Efficacy of celecoxib for pain management after arthroscopic surgery of hip: a prospective randomized placebo-controlled study

Demographic and Socioeconomic Patient Data Are Rarely Included in Randomized Controlled Trials for Femoral Acetabular Impingement and Hip Arthroscopy: A Systematic Review

Purpose

To determine the rate of reporting for sociodemographic variables in randomized controlled trials (RCTs) investigating femoral acetabular impingement (FAI) and hip arthroscopy.

Methods

PubMed, Scopus, and Web of Science were queried for articles relating to FAI and hip arthroscopy. Articles included in final analysis were RCTs investigating operative management of FAI. Included RCTs were analyzed for reporting of age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, housing status, work status, and education level in the results section or any section of the paper. Data was analyzed using χ2 and Fisher exact tests with significance defined as P < .05.

Results

Forty-eight RCTs were identified from 2011 to 2023. Age was reported in 48 of 48 (100%) of included papers; sex or gender was reported in 47 of 48 (97.9%). Reporting of sociodemographic variables in any section respectively was: race (7/48, 14.6%), ethnicity (4/48, 8.33%), insurance status (0/48, 0%), income (1/48, 2.08%), housing status (0/48, 0%), work status (3/48, 6.25%), and education (2/48, 4.17%). There was no significant difference for reporting demographic variables with respect to journal or year of publication (P = .666 and P = .761, respectively). Sociodemographic variables (9/48) were reported significantly less frequently than age and sex or gender (48/48) (P < .001).

Conclusions

This study found that sociodemographic variables in FAI and hip arthroscopy RCTs are reported with much lower frequency than age and sex or gender. These findings may demonstrate the need to include patient sociodemographic data in RCTs so that their results can be better generalized and applied to the appropriate patient population.

Level of Evidence

Level II, systematic review of level I and II evidence.

Multimodal analgesia did not improve post-operative pain scores, reduce opioid consumption or reduce length of stay following hip arthroscopy

PURPOSE

To determine whether different regimens of multimodal analgesia will reduce postoperative pain scores, opioid consumption, costs and hospital length-of-stay following hip arthroscopy.

METHODS

From 2018 to 2021, 132 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) were included in this prospective, single-center randomized controlled trial. Patients were randomized into four treatment groups: (1) Group 1-Control: opioid medication (oxycodone-acetaminophen 5 mg/325 mg, 1-2 tabs q6H as needed), Heterotopic ossification prophylaxis-Naprosyn 500 mg twice daily × 3 weeks); (2) Group 2-Control + postoperative sleeping aid (Zopiclone 7.5 mg nightly × 7 days); (3) Group 3-Control + preoperative and postoperative Gabapentin (600 mg orally, 1 h preoperatively; 600 mg postoperatively, 8 h following pre-op dose); (4) Group 4-Control + pre-medicate with Celecoxib (400 mg orally, 1 h preoperatively) The primary outcome was pain measured with a visual analog scale, monitored daily for the first week and every other day for 6 weeks. Secondary outcomes included opioid consumption, healthcare resource use, and hospital length of stay.

RESULTS

Patient characteristics were similar between groups. There were no statistically significant differences in pain scores between groups at any timepoint after adjusting for intra-operative traction time, intra-operative opioid administration and preoperative pain scores (p > 0.05). There were also no significant differences in the number of days that opioids were taken (n.s.) and the average daily morphine milligram equivalents consumed (n.s.). Similarly, there were no statistically significant differences in length of stay in the experimental groups, compared with the control group (n.s.). Finally, there were no differences in cost between groups (n.s.).

CONCLUSION

The routine use of Zopiclone, Celecoxib and Gabapentin did not improve postoperative pain control or reduce length-of-stay following hip arthroscopy. Therefore, these medications are not recommended for routine postoperative pain control following hip arthroscopy.

LEVEL OF EVIDENCE

l.

Does preoperative gabapentin or intraoperative ketorolac influence postoperative pain following hip arthroscopy?

Optimization of perioperative analgesia has important implications for patient satisfaction and short-term outcomes. This study's purpose is to assess if preoperative gabapentin or intraoperative ketorolac influences postoperative pain or time to discharge following hip arthroscopy. In total, 409 patients who underwent hip arthroscopic femoroplasty and/or acetabuloplasty with a single surgeon for femoroacetabular impingement were retrospectively reviewed (September 2017 to February 2021). The effect of preoperative gabapentin or intraoperative ketorolac on postoperative visual analog scale (VAS) pain scores, perioperative opioids in morphine milligram equivalents (MMEs), time in post-anesthesia care unit (PACU), second-stage recovery and time to discharge was assessed using unadjusted and adjusted t-tests, and generalized linear models controlling for operative time, traction time, preoperative MME, intraoperative MME and postoperative MME were compared between the groups of gabapentin to no gabapentin and ketorolac to no ketorolac. There was no difference in first PACU VAS pain score, final PACU VAS score, VAS pain score prior to discharge, average VAS pain score or pain level on follow-up call in the unadjusted or adjusted analysis for the preoperative gabapentin or intraoperative ketorolac groups. Females had higher first PACU VAS pain score (6.05 versus 5.15 P = 0.0026), final PACU VAS pain score (4.43 versus 3.90, P = 0.0045), final VAS pain score prior to discharge (3.87 versus 3.03, P < 0.001) and average postoperative pain score (4.60 versus 4.03, P < 0.001), but no difference in VAS pain score on follow-up call following surgery. Gabapentin or ketorolac was not associated with decreased VAS pain scores or time to discharge after hip arthroscopy.

Efficacy of regional anesthesia in hip preservation surgeries: a systematic review

The purpose of this study was to review the current literature on perioperative pain management in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation. A systematic review of the literature published from January 2000 to December 2022 was performed. Selection criteria included published randomized controlled trials, prospective reviews and retrospective reviews of all human subjects undergoing hip preservation surgery. Exclusion criteria included case reports, animal studies and studies not reporting perioperative pain control protocols. Thirty-four studies included hip arthroscopy in which peripheral nerve blocks were associated with a significant reduction in pain score (P = 0.037) compared with general anesthesia alone. However, no pain control modality was associated with a significant difference in postanesthesia care unit opioid use (P = 0.127) or length of stay (P = 0.251) compared with general anesthesia alone. Falls were the most common complication reported, accounting for 37% of all complications. Five studies included periacetabular osteotomy and surgical hip dislocation in which peripheral nerve blocks were associated with an 18% reduction in pain on postoperative Day 2, a 48% reduction in cumulative opioid use on postoperative Day 2 and a 40% reduction in hospital stay. Due to the low sample size of the periacetabular osteotomy and surgical hip dislocation studies, we were unable to determine the significant difference between the means. Due to significant between-study heterogeneity, additional studies with congruent outcome measures need to be conducted to determine the efficacy of regional anesthesia in hip arthroscopy, periacetabular osteotomy and surgical hip dislocation.

A Multimodal Pain Management Regimen for Open Treatment of Distal Radius Fractures: A Randomized Blinded Study

BACKGROUND

Adequate pain control is critical after outpatient surgery where patients are not as closely monitored. A multimodal pain management regimen was compared to a conventional pain management method in patients undergoing operative fixation for distal radius fractures. We hypothesized that there would be a decrease in the amount of narcotics used by the multimodal group compared to the conventional pain management group, and that there would be no difference in bone healing postoperatively.

METHODS

Forty-two patients were randomized into 2 groups based on pain protocols. Group 1, the control, received a regional block, acetaminophen, and oxycodone. Group 2 received a multimodal pain regimen consisting of daily doses of pregabalin, celecoxib, and acetaminophen up until postoperative day (POD) #3. They also received a regional block with oxycodone for breakthrough pain.

RESULTS

From POD#3 to week 1, there was a significant increase in oxycodone use in the study group correlating with the point in time when the multimodal regimen was discontinued. The shortened Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) scores taken at 2 weeks postoperation showed a significantly lower average score in the study group compared to the control. There was no difference in bone healing.

CONCLUSIONS

The 2 regimens yielded similar pain control after surgery. The rebound increase in narcotic use after the multimodal regimen was discontinued, and significant difference in QuickDASH scores seen at 2 weeks postoperatively supported that multimodal regimens may not necessarily lead to decreased narcotic use in outpatient upper extremity surgery, but in the short term are shown to improve functional status.

Safety and Efficacy of Postoperative Nonsteroidal Anti-inflammatory Drugs in Sports Medicine

Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used for multimodal pain control after surgery. These medications work by selective or nonselective inhibition of cyclooxygenase, which has downstream effects on thromboxanes, prostaglandins, and prostacyclins. Clinical studies have shown beneficial effects for alleviating pain and reducing opioid consumption after surgery. Within hip arthroscopy, there is evidence that postoperative NSAIDs can also reduce the risk of symptomatic heterotopic bone formation. However, preclinical and animal studies have raised concern over the effect of NSAIDs on bone and soft-tissue healing. In addition, selective and nonselective cyclooxygenase 2 inhibitors may have different safety profiles regarding postoperative soft-tissue healing. The purpose of this review was to outline the mechanisms of action, efficacy, and effect on soft-tissue healing of postoperative NSAIDs and to provide evidence-based recommendations for appropriate use.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age

PURPOSE

Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use.

METHODS

A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage.

RESULTS

Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use.

CONCLUSION

Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use.

LEVEL OF EVIDENCE

Level III.

The Effect of Perioperative Ketorolac Administration on Opioid Use After Hip Arthroscopy

Patients undergoing hip arthroscopy often have postoperative pain that is managed in part with opioids. The hypothesis of this study was that administration of ketorolac at the conclusion of the case may improve postoperative pain control and reduce opioid use. This investigation was a retrospective, observational study of opioid use, pain, and time spent in the postanesthesia care unit (PACU) among opioid-naïve patients undergoing primary hip arthroscopy (Current Procedural Terminology code 29914 or 29916) for femoroacetabular impingement syndrome before and after the institution of a surgeon-driven policy to administer ketorolac at the end of the case. Baseline characteristics and perioperative ketorolac administration were recorded. Outcomes included opioids used in the PACU through discharge measured in oral morphine equivalents, time spent in the PACU, and pain reported by the patient in the PACU. Comparative statistics, including multivariable main effects linear regression modeling, were performed to determine the effect of ketorolac administration on outcomes. Patients who did not receive ketorolac consumed a median of 22.5 oral morphine equivalents in the PACU through discharge, whereas patients who received ketorolac consumed a median of 17.5 oral morphine equivalents. No significant difference was found in pain reported or time spent in the PACU through discharge, although the results favored ketorolac administration. This study showed a modest but statistically significant reduction in early postoperative opioid use among patients receiving ketorolac at closure. Ketorolac could be part of a multimodal preemptive pain management strategy to help to reduce postoperative opioid use. [Orthopedics. 2021;44(3):e417-e421.].

Perioperative nonopioid analgesia reduces postoperative opioid consumption in knee arthroscopy: a systematic review and meta-analysis

PURPOSE

The opioid epidemic has prompted an emphasis on investigating opioid-sparing alternatives for pain management following knee arthroscopy. This review evaluated the effects of perioperative nonopioid adjunct analgesia on postoperative opioid consumption and pain control in patients undergoing knee arthroscopy.

METHODS

A systematic review and meta-analysis was performed using the following databases: PubMed, Embase, Web of Science, MEDLINE, and SCOPUS. Prospective comparative studies assessing the efficacy of various perioperative nonopioid analgesic strategies in patients undergoing knee arthroscopy were included. Twenty-five studies (n = 2408) were included.

RESULTS

Pre-emptive nonopioid pain medications demonstrated a reduction in cumulative postoperative oral morphine equivalent (OME) consumption by 11.8 mg (95% CI - 18.3, - 5.4, p ≤ 0.0001) and VAS pain scores by 1.5 (95% CI - 2.3, - 0.7, p < 0.001) at 24 h compared to placebo. Postoperative nonopioid pain medications significantly reduced cumulative postoperative OME consumption by 9.7 mg (95% CI - 14.4, - 5.1, p < 0.001) and VAS pain scores by 1.0 (95% CI - 1.354, - 0.633, p < 0.001) at 24 h compared to placebo. Saphenous nerve blocks significantly reduced cumulative postoperative OME consumption by 6.5 mg (95% CI - 10.3, - 2.6, p = 0.01) and VAS pain scores by 0.8 (- 1.4, - 0.3, p = 0.03) at 24 h compared to placebo. Both preoperative patient education and postoperative cryotherapy reduced postoperative opioid consumption.

CONCLUSION

Perioperative nonopioid pharmacotherapy, saphenous nerve blocks, and cryotherapy for patients undergoing knee arthroscopy significantly reduce opioid consumption and pain scores when compared to placebo at 24 h postoperatively. These interventions should be considered in efforts to reduce opioid consumption in patients undergoing knee arthroscopy. More research is needed to determine which interventions can reduce pain outside of the immediate postoperative period and the potential synergistic effects of combining interventions.

LEVEL OF EVIDENCE

II.

A comprehensive three-phase opiate sparing multimodal pain protocol for hip arthroscopy: a retrospective review

The aim of this study is to assess the efficacy of a three-phase, multimodal, perioperative pain protocol for primary hip arthroscopy based on pain scores, narcotic use, time to discharge, hospital admission and complications. A retrospective study of patients undergoing primary hip arthroscopy over a 48-month time period was conducted. Patients were separated into a multimodal group consisting of non-narcotic medication, local analgesia and a peripheral nerve block (PNB) versus patients receiving only a PNB. Differences in post-anesthesia care unit (PACU) visual analog scores, PACU time to discharge, PACU opioid consumption, hospital admission and complications between protocols were recorded and analyzed. There were 422 patients who underwent 484 surgeries, with 15 patients crossing over pain protocol groups for surgery on the contralateral hip. One hundred and ninety-six patients underwent 213 procedures in the multimodal group and 241 patients underwent 271 procedures in the PNB group. No differences in baseline characteristics were appreciated between groups. Mean time to discharge was significantly shorter in the multimodal group (137.4 ± 49.3 min versus 176.3 ± 6.5 min; P < 0.001) which also had less post-operative admissions (0 versus 9; P = 0.006) than the PNB group. In patients who crossed over protocol groups, a statistically shorter time to discharge was appreciated with the multimodal protocol compared with the PNB protocol (119.9 ± 32.1 min versus 187.9 ± 9.2; P = 0.012). The three-phase, multimodal pain protocol led to significantly faster discharge times and fewer hospital admissions when compared with isolated PNB in patients undergoing primary hip arthroscopy.

Adjunct Analgesia Reduces Pain and Opioid Consumption After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Patients who undergo hip arthroscopy inevitably experience pain postoperatively; however, the efficacy and safety of adjunct analgesia to prevent or reduce pain are not well-understood.

PURPOSE

To perform a comprehensive qualitative synthesis of available randomized controlled trials evaluating the effect of adjunct analgesia on postoperative (1) pain, (2) opioid use, and (3) length of stay (LOS) in patients undergoing hip arthroscopy.

STUDY DESIGN

Systematic review.

METHODS

PubMed, OVID/MEDLINE, and Cochrane Controlled Register of Trials were queried for studies pertaining to analgesia interventions for patients undergoing hip arthroscopy. Two authors independently assessed article bias and eligibility. Data pertaining to changes in pain scores, additional analgesia requirements, length of hospital stay, and complications were extracted and qualitatively reported. Network meta-analyses were constructed to depict mean pain, opioid use, and LOS among the 3 analgesia categories (blocks, local infiltration analgesia, and celecoxib).

RESULTS

Fourteen level 1 studies were included; 12 (85.7%) reported pain reductions in the immediate and perioperative period after hip arthroscopy. Of the 7 studies that assessed an intervention (2 celecoxib, 1 fascia iliaca block, 1 lumbar plexus block, 1 femoral nerve block, 1 intra-articular bupivacaine, 1 extracapsular bupivacaine) versus placebo, more than half reported that patients who received an intervention consumed significantly fewer opioids postoperatively than patients who received placebo (lowest P value = .0006). Of the same 7 studies, 2 reported significantly shortened LOS with interventions, while 4 reported no statistically significant difference in LOS and 1 did not report LOS as an outcome.

CONCLUSION

The majority of studies concerning adjunct analgesia for patients undergoing hip arthroscopy suggest benefits in pain reduction early in the postoperative period. There is mild evidence that adjunct analgesia reduces postoperative opioid use and currently inconclusive evidence that it reduces length of hospital stay. Furthermore, it appears that local infiltration analgesia may provide the greatest benefits in reductions in pain and opioid consumption. We recommend the use of adjunct analgesia in appropriately selected patients undergoing hip arthroscopy without contraindication who are at a high risk of severe postoperative pain.

Fast Starters and Slow Starters After Hip Arthroscopy for Femoroacetabular Impingement: Correlation of Early Postoperative Pain and 2-Year Outcomes

BACKGROUND

Patients experience varying degrees of pain and symptoms during the early recovery period after hip arthroscopy for femoroacetabular impingement (FAI). Some "fast starters" report minimal discomfort and are eager to advance activities, while "slow starters" describe severe pain and limitations. The relationship between these early postoperative symptoms and 2-year outcomes after hip arthroscopy is unknown.

PURPOSE

To analyze the relationship between early postoperative pain and 2-year patient-reported outcomes (PROs) after hip arthroscopy for FAI.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients without arthritis or dysplasia who were undergoing primary hip arthroscopy for FAI were prospectively enrolled and completed validated PROs. Scores for visual analog scale (VAS) for pain were collected preoperatively and at 1 week, 6 weeks, and 2 years postoperatively. Scores for the modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (HOOS), and 12-Item Short Form Health Survey (SF-12) were collected preoperatively and 2 years postoperatively. Paired t tests were used to evaluate PRO score changes, and correlation analyses were used to assess relationships between early postoperative pain and 2-year postoperative outcomes.

RESULTS

A total of 166 patients were included (55% female; mean ± SD age, 35.29 ± 9.6 years; mean body mass index, 25.07 ± 3.98 kg/m²). Patients demonstrated significant improvements in PRO scores (VAS, SF-12 Physical Component Score, mHHS, and all HOOS subscales) at 2 years after hip arthroscopy for FAI (P < .001). There was a significant correlation between lower 1-week VAS pain level (fast starters) and lower 2-year VAS pain level (R = 0.31; P < .001) as well as higher 2-year PRO scores (SF-12 Physical Component Score, mHHS, and all HOOS subscales: R = -0.21 to -0.3; P < .001). There was no correlation between 1-week VAS pain and 2-year SF-12 Mental Component Score (P = .17). Preoperative VAS pain levels showed positive correlations with 1-week postoperative pain scores (R = 0.39; P < .001) and negative correlations with 2-year patient outcomes (R = -0.15 to -0.33, P < .01). There was no correlation between 6-week postoperative pain scores and 2-year PRO scores.

CONCLUSION

Fast starters after hip arthroscopy for FAI experience sustained improvements in outcomes at 2 years after surgery. Patient pain levels before surgery may delineate potential fast starters and slow starters.

Implementation of the Obturator Nerve Block into a Supra-Inguinal Fascia Iliaca Compartment Block Based Analgesia Protocol for Hip Arthroscopy: Retrospective Pre-Post Study

Background and Objectives: The effect of supra-inguinal fascia iliaca compartment block (SI-FICB) in hip arthroscopy is not apparent. It is also controversial whether SI-FICB can block the obturator nerve, which may affect postoperative analgesia after hip arthroscopy. We compared analgesic effects before and after the implementation of obturator nerve block into SI-FICB for hip arthroscopy. Materials and Methods: We retrospectively reviewed medical records of 90 consecutive patients who underwent hip arthroscopy from January 2017 to August 2019. Since August 2018, the analgesic protocol was changed from SI-FICB to SI-FICB with obturator nerve block. According to the analgesic regimen, patients were categorized as group N (no blockade), group F (SI-FICB only), and group FO (SI-FICB with obturator nerve block). Primary outcome was the cumulative opioid consumption at 24 hours after surgery. Additionally, cumulative opioid consumption at 6 and 12 hours after surgery, pain score, additional analgesic requests, intraoperative opioid consumption and hemodynamic stability, and postoperative nausea and vomiting were assessed. Results: Among 87 patients, there were 47 patients in group N, 21 in group F, and 19 in group FO. The cumulative opioid (fentanyl) consumption at 24 hours after surgery was significantly lower in the group FO compared with the group N (N: 678.5 (444.0–890.0) µg; FO: 482.8 (305.8–635.0) µg; p = 0.014), whereas the group F did not show a significant difference (F: 636.0 (426.8–803.0) µg). Conclusion: Our findings suggest that implementing obturator nerve block into SI-FICB can reduce postoperative opioid consumption in hip arthroscopy.

Reduction of Postoperative Hip Arthroscopy Pain With an Ultrasound-Guided Fascia Iliaca Block: A Prospective Randomized Controlled Trial

BACKGROUND

Ultrasound-guided fascia iliaca blocks have been used for pain control after hip arthroscopy. There is little evidence regarding their effectiveness in comparison with other pain control modalities in patients who have undergone hip arthroscopy.

PURPOSE

To compare the efficacy of ultrasound-guided fascia iliac block with intra-articular ropivacaine in controlling pain after hip arthroscopy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

Between 2015 and 2017, patients (N = 95) undergoing hip arthroscopy were randomly assigned to 2 groups. The first group received an ultrasound-guided fascia iliaca block with 50 to 60 mL of 0.35% ropivacaine. The second group received an intra-articular injection of 20 mL of 0.5% ropivacaine at the completion of the surgical case. Primary outcomes were postoperative pain scores in the recovery room; at postanesthesia care unit (PACU) discharge; and at 2 weeks, 6 weeks, and 3 months. Secondary outcomes included intraoperative and PACU narcotic usage (converted to morphine equivalent use) as well as readmission rates, PACU recovery time, and postoperative nausea and vomiting.

RESULTS

Postoperative pain across all points did not significantly differ between the groups. Intraoperative and PACU narcotics did not differ significantly between the groups. Readmission rates, PACU recovery time, and postoperative nausea and vomiting did not significantly differ between the groups. There were no associated complications in either group.

CONCLUSION

Ultrasound-guided fascia iliaca block for hip arthroscopy had no clinical advantage when compared with onetime intra-articular ropivacaine injection.

REGISTRATION

NCT02365961 (ClinicalTrials.gov identifier).

The efficacy of celecoxib for pain management of arthroscopy: A meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of celecoxib for pain management of arthroscopy remains controversial. We conduct a systematic review and meta-analysis to assess if celecoxib before the surgery decreases postoperative pain intensity of arthroscopy.

METHODS

We search PubMed, Embase, Web of science, EBSCO, and Cochrane library databases for randomized controlled trials (RCTs) assessing the effect of celecoxib versus placebo on pain control of arthroscopy.

RESULTS

Five RCTs are included in the meta-analysis. Celecoxib is administered at 200 mg or 400 mg dosage before the surgery. Overall, compared with control group for arthroscopy, preemptive celecoxib has remarkably positive impact on pain scores at 2 to 6 hours (standard mean difference (SMD) = -0.66; 95% confidence interval (CI) = -0.95 to -0.36; P < .0001) and 24 hours after the surgery (SMD = -1.26; 95% CI = -1.83 to -0.70; P < 0.0001), analgesic consumption (SMD  = -2.73; 95% CI = -5.17 to -0.28; P = .03), as well as the decrease in adverse events (risk ratio (RR) = 0.56; 95% CI = 0.39 to 0.79; P = .001), but shows no obvious effect on first time for analgesic requirement (SMD  = 0.02; 95% CI = -0.22 to 0.26; P = .87), nausea, or vomiting (RR = 0.70; 95% CI = 0.42 to 1.17; P = .18).

CONCLUSION

Celecoxib administered at 200 mg or 400 mg dosage before the surgery decreases postoperative pain intensity of arthroscopy.

Peri-operative pain management in hip arthroscopy: a systematic review of the literature

The purpose of this article was to review current literature on peri-operative pain management in hip arthroscopy. A systematic review of the literature on pain control in hip arthroscopy published January 2008 to December 2018 was performed. Inclusion criteria consisted of English language or articles with English translations, subjects undergoing hip arthroscopy with documented peri-operative pain control protocols in studies reporting Level I to IV evidence. Exclusion criteria were non-English articles, animal studies, prior systematic review or meta-analyses, studies not reporting peri-operative pain control protocols, studies documenting only pediatric (<18 years of age) patients, studies with Level V evidence and studies including less than five subjects. Statistical analysis was performed to assess pain protocols on narcotic consumption in PACU, VAS score on discharge, time to discharge from PACU and incidence of complications. Seventeen studies were included, comprising 1674 patients. Nerve blocks were administered in 50% of patients (n = 838 of 1674), of which 88% (n = 740 of 838) received a pre-operative block while 12% (n = 98 of 838) post-operative block. Sixty-eight complications were recorded: falls (54%, n = 37), peripheral neuritis (41%, n = 28), seizure (1.5%, n = 1), oxygen desaturation and nausea (1.5%, n = 1) and epidural spread resulting in urinary retention (1.5%, n = 1). No significant differences in narcotic consumption, VAS score at discharge, time until discharge or incidence of complication was found based on pain control modality utilized. No statistically significant difference in PACU narcotic utilization, VAS pain scores at discharge, time to discharge or incidence of complications was found between peri-operative pain regimens in hip arthroscopy.

Postoperative Pain Management Strategies in Hip Arthroscopy

PURPOSE OF REVIEW

Hip arthroscopy is a rapidly growing field due to its significant diagnostic and therapeutic value in the management of numerous hip disorders. Adequate control of postoperative pain in patients undergoing hip arthroscopy continues to be a challenging and evolving area in orthopedics. In the absence of standardized protocols for pain management in these patients, a variety of different approaches have been utilized in an effort to find a regimen that is effective at reducing postoperative pain, narcotic consumption, and cost to the patient and healthcare system. The purpose of this article, therefore, is to provide a comprehensive review of current literature regarding postoperative pain management techniques in patients undergoing hip arthroscopy.

RECENT FINDINGS

Recent literature demonstrates the importance of a multimodal approach to treat postoperative pain in patients undergoing hip arthroscopy. When a peripheral nerve block or intraoperative anesthetic is used in combination with a pre- and postoperative analgesic medication regimen, patients report less pain and postoperative narcotic consumption. Patient-reported pain scores and postoperative opioid use were similar between the different modalities, however, postoperative complications appear to be less in groups receiving intra-articular (IA) injection or local anesthetic infiltration (LAI) compared to peripheral nerve blocks. In summary, we present evidence that intraoperative techniques, such as IA injection or LAI, in conjunction with pre- and postoperative pain medications, offers an effective multimodal strategy for treating postoperative pain following hip arthroscopy. This topic is of increasing importance due to the need for cost-effective strategies of managing pain and decreasing opioid consumption following hip arthroscopy.

Efficacy of preemptive analgesia versus postoperative analgesia of celecoxib on postoperative pain, patients' global assessment and hip function recovery in femoroacetabular impingement patients underwent hip arthroscopy surgery

We aimed to investigate the efficacy of preemptive analgesia of celecoxib on postoperative pain, patients' global assessment (PGA) and hip function recovery compared to postoperative analgesia of celecoxib in femoroacetabular impingement (FAI) patients who underwent hip arthroscopy surgery (HAS). The 100 FAI patients underwent HAS were randomly allocated to preemptive analgesia group (N = 50) or postoperative analgesia group (N = 50) as a 1:1 ratio for 3 months. Pain visual analog scale (VAS) score, PGA score, rescue-use pethidine consumption and Harris hip score were assessed. Compared to postoperative analgesia group, pain VAS score decreased on day 1 (P = 0.036), day 2 (P = 0.046) and day 3 (P = 0.046), while was similar prior to operation (P = 0.587), on day 7 (P = 0.398), at month 1 (P = 0.461) and month 3 (P = 0.805) in preemptive analgesia group. Besides, rescue-use pethidine consumption was decreased in preemptive analgesia group than postoperative analgesia group within 3 days (P = 0.016) and within 7 days (P = 0.033) post-operation. For PGA score, it reduced on day 2 (P = 0.030) and day 3 (P = 0.048), while was similar prior to operation (P = 0.699), on day 1 (P = 0.699), day 7 (P = 0.224), at month 1 (P = 0.640) and month 3 (P = 0.400) in preemptive analgesia group than postoperative analgesia group. For Harris hip score, it was similar prior to operation (P = 0.372), on day 7 (P = 0.366), at month 1 (P = 0.466) and month 3 (P = 0.658) between the two groups. In conclusion, preemptive analgesia of celecoxib decreases short-term postoperative pain and PGA, but without effect on long-term hip function recovery than postoperative analgesia of celecoxib in FAI patients who underwent HAS.

Pain Management After Hip Arthroscopy: Systematic Review of Randomized Controlled Trials and Cohort Studies

BACKGROUND

Hip arthroscopy is often associated with significant postoperative pain and opioid-associated side effects. Effective pain management after hip arthroscopy improves patient recovery and satisfaction and decreases opioid-related complications.

PURPOSE

To collect, examine, and provide a comprehensive review of the available evidence from randomized controlled trials and comparative studies on pain control after hip arthroscopy.

STUDY DESIGN

Systematic review.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature for postoperative pain control after hip arthroscopy was performed using electronic databases. Only comparative clinical studies with level 1 to 3 evidence comparing a method of postoperative pain control with other modalities or placebo were included in this review. Case series and studies without a comparative cohort were excluded.

RESULTS

Several methods of pain management have been described for hip arthroscopy. A total of 14 studies met our inclusion criteria: 3 on femoral nerve block, 3 on lumbar plexus block, 3 on fascia iliaca block, 4 on intra-articular injections, 2 on soft tissue surrounding surgical site injection, and 2 on celecoxib (4 studies compared 2 or more methods of analgesia). The heterogeneity of the studies did not allow for pooling of data. Single-injection femoral nerve blocks and lumbar plexus blocks provided improved analgesia, but increased fall rates were observed. Fascia iliaca blocks do not provide adequate pain relief when compared with surgical site infiltration with local anesthetic and are associated with increased risk of cutaneous nerve deficits. Patients receiving lumbar plexus block experienced significantly decreased pain compared with fascia iliaca block. Portal site and periacetabular injections provide superior analgesia compared with intra-articular injections alone. Preoperative oral celecoxib, compared with placebo, resulted in earlier time to discharge and provided significant pain relief up to 24 hours.

CONCLUSION

Perioperative nerve blocks provide effective pain management after hip arthroscopy but must be used with caution to decrease risk of falls. Intra-articular and portal site injections with local anesthetics and preoperative celecoxib can decrease opioid consumption. There is a lack of high-quality evidence on this topic, and further research is needed to determine the best approach to manage postoperative pain and optimize patient satisfaction.

Updates on Multimodal Analgesia for Orthopedic Surgery

Pain control after orthopedic surgery is challenging. A multimodal approach provides superior analgesia with fewer side effects compared with opioids alone. This approach is particularly useful in light of the current opioid epidemic in the United States. Several new nonopioid agents have emerged into the market in recent years. New agents included in this review are intravenous acetaminophen, intranasal ketorolac, and newer nonsteroidal anti-inflammatory drugs, and the established medications ketamine and gabapentinoids. This article evaluates the evidence supporting these drugs in a multimodal context, including a brief discussion of cost.

Perioperative Opioid Analgesics and Hip Arthroscopy: Trends, Risk Factors for Prolonged Use, and Complications

PURPOSE

The purpose of this article is to (1) examine trends in preoperative and prolonged postoperative opioid analgesic use in patient undergoing hip arthroscopy, (2) characterize risk factors for prolonged opioid analgesic use following hip arthroscopy, and (3) explore preoperative and prolonged postoperative opioid analgesic use as independent risk factors for complications following hip arthroscopy.

METHODS

A private insurance database was queried for patients undergoing hip arthroscopy from 2007 to 2015 with a minimum of 6 months of follow-up. Independent risk factors for prolonged opioid analgesic use were determined. Preoperative and prolonged opioid analgesic use as risk factors for complications were examined.

RESULTS

There was a significantly decreasing trend in preoperative (P = .002) and prolonged postoperative (P = .009) opioid analgesic use. The most significant risk factor for prolonged postoperative opioid analgesic use was preoperative use (odds ratio [OR], 3.61; P < .0001). Other preoperative prescriptions, including muscle relaxants (OR, 1.5; P < .0001) and anxiolytics (OR, 2.0; P < .0001), were also significant risk factors. Preoperative opioid analgesic use was a significant risk factor for postoperative complications, including emergency room visits (OR, 2.1; P < .0001) and conversion to total hip arthroplasty (THA) (OR, 1.6; P < .0001). Prolonged postoperative opioid analgesic use was associated with a higher risk of revision hip arthroscopy (OR, 1.4; P = .0004) and conversion to THA (OR, 1.8; P < .0001).

CONCLUSIONS

More than a quarter of patients undergoing hip arthroscopy continue to receive opioid analgesic prescriptions more than 3 months postoperatively. The most significant risk factor for prolonged opioid analgesic use is preoperative opioid analgesic use. Additionally, anxiolytics, substance use or abuse, morbid obesity, and back pain were among the more notable risk factors for prolonged postoperative opioid analgesic use. Preoperative and prolonged postoperative opioid analgesic use was associated with a higher likelihood of several adverse effects/complications.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

The efficacy and safety of early initiation of preoperative analgesia with celecoxib in patients underwent arthroscopic knee surgery: A randomized, controlled study

This study aimed to investigate the efficacy and safety of celecoxib 24 hours preoperative, 1 hour preoperative, and 4 hours postoperative administration in patients with arthroscopic knee surgery (AKS).In all, 206 patients who underwent AKS were consecutively recruited and randomized into 3 groups: (1) early preoperative analgesia group (EPEA), celecoxib 400 mg 24 hours preoperative administration; (2) preoperative analgesia group (PEA), celecoxib 400 mg 1 hour preoperative administration; (3) postoperative analgesia group (POA), celecoxib 400 mg 4 hours postoperative administration. Pain visual analog scale (VAS) scores (at rest and at 90 flexion) and patient global assessment (PGA) score were evaluated before and after operation, and also pethidine consumption and adverse events (AEs).The pain-rest VAS score, percentage of patients with moderate-severe pain at rest, and PGA score in the EPEA and PEA groups were decreased compared with POA group at 8 and 12 hours postoperation. Besides, pain-flexion to 90 VAS score in EPEA and PEA groups were also reduced compared with POA group at 8 hours postsurgery. Interestingly, the percentage of patients with moderate-severe pain at 90 flexion at 8 hours postsurgery in PEA group was fewer compared with POA group, whereas at 4 hours postoperation it was reduced in EPEA group compared with PEA and POA groups. As to consumption of pethidine, it was numerically decreased in EPEA and PEA groups compared with POA group. No difference between each 2 groups was found in AEs.Celecoxib was effective and safe as pre-emptive analgesia in AKS, and 1 hour administration before operation might be an optimal choice.

Efficacy of Celecoxib for Early Postoperative Pain Management in Hip Arthroscopy: A Prospective Randomized Placebo-Controlled Study

PURPOSE

To determine whether 400 mg of celecoxib administered 1 hour before hip arthroscopy surgery would reduce pain, provide reduction in overall narcotic consumption, and lead to more rapid discharge from recovery rooms.

METHODS

Ninety-eight patients were randomized to either the celecoxib group (n = 50) or the placebo group (n = 48). An a priori power analysis was done set to detect a difference of 0.50 on the visual analog scale (VAS), based on the senior author's preference. The number of patients planned for recruitment was rounded up to 100 to allow for flexibility in the study. Inclusion criteria were any patient at least 18 years old who underwent hip arthroscopy surgery performed by the senior author. All patients had less than Tönnis grade 2 arthritis. Exclusion criteria were allergy to sulfa-based drugs, prior adverse reaction to celecoxib, or patients who were on chronic narcotics for whom alternative pain management regimens were arranged before surgery. Randomization was performed on a 1:1 basis in blocks of 10 using sealed envelopes stating celecoxib or placebo. One hour before surgery, all patients received either 400 mg celecoxib or placebo. Patients were evaluated using a VAS preoperatively, immediately postoperatively, and at 1 and 2 hours postoperatively. Time from the operating room to "ready for discharge" and number of morphine equivalents of narcotic medication required in the postanesthesia care unit were recorded.

RESULTS

Age and preoperative VAS were similar between the celecoxib and placebo control group, with average ages of 34.2 ± 11.9 and 35.8 ± 11.6 (P = .27) and preoperative VAS of 2.1 ± 2.06 and 2.3 ± 1.98 (P = .29), respectively. The celecoxib group had 26 females and 24 males, whereas the placebo group had 29 females and 19 males (P = .42). The most common surgical procedures were labral repair (31 patients in the celecoxib group and 29 patients in the placebo group), and labral repair with acetabular osteoplasty (13 patients in the celecoxib group and 11 patients in the placebo group). There were no significant differences in procedures performed between the 2 groups (P > .05). At 1 hour postoperatively, patients who received celecoxib had a lower pain score that was statistically significant compared with the placebo group (4.6 vs 5.4, P = .03). There was a significant difference in discharge time between patients who received celecoxib and the control group (152.9 minutes vs 172.9 minutes, P = .04). There was no significant difference found in morphine equivalents consumed in the postanesthesia care unit between the 2 groups (15.3 vs 15.4, P = .48).

CONCLUSIONS

A preoperative dose of 400 mg of celecoxib led to statistically significantly reduced patient-reported pain on the VAS in the acute postoperative period after hip arthroscopy surgery, though the difference is not likely clinically significant. There was a significantly shorter time to discharge in patients who received celecoxib versus placebo.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Anesthesia for hip arthroscopy: a narrative review

PURPOSE

Hip arthroscopy is a minimally invasive surgical procedure indicated for the treatment of specific hip disorders. In this narrative review, we aim to examine the key components in providing anesthesia for this procedure.

SOURCE

MEDLINE(®), PubMed, and EMBASE™ databases were searched for peer-reviewed articles discussing the anesthetic management of patients undergoing hip arthroscopy.

PRINCIPAL FINDINGS

The primary anesthetic regimen used for hip arthroscopy should balance patient factors, preferences of the surgeon, and the demands of the procedure itself. Both general and neuraxial anesthetic techniques are well suited for this mostly ambulatory surgical procedure. There is a lack of current literature specifically comparing the benefits and risks of the two techniques in this setting. Postoperative pain management consists mainly of intravenous and oral opioids; however, a variety of regional anesthesia techniques, such as lumbar plexus block and fascia iliaca block, can be performed pre- or postoperatively. Overall, hip arthroscopy is safe, although positioning-related difficulties, extravasation of irrigation fluid, hypothermia, infections, and thromboembolic events are potential perioperative complications that warrant specific monitoring and prompt treatment.

CONCLUSIONS

Until now, the anesthetic technique for hip arthroscopy has not been well studied. Thus, increasing emphasis should be directed towards examining relevant clinical outcomes that can better inform evidence-based decision-making in the anesthetic management of hip arthroscopy patients. In the meantime, awareness of potential complications and vigilant monitoring are paramount in providing safe anesthetic care for patients undergoing hip arthroscopy.

Perioperative pain management in hip arthroscopy; what options are there?

Hip arthroscopy is a fast growing orthopedic field of expertise. As in any field of surgery adequate postoperative pain management regimes are of utmost importance. The purpose of this review is to provide an overview of current knowledge on anesthetic options for perioperative pain management for hip arthroscopy. We searched the Pubmed/Medline and Embase database for literature and included 10 studies for our analysis. Because of the variety of pain scales and different ways of measured pain no meta-analysis could be performed and a descriptive review is performed. There are several types of pain regimens that can mostly be divided in two groups: local anesthetics and nerve blocks. Included studies show a rather large variation in reported visual analogue scale scores, post anesthesia care unit admission time and opioid usage. There are several anesthetic options available for hip arthroscopy. Different studies use different dosages, anesthetic regimens and different protocols; this partly explains the differences between studies with similar techniques. Peripheral nerve blocks seems promising but regarding current literature no clear recommendation can be made about what the best perioperative pain management option is, an overview of all reported techniques is given.

Assessment of Intraoperative Intra-articular Morphine and Clonidine Injection in the Acute Postoperative Period After Hip Arthroscopy

BACKGROUND

Previous authors have suggested that intra-articular morphine and clonidine injections after knee arthroscopy have demonstrated equivocal analgesic effect in comparison with bupivacaine while circumventing the issue of chondrotoxicity. There have been no studies evaluating the effect of intra-articular morphine after hip arthroscopy.

PURPOSE

To evaluate the efficacy of intra-articular morphine in combination with clonidine on postoperative pain and narcotic consumption after hip arthroscopy surgery for femoroacetabular impingement.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective chart review was performed on 43 patients that underwent hip arthroscopy for femoroacetabular impingement at a single institution between September 2014 and May 2015. All patients received preoperative celecoxib and acetaminophen, and 22 patients received an additional intra-articular injection of 10 mg morphine and 100 μg of clonidine at the conclusion of the procedure. Narcotic consumption, duration of anesthesia recovery, and perioperative pain scores were compared between the 2 groups.

RESULTS

Patients who received intra-articular morphine and clonidine used significantly less opioid analgesic (mEq) in the postanesthesia recovery (median difference, 17 mEq [95% CI, -32 to -2 mEq]; P = .02) compared with the control group. There were no differences in time spent in recovery before hospital discharge or in visual analog pain scores recorded immediately postoperatively and at 1 hour after surgery.

CONCLUSION

Intraoperative intra-articular injection of morphine and clonidine significantly reduced the narcotic requirement during the postsurgical recovery period after hip arthroscopy. The reduction in postsurgical opioids may decrease adverse effects, improve overall pain management, and lead to better quality of recovery and improved patient satisfaction.

A comparison between fentanyl plus celecoxib therapy and epidural anesthesia for postoperative pain management following laparoscopic gastrectomy

PURPOSE

To clarify the efficacy of postoperative pain management following laparoscopic gastrectomy (LG), we retrospectively compared pain assessments in patients who received fentanyl plus celecoxib with those who received epidural anesthesia.

METHODS

From 2011 to 2012, 55 consecutive LG patients at our institution received 48 h of epidural anesthesia for postoperative pain management (group-E). Since September 2013, epidural anesthesia was replaced with 24 h of intravenous fentanyl and 4 days of oral celecoxib. Thirty-three consecutive LG patients who received this analgesic method (group-FC) were included in this analysis. The severity of postoperative pain as assessed by the FACES Pain Rating Scale and the frequency of rescue pain medication were retrospectively compared between the two groups.

RESULTS

No significant difference in the severity of postoperative pain on postoperative day (POD) 0 or 1 was observed between the two groups. In contrast, pain was significantly lower in group-FC than group-E on PODs 2, 3, 4, and 7. The total use of rescue pain medications during the first 7 days following LG did not differ between the two groups.

CONCLUSION

Pain management using 24 h of intravenous fentanyl and 4 days of oral celecoxib is comparable to epidural anesthesia following LG.

Efficacy of celecoxib for acute pain management following total hip arthroplasty in elderly patients: A prospective, randomized, placebo-control trial

The aim of the present study was to determine whether celecoxib is able to ameliorate pain intensity, provide a narcotic-sparing effect, achieve early ambulation and improve rehabilitation following total hip arthroplasty (THA) in elderly patients. Peri- and post-operative oral celecoxib was administered to verify the efficacy of celecoxib for acute pain management in a multimodal analgesic strategy. All 64 eligible patients were randomly allocated to either the celecoxib group, who took an oral 400 mg capsule of celecoxib peri-operatively and 200 mg per 12 h post-operatively for the first 5 days, or the control group, who were orally treated with a placebo capsule having the same appearance. A multimodal analgesic technique was used in which oral celecoxib or placebo capsule was combined with intravenous patient-controlled analgesia (PCA) morphine pump for peri- and post-operative pain management. Pain assessments were recorded at 6, 12, 24, 48 and 72 h, and 7 and 14 days after THA using the visual analog scale (VAS). PCA morphine consumption; 6, 12, 24 and 48-h post-operative Harris hip score (HHS); time interval until initial ambulation; rates of urinary retention and post-operative nausea and vomiting (PONV) within 72 h; and intra- and post-operative blood loss were also documented. The celecoxib and control groups comprised 34 and 30 patients, respectively. Baseline demographics were comparable between the two groups. The post-operative VAS in the celecoxib group was significantly lower than that in the control group at 12, 24, 48 and 72 h after THA. The post-operative HHS had no significant difference between the two groups, while the time interval until initial ambulation in the celecoxib group (4.5±1.2 days) was significantly less than that in the control group (5.83±2.04 days; P<0.05). Morphine consumption was significantly decreased in the celecoxib group when compared with the control group at 6, 12, 24 and 24 h. Although the 72-h post-operative rates of urinary retention and PONV were lower in the celecoxib group than in the control group, there were no significant differences in these rates between the two groups. The intra- or post-operative blood loss was not significantly different between groups. In conclusion, pre-and post-operative oral celecoxib in a multimodal analgesic strategy can achieve favorable pain relief, reduce opioid consumption, and provide earlier ambulation and improved rehabilitation when compared with PCA morphine alone following THA in elderly patients.