Tramadol or fentanyl analgesia for ambulatory knee arthroscopy

Effects of a synovial fluid substitute on early recovery after arthroscopic subacromial decompression of the shoulder

PURPOSE

The purpose of this pilot study was to determine whether the use of a synovial fluid substitute (Viscoseal) after arthroscopic subacromial decompression (ASD) of the shoulder was safe (primary outcome) and effective in reducing the postsurgical pain on the day of surgery and the time from surgery to discharge (secondary outcomes), compared with patients undergoing standard ASD alone.

METHODS

Forty-six patients with primary isolated shoulder subacromial impingement were randomly assigned to either undergo SAD alone (control group: n = 21) or to receive 10 ml Viscoseal into the subacromial space at the end of the procedure (treatment group: n = 25).

RESULTS

No adverse events were reported in either group. All clinical scores improved significantly in each group from preoperative to 12-week follow-up (p < 0.01). The Viscoseal group experienced significantly (p = 0.001) less severe pain 4 h after the surgery {mean 54.0 ± 43.1, median 50 [interquartile range (IQR) 0-100]} and shorter time from surgery to discharge [mean 5.2 ± 1.4, median 5 (IQR 4-6)] than the control group [mean 102.4 ± 40.2, median 100 (IQR 50-150) and mean 11.0 ± 5.3, median 12 (IQR 6-16), respectively]. The Viscoseal group also required less analgesia postoperatively than the control group in the first 8 h: 24% of the Viscoseal required no analgesia, while all patients in the control group required analgesia; 24% of the control group required opiates compared with 4% in the Viscoseal group.

CONCLUSION

Viscoseal was safe and well tolerated after shoulder arthroscopy. It provided excellent pain relief and a faster discharge time after ASD of the shoulder. The use of Viscoseal should be investigated in larger randomized controlled trials and for other shoulder arthroscopy procedures.

LEVEL OF EVIDENCE

Level II, Pilot Prospective Comparative Study.

The addition of tramadol to morphine via patient-controlled analgesia does not lead to better post-operative pain relief after total knee arthroplasty

BACKGROUND

Tramadol is used as an analgesic in post-operative pain treatment. Intravenous tramadol is often combined with morphine to achieve better pain relief and less side-effects after orthopaedic surgery. However, the available evidence is insufficient to support this combination. For this reason, we conducted the present non-commercial, randomized, double-blind clinical trial.

METHOD

Sixty-three patients with osteoarthritis of the knee, selected for primary total knee arthroplasty (TKA), were randomized to receive saline or tramadol 100 mg/ml intravenously every 6 h during the first post-operative day (total, 400 mg/24 h). All patients had access to morphine via a patient-controlled analgesia (PCA) pump.

RESULTS

Neither during the 6 h after the first dose nor during the first post-operative day could we detect any statistically significant difference with regard to pain intensity, sedation and nausea between patients treated with tramadol and the placebo group. However, the withdrawal rate caused by insufficient pain relief was greater in the tramadol group (7/31) than in the saline group (2/32). This difference did not reach statistical significance. In the group of patients who remained in the study for 24 h ('per protocol'), those randomized to receive tramadol had a significantly (P < 0.05) lower morphine consumption (20 mg or 31%) than the placebo group.

CONCLUSION

Our study does not support the combination of tramadol and morphine via PCA for post-operative pain relief after primary TKA. In addition, our study indicates that morphine via PCA as the sole means of post-operative analgesia does not provide sufficient pain relief after TKA. Thus, other means of post-operative analgesia should be used following TKA.