Efficacy of Periarticular Multimodal Analgesic Injection Containing High-Dose Ketorolac versus Triamcinolone in Early Postoperative Total Knee Arthroplasty: A Randomized Controlled Trial

Abstract

Introduction: Periarticular multimodal analgesic injection associates with less postoperative (post-op) pain after total knee arthroplasty (TKA) with less opioid consumption. The combination of additives and dosage are various and controversial. Evidence of ketorolac compared to triamcinolone as an additive is limited in terms of efficacy and safety. Materials and Methods: Fifty-six patients with unilateral TKA were randomized to receive either 60mg ketorolac or 80mg triamcinolone acetonide as cocktail additives in periarticular injection. Significant threshold was considered if the adjusted mean difference of morphine consumption was greater than 3mg at any timepoint. The primary outcomes were morphine consumptions at immediate post-op, 24 hour (h), 48h, and 72h post-op. Pain visual analogue scale (VAS), knee range of motion, straight leg raising ability, and adverse events were secondary outcomes. Results: Adjusted mean differences (ketorolac-triamcinolone) in morphine consumption were -0.4, 2.5, 2.6, and 2.3mg at given timepoints without significance. No difference observed in pain VAS at rest and during motion, post-op knee extension, and straight leg raising ability. However, post-op knee flexion was significantly higher in triamcinolone group at any timepoints (mean differences 10.3, 10.6, and 9.7, respectively, p<0.05). Conclusions: Periarticular analgesic injection containing 60mg ketorolac provided similar analgesic efficacy and early functional recovery compared with 80mg triamcinolone acetonide. However, triamcinolone may benefit over ketorolac in early post-op knee flexion.

Periarticular infiltration used in total joint replacements: an update and review article

“…Meta-analysis included 3 high-quality studies [ 31 , 52 , 67 ] with ketorolac as an additive to PAI in TKA only 30 mg periarticular infiltration Various Intraoperative PAI with Ketorolac leads to decrease postoperative pain, but effect on opioid usage is unclear – 2/3 studies found no difference in opioid usage with the addition of ketorolac. The addition of Ketorolac to PAI contain long-acting analgesics provides additional benefit compared to PAI without ketorolac Various Apinyankul et al [ 39 ] RCT 56 patients receiving TKA 1. 60 mg Ketorolac as an additive to unspecified PAI cocktail 2.…”

“…Ketorolac's recommended IM and IV dose is 30 mg as a one-time dose or 30 mg every 6 h up to a maximum total of 120 mg in 24 h [ 51 ]. Still, some studies also describe 60 mg as a dosage option[ 39 , 40 ] with a possible dose-dependent response [ 49 , 52 ]. Many studies included visual analog scale (VAS) scores and opioid usage as measures of effectiveness for postoperative pain management.…”

“…Many studies included visual analog scale (VAS) scores and opioid usage as measures of effectiveness for postoperative pain management. All but two studies [ 39 , 45 ] that explored subjective pain scores found improved postoperative pain when ketorolac was added to the PAI. Decreased opioid usage was reported by Nikhar [ 3 ], Tammachote [ 47 ] and Andersen [ 37 ], but opioid usage was otherwise not significantly reduced [ 38 – 40 ].…”

“…Decreased opioid usage was reported by Nikhar [ 3 ], Tammachote [ 47 ] and Andersen [ 37 ], but opioid usage was otherwise not significantly reduced [ 38 – 40 ]. Improvements in postoperative function, including range of motion [ 39 , 40 , 42 , 44 – 46 ] and time to home readiness [ 37 ], were also investigated and were generally favorable, with some exceptions [ 39 , 45 ]. Complications in the studies with ketorolac infiltration were rare, with one episode of hematoma [ 37 ] and one episode of DVT [ 43 ] highlighted across the studies.…”

Efficacy of Periarticular Infiltration with Dexamethasone and Bupivacaine plus Adductor Canal Block Relative to That of Adductor Canal Block Alone for Patients Undergoing Total Knee Arthroplasty: A Retrospective Case-Matched Study

“…Periarticular infiltration (PI) is widely performed during TKA. It involves the intraoperative injection of a local anesthetic combined with other medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids, into the soft tissue around the knee joint [ 12 , 13 ]. A periarticular injection can be administered by the surgeon intraoperatively and at a low cost [ 14 ].…”