Mitchell Brendon C, Siow Matthew Y, Pennock Andrew T, Edmonds Eric W, Bastrom Tracey P, Chambers Henry G
Department of Orthopaedic Surgery, University of California, San Diego, San Diego, California, USA.
Division of Orthopaedic Surgery, Rady Children's Hospital, San Diego, California, USA.
Orthop J Sports Med. 2021 Mar 5;9(3):2325967120985902. doi: 10.1177/2325967120985902. eCollection 2021 Mar.
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.
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.
Cohort study; Level of evidence, 3.
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.
Opioid use was 24.3 MMEs in patients treated with intra-articular injection versus 28.5 MMEs in those with peripheral block ( = .108). Consumption of MMEs was greater in the intra-articular group in the 0- to 4-hour period (7.1 vs 4.6 MMEs; = .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; = .01) and 20 to 24 hours (3.8 vs 6.5 MMEs; < .001). Mean pain scores were not significantly different over the 24-hour period (peripheral block, 2.7; intra-articular injection, 3.0; = .19).
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.
阿片类药物的使用量以及患者满意度受到外科医生的疼痛管理方案以及辅助性疼痛介质使用情况的影响。两种常用于前交叉韧带（ACL）重建的辅助性疼痛调节剂是股神经阻滞和关节内注射；然而，关于哪种方法更有效仍存在争议。
我们假设在骨 - 髌腱 - 骨（BTB）ACL重建术后的头24小时内，关节内注射罗哌卡因和吗啡在术后疼痛管理方面与股神经阻滞同样有效。
队列研究；证据等级，3级。
回顾性分析了一位小儿骨科医生在2013年至2019年期间进行的BTB ACL重建手术的病历。总共确定了116例患者：58例接受关节内注射，58例接受单次股神经阻滞。所有患者均住院24小时。每4小时评估一次疼痛评分。记录每位患者消耗的吗啡毫克当量（MME）。
关节内注射治疗的患者阿片类药物使用量为24.3 MME，而接受外周阻滞的患者为28.5 MME（P = 0.108）。在0至4小时期间，关节内注射组的MME消耗量更大（7.1对4.6 MME；P = 0.008）。在16至20小时（3.2对5.6 MME；P = 0.01）和20至24小时（3.8对6.5 MME；P < 0.001），接受关节内注射的患者MME消耗量明显低于接受外周阻滞的患者。在24小时内平均疼痛评分无显著差异（外周阻滞，2.7；关节内注射，3.0；P = 0.19）。
在本研究的局限性范围内，我们发现在术后头24小时内，单次股神经阻滞组和关节内注射组的MME消耗量无显著差异。虽然外周阻滞在术后头4小时与较低的阿片类药物消耗量相关，但接受关节内阻滞的患者在术后16至24小时需要的阿片类药物较少。鉴于这些发现，我们建议关节内注射是接受BTB ACL重建的青少年患者镇痛的一种可行替代方法。
