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Farronato DM, Pezzulo JD, Juniewicz R, Rondon AJ, Cox RM, Davis DE. Effects of socioeconomic burden on opioid use following total shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00406-3. [PMID: 38852706 DOI: 10.1016/j.jse.2024.04.016] [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: 10/25/2023] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 06/11/2024]
Abstract
BACKGROUND Preoperative opioid users experience worse outcomes and higher complication rates compared to opioid-naïve patients following shoulder arthroplasty. This study evaluates the effects of socioeconomic status, as measured by the Distressed Communities Index (DCI), on pre- and postoperative opioid use and its influence on clinical outcomes such as readmission and revision surgery. METHODS A retrospective review of patients who underwent primary shoulder arthroplasty (Current Procedural Terminology code 23472) from 2014 to 2022 at a single academic institution was performed. Exclusion criteria included arthroplasty for fracture, active malignancy, and revision arthroplasty. Demographics, Charlson Comorbidity Index, DCI, and clinical outcomes including 90-day readmission and revision surgery were collected. Patients were classified according to the DCI score of their zip code. Using the Prescription Drug Monitoring Program database, patient pre- and postoperative opioid use in morphine milligram equivalents was gathered. RESULTS Individuals from distressed communities used more opioids within 90 days preoperatively compared to patients from prosperous, comfortable, mid-tier, and at-risk populations, respectively. Patients from distressed communities also used significantly more opioids within 90 days postoperatively compared with prosperous, comfortable, and mid-tier, respectively. Of patients from distressed communities, 35.1% developed prolonged opioid use (filling prescriptions >30 days after surgery), significantly more than all other cohorts. Among all patients, 3.5% were readmitted within 90 days and were more likely to be prolonged opioid users (38.9 vs. 21.3%, P < .001). Similarly, 1.5% of patients underwent revision surgery. Those who underwent revision were significantly more likely to be prolonged opioid users (38.2 vs. 21.7%, P = .002). CONCLUSIONS Shoulder arthroplasty patients from distressed communities use more opioids within 90 days before and after their surgery and are more likely to become prolonged opioid users, placing them at risk for readmission and revision surgery. Identifying patients at an increased risk for excess opioid use is essential to employ appropriate strategies that minimize the detrimental effects of prolonged use following surgery.
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Affiliation(s)
- Dominic M Farronato
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joshua D Pezzulo
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert Juniewicz
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander J Rondon
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan M Cox
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Daniel E Davis
- Rothman Orthopaedic Institute, Thomas Jefferson University, Philadelphia, PA, USA.
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Yhim HB, Yoo S, Park SK, Kim Y, Lim YJ, Kim JT. The Effect of Postoperative Single-Injection Adductor Canal Block in Total Knee Arthroplasty Under Spinal Anesthesia With Intraoperative Dexmedetomidine Infusion. Arthroplast Today 2024; 27:101366. [PMID: 38665389 PMCID: PMC11043871 DOI: 10.1016/j.artd.2024.101366] [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: 02/20/2023] [Revised: 02/20/2024] [Accepted: 02/27/2024] [Indexed: 04/28/2024] Open
Abstract
Background Single-injection adductor canal block (SACB) is one of the multimodal pain managements in total knee arthroplasty. The effect of an intrathecal local anesthetic is prolonged with an intraoperative dexmedetomidine infusion. Currently, SACB's effect along with the prolonged spinal anesthesia effect by dexmedetomidine has not been studied elsewhere. Methods Seventy-eight patients were randomized to either the SACB group (n = 39) or the control group (n = 39). Spinal anesthesia and continuous infusion of dexmedetomidine were performed intraoperatively. The SACB was performed using 15 mL of either 0.5% ropivacaine or normal saline in postanesthesia care unit postoperatively. Primary endpoint examined the average numerical rating scale (NRS) pain scores at 2, 6, 12, and 24 hours after SACB while resting or moving. The secondary outcomes were the morphine equivalent, postoperative nausea and vomiting score, quadriceps strength, and overall satisfaction score. Results The SACB group showed a lower average NRS pain score until 24 hours than the control group (2.4 vs 3.3 resting, 3.4 vs 4.1 moving). Resting and moving NRS scores at 6 and 12 hours were significantly lower in the SACB group, whereas no difference was found at 2, 24, and 48 hours, regardless of movement. The satisfaction score was higher in the SACB group than in the control group (9 [7.3-10.0] vs 7 [5.3-8.8]), and morphine equivalent at 2 hours was lower in the SACB group (2 [1-3]) than in the control group (2.9 [1.6-4]). Conclusions SACB provided an additional analgesic effect in patients undergoing total knee arthroplasty under spinal anesthesia with continuous dexmedetomidine intravenous infusion.
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Affiliation(s)
- Hyung-Been Yhim
- Department of Anesthesiology and Pain, Seoul Now Hospital, Pyeongchon, Korea
| | - Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Gangnam Severance Hospital, Yonsei University Medical Center, Seoul, Korea
| | - Youngwon Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young-Jin Lim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Seoul National University, Seoul, Korea
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3
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Bahoravitch T, Roberts M, Zhao A, Stake S, Ernst B, Thakkar SC. Trends From 2010 to 2019 in Opioid and Nonopioid Pain Management After Total Knee Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202406000-00006. [PMID: 38866713 PMCID: PMC11175854 DOI: 10.5435/jaaosglobal-d-23-00062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 03/04/2024] [Accepted: 03/11/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION As the opioid epidemic enters its third decade, we reflect on how it has affected clinical practice within the orthopaedic community. Recent studies show prolonged opioid use after total knee arthroplasty (TKA) is associated with worse overall health outcomes. This study aims to elucidate trends in pain management after TKA over the past decade. METHODS A retrospective analysis was performed using the PearlDiver database from 2010 to 2019. Patients who underwent primary TKA without a history of mental illness, complex pain syndromes, or opioids used 6 months before surgery were selected. Postoperative prescription filling rates of opioid and nonopioid at 30, 90 days, and 1 year from surgery were analyzed. Linear regression analysis and compound annual growth rates (CAGRs) were analyzed from 2010 to 2019, a P value <0.05 being considered significant. RESULTS Between 2010 and 2019, 579,269 patients underwent primary TKA. At 30 days, filling of prescriptions for opioids (CAGR = 3.54%) and nonopioids (CAGR = 15.50%) markedly increased from 2010 to 2019. At 90 days, opioids decreased (CAGR = -4.42%). At 1 year, opioid (CAGR = -10.92%) and nonopioid (CAGR = -2.12%) prescriptions markedly decreased from 2010 to 2019. DISCUSSION This study highlights patterns of decreased opioid prescription rates at 90 days and 1 year postoperatively from 2010 to 2019. Decreasing opioid rates may indicate effectiveness in targeted public health campaigns to curb opioid overuse.
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Affiliation(s)
- Tyler Bahoravitch
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Max Roberts
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Amy Zhao
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Seth Stake
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Brady Ernst
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
| | - Savyasachi C. Thakkar
- From the Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC (Dr. Bahoravitch, Ms. Zhao, and Dr. Stake); the Department of Biochemistry, Georgetown University Medical Center, Washington, DC (Dr. Roberts); the Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA (Dr. Ernst); and the Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Dr. Thakkar)
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Wagner ER, Hussain ZB, Karzon AL, Cooke HL, Toston RJ, Hurt JT, Dawes AM, Gottschalk MB. Methylprednisolone taper is an effective addition to multimodal pain regimens after total shoulder arthroplasty: results of a randomized controlled trial: 2022 Neer Award winner. J Shoulder Elbow Surg 2024; 33:985-993. [PMID: 38316236 DOI: 10.1016/j.jse.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/05/2023] [Accepted: 12/17/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Perioperative corticosteroids have shown potential as nonopioid analgesic adjuncts for various orthopedic pathologies, but there is a lack of research on their use in the postoperative setting after total shoulder arthroplasty (TSA). The purpose of this study was to assess the effect of a methylprednisolone taper on a multimodal pain regimen after TSA. METHODS This study was a randomized controlled trial (clinicaltrials.gov NCT03661645) of opioid-naive patients undergoing TSA. Patients were randomly assigned to receive intraoperative dexamethasone only (control group) or intraoperative dexamethasone followed by a 6-day oral methylprednisolone (Medrol) taper course (treatment group). All patients received the same standardized perioperative pain management protocol. Standardized pain journal entries were used to record visual analog pain scores (VAS-pain), VAS-nausea scores, and quantity of opioid tablet consumption during the first 7 postoperative days (POD). Patients were followed for at least one year postoperatively for clinical evaluation, collection of patient-reported outcomes, and observation of complications. RESULTS A total of 67 patients were enrolled in the study; 32 in the control group and 35 in the treatment group. The groups had similar demographics and comorbidities. The treatment group demonstrated a reduction in mean VAS pain scores over the first 7 POD. Between POD 1 and POD 7, patients in the control group consumed an average of 17.6 oxycodone tablets while those in the treatment group consumed an average of 5.5 tablets. This equated to oral morphine equivalents of 132.1 and 41.1 for the control and treatment groups, respectively. There were fewer opioid-related side effects during the first postoperative week in the treatment group. The treatment group reported improved VAS pain scores at 2-week, 6-week, and 12-week postoperatively. There were no differences in Europe Quality of Life, shoulder subjective value (SSV), at any time point between groups, although American Shoulder and Elbow Surgeons questionnaire scores showed a slight improvement at 6-weeks in the treatment group. At mean follow-up, (control group: 23.4 months; treatment group:19.4 months), there was 1 infection in the control group and 1 postoperative cubital tunnel syndrome in the treatment group. No other complications were reported. CONCLUSIONS A methylprednisolone taper course shows promise in reducing acute pain and opioid consumption as part of a multimodal regimen following TSA. As a result of this study, we have included this 6-day methylprednisolone taper course in our multimodal regimen for all primary shoulder arthroplasties. We hope this trial serves as a foundation for future studies on the use of low-dose oral corticosteroids and other nonnarcotic modalities to control pain after shoulder surgeries.
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Affiliation(s)
- Eric R Wagner
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA.
| | - Zaamin B Hussain
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Anthony L Karzon
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Hayden L Cooke
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Roy J Toston
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - John T Hurt
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
| | - Alexander M Dawes
- Department of Orthopaedic Surgery Emory University, Atlanta, GA, USA
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Sarridou D, Gkiouliava A, Argiriadou H, Varrassi G, Chalmouki G, Vadalouca A, Moka E. The Efficacy of the Combination of Continuous Femoral Nerve Block and Intravenous Parecoxib on Rehabilitation in Patients Undergoing Total Knee Arthroplasty: A Double-Blind, Randomized Clinical Trial. Cureus 2024; 16:e56420. [PMID: 38638774 PMCID: PMC11024488 DOI: 10.7759/cureus.56420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/18/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND AND AIM The optimal strategy for the management of postoperative pain after total knee arthroplasty (TKA) remains challenging, while its treatment is crucial to increase patients' outcomes. This study aimed to investigate the effects of parecoxib as add-on therapy, in a standard postoperative pain management protocol, represented by the continuous femoral nervous block. We studied its influence on rehabilitation indices and pain scores in patients undergoing TKA. MATERIAL AND METHODS This is a single-center, prospective, double-blind, randomized, placebo-controlled trial. All patients were operated with the use of subarachnoid anesthesia, and divided into two groups for postoperative analgesia. Both groups received a continuous femoral nerve block. One of the groups received intravenous parecoxib, while the other received a placebo. The primary investigated outcome was the range of motion (ROM). Recordings were noted at different times postoperatively. Bromage score (BS), visual analog scale (VAS), and the State-Trait Anxiety Inventory (STAI) were also studied. RESULTS A total of 90 patients were included and analyzed. ROM was significantly better (p<0.001) and pain scores were significantly lower (p=0.007) in the parecoxib group. No statistically significant difference was found with regard to BS between the two groups. A significant correlation was found between ROM and VAS pain scores at 12 hours (p=0.02), while ROM was inversely correlated with STAI postoperatively. CONCLUSIONS The use of intravenous parecoxib is effective in improving rehabilitation indices and provides decreased postoperative pain scores after TKA.
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Affiliation(s)
- Despoina Sarridou
- Anesthesiology and Intensive Care, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Anna Gkiouliava
- Anesthesiology and Intensive Care, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Helena Argiriadou
- Anesthesiology and Intensive Care, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | | | | | | | - Eleni Moka
- Anesthesiology, Creta InterClinic Hospital, Herakleion, GRC
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6
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Kim JY, Lee JS, Kim JY, Yoon EJ, Lee W, Lee S, Kim DH. Iliopsoas plane block does not improve pain after primary total hip arthroplasty in the presence of multimodal analgesia: a single institution randomized controlled trial. Reg Anesth Pain Med 2024:rapm-2023-105092. [PMID: 38286736 DOI: 10.1136/rapm-2023-105092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 01/17/2024] [Indexed: 01/31/2024]
Abstract
BACKGROUND The clinical analgesic efficacy of iliopsoas plane block remains a subject of discussion. This study aimed to assess the analgesic efficacy of iliopsoas plane block under general anesthesia using multimodal analgesia. METHODS Fifty-six adult patients who underwent elective primary hip arthroplasty were enrolled. Patients were randomized to receive either a single-shot iliopsoas plane block (10 mL 0.75% ropivacaine with 1:200 000 epinephrine) or a sham block (10 mL normal saline). All patients received general anesthesia, multimodal analgesia (preoperative buprenorphine patch, 5 µg/h), intraoperative intravenous dexamethasone (8 mg) and nefopam (20 mg), and round-the-clock acetaminophen and celecoxib. The primary outcome was the numeric rating scale pain score at rest 6 hour after surgery. RESULTS Iliopsoas plane block did not have a notable advantage over the sham block in terms of pain relief at rest, as assessed by the numeric rating scale score, 6 hour after total hip arthroplasty (iliopsoas plane block: median, 4.0; IQR, 2.0-5.8; sham: median, 5.5; IQR, 2.3-6.8; median difference, -1.0; 95% CI -2.0 to 0.0; p≥0.999). Linear mixed model analysis showed no differences in pain scores, opioid consumption, quadriceps strength, or quality of recovery between the groups. CONCLUSIONS Iliopsoas plane block did not improve postoperative analgesia following total hip arthroplasty under general anesthesia with a multimodal analgesic regimen. The blockade of sensory femoral branches supplying the anterior hip capsule using iliopsoas plane block may not yield additional benefits concerning patient outcomes in the aforementioned clinical context. TRIAL REGISTRATION NUMBER NCT05212038, https://clinicaltrials.gov/ct2/show/NCT05212038.
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Affiliation(s)
- Ji Yeong Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong Seok Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Young Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Jang Yoon
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Wootaek Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seungyeon Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Do-Hyeong Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Hansen CW, Carlino EK, Saunee LA, Dasa V, Bhandutia AK. Modern Perioperative Pain Management Strategies to Minimize Opioids after Total Knee Arthroplasty. Orthop Clin North Am 2023; 54:359-368. [PMID: 37718075 DOI: 10.1016/j.ocl.2023.05.002] [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] [Indexed: 09/19/2023]
Abstract
Total Knee Arthroplasty is associated with significant postoperative pain that can limit functional outcomes and patient satisfaction. In recent years, the standard of care for postoperative pain management has reduced reliance on opioids in favor of multimodal analgesia. These regimens consist of systemic medications such as COX-2 inhibitors, acetaminophen, corticosteroids, and gabapentinoids, as well as regional and local approaches such as peripheral nerve blocks and local infiltrative analgesics. Newer therapies, such as cryoneurolysis, are still being studied but have shown promising results. Additional studies are needed to determine the ideal pain regimen that will optimize pain control and eliminate the need for postoperative opioids.
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Affiliation(s)
- Charles W Hansen
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Elizabeth K Carlino
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA.
| | - Lauren A Saunee
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Vinod Dasa
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
| | - Amit K Bhandutia
- Department of Orthopaedic Surgery, Louisiana State University, Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112, USA
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Ihejirika-Lomedico R, Solasz S, Lorentz N, Egol KA, Leucht P. Effects of Intraoperative Local Pain Cocktail Injections on Early Function and Patient-Reported Outcomes: A Randomized Controlled Trial. J Orthop Trauma 2023; 37:433-439. [PMID: 37199438 DOI: 10.1097/bot.0000000000002628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To determine whether a perioperative pain cocktail injection improves postoperative pain, ambulation distance, and long-term outcomes in patients with hip fracture. DESIGN Prospective, single-blinded, randomized controlled trial. SETTING Academic Medical Center. PATIENTS/PARTICIPANTS Patients with OTA/AO 31A1-3 and 31B1-3 fractures undergoing operative fixation, excluding arthroplasty. INTERVENTION Multimodal local injection of bupivacaine (Marcaine), morphine sulfate (Duramorph), ketorolac (Toradol) given at the fracture site at the time of hip fracture surgery (Hip Fracture Injection, HiFI). MAIN OUTCOME MEASUREMENTS Patient-reported pain, American Pain Society Patient Outcome Questionnaire (APS-POQ), narcotic usage, length of stay, postoperative ambulation, Short Musculoskeletal Function Assessment. RESULTS Seventy-five patients were in the treatment group and 109 in the control group. Patients in the HiFI group had a significant reduction in pain and narcotic usage compared with the control group on postoperative day (POD) 0 ( P < 0.01). Based on the APS-POQ, patients in the control group had a significantly harder time falling asleep, staying asleep, and experienced increased drowsiness on POD 1 ( P < 0.01). Patient ambulation distance was greater on POD 2 ( P < 0.01) and POD 3 ( P < 0.05) in the HiFI group. The control group experienced more major complications ( P < 0.05). At 6-week postop, patients in the treatment group reported significantly less pain, better ambulatory function, less insomnia, less depression, and better satisfaction than the control group as measured by the APS-POQ. The Short Musculoskeletal Function Assessment bothersome index was also significantly lower for patients in the HiFI group, P < 0.05. CONCLUSIONS Intraoperative HiFI not only improved early pain management and increased ambulation in patients undergoing hip fracture surgery while in the hospital, it was also associated with early improved health-related quality of life after discharge. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Sara Solasz
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY; and
| | - Nathan Lorentz
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY; and
| | - Kenneth A Egol
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY; and
| | - Philipp Leucht
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY; and
- Department of Cell Biology, NYU Grossman School of Medicine, New York, NY
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9
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Azimi A, Hooshmand E, Mafi AA, Tabatabaei FS. Effect of duloxetine on opioid consumption and pain after total knee and hip arthroplasty: a systematic review and meta-analysis of randomized clinical trials. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1035-1045. [PMID: 37027215 DOI: 10.1093/pm/pnad045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/27/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023]
Abstract
OBJECTIVES The purpose of this study was to investigate the analgesic effects of duloxetine, specifically on postoperative pain, opioid consumption, and related side effects following total hip or knee arthroplasty. METHODS In this systematic review and meta-analysis, Medline, Cochrane, EMBASE, Scopus, and Web of Science were searched until November 2022 for studies which compared duloxetine with placebo when added to routine pain management protocols. Individual study risk of bias assessment was conducted based on Cochrane risk of bias tool 2. Random effect model meta-analysis was done on mean differences, to evaluate the outcomes. RESULTS Nine randomized clinical trials (RCT) were included in the final analysis, totaling 806 patients. Duloxetine reduced opioid consumption (oral morphine milligram equivalents) on postoperative days (POD) 2 (mean difference (MD): -14.35, P = .02), POD 3 (MD: -13.6, P < .001), POD 7 (MD: -7.81, P < .001), and POD 14 (MD: -12.72, P < .001). Duloxetine decreased pain with activity on POD 1, 3, 7, 14, 90 (All P < .05), and pain at rest on POD 2, 3, 7, 14, and 90 (all P < .05). There was no significant difference in the prevalence of the side effects, except for increased risk of somnolence/drowsiness (risk ratio: 1.87, P = .007). CONCLUSION Current evidence shows low to moderate opioid sparing effects of perioperative duloxetine and a statistically but not clinically significant reduction in pain scores. Patients treated with duloxetine had an increased risk for somnolence and drowsiness.
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Affiliation(s)
- Amirali Azimi
- Department of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Elham Hooshmand
- Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Amir Ali Mafi
- Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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10
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McNamara CA, Laurita J, Lambert BS, Sullivan TC, Clyburn TA, Incavo SJ, Park KJ. A multimodal intraosseous infusion of morphine and ketorolac decreases early postoperative pain and opioid consumption following total knee arthroplasty. Knee 2023; 43:129-135. [PMID: 37399631 DOI: 10.1016/j.knee.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/06/2023] [Accepted: 06/03/2023] [Indexed: 07/05/2023]
Abstract
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.
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Affiliation(s)
- Colin A McNamara
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Jason Laurita
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Bradley S Lambert
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Thomas C Sullivan
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Terry A Clyburn
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Stephen J Incavo
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Kwan J Park
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX, USA.
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11
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Arraut J, Thomas J, Oakley C, Umeh UO, Furgiuele DL, Schwarzkopf R. Peripheral Nerve Catheter Reduces Postoperative Opioid Consumption and Pain in Revision Total Knee Arthroplasty. Arthroplast Today 2023; 22:101155. [PMID: 37663072 PMCID: PMC10472143 DOI: 10.1016/j.artd.2023.101155] [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: 12/28/2022] [Revised: 03/22/2023] [Accepted: 05/08/2023] [Indexed: 09/05/2023] Open
Abstract
Background Patients undergoing revision total knee arthroplasty (rTKA) have historically received high doses of opioids during the perioperative period. As awareness of opioid use has heightened, opioid administration has continuously decreased. This study aimed to evaluate if peripheral nerve catheter (PNC) use in rTKA reduces opiate consumption while maintaining similar pain control and postoperative function levels. Methods A retrospective review of 354 patients who underwent rTKA between July 2019 and January 2022 was conducted. Fifty total patients who received an adductor canal PNC were propensity-matched 1:1 to a control group of 50 patients that did not receive a PNC. To assess the primary outcome of opiate consumption, nursing documented opiate administration events were converted into morphine milligram equivalents per 24-hour interval. Postoperative pain and functional status were assessed using the verbal rating scale for pain and the Activity Measure for Post-Acute Care scores, respectively. Results Compared to the control group, the PNC group demonstrated significantly lower overall inpatient opiate consumption (98.68 ± 117.03 vs 176.69 ± 203.47 morphine milligram equivalents; 44.15% decrease, P = .021) and lower verbal rating scale pain scores at 60 to 72 hours postoperatively (4.85 ± 1.24 vs 5.83 ± 1.35; 16.81% decrease, P = .038). There was no significant difference in Activity Measure for Post-Acute Care scores postoperatively (raw score: 19.41 ± 3.61 vs 19.46 ± 3.18; 0.26% decrease, P = .952). Finally, the PNC cohort was significantly less likely to be readmitted within 90 days after surgery (0.0% vs 12.0%; P = .012). Conclusions In rTKA patients, PNC can significantly reduce inpatient opioid consumption while maintaining a comparable functional recovery and superior pain control. Level III Evidence Retrospective Cohort Study.
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Affiliation(s)
- Jerry Arraut
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Christian Oakley
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Uchenna O. Umeh
- Department of Anesthesiology, Critical Care and Pain Medicine, Hospital for Special Surgery, New York, NY, USA
| | - David L. Furgiuele
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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12
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Matthews DE, Rella RT. Retrospective Analysis of Surgeon-Placed Nerve Block and Indwelling Catheter in the Adductor Canal in Total Knee Arthroplasty. Cureus 2023; 15:e39833. [PMID: 37397678 PMCID: PMC10314755 DOI: 10.7759/cureus.39833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is now being performed in the outpatient setting, and often the postoperative pain is managed with opioid analgesics. Non-opioid pain management modalities are in crucial demand, and we propose a surgical technique that can potentially result in less pain and the decrease in the use of opioid analgesia following TKA. The purpose of this study was to investigate the safety and efficacy of a novel peripheral nerve block (PNB) that includes a single injection and catheter placement for a continuous regional nerve block in total knee arthroplasty. METHODS Fifty-six patients underwent TKA by a single surgeon utilizing the novel method. Patient-reported outcomes were entered into an outcomes database and compared to an aggregate of over 3,500 comparative TKA patients. A visual analog scale (VAS) evaluated perioperative pain. Patient perioperative opioid usage, expectations of pain control, the incidence of common side effects, and the average hospital length of stay (LOS) were collected. RESULTS Compared to the aggregate of patients in the database, the patients who received the novel surgeon-placed adductor canal block (ACB) and catheter placement reported findings that suggest this technique can possibly lead to a decrease in the severity of pain in addition to a reduction in side effects and the need for opioid analgesia. LOS for these patients was short, and patient satisfaction scores were excellent for the surgeon performing this technique. CONCLUSIONS Using the placement technique described, surgeons can reproducibly perform a single injection of PNB and place an indwelling catheter in the adductor canal through direct visualization of the muscles that make up the borders of the adductor canal. This technique offers potential advantages over pain management modalities that can be elucidated in further studies. The power of this study is limited due to these findings having not been analyzed for statistical significance.
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Affiliation(s)
- Daniel E Matthews
- Orthopedic Surgery, University of South Alabama College of Medicine, Mobile, USA
- Orthopedic Surgery, Alabama Orthopedic Sports Medicine, Daphne, USA
| | - Robert T Rella
- Orthopedic Surgery, University of South Alabama College of Medicine, Mobile, USA
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13
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Visser TG, Cross AS, Mason MW. Effects of a Continuous Adductor Canal Block After Total Knee Arthroplasty. Orthopedics 2023; 46:185-191. [PMID: 36719421 DOI: 10.3928/01477447-20230125-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.].
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14
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Schwartz A, Cochrane NH, Jiranek WA, Ryan SP. Periarticular Injection in Total Knee Arthroplasty. J Am Acad Orthop Surg 2023:00124635-990000000-00672. [PMID: 37071876 DOI: 10.5435/jaaos-d-22-01179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 03/19/2023] [Indexed: 04/20/2023] Open
Abstract
Optimal pain management after total knee arthroplasty (TKA) can expedite postoperative recovery, improve perioperative outcomes, and increase patient satisfaction. Periarticular injections (PAIs) have become increasingly used to improve pain management after TKA. Similar to peripheral nerve blocks, the use of intraoperative PAIs can lower pain scores and expedite discharge from the hospital. However, there is notable variability in the ingredients and administration techniques of PAIs. Currently, no standard of care exists for PAIs, especially in the setting of adjuvant peripheral nerve blocks. This study seeks to evaluate the ingredients, administration techniques, and outcomes of PAIs used during TKA.
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Affiliation(s)
- Andrew Schwartz
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC (Schwartz, Cochrane, Jiranek, and Ryan), and the Department of Orthopaedic Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA (Schwartz)
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15
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Sparks Joplin T, Bhatia MB, Robbins CB, Morocho CD, Chiang JC, Murphy PB, Miller EM, Meagher AD, Padilla-Jones BB. Implementation of Multimodal Pain Protocol Associated With Opioid Use Reduction in Trauma Patients. J Surg Res 2023; 284:114-123. [PMID: 36563452 DOI: 10.1016/j.jss.2022.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 09/29/2022] [Accepted: 10/17/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Many trauma centers have adopted multimodal pain protocols (MMPPs) to provide safe and effective pain control. The objective was to evaluate the association of a protocol on opioid use in trauma patients and patient-reported pain scores. METHODS This was a retrospective review of adult trauma patients admitted from 7/1-9/30/2018 to 7/1-9/30/2019 at an urban academic level 1 trauma center. The MMPP consisted of scheduled nonopioid medications implemented on July 1, 2019. Patients were stratified by level of care upon admission, intensive care unit (ICU) or floor, and by injury severity score (ISS) (ISS < 16 or ISS ≥ 16). Pain scores, opioid, and nonopioid analgesic medication use were compared for the hospital stay or first 30 d. RESULTS Seven hundred ninety eight patients were included with a mean age of 54 ± 22 y and 511 (64.0%) were men. Demographic and clinical characteristics between those in the pre-MMP (n = 404) and post-MMPP (n = 394) groups were not different. The average pain scores were not different between the two groups (3.7 versus 3.8, P = 0.44), but patients in the post-MMPP group received 36% less morphine milliequivalents (109.6 versus 70; P < 0.0001). The MMPP had the largest effect on patients admitted to the ICU regardless of injury severity. ICU patients with ISS ≥ 16 had the greatest reduction in morphine milliequivalents (174.6 versus 84.4; P < 0.0001). The use of nonopioid analgesics was significantly increased in all groups. CONCLUSIONS A MMPP is associated with a reduction of opioids and increase in nonopioid analgesics with no difference in patient-reported pain scores.
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Affiliation(s)
| | - Manisha B Bhatia
- Indiana University, Department of Surgery, Indianapolis, Indiana
| | - Christopher B Robbins
- South Dakota State University, Department of Allied and Population Health, University Station Brookings, Brookings, South Dakota
| | | | - Jessica C Chiang
- NYU Langone Hospital-Brooklyn, Department of Surgery, Brooklyn, New York
| | - Patrick B Murphy
- Medical College of Wisconsin, Department of Surgery, Division of Trauma and Acute Care Surgery, Milwaukee, Wisconsin
| | - Emily M Miller
- Indiana University Health, Department of Pharmacy, Indianapolis, Indiana
| | - Ashley D Meagher
- Indiana University, Department of Surgery, Indianapolis, Indiana
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16
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Zhang LK, Li Q, Fang YF, Qi JW. Effect of duloxetine on pain relief after total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2023; 102:e33101. [PMID: 36897714 PMCID: PMC9997837 DOI: 10.1097/md.0000000000033101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/06/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Postoperative pain is one of the most feared complications of total knee arthroplasty. Recently, randomized controlled trials have compared the efficacy of duloxetine in patients undergoing total knee arthroplasty. However, there is no definite answer as to the efficacy and safety of duloxetine. METHODS Randomized controlled trials about relevant studies were searched from PubMed (1996 to July 2022), Embase (1996 to July 2022), and Cochrane Library (CENTRAL, July 2022). RESULTS Six high-quality studies containing 532 patients met the inclusion criteria. Results show patients in the duloxetine group had better performance in terms of visual analog scale (P < .05), equivalent morphine consumption (P < .05), and length of stay (P < .05). CONCLUSION Duloxetine can be used to reduce pain after knee arthroplasty in selected patients.
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Affiliation(s)
- Lu-Kai Zhang
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Qiang Li
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Yan-Fen Fang
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
| | - Ji-Wei Qi
- Department of Orthopedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, People’s Republic of China
- Department of Orthopedics, Affiliated Jiangnan Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, People’s Republic of China
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17
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Wang Q, Zhao C, Hu J, Ma T, Yang J, Kang P. Efficacy of a Modified Cocktail for Periarticular Local Infiltration Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial. J Bone Joint Surg Am 2023; 105:354-362. [PMID: 36856693 DOI: 10.2106/jbjs.22.00614] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Periarticular local infiltration analgesia (LIA) is largely utilized for controlling pain after total knee arthroplasty (TKA). The present work aimed to assess the efficacy of a modified LIA cocktail for patients undergoing TKA. METHODS Magnesium sulfate (MgSO4) and sodium bicarbonate (NaHCO3) were added to a conventional LIA cocktail comprising ropivacaine, epinephrine, and dexamethasone. After the safety of this modified cocktail was tested in rats, its efficacy and safety were evaluated in a prospective, double-blinded study including 100 individuals randomized to receive periarticular infiltration of the modified cocktail or a conventional cocktail. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes were the time until the first rescue analgesia, postsurgical pain (on a visual analog scale [VAS]), functional recovery (assessed by range of knee motion and ambulation distance), time to discharge, and complication rates. RESULTS Adding NaHCO3 to the local anesthetics caused some instantaneous precipitation in all cases. Administering the modified cocktail to rats did not obviously damage the injected area of the nerve or surrounding tissues. Administration of the modified cocktail to patients was associated with markedly reduced postsurgical morphine use in the initial 24 hours (4.2 ± 5.0 versus 14.6 ± 8.9 mg, p < 0.001), reduced total morphine use (9.8 ± 8.4 versus 19.6 ± 11.4 mg, p < 0.001), prolonged time to the first rescue analgesia, lower VAS pain scores at rest and during motion at 12 and 24 hours following the operation, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. The modified and conventional cocktail groups had similar rates of complications. CONCLUSIONS The present modification of a conventional cocktail significantly prolonged analgesia and reduced opioid consumption, which may substantially improve pain control in arthroplasty. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Qiuru Wang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Chengcheng Zhao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jian Hu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Ting Ma
- Anesthesia and Surgery Center, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jing Yang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Pengde Kang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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18
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Wang JH, Ma HH, Chou TFA, Tsai SW, Chen CF, Wu PK, Chen WM. Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis. J Knee Surg 2023; 36:345-353. [PMID: 34600437 DOI: 10.1055/s-0041-1733882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: -1.18; 95% confidence interval [CI]: -2.05 to -0.30) and during activity (SMD: -0.26; 95% CI: -0.49 to -0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: -0.295; 95% CI: -0.543 to -0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.
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Affiliation(s)
- Jou-Hua Wang
- Department of Orthopedics, National Cheng Kung University, Tainan, Taiwan
| | - Hsuan-Hsiao Ma
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Te-Feng Arthur Chou
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Wen Tsai
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Fong Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Po-Kuei Wu
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Ming Chen
- Department of Orthopedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Orthopedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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19
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Arraut J, Thomas J, Oakley CT, Barzideh OS, Rozell JC, Schwarzkopf R. The AAHKS Best Podium Presentation Research Award: A Second Dose of Dexamethasone Reduces Postoperative Opioid Consumption and Pain in Total Joint Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00098-0. [PMID: 36775214 DOI: 10.1016/j.arth.2023.02.007] [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: 08/11/2022] [Revised: 01/30/2023] [Accepted: 02/03/2023] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND The optimal administration of dexamethasone for postoperative pain management and recovery following primary elective total joint arthroplasty (TJA) remains unclear. This study aimed to evaluate the effect of a second intravenous (IV) dose of dexamethasone on postoperative pain scores, inpatient opioid consumption, and functional recovery after total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS A retrospective review was conducted of 2,256 primary elective THAs and 1,951 primary elective TKAs between May 2020 and April 2021. Patients who received 2 perioperative doses (2D) of dexamethasone 10 mg IV were propensity-matched 1:1 to a control group who received 1 perioperative dose (1D). Primary outcomes were opiate consumption as morphine milligram equivalences (MMEs), postoperative pain as Verbal Rating Scale (VRS) pain scores, and functional status assessed by the Activity Measure for Post-Acute Care (AM-PAC) scores. RESULTS The 2D THA and 2D TKA cohorts consumed significantly less opiates at the 24 to 48-hour and 48 to 72-hour intervals. The 2D TKA cohort had significantly lower total opiate consumption compared to the 1D TKA cohort. Compared to the 1D cohorts, the 2D THA cohort and 2D TKA cohorts had significantly lower pain scores at the 48 to 60-hour interval; additionally, the 2D TKA cohort had significantly lower pain scores in the 36 to 48-hour interval. AM-PAC scores did not differ between cohorts for both TKA and THA at any interval. CONCLUSION The administration of a second perioperative dexamethasone dose significantly decreased opioid consumption in the immediate postoperative period. Inpatient opioid administration can be significantly reduced while maintaining comparable functional recovery and superior pain control. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Jerry Arraut
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Jeremiah Thomas
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Christian T Oakley
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Omid S Barzideh
- Department of Orthopedic Surgery, NYU Langone Health, Mineola, New York
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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20
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Lemme NJ, Glasser JL, Yang DS, Testa EJ, Daniels AH, Antoci V. Chronic Obstructive Pulmonary Disease Associated with Prolonged Opiate Use, Increased Short-Term Complications, and the Need for Revision Surgery following Total Knee Arthroplasty. J Knee Surg 2023; 36:335-343. [PMID: 34530476 DOI: 10.1055/s-0041-1733883] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a condition which causes a substantial burden to patients, physicians, and the health care system at large. Medical comorbidities are commonly associated with adverse health outcomes in the postoperative period. Here, we present a large database review of patients undergoing total knee arthroplasty (TKA) to determine the effect of COPD on patient outcomes. The PearlDiver database was queried for all patients who underwent TKA between 2007 and the first quarter of 2017. Medical complications, surgical complications, 30-day readmission rates, revision rates, and opioid utilization were assessed at various intervals following TKA among patients with and without COPD. Multivariable regression was used to calculate adjusted odds ratios controlling for age, sex, and medical comorbidities. A total of 46,769 TKA patients with COPD and 120,177 TKA patients without COPD were studied. TKA patients with COPD experienced increased risk of 30-day readmission (40.8% vs. 32.2%, p < 0.0001), 30-day total medical complications (10.2% vs. 7.0%, p < 0.0001), prosthesis explanation at 6 months (0.4% vs. 0.2, p = 0.0130), 1 year (0.6% vs. 0.3%, p = 0.0005), and 2 years (0.8% vs. 0.5%, p = 0.0003), as well as an increased rate of revision (p < 0.0046) compared to TKA patients without COPD. Opioid utilization of TKA patients with COPD was greater significantly than that of TKA patients without COPD at 3, 6, and 12 months. Patients with COPD have an increased risk for medical and surgical complications, readmission, and prolonged opioid use following TKA.
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Affiliation(s)
- Nicholas J Lemme
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jillian Lynn Glasser
- Department of Adult Reconstruction, University Orthopedics, East Providence, Rhode Island
| | - Daniel S Yang
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Spine Surgery, University Orthopedics, East Providence, Rhode Island
| | - Valentin Antoci
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Adult Reconstruction, University Orthopedics, East Providence, Rhode Island
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21
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Management of perioperative pain after TKA. Orthop Traumatol Surg Res 2023; 109:103443. [PMID: 36252926 DOI: 10.1016/j.otsr.2022.103443] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/05/2022] [Accepted: 04/15/2022] [Indexed: 11/05/2022]
Abstract
Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.
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22
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Khan MI, Khandadashpoor S, Rai Y, Vertolli G, Backstein D, Siddiqui N. Comparing Analgesia on an As-Needed Basis to Traditional Intravenous Patient-Controlled Analgesia Within Fast-Track Orthopedic Procedures: A Randomized Controlled Trial. Pain Manag Nurs 2022; 23:832-837. [PMID: 35599141 DOI: 10.1016/j.pmn.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 04/05/2022] [Accepted: 04/16/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The aim was to determine if the use of intravenous patient-controlled analgesia (IVPCA) in a fast-track joint replacement program is associated with increased use of perioperative opioid consumption and increased length of hospital stay. DESIGN A prospective, double-blind, randomized controlled trial. SETTINGS Academic hospital. PARTICIPANTS/SUBJECTS A total of 80 patients aged 18-85 years, with body mass index (BMI) 18-40, undergoing elective total knee arthroplasty were recruited. METHODS Pre-operatively, patients received gabapentin, celecoxib, and acetaminophen. Peri-operatively, patients received spinal anesthesia with morphine and fentanyl, and periarticular local anesthetic administration by the surgeon. Postoperatively, 80 patients were randomized by a computer-generated sequence into IVPCA group (group A, n = 40) and non-IVPCA group (group B, n = 40). RESULTS The primary outcome was 48-hour postoperative opioid consumption and length of hospital stay. Secondary outcomes included side effects of opioids, patient satisfaction, and pain scores. There was no significant difference within 48-hour postoperative opioid consumption (median 61.3 vs. 87.5, p = .181) and length of hospital stay (median 49.8 hours vs. 49.5 hours; p = .89) between the two groups. Also, there was no significant difference in patient satisfaction (median 5 in both groups), pain scores, and opioid-related side effects. CONCLUSIONS IVPCA was associated with nonsignificant reduction in opioid exposure in elective total knee arthroplasty surgery within 48 hours. Neither group was superior in terms of length of hospital stay, opioid related side-effects, pain scores, and patient satisfaction.
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Affiliation(s)
- Muhammad Imran Khan
- From the Department of Anesthesia, Mount Sinai Hospital, University Health Network, University of Toronto, Canada
| | - Shiva Khandadashpoor
- From the Department of Anesthesia, Mount Sinai Hospital, University Health Network, University of Toronto, Canada
| | - Yeshith Rai
- From the Department of Anesthesia, Mount Sinai Hospital, University Health Network, University of Toronto, Canada
| | - Giuliana Vertolli
- From the Department of Anesthesia, Mount Sinai Hospital, University Health Network, University of Toronto, Canada
| | - David Backstein
- Department of Orthopedic Surgery, Mount Sinai Hospital, University Health Network, University of Toronto, Canada
| | - Naveed Siddiqui
- From the Department of Anesthesia, Mount Sinai Hospital, University Health Network, University of Toronto, Canada.
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Periarticular multimodal analgesia in decreasing perioperative pain in tibial plateau fractures: A double blind randomized controlled pilot study. Injury 2022; 53:4123-4128. [PMID: 36207154 DOI: 10.1016/j.injury.2022.09.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 09/22/2022] [Accepted: 09/25/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The use of periarticular multimodal analgesia injections is increasing and has become commonplace in some surgeries. However, there is no data on the effectiveness of local periarticular multimodal analgesia for tibial plateau fractures. We hypothesized that closed tibial plateau fracture patients receiving the local multimodal analgesic medications would experience a decrease in VAS pain scores. METHODS Patients aged between 18 and 79 with an isolated closed tibial plateau fracture (AO 41-B and C) were prospectively enrolled and randomized in a 1:1 double blinded fashion to either a placebo or active medication treatment arm. After ORIF, gel-foam sponges soaked in either multimodal analgesic solution or normal saline. Patients were followed for 24 h post-operatively with Visual Analog pain Scores (VAS). Patients were monitored post-operatively for complications including compartment syndrome, infection, and non-union. RESULTS The planned study was terminated prior to completion due to higher than anticipated rates of infection (18%), distributed equally among active (3) and placebo (2) groups, raising concerns that this may have been due to the presence of the delivery device. Twenty-eight patients were enrolled, 15 in the active group and 13 in the placebo group. Patients in the active medication group had significantly decreased pain scores at hours 4 (p = 0.005, 4.2 vs 6.9), 8 (p = 0.05, 5 vs 7), and 12 (p = 0.02, 3.8 vs 6.2). Pain scores at hours 16 (p = 0.10, 4.5 vs 6.5), 20 (p = 0.08, 4.6 vs 6.4), and 24 (p = 0.10, 4.8 vs 6.5) were also decreased but did not reach significance. DISCUSSION The use of local multimodal periarticular analgesic for closed tibial plateau fractures appears to be beneficial for short-term pain control post-operatively. Concerns regarding an implantable delivery vehicle leading to infection has warranted a change in method of drug administration. Completion of the full study will permit us to validate or refute these findings. LEVEL OF EVIDENCE Therapeutic Level 1.
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Lentine B, Beesley H, Dicken Q, Niu R, Freccero DM, Smith EL. Reduced Narcotic Utilization in Total Joint Arthroplasty Patients in an Urban Tertiary Care Center. Arthroplast Today 2022; 18:125-129. [PMID: 36325518 PMCID: PMC9619144 DOI: 10.1016/j.artd.2022.09.008] [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: 10/14/2021] [Revised: 08/07/2022] [Accepted: 09/12/2022] [Indexed: 11/06/2022] Open
Abstract
Background Opioid use after total joint arthroplasty must be balanced against the risks of opioid dependence and diversion. This study sought to define the baseline patient characteristics and discharge opioid use after the initiation of a preoperative and postoperative institutional opioid prescription protocol in a population with a high prevalence of opioid dependence and substance use. Methods Data on 1004 patients undergoing total joint arthroplasties from July 1, 2017, to June 30, 2019, were retrospectively reviewed. Demographics were collected, and data were grouped into high- and low-discharge opioid groups based on 1 standard deviation above or below the mean. Patient characteristics of the high and low groups were compared using one-way analysis of variance and Pearson chi-square test. Results The prevalence of preoperative opioid dependence was 21.8%. The mean discharge opioid prescription was 264 morphine milligram equivalents (MMEs). The cutoffs of high- and low-use groups were above 424 MMEs and below 104.5 MMEs. The high-discharge opioid group was more likely to be male, younger, to have a history of preoperative opioid use, to undergo general anesthesia, and to be uninsured. The lower-discharge opioid group was more likely to be older, female, to have Medicare, and to stay approximately 1 day longer in the hospital. Body mass index, intraoperative opioid requirement, American Society of Anesthesiologists Classification score, race, total knee vs total hip arthroplasty, or surgical approach for total hip arthroplasty did not affect discharge opioid prescriptions. Conclusions Reduction of opioid prescriptions at discharge in total joint arthroplasty patients may be possible with the use of preoperative and postoperative protocols, optimizing patient risk factors for opioid use and utilizing a patient-specific opioid taper regimen.
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Affiliation(s)
- Brandon Lentine
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | | | | | - Ruijia Niu
- New England Baptist Hospital, Boston, MA, USA
| | - David M. Freccero
- Department of Orthopaedic Surgery, Boston Medical Center, Boston, MA, USA
| | - Eric L. Smith
- New England Baptist Hospital, Boston, MA, USA,Corresponding author. New England Baptist Hospital, 125 Parker Hill Avenue, Boston, MA 02120, USA. Tel.: +1 617 754 6609.
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Rineau E, Dumartinet B, Samson E, Dollfus A, Aubourg C, Lasocki S. Sufentanil sublingual tablet system for enhanced recovery after total knee arthroplasty: a prospective observational case study. Perioper Med (Lond) 2022; 11:50. [PMID: 36195919 PMCID: PMC9531461 DOI: 10.1186/s13741-022-00284-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative pain is one of the main factors that delays recovery after prosthetic knee surgery. The use of sufentanil sublingual tablet systems (SSTS) can effectively relieve postoperative pain, but their value in facilitating early mobilization has been little studied so far. Our aim here was to assess whether their use could facilitate recovery after knee arthroplasty in an enhanced recovery program. CASE PRESENTATION In a prospective observational single-center study, thirty patients operated on for primary knee arthroplasty in the enhanced recovery pathway were included. Patients who received the SSTS (n=15) were compared with those who received an intravenous morphine patient-controlled analgesia (PCA) (n=15). Our recovery program included in particular the use of an adductor canal block, periarticular infiltration of local anesthetic by the surgeon, removal of the venous cannula from the recovery room if possible, the use of an SSTS when available or an IV morphine PCA otherwise, and early physiotherapy. Recovery parameters including the Timed-Up and Go test, pain scores at rest and on exertion, knee flexions, complications, and lengths of hospital stay were not significantly different between the two groups. However, the postoperative opioid consumption in morphine equivalents was significantly greater in the SL-sufentanil group and these patients had their venous cannula removed earlier than in IV-morphine group. CONCLUSION In our center, the use of a SSTS was suitable for treating postoperative pain after knee arthroplasty, but it did not improve early recovery in comparison with a morphine PCA.
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Affiliation(s)
- Emmanuel Rineau
- Department of Anesthesiology and Intensive Care, University Hospital and Health Faculty of the University of Angers, 4 rue Larrey, 49100, Angers, France.
| | - Benjamin Dumartinet
- Department of Anesthesiology and Intensive Care, University Hospital and Health Faculty of the University of Angers, 4 rue Larrey, 49100, Angers, France
| | - Emmanuel Samson
- Department of Anesthesiology and Intensive Care, University Hospital and Health Faculty of the University of Angers, 4 rue Larrey, 49100, Angers, France
| | - Apolline Dollfus
- Department of Anesthesiology and Intensive Care, University Hospital of Rennes, Rennes, France
| | - Corentin Aubourg
- Department of Anesthesiology and Intensive Care, University Hospital and Health Faculty of the University of Angers, 4 rue Larrey, 49100, Angers, France
| | - Sigismond Lasocki
- Department of Anesthesiology and Intensive Care, University Hospital and Health Faculty of the University of Angers, 4 rue Larrey, 49100, Angers, France
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Wood D, Moy SF, Zhang S, Lightfoot N. Impact of a prescriber and patient educational intervention on discharge analgesia prescribing and hospital readmission rates following elective unilateral total hip and knee arthroplasty. BMJ Open Qual 2022; 11:bmjoq-2021-001672. [PMID: 35914816 PMCID: PMC9345064 DOI: 10.1136/bmjoq-2021-001672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 07/11/2022] [Indexed: 11/03/2022] Open
Abstract
IntroductionPain management after elective, unilateral total hip and knee arthroplasty (THA and TKA) should use a multimodal approach. At discharge, challenges include ensuring correct prescribing practices to optimise analgesia and rationalise opioid use as well as ensuring patients are adequately educated to take these medications safely and effectively in the community. This audit cycle reports on a prescriber and patient education intervention using printed guidelines, educational outreach and prescription standardisation along with a patient information sheet to address the high unplanned readmission rate following THA and TKA at our institution.MethodsTwo cohorts of patients were identified before (2016) and after (2019) the introduction of the educational package. The primary outcome was the unplanned hospital readmission rate in the 42 days following discharge. Secondary outcomes were the compliance with the set prescribing standards and the prescription of strong opioid medications (morphine or oxycodone) on discharge.ResultsThere was a reduction in the readmission rate from 20.4% to 10.0% (p=0.004). Readmission rates for pain and constipation were also reduced. The prescribing of tramadol (p<0.001) and non-steroidal anti-inflammatory drugs (p<0.001) both increased while the number of patients who received a strong opioid at discharge decreased (p<0.001) as did the number of patients who received a sustained release strong opioid (p<0.001).ConclusionWe have observed significant improvement in discharge prescribing which coincided with a reduction in unplanned readmissions after elective TKA and THA. Our approach used prescriber guidelines, education and standardisation with printed information for patients to enhance understanding and recall.
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Affiliation(s)
- Daniel Wood
- Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Shuh Fen Moy
- Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Shiran Zhang
- Orthopaedics, Middlemore Hospital, Auckland, New Zealand
| | - Nicholas Lightfoot
- Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
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Kiani SN, Zhong H, Wilson LA, Poultsides L, Liu J, Poeran J, Memtsoudis SG. Considerations when prescribing tramadol postoperatively, in response to Rocha-Romero. Reg Anesth Pain Med 2022; 47:rapm-2022-103938. [PMID: 35906019 DOI: 10.1136/rapm-2022-103938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 07/21/2022] [Indexed: 11/03/2022]
Affiliation(s)
- Sara N Kiani
- Department of Orthopaedics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Lazaros Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, New York, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Jashvant Poeran
- Department of Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA
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Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
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Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
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Frenkel Rutenberg T, Izchak H, Rosenthal Y, Barak U, Shemesh S, Heller S. Earlier Initiation of Postoperative Physical Therapy Decreases Opioid Use after Total Knee Arthroplasty. J Knee Surg 2022; 35:933-939. [PMID: 33167053 DOI: 10.1055/s-0040-1721034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
For patients with advanced osteoarthritis of the knee, total knee arthroplasty (TKA) has been shown to provide significant pain relief and improved function with consistent, reproducible results. Post-operative physical therapy (PT) plays an important role is restoring muscle strength and range of motion (ROM). Yet, the impact of earlier physical therapy initiation after TKA has not been well defined. We assessed 205 patients that underwent primary TKA including 136 patients who started PT on the first post-operative day (POD1) and a second group that started PT 3 days after surgery (POD3), or later. Length of hospital stay (LOS), opioid use during hospital stay, complications, re-admissions, knee ROM and the need for subsequent hospitalized rehabilitation were recorded. LOS was not significantly shorter in the early PT group, compared with the delayed PT group (6.4 ± 2.2 days vs. 6.8 ± 2 days, respectively, P = .217). Patients in the delayed PT group consumed more opioids during their inpatient stay compared with the early PT group on both POD 3 (89% vs 82%, p = 0.013) and POD 4 (81% vs 66%, p = 0.005). There was no significant difference in the incidence of Immediate post-operative complications or final knee ROM between the two groups. While early postoperative PT did not impact hospital LOS or final knee ROM, it was associated with an earlier reduction in postoperative opioid consumption after primary TKA.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Haim Izchak
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Rosenthal
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Barak
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shai Shemesh
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Snir Heller
- Orthopedic Department, Rabin Medical Center, HaSharon Hospital, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Kiani S, Poeran J, Zhong H, Wilson LA, Poultsides L, Liu J, Memtsoudis SG. Tramadol prescribed at discharge is associated with lower odds of chronic opioid use after elective total joint arthroplasty. Reg Anesth Pain Med 2022; 47:rapm-2022-103486. [PMID: 35760515 DOI: 10.1136/rapm-2022-103486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/12/2022] [Indexed: 12/16/2022]
Abstract
INTRODUCTION We aimed to study the association between tramadol prescribed at discharge (after elective total hip and knee arthroplasty (THA/TKA) surgery) and chronic opioid use postoperatively. METHODS This retrospective cohort study queried the Truven MarketScan database and identified patients who underwent an elective THA/TKA surgery between 2016 and 2018 and were prescribed opioids at discharge (n=81 049). Multivariable analysis was conducted to study the association between tramadol prescription at discharge and chronic opioid use, with additional analysis adjusting for the amount of opioids prescribed in oral morphine equivalents. Chronic opioid use was defined as filling ≥10 opioid prescriptions or prescriptions for ≥120 pills within the period from 90 days to 1 year after surgery. RESULTS Overall, tramadol was prescribed at discharge in 11.0% of all THA/TKA cases. Of those, 26.9% and 73.1% received tramadol only or tramadol with another opioid, respectively. Chronic opioid use was observed in 5.4% of cases. After adjustment for relevant covariates, prescription of tramadol combined with another opioid at discharge was associated with lower odds of chronic opioid use comparing to prescription of other opioids (OR 0.69 CI 0.61 to 0.78). DISCUSSION Among patients undergoing elective THA/TKA surgery and discharged with a prescription of opioids, we found that prescription of tramadol combined with another opioid was associated with lower odds of chronic opioid use. This finding must be considered in the context of the tramadol's pharmacology, as well-described genetic differences in metabolism that can make it ineffective in many patients, while for patients with ultrarapid metabolism can cause drug-drug interactions and adverse events, including feelings of high and seizures.
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Affiliation(s)
- Sara Kiani
- Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Jashvant Poeran
- Departments of Orthopedics / Population Health Science & Policy / Medicine, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Lauren A Wilson
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Lazaros Poultsides
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York City, New York, USA
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Lee GC, Berkowitz R, Hacker S, Hu J, Rechter A. HTX-011 in Combination with Multimodal Analgesic Regimen Minimized Severe Pain and Opioid Use after Total Knee Arthroplasty in an Open-Label Study. J Knee Surg 2022. [PMID: 35688442 DOI: 10.1055/s-0042-1747945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total knee arthroplasty (TKA) can be associated with significant postoperative pain despite multimodal analgesic (MMA) protocols, and most patients require the use of opioids postoperatively. HTX-011 is a dual-acting local anesthetic containing bupivacaine and low-dose meloxicam in an extended-release polymer. In a prior randomized controlled trial (RCT), HTX-011 reduced pain and opioid use through 72 hours after TKA compared with bupivacaine hydrochloride. This open-label study (NCT03974932) evaluated the efficacy and safety of HTX-011 combined with an MMA regimen in patients undergoing TKA under spinal anesthesia. All patients received intraoperative HTX-011 (400 mg bupivacaine/12 mg meloxicam) in combination with an MMA regimen consisting of preoperative acetaminophen, celecoxib, and pregabalin and postoperative acetaminophen and celecoxib until discharge. Opioid rescue was allowed upon patient request for additional pain control. Pain scores, opioid consumption, discharge readiness, and adverse events were recorded. Fifty-one patients were treated. Compared with the prior RCT, HTX-011 with this MMA regimen further lowered pain scores and reduced opioid use. Mean patient-reported pain scores remained in the mild range, and 82% of patients or more did not experience severe pain at any individual time point through 72 hours after surgery. Mean total opioid consumption was low over 72 hours: 24.8 morphine milligram equivalents (1-2 tablets of oxycodone 10 mg/day). Approximately 60% of patients were ready for discharge by 12 hours, and 39% were discharged without an opioid prescription and did not call back for pain management. The treatment regimen was well tolerated, and no added risk was observed with the addition of MMA. HTX-011 with an MMA regimen reduced postoperative pain and opioid use following TKA.
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Affiliation(s)
- Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Richard Berkowitz
- University Orthopedic and Joint Replacement Center, Tamarac, Florida
| | - Scott Hacker
- Grossmont Orthopedic Medical Group, La Mesa, California
| | - Jia Hu
- Heron Therapeutics, Inc., San Diego, California
| | - Alan Rechter
- Department of Orthopaedic Surgery, Orthopaedic Associates, LLP, Houston, Texas
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Intraosseous Morphine Decreases Postoperative Pain and Pain Medication Use in Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial. J Arthroplasty 2022; 37:S139-S146. [PMID: 35272897 DOI: 10.1016/j.arth.2021.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/01/2021] [Accepted: 10/15/2021] [Indexed: 02/02/2023] Open
Abstract
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.
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Jennings JM, McNabb DC, Johnson RM, Brady AC, Kim RH, Dennis DA. Use of Cannabis Does Not Decrease Opioid Consumption in Patients Who Underwent Total Joint Arthroplasty. Arthroplast Today 2022; 15:141-146. [PMID: 35586610 PMCID: PMC9108508 DOI: 10.1016/j.artd.2022.03.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/14/2022] [Accepted: 03/19/2022] [Indexed: 11/25/2022] Open
Abstract
Background The primary purpose of this study was to determine if cannabis use decreases narcotic consumption in patients undergoing total joint arthroplasty (TJA). Material and methods Forty-six patients undergoing a primary unilateral TJA, who self-reported the use of cannabis, were prospectively enrolled and completed this study between July 2015 and November 2019. This cohort was prospectively matched to patients who did not report cannabis use. Morphine equivalents (MEs) were averaged and recorded at 1 and 2 weeks postoperatively. Secondary outcomes and complications were recorded and reported. Results There were no differences noted in ME during the hospitalization between the user (78.7 ± 58.5) and nonusers (70.4 ± 46.3), P = .455. ME daily average did not differ between the cohorts (user [36.8 ± 30.7] and nonuser [31.7 ± 25.6] at 1 week (P = .389) or user [22.5 ± 26.3] and nonusers [15.9 ± 18.3] at 2 weeks, P = .164, postoperatively). The total ME at 2 weeks did not differ between the user and nonuser groups (415 ± 375 vs 333 ± 275, P = .235). Pain scores at 1 week were significantly higher in patients who used cannabis (4.1 ± 1.9 vs 3.4 ± 1.6, P = .05). No differences in pain were noted during the patient's hospitalization or at 2- (P = .071) or 6-week (P = .111) follow-up. No differences in secondary outcomes or complications were noted. Conclusion We were unable to show a decrease in narcotic consumption in patients who use cannabis undergoing primary unilateral joint replacement. These findings do not support the routine use of cannabis to decrease or supplement narcotic use after primary TJA. Level of evidence Level II therapeutic.
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Affiliation(s)
- Jason M. Jennings
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| | | | | | - Anna C. Brady
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
| | | | - Douglas A. Dennis
- Colorado Joint Replacement, Porter Adventist Hospital, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
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YaDeau JT, Mayman DJ, Jules-Elysee KM, Lin Y, Padgett DE, DeMeo DA, Gbaje EC, Goytizolo EA, Kim DH, Sculco TP, Kahn RL, Haskins SC, Brummett CM, Zhong H, Westrich G. Effect of Duloxetine on Opioid Use and Pain After Total Knee Arthroplasty: A Triple-Blinded Randomized Controlled Trial. J Arthroplasty 2022; 37:S147-S154. [PMID: 35346549 DOI: 10.1016/j.arth.2022.02.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/01/2022] [Accepted: 02/07/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Duloxetine, a serotonin-norepinephrine dual reuptake inhibitor, may improve analgesia after total knee arthroplasty (TKA). Previous studies had one primary outcome, did not consistently use multimodal analgesia, and used patient-controlled analgesia devices, potentially delaying discharge. We investigated whether duloxetine would reduce opioid consumption or pain with ambulation. METHODS A total of 160 patients received 60 mg duloxetine or placebo daily, starting from the day of surgery and continuing 14 days postoperatively. Patients received neuraxial anesthesia, peripheral nerve blocks, acetaminophen, nonsteroidal anti-inflammatory drugs, and oral opioids as needed. The dual primary outcomes were Numeric Rating Scale (NRS) scores with movement on postoperative days 1, 2, and 14, and cumulative opioid consumption surgery through postoperative day 14. RESULTS Duloxetine was noninferior to placebo for both primary outcomes and was superior to placebo for opioid consumption. Opioid consumption (mean ± SD) was 288 ± 226 mg OME [94, 385] vs 432 ± 374 [210, 540] (duloxetine vs placebo) P = .0039. Pain scores on POD14 were 4.2 ± 2.0 vs 4.8 ± 2.2 (duloxetine vs placebo) P = .018. Median satisfaction with pain management was 10 (8, 10) and 8 (7, 10) (duloxetine vs placebo) P = .046. Duloxetine reduced interference by pain with walking, normal work, and sleep. CONCLUSION The 29% reduction in opioid use corresponds to 17 fewer pills of oxycodone, 5 mg, and was achieved without increasing pain scores. Considering the ongoing opioid epidemic, duloxetine can be used to reduce opioid usage after knee arthroplasty in selected patients that can be appropriately monitored for potential side effects of the medication.
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Affiliation(s)
- Jacques T YaDeau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - David J Mayman
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
| | - Kethy M Jules-Elysee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Yi Lin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Douglas E Padgett
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
| | - Danya A DeMeo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY
| | - Ejiro C Gbaje
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY
| | - Enrique A Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - David H Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Thomas P Sculco
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
| | - Richard L Kahn
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Stephen C Haskins
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill Cornell Medicine, New York, NY
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY
| | - Geoffrey Westrich
- Department of Orthopedic Surgery (Adult Reconstruction and Joint Replacement Service), Hospital for Special Surgery, New York, NY
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Combined application of adductor canal block and local infiltration anesthesia in primary total knee arthroplasty: an updated meta-analysis of randomized controlled trials. Arch Orthop Trauma Surg 2022; 142:913-926. [PMID: 33417022 DOI: 10.1007/s00402-020-03706-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 12/06/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Perioperative pain after total knee arthroplasty (TKA) may seriously affect the rapid recovery of patients. The purpose of this study was to assess whether the combined use of adductor canal block (ACB) and local infiltration anesthesia (LIA) can further reduce postoperative pain and improve early functional recovery. MATERIALS AND METHODS PubMed, Web of Science, EMBASE, and Cochrane Central Register of Controlled Trials were systematically searched for randomized controlled trials (RCTs) comparing ACB + LIA and LIA alone in primary TKA. The primary outcomes were visual analog scale (VAS) scores at rest and walking, morphine consumption, range of motion (ROM) at 24 and 48 h postoperatively and distance walked. The secondary outcomes were the length of stay, the incidence of nausea and vomiting, and the total complications. Subgroup analyses were performed on the VAS at rest and walking, morphine consumption, and distance walked at 24, 48, and 72 h postoperatively. RESULTS A total of 10 RCTs involving 797 patients were enrolled in this meta-analysis. The results demonstrated that the combined application of ACB + LIA had a lower resting VAS at 24 h postoperatively (p = 0.02) and the walking score at 24 (p = 0.0002) and 48 h (p = 0.02) postoperatively compared with LIA alone. Similarly, the combined ACB + LIA group also had less morphine consumption at 48 h postoperatively (p = 0.0005) and had a higher ROM score at 24 h (p = 0.01) postoperatively compared to the LIA group. There were no statistical differences in length of stay, distance walked, and incidence of nausea and vomiting. CONCLUSION The current meta-analysis showed that ACB + LIA significantly reduced postoperative walking pain and morphine consumption and promoted rapid recovery in the early postoperative period. There is no statistical difference in the length of stay and ROM after 72 h in the two groups.
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ALPARSLAN M, AKÇABOY ZN, AYDIN G, GENÇAY I, PEKER K, OKTAŞ B, ŞAHİN AT. Evaluation of preemptive interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block for ostoperative pain management in arthroscopic knee surgeries: a retrospective study. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1088635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Interspace between the popliteal artery and the capsule of the posterior knee (IPACK) block is block, which is done by infiltration of local anesthetic to block terminal branches of genicular nerves and popliteal plexus that innervate the posterior capsule of the knee joint. In this study, we retrospectively reviewed our patient’s data to which IPACK block was applied for arthroscopic knee surgery. Our aim was to evaluate the effectiveness of IPACK block on postoperative analgesia, effects on additional analgesic consumption and patient satisfaction.
Material and Method: The data of 60 patients who underwent arthroscopic knee surgery under spinal anesthesia with or without applied preemptive IPACK block for postoperative analgesia were collected between October 2019 and December 2020. Group I consisted of 30 patients with preemptive IPACK block, while 30 patients without block were classified as the control group (Group II). Postoperative 0-1-2-6-12 and 24th hour VAS scores, additional analgesic needs, patient satisfaction scores, were compared in groups as primary outcome.
Results: As a result of the comparison between the groups, it was seen that there was a significant difference between the groups in favor of the IPACK Block group in terms of postoperative VAS scores after 1st hour, postoperative analgesic needs and patient satisfaction (p
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Affiliation(s)
| | - Zeynep Nur AKÇABOY
- SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ANESTEZİYOLOJİ ANABİLİM DALI
| | - Gülçin AYDIN
- KIRIKKALE ÜNİVERSİTESİ, TIP FAKÜLTESİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ANESTEZİYOLOJİ ANABİLİM DALI
| | - Işın GENÇAY
- KIRIKKALE ÜNİVERSİTESİ, TIP FAKÜLTESİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ANESTEZİYOLOJİ ANABİLİM DALI
| | - Kevser PEKER
- KIRIKKALE ÜNİVERSİTESİ, TIP FAKÜLTESİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ANESTEZİYOLOJİ ANABİLİM DALI
| | - Birhan OKTAŞ
- KIRIKKALE ÜNİVERSİTESİ, TIP FAKÜLTESİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ORTOPEDİ VE TRAVMATOLOJİ ANABİLİM DALI
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Opioid Sparing Effect of Ketamine in Military Pre-Hospital Pain Management - A Retrospective Study. J Trauma Acute Care Surg 2022; 93:S71-S77. [PMID: 35583978 DOI: 10.1097/ta.0000000000003695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Opioids are the most commonly used analgesics in acute trauma, but are limited by slow onset and significant adverse effects. Ketamine is an effective and widely used analgesic. This study was aimed to evaluate the effectiveness and opioid-sparing effects of ketamine when utilized in pre-hospital military trauma setting. METHODS A retrospective analysis of a pre-hospital military trauma registry between 2014 - 2020. Inclusion criteria were age ≥ 16 years, ≥2 documented pain assessments, at least one indicating severe pain, and administration of opioids and/or low-dose ketamine. Joint hypothesis testing was used to compare casualties who received opioids only to those who received ketamine on outcomes of pain score reduction and opioid consumption. RESULTS Overall, 382 casualties were included. 91 (24%) received ketamine (21 as a single analgesic), with a mean dose of 29 mg (SD 11). Mean reduction in pain scores (on an 11-point scale) was not significantly different; 4.3-point (2.8) reduction in the ketamine group and 3.7-points (2.4) in the opioid-only group (p = 0.095). Casualties in the ketamine group received a median of 10 mg (IQR 3.5, 25) of morphine equivalents (ME) compared with a median of 20 ME (10, 20) in the opioid-only group. In a multivariable multinomial logistic regression, casualties in the ketamine group were significantly more likely to receive a low (1-10 ME) rather than a medium (11-20 ME) dose of opioids compared to the opioid-only group (OR 0.032, CI 0.14 - 0.75). CONCLUSIONS The use of ketamine in the pre-hospital military setting as part of a pain management protocol was associated with a low rather than medium dose of opioids in a multivariable analysis, while the mean reduction in pain scores was not significantly different between groups. Using ketamine as a first-line agent may further reduce opioid consumption with a similar analgesic effect. LEVELS OF EVIDENCE Level IV, therapeutic/care management.
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Yang X, Dong J, Xiong W, Huang F. Early Postoperative Pain Control and Inflammation for Total Knee Arthroplasty: A Retrospective Comparison of Continuous Adductor Canal Block versus Single-Shot Adductor Canal Block Combined with Patient-Controlled Intravenous Analgesia. Emerg Med Int 2022; 2022:1351480. [PMID: 35600565 PMCID: PMC9117079 DOI: 10.1155/2022/1351480] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022] Open
Abstract
Objective The aim of this study was to compare pain control and inflammation among patients who received a continuous adductor canal block (CACB) versus single-shot adductor canal block (SACB) combined with patient-controlled intravenous analgesia (PCIA) for total knee arthroplasty (TKA) analgesia in the first two days after surgery. Design Matched cohort retrospective study. Setting. University hospital. Patients. One hundred fifty-six patient charts were included in this study: 78 patients with CACB in Group A and 78 patients with SACB combined with PCIA in Group B. Patients were matched according to age, body mass index, and American Society of Anesthesiologists class. Measurements. The primary outcome of the study was Visual Analogue Scale (VAS) pain scores before operation (Pre) and at postoperative 6 (POH6), 12 (POH12), 24 (POH24), 30 (POH30), 36 (POH36), and 48 hours (POH48). Secondary outcomes included patient-controlled bolus, time of first postoperative ambulation, range of knee flexion and extension, inflammation cytokines on Pre and POH48, percentage of remedial analgesics treatment, incidence of adverse events and complications, hospital stay and cost, and Numerical Rating Scale (NRS) satisfaction scores at discharge. Main Results. Mean VAS scores at rest and with motion were lower in Group B than in Group A on all postoperative hours. At POH30, compared with Group A (1.1 ± 0.6), mean VAS scores at rest in Group B (0.9 ± 0.4) were lower (P=0.048), and compared with Group A (2.6 ± 0.7), mean VAS scores with motion in Group B (2.2 ± 0.8) were lower (P=0.001). The number of patient-controlled bolus was 4.3 ± 1.6 (95% CI 3.9-4.6) in Group A and 3.1 ± 1.3 (95% CI 2.8-3.4) in Group B, respectively (P < 0.001). Patients in Group B displayed better functional recovery and inflammation results at POH48 than Group A with respect to range of knee flexion and extension (117.8 ± 10.9° vs. 125.2 ± 9.4°, P < 0.001) and inflammation cytokines, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and interleukin-6 (IL-6) ((43.8 ± 16.1) vs. (36.8 ± 13.2), P=0.003; (34.9 ± 9.4 mg/L) vs. (29.6 ± 10.6 mg/L), P=0.001; (21.3 ± 8.7 pg/ml) vs. (14.0 ± 7.0 pg/ml), P < 0.001)). Conclusion SACB combined with PCIA in the first two days of patients undergoing TKA has better analgesic and beneficial effects on functional recovery and inflammation.
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Affiliation(s)
- Xiaojuan Yang
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Dong
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wei Xiong
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fusen Huang
- The Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Kleeman-Forsthuber L, Pollet A, Johnson RM, Boyle J, Jennings JM, Dennis DA. Evaluation of Low-Dose Versus High-Dose Opioid Pathway in Opioid-Naïve Patients After Total Knee Arthroplasty. Arthroplast Today 2022; 14:81-85. [PMID: 35252511 PMCID: PMC8889259 DOI: 10.1016/j.artd.2021.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 11/16/2021] [Accepted: 11/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background Pain control after total knee arthroplasty (TKA) remains challenging. Tramadol is a weak opioid with potentially lower side effects and risk for dependency than stronger opioids. The purpose of this study was to evaluate efficacy and safety of tramadol after TKA in opioid-naïve patients compared with stronger opioids. Methods A retrospective review of patients who underwent primary TKA was performed. In September 2018, opioid-naïve patients were prescribed tramadol instead of oxycodone. Patients receiving tramadol (low-opioid group) were matched to patients discharged with oxycodone before this transition (high-opioid group). We compared morphine milligram equivalent (MME) consumption and outcomes up to 3 months postoperatively. Results Two-hundred and five patients underwent TKA, with 126 receiving tramadol. Fourteen patients were converted to stronger opioid (11.2% conversion rate). Seventy patients from the low-opioid group were matched to 70 patients in the high-opioid group. Average daily inpatient MME consumption was higher in the high-opioid group (40.0 ± 27.4 vs 16.3 ± 10.9, P = .000). Outpatient prescribed MME was significantly higher in the high-opioid group (135.5 ± 71.5 vs 75.3 ± 51.3, P = .000) along with a higher number of refills (0.53 ± 1.1 vs 0.886 ± 0.94, P = .041). Knee range of motion was not statistically different at any timepoint postoperatively. There was higher adverse event rate in the low-opioid group (8.6% vs 5.7%) but not statically significant. Conclusions Low opioid regimen following TKA showed lower MME consumption than high opioid regimen with no effect on outcomes up to 3 months. Use of low opioid regimen should be considered for TKA surgery.
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Affiliation(s)
- Lindsay Kleeman-Forsthuber
- Colorado Joint Replacement, Denver, CO, USA
- Corresponding author. Thomas W. Huebner Medical Office Building, 160 Allen Street, Rutland, VT 05701, USA. Tel.: + 1 8027752937.
| | | | | | | | - Jason M. Jennings
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
| | - Douglas A. Dennis
- Colorado Joint Replacement, Denver, CO, USA
- Department of Mechanical and Materials Engineering, University of Denver, Denver, CO, USA
- Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO, USA
- Department of Biomedical Engineering, University of Tennessee, Knoxville, TN, USA
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Dong W, Wang X, Wang H, You J, Zheng R, Xu Y, Zhang X, Guo J, Ruan J, Fan F. Comparison of Multimodal Cocktail to Ropivacaine Intercostal Nerve Block for Chest Pain After Costal Cartilage Harvest: A Randomized Controlled Trial. Facial Plast Surg Aesthet Med 2022; 24:102-108. [PMID: 35230140 DOI: 10.1089/fpsam.2021.0264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective: To compare the effectiveness of an intercostal nerve block after costal cartilage harvest when a multimodal cocktail or ropivacaine plus patient-controlled analgesia is used, as measured by visual analog scale (VAS) scores, rescue analgesic consumption, and related complications. Materials and Methods: Eligible patients who underwent costal cartilage harvest were equally randomized to receive a multimodal cocktail (multimodal group) or ropivacaine plus patient-controlled analgesia (ropivacaine group). Results: Of 112 patients assessed, 12 (10.7%) patients were excluded and 100 (89.3%) patients were enrolled and assigned to multimodal group (n = 50) and ropivacaine group (n = 50). The VAS scores in the multimodal group were significantly lower than those in the ropivacaine group both at rest (0.924 ± 0.073 vs. 1.920 ± 0.073, p < 0.001) and during coughing (2.340 ± 0.083 vs. 3.944 ± 0.083, p < 0.001) in mixed-effects model analysis. Rescue analgesic consumption and rate of complications were significantly lower in the multimodal group compared with the ropivacaine group (all p < 0.05). Conclusions: Multimodal cocktail improved chest pain after costal cartilage harvest with less rescue analgesic consumption and complications compared with ropivacaine plus patient-controlled analgesia. Clinical Trial Registration: ChiCTR2100042445.
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Affiliation(s)
- Wenfang Dong
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Xin Wang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Huan Wang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Jianjun You
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Ruobing Zheng
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Yihao Xu
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Xulong Zhang
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Junsheng Guo
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Jingjing Ruan
- Department of Ear Reconstruction, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
| | - Fei Fan
- The Twelfth Department of Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shijingshan, Beijing, China
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Pre-emptive analgesia with methylprednisolone and gabapentin in total knee arthroplasty in the elderly. Sci Rep 2022; 12:2320. [PMID: 35149701 PMCID: PMC8837623 DOI: 10.1038/s41598-022-05423-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 01/10/2022] [Indexed: 11/10/2022] Open
Abstract
The aim of this study is to assess whether administration of gabapentin and methylprednisolone as “pre-emptive analgesia” in a group of patients above 65 years of age would be effective in complex pain management therapy following total knee arthroplasty (TKA). One hundred seventy patients above 65 years were qualified for the study, with exclusion of 10 patients due to clinical circumstances. One hundred sixty patients were randomly double-blinded into two groups: the study group (80 patients) and the control group (80 patients). The study group received as “pre-emptive” analgesia a single dose of 300 mg oral (PO) gabapentin and 125 mg intravenous (IV) methylprednisolone, while the control received a placebo. All patients received opioid and non-opioid analgesic agents perioperatively calculated for 1 kg of total body weight. We measured (1) pain intensity level at rest (numerical rating scale, NRS), (2) life parameters, (3) levels of inflammatory markers (leukocytosis, C reactive protein CRP), and (4) all complications. Following administration of gabapentin and methylprednisolone as “pre-emptive” analgesia, the NRS score at rest was calculated at 6, 12 (p < 0.000001), 18 (p < 0.00004) and 24 (p = 0.005569) h postoperatively. Methylprednisolone with gabapentin significantly decreased the dose of parenteral opioid preparations (p = 0.000006). The duration time of analgesia was significantly longer in study group (p < 0.000001), with CRP values lower on all postoperative days (1, 2 days—p < 0.00001, 3 days—p = 0.00538), and leukocytosis on day 2 (p < 0.0086) and 3 (p < 0.00042). No infectious complications were observed in the first postoperative days; in the control group, one patient manifested transient ischemic attack (TIA). The use of gabapentin and methylprednisolone as a single dose decreased the level of postoperative pain on the day of surgery, the dose of opioid analgesic preparations, and the level of inflammatory parameters without infectious processes.
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Castro MAD, Cunha GMF, Andrade GF, Yoshida MI, Faria ALD, Silva-Cunha A. Development and characterization of PLGA-Bupivacaine and PLGA-S75:R25 Bupivacaine (Novabupi®) biodegradable implants for postoperative pain. BRAZ J PHARM SCI 2022. [DOI: 10.1590/s2175-97902022e21310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Vig V, Sud A, Singh C, Thakur K. Local infiltration analgesia improves functional outcome after total knee arthroplasty: A randomized controlled trial. MEDICAL JOURNAL OF DR. D.Y. PATIL VIDYAPEETH 2022. [DOI: 10.4103/mjdrdypu.mjdrdypu_38_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Dong W, Wang X, Wang H, You J, Zheng R, Xu Y, Zhang X, Guo J, Fan F. A Prospective Study of Multimodal Cocktail Intercostal Injection for Chest Pain Relief after Costal Cartilage Harvest for Rhinoplasty. Br J Oral Maxillofac Surg 2021; 60:841-846. [DOI: 10.1016/j.bjoms.2021.12.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 12/15/2021] [Accepted: 12/23/2021] [Indexed: 11/28/2022]
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Sirivanasandha B, Sutthivaiyakit K, Kerdchan T, Poolsuppasit S, Tangwiwat S, Halilamien P. Adding a low-concentration sciatic nerve block to total knee arthroplasty in patients susceptible to the adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs): a randomized controlled trial. BMC Anesthesiol 2021; 21:282. [PMID: 34773995 PMCID: PMC8590368 DOI: 10.1186/s12871-021-01491-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/27/2021] [Indexed: 11/25/2022] Open
Abstract
Background This study compared the effects of adductor canal blocks with those of a low concentration of popliteal-sciatic nerve block (SNB) and dexamethasone as an adjunctive technique for total knee arthroplasties (TKA) in patients susceptible to the adverse effects of NSAIDs. Methods A prospective, double-blinded, randomized controlled trial was performed in 50 patients susceptible to the adverse effects of NSAIDs undergoing unilateral TKAs. All patients received spinal anesthesia, adductor canal blocks, and periarticular infiltration. The 25 patients in the intervention group received SNB (0.125% bupivacaine [20 ml] and dexamethasone [5 mg]). Results The SNB group significantly had lower median resting pain scores at 6, 12, and 18 h: the control group, 1 (0–4.5), 3 (0–5), and 3 (2–5); the intervention group, 0 (0–0), 0 (0–3), and 1 (0–3); p-values, 0.012, 0.021, and 0.010, respectively. Movement-evoked pain scores at 6, 12, and 18 h were also lower: control group, 3 (0–5.5), 5 (2.5–6.5), and 7 (4–9); intervention group, 0 (0–1.5), 2 (0–4), and 3 (2–5); p-values, 0.019, 0.005, and 0.001, respectively. There were no differences in motor function. Moreover, the mean morphine consumption 24 h was also reduced in the SNB group: control group, 3.80 ± 2.48 mg; intervention group, 1.96 ± 2 mg; p-value, 0.005. Conclusion For patients susceptible to the adverse effects of NSAIDs, a low concentration of SNB and dexamethasone is an effective adjunctive technique for early postoperative pain control (especially on movement) following TKAs, without an increase in motor weakness. Trial registration ClinicalTrials.gov, NCT03486548, Registered 3 April 2018.
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Affiliation(s)
- Busara Sirivanasandha
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand.
| | - Kulwadee Sutthivaiyakit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Thippatai Kerdchan
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Suppachai Poolsuppasit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Suwimon Tangwiwat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Pathom Halilamien
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wanglang Road, Bangkok Noi, Bangkok, 10700, Thailand
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Truelove EC, Urrechaga E, Fernandez C, Fowler JR. Prospective, Double-blind Evaluation of Perioperative Intravenous Acetaminophen and Ketorolac for Postoperative Pain and Opioid Consumption After Endoscopic Carpal Tunnel Release. Hand (N Y) 2021; 16:785-791. [PMID: 32075440 PMCID: PMC8647326 DOI: 10.1177/1558944720906501] [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] [Indexed: 11/17/2022]
Abstract
Background: The current opioid epidemic highlights the need for pain management strategies to decrease or eliminate postoperative use of opioid medications. The purpose of this study was to determine if perioperative administration of intravenous (IV) acetaminophen and/or IV ketorolac decreases postoperative pain and opioid consumption after endoscopic carpal tunnel release. Methods: In all, 44 subjects were enrolled in this randomized, double-blind, placebo-controlled study from October 2015 to April 2017 and divided into 4 treatment arms: placebo, IV acetaminophen, IV ketorolac, or both IV acetaminophen and IV ketorolac. Patients recorded pain at 8-hour intervals on an 11-point scale and daily opioid use for 7 days after surgery. Analysis of variance and Kruskal-Wallis tests were used to compare mean pain scores and opioid consumption. Results: Mean pain scores over the 7-day study period were lower in the placebo and IV acetaminophen groups. Patients in the placebo and acetaminophen groups reported less pain than those in the ketorolac and combination groups on postoperative days 6 and 7. Patients administered IV acetaminophen had lower daily mean opioid usage. In all, 50% of the patients did not take any opioids after surgery. Conclusions: There are small, statistically significant differences in postoperative pain and opioid consumption supporting the use of IV acetaminophen for pain control after endoscopic carpal tunnel release, though these results are likely not clinically relevant. We recommend continued investigation into multimodal pain management in upper extremity surgery as well as limiting the number and quantity of opioid prescriptions provided to patients postoperatively.
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Affiliation(s)
| | | | | | - John R. Fowler
- University of Pittsburgh Medical Center, PA, USA,John R. Fowler, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, 3471 Fifth Avenue, Kaufmann Building, Suite 1010, Pittsburgh, PA 15213, USA.
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Karam JA, Schwenk ES, Parvizi J. An Update on Multimodal Pain Management After Total Joint Arthroplasty. J Bone Joint Surg Am 2021; 103:1652-1662. [PMID: 34232932 DOI: 10.2106/jbjs.19.01423] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ 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.
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Affiliation(s)
- Joseph A Karam
- Department of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Tranexamic acid in a periarticular multimodal cocktail injection for blood management in total knee arthroplasty: a prospective randomized study. BMC Musculoskelet Disord 2021; 22:675. [PMID: 34376180 PMCID: PMC8356435 DOI: 10.1186/s12891-021-04551-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 07/12/2021] [Indexed: 12/16/2022] Open
Abstract
Background This study aimed to assess the efficacy of tranexamic acid (TXA) mixed in a periarticular multimodal cocktail (PAMC) as a topical administration and to determine whether combined use of intravenous and topical administration is more effective than a single administration of TXA. Methods A total of 240 patients who underwent primary total knee arthroplasty (TKA) was enrolled for this prospective randomized controlled study. Patients were divided into three groups of 80 patients each. Baseline data were comparable for all groups. Average follow-up was 18.7 months. Group 1 consisted of patients who received intravenous (IV) TXA, Group 2 patients were those who received TXA in a PAMC injection for topical administration, and Group 3 consisted of patients who received a combination of both intravenous and topical administration of TXA. Primary outcomes were postoperative hemoglobin drop and amount of suction drainage. Secondary outcomes were estimated blood loss (EBL), postoperative transfusion rate, and complications. Results The mean postoperative hemoglobin drop was significantly lower in Group 3 (2.13 ± 0.77 g/dL, p=0.004), and there was no difference between Group 1 and Group 2 (2.56 ± 1.07 g/dL vs 2.55 ± 0.86 g/dL, p=0.999). The mean drainage amount was significantly lower in Group 3 (326.58 ± 57.55 ml, p<0.001), and there was no difference between Group 1 and Group 2 (367.93 ± 87.26 ml vs 397.66 ± 104.10 ml, p=0.072). Similarly, the mean EBL was significantly lower in Group 3 (p=0.003), and there was no significant difference between Group 1 and Group 2 (p=0.992). There were no significant differences in requirement for postoperative transfusion rate or incidence of complications among the three groups. Conclusion TXA mixed in a PAMC injection showed a similar effect to IV administration of TXA following TKA. Furthermore, combined use of both IV and PAMC injection provided better perioperative bleeding control with similar safety in patients without relevant comorbidities. Trial registration WHO ICTRP identifier KCT0005703. Retrospectively registered: 12/24/2020 Supplementary Information The online version contains supplementary material available at 10.1186/s12891-021-04551-8.
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Pietrantoni P, Cuñat T, Nuevo-Gayoso M, Martín N, Tió M, Basora M, Sastre S, Sala-Blanch X. Ultrasound-guided genicular nerves block: an analgesic alternative to local infiltration analgesia for total knee arthroplasty: A noninferiority, matched cohort study. Eur J Anaesthesiol 2021; 38:S130-S137. [PMID: 34038916 DOI: 10.1097/eja.0000000000001546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Standard analgesic strategies for total knee arthroplasty employ local infiltration analgesia. Blockade and radiofrequency ablation of the genicular nerves are effective treatments for patients with chronic pain because of knee osteoarthritis. OBJECTIVE To test the noninferiority of the analgesic effect of genicular nerves block in comparison with local infiltration analgesia after 24 h of total knee arthroplasty. DESIGN Prospective cohort study. SETTING Perioperative setting. PATIENTS Thirty-five patients scheduled for total knee arthroplasty were prospectively included in the study and compared with 35 patients in a retrospective cohort. INTERVENTION Genicular nerve blocks in the prospective cohort were compared with local infiltration analgesia in the retrospective cohort. MAIN OUTCOME MEASURES The pain numeric rating scale and the cumulative opioid consumption in oral morphine equivalents during the first 24 h. RESULTS We conducted propensity score-matched analyses of patients using acute postoperative pain-related risk covariates. After one-to-one propensity score matching, 21 patients were included in the local infiltration analgesia group and 21 in the genicular nerve block group. The median difference in numeric rating score at rest at 24 h was -0.99 [95% confidence interval (CI), -1.99 to 0.5, P = 0.012] on the unmatched cohort and -1.9 (95% CI, -2 to 0, P = 0.002) on the matched cohort (meeting the noninferiority criteria, Δ=1). The median difference in cumulative opioid consumption was 2.5 mg (95% CI, -13.5 to 2.5, P < 0.001) for the unmatched cohort and 4.99 mg (95% CI, -11.5 to 2.5, P < 0.001) on the matched group (meeting the noninferiority criteria, Δ = 21 mg). CONCLUSION Local infiltration analgesia and genicular nerve block are comparable in terms of analgesic results. Therefore, genicular nerves block is an alternative to local infiltration analgesia in patients undergoing total knee arthroplasty. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT04024319.
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Affiliation(s)
- Pierangela Pietrantoni
- From the School of Medicine, Universitat of Barcelona (PP, TC), Department of Anesthesiology, Hospital Clínic de Barcelona (TC, NM, MT, MB, XSB), Knee Unit, Hospital CLINIC de Barcelona (MNG), Department of Orthopaedic Surgery and Traumatology, Hospital CLINIC de Barcelona (SS) and Anatomy and Embryology Department. School of Medicine. Universitat of Barcelona. Spain (XSB)
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Chen KK, Chan JJ, Zubizarreta NJ, Poeran J, Chen DD, Moucha CS. Enhanced Recovery After Surgery Protocols in Lower Extremity Joint Arthroplasty: Using Observational Data to Identify the Optimal Combination of Components. J Arthroplasty 2021; 36:2722-2728. [PMID: 33757714 DOI: 10.1016/j.arth.2021.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/20/2021] [Accepted: 03/01/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols are increasingly used in orthopedic surgery. Data are lacking on which combinations of ERAS components are (1) the most commonly used and (2) the most effective in terms of outcomes. METHODS This retrospective cohort study utilized claims data (Premier Healthcare, n = 1,539,432 total joint arthroplasties, 2006-2016). Eight ERAS components were defined: (A) regional anesthesia, (B) multimodal analgesia, (C) tranexamic acid, (D) antiemetics on day of surgery, (E) early physical therapy, and avoidance of (F) urinary catheters, (G) patient-controlled analgesia, and (H) drains. Outcomes were length of stay, "any complication," and hospitalization cost. Mixed-effects models measured associations between the most common ERAS combinations and outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. RESULTS In 2006-2012 and 2013-2016, the most common ERAS combinations were B/D/E/F/G/H (20%, n = 172,397) and B/C/D/E/F/G/H (17%, n = 120,266), respectively. The only difference between the most commonly used ERAS combinations over the years is the addition of C (addition of tranexamic acid to the protocol). The most pronounced beneficial effects in 2006-2012 were seen for combination A/B/D/E/F/G/H (6% of cases vs less prevalent ERAS combinations) for the outcome of "any complication" (OR 0.87, CI 0.83-0.91, P < .0001). In 2013-2016, the strongest effects were seen for combination B/C/D/E/F/G/H (17% of cases) also for the outcome of "any complication" (OR 0.86, CI 0.83-0.89, P < .0001). Relatively minor differences existed between ERAS protocols for the other outcomes. CONCLUSION Despite varying ERAS protocols, maximum benefits in terms of complication reduction differed minimally. Further study may elucidate the balance between an increasing number of ERAS components and incremental benefits realized. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kevin K Chen
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jimmy J Chan
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Nicole J Zubizarreta
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jashvant Poeran
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Darwin D Chen
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Calin S Moucha
- Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
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