Intra-articular narcotics have proven efficacy for providing pain relief following knee arthroscopy. This effect is short-lived. Methadone, with its long serum half-life (thirty-five hours, compared with two hours for morphine) could provide improved and prolonged pain relief. The purpose of the present study was to examine the effects of an intra-articular injection of methadone on postoperative analgesia following arthroscopic anterior cruciate ligament reconstruction.
Sixty-five skeletally mature patients undergoing primary anterior cruciate ligament reconstruction were randomly assigned to one of three groups, all of which received an intra-articular injection consisting of 9.5 mL of 0.5% bupivacaine with 1:200,000 epinephrine at the completion of the procedure. In addition, the remaining 0.5 mL of the syringe was filled with one of three substances. The study group (twenty-five patients) received 5 mg of methadone, the comparison group (twenty-one patients) received 5 mg of morphine, and the control group (nineteen patients) received 0.5 mL of saline solution. All supplemental pain medications were given on an as-needed basis, recorded, and converted to morphine equivalents. Specific variables that were measured included supplemental analgesia requirements during both the inpatient period and the outpatient period (from the time of discharge to the seventh postoperative day) and pain scores.
There was no significant difference in inpatient (p = 0.998) or outpatient (p = 0.887) supplemental analgesic requirements or pain scores between the methadone group (Group 1) and the control group (Group 3). The morphine group (Group 2) required significantly less inpatient (p = 0.014) and outpatient (p = 0.044) supplemental analgesia compared with the control group (Group 3). There were no complications.
The present report represents the first known study of the use of intra-articular methadone and establishes that this analgesic is safe at a single dose of 5 mg. At this dose, however, methadone does not provide improved postoperative analgesia following arthroscopic anterior cruciate ligament reconstruction. In contrast, intra-articular morphine does appear to be effective for decreasing postoperative pain.
"The two-tailed, independent t-test was used to assess length of stay, morphine use, and visual analogue scores. An A-priori sample size was calculated for a two-tailed hypothesis utilizing a mean difference in morphine equivalent use of 7 mg with a standard deviation of 8 mg . A sample size of 34 patients would be needed for a power (beta) of 0.8 and probability level (alpha) of 0.05. "
[Show abstract][Hide abstract] ABSTRACT: Background
Multimodal analgesia following total hip arthroplasty has been shown to improve patient satisfaction, participation with physical therapy, and allow early return to self care. Liposomal bupivacaine is a formulation of local anesthetic which has the potential to provide anesthesia for up to 72 hours following administration. The purpose of this study was to compare the effectiveness of liposomal bupivacaine with bupivacaine following total hip arthroplasty.
A retrospective chart review was performed on 28 patients undergoing total hip arthroplasty or hip resurfacing who received intraoperative administration of liposomal bupivacaine. A control group of 30 patients who had previously undergone total hip arthroplasty or hip resurfacing and had received intraoperative administration of bupivacaine also underwent a chart review. Length of stay, post-operative opioid use, and pain scores were compared for both groups.
The average length of stay in the study group was 1.93 days and the control group length of stay was 2.47 days (p ≤ 0.05). Morphine equivalent use was less in the study group during the first 24 hours compared to the control group (p ≤0.05). During the second and third 24 hours the morphine equivalent use difference was not statistically significant. Visual analogue scores were not significantly different between groups at any time point.
Liposomal bupivacaine administration during total hip arthroplasty appears to decrease the need for opioid use post operatively and decrease length of stay. The results of this study justify the need for a well-designed randomized controlled trial utilizing liposomal bupivacaine as part of multimodal analgesia during THA.
"For example, David J. Stewart in 2005 showed that analgesic effect on intra-articular injection reduced pain after primary arthroscopic ACL reconstruction ligament. In his study, 25 patients received 5 mg methadone, 25 patients received 5 mg morphine and 15 patients received 5 mg saline solution (control group) and the results showed that morphine group had a less pain scale and needed less administration of analgesics in the first 24 hours after surgery, but there was not a significance difference between the methadone and the control groups.15 Results of our study were similar to that of a recent study occurred in 2011 by Lykoudi on patients after knee arthroscopic surgery, which compared intra-articular morphine and control group. "
[Show abstract][Hide abstract] ABSTRACT: Pain after knee surgery, if not relieved, it would lead to a more severe and prolonged pain that can delay the patients recovery and rehabilitation. The effect of pain relief by some drugs after intra-articular injection has been shown. This study compared the effect of intra-articular injection of opioids (morphine, pethidine, methadone, and tramadol) on postoperative relieving pain after arthroscopic anterior cruciate ligament (ACL) reconstruction.
150 candidate patients for knee arthroscopic ACL reconstruction were randomly enrolled into five groups. At the end of the procedure, all patients in each group received a joint injection solution including 9.5 millimeters bupivacaine with 1:200,000 epinephrine. The remaining 0.5 milliliters of syringe capacity was filled with one of the five solutions listed below: methadone group I: 5 mg methadone, morphine group II: 5 mg morphine, pethidine group III: 37.5 mg pethidine, tramadol group IV: 100 mg Tramadol, and control group V: 0.5 ml normal saline. Afterwards, any drug further administered to the patients based on need was recorded, and the morphine equivalent for all drugs was calculated. Patients need to narcotic drugs during the first twelve hours of hospitalization and pain scores were recorded. After data gathering, they were analyzed by SPSS 16 software with chi-Square, Kruskal-Wallis and ANOVA statistical tests.
The highest and the lowest significant pain intensity were seen in placebo and morphine groups, respectively, in the first, second and third 4 hours after surgery. There were significant differences among the groups for need to analgesics. In other words, placebo group needed the highest dosage of analgesics and morphine and methadone groups needed the lowest dosage of analgesics. Morphine and methadone groups had maximum and minimum response to pain, respectively, in the first, second and third 4 hours after surgery.
Administering 5 mg intra-articular morphine after arthroscopic ACL reconstruction is a valuable choice and is recommended to be added to other local anesthetics administrated drugs after this procedure.
Journal of research in medical sciences 09/2011; 16(9):1176-82. · 0.65 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rehabilitation protocols after bone–patellar tendon–bone anterior cruciate ligament reconstruction have become significantly more aggressive over the past decade. Key concepts of an accelerated rehabilitation protocol include immediate full weight bearing, unrestricted range of motion, early closed kinetic exercises, and return to play by 4 months. Additional components of a successful rehabilitation program include appropriate timing of surgery, adequate postoperative analgesia, use of cryotherapy, and diligent surveillance for the development of postoperative motion complications. In addition to thorough patient evaluation and meticulous surgical technique, a comprehensive rehabilitation protocol for the reconstructed knee is an essential part of the overall treatment algorithm of the anterior cruciate ligament-injured extremity. This article reviews a variety of different factors involved in successful rehabilitation after anterior cruciate reconstruction using patellar bone–tendon–bone autograft and presents a comprehensive rehabilitation protocol.
Techniques in Orthopaedics 11/2005; 20(4):439-451. DOI:10.1097/01.bto.0000190445.31887.bc
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