The effect of a single dose of preemptive pregabalin administered with COX-2 inhibitor: a trial in total knee arthroplasty

Efficacy and safety of pregabalin for postoperative pain after total hip and knee arthroplasty: a systematic review and meta-analysis

INTRODUCTION

The prevalence of osteoarthritis and postoperative neuropathic pain after arthroplasty highlights the necessity for improved pain management. Many patients develop chronic neuropathic pain, necessitating targeted interventions. Research on pregabalin's effectiveness in pain relief has yielded conflicting findings, necessitating further exploration to determine its therapeutic value. This study sought to assess pregabalin's efficacy and safety in postoperative pain management, reconcile inconsistent literature, and enhance understanding of its clinical use.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A systematic search was conducted across four major databases to select clinical trials. Statistical analysis was performed using Review Manager 5.4.1, applying fixed- or random-effects models depending on heterogeneity (I2). Subgroup analyses were conducted based on the type, timing, and dosage of pregabalin administered.

RESULTS

Pregabalin was associated with significantly reduced pain during movement at 24 h (MD -0.62, 95%CI -1.02 to -0.23), 48 h (MD -0.53, 95%CI -0.90 to -0.15), and 72 h (MD -0.59, 95%CI -1.05 to -0.12) post-surgery. Opioid consumption was also significantly lower at 24 h (SMD - 0.50, 95%CI -0.80 to -0.20), 48 h (SMD - 0.76, 95%CI -1.34 to -0.19), and 72 h (SMD - 1.33, 95%CI -2.16 to -0.49). While there were no significant improvements in the range of motion at 24 and 48 h, pregabalin was associated with significantly enhanced range of motion at 72 h (SMD 1.11, 95%CI 0.12, 2.09). Treatment with pregabalin was associated with a significant decrease in the odds of nausea (OR 0.30, 95%CI 0.09 to 0.99) and vomiting after total knee arthroplasty (TKA) (OR 0.17, 95%CI 0.04 to 0.65). Additionally, pregabalin exposure was associated with increased sedation after TKA (OR 2.27, 95%CI, 1.13 to 4.56) and total hip arthroplasty (THA) (OR 2.54, 95%CI 1.11 to 5.79), as well as blurred vision at 24 h in TKA/THA patients (OR 4.68, 95%CI 1.37 to 15.99; n = 95; I2 = 34). There was no significant association with other adverse events. The administration of pregabalin for more than 24 h before surgery was associated with maximal reductions in pain and opioid use at 72 h post-surgery.

CONCLUSION

Pregabalin was associated with significantly reduced postoperative pain and opioid use following total joint arthroplasty while enhancing mobility on the third day, with acceptable tolerability and safety.

Is perioperative use of a combination of pregabalin and naproxen superior to naproxen only in reducing pain in ankle fractures? A prospective, randomized, multicenter study

PURPOSE

To compare the analgesic efficacy, adverse effects, and long-term functional outcomes of perioperative naproxen alone versus naproxen with pregabalin for treating pain in ankle fractures.

METHODS

This study included 70 patients who underwent operative fixation of rotatory ankle fractures. Group A received naproxen 500 mg only, and Group B received naproxen 500 mg with pregabalin 75 mg 2-hour before surgery and 12 hourly for 14 days thereafter. The minimal clinically important difference of the visual analog scale (VAS) for pain was set at 1.8 out of 10. VAS for pain, opioid consumption, and any adverse effects were recorded for 3 days postoperatively. VAS for pain was checked at 2- and 6-weeks and 3- and 6-months, and functional outcomes were measured at 3- and 6-months postoperatively.

RESULTS

Sixty-three patients (33 and 30 in groups A and B, respectively) completed the 6-month follow-up. Demographic data were similar between groups. VAS for pain did not significantly differ between the groups at any timepoint up to 6 months (P ≥ 0.520), with 95% confidence intervals consistently within 1.8. No significant differences were observed between groups in opioid consumption and functional outcomes (P ≥ 0.211). In group B, dizziness at 48-hour and somnolence at 72-hour were significantly predominant (P ≤ 0.05).

CONCLUSION

Our study demonstrated comparable pain reduction between two groups following operative fixation of rotatory ankle fractures. However, side effects, including dizziness and somnolence, were predominant in Group B between 48 and 72 h.

Efficacy of Oral Nefopam on Multimodal Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial

BACKGROUND

Multimodal analgesia is central to pain management after total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding oral nefopam to multimodal analgesia for post-TKA pain management.

METHODS

In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to either the nefopam or the control group. After surgery, patients in the nefopam group received 200 mg of celecoxib, 150 mg of pregabalin, and 40 mg of nefopam twice daily to control postoperative pain. Patients in the control group received 200 mg of celecoxib, 150 mg of pregabalin, and a placebo. Oxycodone hydrochloride (10 mg) was used as the rescue analgesic. If the pain remained poorly controlled, 10 mg of morphine hydrochloride was injected subcutaneously as a secondary rescue analgesic. The primary outcome was the postoperative consumption of oxycodone and morphine as rescue analgesics. Secondary outcomes were postoperative pain assessed using the visual analogue scale (VAS), functional recovery assessed by the range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates.

RESULTS

Patients in the nefopam group had significantly lower postoperative oxycodone and morphine consumption within 24 hours after surgery and during hospitalization, lower VAS pain scores at rest and during motion within 24 h after surgery, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. However, the absolute reduction in 0 to 24 h opioid consumption, VAS pain scores, and knee range of motion did not exceed the reported minimal clinically important difference. Both groups had similar indicators of liver function and complication rates.

CONCLUSIONS

Adding oral nefopam to multimodal analgesia resulted in statistically significant improvements in opioid consumption, VAS pain scores, and functional recovery. However, the amount of improvement may not be clinically important.

The Impact of Gabapentinoids on Pain-Related Outcomes after Knee and Hip Surgery: A Systematic Review with Meta-Analysis of Randomized Controlled Trials

Background: Postoperative pain remains a significant challenge after knee and hip surgeries, two of the most frequently performed procedures, preventing patients from seeking timely surgical help. Gabapentinoids, gabapentin, and pregabalin, have been gaining attention in postoperative pain management. Methods: We conducted a meta-analysis to evaluate the efficacy of gabapentinoids in pain management after knee and hip surgery. PubMed, Scopus, and Cochrane Library were searched for relevant randomized controlled trials (RCTs) published before January 2023. Results: Fifteen articles reporting 1320 patients were analyzed. Cumulative pain intensity at rest and on movement was lower in the experimental group with the mean difference (MD) = -0.30 [-0.55,-0.05], p-value = 0.02, and MD = -0.41 [-0.68,-0.13], p-value = 0.004, respectively. However, the difference was not clinically meaningful and lacked statistical significance at each time period. The gabapentinoid group required less opioid consumption in morphine equivalents (MD = -6.42 [-9.07, -3.78] mg, p-value < 0.001). There was a lower incidence of postoperative nausea in the experimental group with a risk ratio (RR) of 0.69 [0.55, 0.86], p-value < 0.001. A subgroup analysis showed that gabapentinoids reduced pain on movement on postoperative day two after total knee arthroplasty but not hip arthroplasty. There was insufficient data to examine the efficacy of gabapentinoids in the reduction of chronic postoperative pain in knee/hip surgery. Conclusions: Thus, gabapentinoids were associated with a reduction in postoperative pain intensity at rest and on movement, morphine consumption, and the incidence of postoperative nausea in the early postoperative period following knee and hip surgeries. However, pain reduction was not clinically relevant. Sedation has not been evaluated in this work and, if performed, this may have influenced the conclusions. An important limitation of this study is that different gabapentinoids, their administration times and dosages, as well as varying intraoperative management protocols, were pooled together.

Efficacy of Adding Acetaminophen to Preemptive Multimodal Analgesia in Total Knee Arthroplasty: A Double-blinded Randomized Study

OBJECTIVE

Preemptive multimodal analgesia is a frequently utilized method for controlling pain after total knee arthroplasty (TKA). So far, no studies have specifically examined the efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA. The current work aimed to assess the efficacy of adding acetaminophen to preemptive multimodal analgesia for clinical pain management after TKA.

METHODS

This was a double-blinded randomized study including 80 cases randomized to the acetaminophen and control groups, respectively. The acetaminophen group was administered celecoxib at 400 mg, pregabalin at 150 mg, and acetaminophen at 300 mg 2 h before TKA. Control patients were administered celecoxib, pregabalin, and placebo. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes included the time to the initial rescue analgesia, postsurgical pain as determined by a visual analogue scale (VAS), functional recovery as reflected by the range of knee motion and ambulation distance, hospitalization duration, and complication rates. Continuous data with normal and skewed distributions were compared by the Student's t test and the Mann-Whitney U test, respectively. Categorical variables were compared by the Pearson's chi-squared test.

RESULTS

The control and acetaminophen groups were comparable in postoperative 0-24 h morphine consumption (11.3 ± 6.5 mg vs 12.3 ± 7.7 mg, P = 0.445) and total morphine consumption (17.3 ± 10.1 mg vs 19.3 ± 9.4 mg, P = 0.242). Additionally, time to the initial rescue analgesia, postoperative VAS score at any time point, postoperative functional recovery of the knee, and hospitalization duration were similar in both groups. Both groups also had similar occurrence rates of postoperative complications.

CONCLUSIONS

In this study, adding acetaminophen to preoperative preemptive multimodal analgesia did not decrease postoperative morphine use or ameliorate pain relief. The efficacy of adding acetaminophen to preemptive multimodal analgesia in TKA need to be further explored in future studies.

Comparison of the effects of preoperative celecoxib and gabapentin on pain, functional recovery, and quality of life after total knee arthroplasty: A randomized controlled clinical trial

Background

Acute pain is one of the main complaints of patients after total knee arthroplasty (TKA), which causes delayed mobility, increased morphine consumption, and subsequently increased costs. Therefore, the present study was performed to evaluate the preventive effect of preoperative celecoxib and gabapentin on reducing patient pain as a primary outcome after TKA surgery.

Materials and Methods

This randomized, double-blind controlled clinical trial was performed on 270 patients with osteoarthritis that were candidates for TKA surgery allocated into three groups. In the first group, 900 mg of gabapentin was administered orally on a daily basis for 3 days before surgery. In the second group, 200 mg of oral celecoxib was administered twice daily for 3 days before surgery. In the third group, oral placebo was administered twice daily for 3 days before the surgery. The patients' pain score and knee and its functional score were recoded.

Results

The mean of reduction pain in gabapentin and celecoxib groups was significantly lower than that of the control group at 12, 24, and 48 h after surgery (P < 0.001); however, two groups were not significantly different from each other (P > 0.05). Furthermore, the two medication groups were not significantly different in this regard (P > 0.05). In addition, the knee score in the gabapentin group with the means of 85.40 ± 5.47 and the celecoxib group with the means of 87.03 ± 3.97 were significantly higher than those of the control group with the means of 78.90 ± 4.39 in the 1^st month after the surgery (P < 0.001).

Conclusion

According to the results of the present study, the preventive administration of gabapentin and celecoxib showed a significant and similar effectiveness on reducing patient pain after TKA surgery and on improving the KSS and quality of life scores.

Positive Preemptive Analgesia Effectiveness of Pregabalin Combined with Celecoxib in Total Knee Arthroplasty: A Prospective Controlled Randomized Study

Objective

The purpose of the present study (a randomized clinical trial) was to evaluate the preemptive analgesic effects of pregabalin combined with celecoxib in total knee arthroplasty (TKA).

Methods

From January 2019 to June 2021, we enrolled 149 patients who underwent TKA and divided them into four groups: the placebo group (n = 36), celecoxib group (n = 38), pregabalin group (n = 38), and combination group (n = 37). Each group was given the corresponding preemptive analgesia regimen at 12 and 2 hours before surgery. The pain score at rest and upon movement, cumulative dosage of sufentanil, knee range of motion (ROM), high-sensitivityC-reactive protein (hs-CRP) level, and adverse effects were evaluated after TKA to compare the effects of the preemptive analgesia regimens among the four groups.

Results

The pain scores upon movement were significantly lower in the combination group than in the other three groups at 6, 12, 24, and 48 hours after surgery (P < 0.05). The cumulative dose of sufentanil within 48 hours after surgery was lowest in the combined group among the four groups (P < 0.05). Hs-CRP, ROM, and postoperative nausea and vomiting (PONV) were within 72 hours after surgery significantly improved in the combination group compared with those of the three other groups (P < 0.05).

Conclusion

The preemptive analgesia regimen of pregabalin combined with celecoxib had positive effects on improving acute pain and reducing the cumulative dose of opioids after TKA. This trial is registered with ChiCTR2100041595.

Efficacy of Opioids in Preemptive Multimodal Analgesia for Total Knee Arthroplasty: A Prospective, Double-Blind, Placebo-Controlled, Randomized Trial

BACKGROUND

Preemptive multimodal analgesia is a commonly used technique to control pain following total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of pre-emptive opioids for pain management in patients who underwent TKA.

METHODS

In this prospective, double-blind, placebo-controlled, randomized trial, 100 patients who underwent TKA at our hospital were randomized to the oxycodone or control group. At 2 hours before surgery, patients in the oxycodone group received 400 mg celecoxib, 150 mg pregabalin, and 10 mg extended-release oxycodone hydrochloride. Patients in the control group received 400 mg celecoxib, 150 mg pregabalin, and placebo. The primary outcome was postoperative consumption of morphine hydrochloride as rescue analgesia. Secondary outcomes were time to first rescue analgesia, postoperative pain assessed by the visual analogue scale, functional recovery assessed by range of knee motion and ambulation distance, time until hospital discharge, indicators of liver function, and complication rates.

RESULTS

The 2 groups were similar in mean postoperative 0 to 24 hour morphine consumption (11.4 mg for control versus 12.4 mg for oxycodone group, P = .419) and mean total morphine consumption (18.2 versus 19.8 mg, P = .227). There were no statistical differences in secondary outcomes.

CONCLUSIONS

In our study, preemptive opioid administration did not provide clinical benefits over placebo. Orthopaedic surgeons should consider not using pre-operative opioids in patients undergoing TKA.

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.

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.

The preemptive effects of oral pregabalin on perioperative pain management in lower limb orthopedic surgery: a systematic review and meta-analysis

BACKGROUND

To systematically review the literature and provide a comprehensive understanding of the preemptive effects of oral pregabalin on perioperative pain management in lower limb orthopedic surgery.

METHOD

We searched three electronic databases for randomized controlled trials comparing the results of preoperative pregabalin and placebo in patients undergoing lower limb orthopedic surgery. Data analyses were conducted using RevMan 5.4.

RESULTS

Twenty-one randomized controlled trials met our inclusion criteria. The cumulative opioid consumption within 24 and 48 h postoperatively in the pregabalin group was significantly less than that in the placebo group. The pooled static pain intensity at all time points within the first day was significantly lower in the pregabalin group than in the placebo group. Lower dynamic pain intensity at 48 h was detected in the pregabalin group than in the placebo group. Meanwhile, pregabalin led to a lower incidence of nausea but appeared to be associated with a higher incidence of dizziness and sedation. Subgroup analyses showed that no difference was detected between subgroups stratified by dosing regimen or pregabalin dose in the results of opioid consumption, pain intensity and incidence of complications.

CONCLUSION

This meta-analysis supports the use of pregabalin preoperatively in patients undergoing lower limb orthopedic surgery. However, it was wary of the resulting increase in dizziness and sedation. There is no evidence to support the continued use of pregabalin postoperatively or using more than 150 mg of pregabalin per day.

TRIAL REGISTRATION

This study was registered on 09 November 2021 with INPLASY (registration number: INPLASY2021110031).

Pre-emptive analgesia with methylprednisolone and gabapentin in total knee arthroplasty in the elderly

The aim of this study is to assess whether administration of gabapentin and methylprednisolone as “pre-emptive analgesia” in a group of patients above 65 years of age would be effective in complex pain management therapy following total knee arthroplasty (TKA). One hundred seventy patients above 65 years were qualified for the study, with exclusion of 10 patients due to clinical circumstances. One hundred sixty patients were randomly double-blinded into two groups: the study group (80 patients) and the control group (80 patients). The study group received as “pre-emptive” analgesia a single dose of 300 mg oral (PO) gabapentin and 125 mg intravenous (IV) methylprednisolone, while the control received a placebo. All patients received opioid and non-opioid analgesic agents perioperatively calculated for 1 kg of total body weight. We measured (1) pain intensity level at rest (numerical rating scale, NRS), (2) life parameters, (3) levels of inflammatory markers (leukocytosis, C reactive protein CRP), and (4) all complications. Following administration of gabapentin and methylprednisolone as “pre-emptive” analgesia, the NRS score at rest was calculated at 6, 12 (p < 0.000001), 18 (p < 0.00004) and 24 (p = 0.005569) h postoperatively. Methylprednisolone with gabapentin significantly decreased the dose of parenteral opioid preparations (p = 0.000006). The duration time of analgesia was significantly longer in study group (p < 0.000001), with CRP values lower on all postoperative days (1, 2 days—p < 0.00001, 3 days—p = 0.00538), and leukocytosis on day 2 (p < 0.0086) and 3 (p < 0.00042). No infectious complications were observed in the first postoperative days; in the control group, one patient manifested transient ischemic attack (TIA). The use of gabapentin and methylprednisolone as a single dose decreased the level of postoperative pain on the day of surgery, the dose of opioid analgesic preparations, and the level of inflammatory parameters without infectious processes.

Postoperative outcomes of total knee arthroplasty across varying levels of multimodal pain management protocol adherence

We examined the effect of varying multimodal pain management (MMPM) combinations on oral morphine milligram equivalents (OMME) and length of stay (LOS) after total knee arthroplasty (TKA). Five groups were compared based on the combination of multimodal analgesics ranging from no MMPM to full MMPM with acetaminophen, gabapentinoids, and celecoxib. After risk adjustment, MMPM was associated with decreased odds of LOS ≥2 days and OMME ≥75th percentile. MMPM protocols are effective at reducing LOS and postoperative narcotic requirements post-TKA. Patients appear to derive similar benefit from receiving all three medications, as well as various combinations of these drugs.

Efficacy and safety between early use and late use of celecoxib in hip osteoarthritis patients who receive total hip arthroplasty: a randomized, controlled study

Celecoxib is commonly used for pain management after total hip arthroplasty (THA), while the optimal timing of analgesic celecoxib remains unclear. This randomized, controlled study aimed to investigate the pain control efficacy and safety of preoperative celecoxib versus postoperative celecoxib in osteoarthritis (OA) patients undergoing THA. Totally, 192 hip OA patients about to undergo THA were randomized into pre-treatment group (N = 96) and post-treatment group (N = 96). The former was given 400 mg celecoxib at 4 h before THA, 200 mg at 4 h after THA, and then 200 mg every 12 h until 72 h post-operation. The latter was given 400 mg celecoxib at 4 h after THA, and then 200 mg every 12 h until 72 h post-operation. Pain at rest visual analog scale (VAS) score at 6 h, and pain at flexion VAS scores at 6 h, 12 h, and on D1, D2 were decreased in pre-treatment group compared to post-treatment group (all P < 0.05). Furthermore, additional consumption of patient-controlled analgesia (PCA) (P = 0.006) and total consumption of PCA (P = 0.006) were both reduced in pre-treatment group compared to post-treatment group. Meanwhile, compared to post-treatment group, patient satisfaction in pre-treatment group was higher on D1 (P = 0.010) and D2 (P = 0.039). While, Harris hip score showed no difference between pre-treatment group and post-treatment group on M1 or M3 (both P > 0.05). In conclusion, preoperative celecoxib exhibits better analgesic efficacy and patients' satisfaction management with similar tolerance compared to postoperative celecoxib in hip OA patients undergoing THA.

An Update on Multimodal Pain Management After Total Joint Arthroplasty

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Multimodal analgesia has become the standard of care for total joint arthroplasty as it provides superior analgesia with fewer side effects than opioid-only protocols.

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Systemic medications, including nonsteroidal anti-inflammatory drugs, acetaminophen, corticosteroids, and gabapentinoids, and local anesthetics via local infiltration analgesia and peripheral nerve blocks, are the foundation of multimodal analgesia in total joint arthroplasty.

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Ideally, multimodal analgesia should begin preoperatively and continue throughout the perioperative period and beyond discharge.

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There is insufficient evidence to support the routine use of intravenous acetaminophen or liposomal bupivacaine as part of multimodal analgesia protocols.

Meta-analyses of gabapentinoids for pain management after knee arthroplasty: A caveat emptor? A narrative review

The use of gabapentinoids for perioperative pain management after total knee arthroplasty has been the subject of nine systematic reviews and meta-analyses. A critical analysis of the clinical aspects of the methodology of these publications shows major flaws which limit the interpretation for the recommended use of perioperative gabapentinoids in pain management for unilateral primary total knee arthroplasty. Consequently, readers and authors of systematic reviews and meta-analyses should critically assess the clinical aspects of the included studies.

Evaluation of analgesic efficacy and opioid sparing effect of pregabalin after arthroscopic rotator cuff repair surgery: A retrospective cohort study

BACKGROUND

Considering the adverse effects of opioids, it is essential to minimize their consumption for postoperative pain control. Studies have reported the opioid sparing effects of pregabalin, with conflicting results. Evidence for administering pregabalin in a multimodal regimen after arthroscopic rotator cuff repair surgery is limited.

METHODS

A total of 64 patients who underwent arthroscopic rotator cuff repair were enrolled in the cohort, and their data were retrospectively analyzed to evaluate the ability of pregabalin for postoperative analgesia and opioid sparing. The pregabalin group (n = 32) received additional pregabalin 75 mg for 2 weeks from the day before the surgery with the standard pain medications; in contrast, the control group (n = 32) was prescribed the standard pain medications alone. The total volume of patient-controlled anesthesia, doses of oral oxycodone and intravenous morphine as rescue analgesics, number of adverse events, and patient satisfaction based on the numeric rating scale (0-10) were assessed. Further, we used the visual analog scale for evaluating pain and function for 6 months in each group.

RESULTS

Total patient-controlled anesthesia volume, number of patient-controlled anesthesia attempts on the day of surgery, and total oral oxycodone consumption were significantly lower in the pregabalin group. Visual analog scale scores for pain and function showed no significant differences. Although the total number of adverse effects (nausea, vomiting, dizziness, dry mouth, urinary retention, itching sense, or constipation) was higher in the pregabalin group than in the control group, the difference was not statistically significant.

CONCLUSION

Our multimodal regimen with pregabalin significantly reduced opioid consumption with similar adverse effects. However, there was no significant difference in the pain score. We recommend pregabalin as an additional analgesic for arthroscopic rotator cuff repairs, especially for medium to large sized tears.

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.

Perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty

Knee osteoarthritis is a common arthritic disease which mainly affects the elderly (≥65 years old) population. As a result of the cartilage degeneration, it can cause a significant amount of pain and functional limitation. In patients who are refractory to conservative management, total knee arthroplasty is being utilised as the last resort in management. In this review, we discuss the perioperative management of elderly patients with osteoarthritis requiring total knee arthroplasty.

Effects of preoperative, scheduled administration of antiemetics in reducing postoperative nausea and vomiting in patients undergoing total knee arthroplasty

There is no established protocol regarding the timing of administration of antiemetics in patients undergoing total knee arthroplasty (TKA). The purpose of this study was to determine whether preoperative, rather than postoperative administration of an antiemetic could reduce postoperative nausea and vomiting (PONV) in patients undergoing TKA, and whether there was a difference in postoperative pain, patient satisfaction and complications after TKA between the 2 different administration times.The included patients (N = 101) either received intravenous administration of the ramosetron 1 hour before surgery (N = 50) or at the end of surgery (N = 51) consecutively order. The incidence of PONV and the frequency of rescue medicine use were recorded until 48 hours postoperatively. The severity of postoperative pain and patient satisfaction were assessed using the visual analogue scale. The incidence of complications associated with use of antiemetic was assessed.Preoperative administration of ramosetron did not decrease PONV during the first 48 hours. There was no significant difference in the incidence of nausea and vomiting, use of rescue antiemetics, and the severity of nausea (P > .05). Postoperative pain, satisfaction scores, and the incidence of complications were not different between the 2 groups (P > .05).Preoperative administration of ramosetron did not show clinical advantage in reducing POVN, postoperative pain and improving patient satisfaction. However, the outcomes of complications were not inferior to those of postoperative administration. Therefore, under the current protocol of multimodal therapies, timing of administration of pre-emptive antiemetic did not have significant effect on PONV.

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

BACKGROUND

Gabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids 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 prior to November 2018 on gabapentinoids 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 gabapentinoids.

RESULTS

In total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption.

CONCLUSION

Moderate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids.

Pain Pathways and Nervous System Plasticity: Learning and Memory in Pain

Objective This article reviews the structural and functional changes in pain chronification and explores the association between memory and the development of chronic pain. Methods PubMed was searched using the terms "chronic pain," "central sensitization," "learning," "memory," "long-term potentiation," "long-term depression," and "pain memory." Relevant findings were synthesized into a narrative of the processes affecting pain chronification. Results Pain pathways represent a complex sensory system with cognitive, emotional, and behavioral influences. Anatomically, the hippocampus, amygdala, and anterior cortex-central to the encoding and consolidation of memory-are also implicated in experiential aspects of pain. Common neurotransmitters and similar mechanisms of neural plasticity (eg, central sensitization, long-term potentiation) suggest a mechanistic overlap between chronic pain and memory. These anatomic and mechanistic correlates indicate that chronic pain and memory intimately interact on several levels. Longitudinal imaging studies suggest that spatiotemporal reorganization of brain activity accompanies the transition to chronic pain, during which the representation of pain gradually shifts from sensory to emotional and limbic structures. Conclusions The chronification of pain can be conceptualized as activity-induced plasticity of the limbic-cortical circuitry resulting in reorganization of the neocortex. The state of the limbic-cortical network determines whether nociceptive signals are transient or chronic by extinguishing pathways or amplifying signals that intensify the emotional component of nociceptive inputs. Thus, chronic pain can be seen as the persistence of the memory of pain and/or the inability to extinguish painful memories. Ideally, pharmacologic, physical, and/or psychological approaches should reverse the reorganization accompanying chronic pain.

The Impact of Epinephrine in the Periarticular Injection Cocktail using Ropivacaine for Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Comparison Study

BACKGROUND

Epinephrine is used in periarticular injection using ropivacaine to produce a synergistic effect when used with local anesthetic agents but the effect has not been proven yet. The purpose of this study is to evaluate how effective epinephrine is on postoperative clinical outcomes in primary total knee arthroplasty (TKA).

METHODS

One hundred sixteen cases (89 patients) who underwent primary TKA were randomized into 2 groups depending on whether epinephrine was mixed. Immediately after the operation, patient-controlled analgesia using fentanyl was initiated. The Numerical Rating Scale, the cumulative dose of fentanyl, active range of motion of the knee joint, and wound complications were evaluated postoperatively.

RESULTS

There were no significant differences in mean postoperative Numerical Rating Scale, cumulative dose of fentanyl, and active range of motion between the 2 groups. Neither skin necrosis nor wound dehiscence requiring operative management for skin care was required in either group.

CONCLUSION

The use of epinephrine in periarticular injection using ropivacaine after TKA did not have any effect on postoperative acute pain control and opioid usage.

THE LEVEL OF EVIDENCE

Therapeutic level I.

Combination Preemptive Peripheral Nerve Block in Limb Surgery. A Prospective Study

Background and objectives: Patients often suffer from moderate to severe pain during the early recovery period in orthopedic surgery. We investigated the impact of a single-shot preoperative peripheral nerve block (PNB) on post-anesthesia recovery parameters and interleukin (IL)-6 level during limb surgery. Materials and Methods: A prospective randomized controlled study was conducted, and patients scheduled for limb surgery were recruited. Sixty patients were randomly assigned to either the PNB group or control group, who received morphine as a primary analgesic. The peak verbal numeric rating scale (NRS) score in the post-anesthesia care unit (PACU) was evaluated as a primary outcome. We also recorded rescue analgesics requirement and wake-up time from anesthesia in the PACU. In addition, the change of plasma IL-6 level after incision was measured. Results: Fifty-two patients completed the study, 27 and 25 cases in the PNB and control group, respectively. Preemptive PNB significantly reduced peak NRS score in the PACU compared to control group. Lower rescue analgesics requirement and rapid wake-up from anesthesia were also noted in PNB group. The IL-6 concentration increased less in the PNB group at 2 h after incision. Conclusions: Preemptive PNB attenuates IL-6 expression 2 h after incision and improves pain management in the PACU. PNB was considered as an essential part of pain management in limb surgery.

Evaluation of the Efficacy of Prolonged Pregabalin Administration Before and After Surgery in Patients Undergoing Arthroscopic Anterior Cruciate Ligament Repair: A Prospective, Randomized, Double-blind Study

CONTEXT AND OBJECTIVE

Reconstruction of the knee ligament causes postoperative pain and delayed rehabilitation.

OBJECTIVE

The primary objective of this study was to evaluate the effect of a prolonged preoperative and postoperative pregabalin use for arthroscopic anterior cruciate ligament repair.

MATERIALS AND METHODS

Group 1 (N=25) patients received pregabalin 75 mg/d, and group 2 (N=25) received placebo, 7 days before and 7 days after surgery. Spinal anesthesia was performed using 0.5% hyperbaric bupivacaine (15 mg). The following were evaluated: pain intensity immediately after the surgery, and 12 hours, 24 hours, 1 week, 2 weeks, 1 month, and 2 months after the surgery using a Numerical Rating Scale; dose of postoperative supplementary analgesic for 2 months; time to first analgesic requirement; and side effects during 2 months. For supplementation, the participants received 1 g dipyrone; if there was no pain control, 100 mg ketoprofen was administered; if there was no effect, 100 mg tramadol was administered; and if there was no pain control, 5 mg intravenous morphine was administered until pain control.

RESULTS

There was no difference between the groups with regard to pain intensity (P=0.077). In the pregabalin group, morphine consumption was lower at 12 hours (P=0.039) and 24 hours (P=0.044) after surgery, and the consumption of tramadol and ketoprofen was lower 24 hours after surgery. There was no significant difference in the incidence of nausea and vomiting. Dizziness was higher in the pregabalin group (group 1=12 patients; group 2=3 patients; P=0.005).

DISCUSSION

A prolonged preoperative and postoperative pregabalin prescription for anterior cruciate ligament repair decreased the need for supplementary analgesics during the first 24 postoperative hours but increased dizziness.

Perioperative pregabalin does not reduce opioid requirements in total knee arthroplasty

PURPOSE

The purpose of this prospective, randomized, double-blinded, placebo-controlled study was to determine if pregabalin, when given perioperatively in addition to patient-controlled analgesia morphine, paracetamol and etoricoxib, is effective in reducing morphine requirements and moderating pain scores after primary total knee arthroplasty. We hypothesize that there would be no difference in postoperative opioid requirements, postoperative pain scores, and functional scores with the use of perioperative pregabalin.

METHODS

Eighty-seven patients who underwent primary total knee arthroplasty were randomised and allocated to two groups. One group received capsules containing pregabalin 75 mg, and the other a placebo-one capsule before surgery and one capsule once per night up till postoperative day 2. Multimodal analgesia provided for all patients in this study included femoral nerve block, intravenous patient-controlled analgesia (morphine), paracetamol and etoricoxib. The primary outcome of patient's pain control was based on the measurement of cumulative morphine consumption during the first 72 h postoperatively.

RESULTS

Pregabalin did not reduce the cumulative or effective morphine consumption at 48 h and 72 h post-operation. There were also no significant differences noted in pain scores at 48 h and 72 h after surgery, functional range of motion of the operated knee at 72 h post-op, or outcomes recorded on the Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and 36-Item Short Form Survey (SF-36) questionnaires at 3 and 6 months post-op. None of the patients demonstrated common adverse reactions to pregabalin.

CONCLUSION

This study showed no reduction in postoperative opioid requirements, or improvement in early postoperative pain scores or functional outcomes at 6 months, with perioperative use of pregabalin. Orthopaedic surgeons may consider this when selecting an analgesic regimen for their patients.

LEVEL OF EVIDENCE

II.

Timing of periarticular injection has no effect on postoperative pain and functional recovery in simultaneous bilateral total knee arthroplasty: a prospective randomized, double-blinded trial

BACKGROUND

Given no consensus on optimal timeframe of periarticular multimodal drug injection (PMDI) in knee osteoarthritis patients undergoing total knee arthroplasty (TKA), this study was aimed to compare the postoperative pain and the functional recovery in patients who underwent simultaneous bilateral TKA (SBTKA) and received PMDI at the different intraoperative time points.

METHODS

This prospective, randomized, double-blinded controlled trial study included 48 patients who underwent SBTKA and received PMDI mixture, either before prosthetic implantation (late PMDI), or just after knee arthrotomy (early PMDI). Each subject's knees were randomly selected to different PMDI administration time points. The outcome parameters were postoperative pain assessed by using a visual analog scale (VAS), the maximal angle of knee flexion, and quadriceps function from day 1 to 6 weeks after surgery.

RESULTS

Late PMDI revealed slightly higher VAS at 6 and 12 h after the operation than early PMDI administration. Afterward, the VAS tended to be lower in the late than early PMDI administration until the end of the study, but without statistical significance. The time difference between early and late PMDI had no effect on postoperative VAS, while older age resulted in significantly less pain. No statistical differences between the two groups in all other outcome parameters were observed.

CONCLUSIONS

Postoperative pain reduction and functional recovery of SBTKA with early and late PMDI administration were not significantly different. The time interval of PMDI between knees did not confound the comparison of postoperative pain and functional recovery in SBTKA.

TRIAL REGISTRATION

The protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database No. TCTR20170617001 on 16 June 2017.

Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review

BACKGROUND

Elective total joint arthroplasty may be a gateway to long-term opioid use.

QUESTIONS/PURPOSE

We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

METHODS

We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies.

RESULTS

Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA.

CONCLUSIONS

The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.

Preoperative celecoxib analgesia is more efficient and equally tolerated compared to postoperative celecoxib analgesia in knee osteoarthritis patients undergoing total knee arthroplasty: A randomized, controlled study

The aim of the present study was to evaluate the efficacy and safety of preoperative celecoxib administration in alleviating postoperative pain in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA).A total of 226 knee OA patients underwent TKA were consecutively recruited and randomized into preoperative analgesia group and postoperative analgesia group as 1:1 ratio. Preoperative analgesia group received celecoxib before and post operation; postoperative analgesia group received celecoxib post operation, all patients received TKA and intravenous patient-controlled analgesia (PCA) post operation. Pain visual analog scale (VAS), patient's global assessment (PGA), flexional angles, PCA consumption, percentage of patients receiving pethidine, pethidine consumption, and adverse events were assessed.Pain VAS scores at rest and at flexion were both lower in preoperative analgesia group compared to postoperative analgesia group at 2 hours, 6 hours, 12 hours, and 24 hours post operation. Preoperative analgesia group also exhibited decreased PGA score compared to postoperative analgesia group at 2 hours, 6 hours, 12 hours, 24 hours, and 48 hours post operation. Meanwhile, active flexional angle and passive flexional angle in preoperative analgesia group were larger than that in postoperative analgesia group at 72 hours post operation. More interestingly, preoperative analgesia group patients consumed less PCA compared to postoperative analgesia group patients at 72 hours post operation. No difference of adverse event incidences between 2 groups was observed.Preoperative administration of celecoxib exhibits better efficacy and equal safety profiles compared to postoperative administration of celecoxib in knee OA patients undergoing TKA.

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

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

A Multimodal Analgesic Protocol Reduces Opioid-Related Adverse Events and Improves Patient Outcomes in Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed procedures for the treatment of obesity. Patients with obesity are more prone to experience opioid-related adverse events (ORAE).

OBJECTIVES

The objective of this study is to determine if a multimodal analgesia protocol (MAP) reduces ORAE and provides effective pain relief for patients after LSG.

SETTING

This study was conducted at University Hospital, Singapore.

METHODS

The MAP consists of mandatory pre-operative etoricoxib, intra-operative acetaminophen, and post-operative acetaminophen with optional post-operative tramadol. We identified and collected data for patients who underwent LSG between May 2010 and November 2015 and compared patients before and after the implementation of the MAP.

RESULTS

One hundred fifty-eight patients were included and 68 patients were treated with the MAP. There were no differences in age, gender, body mass index, ethnicity, or comorbidities between the two groups except for the incidence of hypertension (p = 0.015). There was a significant reduction in the incidence of ORAE from 33.3 to 8.8% (p < 0.001) after the implementation of the MAP. There was also a significant reduction in the use of opioids intra-operatively from 58.2 to 43.6 mg (p < 0.001) and post-operatively from 23.7 to 0.7 mg (p < 0.001). Pain scores were similar at 1, 6, and 48 post-operatively, while pain scores were significantly reduced at 12 (p = 0.033) and 24 h (p = 0.02) post-operatively. Multivariate analysis showed that these results remained significant.

CONCLUSION

Our study suggests that a MAP reduces ORAE and provides effective pain relief for patients undergoing LSG.

Ketamine and bupivacaine attenuate post-operative pain following total knee arthroplasty: A randomized clinical trial

Total knee arthroplasty (TKA) is highly associated with post-operative pain. The present randomized trial aimed to explore the possible post-operative pain management by a different combination of analgesics or opioids (ketamine and bupivacaine) following TKA. A total of 84 patients were randomly divided into four groups. All subjects were anesthetized for TKA surgery and received post-operative pain management via intra-articular saline (control group; n=23), ketamine (2 mg/kg) infused with saline (ket group; n=21) bupivacaine (0.5 mg/kg) infused with saline (bupi group; n=20) or ketamine (2 mg/kg)+bupivacaine (0.5 mg/kg) infused with saline (ket+bupi group; n=20) at the end of the surgery. Additional, post-operative analgesia was infused with the aid of patient-controlled analgesia with morphine. A reduction in the levels of pain score (verbal rating scale and visual analog scale), opioid consumption, time of ambulation, hospital stay and adverse events were observed in the ket+bupi group compared with the other groups. Meanwhile, the satisfaction score and knee flexion degree were improved following treatment with the ket+bupi regimen. Therefore, the multimodal analgesic regimen (ket+bupi) may be useful in mitigating post-operative pain as and improving knee mobilization following TKA.

Is pregabalin effective and safe in total knee arthroplasty? A PRISMA-compliant meta-analysis of randomized-controlled trials

BACKGROUND

Pain management after total knee arthroplasty (TKA) varies and has been investigated for years. Pregabalin as an anticonvulsant agent that selectively affects the nociceptive process has been used for pain relief after operation. This meta-analysis was conducted to examine the evidence of pregabalin in TKA.

METHODS

Systematic searches of all related literatures were conducted using the following databases: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Only randomized-controlled trials (RCTs) for TKA were included. The postoperative narcotic requirements, visual analog scale scores, knee flexion range, and relative risk of incidence rate of adverse effects in the pregabalin group versus placebo group were extracted throughout the study.

RESULTS

Seven placebo-controlled RCTs met the inclusion criteria. The use of pregabalin significantly decrease the postoperative total morphine consumption (P < .05) and increase the passive knee flexion range (P < .05). Compared with the control group, the incidence of some side effects (nausea, vomiting, pruritus, and constipation) was less in the pregabalin group (P < .05).

CONCLUSIONS

The administration of pregabalin is not only efficacious in the reduction of narcotic requirements and incidence of some adverse effect, but also workable for the improvement of passive knee flexion range after TKA.

Postoperative pain treatment after total knee arthroplasty: A systematic review

INTRODUCTION

The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA).

METHODS

This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L'Abbe Plots and trial sequential analysis.

RESULTS

The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low.

CONCLUSION

A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA.

The effect of pregabalin and s-ketamine in total knee arthroplasty patients: A randomized trial

BACKGROUND AND AIMS

Pain reduction is important for rehabilitation after total knee arthroplasty. Intra- and peri-articular infiltration with local anesthetics may be an alternative to commonly used locoregional techniques. Adding pregabalin orally and s-ketamine intravenously may further reduce postoperative pain.

MATERIAL AND METHODS

This prospective, randomized, double-blind, placebo-controlled study compared two methods of perioperative analgesia. Control patients received a standardized multimodal postoperative analgesic regime of paracetamol, diclofenac, and piritramide-patient-controlled analgesia, including ropivacaine knee infiltration during surgery. The study group received pregabalin orally and s-ketamine intravenously as an additional medication to the standard multimodal regimen. The control group received placebo.

RESULTS

The study group showed lower piritramide consumption during the first 24 h (P: 0.043), but with more side effects such as diplopia and dizziness.

CONCLUSION

Addition of pregabalin and s-ketamine resulted in lower piritramide consumption during the first 24 h postoperatively. However, more investigation on benefits versus side effects of this medication is required.

The effect of pregabalin on acute postoperative pain in patients undergoing total knee arthroplasty: A meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis of randomised controlled trials (RCTs) was to evaluate the effect of pain control of pregabalin versus placebo after a total knee arthroplasty (TKA).

METHODS

The electronic databases: Medline, Embase, PubMed, CENTRAL (Cochrane Controlled Trials Register), Web of Science and Google were searched from inception to February 2016. This systematic review and meta-analysis were performed according to the PRISMA statement criteria. The primary endpoint was the visual analogue scale (VAS) after a TKA with rest or mobilization at 24 h and 48 h, which represents the effect of pain control after TKA. The cumulative morphine consumption is also assessed to the morphine-sparing effect. The complications of nausea, vomiting, dizziness and sedation were also compiled to assess the safety of pregabalin. Software Stata 12.0 was used for the meta-analysis. After testing for publication bias and heterogeneity across studies, data were aggregated for random-effects modelling when necessary.

RESULTS

Six clinical trials with 769 patients were used for the meta-analysis. The meta-analysis indicated that pregabalin can decrease the VAS with rest at 24 h (MD = -8.14; 95% CI -12.57 to -3.71; P < 0.001) and 48 h (MD = -7.34; 95% CI -11.65 to -3.02; P < 0.001). Pregabalin can decrease the VAS with mobilization at 24 h (MD = -6.56; 95% CI -10.45 to -2.66; P = 0.001) and 48 h (MD = -9.62; 95% CI -12.80 to -6.44; P < 0.001). The results indicated that perioperative pregabalin can decrease the cumulative morphine consumption at 24 h (SMD = -0.97; 95% CI -1.17 to -0.78; P < 0.001) and 48 h (MD = -2.23; 95% CI -2.48 to -1.97; P < 0.001). Moreover, pregabalin can decrease the occurrence of nausea and vomiting but increase the occurrence of dizziness and sedation.

CONCLUSION

Based on the current meta-analysis, pregabalin has an analgesic and opioid-sparing effect in acute postoperative pain management without increasing the rate of nausea, vomiting.

A Meta-Analysis on the Use of Gabapentinoids for the Treatment of Acute Postoperative Pain Following Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty is a painful procedure, with approximately half of patients reporting severe pain during the early postoperative period. Gabapentinoids are used as an adjunct for the management of acute pain in approximately half of enhanced recovery programs. We performed a meta-analysis to assess the effectiveness and safety of gabapentinoids for the treatment of acute postoperative pain following total knee arthroplasty.

METHODS

Randomized controlled trials of patients undergoing elective primary total knee arthroplasty that compared the use of the gabapentinoid class of drugs (gabapentin [Neurontin; Pfizer]) or pregabalin [Lyrica; Pfizer]) with that of placebo were retrieved, with 12 studies meeting inclusion criteria. The primary outcome was pain intensity with activity at 48 hours following the surgical procedure. The secondary outcomes included pain intensity at other time points, opioid consumption, knee function, incidence of chronic pain, and adverse events.

RESULTS

No difference in pain score at 12, 24, 48, or 72 hours following the surgical procedure was seen between gabapentin and placebo. Although pregabalin was associated with reduced pain scores at 24 and 48 hours, this corresponded to a reduction of 0.5 point (95% confidence interval, 0 to 1.0 point) at 24 hours and 0.3 point (95% confidence interval, 0 to 0.6 point) at 48 hours on an 11-point numeric rating scale, which was assessed as not clinically important. Overall, no clinically relevant reduction in pain scores was associated with the use of gabapentinoids. Likewise, gabapentinoids were associated with a small, but not clinically important, reduction in cumulative opioid consumption at 48 hours (mean difference, -23.2 mg [95% confidence interval, -40.9 to -5.4 mg]). There was no difference in knee flexion at 48 hours (p = 0.63) or in the incidence of chronic pain at 3 months (p = 0.31) or 6 months (p = 0.54) associated with the use of gabapentinoids. Although gabapentinoids were associated with a significant reduction in the incidence of nausea (risk ratio, 0.7 [95% confidence interval, 0.6 to 0.9]; p < 0.001), pregabalin was also associated with a significant, clinically relevant increase in the risk of sedation (risk ratio, 1.4 [95% confidence interval, 1.1 to 1.9]; p = 0.02).

CONCLUSIONS

On the basis of this meta-analysis, we found no evidence to support the routine use of gabapentinoids in the management of acute pain following total knee arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Pregabalin for Refractory Radicular Leg Pain due to Lumbar Spinal Stenosis: A Preliminary Prospective Study

We investigated the efficacy of pregabalin (PGB) for neuropathic leg pain in lumbar spinal stenosis (LSS) patients with disturbed activities of daily living (ADL)/quality of life (QOL) in a prospective observational study. Subjects were a total of 104 LSS patients with neuropathic pain (NeP) in leg and neurological intermittent claudication (IMC) refractory to nonsteroidal anti-inflammatory drugs (NSAIDs) for at least a month. NeP was identified using screening tool, Pain DETECT questionnaire. Visual analog scale (VAS) scores and responses to the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) were assessed before and 6 weeks after PGB treatment initiation. Changes in IMC distance and adverse events were also recorded. PGB significantly improved their VAS scores for pain and sleep quality (P < 0.001). With respect to JOABPEQ, significant improvements were observed with regard to the following dimensions: pain-related disorders (P < 0.01), lumbar spine dysfunction (P = 0.031), gait disturbance (P = 0.028), and psychological disorders (P = 0.014). The IMC distance showed an improvement tendency after PGB treatment, albeit with no significance (P = 0.063). Minor adverse events such as dizziness were observed. PGB can be effective for neuropathic leg pain refractory to NSAIDs in LSS patients, resulting in not only pain control but also improving lower back pain-related ADL/QOL scores.

Efficacy of Pregabalin in Acute Postoperative Pain Under Different Surgical Categories: A Meta-Analysis

The efficacy of pregabalin in acute postsurgical pain has been demonstrated in numerous studies; however, the analgesic efficacy and adverse effects of using pregabalin in various surgical procedures remain uncertain. We aim to assess the postsurgical analgesic efficacy and adverse events after pregabalin administration under different surgical categories using a systematic review and meta-analysis of randomized controlled trials.A search of the literature was performed between August 2014 to April 2015, using PubMed, Ovid via EMBASE, Google Scholar, and ClinicalTrials.gov with no limitation on publication year or language. Studies considered for inclusion were randomized controlled trials, reporting on relevant outcomes (2-, 24-hour pain scores, or 24 hour morphine-equivalent consumption) with treatment with perioperative pregabalin.Seventy-four studies were included. Pregabalin reduced pain scores at 2 hours in all categories: cardiothoracic (Hedge's g and 95%CI, -0.442 [-0.752 to -0.132], P = 0.005), ENT (Hedge g and 95%CI, -0.684 [-1.051 to -0.316], P < 0.0001), gynecologic (Hedge g, 95%CI, -0.792 [-1.235 to -0.350], P < 0.0001), laparoscopic cholecystectomy (Hedge g, 95%CI, -0.600 [-0.989 to -0.210], P = 0.003), orthopedic (Hedge g, 95%CI, -0.507 [-0.812 to -0.202], P = 0.001), spine (Hedge g, 95%CI, -0.972 [-1.537 to -0.407], P = 0.001), and miscellaneous procedures (Hedge g, 95%CI, -1.976 [-2.654 to -1.297], P < 0.0001). Pregabalin reduced 24-hour morphine consumption in gynecologic (Hedge g, 95%CI, -1.085 [-1.582 to -0.441], P = 0.001), laparoscopic cholecystectomy (Hedge g, 95%CI, -0.886 [-1.652 to -0.120], P = 0.023), orthopedic (Hedge g, 95%CI, -0.720 [-1.118 to -0.323], P < 0.0001), spine (Hedge g, 95%CI, -1.016 [-1.732 to -0.300], P = 0.005), and miscellaneous procedures (Hedge g, 95%CI, -1.329 [-2.286 to -0.372], P = 0.006). Pregabalin resulted in significant sedation in all surgical categories except ENT, laparoscopic cholecystectomy, and gynecologic procedures. Postoperative nausea and vomiting was only significant after pregabalin in miscellaneous procedures.Analgesic effects and incidence of adverse effects of using pregabalin are not equal in different surgical categories.