Background: In recent years, joint replacement surgery has gradually progressed towards the fast‐track model, and early rehabilitation immediately after surgery is regarded fundamental for optimal recovery of function: the aim of the present study is to describe the efficacy in perioperative management of pain in patients undergoing total hip replacement surgery and treated with tapentadol or oxycodone/naloxone in combination with ketoprofene.Methods: Single‐center retrospective study on patients with moderate‐severe pain, referred to total hip replacement. Patients received either tapentadol (100 mg/twice‐daily post‐surgery – treatment group) or oxycodone/naloxone (10 mg/5 mg post‐surgery – control group) plus ketoprofen 100 mg/ twice daily. Supplemental analgesia (paracetamol 1 g or morphine 0,1 mg/kg sc) was provided if needed. Pain at rest and pain during movement were evaluated on a daily basis for 4 days post‐op, after which patients were usually discharged. All adverse events were reported and compared between the two groups.Results: 106 patients were analyzed in the tapentadol group and compared to 105 patients treated with oxycodone/naloxone. Both pain intensity at rest and upon movement were significantly lower in the tapentadol group at all follow‐up times (p < 0.001). Throughout T1‐T4, supplemental analgesia was needed by significantly less tapentadol patients compared to the control group. Similarly, regarding side effects, a significantly higher occurrence of post‐op nausea, vomit, itching and constipation was observed in the control group (p < 0.001 in all cases).Conclusion: Results from the present study support the use of tapentadol in combination with ketoprofen for the management of moderate‐severe pain in the setting of major orthopedic surgery, given its effectiveness in reducing pain intensity, and its satisfactory tolerance.

Sublingual sufentanil tablet system for the management of acute postoperative pain in a hospital setting: an observational study - Minerva Anestesiologica 2021 February;87(2):156-64 - Minerva Medica - Journals

Background and Objectives: Patient blood management (PBM) strategies are effective in reducing transfusion requirements and improving perioperative outcomes in total hip arthroplasty (THA) and total knee arthroplasty (TKA). The SARS-CoV-2 pandemic profoundly disrupted hospital organization and limited the application of established PBM protocols. This study assessed the impact of COVID-19-related organizational disruption on PBM implementation and perioperative outcomes in primary total hip and knee arthroplasty. Materials and Methods: This monocentric retrospective study included consecutive patients undergoing primary unilateral THA or TKA between January 2019 and February 2023. Patients were stratified into three periods: pre-COVID-19, during COVID-19, and post-COVID-19. Primary outcomes included transfusion rate, allocated RBC units, PRM transfer, hospital length of stay, and postoperative day-4 hemoglobin levels. Secondary outcomes were factors associated with postoperative day-4 hemoglobin and PRM admission. Results: A total of 5789 patients were included: 1889 in the pre-COVID-19 period, 1416 during COVID-19, and 2484 post-COVID-19. Despite reduced PBM implementation during the COVID-19 period, postoperative Hb levels and transfusion rates remained stable across groups. The number of allocated red blood cell units increased without a corresponding rise in transfusion rates, suggesting a precautionary allocation strategy. A descriptive reduction in median length of stay was observed in the post-COVID-19 phase. A significant decrease in the proportion of patients transferred to Physical and Rehabilitation Medicine departments during the COVID-19 and in the post-COVID-19 period was observed. Multivariable analysis identified age, BMI, preoperative Hb, sex, procedure type, IVFCM administration, and transfusion as predictors of postoperative day-4 Hb, while age, IVFCM administration, transfusion, procedure type, and study period were associated with PRM admission. Conclusions: Despite major organizational disruption, perioperative hemoglobin levels and transfusion rates remained stable, while hospital length of stay decreased. These findings may partly reflect strict selection of already optimized patients; however, this strategy is not equivalent to structured PBM and cannot be generalized to an unselected arthroplasty population.

Background/Objectives: Total knee arthroplasty (TKA) is associated with severe postoperative pain that can impair early mobilization and prolong recovery. While adductor canal block combined with iPACK is commonly recommended, this strategy may provide incomplete articular coverage and occasionally compromise quadriceps function. Genicular nerve block (GNB) selectively targets the sensory innervation of the knee, and when combined with iPACK may achieve near-complete joint analgesia while preserving motor function. This case series aimed to evaluate the magnitude and duration of analgesia and functional recovery provided by a four-nerve GNB combined with iPACK. Methods: Five patients undergoing unilateral TKA under spinal anesthesia received ultrasound-guided blocks of the superolateral, superomedial, inferomedial genicular nerves and the nerve to vastus intermedius, together with an iPACK block. Ropivacaine combined with dexamethasone and dexmedetomidine was used. The primary outcome (pain intensity) [Numeric Rating Scale, NRS] and secondary outcomes (time to first rescue analgesia, opioid consumption, range of motion, and complications) were recorded up to 72 h postoperatively within a standardized multimodal analgesic protocol. Results: Pain scores at rest and on movement remained consistently below 3/10 in all patients. Three patients required no rescue analgesia, while two required a single dose at 36–40 h. Knee range of motion exceeded 90° in all cases, and early mobilization was achieved without quadriceps weakness. No neurological or systemic adverse events occurred. Conclusions: Four-nerve genicular block combined with iPACK, enhanced with perineural adjuncts, provided prolonged, opioid-sparing analgesia with preserved motor function after TKA. This joint-selective, motor-sparing strategy warrants further evaluation in randomized trials.

Background: Frail patients undergoing hip and knee revision surgery represent a major anesthetic challenge because of advanced age and multiple comorbidities. Continuous spinal anesthesia (CSA) with titrated low-dose levobupivacaine may offer a potentially useful alternative to general anesthesia or single-shot spinal anesthesia in this high-risk population. Methods: A retrospective review was conducted of ASA II-III patients who underwent complex hip and knee revision surgeries between February and October 2024 under CSA. The technique was performed using a 25-gauge spinal catheter with incremental boluses of 0.25% levobupivacaine (2.5 mg). Hemodynamic parameters, including mean arterial pressure (MAP), stroke volume index (SVI), and cardiac index (CI), were continuously monitored using the EV1000 hemodynamic monitoring system. Postoperative complications were recorded. Results: 37 high-risk patients were included in the study. Catheter placement was successful in all patients, with no conversions to general anesthesia. MAP decreased by a mean of 14.6% after boluses (p < 0.05); 9 patients (24.3%) experienced reductions ≥ 20%, but all remained >65 mmHg and responded to fluid therapy. CI and SVI decreased by 10.1% and 10.5%, respectively (p < 0.05), without clinical instability. No major complications (neurological injury, infection, post-dural puncture headache) were observed. Conclusions: In this retrospective single-center experience, CSA with titrated low-dose levobupivacaine was feasible and associated with stable hemodynamic profiles and a low rate of complications in frail patients undergoing complex lower-limb revision surgery. However, given the absence of a control group and the limited sample size, these findings should be interpreted cautiously. Further prospective comparative studies are needed to better define the role of CSA in high-risk orthopedic patients.