L. Ø. Andersen

High-volume infiltration analgesia in total knee arthroplasty : a randomized, double-blind, placebo-controlled trial

Background: High‐volume infiltration analgesia may be effective with a low risk of side effects in hip and knee arthroplasty. The present placebo‐controlled study was carried out to evaluate the analgesic effect of high‐volume infiltration analgesia in bilateral total knee arthroplasty, along with a detailed description of the infiltration technique.

A compression bandage improves local infiltration analgesia in total knee arthroplasty.

Background High-volume local infiltration analgesia has been shown to be an effective pain treatment after knee replacement, but the role of bandaging to prolong analgesia has not been evaluated. Methods 48 patients undergoing fast-track total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive a compression or a non-compression bandage, and pain was assessed at rest and with mobilization at regular intervals for 24 h postoperatively. Results Pain at rest, during flexion, or on straight leg lift was lower for the first 8 h in patients with compression bandage than in those with non-compression bandage and with a similar low use of oxycodone. Mean hospital stay was similar (2.8 days and 3.3 days, respectively). Interpretation A compression bandage is recommended to improve analgesia after high-volume local infiltration analgesia in total knee arthroplasty.

The role of pain for early rehabilitation in fast track total knee arthroplasty

Purpose. To investigate the relationship between early functional mobility and pain intensity in a fast track program after total knee arthroplasty (TKA). Methods. One hundred consecutive patients operated with TKA in an orthopaedic unit at a University hospital were prospectively studied. Measurements of independence in transfer and ambulation (Cumulated Ambulation Score), pain intensity (Verbal Analog Scale (VAS)), range of knee motion, functional mobility (‘Timed Up & Go’ (TUG) test), and walking distance were recorded daily from the first postoperative day until discharge. Results. On the first postoperative day, 90% of the patients were able to walk independently with median pain intensity of ≤5 on VAS. Of these, 78% walked > 70 m. All patients walked independently on postoperative Day 2 with pain intensity of ≤4. On the day of discharge, all patients walked with crutches with pain intensity of ≤3, walking distance > 70 m, median range of motion 10–80°, and median test time of the ‘TUG’ 19.2 s. The length of hospital stay was median 3 days. Conclusion. Pain has a limited influence on the functional recovery beyond the first postoperative day after TKA, thereby allowing early physiotherapy.

Local anesthetics after total knee arthroplasty: intraarticular or extraarticular administration? A randomized, double-blind, placebo-controlled study.

Background High-volume local infiltration analgesia with additional intraarticular and wound administration of local anesthetic has been shown to be effective after knee replacement, but the optimum site of administration of the local anesthetic (i.e. intraarticular or extraarticular) has not been evaluated. Patients and methods 32 patients undergoing total knee replacement with high-volume (170 mL) 0.2% ropivacaine infiltration analgesia were randomized to receive injection of 20 mL ropivacaine (0.2%) intraarticularly plus 30 mL saline in the extraarticular wound space 24 hours postoperatively or to receive 20 mL ropivacaine (0.2%) intraarticularly plus 30 mL ropivacaine (0.2%) in the extraarticular wound space 24 hours postoperatively. Pain intensity at rest and with mobilization was recorded for 4 hours after administration of additional local anesthetics. Results Intensity of pain at rest, during flexion, or straight leg lift was not statistically significantly different between the two groups, but there was a tendency of improved analgesia with administration of additional local anesthetic in the extraarticular wound space. Interpretation The optimal site of administration of local anesthetic in total knee arthroplasty cannot be determined from the present study. However, the insignificant analgesic effect from additional administration of extraarticular local anaesthetic may have been due to the relatively low pain scores observed 24 h postoperatively, confirming the efficiency of the high-volume infiltration analgesia technique. Further studies are required to define the optimal site of administration of local anesthetic following knee replacement surgery.

High-volume infiltration analgesia in bilateral hip arthroplasty: A randomized, double-blind placebo-controlled trial

Background and purpose High-volume infiltration analgesia may be effective in postoperative pain management after hip arthroplasty but methodological problems prevent exact interpretation of previous studies. Methods In a randomized, double-blind placebo-controlled trial in 12 patients undergoing bilateral total hip arthroplasty (THA) in a fast-track setting, saline or high-volume (170 mL) ropivacaine (0.2%) with epinephrine (1:100,000) was administered to the wound intraoperatively along with supplementary postoperative injections via an intraarticular epidural catheter. Oral analgesia was instituted preoperatively with a multimodal regimen (gabapentin, celecoxib, and acetaminophen). Pain was assessed repeatedly for 48 hours postoperatively, at rest and with 45° hip flexion. Results Pain scores were low and similar between ropivacaine and saline administration. Median hospital stay was 4 (range 2–7) days. Interpretation Intraoperative high-volume infiltration with 0.2% ropivacaine with repeated intraarticular injections postoperatively may not give a clinically relevant analgesic effect in THA when combined with a multimodal oral analgesic regimen with gabapentin, celecoxib, and acetaminophen.

Analgesic efficacy of subcutaneous local anaesthetic wound infiltration in bilateral knee arthroplasty: a randomised, placebo-controlled, double-blind trial

Background: High‐volume wound local infiltration analgesia is effective in knee arthroplasty, but the analgesic efficacy of subcutaneous wound infiltration has not been evaluated.

Wound spread of radiolabeled saline with multi- versus few-hole catheters.

Background and Objectives: Continuous wound infusion of local anesthetics is effective in postoperative pain management and may be useful in major joint arthroplasty, but the optimal technique for postoperative administration of local anesthetics in the wound awaits trials evaluating the optimal type of catheter (single-, few-, or multiholed catheters). Methods: Sixteen patients undergoing total hip arthroplasty were randomized to intraoperative subfascial placement of a triple-orifice epidural catheter or a 15-cm multiholed catheter. Twenty milliliters of technetium Tc 99m diethylenetriaminepentaacetic acid-labeled saline was injected postoperatively and wound spread for 10 mins was recorded with a double-head gamma camera. Results: Mean (SD) wound spread (cm2) was the same with administration through a multiholed catheter versus the epidural catheter in both anterior (89 [15] versus 82 [20], P = 0.4) and lateral (68 [19] versus 60 [11], P = 0.3) projections. Conclusions: Wound spread of a bolus injection through 15-cm multiholed catheters versus triple-orifice epidural catheters is similar with subfascial catheter placement in total hip arthroplasty. Procedure-specific trials are required to evaluate the analgesic efficacy of postoperative administration of local anesthetic in the wound with different types of catheter before general recommendations can be made.