Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA: A Randomized, Double-blind Trial

Abstract

Background Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.Questions/purposes We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. Methods Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. Results The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p \ 0.0001; 12-24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.

Intra-articular Analgesia and Discharge to Home Enhance Recovery following Total Knee Replacement

“…Furthermore, the reduced consumption of narcotics in Group B patients may be the major factor leading to the reduced incidence of nausea, vomiting and dizziness that we observed in Group B. In a previous study [18], we found ropivicaine infusion alone was associated with higher VAS pain scores during the first 48 h compared to Epidural/FNB. In this study, addition of the SNB has eliminated this difference.…”

“…Femoral nerve blocks are now well known to be associated with prolonged quad weakness which slows the progression of post-op mobilization and increases the risk of falling during the hospital stay [6,8,10,18,20,22]. Our current approach combines intra-articular infusion of ropivicaine with a saphenous nerve block.…”

“…Encouraged by other reports we adopted the use of a continuous intra-articular infusion of local anesthetic in place of epidural PCA [7,17,18]. In order to allow earlier more aggressive mobilization we also replaced the femoral nerve block with a saphenous block to avoid quadriceps weakness and the potential for knee buckling and falls [6,8,10,18,20,22]. Additional modifications to the clinical pathway included an emphasis on home discharge aided by a joint effort with our home care agency to provide daily physical therapy home visits for the first 2 weeks after discharge as an alternative to transfer to a acute rehabilitation facility.…”

Postoperative Analgesie nach Knie-TEP

“…Außerdem besteht aufgrund motorischer Blockade und Sensibilitätsverlust im Bereich der unteren Extremität eine erhöhte Sturzgefahr. Folglich kommt es zu einer verzögerten postoperativen Mobilisation [12,21]. Zusätzlich ist die Applikation des Katheters technisch nicht immer möglich und bedarf nicht selten eines deutlichen zeitlichen Aufwandes im Rahmen der Operationsvorbereitung.…”

Periarticular local anaesthetic in knee arthroplasty: A systematic review and meta-analysis of randomised trials

“…From these we identified 12 eligible RCTs. [3][4][5][6][7][8][9][10][11][12][13][14] Inter-observer agreement for trial eligibility was good (kappa = 0.75; SE 0.053). Table I reports the characteristics of the included trials and the local anaesthetic protocols used in the trials.…”