Summary

Pregabalin or celecoxib along with intra-articular injections of morphine and bupivacaine in combination with adductor canal nerve blocks seem to be the most effective method for controlling pain following ACLR surgery.

Abstract

Introduction

Pain control after Anterior Cruciate Ligament Reconstruction (ACLR) is important, as it influences the postoperative recovery and time to return to play. The purpose of this study was to evaluate multimodal pain management strategies following ACL reconstruction and to determine the potential impact on outcomes.

Methods

A systematic review of the literature was performed using PubMed, CINAHL and EMBASE in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analysis) guidelines. From January to February 2022, studies that evaluated post-operative analgesia following ACLR were identified, and reference lists from selected articles were analyzed for additional studies. The inclusion criteria for full article review were randomized control trials (RCTs) with one or more analgesic regiment being compared for efficacy. The following data were extracted: patient demographics, study design, analgesia regiments being compared, VAS scores, and study outcomes.

Results

A total of 40 RCTs met inclusion criteria: n= 18 on regional nerve blocks (45%), n= 14 on intra-articular injections (35%), n=3 on oral medications (7%), n=3 on blood flow/ cryotherapy (7%) and n=2 on IV infusions (5%). Adductor canal blocks (ACBs) provide an effective, but slightly less potent analgesia compared to femoral nerve blocks (FNB), which provides sufficient coverage for ACL reconstruction. ACBs in conjunction with popliteal plexus blocks can be advantageous in that there are no associated motor deficits compared to FNB. Additionally, pregabalin can be administered with an ACB to potentiate analgesia and reduce rescue opioid consumption in patients. Other multimodal pain management strategies also show promise such as an intra-articular (IA) injection of morphine along with an ACB or celecoxib (a COX-2 inhibitor) with an ACB. Cryotherapy and blood flow reduction therapy also reduced pain post-operatively and can be used in conjunction with other methods without causing adverse effects.

Conclusion

Preemptive administration of medications such as pregabalin or celecoxib along with intra-articular injections of morphine and bupivacaine in combination with adductor canal nerve blocks seem to be the most effective method for controlling pain following ACLR surgery.
Multimodal analgesic strategies should be the preferred method of controlling pain following ACLR as differing mechanisms of actions of drugs provide a synergistic and more profound analgesia than one drug alone.