Walczak Brian E, Bernardoni Eamon D, Steiner Quinn, Baer Geoffrey S, Donnelly Melanie J, Shepler John A
Department of Orthopedics and Rehabilitation, University of Wisconsin-Madison, Madison, Wisconsin.
Castle Orthopedics & Sports Medicine, Rush Copley Medical Center, Rush University Health, Aurora, Illinois.
JB JS Open Access. 2023 Mar 27;8(1). doi: 10.2106/JBJS.OA.22.00144. eCollection 2023 Jan-Mar.
Anterior cruciate ligament reconstruction with hamstring tendon autograft (H-ACLR) is a standard ambulatory procedure with the potential for considerable postoperative pain. We hypothesized that general anesthesia combined with a multimodal analgesia regimen would reduce postoperative opioid use associated with H-ACLR.
This study was a single-center, surgeon-stratified, double-blinded, placebo-controlled, randomized clinical trial. The primary end point was the total postoperative opioid use during the immediate postoperative period, and secondary outcomes included postoperative knee pain, adverse events, and ambulatory discharge efficiency.
One hundred and twelve subjects, 18 to 52 years of age, were randomized to placebo (57 subjects) or combination multimodal analgesia (MA) (55 subjects). The MA group required fewer opioids postoperatively (mean ± standard deviation, 9.81 ± 7.58 versus 13.88 ± 8.49 morphine milligram equivalents; p = 0.010; effect size = -0.51). Similarly, the MA group required fewer opioids within the first 24 hours postoperatively (mean ± standard deviation, 16.56 ± 10.77 versus 22.13 ± 10.66 morphine milligram equivalents; p = 0.008; effect size = -0.52). The subjects in the MA group reported lower posteromedial knee pain (median [interquartile range, IQR]: 3.0 [0.0 to 5.0] versus 4.0 [2.0 to 5.0]; p = 0.027) at 1 hour postoperatively. Nausea medication was required for 10.5% of the subjects receiving the placebo versus 14.5% of the subjects receiving MA (p = 0.577). Pruritis was reported for 17.5% of subjects receiving the placebo versus 14.5% receiving MA (p = 0.798). The median time to discharge was 177 minutes (IQR, 150.5 to 201.0 minutes) for subjects receiving placebo versus 188 minutes (IQR, 160.0 to 222.0 minutes) for those receiving MA (p = 0.271).
A combination of general anesthesia and local, regional, oral, and intravenous multimodal analgesia appears to reduce postoperative opioid requirements after H-ACLR compared with placebo. Adding preoperative patient education and focusing on donor-site analgesia may maximize perioperative outcomes.
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
自体腘绳肌腱前交叉韧带重建术（H-ACLR）是一种标准的门诊手术，术后有相当程度疼痛的可能性。我们假设全身麻醉联合多模式镇痛方案可减少H-ACLR术后的阿片类药物使用。
本研究为单中心、外科医生分层、双盲、安慰剂对照的随机临床试验。主要终点是术后即刻期间的术后阿片类药物总使用量，次要结局包括术后膝关节疼痛、不良事件和门诊出院效率。
112名年龄在18至52岁的受试者被随机分为安慰剂组（57名受试者）或联合多模式镇痛（MA）组（55名受试者）。MA组术后所需阿片类药物较少（均值±标准差，9.81±7.58对13.88±8.49吗啡毫克当量；p = 0.010；效应量 = -0.51）。同样，MA组术后24小时内所需阿片类药物也较少（均值±标准差，16.5,6±10.77对22.13±10.66吗啡毫克当量；p = 0.008；效应量 = -0.52）。MA组受试者术后1小时报告的膝后内侧疼痛较低（中位数[四分位间距，IQR]：3.0[0.0至5.0]对4.0[2.0至5.0]；p = 0.027）。接受安慰剂的受试者中有10.5%需要使用止吐药，而接受MA的受试者中有14.5%需要使用（p = 0.577）。接受安慰剂的受试者中有17.5%报告有瘙痒，而接受MA的受试者中有14.5%报告有瘙痒（p = 0.798）。接受安慰剂的受试者出院中位时间为177分钟（IQR，150.5至201.0分钟），而接受MA的受试者为188分钟（IQR，160.0至222.0分钟）（p = 0.271）。
与安慰剂相比，全身麻醉与局部、区域、口服和静脉多模式镇痛相结合似乎可减少H-ACLR术后的阿片类药物需求。增加术前患者教育并关注供区镇痛可能会使围手术期结局最大化。
治疗水平I。有关证据水平的完整描述，请参阅作者指南。
