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Intra-Articular Injection of Bupivacaine in Knee-Replacement Operations. Results of Use for Analgesia and for Preemptive Blockade *
N. H. BADNER, M.D., F.R.C.P.(C)†; R. B. BOURNE, M.D., F.R.C.S.(C)†; C. H. RORABECK, M.D., F.R.C.S.(C)†; S. J. MACDONALD, M.D., F.R.C.S.(C)†; J. A. DOYLE, R.N.†, LONDON, ONTARIO, CANADA
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Investigation performed at the London Health Sciences Centre, University Campus, London.
J Bone Joint Surg Am, 1996 May 01;78(5):734-8
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Abstract

The effectiveness of an intra-articular injection of bupivacaine, administered before the incision or after closure of the wound, was studied in an effort to decrease the need for postoperative narcotics and to improve analgesia for patients who have elective knee replacement. Eighty-two patients received two intra-articular injections in a random, double-blind fashion. Twenty-eight of them received thirty milliliters of 0.5 per cent bupivacaine and 1:200,000 epinephrine in saline solution before the incision and an injection of thirty milliliters of plain saline solution after closure of the wound (Group 1). Twenty-seven patients received an injection of thirty milliliters of plain saline solution before the incision and thirty milliliters of 0.5 per cent bupivacaine and 1:200,000 epinephrine in saline solution after closure of the wound (Group 2). Twenty-seven patients were given thirty milliliters of plain saline solution (a placebo) for both injections (Group 3). The patients who had received bupivacaine after closure of the wound (Group 2) used less morphine from the patient-controlled analgesia pumps than the patients who had received bupivacaine before the incision (Group 1) and the patients who had received the placebo (Group 3). In the first twenty-four hours after the operation, the administration of morphine (mean and standard deviation) was 59 ± 27 milligrams for Group 2 compared with 68 ± 30 milligrams for Group 1 (p = 0.26) and 81 ± 30 milligrams for Group 3 (p = 0.006). At the time of discharge from the hospital, the patients in Group 2 also had a significantly greater mean range of motion (85.2 ± 8.0 degrees) compared with that of the patients in Groups 1 (80.6 ± 6.8 degrees, p = 0.02) and 3 (80.1 ± 6.2 degrees, p = 0.009). However, there was no difference among the groups with respect to the effectiveness of the analgesia, as measured with use of either the visual-analog or the verbal pain-rating scale, or in the prevalence of side effects, including somnolence, urinary retention, nausea and vomiting, or pruritus. Serum concentrations of bupivacaine were well below toxic levels.It was our conclusion that that an intra-articular injection of thirty milliliters of 0.5 per cent bupivacaine and 1:200,000 epinephrine in saline solution after closure of the wound decreases the need for narcotics and increases the range of motion after an elective knee replacement. The clinical importance of the amount of increased motion is questionable and needs longer-term monitoring.

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    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.
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