Abstract:
During
a ligament surgery of the knee, the postoperative analgesia
using femoral perineural catheterization allows active program
of postoperative rehabilitation by facilitating the premature
mobilization and improving the functional outcome of the
patients, this allows also a reduced cost and duration of
hospitalization.
The
use to these techniques allows a decreased postoperative
consumption of analgesics (especially morphine); therefore
decreasing the incidence of the side effects (pruritis, nausea,
vomits and somnolence); this allows also an increased
satisfaction of the patients. The flexion gain of the knee is
significant this is possible by the first post-surgery day and
allows achieving 90° of flexion which is shorter compared to
the multimodal analgesia.
The
objective of this study was to evaluate the impact of
implementing an analgesia using femoral perineural catheter on
the rehabilitation at the post surgery stage and to assess
duration of hospitalization after ligamentous surgery of the
knee.
Key
words: analgesia, femoral perineural catheterization, knee
surgery
J.Orthopaedics 2007;4(2)e16
Introduction:
The
management of the post surgery pain was neglected for a long
time in our institution; actually, more and more importance is
given after a surgical operation. The analgesia using peripheral
perineural catheter is widely recognized as efficient at per and
post surgery stages; especially in orthopedic surgery [1]. In
recent years, abundant studies showed and clarified the
importance of these techniques for fighting against the pain. A
targeted analgesia at the posterior stage of ligamento-plasty of
the knee should consider anatomical and post surgery
rehabilitation requirements. A functional benefit associated to
a better articular mobilization outcome using femoral catheter
analgesia allows a decreased duration of hospitalization.
The
objective of this study was to evaluate the impact of
implementing an analgesia using femoral perineural catheter on
the rehabilitation at the post surgery stage and to assess
duration of hospitalization after ligamentous surgery of the
knee.
Material
and Methods:
In
this study, two stages of ligament surgery of the knee were
compared.
In
the first stage, orthopedic surgeons supervised a series of 15
patients, and post surgery analgesia was carried out using a
combination of analgesic, non-steroidal anti-inflammatory
agents, (NSAI) and morphine.
In
this second stage, anesthesiologist supervised a series of 20
patients; a post surgery analgesia was carried out using a
femoral catheter through anterior veins; intermittent injection
of anesthetic agents such as NSAI, buprenorphine at rate of
0.3mg/8 hours; the goal was to achieve a analog visual
scale (AVS) smaller
than 30 % .
The
femoral catheter was setup at the pre-surgery stage through
anterior vein and using neuron-stimulation for finding the
quadriceps response, a motor stimulus used electric stimulation
of intensities smaller than 0.6 mA. A dose was 20 ml of
bupivacaine at 0.5% was injected in the pre-surgery stage;
another dose of 8 ml of bupivacaine at 0.25% was injected at the
post-surgery phase each 8 hours by the doctor anesthesiologist.
The pain was also evaluated using AVS each 8 hours.
The
studied parameters the second stage of the study were as
follows: the needed time for the achieving 90° angulations by
the knee, the stay duration in the hospital, how were patient
satisfied and finally the side
effects or complication.
Results :
The
epidemiological profile of the series studied in the second
stage was as follows, an average age of (29 ± 5) years old
composed of 16 males and 4 females and the average weight was 61
Kg.
The
anesthetic approach used wasn’t identical in all patients. So,
a general anesthesia was practiced on seven patients, a spinal
anesthesia was done in 10 patients, and a tri bloc was realized
in 3 patients. In the 24 hours following the surgery, the
average morphine administration was 0.8mg of buprenorphine. The
angulation of the knee was evaluated on daily basis by
physiotherapist; the average value was 50° in second days after
surgery and attained 90° by the fifth day (Table I). when
comparing series of the both stages of the study, a 90°
angulation of the knee achieved in 10 days in the first series
while this was reduced to 5 days in the second series (Table II
and III). Evermore,
the average hospitalization period was one 15 days in the first
series while this was lowered to one week in the second series.
All the patients of the second series of the study were
satisfied of the pain care at post surgery stage. Neither side
effect of the local anesthesia nor consequences of the analgesic
technique were observed. However, satisfaction level that
considers side effects in the first series wasn’t evaluated.
|
Stage I
(Multimodal
analgesia) |
Stage II
(perineural analgesia) |
Day
1 |
33 ± 15 |
44 ± 15 |
Day
2 |
44 ± 14 |
60 ± 16 |
Day
3 |
53 ± 17 |
71 ± 12 |
Day
4 |
62 ± 18 |
79 ± 12 |
Day
5 |
68 ± 19 |
88 ± 19 |
Day
6 |
72 ± 15 |
87 ± 6 |
Day
7 |
73 ± 14 |
90 ± 4 |
Day
8 |
73 ± 14 |
90 ± 5 |
Day
9 |
76 ± 11 |
91 ± 5 |
Day
10 |
88 ± 15 |
94 ± 5 |
Off-hospitalization |
89 ± 9 |
97 ± 4 |
6th
week |
99 ± 12 |
114 ± 14 |
Table
I: Flexion of the knee (in degree) in the both stages of the
study
The
site and the type of the orthopedic surgery |
At
rest (%) |
At
mobilisation (muscles spasme and réflexe) (%) |
Average
duration in days |
|
Moderate |
Severe |
Moderate |
Severe |
Moderate
/Severe |
Severe |
Hip
surgery |
30-40 |
40-50 |
20-30 |
40-50 |
3 (2,6) |
70-80 |
Knee
surgery |
25-30 |
55-65 |
30-40 |
55-65 |
3 (2,6) |
60-70 |
Elbow
and shoulder surgery |
25-35 |
45-60 |
30-40 |
45-60 |
3 (2,6) |
60-70 |
Table
II: The pain at rest and at mobilization in en articular
surgery [8]
|
Goranson [10] |
Allen [17] |
Sbai et al |
At
the 1st
post-surgery day |
50 ± 13 |
52 ± 12 |
44 ± 15 |
At
the 3rd
post-surgery day |
82 ± 11 |
79 ± 12 |
71 ± 12 |
At
the 5th
post-surgery day |
93 ± 10 |
92 ± 11 |
88 ± 19 |
By
the 6th
post-surgery week |
105 ± 10 |
100 ± 10 |
114 ± 14 |
Table
III: Flexion of the knee (in degrees), comparison of this
study outcome and thus reported in the literature
Discussion :
The
success of the knee ligament surgery of is well associated to
rehabilitation efficiency at the post surgery, the psychotherapy
is often started very early [1, 2, 3]. Both passive and active
mobilizations allow a limitation of the amyotrophy, a good
muscle-tendon adhesions, post surgery hemato- arthrosis and
avoiding thromboembolic complications [3, 4, 5]. The analgesia
has to be fast efficient at rest and especially in dynamic
condition. The pain generated by the mobilization of a joint is
often very severe and non morphine analgesic even opianic do not
relax enough the patients [4, 6].
The
regional analgesia using femoral catheter is mostly used at the
preoperative stage and continued during the most painful period
that is usually the 72 hours following the surgery, this
constitutes the most important stage for managing this type of
pain in order since this constitute also the phase of start of
the rehabilitation [7, 8, 9], which contribute on its turn to
increased pain.
In
this stage, the epidural analgesia enough effective; it has
higher efficiency when compared to morphine analgesia controlled
by the patient (PCA) moreover, it has fewer side effects such as
urine retention, low blood pressure, dysesthesia [8, 10]. This
work confirms the results reported by the other studies. indeed,
a morphine saving was noted and an increase articular angulation
amplitude in the early post postoperative stage; even more, the
scores of pain at rest and at mobilization was significantly
lower in the patients benefiting from an analgesia using femoral
perineural catheter when compared with the PCA group [10, 11,
12]. Previous studies of post femoral block of ligament-plasty
of the knee reported that related analgesia was of high quality
during 29 hours in 79 % of the patients, and only 8 % required
additional morphine based analgesia [13, 14]. The follow-up of
the degree of flexion of the knee allows appreciating the
functional result, this showed profits of the regional analgesia
approach; therefore, the maximal amplitudes of this flexion were
significantly higher in the fifth day and at the en of the
hospitalization [15, 16]. Hence, faster recovery of the
articular amplitude and accelerating the post surgery
rehabilitation were obtained with the analgesia using femoral
perineural catheter; this allowed a reduced duration of
hospitalization [16, 17].
These
results demonstrated the interest of the choice of analgesia
mode for both: the early post surgery stage and especially enhancing the
prognosis realized of the treatment.
Conclusion:
During
ligament surgery of the knee, the analgesic type used is
indispensable for keeping the functional result. The controlled
analgesia using femoral catheter allows achieving an early
rehabilitation program, to generate a faster recovery of the
articular amplitude as well as faster post-operating
rehabilitation; these contribute to a decreased duration of a
stay at the hospitable.
References
-
Allen
JG, Denny NM, Oakman N. Postoperative analgesia following
total knee arthroplasty: a study comparing spinal anesthesia
and combined sciatic femoral 3-in-1 block. Reg Anesth 1998;
23: 142-6.
-
Todd MM, Brown DL. Regional anesthesia and postoperative
pain management. Long-term benefits from a short-term
intervention. Anesthesiology 1999; 91: 1-2.
-
Munin
MC, Rudy TE, Glynn NW, Crosset LS, Rubash HE. Early in patient
rehabilitation after elective hip and knee arthroplasty. JAMA
1998 ; 18 : 847-52.
-
Tarkkila P, Tuominen M, Huhtal J, et al. Comparison of
intrathecal morphine and continuous femoral 3-in-1 block for
pain after major knee surgery under spinal anesthesia. Eur J
Anaesthesiol 1998 ; 15 : 6-9.
-
Singelyn FJ, Deyaert M, Joris D, Pendeville E, Gouverneur
JM. Effects of intravenous patient-controlled analgesia, and
continuous analgesia with morphine, continuous epidural
analgesia, and continuous three-in-one block on postoperative
pain and knee rehabilitation after unilateral total knee
arthroplasty. Anesth Analg 1998 ; 91 : 8-15.
-
Capdevila
X, Barthelet Y, Biboulet P, Ryckwaert Y, Rubenovitch J, d'Athis
F. Effects of perioperative analgesic technique on the surgical
outcome and duration of rehabilitation after major knee surgery.
Anesthesiology 1999 ; 91 : 8-15.
-
Pope
RO, Corcoran S, McCaul K, Howie DW. Continuous passive motion
after primary total knee arthroplasty. Does it offer any
benefits? J Bone Joint Surg Br 1997 ; 79 : 914-7.
-
Kumar
PJ, PcPherson EJ, Dorr LD, Wan Z, Baldwin K. Rehabilitation
after total knee arthroplasty: a comparison of 2 rehabilitation
techniques. Clin Orthop 1996 ; 331 : 93-101.
-
Kehlet
H. Multimodal approach to control postoperative pathophysiology
and rehabilitation. Br J Anaesth 1997 ; 78 : 606-17.
-
Goranson
BD, Lang S, Cassidy JD, Dust WN, McKerrell J. A comparison of
three regional anaesthesia techniques for outpatient knee
arthroscopy. Can J Anaesth 1997 ; 44 : 371-6.
-
DeAndres
J, Bellver J, Barrera L, Febre E, Bolinches R. A comparative
study of analgesia after knee surgery with intraarticular
bupivacaine, intraarticular morphine, and lumbar plexus block.
Anesth Analg 1993 ; 77 : 727-0.
-
Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of
continuous epidural analgesia on postoperative pain,
rehabilitation, and duration of hospitalization in total knee
arthroplasty. Clin Orthop 1990 ; 260 : 30-7.
-
Dahl
JB, Daugaard JJ, Rasmussen B, Egebo K, Carlsson P, et al.
Immediate and prolonged effects of pre-versus postoperative
epidural analgesia with bupivacaine and morphine on pain at rest
and during mobilisation after total knee arthroplasty. Acta
Anaesthesiol Scand 1994 ; 38 : 557-61.
-
Capdevila
X, Biboulet Ph, Bouregba M, Barthelet Y, Rubenovitch J, d'Athis
F. Comparison of the “3-in-1” and fascia iliaca compartment
blocks in adults: clinical and radiographic analysis. Anesth
Analg 1998 ; 86 : 1039-44.
-
Schwarz
SK, Franciosi LG, Ries CR, Regan WD, Davidson RG, Nevin K, et
al. Addition of femoral 3-in-1 blockade to intra-articular
ropivacaine 0.2% does not reduce analgesic requirements
following arthroscopic knee surgery. Can J Anaesth 1999; 46:
741-7.
-
Allen
JG, Denny NM, Oakman N. Postoperative analgesia following total
knee arthroplasty: a study comparing spinal anesthesia and
combined sciatic femoral 3-in-1 block. Reg Anesth Pain Med 1998;
23: 142-6.
-
Allen
HW, Liu SS, Ware PD, Nairn CS, Owens BD. Peripheral nerve blocks
improve analgesia after total knee replacement surgery. Anesth
Analg 1998; 87: 93-7.
|