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CASE REPORT

Controlling pain after total knee arthroplasty using a multimodal protocol with local periarticular injections

Tsuyoshi Nakai, MD,PhD, Toshiyuki Nakamura, MD, Takaaki Nakai, MD, Atsunori Onishi MD, and Kunihiko Hashimoto, MD

 

Department of Orthopaedic Suregery, Itami City Hospital, Itami, Japan

 

Address for Correspondence

Tsuyoshi Nakai, MD, PhD

Department of Orthopaedic Surgery , Itami City Hospital, 1-100 Koyaike, Itami, Japan

Tel: +81 -72-777-3773

E-mail:tsuyoshi223@gmail.com tsuyoshi223@gmail.com

 

 

Abstract:

The postoperative analgesic effects of periarticular injections of multimodal drug cocktail of an

analgesic drug and an opioid were examined prospectively in 60 patients who had total knee arthroplasty for osteoarthritis.

They were divided randomly into three groups. Group A (20 knees; control group), this group did not receive multimodal drug

cocktail therapy; group B (21 knees), received intra-articular injection of a mixture (30ml) containing 0.5% bupivacaine (20ml),

10mg of morphine hydrochloride (1ml), 0.3mg of epinephrine (0.3ml), and sterile normal saline (8.7ml);

and group C (19 knees), received local periarticular injection of 50 ml of a mixture containing 0.75% ropivacaine (30 ml),

10 mg of morphine hydrochloride (1 ml), 4 mg of betamethasone (1 ml), 0.25 mg of epinephrine (0.25 ml), and saline (17.75 ml) before and after implant placement.

All analgesics administered in the first 24 hours after surgery were recorded. The patients rated their pain on a visual analog scale at 4 and 24 hours.

The VAS scores on the day of surgery and the amounts of diclofenac sodium used indicated good pain relief in groups B and C; The level of pain

control was higher in group C than in group B. Periarticular

injection with multimodal drugs can significantly reduce the requirements for analgesia, with no apparent risks, following total

knee arthroplasty. Total knee arthroplasty (TKA) is performed for pain relief, normal joint motion, and a deformity correction of the

knee.

Postoperative analgesia can be achieved by a variety of techniques such as intravenous analgesia, epidural analgesia, and peripheral nerve block techniques. Local injection of a multimodal drug cocktail consisting of an analgesic drug and an opioid is both safe and easy to administer for pain management following TKA. In this study, we prospectively compared the efficacy and side effects of treatments for pain control between a group in which no multimodal drug cocktail therapy was used following TKA and 2 groups in which different drugs and methods of administration were employed.

 

Keywords:

Pain control, Total knee arthroplasty, periarticular injection

 

Methods

The study participants included 60 patients (11 men and 49 women) who had undergone unilateral TKA between June 2010 and February 2012 for previously diagnosed

osteoarthritis of the knee (Table 1). All they had written informed consent. Exclusion criteria were major psychological problems, previous drug dependency, allergies to any

of the ingredients of the injection, renal insufficiency, abnormal liver enzymes, a history of stroke or a major neurological deficit, or uncontrolled angina and bifascicullar

blocks with prolonged QT intervals. The mean age of the participants was 75.6 years. Two different knee devices were used in this study: Zimmer NexGen LPS Flex was used in 5

1 patients and Zimmer NexGen CR-Flex in 9. The patients were divided randomly into 3 groups: group A (20 knees; control group), this group did not receive multimodal drug

cocktail therapy; group B (21 knees), received intra-articular injection of a mixture (30ml) containing 0.5% bupivacaine (20ml), 10mg of morphine hydrochloride (1ml), 0.3mg of

epinephrine (0.3ml), and sterile normal saline (8.7ml); and group C (19 knees), received local periarticular injection of 50 ml of a mixture containing 0.75% ropivacaine (30 ml),

10 mg of morphine hydrochloride (1 ml), 4 mg of betamethasone (1 ml), 0.25 mg of epinephrine (0.25ml), and saline (17.75 ml) before and after implant placement. Operative

anesthesia was all genera, and anesthesia regimen was standardized. TKA was performed through a mini medial para-patellar approach. Pain assessment was conducted using 5 examination parameters.

A visual analog scale (VAS) was used to assess pain 4 h after the patients returned to their recovery rooms and 24 h after surgery. Assessment of flexion angles was conducted at postoperative week 1 and

at the conclusion of the study. The amounts of diclofenac sodium suppository used during 24 h after the surgery were quantitated. The number of days required to achieve assisted ambulation with a walking cane was recorded.

The nature and frequency of side effects were also recorded. Chi-square test and analysis of variance were used for statistical testing, and the level of significance was set at P < 0.05

 

 

Results :

The mean VAS scores on the day of surgery were 65.0 for group A, 51.7 for group B, and 29.2 for group C,

with significant differences observed between the scores of groups A and C and groups B and C. The mean VAS scores 24 h

after surgery were 45.0 for group A, 55.3 for group B, and 41.3 for group C, with no significant intergroup differences (Figure 1).

The amounts of diclofenac sodium suppository used during the 24-h period after the surgery were 61.3 mg for group A, 25.0 mg

for group B, and 13.2 mg for group C, with significant differences noted between groups A and B and groups A and C (Figure 2).

The mean flexion angles at postoperative week 1 were 117.0 for group A, 114.8 for group B, and 113.7 for group C.

Flexion angles at the conclusion of the study were 124.5 for group A, 126.0 for group B, and 122.1 for group C,

with no significant intergroup differences. The mean number of days required to achieve assisted ambulation with a walking cane was

6.3 for group A, 7.0 for group B, and 6.4 for group C, with no significant intergroup differences.

The primary side effects reported were postoperative nausea and vomiting (PONV).

The incidence rates of PONV were 10.0% for group A, 38.1% for group B, and 10.5% for group C, with the incidence observed in group B

eing significantly higher than those in the other 2 groups. No other side effects were reported.  

 

Discussion

According to reports by TKA specialists, local anesthetic drugs, opioids, and epinephrine are the primary agents used to c

ontrol postoperative pain, along with steroids and non-steroidal anti-inflammatory drugs. The typical method of

administration is periarticular injection1), 2), 3), 4). In our previous report, we suggested the possibility of achieving

different degrees of pain control depending on the drugs used in the multimodal drug cocktail therapy and the method of dosing.

5) On the basis of these results, in this study, we compared drug mixtures and administration methods for groups B and

C against the control group A. The VAS scores on the day of surgery and the amount of diclofenac sodium suppository

administered indicated good pain control in the groups that were administered cocktail therapy (B and C), but the level of

pain control was greater in group C than in group B. Because several components of the drug therapy differed between

groups B and C, the most effective agent or combination of agents remains unknown; nevertheless, we considered that the

agents produced synergistic effects. Regarding PONV due to morphine, measures against PONV were initially not taken in group B,

and thus PONV frequently occurred in group B. Therefore, intramuscular administration of 5mg prochlorperazine was initiated

after the patients of group B returned to the recovery room. The drug was effective to varying extents in some patients,

which was not a sufficient measure. Therefore, we referred to the consensus guidelines for managing PONV published in the USA

6) and started intramuscular administration of 5 mg prochlorperazine during the operation followed by intravenous injection of

droperidol 1.25 mg intraoperatively, which significantly improved PONV.

 

Conclusion


The VAS scores on the day of surgery and the amounts of diclofenac sodium used indicated good pain control in groups B and C; 

the level of pain control was higher in group C than in group B.  Regarding the measures taken to prevent PONV, intramuscular

 administration of prochlorperazine 5 mg and intravenous injection of droperidol 1.25 mg were initiated intraoperatively,

which significantly improved PONV.

 

refference:-

    1)Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat A, et al.  Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty 2007 ; 22 : 33-38  

    2)Busch CA, Shore BJ, Bhandari R, Ganapathy S,MacDonald S,et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty: a randomized trial. J Bone Joint Surg 2006 ; 88-A : 959-963

    3)Essving P, Axelsson K, Aberg E, Spannar H, Gupta A, et al. Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial. Anesth Analg 2011 ; 113 : 926-933

    4)Mullaji A , Kanna R, Shetty GM, Chavda V and Singh DP. Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty: a prospective, randomized trial. J Arthroplasty 2010 ; 25 : 851-857

    5)Nakamura T, Tamaki M, Ueda Y, and Nakai T.  Pain management by periarticular cocktail injection after total knee arthroplasty. Central Japan Journal of Orthopaedic Surgery & Traumatology 2011 ; 54 : 665-666

    6)Gan TJ, Meyer T, Apfel CC, Frances C, Peter JD, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg 2003 ; 97 : 62-71

     

Table 1  Subjects

Group A

Group  B

Group C

 

Number of knees

20 

21 

19 

 

Age (years)

75.0

75.0

77.0

NS

Male-to-female ratio

3/17

5/16

3/16

NS

OA grade

(Kellgren Lawrence Classification)

17 grade IV knees

3 grade III knees

16 grade IV knees

5 grade III knees

16 grade IV knees

3 grade III knees

NS

Preoperative extension angles

-7.0

-6.9

-4.7

NS

Preoperative flexion angles

115.5

118.1

118.4

NS

(LPS/CR)

17/3

18/3

16/3

NS

This is a peer reviewed paper 

Please cite as :

J.Orthopaedics 2012;9(4)e5

URL: http://www.jortho.org/2012/9/4/e5

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