Pre-operative Interventions - ESRA
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Total Hip Arthroplasty 2010

Pre-operative Interventions

Data are available from studies that assessed pre-operative analgesia versus pre-operative placebo, as well as those that, to examine the concept of pre-emptive – or preventive – analgesia, assessed pre-operative analgesia versus the same analgesia given postoperatively. However, a previous systematic review of pre-emptive analgesia for acute or chronic postoperative pain relief in a variety of surgical procedures – such as orthopaedic, dental, gynaecological and abdominal – has concluded that there is no benefit of pre-emptive over postoperative administration (Möiniche 2002). Nevertheless, it is considered that analgesic medication needs to be initiated in time to ensure an adequate analgesic effect in the immediate postoperative period. This may necessitate administration prior to the postoperative period.

Well-informed patients can have a direct influence on their surgical outcome, especially in primary total hip arthroplasty where their active participation in rehabilitation and physiotherapy will determine how quickly they mobilise on their new joint.

Patients should be aware of the main surgical complications in total hip arthroplasty, which include: nerve damage (sciatic nerve and/or femoral nerve), differences in leg length following surgery, and dislocation.

Information should be given on the approximate timetable for return to normal physical activities, that is, early weight-bearing mobility with a cemented prosthesis, and no weight- or low weight-bearing on the joint for approximately up to 6 weeks with a non-cemented prosthesis (requiring mobilisation with crutches).

The patient should also understand the importance of complying with programmed mobility and muscle-strengthening exercises

(Click here for general information on peri-operative patient advice)

Patients undergoing primary total hip arthroplasty are usually elderly and may demonstrate significant medical co-morbidity, such as hypertension, diabetes, ischaemic heart disease, renal dysfunction and obesity, all of which can have an effect on patient management before, during and immediately after surgery.

In most patients, hip arthroplasty is carried out as an elective procedure and there should be sufficient time to optimise the patient’s general medical condition prior to surgery. It is also important to evaluate the pre-operative ‘activities of daily living’ and ‘biological age’ of the individual patient, as these can affect the choice of prosthesis (cemented or non-cemented) and will also affect the pattern of rehabilitation, and the need for patient care, in the postoperative period.

In general, it is considered that non-cemented prostheses should be non-weight bearing for approximately 6 weeks (requiring mobilisation with crutches). However, recent studies have shown that there is no difference between immediate full weight-bearing and delayed weight-bearing following non-cemented implantation for functional scores and osteo-integration, and in addition there may be some benefits of immediate weight-bearing for early walking and hospital discharge (Chan 2003, Kishida 2001). Further studies are required to confirm the effects of immediate weight bearing on the postoperative rehabilitation pattern.

(Click here for general information on peri-operative patient assessment)

Total Hip Arthroplasty-Specific Evidence

[No data found within the parameters of the systematic review]

Transferable Evidence from Other Procedures

Arguments for…

  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use (Harris 2001, Stoltz 2002)
  • Studies in healthy volunteers demonstrated that COX-2-selective inhibitors had no effect on platelet aggregation (Greenberg 2000, Leese 2000, Leese 2002, Noveck 2001, Noveck 2004, Wilner 2002) or bleeding time (Leese 2000, Leese 2002, Noveck 2001) compared with placebo
  • A randomised clinical trial showed that the COX-2-selective inhibitor rofecoxib was associated with significantly less intra-operative blood loss than the conventional NSAID diclofenac in patients undergoing abdominal or vaginal hysterectomy or breast surgery (Hegi 2004)
  • Clinical studies investigating the response to oral challenge with COX-2-selective inhibitors in patients with aspirin-induced asthma have demonstrated that COX-2-selective inhibitors do not have an effect on respiratory function (Bavbek 2004, Gyllfors 2003, Martin-Garcia 2003, Sanchez-Borges 2005, West 2003, Woessner 2004)
  • A study to assess the safety of the COX-2-selective inhibitors parecoxib and valdecoxib following non-cardiac general surgery (including gastrointestinal, orthopaedic, gynaecological, urological, and thoracic surgeries) showed no difference in the incidence of cardiovascular thromboembolic events, renal dysfunction/failure, gastrointestinal ulcer complications, and surgical wound-healing complications, compared with placebo (n=1062) (in press, Anesthesiology)

Arguments against…

  • Two clinical trials showed that in patients who had undergone CABG surgery, COX-2-selective inhibitors (valdecoxib and parecoxib) were associated with a higher rate of serious cardiovascular thromboembolic events (including myocardial infarction) compared with placebo (Nussmeier 2005, Ott 2003)
  • Hypersensitivity reactions and serious skin reactions (e.g. toxic epidermal necrolysis, Stevens-Johnson syndrome, and erythema multiforme) can occur with all COX-2-selective inhibitors. Serious skin reactions have been reported in association with valdecoxib at a higher rate than with other COX-2-selective agents (EPAR Bextra 2004, EPAR Dynastat 2004, CHMP Updated Questions & Answers on Cox 2 Inhibitors 2005)
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible (O’Connor 2003, Teoh 2003)
  • Short-term use of COX-2-selective inhibitors or conventional NSAIDs can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients (Cheng 2004, Harris 2002, Perazella 2002)
  • COX-2-selective inhibitors and conventional NSAIDs may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication (Cheng 2004, Harris 2002, Perazella 2002)
  • Although there is some concern that COX-2-selective inhibitors may impair wound healing, evidence from animal and clinical studies is conflicting (Blomme 2003, Cahill 2004, Nussmeier 2005, Ott 2003)
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies (Gajraj 2003, Gerstenfeld 2004, Harder 2003, Seidenberg 2004) but clinical studies to evaluate the effects of conventional NSAIDs and COX-2-specific inhibitors on bone healing are lacking

Clinical Practice

  • Rofecoxib has been withdrawn from the market, and marketing of valdecoxib has been suspended in most countries
  • There is no difference in the analgesic efficacy between the different COX-specific inhibitors

PROSPECT Recommendations

  • There is no procedure-specific evidence that pre-operative administration of COX-2-selective inhibitors is more effective than postoperative administration. Voting agreement: 8/8
  • As with all analgesics it is recommended that COX-2-selective inhibitors should be administered in enough time to provide sufficient analgesia when the patient wakes (grade B); this could be preoperatively since there is no increased risk of peri-operative blood loss. Voting agreement: 8/8
  • It is recommended that the use of COX-2-selective inhibitors should depend upon assessment of individual patient risks (cardiovascular morbidity, actual or recent gastroduodenal ulcer history, bone healing, renal function and hepatic function [grade B] or aspirin-sensitive asthma [grade D].  Voting agreement: 8/8
  • Although there is concern about impairment of bone-healing with COX-2-selective inhibitors, there are no conclusive clinical studies to show that they have detrimental effects

Total Hip Arthroplasty-Specific Evidence

Arguments for…

  • Pre-operative administration of ketorolac 60 mg intravenously was superior to administration of ketorolac at closure for pain scores in the immediate postoperative period (p=0.03 at rest, p=0.0002 on movement), but the effect was not significant at all other times (6–48 h) (Fletcher 1995)
  • Pre-operative administration of ketorolac was superior to administration of ketorolac at closure for reducing the requirement for supplementary analgesia up to 6 h postoperatively (p<0.01), but not from 6–48 h (Fletcher 1995)

Arguments against…

  • Pre-operative ibuprofen, 600 mg orally three times per day two weeks before surgery, showed no significant benefit in reducing postoperative pain scores or morphine consumption and produced a similar incidence of PONV compared with placebo, for 0–24 h (n=50) (Bugter 2003)
  • Pre-operative ibuprofen, 600 mg orally three times per day two weeks before surgery, significantly increased the median total peri-operative blood loss compared with placebo (1161 ml versus 796 ml; p<0.01; n=50) (Bugter 2003)
  • Pre-operative conventional NSAIDs significantly increased peri-operative blood loss in patients undergoing total hip arthroplasty compared with other analgesic agents in four out of five studies. Pre-operative conventional NSAIDs significantly increased intra- and/or postoperative blood loss compared with other analgesic agents in four studies of total hip arthroplasty, including a total of 515 patients (An 1991, Connelly 1991, Robinson 1993, Slappendel 2002). One study showed that intramuscular ketorolac administered pre-operatively was not associated with significantly increased intra- or postoperative bleeding compared with the use of opioid analgesia (n=60) (Weale 1995). These studies did not report postoperative pain scores.

Transferable Evidence from Other Procedures

Arguments for…

  • Intravenous diclofenac 75 mg or ketorolac 60 mg given pre-operatively significantly reduced pain scores compared with pre-operative placebo in the immediate postoperative period and at 8 h after total hip or knee arthroplasty (Alexander 2002)
  • Intravenous diclofenac 75 mg or ketorolac 60 mg given pre-operatively had a significant opioid-sparing effect compared with pre-operative placebo after hip or knee arthroplasty (for both drugs versus placebo: time 0, p = 0.009 and 8 h, p = 0.026; n =1 02) (Alexander 2002)
  • One randomised trial in patients undergoing transurethral prostatectomy showed that diclofenac did not affect total blood loss compared with placebo (Bricker 1987)

Arguments against…

  • Randomised endoscopic trials in healthy volunteers have shown that COX-2-selective inhibitors are associated with a lower incidence of upper gastrointestinal ulceration compared with conventional NSAIDs for short-term use (Harris 2001, Stoltz 2002)
  • Randomised trials in healthy volunteers showed that conventional NSAIDs (ketorolac, naproxen or diclofenac) reduced the platelet aggregation response compared with placebo; ketorolac and naproxen also prolonged bleeding time compared with placebo (Greer 1999, Leese 2000, Leese 2002)
  • Meta-analyses of randomised controlled trials showed that peri-operative conventional NSAIDs increased the risk of postoperative bleeding requiring treatment and/or the risk of re-operation for haemostasis after tonsillectomy compared with controls (Marret 2003, Möiniche 2003)
  • A randomised trial in healthy volunteers showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) caused a reversible platelet dysfunction (Niemi 1997)
  • A randomised controlled trial showed that three conventional NSAIDs (diclofenac, ketorolac and ketoprofen) were associated with a similar incidence of surgical site bleeding after elective surgery (Forrest 2002)
  • A randomised clinical trial showed that the conventional NSAID diclofenac was associated with significantly greater intra-operative blood loss than the COX-2-selective inhibitor rofecoxib in patients undergoing abdominal or vaginal hysterectomy or breast surgery (Hegi 2004)
  • Aspirin and conventional NSAIDs can induce asthma attacks in patients with aspirin-exacerbated respiratory disease (Stevenson 2004). Aspirin-induced asthma occurs in approximately 4–10% of the adult asthmatic population (Hamad 2004)
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with an increased risk of transient hepatotoxicity. Cases of acute hepatic failure have also been reported. Elderly females, with autoimmune disease, and taking other potentially hepatotoxic drugs, may be most susceptible (O’Connor 2003, Teoh 2003)
  • Short-term use of conventional NSAIDs or COX-2-selective inhibitors can increase the risk of transient renal impairment, especially in patients with existing renal dysfunction, and both types of agent have been associated with cases of acute renal failure in high-risk patients (Cheng 2004, Harris 2002, Perazella 2002)
  • Conventional NSAIDs and COX-2-selective inhibitors may elevate blood pressure, particularly in hypertensive patients receiving antihypertensive medication (Cheng 2004, Harris 2002, Perazella 2002)
  • Conventional NSAIDs and COX-2-selective inhibitors have been associated with impaired bone healing in various animal models and in vitro studies (Gajraj 2003, Gerstenfeld 2004, Harder 2003, Seidenberg 2004) but clinical studies to evaluate the effects of conventional NSAIDs and COX-2-specific inhibitors on bone healing are lacking

Clinical Practice

[None cited]

PROSPECT Recommendations

  • Pre-operative conventional NSAIDs are not recommended, despite their analgesic efficacy, because they are associated with an increased risk of intra- and postoperative bleeding (grade A). Voting agreement: 8/8
  • There is no procedure-specific evidence that suggests that pre-operative administration of conventional NSAIDs is more effective than postoperative administration.
  • Depending on the pharmacokinetic profile of the analgesic drugs, it may be necessary to initiate analgesia pre-operatively to allow sufficient time for the analgesia to reach maximum effect in the early postoperative recovery period (grade D). Voting agreement: 8/8

Total Hip Arthroplasty-Specific Evidence

[None cited]

Transferable Evidence from Other Procedures

Arguments for…

  • Studies of gabapentin and pregabalin in mastectomy, abdominal surgery, laparoscopic cholecystectomy and spinal surgery showed reductions in postoperative pain and supplementary analgesic requirements for at least 24 h (Dahl 2004)

Clinical Practice

[None cited]

PROSPECT Recommendations

  • Alpha-2-delta-receptor modulators are not recommended at this time due to limited procedure-specific evidence, although there are some positive analgesic data from other procedures (grade B). Voting agreement: 8/8

Total Hip Arthroplasty-Specific Evidence

[None cited]

Transferable Evidence from Other Procedures

Arguments for…

  • Studies of ketamine in abdominal, orthopaedic, gastric, hepatic and renal surgery showed a reduction in postoperative pain and opioid use when used as an adjuvant to morphine, either epidurally or intravenously (Subramaniam 2004)

Clinical Practice

[None cited]

PROSPECT Recommendations

  • Pre-operative ketamine is not recommended at this time due to limited procedure-specific evidence, although there are some positive  analgesic data from other procedures and in opiod-tolerant patients (grade B). Voting agreement: 8/8

Total Hip Arthroplasty-Specific Evidence

Arguments for…

  • Pre-operative morphine or pre-operative buprenorphine were not significantly different from placebo for the incidence of nausea or vomiting (O’Sullivan 1983). This study (n=74) assessed the effect of pre-operative intramuscular morphine 10 mg and pre-operative sublingual buprenorphine 0.4 mg compared with placebo on postoperative pain management (O’Sullivan 1983)

Arguments against…

  • Pre-operative morphine or pre-operative buprenorphine were not significantly different from placebo for postoperative pain scores (O’Sullivan 1983)
  • Oral sustained-release morphine 20 mg every 12 h, starting at premedication, did not significantly decrease VAS scores compared with IM morphine 10 mg every 6 h postoperatively (Bourke 2000)

Transferable Evidence from Other Procedures

Arguments for…

  • Pre-operative oral administration of morphine sulphate 20 mg reduced supplementary analgesia requirements compared with pre-operative placebo, in a group of patients undergoing total hip or knee arthroplasty (p<0.05; n=98) (Reiter 2003)

Arguments against…

  • Pre-operative oral administration of morphine sulphate 20 mg did not reduce postoperative pain scores compared with pre-operative placebo, in a group of patients undergoing total hip or knee arthroplasty (n=98) (Reiter 2003)

Clinical Practice

  • As with all types of analgesia for postoperative pain, strong opioids should be instituted in time to secure sufficient analgesia when the patient wakes

PROSPECT Recommendations

  • Pre-operative strong opioids are not recommended because of inconsistent evidence of their postoperative analgesic efficacy (grade A)
  • — As with all analgesia, strong opioids should be administered in time to provide sufficient analgesia in the early postoperative recovery period (grade D)