Optimising analgesia for
day-case cruciate ligament
Kirkham et al.’s systematic review
comparing local inﬁltration and
femoral nerve block (FNB) for ante-
rior cruciate ligament (ACL) recon-
struction , reports that there is
moderate evidence use of FNB is
superior to local inﬁltration in the
ﬁrst 24-h postoperative period.
However, ACL reconstruction is
now frequently performed as a day-
case procedure . Although regio-
nal techniques may meet the crite-
ria of an ideal analgesic, they are
associated with unwanted effects
such as quadriceps weakness, result-
ing in delayed mobilisation .
There is also a risk of inadequate
analgesia in the late postoperative
period (greater than 12 h), particu-
larly in those day-case patients who
may still have a residual block at
time of discharge.
Mehdi et al. suggest that local
inﬁltration combined with oral anal-
gesia can successfully be used instead
of FNB, with similar analgesic efﬁ-
cacy, to facilitate discharge within
24 h . Did the authors consider
length of stay or number of day-case
procedures as a secondary outcome?
In patients who fulﬁl the day-
case criteria, should we not aim for
optimal analgesia over ideal analge-
sia (FNB) in order to allow for early
mobilisation, adequate pain control
and earlier discharge?
University Hospitals Birmingham
NHS Foundation Trust,
No external funding or competing
interests declared. Previously posted
on the Anaesthesia correspondence
1. Kirkham KR, Grape S, Martin R, Albrecht
E. Analgesic efﬁcacy of local inﬁltration
analgesia vs. femoral nerve block after
anterior cruciate ligament reconstruc-
tion: a systematic review and meta-ana-
lysis. Anaesthesia 2017; 72: 1542–53.
2. Kassam A, Schranz P, Mandalia V. Day-
case anterior cruciate ligament recon-
struction: success, pitfalls and patient
pain scores. British Journal of Medical
Practitioners 2013; 6: a632.
3. Williams BA, Kentor ML, Vogt MT. Reduc-
tion of verbal pain scores after anterior
cruciate ligament reconstruction with 2-
day continuous femoral nerve block: a
randomized clinical trial. Anesthesiology
2006; 104: 315–27.
4. Mehdi SA, Dalton DJ, Sivarajan V, Leach
WJ. BTB ACL reconstruction: femoral
nerve block has no advantage over
intraarticular local anaesthetic inﬁltra-
tion. Knee Surgery, Sports Traumatology,
Arthroscopy 2004; 12: 180–3.
analgesia for anterior
reconstruction – a reply
We would like to thank Dr Mughal
and Dr Jagannathan for their
thoughtful comments regarding our
recent meta-analysis comparing the
analgesic efﬁcacy of local inﬁltration
analgesia with femoral nerve block
after anterior cruciate ligament
(ACL) reconstruction .
Their comment brings attention
to the evolving paradigm of regional
anaesthesia and its impact on patient
function. Although previously widely
accepted that regional anaesthesia
improves functional outcomes [2, 3],
more recent contrary arguments
incriminate blocks as responsible for
hindered mobility and falls . One
result is the growing adoption of
alternative techniques such as local
inﬁltration analgesia, even if the sug-
gested solutions are not yet strongly
evidence-based . However, a large
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© 2018 The Association of Anaesthetists of Great Britain and Ireland
Anaesthesia 2018, 73, 515–525