[Perioperative pain therapy in orthopedics]

[Perioperative management in fast-track arthroplasty]

The optimization of organizational processes, as well as surgical procedures intra- and perioperatively, are essential components with respect to fast-track programs in clinical routine. Treatment concepts focus on early postoperative mobilization of patients after joint replacement surgery in an interdisciplinary setting to avoid pain and complications on a scientific basis. This article gives a comprehensive and detailed overview regarding evidence-based peri- and intraoperative fast-track treatment methods: from pain treatment with intraoperative local infiltration analgesia and tranexamic acid application under minimally invasive surgical approach in short-lasting spinal anesthesia to renunciation of drains, regional pain- and urinary catheters, tourniquets, and restrictions.

Evaluation of the Impact of Different Pain Medication and Proton Pump Inhibitors on the Osteogenic Differentiation Potential of hMSCs Using 99mTc-HDP Labelling

First-line analgetic medication used in the field of musculoskeletal degenerative diseases, like Nonsteroidal anti-inflammatory drugs (NSAIDs), reduces pain and prostaglandin synthesis, whereby peptic ulcers are a severe adverse effect. Therefore, proton pump inhibitors (PPI) are frequently used as a concomitant medication to reduce this risk. However, the impact of NSAIDs or metamizole, in combination with PPIs, on bone metabolism is still unclear. Therefore, human mesenchymal stem cells (hMSCs) were cultured in monolayer cultures in 10 different groups for 21 days. New bone formation was induced as follows: Group 1 negative control group, group 2 osteogenic differentiation media (OSM), group 3 OSM with pantoprazole (PAN), group 4 OSM with ibuprofen (IBU), group 5 OSM with diclofenac (DIC), group 6 OSM with metamizole (MET), group 7 OSM with ibuprofen and pantoprazole (IBU + PAN), group 8 OSM with diclofenac and pantoprazole (DIC + PAN), group 9 OSM with metamizole and pantoprazole (MET + PAN) and group 10 OSM with diclofenac, metamizole and pantoprazole (DIC + MET + PAN). Hydroxyapatite content was evaluated using high-sensitive radioactive ^99mTc-HDP labeling. Within this study, no evidence was found that the common analgetic medication, using NSAIDs alone or in combination with pantoprazole and/or metamizole, has any negative impact on the osteogenic differentiation of mesenchymal stem cells in vitro. To the contrary, the statistical results indicate that pantoprazole alone (group 3 (PAN) (p = 0.016)) or diclofenac alone (group 5 (DIC) (p = 0.008)) enhances the deposition of minerals by hMSCS in vitro. There is an ongoing discussion between clinicians in the field of orthopaedics and traumatology as to whether post-surgical (pain) medication has a negative impact on bone healing. This is the first hMSC in vitro study that investigates the effects of pain medication in combination with PPIs on bone metabolism. Our in vitro data indicates that the assumed negative impact on bone metabolism is subsidiary. These findings substantiate the thesis that, in clinical medicine, the patient can receive every pain medication needed, whether or not in combination with PPIs, without any negative effects for the osteo-regenerative potential.

[Fast track in hip and knee arthroplasty]

Fast-track treatment concepts were developed decades ago in general and abdominal surgery and have been adapted in recent years for the special requirements of hip and knee arthroplasty. In this field, Hendrik Husted in particular was able to demonstrate scientific evidence for the components of fast-track concepts. The primary aim is not so much to shorten the patient's hospital length of stay (LOS) but rather to effectively increase the quality of medical treatment for the patient and to reduce complications. The optimization of organizational processes as well as intraoperative and perioperative surgical approaches are essential components regarding the introduction of fast track into the clinical routine. This article gives a comprehensive overview of fast-track treatment concepts and explains the scientific principles for the approach.

Course of pain after total hip arthroplasty within a standardized pain management concept: a prospective study examining influence, correlation, and outcome of postoperative pain on 103 consecutive patients

INTRODUCTION

Postoperative pain management options are of great importance for patients undergoing total hip arthroplasty, as joint replacement surgery is reported to be one of the most painful surgical procedures. This study demonstrates pain outcome until 4 weeks postoperatively and evaluates factors influencing pain in the postoperative course after total hip arthroplasty.

MATERIALS AND METHODS

A total of 103 patients were included in this prospective cohort trial and underwent total hip arthroplasty. Postoperative pain was described using a numerical rating scale (NRS); demographic data and perioperative parameters were correlated with postoperative pain.

RESULTS

Evaluation of pain scores in the postoperative course showed a constant decrease in the first postoperative week (mean NRS 3.1 on day 1 to mean NRS 2.3 on day 8) and, then, a perpetual increase for 3 days (mean NRS 2.6 on day 9 to mean NRS 2.3 on day 12). Afterwards, a continuous pain-level decrease was stated (continuous to a mean NRS 0.9 on day 29). No correlation was found between the potential influencing factors sex, age, body mass index, duration of surgery, ASA score, and postoperative pain levels, but a high significant correlation could be stated for preoperative pain levels and postoperative pain intensity (pain while moving p < 0.02 to p < 0.05 depending on the time period "week 1 postoperatively", "week 2-4", or "week 1-4"; pain while resting p < 0.001, in all the measured time intervals, respectively).

CONCLUSION

Increasing pain levels after the first week postoperatively, for 3 days, are most likely to be caused by the change to more extensive mobilization and physiotherapy in the rehabilitation unit. No significant influence or correlation on the intensity of postoperative pain could be found while evaluating potential predictors except preoperative pain levels. Pain management has to take these findings into account in the future to further increase patients' satisfaction in the postoperative course after total hip arthroplasty and to adapt pain management programs.

Multicenter cohort-study of 15326 cases analyzing patient satisfaction and perioperative pain management: general, regional and combination anesthesia in knee arthroplasty

Numbers of knee replacement surgeries have been rising over the past years. After having ameliorated operation techniques and material, pain management and anesthetic methods have come into focus. All 15326 patients included had undergone primary knee arthroplasty within this multicenter cohort-study, conducted in 46 orthopedic departments. Parameters were evaluated on first postoperative day. Primary outcome values were pain levels (activity, minimum and maximum pain, and pain management satisfaction). Pain medication necessity was analyzed. Parameters were compared between the types of anesthesia used: general, regional and combination anesthesia. Pain scores and pain management satisfaction were significantly better in the groups of either spinal or peripheral anesthesia combined with general anesthesia (p < 0.001, respectively). Patients who received the combination of general and spinal anesthesia were associated with the lowest need for opioids (p < 0.001). The use of a combined general and spinal anesthesia as well as using a combination of general and peripheral anesthesia in knee arthroplasty was associated with a highly significant advantage to other anesthetic techniques regarding perioperative pain management in daily clinical practice, but maybe below clinical relevance. Furthermore they were associated with positive tendency considering side effects and subjective well-being parameters.

No Clinical Difference Comparing General, Regional, and Combination Anesthesia in Hip Arthroplasty: A Multicenter Cohort-Study Regarding Perioperative Pain Management and Patient Satisfaction

BACKGROUND

Steadily increasing numbers of hip arthroplasties are reported in the past years. Different types of anesthetic methods for surgery itself as well as pain management programs have been established. It is one of the main goals to reduce postoperative pain levels and guarantee better and faster mobilization in the postoperative period. The present study aims to compare the use of general and regional spinal anesthesia and their combination regarding perioperative pain management and patient satisfaction.

METHODS

All patients included in the present study had undergone primary hip arthroplasty. Parameters were analyzed on the first postoperative day within the scope of the "Quality Improvement in Postoperative Pain Management" project, which is conducted nationwide in 49 orthopedic departments at the time of data evaluation.

RESULTS

From 2009-2015, 18,118 patients underwent primary hip arthroplasty and have been evaluated. Demographic and general patient data were homogenous. The need for opioids was significantly higher in patients where general and combination anesthesia was applied (P < .001, respectively). Pain scores and pain management satisfaction were significantly better in regional and combination anesthesia (P < .001, respectively).

CONCLUSION

We were able to show a highly significant advantage in the use of regional or the combination of regional and general anesthesia in comparison with general anesthesia alone in hip arthroplasty regarding patients' satisfaction and the requirement of opioid pain medication, although maybe below clinical relevance.

[Total knee arthroplasty in the elderly]

BACKGROUND

The number of total knee arthroplasties in elderly patients is increasing in accordance with the demographic shift in the population.

OBJECTIVE

Analysis of the special situation in the elderly, conservative treatment options, perioperative risk factors, preoperative preparation, special intraoperative features and outcome.

METHODS

Analysis of currently available scientific data and presentation of own scientific study results.

RESULTS

Total knee arthroplasty in elderly patients is related to an increased perioperative risk of complications. A thorough interdisciplinary preparation is required to reduce risk factors. Ligament stability of the knee does not correlate with age. The postoperative outcome after total knee arthroplasty in elderly patients is decisively influenced by the preoperative function and psychosocial parameters.

CONCLUSION

Total knee arthroplasty in elderly patients is particularly challenging for orthopedic surgeons and requires close interdisciplinary cooperation.

Can consistent benchmarking within a standardized pain management concept decrease postoperative pain after total hip arthroplasty? A prospective cohort study including 367 patients

BACKGROUND

The number of total hip replacement surgeries has steadily increased over recent years. Reduction in postoperative pain increases patient satisfaction and enables better mobilization. Thus, pain management needs to be continuously improved. Problems are often caused not only by medical issues but also by organization and hospital structure. The present study shows how the quality of pain management can be increased by implementing a standardized pain concept and simple, consistent, benchmarking.

METHODS

All patients included in the study had undergone total hip arthroplasty (THA). Outcome parameters were analyzed 24 hours after surgery by means of the questionnaires from the German-wide project "Quality Improvement in Postoperative Pain Management" (QUIPS). A pain nurse interviewed patients and continuously assessed outcome quality parameters. A multidisciplinary team of anesthetists, orthopedic surgeons, and nurses implemented a regular procedure of data analysis and internal benchmarking. The health care team was informed of any results, and suggested improvements. Every staff member involved in pain management participated in educational lessons, and a special pain nurse was trained in each ward.

RESULTS

From 2014 to 2015, 367 patients were included. The mean maximal pain score 24 hours after surgery was 4.0 (±3.0) on an 11-point numeric rating scale, and patient satisfaction was 9.0 (±1.2). Over time, the maximum pain score decreased (mean 3.0, ±2.0), whereas patient satisfaction significantly increased (mean 9.8, ±0.4; p<0.05). Among 49 anonymized hospitals, our clinic stayed on first rank in terms of lowest maximum pain and patient satisfaction over the period.

CONCLUSION

Results were already acceptable at the beginning of benchmarking a standardized pain management concept. But regular benchmarking, implementation of feedback mechanisms, and staff education made the pain management concept even more successful. Multidisciplinary teamwork and flexibility in adapting processes seem to be highly important for successful pain management.

Implementing a benchmarking and feedback concept decreases postoperative pain after total knee arthroplasty: A prospective study including 256 patients

Perioperative pain reduction, particularly during the first two days, is highly important for patients after total knee arthroplasty (TKA). Problems are not only caused by medical issues but by organization and hospital structure. The present study shows how the quality of pain management can be increased by implementing a standardized pain concept and simple, consistent benchmarking. All patients included into the study had undergone total knee arthroplasty. Outcome parameters were analyzed by means of a questionnaire on the first postoperative day. A multidisciplinary team implemented a regular procedure of data analyzes and external benchmarking by participating in a nationwide quality improvement project. At the beginning of the study, our hospital ranked 16^th in terms of activity-related pain and 9^th in patient satisfaction among 47 anonymized hospitals participating in the benchmarking project. At the end of the study, we had improved to 1^st activity-related pain and to 2^nd in patient satisfaction. Although benchmarking started and finished with the same standardized pain management concept, results were initially pure. Beside pharmacological treatment, interdisciplinary teamwork and benchmarking with direct feedback mechanisms are also very important for decreasing postoperative pain and for increasing patient satisfaction after TKA.