Local Infiltration in Orthopaedic Surgery

Edward M. Vasarhelyi, M.D., M.Sc., FRCSC
Clinical Fellow, Western University
London, ON

Douglas Naudie, M.D., FRCSC
Associate Professor, Western University
London, ON

Adequate control of postoperative pain following hip and knee arthroplasty can be a challenging task1. Previous studies have shown that over 50% of patients undergoing surgery report postoperative pain as a major concern2. Consequences of uncontrolled pain can include myocardial ischemia and infarctions, thromboembolic events, pulmonary infections, paralytic ileus, urinary retention, impaired immune function, as well as anxiety. In addition, inadequate control of pain may result in patient dissatisfaction, impaired patient rehabilitation, and prolonged hospitalizations2.

 

The negative influence of postoperative pain on rehabilitation is particularly concerning for patients undergoing lower extremity joint replacement surgery. Functional recovery and return of muscle strength is dependent on the ability of patients to comply with rehabilitation. The drawbacks of inadequate rehabilitation are of particular significance in hip and knee arthroplasty, since faster mobilization leads to quicker discharge from the hospital. Furthermore, studies have shown that recovery from knee arthroplasty is prolonged up to 50 days postoperatively, far greater than recovery from hip replacement3. Pain control is therefore especially important for knee arthroplasty patients to reduce the incidence of arthrofibrosis, and to allow recovery of range of motion and muscle strength for ambulation4.

As the adverse outcomes from uncontrolled pain can be very significant to a postoperative arthroplasty patient, adequate pain management is critical. Two current and critical parts of contemporary pain management include pre-emptive analgesia and preventative multimodal techniques. While a multitude of multimodal techniques exist, this review will focus on the use of local infiltration techniques in orthopaedic surgery, particularly as it applies to hip and knee arthroplasty.

Local infiltration is simple and inexpensive, and has virtually no systemic effect or interference with other medications. This makes it a very attractive modality, and only recently has its efficacy been studied rigorously in randomized trials. Several studies have begun to examine the efficacy of intraoperative periarticular drug injection in comparison to other forms of postoperative analgesia.

In both total hip arthroplasty (THA) and total knee arthroplasty (TKA), patients have been shown to derive early benefit from local infiltration. Parvataneni et al.5 randomized patients to receive either a patient-controlled anaesthetic (PCA) pump or periarticular injection. THA patients in the periarticular injection group demonstrated significantly lower average pain scores and higher satisfaction than the PCA group. The injection group also had lower postoperative narcotic usage and side effects and an improved early functional recovery. Similarly, in a case series of 325 patients, Kerr et al.6 examined postoperative pain control in hip resurfacing arthroplasty (HRA), THA and TKA patients. Satisfactory pain control was achieved in nearly all patients. Two-thirds of the patients had no morphine requirements while in hospital during their postoperative course and 71% of patients were discharged home on postoperative day one. Early mobilization was achieved with assisted walking by six hours and independent walking was achieved between 13 and 22 hours.

In further studies, TKA patients alone have shown benefit from intra-articular injection. Vendittoli et al.7 randomized 42 patients to receive morphine via PCA or local infiltration and PCA. The local infiltration group in their study showed significantly lower morphine consumption at both 24 and 40 hours postoperatively and they reported fewer hours of nausea over the five-day postoperative period.

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Figure 1. Schematic diagram of areas typically infiltrated during total knee replacement surgery.

 

When comparing local infiltration and continuous epidural infusion, Andersen et al.8 demonstrated several advantages of local infiltration. In their study, forty TKA patients were randomized to receive either local or epidural infiltration; both groups also received morphine PCA. The local infiltration patients had lower visual analogue scale (VAS) pain scores both at rest and during mobilization, decreased morphine consumption, and a decreased length of stay by 25%.

In two separate studies, Busch et al. 9,10 prospectively randomized TKA and THA patients to receive local periarticular injection or no injection. In both studies patients in the local injection group used less PCA morphine at six and 24 hours. The VAS score for pain on activity in the post anaesthetic care unit (PACU) was significantly less for injected patients in both groups. This finding was also demonstrated in the TKA patients at four hours postoperatively. There were no differences in wound complications; serum levels of ropivacaine were below toxic levels and no toxicities were observed 9,10.

Based on the work by Busch et al.9,10, we now routinely employ local infiltration in our primary and revision hip and knee arthroplasty procedures. A sterile injection mixture of 400 mg of ropivacaine, 30 mg of Toradol (ketorolac), 5 mg of epimorphine, and 0.6 ml of epinephrine (1:1000) is prepared by the anaesthetic team during the arthroplasty procedure. These medications are normally mixed with sterile normal saline solution to make up a combined volume of 100 ml. In total knee arthroplasty, the first aliquot of 20 ml of the mixture is injected in the operating room, just prior to implantation of the component, into the posterior aspect of the capsule and the medial and lateral collateral ligaments. Care is obviously taken to avoid infiltration in the area of the common peroneal nerve. After the implants have been cemented into place and while the cement is curing, the quadriceps mechanism and the retinacular tissues are infiltrated with an additional 20 ml of the mixture (Figure 1). The remaining 60 ml is used to infiltrate the muscle, subcutaneous and subcuticular tissues. A similar technique is employed in THA, with careful attention not to infiltrate in the distribution of the sciatic or femoral nerves.

In summary, intraoperative local periarticular infiltration has been shown to improve patient satisfaction and significantly reduce postoperative patient controlled analgesia requirements in patients undergoing total hip and knee replacement. This technique has also been shown to be safe and without apparent risks. There is evidence to suggest that it may also reduce hospital stay in comparison to other analgesic techniques. Future studies need to look at longer acting injectables, improved drug delivery systems, and development of a more comprehensive multimodal approach to pain control.

References

  1. Apfelbaum J.L., Chen C., Mehta S.S., et al. Postoperative Pain Experience: Results from a National Survey Suggest Postoperative Pain Continues to Be Undermanaged. Anesthesia & Analgesia, 2003. 97:534-540.
  2. Joshi G.P., Ogunnaike B.O. Consequences of Inadequate Postoperative Pain Relief and Chronic Persistent Postoperative Pain. Anesthesiology Clinics of North America, 2005. 23:21-36.
  3. Salmon P., Hall G.H., Peerbhoy D., et al. Recovery from Hip and Knee Arthroplasty: Patients' Perspective on Pain, Function, Quality of Life, and Well-Being Up to 6 Months Postoperatively. Ach Phys Med Rehabil, 2001. 82:360-366.
  4. Shoji H., Solomonow M., Yoshino S., et al. Factors affecting post-operative flexion in total knee arthroplasty. Orthopedics, 1990. 13:643-649.
  5. Parvataneni H.K., Shah V.P., Howard H. Controlling pain after hip and knee arthroplasty using a multimodal protocol with local periarticular injections. A prospective randomized study. J Arthroplasty, 2007. 22(6) Suppl. 2:33-38.
  6. Kerr D.R., Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: A case study of 325 patients. Acta Orthop, 2008. 79(2):174-183.
  7. Vendittoli P.A., Makinen P., Drolet P. A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. JBJS(Am), 2006. 88-A(2):282-289.
  8. Andersen K.V., Bak M., Christensen B.V., et al. A randomized, controlled trial comparing local infiltration analgesia with epidural infusion for total knee arthroplasty. Acta Orthop, 2010. 81(5):606-610.
  9. Busch C.A., Shore B.J., Bhandari R., et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am. 2006 May;88(5):959-63.
  10. Busch C.A., Whitehouse M.R., Shore B.J., et al. The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty. Clin Orthop Relat Res, 2010 468(8):2152-9.

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