- Email: [email protected]
Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study
Acute Pain (2008) 10, 111—116
Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study Kristian S. Otte a, Henrik Husted a, Lasse Ø. Andersen b, Billy B. Kristensen b,∗, Henrik Kehlet c a
Department of Orthopedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark Department of Anesthesiology, Hvidovre University Hospital, Copenhagen, Denmark c Section of Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen University, Copenhagen, Denmark b
Received 6 June 2008 ; received in revised form 21 July 2008; accepted 3 August 2008 Available online 1 October 2008 KEYWORDS Hip; Knee; Arthroplasty; Local; Infiltration; Analgesia
Summary Effective pain management is essential for early recovery and rehabilitation after total hip and knee arthroplasty. Current methods include a multimodal regimen of oral analgesics combined with either continuous epidural analgesia or continuous peripheral nerve blockade both of which have risk of side effects and demand expertise. A simple and effective local infiltration technique with local anaesthetic, epinephrine and NSAID has been developed by D. Kerr and L. Kohan in Sydney, but with variable results reported from others. Since there is no detailed description of the technique we herein present the method in detail as developed by the inventors. © 2008 Elsevier B.V. All rights reserved.
1. Introduction Effective pain management is a prerequisite for early recovery and rehabilitation after total hip (THA) and knee arthroplasty (TKA). So far the most effective techniques have been continuous epidu∗ Corresponding author at: Department of Anesthesiology, Hvidovre University Hospital, Kettegaard Allé 30, DK-2650 Hvidovre, Denmark. Tel.: +45 36322527; fax: +45 36323356. E-mail address: [email protected] (B.B. Kristensen).
ral analgesia or continuous peripheral nerve blocks, which however, have inherent potential problems with hypotension, urinary bladder dysfunction, risk of partial motor blockade or high demand for expertise1 [1—3]. Systemic use of NSAIDs, COX-2 inhibitors, acetaminophen, gabapentin and opioids are also useful, although not optimal as single modality analgesics for pain relief during mobilization (see footnote 1). 1 The PROSPECT Working group, http://www.Postoppain.org, last accessed 22 November 2007.
1366-0071/$ — see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.acpain.2008.08.001
112 Recently, a new local high-volume infiltration technique has been developed by D. Kerr and L. Kohan in Sydney using local anaesthetic, epinephrine and NSAID and reported to be simple, effective and without side effects [4]. However, the analgesic effect has been variable in the existing studies [5—10]. Since the original technique developed by D. Kerr and L. Kohan in Sydney just recently has been reported, the discrepancy between the very effective pain relief described by the inventors and those reported by others may be explained by differences in the infiltration technique, which has not been described in detail in the studies reported till now [5—10]. Based upon two visits to D. Kerr and L. Kohan in Sydney and a counter visit by the inventors to our department we have observed the importance of the many small steps in the infiltration technique for analgesic efficacy. The original technique has recently been reported in detail in an orthopaedic journal [4]. It might therefore be unknown to anaesthesiologists, who traditionally have an interest in fast-track rehabilitation. For that reason we find it important to report our preliminary results with a detailed description of the technique, thereby hopefully to support the need for attention to the methodology and to improve the variable analgesic responses reported so far [5—10].
2. Methods We report the results from early 2007 of our first 12 consecutive patients scheduled for TKA and first 12 patients scheduled for hip resurfacing. Exclusion criteria were (1) treatment with opioids or steroids, (2) rheumatoid arthritis or other immunological diseases, (3) history of stroke, or any neurological or psychiatric condition capable of influencing pain perception (e.g. depression, diabetic neuropathy, etc.), (4) allergies to any of the drugs administered and (5) body mass index >40. Prior to operation patients were informed on the perioperative course—–including information on pain treatment by local infiltration, application of an intraarticular catheter and supplementary injections, bandaging and cooling. Patients were mobilized within 2 h postoperatively and were encouraged to ambulate as much as tolerated. The patients received the following oral analgesic medication—–On the morning on the day of surgery: 2 g slow-release acetaminophen, 400 mg celecoxib and 600 mg gabapentin. In the evening on the day of surgery: 2 g slow-release acetaminophen, 400 mg celecoxib and 300 mg gabapentin. The day
K.S. Otte et al. after surgery and for the following 6 days: 2 g slowrelease acetaminophen and 400 mg celecoxib was given 12 hourly and 300 mg gabapentin in the morning and 600 mg gabapentin in the evening. Pain was assessed 2, 4, 6 and 24 h postoperatively using a visual analogue scale (VAS) (0—100 mm) at rest and during 45◦ of active flexion of the hip or knee. If pain at rest exceeded 30 mm or pain during activity exceeded 50 mm oral oxycodone 5 mg was given.
2.1. Anaesthesia and surgery All patients received lumbar spinal anaesthesia with 10 mg hyperbaric bupivacaine for knee surgery and 12.5 mg isobaric bupivacaine for hip surgery and optional sedation with propofol 0.5—5 mg/(kg h). Low molecular weight heparin 4500 U was administered s.c. 6—8 h postoperatively for thromboprophylaxis and once daily until discharge. A standardized intraoperative regimen for fluid administration was applied consisting of 0.9% saline 5 ml/(kg h) and colloid (Voluven® ) 7.5 ml/(kg h). Standard surgical approaches were used: a midline skin incision with median parapatellar capsular incision extending up into the quadriceps-tendon for TKA and a posterolateral approach for THA. Knees were operated on in a bloodless field obtained by the use of a tourniquet (100 mmHg above systolic blood pressure) used from incision until cementation was finished. The AGC prosthesis (Biomet, Warsaw, Indiana, USA) was used for all patients operated on with TKA. In hip resurfacing the BHR prosthesis (Smith&Nephew, Orthopaedics Ltd., Warvick, UK) was used. Drains were not used.
2.2. Local injection technique Local infiltration was performed using ropivacaine (2 mg/ml) (AstraZeneca, Södertalje, Sweden). 150 ml of the ropivacaine solution was mixed with 1.5 ml of epinephrine (1 mg/ml) giving a concentration of 10 g/ml epinephrine (RE-mixture) and 50 ml ropivacaine without epinephrine. The injection technique was the one developed by Kerr and Kohan [4].
2.3. Total knee arthroplasty After the bone cuts and ligament balancing had been performed (but before insertion of the prosthesis), 50 ml of the RE-mixture was injected in the posterior capsule by starting laterally and moving the needle (14 G × 3 1/4 in.) 1 cm at the time medially with an injection depth of 3—5 mm (Fig. 1a).
Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study
113
The tip of the needle pointed upwards in the direction of the posterior femoral condyles. Both collateral ligaments were injected with 5 ml, as were the borders of the tibia where retractors were placed along with the remnants of the cut cruciate ligament. The prosthesis was inserted and the tourniquet deflated. Then 50 ml of the mixture (needle-size 18 G × 1 1/2 in.) was injected along the borders of and into the capsule and cut quadriceps-tendon, infra-patellar ligament and possible remnants of the fat pad (Fig. 1b). An epidural catheter (Gauge 18) was inserted 10 cm proximal to the incision and tunnelled into the knee joint and placed behind the posterior medial condyle along the posterior capsule (Fig. 1c). The capsule was closed and the catheter connected to a bacterial filter and injected with 20 ml of the RE-mixture to ensure no kinking. The subcutaneous layer was systematically injected in a fanwise manner with 50 ml ropivacaine without epinephrine (needle-size 18 G × 1 1/2 in.) (Fig. 1d). A total of 170 ml was used (120 ml of the RE-mixture and 50 ml ropivacaine without epinephrine).
2.4. Total hip resurfacing
Fig. 1 Perioperative injection during total knee arthroplasty. (a) Injection of posterior capsule shown with multiple needles. (b) Injection of the capsule. (c) The epidural catheter being placed behind the medial condyle. (d) Injection of the subcutaneous layer.
After reaming of the acetabulum and before insertion of the acetabular component 60 ml of the RE-mixture was injected systematically and clockwise in the periacetabular tissues—–including 10 ml in the anterior capsule where the retractor had been placed (needle-size 14 G × 3 1/4 in.). The acetabular component was inserted (Fig. 2a). After insertion of the femoral component another 40 ml of the mixture was injected in the cut rotators, 10 ml into the gluteus minimus muscle and into the femoral muscle laterally where the guide-pin had been placed during the procedure. Finally 20 ml was injected in the gluteus medius and maximus muscle (needle-size 18 G × 1 1/2 in.) (Fig. 2b). An epidural catheter (Gauge 18) was inserted 10 cm distal to the incision and tunnelled into the hip joint with the tip placed near the femoral head (Fig. 2c). The capsule was closed and the catheter connected to a bacterial filter and filled with 20 ml of the mixture to ensure no kinking. The subcutaneous layer was fanwise injected systematically with 50 ml ropivacaine without epinephrine (needle-size 18 G × 1 1/2 in.). A total of 170 ml was used (120 ml of the RE-mixture and 50 ml ropivacaine without epinephrine).
2.5. Postoperative management Knees: after skin closure a firm non-elastic bandage (Acryelastic, BSN Medical S.A.S., Vibraye, France)
114
K.S. Otte et al. both procedures, the bandages were removed after 24 h. Patients were mobilized with full weight bearing immediately after return from the recovery ward and wear off of the spinal analgesia. Walkers or crutches were used depending on the tolerance of the patient. Six hours postoperatively, the catheter was reinjected with 20 ml of RE-mixture and in the following morning re-injected with 50 ml of the mixture: 30 ml into the joint and the remaining 20 ml upon retraction of the catheter 1—2 ml for every cm—–until the catheter was removed. Physiotherapy was started the day after surgery and took place twice a day until discharge. Urinary catheters were not used.
2.6. Discharge All patients were discharged directly to their homes. Discharge criteria were functional and consisted of ability to (1) dress, (2) get in and out of bed, (3) sit down in and rise from a chair/toilet, (4) walk independently 50 m with crutches, (5) master stair climbing, (6) accept discharge and (7) to have a pain score of 30 mm or less at rest and of 50 mm or less at activity using the VAS scale.
3. Results
Fig. 2 Perioperative injection during total hip resurfacing. (a) Injection around acetabulum after insertion of the component. (b) Injection of the rotators and the gluteal muscles. (c) The epidural catheter placed in the joint.
was applied over soft padding from toes to midthigh. A cooling device (Cryo/Cuff, Aircast Europa GmbH, Hässelby, Sweden) was applied and used until discharge. Hips: after skin closure and padding a firm elastic bandage (Dale Abdominal Binder, Dale Medical Products, Plainville, MA, USA) was applied and ice packs were placed under the bandage. For
Demographic data, BMI, and ASA physical status are presented in Table 1. The pain scores in the TKA’s and hip resurfacings are shown in Fig. 3. During the first 24 postoperative hours median VASscore for pain at rest did not exceed 20 mm for TKA and 33 mm for hip resurfacing. The maximum median VAS-score during flexion of the joint was 28 mm for hip resurfacing and 45 mm for TKA. Mean oxycodone administration was 7.9 mg for TKA and 11.2 mg for hip resurfacings during the 24-h postoperative period. None of the patients showed any side effect, especially no hypotension, signs of motor blockade or urinary retention. Median postoperative length of stay was 2 (1—3) nights for the hips and median 3 (1—4) for the knees.
4. Discussion The aim of this study was to describe, reproduce and confirm the analgesic efficacy and simple setup of the technique developed by D. Kerr and L. Kohan in Sydney [4]. Our results confirm the
Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study
115
Table 1 Demographic data in 12 total knee arthroplasty patients and 12 resurfacing hip arthroplasty patients treated with local infiltration analgesia
Sex, F/M Age (years) Weight (kg) BMI (kg/m2 ) ASA, I/II/III
Resurfacing hip arthroplasty (n = 12)
Total knee arthroplasty (n = 12)
3/9 57 (45—63) 79 (59—106) 25 (21—30) 6/6/0
7/5 78 (61—88) 82 (61—111) 26 (19—39) 2/7/3
Values are given as median (min.—max.) where relevant. ASA = American Society of Anesthesiologists physical status.
analgesic effect which together with the detailed description may be of value for others in order to study and implement this interesting and simple technique, which otherwise has not been reported in detail in the literature, thereby hindering interpretation of the reported variable results [5—10]. The main advantage of the high-volume infiltration analgesic technique is its simplicity without any reported side effects so far [4—10]. However, more well-documented data are required from several centres regarding safety, the role of incisional
ketorolac vs. systemic NSAIDs or COX-2 inhibitors [11], the requirement for intermittent vs. continuous administration of local anaesthetic in the postoperative period and whether the technique should be continued after early discharge [12]. Furthermore detailed studies on volume vs. concentration relationship, the type and location of catheter for drug administration (i.e. intra- vs. extraarticular administration, single vs. multihole catheter) [13,14] and the requirement and type of additional systemic analgesic are required. Subsequently, the optimized infiltration technique should be compared in blinded, randomized studies to the present gold standard of continuous peripheral nerve blockade and systemic analgesics (see footnote 1) including the potential for improved early rehabilitation, earlier achievement of discharge criteria and reduction of hospital stay as reported in two preliminary series [15,16] and one randomized, placebo-controlled study with continuous peripheral nerve blockade [17].
References
Fig. 3 Postoperative visual analogue pain scores in 12 patients operated with total knee arthroplasty and in 12 patients operated with hip resurfacing.
[1] Boezaart AP. Perineural infusion of local anesthetics. Anesthesiology 2006;104:872—80. [2] Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief following hip and knee replacement. Cochrane Database Syst Rev 2003:CD003071. [3] Davies AF, Segar EP, Murdoch J, Wright DE, Wilson IH. Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty. Br J Anaesth 2004;93:368—74. [4] 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. [5] Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Søballe K. Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty. Acta Orthop 2007;78: 180—6. [6] Andersen LJ, Poulsen T, Krogh B, Nielsen T. Postoperative analgesia in total hip arthroplasty. Acta Orthop 2007;78:187—92. [7] Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK, Søballe K. Comparison of peri- and intraarticular anal-
116
[8]
[9]
[10]
[11]
[12]
[13]
K.S. Otte et al. gesia with femoral block after total knee arthroplasty. Acta Orthop 2007;78:172—9. Reilly KA, Beard DJ, Barker KL, Dodd CAF, Price AJ, Murray DW. Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty—–a randomised controlled trial. Knee 2005;12:351—7. 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 randomised trial. J Bone Joint Surg Am A 2006;88:959—63. Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, et al. A multimodal analgesia protocol for total knee arthroplasty. J Bone Joint Surg Am A 2006;88:282—9. Rømsing J, Möinicke S, Østergaard D, Dahl JB. Local infiltration with NSAIDs for postoperative analgesia: evidence for a peripheral analgesic action. Acta Anaesthesiol Scand 2000;44:672—83. Röstlund T, Kehlet H. High-dose local infiltration analgesia after hip and knee replacement—–what is it, why does it work, and what are the future challenges? Acta Orthop Scand 2007;78:159—61. Mauerhan DR, Campbell M, Miller JS, Mokris JG, Gregory A, Kiebzak GM. Intra-articular morphine and/or bupivacaine
[14]
[15]
[16]
[17]
in the management of pain after total knee arthroplasty. J Arthroplasty 1997;12:546—52. Ritter MA, Koehler M, Keating EM, Faris PM, Meding JB. Intra-articular morphine and/or bupivacaine after total knee replacement. J Bone Joint Surg Br 1999;81: 301—3. Ilfeld BM, Gearen PF, Enneking FK, Berry LF, Spadoni EH, George SZ, et al. Total knee arthroplasty as an overnightstay procedure using continuous femoral nerve blocks at home: a prospective feasibility study. Anesth Analg 2006;102:87—90. Ilfeld BM, Gearen PF, Enneking FK, Berry LF, Spadoni EH, George SZ, et al. Total hip arthroplasty as an overnight-stay procedure using an ambulatory continuous psoas compartment nerve block: a prospective feasibility study. Reg Anesth Pain Med 2006;31: 113—8. Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty. A randomized, triple-masked, placebo-controlled study. Anesthesiology 2008;108:703—13.
Available online at www.sciencedirect.com
Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study Kristian S. Otte a, Henrik Husted a, Lasse Ø. Andersen b, Billy B. Kristensen b,∗, Henrik Kehlet c a
Department of Orthopedic Surgery, Hvidovre University Hospital, Copenhagen, Denmark Department of Anesthesiology, Hvidovre University Hospital, Copenhagen, Denmark c Section of Surgical Pathophysiology 4074, Rigshospitalet, Copenhagen University, Copenhagen, Denmark b
Received 6 June 2008 ; received in revised form 21 July 2008; accepted 3 August 2008 Available online 1 October 2008 KEYWORDS Hip; Knee; Arthroplasty; Local; Infiltration; Analgesia
Summary Effective pain management is essential for early recovery and rehabilitation after total hip and knee arthroplasty. Current methods include a multimodal regimen of oral analgesics combined with either continuous epidural analgesia or continuous peripheral nerve blockade both of which have risk of side effects and demand expertise. A simple and effective local infiltration technique with local anaesthetic, epinephrine and NSAID has been developed by D. Kerr and L. Kohan in Sydney, but with variable results reported from others. Since there is no detailed description of the technique we herein present the method in detail as developed by the inventors. © 2008 Elsevier B.V. All rights reserved.
1. Introduction Effective pain management is a prerequisite for early recovery and rehabilitation after total hip (THA) and knee arthroplasty (TKA). So far the most effective techniques have been continuous epidu∗ Corresponding author at: Department of Anesthesiology, Hvidovre University Hospital, Kettegaard Allé 30, DK-2650 Hvidovre, Denmark. Tel.: +45 36322527; fax: +45 36323356. E-mail address: [email protected] (B.B. Kristensen).
ral analgesia or continuous peripheral nerve blocks, which however, have inherent potential problems with hypotension, urinary bladder dysfunction, risk of partial motor blockade or high demand for expertise1 [1—3]. Systemic use of NSAIDs, COX-2 inhibitors, acetaminophen, gabapentin and opioids are also useful, although not optimal as single modality analgesics for pain relief during mobilization (see footnote 1). 1 The PROSPECT Working group, http://www.Postoppain.org, last accessed 22 November 2007.
1366-0071/$ — see front matter © 2008 Elsevier B.V. All rights reserved. doi:10.1016/j.acpain.2008.08.001
112 Recently, a new local high-volume infiltration technique has been developed by D. Kerr and L. Kohan in Sydney using local anaesthetic, epinephrine and NSAID and reported to be simple, effective and without side effects [4]. However, the analgesic effect has been variable in the existing studies [5—10]. Since the original technique developed by D. Kerr and L. Kohan in Sydney just recently has been reported, the discrepancy between the very effective pain relief described by the inventors and those reported by others may be explained by differences in the infiltration technique, which has not been described in detail in the studies reported till now [5—10]. Based upon two visits to D. Kerr and L. Kohan in Sydney and a counter visit by the inventors to our department we have observed the importance of the many small steps in the infiltration technique for analgesic efficacy. The original technique has recently been reported in detail in an orthopaedic journal [4]. It might therefore be unknown to anaesthesiologists, who traditionally have an interest in fast-track rehabilitation. For that reason we find it important to report our preliminary results with a detailed description of the technique, thereby hopefully to support the need for attention to the methodology and to improve the variable analgesic responses reported so far [5—10].
2. Methods We report the results from early 2007 of our first 12 consecutive patients scheduled for TKA and first 12 patients scheduled for hip resurfacing. Exclusion criteria were (1) treatment with opioids or steroids, (2) rheumatoid arthritis or other immunological diseases, (3) history of stroke, or any neurological or psychiatric condition capable of influencing pain perception (e.g. depression, diabetic neuropathy, etc.), (4) allergies to any of the drugs administered and (5) body mass index >40. Prior to operation patients were informed on the perioperative course—–including information on pain treatment by local infiltration, application of an intraarticular catheter and supplementary injections, bandaging and cooling. Patients were mobilized within 2 h postoperatively and were encouraged to ambulate as much as tolerated. The patients received the following oral analgesic medication—–On the morning on the day of surgery: 2 g slow-release acetaminophen, 400 mg celecoxib and 600 mg gabapentin. In the evening on the day of surgery: 2 g slow-release acetaminophen, 400 mg celecoxib and 300 mg gabapentin. The day
K.S. Otte et al. after surgery and for the following 6 days: 2 g slowrelease acetaminophen and 400 mg celecoxib was given 12 hourly and 300 mg gabapentin in the morning and 600 mg gabapentin in the evening. Pain was assessed 2, 4, 6 and 24 h postoperatively using a visual analogue scale (VAS) (0—100 mm) at rest and during 45◦ of active flexion of the hip or knee. If pain at rest exceeded 30 mm or pain during activity exceeded 50 mm oral oxycodone 5 mg was given.
2.1. Anaesthesia and surgery All patients received lumbar spinal anaesthesia with 10 mg hyperbaric bupivacaine for knee surgery and 12.5 mg isobaric bupivacaine for hip surgery and optional sedation with propofol 0.5—5 mg/(kg h). Low molecular weight heparin 4500 U was administered s.c. 6—8 h postoperatively for thromboprophylaxis and once daily until discharge. A standardized intraoperative regimen for fluid administration was applied consisting of 0.9% saline 5 ml/(kg h) and colloid (Voluven® ) 7.5 ml/(kg h). Standard surgical approaches were used: a midline skin incision with median parapatellar capsular incision extending up into the quadriceps-tendon for TKA and a posterolateral approach for THA. Knees were operated on in a bloodless field obtained by the use of a tourniquet (100 mmHg above systolic blood pressure) used from incision until cementation was finished. The AGC prosthesis (Biomet, Warsaw, Indiana, USA) was used for all patients operated on with TKA. In hip resurfacing the BHR prosthesis (Smith&Nephew, Orthopaedics Ltd., Warvick, UK) was used. Drains were not used.
2.2. Local injection technique Local infiltration was performed using ropivacaine (2 mg/ml) (AstraZeneca, Södertalje, Sweden). 150 ml of the ropivacaine solution was mixed with 1.5 ml of epinephrine (1 mg/ml) giving a concentration of 10 g/ml epinephrine (RE-mixture) and 50 ml ropivacaine without epinephrine. The injection technique was the one developed by Kerr and Kohan [4].
2.3. Total knee arthroplasty After the bone cuts and ligament balancing had been performed (but before insertion of the prosthesis), 50 ml of the RE-mixture was injected in the posterior capsule by starting laterally and moving the needle (14 G × 3 1/4 in.) 1 cm at the time medially with an injection depth of 3—5 mm (Fig. 1a).
Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study
113
The tip of the needle pointed upwards in the direction of the posterior femoral condyles. Both collateral ligaments were injected with 5 ml, as were the borders of the tibia where retractors were placed along with the remnants of the cut cruciate ligament. The prosthesis was inserted and the tourniquet deflated. Then 50 ml of the mixture (needle-size 18 G × 1 1/2 in.) was injected along the borders of and into the capsule and cut quadriceps-tendon, infra-patellar ligament and possible remnants of the fat pad (Fig. 1b). An epidural catheter (Gauge 18) was inserted 10 cm proximal to the incision and tunnelled into the knee joint and placed behind the posterior medial condyle along the posterior capsule (Fig. 1c). The capsule was closed and the catheter connected to a bacterial filter and injected with 20 ml of the RE-mixture to ensure no kinking. The subcutaneous layer was systematically injected in a fanwise manner with 50 ml ropivacaine without epinephrine (needle-size 18 G × 1 1/2 in.) (Fig. 1d). A total of 170 ml was used (120 ml of the RE-mixture and 50 ml ropivacaine without epinephrine).
2.4. Total hip resurfacing
Fig. 1 Perioperative injection during total knee arthroplasty. (a) Injection of posterior capsule shown with multiple needles. (b) Injection of the capsule. (c) The epidural catheter being placed behind the medial condyle. (d) Injection of the subcutaneous layer.
After reaming of the acetabulum and before insertion of the acetabular component 60 ml of the RE-mixture was injected systematically and clockwise in the periacetabular tissues—–including 10 ml in the anterior capsule where the retractor had been placed (needle-size 14 G × 3 1/4 in.). The acetabular component was inserted (Fig. 2a). After insertion of the femoral component another 40 ml of the mixture was injected in the cut rotators, 10 ml into the gluteus minimus muscle and into the femoral muscle laterally where the guide-pin had been placed during the procedure. Finally 20 ml was injected in the gluteus medius and maximus muscle (needle-size 18 G × 1 1/2 in.) (Fig. 2b). An epidural catheter (Gauge 18) was inserted 10 cm distal to the incision and tunnelled into the hip joint with the tip placed near the femoral head (Fig. 2c). The capsule was closed and the catheter connected to a bacterial filter and filled with 20 ml of the mixture to ensure no kinking. The subcutaneous layer was fanwise injected systematically with 50 ml ropivacaine without epinephrine (needle-size 18 G × 1 1/2 in.). A total of 170 ml was used (120 ml of the RE-mixture and 50 ml ropivacaine without epinephrine).
2.5. Postoperative management Knees: after skin closure a firm non-elastic bandage (Acryelastic, BSN Medical S.A.S., Vibraye, France)
114
K.S. Otte et al. both procedures, the bandages were removed after 24 h. Patients were mobilized with full weight bearing immediately after return from the recovery ward and wear off of the spinal analgesia. Walkers or crutches were used depending on the tolerance of the patient. Six hours postoperatively, the catheter was reinjected with 20 ml of RE-mixture and in the following morning re-injected with 50 ml of the mixture: 30 ml into the joint and the remaining 20 ml upon retraction of the catheter 1—2 ml for every cm—–until the catheter was removed. Physiotherapy was started the day after surgery and took place twice a day until discharge. Urinary catheters were not used.
2.6. Discharge All patients were discharged directly to their homes. Discharge criteria were functional and consisted of ability to (1) dress, (2) get in and out of bed, (3) sit down in and rise from a chair/toilet, (4) walk independently 50 m with crutches, (5) master stair climbing, (6) accept discharge and (7) to have a pain score of 30 mm or less at rest and of 50 mm or less at activity using the VAS scale.
3. Results
Fig. 2 Perioperative injection during total hip resurfacing. (a) Injection around acetabulum after insertion of the component. (b) Injection of the rotators and the gluteal muscles. (c) The epidural catheter placed in the joint.
was applied over soft padding from toes to midthigh. A cooling device (Cryo/Cuff, Aircast Europa GmbH, Hässelby, Sweden) was applied and used until discharge. Hips: after skin closure and padding a firm elastic bandage (Dale Abdominal Binder, Dale Medical Products, Plainville, MA, USA) was applied and ice packs were placed under the bandage. For
Demographic data, BMI, and ASA physical status are presented in Table 1. The pain scores in the TKA’s and hip resurfacings are shown in Fig. 3. During the first 24 postoperative hours median VASscore for pain at rest did not exceed 20 mm for TKA and 33 mm for hip resurfacing. The maximum median VAS-score during flexion of the joint was 28 mm for hip resurfacing and 45 mm for TKA. Mean oxycodone administration was 7.9 mg for TKA and 11.2 mg for hip resurfacings during the 24-h postoperative period. None of the patients showed any side effect, especially no hypotension, signs of motor blockade or urinary retention. Median postoperative length of stay was 2 (1—3) nights for the hips and median 3 (1—4) for the knees.
4. Discussion The aim of this study was to describe, reproduce and confirm the analgesic efficacy and simple setup of the technique developed by D. Kerr and L. Kohan in Sydney [4]. Our results confirm the
Local infiltration analgesia in total knee arthroplasty and hip resurfacing: A methodological study
115
Table 1 Demographic data in 12 total knee arthroplasty patients and 12 resurfacing hip arthroplasty patients treated with local infiltration analgesia
Sex, F/M Age (years) Weight (kg) BMI (kg/m2 ) ASA, I/II/III
Resurfacing hip arthroplasty (n = 12)
Total knee arthroplasty (n = 12)
3/9 57 (45—63) 79 (59—106) 25 (21—30) 6/6/0
7/5 78 (61—88) 82 (61—111) 26 (19—39) 2/7/3
Values are given as median (min.—max.) where relevant. ASA = American Society of Anesthesiologists physical status.
analgesic effect which together with the detailed description may be of value for others in order to study and implement this interesting and simple technique, which otherwise has not been reported in detail in the literature, thereby hindering interpretation of the reported variable results [5—10]. The main advantage of the high-volume infiltration analgesic technique is its simplicity without any reported side effects so far [4—10]. However, more well-documented data are required from several centres regarding safety, the role of incisional
ketorolac vs. systemic NSAIDs or COX-2 inhibitors [11], the requirement for intermittent vs. continuous administration of local anaesthetic in the postoperative period and whether the technique should be continued after early discharge [12]. Furthermore detailed studies on volume vs. concentration relationship, the type and location of catheter for drug administration (i.e. intra- vs. extraarticular administration, single vs. multihole catheter) [13,14] and the requirement and type of additional systemic analgesic are required. Subsequently, the optimized infiltration technique should be compared in blinded, randomized studies to the present gold standard of continuous peripheral nerve blockade and systemic analgesics (see footnote 1) including the potential for improved early rehabilitation, earlier achievement of discharge criteria and reduction of hospital stay as reported in two preliminary series [15,16] and one randomized, placebo-controlled study with continuous peripheral nerve blockade [17].
References
Fig. 3 Postoperative visual analogue pain scores in 12 patients operated with total knee arthroplasty and in 12 patients operated with hip resurfacing.
[1] Boezaart AP. Perineural infusion of local anesthetics. Anesthesiology 2006;104:872—80. [2] Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief following hip and knee replacement. Cochrane Database Syst Rev 2003:CD003071. [3] Davies AF, Segar EP, Murdoch J, Wright DE, Wilson IH. Epidural infusion or combined femoral and sciatic nerve blocks as perioperative analgesia for knee arthroplasty. Br J Anaesth 2004;93:368—74. [4] 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. [5] Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Søballe K. Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty. Acta Orthop 2007;78: 180—6. [6] Andersen LJ, Poulsen T, Krogh B, Nielsen T. Postoperative analgesia in total hip arthroplasty. Acta Orthop 2007;78:187—92. [7] Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK, Søballe K. Comparison of peri- and intraarticular anal-
116
[8]
[9]
[10]
[11]
[12]
[13]
K.S. Otte et al. gesia with femoral block after total knee arthroplasty. Acta Orthop 2007;78:172—9. Reilly KA, Beard DJ, Barker KL, Dodd CAF, Price AJ, Murray DW. Efficacy of an accelerated recovery protocol for Oxford unicompartmental knee arthroplasty—–a randomised controlled trial. Knee 2005;12:351—7. 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 randomised trial. J Bone Joint Surg Am A 2006;88:959—63. Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, et al. A multimodal analgesia protocol for total knee arthroplasty. J Bone Joint Surg Am A 2006;88:282—9. Rømsing J, Möinicke S, Østergaard D, Dahl JB. Local infiltration with NSAIDs for postoperative analgesia: evidence for a peripheral analgesic action. Acta Anaesthesiol Scand 2000;44:672—83. Röstlund T, Kehlet H. High-dose local infiltration analgesia after hip and knee replacement—–what is it, why does it work, and what are the future challenges? Acta Orthop Scand 2007;78:159—61. Mauerhan DR, Campbell M, Miller JS, Mokris JG, Gregory A, Kiebzak GM. Intra-articular morphine and/or bupivacaine
[14]
[15]
[16]
[17]
in the management of pain after total knee arthroplasty. J Arthroplasty 1997;12:546—52. Ritter MA, Koehler M, Keating EM, Faris PM, Meding JB. Intra-articular morphine and/or bupivacaine after total knee replacement. J Bone Joint Surg Br 1999;81: 301—3. Ilfeld BM, Gearen PF, Enneking FK, Berry LF, Spadoni EH, George SZ, et al. Total knee arthroplasty as an overnightstay procedure using continuous femoral nerve blocks at home: a prospective feasibility study. Anesth Analg 2006;102:87—90. Ilfeld BM, Gearen PF, Enneking FK, Berry LF, Spadoni EH, George SZ, et al. Total hip arthroplasty as an overnight-stay procedure using an ambulatory continuous psoas compartment nerve block: a prospective feasibility study. Reg Anesth Pain Med 2006;31: 113—8. Ilfeld BM, Le LT, Meyer RS, Mariano ER, Vandenborne K, Duncan PW, et al. Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty. A randomized, triple-masked, placebo-controlled study. Anesthesiology 2008;108:703—13.
Available online at www.sciencedirect.com