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Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies.

ABSTRACT: OBJECTIVE:To examine the analgesic efficacy and safety of ketamine after total knee or hip arthroplasty. DESIGN:Systematic review and meta-analysis. DATA SOURCES:PubMed, EMBASE and Cochrane Library from inception to 22 May 2019. ELIGIBILITY CRITERIA FOR SELECTING STUDIES:Randomised controlled trials comparing the efficacy and safety of ketamine with placebo for postoperative pain relief in patients undergoing total knee or hip arthroplasty. DATA EXTRACTION AND SYNTHESIS:Data (ie, pain intensity, morphine consumption, gastrointestinal and psychotic adverse effects) were extracted by two reviewers independently. The Cochrane Collaboration's recommended tool was used to determine the methodological quality of included studies. RESULTS:A total of 10 studies were included. One of them was rated as low quality. Compared with placebo, intravenous ketamine was effective for pain relief during 0-8-hour (weighted mean difference (WMD) -1.21, 95%?CI -1.45 to -0.98, p<0.001; three studies, 149 participants) but not during 8-24-hour postoperative periods, and effective for reduction of cumulative morphine consumption during both 0-24-hour (WMD -17.76, 95%?CI -31.25 to -4.27, p=0.01; five studies, 366 participants) and 0-48-hour (WMD -21.79, 95%?CI -25.46 to -18.11, p<0.001; four studies, 252 participants) postoperative periods, without increasing risks of gastrointestinal or psychotic adverse effects. The limited data available for intra-articular (WMD -0.49, 95%?CI -0.70 to -0.29, p<0.001; two studies, 83 participants) and epidural (WMD -2.10, 95%?CI -3.30 to -0.90, p<0.001; one study, 20 participants) ketamine pointed to a significant reduction in pain intensity during 8-24-hour postoperative period. CONCLUSIONS:Intravenous administration of ketamine is effective and safe for postoperative pain relief in patients undergoing total knee or hip arthroplasty. Nevertheless, the analgesic efficacy and safety of ketamine in such patients seem to vary by different administration routes and still warrant further studies to explore.

SUBMITTER: Xu B

PROVIDER: S-EPMC6747636 | biostudies-literature | 2019 Sep

REPOSITORIES: biostudies-literature

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Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies.

Xu Bei B Wang Yilun Y Zeng Chao C Wei Jie J Li Jiatian J Wu Ziying Z He Hongyi H Lei Guanghua G Xie Dongxing D Ding Xiang X

BMJ open 20190913 9

<h4>Objective</h4>To examine the analgesic efficacy and safety of ketamine after total knee or hip arthroplasty.<h4>Design</h4>Systematic review and meta-analysis.<h4>Data sources</h4>PubMed, EMBASE and Cochrane Library from inception to 22 May 2019.<h4>Eligibility criteria for selecting studies</h4>Randomised controlled trials comparing the efficacy and safety of ketamine with placebo for postoperative pain relief in patients undergoing total knee or hip arthroplasty.<h4>Data extraction and syn ...[more]

PMID: 31519671

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Project description:BackgroundTramadol is increasingly used to treat acute postoperative pain among older adults following total hip and knee arthroplasty (THA/TKA). However, tramadol has a complex pharmacology and may be no safer than full opioid agonists. We compared the safety of tramadol, oxycodone, and hydrocodone among opioid-naïve older adults following elective THA/TKA.MethodsThis retrospective cohort included Medicare Fee-for-Service beneficiaries ≥ 65 years with elective THA/TKA between January 1, 2010 and September 30, 2015, 12 months of continuous Parts A and B enrollment, 6 months of continuous Part D enrollment, and no opioid use in the 6 months prior to THA/TKA. Participants initiated single-opioid therapy with tramadol, oxycodone, or hydrocodone within 7 days of discharge from THA/TKA hospitalization, regardless of concurrently administered nonopioid analgesics. Outcomes of interest included all-cause hospitalizations or emergency department visits (serious adverse events (SAEs)) and a composite of 10 surgical- and opioid-related SAEs within 90-days of THA/TKA. The intention-to-treat (ITT) and per-protocol (PP) hazard ratios (HRs) for tramadol versus other opioids were estimated using inverse-probability-of-treatment-weighted pooled logistic regression models.ResultsThe study population included 2,697 tramadol, 11,407 oxycodone, and 14,665 hydrocodone initiators. Compared to oxycodone, tramadol increased the rate of all-cause SAEs in ITT analyses only (ITT HR 1.19, 95%CLs, 1.02, 1.41; PP HR 1.05, 95%CLs, 0.86, 1.29). Rates of composite SAEs were not significant across comparisons. Compared to hydrocodone, tramadol increased the rate of all-cause SAEs in the ITT and PP analyses (ITT HR 1.40, 95%CLs, 1.10, 1.76; PP HR 1.34, 95%CLs, 1.03, 1.75), but rates of composite SAEs were not significant across comparisons.ConclusionsPostoperative tramadol was associated with increased rates of all-cause SAEs, but not composite SAEs, compared to oxycodone and hydrocodone. Tramadol does not appear to have a superior safety profile and should not be preferentially prescribed to opioid-naïve older adults following THA/TKA.

Project description:BackgroundTotal knee arthroplasty (TKA) is currently the main treatment for end-stage knee disease. The number of cases of TKA in China increased from 53,880 in 2011 to 374,833 in 2019, representing a 5.9-fold increase. Moderate to severe pain often occurs after TKA, which seriously affects postoperative rehabilitation, patient satisfaction, and overall outcome. Multimodal analgesia is considered the ideal solution. Adequate postoperative analgesia can not only reduce pain, opioid consumption, and, consequently, opioid-related adverse events, but can also reduce the length of hospital stay and costs and improve rehabilitation and patient satisfaction.ObjectiveEffective multimodal pain management in the early postoperative period is essential for anesthesiologists. Additional studies have demonstrated that a low-dose intravenous infusion of ketamine can be administered as an adjuvant drug to alleviate acute postoperative pain. Therefore, we aim to appraise the efficacy and safety of intraoperative intravenous injection of S(+)-ketamine to relieve acute pain after TKA in older patients.MethodsThis is a protocol for a randomized, placebo-controlled trial. A total of 144 participants aged 65 years and older undergoing TKA will be randomly allocated into the S(+)-ketamine and placebo groups in a 1:1 ratio. S(+)-ketamine or the placebo will be intravenously administered at 0.3 mg/kg/h during the operation by anesthesiologists. Blinded evaluation by trained investigators will be completed at 2 hours, 24 hours, and 48 hours after surgery. The primary outcome measure will be the numeric rating scale score at rest and movement at 24 hours after surgery. The secondary outcomes will include the numeric rating scale scores at rest and movement at 2 hours and 48 hours after surgery, the number of patients who require additional analgesics during the first 48 hours after operation, the total consumption of opioids or nonsteroid anti-inflammatory drugs during the first 48 hours after operation, and adverse events at 2, 24, and 48 hours after operation.ResultsThe protocol was registered at Clinical Trials.gov on February 26, 2022. It was performed in accordance with the approved guidelines and regulations of the participating institutions. Recruitment began in April 2022. Data collection is expected to conclude in September 2024. Study completion is expected in December 2024.ConclusionsA randomized, controlled, clinical study was designed to observe the analgesic effect of intraoperative intravenous administration of a lower dose of S(+)-ketamine (0.3 mg/kg/h) in older patients after TKA surgery. The protocol will appraise the efficacy and safety of intraoperative intravenous injection of S(+)-ketamine to relieve acute pain after TKA in older patients who may benefit from the administration of S(+)-ketamine.Trial registrationClinicalTrials.gov NCT05289050; https://clinicaltrials.gov/ct2/show/NCT05289050.International registered report identifier (irrid)DERR1-10.2196/53063.

Project description:ObjectiveTo search, review, and analyze the efficacy and safety of various anticoagulants from randomized clinical trials (RCTs) of anticoagulants for THA and TKA.DesignPRISMA-compliant Bayesian Network Meta-analysis.Data sources and study selectionThe databases of The Medline, Embase, ClinicalTrial, and Cochrane Library databases were searched until March 2017 for RCTs of patients undergoing a THA or TKA.Main outcomes and measuresThe primary efficacy measurement was the venous thromboembolism Odds ratio (OR). The safety measurement was the odds ratio of major or clinically relevant bleeding. OR with 95% credibility intervals (95%CrIs) were calculated. Findings were interpreted as associations when the 95%CrIs excluded the null value.ResultsThirty-five RCTs (53787 patients; mean age range, mostly 55-70 years; mean weight range, mostly 55-90 kg; and a higher mean proportion of women than men, around 60%) included the following Anticoagulants categories: fondaparinux, edoxaban, rivaroxaban, apixaban, dabigatran, low-molecular-weight heparin, ximelagatran, aspirin, warfarin. Anticoagulants were ranked for effectiveness as follows: fondaparinux (88.89% ± 10.90%), edoxaban (85.87% ± 13.34%), rivaroxaban (86.08% ± 10.23%), apixaban (68.26% ± 10.82%), dabigatran (41.63% ± 12.26%), low-molecular-weight heparin (41.03% ± 9.60%), ximelagatran (37.81% ± 15.87%), aspirin (35.62% ± 20.60%), warfarin (9.89% ± 9.07%), and placebo (4.56% ± 6.37%). Ranking based on clinically relevant bleeding events was as follows: fondaparinux (14.53% ± 15.25%), ximelagatran (18.93% ± 17.49%), rivaroxaban (23.86% ± 15.14%), dabigatran (28.30% ± 14.18%), edoxaban (38.76% ± 24.25%), low-molecular-weight heparin (53.28% ± 8.40%), apixaban (71.81% ± 10.92%), placebo (76.26% ± 14.61%), aspirin (86.32% ± 25.74%), and warfarin (87.95% ± 11.27%). No statistically significant heterogeneity was observed between trials.Conclusions and relevanceAccording to our results, all anticoagulant drugs showed some effectiveness for VTE prophylaxis. Our ranking indicated that fondaparinux and rivaroxaban were safer and more effective than other anticoagulant drugs for patients undergoing THA or TKA.

Project description:BackgroundAs an essential component of multimodal analgesia approaches after total knee arthroplasty (TKA), local infiltration analgesia (LIA) can be classified into peri-articular injection (PAI) and intra-articular injection (IAI) according to administration techniques. Currently, there is no definite answer to the optimal choice between the two techniques. Our study aims to investigate analgesic efficacy and safety of PAI versus IAI in patients receiving simultaneous bilateral TKA.MethodsThis randomized controlled trial was conducted from February 2017 and finished in July 2018. Sixty patients eligible for simultaneous bilateral total knee arthroplasty were randomly assigned to receive PAI on one side and IAI on another. Primary outcomes included numerical rating scale (NRS) pain score at rest or during activity at 3?h, 6?h, 12?h, 24?h, 48?h, and 72?h following surgery. Secondary outcomes contained active or passive range of motion (ROM) at 1, 2, and 3?days after surgery, time to perform straight leg raise, wound drainage, operation time, and wound complications.ResultsPatients experienced lower NRS pain scores of the knee receiving PAI compared with that with PAI during the first 48?h after surgery. The largest difference of NRS pain score at rest occurred at 48?h (PAI: 0.68, 95%CI[0.37, 0.98]; IAI: 2.63, 95%CI [2.16, 3.09]; P <?0.001); and the largest difference of NRS pain score during activity also took place at 48?h (PAI: 2.46, 95%CI [2.07, 2.85]; IAI: 3.90, 95%CI [3.27, 4.52]; P =?0.001). PAI group had better results of range of motion and time to perform straight leg raise when compared with IAI group. There were no differences in operation time, wound drainage, and wound complication.ConclusionPAI had the superior performance of pain relief and improvement of range of motion to IAI. Therefore, the administration technique of peri-articular injection is recommended when performing local infiltration analgesia after total knee arthroplasty.Trial registrationThe trial was retrospectively registered in the Chinese Clinical Trial Registry as ChiCTR1800020420 on 29th December, 2018.Level of evidenceTherapeutic Level I.

Project description:Computer assisted surgery was pioneered in early 1990s. The first computer assisted surgery (CAS) total knee replacement with an imageless system was carried out in 1997. In the past 25 years, CAS has progressed from experimental in vitro studies to established in vivo surgical procedures.A comprehensive body of evidence establishing the advantages of computer assisted surgery in knee and hip arthroplasty is available. Established benefits have been demonstrated including its role as an excellent research tool. Its advantages include dynamic pre-operative and per-operative assessment, increased accuracy in correction of deformities, kinematics and mechanical axis, a better alignment of components, better survival rates of prostheses and a better functional outcome. Adoption of computer navigation in the hip arthroplasty is still at an early stage compared to knee arthroplasty, though the results are well documented. Evidence suggests improved accuracy in acetabular orientation, positioning, hip offset and leg length correction.Among the orthopaedic surgeons, navigated knee arthroplasty is gaining popularity though slowly. The uptake rates vary from country to country. The Australian joint registry data shows increased navigated knee arthroplasty from 2.4% in 2003 to 28.6% in 2015 and decreased revision rates with navigated knee arthroplasty in comparison with traditional instrumented knee arthroplasty in patient cohort under the age of 55 years.Any new technology has a learning curve and with practice the navigation assisted knee and hip arthroplasty becomes easy. We have actively followed the evidence of CAS in orthopaedics and have successfully adopted it in our routine practice over the last decades. Despite the cautious inertia of orthopaedic surgeons to embrace CAS more readily; we are certain that computer technology has a pivotal role in lower limb arthroplasty. It will evolve to become a standard practice in the future in various forms like navigation or robotics.

Dataset Information

Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies.

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Analgesic efficacy and safety of ketamine after total knee or hip arthroplasty: a meta-analysis of randomised placebo-controlled studies.

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