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Murphy J, Pak S, Shteynman L, Winkeler I, Jin Z, Kaczocha M, Bergese SD. Mechanisms and Preventative Strategies for Persistent Pain following Knee and Hip Joint Replacement Surgery: A Narrative Review. Int J Mol Sci 2024; 25:4722. [PMID: 38731944 PMCID: PMC11083264 DOI: 10.3390/ijms25094722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/19/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Chronic postsurgical pain (CPSP) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) is a prevalent complication of joint replacement surgery which has the potential to decrease patient satisfaction, increase financial burden, and lead to long-term disability. The identification of risk factors for CPSP following TKA and THA is challenging but essential for targeted preventative therapy. Recent meta-analyses and individual studies highlight associations between elevated state anxiety, depression scores, preoperative pain, diabetes, sleep disturbances, and various other factors with an increased risk of CPSP, with differences observed in prevalence between TKA and THA. While the etiology of CPSP is not fully understood, several factors such as chronic inflammation and preoperative central sensitization have been identified. Other potential mechanisms include genetic factors (e.g., catechol-O-methyltransferase (COMT) and potassium inwardly rectifying channel subfamily J member 6 (KCNJ6) genes), lipid markers, and psychological risk factors (anxiety and depression). With regards to therapeutics and prevention, multimodal pharmacological analgesia, emphasizing nonopioid analgesics like acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDs), has gained prominence over epidural analgesia. Nerve blocks and local infiltrative anesthesia have shown mixed results in preventing CPSP. Ketamine, an N-methyl-D-aspartate (NMDA)-receptor antagonist, exhibits antihyperalgesic properties, but its efficacy in reducing CPSP is inconclusive. Lidocaine, an amide-type local anesthetic, shows tentative positive effects on CPSP. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) have mixed results, while gabapentinoids, like gabapentin and pregabalin, present hopeful data but require further research, especially in the context of TKA and THA, to justify their use for CPSP prevention.
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Affiliation(s)
- Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Sery Pak
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Lana Shteynman
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Ian Winkeler
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (J.M.); (S.P.); (L.S.); (I.W.)
| | - Zhaosheng Jin
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11794, USA; (M.K.); (S.D.B.)
| | - Martin Kaczocha
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11794, USA; (M.K.); (S.D.B.)
| | - Sergio D. Bergese
- Department of Anesthesiology, Stony Brook University, Stony Brook, NY 11794, USA; (M.K.); (S.D.B.)
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Abouarab AH, Brülle R, Aboukilila MY, Weibel S, Schnabel A. Efficacy and safety of perioperative ketamine for the prevention of chronic postsurgical pain: A meta-analysis. Pain Pract 2024; 24:553-566. [PMID: 37971167 DOI: 10.1111/papr.13314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 09/23/2023] [Accepted: 10/19/2023] [Indexed: 11/19/2023]
Abstract
STUDY OBJECTIVE Assessment of the efficacy and safety of perioperative intravenous ketamine in reducing incidence and severity of chronic postsurgical pain. STUDY DESIGN A systematic review and meta-analysis of randomized controlled trials (RCTs). DATA SOURCES The following data sources were systematically searched: MEDLINE, CENTRAL, and EMBASE (till 02/2021). PATIENTS Adult patients undergoing any surgery. INTERVENTIONS Perioperative use of intravenous ketamine as an additive analgesic drug compared to placebo, no active control treatment, and other additive drugs. MEASUREMENTS Primary outcomes were number of patients with chronic postsurgical pain after 6 months and ketamine related adverse effects. Secondary outcomes were chronic postsurgical pain incidence after 3 and 12 months, chronic postsurgical neuropathic pain incidence, chronic postsurgical moderate to severe pain incidence, intensity of chronic postsurgical pain at rest, and during movement, oral morphine consumption after 3, 6, and 12 months and incidence of opioid-related adverse effects. MAIN RESULTS Thirty-six RCTs were included with a total of 3572 patients. Ketamine compared to placebo may result in no difference in the number of patients with chronic postsurgical pain after 6 months (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.71-1.05; I2 = 34%; 16 studies; low-certainty evidence). Ketamine may reduce the incidence of chronic postsurgical neuropathic pain after 3 months in comparison to placebo (RR 0.78, 95% CI 0.62-0.99, I2 = 31%, seven trials, low-certainty evidence). Ketamine compared to placebo may increase the risk for postoperative nystagmus (RR 9.04, 95% CI 1.15-70.90, I2 30%, two trials, low-certainty evidence) and postoperative visual disturbances (RR 2.29, 95% CI 1.05-4.99, I2 10%, seven trials, low-certainty evidence). CONCLUSIONS There is low-certainty evidence that perioperative ketamine has no effect on chronic postsurgical pain in adult patients. Low-certainty evidence suggests that ketamine compared to placebo may reduce incidence of chronic postsurgical neuropathic pain after 3 months. Questions like ideal dosing, treatment duration and more patient-related outcome measures remain unanswered, which warrants further studies. PROTOCOL REGISTRATION Prospero CRD42021223625, 07.01.2021.
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Affiliation(s)
- Ahmed H Abouarab
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | - Rebecca Brülle
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
| | | | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital of Würzburg, Würzburg, Germany
| | - Alexander Schnabel
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hospital of Muenster, Muenster, Germany
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Bruehl S, Milne G, Polkowski G, Shinar A, Anderson S, Mishra P, Larach DB, Martin R, Billings FT. Oxidative stress mediates associations between preoperative psychosocial phenotype and pain-related outcomes at 6 months following total knee arthroplasty: a longitudinal cohort study. PAIN MEDICINE (MALDEN, MASS.) 2024; 25:71-77. [PMID: 37651583 PMCID: PMC10765146 DOI: 10.1093/pm/pnad120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 07/13/2023] [Accepted: 08/24/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE Greater preoperative depression, anxiety, and pain catastrophizing are associated with more severe long-term pain following total knee arthroplasty (TKA). In a secondary analysis of previously reported data, we tested the hypothesis that these associations are mediated by oxidative stress (OS). DESIGN A mixed between/within-subjects longitudinal cohort design. SETTING A single academic medical center. SUBJECTS Osteoarthritis patients (n = 91; 62.6% female) undergoing unilateral TKA. METHODS We assessed depression, anxiety, and catastrophizing, as well as markers of central sensitization (widespread pain, temporal summation of pain) preoperatively. Blood samples were then obtained immediately prior to intraoperative tourniquet placement for quantification of in vivo biomarkers of systemic OS, F2-isoprostanes and isofurans. Post-TKA pain intensity (numeric rating scale worst pain [NRS], McGill Pain Questionnaire-2 [MPQ-2]) and function (PROMIS Pain Interference) were assessed at 6 months following TKA. RESULTS Greater preoperative depression, catastrophizing, and widespread pain were associated with higher intraoperative combined OS (F2-isoprostanes+isofurans/2), which was in turn associated with higher post-TKA pain intensity and worse function (P < .05). All preoperative phenotype predictors except anxiety were correlated positively with post-TKA pain and/or function (P < .05). Bootstrapped mediation analyses revealed significant (P < .05) indirect (mediated) effects of depression (NRS Worst Pain, MPQ-2, PROMIS Pain Interference), anxiety (MPQ-2, PROMIS Pain Interference), and catastrophizing (PROMIS Pain Interference) on adverse long-term post-TKA outcomes via elevated OS. Central sensitization-related predictors demonstrated only direct effects (P < .05) on post-TKA outcomes that were independent of OS mechanisms. CONCLUSIONS Results suggest that the adverse impact of depression, anxiety, and pain catastrophizing on post-TKA pain and functional outcomes are mediated in part by elevated OS.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Daniel B Larach
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN 37212, United States
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37212, United States
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Jiang C, Lv C, Gao J, Li C. Effect of dexmedetomidine combined with local infiltration analgesia on postoperative wound complications in patients with total knee arthroplasty: A meta-analysis. Int Wound J 2023; 21:e14381. [PMID: 37772317 PMCID: PMC10825073 DOI: 10.1111/iwj.14381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/30/2023] Open
Abstract
Dexmedetomidine has been demonstrated to be effective in the management of pain in total knee replacement (TKA). Nevertheless, a combination of a local anaesthetic and a dose of dexmedetomidine might be a better choice for post-operative pain management of TKA. The aim of this research is to determine if the combination of a local anaesthetic with dexmedetomidine during a knee replacement operation can decrease the post-operation pain. Furthermore, the effectiveness and security of dexmedetomidine combined with topical anaesthetic were evaluated for the management of post-operative TKA. Based on the research results, the author made a research on the basis of four big databases. The Cochrane Handbook on Intervention Systems Evaluation has also evaluated the quality of the literature. Seven randomized controlled trials have been established from this. It was found that the combination of local anaesthesia and dexmedetomidine had a greater effect on postoperative pain in 4 h (mean difference [MD], -0.9; 95% CI, -1.71, -0.09; p = 0.03), 8 h (MD, -0.52; 95% CI, -0.66, -0.38; p < 0.0001), 12 h (MD, -0.72; 95% CI, -1.04, -0.40; p < 0.0001), 24 h (MD, -0.49; 95% CI, -0.83, -0.14; p = 0.006), 48 h (MD, -0.51; 95% CI, -0.92, -0.11; p = 0.01). Nevertheless, because of the limited number of randomized controlled trials covered by this meta-analysis, caution should be exercised with regard to data treatment. More high quality research will be required to confirm the results.
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Affiliation(s)
- Cuifeng Jiang
- Department of Paediatric SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Changli Lv
- Department of Paediatric SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
| | - Juan Gao
- Department of Paediatric SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
- Laiwu Vocational and Technical CollegeLaiwuChina
| | - Chengxue Li
- Department of Paediatric SurgeryPeople's Hospital Affiliated to Shandong First Medical UniversityJinanChina
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Priol R, Pasquier G, Putman S, Migaud H, Dartus J, Wattier JM. Trajectory of chronic and neuropathic pain, anxiety and depressive symptoms and pain catastrophizing after total knee replacement. Results of a prospective, single-center study at a mean follow-up of 7.5 years. Orthop Traumatol Surg Res 2023; 109:103543. [PMID: 36608901 DOI: 10.1016/j.otsr.2022.103543] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/30/2022] [Accepted: 09/22/2022] [Indexed: 01/09/2023]
Abstract
INTRODUCTION A considerable number of patients are not satisfied after total knee replacement (TKR) because of persistent pain. This pain can also be neuropathic in origin. Both types of pain have a large impact on function and quality of life. Furthermore, the trajectory of anxiety and depressive symptoms and pain catastrophizing has rarely been studied after TKR surgery. The primary objective of this study was to define the trajectory of knee pain after primary TKR. The secondary objectives were to evaluate how neuropathic pain, anxiety and depressive symptoms and pain catastrophizing change over time. METHODS This prospective, single-center study included patients who underwent primary TKR for primary osteoarthritis between July 2011 and December 2012. Personal data (age, sex, body mass index, knee history, operated side, surgical approach, type of implant, operative time, and rehabilitation course) and the responses to seven questionnaires (Numerical pain rating scale, DN4-interview for neuropathic pain, Oxford Knee Scale, Hospital and Anxiety Depression Scale, Beck Depression Inventory, Patient Catastrophizing Scale and Brief Pain Inventory) were determined preoperatively, at 6 months postoperative and at a mean follow-up of 7.5 years. RESULTS Preoperatively, 129 patients (35 men, 94 women) filled out all the questionnaires. Subsequently, 32 patients were excluded because of incomplete responses at 6 months postoperative, 6 were excluded because they had undergone revision surgery, 11 patients were lost to follow-up and 5 patients had died. In the end, 65 patients were available for analysis (50% of the initial cohort) who were 74 years old on average at inclusion. Between the preoperative period and 6 months postoperative, pain (p<0.001), function (p<0.001), anxiety symptoms (p<0.001) and catastrophizing (p<0.001) had improved. Depressive symptoms did not change (p=0.63). Between 6 months postoperative and the latest follow-up, none of the parameters changed further (p>0.05). Of the 65 patients analyzed, 21% had chronic pain of undefined origin at 6 months postoperative and 26% had chronic pain at the end of follow-up, with 50% also having neuropathic pain. Preoperatively, 40% of the 65 patients had neuropathic pain, 30% at 6 months (p=0.27) and 18% at 7.5 years after TKR (p=0.01). CONCLUSION The number of patients who have chronic pain after TKR is considerable, especially since knee pain stabilized at 6 months postoperative. Early detection is vital to prevent the pain from becoming chronic, which makes it more difficult to treat. Half the patients with persistent pain also had neuropathic pain, which should be detected before surgery so the patients can be referred to a specialized pain management center. The presence of anxiety and depressive symptoms and pain catastrophizing is not a contraindication to TKR, but these patients should be referred to specialists for treatment before surgery. LEVEL OF EVIDENCE IV, prospective cohort study.
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Affiliation(s)
- Romain Priol
- Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille (CHRU de Lille), rue Emile-Laine, 59037 Lille, France.
| | - Gilles Pasquier
- Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille (CHRU de Lille), rue Emile-Laine, 59037 Lille, France; Université Lille-Nord-de-France, 59000 Lille, France
| | - Sophie Putman
- Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille (CHRU de Lille), rue Emile-Laine, 59037 Lille, France; Université Lille-Nord-de-France, 59000 Lille, France
| | - Henri Migaud
- Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille (CHRU de Lille), rue Emile-Laine, 59037 Lille, France; Université Lille-Nord-de-France, 59000 Lille, France
| | - Julien Dartus
- Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille (CHRU de Lille), rue Emile-Laine, 59037 Lille, France; Université Lille-Nord-de-France, 59000 Lille, France
| | - Jean-Michel Wattier
- Centre d'évaluation et de traitement de la douleur, hôpital Claude-Huriez, centre hospitalier régional universitaire de Lille (CHRU de Lille), rue Michel-Polonowski, 59000 Lille, France
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Hannon CP, Fillingham YA, Gililland JM, Sporer SM, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. A Systematic Review of the Efficacy and Safety of Ketamine in Total Joint Arthroplasty. J Arthroplasty 2023; 38:763-768.e2. [PMID: 36328104 DOI: 10.1016/j.arth.2022.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ketamine is administered intraoperatively to treat pain associated with primary total hip (THA) and knee arthroplasty (TKA). The purpose of this study was to evaluate the efficacy and safety of ketamine in primary THA and TKA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons (AAHKS), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management (ASRA). METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to 2020 on ketamine in THA and TKA. All included studies underwent qualitative assessment and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of ketamine. After a critical appraisal of 136 publications, 7 high-quality studies were included for analyses. RESULTS High-quality evidence demonstrates that intraoperative ketamine decreases postoperative opioid consumption. Four of 7 studies found that ketamine reduces postoperative pain. Intraoperative ketamine is not associated with an increase in adverse events and may reduce postoperative nausea and vomiting (relative risk [RR] 0.68; 95% CI 0.50-0.92). CONCLUSION High-quality evidence supports the use of ketamine intraoperatively in THA and TKA to reduce postoperative opioid consumption. Most studies found ketamine reduces postoperative pain, nausea, and vomiting. Moderate quality evidence supports the safety of ketamine, but it should be used cautiously in patients at risk for postoperative delirium, such as the elderly.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeremy M Gililland
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah
| | - Scott M Sporer
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | | | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
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Petersen KKS. Predicting pain after standard pain therapy for knee osteoarthritis - the first steps towards personalized mechanistic-based pain medicine in osteoarthritis. Scand J Pain 2023; 23:40-48. [PMID: 35993966 DOI: 10.1515/sjpain-2022-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/01/2022] [Indexed: 01/17/2023]
Abstract
OBJECTIVES The prevalence of osteoarthritis (OA) is rising, and pain is the hallmark symptom of OA. Pain in OA is complicated and can be influenced by multiple joint-related factors and factors related to, e.g., physiological, epigenetic, and pain sensory profiles. Increasing evidence suggests that a subset of patients with OA are pain sensitive. This can be assessed using quantitative sensory testing (QST). Common treatments of OA are total knee arthroplasty (TKA) and administration of 3-weeks of non-steroidal anti-inflammatory drugs (NSAIDs), which provide pain relief to many patients with OA. However, approx. 20% of patients experience chronic postoperative pain after TKA, whereas NSAIDs provide an average pain relief of approx. 25%. The current topical review focuses on the emerging evidence linking pretreatment QST to the treatment response of TKA and NSAID treatments. CONTENT MEDLINE was systematically searched for all studies from 2000 to 2022 on pretreatment QST, TKA, and NSAIDs. Pre-clinical studies, reviews, and meta-analyses were excluded. SUMMARY Currently, 14 studies on TKA and four studies on NSAIDs have been published with the aim to attempt prediction of the treatment response. The QST methodologies in the studies are inconsistent, but 11/14 (79%) studies on TKA and 4/4 (100%) studies on NSAIDs report statistically significant associations between pretreatment QST and chronic postoperative pain after TKA or analgesic effect after NSAID treatment. The strength of the associations remains low-to-moderate. The most consistent pretreatment QST predictors are pressure pain thresholds, temporal summation of pain, and conditioned pain modulation. OUTLOOK The use of QST as predictors of standard OA treatment is interesting, but the predictive strength remains low-to-moderate. A transition of QST from a research-based setting and into the clinic is not advised until the predictive strength has been improved and the methodology has been standardized.
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Affiliation(s)
- Kristian Kjær-Staal Petersen
- Center for Neuroplasticity and Pain, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
- Center for Mathematical Modelling of Knee Osteoarthritis, Department of Materials and Production, Aalborg University, Aalborg, Denmark
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Bruehl S, Milne G, Schildcrout J, Shi Y, Anderson S, Shinar A, Polkowski G, Mishra P, Billings FT. Perioperative oxidative stress predicts subsequent pain-related outcomes in the 6 months after total knee arthroplasty. Pain 2023; 164:111-118. [PMID: 35507374 PMCID: PMC9633585 DOI: 10.1097/j.pain.0000000000002670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/25/2022] [Indexed: 01/09/2023]
Abstract
ABSTRACT Total knee arthroplasty (TKA) is effective for pain reduction in most patients, but 15% or more report unsatisfactory long-term pain outcomes. We tested whether oxidative stress (OS) related to extended tourniquet application during TKA and subsequent ischemic reperfusion (IR) contributed to adverse post-TKA pain outcomes. Blood samples were obtained in 91 patients with osteoarthritis (63% female) undergoing TKA before tourniquet placement (T1), 45 minutes after tourniquet inflation (T2), and 15 minutes after tourniquet removal (T3). Plasma levels of F 2 -isoprostanes and isofurans, the most specific measures of in vivo OS, were quantified. Pain intensity and function were assessed at baseline and again at 6 weeks and 6 months after TKA. Results indicated that higher Combined OS (F 2 -isoprostanes + isofurans/2) at T1 baseline and larger increases in Combined OS from T1 to T2 were associated with higher baseline-corrected past 24-hour worst and average pain intensity (numeric rating scale) and higher past week McGill Pain Questionnaire-2 total scores at 6-month follow-up ( P 's < 0.05). Increases in Combined OS from T1 to T3, which should most directly capture OS and IR injury related to tourniquet use, were not associated with short-term or long-term post-TKA pain outcomes. Longer ischemia duration was unexpectedly associated with lower baseline-corrected pain intensity at 6-month follow-up. Combined OS was not linked to functional outcomes at either follow-up. Elevated perioperative OS seems to exert small but significant adverse effects on long-term post-TKA pain outcomes, although this OS seems unrelated to IR injury associated with extended tourniquet use.
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Affiliation(s)
- Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ginger Milne
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan Schildcrout
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara Anderson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew Shinar
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gregory Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Puneet Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T. Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Ketamine in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1688-1690. [PMID: 35970569 DOI: 10.1016/j.arth.2022.02.122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023] Open
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Lavand'homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol 2022; 39:743-757. [PMID: 35852550 PMCID: PMC9891300 DOI: 10.1097/eja.0000000000001691] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Patricia M Lavand'homme
- From the Department of Anaesthesiology and Perioperative Pain Service, Cliniques Universitaires St Luc, University Catholic of Louvain (UCL), Brussels, Belgium (PML), Section of Surgical Pathophysiology 7621, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anaesthesiology, Orebro University, Orebro, Sweden (NR) and Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, United States (GPJ)
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11
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Mion G. Ketamine Analgesia: Not All Patients or Surgeries Seem to Be Equal. Anesth Analg 2021; 132:e114-e116. [PMID: 34032679 DOI: 10.1213/ane.0000000000005507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Georges Mion
- Department of Anaesthesia, Cochin Hospital, Paris, France,
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12
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Pharmacotherapy for the Prevention of Chronic Pain after Surgery in Adults: An Updated Systematic Review and Meta-analysis. Anesthesiology 2021; 135:304-325. [PMID: 34237128 DOI: 10.1097/aln.0000000000003837] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Chronic postsurgical pain can severely impair patient health and quality of life. This systematic review update evaluated the effectiveness of systemic drugs to prevent chronic postsurgical pain. METHODS The authors included double-blind, placebo-controlled, randomized controlled trials including adults that evaluated perioperative systemic drugs. Studies that evaluated same drug(s) administered similarly were pooled. The primary outcome was the proportion reporting any pain at 3 or more months postsurgery. RESULTS The authors identified 70 new studies and 40 from 2013. Most evaluated ketamine, pregabalin, gabapentin, IV lidocaine, nonsteroidal anti-inflammatory drugs, and corticosteroids. Some meta-analyses showed statistically significant-but of unclear clinical relevance-reductions in chronic postsurgical pain prevalence after treatment with pregabalin, IV lidocaine, and nonsteroidal anti-inflammatory drugs. Meta-analyses with more than three studies and more than 500 participants showed no effect of ketamine on prevalence of any pain at 6 months when administered for 24 h or less (risk ratio, 0.62 [95% CI, 0.36 to 1.07]; prevalence, 0 to 88% ketamine; 0 to 94% placebo) or more than 24 h (risk ratio, 0.91 [95% CI, 0.74 to 1.12]; 6 to 71% ketamine; 5 to 78% placebo), no effect of pregabalin on prevalence of any pain at 3 months (risk ratio, 0.88 [95% CI, 0.70 to 1.10]; 4 to 88% pregabalin; 3 to 80% placebo) or 6 months (risk ratio, 0.78 [95% CI, 0.47 to 1.28]; 6 to 68% pregabalin; 4 to 69% placebo) when administered more than 24 h, and an effect of pregabalin on prevalence of moderate/severe pain at 3 months when administered more than 24 h (risk ratio, 0.47 [95% CI, 0.33 to 0.68]; 0 to 20% pregabalin; 4 to 34% placebo). However, the results should be interpreted with caution given small study sizes, variable surgical types, dosages, timing and method of outcome measurements in relation to the acute pain trajectory in question, and preoperative pain status. CONCLUSIONS Despite agreement that chronic postsurgical pain is an important topic, extremely little progress has been made since 2013, likely due to study designs being insufficient to address the complexities of this multifactorial problem. EDITOR’S PERSPECTIVE
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13
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Braaksma C, Wolterbeek N, Veen MR, Prinsen CAC, Ostelo RWJG. Systematic review and meta-analysis of measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical Function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical Function Shortform (KOOS-PS). Osteoarthritis Cartilage 2020; 28:1525-1538. [PMID: 32827668 DOI: 10.1016/j.joca.2020.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to evaluate all evidence on measurement properties of the Hip disability and Osteoarthritis Outcome Score - Physical function Shortform (HOOS-PS) and the Knee Injury and Osteoarthritis Outcome Score - Physical function Shortform (KOOS-PS). DESIGN This study was conducted according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of PROMs. MEDLINE, EMBASE, The Cochrane Library, CINAHL and PsychINFO through February 2019 were searched. Eligible studies evaluated patients with hip or knee complaints and described a measurement property, interpretability, feasibility, or the development of either the HOOS-PS or KOOS-PS. RESULTS Twenty-three studies were included. For both questionnaires, the content validity was found inconsistent and the quality evidence was moderate for a sufficient reliability and high for an insufficient construct validity. The HOOS-PS had a high quality evidence of sufficient structural validity and internal consistency (pooled Cronbach's alpha 0.80; n = 3761) and low quality evidence of sufficient measurement error and indeterminate responsiveness. Concerning the KOOS-PS, the quality evidence was high for an insufficient responsiveness, moderate for an inconsistent structural validity and internal consistency and low for an inconsistent measurement error. CONCLUSIONS The inconsistent evidence for content validity implies that scores on the HOOS-PS and KOOS-PS may inadequately reflect physical functioning. Furthermore, there is evidence for insufficient construct validity and responsiveness in patients with knee osteoarthritis receiving conservative treatment. Using the HOOS-PS or KOOS-PS as outcome measurement instruments for comparing outcomes, measuring improvements or benchmarking in patients with hip or knee complaints or undergoing arthroplasty should only be done with great caution. REVIEW REGISTRATION PROSPERO number CRD42017069539.
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Affiliation(s)
- C Braaksma
- Department of Orthopaedic Surgery, Utrecht, the Netherlands.
| | - N Wolterbeek
- Department of Orthopaedic Surgery, Utrecht, the Netherlands
| | - M R Veen
- Department of Orthopaedic Surgery, Utrecht, the Netherlands
| | - C A C Prinsen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, de Boelelaan 1117, Amsterdam, the Netherlands
| | - R W J G Ostelo
- Department of Health Sciences and the Amsterdam Public Health Research Institute, VU University, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam Public Health Research Institute, de Boelelaan 1117, Amsterdam, the Netherlands
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14
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Pan L, Wu H, Liu H, Yang X, Meng Z, Cao Y. Dexmedetomidine as an adjunct to local anesthetics in nerve block relieved pain more effectively after TKA: a meta-analysis of randomized controlled trials. J Orthop Surg Res 2020; 15:577. [PMID: 33261646 PMCID: PMC7709255 DOI: 10.1186/s13018-020-02105-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 11/19/2020] [Indexed: 02/08/2023] Open
Abstract
Background Dexmedetomidine has shown potential in pain control in patients undergoing total knee arthroplasty (TKA). However, the combination of nerve block and dexmedetomidine may be a preferred alternative for postoperative analgesia after TKA. The aim of this study was to perform a meta-analysis on existing randomized controlled trials (RCTs) to determine the efficacy and safety of dexmedetomidine as an adjunct to local anesthetics in nerve block after TKA. Methods A literature survey was conducted in the databases of PubMed, Embase, Cochrane Library, Web of science, and ScienceDirect for the RCTs completed before February 1st, 2020 that met pre-specified inclusion criteria. The primary outcomes included the pain scores, duration of analgesia, opioid consumption within 24 h postoperatively, and the level of patient satisfaction. The secondary outcomes included the motor strength, degree of sedation, postoperative nausea and vomiting, and other related complications. The methodological quality was assessed by the Cochrane risk of bias tool. Results The initial literature search yielded 143 studies, out of which seven studies met the inclusion criteria. The pooled data indicated that dexmedetomidine combined with local anesthetics in nerve block in TKA decreased the postoperative pain scores at rest as well as at motion (SMD = − 1.01 [95% CI − 1.29 to − 0.72], p < 0.01; SMD = − 1.01 [− 1.25 to − 0.77], p < 0.01) respectively, decreased the total opioid consumption within 24 h (SMD = − 0.63 [− 0.86 to − 0.40], p < 0.01), prolonged the duration of analgesia (SMD = 0.90 [0.64 to 1.17], p < 0.01), improved motor strength (SMD = 0.23 [0.01 to 0.45], p = 0.04), improved the degree of sedation (SMD = 0.94 [0.70 to 1.18], p < 0.01), and increased the level of patient satisfaction (SMD = 0.88 [0.60 to 1.17], p < 0.01) without increasing nausea and vomiting (RD = − 0.05 [− 0.11 to 0.01], p = 0.14), as well as other complications (RD = − 0.01 [− 0.08 to 0.07], p = 0.89), compared with local anesthetics alone. Conclusions It is effective and safe for dexmedetomidine as an adjunct to local anesthetics in nerve block in TKA to relieve postoperative pain, decrease total opioid consumption, prolong analgesic duration, and increase patient satisfaction without increasing related complications. Based on the quality of evidence, this meta-analysis recommends that dexmedetomidine can be used in a regular treatment regimen and as an adjunct addition to local anesthetics in nerve block for patients undergoing TKA. Registration This meta-analysis was prospectively registered on PROSPERO (International prospective register of systematic reviews) and the registering number was CRD42020169171. Supplementary Information The online version contains supplementary material available at 10.1186/s13018-020-02105-7.
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Affiliation(s)
- Liping Pan
- Department of Orthopedics, Peking University First Hospital, No. 8 Xishiku Street, XiCheng District, Beijing, 100034, People's Republic of China
| | - Hao Wu
- Department of Orthopedics, Peking University First Hospital, No. 8 Xishiku Street, XiCheng District, Beijing, 100034, People's Republic of China
| | - Heng Liu
- Department of Orthopedics, Peking University First Hospital, No. 8 Xishiku Street, XiCheng District, Beijing, 100034, People's Republic of China
| | - Xin Yang
- Department of Orthopedics, Peking University First Hospital, No. 8 Xishiku Street, XiCheng District, Beijing, 100034, People's Republic of China
| | - Zhichao Meng
- Department of Orthopedics, Peking University First Hospital, No. 8 Xishiku Street, XiCheng District, Beijing, 100034, People's Republic of China
| | - Yongping Cao
- Department of Orthopedics, Peking University First Hospital, No. 8 Xishiku Street, XiCheng District, Beijing, 100034, People's Republic of China.
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15
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Seki Y, Katagiri H, Otabe K, Nakagawa Y, Miyatake K, Sekiya I, Koga H. Investigation of association between the preoperative intra-articular anesthetic test and persistent pain after total knee arthroplasty. J Orthop Sci 2020; 25:1055-1060. [PMID: 32107135 DOI: 10.1016/j.jos.2020.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 12/12/2019] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND A better understanding of the etiology of persistent pain after total knee arthroplasty (TKA) is required to prevent unfavorable outcomes. The purpose of this study was to investigate the association of persistent pain after TKA, patient characteristics, and the remaining pain ratio per the preoperative intra-articular anesthetic test. METHODS This study included 89 patients who underwent TKA and underwent an intra-articular anesthetic test preoperatively. The remaining pain ratio out of 100 percent 30 min after intra-articular anesthetic injection and demographic data were also evaluated preoperatively. Numerical rating scale (NRS) scores for pain during movement (Q1), at rest (Q2), at first movement in the morning (Q3), and during climbing up and down stairs (Q4) were evaluated 1 year after TKA. Multiple linear regression analysis was performed to assess the impact of independent variables on the NRS score for questionnaire No.4. and the remaining pain ratio per the intra-articular anesthetic. RESULTS The mean remaining pain ratio per the preoperative intra-articular anesthetic test was 29.3%. The NRS score for Q4 was significantly higher than those for any of the other NRS questionnaires administered 1 year after TKA (Q1-Q4, Q2-Q4, P < 0.001; Q3-Q4, P < 0.05). The analysis found the weak correlation between the pain ratio of anesthetic test and the NRS score for Q4 after TKA (R = 0.28, P = 0.018). BMI and preoperative FTA were the major predictors of remaining pain ratio per the intra-articular anesthetic test (R = 0.40, P = 0.002). CONCLUSION This study revealed that the remaining pain ratio per the preoperative intra-articular anesthetic test was weakly correlated with persistent pain during climbing up and down stairs 1 year after TKA. In addition, BMI and preoperative FTA were associated with the remaining pain ratio per the preoperative intra-articular anesthetic test.
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Affiliation(s)
- Yoshie Seki
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Koji Otabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan; Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine (TMDU), 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Chen J, Hu W, Li SM, Li XL, Yang ZM. The efficacy of ketamine in total knee arthroplasty: a randomized controlled trial protocol. Medicine (Baltimore) 2020; 99:e20645. [PMID: 32541504 PMCID: PMC7302669 DOI: 10.1097/md.0000000000020645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/11/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Appropriate pain management is essential to improve the postoperative recovery after total knee arthroplasty (TKA). There is a paucity of literature on ketamine for TKA procedures. The aim of this study was to evaluate the analgesic efficacy of ketamine in patients undergoing primary TKA. METHODS This study was designed as a prospective, double blind, single center, randomized controlled trial. The participants were randomly assigned to either the ketamine or placebo groups, using a set of random numbers for the allocation sequence. All patients underwent TKA without patella resurfacing under spinal anesthesia. Preoperative workup, surgical technique, and postoperative management were standardized for all the patients. The primary outcome of this noninferiority study is opioid consumption within the first 24 hours following surgery, pain scores, distance ambulated, patient satisfaction, length of hospital stay, and complications. RESULTS The results of this study were expected to provide useful information on the effectiveness and safety of ketamine for immediate postoperative analgesia after TKA surgery. TRIAL REGISTRATION This study protocol was registered in Research Registry (researchregistry5575).
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Affiliation(s)
- Jing Chen
- Department of Orthopedics, Aerospace Center Hospital, Beijing
| | - Wei Hu
- Department of Orthopedics, Ningxia Armed Police Corps Hospital, Ningxia Hui Autonomous Region
| | - Shu-Ming Li
- Department of Orthopedics, Aerospace Center Hospital, Beijing
| | - Xiao-Lin Li
- Department of Orthopedics, Ningxia Armed Police Corps Hospital, Ningxia Hui Autonomous Region
| | - Zhan-Min Yang
- Department of Anesthesiology, Aerospace Center Hospital, Beijing, China
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Summers S, Mohile N, McNamara C, Osman B, Gebhard R, Hernandez VH. Analgesia in Total Knee Arthroplasty: Current Pain Control Modalities and Outcomes. J Bone Joint Surg Am 2020; 102:719-727. [PMID: 31985507 DOI: 10.2106/jbjs.19.01035] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Spencer Summers
- Departments of Orthopaedics and Rehabilitation (S.S., N.M., C.M., and V.H.H.), and Anesthesiology, Perioperative Medicine, and Pain Management (B.O. and R.G.), University of Miami, Miami, Florida
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A Review of Nonanesthetic Uses of Ketamine. Anesthesiol Res Pract 2020; 2020:5798285. [PMID: 32308676 PMCID: PMC7152956 DOI: 10.1155/2020/5798285] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/07/2020] [Accepted: 03/05/2020] [Indexed: 12/20/2022] Open
Abstract
Ketamine, a nonselective NMDA receptor antagonist, is used widely in medicine as an anesthetic agent. However, ketamine's mechanisms of action lead to widespread physiological effects, some of which are now coming to the forefront of research for the treatment of diverse medical disorders. This paper aims at reviewing recent data on key nonanesthetic uses of ketamine in the current literature. MEDLINE, CINAHL, and Google Scholar databases were queried to find articles related to ketamine in the treatment of depression, pain syndromes including acute pain, chronic pain, and headache, neurologic applications including neuroprotection and seizures, and alcohol and substance use disorders. It can be concluded that ketamine has a potential role in the treatment of all of these conditions. However, research in this area is still in its early stages, and larger studies are required to evaluate ketamine's efficacy for nonanesthetic purposes in the general population.
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Yang Q, Ren Y, Feng B, Weng X. Pain relieving effect of dexmedetomidine in patients undergoing total knee or hip arthroplasty: A meta-analysis. Medicine (Baltimore) 2020; 99:e18538. [PMID: 31895790 PMCID: PMC6946532 DOI: 10.1097/md.0000000000018538] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND To evaluate the safety and efficacy of dexmedetomidine in patients undergoing total knee and hip arthroplasty for postoperative pain control. METHODS An updated systematic review and meta-analysis of randomized controlled trials (RCTs) identified in systematic searches of MEDLINE, EMBASE, Google Scholar, the Cochrane Database and the Chinese SinoMed Database. RESULTS Fourteen RCTs with a total of 1220 patients were included. Overall, dexmedetomidine therapy was associated with significantly decreased pain scores 24 hours after surgery (WMD, -0.36; 95% CI, -0.49 to -0.22; I = 90.0%, P < .001) compared with scores in the control group after total hip arthroplasty (THA) and total knee arthroplasty (TKA). Furthermore, the rate of postoperative delirium was also markedly decreased with dexmedetomidine therapy (RR, 0.38; 95% CI, 0.24 to 0.59; I = 0.0%, P < .001). Moreover, compared with the control group, dexmedetomidine treatment was associated with a decreased risk of postoperative nausea and vomiting in patients undergoing TKA (RR, 0.34; 95% CI, 0.15 to 0.79; I = 0.0%, P = .012), and there was a similar risk of hypotension (RR, 1.03; 95% CI, 0.72 to 1.49; I = 24.4%, P = .87) regardless of whether patients underwent TKA or THA. However, the rate of bradycardia was significantly increased with dexmedetomidine treatment in those undergoing TKA (RR, 6.11; 95% CI, 2.35 to 15.91; I = 0.0%, P < .001). CONCLUSIONS Dexmedetomidine therapy seems to be an effective treatment for pain control and postoperative delirium in patients undergoing TKA/THA. However, the incidence of bradycardia is markedly increased in patients undergoing TKA. Hence, much larger prospective clinical studies are warranted to confirm these findings.
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Affiliation(s)
- Qi Yang
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing
- Department of Orthopedics, First Hospital of Harbin, Harbin, China
| | - Yi Ren
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing
| | - Bin Feng
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing
| | - Xisheng Weng
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing
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Xu B, Wang Y, Zeng C, Wei J, Li J, Wu Z, He H, Lei G, Xie D, Ding X. Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies. BMJ Open 2019; 9:e028337. [PMID: 31519671 PMCID: PMC6747636 DOI: 10.1136/bmjopen-2018-028337] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To examine the analgesic efficacy and safety of ketamine after total knee or hip arthroplasty. DESIGN Systematic review and meta-analysis. DATA SOURCES PubMed, EMBASE and Cochrane Library from inception to 22 May 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials comparing the efficacy and safety of ketamine with placebo for postoperative pain relief in patients undergoing total knee or hip arthroplasty. DATA EXTRACTION AND SYNTHESIS Data (ie, pain intensity, morphine consumption, gastrointestinal and psychotic adverse effects) were extracted by two reviewers independently. The Cochrane Collaboration's recommended tool was used to determine the methodological quality of included studies. RESULTS A total of 10 studies were included. One of them was rated as low quality. Compared with placebo, intravenous ketamine was effective for pain relief during 0-8-hour (weighted mean difference (WMD) -1.21, 95% CI -1.45 to -0.98, p<0.001; three studies, 149 participants) but not during 8-24-hour postoperative periods, and effective for reduction of cumulative morphine consumption during both 0-24-hour (WMD -17.76, 95% CI -31.25 to -4.27, p=0.01; five studies, 366 participants) and 0-48-hour (WMD -21.79, 95% CI -25.46 to -18.11, p<0.001; four studies, 252 participants) postoperative periods, without increasing risks of gastrointestinal or psychotic adverse effects. The limited data available for intra-articular (WMD -0.49, 95% CI -0.70 to -0.29, p<0.001; two studies, 83 participants) and epidural (WMD -2.10, 95% CI -3.30 to -0.90, p<0.001; one study, 20 participants) ketamine pointed to a significant reduction in pain intensity during 8-24-hour postoperative period. CONCLUSIONS Intravenous administration of ketamine is effective and safe for postoperative pain relief in patients undergoing total knee or hip arthroplasty. Nevertheless, the analgesic efficacy and safety of ketamine in such patients seem to vary by different administration routes and still warrant further studies to explore.
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Affiliation(s)
- Bei Xu
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Yilun Wang
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Chao Zeng
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Jie Wei
- Health Management Center, Xiangya Hospital, Central South University, Changsha, China
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Jiatian Li
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Ziying Wu
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Hongyi He
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Guanghua Lei
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Dongxing Xie
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
| | - Xiang Ding
- Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
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Beswick AD, Dennis J, Gooberman-Hill R, Blom AW, Wylde V. Are perioperative interventions effective in preventing chronic pain after primary total knee replacement? A systematic review. BMJ Open 2019; 9:e028093. [PMID: 31494601 PMCID: PMC6731899 DOI: 10.1136/bmjopen-2018-028093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES For many people with advanced osteoarthritis, total knee replacement (TKR) is an effective treatment for relieving pain and improving function. Features of perioperative care may be associated with the adverse event of chronic pain 6 months or longer after surgery; effects may be direct, for example, through nerve damage or surgical complications, or indirect through adverse events. This systematic review aims to evaluate whether non-surgical perioperative interventions prevent long-term pain after TKR. METHODS We conducted a systematic review of perioperative interventions for adults with osteoarthritis receiving primary TKR evaluated in a randomised controlled trial (RCT). We searched The Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL until February 2018. After screening, two reviewers evaluated articles. Studies at low risk of bias according to the Cochrane tool were included. INTERVENTIONS Perioperative non-surgical interventions; control receiving no intervention or alternative treatment. PRIMARY AND SECONDARY OUTCOME MEASURES Pain or score with pain component assessed at 6 months or longer postoperative. RESULTS 44 RCTs at low risk of bias assessed long-term pain. Intervention heterogeneity precluded meta-analysis and definitive statements on effectiveness. Good-quality research provided generally weak evidence for small reductions in long-term pain with local infiltration analgesia (three studies), ketamine infusion (one study), pregabalin (one study) and supported early discharge (one study) compared with no intervention. For electric muscle stimulation (two studies), anabolic steroids (one study) and walking training (one study) there was a suggestion of more clinically important benefit. No concerns relating to long-term adverse events were reported. For a range of treatments there was no evidence linking them with unfavourable pain outcomes. CONCLUSIONS To prevent chronic pain after TKR, several perioperative interventions show benefits and merit further research. Good-quality studies assessing long-term pain after perioperative interventions are feasible and necessary to ensure that patients with osteoarthritis achieve good long-term outcomes after TKR.
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Affiliation(s)
- Andrew David Beswick
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jane Dennis
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Ashley William Blom
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Vikki Wylde
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
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Riddell JM, Trummel JM, Onakpoya IJ. Low-dose ketamine in painful orthopaedic surgery: a systematic review and meta-analysis. Br J Anaesth 2019; 123:325-334. [DOI: 10.1016/j.bja.2019.05.043] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 05/09/2019] [Accepted: 05/28/2019] [Indexed: 11/30/2022] Open
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Ketamine reduces pain and opioid consumption after total knee arthroplasty: A meta-analysis of randomized controlled studies. Int J Surg 2019; 70:70-83. [PMID: 31446006 DOI: 10.1016/j.ijsu.2019.08.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/25/2019] [Accepted: 08/21/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To examine the analgesic efficacy and safety of ketamine after total knee arthroplasty. METHODS We searched for all articles on ketamine in patients with total knee arthroplasty in electronic databases, including PubMed, Embase, Ovid, Cochrane Library, Web of Science, CNKI, Wanfang Data, and VIP, up to the February 2019. Randomized controlled trials comparing ketamine and the placebo for pain management after total knee arthroplasty were utilized. The outcome measurements consist of the pain score, opioid consumption, length of hospitalization and postoperative complications. All data analyses were conducted using STATA 13.0. Cochrane Collaboration's tool was adopted to assess the risk of bias. RESULTS A total of six randomized controlled trials were included in the meta-analysis. The present meta-analysis demonstrated that there were significant differences between the two groups regarding the pain score within the first 24 postoperative hours. Ketamine was associated with a significant reduction of cumulative morphine consumption. Notably, ketamine could significantly decrease the incidence of nausea and vomiting without increasing the risk of thrombosis. CONCLUSION Ketamine is effective in reducing pain and cumulative morphine consumption during the early post-operative period after total knee arthroplasty. In addition, the use of ketamine is associated with a lower incidence of adverse effects.
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Tan TL, Longenecker AS, Rhee JH, Good RP, Emper WD, Freedman KB, Shaner JL, McComb JJ, Levicoff EA. Intraoperative Ketamine in Total Knee Arthroplasty Does Not Decrease Pain and Narcotic Consumption: A Prospective Randomized Controlled Trial. J Arthroplasty 2019; 34:1640-1645. [PMID: 31084971 DOI: 10.1016/j.arth.2019.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/26/2019] [Accepted: 04/08/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Multiple studies have demonstrated that ketamine, a glutamate receptor blocker, may decrease postoperative pain in abdominal and orthopedic surgeries. However, its role with spinal anesthesia and total knee arthroplasty (TKA) remains unknown. The purpose of this study is to determine the efficacy of subanesthetic dosing of ketamine during TKA on postoperative pain and narcotic consumption. METHODS In this prospective, randomized, double-blinded clinical trial, we enrolled 91 patients undergoing primary TKA with spinal anesthesia in a single institution from 2017 to 2018. Patients were randomized to receive intraoperative ketamine infusion at a rate of 6 mcg/kg/min for 75 minutes or a saline placebo. All patients received spinal anesthesia and otherwise identical surgical approaches, pain management, and rehabilitation protocols. Patient-reported visual analog pain scores were calculated preoperatively, postoperative days (POD) 0-7, and 2 weeks. Narcotic consumption was evaluated on POD 0 and 1. RESULTS There was no difference in average pain between ketamine and placebo at all time points except for at PODs 1 (45 vs 56, P = .041) and 4 (39 vs 49, P = .040). For least pain experienced, patients administered with ketamine experienced a reduction in pain only at POD 4 (22 vs 35, P = .011). There was no difference in maximum pain cohorts at all time points of the study or in-hospital morphine equivalents between the 2 cohorts. CONCLUSION As part of multimodal pain management protocol, intraoperative ketamine does not result in a clinically significant improvement in pain and narcotic consumption following TKA.
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Affiliation(s)
- Timothy L Tan
- Rothman Orthopaedic Institute, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Janet H Rhee
- Rothman Orthopaedic Institute, Bryn Mawr Hospital, Bryn Mawr, PA
| | - Robert P Good
- Rothman Orthopaedic Institute, Bryn Mawr Hospital, Bryn Mawr, PA
| | - William D Emper
- Rothman Orthopaedic Institute, Bryn Mawr Hospital, Bryn Mawr, PA
| | - Kevin B Freedman
- Rothman Orthopaedic Institute, Bryn Mawr Hospital, Bryn Mawr, PA
| | - Julie L Shaner
- Rothman Orthopaedic Institute, Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA
| | | | - Eric A Levicoff
- Rothman Orthopaedic Institute, Bryn Mawr Hospital, Bryn Mawr, PA
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Abstract
Chronic postsurgical pain affects between 5 and 75% of patients, often with an adverse impact on quality of life. While the transition of acute to chronic pain is a complex process-involving multiple mechanisms at different levels-the current strategies for prevention have primarily been restricted to perioperative pharmacological interventions. In the present paper, we first present an up-to-date narrative literature review of these interventions. In the second section, we develop several ways by which we could overcome the limitations of the current approaches and enhance the outcome of our surgical patients, including the better identification of individual risk factors, tailoring treatment to individual patients, and improved acute and subacute pain evaluation and management. The third and final section covers the treatment of established CPSP. Given that evidence for the current therapeutic options is limited, we need high-quality trials studying multimodal interventions matched to pain characteristics.
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Affiliation(s)
- Arnaud Steyaert
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - Patricia Lavand'homme
- Department of Anesthesiology, Acute and Transitional Pain Service, Cliniques Universitaires St-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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von Plato H, Kontinen V, Hamunen K. Efficacy and safety of epidural, continuous perineural infusion and adjuvant analgesics for acute postoperative pain after major limb amputation - a systematic review. Scand J Pain 2019; 18:3-17. [PMID: 29794290 DOI: 10.1515/sjpain-2017-0170] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 01/11/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases. Literature on management of acute post-amputation pain is scarce. We performed a systematic review on this topic to evaluate the efficacy and safety of analgesic interventions for acute pain following major limb amputation. METHODS A literature search was performed in PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews using the following key words: [(amputation) AND (pain OR analgesi* OR pain relief)] AND (acute OR postoperative). Randomized controlled studies (RCTs) and observational studies investigating treatment of acute pain following major amputations for any indication (peripheral vascular disease, malignant disease, trauma) were included. The review was performed according to the standards described in the PRISMA statement. The Cochrane quality assessment tool was used to evaluate the risk of bias in the RCTs. RESULTS Nineteen studies with total of 949 patients were included. The studies were generally small and heterogeneous on outcomes, study designs and quality. There were 16 studies on epidural or continuous perineural analgesia (CPI). Based on five RCTs (n=268) and two observational studies (n=49), epidural analgesia decreased the intensity of acute stump pain as compared to systemic analgesics, during the first 24 h after the operation. Based on one study epidural analgesia caused more adverse effects like sedation, nausea and motor block than continuous perineural local anesthetic infusion. Based on one RCT (n=21) and eight observational studies (n=501) CPI seemed to decrease opioid consumption as compared to systemic analgesics only, on the first three postoperative days, and was well tolerated. Only three trials investigated systemic analgesics (oral memantine, oral gabapentine, iv ketamine). Ketamine did not decrease acute pain or opioid consumption after amputation as compared to other systemic analgesics. Gabapentin did not decrease acute pain when combined to epidural analgesia as compared to epidural analgesia and opioid treatment, and caused adverse effects. CONCLUSIONS The main finding of this systematic review is that evidence regarding pain management after major limb amputation is very limited. Epidural analgesia may be effective, but firm evidence is lacking. Epidural causes more adverse effects than CPI. The results on efficacy of CPI are indecisive. The data on adjuvant medications combined to epidural analgesia or CPI is limited. Studies on efficacy and adverse effects of systemic analgesics for amputation pain, especially concentrating on elderly patients, are needed.
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Affiliation(s)
- Hanna von Plato
- Division of Perioperative Care, Jorvi Hospital, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, P. O. Box 800, 00029 HUS, Helsinki, Finland, Phone: +350504284471
| | - Vesa Kontinen
- Division of Perioperative Care, Jorvi Hospital, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Katri Hamunen
- Division of Pain Medicine, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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The Importance of the Saphenous Nerve Block for Analgesia Following Major Ankle Surgery: A Randomized, Controlled, Double-Blind Study. Reg Anesth Pain Med 2019; 43:474-479. [PMID: 29667940 DOI: 10.1097/aap.0000000000000764] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Major ankle surgery causes intense postoperative pain, and whereas the importance of a sciatic nerve block is well established, the clinical significance of a supplemental saphenous nerve block has never been determined in a prospective, randomized, double-blind, placebo-controlled trial. We hypothesized that a saphenous nerve block reduces the proportion of patients experiencing significant clinical pain after major ankle surgery. METHODS Eighteen patients were enrolled and received a popliteal sciatic nerve block. Patients were randomized to single-injection saphenous nerve block with 10 mL 0.5% bupivacaine with 1:200,000 epinephrine or 10 mL saline (Fig. 1). Primary outcome was the proportion of patients reporting significant clinical pain, defined as a score greater than 3 on the numerical rating scale. Secondary outcomes were maximal pain and analgesia of the cutaneous territory of the infrapatellar branch of the saphenous nerve. RESULTS Eight of 9 patients in the placebo group reported significant clinical pain versus 1 of 9 patients in the bupivacaine-epinephrine group (P = 0.003). Maximal pain was significantly lower in the active compared with the placebo group (median, 0 [0-0] vs 5 [4-6]; P = 0.001). Breakthrough pain from the saphenous territory began within 30 minutes after surgery in all cases. Sensory testing of the cutaneous territory of the infrapatellar branch of the saphenous nerve showed correlation between pain reported in the anteromedial ankle region and the intensity of cutaneous sensory block in the anteromedial knee region. CONCLUSIONS The saphenous nerve is an important contributor to postoperative pain after major ankle surgery, with significant clinical pain appearing within 30 minutes after surgery. CLINICAL TRIALS REGISTRATION This study has been registered at ClinicalTrials.gov, identifier NCT02697955.
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Mills ES, Iorio L, Feinn RS, Duignan KM, Macica CM. Joint replacement in X-linked hypophosphatemia. J Orthop 2018; 16:55-60. [PMID: 30662239 DOI: 10.1016/j.jor.2018.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/02/2018] [Indexed: 10/27/2022] Open
Abstract
X-linked hypophosphatemia (XLH) is associated with a pervasive, severe degenerative osteoarthritis. We conducted a retrospective chart review/patient survey using the Knee or Hip Osteoarthritis Outcome Score Physical Function Short Form. Fourteen total knee arthroplasties and 7 total hip arthroplasties among 11 patients were included. The mean KOOS-PS score was 31.4 ± 9.7 with a mean follow up of 6.9 years. Mean HOOS-PS score was 14.8 ± 12.9 at a mean follow up of 7.6 years. One knee failed due to aseptic loosening and one hip was revised due to polyethylene wear. In conclusion, total joint arthroplasty is beneficial in XLH.
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Affiliation(s)
- Emily S Mills
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Louis Iorio
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Richard S Feinn
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Kevin M Duignan
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
| | - Carolyn M Macica
- Department of Medical Sciences, Frank H. Netter MD School of Medicine at Quinnipiac University, Hamden, CT, 06518, USA
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The efficacy and safety of first-line therapies for preventing chronic post-surgical pain: a network meta-analysis. Oncotarget 2018; 9:32081-32095. [PMID: 30174798 PMCID: PMC6112831 DOI: 10.18632/oncotarget.22611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 07/30/2017] [Indexed: 12/27/2022] Open
Abstract
Background Due to conflicting evidence regarding first-line therapies for chronic post-surgical pain (CPSP), here we comparatively evaluated the efficacy and safety of first-line therapies for the prevention of CPSP. Materials and Methods MEDLINE, EMBASE, and Cochrane CENTRAL databases were searched for randomized, controlled trials (RCTs) of systemic drugs measuring pain three months or more post-surgery. Pairwise meta-analyses (a frequentist technique directly comparing each intervention against placebo) and network meta-analyses (a Bayesian technique simultaneously comparing several interventions via an evidence network) compared the mean differences for primary efficacy (reduction in all pain), secondary efficacy (reduction in moderate or severe pain), and primary safety (drop-out rate from treatment-related adverse effects). Ranking probabilities from the network meta-analysis were transformed using surface under the cumulative ranking analysis (SUCRA). Sensitivity analyses evaluated the impact of age, gender, surgery type, and outlier studies. Results Twenty-four RCTs were included. Mexiletine and ketamine ranked highest in primary efficacy, while ketamine and nefopam ranked highest in secondary efficacy. Simultaneous SUCRA-based rankings of the interventions according to both efficacy and safety revealed that nefopam and mexiletine ranked highest in preventing CPSP. Through the sensitivity analyses, gabapentin and ketamine remained the most-highly-ranked in terms of efficacy, while nefopam and ketamine remained the most-highly-ranked in terms of safety. Conclusions Nefopam and mexiletine may be considered as first-line therapies for the prevention of CPSP. On account of the paucity of evidence available on nefopam and mexiletine, gabapentin and ketamine may also be considered. Venlafaxine is not recommended for the prevention of CPSP.
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Abstract
Chronic postoperative pain is a poorly recognized potential outcome from surgery. It affects millions of patients every year, with pain lasting for months to years, resulting in patient suffering and ensuing economic consequences. The operations with the highest incidence of chronic postoperative pain are amputations, thoracotomies, cardiac surgery, and breast surgery. Other risk factors include preoperative pain, psychological factors, demographics, and the intensity of acute postoperative pain. Attempts to prevent chronic postoperative pain have often led to debatable results. This article presents data from recently published studies examining the incidence, risk factors, mechanisms, treatment options, and preventive strategies for chronic postoperative pain in adults. In summary, many of the previously identified risk factors for chronic postoperative pain have been confirmed and some novel ones discovered, such as the importance of the trajectory of acute pain and the fact that catastrophizing may not always be predictive. The incidence of chronic postoperative pain hasn’t changed over time, and there is limited new information regarding an effective preventive therapy. For example, pregabalin may actually cause more harm in certain surgeries. Further research is needed to demonstrate whether multimodal analgesic techniques have the best chance of significantly reducing the incidence of chronic postoperative pain and to determine which combination of agents is best for given surgical types and different patient populations.
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Affiliation(s)
- Darin Correll
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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31
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de Neumann L, Clairoux A, Brulotte V, McCartney CJL. In Search of the Perfect Balance: a Narrative Review of Analgesic Techniques for Total Knee Arthroplasty. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0218-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Lange T, Rataj E, Kopkow C, Lützner J, Günther KP, Schmitt J. Outcome Assessment in Total Knee Arthroplasty: A Systematic Review and Critical Appraisal. J Arthroplasty 2017; 32:653-665.e1. [PMID: 28341034 DOI: 10.1016/j.arth.2016.09.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/05/2016] [Accepted: 09/13/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The Outcome Measures in Rheumatology (OMERACT) initiative developed a core outcome set (COS) of domains to assess effectiveness of interventions for knee osteoarthritis. These domains (pain, physical function, patient global assessment, imaging at 1 year) should be assessed in every trial to make research evidence meaningful and comparable. We systematically evaluated and critically appraised the use of measurement instruments and outcome domains in prospective studies evaluating patients with knee osteoarthritis undergoing total knee arthroplasty (TKA) and assessed their accordance with the OMERACT COS. METHODS Literature search was performed until August 26, 2014, in Medline and Embase. Clinical trials and prospective observational studies with ≥50 participants and a follow-up of ≥1 year were included. We collected general study characteristics, comprehensive information on measurement instruments, and corresponding domains used. RESULTS This systematic review identified low accordance of used outcome domains with the OMERACT COS of domains published in 1997. Only 4 of 100 included studies included all recommended core domains. Pain (85% of studies) and physical function (86%) were assessed frequently, whereas patient global assessment (21%) and joint imaging (≥1 year; 27%) were rarely assessed. There was substantial heterogeneity in the use of measurement instruments (n = 111) investigating TKA. CONCLUSION More efforts are required to implement the existing COS. In addition, a more consistent use of adequate measurement instruments is important to make research evidence on TKA more relevant, better comparable, and thus more useful for guideline developers and clinical decision makers.
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Affiliation(s)
- Toni Lange
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany; University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Elisabeth Rataj
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany; University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Christian Kopkow
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jörg Lützner
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Klaus-Peter Günther
- University Center of Orthopaedics and Traumatology, University Medicine Carl Gustav Carus Dresden, TU Dresden, Dresden, Germany
| | - Jochen Schmitt
- Center for Evidence-based Healthcare, University Hospital and Medical Faculty Carl Gustav Carus, TU Dresden, Dresden, Germany
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Lindberg MF, Miaskowski C, RustøEn T, Rosseland LA, Cooper BA, Lerdal A. Factors that can predict pain with walking, 12 months after total knee arthroplasty. Acta Orthop 2016; 87:600-606. [PMID: 27658970 PMCID: PMC5119443 DOI: 10.1080/17453674.2016.1237440] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Functional limitations after total knee arthroplasty (TKA) are common. In this longitudinal study, we wanted to identify subgroups of patients with distinct trajectories of pain-related interference with walking during the first year after TKA and to determine which demographic, clinical, symptom-related, and psychological characteristics were associated with being part of this subgroup. Patients and methods - Patients scheduled for primary TKA for osteoarthritis (n = 202) completed questionnaires that evaluated perception of pain, fatigue, anxiety, depression, and illness on the day before surgery. Clinical characteristics were obtained from the medical records. Interference of pain with walking was assessed preoperatively, on postoperative day 4, and at 6 weeks, 3 months, and 12 months after TKA. Results - Using growth mixture modeling, 2 subgroups of patients were identified with distinct trajectories of pain-related interference with walking over time. Patients in the Continuous Improvement class (n = 157, 78%) had lower preoperative interference scores and reported a gradual decline in pain-related interference with walking over the first 12 months after TKA. Patients in the Recurrent Interference class (n = 45, 22%) reported a high degree of preoperative pain-related interference with walking, initial improvement during the first 3 months after TKA, and then a gradual increase-returning to preoperative levels at 12 months. Patients in the Recurrent Interference class had higher preoperative pain, fatigue, and depression scores, and poorer perception of illness than the Continuous Improvement class. Interpretation - 1 in 5 patients did not improve in pain-related interference with walking at 12 months after TKA. Future studies should test the efficacy of interventions designed to modify preoperative characteristics.
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Affiliation(s)
- Maren Falch Lindberg
- Department of Surgery, Lovisenberg Diakonale Hospital, Oslo;,Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway;,Correspondence:
| | | | - Tone RustøEn
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway;,Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Leiv Arne Rosseland
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway;,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Bruce A Cooper
- School of Nursing, University of California, San Francisco, CA, USA
| | - Anners Lerdal
- Department of Surgery, Lovisenberg Diakonale Hospital, Oslo;,Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Na HS, Oh AY, Koo BW, Lim DJ, Ryu JH, Han JW. Preventive Analgesic Efficacy of Nefopam in Acute and Chronic Pain After Breast Cancer Surgery: A Prospective, Double-Blind, and Randomized Trial. Medicine (Baltimore) 2016; 95:e3705. [PMID: 27196485 PMCID: PMC4902427 DOI: 10.1097/md.0000000000003705] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Breast cancer surgery is known to cause severe acute postoperative pain, which can persist for a long time. We administered nefopam preventively to patients undergoing lumpectomy with axillary lymph node dissection or sentinel lymph node biopsy, and evaluated its efficacy on acute and chronic postoperative pain.Enrolled patients were assigned to the nefopam (n = 41) or the control (n = 42) group. Before initiating the operation, 20 mg of nefopam was given to the patients of the nefopam group, and normal saline was used in the control group. Ketorolac was given at the end of surgery, and meloxicam was prescribed in the postoperative period to all patients in both groups. Pain was assessed using a numerical rating scale (NRS), and the rescue analgesic drug was given when the NRS was >5. Implementation of postoperative chemotherapy, radiotherapy (RT), or hormone therapy was evaluated.The NRS of postoperative pain was significantly lower in the nefopam than in the control group in the postanesthetic care unit (4.5 ± 2.2 vs 5.7 ± 1.5, respectively; P = 0.01), at postoperative 6 h (3.0 ± 1.6 vs 4.5 ± 1.3, respectively; P < 0.001), and at postoperative 24 h (3.1 ± 1.1 vs 3.8 ± 1.5, respectively; P = 0.01) with reduced use of rescue analgesic drugs. Significantly fewer patients suffered from chronic postoperative pain in the nefopam than in the control group at postoperative 3 months (36.6% vs 59.5%, P = 0.04). Considering only the cohort without postoperative adjuvant RT, the difference in the proportion of patients reporting chronic pain increased (23.5% in the nefopam group vs 61.5% in the control group, P = 0.04).Preventive nefopam was helpful in reducing the acute postoperative pain, with reduced use of rescue analgesic drugs, and it contributed to reduced occurrence of chronic pain at postoperative 3 months after breast cancer surgery.
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Affiliation(s)
- Hyo-Seok Na
- From the Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam (H-SN, A-YO, B-WK, J-HR, J-WH); Department of Anesthesiology and Pain Medicine, Yonsei Barun Orthopedic Clinic, Yongin (D-JL), Gyeonggi; and Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul (A-YO, J-HR), Republic of Korea
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Lampe F, Marques CJ, Fiedler F, Sufi-Siavach A, Matziolis G. Do Well-Balanced Primary TKA Patients Achieve Better Outcomes Within the First Year After Surgery? Orthopedics 2016; 39:S6-S12. [PMID: 27219731 DOI: 10.3928/01477447-20160509-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/23/2016] [Indexed: 02/03/2023]
Abstract
Some surgically modifiable factors are related to soft tissue balance. With computer-assisted surgery, it is possible to access these variables quantitatively. The aim of this analysis was to study the influence of gap balance on clinical outcomes within the first year after computer-navigated total knee arthroplasty (TKA). Based on navigation data, 3 independent variables reflecting gap balance were used to split the patients in 2 groups. The Knee Society Scores (Function [KSS-F] and Knee [KSS-K]) and the maximal knee flexion (MKF) measured preoperatively and at 3, 6 and 12 months were compared using analyses of variance (2×4 design) for repeated measures. Higher flexion-extension gap equality led to statistically higher KSS-F and KSS-K scores at 1 year (P=.02). Higher medial-lateral flexion gap equality led to superior mean MKF at all measurement points; however the differences were statistically only significant at 3 months (P=.01). The coefficients of variation of the variables used to select the patients were overall very low. With computer-assisted navigation, it is possible to access quantitatively the size of the medial and lateral flexion and extension gaps. Higher flexion-extension gap equality values led to statistically significant better KSS-F and KSS-K scores at 1 year. Higher medial-lateral flexion gap equality values led to better MKF values; however the differences were only statistically significant at 3 months. [Orthopedics. 2016; 39(3):S6-S12.].
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36
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Affiliation(s)
- Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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37
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Thienpont E, Lavand'homme P, Kehlet H. The constraints on day-case total knee arthroplasty: the fastest fast track. Bone Joint J 2015; 97-B:40-4. [PMID: 26430085 DOI: 10.1302/0301-620x.97b10.36610] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Total knee arthroplasty (TKA) is a major orthopaedic intervention. The length of a patient's stay has been progressively reduced with the introduction of enhanced recovery protocols: day-case surgery has become the ultimate challenge. This narrative review shows the potential limitations of day-case TKA. These constraints may be social, linked to patient's comorbidities, or due to surgery-related adverse events (e.g. pain, post-operative nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and multimodal opioid-sparing analgesia, day-case TKA might be achievable in a limited group of patients. The younger, male patient without comorbidities and with an excellent social network around him might be a candidate. Demographic changes, effective recovery programmes and less invasive surgical techniques such as unicondylar knee arthroplasty, may increase the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced against any increase in morbidity and mortality and the cost of advanced follow-up at a distance with new technology. These factors need to be evaluated before adopting this ultimate 'fast-track' approach.
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Affiliation(s)
- E Thienpont
- Catholic University of Louvain Cliniques Universitaires St-Luc, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - P Lavand'homme
- Catholic University of Louvain Cliniques Universitaires St-Luc, Av Hippocrate 10, B-1200 Brussels, Belgium
| | - H Kehlet
- Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
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Aasvang EK, Lunn TH, Hansen TB, Kristensen PW, Solgaard S, Kehlet H. Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty. Acta Anaesthesiol Scand 2015; 60:529-36. [DOI: 10.1111/aas.12667] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/11/2015] [Accepted: 10/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- E. K. Aasvang
- Section of Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- The Lundbeck Centre for fast-track Hip and Knee Arthroplasty; Copenhagen Denmark
| | - T. H. Lunn
- The Lundbeck Centre for fast-track Hip and Knee Arthroplasty; Copenhagen Denmark
- Anesthesiological department; Hvidovre Hospital; Copenhagen Denmark
| | - T. B. Hansen
- Orthopedic department; Holstebro Hospital; Holstebro Denmark
| | | | - S. Solgaard
- Orthopedic department; Gentofte Hospital; Gentofte Denmark
| | - H. Kehlet
- Section of Surgical Pathophysiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- The Lundbeck Centre for fast-track Hip and Knee Arthroplasty; Copenhagen Denmark
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Abstract
INTRODUCTION Total knee arthroplasty (TKA) is a common surgical method in orthopaedics; however, pain management after TKA remains a significant challenge. This review provides a comprehensive evaluation of the effects of acupuncture for postoperative pain after TKA. METHODS AND ANALYSIS The following 10 databases will be searched until August 2015: MEDLINE, EMBASE, CENTRAL, AMED, CINAHL, three Chinese databases (the China National Knowledge Infrastructure Database, the Chongqing VIP Chinese Science and Technology Periodical Database, and Wanfang Database) and five Korean databases (the Korean Medical Database, the Korean Studies Information Service System, the National Discovery for Science Leaders, the Database Periodical Information Academic, and the Oriental Medicine Advanced Searching Integrated System). All eligible randomised controlled trials related to the use of acupuncture for postoperative pain after TKA will be included. Assessment of risk of bias will be performed with the Cochrane risk-of-bias method. Mean differences or standardised mean differences will be calculated with 95% CIs for continuous data; the risk ratio will be used with 95% CIs for dichotomous data. DISSEMINATION This systematic review will be presented in a peer-reviewed journal. The result of this review will also be disseminated at a relevant conference presentation. TRIAL REGISTRATION NUMBER PROSPERO 2015: CRD42015020924.
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Affiliation(s)
- Jae-Young Jung
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Jae-Heung Cho
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Seok-hee Chung
- Department of Korean Rehabilitation Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Republic of Korea
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Comparison of operant escape and reflex tests of nociceptive sensitivity. Neurosci Biobehav Rev 2015; 51:223-42. [PMID: 25660956 DOI: 10.1016/j.neubiorev.2015.01.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 01/17/2015] [Accepted: 01/27/2015] [Indexed: 01/17/2023]
Abstract
Testing of reflexes such as flexion/withdrawal or licking/guarding is well established as the standard for evaluating nociceptive sensitivity and its modulation in preclinical investigations of laboratory animals. Concerns about this approach have been dismissed for practical reasons - reflex testing requires no training of the animals; it is simple to instrument; and responses are characterized by observers as latencies or thresholds for evocation. In order to evaluate this method, the present review summarizes a series of experiments in which reflex and operant escape responding are compared in normal animals and following surgical models of neuropathic pain or pharmacological intervention for pain. Particular attention is paid to relationships between reflex and escape responding and information on the pain sensitivity of normal human subjects or patients with pain. Numerous disparities between results for reflex and operant escape measures are described, but the results of operant testing are consistent with evidence from humans. Objective reasons are given for experimenters to choose between these and other methods of evaluating the nociceptive sensitivity of laboratory animals.
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Factors affecting chronic pain and increases of analgesic drug consumption after knee arthroplasty. Pain 2014; 155:2720-2721. [PMID: 25139584 DOI: 10.1016/j.pain.2014.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 08/07/2014] [Accepted: 08/11/2014] [Indexed: 11/20/2022]
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