Postoperative Analgesia in Patients Undergoing Primary or Revision Knee Arthroplasty with Adductor Canal Block

The Effect of Education Planned According to Health Literacy Level on Functionality, Problems Experienced, and Quality of Life in Patients Undergoing Total Knee Replacement: A Nonrandomized Comparison Group Intervention Study

Total knee arthroplasty procedures significantly improve quality of life for persons with debilitating pain. It is essential to plan patient education according to the level of health literacy. This nonrandomized comparison group intervention study examines the effect of education planned according to health literacy level on functionality, postoperative problems (pain and anxiety), and quality of life in patients who undergo total knee replacement. During the study, patients in the intervention group (n = 51) were provided with the planned patient education according to their health literacy level, whereas patients in the comparison group were given routine care (n = 51). Patients in the postoperative intervention group experienced fewer problems (p < .05). Education tailored to patients' health literacy levels had a positive effect on their functionality and quality of life (p < .05). Our findings suggest planning education according to patient health literacy levels may have a positive influence on functionality, postoperative problems, and quality of life among patients undergoing total knee replacement.

The effect of musical interventions in improving short-term pain outcomes following total knee replacement: a meta-analysis and systematic review

BACKGROUND

A growing number of patients continue to receive total knee replacement (TKR) surgery. Nevertheless, such surgeries result in moderate to severe postoperative pain and difficulty in managing it. Musical interventions are regarded as a type of multimodal analgesia, achieving beneficial results in other clinical treatments. This study aims to evaluate the effect of musical interventions in improving short-term pain outcomes following TKR in order to determine a more reasonable and standard way of delivering musical intervention.

METHODS

A systematic search was conducted to identify available and relevant randomized controlled trials (RCTs) regarding musical interventions compared against non-musical interventions in patients treated with TKR in Embase, MEDLINE, Cochrane Library, Web of Science, CNKI, and Wanfang Med Online up to 8 January 2020. The authors independently assessed study eligibility and risk of bias and collected the outcomes of interest to analyze. The statistical analysis was conducted using the Review Manager (RevMan) version 5.30 software.

RESULTS

Eight RCTs comprised of 555 patients satisfied the inclusion criteria and were enrolled in the present study. The results showed no significant difference between the music and control groups in pain of the visual analog scale (VAS), during postoperative recovery room, back to the ward after surgery; anxiety degree of VAS; heart rate; respiratory rate; oxygen saturation; blood pressure, systolic blood pressure, and diastolic blood pressure. Nevertheless, significant differences were observed between the two groups in average increase in continuous passive motion (CPM) angles and LF/HF ratio (one kind index of heart rate variability).

CONCLUSIONS

Musical interventions fail to demonstrate an obvious effect in improving short-term pain outcomes following TKR. A reasonable standardization of musical interventions, including musical type, outcome measures used, outcomes measured, duration, timing and headphones or players, may improve pain outcomes with certain advantages and should be further explored after TKR.

Revision Total Knee Arthroplasty Is Associated With Significantly Higher Opioid Consumption as Compared With Primary Total Knee Arthroplasty in the Acute Postoperative Period

BACKGROUND

There is a scarcity of studies investigating narcotic use after revision total knee arthroplasty (TKA). We compared immediate postsurgical narcotic consumption after revision TKA and primary TKA.

METHODS

A single-institution database was used to identify patients who underwent revision TKA or primary TKA between 2016 and 2019. Morphine milligram equivalents (MMEs) were calculated to discern narcotic usage, and pain visual analog score was also used.

RESULTS

A total of 7342 cases were identified: 88.65% primary TKA and 11.35% revision TKA. Opioid consumption for the first 24 hours postoperatively was significantly higher for the revision TKA group (133.1 MMEs vs 56.14 MMEs, P < .0001), as well as for the 24- to 48-hour time period. The visual analog pain scores were also higher for the revision TKA group.

CONCLUSION

The revision TKA group had a higher opioid requirement, most significant during the first 24 hours postoperatively, and expressed more pain in the acute postoperative period.

Adductor canal blocks for postoperative pain treatment in adults undergoing knee surgery

BACKGROUND

Peripheral regional anaesthesia techniques are well established for postoperative pain treatment following knee surgery. The adductor canal block (ACB) is a new technique, which can be applied as a single shot or by catheter for continuous regional analgesia.

OBJECTIVES

To compare the analgesic efficacy and adverse events of ACB versus other regional analgesic techniques or systemic analgesic treatment for adults undergoing knee surgery.

SEARCH METHODS

We searched CENTRAL, MEDLINE, and Embase, five other databases, and one trial register on 19 September 2018; we checked references, searched citations, and contacted study authors to identify additional studies.

SELECTION CRITERIA

We included all randomized controlled trials (RCTs) comparing single or continuous ACB versus other regional analgesic techniques or systemic analgesic treatment. Inclusion was independent of the technique used (landmarks, peripheral nerve stimulator, or ultrasound) and the level of training of providers.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. Our primary outcomes were pain intensity at rest and during movement; rate of accidental falls; and rates of opioid-related adverse events. We used GRADE to assess the quality of evidence for primary outcomes.

MAIN RESULTS

We included 25 RCTs (1688 participants) in this review (23 trials combined within meta-analyses). In 18 studies, participants underwent total knee arthroplasty (TKA), whereas seven trials investigated patients undergoing arthroscopic knee surgery. We identified 11 studies awaiting classification and 11 ongoing studies. We investigated the following comparisons. ACB versus sham treatment We included eight trials for this comparison. We found no significant differences in postoperative pain intensity at rest (2 hours: standardized mean difference (SMD) -0.56, 95% confidence interval (CI) -1.20 to 0.07, 4 trials, 208 participants, low-quality evidence; 24 hours: SMD -0.49, 95% CI -1.05 to 0.07, 6 trials, 272 participants, low-quality evidence) or during movement (2 hours: SMD -0.59, 95% CI -1.5 to 0.33; 3 trials, 160 participants, very low-quality evidence; 24 hours: SMD 0.03, 95% CI -0.26 to 0.32, 4 trials, 184 participants, low-quality evidence). Furthermore, they noted no evidence of a difference in postoperative nausea between groups (24 hours: risk ratio (RR) 1.91, 95% CI 0.48 to 7.58, 3 trials, 121 participants, low-quality evidence). One trial reported that no accidental falls occurred 24 hours postoperatively (low-quality evidence). ACB versus femoral nerve block We included 15 RCTs for this comparison. We found no evidence of a difference in postoperative pain intensity at rest (2 hours: SMD -0.74, 95% CI -1.76 to 0.28, 5 trials, 298 participants, low-quality evidence; 24 hours: SMD 0.04, 95% CI -0.09 to 0.18, 12 trials, 868 participants, high-quality evidence) or during movement (2 hours: SMD -0.47, 95% CI -1.86 to 0.93, 2 trials, 88 participants, very low-quality evidence; 24 hours: SMD 0.56, 95% CI -0.00 to 1.12, 9 trials, 576 participants, very low-quality evidence). They noted no evidence of a difference in postoperative nausea (24 hours: RR 1.22, 95% CI 0.42 to 3.54, 2 trials, 138 participants, low-quality evidence) and no evidence that the rate of accidental falls during postoperative care was significantly different between groups (24 hours: RR 0.20, 95% CI 0.04 to 1.15, 3 trials, 172 participants, low-quality evidence).

AUTHORS' CONCLUSIONS

We are currently uncertain whether patients treated with ACB suffer from lower pain intensity at rest and during movement, fewer opioid-related adverse events, and fewer accidental falls during postoperative care compared to patients receiving sham treatment. The same holds true for the comparison of ACB versus femoral nerve block focusing on postoperative pain intensity. The overall evidence level was mostly low or very low, so further research might change the conclusion. The 11 studies awaiting classification and the 11 ongoing studies, once assessed, may alter the conclusions of this review.

The efficacy of combined adductor canal block with local infiltration analgesia for pain control after total knee arthroplasty: A meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the efficiency and safety of the combined adductor canal block (ACB) with local infiltration anesthesia (LIA) versus LIA alone for pain control after total knee arthroplasty (TKA).

METHODS

We searched PubMed, Medline, Embase, Web of Science, the Cochrane Library and Google databases from inception to August 2017 to selected studies that comparing the combined ACB with LIA and LIA alone for pain control after TKA. Only randomized controlled trials (RCTs) were included. Outcomes included visual analogue scale (VAS) with rest or mobilization at 8 h, 24 h and 48 h, total morphine consumption at 6 h, 24 h and 48 h, distance walked at 24 h and 48 h and the length of hospital stay.

RESULTS

Seven randomized controlled trial (RCTs) were finally included in this meta-analysis. The present meta-analysis indicated that, compared with LIA alone, combined ACB with LIA was associated with a reduction of VAS with rest at 24 h and 48 h and VAS with mobilization at 24 h. Additionally, combined ACB with LIA was associated with an increase of the distance walked at 24 h and a reduction of the length of hospital stay.

CONCLUSION

Combined ACB with LIA could significantly reduce pain scores and morphine consumption compared LIA alone after TKA. Further multimodal large sample RCTs are needed to identify the optimal drug of ACB and LIA.

Extended Duration Regional Analgesia for Total Knee Arthroplasty: A Randomised Controlled Trial Comparing Five Days to Three Days of Continuous Adductor Canal Ropivacaine Infusion

There is a growing body of evidence in favour of continuous adductor canal block (CACB) for total knee arthroplasty. However, there are no studies describing the optimal duration of the infusion. At our institution the usual practice was to stop the infusion on day three. Our hypothesis was that extending the infusion to five days would improve analgesia and quality of recovery. A prospective, non-blinded, randomised trial was undertaken. Patients received a continuous infusion of 0.2% ropivacaine via an adductor canal catheter for either three or five days. Primary outcome was pain while walking during the 24-hour period up to day five (numeric rating scale from 0 to 10). The minimum clinically important difference was set at 1.5 on the numeric rating scale. Secondary outcome measures included quality of recovery, mobility, pain while walking on postoperative day six, Oxford Knee Scores, and complications. Eighty-six patients were recruited with 43 randomised to each group. Seventy-eight were analysed. Median pain scores reported on day five were significantly better in the intervention group (1 versus 3, P=0.003). Furthermore, quality of recovery (QOR-15) scores were significantly better in the intervention group (133.6 versus 123.4, P=0.017). No statistically significant difference between groups was identified for other secondary outcome measures. CACB prolonged to five days provides superior analgesia and a higher quality of recovery on postoperative days four and five compared to a three-day infusion. This benefit did not extend beyond the period of infusion.