Analgesic techniques in hip and knee arthroplasty: from the daily practice to evidence-based medicine

Review on Nerve Blocks Utilized for Perioperative Total Knee Arthroplasty Analgesia

Total Knee Arthroplasty (TKA) is an increasingly common procedure performed for advanced osteoarthritis. Optimal perioperative pain management strategies are critical for early mobilization and shorter hospital stays in TKA. Peripheral nerve blocks commonly used in TKA perioperative analgesia including individual and combined femoral, obturator, sciatic, lumbar plexus, and adductor canal nerve blocks. Overall, the safety profile varies depending on which block is utilized, but the current evidence suggests when optimally chosen and delivered, peripheral nerve blocks may provide a safe, effective option for perioperative analgesia. Determining optimal analgesic regimens for total knee arthroplasty is critical to improve postoperative pain, patient satisfaction, decreasing opioid usage, recovery times and functional outcomes, and as such, peripheral nerve blocks may represent a viable option to supplement analgesic requirements in the perioperative period.

The relative analgesic value of a femoral nerve block versus adductor canal block following total knee arthroplasty: a randomized, controlled, double-blinded study

Background

Multiple comparative studies report that adductor canal blocks provide similar pain relief to femoral nerve blocks following total knee arthroplasty. However, adductor canal blockade fails to anesthetize several important femoral nerve branches that contribute to knee innervation. We sought to clarify this anatomic discrepancy by performing both blocks in sequence, using patients as their own controls. We hypothesized that patients would experience additional pain relief following a superimposed femoral nerve block, demonstrating that these techniques are not equivalent.

Methods

Sixteen patients received continuous adductor canal block before undergoing knee arthroplasty under general anesthesia. In the recovery room, patients reported their pain score on a numeric scale of 0–10. Once a patient reached a score of five or greater, he/she was randomized to receive an additional femoral nerve block using 2% chloroprocaine or saline sham, and pain scores recorded every 5 min for 30 min. Patients received opioid rescue as needed. Anesthesiologists performing and assessing block efficacy were blinded to group allocation.

Results

Patients randomized to chloroprocaine versus saline reported significantly improved median pain scores 30 min after the femoral block (2.0 vs. 5.5, P < 0.001). Patients receiving chloroprocaine also required significantly fewer morphine equivalents during the 30 min post-femoral block (1.0 vs. 4.5 mg, P = 0.032).

Conclusions

Adductor canal block is a useful technique for postoperative pain following total knee arthroplasty, but it does not provide equivalent analgesic efficacy to femoral nerve block. Future studies comparing efficacy between various block sites along the thigh are warranted.

Continuous Femoral Catheter for Postoperative Analgesia After Total Knee Arthroplasty

Introduction:

Postoperative pain management in the total knee replacement (TKR) represent a fundamental step for a positive outcome, allowing rapid mobilization, already on the first day. Further, continuous peripheral nerve block techniques have been reported to allow effective and safe control of acute postoperative pain, ensuring the implementation and completion of an accurate and intensive joint rehabilitation program.

Aim:

The aim of this study was to assess early mobility and compliance of patients that underwent TKR surgery using the femoral block.

Methods:

For the study, all patients that underwent TKR from 2015 to 2018 with ASA score between II-III was evaluated. Patients underwent vital parameters monitoring and were treated initially with midazolam (0.05mg / kg) e.v. combined sciatic block + femoral perineural catheter positioning using a peripheral nerve stimulation-assisted technique.

Results:

Intraoperatively, satisfactory analgesia was guaranteed in all patients, associated with a complete muscle relaxation of the affected limb. High patient compliance, associated with good control of acute postoperative pain was obtained in the first 24 hours after surgery (VAS 0- 1). The ROM outcomes were good in all rehabilitation stages, managing to reach 90 degrees bending on the seventh day with an average KSS score of 88-90. Patient satisfaction and impact on quality of life were assessed with the SF-36 showing average scores of 78.

Conclusion:

Continuous femoral nerve blocking ensures good postoperative analgesia in TKR allowing an early joint mobilization, a rapid functional recovery of the knee and increasing patient compliance during the post-operative rehabilitation program.

Post-operative analgesia techniques after total knee arthroplasty: A narrative review

Post-operative knee pain management has become a challenge to provide early relief and pain-free postoperative care to the patient. The major objectives of post-operative analgesic treatment are to reduce opioid requirements, post-operative pain, and adverse events related to opioid intake. This narrative review aimed to document post-operative analgesia techniques after total knee arthroplasty (TKA). The traditional approach involved high-dose opioid-based regimen, though opioid is considered strong analgesic, but are associated with a number of unwanted side effects to seek for alternative techniques. The role of sciatic nerve block in TKA pain is doubtful. Femoral Nerve Block (FNB) is still considered as the gold standard; however, FNB is associated with quadriceps weakness and risk of fall and sciatic block with foot drop. To overcome these drawback more distal nerve block techniques has evolved, namely saphenous nerve block in adductor canal, selective tibial which are claimed to provide comparable analgesia to that of femoral and sciatic nerve block. The combination of pre-emptive and multi-modal analgesia and technically well-delivered regional nerve blocks and postoperative physical therapy are an essential component which not only minimize the side effects of traditional opioid-based analgesia but also speed up functional recovery, increases patient satisfaction, and reduces the overall length of hospitalization and cost.

Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies

OBJECTIVE

To examine the analgesic efficacy and safety of ketamine after total knee or hip arthroplasty.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, EMBASE and Cochrane Library from inception to 22 May 2019.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials comparing the efficacy and safety of ketamine with placebo for postoperative pain relief in patients undergoing total knee or hip arthroplasty.

DATA EXTRACTION AND SYNTHESIS

Data (ie, pain intensity, morphine consumption, gastrointestinal and psychotic adverse effects) were extracted by two reviewers independently. The Cochrane Collaboration's recommended tool was used to determine the methodological quality of included studies.

RESULTS

A total of 10 studies were included. One of them was rated as low quality. Compared with placebo, intravenous ketamine was effective for pain relief during 0-8-hour (weighted mean difference (WMD) -1.21, 95% CI -1.45 to -0.98, p<0.001; three studies, 149 participants) but not during 8-24-hour postoperative periods, and effective for reduction of cumulative morphine consumption during both 0-24-hour (WMD -17.76, 95% CI -31.25 to -4.27, p=0.01; five studies, 366 participants) and 0-48-hour (WMD -21.79, 95% CI -25.46 to -18.11, p<0.001; four studies, 252 participants) postoperative periods, without increasing risks of gastrointestinal or psychotic adverse effects. The limited data available for intra-articular (WMD -0.49, 95% CI -0.70 to -0.29, p<0.001; two studies, 83 participants) and epidural (WMD -2.10, 95% CI -3.30 to -0.90, p<0.001; one study, 20 participants) ketamine pointed to a significant reduction in pain intensity during 8-24-hour postoperative period.

CONCLUSIONS

Intravenous administration of ketamine is effective and safe for postoperative pain relief in patients undergoing total knee or hip arthroplasty. Nevertheless, the analgesic efficacy and safety of ketamine in such patients seem to vary by different administration routes and still warrant further studies to explore.

Evaluation of Intravenous Parecoxib Infusion Pump of Patient-Controlled Analgesia Compared to Fentanyl for Postoperative Pain Management in Laparoscopic Liver Resection

Background

As laparoscopic liver resection is becoming a commonly used method for hepatic surgery, postoperative pain management is emerging as one of the trickiest problems after surgery. The ideal method of pain management is controversial and the optimal strategy for postoperative pain management after surgery remains unclear. The present study evaluated the postoperative analgesic efficacy of parecoxib and fentanyl, and the benefit of a new intravenous parecoxib infusion pump with patient-controlled analgesia after laparoscopic liver resection.

Material/Methods

This controlled, prospective, randomized, double-blind trial compared VAS scores among 3 groups of patients: a fentanyl group (FEN group) using a fentanyl citrate pump, an intravenous parecoxib group (IVPA group) receiving intravenous parecoxib, and a parecoxib pump group (PUPA group) receiving parecoxib sodium by analgesia pump. We enrolled 124 patients planned for laparoscopic liver resection. The primary outcome was VAS score at rest and with movement. Secondary outcomes were adverse effects (including nausea), sedation, pruritus, and quality of life.

Result

For all time intervals, the VAS scores were significantly lower in the PUPA group. VAS scores at rest and with movement in the PUPA group were the lowest among the 3 groups, while the scores in the FEN group were the highest. More adverse effects were detected in the FEN group, and no significant differences in adverse effects were found between the intravenous group and the parecoxib pump group.

Conclusions

Use of the intravenous infusion parecoxib pump for patient-controlled analgesia provides superior analgesic efficacy and fewer adverse effects for patients after laparoscopic liver resection.

Preemptive Analgesia in Total Knee Arthroplasty: Comparing the Effects of Single Dose Combining Celecoxib with Pregabalin and Repetition Dose Combining Celecoxib with Pregabalin: Double-Blind Controlled Clinical Trial

Acute pain is the most common early complication after total knee arthroplasty causing delayed mobilization and increased demands of morphine, leading to higher operative cost. Several studies have assessed the effectiveness, side-effects, and ease of use of various analgesics. Preemptive analgesia with combined celecoxib and pregabalin has been reported to yield positive outcomes. In this randomized, double-blind controlled clinical trial, 30 subjects underwent surgery for total knee arthroplasty using 15-20mg bupivacaine 5% epidural anesthesia. All subjects were divided into three groups. Group 1 was given celecoxib 400mg and pregabalin 150mg 1 hour before the operation, Group 2 was given celecoxib 200mg and pregabalin 75mg twice daily starting from 3 days before the operation, and Group 3 was given a placebo. The outcome was measured with Visual Analog Scale, knee range of motion, and postoperative mobilization. There was a significant difference in postoperative morphine usage between the groups that were administered with preemptive analgesia and the placebo group, but no significant difference was found between Group 1 and Group 2 that were given preemptive analgesia at different doses. ROM and postoperative mobilization were not significantly different among the three groups. Two patients in the first group, one patient in the second group, and one patient in the third group developed nausea. Preemptive analgesia is proven to reduce postoperative usage of morphine independent of the dosage. We recommend the use of combined celecoxib and pregabalin as preemptive analgesia after the total knee arthroplasty procedure. This trial is registered with NCT03523832 (ClinicalTrials.gov).

Clinical effects of single femoral nerve block in combination with general anesthesia on geriatric patients receiving total knee arthroplasty

Objective:

To evaluate the clinical effects of single femoral nerve block (sFNB) combined with general anesthesia on geriatric patients receiving unilateral total knee arthroplasty (UTKA).

Methods:

Sixty geriatric UTKA patients who were treated in The First People's Hospital of Changzhou from January 2015 to August 2015 were randomly divided into an sFNB + laryngeal mask airway (FLA) group, an sFNB + tracheal intubation (FGA) group and a tracheal intubation (GA) group. Their clinical parameters and indices were recorded. They were scored by the Visual Analogue Scale (VAS).

Results:

All patients completed this study. FLA and FGA groups used less propofol, remifentanil and fentanyl than GA group (P<0.01), with shorter recovery time and extubation time (P<0.05). Compared to GA group, FLA and FGA groups had lower systolic blood pressures at T3, T4 and T5 (P<0.05), and lower heart rates at T5 (P<0.05). FLA and FGA groups had fewer cases of adverse reactions after extubation (P<0.01). FLA group was less prone to irritating cough after extubation and pharyngeal pain than FGA and GA groups (P<0.01). The postoperative six hour and 24 hour VAS scores in resting state as well as the postoperative 24 hour and 48 hour scores in training state of FLA and FGA groups were lower than those of GA group (P<0.05). FLA and FGA groups used significantly lower times and total doses of patient-controlled intravenous analgesia pump.

Conclusion:

sFNB combined with general anesthesia, especially that using laryngeal mask, were superior to general anesthesia alone, which reduced recovery and extubation times, and decreased intraoperative and postoperative drug uses, postoperative early VAS score and adverse reactions.

Continuous femoral nerve blockade and single-shot sciatic nerve block promotes better analgesia and lower bleeding for total knee arthroplasty compared to intrathecal morphine: a randomized trial

Background

Knee arthroplasty leads to postoperative pain. This study compares analgesia and postoperative bleeding achieved by intrathecal morphine with a continuous femoral plus single-shot sciatic nerve block.

Methods

A randomized non-blinded clinical trial enrolled patients aged over 18 years old, ASA I to III who underwent total knee arthroplasty. All patients underwent spinal anesthesia with isobaric bupivacaine, 20 mg. One group received 100 mcg of intrathecal morphine (M group), and the other received a femoral nerve block by continuous infusion plus a "single shot" block of the sciatic nerve at the end of the surgery (FI group). Pain score from verbal numeric rating scale (VNRS) and morphine consumption during the first 72 h, as well as motor blockade, adverse effects, and postoperative bleeding were recorded. Analysis of variance of repeated measures with Bonferroni post-test, t-test and Fisher exact test were used for statistical analysis.

Results

Thirty nine patients completed the study (M = 20; FI = 19 patients) and were similar except for higher age in the FI group. Motor blockade as well as movement pain during postanesthesia care unit (PACU) staying were not different between the groups, but movement pain was significantly lower in FI group after 24 h. Postoperative bleeding (ml) was lower in FI group.

Conclusions

Continuous femoral nerve block combined with sciatic nerve block provides effective for postoperative analgesia in patients undergoing total knee arthroplasty, with lower pain scores after 24 h and a lower incidence of adverse effects and bleeding compared to intrathecal morphine.

Trial registration

Retrospectively registered on https://clinicaltrials.gov/ under identifier NCT02882152, 23^rd December, 2016.

Diclofenac Suppository vs. IV Acetaminophen Combined With IV PCA for Postoperative Pain Management in Patients Undergoing Laminectomy: A Randomized, Double-Blinded Clinical Trial

Background

Tissue damage caused by surgical procedures nearly always results in pain. The effective management of postoperative pain remains a challenge because of its influence on the surgical outcome and its critical role in early mobilization and functionality. Recent research on postoperative pain management supports a treatment approach known as “multimodal analgesia,” which comprises the use of more than one method or modality of pain control and management.

Objectives

In the present study, we compared the effects of diclofenac suppository and intravenous (IV) acetaminophen combined with IV patient-controlled analgesia (PCA) for pain management after laminectomy surgery.

Patients and Methods

Our randomized, double-blinded controlled trial during 2013 at Besat hospital in Hamadan, Iran, included 102 ASA I-II patients aged 18 to 65 years who were candidates for laminectomy surgery. The patients were randomly assigned to receive the diclofenac suppository (100 mg) (n = 51) or IV acetaminophen (1 g in 100 mL normal saline) (n = 51) 10 minutes before completing surgery and 12 hours after the operation.

Results

The patients’ characteristics were the same in both study groups. The patients’ satisfaction levels were higher among those who received diclofenac when compared with the acetaminophen group, especially at the time points of 6 and 12 h after surgery. The consumed narcotic using the PCA pump within 24 h of surgery in the diclofenac group was significantly lower than that of the acetaminophen group (735.70 ± 59.61 µg vs. 819.70 ± 80.02 µg; P < 0.001).

Conclusions

The use of diclofenac suppository combined with IV PCA results in reduced narcotic usage and a higher level of patient satisfaction compared to the use of IV acetaminophen combined with IV PCA.

Spouse-related factors associated with quality of recovery of patients after hip or knee replacement - a Nordic perspective

BACKGROUND

Today's shorter hospital stays mean that patients may need support from informal caregivers during their recovery period. The responsibility for providing this support shifts from the healthcare staff to their family members fairly early in the recovery process. Spousal caregivers are considered to be the primary caregivers as their relationship with the patient is more interdependent than that of other family members or caregivers.

OBJECTIVES

The aim was to describe spouse-related factors that were associated with patients' quality of recovery on discharge from hospital after elective hip or knee replacement.

DESIGN

The design was prospective, descriptive and comparative, with two measurements, before arthroplasty and on discharge.

SETTINGS

Two Finnish, three Icelandic and two Swedish university or community hospitals.

PARTICIPANTS

The sample consisted of spouses and patients. The inclusion criteria were as follows: age ≥18 years, ability to complete the questionnaires, and ability to understand Finnish/Icelandic/Swedish. The patients were asked to identify one family member. Spouses were those defining themselves as a wife, husband or cohabiting partner. Out of 463 spouses, 306 (66%) were included. The mean age of the included spouses was 64 years and 54% of them were females.

METHODS

Self-reported instruments were used on expected and received knowledge, access to knowledge, emotional state and quality of recovery.

RESULTS

If the spouses were or had been employed in healthcare or the social services, their partner had greater quality of recovery (p = 0.006). Spouses experiencing negative emotions had partners who experienced lower quality of recovery (p <0.001). Spouses who felt that nurses had enough time for them (p = 0.044) and explained matters concerning their family members' care and treatment (p = 0.011) had partners who experienced greater quality of recovery.

CONCLUSIONS

Spouses' emotional state played an important role in the patients' quality of recovery (QoR), with uncertainty and depressive state as the main predictors. The importance of nurses explaining matters sufficiently to spouses was emphasized, while spouses' fulfilment of knowledge expectations was not associated with patients' recovery.