Analgesia In Total Knee Arthroplasty Research Articles

A randomized, double-blind, dose-ranging study comparing wound infiltration of DepoFoam bupivacaine, an extended-release liposomal bupivacaine, to bupivacaine HCl for postsurgical analgesia in total knee arthroplasty

IntroductionDepoFoam bupivacaine is a novel liposomal formulation of bupivacaine designed to provide prolonged postsurgical analgesia. This dose-ranging study evaluated extent and duration of analgesia following administration of DepoFoam bupivacaine in patients undergoing total knee arthroplasty (TKA). MethodsEfficacy, safety, and pharmacokinetics of DepoFoam bupivacaine doses of 133, 266, 399, or 532mg were compared with bupivacaine HCl (150mg) with epinephrine given as single injections via wound infiltration in TKA patients (N=138). Primary efficacy measure was AUC of pain intensity scores assessed by numeric rating scale with activity (NRS-A) through Day 4 postsurgery. Other assessments included pain intensity at rest (NRS-R), postsurgical opioid consumption, and safety, among others. ResultsMean AUC of NRS-A scores through Day 4 were 20.7, 19.5, 18.8, and 19.1 for the 133-mg, 266-mg, 399-mg, and 532-mg DepoFoam bupivacaine groups vs 20.4 for bupivacaine HCl. With DepoFoam bupivacaine 532-mg, differences in NRS-R scores reached statistical significance (P<0.05) vs bupivacaine HCl on Days 1 and 5 and mean AUC NRS-R scores were significantly lower through Days 2–5; a dose–response trend was demonstrated. Mean rating for blinded care provider's satisfaction with analgesia was significantly higher for DepoFoam bupivacaine 532mg vs bupivacaine HCl (P≤0.05). Other efficacy measures showed no statistically significant differences. ConclusionExposure to bupivacaine increased in a dose-related manner, as reflected by mean and maximum plasma bupivacaine concentrations, and AUC0−∞. Treatment with DepoFoam bupivacaine 532mg was associated with statistically significantly greater analgesia while patients were at rest after surgery compared with bupivacaine HCl.

Complications of Femoral Nerve Blockade in Total Knee Arthroplasty and Strategies to Reduce Patient Risk

Femoral nerve catheters are widely used for analgesia in total knee arthroplasty. Although evidence suggests that catheters improve pain control and may facilitate short-term rehabilitation, few reports exist regarding their complications. This case series explores the experience of femoral nerve catheter use at high-volume orthopedic specialty hospitals. Serious complications including compartment syndrome, periprosthetic fracture, and vascular injury are reported. The authors support femoral nerve catheter use with appropriate precautions taken to reduce risk of patient falls, vascular injury, and wrong-site surgery.

A randomized, controlled trial comparing local infiltration analgesia with epidural infusion for total knee arthroplasty

Background There have been few studies describing wound infiltration with additional intraarticular administration of multimodal analgesia for total knee arthroplasty (TKA). In this study, we assessed the efficacy of wound infiltration combined with intraarticular regional analgesia with epidural infusion on analgesic requirements and postoperative pain after TKA.Methods 40 consecutive patients undergoing elective, primary TKA were randomized into 2 groups to receive either (1) intraoperative wound infiltration with 150 mL ropivacaine (2 mg/mL), 1 mL ketorolac (30 mg/mL), and 0.5 mL epinephrine (1 mg/mL) (total volume 152 mL) combined with intraarticular infusion (4 mL/h) of 190 mL ropivacaine (2 mg/mL) plus 2 mL ketorolac (30 mg/mL) (group A), or (2) epidural infusion (4 mL/h) of 192 mL ropivacaine (2 mg/mL) combined with 6 intravenous administrations of 0.5 mL ketorolac (30 mg/mL) for 48 h postoperatively (group E). For rescue analgesia, intravenous patient-controlled-analgesia (PCA) morphine was used.Morphine consumption, intensity of knee pain (0–100 mm visual analog scale), and side effects were recorded. Length of stay and corrected length of stay were also recorded (the day-patients fulfilled discharge criteria).Results The median cumulated morphine consumption, pain scores at rest, and pain scores during mobilization were reduced in group A compared to group E. Corrected length of stay was reduced by 25% in group A compared to group E.Interpretation Peri- and intraarticular analgesia with multimodal drugs provided superior pain relief and reduced morphine consumption compared with continuous epidural infusion with ropivacaine combined with intravenous ketorolac after TKA.

Removal of a knotted stimulating femoral nerve catheter using a saline bolus injection

Stimulating peripheral nerve catheters have become increasingly popular as part of postoperative multimodal analgesia for total knee arthroplasty. We describe a case of a successful nonsurgical removal of a knotted stimulating femoral nerve catheter after saline expansion of the catheter pocket at the bedside. A 65-year-old female underwent total knee arthroplasty under combined spinal epidural anesthesia. Postoperatively, a stimulating femoral nerve catheter was placed without complication. The catheter was threaded 12 cm past the needle tip with minimal resistance. Function of the catheter was verified by loss of pinprick sensation in the femoral nerve distribution and excellent analgesic efficacy was achieved. The first attempt at catheter removal was unsuccessful. Thigh flexion and rotation also failed to facilitate catheter removal. The catheter was then left to continuous tension for 6 hours, but further attempts at removal remained unsuccessful. Under ultrasound visualization, 10 mL of saline was injected through the catheter with moderate resistance and without patient discomfort, after which the catheter was removed using minimal tension. The catheter was intact but had a single knot at the distal end of the catheter. We present a rare case of a knotted stimulating catheter in which the use of a saline bolus to dilate the catheter pocket proved to be successful after other simple methods of catheter removal had failed. Given the simple nature of this technique, it can be attempted at the bedside before more invasive procedures are planned.

Target driven analgesia for total knee arthroplasty

Target driven analgesia for total knee arthroplasty

High‐volume infiltration analgesia in total knee arthroplasty: a randomized, double‐blind, placebo‐controlled trial

High-volume infiltration analgesia may be effective with a low risk of side effects in hip and knee arthroplasty. The present placebo-controlled study was carried out to evaluate the analgesic effect of high-volume infiltration analgesia in bilateral total knee arthroplasty, along with a detailed description of the infiltration technique. In a randomized, double-blind, placebo-controlled trial in 12 patients undergoing bilateral knee arthroplasty, saline or high-volume (170 ml) ropivacaine (0.2%) with epinephrine was infiltrated around each knee, with repeated doses administered through an intra-articular catheter for 24 h and pain and opioid requirements assessed for 48 h in a fast-track setting. Pain at rest and during movement was significantly reduced for up to 32 h with the high-volume local anesthetic infiltration technique. No major side effects were observed. The median hospital stay was 4 days. High-volume infiltration analgesia is effective in knee arthroplasty and, due to its simplicity, may be preferable compared with other analgesic techniques in knee arthroplasty.

Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study

Summary Effective pain management is essential for early recovery and rehabilitation after total hip and knee arthroplasty. Current methods include a multimodal regimen of oral analgesics combined with either continuous epidural analgesia or continuous peripheral nerve blockade both of which have risk of side effects and demand expertise. A simple and effective local infiltration technique with local anaesthetic, epinephrine and NSAID has been developed by D. Kerr and L. Kohan in Sydney, but with variable results reported from others. Since there is no detailed description of the technique we herein present the method in detail as developed by the inventors.

A compression bandage improves local infiltration analgesia in total knee arthroplasty

Background High-volume local infiltration analgesia has been shown to be an effective pain treatment after knee replacement, but the role of bandaging to prolong analgesia has not been evaluated.Methods 48 patients undergoing fast-track total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive a compression or a non-compression bandage, and pain was assessed at rest and with mobilization at regular intervals for 24 h postoperatively.Results Pain at rest, during flexion, or on straight leg lift was lower for the first 8 h in patients with compression bandage than in those with non-compression bandage and with a similar low use of oxycodone. Mean hospital stay was similar (2.8 days and 3.3 days, respectively).Interpretation A compression bandage is recommended to improve analgesia after high-volume local infiltration analgesia in total knee arthroplasty.

Controle da dor pós-operatória da artroplastia total do joelho: é necessário associar o bloqueio do nervo isquiático ao bloqueio do nervo femoral?

BACKGROUND AND OBJECTIVES: Total knee arthroplasty (TKA) causes severe tissue trauma, leading to severe postoperative pain. Good postoperative analgesia is fundamental and one should consider that early mobilization of the joint is an important aspect to obtain good results. There is a controversy in the literature on the efficacy of isolated femoral nerve block. The objective of this study was to evaluate postoperative analgesia with the association of sciatic and femoral nerve block. METHODS: Seventeen patients undergoing TKA under spinal anesthesia were divided in two groups: A and B. In Group A (n = 9), femoral nerve block was performed, while in Group B (n = 8), femoral and sciatic nerve block were done. The blockades were done in the immediate postoperative period with 20 mL of 0.5% of ropivacaine. Pain was evaluated in the first 24 hours using the Visual Analog Scale and the verbal scale. The length of time between the nerve block and the first complaint of pain (M1) was also evaluated. RESULTS: The median of the duration of analgesia (M1) in Group A was 110 min, while in Group B it was 1285 min (p = 0.0001). There were no complications related to the technique used. CONCLUSIONS: Sciatic nerve block, when associated with femoral nerve block, under the conditions of the present study, improved significantly the quality of postoperative analgesia in TKA.

274: Local infiltration analgesia in total knee arthroplasty: a randomised, double-blind and placebo controlled trial

274: Local infiltration analgesia in total knee arthroplasty: a randomised, double-blind and placebo controlled trial

Local infiltration analgesia in total knee arthroplasty: a randomised, double-blind and placebo controlled trial

Local infiltration analgesia in total knee arthroplasty: a randomised, double-blind and placebo controlled trial

Analgesia for total knee arthroplasty: femoral and sciatic blocks: 170.

Analgesia for total knee arthroplasty: femoral and sciatic blocks: 170.

A Randomized, Blinded Clinical Trial Assessing Efficacy of Periarticular Injection Using Multimodal Analgesia in Total Knee Arthroplasty

A Randomized, Blinded Clinical Trial Assessing Efficacy of Periarticular Injection Using Multimodal Analgesia in Total Knee Arthroplasty

The Efficacy of Femoral Nerve Blockade in Conjunction With Epidural Analgesia for Total Knee Arthroplasty

Zawadsky, M. W.; Cahill, J.; Boettner, F.; Morelli, C. M.; Kahn, R. L.; Deau, J. T. Ya; Sharrock, N. E.; Sculco, T. P. Author Information

Intrathecal Clonidine Added to a Bupivacaine-Morphine Spinal Improves Postoperative Analgesia for Total Knee Arthroplasty

Intrathecal Clonidine Added to a Bupivacaine-Morphine Spinal Improves Postoperative Analgesia for Total Knee Arthroplasty

Evaluation of Combined Spinal-Epidural Anesthesia Using Two Different Techniques

Background and Objectives. This investigation was designed to evaluate combined spinalepidural anesthesia with a needle-through-needle technique using two different needle sets. One kit has a standard 16-gauge Tuohy needle and a 26-gauge spinal needle that extends 13 mm beyond the tip of the Tuohy needle (set A). The other kit consists of a 16-gauge Tuohy needle with an aperture in its curve (back hole) for the insertion of a 26-gauge spinal needle that protrudes 10 mm beyond the tip of the epidural needle (set B). Methods. Combined spinal-epidural anesthesia was used in 40 consecutive consenting patients scheduled for elective total knee arthroplasty who were randomized into two groups. Needle set A was used in group A, and needle set B was used in group B. Special attention was paid to difficulties in performing the blocks and to any complications of the technique. Results. The length of the spinal needle was inadequate in 15% of patients from group B, whereas the length in group A was adequate in all. The aperture on the back of the Tuohy needle from group B provides a better “feel” of dural puncture. There was no difficulty in the insertion of the epidural catheter. There was no evidence of subarachnoid placement of the epidural catheter in either group. None of the patients had unexpectedly extensive spinal block. No patient developed postdural puncture headache. All patients had adequate surgical anesthesia. Infusion of bupivacaine (0.1%) with fentanyl (2 μg/mL) provided adequate postoperative analgesia. No respiratory depression was noted. Conclusions. Combined spinal-epidural provides satisfactory surgical and postoperative analgesia for total knee arthroplasty. An improved needle set for the needle-through-needle technique would be one with a modified Tuohy needle having an aperture at the back and a spinal needle protruding more than 13 mm beyond the Tuohy needle.