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Regional analgesia for improvement of long-term functional outcome after elective large joint replacement.

ABSTRACT: BACKGROUND:Regional analgesia is more effective than conventional analgesia for controlling pain and may facilitate rehabilitation after large joint replacement in the short term. It remains unclear if regional anaesthesia improves functional outcomes after joint replacement beyond three months after surgery. OBJECTIVES:To assess the effects of regional anaesthesia and analgesia on long-term functional outcomes 3, 6 and 12 months after elective major joint (knee, shoulder and hip) replacement surgery. SEARCH METHODS:We performed an electronic search of several databases (CENTRAL, MEDLINE, EMBASE, CINAHL), and handsearched reference lists and conference abstracts. We updated our search in June 2015. SELECTION CRITERIA:We included randomized controlled trials (RCTs) comparing regional analgesia versus conventional analgesia in patients undergoing total shoulder, hip or knee replacement. We included studies that reported a functional outcome with a follow-up of at least three months after surgery. DATA COLLECTION AND ANALYSIS:We used standard methodological procedures expected by Cochrane. We contacted study authors for additional information. MAIN RESULTS:We included six studies with 350 participants followed for at least three months. All of these studies enrolled participants undergoing total knee replacement. Studies were at least partially blinded. Three studies had a high risk of performance bias and one a high risk of attrition bias, but the risk of bias was otherwise unclear or low.Only one study assessed joint function using a global score. Due to heterogeneity in outcome and reporting, we could only pool three out of six RCTs, with range of motion assessed at three months after surgery used as a surrogate for joint function. All studies had a high risk of detection bias. Using the random-effects model, there was no statistically significant difference between the experimental and control groups (mean difference 3.99 degrees, 95% confidence interval (CI) - 2.23 to 10.21; P value = 0.21, 3 studies, 140 participants, very low quality evidence).We did not perform further analyses because immediate adverse effects were not part of the explicit outcomes of any of these typically small studies, and long-term adverse events after regional anaesthesia are rare.None of the included studies elicited or reported long-term adverse effects like persistent nerve damage. AUTHORS' CONCLUSIONS:More high-quality studies are needed to establish the effects of regional analgesia on function after major joint replacement, as well as on the risk of adverse events (falls).

SUBMITTER: Atchabahian A

PROVIDER: S-EPMC4566967 | biostudies-literature | 2015 Aug

REPOSITORIES: biostudies-literature

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Regional analgesia for improvement of long-term functional outcome after elective large joint replacement.

Atchabahian Arthur A Schwartz Gary G Hall Charles B CB Lajam Claudette M CM Andreae Michael H MH

The Cochrane database of systematic reviews 20150813 8

<h4>Background</h4>Regional analgesia is more effective than conventional analgesia for controlling pain and may facilitate rehabilitation after large joint replacement in the short term. It remains unclear if regional anaesthesia improves functional outcomes after joint replacement beyond three months after surgery.<h4>Objectives</h4>To assess the effects of regional anaesthesia and analgesia on long-term functional outcomes 3, 6 and 12 months after elective major joint (knee, shoulder and hip) ...[more]

PMID: 26269416

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Project description:BACKGROUND:Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA). OBJECTIVES:Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA. DESIGN:A web-based prospective observational registry. SETTING:Five Italian Private and University Hospitals from 2012 to 2015. PATIENTS:Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery. INTERVENTION(S):Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability. MAIN OUTCOME MEASURES:Experience of PPSP according to the type of peri-operative analgesia. RESULTS:Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months. CONCLUSION:Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP. TRIAL REGISTRATION:Clinicaltrials.gov identifier: NCT02147730.

Project description:BackgroundThere are no reports describing the long-term outcome of sport horses undergoing unilateral mandibular condylectomy with meniscectomy (UMC) for treatment for severe temporomandibular joint (TMJ) disease (TMD). Whether horses undergoing UMC require a specialized diet, can return to riding with a bit, or return to intended function after surgery is unknown.ObjectiveTo determine the long-term outcome of horses undergoing UMC for treatment of severe TMD.Study designA multi-institutional, retrospective study.MethodsMedical records obtained from seven equine referral hospitals of horses with severe TMD that underwent UMC were reviewed. Details regarding the presenting complaints, results of clinical examination, findings of diagnostic imaging, surgical technique, and outcome (including long-term follow-up with an owner questionnaire) were recorded.ResultsEleven horses fit the inclusion criteria. Three had severe idiopathic osteoarthritis, and eight had confirmed septic osteoarthritis of the TMJ. The most common post-operative complications were drainage and peri-incisional swelling (n = 5). One horse developed a hematoma at the surgical site because the facial artery was inadvertently transected during the approach, causing the condylectomy to be postponed. All horses were discharged alive from the hospital, and 10 returned to their previous or intended use. All had complete resolution of clinical signs of TMD. One mare was retired from athletic use due to her genetic value as a broodmare. One horse was euthanized 2 years after UMC due to progressively worsening of clinical signs of temporohyoid osteoarthropathy (THO), which were not present before surgery. When available, owner satisfaction of the results of the procedure was excellent.Main limitationsSample size; multiple institutions; owner bias.ConclusionsUnilateral mandibular condylectomy should not be considered a salvage procedure. Horses treated for severe TMD by UMC can return to their previous or intended level of athletic performance and do not require a specialized diet.

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Regional analgesia for improvement of long-term functional outcome after elective large joint replacement.

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Regional analgesia for improvement of long-term functional outcome after elective large joint replacement.

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