Anesthesia and analgesia methods for outpatient anterior cruciate ligament reconstruction.

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.

French prospective multicenter comparative assessment of ambulatory surgery feasibility in anterior cruciate ligament reconstruction.

INTRODUCTION: The main objective of this multicenter study was to assess the feasibility of ambulatory surgery in France in anterior cruciate ligament (ACL) reconstructions for any technique or graft used (hamstring, patellar tendon, fascia lata). We hypothesized that a dedicated organization would guarantee the patient's safety. PATIENTS AND METHODS: A multicenter, non-randomized, prospective, comparative study, conducted within the SFA symposium was conducted between January 2014 and March 2015, included all the patients operated on for arthroscopic ACL reconstruction using different surgical techniques. The outpatient group (OP) included patients eligible for day surgery who provided informed consent; the conventional hospitalization group (CH) comprised patients declined for outpatient surgery for organizational reasons. The main outcome was failure of the admission mode defined by hospitalization of a patient undergoing outpatient surgery or rehospitalization within the 1st week after discharge. The secondary outcomes were assessment of pain and postoperative complications. A total of 1076 patients were studied with 680 in the OP group and 396 in the CH group. The mean age was 30years±9years. In the CH group, the mean hospital stay was 2.7±0.8days. RESULTS: Twenty-three OP patients were hospitalized or rehospitalized (3.4%). Thirty-six (5.2%) early postoperative complications were noted in the OP group and 17 (4.3%) in the CH group (non-significant difference). Mean postoperative pain on D0-D4 and satisfaction were comparable between the two groups. CONCLUSION: This prospective multicenter study observed no serious incidents. In a selected population, the risks are comparable to those of conventional hospitalization. Outpatient ACL surgery is therefore feasible in France in 2016. LEVEL OF PROOF: III: case-control study.

Pain after out-patient vs. in-patient ACL reconstruction: French prospective study of 1076 patients.

BACKGROUND: Anterior cruciate ligament (ACL) repair is increasingly performed on an out-patient basis. In France, however, concern about post-operative pain remains a strong barrier to out-patient ACL repair. The primary objective of this study was to compare post-operative pain after ACL repair as out-patient versus in-patient surgery. The secondary objectives were to assess the time-course of post-operative pain and to identify factors associated with pain intensity. MATERIAL AND METHODS: A multicentre, prospective, comparative, non-randomised study was conducted in France for the French Society for Arthroscopy (SFA) symposium. Patients who underwent primary ACL repair between January 2014 and March 2015 were included if they were eligible for out-patient surgery. The choice between out-patient and in-patient surgery was based on organisational and logistical considerations. Pain intensity was self-evaluated by the patients using a visual analogue scale (VAS), pre-operatively then in the evening after surgery, during the night after surgery, and 1, 3, and 5 days after surgery. The patients performed the evaluations at home using websurvey.fr® software. Demographic data, the characteristics of the surgical procedure, and the IKDC and Lysholm scores before and after surgery were collected. RESULTS: Of the 1076 patients included in the study, 680 had out-patient surgery and 396 in-patient surgery. Mean age was 30±9 years. The two groups were comparable at baseline. Pain intensity was not significantly different between the two groups at any of the measurement time points. Pain intensity showed a peak on post-operative day 1 that was similar in the two groups. The initial post-operative pain intensity score predicted subsequent pain intensity: patients with VAS scores <2 on the day of surgery also had low pain scores after surgery. In both groups, factors associated with greater pain intensity were age <25 years, high pre-operative pain score, and surgery performed after noon. Neither surgical technique nor concomitant lesions and methods used to treat them were associated with pain intensity. Risk factors for severe post-operative pain (VAS score >7) in the out-patient group were younger age, female gender, pre-operative VAS score >3, and tourniquet time >50minutes. CONCLUSION: Pain intensity is similar after out-patient and in-patient ACL repair. Concern about pain should not be a barrier to performing ACL repair on an out-patient basis. Our data on the time-course of the pain and factors associated with greater pain intensity should prove useful for improving patient management after ACL repair. LEVEL OF EVIDENCE: Level III, case-control study.

Horizontal posterior hamstring harvest.

Harvesting of the gracilis and semi-tendinosus (ST) hamstring tendons is usually performed by anteromedial approach. Harvesting by a horizontal posterior approach is possible. Based on a series of 90 patients, this technical note describes the perioperative difficulties and the characteristics of the harvested tendon(s) as well as any complications. Only one unsuccessful harvest was reported. Posterior harvesting of the gracilis and ST hamstring tendons is a reliable, reproducible surgical technique with a low rate of complications.

Knee arthodesis using a modular customized intramedullary nail.

INTRODUCTION: Arthrodesis of the knee, particularly in infectious situations, can be achieved using either an external fixator or an intramedullary device. The objective of this study is to report the clinical, functional, and radiographic outcomes of a continuous series of 19 cases of knee arthrodesis using a customized modular intramedullary nailing system. HYPOTHESIS: The modular intramedullary nail offers a satisfactory functional result while maintaining limb length, in spite of a nonunion risk, since acting like a true endoprosthesis. MATERIAL AND METHODS: In our retrospective series of 19 patients, the main source of patients were infected total knee replacements. The nail was customized from assembling a dual surface-sanded titanium component (femoral and tibial). The Lequesne Algofunctional score and the WOMAC score were recorded, as well as the length discrepancy between the lower extremities. Arthrodesis consolidation and the nail's fit in the shaft were verified on anterior-posterior (AP) and lateral radiographs. RESULTS: Five complications were observed: one anterior cortical break, one excessive tibial rotation, two cases of delayed union, and one nail revision due to residual nail instability. The postoperative Lequesne Algofunctional score was 13/24 and the WOMAC score 57/100. The nonunion rate was 32%. From a functional point of view, the patients who did not achieve complete union and those who did had similar scores. The subjective results were not as good in patients who did not achieve final consolidation. DISCUSSION: Modular intramedullary nailing simplifies the technique, shortens the procedure, and reduces the amount of blood loss at surgery. Our nonunion rate was high, although the functional result did not seem compromised by such nonunion. The risk of long-term implant failure was not studied and requires longer follow-up studies. LEVEL OF EVIDENCE: Level IV therapeutic study.