Literature Reviews

Procedure-specific systematic review summary

Bibliography

Total Knee Arthroplasty

Ong et al 2005

The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis.

Ong CK, Lirk P, Seymour RA, Jenkins BJ.

Anesth Analg 2005;100(3):757–73


Eggers et al 1999

Effect of oral and i.v. tenoxicam in postoperative pain after total knee replacement.

Eggers KA, Jenkins BJ, Power I

British Journal of Anaesthesia 1999;83(6):876–81

We have evaluated the effect of oral and i.v. tenoxicam on postoperative pain after unilateral total knee replacement in a double-blind, randomized, controlled study. Tenoxicam was administered to two groups of patients, either before (40 mg orally) or after (40 mg i.v.) surgery, then at 24 h after surgery (40 mg i.v.) and at the end of each day for 8 days (20 mg orally). A third group were given placebo at all times. All patients had access to PCA morphine for the first 48 h and then co-dydramol tablets for the duration of the study. We studied 101 patients, mean age 67 yr. There was no significant reduction in the requirement for PCA morphine for the duration of the study in either of the treatment groups, or for co-dydramol in the first 2 days, but tenoxicam significantly reduced the need for co-dydramol over the remaining 7 days. There were no significant differences in mobility between groups. There was a high incidence of adverse events reported, with a similar number in each of the three groups.


An et al 1991

Effects of hypotensive anesthesia, nonsteroidal antiinflammatory drugs, and polymethylmethacrylate on bleeding in total hip arthroplasty patients.

An HS, Mikhail WE, Jackson WT, Tolin B, Dodd GA.

J Arthroplasty 1991;6(3):245–250.

One hundred forty patients ranging in age from 26 to 88 years, who had primary total hip arthroplasty (performed by the same surgeon and lateral surgical approach), were analyzed for intraoperative and postoperative blood loss. The factors affecting blood loss, which include bleeding disorders, medications, duration of surgery, the mean intraoperative blood pressure, and use of cement, were all recorded. A significant reduction in the intraoperative blood loss was observed in the group of patients with hypotensive anesthesia (greater than 20 mmHg drop in the mean intraoperative blood pressure using inhalation anesthetics) compared to the group of patients who did not have hypotensive anesthesia. The patients who had been on aspirin or nonsteroidal antiinflammatory drugs prior to surgery had increased intraoperative and postoperative blood loss compared to the patients who did not take such medications. The effect of cementing with methylmethacrylate on bleeding was also observed; the patients with uncemented implants had a greater blood loss after operation than the patients who had cemented prosthetic components.


Greenberg et al 2000

A new cyclooxygenase-2 inhibitor, rofecoxib (VIOXX), did not alter the antiplatelet effects of low-dose aspirin in healthy volunteers.

Greenberg HE, Gottesdiener K, Huntington M, Wong P, Larson P, Wildonger L, Gillen L, Dorval E, Waldm

J Clin Pharmacol 2000;40(12 Pt 2):1509–1515.

The present study examined whether rofecoxib (VIOXX), a new specific inhibitor of cyclooxygenase-2 (COX-2), would interfere with the desired antiplatelet effects of aspirin. Thus, the effects of rofecoxib on inhibition of ex vivo serum-generated thromboxane B2 (TXB2) and platelet aggregation by low doses (81 mg) of aspirin were examined in healthy volunteers. This was a double-blind, randomized, placebo-controlled, parallel study of two treatment groups (n=12 per group) in which subjects received 50 mg of rofecoxib or placebo for 10 days in a blinded fashion. Subjects also received 81 mg aspirin once on each of days 4 through 10 in an open-label fashion. Blood for measurement of serum TXB2 production and platelet aggregation studies was collected on day 1 (prior to rofecoxib/placebo), on day 4 (prior to aspirin), and on day 10 (before and 4 hours following the seventh dose of aspirin). Platelet-derived serum TXB2 (COX-1 assay) was measured in blood clotted for 1 hour at 37oC. Platelet aggregation was independently induced employing 1 mM arachidonic acid and 1 µg/ml collagen as agonists. Rofecoxib administered alone had no significant effect on serum TXB2 production or platelet aggregation (day 4). TXB2 production was inhibited 98.4% by aspirin coadministered with either rofecoxib or placebo (day 10). Similarly, platelet aggregation induced by arachidonic acid was inhibited 93.7% and 93.5% by aspirin coadministered with either rofecoxib or placebo, respectively (day 10). The comparable values for inhibition of collagen-induced platelet aggregation were 86.8% and 90.8%, respectively. No important clinical or laboratory adverse experiences were observed. In conclusion, rofecoxib alone (50 mg QD for 4 days) did not inhibit serum TXB2 production or platelet aggregation. In addition, rofecoxib (50 mg QD for 10 days) did not alter the antiplatelet effects of low-dose aspirin (inhibition of platelet aggregation and TXB2 production). Rofecoxib was generally well tolerated when administered alone or in combination with low-dose aspirin.


Yeh et al 2000

Absence of the preemptive analgesic effect of dextromethorphan in total knee replacement under epidural anesthesia.

Yeh CC, Ho ST, Kong SS, Wu CT, Wong CS

Acta Anaesthesiologica Sinica 2000;38(4):187–93 [erratum appears in Acta Anaesthesiol Sin 2001 Mar;

BACKGROUND: Previous studies have shown that dextromethorphan (DM), a N-methyl-D-aspartate (NMDA) receptor antagonist, produces a preemptive analgesic effect on post-operative pain. The aim of this study was to further examine the preemptive analgesic effect of intramuscular (i.m.) DM injection on unilateral total knee replacement (TKR). METHODS: Sixty-four ASA I-III patients scheduled for unilateral TKR surgery were randomly allocated into three groups in a prospective double-blind manner. All patients received epidural anesthesia without any premedication. An initial bolus dose of 2% lidocaine (15-20 mL) followed by a maintenance dose of 8-10 mL/h was decided. Fentanyl (1.5 micrograms/kg) and diazepam (2 mg) were given i.v. before epidural catheter insertion. The epidural catheter was placed via the L2-L3 or L3-L4 interspace and advanced for 5 cm cephalad [corrected]. Patients received i.m. injection of 20 mg chlorpheniramine (CPM) before surgery as control (group C, n = 22). For the study groups, patients were given an i.m. injection containing 40 mg DM and 20 mg CPM, before (group B, n = 22) or after surgery (group A, n = 20), respectively. Postoperation, patients received intravenous morphine by means of a patient controlled analgesia (PCA) device for pain relief. The time to the first pull of PCA trigger, morphine consumption, worse pain scores (resting and incidental), and analgesics related side effects were recorded at 1, 2, 4, 8, 24, 48 and 72 h after surgery. RESULTS: The time from the end of operation to the first PCA trigger were 31.2 +/- 5.2 min in group C, 67.3 +/- 11.1 min in group B (P < 0.05, compared with group C) and 61.8 +/- 7.2 min in group A (P < 0.05, compared with group C) respectively. The relevant pain score at resting, observed at the 8 h postoperatively was respectively 4.2 +/- 0.1 in group C, 3.7 +/- 0.2 in group B (P < 0.05, compared with group C) and 3.4 +/- 0.2 in group A (P < 0.05, compared with group C); and at the 24 h was 3.1 +/- 0.2 in group C, 2.4 +/- 0.2 in group B (P < 0.05, compared with group C) and 2.5 +/- 0.1 in group A (P < 0.05, compared with group C) respectively. There were no significant differences in actual morphine delivery and frequency of PCA triggering at all time among the three groups. Moreover, there was also no significant statistic difference in morphine-associated side effects among the three groups. CONCLUSIONS: In the present study, we failed to observe any preemptive analgesic effect of DM (40 mg, i.m.) on postoperative pain in patients who received TKR under epidural anesthesia, however, DM given either before or after surgery augmented other analgesic (morphine) to offer a better pain relief.


Hendolin et al 1996

Does morphine premedication influence the pain and consumption of postoperative analgesics after total knee arthroplasty?

Hendolin H, Nuutinen L, Kokki H, Tuomisto L

Acta Anaesthesiologica Scandinavica 1996;40(1):81–5

Evidence of pre-emptive analgetic effect of opioid would offer great potential benefit to patients with postoperative pain, a better pain relief with less opioid. The aim of this double blind randomised trial was to study the effect of intramuscular morphine premedication on postoperative pain. Forty-one patients undergoing total knee arthroplasty were randomly allocated to four groups. Two groups received epidural morphine, 4 mg immediately after operation and 3 mg ten hours later, and two groups the same volume of saline. All patients had access to intravenous PCA-fentanyl. One epidural morphine and one epidural saline group (PreEpiMo and PreMo, respectively) received morphine, 0.14 mg/kg i.m. as premedication. Pain was measured with a visual analogue scale (VAS). Respiration was monitored by means of pulseoximetry, arterial blood gas analysis and rate of breathing. Morphine premedication reduced postoperative pain in the immediate postoperative period in patients with epidural placebo (PreMo), but the effect was absent in patients with PreEpiMo. Epidural morphine (EpiMo) provided stable analgesia with reduced need of PCA-fentanyl. Two patients (10%) (one in EpiMo and one in PreEpiMo) developed respiratory depression requiring naloxone treatment. The dosage of epidural morphine used in this study was a likely explanation of this depression. Nausea, vomiting, itching and urinary retention were the most frequent side effects without significant differences between the groups. In conclusion, morphine premedication had a temporary rest effect on the postoperative pain. Epidural morphine provides a better analgesia than intravenous PCA-fentanyl.


Reiter et al 2003

Preoperative oral administration of fast-release morphine sulfate reduces postoperative piritramide consumption.

Reiter A, Zulus E, Hartmann T, Hoerauf K.

Wien Klin Wochenschr 2003;115(12):417–420.

The aim of this prospective randomized placebo-controlled double-blind study was to investigate the effect of premedication with morphine sulfate on postoperative pain. Ninety-eight ASA I-III patients undergoing total replacement of the knee or hip joint were randomly assigned to one of two groups. Group 1 received 20 mg morphine sulfate p.o. approximately one hour before the start of surgery; group 2 received placebo. After surgery, piritramide was administered via patient-controlled analgesia over 24 hours. Piritramide consumption and pain scores (visual analog scale) were recorded. The duration of surgery (mean +/- SD) was comparable in the two groups (group 1: 145 +/- 42 min, group 2: 131 +/- 35 min). In group 1 the cumulative piritramide consumption during 24 hours postoperation was significantly less than in the placebo group (37.5 +/- 12.5 mg versus 46.8 +/- 22.1, t-test, p < 0.05), although similar pain scores were recorded (group 1: 4.8 +/- 1.8 and 3.6 +/- 1.7, group 2: 4.8 +/- 1.6 and 3.4 +/- 2.0, at 1 and 24 hours, respectively). These data show that the preoperative oral administration of morphine sulfate, regardless of its short half-life, can reduce postoperative consumption of opioids at similar pain levels.


Dahl et al 1994

Immediate and prolonged effects of pre- versus postoperative epidural analgesia with bupivacaine and morphine on pain at rest and during mobilisation after total knee arthroplasty.

Dahl JB, Daugaard JJ, Rasmussen B, Egebo K, Carlsson P, Kehlet H

Acta Anaesthesiologica Scandinavica 1994;38(6):557–61

Thirty-two patients scheduled for total knee arthroplasty were randomized to receive an identical epidural blockade initiated 30 min before surgical incision (N = 16), or at closure of the surgical wound (N = 16). Before induction of general anaesthesia the epidural catheter was tested with bupivacaine 7.5 mg.ml-1, 2 ml. General anaesthesia was induced with thiopentone, pancuronium or atracurium, and fentanyl 0.1-0.3 mg, and maintained with N2O/O2 and enflurane. The epidural regimen consisted of a bolus of 16 ml of bupivacaine 7.5 mg.ml-1 plus morphine 2 mg, and continuous infusion of bupivacaine 1.25 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1 for the first 24 h, and bupivacaine 0.625 mg.ml-1 plus morphine 0.05 mg.ml-1, 4 ml.h-1, for the next 24 h after operation. Additional morphine 2.5-5 mg was administered i.v. or i.m. for the first 24 h postoperatively, and ketobemidone or morphine 5-10 mg orally or rectally from 24 h to 7 d postoperatively, on request. Paracetamol 1000 mg every 8 h was administered from 48 h to 7 days postoperatively. No significant differences were observed in request for additional opioids, or in pain scores at rest or during mobilisation of the operated limb, during or after cessation of the epidural regimen. These results do not suggest timing of analgesia with a conventional, continuous epidural regimen to be of major clinical importance in patients undergoing total knee arthroplasty.


Choi et al 2003

Epidural analgesia for pain relief following hip or knee replacement.

Choi PT, Bhandari M, Scott J, Douketis J.

Cochrane Database Syst Rev 2003(3):CD003071.

BACKGROUND: Hip and knee replacement are common operative procedures to improve mobility and quality of life. Adequate pain relief is essential in the postoperative period to enable ambulation and initiation of physiotherapy. Lumbar epidural analgesia is a common modality for pain relief following these procedures. However, there is no systematic review of the evidence comparing the efficacy of epidural analgesia with other postoperative analgesic modalities. As the use of epidural analgesia may delay the initiation of anticoagulant thromboprophylaxis due to the potential risk of epidural hematoma, a synthesis of the evidence is necessary to determine whether or not alternative analgesic modalities are worse, equivalent, or better than epidural analgesia. OBJECTIVES: Our objective is to answer the question: "Is lumbar epidural analgesia more efficacious than systemic analgesia or long-acting spinal analgesia for postoperative pain relief in patients after elective hip or knee replacement?" SEARCH STRATEGY: MEDLINE, EMBASE, CINAHL, LILACS, and the Cochrane Controlled Trials Register were searched from their inception to June 2001. Reference lists of review articles and included studies were also reviewed for additional citations. SELECTION CRITERIA: A study was included if it was a randomized or pseudo randomized controlled clinical trial of patients undergoing hip or knee replacement, in which postoperative lumbar epidural analgesia was compared to other methods for pain relief. Study selection was performed unblinded in duplicate. DATA COLLECTION AND ANALYSIS: Data were collected unblinded in duplicate. Information on the patients, methods, interventions, outcomes (pain relief, postoperative function, length of stay) and adverse events were recorded. Methodological quality was assessed using a validated 5-point scale. Meta-analysis was conducted when sufficient data existed from two or more studies. Heterogeneity testing was performed using the Breslow-Day method. The fixed effects model was used unless heterogeneity was present, in which case, a random effects model was used. Continuous data were summarized as weighted mean differences (WMD) or standardized mean differences (SMD) with 95% confidence intervals (CI). Dichotomous data were summarized as odds ratios (OR) and numbers-needed-to-treat (NNT) or numbers-needed-to-harm (NNH) with their respective 95% CI. Graphical representation of continuous data used the MetaView program. MAIN RESULTS: In the first four to six hours after surgery, patients receiving epidural analgesia had less pain at rest, based on visual analog scores (VAS), than patients receiving systemic analgesia (SMD -0.77; 95% CI -1.24 to -0.31). This effect was not statistically significant by 18 to 24 hours (SMD -0.29; 95% CI -0.73 to 0.16). These observations were based only on studies evaluating populations consisting of total knee replacements alone or mixed populations of total hip or total knee replacements. For pain relief with movement after surgery, patients receiving epidural analgesia reported lower pain scores than patients receiving systemic analgesia in all four studies examining these outcomes. The choice of epidural agents may also influence the extent to which epidural analgesia differs from systemic analgesia. The differences between epidural analgesia and systemic analgesia in the frequency of nausea and vomiting (OR 0.95; 95% CI 0.60 to 1.49) or depression of breathing (OR 1.07; 95% CI 0.45 to 2.54) were not statistically significant. Sedation occurred less frequently with epidural analgesia (OR 0.30; 95% CI 0.09 to 0.97) with a number-needed-to-harm of 7.7 (95% CI 3.5 to 42.0) patients for the systemic analgesia group. Retention of urine (OR 3.50, 95% CI 1.63 to 7.51; NNH 4.5, 95% CI 2.3 to 12.2), itching (OR 4.74, 95% CI 1.76 to 12.78; NNH 6.8, 95% CI 4.4 to 15.8), and low blood pressure (OR 2.78, 95% CI 1.15 to 6.72; NNH 6.7, 95% CI 3.5 to 103) were more frequent with epidural analgesia compared to systemic analgesia. There were insufficient numbers to draw conclusions on the edural analgesia compared to systemic analgesia. There were insufficient numbers to draw conclusions on the effect of epidural analgesia on serious postoperative complications, functional outcomes, or length of hospital stay. REVIEWER'S CONCLUSIONS: Epidural analgesia may be useful for postoperative pain relief following major lower limb joint replacements. However, the benefits may be limited to the early (four to six hours) postoperative period. An epidural infusion of local anesthetic or local anesthetic-narcotic mixture may be better than epidural narcotic alone. The magnitude of pain relief must be weighed against the frequency of adverse events. The current evidence is insufficient to draw conclusions on the frequency of rare complications from epidural analgesia, postoperative morbidity or mortality, functional outcomes, or length of hospital stay.


Lorenzini et al 2002

Efficacy of ropivacaine compared with ropivacaine plus sufentanil for postoperative analgesia after major knee surgery.

Lorenzini C, Moreira LB, Ferreira MB.

Anaesthesia 2002;57(5):424–428.

This study compared the analgesic efficacy of an epidural infusion of ropivacaine and ropivacaine with sufentanil following major knee surgery. In a double-blind clinical trial, 115 adult patients received either epidural ropivacaine (R group, 2 mg/ml), or ropivacaine (2 mg/ml) with sufentanil (RS group, 1 µg/ml), using a patient-controlled epidural analgesia technique. Pain scores (visual analogue scale, VAS, and the simple descriptive scale, SDS), side-effects, motor block and treatment quality were recorded at 6, 12 and 24 h after the insertion of the epidural catheter. In the RS group, analgesic efficacy was significantly greater than in the R group between 12 and 24 h following insertion of the epidural catheter (VAS: 92.9% vs. 72.9%, p=0.009). There was no significant difference during the other periods. Pruritus, nausea and vomiting were significantly more frequent in the RS group. Good postoperative analgesia was obtained with an epidural infusion of ropivacaine (2 mg/ml)). When this local anaesthetic was administered with sufentanil, there was an improvement in the analgesic effect but a significant increase in the number of patients who reported adverse effects. The differences were more pronounced 12 h after the beginning of the analgesic schedule. This study failed to demonstrate any worthwhile clinical benefit from the addition of sufentanil.


Cole et al 2000

Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty.

Cole PJ, Craske DA, Wheatley RG

British Journal of Anaesthesia 2000;85(2):233–7

A randomized, double-blind study of 38 patients undergoing total knee replacement was undertaken to compare the efficacy and respiratory effects of low-dose spinal morphine and patient-controlled i.v. morphine against patient-controlled i.v. morphine alone. Patients received either morphine 0.3 mg or saline 0.3 ml with 0.5% heavy spinal bupivacaine 2-2.5 ml. Respiratory effects were measured continuously for 14 h postoperatively with an Edentec 3711 respiratory monitor. There was an improvement in pain relief in the intrathecal morphine group, with significantly lower median VAS pain scores on movement at 4 h (0 (median 0-1.5) vs 5 (1.25-7.75) P < 0.01), 12 h (2 (1-5) vs 6 (3-8) P < 0.01) and 24 h (3 (1-5) vs 5 (3-7) P < 0.05) postoperatively, despite using significantly less patient-controlled morphine (20 mg (10.25-26.25) vs 38.5 mg (27-51) P < 0.01) in the first 24 h. There was a small but statistically significant reduction in the median oxygen saturation (SpO2) in the intrathecal morphine group 97 (95-99)% compared with the placebo group 99 (97-99)% (P < 0.05). Although marked disturbances in respiratory pattern were observed in both groups, none of the patients in the study had severe hypoxaemia (SpO2 < 85% > 6 min h-1) and there was no significant difference in the incidence of mild (SpO2 < 94% > 12 min h-1) or moderate (SpO2 < 90% > 12 min h-1) hypoxaemia or in the incidence of episodes of apnoea or hypopnoea in the two groups.


Sites et al 2003

Intrathecal clonidine added to a bupivacaine-morphine spinal anesthetic improves postoperative analgesia for total knee arthroplasty.

Sites BD, Beach M, Biggs R, Rohan C, Wiley C, Rassias A, Gregory J, Fanciullo G

Anesthesia & Analgesia 2003;96(4):1083–8

Postoperative pain after total knee arthroplasty (TKA) is severe and can complicate early physical therapy. We tested the hypothesis that intrathecal clonidine would improve postoperative analgesia for TKA using a hyperbaric bupivacaine spinal anesthetic. In a double-blinded, placebo-controlled protocol, 81 ASA physical status I-III patients undergoing either a single or bilateral TKA were randomized into 4 groups with the following 2-mL solutions added to 15 mg of hyperbaric bupivacaine: 1) sterile saline, 2) morphine (250 microg), 3) morphine (250 microg) with clonidine (25 microg), and 4) morphine (250 microg) with clonidine (75 microg). At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales (VAS), cumulative IV morphine consumption, hemodynamics, nausea, ancillary drugs, and side effects. Our primary comparison was between the clonidine with morphine groups versus the morphine group. We found that the combined administration of intrathecal clonidine and morphine decreased 24 h IV morphine consumption by 13 mg (P = 0.028) when compared with intrathecal morphine alone. This corresponded to a decrease in the VAS score of 1.3 cm at 24 h postoperatively (P = 0.047). Adverse side effects were similar among all groups with the exception of more relative hypotension in the clonidine groups through postoperative hour 6. We conclude that the coadministration of intrathecal clonidine and morphine decreases the 24-h IV morphine consumption and improves the 24-h VAS score when compared with intrathecal morphine alone. IMPLICATIONS: In this prospective, randomized, double-blinded, and placebo-controlled trial, we identify an effective postoperative analgesic approach in total knee replacement surgery. Intrathecal morphine (250 microg) combined with clonidine (25 or 75 microg) provided superior analgesia compared with intrathecal morphine alone.


Sites et al 2004

A single injection ultrasound-assisted femoral nerve block provides side effect-sparing analgesia when compared with intrathecal morphine in patients undergoing total knee arthroplasty.

Sites BD, Beach M, Gallagher JD, Jarrett RA, Sparks MB, Lundberg CJ

Anesthesia & Analgesia 2004;99(5):1539–43

Postoperative pain after total knee arthroplasty (TKA) is severe, and achieving adequate analgesia remains a clinical challenge. We tested the hypothesis that, in patients having unilateral TKA under intrathecal (IT) anesthesia, the addition of a femoral nerve block would provide superior analgesia when compared with IT morphine and demonstrate fewer adverse side effects. In a single-blinded and controlled trial, 41 ASA I-III patients undergoing unilateral TKA were randomized into 2 groups. Both groups received 15 mg of IT hyperbaric bupivacaine for the surgical anesthetic. Group ITM received 250 microg of IT morphine and group FNB received an ultrasound-assisted femoral nerve block with 40 mL of 0.5% ropivacaine, 5 microg/mL of epinephrine, and 75 microg of clonidine. At 1, 2, 4, 6, 12, and 24 h postoperatively, we measured visual analog scales for pain, cumulative IV morphine consumption, hemodynamics, and side effects. There were no statistically significant differences in morphine consumption, pain at rest, or pain with movement. However, group FNB had fewer perioperative side effects including nausea, vomiting, and pruritus (P < 0.05 for each event). This corresponded to a decrease in patient satisfaction in group ITM, in which 20% of the patients rated their experience as "unsatisfactory" (P < 0.05). We conclude that, in comparison with IT morphine, a single injection femoral nerve block provides equivalent analgesia but with a significant reduction in side effects for patients having TKA under bupivacaine intrathecal anesthesia.


Tan et al 2001

Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesia after total knee replacement surgery.

Tan PH, Chia YY, Lo Y, Liu K, Yang LC, Lee TH.

Can J Anaesth 2001;48(6):551–556.

PURPOSE: To compare the postoperative analgesic efficacy and safety of intrathecal (IT) neostigmine and IT morphine in patients undergoing total knee replacement under spinal anesthesia. METHODS: Sixty patients scheduled for elective total knee replacement under spinal anesthesia were randomly divided into three equal groups which received IT 0.5% hyperbaric bupivacaine 15 mg with either normal saline 0.5 mL, neostigmine 50 microg, or morphine 300 microg. The maximal level of sensory block, duration of analgesia, time to use of rescue analgesics, the overall 24-hr and four-hour interval visual analogue scale (VAS) pain score, and the incidence of adverse effects were recorded for 24 hr after administration. RESULTS: There was no significant difference in maximal level of sensory block among the three groups. The morphine group had a later onset of postsurgical pain and longer time to first rescue analgesics than the neostigmine group (P <0.05). Overall 24-hr VAS pain scores were significantly higher in the saline group vs the morphine and neostigmine groups (P <0.05). Motor block lasted significantly longer in the neostigmine group than in the morphine and saline groups (P <0.05). The incidence of adverse effects was similar in the neostigmine and morphine groups except for pruritus (70%) occurring more frequently in the morphine group than in the neostigmine and saline groups (0%; P <0.05). Overall satisfaction rates were better in the neostigmine group than in the morphine and saline groups (P <0.05). CONCLUSIONS: IT neostigmine 50 microg produced postoperative analgesia lasting about seven hours with fewer side effects and better satisfaction ratings than IT morphine 300 microg.


Bowrey et al 2005

A comparison of 0.2 and 0.5 mg intrathecal morphine for postoperative analgesia after total knee replacement.

Bowrey S, Hamer J, Bowler I, Symonds C, Hall JE

Anaesthesia 2005;60(5):449–52

The optimal dose of intrathecal morphine for postoperative analgesia after major surgery is a matter of debate, with some uncertainty concerning the therapeutic potential and safety of intrathecal morphine in the dose range 0.3-1.0 mg. This randomised double-blind study compared the efficacy and side-effect profile of 0.2 mg and 0.5 mg intrathecal morphine in 70 patients undergoing knee replacement surgery. The primary endpoint was the number of patients requiring rescue analgesia (tramadol) during the first 24 h postoperatively. Secondary endpoints included consumption of tramadol and the incidence of adverse effects. Fewer patients in the 0.5-mg group required rescue analgesia in the first 24 h than in the 0.2-mg group (16 (48%) vs 28 (85%), respectively; p = 0.003). Median (IQR [range]) tramadol consumption was lower in the 0.5-mg group than in the 0.2-mg group (0 (0-100 [0-350]) mg vs 100 (50-100 [0-350]) mg, respectively; p = 0.02). The incidence of adverse effects was similar in both groups. This study has demonstrated that 0.5 mg intrathecal morphine produces better analgesia than 0.2 mg after knee replacement without any increase in side-effects.


Drakeford et al

Spinal narcotics for postoperative analgesia in total joint arthroplasty. A prospective study.

Drakeford MK, Pettine KA, Brookshire L, Ebert F

Journal of Bone & Joint Surgery - American Volume 1991;73(3):424–8.

No abstract available


Fernandez-Galinski D et al 2005

Comparison of two protocols using low doses of bupivacaine for spinal anaesthesia during joint replacement in elderly patients

Fernandez-Galinski D, Pulido C, Real J, Rodriguez A, Puig MM

The Pain Clinic 2005;17(1):15-24

No abstract available


Lauretti GR et al 1997

Postoperative analgesia and antiemetic efficacy after intrathecal neostigmine in patients undergoing abdominal hysterectomy during spinal anesthesia

Lauretti GR, Mattos AL, Gomes JM, Pereira NL

Reg Anesth 1997a;22(6):527-33

No abstract available


Badner et al 1996

Intra-articular injection of bupivacaine in knee-replacement operations. Results of use for analgesia and for preemptive blockade.

Badner NH, Bourne RB, Rorabeck CH, MacDonald SJ, Doyle JA

Journal of Bone & Joint Surgery - American Volume 1996;78(5):734–8

The effectiveness of an intra-articular injection of bupivacaine, administered before the incision or after closure of the wound, was studied in an effort to decrease the need for postoperative narcotics and to improve analgesia for patients who have elective knee replacement. Eighty-two patients received two intra-articular injections in a random, double blind fashion. Twenty-eight of them received thirty milliliters of 0.5 percent bupivacaine and 1:200,000 epinephrine in saline solution before the incision and an injection of thirty milliliters of plain saline solution after closure of the wound (Group 1). Twenty-seven patients received an injection of thirty milliliters of plain saline solution before the incision and thirty milliliters of 0.5 percent bupivacaine and 1:200,000 epinephrine in saline solution after closure of the wound (Group 2). Twenty-seven patients were given thirty milliliters of plain saline solution (a placebo) for both injections (Group 3). The patients who had received bupivacaine after closure of the wound (Group 2) used less morphine from the patient-controlled analgesia pumps than the patients who had received bupivacaine before the incision (Group 1) and the patients who had received the placebo (Group 3). In the first twenty-four hours after the operation, the administration of morphine (mean and standard deviation) was 59 +/- 27 milligrams for Group 2 compared with 68 +/- 30 milligrams for Group 1 (p = 0.26) and 81 +/- 30 milligrams for Group 3 (p = 0.006). At the time of discharge from the hospital, the patients in Group 2 also had a significantly greater mean range of motion (85.2 +/- 8.0 degrees) compared with that of the patients in Groups 1 (80.6 +/- 6.8 degrees, p = 0.02) and 3 (80.1 +/- 6.2 degrees, p = 0.009). However, there was no difference among the groups with respect to the effectiveness of the analgesia, as measured with use of either the visual-analog or the verbal pain-rating scale, or in the prevalence of side effects, including somnolence, urinary retention, nausea and vomiting, or pruritus. Serum concentrations of bupivacaine were well below toxic levels. It was our conclusion that that and intra-articular injection of thirty milliliters of 0.5 percent bupivacaine and 1:200,000 epinephrine in saline solution after closure of the wound decreases the need for narcotics and increases the range of motion after an elective knee replacement. The clinical importance of the amount of increased motion is questionable and needs long-term monitoring.


Kalso E et al 2002

Five easy pieces on evidence based medicine (5). Trading benefit against harm--pain relief vs. adverse effects

Kalso E, Edwards J, McQuay HJ, Moore RA

Eur J Pain 2002;6(5):409–412.

No abstract available


Rosseland LA 2005

No evidence for analgesic effect of intra-articular morphine after knee arthroscopy: a qualitative systematic review.

Rosseland 2005

Reg Anesth Pain Med 2005;30(1):83-98

BACKGROUND AND OBJECTIVES: Intra-articular (IA) injection of morphine has been the subject of many randomized clinical trials (RCTs). Both negative and positive results have been obtained in trials with a preemptive design, and the question of efficacy remains unresolved. Recent RCTs on patients whose inclusion was delayed until a baseline pain of at least moderate intensity was documented have illuminated the pitfalls of IA analgesic trials. Previously published systematic reviews may have included flawed RCTs in the analyses. METHODS: A systematic, qualitative review of RCTs on the analgesic efficacy of IA morphine after knee arthroscopic surgery. RESULTS: Of the 67 screened RCTs, 46 RCTs (43 publications) of IA morphine were included. Thirty-six trials were placebo controlled. Twenty-three of these RCTs were of low scientific quality; randomization and blinding were not adequately described or the method used for statistical analysis of repeated measurements was unsound. Among the 13 RCTs with usable information, 4 of the positive outcomes may be explained by the uneven distribution of patients whose natural course was low postoperative pain intensity. Uneven sex distribution may be a confounding factor in one of these trials. Seven negative and 2 positive trials had reliable information. The only RCT with documented control over baseline pain intensity was negative. Most positive trials had small sample size. Publication bias favors the reporting and publication of positive trials more often than negative ones. CONCLUSIONS: There are few well-controlled RCTs on IA morphine, and the negative trials of higher quality counter the evidence from the numerous positive ones of lower quality. The quality of most published trials is poor, and performing meta-analysis on these data is not meaningful. Properly controlled trials, in which early postoperative pain intensity is documented, suggest that there is no added analgesic effect of IA morphine compared with saline alone.


Beaupre et al 2004

The effect of a preoperative exercise and education program on functional recovery, health related quality of life, and health service utilization following primary total knee arthroplasty.

Beaupre LA, Lier D, Davies DM, Johnston DB

Journal of Rheumatology 2004;31(6):1166–73

OBJECTIVE: To determine the effectiveness of a preoperative exercise/education program on functional recovery, health related quality of life (HRQOL), health service utilization, and costs following primary total knee arthroplasty (TKA). METHODS: One hundred thirty-one subjects were randomized to either the control (n = 66) or treatment (n = 65) group 6 weeks before TKA surgery. Patients in the treatment group underwent a 4-week exercise/education program before surgery. All subjects were assessed 6 weeks preoperatively (before the exercise/education intervention), immediately preoperatively (after the exercise/education intervention), and 3, 6 and 12 months after surgery utilizing the Western Ontario McMaster Osteoarthritis Index, the SF-36, and knee range of motion (ROM) and strength measures. Data on length of stay, numbers of community rehabilitation or homecare visits following discharge from the surgical hospital, and the costs associated with these services were also collected. RESULTS: Subjects were similar in demographic characteristics and all measurements at the baseline assessment. No differences were seen in knee measurements (ROM and strength), pain, function, or HRQOL between the 2 groups following the intervention program or at any postoperative measurement point. Patients in the treatment group used fewer postoperative rehabilitation services and stayed for a shorter time in hospital than the control group, but these differences did not attain statistical significance. CONCLUSION: The exercise/education intervention did not alter functional recovery or HRQOL following TKA. Health service utilization was less in the treatment group, but our study was underpowered to attain statistical significance for these measures.


D'Lima et al 1996

The effect of preoperative exercise on total knee replacement outcomes.

D'Lima DD, Colwell Jr CW, Morris BA, Hardwick ME, Kozin F

Clinical Orthopaedics & Related Research. Issue 1996;326(pp 174–182)

This study compared the effects of preoperative physical therapy or general cardiovascular conditioning exercises with the routine procedure of no preoperative physical therapy on patients undergoing primary total knee replacement. Thirty patients were randomly assigned to 1 of 3 groups. Group 1 was the control group. Group 2 participated in a physical therapy program designed to strengthen the upper and lower limbs and improve knee range of motion. Group 3 participated in a cardiovascular conditioning program, consisting of arm ergometry, cycle ergometry, aquatic exercises, and aerobic activity. All patients were evaluated preoperatively and postoperatively using the Hospital for Special Surgery Knee Rating, the Arthritis Impact Measurement Scale, and the Quality of Well Being instrument. Both experimental groups tolerated their respective exercise protocols extremely well. All 3 groups showed significant improvement postoperatively as measured by the Hospital for Special Surgery Knee Rating, the Arthritis Impact Measurement Scale and the Quality of Well Being measurement scales. However, neither type of preoperative exercise added to the degree of improvement after surgery at any of the postoperative evaluations.


Pang et al 2003

Tramadol 2.5 mg x kg(-1) appears to be the optimal intraoperative loading dose before patient-controlled analgesia.

Pang WW, Wu HS, Tung CC

Canadian Journal of Anaesthesia 2003;50(1):48–51

PURPOSE: We previously established that a 5 mg x kg(-1) intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA. METHODS: During general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg x kg(-1) (Group I), 2.5 mg x kg(-1) (Group II), 3.75 mg x kg(-1) (Group III), or 5 mg x kg(-1) (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score was < or = 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes. RESULTS: In the PACU, significantly more tramadol (8.4 +/- 3.1 vs 4.3 +/- 2.1, 2.5 +/- 1.8, and 0.4 +/- 0.3, P < 0.05), and a higher incidence (15/15 vs 5/15, 3/15, and 2/15, P < 0.05) of PCA use was observed in Group I compared to Groups II-IV. VAS was significantly higher in Group I than in Groups II-IV at zero and ten minutes (P < 0.05). Unexpected delayed emergence anesthesia (> 30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P < 0.05). CONCLUSION: When considering efficacy and side-effect profile, 2.5 mg x kg(-1) of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.


Farag et al 2005

Epidural analgesia improves early rehabilitation after total knee replacement.

Farag E, Dilger J, Brooks P, Tetzlaff JE

Journal of Clinical Anesthesia 2005;17(4):281–5

STUDY OBJECTIVE: To compare epidural anesthesia and analgesia with spinal anesthesia with intravenous morphine analgesia for its effect on range of motion (ROM) and early rehabilitation after total knee replacement. DESIGN: Randomized prospective study. SETTING: Tertiary care, academic medical center. PATIENTS: Thirty-eight patients scheduled for total knee replacement. INTERVENTIONS: Patients were randomized into 2 groups. One group received spinal anesthesia with 0.5% bupivacaine and analgesia with intravenous patient-controlled analgesia morphine, demand mode only. The other group was given epidural anesthesia with 1.0% ropivacaine with 1:200,000 epinephrine and analgesia with 0.2% ropivacaine at 8 mL/h, maintained for 7 days. Both groups had compression stocking for deep venous thrombosis (DVT) prophylaxis, urinary catheter for the first 24 hours, and duplex scanning at days 3 and 10. The spinal group received low molecular-weight heparin for DVT prophylaxis. MEASUREMENTS: Data collected included pain scores at rest, and with ROM, frequency of DVT, and patient satisfaction. Data were evaluated with Wilcoxon rank sum test for continuous variables and Fisher exact test for categorical variables. Data were considered significant at P < .05. MAIN RESULTS: All 38 patients finished the study, 22 in the spinal group and 16 in the epidural group. There was no difference in demographics between groups. The pain sores at rest and with ROM were significantly less in the epidural group. ROM was better in the epidural group compared with the spinal group after day 1. No DVT was detected on day 3 or 10 in either group. No patient in either group required reinsertion of bladder catheter for urinary retention. CONCLUSION: By using epidural analgesia in the first 7 days postoperatively, we achieved improved early rehabilitation due to excellent pain relief effect and an antithrombotic effect with an efficacy comparable to low molecular-weight heparin.


Kudoh et al 2004

A comparison of anesthetic quality in propofol-spinal anesthesia and propofol-fentanyl anesthesia for total knee arthroplasty in elderly patients.

Kudoh A, Takase H, Takazawa T

Journal of Clinical Anesthesia 2004;16(6):405–10

STUDY OBJECTIVE: To compare propofol plus spinal anesthesia during spontaneous ventilation using the Laryngeal Mask Airway and propofol plus fentanyl anesthesia during mechanical ventilation with an endotracheal tube on quality of recovery after anesthesia. DESIGN: Prospective, randomized study. SETTING: Hirosaki National Hospital. PATIENTS: 150 patients (aged > 70 years) undergoing total knee arthroplasty. INTERVENTIONS: Patients were divided randomly into two groups, to receive spontaneous ventilation with a Laryngeal Mask Airway during propofol-spinal anesthesia, or to receive propofol-fentanyl anesthesia with mechanical ventilation via endotracheal tube. MEASUREMENTS: Quality of anesthesia recovery such as nausea, vomiting, headache, pain throat, hoarse voice, back pain, dizziness, feeling comfortable, dreaming, recovery times in recovery of anesthesia, recovery times, postoperative pain, confusion, was assessed. MAIN RESULTS: The frequency of postoperative pain throat, hoarse voice, and nausea was significantly lower in the propofol-spinal anesthesia group than the propofol-fentanyl anesthesia group. The time to extubation, emergence, response to commands, and orientation were significantly faster (p < 0.001) in the propofol-spinal anesthesia group than the propofol-fentanyl anesthesia group. The frequency of postoperative confusion occurring in the propofol-spinal anesthesia group during the first 24 hours was significantly lower than that of the propofol-fentanyl anesthesia group (p = 0.03). Conclusions: Propofol-spinal anesthesia provided better and faster recovery than did propofol-fentanyl anesthesia for elderly patients undergoing total knee arthroplasty.


Drakeford et al 1991

Spinal narcotics for postoperative analgesia in total joint arthroplasty. A prospective study

Drakeford MK, Pettine KA, Brookshire L, Ebert F

Journal of Bone & Joint Surgery - American Volume 1991;73(3):424-8.

No abstract available


Busch et al 2006

Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial

Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW

J Bone Joint Surg Am 2006;88(5):959–63

BACKGROUND: Postoperative analgesia with the use of parenteral opioids or epidural analgesia can be associated with troublesome side effects. Good perioperative analgesia facilitates rehabilitation, improves patient satisfaction, and may reduce the hospital stay. We investigated the analgesic effect of locally injected drugs around a total knee prosthesis. METHODS: Sixty-four patients undergoing total knee arthroplasty were randomized either to receive a periarticular intraoperative injection containing ropivacaine, ketorolac, epimorphine, and epinephrine or to receive no injection. The perioperative analgesic regimen was standardized. All patients in both groups received patient-controlled analgesia for twenty-four hours after the surgery, and this was followed by standard analgesia. Visual analog scores for pain, during activity and at rest, and for patient satisfaction were recorded preoperatively and postoperatively and at the six-week follow-up examination. The consumption of patient-controlled analgesia at specific postoperative time-points and the overall analgesic requirement were measured. RESULTS: The patients who had received the injection used significantly less patient-controlled analgesia at six hours, at twelve hours, and over the first twenty-four hours after the surgery. In addition, they had higher visual analog scores for patient satisfaction and lower visual analog scores for pain during activity in the post-anesthetic-care unit and four hours after the operation. No cardiac or central nervous system toxicity was observed. CONCLUSIONS: Intraoperative periarticular injection with multimodal drugs can significantly reduce the requirements for patient-controlled analgesia and improve patient satisfaction, with no apparent risks, following total knee arthroplasty


Parker et al 2003

Closed suction surgical wound drainage after orthopaedic surgery.

Parker MJ, Roberts C.

Cochrane Database Syst Rev. 2001;(4):CD001825.

Background: Closed suction drainage systems are frequently used to drain fluids, particularly blood, from surgical wounds. The aim of these systems is to reduce the occurrence of wound haematomas and infection. Objectives: To evaluate the effectiveness of closed suction drainage systems for orthopaedic surgery. Search strategy: We searched the Cochrane Musculoskeletal Injuries Group specialised register (May 2001), MEDLINE (1996-May 2001) and references from articles. Selection criteria: All randomised or quasi-randomised trials comparing the use of closed suction drainage systems with no drainage systems for all types of elective and emergency orthopaedic surgery. Data collection and analysis: Both reviewers independently assessed trial quality, using a nine item scale, and extracted data. Wherever appropriate and possible, the data are presented graphically. Main results: Twenty-one studies involving 2772 patients with 2971 wounds were included in the analysis. The types of surgery involved were hip and knee replacement, shoulder surgery, hip fracture surgery, spinal surgery, cruciate ligament reconstruction, open meniscectomy and fracture fixation surgery. Many of the studies had poor methodology and reporting of outcomes. Pooling of results indicated no difference in the incidence of wound infection, haematoma or dehiscence between those allocated to drains and the un-drained wounds. There was a tendency to an increased risk of re-operation for wound complications in the group with drains (relative risk (RR) 2.25, 95% confidence intervals (CI) 0.95 to 5.33), but due to the small numbers of cases involved definite conclusions cannot be made for this outcome. Blood transfusion was required more frequently in those who received drains (RR 1.41, 95% CI 1.10 to 1.80). The need for reinforcement of wound dressings (RR 0.22, 95% CI 0.13 to 0.40) and bruising around the operation site was more common in the group without drains. Reviewers' conclusions: There is insufficient evidence from randomised trials to support or refute the routine use of closed suction drainage in orthopaedic surgery. Further randomised trials are required before definite conclusions can be made.


Barwell et al 1997

The effects of early tourniquet release during total knee arthroplasty: a prospective randomized double-blind study.

Barwell J, Anderson G, Hassan A, Rawlings I

Journal of Bone & Joint Surgery - British Volume 1997;79(2):265–8 [erratum appears in J Bone Joint S

We studied the effects of the timing of tourniquet release in 88 patients randomly allocated for release after wound closure and bandaging (group A), or before the quadriceps layer had been closed allowing control of bleeding before suture (group B). The groups were similar in mean age, weight, gender, preoperative knee score, radiographic grading, and prosthesis implanted. Patients in group B had less postoperative pain, achieved earlier straight-leg raising, and had fewer wound complications. Five patients in group A had to return to theatre, three for manipulation under anaesthesia, one for secondary closure of wound dehiscence, and one for drainage of a haematoma. The last patient later developed a deep infection, which was treated by a two-stage revision. There were no significant differences between the two groups in operating time, or the decrease in haemoglobin concentration at 48 hours postoperatively. Some of the adverse effects of the use of a tourniquet for knee surgery can be significantly reduced by early tourniquet release, with haemostasis before the quadriceps mechanism and the wound are closed.


Fisher et al 1998

The medial trivector approach in total knee arthroplasty.

Fisher DA, Trimble SM, Breedlove K

Orthopedics 1998;21(1):53–6

This study compares the clinical results of the medial trivector approach to the standard parapatellar approach in primary total knee arthroplasty. Ten patients undergoing simultaneous bilateral total knee arthroplasty were included in this study. Right and left knees were randomized for a standard medial parapatellar arthrotomy or a medial trivector approach. Patients were assessed by the number of days to achieve straight leg raising and range of motion at discharge. In addition, knee scores were obtained at 6 weeks and 6 months with careful assessment of any pain or tenderness around the quadriceps mechanism. At 6 months, patients were tested on a KINCOM machine assessing their concentric and eccentric quadriceps strength. While there was no difference in total range of motion at the time of discharge, patients undergoing a medial trivector approach achieved independent straight-leg raising 2 days sooner than patients undergoing a standard medial parapatellar arthrotomy. No significant differences existed in knee scores, pain scores, or range of motion at 6 weeks or 6 months. KINCOM testing at 6 months revealed the knees undergoing trivector approach to be 15% stronger in concentric contractions. No complications were encountered with the use of the medial trivector approach in these patients. Subjectively, patients reported less discomfort and more strength in the knees having undergone a medial trivector approach. The medial trivector approach may enhance postoperative recovery without adversely affecting the quadriceps function following total knee arthroplasty. The medial trivector approach to the knee does not weaken quadriceps muscle function or adversely affect clinical results of total knee arthroplasty.


Barrack et al 2001

Patellar resurfacing in total knee arthroplasty. A prospective, randomized, double-blind study with five to seven years of follow-up.

Barrack RL, Bertot AJ, Wolfe MW, Waldman DA, Milicic M, Myers L

Journal of Bone & Joint Surgery - American Volume 2001;83-A(9):1376–81

BACKGROUND: Whether to resurface the patella during a primary total knee arthroplasty performed for the treatment of degenerative osteoarthritis remains a controversial issue. Parameters that have been suggested as being useful in guiding this decision include patient height and weight, the presence of anterior knee pain preoperatively, and the grade of chondromalacia encountered intraoperatively. The purpose of this study was to determine whether these parameters were predictive of the clinical result following total knee arthroplasty with or without patellar resurfacing. METHODS: Eighty-six patients (118 knees) undergoing primary total knee arthroplasty for the treatment of osteoarthritis were enrolled in a prospective, randomized, double-blind study. All patients received the same posterior-cruciate-sparing total knee prosthetic components. Patients were randomized to treatment with or without resurfacing of the patella. Evaluations consisted of the determination of a Knee Society clinical score, the completion of a patient satisfaction questionnaire, specific questions relating to patellofemoral symptoms, and radiographs. Sixty-seven patients (ninety-three knees) were followed for a minimum of five years (range, sixty to eighty-four months; average, 70.5 months). RESULTS: With the numbers available, there was no significant difference between the groups treated with and without resurfacing with regard to the overall Knee Society score or the pain and function subscores. Obesity, the degree of patellar chondromalacia, and the presence of preoperative anterior knee pain did not predict postoperative clinical scores or the presence of postoperative anterior knee pain. CONCLUSIONS: The occurrence of anterior knee pain could not be predicted with any clinical or radiographic parameter studied. On the basis of these results, it seems likely that postoperative anterior knee pain is related either to the component design or to the details of the surgical technique, such as component rotation, rather than to whether or not the patella is resurfaced.


Parker et al 2001a

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures.

Parker MJ, Griffiths R, Appadu BN.

Cochrane Database Syst Rev 2001a(1):CD001159.

BACKGROUND: Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture. OBJECTIVES: To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) as part of the treatment for a hip fracture. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group specialised trials register, MEDLINE, and bibliographies of trial reports were searched. Date of the most recent search: October 2000. SELECTION CRITERIA: Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Wherever appropriate, results of outcome measures were pooled. MAIN RESULTS: Seven randomised or quasi-randomised trials involving 269 patients were included. Two trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion. Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit. REVIEWER'S CONCLUSIONS: Because of the small number of patients included in this review and the differing type of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant benefit when compared with other analgesic methods as part of the treatment of a hip fracture. Further trials with larger numbers of patients and full reporting of clinical outcomes would be justified.


Park et al 1996

Oral clonidine reduces postoperative PCA morphine requirements.

Park J, Forrest J, Kolesar R, Bhola D, Beattie S, Chu C

Canadian Journal of Anaesthesia 1996;43(9):900–6

PURPOSE: The purpose of this study was to evaluate the effect of perioperative oral clonidine on postoperative analgesia and PCA morphine requirements in adult patients after major orthopaedic knee surgery. METHODS: In this prospective, double blind, placebo-controlled study 44 patients undergoing either total knee replacement or hemiarthroplasty of the knee were randomly assigned to receive oral placebo or clonidine (5 micrograms . kg-1) 1.5 hr before surgery, and at 12 hr, and 24 hr after the initial dose. Five patients were subsequently withdrawn from study. No other preoperative drugs were given. Preoperative sedation score was recorded. A standardized general anaesthetic was administered to all patients. Postoperative blood pressure, heart rate, PCA morphine use, visual analogue score (VAS) for pain, sedation, nausea, and pruritus were recorded for 36 hr postoperatively. RESULTS: The cumulative PCA morphine used was 37% lower after clonidine 57.3 +/- 26.8 mg (mean +/- SD) compared with placebo 91 +/- 31.6 mg (P = 0.031). There was no difference in pain or sedation scores postoperatively but patients who received clonidine were more sedated preoperatively (P < 0.001) and had a lower mean arterial blood pressure throughout the period of study by 10 to 26 mmHg (P < 0.0001). Clonidine reduced the incidence of postoperative nausea (25% vs 74%) (P < 0.01) and vomiting compared with placebo (10% vs 53%) (P < 0.01) and required less antiemetic (dimenhydrinate 37.5 +/- 20.9 mg vs 82.1 +/- 49.4 mg) but not statistically significant (P = 0.065). CONCLUSIONS: Oral clonidine is a useful component to postoperative balanced analgesia as it decreases PCA morphine requirements and decreases the incidence of nausea and vomiting.


Boeckstyns et al 1992

Piroxicam spares buprenorphine after total joint replacement. Controlled study of pain treatment in 81 patients.

Boeckstyns ME, Backer M, Petersen EM, Hoj I, Albrechtsen H, Andersen HB

Acta Orthopaedica Scandinavica 1992;63(6):658–60

In a blinded, placebo-controlled study, the nonsteroidal antiinflammatory drug piroxicam, in combination with the partial morphine agonist/antagonist buprenorphine, was compared with buprenorphine alone for analgesic effect and side-effects in a 10-day period following total replacement of the hip or knee. 117 patients entered and 81 completed the study. The patients receiving piroxicam consumed less buprenorphine. There were no differences concerning side-effects between the two treatment groups, apart from a tendency towards less nausea after the third postoperative day in the group receiving piroxicam.


Rasmussen et al 2002

Intravenous parecoxib sodium for acute pain after orthopedic knee surgery.

Rasmussen GL, Steckner K, Hogue C, Torri S, Hubbard RC.

Am J Orthop 2002;31(6):336–343.

Our objective in a randomized, multicenter, double-blind, parallel- group, placebo- and active-controlled study was to evaluate and compare the analgesic effectiveness of single intravenous (IV) doses of parecoxib sodium 20 and 40 mg, morphine 4 mg, and ketorolac 30 mg in the postsurgical orthopedic pain model. After undergoing unilateral total knee replacement surgery, 208 healthy adult patients were randomized to receive placebo or a study drug within 6 hours of discontinuation of patient-controlled analgesia on postoperative day 1. Onset of analgesia was similarly rapid with IV parecoxib sodium 40 mg, morphine, and ketorolac. Level and duration of analgesia were significantly superior with parecoxib sodium than with morphine and were similar for parecoxib sodium and ketorolac. Parecoxib sodium was safe and well tolerated. In conclusion, IV parecoxib sodium 40 mg is as effective as ketorolac 30 mg and is more effective than morphine 4 mg and therefore has potential widespread utility in acute postoperative pain management.


Anderson SK et al 1991

Diclofenac in combination with opiate infusion after joint replacement surgery

Anderson SK, al Shaikh BA

Anaesthesia & Intensive Care 1991;19(4):535-8.

No abstract available


Buvanendran et al 2003

Effects of perioperative administration of a selective cyclooxygenase 2 inhibitor on pain management and recovery of function after knee replacement: a randomized controlled trial.

Buvanendran A, Kroin JS, Tuman KJ, Lubenow TR, Elmofty D, Moric M, Rosenberg AG

JAMA 2003;290(18):2411–8

CONTEXT: Controlling postoperative pain after knee replacement while reducing opioid-induced adverse effects and improving outcomes remains an important challenge. OBJECTIVE: To assess the effect of combined preoperative and postoperative administration of a selective inhibitor of cyclooxygenase 2 on opioid consumption and outcomes after total knee arthroplasty (TKA). DESIGN, SETTING, AND PATIENTS: Randomized, placebo-controlled, double-blind trial conducted June 2001 through September 2002, enrolling 70 patients aged 40 to 77 years and undergoing TKA at a university hospital in the United States. INTERVENTIONS: Patients were randomly assigned to receive 50 mg of oral rofecoxib at 24 hours and at 1 to 2 hours before TKA, 50 mg daily for 5 days postoperatively, and 25 mg daily for another 8 days, or matching placebo at the same times. MAIN OUTCOME MEASURES: Postoperative outcomes including postsurgical analgesic consumption and pain scores achieved, nausea and vomiting, joint range of motion, sleep disturbance, patient satisfaction with analgesia, and hematologic and coagulation parameters. RESULTS: Total epidural analgesic consumption and in-hospital opioid consumption were less in the group receiving rofecoxib compared with the group receiving placebo (P<.05). Median pain score (visual analog scale [VAS], 0-10) achieved for the knee was lower in the rofecoxib group compared with the placebo group during hospital stay (2.2 [interquartile range [IQR], 1.4-3.2] vs 3.5 [IQR, 2.7-4.3], P<.001) and 1 week after discharge (2.6 [IQR, 1.4-3.5] vs 3.7 [IQR, 2.9-4.7], P =.03). There was less postoperative vomiting in the rofecoxib group (6%) compared with the placebo group (26%) (P =.047), as well as a decrease in sleep disturbance compared with the placebo group on the night of surgery (P =.006) and on the first (P =.047) and second (P<.001) days postoperatively. Knee flexion was increased in the rofecoxib group compared with the placebo group at discharge (active flexion: mean [SD], 84.2 degrees [11.1 degrees ] vs 73.2 degrees [13.6 degrees ], P =.03; passive flexion: 90.5 degrees [6.8 degrees ] vs 81.8 degrees [13.4 degrees ], P =.05) and at 1 month postoperatively (109.3 degrees [8.5 degrees ] vs 100.8 degrees [11.8 degrees ], P =.01), with shorter time in physical therapy to achieve effective joint range of motion. The rofecoxib group was more satisfied with analgesia and anesthesia at discharge compared with the placebo group (median satisfaction score, 4.3 [IQR, 3.0-4.7] vs 3.3 [IQR, 2.3-4.3], respectively; P =.03), and the differences persisted at 2-week and at 1-month follow-up. There was no intergroup difference in surgical blood loss (P>.05 for both intraoperative and postoperative blood loss). CONCLUSION: Perioperative use of an inhibitor of cyclooxygenase 2 is an effective component of multimodal analgesia that reduces opioid consumption, pain, vomiting, and sleep disturbance, with improved knee range of motion after TKA.


Adam et al 2005

Small-dose ketamine infusion improves postoperative analgesia and rehabilitation after total knee arthroplasty.

Adam F, Chauvin M, Du Manoir B, Langlois M, Sessler DI, Fletcher D

Anesthesia & Analgesia 2005;100(2):475–80

We designed this study to evaluate the effect of small-dose IV ketamine in combination with continuous femoral nerve block on postoperative pain and rehabilitation after total knee arthroplasty. Continuous femoral nerve block was started with 0.3 mL/kg of 0.75% ropivacaine before surgery and continued in the surgical ward for 48 h with 0.2% ropivacaine at a rate of 0.1 mL . kg(-1) . h(-1). Patients were randomly assigned to receive an initial bolus of 0.5 mg/kg ketamine followed by a continuous infusion of 3 mug . kg(-1) . min(-1) during surgery and 1.5 mug . kg(-1) . min(-1) for 48 h (ketamine group) or an equal volume of saline (control group). Additional postoperative analgesia was provided by patient-controlled IV morphine. Pain scores and morphine consumption were recorded over 48 h. The maximal degree of active knee flexion tolerated was recorded daily until hospital discharge. Follow-up was performed 6 wk and 3 mo after surgery. The ketamine group required significantly less morphine than the control group (45 +/- 20 mg versus 69 +/- 30 mg; P < 0.02). Patients in the ketamine group reached 90 degrees of active knee flexion more rapidly than those in the control group (at 7 [5-11] versus 12 [8-45] days, median [25%-75% interquartile range]; P < 0.03). Outcomes at 6 wk and 3 mo were similar in each group. These results confirm that ketamine is a useful analgesic adjuvant in perioperative multimodal analgesia with a positive impact on early knee mobilization. No patient in either group reported sedation, hallucinations, nightmares, or diplopia, and no differences were noted in the incidence of nausea and vomiting between the two groups.


Cheville et al 2001

A randomized trial of controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty.

Cheville A, Chen A, Oster G, McGarry L, Narcessian E

Journal of Bone & Joint Surgery - American Volume 2001;83-A(4):572–6 [erratum appears in J Bone Join

BACKGROUND: Reliance on "as-needed" analgesia following total knee arthroplasty may lead to inadequate control of pain and delayed recovery of function. Preemptive use of controlled-release opioids may improve pain control, accelerate recovery, and reduce the need for inpatient rehabilitative services. This study was designed to determine whether controlled-release opioids enhance post-arthroplasty pain control and facilitate functional recovery during rehabilitation. METHODS: Fifty-nine patients admitted for inpatient rehabilitation following unilateral total knee arthroplasty were randomized to receive OxyContin (controlled-release oxycodone) (twenty-nine patients) or a placebo (thirty patients) every twelve hours. Both groups could receive on-request, immediate-release oxycodone (5 mg every four hours). The dose of study medication was increased on the basis of the frequency of requests for immediate-release oxycodone. Measures of interest included pain ratings as determined with a visual-analog scale, changes in the range of motion of the knee and quadriceps strength, and improvements in selected Functional Independence Measure scores during the first eight physical therapy sessions. The duration of the hospital stay for rehabilitation also was compared between the two groups. RESULTS: Baseline demographic, clinical, and functional characteristics were similar between the OxyContin and placebo groups. Compared with the placebo group, the patients who received OxyContin reported significantly less pain as well as significantly greater range of motion of the knee (passive motion, p = 0.036; active motion, p< 0.001) and quadriceps strength (p = 0.001) by the eighth physical therapy session. The patients who received OxyContin also were discharged from the rehabilitation hospital at an average of 2.3 days earlier than the patients in the placebo group (p = 0.013). CONCLUSIONS: Preemptive use of controlled-release oxycodone during rehabilitation following total knee arthroplasty leads to improved pain control, more rapid functional recovery, and a reduced need for inpatient rehabilitative services.


Ahdieh et al 2004

Efficacy of oxymorphone extended release in postsurgical pain: a randomized clinical trial in knee arthroplast

Ahdieh H, Ma T, Babul N, Lee D

Journal of Clinical Pharmacology 2004;44(7):767–76

Patients with moderate or severe pain following knee arthroplasty and washout from standard patient-controlled analgesia (PCA) were randomized to receive 20 mg of an extended-release (ER) oxymorphone formulation (n = 65) or placebo (n = 61) q12h for 1 day. Oxymorphone PCA was used as rescue analgesic. Oxymorphone ER provided significant improvements over placebo for most standard single-dose analgesic parameters, including mean total pain relief (TOTPAR) over 0 to 12 hours (19.30 vs. 13.72; p = 0.0056), as well as for all multiple-dose (24-h) efficacy assessments. Oxymorphone-treated patients used significantly less rescue PCA than those who received placebo (p < 0.02). Adverse events such as nausea and constipation were typical of opioids, and laboratory and physical findings were similar between groups. Oxymorphone ER was effective and generally well tolerated. A single dose was active from 2 hours until > or = 12 hours after administration. Comparisons with other oral opioids are warranted, especially in the setting of outpatient and day surgery.


Tarradell et al 1996

Respiratory and analgesic effects of meperidine and tramadol in patients undergoing orthopedic surgery.

Tarradell R, Pol O, Farre M, Barrera E, Puig MM.

Methods Find Exp Clin Pharmacol 1996;18(3):211–218.

The respiratory and analgesic effects of i.v. meperidine, tramadol and their correlation with plasma concentrations of meperidine, tramadol and O-demethyltramadol were determined. Forty-eight patients after total hip or knee replacement were randomly distributed into 3 groups (n = 16 each). At the time of analgesia request, they received in a double-blind manner, i.v. single doses of 100 mg meperidine, 100 mg tramadol, or saline. Thirty minutes after treatment, patients who requested additional analgesia were rescued with 75 mg diclofenac and morphine as required. Patients were evaluated at the time of analgesia request and at set intervals during 4 h. Meperidine induced sedation (p<0.05), respiratory depression (tidal volume, p<0.047; respiratory rate, p < 0.004; % O2 Sat, p<0.036), and hypercapnia (PaCO2, p<0.002). Incidence of nausea and vomiting was higher with tramadol (p<0.02). For the first 30 min, meperidine produced lower pain intensity scores than tramadol or saline (p<0.05). At this time, 14/16 patients on saline, 8/16 on meperidine and 11/16 on tramadol were rescued. Onset for meperidine analgesia was 10 min and > 30 min for tramadol. Both opioids produced similar degree of analgesia in patients who were not rescued. A negative correlation (r= -0.99) between analgesia and tramadol concentrations and a poor positive correlation (r= +0.54) with O-demethyltramadol (a metabolite of tramadol) was observed. Pain intensity differences correlated negatively with meperidine plasma concentrations during the first 30 min (r= -0.97) and positively thereafter (r= +0.92). In the present study, meperidine and tramadol produced comparable analgesia, with a different time course profile, but meperidine induced sedation and respiratory depression while tramadol did not.


Love DR et al 1996

A comparison of variable-dose patient-controlled analgesia with fixed-dose patient-controlled analgesia.

Love DR, Owen H, Ilsley AH, Plummer JL, Hawkins RM, Morrison A

Anesthesia & Analgesia 1996;83(5):1060-4.

We examined the effect on the quality of analgesia and side effects of increasing the patient control component of morphine patient-controlled analgesia (PCA) by offering the patient a choice of bolus dose sizes. Using a three-button hand piece, patients could choose between 0.5-, 1.0-, and 1.5-mg boluses of morphine (variable-dose PCA, VDPCA). Successful demands were delivered by a modified Graseby 3400 Anaesthesia Pump controlled by a Toshiba T1900 computer. This system was compared with conventional fixed-dose PCA (FDPCA) (1.0 mg of morphine) delivered by a Graseby 3300 PCA Pump. Both treatment groups had a 5-min lockout interval. Sixty patients were randomly assigned to receive either VDPCA or FDPCA after major abdominal gynecological surgery or hip or knee arthroplasty. Treatment groups did not differ in their duration of PCA therapy, total morphine consumption, or time spent with mild or severe oxyhemoglobin desaturation. There were no differences in their ease of controlling pain, satisfaction with pain control, experience of pain on movement, quality of sleep, severity of nausea, or incidence of vomiting. Although the more complex VDPCA technique provides adequate postoperative analgesia, it does not offer any advantage over conventional FDPCA.


Zhou TJ et al 2001

Propacetamol Versus Ketorolac for Treatment of Acute Postoperative Pain after Total Hip or Knee Replacement.

Zhou TJ, Tang J, White PF

Anesth Analg 2001;92:1569–1575.

We assessed the analgesic efficacy of IV propacetamol and ketorolac in a double-blinded, placebo-controlled study involving patients undergoing total hip or knee replacement procedures. On the first morning after major joint replacement surgery, 164 patients experiencing moderate-to-severe pain were randomly assigned to receive an IV infusion of propacetamol (2 g), ketorolac (15 or 30 mg), or placebo (saline). Patient-controlled analgesia with morphine was made available as a "rescue" analgesic on patient's request during the 6-h postdosing evaluation period. The median time to onset of analgesia with propacetamol (8 [95% confidence interval 6,10] min) was shorter than ketorolac 15 mg (14 [7,16] min), and placebo (16 [8; not estimable] min) although the differences did not reach statistical significance. However, compared with ketorolac 30 mg, propacetamol had a shorter duration of analgesia (3.5 [2;5.4] vs 6 [3.3; not estimable] h). Analysis of pain intensity and pain relief scores demonstrated that propacetamol produced a significantly greater improvement in pain relief than saline from 45 min until 5 h after the injection. Propacetamol was not significantly different from ketorolac 15 mg and 30 mg with respect to the main analgesic efficacy variables during the 6-h assessment period. The most frequently reported adverse event with propacetamol was injection site pain (28% vs 19% for ketorolac 15 mg, 29% for ketorolac 30 mg, and 10% for placebo, respectively). In conclusion, propacetamol (2 g IV) possesses a similar analgesic efficacy to ketorolac (15 or 30 mg IV) after total hip or knee replacement surgery.


Niskanen and Strandberg 2005

Bedside femoral block performed on the first postoperative day after unilateral total knee arthroplasty: a randomized study of 49 patients.

Niskanen RO, Strandberg N

The Journal of Knee Surgery 2005;18(3):192–6

This randomized study compared the effectiveness of a femoral nerve block with other methods of pain control on the first postoperative day after total knee arthroplasty. The femoral block consisted of a single injection administered at patients' bedside during the surgeon's hospital rounds. Compared with control group patients, femoral block patients reported less pain on a visual analog scale and required one half the amount of oxycodone (P = .021). Additional femoral block or continued epidural analgesia was required more frequently by control group patients. Thus, pain management with femoral blocks resulted in less work for nursing staff (P = .004). Performing a femoral nerve block as needed during the surgeon's hospital rounds is quick and requires minimal additional time without any special equipment. Bedside femoral block is a useful adjunct to other pain control methods following primary total knee arthroplasty.


Hirst et al 1996

Femoral nerve block. Single injection versus continuous infusion for total knee arthroplasty.

Hirst GC, Lang SA, Dust WN, Cassidy JD, Yip RW

Regional Anesthesia 1996;21(4):292–7

BACKGROUND AND OBJECTIVES: This study was conducted to ascertain whether there is any advantage to the continuous-infusion femoral 3-in-1 nerve block over the single-injection femoral nerve block for postoperative analgesia after total knee arthroplasty. METHODS: A double-blind, randomized, controlled study was made of 33 patients undergoing total knee arthroplasty, who were randomized into three groups. Group 1 received a single-injection femoral 3-in-1 nerve block with 20 mL 0.5% bupivacaine with 1:200,000 epinephrine. Group 2 had a catheter placed in the femoral nerve sheath, through which a continuous femoral 3-in-1 nerve block was established. Group 3 patients served as controls. All blocks were performed and assessed prior to induction of standardized general anesthesia. All patients received morphine via patient-controlled analgesia. Pain was recorded on a 100-mm visual analog scale at rest and with motion of the knee. Opioid consumption and side effects were recorded; P = .05 was considered statistically significant. RESULTS: In the recovery room, pain scores with motion were lower in the single-injection and continuous-infusion groups (P < .05). There were no significant differences between any of the groups regarding pain scores or morphine requirements beyond the recovery room. The incidence of nausea was higher in the control group. There were no differences between the groups with respect to overall patient satisfaction. CONCLUSIONS: We were unable to confirm improvements in analgesia provided by continuous-infusion femoral 3-in-1 nerve block for total knee arthroplasty except in the recovery room.


Serpell et al 1991

Comparison of lumbar plexus block versus conventional opioid analgesia after total knee replacement.

Serpell MG, Millar FA, Thomson MF

Anaesthesia 1991;46(4):275–7

A randomised controlled study was undertaken to assess the analgesic efficacy of continuous lumbar plexus block for the first 48 hours after total knee replacement surgery. Boluses of 0.5% bupivacaine with adrenaline 1 in 200,000 (0.3 ml/kg) were administered through a cannula inserted into the neurovascular sheath of the femoral nerve. Thirteen patients who received this block required significantly less morphine than a control group of 16 patients. Pain scores were similar and there were no complications related to this technique.


Szczukowski et al 2004

Femoral nerve block for total knee arthroplasty patients: a method to control postoperative pain.

Szczukowski MJ, Jr., Hines JA, Snell JA, Sisca TS

Journal of Arthroplasty 2004;19(6):720–5

This study was designed to determine the effects of a single-injection femoral nerve block (FNB) using 30 mL of 0.5% bupivacaine with epinephrine 1:200,000, on pain control following total knee arthroplasty (TKA). Forty patients were randomly distributed into 2 groups: Group A received general anesthesia plus a FNB (n = 19), whereas Group B received general anesthesia plus a FNB with 30 mL of preservative-free saline (n = 21). The amount of morphine used, sedation, and average pain perception were measured for the first 24 hours and daily postoperatively. Group A used significantly less morphine (48.1 mg) compared with Group B, which used 76.2 mg during the first 24 hours after surgery (P = 0.003). Group A's sedation scale was significantly less than group B's (2.26 vs 2.67) (P = 0.045). The average pain perception was significantly different (P =.002). Postoperative management of pain following TKA can be improved through a preoperative single-injection FNB with 0.5% bupivacaine plus epinephrine 1:200,000. The cost is minimal, risks appear acceptable, and the procedure is efficacious.


Macalou et al 2004

Postoperative analgesia after total knee replacement: the effect of an obturator nerve block added to the femoral 3-in-1 nerve block.

Macalou D, Trueck S, Meuret P, Heck M, Vial F, Ouologuem S, Capdevila X, Virion JM, Bouaziz H

Anesthesia & Analgesia 2004;99(1):251–4

Femoral nerve block (FNB) does not consistently produce anesthesia of the obturator nerve. In this single-blind, randomized, controlled study we added a selective obturator nerve block (ONB) to FNB to analyze its influence on postoperative analgesia after total knee replacement (TKR). Before general anesthesia, 90 patients undergoing TKR received FNB (Group 1), FNB and selective ONB (Group 2), or placebo FNB (Group 3). Postoperative analgesia was further provided by morphine IV via patient-controlled analgesia. Analgesic efficacy and side effects were recorded in the first 6 h after surgery. Adductor strength decreased by 18% +/- 9% in Group 1 and by 78% +/- 22% in Group 2 (P < 0.0001). Total morphine consumption was reduced in Group 2 compared with Groups 1 and 3 (P < or = 0.0001). Patients in Group 2 reported lower pain scores than those in Groups 1 and 3 (P = 0.0003). The incidence of nausea was more frequent in Groups 1 and 3 (P = 0.01). We conclude that FNB does not produce complete anesthesia of the obturator nerve. Single-shot FNB does not provide additional benefits on pain at rest over opioids alone in the early postoperative period. The addition of an ONB to FNB improves postoperative analgesia after TKR.


Allen et al 1998

Peripheral nerve blocks improve analgesia after total knee replacement surgery.

Allen HW, Liu SS, Ware PD, Nairn CS, Owens BD

Anesthesia & Analgesia 1998;87(1):93–7

Total knee replacement (TKR) produces severe postoperative pain. Peripheral nerve blocks can be used as analgesic adjuncts for TKR, but the efficacy of femoral nerve blocks alone is controversial. The sciatic nerve innervates posterior regions of the knee; thus, performance of both sciatic and femoral nerve blocks may be necessary to improve analgesia after TKR. We performed this study to determine whether peripheral nerve blocks improve analgesia after TKR. In a randomized, double-blind fashion, 36 patients undergoing TKR received either femoral, sciatic-femoral, or sham nerve blocks after a standardized spinal anesthetic. Further postoperative analgesia was provided by patient-controlled i.v. morphine and ketorolac. Pain at rest and with physical therapy, morphine use, nausea, pruritus, sedation, and patient satisfaction were assessed. Patients receiving peripheral nerve blocks reported better analgesia at rest for at least 8 h after transfer to the hospital ward (P < 0.05). Morphine use was decreased by approximately 50% in the peripheral nerve block groups until the second postoperative day (P < 0.02). Side effect profiles and patient satisfaction were similar between groups. We conclude that femoral nerve blocks improve analgesia and decrease morphine use after TKR. The addition of a sciatic nerve block to the femoral nerve block did not further improve analgesic efficacy. Implications: Performance of femoral nerve blocks improves analgesia and decreases the need for morphine after total knee replacement surgery. The addition of a sciatic nerve block to the femoral nerve block does not provide additional benefits.


Dang et al 2005

The value of adding sciatic block to continuous femoral block for analgesia after total knee replacement.

Dang CP, Gautheron E, Guilley J, Fernandez M, Waast D, Volteau C, Nguyen JM, Pinaud M

Regional Anesthesia & Pain Medicine 2005;30(2):128–133

Background and Objectives: The benefit of adding a sciatic nerve block to the femoral block to improve analgesia after total knee replacement is controversial. The aim of this study is to address this controversy in a prospective, comparative, and randomized study. Methods: Patients were allocated randomly to receive a continuous femoral nerve block or continuous blocks of both the femoral and sciatic nerves. Stimulating catheters were used in all cases. A loading dose of 15 mL ropivacaine 0.75% was injected into each catheter, followed by administration of ropivacaine 0.2% (2-5 mL/h infusion via the femoral catheter; bolus 10 mL repeated every 12 hours in the sciatic catheter). The primary outcome was visual analog scale (VAS) scores (0 = no pain, 100 mm = worst pain) in postanesthesia care unit and in the 48-hour period after surgery. The secondary outcomes were amplitude of knee flexion, morphine consumption, and occurrence of postoperative nausea and vomiting (PONV). Results: The VAS scores at rest were significantly higher when there was only continuous femoral nerve block than when there was both continuous femoral and sciatic nerve blocks. This difference progressively decreased and disappeared at 36 hours after surgery. The combined femoral and sciatic blocks decreased the morphine consumption by 81% and significantly decreased the occurrence of PONV. Conclusion: During the 36 hours immediately after total knee replacement, the combination of continuous femoral and sciatic nerve blocks improves analgesia while decreasing morphine consumption and PONV.


Salinas et al 2006

The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an establishe

Salinas FV, Liu SS, Mulroy MF

Anesth Analg 2006;102(4):1234–9

Total knee arthroplasty (TKA) may result in severe pain, and single-injection femoral nerve blocks (SFNB) have been demonstrated to have a limited duration of analgesia. Continuous femoral nerve blocks (CFNB) can prolong the analgesic duration of SFNB. We prospectively randomized 36 patients undergoing TKA to CFNB versus SFNB and evaluated the effect on hospital length of stay (LOS) as the primary outcome within a standardized clinical pathway. Secondary outcomes included visual analog scale (VAS) pain scores, opioid consumption, and long-term functional recovery at 12 wk. Mean VAS resting scores were significantly lower among patients who received CFNB versus SFNB: first day (1.7 vs 3.3 [P = 0.002]) and second day (0.9 vs 3.2 [P < 0.0001]) after surgery. Mean maximal VAS scores during physical therapy were significantly lower among patients who received CFNB versus SFNB: first day (4.7 vs 6.3 [P = 0.01]) and second day (3.9 vs 6.1 [P = 0.0005]) after surgery. Mean oxycodone consumption was significantly lower among patients who received CFNB versus SFNB: 15 mg versus 40 mg (P = or < 0.0001) on the first day after surgery; 20 mg versus 43 mg (P = 0.0004) on the second day after surgery. There was no difference in hospital LOS (3.8 vs 3.9 days) or long-term functional recovery (117 degrees versus 113 degrees knee flexion at 12 wk) between the two groups. The lack of effect provided by increased duration of analgesia (from CFNB) after TKA may now have minimal impact on hospital LOS and long-term functional recovery in the contemporary healthcare environment within the United States


Singelyn and Gouverneur 2000

Extended "three-in-one" block after total knee arthroplasty: continuous versus patient-controlled techniques.

Singelyn FJ, Gouverneur JM

Anesthesia & Analgesia 2000;91(1):176–80

This prospective, randomized, double-blinded study assessed the efficacy of patient-controlled analgesia (PCA) techniques for extended "3-in-1" block after total knee arthroplasty. A total of 45 patients were divided into three groups of 15. Over 48 h, all patients received 0.125% bupivacaine with 1 microg/mL clonidine via a femoral nerve sheath catheter in the following manner: as a continuous infusion at 10 mL/h in Group 1; as a continuous infusion at 5 mL/h plus PCA boluses (2.5 mL/30 min) in Group 2; or as PCA boluses only (10 mL/60 min) in Group 3. Pain scores, sensory block, supplemental analgesia, bupivacaine consumption, side effects, and satisfaction scores were recorded. Pain scores and supplemental analgesia were comparable in the three groups. Bupivacaine consumption was significantly less in Groups 2 and 3 than in Group 1 (P < 0.01), and in Group 3 than in Group 2 (P < 0.01). Side effects and satisfaction were comparable in the three groups. We conclude that extended "3-in-1" block provides efficient pain relief after total knee arthroplasty and that, compared with a continuous infusion, PCA techniques reduce the local anesthetic consumption without compromise in patient satisfaction or visual analog scale scores. Of the two PCA techniques tested, PCA boluses (10-mL lockout; time, 60 min) of 0.125% bupivacaine with 1 microg/mL clonidine was associated with the smallest local anesthetic consumption, and is, therefore, the recommended extended "3-in-1" block technique. IMPLICATIONS: We demonstrated that, after total knee arthroplasty, an extended "3-in-1" block consisting of patient-controlled analgesia boluses (10 mL/60 min) of 0.125% bupivacaine with 1 microg/mL clonidine provides efficient postoperative analgesia and significantly minimizes local anesthetic consumption.


Singelyn et al 1998

Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total

Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM

Anesthesia & Analgesia 1998;87(1):88–92

In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA). Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with i.v. patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than i.v. PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. Implications: In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than i.v. patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice.


Singelyn et al 1998

Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total

Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur JM.

Anesth Analg 1998;87(1):88–92.

In this study, we assessed the influence of three analgesic techniques on postoperative knee rehabilitation after total knee arthroplasty (TKA). Forty-five patients scheduled for elective TKA under general anesthesia were randomly divided into three groups. Postoperative analgesia was provided with i.v. patient-controlled analgesia (PCA) with morphine in Group A, continuous 3-in-1 block in Group B, and epidural analgesia in Group C. Immediately after surgery, the three groups started identical physical therapy regimens. Pain scores, supplemental analgesia, side effects, degree of maximal knee flexion, day of first walk, and duration of hospital stay were recorded. Patients in Groups B and C reported significantly lower pain scores than those in Group A. Supplemental analgesia was comparable in the three groups. Compared with Groups A and C, a significantly lower incidence of side effects was noted in Group B. Significantly better knee flexion (until 6 wk after surgery), faster ambulation, and shorter hospital stay were noted in Groups B and C. However, these benefits did not affect outcome at 3 mo. We conclude that, after TKA, continuous 3-in-1 block and epidural analgesia provide better pain relief and faster knee rehabilitation than i.v. PCA with morphine. Because it induces fewer side effects, continuous 3-in-1 block should be considered the technique of choice. Implications: In this study, we determined that, after total knee arthroplasty, loco-regional analgesic techniques (epidural analgesia or continuous 3-in-1 block) provide better pain relief and faster postoperative knee rehabilitation than i.v. patient-controlled analgesia with morphine. Because it causes fewer side effects than epidural analgesia, continuous 3-in-1 block is the technique of choice.


Weber et al 2005

Duration of analgesia is similar when 15, 20, 25 and 30 mL of ropivacaine 0.5% are administered via a femoral catheter.

Weber A, Fournier R, Riand N, Gamulin Z

Canadian Journal of Anaesthesia 2005;52(4):390–6

PURPOSE: This dose-response study was designed to determine the most appropriate dose of ropivacaine 0.5% injected via an indwelling femoral catheter for perioperative peripheral analgesia for total knee replacement (TKR). METHODS: 84 patients were allocated randomly to four groups and received, via a femoral catheter, either 15, 20, 25 or 30 mL of ropivacaine 0.5% in a double-blind fashion. An anterior sciatic block with 20 mL bupivacaine 0.5% was also performed. The evolution of sensory block of femoral, obturator and lateral femoral cutaneous nerves and motor block of femoral nerve were tested every five minutes during the first 30 min. The percentage of patients with complete sensory block of both femoral and obturator nerves determined success rate. General anesthesia was then induced. After surgery, patient-controlled analgesia (PCA) with ropivacaine 0.2% was available via the femoral catheter. The interval between the initial injection and the first PCA administration determined duration of action. RESULTS: The duration of action was not different between the four solutions tested i.e., 534 +/- 379 min for 15 mL, 799 +/- 364 min for 20 mL, 624 +/- 342 min for 25 mL and 644 +/- 266 min for 30 mL. The percentage of patients with complete sensory femoral and obturator blocks was, respectively, 60%, 95%, 85% and 70% for 15, 20, 25 and 30 mL (P = 0.008/15 mL vs 20 mL). CONCLUSION: Although there is no difference in duration of analgesia, because of better sensory spread, 20 mL of ropivacaine 0.5% appears to be the most appropriate dose for peripheral analgesia after TKR.


Casati et al 2005

Adding clonidine to the induction bolus and postoperative infusion during continuous femoral nerve block delays recovery of motor function after total knee arthroplasty.

Casati A, Vinciguerra F, Cappelleri G, Aldegheri G, Fanelli G, Putzu M, Chelly JE

Anesthesia & Analgesia 2005;100(3):866–72

We evaluated the effects of adding clonidine for continuous peripheral nerve infusions. Sixty patients undergoing total knee arthroplasty under combined single-injection sciatic block and continuous femoral infusion were randomly allocated to three groups: block induction with 0.75% ropivacaine followed by 0.2% ropivacaine (group control; n = 20); block induction with 0.75% ropivacaine and 1 microg/kg clonidine followed by 0.2% ropivacaine (group cloni-bolus; n = 20), and block induction with 0.75% ropivacaine and 1 microg/kg clonidine followed by 0.2% ropivacaine with 1 microg/mL clonidine (group cloni-infusion; n = 20). After surgery, continuous femoral infusion was provided with a patient-controlled infusion pump (basal infusion rate, 6 mL/h; incremental dose, 2 mL; lockout time, 15 min). The median (range) onset time of surgical block was 15 min (5-30 min) in group control, 10 min (5-35 min) in group cloni-bolus, and 10 min (5-30 min) in group cloni-infusion (P = 0.07). No differences were reported among groups in the degree of pain measured with the visual analog scale. The total consumption of local anesthetic solution after a 24-h infusion was 170 mL (144-220 mL) in group control, 169 mL (144-260 mL) in group cloni-bolus, and 164 mL (144-248 mL) in group cloni-infusion (P = 0.51); after the second day of infusion, total consumption was 168 mL (144-200 mL) in group control, 156 mL (144-288 mL) in group cloni-bolus, and 150 mL (144-210 mL) in group cloni-infusion (P = 0.48). Hemodynamic profiles and sedation were similar in the three groups. Motor function impairment after 48 h of infusion was observed in 27% of cloni-infusion patients but in only 6% of both the control and cloni-bolus groups (P = 0.05). We conclude that adding clonidine 1 microg/mL to local anesthetic for continuous femoral nerve block does not improve the quality of pain relief but has the potential for delaying recovery of motor function.


Weber et al 2001

Epinephrine does not prolong the analgesia of 20 mL ropivacaine 0.5% or 0.2% in a femoral three-in-one block.

Weber A, Fournier R, Van Gessel E, Riand N, Gamulin Z.

Anesth Analg 2001;93(5):1327–1331.

We tested the effect of epinephrine added to 20 mL ropivacaine 0.5% and 0.2% on postoperative analgesia via a femoral catheter after total knee replacement. Forty-one patients undergoing total knee replacement under combined peripheral block/general anesthesia were randomly allocated to two groups. After insertion of a femoral catheter, 21 patients in the Ropivacaine-Epinephrine (ROPI-EPI) group received 20 mL ropivacaine 0.5% plus epinephrine 1:200,000, whereas 20 patients in the Ropivacaine group (ROPI) received 20 mL plain ropivacaine 0.5%. Thereafter, a sciatic block with 30 mL bupivacaine 0.5% plus epinephrine 1:200,000 was performed in all patients, followed by general anesthesia. After surgery, patient-controlled analgesia (PCA) with ropivacaine 0.2% plus epinephrine 1:200,000 for Group ROPI-EPI and plain ropivacaine 0.2% for Group ROPI was available via the femoral catheter (200 mL ropivacaine 0.2% +/- epinephrine, bolus 20 mL, lockout 120 min). The patients were instructed to use PCA when the knee pain score was >3 cm. The interval between the initial ropivacaine injection and the first PCA injection determined the duration of 20 mL ropivacaine 0.5% +/- epinephrine, whereas the interval between the first and second PCA injection determined the duration of 20 mL ropivacaine 0.2% +/- epinephrine. The average duration of ropivacaine 0.5% was 657 +/- 345 min for the ROPI-EPI group and 718 +/- 423 min for the ROPI group (NS), whereas for ropivacaine 0.2%, the average duration was 409 +/- 245 min for the ROPI-EPI group and 419 +/- 339 min for the ROPI group (not significant). We conclude that epinephrine does not influence the duration of analgesia of the ropivacaine concentrations investigated. IMPLICATIONS: We evaluated the effect of epinephrine on the duration of analgesia of 20 mL ropivacaine 0.5% or 0.2% injected in femoral three-in-one block for pain relief after total knee replacement. Our results show that epinephrine does not alter the duration of analgesia of the two solutions investigated.


Weir and Fee 1998

Double-blind comparison of extradural block with three bupivacaine-ketamine mixtures in knee arthroplasty.

Weir PS, Fee JP

British Journal of Anaesthesia 1998;80(3):299–301

We have compared 0.5% bupivacaine 75 mg (group A; n = 15) with three 0.5% bupivacaine 75 mg-ketamine mixtures for extradural block in 59 ASA I-III patients undergoing total knee replacement in a randomized, double-blind study. The following doses of preservative-free 1% ketamine were used: 0.3 mg kg-1 (group B: n = 14); 0.5 mg kg-1 (group C: n = 5); and 0.67 mg kg-1 (group D: n = 15). Level of sensory block, degree of motor weakness and sedation scores were recorded before and after operation. Duration of postoperative analgesia was also noted. There was no difference between groups in median maximum level of sensory block (group A: T4 (range T10-T2); group B: T4 (T10-T2); group C: T4 (T8-T2); and group D: T3 (T8-C3)) or in the degree of motor block. Thirty-three of the 44 patients who received ketamine showed signs of systemic absorption (blurred vision, sedation) within 10 min of injection. There was no significant difference between groups in median duration of analgesia (group A: 240 (range 115-340) min; group B: 198 (97-460) min; group C: 150 (122-448) min; and group D: 210 (130-390) min). No patient suffered any adverse psychomimetic effects. We conclude that at the doses used, addition of ketamine to extradural bupivacaine did not improve extradural block in adult patients undergoing total knee replacement.


Himmelseher et al 2001

Small-dose S(+)-ketamine reduces postoperative pain when applied with ropivacaine in epidural anesthesia for total knee arthroplasty.

Himmelseher S, Ziegler-Pithamitsis D, Argiriadou H, Martin J, Jelen-Esselborn S, Kochs E

Anesthesia & Analgesia 2001;92(5):1290–5

Reduction of nociceptive input through blockade of N-methyl-D-aspartate (NMDA) receptors has been reported. We compared the effects of epidural S(+)-ketamine versus placebo on postoperative pain in a randomized, double-blinded study in 37 patients undergoing unilateral knee arthroplasty. After lumbar epidural anesthesia with ropivacaine (10 mg/mL, 10-20 mL), 19 patients received 0.9% epidural saline, and 18 patients received 0.25 mg/kg epidural S(+)-ketamine 10 min before surgical incision. After surgery, patient-controlled epidural analgesia with ropivacaine was provided. During the first 8 h after surgery, visual analog scale pain rating was similar between groups. Twenty-four and 48 h after surgery, patients anesthetized with ropivacaine had higher visual analog scale ratings at rest and during movement (P < 0.05) than patients anesthetized with S(+)-ketamine and ropivacaine. Forty-eight hours after surgery, patients anesthetized with ropivacaine also consumed more ropivacaine (558 +/- 210 mg) (P < 0.01) than those anesthetized with S(+)-ketamine and ropivacaine (319 +/- 204 mg). Adverse events were similar between groups. Patients who received S(+)-ketamine and ropivacaine rated the quality of their pain therapy better than those who received ropivacaine alone (P < 0.05). We conclude that the combination of S(+)-ketamine and ropivacaine in epidural anesthesia increases postoperative pain relief when compared with ropivacaine. IMPLICATIONS: Epidural S(+)-ketamine applied with ropivacaine before surgery is a rational approach to decrease injury-induced pain sensitization. Epidural blockade with an N-methyl-D-aspartate receptor antagonist and a local anesthetic may provide better analgesia in the postoperative period than a local anesthetic alone.


Wong et al 1997

Pre-emptive analgesia with ketamine, morphine and epidural lidocaine prior to total knee replacement.

Wong CS, Lu CC, Cherng CH, Ho ST

Canadian Journal of Anaesthesia 1997;44(1):31–7

PURPOSE: Pre-emptive analgesia can improve postoperative pain management. The purpose of this study was to examine the effectiveness of ketamine as a pre-emptive analgesic as previous studies have shown the involvement of N-methyl-D-Aspartate (NMDA) receptor in neuroplasticity. METHODS: Forty-five ASA 1-2 patients, undergoing unilateral total knee replacement were studied. In the study groups, epidural lidocaine was used as the primary anaesthestic. Patients received ketamine + morphine epidurally 30 min either before (group EB) or after skin incision (group EA). Group G patients received general anaesthesia and ketamine + morphine were given 30 min after skin incision via an epidural catheter used for postoperative pain control. Epidural morphine and ketamine in lidocaine was given to all patients at the end of surgery and every 12 hr for three days for analgesia supplemented with PCA morphine. The time until first PCA trigger, morphine consumption, pain scores, satisfaction scores, and morphine related side effects were recorded at 6, 12, 24, 48 and 72 hr after surgery. RESULTS: Epidural ketamine plus morphine with lidocaine before surgical incision produced better pain relief and patient satisfaction than when given after incision. A longer time to PCA and decreased morphine consumption were observed in group EB than in group G. In group EA, epidural anaesthesia also produced some pre-emptive analgesic effect compared with general anaesthesia shown by decreased morphine consumption. CONCLUSIONS: Administration of ketamine plus morphine with epidural lidocaine anesthesia before surgery provided improved postoperative analgesia compared with general anaesthesia alone or when analgesics were given after skin incision.


Møiniche et al 1994

The effect of balanced analgesia on early convalescence after major orthopaedic surgery.

Møiniche S, Hjortso NC, Hansen BL, Dahl JB, Rosenberg J, Gebuhr P, Kehlet H.

Acta Anaesthesiol Scand 1994;38(4):328–335.

Forty-two patients scheduled for total knee arthroplasty (n = 20) or hip arthroplasty (n = 22) were randomly allocated to receive either continuous epidural bupivacaine/morphine for 48 h postoperatively plus oral piroxicam, or general anaesthesia followed by a conventional intramuscular opioid and acetaminophen regimen. Patients undergoing knee- or hip arthroplasty treated with epidural analgesia had significantly lower pain scores during mobilization under the 48 h epidural infusion compared with patients receiving conventional treatment, while no important differences were observed after cessation of the epidural regimen. However, the achieved pain relief had no impact on postoperative convalescence parameters, such as ambulation, patient activity including need for nursing care, fatigue or hospital stay. Late postoperative pain, fatigue and conservative attitudes and routines in the postoperative care, were the most important reasons limiting mobilization and activity. We conclude that effective early (48 h) postoperative pain relief with balanced analgesia does not per se lead to important improvements in convalescence and hospital stay.


Nielsen et al 1989

Less pain with epidural morphine after knee arthroplasty.

Nielsen PT, Blom H, Nielsen SE

Acta Orthopaedica Scandinavica 1989;60(4):447–8

Twenty-two patients were randomly allocated to systemic opioids or epidural morphine the first 10 days after total knee arthroplasty. Pain was recorded daily in a visual analogue scale, and knee motion was measured on Day 10. Pain was lower in the epidural group, with no difference in knee flexion or range of motion.


Klasen et al 1999

Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty.

Klasen JA, Opitz SA, Melzer C, Thiel A, Hempelmann G

Acta Anaesthesiologica Scandinavica 1999;43(10):1021–6

BACKGROUND: After total knee arthroplasty, patients regularly suffer from severe pain. It is unclear whether epidural or systemic pain therapy is superior in terms of postoperative pain relief, patients' comfort and side effects. A new therapeutic approach, intraarticular opioids, has been suggested with the detection of opioid receptors in inflamed tissue. This method has proven suitable for clinical use in small operations (e.g. knee arthroscopy). In this study, we compared epidural analgesia and intraarticular application of morphine plus "on-demand" intravenous analgesia to "on-demand" intravenous analgesia alone. METHODS: Thirty-seven patients, scheduled for total knee arthroplasty, were randomly assigned to three treatment groups: in group 1 (EPI) patients received bolus doses of morphine via an epidural catheter; in group 2 (IA) an intraarticular bolus of 1 mg of morphine was applied at the end of the operation with subsequent use of a patient-controlled analgesia (PCA) pump; group 3 (Control), in which only PCA was provided, served as control for both analgesic procedures. Main outcome measures included visual analogue pain scales, total morphine consumption, and stress hormones. RESULTS: No statistically significant differences in visual analogue pain scales could be detected between the three groups. Application of intraarticular morphine did not reduce the amount of analgesics required for postoperative analgesia as compared to intravenous analgesia alone. Application of epidural morphine significantly suppressed beta-endorphine release, but did not significantly influence other stress hormones as compared to the control group. CONCLUSION: Epidural and intravenous analgesia after total knee arthroplasty are equivalent methods of pain relief. In major orthopaedic procedures, application of intraarticular morphine does not reduce analgesic requirements.


Badner et al 1991

Low-dose bupivacaine does not improve postoperative epidural fentanyl analgesia in orthopedic patients.

Badner NH, Reimer EJ, Komar WE, Moote CA

Anesthesia & Analgesia 1991;72(3):337–41 [erratum appears in Anesth Analg 1991 May;72(5):718]

Epidural infusions of 10 micrograms/mL fentanyl combined with low-dose bupivacaine (0.1%) were compared with epidural infusions of fentanyl alone for postoperative analgesia after total knee joint replacement. There were no detectable differences between the two groups in analgesia (visual analogue scale ranging between 15 and 40 mm), infusion rates (which averaged 7-9 mL/h), or serum fentanyl levels (which reached 1-2 ng/mL). The incidence of side effects, including nausea, vomiting, and pruritus, was also similar. Of the patients receiving fentanyl and low-dose bupivacaine, one developed a transient unilateral motor and sensory loss, and one developed significant hypotension and respiratory depression. The addition of low-dose bupivacaine does not improve epidural fentanyl infusion analgesia after knee surgery and may increase morbidity.


Silvasti and Pitkanen 2001

Patient-controlled epidural analgesia versus continuous epidural analgesia after total knee arthroplasty.

Silvasti M, Pitkanen M

Acta Anaesthesiologica Scandinavica 2001;45(4):471–6

BACKGROUND: Patient-controlled epidural analgesia (PCEA) has been found to be an effective method for pain relief during labour and after surgery. The goal of this study was to compare the efficacy of bupivacaine-fentanyl PCEA and continuous epidural infusion with the same mixture for treatment of pain after total knee arthroplasty. METHODS: Fifty-four patients under spinal anaesthesia were allocated to two groups in this randomized, double-blind study: the PCEA group could demand a bolus of 0.05 ml/kg of the bupivacaine 1.1 mg/ml and fentanyl 5 microg/ml solution, with a lockout interval of 10 min and total dose limit of three bolus doses per hour. The EPI group received a continuous infusion of 0.1 ml kg(-1) h(-1) of the same bupivacaine-fentanyl solution, and only a minimal extra bolus dose of 0.2 ml with the same lockout interval. All the patients received also paracetamol 1 g, orally, three times a day. In addition to pain scores at rest and during leg lifting, the 20-h analgesic consumption and the incidence of side effects were recorded. RESULTS: Forty-nine patients completed the study. The bupivacaine and fentanyl consumption during 20 h was smaller in the PCEA group (P<0.001). Analgesia and the need for rescue-opioid medication were similar in both groups. There were no differences between the PCEA and EPI groups regarding the incidence of side effects. Five patients were confused about how to operate the PCEA apparatus. CONCLUSION: The amount of bupivacaine-fentanyl solution consumed was significantly less with PCEA than with continuous infusion of bupivacaine-fentanyl solution without affecting the quality of postoperative analgesia after total knee arthroplasty. Several of the elderly patients had difficulties in operating the PCEA apparatus.


Grace et al 1995

Postoperative analgesia after co-administration of clonidine and morphine by the intrathecal route in patients undergoing hip replacement.

Grace D, Bunting H, Milligan KR, Fee JPH.

Anesth Analg 1995;80:86–91.

Postoperative analgesia after intrathecal co-administration of clonidine hydrochloride (75 micrograms) and morphine sulfate (0.5 mg) was compared with analgesia produced after either intrathecal morphine (0.5 mg) or 0.9% sodium chloride in 90 patients undergoing total hip replacement under bupivacaine spinal anesthesia. Patient-controlled morphine requirements were significantly reduced (P < 0.001) postoperation by both clonidine/morphine (median 5 mg/24 h) and morphine (median 7 mg/24 h) compared with control (saline) (median 28 mg/24 h). However, no significant additional reduction in postoperative analgesic requirements was shown with the clonidine/morphine combination compared with morphine alone. Visual analog pain scores, although good in all groups at all times, were significantly poorer in the control group at 2 h (P < 0.04) and 4 h (P < 0.001) after operation compared with both treatment groups, and significantly poorer than the clonidine/morphine group at 6 h (P < 0.002) and 24 h (P < 0.009) postoperation. Mean arterial blood pressure was significantly lower in the clonidine/morphine group than in the two other groups (P < 0.001) between 2 and 5 h after operation. The incidence of emesis was similar in the clonidine/morphine and morphine groups and was significantly more than in the control group.


Axelsson et al 2005

Postoperative extradural analgesia with morphine and ropivacaine. A double-blind comparison between placebo and ropivacaine 10 mg/h or 16 mg/h.

Axelsson K, Johanzon E, Essving P, Weckstrom J, Ekback G

Acta Anaesthesiologica Scandinavica 2005;49(8):1191–1199

Background: Some controversy exists in the literature on the benefit of epidurals compared to patient-controlled intravenous analgesia (PCA). Also, the dose of ropivacaine for epidural analgesia when combined with morphine remains uncertain. The aim of this study was to compare the epidural vs. PCA technique and high-dose vs. low-dose ropivacaine combined with morphine during knee replacement surgery. Methods: In this prospective, randomized, double-blind study, postoperative pain relief with a combination of epidural ropivacaine (Group L: 10 mg h-1, Group H: 16 mg h-1) and morphine (0.16 mg h-1) was evaluated in 30 patients. A placebo group (Group PL) of 15 patients having PCA morphine served as the control. Visual analog pain (VAS), morphine consumption, sensory and motor block and side-effects were recorded during 48 h. Results: VAS scores at rest were significantly lower in Groups L and H compared to Group PL. On movement, Group H had lower VAS scores than Group PL during 3-27 h (P < 0.05) and Group L during 4-9 h (P < 0.05), while Group L had lower a VAS than Group PL during 9-18 h (P < 0.05). Morphine consumption after 48 h was greater in Group PL (64.6 +/- 36.3 mg) vs. Group L (23.3 +/- 33.9 mg) (P < 0.001) and Group H (4.3 +/- 9.6 mg) (P < 0.0001). Mild motor block was seen in Group H in 20% and 14% patients at 24 h and 48 h, respectively, but time to mobilization was similar between the groups. Pruritus was more common in the ropivacaine groups (P < 0.05). Conclusion: Lumbar epidural analgesia using a combination of ropivacaine (16 mg h-1) and morphine (0.16 mg h-1) provides superior analgesia compared to the PCA technique or ropivacaine (10 mg h-1) and morphine (0.16 mg h-1). Although this resulted in a mild motor block during the first 12 h, patient mobilization was similar in all groups. copyright Acta Anaesthesiologica Scandinavica (2005).


Muldoon et al 1998

Comparison between extradural infusion of ropivacaine or bupivacaine for the prevention of postoperative pain after total knee arthroplasty.

Muldoon T, Milligan K, Quinn P, Connolly DC, Nilsson K

British Journal of Anaesthesia 1998;80(5):680–1

We have compared the analgesia and motor block produced by extradural infusions of ropivacaine and bupivacaine after total knee arthroplasty. Fifty-two patients received 8 ml h1 of either 0.2% ropivacaine or 0.2% bupivacaine by extradural infusion for 24 h after operation. Analgesia was assessed by postoperative visual analogue scale (VAS) and morphine consumption. At rest these were low in both groups; median VAS was 0-13.3 mm for the ropivacaine group and 0-0.5 mm for the bupivacaine group. Over the 24 h of the infusion, the estimated (ropivacaine bupivacaine) difference in wound pain at rest was 5.6 mm (P = 0.017) and on passive movement 11.6 mm (P = 0.016). Median morphine consumption was 30.7 mg in the ropivacaine group and 20.5 mg in the bupivacaine group. In the ropivacaine group, 50% of patients compared with 19% in the bupivacaine group had no motor block 2 h after operation, increasing to 88% for ropivacaine and 56% for bupivacaine by 24 h. Bupivacaine produced significantly more frequent and intense motor block over the 24 h (P = 0.015).


Turner et al 1996

Continuous extradural infusion of ropivacaine for prevention of postoperative pain after major orthopaedic surgery.

Turner G, Blake D, Buckland M, Chamley D, Dawson P, Goodchild C, Mezzatesta J, Scott D, Sultana A, W

Br J Anaesth 1996;76(5):606–610.

We studied 151 patients undergoing total hip or knee arthroplasty, or cruciate ligament reconstruction in a multicentre study in Australia and New Zealand. Patients were openly allocated randomly to one of five treatment groups or to a control group. General anaesthesia was induced after introduction of extradural block with 0.5% ropivacaine. After surgery, patients received an extradural infusion of 0.2% ropivacaine at 6, 8, 10, 12 or 14 ml/h or received no postoperative extradural infusion (control group). All patients had access to i.v. PCA morphine for supplementary analgesia. Morphine consumption was lower in all treatment groups compared with the control group, decreasing with increasing ropivacaine infusion rate. Median VAS scores were lower in all ropivacaine infusion groups compared with the control group for the first 10 h of the study; however by the end of the study, VAS scores were similar in all groups. The higher ropivacaine infusion rates caused a slower convergence of spread of the initial sensory block and a higher degree of motor block. The overall incidence of side effects was similar, with the exception of a higher incidence of urinary retention and hypotension in the groups receiving the higher rates of ropivacaine. The quality of treatment scores were similar for all treatment groups


Mauerhan et al 1997

Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty.

Mauerhan DR, Campbell M, Miller JS, Mokris JG, Gregory A, Kiebzak GM

Journal of Arthroplasty 1997;12(5):546–52

The purpose of this study was to determine if intra-articular injection of morphine or bupivacaine significantly decreased postoperative pain as well as the use of intravenous narcotics for pain relief in patients undergoing total knee arthroplasty (TKA). In a prospective, double-blind, randomized fashion, 105 patients undergoing TKA were divided into the following 4 groups defined by the intra-articular injection they received: group 1 (n = 27) received saline solution, group 2 (n = 26) received morphine sulfate (5 mg), group 3 (n = 24) received bupivacaine (50 mg), and group 4 (n = 28) received a combination of morphine sulfate and bupivacaine. The injections were administered immediately after wound closure by the Hemovac drainage tubing that remained clamped for 45 minutes after surgery to allow for absorption. Before surgery and at 2, 4, 6, 24, and 48 hours after surgery, pain intensity was recorded using a visual analog scale. Postoperative supplemental intravenous morphine and/or meperidine was administered via a patient-controlled analgesia device, and 24-hour drug usage was tabulated. Results were suggestive of a modest short-term reduction in pain scores in the morphine and bupivacaine treatment groups compared with placebo (saline); however, results were statistically significant only at 4 hours because of the great variability in the pain score data. The total amount of postoperative pain medication used in the first 24 hours after surgery was not statistically significant between the 4 treatment groups. Thus, the results put into question the benefit of postoperative intra-articular administration of morphine or bupivacaine in patients undergoing TKA.


Holmstrom and Hardin 2005

Cryo/Cuff compared to epidural anesthesia after knee unicompartmental arthroplasty: a prospective, randomized and controlled study of 60 patients with a 6-week follow-up.

Holmstrom A, Hardin BC

Journal of Arthroplasty 2005;20(3):316–21

The aim of this prospective, randomized, and controlled study was to evaluate the efficacy of cold compressive dressings (Cryo/Cuff) and epidural anesthesia (EDA) in the postoperative management of primary unicondylar knee arthroplasty. Sixty patients (61 knees) were randomized into 3 groups. No significant difference between groups was detected with respect to subjective pain, bleeding, swelling, range of motion, and function. The consumption of morphine was, however, significantly higher in the control group the first 24 hours than both the EDA group (P < .001) and the Cryo group (P = .028). There was no significant difference in morphine consumption between the 2 treatment groups. Based on the results of this study, Cryo/Cuff seems to be a rational, effective, risk-free, and well-tolerated alternative to EDA to reduce pain and morphine after unicondylar knee arthroplasty.


Angulo and Colwell 1990

Use of postoperative TENS and continuous passive motion following total knee replacement.

Angulo DL, Colwell Jr CW

Journal of Orthopaedic & Sports Physical Therapy 1990;11(12):599–604

This randomized study analyzed the effectiveness of postoperative transcutaneous electrical nerve stimulation (TENS) used continuously for the first three postoperative days following total knee replacement (TKR) for 1) pain relief, 2) knee flexion arc, 3) narcotic dosage, and 4) hospital stay. Group 1 (n=18) received sensory treshold TENS and group 2 (N=18) received subtreshold TENS. Both groups also used continiuous passive motion during their hospitalization as did patients from group 3 (control, N=12) that did not receive TENS. Pain decrease from postoperative day 1-3 was 50% for group 1 patients and 38% for group 2 patients, as measured by the visual analog scale. Wilcoxon Rank Sum did not show a significant difference (p> 0.05) for pain relief or hospital stay for these two groups. Analysis of variance failed to show significant differences (p>0.05) for knee flexion arc or narcotic dosage for the three groups. Although not statistically significant, an observed decrease in pain may be the only indication for postoperative TENS after TKR.


Can and Alpaslan 2003

Continuous passive motion on pain management in patients with total knee arthroplasty.

Can F, Alpaslan M

The Pain Clinic 2003;15(4):479–485

Continuous passive motion (CPM) has found increasing popularity in rehabilitation of patients undergoing total knee arthroplasty (TKA) over the past decade. However, there is still controversy about its benefits on pain. The objective of this study was to determine whether patients undergoing TKA benefit from CPM. Thirty-two female patients who underwent primary TKA due to degenerative osteoarthritis were included in the study. They were divided into two similar groups (CPM group and non-CPM group). Both groups followed the same postoperative rehabilitation program. Sixteen patients received additional CPM therapy according to a defined protocol for 3 weeks after surgery. All patients were evaluated for pain intensity by VAS and by 'The Knee Society Scoring System' before the treatment, after the treatment, and after the follow-up. Patients were hospitalized for three weeks. The follow-up lasted 3 months. The results showed that the standardized postoperative rehabilitation program relived the pain in both groups. There were no significant differences between the groups, although the patients of the CPM group showed slightly lower pain intensity than those in the non-CPM group. It can be concluded that CPM in TKA patients has no clinical importance for pain relief in postoperative rehabilitation.


Harms and Engstrom 1991

Continuous passive motion as an adjunct to treatment in the physiotherapy management of the total knee arthroplasty patient.

Harms M, Engstrom B

Physiotherapy 1991;77(4):301–307

Over the past decade continuous passive motion (CPM) has found increasing popularity in the management of patients undergoing total knee arthroplasty (TKA). However, the literature contains many controversies about the advantages of CPM and although it has been shown to have some value, there has been no conclusive work on its most beneficial mode of use. The objective of this study was to determine whether patients undergoing TKA benefit from having CPM incorporated into their conventional physiotherapy regime (in terms of speed and quality of recovery) and to establish whether further resource allocation was justified. Pre-operatively 113 TKA patients were randomly allocated to one of two groups, in a prospective study. Both groups performed a standardised exercise programme and one group also spent six hours each day on a CPM machine. The results showed that CPM significantly improved knee range of movement following surgery and patients found it easier to regain their movement. Patients who had CPM recorded lower pain levels and spent less time in hospital, with fewer requiring out-patient physiotherapy. However, these latter results did not reach statistical significance. CPM did not increase the patient's analgesic requirements or wound drainage and neither did it increase the incidence of complications. The groups of patients who appeared to gain the most benefit are identified and an optimum CPM regime is recommended. CPM has a value in the treatment of patients following TKA and apart from the initial cost of the machines, there is little increase in resource requirements when CPM is used as an adjunct to treatment.


May 1999

Comparison of Continuous Passive Motion (CPM) Machines and Lower Limb Mobility Boards (LLiMB) in the Rehabilitation of Patients with Total Knee Arthroplasty

May LA, Busse W, Zayac D, Whitridge MR

Canadian Journal of Rehabilitation 1999;12(4):257–263

No abstract available