Intra-articular Group Research Articles

Intravenous vs Intra-Articular Tranexamic Acid in Total Knee Arthroplasty: A Randomized, Double-Blind Trial

BackgroundTranexamic acid (TXA) is commonly used in primary total knee arthroplasty (TKA); however, the most appropriate route of administration is still debated. This study was conducted to compare the 2 most commonly used routes of TXA administration, intravenous (IV) and intra-articular (IA). MethodsThis study was conducted as a double-blind, randomized, noninferiority trial and included patients undergoing primary unilateral TKA. Patients were randomized to receive IV or IA TXA and compared for postoperative fall in hemoglobin (Hb) on day 1 (primary outcome) and day 2, and blood transfusion rates, length of stay, and complications. ResultsOf the 183 patients recruited, 168 were included and supplied complete data. The between-group difference in mean Hb fall at day 1 was 0.08 g/dL with the Hb fall higher in the IA group. The 95% confidence interval was −0.18 to 0.34 which did not reach the noninferiority margin of 0.5 g/dL. No significant difference was seen in the secondary outcomes. ConclusionIA TXA is noninferior to IV TXA in terms of fall in Hb on the first postoperative day. Due to the potential for reduced serum levels and easier administration (single dose), this trial supports the use of IA TXA for primary TKA.

Combined Administration of IV and Topical Tranexamic Acid is Not Superior to Either Individually in Primary Navigated TKA

BackgroundIn this study, we tried to assess if combined method (intravenous [IV] and topical) of tranexamic acid (TXA) administration, which has been shown to be superior in conventional arthroplasty, has similar effect in navigational arthroplasty compared to administration of drug either individually. MethodsIn present randomized control trial, 200 patients were randomly divided in one of the 4 groups using computer-generated tables—control, IV, intraarticular, and combined. We studied evident loss through drain, total loss based on Gross method and hemoglobin balance method, hidden losses, hemoglobin and hematocrit drop, functional scores, and all possible complications related to TXA. ResultsEvident loss in combined group was 535.55 mL, not significantly less than IV (585 mL, P = .15) and intraarticular group (514 mL, P = .74). However, these were significantly less than control group (696 mL, P = .000). Functional scores and recovery rates were, however, comparable in all 4 groups. No patients in any group developed symptomatic deep vein thrombosis. ConclusionTranexamic use decreases blood loss in navigation-assisted arthroplasty, however, less than that observed for conventional arthroplasty in literature. Further, combined group has no added advantage over other methods of drug administration. We believe that additional amount of TXA administered in combined regimen may not be clinically useful. Further TXA group did not have any advantage in terms of functional recovery over control group.

Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

In total knee arthroplasty, both intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) have been shown to reduce blood loss in several randomized controlled trials, although routine use of systemic TXA is considerably more common. However, to our knowledge, the additional benefit of IA administration of TXA when combined with IV administration, without the use of a tourniquet, has not been previously investigated. Thus, the aim of this study was to evaluate whether combined IV and IA administration of TXA reduced total blood loss compared with IV-only administration of TXA. In this randomized, double-blind, placebo-controlled trial, 60 patients scheduled for total knee arthroplasty were randomized to one of two interventions. The TXA IV and IA group received combined administration of TXA consisting of 1 g administered intravenously preoperatively and 3 g diluted in 100 mL of saline solution administered intra-articularly after closure of the capsule. The TXA IV and placebo group received 1 g of TXA administered intravenously only and 100 mL of saline solution administered intra-articularly. IA TXA was administrated through a needle. The primary outcome was the 24-hour calculated blood loss. Secondary outcomes were blood loss on postoperative day 2, thromboembolic complications, and transfusion rate. Blood loss was calculated by hemoglobin differences using the Gross formula. Data on the primary outcome were available for all 60 included patients. Baseline characteristics were comparable between the allocation groups. The mean 24-hour blood loss (and standard deviation) was 466 ± 313 mL in the TXA IV and IA group compared with 743 ± 358 mL in the TXA IV and placebo group; treatment effect (difference), 277 mL (95% confidence interval [CI], 103 to 451 mL) (p = 0.002). Second-day blood loss was 644 ± 382 mL in the TXA IV and IA group compared with 1017 ± 519 mL in the TXA IV and placebo group; treatment effect, 373 mL (95% CI, 132 to 614 mL) (p = 0.003). No thromboembolic complications were observed within 90 days postoperatively. The combined administration of IV and IA TXA resulted in a clinically relevant reduction in blood loss of 37% compared with IV TXA alone both at 24 hours postoperatively and on postoperative day 2. No thromboembolic complications were observed. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Intravenous versus intra-articular tranexamic acid in total knee arthroplasty: A double-blinded randomised controlled noninferiority trial

BackgroundDespite the proven efficacy of both intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) in reducing blood loss during total knee arthroplasty (TKA), the ideal route of administration remained debatable. This study aimed to compare the effect of IV versus IA TXA on transfusion incidences, perioperative blood loss and postoperative lower limb swelling during TKA. MethodsOne hundred patients were prospectively randomised into two groups: 1) IV TXA; and 2) IA TXA. In both groups, TXA was administered intraoperatively after cementing the prostheses. The perioperative blood loss was calculated using the haemoglobin balance method. The thigh, suprapatellar, and calf girths were measured preoperatively and on postoperative day (POD) 4. ResultsTwo patients in the IV group and one patient in the IA group required blood transfusion (p=0.500). The median and interquartile range (IQR) of perioperative blood loss on POD1 and POD4 was 530 (IQR 386,704) and 730 (IQR 523,925) ml for the IV group, compared with 613 (IQR 506,703) and 799 (IQR 563,1067) ml for the IA group (p=0.090 and p=0.232 respectively). The median increment in thigh, suprapatellar, and calf girths were 1.5 (IQR 0, 3.0), 2.0 (IQR 0.5, 4.0) and 0 (IQR 0, 1.0) cm for the IV group, compared to 2.0 (IQR 1.0, 4.0), 2.0 (IQR 0, 4.5) and 0 (IQR 0, 1.5) cm for the IA group (p=0.246, p=0.562, and p=0.937 respectively). ConclusionsBoth IV and IA TXA had comparable effect on transfusion incidences, perioperative blood loss, and postoperative lower limb swelling during TKA. IA TXA is an alternative to IV TXA.Level of evidence: I.

3419 Knee reconstruction with endoprosthesis after extraarticular and intraarticur resection of osteosarcoma

Objective: Extra-articular resection is necessary to obtain a wide margin for primary osteosarcomas invading the knee joint, and the limb is often reconstructed using a prosthesis. Here, outcomes of extra-articular and intra-articular procedures were compared. Methods: Between 1999 and 2012, 14 patients with osteosarcoma underwent extra-articular excision (n ¼ 6; ages 23 –6 5 years; mean follow-up 82.8 months) or intra-articular excision (n ¼ 8; ages 8–58 years; mean follow-up 96.4 months). In the extra-articular group, there was one Enneking Stage IIA case and five Enneking Stage IIB cases. No local recurrences were noted in either group. Results: Patient outcomes were as follows (extra-articular cases vs. intra-articular cases): continuous disease-free (2 vs. 7), alive with disease (2 vs. 0) and death from disease (1 vs. 1). Average Musculoskeletal Tumor Society functional scores were 69.4% (range 63.3 –8 3.3%) and 88.3% (range 70.0 –9 6.7%) in the extra-articular and intra-articular groups, respectively, constituting a significant difference (P , 0.05). The 5-year oncological overall survival exceeded 80% in both groups. Amputation was necessary for one patient in the extra-articular group. The 5-year event-free prosthesis survival rates in the extra-articular and intra-articular groups were 33.3 and 75.0%, respectively (P , 0.05). Conclusion: The extra-articular excision group developed more complications than the intraarticular excision group, as a result of extensive bone and muscle excision. The limb survival rates were similar in both groups. Our results suggest that extra-articular resection was a necessary and clinically acceptable procedure.

Intra-articular injection of tranexamic acid reduce blood loss in cemented total knee arthroplasty.

The purpose of this study was to compare the efficacy of intravenous and topical tranexamic acid (TXA) versus control group for reduction in blood loss following primary total knee arthroplasty (TKA). A total of 90 patients were prospectively allocated to each of three groups (control, intravenous IV and intra-articular) and underwent unilateral total knee arthroplasty. In the IV group, patients received one dose of TXA of 15 mg/kg before deflation of the tourniquet, while in the intra-articular group patients received 2 g TXA via the drain retrogradely after closure of the wound. The mean drained blood loss in control, IV and intra-articular groups was 415 ± 24, 192 ± 21 and 121 ± 17 ml, respectively. About 43 % (control), 23 % (IV) and 17 % (intra-articular) of each group required transfusion, and the mean transfusion was 338, 168 and 79 ml, respectively. Preoperative hemoglobin values decreased at 24 h by 2.80 ± 0.14, 2.24 ± 0.17 and 2.26 ± 0.18 mg/dl, respectively. TXA reduced blood loss and transfusion requirement. Compared with one-dose intravenous administration, intra-articular administration of TXA seems to be more effective in terms of reducing drained blood loss and transfusion frequency. We recommend administration of topical TXA in primary TKA in healthy patients to decrease perioperative blood loss.

Intra-articular versus intravenous magnesium-sulfate as adjuvant to femoral nerve block in arthroscopic knee surgery under general anesthesia: Randomized controlled trial

BackgroundThe combined use of intra-articular (IA) or intravenous (IV) magnesium-sulfate (mgso4) with femoral nerve block might be associated with additive effects on the duration and quality of postoperative analgesia in arthroscopic knee surgery.Patients and methodsThis randomized controlled double-blind study included 90 patients. Femoral nerve block was performed in all patients using 20 ml 0.25% bupivacaine before induction of general anesthesia. At the end of surgery patients were randomly allocated into: Group-IA (intra-articular 1 g MgSO4 in 20 ml), Group-IV (intravenous 1 g MgSO4 in 20 ml), and Group-P (20 ml intra-articular and 20 ml intravenous normal saline). 20 ml normal saline was given IV in IA group and IA in IV group. Visual analogue pain score (VAS) at rest, with movement, time to first postoperative rescue analgesia, total postoperative diclofenac consumption, and the number of meperidine rescue doses during the first 24 h postoperatively were measured.ResultsPain scores were comparable in the three groups at 2 and 4 h and were significantly higher in the control group at 6 h and over 24 h. Group IA had the lowest pain scores. Duration of analgesia was significantly higher [11.6 (4.5) h] in IA group compared to [7.5 (3.6) h] in IV group and [5.2 (2.3) h] in control group (p < 0.01). Total Diclofenac over 24 h was significantly lower in IA group [73.8 (50.9) mg] versus [138.4 (51.6) mg] in IV group and [186.0 (43.9) mg] in the control group (p < 0.01).ConclusionThe combined use of femoral nerve block with IA or IV MgSO4 is associated with significant reduction of the intensity and duration of postoperative pain and postoperative analgesic requirements in patients undergoing arthroscopic knee surgery with the IA MgSO4 being superior to IV route of administration.

Comparação de bloqueio do plexo braquial por via interescalênica e administração de anestésico local intra‐articular no manejo da dor no pós‐operatório de cirurgia artroscópica do ombro

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.

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.

Is Distal Femur Locking Plate a Superior Implant in Distal Femur Fracture?

In spite of advances in techniques and improvements in surgical implants, confusion still prevails regarding use of specific implants in distal femur fracture. Fractures in the distal femur have posed considerable therapeutic challenges throughout the history of fracture treatment. Most of these surgical failures were due to inadequate fixation of the fracture fragments. The Aim of the study is to determine whether distal femur locking plates are superior implants than dynamic condylar screw and distal femur nail. A prospective and observational study was done in Department of Orthopaedics and Traumatology, Sri Ramachandra Medical Collage, Chennai between Jan. 2011 and Jan. 2015. Patients with distal femoral fractures, admitted into the hospital, were treated using various modes of internal fixation and followed up over a period of six months to one year and their functional outcome was evaluated. The functional and radiological assessment of patients during follow-up was done using Neer’s criteria. The use of any one of the implant, i.e. distal femur locking plates, dynamic condylar screw or distal femur nailing for internal fixation, depends on the type of fracture and the pre operative planning and intra operate decision of the surgeon. In our study, 38% of fractures treated by Dynamic condylar screw, 72% of fractures treated by distal femur locking plate and 42% of fractures treated by Distal femur supracondylar nail had excellent/satisfactory results. Locking plates had better outcome in both extra-articular and intra-articular group. They also had better outcome in both younger and older age groups.

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.

Knee reconstruction with endoprosthesis after extra-articular and intra-articular resection of osteosarcoma.

Extra-articular resection is necessary to obtain a wide margin for primary osteosarcomas invading the knee joint, and the limb is often reconstructed using a prosthesis. Here, outcomes of extra-articular and intra-articular procedures were compared. Between 1999 and 2012, 14 patients with osteosarcoma underwent extra-articular excision (n = 6; ages 23-65 years; mean follow-up 82.8 months) or intra-articular excision (n = 8; ages 8-58 years; mean follow-up 96.4 months). In the extra-articular group, there was one Enneking Stage IIA case and five Enneking Stage IIB cases. No local recurrences were noted in either group. Patient outcomes were as follows (extra-articular cases vs. intra-articular cases): continuous disease-free (2 vs. 7), alive with disease (2 vs. 0) and death from disease (1 vs. 1). Average Musculoskeletal Tumor Society functional scores were 69.4% (range 63.3-83.3%) and 88.3% (range 70.0-96.7%) in the extra-articular and intra-articular groups, respectively, constituting a significant difference (P < 0.05). The 5-year oncological overall survival exceeded 80% in both groups. Amputation was necessary for one patient in the extra-articular group. The 5-year event-free prosthesis survival rates in the extra-articular and intra-articular groups were 33.3 and 75.0%, respectively (P < 0.05). The extra-articular excision group developed more complications than the intra-articular excision group, as a result of extensive bone and muscle excision. The limb survival rates were similar in both groups. Our results suggest that extra-articular resection was a necessary and clinically acceptable procedure.

Intra-Articular Versus Periarticular Acromioclavicular Joint Injection: A Multicenter, Prospective, Randomized, Controlled Trial

The purpose of this randomized study was to compare the clinical efficacy of intra-articular versus periarticular acromioclavicular joint injections. In this multicenter, prospective, randomized, controlled trial, 101 patients (106 shoulders) with symptomatic acromioclavicular joints were treated with an injection and were randomly assigned to either the intra-articular group or the periarticular group. To ensure accurate needle placement either intra-articularly or in a periarticular manner, the needle was placed under ultrasound guidance. Baseline values including the Constant-Murley score, pain assessment with a visual analog scale for pain under local pressure and pain at night, and the crossover arm test were investigated in 7 different centers immediately before treatment. Follow-up examinations were scheduled after 1 hour, 1 week, and 3 weeks. All patients completed the study. Overall, a highly significant clinical improvement in all tested variables and in both groups was observed over time (P < .0001) beginning with 1 hour after treatment and lasting for the entire follow-up period of 3 weeks. The difference between the 2 groups was not significant except regarding the crossover arm test (P < .016). With both injection techniques, a highly significant clinical advantage for the patient can be achieved. The difference between the 2 treatments was not significant except for more pain reduction according to the crossover arm test after intra-articular injection at 3 weeks' follow-up. Level II, multicenter, randomized, prospective, controlled trial.

Is intraarticular administration of tranexamic acid better than its intravenous administration in reducing blood loss after total knee arthroplasty?

Context: It has been well-established now that intravenous (IV) tranexamic acid (TXA) is a potent agent to control postoperative blood loss following total knee arthroplasty (TKA). Recently, intraarticular administration of this agent has also shown good efficacy for the same. Aims: Comparison of postoperative blood loss between IV and topical administration of TXA in TKAs. Materials and Design: Eighty-six TKAs on knees were included in this study. Randomization was done so that 40 TKA received 1 g of IV TXA, while 46 had intraarticular administration of 1 g TXA. Subjets and Methods: We compared the postoperative blood loss by calculating the difference in pre- and postop hemoglobin and need for blood transfusion. Functional assessment was done on basis of Western Ontario McMaster Osteo-Arthritis Index (WOMAC) scores and complications like postoperative infection, oozing from the wound site and thromboembolic manifestations. Results: Blood loss was significantly less in the intraarticular administration group as compared to the IV injection group. Total blood loss, blood transfusion group, and drain output was also less but the difference was not significant. The functional assessment (WOMAC) scores were equivocal and so were the complications including thromboembolic manifestations (two cases each of deep vein thrombosis (DVT) and no cases of pulmonary embolism (PE)). Conclusion: Intraarticular administration of TXA to prevent postoperative blood loss in TKA is a safe and effective alternative/adjunct to its IV administration.

A comparison of intra-articular magnesium and/or morphine with bupivacaine for postoperative analgesia after arthroscopic knee surgery

Both magnesium and morphine provide enhanced patient analgesia after arthroscopic knee surgery when administered separately via the intra-articular route. Magnesium sulfate amplifies the analgesic effect of morphine. This study was designed to compare the analgesic effects of intra-articular magnesium and morphine, with bupivacaine, when used separately and in combination. Eighty patients undergoing arthroscopic menisectomy were randomized blindly into four intra-articular groups: group B+Mor+Mg received 20 ml 0.25% bupivacaine, morphine 2 mg, and magnesium 150 mg; group B+Mor received 20 ml 0.25% bupivacaine and morphine 2 mg; group B+Mg received 20 ml 0.25% bupivacaine and magnesium 150 mg; and group B received 20 ml 0.25% bupivacaine. Pain scores at rest and during movement, analgesic duration, and total analgesic consumption were recorded. Group B+Mor and group B+Mg patients had equally effective postoperative analgesia. Group B+Mor+Mg patients had significantly reduced visual analogue scale (VAS) values both at rest and during movement and significantly increased time to first postoperative analgesic request, as well as significantly reduced total analgesic consumption, compared with the other groups. Intra-articular administration of magnesium sulfate or morphine, with bupivacaine, had comparable analgesic effects in the doses used. Their combination provided more effective postoperative analgesia than either drug alone.

Postoperative analgesia for arthroscopic shoulder surgery: a prospective randomized controlled study of intraarticular, subacromial injection, interscalenic brachial plexus block and intraarticular plus subacromial injection efficacy

The aim of the present study was to compare the new combination of intraarticular + subacromial injection, with intraarticular, subacromial injection and interscalenic brachial plexus block as postoperative analgesia in shoulder arthroscopy. One hundred and twenty patients scheduled for shoulder arthroscopy were enrolled and randomly assigned to one of five groups: intraarticular, subacromial, interscalenic brachial plexus block (IBPB), intraarticular + subacromial (intraarticular + subacromial) injection or a control group. All patients received standardized general anaesthesia and all the injections were given with the same dose and volume of local anaesthetic. The number of boluses (fentanyl 1 microg kg(-1) delivered by a patient-controlled analgesia pump applied at the end of the surgery and the visual analogue pain score (VAPS) at 0, 2, 4, 6, 12, 18 and 24 h after the intervention were recorded. A patient satisfaction score was also assessed at 24 h. Mean bolus consumption, compared with control group, was significantly less in all groups (P < 0.01). Intraarticular + subacromial group utilized fewer boluses compared with subacromial group and significantly lower boluses than intraarticular group (P < 0.01), but IBPB group utilized significantly fewer boluses than intraarticular + subacromial group. Patients in IBPB, intraarticular + subacromial and subacromial groups showed VAPSs that were significantly better than that of the control group at all time points (P < 0.01). The VAPS in intraarticular + subacromial group was statistically comparable with those in IBPB and subacromial groups at each time interval. IBPB and intraarticular + subacromial groups showed comparable patient satisfaction scores. These results confirm the analgesic efficacy of IBPB for shoulder surgery. Nonetheless, the combination of intraarticular and subacromial infiltration, studied for the first time, appears to be a clinically valid alternative with no clinical meaningful adverse effects.

Effect of intra-articular dexmedetomidine on postoperative analgesia after arthroscopic knee surgery

BackgroundAlpha-2-adrenergic agonists have peripheral analgesic effects. We have assessed the potential analgesic effect of dexmedetomidine after intra-articular administration in arthroscopic knee surgery. MethodsSixty patients undergoing arthroscopic knee surgery were randomly assigned into three groups in a double-blind placebo controlled study. The control group received i.v. and intra-articular saline, the intra-articular group received i.v. saline and intra-articular dexmedetomidine, and the i.v. group received i.v. dexmedetomidine and intra-articular saline. Haemodynamic changes, pain visual analogue scale (VAS), sedation score, the time to first postoperative analgesic request, and the total postoperative analgesic use during the first 24 h were evaluated. ResultsDexmedetomidine administration resulted in a significant reduction in pain scores for 6 h after operation in the intra-articular group but only for 1 h in the i.v. group. The time to first postoperative analgesic request was longer in the intra-articular group [312.0 (sd 120.7) min] compared with the control group [71.0 (50.1) min] and the i.v. group [102.1 (54.4) min] (P<0.001). Total diclofenac requirement was significantly lower in the intra-articular group [90.0 (46.2) mg] than in the control group [165.0 (52.2) mg] and in the i.v. group [129.3 (54.3) mg] (P<0.05). ConclusionsIntra-articular dexmedetomidine enhanced postoperative analgesia after arthroscopic knee surgery, with an increased time to first analgesic request and a decreased need for postoperative analgesia.

Periphere analgetische Wirkung durch intraartikulär verabreichtes Clonidin

Clonidine applied intra-articularly into the knee joint has a peripheral analgesic effect. We examined intra-articularly injected clonidine to determine whether resorption with a measurable systemic concentration could be detected. A randomised, placebo-controlled double-blind study was carried out on patients undergoing knee arthroscopies. The 69 patients were randomised into three groups: group 1 received 150 ug clonidine intra-articularly, group two 150 ug clonidine intravenously and group three a placebo. Postoperative pain therapy was carried out with i.v. morphine hydrochloride. Pain scores and side-effects were documented for 24 h. There were no significant differences between the three groups in demographics, duration of operation, duration of anaesthesia, diagnoses or type of operation. The pain score at rest was significantly lower in group 1. In the first 20 min, the systemic concentration of clonidine was significantly higher in the intravenous group than in the intra-articular group. Intra-articular clonidine has a postoperative analgesic effect after knee arthroscopies due to a peripheral action.

Intraarticular analgesia after arthroscopic knee surgery: comparison of neostigmine, clonidine, tenoxicam, morphine and bupivacaine

We conducted a randomized, placebo-controlled, double blinded study to compare the analgesic effects of intraarticular neostigmine, morphine, tenoxicam, clonidine and bupivacaine in 150 patients undergoing arthroscopic knee surgery. General anaesthesia protocol was same in all patients. At the end of the surgical procedure, patients were randomized into six intraarticular groups equally. Group N received 500 mug neostigmine, Group M received 2 mg morphine, Group T received 20 mg tenoxicam, Group C received 1 microg kg(-1) clonidine, Group B received 100 mg bupivacaine and Group S received saline 20 ml. Visual analog scale scores 0, 30 and 60 min and 2, 4, 6, 12, 24, 48 and 72 h, time to first analgesic need, analgesic consumption at 48 h and 72 h and side effects were noted. Demographic and operational parameters were similar in six groups. All study groups provided analgesia when compared with saline group (P<0.05). Duration of analgesia in Group N and C was longer than other groups (P<0.001). Analgesic consumptions of Group N, C and T were lower than other groups (P<0.01). Pain scores during 2 h postoperatively were lower in all study groups than the control group (P<0.001). In Group B, median pain scores were higher than Groups N and C at 0 min and 30 min postoperatively (P<0.001). Side effects were not significantly different among the six groups. We conclude that the most effective drugs that are administered intraarticularly are neostigmine and clonidine among the five drugs we studied. Tenoxicam provided longer analgesia when compared with morphine and bupivacaine, postoperatively.

Comparison of the analgesic efficacy and plasma concentrations of high-dose intra-articular and intramuscular morphine for knee arthroscopy

It is important to provide good postoperative analgesia after discharge from day case surgery. The usefulness of intra-articular morphine for analgesia after day case knee arthroscopy remains controversial. A large dose of morphine intra-articularly may provide a good long-lasting analgesia, but its efficacy and pharmacokinetics are not known and may be no better than intramuscular morphine. We compared the effect of 10 mg intra-articular and intramuscular morphine for 24 h post-injection in a randomized double-blind study. Forty adults undergoing knee arthroscopy were recruited and received either 10mg morphine intra-articularly or intramuscularly. Our primary outcome was overall visual analogue assessment of pain (0-100 mm scale where 0 is no pain and 100 is worst possible pain) between 4 h (on discharge) and 24 h (post-operatively). Plasma morphine concentrations were measured at 15 min, and 1, 2, 4 and 24 h. The use of additional analgesia was noted. The assessment of pain experienced between discharge (4 h) and 24 h was significantly better in the intra-articular (n = 20; mean+/-SD: 18+/-19) than the intramuscular (n = 19; mean+/-SD: 34+/-20) group (P = 0.027). The number of patients consuming any additional analgesia between discharge and 24 h was significantly lower in the intra-articular morphine group (P = 0.038), with 4 (20%) patients in the intra-articular group and 11 (60%) patients in the intramuscular group consuming supplementary analgesia. There were no differences in plasma morphine concentrations between the groups. A large dose of intra-articular morphine provided better analgesia than the same dose of intramuscular morphine, low plasma morphine levels suggesting a peripheral mechanism.