Research Award Details

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Post-operative Pain Scores and Opioid Use Following ACL Reconstruction with Quadriceps versus Hamstring Autograft in Adolescents and Young Adults

Grant Recipient: Elizabeth Liotta, MBBS

Boston Children's Hospital
Presentations & Publications:

Further Funding:
Additional Information:
Summary/Description of project:
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 quality initiative project 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. Recent adult studies have suggested that use of quadriceps tendon autograft may be associated with lower post-operative pain scores than other graft sources, but minimal evidence exists for the adolescent and younger adult population. We  therefore investigated an ACLR cohort of patients <25 years-old who received quad tendon autograft (ACLR-Q) and compared their pain scores and opioid use to a control cohort with the more commonly utilized hamstring tendon autograft (ACLR-HS).

Between 2016 and 2020, patients aged 12-24 years who underwent primary ACLR-Q or ACLR-HS by 1 of 3 surgeons at tertiary care children’s hospital, were provided a journal to record daily subjective pain level and medication use in the two-week post-operative period. To avoid confounders, patients with a history of diagnosed regional pain syndrome or psychiatric condition were excluded. Logbooks contained a standard Likert pain 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, 5mg, q4-6 hours PRN for post-operative pain control. Patient demographics, surgical data, and prescription information were extracted from the electronic medical record. A two-sided student’s t-test was used to evaluate statistical relationships of data between graft types.

Logbooks of 83 patients (43 ACLR-Q, 40 ACLR-HS) were collected for analysis. Cohorts had a similar mean age at time of surgery (ACLR-Q: 17.1 years, range:13-24; ACLR-HS: 16.6 years, range:13-21, p=0.440), and a similar preponderance of female subjects (ACLR-Q:65.9%; ACLR-HS:62.5%, p=0.497). The mean weight and BMI of patients who received the quadriceps tendon autograft (68.8kg, range:47-121) was similar to patients who received the hamstring tendon autograft (64.3kg, range:46-93, p=0.103).
More meniscal injuries were identified in ACLR-HS patients (95.0% vs. ACLR-Q:67.4%, p<0.001), and treated with a repair procedure more commonly (77.5% vs. ACLR-Q:34.1%, p<0.001), than with meniscectomy (17.5%; ACLR-Q:31.8%, p<0.001). Mean length of surgery and tourniquet time were longer in the ACLR-Q (139, 117 minutes) group than ACLR-HS group (81, 55 minutes) (p<0.001; p<0.001).

Intra-operative nerve blocks were utilized by a similar proportion of both cohorts (ACLR-Q:88.4%, ACLR-HS:90.0%, p=0.814). The ACLR-Q group received more adductor canal blocks (88.4% vs. 23.0%, p<0.001), while the ACLR-HS group received more femoral nerve blocks most frequently (57.5% vs. 0%, p<0.001).

During the overall study period, the mean number of pills per Oxycodone prescription was 45.0 (range:15-84), though the mean number decreased in both groups over time, secondary to departmental changes imposed in response to growing awareness of the national opioid crisis. ACLR-Q patients consumed an average of 13.5 opioid pain pills (range:0-46) over a mean of 12.7 doses (range:0-36), with the last dose occurring on day 3.9 (range:1-13). ACLR-HS patients consumed an average of 15.9 opioid pain pills (range:0-39) over a mean of 13.2 doses (0-36), with the last dose occurring on day 3.4 (range:0-13). There were no significant differences seen between number of pills consumed (p=0.276), number of doses (p=0.769), or number of days over which opioid medication was taken (p=0.372), between the two cohorts. Subjective pain score was similar on day of surgery (DOS) for the two graft choices (ACLR-Q:2.5, ACLR-HS: 2.6). Average pain scores increased by the same amount on post-operative day 1 for both groups, likely as residual effects from the regional anesthetic wore off. By post-operative day 3, average pain scores in both groups (Chart 1) had returned to or declined to less than that seen on DOS, without statistical difference in the pain level between cohorts.

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. Importantly, both reconstructive techniques resulted in a large surplus of unused opioid medication, furthering our understanding 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.

The study was designed to collect 100 journals, 50 from each surgical arm, which has not yet been achieved by the study team. Patient compliance regarding prompt return of journals to the study staff/surgeon caused delay to achieving this goal. We have found that the placement of reminder phone calls to families before follow-up appointments has increased return rate of the logbooks and we are optimistic that our target will be completed within the next few months.

Was the primary outcome measure of success reached?
The primary objective of this project was to compare post-operative opioid prescriptive habits to patient use. The results of this study have highlighted the issue of ‘blanket’ prescription for post-operative pain control, as the mean number of opioid pills prescribed by providers greatly exceeded the mean patient reported number of pills consumed to adequately control pain.

Future plans, presentations or publications as a result of this grant:
Previous podium and poster presentations at local and national meetings include:
  • Podium            Harvard Medical School Sports Medicine Research day (June 2018)
  • Eposter            Pediatric Research in Sports Medicine Annual Meeting (January 2019)
Planned submission of the manuscript to the American Journal of Sports Medicine will occur in Fall 2020.

Future directions of work stemming from this initial study include looking at post-operative complications of ACLR with the Quadriceps versus Hamstrings tendon autograft, 6- and 12-months strength recovery and return to play testing, as well as assessment of long-term function through patient-reported outcome score analysis.