Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness

Abstract

BackgroundSurgical pain is managed with multi-modal anaesthesia in total hip replacement (THR) and total knee replacement (TKR). It is unclear whether including local anaesthetic infiltration before wound closure provides additional pain control.MethodsWe performed a systematic review of randomised controlled trials of local anaesthetic infiltration in patients receiving THR or TKR. We searched MEDLINE, Embase and Cochrane CENTRAL to December 2012. Two reviewers screened abstracts, extracted data, and contacted authors for unpublished outcomes and data. Outcomes collected were post-operative pain at rest and during activity after 24 and 48 hours, opioid requirement, mobilisation, hospital stay and complications. When feasible, we estimated pooled treatment effects using random effects meta-analyses.ResultsIn 13 studies including 909 patients undergoing THR, patients receiving local anaesthetic infiltration experienced a greater reduction in pain at 24 hours at rest by standardised mean difference (SMD) -0.61 (95% CI -1.05, -0.16; p = 0.008) and by SMD -0.43 (95% CI -0.78 -0.09; p = 0.014) at 48 hours during activity.In TKR, diverse multi-modal regimens were reported. In 23 studies including 1439 patients undergoing TKR, local anaesthetic infiltration reduced pain on average by SMD -0.40 (95% CI -0.58, -0.22; p < 0.001) at 24 hours at rest and by SMD -0.27 (95% CI -0.50, -0.05; p = 0.018) at 48 hours during activity, compared with patients receiving no infiltration or placebo. There was evidence of a larger reduction in studies delivering additional local anaesthetic after wound closure. There was no evidence of pain control additional to that provided by femoral nerve block.Patients receiving local anaesthetic infiltration spent on average an estimated 0.83 (95% CI 1.54, 0.12; p = 0.022) and 0.87 (95% CI 1.62, 0.11; p = 0.025) fewer days in hospital after THR and TKR respectively, had reduced opioid consumption, earlier mobilisation, and lower incidence of vomiting.Few studies reported long-term outcomes.ConclusionsLocal anaesthetic infiltration is effective in reducing short-term pain and hospital stay in patients receiving THR and TKR. Studies should assess whether local anaesthetic infiltration can prevent long-term pain. Enhanced pain control with additional analgesia through a catheter should be weighed against a possible infection risk.

Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management After THA: A Network Meta-analysis

“…In contrast, there are mixed opinions and conflicting results regarding the use of local infiltration analgesia after THA [54,65]. Marques et al [41] concluded that inclusion of local anesthetic infiltration in a multimodal anesthesia regimen is effective in reducing short-term pain and hospital stay for patients undergoing THAs and TKAs. However, Yin et al [65] stated that although local infiltration analgesia is a potential approach for reducing pain scores and analgesic consumption during the early postoperative stages without increasing risk of adverse effects, there was no indication that it could help in the later stages of recovery.…”

Ropivacaine plasma levels following high-dose local infiltration analgesia for total knee arthroplasty

“…Ropivacaine has become the preferred anaesthetic used for local infiltration analgesia in our institution although some recent trials report the use of bupivacaine and levobupivacaine [8]. We did not use adjuvant drugs such as ketorolac, steroids or adrenaline in Figure 2 Mean plasma ropivacaine concentrations at specified time intervals: (a) total; (b) free.…”

“…Wound catheters can be used to deliver additional local anaesthetic postoperatively [3] and allow analgesia to be extended beyond 24 h [4][5][6][7][8]. Despite the increasing popularity of such techniques, concerns have been expressed regarding the safety of injecting large volumes of local anaesthetic into knee joints during orthopaedic procedures [9].…”

CORR Insights®: No Difference in Early Analgesia Between Liposomal Bupivacaine Injection and Intrathecal Morphine After TKA

“…More recently, a meta-analyses [13] reported the same type of positive impact on pain management after TKA when PAI was used. Liposomal bupivacaine (Exparel) was recently approved on the US market and has been used in several studies on TKAs to determine whether it might decrease pain or accelerate recovery after TKA.…”