Full text of DOI:10.1007/BF03018916

220
REPORTS OF INVESTIGATION
Diclofenac premedica-
tion but not intra-articu-
lar ropivacaine alleviates
pain following day-case
knee arthroscopy
Pekka Rautoma MD PhD,
Ulla Santanen MD,
Risto Avela MD,
Harri Luurila MD PhD,
Vesa Perhoniemi MD PhD,
Olli Erkola MD PhD
Purpose: To compare the postoperative analgesic effects of 50 mg diclofenac po before surgery and intra-articu-
lar ropivacaine injected after diagnostic day-case knee arthroscopy performed under spinal anesthesia.
Methods: In a randomized, double-blind investigation, 200 ASA physical status 1-2 outpatients, age 18-60 yr,
received either 50 mg diclofenac po or placebo one hour before operation (100 patients per group), and intra-
articular injections of either 20 ml of ropivacaine 0.5% or 20 ml of saline 0.9% (50 patients in each premedication
groups). Patients received 50 mg diclofenac po prn and, if needed, 0.1 mg·kg–1 oxycodone im for postoperative pain
relief. Patients were discharged home with a supply of 50 mg diclofenac tablets and were given a sheet of paper
with knee pain VAS scales and a questionnaire of analgesics taken. Patients rated their VAS scores eight hours after
surgery and in the morning and at the end of the first and the second postoperative days, respectively.
Results: The only statistically significant difference was found when the diclofenac groups were combined and
compared with the combined placebo premedication groups. The VAS scores of knee pain at eight hours after
the operation were 19 ± 22 in the two diclofenac premedication groups and 32 ± 28 in the two placebo groups
(P=0.001).
Conclusions: Diclofenac premedication po reduced the VAS scores at eight hours postoperatively while intra-
articular ropivacaine did not.
Objectif : Comparer les effets analgésiques postopératoires de 50 mg de diclofénac po, administrés avant
l’opération, à la ropivacaïne intra-articulaire, donnée après l’arthroscopie diagnostique sous rachianesthésie.
Méthode : Lors d’une étude randomisée et en double aveugle, 200 patients d’état physique ASA I-II, âgés de
18-60 ans, ont reçu 50 mg de diclofénac po ou un placebo une heure avant l’opération (100 patients par groupe),
et une injection intra-articulaire de 20 ml de ropivacaïne 0,5 % ou 20 ml de solution salée 0,9 % (50 patients
dans chaque groupe de prémédication). Les patients ont reçu 50 mg de diclofénac po prn et, si nécessaire, 0,1
mg·kg–1 d’oxycodone im pour soulager la douleur postopératoire. À leur départ, ils ont reçu des comprimés de
50 mg de diclofénac, un questionnaire concernant la prise d’analgésiques et une feuille de papier où inscrire le
niveau de douleur au genou selon l’EVA. Les patients ont estimé leurs scores à l’EVA huit heures après l’opéra-
tion et au début et à la fin du premier et du deuxième jours postopératoires, respectivement.
Résultats : La seule différence statistique significative a été trouvée en combinant les groupes de diclofénac et en
les comparant aux groupes combinés de prémédication placebo. Les scores postopératoires de l’EVA ont été de
19 ± 22 dans les deux groupes qui ont reçu une prémédication de diclofénac et de 32 ± 28 dans les groupes
qui ont reçu le placebo (P=0,001).
Conclusion : La prémédication au diclofénac po a réduit les scores postopératoires de l’EVA à huit heures, mais
non pas la ropivacaïne intra-articulaire.
From the Department of Anesthesia, Helsinki City Hospital, Helsinki, Finland.
Address correspondence to: Pekka Rautoma MD PhD, Department of Anesthesia, Maria Hospital, Lapinlahdenkatu 16, 00180 Helsinki,
Finland. Fax: +358-9-31063378; E-mail: rautoma@dlc.fi
Accepted for publication November 26, 1999
CAN J ANESTH 2000 / 47: 3 / pp 220–224

Rautoma et al.: DICLOFENAC PREMEDICATIONA N D INTRA-ARTICULAR ROPIVACAINE
221
NTRA-ARTICULAR bupivacaine has been
shown in some studies to provide postoperative
analgesia after knee arthroscopy,1–8 but others
the authors or the nurses. Patients also were asked if
they had postoperative nausea, vomiting or difficulty in
voiding urine. We provided a stamped, addressed enve-
lope in which the patients could return the completed
data sheets.
8–11
I
have failed to demonstrate such an effect.
These investigations have been performed in healthy
patients under general, spinal (subarachnoidal),
epidural or local anesthesia. Some authors have used
intraoperative opioids, some have used premedication,
and the amount of bupivacaine administered has been
different between the studies. Therefore, the results of
these studies cannot be directly compared. Also, it is
unclear how much postoperative analgesia is provided
by diclofenac premedication.
Ropivacaine has similar pharmacodynamic and
pharmacokinetic properties to bupivacaine but is less
prone to elicit central nervous system or circulatory
adverse effects.12–15 The present study was designed to
examine the postoperative analgesic effect of intra-
articular ropivacaine injected after diagnostic day-case
knee arthroscopy performed under spinal anesthesia.
We also investigated the effect of 50 mg diclofenac
given po one hour before the arthroscopy.
In a double-blind, randomized investigation, 200
patients received either 50 mg diclofenac (Voltaren®,
Novartis Ltd) or a placebo pill (Placebo®, Leiras,
Finland) one hour before spinal anesthesia. The person
who administered the premedication had nothing fur-
ther to do with the patient. There were 100 patients in
each premedication groups. All patients received spinal
anesthesia with 1.5-2.5 ml hyperbaric 0.5% bupivacaine
through a #27 gauge spinal needle with a 22 gauge
introducer. We did not use local anesthesia to the skin. If
the patient was very afraid of the skin puncture, nervous
or unhappy and requested premedication, a bolus dose
of 0.5 mg alfentanil was given as a rescue premedication.
The number of patients receiving alfentanil was record-
ed. Routine monitoring was used. In addition, patients
were randomized to receive, in a double-blind fashion,
intra-articular injection of either 20 ml ropivacaine 0.5%
(Naropin®, Astra Ltd) or 20 ml saline 0.9% through the
arthroscope at the end of knee arthroscopy, ten minutes
before release of the tourniquet. Fifty patients in each
premedication (diclofenac or placebo) group received
ropivacaine, and the remaining 50 patients in each pre-
medication group received saline 0.9% intra-articularly.
When needed, patients received 50 mg diclofenac
po for postoperative pain relief. If this did not give
enough help, patients also received 0.1 mg·kg–1 oxy-
codone im. Patients were discharged home with a sup-
ply of 50 mg diclofenac tablets to be taken prn to a
maximum of four tablets per 24 hr. The postoperative
need for analgesics was recorded in the recovery
room, at the ward and at home.
Materials and methods
The project was institutionally approved, and written
informed consent was obtained from each patient
before operation. Two hundred outpatients (ASA phys-
ical status 1-2, aged 18-60 yr) undergoing spinal anes-
thesia for elective knee arthroscopy were studied. The
surgical procedures included arthroscopy for diagnostic
purposes or partial or total meniscectomy not requiring
intra-articular drainage postoperatively. Exclusion crite-
ria were bilateral arthroscopy, acute traumatic injury to
the knee, known cruciate ligament tear, the use of oral
narcotics or constant use of non-steroidal antiinflam-
matory drugs, history of allergy to any study medica-
tion, patient refusal, contraindication for spinal
anesthesia, and body mass index not within normal lim-
its (not between 15-28).
Before operation, each patient was instructed in the
use of a 100-mm visual analogue scale (VAS) with 0
labelled “no pain” and 100 “the worst pain imagin-
able”. The preoperative knee pain was recorded on the
ward before premedication. Thereafter, pain scores
were recorded at eight hours after surgery and in the
morning and at the end of the first and the second post-
operative days, respectively. All of the pain scores were
recorded with the appropriate knee on movement (at
90 flexion when possible). Patients were given a sheet
of paper with VAS scales and a questionnaire of anal-
gesics taken. They were asked to rate their pain intensi-
ty on the VAS scale at the above fixed times. All of the
knee pain VAS scores were rated by the patient, not by
Statistical analysis
All randomizations were computer-generated. Data are
expressed as mean standard deviation (SD). In the fig-
ures, mean standard error of the mean (SEM) is used.
Analysis of variance (ANOVA) was used to analyze the
data followed by Scheffe´s F-test. The VAS pain scores
were analyzed by a 3-way ANOVA (2x2x5) with (1) type
of premedication (diclofenac or placebo) and (2) type of
intra-articular injection (ropivacaine or NaCl) as the
between-group factors and (3) time (pm operation day,
am 1. postoperative day, pm 1. postoperative day, am 2.
postoperative day, pm 2. postoperative day) as the with-
in groups factor. The chi square test was used to test the
difference in the proportion of patients requesting post-
operative diclofenac tablets or oxycodone. A
0.05 was considered statistically significant.
P value #

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CANADIAN JOURNAL OF ANESTHESIA
TABLE I Patient characteristics. There were no statistically significant differences among the groups with regard to age, height, weight
or gender. Values are mean SD.
Group
Sex m/f
Age (yr)
Height (cm)
Weight (kg)
diclofenac-ropivacaine
diclofenac-saline
placebo-ropivacaine
placebo-saline
16/23
19/24
21/15
19/18
41.3 10.9
41.8 12.1
38.9 12.4
43.8 11.5
171 10
72.7 12.9
73.6 11.9
75.1 11.6
72.5 11.9
171
173
9
9
173 10
TABLE II The number of patients receiving additional premedication (alfentanil) and postoperative pain medicines (diclofenac or oxy-
codone) during the first eight postoperative hours, and the number of patients who suffered from postoperative nausea and vomiting
(PONV) or difficulties in voiding urine postoperatively. There were no statistically significant differences between the groups.
Group
n
Alfentanil
(n)
oxycodone
diclofenac
diclofenac
100 mg po
(n)
PONV (n)
Difficulties
in voiding
urine (n)
0.1 mg·kg– 1 50 mg po
im (n)
(n)
diclofenac-ropivacaine
diclofenac-saline
placebo-ropivacaine
placebo-saline
39
43
36
37
7
1
3
1
0
22
26
21
20
5
6
4
4
4
4
5
9
2
7
2
3
11
18
10
TABLE III The knee pain VAS scores in the four study groups at different time points. There were no statistically significant differences
between the groups. Values are mean SD.
Group
VAS
VAS
VAS
VAS
VAS
VAS
preopera-
tively
8 hr post-
operatively
1. Postopera-
tive day 08 am
1. Postopera-
tive day 08 pm
2. Postopera-
tive day 08 am
2. Postopera-
tive day 08 pm
diclofenac-ropivacaine
diclofenac-saline
placebo-ropivacaine
placebo-saline
17.2 24.2
15.7 12.5
19.0 19.5
17.5 16.6
20.0 24.8
18.5 18.4
27.0 28.4
36.1 27.3
9.1 14.9
10.3 17.4
14.8 19.0
13.8 19.6
8.3 13.6
10.4 17.6
14.9 21.4
10.6 14.4
4.1 8.7
7.1 14.8
9.7 16.7
6.4 9.2
5.0 14.0
8.6 17.4
9.0 17.3
4.7 7.1
Results
There were no differences in the VAS scores of pre-
operative knee pain among the groups (Table III).
The postoperative knee pain VAS scores did not differ
between ropivacaine- and NaCl-treated patients at any
time (Table III, Figure 1). However, when two of the
four groups were combined, the VAS scores of knee
pain were lowest in the two diclofenac premedication
groups (with or without intra-articular ropivacaine) at
eight hours after the operation (Table III, Figure 2)
(P=0.001).
Patient characteristics are presented in Table I.
Four patients were excluded from the study because
they received midazolam for sedation, and two patients
because of general anesthesia. One patient was exclud-
ed because of postoperative drainage, and one patient
because of chest pain. The questionnaires were returned
by 80.7% of the remaining patients (37 patients did not
return the questionnaires). There wee 8, 6, 12 and 11
patients in the diclofenac-ropivacaine, diclofenac-saline,
placebo-ropivacaine and placebo-saline groups who did
not return the questionnaires. Therefore, only 155
patients were available for analysis.
The number of patients who received 0.5 mg alfen-
tanil iv for sedation is presented in Table II. The
surgery time was 35 10 (15-55) min. Patients stayed
1.5 0.5 hr in the recovery room where no patient
needed diclofenac or oxycodone. The number of
patients who received diclofenac or oxycodone during
the first eight postoperative hours is also presented in
Table II.
The number of patients who suffered from PONV
or difficulties in voiding urine is presented in Table II.
The discharge time home after the end of the opera-
tion was 7.3 1.5 (4.3-10.3) hr (P : NS).
Discussion
This study failed to demonstrate a decrease in postop-
erative VAS scores at eight hours and later postopera-
tively when 20 ml of ropivacaine 0.5% was injected
intra-articularly after day-case diagnostic knee
arthroscopy performed under spinal anesthesia. Our

Rautoma et al.: DICLOFENAC PREMEDICATIONA N D INTRA-ARTICULAR ROPIVACAINE
223
the neuroendocrine response and reduces postopera-
tive pain.16–19 Raja et al. used epidural anesthesia,
which may have reduced postoperative pain by atten-
uating spinal cord hyperexcitability.20–21 Sørensen et
al. showed that additional local anesthesia, intra-artic-
ular bupivacaine after intra- articular lidocaine, did not
improve postoperative analgesia.1 1 We think that the
lack of effect of intra-articular ropivacaine in the pre-
sent study was due to the effects of spinal anesthesia.
It may also be that the effect of intra-articular ropiva-
caine 0.5% was too short-acting and, therefore, was
masked under the effects of spinal anesthesia. More
studies are needed to examine if higher concentrations
of ropivacaine under the same circumstances would
improve the knee pain VAS scores.
Diclofenac premedication reduced postoperative
pain scores eight hours after the operation. This time
exceeded the clinical duration of action of the preop-
eratively given diclofenac. Thus, under these circum-
stances, a pre-emptive analgesic effect of diclofenac
may exist. Postoperative pain may originate from the
peripheral fibres at the surgical incision enhanced by
central sensitization.22 Pre-emptive analgesia is based
on the assumption that an analgesic drug given before
surgical stimulus can prevent sensitization and thus
reduce postoperative pain more than the same anal-
gesic drug given postoperatively.1 2 However, it may
not be possible to study pre-emptive analgesia if the
noxious stimuli are already obliterated by central neur-
al axis blockade, i.e. spinal anesthesia. Therefore, this
study was not designed to study pre-emptive analgesia
itself but we merely wanted to examine if diclofenac
premedication is clinically useful. We think that the
effect of 50 mg diclofenac given one hour before
surgery was due to the well documented peripheral
anti-inflammatory effects of diclofenac.
FIGURE 1 Visual analogue scale (VAS) of knee pain against
time. There were no differences among the groups. Data are
mean SEM.
The knee pain VAS scores following arthroscopy
were very low in all groups regardless of treatment.
However, we think that even the small 13 mm change
in the postoperative knee pain VAS score caused by
diclofenac premedication is beneficial to the individual
patient. Diclofenac tablet is cheap and we think that
this treatment is cost-effective and causes minimal
trouble and side-effects to the patients.
In summary, intra-articular ropivacaine injected after
diagnostic day-case knee arthroscopy performed under
bupivacaine spinal anesthesia was of no benefit at eight
hours and later postoperatively. On the contrary,
diclofenac po premedication reduced postoperative pain
scores eight hours after the operation. We recommend
50 mg diclofenac po be given one hour before surgery
for suitable patients when day-case knee arthroscopy is
to be performed under spinal anesthesia.
FIGURE 2 Visual analogue scale (VAS) of knee pain against
time in the two premedication groups. Group diclofenac was dif-
ferent from group placebo at eight hours after the operation
(operation day pm). Data are mean SEM.
results are in accordance with those of Heard et al. who
also used spinal anesthesia in one of the study groups.1
In their study patients who received spinal anesthesia
had lower VAS scores than patients who had received
general anesthesia, irrespective of the intra-articular
treatment and existed up to 12 hr postoperatively.
Therefore, we did not ask the patients to rate their post-
operative knee pain before eight hours postoperatively.
Some studies report that protecting the nervous
system from the noxious insults of surgery, using
regional analgesic techniques, results in blunting of

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15 Knudsen K, Beckman Suurküla M, Blomberg S, Sjövall
J, Edvardsson N. Central nervous and cardiovascular
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16 Breslow MJ, Jordan DA, Christopherson R, et al.
Epidural morphine decreases postoperative hyperten-
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17 Rutberg H, Håkanson E, Anderberg B, Jorfeldt L,
Mårtensson J, Schildt B. Effects of the extradural
administration of morphine, or bupivacaine, on the
endocrine response to upper abdominal surgery. Br J
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