Standardized Management Of Peri-operative Pain For Total Knee Arthroplasty

Total knee arthroplasty (TKA) has been regarded as the best way to cure degenerative diseases of the knee, which can significantly relieve pain, improve function of the joint and life quality. However, TKA usually leads to serious postoperative pain which would prevent patients from choosing the procedure. It was reported that of all the patients who intended to receive selective operation,75%worried about postoperative pain,92%needed postoperative analgesia, and80%complained of the in inefficient analgesia. U.S.A accounts for4.9%of the world population, which consumes58.7%of the analgesics. Canada accounts for0.6%of the world population, which consumes5.8%of the analgesics. Japan accounts for1.0%of the world population, which consumes2.1%of the analgesics. While China accounts for20%of the world population, but consumes only1.6%of the analgesics.Good postoperative analgesia facilitates rehabilitation, improves patient satisfaction, and may reduce length of hospital stay, and decreases the potential for postoperative complications such as pneumonia and deep vein thrombosis. In the last decade, one of the greatest advances in TKA is perioperative pain management.4Although there are varieties of pain management modalities including patient controlled analgesia, epidural analgesia, femoral nerve block with or without sciatic nerve block, and multimodal cocktail periarticular injection that can be utilized, these methods are technically demanding, costly and associated with its own benefits and side effects.Multimodal analgesia was proposed by Dahlhe and Wall, which is becoming an important part of perioperative management of TKA. The principle of multimodal analgesia is combination of analgesics acting on different pathways. The application of multimodal analgesia has greatly improved the development of TKA. However, individual differences of the patients have brought in some problems to be solved in the further research.Section I The application of cocktail during total knee arthroplastyObjective To evalute the application of cocktail at different time point during total knee arthroplasty.Methods Eighty patients diagnosed as osteoarthritis were recruited in this study. The cocktail was consisted of0.2g lidocaine, ropivacaine75mg, morphine5mg and meloxicam15mg, which were mixed with normal saline40ml. All the patients were randomly divided into three gourps. Group A:Before skin incision,10ml cocktail would be injected into subcutaneous tissue, the rest30ml into joint capsule, ligament and tendon. Group B:All of40ml cocktail would be injected into the above anatomical structure before closing the incision. Group C:The cocktail would be applied before skin incision and closing incision, with20ml seperately. Group D:No cocktail would be applied. The following indexes were recorded:visual analogue scale (VAS) of pain at2、4、12、24、48hours after procedure; the consumption of sufentanil and tramadol within72hours after procedure; active range of motion at24、48、72hours after procedure; the healing of the incision.Results Within4hours after procedure, there was no significant of VAS among group A, B and C, all of which were better than group D. Between4-12hours after procedure, pain degree of group A and C were lower than group B and D. The consumption of sufentanil and tramadol of group A and C were lesser, with better active range of motion of the knee. Fat liquefaction occurred in only one patient at bursa suprapatellaris.Conclusions The application of cocktail as preemptive analgesia was effective and safe, which could reduce the postoperative pain and promote the rehabilitation of knee function.Section Ⅱ The appilcation of ice therapies for patients after total knee arthroplastyObjective To compare the clinical therapeutic effects of intermittent and continuous ice therapies for patients after total knee arthroplasty.Methods From2010.12to2011.12,121patients diagnosed as knee osteoarthritis were recruited in this study. Patients from2011.6to2011.12(60cases) were divided into the continuous group, the rest (61cases) were divided into the intermittent group. All of the patients received unilateral total knee arthroplasty (TKA), and different types of ice therapies were performed according to the group. The continuous group received continuous ice therapy for48h with Cry/Cuff system after operation, while the intermittent group received intermittent ice therapy for30min each time,6times per day for2days. Clinical evaluation for pain (VAS), swelling and drainage volume were performed.Results VAS for pain, swelling degree and drainage volume of the continuous group were significantly smaller than the intermittent group at12h,24h and48h after TKA.Conclusion Compared with intermittent, continuous ice therapy has the advantage of relieving post-operative pain and swelling, and reducing intra-articular bleeding, taking effect earlierSection III The influence of postoperative pain on the jint function recovery process after total knee arthroplastyObjective To analysis the influence on the recovery process of joint function after total knee arthroplasty.Methods At3-month postoperative follow-up,82patients undertaken unilateral TKA with a primary diagnosis of osteoarthritis were divided into no-mild pain group and moderate-severe pain group according to the retrospective VAS score after discharge. The preoperative thigh circumference was measured to compare with that of5th day postoperatively. And the difference of the thigh circumference was contrasted between the groups. The preoperative knee flexion mobility was recorded to compared with that of5th day postoperatively, and then the increase about the range of motion was calculated between the groups. The preoperative muscle force of quadriceps femoris was measured to compare with that of5th day postoperatively. And the increase of muscle force of quadriceps femoris was calculated between the groups.30metre walking time was recorded to comprehend the influence of pain degree on the early postoperative walking speed.Results Compared with the preoperative status, the thigh circumference on the3-month postoperatively of no-mild pain group was increased by0.94±0.95%, which was significantly lower than that of the moderate～severe pain group (compared with the preoperative status, the thigh circumference increased by8.03±1.99%, P<0.01). The range of motion on the5th day postoperatively showed no difference between the groups. The flexion mobility of no～mild pain group on the3-month postoperatively increased to110.93±12.54°, however, that of moderate severe pain group decreased to82.18±12.03°(P<0.01). Compared with the status on the5th day postoperatively, the muscle force of quadriceps femoris of no～mild pain group on the3-month postoperatively increased by117.21±22.45%, which was significantly higher than that of moderate～severe pain group (increased by33.78±11.71%, P<0.01). The time spent on walking30metre of the no～mild pain group on the3-month postoperatively was21.01±4.86s, which was significantly lower than that of moderate～severe pain group (29.39±6.29s, P<0.01)..Conclusions The pain showed the significantly means of the influence on the recovery process of joint function after total knee arthroplasty. And the pain could lead to the joint swelling subsided slowly, delay the muscle recovery, reduce the joint mobility and make the patients walk slowly..Section IV The comparison of different methods for post-discharge analgesiaObjective To observe the effect and safety of Celecoxib, Tramcontin combining Voltaren Gel on patients suffering from postoperative pain after total knee replacement.Methods Forty-nine patients undertaken TKR admitted from December2012to December2013were divided into two groups randomly. Treatment group:patients were administered to Celecoxib0.2g bid, Tramcontin0.1g bid and Voltaren Gel tid for6w after surgery. Control group:patients were administered to Celecoxib0.2g bid, Tramcontin0.1g bid for6w after surgery. The VAS-REST, VAS-ACTIVITY, VAS-NIGHT, ROM and KSS score were measured at the2nd,6th and10th week respectively after surgery.Results Compared with the control group, VAS-REST, ACTIVITY and NIGHT of treatment group were significantly lower at2nd,6th and10th week; ROM and KSS score showed no difference between two groups at2nd week, but that of treatment group were higher from6th week on..Conclusions The analgesic strategy of Celecoxib0.2g bid, Tramcontin0.1g bid and Voltaren Gel tid for6w was effective and safe for patients after TKR, which obviously relieved postoperative pain and improved knee function.