Abstract
Purpose
A systematic review and meta-analysis based on randomized controlled trials (RCTs) were conducted to evaluate the efficiency and safety of periarticular multimodal drug injection in total knee arthroplasty (TKA).
Methods
Periarticular injection with the use of multimodal drugs is an efficient alternative for postoperative analgesia in TKA. A systematical electronic search was performed to identify the eligible RCTs in the databases of PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science and the Chinese Biomedical Literature Database. Two independent reviewers completed data collection and assessment of methodological quality. The quality of evidence of outcomes was judged using GRADE criteria. Meta-analysis was performed for the outcomes of pain, straight leg raise, operating time, hospital stay and complications.
Results
Ten RCTs including eight studies with 1,216 TKAs in 835 patients met the inclusion criteria. Periarticular injection with multimodal drugs in TKA was associated with short-term benefits in terms of pain relief, straight leg raise, narcotic consumption, and the rates of nausea, vomiting, rash and pruritus. There were no statistically significant differences in operating time, hospital stay, wound complications and deep vein thrombosis between both groups.
Conclusions
The current evidence suggests that periarticular multimodal drug injection in TKA provides short-term advantages in pain relief, straight leg raise and postoperative complications.
Level of evidence
Therapeutic study, Level I.
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References
Andersen LO, Husted H, Kristensen BB, Otte KS, Gaarn-Larsen L, Kehlet H (2010) Analgesic efficacy of intracapsular and intra-articular local anaesthesia for knee arthroplasty. Anaesthesia 65:904–912
Andersen LO, Husted H, Kristensen BB, Otte KS, Gaarn-Larsen L, Kehlet H (2010) Analgesic efficacy of subcutaneous local anaesthetic wound infiltration in bilateral knee arthroplasty: a randomised, placebo-controlled, double-blind trial. Acta Anaesthesiol Scand 54:543–548
Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, Guyatt GH, Harbour RT, Haugh MC, Henry D, Hill S, Jaeschke R, Leng G, Liberati A, Magrini N, Mason J, Middleton P, Mrukowicz J, O’Connell D, Oxman AD, Phillips B, Schunemann HJ, Edejer TT, Varonen H, Vist GE, Williams JW Jr, Zaza S (2004) Grading quality of evidence and strength of recommendations. BMJ 328:1490
Brisbane O, Sports Medicine Centre Writing C, McMeniman TJ, McMeniman PJ, Myers PT, Hayes DA, Cavdarski A, Wong MS, Wilson AJ, Jones MA, Watts MC (2010) Femoral nerve block vs fascia iliaca block for total knee arthroplasty postoperative pain control: a prospective, randomized controlled trial. J Arthroplast 25:1246–1249
Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW (2006) Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am 88:959–963
Christensen CP, Jacobs CA, Jennings HR (2009) Effect of periarticular corticosteroid injections during total knee arthroplasty. A double-blind randomized trial. J Bone Joint Surg Am 91:2550–2555
DeWeese FT, Akbari Z, Carline E (2001) Pain control after knee arthroplasty: intraarticular versus epidural anesthesia. Clin Orthop Relat Res 392:226–231
Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A (2010) Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty a randomized double-blind study involving 48 patients. Acta orthop 81:354–360
Fu P, Wu Y, Wu H, Li X, Qian Q, Zhu Y (2009) Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty—a randomized controlled trial. Knee 16:280–284
Fu P, Xiao J, Zhu Y, Wu H, Li X, Wu Y, Qian Q (2010) Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial. J Int Med Res 38:1404–1412
Galimba J (2009) Promoting the use of periarticular multimodal drug injection for total knee arthroplasty. Orthop Nurs 28:250–254
Gibbs DM, Green TP, Esler CN (2012) The local infiltration of analgesia following total knee replacement: a review of current literature. J Bone Joint Surg Br 94:1154–1159
Higgins JP, Thompson SG (2002) Quantifying heterogeneity in a meta-analysis. Stat Med 21:1539–1558
Higgins JPT, Altman DG, Sterne JAC (2011) Chapter 8: assessing risk of bias in included studies. Cochrane handbook for systematic reviews of interventions version 5.1.0 (updated March 2011). In: The Cochrane Collaboration. http://www.cochrane-handbook.org
Higgins JPT, Green S (2011) Cochrane handbook for systematic reviews of interventions version 5.1.0 [updated March 2011]. In: The cochrane collaboration. http://www.cochrane-handbook.org
Hu S, Zhang ZY, Hua YQ, Li J, Cai ZD (2009) A comparison of regional and general anaesthesia for total replacement of the hip or knee: a meta-analysis. J Bone Joint Surg Br 91:935–942
Ikeuchi M, Kamimoto Y, Izumi M, Fukunaga K, Aso K, Sugimura N, Yokoyama M, Tani T (2013) Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-013-2367-5
Ikeuchi M, Kamimoto Y, Izumi M, Sugimura N, Takemura M, Fukunaga K, Yokoyama M, Tani T (2012) Local infusion analgesia using intra-articular double lumen catheter after total knee arthroplasty: a double blinded randomized control study. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-012-2004-8
Joo JH, Park JW, Kim JS, Kim YH (2011) Is intra-articular multimodal drug injection effective in pain management after total knee arthroplasty? A randomized, double-blinded prospective study. J Arthroplast 26:1095–1099
Kane RL, Saleh KJ, Wilt TJ, Bershadsky B, Cross WW, MacDonald RM, Rutks I (2003) Total knee replacement. Evid Rep Technol Assess (Summ) 86:1–8
Knudsen K, Beckman Suurkula M, Blomberg S, Sjovall J, Edvardsson N (1997) Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 78:507–514
Koh IJ, Kang YG, Chang CB, Do SH, Seong SC, Kim TK (2012) Does periarticular injection have additional pain relieving effects during contemporary multimodal pain control protocols for TKA? A randomised, controlled study. Knee 19:253–259
Koh IJ, Kang YG, Chang CB, Kwon SK, Seo ES, Seong SC, Kim TK (2010) Additional pain relieving effect of intraoperative periarticular injections after simultaneous bilateral TKA: a randomized, controlled study. Knee Surg Sports Traumatol Arthrosc 18:916–922
Macfarlane AJ, Prasad GA, Chan VW, Brull R (2009) Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res 467:2379–2402
Mather LE (2010) The acute toxicity of local anesthetics. Expert Opin Drug Metab Toxicol 6:1313–1332
Mullaji A, Kanna R, Shetty GM, Chavda V, Singh DP (2010) Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty: a prospective, randomized trial. J Arthroplast 25:851–857
Ng FY, Ng JK, Chiu KY, Yan CH, Chan CW (2012) Multimodal periarticular injection vs continuous femoral nerve block after total knee arthroplasty: a prospective, crossover, randomized clinical trial. J Arthroplast 27:1234–1238
Ng YC, Lo NN, Yang KY, Chia SL, Chong HC, Yeo SJ (2011) Effects of periarticular steroid injection on knee function and the inflammatory response following unicondylar knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 19:60–65
Pang HN, Lo NN, Yang KY, Chong HC, Yeo SJ (2008) Peri-articular steroid injection improves the outcome after unicondylar knee replacement: a prospective, randomised controlled trial with a two-year follow-up. J Bone Joint Surg Br 90:738–744
Parker MJ, Roberts CP, Hay D (2004) Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 86:1146–1152
Qian WW, Weng XS, Fei Q, Li Y, Zhai JL, Bian YY (2010) Application study of periarticular multimodal drug injection in total knee arthroplasty. Zhonghua Yi Xue Za Zhi 90:2593–2596
Sean VW, Chin PL, Chia SL, Yang KY, Lo NN, Yeo SJ (2011) Single-dose periarticular steroid infiltration for pain management in total knee arthroplasty: a prospective, double-blind, randomised controlled trial. Singap Med J 52:19–23
Sreekumar R, Venkiteswaran R, Raut V (2007) Infection in primary hip arthroplasty after previous steroid infiltration. Int Orthop 31:125–128
Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tonnesen EK, Soballe K (2007) Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop 78:172–179
Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, Varin F (2006) A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Joint Surg Am 88:282–289
Zaric D, Boysen K, Christiansen C, Christiansen J, Stephensen S, Christensen B (2006) A comparison of epidural analgesia with combined continuous femoral-sciatic nerve blocks after total knee replacement. Anesth Analg 102:1240–1246
Zhang QD, Guo WS, Zhang Q, Liu ZH, Cheng LM, Li ZR (2011) Comparison between closed suction drainage and nondrainage in total knee arthroplasty: a meta-analysis. J Arthroplast 26:1265–1272
Acknowledgments
The authors would like to thank Matthew H Liou (Canada) and Qiuxian Wang (China) for the English editing of this manuscript.
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The authors declare that they have no conflict of interest.
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Teng, Y., Jiang, J., Chen, S. et al. Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22, 1949–1957 (2014). https://doi.org/10.1007/s00167-013-2566-0
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DOI: https://doi.org/10.1007/s00167-013-2566-0