The Journal of Bone and Joint Surgery 82:1754 (2000)
© 2000 The Journal of Bone and Joint Surgery, Inc.
Pain Management in Patients Who Undergo Outpatient Arthroscopic Surgery of the Knee*
Scott S. Reuben, M.D. and
Joseph Sklar, M.D.
*No benefits in any form have been received or will be received
from a commercial party related directly or indirectly to the subject
of this article. No funds were received in support of this study.
Department of Anesthesiology, Baystate Medical Center, 759 Chestnut
Street, Springfield, Massachusetts 01199. E-mail address: scott.reuben{at}bhs.org
New England Orthopedic Surgery, 300 Carew Street, Springfield,
Massachusetts 01104. E-mail address: jsklar@concentric.net.
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Introduction
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 Arthroscopy of the knee joint produces an initial afferent
barrage of pain signals that have the capacity to initiate prolonged
changes in the nervous system leading to the amplification and prolongation
of postoperative pain.
Preemptive analgesia involves the administration of analgesics
prior to painful stimuli to prevent the amplification of postoperative
pain.
It is currently recommended that multimodal analgesic regimens
be utilized in the management of postoperative pain.
Intra-articular bupivacaine and morphine are effective analgesics
for arthroscopic knee surgery.
Intra-articular ketorolac, corticosteroids, and clonidine may
also have a role in reducing pain following arthroscopic knee surgery.
Nonsteroidal anti-inflammatory drugs play an important role in
the management of postoperative orthopaedic pain, and the newer
cyclooxygenase-2-specific nonsteroidal anti-inflammatory drugs may
have additional advantages with respect to safety.
Preemptive and multimodal analgesic techniques should be utilized
in the management of patients undergoing anterior cruciate reconstruction.
Arthroscopy of the knee joint, including reconstruction of the
anterior cruciate ligament, is a common procedure that is routinely
performed on an outpatient basis. Traditionally, oral analgesics are
prescribed for the management of postoperative pain. The routine
prescription of oral opioid analgesics administered on an as-needed
basis, however, frequently results in inadequate pain relief112. Unrelieved postoperative pain
may delay the patient's eligibility for discharge, resulting in
a prolonged hospital stay, inability to participate in rehabilitation
programs, delayed recovery, poor outcome, and greater use of health-care
resources112. At present, several
techniques are available to treat pain following arthroscopic knee
surgery; these include the use of opioids (providing either peripherally
or centrally mediated analgesia), local anesthetics, nonsteroidal
anti-inflammatory drugs, corticosteroids, clonidine, and cryotherapy (Fig. 1). In this paper,
we will present a review of the current knowledge of the principles
of acute pain physiology as well as current techniques for the control
of pain associated with arthroscopic knee surgery.
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Fig. 1: Drawing
depicting sites of action of analgesics along the pain pathway from
the periphery to the central nervous system (CNS). NSAIDs = nonsteroidal
anti-inflammatory drugs.
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Principles of Acute Pain Physiology
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Operative procedures produce an initial afferent barrage of pain
signals and generate a secondary inflammatory response, both of
which contribute substantially to postoperative pain. The signals have
the capacity to initiate prolonged changes in both the peripheral
and the central nervous system that will lead to the amplification
and prolongation of postoperative pain121.
Peripheral sensitization, a reduction in the threshold of nociceptor
afferent peripheral terminals, is a result of inflammation at the
site of surgical trauma82. Central
sensitization, an activity-dependent increase in the excitability
of spinal neurons, is a result of persistent exposure to nociceptive
afferent input from the peripheral neurons119.
Taken together, these two processes contribute to the postoperative
hypersensitivity state ("spinal wind-up") that is responsible for
a decrease in the pain threshold, both at the site of injury (primary hyperalgesia)
and in the surrounding uninjured tissue (secondary hyperalgesia)121 (Fig. 2).
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Fig. 2: Surgical
trauma leads to the release of inflammatory mediators at the site
of injury, resulting in a reduction in the pain threshold at the
site of injury (primary hyperalgesia) and in the surrounding uninjured
tissue (secondary hyperalgesia). Peripheral sensitization results
from a reduction in the threshold of nociceptor afferent terminals
secondary to surgical trauma. Central sensitization is an activity-dependent
increase in the excitability of spinal neurons (spinal wind-up)
as a result of persistent exposure to afferent input from peripheral
neurons. CNS = central nervous system, and NSAIDs = nonsteroidal
anti-inflammatory drugs.
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Over the past decade, a greater understanding of pain mechanisms
has led to the concept of preemptive analgesia. Preemptive analgesia
involves the administration of analgesics prior to painful stimuli
to prevent the establishment of central sensitization and thus the
amplification of postoperative pain114.
The concept of preemptive analgesia is based on animal studies13,23,120 that revealed that local
anesthetics or opioids can prevent the development of prolonged
behavioral and physiological sequelae following brief noxious stimuli.
In contrast, these agents were found to be less effective when they
were administered after the development of central hyperexcitability. However,
the results of human clinical studies are more controversial57. Although the benefits of preemptive
analgesia have been extensively reported in the anesthesia and general
surgical literature121, they have
received little attention in the orthopaedic literature.
Total or optimal pain relief allowing normal function is difficult
to achieve with a single drug or method55.
It is currently recommended that combined analgesic regimens (multimodal
analgesia) that operate through different mechanisms or sites be utilized.
A multimodal analgesic regimen takes advantage of the additive or
synergistic effects of various analgesics, permitting the use of
smaller doses with a concomitant reduction in side effects55. At present, several analgesic techniques
are available to block nociceptive transmission following arthroscopic
knee surgery. At the peripheral level, one may utilize nonsteroidal
anti-inflammatory drugs, corticosteroids, opioids, or cryotherapy.
Local anesthetics block neuronal transmission at the site of instillation,
and oral opioids work at the level of the central nervous system
(Fig. 1).
The primary goal of modern pain management is to reduce pain
at both the central and the peripheral level, in combination with
preemptive analgesia. This strategy should enhance restoration of function
by allowing patients to walk and to participate in rehabilitation
programs more easily, thereby improving the overall postoperative
outcome.
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Arthroscopic Knee Surgery
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Arthroscopy of the knee has spared patients large incisions and
decreased morbidity compared with those of open procedures, but
it has not eliminated pain44.
Most of the intra-articular structures of the knee, including the
synovial tissue, the anterior fat pad, and the joint capsule, have
free nerve-endings that are capable of sensing painful stimuli and
producing severe pain26. Arthroscopic
procedures may cause enough pain and swelling to delay rehabilitation
and return to work for up to two weeks after surgery25,108. Patients who cannot complete
a rehabilitation program may be at an increased risk for postoperative
complications (delay in strength recovery, prolonged knee stiffness,
anterior knee pain)25,77,98,108.
Therefore, aggressive pain management in the early postoperative
period is essential and can enhance convalescence after arthroscopy84.
Intra-Articular Bupivacaine
Intra-articular local anesthetics are frequently used in perioperative
pain management. Bupivacaine, an amide local anesthetic, is often
utilized because of its extended duration of action78. Serum levels peak within thirty
to sixty minutes after the injection and remain well below toxic
levels following injection of 150 milligrams or less into the knee
joint75. Intra-articular bupivacaine
in doses of 0.5 percent or less does not appear to be harmful to
articular cartilage81.
The analgesic efficacy of bupivacaine that is injected into the
intra-articular space remains somewhat controversial. Several studies43,76 have failed to demonstrate a
substantial analgesic effect, while others12,36,100 have
documented at least some benefit. Unfortunately, these studies had
serious problems with respect to design, data collection, and reporting. There
was considerable variability in the volume and concentration of
the intra-articular bupivacaine that was administered. In addition,
there were confounding variables that are known to affect postoperative
pain, including the use of perioperative nonsteroidal anti-inflammatory
drugs, opioids, tourniquets, and epinephrine and infiltration of
portals with lidocaine or bupivacaine.
The dose of bupivacaine may be an important factor. Smith et
al.100 believed that the lack
of an observed analgesic effect in previous studies of intra-articular
bupivacaine43,76 might have been
the result of use of a concentration of only 0.25 percent. Smith
et al. assessed the efficacy of 150 milligrams (thirty milliliters
of a 0.5 percent solution) of bupivacaine in ninety-seven patients
undergoing arthroscopic knee surgery under general anesthesia. Patients
were randomized to receive either intra-articular bupivacaine or saline
solution at the conclusion of the operative procedure. The patients
who received 0.5 percent bupivacaine were less likely to require
postoperative narcotics and used lower doses of these medications
than did the placebo group. In addition, use of 0.5 percent bupivacaine
resulted in earlier walking and discharge than did use of the placebo.
Another factor that may have led to a negative result in studies
of the analgesic efficacy of bupivacaine is the relatively low mean
visual analog pain scores (less than 3.3 centimeters) in both the bupivacaine
and the control group43,76. Many
of the procedures in these studies were diagnostic arthroscopies,
which require minimal postoperative analgesia. In the study by Geutjens and
Hambidge36, for example, the control
(saline-solution) group required no analgesics after ten hours postoperatively.
Furthermore, another variable that has not been well documented
in the literature is whether patients had postoperative hemarthrosis,
which can increase the level of pain and decrease the concentration
of bupivacaine within the knee joint.
On balance, the majority of studies have suggested that intra-articular
bupivacaine is an effective analgesic and have supported its use
in the management of pain following arthroscopic knee surgery. However,
better-designed trials are still needed for a more conclusive determination.
Intra-Articular Morphine
Intra-articular bupivacaine may provide effective postoperative
analgesia; however, its effectiveness appears to be short-lived
(two to four hours)12,36. Patients
recovering from arthroscopic knee surgery may still require supplemental
analgesia prior to discharge and later at home. Narcotic analgesics are
a popular choice, but they can cause side effects, including respiratory
depression, sedation, pruritus, nausea, and vomiting, that can delay
discharge from the ambulatory surgical center, increase the overall
morbidity of the procedure, and increase the risk to the patient
while he or she is at home. Opioids administered orally may not
be absorbed due to postoperative nausea, vomiting, or ileus. The
recent discovery that opiate receptors exist in peripheral tissue
is of great potential value for preventing or reducing postoperative
pain.
The presence of opioid receptors in the central nervous system
has long been recognized, but recently they also have been demonstrated
in peripheral nerve-endings64 and
have been documented by immunohistochemical analysis of biopsy specimens
from inflamed synovial tissue as well as confirmed by specific binding
of naloxone to receptor sites in the knee61.
All three opioid receptors (mu, delta, and kappa) have been isolated
on peripheral nerves and shown to be responsible for mediating peripheral
antinociception103. These receptors
are synthesized in the cell bodies of primary sensory neurons located
in the dorsal root ganglia and are transported distally by means of
axoplasmic flow106.
The fact that locally administered opioids produce analgesia
in the presence of inflammation105 and
not in normal tissue has been explained in several ways. First,
it has been proposed that inflammation induces a disruption of the
perineurium, allowing easier access of opioids to neuronal receptors.
Alternatively, or in combination with this mechanism, previously
inactive opioid receptors may be rendered active or may be unmasked under
conditions of inflammation107.
The mechanism of the peripheral antinociceptive effect of opioids
in inflamed tissues has not been precisely defined. It has been
hypothesized to occur by either an analgesic effect or an anti-inflammatory
effect, or both61. An analgesic
effect has been postulated because morphine reduces the excitability
of the nociceptive input terminal of C-fiber neurons. This results in
a reduction in the central processing of pain. Opioids also have
a direct anti-inflammatory action in peripheral tissues, since the
binding of peripheral opioid receptors seems to inhibit the release
of proinflammatory neuropeptides, such as substance P105.
To our knowledge, Stein et al.104 were
the first to demonstrate a prolonged analgesic effect from the intra-articular
administration of morphine in humans. Since then, numerous clinical
investigations have confirmed that the administration of relatively
small doses of intra-articular morphine can provide effective and
long-lasting analgesia4,9,11,19,21,22,40-42,45-47,50,52,56,65,66,68,72,80,86,92.
Plasma profiles for morphine and its metabolites following intra-articular
injection have been shown to be too low to produce effective systemic analgesia47. In other studies8,9,11,86,104,
a dose of morphine identical to that given intra-articularly but
administered through the systemic route failed to produce substantial
analgesia. Finally, Stein et al. showed that the analgesic effect of
intra-articular morphine was blocked by intra-articular naloxone,
thus confirming a peripheral analgesic effect.
Many of the studies that have demonstrated a positive analgesic
effect from intra-articular morphine have also documented a delayed
onset of analgesia. Several authors have reported decreased pain scores
as late as eight to twelve hours following intra-articular administration
of morphine19,42,46. As a result,
many investigators now administer a combination of intra-articular
bupivacaine and morphine in an attempt to improve analgesia in the immediate
postoperative period.
Several investigators1,8,24,60,83,95 have
failed to observe any difference in the analgesic efficacy of intra-articular
morphine compared with that of either intra-articular saline solution
or intra-articular bupivacaine (controls). Some of these results
may have been influenced by the perioperative use of systemic opioids
or nonsteroidal anti-inflammatory drugs or regional anesthesia,
all of which can diminish the surgical inflammatory response, thus
decreasing the binding of intra-articular morphine.
Epidural anesthesia can also alter the effect of intra-articular
morphine, for at least two reasons. First, epidural anesthesia has
been shown to substantially blunt the neuroendocrine response to surgical
trauma and to reduce the release of several inflammatory mediators94. Furthermore, epidural anesthesia
can produce a preemptive and prolonged postoperative analgesic effect54,71,121. In fact, one study revealed
that epidural anesthesia had an extended analgesic effect that was
evident for as long as forty-eight hours postoperatively54.
Another confounding variable that may affect the analgesic efficacy
of intra-articular morphine is the timing of tourniquet release.
It is possible that by increasing the time-interval between intra-articular
injection and tourniquet release, the local tissue-binding to opioid
receptors can be increased, enhancing the analgesic effect. To our knowledge,
this effect of tourniquet release has been examined in only two
studies, which demonstrated contradictory findings58,116. Klinken58 found
that tourniquet time (zero, eight, or sixteen minutes) had no significant
effect on the analgesic duration of intra-articular morphine or
the need for supplemental analgesia within twenty-four hours. In
contrast, Whitford et al.116 observed
that keeping the tourniquet inflated for ten minutes provided superior
analgesia and decreased the need for supplementary analgesics compared
with releasing the tourniquet immediately after intra-articular
injection of morphine.
The optimal timing of intra-articular administration of morphine
is yet to be established. Although it is typically injected at the
end of an arthroscopic procedure, two studies22,30 confirmed
an analgesic benefit from preoperative administration.
In summary, most studies have demonstrated a prolonged analgesic
effect from intra-articular administration of morphine, and the
unwanted side effects from systemically administered opioids have
not been observed with intra-articular morphine. Inflammation of
the intra-articular tissue seems to be a prerequisite for morphine
to exert its analgesic effect, although the precise mechanisms of
action are not known. Concurrent use of nonsteroidal anti-inflammatory
drugs and spinal or epidural anesthesia, all of which diminish inflammation,
may mask or attenuate the analgesic effect of intra-articular morphine.
Taken together, these results support the use of intra-articular
morphine in the management of pain following arthroscopic knee surgery.
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Alternative Intra-Articular Opioids
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Intra-Articular Fentanyl
On the basis of the knowledge that opioid receptors are present
in the knee61, Uysalel et al.113 studied the analgesic effects of
intra-articular fentanyl in patients undergoing arthroscopic knee
surgery. They hypothesized that the high liposolubility of fentanyl
should provide prolonged analgesia. The authors compared the analgesic
efficacy of 100 micrograms of fentanyl to that of one milligram
of morphine in combination with 0.25 percent intra-articular bupivacaine.
An immediate, but short, analgesic effect (mean, three hours) was
observed with intra-articular fentanyl, whereas intra-articular
morphine had a delayed but more prolonged analgesic effect (mean,
forty-eight hours). Uysalel et al. concluded that a combination
of morphine and bupivacaine is the best choice for postoperative
analgesia following arthroscopic surgery.
Intra-Articular Meperidine
Meperidine is an opioid agonist with a chemical structure that
is similar to that of local anesthetics15.
It has been used as the sole anesthetic agent for epidural, spinal,
and intravenous regional anesthesia2,3,15,29.
Ekblom et al.29 investigated the
analgesic efficacy of intra-articular meperidine when it was used
as the sole anesthetic for arthroscopic knee surgery. Patients were randomly
assigned to receive either 250 milligrams of intra-articular prilocaine
or 200 milligrams of intra-articular meperidine. There was no difference
in the intraoperative pain scores between the two groups. However,
patients who received intra-articular meperidine reported significantly
less pain at rest and during movement (p < 0.01) in the first
twenty-four hours following surgery than did those who received
intra-articular prilocaine. In addition, patients who received intra-articular
meperidine used significantly fewer analgesics (p < 0.02). Soderlund
et al.102 compared the effect
of three doses of intra-articular meperidine (fifty, 100, and 200
milligrams) with that of 250 milligrams of prilocaine in forty patients
undergoing arthroscopic surgery. Six of ten patients receiving fifty
milligrams of intra-articular meperidine required general anesthesia
for the operative procedure because of intense intraoperative pain.
There were no differences in intraoperative pain scores between
the groups receiving 100 and 200 milligrams of meperidine and the
group receiving prilocaine. Postoperatively, the pain scores and
analgesic use associated with all three meperidine doses were lower
than those associated with the prilocaine. However, use of such
large doses of meperidine may have merely resulted in systemic analgesic
effects. In addition, these doses of intra-articular meperidine resulted
in a higher prevalence of centrally mediated side effects. Lyons
et al.68 investigated the postoperative
analgesic efficacy of fifty milligrams of intra-articular meperidine, five
milligrams of morphine, or saline solution in sixty patients undergoing
arthroscopic meniscectomy under general anesthesia. Both treatment groups
had significantly lower pain scores (p < 0.01) than did the
control group. Patients in the meperidine group had lower pain scores
than did those in the morphine group at 0.5, one, and two hours,
but they had significantly higher scores at twelve and twenty-four
hours (p < 0.01). The authors concluded that the local anesthetic
effect of meperidine may be responsible for the early analgesia,
but its duration of action is less than that of morphine.
In settings where morphine is medically contraindicated, intra-articular
meperidine may be a suitable alternative analgesic. The only advantage
of meperidine compared with morphine is its earlier onset of analgesia.
However, combining bupivacaine with morphine can result in both
an early onset and a prolonged duration of analgesia21,56,66,104. Furthermore, meperidine102, unlike intra-articular morphine,
has been reported to cause unwanted systemic side effects.
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Alternative Intra-Articular Analgesics
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Intra-Articular Ketorolac
Several investigators have examined the analgesic effect of administering
anti-inflammatory drugs intra-articularly. Ketorolac, a nonsteroidal
anti-inflammatory drug, has proven to be a useful analgesic when
administered parenterally for the management of pain after arthroscopy101. One of us (S. S. R.) and Connelly85 examined the analgesic efficacy
of administering sixty milligrams of ketorolac through either a parenteral
or an intra-articular route following arthroscopic meniscectomy.
There was significantly more analgesia of longer duration after
intra-articular administration (p < 0.001).
This study85 generated considerable
controversy regarding the safety of intra-articular ketorolac31,117. Although there were no previous
studies in humans, previous in vitro studies showed
that intra-articular ketorolac had no effect on degradation of bovine
cartilage plugs5. In fact, ketorolac
appears to have a protective effect on articular cartilage by preventing
the release of proinflammatory cytokines, including interleukin-1,
which has been shown to play a pivotal role in inducing cartilage
degradation. Concern was also expressed about the possibility that
the alcohol content (10 percent weight per volume) in ketorolac
would have a deleterious effect on articular cartilage31. However, in this study85, ketorolac was diluted in a volume
of thirty milliliters of 0.25 percent bupivacaine. The resultant
alcohol content (0.7 percent weight per volume) was lower than that
of sterile triamcinolone acetonide suspension (0.9 percent weight
per volume) (Steris Laboratories, Phoenix, Arizona), which has been cleared
by the Food and Drug Administration for intra-articular injection.
One of us (S. S. R.) and Connelly86 subsequently
designed a study to compare the analgesia produced by ketorolac
with that produced by morphine and to determine whether a combination
of the two agents would provide analgesia that was superior to that
provided by either drug alone. Eighty patients undergoing arthroscopic
meniscectomy under local anesthesia were randomized to receive ketorolac
(either intra-articularly or parenterally) or morphine (either intra-articularly or
parenterally). There was a significant benefit when either morphine
alone or ketorolac alone was administered intra-articularly (mean
analgesic duration, thirteen hours) (p < 0.001), but the combination
of these drugs did not result in any additive effect or increase
the analgesic duration. We hypothesize that this last finding may
have been due to a reduction in synovial tissue inflammation, and
thus to a decrease in the binding of intra-articular morphine, brought
about by the intra-articular ketorolac. Alternatively, it is possible
that no additive effect occurred because each drug alone (when given
with intra-articular bupivacaine) provides optimal analgesia that
is difficult to enhance.
Intra-Articular Corticosteroids
Wang et al.115 demonstrated
that, compared with injection of intra-articular saline solution
alone, injection of intra-articular triamcinolone acetonide in saline solution
into knees resulted in lower pain scores and a significant opioid-sparing
effect (p < 0.001). However, pain relief began six hours after
the intra-articular corticosteroid injection and then persisted
throughout the twenty-four-hour study period. Rasmussen et al.84 compared the effects of a combination
of intra-articular bupivacaine, morphine, and methylprednisolone
with the effects of intra-articular bupivacaine and morphine or
saline solution on pain and the durations of immobilization and
convalescence after meniscectomy. Compared with intra-articular
bupivacaine and saline solution, the combination of 150 milligrams
of bupivacaine and four milligrams of morphine significantly reduced pain
and the durations of immobilization and convalescence (p < 0.05).
The addition of forty milligrams of methylprednisolone further reduced pain,
use of additional analgesics, joint-swelling, and the duration of
convalescence; improved muscle function; and prevented the inflammatory
response. Rasmussen et al. recommended this multimodal intra-articular
analgesic regimen for patients undergoing arthroscopic meniscectomy.
As in the case of intra-articular ketorolac, the potential for
intra-articular corticosteroids to reduce pain and enhance convalescence
must be weighed against the risk of complications. The reported risks
associated with a single dose of intra-articular steroids have been
reported to be minimal38 but may
include an increased risk of infection, cartilage damage, impaired
wound-healing, and adverse systemic side effects. The reported risk
of infection is negligible (less than 1:20,000) following intra-articular
administration of a single dose of steroids for rheumatic disorders37. Wang et al.115 observed
no cases of delayed wound-healing, infection, or other side effects
in the thirty patients who received intra-articular triamcinolone
in their study. Additional large-scale randomized studies are needed
to assess the safety of routine use of intra-articular corticosteroids
in the management of pain following arthroscopic knee surgery.
Intra-Articular Clonidine
Several investigators have studied the analgesic effect of administering
intra-articular clonidine following arthroscopic knee surgery35,51,89. Clonidine, an a-2 agonist,
demonstrates several analgesic properties. It has been shown to
prolong the duration of action of local anesthetics34 as well as to selectively block
the conduction of A d and C fibers10.
In addition to its local anesthetic effects, clonidine may produce
analgesia by releasing enkephalin-like substances, resulting in
peripheral analgesia79. Gentili
et al.35 compared the analgesic
effect of 150 micrograms of clonidine, administered either intra-articularly or
subcutaneously, with that of intra-articular saline solution or
one milligram of intra-articular morphine in forty patients undergoing
arthroscopic knee surgery. Patients receiving intra-articular clonidine
had a significantly longer duration of analgesia (533 ± 488 minutes) than did those receiving either the saline
solution alone (70 ± 30 minutes) or subcutaneous
clonidine (132 ± 90 minutes) (p < 0.05).
The analgesic duration of intra-articular clonidine was found to
be similar to that of intra-articular morphine (300 ± 419 minutes). Because subcutaneous administration
did not produce analgesia effectively, Gentili et al. concluded
that clonidine had a peripherally mediated analgesic effect.
Since clonidine can enhance the peripheral nerve block from local
anesthetics, one of us (S. S. R.) and Connelly89 studied
the analgesic efficacy of intra-articular administration of bupivacaine
(seventy-five milligrams) with clonidine (one microgram per kilogram
of body weight) following arthroscopic meniscectomy. The group that
received the combination of intra-articular bupivacaine and clonidine had
a significantly decreased need for postoperative analgesics and
increased analgesic duration compared with patients treated with
either drug alone (p < 0.0001). Joshi et al.51 attempted
to determine if any additional analgesic benefit could be obtained
from the intra-articular use of clonidine with morphine in a study
of sixty patients undergoing arthroscopic meniscectomy under local
anesthesia. The combination of drugs resulted in a significant increase
in analgesic duration (1050 ± 227 minutes,
p < 0.0001) compared with the analgesic duration of either intra-articular
clonidine (640 ± 113 minutes) or intra-articular
morphine (715 ± 106 minutes) alone.
In summary, ketorolac and corticosteroids act as potent analgesics
by reducing the inflammatory response following arthroscopic knee
surgery. In addition, intra-articular clonidine potentiates the effects
of intra-articular morphine and bupivacaine. A reduction in pain
and joint-swelling may accelerate the recovery of muscle strength25,108 and reduce the duration of convalescence84 following arthroscopic meniscectomy.
Taken together, these studies suggest that intra-articular nonsteroidal
anti-inflammatory drugs, corticosteroids, and clonidine may play
important roles in the analgesic regimen of patients undergoing
arthroscopic knee surgery. Additional large-scale randomized studies
are needed to assess the safety and efficacy of these regimens.
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Postoperative Analgesia After
Outpatient Anterior Cruciate Repair
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Improvements in surgical, anesthetic, and pain-management techniques
are allowing more patients to return home on the day that they have
extensive knee surgery such as anterior cruciate reconstruction.
This procedure is associated with a considerable degree of postoperative
pain that may require more than just intra-articular local anesthetics
or opioids. Ineffective pain management may cause unnecessary suffering,
delayed recovery, an inability to participate in rehabilitation
programs, prolonged hospitalization, and increased medical expenditures.
A recent study of anterior cruciate reconstruction revealed that
a cost-saving of up to 58 percent could be achieved when this procedure
was performed on an outpatient basis53.
Furthermore, patient satisfaction depends in part on the degree
of discomfort associated with the procedure. More comprehensive
pain-management strategies that involve both preemptive and multimodal
analgesic techniques have therefore been employed22,33,88,90,110.
Currently, multimodal analgesic regimens described in the literature
for anterior cruciate reconstruction include intra-articular opioids, perioperative
nonsteroidal anti-inflammatory drugs, intra-articular bupivacaine,
femoral nerve block, cryotherapy, and oral opioids.
Intra-Articular Morphine
To our knowledge, Joshi et al.48,49 were
the first investigators to report on the analgesic efficacy of intra-articular
administration of morphine following anterior cruciate reconstruction.
These authors compared the use of five milligrams of intra-articular
morphine with that of intra-articular saline solution following
anterior cruciate repair performed on an inpatient basis. In both
studies48,49, the group that was
given morphine had lower pain scores and morphine use in the twenty-four-hour
period following surgery. Denti et al.22 studied
the analgesic effects of three different doses of intra-articular
morphine (one, two, and five milligrams) in patients undergoing
anterior cruciate reconstruction. The highest dose of morphine (five
milligrams) provided better analgesia and resulted in lower supplementary
analgesic consumption in the first twenty-four hours after the procedure.
Interestingly, in this same study, the authors observed that five
milligrams of intra-articular morphine did not produce better analgesia than
did two milligrams in patients undergoing other knee arthroscopic
procedures. This study supports a dose-response relationship for
intra-articular morphine and highlights the importance of using
larger doses of intra-articular morphine for anterior cruciate reconstruction,
which is a more invasive procedure.
In contrast to these studies22,48,49,
that by one of us (S. S. R.) and colleagues88 failed
to demonstrate an analgesic effect from the addition of five milligrams
of intra-articular morphine following anterior cruciate reconstruction. The
previous studies22,48,49, however,
did not involve use of multimodal analgesia, including perioperative
nonsteroidal anti-inflammatory drugs, cryotherapy, or intra-articular bupivacaine.
Multimodal regimens probably provide sufficient analgesia, so that
intra-articular morphine provides little additional benefit. Alternatively,
intra-articular morphine might not bind effectively to intra-articular
opioid receptors in the presence of perioperative nonsteroidal anti-inflammatory
drugs.
Nonsteroidal Anti-Inflammatory Drugs
In addition to intra-articular analgesics, adjunctive nonsteroidal
anti-inflammatory drugs have been recommended for the management
of acute pain following major orthopaedic operations17. Although nonsteroidal anti-inflammatory
drugs by themselves may not relieve severe postoperative pain, their
use in combination with opioids can produce a substantial additive
analgesic effect17. The parenteral
use of ketorolac has been shown to reduce morphine consumption by
approximately 30 percent following major orthopaedic procedures87. McGuire et al.69 found
a substantial reduction in side effects as well as superior pain
control when ketorolac was used as an adjunct in the management
of pain after outpatient anterior cruciate reconstruction.
Prostaglandins play an important role in promoting the pain and
hyperalgesia associated with the inflammatory response that occurs
following an operative procedure. Nonsteroidal anti-inflammatory
drugs inhibit prostaglandin biosynthesis through the cyclooxygenase
enzyme. Cyclooxygenase is now known to exist as two distinct isoforms:
cyclooxygenase-1 and cyclooxygenase-2. Cyclooxygenase-1 is constitutively
active throughout the body and is responsible for mediating routine
physiological functions, including gastric mucosal function and
vascular hemostasis39. In contrast,
cyclooxygenase-2 is an inducible enzyme that is expressed from both
polymorphonuclear leukocytes and macrophages following inflammatory
stimuli16. Conventional nonsteroidal
anti-inflammatory drugs nonspecifically inhibit both the cyclooxygenase-1
and the cyclooxygenase-2 isoform74.
It is believed that the therapeutic effect of nonsteroidal anti-inflammatory
drugs is primarily through the inhibition of cyclooxygenase-2, whereas
the toxicity results from inhibition of cyclooxygenase-139. Preliminary data from animal studies
have shown that selective inhibition of cyclooxygenase-2 produces
analgesia with substantial safety advantages over the nonselective
inhibition of both cyclooxygenase-1 and cyclooxygenase-2 with the
use of other nonsteroidal anti-inflammatory drugs97.
The cyclooxygenase-2-specific inhibitors, celecoxib and rofecoxib
at therapeutic concentrations, inhibit the cyclooxygenase-2 isoenzyme
without affecting the cyclooxygenase-1 isoform16,39.
Rofecoxib is indicated for the management of osteoarthritis and
acute postoperative pain, while celecoxib is indicated for the management
of both osteoarthritis and rheumatoid arthritis16,39.
In a recent study91, the perioperative
administration of rofecoxib reduced morphine consumption by approximately 35
percent following spinal fusion surgery. Currently, studies are
being performed to assess the analgesic efficacy of cyclooxygenase-2-specific nonsteroidal
anti-inflammatory drugs in the management of pain following arthroscopic
surgery of the knee.
Femoral Nerve Block
Blockade of the femoral nerve has been shown to be a reliable,
safe, and effective method of providing analgesia in the immediate
postoperative period following anterior cruciate reconstruction. Winnie
et al.118 first described a "3-in-1
block" technique for providing anesthesia to the anterior aspect
of the thigh and the knee. The femoral sheath is injected with a local
anesthetic agent in sufficient volume (more than twenty milliliters)
to block the femoral, lateral femoral cutaneous, and obturator nerves.
Ringrose and Cross93 first reported
the efficacy of this technique in the management of pain following
anterior cruciate surgery. This study revealed an 80 percent reduction
in opiate use in the recovery room and a 40 percent reduction in
the first twenty-four hours following surgery. Edkin et al.27 reported similar results: twenty-two
of twenty-four patients undergoing anterior cruciate reconstruction
required no parenteral narcotics postoperatively when a femoral
nerve block had been performed at the conclusion of the operation.
Although these procedures were all done on an inpatient basis, the
mean duration of pain control was twenty-nine hours, and the majority
of patients believed that discharge was possible within twenty-three
hours after the operation.
The use of an indwelling catheter in the femoral sheath has also
been described in the management of pain following anterior cruciate
reconstruction67,73,110. Lynch
et al.67 administered intermittent
doses of bupivacaine through a femoral catheter and concluded that
this technique provided safe and reliable analgesia while increasing
patient mobility and decreasing use of systemic analgesics. Similar
results were reported in later studies73,110 evaluating
the analgesic efficacy of continuous femoral nerve block after anterior
cruciate reconstruction. Unfortunately, continuous femoral nerve
block is not practical in the management of pain following anterior
cruciate reconstruction in an ambulatory setting. In addition, caution
should be exercised when a femoral nerve block is used in conjunction
with intra-articular bupivacaine. The maximum safe dose of bupivacaine
recommended for peripheral nerve block is two milligrams per kilogram
of body weight78.
Cryotherapy
Cryotherapy is the use of cold to decrease swelling and pain
when tissue is damaged secondary to trauma or operative intervention.
Although the exact mechanism of cold therapy is not completely understood,
it is believed to decrease the inflammation, edema, and hematoma
formation after surgical trauma7,96.
In addition, cold therapy decreases nerve-conduction velocity, produces
a local anesthetic effect in pain fibers70,
and can reduce muscle spasm63.
Although it has been applied for years, the use of cryotherapy remains
controversial following anterior cruciate reconstruction. The earliest
report evaluating the analgesic efficacy of continuous cold therapy
(Hot/Ice Thermal Blanket; Thermo Temp, Tampa, Florida) following
anterior cruciate reconstruction revealed a significant reduction
in analgesic use, earlier walking, and greater ease in the performance
of range-of-motion exercises (p < 0.01)14.
A later report also confirmed that, compared with the use of
crushed ice, cryotherapy (Cryocuff; Aircast, Summit, New Jersey)
led to a reduction in the use of pain medications99.
In contrast to these two studies, other studies have failed to demonstrate
any substantial benefit from cryotherapy20,28,59.
To our knowledge, Barber et al.6 were
the only investigators to evaluate the effects of portable devices
for continuous-flow cold therapy following anterior cruciate reconstruction
performed in an outpatient setting. Patients were randomized to
receive either no cold therapy or continuous-flow cold therapy with
use of a device (Orthopedic Technology, Tracy, California, or Aircast,
Summit, New Jersey) that was worn constantly for three days. After
the initial three days, the unit was worn by the patient in conjunction with
the use of a continuous-passive-motion machine and at other times
as the subject desired. There was significant reduction in pain
scores (p < 0.05) and analgesic use (p < 0.01) among the
patients using the cryotherapy, who also had increased knee flexion.
In summary, continuous-flow cold therapy has the capacity to
produce local vasoconstriction, which may reduce bleeding, edema,
and the local inflammatory response postoperatively. In addition, cooling
can depress neuronal pain-signal transmission, inhibit the stretch
reflex, and reduce muscle spasm. In order to obtain these beneficial
results, it is important that the skin temperature be lowered to
about 20 degrees Celsius to obtain measurable changes in intra-articular
temperature18. However, it is
difficult to obtain a persistent decrease in intra-articular temperature
for more than twenty-four hours in the postoperative setting. Multiple
factors, including room temperature, the thickness of the subcutaneous
fat, and the thickness of the postoperative dressings, affect the
ability to cool the intra-articular space; this may explain the
conflicting results reported in the literature on the efficacy of
cryotherapy after anterior cruciate reconstruction.
Long-Acting Opioids
Many patients still require postoperative opioids after the effects
of the local anesthetic and the intra-articular opioid have dissipated.
Although immediate-release oral opioids are usually effective in
relieving moderate-to-severe pain, they must be given every four
to six hours. A delay in administration, especially when the opioids
are ordered on an as-needed basis, may result in a low plasma concentration
of the opioid and, thus, the reemergence of pain. It is currently
recommended that all patients requiring opioid analgesics for more
than forty-eight hours after an operation receive these drugs on
a fixed-dose schedule112. However,
interruption of an around-the-clock dosage schedule, especially
during the hours of sleep, may lead to a recurrence of pain.
A controlled-release formulation of oxycodone (OxyContin; Purdue
Pharma, Norwalk, Connecticut) maintains therapeutic opioid concentrations for
a more prolonged period, thus providing sustained pain relief109. One of us (S. S. R.) and colleagues90 examined the efficacy of controlled-release
oxycodone compared with that of immediate-release oxycodone when
administered on either an as-needed basis or a fixed-dose schedule
in the multimodal management of pain after anterior cruciate reconstruction
in the ambulatory setting. Many patients in the fixed-dose group
failed to take the drug in the manner in which it was prescribed,
and many failed to take it during the night while they slept. In
contrast, the study revealed that use of controlled-release oxycodone
in the immediate seventy-two hours postoperatively provided more effective
analgesia with less sedation, sleep disturbance, or vomiting compared
with oxycodone prescribed on either a fixed-dose or an as-needed basis.
These results may have occurred because of improved compliance with
controlled-release, twice-per-day dosing of oxycodone, which provided
more effective continuous postoperative analgesia.
Preemptive Analgesia
In addition to utilizing various analgesics in a multimodal regimen,
one can administer these drugs preemptively, which may provide even
longer-lasting pain relief following anterior cruciate reconstruction22,30,33,54,62,71,93,111. The preemptive
administration of nonsteroidal anti-inflammatory drugs can reduce
primary and secondary hyperalgesia by inhibiting cyclooxygenase
and decreasing tissue prostaglandin synthesis and, thereby, can
decrease postoperative pain13.
Lee et al.62 observed a significant
reduction in pain scores and opioid use when ketorolac had been
administered prior to knee arthroscopy (p < 0.04). However,
the prophylactic use of ketorolac is contraindicated before any
major operation because of the increased risk of bleeding that is
associated with all nonsteroidal anti-inflammatory drugs. In a study in
which preemptive ibuprofen was given for thirty-six hours prior
to anterior cruciate reconstruction88,
one of us (S. S. R.) and colleagues observed an increased prevalence
of perioperative bleeding (unpublished data) and have since discontinued
the routine use of preoperative nonsteroidal anti-inflammatory drugs
in their practice.
Recent data have demonstrated that the selective cyclooxygenase-2
inhibitors have no clinical effect on coagulation39.
Rofecoxib, a cyclooxygenase-2-specific nonsteroidal anti-inflammatory
drug, was recently shown to be an effective analgesic, and it did
not substantially increase intraoperative blood loss when it was
administered prior to major spine operations91.
Studies are currently being performed to determine whether the preoperative
administration of cyclooxygenase-2-specific nonsteroidal anti-inflammatory
drugs is safe and effective for producing analgesia after knee arthroscopy.
Local anesthetic nerve blocks can produce substantial preemptive
analgesic effects54,71,121, and
the preemptive use of a femoral nerve block with 0.5 percent bupivacaine
has been demonstrated to have a substantial analgesic effect in
patients undergoing anterior cruciate reconstruction93. In that study93,
patients who had had a femoral nerve block before the operation
had a 50 percent reduction in their requirement for opioids in the
first twenty-four hours after the operation compared with patients
who had had a femoral nerve block at the conclusion of the operation.
Just as preoperative intra-articular administration of morphine
has been shown to be efficacious in reducing pain following arthroscopy22,30, it has been shown to be efficacious
in reducing pain following anterior cruciate reconstruction22,33,111. While one might assume that
intra-articular morphine administered prior to surgery, even as
few as ten minutes prior to surgery, may be washed out during the
procedure, effective analgesia was reported, thus confirming the
presence of some peripheral opioid receptor-binding22.
In summary, both preemptive and multimodal analgesic techniques
should be utilized in the management of patients undergoing anterior
cruciate reconstruction. Effective pain management should accelerate
rehabilitation, decrease the risk of postoperative complications,
and speed return to normal activities98.
We routinely perform anterior cruciate reconstruction on an ambulatory
basis, with use of both preemptive and multimodal analgesic techniques88,90. All patients receive five doses
of acetaminophen (650 milligrams every six hours) starting thirty hours
prior to surgery. In addition, all adult patients receive intra-articular
bupivacaine (seventy-five milligrams) and ketorolac (fifteen milligrams) prior
to incision. Postoperatively, all patients receive an additional
dose of intra-articular bupivacaine (seventy-five milligrams) with
morphine (five milligrams), acetaminophen (650 milligrams) and ibuprofen
(600 milligrams) four times per day, controlled-release oxycodone
(twenty milligrams) twice per day, and cryotherapy. We have found
that these analgesic techniques allow for timely discharge of our
patients from the ambulatory surgical center on the day of the anterior cruciate
surgery. In addition, the majority of our patients are able to participate
more easily in an accelerated rehabilitation program.
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References
|
|---|
-
Aasbo, V.; Raeder, J. C.; Grogaard, B.; and Roise, O.: No additional analgesic effect of intra-articular morphine
or bupivacaine compared with placebo after elective knee arthroscopy. Acta Anaesth. Scandinavica, 40: 585-588, 1996.[Medline]
-
Acalovschi, I.; Ene, V.; Lorinczi, E.; and Nicolaus, F.: Saddle block with pethidine for perineal operations. British J. Anaesth., 58: 1012-1016, 1986.[Abstract/Free Full Text]
-
Acalovschi, I, and Cristea, T.: Intravenous regional anesthesia with meperidine. Anesth. and Analg., 81: 539-543, 1995.[Abstract]
-
Allen, G. C.; St. Amand, M. A.; Lui, A. C.; Johnson, D. H.; and Lindsay, M. P.: Postarthroscopy analgesia with intraarticular bupivacaine/morphine.
A randomized clinical trial. Anesthesiology, 79: 475-480, 1993.[Medline]
-
Ball, H. T.; Moore, J.; and Treadwell, B. V.: Ketorolac injectable NSAID effect on in vitro bovine cartilage
degradation. Trans. Orthop. Res. Soc., 18: 726, 1993.
-
Barber, F. A.; McGuire, D. A.; and Click, S.: Continuous-flow cold therapy for outpatient anterior cruciate
ligament reconstruction. Arthroscopy, 14: 130-135, 1998.[Medline]
-
Bierman, W. : The therapeutic uses of cold. J. Am. Med. Assn, 157: 1189-1192, 1955.
-
Björnsson, A.; Gupta, A.; Vegfors, M.; Lennmarken, C.; and Sjöberg, F.: Intraarticular morphine for postoperative analgesia following
knee arthroscopy. Reg. Anesth., 19: 104-108, 1994.
-
Boden, B. P.; Fassler, S.; Cooper, S.; Marchetto, P. A.; and Moyer, R. A.: Analgesic effect of intraarticular morphine, bupivacaine,
and morphine/bupivacaine after arthroscopic knee surgery. Arthroscopy, 10: 104-107, 1994.[Medline]
-
Butterworth, J. F V, and Strichartz, G. R.: The alpha 2-adrenergic agonists clonidine and guanfacine
produce tonic and phasic block of conduction in rat sciatic nerve
fibers. Anesth. and Analg., 76: 295-301, 1993.[Medline]
-
Cepeda, M. S.; Uribe, C.; Betancourt, J.; Rugeles, J.; and Carr, D. B.: Pain relief after knee arthroscopy: intra-articular morphine,
intra-articular bupivacaine, or subcutaneous morphine?. Reg. Anesth., 22: 233-238, 1997.[Medline]
-
Chirwa, S. S.; MacLeod, B. A.; and Day, B.: Intraarticular bupivacaine (Marcaine) after arthroscopic
meniscectomy: a randomized double-blind controlled study. Arthroscopy, 5: 33-35, 1989.[Medline]
-
Coderre, T. J.; Vaccarino, A. L.; and Melzack, R.: Central nervous system plasticity in the tonic pain response
to subcutaneous formalin injection. Brain Res., 535: 155-158, 1990.[Medline]
-
Cohn, B. T.; Draeger, R. I.; and Jackson, D. W.: The effects of cold therapy in the postoperative management
of pain in patients undergoing anterior cruciate ligament reconstruction. Am. J. Sports Med, 17: 344-349, 1989.[Abstract/Free Full Text]
-
Cousins, M. J, and Mather, L. E.: Intrathecal and epidural administration of opioids. Anesthesiology,, 61: 276-310, 1984.[Medline]
-
Crofford, L. J.; Lipsky, P. E.; Brooks, P.; Abramson, S. B.; Simon, L. S.; and van de Putte, L. B.: Basic biology and clinical application of specific cyclooxygenase-2
inhibitors. Arthrit. and Rheumat., 43: 4-13, 2000.
-
Dahl, J. B, and Kehlet, H.: Non-steroidal anti-inflammatory drugs: rationale for use
in severe postoperative pain. British J. Anaesth., 66: 703-712, 1991.[Free Full Text]
-
Dahlstedt, L.; Samuelson, P.; and Dalen, N.: Cryotherapy after cruciate knee surgery. Skin, subcutaneous
and articular temperatures in 8 patients. Acta Orthop. Scandinavica, 67: 255-257, 1996.[Medline]
-
Dalsgaard, J.; Felsby, S.; Juelsgaard, P.; and Froekjaer, J.: Low-dose intra-articular morphine analgesia in day case
knee arthroscopy: a randomized double-blinded prospective study. Pain, 56: 151-154, 1994.[Medline]
-
Daniel, D. M.; Stone, M. L.; and Arendt, D. L.: The effect of cold therapy on pain, swelling, and range
of motion after anterior cruciate ligament reconstructive surgery. Arthroscopy,, 10: 530-533, 1994.[Medline]
-
De Andres, J.; Bellver, J.; Barrera, L.; Febre, E.; and Bolinches, R.: A comparative study of analgesia after knee surgery with
intraarticular bupivacaine, intraarticular morphine, and lumbar
plexus block. Anesth. and Analg, 77: 727-730, 1993.[Abstract/Free Full Text]
-
Denti, M.; Randelli, P.; Bigoni, M.; Vitale, G.; Marino, M. R.; and Fraschini, N.: Pre- and postoperative intra-articular analgesia for arthroscopic
surgery of the knee and arthroscopic-assisted anterior cruciate
ligament reconstruction. A double-blind randomized prospective study. Knee Surg Sports Traumat. Arthrosc., 5: 206-212, 1997.[Medline]
-
Dickenson, A. H, and Sullivan, A. F.: Subcutaneous formalin-induced activity of dorsal horn
neurones in the rat: differential response to an intrathecal opiate
administered pre or post formalin. Pain,, 30: 349-360, 1987.[Medline]
-
Dierking, G. W.; Ostergaard, H. T.; Dissing, C. K.; Kristensen, J. E.; and Dahl, J. B.: Analgesic effect of intra-articular morphine after arthroscopic
meniscectomy. Anaesthesia, 49: 627-629, 1994.[Medline]
-
Durand, A.; Richards, C. L.; and Malouin, F.: Strength recovery and muscle activation of the knee extensor
and flexor muscles after arthroscopic meniscectomy. A pilot study. Clin. Orthop., 262: 210-226, 1991.
-
Dye, S. F.; Vaupel, G. L.; and Dye, C. C.: Conscious neurosensory mapping of the internal structures
of the human knee without intraarticular anesthesia. Am. J. Sports Med., 26: 773-777, 1998.[Abstract/Free Full Text]
-
Edkin, B. S.; Spindler, K. P.; and Flanagan, J. F.: Femoral nerve block as an alternative to parenteral narcotics
for pain control after anterior cruciate ligament reconstruction. Arthroscopy, 11: 404-409, 1995.[Medline]
-
Edwards, D. J.; Rimmer, M.; and Keene, G. C.: The use of cold therapy in the postoperative management
of patients undergoing arthroscopic anterior cruciate ligament reconstruction. Am. J. Sports Med., 24: 193-195, 1996.[Abstract/Free Full Text]
-
Ekblom, A.; Westman, L.; Soderlund, A.; Valentin, A.; and Eriksson, E.: Is intra-articular pethidine an alternative to local anesthetics
in arthroscopy? A double-blind study comparing prilocaine with pethidine. Knee Surg Sports Traumat. Arthrosc., 1: 189-194, 1993.[Medline]
-
El-Mansouri, M.; Reuben, S. S.; Sklar, J.; Gibson, C.; and Maciolek, H.: Preemptive analgesic effect of intraarticular morphine
for arthroscopic knee surgery. Anesthesiology, 91: 953, 1999.
-
Finnegan, M. A.: Off-label use of ketorolac. Anesth. and Analg., 83: 197, 1996.
-
Fithian, D. C, and Daniel, D. N.: Letter to the editor. Arthroscopy,, 11: 515-516, 1995.[Medline]
-
Gatt, C. J Jr.; Parker, R. D.; Tetzlaff, J. E.; Szabo, M. Z.; and Dickerson, A. B.: Preemptive analgesia: its role and efficacy in anterior
cruciate ligament reconstruction. Am. J. Sports Med, 26: 524-529, 1998.[Abstract/Free Full Text]
-
Gaumann, D. M.; Brunet, P. C.; and Jirounek, P.: Clonidine enhances the effects of lidocaine on C-fiber
action potential. Anesth. and Analg., 74: 719-725, 1992.[Abstract/Free Full Text]
-
Gentili, M.; Juhel, A.; and Bonnet, F.: Peripheral analgesic effect of intra-articular clonidine. Pain, 64: 593-596, 1996.[Medline]
-
Geutjens, G, and Hambidge, J. E.: Analgesic effects of intraarticular bupivacaine after
day-case arthroscopy. Arthroscopy, 10: 299-300, 1994.[Medline]
-
Gray, R. G.; Tenenbaum, J.; and Gottlieb, N. L.: Local corticosteroid injection treatment in rheumatic
disorders. Sem. Arthrit. and Rheumat., 10: 231-254, 1981.
-
Grillet, B, and Dequeker, J.: Intra-articular steroid injection. A risk-benefit assessment. Drug Safety, 5: 205-211, 1990.[Medline]
-
Hawkey, C. J. : COX-2 inhibitors. Lancet, 353: 307-314, 1999.[Medline]
-
Haynes, T. K.; Appadurai, I. R.; Power, I.; Rosen, M.; and Grant, A.: Intra-articular morphine and bupivacaine analgesia after
arthroscopic knee surgery. Anaesthesia, 49: 54-56, 1994.[Medline]
-
Heard, S. O.; Edwards, W. T.; Ferrari, D.; Hanna, D.; Wong, P. D.; Liland, A.; and Willock, M. M.: Analgesic effect of intraarticular bupivacaine or morphine
after arthroscopic knee surgery: a randomized, prospective, double-blind
study. Anesth. and Analg., 74: 822-826, 1992.[Abstract/Free Full Text]
-
Heine, M. F.; Tillet, E. D.; Tsueda, K.; Loyd, G. E.; Schroeder, J. A.; Vogel, R. L.; and Yli-Hankala, A.: Intra-articular morphine after arthroscopic knee operation. British J. Anaesth., 73: 413-415, 1994.[Abstract/Free Full Text]
-
Henderson, R. C.; Campion, E. R.; DeMasi, R. A.; and Taft, T. N.: Postarthroscopy analgesia with bupivacaine. A prospective,
randomized, blinded evaluation. Am. J. Sports Med., 18: 614-617, 1990.[Abstract/Free Full Text]
-
Highgenboten, C. L.; Jackson, A. W.; and Meske, N. B.: Arthroscopy of the knee. Ten-day pain profiles and corticosteroids. Am. J. Sports Med., 21: 503-506, 1993.[Abstract/Free Full Text]
-
Ho, S. T.; Wang, J. J.; Liaw, W. J.; Wong, C. S.; and Cherng, C. H.: Analgesic effect of intra-articular morphine after arthroscopic
knee surgery in Chinese patients. Acta Anaesth. Sinica, 33: 79-84, 1995.
-
Jaureguito, J. W.; Wilcox, J. F.; Cohn, S. J.; Thisted, R. A.; and Reider, B.: A comparison of intraarticular morphine and bupivacaine
for pain control after outpatient knee arthroscopy. A prospective,
randomized, double-blinded study. Am. J. Sports Med., 23: 350-353, 1995.[Abstract/Free Full Text]
-
Joshi, G. P.; McCarroll, S. M.; Cooney, C. M.; Blunnie, W. P.; O'Brien, T. M.; and Lawrence, A. J.: Intra-articular morphine for pain relief after knee arthroscopy. J. Bone and Joint Surg., 74-B(5): 749-751, 1992.
-
Joshi, G. P.; McCarroll, S. M.; Brady, O. H.; Hurson, B. J.; and Walsh, G.: Intra-articular morphine for pain relief after anterior
cruciate ligament repair. British J. Anaesth., 70: 87-88, 1993.[Abstract/Free Full Text]
-
Joshi, G. P.; McCarroll, S. M.; McSwiney, M.; O'Rourke, P.; and Hurson, B. J.: Effects of intraarticular morphine on analgesic requirements
after anterior cruciate ligament repair. Reg. Anesth., 18: 254-257, 1993.[Medline]
-
Joshi, G. P.; McCarroll, S. M.; O'Brien, T. M.; and Lenane, P.: Intraarticular analgesia following knee arthroscopy. Anesth. and Analg., 76: 333-336, 1993.[Medline]
-
Joshi, W.; Reuben, S. S.; Kilaru, P. R.; Sklar, J.; and Maciolek, H.: Postoperative analgesia for outpatient arthroscopic knee
surgery with intraarticular clonidine and/or morphine. Anesth. and Analg., 90: 1102-1106, 2000.[Abstract/Free Full Text]
-
Kanbak, M.; Akpolat, N.; Ocal, T.; Doral, M. N.; Ercan, M.; and Erdem, K.: Intraarticular morphine administration provides pain relief
after knee arthroscopy. European J. Anaesth., 14: 153-156, 1997.
-
Kao, J. T.; Giangarra, C. E.; Singer, G.; and Martin, S.: A comparison of outpatient and inpatient anterior cruciate
ligament reconstruction surgery. Arthroscopy, 1: 151-156, 1995.
-
Katz, J.; Clairoux, M.; Kavanagh, B. P.; Roger, S.; Nierenberg, H.; Redahan, C.; and Sandler, A. N.: Pre-emptive lumbar epidural anaesthesia reduces postoperative
pain and patient-controlled morphine consumption after lower abdominal
surgery. Pain,, 59: 395-403, 1994.[Medline]
-
Kehlet, H, and Dahl, J. B.: The value of "multimodal" or "balanced analgesia" in postoperative
pain treatment. Anesth. and Analg., 77: 1048-1056, 1993.[Free Full Text]
-
Khoury, G. F.; Chen, A. C.; Garland, D. E.; and Stein, C.: Intraarticular morphine, bupivacaine, and morphine/bupivacaine
for pain control after knee videoarthroscopy. Anesthesiology, 77: 263-266, 1992.[Medline]
-
Kissin, I.: Preemptive analgesia. Why its effect is not always obvious. Anesthesiology, 84: 1015-1019, 1996.[Medline]
-
Klinken, C.: Effects of tourniquet time in knee arthroscopy patients
receiving intraarticular morphine combined with bupivacaine. CRNA, 6: 37-42, 1995.[Medline]
-
Konrath, G. A.; Lock, T.; Goitz, H. T.; and Scheidler, J.: The use of cold therapy after anterior cruciate ligament
reconstruction. A prospective, randomized study and literature review. Am. J. Sports Med., 24: 629-633, 1996.[Abstract/Free Full Text]
-
Laurent, S. C.; Nolan, J. P.; Pozo, J. L.; and Jones, C. J.: Addition of morphine to intra-articular bupivacaine does
not improve analgesia after day-case arthroscopy. British J. Anaesth., 72: 170-173, 1994.[Abstract/Free Full Text]
-
Lawrence, A. J.; Joshi, G. P.; Michalkiewicz, A.; Blunnie, W. P.; and Moriarty, D. C.: Evidence for analgesia mediated by peripheral opioid receptors
in inflamed synovial tissue. European J. Clin. Pharmacol., 43: 351-355, 1992.[Medline]
-
Lee, V. C.; Kendrick, W. D.; Brown, N. W.; Harman, A. M.; and Grove, G. W.: Ketorolac given prior to arthroscopic knee surgery decreases
postop pain scores and narcotic doses. Anesth. and Analg., 74: 181, 1992.[Medline]
-
Lehman, J. F. Therapeutic Heat and Cold.
Ed. 3. Baltimore, Williams and Wilkins, 1982
-
Levine, J. D., and Taiwo, Y. O.: Involvement of the mu-opiate receptor in peripheral analgesia. Neuroscience, 32: 571-575, 1989.[Medline]
-
Liu, K.; Wang, J. J.; Ho, S. T.; Liaw, W. J.; and Chia, Y. Y.: Opioid in peripheral analgesia: intra-articular morphine
for pain control after arthroscopic knee surgery. Acta Anaesth. Sinica,, 33: 217-221, 1995.
-
Lundin, O.; Rydgren, B.; Sward, L.; and Karlsson, J.: Analgesic effects of intra-articular morphine during and
after knee arthroscopy: a comparison of two methods. Arthroscopy, 14: 192-196, 1998.[Medline]
-
Lynch, J.; Trojan, S.; Arhelger, S.; and Krings-Ernst, I.: Intermittent femoral nerve blockade for anterior cruciate
ligament repair. Use of a catheter technique in 208 patients. Acta Anaesth. Belgica, 42: 207-212, 1991.
-
Lyons, B.; Lohan, D.; Flynn, C. J.; Joshi, G. P.; O'Brien, T. M.; and McCarroll, M.: Intra-articular analgesia for arthroscopic meniscectomy. British J. Anaesth., 75: 522-525, 1995.[Abstract/Free Full Text]
-
McGuire, D. A.; Sanders, K.; and Hendricks, S. D.: Comparison of ketorolac and opioid analgesics in postoperative
ACL reconstruction outpatient pain control. Arthroscopy, 9: 653-661, 1993.[Medline]
-
McMaster, W. C.; Liddle, S.; and Waugh, T. R.: Laboratory evaluation of various cold therapy modalities. Am. J. Sports Med., 6: 291-294, 1978.[Free Full Text]
-
McQuay, H. J.; Carroll, D.; and Moore, R. A.: Postoperative orthopaedic pain - the effect of opiate
premedication and local anesthetic blocks. Pain,, 33: 291-295, 1988.[Medline]
-
McSwiney, M. M.; Joshi, G. P.; Kenny, P.; and McCarroll, S. M.: Analgesia following arthroscopic knee surgery. A controlled
study of intra-articular morphine, bupivacaine or both combined. Anaesth. and Intens. Care, 21: 201-203, 1993.[Medline]
-
Matheny, J. M.; Hanks, G. A.; Rung, G. W.; Blanda, J. B.; and Kalenak, A.: A comparison of patient-controlled analgesia and continuous
lumbar plexus block after anterior cruciate ligament reconstruction. Arthroscopy, 9: 87-90, 1993.[Medline]
-
Meade, E. A.; Smith, W. L.; and DeWitt, D. L.: Differential inhibition of prostaglandin endoperoxide
synthase (cyclooxygenase) isozymes by aspirin and other non-steroidal
anti-inflammatory drugs. J. Biol. Chem, 268: 6610-6614, 1993.[Abstract/Free Full Text]
-
Meinig, R. P.; Holtgrewe, J. L.; Wiedel, J. D.; Christie, D. B.; and Kestin, K. J.: Plasma bupivacaine levels following single dose instillation
for arthroscopy. Am. J. Sports Med., 16: 295-300, 1988.[Abstract/Free Full Text]
-
Milligan, K. A.; Mowbray, M. J.; Mulrooney, L.; and Standen, P. J.: Intra-articular bupivacaine for pain relief after arthroscopic
surgery of the knee joint in daycase patients. Anaesthesia,, 43: 563-564, 1988.[Medline]
-
Moffet, H.; Richards, C. L.; Malouin, F.; Bravo, G.; and Paradis, G.: Early and intensive physiotherapy accelerates recovery
postarthroscopic meniscectomy: results of a randomized controlled
study. Arch. Phys. Med. and Rehab, 75: 415-426, 1994.[Medline]
-
Moore, D. C.; Bridenbaugh, L. D.; Thompson, G. E.; Balfour, R. I.; and Horton, W. G.: Bupivacaine: a review of 11,080 cases. Anesth. and Analg, 57: 42-53, 1978.[Abstract/Free Full Text]
-
Nakamura, M, and Ferreira, S. H.: Peripheral analgesic action of clonidine: mediation by
release of endogenous enkephalin-like substances. European J. Pharmacol, 146: 223-228, 1988.[Medline]
-
Niemi, L.; Pitkanen, M.; Tuominen, M.; Bjorkenheim, J. M.; and Rosenberg, P. H.: Intraarticular morphine for pain relief after knee arthroscopy
performed under regional anesthesia. Acta Anaesth. Scandinavica, 38: 402-405, 1994.[Medline]
-
Nole, R.; Munson, N. M.; and Fulkerson, J. P.: Bupivacaine and saline effects on articular cartilage. Arthroscopy, 1: 123-127, 1985.[Medline]
-
Raja, S. N.; Meyer, R. A.; and Campbell, J. N.: Peripheral mechanisms of somatic pain. Anesthesiology, 68: 571-590, 1988.[Medline]
-
Raja, S. N.; Dickstein, R. E.; and Johnson, C. A.: Comparison of postoperative analgesic effects of intraarticular
bupivacaine and morphine following arthroscopic knee surgery. Anesthesiology,, 77: 1143-1147, 1992.[Medline]
-
Rasmussen, S.; Larsen, A. S.; Thomsen, S. T.; and Kehlet, H.: Intra-articular glucocorticoid, bupivacaine and morphine
reduces pain, inflammatory response and convalescence after arthroscopic
meniscectomy. Pain,, 78: 131-134, 1998.[Medline]
-
Reuben, S. S, and Connelly, N. R.: Postoperative analgesia for outpatient arthroscopic knee
surgery with intraarticular bupivacaine and ketorolac. Anesth. and Analg., 80: 1154-1157, 1995.[Abstract]
-
Reuben, S. S, and Connelly, N. R.: Postarthroscopic meniscus repair analgesia with intraarticular
ketorolac or morphine. Anesth. and Analg., 82: 1036-1039, 1996.[Abstract]
-
Reuben, S. S.; Connelly, N. R.; and Steinberg, R.: Ketorolac as an adjunct to patient-controlled morphine
in postoperative spine surgery patients. Reg. Anesth., 22: 343-346, 1997.[Medline]
-
Reuben, S. S.; Steinberg, R. B.; Cohen, M. A.; Kilaru, P. A.; and Gibson, C. S.: Intraarticular morphine in the multimodal analgesic management
of postoperative pain after ambulatory anterior cruciate ligament
repair. Anesth. and Analg., 86: 374-378, 1998.[Abstract]
-
Reuben, S. S, and Connelly, N. R.: Postoperative analgesia for outpatient arthroscopic knee
surgery with intraarticular clonidine. Anesth. and Analg., 88: 729-733, 1999.[Abstract/Free Full Text]
-
Reuben, S. S.; Connelly, N. R.; and Maciolek, H.: Postoperative analgesia with controlled-release oxycodone
for outpatient anterior cruciate ligament surgery. Anesth. and Analg., 88: 1286-1291, 1999.[Abstract/Free Full Text]
-
Reuben, S. S, and Connelly, N. R.: Postoperative analgesic effects of celecoxib or rofecoxib
after spinal fusion surgery. Anesth. and Analg., 91: 1221-1225, 2000.[Abstract/Free Full Text]
-
Richardson, M. D.; Bjorksten, A. R.; Hart, J. A.; and McCullough, K.: The efficacy of intra-articular morphine for postoperative
knee arthroscopy analgesia. Arthroscopy, 5: 584-589, 1997.
-
Ringrose, N. H., and Cross, M. J.: Femoral nerve block in knee joint surgery. Am. J. Sports Med, 12: 398-402, 1984.[Abstract/Free Full Text]
-
Rutberg, H.; Hakanson, E.; Anderberg, B.; Jorfeldt, L.; Martensson, J.; and Schildt, B.: Effects of extradural administration of morphine, or bupivacaine,
on the endocrine response to upper abdominal surgery. British J. Anaesth, 56: 233-238, 1984.[Abstract/Free Full Text]
-
Ruwe, P. A.; Klein, I.; and Shields, C. L.: The effect of intraarticular injection of morphine and
bupivacaine on postarthroscopic pain control. Am. J. Sports Med., 23: 59-64, 1995.[Abstract/Free Full Text]
-
Schaubel, H. J.: The local use of ice after orthopaedic procedures. Am. J. Surg, 72: 711-714, 1946.
-
Seibert, K.; Zhang, Y.; Leahy, K.; Hauser, S.; Masferrer, J.; Perkins, W.; Lee, L.; and Isakson, P.: Pharmacological and biochemical demonstration of the role
of cyclooxygenase 2 in inflammation and pain. Proc. Nat. Acad. Sci, 91: 12013-12017, 1994.[Abstract/Free Full Text]
-
Shelbourne, K. D, and Nitz, P.: Accelerated rehabilitation after anterior cruciate ligament
reconstruction. Am. J. Sports Med, 18: 292-299, 1990.[Abstract/Free Full Text]
-
Shelbourne, K. D.; Rubinstein, R. A Jr.; McCarroll, J. R.; and Weaver, J.: Postoperative cryotherapy for the knee in ACL reconstructive
surgery. Orthop. Internat. Ed, 2: 165-170, 1994.
-
Smith, I.; Van Hemelrijck, J.; White, P. F.; and Shively, R.: Effects of local anesthesia on recovery after outpatient
arthroscopy. Anesth. and Analg, 73: 536-539, 1991.[Abstract/Free Full Text]
-
Smith, I.; Shively, R. A.; and White, P. F.: Effects of ketorolac and bupivacaine on recovery after
outpatient arthroscopy. Anesth. and Analg., 75: 208-212, 1992.[Abstract/Free Full Text]
-
Soderlund, A.; Boreus, L. O.; Westman, L.; Engstrom, B.; Valentin, A.; and Ekblom, A.: A comparison of 50, 100 and 200 mg of intra-articular
pethidine during knee joint surgery, a controlled study with evidence
for local demethylation to norpethidine. Pain, 80: 229-238, 1999.[Medline]
-
Stein, C.; Millan, M. J.; Shippenberg, T. S.; Peter, K.; and Hertz, A.: Peripheral opioid receptors mediating antinociception
in inflammation. Evidence for involvement of mu, delta and kappa
receptors. J. Pharmacol. and Exper. Ther., 248: 1269-1275, 1989.
-
Stein, C.; Comisel, K.; Haimerl, E.; Yassouridis, A.; Lehrberger, K.; Herz, A.; and Peter, K.: Analgesic effect of intraarticular morphine after arthroscopic
knee surgery. New England J. Med., 325: 1123-1126, 1991.[Abstract]
-
Stein, C.: Peripheral mechanisms of opioid analgesia. Anesth. and Analg., 76: 182-191, 1993.[Abstract/Free Full Text]
-
Stein, C.: The control of pain in peripheral tissue by opioids. New England J. Med., 332: 1685-1690, 1995.[Free Full Text]
-
Stein, C., and Yassouridis, A.: Peripheral morphine analgesia. Pain,, 71: 119-121, 1997.[Medline]
-
St.-Pierre, D. M.: Rehabilitation following arthroscopic meniscectomy. Sports Med., 10: 338-347, 1995.
-
Sunshine, A.; Olson, N. Z.; Colon, A.; Rivera, J.; Kaiko, R. F.; Fitzmartin, R. D.; Reder, R. F.; and Goldenheim, P. D.: Analgesic efficacy of controlled-release oxycodone in
postoperative pain. J. Clin. Pharmacol., 36: 595-603, 1996.[Abstract]
-
Tetzlaff, J. E.; Andrish, J.; O'Hara, J Jr.; Dilger, J.; and Yoon, H. J.: Effectiveness of bupivacaine administered via femoral
nerve catheter for pain control after anterior cruciate ligament
repair. J. Clin. Anesth., 9: 542-545, 1997.[Medline]
-
Tetzlaff, J. E.; Dilger, J. A.; Abate, J.; and Parker, R. D.: Preoperative intra-articular morphine and bupivacaine
for pain control after outpatient arthroscopic anterior cruciate
ligament reconstruction. Reg. Anesth, 24: 220-224, 1999.
-
United States Acute Pain Management Guideline Panel:
Acute Pain Management: Operative or Medical Procedures and Trauma.
Pub. no. 92-0032. Rockville, Maryland, United States Department
of Health and Human Services, Public Health Service Agency for Health
Care Policy and Research, 1992.
-
Uysalel, A.; Kecik, Y.; Kirdemir, P.; Sayin, M.; and Binnet, M.: Comparison of intraarticular bupivacaine with the addition
of morphine or fentanyl for analgesia after arthroscopic surgery. Arthroscopy, 11: 660-663, 1995.[Medline]
-
Wall, P. D.: The prevention of postoperative pain. Pain, 33: 289-290, 1988.[Medline]
-
Wang, J. J.; Ho, S. T.; Lee, S. C.; Tang, J. J.; and Liaw, W. J.: Intraarticular triamcinolone acetonide for pain control
after arthroscopic knee surgery. Anesth. and Analg., 87: 1113-1116, 1998.[Abstract/Free Full Text]
-
Whitford, A.; Healy, M.; Joshi, G. P.; McCarroll, S. M.; and O'Brien, T. M.: The effect of tourniquet release time on the analgesic
efficacy of intraarticular morphine after arthroscopic knee surgery. Anesth. and Analg., 84: 791-793, 1997.[Abstract]
-
Wilkinson, D. J.: Intraarticular ketorolac. Anesth. and Analg., 82: 433, 1996.
-
Winnie, A. P. Ramamurthy, S., and Durrani, Z.: The inguinal paravascular technique of lumbar plexus anesthesia:
the "3-in-1 block". Anesth. and Analg., 52: 989-996, 1973.[Free Full Text]
-
Woolf, C. J.: Evidence for a central component of post-injury pain hypersensitivity. Nature,, 306: 686-688, 1983.[Medline]
-
Woolf, C. J, and Wall, P. D.: Morphine-sensitive and morphine-insensitive actions of
C-fibre input on the rat spinal cord. Neurosci. Lett., 64: 221-225, 1986.[Medline]
-
Woolf, C. J, and Chong, M. S.: Preemptive analgesia - treating postoperative pain by
preventing the establishment of central sensitization. Anesth. and Analg., 77: 362-379, 1993.[Medline]
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Introduction
Principles of Acute Pain...