Periarticular Injections in Knee and Hip Arthroplasty: Where and What to Inject

Pericapsular Nerve Group Block with Periarticular Injection for Pain Management after Total Hip Arthroplasty: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to compare the effectiveness of pericapsular nerve group (PENG) block with periarticular multimodal drug injection (PMDI) on postoperative pain management and surgical outcomes in patients who underwent total hip arthroplasty (THA). We hypothesized that PENG block with PMDI would exhibit superior effects on postoperative pain control after THA compared to PMDI alone.

MATERIALS AND METHODS

From April 2022 to February 2023, 58 patients who underwent THA were randomly assigned into two groups: PENG block with PMDI group (n=29) and PMDI-only group (n=29). Primary outcomes were postoperative numeric rating scale (NRS) at rest and during activity at 6, 24, and 48 hours postoperatively. Secondary outcomes were postoperative complications (nausea and vomiting), Richards-Campbell Sleep Questionnaire (RCSQ) score, length of hospital stay, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, Harris Hip Score (HHS), and total morphine usage after surgery.

RESULTS

There was no significant difference in postoperative pain for either resting NRS or active NRS. Postoperative nausea and vomiting, RCSQ score, length of hospital stay, WOMAC index, HHS, and total morphine usage exhibited no significant differences between the two groups.

CONCLUSION

Both groups showed no significant differences in postoperative pain and clinical outcomes, indicating that the addition of PENG block to PMDI does not improve pain management after applying the posterolateral approach of THA. PMDI alone during THA would be an efficient, fast, and safe method for managing postoperative pain. This article was registered with ClinicalTrials. gov (Gov ID: NCT05320913).

Periarticular injection versus placebo in total knee arthroplasty with intrathecal morphine

INTRODUCTION

Periarticular injection (PAI) is one part of total knee arthroplasty (TKA) multimodal analgesia protocols. PAI combined with neuraxial anesthesia including intrathecal morphine (ITM) has not been previously investigated. This study prospectively compares PAI to placebo injection in patients undergoing TKA under spinal anesthesia with ITM.

METHODS

We performed a prospective, double-blinded randomized controlled trial comparing immediate postoperative outcomes after TKA. All patients received combined spinal-epidural (CSE) anesthesia with ITM and multimodal analgesia. The study group received a standardized PAI with 0.5% ropivacaine, clonidine, ketorolac, and epinephrine, while the control group received PAI with saline. Exclusion criteria were revision surgery, inability to receive epidural anesthesia or PAI, patients taking greater than 80 morphine milligram equivalents (MME) daily prior to surgery, and lack of patient consent to participate in the study.

RESULTS

Sixty-four patients enrolled and completed the study from 2015 to 2021. Thirty-four were randomized to the study group and 30 to the control. There was no difference in mean total postoperative opioid consumption between PAI (125.49 MME) and control (138.80 MME); (p = 0.556). There was also no difference in opioid requirements at 0-24 and 24-48 h between PAI (58.87 and 70.57 MME), and control (70.57 and 69.72 MME); (p = 0.308 and p = 0.556).

CONCLUSION

This study, while underpowered, demonstrates that PAI does not significantly decrease opioid consumption after TKA compared to placebo injection when utilizing ITM spinal anesthesia. When ITM is used, PAI may be reasonably be excluded from the protocol without affecting opioid requirements.

Analgesic efficacy and safety of methylene blue combined with cocktail for periarticular infiltration following total knee arthroplasty: a prospective, randomized, controlled study

OBJECTIVE

This study aims to explore the analgesic effects and safety of periarticular injections of methylene blue (MB) combined with a cocktail formulation following total knee arthroplasty (TKA).

METHODS

A total of 70 patients undergoing total knee arthroplasty were selected and divided into two groups based on the cocktail formula used for periarticular infiltration, including the methylene blue group (M group, n = 35) and the control group (C group, n = 35). Both groups underwent spinal anesthesia. At the end of the surgery, the M group received a 0.05% methylene blue combined cocktail for periarticular infiltration block, while the C group received a conventional cocktail infiltration block. Postoperatively, both groups used intravenous patient-controlled analgesia. Then, the rest and movement Numeric Rating Scale (NRS) scores, postoperative sufentanil consumption, postoperative inflammatory markers, and the occurrence of adverse reactions such as wound infection and poor wound healing were compared after postoperative 24 h, 48 h, 72 h, and 7-day, 14-day, 28-day between the two groups.

RESULTS

The rest and during movement, NRS scores at postoperative 24 h, 48 h, 72 h, 7-day, 14-day, and 28-day were significantly lower in the C group compared with the M group (P < 0.05). The total sufentanil consumption at postoperative 72 h was less in the M group (98.9 ± 11.3 µg) compared to the C group (129.1 ± 12.3 µg) (P < 0.01). It also showed a lower IL-6 in the M group at postoperative 24 h and 72 h (P < 0.05). However, there were no significant differences in CRP levels between the two groups at 24 h and 72 h post-surgery (P > 0.05), and neither group experienced complications such as wound infection or poor wound healing.

CONCLUSION

Methylene blue combined with a cocktail can be safely used for local infiltration after knee arthroplasty, which reduces postoperative opioid consumption and suppresses the release of inflammatory factors. Moreover, it synergistically enhanced the local anesthetic analgesia and provided sustained pain relief for at least 4 weeks.

Advances in perioperative pain management for total knee arthroplasty: a review of multimodal analgesic approaches

Despite significant advancements in total knee arthroplasty (TKA), managing postoperative pain remains a substantial clinical challenge. With advances in surgical techniques and pharmacology, TKA perioperative analgesic strategies continue to evolve, necessitating ongoing reassessment of current data. Multimodal analgesia has become the standard for perioperative pain management in TKA; however, variations in its specific components and applications across studies create challenges in selecting the optimal analgesic approach. Evaluating these pain management strategies is essential for understanding their benefits, limitations, and appropriate use, allowing the development of individualized perioperative analgesic plans. This review aims to summarize current research on perioperative pain control in TKA and assess the effectiveness of different analgesic interventions.

Effects of a Modified Long-Acting Cocktail on Analgesia and Enhanced Recovery After Total Hip Arthroplasty: A Double-Blinded Randomized Clinical Trial

BACKGROUND

We compared the efficacy and safety of a modified cocktail for postoperative analgesia and early functional rehabilitation in patients undergoing total hip arthroplasty (THA).

METHODS

Magnesium sulfate and sodium bicarbonate were added to a cocktail of ropivacaine, epinephrine, and dexamethasone. Primary outcome measures were visual analog scale (VAS) pain scores at various intervals after surgery, morphine consumption for rescue analgesia after surgery, and time to first rescue analgesia. Secondary outcomes were hip function after surgery, daily walking distance, quadriceps muscle strength, and the incidence of postoperative adverse reactions.

RESULTS

Morphine consumption was significantly lower in the modified cocktail group than in the control group in the first 24 hours after surgery (6.2 ± 6.0 versus 14.2 ± 6.4 mg, P < .001), as was total morphine consumption (10.0 ± 8.6 versus 19.2 ± 10.1 mg, P < .001). The duration of the first rescue analgesia was significantly prolonged (23.7 ± 10.3 versus 11.9 ± 5.8 mg, P < .001). Morphine consumption was also reduced in the magnesium sulfate and sodium bicarbonate groups over a 24-hour period compared to the control group (P < .001). The modified cocktail group had significantly lower resting VAS pain scores than the control group within 24 hours after surgery (P < .050). The VAS pain scores during movement within 12 hours after surgery were also lower (P < .050). The experimental groups showed better hip range of motion (P < .050) and longer walking distance (P < .050) on the first postoperative day, and levels of inflammatory markers were significantly reduced. The incidence of postoperative adverse reactions was similar among the 4 groups.

CONCLUSIONS

The modified cocktail with a new adjuvant can prolong the duration of postoperative analgesia, reduce the dosage of rescue analgesics, and accelerate early postoperative functional recovery in patients undergoing THA.

Biopuncture, A Multitarget Therapy in the Treatment of Individuals with Knee Osteoarthritis: state of the art

Objectives

The objective of this manuscript was to carry out a comprehensive review of the published information on the use of Biopuncture in patients with knee osteoarthritis.

Methods

A scientific search was performed using online databases following the terms (Biopuncture) and (Knee Osteoarthritis) to identify scientific manuscripts that were related to the use of Biopuncture in the treatment of individuals with knee osteoarthritis.

Results

With the information found, a theoretical framework was integrated that describes the components of Biopuncture, its mechanism of action and practical topics for the application of the technique.

Conclusion

Biopuncture appears to be a potential, simple and low-risk therapeutic strategy in the treatment of knee osteoarthritis, which is applied through periarticular subcutaneous injections, with multitarget mechanisms of action at various physiopathological levels such as the modulation of the inflammatory process, decreased peripheral sensitization, and stimulation of antidegenerative and trophic mechanisms. Perhaps it can be part of the integrative treatments for knee osteoarthritis.

Study of Efficacy of Extraosseous Local Infiltration of Multimodal Drug Cocktail for Pain Management After Total Joint Arthroplasty in Lower Limb

Background Osteoarthritis (OA) is a chronic debilitating condition involving joints that ultimately leads to chronic pain, restricted mobility, and functional impairment of the joint. The gold standard treatment of end-stage OA is arthroplasty. Following arthroplasty surgery, patients might have excruciating pain in the postoperative period. Our study aimed to evaluate the beneficial effects of a multimodal drug cocktail in patients who underwent arthroplasty surgery concerning postoperative pain and knee range of motion during the healing period. Materials and methods In this randomised case-control study, we enrolled 32 patients, of which 16 patients had knee arthritis and underwent total knee replacement. In contrast, the other 16 patients had hip arthritis and underwent total hip replacement. Randomisation was done using simple random sampling (envelope method), and patients were divided into groups A and B accordingly. Group A consists of a postoperative pain management modality using epidural analgesia with a top-up at a 12-hour interval. Group B consists of a postoperative pain management modality using an extraosseous multimodal drug cocktail consisting of clonidine, cefuroxime, tramadol, bupivacaine, adrenaline, and normal saline in specific quantities. Visual analogue scale (VAS) was assessed post-surgery for walking and resting. Joint range of movement and walking distance were assessed post-surgery and compared between the two groups. Results A total of 32 patients who had OA and underwent total knee arthroplasty (TKA) and total hip arthroplasty (THA) were selected and divided into case and control groups of eight, each by simple random sampling (envelope method). The mean preop VAS scores for the epidural and cocktail groups were 7.88 ± 0.61 and 7.44 ± 0.62, respectively, with p = 0.057, which is insignificant. However, when the groups were compared based on VAS score while standing at 24, 48, and 72 hours, the standing VAS score was found to be significantly higher among subjects, given epidural analgesia with p-values of 0.001, 0.001, and 0.001 at 24, 48, and 72 hours, respectively, which is significant in our study. Also, postoperatively, at 24, 48, and 72 hours, the mean degree of movement was found to be significantly higher among subjects, given cocktail analgesia with p-values of 0.013, 0.001, and 0.001, respectively. Conclusion As a result of early postoperative pain alleviation, the current study concludes that multimodal pain control procedures, which combine more than two medications with distinct mechanisms of action, successfully increase patient satisfaction. A multimodal medication conjunction administered locally to patients resulted in improved functional outcomes, faster recovery, and better rehabilitation.

A Randomized Controlled Trial to Evaluate the Analgesic Effectiveness of Periarticular Injections and Pericapsular Nerve Group Block for Patients Undergoing Total Hip Arthroplasty

Pericapsular nerve group (PENG) block and periarticular injection (PAI) provide motor-sparing analgesia following hip surgery. We hypothesized that PAI offers non-inferior pain relief compared with PENG block in patients undergoing primary total hip arthroplasty (THA). In this randomized trial, 66 patients who underwent primary THA under spinal anesthesia were assigned to the PENG or PAI groups. The primary endpoint was the resting pain score 24 h postoperatively. The secondary endpoints included pain scores at rest and during movement at 6 and 48 h postoperatively, quadriceps strength at 24 h postoperatively, and opioid consumption at 24 and 48 h postoperatively. The mean difference in pain scores at rest between the two groups was 0.30 (95% confidence interval [CI], -0.78 to 1.39) at 24 h postoperatively. The upper 95% CI was lower than the non-inferiority margin, indicating non-inferior performance. No significant between-group differences were observed in the pain scores at 6 and 48 h postoperatively. Additionally, no significant differences in quadriceps strength and opioid consumption were observed between the two groups. The PAI and PENG blocks provided comparable postoperative analgesia during the first 48 h after primary THA. Further investigation is required to determine the optimal PAI technique and local anesthetic mixture.

Clinical and radiologic outcomes in patients with meniscal root tears

BACKGROUND

Meniscal root tears can lead to early knee osteoarthritis and pain. This study aimed (1) to compare clinical and radiological outcomes between patients who underwent arthroscopic meniscal root repair after meniscal root tears and those who received non-surgical treatment, and (2) to identify whether baseline MRI findings could be potential predictors for future treatment strategies.

METHODS

Patients with meniscal root tears were identified from our picture archiving and communication system from 2016 to 2020. Two radiologists reviewed radiographs and MRI studies using Kellgren-Lawrence (KL) grading and a modified Whole Organ MRI Scoring (WORMS) at baseline and follow-up. The median (interquartile range [IQR]) of follow-up radiographs and MRI studies were 134 (44-443) days and 502 (260-1176) days, respectively. MR images were assessed for root tear-related findings. Pain scores using visual analogue scale (VAS) and management strategies (non-surgical vs. arthroscopic root repair) were also collected. Chi-squared tests and independent t-tests were used to assess differences regarding clinical and imaging variables between treatment groups. Logistic regression analyses were performed to evaluate the associations between baseline MRI findings and each future treatment.

RESULTS

Ninety patients were included. VAS pain scores were significantly (p < 0.01) lower after arthroscopic repair compared to conservative treatment (1.27±0.38vs.4±0.52) at the last follow-up visit with median (IQR) of 325 (180-1391) days. Increased meniscal extrusion (mm) was associated with higher odds of receiving non-surgical treatment (OR = 1.65, 95%CI 1.02-2.69, p = 0.04). The odds of having arthroscopic repair increased by 19% for every 1 mm increase in the distance of the tear from the root attachment (OR = 1.19, 95% CI: 1.05-1.36, p < 0.01). The odds of undergoing arthroscopic repair were reduced by 49% for every 1 mm increase in the extent of meniscal extrusion (OR = 0.51, 95% CI: 0.29-0.91, p = 0.02) as observed in the baseline MRI.

CONCLUSIONS

Patients who underwent arthroscopic repair had lower pain scores than patients with conservative treatment in the follow-up. Distance of the torn meniscus to the root attachment and the extent of meniscal extrusion were significant predictors for arthroscopic repair in the next three weeks (time from the baseline MRI to the surgery date).

Cocktail of Ropivacaine, Morphine, and Diprospan Reduces Pain and Prolongs Analgesic Effects after Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

Background

Local infiltration analgesia (LIA) provides postoperative analgesia for total knee arthroplasty (TKA). The purpose of this study was to evaluate the analgesic effect of a cocktail of ropivacaine, morphine, and Diprospan for TKA.

Methods

A total of 100 patients from September 2018 to February 2019 were randomized into 2 groups. Group A (control group, 50 patients) received LIA of ropivacaine alone (80 ml, 0.25% ropivacaine). Group B (LIA group, 50 patients) received an LIA cocktail of ropivacaine, morphine, and Diprospan (80 ml, 0.25% ropivacaine, 0.125 mg/ml morphine, and 62.5 μg/ml compound betamethasone). The primary outcomes were the levels of inflammatory markers C-reactive protein (CRP) and interleukin-6 (IL-6), pain visual analog scale (VAS) scores, opioid consumption, range of motion (ROM), functional tests, and sleeping quality. The secondary outcomes were adverse events, satisfaction rates, HSS scores, and SF-12 scores. The longest follow-up was 2 years.

Results

The two groups showed no differences in terms of characteristics (P  >  0.05). Group B had lower resting VAS pain scores (1.54 ± 0.60, 95% CI = 1.37 to 1.70 vs. 2.00 ± 0.63, 95% CI = 2.05 to 2.34) and active VAS pain scores (2.64 ± 0.62, 95% CI = 2.46 to 2.81 vs. 3.16 ± 0.75, 95% CI = 2.95 to 3.36) within 48 h postoperatively than Group A (P < 0.001), while none of the pain differences exceeded the minimal clinically important difference (MCID). Group B had significantly lower CRP levels (59.49 ± 13.01, 95% CI = 55.88 to 63.09 vs. 65.95 ± 14.41, 95% CI = 61.95 to 69.94) and IL-6 levels (44.11 ± 13.67, 95% CI = 40.32 to 47.89 vs. 60.72 ± 15.49, 95% CI = 56.42 to 65.01), lower opioid consumption (7.60 ± 11.10, 95% CI = 4.52 to 10.67 vs. 13.80 ± 14.68, 95% CI = 9.73 to 17.86), better ROM (110.20 ± 10.46, 95% CI = 107.30 to 113.09 vs. 105.30 ± 10.02, 95% CI = 102.52 to 108.07), better sleep quality (3.40 ± 1.03, 95% CI = 3.11 to 3.68 vs. 4.20 ± 1.06, 95% CI = 3.90 to 4.49), and higher satisfaction rates than Group A within 48 h postoperatively (P  <  0.05). Adverse events, HSS scores, and SF-12 scores were not significantly different within 2 years postoperatively.

Conclusions

A cocktail of ropivacaine, morphine, and Diprospan prolongs the analgesic effect up to 48 h postoperatively. Although the small statistical benefit may not result in MCID, the LIA cocktail still reduces opioid consumption, results in better sleeping quality and faster rehabilitation, and does not increase adverse events. Therefore, cocktails of ropivacaine, morphine, and Diprospan have good application value for pain control in TKA. This trial is registered with ChiCTR1800018372.

The Effect of Aspiration and Corticosteroid Injection After ACL Injury on Postoperative Infection Rate

BACKGROUND

Injecting bioactive substances into the knee is common in orthopaedic practice, and recently it has been shown to mitigate risk factors for posttraumatic osteoarthritis. Therefore, understanding the influence of these injections on postoperative infection rate is imperative.

HYPOTHESIS

Postinjury aspiration and corticosteroid injection (CSI) of the knee before anterior cruciate ligament (ACL) reconstruction (ACLR) would not increase the risk of postoperative infection.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

All patients between the ages of 10 and 65 years who underwent primary bone-patellar tendon-bone ACLR by 1 fellowship-trained sports medicine orthopaedic surgeon between January 1, 2011, and September 8, 2020, at 1 of 2 major academic centers were evaluated for inclusion. A total of 693 patients were included, with 273 patients receiving postinjury and preoperative aspiration and CSI. A postoperative infection was defined as a patient returning to the operating room for an intra-articular washout. The intervals-measured in days-between the CSI and ACLR and between ACLR and the final follow-up were recorded. To further evaluate the infection risk in each cohort (total cohort; aspiration and injection cohort; no aspiration and injection cohort), the upper 95% confidence bound for the infection risk was calculated for each cohort.

RESULTS

There were no postoperative infections in the 693 patients included in this study. The upper 95% confidence bounds were 0.4%, 1.1%, and 0.7% for the total cohort, the cohort that underwent aspiration and injection, and the cohort that did not, respectively. The median number of days between the surgical date and that of the aspiration and injection was 34 days, and the mean follow-up for the entire cohort was 337.4 days (95% CI, 307.6-367.3).

CONCLUSION

Postinjury and preoperative aspiration and CSI is a safe intervention that can be used before ACLR. Future studies with larger sample sizes, longer patient follow-ups, and multiple surgeons would be helpful to both better understand infection risk and better identify the influence of CSI on preventing posttraumatic osteoarthritis.

Periarticular infiltration used in total joint replacements: an update and review article

Periarticular infiltration following total knee and hip arthroplasty has been demonstrated to be equivalent to peripheral nerve blocks for postoperative pain management. The ideal cocktail has not been established yet. We have conducted a literature search on PubMed and Embase. Our search criteria included randomized controlled trials (RCTs) and systematic reviews (SRs). We tried to only include the most recent studies to keep the information current. The included research focused at Dexmedetomidine, Liposomal Bupivacaine, Ropivacaine, Epinephrine, Ketorolac, Morphine, Ketamine and Glucocorticosteroids. Each medication's mode of action, duration, ideal dosage, contraindications, side effects and effectiveness have been summarized in the review article. This article will help the clinician to make an informed evidence-based decision about which medications to include in their ideal cocktail.

Accelerated Protocols in Adolescent Idiopathic Scoliosis Surgery

Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Treatment depends on the degree of curvature, skeletal maturity, and age of the patient. Once the curve reaches 50 degrees, posterior spinal fusion (PSF) is necessary to stabilize the spine and prevent further progression of the curve. PSF causes significant trauma to the tissues and often results in significant pain postoperatively. The purpose of this article is to provide the audience with a review of preoperative, intraoperative, and postoperative pain control with an accelerated protocol in patients with AIS undergoing PSF.

Outpatient Total Knee Arthroplasty Shows Decreasing Complication Burden From 2010 to 2020

BACKGROUND

The number of total knee arthroplasties (TKAs) performed on an outpatient basis continues to increase. The purpose of this study was to compare complication rates over the last decade to evaluate trends in the safety of outpatient TKA.

METHODS

Patients who underwent TKA from 2010 to 2020 from a large administrative claims database were retrospectively identified and stratified based on the year of surgery. Propensity-score matching was performed to match patients who were discharged within 24 hours of surgery to inpatients based on age, sex, comorbidity index, and year of surgery. Linear regression analyses were used to compare trends from 2010 to 2020. The 90-day adverse events in the early cohort (2010-2012) were compared to those in the late cohort (2018-2020) using multivariable regression analyses. Of the 547,137 patients in the sample, 28,951 outpatients (5.3%) were propensity matched to inpatients.

RESULTS

The incidence of outpatient TKA increased from 2010 to 2018 (1.9 versus 13.8%, P < .001). Despite a similar complication rate early (24.1 versus 22.6%, P = .164), outpatient TKA had fewer complications at the end of the study period (13.7 versus 16.7%, P < .001). Multivariate analyses demonstrated that the risk of any complication after outpatient TKA was lower than inpatient from 2018 to 2020 (odds ratio, 0.78; 95% confidence interval, 0.71-0.84).

CONCLUSIONS

Complications in both cohorts declined dramatically suggesting improvements in quality of care over time, with the greatest decline in patients undergoing outpatient surgery. These results suggest that outpatient TKA today is not higher risk for the patient than inpatient TKA.

LEVEL OF EVIDENCE

Level III.

Perioperative multimodal analgesic injection for patients with adolescent idiopathic scoliosis undergoing posterior spinal fusion surgery

PURPOSE

This retrospective cohort study compared postoperative as-needed (PRN) opioid consumption pre and postimplementation of a perioperative multimodal analgesic injection composed of ropivacaine, epinephrine, ketorolac, and morphine in patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Secondary outcomes include pain score measurements, time to ambulation, length of stay, blood loss, 90-day complication rate, operating room time, nonopioid medication usage, and total inpatient medication cost before and after the initiation of this practice.

METHODS

Consecutive patients weighing ≥ 20 kg who underwent PSF for a primary diagnosis of AIS between January 2017 and December 2020 were included. Data from 2018 were excluded to account for standardization of the practice. Patients treated in 2017 only received PCA. Patients treated in 2019 and 2020 only received the injection. Excluded were patients who had any diagnoses other than AIS, allergies to any of the experimental medications, or who were nonambulatory. Data were analyzed utilizing the two-sample t-test or Chi-squared test as appropriate.

RESULTS

Results of this study show that compared with 47 patients treated postoperatively with patient-controlled analgesia (PCA), 55 patients treated with a multimodal perioperative injection have significantly less consumption of PRN morphine equivalents (0.3 mEq/kg vs. 0.5 mEq/kg; p = 0.02). Furthermore, patients treated with a perioperative injection have significantly higher rates of ambulation on postoperative day 1 compared with those treated with PCA (70.9 vs. 40.4%; p = 0.0023).

CONCLUSION

Administration of a perioperative injection is effective and should be considered in the perioperative protocol in patients undergoing PSF for AIS.

LEVEL OF EVIDENCE

Therapeutic Level III.

Surgeon-placed peripheral nerve block and continuous non-opioid analgesia in total knee arthroplasty is accessible intraoperatively: A cadaveric study

BACKGROUND

Pain management in TKA patients is challenged by a postoperative requirement for early ambulation along with the concurrent goal of reducing opioid consumption while simultaneously reducing the length of hospital stay. Peripheral nerve blocks (PNB) address these concerns to some degree, with femoral nerve and adductor canal blocks being the most-used regional nerve blocks for surgeries performed around the knee joint.

PURPOSE

The authors hypothesized that placing a catheter between the muscles that make up the adductor canal during a standard surgical approach for a Total Knee Arthroplasty would provide equitable or superior access for a peripheral nerve block in the adductor canal. The nerves that are located between the muscles that make up the adductor canal transmit the majority of the pain after TKA.

METHODS

This cadaveric study was conducted in 12 fresh-frozen human cadaveric lower limbs, comparing the standard technique of adductor canal block, placed under ultrasound guidance, to this experimental technique. Using colored indicator dyes to locate the site of surrogate peripheral nerves, the techniques were compared.

RESULTS

Through a standard anterior surgical approach to the knee, an intraoperative catheter placement technique can be performed to provide a peripheral nerve block to the saphenous nerve for patients undergoing TKA that is comparable to standard ultrasound guided anesthesia block techniques.

CONCLUSIONS

This cadaveric study demonstrates the availability for the surgeon to place a catheter between the muscles that form the adductor canal during a standard surgical approach for TKA. This novel technique can provide equivalent coverage of the nerves for an ACB when compared to a standard ultrasound guided ACB.

Diagnostic ultrasound and ultrasound-guided injections for peri-articular pain after knee replacement

OBJECTIVE

The purpose of this technical report is to review the sonographic spectrum of abnormalities accounting for peri-articular pain after knee replacement surgery, as well as to demonstrate the clinical utility of ultrasound in the diagnosis and treatment of this subset of patients.

MATERIALS AND METHODS

Utilizing an imaging report database, we performed a search for ultrasound examinations performed by a single radiologist for knee pain after knee arthroplasty at our institution over a 10-year period. The search yielded 63 patients, whom we have categorized by causative pathology, with representative diagnostic and procedural ultrasound images selected for inclusion.

RESULTS

Our search yielded multiple causes of peri-articular knee pain after arthroplasty, including medial and lateral retinacular impingement and scarring, iliotibial band or conjoined tendon irritation, popliteus tendon impingement, medial collateral ligament impingement, pes anserine bursitis, and scarring of Hoffa's fat pad.

CONCLUSION

While knee arthroplasty is an often-successful procedure, it can be complicated by post-operative peri-articular knee pain. Ultrasound provides a valuable tool for the diagnosis of painful peri-articular knee pathology, as it allows for both static and dynamic evaluation, as well as direct correlation with patient symptoms, and is not confounded by the metal components. In addition to its diagnostic utility, ultrasound can also guide diagnostic and/or therapeutic injections of anesthetic and corticosteroid. Given these advantages, ultrasound is an important tool in managing the painful post-arthroplasty knee.

Periarticular Injection in Total Knee Arthroplasty

Optimal pain management after total knee arthroplasty (TKA) can expedite postoperative recovery, improve perioperative outcomes, and increase patient satisfaction. Periarticular injections (PAIs) have become increasingly used to improve pain management after TKA. Similar to peripheral nerve blocks, the use of intraoperative PAIs can lower pain scores and expedite discharge from the hospital. However, there is notable variability in the ingredients and administration techniques of PAIs. Currently, no standard of care exists for PAIs, especially in the setting of adjuvant peripheral nerve blocks. This study seeks to evaluate the ingredients, administration techniques, and outcomes of PAIs used during TKA.

Efficacy of a Modified Cocktail for Periarticular Local Infiltration Analgesia in Total Knee Arthroplasty: A Prospective, Double-Blinded, Randomized Controlled Trial

BACKGROUND

Periarticular local infiltration analgesia (LIA) is largely utilized for controlling pain after total knee arthroplasty (TKA). The present work aimed to assess the efficacy of a modified LIA cocktail for patients undergoing TKA.

METHODS

Magnesium sulfate (MgSO4) and sodium bicarbonate (NaHCO3) were added to a conventional LIA cocktail comprising ropivacaine, epinephrine, and dexamethasone. After the safety of this modified cocktail was tested in rats, its efficacy and safety were evaluated in a prospective, double-blinded study including 100 individuals randomized to receive periarticular infiltration of the modified cocktail or a conventional cocktail. The primary outcome was postsurgical use of morphine hydrochloride for rescue analgesia. Secondary outcomes were the time until the first rescue analgesia, postsurgical pain (on a visual analog scale [VAS]), functional recovery (assessed by range of knee motion and ambulation distance), time to discharge, and complication rates.

RESULTS

Adding NaHCO3 to the local anesthetics caused some instantaneous precipitation in all cases. Administering the modified cocktail to rats did not obviously damage the injected area of the nerve or surrounding tissues. Administration of the modified cocktail to patients was associated with markedly reduced postsurgical morphine use in the initial 24 hours (4.2 ± 5.0 versus 14.6 ± 8.9 mg, p < 0.001), reduced total morphine use (9.8 ± 8.4 versus 19.6 ± 11.4 mg, p < 0.001), prolonged time to the first rescue analgesia, lower VAS pain scores at rest and during motion at 12 and 24 hours following the operation, better functional recovery on postoperative days 1 and 2, and a shorter hospital stay. The modified and conventional cocktail groups had similar rates of complications.

CONCLUSIONS

The present modification of a conventional cocktail significantly prolonged analgesia and reduced opioid consumption, which may substantially improve pain control in arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of epinephrine in local infiltration analgesia on pain relief and opioid consumption following total knee arthroplasty: a randomized controlled trial

BACKGROUND AND PURPOSE

Local infiltration analgesia (LIA) is one of the effective regimens to reduce pain after total knee arthroplasty (TKA). Epinephrine is a commonly used sympathetic adjunct in LIA. It is expected to enhance the intensity and extend the duration of LIA. The primary aim of the study was to evaluate the efficacy of epinephrine on postoperative pain control after primary TKA.

PATIENTS AND METHODS

A total of 80 patients who underwent primary TKA were randomized into an epinephrine (EN) and a control (C) group. Postoperative visual analogue pain score (VAPS) and morphine consumption were recorded every 6 hours until 48 hours after operation. The VAPS 6-48 hours were compared using repeated measure statistics. The range of motion (ROM) on discharge and complications were also compared between these 2 groups.

RESULTS

The study showed that although VAPS differed statistically between the 2 groups at 12 hours (C higher) and 48 hours (C lower) postoperatively (p = 0.04 and 0.02, respectively), repeated measures analysis revealed that there were no significant differences in 6-48 hours VAPS (p = 0.6). Total morphine consumption in the EN and C groups was 3.4 (SD 3.7) and 4.2 (SD 4.4) mg, respectively (p = 0.4). ROM on discharge was also similar between the groups. No complications were detected in this study.

CONCLUSION

Our study showed that additional epinephrine in LIA had a statistically significant reduction in VAPS at 12 hours and morphine usage during 6-12 hours when compared with the control group. However, the magnitude of difference did not reach minimal clinically importance difference (MCID) value for TKA.

Management of perioperative pain after TKA

Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.

Dexmedetomidine Prolongs the Analgesic Effects of Periarticular Infiltration Analgesia following Total Knee Arthroplasty: A Prospective, Double-blind, Randomized Controlled Trial

BACKGROUND

Periarticular infiltration analgesia (PIA) is widely administered to relieve postoperative pain following total knee arthroplasty (TKA). The present study aimed to evaluate the effect of prolonging the analgesic duration by adding dexmedetomidine to PIA for pain management after TKA.

METHODS

One hundred and sixteen patients were randomly allocated into 3 groups based on PIA regimens including Group R (ropivacaine), Group E (ropivacaine plus epinephrine), and Group D (ropivacaine plus dexmedetomidine). The primary outcomes were postoperative visual analog scale (VAS) scores, time until the administration of first rescue analgesia, and opioid consumption. The secondary outcomes included postoperative inflammatory biomarkers and functional recovery. The tertiary outcomes were postoperative complications and adverse events.

RESULTS

The patients in Group D had significantly lower resting VAS scores than those in Groups R and E at 6 hours after surgery. Group R showed the higher pain scores at rest and motion than Groups D and E 12 hours postoperatively. The use of dexmedetomidine or epinephrine postponed the time until the administration of first rescue analgesia and led to lower opioid consumption in the first 24 hours after TKA. The levels of IL-8 and TNF-α in Groups D and E were significantly lower than those in Group R on postoperative Day 3. Furthermore, no significant differences were observed in functional recovery, postoperative complications, or adverse events among the three groups.

CONCLUSIONS

Adding dexmedetomidine as an adjuvant to PIA could potentiate and prolong the analgesic effect in the early stage following TKA without increasing the risk of adverse events.

Surgeon-Performed Intraoperative Peripheral Nerve Blocks and Periarticular Infiltration During Total Hip and Knee Arthroplasty: A Critical Analysis Review

➢

Surgeon-performed intraoperative peripheral nerve blocks may improve operating room efficiency and reduce hospital resource utilization and, ultimately, costs. Additionally, these blocks can be safely performed intraoperatively by most orthopaedic surgeons, while only specifically trained physicians are able to perform ultrasound-guided peripheral nerve blocks.

➢

IPACK (infiltration between the popliteal artery and capsule of the knee) blocks are at least noninferior to periarticular infiltration when combined with an adductor canal block for analgesia following total knee arthroplasty.

➢

Surgeon-performed intraoperative adductor canal blocks are technically feasible and offer reliable anesthesia comparable with ultrasound-guided blocks performed by anesthesiologists. While clinical studies have shown promising results, additional Level-I studies are required.

➢

A surgeon-performed intraoperative psoas compartment block has been described as a readily available and safe technique, although there is some concern for femoral nerve analgesia, and temporary sensory changes have been reported.

Motor-sparing peripatellar plexus block provides noninferior block duration and complete block area of the peripatellar region compared with femoral nerve block: a randomized, controlled, noninferiority study

BACKGROUND

Developing adequate regional anaesthesia for knee surgeries without affecting lower limb mobilization is crucial to perioperative analgesia. However, reports in this regard are limited. We proposed a technique for ultrasound-guided peripatellar plexus (PP) block. Compared with the femoral nerve (FN) block, we hypothesized that this technique would provide a noninferior block duration and a complete cutaneous sensory block in the peripatellar region without affecting lower limb mobilization. An investigation was conducted to verify our hypothesis in cadavers and volunteers.

METHODS

The study was designed in two parts. First, eight cadaveric lower limbs were dissected to verify the feasibility of PP block after methylene blue injection under ultrasound. Second, using a noninferiority study design, 50 healthy volunteers were randomized to receive either a PP block (PP group) or an FN block (FN group). The primary outcome was the duration of peripatellar cutaneous sensory block, with the prespecified noninferiority margin of -3.08 h; the secondary outcome was the area of peripatellar cutaneous sensory block; in addition, the number of complete anaesthesias of the incision line for total knee arthroplasty and the Bromage score 30 min after block were recorded.

RESULTS

The PP was successfully dyed, whereas the FN and saphenous nerve were unstained in all cadaveric limbs. The mean difference of the block duration between the two groups was - 1.24 (95% CI, -2.81 - 0.33) h, and the lower boundary of the two-sided 95% CI was higher than the prespecified noninferiority margin (P_{noninferiority} = 0.023), confirming the noninferiority of our technique over FN block. The cutaneous sensory loss covered the entire peripatellar region in the PP group. PP block achieved complete anaesthesia of the incision line used for total knee arthroplasty and a Bromage score of 0 in 25 volunteers, which differed significantly from that of volunteers who underwent FN block.

CONCLUSION

Ultrasound-guided PP block is a feasible technique. Compared with FN block, PP block provides noninferior block duration and complete blocking of the peripatellar region without affecting lower limb mobilization.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Register (registration no. ChiCTR2000041547, registration date 28/12/2020).

Comparison of the Effect of Intra-Articular, Periarticular, and Combined Injection of Analgesic on Pain Following Total Knee Arthroplasty: A Double-Blinded Randomized Clinical Trial

The aim of this study was to compare the efficacy of 3 methods of intraoperative analgesic cocktail injection during total knee arthroplasty (TKA)—intra-articular (IA), periarticular (PA), and combined intra-articular and periarticular (IA+PA)—on controlling early postoperative pain.

A eficácia da infiltração periarticular anestésica na analgesia pós-operatória de artroplastia total do quadril

Objetivo Este estudo tem como objetivo avaliar a eficácia da técnica de infiltração periarticular do quadril no pós-operatório de artroplastia total do quadril.

Métodos Estudo clínico randomizado duplo-cego controlado. O estudo foi realizado nos pacientes com fratura de colo femoral ou osteoartrose de quadril, submetidos ao procedimento cirúrgico de artroplastia total do quadril em nossa instituição. A técnica de infiltração periarticular consistiu na aplicação da combinação de um anestésico (levobupivacaína) com um corticosteroide (dexametasona) nos tecidos ricos em nociceptores do quadril, após a colocação dos implantes ortopédicos. No grupo controle, foi realizada infiltração de soro fisiológico 0,9% nos mesmos tecidos. Após 24 e 48 horas do procedimento, foram avaliados os quesitos de dor, amplitude de movimentos, uso de analgésicos opióides, presença de efeitos adversos, período do início da deambulação e o tempo total de hospitalização.

Resultados Trinta e quatro pacientes foram estatisticamente avaliados no estudo. Foi observada uma redução no consumo de opioides entre 24 e 48 h no grupo experimental. Uma redução maior da pontuação de dor foi observada no grupo placebo.

Conclusão A infiltração periarticular anestésica como método de analgesia pós-operatória de artroplastia total do quadril, neste estudo, reduziu as taxas de consumo de opioides quando comparamos a evolução entre 24 e 48h. Não houve benefícios quanto às taxas de dor, mobilidade, tempo de internação ou intercorrências com este método.

Adductor canal block combined with local infiltration analgesia with morphine and betamethasone show superior analgesic effect than local infiltration analgesia alone for total knee arthroplasty: a prospective randomized controlled trial

Background

Local infiltration analgesia (LIA) and adductor canal block (ACB) provide postoperative analgesia for total knee arthroplasty (TKA). ACB blocks the saphenous nerve and has smaller impacts on quadriceps muscle weakness. ACB theoretically does not have enough analgesic effects on posterior sensory nerves. LIA may increase its analgesic effects on the posterolateral knee. The purpose of this study was to evaluate whether ACB combined with a LIA cocktail of ropivacaine, morphine, and betamethasone has superior analgesic effect than LIA for TKA.

Methods

A total of 86 patients were assessed for eligibility from February 2019 to May 2019. 26 of those were excluded, and 60 patients were divided into 2 groups by computer-generated random number. Group A (LIA group) received LIA cocktail of ropivacaine, morphine and betamethasone. Group B (LIA+ ACB group) received ultrasound-guided ACB and LIA cocktail of ropivacaine, morphine and betamethasone. Postoperative visual analogue scale (VAS) resting or active pain scores, opioid consumption, range of motion (ROM), functional tests, complications and satisfaction rates were measured. The longest follow-up was 2 years.

Results

Two groups have no differences in terms of characteristics, preoperative pain or function (P > 0.05). ACB combined with LIA had significantly lower resting and active VAS pain scores, better ROM, better sleeping quality and higher satisfaction rates than LIA alone within 72 h postoperatively (P < 0.05). Complications, or adverse events and HSS score, SF-12 score were observed no significant differences within 2 years postoperatively.

Conclusions

Adductor canal block combined with Local infiltration analgesia provide better early pain control. Although the small statistical benefit may not result in minimal clinically important difference, Adductor canal block combined with Local infiltration analgesia also reduce opioid requirements, improve sleeping quality, and do not increase the complication rate. Therefore, Adductor canal block combined with Local infiltration analgesia still have good application prospects as an effective pain management for total knee arthroplasty.

Trial registration

Chinese Clinical Trial Registry, ChiCTR1900021385, 18/02/2019.

Comparison of iPACK and periarticular block with adductor block alone after total knee arthroplasty: a randomized clinical trial

PURPOSE

The infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) has been described to provide analgesia without loss of muscle strength and is effective in functional recovery. This study compared iPACK + ACB (adductor canal block) with PAI (periarticular infiltration) + ACB and ACB alone in terms of postoperative analgesia and functional improvement.

METHODS

This double-blinded randomized controlled trial included 105 patients undergoing unilateral total knee arthroplasty. Patients received ACB, iPACK + ACB, and PAI + ACB along with spinal anesthesia. The primary outcome was the area under the curve (AUC) numeric rating scale (NRS) at 48 h. Secondary outcomes were cumulative postoperative analgesic consumption within 48 h, timed up-and-go test, range of motion, length of hospital stay, patient satisfaction, and adverse events.

RESULTS

The 48-h AUC movement NRS score in the iPACK + ACB group was significantly lower than in the PAI + ACB and ACB groups (p < 0.05). At the postoperative 48th h, the opioid consumption of the iPACK + ACB group was lower than those of the ACB and PAI + ACB groups (p < 0.001). The patients in the iPACK + ACB group had significantly shorter discharge and mobilization days than the ACB and PAI + ACB groups (p < 0.001).

CONCLUSIONS

The adding of an iPACK block to the ACB improves postoperative analgesia and reduces opioid consumption. In addition, this approach improves functional performance and reduces hospital stay.

The Effect of a Local Injection of Flurbiprofen Ester Microspheres on Systemic Inflammatory Model Rats With a Closed Femoral Shaft Fracture

Background: Periarticular injections with a combination of local anesthetics, non-steroidal anti-inflammatory analgesics (NSAIDs), and epinephrine are becoming increasingly popular in the perioperative analgesia of artificial joint replacement. However, data on the efficacy and safety of local injection NSAIDs are still scarce. The purpose of this study was to investigate the efficacy and safety of a local injection of Flurbiprofen Ester Lipid microspheres into the inflammatory model of femoral shaft closed fractures in rats.

Methods: A systemic inflammatory model was induced in SD rats (60) by closed femoral shaft fracture; 12 non-fractured rats were used as the blank control group (group A). The systemic inflammation model of 60 rats was divided into 5 groups (12 in each group); Group B: intramuscular injectionof the same amount of normal saline at different time points as a negative control; Group C: intravenous injection of Flurbiprofen Ester microspheres (4.5 mg/kg) at different time points; Group D: intramuscular injection of Flurbiprofen Ester microspheres (2.25 mg/kg) at different time points; Group E: intramuscular injection of Flurbiprofen Ester microspheres (4.5 mg/kg) at different time points; Group F: intramuscular injection of Flurbiprofen Ester microspheres (9 mg/kg) at different time points. The behavioral test observed the behavior of the rats. Then, the inflammation factors of CRP, IL-6, COX-1, COX-2 and TNF-αby ELISA were recorded.

Results: Through the behavioral test it could be found that the effect of the intramuscular and intravenous injections of Flurbiprofen Ester microspheres was similar. Fracture rats with a local injection of Flurbiprofen Ester microspheres showed lower inflammation levels measured by COX-1, CRP, and TNF-α compared with the control group. Pathological sections at 24, 48, and 96 h after surgery did not display any local muscle necrosis at the local injection site. These findings suggested that a Flurbiprofen Ester microsphere muscular injection exhibited a similar effect to an intravenous injection.

Conclusion: The local injection of Flurbiprofen Ester microspheres significantly reduced the inflammatory response in fracture rats and did not increase the risk of muscle necrosis, suggesting its feasibility in local injection analgesia.

Comparison of Multimodal Cocktail to Ropivacaine Intercostal Nerve Block for Chest Pain After Costal Cartilage Harvest: A Randomized Controlled Trial

Objective: To compare the effectiveness of an intercostal nerve block after costal cartilage harvest when a multimodal cocktail or ropivacaine plus patient-controlled analgesia is used, as measured by visual analog scale (VAS) scores, rescue analgesic consumption, and related complications. Materials and Methods: Eligible patients who underwent costal cartilage harvest were equally randomized to receive a multimodal cocktail (multimodal group) or ropivacaine plus patient-controlled analgesia (ropivacaine group). Results: Of 112 patients assessed, 12 (10.7%) patients were excluded and 100 (89.3%) patients were enrolled and assigned to multimodal group (n = 50) and ropivacaine group (n = 50). The VAS scores in the multimodal group were significantly lower than those in the ropivacaine group both at rest (0.924 ± 0.073 vs. 1.920 ± 0.073, p < 0.001) and during coughing (2.340 ± 0.083 vs. 3.944 ± 0.083, p < 0.001) in mixed-effects model analysis. Rescue analgesic consumption and rate of complications were significantly lower in the multimodal group compared with the ropivacaine group (all p < 0.05). Conclusions: Multimodal cocktail improved chest pain after costal cartilage harvest with less rescue analgesic consumption and complications compared with ropivacaine plus patient-controlled analgesia. Clinical Trial Registration: ChiCTR2100042445.

Adductor Canal Block Combined With IPACK Block for Postoperative Analgesia and Function Recovery Following Total Knee Arthroplasty: A Prospective, Double-Blind, Randomized Controlled Study

BACKGROUND

This study aimed to explore the analgesic effect among adductor canal block (ACB) combined with infiltration between the popliteal artery and the capsule of the posterior knee (IPACK) block, ACB, and IPACK block following total knee arthroplasty (TKA).

METHODS

One hundred twenty patients were randomly allocated into 3 groups including group A (ACB + IPACK block), group B (ACB), and group C (IPACK block). The primary outcome was postoperative pain score. The secondary outcome was opioid consumption. Other outcomes included functional evaluation and postoperative complications.

RESULTS

Group A showed the lowest pain scores within 8 hours at rest and with knee maximum flexion (P < .001). From 12 to 24 hours, group C showed the highest pain scores, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups 24 hours postoperatively. Group C showed the most opioid consumption within the first 24 hours and during the hospitalization, while no significant difference was found between group A and group B. No significant difference was found among the 3 groups including function evaluation and postoperative complications.

CONCLUSION

ACB + IPACK block can improve early analgesia when compared with ACB. However, the small statistical benefit to the addition of IPACK block to ACB may be unlikely to be clinically significant. Further studies may focus on patient selection and how to prolong the effect of IPACK block.

Minimizing the Risk of Opioid Misuse and Abuse in the Surgical Setting

The misuse of opioids continues to be a public health problem. Acute post-surgical pain management requires a careful balance between the benefits and risks of opioids. Opioids should be part of a multimodal treatment plan, including the use of nonopioid and nonpharmacologic treatment options. Multimodal pain management allows for individualized treatment and improved patient satisfaction while limiting the risks inherent to opioids, including diversion. Surgeons should avoid overprescribing opioids and have a plan for decreasing the use of opioids in the postsurgical time frame. With careful consideration of the risks, opioids can be prescribed to treat acute postsurgical pain effectively. [Orthopedics. 2021;44(6):353-359.].

Modern Suture Anchor Techniques for Gluteus Medius Tear Repair With Concomitant Total Hip Arthroplasty Using the Direct Anterior and Posterior Approaches

Gluteus medius (GM) tears are currently a well-established source of pain and disability. However, their role in primary total hip arthroplasty (THA) in the setting of osteoarthritis (OA) has been underexamined in the literature. The purpose of this study was to report on short-term patient-reported outcome measurements (PROMs) for patients who underwent concomitant primary THA and GM repair. Data were prospectively collected from September 2011 and June 2017. Inclusion criteria were primary THA along with concomitant GM repair and complete follow-up for the Harris Hip Score, Forgotten Joint Score 12, Veterans RAND 12-item Health Survey both Physical and Mental, 12-item Short Form Survey both Physical and Mental (SF-12 P and SF-12 M), visual analog scale for pain, and patient satisfaction. Patients were excluded if they did not have follow-up. Thirty patients (30 hips) were included. Mean follow-up was 24.2±19.3 months. Twenty-nine (96.7%) patients were female. Mean age was 65.2±7.4 years. Mean body mass index was 31.1±5.9 kg/m². The posterior approach was used for 16 (53.3%) cases and the anterior approach for the remaining 14 (46.7%). Two (6.7%) patients had a less than 25% tear, 7 (23.3%) had a 25% to 50% tear, 14 (46.7%) had a greater than 50% tear, and 7 (23.3%) had a full-thickness tear. All PROMs except SF-12 M demonstrated significant improvement at latest follow-up. Patients who underwent THA with either the anterior or the posterior approach with concomitant GM repair using modern suture anchor techniques reported favorable PROMs at short-term follow-up. [Orthopedics. 2021;44(5):e653-e660.].

Multimodal Peri-articular Injection with Tranexamic Acid can reduce postoperative blood loss versus Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Trial

Background

Tranexamic acid (TXA) has shown significant reductions in blood loss and transfusion rates in total knee arthroplasty (TKA). However, the optimal administration route continues to be debated. The aim of this trial was to compare the effectiveness of intravenous (IV) versus peri-articular injection (PAI) application of tranexamic acid in patients undergoing total knee arthroplasty.

Methods

We conducted a randomized controlled, double-blinded study. A total of 93 patients undergoing primary unilateral TKA were randomly distributed between 2 groups: the IV group (47 cases; 1 g TXA IV) and the PAI group (46 cases; 1 g TXA injected peri-articularly). The amount of total and hidden blood loss (HBL), drainage, transfusion rate, hemoglobin and hematocrit drift, and complications were recorded.

Results

Peri-articular injection of TXA reduced total blood loss (P < 0.001) and HBL more than IV use of TXA (P < 0.001). No patients in either group received a transfusion. No symptomatic deep venous thrombosis or other severe complications occurred.

Conclusion

Peri-articular injection of TXA significantly reduced total blood loss and hidden blood loss to a greater degree than IV injection in total knee arthroplasty without reduction of drainage volume.

Trial registration

Chinese Clinical Trial Registry, ChiCTR-INR-16010270. Date of registration: December 27, 2016.

Comparison of Periarticular Infiltration and Combination Delivery of Local Anesthetics for Reducing Pain and Opioid Consumption after Total Knee Arthroplasty

Surgical-site delivery of local anesthetics decreases pain and opioid consumption after total knee arthroplasty (TKA). The optimal route of administration is unknown. We compared local anesthetic delivery using periarticular soft-tissue infiltration to delivery using a combination of preimplantation immersion and intra-articular injection (combination treatment). The records of patients who underwent unilateral, cemented, primary TKA with spinal anesthesia and adductor canal blocks at a single Veterans Affairs Medical Center were retrospectively reviewed. Three subgroups were compared, including controls who did not receive additional local anesthetics, patients who received periarticular infiltration, and patients who received combination treatment. Mean daily pain scores and mean 24-hour opioid consumption on postoperative days (PODs) 0 and 1 were calculated, and analysis of variance was used to assess for significant differences. Factors that were associated with lower pain scores and opioid consumption were then identified using multivariate stepwise regression. There were 26 controls, 25 periarticular infiltration patients, and 39 combination patients. The periarticular infiltration cohort had significantly lower mean pain scores and opioid consumption than controls on POD 0, but not on POD 1. The combination cohort had significantly lower mean pain scores and opioid consumption than controls on PODs 0 and 1. There were no significant differences between the infiltration and combination groups on either day. Multivariate regression analysis showed that infiltration was associated with significantly decreased opioid consumption on both days and decreased pain on POD 0. Combination treatment was associated with significantly decreased pain and opioid consumption on both days. Both local anesthetic periarticular infiltration and combination treatment are associated with decreased pain and opioid consumption after TKA. The stronger effects of the combination treatment compared with periarticular infiltration on POD 1 suggests that combination delivery may have a longer duration of action.

Adding corticosteroids to periarticular infiltration analgesia improves the short-term analgesic effects after total knee arthroplasty: a prospective, double-blind, randomized controlled trial

PURPOSE

Periarticular infiltration analgesia (PIA) is widely used to control postoperative pain in patients who underwent total knee arthroplasty (TKA). This study aimed to evaluate the efficacy of adding corticosteroids to the PIA cocktail for pain management in patients who underwent TKA.

METHODS

The patients were randomized to the corticosteroid or control group (double-blind). The patients in the corticosteroid group received a periarticular infiltration of an analgesic cocktail of ropivacaine, epinephrine, and dexamethasone. Dexamethasone was omitted from the cocktail in the control group. The primary outcomes were postoperative pain [assessed using a visual analog scale (VAS)], time until the administration of first rescue analgesia, morphine consumption, and postoperative inflammatory biomarkers [C-reactive protein (CRP) and interleukin-6 (IL-6)]. The secondary outcomes were functional recovery, assessed by the range of knee motion, quadriceps strength, and daily ambulation distance. The tertiary outcomes included postoperative adverse effects.

RESULTS

The patients in the corticosteroid group had significantly lower resting VAS scores at 6 and 12 h after surgery, lower VAS scores during motion up to 24 h after surgery, and lower levels of inflammatory biomarkers. All the differences in the VAS scores between the two groups did not reach the point to be considered clinically significant. The additional use of corticosteroid significantly prolonged analgesic effects and led to lower rescue morphine consumption. The patients in the corticosteroid group had significantly better functional recovery on the first day after surgery. The two groups had a similar occurrence of adverse effects.

CONCLUSIONS

Adding corticosteroids to an analgesic cocktail for PIA could lightly improve early pain relief and accelerate recovery in the first 24 h after TKA.

LEVEL OF EVIDENCE

Randomized controlled trial, Level I.

Intraoperative periarticular injection can alleviate the inflammatory response and enhance joint function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures

PURPOSE

This study aimed to investigate the potential beneficial effects of periarticular injection (PAI) of multimodal drugs on the inflammatory response and joint function after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures.

METHODS

Fifty six elderly patients with unilateral osteoporotic femoral neck fractures were randomly allocated to 2 groups: the PAI group, which received the multimodal drug PAI intraoperatively before incision closure, and the control group, which received an injection of saline at the same time as placebo. The C-reactive protein (CRP), interleukin-1β (IL-1β), and IL-6 levels as well as the erythrocyte sedimentation rate (ESR) in peripheral venous blood samples were measured, along with the Visual Analogue Scale (VAS) score with activity and Harris hip score preoperation at 1, 2, 4, 7, and 14 days as well as 1 and 3 months post-operation.

RESULTS

The 2 groups were comparable in sex and age, and no significant differences were observed in the preoperative CRP, IL-1β, and IL-6 levels, ESR, VAS score, or Harris hip score between the 2 groups (all P > .05). However, during the postoperative period, the PAI group exhibited significantly lower levels of CRP, IL-1β, and IL-6 as well as a lower ERS and VAS score compared with the control group (P < .05), while the Harris hip score was significantly higher postoperatively in the PAI group (P < .05).

CONCLUSION

Multimodal drug PAI can alleviate the inflammatory response and enhance hip function recovery after hip arthroplasty in elderly patients with osteoporotic femoral neck fractures.

Repair of Symptomatic Partial Gluteus Medius Tear During Total Hip Arthroplasty Through the Direct Anterior Approach

Gluteus medius (GM) tears are a well-established source of pain and disability. Considering previous studies, which have reported rates of incidental GM tears in 20% of patients undergoing primary total hip arthroplasty (THA) and a 3-fold greater rate in elderly female patients, additional focus should be placed on identifying treatment options. The direct anterior approach (DAA) for primary THA has gained popularity within the past few years. However, there has been a paucity in the literature on how to address symptomatic and partial GM tears through this approach. The purpose of this Technical Note is to describe a method to repair partial GM tears during primary THA using the DAA.

Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery

BACKGROUND

Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery.

AREAS OF UNCERTAINTY

Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery.

DATA SOURCES

Narrative literature review using keywords, expert opinion, either during or from live conference.

THERAPEUTIC ADVANCES

Local and IA administration of NSAIDs for pain management in orthopedic surgery.

CONCLUSION

There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.

"Outpatient"-Same-calendar-day Discharge Hip and Knee Arthroplasty

As the length of stay for hip and knee arthroplasty has decreased over the years, "outpatient," or same-calendar-day discharge has become increasingly common. Outpatient arthroplasty offers several possible benefits over traditional inpatient arthroplasty, including potential for cost reductions, faster rehabilitation, improved patient satisfaction, and reduced reliance on hospital resources. Despite these possible benefits, concerns remain over feasibility and patient safety. To date, multiple studies have demonstrated that, for select patients, "outpatient" hip and knee arthroplasty can be safe and effective and yield complication and readmission rates similar to inpatient procedures at potentially significant cost savings. Successful outpatient pathways have emphasized careful patient selection, detailed patient education, enlistment of strong social support, utilization of multimodal analgesia and strong "episode ownership," and involvement on behalf of the surgical team. As outpatient hip and knee arthroplasty becomes increasingly common, continued investigation into all aspects of the surgical episode is warranted.

Revision total hip arthroplasty is associated with significantly higher opioid consumption as compared to primary total hip arthroplasty in the acute postoperative period

BACKGROUND

There are currently a lack of investigations that characterised narcotic utilisation following revision total hip arthroplasty (THA). We sought to determine if immediate post-surgical opioid use was different between revision THA and primary THA.

METHODS

A single institution total joint arthroplasty database was used to identify adult patients who underwent revision THA or primary THA from 2016 to 2019. Morphine milligram equivalents (MME) were calculated for different time periods.

RESULTS

6977 patients were identified, 89.72% primary THA and 10.28% revision THA. Aggregate opioid consumption was higher for revision THA patients (317.40 MME vs. 93.01 MME), as was opioid consumption in the first 24 hour and second 24-hour periods. Visual analogue pain (VAS) scores were significantly higher in the 0-12 hour postoperative and the 12-24 hours postoperative periods in the revision THA group.

CONCLUSIONS

Patients undergoing revision THA had significantly higher narcotic utilisation than those undergoing primary THA, particularly in the first 24 hours postoperatively.

Revision Total Knee Arthroplasty Is Associated With Significantly Higher Opioid Consumption as Compared With Primary Total Knee Arthroplasty in the Acute Postoperative Period

BACKGROUND

There is a scarcity of studies investigating narcotic use after revision total knee arthroplasty (TKA). We compared immediate postsurgical narcotic consumption after revision TKA and primary TKA.

METHODS

A single-institution database was used to identify patients who underwent revision TKA or primary TKA between 2016 and 2019. Morphine milligram equivalents (MMEs) were calculated to discern narcotic usage, and pain visual analog score was also used.

RESULTS

A total of 7342 cases were identified: 88.65% primary TKA and 11.35% revision TKA. Opioid consumption for the first 24 hours postoperatively was significantly higher for the revision TKA group (133.1 MMEs vs 56.14 MMEs, P < .0001), as well as for the 24- to 48-hour time period. The visual analog pain scores were also higher for the revision TKA group.

CONCLUSION

The revision TKA group had a higher opioid requirement, most significant during the first 24 hours postoperatively, and expressed more pain in the acute postoperative period.

Evidence-based Review of Periarticular Injections and Peripheral Nerve Blocks in Total Knee Arthroplasty

Background:

Recently, post-operative pain management after Total Knee Arthroplasty (TKA) has focused on a multimodal approach for reducing opioid requirements, promoting early rehabilitation, and expediting discharge from hospital. Regional anesthesia, in the form of Periarticular Injections (PAI) and Peripheral Nerve Blocks (PNB), has shown promise as adjunctive therapy to oral analgesics.

Objective:

To review the current literature surrounding regional anesthesia for TKA.

Discussion:

PNBs provide effective analgesia after TKA. Historically, femoral nerve blocks (FNB) have been commonly employed. FNBs, however, lead to the significant motor blockade to the quadriceps musculature, which can dampen early rehabilitation efforts and increase the risk of post-operative falls. Adductor Canal Blocks (ACB) have shown excellent results in reducing post-operative pain while minimizing motor blockade. Periarticular injections (PAI), and infiltration between the popliteal Artery and Capsule of the Knee (IPACK) have similarly helped in reducing patient discomfort after TKA and providing analgesia to the posterior capsular region of the knee.

Conclusion:

PAIs, and PNBs are important elements in many multimodal postoperative pain management protocols after TKA. Current evidence appears to suggest that a combination of an ACB supplemented by posterior capsular analgesic coverage through PAI or IPACK may provide optimal results.

Efficacy of local infiltration anesthesia versus interscalene nerve blockade for total shoulder arthroplasty

Background

Optimal modalities for pain control in shoulder arthroplasty are not yet established. Although regional nerve blockade has been a well-accepted modality, complications and rebound pain have led some surgeons to seek other pain control modalities. Local injection of anesthetics has recently gained popularity in joint arthroplasty. The purpose of this study was to evaluate the effectiveness and complication rate of a low-cost local anesthetic injection mixture for use in total shoulder arthroplasty (TSA) compared with interscalene brachial plexus blockade.

Methods

A total of 314 patients underwent TSA and were administered general anesthesia with either a local injection mixture (local infiltration anesthesia [LIA], n = 161) or peripheral nerve block (PNB, n = 144). Patient charts were retrospectively reviewed for postoperative pain scores, 24-hour opioid consumption, and 90-day postoperative complications.

Results

Immediate postoperative pain scores were not significantly different between groups (P = .94). The LIA group demonstrated a trend toward lower pain scores at 24 hours postoperatively (P = .10). Opioid consumption during the first 24 hours following surgery was significantly reduced in the LIA group compared with the PNB group (P < .0001). There was a trend toward fewer postoperative nerve and cardiopulmonary complications in the LIA group than the PNB group (P = .22 and P = .40, respectively)

Conclusion

Periarticular local injection mixtures provide comparable pain control to regional nerve blocks while reducing opioid use and postoperative complications following TSA. Local injection of a multimodal anesthetic solution is a viable option for pain management in TSA.

A new improvement: subperiosteal cocktail application to effectively reduce pain and blood loss after total knee arthroplasty

Background

Pain and blood loss after total knee arthroplasty (TKA) are unsolved clinical problems. Some studies reported that periarticular cocktail injection can effectively reduce pain and blood loss. However, there was no gold standard about the cocktail ingredient and injection location. More osteotomy and less soft tissue release in TKA with mild deformity; besides, plenty of nerves and blood vessels are contained in the periosteums and bone marrow. In this study, we aimed to detect the clinical results of subperiosteal cocktail application in TKA.

Methods

Two groups were included according to the different injection location in our study. In group 1, cocktails were injected into the muscles, tendons, suprapatellar bursa, and subpatellar bursa surrounding knee joint. In group 2, cocktail injection was performed under the periosteum of the distal femur and proximal tibia. Our primary outcomes were visual analogue scale (VAS) and hemoglobin (Hb), and the secondary outcomes were wound healing, infection, deep vein thrombosis (DVT), operation time, and hospitalization.

Results

At the first operative day, the mean (standard deviation) VAS score in a state of static was lower in group 2 compared with group 1 (0.98 ± 0.27 in group 1 and 0.86 ± 0.60 in group 2, p < 0.05). In the state of flexion and extension, the mean (standard deviation) VAS was 1.61 ± 0.66 in group 1 and 1.10 ± 0.57 in group 2 (p < 0.05). The mean (standard deviation) blood loss was higher in group 1 than in group 2 at the first postoperative day (440.19 (167.68) ml in group 1 and 333.67 (205.99) ml in group 2, p < 0.05). At the third day after surgery, the mean (standard deviation) blood loss was 686.44 (140.29) ml in group 1 and 609.19 (260.30) ml in group 2, and there was significant difference between these two groups (p < 0.05).

Conclusions

We concluded that subperiosteal cocktail injection can significantly reduce pain and blood loss compared with periarticular cocktail injection after TKA.