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Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial
Örebro University, School of Health and Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
Division of Clinical Medicine, Örebro University Hospital, Örebro, Sweden; Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
Department of Physiotherapy, Örebro University Hospital, Örebro, Sweden.
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2011 (English)In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 113, no 4, p. 926-933Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Local infiltration analgesia (LIA) using a combination of local anesthetics, non-steroidal anti-inflammatory drugs and epinephrine, injected periarticularly during surgery has become popular in postoperative pain management following total knee arthroplasty (TKA). This study compared intrathecal morphine with LIA following TKA.

METHODS:  In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into two groups: Group M: 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and Group L: LIA using ropivacaine, ketorolac and epinephrine was infiltrated in the knee during the operation and two bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during three months follow-up. Primary endpoint was IV morphine consumption the first 48 postoperative hours.

RESULTS: Mean morphine consumption was significantly lower in group L compared to group M during the first 48 postoperative hours: 27 ± 18 vs. 54 ± 30 mg, i.e. a mean difference for each 24-hour-period of 14,2 (CI 95 % 7.6-20.9) mg. Pain scores at rest and on movement were lower during the first 48 h in group L compared to group M (P < 0.001). Pain score was also lower on walking in group L compared to group M at 24 h and 48 h postoperatively (P < 0.01). In group L more patients were able to climb stairs at 24 h: 50 % (11/22) vs. 4 % (1/23), i.e. a difference of 46 % (CI 95 % 23.5-68.5) and at 48 h: 70 % (16/23) vs. 22 % (5/23), i.e. a difference of 48 % (CI 95 % 23-73). Median (range) time to fulfillment of discharge criteria was shorter in group L compared to group M, 51 (24-166) h vs. 72 (51-170) h. The difference was 23 (CI 95 % 18-42) h (P = 0.001). Length of hospital stay also shorter in group L compared to group M: median (range) 3 (2-17) vs. 4 (2-14) days (P = 0.029). Patient satisfaction was greater in group L compared to group M (P = 0.001), but no differences were found in knee function, side effects or in patient-related outcomes, Oxford Knee score or EQ-5D.

CONCLUSIONS: LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, compared to intrathecal morphine following TKA.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2011. Vol. 113, no 4, p. 926-933
National Category
Anesthesiology and Intensive Care
Identifiers
URN: urn:nbn:se:oru:diva-21435DOI: 10.1213/ANE.0b013e3182288debISI: 000295215100036PubMedID: 21821506Scopus ID: 2-s2.0-80053303951OAI: oai:DiVA.org:oru-21435DiVA, id: diva2:487476
Note

Funding Agency:

Research Committee, Orebro University Hospital 

Available from: 2012-01-31 Created: 2012-01-31 Last updated: 2019-04-10Bibliographically approved
In thesis
1. Local infiltration analgesia in knee arthroplasty
Open this publication in new window or tab >>Local infiltration analgesia in knee arthroplasty
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Local infiltration analgesia (LIA) is a new technique for postoperative pain management following knee arthroplasty. LIA involves a long-acting local anesthetic (ropivacaine), a non-steroid anti-inflammatory drug (ketorolac) and epinephrine infiltrated into the knee joint during surgery and injected postoperatively via a catheter.

In the first two studies, LIA was compared with placebo in unicompartmental (I) and total (II) knee arthroplasty. Postoperative pain levels, morphine consumption and the incidence of side effects were lower in the LIA groups. In addition, we found a shorter length of hospital stay in the LIA group following unicompartmental knee arthroplasty compared with placebo (I), while the time to home readiness was shorter in the LIA group following total knee arthroplasty (II). In this study, we found that the unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations in a sub-group of patients.

In the third study, LIA was compared with intrathecal morphine for postoperative pain relief following total knee arthroplasty (III). Pain scores and morphine consumption were lower, length of hospital stay was shorter and patient satisfaction was higher in the LIA group.

In the final study, we investigated the effect of minimally invasive surgery (MIS) compared with conventional surgery in unicompartmental knee arthroplasty (IV). Both groups received LIA. We found no statistically significant differences in postoperative pain, morphine consumption, knee function, home readiness, hospital stay or patient satisfaction.

In conclusion, LIA provided better postoperative pain relief and earlier mobilization than placebo, both in unicompartmental and total knee arthroplasty. When compared to intrathecal morphine, LIA also resulted in improved postoperative pain relief and earlier mobilization. Minimally invasive surgery did not improve outcomes after unicompartmental knee arthroplasty, when both groups received LIA.

Place, publisher, year, edition, pages
Örebro: Örebro universitet, 2012. p. 61
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 66
Keywords
Knee arthroplasty, minimally invasive surgery, ropivacaine, ketorolac, intrathecal morphine, local infiltration analgesia
National Category
Medical and Health Sciences Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:oru:diva-21412 (URN)978-91-7668-855-7 (ISBN)
Public defence
2012-03-16, Wilandersalen, Örebro universitetssjukhus, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2012-01-30 Created: 2012-01-30 Last updated: 2017-10-17Bibliographically approved

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