Utjecaj multimodalne analgezije metamizolom na poslijeoperacijsku bol i ranu rehabilitaciju u bolesnika nakon ugradbe totalne endoproteze koljena [The influence of multimodal analgesia with metamizole on the postoperative pain and early rehabilitation in patient with total knee replacement]

INTRODUCTION: Pain is a major limiting factor of early rehabilitation after total knee replacement (TKR). Pain after TKR is described as severe and very severe and it requires the use of strong analgesics in the treatment of pain. Multimodal analgesia involves a combination of two or more drugs that will treat the central and peripheral component of pain, with the aim of better control of pain with less side effects of the medication. Data regarding the optimal drug combination regimen during the first four weeks of rehabilitation in patients after TKR are insufficient. ----- OBJECTIVES: The aim of this study is to demonstrate equally effective control of the acute postoperative pain and functional outcome in patients receiving metamizole as compared to meloxicam in multimodal analgesic regimens during the first four weeks of rehabilitation after TKR. The specific objective were to determine whether the differences between the groups in the functional outcome and patient satisfaction, and to test the correlation of the pain intensity and the size of the postoperative hematoma with the knee motion range during the 28 days of rehabilitation. ----- MATERIALS AND METHODS: This prospective open randomized study included patients hospitalized for the TKR because of severe knee osteoarthritis. From the first postoperative day (POD1) to POD20, all patients regularly received oxycodone in therapeutic dose, with one group receiving meloxicam, and the other group metamizole in therapeutic doses. As an additional analgesic, paracetamol and tramadol were used at the patient's request throughout the whole study period. At the examination before surgery were recorded the general demographic dana of the patient, the intensity of pain at rest, in activity and during the night, the level of general satisfaction, flexion and extension of the knee and the suprapatellar knee circumference. These variables are measured daily during rehabilitation. The total amount of additional analgesics was recorded during the study period. Prior to surgery and after 4 weeks of rehabilitation, specific questionnaires (WOMAC, KSS) and the length of the walk (6MWT) were measured. ----- RESULTS: In our study 135 patients were included between September 2013. and December 2014. Data were analyzed for 127 divided into two study groups, 63 in metamizole and 64 in the meloxicam group. During the 4 weeks, daily measured pain intensity in both groups was comparable and were reduced proportionately over time. The flexion and extension after initial upward dynamics lost the achieved values at the end of the first and at the beginning of the second week to restart again at the end of the second week. Pain during the first two weeks after surgery largely affects the achievement of flexion, but only after 10th day of rehabilitation. Our findings indicate that postoperative hematoma progression is associated with loss of knee movement. After 4 weeks of rehabilitation, we did not find differences in the achieved functional outcome, the intensity of pain or the satisfaction level between the observed groups of patients. ----- CONCLUSION: Postoperative pain during the first 4 weeks of rehabilitation after TKR was equally well treated in patients receiving metamizole as compared to meloxicam in multimodal analgesic regimens, which was confirmation of the hypothesis. Proper pain control and bleeding prevention measures in the knee area can accelerate recovery during the first month of rehabilitation after TKR

Bifocal Stress Fracture of Pubic Rami after Contralateral Total Hip Arthroplasty and Longstanding Ipsilateral Hip Fusion

In this case report we present a patient with bifocal pubic rami stress fractures after contralateral total hip arthroplasty for congenital hip dysplasia and longstanding ipsilateral hip fusion. Treatment protocol for patients with various degrees of hip arthritis on one side and contralateral longstanding hip fusion are proposed based on the literature and our and previously published cases