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Efficacy of Periarticular Multimodal Drug Injection in Total Knee ArthroplastyA Randomized Trial
Constant A. Busch, FRCS(TR&Orth)1; Benjamin J. Shore, MD2; Rakesh Bhandari, MD2; Su Ganapathy, FRCA2; Steven J. MacDonald, MD2; Robert B. Bourne, MD2; Cecil H. Rorabeck, MD2; Richard W. McCalden, MD2
1 The Rowley Bristow Unit, Ashford and St. Peter's NHS Trust, Guildford Road, Surrey KT16 0PZ, United Kingdom
2 Division of Orthopaedic Surgery, London Health Sciences Centre, University Campus, 339 Windermere Road, London, ON N6A 5A5, Canada. E-mail address for R.B. Bourne: robert.bourne@lhsc.on.ca
View Disclosures and Other Information
Note: The authors acknowledge the work of Dr. L. Kohan and Dr. D. Ker in Sydney, Australia, for the development of the multimodal drug combination used in this study.
The authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at the Division of Orthopaedic Surgery, London Health Sciences Centre, London, Ontario, Canada

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2006 May 01;88(5):959-963. doi: 10.2106/JBJS.E.00344
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Abstract

Background: Postoperative analgesia with the use of parenteral opioids or epidural analgesia can be associated with troublesome side effects. Good perioperative analgesia facilitates rehabilitation, improves patient satisfaction, and may reduce the hospital stay. We investigated the analgesic effect of locally injected drugs around a total knee prosthesis.

Methods: Sixty-four patients undergoing total knee arthroplasty were randomized either to receive a periarticular intraoperative injection containing ropivacaine, ketorolac, epimorphine, and epinephrine or to receive no injection. The perioperative analgesic regimen was standardized. All patients in both groups received patient-controlled analgesia for twenty-four hours after the surgery, and this was followed by standard analgesia. Visual analog scores for pain, during activity and at rest, and for patient satisfaction were recorded preoperatively and postoperatively and at the six-week follow-up examination. The consumption of patient-controlled analgesia at specific postoperative time-points and the overall analgesic requirement were measured.

Results: The patients who had received the injection used significantly less patient-controlled analgesia at six hours, at twelve hours, and over the first twenty-four hours after the surgery. In addition, they had higher visual analog scores for patient satisfaction and lower visual analog scores for pain during activity in the post-anesthetic-care unit and four hours after the operation. No cardiac or central nervous system toxicity was observed.

Conclusions: Intraoperative periarticular injection with multimodal drugs can significantly reduce the requirements for patient-controlled analgesia and improve patient satisfaction, with no apparent risks, following total knee arthroplasty.

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

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    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.
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