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Zhang J, Yuan Y, Zhang Y, Wang Y. Clinical effects of single femoral nerve block in combination with general anesthesia on geriatric patients receiving total knee arthroplasty. Pak J Med Sci 2018; 34:43-48. [PMID: 29643876 PMCID: PMC5857026 DOI: 10.12669/pjms.341.14071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To evaluate the clinical effects of single femoral nerve block (sFNB) combined with general anesthesia on geriatric patients receiving unilateral total knee arthroplasty (UTKA). Methods: Sixty geriatric UTKA patients who were treated in The First People's Hospital of Changzhou from January 2015 to August 2015 were randomly divided into an sFNB + laryngeal mask airway (FLA) group, an sFNB + tracheal intubation (FGA) group and a tracheal intubation (GA) group. Their clinical parameters and indices were recorded. They were scored by the Visual Analogue Scale (VAS). Results: All patients completed this study. FLA and FGA groups used less propofol, remifentanil and fentanyl than GA group (P<0.01), with shorter recovery time and extubation time (P<0.05). Compared to GA group, FLA and FGA groups had lower systolic blood pressures at T3, T4 and T5 (P<0.05), and lower heart rates at T5 (P<0.05). FLA and FGA groups had fewer cases of adverse reactions after extubation (P<0.01). FLA group was less prone to irritating cough after extubation and pharyngeal pain than FGA and GA groups (P<0.01). The postoperative six hour and 24 hour VAS scores in resting state as well as the postoperative 24 hour and 48 hour scores in training state of FLA and FGA groups were lower than those of GA group (P<0.05). FLA and FGA groups used significantly lower times and total doses of patient-controlled intravenous analgesia pump. Conclusion: sFNB combined with general anesthesia, especially that using laryngeal mask, were superior to general anesthesia alone, which reduced recovery and extubation times, and decreased intraoperative and postoperative drug uses, postoperative early VAS score and adverse reactions.
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Affiliation(s)
- Jing Zhang
- Jing Zhang, Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou 213000, P. R. China
| | - Yan Yuan
- Yan Yuan, Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou 213000, P. R. China
| | - Yongjun Zhang
- Yongjun Zhang, Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou 213000, P. R. China
| | - Ying Wang
- Ying Wang, Department of Anesthesiology, The First People's Hospital of Changzhou, Changzhou 213000, P. R. China
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102
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White PB, Ramkumar PN, Meftah M, Ghazi N, Ranawat AS, Ranawat CS. Incidence of Heterotopic Ossification Following a Multimodal Pain Protocol in Total Hip Arthroplasty With the Posterior Approach. Orthopedics 2018; 41:e92-e97. [PMID: 29120007 DOI: 10.3928/01477447-20171102-01] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 10/13/2017] [Indexed: 02/03/2023]
Abstract
Heterotopic ossification (HO) is prevalent after total hip arthroplasty (THA). Oral nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 (COX-2) inhibitors have reduced the incidence of HO; however, to the authors' knowledge, no studies have reported the incidence and severity of HO with a pain protocol highlighted by celecoxib in the pre- and postoperative period with a posterolateral approach. Between October 2014 and October 2015, a retrospective study was conducted of 687 consecutive primary THAs with minimum 1-year follow-up performed between January 2009 and December 2013. All patients underwent a posterolateral THA with a multimodal pain protocol consisting of preoperative celecoxib; local steroid infiltration intraoperatively; postoperative celecoxib, dexamethasone, and ketorolac; and aspirin or warfarin thromboprophylaxis. For all patients, pre- and postoperative radiographs were examined and classified for HO using the Brooker classification. Interobserver reliability was calculated for both incidence of HO and Brooker classification. Overall, HO was present around 98 (14.3%) THAs. The incidence of Brooker I, II, and III HO was 38 (5.5%), 47 (6.8%), and 12 (1.7%), respectively. No patients required surgical excision or had radiographic evidence of Brooker IV HO. Multivariate logistic regression identified male sex and hypertrophic osteoarthritis as significant risk factors. The use of aspirin for thromboprophylaxis significantly reduced the incidence of HO. This study found the overall incidence of HO when using celecoxib during a posterior THA to be 14.3%, which is similar to what others have reported with the direct lateral approach and with other COX-2 inhibitors for a posterior approach. Risk factors include male sex and preoperative hypertrophic osteoarthritis. [Orthopedics. 2018; 41(1):e92-e97.].
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Aspirin/therapeutic use
- Celecoxib/therapeutic use
- Cyclooxygenase 2 Inhibitors/therapeutic use
- Female
- Humans
- Incidence
- Male
- Middle Aged
- Ossification, Heterotopic/diagnostic imaging
- Ossification, Heterotopic/epidemiology
- Ossification, Heterotopic/etiology
- Ossification, Heterotopic/prevention & control
- Osteoarthritis, Hip/complications
- Osteoarthritis, Hip/epidemiology
- Pain, Postoperative/prevention & control
- Radiography
- Reproducibility of Results
- Retrospective Studies
- Risk Factors
- Sex Factors
- United States/epidemiology
- Young Adult
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103
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Adductor Canal Block Versus Femoral Nerve Block for Analgesia After Total Knee Arthroplasty: A Systematic Review and Meta-analysis. Clin J Pain 2017; 33:356-368. [PMID: 27322397 DOI: 10.1097/ajp.0000000000000402] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The efficacy and safety of adductor canal block (ACB) as compared with femoral nerve block (FNB) for postoperative pain management in total knee arthroplasty (TKA) remains controversial. We therefore performed a meta-analysis of randomized-controlled trials (RCTs) to compare ACB with FNB in TKA. MATERIALS AND METHODS Databases, including Pubmed, Medline, Embase, Web of Science, and Cochrane library were searched to identify RCTs comparing ACB with FNB for pain management in patients undergoing TKA. The primary outcomes included pain score with rest or activity and opioid consumption. Secondary outcomes were mobilization ability, quadriceps strength and grade, length of hospital stay, and complications (nausea or vomiting). RESULTS A total of 573 TKAs in 514 patients from 7 RCTs were included in the meta-analysis. Two studies with 155 TKAs reported the mobilization ability assessed by Timed Up and Go Test. The ACB patients performed significantly faster than the FNB patients in the early postoperative period (mean difference=-5.08; 95% confidence interval, -6.03 to -4.13; P<0.00001). The subgroup analysis showed that the outcomes of pain, morphine consumption, quadriceps strength, and length of hospital stay in single shot and continuous subgroups were not statistically different between the 2 groups (P>0.05). DISCUSSION ACB may achieve faster mobilization ability recovery for patients after TKA without a reduction in analgesia when compared with FNB in the early postoperative period. However, due to the variations in the included studies, additional studies are needed to validate these conclusions.
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104
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Onuoha KO, Solow M, Newman JM, Sodhi N, Pivec R, Khlopas A, Sultan AA, Chughtai M, Shah NV, George J, Mont MA. Have the annual trends of total hip arthroplasty in rheumatoid arthritis patients decreased? ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S35. [PMID: 29299482 DOI: 10.21037/atm.2017.11.15] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Rheumatoid arthritis (RA) is characterized by chronic systemic and synovial inflammation, resulting in damage to both cartilage and bone. Medical treatment, which has increasingly relied upon disease modifying anti-rheumatic drugs (DMARDs), may fail to slow disease progression and limit joint damage, ultimately warranting surgical intervention. Up to 25% of RA patients will require lower extremity total joint arthroplasty. Though total hip arthroplasty (THA) is known to improve quality of life and functional measures, clarification is still required with respect to the impact of increased DMARD use on annual rates of THA. Thus, the purpose of this study was to evaluate: (I) the annual trends of THAs due to RA in the United States population; (II) the annual trends in the proportion of THAs due to RA in the United States. Methods This study utilized the Nationwide Inpatient Sample (NIS) to identify all patients who underwent THA between 2002 and 2013 (n=3,135,904). Then, THA patients who had a diagnosis of RA, which was defined by the International Classification of Disease 9th revision diagnosis code 714.0, were identified. The incidence of THAs with a diagnosis of RA in the United States was calculated using the United States population as the denominator. Regression models were used to analyze the annual trends of RA in patients who underwent THA. Results Review of the database identified 90,487 patients who had a diagnosis of RA and underwent THA from 2002 to 2013. The annual prevalence of RA in those who underwent THA slightly decreased over the specified time period, with 28.7 per 1,000 THAs in 2002 and 28.6 per 1,000 THAs in 2013; however, this change was not statistically significant (R2=0.158, P=0.200). Conclusions The annual rates of THA among RA patients did not show any significant change between 2002 and 2013. DMARD use has decreased both disease progression and joint destruction, and DMARDs are now often utilized as primary treatment. The increase in population of the country during the study period may have overestimated THA trends. Moreover, patients may be more likely to opt for surgical management, given the advances in operative techniques as well as peri- and post-operative course.
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Affiliation(s)
- Kemjika O Onuoha
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center Brooklyn, New York, USA
| | - Max Solow
- St. Georges University School of Medicine, St. George's, West Indies, Grenada
| | - Jared M Newman
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center Brooklyn, New York, USA
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert Pivec
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center Brooklyn, New York, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Neil V Shah
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center Brooklyn, New York, USA
| | - Jaiben George
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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105
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Iwakiri K, Kobayashi A, Ohta Y, Minoda Y, Takaoka K, Nakamura H. Efficacy of a Pelvic Lateral Positioner With a Mechanical Cup Navigator Based on the Anatomical Pelvic Plane in Total Hip Arthroplasty. J Arthroplasty 2017; 32:3659-3664. [PMID: 28712802 DOI: 10.1016/j.arth.2017.06.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 05/30/2017] [Accepted: 06/19/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The acetabular component orientation in total hip arthroplasty (THA) is of critical importance to the good clinical results. However, traditional widely used cup alignment guides for cup placement are reported to be relatively unreliable. The present study aims at comparing a novel cup alignment guide, which can be attached to our anatomical pelvic plane (APP) pelvic lateral positioner for reducing discrepancies in sagittal pelvic tilt and indicate a targeted cup angle based on the APP, with a conventional cup alignment guide. METHODS The subjects were 136 hips of 136 patients who underwent unilateral THA using the APP positioner. The procedure was performed with the conventional cup alignment guide (conventional group; 60 hips) and with the novel cup navigator (mechanical navigator group; 76 hips). Postoperative cup angles and discrepancies of postoperative cup angles (inclination and anteversion angles) from the targeted angles were compared between the 2 groups to evaluate the usefulness of these navigators. RESULTS The mean cup angles in the conventional group were 39.0° ± 5.3° for the inclination angle and 21.7° ± 6.4° for the anteversion angle, whereas those in the mechanical navigator group were 40.6° ± 3.2° and 18.3° ± 4.6°, respectively (P = .018, P < .0001). The discrepancies from the targeted angles were 3.5° ± 3.1° for the inclination angle and 4.6° ± 3.4° for the anteversion angle in the conventional group and 2.3° ± 2.3° and 3.2° ± 2.7°, respectively, in the mechanical navigator group (P = .020, P = .012). CONCLUSION The mechanical cup navigator easily attachable to the APP positioner is a tool that can improve the accuracy of cup placement in a simple, economical, and noninvasive manner in THA via the lateral position.
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Affiliation(s)
- Kentaro Iwakiri
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Nara, Japan
| | - Akio Kobayashi
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Nara, Japan
| | - Yoichi Ohta
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yukihide Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kunio Takaoka
- Department of Orthopaedic Surgery, Shiraniwa Hospital, Nara, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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106
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Zhang X, Yang Q, Zhang Z. The efficiency and safety of local liposomal bupivacaine infiltration for pain control in total hip arthroplasty: A systematic review and meta-analysis. Medicine (Baltimore) 2017; 96:e8433. [PMID: 29245214 PMCID: PMC5728829 DOI: 10.1097/md.0000000000008433] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE This meta-analysis aimed to compare the efficiency and safety of local liposomal bupivacaine infiltration and traditional cocktail analgesia for pain management in total hip arthroplasty (THA). METHODS PubMed, Embase, Web of science, Medline, and Cochrane library databases were systematically searched. INCLUSION CRITERIA Participants: patients planned for a THA with a diagnosis of hip osteoarthritis. INTERVENTIONS liposomal bupivacaine was administrated in the experimental groups for pain control. Comparisons: the control groups received local infiltration of traditional analgesics. OUTCOMES pain scores, opioids consumption, and postoperative complications among the patients. STUDY DESIGN randomized control trials (RCTs) and non-RCTs. Methodological Index for Non-Randomized Studies scale was used to assess the methodological quality of the included studies. Meta-analysis was conducted by Stata 11.0 software. Systematic review registration number is CRD42017120981. RESULTS Four articles involving 308 participants were included. Current meta-analysis revealed that there were significant differences regarding postoperative pain score at 12 hours (standard mean difference [SMD] = -0.496, 95% CI: -0.717 to -0.275, P = .000), 24 hours (SMD = -0.537, 95% CI: -0.760 to -0.313, P = .000), and 48 hours (SMD = -0.802, 95% CI: -1.029 to -0.576, P = .000). Liposomal bupivacaine intervention was found to significantly decrease opioid consumption at 12 hours (SMD = -0.544, 95% CI: -0.766 to -0.323, P = .000), 24 hours (SMD = -0.357, 95% CI: -0.577 to -0.138, P = .001), and 48 hours (SMD = -0.370, 95% CI: -0.589 to -0.151, P = .001). CONCLUSION Local liposomal bupivacaine infiltration could significantly reduce visual analogue scale (VAS) scores and opioid consumption within the first 48 hours following THA surgery. In addition, there was a decreased risk of nausea and vomiting in liposomal bupivacaine groups. The overall evidence level was low, which means that further research is likely to significantly alter confidence levels in the effect, as well as potentially changing the estimates. In any subsequent research, further studies should focus on the optimal dose of local anesthetics and the potential adverse side effects. In addition, surgeries that can improve pain relief and enable faster rehabilitation and earlier discharges should also be explored. Several potential limitations of this study should be noted. Four articles are included and the sample size in each trial is small. Some important outcome parameters such as range of motion were not fully described and could not be included in the meta-analysis. All included studies were retrospectives which may decrease evidence levels for the meta-analysis. The evidence quality for each outcome was low which may influence the results of the meta-analysis. Short-term follow-ups may lead to the underestimation of complications, such as neurotoxicity and cardiotoxicity. Publication bias is an inherent weakness that exists in all meta-analyses.
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107
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Azboy I, Barrack R, Thomas AM, Haddad FS, Parvizi J. Aspirin and the prevention of venous thromboembolism following total joint arthroplasty: commonly asked questions. Bone Joint J 2017; 99-B:1420-1430. [PMID: 29092979 PMCID: PMC5742873 DOI: 10.1302/0301-620x.99b11.bjj-2017-0337.r2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022]
Abstract
The number of arthroplasties being performed
increases each year. Patients undergoing an arthroplasty are at
risk of venous thromboembolism (VTE) and appropriate prophylaxis
has been recommended. However, the optimal protocol and the best
agent to minimise VTE under these circumstances are not known. Although
many agents may be used, there is a difference in their efficacy
and the risk of bleeding. Thus, the selection of a particular agent relies
on the balance between the desire to minimise VTE and the attempt
to reduce the risk of bleeding, with its undesirable, and occasionally
fatal, consequences. Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis
following arthroplasty. Many studies have shown its efficacy in
minimising VTE under these circumstances. It is inexpensive and
well-tolerated, and its use does not require routine blood tests.
It is also a ‘milder’ agent and unlikely to result in haematoma
formation, which may increase both the risk of infection and the
need for further surgery. Aspirin is also unlikely to result in persistent
wound drainage, which has been shown to be associated with the use
of agents such as low-molecular-weight heparin (LMWH) and other
more aggressive agents. The main objective of this review was to summarise the current
evidence relating to the efficacy of aspirin as a VTE prophylaxis
following arthroplasty, and to address some of the common questions
about its use. There is convincing evidence that, taking all factors into account,
aspirin is an effective, inexpensive, and safe form of VTE following
arthroplasty in patients without a major risk factor for VTE, such
as previous VTE. Cite this article: Bone Joint J 2017;99-B:1420–30.
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Affiliation(s)
- I Azboy
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
| | - R Barrack
- Washington University Orthopedics, Barnes Jewish Hospital, 660 South Euclid Avenue, Campus Box 8233, St. Louis, Missouri 63110, USA
| | - A M Thomas
- The Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
| | - J Parvizi
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
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108
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Li X. Total Hip Arthroplasty: What Is the Best Perioperative Analgesic Modality?: Commentary on an article by Rebecca L. Johnson, MD, et al.: "Continuous Posterior Lumbar Plexus Nerve Block Versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Total Hip Arthroplasty. A Three-Arm Randomized Clinical Trial". J Bone Joint Surg Am 2017; 99:e117. [PMID: 29088049 DOI: 10.2106/jbjs.17.00978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Xinning Li
- Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, Boston University School of Medicine, Boston, Massachusetts
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109
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Zhao HY, Kang PD, Xia YY, Shi XJ, Nie Y, Pei FX. Comparison of Early Functional Recovery After Total Hip Arthroplasty Using a Direct Anterior or Posterolateral Approach: A Randomized Controlled Trial. J Arthroplasty 2017; 32:3421-3428. [PMID: 28662957 DOI: 10.1016/j.arth.2017.05.056] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Controversy exists as to whether early functional outcomes differ after total hip arthroplasty performed using the direct anterior approach (DAA) or the posterolateral approach (PLA). METHODS One hundred twenty patients were enrolled in this study and were divided into 2 groups based on surgical approach. Group A included patients who had a total hip arthroplasty with a DAA, whereas group B included those with a PLA. Patients were randomized into the DAA or PLA groups (n = 60), and perioperative and postoperative outcomes were recorded. RESULTS When compared with the PLA, the DAA had a shorter incision length (9.1 vs 13.1 cm; P < .01), shorter hospital stay (2.8 vs 3.3 days, P = .04), and lower self-reported pain. Both serum inflammatory and muscle damage markers were lower in the DAA group. However, the PLA had shorter operative times (65.5 vs 83.3 min, P = .03) and less intraoperative blood loss (123.8 vs 165.9 mL, P = .04). The DAA had significantly lower variance in cup inclination and anteversion. Similar rates of intraoperative complications were identified in the 2 groups. The DAA was associated with better functional recovery at 3 months based on the Harris hip score, University of California Los Angeles activity score, and gait analysis; however, functional recovery at 6 months was similar between the 2 groups. CONCLUSION We found functional advantages in early recovery after the DAA compared with the PLA. The DAA can offer rapid functional recovery with less muscle damage, greater pain relief, and lower variance in cup inclination and anteversion. However, no functional difference was found at 6 months follow-up.
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Affiliation(s)
- Hai-Yan Zhao
- Department of Orthopedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Peng-De Kang
- Department of Orthopedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Ya-Yi Xia
- Department of Orthopedics, Lanzhou University Second Hospital, Lanzhou, People's Republic of China
| | - Xiao-Jun Shi
- Department of Orthopedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Yong Nie
- Department of Orthopedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
| | - Fu-Xing Pei
- Department of Orthopedics, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, People's Republic of China
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110
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Murata-Ooiwa M, Tsukada S, Wakui M. Intravenous Acetaminophen in Multimodal Pain Management for Patients Undergoing Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial. J Arthroplasty 2017; 32:3024-3028. [PMID: 28583757 DOI: 10.1016/j.arth.2017.05.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/28/2017] [Accepted: 05/08/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although multimodal pain management including periarticular multidrug injection can provide excellent pain relief in the early postoperative period after total knee arthroplasty (TKA), rebounding pain remains an important challenge. A randomized, double-blind, placebo-controlled trial was performed to investigate the efficacy of adding intravenous acetaminophen to multimodal pain management for TKA. METHODS We enrolled 67 patients scheduled for unilateral TKA. Patients were randomly assigned to receive either 1000 mg of intravenous acetaminophen at 6-hour intervals or normal saline at the same intervals. All patients were treated with intraoperative periarticular multidrug injection and intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome was the postoperative 100-mm visual analog pain scale at the time of administration of study drugs. RESULTS In the intention-to-treat analysis, the pain score was significantly better in the intravenous acetaminophen group than the placebo group at 17:00 one day after TKA (15.3 ± 17.0 mm vs 26.8 ± 19.0 mm; P = .013). There were no significant differences in terms of the rate of complications between groups. CONCLUSION Even in the setting of multimodal pain management including periarticular multidrug injection, intravenous acetaminophen provided better pain relief for patients undergoing unilateral TKA.
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Affiliation(s)
| | - Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan; Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Ibaraki, Japan
| | - Motohiro Wakui
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
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Abstract
Progress in surgical acute pain management has allowed most foot and ankle surgery to be performed in ambulatory outpatient surgical centers. Multimodal analgesia focuses on improving postoperative pain by combining pharmacologic and other modalities, addressing multiple pain mechanisms and receptor pathways while reducing adverse effects through lower doses of oral medications. Local anesthesia techniques provide excellent pain relief with few adverse events. Multimodal analgesia in foot and ankle surgery provides superior pain relief, and reduced opioid dependence and opioid-related side effects, improving patient satisfaction, safety, and timely return to function.
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Affiliation(s)
- Jessica M Kohring
- Department of Orthopaedics, The University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA.
| | - Nathan G Orgain
- Department of Anesthesiology, The University of Utah, SOM 3C444, 30 North 1900 East, Salt Lake City, UT 84132, USA
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112
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Yang L, Du S, Sun Y. Intravenous acetaminophen as an adjunct to multimodal analgesia after total knee and hip arthroplasty: A systematic review and meta-analysis. Int J Surg 2017; 47:135-146. [PMID: 28919091 DOI: 10.1016/j.ijsu.2017.09.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/08/2017] [Accepted: 09/09/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND This meta-analysis aimed to perform a meta-analysis to investigate the impact of additional intravenous acetaminophen for pain management after total joint arthroplasty (TJA). METHODS We conducted electronic searches of Medline (1966-2017.07), PubMed (1966-2017.07), Embase (1980-2017.07), ScienceDirect (1985-2017.07) and the Cochrane Library. Randomized controlled trials (RCTs) and non-RCTs were included. The quality assessments were performed according to the Cochrane systematic review method. The primary outcomes were postoperative pain scores and opioid consumption. Meta-analysis was performed using Stata 11.0 software. RESULTS A total of four studies were retrieved involving 865 participants. The present meta-analysis indicated that there were significant differences between groups in terms of pain scores at POD 1 (WMD = -0.954, 95% CI: -1.204 to -0.703, P = 0.000), POD 2 (WMD = -1.072, 95% CI: -2.072 to -0.073, P = 0.000), and POD 3 (WMD = -0.883, 95% CI: -1.142 to -0.624, P = 0.000). Significant differences were found regarding opioid consumption at POD 1 (WMD = -3.144, 95% CI: -4.142 to -2.146, P = 0.000), POD 2 (WMD = -5.665, 95% CI: -7.383 to -3.947, P = 0.000), and POD 3 (WMD = -3.563, 95% CI: -6.136 to -0.991, P = 0.007). CONCLUSION Additional intravenous acetaminophen to multimodal analgesia could significantly reduce pain and opioid consumption after total joint arthroplasty with fewer adverse effects. Higher quality RCTs are required for further research.
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Affiliation(s)
- Liqing Yang
- Department of Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, China.
| | - Shuai Du
- Department of Orthopedics, Central Hospital of Shenyang Medical College, Shenyang 110024, China
| | - Yuefeng Sun
- Department of Orthopedics, Shengjing Hospital of China Medical University, Shenyang 110004, China
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Enhanced recovery principles applied to revision hip and knee arthroplasty reduces length of stay and blood transfusion. J Orthop 2017; 14:555-560. [PMID: 28878516 DOI: 10.1016/j.jor.2017.08.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 08/08/2017] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION This is the first study reporting the application of Enhanced Recovery Principles (ERP) to revision arthroplasty. METHOD Retrospective series of 132 revision hip and knee replacements treated with ERP. RESULTS Infiltration was associated with reduced LOS in knees (6 vs 8.5 days), lower PCA usage and incidence of transfusion in knees (2 vs 3 days) and hips (1 vs 6 days). Revisions for infection had a longer LOS (5.4 vs 11.5 days p = 0.001), a greater use of PCA and a higher incidence of transfusion (5 vs 0) in both knees and hips. DISCUSSION The application of ERPs to revision arthroplasty is safe. Infiltration appears to be an important factor in improving outcome measures.
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Affiliation(s)
- Neel Desai
- Specialist Registrar in Anaesthetics, Department of Anaesthetics, Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP
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115
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Xing Q, Dai W, Zhao D, Wu J, Huang C, Zhao Y. Adductor canal block with local infiltrative analgesia compared with local infiltrate analgesia for pain control after total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e8103. [PMID: 28930857 PMCID: PMC5617724 DOI: 10.1097/md.0000000000008103] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND This meta-analysis aimed to evaluate the efficiency and safety of the combined adductor canal block with peri-articular infiltration versus periarticular infiltration alone for pain control after total knee arthroplasty (TKA). METHODS PubMed, Medline, Embase, Web of Science, and the Cochrane Library were searched to identify articles comparing the combined adductor canal block with peri-articular infiltration and periarticular infiltration alone for pain control after TKA. Main outcomes were numeric rating scale (NRS) at postoperative day (POD) 0-2 and opioid consumption. Meta-analysis was performed using Stata 11.0 software. RESULTS Four randomized controlled trial (RCTs) including 297 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between the groups regarding NRS score at POD 0 (weighted mean difference [WMD] = -0.849, 95% confidence interval [CI]: -1.345 to -0.353, P = .001), POD 1 (WMD = -0.960, 95% CI: -1.474 to -0.446, P = .000), and POD 2 (WMD = -0.672, 95% CI: -1.163 to -0.181, P = .007) after TKA. Significant differences were found in terms of opioid consumption at POD 0 (WMD = -3.761, 95% CI: -6.192 to -1.329, P = .002), POD 1 (WMD = -4.795, 95% CI: -8.181 to -1.409, P = .006), and POD 2 (WMD = -2.867, 95% CI: -4.907 to -0.827, P = .006). CONCLUSION Combined adductor canal block with peri-articular infiltration could significantly reduce NRS scores and opioid consumption in comparison with periarticular infiltration alone following TKA. Additionally, there is a lower incidence of nausea and vomiting in the combined groups.
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Affiliation(s)
- Qiujuan Xing
- Department of Rehabilitation, Tianshan Traditional Chinese Medicine Hospital of Changning District
| | - Weiwei Dai
- Central Laboratory of Science and Technology Department, Longhua Hospital
| | - Dongfeng Zhao
- Institute of Spine, Shanghai University of Traditional Chinese Medicine, Shanghai, People's Republic of China
| | - Ji Wu
- Department of Rehabilitation, Tianshan Traditional Chinese Medicine Hospital of Changning District
| | - Chunshui Huang
- Department of Rehabilitation, Tianshan Traditional Chinese Medicine Hospital of Changning District
| | - Yun Zhao
- Department of Rehabilitation, Tianshan Traditional Chinese Medicine Hospital of Changning District
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Preoperative Opiate Use Independently Predicts Narcotic Consumption and Complications After Total Joint Arthroplasty. J Arthroplasty 2017; 32:2658-2662. [PMID: 28478186 DOI: 10.1016/j.arth.2017.04.002] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 04/03/2017] [Accepted: 04/03/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Multimodal pain protocols have reduced opioid requirements and decreased complications after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, these protocols are not universally effective. The purposes of this study are to determine the risk factors associated with increased opioid requirements and the impact of preoperative narcotic use on the length of stay and inhospital complications after THA or TKA. METHODS We prospectively evaluated a consecutive series of 802 patients undergoing elective primary THA and TKA over a 9-month period. All patients were managed using a multimodal pain protocol. Data on medical comorbidities and history of preoperative narcotic use were collected and correlated with deviations from the protocol. RESULTS Of the 802 patients, 266 (33%) required intravenous narcotic rescue. Patients aged <75 years (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.10-3.12; P = .019) and with preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) were more likely to require rescue. Multivariate logistic regression analysis demonstrated that preoperative narcotic use (OR, 2.74; 95% CI, 2.01-3.75; P < .001) was the largest independent predictor of increased postoperative opioid requirements. These patients developed more inhospital complications (OR, 1.92; 95% CI, 1.34-2.76; P < .001). This was associated with an increased length of stay (OR, 1.59; 95% CI, 1.06-2.37; P = .025) and a 2.5-times risk of requiring oral narcotics at 3 months postoperatively (OR, 2.48; 95% CI, 1.61-3.82; P < .001). CONCLUSION Despite the effectiveness of multimodal postoperative pain protocols, younger patients with preoperative history of narcotic use require additional opioids and are at a higher risk for complications and a greater length of stay.
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Li J, Song Y. Transcutaneous electrical nerve stimulation for postoperative pain control after total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e8036. [PMID: 28906393 PMCID: PMC5604662 DOI: 10.1097/md.0000000000008036] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This meta-analysis aimed to evaluate the efficiency and safety of transcutaneous electrical nerve stimulation (TENS) for pain control after total knee arthroplasty. METHODS A systematic search was performed in Medline (1966 to June 2017), PubMed (1966 to June 2017), Embase (1980 to June 2017), ScienceDirect (1985 to June 2017), and the Cochrane Library. Only randomized controlled trial (RCT) was included. The fixed/random effect model was used according to the heterogeneity tested by I statistic. Meta-analysis was performed using Stata 11.0 software. RESULTS Five RCTs including 472 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of visual analogue scale score at 12 hours (average: 3.58 vs 4.34, SMD = -0.260, 95% CI: -0.442 to -0.078, P = .005), 24 hours (average: 3.18 vs 3.52, SMD = -0.244, 95% CI: -0.426 to -0.063, P = .008), and 48 hours (average: 2.70 vs 2.96, SMD = -0.214, 95% CI: -0.395 to -0.033, P = .021) after total knee arthroplasty. Significant differences were found regarding opioid consumption at 12 hours (average: 14.44 vs 18.54, SMD = -0.503, 95% CI: -0.687 to -0.319, P = .000), 24 hours (average: 16.10 vs 18.40, SMD = -0.262, 95% CI: -0.443 to -0.080, P = .005), and 48 hours (average: 12.92 vs 15.12, SMD = -0.183, 95% CI: -0.364 to -0.002, P = .048). CONCLUSION TENS could significantly reduce pain and opioid consumption after total knee arthroplasty. In addition, there were fewer adverse effects in the TENS groups. Higher quality RCTs are required for further research.
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Abstract
BACKGROUND Oral multimodal analgesia for hip and knee arthroplasty is increasingly used as part of enhanced recovery protocols designed to minimize early postoperative pain and to facilitate early discharge, while minimizing undesirable side effects related to single-agent opioid administration. METHODS This article is a review of previously published data evaluating the use of various oral medications in the management of postoperative pain after lower extremity arthroplasty and was presented as part of a symposium at the November 2016 AAHKS Annual Meeting. RESULTS Multimodal analgesia has been shown to reduce opioid consumption and side effects, with a positive effect on both early and longer term outcomes for hip and knee arthroplasty patients. Medications directed at multiple points on the pain cascade minimize pain by different mechanisms. Suggested dosing regimens are proposed. CONCLUSION Oral multimodal analgesia incorporating a combination of opioid and nonopioid analgesics, selective and nonselective anti-inflammatory drugs, acetaminophen, and gabapentinoids are recommended as a part of a pre-emptive approach to pain management in patients undergoing hip or knee arthroplasty. Reduction of opioid consumption and minimization of side effects are primary outcomes, and prevention of chronic pain can positively affect long-term results.
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119
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Brooks E, Freter SH, Bowles SK, Amirault D. Multimodal Pain Management in Older Elective Arthroplasty Patients. Geriatr Orthop Surg Rehabil 2017; 8:151-154. [PMID: 28835871 PMCID: PMC5557197 DOI: 10.1177/2151458517720297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 05/30/2017] [Accepted: 06/14/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Pain management after elective arthroplasty in older adults is complicated due to the risk of undertreatment of postoperative pain and potential adverse effects from analgesics, notably opioids. Using combinations of analgesics has been proposed as potentially beneficial to achieve pain control with lower opioid doses. OBJECTIVE We compared a multimodal pain protocol with a traditional one, in older elective arthroplasty patients, measuring self-rated pain, incidence of postoperative delirium, quantity and cost of opioid analgesics consumed. METHODS One hundred fifty-eight patients, 70 years and older, admitted to tertiary care for elective arthroplasty were prospectively assessed postoperative days 1-3. Patients received either traditional postoperative analgesia (acetaminophen plus opioids) or a multimodal pain protocol (acetaminophen, opioids, gabapentin, celecoxib), depending on surgeon preference. Self-rated pain, postoperative delirium, and time to achieve standby-assist ambulation were compared, as were total opioid doses and analgesic costs. RESULTS Despite receiving significantly more opioid analgesics (traditional: 166.4 mg morphine-equivalents; multimodal: 442 mg morphine equivalents; t = 10.64, P < .0001), there was no difference in self-rated pain, delirium, or mobility on postoperative days 1-3. Costs were significantly higher in the multimodal group (t = 9.15, P < .0001). Knee arthroplasty was associated with higher pain scores than hip arthroplasty, with no significant difference in opioid usage. CONCLUSION A multimodal approach to pain control demonstrated no benefit over traditional postoperative analgesia in elective arthroplasty patients, but with significantly higher amounts of opioid consumed. This poses a potential risk regarding tolerability in frail older adults and results in increased drug costs.
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Affiliation(s)
- Elaine Brooks
- Department of Orthopaedic Surgery, Nova Scotia Health Authority (Central Zone), Halifax, Nova Scotia, Canada
| | - Susan H Freter
- Geriatric Medicine, Centre for Health Care of the Elderly, Dalhousie University, Nova Scotia Health Authority (Central Zone), Halifax, Nova Scotia, Canada
| | - Susan K Bowles
- Department of Pharmacy, College of Pharmacy and Geriatric Medicine, Dalhousie University, Nova Scotia Health Authority (Central Zone), Halifax, Nova Scotia, Canada
| | - David Amirault
- Orthopaedic Surgery, Dalhousie University, Nova Scotia Health Authority (Central Zone), Halifax, Nova Scotia, Canada
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Sogbein OA, Sondekoppam RV, Bryant D, Johnston DF, Vasarhelyi EM, MacDonald S, Lanting B, Ganapathy S, Howard JL. Ultrasound-Guided Motor-Sparing Knee Blocks for Postoperative Analgesia Following Total Knee Arthroplasty: A Randomized Blinded Study. J Bone Joint Surg Am 2017; 99:1274-1281. [PMID: 28763413 DOI: 10.2106/jbjs.16.01266] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Pain following total knee arthroplasty (TKA) is often severe and can inhibit rehabilitation. Motor-sparing analgesic techniques such as periarticular infiltrations and adductor canal blocks have been popularized for knee analgesia since they preserve motor strength and permit early mobilization. Our primary objective was to compare the duration of analgesia from motor-sparing blocks with that of a standard periarticular infiltration. We used the time to first rescue analgesia as the end point. METHODS We randomized 82 patients scheduled for elective TKA to receive either the preoperative motor-sparing block (0.5% ropivacaine, 2.5 μg/mL of epinephrine, 10 mg of morphine, and 30 mg of ketorolac) or intraoperative periarticular infiltration (0.3% ropivacaine, 2.5 μg/mL of epinephrine, 10 mg of morphine, and 30 mg of ketorolac). For the motor-sparing block, we modified the ultrasound-guided adductor canal block by combining it with a lateral femoral cutaneous nerve block and posterior knee infiltration. The patients, surgeons, anesthetists administering the blocks, and outcome assessors all remained blinded to group allocation. Our primary outcome was duration of analgesia (time to first rescue analgesia). Secondary outcomes included quadriceps strength, function, side effects, satisfaction, and length of hospital stay. RESULTS The duration of analgesia was significantly longer (mean difference, 8.8 hours [95% confidence interval = 3.98 to 13.62], p < 0.01) for the motor-sparing-block group (mean [and standard error], 18.1 ± 1.7 hours) compared with the periarticular infiltration group (mean, 9.25 ± 1.7 hours). The infiltration group had significantly higher scores for pain at rest for the first 2 postoperative hours and for pain with knee movement at 2 and 4 hours. There were no significant differences between groups with regard to any other secondary outcomes. CONCLUSIONS In patients undergoing a TKA, a motor-sparing block provides longer analgesia than periarticular infiltration with retention of quadriceps muscle strength, function, patient satisfaction, and a short hospital stay. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Olawale A Sogbein
- 1University of Western Ontario, London, Ontario, Canada 2Northern Ontario School of Medicine, Sudbury, Ontario, Canada 3Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada 4Division of Orthopaedic Surgery (D.B., E.M.V., S.M., B.L., and J.L.H.) and Department of Anesthesiology and Perioperative Medicine (D.F.J. and S.G.), University Hospital-London Health Sciences Centre, London, Ontario, Canada
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121
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Multimodal Analgesia Versus Intravenous Patient-Controlled Analgesia for Minimally Invasive Transforaminal Lumbar Interbody Fusion Procedures. Spine (Phila Pa 1976) 2017; 42:1145-1150. [PMID: 27879573 DOI: 10.1097/brs.0000000000001992] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE To compare postoperative narcotic consumption and pain scores between multimodal analgesia (MMA) and patient-controlled analgesia (PCA) following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). SUMMARY OF BACKGROUND DATA A multimodal analgesic approach to pain management may lead to decreased pain and narcotic consumption after orthopedic procedures. Additional evidence is, however, required to determine how MMA compares to intravenous PCA after MIS TLIF. METHODS Patients undergoing 1-level MIS TLIF followed by either MMA or PCA at our institution were compared in terms of inpatient pain scores, narcotic consumption, hospital length of stay, rates of surgical complications, rates of inpatient nausea/vomiting, rates of postoperative urinary retention, and rates of narcotic consumption during the months after discharge. RESULTS A total of 139 patients met inclusion criteria. Of these, 39 (28.1%) received MMA and 100 (71.9%) received PCA. Demographic and comorbidity characteristics did not differ between cohorts. Compared with patients receiving PCA, patients receiving MMA had a lower rate of inpatient narcotic consumption (2.8 ± 1.9 vs. 5.3 ± 4.4 oral morphine equivalents/hour, P < 0.001), a lower rate of inpatient nausea/vomiting (20.5% vs. 48.0%; P = 0.003), and a shorter hospital length of stay (53.0 ± 25.3 vs. 62.6 ± 24.4 h, P = 0.041). There were no differences in Numeric Rating Scale pain score between cohorts for day 0, postoperative day 1, or postoperative day 2 (P > 0.05 for each). There was no difference in the rate of postoperative urinary retention (P > 0.05). Similarly, there were no differences in narcotic consumption at 6 or 12 weeks postoperatively (P > 0.05 for each). CONCLUSION These findings suggest that MMA results in reduced inpatient hospital narcotic consumption compared with PCA after MIS TLIF. The decrease in narcotic consumption may contribute to the observed decrease in the rate of inpatient nausea/vomiting and shorter hospital length of stay. Importantly, MMA and PCA resulted in similar analgesia for patients during the inpatient stay. LEVEL OF EVIDENCE 4.
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Lee YS. Comprehensive Analysis of Pain Management after Total Knee Arthroplasty. Knee Surg Relat Res 2017; 29:80-86. [PMID: 28545171 PMCID: PMC5450578 DOI: 10.5792/ksrr.16.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 06/13/2016] [Accepted: 06/15/2016] [Indexed: 12/14/2022] Open
Abstract
Total knee arthroplasty (TKA) has been much improved recently and it is regarded as one of the most common and successful surgical procedures that provides pain relief and improves function in patients with severe knee arthritis. However, recent studies have reported that 15%–20% of patients are not satisfied after TKA without evident clinical or radiological findings and the most common causes of patient dissatisfaction include residual pain and limited function. The evaluation and treatment of painful TKA relies on a thorough understanding of the origin by careful evaluation, and a systematic approach is essential to efficiently and effectively resolve the pain. Periarticular injections (PAIs) and nerve blocks are gaining popularity because they are associated with less side effects than systemic regimens. The analgesic efficacy and safety of PAI compared with nerve blocks for postoperative pain management still remain controversial. Therefore, more study is needed to determine if any changes in the regimen of the injection or technique could provide added benefit to long-term functional improvement beyond the perioperative period.
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Affiliation(s)
- Yong Seuk Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
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123
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Meyr AJ, Mirmiran R, Naldo J, Sachs BD, Shibuya N. American College of Foot and Ankle Surgeons ® Clinical Consensus Statement: Perioperative Management. J Foot Ankle Surg 2017; 56:336-356. [PMID: 28231966 DOI: 10.1053/j.jfas.2016.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 02/07/2023]
Abstract
A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.
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Affiliation(s)
- Andrew J Meyr
- Committee Chairperson and Clinical Associate Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | | | - Jason Naldo
- Assistant Professor, Department of Orthopedic Surgery, Virginia Tech Carilion School of Medicine, Roanoke, VA
| | - Brett D Sachs
- Private Practice, Rocky Mountain Foot & Ankle Center, Wheat Ridge, CO; Faculty, Podiatric Medicine and Surgery Program, Highlands-Presbyterian St. Luke's Medical Center, Denver, CO
| | - Naohiro Shibuya
- Professor, Department of Surgery, Texas A&M, College of Medicine, Temple, TX
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Comparison of intrathecal and local infiltration analgesia by morphine for pain management in total knee and hip arthroplasty: A meta-analysis of randomized controlled trial. Int J Surg 2017; 40:97-108. [PMID: 28254422 DOI: 10.1016/j.ijsu.2017.02.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 02/15/2017] [Accepted: 02/17/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE We performed a meta-analysis from randomized controlled trials to evaluate the efficiency and safety between local infiltration analgesia and intrathecal morphine for pain control in total knee and hip arthroplasty. METHODS We systemically searched electronic databases including Embase (1980-2016.7), Medline (1966-2016.7), PubMed (1966-2016.7), ScienceDirect (1985-2016.7), web of science (1950-2016.7) and Cochrane Library for relevant articles. All calculation was carried out by Stata 11.0. RESULTS Four randomized controlled trials (RCTs) involving 242 patients met the inclusion criteria. The meta-analysis showed that there were significant differences in terms of postoperative pain scores at 24 h during rest (P = 0.008) and mobilization (P = 0.049) following total knee and hip arthroplasty. Significant difference was found regarding the incidence of nausea (P = 0.030), vomiting (P = 0.005), and pruritus (P = 0.000) between two groups. There was no significant difference between groups in terms of morphine equivalent consumption at postoperative 24 or 48 h. CONCLUSIONS Local infiltration analgesia (LIA) provided superior analgesic effects within the first 24 h compared to intrathecal morphine (ITM) following total knee and hip arthroplasty. There were fewer adverse effects in LIA. Doses of morphine consumption were similar in the two groups.
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125
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Otto Aufranc Award: A Multicenter, Randomized Study of Outpatient versus Inpatient Total Hip Arthroplasty. Clin Orthop Relat Res 2017; 475:364-372. [PMID: 27287858 PMCID: PMC5213925 DOI: 10.1007/s11999-016-4915-z] [Citation(s) in RCA: 174] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Length of stay after total hip arthroplasty (THA) has decreased over the last two decades. However, published studies that have examined same-day and early discharge protocols after THA have been done in highly selected patient groups operated on by senior surgeons in a nonrandomized fashion without control subjects. QUESTIONS/PURPOSES The purpose of this study was to evaluate and compare patients undergoing THA who are discharged on the same day as the surgery ("outpatient," less than 12-hour stay) with those who are discharged after an overnight hospital stay ("inpatient") with regard to the following outcomes: (1) postoperative pain; (2) perioperative complications and healthcare provider visits (readmission, emergency department or physician office); and (3) relative work effort for the surgeon's office staff. METHODS A prospective, randomized study was conducted at two high-volume adult reconstruction centers between July 2014 and September 2015. Patients who were younger than 75 years of age at surgery, who could ambulate without a walker, who were not on chronic opioids, and whose body mass index was less than 40 kg/m2 were invited to participate. All patients had a primary THA performed by the direct anterior approach with spinal anesthesia at a hospital facility. Study data were evaluated using an intention-to-treat analysis. A total of 220 patients participated, of whom 112 were randomized to the outpatient group and 108 were randomized to the inpatient group. Of the 112 patients randomized to outpatient surgery, 85 (76%) were discharged as planned. Of the remaining 27 patients, 26 were discharged after one night in the hospital and one was discharged after two nights. Of the 108 patients randomized to inpatient surgery with an overnight hospital stay, 81 (75%) were discharged as planned. Of the remaining 27 patients, 18 met the discharge criteria on the day of their surgery and elected to leave the same day, whereas nine patients stayed two or more nights. RESULTS On the day of surgery, there was no difference in visual analog scale (VAS) pain among patients who were randomized to discharge on the same day and those who were randomized to remain in the hospital overnight (outpatient 2.8 ± 2.5, inpatient 3.3 ± 2.3, mean difference -0.5, 95% confidence interval [CI], -1.1 to 0.1, p = 0.12). On the first day after surgery, outpatients had higher VAS pain (at home) than inpatients (3.7 ± 2.3 versus 2.8 ± 2.1, mean difference 0.9, 95% CI, 0.3-1.5, p = 0.005). With the numbers available, there was no difference in the number of reoperations, hospital readmissions without reoperation, emergency department visits without hospital readmission, or acute office visits. At 4-week followup, there was no difference in the number of phone calls and emails with the surgeon's office (outpatient: 2.4 ± 1.9, inpatient: 2.4 ± 2.2, mean difference 0, 95% CI, -0.5 to 0.6, p = 0.94). CONCLUSIONS Outpatient THA can be implemented in a defined patient population without requiring additional work for the surgeon's office. Because 24% (27 of 112) of patients planning to have outpatient surgery were not able to be discharged the same day, facilities to accommodate an overnight stay should be available. LEVEL OF EVIDENCE Level I, therapeutic study.
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Ranawat CS, White PB, West S, Ranawat AS. Clinical and Radiographic Results of Attune and PFC Sigma Knee Designs at 2-Year Follow-Up: A Prospective Matched-Pair Analysis. J Arthroplasty 2017; 32:431-436. [PMID: 27600300 DOI: 10.1016/j.arth.2016.07.021] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 06/27/2016] [Accepted: 07/22/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Anterior knee pain (AKP) and/or crepitation are important causes of dissatisfaction after total knee arthroplasty (TKA). Aim of this prospective, matched-pair study was to compare 2 different designs of patellofemoral (ie, trochlear groove) TKA. The Attune knee has an anatomic trochlear groove with a medialized dome patellar component vs the PFC Sigma with a single radius trochlear groove with a domed shaped patella. METHODS Between January 2010 and December 2014, 100 consecutive Attune TKAs were matched to 100 PFC Sigma TKAs based on age, gender, side, and body mass index. All surgeries were performed via medial parapatellar approach and used cemented, posterior-stabilized implants with patellar resurfacing. Clinical evaluations were assessed using Knee Society Scores (KSS) and a patient-administered questionnaire at 2-year follow-up (range, 1.5-3 years). RESULTS Based on the KSS clinical rating system, excellent clinical results were achieved in 89.4% and 90.7% of Attune and PFC Sigma TKAs, respectively. There were no significant differences in the KS pain or function scores. The overall incidence of AKP was significantly lower with the Attune knee compared to that of the PFC Sigma (12.5% vs 25.8%; P = .02). The incidence of hearing or feeling noise was also less with the Attune knee (17.7% vs 30.9%; P = .02). The incidence of painful crepitation was low in both groups (1.0% vs 4.1%) with no significant difference between groups (P = .37). Both groups had similar high satisfaction scores of 8.6 and 8.4 for the Attune and PFC groups, respectively (P = .09). CONCLUSION At 2-year follow-up, there were no differences between the PFC Sigma and Attune knees in KSS or satisfaction. However, the Attune group had a lesser incidence of AKP and crepitation. Further studies should focus on AKP and noise in cruciate-retaining knees.
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Affiliation(s)
| | | | - Sarah West
- Hospital for Special Surgery, New York, New York
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Pain Control and Functional Milestones in Total Knee Arthroplasty: Liposomal Bupivacaine versus Femoral Nerve Block. Clin Orthop Relat Res 2017; 475:110-117. [PMID: 26883652 PMCID: PMC5174020 DOI: 10.1007/s11999-016-4740-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although pain management after total knee arthroplasty (TKA) affects rehabilitation, length of stay, and functional outcomes, pain management for patients undergoing TKA has yet to be standardized. Femoral nerve blocks (FNBs) are commonly used as an adjunct; however, these can result in transient quadriceps weakness and have been associated with in-hospital falls. Periarticular infiltration of liposomal bupivacaine has been recently introduced as a long-acting analgesic that can be administered without affecting motor function. QUESTIONS/PURPOSES (1) Does periarticular liposomal bupivacaine compared with FNB result in improved pain control as measured by pain scores and narcotic consumption? (2) How do liposomal bupivacaine and FNB compare in terms of gait and stairclimbing milestones and the proportion of patients who experienced a fall in the hospital? METHODS Between September 2013 and October 2014, a retrospective analysis was conducted involving 24 surgeons who performed a total of 1373 unilateral, primary TKAs. From September 2013 to April 2014, the routine approach to TKA pain management pathway consisted of preoperative administration of oral analgesics, intraoperative anesthesia (preferred spinal or general), an ultrasound-guided FNB, intraoperative analgesic cocktail injection, patient-controlled analgesia, and oral and IV narcotics for pain as needed. A total of 583 patients were included in this study group. Starting May 2014, FNBs were discouraged and there was department-wide adoption of liposomal bupivacaine. Liposomal bupivacaine became routinely used in all patients undergoing TKA with no other changes made to the multimodal analgesia protocol at that time, and 527 patients in this study group were compared with the FNB cohort. Chart review on a total of 1110 patients was conducted by a research assistant who was not participating in patient care. During the inpatient stay, pain scores during 8-hour intervals, narcotic use, and physical therapy milestones were compared. RESULTS With the numbers available, we detected no clinically important difference in pain scores throughout the hospital stay; however, patients treated with liposomal bupivacaine consumed very slightly less narcotics overall (96 ± 62 versus 84 ± 73 eq mg of morphine; [95% confidence interval, 11-13 mg]; p = 0.004) through postoperative Day 2 of inpatient hospitalization. Seventy-seven percent (406 of 527) of patients receiving liposomal bupivacaine achieved their gait milestones of clearing 100 feet of ambulation versus 60% (349 of 583) of patients receiving FNB (p < 0.001) before discharge. Likewise, 94% (497 of 527) of patients receiving liposomal bupivacaine completed stairs compared with 73% (427 of 583) of patients receiving FNB (p < 0.001). Patients who received liposomal bupivacaine were less likely to experience a fall during the hospital stay than were patients treated with FNB (3 of 527 [0.6%] versus 12 of 583 [2%]; p = 0.03). CONCLUSIONS In the absence of strong data supporting FNB over liposomal bupivacaine, we have modified our TKA pain management protocols by adopting liposomal bupivacaine in lieu of FNBs, facilitating rapid rehabilitation while providing adequate pain control. LEVEL OF EVIDENCE Level III, therapeutic study.
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Comparison of the Effects of Intrathecal Fentanyl and Intrathecal Morphine on Pain in Elective Total Knee Replacement Surgery. Pain Res Manag 2016; 2016:3256583. [PMID: 28115877 PMCID: PMC5223037 DOI: 10.1155/2016/3256583] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 11/28/2016] [Indexed: 11/17/2022]
Abstract
Objective. Total knee replacement is one of the most painful orthopedic surgical procedures. In this study, our goal was to compare the intraoperative and postoperative hemodynamic effects, the side effects, the effect on the duration of pain start, the 24-hour VAS, and the amount of additional analgesia used, of the fentanyl and morphine we added to the local anesthetic in the spinal anesthesia we administered in cases of elective knee replacement. Materials and Methods. After obtaining the approval of the Erciyes University Medical Faculty Clinical Drug Trials Ethics Committee, as well as the verbal and written consent of the patients, we included 50 patients in our prospective, randomized study. Results. In our study, the morphine group (Group M) had lower pain scores in the 2nd, 6th, 12th, and 24th hours compared to the fentanyl group (Group F). When additional analgesic requirements were compared, it was found that in the 2nd, 6th, and 24th hours fewer Group M patients needed more analgesics than did Group F patients. Conclusion. The fentanyl group also had lower first analgesic requirement times than did the morphine group. In terms of nausea and vomiting, there was no statistically significant difference between the two groups.
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Park CN, White PB, Meftah M, Ranawat AS, Ranawat CS. Diagnostic Algorithm for Residual Pain After Total Knee Arthroplasty. Orthopedics 2016; 39:e246-52. [PMID: 26811953 DOI: 10.3928/01477447-20160119-06] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 07/22/2015] [Indexed: 02/03/2023]
Abstract
Although total knee arthroplasty is a successful and cost-effective procedure, patient dissatisfaction remains as high as 50%. Postoperative residual knee pain after total knee arthroplasty, with or without crepitation, is a major factor that contributes to patient dissatisfaction. The most common location for residual pain after total knee arthroplasty is anteriorly. Because residual pain has been associated with an un-resurfaced patella, this review includes only registry data and total knee arthroplasty with patella replacement. Some suggest that the pathogenesis of residual knee pain may be related to mechanical stimuli that activate free nerve endings around the patellofemoral joint. Various etiologies have been implicated in residual pain, including (1) low-grade infection, (2) midflexion instability, and (3) component malalignment with patellar maltracking. Less common causes include (4) crepitation and patellar clunk syndrome; (5) patellofemoral symptoms, including overstuffing and avascular necrosis of the patella; (6) early aseptic loosening; (7) hypersensitivity to metal or cement; (8) complex regional pain syndrome; and (9) pseudoaneurysm. Because all of these conditions can lead to residual pain, identifying the etiology can be a difficult diagnostic challenge. Often, patients with persistent pain and normal findings on radiographs and laboratory workup may benefit from a diagnostic injection or further imaging. However, up to 10% to 15% of patients with residual pain may have unexplained pain. This literature review summarizes the findings on the causes of residual pain and presents a diagnostic algorithm to facilitate an accurate diagnosis for residual pain after total knee arthroplasty.
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Combination Therapy with Continuous Three-in-One Femoral Nerve Block and Periarticular Multimodal Drug Infiltration after Total Hip Arthroplasty. Pain Res Manag 2016; 2016:1425201. [PMID: 28070159 PMCID: PMC5192331 DOI: 10.1155/2016/1425201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 11/23/2016] [Indexed: 11/18/2022]
Abstract
Background. Various postoperative pain relief modalities, including continuous femoral nerve block (CFNB), local infiltration analgesia (LIA), and combination therapy, have been reported for total knee arthroplasty. However, no studies have compared CFNB with LIA for total hip arthroplasty (THA). The aim of this study was to compare the efficacy of CFNB versus LIA after THA. Methods. We retrospectively reviewed the postoperative outcomes of 93 THA patients (20 men, 73 women; mean age 69.2 years). Patients were divided into three groups according to postoperative analgesic technique: CFNB, LIA, or combined CFNB+LIA. We measured the following postoperative outcome parameters: visual analog scale (VAS) for pain at rest, supplemental analgesia, side effects, mobilization, length of hospital stay, and Harris Hip Score (HHS). Results. The CFNB+LIA group had significantly lower VAS pain scores than the CFNB and LIA groups on postoperative day 1. There were no significant differences among the three groups in use of supplemental analgesia, side effects, mobilization, length of hospital stay, or HHS at 3 months after THA. Conclusions. Although there were no clinically significant differences in outcomes among the three groups, combination therapy with CFNB and LIA provided better pain relief after THA than CFNB or LIA alone, with few side effects.
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Ma J, Gao F, Sun W, Guo W, Li Z, Wang W. Combined adductor canal block with periarticular infiltration versus periarticular infiltration for analgesia after total knee arthroplasty. Medicine (Baltimore) 2016; 95:e5701. [PMID: 28033266 PMCID: PMC5207562 DOI: 10.1097/md.0000000000005701] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Both adductor canal block (ACB) and periarticular infiltration (PI) have been shown to reduce pain after total knee arthroplasty (TKA) without the motor blockade. However, the efficacy and safety of combined ACB with PI (ACB + PI) as compared to PI alone for analgesia after TKA remains controversial. We therefore performed a meta-analysis to compare the effects of ACB + PI with PI alone on pain controll after TKA. METHODS PubMed, Medline, Embase, Web of Science, and the Cochrane Library were searched to identify studies comparing ACB + PI with PI alone for TKA patients. The primary outcomes included pain score with rest or activity and morphine consumption. Secondary outcomes were distance walked, length of hospital stay, and postoperative complications. Relevant data were analyzed using RevMan v5.3. RESULTS Three studies involving 337 patients were included. Combined ACB with PI was associated with longer distances walked than PI alone (MD = 7.27, 95% CI: 0.43-14.12, P = 0.04) on postoperative day 1. The outcomes of pain, morphine consumption, length of hospital stay, and postoperative complications were not statistically different between the 2 groups (P > 0.05). CONCLUSION Our meta-analysis suggests that combined ACB with PI may achieve earlier ambulation for patients after TKA without a reduction in analgesia when compared to PI alone in the early postoperative period. There were no significant differences in morphine consumption, length of hospital stay, and postoperative complications between the 2 groups. However, owing to the variation of included studies, no firm conclusions can be drawn.
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Affiliation(s)
- Jinhui Ma
- Peking University China-Japan Friendship School of Clinical Medicine
| | - Fuqiang Gao
- Center for Osteonecrosis and Joint Preserving and Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Wei Sun
- Center for Osteonecrosis and Joint Preserving and Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Wanshou Guo
- Center for Osteonecrosis and Joint Preserving and Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Zirong Li
- Center for Osteonecrosis and Joint Preserving and Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
| | - Weiguo Wang
- Center for Osteonecrosis and Joint Preserving and Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Chaoyang District, Beijing, China
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Skipsey D, Hosny S, Wright E, Allen F, Smoljanovic T, Stafford G. Local infiltration analgesia in total knee arthroplasty: why it may not be effective in surgical practice. ANZ J Surg 2016; 86:844-845. [PMID: 27701833 DOI: 10.1111/ans.13673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 05/27/2016] [Indexed: 11/29/2022]
Affiliation(s)
- David Skipsey
- South West London Elective Orthopaedic Center (SWLEOC), Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
| | - Sherif Hosny
- South West London Elective Orthopaedic Center (SWLEOC), Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
| | - Emily Wright
- South West London Elective Orthopaedic Center (SWLEOC), Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
| | - Felix Allen
- South West London Elective Orthopaedic Center (SWLEOC), Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
| | - Tomislav Smoljanovic
- South West London Elective Orthopaedic Center (SWLEOC), Epsom and St Helier University Hospitals NHS Trust, Surrey, UK.,Department of Orthopaedic Surgery, University Hospital Center Zagreb, School of Medicine, Zagreb University, Zagreb, Croatia
| | - Giles Stafford
- South West London Elective Orthopaedic Center (SWLEOC), Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
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Analgesic Effect of Dexamethasone after Arthroscopic Knee Surgery: A Randomized Controlled Trial. Pain Res Manag 2016; 2016:4216469. [PMID: 27795670 PMCID: PMC5067317 DOI: 10.1155/2016/4216469] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 05/08/2016] [Indexed: 02/08/2023]
Abstract
Background. Dexamethasone is sometimes used as a coanalgesic because of its anti-inflammatory properties. Objective. To evaluate opioid use, postoperative pain intensity, and side effects after a single dose of dexamethasone in patients undergoing arthroscopic knee surgery. Methods. In this randomized controlled study patients were randomized to receive either 10 mg of intravenous dexamethasone (DM group) or 0.9% normal saline (NS group) during the intraoperative period. Primary outcomes were pain intensity and total morphine and codeine use after surgery. Results. Seventy-eight patients were included in the study. The DM group showed statistically significant higher pain intensity at the fourth postoperative hour (DM: 3.96/10, standard deviation [SD] 0.54; NS: 2.46/10, SD 0.45; p = 0.036). No statistically significant difference in total opioid use (morphine plus codeine) was identified with 15.9 (SD 1.97) codeine tablets used in DM group and 20 (SD 2.14) in NS group (p = 0.25). Discussion. Pain intensity tended to decrease in both groups suggesting morphine as the main source of analgesia. Conclusions. Intravenous dexamethasone during the intraoperative period has no clinical impact on postoperative pain intensity during the first 48 h after arthroscopic knee surgery. This trial is registered with R000020892.
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L'Hommedieu CE, Gera JJ, Rupp G, Salin JW, Cox JS, Duwelius PJ. Impact of Anterior vs Posterior Approach for Total Hip Arthroplasty on Post-Acute Care Service Utilization. J Arthroplasty 2016; 31:73-7. [PMID: 27460301 DOI: 10.1016/j.arth.2016.06.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 06/17/2016] [Accepted: 06/28/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Controversy exists as to which surgical approach is best for total hip arthroplasty (THA). Previous studies suggested that the tissue-sparing anterior approach should result in a more rapid recovery requiring fewer postacute services, ultimately decreasing overall episodic cost. The purpose of this cross-sectional study was to determine if any significant differences exist between the anterior vs posterior approaches on postacute care service utilization, readmissions, or episodic cost. METHODS Claims data from 26,773 Medicare fee-for-service beneficiaries receiving elective THAs (Medical Severity-Diagnosis Related Groups (MS-DRGs) 469/470) were analyzed. Claims data were collected from the 2-year period, January 2013 through December 2014. The posterior surgical approach was performed on 23,653 patients while 3120 patients received the anterior approach. RESULTS Data analysis showed negligible effect sizes in postacute care service utilization, readmission rate, and cost between the surgical approaches for elective THA (MS-DRG 469 and 470). Average THA total episode cost was negligibly higher for procedures using the anterior approach compared to the posterior approach ($22,517 and $22,068, respectively). Statistically significant differences were observed in inpatient rehab and home health cost and service utilization. However, the effect sizes of these comparisons are negligible when accounting for the large sample size. All other comparisons showed minimal and statistically insignificant variation. CONCLUSION The results indicate that surgical approach alone is not the primary driver of postacute care service utilization, quality outcomes, or cost. Other factors such as physician-led patient-focused care pathways, care coordination, rapid rehabilitation protocols, perioperative pain management protocols, and patient education are integral for effective patient care.
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Affiliation(s)
| | - James J Gera
- Signature Medical Group, Inc, St. Louis, Missouri
| | - Gerald Rupp
- Signature Medical Group, Inc, St. Louis, Missouri
| | | | - John S Cox
- Oregon Health and Science University, Portland, Oregon
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Physicians With Defined Clear Care Pathways Have Better Discharge Disposition and Lower Cost. J Arthroplasty 2016; 31:54-8. [PMID: 27329578 DOI: 10.1016/j.arth.2016.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/21/2016] [Accepted: 05/03/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is a pronounced need for a sustainable care model for total joint arthroplasty in the United States. Total hip and knee arthroplasty is expected to increase 673% by 2030, and Medicare is the payor for a majority of these episodes. Our objective was to compare orthopedic cohort groups with and without defined postacute care pathways and the effects of the care pathways on service utilization and cost for Medicare patients in the Bundled Payments for Care Improvement program. METHODS Claims data for elective hip and knee arthroplasty episodes from a national bundled payments for care improvement database were the source of our study data. Independent reviewers were used to determine which groups had defined clinical pathways. The 2 cohort groups were then compared between those with defined clinical pathways and those without. Outcomes measures included postacute care costs, utilization rates (both frequency and length of time) for inpatient rehabilitation facilities, skilled nursing facilities, home health, and readmissions. RESULTS Orthopedic physicians with defined postacute care pathways showed consistent decreases in cost and utilization as compared to physicians without defined postacute care pathways. Elective hip arthroplasty per episode cost differential was $3189 per episode between physicians with care pathways ($19,005) and those without ($22,195; P < .001). Elective knee arthroplasty per episode cost difference was $2466 per episode between physicians with care pathways ($18,866) and those without ($21,332; P < .001). Incident rates of utilization for postacute care services displayed significant differences between physicians with and without postacute care pathways. Physicians with defined postacute pathways demonstrated utilization reductions ranging from 7% to 79% with incident rate reductions ranging from 44% to 79%. CONCLUSION The results suggest that orthopedic physicians with defined postacute care pathways affect discharge disposition. The findings show significant cost and utilization reductions for physicians with defined postacute care pathways.
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Impact of Preemptive Analgesia on inflammatory responses and Rehabilitation after Primary Total Knee Arthroplasty: A Controlled Clinical Study. Sci Rep 2016; 6:30354. [PMID: 27578313 PMCID: PMC5005994 DOI: 10.1038/srep30354] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/20/2016] [Indexed: 11/08/2022] Open
Abstract
The aim of this study was to investigate the effects of preemptive analgesia on the inflammatory response and rehabilitation in TKA. 75 patients with unilateral primary knee osteoarthritis were conducted in this prospective study. All patients were randomly divided into two groups (MMA with/without preemptive analgesia group). The following parameters were used to evaluate analgesic efficacy: knee flexion, pain at rest and walking, functional walking capacity (2 MWT and 6 MWT), WOMAC score, and hs-CRP level. Patients in MMA with preemptive analgesia group had lower hs-CRP level and less pain at rest and walking during the first week postoperatively (P < 0.05). The 2 MWT was significantly better in MMA with preemptive analgesia group (17.13 ± 3.82 VS 14.19 ± 3.56, P = 0.001). The 6 MWT scores and WOMAC scores increased significantly within Groups (P = 0.020, 0.000), but no difference between groups postoperatively (P > 0.05). Less cumulative consumption of morphine was found in MMA with preemptive analgesia group at 48 h (P = 0.017, 0.023), but no difference at total requirement (P = 0.113). Preemptive analgesia added to a multimodal analgesic regime improved analgesia, reduced inflammatory reaction and accelerated functional recovery at the first week postoperatively, but not improved long-term function.
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Youm YS, Cho SD, Cho HY, Hwang CH, Jung SH, Kim KH. Preemptive Femoral Nerve Block Could Reduce the Rebound Pain After Periarticular Injection in Total Knee Arthroplasty. J Arthroplasty 2016; 31:1722-6. [PMID: 26928185 DOI: 10.1016/j.arth.2016.02.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/01/2016] [Accepted: 02/02/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We evaluated the effectiveness of postoperative pain management using intraoperative periarticular injection (PAI) and/or electromyography-guided preoperative femoral nerve block (FNB) in knees undergoing total knee arthroplasty (TKA). METHODS This study included 90 patients (90 knees) who underwent primary TKA. Thirty patients received a single injection of electromyography-guided FNB, 30 received intraoperative PAI, and 30 received both. Pain at rest and while moving was evaluated by a visual analog scale (VAS) at 0, 4, 8, 24, and 48 hours. Postoperative range of motion, time to walking, amount of opioid consumption, and complications were analyzed. RESULTS VAS immediately after surgery was significantly higher in the FNB group than in the PAI and combined groups, but did not differ significantly in the latter 2 groups. VAS after 4 and 8 hours showed similar results. VAS after 24 hours was significantly higher in the PAI than in the FNB and combined groups. After 48 hours, there were no differences among the 3 groups. Total opioid consumption was lower in the combined than in the FNB and PAI groups. Postoperative range of motion and time to walking were similar in the 3 groups. CONCLUSION PAI was more effective than FNB during the early (0-8 hours) postoperative period after TKA. Patients treated with PAI, however, experienced rebound pain at 24 hours. The combination of PAI and FNB may provide greater postoperative pain management than either alone for the first 24 hours after TKA.
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Affiliation(s)
- Yoon Seok Youm
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Sung Do Cho
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hye Yong Cho
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Chang Ho Hwang
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung Hyun Jung
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Kwang Ho Kim
- Department of Orthopedic Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Yu SW, Szulc AL, Walton SL, Davidovitch RI, Bosco JA, Iorio R. Liposomal Bupivacaine as an Adjunct to Postoperative Pain Control in Total Hip Arthroplasty. J Arthroplasty 2016; 31:1510-5. [PMID: 26872584 DOI: 10.1016/j.arth.2016.01.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 12/23/2015] [Accepted: 01/06/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although pain management affects rehabilitation, length of stay, and functional outcome, an optimized pain management protocol has yet to be standardized. Opioids are the primary agent used to control acute postoperative pain; however, they are associated with a wide range of side effects. Liposomal bupivacaine (LB), a long-acting analgesic agent administered intraoperatively, has been introduced as a new modality to control pain for up to 72 hours after operation without affecting motor function. METHODS Six hundred eighty-six primary total hip arthroplasty (THA) patients, who received the standard THA pain management protocol, were compared to a cohort of 586 primary THA patients, who were treated with an additional intraoperative injection of LB. All other pain management parameters and standard of care were identical. Statistical significance was set at P ≤ .05. RESULTS Although patient-reported pain scores were statistically similar, the LB cohort demonstrated a significant decrease in total narcotic use (P < .001), specifically up to postoperative day 2 (P = .016). Physical therapy milestones were significantly achieved to a greater degree (P < .001) in the LB cohort. Operation time and hospital cost were unaffected (P = .072 and .811, respectively); however, the LB cohort exhibited a decrease in length of stay by 0.31 days (P < .001) and improvement in discharge disposition to home (P = .017). CONCLUSION LB is a valuable adjunct to our THA pain management protocol, as we strive to achieve improved patient outcomes, reductions in length of stay, and enhanced quality of THA care.
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Affiliation(s)
- Stephen W Yu
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Alessandra L Szulc
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Sharon L Walton
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Roy I Davidovitch
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Joseph A Bosco
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, Hospital for Joint Diseases, NYU Langone Medical Center, New York, New York
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Hinzpeter J, Barrientos C, Zamorano Á, Martinez Á, Palet M, Wulf R, Barahona M, Sepúlveda JM, Guerra M, Bustamante T, Del Campo M, Tapia E, Lagos N. Gonyautoxins: First evidence in pain management in total knee arthroplasty. Toxicon 2016; 119:180-5. [PMID: 27317871 DOI: 10.1016/j.toxicon.2016.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/09/2016] [Accepted: 06/14/2016] [Indexed: 12/19/2022]
Abstract
Improvements in pain management techniques in the last decade have had a major impact on the practice of total knee arthroplasty (TKA). Gonyautoxin are phycotoxins, whose molecular mechanism of action is a reversible block of the voltage-gated sodium channels at the axonal level, impeding nerve impulse propagation. This study was designed to evaluate the clinical efficacy of Gonyautoxin infiltration, as a long acting pain blocker in TKA. Fifteen patients received a total dose of 40 μg of Gonyautoxin during the TKA operation. Postoperatively, all patients were given a standard painkiller protocol: 100 mg of intravenous ketoprofen and 1000 mg of oral acetaminophen every 8 hours for 3 days. The Visual Analog Scale (VAS) pain score and range of motion were recorded 12, 36, and 60 hours post-surgery. All patients reported pain of 2 or less on the VAS 12 and 36 hours post-surgery. Moreover, all scored were less than 4 at 60 hours post-surgery. All patients achieved full knee extension at all times. No side effects or adverse reactions to Gonyautoxin were detected in the follow-up period. The median hospital stay was 3 days. For the first time, this study has shown the effect of blocking the neuronal transmission of pain by locally infiltrating Gonyautoxin during TKA. All patients successfully responded to the pain control. The Gonyautoxin infiltration was safe and effective, and patients experienced pain relief without the use of opioids.
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Affiliation(s)
- Jaime Hinzpeter
- Department of Orthopedic Surgery, University of Chile Clinical Hospital, Santos Dumont 999, Independencia, Santiago, 8380456, Chile
| | - Cristián Barrientos
- Department of Orthopedic Surgery, University of Chile Clinical Hospital, Santos Dumont 999, Independencia, Santiago, 8380456, Chile
| | - Álvaro Zamorano
- Department of Orthopedic Surgery, University of Chile Clinical Hospital, Santos Dumont 999, Independencia, Santiago, 8380456, Chile
| | - Álvaro Martinez
- Department of Orthopedic Surgery, Hospital San José, San José 1196, Independencia, Santiago, 8380419, Chile
| | - Miguel Palet
- Department of Orthopedic Surgery, University of Chile Clinical Hospital, Santos Dumont 999, Independencia, Santiago, 8380456, Chile
| | - Rodrigo Wulf
- Department of Orthopedic Surgery, University of Chile Clinical Hospital, Santos Dumont 999, Independencia, Santiago, 8380456, Chile
| | - Maximiliano Barahona
- Department of Orthopedic Surgery, University of Chile Clinical Hospital, Santos Dumont 999, Independencia, Santiago, 8380456, Chile
| | - Joaquín M Sepúlveda
- Membrane Biochemistry Laboratory, Department of Physiology and Biophysics, Faculty of Medicine, University of Chile, Independencia 1027, Santiago, 8389100, Chile
| | - Matias Guerra
- Membrane Biochemistry Laboratory, Department of Physiology and Biophysics, Faculty of Medicine, University of Chile, Independencia 1027, Santiago, 8389100, Chile
| | - Tamara Bustamante
- Membrane Biochemistry Laboratory, Department of Physiology and Biophysics, Faculty of Medicine, University of Chile, Independencia 1027, Santiago, 8389100, Chile
| | - Miguel Del Campo
- Membrane Biochemistry Laboratory, Department of Physiology and Biophysics, Faculty of Medicine, University of Chile, Independencia 1027, Santiago, 8389100, Chile
| | - Eric Tapia
- Membrane Biochemistry Laboratory, Department of Physiology and Biophysics, Faculty of Medicine, University of Chile, Independencia 1027, Santiago, 8389100, Chile
| | - Nestor Lagos
- Membrane Biochemistry Laboratory, Department of Physiology and Biophysics, Faculty of Medicine, University of Chile, Independencia 1027, Santiago, 8389100, Chile.
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142
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Multimodal Versus Patient-Controlled Analgesia After an Anterior Cervical Decompression and Fusion. Spine (Phila Pa 1976) 2016; 41:994-998. [PMID: 26679869 DOI: 10.1097/brs.0000000000001380] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis of a prospectively maintained surgical registry. OBJECTIVE To compare postoperative narcotic consumption between multimodal analgesia (MMA) and patient-controlled analgesia (PCA) after an anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Studies suggest that a multimodal approach to pain management leads to decreased pain and morphine consumption after total joint arthroplasty and lumbar spinal procedures. Patients and surgeons would benefit from knowing whether a multimodal approach to pain management is superior to PCA for ACDF. METHODS A retrospective cohort study of ACDF patients receiving either MMA or PCA was conducted. Inpatient narcotic consumption, pain scores, nausea/vomiting, hospital length of stay, and narcotic dependence during the months after surgery were compared between MMA and PCA. RESULTS A total of 239 patients met inclusion criteria. Of these, 55 (23.0%) received MMA and 184 (77.0%) received PCA. Patients who received MMA had a lower rate of inpatient narcotic consumption (2.5 OME/h vs. 5.8 OME/h, P < 0.001) were less likely to experience nausea/vomiting during the hospitalization (5.5% vs. 37.5%, P < 0.001), and had a shorter hospital length of stay (27.3 vs. 40.1 h, P < 0.001). However, there was no difference between groups in mean visual analogue pain scale during postoperative day zero (4.7 for MMA vs. 5.2 for PCA, P = 0.126) or during postoperative day one (4.1 for MMA vs. 4.1 for PCA, P = 0.937). In addition, there was no difference in the rate of narcotic dependence at the first (P = 0.626) or second (P = 0.480) postoperative visits. CONCLUSION These data suggest that MMA results in lower narcotic consumption than PCA after an ACDF. This difference is associated with a shorter inpatient stay and a decrease in postoperative nausea/vomiting. Critically, MMA and PCA appear to provide similar postoperative analgesia. LEVEL OF EVIDENCE 3.
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143
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Dasa V, Lensing G, Parsons M, Harris J, Volaufova J, Bliss R. Percutaneous freezing of sensory nerves prior to total knee arthroplasty. Knee 2016; 23:523-8. [PMID: 26875052 DOI: 10.1016/j.knee.2016.01.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 01/06/2016] [Accepted: 01/13/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common procedure resulting in significant post-operative pain. Percutaneous cryoneurolysis targeting the infrapatellar branch of the saphenous nerve and anterior femoral cutaneous nerve could relieve post-operative knee pain by temporarily blocking sensory nerve conduction. METHODS A retrospective chart review of 100 patients who underwent TKA was conducted to assess the value of adding perioperative cryoneurolysis to a multimodal pain management program. The treatment group consisted of the first 50 patients consecutively treated after the practice introduced perioperative (five days prior to surgery) cryoneurolysis as part of its standard pain management protocol. The control group consisted of the 50 patients treated before cryoneurolysis was introduced. Outcomes included hospital length of stay (LOS), post-operative opioid requirements, and patient-reported outcomes of pain and function. RESULTS A significantly lower proportion of patients in the treatment group had a LOS of ≥2days compared with the control group (6% vs. 67%, p<0.0001) and required 45% less opioids during the first 12weeks after surgery. The treatment group reported a statistically significant reduction in symptoms at the six- and 12-week follow-up compared with the control group and within-group significant reductions in pain intensity and pain interference at two- and six-week follow-up, respectively. CONCLUSIONS Perioperative cryoneurolysis in combination with multimodal pain management may significantly improve outcomes in patients undergoing TKA. Promising results from this preliminary retrospective study warrant further investigation of this novel treatment in prospective, randomized trials. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Vinod Dasa
- Department of Orthopaedics, LSUHSC School of Medicine, New Orleans, LA 70112, United States.
| | - Gabriel Lensing
- LSUHSC School of Medicine, 433 Bolivar Street, New Orleans, LA 70112, United States
| | - Miles Parsons
- LSUHSC School of Medicine, 433 Bolivar Street, New Orleans, LA 70112, United States
| | - Justin Harris
- LSUHSC School of Medicine, 433 Bolivar Street, New Orleans, LA 70112, United States
| | - Julia Volaufova
- LSUHSC School of Public Health, 2020 Gravier Street, Office #256, New Orleans, LA 70112, United States
| | - Ryan Bliss
- Department of Orthopaedics, LSUHSC School of Medicine, New Orleans, LA 70112, United States
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144
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Kim YS, Kim BS, Koh YG, Lee JW. Efficacy of multimodal drug injection after supramalleolar osteotomy for varus ankle osteoarthritis: A prospective randomized study. J Orthop Sci 2016; 21:316-22. [PMID: 26926419 DOI: 10.1016/j.jos.2016.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 01/06/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Optimal management of postoperative pain is important to ensure patient comfort and functional improvement. Despite the frequent use of multimodal drug injection for pain control after orthopedic surgery, few studies have evaluated its use after supramalleolar osteotomy. METHODS Supramalleolar osteotomy was performed in 62 patients (65 ankles). Thirty patients (31 ankles) were randomly assigned to receive multimodal drug injection (injection group) and 32 patients (34 ankles) were assigned to receive no multimodal drug injection (control group). The two groups were compared with regard to the degree of postoperative pain, the number of times patients pushed the patient-controlled analgesia (PCA) button, the total amount of fentanyl administered, and the frequency of additional diclofenac sodium injections. RESULTS The injection group had significant pain reduction during the first 36 postoperative hours compared to the control group. There were significant differences between the groups in the number of times that patients pushed the PCA button as well as the total amount of fentanyl administered up to 24 h postoperatively. The mean frequency of additional diclofenac sodium injections in the first 12 postoperative hours was significantly less in the injection group compared to that in the control group. CONCLUSION Multimodal drug injection was effective in reducing pain and decreasing both fentanyl and diclofenac sodium usage in patients undergoing supramalleolar osteotomy. Therefore, multimodal drug injection should be considered for improved pain control and patient comfort in the early postoperative period after supramalleolar osteotomy.
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Affiliation(s)
- Yong Sang Kim
- Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 478-3, Bangbae-dong, Seocho-gu, Seoul 137-060, Republic of Korea.
| | - Bom Soo Kim
- Department of Orthopaedic Surgery, Inha University Graduate School of Medicine, 27, Inhang-ro, Jung-gu, Incheon 400-711, Republic of Korea
| | - Yong Gon Koh
- Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 478-3, Bangbae-dong, Seocho-gu, Seoul 137-060, Republic of Korea
| | - Jin Woo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 120-752, Republic of Korea
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145
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Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the Real Benefits of Single-Shot Interscalene Block Please Stand Up? A Systematic Review and Meta-Analysis. Anesth Analg 2016; 120:1114-1129. [PMID: 25822923 DOI: 10.1213/ane.0000000000000688] [Citation(s) in RCA: 184] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Interscalene block (ISB) can provide pain relief after shoulder surgery, but a reliable quantification of its analgesic benefits is lacking. This meta-analysis examines the effect of single-shot ISB on analgesic outcomes during the first 48 hours after shoulder surgery. METHODS We retrieved randomized and quasirandomized controlled trials examining the analgesic benefits of ISB compared with none in shoulder surgery. Severity of postoperative pain measured on a visual analog scale (10 cm scale, 0 = no pain, 10 = worst pain) at rest at 24 hours was the designated primary outcome. Secondary outcomes included pain severity at rest and with motion at 2, 4, 6, 8, 12, 16, 32, 36, 40, and 48 hours postoperatively. Opioid consumption, postoperative nausea and vomiting, patient satisfaction with pain relief, and postanesthesia care unit and hospital discharge time were also assessed. RESULTS A total of 23 randomized controlled trials, including 1090 patients, were analyzed. Patients in the ISB group had more severe postoperative pain at rest by a weighed mean difference (95% confidence interval) of 0.96 cm (0.08-1.83; P = 0.03) at 24 hours compared with no ISB, but there was no difference in pain severity beyond that point. The duration of pain relief at rest and with motion after ISB were 8 and 6 hours, respectively, with a corresponding weighed mean difference in visual analog scale pain scores (99% confidence interval) of -1.59 cm (-2.60 to -0.58) and -2.20 cm (-4.34 to -0.06), respectively, with no additional pain relief benefits beyond these points. ISB reduced postoperative opioid consumption up to 12 hours, decreased postoperative nausea and vomiting at 24 hours, and expedited postanesthesia care unit and hospital discharge. The type, dose, and volume of local anesthetic used did not affect the results. CONCLUSIONS ISB can provide effective analgesia up to 6 hours with motion and 8 hours at rest after shoulder surgery, with no demonstrable benefits thereafter. Patients who receive an ISB can suffer rebound pain at 24 hours but later experience similar pain severity compared with those who do not receive an ISB. ISB can also provide an opioid-sparing effect and reduce opioid-related side effects in the first 12 and 24 hours postoperatively, respectively. These findings are useful to inform preoperative risk-benefit discussions regarding ISB for shoulder surgery.
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Affiliation(s)
- Faraj W Abdallah
- From the *Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesia and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; ‡Division of Obstetric Anesthesia, Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; §Department of Anesthesia, Hospital for Sick Children, Toronto, Ontario, Canada; ║Department of Anesthesia, Women's College Hospital, Toronto, Ontario, Canada; and ¶Department of Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Canada
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146
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Nursing strategies to reduce length of stay for persons undergoing total knee replacement: integrative review of key variables. J Nurs Care Qual 2016; 30:283-8. [PMID: 25485792 DOI: 10.1097/ncq.0000000000000104] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Decreasing the length of stay for persons undergoing total knee replacement surgery can improve patient and organizational outcomes while reducing health care costs. This integrative review examined selected nurse-driven variables that assist the interdisciplinary team to reduce length of stay. Findings suggest that a targeted clinical pathway including comprehensive preoperative patient education, physical therapy on the day of surgery, multimodal pain control, and proactive discharge planning may provide the best practice with this patient population.
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147
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Prakash J, Mehtani A, Agnihotari A. Letter to the Editor: Epidural versus intra-articular infusion analgesia following total knee replacement. J Orthop Surg (Hong Kong) 2016; 24:135-6. [PMID: 27122532 DOI: 10.1177/230949901602400134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- J Prakash
- Lady Hardinge Medical College, North Delhi, India
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148
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Maempel JF, Clement ND, Ballantyne JA, Dunstan E. Enhanced recovery programmes after total hip arthroplasty can result in reduced length of hospital stay without compromising functional outcome. Bone Joint J 2016; 98-B:475-82. [DOI: 10.1302/0301-620x.98b4.36243] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 11/04/2015] [Indexed: 12/27/2022]
Abstract
Aims The primary aim of this study was to investigate the effect of an enhanced recovery program (ERP) on the short-term functional outcome after total hip arthroplasty (THA). Secondary outcomes included its effect on rates of dislocation and mortality. Patients and Methods Data were gathered on 1161 patients undergoing primary THA which included 611 patients treated with traditional rehabilitation and 550 treated with an ERP. Results The ERP was shown to be a significant independent factor which shortened length of stay (LOS) by a mean of 1.5 days (95% confidence interval (CI) 1.3 to 1.8, p < 0.001) after adjusting for confounding variables. The rates of dislocation (traditional 1.03% vs ERP 0.91%, p = 0.84) and mortality (1.5% vs 0.6%, p = 0.14) one year post-operatively were not significantly different. Both groups showed significant improvement in Harris Hip Score (42.8 vs 41.5) at 12 to 18 months post-operatively and there was no significant difference in the magnitude of improvement on univariate (p = 0.09) and multivariate analysis (p = 0.35). There was no significant difference in any of the eight domain scores of the Short-Form - 36 general health surveys post-operatively (p > 0.38). Conclusion We conclude that an ERP after THA shortens LOS by a mean of 1.5 days and does not increase the rate of complications post-operatively. It gives equivalent functional outcomes to a traditional rehabilitation pathway. Take home message: ERP reduces LOS after THA in comparison to traditional rehabilitation, without adversely affecting functional outcomes, dislocation rates or mortality. Cite this article: Bone Joint J 2016;98-B:475–82.
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Affiliation(s)
- J. F. Maempel
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | - N. D. Clement
- Royal Infirmary of Edinburgh, 51
Little France Crescent, Edinburgh EH16 4SA, UK
| | | | - E. Dunstan
- Victoria Hospital , Hayfield
Road, Kirkcaldy KY2 5AH, Fife, UK
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149
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Gabriel RA, Kaye AD, Jones MR, Dutton RP, Urman RD. Practice Variations in Anesthetic Care and Its Effect on Clinical Outcomes for Primary Total Hip Arthroplasties. J Arthroplasty 2016; 31:918-22. [PMID: 26410553 DOI: 10.1016/j.arth.2015.08.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/19/2015] [Accepted: 08/25/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Knowledge regarding anesthetic practice variations in the use of general anesthesia (GA) vs neuraxial anesthesia (NA) as primary anesthetics for a primary total hip arthroplasty is limited. METHODS A total of 107,490 cases were identified in the National Anesthesia Clinical Outcomes Registry, in which 31.7% and 68.3% were performed with NA and GA, respectively. RESULTS Resident presence, board-certification status, comorbidities, and case duration were associated with the implementation of NA vs GA. Neuraxial anesthesia was associated with decreased rates of extended recovery room stay, inadequate pain control, and postoperative nausea/vomiting. CONCLUSION Anesthetic technique differences were associated with patient and provider characteristics. Our results can help improve quality measures and identify areas that need improvement in cost reduction and efficiency within this specific surgical patient population.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts
| | - Alan D Kaye
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, Louisiana
| | - Mark R Jones
- Department of Anesthesiology, LSU Health Sciences Center, New Orleans, Louisiana
| | | | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, Massachusetts.
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150
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Salam AA, Afshan G. Patient refusal for regional anesthesia in elderly orthopedic population: A cross-sectional survey at a tertiary care hospital. J Anaesthesiol Clin Pharmacol 2016; 32:94-8. [PMID: 27006550 PMCID: PMC4784223 DOI: 10.4103/0970-9185.173372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background and Aims: Improvements in pain management techniques in the last decade have had a major impact on the practice of orthopedic surgeries, for example, total hip arthroplasty and total knee arthroplasty. Although there are a number of treatment options for postoperative pain, a gold standard has not been established. In our institution, both general anesthesia and regional anesthesia (RA), are being offered to the elderly orthopedic population but RA is not frequently accepted by elderly population. The objective of this study was to determine the frequency of various reasons for refusal of RA in elderly patients undergoing orthopedic surgeries. Material and Methods: A prospective study conducted over a period of 1 year, had 549 patients with ages above 60 years who underwent different types of elective orthopedic procedures 182 patients who refused RA were interviewed according to a structured questionnaire designed to assess the reasons of refusal. Results: Most common reason for the refusal of RA was surgeon's choice (38.5%), whereas 20.3% of the patients were unaware about the RA. There was a significant association between female gender and refusing RA due to backache (17.2%) and fear of being awake during the operation (24.1%) respectively. Conclusion: This survey showed that the main reasons among elderly female population were the fear of remaining awake and backache. However, overall it was the surgeon's choice which made patients refuse RA, and the anesthesiologists were the main source of information.
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Affiliation(s)
- Asma Abdus Salam
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
| | - Gauhar Afshan
- Department of Anaesthesiology, Aga Khan University, Karachi, Pakistan
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