Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty

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.

A multimodal intraosseous infusion of morphine and ketorolac decreases early postoperative pain and opioid consumption following total knee arthroplasty

BACKGROUND

Multimodal pain management regimens and intraosseous infusion of morphine are two novel techniques that show promise in decreasing postoperative pain and opioid consumption following total knee arthroplasty. However, no study has analyzed the intraosseous infusion of a multimodal pain management regimen in this patient population. The purpose of our investigation was to examine the intraosseous administration of a multimodal pain regimen comprised of morphine and ketorolac during total knee arthroplasty with regard to immediate and 2-week postoperative pain, opioid pain medication intake, and nausea levels.

METHODS

In this prospective cohort study with comparisons to a historical control group, 24 patients were prospectively enrolled to receive an intraosseous infusion of morphine and ketorolac dosed according to age-based protocols while undergoing total knee arthroplasty. Immediate and 2-week postoperative Visual Analog Score (VAS) pain scores, opioid pain medication intake, and nausea levels were recorded and compared against a historical control group that received an intraosseous infusion of morphine alone.

RESULTS

During the first four postoperative hours, patients who received the multimodal intraosseous infusion experienced lower VAS pain scores and required less breakthrough intravenous pain medication than those patients in our historical control group. Following this immediate postoperative period, there were no additional differences between groups in terms of pain levels or opioid consumption, and there were no differences in nausea levels between groups at any time.

CONCLUSIONS

Our multimodal intraosseous infusion of morphine and ketorolac dosed according to age-based protocols improved immediate postoperative pain levels and reduced opioid consumption in the immediate postoperative period for patients undergoing total knee arthroplasty.

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.

The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis

BACKGROUND

Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine.

METHODS

The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI.

RESULTS

Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine.

CONCLUSION

Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.

Intraosseous Morphine Decreases Postoperative Pain and Pain Medication Use in Total Knee Arthroplasty: A Double-Blind, Randomized Controlled Trial

BACKGROUND

Intraosseous (IO) infusion of medication is a novel technique for total knee arthroplasty (TKA) antibiotic prophylaxis. To decrease postoperative pain in TKA patients, we investigated addition of morphine to a standard IO antibiotic injection.

METHODS

A double-blind, randomized controlled trial was performed on 48 (24 each) consecutive patients undergoing primary TKA. The control group received an IO injection of antibiotics as per the standard protocol. The experimental group received an IO antibiotic injection with 10 mg of morphine. Pain, nausea, and opioid use were assessed up to 14 days postoperatively. Morphine and interleukin-6 serum levels were obtained 10 hours postoperatively in a subgroup of 20 patients.

RESULTS

The experimental group had lower Visual Analog Scale pain score at 1, 2, 3, and 5 hours postoperatively (P = .0032, P = .005, P = .020, P = .010). This trend continued for postoperative day 1, 2, 8, and 9 (40% reduction, P = .001; 49% reduction, P = .036; 38% reduction, P = .025; 33% reduction, P = .041). The experimental group had lower opioid consumption than the control group for the first 48 hours and second week postsurgery (P < .05). Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores for the experimental group showed significant improvement at 2 and 8 weeks postsurgery (P < .05). Serum morphine levels in the experimental group were significantly less than the control group 10 hours after IO injection (P = .049).

CONCLUSION

IO morphine combined with a standard antibiotic solution demonstrates superior postoperative pain relief immediately and up to 2 weeks. IO morphine is a safe and effective method to lessen postoperative pain in TKA patients.

LEVEL OF EVIDENCE

Therapeutic, Level 1.

Comparison of the Effect of Different Local Analgesia Administration Techniques in Total Hip Arthroplasty: A Retrospective Comparative Cohort Study

Objective

To improve postoperative pain management, several authors have described the use of periarticular injection (PAI) or intra-articular injection (IAI) following total hip arthroplasty (THA). However, no comparative studies examining the results between PAI and IAI following THA have been published. This study aimed to evaluate the analgesic and anti-inflammatory effects of PAI and IAI following THA.

Methods

This single-center, retrospective cohort study enrolled patients who underwent unilateral primary THA. A total of 278 patients (281 hips) were included in the final analyses, with 112 patients (113 hips) in the control group, 85 patients (87 hips) in the PAI group, and 81 patients (81 hips) in the IAI group. Numeric rating scale (NRS) scores and laboratory data were assessed preoperatively and on postoperative days (POD) 1 and 7.

Results

NRS scores, creatine phosphokinase, and C-reactive protein levels in the PAI and IAI groups were significantly lower than those in the control group on POD 1 and 7. D-dimer levels were significantly lower in the PAI and IAI groups than in the control group on POD 7. The white blood cell count was significantly higher in the PAI and IAI groups than in the control group on POD 1 and 7. Aspartate transaminase, alanine aminotransferase, blood urea nitrogen, and creatinine levels were within the reference ranges in all three groups at all time points. NRS scores and laboratory data showed no significant differences between the PAI and IAI groups at all time points.

Conclusion

PAI and IAI have equivalent analgesic and anti-inflammatory effects. Considering the technical challenges of PAI, IAI may be preferable because of its simplicity in the case of using a closed suction drain.

Assessing outcome in postoperative pain trials: are we missing the point? A systematic review of pain-related outcome domains reported in studies early after total knee arthroplasty

ABSTRACT

The management of acute postoperative pain remains suboptimal. Systematic reviews and Cochrane analysis can assist with collating evidence about treatment efficacy, but the results are limited in part by heterogeneity of endpoints in clinical trials. In addition, the chosen endpoints may not be entirely clinically relevant. To investigate the endpoints assessed in perioperative pain trials, we performed a systematic literature review on outcome domains assessing effectiveness of acute pain interventions in trials after total knee arthroplasty. We followed the Cochrane recommendations for systematic reviews, searching PubMed, Cochrane, and Embase, resulting in the screening of 1590 potentially eligible studies. After final inclusion of 295 studies, we identified 11 outcome domains and 45 subdomains/descriptors with the domain "pain"/"pain intensity" most commonly assessed (98.3%), followed by "analgesic consumption" (88.8%) and "side effects" (75.3%). By contrast, "physical function" (53.5%), "satisfaction" (28.8%), and "psychological function" (11.9%) were given much less consideration. The combinations of outcome domains were inhomogeneous throughout the studies, regardless of the type of pain management investigated. In conclusion, we found that there was high variability in outcome domains and inhomogeneous combinations, as well as inconsistent subdomain descriptions and utilization in trials comparing for effectiveness of pain interventions after total knee arthroplasty. This points towards the need for harmonizing outcome domains, eg, by consenting on a core outcome set of domains which are relevant for both stakeholders and patients. Such a core outcome set should include at least 3 domains from 3 different health core areas such as pain intensity, physical function, and one psychological domain.

Efficacy of Multimodal Analgesic Injections in Operatively Treated Ankle Fractures: A Randomized Controlled Trial

BACKGROUND

Pain management following surgical treatment of an ankle fracture is an under-studied area of clinical practice. The present study evaluated the efficacy of a multimodal surgical-site injection as an adjunct to postoperative pain management in patients with an operatively treated, closed, rotational ankle fracture.

METHODS

Patients indicated for operative fixation of a rotational ankle fracture were randomized to receive multimodal surgical-site injection (ropivacaine 200 mg, epinephrine 0.6 mg, and morphine 5 mg) or no injection (control). Visual analog scale (VAS) pain and opioid consumption data were collected every 4 hours until discharge from the hospital. Length of stay and discharge destination were recorded. Patients were sent automated text messages to report VAS pain and opioid usage during the first 2 weeks after discharge.

RESULTS

One hundred patients (49 injection and 51 control) were enrolled. Demographic data were similar between the 2 groups. Mean VAS scores over the first 24 and 48 hours postoperatively were slightly lower in the injection group (42 ± 3 and 41 ± 3, respectively) compared with the control group (52 ± 3 and 50 ± 3, respectively; p = 0.01 and p < 0.01, respectively). The median opioid usage, in terms of morphine equivalent dose, was similar over the first 24 hours between the injection group (25.5; range, 0 to 74.7) and the control group (28.3; range, 2.5 to 91.0; p = 0.35). The median opioid usage from recovery room admission to discharge was also similar between the injection group (29.0; range, 0 to 85.3) and the control group (32.7; range, 4.3 to 215.0; p = 0.35). There were no differences in outpatient VAS scores or opioid consumption during the first 2 weeks postoperatively as assessed with use of automated text messaging. Median length of stay was 22.3 hours (range, 1.7 to 182.3 hours) for the injection group and 22.5 hours (range, 2.2 to 123.3 hours) for the control group (p = 0.71). The response rate for the post-discharge automated text messages was 85.1%. Complication rates were similar.

CONCLUSIONS

The use of multimodal surgical-site injections in operatively treated rotational ankle fractures is associated with a reduction in immediate in-hospital pain scores that is statistically significant but below the minimal clinically important difference.

LEVEL OF EVIDENCE

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

Effect of morphine added to multimodal cocktail on infiltration analgesia in total knee arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

The local injection of multimodal cocktail is currently commonly used in the treatment of postoperative pain after total knee arthroplasty (TKA). It is still inconclusive whether the morphine added to the intraoperative injection mixture could make some difference. This meta-analysis aimed to evaluate the efficacy and safety of additional morphine injection on postoperative analgesia in TKA, and provide some useful information on morphine usage in clinical practice.

METHODS

The randomized controlled trials (RCTs) in databases including PubMed, Web of Science, Embase, Cochrane Library, Chinese biomedical literature database (CBM), and Chinese National Knowledge Infrastructure (CNKI) databases were systematically searched. Of 623 records identified, 8 RCTs involving 1093 knees were eligible for data extraction and meta-analysis according to criteria included.

RESULTS

Meta-analysis showed that the use of local morphine injection was not associated with significant pain relief within 48 hours postoperatively at rest and on motion (P > .05, all). The use of morphine reduced postoperative total systemic opioids consumption (P < .05). This study found no significant differences in other outcomes including knee flexion range of motion (ROM) (P > .05), extension ROM (P > .05), The Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (P > .05), Post-operative nausea and vomiting occurrence (P > .05) regardless of the presence of morphine or not in the injections.

CONCLUSION

Additional morphine added to multimodal cocktail did not decrease the postoperative pain scores significantly based on our outcomes, but it reduced the systemic postoperative opioids consumption in total knee arthroplasty.

Local Efficacy of Periarticular Morphine Injection in Simultaneous Bilateral Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Trial

BACKGROUND

The periarticular multimodal cocktail injection including morphine is currently commonly used to reduce postoperative pain following total knee arthroplasty (TKA). Despite its analgesic effect, it frequently causes nausea, which is an adverse effect of opioids. It is inconclusive whether the intraoperative injection of periarticular morphine is effective peripherally. The aim of this study was to assess whether the addition of morphine to unilateral periarticular knee injections improves postoperative pain, range of motion, and swelling in patients undergoing simultaneous bilateral TKA.

METHODS

A prospective, single-center, double-blinded, randomized, controlled trial was conducted to assess the local efficacy of adding morphine to intraoperative periarticular anesthesia in patients undergoing simultaneous bilateral TKA. Fifty-three patients undergoing 106 TKAs received an intraoperative periarticular injection in randomly selected one knee with added morphine (0.1 mg/kg) and the other knee without added morphine. The periarticular injection was composed of ropivacaine (a local anesthetic), epinephrine, ketoprofen, and methylprednisolone sodium. Visual analog scale pain scores at rest and on motion, range of motion (ROM), thigh swelling, the Western Ontario and McMaster Universities Osteoarthritis Index score, and adverse outcomes were compared between the 2 knees.

RESULTS

There were no statistically significant differences in the visual analog scale score, ROM, thigh girth, Western Ontario and McMaster Universities Osteoarthritis Index score, and adverse events between the 2 sides.

CONCLUSION

Adding morphine to periarticular injections is ineffective locally for relieving pain, reducing swelling, and improving the postoperative ROM.

A pragmatic randomised controlled trial comparing the efficacy of a femoral nerve block and periarticular infiltration for early pain relief following total knee arthroplasty

AIMS

The aim of this study was to compare the effectiveness of a femoral nerve block and a periarticular infiltration in the management of early post-operative pain after total knee arthroplasty (TKA).

PATIENTS AND METHODS

A pragmatic, single centre, two arm parallel group, patient blinded, randomised controlled trial was undertaken. All patients due for TKA were eligible. Exclusion criteria included contraindications to the medications involved in the study and patients with a neurological abnormality of the lower limb. Patients received either a femoral nerve block with 75 mg of 0.25% levobupivacaine hydrochloride around the nerve, or periarticular infiltration with 150 mg of 0.25% levobupivacaine hydrochloride, 10 mg morphine sulphate, 30 mg ketorolac trometamol and 0.25 mg of adrenaline all diluted with 0.9% saline to make a volume of 150 ml.

RESULTS

A total of 264 patients were recruited and data from 230 (88%) were available for the primary analysis. Intention-to-treat analysis of the primary outcome measure of a visual analogue score for pain on the first post-operative day, prior to physiotherapy, was similar in both groups. The mean difference was -0.7 (95% confidence interval (CI) -5.9 to 4.5; p = 0.834). The periarticular group used less morphine in the first post-operative day compared with the femoral nerve block group (74%, 95% CI 55 to 99). The femoral nerve block group reported 39 adverse events, of which 27 were serious, in 31 patients and the periarticular group reported 51 adverse events, of which 38 were serious, in 42 patients up to six weeks post-operatively. None of the adverse events were directly attributed to either of the interventions under investigation.

CONCLUSION

Periarticular infiltration is a viable and safe alternative to femoral nerve block for the early post-operative relief of pain following TKA. Cite this article: Bone Joint J 2017;99-B:904-11.

Comprehensive Analysis of Pain Management after Total Knee Arthroplasty

Total knee arthroplasty (TKA) has been much improved recently and it is regarded as one of the most common and successful surgical procedures that provides pain relief and improves function in patients with severe knee arthritis. However, recent studies have reported that 15%–20% of patients are not satisfied after TKA without evident clinical or radiological findings and the most common causes of patient dissatisfaction include residual pain and limited function. The evaluation and treatment of painful TKA relies on a thorough understanding of the origin by careful evaluation, and a systematic approach is essential to efficiently and effectively resolve the pain. Periarticular injections (PAIs) and nerve blocks are gaining popularity because they are associated with less side effects than systemic regimens. The analgesic efficacy and safety of PAI compared with nerve blocks for postoperative pain management still remain controversial. Therefore, more study is needed to determine if any changes in the regimen of the injection or technique could provide added benefit to long-term functional improvement beyond the perioperative period.

Effect of Periarticular Morphine Injection for Total Knee Arthroplasty: A Randomized, Double-Blind Trial

BACKGROUND

The periarticular multimodal cocktail injection including morphine is currently commonly used to treat postoperative pain after total knee arthroplasty (TKA). Despite its analgesic effect, it is frequently reported to cause nausea and vomiting, which are adverse effects of opioids. This study aimed to assess the efficacy of morphine as a component of a multimodal cocktail injection for providing postoperative analgesia and alleviating swelling in patients who underwent TKA.

METHODS

This is a prospective, single-center, randomized controlled trial involving 102 patients scheduled for unilateral TKA. A mixture of steroids, local anesthetics, nonsteroidal anti-inflammatory drugs, and epinephrine with or without morphine (10 mg) was injected to randomly assigned patients. Postoperative assessment was performed with all attending personnel and patients blinded to group assignment. Visual analog scale of pain, range of motion, nausea numerical rating scale, number of patients with vomiting, total dose of antiemetic drugs used, thigh swelling, the Western Ontario and McMaster Universities Osteoarthritis Index score, and adverse outcomes were compared between groups on postoperative days.

RESULTS

Visual analog scale scores did not differ between the 2 groups at any postoperative time point. The nausea numerical rating scale scores during the postoperative period from 30 min to 9 h, the number of vomiting episodes, and the total dose of antiemetic drugs administered were significantly higher in the morphine group. The thigh girth, Western Ontario and McMaster Universities Osteoarthritis Index, and the incidence of complications were not different between groups.

CONCLUSION

The results of this study suggested that addition of morphine to the multimodal cocktail injection is not effective for relieving postoperative pain, alleviating swelling, or improving range of motion, and results in nausea and vomiting.

Postoperative pain treatment after total knee arthroplasty: A systematic review

INTRODUCTION

The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA).

METHODS

This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L'Abbe Plots and trial sequential analysis.

RESULTS

The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low.

CONCLUSION

A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA.

The effect of intra-articular levobupivacaine on shoulder cartilage at different doses-experimental study

BACKGROUND AND OBJECTIVES

In this study it was aimed to examine the histological and morphometric effects on cartilage structure of intra-articular application of levobupivacaine to the shoulder joint.

METHODS

In twenty New Zealand adult male rabbits, 35 shoulders were used for the study and prepared in 5 groups of 7. These groups were defined as Groups L1, L2, L3 and L4 which were right shoulders administered with 0.25% and 0.5% levobupivacaine, Group C which were left shoulders as the control group and Groups S1 and S2 which were left shoulders administered with 0.9% saline. On the 2nd and 15th days the animals were killed, the glenohumeral joints were evaluated macroscopically then cartilage samples were taken. These samples were evaluated with Mankin score, and histomorphometrically by measuring the thickness of the cartilage between the superficial cartilage layer and the tidemark and the thickness of calcified cartilage between the tidemark and the subchondral bone.

RESULTS

Macroscopically, on the 15th day the joint fluid was seen to have reduced in all the groups. After microscopic evaluation, the highest Mankin score (mean: 3.14±2.1/14) was in the L4 group (15th day 0.5% levobupivacaine) and was found to be statistically significant (p<0.05). No statistically significant difference was determined between the other groups.

CONCLUSIONS

Histologically, as the highest Mankin score was in the L4 group, this indicates that in a single intra-articular injection of levobupivacaine a low concentration should be selected.

LEVEL OF EVIDENCE

Level 5, animal study.

[The effect of intra-articular levobupivacaine on shoulder cartilage at different doses-experimental study]

BACKGROUND AND OBJECTIVES

In this study it was aimed to examine the histological and morphometric effects on cartilage structure of intra-articular application of levobupivacaine to the shoulder joint.

METHODS

In twenty New Zealand adult male rabbits, 35 shoulders were used for the study and prepared in 5 groups of 7. These groups were defined as Groups L1, L2, L3 and L4 which were right shoulders administered with 0.25% and 0.5% levobupivacaine, Group C which were left shoulders as the control group and Groups S1 and S2 which were left shoulders administered with 0.9% saline. On the 2nd and 15th days the animals were killed, the glenohumeral joints were evaluated macroscopically then cartilage samples were taken. These samples were evaluated with Mankin score, and histomorphometrically by measuring the thickness of the cartilage between the superficial cartilage layer and the tidemark and the thickness of calcified cartilage between the tidemark and the subchondral bone.

RESULTS

Macroscopically, on the 15th day the joint fluid was seen to have reduced in all the groups. After microscopic evaluation, the highest Mankin score (mean: 3.14±2.1/14) was in the L4 group (15th day 0.5% levobupivacaine) and was found to be statistically significant (p<0.05). No statistically significant difference was determined between the other groups.

CONCLUSIONS

Histologically, as the highest Mankin score was in the L4 group, this indicates that in a single intra-articular injection of levobupivacaine a low concentration should be selected.

LEVEL OF EVIDENCE

Level 5, animal study.

Incidence of cardiovascular complications in knee arthroplasty patients before and after implementation of a ropivacaine local infiltration analgesia protocol: A retrospective study

BACKGROUND

Local infiltration analgesia (LIA) during total knee arthroplasty has been shown to give statistically significant reduction in post-operative pain. The effects of using high volumes of ropivacaine combined with adrenaline as LIA on cardiovascular parameters in knee replacement have not been described before. The objective of this study was to investigate the cardiovascular safety of ropivacaine as part of high volume local infiltration analgesia (LIA) in total knee replacement surgery.

METHODS

This is a retrospective observational comparative cohort study conducted in two independent cohorts, one treated without and one treated with a local infiltration analgesia protocol, containing a total of 744 patients with a mean age of 68years (42 to 89) and 68years (21 to 88) respectively with a follow-up of 12months.

RESULTS

No statistical difference in bradycardia during surgery, post-operative cardiovascular complications, and mortality was found after use of LIA. A statistically significant lower incidence of hypotension was found in the LIA group (P<0.01). This result has to be interpreted with care, due to the use of adrenaline in the LIA mixture, which could mask possible hypotension. No statistical difference was found in the occurrence of hypertension or tachycardia, despite the addition of adrenaline to the LIA mixture. No difference in mortality was found between the two groups (P=0.11).

CONCLUSION

These results show safe use of high volume ropivacaine with adrenaline as local infiltration analgesia during total knee replacement surgery.

Preemptive Femoral Nerve Block Could Reduce the Rebound Pain After Periarticular Injection in Total Knee Arthroplasty

BACKGROUND

We evaluated the effectiveness of postoperative pain management using intraoperative periarticular injection (PAI) and/or electromyography-guided preoperative femoral nerve block (FNB) in knees undergoing total knee arthroplasty (TKA).

METHODS

This study included 90 patients (90 knees) who underwent primary TKA. Thirty patients received a single injection of electromyography-guided FNB, 30 received intraoperative PAI, and 30 received both. Pain at rest and while moving was evaluated by a visual analog scale (VAS) at 0, 4, 8, 24, and 48 hours. Postoperative range of motion, time to walking, amount of opioid consumption, and complications were analyzed.

RESULTS

VAS immediately after surgery was significantly higher in the FNB group than in the PAI and combined groups, but did not differ significantly in the latter 2 groups. VAS after 4 and 8 hours showed similar results. VAS after 24 hours was significantly higher in the PAI than in the FNB and combined groups. After 48 hours, there were no differences among the 3 groups. Total opioid consumption was lower in the combined than in the FNB and PAI groups. Postoperative range of motion and time to walking were similar in the 3 groups.

CONCLUSION

PAI was more effective than FNB during the early (0-8 hours) postoperative period after TKA. Patients treated with PAI, however, experienced rebound pain at 24 hours. The combination of PAI and FNB may provide greater postoperative pain management than either alone for the first 24 hours after TKA.

Intra-articular bupivacaine after joint arthroplasty: a systematic review and meta-analysis of randomised placebo-controlled studies

OBJECTIVES

To evaluate the efficacy and safety of intra-articular (IA) bupivacaine administered for pain relief after joint arthroplasty.

DESIGN

Meta-analysis.

METHODS

A systematic review was conducted to identify the randomised controlled trials using IA bupivacaine for postoperative pain relief from MEDLINE, Cochrane Library and EMBASE databases (up to October 2015). The standardised mean difference (SMD), the relative risk (RR) and their corresponding 95% CIs were calculated using the RevMan statistical software.

RESULTS

A total of 11 randomised controlled trials were included. Statistically significant differences between IA bupivacaine and placebo were observed for the mean visual analogue scale (VAS) values (SMD -0.55; 95% CI -0.89 to -0.22; p<0.001) and narcotic consumption (SMD -0.32; 95% CI -0.55 to -0.08; p=0.008) during the period of 24 hours postoperatively and narcotic consumption during the period between 24 and 48 hours postoperatively (SMD -0.32; 95% CI -0.55 to -0.08; p=0.009). However, there was no significant difference in the mean VAS pain score during the period between 24  and 48 hours postoperatively (SMD -0.09, 95% CI -0.30 to 0.11; p=0.37) and in the incidence of adverse effects 24-72 hours postoperatively (RR 0.97; 95% CI 0.60 to 1.57; p=0.91).

CONCLUSIONS

The administration of IA bupivacaine after joint arthroplasty is effective for pain relief without increasing adverse effects.

Protocol for a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus single-agent femoral nerve blockade as analgesia for total knee arthroplasty: Perioperative Analgesia for Knee Arthroplasty (PAKA)

INTRODUCTION

Total knee arthroplasty (TKA) surgery causes postoperative pain. The use of perioperative injections around the knee containing local anaesthetic, opiates and non-steroidal anti-inflammatory drugs has increased in popularity to manage pain. Theoretical advantages include reduced requirements for analgesia and earlier mobilisation. We propose a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus femoral nerve anaesthetic blockade as analgesia for TKA. The aim is to determine, in patients undergoing TKA, if there is a difference in patient-reported pain scores on the visual analogue scale (VAS) prior to physiotherapy on day 1 postoperatively between treatment groups.

METHODS AND ANALYSIS

Patients undergoing a primary unilateral TKA at University Hospitals Coventry and Warwickshire Hospitals will be assessed for eligibility. A total of 264 patients will provide 90% power to detect a difference of 12 mm on the VAS on day 1 postoperatively at the 5% level. The trial will use 1:1 randomisation, stratified by mode of anaesthetic. Primary outcome measure will be the VAS for pain prior to physiotherapy on day 1. Secondary outcome measures include VAS on day 2, total use of opiate analgesia up to 48 h, ordinal pain scores up to 40 min after surgery, independent functional knee physiotherapist assessment on days 1 and 2. Oxford knee Scores (OKS), EuroQol (EQ-5D) and Douleur Neuropathic Pain Scores (DN2) will be recorded at baseline, 6 weeks and 12 months. Adverse events will be recorded up to 12 months. Analysis will investigate differences in VAS on day 1 between the two treatment groups on an intention-to-treat basis. Tests will be two-sided and considered to provide evidence for a significant difference if p values are less than 0.05.

ETHICS AND DISSEMINATION

NRES Committee West Midlands, 23 September 2013 (ref: 13/WM/0316). The results will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBERS

ISRCTN 60611146 and EUDRACT Number 2013-002439-10 (protocol code number PAKA-33601-AS117013); Pre-results.

Analgesic efficacy of three different dosages of intra-articular morphine in arthroscopic knee surgeries: Randomised double-blind trial

BACKGROUND AND AIMS

Arthroscopic knee surgery is a common procedure and may cause enough pain to delay rehabilitation. Intra-articular (IA) morphine is a known modality for post-operative pain relief. However, the optimal dose of IA morphine has not been studied. The current study has been conducted to find out the optimal dosage of IA morphine when administered with 0.25% bupivacaine.

METHODS

Sixty adult patients of either sex, aged between 18 and 60 years, undergoing diagnostic/therapeutic knee arthroscopic surgery were included in the study and randomised into three groups. All patients underwent surgery under subarachnoid block. After the surgical closure, 20 ml of 0.25% bupivacaine with 1 mg, 3 mg and 5 mg of morphine as additive was injected intra-articularly in Group A, B and C patients, respectively. Post-operative pain assessment was performed with visual analogue scale score in the 1(st), 2(nd), 6(th), 12(th) and 24(th) post-operative hour. The common complications were also recorded.

RESULTS

There was statistically significant analgesia in Group B and C than Group A in the 1(st) and 2(nd) post-operative hour; while at the 24(th) post-operative hour, Group C had statistically significant analgesia than the other two groups. Time to first rescue analgesia was statistically significantly less and consumption of supplemental analgesia was significantly higher in Group A than the other two groups.

CONCLUSION

IA dose of 3 mg and 5 mg morphine with 20 ml of 0.25% bupivacaine provided adequate analgesia. However, 3 mg morphine group patients had fewer side effects than 5 mg group patients although the difference was not statistically significant.

Efficacy of Intra-articular Local Anesthetics in Total Knee Arthroplasty

Pain management after total knee arthroplasty (TKA) remains among the most important challenges for patients with TKA. Intra-articular local anesthetic has been shown to reduce postoperative pain following TKA. However, studies report conflicting results. This meta-analysis evaluated the efficacy and safety of single-dose intra-articular local anesthetics for pain control after TKA. Databases (Cochrane Central Register of Controlled Trials, Embase, PubMed, Web of Science, and Chinese Biomedical Databases) were searched to identify randomized, controlled trials comparing local anesthetic with placebo in patients undergoing TKA. Data were extracted independently by 2 researchers using a standardized form. Risk of bias was assessed with the use of the Cochrane Collaboration's tool for assessing the risk of bias by 2 observers. Relative risk, standardized mean difference, and corresponding 95% confidence interval were calculated. Seventeen trials met the inclusion criteria, for a total of 1338 participants. The results showed that, compared with the placebo group, the single local anesthetic group had a significant lower pain score with rest at 4, 8, 24, and 48 hours; less opioid consumption at 24, 48, and 72 hours postoperatively; and greater range of motion at 24, 48, and 72 hours. There were no significant differences between the 2 groups in length of hospital stay, nausea and vomiting, pruritus, sedation, or deep venous thrombosis. The study findings showed that pain relief after TKA was significantly better with intra-articular local anesthetic than with placebo.

Local infiltration analgesia following total knee arthroplasty: effect on post-operative pain and opioid consumption--a meta-analysis

INTRODUCTION

Local infiltration analgesia (LIA) is a popular method for decreasing post-operative pain after total knee arthroplasty (TKA). The goal of this meta-analysis is to compare the effect of LIA with placebo on the intensity of post-operative pain and the consumption of opioids.

METHODS

A search was performed in the PubMed/MEDLINE, Cochrane, EMBASE and TRIP databases. All (quasi)-randomized controlled trials (RCTs) were included. LIA consists of intra-operative infiltration with at least one analgesic component. Data were pooled using Cochrane software.

RESULTS

Seven placebo-controlled RCTs were included, involving 405 TKAs. On the first post-operative day, LIA provides an average decrease in VAS scores at rest of 12.3 % compared to placebo. Six RCTs studied opioid consumption in patients following TKA. There was a decrease in opioid consumption of 14.8 % compared to placebo 24 h after surgery. This suggests a reduced pain perception due to LIA. On the second post-operative day, the effect on both outcome measures was diminished and no longer significant. Heterogeneity between the studies was 71 % for pain and 39 % for opioid consumption (p = 0.002 and p = 0.0005). No major complications were reported with the use of LIA.

CONCLUSION

LIA might be able to decrease pain and the use of opioids on the first post-operative day following TKA. However, due to the high level of heterogeneity between the studies, no firm conclusions can be drawn.

LEVEL OF EVIDENCE

Meta-analysis, Level II.

Doubtful effect of continuous intraarticular analgesia after total knee arthroplasty: a randomized double-blind study of 200 patients

BACKGROUND AND PURPOSE

Local infiltration analgesia (LIA) is well established for effective postoperative pain relief in total knee arthroplasty (TKA). To prolong the effect of LIA, infusion pumps with local intraarticular analgesia can be used. We evaluated the effect of such an infusion pump for the first 48 h postoperatively regarding pain, knee function, length of stay (LOS) in hospital, and complications.

PATIENTS AND METHODS

200 patients received peroperative LIA and a continuous intraarticular elastomeric infusion pump set at 2 mL/h. The patients were randomized either to ropivacaine (7.5 mg/mL) or to NaCl (9 mg/mL) in the pump. Visual analog scale (VAS) pain (0-100 mm), analgesic consumption, side effects of medicine, range of motion (ROM), leg-raising ability, LOS, and complications during the first 3 months were recorded.

RESULTS

On the first postoperative day, the ropivacaine group had lower VAS pain (33 vs. 40 at 12 noon and 36 vs. 43 at 8 p.m.; p = 0.02 and 0.03, respectively), but after that all recorded variables were similar between the groups. During the first 3 months, the ropivacaine group had a greater number of superficial and deep surgical wound infections (11 patients vs. 2 patients, p = 0.02). There were no other statistically significant differences between the groups.

INTERPRETATION

Continuous intraarticular analgesia (CIAA) with ropivacaine after TKA has no relevant clinical effect on VAS pain and does not affect LOS, analgesic consumption, ROM, or leg-raising ability. There may, however, be a higher risk of wound-healing complications including deep infections.

Pain Control after Total Knee Arthroplasty: Comparing Intra-Articular Local Anesthetic Injection with Femoral Nerve Block

Background. Direct intra-articular injection of low doses of local anesthetic (IALA) after closure of the joint capsule remains controversial for pain control after total knee arthroplasty (TKA). Methods. A retrospective study comparing patients receiving IALA with high doses (0.5% bupivacaine 60 mL) of local anesthetics or FNB in addition to intravenous patient-controlled analgesia with opioids for pain management after TKA was conducted. The primary end point was to compare the analgesic efficacy and early ambulation between the two groups. Results. No significant differences between the two groups in pain intensity, cumulative opioid consumption, incidences of opioid-related side effects, the time interval from the end of operation to the first time the patient could walk assisted with a walker postoperatively, and postoperative hospital stay were identified. Three patients in the IALA group but none in the FNB group walked within 12 hours after the end of operation. Summary. IALA with high doses of local anesthetics provides comparable analgesic efficacy as single-shot FNB after TKA and might be associated with earlier ambulation than FNB postoperatively.

The Chitranjan Ranawat Award: Periarticular injections and femoral & sciatic blocks provide similar pain relief after TKA: a randomized clinical trial

BACKGROUND

Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA.

QUESTIONS/PURPOSES

This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications.

METHODS

One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n=79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n=81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications.

RESULTS

Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 [SD 2.4]; PAI group: 3.0 [SD 2.2]; 95% confidence interval, -0.8 to 0.6; p=0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days [SD 0.65] versus 2.84 days [SD 1.34] for the PNB group; p=0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents [SD 13.1]; PNB group: 4.6 mg [SD 9.1]; p<0.001), but thereafter, there was no difference. More patients in the PNB group had sequelae of peripheral nerve injury (mainly dysesthesia) at 6-week followup (nine [12%] versus one [1%]; p=0.009).

CONCLUSIONS

Patients receiving periarticular injections had similar pain scores, shorter lengths of stay, less likelihood of peripheral nerve dysesthesia, but greater narcotic use on the day of surgery compared with patients receiving peripheral nerve blocks. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Analgesic techniques in hip and knee arthroplasty: from the daily practice to evidence-based medicine

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are major orthopedic surgery models, addressing mainly ageing populations with multiple comorbidities and treatments, ASA II–IV, which may complicate the perioperative period. Therefore effective management of postoperative pain should allow rapid mobilization of the patient with shortening of hospitalization and social reintegration. In our review we propose an evaluation of the main analgesics models used today in the postoperative period. Their comparative analysis shows the benefits and side effects of each of these methods and guides us to how to use evidence-based medicine in our daily practice.

Efficacy and safety of single-dose local infiltration of analgesia in total knee arthroplasty: a meta-analysis of randomized controlled trials

PURPOSE

To examine the efficacy and safety of single-dose local infiltration of analgesia (LIA) for post-operative pain relief in total knee arthroplasty (TKA) patients.

METHODS

A systematic electronic literature search (up to Aug 2013) was conducted to identify the RCTs that address the efficacy and safety of single-dose LIA in the pain management after TKA. Subgroup analysis was conducted to determine changes of visual analog score (VAS) values at six different postoperative time points. Weighted mean differences or relative risks with accompanying 95% confidence intervals were calculated and pooled using a random effect model.

RESULTS

Eighteen trials involving 1858 TKA patients met the inclusion criteria. The trials were liable to medium risk of bias. The VAS values at postoperative 2h, 4h, 6h, 12h, 24h, and 48h per patient were significantly lower in the LIA group than in the placebo group, and the former group also had less morphine consumption and better early functional recovery including range of motion, time to straight leg raise and 90° knee flexion than the latter group. No significant difference in length of hospital stay or side effects was detected between the two groups.

CONCLUSIONS

The current evidence shows that the use of single-dose LIA is effective for postoperative pain management in TKA patients, with satisfactory short-term safety. More high-quality RCTs with long-term follow-ups are required for examining the long-term safety of single-dose LIA.

LEVEL OF EVIDENCE

I, II.

Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial

We analyze the effects of a multimodal analgesic regimen on postoperative pain, function, adverse effects and satisfaction compared to patient-controlled analgesia (PCA). Thirty-six patients undergoing TKA were randomized to receive either (1) periarticular injection before wound closure (30cc 0.5% bupivacaine, 10mg MSO4, 15 mg ketorolac) and multimodal analgesics (oxycodone, tramadol, ketorolac; narcotics as needed) or (2) hydromorphone PCA. Preoperative and postoperative data were collected for VAS pain scores, time to physical therapy milestones, hospital stay length, patient satisfaction, narcotic consumption and medication-related adverse effects. The multimodal group had lower VAS scores, fewer adverse effects, lower narcotic usage, higher satisfaction scores and earlier times to physical therapy milestones. Multimodal pain management protocol decreases narcotic usage, improves pain scores, increases satisfaction and enhances early recovery.

Periarticular injection in knee arthroplasty improves quadriceps function

BACKGROUND

The postoperative analgesic potential of periarticular anesthetic infiltration (PAI) after TKA is unclear as are the complications of continuous femoral nerve block on quadriceps function.

QUESTIONS/PURPOSES

We asked (1) whether PAI provides equal or improved postoperative pain control in comparison to a femoral nerve block in patients who have undergone TKA; and (2) if so, whether PAI improves early postoperative quadriceps control and facilitates rehabilitation.

METHODS

We randomized 60 patients to receive either PAI or femoral nerve block. During the first 5 days after TKA, we compared narcotic consumption, pain control, quadriceps function, walking distance, knee ROM, capacity to perform a straight leg raise, and active knee extension. Medication-related side effects, complications, operating room time, and hospitalization duration were compared.

RESULTS

Opioid consumption was lower in the PAI group during the first 8 postoperative hours (12.5 mg versus 18.7 mg morphine), as was reported pain at rest (1.7 versus 3.5 on a 10-point VAS). Thereafter, narcotic consumption and reported pain were similar up to 120 hours. More subjects in the femoral nerve block group experienced quadriceps motor block (37% versus 0% in the PAI group). On Days 1 to 3, subjects in the PAI group experienced better capacity to perform the straight leg raise, active knee extension, and had longer walking distances.

CONCLUSIONS

PAI provided pain control equivalent to that of a femoral nerve block while avoiding a motor block and its negative functional impacts. The data suggest it should be considered an alternative to a femoral nerve block.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The 2012 Chitranjan Ranawat award: intraarticular analgesia after TKA reduces pain: a randomized, double-blinded, placebo-controlled, prospective study

BACKGROUND

Postoperative pain after total knee arthroplasty remains one of the most important challenges facing patients undergoing this surgery. Providing a balance of adequate analgesia while limiting the functional impact of regional anesthesia and minimizing opioid side effects is critical to minimize adverse events and improve patient satisfaction.

QUESTIONS/PURPOSES

We asked whether bupivacaine delivered through an elastomeric device decreases the (1) patients' perception of pain after TKA; (2) narcotic consumption; and (3) narcotic-related side effects as compared with a placebo.

METHODS

In this prospective, double-blind, placebo-controlled study, all patients received standardized regional anesthesia, a preemptive and multimodal analgesic protocol, and a continuous intraarticular infusion at 5 mL/hour through an elastomeric infusion pump. The patients were randomized to receive either an infusion pump filled with (1) 300 mL of 0.5% bupivacaine, the experimental group (n = 75); or (2) 300 mL of 0.9% normal saline solution, the control group (n = 75). Data concerning postoperative pain levels through a visual analog scale, postoperative opioid consumption, opioid-related side effects, and complications were collected and analyzed.

RESULTS

Patients in the experimental group receiving the bupivacaine reported a reduction in pain levels in highest, lowest, and current visual analog scale scores compared with the placebo group on the first postoperative day and highest visual analog scale score on postoperative Day 2 along with a 33% reduction in opioid consumption on postoperative Day 2 and a 54% reduction on postoperative Day 3.

CONCLUSION

In patients undergoing TKA, continuous intraarticular analgesia provided an effective adjunct for pain relief in the immediate postoperative period without the disadvantages encountered with other analgesic methods.

Combined femoral and sciatic nerve block vs combined femoral and periarticular infiltration in total knee arthroplasty: a randomized controlled trial

This study tests the null hypothesis that there is no difference between sciatic nerve block (SNB) and periarticular anesthetic infiltration (PI) as adjuncts to femoral nerve blockade (FNB) in total knee arthroplasty in terms of postoperative opioid requirements. Fifty-two patients undergoing total knee arthroplasty were randomized to receive either (a) combined FNB-SNB or (b) combined FNB-PI. Average morphine consumption in the first 24 (20 vs 23 mg) and 48 hours (26 vs 33 mg) showed no significant difference. Visual Analogue Scale scores, knee flexion (60° vs 67.5°) and extension lag (0° vs 5°) were comparable. Anesthetic time, surgical time, and length of hospital stay (5.5 vs 6 days) were similar. This study showed no significant difference between the 2 groups. The PI offers a practical and potentially safer alternative to SNB.

The efficacy of intra-articular injections for pain control following the closed reduction and percutaneous pinning of pediatric supracondylar humeral fractures: a randomized controlled trial

BACKGROUND

The purpose of this single-blinded, randomized, controlled trial was to compare the analgesic efficacy of intra-articular injections of bupivacaine or ropivacaine with that of no injection for postoperative pain control after the operative treatment of supracondylar humeral fractures in a pediatric population.

METHODS

Subjects (n=124) were randomized to treatment with 0.25% bupivacaine (Group B) (n=42), 0.20% ropivacaine (Group R) (n=39), or no injection (Group C) (n=43). The opioid doses and the times of administration as well as child-reported pain severity (Faces Pain Scale-Revised) and parent-reported pain severity (Total Quality Pain Management survey) were recorded.

RESULTS

The proportion of subjects who required morphine and/or fentanyl injections was significantly (p=0.004) lower in Group B (10%) as compared with Group R (36%) and Group C (44%). On the basis of the log-rank test, the opioid-free survival rates were significantly greater in Group B as compared to Groups C and R. Total opioid consumption (morphine equivalent mg/kg) in the first seventy-two hours postoperatively was significantly less in Group B as compared with Group C (mean difference, 0.225; [95% confidence interval (CI), 0.0152 to 0.435]; p=0.036). Parent-reported pain scores were also significantly lower in Group B as compared with both Group C (mean difference, 1.81 [95% CI, 0.38 to 3.25]; p=0.014) and Group R (mean difference, 1.66; 95% CI, 0.20 to 3.12; p=0.027). There were no significant differences across the three groups in terms of self-reported pain. Differences between Groups R and C were not significant for any of the outcome variables.

CONCLUSIONS

The intra-articular injection of 0.25% bupivacaine significantly improves postoperative pain control following the closed reduction and percutaneous pinning of supracondylar humeral fractures in pediatric patients.

The local infiltration of analgesia following total knee replacement

Controversy remains regarding the optimal post-operative analgesic regimen following total knee replacement. A delicate balance is required between the provision of adequate pain relief and early mobilisation. By reviewing 29 randomised trials we sought to establish whether local infiltration of analgesia directly into the knee during surgery provides better pain relief and a more rapid rehabilitation. Although we were able to conclude that local infiltration can provide improved post-operative pain relief, and to suggest the most promising technique of administration, there is no evidence that it reduces hospital stay.

Pain management by periarticular multimodal drug injection after anterior cruciate ligament reconstruction: a randomized, controlled study

PURPOSE

We aimed to determine the efficacy of periarticular (PA) multimodal drug cocktail (MDC) infiltration for pain control after anterior cruciate ligament reconstruction with an autogenous bone-patellar tendon-bone graft.

METHODS

We randomly assigned 100 patients to five study groups (20 per group): control group, no injection; intra-articular (IA) ropivacaine group, IA injection of ropivacaine alone; IA MDC group, IA injection of MDC; PA MDC group, PA injection of MDC; and IA + PA MDC group, IA and PA injections of MDC. The MDC consisted of ropivacaine, morphine, ketorolac, epinephrine, and cefuroxime. The five groups were compared in terms of pain levels during the first night after surgery and on postoperative days 1, 2, and 14; patient satisfaction was assessed on postoperative day 14.

RESULTS

The PA MDC and IA + PA MDC groups had less pain during the first night than patients in the other three groups (P < .001) and were more likely to have the same amount of pain or less pain on postoperative day 1 than their preoperative expectation (P = .05). However, there were no group differences in patient satisfaction on postoperative day 14. No MDC-related side effect was reported.

CONCLUSIONS

The MDC injection, particularly when delivered periarticularly, provides an effective, safe means of reducing early postoperative pain after anterior cruciate ligament reconstruction at minimal cost. In addition, a single IA injection would have no value in pain relief, regardless of types of drugs.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Intraarticular vs. extraarticular ropivacaine infusion following high-dose local infiltration analgesia after total knee arthroplasty: a randomized double-blind study

BACKGROUND AND PURPOSE

Ropivacaine infusion following high-volume local infiltration analgesia has been shown to be effective after total knee arthroplasty, but the optimum site of administration of ropivacaine has not been evaluated. We compared the effects of intraarticular and extraarticular adminstration of the local anesthetic for postoperative supplementation of high-volume local infiltration analgesia.

PATIENTS AND METHODS

In this double-blind study, 36 rheumatic patients aged 51-78 years with physical status ASA 2-3 who were scheduled for total knee arthroplasty were randomized into 2 groups. All patients received wound infiltration at the end of surgery with 300 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine (total volume 156 mL). A tunneled catheter was randomly placed either extraarticularly or intraarticularly. Continuous infusion of ropivacain (0.5%, 2 mL/h) was started immediately and was maintained during the next 48 h. Pain intensity at rest, on movement, and with mobilization was estimated by the patients and the physiotherapist; rescue morphine consumption was recorded.

RESULTS

As estimated by the patients, ropivacaine administered intraarticularly did not improve analgesia relative to extraarticular infusion, but improved the first mobilization. The incidence of high intensity of pain (VAS 7-10) was less in the group with intraarticular infusion. Analgesic requirements were similar in the 2 groups (47 mg and 49 mg morphine). No complications of postoperative wound healing were seen and there were no toxic side effects.

INTERPRETATION

Continuous infusion of ropivacaine intraarticulary did not improve postoperative analgesia at rest relative to extraarticular administration, but it appeared to reduce the incidence of high pain intensity during first exercises, and could therefore be expected to improve mobilization up to 24 h after total knee arthroplasty.

Is intra-articular multimodal drug injection effective in pain management after total knee arthroplasty? A randomized, double-blinded, prospective study

We performed a prospective, double-blinded, randomized, and controlled study to assess the clinical efficacy and safety of intra-articular multimodal drug injection after total knee arthroplasty. Two hundred eighty-six patients undergoing simultaneous bilateral total knee arthroplasty were randomized to receive the injection of multimodal drugs in one knee and normal saline solution as a placebo in the contralateral knee. All patients received patient-controlled analgesia for 48 hours after surgery, followed by standard analgesia. Visual analog scores for pain during activity and rest and for patient satisfaction were recorded. The range of motion and blood loss were also recorded. Intraoperative intra-articular injection of multimodal drugs into the knee did not improve patient pain and satisfaction, range of motion, or blood loss compared with the placebo control.

Local infiltration analgesia

Pain after major abdominal, orthopedic, and thoracic surgeries can be significant causing unacceptable morbidity. Poorly controlled pain results in patient dissatisfaction and may also be associated with major morbidities, including perioperative myocardial ischemia, pulmonary complications, altered immune function, and postoperative cognitive dysfunction. Various techniques are currently used to manage this pain, and opioids are amongst the most frequently used. Recent literature supports the use of regional anesthesia in the form of various peripheral nerve blocks as a better alternative. This article discusses the role and evidence for wound infiltration analgesia in general surgery, orthopedic surgery, neurosurgery, and thoracic surgery.

Pain control infusion pumps: a prospective randomized evaluation in bilateral total knee arthroplasty

We prospectively monitored pain scores on 24 patients who underwent bilateral total knee arthroplasty (TKA). Patients were blinded to receiving either a functional or placebo pain control infusion pumps. After 3 days, pump volume was recorded, and patients were asked to identify which knee they believed received the functional pain control infusion pump. Fourteen patients (58%) correctly identified their knee with the functional pain control infusion pump. Pump volumes ranged from 70 to 310 mL, with an average flow rate of 4.3 mL/hour. Positive identification rates were similar to rates routinely generated from standard placebo symptom treatment pain trials (0%-60%). Our data suggest that the placebo effect plays at least a partial role in pain control infusion pump effectiveness, and that pain control infusion pump use for TKA unpredictably contributes to postoperative pain management. [corrected]

Reduced opioid consumption and improved early rehabilitation with local and intraarticular cocktail analgesic injection in total hip arthroplasty: a randomized controlled clinical trial

OBJECTIVE

Postoperative pain after total hip arthroplasty (THA) is not well tolerated. We assessed postoperative pain relief and the need for opioid use after using a cocktail of local and intraarticular analgesic injection (LIA) after THA.

METHODS

Eighty patients undergoing THA under spinal anesthesia were randomly assigned to receive either LIA or placebo. The LIA was composed of 5 mg morphine, 30 mg bupivacaine (15 mg/1.5 mL), 1 mL betamethasone, and 0.5 mL epinephrine (1:1,000) intraoperatively. We compared three outcomes total morphine consumption, visual analog scale (VAS) at rest and during activity, and hip flexion angle while standing.

RESULTS

When compared with placebo, opioid consumption was significantly reduced in the trial group, as well as VAS at rest and during mobilization. Earlier rehabilitation and better range of motion (ROM) were achieved in the trial group. There were no significant differences in side effects or postoperative wound healing between groups.

CONCLUSION

In patients undergoing THA, LIA may reduce postoperative systemic opioid use and offer better pain control and earlier rehabilitation, without observable risks.

Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty:a prospective, randomized trial

We evaluated the efficacy of periarticular infiltration of corticosteroid, opioid, and a local anesthetic by comparing pain scores, knee flexion, and quadriceps function on the day of surgery, first postoperative day, day of discharge, and 2 and 4 weeks after surgery between the infiltrated and the noninfiltrated knee in 40 patients undergoing simultaneous bilateral computer-assisted total knee arthroplasty who were randomized to receive the injection in the right or left knee. In comparison to the noninfiltrated side, the infiltrated knee showed significantly lower pain scores, significantly greater active flexion up to 4 weeks, and superior quadriceps recovery up to 2 weeks after surgery. This simple and inexpensive technique can significantly reduce pain and hasten functional recovery in the first month after total knee arthroplasty.

The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty

BACKGROUND

Patient-controlled analgesia is a widely used and effective method of controlling pain after THA. This method is associated with substantial undesirable side effects. Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively, but its ability to reduce pain without complications is still questioned.

QUESTIONS/PURPOSES

We evaluated patient-controlled analgesia use, pain and satisfaction scores, complication rates, and ropivacaine levels associated with the use of periarticular multimodal drug infiltration in THA.

PATIENTS AND METHODS

We randomized 64 patients undergoing THA to receive a periarticular intraoperative multimodal drug injection or to receive no injection. All patients received patient-controlled analgesia for 24 hours after surgery. The final assessment was at 6 weeks.

RESULTS

Patients receiving the periarticular injection used less patient-controlled analgesia 6 hours postoperatively. The 24-hour patient-controlled analgesia requirement postsurgery also was less. The visual analog scale score for pain on activity in the postanesthetic care unit was less for patients who received an injection. The visual analog scale satisfaction score was similar in the two groups throughout the followup period. Recorded unbound ropivacaine levels were 2.5 times lower than toxic levels.

CONCLUSIONS

Periarticular intraoperative injection with multimodal drugs can reduce postoperative patient-controlled analgesia requirements and pain on activity in patients undergoing THA with no apparent increase in risk.

LEVEL OF EVIDENCE

Level I, therapeutic study. See the guidelines online for a complete description of level of evidence.

Analgesic efficacy of the intra-articular administration of high doses of morphine in patients undergoing total knee arthroplasty

BACKGROUND AND OBJECTIVES

Although the efficacy of intraarticular (IA) morphine is still controversial, it has been shown that higher doses promote better results and consequently decrease postoperative analgesic consumption, characterizing a dose-dependent peripheral action. A controlled, randomized, double-blind study was undertaken to evaluate the efficacy of the intra-articular administration of 10 mg of morphine in patients undergoing total knee arthroplasty.

METHODS

Fifty patients undergoing total knee arthroplasty were randomly divided into two groups: the treatment group received 10 mg (1 mL) of intra-articular morphine diluted in 19 mL of NS, while the control group received the intra-articular administration of 20 mL of NS, both after closure of the capsule at the end of the surgery. On demand subcutaneous morphine was available for residual pain. The following parameters were evaluated: pain severity according to the numeric scale (NS), 2 h (M1), 6 h (M2), 12 h (M3), and 24 h (M4) after the IA injection; time until the first request of analgesic; analgesic consumption, and side effects.

CONCLUSIONS

The treatment group had lower NS than the control group in M1 and M2, while significant differences were not observed in the other moments. The time until the first request of analgesics was significantly higher in the treatment group, and analgesic consumption in the first 24 hours was also lower in this group. The incidence of side effects did not differ between both groups. We concluded that the postoperative IA administration of 10 mg of morphine promoted a longer period without rescue analgesics and reduced their consumption in the first 24 hours.