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

Abstract

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

Fast Track Surgery Program in Knee Replacement

“…Local infiltration anesthesia (LIA) has been gaining focus in recent years, as several wellconducted studies had indicated the potential benefits postoperatively [21,22]. LIA consists of a mixture of medications that include long-acting anesthetic, NSAIDs and epinephrine.…”

CORR ® Insights: Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management after THA: A Network Meta-analysis

“…The limitations of the available evidence summarized in the network meta-analysis by Jiménez-Almonte et al [7] highlight the need for well-designed randomized control trials directly comparing infiltration analgesia to regional nerve blocks with respect to postoperative pain relief, opioid requirements and in-hospital duration of stay. Extrapolating from research in total knee arthroplasty, opioid requirements beyond the first 24 hours may be worth investigating: Recent data indicate that, when infiltration analgesia is used, the need for opioids is substantially reduced following the day of surgery [10]. Further unresolved issues with local infiltration analgesia include the nature and incidence of associated complications [7], the optimal composition of the solution injected [9], the injection sites best corresponding to neural anatomy [9], the application of the technique in revision surgery, and the effectiveness of the newer, long-acting liposomal bupivacaine [1].…”

Editor's Spotlight/Take 5: Is Single-stage Revision According to a Strict Protocol Effective in Treatment of Chronic Knee Arthroplasty Infections?

“…As has been the case every year for nearly two decades now, the partnership between CORR 1 and the Knee Society has produced a collection of papers that should influence thought on the most important current issues in the treatment of the adult knee. While we could feature any of the dozens of papers from those proceedings in the spotlight section, including any of several award-winners [1,3,4], we have chosen to highlight a paper by Professor Fares S. Haddad's group in the United Kingdom on a thorny and resistant topic: Single-stage exchange revision for the infected TKA.…”