George Nicole E, Gurk-Turner Cheryle, Etcheson Jennifer I, Gwam Chukwuweike U, De Souza Randal, Smith Spencer S, Nace James, Delanois Ronald E
Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland.
Department of Pharmacy, Sinai Hospital of Baltimore, Baltimore, Maryland.
Surg Technol Int. 2017 Dec 22;31:346-351.
Total knee arthroplasty (TKA) is a commonly-performed orthopaedic procedure in the United States. However, inadequate postoperative pain management following TKA has been associated with a number of negative consequences, including chronic postoperative pain requiring long-term opioid use. Multimodal pain control is a recently-popularized means of maximizing analgesia and postoperative outcomes. We aimed to evaluate the outcomes of a multimodal pain regimen incorporating diclofenac, including: 1) length of stay (LOS); 2) pain intensity; and 3) opioid consumption in primary TKA patients.
A prospective cohort study was performed. All patients scheduled for primary TKA by a single surgeon between March 1, 2017 and August 31, 2017 were screened for study involvement, yielding 46 consecutive patients (52 TKAs). This study group was treated with a postoperative regimen of intravenous (IV) diclofenac, in addition to a perioperative pain control regimen including adductor canal blockade (ACB) and periarticular multimodal drug injection (PMDI). Postoperative outcomes in this group were compared to those of a matched cohort of 78 patients (88 primary TKAs) who had previously been treated with the same perioperative pain control regimen.
Patients prescribed a postoperative diclofenac regimen had lower mean LOS (2.10 vs. 2.33 days; p=0.053) and lower 24-hour postoperative pain intensity (76 vs. 104; p=0.056) as compared to the untreated group. The diclofenac-treated group had a significantly lower opioid consumption in the first 24 hours postoperatively than did their untreated counterparts (39.8 vs. 53.1 morphine milligram equivalents [MME]; p=0.041). In addition, 17 patients (18 TKAs, 35%) in the diclofenac group had zero opioid requirements during the first 12 hours postoperatively, and 12 of these patients (13 TKAs, 25%) continued to not require any opioids through the first 24 hours postoperatively.
In the midst of the rapidly-increasing rates of TKA in the US, multimodal pain control has emerged as an extremely effective means of maximizing postoperative patient outcomes. To our knowledge, this is the first study to evaluate the postoperative outcomes of TKA patients treated with a regimen of IV diclofenac. We demonstrate shorter LOS, decreased 24-hour pain intensity, and significantly decreased 24-hour opioid consumption in patients treated with adjunctive IV diclofenac compared to patients managed with our institution's standard perioperative regimen.
全膝关节置换术（TKA）在美国是一种常见的骨科手术。然而，TKA术后疼痛管理不足已与许多负面后果相关，包括需要长期使用阿片类药物的慢性术后疼痛。多模式疼痛控制是一种最近流行的最大化镇痛效果和术后结果的方法。我们旨在评估包含双氯芬酸的多模式疼痛方案的效果，包括：1）住院时间（LOS）；2）疼痛强度；3）初次TKA患者的阿片类药物消耗量。
进行了一项前瞻性队列研究。对2017年3月1日至2017年8月31日期间由单一外科医生安排进行初次TKA的所有患者进行研究参与筛查，连续纳入46例患者（52次TKA）。该研究组除接受包括内收肌管阻滞（ACB）和关节周围多模式药物注射（PMDI）的围手术期疼痛控制方案外，还接受静脉注射（IV）双氯芬酸的术后方案治疗。将该组的术后结果与之前接受相同围手术期疼痛控制方案治疗的78例患者（88次初次TKA）的匹配队列的结果进行比较。
与未治疗组相比，接受术后双氯芬酸方案治疗的患者平均住院时间较短（2.10天对2.33天；p = 0.053），术后24小时疼痛强度较低（76对104；p = 0.056）。双氯芬酸治疗组术后前24小时的阿片类药物消耗量明显低于未治疗组（39.8对53.1吗啡毫克当量[MME]；p = 0.041）。此外，双氯芬酸组中有17例患者（18次TKA，35%）在术后前12小时内无需使用阿片类药物，其中12例患者（13次TKA，25%）在术后前24小时内仍无需任何阿片类药物。
在美国TKA手术率迅速上升的背景下，多模式疼痛控制已成为最大化术后患者治疗效果的极其有效的方法。据我们所知，这是第一项评估接受静脉注射双氯芬酸方案治疗的TKA患者术后结果的研究。我们证明，与采用我们机构标准围手术期方案治疗相比，接受辅助静脉注射双氯芬酸治疗的患者住院时间更短，24小时疼痛强度降低，24小时阿片类药物消耗量显著减少。
