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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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Golrokh Moghadam SA, Tajerian A, Mahmoudieh B, Parsi Khamene M, Kamali A. Comparing Apotel and Remifentanil for Multimodal Patient-Controlled Analgesia in Postoperative Pain Management Following Total Knee Arthroplasty Surgery: A Randomized Controlled Trial. Anesth Pain Med 2024; 14:e141975. [PMID: 38741899 PMCID: PMC11088846 DOI: 10.5812/aapm-141975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/05/2024] [Accepted: 02/15/2024] [Indexed: 05/16/2024] Open
Abstract
Background Total knee arthroplasty (TKA) is a standard surgical procedure for individuals with debilitating knee arthritis. Effective postoperative pain management is essential for successful recovery, although traditional opioid-based methods have limitations. Objectives This study aimed to compare the efficacy of Apotel and remifentanil patient-controlled analgesia in managing postoperative pain after TKA. Methods This double-blind, randomized, controlled clinical trial took place at Amir-al-Momenin and Qods Hospitals in Arak, Iran, spanning from June 2022 to September 2023. Sixty-two eligible patients scheduled for knee joint replacement were randomly assigned to receive either Apotel (Group A) or remifentanil (Group R) as part of multimodal analgesia administered via a pain pump for postoperative pain relief in TKA. The study assessed hemodynamic parameters, pain levels (measured using the Visual Analog Scale), analgesic duration, and narcotic consumption. Statistical analyses were performed using SPSS v.27 and Plotly. Results Subjects exhibited no statistically significant differences in age, gender distribution, duration of surgery, or anesthesia. The hemodynamic status assessment in the recovery room showed no significant differences in SPO2, PR, or MAP between the groups. However, remifentanil demonstrated superior effectiveness in reducing pain over 24 hours post TKA surgery compared to Apotel, as evidenced by lower average Visual Analog Scale (VAS) scores (P < 0.001), longer duration without the need for narcotic painkillers (P < 0.001), and lower cumulative opioid analgesic consumption in Group R (P < 0.001). Conclusions Remifentanil demonstrates superior pain control in a multimodal pain management approach compared to Apotel, providing sustained pain reduction over 24 hours post-surgery. Moreover, remifentanil offers longer-lasting pain relief and results in lower cumulative narcotic painkiller consumption compared to Apotel.
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Affiliation(s)
| | - Amin Tajerian
- School of Medicine, Arak University of Medical Sciences, Arak, Iran
| | - Behnam Mahmoudieh
- Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
| | - Mohsen Parsi Khamene
- Department of Orthopedic Surgery, Arak University of Medical Sciences, Arak, Iran
| | - Alireza Kamali
- Department of Anesthesiology and Critical Care, Arak University of Medical Sciences, Arak, Iran
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3
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Gailey AD, Ostrum RF. The use of liposomal bupivacaine in fracture surgery: a review. J Orthop Surg Res 2023; 18:267. [PMID: 37005638 PMCID: PMC10068181 DOI: 10.1186/s13018-023-03583-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Historically, opioids have played a major role in the treatment of postoperative pain in orthopedic surgery. A multitude of adverse events have been associated with opioid use and alternative approaches to pain relief are being investigated, with particular focus on multimodal pain management regimens. Liposomal bupivacaine (EXPAREL) is a component of some multimodal regimens. This formulation of bupivacaine encapsulates the local anesthetic into a multivesicular liposome to theoretically deliver a consistent amount of drug for up to 72 hours. Although the use of liposomal bupivacaine has been studied in many areas of orthopedics, there is little evidence evaluating its use in patients with fractures. This systematic review of the available data identified a total of eight studies evaluating the use of liposomal bupivacaine in patients with fractures. Overall, these studies demonstrated mixed results. Three studies found no difference in postoperative pain scores on postoperative days 1-4, while two studies found significantly lower pain scores on the day of surgery. Three of the studies evaluated the quantity of narcotic consumption postoperatively and failed to find a significant difference between control groups and groups treated with liposomal bupivacaine. Further, significant variability in comparison groups and study designs made interpretation of the available data difficult. Given this lack of clear evidence, there is a need for prospective, randomized clinical trials focused on fully evaluating the use of liposomal bupivacaine in fracture patients. At present, clinicians should maintain a healthy skepticism and rely on their own interpretation of the available data before widely implementing the use of liposomal bupivacaine.
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Affiliation(s)
- Andrew D Gailey
- Department of Orthopaedic Surgery, University of Tennessee Health Science Center-Campbell Clinic and University of North Carolina Health Care, 1584 Forrest Ave, Memphis, TN, 38112, USA.
- Department of Orthopaedic Surgery, Campbell Clinic/University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Robert F Ostrum
- Department of Orthopaedic Surgery, University of Tennessee Health Science Center-Campbell Clinic and University of North Carolina Health Care, 1584 Forrest Ave, Memphis, TN, 38112, USA
- Department of Orthopaedic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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van Deventer L, Bronstone A, Leonardi C, Bennett M, Yager P, Dasa V. A modern multimodal pain protocol eliminates the need for opioids for most patients following total knee arthroplasty: results from a retrospective comparative cohort study. J Exp Orthop 2023; 10:20. [PMID: 36806032 PMCID: PMC9940069 DOI: 10.1186/s40634-023-00585-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/04/2023] [Indexed: 02/22/2023] Open
Abstract
PURPOSE Modern multimodal analgesia has been shown to significantly reduce opioid use following total knee arthroplasty (TKA). This study was conducted to determine if changing TKA discharge opioid prescriptions from automatic to upon request resulted in more opioid free recoveries without compromising pain control. METHODS Between December 2019 and August 2021, an orthopedic surgeon performed 144 primary unilateral TKAs; patients received the same multimodal analgesia protocol except for postoperative opioid prescribing. The first consecutively-treated cohort automatically received an opioid prescription following discharge (automatic group) and the second cohort received opioid prescriptions only upon request (upon request group). Opioid prescription data were derived from a prescription monitoring program and patient-reported outcomes (PROs) were collected preoperatively and at 2 and 12 weeks postoperatively. RESULTS A higher percentage of the upon request group was opioid free 3 months after TKA compared with the automatic group (55.6% vs 4.3%, p < 0.0001) without compromising pain or function. Among opioid-naïve patients, 72% in the upon request group were opioid free after TKA compared with 5.4% in the automatic group. Opioid prescribing was not significantly reduced among opioid-experienced patients regardless of the pain protocol. CONCLUSION Requiring patients to request opioid prescriptions following TKA resulted in a higher rate of opioid free TKA, especially among opioid-naïve patients, without increasing pain compared with offering all patients an initial opioid prescription. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Leland van Deventer
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Amy Bronstone
- grid.279863.10000 0000 8954 1233Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112 USA
| | - Claudia Leonardi
- grid.279863.10000 0000 8954 1233School of Public Health, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Matthew Bennett
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA
| | - Peter Yager
- grid.279863.10000 0000 8954 1233School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA USA ,grid.279863.10000 0000 8954 1233Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA 70112 USA
| | - Vinod Dasa
- School of Medicine, Louisiana State University Health Sciences Center, New Orleans, LA, USA. .,Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, Box T6-7, New Orleans, LA, 70112, USA.
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Wall KC, Elphingstone J, Paul KD, Arguello A, Pandey A, Qureshi H, McGwin G, MacBeth L, Feinstein J, Momaya A, Ponce B, Brabston E. Nerve block with liposomal bupivacaine yields fewer complications and similar pain relief when compared to an interscalene catheter for arthroscopic shoulder surgery: a randomized controlled trial. J Shoulder Elbow Surg 2022; 31:2438-2448. [PMID: 36115616 DOI: 10.1016/j.jse.2022.07.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/13/2022] [Accepted: 07/29/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Following orthopedic surgery, patients frequently experience pain and discomfort. Multiple methods of regional anesthesia are available; however, the optimal technique to adequately manage pain while minimizing complications remains under investigation. This study aims to compare the complication rates and pain relief of single-injection, liposomal bupivacaine brachial plexus nerve block to a conventional, indwelling ropivacaine interscalene catheter (ISC) in patients undergoing arthroscopic shoulder surgery. We hypothesize that liposomal bupivacaine will have fewer patient complications with similar pain relief than an indwelling catheter. METHODS Patients undergoing arthroscopic shoulder surgery were prospectively assessed after randomization into either ropivacaine ISC or single-injection liposomal bupivacaine brachial plexus nerve block (LB) arms. All patients were discharged with 5 analgesics (acetaminophen, methocarbamol, gabapentin, acetylsalicylic acid, and oxycodone) for as-needed pain relief. Preoperatively, patient demographics and baseline Visual Analog Scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Penn Shoulder Scores were obtained. For the first four days postoperatively, complication rates (nausea, dyspnea, anesthetic site discomfort and/or irritation and/or leakage, and self-reported concerns and complications), pain, medication usage, and sleep data were assessed by phone survey every 12 hours. The primary outcome was overall complication rate. At 12 weeks postoperatively, Visual Analog Scale, Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, and Penn scores were reassessed. Outcome scores were compared with Mann-Whitney U tests, and demographics were compared with chi-squared tests. Significance was set at P < .05. RESULTS A total of 63 individuals were allocated into ISC (N = 35) and in the LB arms (N = 28) for analysis. Demographics and preoperative patient-reported outcomes were not different between the arms. Patients in the LB arm experienced fewer (13.1%) overall complications than those in the ISC arm (29.8%) (P < .001), with patients in the ISC arm specifically reporting more anesthetic site discomfort (36.4% vs. 7.1%, P = .007), leakage (30.3% vs. 7.1%, P = .023), and 'other,' free-response complications (ISC: 21.2%; LB: 3.6%; P = .042). No differences were noted in pain, sleep, opioid use, or satisfaction between arms during the perioperative period. More nonopioid medications were consumed on average in the ISC (1.8 ± 1.4) than in the LB arm (1.4 ± 1.3) (P = .001), with greater reported use of acetylsalicylic acid (40.9% vs. 23.4% P < .001) and acetaminophen (69.5% vs. 59.6% P = .013). Patient-reported outcome scores did not differ between groups preoperatively or at 12 weeks. DISCUSSION Patients receiving liposomal bupivacaine experienced fewer complications than traditional ISCs after arthroscopic shoulder surgery. Analgesia, sleep, satisfaction, and functional scores were similar between the 2 groups.
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Affiliation(s)
- Kevin C Wall
- University of Alabama at Birmingham Department of Orthopaedic Surgery, Birmingham, AL, USA
| | - Joseph Elphingstone
- University of Alabama at Birmingham Department of Orthopaedic Surgery, Birmingham, AL, USA
| | - Kyle D Paul
- University of Alabama at Birmingham Department of Orthopaedic Surgery, Birmingham, AL, USA
| | | | - Akash Pandey
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hamza Qureshi
- University of Alabama at Birmingham, Birmingham, AL, USA
| | - Gerald McGwin
- University of Alabama at Birmingham Department of Epidemiology, Birmingham, AL, USA
| | - Lisa MacBeth
- University of Alabama at Birmingham Department of Anesthesiology, Birmingham, AL, USA
| | - Joel Feinstein
- University of Alabama at Birmingham Department of Anesthesiology, Birmingham, AL, USA
| | - Amit Momaya
- University of Alabama at Birmingham Department of Orthopaedic Surgery, Birmingham, AL, USA
| | - Brent Ponce
- Hughston Clinic Foundation, Columbus, GA, USA
| | - Eugene Brabston
- University of Alabama at Birmingham Department of Orthopaedic Surgery, Birmingham, AL, USA.
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Li Y, Shen Z, Wang H, Feng T, Xia Y. Efficacy of liposomal bupivacaine for pain control in shoulder surgery: a systematic review and meta-analysis. J Shoulder Elbow Surg 2022; 31:1957-1968. [PMID: 35430368 DOI: 10.1016/j.jse.2022.02.037] [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: 11/04/2021] [Revised: 02/13/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Total shoulder arthroplasty and rotator cuff repair surgery result in considerable postoperative pain. Optimal postoperative pain management based on a multidisciplinary approach is necessary to promote early postoperative rehabilitation. The purpose of this study was to compare liposomal bupivacaine (LB) with traditional, non-LB agents after total arthroplasty or rotator cuff repair surgery. METHODS Two independent authors searched the PubMed Central, Google Scholar, and Cochrane Library websites for suitable articles. We included randomized controlled trials comparing outcomes after the administration of LB and non-LB agents for rotator cuff repair or total shoulder arthroplasty. The outcome measures for our meta-analysis were visual analog scale (VAS) pain scores at 24 and 48 hours after surgery, opioid consumption 24 and 48 hours after surgery, hospital stay duration, and complications within 48 hours after surgery. We used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) tool to assess the degree of evidence for the outcomes, and we used the Cochrane risk-of-bias assessment tool to assess the risk of bias. RESULTS The current meta-analysis comprised 11 randomized controlled studies with 846 subjects. Seven studies used local infiltration to administer LB, and 3 used a block. Our pooled analysis results showed no significant difference in VAS pain scores at 24 hours after surgery (standardized mean difference [SMD], -0.27; 95% confidence interval [CI], -0.55 to 0.01; prediction interval, -1.25 to 0.70), VAS pain scores at 48 hours after surgery (SMD, -0.18; 95% CI, -0.46 to 0.09; prediction interval, -1.10 to 0.73), opioid consumption at 24 hours after surgery (SMD, 0.04; 95% CI, -0.27 to 0.34; prediction interval, -1.01 to 1.09), and opioid consumption at 48 hours after surgery (SMD, 0.10; 95% CI, -0.44 to 0.64; prediction interval, -1.76 to 1.96) between the LB and non-LB groups. The LB and non-LB groups had similar hospital stay durations (SMD, -0.38; 95% CI, -1.51 to 0.74; prediction interval, -14.7 to 13.9) and adverse events (risk ratio, 0.89; 95% CI, 0.42 to 1.36) following the shoulder procedures. The level of evidence was low according to the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) analysis. CONCLUSION Our meta-analysis provides evidence indicating that LB is similar to non-LB agents in terms of overall pain relief and opioid requirements. The duration of hospital stay and complication rates were also similar in the 2 groups. Future well-designed and adequately powered randomized controlled studies are needed to confirm our results and to be able to recommend LB for various types of shoulder operations.
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Affiliation(s)
- Yujia Li
- Department of Anesthesia Surgery, Zhejiang Hospital, Hangzhou, China
| | - Zhien Shen
- Department of Anesthesia Surgery, Xiaoshan Hospital of Traditional Chinese Medicine, Hangzhou, China
| | - Hongmei Wang
- Department of Anesthesia Surgery, Zhejiang Hospital, Hangzhou, China
| | - Tonghui Feng
- Department of Anesthesia Surgery, Zhejiang Hospital, Hangzhou, China
| | - Yanfei Xia
- Department of Anesthesia Surgery, Zhejiang Hospital, Hangzhou, China.
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Effects of Intravenous Dexamethasone on Glycemic Control in Patients With Type 2 Diabetes Mellitus After Total Knee Arthroplasty. J Arthroplasty 2021; 36:3909-3914. [PMID: 34446328 DOI: 10.1016/j.arth.2021.07.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND We sought to determine whether administrations of intravenous (IV) dexamethasone jeopardize blood glycemic control, increase rates of postoperative complications, and diabetic medication change after TKA. METHODS This retrospective study included 427 patients with DM who underwent TKA. Patients were divided into two groups according to the use of IV dexamethasone (Dexa and No Dexa). For the Dexa, IV dexamethasone (5mg) was administered twice (surgery day, postoperative day 1). Blood glucose level until postoperative day 5, whether the mean blood glucose level was ≥200 mg/dL or not, the rate of a diabetic medication change, and postoperative complications (surgical site infection, delayed wound healing) were analyzed. RESULTS The adverse effects of IV dexamethasone on glycemic control were limited to the day of injection. The mean blood glucose level was 168.8 mg/dL and 204.4 mg/dL on operation day and 193.0 mg/dL and 210.5 mg/dL on postoperative day 1 in the No Dexa and the Dexa, respectively. High preoperative glycated hemoglobin (HbA1c) levels, but not IV dexamethasone administration, increased the risk of postoperative blood glucose level ≥200 mg/dL (odds ratio [OR], 2.810) and diabetic medication change (OR, 3.635, P < .001). A preoperative HbA1c level of >7.05% was associated with the risk of diabetic medication change. There was increase of postoperative complications (OR, 0.693, P = .552). CONCLUSIONS IV dexamethasone have transient effects on increasing the blood glucose level after TKA in patients with DM. However, patients with a preoperative HbA1c level of ≥7.05% may need to change their diabetic medication after TKA, regardless of IV dexamethasone administration.
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Shin SK, Lee DK, Shin DW, Yum TH, Kim JH. Local Infiltration Analgesia Versus Femoral Nerve Block for Pain Control in Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis. Orthop J Sports Med 2021; 9:23259671211050616. [PMID: 34796241 PMCID: PMC8593291 DOI: 10.1177/23259671211050616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Anterior cruciate ligament reconstruction (ACLR) is often performed on an outpatient basis; thus, effective pain management is essential to improving patient satisfaction and function. Local infiltration analgesia (LIA) and femoral nerve block (FNB) have been commonly used for pain management in ACLR. However, the comparative efficacy and safety between the 2 techniques remains a topic of controversy. Purpose: To compare pain reduction, opioid consumption, and side effects of LIA and FNB after ACLR. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed to identify studies comparing pain on the visual analog scale (a 100-mm scale), total morphine-equivalent consumption, and side effects between the 2 techniques after ACLR at the early postoperative period. The LIA was categorized into intra-articular injection and periarticular injection, and subgroup analyses were performed comparing either intra-articular injection or periarticular injection with FNB. Two reviewers performed study selection, risk-of-bias assessment, and data extraction. Results: A total of 10 studies were included in this systematic review and meta-analysis. In terms of VAS pain scores, our pooled analysis indicated that FNB was significantly more effective at 2 hours postoperatively compared with LIA (mean difference, 8.19 [95% confidence interval (CI), 0.75 to 15.63]; P = .03), with no significant difference between the 2 techniques at 4, 8, and 12 hours postoperatively; however, LIA was significantly more effective at 24 hours postoperatively compared with FNB (mean difference, 5.61 [95% CI, −10.43 to −0.79]; P = .02). Moreover, periarticular injection showed a significant improved VAS pain score compared with FNB at 24 hours postoperatively (mean difference, 11.44 [95% CI, −20.08 to −2.80]; P = .009), and the improvement reached the threshold of minimal clinically important difference of 9.9. Total morphine-equivalent consumption showed no difference between the 2 techniques, and side effects were unable to be quantified for the meta-analysis because of a lack of data. Conclusion: Compared with FNB, LIA was not as effective at 2 hours, comparable within 12 hours, and significantly more effective at 24 hours postoperatively for reducing pain after ACLR. Total morphine-equivalent consumption showed no significant differences between the 2 techniques.
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Affiliation(s)
- Seong Kee Shin
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | - Do Kyung Lee
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Dae Won Shin
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | - Tae Hoon Yum
- Department of Orthopedic Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | - Jun-Ho Kim
- Department of Orthopaedic Surgery, Kyung-Hee University Hospital at Gangdong, Seoul, Republic of Korea
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Collett G, Insley AP, Michaelis S, Shaji S, Feierstein B, Martell JR. Reduction of Opioid Use With Enhanced Recovery Program for Total Knee Arthroplasty. Fed Pract 2021; 38:212-219. [PMID: 34177230 DOI: 10.12788/fp.0124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Adequate pain control after total knee arthroplasty (TKA) is critically important to achieve early mobilization, shorten the length of hospital stay, and reduce postoperative complications. At Veterans Affairs North Texas Health Care System (VANTHCS) in Dallas, we implemented a multidisciplinary enhanced recovery after surgery (ERAS) protocol to deal with increasing length of stay and postoperative pain. We hypothesize that this protocol will reduce the overall opioid burden and decrease inpatient hospital length of stay in our TKA population. Methods A retrospective review of all TKAs performed by a single surgeon at VANTHCS from 2013 to 2018 was conducted. A postoperative ERAS protocol was implemented in 2016. We compared perioperative opioid use and LOS between cohorts before and after protocol implementation. Results Inpatient length of stay between cohorts was reduced from 66.8 hours for the standard of care (SOC) period to 22.3 hours in the ERAS cohort. Inpatient opioid use measured by total oral morphine equivalent doses averaged 169.5 mg and 66.7 mg for SOC and ERAS cohorts, respectively (P = .0001). Intraoperative use of opioids decreased from 57.4 mg in the SOC cohort to 10.5 mg in the ERAS cohort (P = .0001). Postanesthesia care unit (PACU) opioid use decreased from 13.6 mg (SOC) to 1.3 mg (ERAS) (P = .0002). There was no significant difference in complications between cohorts (P = .09). Conclusions Initiating a multidisciplinary ERAS protocol for TKA at VANTHCS significantly reduced inpatient length of stay and perioperative opioid use with no deleterious effects on complication rates. The ERAS protocol has major medical and financial implications for our unique VA population and the VA health care system.
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Affiliation(s)
- Garen Collett
- is former Chief of Orthopaedic Surgery; and are Nurse Anesthetists in the Anesthesia Management Departmental; all at Veterans Affairs North Texas Health Care System in Dallas. is a PGY-5 Resident, and John Martell is an Associate Professor both at University of Texas Southwestern Medical Center in Dallas. is a Nurse Anesthetist at NorthStar Anesthesia, City Hospital at White Rock in Dallas. is a Physician Assistant, Orthopaedic Surgery Service at James A. Haley Veterans' Hospital in Tampa, Florida
| | - Allison P Insley
- is former Chief of Orthopaedic Surgery; and are Nurse Anesthetists in the Anesthesia Management Departmental; all at Veterans Affairs North Texas Health Care System in Dallas. is a PGY-5 Resident, and John Martell is an Associate Professor both at University of Texas Southwestern Medical Center in Dallas. is a Nurse Anesthetist at NorthStar Anesthesia, City Hospital at White Rock in Dallas. is a Physician Assistant, Orthopaedic Surgery Service at James A. Haley Veterans' Hospital in Tampa, Florida
| | - Secherre Michaelis
- is former Chief of Orthopaedic Surgery; and are Nurse Anesthetists in the Anesthesia Management Departmental; all at Veterans Affairs North Texas Health Care System in Dallas. is a PGY-5 Resident, and John Martell is an Associate Professor both at University of Texas Southwestern Medical Center in Dallas. is a Nurse Anesthetist at NorthStar Anesthesia, City Hospital at White Rock in Dallas. is a Physician Assistant, Orthopaedic Surgery Service at James A. Haley Veterans' Hospital in Tampa, Florida
| | - Sheryl Shaji
- is former Chief of Orthopaedic Surgery; and are Nurse Anesthetists in the Anesthesia Management Departmental; all at Veterans Affairs North Texas Health Care System in Dallas. is a PGY-5 Resident, and John Martell is an Associate Professor both at University of Texas Southwestern Medical Center in Dallas. is a Nurse Anesthetist at NorthStar Anesthesia, City Hospital at White Rock in Dallas. is a Physician Assistant, Orthopaedic Surgery Service at James A. Haley Veterans' Hospital in Tampa, Florida
| | - Bobbi Feierstein
- is former Chief of Orthopaedic Surgery; and are Nurse Anesthetists in the Anesthesia Management Departmental; all at Veterans Affairs North Texas Health Care System in Dallas. is a PGY-5 Resident, and John Martell is an Associate Professor both at University of Texas Southwestern Medical Center in Dallas. is a Nurse Anesthetist at NorthStar Anesthesia, City Hospital at White Rock in Dallas. is a Physician Assistant, Orthopaedic Surgery Service at James A. Haley Veterans' Hospital in Tampa, Florida
| | - John R Martell
- is former Chief of Orthopaedic Surgery; and are Nurse Anesthetists in the Anesthesia Management Departmental; all at Veterans Affairs North Texas Health Care System in Dallas. is a PGY-5 Resident, and John Martell is an Associate Professor both at University of Texas Southwestern Medical Center in Dallas. is a Nurse Anesthetist at NorthStar Anesthesia, City Hospital at White Rock in Dallas. is a Physician Assistant, Orthopaedic Surgery Service at James A. Haley Veterans' Hospital in Tampa, Florida
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Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia. Anesthesiology 2021; 134:147-164. [PMID: 33372953 DOI: 10.1097/aln.0000000000003651] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics. METHODS The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h. RESULTS Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported. CONCLUSIONS Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks. EDITOR’S PERSPECTIVE
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A three-dimensional finite element analysis on the effects of implant materials and designs on periprosthetic tibial bone resorption. PLoS One 2021; 16:e0246866. [PMID: 33566856 PMCID: PMC7875353 DOI: 10.1371/journal.pone.0246866] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 01/27/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Implant material is a more important factor for periprosthetic tibial bone resorption than implant design after total knee arthroplasty (TKA). The virtual perturbation study was planned to perform using single case of proximal tibia model. We determined whether the implant materials' stiffness affects the degree of periprosthetic tibial bone resorption, and whether the effect of material change with the same implant design differed according to the proximal tibial plateau areas. MATERIALS AND METHODS This three-dimensional finite element analysis included two cobalt-chromium (CoCr) and two titanium (Ti) tibial implants with different designs. They were implanted into the proximal tibial model reconstructed using extracted images from computed tomography. The degree of bone resorption or formation was measured using the strain energy density after applying axial load. The same analysis was performed after exchanging the materials while maintaining the design of each implant. RESULTS The degree of periprosthetic tibial bone resorption was not determined by the type of implant materials alone. When the implant materials were changed from Ti to CoCr, the bone resorption in the medial compartment increased and vice versa. The effect of material composition's change on anterior and posterior areas varied accordingly. CONCLUSIONS Although the degree of bone resorption was associated with implant materials, it differed depending on the design of each implant. The effect on the degree of bone resorption according to the materials after TKA should be evaluated while concomitantly considering design.
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Zhang W, Lin P, Zhang F, Wang J. Femoral nerve block versus obturator nerve block for pain management after total knee replacement: A randomized controlled trial protocol. Medicine (Baltimore) 2020; 99:e21956. [PMID: 32925729 PMCID: PMC7489602 DOI: 10.1097/md.0000000000021956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 07/30/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Several studies reported short-term analgesic efficacy of obturator nerve block (ONB), as in comparison with the femoral nerve block (FNB) in the treatment of postoperative pain after the total knee replacement (TKR). The optimal method remains under debate. The purpose of our current work is to compare the safety and efficacy of FNB and ONB for postoperative analgesia after TKR. METHODS This prospective, randomized, and controlled study was performed from January 2018 to December 2019. It was authorized via the Institutional Review Committee in NO.971 Hospital of the People's Liberation Army Navy (2019-PLAN-132).Two hundred patients were divided randomly into 2 groups, the control group (n = 100) and study group (n = 100). The experimental group received FNB and control groups received ONB. Primary outcome included pain at different time point (Visual Analogue Scale score of anterior knee pain at rest and in motion). The Visual Analogue Scale scores were marked by patients themselves on a paper with a graduated line starting at 0 (no pain) and ending at 10 (the most painful). Opioid consumption was converted to equivalents of oral morphine uniformly for statistical analysis. Secondary outcomes included the knee range of motion, the hospital stay length as well as the postoperative complications such as pulmonary embolism and deep vein thrombosis. RESULTS Table 1 will show the clinical outcomes between the 2 groups. CONCLUSION This trial would provide an evidence for the use of different types of peripheral nerve blocks in TKR.
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Controversial Topics in Total Knee Arthroplasty: A 5-Year Update (Part 1). JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e1900047. [PMID: 32672726 PMCID: PMC7028773 DOI: 10.5435/jaaosglobal-d-19-00047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This review article examines updates to the literature during the past 5 years on numerous topics related to total knee arthroplasty which were felt to have ongoing controversy. These include the use of peripheral nerve blocks and local infiltrative analgesia, intrathecal morphine, patellar resurfacing, and bearing designs.
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Peng L, Luo Y, Liu J, Li Z. The efficacy of patellar denervation with electrocautery after total knee replacement: A meta-analysis of randomized controlled trials. Int J Surg 2020; 78:126-137. [PMID: 32335235 DOI: 10.1016/j.ijsu.2020.04.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/01/2020] [Accepted: 04/16/2020] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of patellar denervation with electrocautery for reducing pain and improving clinical outcomes after total knee replacement. METHODS A comprehensive search was conducted across relevant databases, including PubMed, Scopus, EMBASE, Web of Science, and Cochrane Library databases on February 2020. Two researchers independently completed the literature screening, data extraction, and risk evaluation of bias. Outcome measures included visual analogue scale, opioid consumption, range of motion, patellar score, American Knee Society score, Oxford knee score and postoperative complications. STATA 13.0 software was applied for meta-analysis. RESULT A total of nine studies involving 1319 patients were included in our study. The present meta-analysis indicated that patellar denervation with electrocautery was associated with improved pain relief and decreased opioid consumption after total knee replacement. There was significant difference between groups in terms of knee range of motion. CONCLUSION Patellar denervation with electrocautery is effective in reducing pain and opioid consumption after total knee replacement. Postoperative range of motion is significantly better in patellar denervation group, which means that patellar denervation significantly improves clinical outcome.
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Affiliation(s)
- Lin Peng
- Department of Bone and Joint, Hospital Affiliated to Southwest Medical University, Sichuan Province, 646000, China
| | - Yuhao Luo
- Department of Medical Oncology, Hospital Affiliated to Southwest Medical University, Sichuan Province, 646000, China
| | - Juncai Liu
- Department of Bone and Joint, Hospital Affiliated to Southwest Medical University, Sichuan Province, 646000, China
| | - Zhong Li
- Department of Bone and Joint, Hospital Affiliated to Southwest Medical University, Sichuan Province, 646000, China.
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Elsharkawy H, Saasouh W, Cho YJ, Soliman LM, Horn JL. The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique. J Anaesthesiol Clin Pharmacol 2020; 36:110-114. [PMID: 32174670 PMCID: PMC7047671 DOI: 10.4103/joacp.joacp_358_18] [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: 12/03/2018] [Revised: 02/26/2019] [Accepted: 05/21/2019] [Indexed: 11/04/2022] Open
Abstract
Background and Aims Liposomal bupivacaine (LB) is a formulation of local anesthetic that may exert analgesia over a prolonged period. Anecdotal use of LB suggests benefit and prolonged analgesia when used to supplement infiltration blocks. Our aim was to test the effect of a bolus of LB delivered through a nerve catheter in two types of interfascial plane blocks (transversus abdominis plane and anterior subcostal quadratus lumborum). The effect was evaluated through patient self-reporting of postsurgical pain up to 48 postoperative hours. Material and Methods Medical records of adult postoperative patients who received LB in a peripheral nerve catheter were followed retrospectively and analysed for pain scores and spread of dermatomal numbness over 48 h following the postoperative dose. A chart review of patients who qualified between June 2015 and March 2017 was performed, and clinical data were obtained from the institutional Perioperative Health Documentation System. Results Pain scores decreased following LB bolus, and all patients reported efficient block analgesia after bolus injection. Dermatomal numbness decreased gradually and was minimal by 48 h following bolus. Conclusion LB can be injected through a peripheral nerve catheter to prolong analgesia after catheter removal.
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Affiliation(s)
- Hesham Elsharkawy
- Case Western Reserve University, Cleveland, OH, USA.,Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA
| | - Wael Saasouh
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA.,Department of Anaesthesiology, Detroit Medical Centre, Detroit, MI, USA
| | - Yoon Jeong Cho
- Department of General Anaesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | | | - Jean-Louis Horn
- Department of Anaesthesiology, Stanford University, Stanford, CA, USA
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Abstract
For decades local anesthetics have proven to be safe and effective drugs in the clinical practice, crucially promoting the enormous achievements in regional anesthesia. Meanwhile, it is a well-known fact that local anesthetics are much more than just "simple" sodium channel blockers. They also interact with numerous other ion channels and subcellular structures, enhancing nerve blockade and resulting in systemic "alternative" effects, which can sometimes even be clinically used. By the simultaneous administration of various adjuvants (e.g., opioids, corticosteroids and α2-receptor agonists) attempts are made to prolong the time of action of local anesthetics after a single administration in order to achieve the best possible improvement in postoperative analgesia. In this context, ultralong-acting local anesthetics, such as liposomal bupivacaine, which at least theoretically can provide a sensory nerve block for several days, have been developed and clinically introduced. The coming years will show whether these approaches will develop into genuine alternatives to the personnel and cost-intensive continuous nerve blockades.Local anesthetic-induced systemic toxicity is meanwhile rare but still a potentially life-threatening event, frequently resulting from accidental intravascular injection or extensive systemic resorption. Consequently, slow and fractional application of these agents with intermittent aspiration helps to prevent toxic sequelae. If toxic symptoms occur, however, the intravenous infusion of 20% lipid solutions in addition to basic treatment measures can enhance the success of treatment.
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Affiliation(s)
- W Zink
- Klinik für Anästhesiologie, Operative Intensivmedizin und Notfallmedizin, Klinikum der Stadt Ludwigshafen am Rhein, Bremserstr 79, 67063, Ludwigshafen, Deutschland.
| | - T Steinfeldt
- Klinik für Anästhesiologie und operative Intensivmedizin, Diakonieklinikum Schwäbisch Hall, Schwäbisch Hall, Deutschland
| | - T Wiesmann
- Klinik für Anästhesie und Intensivtherapie, Philipps Universität Marburg, Marburg, Deutschland
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Liu Y, Zeng JF, Zeng Y, Wu YG, Bao XC, Shen B. Comprehensive Comparison of Liposomal Bupivacaine with Femoral Nerve Block for Pain Control Following Total Knee Arthroplasty: An Updated Systematic Review and Meta-Analysis. Orthop Surg 2019; 11:943-953. [PMID: 31762223 PMCID: PMC6904643 DOI: 10.1111/os.12547] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 02/05/2023] Open
Abstract
To compare the efficacy of liposomal bupivacaine (LB) and femoral nerve block following total knee arthroplasty, we conducted this systematic review and meta-analysis. 11 trials with 2,908 patients were included in this study. The pooled data demonstrated that total morphine consumption equivalents during the hospital stay was significantly increased in FNB group. In addition, LB has significantly better outcome in view of the postoperative functional recovery, such as the odds of fall, the incidences of straight leg rise (SLR), the number of patients who can walk independently in the day of surgery,the ambulation distance at POD1, the number of patients discharged at POD1. Consistent with the faster functional recovery, liposomal bupivacaine shortens the length of hospital stay. However, there was no significant difference between LB and FNB in terms of Visual Analogue Score (VAS) during the hospital stay. All in all, liposomal bupivacaine has significantly better outcome in view of the postoperative functional recovery and the length of hospital stay compared with femoral nerve block following the total knee arthroplasty.
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Affiliation(s)
- Yuan Liu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Jun-Feng Zeng
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Zeng
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Yuan-Gang Wu
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Xian-Chao Bao
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Shen
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, China
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Kolade O, Patel K, Ihejirika R, Press D, Friedlander S, Roberts T, Rokito AS, Virk MS. Efficacy of liposomal bupivacaine in shoulder surgery: a systematic review and meta-analysis. J Shoulder Elbow Surg 2019; 28:1824-1834. [PMID: 31324503 DOI: 10.1016/j.jse.2019.04.054] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 04/22/2019] [Accepted: 04/24/2019] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS The aim of this meta-analysis was to compare the safety, efficacy, and opioid-sparing effect of liposomal bupivacaine (LB) vs. nonliposomal local anesthetic agents (NLAs) for postoperative analgesia after shoulder surgery. METHODS A systematic literature review of randomized controlled clinical studies comparing the efficacy of LB with NLAs in shoulder surgery was conducted. Seven level I and II studies were included in the meta-analysis, and shoulder surgical procedures included arthroscopic rotator cuff repair and shoulder arthroplasty. Bias was assessed using The Cochrane Collaboration's tool. The primary outcome measures were visual analog scale pain scores and opioid consumption 24 and 48 hours after shoulder surgery. Subgroup analysis was performed for the method of LB administration (interscalene nerve block vs. local infiltration). RESULTS A total of 7 studies (535 patients) were included in the final meta-analysis comparing LB (n = 260) with NLAs (n = 275). No significant difference was found between the LB and NLA groups in terms of visual analog scale pain scores at 24 hours (95% confidence interval, -1.02 to 0.84; P = .86) and 48 hours (95% confidence interval, -0.53 to 0.71; P = .78). Both groups had comparable opioid consumption at both 24 hours (P = .43) and 48 hours (P = .78) postoperatively and with respect to length of stay (P = .87) and adverse events (P = .97). Subgroup analysis demonstrated comparable efficacy irrespective of the method of administration of LB. CONCLUSION LB is comparable to NLAs with respect to pain relief, the opioid-sparing effect, and adverse effects in the first 48 hours after arthroscopic rotator cuff repair and total shoulder arthroplasty.
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Affiliation(s)
- Oluwadamilola Kolade
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Karan Patel
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Rivka Ihejirika
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Daniel Press
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Scott Friedlander
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Timothy Roberts
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Andrew S Rokito
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA
| | - Mandeep S Virk
- Shoulder & Elbow Division, Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY, USA.
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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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de Araújo DR, Ribeiro LNDM, de Paula E. Lipid-based carriers for the delivery of local anesthetics. Expert Opin Drug Deliv 2019; 16:701-714. [PMID: 31172838 DOI: 10.1080/17425247.2019.1629415] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION There is a clinical need for pharmaceutical dosage forms devised to prolong the acting time of local anesthetic (LA) agents or to reduce their toxicity. Encapsulation of LA in drug delivery systems (DDSs) can provide long-term anesthesia for inpatients (e.g. in immediate postsurgical pain control, avoiding the side effects from systemic analgesia) and diminished systemic toxicity for outpatients (in ambulatory/dentistry procedures). The lipid-based formulations described here, such as liposomes, microemulsions, and lipid nanoparticles, have provided several nanotechnological advances and therapeutic alternatives despite some inherent limitations associated with the fabrication processes, costs, and preclinical evaluation models. AREAS COVERED A description of the currently promising lipid-based carriers, including liposomes, microemulsions, and nanostructured lipid carriers, followed by a systematic review of the existing lipid-based formulations proposed for LA. Trends in the research of these LA-in-DDS are then exposed, from the point of view of administration route and alternatives for non-traditionally administered LA molecules. EXPERT OPINION Considering the current state and potential future developments in the field, we discuss the reasons for why dozens of formulations published every year fail to reach clinical trials; only one lipid-based formulation for the delivery of local anesthetic (Exparel®) has been approved so far.
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Affiliation(s)
| | - Lígia Nunes de Morais Ribeiro
- b Department of Biochemistry and Tissue Biology , Institute of Biology, University of Campinas - UNICAMP , Campinas, São Paulo , Brazil
| | - Eneida de Paula
- b Department of Biochemistry and Tissue Biology , Institute of Biology, University of Campinas - UNICAMP , Campinas, São Paulo , Brazil
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Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS J 2019; 15:57-65. [PMID: 30863234 PMCID: PMC6384219 DOI: 10.1007/s11420-018-9652-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/09/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Elective total joint arthroplasty may be a gateway to long-term opioid use. QUESTIONS/PURPOSE We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). METHODS We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies. RESULTS Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA. CONCLUSIONS The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.
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Affiliation(s)
- Ellen M. Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, 535 East 70th St., New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD USA
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Xu H, Zhang S, Xie J, Lei Y, Cao G, Pei F. Multiple Doses of Perioperative Dexamethasone Further Improve Clinical Outcomes After Total Knee Arthroplasty: A Prospective, Randomized, Controlled Study. J Arthroplasty 2018; 33:3448-3454. [PMID: 30033064 DOI: 10.1016/j.arth.2018.06.031] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/23/2018] [Accepted: 06/25/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This study aimed to evaluate the effect and safety of multiple doses of preoperative dexamethasone on pain and recovery after total knee arthroplasty (TKA). METHODS Altogether, 182 patients undergoing TKA received 3 intravenous injections of normal saline (group A), 1 injection of high-dose dexamethasone (20 mg) and 2 injections of normal saline (group B), or 1 injection of high-dose dexamethasone and 2 injections of low-dose (10 mg) dexamethasone (group C). RESULTS Visual analog scale was lower in group C than in group A or B and was different between groups A and B on postoperative days 1, 2, and 3 (all P < .05). Fewer group C patients required analgesic rescue and had lower total analgesic than those in group A or B, with the same difference between groups A and B (all P < .05). C-reactive protein and interleukin-6 levels were lower in groups B and C than in group A at 24, 48, and 72 hours postoperatively. C-reactive protein at 72 hours and interleukin-6 at 48 and 72 hours were lower in group C than in group B (all P < .05). Incidences of postoperative nausea and vomiting, number of patients requiring antiemetic rescue, and overall consumption of metoclopramide were lower in groups B and C than in group A (all P < .05). No surgical-site infections or gastrointestinal hemorrhages were detected in any group. CONCLUSION Multiple dexamethasone doses further reduced postoperative pain, decreased consumption of analgesic drugs, and provided more powered inflammation control. These findings call for further studies to further evaluate its safety.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Mianyang, People's Republic of China
| | - Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yiting Lei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Guorui Cao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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New local anesthetics. Best Pract Res Clin Anaesthesiol 2018; 32:179-185. [DOI: 10.1016/j.bpa.2018.06.010] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 06/19/2018] [Indexed: 11/30/2022]
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Fan ZR, Ma J, Ma XL, Wang Y, Sun L, Wang Y, Dong BC. The efficacy of dexamethasone on pain and recovery after total hip arthroplasty: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore) 2018; 97:e0100. [PMID: 29595631 PMCID: PMC5895376 DOI: 10.1097/md.0000000000010100] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) perioperative dexamethasone treatment is still a controversial subject. We write this systematic review and meta-analysis to evaluate the efficacy of dexamethasone on pain and recovery after THA. METHODS Two researchers searched the relevant studies from Pubmed, Cochrane, and Embase. The research was reported according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Randomized controlled trials (RCTs) were included in our meta-analysis. At the same time, the assessment of the risk of bias was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions version. The pooled data are processed by software RevMan 5.3. RESULT In accordance with inclusion and exclusion, 3 studies with 207 patients were eligible and accepted into this meta-analysis. For RCTs, the risk of bias was evaluated by Cochrane Collaboration tool. Only one study did not have detection bias. Our study demonstrated that the dexamethasone group was more effective than the placebo group in term of visual analogue scale (VAS) score at 24 hours (P < .001), 48 hours (P = .04); opioid consumption (P < .001); length of stay (LOS, P < .001); and postoperative nausea (P = .001). CONCLUSION Dexamethasone not only reduces postoperative pain scores and postoperative opioids consumption within 48 hours, but also reduces postoperative vomiting and effectively reduces LOS. However, we still need large sample size and high quality studies to explore the relationship between complications and dose response to give the final conclusion.
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Affiliation(s)
- Zheng-rui Fan
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
- Department of Orthopedics, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Jianxiong Ma
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Xin-long Ma
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Ying Wang
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Lei Sun
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Yan Wang
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
| | - Ben-chao Dong
- Biomechanics Labs of Orthopaedics Institute, Tianjin Hospital
- Tianjin Hospital, Tianjin University
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Mulligan RP, Morash JG, DeOrio JK, Parekh SG. Liposomal Bupivacaine Versus Continuous Popliteal Sciatic Nerve Block in Total Ankle Arthroplasty. Foot Ankle Int 2017; 38:1222-1228. [PMID: 28786304 DOI: 10.1177/1071100717722366] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Liposomal bupivacaine (LB) is widely used in joint arthroplasty, but there is little reported on the use of LB in foot and ankle surgery. Continuous popliteal sciatic nerve block (CPSNB) is more commonly used for major foot and ankle reconstructions. The purpose of this study was to compare use of intraoperative LB injection to CPSNB as a regional anesthetic for total ankle arthroplasty (TAA), with attention to postoperative pain scores, narcotic use, and complications. METHODS Retrospective review of TAA patients of 2 fellowship-trained orthopedic foot and ankle surgeons was performed. Patients received either preoperative single-shot popliteal sciatic nerve block with 0.2% ropivacaine followed by intraoperative injection of LB or preoperative CPSNB alone. Outcomes examined were visual analog scale (VAS) pain score at 8 hours, 24 hours, 1 week, and 3 weeks following surgery; need for opioid pain medication refill; physician office notification for pain issues or other adverse events; and complications within the first 90 days following surgery. Standard statistical analysis was performed, and P < .05 was considered significant. Seventy-five patients were identified who underwent TAA and met inclusion criteria. Forty-one received LB, and 34 received CPSNB. RESULTS No statistical difference was seen between groups with regard to complications, emergency department visits, readmissions, reoperations, VAS pain score at any time point, physician office contacts, and narcotic refills. Sixteen of 41 (39%) LB patients had narcotic refills, versus 12 of 34 (35%) CPSNB patients ( P = .81). Two of 41 (5%) LB patients had a complication postoperatively, versus 4 of 34 (12%) CPSNB patients. There were no complications specific to the anesthetic used in either group. CONCLUSION This is the first study evaluating the use of LB for total ankle arthroplasty. Liposomal bupivacaine was safe and effective as an option for regional anesthetic and postoperative pain control, with comparable results to CPSNB. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ryan P Mulligan
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joel G Morash
- 2 Department of Orthopaedic Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - James K DeOrio
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Selene G Parekh
- 1 Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.,3 Duke Fuqua School of Business, Durham, NC, USA
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Liposomal bupivacaine versus interscalene nerve block for pain control after total shoulder arthroplasty: A systematic review and meta-analysis. Int J Surg 2017; 46:61-70. [DOI: 10.1016/j.ijsu.2017.08.569] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/15/2017] [Accepted: 08/20/2017] [Indexed: 11/21/2022]
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Cao X, Pan F. Comparison of liposomal bupivacaine infiltration versus interscalene nerve block for pain control in total shoulder arthroplasty: A meta-analysis of randomized control trails. Medicine (Baltimore) 2017; 96:e8079. [PMID: 28953626 PMCID: PMC5626269 DOI: 10.1097/md.0000000000008079] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND This meta-analysis aimed to compare the efficiency and safety of liposomal bupivacaine infiltration and interscalene nerve block for pain control after total shoulder arthroplasty. METHODS A systematic search was performed in Medline (1966 to May 2017), PubMed (1966 to May 2017), Embase (1980 to May 2017), ScienceDirect (1985 to May 2017) and the Cochrane Library. Only randomized controlled trials (RCTs) were included. Reported surgical outcomes, including visual analogue scale (VAS) scores, opioid consumption, length of stay, and postoperative adverse effects including the risk of nausea and vomiting. Meta-analysis was performed using Stata 11.0 software. RESULTS Four RCTs including 510 patients met the inclusion criteria. The present meta-analysis indicated that there were no significant differences between groups in terms of VAS score at 12 hours (standard mean difference [SMD] = 0.272, 95% CI: -0.150 to 0.695, P = .207), 24 hours (SMD = -0.056, 95% CI: -0.458 to 0.346, P = 0.785), and 48 hours (SMD = 0.183, 95% CI: -0.148 to 0.513, P = .278). Liposomal bupivacaine infiltration groups required an equivalent amount of opioids at postoperative 12 hours (SMD = -0.039, 95% CI: -0.222 to 0.143, P = .672), 24 hours (SMD = 0.046, 95% CI: -0.136 to 0.228, P = .618) and 48 hours (SMD = -0.025, 95% CI: -0.207 to 0.157, P = .785). CONCLUSION Liposomal bupivacaine infiltration provides equivalent postoperative pain control compared with interscalene nerve block following total shoulder arthroplasty. Both of them can reduce the consumption of opioids without severe adverse effects. More high-quality RCTs with long follow-up period are necessary for proper comparisons of the efficacy and safety of liposomal bupivacaine infiltration with interscalene nerve block.
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Affiliation(s)
- Xiuling Cao
- Department of Anesthesiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University
| | - Fang Pan
- Department of Anesthesiology and Pain Medicine, Peking University People's Hospital, Peking University, Beijing, China
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de Neumann L, Clairoux A, Brulotte V, McCartney CJL. In Search of the Perfect Balance: a Narrative Review of Analgesic Techniques for Total Knee Arthroplasty. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0218-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Meng J, Li L. The efficiency and safety of dexamethasone for pain control in total joint arthroplasty: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2017; 96:e7126. [PMID: 28614232 PMCID: PMC5478317 DOI: 10.1097/md.0000000000007126] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This meta-analysis aimed to evaluate the efficiency and safety of dexamethasone administration in total knee and hip arthroplasties. METHODS Two researchers search the relevant studies independently including Embase (1980-017.04), PubMed (1966-017.04), ScienceDirect (1985-017.04), Web of Science (1950-2017.03), and Cochrane Library for potential relevant studies. After testing for heterogeneity between studies, data were aggregated for random-effects models when necessary. The results of dichotomous outcomes were expressed as risk difference (RD) with a 95% confidence intervals (CIs). For continuous various outcomes, mean difference (MD) or standard mean difference (SMD) with a 95% confidence intervals (CIs) was applied for assessment. Meta-analysis was performed using Stata 11.0 software. RESULTS Four randomized controlled trials (RCTs) including 361 patients met the inclusion criteria. The present meta-analysis indicated that there were significant differences between groups in terms of visual analogue scale (VAS) score at 12 hours (SMD = -0.579, 95% CI: -0.780 to -0.357, P = .000), 24 hours (SMD = -0.820, 95% CI: -1.036 to -0.604, P = .000), and 48 hours (SMD = -0.661, 95% CI: -1.149 to -0.172, P = .008). Dexamethasone was associated with a lower opioid consumption at 12 hours (SMD = -0.245, 95% CI: -0.465 to -0.025, P = .029), 24 hours (SMD = -0.285, 95% CI: -0.505 to -0.064, P = .011), and 48 hours (SMD = -0.989, 95% CI: -1.710 to -0.267, P = .007). CONCLUSION Dexamethasone could significantly reduce postoperative pain scores and opioid consumption within the 1st 48 hours following total joint arthroplasty (TJA). The overall evidence quality was moderate to low, further high-quality RCTs are needed to identify the optimal dose of dexamethasone for reducing pain after TJA.
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Affiliation(s)
| | - Lin Li
- Department of Joint Surgery, The First People's Hospital of Jining, Jining, Shandong, China
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Serum Bupivacaine Concentration After Periarticular Injection With a Mixture of Liposomal Bupivacaine and Bupivacaine HCl During Total Knee Arthroplasty. Reg Anesth Pain Med 2017; 42:582-587. [DOI: 10.1097/aap.0000000000000636] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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