Intraarticular vs. extraarticular ropivacaine infusion following high-dose local infiltration analgesia after total knee arthroplasty

Abstract

Background and purpose Ropivacaine infusion following high-volume local infiltration analgesia has been shown to be effective after total knee arthroplasty, but the optimum site of administration of ropivacaine has not been evaluated. We compared the effects of intraarticular and extraarticular adminstration of the local anesthetic for postoperative supplementation of high-volume local infiltration analgesia.Patients and methods In this double-blind study, 36 rheumatic patients aged 51–78 years with physical status ASA 2–3 who were scheduled for total knee arthroplasty were randomized into 2 groups. All patients received wound infiltration at the end of surgery with 300 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine (total volume 156 mL). A tunneled catheter was randomly placed either extraarticularly or intraarticularly. Continuous infusion of ropivacain (0.5%, 2 mL/h) was started immediately and was maintained during the next 48 h. Pain intensity at rest, on movement, and with mobilization was estimated by the patients and the physiotherapist; rescue morphine consumption was recorded.Results As estimated by the patients, ropivacaine administered intraarticularly did not improve analgesia relative to extraarticular infusion, but improved the first mobilization. The incidence of high intensity of pain (VAS 7–10) was less in the group with intraarticular infusion. Analgesic requirements were similar in the 2 groups (47 mg and 49 mg morphine). No complications of postoperative wound healing were seen and there were no toxic side effects.Interpretation Continuous infusion of ropivacaine intraarticulary did not improve postoperative analgesia at rest relative to extraarticular administration, but it appeared to reduce the incidence of high pain intensity during first exercises, and could therefore be expected to improve mobilization up to 24 h after total knee arthroplasty.

Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review

“…Differing modes of delivery/infiltration and/or types of analgesic agents aim to promote an increased ability for the patient to mobilize earlier (for example by reducing pain associated with movement or reducing post operative nausea) which may further increase the likelihood of achieving safe and effective early mobilization. [24][25][26][27] Our findings are similar to other evidence from other research designs not included in our review. An observational design found initiating physiotherapy in total hip arthroplasty on day of surgery reduced length of stay by 0.2 days.…”

Local infiltration analgesia versus femoral nerve block in total knee arthroplasty: A meta-analysis

“…Andersen et al [31] compared the extraarticular wound infiltration or intraarticularly LIA after TKA and found there was no statistical difference between the two groups. Dobrydnjov et al [32] compared the effects of continuous intraarticular and extraarticular adminstration of LIA following TKA and reported that continuous intraarticular reduced the incidence of high pain intensity during first exercises. Future studies should continue to investigate which optimal site of administration is better.…”

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

“…As an alternative to periarticular administration of analgesics, intraarticular delivery of anesthetics has gained recent attention. The optimal site for analgesic infiltration, whether it is given intra-or periarticularly, is still unclear [2,6]. Nonetheless, an intraarticular continuous infusion of ropivacaine, in particular, has been shown to be efficacious in reducing postoperative pain and opioid requirements when compared to placebo in prior studies [8,15].…”