SpringerLink
Log in

A quadruple peripheral nerve block outside the OR for anterior cruciate ligament reconstruction reduces the OR occupancy time

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

The use of regional anesthesia (RA) for anterior cruciate ligament (ACL) reconstruction reduces morphine consumption, the time spent in the post-anesthesia care unit (PACU) and the hospital readmission rate. However, RA failures due to delays in the induction of anesthesia and its unpredictable success rate (Cuvillon et al. Ann Fr Anesth 29:710–715, 2010; Jankowski et al. Anesth Analg 10.1213/01.ANE.0000081798.89853.E7) can lead to disorganization of the operating room (OR) schedule. The hypothesis is that performing RA outside the OR will significantly reduce the OR occupancy time relative to using general anesthesia (GA). The primary objective was to compare the OR occupancy time between RA and GA when performing ACL reconstruction.

Methods

This was a retrospective, single-center study of data collected prospectively from consecutive patients operated by a single surgeon between January 2019 and December 2020. The patients undergoing ACL reconstruction were divided into two groups based on the type of anesthesia they received (GA, RA). RA consisted of a quadruple peripheral nerve block (femoral, sciatic, obturator and lateral femoral cutaneous nerves). The durations of the perioperative stages of the patient’s journey in the OR suite were compared between these two groups.

Results

The analysis involved 469 ACL reconstructions: 356 GA and 113 RA. The two groups were comparable in age, gender and ASA score (American Society of Anesthesiologists). The OR occupancy time for ACL reconstruction with RA was reduced by a mean of 13 min (70 ± 12 SD vs. 83 ± 14 SD; P < 0.0001) and the PACU time by 41 min relative to GA (P < 0.0001). The entry–incision time was reduced by an average of 8 min and the end–exit time by 3 min (P < 0.0001). The care time in the PACU was reduced from 84 ± 35 to 46 ± 26 min (P < 0.0001). However, performing anesthesia outside the OR (i.e., in a RA block room) did not reduce the turnover time (n.s).

Conclusion

Performing RA outside the OR reduced the OR occupancy time by nearly 20% relative to using GA for ACL reconstructions.

Level of evidence

Level IV.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

Data statement is provided in supplementary file 1.

References

  1. Chung KS, Kim JH, Kong DH, Park I, Kim JG, Ha JK (2022) An increasing trend in the number of anterior cruciate ligament reconstruction in Korea: a nationwide epidemiologic study. Clin Orthop Surg 14:220–226

    Article  PubMed  Google Scholar 

  2. Herzog MM, Marshall SW, Lund JL, Pate V, Mack CD, Spang JT (2018) Trends in incidence of ACL reconstruction and concomitant procedures among commercially insured individuals in the United States, 2002–2014. Sports Health 10:523–531

    Article  PubMed  PubMed Central  Google Scholar 

  3. Paudel YR, Sommerfeldt M, Voaklander D (2022) Increasing incidence of anterior cruciate ligament reconstruction: a 17-year population-based study. Knee Surg Sports Traumatol Arthrosc. https://doi.org/10.1007/s00167-022-07093-1

    Article  PubMed  Google Scholar 

  4. Yucens M, Aydemir AN (2019) Trends in anterior cruciate ligament reconstruction in the last decade: a web-based analysis. J Knee Surg 32:519–524

    Article  PubMed  Google Scholar 

  5. Elmallah R, Chughtai M, Khlopas A, Newman J, Stearns K, Roche M, Kelly M, Harwin S, Mont M (2018) Pain control in total knee arthroplasty. J Knee Surg 31:504–513

    Article  PubMed  Google Scholar 

  6. Halawi MJ, Grant SA, Bolognesi MP (2015) Multimodal analgesia for total joint arthroplasty. Orthopedics 38(7):e616–e625

    Article  PubMed  Google Scholar 

  7. Hansen J, Rasmussen LS, Steinmetz J (2020) Management of ambulatory anesthesia in older adults. Drugs Aging 37:863–874

    Article  PubMed  Google Scholar 

  8. Villatte G, Mathonnet M, Villeminot J, Savary M, Theissen A, Ostermann S, Erivan R, Raynaud-Simon A, Slim K (2019) Interest of enhanced recovery programs in the elderly during total hip arthroplasty a systematic review. Geriatr Psychol Neuropsychiatr Vieil 17:234–242

    PubMed  Google Scholar 

  9. den Hartog YM, Mathijssen NM, Vehmeijer SB (2013) Reduced length of hospital stay after the introduction of a rapid recovery protocol for primary THA procedures: a retrospective cohort study with 1,180 unselected patients. Acta Orthop 84:444–447

    Article  Google Scholar 

  10. Badin D, Ortiz-Babilonia CD, Gupta A, Leland CR, Musharbash F, Parrish JM, Aiyer AA (2022) Prescription patterns, associated factors, and outcomes of opioids for operative foot and ankle fractures: a systematic review. Clin Orthop Relat Res. https://doi.org/10.1097/CORR.0000000000002307

    Article  PubMed  Google Scholar 

  11. Fillingham YA, Hannon CP, Kopp SL, Austin MS, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Woznica A, Casambre FD, Nelson N, Hamilton WG, Della Valle CJ (2022) The efficacy and safety of regional nerve blocks in total knee arthroplasty: systematic review and direct meta-analysis. J Arthroplasty 37:1906-1921.e2

    Article  PubMed  Google Scholar 

  12. Peng P, Claxton A, Chung F, Chan V, Miniaci A, Krishnathas A (1999) Femoral nerve block and ketorolac in patients undergoing anterior cruciate ligament reconstruction. Can J Anesth 46:919–924

    Article  CAS  PubMed  Google Scholar 

  13. Rhatomy S, Rasyid FA, Romulo MA, Lumban-Gaol I, Budhiparama NC (2022) Adductor canal block in outpatient clinic for pain control after knee arthroplasty: a randomized controlled, clinical trial. J Orthop Surg (Hong Kong) 30:10225536221122246

    Article  PubMed  Google Scholar 

  14. Tang X, Lai Y, Du S, Ning N (2022) Analgesic efficacy of adding the IPACK block to multimodal analgesia protocol for primary total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg Res 17:429. https://doi.org/10.1186/s13018-022-03266-3

    Article  PubMed  PubMed Central  Google Scholar 

  15. Williams BA, Kentor ML, Vogt MT, Irrgang JJ, Bottegal MT, West RV, Harner CD, Fu FH, Williams JP (2006) Reduction of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block. Anesthesiology 104:315–327

    Article  PubMed  Google Scholar 

  16. Yung EM, Brull R, Albrecht E, Joshi GP, Abdallah FW (2019) Evidence basis for regional anesthesia in ambulatory anterior cruciate ligament reconstruction: part III: local instillation analgesia-a systematic review and meta-analysis. Anesth Analg 128:426–437

    Article  CAS  PubMed  Google Scholar 

  17. Harbell MW, Cohen JM, Kolodzie K, Behrends M, Braehler MR, Kinjo S, Feeley BT, Aleshi P (2016) Combined preoperative femoral and sciatic nerve blockade improves analgesia after anterior cruciate ligament reconstruction: a randomized controlled clinical trial. J Clin Anesth 33:68–74

    Article  PubMed  Google Scholar 

  18. Williams BA, Kentor ML, Vogt MT, Vogt WB, Coley KC, Williams JP, Roberts MS, Chelly JE, Harner CD, Fu FH (2004) Economics of nerve block pain management after anterior cruciate ligament reconstruction: potential hospital cost savings via associated postanesthesia care unit bypass and same-day discharge. Anesthesiology 100:697–706

    Article  PubMed  Google Scholar 

  19. Matava MJ, Prickett WD, Khodamoradi S, Abe S, Garbutt J (2009) Femoral nerve blockade as a preemptive anesthetic in patients undergoing anterior cruciate ligament reconstruction: a prospective, randomized, double-blinded, placebo-controlled study. Am J Sports Med 37:78–86

    Article  PubMed  Google Scholar 

  20. Schloss B, Bhalla T, Klingele K, Phillips D, Prestwich B, Tobias JD (2014) A retrospective review of femoral nerve block for postoperative analgesia after knee surgery in the pediatric population. J Pediatr Orthop 34:459–461

    Article  PubMed  Google Scholar 

  21. Cuvillon P, Nouvellon E, Marchand P, Boisson C, L’Hermite J, Vialles N, de La Coussaye J-E, Ripart J (2010) Tribloc (fémoral, sciatique, obturateur) pour la chirurgie ambulatoire arthroscopique de genou : étude prospective de faisabilité et d’efficacité. Ann Fr Anesth 29:710–715

    Article  CAS  Google Scholar 

  22. Mariano ER, Chu LF, Peinado CR, Mazzei WJ (2009) Anesthesia-controlled time and turnover time for ambulatory upper extremity surgery performed with regional versus general anesthesia. J Clin Anesth 21:253–257

    Article  PubMed  PubMed Central  Google Scholar 

  23. Mazda Y, Peacock S, Wolfstadt J, Matelski J, Chan V, Gleicher YJ (2021) Develo** a business case for a regional anesthesia block room: up with efficiency, down with costs. Reg Anesth Pain Med 46:986–991

    Article  PubMed  Google Scholar 

  24. Toor J, Saleh I, Abbas A, Abouali J, Wong P, Chan TCY, Sarhangian V (2022) An anesthesia block room is financially net positive for a hospital performing arthroplasty. J Am Acad Orthop Surg 30:e1058–e1065

    Article  PubMed  Google Scholar 

  25. Williams BA, Kentor ML, Williams JP, Figallo CM, Sigl JC, Anders JW, Bear TC, Tullock WC, Bennett CH, Harner CD, Fu FH (2000) Process analysis in outpatient knee surgery. Anesthesiology 93:529–538

    Article  CAS  PubMed  Google Scholar 

  26. Oldman M, McCartney CJL, Leung A, Rawson R, Perlas A, Gadsden J, Chan VWS (2004) A survey of orthopedic surgeons: attitudes and knowledge regarding regional anesthesia. Anesth Analg. https://doi.org/10.1213/01.ANE.0000113549.98873.B1

    Article  PubMed  Google Scholar 

  27. Jankowski CJ, Hebl JR, Stuart MJ, Rock MG, Pagnano MW, Beighley CM, Schroeder DR, Horlocker TT (2003) A comparison of psoas compartment block and spinal and general anesthesia for outpatient knee arthroscopy. Anesth Analg. https://doi.org/10.1213/01.ANE.0000081798.89853.E7

    Article  PubMed  Google Scholar 

  28. Chapman WC, Luo X, Doyle M, Khan A, Chapman WC, Kangrga I, Martin J, Wellen J (2020) Time is money: can punctuality decrease operating room cost? J Am Coll Surg 230:182-189.e4

    Article  PubMed  Google Scholar 

  29. Moody AE, Gurnea TP, Shul CP, Althausen PL (2020) True cost of operating room time: implications for an orthopaedic trauma service. J Orthop Trauma 34:271–275

    Article  PubMed  Google Scholar 

  30. Volpin A, Khan O, Haddad FS (2016) Theater cost Is £16/minute so what are you doing just standing there? J Arthroplasty 31:22–26

    Article  PubMed  Google Scholar 

  31. Gonano C, Kettner SC, Ernstbrunner M, Schebesta K, Chiari A, Marhofer P (2009) Comparison of economical aspects of interscalene brachial plexus blockade and general anaesthesia for arthroscopic shoulder surgery. Br J Anaesth 103:428–433

    Article  CAS  PubMed  Google Scholar 

  32. Mesnier T, Cavaignac M, Marot V, Reina N, Cavaignac E (2022) Knee anterolateral ligament reconstruction with knotless soft anchor: shallow fixation prevents tunnel convergence. Arthrosc Tech. https://doi.org/10.1016/j.eats.2021.11.024

    Article  PubMed  PubMed Central  Google Scholar 

  33. Aldrete JA, Kroulik D (1970) A postanesthetic recovery score. Anesth Analg 49:924–934

    Article  CAS  PubMed  Google Scholar 

  34. The Association of Anesthesia Clinical Directors, Boggs SD, Tsai MH, Urman RD (2018) The association of anesthesia clinical directors (AACD) glossary of times used for scheduling and monitoring of diagnostic and therapeutic procedures. J Med Syst 42:171

    Article  Google Scholar 

  35. Mercereau P, Lee B, Head SJ, Schwarz SKW (2012) A regional anesthesia-based “swing” operating room model reduces non-operative time in a mixed orthopedic inpatient/outpatient population. Can J Anesth 59:943–949

    Article  PubMed  Google Scholar 

  36. Catchpole KR, Giddings AEB, Wilkinson M, Hirst G, Dale T, de Leval MR (2007) Improving patient safety by identifying latent failures in successful operations. Surgery 142:102–110

    Article  PubMed  Google Scholar 

  37. Small TJ, Gad BV, Klika AK, Mounir-Soliman LS, Gerritsen RL, Barsoum WK (2013) Dedicated orthopedic operating room unit improves operating room efficiency. J Arthroplasty 28:1066-1071.e2

    Article  PubMed  Google Scholar 

  38. **ao Y, Jones A, Zhang B, Bennett M, Mears SC, Mabrey JD, Kennerly D (2015) Team consistency and occurrences of prolonged operative time, prolonged hospital stay, and hospital readmission: a retrospective analysis. World J Surg 39:890–896

    Article  PubMed  Google Scholar 

  39. Hoffman CR, Green MS, Liu J, Iqbal U, Voralu K (2018) Using operating room turnover time by anesthesia trainee level to assess improving systems-based practice milestones. BMC Med Educ 18:295. https://doi.org/10.1186/s12909-018-1409-6

    Article  PubMed  PubMed Central  Google Scholar 

  40. Urman RD, Sarin P, Mitani A, Philip B, Eappen S (2012) Presence of anesthesia resident trainees in day surgery unit has mixed effects on operating room efficiency measures. Ochsner J 12:25–29

    PubMed  PubMed Central  Google Scholar 

  41. Eappen S, Flanagan H, Lithman R, Bhattacharyya N (2007) The addition of a regional block team to the orthopedic operating rooms does not improve anesthesia-controlled times and turnover time in the setting of long turnover times. J Clin Anesth 19:85–91

    Article  PubMed  Google Scholar 

  42. Edkin BS, Spindler KP, Flanagan JFK (1995) Femoral nerve block as an alternative to parenteral narcotics for pain control after anterior cruciate ligament reconstruction. Arthroscopy 11:404–409

    Article  CAS  PubMed  Google Scholar 

  43. Espelund M, Fomsgaard JS, Haraszuk J, Mathiesen O, Dahl JB (2013) Analgesic efficacy of ultrasound-guided adductor canal blockade after arthroscopic anterior cruciate ligament reconstruction: a randomised controlled trial. Eur J Anaesthesiol 30:422–428

    Article  CAS  PubMed  Google Scholar 

  44. Jansen TK, Miller BE, Arretche N, Pellegrini JE (2009) Will the addition of a sciatic nerve block to a femoral nerve block provide better pain control following anterior cruciate ligament repair surgery? J Am Assoc Nurse Anesth J 77:213–218

    Google Scholar 

  45. Mahmoud A, Boules M, Botros J, Mostafa M, Ragab S, Alsaeid M (2021) Analgesic impact of a popliteal plexus block to standard adductor canal block in arthroscopic anterior cruciate ligament reconstruction: a randomized blind clinical trial. Pain Res Manag 2021:1723471. https://doi.org/10.1155/2021/1723471

    Article  PubMed  PubMed Central  Google Scholar 

  46. Casati A, Cappelleri G, Aldegheri G, Marchetti C, Messina M, De Ponti A (2004) Total intravenous anesthesia, spinal anesthesia or combined sciatic-femoral nerve block for outpatient knee arthroscopy. Minerva Anestesiol 70:493–502

    CAS  PubMed  Google Scholar 

  47. Rane AA, Tyser AR, Kazmers NH (2019) Evaluating the impact of wait time on orthopaedic outpatient satisfaction using the press ganey survey. J Bone Joint Surg Am 4(4):e0014

    Google Scholar 

  48. Secrist ES, Freedman KB, Ciccotti MG, Mazur DW, Hammoud S (2016) Pain management after outpatient anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials. Am J Sports Med 44:2435–2447

    Article  PubMed  Google Scholar 

  49. Cappelleri G, Casati A, Fanelli G, Borghi B, Anelati D, Berti M, Albertin A (2000) Unilateral spinal anesthesia or combined sciatic-femoral nerve block for day-case knee arthroscopy. A prospective, randomized comparison. Minerva Anestesiol 66:131–136 (discussion 137)

    CAS  PubMed  Google Scholar 

  50. Patel NJ, Flashburg MH, Paskin S, Grossman R (1986) A regional anesthetic technique compared to general anesthesia for outpatient knee arthroscopy. Anesth Analg 65:185–187

    CAS  PubMed  Google Scholar 

  51. Atim A, Ergin A, Kurt E, Özdemiroglu Y, Guzeldemir E (2007) Comparison of sciatic psoas compartment block and sciatic femoral 3-in-1 block for knee arthroscopy. J Clin Anesth 19(8):591–595. https://doi.org/10.1016/j.jclinane

    Article  PubMed  Google Scholar 

  52. Muench LN, Wolf M, Kia C, Berthold DP, Cote MP, Fischler A, Arciero RA, Edgar C (2022) A reduced concentration femoral nerve block is effective for perioperative pain control following ACL reconstruction: a retrospective review. Arch Orthop Trauma Surg 142:2271–2277

    Article  PubMed  Google Scholar 

  53. Sites B, Gallagher J, Cravero J, Lundberg J, Blike G (2004) The learning curve associated with a simulated ultrasound-guided interventional task by inexperienced anesthesia residents. Reg Anesth Pain Med 29:544–548

    Article  PubMed  Google Scholar 

  54. Sites B, Spence B, Gallagher J, Wiley C, Bertrand M, Blike G (2007) Characterizing novice behavior associated with learning ultrasound-guided peripheral regional anesthesia. Reg Anesth Pain Med 32:107–115

    Article  PubMed  Google Scholar 

Download references

Funding

There is no funding source.

Author information

Authors and Affiliations

  1. Musculoskeletal Institute, Hôpital Pierre Paul Riquet, CHU Toulouse, 1 Place Baylac, 31000, Toulouse, France

    Maxime Teulières, Nicolas Reina, Fabrice Ferre, Vincent Minville & Etienne Cavaignac

  2. Department of Epidemiology, Health Economics and Public Health, UMR1027, INSERM-University of Toulouse III, Toulouse University Hospital (CHU), Toulouse, France

    Emilie Berard

  3. Orthopaedics Unit, Hospital Nostra Senyora de Meritxell, Escaldes-Engordany, Andorra

    Vincent Marot

Authors
  1. Maxime Teulières
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emilie Berard
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Vincent Marot
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Nicolas Reina
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Fabrice Ferre
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Vincent Minville
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Etienne Cavaignac
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Etienne Cavaignac.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval number RnIPH 2021-74 provided by our institution.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 16 KB)

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Teulières, M., Berard, E., Marot, V. et al. A quadruple peripheral nerve block outside the OR for anterior cruciate ligament reconstruction reduces the OR occupancy time. Knee Surg Sports Traumatol Arthrosc 31, 2917–2926 (2023). https://doi.org/10.1007/s00167-022-07246-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-022-07246-2

Keywords

Search

Navigation