OPAL STUDY OPTIMIZING PATHWAY FOR ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION

Nielsen, Christine Kroer

5. Term (Master thesis)

Medicine, Master

2015

2015-12-21

32

Formålet var at styrke grundlaget for smertebehandling efter rekonstruktion af det forreste korsbånd (ACL) ved at kombinere et knærelateret spørgeskema (KOOS) med målinger af smertetærskel før operation. Derudover undersøgte vi ændringer i musklernes stofskifte under og kort efter operationen. Seks patienter (19–32 år) med ACL-skade indgik i et prospektivt kohortestudie i perioden 19. oktober til 7. december 2015 og gennemgik standard ACL-rekonstruktion. Før operationen udfyldte de KOOS (Knee injury and Osteoarthritis Outcome Score) for knæfunktion og symptomer, EQ-5D-5L for generel livskvalitet samt PainDetect, der hjælper med at skelne mellem typer af smerte. Smertetærskel og -følsomhed blev vurderet med et digitalt tryk-algometer (PPT), som måler hvor meget tryk der skal til, før noget gør ondt, og med en mekanisk fjederklemme som kontrolleret smertestimulus. Under operationen og kort efter anvendte vi mikrodialyse, en tynd kateterteknik til at opsamle små mængder vævsvæske fra skeletmuskulatur, for at måle glukose, laktat, pyruvat, glycerol samt laktat/pyruvat-forholdet (L/P-forhold), indikatorer for vævsiskæmi (iltmangel). Sammenlignet med en referencepopulation scorede patienterne præoperativt dårligere på fire ud af fem KOOS-underskalaer. Preoperativ PainDetect tydede på nociceptiv smerte (smerte fra vævsskade). Patienterne havde en høj tryk-smertetærskel, og der sås ingen signifikant forskel før og efter den mekaniske smertestimulus. Mikrodialyse viste markant stigning i glycerol og L/P-forholdet under operationen. Resultater fra EQ-5D-5L var ikke specificeret. Samlet peger fundene på, at en kombination af spørgeskemaer, smertetærskelmålinger og mikrodialyse kan danne grundlag for at forbedre den postoperative smertebehandling efter ACL-rekonstruktion. Dog er antallet af deltagere lille, og flere forhold skal undersøges, før der kan drages endelige konklusioner.

The aim was to strengthen the basis for pain management after anterior cruciate ligament (ACL) reconstruction by combining a knee-specific questionnaire (KOOS) with preoperative pain-threshold testing, and to explore in vivo metabolic changes in skeletal muscle during and shortly after surgery. Six patients (19–32 years) with ACL injury were enrolled in a prospective cohort study from October 19 to December 7, 2015, and underwent standard ACL reconstruction. Before surgery, they completed KOOS (Knee injury and Osteoarthritis Outcome Score) for knee function and symptoms, EQ-5D-5L for general health-related quality of life, and PainDetect, which helps classify pain types. Pain threshold and sensitivity were assessed with a digital pressure pain threshold algometer (PPT), which measures how much pressure is needed before pain is felt, and with a mechanical spring clamp to deliver a controlled pain stimulus. During surgery and shortly after, we used microdialysis—a thin catheter technique that samples small amounts of tissue fluid from skeletal muscle—to monitor glucose, lactate, pyruvate, glycerol, and the lactate/pyruvate (L/P) ratio as indicators of tissue ischemia (reduced oxygen supply). Compared with a reference population, patients scored worse on four of five KOOS subscales preoperatively. Preoperative PainDetect suggested nociceptive pain (pain arising from tissue injury). Patients showed a high pressure pain threshold with no significant difference before and after the mechanical stimulus. Microdialysis showed marked increases in glycerol and the L/P ratio during the operation. EQ-5D-5L findings were not specified. Overall, these findings suggest that combining questionnaires, pain-threshold measurements, and microdialysis may help improve postoperative pain care after ACL reconstruction. However, the sample was small and further research is needed before drawing firm conclusions.

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