Eur J Orthop Surg Traumatol (2014) 24:919–923 DOI 10.1007/s00590-013-1359-y
ORIGINAL ARTICLE
Efficacy of celecoxib for pain management after arthroscopic surgery of hip: a prospective randomized placebo-controlled study Zhenxiang Zhang • Wei Zhu • Lixian Zhu Yaqing Du
•
Received: 12 August 2013 / Accepted: 31 October 2013 / Published online: 13 November 2013 Ó Springer-Verlag France 2013
Abstract The present work was conducted to examine whether celecoxib, a selective COX-2 inhibitor, 200 mg administered 1 h preoperatively to patients undergoing arthroscopic hip surgery reduces postoperative pain. Fiftythree patients undergoing arthroscopic hip surgery under spinal anesthesia were randomized to receive either 200 mg of celecoxib (Group I) or 200 mg of placebo (Group II) 1 h preoperatively. Narcotic use was monitored for 24 h, and time in recovery room was determined. Visual analog scale (VAS) scores and Short-Form 12 (SF12), including a physical composite score (PCS) and a mental composite score (MCS), documented pain in recovery, 12 h postoperatively, and 24 h postoperatively. Moreover, time in recovery room was also investigated. We enrolled 27 patients in Group I and 26 patients in Group II. Groups were comparable for patient characteristics. No significant difference was detected in terms of VAS scores and SF-12 in recovery room. Statistically, patients in Group I showed significantly lower pain VAS scores at 12 and 24 h postoperatively. Patients taking celecoxib had significantly higher PCS at 12 and 24 h postoperatively. No difference occurred between groups for the MCS. Patients taking celecoxib also showed a significant reduction in postoperative narcotic consumption. The obtained results from the current study indicate that patients who took celecoxib 200 mg 1 h before arthroscopic hip surgery had a less painful and more rapid recovery. Celecoxib 200 mg as a single preoperative dose
Z. Zhang (&) W. Zhu L. Zhu Y. Du Orthopedic Department, The Affiliated Taizhou People’s Hospital of Nantong University, Taizhou 225300, Jiangsu, People’s Republic of China e-mail: [email protected]
could be considered as part of a perioperative analgesic plan in arthroscopic hip surgery. Keywords
Celecoxib Hip Arthroscopy Pain
Introduction Arthroscopy of the hip spares patients large incisions and decreases morbidity compared with those of open procedures, but it fails to eliminate pain. Unrelieved postoperative pain delays patient’s eligibility for discharge, leading to a prolonged hospital stay, inability to take part in rehabilitation programs, delayed recovery, poor outcome, and greater use of health-care resources. The activation of the cyclooxygenase (COX) inflammatory pathway is well established as a part of the body’s response to surgical trauma [1]. These prostaglandins activate peripheral nociceptors, resulting in central sensitization of pain symptoms [1]. Mechanistically, this provides a foundation for using nonsteroidal anti-inflammatory drugs (NSAIDs) as good candidates for adjunctive treatment of pain control [2, 3]. However, traditional NSAIDs have properties that limit their use in this indication. For instance, the use of nonselective NSAIDS, which inhibit both the COX-1 and COX-2 isoenzymes, may cause gastrointestinal (GI) and hematologic adverse events [4, 5]. Moreover, nonselective NSAIDS compromise platelet function and are associated with increased postoperative bleeding and wound hematoma [4, 5]. The COX-2 isoform is expressed at very low levels in normal tissues but is induced rapidly in tissues after surgery [6]. Selective inhibition of the COX-2 enzyme does not compromise platelet function, so it can be administered safely perioperatively with significant benefit in acute
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postoperative pain management [7]. It has been reported perioperative use of a COX-2 inhibitor can significantly reduce narcotic consumption and improve hip range of motion after hip surgery [8]. Celecoxib is a novel selective COX-2 inhibitor, which is structurally distinct from others in this class. It is rapidly absorbed and possesses good oral bioavailability and a short mean plasma half-life [9]. Celecoxib also differs from other selective COX-2 inhibitors in that it is acidic, which promotes its preferential distribution into inflamed tissue, and allows once-daily administration [9]. In clinical studies, the analgesic efficacy of celecoxib in patients with moderateto-severe pain has been demonstrated in several comparator trials [10–12]. An analysis of data from 2 randomized, double-blinded trials indicated that celecoxib was comparable with or superior to rofecoxib for the treatment of moderate pain [13]. Furthermore, in a randomized, doubleblinded pilot trial, celecoxib displayed similar efficacy for most end points but received significantly superior patient ratings compared with lumiracoxib, which is widely regarded as the first-choice analgesic agent for osteoarthritis pain [14]. Finally, it is indicated that celecoxib to be more effective in controlling pain when given preoperatively than when it was given postoperatively [15]. This prospective randomized placebo-controlled study is performed, for the first time in the literature, to determine whether celecoxib 200 mg administered 1 h preoperatively to patients undergoing arthroscopic hip surgery would reduce pain, provide a narcotic-sparing effect, and lead to a more rapid discharge from recovery.
Methods A total of fifty-three patients, 25 men and 28 women, with a median age of 31 years (range 22–51) undergoing arthroscopic surgery of hip were randomized to receive either 200 mg of celecoxib (Group I) or 200 mg of placebo (Group II) 1 h preoperatively to reduce postoperative pain. The surgery was performed between 2011 and 2012. The study was approved by the Regional Ethics Committee. All patients received written and oral information about the project and signed a written consent form. Fifty-three patients undergoing operative arthroscopy of the hip with femoroacetabular impingement and labral tears under spinal anesthesia were included in this study. Informed consent was obtained from all patients. The main exclusion criteria were hypersensitivity to the study medications, acetaminophen, antipyretics, or NSAIDs; evidence of cardiovascular or cerebrovascular disease; peptic ulceration or clinically significant gastrointestinal bleeding; hepatic, renal, pancreatic, gastrointestinal, or blood coagulation disorders; use of analgesic medication or methylphenidate
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hydrochloride within 48 h before surgery; use of alcoholcontaining beverages within the 24 h before surgery or midazolam as an anesthetic adjunct during surgery; use of other investigational drugs within 30 days or 10 half-lives before screening, whichever was longer; use of prohibited medications within the 2 weeks before surgery and until study completion (heparin or coumarin-type anticoagulants, tricyclic antidepressants, tranquilizers, muscle relaxants, lithium; and pregnant or lactating women). Under a randomized, prospective, observer-blind study design, subjects were sorted by random numbers into two groups. Group I received 200 mg of celecoxib 1 h before surgery. Group II received 200 mg placebo 1 h preoperatively. Tablets administered to the patients were of similar color, color, size, and taste to maintain authenticity with respect to the double-blinded nature of the study. All patients then underwent the procedure performed by one surgeon (Zhenxiang Zhang) who was blinded to which preoperative tablet was administered. Arthroscopic surgery of hip was performed under spinal anesthesia without using narcotic agents by the same anesthesiologist who was also blinded to which tablet had been administered. After surgery, patients were taken into recovery room and treated in a routine fashion. In the recovery room, patients were given pain medications if needed. When discharged, hydrocodone 5 mg/acetaminophen 500 mg was prescripted and instructed on its use. Baseline demographics including age, sex, weight, body mass index (BMI), weight, height, and time of surgery were recorded for each patient. Pain scores were measured using a visual analog scale (VAS), with 0 indicating no pain and 10 indicating the worst imaginable pain. Pain scores were checked by the same observer on discharge from the recovery room and at 12 and 24 h postoperatively. The standardized Short-Form 12 (SF-12) was given to each patient, which is a patient-reported general health questionnaire that determines both a physical composite score (PCS), measuring a patient’s overall physical abilities, and a mental composite score (MCS), evaluating a patient’s overall mental health. Narcotic usage was recorded by the same study nurse (Yaqing Du) in the recovery room. Time in the recovery room was recorded in minutes from the time the patient left the operating room until the discharge criteria were met. Patient demographics were analyzed by ANOVA or chisquare test. Pain scores and narcotic usage were analyzed by Mann–Whitney test. Significance was defined as p \ 0.05.
Results Table 1 lists the baseline demographics of the 53 patients successfully completing the study. There were no
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differences in demographics, duration of surgery, or time of surgery. There was a significant difference between the two groups with regard to VAS scores 12 h postoperatively (p \ 0.05) and 24 h postoperatively (p \ 0.05; Table 2). The SF-12 was used to monitor patient health status. Both PCS and MCS are reported (Table 2). PCS and MCS evaluated in the recovery room were similar between the two groups. Patients taking celecoxib had significantly higher PCS 12 h postoperatively (p \ 0.05) and 24 h postoperatively (p \ 0.05; Table 2). No difference occurred between groups for the MCS over the entire course of the study (p [ 0.05). Patients taking celecoxib required 147 min in recovery, and control patients taking a placebo required 152 min. No significant difference was detected between the two groups in terms of time in recovery (p [ 0.05).
Table 1 Comparison of baseline demographics Treatment group
Group I
Group II
p
Number
27
26
Age (year) Sex (F/M)
41.0 ± 4.9 (36.1–61.2) 13/11
43.5 ± 5.1 (37.8–62.1) 15/14
BMI (kg/m2)
33 ± 5.1 (22–56)
35 ± 4.9 (24–53)
[0.05
Weight (kg)
70 ± 15
72 ± 10
[0.05
Height (cm)
171 ± 6
168 ± 4
[0.05
Time of surgery (min)
67 ± 7
90 ± 3
[0.05
– [0.05 [0.05
Table 2 VAS scores, SF-36, number of narcotic usage, and number of minutes in recovery between Group I and Group II Group I
Group II
p value
VAS scores Recovery room
7.23
7.46
[0.05
12 h post-op
7.65
8.93
\0.05
24 h post-op
5.13
7.45
\0.05
PCS Recovery room
28.3 ± 3.2
29.1 ± 4.3
[0.05
12 h post-op
43.8 ± 4.1
35.3 ± 3.2
\0.05
24 h post-op
53.0 ± 6.2
42.2 ± 2.2
\0.05
MCS Recovery room
26.1 ± 2.9
28.9 ± 1.9
[0.05
12 h post-op
42.1 ± 3.5
40.2 ± 4.0
[0.05
57.2 ± 5.3
58.20 ± 4.1
[0.05
2.56 147
4.35 152
\0.05 [0.05
24 h post-op Narcotic usage (pills) Minutes in recovery
Discussion Hip surgery is usually associated with high level of postoperative pain and morbidity. Arthroscopy has decreased the amount of pain that patients experience, but pain still does exist. Pain after arthroscopic hip surgery is a major cause of patient dissatisfaction, suboptimal outcomes, delayed recovery, and delay in return to work. In addition, failure to control pain early may induce changes in the peripheral and central nervous system that amplify postoperative pain. Postoperative pain control of arthroscopic hip surgery has been an area of great interest, as evidenced by the recently accepted standard that pain control is considered a vital sign monitor. It is integral not only from a quality of life perspective for patients but also from a clinical standpoint, as it can have an influence in surgical outcomes. Adequate pain control has been demonstrated to improve clinical outcomes after arthroscopic surgery of hip. Multimodal pain management has been recommended for a relief of postoperative pain to reduce narcotic consumption by coadministering nonopioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) [2, 3, 5, 15, 16]. Ketorolac and opioid analgesic are the usual treatment of postoperative pain relief for arthroscopic surgery in our institution. The use of ketorolac, however, is associated with side effects such as bleeding, gastrointestinal (GI) injury, and renal toxicity. It has been suggested that newer NSAIDs that are more specifically inhibited cyclooxygenase (COX)-2 isoenzyme demonstrate analgesic efficacy equivalent to ketorolac while minimizing adverse effects [17, 18]. The administration of celecoxib, a selective COX-2 inhibitor, has been extensively researched [8, 9, 12, 19, 20]. Besides, a variety of studies indicated that celecoxib use demonstrated a relative risk of cardiovascular events equal to controls and significantly lower than several other NSAIDs [21]. Moreover, celecoxib was shown to be associated with a lower risk of both renal dysfunction and hypertension compared with other NSAIDs [22]. This randomized, double-blind, placebo-controlled study demonstrated a significant clinical benefit for patients to use the COX-2 inhibitor celecoxib 1 h preoperatively. Study patients taking celecoxib required statistically significantly fewer narcotics than placebo-controlled patients. Despite taking more narcotics, the control patients still had significantly higher VAS scores for pain. Furthermore, study patients taking celecoxib had better outcomes in terms of PCS. Besides, no significant difference was detected with regard to MCS and minutes in recovery. Perioperative administration of celecoxib as part of a multimodal approach to the management of postoperative pain maintains sufficient levels of COX-2 selective
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inhibitor in the tissue, thereby reducing the narcotic use postoperatively and allowing optimal recovery, while providing effective analgesia. Our data show that celecoxib provides similar analgesic and narcotic-sparing effects as those seen with other COX-2 selective inhibitors [10, 11, 23, 24]. Previous studies have shown that perioperative administration of the COX-2 selective inhibitors, valdecoxib [25] and parecoxib sodium [26], results in greater analgesic efficacy, reduced postoperative opioid use compared with opioid use alone. Patients who took celecoxib preoperatively obtained a significant reduction in terms of narcotic usage during the first hour postoperatively. This is an important finding because postoperative narcotic usage is usually lead to adverse effects such as sedation, nausea, and vomiting. Avoiding these adverse effects can make patients resume their daily activities and rehabilitation in a more timely fashion. Treatment of patients with a single dose of celecoxib is also a relatively cost-effective means of pain control. One dose costs approximately $1 and lasts for 24 h. The saved cost of delayed recovery resulting from suboptimal pain management should easily make up for the nominal cost of the drug. However, a large cost-saving measure would have been a decrease in time spent in recovery. However, as indicated by Table 2, no significant difference with regard to recovery times was detected. In a work comparing postoperative pain relief with celecoxib, it was reported that a 200-mg preoperative dose was most effective compared with a 200-mg postoperative dose in patients who received intra-articular injections and conscious sedation as anesthesia during the procedures [10]. In our present study, a preoperative regimen was chosen only. Our study differs in terms of the type of anesthesia induced (spinal), the spectrum of procedures performed, and variables, such as recovery room time, that were explored, especially important to the surgeon is the reduced risk of bleeding with celecoxib. In addition, its effectiveness in postoperative pain has been shown in dental surgery, spine surgery, and total knee arthroplasty. The rapid clinical onset and long half-life of celecoxib make this drug desirable for perioperative use. The authors acknowledge that this investigation has some limitations. First, the number of patients was small, and the results might be different from studies with larger sample sizes. Second, although we obtained VAS scores, the utility of SF-12 scores to determine functional outcome has been criticized [27]. Whereas the SF-12 score has been validated, in 2013 other validated, condition-specific, clinical outcome scores may be preferred. However, when we commenced data collection, SF-12 scores were customary and their use allowed preoperative and postoperative comparisons. Finally, an ideal study design would require comparison in the same patient, to eliminate bias
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due to individual variability, while in the present work, comparison was taken in different individuals.
Conclusion Based on the results obtained from the present, it can be indicated that celecoxib 200 mg administered in one dose preoperatively is effective in reducing postoperative pain and provides a narcotic-sparing effect in patients undergoing arthroscopy hip surgery. The results of this study should lead surgeons who perform hip arthroscopy to consider using celecoxib as part of a multimodal analgesia plan. Conflict of interest
None.
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923 21. Wong SYS, Wong KYK, Wie L, Ogston SA, MacDonald TM (2003) Randomised, crossover study comparing celecoxib with nonselective NSAIDs on ambulatory blood pressure of treated hypertensive patients. Am J Hypertens 16(5):65 22. Whalton A (2000) The celecoxib long-term safety study (CLASS): celecoxib is associated with less renal toxicity compared to conventional NSAIDs. Am J Gastroenterol 95(9):2644 23. Malmstrom K, Fricke JR, Kotey P, Kress B, Morrison B (2002) A comparison of rofecoxib versus celecoxib in treating pain after dental surgery: a single-center, randomized, double-blind, placebo- and active-comparator-controlled, parallel-group, singledose study using the dental impaction pain model. Clin Ther 24(10):1549–1560 24. Huang YM, Wang CM, Wang CT, Lin WP, Horng LC, Jiang CC (2008) Perioperative celecoxib administration for pain management after total knee arthroplasty-a randomized, controlled study. BMC Musculoskeletal Disorders 9:77–82 25. Chavez ML, DeKorte CJ (2003) Valdecoxib: a review. Clin Ther 25(3):817–851 26. Lee LH, Irwin MG, Yao TJ, Yuen MK, Cheung CW (2008) Timing of intraoperative parecoxib analgesia in colorectal surgery. Acute Pain 10(3):23–130 27. Kiely JM, Brasel KJ, Guse CE, John A (2006) Weigelt correlation of SF-12 and SF-36 in a trauma population. J Surg Res 132(2):214–218
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ORIGINAL ARTICLE
Efficacy of celecoxib for pain management after arthroscopic surgery of hip: a prospective randomized placebo-controlled study Zhenxiang Zhang • Wei Zhu • Lixian Zhu Yaqing Du
•
Received: 12 August 2013 / Accepted: 31 October 2013 / Published online: 13 November 2013 Ó Springer-Verlag France 2013
Abstract The present work was conducted to examine whether celecoxib, a selective COX-2 inhibitor, 200 mg administered 1 h preoperatively to patients undergoing arthroscopic hip surgery reduces postoperative pain. Fiftythree patients undergoing arthroscopic hip surgery under spinal anesthesia were randomized to receive either 200 mg of celecoxib (Group I) or 200 mg of placebo (Group II) 1 h preoperatively. Narcotic use was monitored for 24 h, and time in recovery room was determined. Visual analog scale (VAS) scores and Short-Form 12 (SF12), including a physical composite score (PCS) and a mental composite score (MCS), documented pain in recovery, 12 h postoperatively, and 24 h postoperatively. Moreover, time in recovery room was also investigated. We enrolled 27 patients in Group I and 26 patients in Group II. Groups were comparable for patient characteristics. No significant difference was detected in terms of VAS scores and SF-12 in recovery room. Statistically, patients in Group I showed significantly lower pain VAS scores at 12 and 24 h postoperatively. Patients taking celecoxib had significantly higher PCS at 12 and 24 h postoperatively. No difference occurred between groups for the MCS. Patients taking celecoxib also showed a significant reduction in postoperative narcotic consumption. The obtained results from the current study indicate that patients who took celecoxib 200 mg 1 h before arthroscopic hip surgery had a less painful and more rapid recovery. Celecoxib 200 mg as a single preoperative dose
Z. Zhang (&) W. Zhu L. Zhu Y. Du Orthopedic Department, The Affiliated Taizhou People’s Hospital of Nantong University, Taizhou 225300, Jiangsu, People’s Republic of China e-mail: [email protected]
could be considered as part of a perioperative analgesic plan in arthroscopic hip surgery. Keywords
Celecoxib Hip Arthroscopy Pain
Introduction Arthroscopy of the hip spares patients large incisions and decreases morbidity compared with those of open procedures, but it fails to eliminate pain. Unrelieved postoperative pain delays patient’s eligibility for discharge, leading to a prolonged hospital stay, inability to take part in rehabilitation programs, delayed recovery, poor outcome, and greater use of health-care resources. The activation of the cyclooxygenase (COX) inflammatory pathway is well established as a part of the body’s response to surgical trauma [1]. These prostaglandins activate peripheral nociceptors, resulting in central sensitization of pain symptoms [1]. Mechanistically, this provides a foundation for using nonsteroidal anti-inflammatory drugs (NSAIDs) as good candidates for adjunctive treatment of pain control [2, 3]. However, traditional NSAIDs have properties that limit their use in this indication. For instance, the use of nonselective NSAIDS, which inhibit both the COX-1 and COX-2 isoenzymes, may cause gastrointestinal (GI) and hematologic adverse events [4, 5]. Moreover, nonselective NSAIDS compromise platelet function and are associated with increased postoperative bleeding and wound hematoma [4, 5]. The COX-2 isoform is expressed at very low levels in normal tissues but is induced rapidly in tissues after surgery [6]. Selective inhibition of the COX-2 enzyme does not compromise platelet function, so it can be administered safely perioperatively with significant benefit in acute
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postoperative pain management [7]. It has been reported perioperative use of a COX-2 inhibitor can significantly reduce narcotic consumption and improve hip range of motion after hip surgery [8]. Celecoxib is a novel selective COX-2 inhibitor, which is structurally distinct from others in this class. It is rapidly absorbed and possesses good oral bioavailability and a short mean plasma half-life [9]. Celecoxib also differs from other selective COX-2 inhibitors in that it is acidic, which promotes its preferential distribution into inflamed tissue, and allows once-daily administration [9]. In clinical studies, the analgesic efficacy of celecoxib in patients with moderateto-severe pain has been demonstrated in several comparator trials [10–12]. An analysis of data from 2 randomized, double-blinded trials indicated that celecoxib was comparable with or superior to rofecoxib for the treatment of moderate pain [13]. Furthermore, in a randomized, doubleblinded pilot trial, celecoxib displayed similar efficacy for most end points but received significantly superior patient ratings compared with lumiracoxib, which is widely regarded as the first-choice analgesic agent for osteoarthritis pain [14]. Finally, it is indicated that celecoxib to be more effective in controlling pain when given preoperatively than when it was given postoperatively [15]. This prospective randomized placebo-controlled study is performed, for the first time in the literature, to determine whether celecoxib 200 mg administered 1 h preoperatively to patients undergoing arthroscopic hip surgery would reduce pain, provide a narcotic-sparing effect, and lead to a more rapid discharge from recovery.
Methods A total of fifty-three patients, 25 men and 28 women, with a median age of 31 years (range 22–51) undergoing arthroscopic surgery of hip were randomized to receive either 200 mg of celecoxib (Group I) or 200 mg of placebo (Group II) 1 h preoperatively to reduce postoperative pain. The surgery was performed between 2011 and 2012. The study was approved by the Regional Ethics Committee. All patients received written and oral information about the project and signed a written consent form. Fifty-three patients undergoing operative arthroscopy of the hip with femoroacetabular impingement and labral tears under spinal anesthesia were included in this study. Informed consent was obtained from all patients. The main exclusion criteria were hypersensitivity to the study medications, acetaminophen, antipyretics, or NSAIDs; evidence of cardiovascular or cerebrovascular disease; peptic ulceration or clinically significant gastrointestinal bleeding; hepatic, renal, pancreatic, gastrointestinal, or blood coagulation disorders; use of analgesic medication or methylphenidate
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hydrochloride within 48 h before surgery; use of alcoholcontaining beverages within the 24 h before surgery or midazolam as an anesthetic adjunct during surgery; use of other investigational drugs within 30 days or 10 half-lives before screening, whichever was longer; use of prohibited medications within the 2 weeks before surgery and until study completion (heparin or coumarin-type anticoagulants, tricyclic antidepressants, tranquilizers, muscle relaxants, lithium; and pregnant or lactating women). Under a randomized, prospective, observer-blind study design, subjects were sorted by random numbers into two groups. Group I received 200 mg of celecoxib 1 h before surgery. Group II received 200 mg placebo 1 h preoperatively. Tablets administered to the patients were of similar color, color, size, and taste to maintain authenticity with respect to the double-blinded nature of the study. All patients then underwent the procedure performed by one surgeon (Zhenxiang Zhang) who was blinded to which preoperative tablet was administered. Arthroscopic surgery of hip was performed under spinal anesthesia without using narcotic agents by the same anesthesiologist who was also blinded to which tablet had been administered. After surgery, patients were taken into recovery room and treated in a routine fashion. In the recovery room, patients were given pain medications if needed. When discharged, hydrocodone 5 mg/acetaminophen 500 mg was prescripted and instructed on its use. Baseline demographics including age, sex, weight, body mass index (BMI), weight, height, and time of surgery were recorded for each patient. Pain scores were measured using a visual analog scale (VAS), with 0 indicating no pain and 10 indicating the worst imaginable pain. Pain scores were checked by the same observer on discharge from the recovery room and at 12 and 24 h postoperatively. The standardized Short-Form 12 (SF-12) was given to each patient, which is a patient-reported general health questionnaire that determines both a physical composite score (PCS), measuring a patient’s overall physical abilities, and a mental composite score (MCS), evaluating a patient’s overall mental health. Narcotic usage was recorded by the same study nurse (Yaqing Du) in the recovery room. Time in the recovery room was recorded in minutes from the time the patient left the operating room until the discharge criteria were met. Patient demographics were analyzed by ANOVA or chisquare test. Pain scores and narcotic usage were analyzed by Mann–Whitney test. Significance was defined as p \ 0.05.
Results Table 1 lists the baseline demographics of the 53 patients successfully completing the study. There were no
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differences in demographics, duration of surgery, or time of surgery. There was a significant difference between the two groups with regard to VAS scores 12 h postoperatively (p \ 0.05) and 24 h postoperatively (p \ 0.05; Table 2). The SF-12 was used to monitor patient health status. Both PCS and MCS are reported (Table 2). PCS and MCS evaluated in the recovery room were similar between the two groups. Patients taking celecoxib had significantly higher PCS 12 h postoperatively (p \ 0.05) and 24 h postoperatively (p \ 0.05; Table 2). No difference occurred between groups for the MCS over the entire course of the study (p [ 0.05). Patients taking celecoxib required 147 min in recovery, and control patients taking a placebo required 152 min. No significant difference was detected between the two groups in terms of time in recovery (p [ 0.05).
Table 1 Comparison of baseline demographics Treatment group
Group I
Group II
p
Number
27
26
Age (year) Sex (F/M)
41.0 ± 4.9 (36.1–61.2) 13/11
43.5 ± 5.1 (37.8–62.1) 15/14
BMI (kg/m2)
33 ± 5.1 (22–56)
35 ± 4.9 (24–53)
[0.05
Weight (kg)
70 ± 15
72 ± 10
[0.05
Height (cm)
171 ± 6
168 ± 4
[0.05
Time of surgery (min)
67 ± 7
90 ± 3
[0.05
– [0.05 [0.05
Table 2 VAS scores, SF-36, number of narcotic usage, and number of minutes in recovery between Group I and Group II Group I
Group II
p value
VAS scores Recovery room
7.23
7.46
[0.05
12 h post-op
7.65
8.93
\0.05
24 h post-op
5.13
7.45
\0.05
PCS Recovery room
28.3 ± 3.2
29.1 ± 4.3
[0.05
12 h post-op
43.8 ± 4.1
35.3 ± 3.2
\0.05
24 h post-op
53.0 ± 6.2
42.2 ± 2.2
\0.05
MCS Recovery room
26.1 ± 2.9
28.9 ± 1.9
[0.05
12 h post-op
42.1 ± 3.5
40.2 ± 4.0
[0.05
57.2 ± 5.3
58.20 ± 4.1
[0.05
2.56 147
4.35 152
\0.05 [0.05
24 h post-op Narcotic usage (pills) Minutes in recovery
Discussion Hip surgery is usually associated with high level of postoperative pain and morbidity. Arthroscopy has decreased the amount of pain that patients experience, but pain still does exist. Pain after arthroscopic hip surgery is a major cause of patient dissatisfaction, suboptimal outcomes, delayed recovery, and delay in return to work. In addition, failure to control pain early may induce changes in the peripheral and central nervous system that amplify postoperative pain. Postoperative pain control of arthroscopic hip surgery has been an area of great interest, as evidenced by the recently accepted standard that pain control is considered a vital sign monitor. It is integral not only from a quality of life perspective for patients but also from a clinical standpoint, as it can have an influence in surgical outcomes. Adequate pain control has been demonstrated to improve clinical outcomes after arthroscopic surgery of hip. Multimodal pain management has been recommended for a relief of postoperative pain to reduce narcotic consumption by coadministering nonopioid analgesics such as nonsteroidal anti-inflammatory drugs (NSAIDs) [2, 3, 5, 15, 16]. Ketorolac and opioid analgesic are the usual treatment of postoperative pain relief for arthroscopic surgery in our institution. The use of ketorolac, however, is associated with side effects such as bleeding, gastrointestinal (GI) injury, and renal toxicity. It has been suggested that newer NSAIDs that are more specifically inhibited cyclooxygenase (COX)-2 isoenzyme demonstrate analgesic efficacy equivalent to ketorolac while minimizing adverse effects [17, 18]. The administration of celecoxib, a selective COX-2 inhibitor, has been extensively researched [8, 9, 12, 19, 20]. Besides, a variety of studies indicated that celecoxib use demonstrated a relative risk of cardiovascular events equal to controls and significantly lower than several other NSAIDs [21]. Moreover, celecoxib was shown to be associated with a lower risk of both renal dysfunction and hypertension compared with other NSAIDs [22]. This randomized, double-blind, placebo-controlled study demonstrated a significant clinical benefit for patients to use the COX-2 inhibitor celecoxib 1 h preoperatively. Study patients taking celecoxib required statistically significantly fewer narcotics than placebo-controlled patients. Despite taking more narcotics, the control patients still had significantly higher VAS scores for pain. Furthermore, study patients taking celecoxib had better outcomes in terms of PCS. Besides, no significant difference was detected with regard to MCS and minutes in recovery. Perioperative administration of celecoxib as part of a multimodal approach to the management of postoperative pain maintains sufficient levels of COX-2 selective
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inhibitor in the tissue, thereby reducing the narcotic use postoperatively and allowing optimal recovery, while providing effective analgesia. Our data show that celecoxib provides similar analgesic and narcotic-sparing effects as those seen with other COX-2 selective inhibitors [10, 11, 23, 24]. Previous studies have shown that perioperative administration of the COX-2 selective inhibitors, valdecoxib [25] and parecoxib sodium [26], results in greater analgesic efficacy, reduced postoperative opioid use compared with opioid use alone. Patients who took celecoxib preoperatively obtained a significant reduction in terms of narcotic usage during the first hour postoperatively. This is an important finding because postoperative narcotic usage is usually lead to adverse effects such as sedation, nausea, and vomiting. Avoiding these adverse effects can make patients resume their daily activities and rehabilitation in a more timely fashion. Treatment of patients with a single dose of celecoxib is also a relatively cost-effective means of pain control. One dose costs approximately $1 and lasts for 24 h. The saved cost of delayed recovery resulting from suboptimal pain management should easily make up for the nominal cost of the drug. However, a large cost-saving measure would have been a decrease in time spent in recovery. However, as indicated by Table 2, no significant difference with regard to recovery times was detected. In a work comparing postoperative pain relief with celecoxib, it was reported that a 200-mg preoperative dose was most effective compared with a 200-mg postoperative dose in patients who received intra-articular injections and conscious sedation as anesthesia during the procedures [10]. In our present study, a preoperative regimen was chosen only. Our study differs in terms of the type of anesthesia induced (spinal), the spectrum of procedures performed, and variables, such as recovery room time, that were explored, especially important to the surgeon is the reduced risk of bleeding with celecoxib. In addition, its effectiveness in postoperative pain has been shown in dental surgery, spine surgery, and total knee arthroplasty. The rapid clinical onset and long half-life of celecoxib make this drug desirable for perioperative use. The authors acknowledge that this investigation has some limitations. First, the number of patients was small, and the results might be different from studies with larger sample sizes. Second, although we obtained VAS scores, the utility of SF-12 scores to determine functional outcome has been criticized [27]. Whereas the SF-12 score has been validated, in 2013 other validated, condition-specific, clinical outcome scores may be preferred. However, when we commenced data collection, SF-12 scores were customary and their use allowed preoperative and postoperative comparisons. Finally, an ideal study design would require comparison in the same patient, to eliminate bias
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due to individual variability, while in the present work, comparison was taken in different individuals.
Conclusion Based on the results obtained from the present, it can be indicated that celecoxib 200 mg administered in one dose preoperatively is effective in reducing postoperative pain and provides a narcotic-sparing effect in patients undergoing arthroscopy hip surgery. The results of this study should lead surgeons who perform hip arthroscopy to consider using celecoxib as part of a multimodal analgesia plan. Conflict of interest
None.
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