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Local Anaesthetic Infiltration for Peri-Operative Pain Control in Total

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Local Anaesthetic Infiltration for Peri-Operative Pain Control in Total Marques et al. BMC Musculoskeletal Disorders 2014, 15:220 http://www.biomedcentral.com/1471-2474/15/220 RESEARCH ARTICLE Open Access Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness Elsa MR Marques1*, Hayley E Jones1, Karen T Elvers2, Mark Pyke3, Ashley W Blom2 and Andrew D Beswick2 Abstract Background: Surgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound closure provides additional pain control. Methods: We performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses. Results: In 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) −0.61 (95% CI −1.05, −0.16; p = 0.008) and by SMD −0.43 (95% CI −0.78 −0.09; p = 0.014) at 48 hours during activity. In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD −0.40 (95% CI −0.58, −0.22; p < 0.001) at 24 hours at rest and by SMD −0.27 (95% CI −0.50, −0.05; p = 0.018) at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block. Patients receiving local anaesthetic infiltration spent on average an estimated 0.83 (95% CI 1.54, 0.12; p = 0.022) and 0.87 (95% CI 1.62, 0.11; p = 0.025) fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting. Few studies reported long-term outcomes. Conclusions: Local anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk. Keywords: Hip replacement, Knee replacement, Anaesthesia, Systematic review, Meta-analysis * Correspondence: [email protected] 1School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK Full list of author information is available at the end of the article © 2014 Marques et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Marques et al. BMC Musculoskeletal Disorders 2014, 15:220 Page 2 of 20 http://www.biomedcentral.com/1471-2474/15/220 Background acquired potentially relevant articles, and decided on in- Total hip replacement (THR) and total knee replace- clusion based on pre-specified criteria, with disputes re- ment (TKR) are widely used to treat diseased and dam- solved by other authors. aged joints. In 2012 there were 75,366 primary THR and We included RCTs of patients with primary unilateral 76,497 primary TKR procedures recorded in the Na- THR or TKR receiving local anaesthetic infiltration be- tional Joint Registry for England, Wales and Northern fore wound closure compared with patients receiving no Ireland [1]. In the USA in 2010, the estimated numbers local anaesthetic infiltration or placebo. We also in- of THR and TKR procedures performed were 332,000 cluded studies comparing local anaesthetic infiltration and 719,000, respectively [2]. with other forms of analgesia and studies with additional Pain is the primary indication for THR and TKR and post-wound closure delivery of analgesics through cathe- many preparatory, surgical and rehabilitation strategies ters and injections. We excluded studies with interven- target reduction in pain. However, both short- and long- tions exclusively after wound closure and studies in term pain after THR and TKR are common [3-5]. Peri- patients receiving hip hemiarthroplasty or unicompart- operative pain is managed with multi-modal analgesia mental TKR. No language restrictions were applied and with additive or synergistic effects [6]. Regimens aim to translations were made by colleagues as required. achieve good pain relief immediately after surgery while allowing for early mobilisation and hospital discharge. Data collection and extraction Other methods such as spinal and epidural anaesthetics Articles and inclusion/exclusion decisions were catalo- and the use of opioids may preclude early mobilisation gued in Endnote X5. Data were extracted on to piloted and rehabilitation [7,8]. forms and an Excel spreadsheet in duplicate. Authors Pain management by infusion of local anaesthetic into were contacted for unpublished outcomes and missing wounds has been evaluated in diverse surgical proce- data. dures. In their systematic review, Liu and colleagues Information was extracted on study characteristics; noted improved pain, reduced opioid use and side ef- participant characteristics; anaesthesia procedures com- fects, increased patient satisfaction, and shorter hospital mon to randomised groups; intervention (content of infil- stay in patients receiving local anaesthetic infiltration trate, timing and volume); additional intervention group [9]. Only one study included patients with THR or TKR treatments; and control group treatment including pla- [10], but further evaluations have been reported [11]. cebo and alternative analgesia regimens. More recent meta-analyses in abdominal surgery [12], and lumbar spine surgery [13], have questioned the clin- Outcomes ical value of local anaesthetic wound infiltration. Outcomes studied were pain at rest or during activity at Using systematic review methods and meta-analysis, our 24 and 48 hours after surgery, opioid consumption, mo- objective was to synthesise evidence from randomised bilisation, length of hospital stay in days, and long-term controlled trials (RCTs) evaluating the effectiveness of pain and function. Serious complications recorded were peri-operative local anaesthetic infiltration for pain control altered state of consciousness, cardiovascular complica- in patients with THR and TKR. Pain outcomes were con- tions requiring treatment, central nervous system tox- sidered along with post-operative opioid requirement, mo- icity, dysarthria, dyspnoea, major surgical complications, bilisation, hospital stay and complications. pneumonia, pulmonary embolism, respiratory depres- sion, seizures, and swollen knee; or complications relat- Methods ing to deep infection. Adverse events were vomiting and We identified RCTs using methods described in the nausea. Cochrane handbook of systematic reviews of interventions [14]. The review was conducted in accordance with PRISMA Study quality guidelines [15] and a checklist is included as Additional Potential sources of bias were recorded in a Cochrane file 1. This review builds on a previous literature review, risk of bias table [14]. We considered random sequence without a further formal protocol published [11]. generation, allocation concealment, blinding of partici- pants and personnel, blind outcome assessment, incom- Search strategy and selection criteria plete outcome data, selective reporting, and other We searched MEDLINE and Embase on OvidSP and sources of bias. We classified overall quality as low, un- Cochrane CENTRAL to 11th December 2012. The search clear or high risk of bias. strategy covered RCTs, anaesthesia and analgesia, and THR and TKR terms (Table 1). We tracked citations of Meta-analysis key articles in ISI Web of Science [10,16-19], and checked We conducted meta-analyses for pain at rest and during reference lists. Two reviewers scanned abstracts and titles, activity at 24 and 48 hours, length of hospital stay, and Marques et al. BMC Musculoskeletal Disorders 2014, 15:220 Page 3 of 20 http://www.biomedcentral.com/1471-2474/15/220 Table 1 Search strategy as applied in MEDLINE 1 Anesthetics, Local/or local anaesthetic.mp. 2 Anesthetics, Local/or Anesthesia, Local/or Local anaesthesia.mp. 3 Anesthetics/or Anesthesia/or anaesthesia.mp. or Anesthetics, Local/or Anesthesia, Local/ 4 anesthesia.mp. 5 anaesthetic.mp. 6 amides.mp. or Amides/ 7(“Huneke neural therapy” or “Neural therapy of Huneke” or benzocaine or bensokain or “Aminobenzoic Acid” or “Aminobenzoate” or bupivacain* or buvacaina or sensorcaine or marcain* or svedocain* or levobupivacaine or carticain* or articain* or dibucaine or cinchocaine or Cincain or Nupercain*
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