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Li B, Yang X, Liu F, Huang H, Zhang B, Li X, Lu Q, Liu P, Fan L. Effect of Perineural or Intravenous Betamethasone on Femoral Nerve Block Outcomes in Knee Arthroplasty: A Randomized, Controlled Study. Orthop Surg 2024; 16:873-881. [PMID: 38384178 PMCID: PMC10984829 DOI: 10.1111/os.14018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/23/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Despite the use of multimodal analgesia, patients undergoing knee arthroplasty still encounter residual moderate pain. The addition of betamethasone to local anesthetic has been shown to improve postoperative pain. However, it remains uncertain whether the positive effects of perineural or intravenous administration of betamethasone on analgesia outcomes lead to better early mobility and postoperative recovery. METHODS Between June 2022 and February 2023, a total of 159 patients who were undergoing knee arthroplasty were included in this study. These patients were allocated randomly into three groups: (i) the NS group, received ropivacaine 0.375% and intravenous 3mL 0.9% normal saline; (ii) the PNB group, received ropivacaine 0.375% plus perineural betamethasone (12mg) 3mL and intravenous 3mL 0.9% normal saline; and (iii) the IVB group, received ropivacaine 0.375% and intravenous betamethasone (12mg) 3mL. RESULTS Both perineural and intravenous administration of betamethasone led to improved median (IQR) numeric rating scale (NRS) scores on the 6-meter walk test, with a score of 1.0 (1.0-2.0) for both groups, compared with 2.0 (1.0-2.0) for the NS group (p = 0.003). Compared to the NS group, both the PNB and IVB groups showed significant reductions in NRS scores at 24 and 36 h after surgery, along with a significant increase in ROM at 24, 36, and 48 h post-operation. Additionally, it exhibited lower levels of cytokine IL-1β and TNF-α in fluid samples, as well as lower level of HS-CRP in blood samples in the PNB and IVB groups compared to the NS group. CONCLUSION The administration of perineural and intravenous betamethasone demonstrated an enhanced analgesic effect following knee arthroplasty. Furthermore, it was associated with reduced levels of IL-1β, TNF-α, and HS-CRP, as well as enhanced knee ROM, which is conducive to early ambulation and postoperative rehabilitation after knee arthroplasty.
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Affiliation(s)
- Binglong Li
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
- Shandong University Cheeloo College of MedicineJinanChina
| | - Xiaomei Yang
- Shandong University Cheeloo College of MedicineJinanChina
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
- Department of Cardiology, the Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, the State and Shandong Province Joint Key Laboratory of Translational Cardiovascular MedicineQilu Hospital of Shandong UniversityJinanChina
| | - Fang Liu
- Shandong University Cheeloo College of MedicineJinanChina
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
| | - Huang Huang
- Institute for In Vitro SciencesGaithersburgMDUSA
| | - Baoqing Zhang
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Xuezhou Li
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Qunshan Lu
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Peilai Liu
- Department of OrthopedicsQilu Hospital of Shandong UniversityJinanChina
| | - Lixia Fan
- Department of Anaesthesiology, Qilu HospitalShandong UniversityJinanChina
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Aloziem OU, Williams BA, Mikolic JM, Boudreaux-Kelly MY, Faruque S, Piva SR, Ibinson JW, Switzer GE. Assessing Common Content and Responsiveness of the QoR-15 and the SF-8 in the Context of Recovery from Regional Anesthesia for Joint Replacement. Mil Med 2023; 188:e3469-e3476. [PMID: 37256753 DOI: 10.1093/milmed/usad191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 04/06/2023] [Accepted: 05/11/2023] [Indexed: 06/02/2023] Open
Abstract
PURPOSE There is no consensus regarding how best to measure postoperative quality of recovery after anesthesia/surgery (e.g., using 24-hour survey instruments) in veterans or active military. Our goals were to (1) describe health-related quality-of-life (HRQoL) and recovery across time in veterans, (2) examine the commonality between the quality of recovery (QoR-15) and short-form (SF) surveys (including the SF-8, 24-hour version), and (3) examine the responsiveness of these surveys. MATERIALS AND METHODS This study was approved by the Institutional Review Boards from the University of Pittsburgh, the VA Pittsburgh, and the Human Research Protection Office of the Department of Defense. Secondary analyses of data were executed based on a randomized trial dataset of knee/hip arthroplasty patients, the study having recruited 135 total veterans. QoR-15 and HRQoL SF surveys were completed and self-reported before surgery (pre-op), on postoperative day 2 (PO-D2), and 6 weeks postoperatively. Descriptive statistics were used to examine scores across time. Common content was examined using Pearson's r. Responsiveness was examined using distribution-based methods. RESULTS Average veteran age was 67 year, 89% were male, 88% white, and average body mass index was 33 kg∙m-2. QoR-15 scores declined from pre-op to PO-D2 but were higher than pre-op at 6 weeks. SF physical component summary (PCS) scores were low both pre-op and PO-D2, but were elevated over baseline at 6 weeks. SF mental component summary (MCS) scores declined from baseline to PO-D2 but were higher than pre-op at 6 weeks. Associations of the QoR-15 total score and PCS/MCS were medium/large and statistically significant at P ≤ .01. Both instruments were responsive to changes. CONCLUSION QoR-15 and SF-8 have high content commonality and performed similarly in veterans across time. SF-8 has added benefits of (1) brevity, (2) assessment of physical and mental health components, and (3) being normed to the general population. The SF-8, if used without the QoR-15 in tandem in future study of anesthesia-related outcomes, would need to be supplemented by separate questions addressing postoperative nausea/vomiting (a frequent outcome after anesthesia that is relevant to same-day and next-day mobilization after elective joint replacement surgery).
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Affiliation(s)
| | - Brian A Williams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Joseph M Mikolic
- StatCore, Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Monique Y Boudreaux-Kelly
- StatCore, Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Saurab Faruque
- School of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Sara R Piva
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - James W Ibinson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240, USA
| | - Galen E Switzer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Center for Research on Healthcare, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Piva SR, Switzer GE, Mikolic JM, Boudreaux-Kelly MY, Faruque S, Aloziem OU, Ibinson JW, Williams BA. Validity of the Modified Defense and Veterans Pain Rating Scale Supplemented With Items Germane to Total Joint Replacement: Secondary Analysis From a Randomized Trial. Mil Med 2023; 188:e3017-e3025. [PMID: 37208305 DOI: 10.1093/milmed/usad155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/18/2023] [Accepted: 04/26/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Valid measures of pain are helpful to adjust treatment plans in real time after total joint replacement (TJR). We enhanced the existing Defense and Veterans Pain Rating Scale (DVPRS) with items related to pain at rest and movement, in specific reference to operative and nonoperative joints, creating the TJR-DVPRS. This manuscript is presented to validate the modified survey instrument. The aims of this psychometric study were to evaluate (1) the latent structure of the TJR-DVPRS, (2) the relationships among the pain dimensions represented on the TJR-DVPRS and the reference-standard Short-Form McGill Pain Questionnaire (version 2, SF-MPQ-2), and (3) the responsiveness of these two measures before and after TJR. MATERIALS AND METHODS This report involves a secondary analysis of pain surveys from 135 veterans undergoing TJR at one center who participated in a randomized trial. The study was approved by the institutional review boards from participating institutions. The TJR-DVPRS and SF-MPQ-2 were completed preoperatively, during postoperative day 1, and 6 weeks post-surgery. Standard psychometric evaluations included correlations, principal component analysis, and internal consistency of survey items and subscales, using preoperative baseline data as a frame of reference. Responsiveness analysis included assessing both effect size and thresholds of clinically important change for survey subscales using data from all three time points. RESULTS Two reliable subscales were identified for the TJR-DVPRS, one including items about pain intensity and interference related to the operative joint (Cronbach's α = .809) and the other including two pain items on the nonoperative joint. Combining the subscales indicated a two-factor solution: The first valid factor entailed the four subscales of the SF-MPQ-2 and the TJR-DVPRS operative joint subscales, indicating that these subscales validly represent the same pain dimension. The second valid factor entailed the TJR-DVPRS subscale addressing the nonoperative joint. Responsiveness analysis following accepted psychometric methods demonstrated significant decreases in pain from the preoperative period to 6 weeks postoperatively for all subscales. The TJR-DVPRS and SF-MPQ-2 subscales were similarly responsive, except for the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales, which were minimally responsive during the preoperative to 6-week period. CONCLUSIONS The TJR-DVPRS is valid for use among veterans undergoing TJR and poses significantly less respondent burden than does the SF-MPQ-2. The brevity and ease of use of the TJR-DVPRS make it a practical tool for use during surgical recovery to monitor pain intensity at rest and with movement in the operative joint, and to assess pain interference with activity, sleep, and mood. The TJR-DVPRS is at least as responsive as the SF-MPQ-2, but the SF-MPQ-2 neuropathic and TJR-DVPRS nonoperative joint subscales were minimally responsive. Limitations of this study include the small sample size, under-representation of women (which would be expected in the veteran population), and using only veterans. Future validations studies should include civilians and active military TJR patients.
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Affiliation(s)
- Sara R Piva
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA 15219-3130, USA
| | - Galen E Switzer
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Joseph M Mikolic
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240-1001, USA
| | - Monique Y Boudreaux-Kelly
- Office of Research and Development, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA 15240-1001, USA
| | - Saurab Faruque
- University of Pittsburgh School of Medicine, Pittsburgh, PA 15216, USA
| | | | - James W Ibinson
- Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, Pittsburgh, PA 15240, USA
| | - Brian A Williams
- Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, University Drive Campus, Pittsburgh, PA 15240, USA
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA 12561, USA
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Ortiz-Gómez JR, Perepérez-Candel M, Martínez-García Ó, Fornet-Ruiz I, Ortiz-Domínguez A, Palacio-Abizanda FJ, Royuela A, Vázquez-Torres JM, Rodríguez-Del-Río JM. Buprenorphine versus dexamethasone as perineural adjuvants in femoral and adductor canal nerve blocks for total knee arthroplasty: a randomized, non-inferiority clinical trial. Minerva Anestesiol 2022; 88:544-553. [PMID: 35199973 DOI: 10.23736/s0375-9393.22.16229-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Optimal control of acute postoperative pain and prevention of chronic persistent pain in total knee arthroplasty (TKA) remain a challenge. METHODS A randomized, non-inferiority clinical trial (385 patients) evaluated every hour immediate postoperative pain during 24 h, using a verbal rating 11-point scale for patient self-reporting of pain (VRS11). All patients received subarachnoid anesthesia and were randomly allocated in 4 groups: single shots femoral (FNB) or adductor canal blocks (ACB), both with dexamethasone (dex) and buprenorphine (bup). Patients received intravenous analgesia (metamizole magnesium, dexketoprofen) and rescue analgesia when needed: intravenous (paracetamol and morphine) and/or regional (femoral and sciatic nerve blocks). Demographics and adverse effects were also recorded. RESULTS A 45.7% of patients had pain: bupACB 56.3%, bupFNB 50.0%, dexACB 40.6% and dexFNB 36.1% (p=0.022). Rescue analgesia was needed in 37.7% of patients (p=0.128). There were statistical differences in percentage of timepoints without pain (95.0±7.9%, p=0.014) and mean VRS11 (0.18±0.3, p=0.012) but no differences in distribution of intensity periods of pain. There were no significant differences in the need of rescue analgesia excepting the use of intravenous morphine (p=0.025). CONCLUSIONS buprenorphine is in the present trial inferior to dexamethasone by less than the established non-inferiority limit when used as perineural adjuvant in femoral nerve or adductor canal blocks in total knee arthroplasty analgesia. So, it could be considered an alternative in patients where dexamethasone is contraindicated, such as diabetics.
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Affiliation(s)
- José R Ortiz-Gómez
- Department of Anesthesiology. University Hospital of Navarre, Pamplona, Spain -
| | | | | | - Inocencia Fornet-Ruiz
- Department of Anesthesiology, University Hospital Puerta de Hierro Majadahonda, Madrid, Spain
| | | | | | - Ana Royuela
- Biostatistics Unit, Puerta de Hierro-Segovia de Arana Health Research Institute, CIBER Epidemiology and Public Health, Madrid, Spain
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Williams BA, Ibinson JW, Bonant SA, Gilbert KL, Piva SR. A Tale of Two Cohorts: The Trials and Tribulations of Ever-Changing Orthopedic / Acute Pain Medicine Hospital Practices During the Execution of Military-Funded Clinical-Translational Research (2013-2021). PAIN MEDICINE 2022; 23:1-3. [PMID: 34905055 DOI: 10.1093/pm/pnab267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Brian A Williams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - James W Ibinson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Samantha A Bonant
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | - Sara R Piva
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Williams BA, Ibinson JW, Mikolic JM, Boudreaux-Kelly MY, Paiste HJ, Gilbert KL, Bonant SA, Ritter ME, Ezaru CS, Muluk VS, Piva SR. Day-One Pain Reductions after Hip and Knee Replacement when Buprenorphine-Clonidine-Dexamethasone is added to Bupivacaine Nerve/Plexus Blocks: A Randomized Clinical Trial. PAIN MEDICINE 2021; 23:57-66. [PMID: 34730810 DOI: 10.1093/pm/pnab325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/13/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare pain outcome reports of patients undergoing hip or knee replacement who received single-injection nerve/plexus blocks with plain bupivacaine (BPV) to patients who received injections of buprenorphine-clonidine-dexamethasone (BCD) admixed with BPV. DESIGN Prospective, parallel arms, randomized, double-blind trial. SETTING A single Veterans hospital. SUBJECTS 98 Veterans, scheduled for total hip or knee replacement surgery, with spinal as the primary anesthetic. METHODS Participants were randomized to BPV-BCD or plain BPV groups. They underwent nerve/plexus blocks in the L2-L4 and L4-S3 distributions in advance of joint replacement surgery. The primary outcome was change in pain from baseline during the post-operative day assessed by the total pain score in the short-form McGill Pain Questionnaire-v2 (SF-MPQ-2). Secondary outcomes were pain during movement, pain interference, range of motion, mobility, and quality of recovery. RESULTS On post-operative day one, the SF-MPQ-2 total score for the BPV-BCD group demonstrated greater pain reduction compared to the plain BPV group (mean difference 1.8 points, 95% CI 0.6 to 3.0, P = 0.003). The BPV-BCD group also had larger reductions in pain during movement in the surgical joint and less pain interference, along with increased range of hip and knee flexion, compared to the plain BPV group. Outcomes of mobility and quality of recovery were not different between groups. CONCLUSIONS Preoperative BPV-BCD blocks in the L2-L4 and L4-S3 nerve distributions for hip and knee replacements led to less pain on post-operative day one and increased knee and hip range of motion, compared to plain BPV blocks.
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Affiliation(s)
- Brian A Williams
- Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and Surgical Service Line, Veterans Affairs Pittsburgh Healthcare System (VAPHS), Pittsburgh, PA, USA
| | - James W Ibinson
- Assistant Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Joseph M Mikolic
- Data Manager and Statistician, StatCore, VAPHS Research Office, Pittsburgh, PA, USA
| | | | - Henry J Paiste
- Medical Student, and Foundation for Anesthesia Education and Research (FAER) Medical Student Summer Research Fellow, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Karen L Gilbert
- Research Coordinator, Veterans Health Foundation, Pittsburgh, PA, USA
| | - Samantha A Bonant
- Clinical Trials Center Manager/Regulatory Coordinator, Veterans Health Foundation, Pittsburgh, PA, USA
| | - Marsha E Ritter
- Assistant Professor. Affiliation: Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Catalin S Ezaru
- Assistant Professor, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, and VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Visala S Muluk
- Associate Professor of Internal Medicine, University of Pittsburgh, IMPACT Clinic, VAPHS Surgical Service Line, Pittsburgh, PA, USA
| | - Sara R Piva
- Professor and Vice Chair for Research; Director of Physical Therapy - Clinical Translational Research Center Affiliation: Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
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Williams BA, Dalessandro JH. Letter to the Editor-Same-Day Pain and Rehabilitation Parameters After Knee Replacement with Multimodal, Mepivacaine-Based, Perineural Analgesia-A Case Report of Bilateral Procedures One Year Apart. PAIN MEDICINE 2021; 22:765-766. [PMID: 32869094 DOI: 10.1093/pm/pnaa257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Brian A Williams
- Anesthesiology and Perioperative Medicine, University of Pittsburgh and VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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