Local ketorolac infiltration for postoperative pain in open trigger finger surgery: a randomized controlled trial

BACKGROUND

Multimodal analgesia is crucial for effective postoperative pain management in minor hand surgeries, enhancing patient satisfaction. The use of local wound infiltration with Ketorolac as an adjuvant pain management strategy is proposed for open trigger finger release surgery. This study aims to compare pain scores and functional outcomes between local wound infiltration with Ketorolac and oral non-steroidal anti-inflammatory drugs.

METHODS

This study is a double-blind, parallel design, randomized controlled trials. Sixty-nine patients underwent trigger finger surgery between December 2021 and October 2022 were randomized into one of three groups: oral Ibuprofen alone group, local Ketorolac alone group and local Ketorolac with oral Ibuprofen group. The assessment included postoperative numeric rating scale (NRS) pain score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, grip strength, mobility of proximal interphalangeal (PIP) joint. and complications.

RESULTS

NRS pain scores during movement of the operated fingers were significantly lower at 6 h in local Ketorolac alone group and local Ketorolac with oral Ibuprofen group compared to oral Ibuprofen alone group. However, there were no significant differences between the groups in postoperative DASH scores, grip strength, mobility of PIP joints, and complications.

CONCLUSIONS

Local infiltration of Ketorolac as an adjunct in postoperative pain management has been shown to provide superior analgesia during finger movement within the initial 6 h following trigger finger surgery, in comparison to oral NSAIDs.

CLINICAL TRIAL REGISTRATION

Thaiclinicaltrials.org identifier: TCTR20210825002. Registered 25/08/2021. https://www.thaiclinicaltrials.org/show/TCTR20210825002.

Optimised fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications

PURPOSE

This literature review aims to present evidence-based clinical recommendations for the eight most debated topics related to perioperative management in total knee arthroplasty: counselling, prehabilitation, transfusion risk, tranexamic acid, drainage, analgesia, urinary catheter and compression stockings.

METHODS

A multidisciplinary team conducted a systematic review on these topics. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the literature review and result presentation. The research encompassed articles from 1 January 2009 to 28 February 2023, retrieved through the MEDLINE database via PubMed, Embase database and Cochrane Library.

RESULTS

Forty-five articles were selected. Preoperative counselling has limited evidence for its impact on postoperative outcomes; yet, it can help alleviate surgery-related anxiety and manage postoperative symptoms. Prehabilitation can also prepare patients for surgery, reducing hospital stays and improving postsurgery functionality. Numerous studies suggest that preoperative Hb levels are independently linked to transfusion risk, with a recommended level of 13 g/dL. Combining intravenous and local tranexamic acid administration is strongly advised to reduce perioperative blood loss, while drainage after primary total knee arthroplasty offers no functional advantages. Employing a multimodal analgesia approach yields better results with reduced opioid usage. Indwelling urinary catheters provide no benefit and avoiding them can lower the risk of urinary tract infections. As for compression stockings, there is insufficient evidence in the literature to support their efficacy in preventing venous thromboembolism.

CONCLUSION

The best-track protocol has demonstrated its efficacy in reducing hospitalisation time and perioperative/postoperative complications. It is success relies on a collaborative, resource-adaptive approach led by a multidisciplinary team. Both patients and hospitals benefit from this approach, as it enhances care quality and lowers costs. Several studies have highlighted the significance of a patient-centred approach in achieving high-quality care. Creating a novel treatment protocol could be a prospective goal in the near future.

LEVEL OF EVIDENCE

Level III.

The Efficacy of the Combination of Continuous Femoral Nerve Block and Intravenous Parecoxib on Rehabilitation in Patients Undergoing Total Knee Arthroplasty: A Double-Blind, Randomized Clinical Trial

BACKGROUND AND AIM

The optimal strategy for the management of postoperative pain after total knee arthroplasty (TKA) remains challenging, while its treatment is crucial to increase patients' outcomes. This study aimed to investigate the effects of parecoxib as add-on therapy, in a standard postoperative pain management protocol, represented by the continuous femoral nervous block. We studied its influence on rehabilitation indices and pain scores in patients undergoing TKA.

MATERIAL AND METHODS

This is a single-center, prospective, double-blind, randomized, placebo-controlled trial. All patients were operated with the use of subarachnoid anesthesia, and divided into two groups for postoperative analgesia. Both groups received a continuous femoral nerve block. One of the groups received intravenous parecoxib, while the other received a placebo. The primary investigated outcome was the range of motion (ROM). Recordings were noted at different times postoperatively. Bromage score (BS), visual analog scale (VAS), and the State-Trait Anxiety Inventory (STAI) were also studied.

RESULTS

A total of 90 patients were included and analyzed. ROM was significantly better (p<0.001) and pain scores were significantly lower (p=0.007) in the parecoxib group. No statistically significant difference was found with regard to BS between the two groups. A significant correlation was found between ROM and VAS pain scores at 12 hours (p=0.02), while ROM was inversely correlated with STAI postoperatively.

CONCLUSIONS

The use of intravenous parecoxib is effective in improving rehabilitation indices and provides decreased postoperative pain scores after TKA.

Periarticular infiltration used in total joint replacements: an update and review article

Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.

Comparing preemptive injection of peri-articular-multimodal drug with oral celexocib for postoperative pain management in total knee arthroplasty: A randomized clinical trial

Background

Total knee arthroplasty (TKA) is associated with tremendous postoperative pain, and pain relief should concisely be considered. This study aims to compare the efficacy of preemptive periarticular multimodal drug injection versus placebo and oral celecoxib on postoperative pain control after TKA.

Materials and Methods

This study is a randomized clinical trial on 146 patients candidate for TKA who were randomly allocated to three treatment groups, including (1) a cocktail consisting of bupivacaine, morphine, epinephrine, and ketorolac (n = 48), (2) only epinephrine (placebo group) (n = 49), and (3) 400 mg celecoxib orally (control group) (n = 49) using the Random Allocation software. The injections and oral therapy were performed within 15 min before the surgical procedure. The study's primary outcome was the Knee Society Score (KSS) calculated at baseline, within 6 weeks and 6 months postoperatively. Range of motion (ROM) and Visual Analog Scale (VAS) to assess pain intensity as the other primary outcomes were evaluated before the procedure, within 24 h, 48 h, and 6 weeks postoperatively.

Results

The three studied groups were similar regarding demographic characteristics, including age (P = 0.33), gender distribution (P = 0.65), and involved knee side (P = 0.94). Baseline comparison of KSS (P = 0.39), VAS (P = 0.24), and ROM (P = 0.37) among the groups revealed insignificant differences. All the studied groups showed a statistically significant trend of improvement in KSS, VAS, and ROM (P < 0.001), while the comparison of the three groups in terms of KSS (P = 0.001), VAS (P < 0.001), and ROM (P < 0.001) revealed remarkable superiority of multimodal injection to the other treatments.

Conclusion

Preemptive periarticular multimodal drug injection, including bupivacaine, morphine, epinephrine, and ketorolac, can cause considerable postoperative pain relief and better ROM achievement in comparison to placebo or oral celecoxib.

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.

Stability and compatibility of admixtures containing bupivacaine hydrochloride and ketorolac tromethamine for parenteral use

OBJECTIVE

Bupivacaine hydrochloride (BH) and ketorolac tromethamine (KT) are commonly used in parenteral admixtures to manage postoperative pain. However, stability and compatibility data for these admixtures applicable to current practice are limited, posing the patient to potential risk.

METHODS

The stability of BH/KT admixtures in commonly used parenteral fluids was studied in Eppendorf tubes and glass vials at ambient room temperature using a newly developed and validated stability-indicating high-performance liquid chromatography (HPLC) method capable of the simultaneous quantification of both drugs. The chemical compatibility of BH/KT was assessed using Fourier transform infrared spectroscopy (FTIR) and thermal analysis. Additionally, the validity of the developed HPLC method for the quantification of BH/KT in human plasma was evaluated.

RESULTS

BH and KT demonstrated <10% loss of their initial concentrations when prepared in Ringer, normal saline or dextrose solution at ambient temperature for up to 4 weeks. FTIR and thermal analysis demonstrated mild intermolecular interactions between BH and KT in solution, with no evidence of incompatibility. The developed HPLC method demonstrated satisfactory accuracy and precision for the simultaneous quantification of BH and KT in human plasma over the range of 0.2-3.2 µg·mL-1.

CONCLUSION

BH/KT parenteral admixtures are chemically stable for a period of 4 weeks when stored at room temperature. The stability-indicating HPLC method is valid for BH/KT simultaneous determination in human plasma, facilitating pharmacokinetics studies.

The effect and safety of periarticular multimodal drug injection without morphine and epinephrine in anterior cruciate ligament reconstruction

Background

Periarticular multimodal drug injection (PMDI) is a safe and effective pain management technique after anterior cruciate ligament reconstruction (ACLR); however, adding morphine and epinephrine sometimes causes adverse effects. Therefore, we evaluated the efficacy of PMDI without morphine and epinephrine after ACLR.

Methods

This retrospective matched case-control study included patients who had undergone primary double-bundle ACLR with PMDI and were then matched one-to-one with a control group without PMDI based on sex, age, and body mass index using propensity-matched analysis. The following clinical outcomes were compared between the groups: visual analog scale (VAS) score, C-reactive protein (CRP) concentration, number of times the patients used additional analgesics, complication rate, and postoperative time to achieve straight leg raise (SLR).

Results

Twenty-nine patients with PMDI and 29 controls were enrolled. The VAS score at 1 day postoperatively was lower in the PMDI than the control group (1.93  ±  1.44 vs. 3.41  ±  1.75, respectively; P < 0.001). The CRP concentration at 1 and 3 days was lower in the PMDI than the control group (0.46  ±  0.47 vs. 1.00  ±  0.69 mg/dL, P < 0.001; and 1.93  ±  1.71 vs. 4.01  ±  2.55 mg/dL, P < 0.001, respectively). The average number of additional analgesics used was significantly lower in the PMDI than the control group. There were no significant differences in the frequency of occurrence of postoperative complications between the two groups. The number of patients who could achieve SLR within 1 day was 27/29 (93%) in PMDI group, which was significantly higher than the control group (12/29, 41%) ( P < 0.001).

Conclusion

PMDI without morphine and epinephrine after ACLR reduced patients’ subjective pain level, objective inflammatory response without complications and enabled patients to achieve early functional recovery.

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.

Periarticular Injection of Ketorolac Augmenting Intravenous Administration of Ketorolac for Postoperative Pain Control: A Randomized Controlled Trial in Simultaneous Bilateral Total Knee Arthroplasty

Adequate postoperative pain control with minimal side effects is necessary for patients undergoing total knee arthroplasty (TKA). Ketorolac is a frequently used nonsteroidal anti-inflammatory drug due to its excellent disposition in all administration routes; however, it possesses an "analgesic ceiling," which means that higher doses of the drug have no additional analgesic effect. Alternatively, increasing the local concentration of ketorolac via periarticular injection may provide additional pain relief to parenteral administration of ketorolac, but evidence demonstrating the benefits and safety of this approach is limited. Therefore, this study assesses whether local ketorolac injection could yield additional pain reduction to intravenous administration of ketorolac. A total of 54 patients who underwent simultaneous bilateral TKA were enrolled. Randomization was performed to determine whether 50 mg of bupivacaine plus 30 mg of ketorolac (ketorolac group), or only 50 mg bupivacaine (bupivacaine group) would be periarticularly injected into the first knee operated on (more painful), and then the contralateral knee would receive another mixture. Ketorolac (30 mg) was intravenously given every 8 hours for the first 48 hours. Visual analog scales (VASs) were used to assess pain, knee recovery function, and patients' preferred knee. Postoperative VAS pain scores in the ketorolac group were lower than those in the bupivacaine group 6 to 96 hours postoperatively and reached statistical significance 12 (4.25 ± 2.38 vs. 5.06 ± 2.48, respectively; p = 0.04) and 24 hours (4.22 ± 1.94 vs. 5.30 ± 2.12, respectively; p < 0.01) postoperatively. The ketorolac group had higher degrees of knee flexion and straight leg raise. No patient experienced adverse effects of ketorolac. On the day of discharge, 61.11% of the patients favored the knee that received local ketorolac injection (p < 0.01). Adjunct local ketorolac injection to systemic administration is well tolerated and may improve its analgesic effect as determined by the patients' perception.

Adding a low-concentration sciatic nerve block to total knee arthroplasty in patients susceptible to the adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs): a randomized controlled trial

Background

This study compared the effects of adductor canal blocks with those of a low concentration of popliteal-sciatic nerve block (SNB) and dexamethasone as an adjunctive technique for total knee arthroplasties (TKA) in patients susceptible to the adverse effects of NSAIDs.

Methods

A prospective, double-blinded, randomized controlled trial was performed in 50 patients susceptible to the adverse effects of NSAIDs undergoing unilateral TKAs. All patients received spinal anesthesia, adductor canal blocks, and periarticular infiltration. The 25 patients in the intervention group received SNB (0.125% bupivacaine [20 ml] and dexamethasone [5 mg]).

Results

The SNB group significantly had lower median resting pain scores at 6, 12, and 18 h: the control group, 1 (0–4.5), 3 (0–5), and 3 (2–5); the intervention group, 0 (0–0), 0 (0–3), and 1 (0–3); p-values, 0.012, 0.021, and 0.010, respectively. Movement-evoked pain scores at 6, 12, and 18 h were also lower: control group, 3 (0–5.5), 5 (2.5–6.5), and 7 (4–9); intervention group, 0 (0–1.5), 2 (0–4), and 3 (2–5); p-values, 0.019, 0.005, and 0.001, respectively. There were no differences in motor function. Moreover, the mean morphine consumption 24 h was also reduced in the SNB group: control group, 3.80 ± 2.48 mg; intervention group, 1.96 ± 2 mg; p-value, 0.005.

Conclusion

For patients susceptible to the adverse effects of NSAIDs, a low concentration of SNB and dexamethasone is an effective adjunctive technique for early postoperative pain control (especially on movement) following TKAs, without an increase in motor weakness.

Trial registration

ClinicalTrials.gov, NCT03486548, Registered 3 April 2018.

Comparison between Local Infiltration Analgesia and Ultrasound Guided Single Shot Adductor Canal Block Post Total Knee Replacement Surgery - A Randomized Controlled Trial

Context:

Good quality analgesia posttotal knee arthroplasty (TKA) contributes majorly to early mobilization and shorter hospital stay.

Aim:

To compare adductor canal block (ACB) versus local infiltration analgesia (LIA) for postoperative pain relief in patients undergoing TKA.

Settings and Design:

This prospective, single-blind, randomized controlled trial was undertaken at a tertiary care university hospital.

Materials and Methods:

Sixty patients of American Society of Anesthesiologists physical status Classes I, II, and III, who received spinal anesthesia for TKA were randomly allocated to two groups. Group A patients had LIA of the knee joint using a mixture of 50 mL of 0.25% bupivacaine, 10 mg morphine (1 mL) and 99 mL of normal saline. Group B patients received ACB using 25 mL of 0.5% bupivacaine under ultrasound guidance. All patients received multimodal analgesia comprising of paracetamol, diclofenac, and patient controlled analgesia with morphine in the first 24 h' postoperative period. The primary outcome measures were first 24 h' morphine consumption and pain scores at 4, 6, 8, 12, and 24 h. The secondary outcome measures were nausea/vomiting, sedation, and patient satisfaction scores.

Statistical Analysis:

Statistical analysis was performed using the Student's t-test, Mann–Whitney test, and Chi-square test.

Results:

The 24 h morphine consumption was 11.97 ± 7.97 and 10.83 ± 6.41 mg in the LIA group and ACB group, respectively (P = 0.54). No significant differences were noted either in the pain scores at rest and flexion or secondary outcome measures between both groups in the first 24 h.

Conclusion:

Single-shot ACB is equally effective as LIA as postoperative analgesia for TKA.

An Update on Multimodal Pain Management After Total Joint Arthroplasty

➤

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.

➤

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.

➤

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

➤

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

A Comparative Study of Periarticular Infiltration with Dexmedetomidine versus Ketorolac as an Additive to Ropivacaine after Total Knee Arthroplasty: A Prospective, Randomized Double-Blind Study

Background:

Periarticular infiltration (PAI) analgesia has been found to be an effective analgesia modality after total knee arthroplasty (TKA). Dexmedetomidine has many beneficial effects on postoperative analgesia by different routes, but studies on PAI are lagging.

Aims and Objectives:

In this study, we compared postoperative analgesia after PAI with dexmedetomidine versus ketorolac as an additive to ropivacaine after TKA.

Setting and Design:

This is a prospective, randomized, double-blind study conducted on 75 patients belonging to American Society of Anesthesiologists I to III, undergoing total knee arthroplasty, of either gender, belonging to American Society of Anesthesiologists I to III.

Materials and Methods:

After institutional ethics committee approval and written informed consent, patients were randomly allocated into three groups. Group C (n = 25) received cocktail of 60 mL ropivacaine (0.25%) infiltration with adrenaline 5 mL (0.1 mg.mL⁻¹), Group D (n = 25) received additive dexmedetomidine 1 ug.kg⁻¹ to above cocktail, and Group K (n = 25) received ketorolac 30 mg. Postoperatively pain by Visual Analog Scale, vitals, total duration of analgesia, need for rescue analgesia, sedation, patient satisfaction, mobilization time, and complications were recorded.

Statistical Analysis:

The Statistical Package for the Social Sciences version 20 was used for statistical analysis. Analysis of variance has been used to find the significance of study parameters between the three groups of patients. P < 0.05 was considered statistically significant.

Results:

Postoperative pain score was lesser in the ketorolac group (1.52 ± 0.71, P = 0.001) than the other two groups. Duration of analgesia was more with ketorolac (343.00 ± 144.45, P < 0.001) compared with the other two groups, and epidural activation timings (462 ± 235.84) were significantly delayed in Group K compared to Group C and Group D. There was no significant difference in mobilization time, patient satisfaction, and complications between the three groups.

Conclusion:

Ketorolac was a better additive to ropivacaine than dexmedetomidine for postoperative analgesia after TKA.

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.

Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis

BACKGROUND

Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief.

METHODS

A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications.

RESULTS

Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups.

CONCLUSION

Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade.

LEVEL OF EVIDENCE

Level 1, randomized controlled trial.

A randomized controlled trial comparing the efficacies of ketorolac and parecoxib for early pain management after total knee arthroplasty

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to reduce pain after orthopedic surgery. Currently, selective COX-2 inhibitors can provide effective pain reduction with less platelet inhibition compared with conventional NSAIDs. We aimed to compare the analgesic effect and perioperative blood loss (PBL) after total knee arthroplasty (TKA) between ketorolac and parecoxib administration.

METHODS

We conducted a prospective randomized controlled study of 100 unilateral TKAs. The ketorolac group of 50 patients received an intraoperative periarticular injection (PAI) with 100 mg of bupivacaine and 30 mg of ketorolac. Afterwards, 30 mg of ketorolac was intravenously injected every 12 h until 48 h. In the parecoxib group of 50 patients, 20 mg of parecoxib was added to PAI, and the first intravenous dose was 20 mg followed by 40 mg every 12 h. The primary outcomes were visual analog scales (VASs) of postoperative pain, amount of morphine consumption, PBL, and blood transfusion rate.

RESULTS

The ketorolac group had a significantly lower VAS pain score than the parecoxib group at 6 h after TKA (2.38 ± 2.52 vs. 4.12 ± 2.86, P < 0.01). Thereafter, the VAS of both groups and total morphine consumption at 24 and 48 h were comparable. The PBLs of the ketorolac and parecoxib groups were 529.72 ± 263.02 and 402.40 ± 191.47 ml, respectively (P = 0.01). However, the blood transfusion rates between groups were not different.

CONCLUSION

Parecoxib provides comparable analgesic effects to ketorolac. Additionally, perioperative use of parecoxib is safe and is associated with significantly less blood loss after TKA.

Diclofenac Versus Ketorolac for Pain Control After Primary Total Joint Arthroplasty: A Comparative Analysis

Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients' satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student's t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.

Population Pharmacokinetics of Periarticular Ketorolac in Adult Patients Undergoing Total Hip or Total Knee Replacement Surgery

BACKGROUND

Ketorolac tromethamine has been used for joint infiltration by the orthopedic surgeons as a part of postoperative multimodal analgesia. The objective of this study is to investigate the pharmacokinetic properties of S (-) and R (+) enantiomers of ketorolac in adult patients undergoing total hip (THA) and knee arthroplasty (TKA).

METHODS

Adult patients with normal preoperative renal function received a periarticular infiltration of 30 mg of ketorolac tromethamine along with 100 mL of 0.2% ropivacaine and 1 mg of epinephrine at the end of their THA or TKA surgery. Blood samples were taken from a venous cannula at various time points after infiltration. Pharmacokinetic modeling was performed using PMetrics 1.5.0.

RESULTS

From 18 participants, 104 samples were analyzed. The peak plasma concentration for S (-) ketorolac was found to be lower than that of R (+) ketorolac, for both THA (0.19-1.22 mg/L vs 0.39-1.63 mg/L, respectively) and TKA (0.28-0.60 mg/L vs 0.48-0.88 mg/L, respectively). The clearance of the S (-) ketorolac enantiomer was higher than R (+) ketorolac (4.50 ± 2.27 vs 1.40 ± 0.694 L/h, respectively).

CONCLUSIONS

Our study demonstrates that with periarticular infiltration, S (-) ketorolac was observed to have increased clearance rate and highly variable volume of distribution and lower peak plasma concentration compared to R (+) ketorolac.

Effect of periarticular morphine injection for total hip arthroplasty: a randomised, double-blind trial

BACKGROUND

The periarticular multimodal cocktail injection is currently commonly used to treat postoperative pain after total hip arthroplasty (THA). Despite its analgesic effect, it is frequently reported to cause nausea and vomiting, which are adverse effects of opioids. This study aimed to assess the efficacy of morphine as a component of a multimodal cocktail injection for providing postoperative analgesia and alleviating swelling in patients who underwent THA.

MATERIALS AND METHODS

This was a prospective, single-centre, randomised controlled trial involving 100 patients scheduled for unilateral THA. A mixture of steroids, local anaesthetics, NSAIDs, and epinephrine with or without morphine (0.1 mg/kg), was injected into randomly assigned patients. Postoperative assessment was performed with all attending personnel and patients blind to group assignment. Visual analogue scale (VAS) of pain, range of motion (ROM), nausea numerical rating scale (NRS), the total dose of antiemetic drugs used and thigh swelling were compared between groups on postoperative days.

RESULTS

Pain VAS scores both at rest and on motion did not differ between the 2 groups at any postoperative time-point. The nausea NRS scores during the postoperative period from 0 minutes to 1 hour and the total dose of antiemetic drugs administered were significantly higher in the morphine group. The thigh girth showed no difference between groups on any of the postoperative days.

CONCLUSIONS

The results of this study suggested that addition of morphine to the multimodal cocktail injection after THA is not effective for relieving postoperative pain, alleviating swelling, or improving ROM, and results in nausea and vomiting. Randomised controlled trial registration number UMIN000022668.

Patellofemoral Arthroplasty

Background

The first report of patellofemoral arthroplasty (PFA) was published in 1979¹. Reviews in 2005 and 2007^2,3 called for studies comparing PFA with total knee arthroplasty (TKA) for isolated patellofemoral osteoarthritis. A blinded randomized controlled trial (RCT) was initiated in 2007 for this purpose, and the first report with 2-year results was awarded the Mark Coventry Award of the Knee Society in 2017⁴. It was found that (1) patients recover more quickly from PFA than from TKA; (2) during the first 2 years after surgery, PFA-treated patients have better average knee function than TKA-treated patients; and (3) PFA-treated patients regain their preoperative range of movement within the first postoperative year whereas TKA-treated patients do not regain it within the first 2 years⁴.

Description

There are general principles that are common to all brands of PFA implants. These include (1) an indication based on bone-on-bone contact in the patellofemoral joint with a preserved tibiofemoral joint; (2) replacing all surfaces of the patellofemoral joint, with metal on the femoral side and polyethylene on the patellar side; (3) ensuring a smooth transition from normal articular cartilage to the trochlear component; and (4) creating normal patellofemoral tracking.

Alternatives

The primary treatment of any degenerative condition should be nonoperative, but when such measures are insufficient surgical treatment may be indicated. Many procedures have been suggested for relieving patellofemoral pain, but if there is bone-on-bone contact in the patellofemoral joint, the only current surgical option (except for experimental treatments) is joint replacement-i.e., either PFA or TKA.

Rationale

Our general principle for joint replacement of the knee is to replace only the affected compartment if unicompartmental changes are found. If ≥2 compartments are affected, we perform TKA. This principle is challenged both by proponents of performing TKA in all cases of knee osteoarthritis and by proponents of bicompartmental knee replacement for 2-compartment disease. The 2-year results of our blinded RCT comparing PFA and TKA⁴ support our current practice of PFA. In our practice, we have found PFA to be a rewarding procedure when the correct indications are used. PFA is likely to remain a fairly rare procedure, but any knee arthroplasty center should be able to offer it.

Effect of ketorolac in intra-articular injection analgesia for postoperative pain in patients undergoing shoulder arthroscopy: a pilot-controlled clinical study

Background

To date, a regional approach using local anesthetics has become a popular analgesic method for arthroscopy. The optimal postoperative analgesia method for shoulder arthroscopy is still debated.

Objective

This study was designed to evaluate the effect and safety of using ketorolac in combination with a multimodal drug regime (ropivacaine, morphine, and triamcinolone acetonide) after shoulder arthroscopy.

Methods

A total of 60 patients were included in a pilot study and patients were randomized into an experimental group (n=30) and a control group (n=30). The following parameters were used to evaluate pain relief levels postoperatively: the Visual Analog Scale (VAS) at 1, 3, 6, 12, 24, and 48 hours postoperatively, morphine consumption, and initial analgesic desired time. Complications were also recorded.

Results

Except for 1 hour postoperatively, patients in the experimental group experienced lower VAS scores during the first 48 hours postoperatively (P<0.05). The VAS score in both groups increased after 3 hours postoperatively and peaked at 12 hours postoperatively (2.54±0.86 vs 3.25±1.18). The VAS scores on movement in the experimental group were lower than those in the control group at 24 or 48 hours postoperatively (P=0.004, 0.001). A total of 18 (60.0%) patients in the experimental group required no additional analgesia, compared with 10 (33.3 %) in the control group (P=0.035). The mean rescue analgesia was 11.40±5.56 mg in the experiment group, while 16.57±8.48 mg in the control group (P=0.016). The initial analgesic desired time was delayed significantly in the experimental group (16.50±14.57 hours vs 8.9±6.32 hours, P=0.000).

Conclusion

Adding ketorolac to intra-articular injection analgesia is a safe and effective method to improve pain relief after shoulder arthroscopy, and further prospective controlled trials are necessary to allow definite treatment recommendations.

No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty

Background and purpose - The use of local infiltration anesthesia (LIA) has become one of the cornerstones of rapid recovery protocols in total knee arthroplasty patients during the past decade. In total hip arthroplasty (THR), however, the study results are more variable and LIA has therefore not yet been generally accepted. There is no consensus on which structure should be infiltrated and the cutaneous nerves are generally neglected. Hence, we hypothesized a pain-reducing effect of specifically blocking these nerves. Patients and methods - We performed a single-center randomized placebo-controlled trial in 162 subjects to evaluate the infiltration of the lateral cutaneous femoral and subcostal nerve with ropivacaine in patients undergoing total hip arthroplasty via a straight lateral approach. The primary endpoint was pain at rest after 24 hours. Patients were followed up to 6 weeks postoperatively. Results - After correction for multiple testing, no statistically significant differences in pain scores were found between the ropivacaine compared with the placebo group after surgery. In addition, no differences were observed in the use of escape pain medication, complications, and the length of hospital stay. Interpretation - We found no clinically meaningful differences in pain scores between placebo and ropivacaine patients in the postoperative period after THA performed via a straight lateral approach under spinal anesthesia and a multimodal pain regimen. Moreover, our primary endpoint, pain reduction after 24 hours, was not met. Further research should focus on the composition and volume of the LIA suspension, the optimal localization of the infiltration, and should be evaluated for every surgical approach separately.

Single Local Infiltration Analgesia (LIA) Aids Early Pain Management After Total Knee Replacement (TKR): An Evidence-Based Review and Commentary

BACKGROUND

There is controversy in the literature regarding the role of single local infiltration analgesia (LIA) after total knee replacement (TKR).

QUESTIONS/PURPOSES

Is single LIA really efficient in controlling pain after TKR?

METHODS

A Cochrane Library and PubMed (MEDLINE) search related to the justification LIA after TKR was analyzed. The main criteria for selection were that the articles were focused in the aforementioned question.

RESULTS

Two hundred ninety-nine articles were found until February 9, 2017, but only 27 were selected and reviewed because they were focused on clinical experience with LIA following TKR. Fifteen of them were considered level of evidence (I-II) while 12 had a lower level of evidence (III-IV). LIA reduced the amount of perioperative opioid administration and enabled adequate pain management in conjunction with oral medication without adverse effects. No clinically marked effects on the functional outcome after TKR were detected.

CONCLUSION

Single dose LIA provides effective analgesia in the initial postoperative period after TKR in most randomized clinical trials, systematic reviews, and meta-analyses.

The Mark Coventry Award: Patellofemoral Arthroplasty Results in Better Range of Movement and Early Patient-reported Outcomes Than TKA

BACKGROUND

Controversy exists over the surgical treatment for severe patellofemoral osteoarthritis. We therefore wished to compare the outcome of patellofemoral arthroplasty (PFA) with TKA in a blinded randomized controlled trial.

QUESTIONS/PURPOSES

In the first 2 years after surgery: (1) Does the overall gain in quality of life differ between the implants based on the area under the curve of patient-reported outcomes (PROs) versus time? (2) Do patients obtain a better quality of life at specific points in time after PFA than after TKA? (3) Do patients get a better range of movement after PFA than after TKA? (4) Does PFA result in more complications than TKA?

METHODS

Patients were eligible if they had debilitating symptoms and isolated patellofemoral disease. One hundred patients were included from 2007 to 2014 and were randomized to PFA or TKA (blinded for the first year; blinded to patient, therapists, primary care physicians, etc; quasiblinded to assessor). Patients were seen for four clinical followups and completed six sets of questionnaires during the first 2 postoperative years. SF-36 bodily pain was the primary outcome. Other outcomes were range of movement, PROs (SF-36, Oxford Knee Score [OKS], Knee injury and Osteoarthritis Outcome Score [KOOS]) as well as complications and revisions. Four percent (two of 50) of patients died within the first 2 years in the PFA group (none in the TKA group), and 2% (one of 50) became ill and declined further participation after 1 year in the PFA group (none in the TKA group). The mean age at inclusion was 64 years (SD 8.9), and 77% (77 of 100) were women.

RESULTS

The area under the curve (AUC) up to 2 years for SF-36 bodily pain of patients undergoing PFA and those undergoing TKA was 9.2 (SD 4.3) and 6.5 (SD 4.5) months, respectively (p = 0.008). The SF-36 physical functioning, KOOS symptoms, and OKS also showed a better AUC up to 2 years for PFA compared with TKA (6.6 [SD 4.8] versus 4.2 [SD 4.3] months, p = 0.028; 5.6 [SD 4.1] versus 2.8 [SD 4.5] months, p = 0.006; 7.5 [SD 2.7] versus 5.0 [SD 3.6] months, p = 0.001; respectively). The SF-36 bodily pain improvement at 6 months for patients undergoing PFA and those undergoing TKA was 38 (SD 24) and 27 (SD 23), respectively (p = 0.041), and at 2 years, the improvement was 39 (SD 24) and 33 (SD 22), respectively (p = 0.199). The KOOS symptoms improvement at 6 months for patients undergoing PFA and those undergoing TKA was 24 (SD 20) and 7 (SD 21), respectively (p < 0.001), and at 2 years, the improvement was 27 (SD 19) and 17 (SD 21), respectively (p = 0.023). Improvements from baseline for KOOS pain, SF-36 physical functioning, and OKS also differed in favor of PFA at 6 months, whereas only KOOS symptoms showed a difference between the groups at 2 years. No PRO dimension showed a difference in favor of TKA. At 4 months, 1 year, and 2 years, the ROM change from baseline for patients undergoing PFA and those undergoing TKA was (-7° [SD 13°] versus -18° [SD 14°], p < 0.001; -4° [SD 15°] versus -11° [SD 12°], p = 0.011; and -3° [SD 12°] versus -10° [SD 12°], p = 0.010). There was no difference in the number of complications. During the first 2 postoperative years, there were two revisions in patients undergoing PFA (one to a new PFA and one to a TKA).

CONCLUSIONS

Patients undergoing PFA obtain a better overall knee-specific quality of life than patients undergoing TKA throughout the first 2 years after operation for isolated patellofemoral osteoarthritis. At 2 years, only KOOS function differs between patients undergoing PFA and those undergoing TKA, whereas other PRO dimensions do not show a difference between groups. The observations can be explained by patients undergoing PFA recovering faster than patients undergoing TKA and the functional outcome being better for patients undergoing PFA up to 9 months. Patients undergoing PFA regain their preoperative ROM, whereas patients undergoing TKA at 2 years have lost 10° of ROM. We found no differences in complications.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Efficacy of perineural dexamethasone with ropivacaine in adductor canal block for post-operative analgesia in patients undergoing total knee arthroplasty: A randomized controlled trial

Adductor canal block (ACB) is an effective analgesic alternative to femoral nerve block after total knee arthroplasty (TKA). The aim of the present study was to investigate whether addition of dexamethasone to ropivacaine for ACB is able to prolong analgesia and reduce pain. Study participants were randomized into groups receiving ACB with either 0.5% ropivacaine + normal saline (control group; n=93) or 0.5% ropivacaine + 8 mg dexamethasone (dexamethasone group; n=93). All patients were subjected to identical peri-operative management. Patients were assessed for the duration of analgesia by the return of pinprick sensation. A numerical rating scale, ranging from 0 to 10, was used to assess post-operative pain at 6, 12, 18, 24 and 48 h. Opioid use was recorded. Serum C-reactive protein and interleukin-6 levels were measured at 3, 6, 12, 24 and 48 h after surgery. The results revealed that the duration of sensory block was significantly longer in the dexamethasone group (23.42±3.35 vs. 14.67±2.96 h in control group, P<0.05). The dexamethasone group also had significantly lower pain scores at 6, 12, 18 and 24 h after surgery (all P<0.001), and at 48 h, pain was comparable in the two groups. Reduction in post-operative pain was associated with a decrease in serum C-reactive protein. Morphine use in the first 24 h after surgery was also lower in the dexamethasone group (4.23±1.80 vs. 8.42±2.44 mg in control group, P<0.05). In conclusion, addition of dexamethasone to ropivacaine for ACB was able to prolong the duration of analgesia and decreased early post-operative pain following TKA.

Comparison of Continuous Femoral Nerve Block versus Local Infiltration Analgesia as a Postoperative Analgesia in Unilateral Total Knee Arthroplasty

INTRODUCTION

Local infiltration of knee joint in arthroplasty, provide postoperative analgesia and preserves motor power of quadriceps, which helps in early mobilisation, as compared to femoral nerve block which paralyses vastus medialis.

AIM

To compare the quality of postoperative analgesia provided by femoral nerve block and local infiltration in unilateral Total Knee Arthroplasty (TKA).

MATERIALS AND METHODS

A prospective study was conducted on 60 patients (25-65 years) of ASA I and II, which were randomly(using random number table) divided into two groups - Group 1-femoral nerve block (FNB) and Group 2-Local Infiltration Analgesia (LIA). Patients with chronic pain and on opioids were excluded. Numeric rating scale (primary objective), sedation score, nausea vomiting score and motor power were analysed. The results were analysed by parametric and nonparametric tests using SPSS software version 22. p<0.05 was considered significant.

RESULTS

Pain relief was better in FNB Group (p-value <0.001) with less fentanyl demand (p-value <0.001), low sedation score (0.013, 0.179, 0.018, 0.129, 0.287, 0.432) but associated with low muscle power grading (<0.001).

CONCLUSION

FNB has better pain relief than LIA Group but range of motion was reduced in FNB Group grossly, effect on mobilisation remained comparable in both group.

Perioperative pain management in fast-track knee arthroplasty

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Effect of Periarticular Morphine Injection for Total Knee Arthroplasty: A Randomized, Double-Blind Trial

BACKGROUND

The periarticular multimodal cocktail injection including morphine is currently commonly used to treat postoperative pain after total knee arthroplasty (TKA). Despite its analgesic effect, it is frequently reported to cause nausea and vomiting, which are adverse effects of opioids. This study aimed to assess the efficacy of morphine as a component of a multimodal cocktail injection for providing postoperative analgesia and alleviating swelling in patients who underwent TKA.

METHODS

This is a prospective, single-center, randomized controlled trial involving 102 patients scheduled for unilateral TKA. A mixture of steroids, local anesthetics, nonsteroidal anti-inflammatory drugs, and epinephrine with or without morphine (10 mg) was injected to randomly assigned patients. Postoperative assessment was performed with all attending personnel and patients blinded to group assignment. Visual analog scale of pain, range of motion, nausea numerical rating scale, number of patients with vomiting, total dose of antiemetic drugs used, thigh swelling, the Western Ontario and McMaster Universities Osteoarthritis Index score, and adverse outcomes were compared between groups on postoperative days.

RESULTS

Visual analog scale scores did not differ between the 2 groups at any postoperative time point. The nausea numerical rating scale scores during the postoperative period from 30 min to 9 h, the number of vomiting episodes, and the total dose of antiemetic drugs administered were significantly higher in the morphine group. The thigh girth, Western Ontario and McMaster Universities Osteoarthritis Index, and the incidence of complications were not different between groups.

CONCLUSION

The results of this study suggested that addition of morphine to the multimodal cocktail injection is not effective for relieving postoperative pain, alleviating swelling, or improving range of motion, and results in nausea and vomiting.

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.

Pain management in total knee arthroplasty: efficacy of a multimodal opiate-free protocol

PURPOSE

this study was conducted to identify the most effective method of postoperative pain management, comparing the intravenous opiate infusion protocol with the use of a single periarticular local anesthetic infiltration (LAI) in patients undergoing total knee arthroplasty (TKA) surgery.

METHODS

50 patients submitted to TKA surgery between 2013 and 2015 were divided into two groups. Buprenorphine was administered intravenously to the patients in Group A, while the Group B patients received a single periarticular LAI (ropivacaine and ketorolac) during surgery. Pain was assessed using a visual analog scale (VAS) and the knee injury and osteoarthritis outcome score. Hemoglobin and hematocrit were measured in the early postoperative period and at 40 days post-surgery. Range of motion and inflammatory markers were also assessed. Statistical analysis was performed using Student's t-test.

RESULTS

student's t-test showed no significant difference between the groups in functional outcomes or blood values, but a difference in VAS score on the day of surgery was found (p < 0.0001), in favor of Group B.

CONCLUSIONS

LAI considerably reduces postoperative pain, allowing rapid mobilization and accelerating functional recovery.

LEVEL OF EVIDENCE

Level I, prospective single-blind randomized trial.

Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty

PURPOSE

To evaluate the effect of the local infiltration of analgesics for pain after total knee arthroplasty in patients treated with femoral and sciatic peripheral nerve blocks. The secondary objective was to detect differences in analgesic consumption as well as blood loss after local infiltration of analgesics.

METHODS

Prospective randomized double-blinded study in patients who underwent a TKA for knee osteoarthritis under spinal anesthesia and treated with femoral and sciatic nerve blocks. This study compared 50 patients treated with local infiltration with ropivacaine, epinephrine, ketorolac and clonidine and 50 patients treated with a placebo with the same technique. The visual analogic score was registered postoperatively at 2, 6, 12, 24, 36, 48 and 72 h after surgery. Analgesic consumption was also registered. Both groups of patients were treated with the same surgical and rehabilitation protocols.

RESULTS

A significant difference of one point was found in the visual analogic pain scores 12 h after surgery (0.6 ± 1.5 vs. 1.7 ± 2.3). There were no significant differences in the visual analogic pain scores evaluated at any other time between 2 and 72 h after surgery. No significant differences were found in the required doses of tramadol or morphine in the postoperative period. Postoperative hemoglobin and blood loss were also similar in both groups.

CONCLUSION

Adding local infiltration of analgesics to peripheral nerve blocks after TKA surgery only provides minimal benefit for pain control. This benefit may be considered as non-clinically relevant. Moreover, the need for additional analgesics was the same in both groups. Therefore, the use of local infiltration of analgesics treatment in TKA surgery cannot be recommended if peripheral nerve blocks are used.

LEVEL OF EVIDENCE

I.

Liposome Bupivacaine Femoral Nerve Block for Postsurgical Analgesia after Total Knee Arthroplasty

Background

The authors evaluated the efficacy of liposome bupivacaine in a femoral nerve block (FNB) after total knee arthroplasty.

Methods

Part 1: subjects received FNB with 20 ml liposome bupivacaine (67, 133, or 266 mg) or placebo. Part 2: subjects were randomized to FNB with liposome bupivacaine 266 mg or placebo. The primary outcome measure was area under the curve of the numeric rating scale score for pain intensity at rest through 72 h (AUC NRS-R0–72) with imputed scores after rescue medication.

Results

In part 1, FNB with liposome bupivacaine 266 mg (n = 24) resulted in analgesia similar to that obtained with 133 mg and was chosen for part 2. In part 2, least-squares mean (standard error) AUC NRS-R0–72 was lower with liposome bupivacaine 266 mg (n = 92) than with placebo (n = 91; 419 [17] vs. 516 [17]; P &lt; 0.0001). This outcome remained unchanged in a post hoc analysis without score imputation (221 [12] vs. 282 [12]; P = 0.0005). Least-squares mean AUC NRS-R with imputed scores was lower with liposome bupivacaine during each 24-h interval (0 to 24, 24 to 48, and 48 to 72 h) after surgery; AUC NRS-R without imputed scores was lower during the 0- to 24-h and 24- to 48-h intervals. The liposome bupivacaine group had lower mean total opioid use (76 vs. 103 mg morphine; P = 0.0016). Pain was sufficiently severe to require second-step rescue with opioids via intravenously administered patient-controlled analgesia in 92% of liposome bupivacaine patients and 81% of placebo patients. With patient-controlled analgesia and other forms of rescue analgesia, mean NRS scores with activity were moderate in both liposome bupivacaine and placebo groups throughout the part 2 study period. Incidence of adverse events was similar between the groups (part 1: 90 vs. 96%; part 2: 96 vs. 96%, respectively).

Conclusion

FNB with liposome bupivacaine (266 mg) resulted in modestly lower pain scores and reduced opioid requirements after surgery, with an adverse event profile similar to placebo.

Evaluation of clonidine as an adjuvant to bupivacaine in wound infiltration for providing postoperative analgesia after abdominal hysterectomy

Background:

Clonidine is an effective adjuvant to local anesthetics in peripheral nerve blocks. We studied the effect of clonidine as an adjuvant in wound infiltration for postoperative analgesia.

Aim:

To evaluate the role of clonidine as an adjuvant to bupivacaine in wound infiltration in terms of quality and duration of postoperative analgesia in patients undergoing total abdominal hysterectomy.

Settings and Study Design:

Prospective, randomized, double-blinded study.

Materials and Methods:

One hundred patients of American Society of Anesthesiologists I–II posted for abdominal hysterectomy were randomly allotted to two groups. Group A received wound infiltration with 45 ml of 0.25% bupivacaine with 3 μg/kg clonidine while Group B received wound infiltration with 45 ml of 0.25% bupivacaine. A standard general anesthesia technique was used in all the patients. Postoperative analgesia was provided with injection ketorolac 0.5 mg/kg intravenous infusion and tramadol being the rescue analgesic. Postoperative pain score, duration of effective analgesia before the first rescue analgesic, percentage of patients requiring rescue analgesic at different time intervals, and total number of rescue analgesic doses in 24 h were compared between the groups.

Statistical Analysis:

Difference between the bivariate samples in independent groups with Mann–Whitney U-test. For categorical data, Chi-square test was used.

Results:

Clonidine group has better pain score, longer duration of effective analgesia, lower percentage of patients requiring rescue analgesic, and less number of doses of rescue analgesia in the first 24 h.

Conclusion:

We conclude that Clonidine 3 μg/kg is an effective adjuvant to bupivacaine for wound infiltration in terms of quality and duration of postoperative analgesia following total abdominal hysterectomy.

Femoral nerve block-sciatic nerve block vs. femoral nerve block-local infiltration analgesia for total knee arthroplasty: a randomized controlled trial

BACKGROUND

The use of femoral nerve block (FNB) combined with sciatic nerve block (SNB) after total knee arthroplasty (TKA) has recently become controversial. Local infiltration analgesia (LIA) has been reported to be effective for postoperative TKA pain control. We aimed to assess whether LIA with continuous FNB is as effective as SNB combined with continuous FNB.

METHODS

This was a prospective, randomized, single-center, observer-blinded, parallel group comparison trial of 34 American Society of Anesthesiologists (ASA) physical status 1-3 patients who underwent TKA and fulfilled the inclusion and exclusion criteria. Patients were randomized into two groups: a periarticular LIA and FNB group (group L, n = 17), and an SNB and FNB group (group S, n = 17). In both groups, participants received FNB with 20 mL of 0.375% ropivacaine, and 5 mL h(-1) of 0.2% ropivacaine after surgery. In group L, participants received 100-ml injections of 0.2% ropivacaine and 0.5 mg epinephrine to the surgical region. In group S, participants received SNB with 20 ml of 0.375% ropivacaine. After TKA, Numeric Rating Scale (NRS) scores for the first 24 h post-operation were compared via repeated-measures analysis of variance (ANOVA) as the primary outcome. Other outcome measures included NRS score changes within groups, area under the curve for the NRS scores, total analgesic dose, change in knee flexion and extension, pain control satisfaction, nausea and vomiting, and hospital stay duration.

RESULTS

NRS score changes were greater in group L than in group S (P < 0.01, ANOVA) and greater in group L than in group S at three postoperative time points: 3 h (P < 0.01), 6 h (P < 0.01), and 12 h (P = 0.013; Mann-Whitney U test). Changes in the mean NRS score were observed in each group (P < 0.01, Friedman test). No significant differences were detected in the other outcome measures (Mann-Whitney U, Wilcoxon signed-rank, and chi-squared tests).

CONCLUSIONS

Sciatic nerve block with femoral nerve block is superior to local anesthetic infiltration with femoral nerve block for postoperative pain control within 3-12 h of total knee arthroplasty.

TRIAL REGISTRATION

UMIN-CTR ID: 000013364 R: 000015591.

Local infiltration analgesia versus femoral nerve block in total knee arthroplasty: a meta-analysis

INTRODUCTION

Local infiltration analgesia (LIA) and femoral nerve block (FNB) are both used for the pain management after total knee arthroplasty (TKA). Controversy still remains regarding the optimal technique for pain relief in patients undergoing TKA. The purpose of this meta-analysis was to compare the analgesia achieved with LIA and the one from FNB following TKA.

HYPOTHESIS

LIA achieves better pain control than FNB in patients with TKA.

METHODS

Databases, including Pubmed, EMBASE, the Cochrane Library and Web of Science were comprehensively searched to identify studies comparing LIA with FNB for patients with TKA. Two reviewers independently selected trials, extracted data, and assessed the methodological qualities of included studies. Data were analyzed by RevMan 5.2.

RESULTS

Nine RCTs involving 782 patients were included. LIA achieved more rapid pain relief (VAS) at 6h postoperatively [SMD6h=-0.92, 95% CI (-1.38, -0.47)] than FNB. There were no significant differences at 24h and 48h [SMD24h=-0.03, 95% CI (-0.46, 0.40); SMD48h=0.28, 95% CI (-0.35, 0.91)], VAS with activity at 24h and 48h [SMD6h=-0.54, 95% CI (-1.62, 0.54); SMD24h=-0.22, 95% CI (-1.41, 0.96); SMD48h=-0.08, 95% CI (-0.52, 0.69)], opioid consumption at 24h and 48h [SMD24h=-0.24, 95% CI (-0.82, 0.34); SMD48h=0.15, 95% CI (0.25, 0.54)] and length of hospital stay [MD=-0.52, 95% CI (-1.13, 0.09)].

DISCUSSION

LIA may be the better choice in the pain management of TKA for it could achieve fast pain relief and is easier to perform than FNB for patients with TKA.

LEVEL OF EVIDENCE

Level II, meta-analysis and systematic review.

Comparison Between Intraoperative Two-Space Injection Thoracic Paravertebral Block and Wound Infiltration as a Component of Multimodal Analgesia for Postoperative Pain Management After Video-Assisted Thoracoscopic Lobectomy: A Randomized Controlled Trial

OBJECTIVE

To compare paravertebral block under thoracoscopy with wound infiltration at an early stage after video-assisted thoracic lobectomy surgery.

DESIGN

A prospective, randomized, triple-blinded, placebo-controlled trial.

SETTING

A single-center university hospital.

PARTICIPANTS

Patients scheduled for video-assisted thoracic lobectomy surgery between February 20, 2014 and June 1, 2014 randomly were allocated into paravertebral block (PVB) (n = 35) and infiltration (n = 35) groups.

INTERVENTIONS

In the PVB group, 0.5% ropivacaine was injected into the paravertebral space by the surgeon under direct vision with placebo infiltration of saline in the wounds. In the infiltration group, the wounds were infiltrated with 0.5% ropivacaine by the surgeon with a placebo paravertebral block. Subsequently, patient-controlled intravenous morphine analgesia and paracoxib were administered.

MEASUREMENTS AND MAIN RESULTS

The primary endpoints were visual analog scale (VAS) pain scores at rest and on cough 0, 2, 6, and 24 hours after surgery. The secondary endpoints were the total morphine during postoperative 0 hours to 24 hours, adverse events, and patient satisfaction with the analgesia. Sixty-one patients completed the study. VAS score on cough at each time point was significantly lower (p<0.05) and median (25th, 75th) morphine consumption was lower in the PVB group than in the infiltration group (26 [10, 35] mg and 42 [29, 58] mg, p<0.001, respectively). There was no difference in VAS score at rest. Patients in the PVB group had higher satisfaction with analgesia than in the infiltration group (p = 0.003).

CONCLUSIONS

As part of the multimodal postoperative analgesia, intraoperative paravertebral block provided better dynamic pain relief and reduced morphine consumption compared with local wound infiltration.

Is ketorolac safe to use in plastic surgery? A critical review

BACKGROUND

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that provides postoperative pain control and reduces narcotic requirements. However, concerns regarding postoperative hematoma have limited its use in plastic surgery.

OBJECTIVES

Our goal is to critically review the risk of bleeding with ketorolac in plastic surgery patients, with a focus on aesthetic surgery.

METHODS

A PubMed/Medline literature search of clinical trials using the keywords "surgery" and "NSAID" yielded 2574 results. Of these results, 1036 included ketorolac and twelve involved plastic surgery patients. Six studies reported postoperative hematoma rates: three prospective randomized trials, two retrospective reviews, and one case series. These were subjected to statistical analysis to determine if an association existed between ketorolac and postoperative hematomas.

RESULTS

Six papers reported 981 cases. Ketorolac use resulted in similar hematoma rates when compared to control groups, 2.5% (12 of 483) versus 2.4% (12 of 498), respectively (P = .79). There were no reported hematomas associated with ketorolac in over 115 patients undergoing aesthetic facial procedures. Hematoma rates of those undergoing aesthetic breast surgery, including reduction and augmentation mammoplasties, were 4.3% (11 of 257) in the ketorolac group versus 2.2% (6 of 277) in controls (P = .59). Reduction in postoperative narcotic use and improved pain scores was also reported.

CONCLUSIONS

Our literature review did not find a significant association between hematoma formation and ketorolac use in a variety of plastic surgery procedures. These findings are similar to those in other surgical subspecialties.

Additives to local anesthetics for peripheral nerve blocks or local anesthesia: a review of the literature

SUMMARY 

A multitude of studies have focused on individual additives to local anesthetics and their effect on quality, onset, duration, spread and selectivity, as well as the potential toxic effects of their use. This review aims to give a broad overview of the current evidence in this developing field, based on beneficial and adverse effects of these drugs. We discuss the limitations of the available data and hope to convey implications and future perspectives for clinicians and researchers alike.

Plasma concentration of ketorolac after local infiltration analgesia in hip arthroplasty

BACKGROUND

Local infiltration analgesia (LIA) with local anaesthetic (ropivacaine), a nonsteroidal anti-inflammatory drug (ketorolac) and epinephrine after lower extremity arthroplasty has gained increasing popularity during the last decade. This method has certain advantages, which include minimal systemic side effects, faster post-operative mobilization, earlier post-operative discharge from hospital and less opioid consumption. However, information regarding plasma concentrations of ketorolac after LIA mixture is insufficient to predict the risk of renal impairment in patients subjected to arthroplasty.

AIM

To determine the maximal plasma concentration and the exposure of ketorolac during the first 30 h following LIA in hip arthroplasty.

METHODS

Thirteen patients scheduled for primary total hip arthroplasty with LIA (ropivacaine 200 mg, ketorolac 30 mg and epinephrine 0.5 mg in a volume of 106 ml) were included. Plasma concentration of ketorolac was quantified by liquid chromatography-mass spectrometry. In addition, we assessed the effect of increasing age and decreasing glomerular filtration rate on the maximal plasma concentration and the total exposure to ketorolac during 30 h.

RESULTS

The range of the maximal plasma concentration, 0.3-2.2 mg/l, was detected 30 min-4 h after completing the infiltration. Similar plasma levels have been reported after intramuscular injection of the same dose of ketorolac to healthy elderly volunteers.

CONCLUSION

Exposure to ketorolac after LIA may be comparable to an intramuscular injection of the same dose. Decision of dose reduction should be based on clinical assessment of risk factors.