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Nucci N, Degen R, Ekhtiari S, Gazendam A, Ayeni OR, Horner N, Wong I, Woodmass J, Grant J, Sheehan B, Pickell M, Kopka M, Khan M, Martin R, Tucker A, Sommerfeldt M, Gusnowski E, Rousseau-Saine A, Lebel ME, Karpyshyn J, Matache B, Carroll M, Da Cunha R, Kwapisz A, Martin RK. Arthroscopy Association of Canada Position Statement on Opioid Prescription After Arthroscopic Surgery. Orthop J Sports Med 2023; 11:23259671231214700. [PMID: 38145216 PMCID: PMC10748902 DOI: 10.1177/23259671231214700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/23/2023] [Indexed: 12/26/2023] Open
Abstract
Background Despite the ongoing opioid epidemic, most patients are still prescribed a significant number of opioid medications for pain management after arthroscopic surgery. There is a need for consensus among orthopaedic surgeons and solutions to aid providers in analgesic strategies that reduce the use of opioid pain medications. Purpose This position statement was developed with a comprehensive systematic review and meta-analysis of exclusively randomized controlled trials (RCTs) to synthesize the best available evidence for managing acute postoperative pain after arthroscopic surgery. Study Design Position statement. Methods The Embase, MEDLINE, PubMed, Scopus, and Web of Science databases were searched from inception until August 10, 2022. Keywords included arthroscopy, opioids, analgesia, and pain, and associated variations. We included exclusively RCTs on adult patients to gather the best available evidence for managing acute postoperative pain after arthroscopic surgery. Patient characteristics, pain, and opioid data were extracted, data were analyzed, and trial bias was evaluated. Results A total of 21 RCTs were identified related to the prescription of opioid-sparing pain medication after arthroscopic surgery. The following recommendations regarding noninvasive, postoperative pain management strategies were made: (1) multimodal oral nonopioid analgesic regimens-including at least 1 of acetaminophen-a nonsteroidal anti-inflammatory drug-can significantly reduce opioid consumption with no change in pain scores; (2) cryotherapy is likely to help with pain management, although the evidence on the optimal method of application (continuous-flow vs ice pack application) is unclear; (3) and (4) limited RCT evidence supports the efficacy of transcutaneous electrical nerve stimulation and relaxation exercises in reducing opioid consumption after arthroscopy; and (5) limited RCT evidence exists against the efficacy of transdermal lidocaine patches in reducing opioid consumption. Conclusion A range of nonopioid strategies exist that can reduce postarthroscopic procedural opioid consumption with equivalent vocal pain outcomes. Optimal strategies include multimodal analgesia with education and restricted/reduced opioid prescription.
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Affiliation(s)
| | - Ryan Degen
- Western University, London, Ontario, Canada
| | | | | | | | - Nolan Horner
- Genesis Orthopaedics & Sports Medicine, Chicago, Illinois, USA
| | - Ivan Wong
- Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - John Grant
- University of Michigan, Ann Arbor, Michigan, USA
| | | | | | | | - Moin Khan
- Investigation performed at McMaster University, Hamilton, Ontario, Canada
| | - Ryan Martin
- University of Calgary, Calgary Alberta, Canada
| | - Allison Tucker
- Nova Scotia Health Authority, Halifax Nova Scotia, Canada
| | | | - Eva Gusnowski
- Saint John Orthopaedics, Saint John, New Brunswick, Canada
| | | | | | | | | | - Michael Carroll
- Queen Elizabeth Hospital, Charlottetown, Prince Edward Island, Canada
| | | | - Adam Kwapisz
- University of Manitoba, Winnipeg, Manitoba, Canada
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Degen RM, Firth A, Sehmbi H, Martindale A, Wanlin S, Chen C, Marsh JD, Willits K, Bryant D. Multimodal analgesia did not improve post-operative pain scores, reduce opioid consumption or reduce length of stay following hip arthroscopy. Knee Surg Sports Traumatol Arthrosc 2023; 31:4016-4026. [PMID: 37170015 DOI: 10.1007/s00167-023-07445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023]
Abstract
PURPOSE To determine whether different regimens of multimodal analgesia will reduce postoperative pain scores, opioid consumption, costs and hospital length-of-stay following hip arthroscopy. METHODS From 2018 to 2021, 132 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) were included in this prospective, single-center randomized controlled trial. Patients were randomized into four treatment groups: (1) Group 1-Control: opioid medication (oxycodone-acetaminophen 5 mg/325 mg, 1-2 tabs q6H as needed), Heterotopic ossification prophylaxis-Naprosyn 500 mg twice daily × 3 weeks); (2) Group 2-Control + postoperative sleeping aid (Zopiclone 7.5 mg nightly × 7 days); (3) Group 3-Control + preoperative and postoperative Gabapentin (600 mg orally, 1 h preoperatively; 600 mg postoperatively, 8 h following pre-op dose); (4) Group 4-Control + pre-medicate with Celecoxib (400 mg orally, 1 h preoperatively) The primary outcome was pain measured with a visual analog scale, monitored daily for the first week and every other day for 6 weeks. Secondary outcomes included opioid consumption, healthcare resource use, and hospital length of stay. RESULTS Patient characteristics were similar between groups. There were no statistically significant differences in pain scores between groups at any timepoint after adjusting for intra-operative traction time, intra-operative opioid administration and preoperative pain scores (p > 0.05). There were also no significant differences in the number of days that opioids were taken (n.s.) and the average daily morphine milligram equivalents consumed (n.s.). Similarly, there were no statistically significant differences in length of stay in the experimental groups, compared with the control group (n.s.). Finally, there were no differences in cost between groups (n.s.). CONCLUSION The routine use of Zopiclone, Celecoxib and Gabapentin did not improve postoperative pain control or reduce length-of-stay following hip arthroscopy. Therefore, these medications are not recommended for routine postoperative pain control following hip arthroscopy. LEVEL OF EVIDENCE l.
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Affiliation(s)
- Ryan M Degen
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada.
- Bone and Joint Institute, Western University, London, ON, Canada.
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
| | - Andrew Firth
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
| | - Herman Sehmbi
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
- Department of Anesthesia, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Ashley Martindale
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
| | - Stacey Wanlin
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
| | - Clara Chen
- Faculty of Health Sciences, Western University, London, Canada
| | | | - Kevin Willits
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Dianne Bryant
- Fowler Kennedy Sport Medicine Clinic, Western University, 1151 Richmond Street, 3M Centre, London, ON, Canada
- Bone and Joint Institute, Western University, London, ON, Canada
- Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Faculty of Health Sciences, Western University, London, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
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Ekhtiari S, Nucci N, Uddin F, Albadran A, Gazendam AM, Bhandari M, Khan M. Opioid-Sparing Strategies in Arthroscopic Surgery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. JBJS Rev 2023; 11:01874474-202307000-00005. [PMID: 37459422 DOI: 10.2106/jbjs.rvw.23.00047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Opioid overprescription is a problem in orthopaedic surgery. Arthroscopic surgery, given its minimally invasive nature, represents an opportunity to minimize opioid prescription and consumption by using effective pain management adjuncts. Thus, the primary question posed in this study was which noninvasive pain management modalities can effectively manage pain and reduce opioid intake after arthroscopic surgery. METHODS The databases PubMed, MEDLINE, EMBASE, Scopus, and Web of Science were searched on August 10, 2022. Randomized controlled trials (RCTs) evaluating noninvasive pain management strategies in arthroscopy patients were evaluated. Eligible studies were selected through a systematic screening process. Meta-analysis was performed for pain scores and opioid consumption at time points which had sufficient data available. RESULTS Twenty-one RCTs were included, with a total of 2,148 patients undergoing shoulder, knee, and hip arthroscopy. Meta-analysis comparing nonopioid, oral analgesic regimens, with or without patient education components, with the standard of care or placebo demonstrated no difference in pain scores at 24 hours, 4 to 7 days, or 14 days postoperatively. Nonopioid regimens also resulted in significantly lower opioid consumption in the first 24 hours postoperatively (mean difference, -37.02 mg oral morphine equivalents, 95% confidence interval, -74.01 to -0.03). Transcutaneous electrical nerve stimulation (TENS), cryotherapy, and zolpidem were also found to effectively manage pain and reduce opioid use in a limited number of studies. CONCLUSIONS A range of noninvasive pain management strategies exist to manage pain and reduce opioid use after arthroscopic procedures. The strongest evidence base supports the use of multimodal nonopioid oral analgesics, with some studies incorporating patient education components. Some evidence supports the efficacy of TENS, cryotherapy, and nonbenzodiazepine sleeping aids. Direction from governing bodies is an important next step to incorporate these adjuncts into routine clinical practice to manage pain and reduce the amount of opioids prescribed and consumed after arthroscopic surgery. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of RCTs. See Instructions for Authors for a complete description of the levels of evidence.
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Affiliation(s)
- Seper Ekhtiari
- Division of Trauma and Orthopaedics, Addenbrooke's Hospital-Cambridge University Hospitals, Cambridge, United Kingdom
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicholas Nucci
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Fares Uddin
- Roth McFarlane Hand & Upper Limb Centre, Western University, London, Ontario, Canada
| | - Adeeba Albadran
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, McMaster University, Hamilton, Ontario, Canada
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Hozack BA, Kistler JM, Vaccaro AR, Beredjiklian PK. Benzodiazepines and Related Drugs in Orthopaedics. J Bone Joint Surg Am 2022; 104:2204-2210. [PMID: 36223476 DOI: 10.2106/jbjs.22.00516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ Benzodiazepines are among the most commonly prescribed drugs worldwide and are often used as anxiolytics, hypnotics, anticonvulsants, and muscle relaxants. ➤ The risk of dependence on and abuse of these medications has recently gained more attention in light of the current opioid epidemic. ➤ Benzodiazepines can increase the risk of prolonged opioid use and abuse. ➤ Given the prevalence of the use of benzodiazepines and related drugs, orthopaedic patients are often prescribed these medications. ➤ Orthopaedic surgeons need to be aware of the prevalence of benzodiazepine and related drug prescriptions in the general population, their current uses in orthopaedic surgery, and the risks and adverse effects of their use.
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Affiliation(s)
- Bryan A Hozack
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Cheah JW, Freshman RD, Mah CD, Kinjo S, Lansdown DA, Feeley BT, Zhang AL, Ma CB. Orthopedic sleep and novel analgesia pathway: a prospective randomized controlled trial to advance recovery after shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:S143-S151. [PMID: 35413431 DOI: 10.1016/j.jse.2022.02.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/05/2022] [Accepted: 02/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lack of sleep is associated with adverse effects on postsurgical pain and recovery. We hypothesized that a multimodal sleep pathway, including nonpharmacologic sleep hygiene interventions and the use of zolpidem and melatonin, could improve patient analgesia and sleep after total shoulder arthroplasty. METHODS We performed a prospective randomized controlled study in which patients undergoing anatomic and reverse total shoulder arthroplasty were treated with or without an interventional multimodal sleep pathway. This pathway included nursing-directed nonpharmacologic measures that promote sleep hygiene and pharmacologic interventions with low-dose zolpidem and melatonin at bedtime. All patients underwent a standardized multimodal analgesia protocol with scheduled acetaminophen, naproxen, and gabapentin, as well as a single-shot interscalene regional nerve block. RESULTS This study enrolled 125 patients (64 in control group and 61 in interventional group) with similar demographic characteristics. The interventional group showed less oral morphine milligram equivalent (MME) consumption on postoperative day (POD) 0 (44.8 ± 36.1 MMEs vs. 60.9 ± 42.1 MMEs, P = .01) and showed a trend toward lower POD 0 visual analog scale pain scores (2.6 ± 1.8 vs. 3.3 ± 3.0, P = .06). Visual analog scale pain scores and MME consumption were similar on POD 1. The interventional group showed a longer objective sleep duration by quantitative wrist actigraphy (5.9 ± 3.1 hours vs. 4.6 ± 2.7 hours, P = .008), with better sleep quality assessed by the Leeds Sleep Evaluation Questionnaire (0-100 scale; 50.3 ± 26.8 vs. 38.5 ± 27.8, P = .01). The 2 groups showed similar satisfaction with pain management (89.2% vs. 79.6%, P = .16) and sleep management (82.1% vs. 76.8%, P = .48). There was no difference in the length of inpatient stay (32.2 ± 14.8 hours vs. 34.1 ± 12.8 hours, P = .44). CONCLUSION In the setting of a regional and multimodal analgesia recovery plan for shoulder arthroplasty patients undergoing inpatient observation, the use of an interventional sleep pathway appears to be safe and beneficial, with improved analgesia, reduced opioid use, increased sleep duration, and improved reported sleep quality during the postoperative recovery period.
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Affiliation(s)
- Jonathan W Cheah
- Department of Orthopaedic Surgery, Santa Clara Valley Medical Center, San Jose, CA, USA; Stanford University, Palo Alto, CA, USA.
| | - Ryan D Freshman
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Cheri D Mah
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Sakura Kinjo
- Department of Anesthesiology and Perioperative Care, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Drew A Lansdown
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, CA, USA
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California, San Francisco Medical Center, San Francisco, CA, USA
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Paul RW, Szukics PF, Brutico J, Tjoumakaris FP, Freedman KB. Postoperative Multimodal Pain Management and Opioid Consumption in Arthroscopy Clinical Trials: A Systematic Review. Arthrosc Sports Med Rehabil 2022; 4:e721-e746. [PMID: 35494281 PMCID: PMC9042766 DOI: 10.1016/j.asmr.2021.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 09/17/2021] [Indexed: 01/01/2023] Open
Affiliation(s)
- Ryan W. Paul
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | - Patrick F. Szukics
- Rowan University School of Osteopathic Medicine, Department of Orthopaedic Surgery, Stratford, New Jersey, U.S.A
| | - Joseph Brutico
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
| | | | - Kevin B. Freedman
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, U.S.A
- Address correspondence to Kevin B. Freedman, M.D., Rothman Orthopaedic Institute, Thomas Jefferson University, 825 Old Lancaster Rd., Suite 200, Bryn Mawr, PA, 19010, U.S.A.
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Cheah JW, Danilkowicz R, Hutyra C, Lewis B, Olson S, Poehlein E, Green CL, Mather R. High Prevalence of Sleep Disturbance Is Associated with Femoroacetabular Impingement Syndrome. Arthrosc Sports Med Rehabil 2022; 4:e495-e501. [PMID: 35494310 PMCID: PMC9042751 DOI: 10.1016/j.asmr.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 11/01/2021] [Indexed: 10/24/2022] Open
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Bolia IK, Haratian A, Bell JA, Hasan LK, Saboori N, Palmer R, Petrigliano FA, Weber AE. Managing Perioperative Pain After Anterior Cruciate Ligament (ACL) Reconstruction: Perspectives from a Sports Medicine Surgeon. Open Access J Sports Med 2021; 12:129-138. [PMID: 34512045 PMCID: PMC8426642 DOI: 10.2147/oajsm.s266227] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/25/2021] [Indexed: 11/23/2022] Open
Abstract
Anterior cruciate ligament reconstructions (ACLR) are a relatively common procedure in orthopedic sports medicine with an estimated 130,000 arthroscopic operations performed annually. Most procedures are carried out on an outpatient basis, and though success rates of ACLR are as high as 95%, pain remains the most common postoperative complication delaying patient discharge, and thereby increasing the costs associated with patient care. Despite the success and relative frequency of ACLR surgery, optimal and widely accepted strategies and regimens for controlling perioperative pain are not well established. In recent years, the paradigm of pain control has shifted from exclusively utilizing opiates and opioid medications in the acute postoperative period to employing other agents and techniques including nerve blocks, intra-articular and periarticular injections of local anesthetic agents, NSAIDs, and less commonly, ketamine, tranexamic acid (TXA), sedatives, gabapentin, and corticosteroids. More often, these agents are now used in combination and in synergy with one another as part of a multimodal approach to pain management in ACLR, with the goal of reducing postoperative pain, opioid consumption, and the incidence of delayed hospital discharge. The purpose of this review is to consolidate current literature on various agents involved in the management of postoperative pain following ACLR, including the role of classically used opiate and opioid medications, as well as to describe other drugs currently utilized in practice either individually or in conjunction with other agents as part of a multimodal regimen in pain management in ACLR.
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Affiliation(s)
- Ioanna K Bolia
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Aryan Haratian
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Jennifer A Bell
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Laith K Hasan
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Nima Saboori
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Ryan Palmer
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Frank A Petrigliano
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
| | - Alexander E Weber
- USC Epstein Family Center for Sports Medicine at Keck Medicine of USC, Los Angeles, CA, USA
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Davey MS, Hurley ET, Anil U, Moses A, Thompson K, Alaia M, Strauss EJ, Campbell KA. Pain Management Strategies After Anterior Cruciate Ligament Reconstruction: A Systematic Review With Network Meta-analysis. Arthroscopy 2021; 37:1290-1300.e6. [PMID: 33515736 DOI: 10.1016/j.arthro.2021.01.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To systematically review randomized controlled trials (RCTs) evaluating various pain control interventions after anterior cruciate ligament reconstruction (ACLR) to determine the best-available evidence in managing postoperative pain and to optimize patient outcomes. METHODS A systematic review of the literature was performed based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A study was included if it was an RCT evaluating an intervention to reduce postoperative pain acutely after ACLR in one of the following areas: (1) nerve blocks, (2) nerve block adjuncts, (3) intra-articular injections, (4) oral medications, (5) intravenous medications, (6) tranexamic acid, and (7) compressive stockings and cryotherapy. Quantitative and qualitative statistics were carried out, and network meta-analysis was performed where applicable. RESULTS Overall, 74 RCTs were included. Across 34 studies, nerve blocks were found to significantly reduce postoperative pain and opioid use, but there was no significant difference among the various nerve blocks in the network meta-analysis. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. CONCLUSIONS Nerve blocks and regional anesthesia are the mainstay treatment of postoperative pain after ACLR, with the commonly used nerve blocks being equally efficacious. Intra-articular injections consisting of bupivacaine and an adjunct were found to reduce reported postoperative pain scores up to 12 hours after ACLR, with significantly lower postoperative opioid use. There was promising evidence for the use of some oral and intravenous medications, tranexamic acid, and nerve block adjuncts, as well as cryotherapy, to control pain and reduce postoperative opioid use. LEVEL OF EVIDENCE Level II, systematic review and meta-analysis of RCTs.
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Affiliation(s)
- Martin S Davey
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eoghan T Hurley
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A.; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Utkarsh Anil
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Akini Moses
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kamali Thompson
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Michael Alaia
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Eric J Strauss
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
| | - Kirk A Campbell
- Sports Medicine Division, Orthopaedic Surgery Department, NYU Langone Health, New York, New York, U.S.A
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O’Hagan ET, Hübscher M, Miller CB, Gordon CJ, Gustin S, Briggs N, McAuley JH. Zolpidem reduces pain intensity postoperatively: a systematic review and meta-analysis of the effect of hypnotic medicines on post-operative pain intensity. Syst Rev 2020; 9:206. [PMID: 32883342 PMCID: PMC7472584 DOI: 10.1186/s13643-020-01458-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/14/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This systematic review aimed to investigate whether the administration of hypnotic medicines, z-drugs, melatonin or benzodiazepines, reduced pain intensity postoperatively. METHODS Medline, Embase, Cinahl, Psych info, Central and PubMed databases were searched, from inception to February 2020 to identify relevant trials. The search was extended, post hoc, to include meta-Register of Controlled Trials, the Web of Science and the conference booklets for the 14th, 15th, and 16th International Association for the Study of Pain conferences. Two independent reviewers screened titles and abstracts and cross-checked the extracted data. RESULTS The search retrieved 5546 articles. After full-text screening, 15 trials were included, which had randomised 1252 participants. There is moderate-quality evidence that in the short-term [WMD - 1.06, CI - 1.48 to - 0.64, p ≤ .01] and low-quality evidence that in the medium-term [WMD - 0.90, CI - 1.43 to - 0.37, p ≤ .01] postoperative period oral zolpidem 5/10 mg with other analgesic medicines reduced pain intensity compared to the same analgesic medicines alone. There is low-quality evidence that melatonin was not effective on postoperative pain intensity compared to placebo. The results of benzodiazepines on pain intensity were mixed. The authors reported no significant adverse events. CONCLUSIONS There is promising evidence that the hypnotic medicine zolpidem, adjuvant to other analgesics, is effective at achieving a minimally clinically important difference in pain intensity postoperatively. There is no consistent effect of melatonin or benzodiazepines on postoperative pain intensity. Readers should interpret these results with some caution due to the lack of data on safety, the small number of trials included in the pooled effects and their sample sizes. SYSTEMATIC REVIEW REGISTRATION The protocol for this systematic review was registered with PROSPERO ID= CRD42015025327 .
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Affiliation(s)
- Edel T. O’Hagan
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- Prince of Wales Clinical School, The University of New South Wales, Randwick, NSW 2031 Australia
| | - Markus Hübscher
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- Prince of Wales Clinical School, The University of New South Wales, Randwick, NSW 2031 Australia
| | - Christopher B. Miller
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, The University of Sydney, Glebe, NSW 2037 Australia
| | - Christopher J. Gordon
- CIRUS, Centre for Sleep and Chronobiology, Woolcock Institute of Medical Research, The University of Sydney, Glebe, NSW 2037 Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW 2050 Australia
| | - Sylvia Gustin
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- Gustin Pain Imaging Laboratory, School of Psychology, The University of New South Wales, Randwick, NSW 2031 Australia
| | - Nancy Briggs
- Stats Central, University of New South Wales, Randwick, NSW 2031 Australia
| | - James H. McAuley
- Centre for Pain IMPACT, Neuroscience Research Australia, Randwick, NSW 2031 Australia
- School of Medical Science, University of New South Wales, Randwick, NSW 2031 Australia
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Petrie K, Matzkin E. Can pharmacological and non-pharmacological sleep aids reduce post-operative pain and opioid usage? A review of the literature. Orthop Rev (Pavia) 2019; 11:8306. [PMID: 31897280 PMCID: PMC6912139 DOI: 10.4081/or.2019.8306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/27/2019] [Indexed: 12/16/2022] Open
Abstract
Sleep is important for our health and well-being and is especially pertinent to orthopedic surgery because it has been shown to play a role in pain tolerance. Knowing the benefits of sleep, one way to positively impact patients’ pain and recovery post-surgery is to encourage sleep. Zolpidem, a pharmacologic sleep aid, has been shown to decrease opioid consumption, reduce pain, and increase quality of life when briefly used after orthopedic procedures. Cognitive Behavioral Therapy for Insomnia (CBT-I), a nonpharmacologic sleep aid, has been shown to increase the quality of sleep and sleep time, decrease sleep onset latency, decrease pain, and help patients maintain those gains. Because of the dangers of opioids, it is important for physicians to search for alternative methods to manage their patients’ pain, like zolpidem and CBT-I. More research is needed to determine which method may be the most efficacious and how these can be integrated into patient care.
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Affiliation(s)
- Kyla Petrie
- Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX
| | - Elizabeth Matzkin
- Department of Orthopedics, Brigham and Women's Hospital, Boston, MA, USA
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Bjurström MF, Irwin MR. Perioperative Pharmacological Sleep‐Promotion and Pain Control: A Systematic Review. Pain Pract 2019; 19:552-569. [DOI: 10.1111/papr.12776] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 01/21/2019] [Accepted: 02/07/2019] [Indexed: 01/15/2023]
Affiliation(s)
- Martin F. Bjurström
- Department of Anesthesiology and Intensive Care Skåne University Hospital LundSweden
- Department of Clinical Sciences Lund University Lund Sweden
- Cousins Center for Psychoneuroimmunology University of California, Los Angeles (UCLA) Los Angeles California U.S.A
| | - Michael R. Irwin
- Cousins Center for Psychoneuroimmunology University of California, Los Angeles (UCLA) Los Angeles California U.S.A
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Rampes S, Ma K, Divecha YA, Alam A, Ma D. Postoperative sleep disorders and their potential impacts on surgical outcomes. J Biomed Res 2019; 34:271-280. [PMID: 32519977 PMCID: PMC7386412 DOI: 10.7555/jbr.33.20190054] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Postoperative sleep disturbance is a common occurrence with significant adverse effects on patients including delayed recovery, impairment of cognitive function, pain sensitivity and cardiovascular events. The development of postoperative sleep disturbance is multifactorial and involves the surgical inflammatory response, the severity of surgical trauma, pain, anxiety, the use of anesthetics and environmental factors such as nocturnal noise and light levels. Many of these factors can be managed perioperatively to minimize the deleterious impact on sleep. Pharmacological and non-pharmacological treatment strategies for postoperative sleep disturbance include dexmedetomidine, zolpidem, melatonin, enhanced recovery after surgery (ERAS) protocol and controlling of environmental noise and light levels. It is likely that a combination of pharmacological and non-pharmacological therapies will have the greatest impact; however, further research is required before their use can be routinely recommended.
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Affiliation(s)
- Sanketh Rampes
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Katie Ma
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Yasmin Amy Divecha
- Faculty of Life Sciences & Medicine, King's College London, London SE1 1UL, UK
| | - Azeem Alam
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Daqing Ma
- Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK
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Affiliation(s)
- David R Hillman
- Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Centre for Sleep Science, University of Western Australia, Perth, Australia.
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Gaspar MP, Kane PM, Jacoby SM, Gaspar PS, Osterman AL. Evaluation and Management of Sleep Disorders in the Hand Surgery Patient. J Hand Surg Am 2016; 41:1019-1026. [PMID: 27702465 DOI: 10.1016/j.jhsa.2016.08.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 05/11/2016] [Accepted: 08/19/2016] [Indexed: 02/02/2023]
Abstract
Despite posing a significant public health threat, sleep disorders remain poorly understood and often underdiagnosed and mismanaged. Although sleep disorders are seemingly unrelated, hand surgeons should be mindful of these because numerous conditions of the upper extremity have known associations with sleep disturbances that can adversely affect patient function and satisfaction. In addition, patients with sleep disorders are at significantly higher risk for severe, even life-threatening medical comorbidities, further amplifying the role of hand surgeons in the recognition of this condition.
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Affiliation(s)
- Michael P Gaspar
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA.
| | - Patrick M Kane
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Sidney M Jacoby
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Patrick S Gaspar
- Department of Anesthesiology, Harborside Surgical Center, Oxon Hill, MD
| | - A Lee Osterman
- Philadelphia Hand Center, PC, Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA
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Secrist ES, Freedman KB, Ciccotti MG, Mazur DW, Hammoud S. Pain Management After Outpatient Anterior Cruciate Ligament Reconstruction: A Systematic Review of Randomized Controlled Trials. Am J Sports Med 2016; 44:2435-47. [PMID: 26684664 DOI: 10.1177/0363546515617737] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Effective pain management after anterior cruciate ligament (ACL) reconstruction improves patient satisfaction and function. PURPOSE To collect and evaluate the available evidence from randomized controlled trials (RCTs) on pain control after ACL reconstruction. STUDY DESIGN Systematic review. METHODS A systematic literature review was performed using PubMed, Medline, Google Scholar, UpToDate, Cochrane Reviews, CINAHL, and Scopus following PRISMA guidelines (July 2014). Only RCTs comparing a method of postoperative pain control to another method or placebo were included. RESULTS A total of 77 RCTs met inclusion criteria: 14 on regional nerve blocks, 21 on intra-articular injections, 4 on intramuscular/intravenous injections, 12 on multimodal regimens, 6 on oral medications, 10 on cryotherapy/compression, 6 on mobilization, and 5 on intraoperative techniques. Single-injection femoral nerve blocks provided superior analgesia to placebo for up to 24 hours postoperatively; however, this also resulted in a quadriceps motor deficit. Indwelling femoral catheters utilized for 2 days postoperatively provided superior analgesia to a single-injection femoral nerve block. Local anesthetic injections at the surgical wound site or intra-articularly provided equivalent analgesia to regional nerve blocks. Continuous-infusion catheters of a local anesthetic provided adequate pain relief but have been shown to cause chondrolysis. Cryotherapy improved analgesia compared to no cryotherapy in 4 trials, while in 4 trials, ice water and water at room temperature provided equivalent analgesic effects. Early weightbearing decreased pain compared to delayed weightbearing. Oral gabapentin given preoperatively and oral zolpidem given for the first week postoperatively each decreased opioid consumption as compared to placebo. Ibuprofen reduced pain compared to acetaminophen. Oral ketorolac reduced pain compared to hydrocodone-acetaminophen. CONCLUSION Regional nerve blocks and intra-articular injections are both effective forms of analgesia. Cryotherapy-compression appears to be beneficial, provided that intra-articular temperatures are sufficiently decreased. Early mobilization reduces pain symptoms. Gabapentin, zolpidem, ketorolac, and ibuprofen decrease opioid consumption. Despite the vast amount of high-quality evidence on this topic, further research is needed to determine the optimal multimodal approach that can maximize recovery while minimizing pain and opioid consumption. CLINICAL RELEVANCE These results provide the best available evidence from RCTs on pain control regimens after ACL reconstruction.
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Affiliation(s)
- Eric S Secrist
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin B Freedman
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael G Ciccotti
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Donald W Mazur
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Sommer Hammoud
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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18
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Levy DM, Frank RM, Bach BR, Verma NN. Perioperative Pain and Swelling Control in Anterior Cruciate Ligament Reconstruction. OPER TECHN SPORT MED 2016. [DOI: 10.1053/j.otsm.2015.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
PURPOSE The aim of this study was to evaluate the effects and safety of a sleep aid for postoperative analgesia in patients undergoing arthroscopic rotator cuff repair. MATERIALS AND METHODS Seventy-eight patients were prospectively assigned to either the zolpidem group (multimodal analgesia+zolpidem; 39 patients) or the control group (multimodal analgesia; 39 patients). Self-rated pain levels were assessed twice a day using a visual analog scale (VAS). The need for additional rescue analgesic, duration of functional recovery, and adverse effects were assessed for the first 5 days after surgery. RESULTS The mean number of times that additional rescue analgesic was required during 5 days after surgery was 2.1±2.0 in the zolpidem group and 3.3±2.8 in the control group, a significant difference. There were no significant differences between the two groups in mean VAS pain scores during the first 5 days after surgery, although the zolpidem group had lower VAS pain scores than the control group. Additionally, there were no significant differences in duration of functional recovery and adverse effects between the two groups. CONCLUSION The use of zolpidem for analgesia after arthroscopic rotator cuff repair provided a significant reduction in the need for rescue analgesic without increasing adverse effects. Nevertheless, mean VAS pain scores during the first 5 days after surgery did not differ between the zolpidem group and the control group.
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Affiliation(s)
- Chul-Hyun Cho
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Korea
| | - Si-Wook Lee
- Department of Orthopedic Surgery, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Korea.
| | - Young-Kuk Lee
- Department of Orthopedic Surgery, Hanmi Hospital, Daegu, Korea
| | - Hong-Kwan Shin
- Department of Orthopedic Surgery, Hanmi Hospital, Daegu, Korea
| | - Ilseon Hwang
- Department of Pathology, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, Korea
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Singla N, Margulis R, Kostenbader K, Zheng Y, Barrett T, Giuliani MJ, Chen Y, Young JL. Randomized, double-blind, placebo-controlled study of the efficacy and safety of biphasic immediate-release/extended-release hydrocodone bitartrate/acetaminophen tablets for acute postoperative pain. PHYSICIAN SPORTSMED 2015; 43:126-37. [PMID: 25796986 DOI: 10.1080/00913847.2015.1025029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND A fixed-dose combination biphasic immediate-release (IR)/extended-release (ER) hydrocodone bitartrate (HB)/acetaminophen (APAP) tablet is being developed for the management of acute pain severe enough to require opioid treatment and for which alternative treatment options are inadequate. METHODS This Phase III, randomized, double-blind, placebo-controlled, parallel-group study evaluated the analgesic efficacy and safety of IR/ER HB/APAP (n = 201) versus placebo (n = 202) over a period of 48 hours in patients with acute moderate to severe pain following unilateral bunionectomy. Patients received three tablets of placebo or IR/ER HB/APAP as an initial dose (hour 0) followed by two tablets every 12 hours for a total daily dose of 37.5/1625 mg HB/APAP on day 1 and 30/1300 mg HB/APAP thereafter. The primary efficacy outcome was the summed pain intensity difference (SPID) over the first 48 hours (SPID48) after the first dose. RESULTS SPID48 was significantly greater with IR/ER HB/APAP versus placebo (p < 0.001). SPID dosing interval analyses demonstrated consistent, superior pain relief with IR/ER HB/APAP for each dosing interval (all p < 0.001). Mean PID was greater with IR/ER HB/APAP versus placebo beginning 30 minutes after the first dose (p < 0.05), and IR/ER HB/APAP demonstrated faster median time to the onset of perceptible, meaningful, and confirmed pain relief (all p < 0.001). Mean total pain relief scores also indicated greater pain relief with IR/ER HB/APAP versus placebo throughout the 48-hour period (p = 0.012) for all comparisons. A greater proportion of IR/ER HB/APAP versus placebo patients was either "very satisfied" or "satisfied" with their pain relief (69.3% vs 49.4%; p < 0.001). Nausea was the most common treatment-emergent adverse event (TEAE; IR/ER HB/APAP, 25%; placebo, 7.9%). All TEAEs in IR/ER HB/APAP-treated patients were mild or moderate in severity. CONCLUSION IR/ER HB/APAP provided rapid, significant, and consistent analgesic efficacy over a period of 48 hours in an established model of acute pain and was tolerated with a safety profile similar to other low-dose opioids.
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Affiliation(s)
- Neil Singla
- Department of Anesthesia, Lotus Clinical Research LLC, Huntington Hospital , Pasadena, CA , USA
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Wei J, Yang HB, Qin JB, Kong FJ, Yang TB. Single-dose intra-articular bupivacaine after knee arthroscopic surgery: a meta-analysis of randomized placebo-controlled studies. Knee Surg Sports Traumatol Arthrosc 2014; 22:1517-28. [PMID: 23749215 DOI: 10.1007/s00167-013-2543-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 05/20/2013] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this meta-analysis was to examine the efficacy and safety of single-dose intra-articular bupivacaine in the management of pain after knee arthroscopic surgery. METHOD The comprehensive literature search, using MEDLINE, the Cochrane Central Register of Controlled Trials, and Embase databases, was conducted to identify randomized controlled trials that used single-dose intra-articular bupivacaine for postoperative pain. The relative risk (RR), weighted mean difference (WMD), and their corresponding 95 % confidence intervals (CIs) were calculated using RevMan(®) statistical software. RESULT Twenty-three studies (n = 1287) were included (647 subjects in bupivacaine group and 640 subjects in the control group). Statistically significant differences were observed in the VAS values (WMD -1.1; 95 % CI -1.7 to -0.5), number of patients requiring supplementary analgesia (RR 0.83; 95 % CI 0.74-0.94), and time to first analgesic request (WMD 129.3; 95 % CI 15.4-243.1) among the bupivacaine group when compared to the control group. However, short-term side effects had no significant difference between these two groups (RR 0.73; 95 % CI 0.44-1.24). CONCLUSIONS On the basis of the currently available literature, single-dose intra-articular bupivacaine was shown to be significantly better than placebo at relieving pain after knee arthroscopic surgery. More high-quality randomized controlled trials with long follow-up are highly required for examining the safety of single-dose intra-articular bupivacaine. Besides, routine use of single-dose intra-articular bupivacaine is still an effective way for pain management after knee arthroscopic surgery.
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Affiliation(s)
- Jie Wei
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, 410008, Hunan Province, China
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Wang X, Jia D, Chen X, Xu Y. Comparison of intra-articular low-dose sufentanil, ropivacaine, and combined sufentanil and ropivacaine on post-operative analgesia of isolated anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc 2013; 21:1140-5. [PMID: 23223947 DOI: 10.1007/s00167-012-2326-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 11/26/2012] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the effect of combined local anaesthetic and opioid in post-operative analgesia, the effect of intra-articular injection of local anaesthetic (ropivacaine), opioid (sufentanil) and combination of these two (ropivacaine combined with sufentanil) after the single-bundle anterior cruciate ligament reconstruction were compared. METHODS In a prospective randomized double-blind design, 80 patients who underwent isolated anterior cruciate ligament reconstruction under epidural analgesia were randomly allocated to 4 groups, group A (n = 20) received 30 mL of 0.9% saline as the control group, group B (n = 20) received 10 mg ropivacaine and 2 μg sufentanil in 30 mL 0.9% saline, group C (n = 20) received 10 mg ropivacaine in 30 mL 0.9% saline, group D (n = 20) received 2 μg sufentanil in 30 mL 0.9% saline at the end of the operation. Pain was assessed by use of a 100-mm visual analogue scale (VAS) which was evaluated at 6 and 24 h post-operation. The pain VAS score in active straight leg raising exercise, sleep quality and the status of the administered supplementary analgesia drugs during the first 24 h were also collected. RESULTS Pain scores of each of the three experiment groups were significantly lower than the control group in every aspect. Group B (ropivacaine with sufentanil) had significant lower pain score than group C (ropivacaine) and group D (sufentanil) both at 6 and 24 h after the operation. Patients in group B, C or D showed significant better sleep qualities than group A. Significantly more patients in group A received supplementary analgesia than group B, C or D. In group B, no patient needed to receive intramuscular dolantin as supplementary analgesia. CONCLUSIONS Intra-articular injection of opioid (sufentanil), local anaesthetic (ropivacaine) or combination of these two kinds of agents could significantly reduce the pain following the reconstruction of anterior cruciate ligament. The combined intra-articular injection of opioid and local anaesthetic provided better analgesia effect than using sufentanil or ropivacaine alone. LEVEL OF EVIDENCE Randomized controlled trial, Level I.
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Affiliation(s)
- Xin Wang
- Institution of Sports Medicine of Third Hospital, Peking University, 49 North Garden Rd, Hai Dian District, Beijing, 100191, China
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Ekmekci P, Bengisun ZK, Akan B, Kazbek BK, Ozkan KS, Suer AH. The effect of magnesium added to levobupivacaine for femoral nerve block on postoperative analgesia in patients undergoing ACL reconstruction. Knee Surg Sports Traumatol Arthrosc 2013; 21:1119-24. [PMID: 22696144 DOI: 10.1007/s00167-012-2093-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 06/04/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The aim of this prospective randomised double-blind study is to investigate the effect of magnesium added to local anaesthetics on postoperative VAS scores, total opioid consumption, time to first mobilisation, patient satisfaction and rescue analgesic requirements in arthroscopic ACL reconstruction surgery. METHODS A total of 107 American Society of Anaesthesiologists physical status grade I and II patients between 18 and 65 years of age who were scheduled to undergo elective anterior crucial ligament (ACL) reconstruction with hamstring autografts were enrolled in the study. The patients were randomly allocated to Groups L (n = 51) and LM (n = 56) using the closed-envelope method. Group LM was administered 19 ml of 0.25% levobupivacaine and 1 ml of 15% magnesium sulphate, while Group L was administered 20 ml of 0.25% levobupivacaine for femoral blockade. General anaesthesia was administered using laryngeal airway masks following neural blockade in both groups. The patients were evaluated for heart rate and mean arterial pressure, oxygen saturation, visual analogue score (VAS), verbal rating scale (VRS), rescue analgesic requirements, total opioid consumption, side effects and time to first mobilisation at the 1st, 2nd, 4th, 6th, 12th and 24th hours postoperatively. RESULTS There was no statistically significant difference in terms of demographic data, mean arterial pressure, heart rate or oxygen saturation between groups. The area under the curve VAS and VRS scores were lower at 4, 6, 12 and 24 h in Group LM (p = 0.001, p = 0.016, respectively). The rescue analgesic requirement and the total opioid consumption were significantly lower in Group LM (p = 0.015, p = 0.019, respectively). The time to first mobilisation and the Likert score (completely comfortable; quite comfortable; slight discomfort; painful; very painful) were higher, and the block onset time was lower in Group LM (p = 0.014 and p = 0.012, respectively). There was no difference in terms of side effects. CONCLUSIONS The addition of magnesium to levobupivacaine prolongs the sensory and motor block duration without increasing side effects, enhances the quality of postoperative analgesia and increases patient satisfaction; however, the addition of magnesium delays the time to first mobilisation and decreases rescue analgesic requirements.
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Affiliation(s)
- Perihan Ekmekci
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Ufuk University, Ankara, Turkey
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Lee YC, Lu B, Edwards RR, Wasan AD, Nassikas NJ, Clauw DJ, Solomon DH, Karlson EW. The role of sleep problems in central pain processing in rheumatoid arthritis. ACTA ACUST UNITED AC 2013; 65:59-68. [PMID: 23124650 DOI: 10.1002/art.37733] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 09/27/2012] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Among rheumatoid arthritis (RA) patients, the intensity of pain may be out of proportion to the severity of peripheral inflammation. This observation suggests that mechanisms of central nervous system pain amplification, such as diminished conditioned pain modulation (CPM), may play a role in enhancing pain perception among some RA patients. This study was undertaken to examine the level of CPM, pressure-pain threshold, and pressure-pain tolerance among RA patients compared to healthy controls. METHODS Fifty-eight female RA patients and 54 age-matched female control subjects without chronic pain underwent quantitative sensory testing (QST) to assess CPM levels, pressure-pain thresholds, and pressure-pain tolerance levels. CPM was induced using a cold water bath, and the pain threshold (when patients first felt pain) and pain tolerance (when pain was too much to bear) were assessed with an algometer. Associations between RA and each QST outcome were analyzed using linear regression. Sleep problems, mental health, and inflammation were assessed as mediators of the relationship between RA and QST outcomes. RESULTS The median CPM level was 0.5 kg/cm2 (interquartile range [IQR] -0.1, 1.6) among RA patients, compared to a median of 1.5 kg/cm2 (IQR -0.1, 2.5) among controls (P=0.04). RA patients, compared to controls, had a lower pain threshold and lower pain tolerance at the wrists (each P≤0.05). In addition, RA patients had greater problems with sleep, pain catastrophizing, depression, and anxiety (P<0.0001 versus controls). Results of mediation analyses suggested that low CPM levels might be attributed, in part, to sleep disturbance (P=0.04). CONCLUSION RA patients have impaired CPM when compared to pain-free control subjects. Sleep problems may mediate the association between RA and attenuated CPM.
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Affiliation(s)
- Yvonne C Lee
- Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Puthiyathu M, Greenspan H, Levitt W, Riccardi G, Montemurro N, Nandu B, Waseem S. The Analgesic Properties of Zolpidem. Psychiatr Ann 2013. [DOI: 10.3928/00485713-20130306-02] [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: 11/20/2022]
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