Intrathecal versus local infiltration analgesia for pain control in total joint arthroplasty

Periarticular injection versus placebo in total knee arthroplasty with intrathecal morphine

INTRODUCTION

Periarticular injection (PAI) is one part of total knee arthroplasty (TKA) multimodal analgesia protocols. PAI combined with neuraxial anesthesia including intrathecal morphine (ITM) has not been previously investigated. This study prospectively compares PAI to placebo injection in patients undergoing TKA under spinal anesthesia with ITM.

METHODS

We performed a prospective, double-blinded randomized controlled trial comparing immediate postoperative outcomes after TKA. All patients received combined spinal-epidural (CSE) anesthesia with ITM and multimodal analgesia. The study group received a standardized PAI with 0.5% ropivacaine, clonidine, ketorolac, and epinephrine, while the control group received PAI with saline. Exclusion criteria were revision surgery, inability to receive epidural anesthesia or PAI, patients taking greater than 80 morphine milligram equivalents (MME) daily prior to surgery, and lack of patient consent to participate in the study.

RESULTS

Sixty-four patients enrolled and completed the study from 2015 to 2021. Thirty-four were randomized to the study group and 30 to the control. There was no difference in mean total postoperative opioid consumption between PAI (125.49 MME) and control (138.80 MME); (p = 0.556). There was also no difference in opioid requirements at 0-24 and 24-48 h between PAI (58.87 and 70.57 MME), and control (70.57 and 69.72 MME); (p = 0.308 and p = 0.556).

CONCLUSION

This study, while underpowered, demonstrates that PAI does not significantly decrease opioid consumption after TKA compared to placebo injection when utilizing ITM spinal anesthesia. When ITM is used, PAI may be reasonably be excluded from the protocol without affecting opioid requirements.

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

Comparison of intramedullary versus extramedullary alignment technique in total knee arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

This meta-analysis aimed to compare the efficacy of intramedullary and extramedullary femoral alignment technique in treating total knee arthroplasty (TKA) patients.

METHODS

PubMed, Embase, Cochrane library, Chinese National Knowledge Infrastructure, and Weipu databases were electronically searched. Potential clinical studies that investigated the effect and safety of intramedullary versus extramedullary femoral alignment technique in TKA patients were searched. The primary outcome was lower limb coronal alignment. Stata 12.0 was used for meta-analysis.

RESULTS

This meta-analysis included 12 prospective randomized controlled studies that reported data on 935 TKA patients. No significant difference was noted in lower limb coronal alignment, coronal alignment of femoral component, sagittal alignment of femoral component and tibial slope between intramedullary and extramedullary alignment techniques ( P  > .05). Further, extramedullary alignment technique significantly decrease the total blood loss than intramedullary alignment technique (weighted mean difference: -86.52; 95% confidence interval: -115.05--57.99; P  = .000) and subsequently transfusion rate (risk ratio: 0.57; 95% confidence interval: 0.41-0.79; P  = .000). Finally, there was no significant difference between intramedullary and extramedullary alignment techniques in terms of the total complications ( P  > .05).

CONCLUSIONS

The present meta-analysis showed that intramedullary and extramedullary femoral alignment technique had comparable precise profiles. And extramedullary femoral alignment technique could reduce blood loss and blood transfusion. Total complications were comparable between the groups. More randomized controlled trials with large samples are required to verify the comparison of intramedullary and extramedullary femoral alignment technique in TKA patients.

Take-Home Video Shortens the Time to First Ambulation in Patients With Inguinal Hernia Repair Under General Anesthesia: A Retrospective Observational Study

Background

Data on the relationship between take-home video and the time to first ambulation remains scant. Here, we aimed to investigate whether viewed take-home video during pre-hospitalization is independently associated with the time to first ambulation in postoperative patients with inguinal hernia repair under general anesthesia.

Methods

We retrospectively reviewed and analyzed the relationship between viewed take-home video and the time to first ambulation between September 2020 and October 2021.The independent t-tests or Mann-Whitney U-tests was used to compare the means of two groups (viewed take-home video and non-viewed take-home video). Chi-square test was used to compare the rates between the two groups. We used a linear regression model to see if there was a difference between exposure and outcome variable. Both models were used to observe the effect size of the exposed variable. Subgroup analysis was employed to assess the impact of various factors.

Results

This study included a total of 120 patients with inguinal hernia repair under general anesthesia following day surgery. The average age of the participants in the two groups was 43.16 and 44.83 years, respectively, and about 82.5% of the patients were male. Our fully adjusted linear regression results showed that individuals in the viewed video group were associated with a decreased time to first ambulation (h) after adjusting for confounders (β = −0.50, 95%CI: −0.83, −0.17; P = 0.004). In addition, the linear regression analysis of the relationship between viewed video and length of stay showed that β = −2.10 (95%CI:CI: −3.85, −0.34; P = 0.021). Similarly, subgroup analysis yielded similar results for the viewed video group patients compared to those in the non-viewed video group.

Conclusion

Taken together, our findings demonstrated that viewed video could shorten the time to first ambulation, which in turn reduce the length of stay in postoperative patients under general anesthesia.

Pharmacological and clinical implications of local anaesthetic mixtures: a narrative review

Various techniques have been explored to prolong the duration and improve the efficacy of local anaesthetic nerve blocks. Some of these involve mixing local anaesthetics or adding adjuncts. We did a literature review of studies published between 01 May 2011 and 01 May 2021 that studied specific combinations of local anaesthetics and adjuncts. The rationale behind mixing long- and short-acting local anaesthetics to hasten onset and extend duration is flawed on pharmacokinetic principles. Most local anaesthetic adjuncts are not licensed for use in this manner and the consequences of untested admixtures and adjuncts range from making the solution ineffective to potential harm. Pharmaceutical compatibility needs to be established before administration. The compatibility of drugs from the same class cannot be inferred and each admixture requires individual review. Precipitation on mixing (steroids, non-steroidal anti-inflammatory drugs) and subsequent embolisation can lead to serious adverse events, although these are rare. The additive itself or its preservative can have neurotoxic (adrenaline, midazolam) and/or chondrotoxic properties (non-steroidal anti-inflammatory drugs). The prolongation of block may occur at the expense of motor block quality (ketamine) or block onset (magnesium). Adverse effects for some adjuncts appear to be dose-dependent and recommendations concerning optimal dosing are lacking. An important confounding factor is whether studies used systemic administration of the adjunct as a control to accurately identify an additional benefit of perineural administration. The challenge of how best to prolong block duration while minimising adverse events remains a topic of interest with further research required.

Comparison of intrathecal morphine versus local infiltration analgesia for pain control in total knee and hip arthroplasty: A meta-analysis

BACKGROUND

The purpose of this meta-analysis was to comprehensively collect randomized controlled trials (RCTs) to assess the clinical efficacy of intrathecal morphine (ITM) versus local infiltration analgesia (LIA) in the treatment of total knee and hip arthroplasty patients.

METHODS

Relevant studies were identified from the Embase, PubMed, Cochrane Library, Web of Science, Wanfang, and Chinese National Knowledge Infrastructure (CNKI) databases. We also reviewed the references of all identified articles to identify additional studies. For each study, we assessed the risk ratio (RR), weighted mean difference (WMD), and corresponding 95% confidence interval (95% CI) to synthesize outcomes. Meta-analysis was performed with Stata 12.0 software.

RESULTS

We included 13 studies with 942 patients for meta-analysis. LIA significantly decreased the pain value with rest or mobilization until 72 hours (P < .05). LIA significantly decreased cumulative morphine consumption by 13.52 mg. Moreover, the length of hospital stay was lower in the LIA group than in the ITM analgesia group. Finally, LIA significantly reduced morphine-related complications (nausea and vomiting, pruritus, and respiration depression).

CONCLUSIONS

LIA was an effective approach for relieving postoperative pain and reducing postoperative consumption of morphine compared with ITM in total knee and hip arthroplasty patients.