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Postoperative pain control by intra-articular local anesthesia versus femoral nerve block following total knee arthroplasty: Impact on discharge
Orthopaedics & Traumatology: Surgery & Research 100 (2014) 313–316
Available online at
ScienceDirect www.sciencedirect.com
Original article
Postoperative pain control by intra-articular local anesthesia versus femoral nerve block following total knee arthroplasty: Impact on discharge M. Antoni a , J.-Y. Jenny a,∗ , E. Noll b a Hôpitaux Universitaires de Strasbourg, Service de Chirurgie Orthopédique et Traumatologique, Centre de Chirurgie Orthopédique et de la Main, 10, avenue Bauymann, 67400 Illkirch-Graffenstaden, France b Hôpitaux Universitaires de Strasbourg, Service d’Anesthésie-Réanimation, Centre de Chirurgie Orthopédique et de la Main, 10, avenue Bauymann, 67400 Illkirch-Graffenstaden, France
a r t i c l e
i n f o
Article history: Accepted 16 December 2013 Keywords: Total knee arthroplasty Multimodal pain control Rehabilitation
a b s t r a c t Introduction: The goal of this retrospective study was to compare pain control following total knee arthroplasty (TKA) on a perioperative protocol of local anesthesia (LA) versus the more classical femoral nerve block (FNB) technique. Hypothesis: Fitness for discharge would be achieved earlier using the LA protocol. Materials: Ninety-eight consecutive TKA patients operated on by a single surgeon were included with no selection criteria. In the study group (49 patients), 200 mL ropivacaine 5% was injected into the surgical wound and an intra-articular catheter was fitted to provide continuous infusion of 20 mL/h ropivacaine for 24 h. The control group (49 patients) received ropivacaine FNB. Discharge fitness (independent walking, knee flexion > 90◦ , quadricipital control, pain on VAS ≤ 3) and hospital stay were assessed. Results: Discharge fitness was achieved significantly earlier in the study group (4.2 ± 2.6 versus 6.7 ± 3.2 days; P = 0.0003), with significantly shorter mean hospital stay (6.1 ± 3.4 versus 8.8 ± 3.5 days; P = 0.0002). The complications rate did not differ between study and control groups. Discussion: Although retrospective, this study indicates that the LA protocol improves management of post-TKA pain and accelerates rehabilitation, thereby, reducing hospital stay. The acceleration effect may be due to the absence of quadriceps inhibition. Level of evidence: Level III – Case control study. © 2014 Elsevier Masson SAS. All rights reserved.
1. Introduction The present economic context and rising health costs are incentives for optimizing the efficiency of care. Reduced hospital stay reduces stay-related costs. Optimized pain control following total knee arthroplasty (TKA) accelerates rehabilitation and discharge home [1,2]. Multimodal pain control procedures associated to accelerated rehabilitation have shown promising results [3]. Associating several analgesic techniques should potentiate impact while limiting adverse effects [3]. Injecting the surgical field with high-dose local anesthetics (LA) has been shown to allow earlier weight bearing while avoiding the adverse motor impact of locoregional and spinal anesthesia [3,4,5].
∗ Corresponding author. E-mail address: [email protected] (J.-Y. Jenny). http://dx.doi.org/10.1016/j.otsr.2013.12.022 1877-0568/© 2014 Elsevier Masson SAS. All rights reserved.
The present study assessed the feasibility of a multimodal pain control protocol in a university hospital department with a high TKA turnover. The hypothesis was that fitness for discharge following TKA would be achieved earlier by a multimodal protocol including per and postoperative intra-articular LA infiltration than by postoperative pain control by continuous femoral nerve block (FNB). 2. Material and methods No specific authorization was required for this assessment of a simple change in procedure. 2.1. Population All patients undergoing TKA in 2010 and 2011 were included, without selection. Inclusion criteria were operation by a single surgeon (JYJ), and primary TKA of whatever etiology, excluding
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evolutive septic osteoarthritis. There were no cases in which one or other of the protocols (LA or FNB) was medically contraindicated. The following preoperative data were collated prospectively and analyzed retrospectively: age, gender, body-mass index (BMI), Charnley class, ASA class, type of surgery, and type of intraoperative anesthesia. 2.2. Methods All patients were operated on under general anesthesia (GA) following the guidelines of the French Society of Anaesthesia and Intensive Care (SFAR) [6]. In 2010 (control group), GA was associated to per and postoperative regional anesthesia by FNB. FNB used neurostimulation (minimum intensity, < 0.5 mA; exhaustion, > 0.32 mA), under ultrasound control. A perineural catheter was fitted for 48 h continuous ropivacaine infiltration by elastomeric pump (ropivacainechlorhydrate, Fresenius Kabi, Bad Homburg, Germany; 2 mg/mL, flow rate 10 mL/h). In 2011 (study group), GA was associated to intra and postoperative LA. All patients were informed as to the novelty of this technique in our department at the time, and provided consent. The operative field (posterior, medial and lateral capsule, collateral ligaments, posterior cruciate ligament if spared, subquadricipital recess, and arthrotomy and incision edges) was injected at end of surgery with 200 mL ropivacaine (2 mg/mL). An intra-articular catheter was fitted for 24 h continuous intra-articular ropivacaine infiltration by elastomeric pump (2 mg/mL, flow rate 10 mL/h). Postoperatively, patients systematically received ketoprofen (ketoprofen, Hexal Biotech Forschungs GmbH, Holzkirchen, Germany: 50 mg, q.i.d. for 2 days, except in over 75 year old) and Neurontin® (gabapentin, Pfizer Inc., New York City, USA: 300 mg b.i.d; for 5 days). Classic step 1, 2 and 3 analgesics were provided according to pain expressed on a visual analog scale (VAS) [step 1: Doliprane® (paracetamol, Sanofi-Aventis France, Paris, France); step 2: Acupan® (nefopamchlorhydrate, Biocodex, Gentilly, France) and/or Tramadol (tramadol chlorhydrate, Grünenthal, Aachen, Germany); step 3: Actiskenan® /Skenan® (morphine sulfate, Bristol-Myers Squibb, New York City, USA) and Oxycontin® /Oxynorm® (oxycodone chlorhydrate, Mundipharma, Cambridge, UK)]. Postoperative nausea and vomiting prevention followed SFAR guidelines [7]. Four weeks’ thromboprophylaxis used low molecular weight non-fractionated heparin (Lovenox) or oral anticoagulants (Pradaxa or Xarelto) on the anesthetist’s decision. In patients preoperatively under anti-vitamin K, treatment was resumed at postoperative day 5. 2.3. Surgical technique A pneumatic tourniquet was routinely used. The surgical approach was medial parapatellar, releasing the distal 2 cm of the vastusmedialis. A rotating platform total knee replacement with patellar resurfacing (e.motion® , Aesculap, Tuttlingen, Germany) was implanted under navigation (Orthopilot® , Aesculap, Tuttlingen, Germany). No postoperative drainage was implemented. 2.4. Functional rehabilitation Immediate free mobilization of the knee within the limits of pain tolerance was authorized systematically. Control patients remained in bed until the motor block resolved, as testified to by active knee control in extension, whereupon walking was resumed. Study group patients resumed full weight bearing on 2 crutches on the day of surgery. Subsequent rehabilitation was progressive but without limitation, to achieve early fitness for discharge, defined as the ability to
walk independently with or without crutches, knee flexion ≥ 90◦ , locking in extension and VAS pain score ≤ 3. 2.5. Follow-up The following data were collated prospectively in the surgery department and analyzed retrospectively: type of postoperative analgesia, time to standing, time to aided walking, time to independent walking, twice-daily evolution of pain on VAS, analgesic intake, time to active quadriceps locking, time to 90◦ flexion, hospital stay, discharge destination, complications and surgical revision. 2.6. Statistics Preoperative data were compared between groups on chi2 or Fisher test (categoric variables) or Student’s test (numeric variables). The principal assessment criterion was discharge fitness. Follow-up data were compared between groups on chi2 or Fisher test (categoric variables) or Student’s test (numeric variables); time intervals were compared between groups by survivorship analysis with log-rank test. Correlations between preoperative variables and the principal assessment criterion were assessed by analysis of variance (categoric variables) or linear correlation coefficient. The significance threshold was systematically 5%. Preliminary calculation based on estimated time to discharge fitness in a population resembling the present control group determined a sample size of 50 per group as required to obtain a first-order risk of 5% and 90% power. 3. Results 3.1. Population Ninety-eight patients were included: 37 male, 61 female; mean age: 68.1 ± 10.1 years; mean BMI: 31.4 ± 6.0 kg/m2 . Fortynine patients were assigned to the control group and 49 to the study group. Table 1 shows patient characteristics; there were no significant inter-group differences on inclusion data, except for a better mean ASA score in the study group (P = 0.04). Results are shown in Table 2. Discharge fitness was achieved significantly earlier in the study group (4.2 ± 2.6 versus 6.7 ± 3.2 days; P = 0.0003; Fig. 1), and mean hospital stay was significantly shorter (6.1 ± 3.4 versus 8.8 ± 3.5 days; P = 0.0002). All other intervals (times to standing, walking, control of knee extension, 90◦ flexion and independent walking) were also significantly shorter in the study group. Fig. 2 shows evolution of pain on VAS: it was significantly lower in the study group at D1 (P = 0.009) and D5 (P = 0.04). In-hospital analgesic intake was greater in the study group (Table 3). Table 1 Patient data.
Number Gender Male Female Age (years) ASA score 1 or 2 3 or 4 Charnley score A B C BMI (kg/m2 )
Control
Study
P
49
49
22 27 69.7 ± 9.4
15 34 66.4 ± 10.7
38 11
46 3
0.04
25 23 1 30.6 ± 5.3
25 23 1 32.2 ± 6.6
NS
NS NS
NS
M. Antoni et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 313–316 Table 2 Results.
4. Discussion
Interval (days) between surgery and:
Control
Fitness for discharge Discharge Standing Assisted walking Independent walking Flexion > 90◦ Locking in extension
6.7 8.8 1.1 2.4 6.0 5.1 3.1
± ± ± ± ± ± ±
Study
3.2 3.5 0.9 1.1 2.9 3.0 2.9
4.2 6.1 0.3 1.1 3.7 2.6 1.5
± ± ± ± ± ± ±
P (log-rank test) 2.6 3.4 0.5 0.7 2.7 2.2 1.1
< 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Fig. 1. Time to discharge fitness.
Fig. 2. Subjective pain (VAS). Table 3 In-hospital analgesic intake.
Step 1 Step 2 Step 3
315
Control (units/day)
Study (units/day)
P (Fisher test)
2.7 1.2 1.5
3.2 1.0 3.2
0.004 NS 0.0002
3.2. Complications Eleven patients showed early complications: 7 in the study group and 4 in the control group (Table 4); this difference was non-significant. There were no infectious complications. Table 4 Complications.
Intra-articular hematoma (surgical evacuation) Stiffness (manipulation under anesthesia) Total
Control
Study
P (Fisher test)
1/49 (2%)
1/49 (2%)
NS
3/49 (6%)
6/49 (12%)
NS
4/49 (8%)
7/49 (14%)
NS
Time to discharge fitness and mean hospital stay were both significantly shortened, by almost 23 days, in the study group. Reduced hospital stay primarily involves early rehabilitation [2], which is possible if pain control is effective and muscle function conserved [8]. Early mobilization, moreover, by reducing confinement to bed, reduces decubitus-related complications [9–11]. It also seems to have an analgesic effect in itself, triggering nociceptive neuromodulation[12]. GA and FNB are classically associated after TKA [13]. The sensory block allows early mobilization [14,15], but quadriceps inhibition delays resumption of weight bearing. Substituting LA for FNB avoids such adverse motor effects [5], and also the complications induced by peripheral nerve block [16,17], whereas in return catheter-related complications are rare [18]. In the present series, intra-operative LA allowed earlier standing and recovery of autonomy. The absence of quadricipital motor block can be presumed to have been the determining factor: perceived pain differed little between the two groups, although opioid intake was greater in the study group. Several studies, many of them randomized [1,4,19–31], focused on LA techniques in TKA. Methodology varied, some being placebo controlled [1,19–22,26–28] and others not [23,29,30,32,33]. Intraarticular infiltration modalities (rhythm, location, substances) also varied. Some studies implemented postoperative intra-articular drainage, risking possible loss of anesthetic [5,22,26,31–33]. Only 4 compared GA and FNB [4,24,25,31], and none compared isolated continuous ropivacaine infusion versus continuous FNB, which seems to be the most widespread technique in France [13,34]. The literature reports contrasting or indeed opposing results, and comparison is hindered by the great variety of study designs. Among the 4 studies comparing LA and FNB by Affas et al. [25], found no significant inter-group difference in pain or analgesic intake over the first 24 h. Carli et al. [24] reported twice as high an analgesic intake in the LA group over the first 2 days, although hospital stay was identical in the two groups. Tofdahl et al. [4] found less subjective pain in the LA group at D1, with identical analgesic intake throughout the hospital stay, the length of which did not significantly differ; quadriceps function, on the other hand, was better in the LA group and walking distance during the first 48 h was longer. Parvataneni et al. [31] reported identical subjective pain and patient satisfaction in the two groups; hospital stay was identical, and function and satisfaction scores were comparable. These various results were close to those of the present study, the originality of which perhaps lies in the principal assessment criterion of fitness for discharge rather than the classical measure of hospital stay, which can be biased by intercurrent factors, such as social problems or rehabilitation centre waiting lists. The study protocol did not increase the risk of complications, including notably that of sepsis due to postoperative intra-articular injection. These findings agree with others for similar protocols [31,32,35]. LA plasma concentrations were not assessed; other studies, however, reported no toxic levels being reached during continuous intra-articular infiltration [1,18,32,36]. The main study limitation is certainly the retrospective design without randomization. The comparability of the two groups could not be checked. However, the preoperative variables that differed significantly between the two groups, and which might therefore have biased the results, had no significant influence on the principal assessment criterion. This suggests that the bias, although inevitable, was not in fact invalidating; the present study has therefore served as a pilot study for a prospective comparative randomized trial under a Hospital Clinical Research Program (PHRC).
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The present complications rate may seem unusually high. Lack of drainage may be implicated in the cases of hematoma, although the recent literature shows no increased risk of bleeding without drainage after TKA [37,38]; the above-cited studies, moreover, did not use drainage either, yet did not have elevated rates of hematoma [4,24,25,31]. The use of new anticoagulants, not governed by protocol, may be one explanation. Another could be the broad indication for surgical evacuation used by the surgeon involved in this study. There was early stiffness in 14% of cases, in agreement with recent reports [39,40]. All patients had at least 90◦ flexion by discharge, but in some cases, this failed to continue to improve or even worsened at postoperative week 6. In these cases, manipulation under general anesthesia was systematically proposed; this attitude may seem aggressive or indeed excessive, but always achieved ≥ 110◦ flexion by end of follow-up [40]. The rate of stiffness did not differ between groups. 5. Conclusion Associating LA rather than FNB to GA may accelerate functional recovery and reduce hospital stay after TKA, without increasing the risk of complications. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010;81:354–60. [2] Husted H, Hansen HC, Holm G, Bach-Dal C, Rud K, Andersen KL, et al. What determine length of stay after total hip and knee arthroplasty? A national wide study in Denmark. Arch Orthop Trauma Surg 2010;130:263–8. [3] Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the RanawatOrthopaedic Center. Clin Orthop Relat Res 2009;467:1418–23. [4] Toftdahl K, Kikolajsen L, Haraldsted V, Madsen F, Tonnesen EK, Soballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty. A randomized clinical trial. ActaOrthoaedica 2007;78:172–9. [5] 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. [6] Aubrun F, Le Guen M. Anesthésie en orthopédie. In: Congrès National d’Anesthésie et de Réanimation. 2007. p. 365–90. [7] Société franc¸aise d’anesthésie réanimation. Prise en charge des nausées et vomissements postopératoires. Expert conferenced’expertsat the 2007 SFAR congress; 2007. [8] Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BK, Kehlet H. Why still in hospital after fast track hip and knee arthroplasty? Acta Orthopaedica 2011;82:679–84. [9] Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fasttrack surgery. Ann Surg 2008;248:189–98. [10] Samama MM, Dahl OE, Quinlan DJ, Mismetti P, Rosencher N. Quantification of risk factors for venous thromboembolism: a preliminary study for the development of a risk assessment tool. Haematologica 2003;88:1410–21. [11] Husted H, Otte KS, Kristensen BB, Ørsnes T, Wong C, Kehlet H. Low risk of thrombo-embolic complications after fast-track hip and knee arthroplasty. ActaOrthop 2010;81:599–605. [12] Lunn TH, Kristensen BB, Gaarn Larsen L, Kehlet H. Possible effects of mobilisation on acute post-operative pain and nociceptive function after total knee arthroplasty. Acta Anaesthesiol Scand 2012;56:1234–40. [13] Bouaziz H, Bondàr A, Jochum D, Fuzier R, Paqueron X, Ripart J, et al. Pain and Regional Anaesthesia Committee of the French Anaesthesia and Intensive Care Society (SFAR). Regional anaesthesia practice for total knee arthroplasty: French national survey – 2008. Ann Fr Anesth Reanim 2010:440–51. [14] Martin F, Martinez V, Mazoit JX, Bouhassira D, Cherif K, Gentili ME, et al. Antiinflammatory effect of peripheral nerve blocks after knee surgery: clinical and biologic evaluation. Anesthesiology 2008;109:484–90.
[15] Gaertner E. Indications des blocs nerveux périphériques. Recommandations formalisée d’experts. Ann Fr Anesth Reanim 2009;28:85–94. [16] Widmer B, Lustig S, Scholes CJ, Molloy A, Leo SP, Coolican MR, et al. Incidence and severity of complications due to femoral nerve blocks performed for knee surgery. Knee 2012. [17] Sharma S, Lorio R, Specht LM, Davies-Lepie S, Healy WL. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res 2010;468:135–40. [18] Beaussier M, Aissou M. Continuous wound infiltration or intra-articular infusion for postoperative analgesia. Ann Fr Anesth Reanim 2009;28:153–62. [19] Andersen LØ, Husted H, Otte KS, Kristensen BB, Kehlet H. High-volume infiltration analgesia in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. Acta Anaethesiol Scand 2008;52:1331–5. [20] Rosen AS, Colwell CW, Pulido PA, Chaffee TL, Copp SN. A randomized controlled trial of intraarticularropivacaine for pain management immediately following total knee arthroplasty. HSSJ 2010;6:155–9. [21] Goyal N, McKenzie J, Sharkey PF, Parvizi J, Hozack WJ, Austin MS. The 2012 Chitranjan Ranawat Award: intraarticular analgesia after TKA reduces pain: a randomized, double-blinded, placebo-controlled prospective study. Clin Orthop Relat Res 2013;471:64–75. [22] Gomez Cardero P, Rodriguez Merchan EC. Post-operative analgesia in TKA. Ropivacaine continuous intraarticular infusion. Clin Orthop Rel Res 2010;468:1242–7. [23] Koh IJ, Kang YG, Chang CB, Do SH, Seong SC, Kim TK. Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA? A randomized, controlled study. Knee 2012;19:253–9. [24] Carli F, Clemente A, Asenjo JF, Kim DJ, Mistraletti G, Gomarasca M, et al. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth 2010;105:185–95. [25] Affas F, Nygards EB, Stiller CO, Wretenberg P, Olofsson C. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthopaedica 2011;82:441–7. [26] Nechleba J, Rogers V, Cortina G, Cooney T. Continuous intra-articular infusion of bupivacaine for postoperative pain following total knee arthroplasty. J Knee Surg 2005;18:197–202. [27] Williams D, PetruccelliD, Paul J, Piccirillo L, Winemaker M, de Beer J. Continuous infiltration of bupivacaine following total knee arthroplasty: a randomized control trial pilot study. J Arthroplasty 2013;28:479–84. [28] Reeves M, Skinner MW. Continuous intraarticular infusion of ropivacaine after unilateral total knee arthroplasty. Anaesth Intensive Care 2009;37(6):918–22. [29] Busch C, Shore B, Bhandari R, Ganapathy Su, Macdonald S, Bourne R, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty: a randomized trial. JBJS Am 2006;88-A:959–63. [30] Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, et al. A multimodal analgesia protocol for total knee arthroplasty: a randomized, controlled study. JBJS Am 2006;88-A:282–9. [31] Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections. A prospective randomized study. J Arthroplasty 2007;22(Suppl. 2):33–8. [32] Rasmussen S, Kramhoft M, Sperling K, et al. Increased flexion and reduced hospital stay with continuous intra-articular morphine and ropivacaine after primary total knee replacement. Acta Orth Scand 2004;75:606–9. [33] Tripuraneni KR, Woolson ST, Giori NJ. Local infiltration analgesia in TKA patients reduces length of stay and postoperative pain scores. Orthopedics 2011;34:173. [34] Fischer HB, Simanski CJ, Sharp C, Bonnet F, Camu F, Neugebauer EA, et al. A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia 2008;63:1105–23. [35] Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg 2006;203:914–32. [36] Bianconi M, Ferraro L, Traina GC, Zanoli G, Antonelli T, Guberti A, et al. Pharmacokinetics and efficacy of ropivacaine wound instillation after joint replacement surgery. Br J Anaesth 2003;91:830–5. [37] Jenny JY, Boeri C, Lafare S. No drainage does not increase complication risk after total knee prosthesis implantation: a prospective, comparative, randomized study. Knee Surg Sports Traumatol Arthrosc 2001;9:299–301. [38] Zhang QD, Guo WS, Zhang Q, Liu ZH, Cheng LM, Li ZR. Comparison between closed suction drainage and non-drainage in total knee arthroplasty: a metaanalysis. J Arthroplasty 2011;26:1265–72. [39] Issa K, Kapadia BH, Kester M, Khanuja HS, Delanois RE, Mont MA. Clinical, objective, and functional outcomes of manipulation under anesthesia to treat knee stiffness following total knee arthroplasty. J Arthroplasty 2013, http://dx.doi.org/10.1016/j.arth.2013.07.046. [40] Harvie P, Larkin J, Scaddan M, Longstaff LM, Sloan K, Beaver RJ. Stiffness after total knee arthroplasty: does component alignment differ in knees requiringmanipulation? A retrospective cohort study of 281 patients. J Arthroplasty 2013;28:14–9.
Available online at
ScienceDirect www.sciencedirect.com
Original article
Postoperative pain control by intra-articular local anesthesia versus femoral nerve block following total knee arthroplasty: Impact on discharge M. Antoni a , J.-Y. Jenny a,∗ , E. Noll b a Hôpitaux Universitaires de Strasbourg, Service de Chirurgie Orthopédique et Traumatologique, Centre de Chirurgie Orthopédique et de la Main, 10, avenue Bauymann, 67400 Illkirch-Graffenstaden, France b Hôpitaux Universitaires de Strasbourg, Service d’Anesthésie-Réanimation, Centre de Chirurgie Orthopédique et de la Main, 10, avenue Bauymann, 67400 Illkirch-Graffenstaden, France
a r t i c l e
i n f o
Article history: Accepted 16 December 2013 Keywords: Total knee arthroplasty Multimodal pain control Rehabilitation
a b s t r a c t Introduction: The goal of this retrospective study was to compare pain control following total knee arthroplasty (TKA) on a perioperative protocol of local anesthesia (LA) versus the more classical femoral nerve block (FNB) technique. Hypothesis: Fitness for discharge would be achieved earlier using the LA protocol. Materials: Ninety-eight consecutive TKA patients operated on by a single surgeon were included with no selection criteria. In the study group (49 patients), 200 mL ropivacaine 5% was injected into the surgical wound and an intra-articular catheter was fitted to provide continuous infusion of 20 mL/h ropivacaine for 24 h. The control group (49 patients) received ropivacaine FNB. Discharge fitness (independent walking, knee flexion > 90◦ , quadricipital control, pain on VAS ≤ 3) and hospital stay were assessed. Results: Discharge fitness was achieved significantly earlier in the study group (4.2 ± 2.6 versus 6.7 ± 3.2 days; P = 0.0003), with significantly shorter mean hospital stay (6.1 ± 3.4 versus 8.8 ± 3.5 days; P = 0.0002). The complications rate did not differ between study and control groups. Discussion: Although retrospective, this study indicates that the LA protocol improves management of post-TKA pain and accelerates rehabilitation, thereby, reducing hospital stay. The acceleration effect may be due to the absence of quadriceps inhibition. Level of evidence: Level III – Case control study. © 2014 Elsevier Masson SAS. All rights reserved.
1. Introduction The present economic context and rising health costs are incentives for optimizing the efficiency of care. Reduced hospital stay reduces stay-related costs. Optimized pain control following total knee arthroplasty (TKA) accelerates rehabilitation and discharge home [1,2]. Multimodal pain control procedures associated to accelerated rehabilitation have shown promising results [3]. Associating several analgesic techniques should potentiate impact while limiting adverse effects [3]. Injecting the surgical field with high-dose local anesthetics (LA) has been shown to allow earlier weight bearing while avoiding the adverse motor impact of locoregional and spinal anesthesia [3,4,5].
∗ Corresponding author. E-mail address: [email protected] (J.-Y. Jenny). http://dx.doi.org/10.1016/j.otsr.2013.12.022 1877-0568/© 2014 Elsevier Masson SAS. All rights reserved.
The present study assessed the feasibility of a multimodal pain control protocol in a university hospital department with a high TKA turnover. The hypothesis was that fitness for discharge following TKA would be achieved earlier by a multimodal protocol including per and postoperative intra-articular LA infiltration than by postoperative pain control by continuous femoral nerve block (FNB). 2. Material and methods No specific authorization was required for this assessment of a simple change in procedure. 2.1. Population All patients undergoing TKA in 2010 and 2011 were included, without selection. Inclusion criteria were operation by a single surgeon (JYJ), and primary TKA of whatever etiology, excluding
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evolutive septic osteoarthritis. There were no cases in which one or other of the protocols (LA or FNB) was medically contraindicated. The following preoperative data were collated prospectively and analyzed retrospectively: age, gender, body-mass index (BMI), Charnley class, ASA class, type of surgery, and type of intraoperative anesthesia. 2.2. Methods All patients were operated on under general anesthesia (GA) following the guidelines of the French Society of Anaesthesia and Intensive Care (SFAR) [6]. In 2010 (control group), GA was associated to per and postoperative regional anesthesia by FNB. FNB used neurostimulation (minimum intensity, < 0.5 mA; exhaustion, > 0.32 mA), under ultrasound control. A perineural catheter was fitted for 48 h continuous ropivacaine infiltration by elastomeric pump (ropivacainechlorhydrate, Fresenius Kabi, Bad Homburg, Germany; 2 mg/mL, flow rate 10 mL/h). In 2011 (study group), GA was associated to intra and postoperative LA. All patients were informed as to the novelty of this technique in our department at the time, and provided consent. The operative field (posterior, medial and lateral capsule, collateral ligaments, posterior cruciate ligament if spared, subquadricipital recess, and arthrotomy and incision edges) was injected at end of surgery with 200 mL ropivacaine (2 mg/mL). An intra-articular catheter was fitted for 24 h continuous intra-articular ropivacaine infiltration by elastomeric pump (2 mg/mL, flow rate 10 mL/h). Postoperatively, patients systematically received ketoprofen (ketoprofen, Hexal Biotech Forschungs GmbH, Holzkirchen, Germany: 50 mg, q.i.d. for 2 days, except in over 75 year old) and Neurontin® (gabapentin, Pfizer Inc., New York City, USA: 300 mg b.i.d; for 5 days). Classic step 1, 2 and 3 analgesics were provided according to pain expressed on a visual analog scale (VAS) [step 1: Doliprane® (paracetamol, Sanofi-Aventis France, Paris, France); step 2: Acupan® (nefopamchlorhydrate, Biocodex, Gentilly, France) and/or Tramadol (tramadol chlorhydrate, Grünenthal, Aachen, Germany); step 3: Actiskenan® /Skenan® (morphine sulfate, Bristol-Myers Squibb, New York City, USA) and Oxycontin® /Oxynorm® (oxycodone chlorhydrate, Mundipharma, Cambridge, UK)]. Postoperative nausea and vomiting prevention followed SFAR guidelines [7]. Four weeks’ thromboprophylaxis used low molecular weight non-fractionated heparin (Lovenox) or oral anticoagulants (Pradaxa or Xarelto) on the anesthetist’s decision. In patients preoperatively under anti-vitamin K, treatment was resumed at postoperative day 5. 2.3. Surgical technique A pneumatic tourniquet was routinely used. The surgical approach was medial parapatellar, releasing the distal 2 cm of the vastusmedialis. A rotating platform total knee replacement with patellar resurfacing (e.motion® , Aesculap, Tuttlingen, Germany) was implanted under navigation (Orthopilot® , Aesculap, Tuttlingen, Germany). No postoperative drainage was implemented. 2.4. Functional rehabilitation Immediate free mobilization of the knee within the limits of pain tolerance was authorized systematically. Control patients remained in bed until the motor block resolved, as testified to by active knee control in extension, whereupon walking was resumed. Study group patients resumed full weight bearing on 2 crutches on the day of surgery. Subsequent rehabilitation was progressive but without limitation, to achieve early fitness for discharge, defined as the ability to
walk independently with or without crutches, knee flexion ≥ 90◦ , locking in extension and VAS pain score ≤ 3. 2.5. Follow-up The following data were collated prospectively in the surgery department and analyzed retrospectively: type of postoperative analgesia, time to standing, time to aided walking, time to independent walking, twice-daily evolution of pain on VAS, analgesic intake, time to active quadriceps locking, time to 90◦ flexion, hospital stay, discharge destination, complications and surgical revision. 2.6. Statistics Preoperative data were compared between groups on chi2 or Fisher test (categoric variables) or Student’s test (numeric variables). The principal assessment criterion was discharge fitness. Follow-up data were compared between groups on chi2 or Fisher test (categoric variables) or Student’s test (numeric variables); time intervals were compared between groups by survivorship analysis with log-rank test. Correlations between preoperative variables and the principal assessment criterion were assessed by analysis of variance (categoric variables) or linear correlation coefficient. The significance threshold was systematically 5%. Preliminary calculation based on estimated time to discharge fitness in a population resembling the present control group determined a sample size of 50 per group as required to obtain a first-order risk of 5% and 90% power. 3. Results 3.1. Population Ninety-eight patients were included: 37 male, 61 female; mean age: 68.1 ± 10.1 years; mean BMI: 31.4 ± 6.0 kg/m2 . Fortynine patients were assigned to the control group and 49 to the study group. Table 1 shows patient characteristics; there were no significant inter-group differences on inclusion data, except for a better mean ASA score in the study group (P = 0.04). Results are shown in Table 2. Discharge fitness was achieved significantly earlier in the study group (4.2 ± 2.6 versus 6.7 ± 3.2 days; P = 0.0003; Fig. 1), and mean hospital stay was significantly shorter (6.1 ± 3.4 versus 8.8 ± 3.5 days; P = 0.0002). All other intervals (times to standing, walking, control of knee extension, 90◦ flexion and independent walking) were also significantly shorter in the study group. Fig. 2 shows evolution of pain on VAS: it was significantly lower in the study group at D1 (P = 0.009) and D5 (P = 0.04). In-hospital analgesic intake was greater in the study group (Table 3). Table 1 Patient data.
Number Gender Male Female Age (years) ASA score 1 or 2 3 or 4 Charnley score A B C BMI (kg/m2 )
Control
Study
P
49
49
22 27 69.7 ± 9.4
15 34 66.4 ± 10.7
38 11
46 3
0.04
25 23 1 30.6 ± 5.3
25 23 1 32.2 ± 6.6
NS
NS NS
NS
M. Antoni et al. / Orthopaedics & Traumatology: Surgery & Research 100 (2014) 313–316 Table 2 Results.
4. Discussion
Interval (days) between surgery and:
Control
Fitness for discharge Discharge Standing Assisted walking Independent walking Flexion > 90◦ Locking in extension
6.7 8.8 1.1 2.4 6.0 5.1 3.1
± ± ± ± ± ± ±
Study
3.2 3.5 0.9 1.1 2.9 3.0 2.9
4.2 6.1 0.3 1.1 3.7 2.6 1.5
± ± ± ± ± ± ±
P (log-rank test) 2.6 3.4 0.5 0.7 2.7 2.2 1.1
< 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Fig. 1. Time to discharge fitness.
Fig. 2. Subjective pain (VAS). Table 3 In-hospital analgesic intake.
Step 1 Step 2 Step 3
315
Control (units/day)
Study (units/day)
P (Fisher test)
2.7 1.2 1.5
3.2 1.0 3.2
0.004 NS 0.0002
3.2. Complications Eleven patients showed early complications: 7 in the study group and 4 in the control group (Table 4); this difference was non-significant. There were no infectious complications. Table 4 Complications.
Intra-articular hematoma (surgical evacuation) Stiffness (manipulation under anesthesia) Total
Control
Study
P (Fisher test)
1/49 (2%)
1/49 (2%)
NS
3/49 (6%)
6/49 (12%)
NS
4/49 (8%)
7/49 (14%)
NS
Time to discharge fitness and mean hospital stay were both significantly shortened, by almost 23 days, in the study group. Reduced hospital stay primarily involves early rehabilitation [2], which is possible if pain control is effective and muscle function conserved [8]. Early mobilization, moreover, by reducing confinement to bed, reduces decubitus-related complications [9–11]. It also seems to have an analgesic effect in itself, triggering nociceptive neuromodulation[12]. GA and FNB are classically associated after TKA [13]. The sensory block allows early mobilization [14,15], but quadriceps inhibition delays resumption of weight bearing. Substituting LA for FNB avoids such adverse motor effects [5], and also the complications induced by peripheral nerve block [16,17], whereas in return catheter-related complications are rare [18]. In the present series, intra-operative LA allowed earlier standing and recovery of autonomy. The absence of quadricipital motor block can be presumed to have been the determining factor: perceived pain differed little between the two groups, although opioid intake was greater in the study group. Several studies, many of them randomized [1,4,19–31], focused on LA techniques in TKA. Methodology varied, some being placebo controlled [1,19–22,26–28] and others not [23,29,30,32,33]. Intraarticular infiltration modalities (rhythm, location, substances) also varied. Some studies implemented postoperative intra-articular drainage, risking possible loss of anesthetic [5,22,26,31–33]. Only 4 compared GA and FNB [4,24,25,31], and none compared isolated continuous ropivacaine infusion versus continuous FNB, which seems to be the most widespread technique in France [13,34]. The literature reports contrasting or indeed opposing results, and comparison is hindered by the great variety of study designs. Among the 4 studies comparing LA and FNB by Affas et al. [25], found no significant inter-group difference in pain or analgesic intake over the first 24 h. Carli et al. [24] reported twice as high an analgesic intake in the LA group over the first 2 days, although hospital stay was identical in the two groups. Tofdahl et al. [4] found less subjective pain in the LA group at D1, with identical analgesic intake throughout the hospital stay, the length of which did not significantly differ; quadriceps function, on the other hand, was better in the LA group and walking distance during the first 48 h was longer. Parvataneni et al. [31] reported identical subjective pain and patient satisfaction in the two groups; hospital stay was identical, and function and satisfaction scores were comparable. These various results were close to those of the present study, the originality of which perhaps lies in the principal assessment criterion of fitness for discharge rather than the classical measure of hospital stay, which can be biased by intercurrent factors, such as social problems or rehabilitation centre waiting lists. The study protocol did not increase the risk of complications, including notably that of sepsis due to postoperative intra-articular injection. These findings agree with others for similar protocols [31,32,35]. LA plasma concentrations were not assessed; other studies, however, reported no toxic levels being reached during continuous intra-articular infiltration [1,18,32,36]. The main study limitation is certainly the retrospective design without randomization. The comparability of the two groups could not be checked. However, the preoperative variables that differed significantly between the two groups, and which might therefore have biased the results, had no significant influence on the principal assessment criterion. This suggests that the bias, although inevitable, was not in fact invalidating; the present study has therefore served as a pilot study for a prospective comparative randomized trial under a Hospital Clinical Research Program (PHRC).
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The present complications rate may seem unusually high. Lack of drainage may be implicated in the cases of hematoma, although the recent literature shows no increased risk of bleeding without drainage after TKA [37,38]; the above-cited studies, moreover, did not use drainage either, yet did not have elevated rates of hematoma [4,24,25,31]. The use of new anticoagulants, not governed by protocol, may be one explanation. Another could be the broad indication for surgical evacuation used by the surgeon involved in this study. There was early stiffness in 14% of cases, in agreement with recent reports [39,40]. All patients had at least 90◦ flexion by discharge, but in some cases, this failed to continue to improve or even worsened at postoperative week 6. In these cases, manipulation under general anesthesia was systematically proposed; this attitude may seem aggressive or indeed excessive, but always achieved ≥ 110◦ flexion by end of follow-up [40]. The rate of stiffness did not differ between groups. 5. Conclusion Associating LA rather than FNB to GA may accelerate functional recovery and reduce hospital stay after TKA, without increasing the risk of complications. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010;81:354–60. [2] Husted H, Hansen HC, Holm G, Bach-Dal C, Rud K, Andersen KL, et al. What determine length of stay after total hip and knee arthroplasty? A national wide study in Denmark. Arch Orthop Trauma Surg 2010;130:263–8. [3] Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the RanawatOrthopaedic Center. Clin Orthop Relat Res 2009;467:1418–23. [4] Toftdahl K, Kikolajsen L, Haraldsted V, Madsen F, Tonnesen EK, Soballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty. A randomized clinical trial. ActaOrthoaedica 2007;78:172–9. [5] 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. [6] Aubrun F, Le Guen M. Anesthésie en orthopédie. In: Congrès National d’Anesthésie et de Réanimation. 2007. p. 365–90. [7] Société franc¸aise d’anesthésie réanimation. Prise en charge des nausées et vomissements postopératoires. Expert conferenced’expertsat the 2007 SFAR congress; 2007. [8] Husted H, Lunn TH, Troelsen A, Gaarn-Larsen L, Kristensen BK, Kehlet H. Why still in hospital after fast track hip and knee arthroplasty? Acta Orthopaedica 2011;82:679–84. [9] Kehlet H, Wilmore DW. Evidence-based surgical care and the evolution of fasttrack surgery. Ann Surg 2008;248:189–98. [10] Samama MM, Dahl OE, Quinlan DJ, Mismetti P, Rosencher N. Quantification of risk factors for venous thromboembolism: a preliminary study for the development of a risk assessment tool. Haematologica 2003;88:1410–21. [11] Husted H, Otte KS, Kristensen BB, Ørsnes T, Wong C, Kehlet H. Low risk of thrombo-embolic complications after fast-track hip and knee arthroplasty. ActaOrthop 2010;81:599–605. [12] Lunn TH, Kristensen BB, Gaarn Larsen L, Kehlet H. Possible effects of mobilisation on acute post-operative pain and nociceptive function after total knee arthroplasty. Acta Anaesthesiol Scand 2012;56:1234–40. [13] Bouaziz H, Bondàr A, Jochum D, Fuzier R, Paqueron X, Ripart J, et al. Pain and Regional Anaesthesia Committee of the French Anaesthesia and Intensive Care Society (SFAR). Regional anaesthesia practice for total knee arthroplasty: French national survey – 2008. Ann Fr Anesth Reanim 2010:440–51. [14] Martin F, Martinez V, Mazoit JX, Bouhassira D, Cherif K, Gentili ME, et al. Antiinflammatory effect of peripheral nerve blocks after knee surgery: clinical and biologic evaluation. Anesthesiology 2008;109:484–90.
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