Periarticular Injection in Total Knee Arthroplasty

Abstract

Optimal pain management after total knee arthroplasty (TKA) can expedite postoperative recovery, improve perioperative outcomes, and increase patient satisfaction. Periarticular injections (PAIs) have become increasingly used to improve pain management after TKA. Similar to peripheral nerve blocks, the use of intraoperative PAIs can lower pain scores and expedite discharge from the hospital. However, there is notable variability in the ingredients and administration techniques of PAIs. Currently, no standard of care exists for PAIs, especially in the setting of adjuvant peripheral nerve blocks. This study seeks to evaluate the ingredients, administration techniques, and outcomes of PAIs used during TKA. Pain control is an important component of recovery after total knee arthroplasty (TKA) and, when managed effectively, can expedite functional recovery and, ultimately, improve patient satisfaction. Evidence suggests that patients with poor pain control in the initial 48 hours postoperatively are limited in their ability to achieve long-term pain relief. 1 Efforts to improve pain control and avoid adverse effects of analgesic medications have led to the widespread use of multimodal analgesia to help facilitate rapid mobilization of TKA patients. Multimodal pain control modalities, including oral opioids, nonsteroidal anti-inflammatory medications, acetaminophen, and local or regional anesthetics including peripheral nerve blocks (PNBs) and periarticular injections (PAIs), have become the standard of care. 2 Still, notable variability exists with the use of local and regional anesthesia. Thus, this review will compare current pain management strategies after TKA and focus on the delivery and efficacy of PAIs. History of Periarticular InjectionsIn the past several decades, pain management after TKA has evolved markedly. During the 1980s, the cornerstone of pain management after TKA consisted of intramuscular injections of opioids. This slowly transitioned to patient-controlled analgesia in the 1990s, PNBs in the early 2000s, and finally, multimodal analgesia with the addition of PAIs in the late 2000s. The first prospective, randomized control trial on PAIs was published by Busch et al 3 in 2006. The authors randomized 64 patients undergoing TKA to receive a PAI containing ropivacaine, ketorolac, morphine, and adrenaline or to receive no