Additional pain relieving effect of intraoperative periarticular injections after simultaneous bilateral TKA: a randomized, controlled study

  • In Jun Koh
  • Yeon Gwi Kang
  • Chong Bum Chang
  • Sae Kwang Kwon
  • Eun Seok Seo
  • Sang Cheol Seong
  • Tae Kyun KimEmail author


The authors investigated the clinical value of intraoperative periarticular multimodal drug injections (PMDI) in patients on continuous epidural analgesia after simultaneous bilateral TKAs. In 55 patients scheduled to undergo simultaneous bilateral TKAs, one knee was randomly assigned to the PMDI group for which intraoperative periarticular injections were administered and the other knee was assigned to the No-PMDI group for which the injections were not done. These two groups were compared for pain level (during the operation night and on postoperative days (POD) 1, 4, and 7), functional recovery (ability to perform straight leg raising on POD 1 and maximum flexion on POD 7), patient satisfaction (POD 7), and the incidence of wound complications. The PMDI group showed a lower pain level during the operation night and on POD 1 than the No-PMDI group, but no differences in pain levels were observed between the groups on POD 4 or 7. Furthermore, no significant group differences were found in terms of functional recovery, patient satisfaction. No wound complication has been occurred in the PMDI group. This study demonstrates that PMDI provides additional pain relief limited to the immediate postoperative period but does not improve pain relief after POD 1, patient satisfaction and functional recovery.


Total knee arthroplasty Periarticular multimodal drug injection 


  1. 1.
    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833–1840PubMedGoogle Scholar
  2. 2.
    Block BM, Liu SS, Rowlingson AJ, Cowan AR, Cowan JA Jr, Wu CL (2003) Efficacy of postoperative epidural analgesia: a meta-analysis. JAMA 290:2455–2463CrossRefPubMedGoogle Scholar
  3. 3.
    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 88:959–963CrossRefPubMedGoogle Scholar
  4. 4.
    Cohen RG, Forrest CJ, Benjamin JB (1997) Safety and efficacy of bilateral total knee arthroplasty. J Arthroplasty 12:497–502CrossRefPubMedGoogle Scholar
  5. 5.
    Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT (2008) A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 33:510–517PubMedGoogle Scholar
  6. 6.
    Insall JN, Dorr LD, Scott RD, Scott WN (1989) Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 248:13–14PubMedGoogle Scholar
  7. 7.
    Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, Stringer TA, Tornetta P 3rd, Haralson RH 3rd, Watters WC 3rd (2009) Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Am Acad Orthop Surg 17:183–196PubMedGoogle Scholar
  8. 8.
    Kampe S, Weigand C, Kaufmann J, Klimek M, Konig DP, Lynch J (1999) Postoperative analgesia with no motor block by continuous epidural infusion of ropivacaine 0.1% and sufentanil after total hip replacement. Anesth Analg 89:395–398CrossRefPubMedGoogle Scholar
  9. 9.
    Kerr DR, Kohan L (2008) 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 79:174–183CrossRefPubMedGoogle Scholar
  10. 10.
    Kim HA, Kim S, Seo YI, Choi HJ, Seong SC, Song YW, Hunter D, Zhang Y (2008) The epidemiology of total knee replacement in South Korea: national registry data. Rheumatology (Oxford) 47:88–91CrossRefGoogle Scholar
  11. 11.
    Kim JM, Moon MS (1995) Squatting following total knee arthroplasty. Clin Orthop Relat Res 313:177–186PubMedGoogle Scholar
  12. 12.
    Kopacz DJ, Sharrock NE, Allen HW (1999) A comparison of levobupivacaine 0.125%, fentanyl 4 microg/mL, or their combination for patient-controlled epidural analgesia after major orthopedic surgery. Anesth Analg 89:1497–1503CrossRefPubMedGoogle Scholar
  13. 13.
    Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB (2004) Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop Relat Res 428:125–130CrossRefPubMedGoogle Scholar
  14. 14.
    Lu H, Mehdi G, Zhou D, Lin J (1996) Simultaneous bilateral total knee arthroplasty for rheumatoid arthritis. Chin Med J 109:937–940PubMedGoogle Scholar
  15. 15.
    Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS (2009) Multimodal pain management after total hip and knee arthroplasty at the Ranawat orthopaedic center. Clin Orthop Relat Res 467:1418–1423CrossRefPubMedGoogle Scholar
  16. 16.
    Mahoney OM, Noble PC, Davidson J, Tullos HS (1990) The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop Relat Res 260:30–37PubMedGoogle Scholar
  17. 17.
    Park KK, Shin KS, Chang CB, Kim SJ, Kim TK (2007) Functional disabilities and issues of concern in female Asian patients before TKA. Clin Orthop Relat Res 461:143–152PubMedGoogle Scholar
  18. 18.
    Parvataneni HK, Ranawat AS, Ranawat CS (2007) The use of local periarticular injections in the management of postoperative pain after total hip and knee replacement: a multimodal approach. Instr Course Lect 56:125–131PubMedGoogle Scholar
  19. 19.
    Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS (2007) Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty 22:33–38CrossRefPubMedGoogle Scholar
  20. 20.
    Parvizi J, Porat M, Gandhi K, Viscusi ER, Rothman RH (2009) Postoperative pain management techniques in hip and knee arthroplasty. Instr Course Lect 58:769–779PubMedGoogle Scholar
  21. 21.
    Peters CL, Shirley B, Erickson J (2006) The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty. J Arthroplasty 21:132–138CrossRefPubMedGoogle Scholar
  22. 22.
    Powell RS, Pulido P, Tuason MS, Colwell CW Jr, Ezzet KA (2006) Bilateral vs unilateral total knee arthroplasty: a patient-based comparison of pain levels and recovery of ambulatory skills. J Arthroplasty 21:642–649CrossRefPubMedGoogle Scholar
  23. 23.
    Ranawat AS, Ranawat CS (2007) Pain management and accelerated rehabilitation for total hip and total knee arthroplasty. J Arthroplasty 22:12–15CrossRefPubMedGoogle Scholar
  24. 24.
    Sinatra RS, Torres J, Bustos AM (2002) Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg 10:117–129PubMedGoogle Scholar
  25. 25.
    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 78:172–179CrossRefPubMedGoogle Scholar
  26. 26.
    Trousdale RT, McGrory BJ, Berry DJ, Becker MW, Harmsen WS (1999) Patients’ concerns prior to undergoing total hip and total knee arthroplasty. Mayo Clin Proc 74:978–982CrossRefPubMedGoogle Scholar
  27. 27.
    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 88:282–289CrossRefPubMedGoogle Scholar
  28. 28.
    Viscusi ER (2005) Emerging techniques in the management of acute pain: epidural analgesia. Anesth Analg 101:S23–S29CrossRefPubMedGoogle Scholar
  29. 29.
    Viscusi ER, Parvizi J, Tarity TD (2007) Developments in spinal and epidural anesthesia and nerve blocks for total joint arthroplasty: what is new and exciting in pain management. Instr Course Lect 56:139–145PubMedGoogle Scholar
  30. 30.
    Ware JE Jr, Sherbourne CD (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30:473–483CrossRefPubMedGoogle Scholar
  31. 31.
    Wheatley RG, Schug SA, Watson D (2001) Safety and efficacy of postoperative epidural analgesia. Br J Anaesth 87:47–61CrossRefPubMedGoogle Scholar
  32. 32.
    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 102:1240–1246CrossRefPubMedGoogle Scholar
  33. 33.
    Zeni JA Jr, Snyder-Mackler L (2009) Clinical outcomes after simultaneous bilateral total knee arthroplasty comparison to unilateral total knee arthroplasty and healthy controls. J Arthroplasty Apr 7. [Epub ahead of print]Google Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • In Jun Koh
    • 1
  • Yeon Gwi Kang
    • 1
    • 2
  • Chong Bum Chang
    • 1
    • 3
  • Sae Kwang Kwon
    • 1
  • Eun Seok Seo
    • 1
  • Sang Cheol Seong
    • 3
  • Tae Kyun Kim
    • 1
    • 3
    Email author
  1. 1.Joint Reconstruction Center, Department of Orthopaedic SurgerySeoul National University Bundang HospitalBundang-gu, Seongnam-siKorea
  2. 2.Department of Statistics, Dankook UniversityYonginKorea
  3. 3.Department of Orthopaedic SurgerySeoul National University College of MedicineSeoulKorea

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