Effects of Adding Morphine to Periarticular Infiltration Analgesia Combined with Single Dose Epidural Morphine in Total Knee Arthroplasty: A Randomized Controlled Study

Abstract

Objective: Morphine plays an important role in postoperative analgesia after total knee arthroplasty (TKA). However, there are limited data that investigate the administration ways of morphine. To evaluate the efficacy and safety of adding morphine to periarticular infiltration analgesia (PIA) combined with single-dose epidural morphine for the patients undergoing TKA. Methods:In total, 120 patients with knee osteoarthritis who underwent the primary TKA from April 2021 and March 2022 were randomized into three groups (a cocktail containing morphine with single-dose epidural morphine [Group A]; a cocktail containing morphine [Group B]; and a cocktail free of morphine [Group C]). The three groups were compared based on the Visual Analog Score at rest and during motion, requirement of tramadol, functional recovery including quadriceps strength and range of motion, and adverse events including nausea and vomiting and local and systemic adverse events. The repetitive measure analysis of variance and chi-square test among three groups were used to analyze the results.Results: Analgesia strategy in Group A (0.4 AE 0.8, and 0.9 AE 1.0 points, respectively) significantly reduced rest pain at 6 and 12 h after surgery relative to Group B (1.6 AE 1.2, and 2.2 AE 1.4 points, respectively) (p < 0.001), and the analgesic effect of Group B was stronger than that of Group C (2.1 AE 0.9, and 2.6 AE 0.9 points, respectively) (p < 0.05). Rest pain at 24 h after surgery was significantly lower in Group A (2.5 AE 0.8 points) and B (1.9 AE 1.0 points) than in Group C (2.5 AE 0.8) (p < 0.05). Within 24 h after surgery, the requirements for tramadol in Group A (0.25 g) and Group B (0.35 g) were significantly lower than those in Group C (0.75 g) (p < 0.05). Within 4 days of surgery, the quadriceps strength in the three groups increased gradually, and no statistical significance was noted among the three groups (p > 0.05). From the second day to the fourth day after surgery, although the three groups showed no statistical difference in the range of motion, the result of Group C was inferior to that of the other two groups. There were no significant differences in the incidence of postoperative nausea and vomiting and metoclopramide consumption among the three groups (p > 0.05). Conclusion:PIA combined with single-dose epidural morphine effectively reduces early postoperative pain and tramadol requirement as well as few complications, which can become a safe and effective measure to improve postoperative pain after TKA.

Periarticular infiltration used in total joint replacements: an update and review article

“…Previous systematic reviews on periarticular morphine have identified a scarcity in the number of studies examining peri/intra-articular morphine [ 70 ]. An equivalent number of studies examined in Table 6 showed benefit [ 32 , 47 , 71 – 73 ] and no difference [ 74 – 78 ] in pain scores. The duration of pain improvement varied between 2 and 24 h [ 32 , 47 , 71 – 73 ].…”

“…An equivalent number of studies examined in Table 6 showed benefit [ 32 , 47 , 71 – 73 ] and no difference [ 74 – 78 ] in pain scores. The duration of pain improvement varied between 2 and 24 h [ 32 , 47 , 71 – 73 ]. Most studies showed a better range of motion with Morphine usage [ 47 , 74 – 78 ].…”

“…This was similar to opioid consumption postoperatively. Six studies demonstrated less morphine consumption [ 32 , 47 , 71 – 73 , 75 ], while some demonstrated no difference [ 74 , 76 – 78 ]. This reduction in opioid consumption was observed in the first 48 h. Dosages used in studies reviewed showed ranges from 1 mg of morphine up to 10 mg.…”

“…IA 100 mg bupivacaine, 3 mg morphine Bupivacaine + 3 mg morphine had improved pain at rest at 12 h and day 1, and improved at 12 h/day 1/day 2 on standing, improved walking scores. Both morphine groups had received less analgesia then bupivacaine alone Report increased nausea and somnolence with addition of morphine, no statistical analysis reported Li et al [ 73 ] RCT 120 TKA 1. Cocktail with morphine + epidural morphine 2.…”

Pre-emptive infiltration with betamethasone and ropivacaine for postoperative pain in laminoplasty and laminectomy (PRE-EASE): a prospective randomized controlled trial

“…Whereas, betamethasone dipropionate is only slightly water soluble, thus serving temporarily as a local reserve and providing a continuous anti-inflammatory effect to locally damaged tissue 16 , 21 . Ropivacaine, a new longer acting local anesthetic, is the drug of choice for regional analgesia and postoperative pain management as it is not lipophilic and is more selective for motor nerves 23 . Ropivacaine exclusively blocks sensory-motor nerve separation at a very low concentration by blocking nerve excitation conduction with the reversible inhibition of sodium ion channels in the neuronal membrane 24 , making early rehabilitation possible.…”