Multimodal Drug Injection Research Articles

Effects of Periarticular Multimodal Drug Injection on Pain Control, Early Mobilization, and Length of Hospital Stay in Patients Undergoing Total Knee Arthroplasty.

We investigated the effects of periarticular multimodal drug injection (PMDI) on postoperative pain control, patients' mobilization, and length of hospital stay in patients undergoing total knee arthroplasty (TKA). We retrospectively enrolled patients who underwent unilateral TKA between 2019 and 2020. The formula for PMDI included 0.5 mL epinephrine (1 mg/mL), 1 mL ketorolac (30 mg/mL), 0.5 mL morphine (10 mg/mL), and 20 mL bupivacaine hydrochloride (5 mg/mL), mixed with 60 mL normal saline. The outcomes of interest included (1) the amount of patient-controlled anesthesia (PCA) consumption in the first 24 h after the surgery, (2) early mobilization within 24 h after the surgery, and (3) the length of hospital stay. A total of 127 patients were analyzed. Compared with patients who did not receive PMDI, those who received PMDI had lower consumption of PCA in the first 24 h (β coefficient -29.9, 95% CI -51.9 to -7.9, p = 0.008), higher odds of early mobilization within 24 h (odds ratio 8.263, 95% CI 3.041 to 22.453, p < 0.001), and shorter length of hospital stay (β coefficient -0.705, 95% CI -1.158 to -0.252, p = 0.003). We suggest that PMDI may be considered for patients undergoing TKA to improve the quality of care and shorten their length of hospital stay.

Comparing preemptive injection of peri-articular-multimodal drug with oral celexocib for postoperative pain management in total knee arthroplasty: A randomized clinical trial.

Total knee arthroplasty (TKA) is associated with tremendous postoperative pain, and pain relief should concisely be considered. This study aims to compare the efficacy of preemptive periarticular multimodal drug injection versus placebo and oral celecoxib on postoperative pain control after TKA. This study is a randomized clinical trial on 146 patients candidate for TKA who were randomly allocated to three treatment groups, including (1) a cocktail consisting of bupivacaine, morphine, epinephrine, and ketorolac (n = 48), (2) only epinephrine (placebo group) (n = 49), and (3) 400 mg celecoxib orally (control group) (n = 49) using the Random Allocation software. The injections and oral therapy were performed within 15 min before the surgical procedure. The study's primary outcome was the Knee Society Score (KSS) calculated at baseline, within 6 weeks and 6 months postoperatively. Range of motion (ROM) and Visual Analog Scale (VAS) to assess pain intensity as the other primary outcomes were evaluated before the procedure, within 24 h, 48 h, and 6 weeks postoperatively. The three studied groups were similar regarding demographic characteristics, including age (P = 0.33), gender distribution (P = 0.65), and involved knee side (P = 0.94). Baseline comparison of KSS (P = 0.39), VAS (P = 0.24), and ROM (P = 0.37) among the groups revealed insignificant differences. All the studied groups showed a statistically significant trend of improvement in KSS, VAS, and ROM (P < 0.001), while the comparison of the three groups in terms of KSS (P = 0.001), VAS (P < 0.001), and ROM (P < 0.001) revealed remarkable superiority of multimodal injection to the other treatments. Preemptive periarticular multimodal drug injection, including bupivacaine, morphine, epinephrine, and ketorolac, can cause considerable postoperative pain relief and better ROM achievement in comparison to placebo or oral celecoxib.

The effect and safety of periarticular multimodal drug injection without morphine and epinephrine in anterior cruciate ligament reconstruction

Background Periarticular multimodal drug injection (PMDI) is a safe and effective pain management technique after anterior cruciate ligament reconstruction (ACLR); however, adding morphine and epinephrine sometimes causes adverse effects. Therefore, we evaluated the efficacy of PMDI without morphine and epinephrine after ACLR. Methods This retrospective matched case-control study included patients who had undergone primary double-bundle ACLR with PMDI and were then matched one-to-one with a control group without PMDI based on sex, age, and body mass index using propensity-matched analysis. The following clinical outcomes were compared between the groups: visual analog scale (VAS) score, C-reactive protein (CRP) concentration, number of times the patients used additional analgesics, complication rate, and postoperative time to achieve straight leg raise (SLR). Results Twenty-nine patients with PMDI and 29 controls were enrolled. The VAS score at 1 day postoperatively was lower in the PMDI than the control group (1.93 ± 1.44 vs. 3.41 ± 1.75, respectively; P &lt; 0.001). The CRP concentration at 1 and 3 days was lower in the PMDI than the control group (0.46 ± 0.47 vs. 1.00 ± 0.69 mg/dL, P &lt; 0.001; and 1.93 ± 1.71 vs. 4.01 ± 2.55 mg/dL, P &lt; 0.001, respectively). The average number of additional analgesics used was significantly lower in the PMDI than the control group. There were no significant differences in the frequency of occurrence of postoperative complications between the two groups. The number of patients who could achieve SLR within 1 day was 27/29 (93%) in PMDI group, which was significantly higher than the control group (12/29, 41%) ( P &lt; 0.001). Conclusion PMDI without morphine and epinephrine after ACLR reduced patients’ subjective pain level, objective inflammatory response without complications and enabled patients to achieve early functional recovery.

Retrospective Comparison of Postoperative Fascia Iliaca Block and Multimodal Drug Injection on Early Function of the Knee in Femoral Fractures Using Retrograde Intramedullary Nailing.

Introduction There is a common concern about the pain and rehabilitation of the knee after femoral retrograde intramedullary nailing. It is essential for early postoperative knee function required for physical self-maintenance in daily life. And a favorable rehabilitation of the knee usually promotes the quality of life. However, early rehabilitation is absent or insufficient for many patients in postoperative management. This retrospective study aims to evaluate the effect of early knee function improvement in comparison to postoperative fascia iliaca blocking (FIB) and multimodal drug injection (MDI). Patients and Methods. A retrospective analysis of 41 patients receiving femoral fracture treatment with retrograde intramedullary nailing, was performed during 2018–2020. 19 patients were treated with MDI as postoperative analgesia, and 22 patients were treated with FIB. Rehabilitation started on the first postoperative day and lasted for 3 months. Visual analog scale (VAS), the range of motion (ROM) of the knee, and single assessment numeric evaluation (SANE) were assessed. Results There was no significant difference shown in any of the demographic, fracture types, and operative time. All patients performed regular and voluntary knee rehabilitation and weight-bearing at home following the instruction from the orthopedic staff. Pain in the FIB group at postoperative 1-day was milder (1.7 ± 1.1), compared with that in the MDI group (2.8 ± 1.3, p=0.038). There was a significant difference in VAS between two groups at postoperative 1-month (p=0.031), with a peak score in the FIB group (3.3 ± 0.9). At postoperative 3-month, both groups had pain relief with similar VAS (p=0.465). The ROM of the knee in both groups was continuously improved during the first three months. The SANE in the MDI group was significantly different compared with FIB at 1-month (p=0.026). However, scores of SANE were similar in both groups at 3 months (p=0.541). All patients were identified as fractures union at 9-month or 12-month follow-up. Conclusion The knee pain was commonly experienced in this series of retrograde femoral nailings. Both MDI and FIB provided immediate and effective pain control after femoral fracture surgery. MDI was more beneficial to continuous pain control and knee rehabilitation in the early follow-up. The extent of pain relief and knee function improvement reached the same level at postoperative 3-month.

How effective is periarticular multimodal drug injection in open elbow arthrolysis? A prospective double-blind randomized controlled trial

Evidence on the efficacy and safety of periarticular multimodal drug injection (PMDI) in open elbow arthrolysis (OEA) is limited. This study aimed to investigate differences in postoperative pain, blood loss, and range of motion (ROM) between PMDI vs. no injection among patients undergoing OEA, and the presence of PMDI-related complications. This prospective, double-blind randomized controlled trial included 59 patients who underwent OEA. Patients randomly received PMDI (ropivacaine, epinephrine, ketoprofen) before wound closure or no injection. The primary outcomes were elbow pain over the first postoperative week at rest and during motion, measured using the visual analog scale (VAS). VAS scores were compared to attain the 20-mm threshold values for a minimum clinically important difference. Parecoxib consumption on OEA night and postoperative days (PODs) 1-3 and total consumption during the first postoperative week were recorded. Blood loss was recorded every 24 hours until POD 3. ROM during rehabilitation was measured daily from day 1 to day 7 after surgery, as well as at 3-month follow-up. Medication-related side effects were recorded prospectively. The mean VAS score showed clinically important differences between PMDI and control groups at rest on OEA night (mean difference [MD], 25 mm; P < .001) and first 3 PODs with motion (POD 1: MD, 28 mm, P < .001; POD 2: MD, 21 mm, P < .001; POD 3: MD, 21 mm, P < .001) but not in other postoperative assessments. Parecoxib consumption was lower in the PMDI group on OEA night and PODs 1-3. Total parecoxib consumption during the first postoperative week was lower in the PMDI group vs. the control group (MD, 148 mg; P < .001). Blood drainage was less in the PMDI group vs. the control group on POD 1 (MD, 38 mL; P = .016) but not on POD 2 (P = .950), POD 3 (P = .259), or total (P = .184). The PMDI group exhibited significantly better ROM during the first 4 PODs than the control group, whereas there was no difference at 3-month follow-up. No medication-related side effects were noted in the PMDI group. PMDI effectively relieves pain and reduces analgesic consumption for OEA patients, without an apparent increase in risks.

Efficacy of Periarticular Multimodal Drug Injection Without NSAIDs in Elderly Patients With Displaced Femoral Neck Fractures Undergoing Bipolar Hemiarthroplasty: A Prospective Triple-Blinded RCT.

IntroductionRecently, periarticular multimodal drug injection (PMDI) has demonstrated the ability to significantly reduce early postoperative pain with hip fractures in the elderly. Nonetheless, data on PMDI without non-steroidal anti-inflammatory drugs (NSAIDs) in these patients are still doubtful. The current study has evaluated the effect of PMDI with NSAIDs in elderly femoral neck fractures (FNFs) underlying bipolar hip arthroplasty (BHA).Materials and methodsA prospective triple-blinded randomized controlled trial (RCT) was conducted in 28 elderly FNFs undergoing BHA. They were randomized into two groups: PMDI group (n=14), which received intraoperative PMDI (50-mL solution of 100-mg bupivacaine, 10-mg morphine, 300-mcg epinephrine, and 750-mg cefuroxime), and a placebo group (n=14), which received only saline solution. The primary outcome was a 10-point visual analog scale (VAS). Secondary outcomes were morphine consumption and cumulative ambulatory score (CAS), postoperative complications, and functional outcomes as a timed up-and-go (TUG) test and Harris hip score (HHS) at two, six, and 12 weeks postoperatively.ResultsThe PMDI group demonstrated a significant reduction in the median VAS at the 48th hour postoperatively as compared to the placebo group (P = 0.019), and a non-significant reduction in the median VAS at the 36th and 60th hours (P = 0.058 and 0.110, respectively) and in a median dosage of morphine consumption on the second postoperative day (P = 0.140). There was no significant difference in postoperative ambulation and functional outcome between both groups (P > 0.05, all).ConclusionThe PMDI regimen without NSAIDs is effective for postoperative analgesia on the second postoperative day in elderly FNFs undergoing BHA without any significant difference in functional outcome or postoperative complications.

Does Surgical-site Multimodal Drug Injection After Palmar Plating of Distal Radius Fractures Improve Pain Scores?

Does Surgical-site Multimodal Drug Injection After Palmar Plating of Distal Radius Fractures Improve Pain Scores?

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

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

Periarticular multimodal drug injection does not improves early postoperative analgesia compared with continuous interscalene brachial plexus block after arthroscopic rotator cuff repair: A retrospective single-center comparative study

BackgroundAlthough continuous interscalene brachial plexus block (CISBPB) is common method in pain management following arthroscopic rotator cuff repair (ARCR), little is known about the analgesic effects of periarticular multimodal drug injection (PMDI) for ARCR. This retrospective study sought to clarify which technique could provide the best analgesic effect after ARCR. MethodsWe retrospectively reviewed consecutive patients who underwent ARCR performed by the same surgeon at our institution between June 2016 and November 2017. Patients who underwent surgery before January 2017 received CISBPB and those who underwent surgery after February 2017 received PMDI for postoperative pain control. Both treatment groups also received fentanyl by intravenous patient-controlled analgesia (IV-PCA). Postoperative pain was evaluated by visual analog scale (VAS) pain scores at 3, 6, 12, 24, and 48 h and need for IV-PCA at 8, 16, and 24 h. ResultsTwenty-eight patients received CISBPB and 21 received PMDI. According to the VAS scores, the postoperative analgesic effect was significantly better in the CISBPB group during the first 6 h (p < 0.05). Total fentanyl consumption by IV-PCA during the first 8 postoperative h was significantly greater in the PMDI group than in the CISBPB group. ConclusionsPMDI does not improve early postoperative analgesia after ARCR compared with CISBPB. CISBPB had a significantly better analgesic effect in the first 8 h postoperatively. Level of evidenceLevel III.

Timing of periarticular injection has no effect on postoperative pain and functional recovery in simultaneous bilateral total knee arthroplasty: a prospective randomized, double-blinded trial

BackgroundGiven no consensus on optimal timeframe of periarticular multimodal drug injection (PMDI) in knee osteoarthritis patients undergoing total knee arthroplasty (TKA), this study was aimed to compare the postoperative pain and the functional recovery in patients who underwent simultaneous bilateral TKA (SBTKA) and received PMDI at the different intraoperative time points.MethodsThis prospective, randomized, double-blinded controlled trial study included 48 patients who underwent SBTKA and received PMDI mixture, either before prosthetic implantation (late PMDI), or just after knee arthrotomy (early PMDI). Each subject’s knees were randomly selected to different PMDI administration time points. The outcome parameters were postoperative pain assessed by using a visual analog scale (VAS), the maximal angle of knee flexion, and quadriceps function from day 1 to 6 weeks after surgery.ResultsLate PMDI revealed slightly higher VAS at 6 and 12 h after the operation than early PMDI administration. Afterward, the VAS tended to be lower in the late than early PMDI administration until the end of the study, but without statistical significance. The time difference between early and late PMDI had no effect on postoperative VAS, while older age resulted in significantly less pain. No statistical differences between the two groups in all other outcome parameters were observed.ConclusionsPostoperative pain reduction and functional recovery of SBTKA with early and late PMDI administration were not significantly different. The time interval of PMDI between knees did not confound the comparison of postoperative pain and functional recovery in SBTKA.Trial registrationThe protocol of this study was retrospectively registered in the Thai Clinical Trials Registry database No.TCTR20170617001 on 16 June 2017.

The effect of morphine added to periarticular multimodal drug injection or spinal anesthesia on pain management and functional recovery after total knee arthroplasty

BackgroundThe efficacy of morphine added to periarticular multimodal drug injection (PMDI) for pain management after total knee arthroplasty (TKA) is controversial. Adding morphine to spinal anesthesia has reportedly improved pain relief for the first 24 h. We examined the effect of morphine added to PMDI or spinal anesthesia on pain management and functional recovery after TKA. MethodsA total of 97 patients were randomized into three groups: in Group A (34 patients), 10 mg morphine was added to PMDI; Group B (31 patients), 0.1 mg morphine was added to spinal anesthesia; and Group C (32 patients), morphine was added to neither the PMDI nor spinal anesthetic. To evaluate the efficacy of added morphine for pain management, we assessed rest pain, the number of times analgesics were used, and the time period until the first analgesic use. The adverse effects of morphine were assessed by counting the numbers of times vomiting occurred and antiemetics were used. Functional recovery was evaluated by recording the range of motion of the knee and the date of ability to walk. ResultsRest pain was the least in Group B at 6 and 12 h after operation. The number of times analgesics were used was the least in Group B. The time period until the first analgesic use was the longest in Group B. The number of vomiting episodes was the least in Group C. The number of times antiemetics were used was higher in Group A than in Group C. There were no significant differences in the range of motion and date of ability to walk among the three groups. ConclusionsThe efficacy of morphine added to PMDI was limited, and that of morphine added to spinal anesthesia disappeared within 20 h postoperatively. Adding morphine to PMDI or spinal anesthesia did not improve functional recovery and caused some adverse effects.

Effect of Surgical-Site, Multimodal Drug Injection on Pain and Stress Biomarkers in Patients Undergoing Plate Fixation for Clavicular Fractures.

BackgroundSurgical-site, multimodal drug injection has recently evolved to be a safe and useful method for multimodal pain management even in patients with musculoskeletal trauma.MethodsFifty consecutive patients who underwent plating for mid-shaft and distal clavicular fractures were included in the study. To evaluate whether surgical-site injections (SIs) have pain management benefits, the patients were divided into two groups (SI and no-SI groups). The injection was administered between the deep and superficial tissues prior to wound closure. The mixture of anesthetics consisted of epinephrine hydrochloride (HCL), morphine sulfate, ropivacaine HCL, and normal saline. The visual analogue scale (VAS) pain scores were measured at 6-hour intervals until postoperative hour (POH) 72; stress biomarkers (dehydroepiandrosterone sulfate [DHEA-S], insulin, and fibrinogen) were measured preoperatively and at POH 24, 48, and 72. In patients who wanted further pain control or had a VAS pain score of 7 points until POH 72, 75 mg of intravenous tramadol was administered, and the intravenous tramadol requirements were also recorded. Other medications were not used for pain management.ResultsThe SI group showed significantly lower VAS pain scores until POH 24, except for POH 18. Tramadol requirement was significantly lower in the SI group until POH 24, except for POH 12 and 18. The mean DHEA-S level significantly decreased in the no-SI group (74.2 ± 47.0 µg/dL) at POH 72 compared to that in the SI group (110.1 ± 87.1 µg/dL; p = 0.046). There was no significant difference in the insulin and fibrinogen levels between the groups. The correlation values between all the biomarkers and VAS pain scores were not significantly different between the two groups (p > 0.05).ConclusionsAfter internal fixation of the clavicular fracture, the surgical-site, multimodal drug injection effectively relieved pain on the day of the surgery without any complications. Therefore, we believe that SI is a safe and effective method for pain management after internal fixation of a clavicular fracture.

Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection and nonsteroidal anti-inflammatory drug use in total knee arthroplasty.

This research examined multimodal analgesia and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for early analgesic effect and rehabilitation after total knee arthroplasty (TKA). A total of 110 patients who were scheduled to undergo TKA were randomly divided into two groups, experimental group and control group. The experimental group received a periarticular multimodal drug injection containing 200 mg ropivacaine, 30 mg ketorolac tromethamine, 0.3 mg epinephrine, and 5 mg hexadecadrol during surgery. The control group received an equal volume of normal saline. All the patients received an analgesia pump and moderate NSAIDs. Resting and motion numeric rating scale (NRS) scores, knee joint range of motion, length of postoperative hospital stay, patient satisfaction, total nonsteroidal anti-inflammatory consumption, and side effects were recorded. The experimental group exhibited significant improvement in pain NRS scores during rest and exercise several days postoperatively. The range of joint motion was more flexible in the experimental group, and the length of postoperative hospital stay was shorter (9.25 ± 1.99 days vs. 10.44 ± 2.62 days, P < 0.05). Patients in the experimental group consumed fewer NSAIDs (965 mg vs. 1325 mg, P < 0.05) and reported greater satisfaction with the surgery. Intraoperative periarticular injection with multimodal drugs significantly relieved pain after surgery and reduced the requirements for NSAIDs. This injection also improved patient satisfaction and the range of joint motion with no apparent risks following TKA.

Periarticular injection and continuous femoral nerve block versus continuous femoral nerve block alone on postoperative opioid consumption and pain control following total knee arthroplasty: Randomized controlled trial

Continuous femoral nerve block (CFNB) has been used to prevent the breakthrough pain after total knee arthroplasty (TKA). Multimodal drug injection (PMDI) has also been shown to decrease opioid consumption and pain. We investigated whether the use of PMDI further improves analgesic and rehabilitation outcomes when used in conjunction with CFNB. This is a prospective randomized controlled study of 44 patients undergoing primary TKA. The treatment group (n=23) received a PMDI of combined ropivacaine, epinephrine, ketorolac and morphine, and the controlled group (n=21) received saline at wound closure. Total opioid consumption, pain scores, knee range of motion (ROM) outcomes, length of stay, and patient satisfaction were measured and compared. The total consumption of morphine is similar between the two groups (52.6±40.6 vs. 41.5±32.9, p=0.325). The mean morphine consumption of the treatment group was significantly lower than the control at 4h after surgery (4.2±5.5 vs. 11.3±8.1, p=0.002) but comparable on POD1, POD2, and POD3. The mean pain scores were significantly higher in the treatment group than the control group at POD2 (at rest: 47.3±29.1 vs. 23.8±20.6, p=0.004; after PT: 57.7±25.4 vs. 35.2±26.8, p=0.007) and POD3 (at rest: 30.9±30.3 vs. 14.8±20.9, p=0.045; after PT: 50.2±30.6 vs. 29.0±32.1, p=0.035), and not significantly different at 4h after surgery or at POD1. Mean maximal knee flexion ROM in degrees during active and active assisted mobilization showed no significant difference between the control and the treatment groups on POD2 and POD3. The mean length of stay of the treatment group is significantly longer than the control group (5.1±2.1 vs. 3.8±1.6, p=0.032). At discharge, no significant difference exists between the two groups for mean patient satisfaction. The addition of PMDI led to a decrease in opioid consumption in the immediate postoperative period but with no significant difference in the total consumption within the first three days postoperatively. This finding provides an opportunity for appropriate preoperative treatment and education for both patients and caregivers.

Efficacy of Surgical-Site, Multimodal Drug Injection Following Operative Management of Femoral Fractures: A Randomized Controlled Trial.

Multimodal analgesia inclusive of periarticular injection with a local anesthetic agent has been rapidly assimilated, with demonstrated safety and efficacy, into the care of patients undergoing elective lower-extremity arthroplasty. The present study was performed to evaluate the efficacy and safety of a surgical-site, multimodal drug injection for postoperative pain control following operative management of femoral fractures. There were 102 patients undergoing operative intervention (plate fixation, intramedullary device, or arthroplasty) for a broad range of femoral fracture patterns who were prospectively randomized either to receive an intraoperative, surgical-site injection into the superficial and deep tissues containing ropivacaine, epinephrine, and morphine or to receive no injection. Visual analog scale (VAS) scores were recorded at regular intervals as the primary outcome measure. Narcotic consumption and medication-related side effects were also monitored. The injection group demonstrated significantly lower VAS scores (p < 0.05) than the control cohort in the recovery room and at the 4, 8, and 12-hour postoperative time points. The median score (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group immediately postoperatively, 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours, 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours, and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours. Additionally, narcotic consumption was significantly lower (p = 0.007) in the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]) over the first 8 hours following the surgical procedure. No cardiac or central nervous system toxicity was observed secondary to infiltration of the local anesthetic. Surgical-site injection with a multimodal analgesic cocktail provides improved pain control and reduces narcotic utilization over the first postoperative day, with no observed adverse effects attributable to the local injection, across a diverse orthopaedic trauma population undergoing operative intervention for femoral fractures. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Anterior vs Posterior Periarticular Multimodal Drug Injections: A Randomized, Controlled Trial in Simultaneous Bilateral Total Knee Arthroplasty

BackgroundCurrently, various techniques are used to overcome postoperative pain after total knee arthroplasty. A local analgesic infiltration with periarticular multimodal drug injection (PMDI) is favorable because of its simplicity, safety, and efficacy. The present study compared the efficacy of a PMDI at the anterior vs posterior compartments. MethodsForty-six patients were randomized to receive the PMDI at either the anterior or posterior compartment, with the contralateral knee receiving the PMDI at the opposite compartment. The PMDI injected to the posterior capsule, medial and lateral meniscal remnant, was defined as the posterior compartment injection, whereas the injection to the medial retinaculum, quadriceps muscle, pes anserinus, and retropatellar fat pad was defined as the anterior compartment injection. Pain scores at rest, knee flexion angle, quadriceps function, and drainage blood loss were evaluated in both groups. ResultsThe anterior PMDI group had significantly lower pain scores at rest during 96 hours postoperatively. On the day of discharge, 19 patients (41.3%) favored the knee with the anterior PMDI, which was superior to 9 patients (19.6%) who favored the knee with the posterior PMDI. The anterior PMDI demonstrated a superior recovery of quadriceps function during the same period, but there was no significant difference in terms of other parameters. ConclusionThe PMDI at the anterior compartment can reduce pain after total knee arthroplasty with potentially better quadriceps function compared with that in the PMDI at the posterior compartment. We recommend infiltrating the anterior compartment with a greater amount of PMDI than the posterior compartment.

Pain management of multimodal drug injection in distal radius fracture

Pain management of multimodal drug injection in distal radius fracture

Effects of periarticular injection on analgesic effects and NSAID use in total knee arthroplasty and total hip arthroplasty

OBJECTIVES:This study examined periarticular multimodal drug injection and the use of nonsteroidal anti-inflammatory drugs for an early analgesic effect after total knee arthroplasty and total hip arthroplasty. Patient satisfaction and benefits from the treatment were also assessed.METHODS:A total of 110 patients who were scheduled to undergo total knee arthroplasty and 86 patients who were scheduled to undergo total hip arthroplasty were divided into two groups, the study group and the control group. The study group received a periarticular multimodal drug injection during surgery. The control group received an equal volume of normal saline. All patients received an analgesia pump and a moderate dose of nonsteroidal anti-inflammatory drugs. Resting and motion Numeric Rating Scale scores, the Western Ontario and McMaster Universities Arthritis Index, knee or hip joint range of motion, length of postoperative hospital stay, patient satisfaction, total nonsteroidal anti-inflammatory drug consumption and side effects were recorded.RESULTS:Both study groups exhibited significant improvement in pain Numeric Rating Scale scores during rest and exercise several days after the surgery. The range of joint motion was greater in the study group, and the length of postoperative hospital stay was shorter than that in the control group. Patients in the study group consumed fewer nonsteroidal anti-inflammatory drugs and reported greater satisfaction with surgery.CONCLUSION:Intraoperative periarticular multimodal drug injection significantly relieved pain after surgery and reduced nonsteroidal anti-inflammatory drug consumption. These patient had a better postoperative experience, including satisfaction and rehabilitation.

The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty: A systematic review and meta-analysis.

Local infiltration analgesia (LIA) has emerged as an alternative treatment for postoperative pain after total knee arthroplasty (TKA). Its efficacy remains inconclusive with inconsistent results from previous studies and meta-analyses. There is no agreement on which local anaesthetic agent and infiltration technique is most effective and well tolerated. The objective was to compare LIA after primary TKA with placebo or no infiltration in terms of early postoperative pain relief, mobilisation, length of hospital stay (LOS) and complications when used as a primary treatment or as an adjunct to regional anaesthesia. The role of injection sites, postoperative injection or infusion and multimodal drug injection with ketorolac were also explored. A systematic review and meta-analysis of randomised controlled trials (RCTs). A literature search was performed using PubMed and SCOPUS up to September 2015. RCTs comparing LIA with placebo or no infiltration after primary TKA in terms of pain score and opioid consumption at 24 and 48 h, mobilisation, LOS and complications were included. In total 38 RCTs were included. LIA groups had lower pain scores, opioid consumption and postoperative nausea and vomiting, higher range of motion at 24 h and shorter LOS than no injection or placebo. After subgroup analysis, intraoperative peri-articular but not intra-articular injection had lower pain score at 24 h than no injection or placebo with the pooled mean difference of pain score at rest of -0.89 [95% CI (-1.40 to -0.38); I = 92.0%]. Continuing with postoperative injection or infusion reduced 24-h pain score with the pooled mean difference at rest of -1.50 [95% CI (-1.92 to -1.08); I = 60.5%]. There was no additional benefit in terms of pain relief during activity, opioid consumption, range of movement or LOS when LIA was used as an adjunct to regional anaesthesia. Four out of 735 patients receiving LIA reported deep knee infection, three of whom had had postoperative catheter placement. LIA is effective for acute pain management after TKA. Intraoperative peri-articular but not intra-articular injection may be helpful in pain control up to 24 h. The use of postoperative intra-articular catheter placement is still inconclusive. The benefit of LIA as an adjunctive treatment to regional anaesthesia was not demonstrated.

Comparative Effects of Periarticular Multimodal Drug Injection and Single-Shot Femoral Nerve Block on Pain Following Total Knee Arthroplasty and Factors Influencing Their Effectiveness.

PurposeThis study compared the analgesic effects of local infiltration analgesia (LIA) and femoral nerve block (FNB) after total knee arthroplasty (TKA) and assessed factors associated with analgesia obtained by these two methods.Materials and MethodsStudy subjects included 66 patients (72 knees) who underwent TKA for osteoarthritis of the knee. Pain visual analogue scale (VAS), the amount of analgesics used, number of days to achieve 90° of flexion of the knee joint, date of initiating parallel-bar walking, range of motion of the knee joint at discharge, and adverse events were investigated.ResultsThe VAS scores did not differ significantly between two groups, whereas the amount of analgesics used was significantly lower in the LIA group. Preoperative flexion contracture was significantly more severe in the LIA group with high VAS compared with low VAS. No serious adverse event occurred in the LIA or FNB group.ConclusionsThe lower analgesic usage in the LIA group than the FNB group indicates that the analgesic effect of LIA was greater than that of singleshot FNB after TKA. There were no serious complications in either group. The postoperative analgesic effect of LIA was smaller in patients with severe than less severe preoperative flexion contracture.