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

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( 1 3.7 +/- 5.8 mg; P=0.008). Treatment patients were ready for discharge approx imately 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.