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Li Q, Xu S, Ou Y, Zhou L, Huang F, Jiang W, Xie H, Zou X, Gao J, Jin S, Zhou H, Huang Y, Pan Z, Liu J, Wang G, Li X, Sun C, Zhao L, Li L, Liu Q, Duan K, Wang S. Evaluating the efficacy and safety of perianal injection of liposomal ropivacaine HR18034 for postoperative analgesia following hemorrhoidectomy: A multicenter, randomized, double-blind, controlled phase II clinical trial. J Clin Anesth 2024; 97:111524. [PMID: 38941870 DOI: 10.1016/j.jclinane.2024.111524] [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: 10/09/2023] [Revised: 06/06/2024] [Accepted: 06/08/2024] [Indexed: 06/30/2024]
Abstract
STUDY OBJECTIVE HR18034, composed of the ropivacaine encapsulated in multi-lamellar, concentric circular structure liposomes as the major component and a small amount of free ropivacaine, has performed well in animal experiments and phase I clinical trials. This trial was to investigate the efficacy, safety, pharmacokinetic profile and the minimum effective dose of HR18034 for postoperative analgesia after hemorrhoidectomy compared with ropivacaine. DESIGN A multicenter, randomized, double-blind trial. SETTING 19 medical centers in China. PATIENTS 85 patients undergoing hemorrhoidectomy between October 2022 to November 2022. INTERVENTIONS Patients were randomly divided into HR 18034 190 mg group, 285 mg group, 380 mg group and ropivacaine 75 mg group, receiving single local anesthetic perianal injection for postoperative analgesia. MEASUREMENTS The primary outcome was the area under the resting state NRS score -time curve within 72 h after injection. The second outcomes included the proportion of patients without pain, the proportion of patients not requiring rescue analgesia, cumulative morphine consumption for rescue analgesia, etc. Safety was evaluated by adverse events incidence and plasma ropivacaine concentrations were measured to explore the pharmacokinetic characteristics of HR18034. MAIN RESULTS The areas under the NRS score (at rest and moving states)-time curve were significantly lower in HR 18034 380 mg group than ropivacaine 75 mg at 24 h, 48 h, and 72 h after administration. However, this superiority was not observed in HR18034 190 mg group and 285 mg group. There was no difference in cumulative morphine consumption for rescue analgesia between HR 18034 groups and ropivacaine group. CONCLUSIONS HR 18034 380 mg showed superior analgesic efficacy and equivalent safety compared to ropivacaine 75 mg after hemorrhoidectomy, thus preliminarily determined as minimum effective dose.
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Affiliation(s)
- Qiuwen Li
- The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Shouyu Xu
- The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Yangwen Ou
- The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Lianbang Zhou
- The Second Affiliated Hospital of Anhui Medical University, Hefei 230022, People's Republic of China
| | - Furong Huang
- The First People's Hospital of Changde, Changde, People's Republic of China
| | - Wanwei Jiang
- Affiliated Zhongshan Hospital of Dalian University, Dalian 116011, People's Republic of China
| | - Haihui Xie
- Dongguan people's Hospital, Dongguan, Guangdong, People's Republic of China
| | - Xiaohua Zou
- The Affiliated Hospital of Guizhou Medical University, Guiyang, People's Republic of China
| | - Jihua Gao
- Traditional Chinese Medicine Hospital of Hebei Province, Shijiazhang,People's Republic of China
| | - Shu''an Jin
- Central Hospital Affiliated to Shandong First Medical University, Jinan, People's Republic of China
| | - Hongmei Zhou
- Jiaxing Second Hospital, Jiaxing, People's Republic of China
| | - Yanjuan Huang
- Nanning Second People's Hospital, Nanning, People's Republic of China
| | - Zhihao Pan
- Li Huili Hospital of Ningbo Medical Center, Ningbo, People's Republic of China
| | - Juying Liu
- Taihe Hospital Affiliated Hospital of Hubei University of medicine, Shiyan, People's Republic of China
| | - Guyan Wang
- Beijing Tongren Hospital Affiliated to Capital Medical University, Beijing, People's Republic of China
| | - Xiangkui Li
- Sichuan Provincial People's Hospital, Chengdu, People's Republic of China
| | - CanLin Sun
- Taizhou People's Hospital, Taizhou, People's Republic of China
| | - Ling Zhao
- The First Affiliated Hospital of Xi'an Medical University, Xi'an, People's Republic of China
| | - Lin Li
- General Hospital of Northern Theater Command, Shenyang, People's Republic of China
| | - Qin Liu
- Jiangsu Hengrui Pharmaceuticals Co, Ltd, Shanghai, China
| | - Kaiming Duan
- The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, People's Republic of China
| | - Saiying Wang
- The Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, People's Republic of China.
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Yoo JD, Huh MH, Lee SH, D'Lima DD, Shin YS. A Network Meta-Analysis of Randomized Controlled Trials Assessing Intraoperative Anesthetic Therapies for Analgesic Efficacy and Morphine Consumption Following Total Knee Arthroplasty. J Arthroplasty 2024; 39:1361-1373. [PMID: 37952743 DOI: 10.1016/j.arth.2023.11.007] [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: 07/07/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND The purpose of this study was to compare intraoperative anesthetic therapies for total knee arthroplasty (TKA) regarding postoperative analgesic efficacy and morphine consumption by conducting a systematic literature search. METHODS Randomized controlled trials of TKA using various anesthetic therapies were identified from various databases from conception through December 31, 2021. A network meta-analysis of relevant literature was performed to investigate which treatment showed better outcomes. In total, 40 trials were included in this study. RESULTS Surface under the cumulative ranking curve showed local infiltration anesthesia (LIA) with saphenous nerve block (SNB) to produce the best pain relief on postoperative days (PODs) 1 and 2 and the best reduction of morphine consumption on PODs 1 and 3. However, femoral nerve block showed the largest effect on pain relief on POD 3, and liposomal bupivacaine showed the largest effect on reduction of morphine consumption on POD 2. CONCLUSIONS According to this network meta-analysis, surface under the cumulative ranking curve percentage showed that LIA with SNB provided the best analgesic effect after TKA. Furthermore, patients receiving LIA with SNB had the lowest consumption of morphine. Although femoral nerve block resulted in better pain relief on POD 3, LIA with SNB could be selected first when trying to reduce morphine consumption or increase early ambulation.
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Affiliation(s)
- Jae-Doo Yoo
- Department of Orthopaedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Min-Hwan Huh
- Department of Medicine, The Graduate School, Yonsei University, Seoul, Republic of Korea
| | - Seung-Hyun Lee
- Department of Orthopaedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research and Education, Scripps Health, La Jolla, California
| | - Young-Soo Shin
- Department of Orthopaedic Surgery, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Casambre FD, Verity TJ, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1928-1938.e9. [PMID: 36162925 DOI: 10.1016/j.arth.2022.03.045] [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: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine. METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI. RESULTS Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine. CONCLUSION Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Vasili Karas
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Thuppal S, Sleiman A, Chawla K, Dynda D, Evans Q, Markwell S, Hazelrigg S, Crabtree T. Randomized Trial of Bupivacaine Versus Liposomal Bupivacaine in Minimally Invasive Lobectomy. Ann Thorac Surg 2022; 114:1128-1134. [PMID: 35331700 DOI: 10.1016/j.athoracsur.2022.02.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/24/2022] [Accepted: 02/22/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND The objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer. METHODS Adult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared. RESULTS The study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001). CONCLUSIONS In narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB.
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Affiliation(s)
- Sowmyanarayanan Thuppal
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois; Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois
| | - Anthony Sleiman
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Kanika Chawla
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Danuta Dynda
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois; Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois
| | - Quadis Evans
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois; Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois
| | - Stephen Markwell
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Stephen Hazelrigg
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois.
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Periarticular Injection in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1701-1707. [PMID: 35970572 DOI: 10.1016/j.arth.2022.03.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 02/06/2023] Open
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Hamilton TW, Knight R, Stokes JR, Rombach I, Cooper C, Davies L, Dutton SJ, Barker KL, Cook J, Lamb SE, Murray DW, Poulton L, Wang A, Strickland LH, Van Duren BH, Leal J, Beard D, Pandit HG. Efficacy of Liposomal Bupivacaine and Bupivacaine Hydrochloride vs Bupivacaine Hydrochloride Alone as a Periarticular Anesthetic for Patients Undergoing Knee Replacement: A Randomized Clinical Trial. JAMA Surg 2022; 157:481-489. [PMID: 35385072 PMCID: PMC8988023 DOI: 10.1001/jamasurg.2022.0713] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Question Among patients undergoing knee replacement surgery, does liposomal bupivacaine and bupivacaine hydrochloride administered at the surgical site improve postoperative recovery at 72 hours and postoperative pain from 6 to 72 hours compared with bupivacaine hydrochloride alone? Findings In this randomized clinical trial of 533 patients undergoing knee replacement surgery, no difference in the coprimary outcomes of Quality of Recovery 40 score at 72 hours or pain visual analog scale score area under the curve from 6 to 72 hours was detected between patients receiving liposomal bupivacaine and bupivacaine hydrochloride and those receiving bupivacaine hydrochloride alone. In addition, liposomal bupivacaine was not found to be cost-effective. Meaning This study found that liposomal bupivacaine did not improve postoperative recovery or pain compared with bupivacaine hydrochloride alone among patients undergoing knee replacement surgery. Importance More than half of patients who undergo knee replacement surgery report substantial acute postoperative pain. Objective To evaluate the efficacy and cost-effectiveness of periarticular liposomal bupivacaine for recovery and pain management after knee replacement. Design, Setting, and Participants This multicenter, patient-blinded, pragmatic, randomized clinical superiority trial involved 533 participants at 11 institutions within the National Health Service in England. Adults undergoing primary unilateral knee replacement for symptomatic end-stage osteoarthritis were enrolled between March 29, 2018, and February 29, 2020, and followed up for 1 year after surgery. Follow-up was completed March 1, 2021. A per-protocol analysis for each coprimary outcome was performed in addition to the main intention-to-treat analysis. Interventions Two hundred sixty-six milligrams of liposomal bupivacaine admixed with 100 mg of bupivacaine hydrochloride compared with 100 mg of bupivacaine hydrochloride alone (control) administered by periarticular injection at the time of surgery. Main Outcome and Measures The coprimary outcomes were Quality of Recovery 40 (QoR-40) score at 72 hours and pain visual analog scale (VAS) score area under the curve (AUC) from 6 to 72 hours. Secondary outcomes included QoR-40 and mean pain VAS at days 0 (evening of surgery), 1, 2, and 3; cumulative opioid consumption for 72 hours; functional outcomes and quality of life at 6 weeks, 6 months, and 1 year; and cost-effectiveness for 1 year. Adverse events and serious adverse events up to 12 months after randomization were also assessed. Results Among the 533 participants included in the analysis, the mean (SD) age was 69.0 (9.7) years; 287 patients were women (53.8%) and 246 were men (46.2%). Baseline characteristics were balanced between study groups. There was no difference between the liposomal bupivacaine and control groups in QoR-40 score at 72 hours (adjusted mean difference, 0.54 [97.5% CI, −2.05 to 3.13]; P = .64) or the pain VAS score AUC at 6 to 72 hours (−21.5 [97.5% CI, −46.8 to 3.8]; P = .06). Analyses of pain VAS and QoR-40 scores demonstrated only 1 statistically significant difference, with the liposomal bupivacaine arm having lower pain scores the evening of surgery (adjusted difference −0.54 [97.5% CI, −1.07 to −0.02]; P = .02). No difference in cumulative opioid consumption and functional outcomes was detected. Liposomal bupivacaine was not cost-effective compared with the control treatment. No difference in adverse or serious adverse events was found between the liposomal bupivacaine and control groups. Conclusions and Relevance This study found no difference in postoperative recovery or pain associated with the use of periarticular liposomal bupivacaine compared with bupivacaine hydrochloride alone in patients who underwent knee replacement surgery. Trial Registration isrctn.com Identifier: ISRCTN54191675
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Affiliation(s)
- Thomas W Hamilton
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Ruth Knight
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jamie R Stokes
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Ines Rombach
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Cushla Cooper
- Surgical Interventional Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Loretta Davies
- Surgical Interventional Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Karen L Barker
- National Institute for Health Research-Biomedical Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom.,Physiotherapy Research Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals, NHS (National Health Service) Foundation Trust, Oxford, United Kingdom
| | - Jonathan Cook
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Sarah E Lamb
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - David W Murray
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Lisa Poulton
- Surgical Interventional Trials Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Ariel Wang
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Louise H Strickland
- Oxford Orthopaedic Engineering Centre, Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Bernard H Van Duren
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, United Kingdom
| | - Jose Leal
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - David Beard
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Hemant G Pandit
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, University of Leeds, Leeds, United Kingdom
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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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Bigalke S, Maeßen TV, Schnabel K, Kaiser U, Segelcke D, Meyer-Frießem CH, Liedgens H, Macháček PA, Zahn PK, Pogatzki-Zahn EM. Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty. Pain 2021; 162:1914-1934. [PMID: 33492036 DOI: 10.1097/j.pain.0000000000002209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/21/2020] [Indexed: 01/04/2023]
Abstract
ABSTRACT The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.
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Affiliation(s)
- Stephan Bigalke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Timo V Maeßen
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Kathrin Schnabel
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Ulrike Kaiser
- University Pain Centre, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Daniel Segelcke
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Christine H Meyer-Frießem
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | | | - Philipp A Macháček
- Faculty of Electrical Engineering and Information Technology, Ruhr-University Bochum, Bochum, Germany
| | - Peter K Zahn
- Clinic for Anaesthesiology, Intensive and Pain Medicine, Ruhr-University Bochum, BG-University Hospital Bergmannsheil gGmbH, Bochum, Germany
| | - Esther M Pogatzki-Zahn
- Clinic for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
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Weksler B, Sullivan JL, Schumacher LY. Randomized trial of bupivacaine with epinephrine versus bupivacaine liposome suspension in patients undergoing minimally invasive lung resection. J Thorac Cardiovasc Surg 2021; 161:1652-1661. [DOI: 10.1016/j.jtcvs.2020.01.112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 10/24/2022]
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10
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Ji YD, Harris JA, Gibson LE, McKinley SK, Phitayakorn R. The Efficacy of Liposomal Bupivacaine for Opioid and Pain Reduction: A Systematic Review of Randomized Clinical Trials. J Surg Res 2021; 264:510-533. [PMID: 33862580 DOI: 10.1016/j.jss.2021.02.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/04/2021] [Accepted: 02/27/2021] [Indexed: 12/22/2022]
Abstract
Background The opioid crisis has prompted surgeons to search for alternative postoperative methods of analgesia. Liposomal bupivacaine is a long-acting local anesthetic formulation used for pain, potentially reducing opioid use. Evaluation of liposomal bupivacaine as a viable alternative for pain management is needed. The objective was to assess the efficacy of randomized clinical trials (RCTs) of liposomal bupivacaine in postoperative pain management and opioid consumption. Material and Methods The authors extracted RCTs comparing liposomal bupivacaine versus placebo or active comparators for postoperative pain or opioid reduction from PubMED/MEDLINE, Cochrane Library, and ClinicalTrials.gov. Exclusion criteria included nonhuman studies, non-RCTs, pooled studies, and inability to access full text. The following variables were abstracted: surgical specialty, number of subjects, pain and opioid outcomes, and authors' financial conflicts of interest. Results We identified 77 published RCTs, of which 63 studies with a total of 6770 subjects met inclusion criteria. Liposomal bupivacaine did not demonstrate significant pain relief compared to placebo or active agents in 74.58% of RCTs. Of the studies evaluating narcotic use, liposomal bupivacaine did not show a reduction in opioid consumption in 85.71% of RCTs. Liposomal bupivacaine, when compared to standard bupivacaine or another active agent, yielded no reduction in opioid use in 83.33% and 100.00% of studies, respectively. Clinical trials with a financial conflict of interest relating to the manufacturer of liposomal bupivacaine were significantly more likely to show pain relief (OR: 14.31 [95% CI, 2.8, 73.10], P = 0.0001) and decreased opioid consumption (OR: 12.35 [95% CI 1.40, 109.07], P = 0.0237). Of the 265 unpublished RCTs on ClinicalTrials.gov, 47.54% were withdrawn, terminated, suspended, or completed without study results available. Conclusions The efficacy of liposomal bupivacaine for providing superior postoperative pain control relative to placebo or another active agent is not supported by a majority of RCTs. Underreporting of trial results and bias due to underlying financial relationships amongst authors are two major concerns that should be considered when evaluating the available evidence.
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Affiliation(s)
| | | | - Lauren E Gibson
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Roy Phitayakorn
- Harvard Medical School, General and Endocrine Surgery, Massachusetts General Hospital, Boston, MA
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Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain. Anesthesiology 2021; 134:283-344. [PMID: 33372949 DOI: 10.1097/aln.0000000000003630] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The authors provide a comprehensive summary of all randomized, controlled trials (n = 76) involving the clinical administration of liposomal bupivacaine (Exparel; Pacira Pharmaceuticals, USA) to control postoperative pain that are currently published. When infiltrated surgically and compared with unencapsulated bupivacaine or ropivacaine, only 11% of trials (4 of 36) reported a clinically relevant and statistically significant improvement in the primary outcome favoring liposomal bupivacaine. Ninety-two percent of trials (11 of 12) suggested a peripheral nerve block with unencapsulated bupivacaine provides superior analgesia to infiltrated liposomal bupivacaine. Results were mixed for the 16 trials comparing liposomal and unencapsulated bupivacaine, both within peripheral nerve blocks. Overall, of the trials deemed at high risk for bias, 84% (16 of 19) reported statistically significant differences for their primary outcome measure(s) compared with only 14% (4 of 28) of those with a low risk of bias. The preponderance of evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics.
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Chen J, Zhou C, Ma C, Sun G, Yuan L, Hei Z, Guo C, Yao W. Which is the best analgesia treatment for total knee arthroplasty: Adductor canal block, periarticular infiltration, or liposomal bupivacaine? A network meta-analysis. J Clin Anesth 2020; 68:110098. [PMID: 33129063 DOI: 10.1016/j.jclinane.2020.110098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/21/2020] [Accepted: 10/10/2020] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To review all randomized controlled trials (RCTs) comparing the analgesic efficacy of adductor canal block (ACB), periarticular infiltration (PAI), and any other mode of these treatments in analgesia, such as PAI with liposomal bupivacaine (LB), continuous adductor canal block (cACB) or ACB + PAI, after total knee arthroplasty (TKA). DESIGN Systematic review and network meta-analysis of RCTs. PATIENTS We searched PubMed, Embase, and the Cochrane database to detect all relevant RCTs on investigating the analgesic effects of ACB, PAI and LB for TKA published until April 2020. INTERVENTIONS Use of different analgesic methods of ACB, PAI, cACB, ACB + PAI and LB. MEASUREMENTS The primary endpoint was visual analog scale (VAS) score at rest and movement. The secondary endpoints were opioids consumption, length of hospitalization and knee range of motion (ROM). We used Cochrane risk of bias to assess the quality of evidence for outcomes. RESULTS Forty-two studies involving 3785 patients with 5 different methods containing ACB, PAI, ACB + PAI, continuous ACB (cACB), LB, were evaluated. According to surface under the cumulative ranking curve value, 24 h resting VAS score was the lowest the ACB + PAI (88.4%), followed by cACB (73.4%); Resting VAS score at 48 h and movement VAS score at 24 h and 48 h was the lowest in the cACB (99.9%, 92% and 100%). Total opioids consumption was the least in LB (81.4%) before cACB (60.8%). ROM was the largest in the ACB + PAI (84.1%) before cACB (78.8%). CONCLUSION Although all analgesic methods available were not evaluated, and further studies are needed to establish our results, the 24 h resting VAS score was lowest in ACB + PAI and 48 h resting and movement VAS score was lowest in cACB. CLINICAL TRIAL REGISTRATION PROSPERO (CRD 42020168102).
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Affiliation(s)
- Junheng Chen
- Department of Anesthesiology, Shantou Central Hospital, Shantou, China
| | - Chunbin Zhou
- Department of Orthopedic, First Affiliated Hospital of Shantou University, Guangdong Province, People's Republic of China
| | - Chuzhou Ma
- Department of Anesthesiology, Shantou Central Hospital, Shantou, China
| | - Guoliang Sun
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China
| | - Lianxiong Yuan
- Department of Research Service Office, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China
| | - Ziqing Hei
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China
| | - Chunming Guo
- Department of Anesthesiology, Shantou Central Hospital, Shantou, China.
| | - Weifeng Yao
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China.
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Hussain N, Brull R, Sheehy BT, Kushelev M, Essandoh MK, Abdallah FW. The mornings after-periarticular liposomal bupivacaine infiltration does not improve analgesic outcomes beyond 24 hours following total knee arthroplasty: a systematic review and meta-analysis. Reg Anesth Pain Med 2020; 46:61-72. [PMID: 33106282 DOI: 10.1136/rapm-2020-101995] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/14/2020] [Accepted: 09/15/2020] [Indexed: 12/19/2022]
Abstract
Periarticular local infiltration analgesia (LIA) is integral to multimodal analgesia following total knee arthroplasty (TKA); however, the duration of analgesia using traditional long-acting local anesthetics is often insufficient. LIA with slow-release liposomal bupivacaine may provide extended analgesia, but evidence of efficacy beyond the first 24 hours is conflicting. This meta-analysis compares the effects of periarticular liposomal and plain bupivacaine LIA on day 2 analgesic outcomes post-TKA. Trials comparing liposomal and plain bupivacaine LIA for TKA were sought. The two coprimary outcomes were (1) cumulative oral morphine equivalent consumption and (2) difference in area under the curve (AUC) of pooled rest pain scores on day 2 (24-48 hours) post-TKA. We also evaluated pain and analgesic consumption on day 3 (48-72 hours), functional recovery, length of hospital stay, patient satisfaction; and opioid-related side effects. Data were pooled using random-effects modeling. Seventeen trials (1836 patients) were analyzed. Comparing liposomal versus plain bupivacaine LIA for TKA failed to detect differences in morphine consumption and pain AUC on day 2 postoperatively, with mean differences of 0.54 mg (95% CI -5.09 to 6.18) and 0.08 cm/hour (95% CI -0.19 to 0.35), respectively (high-quality evidence). Secondary outcome analysis did not uncover any additional analgesic, functional or safety advantages to liposomal bupivacaine on postoperative day 2 or 3. Results indicate that liposomal and plain bupivacaine LIAs are not different for extended postoperative analgesic outcomes, including pain control, opioid consumption, as well as functional and safety outcomes on days 2 and 3 post-TKA. High-quality evidence does not support using liposomal bupivacaine LIA for TKA.
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Affiliation(s)
- Nasir Hussain
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Richard Brull
- Anesthesiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Brendan T Sheehy
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael Kushelev
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Michael K Essandoh
- Anesthesiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Faraj W Abdallah
- Anesthesiology and Pain Medicine, University of Toronto and University of Ottawa, Ottawa, Ontario, Canada
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Summers S, Mohile N, McNamara C, Osman B, Gebhard R, Hernandez VH. Analgesia in Total Knee Arthroplasty: Current Pain Control Modalities and Outcomes. J Bone Joint Surg Am 2020; 102:719-727. [PMID: 31985507 DOI: 10.2106/jbjs.19.01035] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Spencer Summers
- Departments of Orthopaedics and Rehabilitation (S.S., N.M., C.M., and V.H.H.), and Anesthesiology, Perioperative Medicine, and Pain Management (B.O. and R.G.), University of Miami, Miami, Florida
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Abstract
Background Optimal modalities for pain control in shoulder arthroplasty are not yet established. Although regional nerve blockade has been a well-accepted modality, complications and rebound pain have led some surgeons to seek other pain control modalities. Local injection of anesthetics has recently gained popularity in joint arthroplasty. The purpose of this study was to evaluate the effectiveness and complication rate of a low-cost local anesthetic injection mixture for use in total shoulder arthroplasty (TSA) compared with interscalene brachial plexus blockade. Methods A total of 314 patients underwent TSA and were administered general anesthesia with either a local injection mixture (local infiltration anesthesia [LIA], n = 161) or peripheral nerve block (PNB, n = 144). Patient charts were retrospectively reviewed for postoperative pain scores, 24-hour opioid consumption, and 90-day postoperative complications. Results Immediate postoperative pain scores were not significantly different between groups (P = .94). The LIA group demonstrated a trend toward lower pain scores at 24 hours postoperatively (P = .10). Opioid consumption during the first 24 hours following surgery was significantly reduced in the LIA group compared with the PNB group (P < .0001). There was a trend toward fewer postoperative nerve and cardiopulmonary complications in the LIA group than the PNB group (P = .22 and P = .40, respectively) Conclusion Periarticular local injection mixtures provide comparable pain control to regional nerve blocks while reducing opioid use and postoperative complications following TSA. Local injection of a multimodal anesthetic solution is a viable option for pain management in TSA.
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Bravin LN, Ernest EP, Dietz MJ, Frye BM. Liposomal Bupivacaine Offers No Benefit Over Ropivacaine for Multimodal Periarticular Injection in Total Knee Arthroplasty. Orthopedics 2020; 43:91-96. [PMID: 31881086 DOI: 10.3928/01477447-20191223-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/09/2019] [Indexed: 02/03/2023]
Abstract
Local infiltration analgesia has become a mainstay of pain control for total knee arthroplasty. This study compared the efficacy and cost between periarticular injection cocktails containing liposomal bupivacaine vs ropivacaine. Two hundred forty-two primary total knee arthroplasties performed between September 2013 and January 2016 were retrospectively reviewed. All patients received similar pre-operative medications and a periarticular injection. The control group received 300 mg of ropivacaine, while the study group received liposomal bupivacaine. All patients received the same preoperative, intraoperative, and postoperative adjunct medications. Visual analog scale pain scores, narcotic requirements, distance walked, range of motion, length of stay, Knee Society Scores, and need for manipulation under anesthesia were recorded. Mean visual analog scale pain score 23 to 32 hours postoperatively, mean visual analog scale pain score during the entire hospitalization, and length of stay were lower in the ropivacaine group compared with the liposomal bupivacaine group. Knee range of motion was higher at 2 weeks in the ropivacaine group. There were no statistically significant differences in the other outcome measures. The cost of ropivacaine was considerably lower than the cost of liposomal bupivacaine. Bupivacaine added to liposomal bupivacaine addressed the delayed onset of this medication and gave an accurately matched comparison with the ropivacaine cocktail. All outcomes tested with liposomal bupivacaine were either equivalent or inferior to those with ropivacaine. When used as a component of a periarticular injection cocktail, liposomal bupivacaine offers no advantages over ropivacaine and has a considerably higher cost. [Orthopedics. 2020; 43(2):91-96.].
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Meftah M, Boenerjous-Abel S, Siddappa VH, Kirschenbaum IH. Efficacy of Adductor Canal Block With Liposomal Bupivacaine: A Randomized Prospective Clinical Trial. Orthopedics 2020; 43:e47-e53. [PMID: 31770446 DOI: 10.3928/01477447-20191122-05] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/16/2018] [Indexed: 02/03/2023]
Abstract
This study compared the postoperative analgesic efficacy of liposomal bupivacaine as a single-administration adductor canal block (ACB) vs periarticular injection (PAI) for pain control after total knee arthroplasty (TKA). From May 2016 to June 2017, a total of 70 unilateral TKA patients were randomized into 2 groups: PAI (extended-release bupivacaine 266 mg [20-mL vial] with 20 mL of 0.5% bupivacaine hydrochloride and normal saline to a total volume of 120 mL) and ACB (subsartorial saphenous nerve using extended-release bupivacaine 266 mg [20-mL vial]). All patents underwent spinal anesthesia with comprehensive preemptive and postoperative multi-modal pain protocol. All opioids administered were converted to morphine equivalents. Pain was recorded at 4 to 12 hours on the day of surgery, and on postoperative days 1, 2, and 3. Patients and investigators other than the surgeon and anesthesiologist were blinded to the study. The difference in pain scores between the PAI and ACB groups was not statistically significant during the first 12 hours (day 0) after surgery or on postoperative day 1 (5.31 vs 4.26, P=.091). However, on postoperative day 3, the mean pain score increased in the ACB group and decreased in the PAI group (4.8 vs 1.83, P=.037). There was no statistically significant difference between the 2 groups regarding the accumulative daily converted morphine equivalent consumption or total consumption. Although the PAI group demonstrated longer lasting pain relief than the ACB group for the duration of the study, other outcomes were similar between the 2 groups. [Orthopedics. 2020; 43(1):e47-e53.].
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Beltrán-Gracia E, López-Camacho A, Higuera-Ciapara I, Velázquez-Fernández JB, Vallejo-Cardona AA. Nanomedicine review: clinical developments in liposomal applications. Cancer Nanotechnol 2019. [DOI: 10.1186/s12645-019-0055-y] [Citation(s) in RCA: 185] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abstract
Background
In recent years, disease treatment has evolved strategies that require increase in pharmaceutical agent’s efficacy and selectivity while decreasing their toxicity in normal tissues. These requirements have led to the development of nanoscale liposome systems for drug release. This review focuses on lipid features, pharmacological properties of liposomal formulations and the clinical studies of their application.
Main body
Several lipids are available, but their properties could affect pharmacological or clinical efficiency of drug formulations. Many liposomal formulations have been developed and are currently on the market. Proper selection of lipid is essential for the pharmacological effect to be improved. Most of the formulations use mainly zwitterionic, cationic or anionic lipids, PEG and/or cholesterol, which have different effects on stability, pharmacokinetics and delivery of the drug formulation. Clinical trials have shown that liposomes are pharmacologically and pharmacokinetically more efficient than drug-alone formulations in treating acute myeloid leukemia, hepatitis A, pain management, ovary, gastric breast and lung cancer, among others.
Conclusion
Liposomal formulations are less toxic than drugs alone and have better pharmacological parameters. Although they seem to be the first choice for drug delivery systems for various diseases, further research about dosage regimen regarding dose and time needs to be carried out.
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Yayac M, Li WT, Ong AC, Courtney PM, Saxena A. The Efficacy of Liposomal Bupivacaine Over Traditional Local Anesthetics in Periarticular Infiltration and Regional Anesthesia During Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2019; 34:2166-2183. [PMID: 31178385 DOI: 10.1016/j.arth.2019.04.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/30/2019] [Accepted: 04/23/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Since its Food and Drug Administration approval in 2011 as a local anesthetic for postsurgical analgesia, liposomal bupivacaine (LB) has been incorporated into the periarticular injection (PAI) of many knee surgeons. The slow release of this medication from vesicles should significantly extend the duration of its analgesic effect, but current evidence has not clearly demonstrated this benefit. METHODS We systematically searched electronic databases including PubMed, MEDLINE, Cochrane Library, EMBASE, ScienceDirect, and Scopus, as well as the Journal of Arthroplasty web page for relevant articles. All calculations were made using Review Manager 5.3. RESULTS We identified 42 studies that compared LB to an alternate analgesic modality. Seventeen of these studies were controlled trials that were included in meta-analysis. Significant differences were seen in pain scores with LB over a peripheral nerve block (mean difference = 0.45, P = .02) and LB over a traditional PAI (standard mean difference = -0.08, P = .004). CONCLUSION While LB may offer a statistically significant benefit over a traditional PAI, the increase in pain control may not be clinically significant and it does not appear to offer a benefit in reducing opioid consumption. However, there is no standardization among current studies, as they vary greatly in design, infiltration technique, and outcome measurement, which precludes any reliable summarization of their results. Future independent studies using a standardized protocol are needed to provide clear unbiased evidence.
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Affiliation(s)
- Michael Yayac
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - William T Li
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Alvin C Ong
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Arjun Saxena
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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20
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Ketamine reduces pain and opioid consumption after total knee arthroplasty: A meta-analysis of randomized controlled studies. Int J Surg 2019; 70:70-83. [PMID: 31446006 DOI: 10.1016/j.ijsu.2019.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/25/2019] [Accepted: 08/21/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To examine the analgesic efficacy and safety of ketamine after total knee arthroplasty. METHODS We searched for all articles on ketamine in patients with total knee arthroplasty in electronic databases, including PubMed, Embase, Ovid, Cochrane Library, Web of Science, CNKI, Wanfang Data, and VIP, up to the February 2019. Randomized controlled trials comparing ketamine and the placebo for pain management after total knee arthroplasty were utilized. The outcome measurements consist of the pain score, opioid consumption, length of hospitalization and postoperative complications. All data analyses were conducted using STATA 13.0. Cochrane Collaboration's tool was adopted to assess the risk of bias. RESULTS A total of six randomized controlled trials were included in the meta-analysis. The present meta-analysis demonstrated that there were significant differences between the two groups regarding the pain score within the first 24 postoperative hours. Ketamine was associated with a significant reduction of cumulative morphine consumption. Notably, ketamine could significantly decrease the incidence of nausea and vomiting without increasing the risk of thrombosis. CONCLUSION Ketamine is effective in reducing pain and cumulative morphine consumption during the early post-operative period after total knee arthroplasty. In addition, the use of ketamine is associated with a lower incidence of adverse effects.
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Abildgaard JT, Chung AS, Tokish JM, Hattrup SJ. Clinical Efficacy of Liposomal Bupivacaine. JBJS Rev 2019; 7:e8. [DOI: 10.2106/jbjs.rvw.18.00192] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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The efficacy of liposomal bupivacaine compared with traditional peri-articular injection for pain control following total knee arthroplasty: an updated meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 2019; 20:306. [PMID: 31253119 PMCID: PMC6599357 DOI: 10.1186/s12891-019-2660-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/29/2019] [Indexed: 02/07/2023] Open
Abstract
Background The efficacy of postoperative pain management is an important factor that influences the final outcome of total knee arthroplasty (TKA). Whether liposomal bupivacaine offers better efficacy compared with traditional peri-articular injection after TKA remains inconclusive. We conduct this study to compare the true efficacy of liposomal bupivacaine (LB) with traditional peri-articular injection (TPAI) following TKA. Materials and methods Randomized controlled trials (RCTs) from PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) and Web of Science were searched. Thirteen RCTs involving 1373 patients were finally included in our meta-analysis (LB = 691, TPAI = 682). The continuous and dichotomous outcome were collected in a standard form, and the data were analysed by using Review Manager 5.3 software. Finally, the results were presented in the forest plots. Result The pooled data demonstrated that the postoperative visual analogue score (VAS) in the LB group was not significantly different compared with that in the TPAI group at every time period after TKA. The liposomal bupivacaine group had significantly lower consumption of morphine equivalents 24 to 72 h postoperatively and reduced incidence of nausea and vomiting after TKA compared with the TPAI group. Finally, the length of hospital stay in the two groups was not significantly different. Conclusion Liposomal bupivacaine did not yield different results on the visual analogue scale compared with traditional peri-articular injection after total knee arthroplasty. However, liposomal bupivacaine was preferred in terms of lower consumption of morphine equivalents 24–72 h postoperatively and lower incidence of nausea and vomiting after total knee arthroplasty.
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Chung AS, Spangehl MJ. Peripheral Nerve Blocks vs Periarticular Injections in Total Knee Arthroplasty. J Arthroplasty 2018; 33:3383-3388. [PMID: 30197218 DOI: 10.1016/j.arth.2018.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 02/01/2023] Open
Abstract
In patients undergoing surgery, optimal pain management is associated with improved perioperative outcomes, patient satisfaction with surgery, and a more rapid functional recovery. In recent years, the employment of multimodal pain management strategies has become increasingly widespread. In particular, there has been an explosion in the use of peripheral nerve blockade and periarticular injections in total knee arthroplasty. However, there is significant variability in the administration of either modality of anesthesia. As such, a critical evaluation of the current literature is warranted to elucidate the advantages and disadvantages of each technique with the ultimate goal of further refining current pain control strategies. In this symposium, we review each of these modalities and their association with pain management, narcotic consumption, length of hospital stay, and adverse events.
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Affiliation(s)
- Andrew S Chung
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
| | - Mark J Spangehl
- Department of Orthopaedic Surgery, Mayo Clinic, Phoenix, Arizona
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Lee CY, Robinson DA, Johnson CA, Zhang Y, Wong J, Joshi DJ, Wu TT, Knight PA. A Randomized Controlled Trial of Liposomal Bupivacaine Parasternal Intercostal Block for Sternotomy. Ann Thorac Surg 2018; 107:128-134. [PMID: 30170012 DOI: 10.1016/j.athoracsur.2018.06.081] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/07/2018] [Accepted: 06/25/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND Optimal pain control continues to be a concern in cardiac surgery. Current strategies for postoperative pain management often yield suboptimal results. The superiority of Exparel (Pacira Pharmaceuticals, Inc, Parsippany, NJ) in providing postoperative pain control and opioid sparing is equivocal. This prospective, randomized, double-blind study examines the efficacy of Exparel as a novel single-dose application parasternal nerve block in postoperative pain control and opioid sparing. METHODS This single-surgeon study included 79 patients undergoing median sternotomy for coronary revascularization. Study participants were randomized to either the drug or a control arm. Each participant received Exparel or normal saline placebo administered as a parasternal nerve block. Postoperative pain was rated according to the nonverbal pain scale or numeric rating scale. Total amount of narcotic pain medication used and patients' pain scores within the first 72 hours postoperatively were compared. Secondary outcomes compared the intensive care unit length of stay, hospital length of stay, time to extubation, time to return of bowel function, and time to return to work or daily activities. RESULTS The primary endpoint of pain levels between the two groups demonstrated no significant difference when analyzing the individual time points postoperatively. However, overall pain levels were significantly lower in the study drug group (p = 0.04). There was no significant difference in the amount of analgesics required postoperatively or in secondary endpoints between the groups. CONCLUSIONS Exparel does not provide an opioid-sparing benefit or any secondary outcome benefit compared with placebo. Exparel may be associated with a marginal decrease in postoperative pain levels. (Parasternal Nerve Bock in Cardiac Patients; NCT01826851.).
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Affiliation(s)
- Candice Y Lee
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Davida A Robinson
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Carl A Johnson
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Yun Zhang
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Joshua Wong
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Devang J Joshi
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Tong-Tong Wu
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York
| | - Peter A Knight
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York.
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Zlotnicki JP, Hamlin BR, Plakseychuk AY, Levison TJ, Rothenberger S, Urish K. Liposomal Bupivacaine vs Plain Bupivacaine in Periarticular Injection for Control of Pain and Early Motion in Total Knee Arthroplasty: A Randomized, Prospective Study. J Arthroplasty 2018; 33:2460-2464. [PMID: 29656977 PMCID: PMC6054911 DOI: 10.1016/j.arth.2018.03.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/03/2018] [Accepted: 03/06/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of multimodal pain regimens has been shown to be an effective technique for the treatment of postoperative pain after total knee arthroplasty. Periarticular injections, of both short-acting and long-acting anesthetics, have emerged as an additional method of providing significant improvement in postoperative pain relief. The purpose of this study is to compare the efficacy of periarticular injection using long-acting vs short-acting preparations. METHODS A randomized, prospective study of 80 consecutive patients was performed comparing liposomal bupivacaine vs plain bupivacaine periarticular injection. The primary outcomes included pain relief, total narcotic usage, and completion of physical therapy goals, specifically range of motion. RESULTS No significant improvements were noted between liposomal bupivacaine and plain bupivacaine injection groups in overall pain reduction, range of motion, or total narcotic usage. At 24 hours, small statistically significant differences in physical therapy pain scores were noted with liposomal bupivacaine vs plain bupivacaine and control patients, but these differences did not persist at later time points. Both preparations demonstrated statistically significant improvements in range of motion when compared to historical controls, but no differences were noted between preparations. CONCLUSION Overall, minimal significant differences were noted between liposomal bupivacaine and plain bupivacaine at early and late time points. Both preparations of periarticular injection demonstrated superiority over control pain regimens but were relatively equivalent to one another in direct comparison.
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Affiliation(s)
- Jason P. Zlotnicki
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261
| | - Brian R. Hamlin
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212
| | - Anton Y. Plakseychuk
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212
| | - Timothy J. Levison
- The Bone & Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA 15212
| | - Scott Rothenberger
- Clinical and Translation Science Institute; Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | - Kenneth Urish
- Arthritis and Arthroplasty Design Group; The Bone and Joint Center, Magee Womens Hospital of the University of Pittsburgh Medical Center; Department of Orthopaedic Surgery, Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh; Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15219;
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Sah AP, Liang K, Sclafani JA. Optimal Multimodal Analgesia Treatment Recommendations for Total Joint Arthroplasty. JBJS Rev 2018; 6:e7. [DOI: 10.2106/jbjs.rvw.17.00137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Campbell AL, Yu S, Karia R, Iorio R, Stuchin SA. The Effects of Body Mass Index on Pain Control With Liposomal Bupivacaine in Hip and Knee Arthroplasty. J Arthroplasty 2018; 33:1033-1039. [PMID: 29208329 DOI: 10.1016/j.arth.2017.10.048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 10/21/2017] [Accepted: 10/26/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is evidence to suggest that liposomal bupivacaine (LB) is an effective component of a multimodal pain regimen for total joint arthroplasty (TJA). Obesity has been associated with chronic pain following TJA. This study assessed whether early postoperative pain is affected by body mass index (BMI), and whether the standard LB dose has similar effects on obese vs nonobese patients. METHODS A retrospective analysis of 2629 primary TJA over a 12-month period was conducted, with LB used in half of this group. Patients were further classified as nonobese (BMI < 30) or obese (BMI ≥ 30). Pain scores and narcotic use were recorded. Independent-sample t-tests were used for continuous variables and chi-squared analyses for categorical variables. A multivariate regression analysis was performed. RESULTS Significantly less narcotic was required on postoperative days (POD) 0 and 1 in patients receiving LB compared to those who did not in both obese and nonobese patient groups. On POD 2, obese and nonobese patients had an increase in narcotic requirement, which was significant in obese patients. A regression analysis found that on POD 0 and POD 1, lack of LB use, obesity, and younger age were independently associated with increased narcotic use. CONCLUSION While narcotic requirement of obese and nonobese patients decreased on POD 0 and POD 1 with initiation of LB at our institution, all patients demonstrated increased narcotic requirement on POD 2 which was statistically and clinically significant in obese patients. Further studies are needed to determine the optimal pain regimen in the growing obese population undergoing TJA.
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Affiliation(s)
- Abigail L Campbell
- Department of Orthopaedic Surgery, New York University Langone Medical Center/Hospital for Joint Diseases, New York, New York
| | - Stephen Yu
- Department of Orthopaedic Surgery, New York University Langone Medical Center/Hospital for Joint Diseases, New York, New York
| | - Raj Karia
- Department of Orthopaedic Surgery, New York University Langone Medical Center/Hospital for Joint Diseases, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, New York University Langone Medical Center/Hospital for Joint Diseases, New York, New York
| | - Steven A Stuchin
- Department of Orthopaedic Surgery, New York University Langone Medical Center/Hospital for Joint Diseases, New York, New York
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Yu ZX, Yang ZZ, Yao LL. Effectiveness of liposome bupivacaine for postoperative pain control in total knee arthroplasty: A PRISMA-compliant meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e0171. [PMID: 29595645 PMCID: PMC5895431 DOI: 10.1097/md.0000000000010171] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Adequate pain control after total knee arthroplasty (TKA) enables quicker recovery and reduces readmissions and treatment costs. The aim of this study was to determine the effect of liposomal bupivacaine (LB) for postoperative pain control in patients prepared for TKA. METHODS We searched for the reports that evaluating the effect of liposomal bupivacaine for postoperative pain control in patients prepared for TKA between March 1983 and May 2017 in the electronic database Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, EMBASE, Web of Science, and Ovid. The main outcomes were visual analog scale (VAS) at 24, 48, and 72 hours. The secondary outcomes were total morphine consumption, the length of hospital stay, range of motion, and the occurrence of nausea. RESULTS Seven randomized controlled trials (RCTs) enrolling 825 patients, with 413 in the LB group and 412 in the control group, were included in this meta-analysis. Our results suggested that administration LB was associated with a reduction of VAS by 4.22 points at 72 hours after TKA (WMD = -4.22, 95% CI -7.47, -0.97, P = .011) on a 100-point VAS. What's more, LB can decrease the occurrence of nausea when compared with traditional bupivacaine by 18.3% (risk ratio = 0.70, 95% confidence interval 0.55, 0.89, P = .003). LB was associated with an increase of the range of motion than traditional bupivacaine (P < .05). There was no significant difference between the VAS at 24, 48 hours, total morphine consumption and the length of hospital stay. CONCLUSIONS Administration with LB was associated with pain-relieving effects and reduces the morphine-related complications (nausea). Due the limited number of the included RCTs, large number and high quality RCTs are still need to identify the effects of LB for pain control after TKA.
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Affiliation(s)
- Zhan-Xia Yu
- Department of Traumatology, Linyi People's Hospital
| | - Zhao-Zhi Yang
- Department of Traditional Chinese Medicine, Zhifang Branch of Linqu in Chengguan Street Health Center
| | - Lu-Lan Yao
- Department of Surgery, Feixian People's Hospital, Shandong, China
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Affiliation(s)
- Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Abstract
The method by which surgeons conduct outpatient total knee procedures has yet to be fully elucidated. Literature demonstrates different experiences from various care protocols in place across the nation. This article reviews current recommendations for implementing successful total knee arthroplasty (TKA) and unicompartmental knee arthroplasty outpatient protocols. Specifically, information regarding anesthesia and analgesia modalities, perioperative care, operative technique, and postoperative care within outpatient TKA pathways is discussed.
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Dysart SH, Dagenais S. Letter to the Editor on "Effectiveness of Bupivacaine Liposome Injectable Suspension for Postoperative Pain Control in Total Knee Arthroplasty: A Prospective, Randomized, Double Blind, Controlled Study". J Arthroplasty 2018; 33:301-302. [PMID: 28993081 DOI: 10.1016/j.arth.2017.08.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/19/2017] [Indexed: 02/01/2023] Open
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