Simultaneous Bilateral Total Knee Arthroplasty Retrospective Case Control Study: Does Genicular Injection Application Yield a More Effective Pain Control Compared with Periarticular Injection?

Background:The aim of the present study was to investigate the hypothesis that administering the analgesic solution prepared for periarticular injection as a genicular injection to patients undergoing bilateral knee arthroplasty has equivalent effect to periarticuler injection and provides equal or enhanced pain control. Thus, these two different practices were compared.Methods:This was a case control study, during which simultaneous bilateral knee arthroplasty patients were evaluated retrospectively. The analgesic solution prepared for periarticular injection was applied as a genicular injection to one knee of each of 30 patients operated on in the same session, and was applied as standard periarticular injection to the other knee. The study group comprised the patients operated on in the same session who were subject to genicular infiltration anaesthesia and the control group consisted of patients with standard periarticular infiltration anaesthesia administered to the other knee. The study data are summarized via descriptive statistics (mean, standard deviation, etc.). Statistical analyses were performed using SPSS 22.0 software. Wilcoxon’s signed-rank test was used for comparisons. The level of statistical significance was set at p < 0,05.Results:Pain scores were lower during the early postoperative period in the knees of patients who received the genicular injection (p<0.005). There were no statistically significant differences between the groups with regard to drainage volume, complications and range of joint motion.Conclusions:Genicular injection is a reliable and effective procedure for early postoperative pain control.

Local Infiltration Analgesia Versus Femoral Nerve Block for Pain Control in Anterior Cruciate Ligament Reconstruction: A Systematic Review With Meta-analysis

Background: Anterior cruciate ligament reconstruction (ACLR) is often performed on an outpatient basis; thus, effective pain management is essential to improving patient satisfaction and function. Local infiltration analgesia (LIA) and femoral nerve block (FNB) have been commonly used for pain management in ACLR. However, the comparative efficacy and safety between the 2 techniques remains a topic of controversy. Purpose: To compare pain reduction, opioid consumption, and side effects of LIA and FNB after ACLR. Study Design: Systematic review; Level of evidence, 3. Methods: A systematic search of MEDLINE, Embase, and Cochrane Library databases was performed to identify studies comparing pain on the visual analog scale (a 100-mm scale), total morphine-equivalent consumption, and side effects between the 2 techniques after ACLR at the early postoperative period. The LIA was categorized into intra-articular injection and periarticular injection, and subgroup analyses were performed comparing either intra-articular injection or periarticular injection with FNB. Two reviewers performed study selection, risk-of-bias assessment, and data extraction. Results: A total of 10 studies were included in this systematic review and meta-analysis. In terms of VAS pain scores, our pooled analysis indicated that FNB was significantly more effective at 2 hours postoperatively compared with LIA (mean difference, 8.19 [95% confidence interval (CI), 0.75 to 15.63]; P = .03), with no significant difference between the 2 techniques at 4, 8, and 12 hours postoperatively; however, LIA was significantly more effective at 24 hours postoperatively compared with FNB (mean difference, 5.61 [95% CI, −10.43 to −0.79]; P = .02). Moreover, periarticular injection showed a significant improved VAS pain score compared with FNB at 24 hours postoperatively (mean difference, 11.44 [95% CI, −20.08 to −2.80]; P = .009), and the improvement reached the threshold of minimal clinically important difference of 9.9. Total morphine-equivalent consumption showed no difference between the 2 techniques, and side effects were unable to be quantified for the meta-analysis because of a lack of data. Conclusion: Compared with FNB, LIA was not as effective at 2 hours, comparable within 12 hours, and significantly more effective at 24 hours postoperatively for reducing pain after ACLR. Total morphine-equivalent consumption showed no significant differences between the 2 techniques.

Effectiveness of Periarticular Infiltration of the Knee during Total Knee Arthroplasty for Postoperative Pain Management

Background: Different treatment regimens of analgesia, nerve blocks and epidurals are used for pain relief in Total Knee Arthroplasty (TKA). Local infiltration analgesia (LIA) is one of the modalities in which a cocktail combination of different medicines is infiltrated locally into the capsule, surrounding tissues or intraarticular joint space. This study aims to analyze the effectiveness of periarticular injection of combination drugs (Bupivacaine, Ketorolac and Morphine) during TKA for postoperative pain management. Methods: Total of 150 patients who underwent primary unilateral TKA were randomly categorized into 2 groups (75 each). Group A (control group) didn’t receive intraoperative periarticular injection but Group-B received the intraoperative injection of combined local analgesics and anaesthetics (Bupivacaine, Ketorolac and Morphine). Pain following surgery at 0, 1, and 2 postoperative days were recorded with visual analogue scale (VAS) whereas Knee Society Score was used to evaluate the pain and function pre-operative and 3 months’ post-operative. Statistical analysis was done using SPSS software. Results: Patients receiving periarticular infiltration of combination drugs intraoperatively had lower VAS for postoperative pain (p < 0.001) and this group also showed reduced need of analgesia postoperatively. Conclusions: Periarticular infiltration of knee during Total Knee Arthroplasty is effective in management of postoperative pain Keywords: Periarticular; Total Knee Arthroplasty; combination drugs; postoperative pain

Percutaneous periarticular analgesic injection at one day after simultaneous bilateral total knee arthroplasty: an open-label randomized control trial

Background The postoperative pain after total knee arthroplasty (TKA) remains a critical issue. The aim of this study was to assess the clinical effectiveness of percutaneous periarticular injection at 1 day following simultaneous bilateral TKA. Methods A total of 88 knees in 44 patients who underwent simultaneous bilateral TKA were randomly assigned to receive a percutaneous periarticular injection at 1 day following surgery (n = 22 patients) or no injection (n = 22 patients). In the additional injection group, we injected a solution including methylprednisolone, ropivacaine, and epinephrine into the muscle belly of the vastus medialis at 1 day after surgery. In both groups, patients received an intraoperative periarticular multi-drug injection and postoperative intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome measure was the postoperative pain at rest using a visual analog scale (VAS) and analyzed with Student’s t test. Results Compared to the no additional injection group, the additional periarticular injection group had significantly lower VAS score at 8:00 PM postoperative day 1, 6:00 AM postoperative day 2, 12:00 PM postoperative day 2, 6:00 AM postoperative day 5, 12:00 PM postoperative day 5, and 8:00 PM postoperative day 5 (p < 0.05). The rate of complication did not differ between groups (p > 0.05). Conclusion Additional percutaneous periarticular injection at 1 day following TKA adding to intraoperative periarticular injection provided better postoperative pain relief. Trial registration Registered at the University Hospital Medical Information Network (registration number: UMIN000029759).

Discontinuation of the liposomal delivery of bupivacaine has no effect on pain management after primary total knee arthroplasty

Aims Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Methods On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function. Results A total of 888 patients received Protocol 1 and while 789 received Protocol 2. The mean age of the patients was significantly higher in those who did not receive LB (66.80 vs 65.57 years, p = 0.006). The sex, BMI, American Society of Anesthesiologists physical status score, race, smoking status, marital status, operating time, length of stay, and discharge disposition were similar in the two groups. Compared with the LB group, discontinuing LB showed no significant difference in postoperative VRS pain scores up to 72 hours (p > 0.05), opioid administration up to 96 hours (p > 0.05), or AM-PAC scores within the first 24 hours (p > 0.05). Conclusion The control of pain after TKA with a multimodal management protocol is not improved by the addition of LB compared with traditional bupivacaine. Cite this article: Bone Joint J 2021;103-B(6 Supple A):102–107.