Functional recovery after knee arthroplasty with regional analgesia: A systematic review and meta-analysis of randomised controlled trials

[Fast-Track-Arthroplasty]

INTRODUCTION

Essential components of fast-track or enhanced recovery programs in arthroplasty are the optimization of interdisciplinary organizational processes, as well as pre-, intra- and postoperative procedures in everyday clinical practice. The early postoperative mobilization of patients after joint replacement surgery is of central importance, with the aim of avoiding pain and complications. This article provides a detailed overview of fast-track procedures that have already been established in many units. Furthermore, it demonstrates the clinical advantages of FastTrack for total hip arthroplasty (THA) in an evidence-based manner within the framework of a randomized study design.

MATERIAL AND METHODS

194 primary THA patients were examined after randomization into two single-blinded groups; Fast-Track (n = 98) or conventional treatment path (n = 96). Mobilization was defined as the primary outcome parameter, measured in seconds using the Timed Up and Go Test (TUG). Secondary parameters were the achievable walking distance in meters and pain using the numerical rating scale (NRS). All parameters were recorded preoperatively and daily until the sixth postoperative day.

RESULTS

No complications or revisions were recorded within the first postoperative week. The fast-track group showed significantly better TUG values and walking distance results compared to the conventional group until the sixth postoperative day (p < 0.05, respectively). There was no significant difference regarding the pain assessment (NRS) (p > 0.05).

CONCLUSION

The use of Fast-Track in hip arthroplasty can evidently improve short-term postoperative clinical outcomes. This first prospective, single-blinded, randomized controlled study showed very good clinical results with comparable pain after FastTrack THA compared to a conventional treatment path. Fast-Track concepts are highly effective in terms of early mobilization and clinical outcome-without incurring a higher risk of complications in the short term.

[Perioperative management in fast-track arthroplasty]

The optimization of organizational processes, as well as surgical procedures intra- and perioperatively, are essential components with respect to fast-track programs in clinical routine. Treatment concepts focus on early postoperative mobilization of patients after joint replacement surgery in an interdisciplinary setting to avoid pain and complications on a scientific basis. This article gives a comprehensive and detailed overview regarding evidence-based peri- and intraoperative fast-track treatment methods: from pain treatment with intraoperative local infiltration analgesia and tranexamic acid application under minimally invasive surgical approach in short-lasting spinal anesthesia to renunciation of drains, regional pain- and urinary catheters, tourniquets, and restrictions.

Pre-emptive analgesia with methylprednisolone and gabapentin in total knee arthroplasty in the elderly

The aim of this study is to assess whether administration of gabapentin and methylprednisolone as “pre-emptive analgesia” in a group of patients above 65 years of age would be effective in complex pain management therapy following total knee arthroplasty (TKA). One hundred seventy patients above 65 years were qualified for the study, with exclusion of 10 patients due to clinical circumstances. One hundred sixty patients were randomly double-blinded into two groups: the study group (80 patients) and the control group (80 patients). The study group received as “pre-emptive” analgesia a single dose of 300 mg oral (PO) gabapentin and 125 mg intravenous (IV) methylprednisolone, while the control received a placebo. All patients received opioid and non-opioid analgesic agents perioperatively calculated for 1 kg of total body weight. We measured (1) pain intensity level at rest (numerical rating scale, NRS), (2) life parameters, (3) levels of inflammatory markers (leukocytosis, C reactive protein CRP), and (4) all complications. Following administration of gabapentin and methylprednisolone as “pre-emptive” analgesia, the NRS score at rest was calculated at 6, 12 (p < 0.000001), 18 (p < 0.00004) and 24 (p = 0.005569) h postoperatively. Methylprednisolone with gabapentin significantly decreased the dose of parenteral opioid preparations (p = 0.000006). The duration time of analgesia was significantly longer in study group (p < 0.000001), with CRP values lower on all postoperative days (1, 2 days—p < 0.00001, 3 days—p = 0.00538), and leukocytosis on day 2 (p < 0.0086) and 3 (p < 0.00042). No infectious complications were observed in the first postoperative days; in the control group, one patient manifested transient ischemic attack (TIA). The use of gabapentin and methylprednisolone as a single dose decreased the level of postoperative pain on the day of surgery, the dose of opioid analgesic preparations, and the level of inflammatory parameters without infectious processes.

Postoperative Pain Mediates the Association Between Peripheral Nerve Blocks and Postoperative Sleep Following Lower Extremity Arthroplasty

OBJECTIVES

Despite substantial research showing the bidrectional relationship between sleep and pain, there remains a dearth of research examining the role of perioperative pain management interventions in mitigating postoperative sleep disturbances. This secondary analysis of a prospective observational multisite study examined the association between peripheral nerve block (PNB) use during total knee or total hip arthroplasty (TKA/THA) procedures and postoperative pain and sleep outcomes.

MATERIALS AND METHODS

Adult patients undergoing TKA or THA procedures were recruited from 2 tertiary care facilities. Average pain and sleep disturbance scores were collected preoperatively and at 1- and 2-week postoperatively. Participants were not randomized to receive PNB. Postoperative outcomes were compared based on receipt of PNB during surgery. Structural equation modeling path analysis was utilized to model multiple co-occurring relationships, including mediation pathways between perioperative pain management approaches, pain, and postoperative sleep outcomes.

RESULTS

Of the 197 participants, 53% received PNB. Mediation analyses indicated that PNB was indirectly associated with 1-week sleep disturbance via its effects on 1-week pain intensity (β=-0.02, 95% confidence interval [CI] -0.04, -0.001, P=0.04). In addition, PNB was indirectly associated with 2-week sleep disturbance, via its effects on 1-week pain intensity and 1-week sleep disturbance (β=-0.04, 95% CI -0.07, -0.02, P=0.04). Lastly, PNB was indirectly associated with 2-week pain intensity via its effects on 1-week pain intensity (β=-0.10, 95% CI -0.19, -0.02, P=0.02).

CONCLUSIONS

Receipt of PNB during TKA or THA was found to be associated with improved 1-week postoperative pain intensity, which in turn was found to be associated with lower sleep disturbances at both 1- and 2-week postoperative time points. Multimodal opioid sparing pain management interventions, capable of improving postoperative sleep, are vital to improving recovery and rehabilitation following arthroplasty.

[Fast track in hip and knee arthroplasty]

Fast-track treatment concepts were developed decades ago in general and abdominal surgery and have been adapted in recent years for the special requirements of hip and knee arthroplasty. In this field, Hendrik Husted in particular was able to demonstrate scientific evidence for the components of fast-track concepts. The primary aim is not so much to shorten the patient's hospital length of stay (LOS) but rather to effectively increase the quality of medical treatment for the patient and to reduce complications. The optimization of organizational processes as well as intraoperative and perioperative surgical approaches are essential components regarding the introduction of fast track into the clinical routine. This article gives a comprehensive overview of fast-track treatment concepts and explains the scientific principles for the approach.

[Postoperative pain therapy after total knee arthroplasty : Is the local infiltration anesthesia the best therapy?]

BACKGROUND

Optimal perioperative pain management after total knee arthroplasty is necessary to promote mobilization and achieve early rehabilitation. The aim of this study was to determine whether local infiltration anesthesia (LIA) is the better postoperative pain therapy compared to a femoral nerve block (FNB) or a sciatic nerve block (SNB) using routine data.

METHODS

Data from the acute pain registry "Qualitätsverbesserung in der postoperativen Schmerztherapie" (QUIPS) were analyzed. The endpoints included postoperative maximal pain, frequency of pain-related movement impairment, nausea, and number of patients requesting opioids postoperatively. The influence of regional anesthesia in addition to general anesthesia was analyzed in 5 groups.

RESULTS

In total, the data of 8754 patients could be examined. It was found that the addition of LIA (β = -0.087 p = 0.000) or FNB (β = -0.137 p = 0.000) to general anesthesia is associated with a small but significant reduction of postoperative maximum pain. Between LIA, FNB, and SNB no relevant differences could be detected.

DISCUSSION

The pain reduction achieved by adding LIA or FNB in patients after total knee arthroplasty is relatively small. Comparison of techniques is hindered as there exists no widely accepted standard for performing LIAs yet.