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Background and Objectives: Total knee arthroplasty (TKA) is a major procedure which causes severe pain. Adequate pain management promotes rehabilitation and shortens hospital stay. There are several methods for controlling pain after TKA. One of the techniques is local infiltration analgesia (LIA), which is done by injecting the combination of drugs into periarticular tissue. However, variety of drugs can be used for LIA. We aimed to evaluate the postoperative analgesic effect of three different regimens of LIA in TKA patients.
Methods: Retrospective study was conducted in patients who underwent TKA between January 1, 2015 and December 31, 2017 and received one of three different regimens of LIA (group 1; bupivacaine 200 mg plus ketorolac 30 mg and morphine 8 mg, group 2; bupivacaine 200 mg plus ketorolac 60 mg and adrenaline 0.03 mg and group 3; bupivacaine 200 mg plus ketorolac 60 mg, morphine 8 mg and triamcinolone 40 mg) Postoperative morphine consumption, numeric rating pain scores (NRS) at 24 and 48 h and additional analgesic drugs were recorded for assessing pain efficacy. Adverse events were also recorded.
Results: Sixty patients were enrolled, of which 18, 29 and 13 patients received gr.1, 2 and 3 regimen, respectively. Patients’ characteristics were comparable. Postoperative morphine consumption at 24 and 48 h were not different [16.9(12.1), 13.1(8.7) and 12.4(11.1), p = 0.39 and 28.2(15.9), 24.5(14.2) and 22.7(15.6), p = 0.57). Postoperative NRS at rest and on movement were similar at 24 h [3.3(3.1), 2.4(2.5) and 2.3(2.5), p=0.44 and 5.5(3.2), 4.1(3.1) and 4.4(2.1), p=0.28] and at 48 h [2.5(2.5), 2.4(2.2) and 1.8(2.0), p=0.62 and 5.2(1.9), 4.5(2.3) and 4.2(2.1), p=0.39]. All adverse events were similar and no serious complications occurred.
Conclusions: The all three drug regimens of LIA for TKA can relieved postoperative pain to mild pain. The analgesic effect and adverse events were not different among groups.
2. Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, et al. A multimodal analgesia protocal for total knee arthroplasty. A randomized, controlled study. J Bone Joint Surg Am 2006; 88: 282-9.
3. Korean Knee Society. Guidelines for the management of postoperative pain after total knee arthroplasty. Knee Surg Relat Res 2012; 24: 201-7.
4. Veerabhadram G, Christina C. Postoperative pain control. Clin Colon Rectal Surg 2013; 26: 191-6.
5. McNicol E, Ferguson M, Hudcova J. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev 2015; 6: CD003348.
6. Kılıçkaya R, Orak Y, Balcı MA, Balcı F, Ünal İ. Comparison of the effects of intrathecal fentanyl and intrathecal morphine on pain in elective total knee replacement surgery. Pain Res Manag 2016; Article ID 3256583.
7. Choi P, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev 2003; 3: CD003071.
8. Chan EY, Fransen M, Parker DA, Assam PN, Chua N. Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev 2014; 5: CD009941.
9. Marques EMR, Jones HE, Elvers KT, Pyke M, Blom AW, Beswick AD. Local anaesthetic infiltration for peri-operative pain control in total hip and knee replacement: systematic review and meta-analyses of short- and long-term effectiveness. BMC Musculoskelet Disord 2014; 15: 220.
10. Seangleulur A, Vanasbodeekul P, Prapaitrakool S, Worathongchai S, Anothaisintawee T, McEvoy M, Vendittoli PA, Attia J TA. The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty. Eur J Anaesthesiol 2016; 33: 816-31.
11. Bianconi M, Ferraro L, Traina GC, Zanoli G, Antonelli T, Guberti A, et al. Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery Br J Anaesth. 2003; 91: 830-5.
12. Kerr DR, Kohan L. Local infiltration analgesia : a technique for the control of acute postoperative pain following knee and hip surgery : A case study of 325 patients. Acta Orthop 2008; 79: 174-83.
13. Shah VI, Upadhyay S, Shah K, Sheth AN, Kshatriya A, Saini D. Multimodal cocktail injection relieves postoperative pain and improves early rehabilitation following total knee replacement: A prospective, blinded and randomized study. J Recent Adv Pain 2017; 3: 14-24.
14. Niemeläinen M, Kalliovalkama J, Aho AJ, Moilanen T, Eskelinen A. Single periarticular local infiltration analgesia reduces opiate consumption until 48 hours after total knee arthroplasty: A randomized placebo-controlled trial involving 56 patients. Acta Orthop 2014; 85: 614-9.
15. Suthersan M, Pit S, Gordon L, Loman M, Pezzutti B, Freihaut R. Local infiltration analgesia versus standard analgesia in total knee arthroplasty. J Orthop Surg Hong Kong 2015; 23: 198-201.
16. Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Jt Surg 2006; 88: 959-63.
17. Christensen CP, Jacobs CA, Jennings HR. Effect of periarticular corticosteroid injections during total knee arthroplasty. J Bone Jt Surg 2009; 91: 2550-5.
18. McCormack K, Brune K. Dissociation between the antinociceptive and anti- inflammatory effects of the nonsteroidal anti-inflammatory drugs. A survey of their analgesic efficacy. Drugs 1991; 41: 533-47.
19. Stein C. The control of pain in peripheral tissue by opioids. N Engl J Med 1995; 332: 1685-90.
20. Kelley TC, Adams MJ, Mulliken BD, Dalury DF. Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: A randomized, double-blinded study. J Arthroplasty 2013; 28: 1274-7.
21. Jia X feng, Ji Y, Huang G ping, Zhou Y, Long M. Comparison of intrathecal and local infiltration analgesia by morphine for pain management in total knee and hip arthroplasty: A meta-analysis of randomized controlled trial. Int J Surg 2017; 40: 97-108.
22. Spreng UJ, Dahl V, Hjall A, Fagerland MW, Ræder J. High-volume local infiltration analgesia combined with intravenous or local ketorolac plus morphine compared with epidural analgesia after total knee arthroplasty. Br J Anaesth 2010; 105: 675-82.
23. Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tönnesen EK, Søballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: A randomized clinical trial. Acta Orthop 2007; 78: 172–9.