- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT03090152
Minimal Opioid Use After Total Hip Replacement (THR)
July 26, 2022 updated by: Hospital for Special Surgery, New York
Minimal Opioid Use After Total Hip Replacement (THR): a Blinded Randomized Placebo-controlled Study
Total hip arthroplasty can be associated with significant postoperative pain.
Side effects of pain management may impair participation in physical therapy and slow readiness for discharge from the hospital.
In a previous study done by the investigators' group, epidural patient controlled analgesia (EPCA) with a hydromorphone containing solution appeared to have a more favorable pain profile with ambulation, but greater side effects compared to injection of a peri-articular cocktail.
The use of opioid was greater in the peri-articular injection group (PAI).
There was no difference in length of stay.
In view of the controversy over opioid use, the investigators would like to develop an optimal opioid sparing pain management approach by comparing 3 different protocols 1) Plain local anesthetic EPCA; 2) PAI; 3) EPCA + PAI; all in conjunction with a multimodal opioid sparing pain regimen.
The goal would be to maximize pain control while minimizing opioid use and side-effects.
Study Overview
Status
Completed
Conditions
Detailed Description
Long acting narcotics or scheduled doses of narcotics are often used as part of a multimodal pain regimen.
In this study, this is eliminated.
Instead, it uses a cocktail of different drugs including intraoperative Ketamine use (NMDA receptor antagonist), intra-op Benadryl (to decrease excitation of nociceptors) and IV Tylenol.
The narcotic free regimen starts preoperatively with the use of Aspirin,Clonidine patch, Cymbalta (Duloxetine), and is maintained both intraoperatively and post operatively.
Baby ASA (81mg) is being used as an anti-inflammatory agent.
A number of studies including the one by Morris et al. (2009), have shown via in vitro experiments that low dose aspirin decreases polymorphonuclear leukocyte and macrophage accumulation.
It inhibits thromboxane making it an antithrombotic agent as well.
The concern with aspirin has been major bleeding.
Several studies in the orthopedic patient population using ≤81 mg of aspirin have shown that it does not increase bleeding (Cuellar, Mantz).
At HSS, patients are routinely continued on baby aspirin when needed for its cardio protective effect.
Devereaux in the POISE trial did show an increased risk of bleeding when ASA was given preoperatively at a dose of 200 mg.
In our study, all patients will be given intravenous tranexamic acid which should mitigate against the risk of bleeding.
Duloxetine is also being added.
In a recent study done at HSS. Duloxetine was found to decrease the amount of opioid use and nausea.
If found to be more effective with the use of EPCA vs. PAI or combination of the two, a new way of managing postop pain while minimizing Nnartcuoreti co fu Ssetu adsy per CDC recommendation will be helpful in managing patients post-operatively.
Study Type
Interventional
Enrollment (Actual)
180
Phase
- Phase 4
Contacts and Locations
This section provides the contact details for those conducting the study, and information on where this study is being conducted.
Study Locations
-
-
New York
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New York, New York, United States, 10021
- Hospital for Special Surgery
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-
Participation Criteria
Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.
Eligibility Criteria
Ages Eligible for Study
50 years to 75 years (Adult, Older Adult)
Accepts Healthy Volunteers
No
Genders Eligible for Study
All
Description
Inclusion Criteria:
- Any patient with osteoarthritis scheduled for primary total hip arthroplasty with a participating surgeon
- Planned use of regional anesthesia
- Planned posterolateral surgical approach
- Age Range 45-80
- Ability to follow study protocol
Exclusion Criteria:
- Any patient with age <45 or >80
- Any patient with planned anterior surgical approach
- Any patient with prior major ipsilateral hip surgery
- Any patient intending to receive general anesthesia
- Any patient with an ASA of IV
- Any patient with insulin-dependent diabetes
- Any patient with hepatic (liver) failure (history of cirrhosis or elevated LFT's)
- Any patient with chronic renal (kidney) failure (formal diagnosis of renal disease of elevated creatinine)
- Any patient with history of gastric (stomach) ulcer
- Chronic opioid use (taking opioids for >3 mo duration on a daily basis)
- Chronic analgesic use (i.e. lyrica, gabapentin) for >3 mo duration
- Stress dose steroids
- Use of antidepressants
- Contraindications to aspirin
- Allergy to any of the medications (or adhesives) involved in the study protocol
- Dementia
- Non-English speakers.
Study Plan
This section provides details of the study plan, including how the study is designed and what the study is measuring.
How is the study designed?
Design Details
- Primary Purpose: Treatment
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: Triple
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Periarticular Injection (PAI)
|
Deep injection of "cocktail" containing Bupivacaine with Epi, 30mL; Morphine, 8mg/mL, 1mL; Methyprednislone, 40mg/mL, 1mL; Cefazolin, 500mg in 10 mL; saline, 22mL into the anterior capsule, the periosteum, the gluteus maximus, and the abductor muscles and fascia lata.
Superficial injection of 40mL 0.25% Bupivacaine into subcutaneous tissue prior to wound closure.
EPCA: Saline.
|
Active Comparator: Epidural Patient-Controlled Analg (EPCA)
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EPCA: Bupivacaine 0.06%.
|
Experimental: PAI + EPCA
|
Deep injection of "cocktail" containing Bupivacaine with Epi, 30mL; Morphine, 8mg/mL, 1mL; Methyprednislone, 40mg/mL, 1mL; Cefazolin, 500mg in 10 mL; saline, 22mL into the anterior capsule, the periosteum, the gluteus maximus, and the abductor muscles and fascia lata.
Superficial injection of 40mL 0.25% Bupivacaine into subcutaneous tissue prior to wound closure.
EPCA: Bupivacaine 0.06%.
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Opioid Use
Time Frame: within 24 hours after surgery
|
Oral morphine equivalents, cumulative
|
within 24 hours after surgery
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Pain at Rest
Time Frame: Postoperative Day 1,2,3,7,90
|
NRS (Numeric Pain Rating Scale).
0 means no pain, 10 means worst pain imaginable.
A lower score is a better outcome.
|
Postoperative Day 1,2,3,7,90
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Pain With Activity
Time Frame: Postoperative Day 1,2,3,7,90
|
NRS (Numeric Pain Rating Scale).
0 means no pain, 10 means worst pain imaginable.
A lower score is a better outcome.
|
Postoperative Day 1,2,3,7,90
|
Opioid Side Effects
Time Frame: Postoperative Day 1,2
|
via ORSDS (Opioid-Related Symptom Distress Scale).
Each symptom was rated on a 4 point scale from 0-4.
A lower score is a better outcome.
|
Postoperative Day 1,2
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Patient Satisfaction
Time Frame: Postoperative Day 1,2,3,7
|
via Likert scale.
A higher score is a better outcome.
the scale is from 0-10.
|
Postoperative Day 1,2,3,7
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Post-operative Pain
Time Frame: Postoperative Day 1
|
via PAINOUT (Improvement in postoperative PAIN OUTcome) Minumum value is zero, maximum is ten.
Higher scores mean worse outcomes.
|
Postoperative Day 1
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Neuropathic Pain Assessed With S-LANSS
Time Frame: Postoperative Day 7, Postoperative Day 90
|
via S-LANSS (Self-report Leeds Assessment of Neuropathic Symptoms and Signs).
Scores range from 0-24.
A lower score is a better outcome.
|
Postoperative Day 7, Postoperative Day 90
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Quality of Recovery
Time Frame: Postoperative Day 1,2,3
|
Via QoR-40 (Quality of Recovery).
Minimum value of 40, maximum of 200.
Higher values mean better outcome
|
Postoperative Day 1,2,3
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Readiness for Discharge Time
Time Frame: From end of surgery until the date/time of first documented clearance for discharge, assessed up to 1 week.
|
When patient meets all readiness for discharge criteria
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From end of surgery until the date/time of first documented clearance for discharge, assessed up to 1 week.
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Blinding Assessment
Time Frame: Assessed on day of discharge and on seventh post operative day
|
What group do you think you were in
|
Assessed on day of discharge and on seventh post operative day
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Opioid Consumption During the First 3 Days Post-op
Time Frame: Postoperative day 0,1,2,3
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Opioids consumed in the first 3 after surgery (cumulative consumption).
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Postoperative day 0,1,2,3
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No Opioids Consumed
Time Frame: 0 to 24 hours post-operatively
|
Number of patients who did not consume any opioids
|
0 to 24 hours post-operatively
|
Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Investigators
- Principal Investigator: Kethy Jules-Elysee, MD, Hospital for Special Surgery, New York
Study record dates
These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.
Study Major Dates
Study Start (Actual)
March 8, 2017
Primary Completion (Actual)
June 28, 2019
Study Completion (Actual)
September 27, 2019
Study Registration Dates
First Submitted
March 13, 2017
First Submitted That Met QC Criteria
March 20, 2017
First Posted (Actual)
March 24, 2017
Study Record Updates
Last Update Posted (Actual)
July 27, 2022
Last Update Submitted That Met QC Criteria
July 26, 2022
Last Verified
July 1, 2022
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- 2016-0721
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Yes
Studies a U.S. FDA-regulated device product
No
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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