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A Randomized Controlled Trial

Asokumar Buvanendran, MD; Jeffrey S. Kroin, PhD; Kenneth J. Tuman, MD; Timothy R. Lubenow, MD; Dalia Elmofty, MD; Mario Moric, PhD; Aaron G. Rosenberg, MD

JAMA. 2003;290:2411-2418.

Context  Controlling postoperative pain after knee replacement while reducing opiod-induced adverse effects and improving outcomes remains an important challenge.

Objective  To assess the effect of combined preoperative and postoperative administration of a selective inhibitor of cyclooxygenase 2 on opioid consumption and outcomes after total knee arthroplasty (TKA).

Design, Setting, and Patients  Randomized, placebo-controlled, double-blind trial conducted June 2001 through September 2002, enrolling 70 patients aged 40 to 77 years and undergoing TKA at a university hospital in the United States.

Interventions  Patients were randomly assigned to receive 50 mg of oral rofecoxib at 24 hours and at 1 to 2 hours before TKA, 50 mg daily for 5 days postoperatively, and 25 mg daily for another 8 days, or matching placebo at the same times.

Main Outcome Measures  Postoperative outcomes including postsurgical analgesic consumption and pain scores achieved, nausea and vomiting, joint range of motion, sleep disturbance, patient satisfaction with analgesia, and hematologic and coagulation parameters.

Results  Total epidural analgesic consumption and in-hospital opioid consumption were less in the group receiving rofecoxib compared with the group receiving placebo (P<.05). Median pain score (visual analog scale [VAS], 0-10) achieved for the knee was lower in the rofecoxib group compared with the placebo group during hospital stay (2.2 [interquartile range {IQR}, 1.4-3.2] vs 3.5 [IQR, 2.7-4.3], P<.001) and 1 week after discharge (2.6 [IQR, 1.4-3.5] vs 3.7 [IQR, 2.9-4.7], P = .03). There was less postoperative vomiting in the rofecoxib group (6%) compared with the placebo group (26%) (P = .047), as well as a decrease in sleep disturbance compared with the placebo group on the night of surgery (P = .006) and on the first (P = .047) and second (P<.001) days postoperatively. Knee flexion was increased in the rofecoxib group compared with the placebo group at discharge (active flexion: mean [SD], 84.2° [11.1°] vs 73.2° [13.6°], P = .03; passive flexion: 90.5° [6.8°] vs 81.8° [13.4°], P = .05) and at 1 month postoperatively (109.3° [8.5°] vs 100.8° [11.8°], P = .01), with shorter time in physical therapy to achieve effective joint range of motion. The rofecoxib group was more satisfied with analgesia and anesthesia at discharge compared with the placebo group (median satisfaction score, 4.3 [IQR, 3.0-4.7] vs 3.3 [IQR, 2.3-4.3], respectively; P = .03), and the differences persisted at 2-week and at 1-month follow-up. There was no intergroup difference in surgical blood loss (P>.05 for both intraoperative and postoperative blood loss).

Conclusion  Perioperative use of an inhibitor of cyclooxygenase 2 is an effective component of multimodal analgesia that reduces opioid consumption, pain, vomiting, and sleep disturbance, with improved knee range of motion after TKA.

Author Affiliations: Departments of Anesthesiology (Drs Buvanendran, Kroin, Tuman, Lubenow, Elmofty, and Moric) and Orthopedic Surgery (Dr Rosenberg), Rush Medical College at Rush-Presbyterian-St Luke's Medical Center, Chicago, Ill.

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