Opioid Consumption Following Anterior Cruciate Ligament Reconstruction: A Systematic Review

Uniform, data-driven guidelines for oral opioid prescriptions after anterior cruciate ligament reconstruction (ACLR) are lacking.

To provide a concise, systematic review of literature quantifying postoperative opioid pill consumption in patients who underwent ACLR.

Systematic review; Level of evidence, 4.

Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a literature search was performed using Ovid MEDLINE, Ovid Embase, Scopus, and Cochrane CENTRAL databases from inception to August 12, 2022. Search terms included "anterior cruciate ligament reconstruction," "opiate alkaloids," "hydrocodone," "oxycodone," and "narcotics." In total, 752 unique studies were identified. Studies were included if they quantified postoperative oral opioid consumption for ≥4 postoperative days. Exclusion criteria included pediatric studies, abstracts or conference papers, reviews, unpublished randomized controlled trials, case reports, and papers not in the English language. For each included study, the following data were extracted: number of pills in initial prescription, type of pill prescribed, and size of any additional prescriptions given after initial prescription. We also recorded the intervention or context for which prescription size was being investigated. The methodological index for non-randomized studies criteria were used to evaluate the quality of all included studies.

A total of 20 articles were included in the study. For all studies, regardless of postoperative period length, oral opioid consumption ranged from 2.3 ± 2.9 tablets of 5-mg oxycodone (17.3 MMEs) to 32.2 ± 15.9 tablets of 5-mg oxycodone (242 MMEs). Specifically, for studies reporting on oral opioid consumption within the first 7 postoperative days, consumption ranged from 3.0 tablets of 5-mg oxycodone to 32.2 tablets of 5-mg oxycodone. No study reported consumption >35 tablets. Effective ways to decrease postoperative opioid consumption included preoperative adductor canal blocks, intraoperative bupivacaine local anesthetic injection, and postoperative multimodal analgesic regimens.

Our review demonstrated that several pre- and postoperative interventions, including preoperative regional nerve blocks, use of infiltrative local anesthetics like bupivacaine or a similar agent, as well as multimodal analgesic regimens, can decrease perioperative pain and therefore decrease postoperative oral opioid consumption. Due to the heterogeneity of the available literature, no conclusions can be made as to what single nonopioid analgesic, or combination thereof, is optimal. However, this systematic review sets the foundation for future studies investigating opioid consumption in settings of nonopioid analgesic medications such as ketorolac and multimodal analgesic regimens.