Total knee arthroplasty (TKA) has become one of the most effective treatments for relieving joint pain and improving joint function in patients with knee arthritis. With the developments in medicine, TKA patients have higher expectations for surgical outcomes. In addition, the financial burden of health care necessitates that medical institutions shorten hospitalization days and reduce complications. The focus of enhanced recovery after surgery (ERAS) in TKA is to improve surgical techniques and to optimize perioperative management, including reduction of trauma and hemorrhage, optimization of pain and blood management, prevention of infection and deep vein thrombosis, and early mobilization. Pain management contributing to ERAS needs to be procedure specific pain states, analgesic requirements and risk-benefit assessments for a specific surgical procedure.
The PROcedure SPECific Pain management (PROSPECT) collaboration was formed as a collaboration of anesthesiologists and surgeons to fill the gap in the current pool of knowledge regarding pain management options and recommendations for specific surgical procedures. The first detailed publication on this approach by the group was in 2007. The results are presented in a flow diagram form with grades of recommendation according to the quality and levels of evidence and are made easily accessible on the PROSPECT website (www.postoppain.org). PROSPECT recommendation about TKA was made in 2006 and now they want to improve and update the program aiming for 2020.
In this lecture I will add some recent metaanalysis and RCT to the recommendation of PROSPECT about TKA to integrate into ERAS protocols.
In a meta-analysis of eight randomized controlled trials (RCTs), with a total of 571 patients undergoing TKA who received perioperative COX-2 inhibi- tors, the authors concluded that the perioperative use of COX-2 inhibitors resulted in lower pain scores as mea- sured on the visual analog scale (VAS), greater range of motion, less opioid consumption, and a reduction in opioid-related adverse effects at 3 days postoperatively.16 A randomized double-blind placebo-controlled study by Schroer et al17 of 107 patients undergoing TKA suggested clinical benefits to the administration of 200 mg of celecoxib twice daily for 6 weeks postoperatively. They found statistically significant reductions in total postoperative narcotic pill con- sumption (76.3 6 55 versus 138 6 117; P = 0.003) and VAS pain scores at 3, 6, and 12 weeks in the treatment group. They also noted statistically significant improvements in knee flexion up to 1 year, American Knee Society Scores and Oxford Knee Score scales at 3 and 6 weeks, and Medical Outcomes Study 12-Item Short Form (SF-12) disability scores at 6 weeks postoperatively.
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