A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery

Regional Anesthesia and Pain Medicine 24(5): 430-437, 1999

A Systematic R e v i e w of Intra-articular Local Anesthesia for Postoperative Pain Relief After Arthroscopic Knee Surgery Steen Moiniche, M.D., Soren Mikkelsen, M.D., Jorn Wetterslev, M.D., Ph.D., and Jorgen Berg Dahl, M.D., D.M.Sc.

i

Background and Objeaives. In a systematic review, we have evaluated double-blind, randomized, controlled trials of intra-articular local anesthesia compared with placebo or no treatment in the control of postoperative pain after arthroscopic knee surgery. Methods. Outcome measures were pain scores, supplementary analgesics, and time to first analgesic request. Efficacy was estimated by significant difference (P < .05) as reported in the original reports and by calculation of the weighted mean difference of pain scores between treatment groups. Results. Twenty studies with data from 895 patients were considered appropriate for analysis. Twelve of these 20 studies showed improved pain relief after intra-articular local anesthesia in at least one of the considered pain parameters, whereas the eight other studies were without such improvements. In ten of the positive studies, pain scores were significantly lower in the treatment groups compared with the control groups with visual analog scale (VAS)score reductions of between 10 and 35 mm early (1-4 hours) postoperatively. Quantitative analysis with calculation of the weighted mean difference in VAS confirmed a statistically significant but minor clinicallyimportant effect on postoperative pain scores. In nine studies, the consumption of supplementary analgesics was reduced 10-50% during observation periods of up to 4 hours; however, in most cases, the analgesic requirements were small to moderate. Only in two of six studies, where time to first analgesic request was evaluated, a significant prolongation of pain relief was observed as lasting between 30 and 50 minutes. Conclusions. There is a weak evidence for a reduction of postoperative pain after intra-articular local anesthesia in patients undergoIng arthroscopic knee surgery, which although being small to moderate and of short duration, may be of clinical significance in day-case surgery. Reg Anesth Pain Med 1999:24:430-437. Key words: randomized controlled trials, intra-articular, local anesthetic, arthroscopy, pain, postoperative.

creased attention and m a y be an attractive m e t h o d because of its simplicity, safety and low cost. Intraarticular instillation of local anesthesia during arthroscopic procedures has been used by m a n y orthopedic surgeons, and it has been s h o w n that diagnostic and some m i n o r therapeutic procedures m a y satisfactorily be performed during combined incisional and intra-articular local anesthetic administration alone (1-4). Therefore, intra-articular local anesthesia m a y also be expected to provide reliable postoperative pain relief. Indeed, a recent review of intra-

Recently, peripheral use of local anesthetics for treatment of postoperative pain has gained in-

From the Department of Anesthesiology, Herlev University Hospital, Herlev, Denmark. Accepted for publication April 19, 1999. Reprint requests: Steen Moiniche, M.D., Department of Anesthesiology, Herlev University Hospital, DK-2730 Herlev, Copenhagen, Denmark. Copyright © 1999 by the American Society of Regional Anesthesia. 1098-7339/9912405-001155.0010

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articular morphine for postoperative pain relief after knee arthroscopy claimed that treatment arms with intra-articular local anesthetics served as valid active controls and guaranteed internal sensitivity of evaluated studies (5). However, despite widespread use, intra-articular administration of local anesthetics is inconsistently and randomly used by many orthopedic surgeons, and little consensus is available on if, in which doses, and following which surgical procedures (diagnostic, therapeutic), intraarticular local anesthetics provide clinically relevant postoperative pain relief. Furthermore, it is not clear whether immediate recovery may be improved. This systematic review investigated the effect of intra-articular administration of local anesthetics for postoperative pain control by analyzing pain scores, need for and use of supplementary analgesic, and/or time to first request of analgesics, using the evidence from all relevant randomized, controlled trials (RCT). We also examined trial methodology. This review focused exclusively on intra-articular administration of local anesthesia of the knee.

Methods Reports of prospective RCTs with or without open therapeutic control of intra-articular local anesthesia was systematically sought. Reports were identified using the Cochrane Library (1998, issue 2) and the MEDLINE database without language restriction (last search May 1998). Search terms were "intraarticular," "knee," "postoperative pain," "local anesthesia," "bupivacaine," "lidocaine," "prilocaine," "arthroscopy," and "surgery." Additional reports were identified from reference lists of retrieved reports and review articles. No abstracts, correspondences, or unpublished observations were included. Authors were not contacted for original data. Reports that were included were double-blind, randomized comparisons of intra-articular local anesthesia with placebo (saline) or nonplacebo (no treatment). Only reports dealing with intra-articular treatment of the knee were selected, and only arthroscopic procedures were included. Furthermore, only reports discussing adult patients (defined as age >15 years) were included. Articles unable to list pain as an outcome parameter, or articles unrandomized or not double blinded were not included in this review. Studies of open knee surgery and arthroplasty and intra-articular treatment of joints other than the knee were not considered in the present review. In addition, studies where incisional local anesthetic infiltration of port sites or nerve blocks (e.g., lumbar plexus blocks, 3-in-1 block), or other intra-articular treatment [e.g., opioid, nonsteroidal antinflammatory drugs

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(NSAID)] as a part of the treatment were excluded. Finally, reports or treatment arms of direct comparisons of intra-articular local anesthesia with other treatment modalities (e.g., nerve blocks, epidural analgesia) or with intra-articular opioids were not considered. Each report which met the inclusion criteria was read independently by each of the authors and scored using a 3-item, 1-5 score, quality scale (6). Consensus was subsequently achieved. If the reports were described as randomized, one point was given, and an additional point was given if the method of randomization was described and adequate (computer generated, table of random numbers, etc.). One point was deducted if randomization was inappropriate (alternate randomization, randomization according to weekday, etc.). If studies were described as double-blind, one point was given, and an additional point given if blinding was described and appropriate (blinded pharmacy manufactured ampoules, etc.). One point was deducted if blinding was inappropriate. Finally, reports which described the numbers and reasons for withdrawals were given one point. By definition, studies without randomization and blinding were excluded. Thus, the minimum score of an included RCT was 2, and the maximum score was 5. Information about type of anesthesia (general, regional, or infiltration and intra-articular), number of patients enrolled, and adverse effects was taken from each report. Spinal, epidural, or infiltration anesthesia was not accepted to exclude low pain scores in the immediate postoperative period, perhaps rendering the study as insensitive. Postoperative effectiveness was evaluated by significant difference (P < .05, as reported in the original investigation) in pain relief assessed by pain scores (VAS or similar scores), by time to first analgesic request, and by consumption of supplementary analgesics compared with control. Quantitative analysis of combined data was proposed by calculation of the weighted mean difference of VAS scores 1-4 hours postoperatively between treatment groups, taking into account study size and standard deviations of the VAS scores in the individual trials (using the Review Manager software, version 3.11, Cochrane Collaboration, Copenhagen). Finally, sensitivity of evaluated nonsignificant studies (power of statistical tests) was considered. Any statistical power analysis of individual studies was noted.

Results Thirty-six randomized controlled trials of intraarticular local anesthetic in the knee compared with

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placebo or no treatment were identified. Of these were 16 studies excluded because of inappropriate blinding (7-9); the inclusion of intra-articular ketorolac (i0); use of spinal or epidural anesthesia (1113); consideration of open knee surgery (14-16); and use of indsional local anesthetic infiltration ( 15,17-22), leaving 20 reports for analysis. Table 1 contains a full list of the studies excluded because of these criteria. All 20 reports described arthroscopic surgery of which one study considered only diagnostic proced u r e s - e i g h t reports covered a variety of therapeutic procedures (repair of the meniscus, meniscectomy, chondroplasty and shaving, debridement, etc.), seven reports covered a combination of diagnostic and therapeutic procedures while four reports had no information of the type of arthroscopic procedure. A total of 895 patients, of w h o m 458 received local anesthetic, were studied. The range of number of patients included in the studies was 17-100. The median quality score was 3 (range, 2-5). Details of included studies are shown in Table 2. Quantitative and qualitative analysis was performed using VAS pain scores. For the other outcome measures (supplemental analgesic consumption and time to first analgesic request), only a qualitative analysis was performed because of the variety of analgesics and doses used and because of the lack of sufficient data for a meta-analysis. Instead, any statistical Table 1. T r i a l s E x c l u d e d f r o m C o n s i d e r a t i o n E x c l u d e d Trials (reference) Tolksdorf et al., 1991 (8) Cook et al., 1997 (7) Geutjens et al., 1994 (9) Raja et al., 1992 (13) Ates et al., 1994 (12) Heard et al., 1992 (11) White et al., 1990 (18) Sorensen et al., 1991 (17) Osborne et al., 1993 (19) Jaurequito et al., 1995 (20) M o r r o w et al., 1995 (21) Haynes et al., 1994 (22) H6her et al., 1997 (15)

Badner et al., 1996 (14) M a u e r h a n et al., 1997 (16) Reuben et al., 1995 (10)

Reason Single-blinded No information about doubleblinding No information about doubleblinding Epidural anesthesia Spinal anesthesia Not standardized anesthesia (i.e., general and spinal anesthesia) Combined intra-articular and mcisional local anesthetic Combined intra-articular and incisional local anesthetic Combined intra-articular and incisionaI local anesthetic Combined intra-articular and mcisional local anesthetic Combined intra-articular and mclsionaI local anesthetic Combined intra-articular and incisionaI local anesthetic Combined intra-articular and incisional local anesthetic; open knee surgery Open surgery; total knee arthroplasty Open surgery; total knee arthroplasty Intra-articular ketorolac included in study groups

difference between treatments regarding these outcome measures were extracted from the original reports and documented in table format as done previously for other qualitative systematic reviews.

Effect of Intra-articular Local Anesthesia on Postoperative Pain Scores, Analgesic Consumption, and Time to First Analgesic Request In 17 studies, treatment arms compared intraarticular 10-40 mE 0.25-0.5% bupivacaine with saline. Two studies compared bupivacaine with no treatment (23,24) (Table 2). In one study, 20 mL 1% prilocaine was compared with saline (25). Twelve of these 20 studies showed improved pain relief after intra-articular local anesthesia, as at least one of the evaluated pain parameters was significantly different compared with the control group (24,26-36). In the eight other studies, no effect on pain scores, supplementary analgesic consumption (23,25,37-42), and time to first analgesic request (25,39), whatsoever, was observed. Ten studies showed significantly lower pain scores with VAS reduction of between l0 and 35 m m (Fig. 1) (24,26-34). In most studies, pain scores were only reduced early postoperatively (from 1 to 4 hours after arthroscopy); however, in one study (28), pain scores were reduced up to i2 hours postoperatively. In nine studies, supplementary analgesic consumption was reduced 10-50 %, during observation periods of 1-4 hours (26-29,32-36) (although, no P value was provided in references 32 and 34). Seven of these studies also showed reduction in pain scores (26-29,32-34). Although, statistically significant, the reduction in analgesic requirement was, however, in most cases small to moderate. One study reported a reduction in fentanyl requirement of 25 lJg during the stay in the recovery room (35). On the other hand, another study (28) reported a reduction in mefenamic acid requirements from 1050 mg in the control group to 275 mg in the treatment group over a 24-hour postoperative observation period. It was only in two (26,33) of six studies (25,26,33,35,36,39), where time to first analgesic request was evaluated that a significant prolongation of pain relief was observed, lasting between 30 and 50 minutes. Quantitative analysis, with calculation of the weighted mean difference in VAS scores, was performed using a fixed effect model, as a test for heterogeneity was nonsignificant (P = .80). The analysis revealed a statistically significant but less clinically important overall weighted mean difference in VAS scores of approximately l l m m (95% confidence intervals: 14-7 mm) in favor of the

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T a b l e 2. A r t h r o s c o p i c K n e e S u r g e r y

Quality Score

No. Patients Active/ Control

Bupivacaine Dose (mg)

Pain Score

C h i r w a et al. 1989 (26)

3

79 in total

50

P < .05

P < .05

P < .05

Smith et al. 1992 (33)

4

19/20

150

P < .05

P < .05

P < .05

Kaeding et al. 1990 (27) M c S w i n e y et al. 1993 (28) Cepeda et al. 1997 (29)

3 2 5

19/19 10/I0 27/29

100 62.5 I00

P < .05 P < .05 P < .05

P < .05 P < .05 P < .05

Joshi et al. 1993 (32)

2

10/10

62.5

P < .05

?

J a w i s h et al. 1996 (34)

3

I 1/11

75

P < .05

?

Karlsson et al. 1995 (30) Boden et al. 1994 (31) Chan et al. 1995 (24)

3 2 2

10/10 10/.7 10/10

75 100 50

P < .05 P < .05 P < .05

ns ns --

----

Smith et aL i991 (35)

4

48/48

150

ns

P < .05

ns

Shaw et al. I997 (36)

5

31/27

100

ns

P < .05

ns

Denti et al. 1997 (37)

5

10/10

50

ns

ns

--

Milligan et al. 1988 (38)

3

13/13/13

50/100

ns

ns

--

Aasbo et al. 1996 (39)

4

27/27

50

ns

ns

ns

Henderson et al. 1990 (23)

2

51/49

75

ns

ns

Bj6rnsson et al. 1994 (40)

3

19119

50

ns

ns

Ruwe et al. 1995 (41) Richardson et al. 1997 (42)

3 2

23/28 38/32

75 100

ns ns

ns ns

Richmond et al. 1994 (25)

4

19/19

ns

ns

Reference

prilocaine 200 mg

Time to Suppl. First Analgesic Analgesic Consumption Request

m

ns

Comments Significant at 30 min., l, and 2 h; first request prolonged 0.7 h Pain scores significant only at 30 rain.; suppl, analg, significant only in the PACU; first request prolonged 23 min. Pain score significant at 1 and 2 h Pain score significant up to 12 h Significant at 2 h for pain scores and at 1 h for suppl, analg. Pain scores significant up to 4 h, no P value for suppl, analg. Pain scores significant at 30 min. and 1 h, not later; no P value for suppl, analg. Significant at 2 and 4 h, not later Significant until 2 h Significant up to 4 h; fixed analgesia regimen Reduction of suppl, analg, significant at 4 h only, not later Suppl. analg, significant until 3 h, not later At 0-1, 1-3, 3-6, 6-12, 12-24 h postoperatively Two treatment groups with bupivacaine 0.25 and 0.5%, respectively At 1, 2, 3, 4, 8, 12, 24, and 72 h postoperatively At 0-6, 6-12, and 12-24 h postoperatively At 30 min., 1, 1.5, 2, 24, and 48 h postoperatively Up to 48 h postoperatively At 1, 2, 4, 6, and 24 h postoperatively At 4, 8, and 24 h postoperatively

P < .05 = statistical significant difference between local anesthetic group and control group, ns, no significant difference; --, not evaluated; PACU, postanesthesia care unit.

treatment groups compared with the control groups (Fig. 2). H o w e v e r , a n a l y s i s w a s o n l y p o s s i b l e w i t h t w e l v e trials ( 2 3 - 2 5 , 2 9 - 3 3 , 3 5 , 3 6 , 4 0 , 4 2 ) . I n t h e o t h e r e i g h t trials ( 2 6 - 2 8 , 3 4 , 3 7 - 3 9 , 4 1 ) , t h e r e w e r e a l a c k of d a t a (VAS s c o r e s , d i s p e r s i o n m e a s u r e s , etc.) n e c e s s a r y f o r c a l c u l a t i o n of a w e i g h t e d m e a n d i f f e r e n c e ; h o w e v e r of t h e s e e i g h t trials f o u r w e r e p o s i tive and four were negative regarding pain outcome. F i n a l l y , p o w e r a n a l y s i s of t h e s t a t i s t i c a l tests w a s o n l y p e r f o r m e d i n o n e s t u d y (36).

Influence of Dosage of Intra-articular Local Anesthesia on Postoperative Pain Relief Nineteen studies or treatment arms considered bupivacaine and one study considered prilocaine. In studies with improved pain control the mean dose

of i n t r a - a r t i c u l a r b u p i v a c a i n e w a s 90 m g [_+34 m g (SD)] a d m i n i s t e r e d i n c o n c e n t r a t i o n s of 0 . 2 5 - 0 . 5 % in volumes between 20 and 40 mL. In studies with no effect on postoperative pain parameters, the m e a n d o s e of i n t r a - a r t i c u l a r b u p i v a c a i n e w a s 75 m g [_+19 m g (SD)] a d m i n i s t e r e d i n c o n c e n t r a t i o n s of 0 . 2 5 - 0 . 5 % i n v o l u m e s of 1 0 - 3 0 m L . T h e d i f f e r e n c e in mean dose between positive and negative studies w a s , h o w e v e r , n o t s i g n i f i c a n t (P = .196; M a n n W h i t n e y U test). I n t h e s t u d y w h e r e 2 0 0 m g of prilocaine was instillated intra-articularly, no effect o n p o s t o p e r a t i v e p a i n w a s o b s e r v e d (2 5) (Table 2).

Influence on Immediate Recovery and Ambulation of Intra-articular Local Anesthesia O n l y e i g h t r e p o r t s s t u d i e d a p o s s i b l e e f f e c t of intra-articular local anesthesia on varied recovery

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1O0

s h o w e d reduced pain scores (30,33), no effect of intra-articular local anesthesia on the ability to walk, n o r m a l activities, h o m e readiness, or duration of a m b u l a t o r y hospital stay was observed.

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80 1

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Side Effects, Plasma Concentration of Local Anesthetics, and Influence of Surgical Procedure on the Effect of Intra-articular Local Anesthesia on Postoperative Pain

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60

/ / / / / /

r.b

70 •

40

100 •

70 39n//

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54

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• 20 •22

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20

Ai/96

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No side effects or signs of toxicity attributable to the intra-articular local anesthesia w e r e reported. However, such i n f o r m a t i o n was only provided in nine studies (26,27,29-32,35,37,38), and only in three studies was plasma concentration of local anesthetics m e a s u r e d (26,27,38), w h i c h in all cases was well b e l o w a p r e s u m e d toxic bupivacaine plasma level of 2 - 4 p g / m L (43). No p a t t e r n of a possible influence of the type of surgical p r o c e d u r e (diagnostic or therapeutic) on the effect of intra-articular local anesthetic on postoperative p a i n was observed, since there was an equal distribution of diagnostic and therapeutic procedures a m o n g studies w i t h a n d w i t h o u t imp r o v e m e n t s in pain relief.

&17

20

2O 56 • A 39

•

20

/

I 20

, i 40

,

I 6O

80

1O0

VAS with c o n t r o l

Fig. 1. Mean or median VAS early postoperatively (1-4 hours) for intra-articular local anesthesia (LA) versus control in the 18 studies where VAS scores were available (all except reference 27 and 37). Each square represents an individual study with no significant difference (P > .05) in pain scores between groups, and each triangle represents an individual study with significant difference ( P < .05) between groups. Numbers accompanying squares and triangles indicate total number of patients in trials.

Discussion In this systematic review, we h a v e sought to evaluate the effect of intra-articularly applied local anesthesia for postoperative pain after arthroscopic k n e e surgery. M o r e t h a n 50 trials h a v e c o m p a r e d intra-articular instillation of local anesthetics with placebo or n o t r e a t m e n t , w i t h intra-articular opioids, intra-articular NSAIDs, a n d various other treat-

functions. A statistically significant i m p r o v e m e n t in recovery was f o u n d in a study by Smith et al. (35), as patients in the t r e a t m e n t group regained their ability to walk 30 m i n u t e s before patients in the control group. However, in the seven other studies (23,25,30,33,36,39,41), of w h i c h t w o studies

Study Smith 1991 Henderson 1990 Smith 1992 Joshi 1993 Richmond 1994 Karlsson 1995 Boden 1994 BjOmsson 1994 Chart 1995 Shaw 1997 Cepeda 1997 Richardson 1997 Total (95% CI)

WMD (95% CI Fixed)

Weight %

--II--II-

15.0 10.6 8.3 2.8 3.9 8,6 6.7 3,9 7,6 9,2 15.0 8,4

- - - ! - - - ----I

--I-

100.0

41, -100 -50 6 Favours Treatment

5'0

160

Favours Control

WMD (95% CI Fixed)

-10.559[-13.815, -7,304]

Fig. 2. Weighted mean difference (WMD) with 95% confidence intervals (95% CI, horizontal lines) in VAS pain scores early postoperatively (1-4 hours) between the intra-articular local anesthetic and control groups. "Total" at the bottom of the figure indicates the results from pooling all the trials. The numbers under the subheading "Weight" at the right of the figure indicate the weight the individual trials have had in the analysis taking into account study size and standard deviations of VAS scores.

Intra-articular Local Anesthetic for Postoperative Pain

merit modalities. We chose only to review comparisons of local anesthesia with placebo or no treatment using the strict inclusion and exclusion criteria described earlier, to be able to evaluate the effect of intra-articular applied local anesthetics per se on postoperative pain. Twenty studies comprising almost 900 patients fulfilled the inclusion criteria. Of these studies, most showed improvements in postoperative pain relief, usually recorded as reduced pain scores. In contrast, eight studies were unequivocally negative. Because some minor arthroscopic procedures may successfully be performed under intraarticular and incisional local anesthesia alone, one may wonder why evaluated studies did not consistently show improved pain alleviation after intraarticular application of local anesthetics. There are several possible explanations to the observed disparity between studies. First, the dose of local anesthesia used for intraarticular instillation may be important. In a study of arthroscopic knee surgery evaluating three different doses of intra-articular local anesthesia, it was shown that 75 mg intra-articular bupivacaine provided better postoperative pain relief than 25 and 50 rag, respectively (44). Not surprisingly, the dose of peripherally used local anesthetics may be important. Also, in the present review, the mean dose of bupivacaine was slightly higher in positive studies than in studies failing to prove intra-articular local anesthetics to be beneficial for pain control. Although not being statistically significant, this difference may have contributed to the observed results. Second, and of more importance may be the relatively low pain scores observed in the control groups of the eight studies not showing any beneficial effect of intra-articular local anesthesia (23,25,37--42). In no case was VAS scores in the control groups of these studies above 35 mm, and this may have rendered the studies relatively insensitive, because it is difficult to detect an improvement in pain if absent or only mild. Observed low pain scores were probably not caused by use of intraoperative opioids, which in all cases was modest or absent and not different from use in positive studies. In contrast, VAS scores in the control groups of several positive studies were relatively higher with values about 45-65 m m (24,28,30-32), and this may have facilitated the detection of a pain-reducing effect from intra-articular local anesthesia. In other words, the statistically nonsignificant results of some studies may have been due to a type II error; however, power analysis of the statistical tests was only provided in one study (36). Quantitative analysis was only possible to perform with 12 of the induded trials and omitted in four positive and four negative trials, rendering the results of the analysis some-

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what tenuous. Nevertheless the quantitative analysis was in accordance with the qualitative estimate showing a significant but minor clinically important effect. Third, in a recent review of peripheral opioids (all except intra-articular) (45), it was shown that studies with low-quality scores often overestimated the effect of the evaluated pain treatment (45). However, among studies in this review, no difference in quality score was observed between positive and negative studies, of which both had a mean score of about 3. Even though the present review revealed an overall statistically significant improvement of postoperative pain relief from intra-articular local anesthesia, the clinical significance may, as already suggested, be questioned. The observed reductions of pain scores were small to moderate and of short duration. In addition, the reduction in supplementary consumption, which was only observed in about one-third of all studies, was in most cases small. However, because arthroscopic procedures often are performed as day-case surgery, even small reductions in perceived pain and in supplementary analgesic requirements may be clinically important. Furthermore, in studies recording pain scores up to 24 hours postoperatively, pain scores rapidly declined regardless of which treatment was applied. This may justify the use of a relatively short-lasting analgesic regimen. As regarding recovery parameters, there is a lack of evidence for any important effect after intraarticular local anesthesia. However, future studies should emphasize the utilization of any pain-reducing effect to facilitate mobilization and early recovery, as it previously has been shown in knee and hip surgery that pain alleviation alone does not accelerate recovery (46), but has to be accomplished by intensive mobilization regimens. It is only in less than half of the reviewed studies (about 370 out of 895 patients) that information about possible side effects was provided and in no case attributed to the local anesthetic. However, in no study was potential side effects a main parameter, and this may somewhat impair the validity of such information. Although only three studies measured plasma concentration of the local anesthetics, these results were in accordance with a previous study of plasma bupivacaine levels after single-dose intra-articular instillation (47), where it was revealed that up to 30 mL 0.5% bupivacaine was pharmacologically safe for routine clinical administration (47), since the highest peak plasma concentration, occurring 20 minutes after instillation, was 0.625 -+ 0.225 llg/mL (mean _+ SD) (presumed toxic plasma level 2-4 llg/mL).

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In conclusion, there is evidence for a postoperative analgesic effect of intra-articular administration of local anesthesia following arthroscopic knee surgery. However, the evidence is not compelling, and in most cases observed reductions in postoperative pain were small to moderate and short lasting. Furthermore, there is a lack of evidence for such analgesic effects to have any impact o n early recovery. Based on data presented in this review, there does not seem to be an urgent need for further studies focusing exclusively o n local anesthetics. Instead, future research in this area possibly should focus on intra-articular multimodal regimens, which, as recently s h o w n (48), m a y provide e n h a n c e d effects on postoperative pain and convalescence.

References 1. Kirkeby OJ, Aase S. Knee arthroscopy and arthrotomy under local anaesthesia. Acta Orthop Scand 1987: 58: 133-134. 2. Read GO. Local anaesthesia for diagnostic and operative arthroscopy of the knee. S Afr M J 1983: 64: 471-472. 3. Hultin J, Hamberg E Stenstr6m A. Knee arthroscopy using local anesthesia. Arthroscopy 1992: 8: 239-241. 4. Dahl MR, Dasta JE Zuelzer W, McSweeney TD. Lidocaine local anesthesia for arthroscopic knee surgery. Anesth Analg 1990: 71: 670-671. 5. Kalso E, Tram~r MR, Carroll D, McQuay HJ, Moore RA. Pain relief from intra-articular morphine after knee surgery: a qualitative systematic review. Pain 1997: 71: 127-134. 6. Jadad AR, Moore A, Carrol D, Jenkinson C, Reynolds JM, Gavaghan DJ, McQuay HJ. Assessing the quality of reports of randomized dinical trials: Is blinding necessary? Control Clin Trials 1996: 17: 1-12. 7. Cook TM, Tuckey JE Nolan JP. Analgesia after daycase arthroscopy: double-blind study of intraarticular tenoxicam, intra-articular bupivacaine and placebo. Br J Anaesth 1997: 78: 163-168. 8. Tolksdorf W, Albrecht T, Gottschalk D, Breuer R. Intraartikulfire lokalan/isthetika zur post0perativen analgesie nach arthroskopien des kniegelenks. Arthroskopie 1991: 4: 137-142. 9. Geutjens G, Hambridge JE. Analgesic effect of intraarticular bupivacaine after day-case arthroscopy. Arthroscopy 1994: 10: 299-300. 10. Reuben SS, Connelly NR. Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular bupivacaine and ketorolac. Anesth Analg 1995: 80: 1154-1157. 11. Heard SO, Edward W% Ferrari D, Hanna D, Wong PD, Liland A, Willock MM. Analgesic effect of intraarticular bupivacaine or morphine after arthroscopic knee surgery: a randomized, prospective, doubleblind study. Anesth Analg 1992: 74: 822-826.

12. Ares Y, Kinik H, Bfnnet MS, Ares Y, Canakci N, Kecik Y. Comparison of prilocaine and bupivacaine for post-arthroscopy analgesia: a placebo-controlled double-blind trial. Arthroscopy 1994: 10: 108-109. 13. Raja SN, Dickstein RE, Johnson CA. Comparison of postoperative analgesic effects of intraarticular bupivacaine and morphine following arthroscopic knee surgery. Anesthesiology 1992: 77:1143-1147. 14. Badner NH, Bourne RB, Rorabeck CH, MacDonald SJ, Doyle JA. Intra-articular injection of bupivacaine in knee-replacement operations. Results of use for analgesia and for preemptive blockade. J Bone Joint Surg 1996: 78A: 734-738. 15. H6her J, Kersten D, Bouillon B, Neugebauer E, Tiling T. Local and intra-articular infiltration of bupivacaine before surgery: effect on postoperative pain after anterior cruciate ligament reconstruction. Arthroscopy 1997: 13: 210-217. 16. Mauerhan DR, Campel M, Miller JS, Mokris JG, Gregory A, Kiebzak GN. Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty. J Arthroplasty 1997: 12: 546-552. 17. Sorensen TS, Sorensen AI, Strange K. The effect of intra-articular instillation of bupivacaine on postarthroscopic morbidity: a placebo-controlled, doubleblind trial. Arthroscopy 1991: 7:364-367. 18. White AP, Laurent S, Wilkinson DJ. Intra-articular and subcutaneous prilocaine with adrenaline for pain relief in day case arthroscopy of the knee joint. Ann R Coll Surg Engl 1990: 72: 350-352. 19. Osborne D, Keene G. Pain relief after arthroscopic surgery of the knee: a prospective, randomized, and blinded assessment of bupivacaine and bupivacaine with adrenaline. Arthroscopy 1993: 9:177-180. 20. Jaureguito JW, Wilcox JE Cohn SJ, Thisted RA, Reider B. A comparison of intraarticular morphine and bupivacaine for pain control after outpatient knee arthroscopy. A prospective, randomized, double-blinded study. Am J Sports Med 1995: 23: 350-353. 21. Morrow BC, Milligan KR, Murthy BVS. Analgesia following day-case knee arthroscopy--the effect of piroxicam with and without bupivacine infiltration. Anaesthesia 1995: 50: 461-463. 22. Haynes TK, Power I, Rosen M, Grant A. Intraarticular morphine and bupivacaine analgesia after arthroscopic knee surgery, Anaesthesia 1994: 49: 54-56. 23. Henderson RC, Campion ER, DeMasi RA, Taft TN. Postarthroscopy analgesia with bupivacaine. Am J Sports Med 1990: 18: 614-617. 24. Chan ST. Intra-articular morphine and bupivacaine for pain relief after therapeutic arthroscopic knee surgery. Singapore Med J 1995: 36: 35-37. 25. Richmond CE. Alkalinization of local anaesthetic for intra-articular instillation during arthroscopy. Br J Anaesth 1994: 73: 190-193. 26. Chirwa SS, MacLeod BA, Day B. Intra-articular bupivacaine (marcaine) after arthroscopic meniscec-

Intra-articular Local Anesthetic for Postoperative Pain

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

tomy: a randomized, double-blind study. Arthroscopy 1989: 5: 33-35. Kaeding CC, Hill JA, Katz J, Benson L. Bupivacaine use after knee arthroscopy: pharmacokinetics and pain control study. Arthroscopy 1990: 6: 33-39. McSwiney MM, Joshi GP, Kenny P, McCarroll SM. Analgesia following knee surgery. A controlled study of intra-articular morphine, bupivacaine, or both combined. Anaesth Intensive Care 1993: 21: 201-203. Cepeda MS, Uribe C, Betancourt J, Rugeles J, Carr DB. Intra-articular morphine, intra-articular bupivacaine, or subcutaneous morphine. Reg Anesth 1997: 22: 233-238. Karlsson J, Rydgren B, Erikson B, Jarvholm U, Lundin O, Sward L, Hedner T. Postoperative analgesia effects of intra-articular bupivacaine and morphine after arthroscopic cruciate ligament repair. Knee Surg Sports Traumatol Arthrosc 1995: 3: 55-59. Boden BE Fassler S, Cooper S, Marchetto PA, Moyer RA. Analgesic effect of intraarticular morphine, bupivacaine, and morphine/bupivacaine after arthroscopic knee surgery. Arthroscopy 1994: 10: 104-107. Joshi GP, McCarroll SM, O'Brian TM, Leanane R Intraarticular analgesia following knee arthroscopy. Anesth Analg 1993: 76: 333-336. Smith I, Shively RA, White PF. Effect of ketorolac and bupivacaine on recovery after outpatient arthroscopy. Anesth Analg 1992: 75: 208-212. Jawish D, Antakly MC, Dagher E Nasser E, Geahchan N. Analg~sie intra-articulaire apr~s arthroscopie du genou. Cah Anesthesio11996: 44: 415-417. Smith I, Van Hemelrijck J, White PE Shively R. Effects of local anesthesia on recovery after outpatient arthroscopy. Anesth Analg 1991: 73: 536-539. Shaw A, Mobbs PJ, Haines JE Rao S, O'Conner M. Analgesic effect of intra-articular bupivacaine or diamorphine after arthroscopic surgery of the knee joint in day-case patients. Eur J Anaesthesiol 1997: 14: 635-641. Denti M, Randelli P, Bigoni M, Vitale G, Marino MR, Fraschini N. Pre- and postoperative intra-articular analgesia for arthroscopic surgery of the knee and arthroscopy-assisted anterior cruiciate ligament reconstruction. A double-blind randomized, prospec-

38.

39.

40.

41.

42.

43. 44.

45.

46.

47.

48.

•

Moiniche et al.

437

tive study. Knee Surg Sports Traumatol Arthrosc 1997: 5: 206-212. Milligan KA, Mowbray MJ, Mulrooney L, Standen PJ. Intra-articular bupivacaine for pain relief after arthroscopic surgery of the knee joint in daycase patients. Anaesthesia 1988: 43: 563-564. Aasbo V, Roeder JC, Grogaard B, Roise O. No additional analgesic effect of intra-articular morphine or bupivacaine compared with placebo after elective knee arthroscopy. Acta Anaethesiol Scand 1996: 40: 585-588. Bj6rnsson A, Gupta A, Vegfors M, Lennmarken C, Sj6berg F. Intraarticular morphine for postoperative analgesia following knee surgery. Reg Anesth 1994: 19: 104-108. Ruwe PA, Klein I, Shields CL. The effect of intraarticular injection of morphine and bupivacaine on postarthroscopic pain control. Am J Sports Med 1995: 23: 59-64. Richardson MD, Bjorksten AR, Hart JAL, McCullough K. The efficacy of intra-articular morphine for postoperative knee arthroscopy analgesia. Arthroscopy 1997: 13: 584-589. Scott D. Evaluation of the toxicity of local anesthetic agents in man. Br J Anaesth 1975: 47: 56-60. Gym JP, Appelquist E, Chraemmer-Jorgensen B, Duus B, Berner Hansen L. Intra-articular bupivacaine plus adrenaline for arthroscopic surgery of the knee. Acta Anaesthesiol Scand 1992: 36: 643-646. Picard PR, Tram6r, McQnay HJ, Moore RA. Analgesic efficacy of peripheral opioids (all except intraarticular): a qualitative systematic review of randomised controlled trials. Pain 1997: 72: 309-318. Moiniche S, Hjortso NC, Hansen BL, Dahl JB, Rosenberg J, Gebuhr g Kehlet H. The effect of balanced analgesia on early convalescence after orthopaedic surgery. Acta Anaesthesiol Scand 1994: 38: 328-335. Meinig RE Holtgrewe JL, Wiedel JD, Christie DB, Kestin KJ. Plasma bupivacaine levels following single dose intraarticular instillation for arthroscopy. Am J Sports Med 1988: 16: 295-300. Rasmussen S, Larsen AS, Thomsen ST, Kehlet H. Intra-articular glucocorticoid, bupivacaine and morphine reduces pain, inflammatory response and convalescence after arthroscopic meniscectomy. Pain 1998: 78: 131-134.