Intra-articular magnesium is effective for postoperative analgesia in arthroscopic knee surgery

Background. Several medications are commonly injected intra-articularlyfor postoperative analgesia after arthroscopic knee surgery.Among the potentially efficient substances, magnesium couldbe of particular interest through its NMDA-receptor blockingproperties. Methods. A total of 60 patients undergoing arthroscopic kneesurgery were randomly and double-blindly assigned to two groupsto receive intra-articular injection of either 10 ml of magnesiumsulphate (MgSO₄) (50 mg ml^–1) (Group M) or 10 ml of normalsaline (Group C). Analgesic effect was evaluated by measuringpain intensity (visual analogue scale; VAS) 1, 2, 6, 8, 12,18 and 24 h after operation and the time delay between MgSO₄or saline administration and the first requirement of supplementaryanalgesic medication by the patient (diclofenac). Results. Intra-articular magnesium administration resulted ina significant reduction in pain scores in Group M compared withGroup C 1, 2, 6 and 8 h after the end of surgery [1.7 (0.59),2.2 (0.69), 2.8 (1.01) and 3.5 (1.10) in Group M; 8.0 (1.25),5.9 (1.12), 4.4 (0.67) and 4.5 (1.13) in Group C, respectively].A longer delay between intra-articular injection of the studymedication and first administration of diclofenac was observedin Group M [667 (198) min] as compared with Group C [49 (13)min]. Total diclofenac consumption was significantly lower inGroup M [37.5 (38.14) mg] than in Group C [117.5 (46.95) mg].No early side-effects were noted. Conclusion. Intra-articular magnesium is effective for postoperativeanalgesia in arthroscopic knee surgery.      

Intra-articular morphine and bupivacaine analgesia after arthroscopic knee surgery

We assessed the effectiveness of intra-articular solutions of morphine, bupivacaine with adrenaline and a combination of both, compared with placebo in facilitating mobilisation and reducing postoperative pain and analgesic requirements for 24 h after operation. Forty patients undergoing arthroscopic knee surgery were studied in a double-blind, randomised, controlled trial. All treatments proved more effective than placebo in facilitating earlier mobilisation and in decreasing postoperative pain as measured by visual analogue scale. Morphine alone provided the best analgesia and significantly decreased analgesic consumption for 24 h after surgery. We conclude that 1 mg of intra-articular morphine provides effective pain relief following arthroscopic knee surgery and that the addition of bupivacaine is of no benefit.     

The efficacy of intra-articular ketamine for postoperative analgesia in outpatient arthroscopic surgery

PurposeThe purpose of this study was to compare the postoperative analgesic effects of intra-articularly administered ketamine, neostigmine, and bupivacaine after outpatient arthroscopic surgery.Type of studyProspective, randomized, double-blind, clinical study.MethodsIn this study, 60 patients undergoing arthroscopic surgery other than ligament reconstruction were evaluated for postoperative pain. Ketamine, neostigmine, and bupivacaine were administered intra-articularly. The period of effective analgesia, recorded in minutes, was measured between time 0 and first usage of patient-controlled anesthesia (PCA) by the patients. The visual analog scale (VAS) was used to describe the pain level of the patient.ResultsVAS values were lower for the 3 medication groups compared with the placebo at rest and 90° knee flexion. Intra-articular administration of 0.5 mg/kg ketamine provided longer duration of analgesia as defined by the first PCA use time (P < .05). The total amount of pethidine and analgesia time were longer for the 3 medication groups.ConclusionsOur basic finding was reduction in postoperative pain and consumption of adequate analgesic drugs with intra-articular ketamine, bupivacaine, or neostigmine use. We have not seen any psychomimetic side effects, particularly as seen with higher doses or systemic use. This study may conclude that intra-articular administration of ketamine provides long-lasting and effective analgesia, similar to neostigmine but less effective than bupivacaine after knee arthroscopy without any adverse effects.Level of evidenceLevel I.     

Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine

Intraarticular (i.a.) local anesthetics are often used for the management and prevention of pain after arthroscopic knee surgery. Clonidine prolongs the duration of local anesthetics. We designed this study to determine whether clonidine added to an i.a. injection would result in an analgesic benefit. Fifty patients were randomly assigned to one of five groups that received clonidine (either via the subcutaneous or i.a. route) or saline placebo with or without i.a. bupivacaine, as follows: Group 1 received 30 mL of 0.25% bupivacaine i.a.; Group 2 received 30 mL of 0.25% bupivacaine with clonidine (1 microg/kg) i.a.; Group 3 received 30 mL of 0.25% bupivacaine i.a. and subcutaneous clonidine (1 microg/kg); Group 4 received 30 mL of 0.25% bupivacaine with epinephrine (5 microg/mL) i.a.; and Group 5 received clonidine (1 microg/kg) in 30 mL of saline i.a.. The results of this study revealed a significant difference in analgesia from the i.a. administration of clonidine. The group who received a combination of i.a. bupivacaine and clonidine had a significantly decreased need for oral postoperative analgesics and an increased analgesic duration (P < 0.0001). We conclude that i.a. clonidine improved comfort in patients undergoing knee arthroscopy. Implications: The intraarticular administration of clonidine along with bupivacaine results in a significant improvement in analgesia compared with either drug alone. There was an increased time to first analgesic request and a decreased need for postoperative analgesics.     

Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine and/or morphine

Both clonidine, an alpha(2) agonist, and morphine, an opioid agonist, provide enhanced patient analgesia after arthroscopic knee surgery when administered via the intraarticular (IA) route. Clonidine potentiates morphine analgesia in the animal model. We designed this study to determine whether clonidine or morphine results in better analgesia and whether their combination would provide superior analgesia to either drug alone. We evaluated 60 patients undergoing arthroscopic knee meniscus repair under local anesthesia with sedation. After surgery, patients were randomized into four IA groups: Group B received 30 mL 0.25% bupivacaine; Group BC received 30 mL 0.25% bupivacaine and clonidine 1 microg/kg; Group BM received 30 mL 0.25% bupivacaine and morphine 3 mg; and Group BCM received 30 mL 0.25% bupivacaine, clonidine 1 microg/kg, and morphine 3 mg. This study revealed a significant benefit from the individual IA administration of both clonidine and morphine. The combination of these drugs resulted in decreased postoperative pain and analgesic use, as well as an increased analgesic duration compared with either drug alone. We conclude that IA clonidine and morphine improved comfort compared with either drug alone in patients undergoing knee arthroscopy.     

右美托咪定用于膝关节镜术后多模式镇痛的临床观察

目的 观察右美托咪定（dexmedetomidine,Dex）用于膝关节镜术后多模式镇痛的效果.方法 90例美国麻醉医师协会（ASA）分级Ⅰ～Ⅱ级需行关节镜诊治术患者,按随机数字表法分为3组（每组30例）：A组患者关节腔内注入含1μg/kgDex的0.25％罗哌卡因混合溶液20 ml,静脉给予生理盐水20 ml;B组患者关节腔内注入0.25％罗哌卡因20 ml,静脉给予含1 μg/kg Dex的溶液20 ml;C组关节腔内注入0.25％罗哌卡因20 ml,静脉给予生理盐水20 ml.比较3组患者术后1、2、4、8、12、20、24 h的视觉模拟评分（visual analogue scale,VAS）、Ramsay镇静评分、镇痛持续时间、术后24 h芬太尼用量及副作用发生率.结果 患者术后A组,B组1、2、4、8h的VAS静息及运动状态评分明显低于C组（P＜0.05）;但术后12h后,3组患者VAS评分差异无统计学意义;B组1、2h的Ramsay评分明显高于A组、C组（P＜0.05）,A组2、4h的Ramsay评分高于C组分（P＜0.05）,但术后8h以后,A组、B组、C组3组患者Ramsay评分差异无统计学意义（P＞0.05）,镇痛持续时间A组（650±127） min较B组（452±86） min、C组（390±74）m in明显延长,B组较C组延长（P＜0.05）;术后24 h芬太尼用量A组（22±6）μg较B组（92±10） μg、C组（146±21） μg明显减少,B组较C组减少（P＜0.05）;3组心动过缓发生率B组显著高于A组、C组（P＜0.05）.结论 在膝关节镜术后多模式镇痛方案中,关节腔内注射Dex与罗哌卡因混合液可显著减轻关节镜术后疼痛,减少术后阿片类药物的使用,并延长镇痛持续时间.     

Preoperative naproxen sodium reduces postoperative pain following arthroscopic knee surgery

This study was undertaken to assess the efficacy of a single preoperative dose of naproxen sodium in reducing postoperative pain and length of day surgery stay in patients undergoing arthroscopic knee surgery. A randomized, double-blind clinical trial was carried out on 66 ASA I and ASA II patients scheduled for arthroscopic knee surgery. The treatment group (n = 26) received two capsules containing 275 mg of naproxen sodium each, and the control group (n = 40) received placebo. Preoperative and postoperative visual analogue pain scores, postoperative analgesic requirements in hospital as well as 24 hr after discharge, and length of day surgery stay were studied. There was a decrease in postoperative pain, both in hospital (naproxen 0.7 ±1.2 vs placebo 2.2 ±2.3) and at 24 hr after discharge (naproxen 0.8 ±1.9 vs placebo 3.8 ±3.2) (P = 0.0001). There was no difference in the need for in-hospital postoperative analgesics or in the time to discharge. However, there was a difference in the use of analgesics after discharge (naproxen group 30.4% vs placebo group 71.4%) (P < 0.01). The results of this study suggest that a single preoperative dose of 550 mg naproxen sodium is effective in reducing postoperative pain in arthroscopic knee surgery, both in the immediate postoperative period and for up to 24 hr after the completion of surgery.     

Complications after arthroscopic knee surgery

Purpose

To examine the complications of arthroscopic knee surgeries conducted in the Sports Medicine and Knee Center of our hospital.

Subjects and methods

In this prospective study, a total of 2,623 patients (1,396 men and 1,227 women) who underwent arthroscopic knee surgeries in our center between January 2006 and March 2013 (7 years and 3 months) were studied. The ages at surgery ranged 7–96 years (mean 33.5 years). Arthroscopy was conducted because of sports injuries in 1,653 patients (63.0 %). The main diagnoses included meniscal injury in 920 patients, discoid meniscus in 64 patients, anterior cruciate ligament injury in 580 knees, posterior cruciate ligament injury in 30 knees, loose body in 61 knees, and intraarticular fracture in 33 knees. Arthroscopic procedures included meniscectomy in 987 knees, meniscal suture repair in 262 knees, and anterior cruciate ligament reconstruction in 508 knees. Intraoperative and postoperative complications in these cases were investigated.

Results

The rate of complication was 7 in 2,623 cases (0.27 %). Intraoperative complications comprised three cases of intraarticular instrument breakage and one case of meniscal injury. Postoperative complications consisted of two cases of septic arthritis and one case of superficial infection, and reoperation was necessary in the two cases of septic arthritis. There were no neural, vascular and ligament injuries during surgery, and no complex regional pain syndrome, symptomatic deep vein thrombosis, and pulmonary embolism were observed.

Conclusion

Arthroscopic knee surgeries are considered to be minimally invasive, and are conducted relatively safe with low complication rates. In this series, however, seven cases of complications occurred, including two cases (0.08 %) of septic arthritis. Furthermore, symptomatic thromboembolism has been reported to occur also in arthroscopic surgery. The risk of severe complications has to be acknowledged.     

Effect of intra-articular injection of midazolam and/or bupivacaine on postoperative analgesia after arthroscopic knee surgery

BackgroundA variety of analgesic techniques have been used to manage postoperative pain after arthroscopic knee surgery. We investigated the hypothesis that intra-articular midazolam would result in lower pain score and reduced analgesic requirements.MethodsOne-hundred patients undergoing arthroscopic meniscectomy were allocated randomly to receive intra-articular 20 mL of isotonic saline containing 50 μg/kg midazolam (midazolam group (group M),the bupivacaine group (group B) received 0.25% (20 mL) bupivacaine, and the midazolam with bupivacaine group (group MB) received bupivacaine 0.25% and 50 μg/kg of midazolam in 20 mL. The postoperative analgesia was assessed using visual analog score at rest and during movement at 1/2 h, 1 h, 2 h, 6 h, 12 h, and 24 h.ResultsPatients in group MB showed significantly lower visual analog scores, both at rest and during movement, long time to first postoperative analgesic request, as well as reduced total analgesic consumption than the other two groups.ConclusionIntraarticular administration of midazolam in combination with bupivacaine improves the quality of postoperative analgesia after arthroscopic meniscectomy.     

Interscalene brachial plexus block is superior to subacromial bursa block after arthroscopic shoulder surgery

BACKGROUND: Arthroscopic shoulder surgery is often associated with severe postoperative pain. The results concerning subacromial bursa blockade (SUB) as a method of pain relief have been contradictory. We hypothesized that a SUB and interscalene brachial plexus block (ISB) would similarly reduce early postoperative pain and the need for oxycodone as compared to placebo (PLA). METHODS: Forty-five patients scheduled for arthroscopic shoulder surgery were enrolled in this randomised, prospective study. The ISB and SUB blockades were performed with 15 ml of ropivacaine (5 mg/ml). In the PLA group, 15 ml of 0.9% saline was injected into the subacromial bursa. All patients received general anaesthesia. RESULTS: The mean intravenously patient-controlled delivered oxycodone consumption during the first 6 h was significantly lower in the ISB group (6 mg) than in the SUB group (24.1 mg; P=0.001) or in the PLA group (27 mg; P<0.001). No significant differences were detected between the SUB and PLA groups (P=0.791). The postoperative pain scores during the first 4 h at rest and during the first 6 h on movement were significantly lower in the ISB group than in the SUB and PLA groups. CONCLUSION: After arthroscopic shoulder surgery SUB has a minor effect only on postoperative analgesia, whereas an ISB with low-dose ropivacaine effectively relieves early postoperative pain and reduces the need for opioids.     

Gas-gangrene following arthroscopic surgery

An arthroscopic anterior cruciate ligament repair was followed by gas-gangrene and the development of a compartment syndrome. Treatment consisted of extensive fasciotomy, debridement, and antibiotic therapy with penicillin G, cefotiam, and metronidazole. The patient was also treated with five sessions of hyperbaric oxygen in a pressure chamber for a duration of 2 h per session. This therapeutic regimen resulted in the preservation of a functionally intact extremity despite severe complication.     

Postoperative analgesia by intraarticular and epidural neostigmine following knee surgery

STUDY OBJECTIVES: To define the analgesic efficacy, and to identify a possible site of action, of epidural and intraarticular neostigmine. DESIGN: Randomized, double-blind study. SETTING: Postoperative analgesia, teaching hospital. PATIENTS: 58 ASA physical status I and II patients undergoing knee surgery. INTERVENTIONS: All patients were premedicated with 0.05 to 0.1 mg/kg intravenous midazolam and received combined epidural/intrathecal technique. Intrathecal anesthesia consisted of 20 mg bupivacaine. A 10 mL epidural and intraarticular injection was administered to all patients; this consisted of either the study drug or normal saline. Postoperatively, pain was assessed using the 10 cm Visual Analog Scale (VAS), and intramuscular (IM) 75 mg diclofenac was available at patient request. The control group (CG) received both epidural and intraarticular saline. The 1 microg/kg epidural group (1 microg/kg EG) received epidural neostigmine and intraarticular saline. The 1 microg/kg intraarticular group (1 microg/kg AG) received epidural saline and intraarticular neostigmine. Finally, the 500 microg intraarticular group (500 microg AG) received epidural saline and intraarticular neostigmine. MEASUREMENTS AND MAIN RESULTS: 56 patients were evaluated. Groups were demographically the same and did not differ in intraoperative characteristics. The VAS score at first rescue analgesic and the incidence of adverse effects were similar among groups (p< 0.05). The time (min) to first rescue analgesic was shorter for both the CG (228+/-54) and 1 microg/kg AG (251+/-87) groups compared to the 1 microg/kg EG (333+/-78) and 500 microg AG (335+/- 111) groups (p<0.05). The analgesic consumption (number of IM diclofenac injections (mean [25(th)-75(th) percentile]) in 24 hours was higher in the CG group than both the 1 microg/kg EG and 500 microg AG groups (p<0.05). The overall 24-hour pain VAS score (cm) was higher in the CG group than in the 1 microg/kg EG (p<0.05) group. CONCLUSION: Although peripheral neostigmine 1 microg/kg did not result in postoperative analgesia, the same dose applied epidurally resulted in over 5 hours of analgesia, similar to a fivefold dose applied peripherally. The results suggest that epidural neostigmine has a greater analgesic efficacy than peripherally applied neostigmine.     

A comparison of intra-articular magnesium and/or morphine with bupivacaine for postoperative analgesia after arthroscopic knee surgery

Purpose

Both magnesium and morphine provide enhanced patient analgesia after arthroscopic knee surgery when administered separately via the intra-articular route. Magnesium sulfate amplifies the analgesic effect of morphine. This study was designed to compare the analgesic effects of intra-articular magnesium and morphine, with bupivacaine, when used separately and in combination.

Methods

Eighty patients undergoing arthroscopic menisectomy were randomized blindly into four intra-articular groups: group B+Mor+Mg received 20 ml 0.25% bupivacaine, morphine 2 mg, and magnesium 150 mg; group B+Mor received 20 ml 0.25% bupivacaine and morphine 2 mg; group B+Mg received 20 ml 0.25% bupivacaine and magnesium 150 mg; and group B received 20 ml 0.25% bupivacaine. Pain scores at rest and during movement, analgesic duration, and total analgesic consumption were recorded.

Results

Group B+Mor and group B+Mg patients had equally effective postoperative analgesia. Group B+Mor+Mg patients had significantly reduced visual analogue scale (VAS) values both at rest and during movement and significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic consumption, compared with the other groups.

Conclusion

Intra-articular administration of magnesium sulfate or morphine, with bupivacaine, had comparable analgesic effects in the doses used. Their combination provided more effective postoperative analgesia than either drug alone.     

Intraarticular fentanyl compared with morphine for pain relief following arthroscopic knee surgery

PURPOSE: To compare the analgesia produced by comparable doses of intra-articular (IA) morphine and fentanyl. METHODS: Sixty-nine healthy patients undergoing arthroscopic surgery received a standardized general anesthetic of 4 mg x kg(-1) thiopental and 2 microg x kg(-1) fentanyl followed by 2 mg x kg(-1) succinylcholine prior to tracheal intubation and controlled ventilation. Maintenance of anesthesia was achieved with N2O/O2 and isoflurane. At the conclusion of surgery intra-articular injection was: Group I (n=23) 50 microg fentanyl in 20 ml saline; Group II (n=24) 3 mg morphine in 20 ml saline; Group III (n=22) 20 ml saline. Pain scores at rest using a visual analogue scale were recorded by a separate blinded observer at one, two, four, and eight hours postoperatively. RESULTS: Pain scores at one, two, four, and eight hours were 36, 26.3, 20.9, and 12.8 vs 35.8, 33.8, 28.8, and 21.9 vs 70.5, 57.7, 58.4, and 53.6 for the IA-fentanyl, IA-morphine, and control groups respectively. Pain scores were greater at all times for Group III. Pain scores for Groups I and II were similar at one hour, but thereafter were less (P < 0.001) for the IA-fentanyl group. CONCLUSION: Better postoperative analgesia was achieved with 50 microg intraarticular fentanyl than with 3 mg intraarticular morphine.