Efficacy and Safety of an Intra-operative Intra-articular Magnesium/Ropivacaine Injection for Pain Control following Total Knee Arthroplasty

Systemic and local antiinflammatory effect of magnesium chloride in experimental arthritis

OBJECTIVE

Despite some knowledge gaps in scientific evidence, MgCl2 is largely used for pain relief in musculoskeletal diseases. Mg salts were shown to provide analgesia postoperatively in orthopedic surgery and low Mg levels were linked to arthritis development and severity. We determined the anti-inflammatory activity of MgCl2 in an acute arthritis model.

METHODS

Mice received 0.1 mg/25µL Zymosan (Zy) or saline into the knees. Joint pain was evaluated using von Frey test; cell influx, and interleukin (IL)-1 level were assessed in joint lavage at 6 h. Synovia were excised for histopathology and analysis of immunoexpression of nuclear factor kappa B (NFκB) and tumor necrosis factor (TNF)-α. Groups (n = 6/group) received either 90 mg/kg MgCl2/100 µL or saline per os (systemic) or 500 µg/25 µL MgCl2 or saline intra-articularly (i.a.) 30 min prior to Zy.

RESULTS

MgCl2 given either systemically or locally significantly reduced cell influx (p = 0.0012 and p = 0.0269, respectively), pain (p = 0.0005 and p = 0.0038, respectively), and intra-articular IL-1 level (p = 0.0391), as compared to saline. Systemic MgCl2 significantly decreased NFκB (p < 0.05) immmunoexpression, as compared to saline.

CONCLUSION

MgCl2 given systemically or locally displayed anti-inflammatory activity in a severe acute arthritis model reducing cell influx, pain, and cytokine release. MgCl2 operates at least partially via inhibiting NFκB activation. This is the first in vivo demonstration that MgCl2 decreases cytokine release in arthritis, prompting reduction of inflammation and pain relief.

An Injectable Containing Morphine, Ropivacaine, Epinephrine, and Ketorolac Is Not Cytotoxic to Articular Cartilage Explants From Degenerative Knees

PURPOSE

The purpose of this study was to determine the effects of a multidrug injectate containing morphine, ropivacaine, epinephrine, and ketorolac, commonly referred to as the "Orthococktail," on cartilage tissue viability and metabolic responses using an established in vitro model.

METHODS

With institutional review board approval and informed patient consent, tissues normally discarded after total knee arthroplasty (TKA) were recovered. Full-thickness cartilage explants (n = 72, Outerbridge grade 1 to 3) were created and bisected. Paired explant halves were treated with either 1 mL Orthococktail or 1 mL of saline and cultured for 8 hours at 37°C, with 0.5 mL of the treatment being removed and replaced with tissue culture media every hour. Explants were cultured for 6 days, and media were changed and collected on days 3 and 6. After day 6, tissues were processed for cell viability, weighed, and processed for histologic grading. Outcome measures were compared for significant differences between treated and untreated samples.

RESULTS

There were no significant differences in cartilage viability between control and Orthococktail-treated samples across a spectrum of cartilage pathologies. Orthococktail treatment consistently resulted in a significant decrease in the release of PGE2, MCP-1, MMP-7, and MMP-8 on day 3 of culture and PGE2, MMP-3, MMP-7, and MMP-8 on day 6 of culture, compared with saline controls.

CONCLUSION

The results of the present study indicate that an Orthococktail injection composed of morphine, ropivacaine, epinephrine, and ketorolac is associated with a transient decrease in degradative and inflammatory mediators produced by more severely affected articular cartilage and may mitigate perioperative joint pain such that postoperative narcotic drug use could be reduced.

CLINICAL RELEVANCE

The Orthococktail solution used in this study may be a safe intraoperative, intra-articular injection option for patients undergoing joint arthroplasty and other joint preservation surgical procedures.

The Impact of Trace Elements on Osteoarthritis

Osteoarthritis (OA) is a progressive degenerative disease characterized by cartilage degradation, synovial inflammation, subchondral sclerosis and osteophyte formation. It has a multifactorial etiology with potential contributions from heredity, endocrine function, abnormal mechanical load and nutrition. Of particular considerations are trace element status. Several trace elements, such as boron and magnesium are essential for normal development of the bone and joint in human. While cadmium correlates with the severity of OA. The present review focuses on the roles of trace elements (boron, cadmium, copper, iron, magnesium, manganese, selenium, zinc) in OA and explores the mechanisms by which they act.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

Integrity of clinical research conduct, reporting, publishing, and post-publication promotion in rheumatology

The number of rheumatology journals, and papers related to this specialty, is expanding every day. Careful consideration for ethical aspects of such published work is mandatory for authors, readers, reviewers, editors, and all stakeholders. Recent instances of lack of appropriate research ethics committee overview, or participant consent for inclusion in the research study, or a case report, resulting in retractions, emphasize the need for greater awareness regarding these ethical aspects. Authors should strive to avoid redundancy, especially for review articles, both systematic and narrative. Clinical trial registration before commencing enrolment is mandatory as per contemporary norms. Transparent declaration of authorship contributions as well as appropriate attribution of authorship are recommended, since these may help avoid subsequent authorship conflicts. Authors, reviewers, and editors should disclose conflicts of interest, both financial and non-financial. Unbiased peer review is a critical part of editorial decision making; recent instances of peer review fraud have resulted in numerous retractions of scientific papers. Any reproduction of text, figures, or tables should be with due attribution to source, and after seeking permission of the copyright holder. Citations to published work should be relevant and diverse. Research assessment should rely on the assessment of quality of published work, rather than mere citation analyses. Authors should beware predatory, low-quality journals, and utilize social media channels to ethically promote their research with due consideration to privacy and copyright. Rheumatology societies should collaborate to develop guidelines for ethical research reporting, and educate young scientists regarding these principles.

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

BACKGROUND

Regional analgesia (RA) has been widely evaluated for pain relief after total knee arthroplasty (TKA). Its impact on functional recovery is less well known.

OBJECTIVES

To evaluate the functional benefits of RA after TKA.

DESIGN

Systematic review with a random-effects meta-analysis of randomised controlled trials comparing LRA with systemic analgesia on function in adults undergoing TKA for osteoarthritis.

DATABASE SOURCES

MEDLINE, EMBASE, LILAC, Cochrane, CTRD databases.

OUTCOMES

Length of stay (LOS) in hospital and early knee flexion range of motion (ROM), early and long-term knee function, serious adverse effects.

RESULTS

Twenty-three studies (1246 patients) were included. LOS was significantly shorter for RA than for systemic analgesia (0.90 days, 95% confidence interval 0.3 to 1.4). Subgroup analyses found that only infiltration analgesia decreased the LOS. ROM during the first week was significantly higher for all techniques of RA than for systemic analgesia (9.23°, 95% confidence interval 4.6 to 13.9). No impact of regional analgesia techniques on global function in the longer term was demonstrated. No difference in serious adverse effects was found between RA and systemic analgesia.

CONCLUSION

RA techniques compared with systemic analgesia have a beneficial impact on the LOS and the ROM achieved in the early postoperative period. Global function in the longer term after surgery seems unaffected by peri-operative RA.

TRIAL REGISTRATION

CRD42014013995.

Local anaesthetics or their combination with morphine and/or magnesium sulphate are toxic for equine chondrocytes and synoviocytes in vitro

Background

Chondrotoxic effects of local anaesthetics are well reported in humans and some animal species but knowledge on their toxic effects on synoviocytes or equine chondrocytes or the effects on cellular production of inflammatory cytokines is limited. The purpose of this study was to evaluate the in vitro effects of local anaesthetics, morphine, magnesium sulphate (MgSO₄) or their combinations on cell viability and pro-inflammatory cytokine gene expression of equine synoviocytes and chondrocytes.

Equine synoviocytes and cartilage explants harvested from normal joints in a co-culture system were exposed to mepivacaine (4.4 mg/ml), bupivacaine (2.2 mg/ml), morphine (2.85 mg/ml) and MgSO₄ (37 mg/ml) alone or each local anaesthetic plus morphine or MgSO₄ or both together. Chondrocyte and synoviocyte cell viability was assessed by CellTiter-Glo Luminescent Cell Viability Assay. Synoviocyte gene expression of IL-1β, IL-6 or TNF-α was measured and compared using the ∆∆CT method.

Results

Morphine alone, MgSO₄ alone or their combination did not alter cell viability or the expression of IL-1β, IL-6 or TNF-α. However, local anaesthetics alone or in combination with morphine and/or MgSO₄ reduced cell viability and increased the gene expression of IL-1β, IL-6 or TNF-α. Single short exposure to local anaesthetics is toxic to both chondrocytes and synoviocytes and their combination with morphine and/or MgSO₄ enhanced the cytotoxic effects.

Conclusions

This in vitro study gives further evidence of the absence of cytotoxic effects of morphine alone, MgSO₄ alone or their combination on normal articular tissues. However, local anaesthetics alone or in combination with morphine and/or MgSO₄ have cytotoxic effects on equine articular tissues.

Electronic supplementary material

The online version of this article (10.1186/s12917-017-1244-8) contains supplementary material, which is available to authorized users.

The effects of intra-articular levobupivacain versus levobupivacain plus magnesium sulfate on postoperative analgesia in patients undergoing arthroscopic meniscectomy: A prospective randomized controlled study

Objective

The aim of this study was to compared the effectiveness of intraarticular levobupivacain with levobupivacain and magnesium sulfate.

Methods

In this prospective randomized double blinded study, 96 patients (67 male, 29 female; age range: 18–65 years) with ASA (American Society of Anesthesiologist) score I and II, who had undergone arthroscopic meniscectomy operation, were divided to 3 groups that had postoperative analgesia with intra-articular saline injection (control group), levobupivacain injection (L group) or levobupivacain and magnesium sulfate injection (LM group). Patients were compared with postoperative VAS (Visual Analog Score) score during rest and activity, opioid analgesic need, non-opioid analgesic need and other medication needs.

Results

Postoperative VAS scores during rest and activation at early postoperative period were significantly lower at LM group when compared with L group and lower than control group at all time periods. Opioid analgesic need, non-opioid analgesic need and other medication needs for non-pain symptoms were lower at LM group when compared with L and control groups at all time periods.

Conclusion

Intraarticular magnesium sulfate plus Levobupivacain injection is a safe and effective method for post operative pain management after arthroscopic meniscectomy.

Keywords: Intra-articular injection, Magnesium sulfate, Levobupivacain, Postoperative analgesia, Chondrocyte apoptosis, Pain management, Arthroscopic menisectomy

Level of Evidence

Level I, Therapeutic study

Improving patients’ experience and outcome of total joint replacement: the RESTORE programme

Background

Total hip replacements (THRs) and total knee replacements (TKRs) are common elective procedures. In the REsearch STudies into the ORthopaedic Experience (RESTORE) programme, we explored the care and experiences of patients with osteoarthritis after being listed for THR and TKR up to the time when an optimal outcome should be expected.

Objective

To undertake a programme of research studies to work towards improving patient outcomes after THR and TKR.

Methods

We used methodologies appropriate to research questions: systematic reviews, qualitative studies, randomised controlled trials (RCTs), feasibility studies, cohort studies and a survey. Research was supported by patient and public involvement.

Results

Systematic review of longitudinal studies showed that moderate to severe long-term pain affects about 7–23% of patients after THR and 10–34% after TKR. In our cohort study, 10% of patients with hip replacement and 30% with knee replacement showed no clinically or statistically significant functional improvement. In our review of pain assessment few research studies used measures to capture the incidence, character and impact of long-term pain. Qualitative studies highlighted the importance of support by health and social professionals for patients at different stages of the joint replacement pathway. Our review of longitudinal studies suggested that patients with poorer psychological health, physical function or pain before surgery had poorer long-term outcomes and may benefit from pre-surgical interventions. However, uptake of a pre-operative pain management intervention was low. Although evidence relating to patient outcomes was limited, comorbidities are common and may lead to an increased risk of adverse events, suggesting the possible value of optimising pre-operative management. The evidence base on clinical effectiveness of pre-surgical interventions, occupational therapy and physiotherapy-based rehabilitation relied on small RCTs but suggested short-term benefit. Our feasibility studies showed that definitive trials of occupational therapy before surgery and post-discharge group-based physiotherapy exercise are feasible and acceptable to patients. Randomised trial results and systematic review suggest that patients with THR should receive local anaesthetic infiltration for the management of long-term pain, but in patients receiving TKR it may not provide additional benefit to femoral nerve block. From a NHS and Personal Social Services perspective, local anaesthetic infiltration was a cost-effective treatment in primary THR. In qualitative interviews, patients and health-care professionals recognised the importance of participating in the RCTs. To support future interventions and their evaluation, we conducted a study comparing outcome measures and analysed the RCTs as cohort studies. Analyses highlighted the importance of different methods in treating and assessing hip and knee osteoarthritis. There was an inverse association between radiographic severity of osteoarthritis and pain and function in patients waiting for TKR but no association in THR. Different pain characteristics predicted long-term pain in THR and TKR. Outcomes after joint replacement should be assessed with a patient-reported outcome and a functional test.

Conclusions

The RESTORE programme provides important information to guide the development of interventions to improve long-term outcomes for patients with osteoarthritis receiving THR and TKR. Issues relating to their evaluation and the assessment of patient outcomes are highlighted. Potential interventions at key times in the patient pathway were identified and deserve further study, ultimately in the context of a complex intervention.

Study registration

Current Controlled Trials ISRCTN52305381.

Funding

This project was funded by the NIHR Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 12. See the NIHR Journals Library website for further project information.

Magnesium sulfate improves postoperative analgesia in laparoscopic gynecologic surgeries: a double-blind randomized controlled trial

STUDY OBJECTIVE

The aim of this study is to compare the analgesic effect of intravenous infusion of magnesium sulfate to ketorolac during laparoscopic surgeries.

DESIGN

Double-blind randomized controlled trial.

SETTING

University-affiliated teaching hospital.

PATIENTS

Sixty women submitted to laparoscopic gynecologic oncology surgeries.

INTERVENTIONS

Intravenous ketorolac 30 mg in bolus followed by saline infusion (group K), intravenous magnesium sulfate 20 mg/kg in bolus followed by magnesium 2 mg kg(-1) h(-1) (group M) or intravenous saline solution 20 mL in bolus followed by saline infusion during the entire procedure (group S).

MEASUREMENTS

Postoperative pain, nausea, vomiting, sedation, opioid consumption, time to first dose of analgesic.

MAIN RESULTS

Magnesium sulfate reduced opioid consumption compared with placebo in the postoperative, but not in the intraoperative, period. Nausea, not vomiting, was reduced in ketorolac but not in the magnesium group. Pain intensity was higher in placebo than in the other 2 groups during all periods of observation. In the first 60 minutes, pain intensity was lower in the magnesium than in the ketorolac or the placebo group.

CONCLUSION

Intraoperative magnesium sulfate improves postoperative pain control, acting as an opioid-sparing adjuvant, and is similar to ketorolac 30 mg administered in the beginning of surgery.

Unraveling the role of Mg(++) in osteoarthritis

Mg(++) is widely involved in human physiological processes that may play key roles in the generation and progression of diseases. Osteoarthritis (OA) is a complex joint disorder characterized by articular cartilage degradation, abnormal mineralization and inflammation. Magnesium deficiency is considered to be a major risk factor for OA development and progression. Magnesium deficiency is active in several pathways that have been implicated in OA, including increased inflammatory mediators, cartilage damage, defective chondrocyte biosynthesis, aberrant calcification and a weakened effect of analgesics. Abundant in vitro and in vivo evidence in animal models now suggests that the nutritional supplementation or local infiltration of Mg(++) represent effective therapies for OA. The goal of this review is to summarize the current understanding of the role of Mg(++) in OA with particular emphasis on the related molecular mechanisms involved in OA progression.

Endogenous opiates and behavior: 2013

This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.

Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness

Background

Surgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound closure provides additional pain control.

Methods

We performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses.

Results

In 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) -0.61 (95% CI -1.05, -0.16; p = 0.008) and by SMD -0.43 (95% CI -0.78 -0.09; p = 0.014) at 48 hours during activity.

In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD -0.40 (95% CI -0.58, -0.22; p < 0.001) at 24 hours at rest and by SMD -0.27 (95% CI -0.50, -0.05; p = 0.018) at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block.

Patients receiving local anaesthetic infiltration spent on average an estimated 0.83 (95% CI 1.54, 0.12; p = 0.022) and 0.87 (95% CI 1.62, 0.11; p = 0.025) fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting.

Few studies reported long-term outcomes.

Conclusions

Local anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk.

Efficacy and safety of single-dose local infiltration of analgesia in total knee arthroplasty: a meta-analysis of randomized controlled trials

PURPOSE

To examine the efficacy and safety of single-dose local infiltration of analgesia (LIA) for post-operative pain relief in total knee arthroplasty (TKA) patients.

METHODS

A systematic electronic literature search (up to Aug 2013) was conducted to identify the RCTs that address the efficacy and safety of single-dose LIA in the pain management after TKA. Subgroup analysis was conducted to determine changes of visual analog score (VAS) values at six different postoperative time points. Weighted mean differences or relative risks with accompanying 95% confidence intervals were calculated and pooled using a random effect model.

RESULTS

Eighteen trials involving 1858 TKA patients met the inclusion criteria. The trials were liable to medium risk of bias. The VAS values at postoperative 2h, 4h, 6h, 12h, 24h, and 48h per patient were significantly lower in the LIA group than in the placebo group, and the former group also had less morphine consumption and better early functional recovery including range of motion, time to straight leg raise and 90° knee flexion than the latter group. No significant difference in length of hospital stay or side effects was detected between the two groups.

CONCLUSIONS

The current evidence shows that the use of single-dose LIA is effective for postoperative pain management in TKA patients, with satisfactory short-term safety. More high-quality RCTs with long-term follow-ups are required for examining the long-term safety of single-dose LIA.

LEVEL OF EVIDENCE

I, II.