Effects of morphine on peri-articular infiltration analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled trial

Efficacy of Diosmin in Reducing Lower-Extremity Swelling and Pain After Total Knee Arthroplasty: A Randomized, Controlled Multicenter Trial

BACKGROUND

Many patients experience lower-extremity swelling following total knee arthroplasty (TKA), which impedes recovery. Diosmin is a semisynthetic flavonoid that is often utilized to treat swelling and pain caused by chronic venous insufficiency. We aimed to evaluate the efficacy and safety of diosmin in reducing lower-extremity swelling and pain as well as in improving functional outcomes following TKA.

METHODS

This study was designed as a randomized, controlled multicenter trial and conducted in 13 university-affiliated tertiary hospitals. A total of 330 patients undergoing TKA were randomized to either receive or not receive diosmin postoperatively. The diosmin group received 0.9 g of diosmin twice per day for 14 consecutive days starting on the day after surgery, whereas the control group received neither diosmin nor a placebo postoperatively. The primary outcome was lower-extremity swelling 1, 2, 3, and 14 days postoperatively. The secondary outcomes were postoperative pain assessed with use of a visual analogue scale, Hospital for Special Surgery score, range of knee motion, levels of the inflammatory biomarkers C-reactive protein and interleukin-6, and complications.

RESULTS

At all postoperative time points, diosmin was associated with significantly less swelling of the calf, thigh, and upper pole of the patella as well as with significantly lower pain scores during motion. However, no significant differences in postoperative pain scores at rest, Hospital for Special Surgery scores, range of motion, levels of inflammatory biomarkers, or complication rates were found between the diosmin and control groups.

CONCLUSIONS

The use of diosmin after TKA reduced lower-extremity swelling and pain during motion and was not associated with an increased incidence of short-term complications involving the outcomes studied. However, further studies are needed to continue exploring the efficacy and safety of diosmin use in TKA.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Comparing the Effectiveness of Betamethasone and Triamcinolone Acetonide in Multimodal Cocktail Intercostal Injection for Chest Pain After Harvesting Costal Cartilage: A Prospective, Double-Blind, Randomized Controlled Study

BACKGROUND

There has been no previous study on the availability of different glucocorticoid varieties used in the multimodal cocktail for harvesting autologous costal cartilage. This randomized controlled trial (RCT) was to compare the significance and complications of betamethasone and triamcinolone acetonide as a component of the cocktail for harvesting costal cartilage in patients.

MATERIALS AND METHODS

The patients were randomized to two groups. The group A used multimodal cocktail: ropivacaine, parecoxib sodium, epinephrine, and triamcinolone acetonide; group B used multimodal cocktail: ropivacaine, parecoxib sodium, epinephrine, and betamethasone. The primary outcomes were chest pain after surgery evaluated with a visual analog scale (VAS). The secondary outcomes evaluated the quality of recovery. The tertiary outcomes included rescue analgesic consumption, the first feeding time and the time to the first ambulation, and duration of hospital stay.

RESULTS

The VAS scores between the two groups was not considered clinically significant, but the groups achieved a VAS score of 3 or less. However, the time until the first rescue analgesia and the number were significantly longer and smaller for group A. Additionally, there were no significant differences between the two groups in the duration of hospital stay, first feeding time, the quality of recovery, and the first ambulation time.

CONCLUSION

Adding corticosteroids into the multimodal cocktails could improve pain relief after costal cartilage harvest. And the efficacy of Triamcinolone acetonide was better than betamethasone.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Efficacy of Oral Nefopam on Multimodal Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial

BACKGROUND

Multimodal analgesia is central to pain management after total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding oral nefopam to multimodal analgesia for post-TKA pain management.

METHODS

In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to either the nefopam or the control group. After surgery, patients in the nefopam group received 200 mg of celecoxib, 150 mg of pregabalin, and 40 mg of nefopam twice daily to control postoperative pain. Patients in the control group received 200 mg of celecoxib, 150 mg of pregabalin, and a placebo. Oxycodone hydrochloride (10 mg) was used as the rescue analgesic. If the pain remained poorly controlled, 10 mg of morphine hydrochloride was injected subcutaneously as a secondary rescue analgesic. The primary outcome was the postoperative consumption of oxycodone and morphine as rescue analgesics. Secondary outcomes were postoperative pain assessed using the visual analogue scale (VAS), functional recovery assessed by the range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates.

RESULTS

Patients in the nefopam group had significantly lower postoperative oxycodone and morphine consumption within 24 hours after surgery and during hospitalization, lower VAS pain scores at rest and during motion within 24 h after surgery, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. However, the absolute reduction in 0 to 24 h opioid consumption, VAS pain scores, and knee range of motion did not exceed the reported minimal clinically important difference. Both groups had similar indicators of liver function and complication rates.

CONCLUSIONS

Adding oral nefopam to multimodal analgesia resulted in statistically significant improvements in opioid consumption, VAS pain scores, and functional recovery. However, the amount of improvement may not be clinically important.

Periarticular injection, iPACK block, and peripheral nerve block in pain management after total knee arthroplasty: a structured narrative review

INTRODUCTION

Total knee arthroplasty (TKA) is commonly performed in patients with end-stage osteoarthritis or rheumatoid arthritis of the knee to reduce joint pain, increase mobility, and improve quality of life. However, TKA is associated with moderate to severe postoperative pain, which remains a significant clinical challenge. Surgeon-administered PAI and anesthesiologist-administered iPACK have proven viable alternatives to conventional peripheral nerve blocks. This review aims to discuss which IPACK block or periarticular injection, combined or not with different peripheral nerve blocks, has better effects on postoperative rehabilitation, patient satisfaction, and overall outcome.

MATERIAL AND METHODS

The literature review was performed on standards of care, current therapeutic options, a pain management protocol, and innovative treatment options for patients undergoing total knee arthroplasty. The literature was reviewed through four electronic databases: PubMed, Cochrane Library, Google Scholar, and Embase.

RESULTS

The initial search yielded 694 articles. Fifty relevant articles were selected based on relevance, recentness, search quality, and citations. Six studies compared PAI to peripheral nerve block (PNB), and eight studies checked the effectiveness of adding PNB to PAI. Three studies compared iPACK to PNB, and ten reviewed the point of adding PNB to iPACK.

CONCLUSIONS

The literature review indicates that the best analgesic effect is obtained by combining PAI or iPACK with a peripheral nerve block, particularly with ACB, due to its analgesic, motor-sparing effect, and satisfactory analgesia.

Periarticular infiltration used in total joint replacements: an update and review article

Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.

Efficacy of combining intravenous and topical dexamethasone against postoperative pain and function recovery after total knee arthroplasty: A prospective, double-blind, randomized controlled trial

BACKGROUND

Dexamethasone is a corticosteroid with powerful anti-inflammatory effects. This study aimed to explore whether combining intravenous and topical dexamethasone could improve postoperative pain, swelling, and function recovery after total knee arthroplasty (TKA).

METHODS

In this prospective, double-blind, randomized controlled study, 90 patients undergoing primary unilateral TKA were randomized into a dexamethasone group, which received dexamethasone (10 mg) by periarticular infiltration during surgery, as well as intravenous dexamethasone (10 mg) before tourniquet release and at 12 h postoperatively; or a control group, which received equal volumes of isotonic saline instead of dexamethasone. The primary outcome was postoperative pain, as assessed on the visual analogue scale (VAS). Secondary outcomes were postoperative consumption of morphine hydrochloride for rescue analgesia, postoperative swelling ratio of the thigh, knee, and tibia; functional recovery in terms of total range of motion (ROM) of knee and daily ambulation distance; postoperative inflammation biomarkers levels of C-reactive protein and interleukin-6; and postoperative complications.

RESULTS

Resting VAS scores at postoperative 6, 12, and 24 h, and VAS scores during motion at postoperative 2, 6, 12, and 24 h were significantly lower in the dexamethasone group. The dexamethasone group also showed significantly less morphine consumption during the first 24 h after surgery and cumulatively during hospitalization, milder limb swelling at 24 and 48 h postoperatively, greater flexion and total ROM on postoperative day 1, and longer ambulation distance on postoperative days 1 and 2, and lower levels of inflammatory biomarkers on postoperative days 1 and 2. The dexamethasone group had significantly lower incidence of postoperative nausea and vomiting.

CONCLUSION

Compared with placebo, the combination of intravenous and topical dexamethasone can reduce pain, swelling, and inflammation after TKA, it also can improve functional recovery and reduce the incidence of postoperative nausea and vomiting.

Effects of magnesium sulfate on periarticular infiltration analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled trial

BACKGROUND

To investigate whether adding magnesium sulfate to a periarticular infiltration analgesia (PIA) cocktail could improve pain control and functional outcomes in patients undergoing total knee arthroplasty (TKA).

METHODS

Ninety patients were randomly assigned to the magnesium sulfate and control groups, with 45 patients in each group. In the magnesium sulfate group, patients were given a periarticular infusion of a cocktail of analgesics consisting of epinephrine, ropivacaine, magnesium sulfate, and dexamethasone. The control group received no magnesium sulfate. The primary outcomes consisted of visual analogue scale (VAS) pain scores, postoperative morphine hydrochloride consumption for rescue analgesia, and time to first rescue analgesia. Secondary outcomes were postoperative inflammatory biomarkers (IL-6 and CRP), postoperative length of stay, and knee functional recovery (assessed by knee range of motion, quadriceps strength, daily mobilization distance, and time to first straight-leg raising). Tertiary outcomes included the postoperative swelling ratio and complication rates.

RESULTS

Within 24 h of surgery, patients in the magnesium sulfate group had markedly lower VAS pain scores during motion and at rest. After the addition of magnesium sulfate, the analgesic effect was dramatically prolonged, leading to a reduction in morphine dosage within 24 h and the total morphine dosage postoperatively. Postoperative inflammatory biomarker levels were significantly reduced in the magnesium sulfate group compared with the control. There were no considerable differences between the groups in terms of the postoperative length of stay and knee functional recovery. Both groups had similar postoperative swelling ratios and incidences of complications.

CONCLUSIONS

The addition of magnesium sulfate to the analgesic cocktail for PIA can prolong postoperative analgesia, decrease the consumption of opioids, and effectively alleviate early postoperative pain after TKA.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2200056549. Registered on 7 February 2022, https://www.chictr.org.cn/showproj.aspx?proj=151489 .

Efficacy of a Modified Cocktail for Periarticular Local Infiltration Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial

BACKGROUND

Periarticular local infiltration analgesia (LIA) is largely utilized for controlling pain after total knee arthroplasty (TKA). The present work aimed to assess the efficacy of a modified LIA cocktail for patients undergoing TKA.

METHODS

Magnesium sulfate (MgSO4) and sodium bicarbonate (NaHCO3) were added to a conventional LIA cocktail comprising ropivacaine, epinephrine, and dexamethasone. After the safety of this modified cocktail was tested in rats, its efficacy and safety were evaluated in a prospective, double-blinded study including 100 individuals randomized to receive periarticular infiltration of the modified cocktail or a conventional cocktail. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes were the time until the first rescue analgesia, postsurgical pain (on a visual analog scale [VAS]), functional recovery (assessed by range of knee motion and ambulation distance), time to discharge, and complication rates.

RESULTS

Adding NaHCO3 to the local anesthetics caused some instantaneous precipitation in all cases. Administering the modified cocktail to rats did not obviously damage the injected area of the nerve or surrounding tissues. Administration of the modified cocktail to patients was associated with markedly reduced postsurgical morphine use in the initial 24 hours (4.2 ± 5.0 versus 14.6 ± 8.9 mg, p < 0.001), reduced total morphine use (9.8 ± 8.4 versus 19.6 ± 11.4 mg, p < 0.001), prolonged time to the first rescue analgesia, lower VAS pain scores at rest and during motion at 12 and 24 hours following the operation, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. The modified and conventional cocktail groups had similar rates of complications.

CONCLUSIONS

The present modification of a conventional cocktail significantly prolonged analgesia and reduced opioid consumption, which may substantially improve pain control in arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Effects of Adding Morphine to Periarticular Infiltration Analgesia Combined with Single Dose Epidural Morphine in Total Knee Arthroplasty: A Randomized Controlled Study

OBJECTIVE

Morphine plays an important role in postoperative analgesia after total knee arthroplasty (TKA). However, there are limited data that investigate the administration ways of morphine. To evaluate the efficacy and safety of adding morphine to periarticular infiltration analgesia (PIA) combined with single-dose epidural morphine for the patients undergoing TKA.

METHODS

In total, 120 patients with knee osteoarthritis who underwent the primary TKA from April 2021 and March 2022 were randomized into three groups (a cocktail containing morphine with single-dose epidural morphine [Group A]; a cocktail containing morphine [Group B]; and a cocktail free of morphine [Group C]). The three groups were compared based on the Visual Analog Score at rest and during motion, requirement of tramadol, functional recovery including quadriceps strength and range of motion, and adverse events including nausea and vomiting and local and systemic adverse events. The repetitive measure analysis of variance and chi-square test among three groups were used to analyze the results.

RESULTS

Analgesia strategy in Group A (0.4 ± 0.8, and 0.9 ± 1.0 points, respectively) significantly reduced rest pain at 6 and 12 h after surgery relative to Group B (1.6 ± 1.2, and 2.2 ± 1.4 points, respectively) (p < 0.001), and the analgesic effect of Group B was stronger than that of Group C (2.1 ± 0.9, and 2.6 ± 0.9 points, respectively) (p < 0.05). Rest pain at 24 h after surgery was significantly lower in Group A (2.5 ± 0.8 points) and B (1.9 ± 1.0 points) than in Group C (2.5 ± 0.8) (p < 0.05). Within 24 h after surgery, the requirements for tramadol in Group A (0.25 g) and Group B (0.35 g) were significantly lower than those in Group C (0.75 g) (p < 0.05). Within 4 days of surgery, the quadriceps strength in the three groups increased gradually, and no statistical significance was noted among the three groups (p > 0.05). From the second day to the fourth day after surgery, although the three groups showed no statistical difference in the range of motion, the result of Group C was inferior to that of the other two groups. There were no significant differences in the incidence of postoperative nausea and vomiting and metoclopramide consumption among the three groups (p > 0.05).

CONCLUSION

PIA combined with single-dose epidural morphine effectively reduces early postoperative pain and tramadol requirement as well as few complications, which can become a safe and effective measure to improve postoperative pain after TKA.

Comparison of iPACK and periarticular block with adductor block alone after total knee arthroplasty: a randomized clinical trial

PURPOSE

The infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement.

METHODS

This double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events.

RESULTS

The 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001).

CONCLUSIONS

The adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay.

The Efficacy and Safety of Glucocorticoid on Periarticular Infiltration Analgesia in Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

The objective of this systematic review and meta-analysis was to examine the effect and safety of multimodal cocktail protocols implemented with or without glucocorticoids on periarticular infiltration analgesia (PIA) in patients undergoing total knee arthroplasty (TKA).

METHODS

We comprehensively searched the PubMed, Medline, Embase, and Cochrane Library databases up to November 2020 for randomized controlled trials on glucocorticoids as a component of the cocktail protocol used in PIA for patients with TKA.

RESULTS

Our meta-analysis included 11 randomized controlled trial studies with 1051 primary TKAs (930 patients). Visual analog scale scores at postoperative day (POD) 1 and POD 2 in the glucocorticoid groups were significantly lower than those in the control group (95% CI [-1.01--0.10], P = .02; 95% CI [-0.51--0.13], P = .001). Furthermore, the glucocorticoid group was associated with a statistically significant improvement in the range of motion at POD 1 (95% CI [3.20-8.05] P < .00001), reduction in total morphine consumption at 24 hours, and lower levels of C-reactive protein on POD 2/3 compared with the control group. However, neither the length of hospital stays nor the long-term Knee Society Knee Score showed any differences between the two groups. In addition, the results of subgroup analyses favored triamcinolone acetonide over betamethasone, methylprednisolone, and dexamethasone regarding the postoperative visual analog scale scores and range of motion.

CONCLUSION

Glucocorticoid supplementation in PIA is effective and does not increase complications or side effects for patients with either unilateral or bilateral TKA. Moreover, triamcinolone acetonide could be recommended in multimodal cocktail protocols for glucocorticoid supplementation.