Effect of IPACK-Adductor Canal Block Combination on Adolescent Pain Management After Hamstring Autograft Anterior Cruciate Ligament Reconstruction.

BACKGROUND

There is no pain management standard for anterior cruciate ligament reconstruction (ACLR) or one that addresses posterior capsule pain from hamstring autograft collection. IPACK (Infiltration of local anesthetic between the Popliteal Artery and Capsule of the Knee) is a novel peripheral nerve block designed as an analgesic for the posterior capsule. IPACK use has been beneficial in decreasing reported pain and medications needed for adult total knee arthroplasty; thus, it may be helpful for ACLR.

HYPOTHESIS

We hypothesized that adding IPACK to the adductor canal block (ACB) would decrease pain levels and opioids provided for adolescents who undergo ACLR with hamstring autografts as compared with local infiltration analgesia (LIA) or ACB only.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective chart review was conducted for 153 adolescent patients, aged 10 to 18 years, who underwent ACLR with hamstring autografts at a single hospital over 17 months. The type of regional block was determined by the surgeon's preference, and patients received LIA only, ACB only, or IPACK + ACB. They were compared across these groups to identify the efficacy of each analgesic.

RESULTS

Patients across the entire cohort received a mean of 31.6 ± 12.9 morphine milligram equivalents (MME); the MME did not differ significantly based on regional blocks of LIA only, ACB only, and IPACK + ACB ( = .234). Pain levels in the postanesthesia care unit (PACU) were not significantly different from the first ( = .293), last ( = .845), highest ( = .816), or lowest ( = .235) pain scores. Patients who received both opioids and non-steroidal anti-inflammatory drugs (NSAIDs) received more MME than patients who only received opioids (10.7 ± 7.1 vs 7.8 ± 4) ( = .003) in the PACU but received similar MME overall ( = .38). In the PACU, patients who received opioids + NSAIDs had a higher highest pain score than those who received opioids only (7 ± 2.1 vs 5.5 ± 2.4) ( < .001).

CONCLUSION

Overall, the amount of MME used at this institution was relatively low; however, the use of IPACK + ACB did not decrease opioid usage or pain levels after ACLR as compared with LIA or ACB only for the adolescent population. Use of any regional block was not superior to LIA for MME or reported pain levels. Given that IPACK + ACB did not decrease MME, it is not recommended to add an IPACK block for ACLR in adolescent patients.