The effect of morphine added to periarticular multimodal drug injection or spinal anesthesia on pain management and functional recovery after total knee arthroplasty

The use of intrathecal morphine in non-abdominal surgery: a scoping review

Background

Intrathecal morphine can reduce pain and opioid requirements needed for postoperative pain relief. It can potentially aid in the effectiveness of enhanced recovery protocols in non-abdominal surgery. However, concerns about side-effects may have hindered its use. This scoping review evaluates the effectiveness, appropriate dosage, and adverse effects of intrathecal morphine in non-abdominal surgery.

Methods

We systematically searched for randomised controlled trials examining the use of intrathecal morphine in non-abdominal surgery.

Results

The search identified 75 trials involving 4685 patients. We undertook a scoping review of these randomised controlled trials, including bias assessments, to comprehensively analyse the effectiveness and side-effects of intrathecal morphine. The findings indicate that intrathecal morphine reduced postoperative pain and opioid consumption after spinal surgery, thoracic surgery, and orthopaedic lower extremity surgery. However, it was associated with an increased incidence of itching, postoperative nausea and vomiting, and urinary retention, particularly in orthopaedic procedures. Delayed respiratory depression was absent with low to moderate doses (<500 μg) in the reviewed studies.

Conclusions

This review supports the effectiveness of intrathecal morphine in non-abdominal surgery. However, the benefits must be carefully weighed against potential side-effects that could lead to prolonged hospital stays.

Clinical trial registration

PROSPERO-registry CRD42021233936.

Pulmonary complications after intrathecal morphine administration: a systematic review and meta-analysis with meta-regression and trial sequential analysis

INTRODUCTION

Intrathecal morphine provides effective postoperative analgesia, but there are concerns about potential pulmonary complications influencing peri-operative management. We aimed to determine whether there is an association between intrathecal morphine administration and pulmonary complications after non-obstetric surgery. We also aimed to determine whether there was a dose-dependent effect on pulmonary complications.

METHODS

We searched the literature systematically for randomised controlled trials comparing intrathecal morphine vs. control in patients undergoing any type of non-obstetric surgery under general or spinal anaesthesia. Primary outcomes were rates of postoperative sedation, respiratory depression and hypoxaemia. We performed a meta-analysis and meta-regression for each of our outcomes of interest and conducted trial sequential analysis to assess whether the required information size was achieved.

RESULTS

We included 127 trials (7388 patients). Rates of sedation and hypoxaemia were not increased significantly in patients receiving intrathecal morphine (odds ratio 1.00, 95%CI 0.78-1.28, p = 0.98, moderate quality evidence; and 1.22, 95%CI 0.84-1.79, p = 0.30, moderate quality evidence, respectively). There were more episodes of respiratory depression in patients receiving intrathecal morphine than control (odds ratio 1.78, 95%CI 1.19-2.67, p = 0.005, very low-quality evidence), which was no longer significant when morphine doses > 500 μg were not included (odds ratio1.49, 95%CI 0.99-2.23, p = 0.06). Meta-regression revealed associations between dose and rate of sedation, respiratory depression and hypoxaemia, but when doses of > 500 μg were not included, these associations did not persist. Trial sequential analyses suggest that further data may still be required for all outcomes, but statistical significance was reached for respiratory depression.

DISCUSSION

There is moderate evidence that intrathecal morphine does not increase rates of sedation or hypoxaemia after non-obstetric surgery. There is very low-quality evidence that intrathecal morphine might increase the rate of respiratory depression.

Non-pulmonary complications of intrathecal morphine administration: a systematic review and meta-analysis with meta-regression

BACKGROUND

Intrathecal morphine provides effective analgesia for a range of operations. However, widespread implementation into clinical practice is hampered by concerns for potential side-effects. We undertook a systematic review, meta-analysis, and meta-regression with the primary objective of determining whether a threshold dose for non-pulmonary complications could be defined and whether an association could be established between dose and complication rates when intrathecal morphine is administered for perioperative or obstetric analgesia.

METHODS

We systematically searched the literature for randomised controlled trials comparing intrathecal morphine vs control in patients undergoing any type of surgery under general or spinal anaesthesia, or women in labour. Primary outcomes were rates of postoperative nausea and vomiting, pruritus, and urinary retention within the first 24 postoperative hours, analysed according to doses (1-100 μg; 101-200 μg; 201-500 μg; >500 μg), type of surgery, and anaesthetic strategy. Trials were excluded if doses were not specified.

RESULTS

Our analysis included 168 trials with 9917 patients. The rates of postoperative nausea and vomiting, pruritus, and urinary retention were significantly increased in the intrathecal morphine group, with an odds ratio (95% confidence interval) of 1.52 (1.29-1.79), P<0.0001; 6.11 (5.25-7.10), P<0.0001; and 1.73 (1.17-2.56), P=0.005, respectively. Meta-regression could not establish an association between dose and rates of non-pulmonary complications. There was no subgroup difference according to surgery for any outcome. The quality of evidence was low (Grading of Recommendations Assessment, Development, and Evaluation [GRADE] system).

CONCLUSIONS

Intrathecal morphine significantly increased postoperative nausea and vomiting, pruritus, and urinary retention after surgery or labour in a dose-independent manner.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42023387838).

Periarticular injection, iPACK block, and peripheral nerve block in pain management after total knee arthroplasty: a structured narrative review

INTRODUCTION

Total knee arthroplasty (TKA) is commonly performed in patients with end-stage osteoarthritis or rheumatoid arthritis of the knee to reduce joint pain, increase mobility, and improve quality of life. However, TKA is associated with moderate to severe postoperative pain, which remains a significant clinical challenge. Surgeon-administered PAI and anesthesiologist-administered iPACK have proven viable alternatives to conventional peripheral nerve blocks. This review aims to discuss which IPACK block or periarticular injection, combined or not with different peripheral nerve blocks, has better effects on postoperative rehabilitation, patient satisfaction, and overall outcome.

MATERIAL AND METHODS

The literature review was performed on standards of care, current therapeutic options, a pain management protocol, and innovative treatment options for patients undergoing total knee arthroplasty. The literature was reviewed through four electronic databases: PubMed, Cochrane Library, Google Scholar, and Embase.

RESULTS

The initial search yielded 694 articles. Fifty relevant articles were selected based on relevance, recentness, search quality, and citations. Six studies compared PAI to peripheral nerve block (PNB), and eight studies checked the effectiveness of adding PNB to PAI. Three studies compared iPACK to PNB, and ten reviewed the point of adding PNB to iPACK.

CONCLUSIONS

The literature review indicates that the best analgesic effect is obtained by combining PAI or iPACK with a peripheral nerve block, particularly with ACB, due to its analgesic, motor-sparing effect, and satisfactory analgesia.

Periarticular Injection in Total Knee Arthroplasty

Optimal pain management after total knee arthroplasty (TKA) can expedite postoperative recovery, improve perioperative outcomes, and increase patient satisfaction. Periarticular injections (PAIs) have become increasingly used to improve pain management after TKA. Similar to peripheral nerve blocks, the use of intraoperative PAIs can lower pain scores and expedite discharge from the hospital. However, there is notable variability in the ingredients and administration techniques of PAIs. Currently, no standard of care exists for PAIs, especially in the setting of adjuvant peripheral nerve blocks. This study seeks to evaluate the ingredients, administration techniques, and outcomes of PAIs used during TKA.

The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis

BACKGROUND

Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI 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 American Society of Regional Anesthesia and Pain Medicine.

METHODS

The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI 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 PAI.

RESULTS

Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine.

CONCLUSION

Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.

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.

Dexamethasone Does not Compensate for Local Anesthetic Cytotoxic Effects on Tenocytes: Morphine or Morphine Plus Dexamethasone May Be a Safe Alternative

Purpose

The purposes of this in vitro study were to investigate whether the addition of dexamethasone can compensate for any cytotoxic effects of the amide-type local anesthetics (LA) bupivacaine and ropivacaine and whether morphine and morphine-6-glucuronide (M6G) may be a safe alternative for peritendinous application.

Methods

Biopsies of human biceps tendons (n = 6) were dissected and cultivated. Cells were characterized by the expression for tenocyte markers, collagen I, biglycan, tenascin C, scleraxis, and RUNX via reverse transcriptase-polymerase chain reaction and immunohistochemistry. Tenocytes were incubated with bupivacaine, ropivacaine, morphine, M6G, or a saline control with and without addition of dexamethasone for 15, 60, or 240 min. Cell viability was determined by quantifying the presence of adenosine-triphosphate.

Results

Significant time-dependent cytotoxic effects were observed for LA after all exposure times. After 15, 60, and 240 minutes, cell viability decreased to 81.1%, 49.4% and 0% (P < .001) for bupivacaine and to 81.4%, 69.6%, and 9.3% (P < .001) for ropivacaine compared to saline control. Dexamethasone did not compensate for these cytotoxic effects. Cell viability was not affected after 15, 60-min exposures to morphine and M6G but decreased significantly (P < .001) after 240 minutes compared to saline control. However, in combination with dexamethasone, tenocyte viability was significantly increased at all times for morphine (P < .01) and at 15 and 60 minutes for M6G (P < .01).

Conclusions

The results showed that amide-type LA have a time-dependent cytotoxic effect on human tenocytes in vitro, which could not be compensated for by dexamethasone, whereas morphine and M6G had no cytotoxic effects on tenocytes after 15 and 60 minutes. The addition of dexamethasone to morphine and M6G had a positive effect on viability, which increased significantly compared to the opioids.

Clinical Relevance

It is known that amide-type local anesthetics used for local joint analgesia have chondrotoxic side-effects. The combined application of morphine and dexamethasone may be a safe alternative.

Efficacy and safety of intrathecal morphine for analgesia after lower joint arthroplasty: a systematic review and meta-analysis with meta-regression and trial sequential analysis

Widespread adoption of intrathecal morphine into clinical practice is hampered by concerns about its potential side‐effects. We undertook a systematic review, meta‐analysis and trial sequential analysis with the primary objective of determining the efficacy and safety of intrathecal morphine. Our secondary objective was to determine the dose associated with greatest efficacy and safety. We also assessed the impact of intrathecal morphine on respiratory depression. We systematically searched the literature for trials comparing intrathecal morphine with a control group in patients undergoing hip or knee arthroplasty under spinal anaesthesia. Our primary efficacy outcome was rest pain score (0–10) at 8–12 hours; our primary safety outcome was the rate of postoperative nausea and vomiting within 24 hours. Twenty‐nine trials including 1814 patients were identified. Rest pain score at 8–12 hours was significantly reduced in the intrathecal morphine group, with a mean difference (95%CI) of −1.7 (−2.0 to −1.3), p < 0.0001 (19 trials; 1420 patients; high‐quality evidence), without sub‐group differences between doses (p = 0.35). Intrathecal morphine increased postoperative nausea and vomiting, with a risk ratio (95%CI) of 1.4 (1.3–1.6), p < 0.0001 (24 trials; 1603 patients; high‐quality evidence). However, a sub‐group analysis by dose revealed that rates of postoperative nausea and vomiting within 24 hours were similar between groups at a dose of 100 µg, while the risk significantly increased with larger doses (p value for sub‐group difference = 0.02). Patients receiving intrathecal morphine were no more likely to have respiratory depression, the risk ratio (95%CI) being 0.9 (0.5–1.7), p = 0.78 (16 trials; 1173 patients; high‐quality evidence). In conclusion, there is good evidence that intrathecal morphine provides effective analgesia after lower limb arthroplasty, without an increased risk of respiratory depression, but at the expense of an increased rate of postoperative nausea and vomiting. A dose of 100 µg is a ‘ceiling’ dose for analgesia and a threshold dose for increased rate of postoperative nausea and vomiting.

The Effect of Progressive Dynamic Balance Training on Physical Function, The Ability to Balance and Quality of Life Among Elderly Women Who Underwent a Total Knee Arthroplasty: A Double-Blind Randomized Control Trial

Total knee arthroplasty (TKA) is used to treat end-stage osteoarthritis. However, this surgical procedure affects the mechanical receptor function and impairs the ability to balance. Dynamic balance training has been reported to improve stability and self-confidence and safely yield increased physical activity. This study aimed to investigate the effect of dynamic balance training on physical function, the ability to balance and quality of life among patients who underwent TKA. Thirty-eight participants were assigned to either the progressive dynamic balance training (PDBT) with physical therapy group (n = 19) or the control group (n = 19). The experimental group undertook a dynamic balance program with physical therapy for 30 minutes per day, five times per week for six weeks, while the control group undertook physical therapy only. A continuous passive motion exercise was performed for 20 minutes after training by both groups. The outcomes were evaluated using the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index, pain pressure threshold (PPT), range of motion (ROM), Knee Outcome Survey-Activities of Daily Living (KOS-ADLS), Multifunction Force Measuring Plate, timed up and go (TUG) test and Short-Form Health Survey 36 (SF-36). Physical function (WOMAC Osteoarthritis Index, ROM and KOS-ADLS score) and the ability to balance (TUG test score, confidence ellipse area, path length and average velocity) significantly improved (p < 0.05) in the experimental group compared with the control group. In contrast, the physical component summary score for the SF-36 regarding quality of life significantly improved (p < 0.05); however, the mental component summary score for the SF-36 and PPT did not significantly differ between the groups. Therefore, we suggest that PDBT with physical therapy has positive effects on physical function, the ability to balance and quality of life among patients who underwent TKA.