Periarticular injection and continuous femoral nerve block versus continuous femoral nerve block alone on postoperative opioid consumption and pain control following total knee arthroplasty: Randomized controlled trial

Abstract

Continuous femoral nerve block (CFNB) has been used to prevent the breakthrough pain after total knee arthroplasty (TKA). Multimodal drug injection (PMDI) has also been shown to decrease opioid consumption and pain. We investigated whether the use of PMDI further improves analgesic and rehabilitation outcomes when used in conjunction with CFNB. This is a prospective randomized controlled study of 44 patients undergoing primary TKA. The treatment group (n = 23) received a PMDI of combined ropivacaine, epinephrine, ketorolac and morphine, and the controlled group (n = 21) received saline at wound closure. Total opioid consumption, pain scores, knee range of motion (ROM) outcomes, length of stay, and patient satisfaction were measured and compared. The total consumption of morphine is similar between the two groups (52.6 AE 40.6 vs. 41.5 AE 32.9, p = 0.325). The mean morphine consumption of the treatment group was significantly lower than the control at 4 h after surgery (4.2 AE 5.5 vs. 11.3 AE 8.1, p = 0.002) but comparable on POD1, POD2, and POD3. The mean pain scores were significantly higher in the treatment group than the control group at POD2 (at rest: 47.3 AE 29.1 vs. 23.8 AE 20.6, p = 0.004; after PT: 57.7 AE 25.4 vs. 35.2 AE 26.8, p = 0.007) and POD3 (at rest: 30.9 AE 30.3 vs. 14.8 AE 20.9, p = 0.045; after PT: 50.2 AE 30.6 vs. 29.0 AE 32.1, p = 0.035), and not significantly different at 4 h after surgery or at POD1. Mean maximal knee flexion ROM in degrees during active and active assisted mobilization showed no significant difference between the control and the treatment groups on POD2 and POD3. The mean length of stay of the treatment group is significantly longer than the control group (5.1 AE 2.1 vs. 3.8 AE 1.6, p = 0.032). At discharge, no significant difference exists between the two groups for mean patient satisfaction. The addition of PMDI led to a decrease in opioid consumption in the immediate postoperative period but with no significant difference in the total consumption within the first three days postoperatively. This finding provides an opportunity for appropriate preoperative treatment and education for both patients and caregivers.

Postoperative Pain Management in Total Knee Arthroplasty

“…Postoperatively, multimodal analgesia includes pharmacologic agents, neuraxial anesthesia, PNB, and PCA, each of which will be described below. Compared with a monotherapy, multimodal analgesia provides superior postoperative pain relief to promote recovery of the knee, and reduce opioid consumption and related side effects. Consequently, multimodal analgesia is used widely for perioperative pain control in patients undergoing TKA.…”

“…In an attempt to relieve severe postoperative pain, several routine approaches have been proposed, such as use of preemptive analgesia, opioids, cyclooxygenase‐2 inhibitors, epidural anesthesia, peripheral nerve blockade, local infiltration analgesia, patient‐controlled analgesia, and multimodal analgesia. Adequate postoperative analgesia could not only reduce pain, opioid consumption, and, consequently, opioid‐related adverse events, but also reduce length of hospital stay and costs, and improve rehabilitation and patient satisfaction. Therefore, it is necessary for surgeons to fully understand current anesthetic and analgesic regimens for TKA to improve patient outcomes (Fig.…”

Opioid-Prescribing Practices Between Total Knee and Hip Arthroplasty in an Outpatient Versus Inpatient Setting

“…36 Specifically, studies have shown associations between better postoperative pain management after TKA and patient satisfaction. 37-39 As such, it is especially interesting that this study showed significantly lower levels of pain in the OP ASC setting and significantly higher levels of satisfaction of pain control with respect to TKA. This demonstrates some of the reasons, which have not previously been studied, on why an OP ASC may offer advantages over IP settings with respect to patient satisfaction after TKA.…”

Single shot adductor canal block combined with intravenous patient-controlled analgesia can be effective as continuous adductor canal block in reducing opioid consumption and breakthrough pain after total knee arthroplasty

“…However, effective pain control remains an issue due to its subjective nature and patient diversity [ 4 ]. Several postoperative analgesic regimens are utilized to maximize analgesic effects and minimize possible undesired adverse events [ 3 ]. In the past, epidural analgesia was regularly used as postoperative analgesic regimen after TKA.…”