POSTOPERATIVE AND POST-DISCHARGE PAIN OUTCOMES AND OPIOID REQUIREMENTS IN PEDIATRIC ARTHROSCOPIC ACL RECONSTRUCTION AND/OR MENISCUS PROCEDURES MANAGED WITH PERIPHERAL NERVE BLOCKADE

Abstract

Background: Peripheral nerve blockade (PNB) can be a useful component of a multimodal analgesia strategy for managing pain after knee arthroscopy and supports goals of improved opioid stewardship given the national crisis. However, the impact of PNB on short-term recovery in pediatric patients undergoing knee arthroscopy for anterior cruciate ligament (ACL) reconstruction and meniscus surgery (repair or resection) has not been well characterized. This prospective study presents patient outcomes following discharge home in pediatric patients undergoing arthroscopic ACL and/or meniscus procedures managed with PNB. Methods: This is a single-center, single-surgeon prospective observational study conducted over a three year period. We characterized 72-hour postoperative outcomes including pain scores, return of sensation to affected limb, analgesic use (NSAID's and opioids), readmission rate, and activities of daily living via telephone survey. In addition, retrospective chart review was conducted to obtain perioperative and anesthesia details. Results for surgery groups were analyzed using descriptive and Pearson correlations using SPSS v24. Results: We collected data on 47 patients undergoing ACL reconstruction with or without meniscus surgery (n=18) or meniscus surgery only (n=29). The mean ages for each group were 16.0 ± 1.4 years and 15.7 ± 1.4 years, with 13/18 and 18/29 females, respectively. At 72 hours post-surgery, there were no readmissions or complications related to pain. PACU pain scores and follow up data from the post discharge survey is presented in Table 1. Median and interquartile ranges (IQR) of maximum PACU pain ratings were 0 (0.0-3.5) for the ACL group and 0 (0.0-2.5) for the meniscus-only group. Median (IQR) for pain score at 72 hours post-surgery was 2.5 (1.0-5.0) and 5 (3.0-6.0) for the ACL and meniscus-only groups only. For the meniscus-only group, maximum PACU pain scores correlated with 72-hour pain score (r=0.431, p=0.025) but not for the ACL group (r=0.418, 0.084). PACU pain scores and follow up data from the post discharge survey is presented in Table 2. A majority of patients continued to require opioids (45/47) and NSAIDs (46/47) at 72 hours post-surgery, but the number of daily opioid doses taken decreased each day postoperatively. Over 93% of patients could ambulate and shower at 72 hours post-surgery and sensation to affected limbs returned most commonly on postoperative day 1 in both groups. Conclusions / Significance: Regional nerve block appears to be an effective and safe analgesic strategy for pediatric arthroscopic ACL and meniscus procedures, with no short-term complications or readmissions related to pain in our cohort and all patients showing clinically minor levels of pain post-discharge. Future prospective investigation is needed to characterize long-term pain outcomes and opioid use in this surgical population in direct comparison to patients not receiving PNB. Table 2: 72-Hour Postoperative Follow-up Group A: ACL ± Meniscal Surgery Group B: Meniscal Surgery PACU Maximum Pain Score (Median Interquartile Range (25th–75th)) 0.0 (0.0-3.5) 0.0 (0.0-2.5) 72-Hour Pain Score (Median Interquartile Range (25th–75th)) 2.5 (1.0-5.0) 5.0 (3.0-6.0) Day Sensation Returned DOS 3 / 18 4 / 29 POD1 12 / 18 19 / 29 POD2 3 / 18 6 / 29 POD3 0 / 18 0/29 Readmission 0 / 18 0/29 ADL's Shower 18 / 18 26 /29 Ambulation 17 / 18 28 / 29 Ambulation with Crutches 17 / 18 26 / 29 Using NSAID? 18 / 18 27 / 28 NSAlD Type Ibuprofen 17 / 18 28 / 29 Naproxen 1 / 18 0 / 29 Rx/OTC Rx 17 / 18 27 / 29 OTC 1 / 18 2 / 29 NSAID Dose Number DOS 4.0 (3.75-4.0) 4.0 (4.0-4.0) POD1 4.0 (4.0-4.0) 4.0 (4.0-4.0) POD2 4.0 (3.85-4.0) 4.0 (4.0-4.0) POD3 4.0 (3.0-5.0) 4.0 (4.0-4.0) NSAID-Related Side Effects Indigestion 2 / 18 1 / 29 None 15 / 18 27 / 29 Using Opioid? 18 / 18 27 / 29 Opioid Type Oxycodone 18 / 18 26 / 29 Hydrocodone 0 / 18 1 / 29 Number of Opioid Doses (Median, Interquartile Range) DOS 6.0 (4.0-6.0) 6.0 (4.0-6.0) POD1 6.0 (4.0-6.0) 4.8 (4.0-6.0) POD2 4.0 (1.75-6.0) 4.0 (2.0-6.0) POD3 4.0 (0.0-6.0) 1.0 (0.0-4.8) Opioid-Related Side Effects. Constipation 4 / 18 6 / 29 Dizziness 1 / 18 2 / 29 Indigestion 2 / 18 2 / 29 Nausea/Vomiting 3 / 18 1 / 29 Itchiness 4 / 18 0 / 29