Onur AVCI, İclal ÖZDEMİR KOL, Oğuz GÜNDOĞDU, Zekeriya ÖZTEMUR, İdris ERŞAN

Effect of adding dexmedetomidine to intra-articular levobupivacaine on postoperative pain following arthroscopic meniscus surgery: A prospective, double-blind, randomized, placebo- controlled, clinical trial

Objective: The aim of this study was to determine the effect of adding dexmedetomidine to intra-articular levobupivacaine onpostoperative pain levels and analgesic requirements following arthroscopic meniscectomy.Methods: A total of 60 American Society of Anesthesiologist physical status I-II patients, aged 20 to 62 years, and scheduled forarthroscopic partial meniscectomy under general anesthesia were included in this study. All the patients were randomlyassigned to one of four groups (15 patients in each group): Group 1 (8 male, 7 female; mean age = 46.70 ± 13.13 years; 0.9%isotonic 20 ml), group 2 (7 male, 8 female; mean age = 42.60 ± 12.18 years; levobupivacaine 0.5 mg/kg plus 0.9% isotonic), group 3(8 male, 7 female; mean age = 43.80 ± 12.63 years; 1μg/kg dexmedetomidine plus 0.9% isotonic), and group 4 (7 female, 8 male;mean age = 40.40 ± 11.79 years; levobupivacaine 0.5 mg/kg plus 1μg/kg dexmedetomidine and 0.9% isotonic). All medicationswere administered at the end of arthroscopic surgery. Pain levels were measured using a Visual Analogous Scale (VAS) andVerbal Rating Scale (VRS) at postoperative 1, 2, 4, 6, 12, and 24 hours.Results: VAS scores at rest were significantly lower in Group 4 at postoperative 1th, 2nd, 4th, 6th,12th, and 24th hours than in othergroups. The time to take the first analgesic was significantly higher in Group4 (964 ± 288 min), and total analgesic consumptionwas significantly lower in Group 4 compared to those of other groups.Conclusion: Although administration of intra-articular dexmedetomidine alone may have a weaker effect than intra-articularlevobupivacaine on postoperative pain relief after arthroscopic partial meniscectomy, adding dexmedetomidine to intra-articularlevobupivacaine may increase the durationand quality of postoperative analgesia without any side effect.Level of Evidence: Level I, Therapeutic Study

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1. Moiniche S, Mikkelsen S, Wetterslev J, Dahl JB. A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery. Reg Anesth Pain Med. 1999;24(5):430-437. 10.1097/00115550- 199924050-00011

2. Saricaoglu F, Dal D, Atilla P, et al. Effect of intra-articular injection of lornoxicam on the articular cartilage & synovium in rat. Indian J Med Res. 2008;127 (4):362-365.

3. Rasmussen S, Thomsen ST, Madsen SN, Rasmussen PJ, Simonsen OH. The clinical effect of naproxen sodium after arthroscopy of the knee: A randomized, double-blind, prospective study. Arthroscopy. 1993;9(4):375-380. 10.1016/ S0749-8063(05)80309-3

4. Dennis AR, Leeson-Payne CG, Hobbs GJ. A comparison of diclofenac with ketorolac for pain relief after knee arthroscopy. Anaesthesia. 1995;50(10): 904-906. 10.1111/j.1365-2044.1995.tb05862.x

5. Kalso E, Tramer MR, Carroll D, McQuay HJ, Moore RA. Pain relief from intraarticular morphine after knee surgery. Pain. 1997;71:127-134. 10.1016/S0304-3959 (97)03344-7

6. Kalso E. Better standardisation will improve the quality of analgesic studies. Acta Anaesthesiol Scand. 1996;40(4):397-398. 10.1111/j.1399-6576.1996. tb04459.x

7. Dahl MR, Dasta JF, Zuelzer W, McSweeney TD. Lidocaine local anesthesia for arthroscopic knee surgery. Anesth Analg. 1990;71(6):670-674. 10.1213/ 00000539-199012000-00016

8. Eriksson E, Haggmark T, Saartok T, Sebik A, Ortengren B. Knee arthroscopy with local anesthesia in ambulatory patients: Methods, results and patient compliance. Orthopedics. 1986;9(2):186-188. 10.3928/0147-7447- 19860201-09

9. Chirwa SS, MacLeod BA, Day B. Intraarticular bupivacaine after arthroscopic meniscectomy: A randomized double-blind controlled study. Arthroscopy. 1989;5(1):33-35. 10.1016/0749-8063(89)90087-X

10. Jacobson E, Assareh H, Cannerfelt R, Anderson RE, Jakobsson JG. The postoperative analgesic effects of intra-articular levobupivacaine in elective day-case arthroscopy of the knee: A prospective, randomized, double-blind clinical study. Knee Surg Sports Traumatol Arthrosc. 2006;14(2):120-124. 10. 1007/s00167-005-0655-4

11. Gristwood RW. Cardiac and CNS toxicity of levobupivacaine: Strengths of evidence for advantage over bupivacaine. Drug Saf. 2002;25(3):153-163. 10. 2165/00002018-200225030-00002

12. Kamibayashi T, Maze M. Clinical uses of alpha2-adrenergic agonists. Anesthesiology. 2000;93:1345-1349. 10.1097/00000542-200011000-00030

13. Hatem MN, Osama SM, Maha GA, Usama A. Intraarticular magnesium versus dexmedetomidine for postoperative analgesia after knee arthroscopic meniscectomy. JSEMP. 2012;30(2):102-106.

14. Grewal A. Dexmedetomidine: New Avenues. J Anaesthesiol Clin Pharmacol. 2011;27(3):297-302. 10.4103/0970-9185.83670

15. Panzer O, Moitra V, Sladen RN. Pharmacology of sedative-analgesic agents: Dexmedetomidine, remifentanyl, ketamine, volatile anaesthetics, and the role of peripheral Mu antagonists. Crit Care Clin. 2009;25(3):451-469. 10.1016/j.ccc. 2009.04.004

16. El Baz MM, Farahat TEM. Efficacy of adding dexmedetomidine to intra-articular levobupivacaine on postoperative pain after knee arthroscopy. Anesth Essays Res. 2019;13(2):254-258. 10.4103/aer.AER_23_19

17. Elbadawy AM, Salama AK, Mohammad MM. Comparative study of intraarticular dexmedetomidine versus ketamine as adjuvant analgesics after knee arthroscopy. Egypt J Anaesth. 2015;31(4):309-314. 10.1016/j.egja. 2015.05.003

18. Shaimaa FM, Gehan ME, Mohammed AA, Rehab SE. Intra-articular dexmedetomidine with bupivacaine versus bupivacaine alone for postoperative analgesia after knee arthroscopy. South Afr J Anaesth Analg. 2018;24(2):54-59. 10. 1080/22201181.2018.1444443

19. Paul S, Bhattacharjee DP, Ghosh S, Dawn S, Chatterjee N. Efficacy of intra-articular dexmedetomidine for postoperative analgesia in arthroscopic knee surgery. Ceylon Med J. 2010;55(4):111-115. 10.4038/cmj.v55i4.2627

20. Reuben SS, Connelly NR. Postoperative analgesia for outpatient arthroscopic knee surgery with intra-articular clonidine. Anesth Analg. 1999;88(4):729-733. 10.1213/00000539-199904000-00006

21. Tarlika P, Divyang D, Keta T, Prabhanjan S. Effectiveness of intra-articular dexmedetomidine as postoperative analgesia in arthroscopic knee surgery (A comparative study). IOSR J Pharm. 2015;5(7):18-27.

22. Peng K, Chen WR, Meng XW, Zhang J, Ji FH. Intra-articular dexmedetomidine in knee arthroscopy: A systematic review and meta-analysis. Sci Rep. 2018;8 (1):4089. 10.1038/s41598-018-22482-8

23. Akça B, Ankay Yılbaş A, Üzümcügil F, et al. How does intraarticular dexmedetomidine injection effect articular cartilage and synovium? An animal study. BMC Anesthesiol. 2020;20:237. 10.1186/s12871-020-01148-x

24. Çepni Kütahya E, Oc B, Ugurluoglu C, Duman I, Arun O. The effects of intra-articular injection of ibuprofen on knee joint cartilage and synovium in rats. Acta Orthop Traumatol Turc. 2019;53(4):292-296. 10.1016/j.aott.2019.03.013