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Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part III: Local Instillation Analgesia—A Systematic Review and Meta-analysis

Yung, Eric M. BHSc, MD (Cand)*; Brull, Richard MD, FRCPC*,†; Albrecht, Eric MD, DESA, PD-MER; Joshi, Girish P. MBBS, MD, FFARCSI§; Abdallah, Faraj W. MD*,‖,¶

doi: 10.1213/ANE.0000000000002599
Ambulatory Anesthesiology and Perioperative Management

BACKGROUND: Local infiltration analgesia offers effective postoperative analgesia after knee arthroplasty, but the role of its counterpart, local instillation analgesia (LIA), in anterior cruciate ligament reconstruction (ACLR) is unclear. This systematic review and meta-analysis evaluates the analgesic benefits of LIA for outpatient ACLR.

METHODS: We sought randomized controlled trials investigating the analgesic effects of LIA versus control in adults having outpatient ACLR and receiving multimodal analgesia (excluding nerve blocks, which are examined in parts I and II of this project). Cumulative postoperative analgesic consumption at 24 hours was designated as a primary outcome. Analgesic consumption during postanesthesia care unit stay, proportion of patients requiring analgesic supplementation, time-to-first analgesic request, rest pain scores during the first 48 hours, hospital length of stay, and incidence of opioid-related side effects were analyzed as secondary outcomes and pooled using random effects modeling.

RESULTS: Eleven randomized controlled trials (515 patients) were included. Analgesic consumption was selected as the primary outcome in 4 trials (36%). Compared to control, LIA reduced the 24-hour morphine consumption by a weighted mean difference (95% confidence interval) of −18.0 mg (−33.4 to −2.6) (P = .02). LIA reduced postanesthesia care unit morphine consumption by −55.9 mg (−88.4 to −23.4) (P < .05) and decreased the odds (odds ratio [95% confidence interval]) of analgesic supplementation during the first 24 hours by 0.4 (0.2–0.8) (P = .004). LIA also improved pain scores during the 0–24-hour interval, most notably at 4 hours (−1.6 [−2.2 to −1.0) (P < .00001).

CONCLUSIONS: Administering LIA for outpatient ACLR improves postoperative analgesia by decreasing opioid consumption and improving pain control up to 24 hours, with minimal complications. These findings encourage integrating LIA into the care standard for ACLR. Questions regarding the ideal LIA components, location, and role in the setting of hamstring grafts require further research.

From the *Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada

Department of Anesthesia, Women’s College Hospital, Toronto, Ontario, Canada

Department of Anesthesia, Lausanne University Hospital, Lausanne, Switzerland

§Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas

Department of Anesthesia and Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada

Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada.

Published ahead of print 21 September 2017.

Accepted for publication September 21, 2017.

Funding: This work was supported by departmental funding. Both Drs R.B. and F.W.A. are supported by the Merit Award Program, Department of Anesthesia, University of Toronto.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Faraj W. Abdallah, MD, Department of Anesthesia, St Michael’s Hospital, 30 Bond St, Toronto, Ontario, M5B 1W8, Canada. Address e-mail to

Copyright © 2017 International Anesthesia Research Society
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