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Likar R, Poglitsch R, Bejvančický Š, Carl L, Ferencik M, Klein-Watrycz A, Rieger M, Flores KS, Schumich A, Vlamaki Z, Werner M. The Use of High-Dose Intravenous L-Ascorbate in Pain Therapy: Current Evidence from the Literature. Pain Ther 2024; 13:767-790. [PMID: 38864974 PMCID: PMC11255149 DOI: 10.1007/s40122-024-00622-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/24/2024] [Indexed: 06/13/2024] Open
Abstract
INTRODUCTION Pain is the most common reason for seeking medical treatment. Despite extensive research efforts and effective analgesics modulating pain, there is still a major therapeutic gap in addressing the root causes of pain. Pain is associated with tissue damage induced by oxidative stress and induction of inflammatory mediators following high consumption of antioxidants. The role of antioxidants in general, and the administration of L-ascorbate in particular, is still controversially discussed and underestimated in the daily clinical practice. METHODS The current literature on the therapeutic effect of L-ascorbate, ascorbic acid, and vitamin C on various pain conditions was evaluated against the background of evidence-based medicine. Those articles, obtained from systematic search in PubMed, were critically assessed and rated in terms of evidence level and methodological quality by two independent experts. The primary purpose of this work was to establish specific pain therapy guidance for intravenous L-ascorbate. RESULTS A PubMed search revealed 14 suitable articles comprising controlled clinical trials and meta-analyses. An additional ten publications could be identified via secondary literature. There is supporting evidence for the efficacy of ascorbate treatment in inflammatory pain conditions, in the complex regional pain syndrome, in post zoster neuralgia, in neuropathic pain, in post-operative pain conditions, and in tumor-related pain. However, the considered studies differ in the type of administration, in dosage, in duration of treatment, as well as in quality of research. Despite all study heterogeneity, it became evident that research of high scientific quality is in support of the efficacy of L-ascorbate in pain treatment. DISCUSSION Oxidative stress is present in almost all pain conditions. Because oral administration of most magistral formulas of vitamin C does not provide biological availability, parenteral administration should be preferred and can be supported by an oral dose with high bioavailability on days without intravenous treatment. L-ascorbate should be preferred for parenteral high dosage, rather than ascorbic acid, as it does not release acid valences under physiological conditions. CONCLUSIONS L-ascorbate is an effective, safe, and economically favorable integrative treatment option for various pain conditions, addressing the root cause of tissue damage and inflammatory mediator burst.
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Affiliation(s)
- Rudolf Likar
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Klagenfurt Am Wörthersee, Chair of Palliative Medicine SFU Vienna, Klagenfurt am Wörthersee, Austria.
| | - Ruth Poglitsch
- Medical Institute Dr. Poglitsch, Pain Medicine, Graz, Austria
| | - Štěpán Bejvančický
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Pilsen, Pilsen, Czech Republic
| | - Ludwig Carl
- Department of Anesthesiology and Intensive Care Medicine, Klinikum Mutterhaus Trier, Johannes Gutenberg University, Mainz, Germany
| | - Miroslav Ferencik
- Department of Algesiology SZU, F. D. Roosevelt University Hospital, Banska Bystrica, Slovakia
| | - Alfred Klein-Watrycz
- Institute of Physical Medicine and Rehabilitation, Hospital Mistelbach, Mistelbach, Austria
| | - Monika Rieger
- Pain Therapy Practice Rieger, Bingen am Rhein, Germany
| | | | - Astrid Schumich
- Private Practice for General Medicine, Orthopaedics, Orthopaedic Surgery and Functional Myodiagnostics, Vienna, Austria
| | - Zoe Vlamaki
- General Surgery and Breast Oncoplastic Surgery, NMC Royal Hospital, Khalifa City, Abu Dhabi, United Arab Emirates
| | - Marc Werner
- Clinic for Naturopathy and Integrative Medicine, Evangelische Kliniken Essen-Mitte GmbH, Essen, Germany
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Iolascon G, Snichelotto F, Moretti A. An update on the pharmacotherapeutic options for complex regional pain syndrome. Expert Rev Neurother 2024; 24:177-190. [PMID: 38241139 DOI: 10.1080/14737175.2024.2307490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/16/2024] [Indexed: 01/21/2024]
Abstract
INTRODUCTION Complex regional pain syndrome (CRPS) is a rare and painful condition that has a wide range of triggering factors, often traumatic, and can present various clinical manifestations. The lack of knowledge about the underlying mechanisms has led to numerous treatment approaches, both conservative and surgical, which work through different mechanisms of action. AREAS COVERED In this review, the authors explore the key aspects of CRPS, including definition, diagnostic criteria, pitfalls, pathogenic hypotheses, and treatment strategies with a focus on pharmacotherapy. The review was based on a comprehensive search of the literature using PubMed, while also considering international guidelines for managing CRPS. EXPERT OPINION Based on the available evidence, pharmacological interventions appear to be effective in treating CRPS, especially when they target peripheral mechanisms, specifically nociceptive inflammatory pain, and when administered early in the course of the disease. However, there is still a lack of reliable evidence regarding the effects of drugs on central mechanisms of chronic pain in CRPS. In our expert opinion, drug therapy should be initiated as soon as possible, particularly in warm CRPS patient clusters, to prevent significant functional limitations, psychological distress, and negative impacts on individuals' social and economic well-being.
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Affiliation(s)
- Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Snichelotto
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania "Luigi Vanvitelli", Naples, Italy
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Bruehl S, Milne G, Polkowski G, Shinar A, Anderson S, Mishra P, Larach DB, Martin R, Billings FT. Oxidative stress mediates associations between preoperative psychosocial phenotype and pain-related outcomes at 6 months following total knee arthroplasty: a longitudinal cohort study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:71-77. [PMID: 37651583 PMCID: PMC10765146 DOI: 10.1093/pm/pnad120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/13/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE Greater preoperative depression, anxiety, and pain catastrophizing are associated with more severe long-term pain following total knee arthroplasty (TKA). In a secondary analysis of previously reported data, we tested the hypothesis that these associations are mediated by oxidative stress (OS). DESIGN A mixed between/within-subjects longitudinal cohort design. SETTING A single academic medical center. SUBJECTS Osteoarthritis patients (n = 91; 62.6% female) undergoing unilateral TKA. METHODS We assessed depression, anxiety, and catastrophizing, as well as markers of central sensitization (widespread pain, temporal summation of pain) preoperatively. Blood samples were then obtained immediately prior to intraoperative tourniquet placement for quantification of in vivo biomarkers of systemic OS, F2-isoprostanes and isofurans. Post-TKA pain intensity (numeric rating scale worst pain [NRS], McGill Pain Questionnaire-2 [MPQ-2]) and function (PROMIS Pain Interference) were assessed at 6 months following TKA. RESULTS Greater preoperative depression, catastrophizing, and widespread pain were associated with higher intraoperative combined OS (F2-isoprostanes+isofurans/2), which was in turn associated with higher post-TKA pain intensity and worse function (P < .05). All preoperative phenotype predictors except anxiety were correlated positively with post-TKA pain and/or function (P < .05). Bootstrapped mediation analyses revealed significant (P < .05) indirect (mediated) effects of depression (NRS Worst Pain, MPQ-2, PROMIS Pain Interference), anxiety (MPQ-2, PROMIS Pain Interference), and catastrophizing (PROMIS Pain Interference) on adverse long-term post-TKA outcomes via elevated OS. Central sensitization-related predictors demonstrated only direct effects (P < .05) on post-TKA outcomes that were independent of OS mechanisms. CONCLUSIONS Results suggest that the adverse impact of depression, anxiety, and pain catastrophizing on post-TKA pain and functional outcomes are mediated in part by elevated OS.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Daniel B Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
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Frediani JK, Lal AA, Kim E, Leslie SL, Boorman DW, Singh V. The role of diet and non-pharmacologic supplements in the treatment of chronic neuropathic pain: A systematic review. Pain Pract 2024; 24:186-210. [PMID: 37654090 DOI: 10.1111/papr.13291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/01/2023] [Accepted: 08/04/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND/IMPORTANCE Dietary interventions, vitamins, and nutritional supplementation are playing an increasingly important role in the management of neuropathic pain. Current pharmacological treatments are poorly tolerated and ineffective in many cases. OBJECTIVE This systematic review aims to study the efficacy of dietary interventions, vitamins, and nutritional supplementation in the management of chronic neuropathic pain in adults. EVIDENCE REVIEW The review followed PRISMA guidelines and was registered with PROSPERO (#CRD42022300312). Ten databases and gray literature, including Embase.com, MEDLINE and Web of Science, were systematically searched using a combination of keywords and controlled vocabulary related to chronic neuropathic pain and oral non-pharmacological supplements. Studies on adult humans published between 2000 and 2021 were considered for inclusion. The Cochrane Handbook was used to assess risk of bias, and Grading of Recommendations Assessment, Development, and Evaluation was used to determine overall quality of evidence. FINDINGS Forty studies were included in the final review, and results were categorized according to pain type including pain related to chemotherapy-induced peripheral neuropathy (CIPN, 22 studies, including 3 prospective cohorts), diabetic peripheral neuropathy (DPN, 13 studies, including 2 prospective), complex regional pain syndrome (CRPS-I, 3 studies, including 1 prospective), and other (2 studies, both RCT). The CIPN studies used various interventions including goshajinkigan (4 studies), vitamin E (5), vitamin B12 (3), glutamine (3), N-acetyl-cysteine (2), acetyl-l-carnitine (2), guilongtonluofang (1), ninjin'yoeito (1), alpha-lipoic acid (1), l-carnosine (1), magnesium and calcium (1), crocin (1), and antioxidants (1), with some studies involving multiple interventions. All CIPN studies involved varying cancers and/or chemotherapies, advising caution for generalizability of results. Interventions for DPN included alpha-lipoic acid (5 studies), vitamin B12 (3), acetyl-l-carnitine (3), vitamin E (1), vitamin D (2), and a low-fat plant-based diet (1). Vitamin C was studied to treat CRPS-I (3 studies, including 1 prospective). Magnesium (1) and St. John's wort (1) were studied for other or mixed neuropathologies. CONCLUSIONS Based on the review, we cannot recommend any supplement use for the management of CIPN, although further research into N-acetyl-cysteine, l-carnosine, crocin, and magnesium is warranted. Acetyl-l-carnitine was found to be likely ineffective or harmful. Alpha-lipoic acid was not found effective. Studies with goshajinkigan, vitamin B12, vitamin E, and glutamine had conflicting results regarding efficacy, with one goshajinkigan study finding it harmful. Guilongtonluofang, ninjin'yoeito, and antioxidants showed various degrees of potential effectiveness. Regarding DPN, our review supports the use of alpha-lipoic acid, acetyl-l-carnitine, and vitamin D. The early use of vitamin C prophylaxis for the development of CRPS-I also seems promising. Further research is warranted to confirm these findings.
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Affiliation(s)
- Jennifer K Frediani
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Asim A Lal
- Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Esther Kim
- Philadelphia College of Osteopathic Medicine, Suwanee, Georgia, USA
| | - Sharon L Leslie
- Woodruff Health Sciences Center Library, Emory University, Atlanta, Georgia, USA
| | - David W Boorman
- Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Vinita Singh
- Department of Anesthesiology, Emory School of Medicine, Atlanta, Georgia, USA
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Daoust R, Paquet J, Chauny JM, Williamson D, Huard V, Arbour C, Emond M, Rouleau D, Cournoyer A. Impact of vitamin C on the reduction of opioid consumption after an emergency department visit for acute musculoskeletal pain: a double-blind randomised control trial protocol. BMJ Open 2023; 13:e069230. [PMID: 37225265 PMCID: PMC10230879 DOI: 10.1136/bmjopen-2022-069230] [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: 10/14/2022] [Accepted: 04/28/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Recent evidence has shown that vitamin C has some analgesic properties in addition to its antioxidant effect and can, therefore, reduce opioid use during recovery time. Vitamin C analgesic effect has been explored mostly during short-term postoperative context or in disease-specific chronic pain prevention, but never after acute musculoskeletal injuries, which are often seen in the emergency department (ED). The protocol's primary aim is to compare the total morphine 5 mg pills consumed during a 2-week follow-up between patients receiving vitamin C or a placebo after ED discharge for an acute musculoskeletal pain complaint. METHODS AND ANALYSIS We will conduct a two-centre double-blind randomised placebo-controlled trial with 464 participants distributed in two arms, one group receiving 1000 mg of vitamin C two times a day for 14 days and another one receiving a placebo. Participants will be ≥18 years of age, treated in ED for acute musculoskeletal pain present for less than 2 weeks and discharged with an opioid prescription for home pain management. Total morphine 5 mg pills consumed during the 2-week follow-up will be assessed via an electronic (or paper) diary. In addition, patients will report their daily pain intensity, pain relief, side effects and other types of pain medication or other non-pharmacological approach used. Three months after the injury, participants will also be contacted to evaluate chronic pain development. We hypothesised that vitamin C, compared with a placebo, will reduce opioid consumption during a 14-day follow-up for ED discharged patients treated for acute musculoskeletal pain. ETHICS AND DISSEMINATION This study has received approval from the Ethics Review Committee from the 'Comité d'éthique de la recherche du CIUSSS du Nord-de-l'Île-de-Montréal (No 2023-2442)'. Findings will be disseminated through scientific conferences and peer-reviewed journal publication. The data sets generated during the study will be available from the corresponding author on reasonable request. TRIAL REGISTRATION NUMBER NCT05555576 ClinicalTrials.Gov PRS.
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Affiliation(s)
- Raoul Daoust
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Jean Paquet
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - Jean-Marc Chauny
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
| | - David Williamson
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté de Pharmacie, Université de Montréal, Montreal, Quebec, Canada
| | - Vérilibe Huard
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Caroline Arbour
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
- Faculté des sciences infirmières, Université de Montréal, Montréal, Québec, Canada
| | - Marcel Emond
- Department of Family and Emergency Medicine, Universite Laval, Quebec, Quebec, Canada
| | - Dominique Rouleau
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
| | - Alexis Cournoyer
- Département de Médecine Familiale et de Médecine d'Urgence, Université de Montréal, Montreal, Quebec, Canada
- Study Center in Emergency Medicine, Hopital du Sacre-Coeur de Montreal Centre de Recherche, Montreal, Quebec, Canada
- Centre de Recherche, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
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Bruehl S, Milne G, Schildcrout J, Shi Y, Anderson S, Shinar A, Polkowski G, Mishra P, Billings FT. Perioperative oxidative stress predicts subsequent pain-related outcomes in the 6 months after total knee arthroplasty. Pain 2023; 164:111-118. [PMID: 35507374 PMCID: PMC9633585 DOI: 10.1097/j.pain.0000000000002670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/25/2022] [Indexed: 01/09/2023]
Abstract
ABSTRACT Total knee arthroplasty (TKA) is effective for pain reduction in most patients, but 15% or more report unsatisfactory long-term pain outcomes. We tested whether oxidative stress (OS) related to extended tourniquet application during TKA and subsequent ischemic reperfusion (IR) contributed to adverse post-TKA pain outcomes. Blood samples were obtained in 91 patients with osteoarthritis (63% female) undergoing TKA before tourniquet placement (T1), 45 minutes after tourniquet inflation (T2), and 15 minutes after tourniquet removal (T3). Plasma levels of F 2 -isoprostanes and isofurans, the most specific measures of in vivo OS, were quantified. Pain intensity and function were assessed at baseline and again at 6 weeks and 6 months after TKA. Results indicated that higher Combined OS (F 2 -isoprostanes + isofurans/2) at T1 baseline and larger increases in Combined OS from T1 to T2 were associated with higher baseline-corrected past 24-hour worst and average pain intensity (numeric rating scale) and higher past week McGill Pain Questionnaire-2 total scores at 6-month follow-up ( P 's < 0.05). Increases in Combined OS from T1 to T3, which should most directly capture OS and IR injury related to tourniquet use, were not associated with short-term or long-term post-TKA pain outcomes. Longer ischemia duration was unexpectedly associated with lower baseline-corrected pain intensity at 6-month follow-up. Combined OS was not linked to functional outcomes at either follow-up. Elevated perioperative OS seems to exert small but significant adverse effects on long-term post-TKA pain outcomes, although this OS seems unrelated to IR injury associated with extended tourniquet use.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T. Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Same-day bilateral total knee replacement versus unilateral total knee replacement: A comparative study. Orthop Traumatol Surg Res 2022; 108:103301. [PMID: 35508293 DOI: 10.1016/j.otsr.2022.103301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 05/22/2021] [Accepted: 06/02/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Bilateral total knee arthroplasty (TKA) in a single session is rarely done in France, mainly due to the increased risk of perioperative and late complications. The primary objective of this study was to compare the complication rates of same-day bilateral TKA (TKA bilat) with that of unilateral TKA (TKA unilat). The hypothesis was bilateral TKA increases the rate of early and late complications in a group of selected patients (ASA 1 or 2, less than 80 years of age). MATERIAL AND METHODS Retrospective comparative study of 91 bilat TKA and 182 unilat TKA cases operated on between 2009 and 2016 (1 bilat TKA paired with 2 controls). The patients were matched based on age, sex, indication and ASA score. The minimum follow-up was 2 years. Mortality along with early and late complications were documented. The secondary endpoints were implant survival, functional outcomes, and patient satisfaction. RESULTS The early mortality rate was zero in both groups. The early complication rate was lower in the bilat TKA group (9%) than in the unilat TKA group (22%) (p<0.001). The late complications did not differ between groups. Implant survival at 5 years was 99% (95% CI=[95.6-99.7]) in the bilat TKA group and 97% (95% CI=[92.8-98.8]) in the unilat TKA group. The autologous blood transfusion rate was 33% in the bilat TKA group and 2.2% in the unilat TKA group (p<0.001). There was no difference between groups in the satisfaction rate or the KOOS and New IKS scores. A larger share of patients in the unilat TKA group (54%) said they had forgotten about their knee than in the bilat TKA group (43%) (p=0.036). DISCUSSION There were few early complications in the bilat TKA group. There was no significant difference in the number of late complications, survival, functional scores, or patient satisfaction between the two groups. The transfusion rate was higher in the bilat TKA group, while the forgotten knee rate was higher in the unilat TKA group. CONCLUSION Our hypothesis was not confirmed: in the context of this study, in patients who are ASA 1 or 2, and less than 80 years old, same-day bilateral TKA does not increase the complication rate relative to unilateral TKA. LEVEL OF EVIDENCE III, comparative study of continuous paired cases.
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Bruehl S, Billings FT, Anderson S, Polkowski G, Shinar A, Schildcrout J, Shi Y, Milne G, Dematteo A, Mishra P, Harden RN. Preoperative Predictors of Complex Regional Pain Syndrome Outcomes in the 6 Months Following Total Knee Arthroplasty. THE JOURNAL OF PAIN 2022; 23:1712-1723. [PMID: 35470089 PMCID: PMC9560974 DOI: 10.1016/j.jpain.2022.04.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
Abstract
This prospective observational study evaluated preoperative predictors of complex regional pain syndrome (CRPS) outcomes in the 6 months following total knee arthroplasty (TKA). Participants were n = 110 osteoarthritis patients (64.5% female) undergoing unilateral TKA with no prior CRPS history. Domains of negative affect (depression, anxiety, catastrophizing), pain (intensity, widespread pain, temporal summation of pain [TSP]), pain interference, sleep disturbance, and pro-inflammatory status (tumor necrosis factor-alpha [TNF-a]) were assessed preoperatively. CRPS outcomes at 6-week and 6-month follow-up included the continuous CRPS Severity Score (CSS) and dichotomous CRPS diagnoses (2012 IASP criteria). At 6 months, 12.7% of participants met CRPS criteria, exhibiting a "warm CRPS" phenotype. Six-week CSS scores were predicted by greater preoperative depression, anxiety, catastrophizing, TSP, pain intensity, sleep disturbance, and TNF-a (P's < .05). Provisional CRPS diagnosis at 6 weeks was predicted by higher preoperative TSP, sleep disturbance, and TNF-a (P's < .05). CSS scores at 6 months were predicted by more widespread and intense preoperative pain, and higher preoperative TSP, pain interference, and TNF-a (P's < .01). CRPS diagnosis at 6 months was predicted only by more widespread and intense pain preoperatively (P's < .05). Risk for CRPS following TKA appears to involve preoperative central sensitization and inflammatory mechanisms. Preoperative negative affect is unlikely to directly influence long-term CRPS risk. PERSPECTIVE: This article identifies preoperative predictors of CRPS features at 6 months following total knee arthroplasty, including more widespread pain and higher pain intensity, temporal summation of pain, pain interference, and tumor necrosis factor-alpha levels. Findings suggest the importance of central sensitization and inflammatory mechanisms in CRPS risk following tissue trauma.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony Dematteo
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - R Norman Harden
- Departments of Physical Medicine and Rehabilitation and Physical Therapy and Human Movement Science, Northwestern University, Chicago, Illinois
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Wang Y, Jiang M, Dai X, Zhang Q. Determinants of Complex Regional Pain Syndrome Type I among Radial Head Fracture Patients with Unilateral Arthroplasty. Orthop Surg 2022; 14:1395-1403. [PMID: 35673902 PMCID: PMC9251304 DOI: 10.1111/os.13320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 05/07/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE This study aims to assess the proportions of complex regional pain syndrome type I (CRPS I) in radial head fracture patients undergoing unilateral arthroplasty and to explore associated factors. METHODS This is a prospective observational study. From March 2016 to May 2019, a total of 221 adult patients with radial head fracture patients were included in consecutive studies and completed the 1-year follow-up. All patients were treated by unilateral arthroplasty. At each follow-up visit, the visual analogue scale was used to measure patients' pain level. Occurrence of CRPS I, which was diagnosed by Budapest criteria, was the main outcome collected at baseline and the 1-, 3-, 6-, and 9-month follow-ups. The baseline data were collected before surgery and included demographic and clinical data. Independent t-tests and χ2 tests were used as univariate analyses to compare the baseline data of patients with and without CRPS I. Multivariate analysis (Backword-Wald) was used to identify factors independently associated with CRPS I. RESULTS The proportion of CRPS I cases among radial head fracture patients undergoing unilateral arthroplasty was 11% (n = 24). A total of 19 (79%) patients were diagnosed with CRPS I within 1 month after surgery. Multivariable logistic regression analysis revealed that female gender (odds ratios [OR]: 1.537; 95% confidence interval [CI]: 1.138-2.072), age younger than 60 years (OR: 1.682; 95% CI: 1.246-2.267), moderate and severe Mayo Elbow Performance Score (MEPS) pain (OR: 3.229; 95% CI: 2.392-4.351) and anxiety (OR: 83.346; 95% CI: 61.752-112.320) were independently associated with CRPS I. CONCLUSIONS This exploratory study reported that the incidence of CRPS I developing after radial head arthroplasty was 11%. Female sex, younger age, moderate and severe MEPS pain and anxiety patients seems more likely to develop CRPS I.
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Affiliation(s)
- Ye Wang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Menglu Jiang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China.,Soochow University, Soochow, China
| | - Xu Dai
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
| | - Qin Zhang
- Department of Anesthesiology, Wuxi No. 9 People's Hospital Affiliated to Soochow University, Wuxi, China
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10
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Bruehl S, Milne G, Schildcrout J, Shi Y, Anderson S, Shinar A, Polkowski G, Mishra P, Billings FT. Oxidative stress is associated with characteristic features of the dysfunctional chronic pain phenotype. Pain 2022; 163:786-794. [PMID: 34382610 PMCID: PMC8807797 DOI: 10.1097/j.pain.0000000000002429] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/26/2021] [Indexed: 11/25/2022]
Abstract
ABSTRACT The dysfunctional chronic pain (Dysfunctional CP) phenotype is an empirically identifiable CP subtype with unclear pathophysiological mechanisms that cuts across specific medical CP diagnoses. This study tested whether the multidimensional pain and psychosocial features that characterize the dysfunctional CP phenotype are associated broadly with elevated oxidative stress (OS). Measures of pain intensity, bodily extent of pain, catastrophizing cognitions, depression, anxiety, sleep disturbance, pain interference, and function were completed by 84 patients with chronic osteoarthritis before undergoing total knee arthroplasty. Blood samples were obtained at the initiation of surgery before incision or tourniquet placement. Plasma levels of F2-isoprostanes and isofurans, the most highly specific measures of in vivo OS, were quantified using gas chromatography/negative ion chemical ionization mass spectrometry. The results indicated that controlling for differences in age, sex, and body mass index, higher overall OS (mean of isoprostanes and isofurans) was associated with significantly (P < 0.05) greater pain intensity, more widespread pain, greater depressive symptoms and pain catastrophizing, higher pain interference, and lower function. OS measures were not significantly associated with sleep disturbance or anxiety levels (P >0.10). The results build on prior case-control findings suggesting that presence of a CP diagnosis is associated with elevated OS, highlighting that it may specifically be individuals displaying characteristics of the dysfunctional CP phenotype who are characterized by elevated OS. Clinical implications of these findings remain to be determined.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T. Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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11
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Takada S, Setoyama K, Norimatsu K, Otsuka S, Nakanishi K, Tani A, Nakakogawa T, Matsuzaki R, Matsuoka T, Sakakima H, Tancharoen S, Maruyama I, Tanaka E, Kikuchi K, Uchikado H. E8002 Reduces Adhesion Formation and Improves Joint Mobility in a Rat Model of Knee Arthrofibrosis. Int J Mol Sci 2022; 23:ijms23031239. [PMID: 35163163 PMCID: PMC8835358 DOI: 10.3390/ijms23031239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/26/2022] Open
Abstract
Knee arthrofibrosis is a common complication of knee surgery, caused by excessive scar tissue, which results in functional disability. However, no curative treatment has been established. E8002 is an anti-adhesion material that contains L-ascorbic acid, an antioxidant. We aimed to evaluate the efficacy of E8002 for the prevention of knee arthrofibrosis in a rat model, comprising injury to the surface of the femur and quadriceps muscle 1 cm proximal to the patella. Sixteen male, 8-week-old Sprague Dawley rats were studied: in the Adhesion group, haemorrhagic injury was induced to the quadriceps and bone, and in the E8002 group, an adhesion-preventing film was implanted between the quadriceps and femur after injury. Six weeks following injury, the restriction of knee flexion owing to fibrotic scarring had not worsened in the E8002 group but had worsened in the Adhesion group. The area of fibrotic scarring was smaller in the E8002 group than in the Adhesion group (p < 0.05). In addition, the numbers of fibroblasts (p < 0.05) and myofibroblasts (p < 0.01) in the fibrotic scar were lower in the E8002 group. Thus, E8002 reduces myofibroblast proliferation and fibrotic scar formation and improves the range of motion of the joint in a model of knee injury.
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Affiliation(s)
- Seiya Takada
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
| | - Kentaro Setoyama
- Division of Laboratory Animal Science, Natural Science Center for Research and Education, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan;
| | - Kosuke Norimatsu
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Shotaro Otsuka
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
| | - Kazuki Nakanishi
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Akira Tani
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Tomomi Nakakogawa
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Ryoma Matsuzaki
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Teruki Matsuoka
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Harutoshi Sakakima
- Course of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544, Japan; (K.N.); (K.N.); (A.T.); (T.N.); (R.M.); (T.M.); (H.S.)
| | - Salunya Tancharoen
- Department of Pharmacology, Faculty of Dentistry, Mahidol University, Bangkok 10400, Thailand;
| | - Ikuro Maruyama
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
| | - Eiichiro Tanaka
- Division of Brain Science, Department of Physiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan;
| | - Kiyoshi Kikuchi
- Department of Systems Biology in Thromboregulation, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan; (S.T.); (S.O.); (I.M.)
- Division of Brain Science, Department of Physiology, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan;
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
- Correspondence: (K.K.); (H.U.); Tel.: +81-942-31-7542 (K.K.); +81-92-477-2355 (H.U.); Fax: +81-942-31-7695 (K.K.); +81-92-477-2325 (H.U.)
| | - Hisaaki Uchikado
- Department of Neurosurgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka 830-0011, Japan
- Uchikado Neuro-Spine Clinic, 1-2-3 Naka, Hakata-ku, Fukuoka 812-0893, Japan
- Correspondence: (K.K.); (H.U.); Tel.: +81-942-31-7542 (K.K.); +81-92-477-2355 (H.U.); Fax: +81-942-31-7695 (K.K.); +81-92-477-2325 (H.U.)
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