioning technique.

     

Patient satisfaction with inpatient versus outpatient reconstruction of the anterior cruciate ligament: a randomized clinical trial.

OBJECTIVE: To compare satisfaction levels after reconstruction of the anterior cruciate ligament (ACL) between inpatients and outpatients by means of a valid and comprehensive outcome tool. METHODS: Fifty patients examined at a tertiary clinic who met the study's inclusion criteria (15-50 yr old, no previous ACL reconstruction, > 6 h after injury, living < 1 h from hospital, assigned a caregiver for outpatient management within 48 h of injury, no serious health condition, no known hypersensitivity to ASA/NSAIDs, bleeding disorder or gastric ulcer, ability to cope at home after operation) were recruited and randomized into either the inpatient or outpatient groups. Inpatients stayed overnight in hospital after their ACL reconstruction and were discharged home the next day. Outpatients were discharged home on the day of the procedure. All patients attended a preoperative educational session and were required to meet the same discharge criteria (able to bear weight using crutches and to void, to be reasonably pain free, no nausea or vomiting, no excess bleeding or drainage, be alert, be given take-home medications and be in the company of a caregiver). Standardized anesthetic and postoperative analgesic protocols were used. One week after ACL reconstruction, patient satisfaction was quantified with a previously validated visual analogue questionnaire (maximum score of 100). RESULTS: We collected data on 21 inpatients and 19 outpatients. The mean overall-satisfaction score of the outpatient group was higher than that of the inpatient group (85.1 v. 78.2, p = 0.015). Between-group differences in postoperative pain, nausea, rate of readmission and complications were not significant. CONCLUSION: As determined by a comprehensive, population-specific, validated outcome, patient satisfaction is higher when ACL reconstruction is done on an outpatient basis.     

Fracture of the femoral tunnel after an anterior cruciate ligament reconstruction

Fractures after anterior cruciate ligament (ACL) reconstructive surgery are rare. Patella fractures can occur as a complication after bone-patellar tendon-bone autografts, and few case reports of tibia fractures have been published. Although reports of femur fractures have been published, the causes are attributed to stress risers other than the femoral tunnel. To our knowledge, this is the first case report of a femoral tunnel serving as a stress riser after an ACL reconstruction with bone-patellar tendon-bone autograft. The patient’s fracture resulted from minimal trauma and required surgical fixation.     

Analgesic efficacy of local infiltration analgesia vs. femoral nerve block after anterior cruciate ligament reconstruction: a systematic review and meta‐analysis

Many published reports consider blockade of the femoral nerve distribution the best available analgesic treatment after anterior cruciate ligament reconstruction. However, some argue that an alternative approach of infiltrating local anaesthetic into the surgical site has similar efficacy. The objectives of this meta‐analysis were to compare the analgesic and functional outcomes of both treatments following anterior ligament reconstruction. The primary outcomes were pain scores at rest (analogue scale, 0–10) in the early (0–2 postoperative hours), intermediate (3–12 hours) and late postoperative periods (13–24 hours). Secondary outcomes included range of motion, quadriceps muscle strength and complication rates (neurological problems, cardiovascular events, falls and knee infections). Eleven trials, including 628 patients, were identified. Pain scores in the early, intermediate and late postoperative periods were significantly lower in patients who received a femoral nerve block, with mean differences (95%CI) of 1.6 (0.2–2.9), p = 0.02; 1.2 (0.4–1.5), p = 0.002; and 0.7 (0.1–1.4), p = 0.03 respectively. The quality of evidence for our primary outcomes was moderate to high. Regarding functional outcomes, only one trial reported a similar range of motion between groups at 48 postoperative hours. No trial sought to record complications. In conclusion, femoral nerve block provides superior postoperative analgesia after anterior cruciate ligament reconstruction to local infiltration analgesia. The impact of improved analgesia on function remains unclear due to the lack of reporting of functional outcomes in the existing literature.     

Broken femoral cross pin after hamstring anterior cruciate ligament reconstruction: case report

Two years after a quadrupled hamstring anterior cruciate ligament reconstruction using polylactic acid cross pin femoral fixation, a 32-year-old woman presented with symptoms of knee catching, locking, and stiffness. Diagnostic arthroscopy revealed a loose body in the anterior compartment of the knee which was determined to be part of the polylactic acid femoral fixation pin. The graft was intact and well fixed. After simple arthroscopic removal, the patient returned to full activities and resumed normal function postoperatively. We speculate that the fixation pins may have entered the notch and later degraded or fractured. Using axial magnetic resonance images, we provide preliminary data suggesting that pins angled posterior to the epicondylar axis may violate the notch. If pins are to be placed posterior to the epicondylar axis, maximum pin length can be estimated by the formula: 0.4 x the interepicondylar distance.     

前交叉韧带早期重建术后股骨外侧髁压迹远期转归的相关研究

目的:探讨前交叉韧带(anterior cruciate ligament,ACL)早期重建术后股骨外侧髁压迹(lateral femoral notch,LFN)的转归并评估术后膝关节功能恢复情况。方法:对2015年12月至2019年12月间接受早期前交叉韧带重建的32例的临床资料进行回顾性分析,其中男18例,女14例,年龄16～54(25.39±2.82)岁;身体质量指数(body mass index,BMI)为20～30(26.15±3.09) kg/m²;交通伤6例,运动损伤19例,重物压伤7例。膝关节MRI显示所有患者损伤后LFN深度>1.5 mm,且术中对于LFN未进行干预。通过MRI资料观察患者手术前后的LFN缺损深度、面积及体积,对患者手术前后的国际软骨修复学会(International Cartilage Repair Society,ICRS)评分、Lysholm评分、Tegner活动水平、膝关节损伤和骨关节炎结局评分(knee injury and osteoarthritis outcome score,KOOS)进行分析。结果:...     

前交叉韧带重建后翻修的临床研究

目的 探讨前交叉韧带(anterior cruciate ligament, ACL)翻修重建的手术适应证、手术方法和临床疗效.方法 2001年11月至2006年7月收治ACL重建后失稳接受翻修患者12例,其中男性9例,女性3例,年龄16～39岁,平均28岁,均在关节镜下行探查与翻修手术.结合上述病例分析翻修的适应证、术中处理方法.术后应用KT-2000、IKDC、Lysholm及Tegner评分系统对临床疗效进行评价.结果 本组患者术前膝关节明显不稳.2例因骨道骨质严重缺损行一期植骨术.其余10例一期行ACL翻修手术,重建移植物采用同侧腘绳肌腱(STG)4例,对侧STG 4例,同侧骨-髌腱-骨(B-PT-B)1例,髂胫束1例.ACL翻修术后KT-2000检查平均差值在膝关节屈曲90°位和30°位分别为1.6 mm和3.1 mm;术后IKDC、Lysholm及Tegner评分平均分别为72.8、78.3、4.9分,较术前有明显改善.结论 ACL翻修重建后患膝的主观功能和客观稳定性可获明显改善.     

股神经阻滞与收肌管阻滞在前交叉韧带重建术后镇痛效果的Meta分析

目的 比较股神经阻滞（FNB）与收肌管阻滞（ACB）用于前交叉韧带重建（ACLR）术后镇痛效果。
方法 检索Pubmed、Embase、Web of Science、Cochrane Library、Cochrane Controlled Trials Register、万方、知网、维普数据库,检索时间为建库至2021年3月,收集股神经阻滞（FNB组）与收肌管阻滞（ACB组）用于ACLR术后镇痛效果比较的随机对照试验（RCT）,按照Cochrane手册选择文献、提取资料、对纳入文献的方法学质量进行评价,采用RevMan 5.4软件进行Meta分析。
结果 共纳入9篇发表于2014—2021年的RCT研究,共计患者719例,FNB组359例,ACB组360例。FNB组和ACB组术后0～3、6、12、24、48 h疼痛评分差异无统计学意义。FNB组与ACB组术后24、48 h阿片类药物用量、患者满意度差异无统计学意义。5篇文献认为ACB组能更好地保留患者股四头肌肌力,3篇文献认为ACB组与FNB组患者术后股四头肌肌力差异无统计学意义。
结论 ACB与FNB在ACLR术后疼痛评分、阿片类药物用量、患者满意度方面无显著差异,ACB在保留患者股四头肌肌力方面可能更具优势,但还需后续更多研究进一步验证。     

超声引导下左旋布比卡因复合硫酸镁股神经阻滞对前交叉韧带重建术后镇痛效果的影响

目的探讨左旋布比卡因复合硫酸镁用于超声引导下股神经阻滞对前交叉韧带重建术后镇痛效果的影响。方法选择择期行关节镜下前交叉韧带重建术患者107例,男66例,女41例,年龄25~60岁,ASAⅠ或Ⅱ级。将患者随机分为研究组(n=56)和对照组(n=51)。两组均在全麻诱导前实行超声引导患侧股神经阻滞,研究组给予0.25%左布比卡因和2%硫酸镁混合液20ml,对照组给予0.25%左布比卡因20ml。记录股神经感觉和运动阻滞情况,记录术后4、6、12、24和48h的静息和运动时VAS评分,记录术后48h内追加镇痛药情况、曲马多用量、术后48h满意度评分和术后48h内恶心呕吐等不良反应的发生情况。结果术后12h硫酸镁组静息和运动时VAS评分明显低于对照组(P0.05)。硫酸镁组需追加镇痛药5例(8.9%),明显少于对照组的10例(19.6%)(P0.05);硫酸镁组曲马多用量明显少于对照组(P0.05)。硫酸镁组股神经感觉和运动阻滞起效时间明显短于,感觉和运动阻滞持续时间明显长于,满意度评分明显高于对照组(P0.05)。两组恶心呕吐发生率差异无统计学意义。结论左旋布比卡因复合硫酸镁应用于超声引导股神经阻滞,可以缩短阻滞起效时间,延长阻滞持续时间,提高术后镇痛效果及患者的满意度,减少镇痛药物应用,并且不增加不良反应的发生。     

异体肌腱保留残端重建前交叉韧带的前瞻性随机对照研究

目的 比较使用异体肌腱保留残端重建前交叉韧带(ACL)和标准ACL重建术的临床疗效. 方法 前瞻性地将2008年8月至2010年4月收治的符合纳入和排除标准的ACL损伤患者随机分为2组,分别使用保留残端的ACL重建术(保残组,45例)和切除残端的ACL重建术(对照组,45例),移植物均使用4股异体肌腱.两组患者术前一般资料比较差异均无统计学意义(P＞0.05),具有可比性.比较两组患者术后Lysholm评分、IKDC分级、稳定性检查(Lachman试验、轴移试验和KT-1000 测量)、滑膜覆盖情况及本体感觉测试结果.结果 保残组和对照组分别有39例和41例患者完成至少2年(平均25.7个月)的随访.保残组和对照组患者Lysholm评分分别为(96.0±6.0)分和(93.0±7.5)分,分别有97.4％ (38/39)和97.6％ (40/41)的患者评为IKDCA级或B级、97.4％ (38/39)和97.6％(40/41)的患者Lachman试验阴性、94.9％ (37/39)和87.8％ (36/41)的患者轴移试验阴性、KT-1000侧-侧差值分别为(1.6±1.7) mm和(1.8±1.8) mm、滑膜覆盖分型为A或B的分别有71.4％ (20/28)和70.4％ (19/27)、关节位置觉侧-侧差值分别为3.6°±1.8°和3.9°±2.2°,以上指标两组比较差异均无统计学意义(P＞0.05).保残组受伤至手术时间与Lysholm评分、KT-1000侧-侧差值、移植物滑膜覆盖情况和关节位置觉侧-侧差值无明显相关性(P＞0.05).结论 使用异体肌腱时,保留残端重建ACL与标准的ACL重建术相比,对膝关节术后稳定性、移植物滑膜覆盖及膝关节本体感觉恢复等无明显促进作用.