w w w . r b o . o r g . b r
Original
Article
Reconstruction
of
the
anterior
cruciate
ligament:
comparison
of
analgesia
using
intrathecal
morphine,
intra-articular
morphine
and
intra-articular
levobupivacaine
夽
Leandro
Queiroz
Pinheiro
a,
Edmundo
Neri
Junior
a,
Reginaldo
Mendonc¸a
Fernandes
a,
Rodrigo
Tavares
Cardozo
a,∗,
Priscila
Rodrigues
Rezende
b aServic¸odeOrtopediaeTraumatologiadeRibeirãoPreto,RibeirãoPreto,SP,BrazilbCooperativadosAnestesiologistasdeRibeirãoPreto,RibeirãoPreto,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received18December2013
Accepted3April2014
Availableonline16June2015
Keywords:
Morphine/administrationand
dosage Arthroscopy
Anteriorcruciateligament/surgery
Anesthesia
a
b
s
t
r
a
c
t
Objective:Tocomparetheanalgesiceffectofintra-articularadministrationofmorphineand
levobupivacaine(separatelyorincombination)withintrathecaladministrationofmorphine
inpatientsundergoinganteriorcruciateligament(ACL)reconstructionusingautologous
graftsfromthepatellartendon.
Methods:Thiswasaretrospectiveanalysisondatagatheredfromthemedicalfilesof60
patientsaged20to50yearswhounderwentkneevideoarthroscopyforACLreconstruction.
Thepatientsweredividedintofourgroupsof15individuals(A,B,CandD)accordingtothe
agentadministeredintothejointandaroundtheincision:20mLofsalinesolutionwith5mg
ofmorphineinA;20mLof0.5%levobupivacainesolutioninB;10mLofsolutionwith2.5mg
ofmorphineplus10mLof0.5%levobupivacainesolutioninC;andmorphineadministered
intrathecallyinD.
Results:Allthegroupspresentedlowpainscoresduring thefirst12hafterthesurgery.
GroupsBandCpresentedsignificantlygreaterpainscoresthanshownbygroupD(control),
24hafterthesurgery.TherewasnostatisticaldifferenceinpainscoresbetweengroupA
andgroupD.
Conclusion:ThepatientsingroupApresentedanalgesiacomparabletothatofthepatients
ingroupD,whereastheprocedureofgroupCwasnocapableofreproducingtheanalgesic
effectobservedingroupD,asobserved24hafterthesurgery.Furtherstudiesareneededin
ordertoshowtheexactmechanismofaction,alongwiththeidealdoseandconcentration
forapplyingopioidstojoints.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora
Ltda.Allrightsreserved.
夽
WorkdevelopedattheServic¸odeOrtopediaeTraumatologiadeRibeirãoPretoandatHospitalSãoFrancisco,RibeirãoPreto,SP,Brazil.
∗ Correspondingauthor.
E-mail:torradarodrigo@hotmail.com(R.T.Cardozo).
http://dx.doi.org/10.1016/j.rboe.2015.06.002
Reconstruc¸a
˜
o
do
ligamento
cruzado
anterior:
comparac¸ão
da
analgesia
com
morfina
intratecal,
morfina
intra-articular
e
levobupivacaína
intra-articular
Palavras-chave:
Morfina/administrac¸ãoe
dosagem Artroscopia
Ligamentocruzado
anterior/cirurgia Anestesia
r
e
s
u
m
o
Objetivo: Comparar o efeito analgésico da administrac¸ão intra-articular de morfina e
levobupivacaína(isoladasouassociadas)comaadministrac¸ãointratecaldemorfinaem
pacientessubmetidosàreconstruc¸ãodoLCAcomenxertoautólogodetendãopatelar.
Métodos:Análiseretrospectivadosdadoscoletadosnosprontuáriosde60pacientesentre20
e50anos,submetidosàvídeoartroscopiadejoelhoparareconstruc¸ãodoLCA.Ospacientes
encontravam-seseparadosemquatrogruposde15pessoas(A,B,CeD)deacordocom
aadministrac¸ãointra-articulareperi-incisionalde20mLdesoluc¸ãosalinacom5mgde
morfinaemA,20mLdesoluc¸ãoa0.5%levobupivacaínaemB,10mLdesoluc¸ãocom2.5mg
demorfinae10mLdesoluc¸ãoa0.5%delevobupivacaínaemCemorfinaintratecalmente
emD.
Resultados:Todososgruposapresentarambaixosescoresdedornasprimeiras12horasapós
acirurgia.OsgruposBeCapresentaramescoresdedorsignificativamentemaioresdoqueo
grupoD(controle)24horasapósacirurgia.Nãohouvediferenc¸aestatísticaentreosescores
dedordogrupoAedogrupoD.
Conclusão: NospacientesdogrupoAhouveanalgesiacomparávelàdospacientesdoD,ao
passoqueoprocedimentoemCnãofoicapazdereproduziroefeitoanalgésicoobservado
emDquandoosindivíduosforamestudadosapós24horasdacirurgia.Novosestudossão
necessáriosparaevidenciaroexatomecanismodeac¸ão,bemcomoadoseeconcentrac¸ão
ideaisparaaplicac¸ãoarticulardeopioides.
©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier
EditoraLtda.Todososdireitosreservados.
Introduction
Theanterior cruciate ligament (ACL) isthe ligament most
affectedbykneeinjuries.1 ThemajorityofACLinjuriesare
related to practicing sports, especially those that demand
rapidchangesindirectioninassociationwithbodycontact.2
Arthroscopic ACLreconstruction isa successfulorthopedic
procedurethatisfrequentlyperformed.Aconsiderable
vari-etyoftechniquesandmaterialsareusedinit.3IntheUnited
States,approximately175,000reconstructionsinvolvingthis
orthopedicoperationareperformed every year.ACL
recon-struction has now become a worldwide practice4 and is
increasinglybeingperformedasanoutpatientprocedure.In
theservicefromwhichthepresentstudyoriginated,204ACL
reconstructionoperations wereperformedbytwoknee
sur-geonsin2012.
Adequatecontroloverpostoperativepain,particularly
dur-ingitspeakintensityonthefirstdaysaftertheoperation,isa
commonconcernsharedbythesurgeon,anesthetist,patient
andphysiotherapist.Goodcontroloverthispainenablesearly
hospitaldischarge,comfortandtheconfidencetoplaceweight
ontheoperatedlimbearlyonanddophysiotherapeutic
exer-cisesthathavetheobjectiveofallowinggainsinjointrange
ofmotion.Italsopreventsarthrofibrosis,improvestonusand
muscle trophismand allows bettermotor controlover the
limb.5,6Amongthebenefits,greaterindependencein
day-to-dayactivitiesandminimizationofthedurationofinterruption
ofworkactivitiescanbehighlighted.5–7
A variety of types of postoperative analgesia are
fre-quently used: cryotherapy,8,9 systemic analgesic and
anti-inflammatorydrugs(administeredorally,intramuscularlyor
intravenously),10intra-articularinjectionofdrugs,11–18
anes-thetic block of peripheral nerves19,20 and intrathecal and
periduralinjectionofanalgesicdrugs.21
The ideal treatment not only should provide adequate
analgesiabutalsoshouldbesafe,withlowincidenceof
com-plicationsand sideeffects. Intra-articular use ofdrugshas
the advantageofdiminishingthe needfordrugswith
sys-temicaction(intravenousororal)andtheirsideeffects.22This
is thereforean attractivemethodfor clinicalpractice.
Sev-eraldrugshavebeenproposedandtestedforintra-articular
use, including non-steroidal anti-inflammatory drugs,11,21
opioids14,23andlocalanesthetics.17,23
Althoughintra-articularanalgesiaafterACLreconstruction
hasalreadybeen analyzedinmanystudies,therearelarge
numbersofvariablesrelatingtothesurgicaltechnique,type
ofanesthesia,drugdose,timefordruginjectionand
postop-erativeprotocol.
Theexpectationoftheauthorsofthepresentstudyisthat
intra-articulardrugapplicationshouldbecapableof
replac-ingtheuseofintrathecalmorphineandshoulddiminishthe
needforintravenous administrationofanalgesics, inorder
to avoidtheirside effects. Itcanalsobe emphasizedthat,
ininvestigatingthepertinentliterature,itwasobservedthat
inmostofthesestudies,generalanesthesiaandautologous
graftsfromtheflexortendonswereused.However,inthe
andsurgicaltechniquesmostoftenusedarespinalanesthesia
andarthroscopicreconstructionusingautologousgraftsfrom
thepatellartendon.
Thisstudy hadtheobjective ofcomparingthe analgesic
effectsfromintra-articularadministrationofmorphineand
levobupivacaine(separatelyorinassociation)with
intrathe-caladministrationofmorphine,inpatientswhounderwent
ACLreconstructionwithanautologousgraftfromthepatellar
tendon.
Material
and
methods
Aretrospectiveanalysiswasconductedondatagatheredfrom
themedicalfilesof60malepatientsaged20to50years,whose
physicalstategradedinaccordancewiththestandardofthe
AmericanSocietyofAnesthesiology(ASA)wasItoII.These
patientsunderwentvideoarthroscopyonakneeforACL
recon-structionbymeans ofthesamesurgicaltechniquein2012,
consistingofuseofagraftfromthepatellartendonand
inter-ferencescrewsforitsfixationtothefemurandtibia.
ThisstudywasconductedintheOrthopedicsand
Trauma-tologyServiceofHospitalSãoFranciscodeRibeirãoPreto,São
Paulo,afterobtainingapprovalfromtheEthicsCommitteeof
HospitaldasClínicas,RibeirãoPretoMedicalSchool,
Univer-sityofSãoPaulo(USP).
Amongallthemedicalfilesanalyzed,15patientsreceived
intra-articularapplication(15mL) and peri-incisional
appli-cation(5mL)of5mgofmorphinein20mLofphysiological
solution at the end of the operation. These patients were
identifiedasGroupA.Fifteenpatientsreceivedintra-articular
application(15mL) andperi-incisional application(5mL) of
20ml of0.5% levobupivacainewithout vasoconstrictor and
were identifiedas GroupB.Fifteenpatients received
intra-articularapplication (15mL) and peri-incisionalapplication
(5mL)ofasolutioncontaining2.5mgofmorphinein10mL
ofphysiologicalsolutionplus10mLof0.5%levobupivacaine
withoutvasoconstrictorandwereidentifiedasGroupC.
Fif-teenpatientsreceived75mcgofintrathecalmorphinealone,
addedtoaspinalanesthesiasolution,andwereidentifiedas
GroupD(Table1).
Theanalgesiamethodusedforeachpatientwaschosen
onlyasafunction oftheprotocol that wasin forceatthe
timeofthesurgery.Therewasnodraworrandomselectionof
theprotocolforeachindividual.Theotherpatientsoperated
overtheperiodofthisstudywerenotincludedbecauseeither
theydidnotfitwithintheinclusioncriteriadescribedabove
ornodatarelatingtothenumericalpainscalewasavailable
forthem.
Table1–Distributioningroups.
Group No.ofindividuals Interventions
A 15 Intra-articularandperi-incisional
administrationof20mLofsaline solutionwith5mgofmorphine
B 15 Intra-articularandperi-incisional
administrationof20mLof0.5% levobupivacainewithout vasoconstrictor
C 15 Intra-articularandperi-incisional
administrationof10mLofsaline solutionwith2.5mgofmorphine plus10mLof0.5%levobupivacaine withoutvasoconstrictor
D 15 Administrationof75mcgof
intrathecalmorphine
All the patients underwent spinalanesthesia consisting
of 3mL of 0.5% hyperbaric bupivacaine and postoperative
analgesicswereonlyprescribedifnecessary,atthepatient’s request.Thefollowingwereusedpreferentiallyand progres-sively: 1g of dipyrone intravenously, 100mg of ketoprofen intravenously and 100mg oftramadolintravenously.All of thepatientsreceivedaprophylacticdoseofbetween50mg/kg andamaximumof2gofcefalotin,alongwith1gofdipyrone
and30mgofketorolactromethamine,intravenously,
imme-diatelybeforethestartoftheanesthesia.Furthermore,allthe patientsunderwentthesamesurgicaltechniqueforligament
reconstruction, with or without associated meniscectomy,
dependingontheneedsofeachcase,bytwoorthopedistswho werekneesurgeonswithexperienceofthistypeofsurgery.
Assessmentsofpainandpostoperativesideeffectswere
recordedaftersix,12and24hbymeansofanumericalpain
scale and values from 1 to 5 were attributed: 1=absence
ofpain,withoutadministrationofanalgesics;2=mildpain, withoutanyneedtouseanalgesics;3=moderatepain, alle-viated using a singledose ofanalgesic; 4=moderate pain, resolvedusingtwoormoredosesofanalgesics;and5=intense painwithoutanyresponsetoordinaryanalgesics.
TheresultswereanalyzedusingStudent’sttest(p<0.05)in
comparisonwithGroupD.
Results
Allthegroupspresentedsimilardistributionregardingweight and age.Theresultsare presentedinTable2.Thelast
col-umnshowsthevaluesobtainedfromStudent’sttestatthe
5%significancelevelforcomparingGroupDwiththe other
groups.
Table2–AnalgesiceffectofdifferentdosesadministeredinpatientswhounderwentACLreconstruction.
Group n Weight(kg) Age(years) ASA Painindex(1–5) t
8h 12h 24h
A 15 88±14 29±9 ItoII 1.30±0.21 1.40±0.26 2.00±0.23 tDA1.85nstDB2.94stDC4.35s
B 15 80±2.17 29±1.98 ItoII 1.13±0.09 1.69±0.15 2.42±0.25
C 15 82±2.40 31±2.82 ItoII 1.05±0.05 1.20±0.09 2.58±0.18
Regardingthepainevaluation,allthegroupspresentedlow
scoresoverthefirst12hafterthesurgery.GroupsBandC
pre-sentedsignificantlygreaterscoresthanGroupD(control),24h
afterthesurgery.Therewasnostatisticaldifferencebetween
thescoresofgroupsAandD.
There were no records ofany allergicreactions or side
effects.
Discussion
Opioidanalgesicsarewidelyusedforachievingpostoperative
analgesia,eitherorallyorintravenously,withwell-knownside
effects: hypotension,respiratory depression, urinary
reten-tion,pruritus,nausea,constipationandmentalalterations.24
Additionofmorphinetothesolutionusedforspinal
anesthe-siaproduced agoodanalgesiceffectand reducedthe need
forsystemicdrugs, but this presentedgreater incidenceof
sideeffectsthandidtheotheradministrationroutes.25Stein
etal.26showedthepresenceofopioidreceptorsinperipheral
tissues,whichenabled localuse ofthesedrugs.The
litera-turesuggeststhatthesereceptorsarepreferentiallypresent
ininflamed tissues.26,27 Consequently,severalauthors have
studiedways ofusing these drugswith different formsor
associations,dosesandapplicationmethods.Othervariables
involve the surgical procedure itself, the anesthesia
tech-niquesand the patients’ individual characteristics (gender,
age,timewiththeinjuryandpreoperativeconditionofthe
joint,etc.).
The pertinent literature presents contradictory results
regardingthe efficacy ofintra-articular analgesia with
opi-oids.Inasystematicreviewof27articlesontheefficacyof
intra-articularapplicationofmorphine, Guptaet al.16 were
abletoperformameta-analysison19studies,amongwhich
13 presented favorable results. These authors16 concluded
thatmorphineinjectioninthejointspaceseemedtoproduce
dose-dependentanalgesiaforupto24h.However,itwasnot
possibletodetermine whether theeffect was mediatedby
peripheralreceptorsorbysystemicaction.Inthislight,itis
believedthatvariables suchaspreoperativejointmorbidity,
drugdose,volumeofsolutionusedanddifferentanesthesia
protocolsmayhavecontributedtowardtheheterogeneityof
theresultsintheliterature.
Thetypeofgraftusedforligamentreconstructionalsohas
aninfluenceonthepostoperativepain.Harvestinggraftsfrom
thepatellartendoninvolvesgreatersurgicaltraumathanin
relationtografts fromtheflexortendonsandincreasesthe
paingeneratedbyextra-articularstructures.Kohetal.15did
notachievepainreductionthroughintra-articularuseofdrugs
amongpatients who underwent reconstruction withgrafts
from the patellartendon. However,through anassociation
ofintraandperiarticularapplications,therewasasignificant
decreaseinthepainscores.
In the present study, intra-articular and peri-incisional
applicationof5mgofmorphinedilutedin20mLofsaline
solu-tionresultedinpainscoresanduse ofsystemic analgesics
thatwerecomparablewithuseofintrathecalmorphine.The
groupsthatonlyreceived20mLoflevobupivacaineor10mLof
levobupivacaineplus2.5mgofmorphineobtainedpainscores
anduseofsystemicanalgesicsthatweresignificantlygreater
thanthoseofGroupD(intrathecalmorphine),especially24h
aftertheprocedure.NoneofthepatientsinGroupsA,B,Cor
Dpresentedanyallergicreactionsorsideeffects,but
compar-isonbetweenthesideeffectsofdifferenttypesofanalgesia
wouldrequireagreaternumberofpatientsandwasnotan
objectiveofthepresentstudy.
Thisstudypresentssomepossiblelimitations.
Standard-ization ofthe groups in relationto associatedlesions and
proceduressuchasmeniscectomy,synovectomy,notchplasty
and chondral lesions was not taken into consideration.
Becausetheplasmalevelsofthedrugswerenotassayed, it
cannotbestatedwhethertheresultobtainedfromGroupA
wasdueonlytotheeffectofmorphineonlocalreceptorsor
alsotothesystemicdistributionofthedrug.Althoughthere
werestatisticallysignificantdifferencesbetweenGroupsBand
DandbetweenGroupsCandD,thepainscoresanduseof
analgesicswereverylowamongalltheindividuals.This
indi-catesthatadequatepostoperativeanalgesiaandcomfortcan
beachievedefficientlywithanyoftheapproachesused.
Conclusion
Intra-articularandperi-incisionalapplicationof5mgof
mor-phinein20mLofsalinesolution resultedinanalgesia that
was comparable with application of 75mcg of intrathecal
morphine in patients who underwent ACL reconstruction
withgraftsfromthepatellartendon.Localadministrationof
20mLoflevobupivacaineorasolutionof10mLof
levobupi-vacaine plus 10mLof saline solution containing 2.5mgof
morphinewasnotcapableofreproducingtheanalgesiceffect
ofintrathecalmorphineintheindividualsstudied,24hafter
thesurgery.Newstudiesareneededinordertoshowtheexact
mechanismofaction,alongwiththeidealdoseand
concentra-tionforapplyingopioidstojoints.Comparativestudiesonthe
incidenceofsideeffectsandcomplicationsfromthedifferent
typesofanalgesiaarealsonecessary.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
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