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Ifarraguerri AM, Trofa DP, Piasecki DP, Fleischli JE, Saltzman BM. Perioperative non-opioid analgesia strategies after high tibial osteotomy: a systematic review of prospective studies. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2315-2330. [PMID: 38758390 DOI: 10.1007/s00590-024-04000-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/09/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Little is known about the optimal analgesia regimen after HTO. Thus, this study systematically reviewed the literature on clinical and patient-reported outcomes of pain management strategies for patients after HTO. METHODS A comprehensive search of the PubMed, Cochrane CENTRAL, and CINAHL databases was conducted from inception through September 2023. Studies were included if they evaluated pain reduction with analgesia strategies after HTO and were excluded if they did not report pain control outcomes. RESULTS Five studies with 217 patients were included. Patients with a multimodal intraoperative injection cocktail to the knee, femoral nerve block (FNB), or adductor canal block (ACB) for HTO had significant improvement in visual analog scale (VAS) and numerical rating scale (NRS) scores in the first 12 h postoperatively compared to controls. Patients on duloxetine had significantly lower NRS scores at 1, 7, and 14 days postoperatively and significantly lower nonsteroidal anti-inflammatory drug (NSAID) usage throughout the two-week postoperative period than the control group. Patients receiving an ACB had significantly lower opioid consumption than controls at 12 h postoperative. In patients with an FNB or ACB, no significant difference in quadriceps strength or time to straight leg raise postoperatively was observed compared to controls. CONCLUSION A multimodal periarticular injection cocktail, FNB, or an ACB effectively reduces pain on the first day after HTO, with an ACB able to reduce opioid consumption on the first postoperative day. Duloxetine combined with an ACB effectively decreases pain for two weeks postoperatively while reducing NSAID consumption in patients after HTO. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Anna M Ifarraguerri
- OrthoCarolina Sports Medicine Center, 1915 Randolph Road, Charlotte, NC, 28207, USA
- OrthoCarolina Research Institute, 2001 Vail Ave, #300, Charlotte, NC, 28207, USA
- Atrium Health, Musculoskeletal Institute, 2001 Vail Ave, 6th Floor MSKI Suite, Charlotte, NC, 28207, USA
| | - David P Trofa
- Department of Orthopaedics, New York Presbyterian, Columbia University Medical Center, 622 West 168th St, PH 111-1130, New York, NY, 10032, USA
| | - Dana P Piasecki
- OrthoCarolina Sports Medicine Center, 1915 Randolph Road, Charlotte, NC, 28207, USA
- OrthoCarolina Research Institute, 2001 Vail Ave, #300, Charlotte, NC, 28207, USA
- Atrium Health, Musculoskeletal Institute, 2001 Vail Ave, 6th Floor MSKI Suite, Charlotte, NC, 28207, USA
| | - James E Fleischli
- OrthoCarolina Sports Medicine Center, 1915 Randolph Road, Charlotte, NC, 28207, USA
- OrthoCarolina Research Institute, 2001 Vail Ave, #300, Charlotte, NC, 28207, USA
- Atrium Health, Musculoskeletal Institute, 2001 Vail Ave, 6th Floor MSKI Suite, Charlotte, NC, 28207, USA
| | - Bryan M Saltzman
- OrthoCarolina Sports Medicine Center, 1915 Randolph Road, Charlotte, NC, 28207, USA.
- OrthoCarolina Research Institute, 2001 Vail Ave, #300, Charlotte, NC, 28207, USA.
- Atrium Health, Musculoskeletal Institute, 2001 Vail Ave, 6th Floor MSKI Suite, Charlotte, NC, 28207, USA.
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Johnson Z, Scribner M, Patzkowski J, Patzkowski M. Continuous Intravenous Ketamine for Pain Control After Tibial or Femoral Osteotomy. Mil Med 2023; 188:3248-3251. [PMID: 36043263 DOI: 10.1093/milmed/usac241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/16/2022] [Accepted: 07/27/2022] [Indexed: 11/14/2022] Open
Abstract
PURPOSE The purpose of this case series is to evaluate the potential of continuous intravenous ketamine administration as part of a multimodal strategy to reduce opioid requirements after high tibial osteotomy (HTO) and distal femoral osteotomy (DFO). METHODS We examined the average postoperative numerical rating scale pain intensity score from admission to the postanesthesia care unit to 8 am of the first postoperative day of four patients who underwent HTO or DFO. Pain scores were analyzed as the time-weighted sum of pain intensity differences using the trapezoidal rule of the curve, resulting in an area under the curve (AUC). RESULTS Patient A had an AUC of 2,828 over 1,180 minutes with an average pain score of 2.4/10. Patient B had an AUC of 1,418 over 1,285 minutes with an average pain score of 1.1/10. Patient C had an AUC of 4,217 over 1,155 minutes with an average pain score of 3.7/10. Patient D had an AUC of 4,498 over 1,030 minutes with an average pain score of 4.4/10. All were able to go home on postoperative day 1. CONCLUSIONS This novel perioperative pain pathway including multiple non-opioid pain adjuncts and a low-dose continuous ketamine infusion is an effective method for pain management in knee periarticular osteotomies. LEVEL OF EVIDENCE Level 4; Case Series.
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Affiliation(s)
- Zackary Johnson
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Maggie Scribner
- Department of Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, HI 96859, USA
| | - Jeanne Patzkowski
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
| | - Michael Patzkowski
- Department of Anesthesiology, Brooke Army Medical Center, Fort Sam Houston, TX 78234, USA
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Cunningham DJ, LaRose M, Zhang G, Patel P, Paniagua A, Gadsden J, Gage MJ. Regional Anesthesia Associated With Decreased Inpatient and Outpatient Opioid Demand in Tibial Plateau Fracture Surgery. Anesth Analg 2022; 134:1072-1081. [PMID: 35313323 DOI: 10.1213/ane.0000000000005980] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Regional anesthesia (RA) has been used to reduce pain and opioid usage in elective orthopedic surgery. The hypothesis of this study was that RA would be associated with decreased opioid demand in tibial plateau fracture surgery. METHODS Inpatient opioid consumption and 90-day outpatient opioid prescribing in all patients ≥18 years of age undergoing tibial plateau fracture surgery from July 2013 to July 2018 (n = 264) at a single, level I trauma center were recorded. The presence or absence of perioperative RA was noted. Of 60 patients receiving RA, 52 underwent peripheral nerve blockade (PNB) with single-shot sciatic-popliteal (40.0%; n = 24), femoral (26.7%; n = 16), adductor canal (18.3%; n = 11), or fascia iliaca (1.7%; n = 1) block with ropivacaine. Ten patients received epidural analgesia (EA) with either single-shot spinal (11.7%; n = 7) blocks or continuous epidural (5.0%; n = 3). Additional baseline and treatment characteristics were recorded, including age, sex, race, body mass index (BMI), smoking, chronic opioid use, American Society of Anesthesiologists (ASA) score, injury mechanism, additional injuries, open injury, and additional inpatient surgery. Statistical models, including multivariable generalized linear models with propensity score weighting to adjust for baseline patient and treatment characteristics, were used to assess perioperative opioid demand with and without RA. RESULTS RA was associated with reduced inpatient opioid usage from 0 to 24 hours postoperatively of approximately 5.2 oxycodone 5-mg equivalents (0.74 incident rate ratio [IRR]; 0.63-0.86 CI; P < .001) and from 24 to 48 hours postoperatively of approximately 2.9 oxycodone 5-mg equivalents (0.78 IRR; 0.64-0.95 CI; P = .014) but not at 48 to 72 hours postoperatively. From 1 month preoperatively to 2 weeks postoperatively, RA was associated with reduced outpatient opioid prescribing of approximately 24.0 oxycodone 5-mg equivalents (0.87; 0.75-0.99; P = .044) and from 1 month preoperatively to 90 days postoperatively of approximately 44.0 oxycodone 5-mg equivalents (0.83; 0.71-0.96; P = .011), although there was no significant difference from 1 month preoperatively to 6 weeks postoperatively. There were no cases of acute compartment syndrome in this cohort. CONCLUSIONS In tibial plateau fracture surgery, RA was associated with reduced inpatient opioid consumption up to 48 hours postoperatively and reduced outpatient opioid demand up to 90 days postoperatively without an associated risk of acute compartment syndrome. RA should be considered for patients undergoing tibial plateau fracture fixation.
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Affiliation(s)
- Daniel J Cunningham
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Micaela LaRose
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Gloria Zhang
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Preet Patel
- Duke University School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Ariana Paniagua
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey Gadsden
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark J Gage
- From the Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
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