José Wanderley Vasconcelos

Analgesic Efficacy of the Intra-articular Administration of S(+)- Ketamine in Patients Undergoing Total Knee Arthroplasty

BACKGROUND AND OBJECTIVES Total knee arthroplasty (TKA) is associated with significant postoperative pain. Many intra-articular (IA) agents have been used for postoperative analgesia with inconsistent outcomes. Ketamines enantiomer S(+), S(+)- ketamine, was recently introduced commercially, with higher analgesic potency and less side effects than the racemic form. An experimental prospective randomized double-blind study was conducted to evaluate the analgesic efficacy of intra-articular S(+)- ketamine in patients undergoing primary TKA. METHOD In total, 56 patients were evaluated and allocated into three groups: Group A (n=19) received 0.25mg.kg(-1) of S(+)- ketamine diluted in 20mL of saline solution 0.9%; Group B (n=17) received 0.5mg.kg(-1) of S(+)- ketamine diluted in the same way; and Group C (n=20) received only 20mL of intra-articular saline 0.9%, immediately after surgery and drain placement. All patients had access to rescue analgesic therapy, with the use of intravenous morphine alone. Evaluations were made 2, 6, 12, and 24 hours postoperatively, with measurement of pain intensity by Visual Analogue Scale (VAS), use of rescue medication by the evaluation of the time elapsed between the intra-articular injection of the solution and first dose of rescue, total consumption within 24 hours, and adverse effects. RESULTS The S(+)- ketamine groups had lower pain scores compared with the saline group. The lowest dose of intra-articular S(+)- ketamine (Group A: 0.25mg.kg(-1)) resulted in better pain scores and less rescue analgesia, with longer time to first request. Adverse effects were infrequent. The results with lower pain scores in groups using S(+)- ketamine are a trend, as there was no statistical significance between groups. CONCLUSION In this study, with this sample, the analgesic effect of IA S(+)- ketamine was not superior to saline solution in the postoperative period of TKA.

Analgesic efficacy of the intra-articular administration of high doses of morphine in patients undergoing total knee arthroplasty.

BACKGROUND AND OBJECTIVES Although the efficacy of intraarticular (IA) morphine is still controversial, it has been shown that higher doses promote better results and consequently decrease postoperative analgesic consumption, characterizing a dose-dependent peripheral action. A controlled, randomized, double-blind study was undertaken to evaluate the efficacy of the intra-articular administration of 10 mg of morphine in patients undergoing total knee arthroplasty. METHODS Fifty patients undergoing total knee arthroplasty were randomly divided into two groups: the treatment group received 10 mg (1 mL) of intra-articular morphine diluted in 19 mL of NS, while the control group received the intra-articular administration of 20 mL of NS, both after closure of the capsule at the end of the surgery. On demand subcutaneous morphine was available for residual pain. The following parameters were evaluated: pain severity according to the numeric scale (NS), 2 h (M1), 6 h (M2), 12 h (M3), and 24 h (M4) after the IA injection; time until the first request of analgesic; analgesic consumption, and side effects. CONCLUSIONS The treatment group had lower NS than the control group in M1 and M2, while significant differences were not observed in the other moments. The time until the first request of analgesics was significantly higher in the treatment group, and analgesic consumption in the first 24 hours was also lower in this group. The incidence of side effects did not differ between both groups. We concluded that the postoperative IA administration of 10 mg of morphine promoted a longer period without rescue analgesics and reduced their consumption in the first 24 hours.

Eficácia analgésica do uso de dose alta de morfina intra-articular em pacientes submetidos à artroplastia total de joelho

1. Professor Adjunto da Disciplina de Anestesiologia da UFMA; Responsavel pelo Servico de Dor do HU/UFMA e do Instituto Maranhense de Oncologia 2. Pos-graduando; Medico-residente de Anestesiologia no Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo 3. Professor-adjunto da Disciplina de Ortopedia e Traumatologia da UFMA 4. Graduando em Medicina; Membro da Liga Academica de Dor, UFMA

Avaliação da perda sanguínea na artroplastia total do joelho com e sem soltura do torniquete

OBJECTIVE: To evaluate blood loss in patients submitted to cemented total knee arthroplasty with and without perioperative tourniquet release for hemostasis. METHODS: Seventy-two patients (eighty knees) were submitted to total knee arthroplasty, allocated into two groups: in Group 1, in which the pneumatic tourniquet was maintained until suture and dressing of the operated wound, and Group 2, in which the pneumatic tourniquet was released intraoperatively after cementing the prosthesis, with direct hemostasis, before the suture and dressing. The patients were evaluated for blood loss by the suction drain, and hemoglobin and hematocrit counts, at intervals of 2, 24 and 48 hours in the postoperative period tube. RESULTS: There was no significant difference between the groups in terms of postoperative blood loss or decrease in hemoglobin and hematocrit parameters. Only one patient, from Group 2, required a blood transfusion in the postoperative period. CONCLUSION: Postoperative blood loss in TKA was similar with and without perioperative release of the pneumatic tourniquet for hemostasis.

Medium-term evaluation of total knee arthroplasty without patellar replacement

Objective To mid-term evaluate patients who were submitted to total knee arthroplasty without patellar resurfacing. Methods It was realized a retrospective cross-sectional study of patients who were submitted to total knee arthroplasty without patellar resurfacing. In all patients clinical examination was done based on the protocol of the Knee Society Scoring System, which assessed pain, range of motion, stability, contraction, knee alignment and function, and radiological evaluation. Results A total of 36 patients were evaluated. Of these, 07 were operated only on left knee, 12 only on right knee and 17 were operated bilaterally, totaling 53 knees. Ages ranged from 26 to 84 years. Of the 53 knees evaluated, 33 (62.26%) had no pain. The maximum flexion range of motion averaged 104.7°. No knee had difficulty in active extension. As to the alignment for anatomical axis twelve knees (22.64%) showed deviation between 0° and 4° varus. Thirty-nine (75.49%) knees showed pace without restriction and the femorotibial angle ranged between 3° varus and 13° valgus with an average of 5° valgus. The patellar index ranged from 0.2 to 1.1. Conclusion Total knee arthroplasty whitout patellar resurfacing provides good results in mid-term evaluation.

Evaluation of simvastatin in the process of fracture healing in tibiae of rats

Objective Evaluate the effects of simvastatin in the process of fracture healing in rat tibia. Methods Thirty-six rats were subjected to diaphyseal fracture of the leg bones and divided in the statin group (GE) and control group (GC), being subdivided into three subgroups according to days post-fracture (7th, 14th and 28th day) to assess bone healing. In GE was administered by gavage a solution of simvastatin to the sacrifice. In the control group was administered saline by the same route of SG. Immobilization was not used. After the sacrifice was made to limb amputation in the distal femur and conducted the clinical, radiological and histological analysis. Clinical evaluation was made as to the mobility of the fracture. Then the samples were radiographed and evaluated for callus diameter. Histological examination was performed with cuts of 5 micrometers and stained with hematoxylin-eosin, Massons trichrome and Alcian blue pH 2.5. The level of significance to exclude the null hypothesis was 5%. Results All GE animals showed greater stability of the fracture and higher callus area. There were no significant changes in the histological study. Conclusion Simvastatin accelerates the consolidation process by increasing the callus, but does not alter the histology of the newly formed bone.

Prophylactic and Therapeutic Use of Strontium Ranelate Reduces the Progression of Experimental Osteoarthritis

Introduction: Strontium ranelate (SrRan) has the potential to interfere in the progression of osteoarthritis (OA), multifactorial disease associated with mechanical problems and articular inflammatory changes. Objectives: This study aimed to test the effects of prophylactic and therapeutic use of SrRan on clinical parameters of pain, the inflammatory process, and degradation of the articular cartilage. Methods: This was an experimental study, using a model of knee OA induced by intra-articular injection of monoiodoacetate. Thirty Wistar rats were divided into five groups and treated as indicated: control, without intervention; prophylactic, received SrRan at a daily oral dose of 250 mg/kg for 28 days before OA induction; SrRan treatments, administered 250 or 500 mg/kg/day for 28 days after the induction; and model control, received saline solution after the induction. Behavioral tests (joint incapacity, mechanical hyperalgesia, tactile sensitivity, and forced ambulation), histological evaluation of articular cartilage, and determination of inflammatory cytokines in the synovial fluid (interleukin [IL]-6, IL-10, tumor necrosis factor [TNF]-α, and interferon [INF]-γ) were performed. Results: Both prophylactic and therapeutic treatments improved the articular discomfort. A prophylactic dose of 500 mg/kg/day also improved mechanical hyperalgesia and the same dose was beneficial on tactile sensitivity. SrRan did not improve ambulation. Levels of IL-6, IL-10, TNF-α, and IFN-γ in SrRan-treated groups with OA were not significantly different compared with those in the normal control animals. The histopathological evaluation showed less articular damage in the SrRan-treated and control groups compared to the saline-treated group. Conclusion: The prophylactic and therapeutic administration of SrRan was associated with improved behavioral patterns of pain, especially joint discomfort. SrRan administration mitigated histological changes in the articular cartilage and reduced the inflammatory process, which beneficially reduced the progression of OA in the experimental model studied.

Use of risedronate for consolidation and callus formation in Colles fractures in postmenopausal women: SOLID study

Objective This open, randomized and blinded parallel-group multicenter study evaluated the efficacy of Actonel® (35 mg) plus calcium/vitamin D versus calcium/vitamin D alone for preserving bone mineral density (BMD) in postmenopausal women with Colles fractures. Methods Patients with a Colles fracture for seven days were randomized to receive either Actonel® (35 mg) once a week plus calcium/vitamin D (ACD group) or calcium/vitamin D alone (CD group). The patients were evaluated after 90 and 180 days of treatment. Results 59 ACD patients and 56 CD patients completed all the evaluations. At the end of the study, the BMD of the radius at the fracture location showed a negative change in the CD group (32.8%). The loss of BMD in the ACD group (20.8%) was slightly less than that in the CD group. There was a difference in the proportions of patients with BMD losses at the end of the study period in the two treatment groups, in favor of the ACD group, although this was not statistically significant. There was no significant difference in radiological identification of callus formation between the treatment groups. In the majority of the patients, the callus could be radiologically identified after 90 days. Conclusion Postmenopausal women with Colles fractures who received risedronate sodium plus calcium/vitamin D did not show any significant difference in BMD loss in forearm fractures, in comparison with those who received calcium/vitamin D alone. Risedronate presented a tendency toward a protective effect regarding BMD loss due to immobilization. The time taken for fracture consolidation to be achieved was unaffected.

Eficácia analgésica do uso da dextrocetamina intra-articular em pacientes submetidos a artroplastia total do joelho

JUSTIFICATIVA Y OBJETIVOS: La artroplastia total de la rodilla (ATR) esta asociada a un significativo dolor postoperatorio. Muchos agentes de uso intraarticular (IA) han sido usados para la analgesia postoperatoria con resultados inconsistentes. El enantiometro cetamina S(+), la dextrocetamina, recien fue lanzado comercialmente con una potencia analgesica y menos efectos indeseados que la forma racemica. Un estudio prospectivo, experimental, aleatorio y doble ciego se realizo con el objetivo de evaluar la eficacia analgesica del uso de la dextrocetamina por via intraarticular en pacientes sometidos a la ATR primaria. METODO: Se evaluaron 56 pacientes divididos en tres grupos: Grupo A (n = 19), que recibio 0,25 mg.kg-1 de peso de dextrocetamina, diluido en 20 mL de solucion fisiologica al 0,9%; Grupo B (n = 17) 0,5 mg.kg-1 de peso diluido de la misma forma; y Grupo C (n = 20), solamente con 20 mL de solucion fisiologica al 0,9% intraarticular, inmediatamente despues del termino del procedimiento y de la colocacion del drenaje. Todos los pacientes tuvieron acceso a la terapia analgesica de rescate, siendo usada solamente morfina endovenosa. Se evaluaron las 2, 6, 12 y 24 horas del postoperatorio, con la mensuracion de la intensidad del dolor por la Escala Analogica Visual (EAV), el uso de la medicacion de rescate por la evaluacion del tiempo transcurrido entre la inyeccion intraarticular de la solucion y la primera dosis de rescate, su consumo total a las 24 horas y los efectos adversos. RESULTADOS: Los grupos dextrocetamina obtuvieron menores puntajes de dolor cuando se les comparo con la solucion salina. La menor dosis de dextrocetamina intraarticular (Grupo A: 0,25 mg.kg-1) usada, arrojo mejores puntajes de dolor y menos analgesico de rescate, con un tiempo de espera mayor para su solicitacion. Los efectos adversos no fueron frecuentes. Los resultados con menores puntajes de dolor en los grupos que usaron la dextrocetamina son una tendencia, porque no hubo una significancia estadistica entre los grupos. CONCLUSIONES: En este estudio y con esa muestra, el efecto analgesico de la dextrocetamina IA no rebaso la solucion salina en el periodo del postoperatorio de la ATR.

664 ANALGESIC EFFICACY OF INTRA‐ARTICULAR MORPHINE HIGH DOSE IN PATIENTS SUBMITTED TO TOTAL KNEE ARTHROPLASTY

application in postoperative pain (1). We have assessed the safety and efficacy of TF used as main postoperative analgesic in patients undergoing dorsal or lumbar spine fusion. Methods: Randomised, prospective study with Institutional and patient approval. Patients received either a fentanyl (1.5mg/kg Duragesic, group TF) or placebo patch (PL) applied 8 hours before surgery (n =17/group), and removed 72 hours later. We used TIVA with propofol (2mg/kg) and remifentanil at the doses required to maintain MAP and HR within 20% of baseline. Postoperative analgesia: ketorolac-PCA, and rescue with tramadol. We assessed remifentanil requirements, and VAS, Ramsay and adverse effects on arrival to recovery, and every 12 hours until removal of the patch. Results: VAS scores and analgesic requirements were lower in TF (p < 0.05, Table). The TF group had more pruritus and nausea (p < 0.02), while tremor was higher in PL (p< 0.01). No sedation was observed, but one patient in TF presented prolonged drowsiness that resolved spontaneously. No respiratory depression was observed.