The efficacy of intraoperative periarticular injection in Total hip arthroplasty: a systematic review and meta-analysis

A Randomized Controlled Trial to Evaluate the Analgesic Effectiveness of Periarticular Injections and Pericapsular Nerve Group Block for Patients Undergoing Total Hip Arthroplasty

Pericapsular nerve group (PENG) block and periarticular injection (PAI) provide motor-sparing analgesia following hip surgery. We hypothesized that PAI offers non-inferior pain relief compared with PENG block in patients undergoing primary total hip arthroplasty (THA). In this randomized trial, 66 patients who underwent primary THA under spinal anesthesia were assigned to the PENG or PAI groups. The primary endpoint was the resting pain score 24 h postoperatively. The secondary endpoints included pain scores at rest and during movement at 6 and 48 h postoperatively, quadriceps strength at 24 h postoperatively, and opioid consumption at 24 and 48 h postoperatively. The mean difference in pain scores at rest between the two groups was 0.30 (95% confidence interval [CI], -0.78 to 1.39) at 24 h postoperatively. The upper 95% CI was lower than the non-inferiority margin, indicating non-inferior performance. No significant between-group differences were observed in the pain scores at 6 and 48 h postoperatively. Additionally, no significant differences in quadriceps strength and opioid consumption were observed between the two groups. The PAI and PENG blocks provided comparable postoperative analgesia during the first 48 h after primary THA. Further investigation is required to determine the optimal PAI technique and local anesthetic mixture.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations

PURPOSE

Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways.

SOURCE

We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature.

PRINCIPAL FINDINGS

Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen.

CONCLUSION

Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

Implementation of a Fascia Iliaca Compartment Block Program in Geriatric Hip Fractures: The Experience at a Level I Academic Trauma Center

OBJECTIVES

Determine adherence to a newly implemented protocol of fascia iliaca compartment block (FICB) in geriatric hip fractures.

METHODS

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Patients with a hip fracture treated with cephalomedullary nailing or hemiarthroplasty (CPT codes 27245 or 27236).

OUTCOME MEASURES AND COMPARISONS

Adherence to a protocol for FICB, time intervals between emergency department arrival, FICB, and surgery stratified by time of admission.

RESULTS

Three hundred eighty patients were studied (average age 78 years, 70% female). Approximately 53.2% of patients received an FICB, which was less than a predefined acceptable adherence rate of 75% ( P < 0.001). Approximately 5.0% received an FICB within 4 hours and 17.3% within 6 hours from admission. Admission during daylight hours (7 am -7p m ) when compared with evening hours (7 pm -7 am ) was associated with improved timeliness ([8.3% vs. 0% within 4 hours, P < 0.001] [27.5% vs. 2.4% within 6 hours, P < 0.001]). Improved adherence to the protocol was observed over time (odds ratio: 1.0013, 95% confidence interval, 1.0001-1.0025, P = 0.0388).

CONCLUSIONS

FICB implementation was poor but gradually improved over time. Few patients received an FICB promptly, especially during night hours. Overall, this study demonstrates that implementation of an FICB program at a Level I academic trauma center can be difficult; however, many hurdles can be overcome with institutional support and dedication of resources such as staff, space, and additional training.

Accelerated Protocols in Adolescent Idiopathic Scoliosis Surgery

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Treatment depends on the degree of curvature, skeletal maturity, and age of the patient. Once the curve reaches 50 degrees, posterior spinal fusion (PSF) is necessary to stabilize the spine and prevent further progression of the curve. PSF causes significant trauma to the tissues and often results in significant pain postoperatively. The purpose of this article is to provide the audience with a review of preoperative, intraoperative, and postoperative pain control with an accelerated protocol in patients with AIS undergoing PSF.

Perioperative multimodal analgesic injection for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery

PURPOSE

This retrospective cohort study compared postoperative as-needed (PRN) opioid consumption pre and postimplementation of a perioperative multimodal analgesic injection composed of ropivacaine, epinephrine, ketorolac, and morphine in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Secondary outcomes include pain score measurements, time to ambulation, length of stay, blood loss, 90-day complication rate, operating room time, nonopioid medication usage, and total inpatient medication cost before and after the initiation of this practice.

METHODS

Consecutive patients weighing ≥ 20 kg who underwent PSF for a primary diagnosis of AIS between January 2017 and December 2020 were included. Data from 2018 were excluded to account for standardization of the practice. Patients treated in 2017 only received PCA. Patients treated in 2019 and 2020 only received the injection. Excluded were patients who had any diagnoses other than AIS, allergies to any of the experimental medications, or who were nonambulatory. Data were analyzed utilizing the two-sample t-test or Chi-squared test as appropriate.

RESULTS

Results of this study show that compared with 47 patients treated postoperatively with patient-controlled analgesia (PCA), 55 patients treated with a multimodal perioperative injection have significantly less consumption of PRN morphine equivalents (0.3 mEq/kg vs. 0.5 mEq/kg; p = 0.02). Furthermore, patients treated with a perioperative injection have significantly higher rates of ambulation on postoperative day 1 compared with those treated with PCA (70.9 vs. 40.4%; p = 0.0023).

CONCLUSION

Administration of a perioperative injection is effective and should be considered in the perioperative protocol in patients undergoing PSF for AIS.

LEVEL OF EVIDENCE

Therapeutic Level III.

Anterior Approach to Hip Arthroplasty with Early Mobilization Key for Reduced Hospital Length of Stay

Background and Objectives: This study aimed to explore the preoperative factors related to early mobilization and length of stay (LOS) after total hip arthroplasty and the benefits of the anterior approach over the traditional lateral approach. Materials and Methods: Every patient benefits from information regarding details of the surgery approach, possible intra, and postoperative complications, post-operator medical care, and steps in the early mobilization protocol. The patient underwent a pre-anesthetic evaluation, was checked for preoperatory vital function, and was reevaluated for mobilization at 6, 12, 24, 36, 48, and 96 h after total hip arthroplasty using the anterior versus lateral approach. Results: The result of the statistical calculations indicates the independent negative risk factors for reaching the mobilization target: age with a coefficient of -0.046, p = 0.0154 and lateral approach with a relative risk of 0.3802 (95% CI: 0.15-0.90), p = 0.0298. Statistical data concerning the length of stay (LOS) showed significant differences in the total days spent in the hospital. The patients who were operated on using the lateral approach presented a higher body mass index than those with the anterior approach, but this difference did not reach the threshold of statistical significance. Conclusions: In our study, patient mobilization is crucial to reduce LOS.

Extensive skin necrosis following total hip arthroplasty performed through the direct anterior approach

BACKGROUND

Total hip arthroplasty is a widely performed surgical procedure, which enables patients to regain mobility, alleviates pain, and improves overall quality of life. Periarticular multimodal drug infiltration (PAI) is increasingly being used as an effective postoperative pain management, decreasing the systemic consumption of opioids. Extensive postoperative skin necrosis without a deep joint infection as a complication of total hip arthroplasty with PAI has not yet been described.

CASE PRESENTATION

A 71-year-old patient who underwent total hip arthroplasty of the right hip for primary osteoarthritis through the Direct Anterior Approach presented postoperatively a large area of necrotic skin at the incision. Joint infection was excluded. An extensive debridement was performed and the tissue defect was reconstructed by a pedicled anterolateral thigh flap. The skin maintained a satisfactory appearance at 1 year postoperatively, and the hip was pain-free with restored ranges of motion. The patient was able to walk with no support and without limitation.

CONCLUSION

We address the possible risk factors, discuss the use of epinephrine in PAI and explore possible treatment options for such a complication.

[Analgesic effect of a new "cocktail" of local infiltration analgesia after total hip arthroplasty-A prospective randomized controlled study]

Objective

To study the analgesic effect of a new "cocktail" of local infiltration analgesia (LIA) with Deprosone after total hip arthroplasty (THA).

Methods

In a prospective randomized controlled study, 100 patients with hip joint disease requiring unilateral primary THA in West China Hospital of Sichuan University between January 2018 and December 2018 were enrolled and randomly divided into observation group and control group, with 50 cases in each group. There was no significant difference in age, gender, operative side, disease type, body mass index, American Society of Anesthesiologists (ASA) classification, preoperative rest and activity visual analogue scale (VAS) score, hip Harris score (HHS), quality of life scale (SF-12) score, and other general data between the two groups ( P>0.05). The patients in the observation group were treated with a new "cocktail" LIA around the hip joint before suturing the incision, and the drug formula was ropivacaine 200 mg, Diprospan 1 mL, morphine 10 mg, and added normal saline to 80 mL; the patients in the control group were not treated with LIA. The operation time, postoperative hospital stay, the amount of morphine used during hospitalization, and the range of motion of hip joint at discharge were recorded, and the complications were counted. The VAS score at rest and activity, HHS score, and SF-12 score [physiological score (PCS) and psychological score (MCS)] of the hip joint were recorded before and after operation, and the postoperative analgesic effect and the recovery of hip joint function were evaluated.

Results

There was no significant difference in the operation time between the two groups ( P>0.05), and the postoperative hospital stay in the observation group was significantly shorter than that in the control group ( P<0.05). The postoperative morphine consumption in the observation group was significantly less than that in the control group ( P<0.05), and the total morphine consumption in the observation group was less than that in the control group during hospitalization, but the difference was not significant ( P>0.05). Patients in both groups were followed up to 6 months after operation. The resting VAS scores of the observation group were significantly lower than those of the control group at 2, 6, 12 hours after operation and in the morning and afternoon of the first day after operation, and the active VAS scores of the observation group were significantly lower than those of the control group at 6, 12 hours after operation and in the morning of the first day after operation, and the differences were significant ( P<0.05). There was no significant difference in the resting and active VAS scores between the two groups on the day of discharge and at 3 and 6 months after operation ( P>0.05). At discharge, the flexion range of motion of hip joint in the observation group was significantly greater than that in the control group ( P<0.05), but there was no significant difference in the abduction range of motion of hip joint between the two groups ( P>0.05). There was no significant difference in HHS score and SF-12 score between the two groups at 3 and 6 months after operation ( P>0.05). There was no significant difference in analgesic satisfaction and functional satisfaction between the two groups at last follow-up ( P>0.05). There was no complication such as skin pruritus, superficial and deep infection of incision, skin necrosis, deep venous thrombosis of lower extremity, and pulmonary embolism in both groups. There was no significant difference in the incidence of complications such as nausea and vomiting, urine retention, fat liquefaction of incision, local hematoma, and large fluctuation of blood sugar between the two groups ( P>0.05).

Conclusion

The new "cocktail" LIA with Diprospan can effectively reduce the early postoperative pain of THA, reduce the dosage of opioids, shorten the length of hospital stay, and is conducive to the early functional rehabilitation of patients.

A new cocktail formula with diprospan of local infiltration analgesia in primary total hip arthroplasty: A prospective, randomized, controlled, observer-blinded study

OBJECTIVE

This study aimed to observe the analgesic effect of the cocktail formulation with diprospan during total hip arthroplasty (THA).

METHODS

From September 2018 to April 2019, 120 patients undergoing primary unilateral THA were included in this prospective, randomized, observer-blinded study. Patients were randomized into three groups, according to the different local infiltration analgesia (LIA) strategies: LIA with ropivacaine (the ropivacaine group, n = 40), LIA with a new cocktail containing ropivacaine, diprospan, and morphine (the cocktail group, n = 40), and the control group (n = 40). The primary outcomes included postoperative pain scores. The resting visual analogue scale (VAS) scores were measured at 2, 6, and 12 h after the surgery (a.m. and p.m.) on postoperative day (POD) 1, POD2, and the day of discharge. Movement VAS scores were assessed at 6 h, 12 h after the operation (a.m. and p.m.) on POD1, POD2, and the day of discharge. The secondary outcomes included opioid consumption, postoperative hospital stay, range of motion of the hip at discharge, patient satisfaction, and the results of the follow-up.

RESULTS

After the screening, 120 patients were randomized into three groups (40 patients in each group). All of the patients completed the trial. The resting VAS scores in the ropivacaine group and cocktail group at 2 h were lower than those in the control group (P < 0.001 and P < 0.001, respectively, F = 17.054), and the same trend was also postoperatively found at 6 h (p = 0.005 and P = 0.002, F = 6.212). Twelve hours after the operation, the pain score in the cocktail group was lower than that in the other two groups, but only the difference between the cocktail group and the control group was statistically significant (P = 0.018, F = 3.144). From the morning of the first postoperative day to the a.m. on POD 2, the VAS scores in the cocktail group were significantly lower than those in the ropivacaine group and the control group. Furthermore, the movement VAS scores in the ropivacaine group and the cocktail group were better than those in the control group at 6 and 12 h post-operation (P < 0.05). The per capita opioid consumption in the cocktail group was less than that in the ropivacaine group and the control group within 24 h post-operation. There were no significant differences in the comparison of additional indicators among the three groups.

CONCLUSION

The new cocktail with diprospan had a better result and longer duration time for early postoperative pain control in primary THA via the posterolateral approach under general anesthesia, especially for treating resting pain.

Modernizing Total Hip Arthroplasty Perioperative Pathways: The Implementation of ERAS-Outpatient Protocol

Pressure to reduce healthcare costs, limited hospital availability along with improvements in surgical technique and perioperative care motivated many centers to focus on outpatient pathway implementation. However, in many short-stay protocols, the focus has shifted away from aiming to reduce complications and improved rehabilitation, to using length of stay as the main factor of success. To improve patient outcomes and maintain safety, the best way to implement a successful outpatient program would be to combine it with the principles of enhanced recovery after surgery (ERAS), and to improve patient recovery to a level where the patient is able to leave the hospital sooner. This article delivers a case for modernizing total hip arthroplasty perioperative pathways by implementing ERAS-outpatient protocols.

Does the Use of an Intra-Articular Local Anesthetic Injection During Total Hip Arthroplasty Reduce Patient Reported Pain Scores or Patient Opioid Consumption?

BACKGROUND

During primary total hip arthroplasty (THA), some surgeons use an intra-articular injection (IAI) containing 200 mg ropivacaine to target postoperative pain. There is no clear consensus on the efficacy of an IAI alone. The purpose of this study is to evaluate the effect of a 200 mg ropivacaine IAI on pain scores, opioid consumption, and mobility for primary THA patients.

METHODS

We retrospectively reviewed 571 patients who underwent primary THA at a single institution. Patients were grouped according to those who received a 200 mg ropivacaine IAI and those who did not. Primary outcome measures for this study included pain scores, morphine milligram equivalents (MMEs) dosed, distance of ambulation achieved, and time to ambulation.

RESULTS

The intervention group reported higher average pain scores with activity than the control group (P = .024). The intervention group also required higher MMEs. When striated by hour, a statistically significant uptick in pain started at 16 hours (P = .0009) and persisted to 28 hours (P = .032) in patients receiving a 200 mg ropivacaine IAI. This correlated with an increase in MMEs seen at hour 24 through 32 (P = .003 to P = .012). Level of ambulation, time to ambulation, and distance ambulated did not differ between groups. An IAI of 200 mg ropivacaine also appeared to lead to higher pain scores and higher opioid doses in males.

CONCLUSION

The IAI does not appear to reduce postoperative pain scores or MMEs dosed for THA patients. More research is needed to look at the utilization and efficacy of intra-articular ropivacaine, especially focusing on functional outcomes and gender differences.

Local infiltration analgesia with bupivacaine and adrenaline does not reduce perioperative blood loss in total hip arthroplasty

This study evaluates the effect of local infiltration analgesia with bupivacaine and adrenaline on perioperative blood loss in total hip arthroplasty. Patients who had primary total hip arthroplasty were retrospectively assigned to two groups. One group had 100 ml of bupivacaine/adrenaline solution injected into periarticular soft tissues at the end of the procedure. There were 55 patients in the infiltrated hip group and 44 patients in the not infiltrated group. Patients’ hemoglobin level (Hb), hematocrit (HTC), red blood count (RBC), platelet count (PLT) and International Normalized Ratio (INR) as well as the need for blood transfusions were compared statistically between groups preoperatively and postoperatively. There were no significant differences between Hb, HTC or RBC levels as well as the rate and amount of blood transfusions on the 1^st, 4^th postoperative days or at patients’ discharge between infiltrated and not infiltrated groups. This study does not support the hypothesis that the use of local infiltration analgesia with adrenaline may reduce perioperative blood loss in total hip arthroplasty.

The efficacy of periarticular injection intraoperatively for mini-open rotator cuff repair: A comparative study

BACKGROUND

The optimal postoperative analgesia after open rotator cuff repair surgery remains unclear. This study compared the use of a multimodal pain regimen including periarticular injection (PAI), with a control condition. We hypothesized that PAI leads to decreased opioid consumption and lower pain scores.

METHODS

The perioperative analgesic regimen was standardized and implemented from January 1, 2017 to December 31, 2017. The PAI was administered from July 1, 2017 to December 31, 2017. The historical control group was enrolled from January 1, 2017 to June 30, 2017. The evaluation items included assessments of pain using a 10-point visual analog scale (VAS) before and after the mini-open rotator cuff repair and on postoperative days 1, 2, and 3. The dose of ketorolac suppository and its side effects were also evaluated.

RESULTS

The VAS score on the day of the operation was significantly low in the PAI group and less incidence of night pain. The time point of the rescue drug was longer in the PAI group than the control group (12.7 hours vs. 0.62 hours; p < 0.01). No cardiac or central nervous system toxicity was observed.

DISCUSSION

In our study, PAI in the shoulder after mini-open rotator cuff repair showed effective pain control on the day of the surgery, postponed the time of the first dosage of intravenous pain medication, and reduced the total dosage of the intravenous pain medication.

PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations

The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.

Obturator nerve block does not provide analgesic benefits in total hip arthroplasty under multimodal analgesic regimen: a randomized controlled trial

BACKGROUND AND OBJECTIVES

Although regional analgesia is considered an important component of optimal pain management, use of peripheral nerve blocks for total hip arthroplasty remains controversial. Since the obturator nerve innervates the anteromedial part of the joint capsule, we hypothesized that an obturator nerve block would decrease the opioid consumption after total hip arthroplasty.

METHODS

In this single center, prospective, triple blinded study, we randomly allocated 60 patients undergoing total hip arthroplasty under opioid-sparing total intravenous general anesthesia to a preoperative obturator nerve block or a sham block (placebo group) using 20 mL of ropivacaine 0.2% or saline, respectively. All patients received a multimodal analgesic regimen with non-opioid analgesics including periarticular local infiltration analgesia. The primary outcome was the intravenous opioid consumption in the post-anesthesia care unit.

RESULTS

Median (IQR) intravenous oxycodone consumption in the post-anesthesia care unit was 4 (2, 7.5) mg in the obturator nerve block group and 3 (0, 4) mg in the placebo group (p=0.05). There were no differences in pain scores between groups in the first 24 hours except at arrival on the surgical ward with significant higher pain scores in the placebo group (p=0.03). The ability to stand up and walk within 24 hours was comparable between groups as was the time to first walk (180 (90, 720) vs 240 (120, 780) min for the obturator nerve block and placebo groups, respectively; p=0.62).

CONCLUSIONS

Obturator nerve block did not improve postoperative opioid consumption after total hip arthroplasty performed under general anesthesia with a multimodal analgesic regimen.

TRIAL REGISTRATION NUMBER

NCT04085640.

[Fast track in hip and knee arthroplasty]

Fast-track treatment concepts were developed decades ago in general and abdominal surgery and have been adapted in recent years for the special requirements of hip and knee arthroplasty. In this field, Hendrik Husted in particular was able to demonstrate scientific evidence for the components of fast-track concepts. The primary aim is not so much to shorten the patient's hospital length of stay (LOS) but rather to effectively increase the quality of medical treatment for the patient and to reduce complications. The optimization of organizational processes as well as intraoperative and perioperative surgical approaches are essential components regarding the introduction of fast track into the clinical routine. This article gives a comprehensive overview of fast-track treatment concepts and explains the scientific principles for the approach.

Intraoperative periarticular injection can alleviate the inflammatory response and enhance joint function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures

PURPOSE

This study aimed to investigate the potential beneficial effects of periarticular injection (PAI) of multimodal drugs on the inflammatory response and joint function after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures.

METHODS

Fifty six elderly patients with unilateral osteoporotic femoral neck fractures were randomly allocated to 2 groups: the PAI group, which received the multimodal drug PAI intraoperatively before incision closure, and the control group, which received an injection of saline at the same time as placebo. The C-reactive protein (CRP), interleukin-1β (IL-1β), and IL-6 levels as well as the erythrocyte sedimentation rate (ESR) in peripheral venous blood samples were measured, along with the Visual Analogue Scale (VAS) score with activity and Harris hip score preoperation at 1, 2, 4, 7, and 14 days as well as 1 and 3 months post-operation.

RESULTS

The 2 groups were comparable in sex and age, and no significant differences were observed in the preoperative CRP, IL-1β, and IL-6 levels, ESR, VAS score, or Harris hip score between the 2 groups (all P > .05). However, during the postoperative period, the PAI group exhibited significantly lower levels of CRP, IL-1β, and IL-6 as well as a lower ERS and VAS score compared with the control group (P < .05), while the Harris hip score was significantly higher postoperatively in the PAI group (P < .05).

CONCLUSION

Multimodal drug PAI can alleviate the inflammatory response and enhance hip function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures.

Periarticular analgesic injection containing a corticosteroid after total hip arthroplasty may prevent deep venous thrombosis: a retrospective comparative cohort study

BACKGROUND

Of late, periarticular analgesic injection (PAI) has become a common alternative treatment for pain following total hip arthroplasty (THA). However, the systemic effects of PAI containing corticosteroids in patients subjected to THA have not been investigated. This study evaluated the analgesic efficacy and systemic effects of PAI containing a corticosteroid in patients subjected to THA.

METHODS

This single-center, retrospective cohort study enrolled patients undergoing unilateral, primary THA. A total of 197 patients (200 hips) were included in the final analyses, with 87 hips in the PAI group and 113 hips in the control group. Numeric Rating Scale (NRS) and laboratory data were assessed preoperatively and on postoperative days (POD) 1 and 7. Pearson's correlation coefficients were obtained to assess the correlations between the D-dimer level on POD 7 and each outcome measure on POD 1.

RESULTS

The postoperative white blood cell count (WBC) was significantly higher in the PAI group than in the control group. Postoperative NRS, creatine phosphokinase (CK), and C-reactive protein (CRP) levels were significantly lower in the PAI group. D-dimer levels were significantly lower in the PAI group on POD 7. Postoperative aspartate transaminase (AST), alanine aminotransferase, blood urea nitrogen, and creatinine levels were within reference ranges. D-dimer levels on POD 7 showed a significant negative correlation with WBC on POD 1 (r=-0.4652) and a significant positive correlation with the NRS score and AST, CK, CRP, and D-dimer levels on POD 1 (r = 0.1558, 0.2353, 0.2718, 0.3545, and 0.3359, respectively).

CONCLUSIONS

PAI containing a corticosteroid may be an effective treatment for pain and inflammation after THA, and it does not seem to cause drug-induced liver or kidney injury. Moreover, corticosteroid PAI can may accelerate early ambulation, which prevents the elevation of postoperative D-dimer levels, and may reduce the risk of deep venous thrombosis.

Effects of Nurse-Led Pain Management Interventions for Patients with Total Knee/Hip Replacement

BACKGROUND

A literature review was conducted to assess nurse-led nonpharmacologic pain management interventions intended for total knee/hip replacement patients.

DESIGN

This was a systematic review and meta-analysis.

DATA SOURCES

The PubMed, Embase, CINAHL, and Cochrane Library databases were searched to identify relevant studies.

REVIEW METHODS

The systematic review was conducted based on the Cochrane Handbook for Systematic Reviews of Interventions and all Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guidelines. Two reviewers independently selected the studies and appraised their quality. Thereafter, the effects of all described nurse-led nonpharmacologic pain management interventions were estimated regarding pain, anxiety, and satisfaction through a meta-analysis.

RESULTS

In total, 219 relevant studies were found through a search. Finally, 23 studies were selected for review, with 17 included in the meta-analysis. Nurse-led nonpharmacologic pain management was effective for pain relief (effect size, -0.22; 95% confidence interval [CI], -0.42 to -0.02), and educational interventions were especially effective (effect size, -0.36; 95% CI, -0.69 to -0.03). Although interventions reduced anxiety and improved satisfaction, these results were not statistically significant based on the analysis.

CONCLUSION

Our findings support that nurse-led nonpharmacologic pain management interventions could help reduce pain in patients with total knee/hip replacement by supplementing pharmacologic pain management.

IMPLICATIONS FOR NURSING

Nurse-led nonpharmacologic pain interventions should be considered to reduce patient pain with total knee/hip replacement.

Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery

BACKGROUND

Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery.

AREAS OF UNCERTAINTY

Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery.

DATA SOURCES

Narrative literature review using keywords, expert opinion, either during or from live conference.

THERAPEUTIC ADVANCES

Local and IA administration of NSAIDs for pain management in orthopedic surgery.

CONCLUSION

There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.

Does Surgical-site Multimodal Drug Injection After Palmar Plating of Distal Radius Fractures Improve Pain Scores?

BACKGROUND

Although palmar locked plating is a stable fixation method frequently used to treat unstable distal radius fractures (DRFs), surgical treatment may be painful, and so interventions to decrease that pain might improve our patients' experiences with surgery. Some surgeons use local multimodal drug injections to decrease postoperative pain after lower-extremity arthroplasty, but little is known about the effectiveness of a local multimodal drug injection in patients who undergo palmar plating for DRFs.

QUESTIONS/PURPOSES

(1) Do patients who receive a local multimodal drug injection after palmar plating for unstable DRFs have better pain scores at 4, 8, 24, and 48 hours after surgery than patients who have not received such an injection? (2) Do patients who receive a local multimodal drug injection have lower fentanyl consumption and administration of anti-emetic drugs within the first 48 hours after surgery than patients who have not received such an injection?

METHODS

A randomized controlled study was performed between August 2018 and August 2019 at a single tertiary care referral center. Patients who underwent palmar plating for DRFs under general anesthesia were eligible for inclusion. Patients were allocated into two groups: Those who received a local multimodal drug injection, and those who did not receive an injection. During the study period, 101 patients treated with palmar plating for DRFs met the inclusion criteria and were enrolled and randomized. Fifty-two patients were allocated to the multimodal injection group and 49 were allocated to the control group. Three patients (two in the multimodal injection group and one in the control group) were excluded after randomization because their pain level was not registered at any timepoint and so they could not be analyzed; our analysis was by intention to treat, and there was no crossover. After palmar plating, patients in the multimodal injection group received an injection of ropivacaine (10 mL), morphine (5 mL), ceftezole (5 mL) as well as normal saline (5 mL) to the periosteal area, pronator quadratus muscle, subcutaneous area, and skin. There were no differences between the groups in terms of age (62 years ± 13 years in the multimodal injection group versus 62 years ± 11 years in the control group; p = 0.93), gender (84% [42 of 50] women in the multimodal injection group versus 77% [37 of 48] women in the control group; p = 0.39), hand dominance (70% [35 of 50] dominant wrist in the multimodal injection group versus 60% [29 of 48] dominant wrist in the control group; p = 0.32) and AO/Orthopaedic Trauma Association (AO/OTA) classification (p = 0.57). All patients underwent treatment with the same perioperative protocol, and 25 μg of fentanyl was injected intravenously when a patient complained of pain and asked for additional pain control after surgery. In addition, when a patient complained of nausea or vomiting associated with fentanyl use, an anti-emetic drug was also injected. All nursing staff who administered the analgesics and anti-emetic drugs were blinded to treatment allocation. These two groups were compared regarding their pain level using a 100-mm VAS at 4, 8, 24, and 48 hours postoperatively. The minimum clinically important difference (MCID) for the VAS score was set to 20 mm. VAS scores were also collected by nursing staff who remained blinded to the treatment allocation. The total amount of fentanyl use and the number of patients who received anti-emetic drugs associated with administration of fentanyl within the first 48 hours were also recorded.

RESULTS

With an MCID of 20 points, we found no clinically important reduction in VAS scores among patients who received a local multimodal injection compared with those who did not receive an injection at 4 hours (34 ± 15 versus 41 ± 20, mean difference -7.079 [95% CI -13.986 to -0.173]; p = 0.045), 8 hours (27 ± 16 versus 40 ± 19, mean difference -12.263 [95% CI -19.174 to -5.353]; p = 0.001), 24 hours (18 ± 12 versus 29 ± 20, mean difference -11.042 [95% CI -17.664 to -4.419]; p = 0.001), and 48 hours (9 ± 8 versus 10 ± 6, mean difference -1.318 [95% CI -4.000 to 1.365]; p = 0.33). Within the first 48 hours after surgery, fentanyl consumption was lower in patients receiving a local multimodal injection than in control patients (25 μg [range 0-100 μg] versus 37.5 μg [range 0-125 μg], difference of medians -12.5; p = 0.01). There was also a difference between the study groups in terms of the proportion of patients who received anti-emetic medications (16% [8 of 50] in the multimodal injection group versus 35% [17 of 48] in the control group, odds ratio = 2.879 [95% CI 1.102 to 7.519]; p = 0.03).

CONCLUSIONS

Our data suggest that patients who received a surgical-site multimodal analgesic injection after palmar plating for a distal radius fracture had no clinically important reduction in pain scores, but they did consume lower doses of opioid analgesics and fewer of these patients received anti-emetic drugs within 2 days of surgery. The high-potency opioids or other analgesia usually used for postoperative pain management have many side effects. Thus, reducing additional analgesia is as important as postoperative pain management and a surgical-site multimodal analgesic injection is one of the methods to achieve this a goal.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Perioperative Pain Management in Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand?

Total Hip replacement (THR) is a well-discussed topic, and it offers excellent results in patients suffering from end-stage osteoarthritis (OA). However, despite the fact that patients can fully bear weight immediately after the surgery, THR is often associated with a great amount of postoperative pain affecting recovery and rehabilitation. Therefore, the efficient management of pain is of paramount importance. The aim of this review is to examine all the currently available strategies of pain management such as preemptive analgesia (PA), patient-controlled analgesia (PCA), and the various types of anesthesia that are used during the operation. With that objective in mind, we conducted our research by searching through the PubMed database for articles published in 2015 and after. For purely clinical reasons, we have attempted to classify all the best available evidence into three major categories: prior to surgery, during the surgery, and after the surgery. Multimodal analgesia seems to play a major role in the perioperative care of patients undergoing total hip arthroplasty (THA). Therefore, a considerable number of studies have been conducted analyzing all the current strategies that aim to minimize perioperative pain and consequent complications.

The efficacy of continuous versus single-injection femoral nerve block in Total knee Arthroplasty: a systematic review and meta-analysis

Background

Continuous femoral nerve block (cFNB) has been developed to extend the analgesic effect since the efficacy of single-injection femoral nerve block (sFNB) is often limited to approximately 16–24 h. The aim of this meta-analysis was to validate the add-on effect of cFNB in the setting of a multimodal analgesic protocol.

Methods

We performed a comprehensive literature review on Web of Science, Embase, the Cochrane Library and PubMed. Eight randomized controlled trials (N = 626) that compared the efficacy of cFNB with sFNB were included. The primary outcome domains consist of visual analog scale (VAS) score at postoperative 24 and 48 h. The secondary outcome domains include opioid consumption, length of hospital stay and incidence of nausea.

Results

Our analysis revealed that cFNB was associated with a lower VAS score at 24 h (SMD: -0.277;95% CI − 0.503 to − 0.05). However, the difference of VAS score did not meet the minimal clinically importance difference for total knee arthroplasty (TKA). VAS score at 48 h was similar between the cFNB and sFNB group. The cFNB group was associated with less amount of opioids consumed at both 24(SMD: -1.056;95% CI − 1.737 to − 0.375) and 48 h(SMD: -1.040;95% CI − 1.790 to − 0.289). Length of hospital stay and incidence of nausea were similar between the two groups.

Conclusion

In the setting of a multimodal analgesic protocol, patients might benefit from cFNB with regards to a reduced need of opioids in the early postoperative period. However, we did not find a clinically significant difference in pain scores at different time points between the cFNB and sFNB group.

Level of evidence

I; meta-analysis.