Comparative Study Between Systemic Balanced Analgesia, Continuous Femoral Perineural Analgesia and Continuous Intra-articular Analgesia for Primary Reconstruction Surgery of the Anterior Cruciate Ligament of the Knee

Abstract

Introduction. The aim of this prospective study was to compare the analgesic efficacy of three techniques for knee ligamentoplasty and quadricipital deficit with a view to early physiotherapy. Hypothesis. Continuous intra-articular analgesia and well-managed systemic analgesia could replace continuous femoral peri-nerve analgesia in resource-limited countries. Material. - We included 165 patients undergoing primary reconstruction of the anterior cruciate ligament of the knee. All patients underwent spinal anaesthesia. The first group, systemic analgesia (SA), received balanced systemic analgesia postoperatively for a minimum of five days, based on Paracetamol, Diclofenac and a morphine PCA. In addition to the systemic analgesia already described, the second group, femoral analgesia (FA), will benefit from a femoral peri-nervous catheter in the crural position. 20 ml of bupivacaine at 0.125% concentration is injected; maintenance is set up immediately with a continuous flow of 8 ml/h for 36 h. The third intra-articular analgesia (IAA) group received, in addition to the same systemic analgesia, an infusion through an epidural catheter of 20 ml of 0.125% bupivacaine, followed by maintenance with 8 ml/h of the same local anesthetic via an electric syringe pump for 36 h. Cumulative morphine consumption, pain estimation at rest and on mobilization using a numerical scale (EN) from 1 to 10, and quadriceps deficit were evaluated. Results. - Morphine consumption was lower in the AF group and the difference was statistically significant with an F = 3.539(2) and a p = 0.031. A mean difference of 6.12 ± 2.41 between the AS and AF groups with a significant p = 0.012, a mean difference of 1.67 ± 2.41 with a non-significant p = 0.49 between the AF and AIA groups and a mean difference of 4.45 ± 2.31 with a p = 0.056 at the limit of significance between the AS and AIA groups. Analgesia in the femoral peri-nerve group was more effective, with a reduction in mean EN compared with the other two groups. Efficacy was statistically significant at H4, then from H24 to H36 compared with systemic analgesia, but not significant compared with intra-articular analgésia. Intra-articular analgesia was only significantly effective compared with systemic analgesia at H36. Quadriceps muscle deficit is an incident specific to femoral blocks. Discussion. - This study suggests that a continuous intra-articular or even a well-conducted systemic analgesia provides satisfactory analgesia for knee ligamentoplasty, compared with a more effective femoral peri-nerve. The quadricipital lock absent in intra-articular treatment could be an advantage in speeding up functional recovery.