Best Practices
Arthroscopic Anterior Cruciate Ligament/Posterior Cruciate Ligament Repair
All best practices are subject to change and may require modifications depending on a patient’s history and status. Healthcare practitioners should always defer to their clinical judgement and, whenever appropriate, consult with additional resources for further guidance.
| Preoperative | Intraoperative | Postoperative (Inpatient) | Discharge Strategies |
|---|---|---|---|
| •Acetaminophen 1g •NSAIDs | •IV NSAIDs if not given preop •Consider regional anesthesia OR local infiltration; no difference in pain control between adductor canal block vs. femoral nerve block | •Acetaminophen (maximum 4g/day) •NSAIDs (consider selective COX-2 inhibitors for fewer side effects and a prescription for increased compliance) | MANAGEMENT OF PAIN W/O MEDICATION: •Automated cooling system (e.g. Game Ready) •Early physiotherapy; accelerated rehabilitation without postoperative bracing •Ice •Relaxation techniques (breathing, meditation, mindfulness, etc.) CO-ANALGESICS: •Acetaminophen (maximum 4g/day) •NSAIDs (consider selective COX-2 inhibitors for fewer side effects and a prescription for increased compliance) OPIOID PRESCRIPTION: Recommend: 20 tablets Range: 20-30 tablets For higher numbers, consider a.part-fill.prescription |
*All tabs for discharge are 5mg oral morphine. To convert this dosage, please visit this page. We encourage prescribers to consider discharge prescriptions of short-acting opioids at the lowest effective dose, with the lowest potency, for the shortest duration.
Before surgery, and at the surgical safety checklist time, the surgical and anesthesia team should work together to develop a multimodal pain management plan with active strategies to optimize perioperative pain management.
Healthcare practitioners are also encouraged to help patients set realistic expectations around pain management, including the use of prescription medications. Additional useful information to enhance recovery after surgery can be found at Enhanced Recovery Canada.
See our full disclaimer here.
References
Anderson MJ, Browning WM, Urband CE, Kluczynski MA, Bisson LJ. A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. Orthop J Sports Med. 2016 Mar;4(3):2325967116634074.
Dixit A, Prakash R, Yadav AS, Dwivedi S. Comparative Study of Adductor Canal Block and Femoral Nerve Block for Postoperative Analgesia After Arthroscopic Anterior Cruciate Ligament Tear Repair Surgeries. Cureus. 2022 Apr;14(4):e24007.
Felix MMDS, Ferreira MBG, da Cruz LF, Barbosa MH. Relaxation Therapy with Guided Imagery for Postoperative Pain Management: An Integrative Review. Pain Manag Nurs. 2019 02;20(1):3-9.
Glogovac G, Kennedy M, Parman MD, Bowers KA, Colosimo AJ, Grawe BM. Opioid Requirement Following Arthroscopic Knee Surgery: Are There Predictive Factors Associated with Long-Term Use. J Knee Surg. 10.1055/s-0039-3400754
McCartney CJL, McIsaac D. Are Peripheral Nerve Blocks Indicated in Ambulatory Knee Surgery. Anesth Analg. 2019 01;128(1):3-4.
Murgier J, Cassard X. Cryotherapy with Dynamic Intermittent Compression for Analgesia After Anterior Cruciate Ligament Reconstruction. Preliminary Study. Orthop Traumatol Surg Res. 2014 May;100(3):309-12.
Sehmbi H, Brull R, Shah UJ, et al. Evidence Basis for Regional Anesthesia in Ambulatory Arthroscopic Knee Surgery and Anterior Cruciate Ligament Reconstruction: Part II: Adductor Canal Nerve Block-A Systematic Review and Meta-analysis. Anesth Analg. 2019;128(2):223-238.
Tobias AF, Moura ECR, Honda CADO, Pereira EC, de Oliveira CMB, Leal PDC, et al. Evaluation of the Efficacy of Prolonged Pregabalin Administration Before and After Surgery in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Repair: A Prospective, Randomized, Double-blind Study. Clin J Pain. 2020 Aug;36(8):584-8.
Verret M, Lauzier F, Zarychanski R, Perron C, Savard X, Pinard AM, et al. Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain: A Systematic Review and Meta-analysis. Anesthesiology. 2020 08;133(2):265-79.
Yung EM, Brull R, Albrecht E, Joshi GP, Abdallah FW. Evidence Basis for Regional Anesthesia in Ambulatory Anterior Cruciate Ligament Reconstruction: Part III: Local Instillation Analgesia-A Systematic Review and Meta-analysis. Anesth Analg. 2019;128(3):426-437.
Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, et al. Mindfulness Meditation-Based Pain Relief Employs Different Neural Mechanisms Than Placebo and Sham Mindfulness Meditation-Induced Analgesia. J Neurosci. 2015 Nov 18;35(46):15307-25.
Zeidan F, Martucci KT, Kraft RA, Gordon NS, McHaffie JG, Coghill RC. Brain Mechanisms Supporting the Modulation of Pain by Mindfulness Meditation. J Neurosci. 2011 Apr 6;31(14):5540-8.
Treatment Altering Factors
Below are a few of the more common and/or impactful health factors that may result in deviation from the above best practices. Please note that the following list is not exhaustive and that the remarks for each factor are not surgery-specific. Healthcare practitioners should always defer to their clinical judgement and, if appropriate, consult with additional resources for further guidance. See our full disclaimer here.
Organ Dysfunction
Hepatic dysfunction/Excessive alcohol intake
| •In general: Limit or avoid acetaminophen altogether, depending on degree of hepatic dysfunction •Preoperative: Avoid or reduce dose of acetaminophen •Intraoperative: Decrease dose of opioids, benzodiazepines, meperdine •Postoperative: Reduce dose of acetaminophen •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Renal dysfunction
| •In general: Limit or avoid NSAIDs altogether, depending on degree of renal dysfunction •Preoperative: Avoid NSAIDs and use gabapentinoids cautiously •Intraoperative: Avoid morphine and meperidine •Postoperative: Avoid NSAIDs and use lower dose of gabapentin •Discharge: Lower daily maximum dose of tramadol and increase dosing interval; avoid codeine |
Patient Specific Factors
Advanced age
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| •Preoperative: Due to the frequency of multiple comorbidities in advanced age, anesthesia preoperative consult as needed to preoptimize. Also, manage anticoagulants where indicated; avoid long delays in hip fracture patients and practice preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated •Postoperative: Regular dose acetaminophen; oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities |
Chronic pain and/or long-term opiate use
| •In general: May attempt to wean chronic opioids if surgery is to treat issues contributing to the chronic pain but otherwise continue chronic pain medication perioperatively if patient uses it •Preoperative: Anesthesia consult where indicated; continue preop opioids on day of surgery and give preemptive analgesia •Intraoperative: Regional anesthesia and peripheral nerve blocks preferable where indicated; use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance •Postoperative: Use a multi-modal opioid sparing approach; may require higher doses of opioids to account for tolerance; regular dose acetaminophen and oral NSAIDs where indicated •Discharge: Consider minimum amount of opiates based on the surgical procedure, age and comorbidities and avoid opioid dose escalation from preop, if possible |
History of difficulty with postop pain management
| •Consider regional anesthetic techniques, if feasible for specific surgical procedure |
Uncontrolled anxiety/depressive symptoms
| •Preoperative: Consider anxiolytics prior to administration of anesthetic •Discharge: While reviewing expected duration of opioid use, as well as opioid safety strategies including the appropriate storage and disposal of unused pills, should be standard practice, it is of paticular importance with patients who have uncontrolled anxiety/depressive symptoms Special note for paediatric surgeries: Given the risk of opioid misuse in youth with depressive symptoms, consider heightened opioid safety factors including reviewing with caregivers at discharge |
System Disorders
Coagulopathy
| •Avoid neuraxial techniques if any abnormal coagulation; consider following ASRA guidelines |
Obstructive sleep apnea
| •Preoperative: Use multi-modal analgesia; reduce or avoid use of gabapentinoids •Intraoperative: Reduce or avoid benzodiazepines; reduce doses of opioid medications •Postoperative: Use multi-modal analgesia; reduce use of opioids and gabapentinoids •Discharge: Reduce opioid dosing |