The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

A Randomized Double-Blind Prospective Study Comparing the Efficacy of Subperiosteal and Periarticular Injections of a Local Anesthetic for Postoperative Pain Management after Total Knee Arthroplasty

Document Type : RESEARCH PAPER

Authors
Reza Minaei 1
Mohammad Salehpour Roudsari 2
Emad Kouhestani 1
Mahshid Ghasemi 3
1 Department of Orthopedic Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran/Bone Joint and Related Tissues Research Center, Akhtar
2 Department of Orthopedic Surgery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Anesthesiology Research Center, Shahid Beheshti University of Medical Sciences,Tehran, Iran
10.22038/abjs.2023.72484.3371
Abstract
Objectives: Total knee arthroplasty (TKA) serves as an effective surgical treatment method for advanced osteoarthritis (OA). Nonetheless, it is associated with postoperative pain that can influence patients’ functional outcome. This study aimed to compare the analgesic effect of subperiosteal and periarticular injection methods of a special local anesthetic in patients who underwent TKA.
Methods: This double-blind prospective clinical study was conducted on patients with advanced knee OA who underwent TKA. Patients were randomly divided into two groups, with a local anesthetic (21 ml) administered either in periarticular (P group) or subperiosteal (S group) forms prior to wound closure. The local anesthetic consisted of lidocaine 2% (15 cc), dexmedetomidine (1 cc), and marcaine 0.5% (5 cc). A study-blinded orthopedic resident recorded postoperative pain levels using a 10-point visual analogue score (VAS) (0 indicating no pain, 10 indicating worst pain) at 6, 12, 24, and 48 hours after surgery.
Results: A total of 40 patients (P and S group; n=20 each), consisting of 10 males (mean age=67.4 years old), were included in this study. The intensity of pain in the S group was significantly lower than in the P group 24 hours after surgery (mean VAS scores in the P group: 4±1 vs. the S group: 3.3±0.7, P=0.024). Furthermore, VAS scores at 6, 12, and 48 hours post-surgery were lower in the S group compared to the P group; however, the difference was not statistically significant (P>0.05).
Conclusion: Our study indicated that subperiosteal injection of lidocaine, dexmedetomidine, and marcaine is more effective than periarticular injection, providing effective postoperative pain management after TKA.
Level of evidence: II
Keywords
Osteoarthritis
Pain
Postoperative pain
TKA
Total knee arthroplasty
Subjects
  1. Lowe CJM, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ.2007; 335(7624):812. doi: 10.1136/bmj.39311.460093.BE.
    2. Paul JE, Arya A, Hurlburt L, et al. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology.2010; 113(5):1144-62. doi: 10.1097/ALN.0b013e3181f4b18.
    3. Fard AB, Jabalameli M, Khorrami AM, Ghaderi MT, Mohammadpour M, Gharanizadeh K. The Effect of Adding Corticosteroid to the Periarticular Injection Cocktail for Pain Control after Total Hip and Total Knee Arthroplasty: A Double-Blinded Randomized Clinical Trial. Arch Bone Jt Surg.2022; 10(12):1049-1055. doi: 10.22038/ABJS.2022.50610.2509.
    4. Galimba J. Promoting the use of periarticular multimodal drug injection for total knee arthroplasty. Orthop Nurs.2009; 28(5):250-4; quiz 255-6. doi: 10.1097/NOR.0b013e3181b822ed.
    5. Fu P, Wu Y, Wu H, Li X, Qian Q, Zhu Y. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty—a randomized controlled trial. Knee.2009; 16(4):280-4. doi: 10.1016/j.knee.2008.12.012.
    6. Abdulwahab T, Meshram P, Althani S, Albelooshi A. Comparison of Intraarticular Versus Combined Intravenous and Intraarticular Tranexamic Acid Administration in Patients Undergoing Primary Unilateral Total Knee Arthroplasty: A Randomized Controlled Trial in the Middle Eastern Patient Population. Arch Bone Jt Surg.2022; 10(12):1037-1043. doi: 10.22038/ABJS.2022.67705.3210.
    7. Fajardo M, Collins J, Landa J, Adler E, Meere P, Di Cesare PE. Effect of a perioperative intra-articular injection on pain control and early range of motion following bilateral TKA. Orthopedics.2011; 34(5):354. doi: 10.3928/01477447-20110317-11.
    8. Yuenyongviwat V, Pornrattanamaneewong C, Chinachoti T, Chareancholvanich K. Periarticular injection with bupivacaine for postoperative pain control in total knee replacement: a prospective randomized double-blind controlled trial. Adv Orthop.2012:2012:107309. doi: 10.1155/2012/107309.
    9. Dalury DF. A state-of-the-art pain protocol for total knee replacement. Arthroplast Today.2016; 2(1):23-25. doi: 10.1016/j.artd.2016.01.004.
    10. Busch CA, Shore BJ, Bhandari R, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty: a randomized trial. J Bone Joint Surg Am.2006; 88(5):959-63. doi: 10.2106/JBJS.E.00344.                      11. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty.2007; 22(6 Suppl 2):33-8. doi: 10.1016/j.arth.2007.03.034.
    12. Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res.2009; 467(6):1418-23. doi: 10.1007/s11999-009-0728-7.
    13. Packiasabapathy SK, Kashyap L, Arora MK, et al. Effect of dexmedetomidine as an adjuvant to bupivacaine in femoral nerve block for perioperative analgesia in patients undergoing total knee replacement arthroplasty: a dose–response study. Saudi J Anaesth.2017; 11(3):293-298. doi: 10.4103/sja.SJA_624_16.
    14. Gousheh M, Akhondzadeh R, Rashidi M, Olapour A, Moftakhar F. Comparison of dexmedetomidine and morphine as adjuvants to bupivacaine for epidural anesthesia in leg fracture surgery: A randomized clinical trial. Anesth Pain Med.2019; 9(4):e91480. doi: 10.5812/aapm.91480.
    15. Kalamaras AB, Aarnes TK, Moore SA, et al. Effects of perioperative saphenous and sciatic nerve blocks, lumbosacral epidural or morphine–lidocaine–ketamine infusion on postoperative pain and sedation in dogs undergoing tibial plateau leveling osteotomy. Vet Anaesth Analg.2021; 48(3):415-421. doi: 10.1016/j.vaa.2021.02.004.
    16. Modir H, Moshiri E, Azami M, Zad MJ, Hashiani AA. Comparative efficacy of ketamine, lidocaine, acetaminophen, and dexmedetomidine combined with morphine patient-controlled analgesia in treating opium-addicted patients undergoing tibia fracture surgery: A randomized clinical trial. Journal of Acute Disease. 2022; 11(5):181.
    17. Jain N, Tada S, Sethi SK, Patodi V, Jain K, Garg DK. Dexmedetomidine with 0.5% lignocaine enhances postoperative analgesia in patients undergoing upper limb orthopedic surgeries under intravenous regional anesthesia. Journal of Dr NTR University of Health Sciences. 2021; 10(1):8.
    18. Frisch NB, Darrith B, Hansen DC, Wells A, Sanders S, Berger RA. Single-dose lidocaine spinal anesthesia in hip and knee arthroplasty. Arthroplast Today.2018; 4(2):236-239. doi: 10.1016/j.artd.2018.02.011.
    19. Hagar AD, Fang CJ, Dannenbaum JH, Smith EL, Bono JV, Talmo CT. Reducing narcotic usage with 0.5% bupivacaine periarticular injections in total knee arthroplasty. J Arthroplasty.2022; 37(5):851-856. doi: 10.1016/j.arth.2022.01.026.
    20. Yang Q, Ren Y, Feng B, Weng X. Pain relieving effect of dexmedetomidine in patients undergoing total knee or hip arthroplasty: a meta-analysis. Medicine (Baltimore).2020; 99(1):e18538. doi: 10.1097/MD.0000000000018538.
    21. Gutman MJ, Patel MS, Weintraub MT, Singh A, Padegimas EM, Abboud JA, Namdari S. Can Patients Accurately Recall their Preoperative Pain and Functional Scores Following Rotator Cuff Repair and Total Shoulder Arthroplasty? Arch Bone Jt Surg.2023; 11(3):160-165. doi: 10.22038/ABJS.2021.61260.3006.
    22. Joyce CD, Stoll KE, Harper TM, Sherman M, Botros J, Getz CL, Namdari S, Davis DE. Shoulder Synovitis does not Affect Pain after Arthroscopic Rotator Cuff Repair. Arch Bone Jt Surg.2022; 10(12):1013-1019. doi: 10.22038/ABJS.2022.64501.3101.
    23. Li Jw, Ma Ys, Xiao Lk. Postoperative pain management in total knee arthroplasty. Orthop Surg.2019; 11(5):755-761. doi: 10.1111/os.12535.
    24. Petersen KK, Simonsen O, Laursen MB, Nielsen TA, Rasmussen S, Arendt-Nielsen L. Chronic postoperative pain after primary and revision total knee arthroplasty. Clin J Pain.2015; 31(1):1-6. doi: 10.1097/AJP.0000000000000146.
    25. Haegerstam GA. Pathophysiology of bone pain: a review. Acta Orthop Scand.2001; 72(3):308-17. doi: 10.1080/00016470152846682.
    26. Wylde V, Beswick A, Bruce J, Blom A, Howells N, Gooberman-Hill R. Chronic pain after total knee arthroplasty. EFORT Open Rev.2018; 3(8):461-470. doi: 10.1302/2058-5241.3.180004.
    27. Dennis DA. Evaluation of painful total knee arthroplasty. J Arthroplasty.2004; 19(4 Suppl 1):35-40. doi: 10.1016/j.arth.2004.03.003.
    28. Beyzadeoglu T, Yilmaz C, Bekler H, Gokce A, Sayin MM. Intraarticular tramadol plus pericapsular incisional bupivacaine provides better analgesia than intraarticular plus pericapsular incisional bupivacaine after outpatient arthroscopic partial meniscectomy. Knee Surg Sports Traumatol Arthrosc.2007; 15(5):564-8. doi: 10.1007/s00167-006-0221-8.
    29. Altay N, Sarıkaya B, Karahan MA, et al. Comparison of efficacy between combined periarticular and incisional injections versus periarticular injection alone of bupivacaine for pain control after total knee arthroplasty: A prospective randomized controlled trial. Acta Orthop Traumatol Turc.2020; 54(4):402-407. doi: 10.5152/j.aott.2020.20212.
    30. Gibbs D, Green T, Esler C. The local infiltration of analgesia following total knee replacement: a review of current literature. J Bone Joint Surg Br.2012; 94(9):1154-9. doi: 10.1302/0301-620X.94B9.28611.
    31. Akizuki S, Yasukawa Y, Takizawa T. A new method of hemostasis for cementless total knee arthroplasty. Bull Hosp Jt Dis.1997; 56(4):222-4.
    32. Serbest S, Tiftikçi U, Çoban M, Çirpar M, Daglar B. Knee pain and functional scores after intramedullary nailing of tibial shaft fractures using a suprapatellar approach. J Orthop Trauma.2019; 33(1):37-41. doi: 10.1097/BOT.0000000000001337.
    33. Bhana N, Goa KL, McClellan KJ. Dexmedetomidine. Drugs.2000; 59(2):263-8; discussion 269-70. doi: 10.2165/00003495-200059020-00012.
    34. Dunn LK, Durieux ME. Perioperative use of intravenous lidocaine. Anesthesiology.2017; 126(4):729-737. doi: 10.1097/ALN.0000000000001527.
    35. Moore DC, Mather LE, Bridenbaugh LD, Thompson GE, Balfour RI, Lysons DF, Horton WG. Bupivacaine (Marcaine®): an evaluation of its tissue and systemic toxicity in humans. Acta Anaesthesiol Scand.1977; 21(2):109-21. doi: 10.1111/j.1399-6576.1977.tb01201.x.
The Archives of Bone and Joint Surgery
Volume 11, Issue 11
November 2023
Pages 704-710

  • Receive Date 29 May 2023
  • Revise Date 08 October 2023
  • Accept Date 23 October 2023