Skip to main content

Reduced Opioid Use After Surgeon-Administered Genicular Nerve Block for Anterior Cruciate Ligament Reconstruction in Adults and Adolescents

HSS Journal ® volume 15, pages 42–50 (2019)Cite this article

Abstract

Background

Pain management after anterior cruciate ligament reconstruction (ACLR) may pose a risk of prolonged opioid use.

Questions/Purposes

The purposes of this study in ACLR were to investigate the efficacy of a surgeon-administered local–regional block of specific genicular nerves on post-operative analgesia following ACLR and to quantify the outpatient opioid consumption and duration through the complete post-operative course.

Methods

Prospectively, all patients undergoing primary ACLR by a single surgeon were studied over a 10-month period. Exclusion criteria consisted of history of pre-operative opioid use, revision surgery, multi-ligament surgery, allergy to oral opioids, and allergy to local anesthetic. ACLR was performed using autograft or allograft patellar tendon bone (PTB) graft under general anesthesia. At the conclusion of the procedure, all patients received a local anesthetic (bupivacaine 0.25%) injection by the surgeon including a unique circumferential genicular nerve and fat pad block performed based on anatomic landmarks without use of image guidance. Post-operatively, the quantity and duration of opioid use (hydrocodone 5 mg) and pain scores were recorded for 4 months prospectively. Statistical analysis was performed to evaluate risk factors for increased opioid use.

Results

A single surgeon performed 75 ACLRs. After exclusions, a total of 70 patients were enrolled and followed prospectively. None were lost to follow-up. Total opioid consumption ranged from 0 to 30 tablets. The average number of opioid tablets used over the 4-month post-operative course was 5.5 (± 6.7). After surgery, 84% of patients took between 0 and 10 tablets and 21% of patients took no opioids throughout their entire post-operative course. The average duration of consumption was 2.6 days (± 3.1). No patients were taking opioids at the 6-week or 4-month follow-up. There were no refills required. No statistically significant differences were seen in regard to graft choice of autograft PTB (n = 48) vs allograft PTB (n = 22) in total opioid consumption or duration of use. In comparing adolescent (n = 31) versus adult (n = 39), no significant difference was seen in total opioid consumption or duration of use. All patients were satisfied with the post-operative pain management protocol.

Conclusion

Opioid use was unexpectedly low among patients undergoing ACLR after a surgeon-administered circumferential genicular nerve block and fat pad infiltration. With this protocol, the graft choice and patient age did not correlate with increased opioid use. These results could be useful in guiding post-operative opioid prescribing after ACLR.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. Abdallah FW, Whelan DB, Chan VW, et al. Adductor canal block provides noninferior analgesia and superior quadriceps strength compared with femoral nerve block in anterior cruciate ligament reconstruction. Anesthesiology. 2016;124(5):1053–1064.

    Article  PubMed  CAS  Google Scholar 

  2. Anthony CA, Westermann RW, Bedard N, et al. Opioid demand before and after anterior cruciate ligament reconstruction. Am J Sports Med. 2017;45(13):3098–3103.

    Article  PubMed  Google Scholar 

  3. Atkinson HD, Hamid I, Gupte CM, Russell RC, Handy JM. Post-operative fall after the use of the 3-in-1 femoral nerve block for knee surgery: a report of four cases. J Orthop Surg (Hong Kong). 2008;16(3):381–384.

    Article  CAS  Google Scholar 

  4. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Buller LT, Best MJ, Baraga MG, Kaplan LD. Trends in anterior cruciate ligament reconstruction in the United States. Orthop J Sports Med. 2015;3(1):2325967114563664.

    Article  PubMed  Google Scholar 

  6. Casati A, Baciarello M, Di Cianni S, et al. Effects of ultrasound guidance on the minimum effective anaesthetic volume required to block the femoral nerve. Br J Anaesth. 2007;98(6):823–827.

    Article  PubMed  CAS  Google Scholar 

  7. Dautremont EA, Ebramzadeh E, Beck JJ, Bowen RE, Sangiorgio SN. Opioid prescription and usage in adolescents undergoing orthopaedic surgery in the United States: a systematic review. JBJS Rev. 2017;5(8):e5.

    Article  PubMed  Google Scholar 

  8. Dowell D, Haegerich TM. Using the CDC guideline and tools for opioid prescribing in patients with chronic pain. Am Fam Physician. 2016;93(12):970–972.

    PubMed  PubMed Central  Google Scholar 

  9. Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med. 1998;26(6):773–777.

    Article  PubMed  CAS  Google Scholar 

  10. Franco CD, Buvanendran A, Petersohn JD, Menzies RD, Menzies LP. Innervation of the anterior capsule of the human knee: implications for radiofrequency ablation. Reg Anesth Pain Med. 2015;40(4):363–368.

    Article  PubMed  Google Scholar 

  11. Frieden TR, Houry D. Reducing the risks of relief—the CDC opioid-prescribing guideline. N Engl J Med. 2016;374(16):1501–1504.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Frost S, Grossfeld S, Kirkley A, Litchfield B, Fowler P, Amendola A. The efficacy of femoral nerve block in pain reduction for outpatient hamstring anterior cruciate ligament reconstruction: a double-blind, prospective, randomized trial. Arthroscopy. 2000;16(3):243–248.

    Article  PubMed  CAS  Google Scholar 

  13. Herkowitz HN, Dirschl DR, Sohn DH. Pain management: the orthopaedic surgeon’s perspective. J Bone Joint Surg Am. 2007;89(11):2532–2535.

    PubMed  Google Scholar 

  14. Hirasawa Y, Okajima S, Ohta M, Tokioka T. Nerve distribution to the human knee joint: anatomical and immunohistochemical study. Int Orthop. 2000;24(1):1–4.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  15. Horner G, Dellon AL. Innervation of the human knee joint and implications for surgery. Clin Orthop Relat Res. 1994(301):221–226.

    Google Scholar 

  16. Howell R, Hill B, Hoffman C, Treacy E, Mulcahey MK. Peripheral nerve blocks for surgery about the knee. JBJS Rev. 2016;4(12).

  17. Joseph M, Fulkerson J, Nissen C, Sheehan TJ. Short-term recovery after anterior cruciate ligament reconstruction: a prospective comparison of three autografts. Orthopedics. 2006;29(3):243–248.

    Article  PubMed  Google Scholar 

  18. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med. 1982;10(6):329–335.

    Article  PubMed  CAS  Google Scholar 

  19. Kesikburun S, Yaşar E, Uran A, Adigüzel E, Yilmaz B. Ultrasound-guided genicular nerve pulsed radiofrequency treatment for painful knee osteoarthritis: a preliminary report. Pain Physician. 2016;19(5):E751–E759.

    PubMed  Google Scholar 

  20. Kwofie MK, Shastri UD, Gadsden JC, et al. The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med. 2013;38(4):321–325.

    Article  PubMed  Google Scholar 

  21. Labrum JT, Ilyas AM. The opioid epidemic: post-operative pain management strategies in orthopaedics. JBJS Rev. 2017;5(8):e14.

    Article  PubMed  Google Scholar 

  22. Lovecchio F, Derman P, Stepan J, et al. Support for safer opioid prescribing practices: a catalog of published use after orthopaedic surgery. J Bone Joint Surg Am. 2017;99(22):1945–1955.

    Article  PubMed  Google Scholar 

  23. Lubowitz JH, Schwartzberg R, Smith P. Randomized controlled trial comparing all-inside anterior cruciate ligament reconstruction technique with anterior cruciate ligament reconstruction with a full tibial tunnel. Arthroscopy. 2013;29(7):1195–1200.

    Article  PubMed  Google Scholar 

  24. Luo TD, Ashraf A, Dahm DL, Stuart MJ, McIntosh AL. Femoral nerve block is associated with persistent strength deficits at 6 months after anterior cruciate ligament reconstruction in pediatric and adolescent patients. Am J Sports Med. 2015;43(2):331–336.

    Article  PubMed  Google Scholar 

  25. Manchikanti L, Helm S, 2nd, Fellows B, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):Es9–38.

    PubMed  Google Scholar 

  26. Matava MJ, Prickett WD, Khodamoradi S, Abe S, Garbutt J. Femoral nerve blockade as a preemptive anesthetic in patients undergoing anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded, placebo-controlled study. Am J Sports Med. 2009;37(1):78–86.

    Article  PubMed  Google Scholar 

  27. Okoroha KR, Keller RA, Jung EK, et al. Pain assessment after anterior cruciate ligament reconstruction: bone-patellar tendon-bone versus hamstring tendon autograft. Orthop J Sports Med. 2016;4(12):2325967116674924.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Resnik DB, Rehm M, Minard RB. The undertreatment of pain: scientific, clinical, cultural, and philosophical factors. Med Health Care Philos. 2001;4(3):277–288.

    Article  PubMed  CAS  Google Scholar 

  29. Secrist ES, Freedman KB, Ciccotti MG, Mazur DW, Hammoud S. Pain management after outpatient anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Am J Sports Med. 2016;44(9):2435–2447.

    Article  PubMed  Google Scholar 

  30. Seymour RB, Ring D, Higgins T, Hsu JR. Leading the way to solutions to the opioid epidemic: AOA critical issues. J Bone Joint Surg Am. 2017;99(21):e113.

    PubMed  Google Scholar 

  31. US Food and Drug Administration. Safe disposal of medicines: flushing of certain medicines. Silver Spring, MD. 2018. Available from https://www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm

  32. Williams JS, Wexler G, Novak PJ, Bush-Joseph CA, Bach BR, Badrinath SK. A prospective study of pain and analgesic use in outpatient endoscopic anterior cruciate ligament reconstruction. Arthroscopy. 1998;14(6):613–616.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

We thank Patrick Hardigan PhD, MBA, and Natan Gold, Nova Southeastern University, Fort Lauderdale, FL, for statistical assistance.

Author information

Authors and Affiliations

  1. Florida Institute of Orthopaedic Surgical Specialists, 2307 West Broward Blvd. Suite 200, Fort Lauderdale, FL, 33312, USA

    George L. Caldwell Jr MD & Michael A. Selepec PA-C

Authors
  1. George L. Caldwell Jr MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Michael A. Selepec PA-C
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to George L. Caldwell Jr MD.

Ethics declarations

Conflict of Interest

George L. Caldwell, Jr., MD, and Michael A. Selepec, PA-C, declare that they have no conflict of interest.

Human/Animal Rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent

Informed consent was waived from all patients for being included in this study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Level of Evidence: Therapeutic Study: Level IV

Electronic supplementary material

ESM 1

(PDF 1.19 mb)

ESM 2

(PDF 1.19 mb)

ESM 3

(PDF 321 kb)

ESM 4

(PDF 314 kb)

ESM 5

(PDF 312 kb)

ESM 6

(PDF 314 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Caldwell, G.L., Selepec, M.A. Reduced Opioid Use After Surgeon-Administered Genicular Nerve Block for Anterior Cruciate Ligament Reconstruction in Adults and Adolescents. HSS Jrnl 15, 42–50 (2019). https://doi.org/10.1007/s11420-018-09665-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11420-018-09665-9

Keywords

  • anterior cruciate ligament reconstruction
  • ACL
  • opioid
  • adolescent
  • genicular nerves