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Schubert AK, Wiesmann T, Wulf H, Obert JDA, Eberhart L, Volk T, Dinges HC. The analgetic effect of adjuvants in local infiltration analgesia - a systematic review with network meta-analysis of randomized trials. J Clin Anesth 2024; 97:111531. [PMID: 39003958 DOI: 10.1016/j.jclinane.2024.111531] [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: 02/05/2024] [Revised: 04/08/2024] [Accepted: 06/11/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Local infiltration analgesia is commonly used for postoperative pain control after several surgical procedures including intra- and peri-articular as well as wound infiltration. Even though, various adjuvants injected with the local anesthetic have been studied in pairwise comparison or compared to peripheral nerve blocks, the question which adjuvant or combination of adjuvants is the most effective in prolonging the duration of different types of local infiltration analgesia (LIA) has not been answered conclusively. OBJECTIVE The objective of this network meta-analysis was to determine the analgesic effectiveness and safety of adjuvants in local infiltration analgesia. DESIGN Systematic review of randomized controlled trials with network meta-analyses. DATA SOURCES A comprehensive literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023. RESULTS The best interventions to prolong the duration of analgesia were dexamethasone (Ratio of Means (ROM) 3.33) followed by the combinations of clonidine + morphine (ROM 3.35) and morphine + magnesium sulfate (ROM 2.92), fentanyl (ROM 2.27), ketorolac (ROM 2.26), buprenorphine (ROM 2.04), morphine (ROM 1.93), magnesium sulfate (ROM 1.91), clonidine (ROM 1.89), dexmedetomidine (ROM 1.74) and tramadol (ROM 1.58). Serious adverse events were not reported with either investigated adjuvant. CONCLUSION There is moderate evidence that dexamethasone is the most effective adjuvant to prolong the duration of analgesia in LIA. The evidence for the alpha-2 agonists dexmedetomidine and clonidine is also moderate, but their effectivity to prolong analgesia stays behind dexamethasone. Clonidine and dexmedetomidine had a small detectable effect on pain scores, yet below clinical relevance, but the largest effect on MEQ consumption. The effects of different opioids were homogenous for all endpoints. The prespecified subgroup analysis of LIA of the knee did not show significantly different results than the pooled analysis. STUDY REGISTRATION PROSPERO 2020 CRD42020176154 (28.04.2020).
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Affiliation(s)
- Ann-Kristin Schubert
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Germany.
| | - Thomas Wiesmann
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Germany; Department of Anaesthesiology and Intensive Care Medicine, Diakoneo Diak Klinikum Schwäbisch-Hall, Schwäbisch-Hall, Germany
| | - Hinnerk Wulf
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Germany
| | - Jan Daniel Alexander Obert
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Germany
| | - Leopold Eberhart
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Germany
| | - Thomas Volk
- Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg, Germany
| | - Hanns-Christian Dinges
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Marburg, Philipps University of Marburg, Germany
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Stundner O, Hoerner E, Zhong H, Poeran J, Liu J, Illescas A, Memtsoudis SG. Trends of liposomal bupivacaine utilization in major lower extremity total joint arthroplasty in the USA: a population-based study. Reg Anesth Pain Med 2024; 49:139-143. [PMID: 37567594 DOI: 10.1136/rapm-2023-104784] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION Liposomal bupivacaine has been marketed for the achievement of long-acting local or regional anesthesia after major lower extremity total joint arthroplasty. However, it is comparatively expensive and controversy remains regarding its ability to decrease healthcare costs. With mounting evidence suggesting non-superiority in efficacy, compared with plain bupivacaine, we sought to investigate trends in liposomal bupivacaine use and identify changes in practice. METHODS We identified adult patients from the Premier Healthcare Database who underwent elective total joint arthroplasty between 2012 and 2021. Prevalence and trends of liposomal bupivacaine utilization were compared on the individual patient and hospital levels. Log-rank tests were performed to assess the influence of location, teaching status, or hospital size on time to hospital-level liposomal bupivacaine termination. RESULTS Among 103,165 total joint arthroplasty cases, liposomal bupivacaine use increased between 2012 and 2015 (from 0.4% to 22.8%) and decreased by approximately 1%-3% annually thereafter (15.7% in 2021). Liposomal bupivacaine was ever used in approximately 60% of hospitals. Hospital-level initiation of liposomal bupivacaine use peaked in 2014 and decreased thereafter (from 32.8% in 2013 to 4.3% in 2021), while termination rates increased (from 1.4% in 2014 to 9.9% in 2019). Non-teaching hospitals and those located in the South and West regions were more likely to retain liposomal bupivacaine longer than teaching or Midwest/Northeast hospitals, respectively (p=0.023 and p=0.014). DISCUSSION Liposomal bupivacaine use peaked around 2015 and has been declining thereafter on individual patient and hospital levels. How these trends correlate with health outcomes and expenditures would be a strategic target for future research.
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Affiliation(s)
- Ottokar Stundner
- Department of Anesthesiology and Intensive Care, Medizinische Universität Innsbruck, Innsbruck, Austria
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
| | - Elisabeth Hoerner
- Department of Anesthesiology and Intensive Care, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Jashvant Poeran
- Department of Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Alex Illescas
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversität, Salzburg, Austria
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
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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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Kertkiatkachorn W, Ngarmukos S, Tanavalee A, Tanavalee C, Kampitak W. Intraoperative landmark-based genicular nerve block versus periarticular infiltration for postoperative analgesia in total knee arthroplasty: a randomized non-inferiority trial. Reg Anesth Pain Med 2023:rapm-2023-104563. [PMID: 37898482 DOI: 10.1136/rapm-2023-104563] [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: 04/01/2023] [Accepted: 09/19/2023] [Indexed: 10/30/2023]
Abstract
INTRODUCTION Genicular nerve blocks (GNBs) are an emerging technique that have been used as a part of multimodal analgesia for total knee arthroplasty. The efficacy of intraoperative landmark-based GNBs, a recently introduced technique, has been established. We hypothesized that it would provide non-inferior postoperative analgesia compared with periarticular infiltration (PAI) when combined with continuous adductor canal block. METHODS This study randomized 140 patients undergoing total knee arthroplasty to receive either intraoperative landmark-based GNB (GNB group) or PAI (PAI group), with 139 completing the study. The primary outcomes were the pain scores at rest and during movement at 12 hours postoperatively on an 11-point Numerical Rating Scale; the non-inferiority margin was 1. Pain scores at additional time points, intravenous morphine consumption, time to first rescue analgesia, functional performance and muscle strength tests, and sleep disturbance were also assessed. RESULTS At 12 hours postoperatively, the PAI and GNB groups had median resting pain scores of 0 (0-2) and 0 (0-2), respectively. The median difference was 0 (95% CI -0.4 to 0.4, p=1), with the 95% CI upper limit below the prespecified non-inferiority margin. The median pain score during movement was 1.5 (0-2.3) and 2 (1-3.1) in the PAI and GNB groups, respectively. The median difference was 0.9 (95% CI 0.3 to 1.6, p=0.004), failing to demonstrate non-inferiority. The GNB group had higher intravenous morphine consumption at 12 hours postoperatively and a shorter time to first rescue analgesia. CONCLUSIONS GNB compared with PAI provides non-inferior resting pain relief. Non-inferiority was not established for pain during movement. TRIAL REGISTRATION NUMBER TCTR20220406001 (www.thaiclinicaltrials.org).
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Affiliation(s)
| | | | - Aree Tanavalee
- Department of Orthopaedics, Chulalongkorn University, Bangkok, Thailand
| | - Chottawan Tanavalee
- Department of Orthopaedics, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wirinaree Kampitak
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Sikachi RR, Campbell B, Kassin E, Scuderi GR, Marino J. Analgesic Trends in the Management of Pain Following Total Knee Arthroplasty: A Comparison of Peri-Articular Infiltration, Adductor Canal Block, and Adjuvant Treatment for Posterior Knee Pain. Orthop Clin North Am 2023; 54:369-376. [PMID: 37718076 DOI: 10.1016/j.ocl.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
The rising number of total knee arthroplasties (TKA's) in the United States increases demand for perioperative pain modalities, which can promote early mobilization and discharge. Over the decades, a focus has shifted from opioid-dominant regimens to motor-sparing multimodal protocols, which have not only improved pain scores and reduced opioid consumption but also improved overall patient outcomes. In this article, we briefly review the evolution of post-operative pain management in patients undergoing TKA and summarize the literature on the most popular modalities currently used including periarticular injections, adductor canal blocks, distal selective nerve blocks, as well as liposomal bupivacaine as part of a multimodal approach.
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Affiliation(s)
- Rutuja R Sikachi
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai West, Morningside Hospitals, 1000, Tenth Avenue, New York, NY 10019, USA
| | - Brett Campbell
- Department of Orthopedic Surgery, Zucker School of Medicine at Hofstra/Northwell, 1001 Franklin Avenue, Suite 110, Garden City, NY 11530, USA
| | - Ezra Kassin
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, 270-05 76th Avenue, New Hyde Park, NY 11040, USA
| | - Giles R Scuderi
- Department of Orthopedic Surgery, Zucker School of Medicine at Hofstra/Northwell, 1001 Franklin Avenue, Suite 110, Garden City, NY 11530, USA.
| | - Joseph Marino
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, 600 Community Drive, Manhasset, NY 11030, USA
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Eid GM, El said Shaban S, Mostafa TA. Comparison of ultrasound-guided genicular nerve block and knee periarticular infiltration for postoperative pain and functional outcomes in knee arthroplasty - A randomised trial. Indian J Anaesth 2023; 67:885-892. [PMID: 38044925 PMCID: PMC10691610 DOI: 10.4103/ija.ija_449_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 12/05/2023] Open
Abstract
Background and Aims Optimal analgesia after total knee arthroplasty (TKA) enhances patients' and surgical outcomes. The study investigated the ultrasound-guided genicular nerve block versus the periarticular infiltration in TKA. Methods Eighty-eight patients aged above 50 years scheduled for unilateral TKA were randomised as: Group 1 received intraoperative periarticular infiltration (0.5 mL adrenaline [4.5 µg/mL], 20 mL bupivacaine 0.5% with 89.5 mL saline) and Group 2 received immediate postoperative genicular nerve block (15 mL bupivacaine 0.25% with 2.5 g/mL adrenaline). The postoperative morphine consumption was during the first two postoperative days the primary outcome. The secondary outcomes were time to rescue analgesia, pain scores and functional outcomes. The comparison between groups was performed using the Chi-square test, the Student's t-test and the Mann-Whitney U test, as appropriate. Results The postoperative morphine consumption during the first two postoperative days and pain scores at rest at 12 h postoperatively were less in Group 1 than in Group 2 (P < 0.001). Pain scores during movement on the first postoperative day were lower in the periarticular group than the genicular group at 6, 12 and 24 h (P < 0.001). At 18 h, pain scores were higher in the periarticular group than in the genicular group at rest and movement (P < 0.001). Quadriceps motor strength scores were comparable between groups (P > 0.05). The knee range of motion and time up and go test during both days showed a statistically significant difference in the periarticular group compared to the genicular group (P < 0.05). Conclusion Periarticular infiltration and genicular nerve block yield effective postoperative analgesia and functional outcomes after TKA without motor affection.
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Affiliation(s)
- Gehan M. Eid
- Department of Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Shiamaa El said Shaban
- Department of Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Tarek A. Mostafa
- Department of Anesthesiology and Surgical Intensive Care, Faculty of Medicine, Tanta University, Tanta, Egypt
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Morgan PM, Gannon NP. What's New in Hip Surgery. J Bone Joint Surg Am 2023; 105:1395-1402. [PMID: 37486981 DOI: 10.2106/jbjs.23.00484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Affiliation(s)
- Patrick M Morgan
- Department of Orthopedic Surgery, University of Minnesota, Minneapolis, Minnesota
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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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