Intraarticular levobupivacaine or bupivacaine administration decreases pain scores and provides a better recovery after total knee arthroplasty

A Network Meta-Analysis of Randomized Controlled Trials Assessing Intraoperative Anesthetic Therapies for Analgesic Efficacy and Morphine Consumption Following Total Knee Arthroplasty

BACKGROUND

The purpose of this study was to compare intraoperative anesthetic therapies for total knee arthroplasty (TKA) regarding postoperative analgesic efficacy and morphine consumption by conducting a systematic literature search.

METHODS

Randomized controlled trials of TKA using various anesthetic therapies were identified from various databases from conception through December 31, 2021. A network meta-analysis of relevant literature was performed to investigate which treatment showed better outcomes. In total, 40 trials were included in this study.

RESULTS

Surface under the cumulative ranking curve showed local infiltration anesthesia (LIA) with saphenous nerve block (SNB) to produce the best pain relief on postoperative days (PODs) 1 and 2 and the best reduction of morphine consumption on PODs 1 and 3. However, femoral nerve block showed the largest effect on pain relief on POD 3, and liposomal bupivacaine showed the largest effect on reduction of morphine consumption on POD 2.

CONCLUSIONS

According to this network meta-analysis, surface under the cumulative ranking curve percentage showed that LIA with SNB provided the best analgesic effect after TKA. Furthermore, patients receiving LIA with SNB had the lowest consumption of morphine. Although femoral nerve block resulted in better pain relief on POD 3, LIA with SNB could be selected first when trying to reduce morphine consumption or increase early ambulation.

Efficacy of single-shot adductor canal block before Versus after primary total knee arthroplasty - Does timing make a difference? A randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with severe postoperative pain. Multimodal analgesia, including peripheral nerve block, is recommended for post-operative pain relief. Administration of some pain medications prior to surgery has shown to be more effective than after the operation. This is a prospective, randomized controlled trial designed to compare the analgesic efficacy of the adductor canal block (ACB) performed immediately before or immediately after primary total knee arthroplasty (TKA). We hypothesized that ACB before the surgery will reduce postoperative pain and improve knee function.

METHODS

A total of 50 patients were enrolled and randomized into 2 groups, with 26 patients receiving a preoperative ACB and 24 receiving a postoperative ACB.

RESULTS

Treatment groups were similar in terms of gender (p = .83), age (p = 0.61) weight (p = .39) and ASA score. Average visual analogue scale (VAS) on arrival to the post-anesthesia care unit (PACU) were 4.9 ± 3.2 in the preoperative ACB versus 3.4 ± 2.8 for the postoperative ACB (p = .075). VAS scores at different time points as well as the mean, minimal and maximal reported VAS scores were not significantly different between the two groups. The cumulative quantities of Fentanyl administered by the anesthesia team was comparable between the groups. Similarly, the dosage of Morphine, Tramadol, Acetaminophen and Dipyrone showed only small variations. The Quality of Recovery Score, Knee Society Scores and knee range of motion did not differ between the groups.

CONCLUSIONS

Our findings demonstrate no significant differences in patient total narcotics consumption, pain scores and functional scores, between preoperative and postoperative ACB in patients undergoing TKA.

TRIAL REGISTRATION

The trial was registered at www.clinicaltrials.gov and was assigned the registration number NCT02908711.

LEVEL OF EVIDENCE

level I randomized controlled trial.

The effect of musical interventions in improving short-term pain outcomes following total knee replacement: a meta-analysis and systematic review

BACKGROUND

A growing number of patients continue to receive total knee replacement (TKR) surgery. Nevertheless, such surgeries result in moderate to severe postoperative pain and difficulty in managing it. Musical interventions are regarded as a type of multimodal analgesia, achieving beneficial results in other clinical treatments. This study aims to evaluate the effect of musical interventions in improving short-term pain outcomes following TKR in order to determine a more reasonable and standard way of delivering musical intervention.

METHODS

A systematic search was conducted to identify available and relevant randomized controlled trials (RCTs) regarding musical interventions compared against non-musical interventions in patients treated with TKR in Embase, MEDLINE, Cochrane Library, Web of Science, CNKI, and Wanfang Med Online up to 8 January 2020. The authors independently assessed study eligibility and risk of bias and collected the outcomes of interest to analyze. The statistical analysis was conducted using the Review Manager (RevMan) version 5.30 software.

RESULTS

Eight RCTs comprised of 555 patients satisfied the inclusion criteria and were enrolled in the present study. The results showed no significant difference between the music and control groups in pain of the visual analog scale (VAS), during postoperative recovery room, back to the ward after surgery; anxiety degree of VAS; heart rate; respiratory rate; oxygen saturation; blood pressure, systolic blood pressure, and diastolic blood pressure. Nevertheless, significant differences were observed between the two groups in average increase in continuous passive motion (CPM) angles and LF/HF ratio (one kind index of heart rate variability).

CONCLUSIONS

Musical interventions fail to demonstrate an obvious effect in improving short-term pain outcomes following TKR. A reasonable standardization of musical interventions, including musical type, outcome measures used, outcomes measured, duration, timing and headphones or players, may improve pain outcomes with certain advantages and should be further explored after TKR.

Single shot versus continuous technique adductor canal block for analgesia following total knee arthroplasty: A PRISMA-compliant meta-analysis

BACKGROUND

An adductor canal block (ACB) provides recognized analgesia following total knee arthroplasty (TKA). This meta-analysis compared the single-injection ACB (SACB) with the continuous-injection ACB (CACB).

METHOD

Relevant studies were searched from PubMed (1996-October 2018), Embase (1980-October 2018), and Cochrane Library (CENTRAL, October 2018). Four randomized controlled trials (RCTs), which compared SACB with CACB, were included in our meta-analysis.

RESULTS

Four RCTs met the inclusion criteria. Our pooled data indicated that the SACB group had similar efficacy compared with the CACB group in terms of morphine consumption (P = .19), time to first opioid request (P = .32), range of motion (P = .97), and visual analogue scale (VAS) scores at 24 hours at rest (P = .12) and movement (P = .24), without increasing the risk of complications (P = .97) and length of stay (P = .54).

CONCLUSION

The SACB technique provides similar analgesia in the 24 hours following TKA compared with CACB, while the CACB method was better over 48 hours.

Efficacy, chondrotoxicity and plasma concentrations of tramadol following intra-articular administration in horses undergoing arthroscopy: preliminary findings

Intra-articular administration of analgesics is performed to ensure good perioperative pain management avoiding undesirable systemic effects. To evaluate the effect of intra-articular injection of tramadol on postoperative pain after arthroscopy in horses and to determine whether tramadol had a local effect. Before the in vivo study, an in vitro test was performed aiming to evaluate the viability of equine chondrocytes after exposure to various concentrations of tramadol. The concentration identified as most appropriate was used to treat the horses’ joints. Twelve horses affected by osteochondrosis were randomly assigned to two groups that were treated intra-articularly at the end of surgery with tramadol (4 mg/mL) and saline, respectively. At predetermined time-points a Composite Pain Scale was applied and blood samples were collected in order to define the extent of tramadol absorption into the systemic circulation. The Mann-Whitney test was used for statistical analysis. Serum of four out of six treated horses revealed traces of tramadol (range 10.6–19.3 ng/mL) sporadically between 0.5 and 4 hours post-treatment, while in the other two horses, no trace of drug was found. Findings suggested that any eventual effect was probably due to local action rather than systemic absorption. The pain scores obtained in tramadol-treated horses were lower between 1 and 6 hours post-administration, than those obtained in the control group, but the differences were not statistically significant. These preliminary results suggest that tramadol, at this concentration, is only mildly beneficial in the pain management of horses after arthroscopy.

Effectiveness and weakness of local infiltration analgesia in total knee arthroplasty: a systematic review

Local infiltration analgesia has been widely used for pain relief in patients undergoing total knee arthroplasty. However, the effectiveness and major weakness of this technique have not been clarified; therefore, improvements in the technique have been limited. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials and conducted a meta-analysis of randomized controlled trials comparing local infiltration analgesia with placebo infiltration in patients undergoing total knee arthroplasty. Fourteen trials involving 1305 knees were eligible. The results showed that local infiltration analgesia significantly reduced early perioperative pain and total narcotic consumption. However, postoperative functional outcomes were not significantly different between local infiltration analgesia and placebo. The pain-relieving effect of local infiltration analgesia was found to be strong but short in duration. In the future, modified delivery methods and formulas with longer durations of action and analgesia may provide a better environment for patients and therefore improve their function outcomes.

QX-OH/Levobupivacaine: Fixed-dose combination to provide a long-acting postoperative pain of knee surgery in rodents

Although total knee arthroplasty (TKA) is a commonly performed procedure, anesthetic efficacy in post-surgical pain remains an issue. Exparel (45mM liposome bupivacaine), a relatively long-acting local anesthetic, has shown efficacy in blocking peripheral nerve or periarticular infiltration to achieve better post-TKA analgesia. In the present work, we tested whether a fixed-dose combination of QX-OH (35mM) and levobupivacaine (10mM) (QX-OH/LB) could confer longer-lasting pain relief and reduce periarticular tissue toxicity compared to liposome bupivacaine (45mM) after TKA operation. In the sciatic nerve block, the duration of sensory block by QX-OH/LB was 2-fold higher than by liposome bupivacaine (median [25th, 75th percentiles], 9.83 [9.33, 10.83] hours versus 4.83 [4.83, 5] hours; P=0.001). Liposome bupivacaine failed to improve post-surgical travel distance and speed (P=0.373) in rats 6h after TKA surgery (versus saline). Similar results were observed in operated mice treated with liposome bupivacaine. However, QX-OH/LB increased locomotor activities markedly both in rats and mice at 6h post-TKA (P<0.001). In addition, there was no difference in the inflammatory recruitment and articular structural damage among murine models-treated with QX-OH/LB, liposome bupivacaine and saline. In conclusion, we show that QX-OH/LB is a safe and long-lasting anesthetic than liposome bupivacaine in the post-TKA pain management in murine models.

Postoperative pain treatment after total knee arthroplasty: A systematic review

INTRODUCTION

The aim of this systematic review was to document efficacy, safety and quality of evidence of analgesic interventions after total knee arthroplasty (TKA).

METHODS

This PRISMA-compliant and PROSPERO-registered review includes all-language randomized controlled trials of medication-based analgesic interventions after TKA. Bias was evaluated according to Cochrane methodology. Outcomes were opioid consumption (primary), pain scores at rest and during mobilization, adverse events, and length of stay. Interventions investigated in three or more trials were meta-analysed. Outcomes were evaluated using forest plots, Grading of Recommendations Assessment, Development and Evaluation (GRADE), L'Abbe Plots and trial sequential analysis.

RESULTS

The included 113 trials, investigating 37 different analgesic interventions, were characterized by unclear/high risk of bias, low assay sensitivity and considerable differences in pain assessment tools, basic analgesic regimens, and reporting of adverse events. In meta-analyses single and continuous femoral nerve block (FNB), intrathecal morphine, local infiltration analgesia, intraarticular injection of local anaesthetics, non-steroidal anti-inflammatory drugs, and gabapentinoids demonstrated significant analgesic effects. The 24-hour morphine-sparing effects ranged from 4.2 mg (CI: 1.3, 7.2; intraarticular local anaesthetics), to 16.6 mg (CI: 11.2, 22; single FNB). Pain relieving effects at rest at 6 hours ranged from 4 mm (CI: -10, 2; gabapentinoids), to 19 mm (CI: 8, 31; single FNB), and at 24 hours from 3 mm (CI: -2, 8; gabapentinoids), to 16 mm (CI: 8, 23; continuous FNB). GRADE-rated quality of evidence was generally low.

CONCLUSION

A low quality of evidence, small sample sizes and heterogeneity of trial designs prohibit designation of an optimal procedure-specific analgesic regimen after TKA.

Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty

PURPOSE

To evaluate the effect of the local infiltration of analgesics for pain after total knee arthroplasty in patients treated with femoral and sciatic peripheral nerve blocks. The secondary objective was to detect differences in analgesic consumption as well as blood loss after local infiltration of analgesics.

METHODS

Prospective randomized double-blinded study in patients who underwent a TKA for knee osteoarthritis under spinal anesthesia and treated with femoral and sciatic nerve blocks. This study compared 50 patients treated with local infiltration with ropivacaine, epinephrine, ketorolac and clonidine and 50 patients treated with a placebo with the same technique. The visual analogic score was registered postoperatively at 2, 6, 12, 24, 36, 48 and 72 h after surgery. Analgesic consumption was also registered. Both groups of patients were treated with the same surgical and rehabilitation protocols.

RESULTS

A significant difference of one point was found in the visual analogic pain scores 12 h after surgery (0.6 ± 1.5 vs. 1.7 ± 2.3). There were no significant differences in the visual analogic pain scores evaluated at any other time between 2 and 72 h after surgery. No significant differences were found in the required doses of tramadol or morphine in the postoperative period. Postoperative hemoglobin and blood loss were also similar in both groups.

CONCLUSION

Adding local infiltration of analgesics to peripheral nerve blocks after TKA surgery only provides minimal benefit for pain control. This benefit may be considered as non-clinically relevant. Moreover, the need for additional analgesics was the same in both groups. Therefore, the use of local infiltration of analgesics treatment in TKA surgery cannot be recommended if peripheral nerve blocks are used.

LEVEL OF EVIDENCE

I.

Intra-articular bupivacaine after joint arthroplasty: a systematic review and meta-analysis of randomised placebo-controlled studies

OBJECTIVES

To evaluate the efficacy and safety of intra-articular (IA) bupivacaine administered for pain relief after joint arthroplasty.

DESIGN

Meta-analysis.

METHODS

A systematic review was conducted to identify the randomised controlled trials using IA bupivacaine for postoperative pain relief from MEDLINE, Cochrane Library and EMBASE databases (up to October 2015). The standardised mean difference (SMD), the relative risk (RR) and their corresponding 95% CIs were calculated using the RevMan statistical software.

RESULTS

A total of 11 randomised controlled trials were included. Statistically significant differences between IA bupivacaine and placebo were observed for the mean visual analogue scale (VAS) values (SMD -0.55; 95% CI -0.89 to -0.22; p<0.001) and narcotic consumption (SMD -0.32; 95% CI -0.55 to -0.08; p=0.008) during the period of 24 hours postoperatively and narcotic consumption during the period between 24 and 48 hours postoperatively (SMD -0.32; 95% CI -0.55 to -0.08; p=0.009). However, there was no significant difference in the mean VAS pain score during the period between 24  and 48 hours postoperatively (SMD -0.09, 95% CI -0.30 to 0.11; p=0.37) and in the incidence of adverse effects 24-72 hours postoperatively (RR 0.97; 95% CI 0.60 to 1.57; p=0.91).

CONCLUSIONS

The administration of IA bupivacaine after joint arthroplasty is effective for pain relief without increasing adverse effects.

Continuous Local Infiltration Analgesia for Pain Control After Total Knee Arthroplasty: A Meta-analysis of Randomized Controlled Trials

A total knee arthroplasty (TKA) has always been associated with moderate to severe pain. As more research is conducted on the use of continuous local infiltration analgesia (CLIA) to manage pain after a TKA, it is necessary to reassess the efficacy and safety of the TKA method. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the efficacy and safety of pain control of CLIA versus placebo after a TKA. In January 2015, a systematic computer-based search was conducted in the Medline, Embase, PubMed, CENTRAL (Cochrane Controlled Trials Register), Web of Science, Google database, and Chinese Wanfang databases. This systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement criteria. The primary endpoint was the visual analog scale score after a TKA with rest or mobilization at 24, 48, and 72 hours, which represents the effect of pain control after TKA. The complications of infection, nausea, and whether it prolonged wound drainage were also compiled to assess the safety of CLIA. RevMan 5.30 software was used for the meta-analysis. After testing for publication bias and heterogeneity across studies, data were aggregated for random-effects modeling when necessary. Ten studies involving 735 patients met the inclusion criteria. The meta-analysis revealed that continuous infusion analgesia provided better pain control with rest at 24 hours (mean difference [MD] -12.54, 95% confidence interval [CI] -16.63 to 8.45), and with mobilization at 24 hours (MD -18.27, 95% CI -27.52 to 9.02) and 48 hours (MD -14.19, 95% CI -21.46 to 6.93). There was no significant difference with respect to the visual analog scale score at 48 hours (MD -6.15, 95% CI -13.51 to 1.22, P = 0.10) and 72 hours (MD -3.63, 95% CI -10.43 to 3.16, P = 0.29) with rest and at 72 hours with mobilization (MD -4.25, 95% CI -16.27 to 7.77, P = 0.49). However, CLIA increased the rate of infection (relative risk [RR] 3.16, 95% CI 1.18-8.50, P = 0.02) and the rate of nausea or vomiting (RR 0.60, 95% CI 0.37-0.96, P = 0.03). There were no significant differences in the length of hospital stay (MD -0.34, 95% CI -1.09 to 0.42, P = 0.38), deep venous thrombosis (RR 1.02, 95% CI 0.30 to 1.41, P = 0.99), or duration of surgery (MD 1.20, 95% CI -4.59 to 6.98, P = 0.69). On the basis of the current meta-analysis, CLIA was more efficacious for reducing postoperative pain than the placebo at 24 hours with rest and at 24 and 48 hours with mobilization, but it increased the risk of infection. However, CLIA did not prolong the length of hospital stay or the duration of surgery. There was also a higher heterogeneity of different analgesic drugs mixed and a high risk of selection bias in this analysis; therefore, more high-quality randomized controlled trials with standardized CLIA are necessary for proper comparisons of this technique with other methods.

The Analgesic Effects of Morphine and Tramadol Added to Intra-articular Levobupivacaine-Tenoxicam Combination for Arthroscopic Knee Surgery on Postoperative Pain; a Randomized Clinical Trial

BACKGROUND

Arthroscopic knee surgery is commonly performed as an outpatient procedure and is often associated with postoperative pain.

OBJECTIVES

We aimed to compare the effects of intra-articular levobupivacaine-tenoxicam-tramadol and levobupivacaine-tenoxicam-morphine combinations on postoperative pain in patients undergoing elective arthroscopic knee surgery.

MATERIALS AND METHODS

A total of 90 ASA I-II patients undergoing elective arthroscopic meniscectomy under general anesthesia were enrolled. The participants were randomly allocated to three groups to receive the following intra-articular medications after completion of the surgery and before deflation of the tourniquet: Group S, 20 mL of saline; Group T, 35 mg of levobupivacaine, 20 mg of tenoxicam, and 100 mg of tramadol in 20 mL saline; and Group M, 35 mg of levobupivacaine, 20 mg of tenoxicam, and 4 mg of morphine in 20 mL saline. Visual analogue scale values at rest (VASr) and at active flexion of knee (VASa) at postoperation hours 1, 2, 4, 8, 12, and 24, duration of analgesia, total analgesic consumption, and number of rescue analgesia at 24 hours were evaluated.

RESULTS

VASr and VASa were significantly higher in group S in comparison to other groups (P < 0.05). Duration of analgesia was significantly longer in Group T and Group M than in Group S (P < 0.05). The difference between group T and group M was also significant (P < 0.05). Number of rescue analgesia and total analgesic consumption at postoperative hour 24 was significantly fewer in group M compared with other groups (P < 0.05).

CONCLUSIONS

Intra-articular levobupivacaine-tenoxicam-morphine combination provides effective pain relief, longer analgesic duration, and less analgesic requirement when compared with intra-articular levobupivacaine-tenoxicam-tramadol combination and saline after knee arthroscopic surgery.

Efficacy of Intra-articular Local Anesthetics in Total Knee Arthroplasty

Pain management after total knee arthroplasty (TKA) remains among the most important challenges for patients with TKA. Intra-articular local anesthetic has been shown to reduce postoperative pain following TKA. However, studies report conflicting results. This meta-analysis evaluated the efficacy and safety of single-dose intra-articular local anesthetics for pain control after TKA. Databases (Cochrane Central Register of Controlled Trials, Embase, PubMed, Web of Science, and Chinese Biomedical Databases) were searched to identify randomized, controlled trials comparing local anesthetic with placebo in patients undergoing TKA. Data were extracted independently by 2 researchers using a standardized form. Risk of bias was assessed with the use of the Cochrane Collaboration's tool for assessing the risk of bias by 2 observers. Relative risk, standardized mean difference, and corresponding 95% confidence interval were calculated. Seventeen trials met the inclusion criteria, for a total of 1338 participants. The results showed that, compared with the placebo group, the single local anesthetic group had a significant lower pain score with rest at 4, 8, 24, and 48 hours; less opioid consumption at 24, 48, and 72 hours postoperatively; and greater range of motion at 24, 48, and 72 hours. There were no significant differences between the 2 groups in length of hospital stay, nausea and vomiting, pruritus, sedation, or deep venous thrombosis. The study findings showed that pain relief after TKA was significantly better with intra-articular local anesthetic than with placebo.

The effect of intraarticular levobupivacaine and bupivacaine injection on the postoperative pain management in total knee artroplastic surgery

OBJECTIVE

Total knee arthroplasty (TKA) is associated with considerable postoperative pain. We compared the effects of intraoperative intraarticular levobupivacaine and bupivacaine on postoperative analgesia and analgesic consumption after total knee arthroplasty.

METHODS

Sixty ASA (American Society of Anesthesiologists) physical status II-III, 18-75 years old patients scheduled for unilateral TKA were included in this study. For the operative procedure combined spinal epidural anesthesia was given by injecting 15mg levobupivacaine in subarachnoid space at L3-4/L4- 5 in sitting position for all patients. In Group L 20ml levobupivacaine(0.5%), in Group B 20ml bupivacaine (0.5%) was injected intraarticularly 10 minutes before opening of the tourniquet at the end of the surgery. For all patients postoperative analgesia was provided with PCEA (levobupivacaine+fentanyl) and oral 1gr paracetamol four times a day. Patients' intraoperative-postoperative hemodynamical data, postoperative sensorial-motor block characteristics, side effects, PCEA demand ratios and bolus volumes, total analgesic consumption, VAS values, first mobilization time, hospitalization time were recorded. Statistical analysis was performed with SPSS version 13.00 software.

RESULTS

There was no intergroup difference in demographic data, hemodynamical data, PCEA demand ratios, total analgesic consumption, first mobilization time, hospitalization time and VAS values at 0,2,72 hour. Postoperative lower VAS values were determined at 4,8,12,24 hours in Group B and at 48(th) hour in Group L(p<0.05).

CONCLUSIONS

Intraarticular local anesthetic administration in addition to PCEA for post operative pain relief provides good analgesia after TKA surgery.

Single periarticular local infiltration analgesia reduces opiate consumption until 48 hours after total knee arthroplasty. A randomized placebo-controlled trial involving 56 patients

BACKGROUND

Randomized trials evaluating efficacy of local infiltration analgesia (LIA) have been published but many of these lack standardized analgesics. There is a paucity of reports on the effects of LIA on functional capability and quality of life.

METHODS

56 patients undergoing unilateral total knee arthroplasty (TKA) were randomized into 2 groups in this placebo-controlled study with 12-month follow-up. In the LIA group, a mixture of levobupivacaine (150 mg), ketorolac (30 mg), and adrenaline (0.5 mg) was infiltrated periarticularly. In the placebo group, infiltration contained saline. 4 different patient-reported outcome measures (PROMs) were used for evaluation of functional outcome and quality of life.

RESULTS

During the first 48 hours postoperatively, patients in the LIA group used less oxycodone than patients in the placebo group in both cumulative and time-interval follow-up. The effect was most significant during the first 6 postoperative hours. The PROMs were similar between the groups during the 1-year follow-up.

INTERPRETATION

Single periarticular infiltration reduced the amount of oxycodone used and enabled adequate pain management in conjunction with standardized peroral medication without adverse effects. No clinically marked effects on the functional outcome after TKA were detected.

Pain relief in day care arthroscopic knee surgery: A comparison between intra-articular ropivacaine and levobupivacaine: A prospective, double-blinded, randomized controlled study

Background:

Post-operative pain frequently hampers implementation of day care arthroscopic knee surgery in spite of so many analgesic, local anesthetic drugs and routes of administration.

Aims:

The aim of the present study was carried out to compare the efficacy of ropivacaine and levobupivacaine when administered through intra-articular route in controlling pain after day care arthroscopic knee surgery.

Setting and Design:

It was a prospective, double-blinded and randomized controlled study.

Materials and Methods:

April 2008-December 2008, 60 patients of both sex, of American Society of Anesthesiologists physical status I and II, undergoing day care arthroscopic knee surgery were randomly assigned into two groups (R, L). Group R received 10 ml of 0.75% ropivacaine, whereas group L received 10 ml of 0.50% levobupivacaine through intra-articular route at the end of the procedure. Pain assessed using visual analog scale (VAS) and diclofenac sodium given as rescue analgesia when VAS >3. Time of first analgesic request and total rescue analgesic were calculated.

Statistical Analysis and Results:

based on comparable demographic profiles; time for the requirement of first post-operative rescue analgesia (242.16 ± 23.86 vs. 366.62 ± 24.42) min and total mean rescue analgesic requirement was (104.35 ± 18.96 vs. 76.82 ± 14.28) mg in group R and L respectively. Group R had higher mean VAS score throughout the study period. No side effects found among the groups. These two results were clinically and statistically significant (P < 0.05).

Conclusion:

Hence, it was evident that intra-articular levobupivacaine give better post-operative pain relief, with an increase in time of first analgesic request and decreased need of total post-operative analgesia compared with ropivacaine.

Preventive analgesia by local anesthetics: the reduction of postoperative pain by peripheral nerve blocks and intravenous drugs

The use of local anesthetics to reduce acute postoperative pain has a long history, but recent reports have not been systematically reviewed. In addition, the need to include only those clinical studies that meet minimum standards for randomization and blinding must be adhered to. In this review, we have applied stringent clinical study design standards to identify publications on the use of perioperative local anesthetics. We first examined several types of peripheral nerve blocks, covering a variety of surgical procedures, and second, we examined the effects of intentionally administered IV local anesthetic (lidocaine) for suppression of postoperative pain. Thirdly, we have examined publications in which vascular concentrations of local anesthetics were measured at different times after peripheral nerve block procedures, noting the incidence when those levels reached ones achieved during intentional IV administration. Importantly, the very large number of studies using neuraxial blockade techniques (epidural, spinal) has not been included in this review but will be dealt with separately in a later review. The overall results showed a strongly positive effect of local anesthetics, by either route, for suppressing postoperative pain scores and analgesic (opiate) consumption. In only a few situations were the effects equivocal. Enhanced effectiveness with the addition of adjuvants was not uniformly apparent. The differential benefits between drug delivery before, during, or immediately after a surgical procedure are not obvious, and a general conclusion is that the significant antihyperalgesic effects occur when the local anesthetic is present during the acute postoperative period, and its presence during surgery is not essential for this action.

The local infiltration of analgesia following total knee replacement

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.

Intra-articular local anaesthetic on the day after surgery improves pain and patient satisfaction after Unicompartmental Knee Replacement: a randomised controlled trial

Intra-operative local anaesthetic infiltration provides good early pain relief after Unicompartmental Knee Replacement (UKR). However, appreciable pain may occur on the day after surgery. The purpose of this double-blinded, prospective randomised controlled trial was to evaluate the effectiveness of a bolus of local intra-articular anaesthetic given early on the day after surgery. Forty-four patients were randomised to receive an intra-articular injection, via an epidural catheter inserted at operation, of either 20 ml 0.5% plain bupivacaine or 20 ml normal saline. All patients received a femoral nerve block with 20 ml prilocaine 1% and local anaesthetic infiltration by the surgeon. Patients injected with bupivacaine had significantly less (p<0.001) pain than control patients immediately (mean pain score 1.82 v 6.1) and 6 hours (2.5 v 5.7) after injection. Patient satisfaction was also significantly greater (p<0.001) in the local anaesthetic group. We conclude that a bolus dose of intra-articular bupivacaine early on the day after surgery dramatically improves pain control after UKR and improves patient satisfaction.

Usefulness of intra-articular bupivacain and lidocain adjunction in MR or CT arthrography: a prospective study in 148 patients

PURPOSE

To evaluate the influence of shorter- and longer-acting intra-articular anaesthetics on post-arthrographic pain.

MATERIALS AND METHODS

154 consecutive patients investigated by MR or CT arthrographies were randomly assigned to one of the following groups: 1--intra-articular contrast injection only; 2--lidocain 1% adjunction; or 3--bupivacain 0.25% adjunction. Pain was assessed before injection, at 15 min, 4 h, 1 day and 1 week after injection by visual analogue scale (VAS).

RESULTS

At 15 min, early mean pain score increased by 0.96, 0.24 and 0 in groups 1, 2 and 3, respectively. Differences between groups 1 & 3 and 1 & 2 were statistically significant (p=0.003 and 0.03, respectively), but not between groups 2 & 3 (p=0.54). Delayed mean pain score increase was maximal at 4 h, reaching 1.60, 1.22 and 0.29 in groups 1, 2 and 3, respectively. Differences between groups 1 & 2 and 2 & 3 were statistically significant (p=0.002 and 0.02, respectively), but not between groups 1 & 2 (p=0.46). At 24 h and 1 week, the interaction of local anaesthetics with increase in pain score was no longer significant. Results were independent of age, gender and baseline VAS.

CONCLUSION

Intra-articular anaesthesia may significantly reduce post-arthrographic pain. Bupivacain seems to be more effective than lidocain to reduce both early and delayed pain.