L Baverel1, T Cucurulo2, C Lutz3, J Cournapeau4, F Dalmay5, N Lefevre6, R Letartre7, J-F Potel8, X Roussignol9, L Surdeau10, E Servien11. 1. Centre hospitalier universitaire, Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes, France. Electronic address: l.baverel@gmail.com. 2. Institut de Chirurgie Orthopédique et Sportive (ICOS 13), 463, rue Paradis, 13008 Marseille, France. 3. ICOSS, 50, avenue des Vosges, 67000 Strasbourg, France. 4. Centre hospitalier universitaire, Ambroise-Paré, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France. 5. Inserm 1094, UMR, NET, 2, rue du Docteur-Marcland, 87025 Limoges, France. 6. Institut de l'Appareil Locomoteur Nollet, 75017 Paris, France; Clinique du Sport Paris V, 75005 Paris, France. 7. Hôpital privé la Louvière, 122, rue de la Louvière, 59000 Lille, France. 8. Medipôle, 45, rue de Gironis, 31036 Toulouse, France. 9. Centre hospitalier universitaire, Ch.-Nicolle, 76031 Rouen, France. 10. Centre de Chirurgie Orthopédique et Sportive, 2, rue Negrevergne, 33700 Mérignac, France. 11. Hopital universitaire de la croix-rousse, Centre Albert-Trillat, 103, grande rue de la Croix-Rousse, 69004 Lyon, France.
Abstract
INTRODUCTION: More and more anterior cruciate ligament (ACL) reconstructions are being performed as outpatient surgery in France, because of economic considerations. Postoperative pain is the most common reason for delayed discharge that could require hospitalization, and the main reason for unanticipated hospital admission. The purpose of this study was to define the best anesthesia and analgesia methods for ACL reconstruction. MATERIALS AND METHODS: This was a prospective, multicenter, comparative study performed between January 2014 and April 2015. Inclusion criteria were ACL reconstruction in patients above 15 years of age performed as an outpatient surgical procedure. The anesthesia techniques analyzed were general anesthesia, spinal anesthesia and quadruple nerve blockade. The analgesic methods studied were single-shot nerve blocks, continuous nerve blocks, peri-articular and intra-articular local infiltration analgesia (LIA), non-steroidal anti-inflammatory agents (NSAIDs) and intravenous corticosteroids. The main outcome criterion was pain on a visual analog scale (VAS). The secondary outcome criteria were delayed discharge of a patient who had undergone outpatient surgery, consumption of opioids and complications for the various anesthesia techniques and analgesia methods. RESULTS: In all, 680 patients were included in this study, which was 63% of the ACL reconstruction procedures performed during this period. The study population was 69% male and 31% female, with an average age of 30 years. Twenty-three patients (3.4%) could not be discharged on the day of surgery. No correlation was found with the anesthesia technique used. NSAID treatment was protective relative to delayed discharge (P=0.009), while opioid consumption was a risk factor (P<0.01). There were no differences in the pain levels related to the type of anesthesia. Peri-articular LIA of the hamstring tendon harvest site was effective. Intra-articular LIA did not provide better analgesia. Continuous nerve block had complication rates above 13%. DISCUSSION: All types of anesthesia were compatible with outpatient ACL reconstruction. No gold standard analgesia method can be defined based on this study's findings. However, we recommend multimodal analgesia associating peri-articular LIA or one-shot sensory saphenous nerve block, NSAIDs and corticosteroid treatment, and cryotherapy. LEVEL OF EVIDENCE: II, prospective comparative non-randomized study.
INTRODUCTION: More and more anterior cruciate ligament (ACL) reconstructions are being performed as outpatient surgery in France, because of economic considerations. Postoperative pain is the most common reason for delayed discharge that could require hospitalization, and the main reason for unanticipated hospital admission. The purpose of this study was to define the best anesthesia and analgesia methods for ACL reconstruction. MATERIALS AND METHODS: This was a prospective, multicenter, comparative study performed between January 2014 and April 2015. Inclusion criteria were ACL reconstruction in patients above 15 years of age performed as an outpatient surgical procedure. The anesthesia techniques analyzed were general anesthesia, spinal anesthesia and quadruple nerve blockade. The analgesic methods studied were single-shot nerve blocks, continuous nerve blocks, peri-articular and intra-articular local infiltration analgesia (LIA), non-steroidal anti-inflammatory agents (NSAIDs) and intravenous corticosteroids. The main outcome criterion was pain on a visual analog scale (VAS). The secondary outcome criteria were delayed discharge of a patient who had undergone outpatient surgery, consumption of opioids and complications for the various anesthesia techniques and analgesia methods. RESULTS: In all, 680 patients were included in this study, which was 63% of the ACL reconstruction procedures performed during this period. The study population was 69% male and 31% female, with an average age of 30 years. Twenty-three patients (3.4%) could not be discharged on the day of surgery. No correlation was found with the anesthesia technique used. NSAID treatment was protective relative to delayed discharge (P=0.009), while opioid consumption was a risk factor (P<0.01). There were no differences in the pain levels related to the type of anesthesia. Peri-articular LIA of the hamstring tendon harvest site was effective. Intra-articular LIA did not provide better analgesia. Continuous nerve block had complication rates above 13%. DISCUSSION: All types of anesthesia were compatible with outpatient ACL reconstruction. No gold standard analgesia method can be defined based on this study's findings. However, we recommend multimodal analgesia associating peri-articular LIA or one-shot sensory saphenous nerve block, NSAIDs and corticosteroid treatment, and cryotherapy. LEVEL OF EVIDENCE: II, prospective comparative non-randomized study.