High-volume local infiltration analgesia combined with intravenous or local ketorolac+morphine compared with epidural analgesia after total knee arthroplasty (original) (raw)
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Background There have been few studies describing wound infiltration with additional intraarticular administration of mul-timodal analgesia for total knee arthroplasty (TKA). In this study, we assessed the efficacy of wound infiltration combined with intraarticular regional analgesia with epidural infusion on analgesic requirements and postoperative pain after TKA. Methods 40 consecutive patients undergoing elective, primary TKA were randomized into 2 groups to receive either (1) intraop-erative wound infiltration with 150 mL ropivacaine (2 mg/mL), 1 mL ketorolac (30 mg/mL), and 0.5 mL epinephrine (1 mg/mL) (total volume 152 mL) combined with intraarticular infusion (4 mL/h) of 190 mL ropivacaine (2 mg/mL) plus 2 mL ketorolac (30 mg/mL) (group A), or (2) epidural infusion (4 mL/h) of 192 mL ropivacaine (2 mg/mL) combined with 6 intravenous administrations of 0.5 mL ketorolac (30 mg/mL) for 48 h postoperatively (group E). For rescue analgesia, intravenous patient-controlled-analgesia (PCA) morphine was used. Morphine consumption, intensity of knee pain (0–100 mm visual analog scale), and side effects were recorded. Length of stay and corrected length of stay were also recorded (the day-patients fulfilled discharge criteria). Results The median cumulated morphine consumption, pain scores at rest, and pain scores during mobilization were reduced in group A compared to group E. Corrected length of stay was reduced by 25% in group A compared to group E. Interpretation Peri-and intraarticular analgesia with multi-modal drugs provided superior pain relief and reduced morphine consumption compared with continuous epidural infusion with ropivacaine combined with intravenous ketorolac after TKA.
Local infiltration analgesia for total knee arthroplasty: should ketorolac be added?
British Journal of Anaesthesia, 2013
† Early mobilization in patients undergoing total knee arthroplasty benefits from accurate pain relief. † Repeated high-volume local infiltration analgesia (LIA) through an intra-articular catheter was tested. † The addition of ketorolac resulted in a reduced morphine consumption, reduced pain intensity, and earlier readiness for hospital discharge compared with ropivacaine alone or saline injections. Background. Adequate postoperative analgesia with minimal side-effects is essential for early mobilization and recovery in patients undergoing total knee arthroplasty (TKA). High-volume local infiltration analgesia (LIA) with ropivacaine has been introduced, but effects of adjuvants are still debated. We tested the hypothesis that the addition of ketorolac to LIA significantly improves analgesia after TKA. Methods. Sixty patients undergoing TKA were randomized to receive intraoperative LIA (ropivacaine 300 mg and epinephrine 0.5 mg) combined with either ketorolac 30 mg (ketorolac group) or saline (control group). After surgery, eight bolus doses of ropivacaine 100 mg combined with either ketorolac 15 mg (ketorolac group) or saline (control group) were administered every 6 h via an intra-articular catheter. The primary outcome was postoperative consumption of i.v. morphine patient-controlled analgesia (PCA). Secondary outcomes were time to first request of i.v. morphine PCA, pain intensity, side-effects, and readiness for hospital discharge. Results. Consumption of i.v. morphine PCA was lower in the ketorolac group vs control group {0-6 h: 0 (0-0) vs 5 (0-10) mg, P,0.0001; 0-48 h: 10 (0-22.5) vs 48.75 (30-82.5) mg, P,0.0001 [median (inter-quartile range, IQR)]}. Time to first request of i.v. morphine PCA was longer in the ketorolac group vs the control group [490 (248-617) vs 223 (115-319) min, P¼0.02, median (IQR)]. Early postoperative pain (,48 h) and readiness for hospital discharge were also significantly reduced in the ketorolac group. Conclusions. LIA with ketorolac results in reduced morphine consumption, reduced pain intensity, and earlier readiness for hospital discharge.
The Journal of Arthroplasty, 2017
Background: Local infiltration analgesia (LIA) with liposomal bupivacaine (LB) in patients undergoing total knee arthroplasty (TKA) has yielded mixed results. The PILLAR study, which was designed to minimize limitations associated with previous studies, compared the effects of LIA with or without LB on pain scores, opioid consumption, including proportion of opioid-free patients, time to first opioid rescue, and safety after primary unilateral TKA. Methods: Patients (N=140) were randomized to LIA with LB 266 mg/20 mL (admixed with bupivacaine HCl 0.5% 20 mL) or LIA with bupivacaine HCl 0.5% 20 mL. Standardized infiltration techniques and a standardized multimodal pain management protocol were used. The coprimary efficacy endpoints were area under the curve (AUC) of visual analog scale (VAS) pain intensity scores 12-48 hours (AUC 12-48) postsurgery and total opioid consumption 0-48 hours postsurgery. Results: Mean AUC 12-48 of VAS pain intensity score was 180.8 with LB and 209.3 without LB (least squares [LS] mean treatment difference, −26.88; P=0.0381). LS mean total opioid consumption 0-48 hours postsurgery was 18.7 mg with and 84.9 mg without LB (LS ratio, 0.220; P=0.0048). Significant differences in favor of LB were observed for the percentage of opioid-free patients (P<0.01) and time to first opioid rescue (P=0.0230). Treatments were similarly well-tolerated. Conclusion: This study provides data on LIA with LB administered using optimal techniques specific to TKA. In this setting, LIA with LB significantly improved postsurgical pain, opioid consumption, and time to first opioid rescue, with more opioidfree patients and no unexpected safety concerns.
2021
B ST R A C T Background: Managing postoperative pain in TKA is a challenge and needs an imperative strategy to bring maximal knee function early, with minimal side effects and less hospital stay. Though local infiltration analgesia emerged as a potent alternative, consensus on whether local infiltration analgesia offers clinically relevant pain relief is still lacking due to inconsistent studies and lack of standardization. The present study is an attempt to deduce the analgesic efficacy of a standardized single-shot local infiltration analgesia (LIA) with epidural analgesia with comparative analysis of previous most cited studies. Study Design & Methods: This is a prospective, randomized clinical trial done in n=74 patients with moderate to severe arthritis (Mean OKS 15.24, SD 6.153) undergoing unilateral primary TKA in the south Indian population in a single center. The choice of analgesia, surgical technique, postoperative medications, and rescue analgesia and rehabilitation prot...
Evaluation of analgesic regimens in total knee artroplasty, retrospective study
Northern Clinics of Istanbul, 2017
OBJECTIVE: Analgesic therapies have an immense role in early rehabilitation period after total knee arthroplasty (TKA) and multimodal approaches should be considered as the first choice of treatment. In this retrospective study, the aim was to evaluate the effectiveness of multimodal analgesic therapies for TKA, including femoral nerve block (FNB) and patient controlled analgesia (PCA). METHODS: The data of 79 patients who underwent TKA between January and December 2016 were retrospectively evaluated. In all, 63 patients met the inclusion criteria. Hemodynamic records and Visual Analogue Scale (VAS) pain scores for postoperative 0, 2, 4, 6, 9, and 12 hours were evaluated and patients were separated into 3 groups. Group 1: FNB with 0.25% bupivacaine, Group 2: FNB with 0.166% bupivacaine, and Group 3: No FNB. RESULTS: The average age of the patients was 64.3±14.9 years and average body mass index (BMI) was 32.5±5.3 kg/m 2. There was no statistical difference between groups in age, gender, American Society of Anesthesiologists (ASA) classification of physical health scores, BMI, or anesthesia type (p<0.05). When VAS scores at postoperative time intervals were compared, there was a statistically significant difference between Group 1 and Group 2 (p>0.05). When difference between Groups 1 and 3 and Groups 2 and 3 were compared, the difference was statistically significant for VAS 0 (p>0.05). Additional analgesic use was highest in Group 3. CONCLUSION: This study demonstrated that FNB significantly decreases postoperative pain intensity and additional analgesia requirement in patients undergoing TKA. A concentration of 0.166% bupivacaine is as effective as a concentration of 0.25% when used as part of a multimodal analgesia regimen in TKA.
Journal of Arthroscopy and Joint Surgery, 2018
To compare the efficacy of two periarticular cocktail regimens for analgesia in postoperative patients of total knee replacement. Method: This is a Randomized Control study done over the duration of 1.5 years. Twenty-five knees of either gender were selected with inclusion criteria (All osteoarthritis patients planned for TKA) and exclusion criteria (Inflammatory arthritis, patients allergic to local anaesthetic e.g. Ropivacaine, bupivacaine, known cardiac disorder patient having AV block, arrhythmia) & divided into 2 groups. Group A was given a cocktail of Ropivacaine, adrenaline, clonidine & cefuroxime. Group B was given a cocktail of bupivacaine, fentanyl, methylprednisolone & cefuroxime. The preoperative pain of the patient was assessed using VAS score. Combined spinal and epidural anaesthesia was given using 0.5% 2 ml of bupivacaine heavy in all patients. After taking bone cuts & before the placement of the implant, cocktail of the drug was infiltrated using sterile technique into 9 specific sites. The amount of drug infiltrated was calculated according to the weight of the patient. The patients were assessed on: Pain relief postoperatively at specific duration using VAS score. The amount & frequency of epidural top-ups required. Knee ROM, Quadriceps strength, Extensor lag & Knee society score were assessed. Results: Out of the total 25 knees included in the study, 12 belonged to Group A and 13 belonged to Group B. It was observed that 4 (33%) out of 12 Group A patient needed injection tramadol for 2e3 days and fentanyl patch 25mcg. In Group B, one (8%) out of 13 patients required injection tramadol and fentanyl dermal patch for 2e3 days. The difference in additionally required analgesic between patients of the two groups is statistically significant. VAS Score: The VAS score of Group B was statistically lower than Group A patients till first 24 h postoperatively. The extension lag was lower in group B compared to group A at 24 h after the surgery and up to 5 days. Overall after 6 weeks of follow-up, the extensor lag between the groups was not statistically significant. Average KSS in group A was 79.58 and in the group, B was 83.99 and the difference in KSS between patients of the two groups was statistically significant. Conclusion: Both the cocktail regimens are effective in pain control postoperatively. The relief in pain with regimen B containing bupivacaine, fentanyl, methylprednisolone and cefuroxime was more striking in the first 24 h. By the end of two days, both regimens were found to be equally effective.
Anesthesia: Essays and Researches, 2021
Context:Good quality analgesia posttotal knee arthroplasty (TKA) contributes majorly to early mobilization and shorter hospital stay.Aim:To compare adductor canal block (ACB) versus local infiltration analgesia (LIA) for postoperative pain relief in patients undergoing TKA.Settings and Design:This prospective, single-blind, randomized controlled trial was undertaken at a tertiary care university hospital.Materials and Methods:Sixty patients of American Society of Anesthesiologists physical status Classes I, II, and III, who received spinal anesthesia for TKA were randomly allocated to two groups. Group A patients had LIA of the knee joint using a mixture of 50 mL of 0.25% bupivacaine, 10 mg morphine (1 mL) and 99 mL of normal saline. Group B patients received ACB using 25 mL of 0.5% bupivacaine under ultrasound guidance. All patients received multimodal analgesia comprising of paracetamol, diclofenac, and patient controlled analgesia with morphine in the first 24 h' postoperative period. The primary outcome measures were first 24 h' morphine consumption and pain scores at 4, 6, 8, 12, and 24 h. The secondary outcome measures were nausea/vomiting, sedation, and patient satisfaction scores.Statistical Analysis:Statistical analysis was performed using the Student's t-test, Mann–Whitney test, and Chi-square test.Results:The 24 h morphine consumption was 11.97 ± 7.97 and 10.83 ± 6.41 mg in the LIA group and ACB group, respectively (P = 0.54). No significant differences were noted either in the pain scores at rest and flexion or secondary outcome measures between both groups in the first 24 h.Conclusion:Single-shot ACB is equally effective as LIA as postoperative analgesia for TKA.
Archives of Orthopaedic and Trauma Surgery, 2019
Purpose Purpose of the current study was to compare early effectiveness of pain relieve of 3 in 1 regional pain catheter to local infiltration anesthesia (LIA) in primary total knee arthroplasty (TKA). Secondary endpoint was quadriceps muscle strength after both procedures. Material and methods A single-center, prospective, randomized controlled trial was performed. Patients eligible to TKA were either randomized into group 3 in 1 regional pain catheter (C), or group local infiltration anesthesia (L). Pain relieve was assessed by visual analogue scale (VAS) at rest and under physical activity (PA) prior to surgery (t0) and at days one through six. In addition, quadriceps muscle strength (= straight leg raise) was tested according to the Manual Muscle Testing Scale. Functional outcome was measured using the Oxford Knee Score (OKS) preoperatively and 6 months postoperatively. Results 121 patients were included in the study. 59 (48.8%) patients were allocated to group C, 62 (51.2%) patients to Group L. No differences concerning pain level evaluated by VAS could be detected between the groups at any time. Comparing straight leg raise test group L was significantly superior over the complete postoperative period (p < 0.03). The mean OKS decreased significantly (p < 0.001) from preoperatively 34.2 ± 7.5 points to 16.9 ± 6.0 points at the six months final followup. Regarding OKS there were no intergroup differences at the final follow-up at 6 months postoperative. Conclusion There is no significant difference in pain relieve comparing LIA to 3 in 1 catheter in perioperative pain management in TKA. The advantage of LIA is unimpaired quadriceps muscle function in the short-term follow-up.
Doubtful effect of continuous intraarticular analgesia after total knee arthroplasty
Acta orthopaedica, 2014
Background and purpose - Local infiltration analgesia (LIA) is well established for effective postoperative pain relief in total knee arthroplasty (TKA). To prolong the effect of LIA, infusion pumps with local intraarticular analgesia can be used. We evaluated the effect of such an infusion pump for the first 48 h postoperatively regarding pain, knee function, length of stay (LOS) in hospital, and complications. Patients and methods - 200 patients received peroperative LIA and a continuous intraarticular elastomeric infusion pump set at 2 mL/h. The patients were randomized either to ropivacaine (7.5 mg/mL) or to NaCl (9 mg/mL) in the pump. Visual analog scale (VAS) pain (0-100 mm), analgesic consumption, side effects of medicine, range of motion (ROM), leg-raising ability, LOS, and complications during the first 3 months were recorded. Results - On the first postoperative day, the ropivacaine group had lower VAS pain (33 vs. 40 at 12 noon and 36 vs. 43 at 8 p.m.; p = 0.02 and 0.03, ...