Knee Surg Sports Traumatol Arthrosc (2007) 15:564–568 DOI 10.1007/s00167-006-0221-8
KNEE
Intraarticular tramadol plus pericapsular incisional bupivacaine provides better analgesia than intraarticular plus pericapsular incisional bupivacaine after outpatient arthroscopic partial meniscectomy Tahsin Beyzadeoglu Æ Cemil Yilmaz Æ Halil Bekler Æ Alper Gokce Æ Murat M. Sayin
Received: 7 June 2006 / Accepted: 21 September 2006 / Published online: 10 November 2006 Ó Springer-Verlag 2006
Abstract Postoperative analgesic effects of intraarticular tramadol plus periarticular bupivacaine, and intraarticular plus periarticular bupivacaine injections after day-case arthroscopic partial meniscectomy were compared. Seventy-four ASA I/II patients undergoing arthroscopic partial meniscectomy, performed by a single surgeon under general anesthesia were assigned in a randomized, double-blinded manner into two groups: Group TB (n = 41) received intraarticular 100 mg of tramadol in 20 ml normal saline and periarticular incisional injection of 10 ml bupivacaine 0.5%. Group BB (n = 33) received intraarticular 20 ml 0.25% and periarticular incisional 10 ml 0.5% bupivacaine injections. The injections were performed immediately after the portal closures. Pain was assessed with visual analog scale (VAS) at 0, 15, 30 min and at 1, 2, 4 h at rest and active 90° knee flexion by a blinded observer. The first additional analgesic requirement time was recorded. The patients were discharged the same day with a prescription for paracetamol as required, up to six tablets a day and questioned for analgesic use and
T. Beyzadeoglu H. Bekler A. Gokce Department of Orthopaedics and Traumatology, Yeditepe University Hospital, School of Medicine, Devlet Yolu Ankara cad. No.: 102-104, Kozyatagi, Istanbul 34752, Turkey C. Yilmaz M. M. Sayin Department of Anesthesiology, Yeditepe University Hospital, School of Medicine, Istanbul, Turkey T. Beyzadeoglu (&) Ethem Efendi cad. Erenkoy Konutlari No: 19/A-19 Erenkoy, Istanbul 34738, Turkey e-mail:
[email protected]
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pain score at 24 h. VAS scores at rest at 15, 30 min and at movement at 0, 15, 30 min were lower in group TB (P < 0.05). First time requiring additional analgesia was lower in group TB (17.1 ± 21.9, 33.8 ± 26.6) (P < 0.05) and total paracetamol dose at the end of 24 h was 1.2 ± 1.5 g in group BB and 0.9 ± 1.3 g in group TB (P < 0.05). Intraarticular tramadol plus periarticular bupivacaine combination provides better pain relief and less analgesic requirement following arthroscopic outpatient partial meniscectomy surgery. Keywords Postoperative analgesia Arthroscopy Bupivacaine Tramadol Pain Knee Meniscectomy
Introduction Knee arthroscopy is one of the most common surgical procedures preferably done in outpatient settings for lower costs. Postoperative pain may sometimes be the major obstacle for day-case discharge and early rehabilitation. Different techniques and drugs for better postoperative analgesia have been evaluated and wellunderstood with improvements in pain relief of short duration in patients undergoing knee arthroscopy [13]. In this study, we compared the results of two different drugs administered by single or combined techniques to a group of patients who had the same kind of arthroscopic knee surgery.
Patients and methods After institutional review board and signed informed consent were obtained, a prospective, randomized,
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double-blind study was carried out with 74 patients, classified as American Society of Anesthesiologists physical status I or II undergoing elective arthroscopic partial meniscectomy for symptomatic isolated irreparable tears. The patients with any additional procedures like chondral debridement or microfracture, anterior or posterior cruciate ligament reconstruction, plica debridement, meniscus repair, lateral retinacular release, synovectomy, etc. were excluded. Other exclusion criteria were consumption of analgesics or non-steroidal anti-inflammatory drugs within 24 h before surgery, allergy to study drugs, anesthetics, opioids or NSAIDs; the patients having osteoarthrosis and severe systemic disease, bilateral surgeries and refusal by the patient. A single surgeon performed all of the operations from two standard arthroscopic portals. The patients were transported to the operating theater after premedication with midazolam (0.05 mg/kg) intramuscularly. General anesthesia was induced with fentanyl 1 lg/kg, propofol 2 mg/kg, atracurium 0.2 mg/kg, and a laryngeal mask airway was placed. Anesthesia was maintained with sevoflurane 1–3% in 50% mixture of O2. Twenty milligram of tenoxicam was injected intravenously after induction of anesthesia in order to standardize the analgesic consumption postoperatively. The patients were allocated into one of the two groups randomly with random numbers. Group TB (n = 41) received intraarticular 100 mg of tramadol hydrochloride in 20 ml normal saline and periarticular incisional injection of 10 ml of bupivacaine 0.5%. Group BB (n = 33) received intraarticular 20 ml 0.25% and periarticular incisional 10 ml bupivacaine 0.5% injections. The injections were performed immediately after the portal closures before dressing. The tourniquet was inflated to 350 mm Hg just before the portal incisions and was released 10 min after drug injections. Pain was assessed with visual analog scale (VAS) [23] by questioning the patients at 0, 15, 30 min and at 1, 2, 4 h at rest and active 90° knee flexion by a blinded observer. The complaint of pain with a VAS score of higher than 3 was eliminated by a single 20 mg dose injection of tenoxicam. The first additional analgesic requirement time was recorded. The patients were discharged the same day with a prescription for paracetamol as required up to six 500 mg tablets a day and questioned for total analgesic use and pain score at 24 h. The sex and age of the patient, the localization of the partial meniscectomy (medial, lateral or both), the site of the operated knee, tourniquet time were also recorded for each patients. The results were analyzed with the aid of a software package SPSS 9.01 and P < 0.05 is accepted as to be statistically significant. The data between the groups
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were analyzed by t test and the results within the groups were analyzed by One-way ANOVA test. Countable data were analyzed by Chi-Square test.
Results Patient demographics (age, gender), the localization of the partial meniscectomy (medial, lateral or both) and tourniquet time were similar in both the groups (Table 1). No infection was encountered. No patient developed any side effects. VAS scores at rest at 15, 30 min and at movement at 0, 15, 30 min were lower in group TB (P < 0.05) (Fig. 1a, b). VAS scores due to localization of the partial meniscectomy were lower in isolated medial or lateral meniscectomies with respect to medial + lateral meniscectomies. The first additional analgesic requirement time was lower in group TB (17.1 ± 21.9, 33.8 ± 26.6) (P < 0.05) and total paracetamol dose at the end of 24 h was 1.2 ± 1.5 g in group BB and 0.9 ± 1.3 g in group TB (P < 0.05) (Table 2). No side effects have been encountered after the study.
Discussion Intraarticular drug injection for postoperative pain control after knee arthroscopy is a common procedure in orthopedic surgery. The drug and application preference may vary between the physicians. Different combinations for intraarticular analgesic injections with different efficiency have been reported [4, 10, 12, 18, 25, 27]. Kligman et al. reported better pain relief with direct morphine injection into the synovia or the outer third of the meniscus than intraarticular injection following meniscectomy [11]. However, there is not any comparable randomized study for combination of intraarticular and pericapsular injections with other
Table 1 Demographic data of the groups
Age (years) Sex (M/F) Meniscectomy (Medial/lateral/medial + lateral) Site of the operated knee (L/R) Tourniquet time (min)
Group TB (n = 41)
Group BB (n = 33)
40 ± 15 28/13 31/7/3
39 ± 16 19/14 24/4/5
22/19 34 ± 8
18/15 35 ± 8
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Fig. 1 a VAS scores at rest. *P < 0.05. b VAS scores at knee flexion. *P < 0.05
Table 2 Analgesic use of study groups
First analgesic requirement time (min) Total paracetamol dose (g/day)
Group TB (n = 41)
Group BB (n = 33)
33.8 ± 26.6*
17.1 ± 21.9
0.9 ± 1.3*
1.2 ± 1.5
*P < 0.05
methods. In this study, the results of intraarticular tramadol plus pericapsular bupivacaine injections provided better analgesia than intraarticular plus periarticular bupivacaine for day-case arthroscopic meniscectomy patients. The cases with additional arthroscopic procedures were not included as they can change the level of expected pain level and the surgical procedures would not be comparable. Tramadol is an analgesic drug that also has a local anesthetic effect that is not opioid receptor related. It has been showed that 50 mg of intraarticular tramadol provides analgesia equivalent to 5 mg intraarticular morphine [1]. Bupivacaine is a local anesthetic that has been used alone or in combination with morphine
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[2, 9, 16], clonidine [20] or ketorolac [19]. Although levobupivacaine has recently been introduced to daily clinical practice, in this study, we used bupivacaine as it is a conventional local anaesthetic which is used worldwide. Arthroscopic procedures of the knee are amenable to different kinds of regional anesthetic techniques, but recently general anesthesia preference in suitable cases is becoming more popular. Prompt recovery and rapid turnover with lower incidence of side effects are possible by the advent of short-acting intravenous or inhaled anesthetics. In more complicated arthroscopic procedures with elevated expectation of pain, we usually prefer combined regional and general anesthesia in our practice. In fact, the last decision is given in consensus with the patient, surgeon and the anesthesiologist. Preemptive analgesia for the initiation of the analgesia before the onset of surgical pain by preventing the establishment of central sensitization [29] has been popularized and demonstrated to provide pain control and decreased opioids consumption postoperatively [21, 22, 26].
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Incisional and intraarticular injections of local anesthetic agents for preemptive analgesia were performed for open surgery [6]. We do not have any experience in preemptive analgesia for knee arthroscopy, but preferred skin and pericapsular anesthetic injections postoperatively with the combination of intraarticular use. In practice, it is known that the level of pain after knee arthroscopy is in close relation with the performed process. The source of pain is both intraarticular and capsular as the trauma stimulates free nerve endings and afferent nociceptors, and the inflammation factors such as bradykinin, histamine and serotonin are released from the damaged cells. Nociceptive activity with the establishment of primary hyperalgesia and the tissue mediators of pain and inflammation diffuse the pain by involving areas away from the skin incisions [3]. Additional infiltration of the portal incisions and the neighborhood capsular area with local anesthetic agents would diminish the pain. There is a lack of evidence for the effect of analgesic agents on early recovery. Multimodal regimens have been employed for enhanced effects on postoperative pain and convalescence [17]. In some other studies, the addition of clonidine to morphine [8] or bupivacaine [20] has been shown to improve postoperative analgesia. Incisional and intraarticular injections with the same drug have also been investigated [5, 7, 14, 15, 24, 28]. The presented multimodal study with the combination of tramadol and bupivacaine injected intraarticular and pericapsular, respectively, may provide the surgeon a good alternative for a comfortable postoperative period of the patient after arthroscopic meniscectomy. This study was employed as prospective, randomized, double-blind design and perhaps gets its greatest strength from the standardization of the surgical procedure. Only the partial meniscectomy patients were included and a single surgeon performed the operations. Most of the investigations about the local anesthetics during knee arthroscopy enclose patients with different arthroscopic surgical applications. We think postoperative pain after various processes would show differentiation. Partial meniscectomy has a low inflammatory response than anterior cruciate ligament reconstruction, lateral release or plicae removal. In the present study, combination of intraarticular and pericapsular injection technique was found efficient to provide good analgesia after outpatient arthroscopic meniscectomy without any side effects. The injection technique through the arthroscopic portals infiltrating the surrounding capsule, subcutaneous tissues and the skin diminishes the need for high doses
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of intraarticular morphine and improves the postoperative pain-free period. The side effects of analgesic drugs, especially taken in the first 24 h after general anesthesia can be reduced. The patients can be discharged on the operative day without any significant pain leading to cost reduction.
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