Authors: Sadacharam et al.
Regional Anesthesia & Pain Medicine, 2025, 50(6):455-463
Multisite Prospective Study of Perioperative Pain Management Practices for Anterior Cruciate Ligament Reconstruction in Adolescents: Society for Pediatric Anesthesia Improvement Network (SPAIN) Project Report
Key Points
This multisite prospective observational study evaluated perioperative pain management practices for adolescents undergoing anterior cruciate ligament reconstruction.
The study included 519 adolescents, ages 12 to 17.5 years, from 15 sites over 2 years.
Regional analgesia was used in 86% of patients, but there was substantial variation in block type and practice patterns.
Pain greater than 3/10 was common early after surgery, reported by 64% of patients on postoperative day 1 and 46% on postoperative day 3.
Only a small percentage of patients reported longer-term pain or neurologic symptoms, but the study found variability in functional assessments after discharge.
Summary
This Society for Pediatric Anesthesia Improvement Network project report addressed an important gap in pediatric perioperative pain care. Although anterior cruciate ligament reconstruction is common in adolescents, there have been limited benchmarks for pain management, opioid use, regional anesthesia practices, and functional recovery in this population. The investigators created a multicenter prospective observational registry to better describe current practice and recovery patterns after pediatric ACL reconstruction.
The study enrolled 519 adolescents between 12 and 17.5 years of age from 15 sites over a 2-year period. Investigators collected data on perioperative management, surgical factors, pain scores, opioid use, and functional recovery. Follow-up assessments were performed preoperatively, on postoperative day 1, postoperative day 3, at 6 weeks, and at 6 months.
Regional analgesia was used in most patients. Of the 519 participants, 447, or 86%, received regional analgesia. Among those who received a block, a single-shot adductor canal block was the most common technique, used in 54%. Nerve catheters were placed in 24%, and perineural adjuvants were used in 43%. These findings show that regional anesthesia is widely used for adolescent ACL reconstruction, but practice patterns vary substantially across sites.
Pain was common in the first few days after surgery. Pain scores greater than 3/10 were reported by 64% of patients on postoperative day 1 and 46% on postoperative day 3. By 6 weeks, this decreased to 5%, and by 6 months, it decreased to 3%. This pattern suggests that most adolescents improve substantially over time, although early postoperative pain remains common despite widespread use of regional analgesia.
Opioid use followed a similar downward pattern. The mean number of daily oxycodone doses was 2.8 on postoperative day 1 and 1.8 on postoperative day 3. By 6 weeks and 6 months, reported daily oxycodone use was 0. These findings suggest that opioid use after adolescent ACL reconstruction is concentrated primarily in the immediate postoperative period.
The study also examined longer-term symptoms and functional recovery. At 6 weeks, numbness was reported by 11% of patients and weakness by 4%. At 6 months, numbness was reported by 16% and weakness by 2%. The investigators also found considerable variability in how functional assessments were timed and performed after discharge. This makes it harder to compare recovery patterns across institutions and highlights the need for more standardized outcome measures.
The authors concluded that there is substantial variability in the use of regional anesthesia and other pain management practices after pediatric ACL reconstruction. While only a small percentage of patients reported persistent pain or neurologic symptoms, the variability in regional techniques and functional follow-up suggests that more research is needed to define best practices.
What You Should Know
This study is useful because it provides real-world benchmark data for pain management after adolescent ACL reconstruction. Regional anesthesia is already commonly used in this setting, but there is no single clearly established best approach.
For anesthesia providers, the important takeaway is that most adolescents receive regional analgesia, yet many still report meaningful pain during the first few postoperative days. This suggests that regional anesthesia should be part of a broader multimodal pain strategy rather than viewed as a complete solution by itself.
The study also highlights the need for standardized follow-up and functional recovery assessments. Pain scores and opioid use are important, but adolescent ACL recovery also depends on strength, mobility, neurologic symptoms, rehabilitation progress, and readiness to return to activity.
Overall, this report provides a foundation for future studies comparing regional anesthesia techniques, opioid-sparing pathways, and functional recovery outcomes in adolescents undergoing ACL reconstruction.
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