A comparison of intraarticular morphine and bupivacaine for pain control and outpatient status after an arthroscopic knee surgery under a low dose of spinal anaesthesia

Effective pain control is important after an outpatient arthroscopic knee surgery to permit early discharge and improve outcome. The aim of this study was to compare intraarticular morphine and bupivacaine with placebo for postoperative pain control and outpatient status after a knee arthroscopic surgery under a low dose of spinal anaesthesia. After obtaining the ethic committee’s approval and written informed consents from 60 adult outpatients undergoing knee arthroscopy, patients were enroled in this prospective, randomized, double-blinded, placebo-controlled clinical study. All patients received spinal anaesthesia with 1.4 ml of hyperbaric bupivacaine 0.5%. Patients were randomly divided into three groups as morphine (group M, n = 20), bupivacaine (group B, n = 20), and placebo (group C, n = 20). After the surgical procedure, patients received one of the following solutions intraarticularly in a double-blinded randomized manner: 5 mg morphine in 20 ml saline, 20 ml 0.25% bupivacaine, or 20 ml saline. Postoperative pain was assessed using a 10-cm visual analogue scale (VAS). Patient characteristics, hemodynamic values, sensory and motor blocks, VAS values, rescue analgesics, discharge time, and patient satisfaction were recorded. There were no significant differences in patient characteristics, surgery and tourniquet time, hemodynamic values, and sensory and motor blocks. The VAS values at 30, 60, and 90 min were similar among the three groups. The VAS values at rest and during move were higher in group C than in groups M and B at 120, 150, 180 min, and 24 h (P < 0.001). There was no difference in VAS values between the groups M and B. Rescue analgesics used and discharge time were significantly different in the placebo group when compared to groups M and B (P < 0.001). Side effects were similar among the groups. Patient satisfaction scores were high in the groups M and B. Administration of 5 mg morphine and 20 ml of 0.25% bupivacaine intraarticularly provides better pain relief and shorter discharge time without increasing the side effects than placebo for an outpatient arthroscopic knee surgery performed under a low dose of spinal anaesthesia.     

Analgesic effect of intra-articular ketorolac in knee arthroscopy: comparison of morphine and bupivacaine

This prospective study assessed the postoperative analgesic effect of intra-articular ketorolac, morphine, and bupivacaine during arthroscopic outpatient partial meniscectomy. Group 1 patients (n=20) received postoperative injection of 60 mg intra-articular ketorolac, group 2 patients (n=20) 10 cc intra-articular bupivacaine 0.25%, group 3 patients (n=20) 1 mg intra-articular morphine diluted in 10 cc saline, and group 4 patients (n=20, controls) only 10 cc saline. We evaluated the postoperative analgesic effect (period measured from the end of the surgery until further analgesia was demanded), the level of postoperative pain (by visual analog scale 1, 2, 3, 12, and 24 h after surgery), and the need for additional pain medication (during the first 24 h after surgery). The best analgesic effect was in patients treated with intra-articular ketorolac, and this was statistically significant in: postoperative analgesic effect and the need for additional pain medication immediately after surgery, and after 24 h. No complications were found related to the intra-articular treatment. We conclude that 60 mg intra-articular ketorolac provides better analgesic effect than 10 cc intra-articular bupivacaine 0.25% or 1 mg intra-articular morphine.     

Postoperative analgesic effects of intra-articular bupivacaine and morphine after arthroscopic cruciate ligament surgery

Intra-articular administration of local anaesthetics such as bupivacaine can produce short-term postoperative analgesia in patients undergoing diagnostic arthroscopy or arthroscopic meniscectomy. A peripheral anti-nociceptive effect may also be induced by the administration of intra-articular opiates interacting with local opioid receptors in inflamed peripheral tissue. In the present study we aimed to study the analgesic effects of intraarticularly given bupivacaine and morphine sulphate (as well as the combination of both drugs) on postoperative pain. In a prospective, randomized, double-blind manner 40 patients received one of the following: (a) morphine (1 mg in 20 ml NaCl), (b) bupivacaine (20 ml, 0.375%), (c) combination of both or (d) saline (20 ml, control group) intra-articularly at the end of arthroscopic anterior cruciate ligament (ACL) reconstruction. The postoperative pain was assessed via a visual analogue scale (VAS) during the first 48 h after surgery, and supplemental analgesic requirements were noted. All comparisons were made versus the control group receiving saline. The pain scores were significantly lower in the morphine group at 24 and 48 h, and in the bupivacaine group at 2, 4 and 6 h after surgery. In the group that received a combination of both bupivacaine and morphine, the pain scores were significantly reduced throughout the whole postoperative observation period. No side-effects or complications from therapy were seen in any of the groups. The conclusion of this study is that intra-articular morphine is effective in the postoperative period after arthroscopic ACL reconstruction. The combination of bupivacaine and morphine was the most effective postoperative analgesic regimen and resulted in significant analgesia throughout the whole 48-h period following surgery. Patients receiving the combination of bupivacaine and morphine had a significantly shorter hospital stay than the control group.     

Postoperative analgesic effects of an external cooling system and intra-articular bupivacaine/morphine after arthroscopic cruciate ligament surgery

The aim of this study was to evaluate the analgesic effect of an external cooling system with or without the combined effect of intra-articularly administered bupivacaine/morphine after arthroscopic anterior cruciate ligament (ACL) reconstruction. Fifty patients with isolated ACL insufficiency operated on under general anaesthesia were randomized to three different postoperative treatment groups. Group I was treated with the cooling system during the first 24 h after surgery and an intraarticular injection of 20 ml of physiological saline given at the completion of surgery; in group II, the cooling system was combined with an intra-articular injection of 20 ml bupivacaine 3.75 mg/ml and 1 mg of morphine at the end of the operation; while group III (placebo group) received an intra-articular injection of 20 ml of physiological saline at the completion of surgery. Pain was assessed using a visual analogue scale (VAS) at 1, 2, 4, 6, 24 and 48 h postoperatively. Supplementary analgesic requirements were registered. In group I 80% (16/20) and in group II 90% (18/20) of the patients were satisfied with the postoperative pain control regimen (NS). This was significantly better than in group III, where 30% (3/10) were satisfied. The pain scores were significantly lower in the two treatment groups compared with the placebo group during the entire postoperative period. The pain score was significantly lower in group II than in group I at 24 and 48 h after surgery. The supplementary analgesic requirements were also lower in the two treatment groups compared with the placebo group. No complications due to the use of the cooling system or the intra-articular injections of bupivacaine/morphine were observed. The external cooling system used in this study provides an effective method of obtaining pain relief after arthroscopic surgery. The combination with an intra-articular injection of morphine and bupivacaine results in a slightly greater analgesic effect than the cooling system alone.     

Intra-articular morphine and bupivicaine for post-operative analgesia in anterior cruciate ligament reconstruction: a prospective randomised controlled trial

Anterior cruciate ligament reconstruction (ACLR) has the potential for significant post-operative pain. Conventional systemic opiate treatment may cause nausea and drowsiness, which may delay recovery. The use of intra-articular local anaesthesia has been shown to be effective. We wished to examine the additional effect of intra-articular morphine. This is a prospective, randomised, double-blind trial. Sixty patients were randomised to receive 20 ml 0.5% bupivicaine (group L, n = 30) or bupivicaine with 10 mg morphine (group M, n = 30) by intra-articular injection at the end of the operation. Visual analogue scores (VAS) were recorded before ACLR (expected pain) and repeated at 6 and 24 h after surgery. Time to first analgesic request and total systemic opiate and other analgesic use in the first 24 h was recorded. Pre-operative VAS measurements did not predict pain or analgesic use post-operatively. There were no significant differences between groups L and M with regard post-operative VAS or time to first analgesic request. Group M required less opiate analgesic post-operatively (oral morphine equivalent 50 mg for group L and 27 mg for group M, P < 0.007). There were no complications associated with the intra-articular analgesic. The simple addition of morphine to the intra-articular injection of bupivicaine gives a significant reduction in opiate analgesic requirement after ACLR.     

Effects of epinephrine in local anesthetic mixtures on hemodynamics and view quality during knee arthroscopy

We compared three different methods of anesthesia for outpatient knee arthroscopy in terms of perioperative surgical conditions, pain, and hemodynamics. In a prospective and double-blind study ( n=130) the patients were randomized into three groups. A 50-ml mixture composed of 20 ml 0.5% bupivacaine hydrochloride, 10 ml 2% lidocaine hydrochloride, and 20 ml 0.9% sodium chloride was prepared for local anesthesia. The knee joint was injected with 40 ml of the mixture. The portal sites were then injected with 10 ml of the mixture in group I. Using the same technique 250 micro g epinephrine was added to the same mixture in group II. In group III the knee joint was injected with 40 ml of the mixture, and only 50 micro g epinephrine was then added to 10 ml of the mixture left before the portal site injections. A tourniquet was not used. There were some statistically significant changes in hemodynamic data. Also the data on visual analogue scale scores, time of arthroscopy, and amount of liquid used for intra-articular flushing in group II and III were significantly lower than those in group I. According to our experience, bleeding in arthroscopy comes mostly from portal incision to intra-articular field, except when performing extensive synovial shaving, ligament reconstruction, and lateral retinacular release. Therefore, when hemostasis is obtained at portals, the arthroscopic view becomes clearer. We think that adding epinephrine to only portal site injections is sufficient to obtain a clear view and, furthermore, when carrying out arthroscopy in this manner, no significant changes are encountered in heart rate, mean arterial pressure, pain during arthroscopy, or time of arthroscopy.     

Plasma bupivacaine levels following single dose intraarticular instillation for arthroscopy

Arthroscopy of the knee was performed using 30 ml single dose intraarticular instillations of 0.5% or 0.25% solutions of bupivacaine (Marcaine). A total of 18 patients (mean age, 34 years), divided into two groups, participated in this study. Venous plasma levels were measured at 0, 10, 20, 30, 45, 60, 90, 120, and 240 minute intervals following a single instillation into the knee joint. All patients had suspected traumatic internal derangement of the knee. Electrocardiogram tracings, blood pressure, and neurologic assessment were monitored at each venous sampling interval or more often if clinically indicated. The type and amount of supplemental anesthesia were also recorded. None of our 18 patients required a general anesthetic because of pain although the following procedures were performed: meniscectomy, plica release, abrasion chondroplasty, loose body retrieval, and limited meniscal repair. A new methodology for the measurement of plasma bupivacaine using the gas chromatograph mass spectrometer is described. Monitoring specific molecular mass fragments allows the measurement of picogram per milliliter levels of bupivacaine. The highest peak plasma concentration occurred 20 minutes after instillation of 30 ml of 0.5% bupivacaine. The 625 +/- 225 ng/ml level was well below the 2,500 to 4,000 ng/ml reported to elicit early subjective CNS symptoms of bupivacaine toxicity. Thus, a single dose intraarticular instillation of 30 ml 0.5% or 0.25% bupivacaine is convenient, efficacious, and pharmacologically safe for routine clinical arthroscopy.     

Articular cartilage regeneration of the knee joint after proximal tibial valgus osteotomy: a prospective study of different intra- and extra-articular operative techniques

In this prospective study high tibial osteotomy for medial gonarthrosis was performed in 95 patients (105 knee joints). The patients underwent simultaneously diagnostic and operative arthroscopic surgery of the knee joint. A follow-up arthroscopic examination could be performed in 75 patients (85 knee joints) at the time of implant removal. In group 1 (20 knee joints), the osteotomy was performed after diagnostic arthroscopy without arthroscopic operation of the knee joint. The fixation of the osteotomy was accomplished by staples, postoperative plaster fixation and physiotherapy. In group 2 (20 knee joints), osteotomy was performed without additional operative arthroscopy after diagnostic arthroscopy, internal fixation by AOT-plate, no external fixation postoperatively and physiotherapy. In group 3 (22 knee joints), osteotomy was performed with additional operative arthroscopy (Pridie drilling), internal fixation by AOT-plate no external fixation postoperatively no external fixation, physiotherapy and continuous passive motion. In group 4 (23 knee joints), osteotomy was performed with additional operative arthroscopy (abrasio-arthroplasty), internal fixation by AOT-plate, no external fixation postoperatively, physiotherapy and continuous passive motion. All patients underwent arthroscopic examination of the knee with cartilage biopsies taken from three different regions of the femoral condyle during the same operative session as the osteotomy. At follow-up arthroscopy cartilage biopsies were taken from the same regions. There was no great difference in clinical outcome after 1 year between all groups. Arthroscopy as well as routine and electron microscopy showed better cartilage regeneration in groups 3 and 4. Groups 1 and 2 showed only regeneration isles, sometimes not well fixed to the underlying bone, while in groups 3 and 4 cartilage regeneration was thicker and more stable, sometimes covering all of the pre-existing erosions. Therefore, we recommend osteotomy of the tibia for osteoarthritis together with operative arthroscopy in the same operative session. Received: 8 October 1997 Accepted: 5 April 1998     

Comparison of analgesic effects of intra-articular tenoxicam and morphine in anterior cruciate ligament reconstruction

This study compared the analgesic effect of intra-articular injection of tenoxicam with that of morphine on postoperative pain after anterior cruciate ligament (ACL) reconstruction. Forty-two patients undergoing arthroscopically ACL reconstructions using hamstring tendons underwent the same anesthetic protocol. The patients were randomized to receive 25 ml normal saline, 20 mg tenoxicam in 25 ml normal saline, or 2 mg morphine in 25 ml normal saline. Postoperative pain was assessed using a visual analogue scale and measuring analgesic requirements. We found both that both intra-articular tenoxicam and intra-articular morphine provided better analgesia than that in the control group. Although pain scores were similar between tenoxicam and morphine groups 30 min postoperative, the analgesic requirements in with tenoxicam were significantly lower than those with morphine group 3-6 h postoperatively.     

曲马多切口局部浸润用于腹腔镜胆囊切除术术后镇痛

 目的观察曲马多切口局部浸润用于腹腔镜胆囊切除术患者的术后镇痛效果。方法83例择期行腹腔镜胆囊切除术ASAⅠ或Ⅱ级的患者,随机双盲分成4组,在缝皮前均进行切口局部浸润。N组:生理盐水;T组:曲马多2mg/kg;B组:0.25%布比卡因;TB组:曲马多2mg/kg+0.25%布比卡因,各组均稀释至5ml。记录术后0、5min和2、6、24h的VAS、BCS评分,离床时间、排气时间、肩背疼痛及恶心呕吐等不良反应。结果T、B、TB组VAS、BCS评分明显优于N组,差异有统计学意义(P＜0.001);离床时间T组最短,排气时间B组短于N组,差异均有统计学意义(P＜0.05)。结论2mg/kg曲马多切口局部浸润用于腹腔镜胆囊切除术术后镇痛效果,与0.25%布比卡因作用相当,且不良反应较少。     

Continuous femoral nerve block versus intra-articular injection for pain control after anterior cruciate ligament reconstruction

BACKGROUND: Continuous femoral nerve blocks have been recommended for postoperative pain control after anterior cruciate ligament reconstruction. HYPOTHESIS: A pain control protocol involving a continuous ropivacaine femoral nerve block will decrease pain and narcotic use in the first 24 hours after surgery compared with a postoperative pain control protocol involving an intra-articular injection of bupivacaine/morphine. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 2. METHODS: Ninety subjects, aged 15 years or older, who were receiving arthroscopically assisted bone-patellar tendon-bone anterior cruciate ligament reconstruction were randomly assigned to 2 groups. The first group received a ropivacaine continuous femoral nerve block and oral hydrocodone (block group). The second group received an intra-articular bupivacaine/morphine injection and oral oxycodone (injection group). Patients in both groups could receive intramuscular injection of hydromorphone for breakthrough pain; most patients in the block group also received bolus doses of ropivacaine through the femoral catheter. Subjects rated their worst, average, and current pain levels using a visual analog scale and category-ratio scale the morning after surgery. Postoperative narcotic pain medication use was converted to morphine-equivalent doses. RESULTS: Postoperative pain ratings did not differ between the treatment groups. The largest difference in pain ratings between the groups was 0.5 cm for worst pain level (P = .345). Total narcotic use did not differ significantly between groups (1.1 morphine-equivalent doses in both groups; P = .671). CONCLUSIONS: Continuous femoral block with ropivacaine appeared to have no clinical advantage in the immediate postoperative period after anterior cruciate ligament reconstruction when compared with an intra-articular injection of bupivacaine/morphine. Both methods are effective for pain control after anterior cruciate ligament reconstruction.     

Efficacy of continuous intra-articular bupivacaine infusion for postoperative analgesia after anterior cruciate ligament reconstruction: a double-blinded, placebo-controlled, prospective, and randomized study

BACKGROUND: The increasing trend toward outpatient surgery has stimulated the development of techniques focused on decreasing perioperative and postoperative pain. Pain control infusion pumps are gaining in popularity in orthopaedic procedures to control postoperative pain. HYPOTHESIS: Continuous infusion of bupivacaine via a catheter placed intra-articular into the knee after anterior cruciate ligament reconstruction using ipsilateral autograft quadrupled semitendinosus will decrease postoperative pain scores and narcotic and NSAID consumption. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Three randomized study groups of 21 subjects were evaluated: group I, 0.25% bupivacaine infused intra-articular at 4 mL/hour for 72 hours (study); Group II, 0.9% saline infused intra-articular at 4 mL/hr for 72 hours (placebo); Group III, no intra-articular infusion catheter (control). Each subject received general anesthesia and preemptive intra-articular anesthesia. Visual analog scale pain scores and analgesic use were compiled for the 96-hour study period. RESULTS: With the exception of significantly higher total narcotic usage in the control group compared with the study group only for the time period of 48 to 72 hours, there were no other statistically significant differences between each of the study groups with respect to pain and narcotic and NSAID use for the entire study period. CONCLUSION: The continuous infusion of intra-articular bupivacaine via pain control infusion pumps after anterior cruciate ligament reconstruction using ipsilateral autograft quadrupled semitendinosus cannot be supported when postoperative visual analog scale pain scores and analgesic use are the rationale for justification.     

硬膜外吗啡配伍罗哌卡因和氟哌利多用于术后镇痛的临床研究

目的　探讨不同剂量的吗啡配伍罗哌卡因和氟哌利多用于术后硬膜外镇痛的效果、不良反应,为临床用药提供指导。方法　将患者随机分成4组,每组各25例。A组:吗啡1mg+0.15％罗哌卡因10ml;B组吗啡1mg+0.15％罗哌卡因10ml+氟哌利多1mg;C组吗啡2mg+0.15％罗哌卡因10ml;D组吗啡2mg+0.15％罗哌卡因10ml+氟哌利多1mg。观察术后当天和术后1d恶心、呕吐、瘙痒,皮疹、嗜睡及呼吸抑制等情况,观察注药前及注药后20min血压、心率和氧饱和度的变化。结果4组注入镇痛药后,镇痛效果均满意,B组不良反应率最低,C组最多,B组与A,C,D三组相比差异显著。血压、脉搏,氧饱和度的变化,4组间无明显的差异。结论　吗啡、罗哌卡因、氟哌利多三药在硬膜外镇痛中有协同作用,小剂量的吗啡和氟哌利多可降低硬膜外镇痛的不良反应发生率;1mg的吗啡加0.15％罗哌卡因10ml和1mg氟哌利多的混合液作用时间长、副作用少,是硬膜外镇痛较合理的联合用药。     

Intraarticular analgesia after arthroscopic knee surgery: comparison of neostigmine, clonidine, tenoxicam, morphine and bupivacaine

We conducted a randomized, placebo-controlled, double blinded study to compare the analgesic effects of intraarticular neostigmine, morphine, tenoxicam, clonidine and bupivacaine in 150 patients undergoing arthroscopic knee surgery. General anaesthesia protocol was same in all patients. At the end of the surgical procedure, patients were randomized into six intraarticular groups equally. Group N received 500 g neostigmine, Group M received 2 mg morphine, Group T received 20 mg tenoxicam, Group C received 1 g kg^–1 clonidine, Group B received 100 mg bupivacaine and Group S received saline 20 ml. Visual analog scale scores 0, 30 and 60 min and 2, 4, 6, 12, 24, 48 and 72 h, time to first analgesic need, analgesic consumption at 48 h and 72 h and side effects were noted. Demographic and operational parameters were similar in six groups. All study groups provided analgesia when compared with saline group (P<0.05). Duration of analgesia in Group N and C was longer than other groups (P<0.001). Analgesic consumptions of Group N, C and T were lower than other groups (P<0.01). Pain scores during 2 h postoperatively were lower in all study groups than the control group (P<0.001). In Group B, median pain scores were higher than Groups N and C at 0 min and 30 min postoperatively (P<0.001). Side effects were not significantly different among the six groups. We conclude that the most effective drugs that are administered intraarticularly are neostigmine and clonidine among the five drugs we studied. Tenoxicam provided longer analgesia when compared with morphine and bupivacaine, postoperatively.This study was presented as an abstract at the 4th congress of EFIC—the European Federation of the International Association for the Study of Pain Chapters—Pain in Europe IV, Prague, Czech Republic, 2–6 September 2003     

Comparison of efficacy of intraarticular application of tenoxicam, bupivacaine and tenoxicam: bupivacaine combination in arthroscopic knee surgery

Arthroscopic knee surgery is one of the most common surgeries done in outpatient settings; however, postoperative pain is believed to be the major barrier for discharge and early rehabilitation. In this study we evaluated and compared the efficacy of intraarticular application of long-lasting non-steroidal analgesic drug tenoxicam, a long-lasting local anaesthetic bupivacaine and combination of the two on postoperative pain after arthroscopic knee surgery. With the approval of the local ethics committee and signed informed consent of the patients, 75 American Society of Anesthesiologists I-II patients aged between 18 and 65 years going under elective arthroscopic meniscectomy were included in this randomized, blind, prospective study. The patients were divided into three groups: group-T (GT) patients ( n=25) had intraarticular 20 mg of tenoxicam in 20 ml normal saline; group-B (GB) patients ( n=25) had 50 mg bupivacaine in 20 ml normal saline (0.25%); group-BT (GBT) patients ( n=25) had intraarticular 20 mg of tenoxicam and 50 mg bupivacaine (0.25%) in 20 ml normal saline after completion of the surgery and before deflation of the tourniquet. Postoperative analgesia was maintained by intravenous tramadol hydrochloride 50 mg/s at the first 4 h and paracetamol 500 mg and codeine 7.5 mg preparation (Pacofen) as needed (maximum six per day) during the study period. The numeric rating scale (NRS) values were at rest and at active-passive motion at 4, 12, 24 and 48 h, total analgesic consumption, at 4 h for tramadol and at the end of 48 h for oral medication; and patient satisfaction at the end of 48 h was evaluated and recorded. The demographic features of the patients, and tourniquet times, were found to be similar between the groups. Group BT had significantly lower NRS values than GB at 12 h at rest. Group BT was found to have significantly lower NRS values at 4 h compared with GT, and significantly lower NRS values at 12 h compared with GB. Group BT was found to have significantly lower NRS values at 48 h compared with GB. Group T had significantly higher NRS values at 4 h compared with GB. Group B had significantly higher values at 12 h compared with GT and GBT. Group B used significantly more analgesics than GBT and GT throughout the study period. Group BT patients had significantly more satisfaction at the end of the study period when compared with GT and GB. Application of intraarticular tenoxicam-bupivacaine solution is a simple, safe and effective method of analgesia after arthroscopic meniscectomy with high patient satisfaction.     

Bilateral vs. unilateral spinal anesthesia for outpatient knee arthroscopies

This prospective randomized study compared unilateral and bilateral spinal anesthesia with respect to intraoperative and postoperative complications, and time to discharge from hospital for knee arthroscopies in outpatients. We studied 70 ASA I patients scheduled for elective outpatient knee arthroscopy. The patients were randomly allocated into two groups to receive either 3 ml (15 mg) 0.5% hyperbaric bupivacaine (bilateral group) or 1.5 ml (7.5 mg) 0.5% hyperbaric bupivacaine (unilateral group). The duration of motor and sensory block and the time to discharge from the hospital were all recorded. Perioperative complications such as hypotension, bradycardia, nausea, vomiting, urinary retention, if present, were recorded. The patients were interviewed by telephone 7 days later, and each patient was asked about headache or backache. The duration of motor and sensory block, and the time to discharge from hospital was shorter in the unilateral group than in the bilateral group. Three patients in the bilateral group were treated for hypotension. Bradycardia occurred in two patients in the bilateral group, and three patients required temporary bladder catheterization due to delay in recovery of spontaneous urination. Nausea and vomiting occurred in three patients in bilateral group. Nine patients in the bilateral group and six patients in the unilateral group developed postspinal headache. Backache occurred in five patients in the bilateral group and in six patients in the unilateral group. Our data indicate that the use of unilateral spinal block is a suitable technique for knee arthroscopies in outpatients.     

Is intra-articular pethidine an alternative to local anaesthetics in arthroscopy?

We investigated the per- and postoperative pain-reducing effect of pethidine given intra-articularly (i. art.). Thirty patients subjected to knee joint arthroscopy, diagnostic and surgical procedures, were randomly assigned to one of three groups. Group A consisted of ten patients who received 250 mg prilocaine +200 g adrenaline (i. art.) in a volume of 50 ml, group B of ten patients who received 200 mg pethidine (i. art.) in 50 ml saline, and group C of ten patients who received 200 mg pethidine +200 g adrenaline (i. art.) in 50 ml saline. During arthroscopy the patients reported on pain intensity and discomfort using visual analogue scales. Ratings were low and did not differ significantly between the three groups. Two of three patients in each group requested additional analgesics or sedatives due to pain and discomfort, but again with no difference between the three groups. Postoperatively all patients rated their pain intensity at rest and during movement (at 0, 1, 2, 3, 4, 5, 6, 12 and 24 h). The patients receiving pethidine (group B) reported significantly less pain at rest and movement than group A patients, in general at 1–4 h postoperatively. A significant difference was detected between groups B and C at 4 h postoperatively. Calculating the total sum of pain scores, patients receiving pethidine (group B) reported significantly less pain both at rest and during movement than those receiving prilocaine (group A). Furthermore, patients in group B used significantly less analgesics than those in group A. Adrenaline did not potentiate the effect of pethidine. Reported side effects were mild and did not require clinical action. The present study provides evidence for pethidine as a potential alternative to prilocaine in arthroscopy using local anaesthetic techniques.     

Arthroscopy of the knee in children and adolescents

A retrospective review was done of 69 children and adolescents (7-17 years old) who underwent 75 arthroscopies of the knee during a 5-year period. Girls were overrepresented (71%). Thirty-eight were children under the age of 16. Of 46 injuries, 34 (74%) happened during sports. Children and adolescents were divided into two age groups based on their presumed state of skeletal maturity (boys 9–15 and girls 7–14 in group I and boys 16–17 and girls 15–17 in group II); meniscal lesions were equally common in the two groups, whereas anterior cruciate ligament tears were more common in older children (NS). Eleven of 17 (65%) anterior cruciate ligament lesions were combined with other intra-articular pathology, most often meniscal tears (9/11). As in other studies, half of the prearthroscopic diagnoses were incorrect. A high frequency of incorrect prearthroscopic diagnoses and of combined lesions justifies arthroscopy as an important diagnostic tool in children and adolescents with a history of twisting knee injury or chronic nonspecific knee problems. Girls practising ball games seem to be especially prone to knee injuries leading to arthroscopy.     

Single-dose intra-articular bupivacaine after knee arthroscopic surgery: a meta-analysis of randomized placebo-controlled studies

Purpose

The purpose of this meta-analysis was to examine the efficacy and safety of single-dose intra-articular bupivacaine in the management of pain after knee arthroscopic surgery.

Method

The comprehensive literature search, using MEDLINE, the Cochrane Central Register of Controlled Trials, and Embase databases, was conducted to identify randomized controlled trials that used single-dose intra-articular bupivacaine for postoperative pain. The relative risk (RR), weighted mean difference (WMD), and their corresponding 95 % confidence intervals (CIs) were calculated using RevMan^® statistical software.

Result

Twenty-three studies (n = 1287) were included (647 subjects in bupivacaine group and 640 subjects in the control group). Statistically significant differences were observed in the VAS values (WMD ?1.1; 95 % CI ?1.7 to ?0.5), number of patients requiring supplementary analgesia (RR 0.83; 95 % CI 0.74–0.94), and time to first analgesic request (WMD 129.3; 95 % CI 15.4–243.1) among the bupivacaine group when compared to the control group. However, short-term side effects had no significant difference between these two groups (RR 0.73; 95 % CI 0.44–1.24).

Conclusions

On the basis of the currently available literature, single-dose intra-articular bupivacaine was shown to be significantly better than placebo at relieving pain after knee arthroscopic surgery. More high-quality randomized controlled trials with long follow-up are highly required for examining the safety of single-dose intra-articular bupivacaine. Besides, routine use of single-dose intra-articular bupivacaine is still an effective way for pain management after knee arthroscopic surgery.

Level of evidence

II.