Articular injection of opioids for postoperative pain management of knee arthroplasty: current status and progress

doi:10.3969/j.issn.2095-4344.2015.37.024

Abstract

Abstract:

BACKGROUND: Articular injections of opioids are widely adopted for pain management of total knee arthroplasty, with both peri-articular and intra-articular administration routes. Recent studies have indicated that commonly used anesthetics, steroids and non-steroidal anti-inflammatory drugs are associated with potential adverse effects. Peripheral opioids are relatively safe with lower complication rates, but great controversy exits regarding the analgesic effects.

OBJECTIVE: To introduce the current clinical application status and basic research progress in peri-articular and intra-articular opioid injections for postoperative analgesia of knee arthroplasties.

METHODS: A computer-based search in PubMed and Embase databases was conducted for clinical and basic research articles related to pain management of knee arthroplasties using peri-articular and intra-articular injections of opioids published from January 1967 to May 2015, using the keywords of “opioids; peri-articular injection; intra-articular injection; analgesia; knee arthroplasty” in English. Irrelevant, poorly related and repetitive studies were excluded.

RESULTS AND CONCLUSION: Peri-articular and intra-articular opioids injection plans vary greatly between different institutions, which does not support reliable quantitative data synthesis for a meta-analysis. Controversy exists regarding its efficacy, but there are studies supporting the usage of opioids for providing effective analgesia in a dose-dependent manner. The peri-articular administration route is associated with lower complication rates including nausea and vomiting compared to systematic injections. Applications of opioids help to avoid potential chondrocyte and stem cell cytotoxicity caused by other anesthetics, steroids and non-steroidal anti-inflammatory drugs, which is important for pain management of total knee arthroplasties. Future investigations are required to promote articular analgesic effects and time duration by exploring more advanced drug combinations and dosage forms.

中国组织工程研究杂志出版内容重点：组织构建；骨细胞；软骨细胞；细胞培养；成纤维细胞；血管内皮细胞；骨质疏松；组织工程

Key words: Opium, Analgesia, Injections, Intra-Articular, Arthroplasty, Replacement, Knee

CLC Number:

R318

Zhang Miao, Zhang Xu-ran, Sun Yu. Articular injection of opioids for postoperative pain management of knee arthroplasty: current status and progress[J]. Chinese Journal of Tissue Engineering Research, 2015, 19(37): 6037-6041.

Figures/Tables 1

References

[1] Maheshwari AV, Blum YC, Shekhar L, et al. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009;467(6):1418-1423.

[2] Busch CA, Whitehouse MR, Shore BJ, et al. The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty. Clin Orthop Relat Res. 2010;468(8):2152-2159.

[3] Kang H, Ha YC, Kim JY, et al. Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study. J Bone Joint Surg Am. 2013;95(4):291-296.

[4] [4] Lo IK, Sciore P, Chung M, et al. Local anesthetics induce chondrocyte death in bovine articular cartilage disks in a dose- and duration-dependent manner. Arthroscopy. 2009;25(7):707-715.

[5] Dragoo JL, Korotkova T, Kanwar R, et al. The effect of local anesthetics administered via pain pump on chondrocyte viability. Am J Sports Med. 2008;36(8):1484-1488.

[6] Rosseland LA. No evidence for analgesic effect of intra-articular morphine after knee arthroscopy: a qualitative systematic review. Reg Anesth Pain Med. 2005;30(1): 83-98.

[7] Badner NH, Bourne RB, Rorabeck CH, et al. Addition of morphine to intra-articular bupivacaine does not improve analgesia following knee joint replacement. Reg Anesth. 1997;22(4):347-350.

[8] Mauerhan DR, Campbell M, Miller JS, et al. Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty. J Arthroplasty. 1997;12(5): 546-552.

[9] Ritter MA, Koehler M, Keating EM, et al. Intra-articular morphine and/or bupivacaine after total knee replacement. J Bone Joint Surg Br. 1999;81(2):301-303.

[10] Klasen JA, Opitz SA, Melzer C, et al. Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty. Acta Anaesthesiol Scand. 1999;43(10):1021-1026.

[11] Tanaka N, Sakahashi H, Sato E, et al. The efficacy of intra-articular analgesia after total knee arthroplasty in patients with rheumatoid arthritis and in patients with osteoarthritis. J Arthroplasty. 2001;16(3):306-311.

[12] Rasmussen S, Kramhøft MU, Sperling KP, et al. Increased flexion and reduced hospital stay with continuous intraarticular morphine and ropivacaine after primary total knee replacement: open intervention study of efficacy and safety in 154 patients. Acta Orthop Scand. 2004;75(5): 606-609.

[13] Fu P, Wu Y, Wu H, et al. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty - a randomized controlled trial. Knee. 2009;16(4):280-284.

[14] Garcia JB, Barbosa Neto JO, Vasconcelos JW, et al. Analgesic efficacy of the intra-articular administration of high doses of morphine in patients undergoing total knee arthroplasty. Rev Bras Anestesiol. 2010;60(1):1-12.

[15] Fu PL, Xiao J, Zhu YL, et al. Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial. J Int Med Res. 2010;38(4):1404-1412.

[16] Joo JH, Park JW, Kim JS, et al. Is intra-articular multimodal drug injection effective in pain management after total knee arthroplasty? A randomized, double-blinded, prospective study. J Arthroplasty. 2011;26(7):1095-1099.

[17] Lombardi AV Jr, Berend KR, Mallory TH, et al. Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop Relat Res. 2004;(428):125-130.

[18] Busch CA1, Shore BJ, Bhandari R, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am. 2006;88(5):959-963.

[19] Mullaji A, Kanna R, Shetty GM, et al. Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty:a prospective, randomized trial. J Arthroplasty. 2010;25(6):851-857.

[20] Koh IJ, Kang YG, Chang CB, et al. Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA?: A randomised, controlled study. Knee. 2012;19(4):253-259.

[21] Koh IJ, Kang YG, Chang CB, et al. Use of reduced-dose periarticular injection for pain management in simultaneous bilateral total knee arthroplasty. J Arthroplasty. 2012; 27(9): 1731-1736.e1.

[22] Tammachote N, Kanitnate S, Manuwong S, et al. Is pain after TKA better with periarticular injection or intrathecal morphine? Clin Orthop Relat Res. 2013;471(6):1992-1999.

[23] Tsukada S, Wakui M, Hoshino A. Postoperative epidural analgesia compared with intraoperative periarticular injection for pain control following total knee arthroplasty under spinal anesthesia: a randomized controlled trial. J Bone Joint Surg Am. 2014;96(17):1433-1438.

[24] Tsukada S, Wakui M, Hoshino A. Pain control after simultaneous bilateral total knee arthroplasty: a randomized controlled trial comparing periarticular injection and epidural analgesia. J Bone Joint Surg Am. 2015;97(5):367-373.

[25] Gungor I, Yilmaz A, Ozturk AM, et al. Bupivacaine and levobupivacaine induce apoptosis in rat chondrocyte cell cultures at ultra-low doses. Eur J Orthop Surg Traumatol. 2014;24(3):291-295.

[26] Breu A, Rosenmeier K, Kujat R, et al. The cytotoxicity of bupivacaine, ropivacaine, and mepivacaine on human chondrocytes and cartilage. Anesth Analg. 2013;117(2): 514-522.

[27] Cai XY, Xiong LM, Yang SH, et al. Comparison of toxicity effects of ropivacaine, bupivacaine, and lidocaine on rabbit intervertebral disc cells in vitro. Spine J. 2014;14(3): 483-490.

[28] Breu A, Eckl S, Zink W, et al. Cytotoxicity of local anesthetics on human mesenchymal stem cells in vitro. Arthroscopy. 2013;29(10):1676-1684.

[29] Haasters F, Polzer H, Prall WC, et al. Bupivacaine, ropivacaine, and morphine: comparison of toxicity on human hamstring-derived stem/progenitor cells. Knee Surg Sports Traumatol Arthrosc. 2011;19(12):2138-2144.

[30] Abdulla A, Adams N, Bone M, et al. Guidance on the management of pain in older people. Age Ageing. 2013;42 Suppl 1:i1-57.

[31] Dragoo JL, Korotkova T, Kim HJ, et al. Chondrotoxicity of low pH, epinephrine, and preservatives found in local anesthetics containing epinephrine. Am J Sports Med. 2010; 38(6):1154-1159.

[32] Ficklscherer A, Kreuz PC, Sievers B, et al. Fentanyl is less toxic on adult human mesenchymal stem cells compared to ropivacaine when used intraarticularly. A controlled in vitro study. Connect Tissue Res. 2013;54(6):403-407.

[33] Dalury DF, Lieberman JR, MacDonald SJ. Current and innovative pain management techniques in total knee arthroplasty. J Bone Joint Surg Am. 2011;93(20): 1938-1943.

[34] Ishikawa G, Nagakura Y, Takeshita N, et al. Efficacy of drugs with different mechanisms of action in relieving spontaneous pain at rest and during movement in a rat model of osteoarthritis. Eur J Pharmacol. 2014;738: 111-117.

[35] Stein C, Millan MJ, Shippenberg TS, et al. Peripheral opioid receptors mediating antinociception in inflammation. Evidence for involvement of mu, delta and kappa receptors. J Pharmacol Exp Ther. 1989;248(3):1269-1275.

[36] Badner NH, Bourne RB, Rorabeck CH, et al. Intra-articular injection of bupivacaine in knee-replacement operations. Results of use for analgesia and for preemptive blockade. J Bone Joint Surg Am. 1996;78(5):734-738.