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European Journal of Orthopaedic Surgery & Traumatology

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01-05-2018 | Original Article • KNEE - ARTHROPLASTY

Periarticular multimodal drug injection is better than single anesthetic drug in controlling pain after total knee arthroplasty

Authors: Nattapol Tammachote, Supakit Kanitnate, Sudsayam Manuwong, Phonthakorn Panichkul

Published in: European Journal of Orthopaedic Surgery & Traumatology | Issue 4/2018

Abstract

Background

Postoperative pain is one of the issues that concern most patients after total knee arthroplasty (TKA). Periarticular multimodal drug injection and single anesthetic agent injection have been shown to effectively reduce postoperative pain. The purpose of this study was to compare the efficacy between multimodal drug injection and single anesthetic drug injection in controlling pain after TKA using a double-blinded randomized controlled trial.

Methods

Sixty-four osteoarthritic patients who underwent primary TKA were randomized into two groups. The multimodal drug injection group (group M) received levobupivacaine 150 mg, ketorolac 30 mg and morphine 5 mg, while the single anesthetic drug injection group (group S) received only levobupivacaine 150 mg. The primary outcomes were pain level (VAS), quantity of opioid consumption (mg) and time to request the first dose of analgesic drug (min).

Results

Multimodal drug injection provided lower pain level in the first 4 h after surgery (VAS rest: 30 vs 46, p = 0.02; VAS motion: 45 vs 66, p = 0.03). They consumed less morphine mostly in the first 8 h after surgery (5 vs 12 mg, p < 0.0001) and had approximately 2 h longer time to request the first dose of analgesic drug (254 vs 148 min, p = 0.02).

Conclusions

Multimodal drug injection decreases pain level, reduces morphine consumption in the early postoperative period and prolongs the analgesic effect compared to single anesthetic drug. One may consider using single anesthetic agent only in patients who have high risk of opioid or NSAIDs side effect.

Park KK, Shin KS, Chang CB, Kim SJ, Kim TK (2007) Functional disabilities and issues of concern in female Asian patients before TKA. Clin Orthop Relat Res 461:143–152PubMed

Lavernia CJ, Alcerro JC, Rossi MD (2010) Fear in arthroplasty surgery: the role of race. Clin Orthop Relat Res 468(2):547–554. https://doi.org/10.1007/s11999-009-1101-6 CrossRefPubMed

Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW (2006) Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Jt Surg Am 88(5):959–963. https://doi.org/10.2106/jbjs.e.00344 CrossRef

Chaumeron A, Audy D, Drolet P, Lavigne M, Vendittoli PA (2013) Periarticular injection in knee arthroplasty improves quadriceps function. Clin Orthop Relat Res 471(7):2284–2295. https://doi.org/10.1007/s11999-013-2928-4 CrossRefPubMedPubMedCentral

Jiang J, Teng Y, Fan Z, Khan MS, Cui Z, Xia Y (2013) The efficacy of periarticular multimodal drug injection for postoperative pain management in total knee or hip arthroplasty. J Arthroplast 28(10):1882–1887. https://doi.org/10.1016/j.arth.2013.06.031 CrossRef

Kerr DR, Kohan L (2008) Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 79(2):174–183. https://doi.org/10.1080/17453670710014950 CrossRefPubMed

Mullaji A, Kanna R, Shetty GM, Chavda V, Singh DP (2010) Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty: a prospective, randomized trial. J Arthroplast 25(6):851–857. https://doi.org/10.1016/j.arth.2009.09.007 CrossRef

Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, Varin F (2006) A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Jt Surg Am. 88(2):282–289. https://doi.org/10.2106/jbjs.e.00173 CrossRef

Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS (2007) Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplast 22(6 Suppl 2):33–38. https://doi.org/10.1016/j.arth.2007.03.034 CrossRef

10.

Fu P, Wu Y, Wu H, Li X, Qian Q, Zhu Y (2009) Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty—a randomized controlled trial. The Knee 16(4):280–284. https://doi.org/10.1016/j.knee.2008.12.012 CrossRefPubMed

11.

Krenzel BA, Cook C, Martin GN, Vail TP, Attarian DE, Bolognesi MP (2009) Posterior capsular injections of ropivacaine during total knee arthroplasty: a randomized, double-blind, placebo-controlled study. J Arthroplast 24(6 Suppl):138–143. https://doi.org/10.1016/j.arth.2009.03.014 CrossRef

12.

Yuenyongviwat V, Pornrattanamaneewong C, Chinachoti T, Chareancholvanich K (2012) Periarticular injection with bupivacaine for postoperative pain control in total knee replacement: a prospective randomized double-blind controlled trial. Adv Orthop 2012:107309. https://doi.org/10.1155/2012/107309 CrossRefPubMedPubMedCentral

13.

Kuptniratsaikul V, Rattanachaiyanont M (2007) Validation of a modified Thai version of the Western Ontario and McMaster (WOMAC) osteoarthritis index for knee osteoarthritis. Clin Rheumatol 26(10):1641–1645. https://doi.org/10.1007/s10067-007-0560-y CrossRefPubMed

14.

Kelly AM (2001) The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J EMJ 18(3):205–207CrossRefPubMed

15.

Kelley TC, Adams MJ, Mulliken BD, Dalury DF (2013) Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: a randomized, double-blinded study. J Arthroplast 28(8):1274–1277. https://doi.org/10.1016/j.arth.2013.03.008 CrossRef

16.

Koh IJ, Kang YG, Chang CB, Do SH, Seong SC, Kim TK (2012) Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA? a randomised, controlled study. The Knee 19(4):253–259. https://doi.org/10.1016/j.knee.2011.03.007 CrossRefPubMed

17.

Niemelainen M, Kalliovalkama J, Aho AJ, Moilanen T, Eskelinen A (2014) Single periarticular local infiltration analgesia reduces opiate consumption until 48 hours after total knee arthroplasty. A randomized placebo-controlled trial involving 56 patients. Acta Orthop 85(6):614–619. https://doi.org/10.3109/17453674.2014.961399 CrossRefPubMedPubMedCentral

18.

Andersen KV, Nikolajsen L, Haraldsted V, Odgaard A, Soballe K (2013) Local infiltration analgesia for total knee arthroplasty: should ketorolac be added? Br J Anaesth 111(2):242–248. https://doi.org/10.1093/bja/aet030 CrossRefPubMed

19.

Andersen LO, Otte KS, Husted H, Gaarn-Larsen L, Kristensen B, Kehlet H (2011) High-volume infiltration analgesia in bilateral hip arthroplasty. A randomized, double-blind placebo-controlled trial. Acta Orthop 82(4):423–426. https://doi.org/10.3109/17453674.2011.596063 CrossRefPubMedPubMedCentral

20.

Tammachote N, Kanitnate S, Manuwong S, Yakumpor T, Panichkul P (2013) Is pain after TKA better with periarticular injection or intrathecal morphine? Clin Orthop Relat Res 471(6):1992–1999. https://doi.org/10.1007/s11999-013-2826-9 CrossRefPubMedPubMedCentral

21.

Murphy TP, Byrne DP, Curtin P, Baker JF, Mulhall KJ (2012) Can a periarticular levobupivacaine injection reduce postoperative opiate consumption during primary hip arthroplasty? Clin Orthop Relat Res 470(4):1151–1157. https://doi.org/10.1007/s11999-011-2108-3 CrossRefPubMed

22.

Gristwood RW, Greaves JL (1999) Levobupivacaine: a new safer long acting local anaesthetic agent. Expert Opin Investig Drugs 8(6):861–876. https://doi.org/10.1517/13543784.8.6.861 CrossRefPubMed

23.

Stewart J, Kellett N, Castro D (2003) The central nervous system and cardiovascular effects of levobupivacaine and ropivacaine in healthy volunteers. Anesth Analg 97(2):412–416CrossRefPubMed

24.

Romsing J, Moiniche S, Ostergaard D, Dahl JB (2000) Local infiltration with NSAIDs for postoperative analgesia: evidence for a peripheral analgesic action. Acta Anaesthesiol Scand 44(6):672–683CrossRefPubMed

25.

Affas F, Eksborg S, Wretenberg P, Olofsson C, Stephanson N, Stiller CO (2014) Plasma concentration of ketorolac after local infiltration analgesia in hip arthroplasty. Acta Anaesthesiol Scand 58(9):1140–1145. https://doi.org/10.1111/aas.12371 CrossRefPubMed

26.

Stein C (1995) The control of pain in peripheral tissue by opioids. N Engl J Med 332(25):1685–1690. https://doi.org/10.1056/nejm199506223322506 CrossRefPubMed

27.

Mousa SA, Straub RH, Schafer M, Stein C (2007) Beta-endorphin, Met-enkephalin and corresponding opioid receptors within synovium of patients with joint trauma, osteoarthritis and rheumatoid arthritis. Ann Rheum Dis 66(7):871–879. https://doi.org/10.1136/ard.2006.067066 CrossRefPubMedPubMedCentral

28.

Kim TW, Park SJ, Lim SH, Seong SC, Lee S, Lee MC (2015) Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? prospective, randomized, double-blind study. Knee Surg Sports Traumatol Arthrosc 23(3):838–845. https://doi.org/10.1007/s00167-014-3366-x CrossRefPubMed

Title: Periarticular multimodal drug injection is better than single anesthetic drug in controlling pain after total knee arthroplasty
Authors: Nattapol Tammachote
Supakit Kanitnate
Sudsayam Manuwong
Phonthakorn Panichkul
Publication date: 01-05-2018
Publisher: Springer Paris
Published in: European Journal of Orthopaedic Surgery & Traumatology / Issue 4/2018
Print ISSN: 1633-8065
Electronic ISSN: 1432-1068
DOI: https://doi.org/10.1007/s00590-017-2110-x

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Periarticular multimodal drug injection is better than single anesthetic drug in controlling pain after total knee arthroplasty

Abstract

Background

Methods

Results

Conclusions

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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