Comparison of Periarticular Infiltration and Combination Delivery of Local Anesthetics for Reducing Pain and Opioid Consumption after Total Knee Arthroplasty

2020 ◽  
Author(s):  
Derek T. Ward ◽  
Eva Grotkopp ◽  
Robert C. Detch ◽  
Hubert T. Kim ◽  
Alfred C. Kuo
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Local Anesthetic ◽  
Combination Treatment ◽  
Local Anesthetics ◽  
Opioid Consumption ◽  
Duration Of Action ◽  
Pain Scores ◽  
Total Knee ◽  
Periarticular Infiltration

AbstractSurgical-site delivery of local anesthetics decreases pain and opioid consumption after total knee arthroplasty (TKA). The optimal route of administration is unknown. We compared local anesthetic delivery using periarticular soft-tissue infiltration to delivery using a combination of preimplantation immersion and intra-articular injection (combination treatment). The records of patients who underwent unilateral, cemented, primary TKA with spinal anesthesia and adductor canal blocks at a single Veterans Affairs Medical Center were retrospectively reviewed. Three subgroups were compared, including controls who did not receive additional local anesthetics, patients who received periarticular infiltration, and patients who received combination treatment. Mean daily pain scores and mean 24-hour opioid consumption on postoperative days (PODs) 0 and 1 were calculated, and analysis of variance was used to assess for significant differences. Factors that were associated with lower pain scores and opioid consumption were then identified using multivariate stepwise regression. There were 26 controls, 25 periarticular infiltration patients, and 39 combination patients. The periarticular infiltration cohort had significantly lower mean pain scores and opioid consumption than controls on POD 0, but not on POD 1. The combination cohort had significantly lower mean pain scores and opioid consumption than controls on PODs 0 and 1. There were no significant differences between the infiltration and combination groups on either day. Multivariate regression analysis showed that infiltration was associated with significantly decreased opioid consumption on both days and decreased pain on POD 0. Combination treatment was associated with significantly decreased pain and opioid consumption on both days. Both local anesthetic periarticular infiltration and combination treatment are associated with decreased pain and opioid consumption after TKA. The stronger effects of the combination treatment compared with periarticular infiltration on POD 1 suggests that combination delivery may have a longer duration of action.

Pain Management Modalities after Total Knee Arthroplasty

2017 ◽  
Vol 126 (5) ◽  
pp. 923-937 ◽  
Author(s):  
Abdullah Sulieman Terkawi ◽  
Dimitris Mavridis ◽  
Daniel I. Sessler ◽  
Megan S. Nunemaker ◽  
Khaled S. Doais ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Epidural Analgesia ◽  
Range Of Motion ◽  
Nerve Block ◽  
Knee Arthroplasty ◽  
Opioid Consumption ◽  
Lumbar Plexus ◽  
Pain Scores ◽  
Total Knee ◽  
Periarticular Infiltration

Abstract Background Optimal analgesia for total knee arthroplasty remains challenging. Many modalities have been used, including peripheral nerve block, periarticular infiltration, and epidural analgesia. However, the relative efficacy of various modalities remains unknown. The authors aimed to quantify and rank order the efficacy of available analgesic modalities for various clinically important outcomes. Methods The authors searched multiple databases, each from inception until July 15, 2016. The authors used random-effects network meta-analysis. For measurements repeated over time, such as pain, the authors considered all time points to enhance reliability of the overall effect estimate. Outcomes considered included pain scores, opioid consumption, rehabilitation profile, quality of recovery, and complications. The authors defined the optimal modality as the one that best balanced pain scores, opioid consumption, and range of motion in the initial 72 postoperative hours. Results The authors identified 170 trials (12,530 patients) assessing 17 treatment modalities. Overall inconsistency and heterogeneity were acceptable. Based on the surface under the cumulative ranking curve, the best five for pain at rest were femoral/obturator, femoral/sciatic/obturator, lumbar plexus/sciatic, femoral/sciatic, and fascia iliaca compartment blocks. For reducing opioid consumption, the best five were femoral/sciatic/obturator, femoral/obturator, lumbar plexus/sciatic, lumbar plexus, and femoral/sciatic blocks. The best modality for range of motion was femoral/sciatic blocks. Femoral/sciatic and femoral/obturator blocks best met our criteria for optimal performance. Considering only high-quality studies, femoral/sciatic seemed best. Conclusions Blocking multiple nerves was preferable to blocking any single nerve, periarticular infiltration, or epidural analgesia. The combination of femoral and sciatic nerve block appears to be the overall best approach. Rehabilitation parameters remain markedly understudied.

Continuous Bupivacaine Infusion versus Liposomal Bupivacaine in Adductor Canal Block for Total Knee Arthroplasty

2021 ◽  
Author(s):  
Chang-Hwa Mary Chen ◽  
Andrew G. Yun ◽  
Teresa Fan
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Local Anesthetic ◽  
Recovery Room ◽  
Analysis Of Covariance ◽  
Opioid Use ◽  
Liposomal Bupivacaine ◽  
Adductor Canal ◽  
Pain Scores ◽  
Total Knee

AbstractMultimodal pain management for total knee arthroplasty (TKA) is essential to enhance functional recovery. Regional anesthesia became a vital component to decrease pain after TKA. Several studies compared femoral versus adductor canal blocks, including evaluating medications that can prolong adductor canal blocks. Liposomal bupivacaine (LB) and continuous local infusion (OnQ) both extend local anesthetic delivery beyond 24 hours. This superiority study compared the use of OnQ versus LB in adductor canal blocks. A retrospective study was conducted between two cohorts of consecutive patients who received adductor canal blocks with either LB or a continuous ropivacaine infusion catheter. Morphine equivalent dose (MED), pain scores, and length of stay (LOS) were compared between the two groups by using the analysis of covariance test. There were 106 patients in the OnQ group and 146 in the LB group. The OnQ group consumed significantly fewer opioids compared with the LB group in the recovery room (5.7 MED vs. 11.7 MED, p = 0.002) and over the entire hospitalization (the recovery room plus on the floor; 33.3 MED vs. 42.8 MED, p = 0.009). Opioid use between the OnQ and LB group did not reach statistical significance (p = 0.21). The average pain scores at rest and with activity were similar in both groups (p = 0.894, p = 0.882). The LOS between the OnQ and LB groups was not statistically significant (1.2 vs. 1.3, p = 0.462). OnQ and LB were equally effective in decreasing opioid consumption on the floor over the averaged 1.3 days of hospitalization; however, the OnQ group significantly reduced opioid use in the recovery room. There was no difference in pain scores or LOS between the two groups. OnQ comparatively prolonged infusion of local anesthetic is a potential edge over LB. This advantage may offset the inconvenience of catheter management and infrequent catheter complications.

The Use of Navigation or Robotic-Assisted Technology in Total Knee Arthroplasty Does Not Reduce Postoperative Pain

2021 ◽  
Author(s):  
Stephen Gerard Zak ◽  
David Yeroushalmi ◽  
Alex Tang ◽  
Morteza Meftah ◽  
Erik Schnaser ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Postoperative Pain ◽  
Knee Arthroplasty ◽  
Opioid Consumption ◽  
Perioperative Outcomes ◽  
Computer Assisted ◽  
Surgical Time ◽  
Pain Scores ◽  
Pain Outcomes ◽  
Total Knee

AbstractThe use of intraoperative technology (IT), such as computer-assisted navigation (CAN) and robot-assisted surgery (RA), in total knee arthroplasty (TKA) is increasingly popular due to its ability to enhance surgical precision and reduce radiographic outliers. There is disputing evidence as to whether IT leads to better clinical outcomes and reduced postoperative pain. The purpose of this study was to determine if use of CAN or RA in TKA improves pain outcomes. This is a retrospective review of a multicenter randomized control trial of 327 primary TKAs. Demographics, surgical time, IT use (CAN/RA), length of stay (LOS), and opioid consumption (in morphine milligram equivalents) were collected. Analysis was done by comparing IT (n = 110) to a conventional TKA cohort (n = 217). When accounting for demographic differences and the use of a tourniquet, the IT cohort had shorter surgical time (88.77 ± 18.57 vs. 98.12 ± 22.53 minutes; p = 0.005). While postoperative day 1 pain scores were similar (p = 0.316), the IT cohort has less opioid consumption at 2 weeks (p = 0.006) and 1 month (p = 0.005) postoperatively, but not at 3 months (p = 0.058). When comparing different types of IT, CAN, and RA, we found that they had similar surgical times (p = 0.610) and pain scores (p = 0.813). Both cohorts had similar opioid consumption at 2 weeks (p = 0.092), 1 month (p = 0.058), and 3 months (p = 0.064) postoperatively. The use of IT in TKA does not yield a clinically significant reduction in pain outcomes. There was also no difference in pain or perioperative outcomes between CAN and RA technology used in TKA.

Effect of Liposomal Bupivacaine on Postoperative Opioid Requirements for Total Hip Arthroplasty, Total Knee Arthroplasty, Laminectomy, Hysterectomy, and Abdominoplasty Procedures

2019 ◽  
pp. 001857871986764
Author(s):  
J. Lacie Bradford ◽  
Beatrice Turner ◽  
Megan A. Van Berkel
Keyword(s):  
Total Knee Arthroplasty ◽  
Total Hip Arthroplasty ◽  
Adverse Events ◽  
Knee Arthroplasty ◽  
Pain Control ◽  
Opioid Consumption ◽  
Control Group ◽  
Liposomal Bupivacaine ◽  
Pain Scores ◽  
Total Knee

Purpose: Opioid use postoperatively has been linked to adverse events and an increase in opioid dependency. This retrospective study evaluated the effect of using liposomal bupivacaine (LB) for postoperative pain control on total opioid consumption, pain control, serious opioid-related adverse events (ORAEs), and hospital length of stay (LOS) in total knee arthroplasty (TKA), total hip arthroplasty (THA), laminectomy, hysterectomy, and abdominoplasty procedures when compared with a control group. Methods: Patients receiving LB from August 1, 2017, to February 1, 2018, for the aforementioned procedures were included for evaluation, and patients undergoing similar procedures who did not receive LB served as the control group. The principal outcome was opioid consumption through postoperative day 5 or discharge, whichever came first, assessed by morphine milligram equivalents (MMEs). Secondary outcomes included pain scores within 72 hours postoperation, hospital LOS, and serious ORAEs. Results: A total of 323 patients were identified for inclusion in the study: TKA, n = 144; THA, n = 48; laminectomy, n = 73; hysterectomy, n = 30; and abdominoplasty, n = 28. Liposomal bupivacaine use was associated with reduced postoperative opioid consumption compared with alternative therapies with a median 71 MME (25%-75%; interquartile range [IQR] = 32.5-148.5) versus 102 MME (25%-75%; IQR = 57-165), P < .005. However, higher numeric pain scores were reported in the LB group compared with the control group for postoperative day 0 with a median of 5.5 (25%-75%; IQR = 4.5-7.4) versus 5.5 (25%-75%; IQR = 4-7) in the control group ( P < .001) and on postoperative day 1 with a median of 6 (25%-75%; IQR = 4.5-7) versus 5.5 (25%-75%; IQR = 4.3-7), P < .001. There was no difference in hospital LOS or ORAEs. Conclusion: In this retrospective analysis of pain management after TKA, THA, laminectomy, hysterectomy, and abdominoplasty procedures, patients receiving LB consumed significantly less opioid medications. However, this was not associated with clinically meaningful improvements in pain scores, hospital LOS, or serious ORAEs.

Liposomal Bupivacaine Infiltration Versus Bupivacaine Hydrochloride for the Management of Unilateral Total Knee Arthroplasty in Geriatric Patients at a 287-Bed Community Hospital

2020 ◽  
pp. 001857872096542
Author(s):  
Abdus-Samad Syed Minhaj ◽  
Ashley Marie Skipper ◽  
Mckenna Murphy
Keyword(s):  
Total Knee Arthroplasty ◽  
Hospital Stay ◽  
Knee Arthroplasty ◽  
Geriatric Patients ◽  
Opioid Consumption ◽  
Liposomal Bupivacaine ◽  
Lengths Of Stay ◽  
Pain Scores ◽  
Significant Difference ◽  
Total Knee

Introduction: Geriatric patients receiving total knee arthroplasty (TKA) are found to have similar postoperative complications, functional scores, and perioperative mortality, as compared to younger patients. Conversely, geriatric patients often have longer lengths of stay. Periarticular injection (PAI) of liposomal bupivacaine (LB) as part of the multimodal pain management strategy is thought to improve recovery, however, mixed comparative efficacy data exists for its use in TKA.2-5. Methods: A retrospective, chart review was conducted at a 287-bed community teaching hospital. Orthopedic surgical patients who received an infiltration with liposomal bupivacaine versus bupivacaine HCl for unilateral TKA were compared. Patients identified in the electronic medical record by Diagnosis Related Group (DRG) 470—major joint replacement or reattachment of lower extremity without major complication or comorbidity codes were utilized. Patients who meet the following criteria were included: age 65 and older who underwent a TKA between 8/1/2018 to 7/31/2019 were discharged to home. Patients who have contraindications or hypersensitivity to bupivacaine formulations or a history of opioid dependence were excluded. The primary outcome is to identify whether patients who received an infiltration with liposomal bupivacaine had a lower total opioid consumption during their hospital stay. Results: A total of 114 patients who had a DRG 470 code and were above the age of 65 years were studied. There was no statistically significant difference in mean total opioid consumption (oral morphine equivalents) between the bupivacaine HCl (n = 25) and liposomal groups (n = 85) respectively, 93.76 versus 83.72 mg; P = .569. In addition, patients in both groups had similar lengths of hospital stay, 2.5 versus 3 days; P = .529 and mean pain scores until discharge 3.7 versus 4.34 on VAS; P = .305. Conclusion: The results of this drug utilization evaluation do not support a strong clinical advantage with local infiltration of liposomal bupivacaine over bupivacaine HCl in geriatric patients undergoing primary TKA surgery at this institution. There was not a statistically significant difference in mean total opioid consumption between the 2 groups. Additionally, the use of non-opioid analgesics, mean pain scores, and hospital lengths of stay were similar in both groups.

scholarly journals Pain Control after Total Knee Arthroplasty: Comparing Intra-Articular Local Anesthetic Injection with Femoral Nerve Block

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
Author(s):  
Shengchin Kao ◽  
Hungchen Lee ◽  
Chihwen Cheng ◽  
Chingfeng Lin ◽  
Hsini Tsai
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Local Anesthetic ◽  
Local Anesthetics ◽  
Pain Control ◽  
Analgesic Efficacy ◽  
Time Interval ◽  
Single Shot ◽  
Total Knee ◽  
High Doses

Background. Direct intra-articular injection of low doses of local anesthetic (IALA) after closure of the joint capsule remains controversial for pain control after total knee arthroplasty (TKA).Methods. A retrospective study comparing patients receiving IALA with high doses (0.5% bupivacaine 60 mL) of local anesthetics or FNB in addition to intravenous patient-controlled analgesia with opioids for pain management after TKA was conducted. The primary end point was to compare the analgesic efficacy and early ambulation between the two groups.Results. No significant differences between the two groups in pain intensity, cumulative opioid consumption, incidences of opioid-related side effects, the time interval from the end of operation to the first time the patient could walk assisted with a walker postoperatively, and postoperative hospital stay were identified. Three patients in the IALA group but none in the FNB group walked within 12 hours after the end of operation.Summary. IALA with high doses of local anesthetics provides comparable analgesic efficacy as single-shot FNB after TKA and might be associated with earlier ambulation than FNB postoperatively.

Continuous Infusion Ketorolac for Postoperative Analgesia Following Unilateral Total Knee Arthroplasty

2017 ◽  
Vol 51 (6) ◽  
pp. 451-456 ◽  
Author(s):  
Amy J. Schwinghammer ◽  
Alex N. Isaacs ◽  
Rodney W. Benner ◽  
Heather Freeman ◽  
Jacob A. O’Sullivan ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Adverse Effects ◽  
Continuous Infusion ◽  
Knee Arthroplasty ◽  
Opioid Consumption ◽  
Pain Scores ◽  
Conflicting Objectives ◽  
Patient Reported ◽  
Total Knee ◽  
Median Pain

Background: Previous clinical trials have demonstrated benefit with the addition of continuous infusion (CI) ketorolac to a multimodal pain regimen in surgical patients. Data following major orthopedic surgery are minimal and conflicting. Objectives: To evaluate CI ketorolac use following unilateral total knee arthroplasty (TKA) through assessment of patient-reported pain scores, opioid consumption, and safety outcomes. Methods: This was a retrospective, open-label cohort study that included patients undergoing unilateral TKA at a single-center teaching hospital. Participants were categorized into 2 study groups based on postoperative management: CI ketorolac or opioid protocol (OP). The first group received a ketorolac 30-mg bolus followed by CI 3.6 mg/h plus as-needed (PRN) opioids. The OP group received PRN narcotics in a tiered protocol. The primary end point was comparison of median pain scores. Secondary end points included opioid consumption (morphine equivalent units [MEUs]) in the first 48 hours postoperatively, length of stay, and adverse effects. Results: Of 447 patients screened, 191 were analyzed (CI ketorolac, n = 116; OP, n = 75). Median pain scores were significantly lower in the CI ketorolac group at 48 hours postoperatively (3 [2-4] vs 3.5 [2.5-5], P = 0.033). Cumulative MEUs at 48 hours were significantly lower in the CI ketorolac group (33.9 ± 38.5 mg vs 301.6 ± 36.6 mg, P < 0.001). Patients in the CI ketorolac group experienced less respiratory depression (5.2% vs 25.3%, P < 0.001) and less naloxone administration (0% vs 8%, P = 0.002) compared with the OP group. Other adverse effects were similar among groups. Conclusions: Postoperative CI ketorolac improved pain control while reducing opioid consumption and adverse effects.

scholarly journals Comparison of two low dose local anesthetics in combination with morphine for spinal anesthesia for total knee arthroplasty

2020 ◽  
Vol 24 (4) ◽  
Author(s):  
Handan Gulec ◽  
Handan Gulec ◽  
Esra Ozayar ◽  
Asli Alkan ◽  
Merve Kacan ◽  
...  
Keyword(s):  
Total Knee Arthroplasty ◽  
Side Effects ◽  
Spinal Anesthesia ◽  
Knee Arthroplasty ◽  
Local Anesthetic ◽  
Local Anesthetics ◽  
Low Dose ◽  
Total Knee ◽  
High Doses

There is a lack of consensus on the combination doses of local anesthetics and opioids for spinal anesthesia in patients undergoing total knee arthroplasty (TKA) surgery. Opioids and local anesthetic combinations are associated with many postoperative side effects at high doses. We aimed to assess the use of the lowest possible doses of intrathecal bupivacaine and morphine for TKA.

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