Don Johnson MD
Director Sports Medicine Clinic Carleton University
Assistant Professor Orthopaedic Surgery University of Ottawa
Figure 1 The setup for ACL reconstruction
We have only learned a few things over the past decade about ACL reconstruction. First of all, mark the site that you are going to operate on. This should be done outside of the OR with the patient awake. We know that the choice of graft is probably immaterial, but the most important factor in a satisfactory stability outcome is to put the tunnels in the correct position and fix the graft adequately. But, from a patient’s perspective, the biggest improvement is in pain management. This is an important aspect nowadays as all ACL reconstruction is done as an outpatient. So what do we do that is new and improved? This is the list of pain management modalities that we currently use for outpatient anesthesia in ACL reconstruction:
Pre-emptive Multi-modal analgesia
IV 30 mg Ketorolac (Toradol)
Intra-articular injection of Marcaine and Morphine
Incisional Injection of Marcaine
Femoral Nerve Block
Post op NSAI – Vioxx/Celebrex
Lets look at some of these techniques in detail.
Multimodal or balanced analgesia  means to make use of multiple modalities to augment the anaesthesia. In our protocol it refers to the IV ketolorac, the femoral nerve block and the intra-articular injection of marcaine and morphine.
Figure 2 The femoral nerve block done with a nerve stimulator
The femoral nerve block is done with the patient awake and sedated. The nerve stimulator is used to locate the nerve,. This is one of the safest blocks that can be performed. We have done over 4,000 anterior cruciate ligament reconstructions with this block. Even though physicians with varying degree of skill have performed the block, I have not seen a significant problem or complication as a result of the femoral nerve block.
Figure 3 The injection of the anterolateral portal and the joint
Figure 4 The injectionof the incision for the harvest of the hamstring tendons
The portals, incision and the joint are injected with marcaine and morphine before the leg is prepped and draped. Turner  has demonstrated the benefit of infiltrating the Incisional site with local anaesthetic. Numerous authors have shown the efficacy of the joint injection with Marcaine and/or morphine [3-10]
We have been performing the nerve block, intra-articular injection and the IV Torodol pre-emptively since 1999 when we found that this improved the VAS score in the recovery room. The long-term improvement in the pain score was not as dramatic as we had expected due to the nature of the hamstring reconstruction that we were studying. There seems to be much less morbidity from the hamstring harvest from the ipislateral knee compared to the patellar tendon harvest from the ipislateral knee. We had been convinced of the effectiveness of the femoral nerve block since our first study in 1987. The femoral nerve block had been described by Ringrose in 1984 for post operative pain relief after open knee surgery. This year at the AAOS meeting a poster presentation by Thomas et al also found improved VAS scores when the block was done at the beginning of the case. In 1993 we found that the intra-articular injection of Marcaine and Morphine improved in the post-op VAS scores. Shelbourne has also emphasized the importance of pre-emptive analgesia. He uses IV Ketorlac, and local injection of the wound with marcaine pre-op. Immediately post op in the OR, the CPM and cryocuff are applied. The Cox-2 inhibtors are started the day of surgery. We have been considering starting them on the morning of surgery.
We felt that the tourniquet may be a factor in increasing the pain post-op. In a study to compare tourniquet versus no tourniquet we found no difference in cases that only took about 1 hour. Tourniquet pain may be more of a factor with longer cases.
Since McGuire pointed out to us the advantages IV ketolorac, we had been using Toradol both pre op and post op, but have switched to Vioxx about 1 year ago. We have not done any randomized study of this but have the impression that there are fewer GI complaints with Vioxx as compared to the Toradol. Reuben has shown that the rofecoxib given 1 hour before surgery lengthens the effect of the blocks. He further found that rofecoxib was better than celecoxib over the first 24 hours. The preferred regime now should be the rofecoxib taken on the morning of surgery with sips of water.
Figure 5 The CPM and cryocuff
We have been extremely happy with cryotherapy over the past decade. Some patients like the cold pack so much we have to surgical extract the pack from the leg after a couple of months. The efficacy of cryotherapy has been documented by Cohn  Shelbourne and Barber and McGuire. Shelbourne was one of the early proponents of the Cryocuff. In the 1994 study he showed less narcotic use with the use of the pneumatic cryocuff. This group also showed an improvement over the application of ice packs. This may be due to the compression and the use of the cryocuff while ambulatory. Barber and McGuire found less Vicodin use and better VAS scores with the cryotherapy group. Barber  has also shown in a clinical trial that the cryotherapy is superior to crushed ice to cool the knee.
There have been several studies to examine the efficacy of the CPM after ACL reconstruction [24-30] The consensus seems to be that the range of motion is not significantly improved, but there is less swelling. Richmond examined the use of the CPM and found that the use for 4 days post op was as effective as 14 days. In summary, the main use of the CPM is to keep the knee elevated post op, and consequently this reduces the pain and swelling.
The champion of accelerated rehab has been Don Shelbourne[31-33]. However, no one else that I know has been misquoted so often. This program is not something that he thought up one day, but is the result 20 years of experience of listening to the patient. He would fine tune one thing at a time, look at the outcome, and use that change or reject it. I will try to summarize what he does, and not mangle the protocol too badly. One day when he is not too busy, maybe I can convince him (Or Tinker) to write a short summary of his concepts. But until then here is my take on it.
The early phase of the accelerated program is designed to regain the range of motion, and reduce the swelling of the knee. He keeps the patient down with a CPM and cryocuff for the first 5 days. They are doing active slides for flexion and full hyperextension. The second phase is to regain the strength and keep the range of motion. He felt that these 2 goals were at odds when he was harvesting the graft from the same knee. After one satisfying result from harvesting from the patellar tendon from the opposite knee, he developed a rehab program that split the rehab into the 2 knees, one to regain the strength of the harvested knee, and the other to regain the range of motion of the reconstructed knee. This concept works well in his hands, as he is meticulous with follow up to prevent problems and complications. He allows early running at 4 weeks and sports specific exercises at 6 weeks, ie shooting hoops. The average return to sport after contralateral harvest of the patellar tendon is 4.2 months.
The rest of us can learn from him that the program must be well monitored to anticipate and prevent problems. Everyone must select what will work in his hands and his setting. The message is to listen to the patient, answer his questions, but try not to make the mistakes that many of us have made in the past.
For further information on Cox 2 inhibitors and pain management see:
1. Kehlet H, D.J., The value of "multimodal" or 'balanced analgesia' in postoperative pain treatment. Anesth Analg, 1993. 77: p. 1048-1056.
2. Turner GA, C.G., Comparison of peroperative with postoperative lignocaine infiltration on postoperative analgesic requirements. Br J Anaesth, 1994. 72: p. 541-543.
3. Joshi GP, M.M., Hurson BJ, McCarroll SM, O'Rourke P., Effects of Intra-articular morphine on analgesic requirements after anterior cruciate ligament surgery. Reg Anesth, 1993. 18: p. 254-257.
4. Reuben, S.S., et al., Intraarticular morphine in the multimodal analgesic management of postoperative pain after ambulatory anterior cruciate ligament repair. Anesth Analg, 1998. 86(2): p. 374-8.
5. Stein C, C.K., Haimerl E, Yassouridis A, Lehrberger K, Herz A, Peter K., Analgesic effect of intra-articular morphine after arthroscopic knee surgery. N Engl J Med, 1991. 325: p. 1123-1126.
6. Heard SO, E.W., Ferrari D, Hanna D, Wong PD, Liland A, Willock MM., Analgesic effect of intra-articular bupivacaine or morphine after arthroscopic knee surgery. A randomized prospective double blind study. Anesth Analg, 1992. 72: p. 822-826.
7. Denti M, R.P., Bigoni M, Vitale G, Marino MR, Fraschini N., Pre and postoperative intra-articular analgesia or arthroscopic assisted anterior cruciate ligament reconstruction. A double blind randomized prospective study. Knee Surg Sports Traumatol Arthrosc, 1997. 5: p. 206-212.
8. Kalso E, T.K., Carroll D, McQuay HJ, Moore RA., Pain relief from intra-articular morphine after knee surgery. Pain, 1997. 71: p. 127-134.
9. Tetzlaff JE, D.J., Abate J, Parker RD., Preoperative intra-articular morphine and bupivacaine for pain control after outpatient anterior cruciate ligament reconstruction. reg Anesth Pain Med, 1999. 24: p. 220-224.
10. Reuben, S.S., J. Sklar, and M. El-Mansouri, The preemptive analgesic effect of intraarticular bupivacaine and morphine after ambulatory arthroscopic knee surgery. Anesth Analg, 2001. 92(4): p. 923-6.
11. Rosaeg OP, K.B., Cicutti N, Dennehy K, Lui A, Johnson DH., Effect of Pre-emptive Multi-modal Analgesia for Arthroscopic Knee Ligament Repair. Regional Anesthesia and Pain Medicine, 2001. 26(2): p. 125-130.
12. Tierney E, L.G., Hurtig MB, Johnson DH, . Femoral Nerve Block with Bupivicaine 0.25% for post operative analgesia after open knee surgery. Can J. Anaesth, 1987. 34: p. 455-458.
13. Ringrose NH, C.M., Femoral nerve block in knee joint surgery. Am J Sports Med, 1984. 12: p. 398-402.
14. Thomas B, B.A., Levy M. A Prospective Randomized Trial of Femoral Nerve Blocks Before and After Anterior Cruciate Ligament Reconstruction. in AAOS. 2002. Dallas, Tx.
15. Allen GC, A.M., Lui ACP, Johnson DH, Lindsay MP, Postarthroscopy analgesia with intraarticular bupivacaine/morphine. A randomized clinical trial. Anesthesiology, 1993. 79: p. 475-480.
16. Shelbourne, K.D., F.J. Liotta, and S.L. Goodloe, Preemptive pain management program for anterior cruciate ligament reconstruction. Am J Knee Surg, 1998. 11(2): p. 116-9.
17. Hooper, J.R., O.P.; Krepski,B.; Johnson,D.H, Tourniquet inflation during arthroscopic knee ligament surgery does not increase postoperative pain. . Can.J.Anaesth, 1999. 46(10): p. 925-929.
18. McGuire, D.A., K. Sanders, and S.D. Hendricks, Comparison of ketorolac and opioid analgesics in postoperative ACL reconstruction outpatient pain control. Arthroscopy, 1993. 9(6): p. 653-61.
19. Reuben, S.S., et al., The preemptive analgesic effect of rofecoxib after ambulatory arthroscopic knee surgery. Anesth Analg, 2002. 94(1): p. 55-9, table of contents.
20. Cohn, B.T., R.I. Draeger, and D.W. Jackson, The effects of cold therapy in the postoperative management of pain in patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med, 1989. 17(3): p. 344-9.
21. Shelbourne, K.D., Post-operative Cryotherapy for the Knee In ACL Reconstructive Surgery. Orthopedics International Edition, 1994. 2(2).
22. Barber FA, M.D., Click S, Continuous-flow cold therapy for outpatient anterior cruciate ligament reconstruction. Arthroscopy, 1998. 14(2): p. 130 to p135.
23. Barber, F.A., A comparison of crushed ice and continuous flow cold therapy. Am J Knee Surg, 2000. 13(2): p. 97-101; discussion 102.
24. Casscells, S.W., Is continuous passive motion useful following cruciate ligament reconstruction? Arthroscopy, 1991. 7(1): p. 38.
25. Engstrom, B., A. Sperber, and T. Wredmark, Continuous passive motion in rehabilitation after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc, 1995. 3(1): p. 18-20.
26. Gaspar, L., et al., Therapeutic value of continuous passive motion after anterior cruciate replacement. Acta Chir Hung, 1997. 36(1-4): p. 104-5.
27. McCarthy, M.R., et al., The effects of immediate continuous passive motion on pain during the inflammatory phase of soft tissue healing following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther, 1993. 17(2): p. 96-101.
28. Richmond JR, G.J., MacGillivray J, Continuous passive motion after arthroscopically assisted anterior cruciate ligament reconstruction: comparison of short- versus long-term use. Arthroscopy, 1991. 7(1).
29. Rosen, M.A., D.W. Jackson, and E.A. Atwell, The efficacy of continuous passive motion in the rehabilitation of anterior cruciate ligament reconstructions. Am J Sports Med, 1992. 20(2): p. 122-7.
30. Witherow, G.E., S.R. Bollen, and L.A. Pinczewski, The use of continuous passive motion after arthroscopically assisted anterior cruciate ligament reconstruction: help or hindrance? Knee Surg Sports Traumatol Arthrosc, 1993. 1(2): p. 68-70.
31. Shelbourne, K.D., Anterior cruciate ligament reconstruction with autogenous patellar tendon graft followed by accelerated rehabilitation. A two- to nine-year followup. American Journal Sports Medicine, 1997. 25: p. 96-98.
32. Shelbourne, K.D., Evaluation of Knee Stability Before and After Participation in a Functional Sports Agility Program During Rehabilitation After Anterior Cruciate Ligament Reconstruction. American Journal Sports Medicine, 1999. 27: p. 155-161.
33. Shelbourne, K.D., Primary Anterior Cruciate Ligament Reconstruction Using the Contralateral Autogenous Patellar Tendon. American Journal Sports Medicine, 2000. 28: p. 651-658.