Total Knee Arthroplasty 2005

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PROSPECT Total Knee Arthroplasty Subgroup

For each review, a Subgroup of the prospect Working Group performs an initial evaluation of the evidence and also drafts clinical practice statements and recommendations, which are then discussed by the whole Working Group before a final consensus is reached. The Subgroup may sometimes include a non-Working Group member, to provide additional expertise in the procedure being reviewed.   For the total knee arthroplasty review, the Subgroup members were:

• Dr Christian Simanski
• Dr Barrie Fischer

Grades of Recommendation

Recommendations are graded according to the overall level of evidence (LoE) on which the recommendations are based, which is determined by the quality and source of evidence: (Levels of evidence and grades of recommendation in PROSPECT reviews (from 2006)) PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Summary Recommendations

Pre-, intra- and postoperative interventions have been evaluated for the management of postoperative pain following total knee arthroplasty. Unless otherwise stated, ‘pre-operative’ refers to interventions applied before surgical incision, ‘intra-operative’ refers to interventions applied after incision and before wound closure, ‘postoperative’ refers to interventions applied at or after wound closure. The following peri-operative interventions for total knee arthroplasty have been reviewed:

• Pre-operative Recommendations for total knee arthroplasty
• Intra-operative Recommendations for total knee arthroplasty
• Postoperative Recommendations for total knee arthroplasty
• Not recommended for total knee arthroplasty for postoperative analgesia

See Overall Recommendations for the overall strategy for managing pain after total knee arthroplasty.

PROSPECT overall recommendations for postoperative pain management following total knee arthroplasty:

• Recommended (Overall PROSPECT recommendations for TKA)
• Not recommended for postoperative analgesia (Not recommended for total knee arthroplasty)

Description of studies

Literature search

• Systematic review of the literature from 1966–November 2005 using MEDLINE and EmBASE, following the protocol of the Cochrane Collaboration (Total Knee Arthroplasty November 2005 Search Terms)
• Inclusion of randomised studies in English, assessing analgesic interventions in total knee arthroplasty in adults, and reporting pain on a verbal or numerical rating scale or a linear analogue scale
  • Primary outcome measure: postoperative pain scores
  • Secondary outcome measures: supplemental analgesic requirements, other recovery outcomes (adverse effects, functional recovery)
• Identification of 247 studies of peri-operative interventions for postoperative pain following total knee arthroplasty
• 112 studies included (Total Knee Arthroplasty November 2005 Included References
• 135 studies excluded Total Knee Arthroplasty November 2005 Excluded References
• The most common reasons for exclusion were that the study combined data from knee and hip arthroplasty groups (51 studies) without an identifiable knee subgroup, or that pain scores were not reported (39 studies) (Table 1: Total Knee Arthroplasty November 2005 Reasons for Exclusion)

Study quality assessments, levels of evidence and grades of recommendation Recommendations are graded according to the overall level of evidence (LoE) on which the recommendations are based, which is determined by the quality and source of evidence: (Levels of evidence and grades of recommendation in PROSPECT reviews (from 2006)

• Click here for quality scores and levels of evidence for included procedure-specific studies: (Total Knee Arthroplasty November 2005 Quality Scoring + Levels of Evidence)

Quantitative analyses

Overall, few meta-analyses could be performed that used data from more than two studies. This is because there are a limited number of studies of homogeneous design that report similar outcome measures. Therefore, the majority of the procedure-specific evidence was assessed only qualitatively.

Transferable evidence

Transferable evidence of analgesic efficacy from comparable procedures or evidence of other outcomes, such as adverse effects, has been included to support the procedure-specific evidence where this is insufficient to formulate the recommendations.

Many studies that were identified in the literature search included patients undergoing total knee or hip replacement and reported data pooled from all these patients. Such studies are excluded from the procedure-specific systematic review but have been used as additional transferable evidence where required. Data from other types of orthopaedic surgery (e.g. ACL reconstruction, spinal surgery, hip surgery) were not used for transferable evidence of analgesic efficacy in most instances because it was considered that the pain profile of these procedures was too different from that of TKA. However, data from studies in a variety of procedures have been used for evidence of adverse-effects, which can occur regardless of the procedure.

Topics for future research:

• Pre-operative corticosteroids
• Alpha-2-delta subunit ligands (gabapentinoids)
• Peri-operative ketamine
• Single injection versus continuous infusion peripheral nerve block
• Combination femoral and sciatic/obturator nerve block
• Intra-articular/incisional techniques
• Pre- versus post-incisional administration of various agents
• Dose- and duration-dependent effects of conventional NSAIDs and COX-2-selective inhibitors on bone healing
• Combination of conventional NSAIDs with regional analgesic techniques
• Combination of COX-2-selective inhibitors with regional analgesic techniques

 

Abbreviations

bd	twice per day
GA	general anaesthetic
IM	intramuscular
Intra-op	intra-operatively
IV	intravenous
LA	local anaesthetic
NRS	numerical rating scale
PACU	post-anaesthesia care unit
PCA	patient-controlled analgesia
PCEA	patient-controlled epidural analgesia
POD	postoperative day
PONV	postoperative nausea and vomiting
Pre-op	pre-operatively
Postop	postoperatively
RCT	randomised controlled trial
ROM	range of motion
SpO2	median oxygen saturation
TKA	total knee arthroplasty
VAS	visual analogue scale
VRS	verbal rating scale

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Data are available from studies that assessed intra-operative analgesia versus intra-operative placebo, as well as those that assessed intra-operative analgesia versus the same analgesia given pre- or postoperatively. It is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period.

Where there is evidence that the time of administration of analgesics has no significant effect on postoperative pain outcomes, studies are presented in the Postoperative section only, except for those studies specifically comparing different times of administration.

Studies of analgesics that are given peri-operatively (pre-/intra- and postoperatively) are also presented in the Postoperative section only.

Pre-operative analgesia

Data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that, to examine the concept of pre-emptive — or preventive — analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively.

A meta-analysis of studies comparing pre-operative interventions with similar postoperative interventions in various procedures found that pre-operative epidural analgesia resulted in improvements in pain scores, analgesic consumption and time to first rescue analgesic request, whereas pre-operative NSAIDs and local anaesthetic wound infiltration improved analgesic consumption and time to first rescue analgesic request, but not pain scores. Evidence did not support an improvement in postoperative analgesia following administration of pre-operative NMDA antagonists and opioids (Ong 2005).

A previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures — such as orthopaedic, dental, gynaecological and abdominal — has concluded that there is no benefit of pre-emptive over postoperative administration (Møiniche 2002; LoE 1). 

It is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period.

Where there is evidence that the time of administration of analgesics has no significant effect on postoperative pain outcomes, studies are presented in the Postoperative section only, except for those studies specifically comparing different times of administration. This is to simplify interpretation of the overall evidence for efficacy of each analgesic agent or intervention.

Studies of analgesics that are given peri-operatively (administration pre-/intra- and postoperatively) are also presented in the Postoperative section only.

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