Effective of local morphine, ketorolac, and bupivacaine in pediatric tendon surgery: a randomized controlled trial

Tendon surgery in the pediatric lower extremities could cause severe postoperative pain, leading to psychological distress and chronic pain. Local wound anesthesia could significantly improve postoperative pain, but the best anesthesia regimen after tendon surgery in pediatric patients remains unknown. This study aimed to compare the efficacy of single-modal and multimodal local analgesia, and to determine the amount of morphine consumed in pediatric patients who underwent lower extremities tendon surgery. Patients aged 1-17 who underwent lower extremity tendon surgery were stratified into two age groups due to different appropriate pain evaluation scales. Group 1 included patients aged 1-6 using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), and Group 2 included patients aged 7-17 using the Numeric Rating Scale (NRS). Each group was then randomized into two groups of different local anesthesia regimens: A single modal group (1 A and 2 A: n = 20) who received 0.5% bupivacaine, and the multimodal group (1B and 2B: n = 20), who received a combination of 0.5% bupivacaine, ketorolac, and morphine. Pain score was recorded every 4 h until 48 h after surgery. Postoperative morphine consumption and complications were also recorded. Forty pediatric patients (26 male and 14 female) with an average age of 9.2 ± 4.4 years. The average day of admission was 3.08 ± 0.35 days. In population-averaged analyses, the odds of adequate pain control did not differ between groups (OR 1.01, 95% CI 0.41-2.50), while pain scores decreased significantly over time in both groups. Subgroup analyses using continuous pain scores showed no significant treatment effect in either age stratum. Time-weighted average pain over 48 h demonstrated minimal between-group differences (CHEOPS: mean difference + 0.05, 95% CI - 0.30 to 0.40; NRS: +0.22, 95% CI - 0.95 to 1.40). No major adverse events were observed; one minor adverse event (pruritus) occurred. Multimodal wound infiltration using Bupivacaine, Ketorolac, and morphine did not yield any clinically important reduction in pain or opioid consumption compared with bupivacaine alone in pediatric patients who underwent lower extremities tendon surgery. TCTR20220504001 (4/5/2022).