Mousad Albert D, Nithagon Pravarut, Grant Andrew R, Yu Henry, Niu Ruijia, Smith Eric L
Tufts University School of Medicine, Boston, Massachusetts.
Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts.
J Arthroplasty. 2025 Jun;40(6):1643-1652.e6. doi: 10.1016/j.arth.2024.11.013. Epub 2024 Nov 15.
Despite their effectiveness in postoperative analgesia regimens for total knee arthroplasty (TKA) and total hip arthroplasty (THA), opioid medications are accompanied by well-known side effects and a risk of long-term dependence. These drawbacks have prompted the exploration of opioid-free analgesia protocols. The purpose of this study was to summarize the nature and extent of evidence available on opioid-free analgesia protocols in THA and TKA management.
A scoping review of all Medline, Embase, and CENTRAL-indexed studies published between March 2019 and May 2023 was conducted, focusing on opioid-free analgesia regimens following THA and TKA. All included studies were assessed for potential risk of bias. Meta-analyses of pooled opioid-free percentages and pain scores were conducted using odds ratio and standardized mean difference, respectively, in a random-effects model.
A total of 23 studies (15 TKAs and eight THAs) were included. Among both TKA and THA, rescue opioids were the most commonly reported postoperative intervention. The most commonly investigated nonopioid analgesic modality was local anesthetics/nerve blocks with 52.2% (12 of 23) of the studies, followed by multimodal combinations (21.7%) and intravenous corticosteroids (13.0%). Only two of the 10 included TKA randomized controlled studies demonstrated statistically significant increases in the postoperative opioid-free rates. Of the six included THA randomized controlled trials, four demonstrated statistically significant increases in patients completing the postoperative period opioid-free. Our meta-analysis demonstrated a statistically significant impact of nerve blocks following TKA on the opioid-free rate and postoperative pain scores. Among the included THA studies, all studies in which patients received postoperative intravenous corticosteroids demonstrated significant increases in opioid-free percentage.
Despite some nonopioid analgesics demonstrating promise, rescue opioids remained the most frequently employed postoperative pain medication. The optimized opioid-free analgesic regimen likely requires a multimodal approach, especially using both local anesthetics/nerve blocks and intravenous corticosteroids. Further investigation and reporting of opioid-free episodes of care are needed.
尽管阿片类药物在全膝关节置换术（TKA）和全髋关节置换术（THA）的术后镇痛方案中有效，但它们伴随着众所周知的副作用和长期依赖的风险。这些缺点促使人们探索无阿片类药物的镇痛方案。本研究的目的是总结THA和TKA管理中无阿片类药物镇痛方案的现有证据的性质和范围。
对2019年3月至2023年5月发表的所有Medline、Embase和CENTRAL索引研究进行了范围综述，重点关注THA和TKA后的无阿片类药物镇痛方案。对所有纳入研究进行潜在偏倚风险评估。分别使用随机效应模型中的比值比和标准化平均差对汇总的无阿片类药物百分比和疼痛评分进行荟萃分析。
共纳入23项研究（15项TKA和8项THA）。在TKA和THA中，补救性阿片类药物是最常报告的术后干预措施。最常研究的非阿片类镇痛方式是局部麻醉剂/神经阻滞，占研究的52.2%（23项中的12项），其次是多模式联合（21.7%）和静脉注射皮质类固醇（13.0%）。纳入的10项TKA随机对照研究中，只有两项显示术后无阿片类药物率有统计学意义的增加。在纳入的6项THA随机对照试验中，4项显示术后无阿片类药物完成期的患者有统计学意义的增加。我们的荟萃分析表明，TKA后神经阻滞对无阿片类药物率和术后疼痛评分有统计学意义的影响。在纳入的THA研究中，所有患者接受术后静脉注射皮质类固醇的研究均显示无阿片类药物百分比显著增加。
尽管一些非阿片类镇痛药显示出前景，但补救性阿片类药物仍然是最常用的术后疼痛药物。优化的无阿片类药物镇痛方案可能需要多模式方法，特别是同时使用局部麻醉剂/神经阻滞和静脉注射皮质类固醇。需要进一步调查和报告无阿片类药物的护理情况。
