Abstract
PurposeThis study was performed to determine whether periarticular injection performed in the early stage of total knee arthroplasty (TKA) could provide a better postoperative pain relief than periarticular injection performed in the late stage of TKA. The hypothesis was based on the concept that analgesic intervention before the onset of noxious stimuli would be associated with less postoperative pain.MethodsA total of 105 participants were randomly assigned to receive superficial injection just prior to arthrotomy (early stage periarticular injection group) or superficial injection after implanting the prosthesis (late-stage periarticular injection group) in patients undergoing unilateral TKA with 1:1 treatment allocation. In both groups, deep injection was performed according to the same schedule (just prior to implanting prosthesis). The solution consisted of 300 mg of ropivacaine, 8 mg of morphine, 40 mg of methylprednisolone, 50 mg of ketoprofen, and 0.3 mg of epinephrine mixed with normal saline to a final volume of 60 mL. All surgeries were managed under general anesthesia without any regional blocks. Registry-specified primary outcome was postoperative pain score at rest measured at the recovery room using a 100-mm visual analog scale (VAS). The VAS score was compared between two groups and assessed to reach the reported threshold values for the minimal clinically important difference (MCID) of 10 mm for the postoperative VAS score.ResultsThe VAS score at the recovery room was significantly lower in the early stage periarticular injection group than the late-stage periarticular injection group (23 ± 25 mm versus 39 ± 34 mm, respectively; 95% confidence interval 4–28 mm; p = 0.0078). The mean difference in the primary outcome fulfilled the MCID value.ConclusionsBringing forward the timing of periarticular injection may provide significant and clinically meaningful improvement in pain following TKA under general anesthesia.Level of evidenceI.
Highlights
Multimodal pain management has become standard practice to resolve severe pain after total knee arthroplasty (TKA) [12]
In TKA managed with spinal anesthesia, both injections have been performed in the late stage of surgery; deep injection has been performed just before implantation and superficial injection just after implantation [2, 16, 24, 25]
One patient in the early stage periarticular injection group was excluded from the analysis of primary outcome because of missing data regarding pain visual analog scale (VAS) score at the recovery room due to postoperative delirium
Summary
Multimodal pain management has become standard practice to resolve severe pain after total knee arthroplasty (TKA) [12]. Periarticular injection for TKA consists of superficial injection and deep injection [25]. Multi-drug solution is injected into the extensor mechanism, pes anserinus, and anteromedial capsule as superficial injection, and into the posterior capsule, posteromedial structures, and periarticular synovium as deep injection. In TKA managed with spinal anesthesia, both injections have been performed in the late stage of surgery; deep injection has been performed just before implantation and superficial injection just after implantation [2, 16, 24, 25]. In the setting of general anesthesia without any regional blocks, there has been a paucity of studies investigating the optimal timing of periarticular injection during TKA. To achieve pre-emptive analgesia, earlier analgesic intervention using periarticular injection may be associated with a better pain relief than the conventional technique of periarticular injection
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