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Keijsers R, van Delft R, van den Bekerom MPJ, de Vries DCAA, Brohet RM, Nolte PA. Local infiltration analgesia following total knee arthroplasty: effect on post-operative pain and opioid consumption--a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2015; 23:1956-63. [PMID: 24292980 DOI: 10.1007/s00167-013-2788-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 11/17/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Local infiltration analgesia (LIA) is a popular method for decreasing post-operative pain after total knee arthroplasty (TKA). The goal of this meta-analysis is to compare the effect of LIA with placebo on the intensity of post-operative pain and the consumption of opioids. METHODS A search was performed in the PubMed/MEDLINE, Cochrane, EMBASE and TRIP databases. All (quasi)-randomized controlled trials (RCTs) were included. LIA consists of intra-operative infiltration with at least one analgesic component. Data were pooled using Cochrane software. RESULTS Seven placebo-controlled RCTs were included, involving 405 TKAs. On the first post-operative day, LIA provides an average decrease in VAS scores at rest of 12.3 % compared to placebo. Six RCTs studied opioid consumption in patients following TKA. There was a decrease in opioid consumption of 14.8 % compared to placebo 24 h after surgery. This suggests a reduced pain perception due to LIA. On the second post-operative day, the effect on both outcome measures was diminished and no longer significant. Heterogeneity between the studies was 71 % for pain and 39 % for opioid consumption (p = 0.002 and p = 0.0005). No major complications were reported with the use of LIA. CONCLUSION LIA might be able to decrease pain and the use of opioids on the first post-operative day following TKA. However, due to the high level of heterogeneity between the studies, no firm conclusions can be drawn. LEVEL OF EVIDENCE Meta-analysis, Level II.
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Affiliation(s)
- Renée Keijsers
- Department of Orthopaedic Surgery, Spaarne Hospital, P.O. Box 770, 2130 AT, Hoofddorp, The Netherlands,
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Guler O, Mutlu S, Isyar M, Mutlu H, Bulbul AM, Mahirogullari M. Efficacy of periarticular injection applied trough knee other than posterior capsule in simultaneous bilateral total knee arthroplasty. J Orthop 2015; 12:205-10. [PMID: 26566320 DOI: 10.1016/j.jor.2015.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2015] [Accepted: 05/24/2015] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND We aimed to evaluate periarticular multimodal drug injection (PMDI) in bilateral total knee arthroplasty. METHODS In 154 knees of 77 patients, PMDI was administered intraoperatively through the regions other than posterior capsule to one knee; other knee was control. RESULTS Drug-injected knees had lower visual analog scale scores and higher passive range of motion postoperatively (p < 0.05). The active straight leg raise was higher in drug-injected knees (47 [61%] vs 19 [24.7%], p = 0.001). CONCLUSIONS PMDI is a safe and effective method of early postoperative pain management in total knee arthroplasty when applied through regions other than posterior capsule.
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Affiliation(s)
- Olcay Guler
- Medipol University Medical Faculty, Orthopedics and Traumatology Department, 34083, Istanbul, Turkey
| | - Serhat Mutlu
- Orthopedics and Traumatology Department, Kanuni Sultan Suleyman Training Hospital, 34303, Istanbul, Turkey
| | - Mehmet Isyar
- Medipol University Medical Faculty, Orthopedics and Traumatology Department, 34083, Istanbul, Turkey
| | - Harun Mutlu
- Orthopedics and Traumatology Department, Gaziosmanpaşa Taksim Training Hospital, 34200, Istanbul, Turkey
| | - Ahmet M Bulbul
- Medipol University Medical Faculty, Orthopedics and Traumatology Department, 34083, Istanbul, Turkey
| | - Mahir Mahirogullari
- Medipol University Medical Faculty, Orthopedics and Traumatology Department, 34083, Istanbul, Turkey
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Turbitt L, Choi S, McCartney CJL. Peripheral Nerve Blockade for Total Knee Arthroplasty: An Evidence-Based Review. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0104-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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den Hartog YM, Mathijssen NMC, van Dasselaar NT, Langendijk PNJ, Vehmeijer SBW. No effect of the infiltration of local anaesthetic for total hip arthroplasty using an anterior approach. Bone Joint J 2015; 97-B:734-40. [DOI: 10.1302/0301-620x.97b6.35343] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Only limited data are available regarding the infiltration of local anaesthetic for total hip arthroplasty (THA), and no studies were performed for THA using the anterior approach. In this prospective, randomised placebo-controlled study we investigated the effect of both standard and reverse infiltration of local anaesthetic in combination with the anterior approach for THA. The primary endpoint was the mean numeric rating score for pain four hours post-operatively. In addition, we recorded the length of hospital stay, the operating time, the destination of the patient at discharge, the use of pain medication, the occurrence of side effects and pain scores at various times post-operatively. Between November 2012 and January 2014, 75 patients were included in the study. They were randomised into three groups: standard infiltration of local anaesthetic, reversed infiltration of local anaesthetic, and placebo. There was no difference in mean numeric rating score for pain four hours post-operatively (p = 0.87). There were significantly more side effects at one and eight hours post-operatively in the placebo group (p = 0.02; p = 0.03), but this did not influence the mobilisation of the patients. There were no differences in all other outcomes between the groups. We found no clinically relevant effect when the infiltration of local anaesthetic with ropivacaine and epinephrine was used in a multimodal pain protocol for THA using the anterior approach. Cite this article: Bone Joint J 2015; 97-B:734–40.
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Affiliation(s)
- Y. M. den Hartog
- Reinier de Graaf Hospital, Postbus
5011, 2626 AD Delft, The
Netherlands
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55
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Ali A, Sundberg M, Hansson U, Malmvik J, Flivik G. Doubtful effect of continuous intraarticular analgesia after total knee arthroplasty: a randomized double-blind study of 200 patients. Acta Orthop 2015; 86:373-7. [PMID: 25428755 PMCID: PMC4443449 DOI: 10.3109/17453674.2014.991629] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
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, respectively), but after that all recorded variables were similar between the groups. During the first 3 months, the ropivacaine group had a greater number of superficial and deep surgical wound infections (11 patients vs. 2 patients, p = 0.02). There were no other statistically significant differences between the groups. INTERPRETATION Continuous intraarticular analgesia (CIAA) with ropivacaine after TKA has no relevant clinical effect on VAS pain and does not affect LOS, analgesic consumption, ROM, or leg-raising ability. There may, however, be a higher risk of wound-healing complications including deep infections.
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Affiliation(s)
- Abdulemir Ali
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden.
| | - Martin Sundberg
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden.
| | - Ulrik Hansson
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden.
| | - Johan Malmvik
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden.
| | - Gunnar Flivik
- Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden.
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Tsukada S, Wakui M, Hoshino A. Pain control after simultaneous bilateral total knee arthroplasty: a randomized controlled trial comparing periarticular injection and epidural analgesia. J Bone Joint Surg Am 2015; 97:367-73. [PMID: 25740026 DOI: 10.2106/jbjs.n.00373] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Periarticular injection is becoming more commonly utilized for pain relief following total knee arthroplasty. However, we are aware of no randomized controlled trial that has investigated the efficacy of periarticular injection for pain relief after simultaneous bilateral total knee arthroplasty. METHODS We performed a randomized controlled trial of patients scheduled for simultaneous bilateral total knee arthroplasty. Seventy-one patients with 142 involved knees were randomly assigned to receive periarticular injection or epidural analgesia. Other perioperative interventions, including spinal anesthesia, surgical techniques, and postoperative medication protocols, were identical for all patients. The primary outcome was postoperative pain at rest, measured with the use of a 100-mm visual analog scale (VAS) during the initial twenty-four-hour postoperative period. The cumulative VAS score was calculated with use of the area under the curve and compared between the groups. RESULTS Postoperative pain at rest, quantified as the area under the curve of serial assessments during the initial twenty-four-hour postoperative period, was significantly less in the periarticular injection group than in the epidural analgesia group (174.9 ± 181.5 mm × day compared with 360.4 ± 360.6 mm × day; p = 0.0073). The prevalences of nausea on the night of surgery and postoperative day 1 and of pruritus were significantly lower in the periarticular injection group than in the epidural analgesia group (14% and 45%, p = 0.0031; 14% and 55%, p = 0.0003; and 0% and 15%, p = 0.014, respectively). CONCLUSIONS Periarticular injection was associated with better pain relief during the first twenty-four hours following simultaneous bilateral total knee arthroplasty and decreased opioid-related side effects compared with epidural analgesia. Periarticular injection may be preferable to epidural analgesia for pain relief after simultaneous bilateral total knee arthroplasty.
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Affiliation(s)
- Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, 14-7 Konan, Chuo-ku, Niigata, Niigata 950-1151, Japan. E-mail address for S. Tsukada:
| | - Motohiro Wakui
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, 14-7 Konan, Chuo-ku, Niigata, Niigata 950-1151, Japan. E-mail address for S. Tsukada:
| | - Akiho Hoshino
- Department of Orthopaedic Surgery, Kawaguchi Kogyo General Hospital, 1-18-15 Aoki, Kawaguchi, Saitama 332-0031, Japan
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HARSTEN A, KEHLET H, LJUNG P, TOKSVIG-LARSEN S. Total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty: a randomised, controlled trial. Acta Anaesthesiol Scand 2015; 59:298-309. [PMID: 25522681 DOI: 10.1111/aas.12456] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 10/24/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND The choice of anaesthetic technique for patients undergoing joint arthroplasty is debatable. The hypothesis of this study was that general anaesthesia would generate a more favourable recovery profile than spinal anaesthesia. METHODS We randomly allocated 120 patients to either intrathecal bupivacaine or general anaesthesia with target-controlled infusion of remifentanil and propofol. Length of hospital stay assessed as meeting discharge criteria was the primary outcome parameter. Other outcome parameters were actual time of discharge, pain, use of rescue pain medication, blood loss, length of stay in the post-operative care unit, dizziness, post-operative nausea, need of urinary catheterisation and patient satisfaction. RESULTS General anaesthesia resulted in slightly reduced length of hospital stay (26 vs. 30 h, P = 0.004), less nausea (P = 0.043) and dizziness (P < 0.001). General anaesthesia patients had higher pain scores during the first two post-operative hours (P < 0.001) but lower after 6 h compared with the spinal anaesthesia group (P < 0.01 and P < 0.05). General anaesthesia patients had better orthostatic function compared with spinal anaesthesia patients (P = 0.008). Patients in the spinal anaesthesia group fulfilled the discharge criteria from the post-operative care unit earlier compared with the general anaesthesia patients (P = 0.004). General anaesthesia patients requested a change in the method of anaesthesia for a subsequent operation less often than the spinal anaesthesia patients (5 vs. 13, P = 0.022). CONCLUSION General anaesthesia resulted in a more favourable recovery profile compared with spinal anaesthesia.
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Affiliation(s)
- A. HARSTEN
- Department of Anesthesiology; Hässleholm Hospital and Lund University; Hässleholm Sweden
| | - H. KEHLET
- Lundbeck Centre for Fast-Track Hip and Knee Arthroplasty; Copenhagen Denmark
- Department of Surgical Pathophysiology; Rigshospitalet; Copenhagen University; Copenhagen Denmark
| | - P. LJUNG
- Department of Orthopedic Surgery; Hässleholm Hospital and Lund University; Hässleholm Sweden
| | - S. TOKSVIG-LARSEN
- Department of Orthopedic Surgery; Hässleholm Hospital and Lund University; Hässleholm Sweden
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58
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Brydone AS, Souvatzoglou R, Abbas M, Watson DG, McDonald DA, Gill AM. Ropivacaine plasma levels following high-dose local infiltration analgesia for total knee arthroplasty. Anaesthesia 2015; 70:784-90. [DOI: 10.1111/anae.13017] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2014] [Indexed: 11/25/2022]
Affiliation(s)
- A. S. Brydone
- Department of Orthopaedic Surgery; Golden Jubilee National Hospital; Glasgow UK
| | - R. Souvatzoglou
- Department of Anaesthesia; Golden Jubilee National Hospital; Glasgow UK
| | - M. Abbas
- Institute of Pharmacy and Biomedical Sciences; Institute of Pharmacy and Biomedical Sciences; University of Strathclyde; Strathclyde UK
| | - D. G. Watson
- Institute of Pharmacy and Biomedical Sciences; Institute of Pharmacy and Biomedical Sciences; University of Strathclyde; Strathclyde UK
| | - D. A. McDonald
- Department of Anaesthesia; Golden Jubilee National Hospital; Glasgow UK
| | - A. M. Gill
- Department of Rehabilitation; Golden Jubilee National Hospital; Glasgow UK
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Tanikawa H, Sato T, Nagafuchi M, Takeda K, Oshida J, Okuma K. Comparison of local infiltration of analgesia and sciatic nerve block in addition to femoral nerve block for total knee arthroplasty. J Arthroplasty 2014; 29:2462-7. [PMID: 24848782 DOI: 10.1016/j.arth.2014.04.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 04/07/2014] [Accepted: 04/08/2014] [Indexed: 02/01/2023] Open
Abstract
We conducted a prospective randomized controlled trial to test the null hypothesis that there is no difference between sciatic nerve block (SNB) and local infiltration of analgesia (LIA) regarding postoperative analgesia after total knee arthroplasty (TKA), when administrated in addition to femoral nerve block (FNB). Forty-six patients scheduled for TKA were randomized into two groups: concomitant administration of FNB and SNB or FNB and LIA. Average pain scores during the first 21days after surgery were similar in the two groups and remained at low level. There was no significant difference in the need for adjuvant analgesics, patient satisfaction level, the time to achieve rehabilitation goals, and length of hospital stay. The LIA offers a potentially safer alternative to SNB as an adjunct to FNB.
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Affiliation(s)
- Hidenori Tanikawa
- Department of Orthopaedic Surgery, Saitama City Hospital, Saitama-ken, Japan
| | - Tomoyuki Sato
- Department of Anesthesiology, Saitama City Hospital, Saitama-ken, Japan
| | - Mari Nagafuchi
- Department of Anesthesiology, Saitama City Hospital, Saitama-ken, Japan
| | - Kentaro Takeda
- Department of Orthopaedic Surgery, Saitama City Hospital, Saitama-ken, Japan
| | - Junya Oshida
- Department of Anesthesiology, Saitama City Hospital, Saitama-ken, Japan
| | - Kazunari Okuma
- Department of Orthopaedic Surgery, Saitama City Hospital, Saitama-ken, Japan
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Andersen LØ, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth 2014; 113:360-74. [PMID: 24939863 DOI: 10.1093/bja/aeu155] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We conducted a systematic review of randomized clinical trials investigating LIA for total knee arthroplasty (TKA) and total hip arthroplasty (THA) to evaluate the analgesic efficacy of LIA for early postoperative pain treatment. In addition, the analgesic efficacy of wound catheters and implications for length of hospital stay (LOS) were evaluated. Twenty-seven randomized controlled trials in 756 patients operated on with THA and 888 patients operated on with TKA were selected for inclusion in the review. In THA, no additional analgesic effect of LIA compared with placebo was reported in trials with low risk of bias when a multimodal analgesic regimen was administered perioperatively. Compared with intrathecal morphine and epidural analgesia, LIA was reported to have similar or improved analgesic efficacy. In TKA, most trials reported reduced pain and reduced opioid requirements with LIA compared with a control group treated with placebo/no injection. Compared with femoral nerve block, epidural or intrathecal morphine LIA provided similar or improved analgesia in the early postoperative period but most trials had a high risk of bias due to different systemic analgesia between groups. Overall, the use of wound catheters for postoperative administration of local anaesthetic was not supported in the included trials, and LOS was not related to analgesic efficacy. Despite the many studies of LIA, final interpretation is hindered by methodological insufficiencies in most studies, especially because of differences in use of systemic analgesia between groups. However, LIA provides effective analgesia in the initial postoperative period after TKA in most randomized clinical trials even when combined with multimodal systemic analgesia. In contrast, LIA may have limited additional analgesic efficacy in THA when combined with a multimodal analgesic regimen. Postoperative administration of local anaesthetic in wound catheters did not provide additional analgesia when systemic analgesia was similar and LOS was not related to use of LIA with a fast-track set-up.
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Affiliation(s)
- L Ø Andersen
- The Lundbeck Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark Department of Anesthesiology and Intensive Care, Bispebjerg Hospital, Copenhagen, Denmark
| | - H Kehlet
- The Lundbeck Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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61
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Grosu I, Lavand'homme P, Thienpont E. Pain after knee arthroplasty: an unresolved issue. Knee Surg Sports Traumatol Arthrosc 2014; 22:1744-58. [PMID: 24201900 DOI: 10.1007/s00167-013-2750-2] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 10/25/2013] [Indexed: 12/27/2022]
Abstract
PURPOSE Despite the recent advances in the understanding of pain mechanisms and the introduction of new drugs and new techniques in the postoperative management, pain after total knee arthroplasty (TKA) is still an unresolved issue. It affects the quality of life and rehabilitation of an important percentage of patients undergoing TKA. The aim of this narrative review was to give an overview on pain mechanisms and multimodal pain management. METHODS A review of all peer-reviewed articles on pain after knee arthroplasty was performed by two reviewers. Recent articles on incisional pain mechanisms were included because of their importance in the understanding of postsurgical pain. Search was performed in Pubmed, Cochrane and Google Scholar data bases. RESULTS Postsurgical pain mechanisms are based on both local and systemic inflammatory reactions. Peri-operative pain management starts with the anaesthetic technique and resides on a multimodal analgesia regimen. New concepts, drugs and techniques have shown their efficacy in reducing the severity of acute postoperative pain and the risk of developing chronic pain after TKA. CONCLUSION This narrative review offers a clear overview of pain mechanism after knee arthroplasty and an understanding on how multimodal pain management can reduce the intensity and duration of pain after knee arthroplasty.
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Affiliation(s)
- Irina Grosu
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Av. Hippocrate 10, 1200, Brussels, Belgium
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62
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Xu CP, Li X, Wang ZZ, Song JQ, Yu B. Efficacy and safety of single-dose local infiltration of analgesia in total knee arthroplasty: a meta-analysis of randomized controlled trials. Knee 2014; 21:636-46. [PMID: 24704172 DOI: 10.1016/j.knee.2014.02.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 01/03/2014] [Accepted: 02/26/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the efficacy and safety of single-dose local infiltration of analgesia (LIA) for post-operative pain relief in total knee arthroplasty (TKA) patients. METHODS A systematic electronic literature search (up to Aug 2013) was conducted to identify the RCTs that address the efficacy and safety of single-dose LIA in the pain management after TKA. Subgroup analysis was conducted to determine changes of visual analog score (VAS) values at six different postoperative time points. Weighted mean differences or relative risks with accompanying 95% confidence intervals were calculated and pooled using a random effect model. RESULTS Eighteen trials involving 1858 TKA patients met the inclusion criteria. The trials were liable to medium risk of bias. The VAS values at postoperative 2h, 4h, 6h, 12h, 24h, and 48h per patient were significantly lower in the LIA group than in the placebo group, and the former group also had less morphine consumption and better early functional recovery including range of motion, time to straight leg raise and 90° knee flexion than the latter group. No significant difference in length of hospital stay or side effects was detected between the two groups. CONCLUSIONS The current evidence shows that the use of single-dose LIA is effective for postoperative pain management in TKA patients, with satisfactory short-term safety. More high-quality RCTs with long-term follow-ups are required for examining the long-term safety of single-dose LIA. LEVEL OF EVIDENCE I, II.
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Affiliation(s)
- Chang-Peng Xu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Xue Li
- Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Zhi-Zhong Wang
- Department of Orthopaedics and Traumatology, People's Hospital of Sanshui District of Foshan, Foshan, Guangdong, People's Republic of China
| | - Jin-Qi Song
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Bin Yu
- Department of Orthopaedics and Traumatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.
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Antoni M, Jenny JY, Noll E. Postoperative pain control by intra-articular local anesthesia versus femoral nerve block following total knee arthroplasty: impact on discharge. Orthop Traumatol Surg Res 2014; 100:313-6. [PMID: 24703792 DOI: 10.1016/j.otsr.2013.12.022] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 11/08/2013] [Accepted: 12/16/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The goal of this retrospective study was to compare pain control following total knee arthroplasty (TKA) on a perioperative protocol of local anesthesia (LA) versus the more classical femoral nerve block (FNB) technique. HYPOTHESIS Fitness for discharge would be achieved earlier using the LA protocol. MATERIALS Ninety-eight consecutive TKA patients operated on by a single surgeon were included with no selection criteria. In the study group (49 patients), 200 mL ropivacaine 5% was injected into the surgical wound and an intra-articular catheter was fitted to provide continuous infusion of 20 mL/h ropivacaine for 24h. The control group (49 patients) received ropivacaine FNB. Discharge fitness (independent walking, knee flexion>90°, quadricipital control, pain on VAS≤3) and hospital stay were assessed. RESULTS Discharge fitness was achieved significantly earlier in the study group (4.2±2.6 versus 6.7±3.2 days; P=0.0003), with significantly shorter mean hospital stay (6.1±3.4 versus 8.8±3.5 days; P=0.0002). The complications rate did not differ between study and control groups. DISCUSSION Although retrospective, this study indicates that the LA protocol improves management of post-TKA pain and accelerates rehabilitation, thereby, reducing hospital stay. The acceleration effect may be due to the absence of quadriceps inhibition. LEVEL OF EVIDENCE Level III - Case control study.
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Affiliation(s)
- M Antoni
- Hôpitaux Universitaires de Strasbourg, Service de Chirurgie Orthopédique et Traumatologique, Centre de Chirurgie Orthopédique et de la Main, 10, avenue Bauymann, 67400 Illkirch-Graffenstaden, France
| | - J-Y Jenny
- Hôpitaux Universitaires de Strasbourg, Service de Chirurgie Orthopédique et Traumatologique, Centre de Chirurgie Orthopédique et de la Main, 10, avenue Bauymann, 67400 Illkirch-Graffenstaden, France.
| | - E Noll
- Hôpitaux Universitaires de Strasbourg, Service d'Anesthésie-Réanimation, Centre de Chirurgie Orthopédique et de la Main, 10, avenue Bauymann, 67400 Illkirch-Graffenstaden, France
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Bech RD, Ovesen O, Lindholm P, Overgaard S. Local anesthetic wound infiltration for pain management after periacetabular osteotomy. A randomized, placebo-controlled, double-blind clinical trial with 53 patients. Acta Orthop 2014; 85:141-6. [PMID: 24650022 PMCID: PMC3967255 DOI: 10.3109/17453674.2014.899840] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE To our knowledge, there is no evidence to support the use of local infiltration analgesia (LIA) for postoperative pain relief after periacetabular osteotomy (PAO). We investigated the effect of wound infiltration with a long-acting local anesthetic (ropivacaine) for postoperative analgesia after PAO. PATIENTS AND METHODS We performed a randomized, double-blind, placebo-controlled trial (ClinicalTrials.gov: NCT00815503) in 53 patients undergoing PAO to evaluate the effect of local anesthetic infiltration on postoperative pain and on postoperative opioid consumption. All subjects received intraoperative infiltration followed by 5 postoperative injections in 10-hour intervals through a multi-holed catheter placed at the surgical site. 26 patients received ropivacaine and 27 received saline. The intervention period was 2 days and the observational period was 4 days. All subjects received patient-controlled opioid analgesia without any restrictions on the total daily dose. Pain was assessed at specific postoperative time points and the daily opioid usage was registered. RESULTS Infiltration with 75 mL (150 mg) of ropivacaine did not reduce postoperative pain or opioid requirements during the first 4 days. INTERPRETATION The clinical importance of ropivacaine as single component in postoperative treatment of pain is questionable, and we are planning further studies to explore the potential of LIA in larger volume-and also a multimodal regimen-to treat pain in this category of patients.
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Affiliation(s)
- Rune D Bech
- Department of Orthopaedics and Traumatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
| | - Ole Ovesen
- Department of Orthopaedics and Traumatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
| | - Peter Lindholm
- Department of Anaesthesiology and Intensive Care, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
| | - Søren Overgaard
- Department of Orthopaedics and Traumatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
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Merritt CK, Mariano ER, Kaye AD, Lissauer J, Mancuso K, Prabhakar A, Urman RD. Peripheral nerve catheters and local anesthetic infiltration in perioperative analgesia. Best Pract Res Clin Anaesthesiol 2014; 28:41-57. [DOI: 10.1016/j.bpa.2014.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 02/09/2014] [Accepted: 02/19/2014] [Indexed: 11/16/2022]
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Effects of local infiltration analgesia for posterior knee pain after total knee arthroplasty: comparison with sciatic nerve block. J Anesth 2014; 28:696-701. [DOI: 10.1007/s00540-014-1793-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 01/16/2014] [Indexed: 11/28/2022]
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Kristensen PK, Pfeiffer-Jensen M, Storm JO, Thillemann TM. Local infiltration analgesia is comparable to femoral nerve block after anterior cruciate ligament reconstruction with hamstring tendon graft: a randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 2014; 22:317-23. [PMID: 23338666 DOI: 10.1007/s00167-013-2399-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 01/14/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE Arthroscopic anterior cruciate ligament (ACL) reconstruction is a painful procedure requiring intensive postoperative pain management. Femoral nerve block is widely used in ACL surgery. However, femoral nerve block does not cover the donor site of the hamstring tendons. Local infiltration analgesia is a simple technique that has proven effective in postoperative pain management after total knee arthroplasty. Further, local infiltration analgesia covers the donor site and is associated with few complications. It was hypothesised that local infiltration analgesia at the donor site and wounds would decrease pain and opioid consumption after ACL reconstruction with hamstring tendon graft. METHODS Sixty patients undergoing primary ACL surgery with hamstring tendon graft were randomised to receive either local infiltration analgesia or femoral nerve block. Pain was scored on the numeric rating scale, and use of opioid, range of motion and adverse effects were assessed at the postoperative recovery unit (0 h), 3, 24 and 48 h, postoperatively. RESULTS There were no significant differences between the groups in pain intensity or total opioid consumption at any of the follow-up points. Further, there were no differences between groups concerning side effects and range of motion. CONCLUSIONS Local infiltration analgesia and femoral nerve block are similar in the management of postoperative pain after ACL reconstruction with hamstring tendon graft. Until randomised studies have investigated femoral nerve block combined with infiltration at the donor site, we recommend local infiltration analgesia in ACL reconstruction with hamstring tendon graft.
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Affiliation(s)
- Pia Kjær Kristensen
- Department of Orthopedic Surgery, Region Hospital Horsens, Sundvej 30, Horsens, Denmark,
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Znojek-Tymborowska J, Kęska R, Paradowski PT, Witoński D. Relevance of infiltration analgesia in pain relief after total knee arthroplasty. ACTA ORTOPEDICA BRASILEIRA 2014; 21:262-5. [PMID: 24453679 PMCID: PMC3875000 DOI: 10.1590/s1413-78522013000500004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 07/08/2013] [Indexed: 12/22/2022]
Abstract
OBJECTIVE: The aim of the study was to assess the effect of different types of anesthesia on pain intensity in early postoperative period. PATIENTS AND METHODS: A total of 87 patients (77 women, 10 men) scheduled for total knee arthroplasty (TKA) were assigned to receive either subarachnoid anesthesia alone or in combination with local soft tissue anesthesia, local soft tissue anesthesia and femoral nerve block and pre-emptive infiltration together with local soft tissue anesthesia. We assessed the pain intensity, opioid consumption, knee joint mobility, and complications of surgery. RESULTS: Subjects with pre-emptive infiltration and local soft tissue anesthesia had lower pain intensity on the first postoperative day compared to those with soft tissue anesthesia and femoral nerve block (P=0.012, effect size 0.68). Subjects who received pre-emptive infiltration and local soft-tissue anesthesia had the greatest range of motion in the operated knee at discharge (mean 90 grades [SD 7], P=0.01 compared to those who received subarachnoid anesthesia alone, and P=0.001 compared to those with subarachnoid together with soft tissue anesthesia). CONCLUSION: Despite the differences in postoperative pain and knee mobility, the results obtained throughout the postoperative period do not enable us to favour neither local nor regional infiltration anesthesia in TKA. Level of Evidence II, Prospective Comparative Study.
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Affiliation(s)
| | | | - Przemysław T. Paradowski
- Medical University, Polônia; Haugesund Hospital, Noruega; Sunderby Central Hospital of Norrbotten, Suécia
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Ikeuchi M, Kamimoto Y, Izumi M, Sugimura N, Takemura M, Fukunaga K, Yokoyama M, Tani T. Local infusion analgesia using intra-articular double lumen catheter after total knee arthroplasty: a double blinded randomized control study. Knee Surg Sports Traumatol Arthrosc 2013; 21:2680-4. [PMID: 22491708 DOI: 10.1007/s00167-012-2004-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Accepted: 04/02/2012] [Indexed: 11/28/2022]
Abstract
PURPOSE Although intra-operative local infiltration analgesia has gained increasing popularity in joint replacement surgery, it is not clear whether postoperative local infusion analgesia using an indwelling catheter provides clinically important additional effects. We, therefore, conducted a randomized controlled trial to clarify the efficacy of the originally developed local infusion analgesia technique in total knee arthroplasty. METHODS Forty patients were randomly allocated to the local infusion analgesia or control group. Patients in the local infusion analgesia group received intermittent bolus intra-articular injection of analgesics consisting of ropivacaine, dexamethasone, and isepamicin until postoperative 48 h. Primary outcome was pain severity at rest using 100-mm visual analogue scale. RESULTS Pain severity in patients of the local infusion analgesia group was lower than control group, and there were significant differences between groups at POD1 (p = 0.025) and POD3 (p = 0.007). Reduction of postoperative pain was associated with a decrease in C-reactive protein level and earlier achievement of straight leg raise. In addition, postoperative drain volume was reduced in the local infusion analgesia group. CONCLUSION Although larger studies are needed to examine its safety, the local infusion analgesia alone provided clinically significant analgesic effects and rapid recovery in total knee arthroplasty.
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Affiliation(s)
- Masahiko Ikeuchi
- Department of Orthopedic Surgery, Kochi University, 185-1 Oko-cho, Nankoku, Kochi, 783-8505, Japan,
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Ashraf A, Raut VV, Canty SJ, McLauchlan GJ. Pain control after primary total knee replacement. A prospective randomised controlled trial of local infiltration versus single shot femoral nerve block. Knee 2013; 20:324-7. [PMID: 23665124 DOI: 10.1016/j.knee.2013.04.009] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Revised: 03/29/2013] [Accepted: 04/08/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND We report a prospective blinded randomised trial of local infiltration versus femoral nerve block in patients undergoing primary total knee replacement (TKR), in accordance with the CONSORT statement 2010. METHODS Fifty patients in a teaching hospital were consented for the study. The study arms were intraoperative local anaesthesia (150ml 0.2% ropivacaine/1ml 1:1000 adrenaline/30mg ketolorac) and femoral nerve block (30ml 0.2% ropivacaine) with a primary outcome of pain score at 4h post operatively. Secondary outcomes were pain at 2h, pain scores before and after physiotherapy on day one, total opiate administered, time to physiotherapy goals and length of stay. Randomisation was by sealed envelope. The assessor was blinded and the patients partially blinded to the intervention. RESULTS Ten patients were excluded, eight before randomisation. The trial is complete. Forty patients were analysed for the primary outcome measure. The local infiltration group had significantly lower pain scores at 4h post-operatively; mean [SD] score 2.1 [2.6] versus 6.8 [3.2], p<0.00001 and on post-operative day one prior to physiotherapy; mean score 2.4 [2.3] versus 4.4 [2.3], p<0.05. Total opiate use was also significantly lower in the local infiltration group; mean total 115 [50.3]mg versus 176.5 [103.5]mg, p<0.01. There was no difference in any other outcome. There were no harms as a result of either intervention. CONCLUSION Intraoperative local infiltration gives superior pain relief compared to single shot femoral nerve block over the first 24h following primary TKR and minimises post-operative opiate use.
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Affiliation(s)
- Anam Ashraf
- Manchester Medical School, The University of Manchester, Stopford Building, Oxford Road, Manchester, M13 9PT, UK
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An anatomic study of local infiltration analgesia in total knee arthroplasty. Knee 2013; 20:319-23. [PMID: 23867348 DOI: 10.1016/j.knee.2013.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 06/19/2013] [Accepted: 06/21/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Local infiltration analgesia (LIA) is a relatively novel technique developed for effective pain control following total knee arthroplasty (TKA), reducing requirements for epidural or parenteral postoperative analgesia. This study investigated the anatomical spread of an LIA used in TKA to identify the nerve structures reached by the injected fluid. METHODS Six fresh-frozen cadaveric lower limbs were injected according to a standardised LIA technique with a solution of latex and India ink to enable visualisation. Wounds were closed and limbs placed flat in a freezer at -20°C for two weeks. Limbs were then either sliced or dissected to identify solution locations. RESULTS Solution was found from the proximal thigh to the middle of the lower leg. The main areas of concentration were the popliteal fossa, the anterior aspect of the femur and the subcutaneous tissue of the anterior aspect of the knee. There was less solution in the lower popliteal fossa. The solution was found to reach the majority of nerves, with good infiltration of nerves supplying the knee. CONCLUSIONS These results support the positive clinical outcomes with this LIA technique. However, the lack of infiltration into the lower popliteal fossa suggests more fluid or a different injection point could be used. The solution reaching the extensor muscles of the lower leg is likely to have no beneficial analgesic effect for a TKA patient. The LIA technique is already used in clinical practice following total knee arthroplasty. Results from this study show there may be scope to optimise the injection sites in LIA technique.
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Harsten A, Kehlet H, Toksvig-Larsen S. Recovery after total intravenous general anaesthesia or spinal anaesthesia for total knee arthroplasty: a randomized trial † †This article is accompanied by Editorial IV. Br J Anaesth 2013; 111:391-9. [DOI: 10.1093/bja/aet104] [Citation(s) in RCA: 95] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Andersen K, Nikolajsen L, Haraldsted V, Odgaard A, Søballe K. Local infiltration analgesia for total knee arthroplasty: should ketorolac be added? Br J Anaesth 2013; 111:242-8. [DOI: 10.1093/bja/aet030] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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KARASON S, OLAFSSON TA. Avoiding bladder catheterisation in total knee arthroplasty: patient selection criteria and low-dose spinal anaesthesia. Acta Anaesthesiol Scand 2013; 57:639-45. [PMID: 23432613 DOI: 10.1111/aas.12089] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Bladder catheterisation may be inconvenient for patients, delay mobilisation and risk complications. We hypothesised that by excluding pre-operatively patients at high risk of post-operative urinary retention, the majority of patients could avoid perioperative catheterisation during low-dose spinal anaesthesia. METHODS Patients undergoing total knee arthroplasty were assigned if fit for spinal anaesthesia and without severe symptoms of lower urinary tract obstruction, gross incontinence, mobilisation difficulties hindering micturition and > 200 ml residual urine volume. Bladder volume was monitored by ultrasound and temporary catheterisation advised if > 400 ml. RESULTS Fifty-two patients (men 54%, age 65 ± 9 years, body mass index 31 ± 5, 30% with history of urinary tract problems) were included. Intrathecal hyperbaric bupivacaine given was 7.8 ± 1.08 mg and always 7.5 μg sufentanil providing sufficient anaesthesia in all cases. Crystalloid given during surgery was 8.5 ± 4.0 ml/kg. Voluntary micturition was reached by 46 patients (88%, confidence interval (CI) 79-97%), but six (12%, CI 3-21%) needed temporary catheterisation once (four men/two women). Larger bladder volumes were found in those catheterised than those with voluntary micturition on the pre-operative (131 ± 76 ml vs. 68 ± 57 ml, P = 0.03) and first post-operative bladder scan (445 ± 169 ml vs. 271 ± 129 ml, P = 0.004). All but two patients (96%) could be mobilised the same day. No patient suffered bladder dysfunction. CONCLUSION Low-dose spinal anaesthesia combined with simple selection criteria allowed for early mobilisation (96%) and avoidance of bladder catheterisation in the vast majority (88%) of patients undergoing total knee arthroplasty, and the rest (12%) only needed a single temporary catheterisation.
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Affiliation(s)
- S. KARASON
- Department of Anaesthesia and Intensive Care; Landspitali University Hospital; University of Iceland; Reykjavik; Iceland
| | - T. A. OLAFSSON
- Department of Anaesthesia and Intensive Care; Landspitali University Hospital; University of Iceland; Reykjavik; Iceland
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Er MS, Eroglu M, Altinel L, Kose KC. Comment on "use of reduced-dose periarticular injection for pain management in simultaneous bilateral total knee arthroplasty" (volume 27 [number 9] 2012). J Arthroplasty 2013; 28:544-5. [PMID: 23246350 DOI: 10.1016/j.arth.2012.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 11/09/2012] [Indexed: 02/01/2023] Open
Affiliation(s)
- Mehmet S Er
- University of Afyon Kocatepe, School of Medicine, Afyonkarahisar, Turkey
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Ibrahim MS, Khan MA, Nizam I, Haddad FS. Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review. BMC Med 2013; 11:37. [PMID: 23406499 PMCID: PMC3606483 DOI: 10.1186/1741-7015-11-37] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 02/13/2013] [Indexed: 01/01/2023] Open
Abstract
The increasing numbers of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA), combined with the rapidly growing repertoire of surgical techniques and interventions available have put considerable pressure on surgeons and other healthcare professionals to produce excellent results with early functional recovery and short hospital stays. The current economic climate and the restricted healthcare budgets further necessitate brief hospitalization while minimizing costs.Clinical pathways and protocols introduced to achieve these goals include a variety of peri-operative interventions to fulfill patient expectations and achieve the desired outcomes.In this review, we present an evidence-based summary of common interventions available to achieve enhanced recovery, reduce hospital stay, and improve functional outcomes following THA and TKA. It covers pre-operative patient education and nutrition, pre-emptive analgesia, neuromuscular electrical stimulation, pulsed electromagnetic fields, peri-operative rehabilitation, modern wound dressings, standard surgical techniques, minimally invasive surgery, and fast-track arthroplasty units.
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Affiliation(s)
- Mazin S Ibrahim
- Department of Trauma and Orthopaedics, University College Hospital, 235 Euston Road, London, NW1 2BU, UK.
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Continuous Saphenous Nerve Block as Supplement to Single-Dose Local Infiltration Analgesia for Postoperative Pain Management After Total Knee Arthroplasty. Reg Anesth Pain Med 2013; 38:106-11. [DOI: 10.1097/aap.0b013e31827900a9] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Scott NB, McDonald D, Campbell J, Smith RD, Carey AK, Johnston IG, James KR, Breusch SJ. The use of enhanced recovery after surgery (ERAS) principles in Scottish orthopaedic units--an implementation and follow-up at 1 year, 2010-2011: a report from the Musculoskeletal Audit, Scotland. Arch Orthop Trauma Surg 2013; 133:117-24. [PMID: 23070220 DOI: 10.1007/s00402-012-1619-z] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To establish whether a nationally guided programme can lead to more widespread implementation of enhanced recovery after surgery (ERAS), a well-established optimised care pathway for lower limb arthroplasty. DESIGN In 2010, National Services Scotland's Musculoskeletal Audit was asked to perform a 'snapshot' audit of the current peri-operative management of patients undergoing total hip and knee arthroplasty in all 22 Scottish orthopaedic units with an identical follow-up audit in 2011 after input and support from the national steering group. POPULATION Audit 1 and audit 2 involved 1,345 and 1,278 patients, respectively. RESULTS The number of Scottish units that developed an ERAS programme increased from 8 (36 %) to 15 (68 %). Units that included more ERAS patients had earlier mobilisation rates (146/474, 36 % ERAS patients mobilised same day vs. 34/873, 4 % non-ERAS; n = 22 units, r = 0.55, p = 0.008) and shorter post-operative length of stay (median 4 days vs. ERAS, 5 days non-ERAS, n = 22 units, r = -0.64, p = 0.001). ERAS knee arthroplasty patients had lower blood transfusion rates (5/205, 2 % vs. 51/399, 13 %, n = 22 units, r = -0.62, p = 0.002). Units that restricted the use of IV fluids post-operatively had higher early mobilisation rates (n = 22 units, r = 0.48, p = 0.03) and shorter post-operative length of stay (n = 22 units, r = -0.56, p = 0.007). Reduced use of patient-controlled analgesia was also associated with earlier mobilisation (n = 22 units, r = 0.49, p = 0.02) and shorter length of stay (n = 22 units, r = -0.39, p = 0.07). Urinary catheterisation rates also dropped from 468/1,345 (35 %) in 2010 to 337/1,278 (26 %) in 2011 (n = 22 units, z = 2.19, p = 0.03). CONCLUSION A clinically guided and nationally supported process has proven highly successful in achieving a further uptake of enhanced recovery principles after lower limb arthroplasty in Scotland, which has resulted in clinical benefits to patients and reduced length of hospital stay.
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Affiliation(s)
- Nicholas B Scott
- Departments of Anaesthesia and Rehabilitation, Golden Jubilee National Hospital, Clydebank G81 4HX, UK.
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Essving P, Axelsson K, Otterborg L, Spännar H, Gupta A, Magnuson A, Lundin A. Minimally invasive surgery did not improve outcome compared to conventional surgery following unicompartmental knee arthroplasty using local infiltration analgesia: a randomized controlled trial with 40 patients. Acta Orthop 2012; 83:634-41. [PMID: 23043272 PMCID: PMC3555459 DOI: 10.3109/17453674.2012.736169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE There has recently been interest in the advantages of minimally invasive surgery (MIS) over conventional surgery, and on local infiltration analgesia (LIA) during knee arthroplasty. In this randomized controlled trial, we investigated whether MIS would result in earlier home-readiness and reduced postoperative pain compared to conventional unicompartmental knee arthroplasty (UKA) where both groups received LIA. PATIENTS AND METHODS 40 patients scheduled for UKA were randomized to a MIS group or a conventional surgery (CON) group. Both groups received LIA with a mixture of ropivacaine, ketorolac, and epinephrine given intra- and postoperatively. The primary endpoint was home-readiness (time to fulfillment of discharge criteria). The patients were followed for 6 months. RESULTS We found no statistically significant difference in home-readiness between the MIS group (median (range) 24 (21-71) hours) and the CON group (24 (21-46) hours). No statistically significant differences between the groups were found in the secondary endpoints pain intensity, morphine consumption, knee function, hospital stay, patient satisfaction, Oxford knee score, and EQ-5D. The side effects were also similar in the two groups, except for a higher incidence of nausea on the second postoperative day in the MIS group. INTERPRETATION Minimally invasive surgery did not improve outcome after unicompartmental knee arthroplasty compared to conventional surgery, when both groups received local infiltration analgesia. The surgical approach (MIS or conventional surgery) should be selected according to the surgeon's preferences and local hospital policies. ClinicalTrials.gov. (Identifier NCT00991445).
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Affiliation(s)
| | | | | | | | | | - Anders Magnuson
- Clinical Epidemiology and Biostatistics, Institution for Clinical Medicine, University Hospital, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
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Wound/intra-articular infiltration or peripheral nerve blocks for orthopedic joint surgery. Curr Opin Anaesthesiol 2012; 25:615-20. [DOI: 10.1097/aco.0b013e328357bfc5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
Fast-track hip and knee arthroplasty aims at giving the patients the best available treatment at all times, being a dynamic entity. Fast-track combines evidence-based, clinical features with organizational optimization including a revision of traditions resulting in a streamlined pathway from admission till discharge – and beyond. The goal is to reduce morbidity, mortality and functional convalescence with an earlier achievement of functional milestones including functional discharge criteria with subsequent reduced length of stay and high patient satisfaction. Outcomes are traditionally measured as length of stay; safety aspects in the form of morbidity/mortality; patient satisfaction; and – as a secondary parameter – economic savings. Optimization of the clinical aspects include focusing on analgesia; DVT-prophylaxis; mobilization; care principles including functional discharge criteria; patient-characteristics to predict outcome; and traditions which may be barriers in optimizing outcomes. Patients should be informed and motivated to be active participants and their expectations should be modulated in order to improve satisfaction. Also, organizational aspects need to be analyzed and optimized. New logistical approaches should be implemented; the ward ideally (re)structured to only admit arthroplasties; the staff educated to have a uniform approach; extensive preoperative information given including discharge criteria and intended length of stay. This thesis includes 9 papers on clinical and organizational aspects of fast-track hip and knee arthroplasty (I–IX). A detailed description of the fast-track set-up and its components is provided. Major results include identification of patient characteristics to predict length of stay and satisfaction with different aspects of the hospital stay (I); how to optimize analgesia by using a compression bandage in total knee arthroplasty (II); the clinical and organizational set-up facilitating or acting as barriers for early discharge (III); safety aspects following fast-track in the form of few readmissions in general (IV) and few thromboembolic complications in particular (V); feasibility studies showing excellent outcomes following fast-track bilateral simultaneous total knee arthroplasty (VI) and non-septic revision knee arthroplasty (VII); how acute pain relief in total hip arthroplasty is not enhanced by the use of local infiltration analgesia when multi-modal opioid-sparing analgesia is given (VIII); and a detailed description of which clinical and organizational factors detain patients in hospital following fast-track hip and knee arthroplasty (IX). Economic savings following fast-track hip and knee arthroplasty is also documented in studies, reviews, metaanalyses and Cochrane reviews – including the present fast-track (ANORAK). In conclusion, the published results (I–IX) provide substantial, important new knowledge on clinical and organizational aspects of fast-track hip and knee arthroplasty – with concomitant documented high degrees of safety (morbidity/mortality) and patient satisfaction. Future research strategies are multiple and include both research strategies as efforts to implement the fast-track methodology on a wider basis. Research areas include improvements in pain treatment, blood saving strategies, fluid plans, reduction of complications, avoidance of tourniquet and concomitant blood loss, improved early functional recovery and muscle strengthening. Also, improvements in information and motivation of the patients, preoperative identification of patients needing special attention and detailed economic studies of fast- track are warranted.
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Affiliation(s)
- Henrik Husted
- Department of Orthopaedic Surgery 333, University Hospital of Hvidovre, Copenhagen, Kettegaard Alle 30 DK-2650 Hvidovre, Denmark.
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McDonald DA, Siegmeth R, Deakin AH, Kinninmonth AWG, Scott NB. An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom--follow up at one year. Knee 2012; 19:525-9. [PMID: 21880493 DOI: 10.1016/j.knee.2011.07.012] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 07/25/2011] [Accepted: 07/29/2011] [Indexed: 02/02/2023]
Abstract
The concepts of Enhanced Recovery Programmes (ERP) are to reduce peri-operative morbidity whilst accelerating patient's rehabilitation resulting in a shortened hospital stay following primary joint arthroplasty. These programmes should include all patients undergoing surgery and should not be selective. We report a consecutive series of 1081 primary total knee arthroplasties undergoing an enhanced recovery programme with a one year follow up period. A comparative cohort of 735 patients from immediately prior to the enhanced recovery programme implementation was also reviewed. The median day of discharge home was reduced from post-operative day six to day four (p<0.001) for the ERP group. Post-operative urinary catheterisation (35% vs. 6.9%) and blood transfusion (3.7% vs. 0.6%) rates were significantly reduced (p<0.001). Within the ERP group median pain scores (0 = no pain, 10 = maximal pain) on mobilisation were three throughout hospital stay with 95% of patients ambulating within 24h. No statistical difference was found in post-operative thrombolytic events (p=0.35 and 0.5), infection (p=0.86), mortality rates (p=0.8) and Oxford Knee Scores (p=0.99) at follow up. This multidisciplinary approach provided satisfactory post-operative analgesia allowing early safe ambulation and expedited discharge to home with no detriment to continuing rehabilitation, infection or complication rates at one year.
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Affiliation(s)
- D A McDonald
- Department of Orthopaedic Surgery, Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, United Kingdom.
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Koh IJ, Kang YG, Chang CB, Song J, Jeon YT, Kim TK. Use of reduced-dose periarticular injection for pain management in simultaneous bilateral total knee arthroplasty. J Arthroplasty 2012; 27:1731-1736.e1. [PMID: 22682046 DOI: 10.1016/j.arth.2012.03.054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 03/28/2012] [Indexed: 02/01/2023] Open
Abstract
We investigated the safety and efficacy of the bilateral periarticular multimodal drug injection (PMDI) at a reduced dosage in patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). In total, 45 patients undergoing SBTKA received 65 mL PMDI in each knee (reduced-dose group). The incidence of drug-related adverse effects and wound complications were evaluated. Pain levels during the night of the operation and postoperative day 1 and opioid consumption during the first 24 hours after surgery were compared with the regular-dose group of 55 patients undergoing SBTKA who received 100 mL of PMDI in 1 knee. No patient experienced a serious drug-related adverse effect or wound complication. Blood levels of ropivacaine were observed to be lower than a toxic level throughout the monitored period in all patients examined. Patients in the reduced-dose group experienced less pain during the night of operation, but a similar pain level at postoperative day 1.
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Affiliation(s)
- In Jun Koh
- Department of Orthopaedic Surgery, Uijeongbu St Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Gyeonggi-do, South Korea
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85
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Ansari D, Gianotti L, Schröder J, Andersson R. Fast-track surgery: procedure-specific aspects and future direction. Langenbecks Arch Surg 2012; 398:29-37. [PMID: 23014834 DOI: 10.1007/s00423-012-1006-9] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/14/2012] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Fast-track (FT) surgery can be defined as a coordinated perioperative approach aimed at reducing surgical stress and facilitating postoperative recovery. The objective of this review was to examine the literature on the procedure-specific application of FT surgery. DISCUSSION The concept of FT rehabilitation has been applied mainly in colorectal surgery, but positive data have appeared also in other areas such as orthopedic, hepatopancreaticobiliary, urological, upper gastrointestinal, gynecological, thoracic, vascular, endocrine, breast, and pediatric surgeries. There is very little experience with comprehensive FT programs in cardiac surgery or trauma. Quantitative analysis from randomized trials and cohort studies suggest that FT is effective in reducing hospital stay without increased adverse events. Other benefits of the FT approach include a reduction in complications, ileus, fatigue, pain, and hospital expenses. However, despite clear benefits of FT care, implementation in daily practice has been slow. Further efforts must be undertaken to secure implementation in routine clinical practice. Standardized FT protocols should be provided on a procedure-specific basis.
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Affiliation(s)
- Daniel Ansari
- Department of Surgery, Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
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86
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Gibbs DMR, Green TP, Esler CN. The local infiltration of analgesia following total knee replacement. ACTA ACUST UNITED AC 2012; 94:1154-9. [DOI: 10.1302/0301-620x.94b9.28611] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Controversy remains regarding the optimal post-operative analgesic regimen following total knee replacement. A delicate balance is required between the provision of adequate pain relief and early mobilisation. By reviewing 29 randomised trials we sought to establish whether local infiltration of analgesia directly into the knee during surgery provides better pain relief and a more rapid rehabilitation. Although we were able to conclude that local infiltration can provide improved post-operative pain relief, and to suggest the most promising technique of administration, there is no evidence that it reduces hospital stay.
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Affiliation(s)
- D. M. R. Gibbs
- Leicester General Hospital, Gwendolen
Road, Leicester LE5 4PW, UK
| | - T. P. Green
- Leicester General Hospital, Gwendolen
Road, Leicester LE5 4PW, UK
| | - C. N. Esler
- Leicester General Hospital, Gwendolen
Road, Leicester LE5 4PW, UK
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87
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Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Reg Anesth Pain Med 2012; 36:63-72. [PMID: 22002193 DOI: 10.1097/aap.0b013e31820307f7] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Fast-track programs have been developed with the aim to reduce perioperative surgical stress and facilitate patient's recovery after surgery. Potentially, regional anesthesia and analgesia techniques may offer physiological advantages to support fast-track methodologies in different type of surgeries. The aim of this article was to identify and discuss potential advantages offerred by regional anesthesia and analgesia techniques to fast-track programs.In the first section, the impact of regional anesthesia on the main elements of fast-track surgery is addressed. In the second section, procedure-specific fast-track programs for colorectal, hernia, esophageal, cardiac, vascular, and orthopedic surgeries are presented. For each, regional anesthesia and analgesia techniques more frequently used are discussed. Furthermore, clinical studies, which included regional techniques as elements of fast-track methodologies, were identified. The impact of epidural and paravertebral blockade, spinal analgesia, peripheral nerve blocks, and new regional anesthesia techniques on main procedure-specific postoperative outcomes is discussed. Finally, in the last section, implementations required to improve the role of regional anesthesia in the context of fast-track programs are suggested, and issues not yet addressed are presented.
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88
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Dobie I, Bennett D, Spence DJ, Murray JM, Beverland DE. Periarticular local anesthesia does not improve pain or mobility after THA. Clin Orthop Relat Res 2012; 470:1958-65. [PMID: 22270468 PMCID: PMC3369082 DOI: 10.1007/s11999-012-2241-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 01/03/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Periarticular infiltration of local anesthetic, NSAIDs, and adrenaline have been reported to reduce postoperative pain, improve mobility, and reduce hospital stay for patients having THAs, but available studies have not determined whether local anesthetic infiltration alone achieves similar improvements. QUESTIONS We therefore asked whether periarticular injection of a local anesthetic during THA reduced postoperative pain and opioid requirements and improved postoperative mobility. METHODS We randomized 96 patients to either treatment (n = 50) or control groups (n = 46). Before wound closure, the treatment group received local infiltration of 160 mL of levobupivacaine with adrenaline. The control group received no local infiltration. We assessed postoperative morphine consumption and pain during the 24 hours after surgery. Mobilization was assessed 24 hours postoperatively with supine-to-sit and sit-to-stand transfers, timed 10-m walk test, and timed stair ascent and descent. Patients and assessing physiotherapists were blind to study status. RESULT We observed no differences in postoperative morphine consumption, time to ascend and descend stairs, or ability to transfer between treatment and control groups. The treatment group reported more pain 7 to 12 hours postoperatively, but there were no differences in pain scores between groups at all other postoperative intervals. The treatment group showed increased postoperative walking speed greater than 6 m, but not greater than 10 m, compared with the control group. CONCLUSIONS Periarticular infiltration of local anesthetic during THA did not reduce postoperative pain or length of hospital stay and did not improve early postoperative mobilization.
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Affiliation(s)
- I. Dobie
- Orthopaedic Outcomes Assessment Unit, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB Northern Ireland, UK
| | - D. Bennett
- Orthopaedic Outcomes Assessment Unit, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB Northern Ireland, UK
| | - D. J. Spence
- Orthopaedic Outcomes Assessment Unit, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB Northern Ireland, UK
| | - J. M. Murray
- Department of Anaesthetics, Musgrave Park Hospital, Belfast, Northern Ireland, UK
| | - D. E. Beverland
- Orthopaedic Outcomes Assessment Unit, Musgrave Park Hospital, Stockmans Lane, Belfast, BT9 7JB Northern Ireland, UK
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89
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RIKALAINEN-SALMI R, FÖRSTER JG, MÄKELÄ K, VIROLAINEN P, LEINO KA, PITKÄNEN MT, NEUVONEN PJ, KUUSNIEMI KS. Local infiltration analgesia with levobupivacaine compared with intrathecal morphine in total hip arthroplasty patients. Acta Anaesthesiol Scand 2012; 56:695-705. [PMID: 22404241 DOI: 10.1111/j.1399-6576.2012.02667.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Recently, local infiltration analgesia (LIA) has been promoted for pain control after total hip arthroplasty (THA). We hypothesized that LIA would offer equal analgesic efficacy but less adverse effects, e.g., nausea and vomiting, when compared with an established regimen [intrathecal morphine (it-M)] after THA. METHODS This randomized controlled trial comprised 60 patients undergoing THA under spinal anaesthesia. For LIA, the surgeon administered levobupivacaine, ketorolac and epinephrine at the surgical site intraoperatively. LIA patients received a LIA top-up through a wound catheter on the morning of the 1st post-operative day (POD). In group it-M, 0.1 mg morphine was given together with the spinal anaesthetic. Study parameters included pain scores, vital parameters and side effects, e.g., post-operative nausea and vomiting (PONV). Besides, levobupivacaine plasma concentrations were determined in 10 LIA patients. RESULTS The median (25th/75th percentiles) rescue oxycodone demand differed significantly with LIA 15 (10/25) mg vs. 8.5 (1.5/15) mg with it-M (P < 0.006) during the day of surgery, but not anymore on 1st or 2nd POD. The LIA top-up had no effect. However, both analgesic regimens resulted in comparable pain scores and patient satisfaction. PONV incidence and medication did not vary significantly. LIA offered certain advantages regarding early post-operative mobilization. Maximum levobupivacaine plasma concentrations (229-580 ng/ml) remained under the toxic level. CONCLUSIONS While LIA might enable earlier mobilization after THA, it was not associated with less nausea as compared with it-M. Less rescue oxycodone was given early after it-M, but urinary retention was more common in that group.
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Affiliation(s)
- R. RIKALAINEN-SALMI
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine; Turku University Hospital; Turku; Finland
| | - J. G. FÖRSTER
- Department of Anaesthesiology; Orton Orthopaedic Hospital; Helsinki; Finland
| | - K. MÄKELÄ
- Department of Orthopaedics; Turku University Hospital; Turku; Finland
| | - P. VIROLAINEN
- Department of Orthopaedics; Turku University Hospital; Turku; Finland
| | - K. A. LEINO
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine; Turku University Hospital; Turku; Finland
| | - M. T. PITKÄNEN
- Department of Anaesthesiology; Orton Orthopaedic Hospital; Helsinki; Finland
| | - P. J. NEUVONEN
- Department of Clinical Pharmacology; University of Helsinki and HUSLAB, Helsinki University Central Hospital; Helsinki; Finland
| | - K. S. KUUSNIEMI
- Department of Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine; Turku University Hospital; Turku; Finland
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90
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Ng FY, Ng JKF, Chiu KY, Yan CH, Chan CW. Multimodal periarticular injection vs continuous femoral nerve block after total knee arthroplasty: a prospective, crossover, randomized clinical trial. J Arthroplasty 2012; 27:1234-8. [PMID: 22325963 DOI: 10.1016/j.arth.2011.12.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 12/16/2011] [Indexed: 02/01/2023] Open
Abstract
This study compares the efficacy of pain control using continuous femoral nerve block (FNB) and multimodal periarticular soft tissue injection. This is a randomized, crossover, clinical trial. Sixteen patients having bilateral osteoarthritis of the knee scheduled for staged total knee arthroplasty were randomized to receive either FNB (0.2% ropivacaine), via indwelling catheter for 72 hours, or multimodal periarticular soft tissue injection in the first stage. In the second stage, they received the opposite treatment. The primary outcome measure was morphine consumption by patient-controlled analgesia in the first 72 hours postoperatively. Cumulative morphine consumption as well as rest pain and motion pain in the first 72 hours was comparable between the 2 groups. The functional outcomes did not differ significantly. We conclude that multimodal periarticular soft tissue injection provides comparable analgesia to continuous FNB after total knee arthroplasty.
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MESH Headings
- Aged
- Aged, 80 and over
- Amides/administration & dosage
- Amides/therapeutic use
- Analgesics, Opioid/therapeutic use
- Anesthetics, Local/administration & dosage
- Anesthetics, Local/therapeutic use
- Arthroplasty, Replacement, Knee/methods
- Catheters, Indwelling
- Cross-Over Studies
- Female
- Humans
- Injections, Intra-Articular
- Male
- Middle Aged
- Morphine/therapeutic use
- Nerve Block/methods
- Osteoarthritis, Knee/surgery
- Outcome Assessment, Health Care
- Pain, Postoperative/prevention & control
- Prospective Studies
- Ropivacaine
- Treatment Outcome
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Affiliation(s)
- Fu-Yuen Ng
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Pokfulam, Hong Kong
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91
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Crowley C, Dowsey MM, Quinn C, Barrington M, Choong PFM. Impact of regional and local anaesthetics on length of stay in knee arthroplasty. ANZ J Surg 2012; 82:207-14. [DOI: 10.1111/j.1445-2197.2011.05991.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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92
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Holm B, Husted H, Kehlet H, Bandholm T. Effect of knee joint icing on knee extension strength and knee pain early after total knee arthroplasty: a randomized cross-over study. Clin Rehabil 2012; 26:716-23. [PMID: 22261815 DOI: 10.1177/0269215511432017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To investigate the acute effect of knee joint icing on knee extension strength and knee pain in patients shortly after total knee arthroplasty. DESIGN A prospective, single-blinded, randomized, cross-over study. SETTING A fast-track orthopaedic arthroplasty unit at a university hospital. PARTICIPANTS Twenty patients (mean age 66 years; 10 women) scheduled for primary unilateral total knee arthroplasty. INTERVENTIONS The patients were treated on two days (day 7 and day 10) postoperatively. On one day they received 30 minutes of knee icing (active treatment) and on the other day they received 30 minutes of elbow icing (control treatment). The order of treatments was randomized. MAIN OUTCOME MEASURES Maximal knee extension strength (primary outcome), knee pain at rest and knee pain during the maximal knee extensions were measured 2-5 minutes before and 2-5 minutes after both treatments by an assessor blinded for active or control treatment. RESULTS The change in knee extension strength associated with knee icing was not significantly different from that of elbow icing (knee icing change (mean (1 SD)) -0.01 (0.07) Nm/kg, elbow icing change -0.02 (0.07) Nm/kg, P = 0.493). Likewise, the changes in knee pain at rest (P = 0.475), or knee pain during the knee extension strength measurements (P = 0.422) were not different between treatments. CONCLUSIONS In contrast to observations in experimental knee effusion models and inflamed knee joints, knee joint icing for 30 minutes shortly after total knee arthroplasty had no acute effect on knee extension strength or knee pain.
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Affiliation(s)
- Bente Holm
- The Lundbeck Centre for Fast-track Hip- and Knee Arthroplasty, Copenhagen University Hospital, Hvidovre, Denmark.
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93
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Affas F, Stiller CO, Nygårds EB, Stephanson N, Wretenberg P, Olofsson C. A randomized study comparing plasma concentration of ropivacaine after local infiltration analgesia and femoral block in primary total knee arthroplasty. Scand J Pain 2012; 3:46-51. [DOI: 10.1016/j.sjpain.2011.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 09/09/2011] [Indexed: 11/16/2022]
Abstract
Abstract
Pain after total knee arthroplasty (TKA) is difficult to control. A recently developed and increasingly popular method for postoperative analgesia following knee and hip arthroplasty is Local Infiltration Analgesia (LIA) with ropivacaine, ketorolac and epinephrine. This method is considered to have certain advantages, which include administration at the site of traumatized tissue, minimal systemic side effects, faster postoperative mobilization, earlier postoperative discharge from hospital and less opioid consumption. One limitation, which may prevent the widespread use of LIA is the lack of information regarding plasma concentrations of ropivacaine and ketorolac.
The aim of this academically initiated study was to detect any toxic or near-toxic plasma concentrations of ropivacaine and ketorolac following LIA after TKA.
Methods
Forty patients scheduled for primary total knee arthroplasty under spinal anaesthesia, were randomized to receive either local infiltration analgesia with a mixture of ropivacaine 300 mg, ketorolac 30mg and epinephrine or repeated femoral nerve block with ropivacaine in combination with three doses of 10mg intravenous ketorolac according to clinical routine. Plasma concentration of ropivacaine and ketorolac were quantified by liquid chromatography–mass spectrometry (LC–MS).
Results
The maximal detected ropivacaine plasma level in the LIA group was not statistically higher than in the femoral block group using the Mann–Whitney U-test (p = 0.08). However, the median concentration in the LIA group was significantly higher than in the femoral block group (p < 0.0001; Mann–Whitney U-test).
The maximal plasma concentrations of ketorolac following administration of 30mg according to the LIA protocol were detected 1 h or 2 h after release of the tourniquet in the LIA group: 152–958 ng/ml (95% CI: 303–512 ng/ml; n = 20). The range of the plasma concentration of ketorolac 2–3 h after injection of a single dose of 10mg was 57–1216 ng/ml (95% CI: 162–420 ng/ml; n = 20).
Conclusion
During the first 24 h plasma concentration of ropivacaine seems to be lower after repeated femoral block than after LIA. Since the maximal ropivacaine level following LIA is detected around 4–6 h after release of the tourniquet, cardiac monitoring should cover this interval. Regarding ketorolac, our preliminary data indicate that the risk for concentration dependent side effects may be highest during the first hours after release of the tourniquet.
Implication
Femoral block may be the preferred method for postoperative analgesia in patients with increased risk for cardiac side effects from ropivacaine. Administration of a booster dose of ketorolac shortly after termination of the surgical procedure if LIA was used may result in an increased risk for toxicity.
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Affiliation(s)
- Fatin Affas
- Department of Anaesthesiology and Intensive Care , Karolinska Institutet and Karolinska University Hospital , Solna , Sweden
| | - Carl-Olav Stiller
- Department of Medicine, Clinical Pharmacology Unit , Karolinska Institutet and Karolinska University Hospital , Solna , Sweden
| | - Eva-Britt Nygårds
- Department of Anaesthesiology and Intensive Care , Karolinska Institutet and Karolinska University Hospital , Solna , Sweden
| | - Niclas Stephanson
- Department of Medicine, Clinical Pharmacology Unit , Karolinska Institutet and Karolinska University Hospital , Solna , Sweden
| | - Per Wretenberg
- Department Molecular Medicine, Section of Orthopaedics , Karolinska Institutet and Karolinska University Hospital , Solna , Sweden
| | - Christina Olofsson
- Department of Anaesthesiology and Intensive Care , Karolinska Institutet and Karolinska University Hospital , Solna , Sweden
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94
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Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BB, Kehlet H. Why still in hospital after fast-track hip and knee arthroplasty? Acta Orthop 2011; 82:679-84. [PMID: 22066560 PMCID: PMC3247885 DOI: 10.3109/17453674.2011.636682] [Citation(s) in RCA: 280] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Length of stay (LOS) following total hip and knee arthroplasty (THA and TKA) has been reduced to about 3 days in fast-track setups with functional discharge criteria. Earlier studies have identified patient characteristics predicting LOS, but little is known about specific reasons for being hospitalized following fast-track THA and TKA. PATIENTS AND METHODS To determine clinical and logistical factors that keep patients in hospital for the first postoperative 24-72 hours, we performed a cohort study of consecutive, unselected patients undergoing unilateral primary THA (n = 98) or TKA (n = 109). Median length of stay was 2 days. Patients were operated with spinal anesthesia and received multimodal analgesia with paracetamol, a COX-2 inhibitor, and gabapentin-with opioid only on request. Fulfillment of functional discharge criteria was assessed twice daily and specified reasons for not allowing discharge were registered. RESULTS Pain, dizziness, and general weakness were the main clinical reasons for being hospitalized at 24 and 48 hours postoperatively while nausea, vomiting, confusion, and sedation delayed discharge to a minimal extent. Waiting for blood transfusion (when needed), for start of physiotherapy, and for postoperative radiographic examination delayed discharge in one fifth of the patients. INTERPRETATION Future efforts to enhance recovery and reduce length of stay after THA and TKA should focus on analgesia, prevention of orthostatism, and rapid recovery of muscle function.
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Affiliation(s)
| | | | | | - Lissi Gaarn-Larsen
- The Lundbeck Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
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95
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Fredheim OMS, Borchgrevink PC, Kvarstein G. [Post-operative pain management in hospitals]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2011; 131:1772-6. [PMID: 21946595 DOI: 10.4045/tidsskr.10.1184] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Relief of post-operative pain has a bearing on the patient's well-being, mobilisation and time confined to bed. The article discusses indications, contraindications and the efficacy of the various treatment modalities. MATERIAL AND METHOD We have examined review articles, meta-analyses and randomised controlled trials, identified through literature searches in PubMed. RESULTS The use of several medicines and techniques (multimodal pain treatment) is necessary to achieve a good balance between pain relief, side effects and risk. Systemic administration of paracetamol, NSAIDs, opioids and glucocorticoids is effective for post-operative pain. The same applies to epidural analgesia, peripheral nerve blocks and local anaesthetic wound infiltration. Subanaesthetic doses of ketamine have an opioid-sparing effect, but the optimal dosing regimen is uncertain. Gabapentinoids have an effect on post-operative pain, but the effect appears to vary depending on the type of operation and analgesic regimen. The effect of one analgesic will depend on which other drugs are used in multimodal pain treatment. Epidural analgesia, peripheral nerve blocks or extensive local infiltration analgesia is often necessary to relieve movement-related pain. INTERPRETATION Many treatment modalities are effective for post-operative pain. It is crucial that the treatment is well organised and that it includes routines for systematic pain assessment, efficacy and side effects of the pain management.
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Affiliation(s)
- Olav Magnus S Fredheim
- Nasjonalt kompetansesenter for sammensatte lidelser og Avdeling for smerte og sammensatte lidelser, Klinikk for anestesi og akuttmedisin, St. Olavs hospital, Norway.
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96
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Fant F, Axelsson K, Sandblom D, Magnuson A, Andersson SO, Gupta A. Thoracic epidural analgesia or patient-controlled local analgesia for radical retropubic prostatectomy: a randomized, double-blind study. Br J Anaesth 2011; 107:782-9. [DOI: 10.1093/bja/aer296] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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97
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Raeder JC. Local Infiltration Analgesia for Pain After Total Knee Replacement Surgery. Anesth Analg 2011; 113:684-6. [DOI: 10.1213/ane.0b013e3182288e14] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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98
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Essving P, Axelsson K, Åberg E, Spännar H, Gupta A, Lundin A. Local Infiltration Analgesia Versus Intrathecal Morphine for Postoperative Pain Management After Total Knee Arthroplasty. Anesth Analg 2011; 113:926-33. [DOI: 10.1213/ane.0b013e3182288deb] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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99
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Malviya A, Martin K, Harper I, Muller SD, Emmerson KP, Partington PF, Reed MR. Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop 2011; 82:577-81. [PMID: 21895500 PMCID: PMC3242954 DOI: 10.3109/17453674.2011.618911] [Citation(s) in RCA: 203] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Multimodal techniques can aid early rehabilitation and discharge of patients following primary joint replacement. We hypothesized that this not only reduces the economic burden of joint replacement by reducing length of stay, but also helps in reduction of early complications. PATIENTS AND METHODS We evaluated 4,500 consecutive unselected total hip replacements and total knee replacements regarding length of hospital stay, mortality, and perioperative complications. The first 3,000 underwent a traditional protocol while the other 1,500 underwent an enhanced recovery protocol involving behavioral, pharmacological, and procedural modifications. RESULTS There was a reduction in 30-day death rate (0.5% to 0.1%, p = 0.02) and 90-day death rate (0.8% to 0.2%, p = 0.01). The median length of stay decreased from 6 days to 3 days (p < 0.001), resulting in a saving of 5,418 bed days. Requirement for blood transfusion was reduced (23% to 9.8%, p < 0.001). There was a trend of a reduced rate of 30-day myocardial infarction (0.8% to 0.5%. p = 0 .2) and stroke (0.5% to 0.2%, p = 0.2). The 60-day deep vein thrombosis figures (0.8% to 0.6%, p = 0.5) and pulmonary embolism figures (1.2% to 1.1%, p = 0.9) were similar. Re-admission rate remained unchanged during the period of the study (4.7% to 4.8%, p = 0.8). INTERPRETATION This large observational study of unselected consecutive hip and knee arthroplasty patients shows a substantial reduction in death rate, reduced length of stay, and reduced transfusion requirements after the introduction of a multimodal enhanced recovery protocol.
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Affiliation(s)
- Ajay Malviya
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
| | - Kate Martin
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
| | - Ian Harper
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
| | - Scott D Muller
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
| | | | | | - Mike R Reed
- Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK
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100
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Kristensen BB, Rasmussen YH, Agerlin M, Topp MW, Weincke MO, Kehlet H. Local infiltration analgesia in urogenital prolapse surgery: a prospective randomized, double-blind, placebo-controlled study. Acta Obstet Gynecol Scand 2011; 90:1121-5. [PMID: 21722098 DOI: 10.1111/j.1600-0412.2011.01234.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the analgesic effect of high-volume infiltration analgesia in urogenital prolapse surgery and provide a detailed description of the infiltration technique. DESIGN A randomized, double-blind, placebo-controlled study following the CONSORT criteria. SETTING A university hospital. PATIENTS 48 patients undergoing posterior wall repair and perineorraphy. METHODS Patients received high-volume (26 ml) ropivacaine 1% with epinephrine (n=23) or saline (n=22) infiltration using a systematic technique ensuring uniform delivery to all tissues incised, handled or instrumented during the procedure. MAIN OUTCOME MEASURES Pain and opioid requirements were assessed for 24 hours as well as time spent in the post-anesthesia care unit and time to first mobilization. RESULTS Pain at rest, during coughing and movement was significantly reduced for the first four hours with the high-volume local anesthetic infiltration technique (p<0.001-0.006). Opioid requirements and time spent in the post-anesthesia care unit were significantly reduced in the ropivacaine group (p<0.001 and p<0.001, respectively) as well as the time to first mobilization (p<0.014). CONCLUSION Systematic high-volume infiltration analgesia is an effective analgesic technique in patients undergoing posterior wall repair and perineorraphy, and improves early recovery.
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Affiliation(s)
- Billy B Kristensen
- Department of Anesthesiology, Hvidovre University Hospital, Kettegård Allé 30, Copenhagen, Denmark.
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