Editorial Views  |   July 2007
Multimodal Analgesia for Orthopedic Procedures
Author Notes
  • From the Stanford University Medical Center, Stanford, California.
Article Information
Editorial Views / Pain Medicine
Editorial Views   |   July 2007
Multimodal Analgesia for Orthopedic Procedures
Anesthesiology 7 2007, Vol.107, 19-20. doi:10.1213/01.ane.0000265444.73604.f0
Anesthesiology 7 2007, Vol.107, 19-20. doi:10.1213/01.ane.0000265444.73604.f0
Multimodal analgesic protocols after elective orthopedic surgical procedures have the potential to improve pain control perioperatively and facilitate postoperative rehabilitation. Reuben et al. (1,2) have been at the forefront of redesigning pain management protocols for orthopedic procedures by performing carefully planned, meticulously documented, prospective, randomized studies. In the first of two articles appearing in this month's issue of Anesthesia & Analgesia  (1), Reuben et al. demonstrate in a randomized, prospective study that celecoxib (400 mg 1–2 h before anterior cruciate ligament (ACL) surgery, and then 200 mg every 12 h for 14 days postoperatively) decreases pain in the recovery room, opioid use, nausea and vomiting, and hastens discharge home compared with placebo. While at home, the celecoxib group reported decreased pain and used less oral narcotic analgesics compared with those receiving a placebo. When the same cohort of patients was examined 6 months later (2), the patients receiving celecoxib had less anterior knee pain, chronic regional pain syndrome, knee flexion contracture, and scar tissue requiring rearthroscopy than those taking a placebo. Furthermore, the celecoxib group had a higher, more intense activity level, and more commonly participated in full sports activities.
These studies demonstrate that multimodal pain management, using celecoxib according to the protocol outlined by the authors, is safe and effective. Although one may quibble with the use of “long-term” in the second study (6 months is “short-term” when discussing ACL surgery), the point is that celecoxib use may also have delayed benefits. The optimal dose and time of use of these drugs in orthopedic conditions is unknown. Higher doses used for longer time periods may increase the probability of a complication (3,4).
When reviewing these and similar studies, the reader should keep in mind that the patients undergoing ACL reconstruction are young (average age in the late 20s in the present study) and generally healthy (without comorbidities), and usually are not taking other medications that might be associated with adverse drug interactions. This younger, more robust population is the optimal group in which to perform multimodal pain studies. Furthermore, there are validated outcome measures to assess function of patients undergoing ACL reconstruction.
The use of celecoxib as part of multimodal pain management in other orthopedic surgical procedures is more controversial. There is substantial evidence in animal studies that nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors slow fracture and ligament healing and bone ingrowth into porous coated implants (5–8), although definitive outcome studies in humans have not been performed. In addition, elderly patients are generally not as robust as younger, more athletic, individuals, and take more potentially interactive medications. This underscores the importance of the studies by Reuben et al. in which a well-defined healthy patient cohort was chosen.
Reuben SS, Ekman EF, Charron D. Evaluating the analgesic efficacy of administering celecoxib as a component of multimodal analgesia for outpatient anterior cruciate ligament reconstruction surgery. Anesth Analg 2007;105:222–7.Reuben, SS Ekman, EF Charron, D
Reuben SS, Ekman EF. The effect of initiating a preventive multimodal analgesic regimen upon long-term patient outcomes for outpatient anterior cruciate ligament reconstruction surgery. Anesth Analg 2007;105:228–32.Reuben, SS Ekman, EF
Zhang J, Ding EL, Song Y. Adverse effects of cyclooxygenase 2 inhibitors on renal and arrhythmia events: meta-analysis of randomized trials. JAMA 2006;296:1619–1632.Zhang, J Ding, EL Song, Y
Hur C, Chan AT, Tramontano AC, Gazelle GS. Coxibs versus combination NSAID and PPI therapy for chronic pain: an exploration of the risks, benefits, and costs. Ann Pharmacother 2006;40:1052–1063.Hur, C Chan, AT Tramontano, AC Gazelle, GS
Radi ZA, Khan NK. Effects of cyclooxygenase inhibition on bone, tendon, and ligament healing. Inflamm Res 2005;54:358–366.Radi, ZA Khan, NK
Seidenberg AB, An YH. Is there an inhibitory effect of COX-2 inhibitors on bone healing? Pharmacol Res 2004;50:151–156.Seidenberg, AB An, YH
Gerstenfeld LC, Einhorn TA. COX inhibitors and their effects on bone healing. Expert Opin Drug Saf 2004;3:131–136.Gerstenfeld, LC Einhorn, TA
Goodman SB, Ma T, Genovese M, Lane Smith R. COX-2 selective inhibitors and bone. Int J Immunopathol Pharmacol 2003;16:201–205.Goodman, SB Ma, T Genovese, M Lane Smith, R