Replacement Arthroplasty: Reuben SS

Reuben SS, Fingeroth R, Krushell R, Maciolek H. · Department of Anesthesiology, Baystate Medical Center and the Tufts University School of Medicine, Springfield, Massachusetts 01199, USA. · J Arthroplasty. · Pubmed #11805921 No free full text.

Abstract: Nonsteroidal anti-inflammatory drugs (NSAIDs) frequently are discontinued before elective total knee arthroplasty (TKA) because of the increased incidence of perioperative bleeding. Rofecoxib, a selective cyclooxygenase 2 inhibitor, does not interfere with the coagulation system and may be a safer NSAID for patients undergoing TKA. In this study, 100 patients undergoing elective TKA discontinued their use of NSAIDs 10 days before surgery and were assigned randomly to receive either placebo (n = 50) or rofecoxib (n = 50), 25 mg daily for 5 consecutive days starting 3 days before surgery. The administration of rofecoxib resulted in improved preoperative pain scores and no significant increase in the incidence of perioperative bleeding or international normalized ratio compared with placebo. Rofecoxib does not need to be discontinued before elective TKA.

Reuben SS, Buvenandran A, Katz B, Kroin JS. · Department of Anesthesiology, Baystate Medical Center and the Tufts University School of Medicine, Springfield, MA 01199, USA. · Anesth Analg. · Pubmed #18349203 links to  free full text

Abstract: BACKGROUND: Total knee arthroplasty (TKA) is associated with considerable postoperative pain, which, if unrelieved, may result in prolonged hospital stay, inability to participate in rehabilitation programs, poor outcomes, and greater use of healthcare resources. The hypothesis of this study is that perioperative administration of celecoxib will improve analgesic efficacy, with a resultant improvement in short- and long-term clinical outcomes after TKA. METHODS: We studied 200 patients undergoing elective TKA in a prospective, randomized, double-blind, placebo-controlled fashion. All patients underwent a similar perioperative anesthetic/analgesic procedure. After completion of surgery, patients were started on an epidural infusion with patient-controlled epidural analgesia. Patients were instructed to keep their numerical rating score pain < or = 3. Patients were randomly assigned to one of two groups: celecoxib or placebo. The celecoxib group received celecoxib 100 mg orally twice a day 7 days before surgery. On the day of surgery, celecoxib 400 mg was administered 1-2 h before surgery and then 200 mg every 12 h for 10 postoperative days. The control group received matching placebo capsules at the same times. The primary objective of this study was to determine whether the perioperative use of celecoxib reduces the amount of postoperative opioid consumption. Secondary objectives were to determine whether celecoxib is associated with improved clinical outcomes and a reduction in opioid-related adverse effects. RESULTS: The celecoxib group required less patient-controlled epidural analgesia over the 40-h postoperative period: placebo 232.8 +/- 2.0 mL, celecoxib 209.1 +/- 1.8 mL (P < 0.001). At home over days 4-10 after surgery, the celecoxib group had reduced pain intensity with movement (F = 109.7, P < 0.001) at all time points. The celecoxib group also consumed less oxycodone at home than placebo group (F = 417.8, P < 0.001). With active movement, range of motion (ROM) differed between the two groups over postoperative days 1-3 (F = 50.7, P < 0.001), with the celecoxib group having greater ROM at all time points. There was earlier achievement of 90 degrees knee flexion with celecoxib compared with placebo (P < 0.001). Celecoxib patients had a better overall Knee Society Score (93.3 +/- 0.6) than placebo patients (86.4 +/- 0.9) at 12-mo follow-up (P < 0.001). The incidence of side effects (nausea, vomiting, and pruritus) in the immediate postoperative period was less in the celecoxib group. CONCLUSIONS: Perioperative use of celecoxib reduces postoperative pain, opioid consumption, opioid-related adverse effects, and is associated with long-term benefits including improved knee function and less time to achieve effective knee ROM after TKA.

Reuben SS, Buvanendran A. · Department of Anesthesiology, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA. · J Bone Joint Surg Am. · Pubmed #17545440 No free full text.

Abstract: The prevalences of complex regional pain syndrome, phantom limb pain, chronic donor-site pain, and persistent pain following total joint arthroplasty are alarmingly high. Central nervous system plasticity that occurs in response to tissue injury may contribute to the development of persistent postoperative pain. Many researchers have focused on methods to prevent central neuroplastic changes from occurring through the utilization of preemptive or preventive multimodal analgesic techniques. Multimodal analgesia allows a reduction in the doses of individual drugs for postoperative pain and thus a lower prevalence of opioid-related adverse events. The rationale for this strategy is the achievement of sufficient analgesia due to the additive effects of, or the synergistic effects between, different analgesics. Effective multimodal analgesic techniques include the use of nonsteroidal anti-inflammatory drugs, local anesthetics, alpha-2 agonists, ketamine, alpha(2)-delta ligands, and opioids.