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Combined pre- and post-surgical bupivacaine wound infiltrations decrease opioid requirements after knee ligament reconstruction

Noam N. Butterfield, BSc^*, Stephan K.W. Schwarz, MD DR MED^*,, Craig R. Ries, MD FRCPC PhD^*,, Luigi G. Franciosi, MSc^*, Brian Day, MB CHB MSc FRCS and Bernard A. MacLeod, MD FRCPC^*,

^* From the Clinical Pharmacology Research Organization (CPRO), Departments of Pharmacology & Therapeutics
and Anesthesia
and the Department of Orthopaedics, The University of British Columbia, Vancouver, British Columbia, Canada.

Address correspondence to: Dr. B.A. MacLeod, Clinical Pharmacology Research Organization, Department of Pharmacology & Therapeutics, The University of British Columbia, Vancouver, British Columbia, V6T 1Z3, Canada. Phone: 604-822-2103; Fax: 604-822-6012; E-mail: bmacleod{at}interchange.ubc.ca

Purpose: To test the efficacy of a combination of selective pre- and post-surgical local anesthetic infiltrations of the knee, compared with standard intra-articular injection at the end of surgery alone, to reduce postoperative opioid requirements following arthroscopic cruciate ligament reconstruction (ACLR).

Methods: In a double-blind, randomized, controlled trial, we studied 23 patients (ASA I or II) scheduled for elective ACLR under general anesthesia. The treatment group (n=12) received infiltrations with bupivacaine 0.25% with epinephrine 1:200 000 presurgically (10 ml into the portals, 10 ml at the medial tibial incision site, 10 ml at the lateral femoral incision site, and 10 ml intra-articularly) and postsurgically (5 ml at the medial tibial incision and 10 ml at the lateral femoral incision). The control group (n=11) received infiltrations with saline 0.9% in the same manner. All patients received a standard intra-articular local anesthetic instillation of the knee (25 ml of bupivacaine 0.25% with epinephrine 1:200 000) at the completion of surgery.

Results: Postoperative opioid requirements were lower in the treatment group (5.8 ± 2.9 mg morphine equivalent) than in the control group (13.7 ± 5.8 mg; P=0.008). Treatment patients were ready for discharge approximately 30 min earlier than control patients (P=0.046). There were no adverse events in the treatment group. In the control group, 2/11 patients vomited and a third experienced transient postoperative diaphoresis, dizziness and pallor.

Conclusion: We conclude that a combination of selective pre- and post-surgical wound infiltration with bupivacaine 0.25% provides superior analgesia compared with a standard post-surgical intra-articular injection alone.

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