Intraarticular vs. extraarticular ropivacaine infusion following high-dose local infiltration analgesia after total knee arthroplasty: a randomized double-blind study

Effects of Novel Multimodal Transversus Abdominis Plane Block on Postoperative Opioid Usage and Hospital Length of Stay Following Elective Ventral Hernia Repair

Background and objective Traditional transversus abdominis plane (TAP) blocks consisting of a local anesthetic, typically bupivacaine, have previously been shown to reduce postoperative pain following gastrointestinal surgery, including hernia repair. However, elective abdominal wall reconstructions for the repair of large ventral hernias continue to cause patients significant postoperative pain, resulting in prolonged hospital stays and need for opioid pain medication. This study aimed to analyze the postoperative opioid pain medication usage and hospital length of stay (LOS) in patients who received a nontraditional multimodal TAP block of ropivacaine (local anesthetic), ketorolac (non-steroidal anti-inflammatory), and epinephrine following elective ventral hernia repair. Methods A retrospective review of medical records for patients who underwent elective robotic ventral hernia repair by a single surgeon was conducted. Postoperative hospital LOS and opioid usage for patients with the multimodal TAP block were compared to those without. Results A total of 334 patients met the inclusion criteria for LOS analysis: 235 received the TAP block and 109 did not. Patients who received the TAP block had a statistically significant shorter LOS compared to patients who had no TAP block (1.09 ± 1.22 days vs. 2.53 ± 1.57 days; P<0.001). Medical records for 281 patients, 214 with the TAP block and 67 without the TAP block, contained information and were analyzed for postoperative opioid usage. A statistically significantly fewer number of patients who had the TAP block required hydromorphone patient-controlled analgesia pump (3.3% vs. 36%; P<0.001) and oral opioids (29% vs. 78%; P<0.001) postoperatively. Those with TAP block required intravenous opioids more frequently (50% vs 10%; P<0.001) although at much less dosages than those without TAP block (4.86 ± 2.62 mg vs. 10.29 ±3.90 mg; P<0.001). Conclusion In conclusion, this multimodal TAP block of ropivacaine, ketorolac, and epinephrine may represents an effective method to improve hospital LOS and postoperative opioid usage in patients undergoing robotic abdominal wall reconstruction for ventral hernia repair.

Effect of commonly used surgical solutions on the tensile strength of absorbable sutures: an in-vitro study

BACKGROUND

Within recent decades the use of various surgical solutions to prevent bleeding, ward off infection or decrease post-operative pain has become common-place in orthopaedic procedures. However, little work has been done to determine the effects that these solutions have on the tensile strength of various sutures, particularly those that are used for deep closures, which are often absorbable in nature. Whilst numerous authors have attempted to reach conclusions regarding the nature of these effects, a consensus has yet to be reached and this paper is designed with the aim to contribute to the current literature on the subject and improve surgical practice.

METHODS

This in-vitro study incubated three different surgical sutures in five commonly used surgical solutions at 37°C for 30 min, prior to applying a constant increase in force to determine the effects these solutions have on tensile strength. A control set was included.

RESULTS

No significant difference was found in the tensile strength of Vicryl and PDS-II sutures, whilst Monocryl incubated in chlorhexidine exhibited a borderline significant increase in tensile strength.

CONCLUSIONS

Common surgical solutions used on orthopaedic procedures can impact on the tensile strength of suture materials; however, further research is required on the subject.

Efficacy of Local Anesthetic Wound Infiltration in Temporomandibular Joint Ankylosis Surgery for Control of Postoperative Pain: A Prospective, Randomized Controlled, and Double-Blinded Trial

PURPOSE

This study aimed to compare the analgesic efficacy of wound infiltration with ropivacaine alone or with adjuvants clonidine or dexamethasone for postoperative pain in temporomandibular joint ankylosis (TMJA) surgery.

MATERIALS AND METHODS

The investigators implemented a randomized controlled trial with 3 parallel groups, among the patients of bilateral TMJA visiting the maxillofacial surgery unit between March 12, 2015 and February 5, 2017. At the completion of surgery, wound infiltration was done with 0.25% of ropivacaine (R group), 0.25% of ropivacaine with 0.5 mcg/kg of clonidine (RC group), 0.25% of ropivacaine with 0.1 mg/kg of dexamethasone (RD group), and 0.2 mL/kg of drug volume on each side. The primary outcome variables were total opioid consumption (fentanyl in micrograms/kilogram) and visual analog scale for pain at rest and movement for 24 hours after surgery. The secondary outcome variables were time (minutes) to first rescue analgesic requirement and patient satisfaction scores. The patients, surgeons, and anesthesiologists collecting the data were blinded to the group allocation. Continuous and qualitative data were summarized using mean (standard deviation) and frequency distribution, respectively.

RESULTS

About 45 patients were randomized into 3 equal groups. Mean age of the sample was 17.6 ± 8.04 years (males = 24 [53%]; females = 21 [47%]). Surgery for TMJA included gap arthroplasty (n = 17), interpositional arthroplasty (n = 24), and total TMJ replacement (n = 4). Total fentanyl (micrograms) consumption during 24 hours was comparable between all the 3 groups and statistically not significant (P = .40). The pain scores (visual analog scale at rest and movement) were comparable at all time points. No significant difference was noted for time to first rescue analgesic requirement (P = .31). Patient satisfaction was higher in RC group as compared with R group (P = .009). No adverse effects were noted in any group.

CONCLUSIONS

Within the confines of the sample size and the absence of power calculation, the study implies that wound infiltration with ropivacaine was as efficacious as when mixed with adjuvants, either clonidine or dexamethasone, for control of postoperative pain for 24 hours.

Postoperative nausea and vomiting following lower limb surgery :a comparison between single-injection intraarticular anesthesia and continuous epidural anesthesia

Study Objective : the incidence of postoperative nausea and vomiting (PONV) following single-injection intraarticular anesthesia was compared to that following continuous epidural anesthesia. Design : Prospective, double-blind, randomized study. Setting : University-affiliated teaching hospital. Patients : Forty-eight patients finally participated in this study, and each group contained twenty-four patients. Interventions : Patients scheduled to undergo lower limb surgery under general anesthesia were randomly allocated into two groups, to receive either single-injection intraarticular or continuous epidural anesthesia for postoperative analgesia. Measurements : The incidence and severity of PONV, complete response rates (i.e., no vomiting or rescue antiemetic use), and pain scores were recorded 2, 24, and 48 h postoperatively. Main results : No significant differences between groups were observed in the incidence and severity of PONV, rescue antiemetic use, or complete response rate at any of the time points, but only the use of rescue analgesics was significantly less in continuous epidural anesthesia group during the 2-24h postoperative period (P=0.04). Conclusion : While the use of single-injection intraarticular anesthesia following lower limb surgery did not prevent PONV more than continuous epidural anesthesia in this study, the intraarticular technique still provides greater simplicity, safety, and cost-effectiveness. J. Med. Invest. 66 : 303-307, August, 2019.

Continuous Wound Infiltration of Local Anesthetics in Postoperative Pain Management: Safety, Efficacy and Current Perspectives

Local infiltration and continuous infusion of surgical wound with anesthetics are parts of multimodal analgesia for postoperative pain control. The techniques, given the simplicity of execution that does not increase the timing of the intervention and does not require additional technical skills, are applied in several kinds of surgeries. The continuous wound infiltration can be used for days and a variety of continuous delivery methods can be chosen, including patient-controlled analgesia, continuous infusion or intermittent bolus. The purpose of this narrative review is to analyze the literature, in particular by researching the safety, efficacy and current perspectives of continuous wound infiltration for postoperative pain management in different surgical settings. We have identified 203 articles and 95 of these have been taken into consideration: 17 for the lower limb surgery; 7 for the upper limb surgery, 51 for the laparotomy/laparoscopic surgery of the abdominopelvic area, 13 studies regarding breast surgery and 7 for cardiothoracic surgery. The analysis of these studies reveals that the technique has a variable effectiveness based on the type of structure involved: it is better in structures rich in subcutaneous and connective tissue, while the effectiveness is limited in anatomic districts with a greater variability of innervation. However, regardless the heterogeneity of results, a general reduction in pain intensity and in opioid consumption has been observed with continuous wound infiltration: it is an excellent analgesic technique that can be included in the multimodal treatment of postoperative pain or represents a valid alternative when other options are contraindicated.

Enhanced recovery after posterior minimally invasive total hip arthroplasty with continuous intraarticular anaesthesia

BACKGROUND

The aim of this study was to evaluate the possible complications specific to the continuous intraarticular anaesthesia (CIA) in a minimally invasive posterior approach in total hip arthroplasty and its possible effects on the recovery, especially on pain and the length of hospitalisation.

MATERIALS AND METHODS

The surgical procedure is first precisely described step by step with numerous per-operating photographs. Particular technical points are detailed. The errors to be avoided are specified. A prospective series of 70 first-line total hip arthroplasties (one half with and one half without CIA) are analysed for the well-known results of total hip arthroplasty but specifically assessing: (a) specific possible complications to the minimally invasive posterior technique with the prolonged local anaesthesia and (b) effects on pain, duration of hospitalisation and satisfaction in patients (questionnaire).

RESULTS

(a) Very low level of immediate post-operative pain was observed in almost all of the patients. (b) Patient satisfaction was high in our series. (c) A repeated education was provided multiple times to avoid specific complications following the absence of pain and consequent inattention.

DISCUSSION AND CONCLUSION

The minimally invasive posterior approach with continuous intraarticular anaesthesia is an entirely reliable hip arthroplasty procedure. The patients exhibited a significantly less pain and a fast rate of recovery, but preparatory education must be even more significant.

Continuous Wound Infiltration After Hallux Valgus Surgery

BACKGROUND

Hallux valgus surgery is associated with significant early postoperative pain. The aim of this study was to investigate the use of continuous wound infiltration (CWI) with ropivacaine for pain management after hallux valgus surgery.

METHODS

In this prospective, randomized, double-blind, and placebo-controlled single-center trial, 50 patients undergoing distal metatarsal osteotomy for idiopathic hallux valgus were allocated to CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h or placebo for 24 hours postoperatively. Average and peak pain levels on the verbal numeric rating scale (NRS; 1-10) during the first 48 hours after surgery were recorded as primary outcome parameters. Secondary outcome parameters included consumption of narcotics, clinical outcome, incidence of postoperative complications, and patient satisfaction.

RESULTS

No significant difference in mean ( P = .596) and peak ( P = .353) postoperative pain level was found for CWI with either ropivacaine (mean NRS 1.9 ± 0.8; peak NRS 3.5 ± 2.0) or placebo (mean NRS 2.0 ± 0.7; peak NRS 3.9 ± 1.7) during the early postoperative course. Furthermore, no significant difference between both groups was detected regarding narcotic consumption ( P = .354) and all other secondary outcome parameters. Two severe complications (local dysesthesia with CWI, catheter accidentally fixed by a suture) and 5 catheter dislocations were observed.

CONCLUSION

CWI with ropivacaine 2 mg/mL at a rate of 2 mL/h for 24 hours after hallux valgus surgery did not reduce postoperative pain level in an inpatient setting.

LEVEL OF EVIDENCE

Level I, prospective randomized trial.

No advantage of adrenaline in the local infiltration analgesia mixture during total knee arthroplasty

PURPOSE

Local infiltration analgesia (LIA) is widely applied in patients undergoing total knee arthroplasty (TKA). In daily practice, adrenaline is added to the LIA mixture to achieve vasoconstriction. However, adrenaline has some possible negative side effects (e.g. tissue necrosis). This trial investigated whether ropivacaine alone is at least as effective for postoperative pain relief after LIA.

METHODS

Fifty patients scheduled for primary TKA were included in this prospective randomized, double-blind, controlled pilot study receiving high-volume (150 mL) single-shot intra-capsular LIA with ropivacaine (2 %) with (Ropi+) or without (Ropi-) adrenaline (0.01 %). All patients received the same pre-, peri- and postoperative care with multimodal oral pain protocol. Postoperative pain was assessed before and after the first mobilization and during the first 48 h postoperative using the visual analogue scale (VAS). Secondary outcomes were rescue medication use, early mobilization, length of hospital stay, adverse events (AE's) and readmission rates. Patient reported outcomes measures (PROMS); Oxford Knee Score and WOMAC, were obtained preoperative and 3 months postoperative.

RESULTS

VAS scores were not significantly different before (n.s.) and after the first mobilization (n.s.), neither over the first 48 h postoperative (n.s.). Patients who needed rescue medication (n.s.), who mobilized <6 h postoperative (n.s.), who were discharged before postoperative day 3 (n.s.), AE's and readmission rate (n.s.) were comparable between both groups. At 3-month follow-up, PROMS significantly improved within both groups.

CONCLUSION

To prevent possible negative side effects (e.g. tissue necrosis), adrenaline should be omitted from the LIA mixture. Single-shot LIA with ropivacaine alone results in clinical acceptable adequate pain control and can be used in daily TKA practice.

LEVEL OF EVIDENCE

Randomized, double-blind, prospective clinical trial, Level I.

Continuous intra-articular local anesthetic drug instillation versus discontinuous sciatic nerve block after total knee arthroplasty

STUDY OBJECTIVE

Sciatic nerve block (SNB) is commonly used as adjunct to femoralis nerve block (FNB) to achieve high-quality pain relief after total knee arthroplasty (TKA). However, this combination is associated with considerable muscle weakness, foot drop and surgically related nerve injuries may be masked. The purpose of this study was to assess whether low risk continuous intra-articular anesthetic drug instillation is an adequate alternative to SNB when adding to FNB after TKA.

DESIGN

Retrospective investigational follow-up study.

SETTING

University teaching hospital. Interdisciplinary postoperative anesthetic and orthopedic survey.

PATIENTS

For this investigational analysis, 34 of 50 consecutive patients were available.

INTERVENTIONS

All patients underwent primary unilateral TKA. Group A (18 patients) received a continuous intra-articular 0.33% ropivacaine (5 mL/h) instillation for the first 48 h postoperatively. In Group B (16 patients) a discontinuous SNB was used. Both groups were treated with a continuous FNB.

MEASUREMENTS

Main endpoints were mean and maximum postoperative pain intensity levels for both anterior and posterior knee side, amount of postoperative administered opioid drugs, differences in functional outcome or hospital stay and rate of postoperative complications.

MAIN RESULTS

Group A showed higher pain intensity levels for the posterior knee side (P≤.042). Merely on the second postoperative day there were no differences within either study group. No differences were found regarding anterior knee pain. Group A showed a significant higher postoperative piritramid consumption (P≤.007). Length of hospital stay or postoperative functional outcome was not significant different. Postoperative complications were not related to anesthesia techniques.

CONCLUSIONS

SNB technique resulted in superior pain relief in comparison to continuous intra-articular local anesthetic drug instillation as adjunct to continuous FNB after TKA.

Biodegradable nanofiber-membrane for sustainable release of lidocaine at the femoral fracture site as a periosteal block: In vitro and in vivo studies in a rabbit model

The aim of this study was to evaluate the efficacy of a biodegradable, lidocaine-embedded, nanofibrous membrane for the sustainable analgesic release onto fragments of a segmental femoral fracture site. Membranes of three different lidocaine concentrations (10%, 30%, and 50%) were produced via an electrospinning technique. In vitro lidocaine release was assessed by high-performance liquid chromatography. A femoral segmental fracture, with intramedullary Kirschner-wire fixation and polycaprolactone stent enveloping the fracture site, was set-up in a rabbit model for in vivo assessment of post-operative recovery of activity. Eighteen rabbits were randomly assigned to three groups (six rabbits per group): group A comprised of rabbits with femoral fractures and underwent fixation; group B comprised of a comparable fracture model to that of group A with the implantation of lidocaine-loaded nanofibers; and group C, the control group, received only anesthesia. The following variables were measured: change in body weight, food and water intake before and after surgery, and total activity count post-surgery. All membranes eluted effective levels of lidocaine for more than 3 weeks post-surgery. Rabbits in group B showed faster recovery of activity post-operatively, compared with those in group A, which confirmed the pain relief efficacy of the lidocaine-embedded nanofibers. Nanofibers with sustainable lidocaine release have adequate efficacy and durability for pain relief in rabbits with segmental long bone fractures.

Local Anaesthetic Infiltration and Indwelling Postoperative Wound Catheters for Patients with Hip Fracture Reduce Death Rates and Length of Stay

Background. An analgesic enhanced recovery (ER) protocol for patients with a hip fracture was introduced. It was hypothesised that the ER would reduce pain, length of stay and improve clinical outcomes. The protocol used intraoperative infiltration of levobupivacaine followed by ongoing wound infusions. Methods. Consecutive patients admitted to two hospitals were eligible for the ER protocol. Numerical Reporting Scale pain scores (0–10) were recorded alongside opiate requirements. 434 patients in the ER group (316 full ER, 90 partial ER, and 28 no ER) were compared to a control group (CG) of 100 consecutive patients managed with traditional opiate analgesia. Results. Mean opiate requirement was 49.2 mg (CG) versus 32.5 mg (ER). Pain scores were significantly reduced in the full ER group, p < 0.0001. Direct discharge home and mean acute inpatient stay were significantly reduced (p = 0.0031 and p < 0.0001, resp.). 30-day mortality was 15% (CG) versus 5.5% (ER), p = 0.0024. Conclusions. This analgesic ER protocol for patients with a hip fracture was safe and effective and was associated with reduced inpatient stay and mortality.

Comparison of the effects of intra-articular sole ropivacaine and combined ketorolac and ropivacaine for pain control after knee arthroscopy surgery

INTRODUCTION

Effective pain relief is important after arthroscopic knee surgery to permit initiation of daily activities of life. This study is performed in order to investigate the effect of multi-model therapy for pain control after surgery. This clinical, randomized and double-blind trial is conducted on patients who get knee arthroscopy surgery.

METHODS

Of these patients, 40 were divided into two groups by Block Randomization method: 1 - sole ropivacaine group (150 mg); 2 - combined ketorolac (30 mg); and ropivacain (150 mg) group. These drugs were injected intra-articularly at the end of knee arthroscopic surgery. The first consequence including measurement of pain severity after entrance to recovery room and 2, 4, 8, 12, 18 and 24 hours after surgery were evaluated according to the visual analogue pain score. The second consequence, including nausea, vomiting and sedation, was assessed by expert nurses in the recovery room and surgery part according to nausea and vomiting scale and Ramsay sedation scale, respectively.

RESULTS

All groups had excellent analgesia at 0 and 4 hours, postoperatively. Group-combined ketorolac and ropivacaine had significantly lower visual analogue pain score as well as higher sedative scale at 8, 12, 18 and 24 hours after surgery at rest and during movement compared with the other group (p < 0.05). Moreover, there was no statistical difference between groups in regard of nausea and vomiting.

CONCLUSION

Addition of ketolorac to ropivacaine intra-articularly in arthroscopic knee surgery enhances analgesic efficacy of local anaesthetics and cause more sedation after surgery.

Local infiltration analgesia versus femoral nerve block in total knee arthroplasty: a meta-analysis

INTRODUCTION

Local infiltration analgesia (LIA) and femoral nerve block (FNB) are both used for the pain management after total knee arthroplasty (TKA). Controversy still remains regarding the optimal technique for pain relief in patients undergoing TKA. The purpose of this meta-analysis was to compare the analgesia achieved with LIA and the one from FNB following TKA.

HYPOTHESIS

LIA achieves better pain control than FNB in patients with TKA.

METHODS

Databases, including Pubmed, EMBASE, the Cochrane Library and Web of Science were comprehensively searched to identify studies comparing LIA with FNB for patients with TKA. Two reviewers independently selected trials, extracted data, and assessed the methodological qualities of included studies. Data were analyzed by RevMan 5.2.

RESULTS

Nine RCTs involving 782 patients were included. LIA achieved more rapid pain relief (VAS) at 6h postoperatively [SMD6h=-0.92, 95% CI (-1.38, -0.47)] than FNB. There were no significant differences at 24h and 48h [SMD24h=-0.03, 95% CI (-0.46, 0.40); SMD48h=0.28, 95% CI (-0.35, 0.91)], VAS with activity at 24h and 48h [SMD6h=-0.54, 95% CI (-1.62, 0.54); SMD24h=-0.22, 95% CI (-1.41, 0.96); SMD48h=-0.08, 95% CI (-0.52, 0.69)], opioid consumption at 24h and 48h [SMD24h=-0.24, 95% CI (-0.82, 0.34); SMD48h=0.15, 95% CI (0.25, 0.54)] and length of hospital stay [MD=-0.52, 95% CI (-1.13, 0.09)].

DISCUSSION

LIA may be the better choice in the pain management of TKA for it could achieve fast pain relief and is easier to perform than FNB for patients with TKA.

LEVEL OF EVIDENCE

Level II, meta-analysis and systematic review.

Doubtful effect of continuous intraarticular analgesia after total knee arthroplasty: a randomized double-blind study of 200 patients

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.

Regional analgesia techniques for total knee replacement

PURPOSE OF REVIEW

Pain following total knee arthroplasty is a challenging task for healthcare providers. Concurrently, fast recovery and early ambulation are required to regain function and to prevent postoperative complications. Ideal postoperative analgesia provides sufficient pain relief with minimal opioid consumption and preservation of motor strength. Regional analgesia techniques are broadly used to answer these expectations. Femoral nerve blocks are performed frequently but have suggested disadvantages, such as motor weakness. The use of lumbar epidurals is questioned because of the risk of epidural hematoma. Relatively new techniques, such as local infiltration analgesia or adductor canal blocks, are increasingly discussed. The present review discusses new findings and weight between known benefits and risks of all of these techniques for total knee arthroplasty.

RECENT FINDINGS

Femoral nerve blocks are the gold standard for total knee arthroplasty. The standard use of additional sciatic nerve blocks remains controversial. Lumbar epidurals possess an unfavourable risk/benefit ratio because of increased rate of epidural hematoma in orthopaedic patients and should be reserved for lower limb amputation; peripheral regional techniques provide comparable pain control, greater satisfaction and less risk than epidural analgesia. Although motor weakness might be greater with femoral nerve blocks compared with no regional analgesia, new data point towards a similar risk of falls after total knee arthroplasty with or without peripheral nerve blocks. Local infiltration analgesia and adductor canal blockade are promising recent techniques to gain adequate pain control with a minimum of undesired side-effects.

SUMMARY

Femoral nerve blocks are still the gold standard for an effective analgesia approach in knee arthroplasty and should be supplemented (if needed) by oral opioids. An additional sciatic nerve blockade is still controversial and should be an individual decision. Large-scale studies are needed to reinforce the promising results of newer regional techniques, such as local infiltration analgesia and adductor canal block.

Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review

OBJECTIVE

To systematically review the effect of early mobilization after hip or knee joint replacement surgery on length of stay in an acute hospital.

METHODS

Randomized controlled trials were selected from electronic databases based on inclusion criterion requiring an experimental group mobilizing (sitting out of bed/walking) earlier than a comparison group post joint replacement surgery of the hip or knee in an acute hospital. Clinically homogeneous data were analyzed with meta-analysis.

RESULTS

Five randomized controlled trials (totaling 622 participants) were included for review. A meta-analysis of 5 trials found a reduced length of stay of 1.8 days (95% confidence interval 1.1 to 2.6) in favor of the experimental group. In 4 of the 5 trials the experimental group first sat out of bed within 24 hours post operatively. In 4 of the 5 trials the experimental group first walked within 48 hours post operatively. Individual trials reported benefits in range of motion, muscle strength and health-related quality of life in favor of the experimental group. There were no differences in discharge destinations, incidence of negative outcomes or adverse events attributable to early mobilization when compared to the comparison groups.

CONCLUSION

Early mobilization post hip or knee joint replacement surgery can result in a reduced length of stay of about 1.8 days. Trials that reported these positive results showed that early mobilization can be achieved within 24 hours of operation. This positive gain was achieved without an increase in negative outcomes.

Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review

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.

Systematic review of high-volume multimodal wound infiltration in total knee arthroplasty

Pain relief following total knee arthroplasty (TKA) is challenging because early mobilization and rehabilitation are essential for a successful outcome. Postoperative pain can limit recovery, leading to reduced mobility and prolonged hospitalization. There are potential benefits of infiltrating high volumes of local anesthetics around the soft tissues of replaced hip and knee joints. The risk of systemic toxicity is minimized with diluted local anesthetic solution, which also allows a high volume to be used. One of the principal advantages is that analgesia agents are administered intraoperatively by the surgeon, thereby minimizing the need for additional invasive procedures. The authors conducted a systematic review to evaluate whether high-volume multimodal wound infiltration reduces pain and opiate intake while enhancing early rehabilitation and discharge when used in patients undergoing TKA. Only randomized controlled studies were included. Although better pain relief in the immediate postoperative period with wound infiltration is gained after TKA, there is no definite evidence that this leads to a reduction in opiate consumption, the achievement of early milestones, or a reduction in hospital stay. The roles of individual agents in achieving pain relief and the use of percutaneous wound catheter for postoperative doses are also unclear. There are few reports of complications, including falls and delayed mobilization, when femoral nerve blocks are used. Wound infiltration analgesia should be used at the preference of the surgeon and anesthetist provided regular review of their practice is undertaken to identify any untoward side effects. Further randomized trials with sufficient sample size comparing each outcome, including pain scores, opiate consumption, and length of hospital stay, should be undertaken.

Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial

BACKGROUND

Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.

QUESTIONS/PURPOSES

We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA.

METHODS

Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded.

RESULTS

The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p < 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.

CONCLUSIONS

A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach.

LEVEL OF EVIDENCE

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial

We analyze the effects of a multimodal analgesic regimen on postoperative pain, function, adverse effects and satisfaction compared to patient-controlled analgesia (PCA). Thirty-six patients undergoing TKA were randomized to receive either (1) periarticular injection before wound closure (30cc 0.5% bupivacaine, 10mg MSO4, 15 mg ketorolac) and multimodal analgesics (oxycodone, tramadol, ketorolac; narcotics as needed) or (2) hydromorphone PCA. Preoperative and postoperative data were collected for VAS pain scores, time to physical therapy milestones, hospital stay length, patient satisfaction, narcotic consumption and medication-related adverse effects. The multimodal group had lower VAS scores, fewer adverse effects, lower narcotic usage, higher satisfaction scores and earlier times to physical therapy milestones. Multimodal pain management protocol decreases narcotic usage, improves pain scores, increases satisfaction and enhances early recovery.

Investigation of effects of levobupivacaine injection to rabbit knee joint on histopathologic changes of joint cartilage tissue and changes of serum biochemical parameters

The aim of this study is to evaluate the effects of intra-articular levobupivacaine on rabbit knee articular cartilage and certain biochemical parameters in the blood. A total of 24 New Zealand rabbits were included to study. Blood sampling was carried out in all animals on the first day, then the subjects were randomly allocated either to the control group (Group C, n = 9) or to the levobupivacaine group (Group L, n = 15). Group C underwent each two intra-articular injections of saline, 0.25 mL into the right knee and 0.50 mL into the left one. Group L was injected 0.25 mL (1.25 mg) of levobupivacaine into the right knee and 0.50 mL (2.5 mg) into the left one. The groups were divided randomly into three. Tissue and blood samples for histologic and biochemical examination were collected from Groups C1 and L1 on the first, C2 and L2 on the second, and C3 and L3 on the tenth day of the study. Interleukin-1β (IL-1 β), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and C-reactive protein (CRP) levels were analyzed. No statistically significant differences could be detected when comparing either left or right joints within the same groups and with Group C and L (P > 0.05). Significant elevations of biochemical parameters were found in Group C. It is concluded that levobupivacaine does not lead to significant histologic changes in rabbit articular cartilage. Significant elevations of biochemical parameters being generally found in the C Group, it is thought that such elevations are not linked to levobupivacaine. Intra-articular levobupivacaine may be a safe alternative for use in post-operative analgesia.

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.

Multimodal pain management in orthopedics: implications for joint arthroplasty surgery

Multimodal pain management has become an important part of the perioperative care of patients undergoing total joint replacement. The principle of multimodal therapy is to use interventions that target several different steps of the pain pathway, allowing more effective pain control with fewer side effects. Many different protocols have shown clinical benefit. The goal of this review is to provide a concise overview of the principles and results of multimodal pain management regimens as a practical guide for the management of joint arthroplasty patients.