Single-dose intra-articular bupivacaine plus morphine versus bupivacaine alone after arthroscopic knee surgery: a meta-analysis of randomized controlled trials

  • Ye Yang
  • Chao Zeng
  • Jie Wei
  • Hui li
  • Tuo Yang
  • Zhen-han Deng
  • Yu-sheng Li
  • Tu-bao Yang
  • Guang-hua Lei
Knee

Abstract

Purpose

The purpose of this meta-analysis was to compare the efficacy and safety of single-dose intra-articular bupivacaine plus morphine versus bupivacaine alone for pain management following arthroscopic knee surgery.

Method

A comprehensive literature search was conducted to identify randomized controlled trials that used single-dose intra-articular bupivacaine plus morphine and bupivacaine alone for post-operative pain, using MEDLINE (1966–2014), Cochrane Library and EMBASE databases. The weighted mean difference (WMD), relative risk (RR) and their corresponding 95 % confidence intervals (CIs) were calculated using RevMan statistical software.

Result

A total of twenty-nine trials (n = 1167) were included. The post-operative visual analog scale (VAS) pain score of the bupivacaine plus morphine group compared with the bupivacaine alone group was significantly lower (WMD −1.15, 95 % CI −1.67 to −0.63, p < 0.0001). As far as safety, there was no significant difference in side effects between the two groups (RR 1.10, 95 % CI 0.59–2.04, n.s.). Sensitivity analyses suggested that the results of these two primary outcomes were stable and reliable. However, the current evidence did not suggest a superior effect with respect to the time to first analgesic request (WMD 51.33, 95 % CI −110.99 to 213.65, n.s.) and the number of patients requiring supplementary analgesia (RR 1.13, 95 % CI 0.92–1.39, n.s.).

Conclusions

On the basis of the currently available literature, this study is the first to suggest that single-dose intra-articular bupivacaine plus morphine was shown to be significantly better than bupivacaine alone at relieving post-operative pain after arthroscopic knee surgery without increasing the short-term side effects. Routine use of single-dose intra-articular bupivacaine plus morphine is an effective way for pain management after arthroscopic knee surgery.

Level of evidence

II.

Keywords

Analgesics Bupivacaine Morphine Arthroscopy 

Notes

Acknowledgments

This work was supported by Hunan Provincial Innovation Foundation For Postgraduate (CX2014A005), the Fundamental Research Funds for the Central Universities of Central South University, the National Natural Science Foundation of China (Nos. 81201420, 81272034 and 81472130), the Provincial Science Foundation of Hunan (No. 14JJ3032), the Scientific Research Project of the Development and Reform Commission of Hunan Province ([2013]1199), the Scientific Research Project of Science and Technology Office of Hunan Province (2013SK2018) and the Doctoral Scientific Fund Project of the Ministry of Education of China (20120162110036).

Contribution of authors

All authors made substantial contributions to all three sections: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of the data, (2) the drafting of the article or revising it critically for important intellectual content and (3) final approval of the version submitted.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Aasbo V, Raeder JC, Grogaard B (1996) No additional analgesic effect of intra-articular morphine or bupivacaine compared with placebo after elective knee arthroscopy. Acta Anaesthesiol Scand 40:585–588CrossRefPubMedGoogle Scholar
  2. 2.
    Allen GC, St AM, Lui AC (1993) Postarthroscopy analgesia with intraarticular bupivacaine/morphine. A randomized clinical trial. Anesthesiology 79:475–480CrossRefPubMedGoogle Scholar
  3. 3.
    Anz A, Smith MJ, Stoker A (2009) The effect of bupivacaine and morphine in a coculture model of diarthrodial joints. Arthroscopy 25:225–231CrossRefPubMedGoogle Scholar
  4. 4.
    Arti H, Arti S (2013) The effects of intraarticular opioids in pain relief after arthroscopic meniscectomy: a randomized clinical trial study. Pak J Med Sci 29:625–628CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Arti H, Mehdinasab SA (2011) The comparison effects of intra-articular injection of different opioids on postoperative pain relieve after arthroscopic anterior cruciate ligament reconstruction: a randomized clinical trial study. J Res Med Sci 16:1176–1182PubMedPubMedCentralGoogle Scholar
  6. 6.
    Begg CB, Mazumdar M (1994) Operating characteristics of a rank correlation test for publication bias. Biometrics 50:1088–1101CrossRefPubMedGoogle Scholar
  7. 7.
    Bjornsson A, Gupta A, Vegfors M (1994) Intraarticular morphine for postoperative analgesia following knee arthroscopy. Reg Anesth 19:104–108Google Scholar
  8. 8.
    Boden BP, Fassler S, Cooper S (1994) Analgesic effect of intraarticular morphine, bupivacaine, and morphine/bupivacaine after arthroscopic knee surgery. Arthroscopy 10:104–107CrossRefPubMedGoogle Scholar
  9. 9.
    Buvanendran A, Kroin JS (2009) Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol 22:588–593CrossRefPubMedGoogle Scholar
  10. 10.
    Chan ST (1995) Intra-articular morphine and bupivacaine for pain relief after therapeutic arthroscopic knee surgery. Singap Med J 36:35–37Google Scholar
  11. 11.
    Danieli MV, Cavazzani NA, Herrera PA (2012) Intra-articular bupivacaine or bupivacaine and morphine after ACL reconstruction. Acta Orthop Bras 20:258–261CrossRefGoogle Scholar
  12. 12.
    De Andres J, Valia JC, Barrera L (1998) Intra-articular analgesia after arthroscopic knee surgery: comparison of three different regimens. Eur J Anaesthesiol 15:10–15PubMedGoogle Scholar
  13. 13.
    Denti M, Randelli P, Bigoni M (1997) Pre- and postoperative intra-articular analgesia for arthroscopic surgery of the knee and arthroscopy-assisted anterior cruciate ligament reconstruction. A double-blind randomized, prospective study. Knee Surg Sports Traumatol Arthrosc 5:206–212CrossRefPubMedGoogle Scholar
  14. 14.
    Farouk S, Aly A (2009) A comparison of intra-articular magnesium and/or morphine with bupivacaine for postoperative analgesia after arthroscopic knee surgery. J Anesth 23:508–512CrossRefPubMedGoogle Scholar
  15. 15.
    Gatt CJ, Parker RD, Tetzlaff JE (1998) Preemptive analgesia: its role and efficacy in anterior cruciate ligament reconstruction. Am J Sports Med 26:524–529PubMedGoogle Scholar
  16. 16.
    Goodwin RC, Amjadi F, Parker RD (2005) Short-term analgesic effects of intra-articular injections after knee arthroscopy. Arthroscopy 21:307–312CrossRefPubMedGoogle Scholar
  17. 17.
    Haynes TK, Appadurai IR, Power I (1994) Intra-articular morphine and bupivacaine analgesia after arthroscopic knee surgery. Anaesthesia 49:54–56CrossRefPubMedGoogle Scholar
  18. 18.
    Heine MF, Tillet ED, Tsueda K (1994) Intra-articular morphine after arthroscopic knee operation. Br J Anaesth 73:413–415CrossRefPubMedGoogle Scholar
  19. 19.
    Jadad AR, Moore RA, Carroll D (1996) Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials 17:1–12CrossRefPubMedGoogle Scholar
  20. 20.
    Jaureguito JW, Wilcox JF, Thisted RA (2002) The effects of morphine on human articular cartilage of the knee: an in vitro study. Arthroscopy 18:631–636CrossRefPubMedGoogle Scholar
  21. 21.
    Joshi GP, McCarroll SM, O’Brien TM (1993) Intraarticular analgesia following knee arthroscopy. Anesth Analg 76:333–336PubMedGoogle Scholar
  22. 22.
    Joshi W, Reuben SS, Kilaru PR (2000) Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular clonidine and/or morphine. Anesth Analg 90:1102–1106CrossRefPubMedGoogle Scholar
  23. 23.
    Karlsson J, Rydgren B, Eriksson B (1995) Postoperative analgesic effects of intra-articular bupivacaine and morphine after arthroscopic cruciate ligament surgery. Knee Surg Sports Traumatol Arthrosc 3:55–59CrossRefPubMedGoogle Scholar
  24. 24.
    Kehlet H, Dahl JB (1993) The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg 77:1048–1056CrossRefPubMedGoogle Scholar
  25. 25.
    Khoury GF, Chen AC, Garland DE (1992) Intraarticular morphine, bupivacaine, and morphine/bupivacaine for pain control after knee videoarthroscopy. Anesthesiology 77:263–266CrossRefPubMedGoogle Scholar
  26. 26.
    Laurent SC, Nolan JP, Pozo JL (1994) Addition of morphine to intra-articular bupivacaine does not improve analgesia after day-case arthroscopy. Br J Anaesth 72:170–173CrossRefPubMedGoogle Scholar
  27. 27.
    Liberati A, Altman DG, Tetzlaff J (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 62:e1–e34CrossRefPubMedGoogle Scholar
  28. 28.
    Lundin O, Rydgren B, Sward L (1998) Analgesic effects of intra-articular morphine during and after knee arthroscopy: a comparison of two methods. Arthroscopy 14:192–196CrossRefPubMedGoogle Scholar
  29. 29.
    Marchal JM, Delgado-Martinez AD, Poncela M (2003) Does the type of arthroscopic surgery modify the analgesic effect of intraarticular morphine and bupivacaine? A preliminary study. Clin J Pain 19:240–246CrossRefPubMedGoogle Scholar
  30. 30.
    Marx RG (2008) Arthroscopic surgery for osteoarthritis of the knee? N Engl J Med 359:1169–1170CrossRefPubMedGoogle Scholar
  31. 31.
    McDermott ID, Crowhurst EC, Crawfurd EJP (1999) Does the addition of morphine to intra-articular bupivacaine injection improve pain relief after knee arthroscopy? Knee 6:17–19CrossRefGoogle Scholar
  32. 32.
    McSwiney MM, Joshi GP, Kenny P (1993) Analgesia following arthroscopic knee surgery. A controlled study of intra-articular morphine, bupivacaine or both combined. Anaesth Intensive Care 21:201–203PubMedGoogle Scholar
  33. 33.
    Park J, Sutradhar BC, Hong G (2011) Comparison of the cytotoxic effects of bupivacaine, lidocaine, and mepivacaine in equine articular chondrocytes. Vet Anaesth Analg 38:127–133CrossRefPubMedGoogle Scholar
  34. 34.
    Pavlin DJ, Chen C, Penaloza DA (2004) A survey of pain and other symptoms that affect the recovery process after discharge from an ambulatory surgery unit. J Clin Anesth 16:200–206CrossRefPubMedGoogle Scholar
  35. 35.
    Pavlin DJ, Chen C, Penaloza DA (2002) Pain as a factor complicating recovery and discharge after ambulatory surgery. Anesth Analg 95:627–634PubMedGoogle Scholar
  36. 36.
    Reuben SS, Sklar J (2000) Pain management in patients who undergo outpatient arthroscopic surgery of the knee. J Bone Joint Surg Am 82-A:1754–1766CrossRefPubMedGoogle Scholar
  37. 37.
    Reuben SS, Steinberg RB, Cohen MA (1998) Intraarticular morphine in the multimodal analgesic management of postoperative pain after ambulatory anterior cruciate ligament repair. Anesth Analg 86:374–378PubMedGoogle Scholar
  38. 38.
    Ruwe PA, Klein I, Shields CL (1995) The effect of intraarticular injection of morphine and bupivacaine on postarthroscopic pain control. Am J Sports Med 23:59–64CrossRefPubMedGoogle Scholar
  39. 39.
    Senthilkumaran S, Tate R, Read JR (2010) Intra-articular morphine and bupivacaine for post-operative analgesia in anterior cruciate ligament reconstruction: a prospective randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 18:731–735CrossRefPubMedGoogle Scholar
  40. 40.
    Stein C, Lang LJ (2009) Peripheral mechanisms of opioid analgesia. Curr Opin Pharmacol 9:3–8CrossRefPubMedGoogle Scholar
  41. 41.
    Stein C, Millan MJ, Shippenberg TS (1989) Peripheral opioid receptors mediating antinociception in inflammation. Evidence for involvement of mu, delta and kappa receptors. J Pharmacol Exp Ther 248:1269–1275PubMedGoogle Scholar
  42. 42.
    Stein C, Millan MJ, Yassouridis A (1988) Antinociceptive effects of mu- and kappa-agonists in inflammation are enhanced by a peripheral opioid receptor-specific mechanism. Eur J Pharmacol 155:255–264CrossRefPubMedGoogle Scholar
  43. 43.
    Stewart DJ, Lambert EW, Stack KM (2005) The effect of intra-articular methadone on postoperative pain following anterior cruciate ligament reconstruction. J Bone Joint Surg Am 87:140–144PubMedGoogle Scholar
  44. 44.
    Sun R, Zhao W, Hao Q (2014) Intra-articular clonidine for post-operative analgesia following arthroscopic knee surgery: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 22:2076–2084CrossRefPubMedGoogle Scholar
  45. 45.
    Tetzlaff JE, Dilger JA, Abate J (1999) Preoperative intra-articular morphine and bupivacaine for pain control after outpatient arthroscopic anterior cruciate ligament reconstruction. Reg Anesth Pain Med 24:220–224CrossRefPubMedGoogle Scholar
  46. 46.
    Wei J, Lei GH, Gao SG (2014) Single-dose intra-articular bupivacaine versus morphine after arthroscopic knee surgery: a meta-analysis of randomized-controlled studies. Clin J Pain 30:630–638PubMedGoogle Scholar
  47. 47.
    Wei J, Yang HB, Qin JB (2014) Single-dose intra-articular bupivacaine after knee arthroscopic surgery: a meta-analysis of randomized placebo-controlled studies. Knee Surg Sports Traumatol Arthrosc 22:1517–1528CrossRefPubMedGoogle Scholar
  48. 48.
    Yari M, Saeb M, Golfam P (2013) Analgesic efficacy of intra-articular morphine after arthroscopic knee surgery in sport injury patients. J Inj Violence Res 5:84–88CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Zeng C, Gao SG, Cheng L (2013) Single-dose intra-articular morphine after arthroscopic knee surgery: a meta-analysis of randomized placebo-controlled studies. Arthroscopy 29:1450–1458CrossRefPubMedGoogle Scholar

Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2015

Authors and Affiliations

  • Ye Yang
    • 1
  • Chao Zeng
    • 1
  • Jie Wei
    • 2
  • Hui li
    • 1
  • Tuo Yang
    • 1
  • Zhen-han Deng
    • 1
  • Yu-sheng Li
    • 1
  • Tu-bao Yang
    • 2
  • Guang-hua Lei
    • 1
  1. 1.Department of Orthopaedics, Xiangya HospitalCentral South UniversityChangshaChina
  2. 2.Department of Epidemiology and Health Statistics, School of Public HealthCentral South UniversityChangshaChina

Personalised recommendations