Caldwell George L, Selepec Michael A
Florida Institute of Orthopaedic Surgical Specialists, 2307 West Broward Blvd. Suite 200, Fort Lauderdale, FL 33312 USA.
HSS J. 2019 Feb;15(1):42-50. doi: 10.1007/s11420-018-09665-9. Epub 2019 Jan 28.
Pain management after anterior cruciate ligament reconstruction (ACLR) may pose a risk of prolonged opioid use.
QUESTIONS/PURPOSES: The purposes of this study in ACLR were to investigate the efficacy of a surgeon-administered local-regional block of specific genicular nerves on post-operative analgesia following ACLR and to quantify the outpatient opioid consumption and duration through the complete post-operative course.
Prospectively, all patients undergoing primary ACLR by a single surgeon were studied over a 10-month period. Exclusion criteria consisted of history of pre-operative opioid use, revision surgery, multi-ligament surgery, allergy to oral opioids, and allergy to local anesthetic. ACLR was performed using autograft or allograft patellar tendon bone (PTB) graft under general anesthesia. At the conclusion of the procedure, all patients received a local anesthetic (bupivacaine 0.25%) injection by the surgeon including a unique circumferential genicular nerve and fat pad block performed based on anatomic landmarks without use of image guidance. Post-operatively, the quantity and duration of opioid use (hydrocodone 5 mg) and pain scores were recorded for 4 months prospectively. Statistical analysis was performed to evaluate risk factors for increased opioid use.
A single surgeon performed 75 ACLRs. After exclusions, a total of 70 patients were enrolled and followed prospectively. None were lost to follow-up. Total opioid consumption ranged from 0 to 30 tablets. The average number of opioid tablets used over the 4-month post-operative course was 5.5 (± 6.7). After surgery, 84% of patients took between 0 and 10 tablets and 21% of patients took no opioids throughout their entire post-operative course. The average duration of consumption was 2.6 days (± 3.1). No patients were taking opioids at the 6-week or 4-month follow-up. There were no refills required. No statistically significant differences were seen in regard to graft choice of autograft PTB ( 48) vs allograft PTB ( 22) in total opioid consumption or duration of use. In comparing adolescent ( 31) versus adult ( 39), no significant difference was seen in total opioid consumption or duration of use. All patients were satisfied with the post-operative pain management protocol.
Opioid use was unexpectedly low among patients undergoing ACLR after a surgeon-administered circumferential genicular nerve block and fat pad infiltration. With this protocol, the graft choice and patient age did not correlate with increased opioid use. These results could be useful in guiding post-operative opioid prescribing after ACLR.
前交叉韧带重建（ACLR）后的疼痛管理可能存在长期使用阿片类药物的风险。
问题/目的：本研究在ACLR中的目的是调查外科医生实施的特定膝部神经局部区域阻滞对ACLR术后镇痛的疗效，并量化整个术后过程中的门诊阿片类药物消耗量和使用持续时间。
前瞻性地，对一位外科医生进行的所有初次ACLR患者进行了为期10个月的研究。排除标准包括术前使用阿片类药物史、翻修手术、多韧带手术、对口服阿片类药物过敏以及对局部麻醉药过敏。在全身麻醉下使用自体移植物或同种异体髌腱骨（PTB）移植物进行ACLR。手术结束时，所有患者均接受外科医生注射的局部麻醉药（0.25%布比卡因），包括基于解剖标志进行的独特的膝部神经和脂肪垫周围阻滞，无需图像引导。术后，前瞻性记录4个月内阿片类药物（氢可酮5毫克）的使用量和持续时间以及疼痛评分。进行统计分析以评估阿片类药物使用增加的风险因素。
一位外科医生进行了75例ACLR手术。排除后，共纳入70例患者并进行前瞻性随访。无一例失访。阿片类药物总消耗量为0至30片。术后4个月内阿片类药物的平均使用片数为5.5（±6.7）。术后，84%的患者服用0至10片，21%的患者在整个术后过程中未服用阿片类药物。平均使用持续时间为2.6天（±3.1）。在6周或4个月随访时，无患者服用阿片类药物。无需重新配药。在自体PTB移植物（48例）与同种异体PTB移植物（22例）的阿片类药物总消耗量或使用持续时间方面，未观察到统计学上的显著差异。在比较青少年（31例）与成人（39例）时，阿片类药物总消耗量或使用持续时间也未观察到显著差异。所有患者对术后疼痛管理方案均满意。
在外科医生实施膝部神经周围阻滞和脂肪垫浸润后，ACLR患者的阿片类药物使用量出人意料地低。采用该方案，移植物选择和患者年龄与阿片类药物使用增加无关。这些结果可能有助于指导ACLR术后的阿片类药物处方。
