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Ambulatory Anesthesiology

Pain Management for Ambulatory Arthroscopic Anterior Cruciate Ligament Reconstruction: Evidence-Based Recommendations From the Society for Ambulatory Anesthesia

Abdallah, Faraj W. MD*,†; Brull, Richard MD, FRCPC; Joshi, Girish P. MBBS, MD, FFARCSI§; on behalf of the Society for Ambulatory Anesthesia (SAMBA)

Author Information
doi: 10.1213/ANE.0000000000003976
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Abstract

The anterior cruciate ligament is the most commonly injured ligament of the knee.1,2 Anterior cruciate ligament reconstruction is performed primarily on an ambulatory basis.3,4 The advances in surgical techniques, anesthesia, and rehabilitation achieved in recent years have allowed a faster return of activity of daily living after anterior cruciate ligament reconstruction.5 However, inadequate postoperative analgesia can delay discharge home, increase unplanned admission and readmission after discharge, delay functional recovery, and reduce patient satisfaction.5,6

It is well recognized that regional analgesia techniques should be an integral component of an optimal multimodal analgesic regimen.7 For anterior cruciate ligament reconstruction in specific, nonopioid analgesics that are commonly prescribed after discharge from an ambulatory surgical center are necessary but may not be sufficient to provide adequate analgesia.5,6 The possible and commonly used options for regional analgesia in patients undergoing anterior cruciate ligament reconstruction include femoral nerve block, adductor canal block, and local instillation analgesia.8 However, the best choice of regional analgesia remains controversial. Because of the inconsistent use of multimodal analgesia in studies examining nerve blocks, it is not clear which regional analgesia modality would provide a balance between analgesic efficacy and associated potential risks in the setting of nonopioid analgesic strategies (eg, acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs], and cyclooxygenase-2–specific inhibitors).9,10 Other components of multimodal analgesia, such as antidepressants, anticonvulsants, and ketamine, may also be useful, but their undesirable side effects (eg, sedation and hallucination) preclude their broad use in the ambulatory settings.

The purpose of this review is to identify the optimal regional analgesic technique in patients undergoing arthroscopic anterior cruciate ligament reconstruction on an ambulatory basis using published systematic reviews.11–13 The clinical recommendations based on this work have been endorsed by the Society of Ambulatory Anesthesia and approved by its board of directors.

METHODS

We assessed the analgesic efficacy and potential adverse effects of the addition of the 3 modalities of interest, namely femoral nerve block, adductor canal block, and local instillation analgesia, to the standard of care multimodal analgesia in patients having ambulatory arthroscopic anterior cruciate ligament reconstruction. For the sake of this endeavor, we defined the standard of care as multimodal analgesia inclusive of ≥2 nonopioid analgesics (eg, acetaminophen and NSAID or cyclooxygenase-2 specific inhibitor), excluding regional analgesia interventions.9

The clinical questions to be addressed in this document included the following:

  • Does adding femoral nerve block to multimodal nonopioid oral analgesia improve pain control after ambulatory arthroscopic anterior cruciate ligament reconstruction?11
  • Does adding adductor canal block (both midthigh and the distal-thigh injection sites) to multimodal nonopioid oral analgesia improve pain control after ambulatory arthroscopic anterior cruciate ligament reconstruction?12
  • Does adding local instillation analgesia to multimodal nonopioid oral analgesia improve pain control after ambulatory arthroscopic anterior cruciate ligament reconstruction?13

For details of the evidence used to address the above questions, please refer to the published studies.11–13 Briefly, the literature search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines14 using the Cochrane CENTRAL Register of Controlled Trials (second quarter 2017), Cochrane Database of Systematic Reviews (2005 to April 2017), MEDLINE (R) (1948 to April 2017), and EMBASE (1980 to April 2017). A reference librarian familiar with literature search protocol of the Cochrane Collaboration conducted the electronic search strategy with input from members of the consensus panel. The key words used for the literature search included “ambulatory surgery,” “ambulatory anesthesia,” combined using the Boolean operator “AND” with search terms relating to anterior cruciate ligament reconstruction, including “anterior cruciate,” “anterior cruciform,” “expanded terms for knee,” “knee injuries,” “knee joint and reconstructive surgical procedures,” “arthroscopy,” “arthroscopes,” and various terms related to grafts used in anterior cruciate ligament reconstruction; AND “acute pain,” “postoperative pain,” “post-surgery pain,” “analgesia,” “pain management,” “pain relief,” “pain control”; AND “regional anesthesia,” “nerve block,” “femoral nerve,” “3-in-1 block”; OR “ACB,” “saphenous nerve block,” “infrapatellar block”; OR “local infiltration,” “instillation analgesia,” “local anesthesia,” “local anesthetics.” We also hand-searched reference lists from the retrieved articles to identify further trials. The search was limited to English language and human trials in adults. Finally, duplicate records were deleted.

Only randomized controlled trials comparing the regional anesthesia interventions of interest to control (no block) in the setting of multimodal analgesia and reporting analgesic outcomes were considered. Randomized controlled trials were not considered if multimodal analgesia was not used in all study arms. Eligibility was restricted to arthroscopic anterior cruciate ligament reconstruction performed on ambulatory basis. Identification of eligible studies, rating methodological quality, data extraction, and data entry for each of the modalities were done by 2 authors (F.W.A., G.P.J.); discrepancies were resolved by consulting with a third author (R.B.), as described in parts I, II, and III of this project.11–13 The risk of bias was assessed using the Cochrane Collaboration’s tool for assessing risk of bias.15

The common outcomes considered for evaluating the 3 analgesic modalities of interest included oral morphine equivalent analgesic consumption between 0–24 and 24–48 hours; resting pain severity scores at 0, 6, 12, 24, and 48 hours postoperatively; time to first analgesic request; postanesthesia care unit time (hours); hospital discharge time; risk of postoperative nausea and vomiting; patient satisfaction; risk of persistent quadriceps weakness; and occurrence of intervention-related complications.

The quantitative analysis for the outcomes of interest was performed using random-effects modeling, as described in the respective articles examining the 3 interventions.11–13 For this purpose, we used the Review Manager statistical package (RevMan Version 5.3; The Nordic Cochrane Centre, The Cochrane Collaboration, 2014, Copenhagen, Denmark). For continuous outcomes, we estimated the weighted mean difference and 95% CI. For dichotomous outcomes, we estimated the odds ratio and 95% CI. Results reported in any other format in parts I, II, and III were converted to weighted mean difference and odds ratio. Differences were considered statistically significant if P value was <0.05, and the 95% CI did not include 0 for the weighted mean difference or 1 for the odds ratio. The heterogeneity of results was quantified using the I2 statistic; values of 50% were considered indicative of significant heterogeneity. When possible, we used subgroup analysis and/or meta-regression analysis to explore the sources of heterogeneity using preidentified covariates. The results for outcomes examined are presented in the summary of findings table (Table 1). In this table, and unlike the earlier parts of this project, in which we pooled data only if available for ≥3 studies,11–13 we did not impose any restrictions based on the number of trials available for a certain outcome. When possible, heterogeneity of results was explored using meta-regression analysis to identify the associations between outcomes and potential predictors that were predesignated in the respective articles. Presenting the results for each of the examined outcomes across the 3 modalities in Table 1 is meant to: (1) ensure the quality of the evidence reviewed; (2) ensure the certainty of having a favorable risk/benefit ratio; and (3) allow comparing values between the 3 modalities.

Table 1.
Table 1.:
Summary of Findings and Grading of Evidence for Outcomes of Interest

The strength of evidence for the 3 analgesic modalities that were pooled from the included trials was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation guidelines.16 These guidelines classify the strength of evidence according to methodological quality, consistency, directness, precision, and publication bias. For each of these, the grade of evidence may be increased or decreased by 1 or 2 points based on strengths or weaknesses.17 According to the Grades of Recommendation, Assessment, Development, and Evaluation guidelines and reporting format, evidence strength may be rated as: (1) high quality (⊕⊕⊕⊕), meaning that further research is very unlikely to change the confidence in the estimate of effect; (2) moderate quality (⊕⊕⊕⊝), meaning that further research is likely to have an important impact on the confidence in the estimate of effect and may change the estimate; (3) low quality (⊕⊕⊝⊝), meaning that further research is very likely to have an important impact on the confidence in the estimate of effect and is likely to change the estimate; and (4) very low quality (⊕⊝⊝⊝), meaning that we are very uncertain about the estimate. The strength of evidence of the outcomes examined for the 3 analgesic modalities is presented in Table 1.

Table 2.
Table 2.:
Recommendations for Use of Regional Anesthesia in Patients Having Ambulatory Anterior Cruciate Ligament Reconstruction With Multimodal Analgesia

Subsequently, a set of clinical recommendations was generated based on the evidence as well as the application of general principles of safe perioperative care. The benefits and risks of interventions and clinical practice information were taken into account to ensure that the recommendations preserved patient safety, clinical validity, and usefulness. We used the Grades of Recommendation, Assessment, Development, and Evaluation system for grading the recommendations18 for the outcomes that were commonly examined across all 3 analgesic interventions. The strength of recommendations was graded either as “strong” or “weak.” The determinants of strength of recommendations included balance between desirable and undesirable effects, quality of evidence, values and preferences, and costs (resource allocation). As such, a strong recommendation was more likely to be offered when: (1) the desirable effects of an intervention clearly outweighed the undesirable effects; (2) the quality of supporting evidence was high; (3) there was certainty in the values and preferences of the stakeholders; and (4) the impact on resources was limited. Conversely, a weak recommendation was more likely to be offered when the overall effects were less certain because: (1) the evidence suggested that desirable and undesirable effects were closely balanced; (2) the evidence was of low quality; (3) there was little certainty about the values and preferences of stakeholders; and (4) the cost of the intervention was high. The categories of evidence were based on the level of evidence and agreement between the members of the consensus panel. These resultant recommendations are presented in Table 2.

RESULTS

The literature search yielded a total of 19 randomized controlled trials that met the inclusion criteria for the 3 comparisons examined. These were divided into 3 subgroups of comparisons that included 5 for the femoral nerve block versus control (645 patients),19–23 3 for the adductor canal block versus control (135 patients),24–26 and 11 in the local instillation analgesia versus control (972 patients).27–37 The details of the flow of the studies, Preferred Reporting Items for Systematic reviews and Meta-Analyses diagrams, rating of the risk of bias, and characteristics of the included studies are presented in the respective articles.11–13

Outcomes Examined

The results for the outcomes examined are presented in Table 1. Briefly, femoral nerve block reduced postoperative opioid consumption at 24 hours, and pain scores up to 12 hours, compared to control; but there were no further benefits in any of the other outcomes examined. In contrast, we could not detect any benefit at all when adductor canal block was compared to control. Finally, local instillation analgesia reduced postoperative opioid consumption at 24 hours, and pain scores up to 24 hours, compared to control, but there were no further benefits in any of the other outcomes examined. The pooled data from the control groups across 3 comparisons examined showed that this group consumed a weighted mean of 87.7 mg oral morphine equivalents during the first 24 hours postoperatively. Patients in the control groups also experienced moderate rest pain (ie, numerical rating scale scores >3.0 units) at both 12 hours (weighted mean of 3.8 numerical rating scale units) and 24 hours (weighted mean of 3.1 numerical rating scale units), postoperatively.

Quality Assessment

Limitations.

The overall methodological quality was good across all the trials examined. Most of the trials had low risk for selection, attrition, and reporting biases. The only exceptions were noted in the femoral nerve block subgroup of trials, in which there were concerns regarding potential patient unblinding due to use of nerve stimulation for guidance, leading to potential performance and detection biases. Consequently, we reduced the score by 1 point for all of the femoral nerve block subgroup trials.

Consistency.

The characteristics of the population examined, definitions of outcomes of interest, and the direction of the treatment effect were consistent across studies for all study subgroups. However, there were some inconsistencies in the technical details of the regional technique used (eg, doses, local anesthetic duration of action, localization techniques), as well as the surgical technique performed (eg, type of graft used). In addition, while local anesthetic dose used in local instillation analgesia was associated with the primary outcome,13 there was some residual heterogeneity that was not explained by meta-regression or resolved by subgroup analysis. Consequently, we reduced the score by 1 point for most of the outcomes examined. An additional point was deducted for opioid consumption at 24 hours in the adductor canal block subgroup because of inconsistency of the direction of the treatment effect.

Directness.

All of the trials reviewed examined the regional anesthesia modalities of interest; no trials examined any cointerventions concomitantly. Outcomes like opioid consumption and pain scores were explicitly reported at the exact time points of interest. The only concerns were in the adductor canal block group, for which assumptions were made regarding the risk of postoperative nausea and vomiting (reported as antiemetic consumption) and patient satisfaction (reported as percentage of patients). In that case, we reduced the score by 1 point.

Precision.

No serious imprecisions were noted in any of the trial subgroups. Most of the findings were characterized by relatively narrow CIs, and the sample sizes of the included randomized controlled trials exceeded 50 patients for the majority of studies. The outcomes of interest were common in the control group, and the results of this group resembled what is prevalent for this specific surgical procedure, reflecting reasonable precision.8 The outcomes of interest were not sparse, but the number of source trials for some of the outcomes in the femoral nerve block and adductor canal block subgroups was limited to 1 or 2 studies. In that case, we reduced the score by 1 point.

Publication Bias.

Visual inspection of respective funnel plots in addition to calculating the P value for the Egger test (for local instillation analgesia) did not suggest publication bias in any of randomized controlled trial subgroups.

Strength of Evidence

The strength of evidence for the outcomes commonly examined in the 3 groups of randomized controlled trials included in this review is presented in Tables 1 and 2. Briefly, femoral nerve block was rated to have weak evidence for the majority of outcomes commonly examined, except for rest pain at 6 hours (very weak evidence). Similarly, adductor canal block was rated to have weak evidence for the majority of outcomes commonly examined, except for 0- to 24-hour opioid consumption and the risk of postoperative nausea and vomiting (very weak evidence). Finally, local instillation analgesia was rated to have moderate for all the outcomes commonly examined.

Strength of Recommendations

The strength of recommendation regarding the use of the examined regional anesthesia techniques in ambulatory arthroscopic anterior cruciate ligament reconstruction varied based on several factors, as summarized below (Table 2).

For femoral nerve block, the strength of evidence of benefit was weak; despite the potential analgesic advantages, there are recent concerns about persistent weakness38 as well as the risk of falls caused by transient quadriceps muscle weakness in outpatients having anterior cruciate ligament reconstruction.39 In contrast, the impact on resources was thought to be modest, and the intervention was acceptable by most stakeholders. Of note, there was lack of evidence of benefit to femoral nerve block when used in the setting of local instillation analgesia.11 Consequently, the strength of recommendation for femoral nerve block was considered weak.

For adductor canal block, the strength of evidence of benefit was weak; the trials reviewed did not capture any analgesic benefits. While there were no concerns about harm, the impact on resources was thought to be modest, and the intervention was acceptable by most stakeholders. Consequently, the strength of recommendations for adductor canal block was considered weak.

For local instillation analgesia, the strength of evidence of benefit was moderate, and the potential analgesic advantages were robust. In addition, there were no concerns about harm, and the impact on resources was minimal. Local instillation analgesia was also acceptable by all stakeholders. Consequently, the strength of recommendations for local instillation analgesia was considered strong.

Recommendations for Best Practice

As a result of the assessments summarized above, local instillation analgesia would enhance pain control in the first postoperative 24 hours in patients having outpatient arthroscopic anterior cruciate ligament reconstruction with multimodal analgesia (moderate level of evidence). Furthermore, in the absence of local instillation analgesia, adductor canal block or femoral nerve block might be used to enhance pain control in the first postoperative 24 hours in patients having outpatient arthroscopic anterior cruciate ligament reconstruction with multimodal analgesia (weak level of evidence).

There appears no incremental analgesic benefit to support the addition of femoral nerve block to local instillation analgesia in the setting of multimodal analgesia.11 The benefits of adding adductor canal block to local instillation analgesia cannot be ascertained due to the lack of data, but adductor canal block may not be different from femoral nerve block in providing pain control after anterior cruciate ligament reconstruction.11 Finally, the use of continuous femoral nerve block is still not supported by sufficient data. We present these additional findings herein merely to inform researchers and practitioners, and not to guide practice.

DISCUSSION

The underling evidence generated by the accompanying systematic reviews and meta-analyses have resulted in evidence-based clinical recommendations for enhancing analgesia in the first 24 hours postoperatively in patients having ambulatory arthroscopic anterior cruciate ligament reconstruction with multimodal analgesia. Based on moderate-level evidence and according to the Grades of Recommendation, Assessment, Development, and Evaluation approach, we strongly recommend local instillation analgesia (intraarticular instillation of local anesthetic). Contrastingly, based on weak-level evidence, we weakly recommend using femoral nerve block or adductor canal block in the absence of local instillation analgesia. These recommendations seem to reflect the varying efficacy of these modalities in treating the different sources of pain after anterior cruciate ligament reconstruction, and underscore the presence of an important component of postoperative pain that does not originate from the anterior knee.40 To that end, our findings signal that, unlike oral/systemic multimodal analgesia, local instillation analgesia treats pain from all sources. Interventions (eg, femoral nerve block and adductor canal block) that exclusively treat pain originating from the anterior knee may not be sufficient to guarantee adequate analgesia after anterior cruciate ligament reconstruction. This also emphasizes the importance of matching the choice analgesic technique with the specific type of surgery performed and the nature of graft used.10

It is noteworthy that these recommendations are based on the premise that patients undergoing anterior cruciate ligament reconstruction will routinely receive multimodal analgesia inclusive of nonopioid analgesics, regardless of the regional anesthesia modality administered. This includes several analgesics that have been shown to possess analgesic and opioid-sparing effects after anterior cruciate ligament reconstruction, including acetaminophen,41 NSAIDs,42,43 cyclooxygenase-2 specific inhibitors,44,45 dexamethasone,46 and even cryotherapy.47,48

NOVELTY

This is the first set of evidence-based recommendations addressing the use of regional analgesia in the anterior cruciate ligament reconstruction patient population for whom clinical practice has continued to rely on practitioners’ interpretation of conflicting and generally weak evidence. Actually, the most authoritative existing recommendations on this topic are based on 2 recent qualitative reviews.8,49 In contrast to the current recommendations, both reviews unconditionally promoted single-injection nerve blocks (femoral nerve block 8,49 and adductor canal block49) for pain management after anterior cruciate ligament reconstruction. This primarily reflects the intrinsic limitations of the qualitative design (eg, no data pooling and not accounting for bias) as well as failure to identify and isolate the analgesic effect of concomitant local instillation analgesia. A third previous review had signaled the limited role of femoral nerve block in anterior cruciate ligament reconstruction44; interestingly, local instillation analgesia was incorporated into multimodal analgesia in several of the trials included, yielding a conclusion similar to the observed in part I of this series,11 namely that adding femoral nerve block to local instillation analgesia does not enhance pain control.

IMPACT

Strategies that optimize pain control while limiting opioid requirements is specifically meaningful in the setting of an outpatient procedure that is moderately painful such as anterior cruciate ligament reconstruction.50 The control groups in meta-analyses that did not receive the analgesic intervention of interest have recently been proposed to inform pain severity.51 Our examination of the control group indicated that patients who did not receive any of the interventions examined consumed higher amounts of oral morphine and experienced moderate pain during the first 24 hours after anterior cruciate ligament reconstruction, despite receiving nonopioid analgesics. Consequently, regional analgesic interventions that enhance pain control, limit opioid use, and supplement nonopioids analgesia are clearly a priority in this population. While the Society of Ambulatory Anesthesia mandate focuses on the ambulatory population, these conclusions are likely generalizable to inpatients.

LIMITATIONS OF THE CURRENT LITERATURE

This work is characterized by some limitations. First and foremost, our recommendations reflect the current status of evidence; they are subject to update if/when further relevant evidence becomes available. Our recommendations are also confined to ambulatory arthroscopic anterior cruciate ligament reconstruction performed in the setting of nonopioid multimodal analgesia; we did not question the clinical meaningfulness of using of nonopioid analgesics, which may not reflect the standard of care in all centers. This choice reflects the World Health Organization “analgesic ladder” concept for pain management.45 Indeed, even the studies included in this review displayed some variations (eg, dose and time of administration) in the multimodal analgesic regimens used. Our analysis had limited ability to adjust findings according to the type of graft used because the majority of trials reviewed used a mixture of graft types. In addition, we could not comment on several important outcomes that were infrequently assessed in the source trials, such as impact on motor power, risk of persistent quadriceps weakness,38,52 long-term opioid consumption, functional recovery, and time-to-return to sport. While dynamic pain was not measured in most trials, the value of this outcome is undermined by common clinical practices, including discharging ambulatory anterior cruciate ligament reconstruction patients with knee immobilizers and instructions to avoid early weight bearing. Furthermore, the scope of this consensus statement is limited to the analgesic modalities examined (femoral nerve block, adductor canal block, and local instillation analgesia); it is important to acknowledge that there are several other relevant modalities that have been identified and which are supported by some preliminary evidence. However, the existing evidence is still sparse and too heterogeneous to permit conceiving any evidence-based recommendations. These modalities include periarticular infiltration,34 graft donor site block,53 infiltration with liposomal bupivacaine,54 sciatic nerve block,55 and obturator nerve block.56 Similarly, the potential role of local anesthetic infusions, whether with nerve blocks or local instillation analgesia, was not examined because of limited available evidence, as well as persistent concerns about chondrolysis.8 While contemporary evidence favors local instillation analgesia, an intervention generally delivered by surgeons, anesthesiologists are well positioned to perform ultrasound-guided local anesthetic infiltration techniques for knee surgery.57 Finally, the limitations of the individual reviews used to generate this consensus statement should also be considered.11–13

CONCLUSIONS

Based on the currently available evidence, we recommend the use of local instillation analgesia with nonopioid multimodal analgesia for pain control after outpatient arthroscopic anterior cruciate ligament reconstruction (strong recommendation, moderate level of evidence). In the absence of local instillation analgesia, femoral nerve block or adductor canal block might be used for pain control (weak recommendation, weak level of evidence). Future adequately powered and well-designed prospective studies examining all modalities are needed because evidence continues to be limited. These studies should examine patient-based functional outcomes and identify the role of type of graft used. Finally, assessing the impact of the recommendations generated by this consensus statement on patient outcome should be a priority.

DISCLOSURES

Name: Faraj W. Abdallah, MD.

Contribution: This author helped design and conduct the study, collect and analyze the data, and prepare the final manuscript.

Conflicts of Interest: F. W. Abdallah receives research time support from the Department of Anesthesiology and the Ottawa Hospital Research Institute, University of Ottawa, ON, Canada.

Name: Richard Brull, MD, FRCPC.

Contribution: This author helped conduct the study and prepare the final manuscript.

Conflicts of Interest: None.

Name: Girish P. Joshi, MBBS, MD, FFARCSI.

Contribution: This author helped design and conduct the study and prepare the final manuscript.

Conflicts of Interest: G. P. Joshi receives honoraria from Pacira Pharmaceuticals, Baxter Pharmaceuticals, Mallinckrodt Pharmaceuticals, and Merck Pharmaceuticals.

This manuscript was handled by: Tong J. Gan, MD.

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