Clinical Orthopaedics and Related Research®

Clin Orthop Relat Res DOI 10.1007/s11999-013-3351-6

A Publication of The Association of Bone and Joint Surgeons®

SYMPOSIUM: PERIOPERATIVE PAIN MANAGEMENT IN ORTHOPAEDIC SURGERY

Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA A Randomized, Double-blind Trial Keith R. Reinhardt MD, Shivi Duggal BS, MBA, Ben-Paul Umunna BA, Gregory A. Reinhardt MSPT, Denis Nam MD, Michael Alexiades MD, Charles N. Cornell MD

Ó The Association of Bone and Joint Surgeons1 2013

Abstract Background Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.

The institution of one or more of the authors (KRR, SD, GAR, DN, MA, CNC) has received, during the study period, funding from three institutional research grants, namely the Hospital for Special Surgery Adult Reconstruction and Joint Replacement Division research grant, the Surgeon-in-chief fund research grant, and the Eduardo A. Salvati MD resident research grant. The authors did not receive outside commercial funding in support of the research for or preparation of this manuscript. Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. Clinical Orthopaedics and Related Research1 neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDAapproval status, of any drug or device prior to clinical use. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. This work was performed at Hospital for Special Surgery, New York, NY, USA. K. R. Reinhardt (&), S. Duggal, G. A. Reinhardt, D. Nam, M. Alexiades, C. N. Cornell Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA e-mail: [email protected] B.-P. Umunna Weill Cornell Medical College, Cornell University, New York, NY, USA

Questions/purposes We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA. Methods Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded. Results The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p \ 0.0001; 12–24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.

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Conclusions A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach. Level of Evidence Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Introduction Pain management during the postoperative period after TKA remains challenging. A multimodal approach to combating postoperative pain after TKA has been commonly utilized and has consisted of a combination of oral and/or intravenous analgesics/opioids, epidural analgesics, and peripheral neural blockade. Epidural analgesia, while effective at controlling postoperative pain, has undesirable side effects, including nausea, hypotension, pruritis, somnolence, dizziness, and respiratory depression [5]. Likewise, femoral nerve blockade (FNB) has been associated with poor early postoperative ambulatory ability and the risk of in-hospital falls [7, 9, 12]. As a result, alternative methods of analgesia are being sought and there has been increasing support for the inclusion of peri- or intraarticular local anesthetics in the multimodal pain regimen after TKA. The reported efficacy of periarticular analgesic injections after TKA has been inconsistent and plagued by significant heterogeneity among studies with regard to volume and content of local infiltrations [4, 11, 14]. As an alternative to periarticular administration of analgesics, intraarticular delivery of anesthetics has gained recent attention. The optimal site for analgesic infiltration, whether it is given intra- or periarticularly, is still unclear [2, 6]. Nonetheless, an intraarticular continuous infusion of ropivacaine, in particular, has been shown to be efficacious in reducing postoperative pain and opioid requirements when compared to placebo in prior studies [8, 15]. However, the superiority of a continuous intraarticular infusion of ropivacaine over other commonly used analgesic methods, such as epidural analgesia or FNB, has yet to be definitely determined [1, 18]. Furthermore, no prior study has compared a continuous intraarticular infusion of ropivacaine to a combined regimen of epidural analgesia and FNB. We therefore compared, in a prospective, randomized, double-blinded trial, (1) the side effect profile, (2) analgesic efficacy, and (3) functional recovery between patients

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receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus FNB after TKA.

Patients and Methods Study Design After institutional review board approval, all patients of two senior arthroplasty surgeons (MA, CNC) undergoing unilateral primary TKA for osteoarthritis were considered for enrollment in this clinical trial. Between August 2010 and February 2012, one hundred two patients were randomized to one of two treatment groups as described in the CONSORT flow diagram [16] (Fig. 1). We included all patients between the ages of 18 and 85 years, with an American Society of Anesthesiologists (ASA) Class II or less and an ability to provide informed written consent for, and cooperate with, the study. ASA Class III patients were excluded per institutional policy. Exclusion criteria were a known history of narcotic dependency, history of stroke or major neurologic deficit, or spinal pathology that precluded neuraxial anesthesia. During the study enrollment period, 383 TKAs were assessed for eligibility. Patients were assessed for eligibility at their preoperative office visit and enrolled during their preoperative testing visit (within 2 weeks before surgery). Patients were randomly allocated using a computer-generated random numbers table 3 days before surgery, which was maintained by the pharmacy department for blinding and safety purposes. Forty-nine patients were allocated to receive an epidural plus FNB, and 45 patients were allocated to receive a continuous intraarticular infusion of ropivacaine through an intraarticular knee catheter (Table 1). Operative anesthesia consisted of a spinal anesthetic (2.5 mL 0.5% bupivacaine) for all patients in both groups. In the epidural group, patients were given a combined spinal-epidural (epidural: 500 mL hydromorphone 10 lg/mL and bupivacaine HCl 0.06%) and a single-injection FNB (30 mL 0.25% bupivacaine) administered intraoperatively. Postoperatively, a continuous epidural infusion (4 mL/hour with 4 mL per demand dose, locked out every 10 minutes with an hourly limit of 20 mL) was started and weaned over 48 hours. The epidural infusion was weaned to 2 mL/hour at 0700 on Postoperative Day 1 and to 0 mL/hour at 1700 on Postoperative Day 1. The demand dose with lockout parameters as above was continued for the full 48 hours. Patients in the epidural group also received a placebo intraarticular knee catheter placed intraoperatively with a continuous 0.9% normal saline 7 mL/hour infusion given postoperatively until Postoperative Day 2. In the ropivacaine group, patients instead received an intraarticular knee catheter placed intraoperatively with a continuous 0.2% ropivacaine infusion at 7 mL/hour

Intraarticular Analgesia After TKA

Assessed for eligibility (n = 238)

Excluded (n =136) ♦ Not meeting inclusion criteria (n = 25) ♦ Declined to participate (n = 106) ♦ Planned general anesthesia (n = 5)

Enrollment

Randomized (n =102)

Allocation Allocated to Group E (epidural + FNB) (n = 51) ♦ Received allocated intervention (n = 49)

Allocated to Group R (knee catheter) (n = 51) ♦ Received allocated intervention (n = 45)





Did not receive allocated intervention (n = 2) 1 withdrew before surgery* † 1 unable to have epidural catheter

Did not receive allocated intervention (n = 6) 2 withdrew before surgery* † 3 unable to have epidural catheter ‡ 1 late disclosure of chronic narcotic use

Followup Lost to followup (n = 0) • Discontinued intervention (n = 3) 1 epidural dislodged Postoperative Day 1 2 epidurals removed early (1 severe hypotension, 1 increasing INR)

Lost to followup (n = 0) • Discontinued intervention (n = 2) 1 knee catheter dislodged Postoperative Day 1 1 patient opted out of study for severe pain

Analysis Analyzed (n = 49) ♦ Excluded from analysis (n = 0)

Analyzed (n = 45) ♦ Excluded from analysis (n = 0)

*3 patients changed their minds (after inclusion, before surgery) and refused to participate † 4 patients unable to have epidural catheters (3 with bleeding disorders [2 Factor VII deficiency, 1 idiopathic thrombocytopenic purpura], 1 with spinal pathology) ‡ 1 patient disclosed prior chronic narcotic use (after inclusion, before surgery)

Fig. 1 A CONSORT flow diagram shows the enrollment process in this trial. INR = international normalized ratio.

postoperatively until Postoperative Day 2. The ropivacaine group also had a placebo epidural catheter placed intraoperatively, no FNB, and a postoperative placebo continuous epidural infusion of 0.9% normal saline that was weaned in exactly the same manner as in the epidural group. The knee catheter used in all patients was a 16-gauge catheter and was connected to an infusion pump. All patients in both groups were given the same pain medication regimen, including Mobic1 (Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA) 15 mg daily, one or two tablets of Percocet1 (Endo Pharmaceuticals Inc, Malvern PA, USA) 5/ 325 mg orally every 4 hours as needed (substituted Norco

[Actavis, Inc, Parsippany, NJ, USA] 5/325 mg or Vicodin [AbbVie, Inc, North Chicago, IL, USA] 5/500 mg if intolerant of Percocet1), and Dilaudid1 (Purdue Pharma LP, Stamford, CT, USA) 0.5 mg subcutaneously every 4 hours as needed for severe breakthrough pain. Patients also received 6 mg Decadron1 (Merck & Co, Inc, Whitehouse Station, NJ, USA) in the preoperative holding area along with 15 mg Mobic1 (7.5 mg if older than 75 years) as part of the standard antinausea protocol for TKA at our institution. Patients also received 30 mg Toradol1 (Hoffman-LaRoche, Inc, Nutley, NJ, USA) intravenously intraoperatively at the completion of the surgery before transferring the patient to

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Reinhardt et al. Table 1. Baseline characteristics Variable

Group E (n = 49)

Group R (n = 45)

p value

Age (years)

67.9 ± 10.9

66.6 ± 10.1

0.545

Sex (% male)

40.8

42.2

1.000

BMI (kg/m2)

30.2 ± 5.4

29.7 ± 6.6

0.692

Knee Society Score (points)

54.4 ± 19.3

56.5 ± 17.5

0.594

Knee Society functional score (points)

53.6 ± 19.1

54.9 ± 21.9

0.763

TUG test time (seconds)

15.7 ± 16.8

12.7 ± 7.3

0.260

Quadriceps strength (%)*

89.5 ± 19.4

93.2 ± 20.4

0.372

WOMAC score (points)

48.8 ± 17

45.4 ± 14.5

0.291

VAS pain score (points)

6.1 ± 2.4

6.7 ± 2.4

0.223

All values except for sex are expressed as mean ± SD; * peak isometric quadriceps voluntary contraction expressed as a percentage of nonoperative leg; Group E = patients receiving a spinal-epidural analgesic infusion plus a single-injection femoral nerve block; Group R = patients receiving a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine.

the recovery room, and two subsequent doses of Toradol1 intravenously 30 mg every 6 hours postoperatively. All medications used in this study are FDA approved. All surgeries were performed under tourniquet through a standard medial parapatellar approach with posterior-stabilized implants. Postoperatively, no knee wound drains were used in order to maintain the anesthetic infusion within the knee. Physical therapy with attempted ambulation and continuous passive motion was started in the postanesthesia care unit. All patients received multimodal venous thromboembolism prophylaxis with compression boots, early mobilization, and warfarin dosed according to the prothrombin time.

Followup All testing and data collection were performed by a blinded research assistant (SD) and blinded physical therapist (GAR). Patients were assessed preoperatively, during each postoperative day while in the hospital, and at their 6-week, 3-month, and 1-year followup visits. Blinding efficacy of patients was assessed at the 6-week visit, where patients were asked which intervention they thought they had received, and 76% of patients were either unsure or were incorrect in guessing which of the two interventions they had. Blinding was maintained until followup was complete. The primary outcome was the incidence of episodes of nausea. In addition to reviewing electronic nursing flowsheets, a research assistant interviewed each patient twice daily during his/her inpatient stay to record episodes of nausea, hypotension, and maximum pain levels on a VAS

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ranging from 0 to 10 points. An episode of nausea was defined as nausea requiring antinausea medication or an episode of vomiting. Hypotension was defined as a systolic blood pressure of less than 90 mm Hg or a drop in systolic blood pressure of at least 30% from preoperative baseline levels with symptoms. Oral and intravenous narcotic consumption was recorded and converted to morphine equivalents for comparison. Patients were asked to bring their narcotic pill bottles to their 6-week and 3-month followup visits. Additional secondary outcomes included the timed up and go (TUG) test [19], quadriceps peak voluntary isometric strength [13], Knee Society clinical and functional score [10], WOMAC score [3], early postoperative ambulatory ability, and the incidence of in-hospital falls. Peak voluntary isometric quadriceps strength testing was performed using a hand-held dynamometer and standardized technique [13]. Force of quadriceps contraction was measured in newtons and expressed as a percentage of the force of contraction measured on the nonoperative leg. Physical therapy progress notes were reviewed for initial attempted ambulation for each patient. If the patient was unable to ambulate, this was recorded and it was noted whether the inability to ambulate was due to quadriceps weakness (knee buckling) or another cause. All in-hospital falls, complications, and adverse events were recorded. A safety advisory panel was developed at the beginning of enrollment to monitor and ensure the safety of the trial participants.

Sample Size and Statistical Analysis The incidence of nausea in prior studies is approximately 33% [5] (varies by study). A clinically relevant reduction in nausea to 10% required a sample size of 94 patients to provide 80% power in detecting such a difference. Enrollment in the trial was complete when the sample size was met. Patients who discontinued their allocated intervention were included in the analysis of their respective groups under the intention-to-treat principle. Univariate comparisons for continuous variables were performed using the Wilcoxon rank-sum test. Categorical variables were evaluated using Fisher’s exact test. The continuous outcomes of VAS pain score, narcotic consumption, TUG time, and patient-reported outcomes (Knee Society Score, WOMAC score) were analyzed with generalized linear models. Generalized estimating equation (GEE) methods were used for all models to account for the correlation between repeated measurements on the same patient. All analyses were performed using SAS1 software (Version 9.2; SAS Institute, Inc, Cary, NC, USA).

Intraarticular Analgesia After TKA

Results Side Effect Profile There was no significant reduction in the incidence of nausea in the ropivacaine group compared to epidural group (odds ratio [OR]: 0.74; 95% CI: 0.38–1.44), and there were no differences between groups in terms of nausea at any individual time point (Fig. 2). Similarly, in a GEE model, there was overall no difference in the incidence of hypotension between groups (OR: 0.90; 95% CI: 0.51–1.60) (Fig. 3).

Analgesic Efficacy During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were significantly higher in the ropivacaine group than in the epidural group (Fig. 4). After 24 hours, pain scores were similar between groups (Fig. 4). Narcotic consumption was significantly higher in the ropivacaine group (17.7 mg) on the day of surgery than in the epidural group (5.9 mg) (p \ 0.001). For the remainder of the hospital stay, mean narcotic consumption was similar between groups, and in particular during the rest of the time in which the catheters were in place (up to 48 hours postoperatively) (Table 2). When the entire hospital stay was considered, mean narcotic consumption was equivalent between groups (Table 2). No difference was found in narcotic intake at the 6-week or 3-month followup visits (p = 0.138 and p = 0.247, respectively).

Functional Recovery There were no clinically important differences observed between groups at any time point in terms of the TUG

(Fig. 5), quadriceps strength (Fig. 6), WOMAC scores (Table 3), or Knee Society Scores (Table 3). Knee buckling and inability to ambulate occurred more frequently in epidural group than in the ropivacaine group (Table 4). Two patients had an in-hospital fall in the epidural group, and no patients fell in the ropivacaine group; with the numbers available, this difference was not significant (Table 4).

Complications There were no wound-related complications or infections in either group. Hospital length of stay was similar between groups as well (epidural group: 94 ± 22 hours; ropivacaine group: 92 ± 17 hours; p = 0.946). Thromboembolic events occurred in two patients in the epidural group (one deep vein thrombosis, one deep vein thrombosis plus pulmonary embolism) and in no patients in the ropivacaine group. Arthrofibrosis occurred in two patients in the epidural group and in one patient in the ropivacaine group.

Discussion The ideal postoperative pain regimen after TKA maximizes analgesic efficacy, avoids inhibition of early functional recovery, and minimizes undesirable side effects. Regarding side effect profiles, we found no difference in the incidence of nausea or hypotension between patients receiving an intraarticular infusion of ropivacaine and those receiving an epidural plus FNB. Analgesic efficacy overall was similar between groups in this study, but analysis of specific time points revealed an analgesic advantage during the initial 24 postoperative hours with an epidural plus FNB. On the other hand, an early functional advantage was found with an intraarticular infusion of ropivacaine, with improved early ambulatory ability and

Fig. 2 A graph shows the incidence of nausea during the hospital stay for the two groups. There were no significant differences in the incidence of nausea between groups. POD = postoperative day; DOD = day of discharge from hospital.

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Fig. 3 A graph shows the incidence of hypotension during the hospital stay for the two groups. There was overall no significant difference in the incidence of hypotension between groups. POD = postoperative day; DOD = day of discharge from hospital.

Fig. 4 A graph compares the mean maximum VAS pain scores between the two groups at each postoperative time point. Pain scores were significantly lower in the epidural group from 0 to 12 hours postoperatively (p \ 0.0001) and from 12 to 24 hours postoperatively

(p = 0.008). Pain scores were equivalent at all time points after the initial 24 postoperative hours. POD = postoperative day; DOD = day of discharge from hospital.

Table 2. Comparison of mean narcotic consumption during the postoperative period while in the hospital

Our study is subject to a number of limitations. First, the generalizability of our data is limited to patients with a diagnosis of osteoarthritis, as those with inflammatory or posttraumatic arthropathy were excluded, as were patients of ASA Class III and higher. Also, this study was designed and powered to assess efficacy of the intervention rather than safety. It is also noteworthy that infusion of fluid into the knee after surgery may raise concerns of wound healing, but in this study there were no cases of wound dehiscence or delayed healing. There is also the potential for Type II errors in detecting clinically relevant differences between groups in our secondary variables that may have been below the detection threshold set in our power calculation for our primary variable. Furthermore, there is the potential for Type I errors in an extensive analysis with many variables where statistical correction for multiple variables is not performed. This may be applicable to differences in secondary end points such as the Knee Society functional score at 6 weeks or the TUG test at 1 year, which were statistically significant but may not be clinically significant. Finally, our randomization was not stratified by surgeon.

Time

Narcotic consumption (mg of morphine equivalents) Group E (n = 49)

POD 0

5.92 ± 12.1

p value

Group R (n = 45) 17.7 ± 17.2

\ 0.001

POD 1

27.9 ± 31

38.5 ± 36.2

0.074

POD 2

44.2 ± 42.2

45.3 ± 34.9

0.665

POD 3

52.2 ± 67.4

40.7 ± 33.6

0.992

DOD

37.3 ± 71.2

31.8 ± 29.7

0.377

In-hospital total 151.1 ± 202

155.6 ± 109

0.147

Values are expressed as mean ± SD; Group E = patients receiving a spinal-epidural analgesic infusion plus a single-injection femoral nerve block; Group R = patients receiving a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine; POD = postoperative day; DOD = day of discharge from hospital.

less knee buckling. No significant difference was found between groups in terms of in-hospital falls, which remain an uncommon event.

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Intraarticular Analgesia After TKA

Fig. 5 A graph shows the progression of functional recovery based on the TUG test in the two groups. The ropivacaine group was significantly faster (9.35 seconds) than the epidural group (11.61 seconds) at the 1-year followup visit (p = 0.0146). DOD = day of discharge from hospital.

Fig. 6 A graph shows the recovery of quadriceps strength based on peak voluntary isometric quadriceps force of contraction as measured by hand-held dynamometry in the two groups. Quadriceps strength

was similar between groups at all time points. POD = postoperative day; DOD = day of discharge from hospital.

While epidural anesthetics, FNBs, and intraarticular local anesthesia pumps are often chosen with an eye on analgesic advantage, we believe it is important also to consider side effect profiles when making this choice. We found no differences in the side effect profile, including

nausea and hypotension, between the two study groups. Other studies in the literature have not focused on side effect profiles as primary outcome measures, which limits the ability to make useful comparisons. Perhaps this is an area for focus of future studies.

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Reinhardt et al. Table 3. Outcome scores Time

Knee Society Score (points) Group E (n = 49)

WOMAC score (points)

Group R (n = 45)

p value

Group E (n = 49)

Group R (n = 45)

p value

Preoperative

54.4 ± 19.3

56.5 ± 17.5

0.527

48.8 ± 17

45.4 ± 14.5

0.259

6 weeks

80.4 ± 15

79.5 ± 14.3

0.732

25.4 ± 12.7

27.4 ± 15.5

0.611

3 months

87.3 ± 10.9

85.1 ± 12.7

0.378

16.4 ± 11.1

20.5 ± 16

0.383

90.46 ± 15.82

89.22 ± 11.9

0.039

13.64 ± 14.72

15.5 ± 13.7

0.284

1 year

Values are expressed as mean ± SD; Group E = patients receiving a spinal-epidural analgesic infusion plus a single-injection femoral nerve block; Group R = patients receiving a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine.

Table 4. Incidence of knee buckling, inability to ambulate during initial postoperative attempt at ambulation with a physical therapist, and in-hospital falls Variable

Number of patients

p value

Group E (n = 49) Group R (n = 45) Knee buckling

16 (32.7%)

3 (6.7%)

0.002

Unable to ambulate

8 (16.3%)

0 (0.0%)

0.006

In-hospital falls

2 (4.1%)

0 (0.0%)

0.496

Group E = patients receiving a spinal-epidural analgesic infusion plus a single-injection femoral nerve block; Group R = patients receiving a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine.

When compared to a more robust comparison group as used in our study, we did not find an analgesic advantage of an intraarticular ropivacaine infusion over an epidural plus FNB. In fact, we found improved pain scores during the first 24 postoperative hours with an epidural plus FNB. However, the effect size was not large, and its clinical significance may be only borderline; in fact, even the average maximum pain scores in the ropivacaine group were low and were comparable to prior studies that have supported intraarticular ropivacaine as an analgesic option after TKA [8, 18]. It is also conceivable that much of the difference seen may be attributed to the FNB, which is expected to be effective during the first 24 postoperative hours. This contrasts with the findings of Toftdahl et al. [18] who found analgesic benefits of local ropivacaine over a continuous FNB but can perhaps be explained by the fact that the injection was administered periarticularly in that study. This then raises the question of whether the location of the local anesthetic plays a role in its efficacy. However, in a randomized study in 2008, addition of periarticular ropivacaine to patients receiving intraarticular ropivacaine after TKA did not improve numerical pain scores at rest or during activity [2]. When compared to FNB, beneficial effects of intraarticular ropivacaine have been shown. In 2007, Toftdahl et al. [18] randomized 80 patients after TKA to receive either a continuous FNB or a local analgesic injection of ropivacaine, ketorolac, and epinephrine

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with bolus injections of ropivacaine through a knee catheter and found lower pain scores and reduced opioid consumption in the local ropivacaine group. Patients who received an epidural with a FNB were more likely to have knee buckling and delayed ambulation than the patients treated with a spinal anesthetic and an intraarticular ropivacaine pump, though with the numbers available, there were no differences in in-hospital falls between the two groups. Others have raised similar safety concerns about FNB after TKA. Data from three previously published multicenter, randomized, controlled trials were pooled by Ilfeld et al. [9] in 2010 to assess the association between patient falls and peripheral nerve blocks. During the postoperative course, the pooled data revealed that there were seven falls (7%) in patients who received a perineural ropivacaine blockade and no falls in patients where placebo saline was injected instead (p = 0.013). Similarly, in a study of 1018 TKAs with or without a single-injection FNB, 12 patients in the FNB group fell, whereas only one patient fell in the group without a FNB. Also, eight of the 12 patients who fell had documented quadriceps weakness before their fall [17]. In our study, quadriceps strength was tested on Postoperative Day 2 for the first time after surgery. Assuming a high incidence of motor blockade and quadriceps weakness during the first 24 postoperative hours, we were instead interested in determining whether there was a persistent quadriceps strength deficit beyond 24 hours. Using hand-held dynamometry, we were unable to demonstrate a difference in quadriceps strength after the FNB had worn off. Quadriceps strength recovered similarly in both groups during followup over the first year after TKA, and there did not appear to be a lasting effect of the FNB on quadriceps strength. To our knowledge, this is the first study comparing an intraarticular continuous infusion of ropivacaine to an epidural plus FNB for pain control after TKA. We found similar side effect profiles between the groups. We also found that, although intraarticular ropivacaine resulted in worse early postoperative analgesic efficacy, it also resulted in improved early functional recovery compared to an

Intraarticular Analgesia After TKA

epidural anesthetic with a single-shot FNB. After the initial 24 postoperative hours, analgesic efficacy was similar, and functional outcomes up to 1 year after TKA were similar. Given the results of this prospective, double-blinded, randomized, controlled trial, a continuous intraarticular infusion of ropivacaine after TKA can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB. Surgeons should weigh improved analgesic efficacy against delayed ambulation when making the choice between these approaches. Acknowledgments We thank Huong Do MA for designing and performing the statistical analysis for this study and Drs. Spencer Liu, Douglas S.T. Green, Yi Lin, and Daniel B. Maalouf for their participation in the care of the patients enrolled in this trial.

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Intraarticular analgesia versus epidural plus femoral nerve block after TKA: a randomized, double-blind trial.

Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic...
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