Management of Postoperative Pain After Arthroscopic Elbow Surgery with Oral Analgesics and Local Anesthesia

Summary

Here, we present a protocol for combined oral and local analgesia that effectively relieves post-arthroscopic elbow surgery pain and merits clinical promotion.

Abstract

Pain after arthroscopic elbow surgery seriously impairs patients’ quality of life, and its clinical management remains a significant challenge at present. Objective: This study aims to analyse the efficacy of oral analgesia and local anaesthesia in the management of pain levels after arthroscopic elbow surgery. Methods: A single-center retrospective observational study was conducted. A total of 120 patients with postoperative pain after arthroscopic elbow surgery were recruited from Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine in Hebei Province between December 2020 and December 2023. The patients were divided into two groups with 60 cases in each group: the LA group received local anaesthesia alone, while the LC group was administered local anaesthesia combined with oral Celecoxib capsules. The treatment cycle was 3-5 days. The main assessments were pain level (VAS score), Ramsay sedation score, elbow function (MEPS score), and clinical efficacy in both groups. Secondary outcomes included stress factor levels [malondialdehyde (MDA), aldosterone (ALD)], patient satisfaction, quality of life [Short Form of the Health Status Survey (SF-36) score], complication status, and incidence of adverse effects. Results: After treatment, the indicators of the both groups were significantly differences with pre-treatment (P<0.05). Ramsay score, MEPS score, elbow mobility, clinical efficacy, SF-36 score and satisfaction score were significantly higher the LA group, and VAS score, MDA and ALD levels, total complication rate and adverse reaction rate were significantly lower the LA group (P<0.05).

Introduction

With the implementation of the national strategies of 'Healthy China' and 'National Fitness', the number of fitness enthusiasts is increasing. However, due to insufficient knowledge of sports medicine and rehabilitation medicine, coupled with chronic repetitive upper limb load related to fitness and professional activities, the incidence rate of elbow disorders in the population continues to rise¹. Among them, the incidence of primary elbow osteoarthritis with stiffness is about 2%, and the incidence is as high as 33% in the occupational groups (e.g., chefs, throwers, etc.) that have been engaged in long-term loading of the upper limbs². Primary elbow osteoarthritis is characterized by degenerative changes in the cartilage and subchondral bone of the elbow joint. As the disease progresses, cartilage damage, fragmentation, and osteophyte formation may occur, leading to joint pain and varying degrees of functional limitation. A typical symptom is pain at the terminal range of motion; in severe cases, pain may also occur in the mid-range of motion and may be accompanied by mechanical locking or catching. These symptoms can interfere with basic daily activities such as eating and dressing, thereby significantly reducing quality of life^3,4,5.

Due to the varying severity of elbow osteoarthritis symptoms, primary elbow osteoarthritis with stiffness can be treated conservatively with medication, physiotherapy, and rehabilitative exercises when symptoms progress slowly and are well tolerated early in the course of the disease⁶. Pharmacological treatments for osteoarthritis include oral non-steroidal analgesics and anti-inflammatory drugs, and intra-articular corticosteroid and/or sodium vitrate injections, all of which can help to relieve elbow pain. Physiotherapy, including shockwave, herbal fumigation, and local massage, can also relieve pain, but the duration is short. Rehabilitation exercises include elbow decompression activities and flexion and extension exercises to maintain elbow joint mobility and avoid further aggravation of elbow capsular contracture, and passive flexion and extension exercises need to pay attention to the risk of periarticular fracture, nerve pulling (especially the ulnar nerve), and the formation and aggravation of ossified myositis foci⁷.

Surgery is often used for patients with osteoarthritis of the elbow joint who are symptomatic and for whom conservative treatment is ineffective. Arthroscopic surgery is a minimally invasive surgical technique in which an arthroscope and associated instruments are inserted into the joint cavity by creating several small incisions around the elbow joint⁸. The arthroscope is equipped with a camera that transmits images of the internal structure of the joint to a display screen, allowing the surgeon to visualize the cartilage, synovium, ligaments, and other tissues of the elbow joint, and to perform precise therapeutic operations. Compared with traditional open surgery, arthroscopic elbow surgery has significant advantages. Firstly, the incision is small and causes minimal damage to the surrounding soft tissues, resulting in a limited postoperative scar, which is cosmetically favorable and reduces the risk of joint dysfunction associated with scar contracture; secondly, the postoperative pain is mild, and the patient can start the rehabilitation training earlier, which is conducive to the recovery of the joint function; thirdly, it greatly reduces the risk of surgical infection, shortens the hospital stay, and reduces the cost of the treatment, so that the patient can return to the normal life and work more quickly⁹.

Postoperative pain control is an important part of successful arthroscopic surgery. Currently, non-steroidal anti-inflammatory drugs (NSAIDs) and selective COX-2 inhibitors have become the basic medications for postoperative elbow analgesia¹⁰. Studies have shown that preoperative prophylactic use of selective COX-2 inhibitors (e.g., celecoxib) significantly reduces the level of postoperative pain and decreases the dose of opioids and related side effects. By inhibiting prostaglandin synthesis, this class of drugs can achieve a dual analgesic effect by both relieving the local inflammatory response and inhibiting central nociceptive sensitisation. In patients with gastrointestinal risks, selective COX-2 inhibitors have a safety advantage over conventional NSAIDs¹¹. Local anesthesia is increasingly used in elbow surgery and consists mainly of nerve block anesthesia and local infiltration anesthesia. Elbow nerve blocks (e.g., ulnar, radial, or median nerve blocks) provide precise regional analgesia, allowing patients to cooperate with surgery while awake and reducing general anesthesia-related complications¹². In addition, local anesthesia is effective in reducing early postoperative pain and suppressing the synovial inflammatory response through intraoperative intra-articular injection of a lidocaine mixture containing adrenaline¹³.

Therefore, this study observed the efficacy of the combination of oral analgesia and local anesthesia in the treatment of pain after arthroscopic elbow surgery, analyzed the pain relief after treatment, clarified the effectiveness and safety of the combination of the two treatments, and improved the quality of life of patients to provide more treatment options for the clinic.

Protocol

The study was conducted in compliance with the Declaration of Helsinki and the hospital's ethical guidelines and was endorsed by the ethical committees of Hebei Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine. Written informed consent was obtained from every participant in this study.

1. Study design and participants

NOTE: The present study is a single-center retrospective observational study involving 120 patients with postoperative pain after arthroscopic elbow surgery admitted to Hebei Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine between December 2020 and December 2023. All eligible patients during the study period were continuously monitored.

1. Divide the patients into two groups according to the intervention received: the local anesthesia alone (LA) group and the local anesthesia combined with oral Celecoxib capsules (LC) group.
   NOTE: It should be pointed out that due to the retrospective nature of the study, non-randomized grouping may lead to potential selection bias. As a retrospective study, this study is based on relatively complete clinical data extracted from hospital standardized electronic medical record systems.
2. For lost visits and data loss, strictly follow the following handling methods:
   1. For lost patients, actively track them through phone calls and outpatient follow-up. If the follow-up cannot be completed after three attempts, define the case as lost to follow-up and record it.
   2. For missing data, considering the high completeness of the retrospective dataset, use interpolation for data with a missing rate < 20%, and exclude data with a missing rate > 20% from the final statistical analysis.
      NOTE: The study aims to compare the efficacy of combined oral analgesia and local anesthesia for the treatment of postoperative pain after elbow surgery and to further assess their impact on patients' pain levels. The flow chart of this study is illustrated in Figure 1.

2. Inclusion and exclusion criteria

1. Inclusion criteria:
   1. Include patients with a history of elbow stiffness greater than 6 months, ineffective conservative treatment, and arthroscopic elbow surgery.
   2. Include patients aged 35–65 years old with pain after elbow joint surgery.
   3. Include patients with obvious elbow joint activity limitation seriously affecting life.
   4. Include patients whose imaging examination showed that the joint space was generally normal, and there was no obvious damage to the articular cartilage.
   5. Include patients whose compliance is good and who are willing to cooperate with the treatment plan developed by the study.
   6. Include patients who have no severe systemic diseases affecting the study, who can truthfully express symptom complaints, and who can answer the medical staff's questions.
   7. Include patients who can tolerate the drugs involved in this study.
   8. Ensure patients and their family members are informed and agree to the procedure, and sign an informed consent form.
2. Exclusion criteria:
   1. Exclude patients with a clear history of elbow trauma, a clear cutaneous scar contracture, and peripheral muscle disease.
   2. Exclude patients who are unable to cooperate with rehabilitation exercises after surgery.
   3. Exclude patients with malignant tumor of any site or type.
   4. Exclude patients with hemorrhagic and coagulation dysfunction, severe liver or renal function defects, serious cardiovascular disease, or other severe systemic diseases (including chronic infectious diseases).
   5. Exclude patients with combined chronic infectious diseases.
   6. Exclude patients with combined cerebral, cardiac, hepatic, and renal functional abnormalities.
   7. Exclude patients who have been involved in clinical drug trials or clinical research.
   8. Exclude patients requesting cessation of treatment or automatic discharge for personal reasons.
   9. Exclude other conditions that, in the opinion of the study physician, should not be included.
   10. Exclude patients with other circumstances affecting the indicators of follow-up observation.

3. Interventions

NOTE: To reduce confounding factors, all arthroscopic elbow surgeries in this study were performed by the same team of senior orthopedic surgeons with rich clinical experience, and the surgical procedure, operation specifications, and perioperative management were strictly unified.

1. Administer local anesthesia to patients in both groups. Prepare the anesthetic solution at the following ratio: 5 mL of 2% lidocaine + 10 mL of 0.9% NaCl, and 0.4 mL of 1 mg/mL epinephrine hydrochloride.
   NOTE: The local anesthetic injection was executed by the same designated anesthesiologist for all patients.
2. Perform the injection using sterile 22 G needles, evenly injecting the solution into the periarticular soft tissue and joint capsule of the elbow 30 min before the initiation of surgery, at a slow injection rate of 2 mL/min to avoid local tissue irritation.
3. Add oral celecoxib capsules to the intervention regimen for the LC group. Prescribe celecoxib capsules at a fixed initial dose of 0.2 g orally, followed by an additional 0.2 g dose 12 h later if pain symptom relief is not obvious, with the maximum daily dose not exceeding 0.4 g.
4. To standardize administration and ensure comparability, instruct patients to record the actual number of doses taken daily and the corresponding pain intensity at each dose. Limit the maximum continuous administration period to 3–5 days per cycle.

4. Observational indicators

1. Evaluate all observation indicators using a standardized three-point evaluation framework to ensure the accuracy and comparability of data collection.
   1. Pre-treatment: Within 24 h prior to surgery, admit the patient to the hospital and ensure they are in a stable condition.
   2. Post-treatment: Evaluate the immediate treatment effect on the day after the end of the treatment cycle.
2. Primary indicators
   1. Pain scores
      1. Use the pain score (VAS) to evaluate pain levels at pre-treatment and post-treatment¹⁴. The scale has scores 0–10. Score 1–3 for mild pain, 4–7 for moderate pain, and >7–10 for severe pain.
      2. Conduct the assessment by the same trained investigator at a fixed time (9:00–10:00 a.m.) to avoid diurnal variation bias, and record and document all VAS scores accurately.
   2. Ramsay sedation score
      1. Use the Ramsay sedation score to analyze the sedation of the patients at pre-treatment and post-treatment¹⁵. Give a score of 1 for obvious anxiety and irritability, 2 for wakefulness and calm co-operation, 3 for being able to follow instructions but feeling sleepy, 4 for drowsiness but wakefulness on a gentle call, and 5 for going to sleep but being able to wake up on a strong stimulus.
      2. Record each patient's sedation score at the specified time points.
   3. Elbow function
      1. Assess the patients' elbow function using the Mayo elbow function scoring system (MEPS score) at pre-treatment and post-treatment¹⁶.
      2. Follow the MEPS scoring standard: 100 is the highest score, with specific scores of 45 for pain, 20 for range of motion, 25 for function in daily life, and 10 for elbow stability.
      3. Rate the scores as follows: excellent ≥ 90, good 75–89, fair 60–74, and poor <60. Measure and record patients' elbow extension, flexion, and flexion-extension mobility precisely.
   4. Clinical effectiveness
      1. Evaluate the clinical therapeutic effects of the two groups of patients at post-treatment.
      2. Obvious effect: Record the effect as obvious if the patients' pain symptoms subside and their sleep quality and daily life return to normal.
      3. Effective: Record it as effective if the patients' pain symptoms improve significantly, but paroxysmal pain still exists, and sleep quality and daily life improve significantly.
      4. Ineffective: Record it as ineffective if the above criteria are not met, and the pain is not reduced or even aggravated. Total effective rate = (obvious effect + effective) / total × 100%.
3. Secondary indicators
   1. Stress factor levels
      1. Draw 4 mL of the patients' venous blood at pre-treatment and post-treatment, and collect fasting serum samples from both groups.
      2. Detect trauma stress factors, malondialdehyde (MDA), and aldosterone (ALD) levels using a clinical chemistry analyzer¹⁷. Record all test results in the designated database.
   2. Quality of life
      1. Use the health status survey short form (SF-36 score) to compare the quality of life between the two groups of patients at pre-treatment and post-treatment in terms of the dimensions of physiological functioning, physical functioning, somatic pain, general health status, social functioning, emotional functioning, and mental health. It has a total score of 100 points, with higher scores indicating a better quality of life¹⁸.
      2. Tabulate the scores for each dimension for statistical analysis.
   3. Patient satisfaction
      1. Use a custom-made satisfaction questionnaire to compare the two groups' satisfaction with post-treatment pain relief and to assess the four dimensions of professionalism, nursing operations, communication, and attitude, with a total score of 25 for each dimension; higher scores indicate greater satisfaction with that dimension.
      2. Collect and collate all completed questionnaires.
   4. Complications
      1. Monitor and record the incidence of complications in both groups throughout the follow-up period from surgery to the 3-month follow-up time point, including joint stiffness, activity limitation, and muscle atrophy.
      2. Document the onset time, severity, and management measures for each complication.
   5. Incidence of adverse reactions
      1. Track and record the incidence of adverse reactions from the start of medication to the post-treatment evaluation time point in both groups, including nausea/vomiting, hot flashes/sweating, and headache.
      2. Note the duration and severity of each adverse reaction, and record any corresponding interventions applied.

5. Follow-up visits

1. Schedule a 3-month post-treatment follow-up for all included patients. Conduct follow-up assessments to evaluate the durability of treatment effects.
2. Address any potential adverse reactions or health problems reported by patients during the follow-up period. Document all follow-up findings.

6. Sample size calculation

1. Use G*power 3.1.9.7 computer software to determine sample size through power analysis, with VAS score as the primary outcome measure. Set the key calculation parameters as follows: α (Type I error rate)=0.05, power (1- β)=85% (β=0.15), and the allocation ratio between the two groups is 1:1. Set the average difference (Δ) between the two VAS scores to 2.0 points, and the standard deviation (SD) to 4.0 points^19,20,21.
   NOTE: Based on these parameters, this study estimated that each group requires 49 patients. Given potential uncertainties, such as follow-up failures, ultimately a sample size of 60 patients per group was chosen to ensure sufficient statistical power to draw reliable conclusions.

7. Statistical methods

1. Use appropriate statistical analysis software (e.g., SPSS 27.0) to analyze the data. Represent the measurements that conform to a normally distributed value as x ± s, and perform inter-group comparisons of measurement data using the independent samples t-test, and perform the intra-group comparisons before and after treatment using the paired samples t-test.
2. Express count data as a rate (%) and compare it using the x² test.
3. Conduct effect size analysis to evaluate the clinical significance of differences: for measurement data, use Cohen's d (negligible effect: d < 0.2; small effect: 0.2 ≤ d < 0.5; moderate effect: 0.5 ≤ d < 0.8; large effect: 0.8 ≤ d < 1.2; extremely large effect: d ≥ 1.2); for count data, use Cramer's V (negligible effect: V < 0.1; small effect: 0.1 ≤ V < 0.3; moderate effect: 0.3 ≤ V < 0.5; large effect: V ≥ 0.5). Consider P < 0.05 as a statistically significant difference.

Results

Basic information
In this study, 120 patients with postoperative pain after arthroscopic elbow surgery from Hebei Cangzhou Hospital of Integrated Traditional Chinese and Western Medicine between December 2020 and December 2023 were divided into LA (n = 60) and LC (n = 60) groups based on different interventions. The baseline demographic and baseline characteristics of the patients in both groups are presented in Table 1, and these characteristics revealed no signifi...

Discussion

As one of the most mobile compound joints in the body, the elbow joint is susceptible to trauma, degeneration, and inflammatory diseases. According to epidemiological investigations, osteoarthritis, free body, and post-traumatic stiffness are the most common among different degrees of elbow dysfunction²². The prevalence of post-traumatic elbow stiffness is as high as 30%, and although traditional open surgery can release adhesions, it is traumatic, has a long recovery period, and carries a signifi...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Lidocaine	Shanghai Chaohui Pharmaceutical Co., Ltd	H31021071
NaCl	Shanghai Baxter Medical Supplies Co., Ltd.	H19983149
Epinephrine hydrochloride	Shanghai WoFeng Pharmaceutical Co., Ltd.	H31021062
Celecoxib capsule	Qingdao Baiyang Pharmaceutical Co., Ltd	H20203325
Beckman Coulter chemistry analyser	Beckman Coulter Inc.	AU5800