Intra-articular Injection Of Bupivacaine Research Articles

Ultrasound Guided Suprascapular Nerve Block Combined with Intra-Articular Injection of Bupivacaine versus Ultrasound-Guided Interscalene Nerve Block in Shoulder Arthroscopy

Abstract Background Severe intraoperative and postoperative pain associated with arthroscopic shoulder surgery has a high incidence reaching up to 45%; it is often significant enough to interfere with initial recovery and rehabilitation. This pain is difficult to manage without large doses of opioids. Objective To compare Interscalene nerve block ISNB with the suprascapular nerve and Intra- articular injection (SSNB+IAI) for postoperative analgesia after shoulder arthroscopic surgery guided with ultrasound. Patients and Methods This is a prospective, randomized, double-blinded study, that was carried out in Ain Shams University Educational Hospitals, through a period of six months. Results The ISNB and SSNB+IAI have the same efficacy for postoperative analgesia after shoulder arthroscopy done for different purposes. A non-significant difference in patient satisfaction assessed 24-hour post-operative, with p-value 0.054. There is a significant difference between the two groups regarding the reported complications, with a p-value of 0.017. Highly significant difference between the two groups regarding phrenic nerve paresis which is assessed using diaphragmatic ultrasound, with a p-value of 0.000. Based on our results we recommend further studies on larger patients and longer periods of follow-up to emphasize our conclusion. Conclusion ISNB and SSNB+IAI provided similar postoperative analgesia and patient satisfaction, but the higher rate of complications in ISNB made the SSNB+IAI superior for use in arthroscopic shoulder surgery.

“Ultrasound-guided suprascapular nerve block combined with intra-articular injection of bupivacaine versus ultrasound-guided interscalene nerve block in shoulder arthroscopy”

“Ultrasound-guided suprascapular nerve block combined with intra-articular injection of bupivacaine versus ultrasound-guided interscalene nerve block in shoulder arthroscopy”

Is there a difference in the analgesic response to intra-articular bupivacaine injection in people with knee osteoarthritis pain with or without central sensitisation? Protocol of a feasibility randomised controlled trial

IntroductionPain is the main symptom of osteoarthritis (OA) with approximately 50% of patients reporting moderate-to-severe pain. Total knee replacement (TKR) is the ultimate treatment option to alleviate pain in knee...

Erector spinae plane block versus intraarticular injection of local anesthetic for postoperative analgesia in patients undergoing shoulder arthroscopy: A randomized controlled study

ABSTRACT Background To improve the outcome after shoulder arthroscopy, effective pain control is needed. We aimed to compare the efficacy of ultrasound (US) guided erector spinae plane block (ESPB) versus the intraarticular injection (IAI) of bupivacaine in managing postoperative pain in patients undergoing shoulder arthroscopy. Methods This prospective randomized, double-blind, parallel-controlled trial was conducted on sixty patients aged 18–60 years of either gender, BMI < 40 kg/m2, American Society of Anesthesiologists physical status I–II, posted for elective shoulder arthroscopy. Patients were randomly allocated into two equal groups. Group IA: received IAI using 20 ml of bupivacaine 0.25% done through the surgical port by the surgeon after closure of the shoulder capsule and sham ESBP. Group ES: received US guided ESPB at the T2 level using 20 ml bupivacaine 0.25% after the end of surgery and sham IAI. Results Postoperative visual analogue scale (VAS), heart rate and mean arterial blood pressure were significantly decreased at 30 min, 1 h, 2 h, 8 h, 12 h and 24 h in group ES compared to group IA. VAS increased at 4 h, 6 h in group ES compared to group IA. The time of first postoperative analgesic requirement was significantly increased in group ES compared to group IA. The total diclofenac consumption over 1st 24 hrs postoperatively was decreased in group ES compared to group IA. Conclusion US-guided ESPB controlled postoperative pain effectively in patients undergoing shoulder surgeries with superiority over IAI of bupivacaine.

Evaluation of intra-articular injection of bupivacaine with morphine or methylprednisolone or alone on pain after knee arthroscopy

Background and Aim: Knee arthroscopy is used to diagnose and treat intra-articular lesions. Controlling acute pain after arthroscopy requires the use of a method with the least side effects and the most efficiency. The aim of this study was to compare the sedative effect after intra-articular injection of bupivacaine combination with morphine or methylprednisolone or alone in knee arthroscopy. Materials and Methods: In this study clinical-randomized three-blind trial, 99 volunteer patients with knee arthroscopy were randomly divided into three groups: 1. Bupivacaine (0.5%), 2. Morphine (5 mg)+ bupivacaine (0.5%) and 3. Methylprednisolone (40 mg) + bupivacaine (0.5%). At the end of the operation, drugs were injected intra-articular and the amount of postoperative pain was evaluated and recorded based on visual analog scales 6, 12, 18, and 24 hours after injection. Also, receiving the injected analgesic within 24 hours, was recorded. Data were analyzed using SPSS software and repeated measures analysis of variance. Results: In all three groups, the pain intensity decreased significantly over time. The pain intensity of the methylprednisolone + bupivacaine and morphine+bupivacaine group was the similar, at different postoperative periods, but the pain intensity of these groups was significantly lower than the control. Also, consumption of the analgesics was significantly reduced in methylprednisolone+bupivacaine group compared to the two other groups. Conclusion: The results of this study showed that intra-articular injection of methylprednisolone + bupivacaine and morphine+bupivacaine was more effective than bupivacaine alone in reducing pain and the need for injectable analgesia.

Comparison of Pain Scores and Medication Usage Between Three Pain Control Strategies for Pediatric Anterior Cruciate Ligament Surgery.

IntroductionAssessment and management of postoperative pain in the pediatric population after anterior cruciate ligament (ACL) surgery can be challenging; the optimal approach to pain control remains controversial. Recent studies show that use of intraoperative nerve blocks may reduce the need for opioids to control pain in the postoperative period. However, it is unclear which block type is most beneficial in the pediatric outpatient setting. This study compared effectiveness of pain control among three different pain management strategies.MethodsWe retrospectively reviewed charts of patients aged 12-17 years who received an elective ACL reconstruction between 2013 and 2017. The three groups were femoral nerve block, combined femoral and sciatic block, and intraarticular injection of bupivacaine (n = 50 per group). The primary variable was postoperative pain scores (visual analog scale 1-10) in the postanesthesia care unit (PACU).ResultsLess than 50% of patients in the combined nerve block group had opioids intraoperatively or in the PACU compared with nearly 100% of patients in the other two groups (p < 0.0001). Also, for patients receiving opioids, the total intraoperative morphine equivalents and PACU pain scores (all patients) were significantly less in the combined block group (p < 0.001). For patients receiving opioids in the PACU, the total morphine equivalents were significantly higher in the intraarticular injection group compared with the nerve block groups (p < 0.0001).ConclusionPatients in the combined femoral and sciatic nerve block group had significantly better pain scores in the PACU with less cumulative morphine equivalent consumption compared with the femoral nerve block group and the intraarticular injection group.

COMPARISON OF POSTOPERATIVE PAIN SCORES AND MEDICATION USAGE BETWEEN THREE PAIN CONTROL STRATEGIES FOR PEDIATRIC ANTERIOR CRUCIATE LIGAMENT (ACL) SURGERY

Background: Assessment and management of postoperative pain in the pediatric population after ACL surgery can be challenging, and the optimal approach to pain control remains controversial. Recent studies have shown that the use of intraoperative nerve blocks may reduce the need for opioids to control pain in the immediate postoperative period. However, it is not clear which block type is the most beneficial for the pediatric outpatient setting. The objective of our study was to compare effectiveness of pain control between three different pain management strategies in the pediatric ACL population. Methods: A retrospective chart review from 2013-2017 of patients ages 12-17 receiving an elective ACL reconstruction. Three types of analgesia were included: femoral nerve block, combined femoral + sciatic block, and intraarticular injection of bupivacaine with cold therapy in the Post Anesthesia Care Unit (PACU) (each used by three different surgeons as their standard preference in three different hospitals), n = 50 per group. The primary variable was postoperative pain scores (visual analog scale 1-10) in the PACU. Secondary variables collected were demographic data, graft type, time in PACU and intraoperative/postoperative opioid use. Results: The mean (+ SD) age of the cohort was 15.3 + 1.4 years; there were no differences in age, BMI or ratio of boys and girls between the 3 groups (n=50 per group). However, the femoral nerve block group had a significantly lower percentage of Caucasians (28%, P = 0.002) compared to the group with combined blocks (58%) and intraarticular injection (56%). Less than 50% of patients in the combined nerve block group had opioids intraoperatively or in the PACU compared to nearly 100% of patients in the other two groups (P &lt; 0.0001). Also, for patients receiving opioids, the total intraoperative morphine equivalents and PACU pain scores (all patients) were significantly less in the combined block group (P &lt; 0.001). For patients receiving opioids in the PACU, the total morphine equivalents was significantly higher in the intraarticular injection group compared to the nerve block groups (P &lt; 0.0001). Total time in the PACU was 25% longer for patients in the combined block group (P &lt; 0.0001). Conclusion: Patients in the combined femoral and sciatic nerve block group had significantly better pain scores in the PACU with less cumulative morphine equivalent consumption compared to the femoral nerve block group and the intraarticular injection group.

Improved rehabilitation and functional outcome with dedicated joint irrigation at the end of ACL reconstruction

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; ACL is most common ligament injured during sports. Postoperative pain and swelling is one of the major limiting factors for the rehabilitation of ACL reconstructed patients. Cryotherapy and intra-articular bupivacaine injection are few measures to reduce the pain. One of the main reason for pain is inflammatory mediators, by joint irrigation it reduce the inflammatory mediator that reduce pain and swelling.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; We treated 33 patients of ACL injury with arthroscopic ACL reconstruction from July 2015 to April 2017. Postoperative pain and swellings were assed with VAS and suprapatellar fullness. VAS assessment done on 1&lt;sup&gt;st&lt;/sup&gt; day, 2&lt;sup&gt;nd&lt;/sup&gt; day and 12&lt;sup&gt;th&lt;/sup&gt; day and for swelling 2&lt;sup&gt;nd&lt;/sup&gt; day and 12&lt;sup&gt;th&lt;/sup&gt; day. We had used closed loop endobutton for femur and bioscrew for tibia. In twenty patients at the end of the surgery we used 2 liter saline for joint irrigation.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; As a result of wash of pro inflammatory mediators and debris, there were reduced inflammation which reduces pain and swelling. Patients who received irrigation had less VAS score and suprapatellar fullness than the other group. There was better knee flexion on 12&lt;sup&gt;th&lt;/sup&gt; day.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Adding up a dedicated joint irrigation at the end of surgery does not deviate from standard surgical protocol. No studies have stress upon joint irrigation. It reduce the pain and swelling by reducing inflammation which gives better result.&lt;/p&gt;&lt;p class="abstract"&gt; &lt;/p&gt;

Effects of Multiple Intra-articular Injections of 0.5% Bupivacaine on Normal and Osteoarthritic Joints in Rats

To determine the invivo effects of multiple local anesthetic injections of 0.5% bupivacaine on normal and osteoarthritic articular cartilage. Rats with normal knee joints received an intra-articular injection of 0.9% saline solution or 0.5% bupivacaine in their right knees joint once a week for 5 consecutive weeks, starting 4weeks after the beginning of the experiment. Rats were humanely killed at 8, 16, and 24weeks. In a parallel experiment, rats underwent anterior cruciate ligament transection to induce osteoarthritic changes. These rats were subjected to the same protocol as those with normal knee joints, starting 4weeks after the procedure. Static weight-bearing tests were performed on both hind limbs to evaluate changes in weight-bearing ability throughout the experiments. Rats were humanely killed at 8 and 16weeks. Cell viability was assessed with confocal microscopy, using samples from the distal femur. Histologic assessment of osteoarthritis was performed using samples from the tibial plateau based on the Osteoarthritis Research Society International (OARSI) cartilage histopathology assessment system (i.e., OARSI score). Static weight-bearing tests showed no significant changes after intra-articular injection of saline solution or bupivacaine, and bupivacaine injection did not increase weight bearing compared with saline solution injection, regardless of whether there were osteoarthritic changes. There were also no significant differences in cell viability, cell density, or OARSI scores between the saline solution and bupivacaine groups at each time point, regardless of whether osteoarthritic changes were induced. This study suggested that single or intermittent intra-articular bupivacaine injections might not have deleterious effects on either osteoarthritic or normal joints. There is no strong evidence that intra-articular bupivacaine injection induces degenerative changes in articular cartilage. Therefore, these results may apply to normal and osteoarthritic joints.

Does Reducing the Concentration of Bupivacaine When Performing Therapeutic Shoulder Joint Injections Impact the Clinical Outcome?

Mixtures of local anesthetics and steroids are routinely injected intraarticularly to temporarily relieve joint pain, even though local anesthetics have been reported to cause chondrocyte death in a dose- and time-dependent manner. This study aimed to determine if intraarticular injections of bupivacaine 0.5% and bupivacaine 0.25% would provide similar pain relief. All fluoroscopically guided glenohumeral joint injections performed using 2.5 mL of bupivacaine and 0.5 mL (20 mg) of triamcinolone acetonide over a 42-month period were included if a pain score was recorded before, 5-10 minutes after, and 1 week after injection. Pain reduction of more than 2 points was considered much improved clinically with pain reduction of more than 1 point considered the minimum clinically important difference (MCID) threshold. Statistically significant and much improved pain reduction was achieved using both bupivacaine 0.5% and 0.25% 5-10 minutes (-3.7 points; 95% CI, -3.4 to -4.0 points; p ≤ 0.001; and -3.3 points; 95% CI, -3.0 to -3.5 points; p ≤ 0.001) and 1 week (-2.5 points; 95% CI, -2.2 to -2.9 points; p ≤ 0.001; and -2.1 points; 95% CI, -1.8 to -2.3 points; p ≤ 0.001) after injection, respectively. Adjusting for age, sex, pain score before injection, and indication, the mean decrease in pain was greater in the bupivacaine 0.5% group by 0.30 points 5-10 minutes after injection (95% CI, -0.03 to 0.63 points; p = 0.08) and 0.46 points 1 week after injection (95% CI, 0.13-0.77 points; p = 0.01). Both bupivacaine 0.5% and bupivacaine 0.25% provide statistically significant and much improved pain relief 5-10 minutes and 1 week after intraarticular glenohumeral injections. Bupivacaine 0.5% provided greater pain relief than bupivacaine 0.25%, but the difference was less than 0.5 points and therefore did not meet the MCID threshold.

Synovial fluid bupivacaine concentrations following single intra‐articular injection in normal and osteoarthritic canine stifles

Intra-articular bupivacaine helps alleviate pain in animals receiving joint surgery, but its use has become controversial as ex vivo studies have illuminated the potential for chondrotoxicity. Such studies typically involve cell cultures incubated in solutions containing high bupivacaine concentrations for long durations. The aim of this study was to measure the actual synovial fluid bupivacaine concentrations after intra-articular injection. Eight healthy beagles with normal stifles and 22 large and giant-breed dogs with stifle osteoarthritis (OA) were treated with a single intra-articular injection of bupivacaine (1 mg/kg) into a stifle. Joint fluid samples were taken from the treated stifle immediately after injection and 30 min after injection and analyzed for bupivacaine concentrations. Immediately after injection, the median bupivacaine concentrations in normal and OA stifles were 3.6 and 2.5 mg/mL, respectively. Thirty minutes after injection, bupivacaine concentrations in normal and OA stifles were 0.4 and 0.6 mg/mL, respectively. These results provide insight into the pharmacokinetics of bupivacaine after injection into a joint. Given its immediate dilution and rapid drop in synovial fluid concentration, bupivacaine is unlikely to damage chondrocytes when administered as a single intra-articular injection.

A Retrospective Review of Femoral Nerve Block for Postoperative Analgesia After Knee Surgery in the Pediatric Population

To investigate the outcomes of pediatric patients receiving a femoral nerve block (FNB) in addition to general anesthesia for arthroscopic knee surgery compared with those receiving general anesthesia alone. This retrospective review included all patients undergoing arthroscopic knee surgery from January 2009 to January 2011 under general anesthesia both with and without a FNB. After the induction of general anesthesia, those patients selected for regional anesthesia received a FNB using real-time ultrasound or nerve stimulator guidance. For the FNB, 0.2 to 0.4 mL/kg of local anesthetic solution was injected around the femoral nerve at the level of the inguinal crease. Intra-articular injection of bupivacaine (0.25%, 10 mL) was administered by the surgeon for all patients not receiving a FNB. Additional analgesic medications, PACU length of stay, duration of hospitalization, hospital course, and any acute or nonacute complications were recorded and evaluated. There were no adverse effects related to the FNB. Using a 0 to 10 visual analogue scale (0=no pain), there was a statistically significant difference in both the high (4.0 ± 4.0 vs. 5.3 ± 3.1, P=0.0004) and low (1.5 ± 1.8 vs. 2.1 ± 2.0, P=0.002) pain scores in patients who received a FNB versus those who did not with the scores being lower in those who had received a FNB. There was a decreased need for the use of opioids postoperatively (61% vs. 71%, P=0.04) and a decreased duration of postoperative stay in patients who were admitted to the hospital (11.7 ± 8.1 vs. 15.8 ± 10 h, P=0.044) in individuals who had a FNB. There was a significantly lower admission rate in patients undergoing anterior cruciate ligament repair in the FNB group (72% vs. 95%, P=0.001). There was no difference in the incidence of postoperative nausea and vomiting between the groups. After arthroscopic knee surgery in pediatric patients, a FNB shortens hospital stay, reduces opioid requirements, and decreases postoperative pain scores. For anterior cruciate ligament repairs, FNB lowers postoperative admission rates. Level III.

Intra-Articular Bupivacaine Reduces Postoperative Pain and Meperidine Use After Total Hip Arthroplasty: A Randomized, Double-Blind Study

One hundred patients receiving unilateral total hip arthroplasty (THA) were randomized to receive an intra-articular injection of 300mg bupivacaine or normal saline after completion of surgery. Pain scores of the bupivacaine group were significantly lower than those of the control group the first 12hours postoperatively (all, P<0.001). A significantly lower dose of meperidine was used in the study group than in the control group the first 24hours postoperatively (median, 25 vs. 45mg, P<0.001). Nineteen patients in the study group required meperidine the first day after surgery, as compared to 45 patients in the control group. We conclude that intra-articular injection of bupivacaine after THA reduces pain and meperidine use in the first 12hours after surgery.

The Efficacy of Intra-Articular Injections for Pain Control Following the Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures

The purpose of this single-blinded, randomized, controlled trial was to compare the analgesic efficacy of intra-articular injections of bupivacaine or ropivacaine with that of no injection for postoperative pain control after the operative treatment of supracondylar humeral fractures in a pediatric population. Subjects (n=124) were randomized to treatment with 0.25% bupivacaine (Group B) (n=42), 0.20% ropivacaine (Group R) (n=39), or no injection (Group C) (n=43). The opioid doses and the times of administration as well as child-reported pain severity (Faces Pain Scale-Revised) and parent-reported pain severity (Total Quality Pain Management survey) were recorded. The proportion of subjects who required morphine and/or fentanyl injections was significantly (p=0.004) lower in Group B (10%) as compared with Group R (36%) and Group C (44%). On the basis of the log-rank test, the opioid-free survival rates were significantly greater in Group B as compared to Groups C and R. Total opioid consumption (morphine equivalent mg/kg) in the first seventy-two hours postoperatively was significantly less in Group B as compared with Group C (mean difference, 0.225; [95% confidence interval (CI), 0.0152 to 0.435]; p=0.036). Parent-reported pain scores were also significantly lower in Group B as compared with both Group C (mean difference, 1.81 [95% CI, 0.38 to 3.25]; p=0.014) and Group R (mean difference, 1.66; 95% CI, 0.20 to 3.12; p=0.027). There were no significant differences across the three groups in terms of self-reported pain. Differences between Groups R and C were not significant for any of the outcome variables. The intra-articular injection of 0.25% bupivacaine significantly improves postoperative pain control following the closed reduction and percutaneous pinning of supracondylar humeral fractures in pediatric patients.

Reply to: Letter regarding manuscript: KSST-D-11-00615R3: ‘A randomised controlled trial for the effectiveness of intra-articular Ropivacaine and Bupivacaine on pain after knee arthroscopy: the DUPRA (DUtch Pain Relief after Arthroscopy)-trial’

Dear Sirs, Thank you for your interest in our manuscript. With pleasure, we took time to read your comments. In general, we would like to state that it is obvious that high level of evidence research costs time for design of a study, time for the study to be executed and results to be analysed and subsequently for the results to be published. In this time period, the evidence- and eminence-based opinion based on latest literature can change. This, however, does not implicate that results from randomised clinical trials with negative outcome should not be shared with the research community. Allow us to comment that you quote the study performed by Farkas et al. [3]. This study is methodologically very solid. However, it remains an in vitro study with partly monolayer cultures tested, and partly with osteochondral samples, where both had long times of exposure to the agents, and in the osteochondral sample group, only the superficial layer was affected. There are also in vivo studies to quote when commenting that intra-articular use of Bupivacaine seems not safe. The DUPRA trial was primarily designed to come up with level 1 evidence regarding the effectiveness of single dose intra-articular Ropivacaine and Bupivacaine after arthroscopy. During the design of the DUPRA trial, the first in vivo studies on the safety aspects of intra-articular injection of Bupivacaine were not yet published, and therefore the DUPRA trial was without concern regarding safety approved by the medical ethical committee of the University of Utrecht. During inclusion, publications on the safety of intra-articular Bupivacaine and Ropivacaine came out; the first being an in vitro study by Chu et al. [2]. Other in vitro studies followed and raised general concern. The first well-designed in vivo studies were published in 2010 [1]. At this time, inclusion of our study was completed and data analysis was started. Study results were then presented at congress meetings as well as a manuscript was written and prepared for publication in the KSSTA journal. Although the aforementioned information gives a clear picture on how it works in the field of research and publication, we felt that the information from the DUPRA trial was still very much worth sharing with other researchers in the field considering that our outcomes provide an extra definitive argument to stop with the daily use of intra-articular injection of Bupivacaine or Ropivacaine after arthroscopy. Allow us to explain. In daily practice, the discussion on safety aspects remained viable for the use of single-shot, low doses of an intra-articular injection with Bupivacaine or Ropivacaine, simply because of the fact that numerous colleagues were not convinced of the chondrotoxic effect of low-dose single-shot intra-articular injections—Bupivacaine and Ropivacaine have time- and dose-dependent chondrotoxicity [3–5]—and were convinced advocates of the beneficial effect on pain reduction of these aforementioned low doses. The DUPRA trial failed to demonstrate clinically relevant beneficial effects of both Bupivacaine and Ropivacaine and therefore ends the discussion. Hence, there is no need to argue on the details of the safety aspects of low-dose single-shot intra-articular injections at all anymore, since there is no clinically relevant beneficial aspect to be expected.

Supraphysiologic Temperature Enhances Cytotoxic Effects of Bupivacaine on Bovine Articular Chondrocytes in an In Vitro Study

The purpose of this study was to determine the effects of temperature or 0.25% bupivacaine treatment in combination with supraphysiologic temperatures on chondrocyte viability. Bovine articular chondrocytes in suspension culture were treated with phosphate-buffered saline solution at 20°C, 37°C, 40°C, 42°C, 45°C, 47°C, and 50°C for 15, 30, and 60 minutes or with phosphate-buffered saline solution at 37°C, 45°C, and 50°C for 30 and 60 minutes followed by 0.25% bupivacaine at 20°C for 60 minutes. Chondrocyte viability was analyzed by flow cytometry with the LIVE/DEAD Viability/Cytotoxicity Kit (Molecular Probes, Eugene, OR). Annexin V and ethidium double staining determined whether apoptosis or necrosis occurred. Temperatures from 20°C to 42°C did not cause chondrocyte death. Temperatures at or above 45°C caused significant chondrocyte death, particularly at 50°C for 60 minutes, compared with 37°C at 60 minutes (P < .01). When the chondrocytes were incubated at 50°C, subsequent exposure to bupivacaine significantly increased chondrocyte death compared with the saline solution-treated control group (P < .001). There were additive cytotoxic effects when bupivacaine was combined with supraphysiologic temperatures. It was also found that bupivacaine at supraphysiologic temperatures caused necrosis of articular chondrocytes. Temperatures at or above 45°C caused significant chondrocyte death. Bupivacaine treatment in the presence of 45°C and 50°C temperatures significantly increased necrosis of bovine articular chondrocytes in this in vitro study. Immediate intra-articular injection of bupivacaine after heat-generating procedures may cause damage to the cartilage because of the additive cytotoxic effects of bupivacaine and elevated temperature.

Comparison of intra-articular injections of Hyaluronic Acid and Corticosteroid in the treatment of Osteoarthritis of the hip in comparison with intra-articular injections of Bupivacaine. Design of a prospective, randomized, controlled study with blinding of the patients and outcome assessors

BackgroundAlthough intra-articular hyaluronic acid is well established as a treatment for osteoarthritis of the knee, its use in hip osteoarthritis is not based on large randomized controlled trials. There is a need for more rigorously designed studies on hip osteoarthritis treatment as this subject is still very much under debate.Methods/DesignRandomized, controlled trial with a three-armed, parallel-group design. Approximately 315 patients complying with the inclusion and exclusion criteria will be randomized into one of the following treatment groups: infiltration of the hip joint with hyaluronic acid, with a corticosteroid or with 0.125% bupivacaine.The following outcome measure instruments will be assessed at baseline, i.e. before the intra-articular injection of one of the study products, and then again at six weeks, 3 and 6 months after the initial injection: Pain (100 mm VAS), Harris Hip Score and HOOS, patient assessment of their clinical status (worse, stable or better then at the time of enrollment) and intake of pain rescue medication (number per week). In addition patients will be asked if they have complications/adverse events. The six-month follow-up period for all patients will begin on the date the first injection is administered.DiscussionThis randomized, controlled, three-arm study will hopefully provide robust information on two of the intra-articular treatments used in hip osteoarthritis, in comparison to bupivacaine.Trial registrationNCT01079455

Intra-Articular Morphine for Postoperative Analgesia in Knee Arthroscopy

THERE exists evidence that in addition to their central effects opioids can produce potent antinociceptive effects by interacting with opioid receptors in peripheral tissue. The recent growth in outpatient surgery has presented new challenges in the field of postoperative pain management. The search continues for an ideal analgesic technique that is site specific, long-lasting easily administered and has a high therapeutic safety index. Arthroscopic surgery of the knee is a common outpatient procedure. Although intra-articular injection of bupivacaine following arthroscopy has been demonstrated to be safe and effective in providing postoperative analgesia, the mean duration of analgesia is only two hour. More recently longer lasting analgesia has been achieved using intra-articular morphine, although the onset of analgesia may be delayed.

The Analgesic Effect of Postoperative Combined Epidural, Soft Tissue, and Intra-articular Injection of Morphine and Bupivacaine in Patients undergoing Total Knee Arthroplasty

Background: Epidural opioids and local anesthetics provide excellent postoperative analgesia. In addition, soft tissue and intra-articular injection of bupivacaine and morphine may have a beneficial analgesic effects after total knee arthroplasty (TKA). This study was designed to assess the additional analgesic effect of combined soft tissue, and intra-articular injection of morphine and bupivacaine in patients undergoing TKA under spinal anesthesia with continuous epidural morphine and bupivacaine injection. Methods: Forty patients aged 55 to 75 years for a TKA under spinal anesthesia were randomly divided into 2 groups. The both group of patients received a continuous epidural infusion using a two-day infusor containing morphine 5 mg in 100 ml of 0.125% bupivacaine. The experimental group of patients (n = 20) received soft tissue, and intra-articular injection containing 10 mg morphine in 100 ml bupivacaine 0.125%. The control group of patients (n = 20) received soft tissue, and intra-articular injection of 100 ml normal saline. Postoperative pain was assessed using the visual analog scale (VAS) at 1, 2, 4, 8, 12, 24, and 48 h postoperatively and side effects, such as hypotension, nausea, vomiting, pruritus, and respiratory distress were recorded. Whenever patients demanded supplemental analgesia, diclofenac sodium 75 mg was injected intramuscularly and the need for additional analgesic requirement was recorded. Results: The experimental group of patients had significantly lower pain score and analgesic requirements than the control group for 2 days. There was no difference in the incidence of side effects between groups. Conclusions: Combined soft tissue, and intra-articular injection of morphine and bupivacaine with continuous epidural morphine and bupivacaine infusion reduces postoperative pain and supplementary analgesic requirements than continuous epidural morphine and bupivacaine infusion only in patients undergoing TKA.

Intra-articular corticosteroid hip injections: a review of 63 consecutive patients

In our study of 63 consecutive patients, we present the result of prospective intra-articular injections of bupivacaine and methylprednisolone acetate for osteoarthritis of the hip. Fluoroscopically guided intra-articular hip injections were performed in operating theatre. The effectiveness of the injection was assessed by the help of oxford hip score and was measured before the injection and then at 3 months after the injection. At 3 months, fifty-one patients (81%) showed improvement, four patients (6.3%) showed no improvement while eight patients (12.7%) were worse off after the injection. Two patients had thigh numbness after the procedure, which improved later. No statistical differences were found in the pre-injection and post-injection Oxford hip scores. We conclude that intra-articular hip injections of bupivacaine and methylprednisolone is a safe technique, which can be used with care in patients deemed not fit for hip replacement.