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Abstract

Background:

The effect of the opioid epidemic has caused legislators and physicians alike to consider limitations on opioid prescription sizes. For anterior cruciate ligament reconstruction (ACLR) in particular, current knowledge is lacking on the size of postoperative opioid prescriptions written by orthopaedic surgeons.

Purpose/Hypothesis:

This review sought to quantify opioid prescriptions after ACLR. It was hypothesized that no consensus would exist among orthopaedic surgeons regarding current prescribing practices, leading to variability in prescription amounts.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

Under PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a literature search was performed using PubMed, MEDLINE, Ovid Embase, Scopus, and Cochrane CENTRAL databases from each database’s inception through August 12, 2022. Search terms included “anterior cruciate ligament reconstruction,” “opiate alkaloids,” “hydrocodone,” “oxycodone,” and “narcotics.” Studies were included if they quantified postoperative opioid prescriptions. The exclusion criteria included pediatric studies, abstracts or conference papers, reviews, unpublished randomized controlled trials, case reports, and papers not in the English language. Methodological Index for Non-Randomized Studies criteria were used to evaluate the quality of all included studies. This search strategy yielded a total of 1668 studies.

Results:

Eight studies quantified postoperative ACLR opioid prescriptions. Initial prescription amount in the absence of legislation or guidelines ranged, on average, from 49.78 opioid tablets to 104.5 opioid tablets, with prescription amounts varying by regions of the United States. Half of the studies (n = 4) examined the effect of opioid-limiting legislation or guidelines on prescribing practices. They found that enactment correlated with significant decreases in the number of opioids prescribed. When pain interventions were given to supplement opioid prescriptions, prescribers also decreased their prescription size.

Conclusion:

Our review demonstrates that differences exist in the quantity of oral opioids prescribed to patients undergoing ACLR. Opioid limiting legislation is effective in decreasing prescription size. However, there is no consistency of data used as evidence for guiding opioid-limiting legislation. This review is the first to explore opioid prescription size after ACLR and underscores the need for further research exploring patient opioid consumption, particularly as a means for formulating data-driven legislation.

Keywords

hydrocodone narcotics opioid-limiting legislation oxycodone prescription

As of 2019, the number of adolescents and adults living with opioid use disorder in the United States is estimated between 6.7 and 7.6 million individuals.¹⁸ In 2020, the Centers for Disease Control and Prevention reported that 75% of the 91,799 overdose-induced deaths involved an opioid.⁶ Excessive postoperative opioid prescribing practices have been recognized as a dominant contributor to addiction, with prescription opioid-related deaths rising by 17% in 2020 alone.^6,21 Orthopaedic surgeons prescribe more opioids than physicians in most other specialties, making it incumbent on physicians in this field to change prescribing habits to prevent further damage.^20,25,37 This is especially important in light of recent research demonstrating patient perspectives of opioid consumption after orthopaedic surgeries. In a 2022 survey of public opinion on opioid usage after orthopaedic surgeries, Alexander et al² reported that 15% of orthopaedic surgery patients would continue to take opioid medication until the prescription ran out, and 50% of patients would save leftover opioid pills to treat potential future pain.² Considering these findings, it is crucial that orthopaedic surgeons define data-informed postoperative opioid prescribing practices.

Anterior cruciate ligament reconstruction (ACLR) surgeries present an ideal target for opioid prescription guidelines given their relative frequency compared with other orthopaedic procedures. 200,000 to 250,000 ACL injuries occur yearly in the United States, making ACL tears the single most common ligamentous injury in the United States and the most common sports-related injury.^14,16,33 Over 120,000 reconstructions are performed per year, with upwards of 75% of patients receiving opioid prescriptions to manage pain.^16,27 Informed prescribing practices for these surgeries therefore pose immense potential to minimize the detrimental effects of overprescribing practices.

Previous research in this area has primarily focused on perioperative pain control modalities and in-patient medication consumption after ACLR.^13,24,26,41 However, there is limited evidence to instruct surgeons on how to prescribe opioids after ACLR. This has manifested as variation in opioid prescription volume.^4,10 Information on current opioid prescribing practices is needed to inform ACLR prescription guidelines. To our knowledge, no study has systematically organized recent literature on post-ACLR opioid prescribing practices. The purpose of this systematic review is to assess how many opioid pills are being prescribed to patients after ACLR surgery in the United States. The aims of this systematic review are 3-fold: (1) establish a baseline understanding of current opioid prescribing practices after ACLR; (2) identify what guidelines, policies, and legislations exist to guide prescription; and (3) identify gaps in opioid prescribing policy to inspire future investigations. We hypothesized that no consensus would exist among prescribers regarding the number of opioid pills to prescribe after ACLR.

Methods

We performed this systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines on August 12, 2020. Studies were included if they quantified the number of opioid pills prescribed to patients after ACLR. Minor secondary procedures such as meniscal repair or chondroplasty with ACLR were included, while studies with secondary procedures—including osteotomies, lateral extra-articular tenodesis, multiligamentous reconstructive surgeries, or revisional surgery—were excluded. Secondarily, studies were included if they commented on legislation or policy. Studies were excluded if data were reported on pediatric patients only, were review articles, incomplete randomized controlled trials, abstracts, or conference posters, or were not written in the English language.

Search Strategy

A medical librarian (T.K., with 9 years of experience) developed the following search strategy. Controlled vocabulary and keywords, including but not limited to “anterior cruciate ligament reconstruction,” “opiate alkaloids,” “hydrocodone,” “oxycodone,” and “narcotics,” were used along with truncation and adjacency operators to search for relevant literature. The search was conducted in Ovid MEDLINE, Ovid Embase, Scopus, and Cochrane CENTRAL databases from inception to August 12, 2022. Search was not restricted by date, language, or publication type.

Study Selection

A total of 1668 studies were filtered from all databases. All studies were transferred to the Covidence (Veritas Health Innovation Ltd) application, and 3 authors (M.E.H., M.S.R., and M.J.S.) were granted access. A total of 916 duplicates were then removed. Two medical student authors (M.E.H. and M.S.R.) independently screened the titles and abstracts of the remaining 752 articles. Discrepancies between authors were resolved by the senior author (M.J.S.). A total of 149 articles were selected for full-text review. Two medical student authors (M.E.H. and M.S.R.) then screened these articles with discrepancies arbitrated by the senior author (M.J.S.). Of these, 8 articles were eligible for inclusion in this review (Figure 1).

Figure 1.

A PRISMA flow diagram for the study selection process. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Data Items and Quality Assessment

The extracted data included the title of the article, author names, publication year, methodology for the publication, data collection methods for prescription quantification, prescription duration, prescription amount, and pain complications. Furthermore, the policy and/or legislation were documented, as well as the effect on the prescription amount. For easier cross-study comparison, opioid tablets were converted to morphine milligram equivalents (MME) using the Centers for Disease Control and Prevention guidelines when possible.⁵ If multiple opioid pill types were included in prescriptions, conversions were appropriately made to 5 mg oxycodone for ease of comparison. If the specific pill type was not specified, conversion to MME was made assuming a prescription of 5 mg oxycodone. If only MME were provided, conversion was made to 5 mg oxycodone tablets for the clinical context. Otherwise, the initial type and concentration of opioid tablet were retained and reported from the original study. Each study was reviewed according to the Methodological Index for Non-Randomized Studies (MINORS) criteria, which reliably assesses the methodological quality of nonrandomized surgical studies,³⁴ and the level of evidence of each study was documented.

Results

This systematic review identified 752 studies with potential for inclusion. Of these, 603 were excluded based on title and abstract review, leaving 149 studies for full-text review (Figure 1). After review, 8 studies remained.^{3,8,11,12,17,29,36,38} A total of 141 studies were excluded for the following reasons: 86 studies did not record postoperative opioid prescriptions, 19 were incomplete randomized control trials either still enrolling patients or without published data, 12 were abstracts, 8 were irretrievable, 4 did not have ACL-specific outcomes, 4 did not use oral administration of postoperative opioids, 3 were retracted since publication, 3 utilized the wrong study design 1 studied the wrong patient population, and 1 reported duplicate data.

Nonopioid Pain Interventions

Two studies^11,36 related perioperative nonopioid pain interventions to the number of opioid tablets prescribed (Table 2). Hajewski et al¹¹ compared opioid prescription size before and after the introduction of a multimodal analgesic regimen, whereas Stryder et al³⁶ compared opioid prescription size with experimental liposomal bupivacaine versus a control regimen without bupivacaine. In both studies, the addition of nonopioid perioperative pain management reduced the number of prescribed opioids without affecting patient-reported pain levels.

Table 1

Summary of Included Studies Quantifying Opioid Prescribing Practices Within the Context of Postoperative Pain Interventions ^a

Author (Year)	Pain Intervention	Data Collection Time Frame	Prescription Duration ^b	Prescription Amount ^c	P	Pain Complications	Level of Evidence
Hajewski et al¹¹ (2019)	Standardized multimodal analgesic protocol: 650 mg acetaminophen QID, 15 mg meloxicam daily, 300 mg gabapentin TID, 325 mg aspirin daily, 5 mg oxycodone PRN	12 months before and 6 months after multimodal analgesic introduction	Initial prescription	Before: 73.3 ± 13.9 tablets (549.8 ± 104.3 MME)	<.0001	19.6% (before) vs 14.3% for patients requiring refill; P = .2492	3
Hajewski et al¹¹ (2019)			Initial prescription	After: 39.7 ± 2.6 tablets (297.8 ± 19.5 MME)	<.0001		3
Stryder et al³⁶ (2021)	Liposomal bupivacaine as part of multimodal analgesia	2 years after the addition of liposomal bupivacaine to the analgesic regimen	Initial prescription	Control: 66.3 ± 37.1 tablets (497 ± 278.5 MME)	<.01	2.8 ± 2.1 (LB) vs 3.8 ± 2.4 for VAS-Pain rating scale at POD 14; P = .09	3
Stryder et al³⁶ (2021)	Liposomal bupivacaine as part of multimodal analgesia		Initial prescription	Liposomal bupivacaine: 9.3 ± 10.3 tablets (69.7 ± 77.2 MME)	<.01		3

Values are presented as mean ± SD, unless otherwise indicated. LB, liposomal bupivacaine; MME, morphine milligram equivalents; PACU, postanesthesia care unit; POD, postoperative day; PRN, as needed; QID, 4 times a day; TID, 3 times a day; VAS, visual analog scale.

Initial prescription, defined as a script written in PACU.

5 mg oxycodone tablet, unless otherwise specified.

Opioid-Limiting Legislation

Four studies related the enactment of opioid-limiting legislation or prescribing guidelines to the number of opioid tablets prescribed (Table 2).^3,8,17,29 Bisson et al³ were the only investigators to study institutional opioid prescribing guidelines rather than state-wide limiting legislation. Across all 4 studies, legislation or hospital guideline enactment correlated with smaller initial prescription size (Table 3). The median percentage decrease in initial prescription size after legislation or guidelines enactment was 43.5% (range, 40.2%-55.7%). Two out of 4 studies reported pain outcomes before and after opioid limitation, and found that limitations did not affect pain-related complications or patient satisfaction with pain management.^3,1

Table 2

Summary of Studies Examining Opioid-Limiting Legislation and Guideline Restrictions and Prescription Data Collection Methods ^a

Author (Year)	State of Enactment	Legislation Restrictions ^b	Data Collection Time Frame	Data Collection Methods	Level of Evidence
Reid et al²⁹ (2019)	Rhode Island	Limit of 4 tablets (30 MME) per day, 20 tablets (150 MME) total, or 20 total doses	6 months before and 6 months after the law enactment	Rhode Island Prescription Drug monitoring program for all opioid prescriptions filled within 90 days after ACLR	3
Kamaci et al¹⁷ (2021)	Ohio	Limit of 4 tablets (30 MME) per day with a maximum of 7-day duration	1 year before and 1 year after the law enactment	Ohio Automated Rx Reporting Systems and patient medical charts for all opioid prescriptions filled within 90 days after ACLR	3
Cunningham et al⁸ (2021)	North Carolina	Limit of 5-day supply of schedule 2 and 3 opioids and mandated controlled substances reporting systems check	1 year before, 1 year during, and 1 year after the law enactment	Extracted using Analytics Center for Excellence	3
Bisson et al³ (2021)	New York	Recommendation of 20 opioid pills post-ACLR	4 months before and 5 months after guideline introduction	Retrospective patient chart review	3

ACLR, anterior cruciate ligament reconstruction; MME, morphine milligram equivalent.

Tablet, 5 mg oxycodone tablet, unless otherwise specified.

Table 3

Postoperative Prescription Amounts for Studies Examining the Effects of Opioid-Limiting Legislation and Guidelines ^a

		Prescription Amount ^c
Author (Year)	Prescription Duration ^b	Before Enactment	During Enactment	After Enactment	P
Reid et al²⁹ (2019)	Initial prescription	46.8 tablets (350.9 MME)	NR	20.7 tablets (155.1 MME)	<.001
	POD 1-30	76.4 tablets (571.3 MME)	NR	39 tablets (292.5 MME)	<.001
	POD 30-90	2.6 tablets (19.7 MME)	NR	3.0 tablets (22.2 MME)	.8925
Kamaci et al¹⁷ (2021)	POD 1-30	85.3 ± 49.1 tablets (639.7 ± 368.9 MME)	NR	49.5 ± 19.4 tablets (367.7 ± 145.9 MME)	<.001
Kamaci et al¹⁷ (2021)	POD 1-90	88.6 ± 52.6 tablets (664.7 ± 394.6 MME)	NR	52.1 ± 30.3 tablets (390.4 ± 227 MME)	<.001
Cunningham et al⁸ (2021)	Initial prescription	52.3 ± 31.7 tablets (392.3 ± 237.8 MME)	49.2 ± 20.6 tablets (369 ± 154.3 MME)	31.3 ± 17.7 tablets (233.3 ± 132.4 MME)	<.001
Cunningham et al⁸ (2021)	POD 1-42	66.3 ± 59.5 tablets (497.3 ± 446.3 MME)	66.7 ± 43.9 tablets (500.3 ± 329.3 MME)	38.7 ± 31 tablets (290.3 ± 232.6 MME)	.003
Bisson et al³ (2021)	Initial prescription	54.52 ± 36.15 opioid pills	NR	30 ± 12.5 opioid pills	.01

Values are presented as mean ± SD. MME, morphine milligram equivalent; NR, not reported; PACU, postanesthesia care unit; POD, postoperative day.

Initial prescription, defined as a script written in PACU.

5 mg oxycodone tablet unless otherwise specified.

Prescription by Geographic Region

Two studies related geographic regions of the United States to the number of opioid tablets prescribed (Table 4).^12,38 Henry et al¹² quantified regional prescription sizes for Maryland and the surrounding states to correlate them with patient satisfaction with pain management. Conversely, Traven et al³⁸ were specifically interested in examining prescription trends across regions of the United States. The size of initial prescriptions varied by geographic region between the 2 studies. They found that the South and West regions of the United States recorded the largest initial prescriptions (60 tablets), whereas the Northeast and Midwest regions recorded the smallest (50 tablets).³⁸

Table 4

Summary of Included Studies Quantifying Opioid Prescribing Practices by Location in the Absence of Opioid Prescription Legislation or Guidelines ^a

Author (Year)	Data Collection Methods	Data Collection Time Frame	Prescription Duration ^b	Region or State of Interest	Prescription Amount ^c	P	Level of Evidence
Traven et al³⁸ (2021)	Truven Health MarketScan database of privately insured patients	6-month postop period between 2015 and 2016	Initial prescription	National	53.3 [40-72] tablets (400 [300-540] MME)	<.0001	3
				Northeast	50 [40-60] tablets (375 [300-450] MME)
				Midwest	50 [40-70] tablets (375 [300-525] MME)
				South	60 [40-80] tablets (450 [300-600] MME)
				West	60 [50-90] tablets (450 [375-675] MME)
			POD1-90	National	68 [50-108] tablets (510 [375-810] MME)	<.001
				Northeast	60 [40-80] tablets (450 [300-600] MME)
				Midwest	70 [50-107] tablets (525 [375-800] MME)
				South	76 [50-120] tablets (570 [375-900] MME)
				West	74.6 [50-120] tablets (560 [375-900] MME)
Henry et al¹² (2021)	Regional prescription monitoring database searches for patients undergoing ACLR	June 2015 to May 2017	Initial prescription	Maryland and the surrounding states	104.5 ± 28.5 tablets (784 ± 213.8 MME)	NA	3
Henry et al¹² (2021)		June 2015 to May 2017	Refill prescription	Maryland and the surrounding states	13.7 ± 40.1 tablets (102.4 ± 300.8 MME)	NA	3

Values are presented as mean ± SD or median [Q1-Q3]. ACLR, anterior cruciate ligament reconstruction; MME, morphine milligram equivalent; NA, not applicable; PACU, post anaesthesia care unit; POD, postoperative day; Postop, postoperative; Q, quartile.

Initial prescription, defined as a script written in PACU.

5 mg oxycodone tablet unless otherwise specified.

Quality Assessment

Table 5 shows the composite MINORS score assigned to each study by each rater. The intraclass correlation coefficient to assess complete agreement between raters was 0.985 (95% CI, 0.927-0.996), which is considered excellent agreement.¹⁹

Table 5

Total MINORS Scores Awarded to Each Included Manuscript by 2 Independent Rates ^a

Author (Year)	Total MINORS Score
Author (Year)	Rater 1	Rater 2
Hajewski et al¹¹ (2019)	19	19
Stryder et al³⁶ (2021)	21	20
Reid et al²⁹ (2019)	19	19
Kamaci et al¹⁷ (2021)	20	20
Cunningham et al⁸ (2021)	18	18
Bisson et al³ (2021)	18	18
Traven et al³⁸ (2021)	13	14
Henry et al¹² (2021)	12	12

ICC of 0.985 (95% CI, 0.927-0.996) signifies excellent agreement between raters. ICC, intraclass correlation coefficient; MINORS, Methodological Index for Non-Randomized Studies.

Discussion

Our systematic review found significant variation in the number of opioids prescribed after ACLR. Without limitations on prescribing practices, physicians prescribed anywhere between 49.78 opioid tablets²⁹ and 104.5 opioid tablets¹² for an initial discharge prescription.^{3,8,11,12,17,29,36,38} Furthermore, there was significant regional variation, with physicians in the South and the West tending to prescribe more initial opioids than those in the Northeast and Midwest.^{3,12,17,29,38} Without prescription mandates, physicians tended to prescribe >500 MME for an initial prescription, which would be equivalent to 66 tablets of 5 mg oxycodone.^11,12,17 Toward our second aim, we found that enactment of opioid-limiting legislation correlated with decreases in initial prescription size by between 40% and 56% (decrease range, 21-36 opioid tablets).^3,8,17,29 However, none of the legislations or policies were based on evidence-based guidelines, highlighting an opportunity for future research to better guide clinicians.

Geographic variation was a strong theme that emerged across our studies: geographic location had a highly influential effect on the size of postoperative prescriptions. This supported our hypothesis that no uniformity would exist among orthopaedic surgeons for post-ACLR prescribing practices. Similar variation was found by Marrache et al²³ when assessing geographic variability in ACLR opioid prescriptions. Both the number of opioid prescriptions and the proportion of those prescriptions that prescribed >12 tablets of 5 mg oxycodone varied significantly by state. Similar trends have been shown for more minor knee procedures, suggesting that prescribing practices for ACLR are not uniquely variable in the absence of guidelines.⁴⁰

Although we can celebrate the success of opioid-limiting legislation, further efforts are still needed. As of 2019, a total of 39 out of 50 states have enacted some opioid legislation, which is immensely promising.⁹ However, a recent study commented that, as more states pass opioid-limiting legislation, greater heterogeneity between states has emerged, specifically for limitations on prescription population, duration, and amount. Such is evidenced in this review: the 4 states where legislation was studied all set different limitations. This legislative heterogeneity issue dates back to 1990, when physicians and lawmakers still struggled to achieve standardization.^9,15 This blatantly illustrates the lack of consensus between providers and lawmakers for how opioids should be prescribed after surgical procedures. In addition, there is little transparency to the public on how limitations for prescribing practices are chosen, leaving patients and physicians alike wondering what evidence-based studies guide law-making. All this underscores the importance of more studies to investigate the optimal prescription size for orthopaedic procedures where pain control is maximized and opioids are minimized.

Against such a heterogeneous geographic backdrop, the efficacy of uniform opioid-limiting legislation and hospital-based prescribing guidelines remains more important than ever. Of the 4 studies included in this review that implemented opioid prescription guidelines, all found significant and clinically relevant reductions in opioid prescribing.^3,8,17,29 These findings are further supported by evidence demonstrating a 54.5% reduction in average prescription MME across orthopaedic subspecialties when prescribing interventions are implemented.³⁹ The power of opioid-limiting legislation is not unique; it traverses other states and orthopaedic procedures, including but not limited to shoulder surgery,^28,30,32 hip arthroscopy,²⁸ and total joint arthroplasty.⁷

Opioid guidelines are promising, but they are only one piece of the puzzle. Continued surgeon education on prescribing guidelines is crucial for maintaining adherence to prescribing practices over time. Stanley et al³⁵ found that adherence to opioid-limiting guidelines can be low (23.1%). Still, physician reeducation after the introduction of guidelines can increase compliance with the ultimate improvement in reducing patient opioid prescriptions. Surgeon education can be additionally important for overcoming physician-perceived barriers to guideline-based prescribing and improving physician confidence surrounding prescribing practices.^1,31 This shows how opioid-limiting efforts must be performed on an institutional level and not only a state-wide or national level. Both education and legislation can be effective on their own, but their potency would be synergized if implemented together.

There were several limitations to this study. First, all the included studies were retrospective, which made it less possible to quantify the direct effect of legislation versus other factors influencing prescribing practices. Second, the heterogeneity of the intervention being examined (ie, legislation vs pain modality) prevented us from conducting a meta-analysis. Different interventions can lead to varying levels of change in prescribing practices. Third, this systematic review is limited in its ability to formally propose opioid prescribing guidelines because a meta-analysis was not performed. The previously mentioned heterogeneity of techniques among studies prevented direct comparison of studies. However, the heterogeneity does not detract from the overall presentation of data or the conclusion of this study. The associated findings provide a generalized framework for prescribing guidelines that can be applied to routine clinical practices, indirectly accounting for the variation that exists within the orthopaedic community at large. Fourth, this review does not include any hospital- or clinic-specific surveys of prescribing practices; instead, the included studies are predominantly state-wide or national database studies or those quantifying prescribing practices within the context of an experimental intervention. While important to characterize macro trends, these studies may be less practical for demonstrating contemporary, day-to-day prescribing practices, which smaller survey studies may better characterize. To this end, we cite an internal institutional quality assessment that reports physician opioid prescribing practices after simple knee arthroscopies. This study was conducted at multiple hospital sites across 2 states (Ohio and Florida) and included physicians operating at academic, private, and public hospitals. It demonstrated that, despite a 4 opioid tablet evidence-based prescription guideline for simple knee arthroscopy, which was established by a previous institutional study, median initial prescription size was 12 tablets with a range from 0 to 90 tablets. While the pain of ACLR procedures typically necessitates more aggressive perioperative pain management than simple knee arthroscopies, we believe that the results of this study can be extrapolated to ACLR procedures, evidencing that initial opioid prescription size remains higher than desired despite a national movement toward decreased prescription size. Finally, this review is limited in its scope in 2 important ways. Because this review only includes studies conducted in the United States, the findings herein have limited international applicability. While our comprehensive search strategy did not impose geographic or journal limitations, all articles that qualified for inclusion came from American institutions. This is logical when put into the context that the United States consumes 80% of the world’s opioids while only making up 4.6% of the global population.²² Patient pain perspectives also fall outside the scope of this review; however, information on this topic can be found in another review on opioid consumption from our group (Hale et al, 2025).

Conclusion

Our review demonstrates that differences exist in the quantity of oral opioids prescribed to patients undergoing ACLR. Opioid-limiting legislation is effective in reducing prescription size. However, there is no consistency of data used as evidence for guiding opioid-limiting legislation. This review is the first to explore opioid prescription size after ACLR and underscores the need for further research exploring patient opioid consumption, particularly as a means for formulating data-driven legislation. The findings in this study act as the foundation for a grant-funded randomized clinical trial that will evaluate opioid consumption and postoperative patient-reported outcomes. In doing so, it will be the first study to provide targeted data and establish a basis for evidence-based opioid prescribing guidelines.

Footnotes

Acknowledgements

The authors acknowledge Jennifer Baldwin for her work in organizing and submitting this manuscript.

Final revision submitted May 21, 2025; accepted July 8, 2025.

One or more of the authors has declared the following potential conflict of interest or source of funding: This study was supported by grants from the National Institutes of Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (AR075422, R01 AR074131, and AR053684). K.P.S. has received support for education from Summit Surgical; consulting fees from Novo Pedics, Flexion Therapeutics, and the National Football League; and honoraria from Novo Pedics and PRO-T. The Cleveland Clinic licensed the Outcomes Measurement and Evaluation technology used in this study from Oberd. K.P.S. is an inventor of the technology, and he and the Cleveland Clinic are entitled to royalties from Oberd. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Ethical approval was not sought for the present study.

ORCID iDs

Martina E. Hale

Michael S. Ramos

Kurt P. Spindler

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Opioid Prescribing Practices After Anterior Cruciate Ligament Reconstruction: A Systematic Review

Abstract

Background:

Purpose/Hypothesis:

Study Design:

Methods:

Results:

Conclusion:

Keywords

Methods

Search Strategy

Study Selection

Data Items and Quality Assessment

Results

Nonopioid Pain Interventions

Opioid-Limiting Legislation

Prescription by Geographic Region

Quality Assessment

Discussion

Conclusion

Footnotes

Acknowledgements

ORCID iDs

References