Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center

Incidence of Venous Thromboembolism after Primary Total Hip Arthroplasty with Mechanical Prophylaxis in Hong Kong Chinese

Purpose

The incidence of deep vein thrombosis (DVT) following total hip arthroplasty (THA) without chemoprophylaxis could be as high as 50% in Caucasians. However, according to several subsequent studies, the incidence of venous thromboembolic events (VTE) in Asians was much lower. The routine use of chemoprophylaxis, which could potentially cause increased bleeding, infection, and wound complications, has been questioned in low-incidence populations. The objective of this study is to determine the incidence of VTE after primary THA without chemoprophylaxis in an Asian population using a fast-track rehabilitation protocol and to verify the safety profile for use of 'mechanical prophylaxis alone' in patients with standard risk of VTE.

Materials and Methods

This is a retrospective cohort study of 542 Hong Kong Chinese patients who underwent primary THA without chemoprophylaxis. All patients received intermittent pneumatic compression and graduated compression stockings as mechanical prophylaxis. Multimodal pain management was applied in order to facilitate early mobilisation. Routine duplex ultrasonography was performed between the fourth and seventh postoperative day for detection of proximal DVT.

Results

All patients were Chinese (mean age, 63.0±11.9 years). Six patients developed proximal DVT (incidence rate, 1.1%). None of the patients had symptomatic or fatal pulmonary embolism.

Conclusion

The incidence of VTE after primary THA without chemical prophylaxis can be low in Asian populations when following a fast-track rehabilitation protocol. Mechanical prophylaxis alone can be regarded as a reasonably safe practice in terms of a balanced benefit-to-risk ratio for Asian patients with standard risk of VTE.

The AAHKS Clinical Research Award: Extended Postoperative Oral Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Pilot Study

BACKGROUND

Perioperative tranexamic acid (TXA) use with total knee arthroplasty (TKA) is widely accepted today. Recently, a few international groups have published on the safety and outcomes of extending TXA use in the postoperative period. Through a double-blinded, randomized control trial (RCT), we aimed to investigate the safety and clinical efficacy of extended postoperative oral TXA use in TKA performed in an American, free-standing ambulatory surgery center (ASC).

METHODS

Based on a power analysis, 40 patients undergoing primary TKA were randomized into 2 groups: extended oral TXA versus placebo. Both groups received a standard 1g intravenous TXA dose prior to incision and at the time of closure. The extended TXA group received an additional 1.95 g oral TXA dose following ambulation the day of surgery, plus on postoperative days 1,2, and 3. Patients who had a history of venous thromboembolism (VTE) or cancer were excluded. All patients received 81 mg of aspirin twice daily for VTE prophylaxis. Patients were followed on postoperative day 3 and weeks 2 and 6. Paired t-tests determined statistical significance.

RESULTS

Extended TXA patients showed significantly increased knee flexion at 6 weeks (116.05 versus 106.5, P = .0308), improved VAS at 2 (2.5 versus 3.85, P = .039) and 6 weeks (1.35 versus 2.8, P = .011), and superior KOOS JR at 2 (66.87 versus 60.63, P = .03) and 6 weeks (73.33 versus 62.47, P = .0019) compared to placebo patients. No significant differences were found for changes in hemoglobin levels at any time points. No significant differences were found at 12 weeks for any clinical endpoints. No adverse events were noted in either cohort.

CONCLUSIONS

When compared to placebo, the extended use of oral TXA in the postoperative period may safely result in improved motion, pain, and functional scores. Further investigation into 1-to-2-year outcomes, as well as the duration and dose of postoperative TXA use is warranted.

Associations of parecoxib and other variables with recovery and safety outcomes in total knee arthroplasty: insights from a retrospective cohort study

Background

Early mobilization post-total knee arthroplasty (TKA) significantly affects patient outcomes. While parecoxib is known to reduce postoperative pain and morphine use with a favorable safety profile, its impact on mobilization timing post-TKA remains uncertain. This retrospective study aims to assess parecoxib's influence on postoperative mobilization timing in TKA patients without compromising safety.

Methods

This study included unilateral TKA patients treated for primary knee osteoarthritis under general anesthesia. We divided the study period into two intervals, 2007-2012 and 2013-2018, to evaluate temporal differences. Both the control group and parecoxib group received standard postoperative oral analgesics and as-needed intramuscular morphine. The control group did not receive parecoxib, while the parecoxib group did. Primary outcomes compared postoperative complications and mobilization timing between groups, with secondary outcomes including length of hospital stay (LOS), Visual Analog Scale (VAS) scores for pain, as-needed morphine use, and postoperative nausea/vomiting.

Results

Parecoxib did not increase postoperative complications. Unmatched comparison with patients in controlled group found that patients in parecoxib group had significantly shortened mobilization time (2.2 ± 1.1 vs. 2.7 ± 1.6 days, P < 0.001) and LOS (6.7 ± 2.5 vs. 7.2 ± 2.1 days, P = 0.01). Multivariate analysis linked parecoxib use with faster mobilization (β = -0.365, P < 0.001) but not LOS. Males showed increased mobilization time and LOS compared to females during the period of 2007-2018, but gender had no significant association with LOS during the period of 2013-2018. The 2013-2018 period saw significant reductions in both mobilization time and LOS. Use of a tourniquet and local infiltration analgesia showed no significant impact. ASA classification 1-2 was positively associated with faster mobilization but not LOS. Longer operation times were linked to delayed mobilization and increased LOS.

Conclusion

In this study, intravenous parecoxib injection, female gender, and shorter OP time had consistent positive association with shorter time to mobilization after individual multivariate analysis in 2 different period. The use of parecoxib had consistent no significant association with LOS. Only shorter OP time was consistent positive associated with shorter LOS.

Efficacy of Intraoperative Periarticular Local Infiltration for Pain Control and Ambulation in Total Knee Arthroplasty: A Randomized Case-Control Study

INTRODUCTION

Total knee arthroplasty (TKA) is a leading operative procedure for late-stage knee osteoarthritis. The cornerstone of a successful TKA is swift and effective rehabilitation to achieve a pain-free and good range of motion. Pain post-replacement hinders an effective rehabilitation protocol. Reported preoperative, perioperative, and postoperative analgesia modes have undesirable side effects. The purpose of this study is to assess the effect of a unique cocktail injection on immediate postoperative pain using the visual analog score, the need for additional analgesics during the initial period, and the ambulation time between the case and control groups.

MATERIALS AND METHODS

In this randomized case-control study, the periarticular injection consisted of ropivacaine 0.75 mg/ml (28 ml), epinephrine 1 mg/ml (0.5 ml), and ketorolac 30 mg/ml (1 ml) added to 50 ml of normal saline to make 80 ml of solution. Fifty patients were chosen and randomly divided into two groups of 25 each by computer-generated randomization. The case group received the cocktail injection, and the control group was injected locally with normal saline. Visual analog scale (VAS) was assessed at 3, 6, 12, and 24 hr post-surgery, and the amount of additional analgesics used and ambulation time were assessed.

RESULTS

A total of 50 patients who underwent TKA were selected and divided into case and control groups of 25 each. The majority of the patients had osteoarthritis, and a few had rheumatoid arthritis. No significant differences in demographic data (age, gender, body-mass index) or surgical time. The case group had excellent VAS scores between 0 and 3 at 3, 6, 12, and 24 hr (p < .001). The amount of additional analgesia required in the case group was minimal (<3 doses) in 96% of the patients on Day 1. More than 80% of patients could ambulate pain-free on Day 1.

CONCLUSION

Pain reduction with early ambulation was noted in a significant number of individuals with the use of this unique intraoperative local cocktail injection. This pain-free initial period following TKA prepared patients for an effective rehabilitation program.

Novel Techniques for Musculoskeletal Pain Management after Orthopedic Surgical Procedures: A Systematic Review

Effective postoperative pain management is critical for recovery after orthopedic surgery, but often remains inadequate despite multimodal analgesia. This systematic review synthesizes evidence on innovative modalities for enhancing pain control following major orthopedic procedures. Fifteen randomized controlled trials and comparative studies evaluating peripheral nerve blocks, local anesthetic infiltration, cryotherapy, transcutaneous electrical stimulation, adjunct medications, and other techniques are included. Thematic analysis reveals that peripheral nerve blocks and local anesthetic infiltration consistently demonstrate reduced pain scores, opioid consumption, and side effects versus conventional analgesia alone. Oral multimodal medications also show promise as part of opioid-sparing regimens. Adjunctive approaches like cryotherapy, music, and dexmedetomidine require further research to optimize protocols. Despite promising innovations, critical knowledge gaps persist regarding comparative effectiveness, optimal interventions and dosing, combination strategies, cost-effectiveness, and implementation. High-quality randomized controlled trials using standardized protocols are essential to guide the translation of enhanced multimodal regimens into clinical practice. This review provides a framework for pursuing research priorities and advancing evidence-based postoperative pain management across orthopedic surgeries.

Arthrofibrosis After Total Knee Arthroplasty: A Critical Analysis Review

» Arthrofibrosis after total knee arthroplasty (TKA) is the new formation of excessive scar tissue that results in limited ROM, pain, and functional deficits.» The diagnosis of arthrofibrosis is based on the patient's history, clinical examination, absence of alternative diagnoses from diagnostic testing, and operative findings. Imaging is helpful in ruling out specific causes of stiffness after TKA. A biopsy is not indicated, and no biomarkers of arthrofibrosis exist.» Arthrofibrosis pathophysiology is multifactorial and related to aberrant activation and proliferation of myofibroblasts that primarily deposit type I collagen in response to a proinflammatory environment. Transforming growth factor-beta signaling is the best established pathway involved in arthrofibrosis after TKA.» Management includes both nonoperative and operative modalities. Physical therapy is most used while revision arthroplasty is typically reserved as a last resort. Additional investigation into specific pathophysiologic mechanisms can better inform targeted therapeutics.

Analgesic Trends in the Management of Pain Following Total Knee Arthroplasty: A Comparison of Peri-Articular Infiltration, Adductor Canal Block, and Adjuvant Treatment for Posterior Knee Pain

The rising number of total knee arthroplasties (TKA's) in the United States increases demand for perioperative pain modalities, which can promote early mobilization and discharge. Over the decades, a focus has shifted from opioid-dominant regimens to motor-sparing multimodal protocols, which have not only improved pain scores and reduced opioid consumption but also improved overall patient outcomes. In this article, we briefly review the evolution of post-operative pain management in patients undergoing TKA and summarize the literature on the most popular modalities currently used including periarticular injections, adductor canal blocks, distal selective nerve blocks, as well as liposomal bupivacaine as part of a multimodal approach.

Effects of tourniquet on surgical site wound infection and pain after total knee arthroplasty: A meta-analysis

The application of a tourniquet (TNQ) for haemostasis in total knee arthroplasty (TKA) is controversial and lacking systematic evaluation. This meta-analysis assessed relevant international data to quantitatively evaluate the implications of using TNQ in TKA, further guide clinical diagnosis and treatment, and improve postoperative outcomes. A comprehensive computerised search of PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, VIP, and Wanfang databases was conducted to retrieve randomised controlled trials on the application of TNQ in TKA published from database inception to August 2023. The included data, ultimately comprising 1482 patients in 16 studies, were collated and subjected to meta-analysis using Stata 17.0 software. The results showed that the use of TNQ during TKA led to significantly higher rates of postoperative surgical site wound infection (3.96% vs. 1.79%, odds ratio: 2.15, 95% confidence intervals [CIs]: 1.11-4.16, p = 0.023) and wound pain scores on the first (standardised mean difference [SMD]: 0.65, 95% CI: 0.35-0.94, p < 0.001), second (SMD: 0.66, 95% CI: 0.01-1.31, p = 0.045), and third (SMD: 0.68, 95% CI: 0.31-1.05, pP < 0.001) day after the procedure. In conclusion, the application of TNQ in TKA increases the risk of postoperative surgical site wound infection and worsens short-term postoperative wound pain; therefore, TNQ should be used sparingly during TKA, or its use should be decided in conjunction with the relevant clinical indications and the surgeon's experience.

Hydrogel device for analgesic drugs with in-situ loading and polymerization

The high prevalence of opioid addiction and the shortcomings of systemic opioids has increased the pace of the search for alternative methods of pain management. The local delivery of pain medications has started to be used as a tool for pain management and to decrease the use of systemic opioids for these patients. Here, we explored an in-situ polymerizable hydrogel system for the local delivery of analgesics and nonsteroid anti-inflammatory drugs (NSAID) for orthopaedic applications. We synthesized a series of methacrylated oligomeric polyethylene glycol-co-lactic acid polymer using microwave radiation for the delivery of bupivacaine hydrochloride as an analgesic and ketorolac tromethamine as an NSAID. We determined drug elution and gel degradation profiles in vitro. Biocompatibility was assessed against osteoblasts in vitro and by histological analysis after subcutaneous implantation for 4 weeks in vivo. Intra-articular and systemic concentrations and pharmacokinetic parameters were estimated using a two-compartment pharmacodynamic model based on in-vitro elution profiles. This type of in-situ applicable hydrogels is promising for extending the local efficacy of pain medication and further reducing the need for opioids.

A multimodal intraosseous infusion of morphine and ketorolac decreases early postoperative pain and opioid consumption following total knee arthroplasty

BACKGROUND

Multimodal pain management regimens and intraosseous infusion of morphine are two novel techniques that show promise in decreasing postoperative pain and opioid consumption following total knee arthroplasty. However, no study has analyzed the intraosseous infusion of a multimodal pain management regimen in this patient population. The purpose of our investigation was to examine the intraosseous administration of a multimodal pain regimen comprised of morphine and ketorolac during total knee arthroplasty with regard to immediate and 2-week postoperative pain, opioid pain medication intake, and nausea levels.

METHODS

In this prospective cohort study with comparisons to a historical control group, 24 patients were prospectively enrolled to receive an intraosseous infusion of morphine and ketorolac dosed according to age-based protocols while undergoing total knee arthroplasty. Immediate and 2-week postoperative Visual Analog Score (VAS) pain scores, opioid pain medication intake, and nausea levels were recorded and compared against a historical control group that received an intraosseous infusion of morphine alone.

RESULTS

During the first four postoperative hours, patients who received the multimodal intraosseous infusion experienced lower VAS pain scores and required less breakthrough intravenous pain medication than those patients in our historical control group. Following this immediate postoperative period, there were no additional differences between groups in terms of pain levels or opioid consumption, and there were no differences in nausea levels between groups at any time.

CONCLUSIONS

Our multimodal intraosseous infusion of morphine and ketorolac dosed according to age-based protocols improved immediate postoperative pain levels and reduced opioid consumption in the immediate postoperative period for patients undergoing total knee arthroplasty.

A Comparative Evaluation of Combined Nerve Block Versus Periarticular Infiltration on Postoperative Pain Relief in Total Hip Arthroplasty

Introduction

To minimize the side effects of the central neuraxial blockade to obtain postoperative pain relief, there has been an increasing preference for targeting the peripheral structures in patients undergoing total hip arthroplasty (THA).

Patients and Methods

This prospective study was performed between September 2019 and September 2021 and involved 30 patients that were randomized to two groups. One group (n = 15) received combined nerve block (CNB) [obturator nerve, nerve to quadratus femoris, superior gluteal nerve, and femoral nerve], while another group (n = 15) received periarticular infiltrative analgesia (PIA). All the patients were given the same volume and composition of the drug cocktail (20 ml 0.5% ropivacaine, 1 ml (100 mcg) dexmedetomidine, and 29 ml normal saline).

Results

The patients in group CNB had a significantly lower visual analog score (VAS) at 6, 12, 18, 24, 30, 36, 42 and 48 h after surgery (p < 0.05). Patients in group CNB required fewer (p < 0.001) doses of the rescue analgesic (1.67 ± 0.90 doses) as compared to group PIA (3.53 ± 0.64 doses). Time to the first rescue analgesia was significantly longer (p = 0.01) in group CNB (6.71 ± 2.36 h) as compared to group PIA (4.80 ± 1.26 h). However, patients in group PIA had significantly faster sensory (p < 0.001) and motor recovery (p < 0.001) as compared to group CNB. It took significantly longer (p < 0.001) to administer the nerve block (16.87 ± 1.80 min) as compared to periarticular infiltration (6.53 ± 1.18 min). There were no complications in either group.

Conclusion

CNB registered significant superiority over PIA with respect to postoperative pain relief and time to rescue analgesia. However, the time taken to administer CNB was significantly higher and the patients in the PIA group had early recovery in sensory and motor modalities.

Level of Evidence

III (therapeutic).

Comparing preemptive injection of peri-articular-multimodal drug with oral celexocib for postoperative pain management in total knee arthroplasty: A randomized clinical trial

Background

Total knee arthroplasty (TKA) is associated with tremendous postoperative pain, and pain relief should concisely be considered. This study aims to compare the efficacy of preemptive periarticular multimodal drug injection versus placebo and oral celecoxib on postoperative pain control after TKA.

Materials and Methods

This study is a randomized clinical trial on 146 patients candidate for TKA who were randomly allocated to three treatment groups, including (1) a cocktail consisting of bupivacaine, morphine, epinephrine, and ketorolac (n = 48), (2) only epinephrine (placebo group) (n = 49), and (3) 400 mg celecoxib orally (control group) (n = 49) using the Random Allocation software. The injections and oral therapy were performed within 15 min before the surgical procedure. The study's primary outcome was the Knee Society Score (KSS) calculated at baseline, within 6 weeks and 6 months postoperatively. Range of motion (ROM) and Visual Analog Scale (VAS) to assess pain intensity as the other primary outcomes were evaluated before the procedure, within 24 h, 48 h, and 6 weeks postoperatively.

Results

The three studied groups were similar regarding demographic characteristics, including age (P = 0.33), gender distribution (P = 0.65), and involved knee side (P = 0.94). Baseline comparison of KSS (P = 0.39), VAS (P = 0.24), and ROM (P = 0.37) among the groups revealed insignificant differences. All the studied groups showed a statistically significant trend of improvement in KSS, VAS, and ROM (P < 0.001), while the comparison of the three groups in terms of KSS (P = 0.001), VAS (P < 0.001), and ROM (P < 0.001) revealed remarkable superiority of multimodal injection to the other treatments.

Conclusion

Preemptive periarticular multimodal drug injection, including bupivacaine, morphine, epinephrine, and ketorolac, can cause considerable postoperative pain relief and better ROM achievement in comparison to placebo or oral celecoxib.

The Effect of Aromatherapy with Citrus aurantium Aroma on Pain after Orthopedic Surgery: A Randomized Clinical Trial

Introduction

Postoperative pain is one of the most common physiological and psychological stress in patients that disrupts body function and can endanger patients' health. This study aims to determine the effect of aromatherapy with Citrus aurantium essential on pain after orthopedic surgery.

Methods

This randomized clinical trial was performed on 60 candidates for orthopedic surgery. Patients were selected through convenience sampling and divided into intervention and control groups through randomized block allocation. If the visual analogue scale (VAS) score was above 3, patients in the intervention group received aromatherapy with C. aurantium essential and the patients in the control group received a placebo (almond oil). VAS was used to measure pain. Data analysis was performed using independent t test, paired t test, and analysis of variance with repeated measures using SPSS software version 13.

Results

Mean (SD) of pain intensity after intervention in experimental and control groups within 4, 8, and 12 hours after surgery was 7.30 (1.23) vs. 7.90 (0.99), 5.30 (0.98) versus 5.53 (0.68) and 2.53 (0.9) vs. 3.60 (0.77) respectively. The findings indicated that there was a significant difference in mean pain intensity between the experimental and control groups at 4 and 12 hours after surgery. Use of analysis of variance with repeated measures test with taking into account the interaction of time and group also showed a significant difference in mean pain intensity between the two experimental and control groups.

Conclusion

Aromatherapy with Citrus aurantium essential can be effective in reducing mild to moderate pain after orthopedic surgery. Further studies are recommended to confirm this finding.

Pain management following simultaneous bilateral total knee arthroplasty: genicular nerve blockade versus periarticular injection

The aim of the present study was to investigate whether the analgesic solution prepared for periarticular injection (PAI) could be utilized as a genicular nerve blockade (GNB) agent in bilateral knee arthroplasty, and to assess the pain control efficacy of this approach in comparison with PAI. This was a retrospective cohort in which patients undergoing simultaneous bilateral total knee arthroplasty (TKA) were evaluated. Thirty patients were enrolled. The standard PAI was used for one knee, while the PAI solution was applied in the form of GNB to the other. Visual Analog Scale (VAS) pain scores were measured and recorded separately for each knee, at rest (static) and during exercise (dynamic). Active range of joint motion (JRM) for both knee joints was measured preoperatively, at postoperatively. Compared to the PAI group, the GNB group had lower VAS scores at 2 and 8 hours (p = 0.030 and p < 0.001, respectively). The GNB group also had lower dynamic VAS scores at 2, 8, and 24 hours (p = 0.009, p <0.001 and p<0.001, respectively). Static and dynamic VAS measurements did not demonstrate any differences between groups (GNB vs. PAI) at 48 hours and 30 days (p>0.05). When the reduction in VAS scores was assessed, we found that the decrease in both scores was significantly greater in the PAI group compared to the GNB group (p<0.001, for both). There were no significant differences between the groups with regard to drainage volume, complications and JRM (p>0.05). GNB was found to be more effective for pain control throughout the first postoperative day in patients who underwent simultaneous bilateral TKA.

Effects of a Continuous Adductor Canal Block After Total Knee Arthroplasty

This retrospective cohort study analyzed the short-term outcomes of patients undergoing total knee arthroplasty receiving periarticular anesthetic injections (PAIs) with and without continuous adductor canal blocks (CACBs) regarding early postoperative narcotic use, pain scores, and range of motion with otherwise similar postoperative regimens. Two hundred ninety-four patients were included: 120 received PAIs with CACBs, and 174 received PAIs only. Matched analysis was performed for type of anesthesia. There were substantial decreases in early inpatient narcotic use with the addition of CACBs to PAIs with general and spinal anesthesia without an adverse effect on pain, knee range of motion, or length of stay. [Orthopedics. 2023;46(3):185-191.].

The effect and safety of periarticular multimodal drug injection without morphine and epinephrine in anterior cruciate ligament reconstruction

Background

Periarticular multimodal drug injection (PMDI) is a safe and effective pain management technique after anterior cruciate ligament reconstruction (ACLR); however, adding morphine and epinephrine sometimes causes adverse effects. Therefore, we evaluated the efficacy of PMDI without morphine and epinephrine after ACLR.

Methods

This retrospective matched case-control study included patients who had undergone primary double-bundle ACLR with PMDI and were then matched one-to-one with a control group without PMDI based on sex, age, and body mass index using propensity-matched analysis. The following clinical outcomes were compared between the groups: visual analog scale (VAS) score, C-reactive protein (CRP) concentration, number of times the patients used additional analgesics, complication rate, and postoperative time to achieve straight leg raise (SLR).

Results

Twenty-nine patients with PMDI and 29 controls were enrolled. The VAS score at 1 day postoperatively was lower in the PMDI than the control group (1.93  ±  1.44 vs. 3.41  ±  1.75, respectively; P < 0.001). The CRP concentration at 1 and 3 days was lower in the PMDI than the control group (0.46  ±  0.47 vs. 1.00  ±  0.69 mg/dL, P < 0.001; and 1.93  ±  1.71 vs. 4.01  ±  2.55 mg/dL, P < 0.001, respectively). The average number of additional analgesics used was significantly lower in the PMDI than the control group. There were no significant differences in the frequency of occurrence of postoperative complications between the two groups. The number of patients who could achieve SLR within 1 day was 27/29 (93%) in PMDI group, which was significantly higher than the control group (12/29, 41%) ( P < 0.001).

Conclusion

PMDI without morphine and epinephrine after ACLR reduced patients’ subjective pain level, objective inflammatory response without complications and enabled patients to achieve early functional recovery.

Early Stage Versus Late Stage Periarticular Injection during Unicompartmental Knee Arthroplasty for Postoperative Pain Relief: A Randomized Controlled Trial

Controlling postoperative pain after unicompartmental knee arthroplasty (UKA) is essential to improve patient satisfaction and promote early recovery. The purpose of this study was to investigate the difference in clinical efficacy between early and late stage periarticular injection during UKA for postoperative pain relief. Eighty-four patients meeting the inclusion and exclusion criteria were randomly divided into the early stage periarticular injection group and late stage periarticular injection group by using a random number tables method. The difference between the two groups was that the early stage periarticular injection group received superficial injection before the joint incision, while the late stage periarticular injection group received superficial injection after implantation of the prosthesis. Deep injection and other perioperative conditions of the two groups were controlled identically. The primary outcome of the study was the recovery room immediate visual analog scale (VAS) at rest. The secondary outcomes were the postoperative VAS (at rest) at 3, 6, 9, 12, 18, 24, 48, 72, 96, and 120 hours, drug dosage of rescue analgesia, range of motion (ROM), and complications. The recovery room immediate VAS (at rest) in the early stage periarticular injection group was significantly lower than that of the late stage periarticular injection group (21 ± 24 vs. 32 ± 34 mm, p = 0.018), the average difference of the VAS reached the minimal clinically important difference. No statistically significant difference in postoperative drug dosage of rescue analgesia, ROM, and complications. Preemptive analgesia combined with the early stage periarticular injection can better alleviate postoperative pain than the late stage periarticular injection.

Multimodal Pain Management in Orthopedic Surgery

Background: Orthopedic surgery typically results in moderate to severe pain in a majority of patients. Opioids were traditionally the primary medication to target mechanisms of pain transmission. Multimodal analgesia has become a preferred method of pain management in orthopedic practice. Utilizing more than one mode to address post-surgical pain by recruiting multiple receptors through different medications accelerates the recovery process and decreases the need for opioids. By implementing effective analgesic techniques and interventions, this practice, in turn, decreases the usage of perioperative opioids, and in the long term, prevents addiction to pain medications and risk of opioid overdose. In orthopedic surgeries, previous studies have found that multimodal analgesia has reduced early opioid usage in the postoperative course. Pain is the result of direct injury to the nervous system, with a wide variety of chemicals directly stimulating or sensitizing the peripheral nociceptors. The pathophysiology behind the mechanism of post-surgical pain, along with the importance of preoperative, perioperative, and postoperative pain regimens are emphasized. A brief overview of pain medications and their properties is provided. These medications are further categorized, with information on special considerations and typical dosage requirements. Pain management should address both neuropathic and subjective types of pain. Effective pain control requires constant reassessment with individualized strategies. Conclusion: By focusing on multimodal analgesia, anesthesiologists can now utilize newer techniques for postoperative pain relief from orthopedic surgery, with better short-term and long-term outcomes for the patient.

Efficacy of single-shot adductor canal block before Versus after primary total knee arthroplasty - Does timing make a difference? A randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with severe postoperative pain. Multimodal analgesia, including peripheral nerve block, is recommended for post-operative pain relief. Administration of some pain medications prior to surgery has shown to be more effective than after the operation. This is a prospective, randomized controlled trial designed to compare the analgesic efficacy of the adductor canal block (ACB) performed immediately before or immediately after primary total knee arthroplasty (TKA). We hypothesized that ACB before the surgery will reduce postoperative pain and improve knee function.

METHODS

A total of 50 patients were enrolled and randomized into 2 groups, with 26 patients receiving a preoperative ACB and 24 receiving a postoperative ACB.

RESULTS

Treatment groups were similar in terms of gender (p = .83), age (p = 0.61) weight (p = .39) and ASA score. Average visual analogue scale (VAS) on arrival to the post-anesthesia care unit (PACU) were 4.9 ± 3.2 in the preoperative ACB versus 3.4 ± 2.8 for the postoperative ACB (p = .075). VAS scores at different time points as well as the mean, minimal and maximal reported VAS scores were not significantly different between the two groups. The cumulative quantities of Fentanyl administered by the anesthesia team was comparable between the groups. Similarly, the dosage of Morphine, Tramadol, Acetaminophen and Dipyrone showed only small variations. The Quality of Recovery Score, Knee Society Scores and knee range of motion did not differ between the groups.

CONCLUSIONS

Our findings demonstrate no significant differences in patient total narcotics consumption, pain scores and functional scores, between preoperative and postoperative ACB in patients undergoing TKA.

TRIAL REGISTRATION

The trial was registered at www.clinicaltrials.gov and was assigned the registration number NCT02908711.

LEVEL OF EVIDENCE

level I randomized controlled trial.

Complement C3-α and C3-β Levels in Synovial Fluid But Not in Blood Correlate With the Severity of Osteoarthritis Research Society International Histopathological Grades in Primary Knee Osteoarthritis

BACKGROUND

Primary osteoarthritis (OA) is the most common cause of knee arthritis worldwide. The knee synovial fluid complement C3-β chain levels have been shown to correlate with clinical symptoms of knee OA. It is not known whether the complement C3 in the synovial fluid is derived from the circulation or is produced locally in the knee.

METHODS

Fifty primary OA patients undergoing a total knee arthroplasty procedure were evaluated for biochemical analyses of C3-α and C3-β chains in the synovial fluid and blood plasma. These levels were corelated with the severity of corresponding knee OA based on the Osteoarthritis Research Society International (OARSI) grade.

RESULTS

Both synovial C3-α and C3-β levels correlated significantly with the severity of OA. Neither plasma C3-α levels nor C3-β levels significantly correlated with OARSI grading. Neither synovial C3-α levels nor C3-β correlated significantly with plasma C3-α or C3-β levels, respectively. Synovial C3-α chain and C3-β chain levels were significantly higher in the grade >6 group. In plasma, neither C3-α chain levels nor C3-β chain levels were significantly different between the groups. Neither synovial C3-α nor C3-β levels significantly correlated with plasma erythrocyte sedimentation rate or C-reactive protein levels.

CONCLUSION

In knee primary OA, C3 seems to be produced and released locally into the synovial fluid instead of being derived from blood in the circulation. Synovial C3 levels, but not blood plasma C3, correlate with the histopathological severity of primary OA in the knee. Synovial C3 may be an important factor in the pathogenesis of primary OA clinical symptoms and a potential target for therapeutic intervention.

Learning curve for robotic assisted total knee arthroplasty: our experience with imageless hand-held Navio system

The main purpose of this study was to determine the learning curve of Robotic assisted Total Knee Arthroplasty surgery through assessment of operative time and comparison with that of conventional jig based Total Knee Arthroplasty. The study included our first 75 Robotic assisted Total Knee Arthroplasty and 25 randomly selected conventional jig-based Total knee arthroplasty from June 2017 to December 2017. The 75 cases were divided into 3 groups of 25 consecutive cases. The mean of operative time for each phase and total time was compared between the 3 groups and with the mean of total time for conventional jig based group. In our experience, Robotic assisted Total Knee arthroplasty was associated with a learning curve of approximately 25 cases. The mean for Registration phase of Group A (1st set of 25 cases) was 6.12 min (SD 1.8 min), group B (2nd set of 25 cases) was 4.46 min (SD 0.79 min) and group C (3rd set of 25 cases) was 4.17 min (SD 0.59 min). The mean for Planning phase of group A was 5.08 min (SD 1.01 min), group B was 4.04 min (SD 0.37 min) and group C was 4.01 min (SD 0.35 min). The mean for Cutting Phase of group A was 28.22 min (SD 6.24 min), group B was 22.49 min (SD 0.79 min) and group C was 22.36 min (SD 0.88 min). The mean for total time of group A was 39.42 min (SD 8.02), group B was 31 min (SD 1.22 min), group C was 30.53 min (SD 1.14 min) and conventional group was 30.54 min (SD 1.14 min). On comparing the Registration phase (Group A vs B, p < 0.001; Group B vs C, p 0.14; Group A vs C, p < 0.001), Planning phase (Group A vs B, p < 0.001; Group B vs C, p 0.75; Group A vs C, p < 0.001), Cutting phase (Group A vs B, p < 0.001; Group B vs C, p 0.58; Group A vs C, p < 0.001) and Total time (Group A vs B, p < 0.001; Group B vs C, p 0.74; Group A vs C, p < 0.001; Group A vs Conventional, p < 0.001; Group B vs Conventional, p 0.17, Group C vs Conventional, p 0.99), the results showed that the inflection point for learning curve in our hands was 25 cases. The learning curve and increased operation theatre time are likely to be major barrier in widespread acceptance of robotic technology amongst arthroplasty surgeons. We, in our experience can say that the learning curve was approximately 25 cases. The results of this study will help the arthroplasty surgeons in accepting this technology and achieve better outcomes.

Intraosseous Morphine Decreases Postoperative Pain and Pain Medication Use in Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Intraosseous (IO) infusion of medication is a novel technique for total knee arthroplasty (TKA) antibiotic prophylaxis. To decrease postoperative pain in TKA patients, we investigated addition of morphine to a standard IO antibiotic injection.

METHODS

A double-blind, randomized controlled trial was performed on 48 (24 each) consecutive patients undergoing primary TKA. The control group received an IO injection of antibiotics as per the standard protocol. The experimental group received an IO antibiotic injection with 10 mg of morphine. Pain, nausea, and opioid use were assessed up to 14 days postoperatively. Morphine and interleukin-6 serum levels were obtained 10 hours postoperatively in a subgroup of 20 patients.

RESULTS

The experimental group had lower Visual Analog Scale pain score at 1, 2, 3, and 5 hours postoperatively (P = .0032, P = .005, P = .020, P = .010). This trend continued for postoperative day 1, 2, 8, and 9 (40% reduction, P = .001; 49% reduction, P = .036; 38% reduction, P = .025; 33% reduction, P = .041). The experimental group had lower opioid consumption than the control group for the first 48 hours and second week postsurgery (P < .05). Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores for the experimental group showed significant improvement at 2 and 8 weeks postsurgery (P < .05). Serum morphine levels in the experimental group were significantly less than the control group 10 hours after IO injection (P = .049).

CONCLUSION

IO morphine combined with a standard antibiotic solution demonstrates superior postoperative pain relief immediately and up to 2 weeks. IO morphine is a safe and effective method to lessen postoperative pain in TKA patients.

LEVEL OF EVIDENCE

Therapeutic, Level 1.

Adductor canal block combined with local infiltration analgesia with morphine and betamethasone show superior analgesic effect than local infiltration analgesia alone for total knee arthroplasty: a prospective randomized controlled trial

Background

Local infiltration analgesia (LIA) and adductor canal block (ACB) provide postoperative analgesia for total knee arthroplasty (TKA). ACB blocks the saphenous nerve and has smaller impacts on quadriceps muscle weakness. ACB theoretically does not have enough analgesic effects on posterior sensory nerves. LIA may increase its analgesic effects on the posterolateral knee. The purpose of this study was to evaluate whether ACB combined with a LIA cocktail of ropivacaine, morphine, and betamethasone has superior analgesic effect than LIA for TKA.

Methods

A total of 86 patients were assessed for eligibility from February 2019 to May 2019. 26 of those were excluded, and 60 patients were divided into 2 groups by computer-generated random number. Group A (LIA group) received LIA cocktail of ropivacaine, morphine and betamethasone. Group B (LIA+ ACB group) received ultrasound-guided ACB and LIA cocktail of ropivacaine, morphine and betamethasone. Postoperative visual analogue scale (VAS) resting or active pain scores, opioid consumption, range of motion (ROM), functional tests, complications and satisfaction rates were measured. The longest follow-up was 2 years.

Results

Two groups have no differences in terms of characteristics, preoperative pain or function (P > 0.05). ACB combined with LIA had significantly lower resting and active VAS pain scores, better ROM, better sleeping quality and higher satisfaction rates than LIA alone within 72 h postoperatively (P < 0.05). Complications, or adverse events and HSS score, SF-12 score were observed no significant differences within 2 years postoperatively.

Conclusions

Adductor canal block combined with Local infiltration analgesia provide better early pain control. Although the small statistical benefit may not result in minimal clinically important difference, Adductor canal block combined with Local infiltration analgesia also reduce opioid requirements, improve sleeping quality, and do not increase the complication rate. Therefore, Adductor canal block combined with Local infiltration analgesia still have good application prospects as an effective pain management for total knee arthroplasty.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1900021385, 18/02/2019.

Reducing Narcotic Usage With 0.5% Bupivacaine Periarticular Injections in Total Knee Arthroplasty

BACKGROUND

Periarticular injections (PAIs) and adductor canal blocks (ACBs) are widely accepted pain management strategies for total knee arthroplasty (TKA); however, the optimal anesthetic concentration to provide adequate pain relief while avoiding toxicity remains controversial. The purpose of this study is to evaluate the efficacy of different anesthetic concentrations for PAI alone and in combination with ACB.

METHODS

This retrospective cohort study of patients undergoing primary TKAs between January 2019 and November 2020 included 3 groups: 0.25% PAI (50 cc of 0.25% bupivacaine PAI diluted with 50 cc of saline and ketorolac), 0.5% PAI (50 cc of 0.5% bupivacaine with 50 cc of saline and ketorolac), and PAI + ACB (ultrasound-guided preoperative anesthesiologist-administered ACB and 0.25% PAI).

RESULTS

In total, 368 TKAs were analyzed (123 0.25%, 132 0.5%, and 113 PAI + ACB). Total overall hospital narcotic usage in oral morphine equivalents (OME) was significantly lower for the 0.5% group (120.09 vs 165.26 and 175.75) compared to the 0.25% and PAI + ACB groups, respectively (P < .0001). Cumulative OME for the first 3 shifts was also lower for 0.5% (68.7 vs 83.7 and 76.4) compared to the 0.25% and PAI + ACB groups, respectively (P = .030). Total postoperative narcotics in OME were significantly lower for 0.5% (617.9 vs 825.2 and 1047.6) than 0.25% and PAI + ACB, respectively (P = .0003). Number of prescriptions within 6 weeks postoperatively were also significantly lower for 0.5% (1.7) than 0.25% (2.1) and PAI + ACB (2.4) (P = .0003).

CONCLUSION

Patients receiving 0.5% PAI had lower narcotic usage compared to 0.25% PAI or PAI + ACB. ACB may be eliminated without compromising pain control if the dose of local anesthetic in the PAI is sufficiently high.

Does Resident Participation Influence Surgical Time and Clinical Outcomes? An Analysis on Primary Bilateral Single-Staged Sequential Total Knee Arthroplasty

Background

Although several studies have indirectly compared teaching and nonteaching hospitals, results are conflicting, and evaluation of the direct impact of trainee involvement is lacking. We investigated the direct impact of resident participation in primary total knee arthroplasties (TKAs).

Material and methods

Fifty patients undergoing single-staged sequential bilateral primary TKAs were evaluated. The more symptomatic side was performed by the attending surgeon first, followed by the contralateral side performed by a chief resident under direct supervision and assistance of the same attending surgeon. Surgery was subdivided into 8 critical steps on both sides. The overall time and critical stepwise surgical time and short-term clinical outcomes were then compared between the 2 sides.

Results

The attending surgeon completed the surgery (skin incision to dressing) significantly faster than the resident (70.2 vs 96.9 minutes) by a mean of 26.7 minutes (P < .05) and was also faster in all steps. The most significant differences in time were in “exposure” (9.5 vs 16.5 minutes) and “closure” steps (13.2 vs 24.9 minites), all P < .001. Adverse events occurred in 7 patients; 5 of these resolved uneventfully. There were no significant differences in surgical complications, objective outcome scores, or patient satisfaction scores between both sides.

Conclusion

Resident participation in TKA increased operative time without jeopardizing short-term patient clinical outcomes, satisfaction, and complications. This may alleviate concerns from patients and policymakers about TKA in an academic setting. Surgical “exposure” and “closure” were the most prolonged steps for the residents, and they may benefit with more focus and/or simulation studies during training.

The Efficacy and Safety of Celecoxib for Pain Management After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

This study aimed to determine the efficacy and safety of celecoxib for pain management after total knee arthroplasty (TKA).

Methods

PubMed, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify eligible randomized controlled trials (RCTs) that compared celecoxib with a placebo in term of pain control efficacy after TKA. Primary outcomes included pain scores at 24, 48, and 72 h after TKA. Secondary outcomes included the active range of motion (ROM) at 24, 48,72 h, and 7 days postoperatively, morphine consumption over 72 h after TKA, incidence of postoperative nausea and vomiting (PONV), and total blood loss after surgery. Data analysis was conducted using RevMan version 5.3.

Results

Five RCTs involving 593 participants were included in the study. Compared with a placebo, celecoxib significantly reduced visual analog scale (VAS) scores at rest at 24 h [mean difference (MD) = −0.72; 95% confidence interval (CI), −1.27 to −0.17; I² = 82%; P = 0.01], 48 h (MD = −1.51; 95% CI, −2.07 to −0.95; I² = 0%; P < 0.00001), and 72 h (MD = −1.30; 95% CI, −2.07 to −0.54; I² = 82%; P = 0.0009) after TKA, decreased morphine consumption over postoperative 72 h (MD = −0.73; 95% CI, −0.96 to −0.51; I² = 96%; P < 0.00001), and increased active ROM at 48 h (MD = 13.23; 95% CI, 7.79 to 18.67; I² = 0%; P < 0.00001), 72 h (MD = 6.52; 95% CI, 4.95 to 8.10; I² = 68%; P < 0.00001), and 7 days (MD = 7.98; 95% CI, 3.64 to 12.31; I² = 68%; P = 0.0003) after the operation. No significant difference was found in the active ROM at 24 h (MD = 7.60; 95% CI, −6.14 to 21.34; I² = 94%; P = 0.28) and the incidence of PONV after surgery [risk ratio (RR) = 0.66; 95% CI, 0.40 to 1.09; I² = 0%; P = 0.11].

Conclusion

The administration of celecoxib is an effective and safe strategy for postoperative analgesia after TKA.

Decreasing Post-Operative Opioid Prescriptions Following Orthopedic Trauma Surgery: The "Lopioid" Protocol

OBJECTIVE

To assess the effectiveness of a multimodal analgesic regimen containing "safer" opioid and non-narcotic pain medications in decreasing opioid prescriptions following surgical fixation in orthopedic trauma.

DESIGN

Retrospective cohort study.

SETTING

One urban, academic medical center.

SUBJECTS

Traumatic fracture patients from 2018 (848) and 2019 (931).

METHODS

In 2019 our orthopedic trauma division began a standardized protocol of post-operative pain medications that included: 50 mg of tramadol four times daily, 15 mg of meloxicam once daily, 200 mg gabapentin twice daily, and 1 g of acetaminophen every 6 hours as needed. This multimodal regimen was dubbed the "Lopioid" protocol. We compared this protocol to all patients from the prior year who followed a standard protocol that included Schedule II narcotics.

RESULTS

Greater mean MME were prescribed at discharge from fracture surgery under the standard protocol compared to the Lopioid protocol (252.3 vs 150.0; p < 0.001) and there was a difference in the type of opioid medication prescribed (p < 0.001). There was a difference in the number of refills filled for patients discharged with opioids after surgical treatment between standard and Lopioid cohorts (0.31 vs 0.21; p = 0.002). There was no difference in the types of medication-related complications (p = 0.710) or the need for formal pain management consults (p = 0.199), but patients in the Lopioid cohort had lower pain scores at discharge (2.2 vs 2.7; p = 0.001).

CONCLUSIONS

The Lopioid protocol was effective in decreasing the amount of Schedule II narcotics prescribed at discharge and the number of opioid refills following orthopedic surgery for fractures.

Periarticular liposomal bupivacaine mixture injection vs. single-shot interscalene block for postoperative pain in arthroscopic rotator cuff repair: a prospective randomized controlled trial

BACKGROUND

The pain control efficacy, postoperative opioid requirements, and costs among patients undergoing major shoulder surgery using different perioperative analgesia modalities have been topics of active debate. Several studies have compared periarticular injection (PAI) to interscalene block (ISB) in shoulder arthroplasty, but there is a paucity of data comparing them in arthroscopic rotator cuff repair.

METHODS

Patients aged 18-80 years with full-thickness rotator cuff tears and undergoing primary arthroscopic rotator cuff repair at 2 different shoulder centers were screened and subsequently randomized to receive either periarticular injection (PAI) of liposomal bupivacaine mixed with 0.25% bupivacaine (n = 41) or single-shot interscalene nerve block (ISB) (n = 36). Visual analog scale (VAS) pain scores, oral morphine equivalent (OME) use, Single Assessment Numerical Evaluation (SANE) scores, and costs were collected. Differences with P <.05 were considered statistically significant.

RESULTS

Day of surgery VAS score and OME usage were significantly reduced with ISB vs. PAI (0.69 vs. 4.65, P < .001, and 18.66 vs. 34.39, P < .001, respectively). There were no significant differences between groups regarding VAS score on postoperative days (PODs) 1-3; however, OME usage on PODs 1 (50.5 vs. 38.8, P = .03) and 2 (48.1 vs. 37.8, P = .04) was significantly more in the ISB group. At POD 3, VAS score (4.13 vs. 3.97, P = .60) and OME use (28.60 vs. 31.16, P = .51) were similar. At 6 and 12 weeks, there were also no significant differences between groups regarding VAS and OME use. There was no difference in SANE score at 12 weeks following surgery between groups and no difference between average 12-week cumulative OME use between groups. The average charge for the PAI was $455, and the average charge for ISB was $745.

CONCLUSION

Both ISB and PAI provide acceptable pain control following arthroscopic rotator cuff repair. Patients have less pain on the day of surgery with ISB, but rebound pain is significant after the block wears off, resulting in substantially increased opioid use in the first 2 PODs. However, cumulative opioid use between groups was similar. There were also no significant differences at the end of the 12-week episode of care in any of the other variables studied. The charge per patient for PAI is approximately $300 less than ISB. Thus, PAI may offer surgeons and patients an effective postoperative analgesic modality as an alternative to ISB.

An Update on Multimodal Pain Management After Total Joint Arthroplasty

➤

Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols.

➤

Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty.

➤

Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge.

➤

There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.

Comparison of local infiltration analgesia and interscalene block for postoperative pain management in shoulder arthroscopy: a prospective randomized controlled trial

Background/aim

The aim of this study was to compare the effects of local infiltration analgesia and interscalene brachial plexus block techniques on postoperative pain control and shoulder functional scores in patients undergoing arthroscopic rotator cuff repair.

Materials and methods

Sixty patients who underwent arthroscopic rotator cuff repair were prospectively included in the study. Patients were randomly divided into two groups. Group 1 was comprised of patients who had interscalene brachial plexus block, while group 2 was comprised of patients who had local infiltration analgesia. In group 1, interscalene block was applied with 20 mL 0.5% bupivacaine. In group 2, the Ranawat cocktail was used for local infiltration analgesia. Sixty milliliters of Ranawat cocktail was applied to the subacromial space and glenohumeral joint in equal amounts. Postoperative pain was assessed by the VAS score. Functional scores of the shoulder were also evaluated by Constant–Murley and UCLA scores. The time of first analgesic requirement and total analgesic consumption in the postoperative period were assessed.

Results

The first analgesic requirement was significantly late in the interscalene brachial plexus block group (p = 0.000). There was no statistically significant difference between the groups in terms of total analgesic consumption (p = 0.204). In the postoperative 6th h, the VAS score was 2.43 in the interscalene brachial plexus block group, whereas 2.86 in the local infiltration analgesia group (p = 0.323). There was no statistically significant difference between the groups in terms of Constant–Murley shoulder and UCLA scores in the 3rd postoperative month (respectively, p = 0.929, p = 0.671). Besides, postoperative VAS scores and functional scores were negatively correlated (p < 0.01).

Conclusion

Local infiltration analgesia is an effective alternative to interscalene brachial plexus block for postoperative pain management and total analgesic consumption in arthroscopic rotator cuff repair. However, the interscalene brachial plexus block provides a longer postoperative painless period.

Effects of music therapy on physiological outcomes for post-operative total knee arthroplasty (TKA) patients

This study aimed to investigate the effects of music on physiological outcomes for post-operative TKA patients in the recovery unit. Fifty-six patients from Hospital Melaka were randomized equally into intervention (IG) and control groups (CG). IG received the usual care and listened to selected music for 60min, while the CG received only the usual care. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), respiration rate (RR) and oxygen saturation (SpO₂) were measured on arrival and after 10, 20, 30, and 60min in the recovery unit. A significant difference between groups was observed in RR upon arrival (U=276.5, p=0.029) and after 10min (U=291, p=0.45). Meanwhile, there were significant differences in DBP (F=3.158, p=0.032), RR (χ²=15.956, p=0.003) and SpO₂ (χ²=14.084, p=0.007) over time in the IG. Overall, listening to music immediately after TKA has an effect on DBP, RR, and SpO₂.

Ultrasound-Guided Local Anesthetic Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (IPACK) Block for Primary Total Knee Arthroplasty: A Systematic Review of Randomized Controlled Trials

Posterior knee pain after total knee arthroplasty (TKA) is common despite multimodal analgesia and regional anesthesia use. This review included randomized controlled trials (RCTs) comparing analgesic outcomes after inclusion of local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block versus pathways without iPACK. Electronic databases (MEDLINE, Cochrane Library, Web of Science, Scopus) were searched from inception to 10/11/2020. Eligible studies evaluated iPACK use on primary outcomes: opioid consumption and pain scores with movement. Secondary outcomes included rest pain, patient satisfaction, length of stay (LOS), gait distance, knee range of motion (ROM), and complications. Bias and quality were appraised using the Cochrane Risk of Bias tool and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. Eight RCTs (777 patients) were included. iPACK block use demonstrated similar opioid consumption in the PACU (4/7 RCTs) and 24 hours after TKA (5/7 RCTs) compared to without iPACK (moderate-quality GRADE evidence). Additionally, iPACK block use demonstrated lower movement pain scores in PACU (3/5 RCTs) but similar or higher pain scores after 24 hours (5/7 RCTs; low-quality GRADE evidence). Studies consistently reported no difference in gait distance (4/4 RCTs) or complications (7/7 RCTs) between treatment arms (high-quality GRADE evidence), although differing effect estimates were observed with resting pain, satisfaction, LOS, and knee ROM. This review provides a foundation of knowledge on iPACK efficacy. While evidence does not currently support widespread inclusion of iPACK within enhanced recovery pathways for TKA, limitations suggest further study is warranted.

Drug Utilization for Pain Management during Perioperative Period of Total Knee Arthroplasty in China: A Retrospective Research Using Real-World Data

Background and Objective: Total knee arthroplasty (TKA) is one of the most painful procedures and perioperative pain usually requires the use of many analgesics to relieve it. The appropriate use of analgesics to relieve patient pain is an important issue of TKA. To characterize the drug utilization for pain management during perioperative period of TKA in China using real-world data of electronic medical records. Materials and Methods: This research used the data of all inpatients who received TKA at 145 hospitals covered 31 provinces in China from 1 January 2016 to 31 December 2018. The exclusion criteria included pregnancy and cancer diagnosis. In the analysis of drug utilization mode (DUM), medicines were classified into 5 groups: non-steroidal anti-inflammatory drugs (NSAIDs), opioids, non-opioid central analgesics, acetaminophen and others. Results: Among the 2017 patients included in this study, there were 1537 (76.20%) female and 480 (23.80%) male, aged 65.77 ± 7.73 years. Regarding the surgery characteristics, 1658 (82.20%) were unilateral; 1220 (60.49%) was graded Level 4; 1312 (65.05%) used local anesthesia as the main anesthesia method, and 1450 (71.89%) lasted for more than 2 h. The most common DUM was “NSAIDs + opioids” (55.92%), followed by “NSAIDs only” (17.85%), and “NSAIDs + Opioids + Non-opioid central analgesics” (17.15%). The results of the Chi-square test showed that differences in DUM were associated with surgery types, surgery levels, surgery duration, and types of anesthesia used. Up to 81.14% of the total drug expenses for pain management was spent on NSAIDs. Due to the limitation of database, this study could not subdivide operation stages, anesthesia methods, dosage forms of drugs. Conclusion: In China, the use of analgesics in perioperative period of TKA was diversified and influenced by a number of surgery characteristics. The rational use of analgesics should be considered in combination with surgery type, surgery level, surgery duration and anesthesia method.

Average narcotic usage in a group of TKA patients following a modern TKA protocol

INTRODUCTION

The optimal dosing of post-operative total knee arthroplasty (TKA) narcotics is unclear. We report on the average narcotic usage in a group of patients treated with an identical multimodal pain protocol following TKA.

MATERIALS AND METHODS

49 patients undergoing TKA participated in the survey. Patients with pre-op narcotic use, recent prior total joint arthroplasty or study refusal were excluded. All patients received a spinal anesthetic. No pre-surgery narcotics were given. All received an identical local infiltrative anesthetic combination along with a multimodal pain protocol. Patients were placed into an identical rapid rehab program. Narcotic usage during hospitalization was recorded in morphine equivalent doses (MED). Patients were given a journal to record their daily narcotic utilization.

RESULTS

Pre-operative pain scores of the excluded groups had slightly higher but clinically insignificant differences compared to the study group. In the hospital, POD1 study group daily MED averaged 28 (range 0-110). POD2 had an average of 33.6 and POD 3 daily usages averaged 28.6 (range 0-100). By the end of week two, the average daily use was 19.2 and 24% patients were off all narcotics. By the end of week four, the average daily usage was 7.5 and 63% of patients were off all narcotics. By 8 weeks, there were no patients still taking narcotics. KSS averaged 76.9 (range 51-97) at the 6 week visit, and 94.2 at the 3-month visit (range 72-100).

SUMMARY

This study documents the average needs of an average TKA patient treated with modern pain protocols. The majority of these patients were off narcotics by week four.

Perioperative Opioid Prescribing Patterns and Readmissions After Total Knee Arthroplasty in a National Cohort of Veterans Health Administration Patients

OBJECTIVE

Among Veterans Health Administration (VHA) patients who undergo total knee arthroplasty (TKA) nationally, what are the underlying readmission rates and associations with perioperative opioid use, and are there associations with other factors such as preoperative health care utilization?

METHODS

We retrospectively examined the records of 5,514 TKA patients (primary N = 4,955, 89.9%; revision N = 559, 10.1%) over one fiscal year (October 1, 2010-September 30, 2011) across VHA hospitals nationwide. Opioid use was classified into no opioids, tramadol only, short-acting only, or any long-acting. We measured readmission within 30 days and the number of days to readmission within 30 days. Extended Cox regression models were developed.

RESULTS

The overall 30-day hospital readmission rate was 9.6% (N = 531; primary 9.5%, revision 11.1%). Both readmitted patients and the overall sample were similar on types of preoperative opioid use. Relative to patients without opioids, patients in the short-acting opioids only tier had the highest risk for 30-day hospital readmission (hazard ratio = 1.38, 95% confidence interval = 1.14-1.67). Preoperative opioid status was not associated with 30-day readmission. Other risk factors for 30-day readmission included older age (≥66 years), higher comorbidity and diagnosis-related group weights, greater preoperative health care utilization, an urban location, and use of preoperative anticonvulsants.

CONCLUSIONS

Given the current opioid epidemic, the routine prescribing of short-acting opioids after surgery should be carefully considered to avoid increasing risks of 30-day hospital readmissions and other negative outcomes, particularly in the context of other predisposing factors.

Short-Term Effects of Early Postoperative Celecoxib Administration for Pain, Sleep Quality, and Range of Motion After Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

We hypothesized that early postoperative administration of celecoxib would reduce pain scores and improve sleep quality and active range of motion after total knee arthroplasty (TKA) under general anesthesia.

METHODS

Patients in the celecoxib group received 400 mg of celecoxib 2 hours after TKA, followed 6 hours later by 200 mg of celecoxib. Patients in the control group received 400 mg of celecoxib the second day after surgery. Patients in both group had access to patient-controlled analgesia fentanyl. The primary outcome measure was the patient-reported visual analog scale (VAS) pain score the second day after TKA. The secondary outcome measure was sleep quality (days 1, 2, and 7 postoperatively). Active knee joint range of motion was assessed on days 2 and 7 postoperatively, and VAS pain scores were evaluated on postoperative days 1 to 7. Total fentanyl consumption was also assessed.

RESULTS

Compared to the control group, the celecoxib group had significantly lower median VAS pain scores on postoperative days 1 and 2, significantly less nocturnal awakening (in minutes) and frequency of body motion, and better sleep efficacy on postoperative day 1. The celecoxib group also had a significantly better median flexion angle (°) on postoperative days 2 and 7, and lower cumulative fentanyl consumption.

CONCLUSION

Early administration of celecoxib after TKA was associated with significantly reduced early VAS pain scores and improved sleep quality and active knee flexion angles. Thus, the early administration of celecoxib after TKA under general anesthesia may reduce pain and improve sleep quality and functional recovery.

LEVELS OF EVIDENCE

Level II, therapeutic study.

TRIAL REGISTRATION

UMIN-CTR 000014624 (July 23, 2014).

Opioid Versus Nonopioid Analgesia After Carpal Tunnel Release: A Randomized, Prospective Study

Background: The purpose of this investigation was to compare pain control and patient satisfaction for conventional postoperative opioid analgesia and nonopioid multimodal analgesia after elective open or endoscopic carpal tunnel release (CTR). Methods: As part of a randomized, prospective study, patients undergoing primary, elective CTR were randomized to receive either postoperative opioids or nonopioid medications as part of a multimodal pain control strategy. Patients currently taking opioids were excluded. Patients completed a postoperative pain journal and completed the shortened version of the Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH), Boston Carpal Tunnel Questionnaire, Numeric Pain Rating Scale (NPRS), and satisfaction ratings at their 2-week visit. Results: A total of 68 patients were included. Preoperatively, there were no statistically significant differences between the 2 groups with respect to pain scores, coping skills, or carpal tunnel symptoms. At 2 weeks postoperatively, patients in the nonopioid group had lower average NPRS and QuickDASH scores. Patients who took opioids consumed an average of 5 pills. No patient randomized to the nonopioid group required any opioids. Patients in the nonopioid group demonstrated lower early postoperative NPRS scores. Patient satisfaction with their pain control regimen and outcome was not significantly different between the 2 groups at any time point. Conclusions: Nonopioid medications as part of a perioperative pain control strategy demonstrate improved pain scores compared with opioid medications with similar patient satisfaction and functional outcomes. Considering the risks associated with the use of opioid analgesics, we recommend against prescribing opioids after CTR, particularly in patients not currently taking narcotic medications.

Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery

BACKGROUND

Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery.

AREAS OF UNCERTAINTY

Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery.

DATA SOURCES

Narrative literature review using keywords, expert opinion, either during or from live conference.

THERAPEUTIC ADVANCES

Local and IA administration of NSAIDs for pain management in orthopedic surgery.

CONCLUSION

There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.

Assessing Preoperative Pain Sensitivity Predicts the Postoperative Analgesic Requirement and Recovery after Total Knee Arthroplasty: A Prospective Study of 178 Patients

BACKGROUND

The aim of this article is to study the correlation between preoperative pain sensitivity and postoperative pain and analgesic requirements for patients undergoing primary total knee arthroplasty.

METHODS

Between December 2018 and April 2019, the pain sensitivity of 178 consecutive patients undergoing primary total knee arthroplasty was assessed preoperatively with a digital algometer. The patients reported the VAS (visual analog scale) score at 3 instances of needle prick (phlebotomy, glucometer blood sugar, intradermal antibiotic test dose), during the range of movements and completed the Depression Anxiety Stress Scale score. Postoperative VAS score, analgesic requirement, and physiotherapy milestones were recorded in all these patients on day 0 to day 4.

RESULTS

The average age of the patients was 64.13 years and 69.1% were females. Females had lower mean algometry values (56.12 ± 12.77 [standard deviation]) compared to males (71.09 ± 18.78 [standard deviation]) (P < .001). Higher Depression Anxiety Stress Scale correlated with lower algometry values (P < .001). The postoperative VAS score was 2.54 ± 0.59 on the day of surgery which increased to 3.27 ± 0.69 on day 1 after mobilization (P < .001) and reduced to 1.67 ± 0.62 on day 4. Low algometer score correlated with higher postoperative VAS score (P < .05), increased analgesic requirement, and opioid utilization (P < .001), delay in achieving an optimum range of movements (P < .001) and independent ambulation (P < .001).

CONCLUSION

Preoperative assessment of pain sensitivity predicts postoperative analgesic requirements and recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively and prolonged physiotherapy.

Retrospective analyzing the effects of nerve block on postoperative pain management after total knee arthroplasty

Objective:

Total knee arthroplasty (TKA) is usually associated with moderate-to-severe postoperative pain. Our study investigated the possible benefits of the use of nerve blocks (NBs), including pain score reduction, the rescuing dosage of morphine, the timing of ambulation, and the length of stay (LOS) in the hospital.

Materials and Methods:

We included patients who underwent unilateral primary TKA due to primary knee osteoarthritis under general anesthesia with laryngeal mask airway. The control group only received oral pain medication with rescuing morphine injections, whereas the NB group received oral pain medication with an NB and rescuing morphine injections. We collected data on the patients' basic characteristics, postoperative visual analog scale (VAS), the dosage of rescuing morphine over 3 days, time to ambulation, and LOS in the hospital.

Results:

The NB group received significantly fewer morphine dose compared with the control group during postoperative days 1 to 3. There were no statistically significant differences between the NB and control groups on days 1 and 2 in the VAS score, and the VAS score was significantly lower in the NB group on postoperative day 3. The NB group had a significantly shorter time to ambulation compared with the control group. LOS did not differ significantly between the NB and control groups.

Conclusion:

Patients, who underwent TKA under general anesthesia with laryngeal mask airway (LMAGA) receiving NB for postoperative pain, needed less dosage of morphine and had the trend of having lower VAS. There was no association with LOS between two groups, but time to ambulation might be decreased with NB group. Some limitations might need to be further investigated in future study, such as NB regimens, knee function after TKA, muscle power, information after discharge, and NB-related complications.

The Impact of Epinephrine in the Periarticular Injection Cocktail using Ropivacaine for Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Comparison Study

BACKGROUND

Epinephrine is used in periarticular injection using ropivacaine to produce a synergistic effect when used with local anesthetic agents but the effect has not been proven yet. The purpose of this study is to evaluate how effective epinephrine is on postoperative clinical outcomes in primary total knee arthroplasty (TKA).

METHODS

One hundred sixteen cases (89 patients) who underwent primary TKA were randomized into 2 groups depending on whether epinephrine was mixed. Immediately after the operation, patient-controlled analgesia using fentanyl was initiated. The Numerical Rating Scale, the cumulative dose of fentanyl, active range of motion of the knee joint, and wound complications were evaluated postoperatively.

RESULTS

There were no significant differences in mean postoperative Numerical Rating Scale, cumulative dose of fentanyl, and active range of motion between the 2 groups. Neither skin necrosis nor wound dehiscence requiring operative management for skin care was required in either group.

CONCLUSION

The use of epinephrine in periarticular injection using ropivacaine after TKA did not have any effect on postoperative acute pain control and opioid usage.

THE LEVEL OF EVIDENCE

Therapeutic level I.

Efficacy of Periarticular Cocktail Injection in Rheumatoid Patients Undergoing Total Knee Replacement

BACKGROUND

Pain control after total knee replacement (TKR) is of primary importance to joint replacement surgeons to achieve good functional outcome post-surgery. This becomes even more challenging when these major procedures are done in immunocompromised patients like rheumatoid arthritis. Good peri-operative analgesia facilitates early rehabilitation, improves patient satisfaction, and reduces the hospital stay. The adverse effects caused by epidural analgesia or parenteral opioids can be avoided by replacing it with an analgesic cocktail locally. Our prospective study was to evaluate the benefits of a periarticular cocktail injection which was given in rheumatoid patients undergoing bilateral TKR in single sitting with respect to pain and knee motion recovery.

METHODS

Sixty-four rheumatoid arthritis patients undergoing simultaneous primary total knee replacement were included in the study. A total of 128 knees were randomized either to receive a periarticular intra-operative injection containing ropivacaine, fentanyl, clonidine, cefuroxime and epinephrine (Group A) on one knee and to receive plain ropivacaine (Group B) on the opposite knee. The perioperative and post-operative analgesic regimens were standardized. All patients received the same standard analgesia protocol. Visual analog scores for pain, knee range of motion and quadriceps function were recorded on the day of surgery, first post-operative day, second post-operative day, day of discharge, and 2 weeks and 6 weeks during follow-up. The need for rescue analgesic requirement and adverse effects to the cocktail injection were also noted during the study period.

RESULTS

The patients who received the periarticular cocktail fared better in terms of pain scores and functional recovery. Additional rescue agents used were significantly less at 6 h, at 12 h, and over the first 24 h after the surgery in group A when compared with group B. No cardiac or central nervous system toxicity was observed.

CONCLUSIONS

Periarticular cocktail injection significantly reduces the requirements for post-operative analgesia and also improves patient satisfaction, with no apparent risks, following total knee arthroplasty in rheumatoid arthritis.

Comparative study of the influence of adductor canal block plus multimodal periarticular infiltration versus combined adductor canal block, multimodal periarticular infiltration and intra-articular epidural catheter ropivacaine infiltration on pain relief after total knee arthroplasty: a prospective study

BACKGROUND

A combined regimen of adductor canal block (ACB) and multimodal periarticular infiltration (MPI) with local anesthetic (ropivacaine) is a known effective method of controlling pain in the first 6-8 h after total knee arthroplasty (TKA); however, managing breakthrough pain after their combined effect wears off can be challenging. We hypothesized that, by additionally leaving an intra-articular epidural catheter (IAEC) inside the knee with intermittent infiltration of local anesthetic in conjunction with ACB and MPI, it would help manage the breakthrough pain when their combined effect wears off.

METHODS

We did a prospective study in our institution between December 2015 and August 2016 on a total of 206 patients undergoing primary unilateral TKA. The initial consecutive 106 patients received ACB + MPI (Group 1, n = 106), and the subsequent 100 patients received ACB + MPI + IAEC (Group 2, n = 100). The primary outcome measure was pain using visual analogue scale (VAS) recorded at 6, 12, 24 and 48 h, and the secondary outcome measures were requirement for rescue analgesics and repeat adductor canal block and length of hospital stay.

RESULTS

There was no statistically significant difference in VAS scores between the two groups at 6 h but at 12, 24 and 48 h; there was a statistically significant difference between the two groups in terms of VAS scores, rescue analgesic requirements, repeat adductor canal block and shorter hospital stay favoring the ACB + MPI + IAEC group.

CONCLUSION

Intermittent knee infiltration with ropivacaine is a safe, reproducible and effective method to control pain in the first 48 h postoperative period after TKA.

Effect of Flurbiprofen and S-Flurbiprofen Patches on Multimodal Pain Management After Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

BACKGROUND

Total knee arthroplasty (TKA) is an established procedure for knee osteoarthritis. Multimodal analgesia is reportedly more effective for postoperative analgesia. We investigated the efficacy of 2 patches after TKA.

METHODS

Seventy-nine knees that underwent unilateral TKA for osteoarthritis were included. Oral administration, local periarticular analgesic injection, and patches were adopted for pain management. The knees were randomly assigned to the flurbiprofen patch (FPP), S-flurbiprofen patch (SFPP), and control (no patch) groups. Patch treatment was continued for 14 days. Pain according to the visual analog scale, knee flexion angle, renal dysfunction, gastrointestinal injury, duration of hospitalization, dermatitis, and the rate of using additional oral nonsteroidal anti-inflammatory drugs were compared (from preoperative to postoperative day 14).

RESULTS

The FPP, SFPP, and control groups included 29, 27, and 23 knees, respectively. Visual analog scale was lower in the FPP and SFPP groups than in the control group on days 1 and 3 (day 1: 24.4, 25.0, and 39.4, respectively; day 3: 25.5, 23.3, and 39.3, respectively). Knee flexion angle was larger in the SFPP group than in the control group on days 7 and 14 (day 7: 89.8° and 76.6°, respectively; day 14: 98.3° and 84.2°, respectively). Neither renal dysfunction nor gastrointestinal injury was confirmed. The duration of hospitalization did not differ among the groups. Dermatitis occurred only in the SFPP group. The rate of using additional oral nonsteroidal anti-inflammatory drugs was higher in the control group.

CONCLUSION

Both patches were effective and safe as part of multimodal analgesia for postoperative TKA.

Associations between ASA classification, self-estimated physical health, psychological wellbeing and anxiety among Swedish orthopaedic patients

BACKGROUND

The evaluation of one's physical health and psychological wellbeing may be subjective. Aspects of functional capacity, including the patients' own estimation of physical health and wellbeing, have been shown to be strong predictors of postoperative outcomes and should be the focus of further research.

AIM

This study aimed to explore the associations between ASA classification, self-estimated physical health, psychological wellbeing and anxiety among orthopaedic patients.

METHODS

This was a longitudinal study using a quantitative approach.

SETTINGS

A central county hospital in northern Sweden.

RESULTS

A high ASA classification rated by anaesthetists was not associated with physical health and psychological wellbeing self-estimated as less than good. A high ASA classification was significantly associated with self-estimated anxiety prior to surgery. Three days and one month post-surgery, the situation was reversed, and the ASA I/II group, to a significantly higher extent, rated that they felt anxiety.

CONCLUSION

Preoperative screening systems for orthopaedic patients should not only focus on the medical and objective physical issues but also include the patients' own estimation of their physical health and psychological wellbeing. It is essential that orthopaedic patients receive relevant information that provides a realistic outlook, as well as an honest and optimistic future view.

Efficacy and Safety of Buprenorphine Transdermal Patch for Immediate Postoperative Analgesia After Total Knee Arthroplasty Surgery

BACKGROUND

Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain. Satisfactory perioperative analgesia is essential for a good and predictable surgical outcome. Effective postoperative pain control is a major challenge to the treating surgeon and his team. Old age and multiple comorbidities restrict the choice of analgesics one can offer. Transdermal buprenorphine (TDB), widely used in chronic pain management, has been rarely studied in acute postoperative setting. The purpose of this study was to compare the safety and efficacy of a TDB patch to conventional analgesics after knee arthroplasty surgery.

METHODS

A prospective randomized study was conducted with 200 patients aged 60-75 years undergoing TKA surgery under neuraxial anesthesia. All patients received periarticular local anesthetic infiltration and epidural/femoral nerve block infusion for 72 hours postoperatively. Group A received the TDB patch 5 mcg applied at the end of surgery. Group B received a combination of paracetamol and tramadol. All patients received intravenous diclofenac as rescue analgesia. Pain scores at rest, on movement, and side effects, if any, were compared over 7 days using the numerical rating scale score.

RESULTS

Pain scores at rest and on movement were significantly lower in group A (P values .008 and .01). Rescue analgesia requirement was also significantly less in this group. Only one patient had clinically significant respiratory depression, and 3 patients had local erythema.

CONCLUSION

Our data shows that the TDB patch is more efficacious in reducing postoperative pain after TKA surgery and can be safely used with fewer systemic side effects when compared to conventional analgesics.

Factors Associated with a Second Opioid Prescription Fill in Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) creates a relatively large degree of nociception, making it a good setting to study variation in pain intensity and pain alleviation. The purpose of this study is to investigate factors associated with a second prescription of opioid medications within 30 days of primary TKA.

METHODS

Using an insurance database, we studied 1372 people over a 6-year period with no mental health comorbidities including substance misuse and no comorbid pain illness at the time of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA were sought among patient demographics and the overall prescription morphine milligram equivalents. Patient and prescription-related risk factors were evaluated utilizing logistic relative risk regression. We reserved a year of data, 222 people, to evaluate the performance of the derived model.

RESULTS

More than half the patients filled a second prescription for opioids within 30 days of TKA. Factors associated with a second prescription of opioid medication within 30 days of TKA included age (P < .01), current smoker (P = .01), and the total morphine milligram equivalents of the initial prescription (P < .01). Applied to the 222 people we reserved for validation, the model was 81% sensitive and 14% specific for a second prescription within 30 days, with a positive predictive value of 74%, and a negative predictive value of 20%.

CONCLUSION

People that are given more opioids tend to request more opioids, but our model had limited diagnostic performance characteristics indicating that we are not accounting for the key factors associated with a second opioid prescription. Future studies might address undiagnosed patient social and mental health opportunities, factors known to associate with pain intensity and satisfaction with pain alleviation.

LEVEL OF EVIDENCE

Diagnostic Level III.