Effect of high-dose preoperative methylprednisolone on recovery after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: High-dose glucocorticoid may reduce postsurgical pain and improve recovery. We hypothesized that 125 mg methylprednisolone (MP) would reduce time to meet functional discharge criteria after total hip arthroplasty (THA). METHODS: Forty-eight patients undergoing unilateral THA under spinal anaesthesia were consecutively included in this randomized, double-blind, placebo-controlled trial receiving preoperative i.v. MP or saline. All patients received a standardized, multimodal analgesic regime with paracetamol, celecoxib, and gabapentin. The primary outcome was time to meet well-defined functional discharge criteria. Secondary outcomes were handgrip strength and endurance, pain, nausea, vomiting, fatigue, sleep quality, and rescue analgesic-, antiemetic-, and hypnotic medicine requirements. The inflammatory response measured by C-reactive protein (CRP) and actual length of stay were also registered. Discharge criteria were assessed twice daily (at 09:00 and 14:00 h) until discharge. Other outcomes were assessed at 2, 4, 6, 8, and 24 h after operation, and also in a questionnaire from postoperative day (POD) 1-4. RESULTS: Time to meet discharge criteria was [median (IQR) (95% CI), MP vs placebo]: 23.5 (23.3-23.7) (17.8-43.8) vs 23.5 (23.0-23.8) (20.0-46.8) h, the mean difference (95% CI) being -1.3 (-4.7 to 2.2) h, P=0.65. Overall pain for the first 24 h after surgery was significantly reduced in the MP vs the placebo group (P<0.01), as was CRP at 24 h (P<0.0001). No other between-group differences were observed. No drug-related complications were observed at follow-up on POD30. CONCLUSIONS: MP 125 mg i.v. before surgery added to a multimodal oral analgesic regime did not reduce time to meet functional discharge criteria after THA, but improved analgesia for the first 24 h.

Possible effects of mobilisation on acute post-operative pain and nociceptive function after total knee arthroplasty.

BACKGROUND: Experimental studies in animals, healthy volunteers, and patients with chronic pain suggest exercise to provide analgesia in several types of pain conditions and after various nociceptive stimuli. To our knowledge, there is no data on the effects of exercise on pain and nociceptive function in surgical patients despite early mobilisation being an important factor to enhance recovery. We therefore investigated possible effects of mobilisation on post-operative pain and nociceptive function after total knee arthroplasty (TKA). METHODS: Thirty patients undergoing TKA under standardised anaesthesia and analgesia underwent an exercise (mobilisation) strategy on the first post-operative morning consisting of 25-m walking twice, with a 20-min interval. Pain was assessed at rest and during passive hip and knee flexion before, and 5 and 20 min after walk, as well as during walk. Nociceptive function (pain threshold and tolerance) was assessed with pressure algometry and an electrical stimulus. RESULTS: Pain at rest (supine) and during hip and knee flexion was significantly reduced 5 min (P < 0.03) and 20 min (P < 0.003) after walk compared with before walk, and pain was reduced during the second walk compared with the first walk (P < 0.034). Knee pain pressure threshold (P = 0.002) but not tolerance (P = 0.27) was increased following walk compared with before walk. CONCLUSION: This first exploratory hypothesis-generating pilot study suggests mobilisation to promote analgesic effects after TKA calling for future studies with a randomised, controlled design on exercise dose-response effects in post-surgical patients.

Post-anaesthesia care unit stay after total hip and knee arthroplasty under spinal anaesthesia.

BACKGROUND: Post-anaesthesia care unit (PACU) admission must be well founded and the stay as short as possible without compromising patient safety. However, within the concept of fast-track surgery, studies are limited in addressing the question: why are patients staying in the PACU? METHODS: All patients operated with primary unilateral total hip or knee arthroplasty (THA or TKA) under spinal anaesthesia were included in this hypothesis-generating, prospective, observational cohort study during a 4-month period. Surgical technique, analgesia, and perioperative care were standardized. Well-defined PACU discharge criteria that had to be met on two successive assessments were evaluated every 15 min until discharge. The primary outcome was time to meet PACU discharge criteria. Secondary outcomes were actual discharge time from the PACU, specific factors detaining patients in the PACU, and potential complications at the surgical ward at follow-up 24 h post-operatively. RESULTS: One hundred sixty-three patients were included in the final analysis (69 THA and 94 TKA). Time to meet PACU discharge criteria was [median (interquartile range)(95% confidence interval)]: 15 min (15-15)(15-116) for THA and 15 min (15-15)(15-75) for TKA. Actual discharge time from PACU was: 25 min (20-35)(16-198) for THA and 25 min (20-31)(15-107) for TKA. Reasons for not meeting PACU discharge criteria in 15 min were mainly low oxygen saturation and pain. The short stay in the PACU did not impose complications at the surgical ward. CONCLUSION: The vast majority of patients (> 85%) operated with THA and TKA under low-dose spinal anaesthesia may achieve pre-defined PACU discharge criteria in 15 min. Large-scale studies should be performed to evaluate safety aspects after short PACU stay.

Effect of high-dose preoperative methylprednisolone on pain and recovery after total knee arthroplasty: a randomized, placebo-controlled trial.

BACKGROUND: Total knee arthroplasty (TKA) is associated with severe pain and inflammation despite an extensive multimodal analgesic approach, but the effect of high-dose glucocorticoid administration has not been studied. METHODS: Forty-eight patients undergoing unilateral TKA were included in a randomized, double-blind, placebo-controlled trial receiving preoperative methylprednisolone (MP) 125 mg i.v. or saline. All surgery was performed under lumbar spinal anaesthesia and patients received a standardized, multimodal analgesic regime. The primary endpoint was pain during walking 24 h after surgery, and secondary endpoints were pain at rest, pain upon hip flexion, and pain upon knee flexion. Pain assessments were performed repeatedly for the first 48 h after surgery, in a questionnaire from days 2 to 10, and at follow-up on days 21 and 30. Tertiary endpoints were postoperative nausea and vomiting (PONV), plasma C-reactive protein (CRP) concentrations, fatigue, sleep quality, and rescue analgesic and antiemetic requirements. RESULTS: Pain during walking was significantly lower in the MP group up to 32 h after operation. Overall pain and cumulative pain scores (2-48 h) were lower for all pain assessments (P<0.04). Consumption of rescue oxycodone was lower from 0 to 24 h (P=0.02) and PONV, consumption of ondansetron reduced (P<0.05), and CRP concentrations were lower at 24 h (P<0.000001). Fatigue throughout the day of surgery was lower (P=0.02), but sleep quality was worse on the first night (P=0.002). No side-effects or complications were observed in other respects. CONCLUSIONS: MP 125 mg before surgery improves analgesia and immediate recovery after TKA, even when combined with a multimodal analgesic regime. These findings call for further studies on safety aspects.

Analgesic efficacy of intracapsular and intra-articular local anaesthesia for knee arthroplasty.

The optimal site for wound delivery of local anaesthetic after total knee arthroplasty is undetermined. Sixty patients having total knee arthroplasty received intra-operative infiltration analgesia with ropivacaine 0.2% and were then were randomly assigned to receive either intracapsular or intra-articular catheters with 20 ml ropivacaine 0.5% given at 6 h and again at 24 h, postoperatively. Analgesic efficacy was assessed for 3 h after each injection, using a visual analogue score, where 0 = no pain and 100 = worst pain. There was no statistically significant difference between groups. Maximum pain relief (median (IQR [range])) at rest observed in the 3 h after the 6 and 24 h postoperative injections was 17 (7-31 [0-80]) and 10 (4-27 [0-50]) p = 0.27 for 6-9 h; and 17 (7-33 [0-100]) and 13 (3-25 [0-72]) p = 0.28 for 24-27 h, for intracapsular and intra-articular, respectively. Intracapsular local anaesthetic has similar analgesic efficacy to intra-articular after total knee arthroplasty.

Analgesic efficacy of local anaesthetic wound administration in knee arthroplasty: volume vs concentration.

Wound administration of local anaesthetic may be effective for postoperative pain management in knee arthroplasty, but the analgesic efficacy of local anaesthetic in relation to volume vs concentration has not been determined. In a double-blinded trial, 48 patients scheduled for total knee arthroplasty were randomly assigned to receive either a high volume/low concentration solution of ropivacaine (20 ml, 0.5%) or a low volume/high concentration solution of ropivacaine (10 ml, 1%), 6 and 24 h postoperatively through an intracapsular catheter. Pain was assessed for 2 h after administration. Pain was reduced in both groups with ropivacaine administration 24 h postoperatively (p < 0.02), but with no difference in analgesia between groups at all time intervals. No reduction in pain scores was observed with ropivacaine injection 6 h postoperatively. The median (IQR [range]) dose of oxycodone administered was 12.5 (10-19 [0-35]) mg in the high volume/low concentration group, and 20 mg (16-40 [0-65]) mg in the low volume/high concentration group (p = 0.005). In conclusion, intracapsular administration of local anaesthetic may have limited analgesic efficacy with no volume vs concentration relationship after total knee arthroplasty.

Analgesic efficacy of subcutaneous local anaesthetic wound infiltration in bilateral knee arthroplasty: a randomised, placebo-controlled, double-blind trial.

BACKGROUND: High-volume wound local infiltration analgesia is effective in knee arthroplasty, but the analgesic efficacy of subcutaneous wound infiltration has not been evaluated. METHODS: In a randomised, double-blind, placebo-controlled trial in 16 patients undergoing bilateral knee arthroplasty with high-volume local infiltration analgesia in the deeper layers, saline or ropivacaine 2 mg/ml was infiltrated into the subcutaneous part of the wound in each knee along with the placement of multi-fenestrated catheters in the subcutaneous wound layers in both knees. Pain was assessed for 6 h post-operatively and for 3 h after a bolus injection given through the catheter 24 h post-operatively. RESULTS: Visual analogue scale (VAS) pain scores were significantly lower from the knee infiltrated with ropivacaine compared with the knee infiltrated with saline in the subcutaneous layer of the wound, at rest (P<0.02), with flexion of the knee (P<0.04) and when the leg was straight and elevated (P<0.04). Twenty-four hours post-operatively, a decline in the VAS pain scores was observed in both groups, with no statistically significant difference between injection of ropivacaine or saline in the subcutaneously placed catheters (P>0.05). CONCLUSION: As part of a total wound infiltration analgesia intraoperative subcutaneous infiltration with ropivacaine in bilateral total knee arthroplasty is effective in early post-operative pain management, while a post-operative subcutaneous bolus administration through a multiholed catheter 24 h post-operatively did not show improved analgesia compared with the administration of saline.

Subacute pain and function after fast-track hip and knee arthroplasty.

In a well-defined fast-track setup for total hip and knee arthroplasty, with a multimodal analgesic regimen consisting of intra-operative local anaesthetic infiltration and oral celecoxib, gabapentin and paracetamol for 6 days postoperatively, we conducted a prospective, consecutive, observational study. The purpose was to describe the prevalence and intensity of subacute postoperative pain and opioid related side effects, use of analgesics and functional ability 1-10 and 30 days postoperatively. Fast-track total hip and knee arthroplasty with early discharge (< 3 days) resulted in acceptable levels of pain and postoperative nausea and vomiting with concomitant low use of opioids in > 95% of patients after discharge before day 10 after total hip arthroplasty. However, after total knee arthroplasty 52% patients reported moderate pain (VAS 30-59 mm), and 16% severe pain (VAS > or = 60 mm) when walking 1 month after surgery with a concomitant increase in the use of strong opioids. These results emphasise the need for improvement in analgesia after discharge following total knee arthroplasty, to facilitate rehabilitation.