Multimodal Drug Injection Research Articles

Efficacy of multimodal drug injection after supramalleolar osteotomy for varus ankle osteoarthritis: A prospective randomized study.

Optimal management of postoperative pain is important to ensure patient comfort and functional improvement. Despite the frequent use of multimodal drug injection for pain control after orthopedic surgery, few studies have evaluated its use after supramalleolar osteotomy. Supramalleolar osteotomy was performed in 62 patients (65 ankles). Thirty patients (31 ankles) were randomly assigned to receive multimodal drug injection (injection group) and 32 patients (34 ankles) were assigned to receive no multimodal drug injection (control group). The two groups were compared with regard to the degree of postoperative pain, the number of times patients pushed the patient-controlled analgesia (PCA) button, the total amount of fentanyl administered, and the frequency of additional diclofenac sodium injections. The injection group had significant pain reduction during the first 36 postoperative hours compared to the control group. There were significant differences between the groups in the number of times that patients pushed the PCA button as well as the total amount of fentanyl administered up to 24h postoperatively. The mean frequency of additional diclofenac sodium injections in the first 12 postoperative hours was significantly less in the injection group compared to that in the control group. Multimodal drug injection was effective in reducing pain and decreasing both fentanyl and diclofenac sodium usage in patients undergoing supramalleolar osteotomy. Therefore, multimodal drug injection should be considered for improved pain control and patient comfort in the early postoperative period after supramalleolar osteotomy.

Periarticular multimodal drug injection improves post-operative pain and functional recovery after total knee arthroplasty.

This study retrospectively compared the clinical benefits of periarticular multimodal drug injection (PMDI) and continuous femoral nerve block (CFNB) after total knee arthroplasty (TKA). From 2010 to 2012, 520 primary TKAs were performed, and patients were treated with CFNB or PMDI after surgery. Patients who underwent simultaneous bilateral TKA were excluded, leaving 185 and 166 patients in the CFNB and PMDI groups, respectively. Numeric rating scale for pain (NRS) scores and analgesic consumption were evaluated to compare the effectiveness of pain control between the groups. Further, range of motion (ROM), extension lag, the time to recovery of functions, and postoperative C-reactive protein (CRP) levels were monitored. Complications such as deep infection were assessed. The PMDI group displayed a significantly smaller NRS score on postoperative day (POD) 1 and lower analgesic consumption on PODs 0 and 1. The times to functional recovery were significantly shorter and the extension lag was smaller in the PMDI group. Furthermore, CRP levels were lower in the PMDI group by POD 7. No obvious deep infections were noted. Our results indicate that PMDI induced earlier functional recovery after TKA than CFNB, partially via its analgesic effect.

Efficacy of periarticular injection applied trough knee other than posterior capsule in simultaneous bilateral total knee arthroplasty

BackgroundWe aimed to evaluate periarticular multimodal drug injection (PMDI) in bilateral total knee arthroplasty. MethodsIn 154 knees of 77 patients, PMDI was administered intraoperatively through the regions other than posterior capsule to one knee; other knee was control. ResultsDrug-injected knees had lower visual analog scale scores and higher passive range of motion postoperatively (p < 0.05). The active straight leg raise was higher in drug-injected knees (47 [61%] vs 19 [24.7%], p = 0.001). ConclusionsPMDI is a safe and effective method of early postoperative pain management in total knee arthroplasty when applied through regions other than posterior capsule.

Efficacy of Periarticular Multimodal Drug Injection After Medial Opening-Wedge High Tibial Osteotomy: A Randomized, Controlled Study

The purpose of this study was to evaluate the efficacy of periarticular multimodal drug injection after medial opening-wedge high tibial osteotomy regarding the postoperative pain level. From January 2011 to January 2012, 70 patients underwent medial opening-wedge high tibial osteotomy. Thirty-five patients were randomly assigned to receive no injection (group I), and 35 patients were assigned to receive periarticular multimodal drug injection (group II). These 2 groups were compared regarding the postoperative pain level, frequency of additional nonsteroidal anti-inflammatory drug injections, total amount of patient-controlled analgesia, and number of times that patients pushed the patient-controlled analgesia button at each time interval. Statistical results were based on multivariate analysis of variance and repeated-measures analyses. Multivariate analysis of variance of mean visual analog scale (VAS) scores over the 2-week postoperative period showed statistical significance (P < .001). Repeated-measures analysis yielded a statistically significant difference (P= .001) for the time-by-treatment interaction, showing a clear periarticular multimodal drug injection benefit over time based on VAS scores. In addition, the mean number of times that patients pushed the patient-controlled analgesia button differed significantly between groups over time (P= .01). The VAS scores, frequency of additional nonsteroidal anti-inflammatory drug injections, mean number of times that patients pushed the patient-controlled analgesia button, and mean total amount of fentanyl consumption differed significantly within each group over time (P < .001 for all variables). However, the frequency of additional nonsteroidal anti-inflammatory drug injections and mean total amount of fentanyl consumption did not differ significantly between groups over time (P= .822, P= .529, and P= .282). Opioid- and injection-related complications were not found. This prospective randomized study shows that intraoperative periarticular multimodal drug injections in patients undergoing medial opening-wedge high tibial osteotomy for unicompartmental osteoarthritis of the knee could result in significant reductions in VAS scores at 2weeks postoperatively. Level I, high-quality randomized controlled trial with statistically significant differences.

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

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

Relationship between muscle strength and knee pain in knee osteoarthritis patients

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

The Efficacy of Periarticular Multimodal Drug Injection for Postoperative Pain Management in Total Knee or Hip Arthroplasty

The efficacy of periarticular multimodal drug injection (PMDI) to reduce pain after total knee or hip arthroplasty (TKA or THA) still remains controversial. Our study aimed at evaluating the efficacy of PMDI after TKA or THA. A fully recursive literature search was conducted to identify relevant randomized controlled trials. Ultimately, 21 studies were included in the analysis. Pooled results showed that the PMDI group had better pain relief, less opioid consumption, larger range of motion, and lower rates of nausea and vomiting than the placebo group. No significant difference was seen in regard to the length of hospital stay between the two groups. In conclusion, PMDI should be recommended for the pain management after TKA or THA.

Periarticular multimodal drug injection in total knee arthroplasty

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

Is Pain After TKA Better with Periarticular Injection or Intrathecal Morphine?

Postoperative pain after TKA is a major concern to patients. The best technique to control pain is still controversial. Intrathecal morphine or periarticular multimodal drug injection are both commonly used and both appear to provide better pain control than placebo, but it is unclear whether one or the other provides better pain control. We asked whether intrathecal morphine or periarticular multimodal drug injection provides better pain control with fewer adverse events. In a prospective, double-blind, randomized controlled trial we randomized 57 patients with osteoarthritic knees who underwent TKAs into two groups. Group M (n = 28) received 0.2 mg intrathecal morphine while Group I (n = 29) received periarticular multimodal drug injection. Postoperative pain was managed with patient-controlled analgesia using ketorolac. The outcomes were pain levels, the amount of analgesic drug used, and drug-related side effects. Patients and evaluators were blinded. All patients were followed up to 3 months. We found no difference in postoperative pain level, analgesia drug consumption, blood loss in drain, and knee function. More patients in Group M required antiemetic (19 [69%] versus 10 [34%]) and antipruritic drugs (10 [36%] versus three [10%]) than patients in Group I. The two techniques provide no different pain control capacity. The periarticular multimodal drug injection was associated with lower rates of vomiting and pruritus.

Use of Reduced-Dose Periarticular Injection for Pain Management in Simultaneous Bilateral Total Knee Arthroplasty

We investigated the safety and efficacy of the bilateral periarticular multimodal drug injection (PMDI) at a reduced dosage in patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). In total, 45 patients undergoing SBTKA received 65 mL PMDI in each knee (reduced-dose group). The incidence of drug-related adverse effects and wound complications were evaluated. Pain levels during the night of the operation and postoperative day 1 and opioid consumption during the first 24 hours after surgery were compared with the regular-dose group of 55 patients undergoing SBTKA who received 100 mL of PMDI in 1 knee. No patient experienced a serious drug-related adverse effect or wound complication. Blood levels of ropivacaine were observed to be lower than a toxic level throughout the monitored period in all patients examined. Patients in the reduced-dose group experienced less pain during the night of operation, but a similar pain level at postoperative day 1.

Pain Management by Periarticular Multimodal Drug Injection After Anterior Cruciate Ligament Reconstruction: A Randomized, Controlled Study

We aimed to determine the efficacy of periarticular (PA) multimodal drug cocktail (MDC) infiltration for pain control after anterior cruciate ligament reconstruction with an autogenous bone-patellar tendon-bone graft. We randomly assigned 100 patients to five study groups (20 per group): control group, no injection; intra-articular (IA) ropivacaine group, IA injection of ropivacaine alone; IA MDC group, IA injection of MDC; PA MDC group, PA injection of MDC; and IA + PA MDC group, IA and PA injections of MDC. The MDC consisted of ropivacaine, morphine, ketorolac, epinephrine, and cefuroxime. The five groups were compared in terms of pain levels during the first night after surgery and on postoperative days 1, 2, and 14; patient satisfaction was assessed on postoperative day 14. The PA MDC and IA + PA MDC groups had less pain during the first night than patients in the other three groups (P < .001) and were more likely to have the same amount of pain or less pain on postoperative day 1 than their preoperative expectation (P = .05). However, there were no group differences in patient satisfaction on postoperative day 14. No MDC-related side effect was reported. The MDC injection, particularly when delivered periarticularly, provides an effective, safe means of reducing early postoperative pain after anterior cruciate ligament reconstruction at minimal cost. In addition, a single IA injection would have no value in pain relief, regardless of types of drugs. Level I, randomized controlled trial.

Comparason of Peri-Articular Multimodal Drug Injection with Femoral and Sciatic Nerve Block after Total Knee Arthroplasty

Good perioperative analgesia following total knee arthroplasty facilitates rehabilitation and may reduce hospital stay. We present the patient analgesic requirements and rehabilitation of a prospective single surgeon series after the introduction of a multimodal drug injection during his total knee arthroplasty. Basic epidemiological data as well as analgesic, antiemetic requirements and time to straight leg raised was collected on 27 consecutive patients (group 1) whom received the multimodal drug injection, consisting of levobupivacaine, ketorolac and adrenaline at the time of their total knee arthroplasty under spinal anaesthesia. Their rehabilitation was compared to a retrospective review of patients who were case matched by age and sex (group 2n = 26), whom had received the unit standard of spinal anaesthetic and a femoral and sciatic block at the time of their operation. Patients in group 1 had significantly lower analgesic and antiemetic requirements than group 2. Group 1 also had a significantly shorter hospital stay. We have demonstrated that periarticular multimodal drug injection can improve perioperative analgesia and mobilisation following total knee arthroplasty as well as reducing opioid requirements and side effects.

Pain management after total knee arthroplasty using periarticular multimodal drug injection

Pain management after total knee arthroplasty using periarticular multimodal drug injection

Is Intra-Articular Multimodal Drug Injection Effective in Pain Management After Total Knee Arthroplasty?: A Randomized, Double-Blinded, Prospective Study

We performed a prospective, double-blinded, randomized, and controlled study to assess the clinical efficacy and safety of intra-articular multimodal drug injection after total knee arthroplasty. Two hundred eighty-six patients undergoing simultaneous bilateral total knee arthroplasty were randomized to receive the injection of multimodal drugs in one knee and normal saline solution as a placebo in the contralateral knee. All patients received patient-controlled analgesia for 48 hours after surgery, followed by standard analgesia. Visual analog scores for pain during activity and rest and for patient satisfaction were recorded. The range of motion and blood loss were also recorded. Intraoperative intra-articular injection of multimodal drugs into the knee did not improve patient pain and satisfaction, range of motion, or blood loss compared with the placebo control.

Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA?: A randomised, controlled study

Although the analgesic effects of periarticular multimodal drug injection (PMDI) after TKA have been well documented, there is little information about additional pain relieving effects of PMDI incorporated to contemporary multimodal pain control protocols which have been proved to provide excellent analgesia. We performed a parallel-group, randomised, controlled study to determine whether PMDI provides additional clinical benefits on contemporary multimodal analgesic protocols including preemptive analgesics, continuous femoral nerve block, and IV-PCA. Eighty-seven patients were randomized to a PMDI group (n=45) or to a No-PMDI group (n=42). Pain level and opioid consumption were compared as primary outcomes. The incidences of narcotic and ropivacaine related side effects and complications, functional recovery, and satisfaction were also compared. The PMDI group experienced less pain during the operation night and the 1st postoperative day and showed lower opioid consumption over 24h after surgery. However, the PMDI group had a higher VAS pain score on the 1st postoperative day than during the operation night. No group differences in side-effects and complication incidences, functional recovery, and satisfaction were found. This study demonstrates that PMDI provides additional pain relief and reduces opioid consumption only during the early postoperative period in patients managed by the contemporary pain management protocol following TKA.

Pain Control after Total Hip Replacement Arthroplasty Using Periarticular Multimodal Drug Injection

Purpose: This study attempted to evaluate the pattern of change of the pain after total hip arthroplasty (THA) and to confirm the effect of periarticular multimodal drug injection (PMDI) on controlling the early postoperative pain. Materials and Methods: Of the total patients who underwent primary THA at our hospital because of osteonecrosis of the femoral head from March to October 2008, 60 patients were enrolled in this study. The subjects were divided into three groups. Groups 1 & 2 received periarticular injection. Group 1 included the patients who were injected with a combination of opioid, long-acting local anesthetics, a non-steroidal anti-inflammatory drug and epinephrine. Group 2 received a combination of morphine and ropivacaine and group 3 was not injected with any analgesics. The visual analogue scale (VAS) at 4 hours, 8 hours, 12 hours, 24 hours, 2 days, 3 days, 5 days, 14 days and 1 month after surgery, the frequency that patients pushed the self-controlled pain medication machine for 2 days after surgery and the amount of clonac that was injected according to the needs of the patients were used as objective measures. Results: The VAS score at postoperative 4 hours to 3 days among the groups showed a significant difference (P 0.05). The frequency of pushing the self-controlled pain medication machine among the groups and the amount of clonac according to the needs of the patients among the groups showed that there were significant decreases at the operation day, the postoperative 1, 2 day and the 3 days (P<0.05). Conclusion: PMDI has a significant effect on controlling the early postoperative pain after THA.

The Efficacy of Periarticular Multimodal Drug Infiltration in Total Hip Arthroplasty

Patient-controlled analgesia is a widely used and effective method of controlling pain after THA. This method is associated with substantial undesirable side effects. Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively, but its ability to reduce pain without complications is still questioned. We evaluated patient-controlled analgesia use, pain and satisfaction scores, complication rates, and ropivacaine levels associated with the use of periarticular multimodal drug infiltration in THA. We randomized 64 patients undergoing THA to receive a periarticular intraoperative multimodal drug injection or to receive no injection. All patients received patient-controlled analgesia for 24 hours after surgery. The final assessment was at 6 weeks. Patients receiving the periarticular injection used less patient-controlled analgesia 6 hours postoperatively. The 24-hour patient-controlled analgesia requirement postsurgery also was less. The visual analog scale score for pain on activity in the postanesthetic care unit was less for patients who received an injection. The visual analog scale satisfaction score was similar in the two groups throughout the followup period. Recorded unbound ropivacaine levels were 2.5 times lower than toxic levels. Periarticular intraoperative injection with multimodal drugs can reduce postoperative patient-controlled analgesia requirements and pain on activity in patients undergoing THA with no apparent increase in risk. Level I, therapeutic study. See the guidelines online for a complete description of level of evidence.

Promoting the Use of Periarticular Multimodal Drug Injection for Total Knee Arthroplasty

Postoperative pain in total knee arthroplasty is a challenge that affects the facets of an optimal recovery process. Adequate pain management can be achieved with traditional methods, such as parenteral opioids, epidural analgesic, and peripheral nerve blocks, but is often associated with disruptive side effects, mostly attributed to the opioids. Periarticular multimodal drug injection is an efficient alternative form of postoperative analgesia with minimal risk for opioid-related side effects. The purpose of this article is to describe the use and effectiveness of periarticular multimodal drug injection for postoperative pain management and accentuate the potential consequent effects of effective pain control. Comparative differentiation of this method with other forms of pain management modality is illustrated with strong emphasis on safety and efficacy.

Promoting the Use of Periarticular Multimodal Drug Injection for Total Knee Arthroplasty

Promoting the Use of Periarticular Multimodal Drug Injection for Total Knee Arthroplasty

Efficacy of Periarticular Multimodal Drug Injection in Total Knee Arthroplasty

Postoperative analgesia with the use of parenteral opioids or epidural analgesia can be associated with troublesome side effects. Good perioperative analgesia facilitates rehabilitation, improves patient satisfaction, and may reduce the hospital stay. We investigated the analgesic effect of locally injected drugs around a total knee prosthesis. Sixty-four patients undergoing total knee arthroplasty were randomized either to receive a periarticular intraoperative injection containing ropivacaine, ketorolac, epimorphine, and epinephrine or to receive no injection. The perioperative analgesic regimen was standardized. All patients in both groups received patient-controlled analgesia for twenty-four hours after the surgery, and this was followed by standard analgesia. Visual analog scores for pain, during activity and at rest, and for patient satisfaction were recorded preoperatively and postoperatively and at the six-week follow-up examination. The consumption of patient-controlled analgesia at specific postoperative time-points and the overall analgesic requirement were measured. The patients who had received the injection used significantly less patient-controlled analgesia at six hours, at twelve hours, and over the first twenty-four hours after the surgery. In addition, they had higher visual analog scores for patient satisfaction and lower visual analog scores for pain during activity in the post-anesthetic-care unit and four hours after the operation. No cardiac or central nervous system toxicity was observed. Intraoperative periarticular injection with multimodal drugs can significantly reduce the requirements for patient-controlled analgesia and improve patient satisfaction, with no apparent risks, following total knee arthroplasty.