Effects of anaesthesia and analgesia on long-term outcome after total knee replacement: A prospective, observational, multicentre study

Impact of Preemptive Analgesia on inflammatory responses and Rehabilitation after Primary Total Knee Arthroplasty: A Controlled Clinical Study

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.

Corticosteroids or Not for Postoperative Nausea: A Double-Blinded Randomized Study

BACKGROUND

Postoperative nausea and vomiting (PONV) is common after general anaesthesia, and corticosteroids are used in many protocols for enhanced recovery after surgery (ERAS). However, surgical techniques are developing, and ERAS protocols need to be reevaluated from time to time.

PATIENTS AND METHOD

In this study, we compared the effects of oral vs. parenteral corticosteroid administration on postoperative nausea. Elective Roux-y-gastric bypass (RYGB) patients were randomly assigned to either 8 mg betamethasone orally (n = 50) or parentally (n = 25) or as controls (n = 25), in a double-blind design. PONV risk factors were noted. All patients had the same anaesthetic technique. Data were collected at baseline, on arrival to the recovery room (RR) and at five more time points during the first 24 h. Nausea and tiredness were patient assessed using visual analogue scales; rescue drug consumption was recorded.

RESULTS

Operation time was 30-40 min. Neither demographics nor risk factors for nausea differed between groups. Neither peak values for nor total amount of nausea differed between groups. The number of supplemental injections was the same for all groups.

COMMENTS

In a setting of modern laparoscopic RYGB, the value of betamethasone in preventing PONV seems to be limited. ERAS protocols may need re-evaluation.

Perioperative Dexamethasone Administration Does Not Increase the Incidence of Postoperative Infection in Total Hip and Knee Arthroplasty: A Retrospective Analysis

BACKGROUND

Dexamethasone is frequently used for the treatment of postoperative nausea and vomiting and as an adjunct in multimodal postoperative analgesia after total joint arthroplasty; however, the incidence of periprosthetic joint infection (PJI) after the use of perioperative dexamethasone in total joint arthroplasty has yet to be fully elucidated.

METHODS

A retrospective chart review was conducted of all patients who underwent total hip or knee arthroplasty (N = 6294) between January 1, 2002 and January 31, 2014. The primary outcome was PJI requiring surgical intervention. Patients were subdivided into 2 cohorts; patients who received perioperative dexamethasone, a single 4- to 10-mg intravenous dose, as prophylaxis against postoperative nausea and vomiting (Dex group; N = 557) and those that did not receive perioperative dexamethasone (No Dex group; N = 5737). Secondary measures included timing of infection, culture data, and the type and number of subsequent procedures. Statistical analysis was performed using a chi-square or Fisher's exact test where appropriate.

RESULTS

Seventy-four joints of the 6294 joints included in this analysis ultimately developed a PJI for an overall incidence of infection of 1.2%. Seven of the 557 joints (1.3%) in the Dex group developed a PJI; 67 of the 5737 joints (1.2%) in the No Dex group developed an infection. This difference was not significant (P = .8022). No significant difference in the timing of infection or the number of subsequent procedures was seen.

CONCLUSION

A single intravenous perioperative dose of dexamethasone had no statistically significant difference in the rate of PJI after total hip or knee arthroplasty.

Effects of Cold Irrigation on Early Results after Total Knee Arthroplasty: A Randomized, Double-Blind, Controlled Study

Several studies have indicated that pain peaks at 24 to 48 hours after total knee arthroplasty (TKA) surgery. TKA has been associated with disruption in normal sleep patterns, swelling knee, and significant blood loss. However, a satisfactory regime to resolve these mentioned problems has yet to be found.In this study, a total of 420 patients were randomly allocated into two groups and treated with continuous irrigation of either 4000 mL cold saline with 0.5% epinephrine or normal temperature solution. Clinical outcomes including pain scores at rest during postoperative three days, drainage output, analgesic consumption, decreased hemoglobin, sleep quality, and satisfaction rate were analyzed. Mean scores and postoperative change in scores were calculated.Visual analog scale (VAS) pain scores in the treatment group were significantly reduced from 4 hours (P = 0.0016) to 24 hours (P = 0.0004) after TKA. Additional benefits including reduced analgesic consumption, improved satisfaction rate, and sleep quality were observed. In addition, a significant reduction in blood loss reflected by decreased Hb and drainage was found.In this study, irrigation with a cold 0.5% epinephrine solution was a beneficial and cost-effective treatment that decreased acute postoperative VAS pain scores immediately after and 1 day after surgery. Patients reported postoperative improvement in sleep quality and overall satisfaction rate with a decrease in morphine usage. In addition, a reduction of intraoperative blood loss might decrease the blood transfusion rate and related costs. Collectively, irrigation with cold 0.5% epinephrine offers a safe, simple, and effective treatment that might improve recovery and enhance quality of life of patients undergoing TKA.

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice

Background

The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme.

Methods

Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature.

Results

This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations.

Conclusions

Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ^®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.

Enhanced recovery after giant ventral hernia repair

PURPOSE

Giant ventral hernia repair is associated with a high risk of postoperative morbidity and prolonged length of stay (LOS). Enhanced recovery (ERAS) measures have proved to lead to decreased morbidity and LOS after various surgical procedures, but never after giant hernia repair. The current study prospectively examined the results of implementation of an ERAS pathway including high-dose preoperative glucocorticoid, and compared the outcome with patients previously treated according to standard care (SC).

METHODS

Consecutive patients who underwent giant ventral hernia repair were included. Pain, nausea and fatigue were registered prospectively in all patients treated according to ERAS, as well as continuous measurement of transcutaneous capillary oxygen saturation. Postoperative morbidity and LOS were compared between patients treated according to ERAS and a historic group treated with SC.

RESULTS

A total of 32 patients were included. Postoperative LOS was decreased after the introduction of the ERAS pathway compared with SC (median 3.0 vs. 5.5 days, P = 0.003). Scores of pain, nausea and fatigue were low, while mean oxygen saturation during the first three postoperative days was 0.92. There were no differences when comparing readmission (5 vs. 2, P = 0.394), postoperative complications (7 vs. 4, P = 0. 458), or reoperation (5 vs. 1, P = 0.172) in ERAS versus controls.

CONCLUSIONS

The current study suggests that an ERAS pathway including preoperative high-dose glucocorticoid may lead to low scores of pain, fatigue and nausea after giant ventral hernia repair with reduced LOS compared with patients treated according to SC.

Factors Related to Postoperative Pain Trajectories following Total Knee Arthroplasty: A Longitudinal Study of Patients Admitted to a Russian Orthopaedic Clinic

This study explores sociodemographic, clinical, and surgical factors in relation to pain trajectories during the first 3 days following total knee arthroplasty (TKA). 100 patients (mean age 63.5 ± 7.8 years and 93% female) consecutively admitted for uncomplicated primary TKA were prospectively included. Postoperative pain was assessed using pain diaries. Measures of preoperative pain, symptoms, daily functioning, quality of life, comorbidities, knee function, perioperative characteristics, and physical/biochemical parameters were also evaluated. All pain ratings decreased in the three days following surgery (p < .001) as well as the reported number of daily hours in moderate/severe pain (p < .001). Women reported more pain than men (p = .009). Pain trajectories did not differ by education, employment, cohabitation, or any patient clinical and biochemical characteristics but were significantly related to preoperative anxiety (p = .029). Patients reporting moderate/severe pain prior to surgery also reported more hours in moderate/severe pain on days 0–3 postoperatively (p = .029). Patients with surgeries longer than 90 min reported more hours of moderate/severe pain compared with patients who had shorter surgeries (p = .008), and similar results were observed for ratings of pain with activity (p = .012). In this sample, only female gender, higher levels of preoperative pain and anxiety, and longer surgical duration were associated with increased pain after TKA.

The constraints on day-case total knee arthroplasty: the fastest fast track

Total knee arthroplasty (TKA) is a major orthopaedic intervention. The length of a patient's stay has been progressively reduced with the introduction of enhanced recovery protocols: day-case surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case TKA. These constraints may be social, linked to patient's comorbidities, or due to surgery-related adverse events (e.g. pain, post-operative nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and multimodal opioid-sparing analgesia, day-case TKA might be achievable in a limited group of patients. The younger, male patient without comorbidities and with an excellent social network around him might be a candidate. Demographic changes, effective recovery programmes and less invasive surgical techniques such as unicondylar knee arthroplasty, may increase the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced against any increase in morbidity and mortality and the cost of advanced follow-up at a distance with new technology. These factors need to be evaluated before adopting this ultimate 'fast-track' approach.

Femoral nerve block-sciatic nerve block vs. femoral nerve block-local infiltration analgesia for total knee arthroplasty: a randomized controlled trial

BACKGROUND

The use of femoral nerve block (FNB) combined with sciatic nerve block (SNB) after total knee arthroplasty (TKA) has recently become controversial. Local infiltration analgesia (LIA) has been reported to be effective for postoperative TKA pain control. We aimed to assess whether LIA with continuous FNB is as effective as SNB combined with continuous FNB.

METHODS

This was a prospective, randomized, single-center, observer-blinded, parallel group comparison trial of 34 American Society of Anesthesiologists (ASA) physical status 1-3 patients who underwent TKA and fulfilled the inclusion and exclusion criteria. Patients were randomized into two groups: a periarticular LIA and FNB group (group L, n = 17), and an SNB and FNB group (group S, n = 17). In both groups, participants received FNB with 20 mL of 0.375% ropivacaine, and 5 mL h(-1) of 0.2% ropivacaine after surgery. In group L, participants received 100-ml injections of 0.2% ropivacaine and 0.5 mg epinephrine to the surgical region. In group S, participants received SNB with 20 ml of 0.375% ropivacaine. After TKA, Numeric Rating Scale (NRS) scores for the first 24 h post-operation were compared via repeated-measures analysis of variance (ANOVA) as the primary outcome. Other outcome measures included NRS score changes within groups, area under the curve for the NRS scores, total analgesic dose, change in knee flexion and extension, pain control satisfaction, nausea and vomiting, and hospital stay duration.

RESULTS

NRS score changes were greater in group L than in group S (P < 0.01, ANOVA) and greater in group L than in group S at three postoperative time points: 3 h (P < 0.01), 6 h (P < 0.01), and 12 h (P = 0.013; Mann-Whitney U test). Changes in the mean NRS score were observed in each group (P < 0.01, Friedman test). No significant differences were detected in the other outcome measures (Mann-Whitney U, Wilcoxon signed-rank, and chi-squared tests).

CONCLUSIONS

Sciatic nerve block with femoral nerve block is superior to local anesthetic infiltration with femoral nerve block for postoperative pain control within 3-12 h of total knee arthroplasty.

TRIAL REGISTRATION

UMIN-CTR ID: 000013364 R: 000015591.

Regional or general anesthesia for fast-track hip and knee replacement - what is the evidence?

Regional anesthesia for knee and hip arthroplasty may have favorable outcome effects compared with general anesthesia by effectively blocking afferent input, providing initial postoperative analgesia, reducing endocrine metabolic responses, and providing sympathetic blockade with reduced bleeding and less risk of thromboembolic complications but with undesirable effects on lower limb motor and urinary bladder function. Old randomized studies supported the use of regional anesthesia with fewer postoperative pulmonary and thromboembolic complications, and this has been supported by recent large non-randomized epidemiological database cohort studies. In contrast, the data from newer randomized trials are conflicting, and recent studies using modern general anesthetic techniques may potentially support the use of general versus spinal anesthesia. In summary, the lack of properly designed large randomized controlled trials comparing modern general anesthesia and spinal anesthesia for knee and hip arthroplasty prevents final recommendations and calls for prospective detailed studies in this clinically important field.

The efficacy of steroid injection in total knee or hip arthroplasty

PURPOSE

A systematic review and meta-analysis based on randomized controlled trials (RCTs) was conducted to evaluate the efficacy and safety of steroid injection in total knee or hip arthroplasty (TKA/THA).

METHODS

A systematical electronic search identified the relevant RCTs in the databases of PubMed, EMBASE, MEDLINE and Cochrane Central Register of Controlled Trials. Two reviewers independently completed data collection and assessment of methodological quality. Meta-analysis was performed for the outcomes of visual analogue pain score, range of motion (ROM), postoperative nausea and vomiting (PONV), morphine consumption, length of stay and complications.

RESULTS

A total of 863 participants were enrolled. Patients who received steroid injection had a significant reduction in the incidence of PONV and improvement in short-term pain score, and ROM (p < 0.05). Regarding morphine consumption and hospitalization time, the steroid group showed a significant reduction in TKA but no statistically significant difference in THA. In addition, there were no significant differences in complications (n.s.).

CONCLUSIONS

The current evidence suggests that steroid injection in TKA/THA provides short-term advantages in pain relief and antiemetic effects. The optimal dose and long-term effects of steroid injection still require numerous studies.

LEVEL OF EVIDENCE

II.

Multimodal Analgesia for Total Joint Arthroplasty

Optimal perioperative pain control for total joint arthroplasty remains a challenge. Whereas traditional regimens have relied heavily on opioids, newer multimodal pathways are increasingly gaining popularity as safer and more effective alternatives. The main premise of multimodal analgesia is decreased consumption of opioids, and hence lesser opioid-related adverse events. Other reported advantages include lower pain scores, faster functional recovery, higher patient satisfaction, and shorter length of hospital stay. Unfortunately, despite the advent of numerous analgesic techniques, the multimodal approach has remained widely variable, making direct comparison between studies difficult to interpret. This article provides an extensive review of traditional and modern perioperative interventions in pain management for total joint arthroplasty, including intravenous patient-controlled analgesia, epidural infusion, oral opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks, periarticular infiltration, steroids, anticonvulsants, and long-acting local anesthetics. Emphasis is placed on pathophysiology, clinical evidence, and timing. A standardized multimodal analgesia protocol is also proposed based on best available evidence. In addition to pharmacologic interventions, patient education and interdisciplinary collaboration among the care teams play an important role in the success of any treatment pathway. With a growing demand for total joint arthroplasty in an era of bundled payments and accountable care, there has never been a greater need for a standardized multimodal analgesia pathway.

Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty: a randomised, controlled trial

BACKGROUND

The choice of anaesthetic technique for patients undergoing joint arthroplasty is debatable. The hypothesis of this study was that general anaesthesia would generate a more favourable recovery profile than spinal anaesthesia.

METHODS

We randomly allocated 120 patients to either intrathecal bupivacaine or general anaesthesia with target-controlled infusion of remifentanil and propofol. Length of hospital stay assessed as meeting discharge criteria was the primary outcome parameter. Other outcome parameters were actual time of discharge, pain, use of rescue pain medication, blood loss, length of stay in the post-operative care unit, dizziness, post-operative nausea, need of urinary catheterisation and patient satisfaction.

RESULTS

General anaesthesia resulted in slightly reduced length of hospital stay (26 vs. 30 h, P = 0.004), less nausea (P = 0.043) and dizziness (P < 0.001). General anaesthesia patients had higher pain scores during the first two post-operative hours (P < 0.001) but lower after 6 h compared with the spinal anaesthesia group (P < 0.01 and P < 0.05). General anaesthesia patients had better orthostatic function compared with spinal anaesthesia patients (P = 0.008). Patients in the spinal anaesthesia group fulfilled the discharge criteria from the post-operative care unit earlier compared with the general anaesthesia patients (P = 0.004). General anaesthesia patients requested a change in the method of anaesthesia for a subsequent operation less often than the spinal anaesthesia patients (5 vs. 13, P = 0.022).

CONCLUSION

General anaesthesia resulted in a more favourable recovery profile compared with spinal anaesthesia.

Preventive analgesia in hip or knee arthroplasty: a systematic review

OBJECTIVE

To analyze the efficacy and safety of preventive analgesia in patients undergoing hip or knee arthroplasty due to osteoarthritis.

METHODS

A systematic literature review was performed, using a defined a sensitive strategy on Medline, Embase and Cochrane Library up to May 2013. The inclusion criteria were: patients undergoing knee and/or hip arthroplasty, adults with moderate or severe pain (≥4 on a Visual Analog Scale). The intervention, the use (efficacy and safety) of pharmacological treatment (preventive) close to surgery was recorded. Oral, topical and skin patch drugs were included. Systematic reviews, meta-analysis, controlled trials and observational studies were selected.

RESULTS

A total of 36 articles, of moderate quality, were selected. The patients included were representative of those undergoing knee and/or hip arthroplasty in Spain. They had a mean age >50 years, higher number of women, and reporting moderate to severe pain (≥4 on a Visual Analog Scale). Possurgical pain was mainly evaluated with a Visual Analog Scale. A wide variation was found as regards the drugs used in the preventive protocols, including acetaminophen, classic NSAID, Cox-2, opioids, corticosteroids, antidepressants, analgesics for neuropathic pain, as well as others, such as magnesium, ketamine, nimodipine or clonidine. In general, all of them decreased post-surgical pain without severe adverse events.

CONCLUSIONS

The use or one or more pre-surgical analgesics decreases the use of post-surgical drugs, at least for short term pain.

Adverse effects of perioperative paracetamol, NSAIDs, glucocorticoids, gabapentinoids and their combinations: a topical review

Post-operative pain affects millions of patients worldwide and the post-operative period has high rates of morbidity and mortality. Some of this morbidity may be related to analgesics. The aim of this review was to provide an update of current knowledge of adverse events (AE) associated with the most common perioperative non-opioid analgesics: paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids (GCCs), gabapentinoids and their combinations. The review is based on data from systematic reviews with meta-analyses of analgesic efficacy and/or adverse effects of perioperative non-opioid analgesics, and randomised trials and cohort/retrospective studies. Generally, data on AE are sparse and related to the immediate post-operative period. For paracetamol, the incidence of AEs appears trivial. Data are inconclusive regarding an association of NSAIDs with mortality, cardiovascular events, surgical bleeding and renal impairment. Anastomotic leakage may be associated with NSAID usage. No firm evidence exists for an association of NSAIDs with impaired bone healing. Single-dose GCCs were not significantly related to increased infection rates or delayed wound healing. Gabapentinoid treatment was associated with increased sedation, dizziness and visual disturbances, but the clinical relevance needs clarification. Importantly, data on AEs of combinations of the above analgesics are sparse and inconclusive. Despite the potential adverse events associated with the most commonly applied non-opioid analgesics, including their combinations, reporting of such events is sparse and confined to the immediate perioperative period. Knowledge of benefit and harm related to multimodal pain treatment is deficient and needs clarification in large trials with prolonged observation.

Post-operative analgesic effects of paracetamol, NSAIDs, glucocorticoids, gabapentinoids and their combinations: a topical review

In contemporary post-operative pain management, patients are most often treated with combinations of non-opioid analgesics, to enhance pain relief and to reduce opioid requirements and opioid-related adverse effects. A diversity of combinations is currently employed in clinical practice, and no well-documented 'gold standards' exist. The aim of the present topical, narrative review is to provide an update of the evidence for post-operative analgesic efficacy with the most commonly used, systemic non-opioid drugs, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs)/COX-2 antagonists, glucocorticoids, gabapentinoids, and combinations of these. The review is based on data from previous systematic reviews with meta-analyses, investigating effects of non-opioid analgesics on pain, opioid-requirements, and opioid-related adverse effects. Paracetamol, NSAIDs, COX-2 antagonists, and gabapentin reduced 24 h post-operative morphine requirements with 6.3 (95% confidence interval: 3.7 to 9.0) mg, 10.2 (8.7, 11.7) mg, 10.9 (9.1, 12.8) mg, and ≥ 13 mg, respectively, when administered as monotherapy. The opioid-sparing effect of glucocorticoids was less convincing, 2.33 (0.26, 4.39) mg morphine/24 h. Trials of pregabalin > 300 mg/day indicated a morphine-sparing effect of 13.4 (4, 22.8) mg morphine/24 h. Notably, though, the available evidence for additive or synergistic effects of most combination regimens was sparse or lacking. Paracetamol, NSAIDs, selective COX-2 antagonists, and gabapentin all seem to have well-documented, clinically relevant analgesic properties. The analgesic effects of glucocorticoids and pregabalin await further clarification. Combination regimens are sparsely documented and should be further investigated in future studies.

Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review

In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We conducted a systematic review of randomized clinical trials investigating LIA for total knee arthroplasty (TKA) and total hip arthroplasty (THA) to evaluate the analgesic efficacy of LIA for early postoperative pain treatment. In addition, the analgesic efficacy of wound catheters and implications for length of hospital stay (LOS) were evaluated. Twenty-seven randomized controlled trials in 756 patients operated on with THA and 888 patients operated on with TKA were selected for inclusion in the review. In THA, no additional analgesic effect of LIA compared with placebo was reported in trials with low risk of bias when a multimodal analgesic regimen was administered perioperatively. Compared with intrathecal morphine and epidural analgesia, LIA was reported to have similar or improved analgesic efficacy. In TKA, most trials reported reduced pain and reduced opioid requirements with LIA compared with a control group treated with placebo/no injection. Compared with femoral nerve block, epidural or intrathecal morphine LIA provided similar or improved analgesia in the early postoperative period but most trials had a high risk of bias due to different systemic analgesia between groups. Overall, the use of wound catheters for postoperative administration of local anaesthetic was not supported in the included trials, and LOS was not related to analgesic efficacy. Despite the many studies of LIA, final interpretation is hindered by methodological insufficiencies in most studies, especially because of differences in use of systemic analgesia between groups. However, LIA provides effective analgesia in the initial postoperative period after TKA in most randomized clinical trials even when combined with multimodal systemic analgesia. In contrast, LIA may have limited additional analgesic efficacy in THA when combined with a multimodal analgesic regimen. Postoperative administration of local anaesthetic in wound catheters did not provide additional analgesia when systemic analgesia was similar and LOS was not related to use of LIA with a fast-track set-up.

Pain after knee arthroplasty: an unresolved issue

PURPOSE

Despite the recent advances in the understanding of pain mechanisms and the introduction of new drugs and new techniques in the postoperative management, pain after total knee arthroplasty (TKA) is still an unresolved issue. It affects the quality of life and rehabilitation of an important percentage of patients undergoing TKA. The aim of this narrative review was to give an overview on pain mechanisms and multimodal pain management.

METHODS

A review of all peer-reviewed articles on pain after knee arthroplasty was performed by two reviewers. Recent articles on incisional pain mechanisms were included because of their importance in the understanding of postsurgical pain. Search was performed in Pubmed, Cochrane and Google Scholar data bases.

RESULTS

Postsurgical pain mechanisms are based on both local and systemic inflammatory reactions. Peri-operative pain management starts with the anaesthetic technique and resides on a multimodal analgesia regimen. New concepts, drugs and techniques have shown their efficacy in reducing the severity of acute postoperative pain and the risk of developing chronic pain after TKA.

CONCLUSION

This narrative review offers a clear overview of pain mechanism after knee arthroplasty and an understanding on how multimodal pain management can reduce the intensity and duration of pain after knee arthroplasty.

Dexamethasone for pain after outpatient shoulder surgery: a randomised, double-blind, placebo-controlled trial

BACKGROUND

Dexamethasone has analgesic properties when given intravenously before surgery, but the optimal dose has not been determined. We hypothesised that a dose of 40 mg dexamethasone would improve analgesia after outpatient shoulder surgery compared with 8 mg.

METHODS

A randomised, double-blind, placebo-controlled clinical trial was conducted at Horsens Regional Hospital, Denmark. Patients scheduled for arthroscopic subacromial decompression and/or acromioclavicular joint resection as an outpatient procedure (n = 101) were randomised to receive intravenous dexamethasone 40 mg (D40), 8 mg (D8) or placebo (D0) before surgery. The primary outcome was pain intensity 8 h after surgery rated on a numeric rating scale of 0 to 10. Secondary outcomes were pain intensity, analgesic consumption and side effects during the first 3 days after surgery.

RESULTS

Data from 73 patients were available for analysis: (D40: 25, D8: 26, D0: 22 patients). Eight hours after surgery, pain intensity were: [median (interquartile range)] group D40: 2 (1-4), group D8: 2.5 (1-5), group D0: 4 (2-7). There was no significant difference in pain intensity between group D40 and D8 after 8 h (P = 0.46) or at any other time. When comparing all three groups, a statistically significant dose-response relationship was seen for present, average and worst pain intensity after 8 h and on the following morning. No differences were found in analgesic consumption. No serious side effects were observed.

CONCLUSION

Although our data supported a dose-response relationship, increasing the dexamethasone dose from 8 to 40 mg did not improve analgesia significantly after outpatient shoulder surgery.

Systematic review of high-volume multimodal wound infiltration in total knee arthroplasty

Pain relief following total knee arthroplasty (TKA) is challenging because early mobilization and rehabilitation are essential for a successful outcome. Postoperative pain can limit recovery, leading to reduced mobility and prolonged hospitalization. There are potential benefits of infiltrating high volumes of local anesthetics around the soft tissues of replaced hip and knee joints. The risk of systemic toxicity is minimized with diluted local anesthetic solution, which also allows a high volume to be used. One of the principal advantages is that analgesia agents are administered intraoperatively by the surgeon, thereby minimizing the need for additional invasive procedures. The authors conducted a systematic review to evaluate whether high-volume multimodal wound infiltration reduces pain and opiate intake while enhancing early rehabilitation and discharge when used in patients undergoing TKA. Only randomized controlled studies were included. Although better pain relief in the immediate postoperative period with wound infiltration is gained after TKA, there is no definite evidence that this leads to a reduction in opiate consumption, the achievement of early milestones, or a reduction in hospital stay. The roles of individual agents in achieving pain relief and the use of percutaneous wound catheter for postoperative doses are also unclear. There are few reports of complications, including falls and delayed mobilization, when femoral nerve blocks are used. Wound infiltration analgesia should be used at the preference of the surgeon and anesthetist provided regular review of their practice is undertaken to identify any untoward side effects. Further randomized trials with sufficient sample size comparing each outcome, including pain scores, opiate consumption, and length of hospital stay, should be undertaken.

Effect of intravenous methylprednisolone on pain after intertrochanteric femoral fracture surgery

BACKGROUND

Pain after surgery is one of the major problems in patients with intertrochanteric fracture. This study investigates administration of single-dose Methylprednisolone prior to surgery with the goal of reducing Post-operative pain.

MATERIALS AND METHODS

The study was a Double Blind Randomized Clinical Trial. Eighty two patients with stable intertrochanteric unilateral fracture were selected and divided into two groups: one received Methylprednisolone (MP) 125 mg and the other received placebo. Pain was evaluated at rest and 45° flexion of the hip in times 4, 6, 8, 12, 24, 36, and 48 hours and during walking in times 24, 36, and 48 hours after the surgery. Post-operative nausea, vomiting and fatigue and changes in C - reactive protein (CRP) levels before and after the surgery were also recorded.

RESULTS

Pain at rest, 45° flexion of the hip and during walking after the surgery was significantly lower in the MP group compared to the control group (p < 0.001). Fatigue (p = 0.002) and changes in CRP (p=0.001) were significantly lower in MP group. Incidence of nausea, vomiting (p = 0.37) and opioid consumption (p = 0.49) were not significantly different between the two groups.

CONCLUSION

Single-dose methylprednisolone 125 mg (IV) can reduce Post-operative pain in patients with intertrochanteric fracture undergoing elective surgery.

Periarticular infiltration for pain relief after total hip arthroplasty: a comparison with epidural and PCA analgesia

PURPOSE

Epidural and intravenous patient-controlled analgesia (PCA) are established methods for pain relief after total hip arthroplasty (THA). Periarticular infiltration is an alternative method that is gaining ground due to its simplicity and safety. Our study aims to assess the efficacy of periarticular infiltration in pain relief after THA.

METHODS

Sixty-three patients undergoing THA under spinal anaesthesia were randomly assigned to receive postoperative analgesia with continuous epidural infusion with ropivacaine (epidural group), intraoperative periarticular infiltration with ropivacaine, clonidine, morphine, epinephrine and corticosteroids (infiltration group) or PCA with morphine (PCA group). PCA morphine provided rescue analgesia in all groups. We recorded morphine consumption, visual analog scale (VAS) scores at rest and movement, blood loss from wound drainage, mean arterial pressure (MAP) and adverse effects at 1, 6, 12, 24 h postoperatively.

RESULTS

Morphine consumption at all time points, VAS scores at rest, 6, 12 and 24 h and at movement, 6 and 12 h postoperatively were lower in infiltration group compared to PCA group (p < 0.05), but did not differ between infiltration and epidural group. There was no difference in adverse events in all groups. At 24 h, MAP was higher in the PCA group (p < 0.05) and blood loss was lower in the infiltration group (p < 0.05).

CONCLUSIONS

In our study periarticular infiltration was clearly superior to PCA with morphine after THA, providing better pain relief and lower opioid consumption postoperatively. Infiltration seems to be equally effective to epidural analgesia without having the potential side effects of the latter.

Activity, sleep and cognition after fast-track hip or knee arthroplasty

Optimized perioperative care after total hip and knee arthroplasty (THA/TKA) has decreased length of stay (LOS) but data on activity, sleep and cognition after discharge are limited. We included 20 patients ≥ 60 years undergoing THA/TKA, monitoring them for 3 days preoperatively and 9 days postoperatively with actigraphs for sleep and activity assessment. Pain scores were recorded daily. Cognition was evaluated by 2 cognitive tests. Results showed a mean age was 70.5 years and mean LOS was 2.6 days. Actigraphs showed increased daytime sleep and decreased motor activity postoperatively. Early postoperatively cognitive decline and increased pain returned to preoperative levels by postoperative day (POD) 5-9. Despite the small sample size the study illustrated that post-discharge activity is decreased and daytime sleep is increased after fast-track THA/TKA, while cognition and pain return to preoperative levels by POD 9. Objective assessment of these recovery parameters may be valuable in future interventional studies to enhance recovery after THA/TKA.

Preemptive low-dose dexamethasone reduces postoperative emesis and pain after TKA: a randomized controlled study

BACKGROUND

Dexamethasone is a potent analgesic and antiemetic. However, the benefit of dexamethasone after TKA is unclear, as is the efficacy in a current multimodal regime.

QUESTIONS/PURPOSES

We determined (1) whether the addition of dexamethasone to a protocol including ramosetron further reduces postoperative emesis compared with ramosetron alone; (2) whether it reduces postoperative pain; and (3) whether it increases the risk for wound complications in a current multimodal regime after TKA.

METHODS

We randomized 269 patients undergoing TKAs to receive dexamethasone (10 mg) 1 hour before surgery and ramosetron immediately after surgery (Dexa-Ra group, n = 135), or ramosetron alone (Ra group, n = 134). We recorded the incidence of postoperative nausea and vomiting (PONV), severity of nausea, incidence of antiemetic requirement, complete response, pain level, and opioid consumption. Patients were assessed 0 to 6, 6 to 24, 24 to 48, and 48 to 72 hours postoperatively. In addition, patients were evaluated for wound complications and periprosthetic joint infections at a minimum of 1 year after surgery.

RESULTS

The Dexa-Ra group had a lower incidence of PONV during the entire 72-hour evaluation period and experienced less severe nausea for the first 6 hours after TKA, although not between 6 to 72 hours. Overall use of a rescue antiemetic was less frequent, and complete response was more frequent in the Dexa-Ra group. Patients in the Dexa-Ra group experienced lower pain and consumed less opioids during the 6- to 24-hour period and during the overall study period. No differences were found in wound complications between the groups, and each group had one case of periprosthetic joint infection.

CONCLUSIONS

Patients who received prophylactic dexamethasone in addition to ramosetron had reduced postoperative emesis and pain without increased risks for wound complications, compared with patients who received ramosetron alone in patients managed using a multimodal regimen after TKA.

Fast-track knee arthroplasty -- status and future challenges

BACKGROUND

Fast-track programs have been developed for different surgical procedures leading to higher patient satisfaction and lower morbidity. This concept has been extended to knee arthroplasty in recent years. The purpose of this narrative review was to discuss the different aspects of fast-track knee arthroplasty.

METHOD

Both authors searched the contemporary literature on minimally invasive knee arthroplasty and review articles on fast-track surgery aiming to summarize recent developments.

RESULTS

Length of stay after knee arthroplasty is influenced by preoperative risk factors, anaesthetic and surgical techniques, pain, orthostatic intolerance, cognitive function, sleep disturbances, bleeding and anaemia and finally muscle function and rehabilitation.

CONCLUSIONS

Fast-track surgery reduces the length of stay and the morbidity after knee arthroplasty.

CLINICAL RELEVANCE

Optimisation of pre-, per- and postoperative pathway for knee arthroplasty reduces morbidity after this type of surgery and results in shorter length of stay.

Perioperative glucocorticoids in hip and knee surgery - benefit vs. harm? A review of randomized clinical trials

Glucocorticoids are frequently used to prevent post-operative nausea and vomiting (PONV), and may be part of multimodal analgesic regimes. The objective of this review was to evaluate the overall benefit vs. harm of perioperative glucocorticoids in patients undergoing hip or knee surgery. A wide search was performed in PubMed, Embase, and Cochrane Central to identify relevant randomized clinical trials. A systematic approach was used, starting from the PRISMA recommendations. The Cochrane Collaboration's tool was used for risk of bias assessment. Studies were divided into three groups: systemic glucocorticoid administration analogous to > 10 mg or ≤ 10 mg dexamethasone, and local glucocorticoid administration. Seventeen studies with data from 1081 patients were included in the final qualitative synthesis. Benefit (of any kind) with glucocorticoid vs. placebo was reported in 15 studies. PONV was reduced with systemic glucocorticoid. Pain was reduced with high-dose systemic and local glucocorticoid, but not with low-dose systemic glucocorticoid. Systemic inflammatory markers were reduced with low-dose and high-dose systemic glucocorticoid, and with local glucocorticoid. Functional recovery was improved with local glucocorticoid. All studies were small-sized and none sufficiently powered to meaningfully evaluate uncommon adverse events. Most of the local administration studies had poor scientific quality (high risk of bias). Due to clinical heterogeneity and poor scientific quality, no meta-analysis was performed. In conclusion, in addition to PONV reduction with low-dose systemic glucocorticoid, this review supports high-dose systemic glucocorticoid to ameliorate post-operative pain after hip and knee surgery. However, large-scale safety and dose-finding studies are warranted before final recommendations.

A comprehensive multimodal pain treatment reduces opioid consumption after multilevel spine surgery

PURPOSE

Major spine surgery with multilevel instrumentation is followed by large amount of opioid consumption, significant pain and difficult mobilization in a population of predominantly chronic pain patients. This case-control study investigated if a standardized comprehensive pain and postoperative nausea and vomiting (PONV) treatment protocol would improve pain treatment in this population.

METHODS

A new regimen with acetaminophen, NSAIDs, gabapentin, S-ketamine, dexamethasone, ondansetron and epidural local anesthetic infusion or patient controlled analgesia with morphine, was introduced in a post-intervention group of 41 consecutive patients undergoing multilevel (median 10) instrumented spinal fusions and compared with 44 patients in a pre-intervention group.

RESULTS

Compared to patients in the pre-intervention group, patients treated according to the new protocol consumed less opioid on postoperative day (POD) 1 (P = 0.024) and 2 (P = 0.048), they were mobilized earlier from bed (P = 0.003) and ambulation was earlier both with and without a walking frame (P = 0.027 and P = 0.027, respectively). Finally, patients following the new protocol experienced low intensities of nausea, sedation and dizziness on POD 1-6.

CONCLUSIONS

In this study of patients scheduled for multilevel spine surgery, it was demonstrated that compared to a historic group of patients receiving usual care, a comprehensive and standardized multimodal pain and PONV protocol significantly reduced opioid consumption, improved postoperative mobilization and presented concomitant low levels of nausea, sedation and dizziness.

Delirium in the fast-track surgery setting

Postoperative delirium (PD) and postoperative cognitive dysfunction (POCD) are two separate syndromes of cognitive decline after major surgery, especially in the elderly. Pathogenesis is multifactorial with some common risk factors, and to reduce the risk, a multimodal approach is necessary. The fast-track methodology is becoming a well-established perioperative care regime with possible preventive effects for postoperative cognitive decline, including reduced pain and use of opioids, and early mobilisation with early discharge (≤3 days) to preoperative environment after total hip/knee arthroplasty (THA/TKA). The fast-track set-up seems to be associated with a lower frequency of PD and early POCD after THA/TKA. Thus, in a series of 225 patients ≥60 years, no cases of PD were seen and the incidence of POCD was reduced by more than 50% at 1 week postoperatively compared to previous studies. In conclusion, the fast-track methodology may reduce the incidence of postoperative cognitive decline after surgery.

Fast-track hip and knee arthroplasty: clinical and organizational aspects

Fast-track hip and knee arthroplasty aims at giving the patients the best available treatment at all times, being a dynamic entity. Fast-track combines evidence-based, clinical features with organizational optimization including a revision of traditions resulting in a streamlined pathway from admission till discharge – and beyond. The goal is to reduce morbidity, mortality and functional convalescence with an earlier achievement of functional milestones including functional discharge criteria with subsequent reduced length of stay and high patient satisfaction. Outcomes are traditionally measured as length of stay; safety aspects in the form of morbidity/mortality; patient satisfaction; and – as a secondary parameter – economic savings. Optimization of the clinical aspects include focusing on analgesia; DVT-prophylaxis; mobilization; care principles including functional discharge criteria; patient-characteristics to predict outcome; and traditions which may be barriers in optimizing outcomes. Patients should be informed and motivated to be active participants and their expectations should be modulated in order to improve satisfaction. Also, organizational aspects need to be analyzed and optimized. New logistical approaches should be implemented; the ward ideally (re)structured to only admit arthroplasties; the staff educated to have a uniform approach; extensive preoperative information given including discharge criteria and intended length of stay. This thesis includes 9 papers on clinical and organizational aspects of fast-track hip and knee arthroplasty (I–IX). A detailed description of the fast-track set-up and its components is provided. Major results include identification of patient characteristics to predict length of stay and satisfaction with different aspects of the hospital stay (I); how to optimize analgesia by using a compression bandage in total knee arthroplasty (II); the clinical and organizational set-up facilitating or acting as barriers for early discharge (III); safety aspects following fast-track in the form of few readmissions in general (IV) and few thromboembolic complications in particular (V); feasibility studies showing excellent outcomes following fast-track bilateral simultaneous total knee arthroplasty (VI) and non-septic revision knee arthroplasty (VII); how acute pain relief in total hip arthroplasty is not enhanced by the use of local infiltration analgesia when multi-modal opioid-sparing analgesia is given (VIII); and a detailed description of which clinical and organizational factors detain patients in hospital following fast-track hip and knee arthroplasty (IX). Economic savings following fast-track hip and knee arthroplasty is also documented in studies, reviews, metaanalyses and Cochrane reviews – including the present fast-track (ANORAK). In conclusion, the published results (I–IX) provide substantial, important new knowledge on clinical and organizational aspects of fast-track hip and knee arthroplasty – with concomitant documented high degrees of safety (morbidity/mortality) and patient satisfaction. Future research strategies are multiple and include both research strategies as efforts to implement the fast-track methodology on a wider basis. Research areas include improvements in pain treatment, blood saving strategies, fluid plans, reduction of complications, avoidance of tourniquet and concomitant blood loss, improved early functional recovery and muscle strengthening. Also, improvements in information and motivation of the patients, preoperative identification of patients needing special attention and detailed economic studies of fast- track are warranted.

Post-anaesthesia care unit stay after total hip and knee arthroplasty under spinal anaesthesia

BACKGROUND

Post-anaesthesia care unit (PACU) admission must be well founded and the stay as short as possible without compromising patient safety. However, within the concept of fast-track surgery, studies are limited in addressing the question: why are patients staying in the PACU?

METHODS

All patients operated with primary unilateral total hip or knee arthroplasty (THA or TKA) under spinal anaesthesia were included in this hypothesis-generating, prospective, observational cohort study during a 4-month period. Surgical technique, analgesia, and perioperative care were standardized. Well-defined PACU discharge criteria that had to be met on two successive assessments were evaluated every 15 min until discharge. The primary outcome was time to meet PACU discharge criteria. Secondary outcomes were actual discharge time from the PACU, specific factors detaining patients in the PACU, and potential complications at the surgical ward at follow-up 24 h post-operatively.

RESULTS

One hundred sixty-three patients were included in the final analysis (69 THA and 94 TKA). Time to meet PACU discharge criteria was [median (interquartile range)(95% confidence interval)]: 15 min (15-15)(15-116) for THA and 15 min (15-15)(15-75) for TKA. Actual discharge time from PACU was: 25 min (20-35)(16-198) for THA and 25 min (20-31)(15-107) for TKA. Reasons for not meeting PACU discharge criteria in 15 min were mainly low oxygen saturation and pain. The short stay in the PACU did not impose complications at the surgical ward.

CONCLUSION

The vast majority of patients (> 85%) operated with THA and TKA under low-dose spinal anaesthesia may achieve pre-defined PACU discharge criteria in 15 min. Large-scale studies should be performed to evaluate safety aspects after short PACU stay.

Sleep disturbances after fast-track hip and knee arthroplasty

BACKGROUND

Major surgery is followed by pronounced sleep disturbances after traditional perioperative care potentially leading to prolonged recovery. The aim was to evaluate the rapid eye movement (REM) sleep duration and sleep architecture before and after fast-track hip and knee replacement with length of stay (LOS) <3 days. The primary endpoint was REM sleep duration on the first postoperative night compared with before operation.

METHODS

Ten subjects (≥60 yr) receiving spinal anaesthesia and multimodal opioid-sparing postoperative analgesia for total hip or knee arthroplasty were included. Ambulatory polysomnography was performed one night before operation at home, continuously during hospitalization, and on the fourth postoperative night at home. Sleep staging was performed according to the American Academy of Sleep Medicine manual. Opioid use, pain, and inflammatory response (C-reactive protein) were also evaluated.

RESULTS

The mean LOS was 1.5 (1-2) days. The mean REM sleep time decreased from a mean of 18.2 (9.5-23.5)% of total sleep time to 1.2 (0-5.8)% on the first postoperative night (P=0.002); awake time increased from 19.1 (3.7-44.4)% to 44.3 (12.2-70.6)% (P=0.009); and sleep architecture on the first postoperative night was more disturbed than before operation. Sleep architecture normalized on the fourth postoperative night. There was no association between opioid use, pain scores, and inflammatory response with a disturbed sleep pattern.

CONCLUSIONS

Despite ultra-short LOS and provision of spinal anaesthesia with multimodal opioid-sparing analgesia, REM sleep was almost eliminated on the first postoperative night after fast-track orthopaedic surgery but returned to pre-admission levels when at home on the fourth postoperative night.

A comparison between dexamethasone and methylprednisolone for vomiting prophylaxis after tonsillectomy in inpatient children: a randomized trial

BACKGROUND

The frequent incidence of postoperative vomiting in children undergoing tonsillectomy, in addition to the occurrence of severe pain, may delay postoperative oral intake and lead to increased risk of dehydration. Thus, prophylactic therapy is indicated in this high-risk group. Glucocorticoids, such as dexamethasone and methylprednisolone, have anti-inflammatory and antiemetic properties with dexamethasone being frequently used. We hypothesized that methylprednisolone should be noninferior to dexamethasone for the prevention of vomiting in children after tonsillectomy.

METHODS

We designed a randomized double-blind trial to compare the efficacy of a single prophylactic dose of 0.5 mg/kg dexamethasone with a dose of 2.5 mg/kg methylprednisolone on the incidence of postoperative vomiting during the first 24 hours (primary outcome) in children undergoing total or partial tonsillectomy with a noninferiority margin set at 9%. One hundred sixty children undergoing total or partial tonsillectomy under general anesthesia were randomly assigned to receive either IV dexamethasone 0.5 mg/kg (n = 79) or methylprednisolone 2.5 mg/kg (n = 81) after induction of anesthesia. Secondary analysis of all studied outcomes was also performed according to the type of surgery.

RESULTS

An intention-to-treat analysis showed an overall incidence of vomiting of 30% in the dexamethasone group and of 22% in the methylprednisolone group (difference: 8%, 95% confidence interval [CI]: -5% to 21%). A per protocol analysis showed an incidence of vomiting of 32% and 23%, respectively (difference: 9%, and 95% CI of the difference: -5 to 23%, P(sup) = 0.28). The time and quality of oral intake and the duration of IV hydration, as well as pain and satisfaction scores and the need for analgesics, were similar between the 2 groups. The incidence of vomiting was also similar in patients who had total versus partial tonsillectomy; however, time to first oral intake, duration of IV hydration, and the need for analgesics were less with better satisfaction scores in partial versus total tonsillectomy patients.

CONCLUSION

Methylprednisolone is at worst 5% less effective than dexamethasone by the intention-to-treat analysis, and by the per protocol analysis. Thus, it is noninferior to dexamethasone in preventing vomiting after tonsillectomy in children.

Early recovery after fast-track Oxford unicompartmental knee arthroplasty. 35 patients with minimal invasive surgery

BACKGROUND AND PURPOSE

After total knee arthroplasty with conventional surgical approach, more than half of the quadriceps extension strength is lost in the first postoperative month. Unicompartmental knee arthroplasty (UKA) operated with minimally invasive surgery (MIS) results in less operative trauma. We investigated changes in leg-extension power (LEP) in the first month after MIS Oxford UKA and its relation to pain, knee motion, functional performance, and knee function.

PATIENTS AND METHODS

In 35 consecutive Oxford UKA patients, LEP was measured 1 week before and 1 month after surgery together with knee motion, knee swelling, the 30-second chair-stand test, and Oxford knee score. Assessment of knee pain at rest and walking was done using a visual analog scale.

RESULTS

30 patients were discharged on the day after surgery, and 5 on the second day after surgery. LEP and functional performance reached the preoperative level after 1 month. Only slight postoperative knee swelling was observed with rapid restoration of knee flexion and function. A high level of pain during the first postoperative night and day fell considerably thereafter. None of the patients needed physiotherapy supervision in the first month after discharge.

INTERPRETATION

Fast-track MIS Oxford UKA with discharge on the day after surgery is safe and leads to early recovery of knee motion and strength even when no physiotherapy is used.