401: Opioid Use following Anterior Cruciate Ligament Reconstruction: Systematic review with meta-analysis

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Acute postsurgical pain, Pharmacological treatments, Epidemiology, Treatment/management

Background and Aims: Opioids are commonly prescribed to manage postoperative pain after anterior cruciate ligament (ACL) reconstruction. However, opioid overuse is a recognised global problem associated with important harms including dependence, overdose, and death. Despite multiple primary studies reporting opioid prescribing and consumption patterns following ACL reconstruction, no comprehensive synthesis of this evidence existed. This systematic review aimed to evaluate the prevalence and prescription of opioid analgesic after ACL reconstruction, and to determine associations between study and patient characteristics and opioid use, and geographical variation in use.

Methods: This systematic review and meta-analysis was prospectively registered (PROSPERO: CRD42024626606) and reported according to PRISMA 2020. Five databases (PubMed, MEDLINE, EMBASE, Web of Science, and International Pharmaceutical Abstracts) were searched from inception to January 2025. Randomised controlled trials and observational studies of patients undergoing ACL reconstruction were eligible if they reported prevalence of opioid use or cumulative consumption in morphine milligram equivalents (MME). Two reviewers independently screened studies, extracted data, and assessed risk of bias using a modified Hoy et al. tool. Meta-analyses were performed in Stata using Freeman-Tukey transformation for prevalence data and random-effects REML models for MME. Certainty of evidence was assessed using the GRADE approach.

Results: 117 studies involving 158,741 participants were included; 67 (57%) were randomised controlled trials and 50 (43%) observational studies. Pooled prevalence of cumulative dose of opioids prescribed was 48.6% (95% CI 11.2–86.0%) at Day 1, 23.3% (95% CI 15.0–31.7%) at Day 3, and 35.7% (95% CI 8.0–63.4%) at 3–6 months. Pooled mean cumulative cumulative dose of opioids prescribed increased over time, from 44.0 MME (95% CI 34.0–53.3) at Day 1, to 130.0 MME (95% CI 57.9–202.2) at Day 7, 402.5 MME (95% CI 255.2–549.7) at Month 1, and 519.6 MME (95% CI 366.6–672.6) at Month 3.

Conclusions: Opioids are widely prescribed after ACL reconstruction, with a high prevalence of cumulative dose of opioids prescribed in the first 24–72 hours and a subset of patients continuing to receive opioids for months or longer. The cumulative dose of opioids prescribed varies markedly across settings, reflecting differences in analgesic strategies, prescribing culture, and patient characteristics. Minimising unnecessary opioid prescribing is a priority across all patient populations undergoing ACL reconstruction. Further high-quality research is needed to standardise outcome reporting, including consistent definitions of opioid prescribing and time points for measurement. In particular, longitudinal cohort studies are needed to better characterise long-term cumulative dose of opioids prescribed in populations beyond North America, where the current evidence base is heavily concentrated. Research evaluating strategies to safely reduce opioid prescribing following ACL reconstruction also remains a priority.

References: 1- Page MJ, et al. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. Journal of Clinical Epidemiology. 2021;134:103–12.
2- Anthony CA, et al. Opioid demand before and after anterior cruciate ligament reconstruction. American Journal of Sports Medicine. 2017;45(13):3098–103.
3- Gomes T, et al. The burden of opioid-related mortality in the United States. JAMA Network Open. 2018;1(2):e180217.
4- Moutzouros V, et al. Can we eliminate opioids after anterior cruciate ligament reconstruction? A prospective, randomized controlled trial. American Journal of Sports Medicine. 2021;49(14):3794–801.
5- Freeman MF, Tukey JW. Transformations related to the angular and the square root. Annals of Mathematical Statistics. 1950;21(4):607–11.

Presenting Author: Fahd Dibsh
Submitting Author: Fahd Dibsh

Senior Author: A/Prof Joshua Zadro

IASP 2026 Global Year theme of Neuropathic Pain: No

• Giovanni Ferreira - The University of Sydney
• Chris Maher - The University of Sydney
• Adam Culvenor - La Trobe University
• Christina Abdelshaheed - The University of Sydney
• Masoud Jamshidi - The Unversity of Sydney
• Holly Kazanzidis - The University of Sydney
• Ziqi Zhou - The University of Sydney