Efficacy of Periarticular Multimodal Drug Injection in Total Knee Arthroplasty

Background The postoperative analgesic potential of periarticular anesthetic infiltration (PAI) after TKA is unclear as are the complications of continuous femoral nerve block on quadriceps function. Questions/purposes We asked (1) whether PAI provides equal or improved postoperative pain control in comparison to a femoral nerve block in patients who have undergone TKA; and (2) if so, whether PAI improves early postoperative quadriceps control and facilitates rehabilitation. Methods We randomized 60 patients to receive either PAI or femoral nerve block. During the first 5 days after TKA, we compared narcotic consumption, pain control, quadriceps function, walking distance, knee ROM, capacity to perform a straight leg raise, and active knee extension. Medication-related side effects, complications, operating room time, and hospitalization duration were compared.

“…No patients in our study experienced any ropivacaine-related side effects. Similar large doses of ropivacaine reportedly do not lead to toxic blood levels [6,27].…”

Section: Discussionmentioning

confidence: 62%

Periarticular Injection in Knee Arthroplasty Improves Quadriceps Function

Chaumeron

Audy

Drolet

et al. 2013

“…A notable difference between these two studies was the intraoperative infiltration of the posterior capsule in both the injection and nerve block groups in the study by Carli et al [8]. When comparing studies using intraarticular injection after closure of the capsule with intraoperative periarticular injection, unlike pain scores that were generally more favorable with the periarticular injections, narcotic consumption was usually lower in both intraarticular and periarticular injection studies, although the difference tended to be greater for periarticular injections [5,6,12,19,27,36].…”

Section: Discussionmentioning

confidence: 99%

“…A sample of 75 patients per group was planned to have 80% power (a = 0.05) to detect a difference of 1 point (0.5 SD) on the primary outcome measure. The SD was estimated from Browne et al [5] and Busch et al [6]. Data were recorded using REDCap electronic data capture [16].…”

Section: Methodsmentioning

confidence: 99%

“…However, they are simpler to administer, provide for earlier return of lower extremity function [9], may have a lower risk of complications, and are less costly [2]. Many authors have shown that periarticular injections provide improved pain relief compared with no injection [6,22,36]. Additionally, numerous studies have compared the efficacy of various types of neuraxial anesthetics and peripheral blocks [1,7,23,28,31,37,38].…”

Section: Introductionmentioning

confidence: 99%

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The Chitranjan Ranawat Award: Periarticular Injections and Femoral & Sciatic Blocks Provide Similar Pain Relief After TKA: A Randomized Clinical Trial

Spangehl

Clarke

Hentz

et al. 2015

128

Background Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA. Questions/purposes This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications. Methods One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n = 79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n = 81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications. Results Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 [SD 2.4]; PAI group: 3.0 [SD 2.2]; 95% confidence interval, À0.8 to 0.6; p = 0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days [SD 0.65] versus 2.84 days [SD 1.34] for the PNB group; p = 0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents [SD 13

“…The reported efficacy of periarticular analgesic injections after TKA has been inconsistent and plagued by significant heterogeneity among studies with regard to volume and content of local infiltrations [4,11,14]. As an alternative to periarticular administration of analgesics, intraarticular delivery of anesthetics has gained recent attention.…”

Section: Introductionmentioning

confidence: 99%

Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA: A Randomized, Double-blind Trial

Reinhardt

Duggal

Umunna

et al. 2014

Background Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.Questions/purposes We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. Methods Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. Results The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p \ 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.