High-volume infiltration analgesia in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial

Anatomical Safety Area for Periarticular Analgesic Infiltration through the Posterior Capsule in Total Knee Arthroplasty: Radiological Study in Magnetic Resonance

Background: One of the main challenges of orthopedic surgery is adequate pain management after total knee arthroplasty. This work aimed to determine the anatomical safety area for infiltration through the posterior capsule of the knee in prosthetic surgery using Magnetic Resonance Imaging (MRI). Methods: A descriptive, observational, cross-sectional study was performed on 126 knee MRIs. The variables studied were age, sex, and distance between different neurovascular structures of the popliteal fossa (tibial nerve, common peroneal nerve, and vascular bundle). Data were analyzed for normality (Kolmogorov-Smirnov) and variance homogeneity (Levène). A value of p < 0.05 and a confidence interval of 9% were considered statistically significant for all comparisons. Student's t-test was used to compare the means between independent samples. Results: We observed statistically significant differences between the sexes regarding EP-EPS (external plateau-external popliteal sciatic nerve (common peroneal)), EP-IPS (external plateau-internal popliteal sciatic nerve (tibial)), and IP-PA (internal plateau-popliteal artery) measurements. The average distance between both nerves, EPS-IPS (external popliteal sciatic nerve and internal popliteal sciatic nerve), was 25.96 mm in females, while the value obtained in males was 29.93 mm, but this difference was not statistically significant. Conclusions: The average distance from the posterior capsule to the EPS and IPS nerves is greater in males than in females, despite no statistical differences. The presence of a lateralized arteriovenous bundle reduces the infiltration area of the external compartment. Regarding the safety area, infiltration of the internal compartment is safe since the volume diffuses into the muscle mass of the internal gastrocnemius upon injection. To infiltrate the external compartment, the needle must move at least 2 cm from the midline toward the external side (to exceed the maximum displacement of the neurovascular bundle established at 1.82 cm), and not advance beyond 0.76 cm (minimum distance at which we located the common peroneal nerve in the external compartment).

Current advancements in therapeutic approaches in orthopedic surgery: a review of recent trends

Recent advancements in orthopedic surgery have greatly improved the management of musculoskeletal disorders and injuries. This review discusses the latest therapeutic approaches that have emerged in orthopedics. We examine the use of regenerative medicine, including stem cell therapy and platelet-rich plasma (PRP) injections, to accelerate healing and promote tissue regeneration. Additionally, we explore the application of robotic-assisted surgery, which provides greater precision and accuracy during surgical procedures. We also delve into the emergence of personalized medicine, which tailors treatments to individual patients based on their unique genetic and environmental factors. Furthermore, we discuss telemedicine and remote patient monitoring as methods for improving patient outcomes and reducing healthcare costs. Finally, we examine the growing interest in using artificial intelligence and machine learning in orthopedics, particularly in diagnosis and treatment planning. Overall, these advancements in therapeutic approaches have significantly improved patient outcomes, reduced recovery times, and enhanced the overall quality of care in orthopedic surgery.

Efficacy and safety of different bupivacaine concentrations in periarticular infiltration combined with adductor canal block for bilateral total knee arthroplasty: a randomized controlled trial

BACKGROUND

Pain management for bilateral total knee arthroplasty (BTKA) often combines adductor canal block (ACB) with periarticular infiltration (PAI). However, concerns arise regarding local anesthetic toxicity. This study evaluated the efficacy and safety of different bupivacaine concentrations in simultaneous BTKA.

METHODS

Patients undergoing simultaneous BTKA under spinal anesthesia were included in the study. They received ACB with 50 mg bupivacaine for each thigh. The patients were then randomized into two groups. Group A was administered a PAI of 100 mg bupivacaine per knee (totaling 300 mg bupivacaine for ACB and PAI). Group B received a PAI with 50 mg bupivacaine per knee (totaling 200 mg bupivacaine for ACB and PAI). Postoperative pain was assessed using a visual analog scale at 4-h intervals for 48 h after surgery. Plasma bupivacaine concentrations were measured at eight specified times. Postsurgery walking ability was also evaluated.

RESULTS

Among the 57 participants analyzed, visual analog scale pain scores revealed no significant differences between the two groups. An interim analysis of plasma bupivacaine concentrations in both groups indicated no significant disparities. In group B, 93.1% managed to walk with assistance within 48 h, as opposed to group A's 71.4% (P = 0.041).

CONCLUSIONS

Combining ACB with 100 mg bupivacaine and PAI with another 100 mg bupivacaine provided effective pain relief. This combination also had a better safety profile and led to more patients walking postsurgery than when combining ACB with 100 mg bupivacaine and PAI with 200 mg bupivacaine. Thus, ACB combined with PAI with a total dose of 200 mg bupivacaine appears suitable for simultaneous BTKA.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03249662).

The effects of continuous catheter adductor canal block for pain management in knee replacement therapy: a meta-analysis

PURPOSE

Adductor canal block has emerged as a favourable element of multimodal analgesia regimens for total knee arthroplasty, due to the exclusive sensory blockade it provides. However, it is controversial as to whether a single shot or continuous technique adductor canal block is superior. This meta-analysis examined the effect of both these techniques on pain management associated with total knee arthroplasty.

METHODS

All randomised controlled trials published on Cochrane Library, PubMed, and EMBASE, Scopus, and PsychINFO were systematically searched. The PEDro scale was used to assess the quality of studies. A total of 8 articles, 2 of which were split by subgroup analyses to create 10 studies, with 828 adults were selected for inclusion in the analysis. The mean difference and effect size with a 95% confidence interval (CI) were analysed for the pooled results.

RESULTS

Statistically significant pooled effects of analgesia technique in favour of catheter use were found in the reduction of pain scores and VAS scores, and total rescue analgesia dosage. No significant changes were observed in the hospital stay time. Subgroup analysis revealed that patients with BMI 30 or more reported higher pain scores than those with BMI below 30.

CONCLUSION

Based upon studies that are currently available, our meta-analysis appears to demonstrate that continuous administration of analgesia through an adductor canal catheter provides greater pain reduction in total knee arthroplasty than single shot analgesia. Despite these current findings, future studies with larger sample sizes and greater control of study parameters are required to confirm the current findings.

The Effects of Liposomal Bupivacaine on Long-term Outcomes and Decreasing Immediate Postoperative Opioid Use Following One-level and Two-level Posterior Lumbar Fusions

STUDY DESIGN

This is a retrospective observational study.

OBJECTIVE

This study aims to determine the efficacy of liposomal bupivacaine in postoperative analgesia and long-term outcomes in patients undergoing one-level and two-level posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

Multiple studies have investigated the use of liposomal bupivacaine in spine surgery with varying results. The potential benefits of its use include decreasing postoperative opioid use, improved pain control, and a shorter hospital stay. Several studies have supported its use in spine surgery with others showing minimal to no benefit. No studies have investigated its possible impact on long-term outcomes.

MATERIALS AND METHODS

A total of 42 patients (22 one-level, 20 two-level) received liposomal bupivacaine injection just before surgical closure and were compared with a historical control group of 42 patients (27 one-level, 15 two-level) that did not receive liposomal bupivacaine. Daily opioid consumption was collected and converted to oral morphine equivalents. Length of stay and daily average pain scores using the visual analog scale were also recorded. In addition, SF-36 bodily pain and physical function outcome measures were collected preoperatively and at 6 months, 1 year and 2 years postoperatively.

RESULTS

The liposomal bupivacaine group was found to have a significantly lower total opioid consumption compared with the control group ( P =0.001). The liposomal bupivacaine group was also found to use significantly fewer opioids on the day of surgery compared with the control group ( P <0.0001). There was no significant difference shown in the average visual analog scale pain scores, length of stay, or long-term outcomes between the 2 groups.

CONCLUSIONS

The use of liposomal bupivacaine in one-level and two-level posterior lumbar fusions shows promise as an adjuvant for postoperative analgesia by decreasing postoperative opioid consumption. With the varying results demonstrated with the utilization of liposomal bupivacaine in spine surgery, further investigation is warranted, namely a larger prospective randomized control study.

LEVEL OF EVIDENCE

Level III.

Adductor Canal Block Combined with Interspace between the Popliteal Artery and Capsule of the Knee (iPACK) versus Periarticular Injection for Total Knee Arthroplasty

BACKGROUND

The combination of the adductor canal block (ACB) and the infiltration of anesthetic solution into the interspace between the popliteal artery and capsule of the knee (iPACK) has become increasingly used to augment rapid recovery protocols in total knee arthroplasty (TKA). However, its efficacy in comparison with periarticular anesthetic injection (PAI) alone has yet to be evaluated. Hence, we conducted a retrospective study to compare PAI and ACB + iPACK for controlling pain after TKA.

METHODS

Propensity scores, incorporating American Society of Anesthesiologists scores, body mass index, age, and sex, were used to match the ACB + iPACK group with the PAI group. All patients received the identical surgical technique and postoperative care. Outcome measures were visual analog scale (VAS) for pain, morphine consumption, knee flexion angle, straight leg raising (SLR), postoperative nausea vomiting (PONV), and length of stay (LOS) after the surgery.

RESULTS

After matching by propensity score, there were 49 patients with comparable demographic data in each group. The VAS and morphine requirements of the PAI and ACB + iPACK groups were not different during the first 48 hours after TKA. At 72 hours postoperatively, the VAS of the ACB + iPACK was 0.97 higher than that of the PAI group (p = 0.020). Knee flexion angle, SLR, PONV, and LOS were not significantly different between groups. No procedure-related complications were identified in either group.

CONCLUSIONS

The anesthesiologist-administered ACB + iPACK was as effective as surgeon-administered PAI in controlling pain in the first 48 hours after TKA. However, the ACB + iPACK group had higher intensity of pain than did the PAI group at 72 hours after TKA.

Mitochondrial function, grip strength, and activity are related to recovery of mobility after a total knee arthroplasty

Low muscle quality and a sedentary lifestyle are indicators for a slow recovery after a total knee arthroplasty (TKA). Mitochondrial function is an important part of muscle quality and a key driver of sarcopenia. However, it is not known whether it relates to recovery. In this pilot study, we monitored activity after TKA using a wrist mounted activity tracker and assessed the relation of mitochondrial function on the rate of recovery after TKA. Additionally, we compared the increase in activity as a way to measure recovery to traditional outcome measures. Patients were studied 2 weeks before TKA and up to 6 months after. Activity was monitored continuously. Baseline mitochondrial function (citrate synthase and complex [CP] 1-5 abundance of the electron transport chain) was determined on muscle tissue taken during TKA. Traditional outcome measures (Knee Injury and Osteoarthritis Outcome Score [KOOS], timed up-and-go [TUG] completion time, grip, and quadriceps strength) were performed 2 weeks before, 6 weeks after, and 6 months after TKA. Using a multivariate regression model with various clinical baseline parameters, the following were significantly related to recovery: CP5 abundance, grip strength, and activity (regression weights 0.13, 0.02, and 2.89, respectively). During recovery, activity correlated to the KOOS-activities of daily living (ADL) score (r = 0.55, p = 0.009) and TUG completion time (r = -0.61, p = 0.001). Mitochondrial function seems to be related to recovery, but so are activity and grip strength, all indicators of sarcopenia. Using activity trackers before and after TKA might give the surgeon valuable information on the expected recovery and the opportunity to intervene if recovery is low.

Effect of Local Infiltration Analgesia on Functional Outcomes in Total Knee Arthroplasty: A Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Local infiltration analgesia (LIA) is a simple, surgeon-administered technique for the treatment of postoperative pain after total knee arthroplasty (TKA). The aim of the study was to investigate the efficacy of LIA and its effects on functional outcomes in TKA. A total of 135 patients with primary TKA were recruited and randomized either to receive LIA or to receive placebo injection (PI). Pain, active range of motion (ROM), knee function score, functional activities, and hospital length of stay (LOS) were assessed before surgery and from postoperative day (POD) 1 to at discharge. Lower pain scores at rest were recorded on POD1 and POD2 in the LIA group (p = 0.027 and p = 0.020, respectively). Lower pain score on walking was recorded on POD1 in the LIA group (p = 0.002). There was a statistically significant difference in active knee flexion between groups on POD1 (p = 0.038). There was a significant difference in LOS between LIA and PI groups. Shorter stay was seen in LIA group. There were no statistically significant differences between the groups in terms of knee function score and functional outcomes. LIA technique is effective for pain management in the early postoperative period. LIA added benefit for knee function in terms of active knee flexion ROM after TKA. A shorter hospital LOS was observed in LIA group. However, we did not find any differences in groups in terms of functional assessment such as ability to rise from a chair and walking capacity.The level of evidence is randomized controlled trial, level I.

Population pharmacokinetics of ropivacaine used for local infiltration anaesthesia during primary total unilateral and simultaneous bilateral knee arthroplasty

BACKGROUND

Ropivacaine is commonly used in local infiltration anaesthesia (LIA) as pain management after total knee arthroplasty (TKA). Although considered safe, no studies evaluated the pharmacokinetics of high-dose ropivacaine infiltration in simultaneous bilateral TKA.

METHODS

We studied 13 patients undergoing unilateral and 15 undergoing bilateral TKA. Standard LIA technique was used with ropivacaine 0.2%, 200 ml (400 mg) injected peri-articularly in each knee. Free and total plasma concentrations of ropivacaine were measured within 24 h using liquid chromatography-mass spectrometry. A population pharmacokinetic model was built using non-linear mixed-effects models.

RESULTS

Peak free ropivacaine concentration was 0.030 (0.017-0.071) μg ml^-1 (mean [99% confidence interval]) vs 0.095 (0.047-0.208) μg ml^-1, and peak total ropivacaine concentration was 0.756 (0.065-1.222) μg ml^-1vs 1.695 (0.077-3.005) μg ml^-1 for unilateral and bilateral TKA, respectively. The pharmacokinetics was ascribed a one-compartment model with first-order absorption. The main identified covariates were protein binding, allometrically scaled body weight on clearance and volume, and unilateral or bilateral surgery on volume.

CONCLUSIONS

This is the first study to investigate the pharmacokinetics of free and total ropivacaine after unilateral and bilateral TKA. A population model was successfully built and peak free ropivacaine concentration stayed below previously proposed toxic thresholds in patients undergoing unilateral and bilateral TKA receiving LIA with high-dose ropivacaine.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04702282.

Combination Effect of High-Dose Preoperative and Periarticular Steroid Injection in Total Knee Arthroplasty. A Randomized Controlled Study

BACKGROUND

Postoperative pain remains a major barrier to a patient's recovery after total knee arthroplasty (TKA). Periarticular corticosteroids in local infiltration analgesics (LIA) and high-dose intravenous corticosteroids have individually shown to improve pain control after TKA. However, potential interactions between them have not been investigated. This study aims to evaluate any combination effect of both routes of corticosteroids in TKA.

METHODS

This is a double-blinded, paired, randomized controlled trial involving 1-stage bilateral TKAs. All received 16 mg of dexamethasone intravenously. One knee was randomized to receive LIA with 40 mg of triamcinolone, while the other knee receives LIA without corticosteroids. For each patient, one knee was affected by intravenous steroids only, while the other was under the combined effect of intravenous and periarticular steroids (IVPAS). Knee pain, Southampton wound scores, and functional knee scores (Knee Society Knee Score and Oxford Knee Scores) were compared between knees of the same patient.

RESULTS

Forty-six patients (92 TKAs) were included. IVPAS knees showed significantly lower visual analog scale scores from day 1 to 6 weeks (P < .05) and a larger range of movement from day 2 to 4 (P < .05). IVPAS knees achieved active straight leg raise earlier than intravenous steroids (1.6 vs 2.3 days, P < .05). No differences in Southampton wound scores and functional knee scores for up to 1 year.

CONCLUSION

Combining intravenous and periarticular corticosteroids improved pain control and recovery after TKA with no increase in wound complications up to 1 year.

Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty

Background

The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI).

Methods

This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M₀), ITM 0.1 mg (M₁), and ITM 0.2 mg (M₂). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared.

Results

The trial enrolled 102 patients: M₀ (n = 32), M₁ (n = 35), and M₂ (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M₁ and M₂ did not differ significantly within the first 24 hours and were significantly lower than those in group M₀. Nausea and vomiting were observed more frequently 4 hours postoperatively in M₂ than in groups M₁ and M₀ (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09).

Conclusion

Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.

Effect of Multimodal Drugs Infiltration on Postoperative Pain in Split Laminectomy of Lumbar Spine: A Randomized Controlled Trial

STUDY DESIGN

A randomized, double-blinded controlled trial.

OBJECTIVE

This study tested the effect of single-dose wound infiltration with multiple drugs for pain management after lumbar spine surgery.

SUMMARY OF BACKGROUND DATA

Patients undergoing spine surgery often experience severe pain especially in early postoperative period. We hypothesized that intraoperative wound infiltration with multiple drugs would improve outcomes in lumbar spine surgery.

METHODS

Fifty-two patients who underwent one to two levels of spinous process splitting laminectomy of lumbar spine, were randomized into two groups. Infiltration group received intraoperative wound infiltration of local anesthetics, morphine sulfate, epinephrine, and nonsteroidal anti-inflammatory drugs at the end of surgery, and received patient-controlled analgesia (PCA) postoperatively. The control group received only PCA postoperatively. The primary outcome measures were amount of morphine consumption and visual analogue scale (VAS) for pain. The secondary outcome measures were Oswestry Disability Index (ODI), Roland-Morris Low Back Pain and Disability Questionnaire (RMDQ), patient satisfaction, length of hospital stay, and side effects.

RESULTS

A total of 49 patients (23 patients for local infiltration group, and 26 patients for control group) were analyzed. There were statistically significant [P < 0.001, the effect size -5.0, 95% CI (-6.1, -3.9)] less morphine consumptions in the local infiltration group than the control group during the first 12 hours, 12 to 24 hours, and 24 to 48 hours after surgery. The VAS of postoperative pain reported by patients at rest and during motion was significantly lower in the local infiltration group than the control group at all assessment times (P < 0.001). The effect size of VAS of postoperative pain at rest and during motion were -2.0, 95% CI (-2.5, -1.4) and -2.0, 95% CI (-2.6, -1.4) respectively. ODI and RMDQ at 2 week and 3 month follow-ups in both groups had significant improvement from baseline (P < 0.001). No significant differences were found between groups (P = 0.262 for ODI and P = 0.296 for RMDQ). There were no significant differences of patient satisfaction, length of stay, and side effects between both groups (P = 0.256, P = 0.262, P = 0.145 respectively).

CONCLUSION

Intraoperative wound infiltration with multimodal drugs reduced postoperative morphine consumption, decreased pain score with no increased side effects.

LEVEL OF EVIDENCE

1.

Increase in early wound leakage in total knee arthroplasty with local infiltrative analgesia (LIA) that includes epinephrine: a retrospective cohort study

Background and purpose - After introducing a new local infiltration anesthesia (LIA) protocol with addition of 30 mL ropivacaine 2% and 1 mg epinephrine, we noted an increase in early wound leakage. As wound leakage is associated with prosthetic joint infection, our department aims to minimize postoperative wound leakage. This study evaluates the incidence of early wound leakage and postoperative pain after knee arthroplasty (KA) following adjustment of the LIA protocol with addition of 30 cc ropivacaine 2% and 1 mg epinephrine. Patients and methods - In this retrospective medical dossier study all patients (n = 502) undergoing a primary total or unicondylar knee arthroplasty between January 1, 2018 and July 1, 2019 were included. Patients received an LIA protocol containing 120 mL 2 mg/mL ropivacaine (ROPI- group; n = 256). After October 30, patients received an LIA protocol containing 150 mL 2 mg/mL ropivacaine with 1 mg epinephrine in the first 100 mL (ROPI + group; n = 246). The primary outcome measure was early wound leakage (< 72 hours postoperatively), defined as wound fluid leaking past the barrier of the wound dressing. Secondary outcome measure, 10-point numeric rating scale (NRS) pain (< 72 hours postoperatively) was also assessed. Data was evaluated using logistic regression. Results - The incidence of wound leakage was higher in the ROPI + group: 24% versus 17% in the ROPI- group (p = 0.06). After adjusting for the differences between surgeons the relative risk of this increase was 1.4 (1.0-2.0). The ROPI + and ROPI- group were similar regarding postoperative pain assessment. Interpretation - Adjustment of the LIA protocol with 30 mL 2% ropivacaine and 1 mg epinephrine led to an increase in early wound leakage in knee arthroplasty but no difference in pain scores.

Reasons for Unsuccessful Same-Day Discharge Following Outpatient Hip and Knee Arthroplasty: 5½ Years' Experience From a Single Institution

BACKGROUND

Outpatient joint arthroplasty (OJA) is considered safe and feasible in selected patients but should be further optimized to improve success rates. The purposes of this study are to (1) identify the main reasons of unsuccessful same-day discharge (SDD) following hip and knee arthroplasty; (2) determine the hospital length of stay (LOS) following unsuccessful SDD; and (3) assess which independent variables are related to specific reasons for unsuccessful SDD.

METHODS

Five hundred twenty-five patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty between 2013 and 2019 were retrospectively identified. SDD to home was planned in all patients. Specific reasons for unsuccessful SDD and LOS were assessed. Bivariate analysis was performed to find differences in independent variables between patients experiencing a specific reason for unsuccessful SDD and control patients.

RESULTS

One hundred ten patients (21%) underwent unsuccessful SDD. The main reason was postoperative reduced motor function and sensory disturbances (33%). The mean LOS in the unsuccessful SDD group was 1.7 days (standard deviation ± 1.0 days). Postoperative transient reduced motor function and sensory disturbances occurred more often in patients undergoing TKA (P < .001).

CONCLUSION

An option for overnight stay should be available when performing outpatient hip and knee arthroplasty. The main reason for unsuccessful SDD in this study was transient postoperative reduced motor function and sensory disturbance, most likely due to intraoperative local infiltration analgesia in TKA. No other studies have found local infiltration analgesia to be an issue preventing SDD.

[PECS I block for postoperative analgesia in patients undergoing breast augmentation surgery: a randomized double-blind placebo-controlled study]

BACKGROUND AND OBJECTIVES

PECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population.

METHODS

This was a randomized, double-blind, placebo-controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg^-1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0-10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha<0.05).

RESULTS

In the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23-5.56; mean 95% CI), 3.75 (3.13-4.37), 3.79 (2.93-4.64), and 2.29 (1.56-3.01), respectively, whereas in the placebo group, they were 4.96 (4.32-5.60), 4.00 (3.50-4.49), 3.93 (3.12-4.73), and 2.29 (1.56-3.01), respectively.

CONCLUSIONS

PECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.

PECS I block for postoperative analgesia in patients undergoing breast augmentation surgery: a randomized double-blind placebo-controlled study

Background and objectives

Methods

Results

Conclusions

A prospective comparative study of local infiltration versus adductor block versus combined use of the two techniques following knee arthroplasty

BACKGROUND

Pain management after total knee arthroplasty (TKA) is important as acute postoperative pain can affect patient's ability to walk and participate in rehabilitation required for good functional outcome. This is achieved by effective intra-operative and post-operative analgesia to facilitate early recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) are analgesic regimens and commonly used for effective post-operative analgesia after TKA. Our aim was to compare the efficacy and outcomes of these two methods, combined and independently.

METHODS

Our study included 120 patients undergoing unilateral TKA, who were randomized into three groups: LIA (Group I), ACB (Group II) and combined LIA + ACB (Group III). Patients were operated by a single surgeon. The outcome was defined by post-operative analgesia achieved by the three techniques (measured by the NPRS) and amount of fentanyl consumed postoperatively. Secondary outcome was evaluated based on postoperative functional outcomes in terms of ability to stand, distance covered, range of motion of knee on the 1st post-operative day, complications and WOMAC (Western Ontario & McMaster Universities Osteoarthritis Index) scores.

RESULTS

All patients were available for analysis. Numerical Pain Rating Scale for pain showed significant differences at 24 h between Group I and Group II, with a p value of 0.018 (GroupI was better), significant differences were found at 24 h between Group III and Group II, with p values being 0.023 and 0.004 (GroupIII was better). No significant differences were found between Group I and Group III at 24 h. Total fentanyl consumption was significantly less in Group III than in Group I and Group II, with p value being 0.042 and 0.005, respectively (Group III was better and consumed less fentanyl). No significant differences were found in WOMAC scores between the three groups at baseline, 2 and 6 weeks after operation.

CONCLUSION

In patients undergoing TKA, analgesic effect of combined ACB and LIA was superior, as indicated by reduced opioid consumption and no differences in functional outcomes and complications were observed as compared to separate use of the two techniques.

Pain management after total knee arthroplasty: A prospective randomized study

INTRODUCTION

Total knee arthroplasty (TKA) is a common procedure for improving mobility and quality of life in patients with osteoarthritis. Postoperative pain control management after TKA is still a concern as it relates to patients satisfaction and functional recovery.Many anesthetic regimens and techniques have been explored to decrease postoperative pain and enhance the fast recovery after TKA. The aim of this study was to evaluate the best anesthetic treatment in pain control after TKA.

METHODS

51 patients were included in a randomized prospective study and distributed in three groups. The first group (CG) in which no analgesic protocol was implemented (control group). The second group (LIA group) received an intraoperative local infiltration anesthesia (LIA) (60 ml mixture of two ropivacaine 75mg/10 mL + adrenaline 100μg/10 mL + physiological solution). The third group (FNB group) had only a femoral nerve block (FNB). Continuous outcomes including visual analogue scale (VAS) at 5,24,48 h and at 1 week, morphine consumption and range of motion (ROM) at 1,2,7 days.

RESULTS

There was significant difference between all groups (p < 0,001) in terms of the VAS score: at 5h after surgery (4.55,2.15,1.82); at 24h (4.15,2.65,3.36); at 48h (3.85,2.45,2.73); at 1 week (2.95,1.80, 1.64), respectively for groups CG, LIA, FNB.ROM was better in LIA and FNB groups than CG: at 1 die after surgery (44°,50°,54°); at 3 dies (69°,70°,71°); at 7 dies (91°,98°,98°), respectively for groups CG, LIA, FNB (p < 0,001).

DISCUSSION

LIA and FNB groups both showed a significant reduction at VAS score, better range of motion and less morphine consumption than CG (control group). LIA group has obtained a constant pain control in the postoperative days; FNB group had a good pain control in the hours after surgery, with a decrease in efficacy in the following days.

CONCLUSION

Further studies are still needed in order to define LIA as the reference pain management in TKA.

The Hemodynamic Effect of Epinephrine-Containing Local Infiltration Analgesia After Tourniquet Deflation During Total Knee Arthroplasty: A Retrospective Observational Study

BACKGROUND

Local infiltration analgesia (LIA) is widely used in patients undergoing total knee arthroplasty and often contains epinephrine for a prolonged analgesic effect and to reduce systemic absorption of the local anesthetic. This retrospective observational study investigated the hemodynamic effect of locally infiltrated epinephrine after deflation of the tourniquet during total knee arthroplasty.

METHODS

We reviewed the electronic medical records of patients who underwent total knee arthroplasty between January 2017 and February 2018 at a tertiary care university hospital. Total knee arthroplasty was performed using a conventional technique with a pneumatic tourniquet. LIA consisted of ropivacaine, morphine sulfate, ketorolac, and methylprednisolone. The patients were grouped according to whether or not epinephrine was included in the LIA. The incidence of a hypertensive response (systolic blood pressure >160 mmHg or mean blood pressure >110 mmHg) after deflation of the tourniquet was compared between the 2 groups.

RESULTS

A total of 452 patients had received LIA with (n = 188) or without (n = 264) epinephrine. A hypertensive response after deflation of the tourniquet was more common in patients who received LIA containing epinephrine (42/188 [22.3%]) than in those who received LIA without epinephrine (14/264 [5.3%], P < .001). However, the incidence of hypotension after deflation of the tourniquet was not significantly different between the 2 groups (P = .976).

CONCLUSION

Because epinephrine-containing LIA can result in a hypertensive response after deflation of the tourniquet during total knee arthroplasty, it should be cautiously administered, especially in patients with cardiovascular comorbidities.

Adductor Canal Block or Local Infiltrate Analgesia for Pain Control After Total Knee Arthroplasty? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Total knee arthroplasty is a treatment option for debilitating arthritis. In the postoperative period, patients experience moderate to severe pain affecting the rehabilitation, hospital stay, and patient satisfaction. This study aims at utilizing current best evidence to determine whether adductor canal block (ACB) or periarticular injection (PAI) is a better modality for managing short-term postoperative pain and opioid consumption.

METHODS

Embase, MEDLINE, HealthStar, Emcare, and PubMed were searched for randomized controlled trials from 1946 to August 2018, for literature addressing the comparison of ACB and PAI for pain management in the setting of total knee arthroplasty. A systematic review and meta-analysis were performed.

RESULTS

Six studies were included in our meta-analysis. When examining the combined visual analog scale (VAS) pain values for each group, analysis demonstrated greater reduction in scores for the PAI group, and the difference was statistically significant (P = .001). When comparing the VAS scores of subgroups analyzed at specific periods in time, there was a trend toward lower VAS scores in subgroups analyzed at 24 hours and 48 hours postoperatively (at rest and at movement) in the PAI group. Overall opioid consumption was lower in the PAI group, with demonstrated statistical significance (P = .03). When comparing the postoperative subgroups, there was a trend toward decreased opioid use in the PAI group, with 13.25% less opioid use at 48 hours and 9.5% less opioid use at 24 hours.

CONCLUSION

PAI could significantly improve postoperative pain and opioid consumption when compared with ACB. Additional, high-quality studies are required to further address this topic.

Local Anesthetic Wound Infiltration after Osteosynthesis of Extracapsular Hip Fracture Does Not Reduce Pain or Opioid Requirements: A Randomized, Placebo-Controlled, Double-Blind Clinical Trial in 49 Patients

Background and purpose

Local infiltration analgesia (LIA) supports early mobilization after hip and knee arthroplasty. Inspired by this, we studied the effectiveness of wound infiltration with the long acting local anesthetic ropivacaine in an effort to decrease the need for postoperative opioids after osteosynthesis of extracapsular hip fracture.

Methods

Forty-nine patients undergoing osteosynthesis with a sliding hip screw were randomized into two groups in a double-blind study (ClinicalTrials.gov:NCT01119209). The patients received intraoperative infiltration followed by 6 postoperative injections through a wound catheter in eight-hour intervals. 23 patients received ropivacaine and 26 received saline. The intervention period was 2 days, and the observation period was 5 days. In both groups, there were no restrictions on the total daily dose of opioids. Pain was assessed at specific postoperative time points, and the daily opioid usage was registered.

Results

Intraoperative infiltration with 200 mg ropivacaine and postoperative repeated infiltration with 100 mg ropivacaine did not result in statistically significant difference between the groups regarding postoperative opioid consumption or pain.

Interpretation

Ropivacaine as single component in postoperative treatment of pain after hip fracture is not effective. In our setup, wound infiltration with ropivacaine is not statistically significantly better than placebo.

Does ethnicity and education influence preoperative disability and expectations in patients undergoing total knee arthroplasty?

AIM

To investigate whether minority ethnicity and the duration of education influence preoperative disability and expectations in patients undergoing total knee arthroplasty.

METHODS

We prospectively included 829 patients undergoing primary unilateral total knee arthroplasty (TKA) from April 2013 to December 2014 at a single centre. Patients filled in pre-operative questionnaires with information regarding place of birth, duration of education, expectations for outcome of surgery and baseline characteristics. Patients were stratified based on ethnicity. Majority ethnicity was defined as born in the study country and minority ethnicity was defined as born in any other country. Similarly, patients were stratified based on duration of education in groups defined as < 9 years, 9-12 years and > 12 years, respectively.

RESULTS

We found that 92.2% of patients were of majority ethnicity. We found that 24.5%, 44.8% and 30.8% of patients had an education of < 9 years, 9-12 years and > 12 years, respectively. The mean preoperative (pre-OP) oxford knee score (OKS) in the total population was 23.6. Patients of minority ethnicity had lower mean pre-OP OKS (18.6 vs 23.9, P < 0.001), higher pain levels (VAS 73.0 vs 58.7, P < 0.001), expected higher levels of post-OP pain (VAS 14.1 vs 6.1, P = 0.02) and of overall symptoms (VAS 16.6 vs 6.4, P = 0.006). Patients with > 12 years education had lower mean pre-OP OKS (21.5 vs 23.8 and 24.6, P < 0.001) and higher pre-OP VAS pain (65.4 vs 59.2 and 56.4, P < 0.001) compared to groups with shorter education. One year post-operative (post-OP) patients of minority ethnicity had lower mean OKS, higher pain and lower QoL. One year post-OP patients with > 12 years education reported higher pain compared to patients with shorter educations. However, the response-rate was low (44.6%), and therefore post-OP results were not considered to be significant.

CONCLUSION

Minority ethnicity and the duration of education influence preoperative disability and expectation in patients undergoing TKA. This should be taken into account when patients are advised pre-operatively.

Effectiveness and weakness of local infiltration analgesia in total knee arthroplasty: a systematic review

Local infiltration analgesia has been widely used for pain relief in patients undergoing total knee arthroplasty. However, the effectiveness and major weakness of this technique have not been clarified; therefore, improvements in the technique have been limited. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and conducted a meta-analysis of randomized controlled trials comparing local infiltration analgesia with placebo infiltration in patients undergoing total knee arthroplasty. Fourteen trials involving 1305 knees were eligible. The results showed that local infiltration analgesia significantly reduced early perioperative pain and total narcotic consumption. However, postoperative functional outcomes were not significantly different between local infiltration analgesia and placebo. The pain-relieving effect of local infiltration analgesia was found to be strong but short in duration. In the future, modified delivery methods and formulas with longer durations of action and analgesia may provide a better environment for patients and therefore improve their function outcomes.

The effect of morphine added to periarticular multimodal drug injection or spinal anesthesia on pain management and functional recovery after total knee arthroplasty

BACKGROUND

The efficacy of morphine added to periarticular multimodal drug injection (PMDI) for pain management after total knee arthroplasty (TKA) is controversial. Adding morphine to spinal anesthesia has reportedly improved pain relief for the first 24 h. We examined the effect of morphine added to PMDI or spinal anesthesia on pain management and functional recovery after TKA.

METHODS

A total of 97 patients were randomized into three groups: in Group A (34 patients), 10 mg morphine was added to PMDI; Group B (31 patients), 0.1 mg morphine was added to spinal anesthesia; and Group C (32 patients), morphine was added to neither the PMDI nor spinal anesthetic. To evaluate the efficacy of added morphine for pain management, we assessed rest pain, the number of times analgesics were used, and the time period until the first analgesic use. The adverse effects of morphine were assessed by counting the numbers of times vomiting occurred and antiemetics were used. Functional recovery was evaluated by recording the range of motion of the knee and the date of ability to walk.

RESULTS

Rest pain was the least in Group B at 6 and 12 h after operation. The number of times analgesics were used was the least in Group B. The time period until the first analgesic use was the longest in Group B. The number of vomiting episodes was the least in Group C. The number of times antiemetics were used was higher in Group A than in Group C. There were no significant differences in the range of motion and date of ability to walk among the three groups.

CONCLUSIONS

The efficacy of morphine added to PMDI was limited, and that of morphine added to spinal anesthesia disappeared within 20 h postoperatively. Adding morphine to PMDI or spinal anesthesia did not improve functional recovery and caused some adverse effects.

Post-operative pain control following arthroscopic rotator cuff repair: peri-articular injection versus interscalene brachial plexus block

PURPOSE

To compare post-operative pain relief with peri-articular injection (PI) versus interscalene brachial plexus block (IBPB) after arthroscopic rotator cuff repair (ARCR) surgery.

METHODS

We retrospectively reviewed 121 consecutive patients undergoing ARCR surgery divided into two groups: the PI group and the IBPB group. We compared complications and self-reported pain score measured using a Numerical Rating Scale (NRS) during the initial 24 hours after surgery.

RESULTS

The NRS scores recorded in the recovery room (0), 0.5, and four hours post-operatively were higher in the PI group (n = 38) than the IBPB group (n = 52) (2.1 vs. 0.8, p = 0.014; 1.4 vs. 0.5, p = 0.0069; and 1.3 vs. 0.5, p = 0.012, respectively). However, the NRS scores recorded at 16, 20, and 24 hours post-operatively were lower in the PI group than in the IBPB group (1.4 vs. 3.1, p < 0.0001; 1.4 vs. 3.2, p < 0.0001; and 1.7 vs. 3.2, p = 0.00046, respectively). The incidences of post-operative nausea and temporary numbness in the upper arm were significantly lower in the PI group than in the IBPB group (7.9% vs. 33%, p = 0.0052; and 13% vs. 85%, p < 0.0001, respectively).

CONCLUSIONS

Although IBPB provided superior pain control during the initial few hours after ARCR surgery, PI was superior from 16 to 24 hours post-operatively. The rates of side effects, such as nausea and temporary arm numbness, were also lower in the PI group than in the IBPB group.

No effect of double nerve block of the lateral cutaneous nerve and subcostal nerves in total hip arthroplasty

Background and purpose - The use of local infiltration anesthesia (LIA) has become one of the cornerstones of rapid recovery protocols in total knee arthroplasty patients during the past decade. In total hip arthroplasty (THR), however, the study results are more variable and LIA has therefore not yet been generally accepted. There is no consensus on which structure should be infiltrated and the cutaneous nerves are generally neglected. Hence, we hypothesized a pain-reducing effect of specifically blocking these nerves. Patients and methods - We performed a single-center randomized placebo-controlled trial in 162 subjects to evaluate the infiltration of the lateral cutaneous femoral and subcostal nerve with ropivacaine in patients undergoing total hip arthroplasty via a straight lateral approach. The primary endpoint was pain at rest after 24 hours. Patients were followed up to 6 weeks postoperatively. Results - After correction for multiple testing, no statistically significant differences in pain scores were found between the ropivacaine compared with the placebo group after surgery. In addition, no differences were observed in the use of escape pain medication, complications, and the length of hospital stay. Interpretation - We found no clinically meaningful differences in pain scores between placebo and ropivacaine patients in the postoperative period after THA performed via a straight lateral approach under spinal anesthesia and a multimodal pain regimen. Moreover, our primary endpoint, pain reduction after 24 hours, was not met. Further research should focus on the composition and volume of the LIA suspension, the optimal localization of the infiltration, and should be evaluated for every surgical approach separately.

Optimizing the dose of local infiltration analgesia and gabapentin for total knee arthroplasty, a randomized single blind trial in 128 patients

BACKGROUND AND PURPOSE

Effective analgesia is essential for postoperative recovery and rehabilitation in TKA. The challenge of analgesic regimes is to obtain adequate pain relief and maximum muscle control to mobilize and rehabilitate patients early. However, the optimal dose and best composition are not known. We hypothesized that there would be no differences in reported postoperative pain on the day of the TKA surgery as well as the first day after surgery when different combinations of ropivacain for LIA and gabapentin are given.

METHODS

This prospective randomized trial examined 128 TKA patients treated with LIA and gabapentin in four groups. Group A: 300-mg ropivacain/600-300-300-mg gabapentin. Group B: 150-mg ropivacain/600-300-300-mg gabapentin. Group C: 300-mg ropivacain/300-100-100-mg gabapentin. Group D: 150-mg ropivacain/300-100-100-mg gabapentin. Primary endpoint was pain (NRS) at multiple moments. Secondary endpoints were number of adverse effects, length of hospital stay (LOS), the amount of consumption of pain medication, and wound leakage. Generalized estimating equation (GEE) was used to detect differences between the four groups regarding the course of pain.

RESULTS

No differences regarding adverse effects, LOS, and wound leakage were found. GEE revealed a significant difference in course of pain between group A and B, with group B experiencing higher NRS scores postoperatively than group A (p=0.021). No differences between the other groups were found.

INTERPRETATION

The results of the current study suggest that LIA with 300-mg (150ml) ropivacain might be more effective than 150-mg (75ml) ropivacain. Alteration in dose of gabapentin appears not to have influence on the course of pain.

No advantage of adrenaline in the local infiltration analgesia mixture during total knee arthroplasty

PURPOSE

Local infiltration analgesia (LIA) is widely applied in patients undergoing total knee arthroplasty (TKA). In daily practice, adrenaline is added to the LIA mixture to achieve vasoconstriction. However, adrenaline has some possible negative side effects (e.g. tissue necrosis). This trial investigated whether ropivacaine alone is at least as effective for postoperative pain relief after LIA.

METHODS

Fifty patients scheduled for primary TKA were included in this prospective randomized, double-blind, controlled pilot study receiving high-volume (150 mL) single-shot intra-capsular LIA with ropivacaine (2 %) with (Ropi+) or without (Ropi-) adrenaline (0.01 %). All patients received the same pre-, peri- and postoperative care with multimodal oral pain protocol. Postoperative pain was assessed before and after the first mobilization and during the first 48 h postoperative using the visual analogue scale (VAS). Secondary outcomes were rescue medication use, early mobilization, length of hospital stay, adverse events (AE's) and readmission rates. Patient reported outcomes measures (PROMS); Oxford Knee Score and WOMAC, were obtained preoperative and 3 months postoperative.

RESULTS

VAS scores were not significantly different before (n.s.) and after the first mobilization (n.s.), neither over the first 48 h postoperative (n.s.). Patients who needed rescue medication (n.s.), who mobilized <6 h postoperative (n.s.), who were discharged before postoperative day 3 (n.s.), AE's and readmission rate (n.s.) were comparable between both groups. At 3-month follow-up, PROMS significantly improved within both groups.

CONCLUSION

To prevent possible negative side effects (e.g. tissue necrosis), adrenaline should be omitted from the LIA mixture. Single-shot LIA with ropivacaine alone results in clinical acceptable adequate pain control and can be used in daily TKA practice.

LEVEL OF EVIDENCE

Randomized, double-blind, prospective clinical trial, Level I.

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.

Safety Aspects of Postanesthesia Care Unit Discharge without Motor Function Assessment after Spinal Anesthesia

Background

Postanesthesia care unit (PACU) discharge without observation of lower limb motor function after spinal anesthesia has been suggested to significantly reduce PACU stay and enhance resource optimization and early rehabilitation but without enough data to allow clinical recommendations.

Methods

A multicenter, semiblinded, noninferiority randomized controlled trial of discharge from the PACU with or without assessment of lower limb motor function after elective total hip or knee arthroplasty under spinal anesthesia was undertaken. The primary outcome was frequency of a successful fast-track course (length of stay 4 days or less and no 30-day readmission). Noninferiority would be declared if the odds ratio (OR) for a successful fast-track course was no worse for those patients receiving no motor function assessment versus those patients receiving motor function assessment by OR = 0.68.

Results

A total of 1,359 patients (98.8% follow-up) were available for analysis (93% American Society of Anesthesiologists class 1 to 2). The primary outcome occurred in 92.2% and 92.0%, corresponding to no motor function assessment being noninferior to motor function assessment with OR 0.97 (95% CI, 0.70 to 1.35). Adverse events in the ward during the first 24 h occurred in 5.8% versus 7.4% with or without motor function assessment, respectively (OR, 0.77; 95% CI, 0.5 to 1.19, P = 0.24).

Conclusions

PACU discharge without assessment of lower limb motor function after spinal anesthesia for total hip or knee arthroplasty was noninferior to motor function assessment in achieving length of stay 4 days or less or 30-day readmissions. Because a nonsignificant tendency toward increased adverse events during the first 24 h in the ward was discovered, further safety data are needed in patients without assessment of lower limb motor function before PACU discharge.

Pharmacokinetics of 400 mg ropivacaine after periarticular local infiltration analgesia for total knee arthroplasty

BACKGROUND

Although considered safe, no pharmacokinetic data of high dose, high volume local infiltration analgesia (LIA) with ropivacaine without the use of a surgical drain or intra-articular catheter have been described. The purpose of this study is to describe the maximum total and unbound ropivacaine concentrations (C_max , C_{u max} ) and corresponding maximum times (T_max , T_{u max} ) of a single-shot ropivacaine (200 ml 0.2%) and 0.75 mg epinephrine (1000 μg/ml) when used for LIA in patients for total knee arthroplasty.

METHODS

In this prospective cohort study, 20 patients were treated with LIA of the knee for primary total knee arthroplasty. Plasma samples were taken at 20, 40, 60, 90, 120, 240, 360 min and at 24 h after tourniquet release, in which total and unbound ropivacaine concentrations were determined.

RESULTS

Results are given as median [IQR]. Highest ropivacaine concentration (C_max ) was 1.06 μg/ml [0.34]; highest unbound ropivacaine concentration (C_{u max} ) was 0.09 μg/ml [0.05]. The corresponding time to reach the maximum concentration for total ropivacaine was 312 min [120] after tourniquet release, and for the unbound fraction 265 [110] min after tourniquet release.

CONCLUSION

Although great inter-individual variability was found between the maximum ropivacaine concentrations, both maximum total and unbound serum concentrations of ropivacaine remained well below the assumed systemic toxic thresholds of 4.3 and 0.56 μg/ml.

Pilot study: Post-operative rehabilitation pathway changes and implementation of functional closed kinetic chain exercise in total hip and total knee replacement patient

OBJECTIVE

The aim of this study was to assess the feasibility of introducing a functional closed kinetic chain exercise program to an acute care setting to reduce length of hospital stay and assess tolerance to exercise immediately following total hip or total knee arthroplasty.

METHODS

A protocol change implementing a functional closed kinetic chain based exercise program, post total hip (n = 535) and total knee (n = 695) arthroplasty, was performed at Windsor Regional Hospital Ouellette Campus in Windsor, Ontario Canada. A chart review was performed to compare the length of stay, post-surgery, of the new protocol to the length of stay of the previous range of motion and open kinetic chain based protocols of the previous two years.

RESULTS

A significant (P-value <0.05) number of total hip and total knee arthroplasty patients reduced the length of hospital stay to less than 4 days using the closed kinetic chain program.

CONCLUSION

Evidence suggests that closed kinetic chain exercises are tolerated in the acute care setting and may be useful in reducing hospital length of stay post total hip and total knee arthroplasty.

Can local infiltration analgesia increase satisfaction in postoperative short-term pain control in total knee arthroplasty?

BACKGROUND

One of the major challenges to total knee arthroplasty (TKA) is optimal pain control. Effective analgesia is capital in fast-track surgery programs to allow patient's early functional outcomes.

OBJECTIVES

Compare length of stay (LOS) short-term pain control, and patients' satisfaction at 1 month between local infiltration analgesia (LIA) combined with femoral nerve block (FNB) and FNB only in patients undergoing TKA.

PATIENTS AND METHODS

Two hundred and fifty-four patients were included in a randomized prospective study and distributed in two groups. The first group received an intraoperative LIA (150 mL mixture of ropivacaine 2.0 mg/mL + ketorolac 30 mg + adrenaline 10 μg/mL) combined to an FNB. The control group had only an FNB. Demographical data and visual analog scale (VAS) score were obtained preoperatively, at 36 h after surgery and at the 15-day follow-up. Patients' satisfaction at 1 month was also evaluated. Statistical analysis data was performed.

RESULTS

No differences in demographical data and preoperative VAS score were observed between both groups. LIA group had a lower VAS score at 36 h after surgery (1.34 ± 1.31 vs. 3.68 ± 1.932 in the control group, p = 0.00), but these differences were not maintained at the 15-day follow-up (4.51 ± 1.889 vs. 4.11 ± 1.940 in the control group, p > 0.05). LOS and patients' satisfaction were comparable between groups. Patients with LIA had no additional complications.

CONCLUSIONS

LIA is a safe adjuvant to FNB to reduce perioperative pain during the first 36 h after TKA. Its effects wean with time, but do cover the first crucial hours of rehabilitation in a fast-track program. LIA seems don't modify postoperative course nor patient's satisfaction at short-term follow-up. The final impact of LIA on surgical outcome is still to be determined.

Potential superiority of periarticular injection in analgesic effect and early mobilization ability over femoral nerve block following total knee arthroplasty

PURPOSE

Pain management after total knee arthroplasty (TKA) should permit early knee mobilization with minimal pain. Periarticular injection (PAI) with local anaesthetics has been recently discussed as a protocol of pain control. The purpose of this review of the literature was to evaluate the efficacy of PAI in comparison with femoral nerve block (FNB).

METHODS

A literature search was performed in PubMed, EMBASE, the OVID database and the Cochrane Library databases. Risk of bias was assessed using the Cochrane collaboration tool. Outcomes of interest included narcotic consumption, pain score, early mobilization ability, length of stay and adverse effects or events.

RESULTS

Research identified 918 articles, of which six with a total of 284 knees, met the inclusion criteria and were eligible for the current study. Conflicting evidence was found in terms of narcotic consumption on the postoperative day 1 and early mobilization ability. Total narcotic consumption, pain score in the first 2 days after surgery, length of stay and adverse effects or events showed no difference between two groups. Lower pain score on the day of surgery was detected after PAI. When compared to continuous FNB, patients in PAI group showed a tendency to achieving better ability of early mobilization.

CONCLUSIONS

In consideration of its relatively simple practice and its potential in analgesic effects or early mobilization ability, PAI had superiority to FNB in the management of pain control after TKA. Before PAI could be widely used in clinical practice after TKAs, further investigations would be necessary to confirm or refute our observed results and to unify the protocol of PAI.

LEVEL OF EVIDENCE

I.

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.

Local anaesthetic wound infiltration after internal fixation of femoral neck fractures: a randomized, double-blind clinical trial in 33 patients

Pain control may assist early mobilisation after internal fixation of femoral neck fractures. Systemic opioids have significant side effects in elderly patients. We present an evaluation of the effect of local anaesthetic infiltration in such cases , the objective being to decrease the need for postoperative opioids and to improve pain control for patients after surgery. 33 patients undergoing internal fixation with 2 parallel hook pins were randomized into 2 groups in a double blind study (ClinicalTrials.gov: NCT00529425). 33 patients received intraoperative infiltration followed by 6 postoperative injections through an intraarticular catheter in eight-hour intervals. 19 patients received ropivacaine and 14 received saline. The intervention period was 48 hours and the observation period was 5 days. In both groups there were no restrictions on the total daily dose of rescue analgesics. Pain was assessed at specific postoperative time-points and the daily consumption of opioid drugs needed for analgesia was registered. There was no significantly reduced consumption of standardized opioid rescue analgesics or pain in the study group receiving ropivacaine injections. Apart from a reduction in nausea in the study group on the second postoperative day, there were no significant differences in the occurrence of side effects between the groups. On day 2 the placebo group had less pain than the study group. Local anaesthetic infiltration after fixation of femoral neck fractures does not reduce opioid consumption or pain'.

The impact of including corticosteroid in a periarticular injection for pain control after total knee arthroplasty: a double-blind randomised controlled trial

There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA. A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve. The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively. The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection.

TAKE HOME MESSAGE

The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA.

Regional analgesia for improvement of long-term functional outcome after elective large joint replacement

BACKGROUND

Regional analgesia is more effective than conventional analgesia for controlling pain and may facilitate rehabilitation after large joint replacement in the short term. It remains unclear if regional anaesthesia improves functional outcomes after joint replacement beyond three months after surgery.

OBJECTIVES

To assess the effects of regional anaesthesia and analgesia on long-term functional outcomes 3, 6 and 12 months after elective major joint (knee, shoulder and hip) replacement surgery.

SEARCH METHODS

We performed an electronic search of several databases (CENTRAL, MEDLINE, EMBASE, CINAHL), and handsearched reference lists and conference abstracts. We updated our search in June 2015.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing regional analgesia versus conventional analgesia in patients undergoing total shoulder, hip or knee replacement. We included studies that reported a functional outcome with a follow-up of at least three months after surgery.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We contacted study authors for additional information.

MAIN RESULTS

We included six studies with 350 participants followed for at least three months. All of these studies enrolled participants undergoing total knee replacement. Studies were at least partially blinded. Three studies had a high risk of performance bias and one a high risk of attrition bias, but the risk of bias was otherwise unclear or low.Only one study assessed joint function using a global score. Due to heterogeneity in outcome and reporting, we could only pool three out of six RCTs, with range of motion assessed at three months after surgery used as a surrogate for joint function. All studies had a high risk of detection bias. Using the random-effects model, there was no statistically significant difference between the experimental and control groups (mean difference 3.99 degrees, 95% confidence interval (CI) - 2.23 to 10.21; P value = 0.21, 3 studies, 140 participants, very low quality evidence).We did not perform further analyses because immediate adverse effects were not part of the explicit outcomes of any of these typically small studies, and long-term adverse events after regional anaesthesia are rare.None of the included studies elicited or reported long-term adverse effects like persistent nerve damage.

AUTHORS' CONCLUSIONS

More high-quality studies are needed to establish the effects of regional analgesia on function after major joint replacement, as well as on the risk of adverse events (falls).

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.