Optimal Multimodal Analgesia Treatment Recommendations for Total Joint Arthroplasty

Outpatient Total Knee Arthroplasty Shows Decreasing Complication Burden From 2010 to 2020

BACKGROUND

The number of total knee arthroplasties (TKAs) performed on an outpatient basis continues to increase. The purpose of this study was to compare complication rates over the last decade to evaluate trends in the safety of outpatient TKA.

METHODS

Patients who underwent TKA from 2010 to 2020 from a large administrative claims database were retrospectively identified and stratified based on the year of surgery. Propensity-score matching was performed to match patients who were discharged within 24 hours of surgery to inpatients based on age, sex, comorbidity index, and year of surgery. Linear regression analyses were used to compare trends from 2010 to 2020. The 90-day adverse events in the early cohort (2010-2012) were compared to those in the late cohort (2018-2020) using multivariable regression analyses. Of the 547,137 patients in the sample, 28,951 outpatients (5.3%) were propensity matched to inpatients.

RESULTS

The incidence of outpatient TKA increased from 2010 to 2018 (1.9 versus 13.8%, P < .001). Despite a similar complication rate early (24.1 versus 22.6%, P = .164), outpatient TKA had fewer complications at the end of the study period (13.7 versus 16.7%, P < .001). Multivariate analyses demonstrated that the risk of any complication after outpatient TKA was lower than inpatient from 2018 to 2020 (odds ratio, 0.78; 95% confidence interval, 0.71-0.84).

CONCLUSIONS

Complications in both cohorts declined dramatically suggesting improvements in quality of care over time, with the greatest decline in patients undergoing outpatient surgery. These results suggest that outpatient TKA today is not higher risk for the patient than inpatient TKA.

LEVEL OF EVIDENCE

Level III.

Does the Addition of iPACK Block to Adductor Canal Block Provide Improved Analgesic Effect in Total Knee Arthroplasty? A Systematic Review and Meta-Analysis

The interspace between popliteal artery and the capsule of posterior knee (iPACK) block was proposed in recent years to relieve posterior knee pain. Since adductor canal block (ACB) and iPACK involve different branches of the sensory nerves, it is theoretically feasible to combine iPACK block and ACB to relief pain after total knee arthroplasty (TKA). We aim to validate the efficacy of adding iPACK block to ACB in the setting of a multimodal pain management protocol following TKA. A comprehensive literature review on Web of Science, Embase, the Cochrane Library, and PubMed was performed. Eight studies (N = 1,056) that compared the efficacy of iPACK block + ACB with ACB alone were included. Primary outcomes consisted of Visual Analogue Scale (VAS) score at rest or during activity at various time points. Secondary outcomes include opioids consumption, walking distance, and length of hospital stay (LOS). Compared to ACB alone, VAS scores at rest (standardized mean difference [SMD]: -1.18; 95% confidence interval [CI]: -2.05 to -0.30) and during activity (SMD: -0.26; 95% CI: -0.49 to -0.03) on the day of surgery were lower in the iPACK block + ACB group. However, the difference did not reach the minimal clinically important difference. Opioids consumption at postoperative 24 hours was lower in the iPACK + ACB group (SMD: -0.295; 95% CI: -0.543 to -0.048). VAS score on postoperative day (POD) 1 and POD2, opioids consumption from 24 to 48 hours, walking distance, and LOS were not different. In conclusion, the addition of iPACK block to ACB in a multimodal pain management protocol can effectively reduce opioids consumption in the early postoperative period. This is a level III, meta-analysis study.

Efficacy of Adductor Canal Blocks in Total Knee Arthroplasty

Total knee arthroplasty (TKA) is associated with significant postoperative pain. The population receiving TKA is generally elderly and often have multiple comorbidities that can present a challenge to postoperative management. Safe and effective multimodal pain management has led to improved outcomes while minimizing complications and side effects. The objective of this study was to investigate the efficacy of adductor canal blocks (ACB) in patients receiving TKA within a regional Queensland population. We performed a retrospective comparative cohort analysis of 458 patients who received TKA at a regional private hospital between January 2016 and December 2018. Inclusion criteria included body mass index (BMI) <50 kg/m² and unilateral TKA. Using the patients' hospital records, age, gender, American Society of Anesthesiologists' score (ASA), BMI, diabetic status, length of stay (LOS), opioid requirement on discharge, range of motion (ROM) on discharge, return to theater, and readmission within 12 months were recorded. One hundred and thirty-eight patients received ACB and 263 did not. The two groups were comparable for age, gender, diabetic status, and ASA. Patients who received an ACB had an 18-hour longer LOS (p < 0.0001), but were discharged on lower dosages of opioids equivalent to 7.9 oral morphine milligram equivalent (MME; p < 0.0001). Patients who had an ACB had a similar ROM on discharge and did not have an increased rate of readmission or return to theater. This study demonstrates that ACB are efficacious when used as part of a multimodal analgesia regime for TKA.

Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations

BACKGROUND

The PROSPECT (PROcedure SPEcific Postoperative Pain ManagemenT) Working Group is a global collaboration of surgeons and anaesthesiologists formulating procedure-specific recommendations for pain management after common operations. Total knee arthroplasty (TKA) is associated with significant postoperative pain that is difficult to treat. Nevertheless, pain control is essential for rehabilitation and to enhance recovery.

OBJECTIVE

To evaluate the available literature and develop recommendations for optimal pain management after unilateral primary TKA.

DESIGN

A narrative review based on published systematic reviews, using modified PROSPECT methodology.

DATA SOURCES

A literature search was performed in EMBASE, MEDLINE, PubMed and Cochrane Databases, between January 2014 and December 2020, for systematic reviews and meta-analyses evaluating analgesic interventions for pain management in patients undergoing TKA.

ELIGIBILITY CRITERIA

Each randomised controlled trial (RCT) included in the selected systematic reviews was critically evaluated and included only if met the PROSPECT requirements. Included studies were evaluated for clinically relevant differences in pain scores, use of nonopioid analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs and current clinical relevance.

RESULTS

A total of 151 systematic reviews were analysed, 106 RCTs met PROSPECT criteria. Paracetamol and nonsteroidal anti-inflammatory or cyclo-oxygenase-2-specific inhibitors are recommended. This should be combined with a single shot adductor canal block and peri-articular local infiltration analgesia together with a single intra-operative dose of intravenous dexamethasone. Intrathecal morphine (100 μg) may be considered in hospitalised patients only in rare situations when both adductor canal block and local infiltration analgesia are not possible. Opioids should be reserved as rescue analgesics in the postoperative period. Analgesic interventions that could not be recommended were also identified.

CONCLUSION

The present review identified an optimal analgesic regimen for unilateral primary TKA. Future studies to evaluate enhanced recovery programs and specific challenging patient groups are needed.

A new cocktail formula with diprospan of local infiltration analgesia in primary total hip arthroplasty: A prospective, randomized, controlled, observer-blinded study

OBJECTIVE

This study aimed to observe the analgesic effect of the cocktail formulation with diprospan during total hip arthroplasty (THA).

METHODS

From September 2018 to April 2019, 120 patients undergoing primary unilateral THA were included in this prospective, randomized, observer-blinded study. Patients were randomized into three groups, according to the different local infiltration analgesia (LIA) strategies: LIA with ropivacaine (the ropivacaine group, n = 40), LIA with a new cocktail containing ropivacaine, diprospan, and morphine (the cocktail group, n = 40), and the control group (n = 40). The primary outcomes included postoperative pain scores. The resting visual analogue scale (VAS) scores were measured at 2, 6, and 12 h after the surgery (a.m. and p.m.) on postoperative day (POD) 1, POD2, and the day of discharge. Movement VAS scores were assessed at 6 h, 12 h after the operation (a.m. and p.m.) on POD1, POD2, and the day of discharge. The secondary outcomes included opioid consumption, postoperative hospital stay, range of motion of the hip at discharge, patient satisfaction, and the results of the follow-up.

RESULTS

After the screening, 120 patients were randomized into three groups (40 patients in each group). All of the patients completed the trial. The resting VAS scores in the ropivacaine group and cocktail group at 2 h were lower than those in the control group (P < 0.001 and P < 0.001, respectively, F = 17.054), and the same trend was also postoperatively found at 6 h (p = 0.005 and P = 0.002, F = 6.212). Twelve hours after the operation, the pain score in the cocktail group was lower than that in the other two groups, but only the difference between the cocktail group and the control group was statistically significant (P = 0.018, F = 3.144). From the morning of the first postoperative day to the a.m. on POD 2, the VAS scores in the cocktail group were significantly lower than those in the ropivacaine group and the control group. Furthermore, the movement VAS scores in the ropivacaine group and the cocktail group were better than those in the control group at 6 and 12 h post-operation (P < 0.05). The per capita opioid consumption in the cocktail group was less than that in the ropivacaine group and the control group within 24 h post-operation. There were no significant differences in the comparison of additional indicators among the three groups.

CONCLUSION

The new cocktail with diprospan had a better result and longer duration time for early postoperative pain control in primary THA via the posterolateral approach under general anesthesia, especially for treating resting pain.

Incidence and risk factors for acute kidney injury after total joint arthroplasty

BACKGROUND

Acute kidney injury (AKI) is one of the most common medical causes for readmission following total joint arthroplasty (TJA). This study aimed to (1) examine whether the incidence of AKI has changed over the past decade with the adoption of modern perioperative care pathways and (2) identify the risk factors and concomitant adverse events (AEs) associated with AKI.

METHODS

535,291 primary TJA procedures from the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2018 were retrospectively reviewed. The annual incidence of AKI was analyzed for significant changes over time. Matched cohort analyses were performed to identify the risk factors and AEs associated with AKI using multivariate logistic regression.

RESULTS

The mean incidence of AKI was 0.051%, which remained unchanged during the study period (P = 0.121). Factors associated with AKI were diabetes (OR 1.96, P = 0.009), bilateral procedure (OR 6.93, P = 0.030), lower preoperative hematocrit level (OR 1.09, P = 0.015), body mass index (OR 1.04, P = 0.025), and higher preoperative BUN (OR 1.03, P = 0.043). AKI was associated with length of stay (LOS) > 2 days (OR 4.73, P <  0.001), non-home discharge (OR 0.25, P <  0.001), 30-day readmission (OR 12.29, P <  0.001), and mortality (OR 130.7, P <  0.001).

CONCLUSIONS

The incidence of AKI has not changed over the past decade, and it remains a major bundle buster resulting in greater LOS, non-home discharge, readmissions, and mortality. Avoidance of bilateral TJA in patients with DM and high BMI as well as preoperative optimization of anemia and BUN levels are advised.

Does Nefopam Provide Analgesic Effect and Reduce Morphine Consumption After Primary Total Knee Arthroplasty? A Prospective, Double-Blind, Randomized Controlled Trial

BACKGROUND

One of the most undesirable results after total knee arthroplasty (TKA) is severe immediate postoperative pain, resulting in patient dissatisfaction. We aimed to evaluate nefopam's analgesic efficacy after primary TKA along with related outcomes, including morphine consumption and adverse events.

METHODS

We conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 24 hours of 80 mg of continuous intravenous nefopam to placebo infusion. A 100-mm Visual Analog Scale (VAS) for pain-at-rest and in-motion ≤48 hours was the primary outcome measure. Secondary outcomes were morphine and antiemetic consumption, adverse events, and functional outcomes: time-to-walk, timed up-and-go test, postoperative knee range of motion at 24 and 48 hours, time-to-discharge, and patient satisfaction scores.

RESULTS

Patients in the nefopam group had significantly lower VAS at rest 6 hours postop (20.3 ± 27.3 vs 35 ± 24.3, P = .01). Other timepoints and in-motion VAS did not significantly differ. Total morphine consumption (0-48 hours) was 37% less, significantly lower, in the nefopam group (5.3 ± 4.5 vs 8.4 ± 7.5 mg, P = .03). Antiemetic consumption was also 61% lower in the nefopam group but not statistically significant (0.8 ± 2.3 vs 2.0 ± 3.8 mg, P = .08). There were no variations in adverse events, functional outcomes, and satisfaction scores between groups.

CONCLUSION

Continuous nefopam administration as part of multimodal analgesia for 24 hours post-TKA produced a significant analgesic effect but only within the first 6 hours. However, there was a notable reduction in morphine use 48 hours postop. Nefopam is a useful agent for contemporary pain control after TKA.

LEVEL OF EVIDENCE

Therapeutic Level I.

Assessing Preoperative Pain Sensitivity Predicts the Postoperative Analgesic Requirement and Recovery after Total Knee Arthroplasty: A Prospective Study of 178 Patients

BACKGROUND

The aim of this article is to study the correlation between preoperative pain sensitivity and postoperative pain and analgesic requirements for patients undergoing primary total knee arthroplasty.

METHODS

Between December 2018 and April 2019, the pain sensitivity of 178 consecutive patients undergoing primary total knee arthroplasty was assessed preoperatively with a digital algometer. The patients reported the VAS (visual analog scale) score at 3 instances of needle prick (phlebotomy, glucometer blood sugar, intradermal antibiotic test dose), during the range of movements and completed the Depression Anxiety Stress Scale score. Postoperative VAS score, analgesic requirement, and physiotherapy milestones were recorded in all these patients on day 0 to day 4.

RESULTS

The average age of the patients was 64.13 years and 69.1% were females. Females had lower mean algometry values (56.12 ± 12.77 [standard deviation]) compared to males (71.09 ± 18.78 [standard deviation]) (P < .001). Higher Depression Anxiety Stress Scale correlated with lower algometry values (P < .001). The postoperative VAS score was 2.54 ± 0.59 on the day of surgery which increased to 3.27 ± 0.69 on day 1 after mobilization (P < .001) and reduced to 1.67 ± 0.62 on day 4. Low algometer score correlated with higher postoperative VAS score (P < .05), increased analgesic requirement, and opioid utilization (P < .001), delay in achieving an optimum range of movements (P < .001) and independent ambulation (P < .001).

CONCLUSION

Preoperative assessment of pain sensitivity predicts postoperative analgesic requirements and recovery. Patients with a lower pain threshold should be counseled preoperatively and also receive a better titration of analgesics perioperatively and prolonged physiotherapy.

The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BACKGROUND

Opioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.

METHODS

The MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids.

RESULTS

Preoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness.

CONCLUSION

Moderate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.

A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage

INTRODUCTION

Despite the pain associated with inflatable penile prosthesis (IPP) implantation, there has been a lack of standardized, nonopioid pain control regimens described to date.

AIM

To assess the effectiveness of a multimodal analgesic regimen in patients undergoing implantation of an IPP compared with patients treated with an opioid-only regimen.

METHODS

A large, multicenter patient cohort undergoing IPP implantation whose pain was managed using a multimodal analgesia (MMA) protocol (preoperative and postoperative acetaminophen, meloxicam orcelecoxib, and gabapentin and intraoperative dorsal and pudendal nerve blocks) was compared with a matched cohort of patients managed via an opioid-only protocol. Both groups were compared with respect to visual analog score (VAS) and opioid usage (total morphine equivalents [TME]) in the post-anesthesia care unit (PACU), postoperative day 0 (POD0) and postoperative day 1 (POD1), and in the immediate postdischarge period. Narcotic usage on discharge and follow-up were assessed and compared.

MAIN OUTCOME MEASURE

Postoperative pain scores and narcotic usage are the main outcome measures.

RESULTS

203 patients were eligible for final analysis: 103 (50.7%) patients receiving MMA medication and 100 (49.3%) patients receiving opioids only. The VAS was significantly lower in the multimodal group in PACU (median 0.0 vs 2.0, P = .001), POD0 (median 3.0 vs 4.0, P = .001), and POD1 (median 3.0 vs 4.3, P = .04). Patients in the multimodal group also used fewer narcotics in PACU (median 0.0 vs 4.0 TME, P = .001), POD0 (median 7.5 vs 12.5 TME, P < .001), and POD1 (median 7.5 vs 13.5 TME, P = .01). Despite being discharged with fewer narcotics (median 20.0 vs 30.0 tablets, P < .001), a smaller proportion of patients in the MMA cohort required narcotic refills (10.7% vs 28.0%, P = .001). There were no narcotic- or MMA medication-related side effects in the entire cohort.

CLINICAL IMPLICATIONS

MMA confers significant improvement in pain management while also providing a significant reduction in narcotic usage in patients undergoing implantation of IPP.

STRENGTH & LIMITATIONS

This is the 1st large multi-institutional assessment of a multimodal analgesic regimen in urologic prosthetic surgery. The analgesic regimen targets several pain pathways that provide excellent pain control throughout the recovery process. Limitations include retrospective design and lack of standardization of the nonsteroidal anti-inflammatory drug type within the multimodal analgesic regimen.

CONCLUSION

The use of a MMA protocol significantly reduces postoperative pain measures in penile implant recipients and further reduces both inpatient and outpatient narcotic usage without any discernable side effects. Lucas J, Gross M, Yafi F, et al. A Multi-institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Reduction in Pain Scores and Narcotic Usage. J Sex Med 2020;17:518-525.