Intraosseous Morphine Decreases Postoperative Pain and Pain Medication Use in Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial

The AAHKS Clinical Research Award: Intraosseous Regional Diclofenac for Postoperative Pain Management in Total Knee Arthroplasty

BACKGROUND

Effective postoperative pain management is important following primary total knee arthroplasty (TKA). Intraosseous regional administration (IORA) of antibiotics in TKA results in higher local tissue concentrations, potentially improving efficacy. We investigated using IORA diclofenac to improve postoperative pain management in TKA compared to intravenous (IV) diclofenac.

METHODS

There were 46 primary TKA patients (twenty-three per group) enrolled in a prospective, double-blinded, randomized controlled trial. The intervention group received 75 mg IORA diclofenac and an IV normal saline placebo. The control group received 75 mg IV diclofenac and an intraosseous (IO) normal saline placebo. The primary outcome was pain measured on a Visual Analog Scale (VAS-P) until postoperative day (POD) seven. The secondary outcomes included opioid consumption, quality of recovery (QoR-15), impact of pain on walking and sleep, length of admission, patient satisfaction, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacements (KOOS, Jr.), and Oxford Knee Score (OKS).

RESULTS

Intervention group VAS-P scores (mm, [95% confidence interval]) were lower at one (21.2 [16.3, 31.4] versus 40.2 [30.8 to 50.8]; P = 0.007), 12 (18.2 [12.1 to 25.6] versus 36.5 [27.6 to 46.6]; P = 0.002), and 24 hours (21.3 [14.6 to 29.2] versus 39.5 [30.2 to 50]; P = 0.003), and POD one (23.5 [17.8 to 30] versus 35.4 [28.3 to 43.3]; P = 0.01). The Intervention group consumed fewer opioids (mean morphine milligram equivalent in mg) from POD zero (20.2 versus 45.3), POD one (27.7 versus 43), POD2 (32.1 versus 51.5), and POD three (27.4 versus 41.3). Moreover, they demonstrated better QoR-15 scores (P = 0.04), POD one walking (P = 0.001) and sleeping (P = 0.003), KOOS Jr. scores (P = 0.03), and patient satisfaction (P = 0.04) at two weeks post-surgery.

CONCLUSION

The IORA diclofenac provided enhanced early postoperative pain relief and reduced opioid consumption, with better early knee function and patient satisfaction following TKA.

Limb Occlusion Pressure Versus Standard Pneumatic Tourniquet Pressure in Anterior Cruciate Ligament Surgery: A Randomized Controlled Trial

BACKGROUND

Tourniquets are frequently used to minimize blood loss. Standard pressures (STPs) are typically higher than minimum limb occlusion pressure (LOP), which can contribute to postoperative pain among other complications. We sought to investigate the effect of STP versus LOP on postoperative pain and opioid medication use after anterior cruciate ligament reconstruction (ACLR).

METHODS

Sixty patients (age = 37 ± 15 years) undergoing ACLR were recruited and randomized into STP (275 mm Hg; M = 15/F = 15) or LOP (180 ± 29 mm Hg; M = 15/F = 15) group. A photoplethysmography probe was used to determine appropriate tourniquet pressures for the LOP group. Tourniquet and surgical site pain (Visual Analog Scale scores 0 to 10), as well as opioid medication usage, was recorded for 14 days after surgery. A generalized linear mixed model was used to detect differences in pain and medication use over the 14 days. The type-I error was defined as = 0.05.

RESULTS

Tourniquet site pain was less in the LOP group during postoperative days (PODs) 1 to 5 (P < 0.05) and averaged across the two-week postoperative period (P = 0.015). Surgery site pain was less in the LOP group at PODs 9 and 14 (P < 0.05). Reduced opioid medication use was observed in the LOP group at PODs 3, 4, and 7 and averaged across the postoperative window (P < 0.05).

CONCLUSION

Individualized LOPs yield decreased postoperative pain and narcotic use compared with STP during ACLR.

Cannabidiol Perceptions and Use in the Orthopaedic Patient Population

Background

Although explored in other medical fields, cannabidiol (CBD) use for pain management remains understudied in orthopaedics. The purpose of this study was to evaluate the frequency of CBD use and perceptions among an orthopaedic population. We hypothesized that most patients would be aware of CBD, that the prevalence of CBD use would at least be comparable with the general population (∼15%), and that the overall perception of CBD use for pain relief would be favorable.

Methods

Five hundred adult orthopaedic patients (♂249/♀247; 4 = undisclosed, 54 ± 16 years, 18-86 years) seeking treatment for a wide range of conditions were recruited from a single hospital system before undergoing surgery. Patients were sent an email with a REDCap link for an anonymous survey that included questions about the following: demographics, procedure type, current pain levels, previous knowledge of and/or use of CBD, and indication of favorability regarding CBD use for pain management.

Results

Among all patients, >80% reported having heard of CBD and 41.8% reported having used CBD. Among patients reporting previous CBD use, "pain management" (79.43%) and "seeking alternative pain treatment" (58.81%) were the most common reasons. Among patients reporting no use, the most common reasons were "unsure of how to obtain" (42.76%) or "lack of familiarity" (37.24%); although the same patients indicated they would consider using if prescription CBD was available (61.22%) along with more evidence regarding safety/efficacy (44.90%). Over 80% of the surveyed patients agreed that CBD might be effective for pain management (p < 0.05).

Conclusion

A large proportion of orthopaedic patients have used, or are aware of, CBD for pain management. Presently, barriers to use appear to be most associated with the need for more evidence regarding efficacy/safety and the availability of physician-prescribed pharmaceutical-grade CBD. These results highlight an important need for large-scale randomized trials that may support pharmaceutical-grade CBD use for pain management.

Level of Evidence

Level III, Descriptive Survey Study. See Instructions for Authors for a complete description of levels of evidence.

Safety and effectiveness of intraosseous regional prophylactic antibiotics in total knee arthroplasty: a systematic review and meta-analysis

BACKGROUND

Intraosseous regional administration (IORA) as a widely applicable and clinically valuable route of administration has gained significant attention in the context of total knee arthroplasty (TKA) for the prophylactic administration of antibiotics. However, there is still controversy regarding its effectiveness and safety. The latest meta-analysis reports that the use of IORA for antibiotics in TKA is as safe and effective as IV administration in preventing prosthetic joint infection (PJI), but they did not separate the statistics for primary TKA and revision TKA, which may be inappropriate. There is currently a lack of evidence specifically comparing the outcomes of prophylactic antibiotic administration via IORA or IV route in primary/revision TKA, respectively, and new research evidence has emerged.

PURPOSES

In this study, we conducted a systematic review and meta-analysis with the primary objective of comparing the local drug tissue concentration and the incidence of PJI between preoperative IORA and intravenous (IV) administration of prophylactic antibiotics in TKA. Additionally, the occurrence of complications between the two administration routes was also compared.

PATIENTS AND METHODS

This meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement (PRISMA) guidelines. Retrospective cohort studies and prospective randomized controlled trials that utilized intraosseous local drug delivery for prophylactic antibiotics in knee arthroplasty were included. English literature from PubMed, Embase, and Cochrane Library databases was searched from the inception of each database until December 2023. Two researchers independently screened the literature, assessed the quality, and extracted data according to the inclusion criteria. The primary outcomes were local antibiotic tissue concentration and postoperative PJI incidence, while the secondary outcome was the occurrence of postoperative complications. Statistical analysis was performed using Review Manager 5.3 software.

RESULTS

This study included 7 prospective randomized controlled trials and 5 retrospective cohort studies. A total of 4091 patients participated in the 12 included studies, with 1,801 cases receiving IORA and 2,290 cases in the control group. In terms of local drug tissue concentration, intraosseous infusion (IO) 500 mg vancomycin significantly increased the drug concentration in the periarticular adipose tissue (SMD: 1.36; 95% CI: 0.87-1.84; P < 0.001; I2 = 0%) and bone tissue (SMD: 0.94; 95% CI: 0.49-1.40; P < 0.001; I2 = 0%) compared to IV 1 g vancomycin. Regarding the incidence of postoperative PJI after primary TKA, IO 500 mg vancomycin was more effective in reducing the occurrence of PJI compared to IV 1 g vancomycin (OR: 0.19; 95% CI: 0.06-0.59; P < 0.001; I2 = 36%). Finally, no significant differences were found between the two groups in terms of postoperative pulmonary embolism (PE) (OR: 1.72; 95% CI: 0.22-13.69; P = 0.59; I2 = 0%) and vancomycin-related complications (OR: 0.54; 95% CI: 0.25-1.19; P = 0.44; I2 = 0%).

CONCLUSIONS

Preoperative prophylactic antibiotic administration via IORA in TKA significantly increases local drug tissue concentration without significantly increasing systemic drug-related complications compared to traditional IV administration. In primary TKA, low-dose vancomycin via IORA is more effective in reducing the incidence of PJI compared to traditional IV regimens. However, its effectiveness remains controversial in high-risk populations for PJI, such as obese, diabetic, and renal insufficiency patients, as well as in revision TKA.

Intraosseous Versus Intravenous Vancomycin in Tourniquetless Primary Total Knee Arthroplasty: A Randomized Trial

BACKGROUND

Intraosseous (IO) administration of vancomycin at the time of total knee arthroplasty (TKA) has been shown to be safer and more effective than intravenous (IV) administration at preventing early periprosthetic joint infection. Previous studies have relied on tourniquet inflation to enhance local tissue concentrations and mitigate systemic release.

METHODS

A single-blinded, randomized clinical trial was performed on 20 patients (10 IV, 10 IO) undergoing primary TKA. The control (IV) group received weight-dosed vancomycin approximately 1 hour prior to the incision and weight-dosed cefazolin immediately prior to the incision. The interventional (IO) group received weight-dosed cefazolin immediately prior to the incision and 500 mg of vancomycin delivered via the IO technique at the time of the incision. Systemic samples for vancomycin levels were taken prior to the incision and at closure. During the procedure, tissue samples were taken from the distal femur, proximal tibia, and suprapatellar synovium. There were no differences in patient demographics or changes in serum creatinine from preoperative to postoperatively between groups.

RESULTS

Significant differences in systemic vancomycin levels (ug/mL) were found at the start of the case (IV = 27.9 ± 4.9 versus IO = 0 ± 0, P = .0004) and at the end of the case (IV = 19.6 ± 2.6 versus IO = 7.8 ± 1.0, P = .001). No significant differences were seen in the average vancomycin concentration in the distal femur (IV = 61.0 ± 16.0 versus IO = 66.2 ± 12.3, P = .80), proximal tibia (IV = 52.8 ± 13.5 versus IO = 57.1 ± 17.0, P = .84), or suprapatellar synovial tissue (IV = 10.7 ± 5.3 versus IO = 9.0 ± 3.3, P = .80). There were no complications associated with vancomycin administration in either group.

CONCLUSIONS

This study demonstrates the utility of IO vancomycin in tourniquetless TKA with similar local tissue and significantly lower systemic concentrations than IV administration.

LEVEL OF EVIDENCE

Level 1 therapeutic randomized trial.

Opioid Consumption After Discharge From Total Knee and Hip Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Pain is challenging after recovery from total knee arthroplasty (TKA) and total hip arthroplasty (THA) procedures, and patients often receive prescription opioids. However, opioid consumption by patients remains unclear, and unused opioids may lead to risks including misuse and diversion. The objective of this systematic review and meta-analysis was to compare prescription size versus patient-reported consumption of opioids after discharge following TKA and THA.

METHODS

PubMed and Embase were systematically searched for publications published between 2015 and 2022 on patient-reported consumption of opioids after TKA and THA. The primary outcome was opioid use in oxycodone 5-mg equivalents. Team members independently reviewed studies for screening, inclusion, data extraction, and risk of bias.

RESULTS

Among the 17 included studies (15 TKA and 11 THA), discharge opioid prescribing exceeded consumption for both TKA (88.4 versus 65.0 pills at 6 weeks) and THA (64.0 versus 29.8 pills at 12 weeks). For both TKA and THA, the range of opioids prescribed varied significantly, by 1.6-fold for TKA and 2.8-fold for THA. Most studies reported pain outcomes (89%) and the use of nonopioid medications (72%). Of the 4 studies offering prescribing recommendations, the amounts ranged from 50 to 104 pills for TKA and 30 to 45 pills for THA.

CONCLUSIONS

Opioid prescribing exceeds the amount consumed following TKA and THA. These findings serve as a call to action to tailor prescribing guidelines to how much patients actually consume while emphasizing the use of nonopioid medications to better optimize recovery from surgery.

Pain in osteoarthritis: Driven by intrinsic rather than extrinsic joint afferents and why this should impact treatment

Pain in osteoarthritis (OA) results from erosion of joint cartilage, resulting in bone contacting bone without an intervening cushion. The periosteum, including its nociceptive innervation, ends at the border of the cartilage. No other innervated tissue is present between the denuded articular bone ends that could serve as a neuronal pathway to carry a bone-on-bone pain signal to the brain. The pain signaling pathway must therefore originate in afferent axons with electrogenic nociceptive sensory endings that reside within the bone itself, specifically in the opposing surfaces of epiphyseal subchondral bone. Selective ablation of this intrinsic nerve pathway, using any of a variety of approaches, is expected to permanently eliminate OA pain.

Effectiveness and safety of auricular acupuncture on adjuvant analgesia in patients with total knee arthroplasty: a randomized sham-controlled trial

Objective

This study aimed to evaluate the effectiveness and safety of auricular acupuncture (AA) on postoperative analgesia, the degree of postoperative nausea, and the effect of inflammation after total knee arthroplasty (TKA).

Methods

This was a single-center, placebo-controlled, randomized clinical trial. In total, 96 patients were randomly divided into an AA group with an indwelling intradermal needle (n = 48) and a sham auricular acupuncture (SAA) group with a non-penetrating placebo needle (n = 48). Intra-spinal anesthesia was adopted in both groups during surgery, and an epidural analgesic pump was implanted after surgery for 48 h. The primary outcome was the post-surgery visual analog score (VAS) of resting and movement states (at 6, 12 h and 1, 2, 3, 5, and 7 days). The secondary outcomes included additional doses of analgesic injection during the treatment, C-reactive protein (CRP) levels, erythrocyte sedimentation rate (ESR), and white blood cell (WBC) count on the 1st, 3rd, and 7th day after the operation, nausea on the 1st, 2nd, and 3rd day after the operation, the Hospital for Special Surgery Knee Score (HSS) on the 2nd and 12th week after the operation, and adverse events.

Results

The VAS in the AA group at 6 h, 12 h, 2, 3, and 5 days after surgery were lower than those of the SAA group (p < 0.05). Among the secondary outcomes, the total dose of additional analgesic injection after surgery in the AA group was lower than that in the SAA group (p < 0.05). The serum CRP on the 1st day after operation in the AA group was lower than that in the SAA group (p < 0.05). The degree of nausea on 2nd day after surgery in the AA group was lower than that in the SAA group (p < 0.05). There was no significant difference in other outcomes (p > 0.05).

Conclusion

In this study, AA was shown to be an effective and safe complementary and alternative therapy for pain relief after TKA, which was able to reduce the total postoperative dose of additional painkillers, decrease serum CRP 1 day after surgery, and improve the degree of postoperative nausea.

Clinical trial registration

www.chictr.org.cn, ChiCTR2100054403.

Efficacy of a Combined Periarticular and Intraosseous Multimodal Analgesic Injection Technique in Simultaneous Bilateral Total Knee Arthroplasty: A Randomized Controlled Trial

Introduction Early postoperative pain poses a challenge for surgeons to manage after total knee arthroplasty (TKA). Various techniques have been employed to optimize pain reduction, including Periarticular Multimodal Analgesia (PMA), recognized as a safe and effective method. Our study aims to enhance PMA through a combined intraosseous injection (PMA-I) and compare it with standard PMA. Methods Forty patients undergoing simultaneous bilateral TKA surgery were enrolled. Patients were randomized to receive PMA-I on one side of the knee, while the contralateral knee received standard PMA. Pain scores, bleeding, and range of motion (ROM) were assessed in both groups. Results The PMA-I group demonstrated statistically significant lower visual analog scale (VAS) scores at all postoperative time points, except at 48 hours, where the difference was not statistically significant. Postoperative bleeding and ROM did not significantly differ between groups. Conclusion PMA-I demonstrated both statistically and clinically significant reduction in early post-TKA pain, without additional costs, providing a technique that can be used to optimize postoperative pain control in TKA.

Intraosseous regional prophylaxis in total knee arthroplasty

Prophylactic antibiotics are important in reducing the risk of periprosthetic joint infection (PJI) following total knee arthroplasty. Their effectiveness depends on the choice of antibiotic and the optimum timing of their administration, to ensure adequate tissue concentrations. Cephalosporins are typically used, but an increasing number of resistant organisms are causing PJI, leading to the additional use of vancomycin. There are difficulties, however, with the systemic administration of vancomycin including its optimal timing, due to the need for prolonged administration, and potential adverse reactions. Intraosseous regional administration distal to a tourniquet is an alternative and attractive mode of delivery due to the ease of obtaining intraosseous access. Many authors have reported the effectiveness of intraosseous prophylaxis in achieving higher concentrations of antibiotic in the tissues compared with intravenous administration, providing equal or enhanced prophylaxis while minimizing adverse effects. This annotation describes the technique of intraosseous administration of antibiotics and summarizes the relevant clinical literature to date.

A multimodal intraosseous infusion of morphine and ketorolac decreases early postoperative pain and opioid consumption following total knee arthroplasty

BACKGROUND

Multimodal pain management regimens and intraosseous infusion of morphine are two novel techniques that show promise in decreasing postoperative pain and opioid consumption following total knee arthroplasty. However, no study has analyzed the intraosseous infusion of a multimodal pain management regimen in this patient population. The purpose of our investigation was to examine the intraosseous administration of a multimodal pain regimen comprised of morphine and ketorolac during total knee arthroplasty with regard to immediate and 2-week postoperative pain, opioid pain medication intake, and nausea levels.

METHODS

In this prospective cohort study with comparisons to a historical control group, 24 patients were prospectively enrolled to receive an intraosseous infusion of morphine and ketorolac dosed according to age-based protocols while undergoing total knee arthroplasty. Immediate and 2-week postoperative Visual Analog Score (VAS) pain scores, opioid pain medication intake, and nausea levels were recorded and compared against a historical control group that received an intraosseous infusion of morphine alone.

RESULTS

During the first four postoperative hours, patients who received the multimodal intraosseous infusion experienced lower VAS pain scores and required less breakthrough intravenous pain medication than those patients in our historical control group. Following this immediate postoperative period, there were no additional differences between groups in terms of pain levels or opioid consumption, and there were no differences in nausea levels between groups at any time.

CONCLUSIONS

Our multimodal intraosseous infusion of morphine and ketorolac dosed according to age-based protocols improved immediate postoperative pain levels and reduced opioid consumption in the immediate postoperative period for patients undergoing total knee arthroplasty.