Injection In Total Knee Arthroplasty Research Articles

Posteromedial Periarticular Injection in Total Knee Arthroplasty: A Cadaveric Study.

Achieving optimal pain control in total knee arthroplasty has improved with the use of regional anesthesia and periarticular injections (PAIs). When performing a PAI, the relative location of the anesthetic spread is not well defined in comparison with an adductor canal block (ACB). In this study, our aim was to evaluate the location of posteromedial PAI spread compared with a surgeon administered ACB. One PAI and one surgeon-administered ACB were performed in the contralateral limbs of four human cadavers. The injectate was composed of methylene blue dye to visually inspect the dye spread from the tip of the needle. Dissections were performed on each cadaver to quantify the dye spread from the tip of the needle and compare the location of the dye spread. Dye spread location was characterized as either entering the adductor canal or including the posterior capsule. The mean distance of dye spread from the needle tip to the proximal most aspect of the dyed tissue was 10.125 cm in the ACB group compared with 6.5 cm in the posteromedial PAI group. In the ACB group, 4 of 4 injections were present in the adductor canal block group compared with 3 of 4 in the posteromedial PAI group. The posteromedial PAI group also had 3 of 4 injections involve the area around the posterior capsule compared with 0 of 4 in the ACB group. Posteromedial PAI appears to provide local delivery to both the adductor canal and the posterior capsule. Intraoperative, surgeon-administered ACB reliably delivers injectate to the adductor canal only but may allow for more proximal dye spread. Posteromedial PAI may provide a benefit in delivering injectate to the posterior capsule in addition to the ACB. Additional clinical studies are necessary to determine the clinical effects of this finding.

Periarticular Injection in Total Knee Arthroplasty.

Optimal pain management after total knee arthroplasty (TKA) can expedite postoperative recovery, improve perioperative outcomes, and increase patient satisfaction. Periarticular injections (PAIs) have become increasingly used to improve pain management after TKA. Similar to peripheral nerve blocks, the use of intraoperative PAIs can lower pain scores and expedite discharge from the hospital. However, there is notable variability in the ingredients and administration techniques of PAIs. Currently, no standard of care exists for PAIs, especially in the setting of adjuvant peripheral nerve blocks. This study seeks to evaluate the ingredients, administration techniques, and outcomes of PAIs used during TKA.

Methods of hamstring muscle injection of botulinum toxin type A combined with periarticular injection after total knee arthroplasty

This study aimed to report on a method for injecting botulinum toxin type A into the hamstring muscles combined with periarticular injection in total knee arthroplasty (TKA) patients. We enrolled patients who underwent elective unilateral TKA at our hospital from February 2021 to December 2021 and administered botulinum toxin type A hamstring muscle injection combined with periarticular injection. We established and reported a detailed method for this combined approach, which could provide an alternative analgesic regimen after TKA in clinical practice.

Quality indicators in primary elective total hip and knee arthroplasty.

Total hip arthroplasty (THA) and total knee arthroplasty (TKA) represent a significant portion of healthcare spending and are high-priority for quality improvement initiatives. This study aims to develop quality indicators (QIs) in the care of primary elective THA and TKA patients. These QIs serve a number of purposes including documentation of the quality of care, objective comparisons of institutions/providers, facilitating pay-for-performance initiatives, and supporting accountability, regulation, and accreditation. A guideline-based approach, initially described by Kötter et al., was utilized. Eight clinical practice guidelines (CPGs) were evaluated for candidate indicators (CIs). CIs with high-quality evidence and consensus statements were extracted. Eighteen additional CIs were included from previous work that evaluated quality improvement databases. Each CI and supporting evidence was submitted for independent review by an expert panel. The RAND Corporation-University of California, Los Angeles (RAND/UCLA) appropriateness methodology was utilized and items were rated based on validity, reliability, and feasibility of measurement. After two rounds of ratings and ranking, a final ranked list of QIs was obtained. Fifty-six CIs were identified from the literature and CPGs or proposed by the expert panel. Two rounds of voting resulted in 12 total QIs that were deemed appropriate measures of high-quality care. The final 12 QIs were ranked by order of importance: use of peri-operative tranexamic acid, infusion of prophylactic antibiotics prior to inflation of tourniquet, appropriate post-operative venous thromboembolic prophylaxis, complication rate, rate of secondary procedure, readmission rate, early mobilization, average change of pre- to oneyear post-operative functional status, use of multimodal analgesia, use of neuraxial anesthesia, use of peri-articular injection in TKA, and use of pre-operative PO analgesia. This study is an expert opinion based on parameters observed in modern and high-quality academic settings. Twelve QIs are proposed to assess the quality of care in the peri-operative management of primary elective THA and TKA patients.

Comparison Between Periarticular Analgesia Versus Intraarticular Injection for Effectiveness and Safety After Total Knee Arthroplasty

PurposeIn most studies, local infiltration analgesia (LIA) can provide better analgesic effect in the early postoperative period, but the optimal technique is unknown. Our study was designed to evaluated the early clinical efficacy and safety of periarticular analgesia versus intraarticular injection in Total knee arthroplasty (TKA). DesignA prospective study was conducted on 100 patients admitted for TKA. Subjects were divided into two groups: 50 in group A, 50 in Group B. MethodsPatients in group A received periarticular analgesia with ropivacaine 300 mg and morphine 5 mg (the drugs were diluted with saline to 50 ml) in the periosteal borders, posterior capsule and extensor apparatus and subcutaneous tissues during surgery. After stitching of joint capsule, tranexamic acid (TXA) 2 g (20 ml) was injected into the articular cavity. Group B patients had all of the 70 mL mixture (ropivacaine 300 mg, morphine 5 mg and TXA 2 g) injected intraarticularly after stitching of the joint capsule. We assessed postoperative length of stay (LOS), knee functional outcome, pain, and complications after surgery. FindingsThere was no statistical difference in visual analog scale (VAS) scores for knee pain between the two groups on postoperative day (POD)1, 3, or 30 (P > .05). Mean postoperative LOS was 7.40 ± 1.98 days in Group A, compared to 8.02 ± 2.09 days in Group B (P > .05). No significant differences between groups were seen in the mean swelling ratio (P > .05), and no significant differences were found in the Hospital for Special Surgery (HSS) knee score and range of motion (ROM) at 30 days follow-up (P > .05). There was also no statistical difference in the incidence of complications (such as superficial wound infection, deep vein thrombosis (DVT) and nausea and vomiting) between the Group A and the Group B. ConclusionsIn conclusion, it seems that intraarticular injection had a similar analgesic effect compared with periarticular injection when adopting a multi-modal analgesia regimen. Our results suggest that there is no obvious advantage with the use of periarticular injections compared to intraarticular injection. The authors believe that intraarticular injection may be a better technique compared with periarticular injections in the absence of a drainage tube because intraarticular injection can reduce the number of surgical steps and have similar postoperative outcomes.

Multimodal Peri-articular Injection with Tranexamic Acid can reduce postoperative blood loss versus Intravenous Tranexamic Acid in Total Knee Arthroplasty: A Randomized Controlled Trial

BackgroundTranexamic acid (TXA) has shown significant reductions in blood loss and transfusion rates in total knee arthroplasty (TKA). However, the optimal administration route continues to be debated. The aim of this trial was to compare the effectiveness of intravenous (IV) versus peri-articular injection (PAI) application of tranexamic acid in patients undergoing total knee arthroplasty.MethodsWe conducted a randomized controlled, double-blinded study. A total of 93 patients undergoing primary unilateral TKA were randomly distributed between 2 groups: the IV group (47 cases; 1 g TXA IV) and the PAI group (46 cases; 1 g TXA injected peri-articularly). The amount of total and hidden blood loss (HBL), drainage, transfusion rate, hemoglobin and hematocrit drift, and complications were recorded.ResultsPeri-articular injection of TXA reduced total blood loss (P < 0.001) and HBL more than IV use of TXA (P < 0.001). No patients in either group received a transfusion. No symptomatic deep venous thrombosis or other severe complications occurred.ConclusionPeri-articular injection of TXA significantly reduced total blood loss and hidden blood loss to a greater degree than IV injection in total knee arthroplasty without reduction of drainage volume.Trial registrationChinese Clinical Trial Registry, ChiCTR-INR-16010270. Date of registration: December 27, 2016.

Efficacy of additional corticosteroids to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis of randomized controlled trials

BackgroundAs the ultimate method for the treatment of osteoarthritis, total knee arthroplasty (TKA) has been widely used in the clinic. Local injection of multimodal cocktails, including corticosteroids, is commonly used for pain management after TKA. This meta-analysis aims to systematically evaluate the effect of periarticular injection of corticosteroids on postoperative pain relief and knee functional recovery in patients undergoing TKA.MethodsPubMed, Cochrane Library, EMBASE, and Web of Science databases were comprehensively searched for all randomized controlled trials (RCTs) published before July 1, 2020, that investigated the efficacy of corticosteroids for TKA.ResultsTen RCTs involving a total of 829 patients were assessed in the meta-analysis. Compared with the control group, the visual analogue scale (VAS) score at rest of the corticosteroid group decreased significantly at postoperative day 1 (POD1), POD2, and POD3 (p < 0.05). Besides, the range of flexion motion of the knee joint in the corticosteroid group at POD1 and POD2 was significantly increased (p < 0.05); at the same time, the range of extension motion at POD2 and POD3 showed the opposite trend between the two groups (p < 0.05). The morphine equivalent of postoperative analgesia was significantly reduced (p < 0.05), and the time required for straight leg raising (SLR) was significantly shortened (p < 0.05). There was no significant difference between the two groups in terms of postoperative drainage, length of hospital stay, and complications such as infection, nausea, and vomiting (p > 0.05).ConclusionThe additional corticosteroids to multimodal cocktail periarticular injection can relieve the early pain intensity at rest after TKA, increase the early range of motion (ROM) of the knee joint, reduce the dosage of postoperative analgesics, and shorten the duration of time required for SLR. However, it has no effect on reducing postoperative complications and shortening the length of hospital stay.

The feasibility of direct adductor canal block (DACB) as a part of periarticular injection in total knee arthroplasty

BackgroundAdductor canal block (ACB) is one of the preferred methods of analgesia in total knee arthroplasty (TKA). However, conventionally its use is time-consuming, requires ultrasound guidance, a trained anaesthesia team and adherence to strict asepsis by members of the allied teams. This study was done to assess the feasibility and safety of direct adductor canal block (DACB) as a part of surgeon-administered periarticular infiltration.Materials and methodsThirty computed tomography (CT) angiography films of the patients were retrospectively reviewed. The trajectory of the needle placement for a DACB in relation to the target region of the adductor block was determined. Fourteen knees in seven cadavers, were dissected through a medial parapatellar approach to perform TKA. After administering the DACB using the technique based on CT data, dissection was carried out to ascertain the correct placement of the dye by visualising the stained areas.ResultsThe angle of approach in the coronal plane from the entry point to the medial high point and to the adductor hiatus was 10.2° (8−14°) and 6° (3.8−11°), respectively. The angle of approach in the sagittal plane from the entry point to the medial high point and to the adductor hiatus was 7° (5−10.5°) and 29° (19−43°), respectively. In all the 14 cadaveric knees, we confirmed the correct placement of the methylene blue dye as demonstrated by the staining of the adductor canal.ConclusionThe study demonstrates the feasibility of the DACB. This surgeon-driven technique is likely to reduce the cost of the procedure, reduce operating room time and also eliminate the risks of surgical-site contamination.

Combination Effect of High-Dose Preoperative and Periarticular Steroid Injection in Total Knee Arthroplasty. A Randomized Controlled Study

BackgroundPostoperative pain remains a major barrier to a patient’s recovery after total knee arthroplasty (TKA). Periarticular corticosteroids in local infiltration analgesics (LIA) and high-dose intravenous corticosteroids have individually shown to improve pain control after TKA. However, potential interactions between them have not been investigated.This study aims to evaluate any combination effect of both routes of corticosteroids in TKA. MethodsThis is a double-blinded, paired, randomized controlled trial involving 1-stage bilateral TKAs. All received 16 mg of dexamethasone intravenously. One knee was randomized to receive LIA with 40 mg of triamcinolone, while the other knee receives LIA without corticosteroids.For each patient, one knee was affected by intravenous steroids only, while the other was under the combined effect of intravenous and periarticular steroids (IVPAS).Knee pain, Southampton wound scores, and functional knee scores (Knee Society Knee Score and Oxford Knee Scores) were compared between knees of the same patient. ResultsForty-six patients (92 TKAs) were included. IVPAS knees showed significantly lower visual analog scale scores from day 1 to 6 weeks (P < .05) and a larger range of movement from day 2 to 4 (P < .05). IVPAS knees achieved active straight leg raise earlier than intravenous steroids (1.6 vs 2.3 days, P < .05).No differences in Southampton wound scores and functional knee scores for up to 1 year. ConclusionCombining intravenous and periarticular corticosteroids improved pain control and recovery after TKA with no increase in wound complications up to 1 year.

Comparison of the postoperative analgesic effect for infiltration between the popliteal artery and the capsule of the posterior knee and that of periarticular multimodal drug injection in total knee arthroplasty: retrospective study in the immediate postoperative period

BackgroundThe aim of this study is to compare the postoperative analgesic effect of infiltration between the popliteal artery and the capsule of the knee (IPACK) and the effect of periarticular multimodal drug injection (PMDI) in addition to adductor canal block (ACB) after total knee arthroplasty.MethodsAmong patients who received total knee arthroplasty from June 2017 to December 2017, 50 who underwent ACB with additional IPACK and 50 who received ACB with additional PMDI were selected for this study. We compared the postoperative pain numerical rating scale (NRS), the number of times patient-controlled analgesia was administered and the amount administered, the total amount of opioids given, and complications associated with the procedure between the two groups.ResultsNRS measured at rest and 45° knee flexion at days 1 and 2 after surgery was significantly lower in the IPACK group than in the PMDI group. The resting NRS measured at day 3 after surgery was also significantly lower in the IPACK group than in the PMDI group, and the NRS at 45° knee flexion measured from day 3 to day 5 showed a significant reduction in the IPACK group. No complications relating to the procedure occurred.ConclusionsIPACK may be a better option than PMDI for controlling acute phase pain in patients undergoing total knee arthroplasty.

Intra-operative periarticular multimodal injection in total knee arthroplasty: a local hospital experience in Hong Kong.

Data from a local report revealed the superior outcome of regional anaesthesia and analgesia compared with general anaesthesia and intravenous patient-controlled analgesia in total knee arthroplasty. This retrospective study aimed to assess the efficacy of intra-operative periarticular multimodal injection in improving postoperative pain and reducing morphine consumption with patient-controlled analgesia after total knee arthroplasty in patients with knee osteoarthritis. From July 2005 to May 2009, 213 total knee arthroplasties without intra-operative periarticular multimodal injection (control group) were performed at a local hospital. From June 2009 to December 2012, 185 total knee arthroplasties were performed with intra-operative periarticular multimodal injection (cocktail group). The inclusion criteria were osteoarthritis of the knee, single method of anaesthesia (general or neuraxial), simple total knee arthroplasty without any metal augmentation or constraint, and postoperative patient-controlled analgesia. Postoperative patient-controlled morphine doses were compared. A total of 152 total knee arthroplasties were recruited to the cocktail group, and 89 to the control group. Duration of tourniquet application and preoperative knee score did not significantly correlate with morphine consumption by patient-controlled analgesia. Multimodal injection significantly decreased such consumption for 36 h. When injection was separately analysed for general and neuraxial anaesthesia, the effect lasted for 42 h and 24 h, respectively. Intra-operative periarticular multimodal injection decreased morphine consumption for up to 42 h postoperatively.

Intra-articular Application is More Effective Than Intravenous Application of Tranexamic Acid in Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

BackgroundThe optimal administration route of tranexamic acid (TXA) in total knee arthroplasty (TKA), and the effect of TXA on hidden blood loss and total blood loss are undetermined. The purpose of this study was to compare the effectiveness of intravenous versus intra-articular application of tranexamic acid in patients undergoing knee arthroplasty. MethodsA total of 150 patients undergoing primary unilateral total knee arthroplasty were randomly distributed to 3 groups (IV, intra-articular, and control group; each 50 patients) and administrated TXA (1 g IV and 50 mL intra-articular saline, 1 g intra-articularly and 50 mL intra-articular saline, and 0 g and 50 mL intra-articular saline, respectively). The amount of total and hidden blood loss (HBL), drainage, transfusion, changes in hemoglobin levels, and complications were recorded. ResultsIntra-articular use of TXA reduced more total blood loss (P = .011) and reduced more total 48 hours drainage volume than IV use of TXA (P < .001). Two patients received transfusion in IV and control group. No deep venous thrombosis or other severe complications had occurred. The HBL volume had no significant difference among the control, IV, and intra-articular groups (708.6 ± 308.2, 651.7 ± 302.9, and 625.2 ± 252.1 mL, respectively; which was 65.6%, 70.8%, and 81.1% of the total loss). ConclusionIntra-articular administration of TXA significantly reduced total blood loss and drainage volume to a greater degree than IV injection in total knee arthroplasty without reduction of HBL.

Preemptive Femoral Nerve Block Could Reduce the Rebound Pain After Periarticular Injection in Total Knee Arthroplasty

BackgroundWe evaluated the effectiveness of postoperative pain management using intraoperative periarticular injection (PAI) and/or electromyography-guided preoperative femoral nerve block (FNB) in knees undergoing total knee arthroplasty (TKA). MethodsThis study included 90 patients (90 knees) who underwent primary TKA. Thirty patients received a single injection of electromyography-guided FNB, 30 received intraoperative PAI, and 30 received both. Pain at rest and while moving was evaluated by a visual analog scale (VAS) at 0, 4, 8, 24, and 48 hours. Postoperative range of motion, time to walking, amount of opioid consumption, and complications were analyzed. ResultsVAS immediately after surgery was significantly higher in the FNB group than in the PAI and combined groups, but did not differ significantly in the latter 2 groups. VAS after 4 and 8 hours showed similar results. VAS after 24 hours was significantly higher in the PAI than in the FNB and combined groups. After 48 hours, there were no differences among the 3 groups. Total opioid consumption was lower in the combined than in the FNB and PAI groups. Postoperative range of motion and time to walking were similar in the 3 groups. ConclusionPAI was more effective than FNB during the early (0-8 hours) postoperative period after TKA. Patients treated with PAI, however, experienced rebound pain at 24 hours. The combination of PAI and FNB may provide greater postoperative pain management than either alone for the first 24 hours after TKA.

Efficacy of steroid addition to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis.

BackgroundTotal knee arthroplasty (TKA) has been reported to be the most successful treatment for patients with advanced osteoarthritis, however, early postoperative pain has become an unresolved issue. The aim of this Meta-analysis is to evaluate the efficacy and safety of steroid addition to multimodal cocktail periarticular injection (MCPI) in patients undergoing TKA.MethodClinical randomized controlled trials concerning the efficacy and safety of MCPI containing steroids in TKA published up to December 2014 were retrieved from PubMed, Cochrane library, EMbase databases. The methodological quality of the included studies was assessed by the 12-item scale. Data analysis was performed using StataSE12.0.ResultsSix randomized controlled trials involving a total of 567 patients were assessed; the steroid group included 305 patients, and the control group included 262 patients. The meta-analysis showed that MCPI with steroids in TKA significantly reduced postoperative pain; duration of time required to perform straight-leg raising and length of hospital stay was (P < 0.05). Neither the early postoperative nor the long-term range of motion of knee showed any statistical difference between the non-steroid and steroid group (P >0.05). For safety, steroids did not increase the incidence of postoperative infection and wound oozing (P >0.05); no tendon rupture was reported up to now. In addition, steroids did not decrease the postoperative drainage through the reduction of prostaglandins (P >0.05).ConclusionFor patients undergoing TKA, the addition of steroids to MCPI improved the analgesic effect and was proved to be highly safe. The duration of time required to perform straight-leg raising and length of hospital stay was significantly reduced. However, MCPI with steroids neither increased the early postoperative range of motion (ROM) or the long-term ROM of knee, nor did it reduce the postoperative drainage. However, the best results are acquired in patients without any altered immunological status.

Relationship between muscle strength and knee pain in knee osteoarthritis patients

s / Osteoarthritis and Cartilage 22 (2014) S57–S489 S415 747 RELATIONSHIP BETWEEN MUSCLE STRENGTH AND KNEE PAIN IN KNEE OSTEOARTHRITIS PATIENTS R. Fujita y, Y. Matsui y, A. Harada y, M. Takemura y, I. Kondo z, T. Nemoto x, S. Ota k. yDept. of Orthopaedic Surgery, Natl. Ctr. for Geriatrics and Gerontology, Obu, Japan; zDept. of Rehabilitation Med., Natl. Ctr. for Geriatrics and Gerontology, Obu, Japan; xDept. of Gerontechnology, Natl. Ctr. for Geriatrics and Gerontology, Obu, Japan; k Seijoh Univ., Tokai, Japan Purpose: Knee osteoarthritis is a motor disorder that leads to decreased QOL and physical function in old age, and is one cause of the need for nursing care. The prevention of knee osteoarthritis and amelioration of its symptoms are an urgent issue today with rapidly increasing elderly populations. The importance of knee muscle strength training in conservative treatment is well known, and it effects have been verified. To elucidate the relationship between muscle strength and pain symptoms, we investigated the relationship between muscle strength, measured with a knee extension and flexion strength measurement instrument we are currently developing, and knee pain in activities of daily living. Methods: The subjects were 92 women (mean age 73.8 8.6 years) with knee osteoarthritis who were being treated in the orthopedics department of our center, comprising 160 knees (right 75, left 85) that had not been treated surgically. Standing frontal X-ray images of the knee were evaluated and knee pain during activities of daily living (level ground walking, stair climbing, lying down, standing up, and sitting on floor with legs folded underneath the body) was surveyed with a questionnaire. Knee extension and flexion strength was measured using a prototype measuring instrument developed jointly with the Department of Gerontechnology at our center. The knee extension and flexion measuring instrument can be transported on a cart, and uses an Imada Co., Ltd. force gauge for measuring the precision of industrial products. With subjects in a sitting position with legs flexed 90 and a strap on the ankle joint, knee extension and flexion strength were measured isometrically for 3 seconds. Knee flexion strength and extension strength were measured two times each in the left and right legs and the better value for each side was utilized. Knee extension and flexion strength were expressed as the proportion to body weight, and the difference of the two, (extension strength/weight) minus (flexion strength/weight), was also calculated. The correlation between those indices and the knee pain score during activities of daily living was investigated. Results: In the right knee, significant correlations were seen between knee extension strength/weight and the scores for knee pain during level ground walking, stair climbing, and sitting on the floor with legs underneath the body (walking, stair climbing p < 0.01, sitting on the floor with legs underneath p < 0.05). In the left knee, significant correlations were seen between knee extension strength/weight and knee pain scores during level ground walking, stair climbing, standing up, and sitting on the floor with legs underneath the body (walking, standing up, sitting on the floor with legs underneath p < 0.01, stair climbing p < 0.05). Knee flexion strength/weight was found to be significantly correlated with knee pain during level ground walking in the right knee (p < 0.05). The correlation with the knee pain score and the difference between extension strength/weight and flexion strength/ weight were significant in all activities in the right knee (walking, stair climbing p < 0.01, others p < 0.05), while in the left knee these values were significant during walking, standing up, and sitting on the floor with legs underneath (standing up p< 0.01, walking, sitting on the floor with legs underneath p<0.05). Conclusions: In knee osteoarthritis patients, knee pain during activities of daily living increases with decreases in knee extension strength in both left and right legs. Differences were seen between right and left in the activities in which a relation between muscle strength and knee pain appeared. Investigations that consider leg strength in proportion to weight or include flexion strength are considered to be useful. 748 EFFICACY OF PERIARTICULAR MULTIMODAL DRUG INJECTION IN TOTAL KNEE ARTHROPLASTY FOR PAIN MANAGEMENT AND REHABILITATION A. Osawa y, K. Yoshida y, H. Kanazawa y, Y. Maruyama y, K. Kaneko z. y Juntendo Univ. Urayasu Hosp., Urayasu, Japan; z Juntendo Univ., Tokyo,

Efficacy of periarticular multimodal drug injection in total knee arthroplasty for pain management and rehabilitation

Efficacy of periarticular multimodal drug injection in total knee arthroplasty for pain management and rehabilitation

Periarticular multimodal drug injection in total knee arthroplasty

A systematic review and meta-analysis based on randomized controlled trials (RCTs) were conducted to evaluate the efficiency and safety of periarticular multimodal drug injection in total knee arthroplasty (TKA). Periarticular injection with the use of multimodal drugs is an efficient alternative for postoperative analgesia in TKA. A systematical electronic search was performed to identify the eligible RCTs in the databases of PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science and the Chinese Biomedical Literature Database. Two independent reviewers completed data collection and assessment of methodological quality. The quality of evidence of outcomes was judged using GRADE criteria. Meta-analysis was performed for the outcomes of pain, straight leg raise, operating time, hospital stay and complications. Ten RCTs including eight studies with 1,216 TKAs in 835 patients met the inclusion criteria. Periarticular injection with multimodal drugs in TKA was associated with short-term benefits in terms of pain relief, straight leg raise, narcotic consumption, and the rates of nausea, vomiting, rash and pruritus. There were no statistically significant differences in operating time, hospital stay, wound complications and deep vein thrombosis between both groups. The current evidence suggests that periarticular multimodal drug injection in TKA provides short-term advantages in pain relief, straight leg raise and postoperative complications.

Efficacy of Multimodal Perioperative Analgesia Protocol With Periarticular Medication Injection in Total Knee Arthroplasty

Pain control is necessary for successful rehabilitation and outcome after total knee arthroplasty. Our goal was to compare the clinical efficacy of periarticular injections consisting of a long-acting local anesthetic (ropivacaine) and epinephrine with and without combinations of an α2-adrenergic agonist (clonidine) and/or a nonsteroidal anti-inflammatory agent (ketorolac). In a double-blinded controlled study, we randomized 160 patients undergoing total knee arthroplasty to receive 1 of 4 intraoperative periarticular injections: Group A, ropivacaine, epinephrine, ketorolac, and clonidine; Group B, ropivacaine, epinephrine, and ketorolac; Group C, ropivacaine, epinephrine, and clonidine; Group D (control), ropivacaine and epinephrine. Compared with Group D, Group A and B patients had significantly lower postoperative visual analog pain scores and nurse pain assessment and Group C patients had a significantly greater reduction in physical therapist pain assessment. We found no differences in other parameters analyzed.

Peri-articular Steroid Injection in Total Knee Arthroplasty: A Prospective, Double Blinded, Randomized Controlled Trial

Total knee arthroplasty is a painful operation. Peri-articular local anesthetic injections reduce post-operative pain and assist recovery. It is inconclusive whether intra-operative injections of peri-articular corticosteroids are of benefit. Therefore our clinical question was: in patients with osteoarthritis who are undergoing TKA, does the addition of high or low dose corticosteroid to peri-articular injections of local anesthetic and adrenaline improve post-operative pain and range of motion? We performed a prospective, double-blinded, randomized controlled trial of two different doses of triamcinolone acetate (N = 42 in each group) added to local anesthetic in TKA for osteoarthritis. There were no significant differences in pain scores or ROM between the control and corticosteroid groups. Differences in secondary outcomes were also non-significant. Peri-articular corticosteroids do not appear to be of benefit in TKA.

Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty — A randomized controlled trial

In a randomized, double-blind, placebo, parallel and controlled study, 80 patients with osteoarthritis who underwent unilateral TKA were randomly assigned to two groups: Trial Group, where patients received intra-articular intraoperative injection containing morphine, bupivacaine and betamethasone, and Control Group, where patients received normal saline as control. All patients received patient-controlled analgesia (PCA) for 48 h postoperatively. We found that intra-articular cocktail analgesic injection significantly reduced the morphine consumption during the 0–36 h postoperative period and the total morphine consumption. VAS at rest in Trial Group at postoperative 6, 10, 24 and 36 h was significantly lower than that in Control Group, and VAS during activity in Trial Group at postoperative 24 h and 36 h was significantly lower than that in Control Group. The time of ability to perform an active straight leg raise and to actively reach 90° knee flexion, as well as ROM of the knee at the 15th postoperative day, was better in Trial Group than those in Control Group. There were no significant differences in postoperative wound healing, infection, blood pressure, heart rate, rash, respiratory depression, urine retention and DVT between the two groups. The occurrence of nausea and vomiting in Trial Group was lower than that of Control Group. This study revealed that intra-articular cocktail analgesic injection reduced the need for morphine and offered a better pain control, without apparent risks following TKA.