Pot beta-blocantele să reducă necesarul intraoperator de agenţi anestezici?
Jurnalul Român de Anestezie Terapie Intensivă 2014 Vol.21 Nr.1, 5-6
EDITORIAL II
Looking for a better outcome after total knee arthroplasty
Total knee arthroplasty (TKA) is a very painful sur-
gical procedure. Although today there are developed
mini invasive surgical techniques that allow a faster
patient discharge, at 48 hours after surgery, there is
still a concern regarding the best postoperative anal-
gesic regimen that would permit a good functional
recovery of the operated knee.
According to the International Association for the
Study of Pain, the pain persisting three months after
TKA should be considered chronic pain, and its expla-
nation is considered as a combination of neuropathic
and nociceptive pain [1].
In USA, in 2008, 680 000 TKA have been per-
formed and this number is expected to increase by
174% in 2030. About 20% of TKA patients, with a
prevalence ranging up to 44%, complain of pain at 12
months, and this makes them dissatisfied with TKA
intervention that was supposed to improve their life
quality and comfort after all. In a recent survey Liu et
al. reported a 46% incidence of persistent postsurgical
pain after TKA, and the list of risk factors included:
female sex, younger age, prior surgery on the same
joint, lower-quality postsurgical pain control, knee
versus hip replacement and the presence of post-
surgical persistent complaints in other body areas [2].
The increased number of patients [2, 3] presenting
with moderate/severe pain of the knee at 12 months
after TKA raises a legitimate question about the utility
and efficiency of this kind of expensive and trauma-
tizing surgery.
However many efforts have been made in order to
find the best postoperative analgesic regimen that
would allow a faster functional recovery, thus improving
outcome [4].
In the last decade a lot of research was focused
mainly on the acute postoperative pain management
Address for correspondence: Dr. Adela Hilda Onuţu
Clinica de Ortopedie şi Traumatologie
Departamentul ATI
Str. Patiţia Rubin nr. 1
400121 Cluj-Napoca, România
E-mail: adela_hilda@yahoo.com
and the functional recovery at six weeks after surgery,
leaving the patient’s 12-month outcome in a sort of
shadow. The role of the multimodal postoperative anal-
gesic regimen, including acetaminophen, nonsteriodal
anti-inflammatory drugs, associated with femoral nerve
block, plus cooling and compressing at the surgical site,
was documented and recommended by the PROSPECT
working group, but the majority of their accepted stu-
dies are dated before 2010 [5]. Recently many studies
were focused on other tools in order to improve post-
operative analgesia and to improve outcome after TKA:
local infiltration analgesia (using local anaesthetics,
ketorolac and epinephrine), perioperative gabapentinoids,
ultrasound guided adductor canal block, perioperative
intravenous low-dose steroids, etc. [6-8].
Despite of all the debates, there is a general agree-
ment about the fact that regional analgesia improves
early rehabilitation after TKA, especially the use of con-
tinuous peripheral nerve blocks (femoral and sciatic)
that provide a high quality of postoperative analgesia
in TKA. This effect seems to be similar to that of
continuous epidural analgesia by reducing side effects
and providing an important opioid sparing effect [9].
In addition, more recent studies showed that single-
injection sciatic nerve block would provide the same
impact on 12-month outcome as that of continuous
sciatic block when added to femoral nerve for post-
operative analgesia in TKA [10].
In the present issue of the Journal, Anastase et al.
present an interesting study regarding the patient
satisfaction after TKA performed under spinal anaes-
thesia, comparing a continuous combination of femoral
and sciatic nerve block (FEM/SCI) (0.2% ropivacaine),
with the traditional continuous epidural analgesia applied
for the first 48 postoperative hours [11].
The authors studied the early postoperative para-
meters for patient satisfaction with anaesthesia and
analgesia, and also at 6 and 12 months for the overall
patient status (questionnaire included physical general
status, pain, mobilization, analgesic requirements).
They used a more simple instrument as compared to
6 Onuţu
SF-12 (short form 12 items) Health Survey [12] or
WOMAC (Western Ontario and McMaster osteo-
arthritis index), and got a picture about the outcome
after TKA in the studied sample [13].
Both regional analgesic methods proved comparable
in terms of postoperative pain scores and opioid con-
sumption, as well as patient acceptance. The functional
capacity of quadriceps muscle was equally preserved
in both groups.
But the authors also looked at the early outcome at
six postoperative months. They showed a significant
difference regarding the analgesic consumption
(patients in the FEM/SCI group required less oral anal-
gesic than group EA; p = 0.001). Besides that, at 12
months a significant difference was found regarding
patient’s satisfaction, favourably to group FEM/SCI:
better physical status (p = 0.035), less pain in the
operated knee (p = 0.004), less analgesic consumption
(p < 0.0001) and a better mobility (p = 0.042).
Even if the response rate to the telephone survey
at 6 and 12 months was only 76%, data proved the
long term benefits of peripheral continuous nerve blocks
(femoral and sciatic) used for postoperative analgesia
in TKA with a significant satisfaction for patients in
FEM/SCI group.
Whether this is the result of the blockage of the
nociceptive stimuli, preventing central sensitization, or
of a supplementary systemic effect of the local anaes-
thetic per se, as a blocker of the alpha subunits of
voltage gated sodium channels, subtypes Nav 1.6, 1.8,
1.9 involved in nociceptive impulse generation, and/or
of an added anti-inflammatory effect, it is hard to appre-
ciate yet [14].
Atanase’s study has the merit of looking not only
for the surgery result but also for patient’s satisfaction
in the postTKA period. Their message is clear: a suc-
cessfully replaced knee is to be doubled by a free-of-
pain status and an excellent range of motion of the joint.
Recuse note
Dr. Adela Hilda Onuţu is the Assistant Editor for the
Jurnalul Român de Anestezie şi Terapie Intensivă. This
manuscript was handled by Dr. Iurie Acalovschi, Editor-in-
Chief, and Dr. Onuţu was not involved with the editorial
process or decision.
Adela Hilda Onuţu, MD, PhD
Orthopaedic and Traumatology Clinic
„Alexandru Rădulescu”
Cluj­Napoca, Romania
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