Background
In recent years, there has been a trend towards performing anterior cruciate ligament reconstruction as a day-case procedure.1 In order to accomplish this, effective and early control of postoperative pain must be achieved, including at the graft harvest site.
Technique
After a standardised anaesthetic is administered, comprising general anaesthetic and femoral nerve blockade for reconstruction site comfort, guided peritendinous injection of local anaesthetic is performed (Figs 1 and 2). Ultrasonography is used to visualise the gracilis and semitendinosus tendons from the pes anserine insertion proximally to a point 5cm beyond the musculotendinous junction. Under aseptic conditions, a syringe and needle are used to administer 30ml of 0.25% bupivacaine with 1:200,000 adrenaline percutaneously to the peritendinous tissues, avoiding intratendinous injection. Tendons are harvested intraoperatively using an open ended tendon stripper.
Figure 1.
Ultrasonography guided peritendinous administration of anaesthetic
Figure 2.
Ultrasonography showing the tip of the hypodermic needle in the peritendinous tissue
Discussion
Previous reports have described techniques to administer local anaesthetic to the hamstrings tendon bed via the harvest tract after graft harvest.2,3 In these descriptions, the injection was given via a blunt device such as a suction catheter or arthroscopic shaver sleeve into the donor site space, without image guidance. The use of ultrasonography guidance allows anaesthetic to be introduced to the target site with improved accuracy. In addition, it allows the safe use of a hypodermic needle, allowing peritendinous tissue infiltration rather than simple filling of a dead space. We have performed this technique without complication in 14 patients. Postoperative pain scores were uniformly low and all were discharged successfully as day cases.
References
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