Intra-articular Injection Of Local Anaesthetic Research Articles

Tek Doz İntraartiküler Lokal Anestezik ile İnterskalen Brakiyal Pleksus Bloğunun Postoperatif Ağrı Üzerine Etkisi

Aim: Postoperative pain management is important because shoulder surgery causes severe pain. In this present study our aim was to analyse the comparison of the influences of ultrasonography-guided interscalene block and perioperative intra-articular local anesthetic injection on postoperative pain in cases who will undergo arthroscopic shoulder procedure.
 Material and Method: It was planned as a prospective randomized controlled trial. After the confirmation of the local ethical committee, our cases were randomly divided into two groups and one group (Group ISBPB) was administered general anesthesia after ultrasonography guided interscalene block. In the other group (Group LA), surgical procedure was carried out under general anesthesia and a single dose of intra-articular local anesthetic was administered peroperatively. Postoperative analgesia requirement, time, VAS scores, patient and surgeon satisfaction were registered.
 Results: We could not obtain a statistically significance between group LA and group ISBPB groups according to gender, side, comorbidity, additional procedure and age variables in the participants included in the study (p>0.05). A numerically significance was observed between Group LA and Group ISBPB groups in terms of first analgesia requirement and patient satisfaction variables in the participants included in the study (p

Paper 89: Ultrasound-guided Glenohumeral Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder: The Role of Clinical Stage in Response to Treatment

Objectives:The treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. The pathophysiology of adhesive capsulitis supports the rationale for intra-articular glenohumeral joint corticosteroid injection to treat the synovial inflammation in stages 1 and 2, that results in capsular fibrosis in the later stages of adhesive capsulitis. We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with stage 1 or stage 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness.Methods:This is a retrospective analysis of a cohort of patients with stage 1 or stage 2 idiopathic adhesive capsulitis, diagnosed using history and physical examination. A total of 61 patients met inclusion criteria. Range of motion (ROM) measurements documented in the patient charts were recorded in four planes: forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre-injection and at all subsequent post-injection visits by a single treating physician. All patients were treated with an ultrasound-guided intra-articular injection of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation to within 15 degrees of the contralateral side and internal rotation to within three spinous process levels of the contralateral side.Results:A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the study cohort. The mean age was 55 years (SD=8, range: 38 to 72) and 49 (80%) patients were female. Within the stage 1 cohort, all 11 patients met recovery criteria for forward flexion (100%), 10 patients met recovery criteria for abduction (91%), 11 patients met recovery criteria for internal rotation (100%), and 8 patients met recovery criteria for external rotation (73%). Within the stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 patients met recovery criteria for abduction (60%), 36 patients met recovery criteria for internal rotation (72%), and 24 patients met recovery criteria for external rotation (48%). Time to recovery in days for each ROM compared between the stage 1 and stage 2 cohorts was statistically significant in all ROM planes (forward flexion (p<0.0001), abduction (p<0.0001), internal rotation (p=0.0008), and external rotation (p=0.0096)), indicating a greater proportion of stage 1 patients had a shorter time to recovery after injection. Figures 1-4 depict cumulative survival functions between Stage 1 and Stage 2 patients for each individual ROM measurement.Conclusions:USGI for early adhesive capsulitis allows patients to recover ROM more rapidly. Importantly, Stage 1 patients recovered faster than Stage 2 patients in all ROM planes, with only forward flexion reaching statistical significance. This suggests that prompt recognition of early idiopathic adhesive capsulitis and subsequent USGI with corticosteroid and local anesthetic plays an important role in timely recovery of motion and symptom resolution thus shortening the natural history of this disease and preventing the development of significant fibrosis.Figure 1.Cumulative survival functions between Stage 1 and Stage 2 patients for Forward FlexionFigure 2.Cumulative survival functions between Stage 1 and Stage 2 patients for AbductionFigure 3.Cumulative survival functions between Stage 1 and Stage 2 patients for Internal RotationFigure 4.Cumulative survival functions between Stage 1 and Stage 2 patients for External Rotation

Does the Use of an Intra-Articular Local Anesthetic Injection During Total Hip Arthroplasty Reduce Patient Reported Pain Scores or Patient Opioid Consumption?

During primary total hip arthroplasty (THA), some surgeons use an intra-articular injection (IAI) containing 200 mg ropivacaine to target postoperative pain. There is no clear consensus on the efficacy of an IAI alone. The purpose of this study is to evaluate the effect of a 200 mg ropivacaine IAI on pain scores, opioid consumption, and mobility for primary THA patients. We retrospectively reviewed 571 patients who underwent primary THA at a single institution. Patients were grouped according to those who received a 200 mg ropivacaine IAI and those who did not. Primary outcome measures for this study included pain scores, morphine milligram equivalents (MMEs) dosed, distance of ambulation achieved, and time to ambulation. The intervention group reported higher average pain scores with activity than the control group (P= .024). The intervention group also required higher MMEs. When striated by hour, a statistically significant uptick in pain started at 16hours (P= .0009) and persisted to 28hours (P= .032) in patients receiving a 200 mg ropivacaine IAI. This correlated with an increase in MMEs seen at hour 24 through 32 (P= .003 to P= .012). Level of ambulation, time to ambulation, and distance ambulated did not differ between groups. An IAI of 200 mg ropivacaine also appeared to lead to higher pain scores and higher opioid doses in males. The IAI does not appear to reduce postoperative pain scores or MMEs dosed for THA patients. More research is needed to look at the utilization and efficacy of intra-articular ropivacaine, especially focusing on functional outcomes and gender differences.

Chondrotoxic effects of intra-articular injection of local anaesthetics in the rabbit temporomandibular joint

The aim of this study was to investigate the chondrotoxic effects of a single-dose intra-articular injection of articaine, lidocaine, and bupivacaine on the rabbit temporomandibular joint (TMJ). Twenty-four rabbits were divided into four groups: control (group 1), articaine (group 2), lidocaine (group 3), and bupivacaine (group 4). Synovial fluid samples and venous blood were taken to evaluate matrix metalloproteinase 3 (MMP-3) levels. One millilitre of local anaesthetic solution was injected in the study groups and saline solution in the control group. The rabbits were euthanized after 4 weeks and the mandibular condyles and articular discs were evaluated. On histological examination, the study group samples had irregular joint surfaces, decreased collagen, and a thinner cartilage layer. Apoptotic cells were evaluated with the TUNEL method. TUNEL-positive apoptotic cell counts were higher in all study groups compared to the control group, and the difference was significant (P < 0.001). The mean preoperative serum MMP-3 level for all groups was 5.71 ± 3.33 ng/mL, while the mean postoperative level was 22.61 ± 6.36 ng/mL; this difference was significant (P < 0.001). A single-dose intra-articular injection of local anaesthetic had apoptotic effects on chondrocytes, leading to degenerative changes in the TMJ articular structures. Articaine was found to have less harmful effects than lidocaine and bupivacaine. Intra-articular injection of local anaesthetics should be limited in the TMJ because of the potential toxic effects.

Comparison of two different treatment methods in the approach to facet (Zygapophyseal) joint pain

Low back pain has been recorded as the second most common pathology in adults. Irregularities in the zygapophyseal joints constitute one of the most well-known pathologies in this type of pain. Medial branch blocks and intra-articular injections have been used for the treatment. Local corticosteroid injections are also reliable for the treatment of low back pain. This study aims to compare the efficiency, in terms of low back pain palliation, of “intra-articular injection of local anesthetic and steroid drug combination” and “oral pain reliever and muscle relaxant combination” in the treatment of diagnosed non-discogenic low back pain. After Ethics Committee aproval 96 patients who had applied to outpatient clinic with low back pain complaints and were then treated for the diagnosis of facet joint pain between 2016 June -2019 June were examined. This retrospective study included 80 patients whose records were properly recorded and followed up in the scope of this one-center. Patients were classified into two groups; those given oral pain killers and muscle relaxants (n=40) and those who injected steroids and local anesthetics into the lumbar facet joint (n=40). Pain scores significantly decreased in both groups. When the low back pain is not discogenic, the patient should be subjected to further examination, and pain treatment should be started since this painful condition results in severe labor loss in society. We suggest that oral treatment or combined injections of steroids and local anesthetics for the cases, whose low back pain is determined to originate from the lumbar facet joint, will be very effective in therapeutic pain relief.

Preoperative pericapsular nerve group (PENG) block for total hip arthroplasty: a randomized, placebo-controlled trial

BackgroundWe hypothesized that the addition of a preoperative pericapsular nerve group (PENG) block to intra-articular local anesthetic injection would improve analgesia after total hip arthroplasty.MethodIn this double-blinded trial, 71 patients...

Impact of Intra-Articular Local Anesthesia Infiltration versus Femoral Nerve Block for Postoperative Pain Management in Total Knee Arthroplasty.

Background:Postoperative pain relief after total knee arthroplasty (TKA) can be attained by using several techniques such as intravenous analgesia, epidural analgesia, and peripheral nerve blocks that include femoral nerve and saphenous nerve. Several authors recommended intra-articular injection of local anesthetic (IALA) as a part of multimodal analgesia regimens for TKA instead of other techniques.Aims:The present study compares IALA technique efficacy with single-shot femoral nerve block (FNB) as part of multimodal analgesia regimen in TKA patients for postoperative pain management.Setting and Design:Perioperative care, randomized double-blind comparative study.Subjects and Methods:We recruited a total of 60 patients scheduled for unilateral total knee replacement under spinal anesthesia. Subjects were allocated randomly into two groups FNB and IALA receiving ultrasound-guided FNB and Intra-articular local anesthesia and morphine mix infiltration, respectively. Twenty-four hour postoperative morphine consumption through patient-controlled analgesia was the primary outcome measure in our study. Secondary outcome measures were pain scores, nausea and vomiting.Statistical Analysis:Chi-square test, Mann–Whitney test.Results:The amount of morphine consumed at the end of 24 h was noted to be higher in IALA group as compared to FNB (FNB − 16.03 ± 9.37 mgs; IALA − 23.60 ± 13.73 mgs P = 0.03). Visual analog score at 24 h with knee flexion was better in FNB group (FNB − 1.27 ± 1.43; IALA 2.42 ± 2.54, P = 0.04).Conclusion:FNB technique provides better analgesia in comparison to IALA for postoperative pain management in terms of PCA morphine consumption.

BET 1: Can acute shoulder dislocations be reduced using intra-articular local anaesthetic infiltration as an alternative to intravenous analgesia with or without sedation?

A short cut review was carried out to establish whether intra-articular injection of local anaesthetic is an effective alternative to intravenous analgesia with or without sedation to facilitate reduction of...

The Influence of a Single Intra-Articular Lidocaine Injection on the Viability of Articular Cartilage in the Knee.

To evaluate the in vivo effect of a single intra-articular injection of local anesthetic (LA) lidocaine on the viability of articular cartilage in the intact or osteoarthritic (OA) human knees, and to measure the synovial postinjection concentration of lidocaine in the knee. This study includes 3 interconnected experiments: (A) Synovial LA concentration measurement after a 2% lidocaine injection before knee arthroscopy in 10 patients by liquid chromatography-tandem mass spectrometry (LC-MS/MS). (B) Human osteochondral explants (N = 27) from intact knees procured at autopsies were incubated for different time intervals (30 minutes, 2 hours, 24 hours) with 2% lidocaine, 0.04% lidocaine (measured), or culture medium (control), and later evaluated for cell viability by LIVE/DEAD staining. (C) Ten out of 19 matched patients scheduled for knee replacement received a single intra-articular injection of 2% lidocaine approximately 30 minutes prior to the procedure; 9 patients served as control. Osteochondral samples with OA changes were harvested during surgery and analyzed for chondrocyte viability by LIVE/DEAD staining. (A) The synovial LA concentration was significantly lower than the primary concentration injected: average 0.23 mg/mL (0.02%), highest measured 0.37 mg/mL (0.04%). (B) In vitro exposure to a reduced LA concentration had no significant influence on chondrocyte viability in intact cartilage explants (24-hour averages: control, 93%; 0.04% lidocaine, 92%; 2% lidocaine, 79%). (C) Viability of chondrocytes in OA knees was similar between 2% lidocaine injection (85%) and control (80%). A single intra-articular knee injection of 2% lidocaine did not influence the chondrocyte viability neither in healthy nor in OA cartilage. A fast postinjection reduction of synovial LA concentration (more than 40 times) is the most likely protective mechanism.

Preoperative Fascia Iliaca Block Does Not Improve Analgesia after Arthroscopic Hip Surgery, but Causes Quadriceps Muscles Weakness: A Randomized, Double-blind Trial.

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia. In a prospective, double-blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness. The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 ± 2) versus placebo group (7 ± 2), difference: -0.2 (95% CI, -1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 ± 7mg [block] vs. 16 ± 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 ± 7 mg [block] vs. 12 ± 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group. Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.

Arthroscopic findings of a diagnostic dilemma- hip pathology with normal imaging

BackgroundPatients with groin, hip and pelvic pain but normal findings on MRI and minimal changes on x-ray can be a diagnostic problem. This paper looks at the arthroscopic findings of patients who have had hip pain and a positive response to an intra-articular anaesthetic but have non-contributory imaging. We hypothesized that standard MRI’s were missing significant pathology and if there was a response to intra-articular local anaesthesia, pathology found during arthroscopy was likely.MethodsA retrospective review of all hip arthroscopies performed from March 2011 to January 2015 by two orthopaedic surgeons specializing in hip arthroscopy was conducted to identify patients with clinically suspected intra-articular hip pathology despite a normal MRI report and X-ray. Clinical suspicion of intra-articular hip pathology was confirmed with a positive response to a fluoroscopically guided intra-articular injection of local anaesthetic and corticosteroid. Pathologic findings were collated from the standardised operative notes.ResultsFifty-three hip arthroscopies performed in 51 patients met the inclusion criteria from a total of 1348 hip arthroscopies performed over a 46-month period. All but one of the 53 (98%) hips had arthroscopically confirmed pathology. Mean patient age was 32.5 years [15 to 67 years] with 40 (78%) females and 11 (22%) males. 92.5% of the hips (49/53) were FADIR (flexion, adduction and internal rotation) positive on clinical examination, giving this test a positive predictive value of 98% (95% CI: 89.31 to 99.67%) for intra-articular pathology.ConclusionsIn patients with a normal MRI without contrast and a positive response (relief of pain) to an intra-articular injection that failed conservative management, there is a 98% chance of intra-articular hip pathology being discovered on hip arthroscopy.

Analgesic Effect of Intra-articular Morphine or Dexmedetomidine Added with Levobupivacaine in Arthroscopic Knee Surgeries - A Comparative Evaluation.

Knee arthroscopy is associated with variable amount of postoperative pain. In an attempt to improve postoperative analgesia, intra-articular injection of local anaesthetic in combination with other agent have been studied. However, the best combination is not known. To compare the analgesic efficacy of intra-articular injection of morphine and dexmedetomidine when added with levobupivacaine in arthroscopic knee surgeries. Seventy eight patients, scheduled to undergo elective arthroscopic procedure under spinal anaesthesia were recruited for the study. All the patients received 18 ml of 0.25% levobupivacaine however in addition to this Group M patients received 8 mg (2 ml) morphine, Group D patients received 100μg (2 ml) of dexmedetomidine while Group C patients received 2 ml of isotonic saline intra-articularly. Postoperatively the intensity of pain was assessed using Numerical Rating Scale (NRS). Rescue analgesia was given at NRS ≥ 4. The duration of analgesia and total diclofenac consumption was noted. The mean duration of analgesia was longest in Group M (576.20±67.09 minutes) followed by Group D (460.93±38.95 minutes) and Group C (370.27±58.80 minutes) statistically this difference was found to be highly significant (p-value < 0.001). Total consumption of diclofenac in 24 hours was found lowest in group M (86.25±27.48 mg) followed by group D (110.87±44.48 mg) and group C (141.35±44.13 mg) this difference was found to be highly significant (p-value < 0.001). Morphine when added with levobupivacaine in patients undergoing arthroscopic knee surgery improves the quality and prolongs the duration of postoperative analgesia.

Fluoroscopy-Guided Sacroiliac Joint Injection: Description of a Modified Technique

Sacroiliac joint (SIJ) pathology is a common etiologic cause for 10 - 27% of cases of mechanical low back pain (LBP) below the L5 level. In the absence of definite clinical or radiologic diagnostic criteria, controlled blocks of the SIJ have become the choice assessment method for making the diagnosis of SIJ pain. The SI joint is most often characterized as a large, auricular-shaped, diarthrodial synovial joint. In reality, its synovial characteristic is limited only to the distal third and anterior third. In SIJ interventions, the lateral view has been underutilized. In our technique, we used the lateral view to create a three-dimensional view of the SIJ to aid in gauging the accurateness of the contrast spread and to obtain a precise block. After obtaining appropriate fluoroscopic images, a curved tip spinal needle was directed into the inferior aspect of the SIJ using a posterior approach. As the needle contacts firm tissues on the posterior aspect of the joint, position of the needle tip is checked using lateral fluoroscopy. In the lateral view, the needle tip position is manipulated to keep it in the anterior third of the SIJ and contrast is injected. Our criteria for accurate SIJ block, in posteroanterior (PA) view, is the injection of the contrast medium should outline the joint space and the contrast medium should be seen to travel cephalad along the joint line. In the lateral view, the contrast medium most densely outlines the parameter of the joint. We have utilized this method with good effect in approximately 30 cases over one year. Out of 30 cases, needle position and contrast spread was satisfactory in 28 and 27 cases, respectively. So satisfactory needle placement and contrast spread was in 93% and 87% cases. Pain relief of 80% or more after intra-articular injection of local anesthetic was seen in 50% (15 of 30) patients; pain relief of 50 - 79% was witnessed in 30% (9 of 30) patients. Thus, pain decreased 50% or more in 80% (24 of 30) of the joints. Out of 24 joints where we got satisfactory needle position and contrast spread, 23 joints got more than 50% relief. Thus, if needle position and contrast spread is satisfactory as per the criteria, pain relief of 50% or more was in 96% (23 of 24) of joints. There are few possible limitations with this study like difficulty to go up to the anterior third of the SIJ, it may be more painful as a narrow joint line has to be travelled in depth, sciatic numbness due to drug leak, or injuring the pelvic structure. Advantages of this method are that depth and level of the needle tip for a SIJ block is described for the more precise block. This will reduce false positive and false negative results, i.e., sensitivity and specificity of SIJ blocks and results for diagnostic blocks become more reliable. It will also reduce the chances of a case getting abandoned due to inappropriate contrast spread obscuring the fluoroscopic landmarks. As we know the depth of the needle, the chances of injuring pelvic structures become less and safety improves.

In Vitro Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte Viability and Metabolism.

Objective:There is growing concern that intra-articular injection of local anesthetic and/or corticosteroids may cause significant morbidity, including potential toxicity to chondrocytes and synoviocytes, after even a single exposure. We demonstrate that full thickness canine chondral and synovial samples exposed to various local anesthetics and corticosteroids exhibit decreased loss of cell viability compared with prior in vitro studies using monolayer culture, due to the protective effects of intact extracellular matrix and cell heterogeneity.Methods:Full-thickness cartilage and synovial explants were obtained from canine cadavers and exposed in culture media to the following for 24 hours: 1% lidocaine, 0.5% lidocaine, 0.25% bupivacaine, 0.125% bupvacaine, 0.0625% bupivacaine, betamethasone acetate, methylprednisolone acetate, triamcinolone acetonide, or culture media only (control). Cell viability was determined on days 1 and 7 of culture using a microscopic live-dead and alamar blue metabolic assays.Results:Complete loss of chondrocyte and synoviocyte viability was noted in the 1% and 0.5% lidocaine group, 0.25% and 0.125% bupivacaine group, betamethasone group, and methylprednisolone groups after 1 and 7 days of culture. Treatment with 0.0625% bupivacaine and triamcinolone demonstrated no decrease in cell viability or metabolism when compared to negative control.Conclusions:In this canine explant model, 1% and 0.5% lidocaine, 0.25% and 0.125% bupivacaine, betamethasone acetate, and methylpresdnisolone acetate were severely chondrotoxic and synoviotoxic after a single exposure, despite intact extracellular matrix. In contrast, chondrocytes and synoviocytes exposed to 0.0625% bupivacaine and triamcinolone remained viable after treatment. Further in vivo study is needed before definitive recommendations can be made.

Single provider reduction and splinting of displaced ankle fractures: a modification of Quigley's classic technique.

Ankle fractures are commonly treated by orthopaedic surgeons and often require manipulative reduction. This can be painful for the patient and frequently uses 2 or more providers. Intra-articular injection of local anesthetic into the ankle joint precludes the need for conscious sedation (intravenous narcotics and benzodiazepines, propofol, or ketamine). By combining an ankle block with a modification of the classic ankle fracture reduction technique described by Quigley 1959, a single provider can effectively perform a manipulative reduction and splinting of an ankle fracture without conscious sedation.

Comparación de bloqueo del plexo braquial por vía interescalénica y administración de anestésico local intraarticular en el manejo del dolor en el postoperatorio de cirugía artroscópica del hombro

Background and objectivesIn this study, the aim was to compare postoperative analgesia effects of the administration of ultrasound-guided interscalene brachial plexus block and intraarticular bupivacaine carried out with bupivacaine. MethodsIn the first group of patients 20mL 0.25% bupivacaine and ultrasound-guided interscalene brachial plexus block (ISPB) were applied, while 20mL 0.25% bupivacaine was given vía intraarticular (IA) administration to the second group patients after surgery. Patients in the third group were considered the control group and no block was performed. Patient-controlled analgesia with morphine was used in all three groups for postoperative analgesia. ResultsIn the ISPB group, morphine consumption in the periods between 0-4, 6-12 and 12-24 postoperative hours and total consumption within 24h was lower than in the other 2 groups. Morphine consumption in the IA group was lower than in the control group in the period from 0-6h and the same was true for total morphine consumption in 24h. Postoperative VASr scores in the ISPB group were lower than both of the other groups in the first 2h and lower than the control group in the 4th and 6thh (P<.05). In the IA group, VASr and VASm scores in the 2nd, 4th and 6thh were lower than in the control group (P<.05). ConclusionISPBl plexus block was found to be more effective than intraarticular local anesthetic injection for postoperative analgesia.

In Vivo Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte Viability and Metabolism.

Objective:Intra-articular injection of local anesthetic and/or corticosteroid is an adjunct treatment for arthritic and inflammatory orthopedic conditions. Despite potential benefits, there is growing concern that these medications may cause significant morbidity, including potential toxicity to intra-articular chondrocytes and synoviocytes.Design:Twenty dogs underwent intra-articular injection of the shoulder joint using ultrasound guidance, with the following injectates (n = 5 each): negative control (saline), methylprednisolone/1.0% lidocaine, triamcinolone/1.0% lidocaine, and triamcinolone/0.0625% bupivacaine. The dogs were euthanized 24 hours postinjection for reasons unrelated to this study. Synovium/cartilage explants were harvested under sterile conditions and assessed immediately or cultured for 7 days. Synoviocyte and chondrocyte viability was determined on day 1 and day 7 using Calcien AM and Sytox Blue live/dead fluorescent stains, and cell metabolism determined on day 2 using the alamar blue additive test. Results were compared statistically.Results:On day 1 synovium exposed to 1%L/M demonstrated a significant decrease in cell metabolism (P = 0.0107) and subjective synoviocyte viability scores (P = 0.013) compared with the negative control. Cartilage exposed to 1%L/M demonstrated decreased chondrocyte viability and cell metabolism versus all other groups, although not significantly. After 7 days of culture, cartilage viable cell density in the 1%L/M group was significantly (P ≤ 0.001) lower than the negative control. Subjective synoviocyte viability scores was significantly lower in the 1%L/M (P = 0.013), 1%L/T (P ≤ 0.001), and 0.0625%B/T groups (P = 0.006) compared with the negative control.Conclusions:This study suggests potential negative effects of combination local anesthetic/corticosteroid on intra-articular cell viability and cell metabolism. Further study is needed before determining definitive clinical recommendations.

Pain Control after Total Knee Arthroplasty: Comparing Intra-Articular Local Anesthetic Injection with Femoral Nerve Block.

Background. Direct intra-articular injection of low doses of local anesthetic (IALA) after closure of the joint capsule remains controversial for pain control after total knee arthroplasty (TKA). Methods. A retrospective study comparing patients receiving IALA with high doses (0.5% bupivacaine 60 mL) of local anesthetics or FNB in addition to intravenous patient-controlled analgesia with opioids for pain management after TKA was conducted. The primary end point was to compare the analgesic efficacy and early ambulation between the two groups. Results. No significant differences between the two groups in pain intensity, cumulative opioid consumption, incidences of opioid-related side effects, the time interval from the end of operation to the first time the patient could walk assisted with a walker postoperatively, and postoperative hospital stay were identified. Three patients in the IALA group but none in the FNB group walked within 12 hours after the end of operation. Summary. IALA with high doses of local anesthetics provides comparable analgesic efficacy as single-shot FNB after TKA and might be associated with earlier ambulation than FNB postoperatively.

Comparison of interscalene brachial plexus block and intra-articular local anesthetic administration on postoperative pain management in arthroscopic shoulder surgery

Background and objectivesIn this study, the aim was to compare postoperative analgesia effects of the administration of ultrasound-guided interscalene brachial plexus block and intra-articular bupivacaine carried out with bupivacaine. MethodsIn the first group of patients 20mL 0.25% bupivacaine and ultrasound-guided interscalene brachial plexus block (ISPB) were applied, while 20mL 0.25% bupivacaine was given via intra-articular (IA) administration to the second group patients after surgery. Patients in the third group were considered the control group and no block was performed. Patient-controlled analgesia (PCA) with morphine was used in all three groups for postoperative analgesia. ResultsIn the ISPB group, morphine consumption in the periods between 0–4, 6–12 and 12–24 postoperative hours and total consumption within 24h was lower than in the other two groups. Morphine consumption in the IA group was lower than in the control group in the period from 0 to 6h and the same was true for total morphine consumption in 24h. Postoperative VASr scores in the ISPB group were lower than both of the other groups in the first 2h and lower than the control group in the 4th and 6th hours (p<0.05). In the IA group, VASr and VASm scores in the 2nd, 4th and 6th hours were lower than in the control group (p<0.05). ConclusionInterscalene brachial plexus block was found to be more effective than intra-articular local anesthetic injection for postoperative analgesia.

The Cytotoxicity of Bupivacaine, Ropivacaine, and Mepivacaine on Human Chondrocytes and Cartilage

Intraarticular injections of local anesthetics are frequently used as part of multimodal pain regimens. However, recent data suggest that local anesthetics affect chondrocyte viability. In this study, we assessed the chondrotoxic effects of mepivacaine, ropivacaine, and bupivacaine. We hypothesized that specific cytotoxic potencies directly correlate with analgesic potencies, and that cytotoxic effects in intact cartilage are different than in osteoarthritic tissue. Human articular chondrocytes were exposed to equal and equipotent concentrations of bupivacaine, ropivacaine, and mepivacaine for 1 hour. Cell viability, apoptosis, and necrosis were determined at predefined time points using flow cytometry, live-dead staining, and caspase detection. Intact and osteoarthritic human cartilage explants were treated with equipotent concentrations of named drugs to determine cell viability applying fluorescence microscopy. Chondrotoxic effects increased from ropivacaine to mepivacaine to bupivacaine in a time-dependent and concentration-dependent manner. Compared with control, bupivacaine 0.5% decreased chondrocyte viability to 78% ± 9% (P = 0.0183) 1 hour and 16% ± 10% (P < 0.0001) 24 hours later, as determined by live-dead staining in monolayer cultures. Viability rates were reduced to 80% ± 7% (P = 0.0475) 1 hour and 80% ± 10% (P = 0.0095) 24 hours after treatment with ropivacaine 0.75%. After exposure to mepivacaine 2%, viable cells were scored 36% ± 6% (P < 0.0001) after 1 hour and 30% ± 11% (P < 0.0001) after 24 hours. Ropivacaine treatment was less chondrotoxic than bupivacaine (P = 0.0006) and mepivacaine exposure (P = 0.0059). Exposure to concentrations up to 0.25% of bupivacaine, 0.5% of ropivacaine, and 0.5% of mepivacaine did not reveal significant chondrotoxicity in flow cytometry. However, chondrotoxicity did not correlate with potency of local anesthetics. Immediate cell death was mainly due to necrosis followed by apoptosis. Cellular death rates were clearly higher in osteoarthritic compared with intact cartilage after bupivacaine, mepivacaine, and ropivacaine treatment in a decreasing order. Bupivacaine, ropivacaine, and mepivacaine are chondrotoxic in a time-dependent, concentration-dependent, and drug-dependent manner. Chondrotoxic and analgesic potencies do not directly correlate. Cellular death rates were higher in osteoarthritic compared with intact cartilage after local anesthetic treatment.