Postoperative analgesic effects of intra-articular bupivacaine and morphine after arthroscopic cruciate ligament surgery

Intra-articular administration of local anaesthetics such as bupivacaine can produce short-term postoperative analgesia in patients undergoing diagnostic arthroscopy or arthroscopic meniscectomy. A peripheral anti-nociceptive effect may also be induced by the administration of intra-articular opiates interacting with local opioid receptors in inflamed peripheral tissue. In the present study we aimed to study the analgesic effects of intraarticularly given bupivacaine and morphine sulphate (as well as the combination of both drugs) on postoperative pain. In a prospective, randomized, double-blind manner 40 patients received one of the following: (a) morphine (1 mg in 20 ml NaCl), (b) bupivacaine (20 ml, 0.375%), (c) combination of both or (d) saline (20 ml, control group) intra-articularly at the end of arthroscopic anterior cruciate ligament (ACL) reconstruction. The postoperative pain was assessed via a visual analogue scale (VAS) during the first 48 h after surgery, and supplemental analgesic requirements were noted. All comparisons were made versus the control group receiving saline. The pain scores were significantly lower in the morphine group at 24 and 48 h, and in the bupivacaine group at 2, 4 and 6 h after surgery. In the group that received a combination of both bupivacaine and morphine, the pain scores were significantly reduced throughout the whole postoperative observation period. No side-effects or complications from therapy were seen in any of the groups. The conclusion of this study is that intra-articular morphine is effective in the postoperative period after arthroscopic ACL reconstruction. The combination of bupivacaine and morphine was the most effective postoperative analgesic regimen and resulted in significant analgesia throughout the whole 48-h period following surgery. Patients receiving the combination of bupivacaine and morphine had a significantly shorter hospital stay than the control group.     

Postoperative analgesic effects of an external cooling system and intra-articular bupivacaine/morphine after arthroscopic cruciate ligament surgery

The aim of this study was to evaluate the analgesic effect of an external cooling system with or without the combined effect of intra-articularly administered bupivacaine/morphine after arthroscopic anterior cruciate ligament (ACL) reconstruction. Fifty patients with isolated ACL insufficiency operated on under general anaesthesia were randomized to three different postoperative treatment groups. Group I was treated with the cooling system during the first 24 h after surgery and an intraarticular injection of 20 ml of physiological saline given at the completion of surgery; in group II, the cooling system was combined with an intra-articular injection of 20 ml bupivacaine 3.75 mg/ml and 1 mg of morphine at the end of the operation; while group III (placebo group) received an intra-articular injection of 20 ml of physiological saline at the completion of surgery. Pain was assessed using a visual analogue scale (VAS) at 1, 2, 4, 6, 24 and 48 h postoperatively. Supplementary analgesic requirements were registered. In group I 80% (16/20) and in group II 90% (18/20) of the patients were satisfied with the postoperative pain control regimen (NS). This was significantly better than in group III, where 30% (3/10) were satisfied. The pain scores were significantly lower in the two treatment groups compared with the placebo group during the entire postoperative period. The pain score was significantly lower in group II than in group I at 24 and 48 h after surgery. The supplementary analgesic requirements were also lower in the two treatment groups compared with the placebo group. No complications due to the use of the cooling system or the intra-articular injections of bupivacaine/morphine were observed. The external cooling system used in this study provides an effective method of obtaining pain relief after arthroscopic surgery. The combination with an intra-articular injection of morphine and bupivacaine results in a slightly greater analgesic effect than the cooling system alone.     

Complications of intra-articular anterior cruciate reconstruction

Intra-articular reconstruction of the ACL is a powerful technique, but is associated with a variety of potential complications. Careful patient selection, precise intraoperative technique, and aggressive rehabilitation can help minimize these problems. Our most common complication, postoperative limitation of motion, was nearly eliminated by a change to arthroscopic surgical technique and early motion.     

Arthroscopic anterior cruciate ligament reconstruction

Our understanding of the structure and function of the anterior cruciate ligament has progressed rapidly over the past decade. Arthroscope-assisted anterior cruciate ligament replacement is a new procedure that allows isometric placement of the anterior cruciate ligament graft. Postoperative rehabilitation is enhanced by preservation of the extensor mechanism.     

Comparison of Achilles and tibialis anterior tendon allografts after anterior cruciate ligament reconstruction

Purpose

The purpose of this study was to compare the outcomes after anterior cruciate ligament (ACL) reconstruction using Achilles tendon allografts and tibialis anterior (TA) tendon allografts with respect to objective knee testing measures, second-look arthroscopy and femoral tunnel enlargement.

Methods

A total of 131 patients who underwent ACL reconstruction between 2000 and 2006 were retrospectively reviewed. Achilles tendon allografts were used in 81 patients (group I). These patients were compared with 50 patients in whom TA tendon allografts were used (group II). The two groups were assessed using International Knee Documentation Committee (IKDC), Lysholm and Tegner activity scores, as well as KT-2000 testing. Second-look arthroscopic findings were evaluated. Cross-sectional area (CSA) perpendicular to the long axis of the femoral tunnel was also calculated digitally using magnetic resonance imaging.

Results

No significant differences were observed between the two groups with respect to IKDC, Lysholm or Tegner activity scores or the results of laxity testing with arthrometry. Synovial coverage of more than 50 % was found in 71.1 % cases in group I and 75 % cases in group II. Mean CSA enlargement of 15 % (group I) and 38 % (group II) was detected (p = 0.017).

Conclusions

The clinical results associated with Achilles and TA tendons were not significantly different. The laxity evaluation and second-look arthroscopy demonstrated no significant differences between group I and group II. However, Achilles tendon-bone plugs for femoral tunnel fixation reduced femoral tunnel enlargement compared to the TA allograft. Achilles tendon allografts for ACL reconstruction could be a reasonable option in selected patients.

Level of evidence

Retrospective case series, Level IV.     

Secondary intra-articular dislocation of a broken bioabsorbable interference screw after anterior cruciate ligament reconstruction

We report a case of intra-articular migration of the proximal part of a broken polylactic acid screw from the tibial site of anterior cruciate ligament-reconstruction with quadrupled semi-tendinosus tendon. Five months after initially successful ACL surgery the patient felt a sudden locking of the knee without another injury. MRI showed intra-articular migration of one-half of the polylactic acid screw, and standard radiographs a widening of the proximal tibial tunnel. At revision arthroscopy the broken part was easily removed. The patient had full recovery. This case demonstrates the problem of "bioscrew" breakage in ACL surgery.     

Fresh-frozen allograft anterior cruciate ligament reconstruction

Reconstruction of the anterior cruciate ligament provides consistently good to excellent results allowing return to work and sport. Allograft tissue is an alternative to autografts when appropriate donor tissue is not available or its use is not advisable for other reasons. The technique and results for allograft use are similar to those for autograft, making its use appropriate in a variety of clinical scenarios. This article reviews the indications for allograft ACL reconstruction, graft options, and technique for allograft use.     

Anatomical double-bundle anterior cruciate ligament reconstruction

A careful review of the literature suggests that a significant number of patients undergoing anterior cruciate ligament (ACL) reconstruction have less than optimal results. Although overall outcomes of ACL reconstruction are favourable, there remains considerable room for improvement. Anatomically, the ACL consists of two major functional bundles, the anteromedial and the posterolateral bundle. Biomechanically, both bundles contribute significantly to the anterior and the rotational stability of the knee. Therefore, anatomical double-bundle ACL reconstruction techniques may further improve the outcomes in ACL surgery. Our preferred technique for arthroscopic double-bundle ACL reconstruction includes the use of two femoral and two tibial tunnels to restore both the anteromedial and the posterolateral bundle of the ACL and their anatomical footprints at their tibial and femoral insertion site. We use two tibialis anterior tendon allografts for the restoration of the two ACL bundles. Clinical long-term outcome studies may focus on the evaluation of functional outcomes, restoration of anterior and rotational knee stability, and the risk of degenerative osteoarthritis of the knee joint following anatomical double-bundle ACL reconstruction versus single-bundle ACL reconstruction.     

Simultaneous bilateral anterior cruciate ligament reconstruction

BACKGROUND: There are no reports on the outcome of bilateral simultaneous anterior cruciate ligament reconstruction. HYPOTHESIS: There is no difference in outcome between unilateral and simultaneous bilateral operations. STUDY DESIGN: Case control study. METHODS: We compared the short-term outcome (mean, 37.2 months) of 28 patients who had bilateral simultaneous reconstructions with that of a matched group of patients who had unilateral reconstruction. RESULTS: Postoperative narcotic requirements for pain did not differ between groups. The mean quadriceps muscle strength for the simultaneous group was 99% in the right leg and 102% in the left leg compared with the strongest leg preoperatively; the mean for the unilateral group was 99%. The mean modified Noyes score for the simultaneous group was 91.2 points in the left knee and 93.5 points for the right knee; the mean for the unilateral group was 88.7 points. The mean time to return to full-time work and to full sports was 4.1 weeks and 6.1 months for the simultaneous group and 3.0 weeks and 6.3 months for the unilateral group. The mean hospital costs were US dollars 6687 and US dollars 4307, respectively. CONCLUSIONS: When clinical indications exist, we recommend simultaneous bilateral anterior cruciate ligament reconstruction as opposed to staged procedures because it is a safe, effective, and cost-effective option.     

One-stage bilateral anterior cruciate ligament reconstruction

Purpose

The ideal treatment for patients presenting with bilateral anterior cruciate ligament (ACL) deficiency remains controversial. The purpose was to evaluate cost and functional results after one-stage bilateral ACL reconstruction using either hamstring or patella tendon autograft.

Methods

This prospective comparative study was compared the mid-term outcome of 7 patients (14 knees) who had one-stage bilateral ACL reconstruction with that of a matched group of patients who had unilateral reconstruction (21 patients).

Results

The median length of hospital stay was 4 (3–5) nights for the bilateral group and 2 (1–4) nights for the control group. The duration of rehabilitation process in patients from control group with unilateral ACL reconstruction was one week shorter (9 vs 8 weeks). In the bilateral group, the median Lysholm score was 96 (85–100), and in the control group, the median score was 93 (81–100). The median time to return to full-time work and to full sports was 9 weeks and 7 months for the one-stage group and 8 weeks and 6 months for the unilateral group. Six patients (86 %) in the bilateral group and 17 patients (81 %) in the control group were still performing at their pre-injury level of activity. National Health Institution saved 2925 EUR when we performed one-stage bilateral reconstruction instead of two-stage ACL reconstruction.

Conclusions

Mid-term clinical results suggested that one-stage bilateral ACL reconstruction using either hamstring or patella tendon autograft is clinically effective. For patients presenting bilateral ACL-deficient knees, one-stage bilateral ACL reconstruction is reproducible, cost effective and does not compromise functional results.

Level of evidence

II.     

Effect of muscle preserved on tendon graft on intra-articular healing in anterior cruciate ligament reconstruction

Purpose

The aim of this study was to determine the impact on intra-articular healing of muscle tissue retained on tendon grafts used for anterior cruciate ligament (ACL) reconstruction.

Methods

In an animal study on 40 New Zealand rabbits, a semi-tendon/semi-muscle graft (SSG) and a total tendon graft (TTG) were individually harvested from the Achilles tendons in each animal. After transecting the ACLs in both knees of each rabbit, SSG and TTG were randomly used on bilateral sides of the knee for ACL reconstruction. After 2, 4, and 8 weeks, functional scoring, gross observations, and histological evaluations of the repaired knees were performed (each time point; n = 10). Biomechanical testing was conducted on remaining animals at 8 weeks (n = 10).

Results

At 2, 4, and 8 weeks after surgery, there were no statistically significant differences in functional scores between the SSG group and TTG group (n.s.). As healing progressed, skeletal muscle on the SSG was gradually absorbed with a corresponding decrease in graft diameter, compared to TTG, at each time point (P < 0.001). However, healing and incorporation of the intra-articular graft in the SSG were more apparent than those in the TTG, based on histology. The vascularity and cellularity in the center of the sample were significantly greater in the SSG group than the TTG group at all the time points (P < 0.01). At 8 weeks, the SSG group’s ultimate failure load, yield load, and elongation at failure were significantly less than for the TTG group (P < 0.01). There were no significant differences in stiffness between the two groups with biomechanical testing (n.s.).

Conclusion

Results of this study indicate that muscle left on tendon grafts promotes intra-articular healing and remodeling of the graft in a rabbit model. However, excessive amounts of retained skeletal muscle weaken tendon graft’s strength for ACL reconstruction. Preserving small amounts of muscle on tendon grafts is feasible for improving the biological success of ACL reconstruction in humans.     

Graft healing in anterior cruciate ligament reconstruction

Graft healing within the bone tunnel after anterior cruciate ligament (ACL) reconstruction is still a complex, poorly understood biological process that is influenced by multiple surgical and postoperative variables. However, remarkable advances in knowledge of this process have been made based primarly on animal models. According to the findings of this review, some surgical and postoperative variables are known to directly affect time-course and quality of graft-tunnel healing. The type of graft, graft motion, and fixation methods have shown to directly affect time-course and quality of graft-tunnel healing. Therefore, the application of early and aggressive rehabilitation protocols should be cautious when using soft-tissue graft, allografts, and direct or aperture type of fixation for ACL reconstruction. With regard to graft placement, several cadaveric models showed biomechanical advantages of a more anatomical graft location; however, there are no studies that explore the relationship between graft placement and healing process. The precise effect of graft tensioning, graft/tunnel diameter disparity, and graft length within the bone tunnel in the graft healing process remains unclear and requires more research. To enhance graft-tunnel healing, tissue-engineering approaches, including the use of growth factors, mesenchymal stem cells, and periosteum graft augmentation, have been tested on animal models. These have shown promising results in terms of enhancement of bone-graft healing rate.     

Graft impingement in anterior cruciate ligament reconstruction

Anterior cruciate ligament (ACL) graft impingement is one of the most troubling complications in ACL reconstruction. In the previous strategy of isometric “non-anatomical” ACL reconstruction, posterior tibial tunnel placement and notchplasty were recommended to avoid graft impingement. Recently, the strategy of ACL reconstruction is shifting towards “anatomical” reconstruction. In anatomical ACL reconstruction, the potential risk of graft impingement is higher than in non-anatomical reconstruction because the tibial tunnel is placed at a more anterior portion on the tibia. However, there have been few studies reporting on graft impingement in anatomical ACL reconstruction. This study will provide a review of graft impingement status in both non-anatomical and the more recent anatomical ACL reconstruction techniques. In conclusion, with the accurate creation of bone tunnels within ACL native footprint, the graft impingement might not happen in anatomical ACL reconstruction. For the clinical relevance, to prevent graft impingement, surgeons should pay attention of creating correct anatomical tunnels when they perform ACL reconstruction. Level of evidence IV.     

Biomechanical effects of femoral notchplasty in anterior cruciate ligament reconstruction.

Notchplasty is frequently performed in conjunction with anterior cruciate ligament reconstruction. Bench loading tests were performed on 26 fresh-frozen knee specimens to measure excursion of a bone-patellar tendon-bone graft, anterior-posterior laxity of the knee, and graft forces before and after performing a 2-mm and a 4-mm notchplasty. The mean intraarticular pretension required to restore normal anterior-posterior laxity at 30 degrees of flexion (laxity-matched pretension level) was 27 N before notchplasty, 48 N after 2-mm notchplasty, and 65 N after 4-mm notchplasty. The mean graft pretension decreased 53% and 58%, respectively, on completion of a loading test series involving anterior-posterior and constant tibial loading forces. Mean laxity increased 1.4 mm at full extension and decreased 1.8 mm at 90 degrees of flexion after a 2-mm notchplasty. Mean graft forces increased markedly between 30 degrees and 90 degrees of passive flexion after notchplasty. Our results show that after a notchplasty, a higher level of graft pretension will be necessary to restore normal laxity at 30 degrees of flexion. This increased level of pretension, combined with changes in graft excursion, produced dramatic increases in graft force when the knee was flexed to 90 degrees. These relatively high forces would be detrimental to a remodeling graft and could lead to subsequent failure of the reconstruction.     

Allograft safety in anterior cruciate ligament reconstruction

Allograft tissue seems to provide an excellent option for reconstruction of the ACL in the primary and revision setting. Although in general the risks of using allograft tissue in ACL reconstruction are low, the consequences of complications associated with disease or infection transmission or of recurrent instability secondary to graft failure are large. Surgeons should provide patients with the information available regarding allograft risks and should have thorough knowledge of the source and preparation of the grafts by their tissue bank before implantation for ACL reconstruction.     

Trans-physeal anterior cruciate ligament reconstruction in adolescents

Purpose

The aim of the study was to evaluate, in a group of adolescents, the onset of varus–valgus deviations in the sagittal plane after performing a trans-tibial trans-epiphyseal technique of ACL reconstruction with a follow-up of at least 2 years.

Methods

Seventy-one patients aged 12–15 years old (Tanner scale 3 and 4) have undergone ACL reconstruction with STG using arthroscopy. All patients were evaluated clinically using the visual analogue scale (VAS), the Lysholm score and the Tegner activity score at the time of surgery. All patients were reevaluated after a follow-up period of at least 2 years (T1) using the VAS, the Lysholm score, the Tegner activity score and radiographic studies in order to compare the operated limb with the healthy control limb.

Results

Valgus difference exceeding 2° in the knee axis between the operated limb and the healthy control limb was observed only in three patients (4.2 %: 95 % CI 0.88–11.86 %). The average difference was <1° (0.3°, 95 % CI 0.0–0.55).

Conclusion

The trans-tibial trans-epiphyseal technique of ACL reconstruction, according to the results obtained, seems to be a valid alternative procedure, when performed by a skilled orthopaedic surgeon, offering an excellent safety profile and at the same time very good clinical results.

Level of evidence

IV.

     

Synthetic and allograft anterior cruciate ligament reconstruction

Although still in the early stages of development, the use of synthetics and allografts in ACL surgery appears promising. Two prosthetic ligaments, the Kennedy LAD and Gore-Tex, are FDA approved for limited indications. The Kennedy LAD has been shown to be effective in augmenting an autograft with inherent structural weakness in its central portion. The proposed benefits of using this device with grafts of greater strength are unproved. The Gore-Tex ACL reconstruction allows a rapid initiation of vigorous rehabilitation and return to full activities. However, the complication rate with this procedure appears to be higher than that with autograft reconstruction. The use of allograft for ACL reconstruction also has many potential advantages and short-term clinical trials have shown good results. However, the benefits must be weighed against the possibility of long-term failure and potential spread of infectious disease.     

Comparison of outcomes between males and females after anterior cruciate ligament reconstruction

Few studies have specifically addressed the potential differences in outcome from ACL reconstruction between males and females. The present study compared patient-reported outcomes between the sexes after a minimum of 2 years following arthroscopic ACL reconstruction using bone-patellar tendon-bone autograft. Patients were also categorized as acute or chronic based on the time from injury to surgery. Outcome questionnaires were mailed to 638 patients, resulting in 151 eligible respondents included in the analysis. The outcome instruments used were the Cincinnati scale, the ACL-Quality of Life scale, and the Tegner activity rating scale. At an average of 5 years following ACL reconstruction no differences were found between males (n=74) and females (n=77) on the ACL-QOL scale. Females perceived a significantly higher activity level prior to surgery according to the Tegner scale. However, no other differences were identified by gender or stage based on prior, highest, or current Tegner activity levels. Results of the Cincinnati scale for the entire sample showed that females scored an average of 5.7 points lower than males. Analysis of this difference by patient age indicates a trend toward lower scores in females between 12-18 and over 24 years old. Chronicity was not a factor that affected outcome in either males or females. No differences were found in the number of patients who complained of anterior knee pain. We conclude that autogenous bone-patella tendon-bone ACL reconstruction is equally successful in well-matched populations of males and females.     

Comparison of score evaluations and instrumented measurement after anterior cruciate ligament reconstruction

Forty-four patients who had undergone unilateral anterior cruciate ligament reconstructions were evaluated retrospectively with seven different scoring systems (International Knee Documentation Committee, Orthopadische Arbeitsgruppe Knie, Lysholm, Feagin and Blake, Zarins and Rowe, Cincinnati, and Marshall scores). The results varied between systems and therefore lacked reliability. Of the 44 patients, 32 were rated as excellent according to the Cincinnati score while only 3 patients were rated as normal according to the International Knee Documentation Committee form. Good and excellent results were found twice as frequently with the Cincinnati and Lysholm scores compared with the scores of Zarins and Rowe or the International Knee Documentation Committee form. Statistical analysis confirmed this observation and revealed significant differences between the scoring systems. Side-to-side differences using the manual maximum displacement test with the KT-1000 arthrometer revealed good correlation with the International Knee Documentation Committee and the Orthopadische Arbeitsgruppe Knie questionnaires. None of the other scoring systems, which do not measure anterior laxity, produced reasonable correlation with instrumented measurements. We found that certain population-specific factors as well as the distribution of single findings can distort the results of scoring systems. To avoid these interference factors, the patient sample should be homogeneous and selected prospectively and there should be agreement about the value of single findings.