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Luo Z, Zeng W, Chen X, Xiao Q, Chen A, Chen J, Wang H, Zhou Z. Cocktail of Ropivacaine, Morphine, and Diprospan Reduces Pain and Prolongs Analgesic Effects after Total Knee Arthroplasty: A Prospective Randomized Controlled Trial. Int J Clin Pract 2024; 2024:3697846. [PMID: 38450292 PMCID: PMC10917473 DOI: 10.1155/2024/3697846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/26/2023] [Accepted: 01/17/2024] [Indexed: 03/08/2024] Open
Abstract
Background Local infiltration analgesia (LIA) provides postoperative analgesia for total knee arthroplasty (TKA). The purpose of this study was to evaluate the analgesic effect of a cocktail of ropivacaine, morphine, and Diprospan for TKA. Methods A total of 100 patients from September 2018 to February 2019 were randomized into 2 groups. Group A (control group, 50 patients) received LIA of ropivacaine alone (80 ml, 0.25% ropivacaine). Group B (LIA group, 50 patients) received an LIA cocktail of ropivacaine, morphine, and Diprospan (80 ml, 0.25% ropivacaine, 0.125 mg/ml morphine, and 62.5 μg/ml compound betamethasone). The primary outcomes were the levels of inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6), pain visual analog scale (VAS) scores, opioid consumption, range of motion (ROM), functional tests, and sleeping quality. The secondary outcomes were adverse events, satisfaction rates, HSS scores, and SF-12 scores. The longest follow-up was 2 years. Results The two groups showed no differences in terms of characteristics (P > 0.05). Group B had lower resting VAS pain scores (1.54 ± 0.60, 95% CI = 1.37 to 1.70 vs. 2.00 ± 0.63, 95% CI = 2.05 to 2.34) and active VAS pain scores (2.64 ± 0.62, 95% CI = 2.46 to 2.81 vs. 3.16 ± 0.75, 95% CI = 2.95 to 3.36) within 48 h postoperatively than Group A (P < 0.001), while none of the pain differences exceeded the minimal clinically important difference (MCID). Group B had significantly lower CRP levels (59.49 ± 13.01, 95% CI = 55.88 to 63.09 vs. 65.95 ± 14.41, 95% CI = 61.95 to 69.94) and IL-6 levels (44.11 ± 13.67, 95% CI = 40.32 to 47.89 vs. 60.72 ± 15.49, 95% CI = 56.42 to 65.01), lower opioid consumption (7.60 ± 11.10, 95% CI = 4.52 to 10.67 vs. 13.80 ± 14.68, 95% CI = 9.73 to 17.86), better ROM (110.20 ± 10.46, 95% CI = 107.30 to 113.09 vs. 105.30 ± 10.02, 95% CI = 102.52 to 108.07), better sleep quality (3.40 ± 1.03, 95% CI = 3.11 to 3.68 vs. 4.20 ± 1.06, 95% CI = 3.90 to 4.49), and higher satisfaction rates than Group A within 48 h postoperatively (P < 0.05). Adverse events, HSS scores, and SF-12 scores were not significantly different within 2 years postoperatively. Conclusions A cocktail of ropivacaine, morphine, and Diprospan prolongs the analgesic effect up to 48 h postoperatively. Although the small statistical benefit may not result in MCID, the LIA cocktail still reduces opioid consumption, results in better sleeping quality and faster rehabilitation, and does not increase adverse events. Therefore, cocktails of ropivacaine, morphine, and Diprospan have good application value for pain control in TKA. This trial is registered with ChiCTR1800018372.
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Affiliation(s)
- Zhenyu Luo
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Weinan Zeng
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Xi Chen
- Department of Operative Dentistry and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, China
| | - Qiang Xiao
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Anjing Chen
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Jiali Chen
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
- Department of Orthopedics, West China Hospital, West China School of Nursing, Sichuan University, Chengdu 610041, China
| | - Haoyang Wang
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
| | - Zongke Zhou
- Department of Orthopedics, Institute of Orthopedic Research, West China Hospital, West China School of Medicine, Sichuan University, Chengdu 610041, China
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Domagalska M, Wieczorowska-Tobis K, Reysner T, Kowalski G. Periarticular injection, iPACK block, and peripheral nerve block in pain management after total knee arthroplasty: a structured narrative review. Perioper Med (Lond) 2023; 12:59. [PMID: 37968690 PMCID: PMC10652613 DOI: 10.1186/s13741-023-00346-8] [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: 06/20/2023] [Accepted: 10/25/2023] [Indexed: 11/17/2023] Open
Abstract
INTRODUCTION Total knee arthroplasty (TKA) is commonly performed in patients with end-stage osteoarthritis or rheumatoid arthritis of the knee to reduce joint pain, increase mobility, and improve quality of life. However, TKA is associated with moderate to severe postoperative pain, which remains a significant clinical challenge. Surgeon-administered PAI and anesthesiologist-administered iPACK have proven viable alternatives to conventional peripheral nerve blocks. This review aims to discuss which IPACK block or periarticular injection, combined or not with different peripheral nerve blocks, has better effects on postoperative rehabilitation, patient satisfaction, and overall outcome. MATERIAL AND METHODS The literature review was performed on standards of care, current therapeutic options, a pain management protocol, and innovative treatment options for patients undergoing total knee arthroplasty. The literature was reviewed through four electronic databases: PubMed, Cochrane Library, Google Scholar, and Embase. RESULTS The initial search yielded 694 articles. Fifty relevant articles were selected based on relevance, recentness, search quality, and citations. Six studies compared PAI to peripheral nerve block (PNB), and eight studies checked the effectiveness of adding PNB to PAI. Three studies compared iPACK to PNB, and ten reviewed the point of adding PNB to iPACK. CONCLUSIONS The literature review indicates that the best analgesic effect is obtained by combining PAI or iPACK with a peripheral nerve block, particularly with ACB, due to its analgesic, motor-sparing effect, and satisfactory analgesia.
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Affiliation(s)
- Małgorzata Domagalska
- Chair and Department of Palliative Medicine, University of Medical Sciences, Os.Rusa 55 61-245, Poznań, Poland.
| | | | - Tomasz Reysner
- Chair and Department of Palliative Medicine, University of Medical Sciences, Os.Rusa 55 61-245, Poznań, Poland
| | - Grzegorz Kowalski
- Chair and Department of Palliative Medicine, University of Medical Sciences, Os.Rusa 55 61-245, Poznań, Poland
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King GA, Le A, Nickol M, Sarkis B, van der Merwe JM. Periarticular infiltration used in total joint replacements: an update and review article. J Orthop Surg Res 2023; 18:859. [PMID: 37957753 PMCID: PMC10641975 DOI: 10.1186/s13018-023-04333-z] [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] [Received: 09/27/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.
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Affiliation(s)
- Gavin Anthony King
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Alexander Le
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Michaela Nickol
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
| | - Bianca Sarkis
- College of Medicine - Department of Orthopaedic Surgery, University of Saskatchewan, Saskatoon, Canada
- Faculty of Medicine - Division of Orthopaedic Surgery, University of Montreal, Montreal, Canada
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Yoshida B, Piple AS, Wang JC, Richardson MK, Christ AB, Heckmann ND. Perioperative Dexamethasone Associated With Decreased Length of Stay After Total Hip and Knee Arthroplasty. J Am Acad Orthop Surg 2023; 31:e778-e787. [PMID: 37205878 DOI: 10.5435/jaaos-d-22-01146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 04/01/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Dexamethasone is increasingly used after total joint arthroplasty (TJA) to reduce postoperative nausea and vomiting (PONV) and pain. The primary aim of this study was to examine the relationship between perioperative intravenous (IV) dexamethasone and length of stay (LOS) in patients undergoing primary, elective TJA. METHODS All patients who underwent TJA from 2015 to 2020 and received perioperative IV dexamethasone were queried from the Premier Healthcare Database. The cohort of patients who received dexamethasone was randomly truncated by a power of 10 and matched in a 1:2 ratio based on age and sex to patients who did not receive dexamethasone. Patient characteristics, hospital factors, comorbidities, 90-day postoperative complications, LOS, and postoperative morphine milligram equivalents were recorded for each cohort. Univariate and multivariate analyses were conducted to assess differences. RESULTS Overall, 190,974 matched patients were included, 63,658 (33.3%) of whom received dexamethasone and 127,316 (66.7%) did not. The dexamethasone cohort was composed of fewer patients with uncomplicated diabetes (11.6% vs. 17.5%, P < 0.001). Patients who received dexamethasone had significantly decreased mean LOS compared with patients who did not receive dexamethasone (1.66 vs. 2.03 days, P < 0.001). After controlling for confounding variables, dexamethasone was associated with significantly lower risk of pulmonary embolism (adjusted odds ratio [aOR]: 0.74, 95% CI: 0.61 to 0.90, P = 0.003), deep vein thrombosis (aOR: 0.78, 95% CI: 0.68 to 0.89, P < 0.001), PONV (aOR: 0.75, 95% CI: 0.70 to 0.80, P < 0.001), acute kidney injury (aOR: 0.82, 95% CI: 0.75 to 0.89, P < 0.001), and urinary tract infection (aOR: 0.77, 95% CI: 0.70 to 0.80, P < 0.001). In aggregate, dexamethasone was associated with similar postoperative opioid utilization between cohorts ( P = 0.061). CONCLUSION Perioperative dexamethasone was associated with reduced LOS and decreased postoperative complications including PONV, pulmonary embolism, deep vein thrombosis, acute kidney injury, and urinary tract infection after TJA. Although perioperative dexamethasone was not associated with notable reductions in postoperative opioid utilization, this study supports the use of dexamethasone to decrease LOS through multifactorial mechanisms beyond decreased pain.
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Affiliation(s)
- Brandon Yoshida
- From the Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
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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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Li Y, Wulamu W, Yushan N, Guo X, Gu W, Cao L, Zhang X. Effects of Adding Morphine to Periarticular Infiltration Analgesia Combined with Single Dose Epidural Morphine in Total Knee Arthroplasty: A Randomized Controlled Study. Orthop Surg 2023; 15:1021-1027. [PMID: 36793155 PMCID: PMC10102286 DOI: 10.1111/os.13637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/18/2022] [Accepted: 11/26/2022] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE Morphine plays an important role in postoperative analgesia after total knee arthroplasty (TKA). However, there are limited data that investigate the administration ways of morphine. To evaluate the efficacy and safety of adding morphine to periarticular infiltration analgesia (PIA) combined with single-dose epidural morphine for the patients undergoing TKA. METHODS In total, 120 patients with knee osteoarthritis who underwent the primary TKA from April 2021 and March 2022 were randomized into three groups (a cocktail containing morphine with single-dose epidural morphine [Group A]; a cocktail containing morphine [Group B]; and a cocktail free of morphine [Group C]). The three groups were compared based on the Visual Analog Score at rest and during motion, requirement of tramadol, functional recovery including quadriceps strength and range of motion, and adverse events including nausea and vomiting and local and systemic adverse events. The repetitive measure analysis of variance and chi-square test among three groups were used to analyze the results. RESULTS Analgesia strategy in Group A (0.4 ± 0.8, and 0.9 ± 1.0 points, respectively) significantly reduced rest pain at 6 and 12 h after surgery relative to Group B (1.6 ± 1.2, and 2.2 ± 1.4 points, respectively) (p < 0.001), and the analgesic effect of Group B was stronger than that of Group C (2.1 ± 0.9, and 2.6 ± 0.9 points, respectively) (p < 0.05). Rest pain at 24 h after surgery was significantly lower in Group A (2.5 ± 0.8 points) and B (1.9 ± 1.0 points) than in Group C (2.5 ± 0.8) (p < 0.05). Within 24 h after surgery, the requirements for tramadol in Group A (0.25 g) and Group B (0.35 g) were significantly lower than those in Group C (0.75 g) (p < 0.05). Within 4 days of surgery, the quadriceps strength in the three groups increased gradually, and no statistical significance was noted among the three groups (p > 0.05). From the second day to the fourth day after surgery, although the three groups showed no statistical difference in the range of motion, the result of Group C was inferior to that of the other two groups. There were no significant differences in the incidence of postoperative nausea and vomiting and metoclopramide consumption among the three groups (p > 0.05). CONCLUSION PIA combined with single-dose epidural morphine effectively reduces early postoperative pain and tramadol requirement as well as few complications, which can become a safe and effective measure to improve postoperative pain after TKA.
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Affiliation(s)
- Yicheng Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Wuhuzi Wulamu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Nuerailijiang Yushan
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Xiaobin Guo
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Wenchao Gu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Xiaogang Zhang
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
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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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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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Luo ZY, Yu QP, Zeng WN, Xiao Q, Chen X, Wang HY, Zhou Z. Adductor canal block combined with local infiltration analgesia with morphine and betamethasone show superior analgesic effect than local infiltration analgesia alone for total knee arthroplasty: a prospective randomized controlled trial. BMC Musculoskelet Disord 2022; 23:468. [PMID: 35590308 PMCID: PMC9118585 DOI: 10.1186/s12891-022-05388-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 04/26/2022] [Indexed: 02/08/2023] Open
Abstract
Background Local infiltration analgesia (LIA) and adductor canal block (ACB) provide postoperative analgesia for total knee arthroplasty (TKA). ACB blocks the saphenous nerve and has smaller impacts on quadriceps muscle weakness. ACB theoretically does not have enough analgesic effects on posterior sensory nerves. LIA may increase its analgesic effects on the posterolateral knee. The purpose of this study was to evaluate whether ACB combined with a LIA cocktail of ropivacaine, morphine, and betamethasone has superior analgesic effect than LIA for TKA. Methods A total of 86 patients were assessed for eligibility from February 2019 to May 2019. 26 of those were excluded, and 60 patients were divided into 2 groups by computer-generated random number. Group A (LIA group) received LIA cocktail of ropivacaine, morphine and betamethasone. Group B (LIA+ ACB group) received ultrasound-guided ACB and LIA cocktail of ropivacaine, morphine and betamethasone. Postoperative visual analogue scale (VAS) resting or active pain scores, opioid consumption, range of motion (ROM), functional tests, complications and satisfaction rates were measured. The longest follow-up was 2 years. Results Two groups have no differences in terms of characteristics, preoperative pain or function (P > 0.05). ACB combined with LIA had significantly lower resting and active VAS pain scores, better ROM, better sleeping quality and higher satisfaction rates than LIA alone within 72 h postoperatively (P < 0.05). Complications, or adverse events and HSS score, SF-12 score were observed no significant differences within 2 years postoperatively. Conclusions Adductor canal block combined with Local infiltration analgesia provide better early pain control. Although the small statistical benefit may not result in minimal clinically important difference, Adductor canal block combined with Local infiltration analgesia also reduce opioid requirements, improve sleeping quality, and do not increase the complication rate. Therefore, Adductor canal block combined with Local infiltration analgesia still have good application prospects as an effective pain management for total knee arthroplasty. Trial registration Chinese Clinical Trial Registry, ChiCTR1900021385, 18/02/2019.
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Affiliation(s)
- Zhen-Yu Luo
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China.,Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qiu-Ping Yu
- Health Management Center, West China Hospital/West China School of Medicine, Sichuan University, Chengdu, 610041, China
| | - Wei-Nan Zeng
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China.,Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qiang Xiao
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China.,Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xi Chen
- Department of Operative Dentistry and Endodontics, West China Hospital of Stomatology, Sichuan University, Chengdu, 610041, China
| | - Hao-Yang Wang
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China.,Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Zongke Zhou
- Department of Orthopedics, West China Hospital/West China School of Medicine, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China. .,Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Cooke C, Osborne J, Jackson N, Keating P, Flynn J, Markel D, Chen C, Lemos S. Acetaminophen, bupivacaine, Duramorph, and Toradol: A comparison of chondrocyte viability and gene expression changes in osteoarthritic human chondrocytes. Knee 2020; 27:1746-1752. [PMID: 33197813 DOI: 10.1016/j.knee.2020.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 10/12/2020] [Accepted: 10/18/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND A multitude of chemical agents are currently used intra-articularly to decrease pain after orthopaedic procedures including total knee arthroplasty. However, the possible deleterious effects of these injectable chemicals on chondrocyte viability have not been weighed against their potential benefits. Using a human osteoarthritic chondrocyte model, the purpose of this study was to assess the potential for cartilage damage caused by bupivacaine, Toradol, Duramorph, and acetaminophen from surgical local anesthesia. METHODS Human distal femur and proximal tibia cross sections were obtained during total knee arthroplasty and divided into control group and experimental groups treated by bupivacaine, Toradol, Duramorph, and acetaminophen respectively. Chondrocytes obtained from enzymatically digested cartilage were cultured using a 3D alginate bead culture method to ensure lower rates of dedifferentiation. Chondrocyte bead cultures were exposed to the study chemicals. The gene expression and chondrocyte viability were measured by RT-PCR and flow cytometry, respectively. RESULTS Compared with untreated group bupivacaine treatment led to the greatest cellular apoptosis with 30.5 ± 11% dead cells (P = 0.000). Duramorph and acetaminophen did not result in a significant increase in cell death. Bupivacaine treatment led to an increase in Caspase 3 gene expression (P = 0.000) as well as the acetaminophen treatment (P = 0.001) when compared to control. CONCLUSION Our data demonstrated that Duramorph and Toradol were not cytotoxic to human chondrocytes and may be better alternatives to the frequently used and more cytotoxic bupivacaine. Acetaminophen did not result in increased cell death; however, it did show increased caspase 3 gene expression and caution should be considered.
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Affiliation(s)
- Christopher Cooke
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, 3990 John R Street, PO Box 137, Detroit, MI 48201, USA
| | - Jeffrey Osborne
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, 3990 John R Street, PO Box 137, Detroit, MI 48201, USA
| | - Nancy Jackson
- Ascension Providence Hospital, 16001 W Nine Mile Rd, Southfield, MI 48075, USA
| | - Patrick Keating
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, 3990 John R Street, PO Box 137, Detroit, MI 48201, USA
| | - Jeff Flynn
- Ascension Providence Hospital, 16001 W Nine Mile Rd, Southfield, MI 48075, USA
| | - David Markel
- Ascension Providence Hospital, 16001 W Nine Mile Rd, Southfield, MI 48075, USA; The CORE Institute, 22250 Providence Drive #401, Southfield, MI 48075, USA
| | - Chaoyang Chen
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, 3990 John R Street, PO Box 137, Detroit, MI 48201, USA.
| | - Stephen Lemos
- Department of Orthopaedic Surgery and Sports Medicine, Detroit Medical Center, 3990 John R Street, PO Box 137, Detroit, MI 48201, USA; Wayne State University, Detroit, MI 48201, USA.
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Abstract
As the length of stay for hip and knee arthroplasty has decreased over the years, "outpatient," or same-calendar-day discharge has become increasingly common. Outpatient arthroplasty offers several possible benefits over traditional inpatient arthroplasty, including potential for cost reductions, faster rehabilitation, improved patient satisfaction, and reduced reliance on hospital resources. Despite these possible benefits, concerns remain over feasibility and patient safety. To date, multiple studies have demonstrated that, for select patients, "outpatient" hip and knee arthroplasty can be safe and effective and yield complication and readmission rates similar to inpatient procedures at potentially significant cost savings. Successful outpatient pathways have emphasized careful patient selection, detailed patient education, enlistment of strong social support, utilization of multimodal analgesia and strong "episode ownership," and involvement on behalf of the surgical team. As outpatient hip and knee arthroplasty becomes increasingly common, continued investigation into all aspects of the surgical episode is warranted.
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12
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Wang Q, Sun J, Hu Y, Zeng Y, Hu J, Yang J, Kang P. Effects of morphine on peri-articular infiltration analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2020; 44:2587-2595. [DOI: 10.1007/s00264-020-04700-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
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Gaukhman A, Garceau S, Schwarzkopf R, Slover J. Evidence-based Review of Periarticular Injections and Peripheral Nerve Blocks in Total Knee Arthroplasty. Open Orthop J 2020. [DOI: 10.2174/1874325002014010069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
Recently, post-operative pain management after Total Knee Arthroplasty (TKA) has focused on a multimodal approach for reducing opioid requirements, promoting early rehabilitation, and expediting discharge from hospital. Regional anesthesia, in the form of Periarticular Injections (PAI) and Peripheral Nerve Blocks (PNB), has shown promise as adjunctive therapy to oral analgesics.
Objective:
To review the current literature surrounding regional anesthesia for TKA.
Discussion:
PNBs provide effective analgesia after TKA. Historically, femoral nerve blocks (FNB) have been commonly employed. FNBs, however, lead to the significant motor blockade to the quadriceps musculature, which can dampen early rehabilitation efforts and increase the risk of post-operative falls. Adductor Canal Blocks (ACB) have shown excellent results in reducing post-operative pain while minimizing motor blockade. Periarticular injections (PAI), and infiltration between the popliteal Artery and Capsule of the Knee (IPACK) have similarly helped in reducing patient discomfort after TKA and providing analgesia to the posterior capsular region of the knee.
Conclusion:
PAIs, and PNBs are important elements in many multimodal postoperative pain management protocols after TKA. Current evidence appears to suggest that a combination of an ACB supplemented by posterior capsular analgesic coverage through PAI or IPACK may provide optimal results.
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Iwakiri K, Ohta Y, Shibata Y, Minoda Y, Kobayashi A, Nakamura H. Initiating range of motion exercises within 24 hours following total knee arthroplasty affects the reduction of postoperative pain: A randomized controlled trial. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2020; 21:11-16. [PMID: 32373475 PMCID: PMC7191316 DOI: 10.1016/j.asmart.2020.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 03/18/2020] [Accepted: 03/31/2020] [Indexed: 10/26/2022]
Abstract
Background Postoperative limitations in the range of motion (ROM) after TKA may occur occasionally and restrict a patient's ADL. Although ROM exercise is a means of increasing the ROM after TKA, the optimal time of initiating ROM exercise is still unclear. The purpose of this study is to examine different initiation timings of postoperative ROM exercises after TKA and to compare the results in terms of postoperative pain, swelling, and ROM improvement to determine the optimal time of initiating ROM exercises following TKA. Methods This was a prospective, single-center, single-blinded randomized controlled trial involving 109 patients scheduled for unilateral TKA. All patients underwent the physiotherapist assisted passive and active same rehabilitation program that only differed in the starting time of ROM exercise on postoperative day 1 or day 7. Postoperative assessment was performed with all attending personnel blinded to group assignment. Visual analog scale (VAS) of pain, ROM, thigh swelling, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and adverse outcomes were compared between groups on postoperative days within 2 years after surgery. Results VAS scores during the postoperative period from 18 to 72 h were significantly lower in the group with starting time of ROM exercise on postoperative day 1. The ROM, laboratory data, thigh girth, WOMAC and the incidence of complications did not differ between the two groups at any postoperative time-point. Conclusions The results of this study suggested that ROM exercises beginning in the early postoperative stage are advantageous in reducing the postoperative pain after TKA.
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Affiliation(s)
- Kentaro Iwakiri
- Department of Orthopaedic Surgery, Shiraniwa Hospital Joint Arthroplasty Center, 6-10-1 Shiraniwadai Ikoma-city, Nara, 630-0136, Japan
| | - Yoichi Ohta
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka-city, Osaka, 545-8585, Japan
| | - Yuuki Shibata
- Department of Orthopaedic Surgery, Shiraniwa Hospital Joint Arthroplasty Center, 6-10-1 Shiraniwadai Ikoma-city, Nara, 630-0136, Japan
| | - Yukihide Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka-city, Osaka, 545-8585, Japan
| | - Akio Kobayashi
- Department of Orthopaedic Surgery, Shiraniwa Hospital Joint Arthroplasty Center, 6-10-1 Shiraniwadai Ikoma-city, Nara, 630-0136, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka-city, Osaka, 545-8585, Japan
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15
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Zhang Y, Mi F, Zhao H, Xie D, Shi X. Effect of morphine added to multimodal cocktail on infiltration analgesia in total knee arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2019; 98:e17503. [PMID: 31593120 PMCID: PMC6799858 DOI: 10.1097/md.0000000000017503] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The local injection of multimodal cocktail is currently commonly used in the treatment of postoperative pain after total knee arthroplasty (TKA). It is still inconclusive whether the morphine added to the intraoperative injection mixture could make some difference. This meta-analysis aimed to evaluate the efficacy and safety of additional morphine injection on postoperative analgesia in TKA, and provide some useful information on morphine usage in clinical practice. METHODS The randomized controlled trials (RCTs) in databases including PubMed, Web of Science, Embase, Cochrane Library, Chinese biomedical literature database (CBM), and Chinese National Knowledge Infrastructure (CNKI) databases were systematically searched. Of 623 records identified, 8 RCTs involving 1093 knees were eligible for data extraction and meta-analysis according to criteria included. RESULTS Meta-analysis showed that the use of local morphine injection was not associated with significant pain relief within 48 hours postoperatively at rest and on motion (P > .05, all). The use of morphine reduced postoperative total systemic opioids consumption (P < .05). This study found no significant differences in other outcomes including knee flexion range of motion (ROM) (P > .05), extension ROM (P > .05), The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (P > .05), Post-operative nausea and vomiting occurrence (P > .05) regardless of the presence of morphine or not in the injections. CONCLUSION Additional morphine added to multimodal cocktail did not decrease the postoperative pain scores significantly based on our outcomes, but it reduced the systemic postoperative opioids consumption in total knee arthroplasty.
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MESH Headings
- Aged
- Aged, 80 and over
- Analgesia/adverse effects
- Analgesia/methods
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/therapeutic use
- Anesthesia, Local/methods
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Combined Modality Therapy/methods
- Female
- Humans
- Male
- Middle Aged
- Morphine/administration & dosage
- Morphine/therapeutic use
- Pain Measurement/drug effects
- Pain Measurement/methods
- Pain, Postoperative/drug therapy
- Postoperative Nausea and Vomiting/epidemiology
- Randomized Controlled Trials as Topic
- Range of Motion, Articular/drug effects
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Affiliation(s)
- Yinxia Zhang
- Department of Health, Northwest Minzu University Hospital
| | - Faduo Mi
- Orthopedics Surgery Department, Qingyang People's Hospital, Qingyang, Gansu province
| | - Haiyan Zhao
- Orthopedics Surgery Department, Lanzhou University First Hospital
| | | | - Xiaoyuan Shi
- Department of Medical Record, Lanzhou University Second Hospital, Lanzhou, Gansu province, PR China
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16
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Halawi MJ, Lieberman JR. Battling the opioid epidemic: lessons learned and management strategies. Arthroplast Today 2019; 5:2-4. [PMID: 31020012 PMCID: PMC6470326 DOI: 10.1016/j.artd.2018.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/01/2018] [Accepted: 10/04/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Mohamad J Halawi
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, CT, USA
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA.,American Association of Hip and Knee Surgeons, Rosemont, IL, USA
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Laoruengthana A, Jarusriwanna A, Rattanaprichavej P, Rasamimongkol S, Varakornpipat P, Pongpirul K. Timing of periarticular injection has no effect on postoperative pain and functional recovery in simultaneous bilateral total knee arthroplasty: a prospective randomized, double-blinded trial. BMC Musculoskelet Disord 2019; 20:162. [PMID: 30971241 PMCID: PMC6458680 DOI: 10.1186/s12891-019-2526-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/24/2019] [Indexed: 12/15/2022] Open
Abstract
Background Given no consensus on optimal timeframe of periarticular multimodal drug injection (PMDI) in knee osteoarthritis patients undergoing total knee arthroplasty (TKA), this study was aimed to compare the postoperative pain and the functional recovery in patients who underwent simultaneous bilateral TKA (SBTKA) and received PMDI at the different intraoperative time points. Methods This prospective, randomized, double-blinded controlled trial study included 48 patients who underwent SBTKA and received PMDI mixture, either before prosthetic implantation (late PMDI), or just after knee arthrotomy (early PMDI). Each subject’s knees were randomly selected to different PMDI administration time points. The outcome parameters were postoperative pain assessed by using a visual analog scale (VAS), the maximal angle of knee flexion, and quadriceps function from day 1 to 6 weeks after surgery. Results Late PMDI revealed slightly higher VAS at 6 and 12 h after the operation than early PMDI administration. Afterward, the VAS tended to be lower in the late than early PMDI administration until the end of the study, but without statistical significance. The time difference between early and late PMDI had no effect on postoperative VAS, while older age resulted in significantly less pain. No statistical differences between the two groups in all other outcome parameters were observed. Conclusions Postoperative pain reduction and functional recovery of SBTKA with early and late PMDI administration were not significantly different. The time interval of PMDI between knees did not confound the comparison of postoperative pain and functional recovery in SBTKA. Trial registration The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database No.TCTR20170617001 on 16 June 2017.
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Affiliation(s)
- Artit Laoruengthana
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9, Phitsanulok-Nakhon Sawan Road, Tha Pho, Mueang Phitsanulok, Phitsanulok, 65000, Thailand
| | - Atthakorn Jarusriwanna
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9, Phitsanulok-Nakhon Sawan Road, Tha Pho, Mueang Phitsanulok, Phitsanulok, 65000, Thailand.
| | - Piti Rattanaprichavej
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9, Phitsanulok-Nakhon Sawan Road, Tha Pho, Mueang Phitsanulok, Phitsanulok, 65000, Thailand
| | - Supachok Rasamimongkol
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9, Phitsanulok-Nakhon Sawan Road, Tha Pho, Mueang Phitsanulok, Phitsanulok, 65000, Thailand
| | - Panapol Varakornpipat
- Department of Orthopaedics, Faculty of Medicine, Naresuan University, 99 Moo 9, Phitsanulok-Nakhon Sawan Road, Tha Pho, Mueang Phitsanulok, Phitsanulok, 65000, Thailand
| | - Krit Pongpirul
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathum Wan, Pathum Wan, Bangkok, 10330, Thailand.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Pepper AM, Mercuri JJ, Behery OA, Vigdorchik JM. Total Hip and Knee Arthroplasty Perioperative Pain Management. JBJS Rev 2018; 6:e5. [DOI: 10.2106/jbjs.rvw.18.00023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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