Department of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, David Geffen School of Medicine at the University of California, Los Angeles. Los Angeles, CA.
Department of Orthopedic Surgery, Division of Pediatric Orthopedic Surgery, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL.
J Pediatr Orthop. 2024;44(10):e921-e928. doi: 10.1097/BPO.0000000000002779. Epub 2024 Aug 14.
One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP.
After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3 mg/kg), epinephrine (0.5 mg), and ketorolac (0.5 mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables.
Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P =0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P <0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group.
In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects.
Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries.
Level I-therapeutic.
脑瘫患儿中有四分之一（1/4）会在儿童时期接受矫形外科手术。尽管这种情况很常见，但在该患者群体中，术后疼痛控制的研究却很少。此外，疼痛管理不善与不良的手术结果有关。多模式镇痛注射在成年人群中已得到充分研究，证明其在减轻术后疼痛和减少阿片类药物消耗方面是安全有效的，但这种方法尚未在接受类似复杂手术的儿科患者中进行研究。本研究的目的是评估多模式手术部位注射在脑瘫患者髋关节发育不良手术治疗后的术后疼痛控制中的疗效。
在获得机构审查委员会批准后，完成了一项多中心、随机、双盲安慰剂对照试验。纳入接受股骨近端内翻旋转移位截骨术（VDRO）的年龄在 18 岁以下、诊断为脑瘫的患者，并将其随机分为实验组（接受罗哌卡因（3mg/kg）、肾上腺素（0.5mg）和酮咯酸（0.5mg/kg）的联合手术部位注射）或对照组（接受生理盐水注射）。所有纳入的患者均接受相同的术后护理，包括固定、物理治疗和标准化的多模式术后疼痛控制。利用双尾 t 检验或非参数曼-惠特尼检验比较组间的疼痛评分和阿片类药物的使用情况，并利用 Fischer 精确检验比较分类变量。
共纳入 34 例患者，两组各占一半。两组患者的人口统计学变量、粗大运动功能分类系统（GMFCS）、合并症、术前影像学参数或伴随手术均无显著差异。与对照组相比，实验组患者在 PACU 至出院期间的所有术后时间点均需要使用明显较少的阿片类药物（0.41±0.42 与 1.87±2.05 总吗啡 mEQ/kg，P=0.01）。同样，实验组患者在整个住院期间的疼痛评分也明显低于对照组（1.0±0.6 与 2.4±1.1 平均疼痛评分，P<0.001）。两组患者的手术时间、手术室时间、输血需求或住院时间均无显著差异。两组均无药物不良反应或注射部位并发症。
在接受髋关节重建术的脑瘫患者中，手术部位注射多模式镇痛联合用药可改善术后早期的疼痛控制，并减少阿片类药物的消耗，且无观察到不良影响。
局部多模式镇痛注射应作为该患者群体中所有骨手术标准多模式疼痛控制的一部分。
I 级-治疗性。
