Abstract
Background:
The culture of opioid abuse in the United States has brought attention to prescribing habits, especially as recent studies identify practices within the post-operative period as a risk factor for the development of opioid dependence in adolescents. The current study sought to explore the concept of post-operative pain control and opioid use following ACL reconstruction (ACLR), one of the most common orthopaedic procedures for adolescents. Because recent adult studies have suggested that use of quadriceps tendon autograft, a graft choice that appears to be growing in popularity, may be associated with lower post-operative pain scores than other graft sources, we additionally investigated an ACLR cohort who received quad tendon autograft (ACLR-Q) and compared their pain scores and opioid use to a cohort with the more commonly used hamstring tendon autograft (ACLR-HS).
Methods:
Between 2016 and 2018, patients aged 12-25 years who underwent primary ACLR-Q or ACLR-HS by one of three surgeons at tertiary care children’s hospital, were provided a journal to record daily subjective pain level and medication use. To avoid confounder or outliers, patients with a history of diagnosed clinical pain syndrome or underlying psychiatric condition were excluded. Logbooks contained a scale from ‘0-5’ to record pain level prior to each medication use and tables to record information detailing medication consumption. All patients were prescribed Oxycodone, 5 mg, for post-operative pain control. Patient demographics, surgical data, and prescription information were extracted from the electronic medical record. A two-sided t-test was used to evaluate statistical relationships of data between graft types.
Results:
Logbooks of 54 patients (27 ACLR-Q and 27 ACLR-HS) were collected for analysis. Both cohorts had a similar mean age at time of surgery (ACLR-Q: 16.7 years, range: 12-23; ACLR-HS: 16.8 years, range: 13-21), and preponderance of female subjects (ACLR-Q: 83.3%; ACLR-HS: 81.5%). The mean weight of patients who received the quadriceps tendon autograft (mean: 68.8lbs, range: 47-121) was slightly heavier than for patients who received the hamstring tendon autograft (mean: 62.0lbs, range 49-93), but not to a significant degree (p=0.084).
More meniscal injuries were identified in ACLR-HS patients (77.8% vs. ACLR-Q: 48.1%, p=0.024), and treated with a repair procedure more commonly (81% vs. ACLR-Q: 46.2%, p=<0.001), than with meniscectomy (19%; ACLR-Q: 46.2%, p=0.282). Mean length of surgery and tourniquet time were longer in the ACLR-Q (129, 115 minutes) group than ACLR-HS group (80, 54 minutes) (p=<0.001; p=<0.001).
While intra-operative nerve blocks were utilized by a similar proportion of both cohorts (ACLR-Q: 88.9%, ACLR-HS: 85.2%, p:0.692), the ACLR-Q group received more adductor canal blocks (89.9% vs. 14.8%, p: <0.001), while the ACLR-HS group received more femoral nerve blocks most frequently (ACLR-Q: 63% vs. 0%, p: <0.001).
For the overall study population, the mean number of pills per Oxycodone prescription was 47.5 (range: 30-84). ACLR-Q patients consumed an average of 14.6 opioid pain pills (range: 3-46) over a mean of 13.7 doses (range: 3-36), with the last dose occurring on day 4.4 (range: 1-13). ACLR-HS patients consumed an average of 16.9 opioid pain pills (range: 0-39) over a mean of 14.0 doses (0-36), with the last dose occurring on day 3.7 (range: 0-13). There were no significant differences seen between number of pills consumed (p=0.387), number of doses (p=0.880), or number of days over which opioid medication was taken (p=0.364), between the two cohorts. Subjective pain experience was the same on day of surgery (DOS) for the two graft choices (score: 2.4). Average pain scores increased by the same amount on post-operative day 1 (score: 2.7) for both groups, likely as residual effects from regional anesthetic wore off. By post-operative day 3, average pain scores in the ACLR-Q group (score: 2.3) and ACLR-HS group (score: 2.0) had declined to less than that seen on DOS, without statistical difference (p=0.350) in the pain level between the cohorts.
Conclusion/Significance:
Despite longer tourniquet and operative times in the ACLR-Q group, which is likely reflective of graft harvest/preparation time and a surgical learning curve associated with a relatively newer technique, adolescents and young adults who received quadriceps and hamstring tendon grafts had a similar profile of subjective pain and use of post-operative opioid medication in the immediate post-operative period. Differing rates of concomitant meniscal injury and regional anesthetic techniques may represent confounding factors that warrant future studies controlling for such factors. Importantly, both reconstructive techniques resulted in a large surplus of unused opioid medication, furthering the notion that evidence-based prescription practices for post-operative care in different surgical techniques is warranted by orthopaedic surgeons and sports medicine physicians to help stem the rising tide of the opioid epidemic.