Intra-Operative Adjunctive Magnesium Sulfate in Pain Management of Total Knee Arthroplasty; a Systematic Review and Meta-analysis
Archives of Academic Emergency Medicine,
Vol. 11 No. 1 (2023),
15 November 2022
Introduction: There has been growing interest in the potential role of adjunctive magnesium sulfate in improving pain management. This systematic review and meta-analysis aimed to assess the effect of intra-operative adjunctive magnesium sulfate on pain management and opioid consumption in total knee arthroplasty (TKA).
Methods: A comprehensive search was conducted in Medline, Embase, Scopus, Web of Science, and Cochrane Library databases, covering studies up to April 2023. The extracted data included pain management outcomes, opioid consumption, and adverse effects from the selected studies. Standardized mean differences (SMDs) were calculated for continuous outcomes, while risk ratios (RRs) were calculated for dichotomous outcomes. Meta-analysis was conducted employing random-effects models in STATA 17.
Results: In this meta-analysis of 8 randomized controlled trials involving 536 patients, adjunctive magnesium sulfate in TKA was found to significantly reduce opioid consumption during the first 24 hours after operation (SMD: -1.88, 95% confidence interval (CI): [-3.66 to -0.10]; p = 0.038). It also resulted in lower pain scores at rest 24 hours after surgery (SMD: -1.53, 95% CI: [-2.70 to -0.37]; p = 0.010). There were no significant differences in time to first rescue analgesic and adverse effects between the groups. The included studies were assessed to have low to high levels of risk of bias.
Conclusion: This study presents evidence at low to moderate levels supporting the use of intra-operative adjunctive magnesium sulfate in TKA for improved pain management and reduced opioid consumption. However, further research is needed to address the heterogeneity and to explore optimal dosing regimens and routes of administration to maximize the benefits of magnesium sulfate in TKA.
- Total Knee Arthroplasty;
- Magnesium Sulfate;
- Pain Management;
- Opioid Consumption;
- Arthroplasty, replacement
- Analgesics, opioid
How to Cite
Ponnusamy KE, Vasarhelyi EM, Somerville L, McCalden RW, Marsh JD. Cost-Effectiveness of Total Knee Arthroplasty vs Nonoperative Management in Normal, Overweight, Obese, Severely Obese, Morbidly Obese, and Super-Obese Patients: A Markov Model. J Arthroplasty. 2018;33(7, Supplement):S32-S8.
Christensen TH, Gemayel AC, Bieganowski T, Lawrence KW, Rozell JC, Macaulay W, et al. Opioid Use During Hospitalization Following Total Knee Arthroplasty: Trends in Consumption From 2016 to 2021. J Arthroplasty. 2023;38(6, Supplement):S26-S31.
Karam JA, Schwenk ES, Parvizi J. An update on multimodal pain management after total joint arthroplasty. JBJS. 2021;103(17):1652-62.
Suthersan M, Pit S, Gordon L, Loman M, Pezzutti B, Freihaut R. Local infiltration analgesia versus standard analgesia in total knee arthroplasty. J Orthop Surg (Hong Kong). 2015;23(2):198-201.
Azimi A, Hooshmand E, Mafi AA, Tabatabaei F-S. Effect of duloxetine on opioid consumption and pain after total knee and hip arthroplasty: a systematic review and meta-analysis of randomized clinical trials. Pain Med. 2023 pnad045. Online ahead of print. https://doi.org/10.1093/pm/pnad045
Gupta K, Vohra V, Sood J. The role of magnesium as an adjuvant during general anaesthesia. Anaesthesia. 2006;61(11):1058-63.
Felsby S, Nielsen J, Arendt-Nielsen L, Jensen TS. NMDA receptor blockade in chronic neuropathic pain: a comparison of ketamine and magnesium chloride. Pain. 1996;64(2):283-91.
Kara H, Şahin N, Ulusan V, Aydoğdu T. Magnesium infusion reduces perioperative pain. Eur J Anaesthesiol. 2002;19(1):52-6.
Ryu J-H, Kang M-H, Park K-S, Do S-H. Effects of magnesium sulphate on intraoperative anaesthetic requirements and postoperative analgesia in gynaecology patients receiving total intravenous anaesthesia. Br J Anaesth. 2008;100(3):397-403.
Apan A, Buyukkocak U, Ozcan S, Sarı F, Basar H. Postoperative magnesium sulphate infusion reduces analgesic requirements in spinal anaesthesia. Eur J Anaesthesiol. 2004;21(10):766-9.
Levaux C, Bonhomme V, Dewandre P-Y, Brichant J-F, Hans P. Effect of intra‐operative magnesium sulphate on pain relief and patient comfort after major lumbar orthopaedic surgery. Anaesthesia. 2003;58(2):131-5.
Ng KT, Yap JL, Izham IN, Teoh WY, Kwok PE, Koh WJ. The effect of intravenous magnesium on postoperative morphine consumption in noncardiac surgery: A systematic review and meta-analysis with trial sequential analysis. Eur J Anaesthesiol. 2020;37(3):212-23.
Hwang J-Y, Na H-S, Jeon Y-T, Ro Y-J, Kim C-S, Do S-H. I.V. infusion of magnesium sulphate during spinal anaesthesia improves postoperative analgesia. Br J Anaesth. 2009;104(1):89-93.
Arcioni R, Palmisani S, Tigano S, Santorsola C, Sauli V, Romano S, et al. Combined intrathecal and epidural magnesium sulfate supplementation of spinal anesthesia to reduce post‐operative analgesic requirements: a prospective, randomized, double‐blind, controlled trial in patients undergoing major orthopedic surgery. Acta Anaesthesiol Scand. 2007;51(4):482-9.
Zeng J, Chen Q, Yu C, Zhou J, Yang B. The Use of Magnesium Sulfate and Peripheral Nerve Blocks: An Updated Meta-analysis and Systematic Review. Clin J Pain. 2021;37(8):629-37.
Shi LJ, Zhu HY, Ma JH, Shi LL, Gao FQ, Sun W. Intra-articular magnesium to alleviate postoperative pain after arthroscopic knee surgery: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2021;16(1):111.
Pascual-Ramírez J, Gil-Trujillo S, Alcantarilla C. Intrathecal magnesium as analgesic adjuvant for spinal anesthesia: A meta-analysis of randomized trials. Minerva Anestesiologica. 2013;79(6):667-78.
Peng Y-N, Sung F-C, Huang M-L, Lin C-L, Kao C-H. The use of intravenous magnesium sulfate on postoperative analgesia in orthopedic surgery: A systematic review of randomized controlled trials. Medicine. 2018; 97(50):e13583.
Xiang W, Jiang L, Shi L, Jiang C, Zhou Y, Yang C. The effect of magnesium added to bupivacaine for arthroscopy: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2021;16(1):583.
Zoratto D, Phelan R, Hopman WM, Wood GCA, Shyam V, DuMerton D, et al. Adductor canal block with or without added magnesium sulfate following total knee arthroplasty: a multi-arm randomized controlled trial. Canadian Journal of Anesthesia-Journal Canadien D Anesthesie. 2021;68(7):1028-37.
Zhao ZR, Zhang XZ, Peng H, Li W, Liu HZ, Wu H. Magnesium Sulfate Combined with a Levobupivacaine Periarticular Cocktail for Analgesia in the Early Postoperative Period after Total Knee Arthroplasty. J Knee Surg. 2021;34(13):1463-8.
Zhao CC, Wang LY, Chen LYL, Wang QR, Kang PD. Effects of magnesium sulfate on periarticular infiltration analgesia in total knee arthroplasty: a prospective, double-blind, randomized controlled trial. J Orthop Surg Res. 2023;18(1):301.
Frassanito L, Messina A, Vergari A, Colombo D, Chierichini A, Della Corte F, et al. Intravenous infusion of magnesium sulfate and postoperative analgesia in total knee arthroplasty. Minerva Anestesiol. 2015;81(11):1184-91.
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1.
UpToDate. Approximate dose conversions for commonly used opioids 2023 [Available from: https://www.uptodate.com/contents/image?imageKey=PALC%2F111216.
Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366: l4898.
Piggott T, Morgan RL, Cuello-Garcia CA, Santesso N, Mustafa RA, Meerpohl JJ, et al. Grading of Recommendations Assessment, Development, and Evaluations (GRADE) notes: extremely serious, GRADE's terminology for rating down by three levels. J Clin Epidemiol. 2020;120:116-20.
Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-60.
Egger M, Smith GD, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-34.
Zota G, Lavan D'homme P, Grosu I, Thienpont E. Impact of perioperative analgesic treatments on pain intensity after total knee arthroplasty. Reg Anesth Pain Med. 2013;38(5):E190.
Wang QR, Zhao CC, Hu J, Ma T, Yang J, Kang PD. Efficacy of a Modified Cocktail for Periarticular Local Infiltration Analgesia in Total Knee Arthroplasty A Prospective, Double-Blinded, Randomized Controlled Trial. J Bone Joint Surg Am. 2023;105(5):354-62.
Shin HJ, Do SH. Reply to: Does intraoperative magnesium lessen pain after knee replacement surgery? Br J Anaesth. 2017;119(6):1236-7.
Park JW, Kim EK, Lee J, Chung SH, Boo G, Do SH. Effect of Intraoperative Magnesium Sulfate Administration on Blood Glucose Control following Total Joint Arthroplasty in Patients with Diabetes. J Clin Med. 2022;11(11):3040.
Oh TK, Chung SH, Park J, Shin H, Chang CB, Kim TK, et al. Effects of Perioperative Magnesium Sulfate Administration on Postoperative Chronic Knee Pain in Patients Undergoing Total Knee Arthroplasty: A Retrospective Evaluation. J Clin Med. 2019;8(12):2231.
Modir H, Moshiri E, Azami M, Sayafi-Sharifi TS. Comparison of impact of adjuvant treatment of midazolam, fentanyl, and magnesium sulfate with intrathecal bupivacaine on block characteristics and postoperative analgesia in knee arthroplasty: A randomized clinical trial. J. Acute Dis. 2022;11(3):94-100.
Koinig H, Wallner T, Marhofer P, Andel H, Horauf K, Mayer N. Magnesium sulfate reduces intra- and postoperative analgesic requirements. Anesth Analg. 1998;87(1):206-10.
Kim EY, Do SH, Nam S, Hwang JW. The preventive effect of magnesium on postoperative pain in staged bilateraltotal knee arthroplasty: Randomized controlled trial. Reg Anesth Pain Med. 2015;40(5):e182.
El Menesy TM, Hamden GA, Nassef MA, Ahmed HI, El Abd NE. The anti-nociceptive action of magnesium during continuous femoral nerve block. Is it associated with prophylactic anticoagulant or adverse hypotensive effects following TKR surgery? Egypt. J. Anaesth. 2009;25(2):125-37.
Buswell VR, Fregene T. Does intraoperative magnesium lessen pain after knee replacement surgery? Br J Anaesth. 2017;119(6):1236-.
Bujalska-Zadrozny M, Tatarkiewicz J, Kulik K, Filip M, Naruszewicz M. Magnesium enhances opioid-induced analgesia - What we have learnt in the past decades? Eur J Pharm Sci. 2017;99:113-27.
Shin HJ, Kim EY, Na HS, Kim TK, Kim MH, Do SH. Magnesium sulphate attenuates acute postoperative pain and increased pain intensity after surgical injury in staged bilateral total knee arthroplasty: a randomized, double-blinded, placebo-controlled trial. Br J Anaesth. 2016;117(4):497-503.
Park JW, Kim EK, Lim D, Oh TK, Park S, Do SH. Magnesium Sulfate Treatment During Total Knee Arthroplasty Decreases Postoperative Urinary Retention: A Retrospective Propensity Score-Matched Analysis. J Clin Med. 2020;9(3):320.
Elmawgoud MAA, Badawy A, Elkassem SA, Rashwan D. Effect of addition of magnesium sulphate and fentanyl to ropivacaine continuous femoral nerve block in patients undergoing elective total knee replacement. J Med. Sci. 2008;8(4):395-9.
Daabiss MA, Kandil A. Evaluation of the effect of magnesium vs. midazolam as adjunct to epidural bupivacaine in patients undergoing total knee replacement. Br J Med Pract 2013;6(2):2.
Choi JW, Lahori A, Merlo JA, Gill O, Ghoddoussi F, Patel KM, et al. Adductor Canal Blocks With Bupivacaine and Magnesium After Same-day Discharge Total Knee Arthroplasty Improve Postoperative Pain Relief and Decrease Opioid Consumption A Prospective Randomized Controlled Trial. Clin J Pain. 2022;38(6):388-95.
Morel V, Pickering ME, Goubayon J, Djobo M, Macian N, Pickering G. Magnesium for Pain Treatment in 2021? State of the Art. Nutrients. 2021;13(5):1397.
Muthiah T, Arora MK, Trikha A, Sunder RA, Prasad G, Singh PM. Efficacy of magnesium as an adjuvant to bupivacaine in 3-in-1 nerve block for arthroscopic anterior cruciate ligament repair. Indian J Anaesth. 2016;60(7):491-5.
Schulz-Stübner S, Wettmann G, Reyle-Hahn S, Rossaint R. Magnesium as part of balanced general anaesthesia with propofol, remifentanil and mivacurium: a double-blind, randomized prospective study in 50 patients. Eur J Anaesthesiol. 2001;18(11):723-9.
Ko S-H, Lim H-R, Kim D-C, Han Y-J, Choe H, Song H-S. Magnesium sulfate does not reduce postoperative analgesic requirements. Anesthesiology. 2001;95(3):640-6.
Jaoua H, Zghidi SM, Wissem L, Laassili S, Ammar N, Ali J, et al. Effectiveness of intravenous magnesium on postoperative pain after abdominal surgery versus placebo: double blind randomized controlled trial. Tunis Med. 2010;88(5):317-23.
Xiang WN, Jiang L, Shi LT, Jiang CM, Zhou Y, Yang CH. The effect of magnesium added to bupivacaine for arthroscopy: a meta-analysis of randomized controlled trials. J Orthop Surg Res. 2021;16(1):583.
Soleimanpour H, Imani F, Dolati S, Soleimanpour M, Shahsavarinia K. Management of pain using magnesium sulphate: a narrative review. Postgrad Med. 2022;134(3):260-6.
Franzoni S, Rossi SM, Cassinadri A, Sangaletti R, Benazzo F. Perioperative Pain Management in Total Knee Arthroplasty: A Narrative Review of Current Multimodal Analgesia Protocols. Appl. Sci. 2023; 13(6):3798.
Lavand'homme PM, Kehlet H, Rawal N, Joshi GP. Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol. 2022;39(9):743-57.
- Abstract Viewed: 132 times
- pdf Downloaded: 236 times