DOS BULLETIN - Dansk Ortopædisk Selskab
DOS BULLETIN - Dansk Ortopædisk Selskab DOS BULLETIN - Dansk Ortopædisk Selskab
2010-378_DOS nr. 3 2010 29/09/10 10:08 Side 136 Effect of Preoperative Methylprednisolone on Pain and Recovery after Total Knee Arthroplasty: A Randomized, Double-blind, Placebo-controlled Trial Troels H. Lunn, Henrik Husted, Kristian Stahl Otte, Billy B Kristensen, Lasse Ø Andersen, Lasse Ø Andersen, Henrik Kehlet Dep. of anaesthesiology & Dep. of Orthopedics, Hvidovre University Hospital, Dep. of surgical pathophysiology, Rigshospitalet Background: Several postoperative clinical symptoms including pain are related to the inflammatory stress response caused by the surgical trauma. Glucocorticoids may provide positive analgesic effects by suppressing the inflammatory response as demonstrated in many procedures. Unfortunately, no data exists in total knee arthroplasty (TKA), where inflammation and pain is dominant. Purpose: We hypothesized that a single, high- dose of methylprednisolone (MP) would improve acute, postoperative analgesia after TKA. Methods: Patients scheduled for unilateral, primary TKA were consecutively included in a randomized, double-blind, placebo- controlled trial receiving preoperative MP 125 mg IV or placebo (saline). The primary endpoint was pain after walking 5 meters, and secondary endpoints were pain at rest, pain upon 45° flexion of the hip with the leg straight, and pain upon 45 ° knee flexion. Assessment was performed preoperatively and 2, 4, 6, 24, 28, 32 and 48h after surgery, and in a questionnaire from day 2 to 10, and at follow up on day 21 and day 30. Tertiary endpoints were postoperative nausea and vomiting (PONV), C-reactive protein (CRP), sleep quality, fatigue, rescue analgesic- and antiemetic requirements, length of stay (LOS) and side effects. Findings: Forty-eight included patients (24 in each group) all completed the trial. Pain scores were significantly lower in the MP group up to 32h postoperatively. Summarized pain scores (2-48h) were lower for all assessments: pain after walking (p=0.0002); pain at rest (p=0.002); pain upon flexion of the hip (p=0.016); and pain upon knee flexion (p=0.001). Fewer patients required rescue sufentanil in the PACU (p=0.017) and oxycodone requirement was lower from 0- 24h (p=0.012). PONV-frequency and consumption of antiemetic was reduced (p
2010-378_DOS nr. 3 2010 29/09/10 10:08 Side 137 Local infiltration analgesia for acute pain relief in hip arthroplasty: Do we need it? A randomized, doubleblind, placebo-controlled trial in 120 patients Troels H. Lunn, Henrik Husted, Søren Solgaard Kristian Stahl Otte, Anne Grete Kjersgaard, Henrik Kehlet Arthroplasty Section, Department of Orthopaedics, Hvidovre Hospital, Denmark; Hip Clinic, Hørsholm Hospital, Department of Orthopaedics, Hillerød Hospital, Denmark; Section for Surgical Pathophysiology, Rigshospitalet Background: High-volume local infiltration analgesia (LIA) is widely applied as part of a multimodal pain management strategy in total hip arthroplasty (THA). However, methodological problems hinder exact interpretation of previous trials, and the evidence for LIA in THA is questionable. Purpose: We aimed to evaluate if intraoperative high-volume LIA, in addition to a multimodal oral analgesic regime, would further reduce acute postoperative pain after THA. Methods: Ethics committee approval was granted. One hundred twenty patients scheduled for unilateral, primary THA using spinal anaesthesia were included in this randomized, double-blind, placebo- controlled trial receiving high-volume (150 ml) infiltration with ropivacaine 0.2% with epinephrine (10µg ml-1) or saline 0.9% in the wound intraoperatively. The multimodal oral analgesic regime was instituted preoperatively and consisted of slow release acetaminophen 2g, celecoxib 400mg and gabapentin 600mg. Rescue analgesic consisted of oral oxycodone. The primary endpoint was pain during walking (5 meters) up to 8h after surgery. Secondary endpoints were pain at rest, pain upon 45° flexion of the hip with straight leg and cumulated consumption of oxycodone. Pain was assessed repeatedly the first 8h after surgery using the 100mm visual analog scale. Non-parametric statistics with post hoc Bonferroni correction for repeated measures was applied. Findings: Pain scores were low for all pain assessments (median around 20 mm) and did not differ between the ropivacaine and the placebo group (p>0.05). Consumption of rescue oxycodone and summarized (added) pain scores (2-8h) did not differ between groups (p>0.05). Conclusion: This study demonstrated that a multimodal oral analgesic regime with gabapentin, celecoxib and acetaminophen caused low acute postoperative pain following THA, and LIA did not further improve analgesia. Positive results reported in previous trials may be due to a systemic analgesic effect of NSAID added to the LIA-mixture (but not in the control group). We cannot rule out that LIA may have an analgesic effect with a less comprehensive oral regime or in selected patients (high pain responders). 137
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2010-378_<strong>DOS</strong> nr. 3 2010 29/09/10 10:08 Side 137<br />
Local infiltration analgesia for acute pain relief in hip<br />
arthroplasty: Do we need it? A randomized, doubleblind,<br />
placebo-controlled trial in 120 patients<br />
Troels H. Lunn, Henrik Husted, Søren Solgaard Kristian Stahl Otte,<br />
Anne Grete Kjersgaard, Henrik Kehlet<br />
Arthroplasty Section, Department of Orthopaedics, Hvidovre Hospital,<br />
Denmark; Hip Clinic, Hørsholm Hospital, Department of<br />
Orthopaedics, Hillerød Hospital, Denmark;<br />
Section for Surgical Pathophysiology, Rigshospitalet<br />
Background: High-volume local infiltration analgesia (LIA) is widely applied<br />
as part of a multimodal pain management strategy in total hip arthroplasty<br />
(THA). However, methodological problems hinder exact interpretation of previous<br />
trials, and the evidence for LIA in THA is questionable.<br />
Purpose: We aimed to evaluate if intraoperative high-volume LIA, in addition<br />
to a multimodal oral analgesic regime, would further reduce acute postoperative<br />
pain after THA.<br />
Methods: Ethics committee approval was granted. One hundred twenty patients<br />
scheduled for unilateral, primary THA using spinal anaesthesia were included<br />
in this randomized, double-blind, placebo- controlled trial receiving high-volume<br />
(150 ml) infiltration with ropivacaine 0.2% with epinephrine (10µg ml-1)<br />
or saline 0.9% in the wound intraoperatively. The multimodal oral analgesic<br />
regime was instituted preoperatively and consisted of slow release acetaminophen<br />
2g, celecoxib 400mg and gabapentin 600mg. Rescue analgesic consisted<br />
of oral oxycodone. The primary endpoint was pain during walking (5 meters) up<br />
to 8h after surgery. Secondary endpoints were pain at rest, pain upon 45° flexion<br />
of the hip with straight leg and cumulated consumption of oxycodone. Pain<br />
was assessed repeatedly the first 8h after surgery using the 100mm visual analog<br />
scale. Non-parametric statistics with post hoc Bonferroni correction for<br />
repeated measures was applied.<br />
Findings: Pain scores were low for all pain assessments (median around 20<br />
mm) and did not differ between the ropivacaine and the placebo group (p>0.05).<br />
Consumption of rescue oxycodone and summarized (added) pain scores (2-8h)<br />
did not differ between groups (p>0.05).<br />
Conclusion: This study demonstrated that a multimodal oral analgesic regime<br />
with gabapentin, celecoxib and acetaminophen caused low acute postoperative<br />
pain following THA, and LIA did not further improve analgesia. Positive results<br />
reported in previous trials may be due to a systemic analgesic effect of NSAID<br />
added to the LIA-mixture (but not in the control group). We cannot rule out that<br />
LIA may have an analgesic effect with a less comprehensive oral regime or in<br />
selected patients (high pain responders).<br />
137