Received Date: November 14, 2011; Accepted Date: December 13, 2011; Published Date: December 20, 2011
Citation: Siavashi B, Bahador R, Zehtab MJ (2012) Effectiveness of Celecoxib and Acetaminophen after Anterior Crutiate Ligament Reconstruction. Orthopedic Muscul Sys 1: 104. doi: 10.4172/2161-0533.1000104
Copyright: © 2012 Siavashi B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Aim: To evaluate the analgesic efficacy of administering Celecoxib as a component of multimodal analgesia for patients undergoing anterior cruciate ligament reconstruction surgery.
Methods: We conducted a randomized double blind placebo controlled clinical trial and included all 90 patients who were going to treated with ACL reconstruction in Sina Hospital during 2009-2010. After obtaining written informed consent, we administered Celecoxib 400 mg and Acetaminophen 750 mg 1-2 hours preoperatively to one group (43 patients) and placebo and the same dosage of acetaminophen to the second (47 patients). Postoperatively, all patients received Acetaminophen 750 mg every 6 hours in addition to Celecoxib 200 mg every 12 hours for case group or placebo for controls. This analgesic regimen continued for duration of 2 weeks in which all patients participated in a aggressive rapid rehabilitation program. The patients were evaluated at the end of 2nd week and 6th month. Data analysis performed using SPSS.
Results: Patients of two groups were similar with respect to probable confounder variables such as age, sex, weight, level of activity, side of operated knee and the duration of operation. Patellofemoral complications were observed in 13 and 39 patients of case and control group, respectively. The difference was statistically significant. However, the difference between the rate of observed regional pain syndrome among patients of two groups were not statistically significant.
Conclusion: It seems that using Celecoxib as a component of multimodal analgesia leads to increase patient cooperation in participation to rehabilitation program and finally improve the outcomes.
ACL Tear; Reconstruction; Multimodal analgesia; Celecoxib
Todays, anterior cruciate ligament (ACL) reconstruction is a common operation. After surgery, there is sever pain in the knee region  which interfere with rehabilitation program of patient and can delay returning him or her to daily living or sport . If patient cannot participate in rehabilitation program in post operative period, some complications like muscle spasm, anterior knee pain and complex regional pain syndrome (CRPS) and delay in regaining preoperative muscle strength are anticipated [3-7].
Post operative pain may change from acute to chronic pain. Appropriate pain control in acute phase can inhibit formation of chronic pain [8,9]. Also, during operation pain impulses which received by pain centers in brain may the source of chronic pain in postoperative periods . Transient and short time pain relief is reported after administration of opiates during operation . The goal of some preventive regimens is eliminating pain during surgery and postoperative period not only during skin incision . Appropriate pain control can prevent both acute and chronic pain in postoperative period [13,14]. The aim of this study is evaluation of effectiveness celecoxib as a part of multimodal pain control on long term results of ACL reconstruction surgery.
It is a double blind clinical trial study. All patients who undergone fully arthroscopic ACL reconstruction with hamstring graft in 2010 in Sina hospital (Tehran , Iran) after a written consent based on Helsinki rules , enter this study (inclusion criteria). Previous knee surgery, osteotomies around knee, bilateral operations, chondral lesions, heart diseases, preoperative addiction to opiates and hypersensitivity to nonstriodal anti inflammatory drugs (NSAIDS) are exclusion criterias.
These patients are divided randomly to two groups. One group named case group receive 400 mg celecoxib and 750 mg acetaminophen 1 hour before operation. The other group named control group receive 750 mg acetaminophen and placebo 1 hour before surgery. Anesthesia induced with propofol (2 mg/kg) and fentanyl (2 micro gram/kg) and ketamin 30 mg and maintain with 30-50% NO2 gas inhalation. All of the patients receive 20cc intraarticular bupivacain 0.25% before skin suture. After operation, case group receive 200 mg celecoxib each 12 hours but in control group, they receive placebo in the same time intervals. Both groups receive 750 mg acetaminophen each 6 hours. This regimen continues for 2 weeks. All of them had rapid rehabilitation program. At the end of 2nd week and 6th month, patients are evaluated for patellofemoral complications (anterior knee pain, flexion contracture, quadriceps weakness and) and pain (Table 1). Patients are requested to clarify their pain in the first 2 weeks from 0 to 10 and bring the results in the first visit in the 2nd week with themselves. Examination in 2nd week and 6th month were about anterior knee pain, flexion contracture, quadriceps strength, knee range of motion and sign and symptoms of CRPS (Table 2). Results and findings are evaluated with chi-square and t- test with SPSS soft ware.
|% within Patellofemoral Complications||20.0%||80.0%||100.0%|
|% within Group||4.7%||17.0%||11.1%|
|% of Total||2.2%||8.9%||11.1%|
|Ant. Knee Pain||Count||10||28||38|
|% within Patellofemoral Complications||26.3%||73.7%||100.0%|
|% within Group||23.3%||59.6%||42.2%|
|% of Total||11.1%||31.1%||42.2%|
|% within Patellofemoral Complications||25.0%||75.0%||100.0%|
|% within Group||2.3%||6.4%||4.4%|
|% of Total||1.1%||3.3%||4.4%|
|% within Patellofemoral Complications||78.9%||21.1%||100.0%|
|% within Group||69.8%||17.0%||42.2%|
|% of Total||33.3%||8.9%||42.2%|
|% within Patellofemoral Complications||47.8%||52.2%||100.0%|
|% within Group||100.0%||100.0%||100.0%|
|% of Total||47.8%||52.2%||100.0%|
Sign and symptoms of CRPS were seen in 4 patients (9.3%) in case group and 8
patients (17%) in control group with no significant difference (p=0.360).
Failure of regaining full range of motion was seen in 2 patients (4.7%) in case group and in 14 patients (29.8%) in control group which is meaningful (p=0.002).
Table 1: Patellofemoral complications.
|% within Knee ROM||55.4%||44.6%||100.0%|
|% within Group||95.3%||70.2%||82.2%|
|% of Total||45.6%||36.7%||82.2%|
|% within Knee ROM||12.5%||87.5%||100.0%|
|% within Group||4.7%||29.8%||17.8%|
|% of Total||2.2%||15.6%||17.8%|
|% within Knee ROM||47.8%||52.2%||100.0%|
|% within Group||100.0%||100.0%||100.0%|
|% of Total||47.8%||52.2%||100.0%|
Table 2: Knee range of motion.
90 patients entered this study (43 in case group and 47 in control group). Average age in case and control groups were 33.9 year and 32.8year respectively. There were 5 female (11.6%) in case group and 7 female (14.9%) in control group. Average weight was 68.3 kg in case group and 68.4 kg in control group. So, there were no statistical meaningful difference regard age, sex, weight between two groups. Also, mechanism of injury was the same in both groups and average operation time in case group was 102 minutes and in control group was 102.9 minutes with no statistical difference (p=0.795).
Post operative patellofemoral complications were reported in 13 patients (30.2%) in case group and 39 patients (83%) in control group with a meaningful difference (p=0.000).
Patients who cannot participate in post operative rehabilitation program after arthroscopic ACL reconstruction are prone to complications such as anterior knee pain, knee stiffness, quadriceps weakness and chronic pain.
Studies documented that receiving pain killers in post operative period can decrease not only acute pain but also chronic pain . In 2007, Reabon SS et al. in a similar study on 200 patients showed that patellofemoral complications like anterior knee pain, flexion contracture and CRPS are lower in the group which received celecoxib and they return to athletic activity sooner .
Because single drug therapy for pain control has little role in controlling pain so there is more trend toward multi modal pain control regimens like NSAIDS, intraarticular anesthetics, cryotherapy and regional blocks [3-7].
In our study , there were no difference regard to confounding parameters such as age, sex, preoperative activity level and time of operation between case and control groups, so it can be concluded that difference between results (patellofemoral complications, anterior knee pain, quadriceps atrophy, restricted range of motion) are duo to celecoxib in case group.
Acetaminophen with cox2 inhibitors (like celecoxib) has synergistic effect on pain control and on the other hand, although opiates are useful in this manner, but there may be nausea in postoperative period with opioids.
So, it is safe and wise to use combination of acetaminophen and celecoxib before and after ACL reconstruction surgery.