0
Scientific Articles   |    
Local Infiltration Analgesia Followed by Continuous Infusion of Local Anesthetic Solution for Total Hip ArthroplastyA Prospective, Randomized, Double-Blind, Placebo-Controlled Study
Olga Solovyova, MD1; Courtland G. Lewis, MD2; Jonathan H. Abrams, MD2; John Grady-Benson, MD2; Michael E. Joyce, MD2; Steven F. Schutzer, MD2; Sivasenthil Arumugam, MBBS2; Stephanie Caminiti, APRN2; Sanjay K. Sinha, MBBS2
1 University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT 06032
2 Connecticut Joint Replacement Institute, St. Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT 06105. E-mail address for S.K. Sinha: sanjaysinha@comcast.net
View Disclosures and Other Information
  • Disclosure statement for author(s): PDF

Investigation performed at the Connecticut Joint Replacement Institute, St. Francis Hospital and Medical Center, Hartford, Connecticut



Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Nov 06;95(21):1935-1941. doi: 10.2106/JBJS.L.00477
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

We studied the efficacy of local infiltration analgesia in surgical wounds with 0.2% ropivacaine (50 mL), ketorolac (15 mg), and adrenaline (0.5 mg) compared with that of local infiltration analgesia combined with continuous infusion of 0.2% ropivacaine as a method of pain control after total hip arthroplasty. We hypothesized that as a component of multimodal analgesia, local infiltration analgesia followed by continuous infusion of ropivacaine would result in reduced postoperative opioid consumption and lower pain scores compared with infiltration alone, and that both of these techniques would be superior to placebo.

Methods: 

In this prospective, double-blind, placebo-controlled study, 105 patients were randomized into three groups: Group I, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of 0.2% ropivacaine at 5 mL/hr; Group II, in which patients received infiltration with ropivacaine, ketorolac, and adrenaline followed by continuous infusion of saline solution at 5 mL/hr; and Group III, in which patients received infiltration with saline solution followed by continuous infusion of saline solution at 5 mL/hr.

All patients received celecoxib, pregabalin, and acetaminophen perioperatively and patient-controlled analgesia; surgery was performed under general anesthesia. Before wound closure, the tissues and periarticular space were infiltrated with ropivacaine, ketorolac, and adrenaline or saline solution and a fenestrated catheter was placed. The catheter was attached to a pump prefilled with either 0.2% ropivacaine or saline solution set to infuse at 5 mL/hr.

The primary outcome measure was postoperative opioid consumption and the secondary outcome measures were pain scores, adverse side effects, and patient satisfaction.

Results: 

There were no differences between groups in the administration of opioids in the operating room, in the recovery room, or on the surgical floor. The pain scores on recovery room admission and discharge and the floor were low and similar between groups. There were no differences in the incidence of adverse side effects among groups. Patient satisfaction with pain management was similar in all groups.

Conclusions: 

Local infiltration analgesia alone or followed by continuous infusion of ropivacaine as part of multimodal analgesia provides no additional analgesic benefit or reduction in opioid consumption compared with placebo following total hip arthroplasty.

Level of Evidence: 

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

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Sanjay K. Sinha, MBBS, Olga Solovyova, BS, Courtland G. Lewis, MD, Jonathan H. Abrams, MD, John Grady-Benson, MD, Michael E. Joyce, MD, Steven F. Schutzer, MD, Sivasenthil Arumugam, MD
    Posted on January 16, 2014
    Reply to 'The results of our study, which was slightly different, were better'
    Connecticut Joint Replacement Institute, St. Francis Hospital and Medical Center, Hartford, CT, USA

    We would like to thank Drs. Borgeat, Aguirre and Dora for their interest in our study (1). Even though we included many references that produced contrary results to our study, not citing their article was an oversight on our part (2). We take this opportunity to respond to the specific issues raised by the authors. First, as stated in our manuscript, an analysis of distribution of patients with the two surgical approaches in the study groups did not yield any statistical differences, thereby decreasing the likelihood of bias in interpreting data. Secondly, we did acknowledge, in our manuscript, that a different pattern of laying the catheter could produce different results, though our catheters were placed extra-capsular as well.

    Comparing the results between the two studies and drawing meaningful conclusions is a challenge, because different concentrations (0.2% vs 0.3%) and dose (100mg vs 60mg) of ropivacaine were used for infiltration and infusion (5mL/h vs 8mL/h) in combination with different multimodal medications (celecoxib, acetaminophen, pregabalin vs acetaminophen). Our data clearly shows that local infiltration analgesia alone or in combination with infusion of local solution does not provide any additional analgesic benefit when compared to use of multimodal medications in patients undergoing total hip arthroplasty. Other investigators have corroborated these findings (3,4,5). In contrast, there are studies, not unlike yours, which show improved pain control with local infiltration when only acetaminophen is used as the only adjunct to opioids (6,7). Indeed, it makes us wonder if the results of your study would have been different if a more comprehensive multimodal regimen had been used in your patients. In addition, we are surprised that you describe our multimodal medications as “heavy” because this regimen is based on current evidence and recommendations (8). However, we were encouraged that in your paper you advocate the use of multimodal medications similar to the ones used in our study.

    Until a well designed study demonstrates superior analgesia using higher concentration of ropivacaine compared to comprehensive multimodal medications, the risk of the local infiltration analgesia has to be weighed against the benefit of using comprehensive multimodal medications in total hip arthroplasty patients. We believe that current evidence does not justify the use of local infiltration in total hip arthroplasty patients.

    REFERENCES
    1. Solovyova O, Lewis CG, Abrams JH, Grady-Benson J, Joyce ME, Schutzer SF, Arumugam S, Caminiti S, Sinha SK. Local Infiltration Analgesia Followed by Continuous Infusion of Local Anesthetic Solution for Total Hip Arthroplasty: A Prospective, Randomized, Double-Blind, Placebo-Controlled Study. J Bone Joint Surg Am, 2013; 95 :1935-1941. doi: 10.2106/JBJS.L.00477
    2. Aguirre J, Baulig B, Dora C, Ekatodramis G, Votta-Velis G, Ruland P, Borgeat A. Continuous Epicapsular Ropivacaine 0.3% Infusion After Minimally Invasive Hip Arthroplasty: A Prospective, Randomized, Double-Blinded, Placebo-Controlled Study Comparing Continuous Wound Infusion with Morphine Patient-Controlled Analgesia. Anesth Analg, 2012; 114: 456–461
    3. Specht K, Leonhardt JS, Revald P; Mandøe H, Andresen EB, Brodersen J, Kreiner S, Kjaersgaard-Andersen P. No evidence of a clinically important effect of adding local infusion analgesia administrated through a catheter in pain treatment after total hip arthroplasty. Acta Orthop. 2011; 82: 315-20
    4. Lunn TH, Husted H, Solgaard S, Kristensen BB, Otte KS, Kjersgaard AG, Gaarn-Larsen L, Kehlet H. Intraoperative local infiltration analgesia for early analgesia after total hip arthroplasty: a randomized, double-blind, placebo-controlled trial. Reg Anesth Pain Med. 2011; 36: 424-9.
    5. Andersen LØ, Otte KS, Husted H, Gaarn-Larsen L, Kristensen B, Kehlet H. High-volume infiltration analgesia in bilateral hip arthroplasty. A randomized, double-blind placebo-controlled trial. Acta Orthop. 2011; 82: 423-6.
    6. Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Søballe K. Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty: a randomized clinical trial of an intraarticular technique versus epidural infusion in 80 patients. Acta Orthop. 2007; 78: 180-6
    7. Andersen LJ, Poulsen T, Krogh B, Nielsen T. Postoperative analgesia in total hip arthroplasty: a randomized double-blinded, placebo-controlled study on peroperative and postoperative ropivacaine, ketorolac, and adrenaline wound infiltration. Acta Orthop. 2007; 78: 187-92
    8. Practice Guidelines for Acute Pain Management in the Perioperative Setting: An Updated Report by the American Society of Anesthesiologist Task Force on Acute Pain Management. Anesthesiology 2012; 116: 248-73

    Alain Borgeat, MD (1), José Aguirre, MD (1), Claudio Dora, MD (2)
    Posted on December 09, 2013
    The results of our study, which was slightly different, were better
    (1) Department of Anesthesiology, and (2) Department of Hip Surgery, Balgrist University Hospital, Zurich, Switzerland

    This study, which was well conducted, showed that local infiltration vs placebo after total hip arthroplasty had similar outcomes in terms of morphine consumption, side-effects, and patient satisfaction. These results are contradictory to those obtained in our prospective, randomized, double blind study “Continuous epicapsular ropivacaine 0.3 % infusion after minimally invasive hip arthroplasty”(1). Unfortunately our work was neither cited nor discussed, despite the fact that both investigations have many similarities. However, some points need to be mentioned, which can partly explain the different results. First, Solovyova et al. had two surgical approaches, in contrast to our work, which can create some bias in the interpretation of the results. Second, the amount and concentration of ropivacaine was different. We used 0.3 % vs 0.2 % and our infusion rate was 8 ml vs 5 ml/h. The amount of ropivacaine given by Solovyova et al. may not have been sufficient. Thirdly, the exact placement of the catheter was not clearly defined, in contrast to our protocol which specified an epicapsular placement. The placement of the catheter deep on the capsule and then a “catheter-S-shape” form the deep structures to the subcutaneous part in order to cover all the different surgical plans may also explain some of the differences between the 2 studies. Finally, the heavy multimodal analgesic regimen given to their patients may have blunted the beneficial effect of the infiltration.

    Local infiltration is now the standard technique after MIS hip arthroplasty in our institution and the results in terms of postoperative analgesia, early mobilization and patient satisfaction are more than excellent.

    References

    1. Aguirre J, Baulig B, Dora C, Ekatodramis G, Votta-Velis G, Ruland, P, Borgeat A. Continuous epicapsular ropivacaine 0.3% infusion after minimally invasive hip arthroplasty: A prospective, randomized, double-blinded, placebo-controlled study comparing continuous wound infusion with morphine patient-controlled analgesia. Anesth Analg. 2012 Feb;114(2):456-61. Epub 2011 Nov 10.  Erratum in Anesth Analg. 2013 Jun;116(6):1394.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    01/08/2014
    PA - Penn State Milton S. Hershey Medical Center
    03/17/2014
    CT - Orthopaedic Foundation
    02/28/2014
    DC - Children's National Medical Center