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A Prospective Study of Pain and Analgesic Use in Outpatient Endoscopic Anterior Cruciate Ligament Reconstruction James S. Williams, Jr., M.D., Gary Wexler, M.D., Peter J. Novak, M.D., Charles A. Bush-Joseph, M.D., Bernard R. Bach, Jr., M.D., and Shyamala K. Badrinath, M.D.
Summary: A prospective study was undertaken to evaluate the postoperative pain
and analgesic profiles of a group of 50 patients undergoing outpatient anterior
cruciate ligament (ACL) reconstruction and to compare their profiles with those of
a group of 50 patients undergoing outpatient non-ACL arthroscopic surgery. All
patients received preoperative and postoperative ketorolac, intraincisional/intra-
articular bupivacaine, intraoperative ketorolac, and propofol anesthetic. The
percentage of patients receiving supplemental analgesia in the recovery room was
49% (average, 2.2 mg intravenous morphine sulfate) for the ACL group and 31%
(average, 1.2 mg intravenous morphine sulfate) in the non-ACL group. Narcotic
use and pain scores peaked in both groups on postoperative days 1 and 2. The ACL
group used significantly more narcotic and had higher pain scores in the first week
after surgery than did the non-ACL group. However, there were no subsequent
admissions, readmissions, or emergency room visits for pain. All were satisfied
with the outpatient nature of this surgery. Patients tolerate outpatient endoscopic
ACL reconstruction with moderate pain and narcotic use. Outpatient endoscopic
ACL reconstruction can be performed safely, effectively, and with considerable
cost savings. Key Words: ACL reconstruction—Pain—Analgesia—Outpatient—
Cost-containment issues have had a major impact currentpainprotocol.Kaoetal.1werethefirsttoreport
on orthopaedic practice. Many procedures previ- on the effectiveness of outpatient ACL reconstruction.
ously performed in an inpatient setting are now being Their study was limited by being retrospective and performed on an outpatient basis at a large cost having inherent bias built in by giving patients the savings. As surgical and pain control techniques have choice of inpatient versus outpatient ACL reconstruc- evolved, the ability to perform more complex surgeries tive surgery. The purpose of our study was twofold: on an outpatient basis has become feasible. Outpatient first, to prospectively record the pain response (using a endoscopic anterior cruciate ligament (ACL) recon- visual analog pain scale) and analgesic use in patients structions (with or without meniscal repair) have been undergoing outpatient endoscopic ACL reconstruc- performed at our institution since April 1994 using our tion; and second, to compare this group with anon-ACL outpatient knee arthroscopy group.
From the Section of Sports Medicine, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Westlake, Ohio (J.S.W.); theSection of Sports Medicine, Department of Orthopaedic Surgery MATERIALS AND METHODS
((G.W., P.J.N., C.A.B.-J., B.R.B.), and the Department of Anesthesia(S.K.B.), Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Fifty patients scheduled to undergo outpatient endo- scopic ACL reconstruction with or without concomi- Address correspondence and reprint requests to James S. Wil- liams, Jr., M.D., Section of Sports Medicine, Department of tant arthroscopic procedures and 50 patients scheduled Orthopaedic Surgery, Cleveland Clinic Foundation - Westlake for non-ACL outpatient knee arthroscopy comprised Satellite, 30033 Clemens Rd, Westlake, Ohio 44145, U.S.A. the study groups. Middle third autogenous bone– ௠ 1998 by the Arthroscopy Association of North America patellar tendon–bone autograft was used in each Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 14, No 6 (September), 1998: pp 613–616 endoscopic ACL reconstruction. All surgeries were TABLE 1. Day of Surgery Pain and Analgesic Protocol
performed by the senior authors B.R.B. and C.B.J. and Used for Outpatient Arthroscopic Knee Surgery both used an arthroscopically assisted ACL reconstruc- tion technique previously described by B.R.B.2 The Midazolam HCl 1 mg IV 30 min before surgery study met guidelines of and was approved by the Propofol 2-2.5 mg/kg induction, maintenance 75 µg/kg The specifics of the study were explained to each to 160 µg/kg and nitrous oxide (66% nitrous and33% oxygen) patient in the preoperative holding unit before surgery.
The visual analog pain scale was a 10-cm horizontal Rocuronium bromide (muscle relaxant) 0.6-0.8 mg/kg line with one end labeled ‘‘no pain’’ and the other labeled ‘‘pain as bad as it could be’’ (Fig 1). Patients were told that they would need to place a vertical line Cefazolin 1 g IVBupivacaine (.25%) and epinephrine (1:300,000)–half along the horizontal line at the point that corresponded maximal dose (based on body weight) injected to their average pain level for each postoperative day.
Also, daily accounts of the types, amounts, and times of analgesic use were to be recorded. While still in the preoperative unit, patients signed a consent form and Bupivacaine (.25%) and epinephrine (1:300,000)– remaining half of maximal dose injected intrainci- recorded on their data sheets their pain level for the Thirty minutes before surgery, patients received 1 mg of intravenous (IV) midazolam hydrochloride. In Morphine sulfate IV supplementally if needed the operating room, propofol with nitrous oxide (anes- Midazolam IV supplementally if neededCryotherapy* thetic), sufentanil (narcotic, 12.5 to 25 µg), and rocuronium bromide (muscle relaxant, 0.6 to 0.8 mg/kg) were used. Before the start of surgery, patients received 60 mg intramuscular ketorolac and all poten- *Not used for the non-ACL knee arthroscopy patients.
tial incision sites were injected with one half themaximal dose (based on body weight in kilograms) ofa 0.25% bupivacaine and 1:300,000 epinephrine solu- patients were seen on POD 3. Data sheets were tion. At the conclusion of surgery, 30 mg IV ketorolac collected POD 7 to 14 or mailed in at a later date. The was administered, intraincisional and intra-articular pain and analgesic protocol in the non-ACL knee injection of the remaining half of the maximal dose of arthroscopy group differed from the ACL reconstruc- bupivacaine/epinephrine solution was performed, and tion group protocol only in that no cryotherapy unit a cryotherapy unit (Polar Care, Carlsbad, CA) was was used and patients did not receive physical therapy applied to the knee. Patients were then transferred to (Table 1). Data analysis was performed using a paired the recovery room where the cryotherapy unit was Student’s t test. Significance was defined as P Յ .05.
connected, and all supplemental analgesics adminis-tered were recorded. After 1 hour in the recoveryroom, patients were transferred back to the holding unit where they received physical therapy. Drains (if Fifty outpatient endoscopic ACL reconstruction present) were removed, a hydrocodone prescription (5 patients and 50 non-ACL knee arthroscopy patients to 10 mg every 4 to 6 hours) was given with follow-up comprised the study groups (Table 2). Average age was instructions, and pain study data sheets were re- 28 years for the ACL group and 40 years for the reviewed. Patients were seen on postoperative day non-ACL group. Average surgical time was 118 min- (POD) 1 for wound check, dressing change, and utes for the ACL group and 34 minutes for the referral to therapy. For patients who were unable for non-ACL group. Only 23% of the ACL group and 5% follow-up on POD 1, telephone contact was made by of the non-ACL group required tourniquet inflation, senior surgeons within 24 hours of the surgery and with average times of 13 minutes and 3 minutes,respectively. There were no intraoperative or immedi-ate postoperative complications. Supplemental recov-ery room analgesia was required in 49% of the ACLgroup and 31% of the non-ACL group. The average FIGURE 1.
recovery room IV morphine sulfate dose was 2.2 mg in PROSPECTIVE OUTPATIENT ACL RECONSTRUCTOIN PAIN STUDY TABLE 2. Study Groups
the ACL group and 1.1 mg in the non-ACL group. Noantiemetic medications were required in the recoveryroom. Recovery room time averaged 53 minutes.
No patient required postoperative admission, read- mission, or visited an emergency room for pain control industry have resulted in an ever increasing number of or complications from the surgery. Telephone calls by outpatient surgeries. Surgical treatment of the ACL- patients complaining about pain or requesting addi- deficient knee has evolved from open and extra- articular procedures to endoscopic reconstruction tech- Postoperative oral narcotic use peaked on POD 1 in niques. Improvements in surgical instrumentation and the non-ACL group and on POD 2 in the ACL group technique, stronger graft constructs and fixation meth- (Fig 2). Narcotic use was significantly higher on PODs ods, and improved understanding of graft healing and 2, and 5 to 8 in the ACL group (P Ͻ.05). Non-narcotic maturation have resulted in more aggressive rehabilita- analgesic use peaked on POD 4 in the ACL group and tion programs and faster return to activity.
on PODs 7 to 8 in the non-ACL group (Fig 3). There Our clinical experience with outpatient endoscopic was no significant difference in non-narcotic analgesic ACL reconstruction has been that patients tolerate the use between the two groups. Visual analog pain scores procedure well. The purpose of this study was to peaked on POD 1 in both groups and remained higher prospectively evaluate postoperative pain (using a in the ACL group throughout the study (Fig 4).
visual analog pain scale) and analgesic use in outpa- Preoperative pain scores were significantly higher in tients undergoing endoscopic ACL reconstruction and the non-ACL group. However, patients in the ACL to compare the results with a non-ACL outpatient group had significantly higher pain scores on PODs 1 We defined mild pain as 1 to 3, moderate as 4 to 7, and severe as 8 to 10 on the visual analog scale. Themaximum daily dose of hydrocodone is 12 tablets. We DISCUSSION
defined taking 0 to 4 tablets per day as infrequent, 5 to Improvements in surgical technology and tech- 8 tablets per day as moderate, and 9 to 12 tablets per niques coupled with improved pain control and the day as frequent narcotic usage. Pain scores peaked on ongoing push for cost containment in the health care POD 1 in the moderate range for both groups; how- FIGURE 2.
ever, scores stayed significantly higher in the ACL pain medication and cryotherapy. This study shows a group reaching significance on PODs 5 to 8. In the discrepancy between pain scores (moderate category) non-ACL group, narcotic use was never higher than and narcotic use (infrequent category) in the ACL the infrequent category, which was reflected by a pain group. As a result, we now encourage patients to take score that remained in the mild category except for their pain medicine as prescribed during the first POD1 (which bordered on the moderate category). In the ACL group, narcotic use and pain scores were In previous work,10 we have shown average total higher. They remained in or bordering on the moderate surgical charge (excluding surgical and anesthesiology category for 1 week after their surgery. These differ- fees) for inpatient ACL reconstruction performed in ences reflect longer surgical times, additional inci- the main operating room patients to be $11,791 for an sions, osseous work, and an overall increased complex- overnight stay and $13,503 for a 2 night stay between ity of endoscopic ACL reconstructions over non-ACL 1989 and 1991. In 1991, with the advent of endoscopic ACL reconstruction, a decreased need for postopera- In a retrospective study comparing two-incision tive hospitalization was noted. Average charges for autogenous middle third bone patellar bone ACL endoscopic outpatient ACL reconstruction in the main reconstruction in inpatients versus outpatients, Kao et operating room were $8,834 and reflected a` la carte al.1 found no significant difference in pain level and pricing. Since April 1994, an average set fee of $3,855 analgesic frequency between the two groups. How- has been charged for outpatient endoscopic ACL ever, selection bias was built into their study as they reconstruction performed in our free-standing surgical gave patients the choice of outpatient or inpatient center. In conclusion, outpatient endoscopic ACL surgery. Their study was also limited by the patients’ reconstruction using our pain and analgesic protocol need to recall their pain frequency, severity, and relief can be done safely, effectively (from a pain stand- for the first 5 days after surgery some 2 to 6 weeks after point), and with considerable reduction in hospital surgery. Frey et al.3 reported on pain level and analgesic use for the first 48 hours after outpatientACL reconstruction using a combination of femoral REFERENCES
nerve block, intra-articular analgesia, nonsteroidal andanti-inflammatory agents (naproxen), opiates (subcuta- 1. Kao JT, Giangarra CE, Singer G, Martin S. A comparison of neous patient-controlled anesthesia with imipramine outpatient and inpatient anterior cruciate ligament reconstruc- initially, which was changed to oral acetaminophen tion surgery. Arthroscopy 1995;2:151-156.
2. Hardin GT, Bach BR, Bush-Joseph CA, Farr J. Endoscopic with hydrocodone half way through the study), and single-incision anterior cruciate ligament reconstruction using cryotherapy (Polar Care). Although their study differs patellar tendon autograft. Am J Knee Surg 1992;3:144-155.
from ours in the use of a femoral nerve block, failure to 3. Frey K, Sukhani R, Pappas AL, Tonino P. ‘‘Multimodal’’ approach to postoperative pain management in patients under- inject incisional sites before surgery, use of ketorolac going ambulatory anterior cruciate ligament repair. Soc Ambu- at the discretion of the anesthesiologist, and follow-up of only 48 hours, their results were similar to ours in that 4. Daniel DM, Stone ML, Arendt DL. The effect of cold therapy on pain swelling, and range of motion after anterior cruciate patients tolerated outpatient ACL reconstruction well.
ligament reconstructive surgery. Arthroscopy 1994;10:530- Postoperative pain management following knee ar- throscopy continues to evolve. Cold therapy, corticos- 5. Edwards DJ, Rimmer M, Keene G. The use of cold therapy in the postoperative management of patients undergoing arthoro- teroids, local anesthetics, and regional blocks alone or scopic anterior cruciate ligament reconstruction. Am J Sports in combination have all been shown to be beneficial in redirecting postoperative pain.4-9 Using our current 6. Highgonboten CL, Jackson AW, Meske NB. Arthroscopy of the knee: Ten day pain profiles and corticosteroids. Am J Sports pain/anesthesia endoscopic ACL reconstruction proto- col, we have successfully performed over 140 such 7. Lintner S, Shawen S, Lohnes J, Levy A, Garrett W. Local surgeries since April 1994 without a single postopera- anesthesia in outpatient knee arthroscopy: A comparison ofefficacy and cost. Arthroscopy 1996;12:482-488.
tive admission, readmission after discharge, or emer- 8. Gatt CJ, Parker RD, Tetalaff JE, Szabo MZ, Dickerson AB.
gency room visit for pain. Our day-of-surgery pain Pre-emptive analgesia: Its role in efficiency in anterior cruciate protocol results in low pain scores and infrequent ligament reconstruction. Am J Sports Med 1998;26:524-529.
9. Uysalel A, Kecik Y, Kirdemir P, Sayin M, Binnet M. Compari- narcotic use the night of surgery. Although narcotic use son of intraarticular bupivicaine with the addition of morphine and pain scores in the ACL group remain moderate and or fentanyl for analgesia after arthroscopic surgery. Arthros- are significantly higher than the non-ACL group 10. Novak PJ, Bach BR Jr, Bush-Joseph CA, Badrinath S. Cost during the first postoperative week, patients tolerate containment: A charge comparison of anterior cruciate liga- this procedure well on an outpatient basis with oral ment reconstruction. Arthroscopy 1996;12:160-164.


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