Prediction of postoperative pain by preoperative pain response to heat stimulation in total knee arthroplasty.

It has been estimated that up to 54% of the variance in postoperative pain experience may be predicted with preoperative pain responses to experimental stimuli, with suprathreshold heat pain as the most consistent test modality. This study aimed to explore whether 2 heat test paradigms could predict postoperative pain after total knee arthroplasty (TKA). Patients scheduled for elective, unilateral, primary TKA under spinal anesthesia were consecutively included in this prospective, observational study. Perioperative analgesia was standardized for all patients. Outcomes were postoperative pain during walk: from 6 to 24 hours (primary), from postoperative day (POD) 1 to 7 (secondary), and from POD 14 to 30 (tertiary). Two preoperative tonic heat stimuli with 47°C were used; short (5 seconds) and long (7 minutes) stimulation upon which patients rated their pain response on an electronic visual analog scale. Multivariate stepwise linear and logistic regressions analyses were carried out, including 8 potential preoperative explanatory variables (among these anxiety, depression, preoperative pain, and pain catastrophizing) to assess pain response to preoperative heat pain stimulation as an independent predictor for postoperative pain. A total of 100 patients were included, and 3 were later excluded. A weak correlation [rho (95% confidence interval); P value] was observed between pain from POD 1 to 7 and pain response to short [rho=0.25(0.04 to 0.44); P=.02] and to long [rho=0.27 (0.07 to 0.46); P=.01] heat pain stimulation. However, these positive correlations were not supported by the linear and logistic regression analyses, in which only anxiety, preoperative pain, and pain catastrophizing were significant explanatory variables (but with low R-squares; 0.05 to 0.08). Pain responses to 2 types of preoperative heat stimuli were not independent clinically relevant predictors for postoperative pain after TKA.

No effect of fibrin sealant on drain output or functional recovery following simultaneous bilateral total knee arthroplasty: a randomized, double-blind, placebo-controlled study.

BACKGROUND AND PURPOSE: Blood loss after total knee arthroplasty (TKA) may lead to anemia, blood transfusions, and increased total costs. Also, bleeding into the periarticular tissue may cause swelling and a reduction in quadriceps strength, thus impairing early functional recovery. In this randomized, double-blind, placebo-controlled study, we analyzed the possible effect of fibrin sealant on blood loss and early functional recovery in a fast-track setting. METHODS: 24 consecutive patients undergoing bilateral simultaneous TKA were included. 10 mL of fibrin sealant (Evicel) was sprayed onto one knee whereas the contralateral knee had saline. Drain output, the primary outcome, was measured from knee drains removed exactly 24 h after surgery. Secondary outcomes (knee swelling, pain, strength of knee extension, and range of movement (ROM)) were evaluated up to 21 days after surgery. RESULTS: The drain output in knees treated with fibrin sealant and placebo was similar (582 mL and 576 mL, respectively). Likewise, no statistically significant differences were found between groups regarding swelling, pain, strength of knee extension, and ROM. INTERPRETATION: Fibrin sealant as a local hemostatic in TKA showed no benefit in reducing drain output or in facilitating early functional recovery when used with a tourniquet, tranexamic acid, and a femoral bone plug.

Why still in hospital after fast-track hip and knee arthroplasty?

BACKGROUND AND PURPOSE: Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge criteria. Earlier studies have identified patient characteristics predicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA. PATIENTS AND METHODS: To determine clinical and logistical factors that keep patients in hospital for the first postoperative 24-72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin-with opioid only on request. Fulfillment of functional discharge criteria was assessed twice daily and specified reasons for not allowing discharge were registered. RESULTS: Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postoperatively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients. INTERPRETATION: Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, prevention of orthostatism, and rapid recovery of muscle function.

High-volume infiltration analgesia in bilateral hip arthroplasty. A randomized, double-blind placebo-controlled trial.

BACKGROUND AND PURPOSE: High-volume infiltration analgesia may be effective in postoperative pain management after hip arthroplasty but methodological problems prevent exact interpretation of previous studies. METHODS: In a randomized, double-blind placebo-controlled trial in 12 patients undergoing bilateral total hip arthroplasty (THA) in a fast-track setting, saline or high-volume (170 mL) ropivacaine (0.2%) with epinephrine (1:100,000) was administered to the wound intraoperatively along with supplementary postoperative injections via an intraarticular epidural catheter. Oral analgesia was instituted preoperatively with a multimodal regimen (gabapentin, celecoxib, and acetaminophen). Pain was assessed repeatedly for 48 hours postoperatively, at rest and with 45° hip flexion. RESULTS: Pain scores were low and similar between ropivacaine and saline administration. Median hospital stay was 4 (range 2-7) days. Interpretation Intraoperative high-volume infiltration with 0.2% ropivacaine with repeated intraarticular injections postoperatively may not give a clinically relevant analgesic effect in THA when combined with a multimodal oral analgesic regimen with gabapentin, celecoxib, and acetaminophen.

Intraoperative local infiltration analgesia for early analgesia after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial.

BACKGROUND AND OBJECTIVES: High-volume local infiltration analgesia (LIA) is widely applied as part of a multimodal pain management strategy in total hip arthroplasty (THA). However, methodological problems hinder the exact interpretation of previous trials, and the evidence for LIA in THA remains to be clarified. Therefore, we evaluated whether intraoperative high-volume LIA, in addition to a multimodal oral analgesic regimen, would further reduce acute postoperative pain after THA. METHODS: Patients scheduled for unilateral, primary THA under spinal anesthesia were included in this randomized, double-blind, placebo-controlled trial receiving high-volume (150 mL) wound infiltration with ropivacaine 0.2% with epinephrine (10 µg/mL) or saline 0.9%. A multimodal oral analgesic regimen consisting of slow-release acetaminophen 2 g, celecoxib 400 mg, and gabapentin 600 mg was instituted preoperatively. Rescue analgesic consisted of oral oxycodone. Pain was assessed repeatedly the first 8 hrs after surgery using the 100-mm visual analog scale. The primary end point was pain during walking (5 m) 8 hrs after surgery. Secondary end points were pain at rest, pain on 45 degrees of passive flexion of the hip with the leg straight, and cumulative consumption of oxycodone. RESULTS: A total of 120 patients were included. Pain during walking (median [interquartile range] [95% confidence interval]) was low in the ropivacaine versus the placebo group (20 [14-38] [0-93] vs 22 [10-40] [0-83]) and did not differ significantly (P = 0.71). Consumption of rescue oxycodone (5 mg [0-10 mg] [0-24 mg] vs 10 mg [0-15 mg] [0-29 mg]) did not differ (P = 0.45). CONCLUSIONS: Intraoperative high-volume LIA with ropivacaine 0.2% provided no additional reduction in acute pain after THA when combined with a multimodal oral analgesic regimen consisting of acetaminophen, celecoxib, and gabapentin and is therefore not recommended.