The Role of Intrathecal Morphine for Postoperative Analgesia in Primary Total Joint Arthroplasty under Spinal Anesthesia: A Systematic Review and Meta-Analysis.

OBJECTIVE: To assess the efficacy and safety of intrathecal morphine (ITM) for postoperative analgesia in primary total joint arthroplasty (TJA) under spinal anesthesia and to explore the dose-response relationship for analgesic efficacy or risk of side effects. METHODS: We searched MEDLINE, EMBASE, Web of Science, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov for any studies meeting the inclusion criteria. All the data were summarized using the random effects model. Subgroup analyses were performed based on the surgical procedure and dose of ITM. Meta-regression was used to explore the dose-response relationship. RESULTS: Eighteen randomized controlled trials were included. Compared with the placebo or blank control, ITM reduced the postoperative 24-h morphine consumption by 10.07 mg and prolonged the duration of analgesia. However, ITM significantly increased the risk of pruritus by 2.79 fold, with a tendency to increase the risk of postoperative nausea and/or vomiting (P = 0.08). No difference was observed regarding the length of stay (LOS) and incidence of respiratory depression or urinary retention. Furthermore, meta-regression showed a linear dose-response relationship for the postoperative 24-h morphine consumption but no linear dose-response relationship for the risk of side effects. CONCLUSIONS: Adding morphine to intrathecal anesthetics provides a prolonged and robust analgesic effect without significantly increasing the risk of side effects other than pruritus. Although we found a linear dose-response relationship for the postoperative 24-h morphine consumption, the optimal dose of ITM remains to be further explored in high-quality RCTs with a large sample size.

Effectiveness of High Tibial Osteotomy with or without Other Procedures for Medial Compartment Osteoarthritis of Knee: An Update Meta-Analysis.

To improve the long-term outcomes of high tibial osteotomy (HTO) for gonarthritis, many cartilage repair procedures appeared, but their effects were controversial. To evaluate the efficacy of cartilage repair procedures during HTO for gonarthritis, we performed this update meta-analysis. We performed the system retrieval for clinical trials using various databases and then pooled the outcomes of the included studies. Fifteen studies were involved. The pooled results indicated that there were no significant differences in Kellgren and Lawrence (KL) scale (mean difference [MD] = 0.02, 95% confidence interval [CI] = -0.01 to 0.06, p = 0.24), the femorotibial angle (MD = 0.06, 95% CI = -0.04 to 0.16, p = 0.22), and magnetic resonance imaging (MRI) outcomes (MD = 12.53, 95% CI = -2.26 to 27.32, p = 0.10) of patients in experimental group than control. The subgroup analysis showed that the clinical outcomes of abrasion arthroplasty (AA) were worse than control group (standardized mean difference [SMD] -2.65, 95% CI = -3.67 to -1.63, p < 0.001), while mesenchymal stem cells (MSCs) injection improved the clinical outcomes (SMD = 2.37, 95% CI = 1.25-3.50, p < 0.001). There were significant differences between the two groups in arthroscopic (SMD = 1.38, 95% CI = 0.82-1.94, p < 0.001) and histologic results (relative risk [RR] = 1.77, 95% CI = 1.36-2.29, p < 0.001). The pain relief (MD = 0.17, 95% CI = -3.26 to 3.61, p = 0.92) and operative complications (RR = 1.42, 95% CI = 0.83-2.42; p = 0.19) of the two groups had no significant differences. Our analysis supports that concurrent cartilage repair procedures might improve arthroscopic and histologic outcomes, but they have no beneficial effect on clinical outcomes, radiograph, MRI, and pain relief. The concurrent procedures do not increase the risk of operative complication. Furthermore, MSC has some beneficial effects on clinical outcomes, while AA might play an opposite role.

Efficacy and Safety of Tranexamic Acid in Reducing Blood Loss of Lower Extremity Osteotomy in Peri-acetabulum and High Tibia: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess the efficacy of tranexamic acid (TXA) in reducing total blood loss and transfusion, and the risk of thromboembolic events in patients undergoing periacetabular osteotomy (PAO) and high tibial osteotomy (HTO). METHODS: A systematic literature search was performed using PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), Embase (Ovid), Medline (Ovid), and Web of Science. ClinicalTrials.gov, American Academy of Orthopaedic Surgeons (AAOS), and Orthopaedic Trauma Association (OTA) conference proceedings were also searched to gain more eligible studies. The primary outcome measure was total blood loss and the blood transfusion rate of the TXA group versus control. The meta-analysis was conducted using the RevMan 5.3 and Stata 14.0 software. RESULTS: A total of six studies were included involving 665 patients. Three studies were PAO, and the other three were HTO. The total blood loss in PAO (WMD, -330.49; 95% CI, -390.16 to -270.83; P < 0.001) and HTO (WMD, -252.50; 95% CI, -356.81 to -148.18; P < 0.001) and hemoglobin decline (WMD, -0.74; 95% CI, -1.09 to -0.38; P < 0.001) were significantly less in the TXA group than in the control group. TXA could reduce transfusion rates in PAO (RR, 0.26; 95% CI, 0.09 to 0.75; P = 0.01) but had no effect on HTO (RR, 0.20; 95% CI, 0.01 to 4.10; P = 0.30). The wound complications (RR, 0.62; 95% CI, 0.13 to 2.94; P = 0.54) had no significant difference between TXA and control groups. CONCLUSIONS: This meta-analysis demonstrated that TXA reduces total blood loss and hemoglobin decline in patients undergoing PAO and is safe, but it has little benefit in regard to reducing transfusion rates or wound complications in HTO, so TXA might be unwarranted for routine use for HTO.