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Mifsut-Aleixandre M, Mifsut D, González-Soler EM, Blasco-Serra A, Valverde AA. Anatomical Safety Area for Periarticular Analgesic Infiltration through the Posterior Capsule in Total Knee Arthroplasty: Radiological Study in Magnetic Resonance. J Clin Med 2024; 13:2123. [PMID: 38610888 PMCID: PMC11012736 DOI: 10.3390/jcm13072123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/15/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
Background: One of the main challenges of orthopedic surgery is adequate pain management after total knee arthroplasty. This work aimed to determine the anatomical safety area for infiltration through the posterior capsule of the knee in prosthetic surgery using Magnetic Resonance Imaging (MRI). Methods: A descriptive, observational, cross-sectional study was performed on 126 knee MRIs. The variables studied were age, sex, and distance between different neurovascular structures of the popliteal fossa (tibial nerve, common peroneal nerve, and vascular bundle). Data were analyzed for normality (Kolmogorov-Smirnov) and variance homogeneity (Levène). A value of p < 0.05 and a confidence interval of 9% were considered statistically significant for all comparisons. Student's t-test was used to compare the means between independent samples. Results: We observed statistically significant differences between the sexes regarding EP-EPS (external plateau-external popliteal sciatic nerve (common peroneal)), EP-IPS (external plateau-internal popliteal sciatic nerve (tibial)), and IP-PA (internal plateau-popliteal artery) measurements. The average distance between both nerves, EPS-IPS (external popliteal sciatic nerve and internal popliteal sciatic nerve), was 25.96 mm in females, while the value obtained in males was 29.93 mm, but this difference was not statistically significant. Conclusions: The average distance from the posterior capsule to the EPS and IPS nerves is greater in males than in females, despite no statistical differences. The presence of a lateralized arteriovenous bundle reduces the infiltration area of the external compartment. Regarding the safety area, infiltration of the internal compartment is safe since the volume diffuses into the muscle mass of the internal gastrocnemius upon injection. To infiltrate the external compartment, the needle must move at least 2 cm from the midline toward the external side (to exceed the maximum displacement of the neurovascular bundle established at 1.82 cm), and not advance beyond 0.76 cm (minimum distance at which we located the common peroneal nerve in the external compartment).
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Affiliation(s)
| | - Damián Mifsut
- Anatomy Department, Universitat de Valencia, 15 Av. Blasco Ibáñez, 46010 Valencia, Spain; (M.M.-A.); (E.M.G.-S.); (A.B.-S.); (A.A.V.)
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Management of perioperative pain after TKA. Orthop Traumatol Surg Res 2023; 109:103443. [PMID: 36252926 DOI: 10.1016/j.otsr.2022.103443] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 03/05/2022] [Accepted: 04/15/2022] [Indexed: 11/05/2022]
Abstract
Postoperative pain is the prime obstacle to recovery of motion and return to activity after total knee arthroplasty (TKA). Combating pain is a key point in enhanced recovery after surgery (ERAS) protocols. Outcome depends on the efficacy of pain relief, making it a major issue. The pain originates locally in the knee and also remotely via neural pathways. Regression can be slow, over several months. Pain may sometimes be definitive, to a varying degree. Pain should be managed at each step of ERAS, from the preoperative period to the last follow-up consultation, and most especially during the perioperative phase. Pain needs to be anticipated and limited for as long as necessary. The impact of analgesics should be enhanced by means of potentiators. Some are administered by general route, sometimes preoperatively; others are applied locally, directly in the surgical site by local injection, or close to the nerves, to reduce painful stimuli. The two main principles of pain management are preventive analgesia and multimodal analgesia associating various molecules and routes.
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Aguado-Maestro I, Cebrián-Rodríguez E, Fraile-Castelao O, Rodríguez-López R, de Blas-Sanz I, Rizzo-Raza S, Vielma-Cabrera D, García-Alonso M. [Translated article] Implementation of a rapid recovery protocol in total knee arthroplasty. A randomised controlled trial. Rev Esp Cir Ortop Traumatol (Engl Ed) 2022; 66:T380-T388. [DOI: 10.1016/j.recot.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 05/13/2021] [Indexed: 10/17/2022] Open
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Aguado-Maestro I, Cebrián-Rodríguez E, Fraile-Castelao O, Rodríguez-López RJ, de Blas-Sanz I, Rizzo-Raza S, Vielma-Cabrera D, García-Alonso M. Implementation of a rapid recovery protocol in total knee arthroplasty. A randomized controlled trial. Rev Esp Cir Ortop Traumatol (Engl Ed) 2021; 66:380-388. [PMID: 34353774 DOI: 10.1016/j.recot.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/18/2021] [Accepted: 05/13/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Rapid recovery (RP) in total knee arthroplasty may increase the functionality while reducing costs. The aim of this study is to prove the benefits of a rapid recovery program compared to our classic protocol. PATIENTS AND METHODS We performed a RCT (NCT03823573) in patients undergoing otal knee arthroplasty. Intervention group (RP protocol) received local infiltration of levo-bupivacaine in the periarticular tissue and supervized ambulation 4-6h after surgery. Control (C) group received a femoral nerve block with levo-bupivacaine, while a drain was used. Ambulation after its removal. All the patients completed an Oxford Knee Score prior to surgery and 6 months after discharge. An ecodoppler to assess the presence of deep vein thrombosis was made one month after discharge. Minimum follow-up was of 6 months. RESULTS A total of 175 patients were included in the trial (92 patients in the control group, 83 patients in the RP group). There were no differences in sex, age, implanted prosthesis, hemoglobin drop, need for transfusion, range of motion on discharge (C: 82.6°, RP: 85°) and at the end of the follow-up (C: 105.1, RP: 106.6), Oxford Knee Score improvement (C: 17.5 points; RP: 19.3 points), patient satisfaction or re-admissions at the emergency department (C: 7.6%; RP: 10.8%). Significancy was found on time of ischemia (C: 81.29min; RP: 85.35min; P=0.03), need for morphine shots (C: 19.7%; RP: 38.6%; P=0.007), hospital stay (C: 3.84 days; RP: 2.54 days, P<0.0001) and time until ambulation (C: 2.46 days; RP: 0.23 days; P<0.0001). CONCLUSION Rapid recovery protocols can reduce hospital stay without increasing complications or need for re-admission.
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Affiliation(s)
- I Aguado-Maestro
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Río Hortega, Valladolid, España.
| | - E Cebrián-Rodríguez
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Río Hortega, Valladolid, España
| | - O Fraile-Castelao
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Río Hortega, Valladolid, España
| | - R J Rodríguez-López
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Río Hortega, Valladolid, España
| | - I de Blas-Sanz
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Río Hortega, Valladolid, España
| | - S Rizzo-Raza
- Departamento de Radiología, Hospital Universitario Río Hortega, Valladolid, España
| | - D Vielma-Cabrera
- Departamento de Rehabilitación, Hospital Universitario Río Hortega, Valladolid, España
| | - M García-Alonso
- Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario Río Hortega, Valladolid, España
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Tubtim C, Laupattarakasem P, Laupattarakasem W, Chaisiwamongkol K. A comparative study comparing area of extension of posterior knee capsule via posteromedial injection: a cadaveric study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1095-1100. [PMID: 30747277 DOI: 10.1007/s00590-019-02399-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/09/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Periarticular multimodal drug injection (PMDI) has gained popularity as common postoperative pain protocols in knee arthroplasty. PMDI sites can vary, but posterior capsule (PC) is a common injection site because of its abundance of pain nociceptors. PURPOSE To prove the hypothesis whether posteromedial drug injection alone is sufficient to provide enough effect covering the PC in order to reduce risks of neurovascular injury. Secondary outcomes are to find proper volume of injection and safe zone for PMDI injection. METHODS Ten fresh cadaveric knees were allocated into two equal groups, which differed in volume of dye injection: 25 ml and 50 ml. Dyes were injected into posteromedial capsule compartment, and the limbs were stored in a freezer for 2 weeks. Then the posterior compartment was carefully dissected to examine spreading of the dye solution. RESULTS No dye staining was seen superficially beneath subcutaneous tissue of the knees. In deeper layer, the dye mostly occupied medially along the fascia covering semimembranosus muscles. However, dispersion was limited distally by intermuscular septa and popliteal vessels. The 50-ml injection group provided wider extension in the superficial layer, but not in the deep layer. CONCLUSION The intermuscular septa and the fascia of popliteal vessels were shown to be the boundary between posteromedial and posterolateral compartments of the knee. Separate PMDI for both compartments is necessary to occupy the entire PC. We suggest that 1.5 cm lateral to lateral border of PCL insertion, just above popliteus tendon, is the safe zone for injecting PMDI into the posterolateral capsule.
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Affiliation(s)
- Chatnarong Tubtim
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pat Laupattarakasem
- Department of Orthopedics, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand.
| | | | - Kowit Chaisiwamongkol
- Department of Anatomy, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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Berninger MT, Friederichs J, Leidinger W, Augat P, Bühren V, Fulghum C, Reng W. Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in total knee arthroplasty. BMC Musculoskelet Disord 2018; 19:232. [PMID: 30021587 PMCID: PMC6052689 DOI: 10.1186/s12891-018-2154-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 06/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Postoperative pain control and enhanced mobilization, muscle strength and range of motion following total knee arthroplasty (TKA) are pivotal requisites to optimize rehabilitation and early recovery. The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary total knee arthroplasty. METHODS Between January 2016 until August 2016, 280 patients underwent primary TKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 81) or epidural catheter (group SP&EPI, n = 51) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 86) or spinal anesthesia (group SP&LIA, n = 61). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. RESULTS Pain relief was similar in all groups, while the use of opioid medication was significantly lower (up to 58%) in combination with spinal anesthesia, especially in SP&EPI. The LIA groups, in contrast, revealed significant higher mobilization (up to 26%) and muscle strength (up to 20%) in the early postoperative period. No analgesic technique-related or surgery-related complications occurred within the first 7 days. Due to insufficient pain relief, 8.4% of the patients in the catheter-based groups and 12.2% in the LIA groups resulted in a change of the anesthetics pain management. CONCLUSIONS The LIA technique offers a safe and effective treatment option concerning early functional recovery and pain control in TKA. Significant advantages were shown for mobilization and muscle strength in the early postoperative period while pain relief was comparable within the groups.
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Affiliation(s)
- M T Berninger
- endogap, Joint Replacement Institute, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany. .,Department of Trauma Surgery, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany.
| | - J Friederichs
- Department of Trauma Surgery, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany
| | - W Leidinger
- Department of Anesthesiology and Intensive Care, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany
| | - P Augat
- Institute of Biomechanics, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany.,Institute of Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - V Bühren
- Department of Trauma Surgery, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418, Murnau, Germany
| | - C Fulghum
- endogap, Joint Replacement Institute, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany
| | - W Reng
- endogap, Joint Replacement Institute, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467, Garmisch-Partenkirchen, Germany
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Picard F, Deakin A, Balasubramanian N, Gregori A. Minimally invasive total knee replacement: techniques and results. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2018; 28:781-791. [PMID: 29564615 PMCID: PMC6003981 DOI: 10.1007/s00590-018-2164-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Accepted: 02/18/2018] [Indexed: 02/07/2023]
Abstract
In this review, we outlined the definition of minimally invasive surgery (MIS) in total knee replacement (TKR) and described the different surgical approaches reported in the literature. Afterwards, we went through the most recent studies assessing MIS TKR. Next, we searched for potential limitations of MIS knee replacement and tried to answer the following questions: Are there selective criteria and specific patient selection for MIS knee surgery? If there are, then what are they? After all, a discussion and conclusion completed this article. There is certainly room for MIS or at least less invasive surgery for appropriate selected patients. Nonetheless, there are differences between approaches. Mini-medial parapatellar is easy to master, quick to perform and potentially extendable, whereas mini-subvastus and mini-midvastus are trickier and require more caution related to risk of haematoma and vastus medialis oblique (VMO) nerve damage. Current evidence on the safety and efficacy of mini-incision surgery for TKR does not appear fully adequate for the procedure to be used without special arrangements for consent and for audit or continuing research. There is an argument that a sudden jump from standard TKR to MIS TKR, especially without computer assistance such as navigation, patient-specific instrumentation or robotic, may breach a surgeon's duty of care towards patients because it exposes patients to unnecessary risks. As a final point, more evidence is required on the long-term safety and efficacy of this procedure which will give objective shed light on real benefits of MIS TKR.
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Affiliation(s)
- Frederic Picard
- Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK.
- Biomedical Engineering, Strathclyde University, Glasgow, UK.
| | - Angela Deakin
- Biomedical Engineering, Strathclyde University, Glasgow, UK
- Surgiconcept Ltd, Glasgow, UK
| | | | - Alberto Gregori
- Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
- Hairmyres Hospital, Eaglesham East Kilbride, Glasgow, G758RG, UK
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Nair A, Dolan J, Tanner KE, Kerr CM, Jones B, Pollock PJ, Kellett CF. Ultrasound-guided adductor canal block: a cadaver study investigating the effect of a thigh tourniquet. Br J Anaesth 2018; 121:890-898. [PMID: 30236251 DOI: 10.1016/j.bja.2018.04.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/08/2018] [Accepted: 05/16/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Placement of local anaesthetic within the adductor canal using ultrasonography is an alternative to femoral nerve blocks for postoperative pain relief after knee joint replacement surgery. However, the effect of an inflated thigh tourniquet on the distribution of local anaesthetic within the adductor canal is unknown. The aim of this cadaveric study was to compare the distribution of radio-opaque dye within the adductor canal in the presence or absence of an inflated thigh tourniquet. METHODS Bilateral ultrasound-guided adductor canal blocks were performed on the thawed lower limbs of five fresh frozen human cadavers. The left and right lower cadaver limbs were randomised to receive or not receive a thigh tourniquet inflated to 300 mm Hg for 1 h. X-rays with iohexol radio-opaque dye were obtained in four views, and fiducial markers inserted as reference points. Virtual editing technology was used to recreate outlines representing the distribution of the radio-opaque dye and superimpose these on anatomical images. RESULTS Radio-opaque dye was distributed on the medial aspect of the thighs with entire and well circumscribed margins. The majority of the radio-opaque dye was confined within the adductor canal. Superior-inferior dye distribution was 315 mm [95% confidence intervals (CI) 289-342] and 264 mm (95% CI 239-289) in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI -80.46 to -22.22, P=0.0081). Image analysis using the recreated radio-opaque outlines suggested that the most proximal point of the radio-opaque dye was 100 mm (95% CI 82-117) or 117 mm (95% CI 62-171) below the inguinal ligament in the presence and absence of an inflated thigh tourniquet, respectively (diff 95% CI -38 to 72, P=0.456). CONCLUSIONS Application and inflation of thigh tourniquets significantly increased the combined superior-inferior dye distribution within the adductor canal of cadaveric limbs. There was insufficient evidence to suggest significant proximal spread of 25 ml of local anaesthetic to involve the motor branches of the femoral nerve. In some patients, the local anaesthetic may reach the popliteal fossa in close approximation to the sciatic nerve.
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Affiliation(s)
- A Nair
- School of Medicine, Glasgow, UK
| | - J Dolan
- Department of Anaesthesia, Glasgow, UK.
| | | | - C M Kerr
- School of Engineering, Glasgow, UK
| | - B Jones
- Department of Orthopaedics, Glasgow Royal Infirmary, Glasgow, UK
| | - P J Pollock
- School of Veterinary Medicine, University of Glasgow, Glasgow, UK
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Rodriguez-Merchan EC. Single Local Infiltration Analgesia (LIA) Aids Early Pain Management After Total Knee Replacement (TKR): An Evidence-Based Review and Commentary. HSS J 2018; 14:47-49. [PMID: 29398994 PMCID: PMC5786581 DOI: 10.1007/s11420-017-9560-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 04/19/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is controversy in the literature regarding the role of single local infiltration analgesia (LIA) after total knee replacement (TKR). QUESTIONS/PURPOSES Is single LIA really efficient in controlling pain after TKR? METHODS A Cochrane Library and PubMed (MEDLINE) search related to the justification LIA after TKR was analyzed. The main criteria for selection were that the articles were focused in the aforementioned question. RESULTS Two hundred ninety-nine articles were found until February 9, 2017, but only 27 were selected and reviewed because they were focused on clinical experience with LIA following TKR. Fifteen of them were considered level of evidence (I-II) while 12 had a lower level of evidence (III-IV). LIA reduced the amount of perioperative opioid administration and enabled adequate pain management in conjunction with oral medication without adverse effects. No clinically marked effects on the functional outcome after TKR were detected. CONCLUSION Single dose LIA provides effective analgesia in the initial postoperative period after TKR in most randomized clinical trials, systematic reviews, and meta-analyses.
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Affiliation(s)
- E. Carlos Rodriguez-Merchan
- 0000 0000 8970 9163grid.81821.32Department of Orthopaedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046 Madrid, Spain
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van Haagen MHM, Verburg H, Hesseling B, Coors L, van Dasselaar NT, Langendijk PNJ, Mathijssen NMC. Optimizing the dose of local infiltration analgesia and gabapentin for total knee arthroplasty, a randomized single blind trial in 128 patients. Knee 2018; 25:153-160. [PMID: 29343448 DOI: 10.1016/j.knee.2017.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 09/19/2017] [Accepted: 10/25/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND AND PURPOSE Effective analgesia is essential for postoperative recovery and rehabilitation in TKA. The challenge of analgesic regimes is to obtain adequate pain relief and maximum muscle control to mobilize and rehabilitate patients early. However, the optimal dose and best composition are not known. We hypothesized that there would be no differences in reported postoperative pain on the day of the TKA surgery as well as the first day after surgery when different combinations of ropivacain for LIA and gabapentin are given. METHODS This prospective randomized trial examined 128 TKA patients treated with LIA and gabapentin in four groups. Group A: 300-mg ropivacain/600-300-300-mg gabapentin. Group B: 150-mg ropivacain/600-300-300-mg gabapentin. Group C: 300-mg ropivacain/300-100-100-mg gabapentin. Group D: 150-mg ropivacain/300-100-100-mg gabapentin. Primary endpoint was pain (NRS) at multiple moments. Secondary endpoints were number of adverse effects, length of hospital stay (LOS), the amount of consumption of pain medication, and wound leakage. Generalized estimating equation (GEE) was used to detect differences between the four groups regarding the course of pain. RESULTS No differences regarding adverse effects, LOS, and wound leakage were found. GEE revealed a significant difference in course of pain between group A and B, with group B experiencing higher NRS scores postoperatively than group A (p=0.021). No differences between the other groups were found. INTERPRETATION The results of the current study suggest that LIA with 300-mg (150ml) ropivacain might be more effective than 150-mg (75ml) ropivacain. Alteration in dose of gabapentin appears not to have influence on the course of pain.
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Affiliation(s)
- Maurik H M van Haagen
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2625AD Delft, The Netherlands.
| | - Hennie Verburg
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2625AD Delft, The Netherlands
| | - Brechtje Hesseling
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2625AD Delft, The Netherlands
| | - Lauri Coors
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2625AD Delft, The Netherlands
| | - Nick T van Dasselaar
- Department of Anesthesiology and Pain Medicine, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2625AD Delft, The Netherlands
| | - Pim N J Langendijk
- Department of Hospital Pharmacy, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2625AD Delft, The Netherlands
| | - Nina M C Mathijssen
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Reinier de Graafweg 5, 2625AD Delft, The Netherlands
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A Three-arm Randomized Clinical Trial Comparing Continuous Femoral Plus Single-injection Sciatic Peripheral Nerve Blocks versus Periarticular Injection with Ropivacaine or Liposomal Bupivacaine for Patients Undergoing Total Knee Arthroplasty. Anesthesiology 2017; 126:1139-1150. [PMID: 28234636 DOI: 10.1097/aln.0000000000001586] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Multimodal analgesia is standard practice for total knee arthroplasty; however, the role of regional techniques in improved perioperative outcomes remains unknown. The authors hypothesized that peripheral nerve blockade would result in lower pain scores and opioid consumption than two competing periarticular injection solutions. METHODS This three-arm, nonblinded trial randomized 165 adults undergoing unilateral primary total knee arthroplasty to receive (1) femoral catheter plus sciatic nerve blocks, (2) ropivacaine-based periarticular injection, or (3) liposomal bupivacaine-based periarticular injection. Primary outcome was maximal pain during postoperative day 1 (0 to 10, numerical pain rating scale) in intention-to-treat analysis. Additional outcomes included pain scores and opioid consumption for postoperative days 0 to 2 and 3 months. RESULTS One hundred fifty-seven study patients received peripheral nerve block (n = 50), ropivacaine (n = 55), or liposomal bupivacaine (n = 52) and reported median maximal pain scores on postoperative day 1 of 3, 4, and 4.5 and on postoperative day 0 of 1, 4, and 5, respectively (average pain scores for postoperative day 0: 0.6, 1.7, and 2.4 and postoperative day 1: 2.5, 3.5, and 3.7). Postoperative day 1 median maximal pain scores were significantly lower for peripheral nerve blockade compared to liposomal bupivacaine-based periarticular injection (P = 0.016; Hodges-Lehmann median difference [95% CI] = -1 [-2 to 0]). After postanesthesia care unit discharge, postoperative day 0 median maximal and average pain scores were significantly lower for peripheral nerve block compared to both periarticular injections (ropivacaine: maximal -2 [-3 to -1]; P < 0.001; average -0.8 [-1.3 to -0.2]; P = 0.003; and liposomal bupivacaine: maximal -3 [-4 to -2]; P < 0.001; average -1.4 [-2.0 to -0.8]; P < 0.001). CONCLUSIONS Ropivacaine-based periarticular injections provide pain control comparable on postoperative days 1 and 2 to a femoral catheter and single-injection sciatic nerve block. This study did not demonstrate an advantage of liposomal bupivacaine over ropivacaine in periarticular injections for total knee arthroplasty.
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Sivapurapu V, Murugharaj SS, Venkata SSP. Comparison of intra-articular analgesics in arthroscopic anterior cruciate ligament reconstruction surgeries: A randomized controlled trial. J Anaesthesiol Clin Pharmacol 2017; 33:391-396. [PMID: 29109642 PMCID: PMC5672517 DOI: 10.4103/joacp.joacp_257_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background and Aims: Arthroscopic anterior cruciate ligament reconstruction (ACLR) is one of the most common knee surgeries done worldwide today. It involves immense pain at sites of graft harvest, tibial, and femoral tunnels, thereby delaying recovery and increased patient morbidity, and delayed rehabilitation. Various drugs and combination of drugs administered intra-articularly have been studied for analgesic efficacy. Our study gives an insight if there is any added advantage of additives morphine or clonidine to bupivacaine when compared to administering bupivacaine alone. Material and Methods: After obtaining the Institute Ethics Committee approval, ninety American Society of Anesthesiology I-II patients undergoing arthroscopic ACLR under spinal anesthesia were randomly assigned to one of three groups (Group B – bupivacaine alone 0.25%, Group BM – bupivacaine 0.25% with morphine 5 mg, Group BC – bupivacaine 0.25% with clonidine 150 mcg). At the end of procedure, 20 mL of the respective drug was administered intra-articularly and postoperative time duration to rescue analgesia, 24 h analgesic requirement, visual analog scale (VAS) score findings at rest and on movement were observed. Results: The mean duration of time to request for first rescue analgesia in minutes was significantly longer in Group BC 341.55 (103.66 SD) with P < 0.001. The VAS scores at that time point were least in Group BM 6.1 (1.7 SD), but not statistically significant. The 24 h analgesic consumption was least in Group B 2.24 (0.79 SD), but not statistically significant. Conclusion: Combination of bupivacaine and clonidine administered intra-articularly provided a longer duration of analgesia though the quality of analgesia was comparable between the three groups.
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Affiliation(s)
- Vijayalakshmi Sivapurapu
- Department of Anaesthesiology, Indira Gandhi Medical College and Research Institute, Puducherry, India
| | | | - Sai Saran Panathula Venkata
- Department of Critical Care, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Nakagawa S, Arai Y, Inoue H, Kan H, Hino M, Ichimaru S, Ikoma K, Fujiwara H, Amaya F, Sawa T, Kubo T. Comparative Effects of Periarticular Multimodal Drug Injection and Single-Shot Femoral Nerve Block on Pain Following Total Knee Arthroplasty and Factors Influencing Their Effectiveness. Knee Surg Relat Res 2016; 28:233-8. [PMID: 27595078 PMCID: PMC5009049 DOI: 10.5792/ksrr.2016.28.3.233] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/14/2016] [Accepted: 03/27/2016] [Indexed: 11/04/2022] Open
Abstract
Purpose This study compared the analgesic effects of local infiltration analgesia (LIA) and femoral nerve block (FNB) after total knee arthroplasty (TKA) and assessed factors associated with analgesia obtained by these two methods. Materials and Methods Study subjects included 66 patients (72 knees) who underwent TKA for osteoarthritis of the knee. Pain visual analogue scale (VAS), the amount of analgesics used, number of days to achieve 90° of flexion of the knee joint, date of initiating parallel-bar walking, range of motion of the knee joint at discharge, and adverse events were investigated. Results The VAS scores did not differ significantly between two groups, whereas the amount of analgesics used was significantly lower in the LIA group. Preoperative flexion contracture was significantly more severe in the LIA group with high VAS compared with low VAS. No serious adverse event occurred in the LIA or FNB group. Conclusions The lower analgesic usage in the LIA group than the FNB group indicates that the analgesic effect of LIA was greater than that of singleshot FNB after TKA. There were no serious complications in either group. The postoperative analgesic effect of LIA was smaller in patients with severe than less severe preoperative flexion contracture.
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Affiliation(s)
- Shuji Nakagawa
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Arai
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Inoue
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroyuki Kan
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Manabu Hino
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shohei Ichimaru
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuya Ikoma
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroyoshi Fujiwara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Fumimasa Amaya
- Department of Anesthesiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Teiji Sawa
- Department of Anesthesiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshikazu Kubo
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Fan L, Yu X, Zan P, Liu J, Ji T, Li G. Comparison of Local Infiltration Analgesia With Femoral Nerve Block for Total Knee Arthroplasty: A Prospective, Randomized Clinical Trial. J Arthroplasty 2016; 31:1361-1365. [PMID: 26810604 DOI: 10.1016/j.arth.2015.12.028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 12/07/2015] [Accepted: 12/10/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is usually associated with severe postoperative pain, which can prevent rehabilitation of patients' knee function and influence the satisfaction of surgery. Local infiltration analgesia (LIA) as a new method to managing postoperative pain has been applied in clinical practice recently. However, the safety and efficacy of LIA compared with femoral nerve block (FNB) in postoperative pain management of TKA still remains controversial. Thus, we conducted an original clinical trial to compare LIA and FNB. METHOD One hundred fifty-seven patients undergoing TKA were enrolled in a randomized, double-blind, single-center study. The patients received either FNB (group A) or periarticular infiltration of local anesthetic (group B). The morphine consumption used in patient-controlled analgesia after surgery, postoperative Visual Analogue Scale (VAS), Knee Society Score, and range of motion before and after surgery in both groups were analyzed, as well as the adverse effects. RESULTS Group A consisted 78 patients, and group B contained 79 patients. The patients' characteristics including age and body mass index had no significant difference (P > .05). Morphine consumption, VAS at rest, range of motion, and Knee Society Score were similar between the 2 groups. Our study showed group B, the local anesthetic group had less VAS with movement on postoperative day 1 (P = .01) than that of group A, which means a better pain control. Because of the study design, the surgery time showed no significant difference. Eighteen patients in group A and 21 patients in group B experienced mild-to-medium nausea or vomiting. One patient in group B had dizziness and one patient in group A suffered a neuropraxic injury to the femoral nerve. No urinary retention case was seen during inpatient days. There were no significant differences between the 2 groups about side effects. CONCLUSIONS Our research showed that no significant differences were observed between the 2 treatment groups. LIA could provide a similar analgesic effect to FNBs with a low incidence of complications.
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Affiliation(s)
- Lin Fan
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Xiao Yu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Nan Jing Medical University, Nangjing, People's Republic of China
| | - Pengfei Zan
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Jin Liu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Nan Jing Medical University, Nangjing, People's Republic of China
| | - Tongxiang Ji
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
| | - Guodong Li
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, People's Republic of China
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Single-Dose Adductor Canal Block With Local Infiltrative Analgesia Compared With Local Infiltrate Analgesia After Total Knee Arthroplasty. Reg Anesth Pain Med 2016; 41:678-684. [DOI: 10.1097/aap.0000000000000494] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Local infiltration analgesia versus continuous interscalene brachial plexus block for shoulder replacement pain: a randomized clinical trial. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1245-52. [DOI: 10.1007/s00590-015-1678-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 07/29/2015] [Indexed: 01/01/2023]
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