Intraoperatively local infiltration anesthesia in hemiarthroplasty patients reduces the needs of opioids: a randomized, double-blind, placebo-controlled trial with 96 patients in a fast-track hip fracture setting

Background and purpose — Local infiltration analgesia (LIA) is commonly used as a component in multimodal analgesia. Pain management directed towards hip fracture patients operated on with hemiarthroplasty is often based on knowledge regarding pain treatment following elective surgery. In this elderly patient population, it is of value to clarify whether adding local infiltration analgesia (LIA) to the postoperative analgesic regimen might reduce postoperative pain or have an opioid-reducing effect. Patients and methods — 96 hip fracture patients undergoing hemiarthroplasty in spinal anesthesia were included. All patients received a multimodal pain regimen and were randomized to receive either ropivacaine or placebo. All patients received morphine depot-opioid and morphine as rescue medication postoperatively. The primary endpoint was pain during mobilization in the recovery unit on the day of surgery. Secondary endpoints were pain during mobilization the day after surgery and postoperative opioid requirements on the first postoperative day. Results — The levels of pain (NRS) during mobilization both in the recovery unit and on the day after surgery were similar in the 2 groups, with median 4 and 0.5 in the placebo group and median 3.5 and 1 in the ropivacaine group respectively. Total consumption of opioids on day 0 and day 1 were 4.6 mg lower in the ropivacaine group (p = 0.04). Pain during mobilization was registered for only 44 of 96 patients for several reasons, including lack of mobilization. Interpretation — There were similar pain scores in both the local infiltration and placebo group postoperatively. However, substantially reduced opioid consumption was found in patients receiving LIA.

Fast Track Arthroplasty Using Local Infiltration Analgesia

Fast track arthroplasty is a holistic approach to patients who undergo total hip and knee arthroplasty, a journey or care that begins with setting patient’s expectation, optimising medical status, using intraoperative local anaesthetic infiltra-tion, decreasing narcotics usage either in spinal or post-operative medication, discouraging usage of patient controlled analgesia or urinary catheters, encouraging day of operation mobilisation and optimising post-operative physiotherapy protocols. The use of local infiltration analgesia (LIA) is a good alternative compared to other traditional pain management techniques. The purpose of adoption of LIA technique is to provide comfort from the trauma associated with hip and knee arthroplasty particularly for the first 36 h post-operatively, during the time of high post-operative pain, to facilitate increased post-operative mobilisation and function. LIA is safe and effective to achieve good outcomes, early mobilisation and decreasing length of stay without jeopardising clinical outcomes. This chapter discusses LIA and its multimodal approach to analgesia, regional anaesthesia and early mobilisation that improves overall patient experience and satisfaction. The chapter discusses LIA techniques, wound catheter placement, and postoperative protocol to achieve fast track hip and knee arthroplasty.

Additional nerve blocks are not superior to multiple-site infiltration analgesia in total knee arthroplasty under adductor canal block

Background Adductor canal block (ACB) with additional nerve blocks (ANBs) is reported to provide adequate analgesia and enhanced functional rehabilitation in total knee arthroplasty (TKA). The present study aims to evaluate whether ANBs are superior to multiple-site infiltration analgesia (MIA) in patients undergoing TKA under ACB. Methods We enrolled 530 patients undergoing primary TKA from 2015 to 2019 at our institution in this retrospective cohort study. Patients were divided into two groups: Group A was treated with ANBs + ACB; Group B was treated with MIA + ACB. Primary outcomes were pain scores and morphine consumption. Functional recovery was the secondary outcome. Other outcomes included satisfaction score, cost-effectiveness, adverse events, and length of hospital stay (LOS). Results Pain scores at rest and morphine consumption were slightly lower in the ANBs + ACB group than in the MIA + ACB group. No significant difference was found in functional recovery, post-operative complications or LOS between the groups. Meanwhile, the cost of analgesic intervention in the MIA + ACB group was less than that in the ANBs + ACB group. Conclusion The present study suggests that ANBs do not provide superior pain relief compared to MIA for patients undergoing TKA under ACB. Trial registration Chinese Clinical Trial Registry, ChiCTR2100043227. Registered 9 February 2021, https://www.chictr.org.cn/showproj.aspx?proj=121745.

Local infiltration analgesia with bupivacaine and adrenaline does not reduce perioperative blood loss in total hip arthroplasty

This study evaluates the effect of local infiltration analgesia with bupivacaine and adrenaline on perioperative blood loss in total hip arthroplasty. Patients who had primary total hip arthroplasty were retrospectively assigned to two groups. One group had 100 ml of bupivacaine/adrenaline solution injected into periarticular soft tissues at the end of the procedure. There were 55 patients in the infiltrated hip group and 44 patients in the not infiltrated group. Patients’ hemoglobin level (Hb), hematocrit (HTC), red blood count (RBC), platelet count (PLT) and International Normalized Ratio (INR) as well as the need for blood transfusions were compared statistically between groups preoperatively and postoperatively. There were no significant differences between Hb, HTC or RBC levels as well as the rate and amount of blood transfusions on the 1st, 4th postoperative days or at patients’ discharge between infiltrated and not infiltrated groups. This study does not support the hypothesis that the use of local infiltration analgesia with adrenaline may reduce perioperative blood loss in total hip arthroplasty.