全膝关节置换局部应用氨甲环酸下肢深静脉血栓发生率的分层比较

[目的]探讨全膝关节置换患者局部应用氨甲环酸(tranexamic acid,TXA)对下肢深静脉血栓(deep venous thrombosis,DVT)发生率的影响。[方法]回顾分析2014年1月~2015年10月于本院接受全膝关节置换(total knee arthroplasty,TKA)的526例患者的基本信息及临床资料,其中未使用氨甲环酸的患者291例(非氨甲环酸组),局部应用氨甲环酸的患者235例(氨甲环酸组),按照血栓危险因素-体重指数,将两组患者分为正常体重、超重及肥胖三个亚层,在每个亚层中匹配年龄、性别、凝血功能等影响血栓形成的危险因素,分析比较三个亚层中氨甲环酸组和非氨甲环酸组下肢深静脉血栓发生率的差异。[结果]正常体重患者中,氨甲环酸组的DVT发生率为11.1%,非氨甲环酸组DVT发生率为10.4%,两组血栓发生率比较差异无统计学意义(χ~2=0.01,P0.05);超重患者中,氨甲环酸组的DVT发生率为14.0%,非氨甲环酸组DVT发生率为13.0%,两组血栓发生率比较差异无统计学意义(χ~2=0.05,P0.05);肥胖患者中,氨甲环酸组的DVT发生率为28.0%;非氨甲环酸组DVT发生率为16.3%,两组血栓发生率差异有统计学意义(χ~2=4.70,P0.05),且差异主要来自两组肌间静脉血栓发生率的不同(19.6%vs7.4%,χ~2=7.48,P0.05)。[结论]在国人正常体重及超重的低血栓风险患者中,膝关节置换术中局部运用氨甲环酸对下肢深静脉血栓发生无影响,肥胖患者应用氨甲环酸将增加下肢深静脉血栓,尤其是肌间静脉血栓发生的风险。     

2022年ACR/AAHKS风湿性疾病患者择期全髋或全膝关节置换术围手术期抗风湿类药物管理指南解读

美国风湿病学会(American College of Rheumatology, ACR)联合美国髋关节和膝关节外科医师协会(American Association of Hip and Knee Surgeons, AAHKS)的专家小组于2022年6月更新了《风湿性疾病患者择期全髋或全膝关节置换术围手术期抗风湿类药物管理指南》, 特别对靶向合成改善病情抗风湿药的应用及系统性红斑狼疮患者的围手术期用药管理进行了更新, 同时增加了新获批的抗风湿类药物应用建议。本文对该指南的相关内容进行解读, 为我国风湿性疾病患者全髋或全膝关节置换术的围手术期抗风湿类药物管理提供参考。     

血液管理方案对日间全髋关节置换术中失血量及输血率的影响

目的探讨改良血液管理方案对日间全髋关节置换(total hip arthroplasty, THA)术中失血量及输血率的影响。方法回顾性分析2019年1月至2021年12月125例行日间THA手术的患者资料, 按照血液管理方案分为原方案组(切皮前10 min静脉输注1 g氨甲环酸)和改良方案组(原方案+关闭切口前关节腔内局部喷洒2 g氨甲环酸+术后3 h静脉输注1 g氨甲环酸+术后第1天静脉输注1 g氨甲环酸)。原方案组52例, 男32例、女20例, 年龄(58.5±9.8)岁(范围39～69岁), 包括发育性髋关节发育不良(CroweⅠ～Ⅱ度)13例、股骨头坏死24例、髋关节骨关节炎10例、强直性脊柱炎累及髋关节3例、股骨颈骨折2例;改良方案组73例, 男43例、女30例, 年龄(55.8±10.4)岁(范围42～67岁), 发育性髋关节发育不良(CroweⅠ～Ⅱ度)17例、股骨头坏死32例、髋关节骨关节炎16例、强直性脊柱炎累及髋关节7例、股骨颈骨折1例。主要观察指标为术中失血量、术前-术后第1天的血红蛋白、红细胞压积的差值及输血率, 次要观察指标为术后2周进行下肢血管超声检查是否...     

氨甲环酸对初次全膝关节置换术后引流管拔除时机的影响

目的探讨初次单侧全膝关节置换术中应用氨甲环酸对术后引流管拔除时机的影响。方法纳入2017年6月至2018年12月拟行初次单侧全膝关节置换术的患者182例,男42例,女140例;年龄(68.1±7.1)岁(范围60～76岁)。按随机数字表法分为四组:氨甲环酸1组45例、氨甲环酸2组46例、氨甲环酸3组46例和非氨甲环酸组45例,分别于术后12 h、18 h、24 h、24 h拔除引流管。氨甲环酸1～3组术前30 min静脉滴注联合局部应用氨甲环酸;非氨甲环酸组术后仅以100 ml生理盐水关节腔内局部灌注。比较四组引流量、总失血量、隐性失血量、术后关节肿胀度、美国特种外科医院(Hospital for Special Surgery,HSS)膝关节评分、疼痛视觉模拟评分(visual analogue scale,VAS)的差异。结果氨甲环酸1～3组术后引流量分别为(85.5±34.3) ml、(189.4±72.3) ml、(215.3±93.4) ml,少于非氨甲环酸组的(351.3±113.5) ml,差异有统计学意义(F=11.5,P=0.005),其中氨甲环酸1组术后引流量少于氨...     

氨甲环酸对初次单侧全髋关节置换术隐性失血的影响分析

目的探讨术中静脉使用氨甲环酸对初次单侧全髋关节置换术隐性失血的影响,以进一步指导临床工作。 方法回顾性筛选、对比、分析2013年12月至2015年6月共52例于中山大学附属第一医院被诊断为股骨头缺血坏死、骨关节炎、发育性髋关节发育不良、股骨颈骨折并行初次单侧全髋关节置换术患者;排除双侧同期置换髋关节、氨甲环酸过敏、凝血功能异常等患者。其中,实验组术中静脉使用氨甲环酸,而对照组术中不静脉使用氨甲环酸,两组均为26例,采用独立样本t检验比较两组患者围手术期总失血量、显性失血量及隐性失血量等。采用卡方检验比较性别、患侧和基础疾病。 结果实验组围手术期总失血量(905±348)ml低于对照组(1 113±389)ml,差异有统计学意义(t＝2.037,P<0.05)。同样,实验组隐性失血量(261±252)ml也低于对照组(429±399)ml,差异有统计学意义(t＝2.027,P<0.05)。而实验组显性失血量(643±313)ml与对照组(684±237)ml相似,差异无统计学意义(P>0.05)。两组患者性别、年龄、术前白蛋白及凝血指标等均无统计学意义(P>0.05)。此外,合并两组数据后围手术期总失血量与隐性失血量呈正相关,相关系数为0.698。 结论对初次单侧全髋关节置换术患者术中静脉使用氨甲环酸可安全有效减少总失血量及隐性失血量,但对显性失血量的影响有待进一步研究。     

局部应用骨蜡和氨甲环酸在全膝关节置换术中止血作用的比较

[目的]比较骨蜡和氨甲环酸在单侧初次全膝关节置换术中减少出血量的效果。[方法]回顾性分析本院2013年1月~2014年12月符合纳入和排除标准的136例行单侧初次全膝关节置换术的患者资料。按照骨蜡和氨甲环酸的使用情况分为四组,分别为A组:骨蜡和氨甲环酸均未使用;B组:仅使用骨蜡;C组:仅使用氨甲环酸;D组:联合使用氨甲环酸和骨蜡。对术中失血量、术后24 h引流量、术后血红蛋白变化、总失血量、输血比例、临床效果等指标进行评估,分析比较局部使用骨蜡和氨甲环酸减少单侧初次全膝关节置换术患者出血量的有效性和安全性。[结果]四组患者年龄、性别、BMI、Hb、PLT、PT、APTT、手术时间和术中止血带时间之间差异均无统计学意义(P0.05);总失血量B组(728.84±240.15)ml、C组(570.55±235.12)ml和D组(531.99±167.55)ml,均明显低于A组(877.43±232.67)ml,差异具有统计学意义(P0.05),但B、C、D三组之间差异无统计学意义(P0.05);输血率A组56.76%(21/37)、B组46.15%(18/39)之间差异无统计学意义(P0.05),但C组30.43%(7/23)和D组24.32%(9/37)输血率明显低于A组,差异有统计学意义(P0.05);四组之间在并发症和功能恢复方面差异无统计学意义(P0.05)。[结论]骨蜡或氨甲环酸均能明显减少行单侧初次全膝关节置换术患者的失血量,但氨甲环酸止血效果优于骨蜡;联合使用骨蜡和氨甲环酸,止血效果优于单独使用骨蜡,但并不明显优于单独使用氨甲环酸;骨蜡和氨甲环酸没有增加感染、切口愈合不良和血栓形成等风险,不影响术后功能康复。     

氨甲环酸不同给药时间对全髋关节置换术中及术后失血量的影响

目的 探讨不同时间给予氨甲环酸静脉滴注对全髋关节置换术(total hip replacement,THA)术中及术后失血量的影响.方法 选取2012年2月至2014年2月我科收治的行单侧THA患者90例,按入院顺序随机分为三组,每组30例.对照组不给予氨甲环酸及同类药物;术前组于术前10 min及6h后分别给予1 g氨甲环酸静脉滴注;术中组于手术结束前10 min、术后6h分别给予1 g氨甲环酸静脉滴注.比较三组患者的术中失血量、术后失血量、术后绝对失血量、血红蛋白含量值变化、深静脉血栓形成(deep vein thrombosis,DVT)发生率.结果 三组患者术中、术后失血量和术后绝对失血量的差异有统计学意义(P＜0.05),术前组患者的上述指标均最低;三组患者血红蛋白减少值的差异有统计学意义(P＜0.05),术前组患者血红蛋白减少值最低;三组患者DVT发生率的差异无统计学意义(P＞0.05).结论 行THA患者于术前10 min及6h后分别静脉滴注氨甲环酸能很好地减少术中及术后失血量.     

氨甲环酸对全髋关节翻修术患者术后静脉血栓形成风险的影响

目的 评价氨甲环酸对全髋关节翻修术患者术后静脉血栓形成风险的影响.方法 择期全麻下行全髋关节翻修术患者56例,性别不限,年龄35 ～ 64岁,体重指数20 ～ 25 kg/m2,ASA分级Ⅰ级或Ⅱ级,采用随机数字表法,将患者分为2组(n=28):对照组(C组)和氨甲环酸组(T组),T组气管插管后静脉注射氨甲环酸15 mg/kg,随后以10 mg·kg-1·h-1速率静脉输注至术毕,C组给予等容量生理盐水.分别于术前、术毕、术后6h及术后24h时采集静脉血样,测定血常规及凝血功能指标.记录术中出血量、自体血回收量、术后24h内引流量和异体输血情况.术后7d行下肢彩色多普勒超声检查,记录下肢深静脉血栓形成的发生情况.结果 与C组比较,T组术中出血量、自体血回收量和术后24h内引流量均减少,异体输血率降低,术毕及术后各时间点Hb和Hct均升高(P＜0.05),活化部分凝血酶原时间、凝血酶原时间和纤维蛋白原差异无统计学意义(P＞0.05).C组和T组下肢深静脉血栓形成发生率分别为18％和14％,组间比较差异无统计学意义(P＞0.05).结论 术中静脉注射氨甲环酸15 mg/kg负荷量,随后以10 mg·kg-1·h-1速率静脉输注不增加全髋关节翻修术患者术后静脉血栓的形成.     

氨甲环酸减少全髋关节翻修术围手术期失血的安全性及有效性研究

目的探讨氨甲环酸减少全髋关节翻修术围手术期失血的有效性及安全性。方法将60例拟行单侧全髋关节翻修手术的患者随机分为氨甲环酸组与对照组,每组30例。术前所有患者均进行血常规、凝血常规、双下肢静脉彩超等检查,氨甲环酸组患者于切皮前10min静脉单次使用10mg／kg的氨甲环酸,对照组予以相当剂量的生理盐水。记录术中出血量、术后引流量,术后第1天、第3天复查血常规并记录患者血红蛋白水平和红细胞压积,术后第5天复查双下肢静脉彩超。如患者术后血红蛋白水平低于80g／L或患者有贫血表现时予以输入同型红细胞悬液。通过公式计算并比较患者血容量、总失血量、隐性失血量等指标。记录患者术后输血量和深静脉血栓的发生率。结果氨甲环酸组患者术中出血、术后引流、总失血量及隐形失血量均低于对照组,差异有统计学意义。氨甲环酸组患者术后14例（46．7％,14／30）,对照组26例（86．7％,26／30）需要输血,差异有统计学意义。两组患者术后深静脉血栓发生率及术后住院Et比较差异无统计学意义。结论以10mg／kg氨甲环酸术前静脉单次用药为主的多模式控制血液丢失方案可以有效减少髋关节翻修手术围手术期的血液丢失且不增加下肢深静脉血栓和肺栓塞的发生风险,该方案是髋关节翻修术围手术期控制血液丢失的安全、有效的方法。     

氨甲环酸对老年全髋关节置换术患者的血液保护效果

目的 评价氨甲环酸对老年全髋关节置换术患者的血液保护效果.方法 择期全髋关节置换术患者160例,性别不限,年龄65-70岁,体重指数16-22 kg/m2,ASA分级Ⅱ或Ⅲ级,采用随机数字表法,将其分为2组(n=80):对照组(C组)和氨甲环酸组(T组).切皮前T组经15 m in静脉输注氨甲环酸15 mg/kg,C组给予等容量生理盐水.术中监测Hb、PIt、PT和APTT指导输血.记录术中出血量、术后12 h和48 h出血量,术中、术后异体血输注情况.记录术后并发症的发生情况.结果 两组术中出血量比较差异无统计学意义(P＞0.05).与C组比较,T组术后出血量、异体红细胞使用率降低(p＜0.05),两组末见术后并发症的发生.结论 氨甲环酸对老年全髋关节置换术患者具有一定血液保护效应,但是临床价值有限.     

Return to athletic activity after total hip arthroplasty. Consensus guidelines based on a survey of the Hip Society and American Association of Hip and Knee Surgeons

A web-based survey was developed to evaluate joint arthroplasty surgeon's preferences for the return to sporting activities after total hip arthroplasty. This survey listed 30 groups of activities (37 specific sports) and was sent to all members of the Hip Society and American Association of Hip and Knee Surgeons. All surgeons were asked to grade each activity as follows: allow, allow with experience, not allowed, or undecided. Results were computed using a power analysis, Z test, and chi(2) test to determine statistical significance. There were a total of 549 responses giving an overall response rate of 72%, with 93% (92/99) of the Hip Society members and 72% (522/727) of American Association of Hip and Knee Surgeons members responding to the survey. Consensus guidelines and postoperative timing for the return to specific activities are presented.     

The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-analysis

Background

Tranexamic acid (TXA) is an antifibrinolytic agent commonly used to reduce blood loss in total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy of TXA in primary THA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty.

The Efficacy of Tranexamic Acid in Total Knee Arthroplasty: A Network Meta-Analysis

Background

A growing body of published research on tranexamic acid (TXA) suggests that it is effective in reducing blood loss and the risk for transfusion in total knee arthroplasty (TKA). The purpose of this network meta-analysis was to evaluate TXA in primary TKA as the basis for the efficacy recommendations of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine on the use of TXA in primary total joint arthroplasty.

A Systematic Review of the Efficacy and Safety of Ketamine in Total Joint Arthroplasty

BackgroundKetamine is administered intraoperatively to treat pain associated with primary total hip (THA) and knee arthroplasty (TKA). The purpose of this study was to evaluate the efficacy and safety of ketamine in primary THA and TKA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons (AAHKS), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management (ASRA).MethodsThe MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to 2020 on ketamine in THA and TKA. All included studies underwent qualitative assessment and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of ketamine. After a critical appraisal of 136 publications, 7 high-quality studies were included for analyses.ResultsHigh-quality evidence demonstrates that intraoperative ketamine decreases postoperative opioid consumption. Four of 7 studies found that ketamine reduces postoperative pain. Intraoperative ketamine is not associated with an increase in adverse events and may reduce postoperative nausea and vomiting (relative risk [RR] 0.68; 95% CI 0.50-0.92).ConclusionHigh-quality evidence supports the use of ketamine intraoperatively in THA and TKA to reduce postoperative opioid consumption. Most studies found ketamine reduces postoperative pain, nausea, and vomiting. Moderate quality evidence supports the safety of ketamine, but it should be used cautiously in patients at risk for postoperative delirium, such as the elderly.     

The Efficacy and Safety of Acetaminophen in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundOral and intravenous (IV) acetaminophen has become widely used perioperatively as part of a multi-modal pain management protocol for primary total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of acetaminophen in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies published prior to September 2019 on acetaminophen in primary TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of acetaminophen.ResultsIn total, 1287 publications were critically appraised yielding 17 publications representing the best available evidence for analysis. Oral and IV acetaminophen demonstrates the ability to safely reduce postoperative pain and opioid consumption during the inpatient hospital stay. No evidence was available to assess the efficacy and safety of oral acetaminophen after discharge.ConclusionModerate evidence supports the use of oral and IV acetaminophen as a non-opioid adjunct for pain management during the inpatient hospitalization. Strong evidence supports the safety of oral and IV acetaminophen when appropriately administered to patients undergoing primary TJA. Although there is lack of robust evidence for use of acetaminophen following discharge, it remains a low-cost and low-risk option as part of a multimodal pain regimen.     

International Perception of Perioperative Risk for Arthroplasty—Experience of the Colombian Health System

BackgroundFollowing a recent publication of the American Association of Hip and Knee Surgeons (AAHKS) which found that 95% of respondents address risk factors before surgery and the challenges in the ultimate access to care, the authors proposed an international collaboration in order to gain insight on how performance measures affect access to care as well as what medical and/or socioeconomic factors are considered obstacles to good outcomes from an international perspective. The aim of this study was to poll Colombia's arthroplasty surgeons regarding their approach to patients who have modifiable risk factors.MethodsThe survey used in the AAHKS study was adapted for use in the Colombian context and distributed to the members of the Colombian Society of Hip and Knee Surgeons (SOCCAR) via a collaborative format online, and it was completed by 109 out of 163 members, a response rate of 67%.ResultsOverall, 67% limit or restrict surgery in patients with specific modifiable risk factors. Those factors most likely to delay or restrict treatment were malnutrition/hypoalbuminemia (95.9%), poor diabetic control (89%), and active smoking (61.6%). Limited social support was considered a liability by 82.2% of surgeons. Over 80% of respondents decide based on personal experience or literature review. Low socioeconomic status was considered a factor for limiting access by 53.4% of polled surgeons. 91.8% believe some patient populations would benefit with better access to care if payment systems provided better risk adjustment.ConclusionOnly 67% of Colombian arthroplasty surgeons limit or restrict elective surgery in patients with modifiable risk factors, mainly considering malnutrition and poorly controlled diabetes as a cause for restriction, and half of the surgeons consider low socioeconomic status as a limitation to arthroplasty surgery. These findings contrast dramatically to the practice patterns of American AAHKS members.     

The Efficacy and Safety of Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundNonsteroidal anti-inflammatory drugs (NSAIDs) have become widely used to manage perioperative pain following total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of NSAIDs in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsDatabases including MEDLINE, EMBASE, and the Cochrane Central Registry of Controlled Trials were searched for studies published prior to November 2018 on NSAIDs in TJA. Studies included after a systematic review evaluated through direct comparisons and/or meta-analysis, including qualitative and quantitative heterogeneity testing, to evaluate effectiveness and safety of NSAIDs.ResultsAfter critical appraisal of 2921 publications, 25 articles represented the best available evidence for inclusion in the analysis. Oral selective cyclooxygenase (COX)-2 and non-selective NSAIDs and intravenous ketorolac safely reduce postoperative pain and opioid consumption during the hospitalization for primary TJA. Administration of an oral selective COX-2 NSAID reduced postoperative opioid consumption after discharge from TKA.ConclusionStrong evidence supports the use of an oral selective COX-2 or non-selective NSAID and intravenous ketorolac as adjunctive medications to manage postoperative pain during the hospitalization for TJA. Although no safety concerns were observed, prescribers need to remain vigilant when prescribing NSAIDs.     

The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundRegional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management.MethodsWe searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks.ResultsCritical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective.ConclusionSingle shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.     

The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundOpioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.MethodsThe MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids.ResultsPreoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness.ConclusionModerate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.     

The Efficacy and Safety of Gabapentinoids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis

BackgroundGabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management.MethodsThe MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies published prior to November 2018 on gabapentinoids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of gabapentinoids.ResultsIn total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption.ConclusionModerate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids.