Article Text

Download PDFPDF
Preoperative Intra-articular Morphine and Bupivacaine for Pain Control After Outpatient Arthroscopic Anterior Cruciate Ligament Reconstruction
  1. John E. Tetzlaff, M.D.*,
  2. John A. Dilger, M.D.*,
  3. Joseph Abate, M.D. and
  4. Richard D. Parker, M.D.P.
  1. * From the Department of Anesthesiology
  2. Orthopaedic Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio;
  3. The Department of Orthopaedic Surgery, University of Vermont, Killington, Vermont.
  1. Reprint requests: John E. Tetzlaff, M.D., Department of General Anesthesiology, E31, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.


Background and Objectives. The purpose of this study was to determine whether intra-articular injection of bupivacaine, morphine, or a combination prior to surgery provided pain control after arthroscopic anterior cruciate ligament (ACL) reconstruction.

Methods. These data were collected as a two-stage prospective, randomized, blinded observer study. All patients received a standard general anesthetic, which included an intra-articular injection 20 minutes prior to incision. In phase I, three solutions were assigned randomly in a 60-mL volume. Group 1 was saline, group 2 was 0.25% bupivacaine, and group 3 was 0.25% bupivacaine with 1 mg morphine sulfate (MS). Phase II was identical to phase I in technique and had four groups. Group 1 was 0.25% bupivacaine, group 2 was 1 mg MS in saline, group 3 was 0.25% bupivacaine with 1 mg MS, and group 4 was 0.25% bupivacaine with 3 mg MS. All groups in phases I and II contained 1:200,000 epinephrine, freshly added. Pain scores were evaluated at 0, 30, 60, 90, 120, and 240 minutes postoperative using a visual analog scale. For pain scores of 5 or greater, 50 μg fentanyl was administered at 5-minute intervals until pain was controlled. After transition from phase I to phase II of the postanesthesia care unit (PACU), hydrocodone/acetaminophen tablets were used.

Results. Thirty patients were entered into phase I of the study. Both treatment groups (2 and 3) had significant (P < .05) pain reduction on arrival to the PACU. Group 3 had significantly (P < .05) reduced need for fentanyl during the PACU stay. Forty-nine patients entered phase II of the study. In phase II, group 3 had the lowest pain scores on arrival to the PACU. At 120 and 240 minutes, pain scores were lower in groups 3 and 4. Fentanyl and hydrocodone uses were significantly lower during the PACU stay in groups 3 and 4.

Conclusions. Presurgical injection of a solution of 0.25% bupivacaine, morphine, and epinephrine provided pain control and decreased opioid use in the PACU. Increasing the morphine dose did not improve the clinical result.

  • intra-articular bupivacaine
  • intra-articular morphine
  • arthroscopy
  • anterior cruciate ligament reconstruction.

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.