Comparison of patient outcomes in periarticular and intraarticular local anaesthetic infiltration techniques in total knee arthroplasty

Abstract

BackgroundThe use of local infiltration analgesia in the setting of knee arthroplasty is well established. There are no studies to date which have directly compared differences in infiltration techniques. The purpose of this study is to establish if a difference in patient outcomes exists when the infiltrate is injected into the periarticular tissues or directly into the joint.MethodsOne hundred and forty-two consecutive patients waitlisted for primary total knee arthroplasty were enrolled after primary exclusion criteria were applied. These included the following: allergy to study drugs, inability to receive spinal anaesthesia, and planned bilateral surgery. Patients were divided into two groups, a periarticular infiltration group (group A) and an intraarticular infiltration group (group B). Secondary exclusion criteria of regular opioid use, psychiatric illness, and serious medical comorbidity left a total of 47 patients in group A and 54 patients in group B. Both groups received a combination of 30 mg ketorolac, 500 μg of adrenaline, and 300 mg of ropivacaine, and normal saline. This was either injected into the periarticular tissues during surgery (group A) or intraarticularly after closure of the wound (group B).Primary outcome measures included opioid consumption during the first 24 h postoperatively and over the total admission, and visual analogue scales (VAS) on postoperative day 1 and at discharge. Secondary measures included Oxford Knee Score, knee flexion, length of stay, haemoglobin drop, and transfusion requirement.Ethics approval was granted by the hospital review board. The trial is registered in the Australian New Zealand Clinical Trials Registry, registration ACTRN12615000488505.ResultsNo statistically significant differences in postoperative analgesic use were observed between the two groups. However, there was a trend toward decreased postoperative patient-controlled analgesia use in the periarticular group (mean 53.1 vs 68.3 mg morphine equivalents; p = 0.093), as well as a statistically significant reduction in postoperative visual analogue pain scores. No statistically significant differences were observed for haemoglobin drop, range of motion, or pre- to 6-week postoperative Oxford Score difference.ConclusionsOur study is the first we are aware of to directly compare a periarticular to intraarticular injection technique when using local infiltration analgesia for total knee arthroplasty. Our results show no clear statistically significant benefit with either technique. The periarticular group showed a statistically significant reduction in postoperative VAS pain scores alongside a trend in that group toward reduced overall opioid use.

The analgesic efficacy and safety of peri-articular injection versus intra-articular injection in one-stage bilateral total knee arthroplasty: a randomized controlled trial

“…Therefore, PAI technique was recommended for performing LIA in TKA. PAI group showed a statistically significant reduction in postoperative VAS pain scores in a previous study [17], which positively correlated with NRS pain scores in our study [26]. In a retrospective study [27], Tietje demonstrated that patients receiving PAI of local anaesthetics in TKA had a noticeable decrease in length of hospital stay and incidence of postoperative nausea and vomiting when compared to patients receiving IAI.…”

“…To show a clinically important difference of 1.3 [25] in NRS pain score between PAI group and IAI group, with a standard deviation of 2.0 according to the published article [17], a power 0.90 and a two-tailed significance of <0.05, each group required 49 subjects.…”

“…Therefore, although most surgeons perform LIA in TKA as PAI, and never just IAI, we are curious about the comparison within LIA administration techniques, between PAI and IAI. In 2015, Perret published an article comparing PAI and IAI in TKA in Australia [17]. The study failed to show statistically significant benefit in either technique.…”

Comparison of local infiltration and epidural analgesia for postoperative pain control in total knee arthroplasty and total hip arthroplasty: A systematic review and meta-analysis

“…There were several trials comparing intra-articular infiltration with periarticular infiltration. Andersen et al [25] and Perret et al [26] concluded no clear statistically significant benefit with either technique. On the contrary, Tsuyoshi Nakai et al [27] showed the level of pain control was higher in periarticular infiltration than in intra-articular infiltration.…”

Office-Based Kyphoplasty: A Viable Option Using Local Anesthesia with Oral Sedation

“…This technique soaks the cortical bone and appears to provide enough anesthesia to permit trocar rotational advancement. Approximately 2-5 ccs of 2% lidocaine seemed to reduce the noxious stimulation, much like the periarticular infiltration analgesia used for the total knee arthroplasties (18). Next, the bone drill was inserted to create a cortical window in the vertebral body.…”