Pain Management in Patients After Hip and Knee Arthroplasty – Data from Clinical Practice
Inadequate analgesia after hip and knee arthroplasty can result in delayed postoperative recovery accompanied by chronic pain. The retrospective study presented below compared the efficacy of analgesia via continuous epidural infusion of ropivacaine, patient-controlled IV analgesia with the so-called Würzburg drip, and piritramide.
Study Methodology and Population
A total of 769 patients who underwent primary or revision hip or knee arthroplasty (including osteosynthesis, tumor resection, prosthetic replacement, etc.) under general anesthesia at a German university hospital between 2016 and 2018 were included in this retrospective study.
Postoperative analgesia for patients after hip replacement (n = 453) was provided via continuous epidural infusion of ropivacaine (Epi; 0.133%), patient-controlled intravenous analgesia (PCA) with the so-called Würzburg drip (WPD; tramadol, metamizole, droperidol), or piritramide (Pir) in boluses. Surgery was performed using a modified direct lateral approach according to Bauer/Hardinger. There were 263 primary prosthetic replacements and 190 revisions.
For patients after knee replacement (n = 316), postoperative analgesia was provided via continuous femoral nerve block (PNB; ropivacaine 0.2%) or piritramide (Pir) in boluses. There were 145 primary prosthetic replacements and 171 revisions.
Findings
The use of the Würzburg drip after hip arthroplasty (n = 333) brought significantly greater pain relief according to the numeric rating scale (NRS) compared to ropivacaine (n = 48) and piritramide (n = 72) (0.75 [interquartile range /IQR/ 1.14] vs. 1.17 [1.5]; p = 0.02 vs. 1.47 [1.33]; p < 0.001) and maximum NRS scores (2.40 [1.70] vs. 3.29 [1.94]; p < 0.001 vs. 3.32 [1.76]; p < 0.0001). Positive feedback during subsequent hospital visits was significantly more frequent in patients after WPD (p < 0.0001). Negative feedback (sensorimotor weakness, nausea, vertigo, constipation) was markedly more frequent in patients after Epi and least frequent in patients after WPD (p < 0.0001).
After knee replacement, Pir (n = 131) was more effective than PNB (n = 185) (1.4 [1.4] vs. 1.6 [1.68]; p = 0.02). Positive feedback was more common in patients after Pir compared to those with PNB (p = 0.04), while negative was the opposite (p = 0.04).
Overall, WPD exhibited the lowest complication rate (8.7%), followed by Pir (20.2%), PNB (27.6%), and Epi (31.3%; p < 0.001).
Conclusion
Patient-controlled intravenous analgesia with the so-called Würzburg drip (tramadol, metamizole, droperidol) after hip arthroplasty provides better pain relief with fewer complications compared to the other two modalities, namely continuous epidural infusion of ropivacaine and piritramide in boluses.
After knee replacement, piritramide in boluses provides better analgesia compared to continuous femoral nerve block with ropivacaine.
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Source: Yurutkina A., Klaschik S., Kowark P. et al. Pain levels and patients' comfort after lower limb arthroplasty comparing i.v. patient-controlled analgesia, continuous peripheral nerve block, and neuraxial analgesia: a retrospective cohort analysis of clinical routine data. J Orthop Surg Res 2022, 17: 3811, doi: 10.1186/s13018-022-03277-0.
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