Question:
In patients having total knee arthroplasty, what is the effectiveness of an intra-articular compared with an extra-articular infusion of local anesthetics with use of a local infiltration of analgesia approach at the end of surgery?
Design:
Randomized (allocation concealed), blinded (patients, investigators, physiotherapists, and postoperative care staff), controlled trial with 3-month follow-up.
Setting:
The unit for Rheumatic Surgery, Spenshult Hospital, Oskarström, Sweden.
Patients:
36 patients <80 years of age (mean age, 67 years; 73% women) who were scheduled for total knee arthroplasty because of rheumatoid arthritis. Exclusion criteria were major psychological problems, contraindication to any of the study drugs, renal insufficiency, abnormal liver enzymes, stroke or neurological deficit, angina, severe diabetes, chronic opioid use, or inability to use patient-controlled analgesia. 33 patients (92%) completed the study.
Intervention:
Patients were allocated to receive a continuous infusion of ropivacaine administered intra-articularly (n = 18) or extra-articularly (n = 18). Under spinal anesthesia, all patients had total knee arthroplasty by 1 of 2 surgeons with use of a medial parapatellar approach. At the end of the operation, a solution of 300 mg of ropivacaine, 30 mg of Toradol (ketorolac), and 0.5 mg of epinephrine was infiltrated periarticularly into the soft tissues. 30 mL was injected into the posterior aspect of the capsule and the medial and lateral collateral ligaments just before implantation of the component; 50 mL was injected into the deep tissues surrounding the medial and collateral ligaments and the wound edges before suturing; and the rest was injected into the capsule incision, the synovial sheet, the ligaments, and the subcutaneous tissue. A multi-hole Perifix One catheter (B. Braun Medical AB, Danderyd, Sweden) was tunneled 6 to 8 cm from the edge of the wound and placed intra-articularly in the distal part of the joint or extra-articularly into the soft tissues next to the patella. The catheter administered a continuous infusion of 5 mg/mL of ropivacaine. All patients received paracetamol (acetaminophen), intravenous morphine if necessary, and a patient-controlled analgesia (PCA) device with morphine as a rescue medication for 48 hours after surgery.
Main outcome measures:
The primary outcome measures were the total amounts of PCA morphine; pain intensity at rest, with motion, and during mobilization assessed with a 10-point visual analog scale (VAS) (0 = no pain, 10 = worst possible pain); and pain during mobilization, assessed by the physical therapist with use of a 5-point verbal rating scale (VRS) (0 = none, 5 = unbearable). Secondary outcomes included knee flexion, adverse effects, and readiness for discharge. The study had sufficient power to detect a minimum difference of 10 mm in a 10-cm VAS measurement for pain between groups.
Main results:
Patients in the intra-articular and extra-articular groups had similar postoperative morphine consumption, with both groups reaching 50 mg after 48 hours. The groups did not differ in VAS score at rest or with movement. The mean VAS score at rest was <3 and the highest score reached during movement was 6. During mobilization, severe pain was experienced by 3 patients in the intra-articular group compared with 11 patients in the extra-articular group (p = 0.03). The VRS by the physical therapist concerning the first mobilization favored the intra-articular group (p < 0.05). There were no differences between the groups for knee flexion, adverse effects, or readiness for discharge.
Conclusion:
Compared with extra-articular infusion, intra-articular infusion of ropivacaine was better at reducing severe pain intensity during postoperative mobilization after total knee arthroplasty.
Question:
In patients having total knee arthroplasty, does intraoperative periarticular infiltration analgesia provide better postoperative pain management than that provided by intrathecal morphine?
Design:
Randomized (allocation concealed), blinded (patients, investigators [other than the surgeon], physiotherapist, and postoperative healthcare staff), controlled trial with 3 months of follow-up after surgery.
Setting:
Department of Orthopaedic Surgery, Örebro University Hospital, Örebro, Sweden.
Patients:
50 patients (40 to 85 years of age; mean age, 71 years; 62% women) who were scheduled to undergo total knee arthroplasty because of osteoarthritis and who had an American Society of Anesthesiologists grade of 1 to 3 were enrolled. Exclusion criteria were contraindications to any of the study drugs or spinal anesthesia; severe liver, heart, or renal disease; inflammatory joint disease; chronic pain requiring opioids; or bleeding disorder. 48 patients (96%) completed the study.
Intervention:
Patients were allocated to intraoperative local infiltration analgesia (n = 25) or intrathecal morphine (n = 25). Total knee arthroplasty was performed through a standard medial parapatellar approach with the patient under spinal analgesia. Patients in the local infiltration group received intrathecal 0.9% saline solution together with 17.5 mg of bupivacaine, and patients in the morphine group received 0.1 mg of morphine intrathecally with bupivacaine. Patients could receive intravenous propofol and fentanyl if analgesia was insufficient. During surgery, the local infiltration group received 300 mg of ropivacaine, 30 mg of ketorolac, and 0.5 mg of epinephrine (total volume, 116 mL) periarticularly into the soft tissues. 40 to 50 mL was injected into the posterior capsule and the collateral ligaments after the bone cuts were made. 50 to 70 mL was injected into the capsule incision, the quadriceps tendon, the infrapatellar tendon, and around the posterior cruciate ligament after the prosthesis was inserted. 50 mL of ropivacaine alone was infiltrated into the subcutaneous tissue before skin closure. Patients in the morphine group received no intraoperative injection. On the first and second postoperative mornings, a bolus injection of the same mixture was given via an intra-articular catheter in the local infiltration group. In the morphine group, a similar volume of saline solution was injected.
Main outcome measures:
The outcome measure was morphine consumption during the first 48 postoperative hours. Secondary outcomes were pain relief, measured with the 100-mm visual analog scale (VAS) (0 = no pain, 100 = worst possible pain), at rest, on flexion of the knee by 60°, and while walking; patient satisfaction with the quality of analgesia (1 [poor] to 4 [excellent]); functional recovery measured by maximum knee extension and flexion and the Timed Up and Go (TUG) test; time to fulfillment of discharge criteria and hospital length of stay; and adverse effects.
Main results:
Morphine consumption in the first 48 postoperative hours was lower in the local infiltration group than in the morphine group (26 versus 54 mg, 95% confidence interval [CI] [for the mean 14.2-mg difference for each 24-hour period], 7.6 to 20.9). The median VAS pain scores at 48 hours were lower in the local infiltration group than in the morphine group at rest (5 versus 20, p < 0.001), on flexion (30 versus 59, p < 0.001), and while walking (10 versus 39, p = 0.001). Patient satisfaction was greater in the local infiltration group on the first postoperative day, but the groups did not differ on day 2 or day 7. More patients in the local infiltration group were able to climb stairs at 48 hours (70% versus 22%, 95% CI for the 48% difference, 23% to 73%). The groups did not differ with regard to knee extension, knee flexion, or the TUG test. The local infiltration group had a shorter time to fulfillment of discharge criteria (51 versus 72 hours, 95% CI for the 23-hour difference, 18 to 42) and median hospital length of stay (3 versus 4 days, p = 0.029). The prevalence of side effects did not differ between the groups.
Conclusion:
In patients having total knee arthroplasty, the intraoperative administration of analgesia through local infiltration led to lower postoperative morphine consumption and better pain control than that provided by intrathecal morphine.
Question:
In patients having total hip arthroplasty, what is the effectiveness of intraoperative periarticular infiltration of levobupivacaine in reducing postoperative pain, morphine consumption, and complications associated with opiate use?
Design:
Randomized (allocation concealed), blinded (patients and surgeons up to the time of the intraoperative injection), controlled trial with mean 72-hour postoperative follow-up.
Setting:
Cappagh National Orthopaedic Hospital in Dublin, Ireland.
Patients:
91 patients (mean age, 56 years; 56% men) who were receiving primary hip arthroplasty for osteoarthritis were included. Exclusion criteria were cognitive impairment, neurologic disorders, liver or renal impairment, ischemic heart disease, a previous chronic pain syndrome, opiate dependence, or postoperative surgical or medical complications. All patients were included in the analysis.
Intervention:
Patients were allocated to intraoperative periarticular infiltration of levobupivacaine, 150 mg in 60 mL 0.9% saline solution (n = 45) or 60 mL 0.9% saline solution (n = 46). All hip arthroplasties were performed by the same surgeon with use of a posterior approach. Levobupivacaine or saline solution was injected through the medial and anterior capsular spaces near the obturator and femoral nerves and into the short external rotators and gluteus maximus near the inferior and superior gluteal nerves. The infiltration was done after insertion of the acetabular component and before insertion of the femoral stem. 10 mL of levobupivacaine and saline solution or saline solution alone was infiltrated around the fascia lata and subcutaneously before wound closure. All patients received opioid analgesia with a patient-controlled analgesia device for 48 hours after surgery and then paracetamol (acetaminophen), diclofenac, and regular oral opioids. Full weight-bearing mobilization (with crutches) was begun the day after surgery.
Main outcome measures:
The primary outcomes were postoperative pain measured with use of the short-form and standard versions of the McGill pain questionnaire and the 10-point visual analog scale (VAS) (0 = no pain, 10 = worst pain) and morphine consumption up to 48 hours after surgery. Secondary outcomes were urinary retention requiring catheterization and antiemetic use. A post hoc power analysis based on the VAS results of an initial study of 48 patients indicated the need to include at least 42 patients in each study group (84 in total) to achieve a power of 80%. This calculation was based on the minimally detectable change for VAS of 1.3 (±2.1 standard deviation; alpha = 0.05).
Main results:
The levobupivacaine and saline solution groups did not differ in the sensory and affective dimensions of pain (p = 0.731) or in overall pain intensity scores on the VAS (p = 0.463) or patient pain intensity (p = 0.814). Morphine consumption in the levobupivacaine group was lower than in the saline solution group during the first 12 hours after surgery (11.46 versus 21.23 mg, p < 0.001). Urinary retention occurred in 1 patient in the levobupivacaine group and in 3 patients in the saline-solution group (p = 0.317). The groups did not differ with regard to antiemetic use (p = 0.221).
Conclusion:
In patients having total hip arthroplasty, intraoperative periarticular infiltration of levobupivacaine did not alleviate postoperative pain more than placebo did, but reduced opiate consumption in the first 12 hours after surgery.
Effective analgesia, particularly after total knee arthroplasty, can substantially affect rehabilitation and ultimate outcome. The extensive soft-tissue dissection and knee debridement that are often necessary during knee arthroplasty procedures, coupled with the need to immediately mobilize the knee to achieve knee flexion and extension, produces increased pain compared with the pain experienced by the patient after total hip arthroplasty. Due to the immediate relief of the arthritic pain after total hip arthroplasty, the need for analgesic medications after that procedure can often be less than the need for analgesics after total knee arthroplasty. Many types of analgesic control have been employed after total knee arthroplasty, including femoral and/or sciatic nerve block, indwelling intra-articular catheters, continuous epidural analgesia, and potent opioid medication. More recently, attempts have been made to improve pain control with use of local analgesia, ranging from periarticular injection of local anesthetics to “cocktails” containing seven or eight different medications (by means of different routes), including hydrocortisone, other anti-inflammatory medications, local anesthetics, and analgesics. The arguments against these injections have been that they are effective for only the immediate postoperative period, or that local administration of analgesics via a catheter into the knee joint or into soft tissues may lead to possible contamination of the catheter, leading to secondary prosthetic infection.
Murphy et al. evaluated periarticular injections of levobupivacaine (a long-acting local anesthetic) compared with placebo in patients having total hip arthroplasty. Pain scores and pain intensity scores were similar between the levobupivacaine and placebo groups and there was no reduction in nausea, vomiting, or urinary retention. The overall morphine consumption was less in the levobupivacaine group and, as would be expected, the reduction was greatest in the first twelve hours postoperatively.
In the study by Essving et al., spinal anesthesia was used in both groups, with instillation of intrathecal morphine in one group while the second group had both intra-articular and extra-articular injection of a combination of ropivacaine, ketorolac, and epinephrine at the time of surgery and then on postoperative days one and two by intra-articular catheter. The infiltration group had less morphine consumption in the first forty-eight hours, less pain with therapy, and a shorter time to hospital discharge. Both groups were similar after forty-eight hours and did not differ with regard to side effects.
In the study by Dobrydnjov et al., all patients received intraoperative ropivacaine but were randomized to either intra-articular or extra-articular postoperative continuous infusion of ropivacaine via a catheter. Overall morphine consumption was similar in the two groups, and pain scores were similar. Patients receiving intra-articular infusion had less pain on mobilization for physical therapy and lower pain scores during exercise.
All three trials demonstrate some (but not overwhelming) benefit from infiltration of local anesthetic agents in patients having total knee arthroplasty. Despite the fact that all three trials used different analgesic techniques, some conclusions can be drawn: (1) use of intraoperative and postoperative injection and infusion techniques of local anesthetic with or without ketorolac reduced the need for opioids postoperatively, at least during the time of infusion; (2) mobilization and postoperative physical therapy were less painful when infusions were used, although intraoperative injection alone probably does not make an important difference; and (3) there were no untoward effects with use of these techniques in the patients studied, although the use of postoperative catheters in the acute periprosthetic environment always raises the issue of potential bacterial contamination of the wound. These studies provide evidence that there is a role for the use of local anesthetics and anti-inflammatory medications both intraoperatively and postoperatively in total knee arthroplasty but that use of these medications was not associated with a dramatic overall reduction in the consumption of opioids or a significant improvement in rehabilitation.