Pain Management In Total Knee Arthroplasty Research Articles

Quantifying fluid retention following modern pain management in TKA: an observational study

BackgroundBody fluid retention after major surgeries, including total knee arthroplasty (TKA), is well documented in the literature. Currently, multimodal pain control protocols consisting of several medications together with early discharge protocol may magnify this adverse event after a patient’s discharge. However, no study has focused on the quantitative and chronological changes in body fluids following modern pain management protocols for TKA. The aim of this study was to investigate the perioperative total body water (TBW) change in patient undergoing TKA.Patients and methodsA consecutive series of 85 patients undergoing primary unilateral TKA, with uniform hospital admission, multimodal pain control, and rehabilitation protocol, had five consecutive multifrequency bioelectrical impedance analysis (BIA) scans; baseline, postoperative day 1 (POD 1), postoperative day 3 (POD 3), 2 weeks, and 6 weeks. Changes in TBW, body weight, corticosteroid-fluid retention dose–response relationship, and complications were evaluated.ResultsSeventy patients completed all five scans and follow-ups. Female patients were dominant, with a mean age of 69.5 years. There were no perioperative complications. At 24 h, the mean total fluid input and output were 3695.14 mL and 1983.43 mL, respectively, with 1711.71 mL increments and a mean accumulative dosage of dexamethasone of 15.14 mg. The mean TBW increased by 2.61 L on POD 1 and continued to peak at 3.2 L on POD 3, then gradually decreased at 2 weeks and reached the baseline level at 6 weeks postoperatively. Similarly, the mean body weight increased to 2.8 kg on POD 1, reached the maximum point at 3.42 kg on POD 3, and returned to baseline at 6 weeks.ConclusionsFluid retention following multimodal pain control in TKA increased from POD 1, peaked on POD 3, and gradually returned to the baseline at 6 weeks. With early discharge protocol, patient education regarding fluid retention after discharge should be considered.

Pain management in total knee arthroplasty. A comprehensive review

Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end-stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for the perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and urine retention, which limit their application in daily clinical practice. This review aimed to discuss the current postoperative pain management regimens for TKA. Our review of literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications, including preemptive analgesia, especially local infiltration analgesia and peripheral nerve blockade. Multimodal analgesia provides superior pain relief, promotes knee recovery, and reduces opioid consumption and related adverse effects in patients undergoing TKA.

Reducing opioid usage in total knee arthroplastypostoperative pain management: a literature review and future directions.

Total knee arthroplasty (TKA) is a common orthopedic surgery performed with a projected 3.5million procedures to be done by 2030. Current postoperative pain management for TKA is insufficient, as it results in extensive opioid consumption and functional decline postoperatively. This study identifies the best practices for postoperative TKA pain management through a literature review of the last three years. Studies utilizing interventional techniques (local infiltration analgesia, nerve blocks) and pharmacologic options were reviewed on PubMed, Embase, Ovid Medline and Scopus. Primary outcomes analyzed were the effect of different analgesic approaches on pain reduction, opioid use reduction and improvements in functional mobility or quadriceps strength postoperatively. Additionally, this paper explores the use of cooled radiofrequency ablation, a minimally invasive therapy, for preoperative and postoperative TKA pain management.

Relationship of epidural patient-controlled analgesia with postoperative bleeding after unilateral total knee arthroplasty: a propensity score-matching analysis

Although epidural patient-controlled analgesia (PCA) to control postoperative pain after total knee arthroplasty (TKA), the relationship of epidural PCA with postoperative bleeding remains controversial. Therefore, we aimed to evaluate the effect of epidural and intravenous PCA on postoperative bleeding in patients undergoing unilateral TKA. Total of 2467 patients who underwent TKA were divided to intravenous PCA (n = 2339) or epidural PCA (n = 128) group. After 1:1 propensity score-matching, 212 patients were analyzed to assess the associations between the perioperative blood loss and epidural PCA between the groups. Mean postoperative blood loss was significantly greater in epidural PCA than in intravenous PCA (900.9 ± 369.1 mL vs. 737.8 ± 410.1 mL; P = 0.007). The incidence of red blood cell (RBC) administration (> 3 units) was significantly higher in epidural PCA than in intravenous PCA (30.2% vs. 16.0%; OR 2.5; 95% CI 1.201–5.205; P = 0.014). Epidural PCA may be strongly related to postoperative bleeding and the incidence of RBC transfusion of more than 3 units after unilateral TKA, as compared to intravenous PCA. Therefore, the use of epidural PCA may be carefully considered for postoperative pain management in TKA.

Administration with corticosteroid relieving pain following total knee arthroplasty: A meta-analysis.

Background:This meta-analysis compares the effectiveness of corticosteroid in relieving pain and inflammation in total knee arthroplasty (TKA) patients.Method:Randomized controlled trials in PubMed (1996 to March 2020), Embase (1996 to March 2020), and the Cochrane Library (CENTRAL, March 2020) compared corticosteroid and placebo in pain in TKA patients were identified by a software and manual searching. The risk of bias and clinical relevance of the included studies were assessed. Sensitivity analysis was performed by omitting each study in turn. The major outcomes of the studies were analyzed by the Stata 12.0.Results:13 randomized controlled trials that involved 193 patients were included in the present meta-analysis. The results of the study revealed a significantly lower visual analog scale (VAS) score of pain at rest in the corticosteroid group (12 hours: weighted mean difference (WMD)=−1.35, P = .005; 24 hours: WMD=−1.11, P = .000; 48 hours: WMD=−0.31, P = .000; 72 hours: WMD = −0.30, P = .000). And Postoperative VAS scores during mobilization at 12 hours and 24 hours were significantly lower at corticosteroid group when compared with control group (12 hours: WMD = −0.81, P = 0.000; 24 hours: WMD = −1.66, P = .018). Meta-analyses show that administration of corticosteroid can reduce the length of hospital stay, incidence nausea and the C-reactive protein level. While no significant difference was observed in the VAS scores during mobilization at 48 hours and 72 hours and total morphine consumption (P > .05).Conclusions:Compared to the control group, intraoperative corticosteroid was benefit to the pain management in TKA. However, more high-quality studies are still warranted to further validate our findings, considering there are several limitations in this meta-analysis.

Postoperative Pain Management in Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end‐stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient‐controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.

Construction and effect evaluation of pain control quality system in patients with total knee arthroplasty

Objective To establish, implement and evaluate the pain control quality system for patients with total knee arthroplasty (TKA) . Methods Through literature search and interviews with medical staff and retrospective reviews of TKA cases in orthopedic wards, the problems in pain control of TKA patients during perioperative period were analyzed. According to the evidence-based practice guideline and the existing problems in pain nursing practice, the pain control quality system was constructed. From January to November 2018, 75 TKA patients in Orthopedic Department, Ningbo First Hospital were selected as the research objects and randomly divided into the control group (n=35) and the intervention group (n=40) . The control group received the routine pain nursing mode, and the intervention group was managed by the pain control quality system. The static and dynamic VAS scores on the 1st, 3rd and 7th day after TKA, the incidence of analgesia-related complications and the quality of pain nursing were compared between the two groups. Results There were significant statistical differences in static and dynamic VAS scores of knee joint between the two groups on the 1st, 3rd and 7th day after operation (P 0.05) . The total score of TKA perioperative pain nursing quality in the intervention group was 84 (80, 85) , while that of the control group was 56 (53, 58) . The difference between the two groups was statistically significant (P<0.01) . Conclusions The construction of pain control quality system can effectively improve the level of perioperative pain management of TKA, the quality of pain nursing care, and improve the perioperative pain of TKA patients. Key words: Arthroplasty, replacement; Knee joint; Perioperative nursing; Pain; Quality control

Pain relieve without impairing muscle function after local infiltration anaesthesia in primary knee arthroplasty: a prospective randomized study.

Purpose of the current study was to compare early effectiveness of pain relieve of 3 in 1 regional pain catheter to local infiltration anesthesia (LIA) in primary total knee arthroplasty (TKA). Secondary endpoint was quadriceps muscle strength after both procedures. A single-center, prospective, randomized controlled trial was performed. Patients eligible to TKA were either randomized into group 3 in 1 regional pain catheter (C), or group local infiltration anesthesia (L). Pain relieve was assessed by visual analogue scale (VAS) at rest and under physical activity (PA) prior to surgery (t0) and at days one through six. In addition, quadriceps muscle strength ( = straight leg raise) was tested according to the Manual Muscle Testing Scale. Functional outcome was measured using the Oxford Knee Score (OKS) preoperatively and 6months postoperatively. 121 patients were included in the study. 59 (48.8%) patients were allocated to group C, 62 (51.2%) patients to Group L. No differences concerning pain level evaluated by VAS could be detected between the groups at any time. Comparing straight leg raise test group L was significantly superior over the complete postoperative period (p < 0.03). The mean OKS decreased significantly (p < 0.001) from preoperatively 34.2 ± 7.5 points to 16.9 ± 6.0 points at the six months final follow-up. Regarding OKS there were no intergroup differences at the final follow-up at 6months postoperative. There is no significant difference in pain relieve comparing LIA to 3 in 1 catheter in perioperative pain management in TKA. The advantage of LIA is unimpaired quadriceps muscle function in the short-term follow-up.

Pain management in total knee arthroplasty by intraoperative local anesthetic application and one-shot femoral block.

Background:Pain after total knee arthroplasty (TKA) is a big problem in orthopaedic surgery. Although opioids and continuous epidural analgesia remain the major options for the postoperative pain management of TKA, they have some undesirable side effects. Epidural analgesia is technically demanding, and the patient requires close monitoring. Different types of local anesthetic applications can successfully treat TKA pain. Local anesthetics have the advantage of minimizing pain at the source. This study investigates the efficacy of different local anesthetic application methods on early, (1st day) pain control after total knee arthroplasty.Materials and Methods:200 patients who underwent unilateral TKA surgery under spinal anesthesia were randomly assigned into four different groups (fifty in each group) and were administered pain control by different peri- and postoperative regimens. Group A was the control group wherein no postsurgical analgesia was administered to assess spinal anesthesia efficacy; in Group B, only postsurgical one-shot femoral block was applied; in Group C, intraoperative periarticular local anesthetic was applied; in Group D, a combination of the one-shot femoral block and intraoperative periarticular local anesthetics were applied. Demographic data consisting of age, weight, gender and type of deformity of patients were collected. The data did not differ significantly between the four groups.Results:Group D patients experienced significantly better postoperative pain relief (P < 0.05) and were therefore more relaxed in pain (painless time, VAS score) and knee flexion (degrees) than the other patient groups in the 1st postoperative day followup. Painless time of Group D was 10.5 hours and was better than Group C (6.8 hours), Group B (6.2 hours) and Group A (3.0 hours) (P < 0.05). Group A got the best pain Vas score degrees in the 1st postoperative day which showed the success of combined periarticülar local anesthetic injection and femoral nerve block.Conclusion:The intraoperative periarticular application of local anesthetics in addition to one-shot femoral block is an efficient way of controlling postsurgical pain after TKA.

Intravenous Acetaminophen in Multimodal Pain Management for Patients Undergoing Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

BackgroundAlthough multimodal pain management including periarticular multidrug injection can provide excellent pain relief in the early postoperative period after total knee arthroplasty (TKA), rebounding pain remains an important challenge. A randomized, double-blind, placebo-controlled trial was performed to investigate the efficacy of adding intravenous acetaminophen to multimodal pain management for TKA. MethodsWe enrolled 67 patients scheduled for unilateral TKA. Patients were randomly assigned to receive either 1000 mg of intravenous acetaminophen at 6-hour intervals or normal saline at the same intervals. All patients were treated with intraoperative periarticular multidrug injection and intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome was the postoperative 100-mm visual analog pain scale at the time of administration of study drugs. ResultsIn the intention-to-treat analysis, the pain score was significantly better in the intravenous acetaminophen group than the placebo group at 17:00 one day after TKA (15.3 ± 17.0 mm vs 26.8 ± 19.0 mm; P = .013). There were no significant differences in terms of the rate of complications between groups. ConclusionEven in the setting of multimodal pain management including periarticular multidrug injection, intravenous acetaminophen provided better pain relief for patients undergoing unilateral TKA.

Overview of Total Knee Arthroplasty and Modern Pain Control Strategies.

Perioperative pain management of total knee arthroplasty (TKA) remains a challenge for physicians and anesthesiologists. Reducing postoperative pain is an essential component of patient satisfaction, functional outcomes, and hospital length of stay. Multimodal pain management regimens have been demonstrated to be superior to monotherapy in achieving adequate pain control, as well as an effective method of limiting side effects of analgesics. In the present investigation, we present literature published over the last year relating to new advancements in perioperative pain management for TKA. While it is widely accepted that methods including peripheral nerve blocks and local anesthetic injections are essential to pain protocols, there is still conflicting evidence over what modalities provide superior relief. The incorporation of cryoneurolysis preoperatively is a new modality which has been incorporated and has been shown to improve pain control in patients undergoing TKA.

Infiltration analgésique locale versus bloc nerveux fémoral dans la prothèse totale de genou : une méta-analyse

IntroductionLocal infiltration analgesia (LIA) and femoral nerve block (FNB) are both used for the pain management after total knee arthroplasty (TKA). Controversy still remains regarding the optimal technique for pain relief in patients undergoing TKA. The purpose of this meta-analysis was to compare the analgesia achieved with LIA and the one from FNB following TKA. HypothesisLIA achieves better pain control than FNB in patients with TKA. MethodsDatabases including Pubmed, EMBASE, the Cochrane Library and Web of Science were comprehensively searched to identify studies comparing LIA with FNB for patients with TKA. Two reviewers independently selected trials, extracted data, and assessed the methodological qualities of included studies. Data were analyzed by RevMan 5.2. ResultsNine RCTs involving 782 patients were included. LIA achieved more rapid pain relief (VAS) at 6h postoperatively [SMD6 h=−0.92, 95 %CI (−1.38, −0.47)] than FNB. There were no significant differences at 24 and 48h [SMD24 h=− 0.03, 95 %CI (−0.46, 0.40); SMD48 h=0.28, 95 %CI (−0.35, 0.91)], VAS with activity at 24 and 48h [SMD6 h=−0.54, 95 %CI (−1.62, 0.54); SMD24 h=−0.22, 95 %CI (−1.41, 0.96); SMD48 h=−0.08, 95 %CI (−0.52, 0.69)], opioid consumption at 24 and 48h [SMD24 h=−0.24, 95 %CI (−0.82, 0.34); SMD48 h=0.15, 95 %CI (0.25, 0.54)] and length of hospital stay [MD=−0.52, 95 % CI (−1.13, 0.09)]. DiscussionLIA may be the better choice in the pain management of TKA for it could achieve fast pain relief and is easier to perform than FNB for patients with TKA. Level of evidenceLevel II, meta-analysis and systematic review.

Local infiltration analgesia versus femoral nerve block in total knee arthroplasty: A meta-analysis

IntroductionLocal infiltration analgesia (LIA) and femoral nerve block (FNB) are both used for the pain management after total knee arthroplasty (TKA). Controversy still remains regarding the optimal technique for pain relief in patients undergoing TKA. The purpose of this meta-analysis was to compare the analgesia achieved with LIA and the one from FNB following TKA. HypothesisLIA achieves better pain control than FNB in patients with TKA. MethodsDatabases, including Pubmed, EMBASE, the Cochrane Library and Web of Science were comprehensively searched to identify studies comparing LIA with FNB for patients with TKA. Two reviewers independently selected trials, extracted data, and assessed the methodological qualities of included studies. Data were analyzed by RevMan 5.2. ResultsNine RCTs involving 782 patients were included. LIA achieved more rapid pain relief (VAS) at 6h postoperatively [SMD6h=−0.92, 95% CI (−1.38, −0.47)] than FNB. There were no significant differences at 24h and 48h [SMD24h=−0.03, 95% CI (−0.46, 0.40); SMD48h=0.28, 95% CI (−0.35, 0.91)], VAS with activity at 24h and 48h [SMD6h=−0.54, 95% CI (−1.62, 0.54); SMD24h=−0.22, 95% CI (−1.41, 0.96); SMD48h=−0.08, 95% CI (−0.52, 0.69)], opioid consumption at 24h and 48h [SMD24h=−0.24, 95% CI (−0.82, 0.34); SMD48h=0.15, 95% CI (0.25, 0.54)] and length of hospital stay [MD=−0.52, 95% CI (−1.13, 0.09)]. DiscussionLIA may be the better choice in the pain management of TKA for it could achieve fast pain relief and is easier to perform than FNB for patients with TKA. Level of evidenceLevel II, meta-analysis and systematic review.