Derogatis Michael J, Sodhi Nipun, Anis Hiba K, Ehiorobo Joseph O, Bhave Anil, Mont Michael A
Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York.
Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio.
Surg Technol Int. 2019 Nov 10;35:301-310.
Due to the rising concern regarding excessive opioid use, several alternative pain control options have been developed for total knee arthroplasty (TKA). Therefore, the purpose of this article was to review non-narcotic treatments to manage pain after TKA. Specifically, we evaluated: 1) acetaminophen; 2) cyclooxygenase-2 (cox-2) inhibitors; 3) gabapentinoids; 4) dexmedetomidine, 5) nerve blocks; 6) local analgesic infiltration; 7) transcutaneous electrical nerve stimulation (TENS); and 8) perioperative bracing.
A literature search was conducted using the PubMed and EBSCO host electronic databases. All available studies between 1998 and 2018 were evaluated. Searches were performed using the following terms: total knee arthroplasty (title), acetaminophen (title), cyclooxygenase-2 inhibitors (title), gabapentinoids (title), nerve blocks (title), local analgesic infiltration (title), transcutaneous electrical nerve stimulation (title), knee (title), postoperative outcome (title), opioids (title), analgesics (title), alternative (title), heroin (title), chronic pain (title), opioid overdose (title), and cost (title). After full-text analysis of 273 reports that satisfied the search criteria, 58 studies were included in this review.
There is conflicting evidence on acetaminophen and gabapentinoids, with some studies reporting opioid use reduction with their use; whereas, others found no difference. Cox-2 inhibitors can potentially reduce opioid requirements and improve pain scores following TKA; however, they are associated with several side effects. Dexmedetomidine has been associated with reduced postoperative opioid consumption, but it has limited applications as it is associated with several major side effects. Neuraxial anesthesia can potentially help control postoperative pain; however, there is a limited effective window and identifying the specific nerve can be challenging. Local infiltrating analgesia have been found to help relieve pain in the early postoperative period. Multiple studies have identified substantial reductions in pain with knee braces. The non-invasive and non-pharmacologic nature of this treatment option makes it very safe and effective for the generalized TKA population.
The optimal solution for postoperative TKA pain management has yet to be determined. Although several options exist, many of them have been associated with adverse effects limiting their generalizability. Knee braces, however, have been identified as one potentially successful option. Importantly, knee braces are safe for the majority of patients and should be widely recommended for patient use.
由于对阿片类药物过度使用的担忧日益增加，已开发出几种用于全膝关节置换术（TKA）的替代疼痛控制方案。因此，本文的目的是综述用于管理TKA术后疼痛的非麻醉性治疗方法。具体而言，我们评估了：1）对乙酰氨基酚；2）环氧化酶-2（cox-2）抑制剂；3）加巴喷丁类药物；4）右美托咪定；5）神经阻滞；6）局部镇痛浸润；7）经皮电刺激神经疗法（TENS）；以及8）围手术期支具。
使用PubMed和EBSCO主机电子数据库进行文献检索。对1998年至2018年间所有可用的研究进行评估。检索使用以下术语：全膝关节置换术（标题）、对乙酰氨基酚（标题）、环氧化酶-2抑制剂（标题）、加巴喷丁类药物（标题）、神经阻滞（标题）、局部镇痛浸润（标题）、经皮电刺激神经疗法（标题）、膝关节（标题）、术后结果（标题）、阿片类药物（标题）、镇痛药（标题）、替代（标题）、海洛因（标题）、慢性疼痛（标题）、阿片类药物过量（标题）以及成本（标题）。在对满足检索标准的273份报告进行全文分析后，本综述纳入了58项研究。
关于对乙酰氨基酚和加巴喷丁类药物的证据存在矛盾，一些研究报告称使用它们可减少阿片类药物的使用；而另一些研究则未发现差异。Cox-2抑制剂可能会减少TKA术后的阿片类药物需求并改善疼痛评分；然而，它们与多种副作用相关。右美托咪定与术后阿片类药物消耗减少有关，但由于其与多种主要副作用相关，应用有限。椎管内麻醉可能有助于控制术后疼痛；然而，有效窗口有限，识别特定神经可能具有挑战性。已发现局部浸润镇痛有助于缓解术后早期疼痛。多项研究表明膝关节支具可显著减轻疼痛。这种治疗选择的非侵入性和非药物性质使其对一般TKA人群非常安全有效。
TKA术后疼痛管理的最佳解决方案尚未确定。虽然存在多种选择，但其中许多都与不良反应相关，限制了它们的通用性。然而，膝关节支具已被确定为一种潜在成功的选择。重要的是，膝关节支具对大多数患者来说都是安全的，应广泛推荐给患者使用。
