Best multimodal analgesic protocol for total knee arthroplasty

[Translated article] In vitro elution of local anaesthetics from PMMA bone cement

BACKGROUND AND AIM

Currently, we do not have a gold standard for pain management after total knee arthroplasty. We may use one of more drug delivery systems, none of which are ideal. An ideal depot delivery system would provide therapeutic, nontoxic, doses of drug at the surgical side, especially during 72h postoperatively. The bone cement used in arthroplasties has been used as a drug delivery system, especially antibiotics, since 1970. Based on this principle, we developed this study with the aim to characterize the elution profile of two local anaesthetics (lidocaine hydrochloride and bupivacaine hydrochloride) from PMMA (polymethilmethacrylate) bone cement.

MATERIAL AND METHODS

Palacos® R+G bone cement and lidocaine hydrochloride or bupivacaine hydrochloride specimens were obtained depending on the study group. These specimens were immersed in PBS (phosphate buffered saline) and removed from the solution at different set times. Subsequently, the concentration of local anaesthetic in the liquid was analyzed by liquid chromatography.

RESULTS

The percentage of lidocaine eluted from PMMA bone cement in this study was 9.74% of the total lidocaine content per specimen at 72h and 18.73% at 336h (14 days). In case of bupivacaine, the elution percentage was 2.71% of the total bupivacaine content per specimen at 72h and 2.70% at 336h (14 days).

CONCLUSIONS

Local anaesthetics elute in vitro from PMMA bone cement, reaching doses at 72h close to the doses used in anaesthetic blocks.

In vitro elution of local anesthetics from PMMA bone cement

BACKGROUND AND AIM

Currently, we do not have a gold standard for pain management after total knee arthroplasty. We may use one of more drug delivery systems, none of which are ideal. An ideal depot delivery system would provide therapeutic, nontoxic, doses of drug at the surgical side, especially during 72h postoperatively. The bone cement used in arthroplasties has been used as a drug delivery system, especially antibiotics, since 1970. Based on this principle, we developed this study with the aim to characterize the elution profile of two local anesthetics (lidocaine hydrochloride and bupivacaine hydrochloride) from PMMA (polymethilmethacrylate) bone cement.

MATERIAL AND METHODS

Palacos® R+G bone cement and lidocaine hydrochloride or bupivacaine hydrochloride specimens were obtained depending on the study group. These specimens were immersed in PBS (phosphate buffered saline) and removed from the solution at different set times. Subsequently, the concentration of local anesthetic in the liquid was analyzed by liquid chromatography.

RESULTS

The percentage of lidocaine eluted from PMMA bone cement in this study was 9.74% of the total lidocaine content per specimen at 72h and 18.73% at 336h (14 days). In case of bupivacaine, the elution percentage was 2.71% of the total bupivacaine content per specimen at 72h and 2.70% at 336h (14 days).

CONCLUSIONS

Local anesthetics elute in vitro from PMMA bone cement, reaching doses at 72h close to the doses used in anesthetic blocks.

[Translated article] In vitro elution of local anaesthetics from PMMA bone cement

BACKGROUND AND AIM

Currently, we do not have a gold standard for pain management after total knee arthroplasty. We may use one of more drug delivery systems, none of which are ideal. An ideal depot delivery system would provide therapeutic, nontoxic, doses of drug at the surgical side, especially during 72h postoperatively. The bone cement used in arthroplasties has been used as a drug delivery system, especially antibiotics, since 1970. Based on this principle, we developed this study with the aim to characterise the elution profile of two local anaesthetics (lidocaine hydrochloride and bupivacaine hydrochloride) from PMMA (polymethilmethacrylate) bone cement.

MATERIAL AND METHODS

Palacos® R+G bone cement and lidocaine hydrochloride or bupivacaine hydrochloride specimens were obtained depending on the study group. These specimens were immersed in PBS (phosphate buffered saline) and removed from the solution at different set times. Subsequently, the concentration of local anaesthetic in the liquid was analysed by liquid chromatography.

RESULTS

The percentage of lidocaine eluted from PMMA bone cement in this study was 9.74% of the total lidocaine content per specimen at 72h and 18.73% at 336h (14 days). In case of bupivacaine, the elution percentage was 2.71% of the total bupivacaine content per specimen at 72h and 2.70% at 336h (14 days).

CONCLUSIONS

Local anaesthetics elute in vitro from PMMA bone cement, reaching doses at 72h close to the doses used in anaesthetic blocks.

Positioning the Catheter Tip Anterior or Posterior to the Saphenous Nerve in Continuous Adductor Canal Block: A Mono-Centric Retrospective Comparative Study

Background and Aim

Ultrasound-guided continuous adductor canal block (cACB) is a conventional choice in patients undergoing total knee arthroplasty (TKA) for the management of the postoperative pain. This study aims to compare different catheter tip locations for cACB relative to the saphenous nerve (anteriorly vs posteriorly) in terms of efficacy and complications.

Methods

At the department of Surgical Sciences, Orthopedic Trauma and Emergencies of the University of Naples Federico II (Naples, Italy), between January 2020 and November 2021, retrospective comparative study was executed. Patients planned for TKA were included in the study if they met the follow inclusion criteria: patients undergone TKA; aged 50-85 years; body mass index (BMI) of 18-35 kg/m2; American Society of Anesthesiologists (ASA) physical status classification from I to III; subarachnoid technique for anesthesiology plane; continuous adductor canal block performed by an anesthetist with considerable experience. Patients were assigned to receive cACB with the catheter tip located anteriorly (Group 1, G1) or posteriorly to the saphenous nerve (Group 2, G2). Postoperative pain, ambulation ability, episodes of pump block and rate of catheter dislodgement and leakage were evaluated and analyzed.

Results

Altogether, 102 patients were admitted to the study (48 in G1 and 54 in G2). After the first 8 postoperative hours, in G1 17 patients (35.4%) had a VAS greater than 4, while in group 2 only 3 patients (5.6%) had a VAS greater than 4 (p-value <0.01). All patients of both groups showed ambulation ability in the postoperative period. No episode of leakage was recorded. While the catheter displacement rate was similar in the two groups (2.1% for G1 vs 3.7% for G2; p-value >0.05), the episodes of pump block were significantly less in G2 than in G1 (3.7% vs 20.8%; p-value <0.01).

Conclusion

In cACB for TKA, we found that positioning the catheter tip posteriorly to the saphenous nerve may lead to a greater postoperative analgesia and reduce the risk of pump block compared to placing the catheter tip anteriorly to the nerve.

Synergistic effects of robotic surgery and IPACK nerve block on reduction of opioid consumption in total knee arthroplasty

Background

There are numerous strategies to combat postoperative analgesia and expedite recovery after total knee arthroplasty (TKA). The purpose of this study was to determine opioid consumption, length of stay, and functional outcomes after robotic versus standard TKA in the setting of various regional pain modalities.

Methods

A consecutive series of patients treated with unilateral primary robotic or standard TKA from January 2018-February 2021 were retrospectively identified. Regional pain modalities included peri-articular injection (PAI), adductor canal block (ACB), and infiltration between popliteal artery and capsule of knee (IPACK). Patient demographics, operative/perioperative variables, and postoperative function were recorded. Daily opiate consumption was calculated as morphine milligram equivalents (MME). Multivariate regression was performed to control for age, sex, and race.

Results

After review, 283 patients (177 Females; 106 Males) were included. Robotic TKA patients received IPACK + ACB (36), while standard TKA patients received either ACB (45), IPACK + ACB (167), or PAI (35). Daily inpatient opioid consumption in the standard IPACK + ACB (p = 0.02) and robotic IPACK + ACB groups (p = 0.0001) was significantly lower compared to standard ACB. When combined with IPACK block, robotic procedures synergistically lowered opiate consumption (p = 0.004) compared to standard procedures and led to earlier discharge (p = 0.003). The robotic IPACK + ACB cohort also demonstrated improved early ambulation compared to standard ACB, (p = 0.05), whereas the same benefit was not seen for patients who received IPACK during standard TKA.

Conclusions

The utilization of IPACK block decreases inpatient postoperative opioid requirements following TKA. Robotic TKA and IPACK block appeared to have a synergistic effect on opioid consumption and postoperative recovery.

Efficacy of single-shot adductor canal block before Versus after primary total knee arthroplasty - Does timing make a difference? A randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with severe postoperative pain. Multimodal analgesia, including peripheral nerve block, is recommended for post-operative pain relief. Administration of some pain medications prior to surgery has shown to be more effective than after the operation. This is a prospective, randomized controlled trial designed to compare the analgesic efficacy of the adductor canal block (ACB) performed immediately before or immediately after primary total knee arthroplasty (TKA). We hypothesized that ACB before the surgery will reduce postoperative pain and improve knee function.

METHODS

A total of 50 patients were enrolled and randomized into 2 groups, with 26 patients receiving a preoperative ACB and 24 receiving a postoperative ACB.

RESULTS

Treatment groups were similar in terms of gender (p = .83), age (p = 0.61) weight (p = .39) and ASA score. Average visual analogue scale (VAS) on arrival to the post-anesthesia care unit (PACU) were 4.9 ± 3.2 in the preoperative ACB versus 3.4 ± 2.8 for the postoperative ACB (p = .075). VAS scores at different time points as well as the mean, minimal and maximal reported VAS scores were not significantly different between the two groups. The cumulative quantities of Fentanyl administered by the anesthesia team was comparable between the groups. Similarly, the dosage of Morphine, Tramadol, Acetaminophen and Dipyrone showed only small variations. The Quality of Recovery Score, Knee Society Scores and knee range of motion did not differ between the groups.

CONCLUSIONS

Our findings demonstrate no significant differences in patient total narcotics consumption, pain scores and functional scores, between preoperative and postoperative ACB in patients undergoing TKA.

TRIAL REGISTRATION

The trial was registered at www.clinicaltrials.gov and was assigned the registration number NCT02908711.

LEVEL OF EVIDENCE

level I randomized controlled trial.

Review on Nerve Blocks Utilized for Perioperative Total Knee Arthroplasty Analgesia

Total Knee Arthroplasty (TKA) is an increasingly common procedure performed for advanced osteoarthritis. Optimal perioperative pain management strategies are critical for early mobilization and shorter hospital stays in TKA. Peripheral nerve blocks commonly used in TKA perioperative analgesia including individual and combined femoral, obturator, sciatic, lumbar plexus, and adductor canal nerve blocks. Overall, the safety profile varies depending on which block is utilized, but the current evidence suggests when optimally chosen and delivered, peripheral nerve blocks may provide a safe, effective option for perioperative analgesia. Determining optimal analgesic regimens for total knee arthroplasty is critical to improve postoperative pain, patient satisfaction, decreasing opioid usage, recovery times and functional outcomes, and as such, peripheral nerve blocks may represent a viable option to supplement analgesic requirements in the perioperative period.

Early Postoperative Pain Control and Inflammation for Total Knee Arthroplasty: A Retrospective Comparison of Continuous Adductor Canal Block versus Single-Shot Adductor Canal Block Combined with Patient-Controlled Intravenous Analgesia

Objective

The aim of this study was to compare pain control and inflammation among patients who received a continuous adductor canal block (CACB) versus single-shot adductor canal block (SACB) combined with patient-controlled intravenous analgesia (PCIA) for total knee arthroplasty (TKA) analgesia in the first two days after surgery.

Design

Matched cohort retrospective study. Setting. University hospital. Patients. One hundred fifty-six patient charts were included in this study: 78 patients with CACB in Group A and 78 patients with SACB combined with PCIA in Group B. Patients were matched according to age, body mass index, and American Society of Anesthesiologists class. Measurements. The primary outcome of the study was Visual Analogue Scale (VAS) pain scores before operation (Pre) and at postoperative 6 (POH6), 12 (POH12), 24 (POH24), 30 (POH30), 36 (POH36), and 48 hours (POH48). Secondary outcomes included patient-controlled bolus, time of first postoperative ambulation, range of knee flexion and extension, inflammation cytokines on Pre and POH48, percentage of remedial analgesics treatment, incidence of adverse events and complications, hospital stay and cost, and Numerical Rating Scale (NRS) satisfaction scores at discharge. Main Results. Mean VAS scores at rest and with motion were lower in Group B than in Group A on all postoperative hours. At POH30, compared with Group A (1.1 ± 0.6), mean VAS scores at rest in Group B (0.9 ± 0.4) were lower (P=0.048), and compared with Group A (2.6 ± 0.7), mean VAS scores with motion in Group B (2.2 ± 0.8) were lower (P=0.001). The number of patient-controlled bolus was 4.3 ± 1.6 (95% CI 3.9-4.6) in Group A and 3.1 ± 1.3 (95% CI 2.8-3.4) in Group B, respectively (P < 0.001). Patients in Group B displayed better functional recovery and inflammation results at POH48 than Group A with respect to range of knee flexion and extension (117.8 ± 10.9° vs. 125.2 ± 9.4°, P < 0.001) and inflammation cytokines, including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and interleukin-6 (IL-6) ((43.8 ± 16.1) vs. (36.8 ± 13.2), P=0.003; (34.9 ± 9.4 mg/L) vs. (29.6 ± 10.6 mg/L), P=0.001; (21.3 ± 8.7 pg/ml) vs. (14.0 ± 7.0 pg/ml), P < 0.001)).

Conclusion

SACB combined with PCIA in the first two days of patients undergoing TKA has better analgesic and beneficial effects on functional recovery and inflammation.

Minimizing the Risk of Opioid Misuse and Abuse in the Surgical Setting

The misuse of opioids continues to be a public health problem. Acute post-surgical pain management requires a careful balance between the benefits and risks of opioids. Opioids should be part of a multimodal treatment plan, including the use of nonopioid and nonpharmacologic treatment options. Multimodal pain management allows for individualized treatment and improved patient satisfaction while limiting the risks inherent to opioids, including diversion. Surgeons should avoid overprescribing opioids and have a plan for decreasing the use of opioids in the postsurgical time frame. With careful consideration of the risks, opioids can be prescribed to treat acute postsurgical pain effectively. [Orthopedics. 2021;44(6):353-359.].

Efficacy of Two Unique Combinations of Nerve Blocks on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BACKGROUND

This study aimed to explore the efficacy of two unique combinations of nerve blocks on postoperative pain and functional outcome after total knee arthroplasty (TKA).

METHODS

Patients scheduled for TKA were randomized to receive a combination of adductor canal block (ACB) + infiltration between the popliteal artery and capsule of the posterior knee block (IPACK) + sham obturator nerve block (ONB) + sham lateral femoral cutaneous nerve block (LFCNB) (control group), or a combination of ACB + IPACK + ONB + sham LFCNB (triple nerve block group), or a combination of ACB + IPACK + ONB + LFCNB (quadruple nerve block group). All patients received local infiltration analgesia. Primary outcome was postoperative morphine consumption. Secondary outcomes were the time until first rescue analgesia, postoperative pain assessed on the visual analog scale (VAS), QoR-15 score, functional recovery of knee, and postoperative complications.

RESULTS

Compared with the control group, the triple and quadruple nerve block groups showed significantly lower postoperative morphine consumption (17.2 ± 9.7 mg vs. 11.2 ± 7.0 mg vs. 11.4 ± 6.4 mg, P = .001). These two groups also showed significantly longer time until first rescue analgesia (P = .007 and .010, respectively, analyzed with Kaplan-Meier method), significantly lower VAS scores on postoperative day 1 (P < .01), significantly better QoR-15 scores on postoperative days 1 and 2 (P < .001), and significantly better functional recovery of knee including range of motion (P = .002 and .001 on postoperative days 1 and 2), and daily ambulation distance (P < .001 and P = .004 on postoperative days 1 and 2). However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the reported minimal clinically important differences (MCIDs) (morphine consumption: 10 mg; VAS scores: 1.5 at rest and 1.8 during movement; QoR-15 scores: 8.0). The MCIDs of other outcomes have not been reported in literature. The triple and quadruple nerve block groups showed no significant differences in these outcomes between each other. The three groups did not show a significant difference in complication rates.

CONCLUSION

Adding ONB or ONB + LFCNB to ACB + IPACK can statistically reduce morphine consumption, improve early pain relief, and functional recovery. However, the absolute change in morphine consumption, VAS scores, and QoR-15 scores did not exceed the MCIDs. Based on our findings and considering the sample size of this study, there is not enough clinical evidence to support the triple or quadruple nerve block use within a multimodal analgesic pathway after TKA.

Influence of sex and gender on the management of late-stage knee osteoarthritis

PURPOSE

The exact nature of sex and gender differences in knee osteoarthritis (OA) among patient candidates for total knee arthroplasty (TKA) remains unclear and requires better elucidation to guide clinical practice. The purpose of this investigation was to survey physician practices and perceptions about the influence of sex and gender on knee OA presentation, care, and outcomes after TKA.

METHODS

The survey questions were elaborated by a multidisciplinary scientific board composed of 1 pain specialist, 4 orthopedic specialists, 2 physiatrists, and 1 expert in gender medicine. The survey included 5 demographic questions and 20 topic questions. Eligible physician respondents were those who treat patients during all phases of care (pain specialists, orthopedic specialists, and physiatrists). All survey responses were anonymized and handled via remote dispersed geographic participation.

RESULTS

Fifty-six physicians (71% male) accepted the invitation to complete the survey. In general, healthcare professionals expressed that women presented worse symptomology, higher pain intensity, and lower pain tolerance and necessitated a different pharmacological approach compared to men. Pain and orthopedic specialists were more likely to indicate sex and gender differences in knee OA than physiatrists. Physicians expressed that the absence of sex and gender-specific instruments and indications is an important limitation on available studies.

CONCLUSIONS

Healthcare professionals perceive multiple sex and gender-related differences in patients with knee OA, especially in the pre- and perioperative phases of TKA. Sex and gender bias sensitivity training for physicians can potentially improve the objectivity of care for knee OA among TKA candidates.

A meta-analysis on advantages of peripheral nerve block post-total knee arthroplasty

Background

Postoperative pain management is crucial for patients undergoing total knee arthroplasty (TKA). There have been many recent clinical trials on post-TKA peripheral nerve block; however, they have reported inconsistent findings. In this meta-analysis, we aimed to comprehensively analyze studies on post-TKA analgesia to provide evidence-based clinical suggestions.

Methods

We performed a computer-based query of PubMed, Embase, the Cochrane Library, and the Web of Science to retrieve related articles using neurothe following search terms: nerve block, nerve blockade, chemodenervation, chemical neurolysis, peridural block, epidural anesthesia, extradural anesthesia, total knee arthroplasty, total knee replacement, partial knee replacement, and others. After quality evaluation and data extraction, we analyzed the complications, visual analogue scale (VAS) score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices. Evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Results

We included 16 randomized controlled trials involving 981 patients (511 receiving peripheral nerve block and 470 receiving epidural block) in the final analysis. Compared with an epidural block, a peripheral nerve block significantly reduced complications. There were no significant between-group differences in the postoperative VAS score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices.

Conclusions

Our findings demonstrate that the peripheral nerve block is superior to the epidural block in reducing complications without compromising the analgesic effect and patient satisfaction. Therefore, a peripheral nerve block is a safe and effective postoperative analgesic method with encouraging clinical prospects.

Which is the best analgesia treatment for total knee arthroplasty: Adductor canal block, periarticular infiltration, or liposomal bupivacaine? A network meta-analysis

STUDY OBJECTIVE

To review all randomized controlled trials (RCTs) comparing the analgesic efficacy of adductor canal block (ACB), periarticular infiltration (PAI), and any other mode of these treatments in analgesia, such as PAI with liposomal bupivacaine (LB), continuous adductor canal block (cACB) or ACB + PAI, after total knee arthroplasty (TKA).

DESIGN

Systematic review and network meta-analysis of RCTs.

PATIENTS

We searched PubMed, Embase, and the Cochrane database to detect all relevant RCTs on investigating the analgesic effects of ACB, PAI and LB for TKA published until April 2020.

INTERVENTIONS

Use of different analgesic methods of ACB, PAI, cACB, ACB + PAI and LB.

MEASUREMENTS

The primary endpoint was visual analog scale (VAS) score at rest and movement. The secondary endpoints were opioids consumption, length of hospitalization and knee range of motion (ROM). We used Cochrane risk of bias to assess the quality of evidence for outcomes.

RESULTS

Forty-two studies involving 3785 patients with 5 different methods containing ACB, PAI, ACB + PAI, continuous ACB (cACB), LB, were evaluated. According to surface under the cumulative ranking curve value, 24 h resting VAS score was the lowest the ACB + PAI (88.4%), followed by cACB (73.4%); Resting VAS score at 48 h and movement VAS score at 24 h and 48 h was the lowest in the cACB (99.9%, 92% and 100%). Total opioids consumption was the least in LB (81.4%) before cACB (60.8%). ROM was the largest in the ACB + PAI (84.1%) before cACB (78.8%).

CONCLUSION

Although all analgesic methods available were not evaluated, and further studies are needed to establish our results, the 24 h resting VAS score was lowest in ACB + PAI and 48 h resting and movement VAS score was lowest in cACB.

CLINICAL TRIAL REGISTRATION

PROSPERO (CRD 42020168102).

Slightly better pain relief but more frequently motor blockade with combined nerve block analgesia compared to continuous intraarticular analgesia after total knee arthroplasty

PURPOSE

Pain management after total knee arthroplasty (TKA) is still under debate. Continuous peripheral nerve blocks (PNB) can provide long pain relief but impair muscle function. Continuous intraarticular analgesia could result in longer pain relief than local infiltration analgesia without negative effects on muscle function. This study investigated the efficacy of pain control between PNB's and continuous intraarticular analgesia after TKA.

METHODS

A prospective randomized study on 140 patients undergoing TKA was performed. Patients received either a combination of continuous femoral nerve block, continuous sciatic nerve block and single-shot obturator nerve block (group R) or a local infiltration analgesia and a continuous intraarticular catheter with ropivacaine (group L). Primary outcome was pain measured on a numerical rating scale. Knee function, patient-reported outcome (PRO) and adverse events were assessed until 1 year after surgery.

RESULTS

Pain at rest was lower in group R on the day of surgery (mean NRS 3.0 vs. 4.2) and the morning of postoperative day 1 (mean NRS 3.4 vs. 4.4). Motor blockade longer than postoperative day 3 occurred more often in group R compared to group L (15.3% vs. 1.5%). Pain levels, PRO and satisfaction 3-month and 1-year after surgery were similar.

CONCLUSION

Continuous PNB's were slightly more effective in the first 24 h after surgery but were associated more often with motor blockade which should be avoided. It must be balanced if the small amount of better pain relief immediately after surgery justifies the risks associated with motor blockade following PNB's.

LEVEL OF EVIDENCE

I.

Establishing a patient centered, outpatient total joint home recovery program within an integrated healthcare system

Outpatient total joint home recovery (HR) is a rapidly growing initiative being developed and employed at high volume orthopedic centers. Minimally invasive surgery, improved pain control and home health services have made HR possible. Multidisciplinary teams with members ranging from surgeons and anesthesiologists to hospital administrators, physical therapists, nurses and research analysts are necessary for success. Eligibility criteria for outpatient total joint arthroplasty will vary between medical centers. Surgeon preference in addition to medical comorbidities, social support, preoperative patient mobility and safety of the HR location are all factors to consider when selecting patients for outpatient total joint HR. As additional knowledge is gained, the next steps will be to establish 'best practices' and speciality society-endorsed guidelines for patients undergoing outpatient total joint arthroplasty.

An evidence-based review of enhanced recovery after surgery in total knee replacement surgery

Rationale: Enhanced recovery after surgery is gaining popularity among orthopaedic surgeons across the globe and hence a strong evidence base had to be reviewed to make an evidence-based sustainable protocol.

Methods

The following databases, PubMed, OVID, Cochrane database and EMBASE were searched. The search was limited to 15 components of enhanced recovery after surgery programme which is divided into preoperative, intraoperative and postoperative phases. Inclusion criteria were restricted to articles published in English within the last 15 years and articles comprising of unicompartmental arthroplasty, revision knee arthroplasty, bilateral simultaneous knee arthroplasty and only hip arthroplasty excluded. The full texts were analysed and controversies and limitations of various studies were summarised.

Discussion

Each component of the programme was thoroughly reviewed and strength and weaknesses of the evidence base summarised. The strength of the evidence was assessed by critically appraising the study methodology and justifying the appropriateness of the inclusion in enhanced recovery after surgery protocol.

Conclusion

Enhanced recovery after surgery has already been used successfully in various surgical specialities. Enhanced recovery after surgery programmes in knee arthroplasty are yet to be established as a universal practice to be adopted globally. This evidence-based review provides an insight into the best evidence linked to each component and their rationale for inclusion in the proposed enhanced recovery after surgery protocol.

Efficacy of Single-Shot Adductor Canal Block Combined With Posterior Capsular Infiltration on Postoperative Pain and Functional Outcome After Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BACKGROUND

Adductor canal block (ACB) may preserve muscle strength and promote faster recovery than other methods of analgesia following total knee arthroplasty (TKA). However, there are contradictory reports on the efficacy of ACB. Here, we evaluated the efficacy of single-shot ACB combined with posterior capsular infiltration (PCI) vs multimodal periarticular infiltration analgesia in treating postoperative pain.

METHODS

This study involved patients undergoing unilateral primary TKA at our institution from January 2018 to January 2019. Patients were randomized into 2 groups, one of which was treated with ACB combined with PCI, and the other with periarticular infiltration analgesia. Primary outcomes included postoperative pain as assessed by the visual analog scale (VAS) and consumption of morphine hydrochloride. The secondary outcome was functional recovery, as assessed by range of knee motion, quadriceps strength, and daily ambulation distance. Tertiary outcomes included the duration of hospital stay and postoperative adverse effects.

RESULTS

Patients treated with ACB and PCI had lower resting VAS scores at 8 and 24 hours after surgery, and lower VAS scores during motion within 48 hours after surgery. Patients treated with ACB and PCI also consumed less morphine. There was no difference in functional recovery, duration of hospitalization, or incidence of adverse events.

CONCLUSION

The ACB combined with PCI can reduce postoperative pain sooner after TKA without affecting postoperative functional recovery and increasing complications.

Can recent chronic pain techniques help with acute perioperative pain?

PURPOSE OF REVIEW

This article discussed how the knowledge and technique of a few chronic pain procedures benefited the perioperative clinicians in their care of patients receiving specific orthopaedic surgical procedures.

RECENT FINDINGS

Recent emerging interest in hip and knee denervation for chronic pain management secondary to osteoarthritis stimulates publications on the new understanding of hip and knee joint innervation. The improved understanding of the anatomy allows better precision in targeting the articular branches. The procedures for chronic joint pain such as radiofrequency ablation, chemical neurolysis and neuromodulation procedure have recently been applied to the perioperative care in orthopaedic procedures because of the potential long-lasting analgesia, opioid-sparing effect and consequent improvement in physical function and health-related quality of life after surgery.

SUMMARY

Despite the widespread use of regional anaesthesia and multimodal analgesia in the perioperative pain management, more than two-third of the patients reported severe postoperative pain. Therefore, other therapeutic strategies used in chronic pain management such as radiofrequency ablation and neuromodulation have been proposed to optimize acute postsurgical pain. The early experience with those techniques is encouraging, and more studies are required to explore the incorporation of these procedures in the perioperative care.

Continuous Adductor Canal Block used for postoperative pain relief after medial Unicondylar Knee Arthroplasty: a randomized, double-blind, placebo-controlled trial

Background

Peripheral nerve block and local infiltration analgesia (LIA) provide good analgesia after knee replacement. This study evaluated the additional analgesic efficacy of continuous adductor canal block (ACB) added to single-dose LIA after medial unicondylar knee arthroplasty (UKA). We hypothesized ACB would lower pain scores and facilitate postoperative ambulation.

Methods

Forty-six patients were enrolled into this double-blind, randomized, placebo-controlled trial. UKA was performed and all patients received single-dose LIA intraoperatively. Patients were randomized into two groups: Group RP receiving 0.2% ropivacaine or Group Con receiving normal saline. A flow at 6 mL/h was administered for 48 h through a catheter in the adductor canal. Primary outcome was movement pain score at 24 h using the numeric rating scale (NRS-11). Secondary outcomes included serial postoperative pain scores, rate of patients with NRS>3 at rest and movement within 24 and 48 h postoperatively, time to breakthrough pain, quadriceps motor strength, ambulated distance, catheter related infection and patient satisfaction.

Results

Forty-two patients were analyzed. Pain scores with movement at 24 h postoperatively were significantly lower in Group RP than that in Group Con (3 vs. 5 NRS, P<0.001). Compared with Group Con, breakthrough pain occurred later in Group RP (18.5 vs 10.0 h, P = 0.002), serial pain scores at rest and with movement and rate of patients with NRS>3 with movement after surgery were significantly lower. Quadriceps motor strength was equivalent, however, ambulated distance on postoperative day 1 and 2 in Group Con was significant less (19.7 vs 37.3 m, P = 0.046; 33.4 vs 59.5 m, P = 0.002).

Conclusions

Continuous adductor canal block added to single-dose LIA offered better analgesia and facilitated ambulation without motor weakness after medial UKA.

Trial registration

Clinical Trial Registration: ChiCTR-IOR-16008720; Registered 25 June 2016.

Regional Anesthesia and Readmission Rates After Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty is a commonly performed procedure and an important contributor to national health care spending. Reducing the incidence of readmission could have important consequences for patient well-being and relevant financial implications. Whether regional anesthesia techniques are associated with decreased readmission rates and costs among privately insured patients remains unknown.

METHODS

Using administrative claims data, we identified 138,362 privately insured patients 18-64 years of age who underwent total knee arthroplasty between 2002 and 2013. We then examined whether the use of a nerve block was associated with decreases in readmission rates and related costs during the 90 days after discharge. Our analyses were adjusted for potential confounding variables including medical comorbidities and previous use of opioids and other medications.

RESULTS

After adjusting for patient demographics, comorbidities, and preoperative medication use, the adjusted 90-day readmission rate was 1.8% (95% confidence interval [CI], 1.1-2.4) among patients who did not receive a block compared to 1.7% (95% CI, 1.1-2.4) among patients who did (odds ratio, 0.99; 95% CI, 0.91-1.09; P = .85). The adjusted readmission-related postoperative cost for patients who did not receive a block was $561 (95% CI, 502-619) and $574 (95% CI, 508-639) for patients who did (difference, $13; 95% CI, -75 to 102; P = .74). This lack of statistically significant differences held for subgroup and sensitivity analyses.

CONCLUSIONS

Nerve blocks were not associated with improved measures of long-term postoperative resource use in this younger, privately insured study population.

Single shot versus continuous technique adductor canal block for analgesia following total knee arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

An adductor canal block (ACB) provides recognized analgesia following total knee arthroplasty (TKA). This meta-analysis compared the single-injection ACB (SACB) with the continuous-injection ACB (CACB).

METHOD

Relevant studies were searched from PubMed (1996-October 2018), Embase (1980-October 2018), and Cochrane Library (CENTRAL, October 2018). Four randomized controlled trials (RCTs), which compared SACB with CACB, were included in our meta-analysis.

RESULTS

Four RCTs met the inclusion criteria. Our pooled data indicated that the SACB group had similar efficacy compared with the CACB group in terms of morphine consumption (P = .19), time to first opioid request (P = .32), range of motion (P = .97), and visual analogue scale (VAS) scores at 24 hours at rest (P = .12) and movement (P = .24), without increasing the risk of complications (P = .97) and length of stay (P = .54).

CONCLUSION

The SACB technique provides similar analgesia in the 24 hours following TKA compared with CACB, while the CACB method was better over 48 hours.

Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement

Background

The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients.

Methods

With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days.

Results

Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th–90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0–4.3] vs. 2.5 [0–7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes.

Conclusions

Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.

Managing Prolonged Pain After Surgery: Examining the Role of Opioids

A notable minority of patients experience persistent postsurgical pain and some of these patients consequently have prolonged exposure to opioids. Risk factors for prolonged opioid use after surgery include preoperative opioid use, anxiety, substance abuse, and alcohol abuse. The window to intervene and potentially prevent persistent opioid use after surgery is short and may best be accomplished by both surgeon and anesthesiologist working together. Anesthesiologists in particular are well positioned in the perioperative surgical home model to affect multiple aspects of the perioperative experience, including tailoring intraoperative medications and providing consultation for possible discharge analgesic regimens that can help minimize opioid use. Multimodal analgesia protocols reduce opioid consumption and thereby reduce exposure to opioids and theoretically the risk of persistent use. Regional anesthesia and analgesia techniques also reduce opioid consumption. Although many patients will recover without difficulty, the small minority who do not should receive customized care which may involve multiple office visits or consultation of a pain specialist. Enhanced recovery pathways are useful in optimizing outcomes after surgery.

A pragmatic approach to evaluating new techniques in regional anesthesia and acute pain medicine

Anesthesiologists set up regional anesthesia and acute pain medicine programs in order to improve the patient outcomes and experience. Given the increasing frequency and volume of newly described techniques, applying a pragmatic framework can guide clinicians on how to critically review and consider implementing the new techniques into clinical practice. A proposed framework should consider how a technique: increases access; enhances efficiency; decreases disparities and improves outcomes. Quantifying the relative contribution of these four factors using a point system, which will be specific to each practice, can generate an overall scorecard to help clinicians make decisions on whether or not to incorporate a new technique into clinical practice or replace an incumbent technique within a clinical pathway.

Establishing an Acute Pain Service in Private Practice and Updates on Regional Anesthesia Billing

Acute pain management is an expanding perioperative specialty and there is a renewed focus on implementing and developing an acute pain service (APS) in nonacademic hospitals (ie, "private practice"). An anesthesiologist-led APS can improve patient care by decreasing perioperative morbidity and potentially reducing the risk of chronic postsurgical pain syndromes. Elements of a successful APS include multidisciplinary collaboration to develop perioperative pain protocols, education of health care providers and patients, and regular evaluation of patient safety and quality of care metrics. Standardization of regional anesthesia procedures and billing practices can promote consistent outcomes and efficiency.

Anesthesia and analgesia for total knee arthroplasty

The demand for total knee arthroplasty (TKA) is rising worldwide. Controversy persists in the literature regarding the benefits of general versus neuraxial anesthesia and which anesthetic is associated with the best outcomes. Likewise, the abundance of analgesic options for post-TKA pain have led to debate regarding the safest, most effective regimens. In this paper, we evaluated a selection of recent publications regarding anesthetic and analgesic choices for TKA. High-quality studies and meta-analyses linking anesthetic agents and analgesic modalities to clinically important outcomes were chosen wherever possible. We included a range of clinical and population-based research, incorporating established and emerging techniques. Although not uniform, clinical and population-based data favor neuraxial anesthesia, and suggest less morbidity compared to general anesthesia. There is good evidence to support an opioid-minimizing, multimodal approach to post-TKA analgesia, featuring peripheral nerve blocks and/or peri-articular injection. The recently described IPACK (interspace between the popliteal artery and posterior capsule of the knee) block may address posterior knee pain after TKA. Ultrasound-guided regional analgesia techniques are cost and clinically effective. Liposomal bupivacaine represents an expanding topic of research in TKA-analgesia, but currently, data do not support routine use. Evidence to guide the creation of pathways of care for TKA abounds, but must be tailored to local practice to maximize chances of success. Recent data supports the use of neuraxial anesthesia and regional analgesia techniques for TKA. Recommendations for clinical practice and future research to improve the state of the art are provided.

A Randomized Non-Inferiority Trial of Adductor Canal Block for Analgesia After Total Knee Arthroplasty: Single Injection Versus Catheter Technique

BACKGROUND

Adductor canal blocks (ACBs) provide effective analgesia following total knee arthroplasty. We hypothesized that ACB single injection plus intravenous (IV) dexamethasone (Dex) shows non-inferiority to catheter, while ACB single injection does not.

METHODS

One hundred eighty patients were randomized and 177 analyzed from among 1 of 3 ACB interventions: (1) 0.5% ropivacaine 20 mL; (2) 0.5% ropivacaine 20 mL plus IV Dex 8 mg; (3) 0.5% ropivacaine 20 mL followed by continuous infusion of 0.2% ropivacaine at 5 mL/h for 48 hours. The primary endpoint was cumulative opioid consumption at 24 hours in oral morphine equivalents, with a non-inferiority limit of 30 mg. Secondary endpoints included opioid consumption at 12 and 48 hours, rest pain scores, quality of recovery survey, length of stay, and anti-emetic usage.

RESULTS

For 24-hour opioid consumption, single injection ACB with and without IV Dex had a mean difference of -24.2 mg (confidence interval [CI] 0.5 to -48.9, P < .001) and -21 mg (CI 3.2 to -45.1, P < .001) relative to catheter, demonstrating non-inferiority. Non-inferiority was also shown at 12 hours by Dex and single injection over catheter with mean difference of -20.4 mg (CI -6.8 to -33.9, P < .001) and -15.1 mg (CI -2.1 to -28.2, P < .001), respectively. No intergroup difference was found for 48-hour opioid consumption. No differences in other secondary outcomes were observed across the 3 groups.

CONCLUSION

Single injection ACB, with and without IV Dex, is non-inferior to ACB catheters in 24-hour opioid consumption, and may be attractive options for early-discharge, fast-track total knee arthroplasty.

Total knee arthroplasty: improving outcomes with a multidisciplinary approach

Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a multidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice.

A comparative analysis of femoral nerve block with adductor canal block following total knee arthroplasty: A systematic literature review

Background:

Patients undergoing total knee arthroplasty suffer from moderate-to-severe postoperative pain resulting in immobility-related complications and prolonged hospitalization. Femoral nerve block is associated with reduction in the quadriceps strength and increasing incidence of falls. Adductor canal block has been shown to be as effective as femoral nerve block without causing quadriceps weakness.

Objectives:

To compare outcomes of studies comparing adductor canal block and femoral nerve block in patients undergoing primary total knee arthroplasty.

Data Sources:

Original articles, published between July 2013 and April 2017, comparing the above interventions.

Study Eligibility Criteria, Participants, and Interventions:

Comparison of outcome measures of all original articles shortlisted by the PUBMED and Google Scholar databases search using key words, “adductor canal block; femoral nerve block; total knee arthroplasty; total knee replacement.”

Study Appraisal and Synthesis Methods:

The primary outcome measures reviewed were: pain scores; interventional failure; post-operative opioid consumption; patient fall or near fall during postoperative rehabilitation; and length of stay.

Results:

The opioid consumption was found to be comparable with both the interventions on the first and second postoperative day. Patients administered adductor canal block had better quadriceps power, longer ambulation distance, and shorter length of hospital stay.

Limitations:

Of the studies reviewed five were retrospective and thus data quality amongst the studies may have been compromised.

Conclusions and Implications of Key Findings:

Mobilization and ambulation, which are both important for recovery after total knee arthroplasty are both inhibited less by adductor canal block.

A matched case-control comparison of hospital costs and outcomes for knee replacement patients admitted postoperatively to acute care versus rehabilitation

For select total knee arthroplasty (TKA) patients, we have established an alternative pathway to bypass the acute care surgical ward and directly admit patients from the post-anesthesia care unit to on-campus rehabilitation. We retrospectively examined whether this 'fast track' pathway decreased costs and improved patient outcomes. After reviewing records of consecutive primary unilateral TKA patients over a 15-month period, each patient admitted to rehabilitation was matched with a control admitted to the acute care ward. The primary outcome was estimated total hospitalization cost (length of stay in days multiplied by the average cost per day). Secondary outcomes were length of stay, in-hospital pain scores, opioid use, maximum ambulatory distance and 30-day readmission, morbidity, and mortality. Of the 262 TKA patients during the study period, 14 were admitted to rehabilitation and were matched to 14 patients admitted to acute care. Estimated total hospitalization cost [median (10th-90th percentiles)] was US$30,755 (US$23,066-38,444) for ward patients compared to US$17,620 (US$13,215-33,918) for rehabilitation patients (P = 0.006). This difference [mean (95% CI)] was US$10,143 (US$2174-18,112). There were no other differences. For facilities similar to ours, direct postoperative admission of select TKA patients to subacute rehabilitation may be less costly than acute care and may not negatively affect outcomes.

Virtual reality distraction decreases routine intravenous sedation and procedure-related pain during preoperative adductor canal catheter insertion: a retrospective study

Background

Virtual reality (VR) distraction is a nonpharmacological method to prevent acute pain that has not yet been thoroughly explored for anesthesiology. We present our experience using VR distraction to decrease routine intravenous sedation for patients undergoing preoperative perineural catheter insertion.

Methods

This 1-month quality improvement project involved all elective unilateral primary total knee arthroplasty patients who received a preoperative adductor canal catheter. Clinical data were analyzed retrospectively. For the first half of the month, all patients received usual care; intravenous sedation was administered at the discretion of the regional anesthesiologist. For the second half of the month, patients were offered VR distraction with intravenous sedation upon request. The primary outcome was fentanyl dosage; other outcomes included midazolam dosage, procedure-related pain, procedural time, and blood pressure changes.

Results

Seven patients received usual care and seven used VR. In the VR group, 1/7 received intravenous sedation versus 6/7 who received usual care (P = 0.029). The fentanyl dose was lower (median [10th–90th percentiles]) in the VR group (0 [0–20] µg) versus the non-VR group (50 [30–100] µg; P = 0.008). Midazolam use was lower in the VR group (0 [0–0] mg) than in the non-VR group (1 [0–1] mg; P = 0.024). Procedure-related pain was lower in the VR group (1 [1–4] NRS) versus the non-VR group (3 [2–6] NRS; P = 0.032). There was no difference in other outcomes.

Conclusions

VR distraction may provide an effective nonpharmacological alternative to intravenous sedation for the ultrasound-guided placement of certain perineural catheters.

LOCAL PERIARTICULAR ANALGESIA IN TOTAL KNEE ARTHROPLASTY

OBJECTIVE

To evaluate the use of infiltration of periarticular analgesic agents intraoperatively in total knee arthroplasty (TKA), with regard to benefits, reduction of pain, opioid consumption, improvement of range of motion and early ambulation.

METHODS

To analyze the benefits of periarticular drug infiltration, the patients submitted to TKA were evaluated, being separated into two groups. One group received the local periarticular infiltration protocol containing 0.5% bupivacaine (400mg/20ml), 1/1000 epinephrine (0.3ml), triamcinolone hexacetonide (20mg/1ml), clonidine (150mcg/1ml) and 20 ml of saline (0.9% SS) and, the other group underwent conventional intravenous analgesia. The results were compared and the variables analyzed were age, sex, BMI, comorbidities, postoperative complications, pain, functional capacity, range of motion, transfusion and rescue opioids for analgesia.

RESULTS

The mean age of the patients was 68 years and most were female and presented involvement of the left knee. Postoperatively, patients who had received periarticular infiltration showed improvement of pain as well as functional capacity.

CONCLUSION

The analysis of data obtained demonstrated that the periarticular infiltration of analgesic agents is significantly effective for pain control and functional recovery. Level of Evidence II, Prospective Comparative Study.

Efficacy and safety of Postoperative Intravenous Parecoxib sodium Followed by ORal CElecoxib (PIPFORCE) post-total knee arthroplasty in patients with osteoarthritis: a study protocol for a multicentre, double-blind, parallel-group trial

INTRODUCTION

Total knee arthroplasty (TKA) has been regarded as a most painful orthopaedic surgery. Although many surgeons sequentially use parecoxib and celecoxib as a routine strategy for postoperative pain control after TKA, high quality evidence is still lacking to prove the effect of this sequential regimen, especially at the medium-term follow-up. The purpose of this study, therefore, is to evaluate efficacy and safety of postoperative intravenous parecoxib sodium followed by oral celecoxib in patients with osteoarthritis (OA) undergoing TKA. The hypothesis is that compared to placebo with opioids as rescue treatment, sequential use of parecoxib and celecoxib can achieve less morphine consumption over the postoperative 2 weeks, as well as better pain control, quicker functional recovery in the postoperative 6 weeks and less opioid-related adverse events during the 12-week recovery phase.

METHODS AND ANALYSIS

This study is designed as a multicentre, randomised, double-blind, parallel-group and placebo-controlled trial. The target sample size is 246. All participants who meet the study inclusion and exclusion criteria will be randomly assigned in a 1:1 ratio to either the parecoxib/celecoxib group or placebo group. The randomisation and allocation will be study site based. The study will consist of three phases: an initial screening phase; a 6-week double-blind treatment phase; and a 6-week follow-up phase. The primary end point is cumulative opioid consumption during 2 weeks postoperation. Secondary end points consist of the postoperative visual analogue scale score, knee joint function, quality of life, local skin temperature, erythrocyte sedimentation rate, C reactive protein, cytokines and blood coagulation parameters. Safety end points will be monitored too.

ETHICS AND DISSEMINATION

Ethics approval for this study has been obtained from the Ethics Committee, Peking Union Medical College Hospital, China (Protocol number: S-572) Study results will be available as published manuscripts and presentations at national and international meetings.

TRIAL REGISTRATION NUMBER

NCT02198924.