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Postoperative pain, inflammation and functional recovery after total hip arthroplasty: Prospective, randomized, clinical studies
Örebro University, School of Medical Sciences.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Total hip arthroplasty (THA) is performed in patients with osteoarthritis of the hip joint. Pain following THA is often moderate but no gold stand-ard exists for pain management. Good postoperative pain management may lead to a better quality of life and hip function. In study I, we inves-tigated whether intrathecal morphine (ITM) or local infiltration analgesia (LIA) is better for pain management. Eighty patients were randomized to one of two groups, ITM or LIA in this randomized double-blind study. Lower pain intensity was recorded early after surgery (< 8 h) in ITM group but subsequently (> 24 h), analgesic consumption, pain intensity on mo-bilization, and side-effects were lower in patients receiving LIA. In study II, in a randomized, double blind study, we compared LIA with femoral nerve block (FNB) for pain management following THA in 56 patients. We found that LIA significantly reduces pain intensity on standing and mobilization at 24 -48 h, as well as rescue analgesic consumption (0 – 24 h) compared to FNB without causing significant side effects. In study III, the same patients were included as in study II to determine the role of inflammation on postoperative pain by analyzing a battery of cytokines in the plasma before and at fixed time points after surgery. We found that LIA has a modest but short-lasting effect (≈4 h) on postoperative inflam-mation, specifically IL-6. This is likely to be due to local infiltration of ketorolac and/or local anesthetics.

Study IV was a long-term follow-up of patients included in study I. We found no differences in quality of life or hip function up to 6 months after surgery when comparing LIA with ITM. Additionally, the incidence of persistent post-surgical pain and postoperative complications was similar between the groups and LIA had no long-term negative effects.

In conclusion, LIA is a good alternative to intrathecal morphine or fem-oral nerve block in patients undergoing THA. The analgesic effect may be due to anti-inflammatory effect of ketorolac injected locally or local anes-thetics. No negative long-term effects of LIA were found. The technique is efficacious, simple to apply and offers a good alternative to intrathecal morphine or femoral nerve block without negative effects during THA.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2017. , 92 p.
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 166
Keyword [en]
Total hip arthroplasty, local infiltration analgesia, intrathecal morphine, femoral nerve block, postoperative pain, spinal anesthesia
National Category
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-58066ISBN: 978-91-7529-210-6 (print)OAI: oai:DiVA.org:oru-58066DiVA: diva2:1110771
Public defence
2017-10-27, Örebro universitet, Campus USÖ, hörsal C3, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2017-06-16 Created: 2017-06-16 Last updated: 2017-09-29Bibliographically approved
List of papers
1. Postoperative pain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and local infiltration analgesia
Open this publication in new window or tab >>Postoperative pain relief after total hip arthroplasty: a randomized, double-blind comparison between intrathecal morphine and local infiltration analgesia
Show others...
2013 (English)In: British Journal of Anaesthesia, ISSN 0007-0912, E-ISSN 1471-6771, Vol. 111, no 5, 793-799 p.Article in journal (Refereed) Published
Abstract [en]

Postoperative pain after total hip arthroplasty (THA) can delay mobilization. This was assessed after intrathecal morphine (ITM) compared with local infiltration analgesia (LIA) using a non-inferiority design. Eighty patients were recruited in this randomized, double-blind study. ITM 0.1 mg (Group ITM) or periarticular local anaesthetic (ropivacaine 300 mg)ketorolac 30 mg epinephrine 0.5 mg (total volume 151.5 ml) (Group LIA) were compared. After 24 h, 22 ml of saline (Group ITM) or ropivacaine (150 mg)ketorolac (30 mg)epinephrine (0.1 mg) (Group LIA) were injected via a catheter. After operation, rescue analgesic consumption, pain intensity, and home-readiness were measured. Morphine consumption was equivalent, median difference 0 mg (95 confidence interval 4 to 4.5) between the groups at 024 h. During 2448 h, it was lower in Group LIA (3 mg, 060 mg, median, range) compared with Group ITM (10 mg, 081 mg) (P0.01). Lower pain scores were recorded at rest at 8 h in Group ITM (P0.01), but in Group LIA on standing and mobilization, at 2448 h (P0.01). Paracetamol and tramadol consumption was lower in Group LIA (P0.05 and 0.05, respectively) as was pruritus, nausea, and vomiting (P0.05). Lower pain intensity was recorded early after surgery in ITM group but later, analgesic consumption, pain intensity on mobilization, and side-effects were lower in patients receiving LIA. LIA is a good alternative to ITM in patients undergoing THA.

Keyword
analgesic techniques, infiltration, pain, postoperative, surgery, orthopaedic
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:oru:diva-56584 (URN)10.1093/bja/aet248 (DOI)000325759100015 ()23872462 (PubMedID)
Available from: 2017-03-20 Created: 2017-03-20 Last updated: 2017-09-29Bibliographically approved
2. Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty: A randomized, double-blind study
Open this publication in new window or tab >>Local infiltration analgesia or femoral nerve block for postoperative pain management in patients undergoing total hip arthroplasty: A randomized, double-blind study
2017 (English)In: Scandinavian Journal of Pain, ISSN 1877-8860, E-ISSN 1877-8879, Vol. 16, 223-230 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND AIMS: Several methods for pain management following total hip arthroplasty (THA) have been described but the best postoperative pain management technique remains uncertain. We compared surgeon applied local infiltration analgesia (LIA) with anaesthesiologist performed femoral nerve block (FNB) using ultrasound. The primary aim was to assess pain intensity 24h after THA.

METHODS: In this randomized, double-blind study, 56 patients (ASA I-III) undergoing THA consented to participate. In Group FNB, patients received an ultrasound-guided femoral nerve block using 30ml of ropivacaine 7.5mg/ml (225mg) while Group LIA received a similar volume of saline. Spinal anaesthesia was then performed and bupivacaine heavy, 3-3.5ml injected depending on patient characteristics. During surgery, patients in Group LIA received a mixture of 300mg (150ml) ropivacaine, ketorolac 30mg (1ml) and adrenaline 0.5mg (0.5ml) (total volume 151.5ml) peri-articularly and subcutaneously while Group FNB received 151.5ml of saline peri-articularly in a systematic way by the surgeon. A multi-hole catheter was placed with the tip placed intra-articularly at the end of surgery in both groups. After 23h, the LIA mixture consisting of 20ml ropivacaine (7.5mg/ml), ketorolac 30mg (1ml), adrenaline 0.1mg (1ml) (total volume 22ml) was injected in Group LIA and the same volume of saline in Group FNB. Postoperative pain, analgesic consumption (postoperative and post-discharge), side effects, home discharge, quality of life and hip function were recorded, the latter up to 6 months after surgery.

RESULTS: Postoperative pain intensity was significantly lower in Group LIA compared to Group FNB during mobilization at 24h (primary endpoint), mean difference 1.8 NRS units (95% CI 0.7-2.9) (P=0.006), at rest after 4h (P=0.029) and on standing after 24 (P=0.0003) and 48h (P=0.043). Rescue morphine consumption was also significantly lower in Group LIA during 0-24, mean difference 13.5mg (95% CI, 6.1-20.9) (P=0.002) postoperatively. Motor block was greater at 6h (P=0.029) postoperatively in Group FNB. Two patients (one in each group) had persistent post-surgical pain (NRS>3) at 3 months (3.6%) but none at 6 month. No other differences were found between the groups.

CONCLUSION: Local infiltration analgesia significantly reduces pain intensity on standing and mobilization, and rescue analgesic consumption compared to femoral nerve block without causing significant side effects. The superior analgesia in the LIA group may result from the secondary injection at 23h postoperatively and needs to be further evaluated in future studies. No differences were found in home discharge, quality of life and hip dysfunction between the groups.

IMPLICATION: Local infiltration analgesia is the preferred method for postoperative pain management following THA compared to single-shot femoral nerve block.

Keyword
Femoral nerve block, Local infiltration analgesia, Postoperative pain, Total hip arthroplasty
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:oru:diva-61186 (URN)10.1016/j.sjpain.2017.05.002 (DOI)28850408 (PubMedID)2-s2.0-85020070292 (Scopus ID)
Available from: 2017-09-29 Created: 2017-09-29 Last updated: 2017-11-13Bibliographically approved
3. Does local infiltration analgesia reduce peri-operative inflammation following total hip arthroplasty?: A randomized, double-blind study
Open this publication in new window or tab >>Does local infiltration analgesia reduce peri-operative inflammation following total hip arthroplasty?: A randomized, double-blind study
2017 (English)In: BMC Anesthesiology, ISSN 1471-2253, E-ISSN 1471-2253, Vol. 17, 63Article in journal (Refereed) Published
Abstract [en]

Background: Postoperative inflammation following total hip arthroplasty (THA) can lead to delayed mobilization and return of hip function. Our primary aim was to assess whether local infiltration analgesia (LIA) during surgery can prevent postoperative inflammation.

Methods: This is a sub-analysis of data from a broader double-blind study where 56 patients received spinal anaesthesia for THA. Additionally, Group FNB (Femoral Nerve Block) received an ultrasound-guided femoral nerve block using 30 mL of ropivacaine 7.5 mg/mL (225 mg), and 151.5 mL of saline peri-articularly intra-operatively. Group LIA received 30 mL saline in the femoral nerve block and ropivacaine 2 mg/mL, 300 mg (150 mL) + ketorolac 30 mg (1 mL) + adrenaline 0.5 mg (0.5 mL) peri-articularly. After 23 h, the LIA mixture (22 mL) was injected via a catheter placed peri-articularly in Group LIA and 22 mL saline in Group FNB. A battery of pro-and anti-inflammatory cytokines was assessed using a commercially available kit preoperatively and after 4 h and 3 days postoperatively. Additionally, CRP, platelet count and white blood count was determined pre- and postoperatively.

Results: There was a general trend towards an increase in pro-inflammatory cytokines postoperatively, which returned to normal levels after 3 days. IL-6 concentration was significantly lower 4 h postoperatively in Group LIA compared to Group FNB (p = 0.015). No other significant differences were found between the groups in other cytokines. CRP levels were significantly higher in Group FNB compared to Group LIA 3 days postoperatively (p < 0.001). No other significant differences were seen between the groups.

Conclusion: Local infiltration analgesia has a modest but short-lasting effect on postoperative inflammation in patients undergoing total hip arthroplasty. This is likely to be due to local infiltration of ketorolac and/or local anaesthetics in the LIA mixture. Future studies should be directed towards assessing whether the use of LIA translates into better patient outcomes.

Place, publisher, year, edition, pages
BioMed Central, 2017
Keyword
Total hip arthroplasty, Local infiltration analgesia, Postoperative inflammation
National Category
Anesthesiology and Intensive Care Surgery
Identifiers
urn:nbn:se:oru:diva-57862 (URN)10.1186/s12871-017-0354-y (DOI)000400426200001 ()28468607 (PubMedID)2-s2.0-85018738510 (Scopus ID)
Note

Funding Agency:

Research Committee, orebro University HospitaL  OLL-590351

Available from: 2017-05-31 Created: 2017-05-31 Last updated: 2017-10-18Bibliographically approved
4. Local infiltration analgesia: a 2-year follow-up of patients undergoing total hip arthroplasty
Open this publication in new window or tab >>Local infiltration analgesia: a 2-year follow-up of patients undergoing total hip arthroplasty
2017 (English)In: Journal of Anesthesia, ISSN 0913-8668, E-ISSN 1438-8359Article in journal (Refereed) Epub ahead of print
Abstract [en]

PURPOSE: Local infiltration analgesia (LIA) is commonly used for postoperative pain management following total hip arthroplasty (THA). However, the long-term effects of the component drugs are unclear. The aim of our study was to investigate functional outcome, quality of life, chronic post-surgical pain, and adverse events in patients within 2 years of undergoing THA.

METHODS: The study was a secondary analysis of data from a previous larger study. Eighty patients were randomized to receive either intrathecal morphine (Group ITM) or local infiltration analgesia (Group LIA) for pain management in a double-blind study. The parameters measured were patient-assessed functional outcome [using the Hip dysfunction and Osteo-arthritis Outcome Score (HOOS) questionnaire], health-related quality of life [using the European Quality of Life-5 dimensions (EQ-5D) questionnaire and the 36-Item Short Form Health Survey (SF-36) score], and pain using the numeric rating score (NRS), with persistent post-surgical pain having a NRS of > 3 or a HOOS pain sub-score of > 30. All complications and adverse events were investigated during the first 2 years after primary surgery.

RESULTS: Pain intensity and rescue analgesic consumption were similar between the groups after hospital discharge. No differences were found in HOOS or SF-36 score between the groups up to 6 months after surgery. A significant group × time interaction was seen in the EQ 5D form in favor of the LIA group. No between-group difference in persistent post-surgical pain was found at 3 or 6 months, or in adverse events up to 2 years after surgery.

CONCLUSION: Analysis of functional outcome, quality of life, and post-discharge surgical pain did not reveal significant differences between patients receiving LIA and those receiving ITM. LIA was found to be a safe technique for THA during the long-term follow-up. However, it should be noted that these conclusions are based on a limited number of patients.

Place, publisher, year, edition, pages
Springer Japan KK, 2017
Keyword
Local anesthetics, Postoperative complications, Quality of life, Total hip arthroplasty
National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:oru:diva-61185 (URN)10.1007/s00540-017-2403-6 (DOI)28856511 (PubMedID)
Available from: 2017-09-29 Created: 2017-09-29 Last updated: 2017-11-14Bibliographically approved

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