Rev Bras Anestesiol.

2019;69(1):35---41

REVISTA
BRASILEIRA DE
ANESTESIOLOGIA Publicação Oficial da Sociedade Brasileira de Anestesiologia
www.sba.com.br

SCIENTIFIC ARTICLE

Effects of intraarticular tramadol, magnesium and

ketamine on postoperative pain in arthroscopic
meniscectomy
Nevriye Salman a,∗ , Bilge Olgunkeleş b , Umut Bektaş c , Derviş Güner c ,
Meltem Bektas d , Şadan Ay c , Sumru Şekerci a

a
Saglik Bilimleri Universitesi Yuksek Ihtisas Ankara Training and Education Hospital, Department of Anesthesiology and
Reanimation, Ankara, Turkey
b
Ankara Beytepe Murat Erdi Eker Hospital, Department of Anesthesiology and Reanimation, Ankara, Turkey
c
Medicana International Ankara Hospital, Department of Orthopedics and Traumatology, Ankara, Turkey
d
Saglik Bilimleri Universitesi Ankara Training and Education Hospital, Department of Anesthesiology and Reanimation, Ankara,
Turkey

Received 7 December 2017; accepted 4 September 2018

Available online 6 October 2018

KEYWORDS Abstract
Intraarticular Objective: Postoperative pain control is important in terms of early recovery and rehabilitation
analgesia; in arthroscopic meniscectomy. For this purpose, we aimed to compare the effects of intraar-
Ketamine; ticular tramadol, magnesium, and ketamine with combinations of pericapsular bupivacaine on
Tramadol; postoperative pain and recovery in arthroscopic meniscectomy.
Magnesium; Methods: Ninety patients who underwent arthroscopic meniscectomy were enrolled in the
Knee arthroscopy study. Group T was given tramadol, Group K was given ketamine, and Group M was given
magnesium reconstituted intraarticularly, and all groups received periarticular bupivacaine.
Comparisons were made in terms of the patients’ postoperative Visual Analogue Scale scores
with and without movement, need for additional analgesics, first analgesic time, mobilization
times, adverse effects, and satisfaction with the analgesics.
Results: The Visual Analogue Scale scores were lowest in Group T at 0 minutes, and were higher
in the 15th and 30th minutes and 1st, 2nd, and 6th hours. Visual Analogue Scale values with
movement were found to be high in Group M at 0 and 15 minutes, but they were found to
be higher in group T in the 30th minute, 1st, 2nd and 6th hour. The groups were similar in
terms of postoperative additional analgesic use, number of analgesic use, and satisfaction with
analgesics; however, the first analgesic time was earlier in Group M, and the first mobilization
time was earlier in Group K.

∗ Corresponding author.
E-mail: [email protected] (N. Salman).

https://doi.org/10.1016/j.bjane.2018.09.002
0104-0014/© 2018 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
36 N. Salman et al.

Conclusion: Intraarticular ketamine enables early mobilization and less need for additional
analgesics, it also provides a better analgesic effect in comparison with intraarticular tramadol
and magnesium.
© 2018 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

PALAVRAS-CHAVE Efeitos de tramadol, magnésio e cetamina por via intra-articular sobre a dor
Analgesia pós-operatória em meniscectomia artroscópica
intra-articular;
Resumo
Cetamina;
Objetivo: O controle da dor pós-operatória é importante para recuperação e reabilitação pre-
Tramadol;
coces em meniscectomia artroscópica. Portanto, nosso objetivo foi comparar os efeitos de
Magnésio;
tramadol, magnésio e cetamina administrados por via intra-articular em associação com bupi-
Artroscopia de joelho
vacaína pericapsular sobre a dor e a recuperação após meniscectomia artroscópica.
Métodos: Noventa pacientes submetidos à meniscectomia artroscópica foram incluídos no
estudo. O Grupo T recebeu tramadol, o Grupo K recebeu cetamina e o Grupo M recebeu mag-
nésio em doses reconstituídas por via intra-articular e todos os grupos receberam bupivacaína
por via periarticular. As avaliações foram feitas mediante comparação dos escores em escala
visual analógica no pós-operatório dos pacientes em movimento e em repouso, necessidade de
analgésicos adicionais, tempo até a primeira necessidade de analgésico, tempo de mobilização,
efeitos adversos e satisfação com os analgésicos.
Resultados: Os escores da escala visual analógica foram menores no minuto zero e maiores nos
minutos 15 e 30 e nas horas 1, 2 e 6 no Grupo T. Os escores da escala visual analógica em
movimento foram maiores nos minutos zero e 15 no Grupo M e maiores no minuto 30 e nas
horas 1, 2 e 6 no Grupo T. Os escores dos grupos foram semelhantes em relação à necessidade
de analgésico adicional no pós-operatório, ao consumo de analgésico e à satisfação com os
analgésicos, mas os tempos até a primeira necessidade de analgesia e até a primeira mobilização
foram mais curtos nos grupos M e K, respectivamente.
Conclusão: A administração intra-articular de cetamina permite mobilização precoce e diminui
a necessidade de analgésicos adicionais, além de proporcionar um melhor efeito analgésico em
comparação com tramadol e magnésio por via intra-articular.
© 2018 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. Este é um
artigo Open Access sob uma licença CC BY-NC-ND (http://creativecommons.org/licenses/by-
nc-nd/4.0/).

Introduction anesthetic-type effect in minor operations, similar to that

of lidocaine on the sodium channel of axons.3,4 Due to these
Arthroscopic meniscectomy is one of the most frequently features, intraarticular tramadol has frequently been used
performed ambulatory surgeries. Therefore, aggressive pain intraarticularly in knee arthroscopies.2,5---7 As to ketamine,
control in the early postoperative period becomes highly with its effects on the N-Methyl d-Aspartate (NMDA), opioid,
important in terms of early recovery and rehabilitation.1 and muscarinic receptors, it is known to be a strong anal-
Many different anesthetic techniques and medicines (e.g., gesic that has both systemic and peripheral (skin, muscle,
local anesthetic, opioids, Non-Steroidal Anti-Inflammatory knee-joint) effects.8 Due to these features, intraarticular
Drugs --- NSAIDs) have been used for pain control in these ketamine has been used in knee arthroscopies.9 Magne-
surgeries. Agents used for this purpose should both control sium is an NMDA receptor blocker, and is mainly used in
pain effectively and have minimal adverse effects.2 How- eclampsia, headache, and acute migraine attacks.8 Recent
ever, despite several studies that aimed at finding the ideal studies reported that due to its systemic and local analgesic
treatment and technique, no conclusion has yet been drawn effects, magnesium has been frequently used in postopera-
on this issue. tive pain protocols in arthroscopic surgeries.10,11 However,
Tramadol, which is one of the opioids used for anal- no research has been conducted regarding the superiority
gesic purposes in arthroscopic surgeries, demonstrates an of intraarticular use of tramadol, ketamine, and magnesium
analgesic effect due to its opioid agonist effect and --- which also have local effects --- over each other in terms
preventive interaction for the withdrawal of noradrena- of analgesia, recovery, and adverse effects.
line and serotonin in the central nervous system. Some The purpose of this study was to compare the effects
studies demonstrated that tramadol might have a local of intraarticular tramadol, magnesium, and ketamine with
Intraarticular analgesia in arthroscopic meniscectomy 37

combinations of pericapsular bupivacaine in outpatient (nausea, vomiting, dizziness, rash, hallucination, somno-
arthroscopic meniscectomy in terms of postoperative pain lence, diarrhea, cramps, weakness, flushing), mobilization
and recovery. time (1 = 0---2 hours, 2 = 2---4 hours, 3 = 4---6 hours, 4 = 6---8
hours, 5 = 8---10 hours) and satisfaction with analgesia
(1 = poor, 2 = good, 3 = excellent) were recorded.
Methods All data were analyzed using the Statistical Package for
the Social Sciences (SPSS), version 11.5 (SPSS Company,
Ninety patients who were aged between 30 and 70 years, Chicago, IL, USA). The t-test was used for comparing group
American Society of Anesthesiologists (ASA) Status I---II, and means and the Chi-square or Fisher test was used to compare
who were scheduled to undergo elective knee arthroscopy percentages. Statistical analyses used an ordinary ANOVA
meniscectomy surgery were prospectively enrolled in the test for intra-group differences with post hoc test when
study after receiving ethics committee approval and signed p < 0.05 and the Mann---Whitney U test for intergroup dif-
informed consent from the patients. Patients who had ferences. Differences in group demographic characteristics
severe cardiac disease, kidney failure, liver failure, Body were tested using Student’s t-test or the contingency table
Mass Index (BMI) ≥ 30 kg.m−2 , those who used ␣-methyl Chi-square test for categorical measures. A p-values <0.05
dopa, clonidine, ␤-blockers, calcium channel blockers due were considered statistically significant. Sample size was
to hypertension; those with neuromuscular disease; patients estimated using pain scores as the primary variable. Assum-
who were allergic to the drugs investigated; those who ing an SD of 1 cm, we calculated that a group size of 30
received opioid or NSAID analgesics up to 24 hours before patients would be sufficient to detect a difference of 1 cm
surgery; and patients who did not want to participate were on the VAS at an alpha threshold of 0.007 with 90% power. A
not included in the study. In addition, patients who used p-value lowers than 0.05 was considered statistically sig-
analgesics other than the recommended pain killers after nificant and adjusted to a value of 0.007 when multiple
discharge from hospital were excluded. comparisons were performed, according to Bonferroni.
During the preoperative visit, all patients were informed
about using Visual Analogue Scale (VAS) scores from 0 to 10,
where 0 = no pain, and 10 = unbearable pain, and 30 min- Results
utes before the operation they were given 0.05 mg.kg−1
intravenous (IV) midazolam premedication. In the operat- After obtaining local Ethics Committee approval for the
ing room, the patients were monitored in a standard way study and written informed consent from the patients, when
via electrocardiogram, noninvasive blood pressure, capnog- the demographic data of patients were compared, the gen-
raphy, and with pulse oximetry. The general anesthesia der sex distribution was 12 females and 18 males in all
induction was performed with propofol 2 mg.kg−1 and fen- groups. An analysis of the age distribution showed that the
tanyl 0.1 ␮g.kg−1 , which was followed by placement of a average age was 45.7 ± 12.1 years in Group K, 45.2 ± 14.1
laryngeal mask; during the procedure, spontaneous breath- years in Group T, and 43.0 ± 10.5 years in Group M, and
ing of the patients was enhanced. Anesthesia management there were no statistically significant differences between
was provided with 1 MAC of sevoflurane (Primus, Drager), the groups. BMI was found to be statistically similar across
50% O2 and N2 O, and no additional analgesics were given the groups. In addition, an analysis of ASA scores showed
throughout the surgery. that ASA I/II grades were 23/7 in Group K, 22/8 in Group T,
Ninety patients were randomly assigned to three groups and 18/12 in Group M, which indicated statistically similar
using the closed envelope method such that three groups of values (Table 1).
thirty patients were formed. The skin incision of the por- An analysis of the patients’ intra-operative parameters
tals was closed and no tourniquet was used, and the groups showed that the total amount of crystalloid solution given
were formed by administering 100 mg tramadol in Group T, and duration of anesthesia and surgery were statistically
1 mg.kg−1 ketamine in Group K, and 1.5 g 10 mL 10% mag- similar (Table 2).
nesium in Group M, which was administered intraarticularly Postoperative 0th and 15th minute VAS scores
and diluted in 20 mL of saline. In addition, a 10 mL periartic- with/without movement indicated statistically signifi-
ular injection of 0.5% bupivacaine was administered to all cant differences with the highest pain score in Group M
groups. All surgical procedures were performed by a single compared with the other groups. Thirtieth minute, 1st,
surgeon by opening two standard arthroscopic portals. The 2nd and 6th hour VAS scores with/without movement in
injections were made by a surgeon who was blinded to the Group T were found to have significantly higher pain scores
contents, and the evaluations were also made by a differ- compared with Groups K and M. In addition, pain scores
ent anesthetist who did not know about which injection had with/without movement at 0th, 15th, and 30th minutes
been administered. were lowest in Group K and at Group M in the 1st, 2nd, and
All patients’ VAS scores with and without movement (0 6th hours (Table 3).
mins, 15th min, 30th min, 1st hr, 2nd hr, and 6th hr), use Regarding postoperative adverse effects, there were no
of additional analgesics at the hospital (20 mg lornoxicam statistical differences in nausea and vomiting between the
administered to 4 patients with VAS ≥ 4), time of first anal- groups at 0th, 15th, and 30th minutes, and the 1st, 2nd,
gesic (paracetamol) within the first 24 hours after discharge and 6th hour. Postoperative hallucination was seen only in
from hospital (scored as 1 = none, 2 = 15 min, 3 = 30 min, 4 = 1 Group K and demonstrated significant differences compared
hour, 5 = 2 hours, 6 = 6 hours) and the number of analgesics, with the other two groups (Table 4). None of the patients
if any, were questioned by calling the patient. In addi- demonstrated any adverse effects such as dizziness, rash,
tion, the patients’ postoperative medicine adverse effects somnolence, diarrhea, cramps, weakness, and flushing.
38 N. Salman et al.

Table 1 Demographic data findings.

Group K (n = 30) Group T (n = 30) Group M (n = 30) p
Sex (F/M), n 12/18 12/18 12/18 0.999
Age (years) mean ± SD 45.7 ± 12.1 45.2 ± 14.1 43.0 ± 10.5 0.679
BMI (kg.m−2 )mean ± SD 27.8 ± 5.8 28.9 ± 5.7 28.9 ± 5.7 0.161
ASA (I/II), n 23/7 22/8 18/12 0.329
Among three groups p > 0.05.
F, female; M, male; BMI, Body Mass Index; ASA, American Society of Anesthesiologists Classification.

Table 2 Intra-operative data findings.

Group K (n = 30) Group T (n = 30) Group M (n = 30)
Anesthesia duration (min), mean ± SD 52.0 ± 12.8 48.7 ± 13.3 51.7 ± 8.9
Surgery duration (min), mean ± SD 34.7 ± 8.4 30.6 ± 9.8 33.3 ± 2
Total crystalloid given (mL), mean ± SD 401.7 ± 122.8 397.3 ± 217.4 340.7 ± 106.2
Among three groups p > 0.05.

Table 3 Postoperative VAS scores.

Group K (n = 30) Group T (n = 30) Group M (n = 30)
VAS with movement 0th min, mean ± SD 0.1 ± 0.3b 0.6 ± 1.7b 5.2 ± 3.2
VAS with movement 15th min, mean ± SD 0.3 ± 1.6a 3.9 ± 3.9 4.8 ± 3.2c
VAS with movement 30th min, mean ± SD 0.8 ± 2.1a 4.0 ± 3.4 1.7 ± 2.0a
VAS with movement 1st hr, mean ± SD 1.1 ± 2.2a 3.4 ± 2.9 0.1 ± 0.6a
VAS with movement 2nd hr, mean ± SD 0.6 ± 1.3a 2.6 ± 2.8 0a
VAS with movement 6th hr, mean ± SD 0.3 ± 1.2b 1.9 ± 2.3b 0
VAS without movement 0th min, mean ± SD 0.0 ± 1.2b,a 0.0 ± 0.4b 4.5 ± 3.1
VAS without movement 15th min, mean ± SD 0.3 ± 1.6 2.8 ± 3.4c 4.2 ± 2.8c
VAS without movement 30th min, mean ± SD 0.5 ± 1.6a 3.0 ± 3.3 1.6 ± 2.6a
VAS without movement 1st hr, mean ± SD 0.6 ± 1.6a 2.3 ± 2.6 0.2 ± 0.9a
VAS without movement 2nd hr, mean ± SD 0.4 ± 1.0a 1.5 ± 1.9 0a
VAS without movement 6th hr, mean ± SD 0.4 ± 1.4 1.0 ± 1.7 0a
VAS, Visual Analogue Scale.
a p < 0.05, when compared with Group T.
b p < 0.05, when compared with Group M.
c p < 0.05, when compared with Group K.

In the postoperative period, patients using additional avoidance of opioid medicine, which has important adverse
analgesia and the mean number of additional analgesics used effects, have directed us to use local infiltration methods.12
were statistically similar, but the first time of additional Pain in arthroscopies is caused by the stimulation of free
analgesic intake was earlier in Group M than in the other nerve endings and afferent nociceptors and release of
groups. The number of patients with pain at the 24th hour inflammatory factors such as bradykinin, histamine, and
and analgesic satisfaction were similar, whereas the Group serotonin from damaged cells.1 Nociceptive activity is
K was mobilized earlier (Table 5). associated with primary hyperalgesia, and pain and inflam-
mation mediators disseminate pain from the incision to
wider areas.1,2,5 Therefore, exposure to agents that have
Discussion local effects and portal incisions and surrounding capsu-
lar areas have been proven to provide more effective
Outpatient surgery procedures are defined as a patient stay- analgesia in postoperative pain.5 Hence, we aimed to iden-
ing in hospital for less than 12 hours following surgery, tify and compare intraarticular administration of tramadol,
and knee arthroscopic surgeries are one of the most fre- ketamine, and magnesium, with combinations of periar-
quently conducted outpatient surgeries in many countries.12 ticular bupivacaine in terms of their analgesic effects,
In all outpatient surgeries, postoperative pain is the most postoperative adverse effects, postoperative mobilization
important contraindication that prevents discharge from and satisfaction, and postoperative analgesic requirements
hospital.12 In addition, similar to many studies, choice by administering both weak opioid and non-opioid medi-
of medicine to be used for postoperative analgesics and cations in terms of their analgesic effects, postoperative
Intraarticular analgesia in arthroscopic meniscectomy 39

found that 0.25% bupivacaine added to 100 mg of tramadol

Table 4 Analysis of postoperative nausea, vomiting, and
resulted in lower VAS pain scores, longer analgesia, and less
hallucination.
additional analgesic need without causing adverse effects
Group K Group T Group M in the postoperative 24 hour compared with groups in which
(n = 30) (n = 30) (n = 30) these medicines were used alone.5 In our study, it was found
Nausea 0th, n (%) 0 (0) 1 (100) 0 (0)
that despite the satisfaction of all patients in each group
Nausea 15th min, n (%) 1 (50) 1 (50) 0 (0)
about postoperative analgesia, the effect of intraarticular
Nausea 30th min, n (%) 2 (40) 3 (60) 0 (0)
100 mg tramadol, apart from in the early period, was higher
Nausea 1st hr, n (%) 2 (100) 0 (0) 0 (0)
in the VAS scores with and without movement in comparison
Nausea 2nd hr, n (%) 1 (50) 1 (50) 0 (0)
with the ketamine and magnesium groups. In addition,
Nausea 6th hr, n (%) 0 (33) 0 (33) 0 (33)
although previous research showed that tramadol enabled
Vomiting 0th min, n (%) 0 (33) 0 (33) 0 (33)
early mobilization, our study showed that the ketamine
Vomiting 15th min, n (%) 1 (100) 0 (0) 0 (0)
group was mobilized earlier than both the tramadol and the
Vomiting 30th min, n (%) 1 (100) 0 (0) 0 (0)
magnesium group.
Vomiting 1st hr, n (%) 2 (100) 0 (0) 0 (0)
Ketamine NMDA interacts with serotonergic and adren-
Vomiting 2nd hr, n (%) 1 (100) 0 (0) 0 (0)
ergic receptors and has analgesic activity apart from its
Vomiting 6th hr, n (%) 0 (33) 0 (33) 0 (33)
anesthetic effect.8 As an NMDA receptor antagonist, the
Hallucination, n (%) 30 (100)a 0 (0) 0 (0)
intraarticular administration of ketamine, which has anti-
nociceptive effects on both peripheral and central pain
a p < 0.05 with Chi-square test in three groups. pathways, is frequently applied as a non-opioid analgesic.
Several publications have shown that adjuvant use of
adverse effects, postoperative mobilization and satisfac- ketamine with local anesthetics in knee arthroscopy pro-
tion, and postoperative analgesic requirements. vided rapid onset of movements and better analgesia.14 The
Use of both pericapsular bupivacaine and intraarticu- present study also found that intraarticular ketamine pro-
lar analgesics in arthroscopic meniscectomy operations has vided better analgesia than tramadol and magnesium by
been proven to be more effective in pain control and have requiring less additional analgesics. However, it should be
effects that reduce postoperative adverse effects such as kept in mind that adverse effects may be encountered due to
nausea, sedation, hypotension, rash, diplopia, and respira- systemic absorption of high-dose intraarticular ketamine.15
tory depression.1 Therefore, local anesthetics have been Patients hallucinating due to high doses of intraarticular
frequently used with the infiltration method in arthro- ketamine presents a disadvantage in terms of discharge.
scopic operations.2 Bupivacaine, one of the local anesthetic However, if the more potent S (+)-ketamine form instead
medicines, shows its effects by enabling the formation of of R (−)-ketamine is used, which we used in our study,
action potentials in the neuronal membrane and/or pre- less ketamine can be given to reduce hallucinations, agi-
venting their spread, thus enabling afferent nociceptive tation, disorientation, pain, and anxiety.16 In addition, this
blockage.13 Therefore, all groups in this study were admin- adverse effect can be present during administration but
istered periarticular bupivacaine; this way, without harming rapidly dissipates upon termination of treatment and low-
articular chondrocytes, we aimed to increase the analgesic dose of ketamine and/or by adding a benzodiazepine or an
effect and decrease the adverse effects of intraarticular alpha-2-receptor agonist. The occurrence of adverse effects
medication. is limited and often well-tolerated by the patient. Despite
Intraarticular medicine injection is almost routine the hallucination adverse effects, earlier mobilization was
practice for postoperative pain control after knee achieved in the ketamine group compared with the tramadol
arthroscopies.5 A number of studies have been conducted and magnesium groups. However, although there were fewer
on the combinations of many medicines and practices and adverse effects when 0.5 mg.kg−1 intraarticular ketamine
their effectiveness.1,2,5---7 Besides its peripheral analgesic was administered, it may not provide better analgesia than
effects, tramadol is a weak opioid that increases the intraarticular bupivacaine.17
function of the descending tramadol peripheral by enabling Although the peripheral anti-nociceptive effect of mag-
the activation of opioid receptors and inhibition of 5 nesium induced by voltage-dependent NMDA antagonism has
hydroxytryptamine and noradrenalin reuptake.2 A study not been fully identified, it is known that NMDA blockage of

Table 5 Analysis of postoperative analgesia and mobilization.

Group K (n = 30) Group T (n = 30) Group M (n = 30)
Patients who used additional analgesia, n (%) 25 (31.3) 29 (36.3) 26 (32.5)
Time of first analgesic (hour), mean ± SD 3.5 ± 1.6a 4.2 ± 1.9a 1.9 ± 0.5
Number of additional analgesics, mean ± SD 1.5 ± 1.1 1.6 ± 0.9 1.7 ± 1.0
Patients with pain on 24th hour, n (%) 1 (33.3) 2 (66.7) 0 (0)
Satisfaction about analgesia, mean ± SD 2.4 ± 0.5 2.2 ± 0.5 2.2 ± 0.5
Time of mobilization (hour), mean ± SD 1.6 ± 0.6 1.9 ± 0.6b 1.9 ± 0.2b
a p < 0.05, when compared with Group M.
b p < 0.05, when compared with Group K.
40 N. Salman et al.

receptors decreases the excitability of the nociceptive input analgesia than intraarticular plus pericapsular incisional bupiva-
terminal in the C-fibers of the NMDA receptor blockade.18 caine after outpatient arthroscopic partial meniscectomy. Knee
Calcium channel inhibition is also considered to be effective Surg Sports Traumatol Arthrosc. 2007;15:564---8.
in the analgesic effect of magnesium.19 Magnesium, which 2. Ayoglu H, Altunkaya H, Bayar A, et al. The effect of intraartic-
is known to reduce postoperative analgesic requirement,10 ular combinations of tramadol and ropivacaine with ketamine
has parenteral, oral, rectal, subcutaneous, transdermal, and on postoperative pain after arthroscopic meniscectomy. Arch
Orthop Trauma Surg. 2010;130:307---12.
intranasal administration use for this purpose.20 A study
3. Kargi E, Babuccu O, Altunkaya H, et al. Tramadol as a local
reported that intraarticular magnesium was more effec- anaesthetic in tendon repair surgery of the hand. J Int Med Res.
tive than many intraarticular combinations.21 Our this study 2008;36:971---8.
found that intraarticular magnesium provided better analge- 4. Jou IM, Chu KS, Chen HH, et al. The effects of intrathecal
sia than tramadol. Although it had similar analgesic results tramadol on spinal somatosensory-evoked potentials and motor-
to the group given ketamine, additional analgesic use was evoked responses in rats. Anesth Analg. 2003;96:783---8.
found to be higher compared with the other two groups. 5. Zeidan A, Kassem R, Nahleh N, et al. Intraarticular
In addition, adverse effects such as dizziness, somnolence, tramadol---bupivacaine combination prolongs the duration of
diarrhea, cramps, weakness, flushing, which are mainly seen postoperative analgesia after outpatient arthroscopic knee
in the use of systemic magnesium, were not observed in our surgery. Anesth Analg. 2008;107:292---9.
6. Tuncer B, Babacan A, Arslan M. Preemptive intraarticular tra-
intraarticular magnesium use.
madol for pain control after arthroscopic knee surgery. Agrı.
Intraarticular ketamine was administered as 1 mg.kg−1 , 2007;19:42---9.
as with doses of similar studies, and we similarly found 7. Alagöl A, Calpur OU, Kaya G, et al. The use of intraartic-
that ketamine-containing combinations provided better ular tramadol for postoperative analgesia after arthroscopic
analgesia.22,23 However, further studies24 suggested that knee surgery: a comparison of different intraarticular and
intraarticular ketamine might be toxic to chondrocytes. The intravenous doses. Knee Surg Sports Traumatol Arthrosc.
results of the in vitro study by Ozturk et al. may not be fully 2004;12:184---8.
reflected in clinical practice because of the increased dilu- 8. Petrenko AB, Yamakura T, Baba H, et al. The role of N-methyl-
tion of ketamine with the further increase of intraarticular d-aspartate (NMDA) receptors in pain: a review. Anesth Analg.
2003;97:1108---16.
fluid with portal hollies, intraarticular ketamine dilution to
9. Webb AR, Skinner BS, Leong S, et al. The addition of a small-
20 mL, and only single-dose administration. Also, cell culture
dose ketamine infusion to tramadol for postoperative analgesia:
studies may lack several enzyme mechanisms, they are not a double-blinded, placebo-controlled, randomized trial after
embedded in their surrounding tissue and important cell abdominal surgery. Anesth Analg. 2007;104:912---7.
repair mechanisms may be absent when used in vitro.25 How- 10. Levaux Ch, Bonhomme V, Dewandre PY, et al. Effect of intra-
ever, we believe that new studies to determine the dose of operative magnesium sulphate on pain relief and patient
intraarticular ketamine to provide the best analgesia with comfort after major lumbar orthopaedic surgery. Anaesthesia.
minimal dosing will further reduce possible chondrotoxic 2003;68:131---5.
effects. 11. Koinig H, Wallner T, Marhofer P, et al. Magnesium sulfate reduces
A limitation of this study is that postoperative the intra- and postoperative analgesic requirements. Anesth Analg.
1998;87:206---10.
patients’ VAS scores, complications, and analgesic require-
12. Baverel L, Cucurulo T, Lutz C, et al. Anesthesia and analgesia
ments were assessed for the first postoperative 24 hours
methods for outpatient anterior cruciate ligament reconstruc-
only. The lack of investigation of different doses of intraar- tion. Orthop Traumatol Surg Res. 2016;102:251---5.
ticular ketamine that provide less but sufficient analgesia 13. Hosseini H, Abrisham SM, Jomeh H, et al. The com-
limits our ability to study. parison of intraarticular morphine---bupivacaine and
tramadol---bupivacaine in postoperative analgesia after
Summary arthroscopic anterior cruciate ligament reconstruction. Knee
Surg Sports Traumatol Arthrosc. 2012;20:1839---44.
14. Borner M, Burkle H, Trojan S, et al. Intra-articular ketamine
In conclusion, given that ketamine enables better postop- after arthroscopic knee surgery. Optimisation of postoperative
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