Comparison of the effects of intra-articular sole ropivacaine and combined ketorolac and ropivacaine for pain control after knee arthroscopy surgery

The analgetic effect of adjuvants in local infiltration analgesia - a systematic review with network meta-analysis of randomized trials

BACKGROUND

Local infiltration analgesia is commonly used for postoperative pain control after several surgical procedures including intra- and peri-articular as well as wound infiltration. Even though, various adjuvants injected with the local anesthetic have been studied in pairwise comparison or compared to peripheral nerve blocks, the question which adjuvant or combination of adjuvants is the most effective in prolonging the duration of different types of local infiltration analgesia (LIA) has not been answered conclusively.

OBJECTIVE

The objective of this network meta-analysis was to determine the analgesic effectiveness and safety of adjuvants in local infiltration analgesia.

DESIGN

Systematic review of randomized controlled trials with network meta-analyses.

DATA SOURCES

A comprehensive literature search in Embase, CENTRAL, MEDLINE and Web of Science was performed up to March 2023.

RESULTS

The best interventions to prolong the duration of analgesia were dexamethasone (Ratio of Means (ROM) 3.33) followed by the combinations of clonidine + morphine (ROM 3.35) and morphine + magnesium sulfate (ROM 2.92), fentanyl (ROM 2.27), ketorolac (ROM 2.26), buprenorphine (ROM 2.04), morphine (ROM 1.93), magnesium sulfate (ROM 1.91), clonidine (ROM 1.89), dexmedetomidine (ROM 1.74) and tramadol (ROM 1.58). Serious adverse events were not reported with either investigated adjuvant.

CONCLUSION

There is moderate evidence that dexamethasone is the most effective adjuvant to prolong the duration of analgesia in LIA. The evidence for the alpha-2 agonists dexmedetomidine and clonidine is also moderate, but their effectivity to prolong analgesia stays behind dexamethasone. Clonidine and dexmedetomidine had a small detectable effect on pain scores, yet below clinical relevance, but the largest effect on MEQ consumption. The effects of different opioids were homogenous for all endpoints. The prespecified subgroup analysis of LIA of the knee did not show significantly different results than the pooled analysis.

STUDY REGISTRATION

PROSPERO 2020 CRD42020176154 (28.04.2020).

[Translated article] Postsurgical analgesic efficacy by the intra-articular administration of ropivacaine with dexmedetomidine versus simple ropivacaine in patients undergoing knee arthroscopy

The effective relief of postsurgical pain in patients undergoing knee arthroscopy is important to allow the initiation of activities of daily living. The objective of this study is to demonstrate the analgesic efficacy of dexmedetomidine as an adjuvant added to ropivacaine by the intra-articular route.

METHOD

Seventy patients underwent knee arthroscopy which were randomly assigned into two groups (n=35). The RD group received ropivacaine 1.5mg/kg plus dexmedetomidine 1μg/kg intra-articularly. Group R received ropivacaine 1.5mg/kg intra-articularly. The analgesic effect was evaluated by measuring the intensity of pain (VAS score) and the duration of analgesia.

RESULTS

A longer duration of the analgesic effect was observed in the RD group (655min) compared to the R group (318min) being statistically significant (p=0.03).

CONCLUSION

Dexmedetomidine as an adjuvant to intra-articular ropivacaine improves the quality and duration of postoperative analgesia in patients undergoing knee arthroscopy.

Postsurgical analgesic efficacy by the intra-articular administration of ropivacaine with dexmedetomidine versus simple ropivacaine in patients undergoing knee arthroscopy

The effective relief of postsurgical pain in patients undergoing knee arthroscopy is important to allow the initiation of activities of daily living. The objective of this study is to demonstrate the analgesic efficacy of dexmedetomidine as an adjuvant added to ropivacaine by the intra-articular route.

METHOD

Seventy patients underwent knee arthroscopy which were randomly assigned into two groups (n=35). The RD group received ropivacaine 1.5mg/kg plus dexmedetomidine 1μg/kg intra-articularly. Group R received ropivacaine 1.5mg/kg intra-articularly. The analgesic effect was evaluated by measuring the intensity of pain (VAS score) and the duration of analgesia.

RESULTS

A longer duration of the analgesic effect was observed in the RD group (655min) compared to the R group (318min) being statistically significant (p=0.03).

CONCLUSION

Dexmedetomidine as an adjuvant to intra-articular ropivacaine improves the quality and duration of postoperative analgesia in patients undergoing knee arthroscopy.

Efficacy of intra-articular ketorolac for pain control in arthroscopic surgeries: a systematic review and meta-analysis

BACKGROUND

The current systematic review and meta-analysis aimed to synthesize evidence on the efficacy of intra-articular ketorolac for patients undergoing arthroscopic surgeries.

METHODS

PubMed, Embase, ScienceDirect, and Google Scholar databases were searched for randomized controlled trials assessing the analgesic effect of intra-articular ketorolac for arthroscopic surgery of hip/knee or shoulder joint.

RESULTS

Six studies were included. Two studies were on shoulder arthroscopy, while others were on knee joint. Meta-analysis revealed that patients receiving intra-articular ketorolac had significantly lower pain scores at 2-4 h (MD: - 0.58 95% CI: - 0.88, - 0.19 I2 = 49% p = 0.002), 6-8 h (MD: - 0.77 95% CI: - 1.11, - 0.44 I2 = 31% p < 0.00001), 12 h (MD: - 0.94 95% CI: - 1.21, - 0.67 I2 = 0% p < 0.00001), and 24 h (MD: - 1.28 95% CI: - 1.85, - 0.71 I2 = 84% p < 0.00001) as compared to the control group (Certainty of evidence: low-moderate). Analysis of three studies revealed a tendency of reduced analgesic consumption in patients receiving intra-articular ketorolac, but the difference did not reach statistical significance (MD: - 0.53 95% CI: - 1.07, 0.02 I2 = 55% p = 0.06).

CONCLUSIONS

Preliminary evidence from a limited number of studies indicates that additional intra-articular ketorolac to multimodal analgesia results in reduced pain scores up to 24 h after arthroscopic surgery. The clinical relevance of small changes in pain scores is debatable. Also, scarce data suggest that consumption of analgesics may not be reduced with intra-articular ketorolac. Since pain scores can be influenced by the primary diagnosis and dose of ketorolac, the results should be interpreted with caution. The certainty of the evidence is low-moderate. There is a need for future RCTs to further strengthen current evidence.

Avaliação da adição da epinefrina à bupivacaína intra-articular no controle da dor aguda em pacientes submetidos a reconstrução do ligamento cruzado anterior

Objective  To evaluate postoperative pain, using the visual analog scale (VAS), in patients undergoing anterior cruciate ligament reconstruction (ACLR) and receiving intra-articular anesthetic solutions.

Methods  The present is a randomized clinical trial with a sample of 48 patients divided into 4 groups: Group I (n = 12) – 20 mL of saline solution (control); Group II (n = 12) – 20 mL of 0.5% bupivacaine; Group III (n = 12) – 20 mL of 0.5% bupivacaine + 0.1 mg of epinephrine; and Group IV (n = 12) – 20 mL of saline solution + 0.1 mg of epinephrine. These solutions were injected into the knee at the end of the surgery. Pain was assessed using the VAS immediately and 6, 12, 24 and 48 hours after the procedure.

Results  The VAS scores were highly variable among the groups. A Kruskal-Wallis analysis of variance (ANOVA), considering a level of significance of 5%, revealed that all intra-articular anesthetic solutions influenced the assessment of pain ( p  = 0.003), and that Group-III subjects presented less postoperative pain. There was no evidence of a higher or lower use of supplemental analgesic agents, or of adverse effects resulting from these anesthetic solutions.

Conclusion  Bupivacaine combined with epinephrine was the most effective solution for pain control in patients undergoing ACLR, but with no statistically significant differences when compared to Group II ( p  = 0.547). There was no decrease or increase in the use of supplemental analgesics or in the occurrence of adverse systemic effects ( p  > 0.05).

Local anesthesia combined with intra-articular ropivacaine can provide satisfactory pain control in ankle arthroscopic surgery: A retrospective cohort study

BACKGROUND

Local anesthesia (LA) is widely used in knee arthroscopic surgery but not in ankle arthroscopy.

OBJECTIVE

To understand the effectiveness and safety of LA combined with ropivacaine in pain control for ankle arthroscopy.

STUDY DESIGN

Retrospective cohort.

METHODS

We retrospectively collected data for patients who underwent ankle arthroscopy from April 2012 to April 2017. Patients were grouped by anesthesia method: LA, LA with ropivacaine (LA+R), spinal anesthesia (SA), and SA with ropivacaine (SA+R). Intra- and postoperative visual analog scale (VAS) scores, complications, doses of supplemental pain medication, hospitalization cost and duration, and satisfaction with pain control during hospitalization were analyzed.

RESULTS

The study included 276 patients (LA: 93; LA+R: 124; SA: 31; SA+R: 28). The LA and LA+R groups had significantly higher intraoperative VAS scores (LA vs. SA, p = 0.001; LA vs. SA+R, p = 0.002; LA+R vs. SA, p = 0.00; LA+R vs. SA+R, p = 0.00), but fewer complications, than the SA and SA+R groups. The LA+R and SA+R groups had significantly better outcomes for postoperative pain control (LA vs. LA+R, p = 0.01; LA vs. SA+R, p = 0.01; SA vs. SA+R, p = 0.01; SA vs. LA+R, p = 0.03) and required less supplemental pain medication. Hospitalization cost was lower and duration shorter in the LA and LA+R groups than in the SA and SA+R groups. There was no significant difference in satisfaction among the four groups.

LIMITATIONS

This was a single-center retrospective and relatively short-term study.

CONCLUSIONS

LA+R which could be safely applied in ankle arthroscopy provided satisfactory pain control, reduced postoperative pain intensity, fewer complications, shorter hospital stay, and good cost-effectiveness. It can be safely applied in ankle arthroscopy for the specific patients with ankle osteoarthritis.

Influence of Ketorolac Supplementation on Pain Control for Knee Arthroscopy: A Meta-Analysis of Randomized Controlled Trials

Introduction

The efficacy of ketorolac supplementation on pain control for knee arthroscopy remains controversial. We conduct a systematic review and meta‐analysis to explore the impact of ketorolac supplementation on pain intensity after knee arthroscopy.

Methods

We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2018 for randomized controlled trials (RCTs) assessing the effect of ketorolac supplementation vs placebo on pain management after knee arthroscopy. This meta‐analysis is performed using the random‐effect model.

Results

Ten RCTs involving 402 patients are included in the meta‐analysis. Overall, compared with control group for knee arthroscopy, ketorolac supplementation is associated with notably reduced pain scores at 1 h (MD = −0.66; 95% CI = −1.12 to −0.21; P = 0.004) and 2 h (MD = −0.90; 95% CI = −1.74 to −0.07; P = 0.03), prolonged time for first analgesic requirement (MD = 1.94; 95% CI = 0.33 to 3.55; P = 0.02) and decreased number of analgesic requirement (RR = 0.41; 95% CI = 0.23 to 0.75; P = 0.003), but has no obvious impact on analgesic consumption (MD = −0.56; 95% CI = −1.14 to 0.02; P = 0.06), as well as nausea and vomiting (RR = 0.44; 95% CI = 0.12 to 0.21; P = 0.21).

Conclusions

Ketorolac supplementation is effective to produce pain relief for knee arthroscopy.

In Vitro Chondrotoxicity of Nonsteroidal Anti-inflammatory Drugs and Opioid Medications

BACKGROUND

A variety of medications are administered to the intra-articular space for the relief of joint pain. While amide-type local anesthetics have been extensively studied, there is minimal information regarding the potential chondrotoxicity of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid medications.

PURPOSE

To investigate the in vitro chondrotoxicity of single-dose equivalent concentrations of ketorolac, morphine, meperidine, and fentanyl on human chondrocytes.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human cartilage was arthroscopically harvested from the intercondylar notch and expanded in vitro. Gene expression of cultured chondrocytes before treatment was performed with quantitative polymerase chain reaction for type I collagen, type II collagen, aggrecan, and SOX9. Chondrocytes were then exposed to 0.01%, 0.02%, and 0.04% morphine sulfate; 0.3% and 0.6% ketorolac tromethamine; 0.5%, 1.0%, and 1.5% meperidine hydrochloride; 0.0005% and 0.001% fentanyl citrate; and saline. A custom bioreactor was used to constantly deliver medications, with the dosage of each medication and the duration of exposure based on standard dose equivalents, medication half-lives, and differences in the surface area between the 6-well plates and the native joint surface. After treatment, a live/dead assay was used to assess chondrocyte viability and if minimal cell death was detected. A subset of samples after treatment was maintained to analyze for possible delayed cell death.

RESULTS

All tested concentrations of ketorolac and meperidine caused significantly increased cell death versus the saline control, demonstrating a dose-response relationship. The morphine and fentanyl groups did not show increased chondrotoxicity compared with the saline group, even after 2 weeks of additional culture.

CONCLUSION

In vitro exposure of chondrocytes to single-dose equivalent concentrations of either ketorolac or meperidine demonstrated significant chondrotoxicity, while exposure to morphine or fentanyl did not lead to increased cell death.

Analgesic Effects of Locally Administered Ketorolac-based Analgesics After Breast Surgery: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Reducing postoperative pain following breast surgery is crucial for rapid recovery and shortening hospital stay. Ketorolac, a nonsteroidal anti-inflammatory drug, has been used as a postoperative analgesic in many surgical procedures. We conducted a systemic review and meta-analysis on the efficacy of locally administered ketorolac-based analgesics in managing pain after breast surgery.

METHODS

We searched the PubMed, Embase, Cochrane Library, Scopus, and ClinicalTrials.gov registry for randomized control trials (RCTs) published up to September 2016. The primary outcome was pain level assessed using a visual analog scale (VAS) at 1 and 6 hours following breast surgery.

RESULTS

We reviewed 4 RCTs with 255 patients. For meta-analysis, VAS at 1 and 6 hours of 3 similar RCTs were compared. At 1 hour, VAS scores were significantly lower in patients administered a ketorolac solution [weighted mean difference (WMD)=-2.04; 95% confidence interval (CI): -3.08 to -1.00] or ketorolac-bupivacaine solution (WMD=-2.30; 95% CI, -4.07 to -0.54) than in controls. At 6 hours, the ketorolac-bupivacaine solution reduced VAS scores significantly (WMD=-1.40; 95% CI, -2.48 to -0.32) compared with controls. However, at 1 hour, the ketorolac solution was significantly more effective than the bupivacaine solution was (WMD=-1.70; 95% CI, -2.81 to -0.59).

DISCUSSION

The effects of ketorolac-based analgesics vary as per the surgery and disease type. Locally administered ketorolac-based analgesics decreased postoperative pain in breast surgery patients, and the effect of local ketorolac was better than local bupivacaine. Therefore, ketorolac-based analgesics demonstrate considerable local infiltration during pain management after breast surgery.