Advertisement

Most Analgesia Treatments Have No Clinical Significance for Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis of 66 Randomized Controlled Trials

      Purpose

      To assess the relative efficacy of several clinical treatments for postoperative analgesia of anterior cruciate ligament reconstruction through network meta-analysis based on multiple published randomized controlled trials.

      Methods

      We searched PubMed, the Cochrane library, EMBASE, and Web of Science, each from inception until February 15, 2021. Outcomes including pain scores at rest (visual analog scale, numerical rating scales, and other scales, which were converted to a standardized 0-10 scale), morphine consumption, and complications were meta-analyzed. Quality of the included studies was assessed using the Cochrane risk-of-bias tool. The authors defined the best choice for postoperative analgesia as the one that had significant difference in pain scores, morphine consumption, and had no significant difference in the risk of complications compared with placebo in the initial 48 postoperative hours.

      Results

      In total, 66 studies with 4,168 patients were included in this network meta-analysis. Only periarticular infiltration was significantly superior to placebo in pain scores and morphine consumption (pain at 2 hours: mean difference [MD] –0.74, 95% confidence interval [CI] –1.36 to –0.12; pain at 6 hours: MD –0.81, 95% CI –1.42 to –0.21; pain at 12 hours: MD –0.85, 95% CI –1.53 to –0.17; pain at 24 hours: MD –0.80, 95% CI –1.19 to –0.40; morphine consumption at 24 hours: MD –10.12, 95% CI –14.31 to –5.93; morphine consumption at 48 hours: MD –5.62, 95% CI –6.74 to –4.51). Periarticular infiltration did not increase the risk of complications compared with placebo (nausea and vomiting: odds ratio [OR] 0.63, 95% CI 0.34-1.16; pruritus: OR 0.74, 95% CI 0.35-1.58; urinary retention: OR 0.55, 95% CI 0.25-1.23). In addition, There was no significant difference between adductor canal block and femoral nerve block in pain scores and morphine consumption (pain at 2 hours: MD –0.01, 95% CI –1.44 to 1.42; pain at 6 hours: MD 0.29, 95% CI –0.28 to 0.86; pain at 12 hours: MD 0.36, 95% CI –0.44 to 1.16; pain at 24 hours: MD 0.26, 95% CI –0.22 to 0.75; pain at 48 hours: MD –0.36, 95% CI –0.97 to 0.24; morphine at 24 hours: MD 1.04, 95% CI –4.70 to 6.79; morphine at 48 hours: MD –0.32, 95% CI –0.70 to 0.07; postoperative nausea and vomiting: OR 1.07, 95% CI 0.55-2.09; pruritus: OR 1.36, 95% CI 0.66-2.79; urinary retention: OR 1.41, 95% CI 0.37-5.29).

      Conclusions

      Based on current evidence, most analgesic methods could result in lower pain scores and decrease morphine consumption when compared with placebo; however, differences between methods were small and inconsistent. There seemed to be no significant difference between adductor canal block and femoral nerve block in pain score, morphine consumption and complications.

      Level of Evidence

      Level I, meta-analysis of Level I RCTs.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Arthroscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Mall N.A.
        • Chalmers P.N.
        • Moric M.
        • et al.
        Incidence and trends of anterior cruciate ligament reconstruction in the United States.
        Am J Sports Med. 2014; 42: 2363-2370
        • Secrist E.S.
        • Freedman K.B.
        • Ciccotti M.G.
        • Mazur D.W.
        • Hammoud S.
        Pain management after outpatient anterior cruciate ligament reconstruction: A systematic review of randomized controlled trials.
        Am J Sports Med. 2016; 44: 2435-2447
        • Cote M.P.
        • Lubowitz J.H.
        • Brand J.C.
        • Rossi M.J.
        Understanding Network meta-analysis (NMA) conclusions requires scrutiny of methods and results: Introduction to NMA and the geometry of evidence.
        Arthroscopy. 2021; 37: 2013-2016
        • Hutton B.
        • Salanti G.
        • Caldwell D.M.
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: Checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
        • Terkawi A.S.
        • Mavridis D.
        • Sessler D.I.
        • et al.
        Pain management modalities after total knee arthroplasty: A network meta-analysis of 170 randomized controlled trials.
        Anesthesiology. 2017; 126: 923-937
        • Hozo S.P.
        • Djulbegovic B.
        • Hozo I.
        Estimating the mean and variance from the median, range, and the size of a sample.
        BMC Med Res Methodol. 2005; 5: 13
        • Wan X.
        • Wang W.
        • Liu J.
        • Tong T.
        Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.
        BMC Med Res Methodol. 2014; 14: 135
        • Kurosaka K.
        • Tsukada S.
        • Nakayama H.
        • et al.
        Periarticular injection versus femoral nerve block for pain relief after anterior cruciate ligament reconstruction: A randomized controlled trial.
        Arthroscopy. 2018; 34: 182-188
        • Yung E.M.
        • Brull R.
        • Albrecht E.
        • Joshi G.P.
        • Abdallah F.W.
        Evidence basis for regional anesthesia in ambulatory anterior cruciate ligament reconstruction: Part III: Local instillation analgesia—a systematic review and meta-analysis.
        Anesth Analg. 2019; 128: 426-437
        • Baverel L.
        • Cucurulo T.
        • Lutz C.
        • et al.
        Anesthesia and analgesia methods for outpatient anterior cruciate ligament reconstruction.
        Orthop Traumatol Surg Res. 2016; 102: S251-s255
        • Palanne R.
        • Rantasalo M.
        • Vakkuri A.
        • et al.
        Effects of anaesthesia method and tourniquet use on recovery following total knee arthroplasty: A randomised controlled study.
        Br J Anaesth. 2020; 125: 762-772
        • de Lima E.S.R.
        • Correa C.H.
        • Henriques M.D.
        • de Oliveira C.B.
        • Nunes T.A.
        • Gomez R.S.
        Single-injection femoral nerve block with 0.25% ropivacaine or 0.25% bupivacaine for postoperative analgesia after total knee replacement or anterior cruciate ligament reconstruction.
        J Clin Anesth. 2008; 20: 521-527
        • Ng H.P.
        • Cheong K.F.
        • Lim A.
        • Lim J.
        • Puhaindran M.E.
        Intraoperative single-shot "3-in-1" femoral nerve block with ropivacaine 0.25%, ropivacaine 0.5% or bupivacaine 0.25% provides comparable 48-hr analgesia after unilateral total knee replacement.
        Can J Anaesth. 2001; 48: 1102-1108
        • Schuster M.
        • Engelhardt L.
        • Erler W.
        • et al.
        [Levobupivacaine vs. ropivacaine for continuous femoral analgesia after anterior cruciate ligament reconstruction].
        Schmerz. 2011; 25: 62-68
        • Baverel L.
        • Demey G.
        • Odri G.A.
        • Leroy P.
        • Saffarini M.
        • Dejour D.
        Do outcomes of outpatient ACL reconstruction vary with graft type?.
        Orthop Traumatol Surg Res. 2015; 101: 803-806
        • Gupta R.
        • Kapoor D.
        • Kapoor L.
        • et al.
        Immediate post-operative pain in anterior cruciate ligament reconstruction surgery with bone patellar tendon bone graft vs hamstring graft.
        J Orthop Surg Res. 2016; 11: 67
        • Guirro U.B.
        • Tambara E.M.
        • Munhoz F.R.
        Femoral nerve block: Assessment of postoperative analgesia in arthroscopic anterior cruciate ligament reconstruction.
        Braz J Anesthesiol. 2013; 63: 483-491
        • Peng P.
        • Claxton A.
        • Chung F.
        • Chan V.
        • Miniaci A.
        • Krishnathas A.
        Femoral nerve block and ketorolac in patients undergoing anterior cruciate ligament reconstruction.
        Can J Anaesth. 1999; 46: 919-924
        • Wulf H.
        • Loewe J.
        • Gnutzmann K.H.
        • Steinfeldt T.
        Femoral nerve block with ropivacaine or bupivacaine in day case anterior crucial ligament reconstruction.
        Acta Anaesthesiol Scand. 2010; 54: 414-420
        • Williams B.A.
        • Kentor M.L.
        • Vogt M.T.
        • et al.
        Reduction of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block: A randomized clinical trial.
        Anesthesiology. 2006; 104: 315-327
        • Swank K.R.
        • DiBartola A.C.
        • Everhart J.S.
        • Kaeding C.C.
        • Magnussen R.A.
        • Flanigan D.C.
        The effect of femoral nerve block on quadriceps strength in anterior cruciate ligament reconstruction: A systematic review.
        Arthroscopy. 2017; 33: 1082-1091.e1081
        • Jaeger P.
        • Nielsen Z.J.
        • Henningsen M.H.
        • Hilsted K.L.
        • Mathiesen O.
        • Dahl J.B.
        Adductor canal block vs femoral nerve block and quadriceps strength: A randomized, double-blind, placebo-controlled, crossover study in healthy volunteers.
        Anesthesiology. 2013; 118: 409-415
        • Espelund M.
        • Fomsgaard J.S.
        • Haraszuk J.
        • Mathiesen O.
        • Dahl J.B.
        Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction: A randomised controlled trial.
        Eur J Anaesthesiol. 2013; 30: 422-428
        • Lundblad M.
        • Forssblad M.
        • Eksborg S.
        • Lonnqvist P.-A.
        Ultrasound-guided infrapatellar nerve block for anterior cruciate ligament repair: A prospective, randomised, double-blind, placebo-controlled clinical trial.
        Eur J Anaesthesiol. 2011; 28: 511-518
        • El Ahl M.S.
        Femoral nerve block vs adductor canal block for postoperative pain control after anterior cruciate ligament reconstruction: A randomized controlled double blind study.
        Saudi J Anaesth. 2015; 9: 279-282
        • Abdallah F.W.
        • Whelan D.B.
        • Chan V.W.
        • et al.
        Adductor canal block provides noninferior analgesia and superior quadriceps strength compared with femoral nerve block in anterior cruciate ligament reconstruction.
        Anesthesiology. 2016; 124: 1053-1064
        • Faiaz A.F.
        • Kamath S.S.
        Randomised controlled trial between ultrasound guided femoral nerve block and adductor canal block for postoperative pain and functional outcome in anterior cruciate ligament reconstruction.
        J Clin Diagn Res. 2019; 13: UC11-UC14
        • Bailey L.
        • Griffin J.
        • Elliott M.
        • et al.
        Adductor canal nerve versus femoral nerve blockade for pain control and quadriceps function following anterior cruciate ligament reconstruction with patellar tendon autograft: A prospective randomized trial.
        Arthroscopy. 2019; 35: 921-929
        • Ghodki P.
        • Shalu P.
        • Sardesai S.
        Ultrasound-guided adductor canal block vs femoral nerve block for arthroscopic anterior cruciate ligament repair under general anesthesia.
        J Anaesthesiol Clin Pharmacol. 2018; 34: 242-246
        • Follak N.
        • Ganzer D.
        Postoperative analgesic value of the intra-articular instillation of bupivacaine and morphine after arthroscopic knee surgery.
        Arch Orthop Trauma Surg. 2001; 121: 278-281
        • Hosseini H.
        • Abrisham S.M.
        • Jomeh H.
        • et al.
        The comparison of intraarticular morphine-bupivacaine and tramadol-bupivacaine in postoperative analgesia after arthroscopic anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1839-1844
        • Koh I.J.
        • Chang C.B.
        • Seo E.S.
        • Kim S.J.
        • Seong S.C.
        • Kim T.K.
        Pain management by periarticular multimodal drug injection after anterior cruciate ligament reconstruction: A randomized, controlled study.
        Arthroscopy. 2012; 28: 649-657
        • Denti M.
        • Randelli P.
        • Bigoni M.
        • Vitale G.
        • Marino M.R.
        • Fraschini N.
        Pre-and postoperative intra-articular analgesia for arthroscopic surgery of the knee and arthroscopy-assisted anterior cruciate ligament reconstruction: A double-blind randomized, prospective study.
        Knee Surg Sports Traumatol Arthrosc. 1997; 5: 206-212
        • Karlsson J.
        • Rydgren B.
        • Eriksson B.
        • et al.
        Postoperative analgesic effects of intra-articular bupivacaine and morphine after arthroscopic cruciate ligament surgery.
        Knee Surg Sports Traumatol Arthrosc. 1995; 3: 55-59
        • Musil D.
        • Sadovsky P.
        • Stehlik J.
        Intra-articular analgesia after anterior cruciate ligament reconstruction.
        Acta Chir Orthop Traumatol Cech. 2007; 74: 182-188
        • Tetzlaff J.E.
        • Dilger J.A.
        • Abate J.
        • Parker R.D.
        Preoperative intra-articular morphine and bupivacaine for pain control after outpatient arthroscopic anterior cruciate ligament reconstruction.
        Reg Anesth Pain Med. 1999; 24: 220-224
        • Gatt Jr., C.J.
        • Parker R.D.
        • Tetzlaff J.E.
        • Szabo M.Z.
        • Dickerson A.B.
        Preemptive analgesia: its role and efficacy in anterior cruciate ligament reconstruction.
        Am J Sports Med. 1998; 26: 524-529
        • Hoher J.
        • Kersten D.
        • Bouillon B.
        • Neugebauer E.
        • Tiling T.
        Local and intra-articular infiltration of bupivacaine before surgery: Effect on postoperative pain after anterior cruciate ligament reconstruction.
        Arthroscopy. 1997; 13: 210-217
        • Wang X.
        • Jia D.
        • Chen X.
        • Xu Y.
        Comparison of intra-articular low-dose sufentanil, ropivacaine, and combined sufentanil and ropivacaine on post-operative analgesia of isolated anterior cruciate ligament reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2013; 21: 1140-1145
        • Danieli M.V.
        • Cavazzani Neto A.
        • Herrera P.A.
        Intra-articular bupivacaine or bupivacaine and morphine after ACL reconstruction.
        Acta Ortop Bras. 2012; 20: 258-261
        • Kreuz P.C.
        • Steinwachs M.
        • Angele P.
        Single-dose local anesthetics exhibit a type-, dose-, and time-dependent chondrotoxic effect on chondrocytes and cartilage: A systematic review of the current literature.
        Knee Surg Sports Traumatol Arthrosc. 2018; 26: 819-830
        • Lo I.K.
        • Sciore P.
        • Chung M.
        • et al.
        Local anesthetics induce chondrocyte death in bovine articular cartilage disks in a dose- and duration-dependent manner.
        Arthroscopy. 2009; 25: 707-715
        • Kristensen P.K.
        • Pfeiffer-Jensen M.
        • Storm J.O.
        • Thillemann T.M.
        Local infiltration analgesia is comparable to femoral nerve block after anterior cruciate ligament reconstruction with hamstring tendon graft: A randomised controlled trial.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 317-323
        • Mayr H.O.
        • Entholzner E.
        • Hube R.
        • Hein W.
        • Weig T.G.
        Pre- vs postoperative intraarticular application of local anesthetics and opioids vs femoral nerve block in anterior cruciate ligament repair.
        Arch Orthop Trauma Surg. 2007; 127: 241-244
        • Mehdi S.A.
        • Dalton D.J.
        • Sivarajan V.
        • Leach W.J.
        BTB ACL reconstruction: Femoral nerve block has no advantage over intraarticular local anaesthetic infiltration.
        Knee Surg Sports Traumatol Arthrosc. 2004; 12: 180-183
        • Woods G.W.
        • O'Connor D.P.
        • Calder C.T.
        Continuous femoral nerve block vs intra-articular injection for pain control after anterior cruciate ligament reconstruction.
        Am J Sports Med. 2006; 34: 1328-1333
        • Dauri M.
        • Polzoni M.
        • Fabbi E.
        • Sidiropoulou T.
        • Servetti S.
        • Coniglione F.
        Comparison of epidural, continuous femoral block and intraarticular analgesia after anterior cruciate ligament reconstruction.
        Acta Anaesthesiol Scand. 2003; 47: 20-25
        • Iskandar H.
        • Benard A.
        • Ruel-Raymond J.
        • Cochard G.
        • Manaud B.
        Femoral block provides superior analgesia compared with intra-articular ropivacaine after anterior cruciate ligament reconstruction.
        Reg Anesth Pain Med. 2003; 28: 29-32
        • Tran K.M.
        • Ganley T.J.
        • Wells L.
        • Ganesh A.
        • Minger K.I.
        • Cucchiaro G.
        Intraarticular bupivacaine-clonidine-morphine vs femoral-sciatic nerve block in pediatric patients undergoing anterior cruciate ligament reconstruction.
        Anesth Analg. 2005; 101: 1304-1310
        • Iamaroon A.
        • Tamrongchote S.
        • Sirivanasandha B.
        • et al.
        Femoral nerve block vs intra-articular infiltration: A preliminary study of analgesic effects and quadriceps strength in patients undergoing arthroscopic anterior cruciate ligament reconstruction.
        J Med Assoc Thai. 2016; 99: 578-583
        • Sahni N.
        • Panda N.B.
        • Jain K.
        • Batra Y.K.
        • Dhillon M.S.
        • Jagannath P.
        Comparison of different routes of administration of clonidine for analgesia following anterior cruciate ligament repair.
        J Anaesthesiol Clin Pharmacol. 2015; 31: 491-495
        • Kirkham K.R.
        • Grape S.
        • Martin R.
        • Albrecht E.
        Analgesic efficacy of local infiltration analgesia vs. femoral nerve block after anterior cruciate ligament reconstruction: A systematic review and meta-analysis.
        Anaesthesia. 2017; 72: 1542-1553
        • Stebler K.
        • Martin R.
        • Kirkham K.R.
        • Lambert J.
        • De Sede A.
        • Albrecht E.
        Adductor canal block vs local infiltration analgesia for postoperative pain after anterior cruciate ligament reconstruction: A single centre randomised controlled triple-blinded trial.
        Br J Anaesth. 2019; 123: e343-e349
        • Harbell M.W.
        • Cohen J.M.
        • Kolodzie K.
        • et al.
        Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: A randomized controlled clinical trial.
        J Clin Anesth. 2016; 33: 68-74
        • Jansen T.K.
        • Miller B.E.
        • Arretche N.
        • Pellegrini J.E.
        Will the addition of a sciatic nerve block to a femoral nerve block provide better pain control following anterior cruciate ligament repair surgery?.
        AANA J. 2009; 77: 213-218