ABSTRACT

Corresponding Author:
Dr. Shashidhar Gowdra Sugandarajappa,
Assistant Professor,
Department of Anaesthesia & Pain Relief,
Kidwai Memorial Institute of Oncology,
Dr. M. H. Marigowda Road,
Bengaluru-560029.
E-mail: drshashi_2007@yahoo.co.in

ABSTRACT

BACKGROUND AND AIMS

Pain after orthopaedic surgery depends on the site and extent of surgery and the preoperative use of analgesics by the patient. Arthroscopic procedures are routinely performed on outpatient basis and have spared patients large incisions and decreased morbidity compared with open incisions, but has not eliminated pain. At present several techniques are available to treat pain following arthroscopic surgeries; these include the use of opioids, local anaesthetics, NSAIDs, corticosteroids, clonidine and cryotherapy. Here, we compared the analgesic effect of intra-articular administration of morphine, buprenorphine and placebo following arthroscopic surgery of knee.

METHODS

A prospective, randomised, placebo-controlled double-blind comparative study conducted in 60 patients of either sex who underwent arthroscopic surgery of knee; between the age group of 18 and 65 years and of ASA class I and II physical status were included in the study. Patients were randomly assigned equally to one of the 3 groups of 20 each by a sealed envelope method. The groups were Group A - Patients receiving IA Buprenorphine 100 mcg in 20 mL normal saline. Group B - Patients receiving IA Morphine 3 mg in 20 mL normal saline. Group C - Patients receiving IA 20 mL normal saline as placebo. Parameters monitored were degree of analgesia along with haemodynamic parameters and side effects. Data were analysed using student’s t-test for continuous variables and Chi-Square test.

RESULTS

We found that 100 mcg buprenorphine when injected intra-articularly produced good and comparable postoperative pain control and reduced supplementary analgesic requirement when compared to other groups.

CONCLUSION

In summary, this study demonstrated that for eight hours postoperatively 100 mcg buprenorphine provided superior post-operative analgesia to that of 3 mg morphine.

KEYWORDS

Intraarticular, Analgesia, Opioids, Arthroscopy.

INTRODUCTION

Pain is a common human experience, a symptom frequently encountered in clinical practice that is usually associated with actual or impending tissue damage. “Failure to relieve pain is morally and ethically unacceptable.” Adequate pain relief could be considered a basic human right. Pain is not a straightforward sensory “perception.” It is an “experience” as the physiological sensation is inseparable from the associated emotional distress.

Pain after orthopaedic surgery depends on the site and extent of surgery.

Sex Distribution

Surgery

Comparison of Analgesia

Visual analogue scores assessed at 0, 1, 2, 4 and 8 hours were compared with chi-square test for statistical difference among the groups.

Visual Analogue Score with Respect to Groups at 0 Hour

VAS <3 - Adequate analgesia, VAS >3 - Inadequate analgesia.

Mean visual analogue scores analysed during the 0 hour were lower (VAS-0) in A and B groups, when compared to group (C) (Table 5). There was statistically significant difference among 3 groups with respect to VAS at 0 hour (p- 0.000). Pain intensity scores were higher in group (C) when compared with other 2 groups. However, there was no statistical difference among A and B groups (p-0.944). All placebo group patients received rescue analgesia during 0 hour (VAS >3), which indicated inadequate analgesia while none in other 2 drug groups.

Visual Analogue Score with Respect to Groups at 1 Hour

Visual analogue scores compared at 1 hour (Table 6) had high scores in placebo in comparison with A and B groups. There was significant difference (p - 0.000) between placebo and the drug groups. However, there was no significant difference (p - 0.944) between the two drug groups (A and B).

Visual Analogue Score with Respect to Groups at 2 Hours

At 2^nd hour VAS score (Table 8) showed significant difference between placebo and other two groups (p - 0.000). Pain intensity scores was significantly different (p - 0.002) between group A and B. Even though morphine had significant p values when compared to buprenorphine, none of the patients received rescue analgesia (Table 9).

Visual Analogue Score with Respect to Groups at 4 Hours

At 4 hours, there was significant difference with respect to VAS score among all 3 groups (Table 10). Placebo had high scores (p - 0.000). A and B groups differed significantly as 6 patients (morphine) (p-0.04), had inadequate analgesia with VAS >3.

Visual Analogue Score with Respect to Groups at 8 Hours

At 8 hours, P values were significantly different among 3 groups. Placebo was significantly different (p - 0.000) from A and B groups in terms of VAS score (Table 12). However, the number of patients with inadequate analgesia (VAS >3) was same in morphine and placebo group (Table 13). VAS score in morphine group showed significant difference when compared to buprenorphine (Table 13). After rescue analgesia, placebo group had 10 patients with VAS >3. This was significant difference among groups.

Heart Rate with Respect to Groups from 0 to 8 Hours

Mean Arterial Pressure with Respect to Groups from 0 to 8 Hours.

Heart rate and MAP was higher in the placebo group when compared to A and B groups (Table 15) throughout observation period and was statistically significant (p - 0.01). Nevertheless, there was no significant difference between the other 2 drug groups (p - 0.00).

Patients in placebo group had highest dose of rescue analgesia followed by morphine group, while buprenorphine group had none.

None of the patients in any of the group had any of these side effects during the observation period.

DISCUSSION

The knee is a joint in which arthroscopy has the greatest IA surgical application. There is rich innervation to articular capsule, tendons, ligaments, synovium and periosteum via a mixture of free nerve endings and receptors.

These sensory nerves respond to mechanical stimuli, such as stretching of the joint capsule as well as intra-articular surgical instrumental intervention. Many nerve fibers, for example are non-responsive under normal conditions but react after inflammation, therefore there is a potential for acute injury or inflammation to sensitize nerves such that they respond even when the original stimuli is removed. Hence, just like any other surgical procedure, the arthroscopic intervention of the knee joint can cause considerable postoperative pain that limits ambulation and combined with a stress-induced hypercoagulable state, may contribute to an increased incidence of deep vein thrombosis.

Postoperative analgesia following arthroscopic knee surgery can be provided either by systemic administration of narcotic and non-narcotic analgesic drugs.¹⁷ or IA administration of local anaesthetic drugs.¹⁸ non-narcotic analgesic drugs (Ketorolac).¹⁹ and narcotic analgesic drugs (Morphine.²⁰ pethidine and fentanyl).

In our study, we sought to evaluate the analgesic efficacy and the need for rescue analgesia with 3 mg morphine and 100 mcg buprenorphine were compared with a placebo (20 mL 0.9% normal saline) when administered intra-articularly following arthroscopic knee surgery.

Various studies compared the analgesic effect of different opioids with different doses. Varrassi G et al²¹ in their study compared 100 mcg of IA buprenorphine, 50 mg 0.5% IA bupivacaine with placebo. They found that 100 mcg buprenorphine or 0.5% bupivacaine when injected intra-articularly produced good and comparable postoperative pain control and reduced supplementary analgesic requirement.

We found that in immediate postoperative period, i.e. at 0 and 1 hour, buprenorphine and morphine had good and equal analgesic effect as none of the patients required rescue analgesia. In contrast, all 20 patients in placebo group had moderate-to-severe pain and all required supplementary analgesics. These results were similar to Kazemi et al²², Mandal P et al²³, Varrassi et aland Varkel et al studies.

Further comparing the analgesic efficacy at 2 and 4 hours postoperatively, all 20 patients had no pain in buprenorphine group indicating good analgesic effect. Even though morphine provided analgesia, 12 patients had mild pain but did not require rescue medication. This was similar to study by Rosseland et al²⁴ who concluded that postoperative analgesic effect of IA morphine was found only in subgroup of patients with higher pain intensity in the immediate post-anaesthetic period. The possible reasons quoted were lack of inflammation that was prerequisite for peripheral opioid analgesia, lack of expression of opioid receptors and due to weak pain stimulus. This could be explained with its partial agonist action, high receptor affinity and slow dissociation.

At 8 hours morphine did not differ much in analgesic action from that of placebo group as all 20 patients had inadequate pain relief and required supplementary analgesics. This was similar to the conclusion drawn by Heard et al¹² who considered IA morphine no better than placebo, except for prolonging the time of first analgesic request and for its systemic effect. Buprenorphine had longer duration of analgesia with less pain scores and no rescue analgesic requirement when compared to morphine. This was consistent with the study by Varrassi et al studies and efficacy of buprenorphine could be related to a local peripheral action as suggested by Stein C et al.

We compared the haemodynamic data in which the placebo group had higher heart rate and mean arterial pressure than the other two drug groups and this was statistically significant. This could be due to pain and anxiety causing sympathetic stimulation. However, no significant difference with haemodynamic data among the two drug groups.

We also noted the time of request for first rescue analgesia with placebo group requiring analgesics in the immediate postoperative period, six patients required first rescue analgesia at 4^th hour of observation in morphine group and none in buprenorphine group.

The total dose of analgesic consumption was highest dose in placebo and morphine group, while buprenorphine group hardly required any analgesic dose.

None of them in two drug groups had any significant side effects during 8-hour observation period.

CONCLUSION

In summary, this study demonstrated that for eight hours postoperatively 100 mcg buprenorphine provided superior post-operative analgesia to that of 3 mg morphine.

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