Impact of an Opioid Avoidance Protocol for ACL Reconstruction: A Pilot Sequential Cohort Study.

BACKGROUND: Anterior cruciate ligament reconstructions (ACLRs) are commonly performed in healthy, opioid-naive patients aged ≤29 years, yet up to 6% of patients undergoing ACLR become persistent opioid users for 90 days after surgery. Multimodal analgesia (MMA) protocols have recently been implemented, but opioids remain a primary rescue medication, with surgeons accounting for 73% of opioids prescribed. PURPOSE: To determine whether an opioid avoidance protocol (OAP) including cryoneurolysis could eliminate or markedly reduce opioid use without compromising pain control after ACLR. STUDY DESIGN: This was a pilot, unblinded, sequential cohort study of patients aged ≥15 years undergoing ACLR. Level of evidence: II.1. METHODS: The standard of care (SOC) protocol group received oral analgesics, regional anesthesia, and rescue opioid therapy, whereas the OAP group received cryoneurolysis 7 to 21 days before surgery as well as oral analgesics and regional anesthesia, with opioids prescribed upon request. The primary end point was opioid use in morphine milligram equivalents (MMEs) from postoperative day (POD) 0 to POD 7, with secondary end points of daily worst and average pain, Quality of Recovery 15 (QoR-15) scores, opioid-free status, Knee Injury and Osteoarthritis Outcome Score (KOOS) pain and symptom subscales, and opioid prescriptions. RESULTS: No notable differences were found in patient characteristics at baseline. Patients in the OAP group used markedly fewer MMEs postoperatively versus the SOC group (35 vs 172.5). No notable differences were observed in worst or average pain at any time. The OAP group had markedly improved KOOS symptom scores at week 8. CONCLUSION: This study is the first to use an MMA protocol incorporating cryoneurolysis 7 to 21 days before ACLR and to demonstrate notable reductions in opioid use without sacrificing pain control, but opioid needs were not entirely eliminated. The OAP is a step toward preventing opioid use disorder in young patients and can be supplemented with additional modalities to further reduce or eliminate opioid use.