HSS Journal ®

, Volume 15, Issue 1, pp 17–19 | Cite as

Opioid-Free Total Knee Arthroplasty? Local Infiltration Analgesia Plus Multimodal Blood-Loss Prevention Make it Possible

  • E. Carlos Rodriguez-MerchanEmail author
  • Alfonso Vaquero-Picado
  • Juan S. Ruiz-Perez


Opioids have been widely used in the USA for pain control after total knee arthroplasty (TKA). However, adverse effects, especially the possibility of addiction, have increased interest in opioid-free pain management after surgery. We therefore sought to review current pain management protocols after TKA, focusing especially on opioid-free alternatives. We reviewed the literature on pain management after TKA using Medline (PubMed), through June 30, 2018, using the keywords “TKA” and “analgesia.” We found 388 articles but chose to analyze the 34 that presented high-quality (levels I and II) evidence. Local infiltration analgesia (LIA) is a good option for reducing the use of post-operative opioids; many reports have compared LIA against a nerve block or studied the synergies between two protocols of loco-regional anesthesia. Multimodal blood-loss prevention is sometimes recommended in combination with opioid-free analgesia. In most studies, however, no differences are reported or contradictory results exist. Post-operative pain management protocols vary so much that it is difficult to strongly favor a determined pathway.


knee total knee arthroplasty post-operative pain opioids local infiltration analgesia opioid-free TKA 


Compliance with Ethical Standards

Conflict of Interest: E. Carlos Rodriguez-Merchan, MD, PhD, Alfonso Vaquero-Picado, MD, FEBOT, and Juan S. Ruiz-Perez, MD, declare that they have no conflicts of interest.

Human/Animal Rights: N/A

Informed Consent: N/A 

Required Author Forms : Disclosure forms provided by the authors are available with the online version of this article.

Supplementary material

11420_2018_9636_MOESM1_ESM.pdf (1.2 mb)
ESM 1 (PDF 1224 kb)


  1. 1.
    Barastegui D, Robert I, Palau E, Haddad S, Reverte-Vinaixa M, Lorente L, et al. Can local infiltration analgesia increase satisfaction in post-operative short-term pain control in total knee arthroplasty? J Orthop Surg Hong Kong. 2017; 25:2309499017690461.Google Scholar
  2. 2.
    Breindahl T, Simonsen O, Hindersson P, Brødsgaard Dencker B, Brouw Jørgensen M, Rasmussen S. Autologous blood transfusion after local infiltration analgesia with ropivacaine in total knee and hip arthroplasty. Anesthesiol Res Pract. 2012;2012:458795.Google Scholar
  3. 3.
    Chaubey D, Mahajan HK, Chauhan PR, Govind PS, Singh P, Dhanevar R, et al. Comparison of continuous femoral nerve block versus local infiltration analgesia as a postoperative analgesia in unilateral total knee arthroplasty. J Clin Diagn Res. 2017;11:UC13–UC16.CrossRefGoogle Scholar
  4. 4.
    Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop. 2010;81:354–360.CrossRefGoogle Scholar
  5. 5.
    Fan L, Yu X, Zan P, Liu J, Ji T, Li G. Comparison of local infiltration analgesia with femoral nerve block for total knee arthroplasty: a prospective, randomized clinical trial. J Arthroplasty. 2016;31:1361–1365.CrossRefGoogle Scholar
  6. 6.
    Gomez-Barrena E, Ortega-Andreu M, Padilla-Eguiluz NG, Pérez-Chrzanowska H, Figueredo-Zalve R. Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial. J Bone Joint Surg Am. 2014;96:1937–1944.CrossRefGoogle Scholar
  7. 7.
    Inacio MCS, Paxton EW, Graves SE, Namba RS, Nemes S. Projected increase in total knee arthroplasty in the United States—an alternative projection model. Osteoarthritis Cartilage. 2017;25:1797–1803.CrossRefGoogle Scholar
  8. 8.
    Inacio MCS, Cashman K, Pratt NL, Gillam MH, Caughey G, Graves SE, et al. Prevalence and changes in analgesic medication utilisation 1 year prior to total joint replacement in an older cohort of patients. Osteoarthritis Cartilage. 2018;26:356–362.Google Scholar
  9. 9.
    Kampitak W, Tanavalee A, Ngarmukos S, Amarase C, Apihansakorn R, Vorapalux P. Does adductor canal block have a synergistic effect with local infiltration analgesia for enhancing ambulation and improving analgesia after total knee arthroplasty? Knee Surg Relat Res. 2018;30:133–141.CrossRefGoogle Scholar
  10. 10.
    Kampitak W, Tanavalee A, Ngarmukos S, Amarase C, Songthamwat B, Boonshua A. Comparison of adductor canal block versus local infiltration analgesia on postoperative pain and functional outcome after total knee arthroplasty: a randomized controlled trial. Malays Orthop J. 2018;12:7–14.Google Scholar
  11. 11.
    Keijsers R, van Delft R, van den Bekerom MPJ, de Vries DC, Brohet RM, Nolte PA. Local infiltration analgesia following total knee arthroplasty: effect on post-operative pain and opioid consumption—a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2015;23:1956–1963.CrossRefGoogle Scholar
  12. 12.
    Li J, Deng X, Jiang T. Combined femoral and sciatic nerve block versus femoral and local infiltration anesthesia for pain control after total knee arthroplasty: a meta-analysis of randomized controlled trials. J Orthop Surg. 2016;11:158.CrossRefGoogle Scholar
  13. 13.
    Ma L-P, Qi Y-M, Zhao D-X. Comparison of local infiltration analgesia and sciatic nerve block for pain control after total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg. 2017;12:85.CrossRefGoogle Scholar
  14. 14.
    Madras BK. The president’s commission on combating drug addiction and the opioid crisis: origins and recommendations. Clin Pharmacol Ther. 2018 23.
  15. 15.
    Milani P, Castelli P, Sola M, Invernizzi M, Massazza G, Cisari C. Multimodal analgesia in total knee arthroplasty: a randomized, double-blind, controlled trial on additional efficacy of periarticular anesthesia. J Arthroplasty 2015;30:2038–2042.CrossRefGoogle Scholar
  16. 16.
    Mont MA, Beaver WB, Dysart SH, Barrington JW, Del Gaizo DJ. Local infiltration analgesia with liposomal bupivacaine improves pain scores and reduces opioid use after total knee arthroplasty: results of a randomized controlled trial. J Arthroplasty. 2018;33:90–96.Google Scholar
  17. 17.
    Moráis S, Ortega-Andreu M, Rodríguez-Merchán EC, Padilla Eguiluz NG, Pérez-Chrzanowska H, Figueredo-Zalve R, GómezBarrena E. Blood transfusion after primary total knee arthroplasty can be significantly minimised through a multimodal blood-loss prevention approach. Int Orthop. 2014;38:347–354.CrossRefGoogle Scholar
  18. 18.
    Mulford JS, Watson A, Broe D, Solomon M, Loefler A, Harris I. Short-term outcomes of local infiltration anaesthetic in total knee arthroplasty: a randomized controlled double-blinded controlled trial. ANZ J Surg. 2016;86:152–156.CrossRefGoogle Scholar
  19. 19.
    Murphy DL, Lebin JA, Severtson SG, Olsen HA, Dasgupta N, Dart RC. Comparative rates of mortality and serious adverse effects among commonly prescribed opioid analgesics. Drug Saf. 2018.
  20. 20.
    Nagafuchi M, Sato T, Sakuma T, Uematsu A, Hayashi H, Tanikawa H, et al. Femoral nerve block-sciatic nerve block vs. femoral nerve block-local infiltration analgesia for total knee arthroplasty: a randomized controlled trial. BMC Anesthesiol. 2015;15:182.Google Scholar
  21. 21.
    Nakagawa S, Arai Y, Inoue H, Kan H, Hino M, Ichimaru S, et al. Comparative effects of periarticular multimodal drug injection and single-shot femoral nerve block on pain following total knee arthroplasty and factors influencing their effectiveness. Knee Surg Relat Res. 2016;28:233–238.CrossRefGoogle Scholar
  22. 22.
    Niemelainen M, Kalliovalkama J, Aho AJ, Moilanen T, Eskelinen A. Single periarticular local infiltration analgesia reduces opiate consumption until 48 hours after total knee arthroplasty. A randomized placebo-controlled trial involving 56 patients. Acta Orthop. 2014;85:614–9.CrossRefGoogle Scholar
  23. 23.
    Ortega-Andreu M, Pérez-Chrzanowska H, Figueredo R, GómezBarrena E. Blood loss control with two doses of tranexamic acid in a multimodal protocol for total knee arthroplasty. Open Orthop J. 2011;5:44–48.CrossRefGoogle Scholar
  24. 24.
    Ortega-Andreu M, Talavera G, Padilla-Eguiluz NG, Perez Chrzanowska H, Figueredo-Galve R, Rodriguez-Merchán, et al. Tranexamic acid in a multimodal blood loss prevention protocol to decrease blood loss in revision total knee arthroplasty: a cohort study. Open Orthop J. 2016;10:439–447.Google Scholar
  25. 25.
    Rodriguez-Merchan EC, Ortega-Andreu M, Padilla-Eguiluz NG, Gomez-Cardero P, Martinez-Lloreda Á, Gomez-Barrena E. Low-volume formulation of intra-articular tranexamic acid, 25-ml tranexamic acid (2.5 g) plus 20-ml saline, is effective in decreasing blood transfusion rate in primary total knee replacement even without preoperative haemoglobin optimization. Blood Coagul Fibrinolysis. 2016;27:660–666.CrossRefGoogle Scholar
  26. 26.
    Rodriguez-Merchan EC, Romero-Garrido JA, Gomez-Cardero P. Multimodal blood loss prevention approach including intra-articular tranexamic acid in primary total knee arthroplasty for patients with severe haemophilia A. Haemophilia. 2016;22:e318–320.CrossRefGoogle Scholar
  27. 27.
    Runge C, Jensen JM, Clemmesen L, Knudsen HB, Holm C, Børglum J, et al. Analgesia of combined femoral triangle and obturator nerve blockade is superior to local infiltration analgesia after total knee arthroplasty with high-dose intravenous dexamethasone. Reg Anesth Pain Med. 2018;43:352–356.CrossRefGoogle Scholar
  28. 28.
    Seangleulur A, Vanasbodeekul P, Prapaitrakool S, et al. The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty: a systematic review and meta-analysis. Eur J Anaesthesiol. 2016;33:816–831.CrossRefGoogle Scholar
  29. 29.
    Schotanus MGM, Bemelmans YFL, van der Kuy PHM, Jansen J, Kort NP. No advantage of adrenaline in the local infiltration analgesia mixture during total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2017;25:2778–2783.Google Scholar
  30. 30.
    Tran J, Schwarzkopf R. Local infiltration anesthesia with steroids in total knee arthroplasty: a systematic review of randomized control trials. J Orthop. 2015;12:S44–50.CrossRefGoogle Scholar
  31. 31.
    Tziona D, Papaioannou M, Mela A, Potamianou S, Makris A. Local infiltration analgesia combined with a standardized multimodal approach including an adductor canal block in total knee arthroplasty: a prospective randomized, placebo-controlled, double-blinded clinical trial. J Anesth. 2018;32:326–332.CrossRefGoogle Scholar
  32. 32.
    Zhang Z, Yang Q, Xin W, Zhang Y. Comparison of local infiltration analgesia and sciatic nerve block as an adjunct to femoral nerve block for pain control after total knee arthroplasty: a systematic review and meta-analysis. Medicine (Baltimore). 2017;96:e6829.Google Scholar
  33. 33.
    Zhang L-K, Ma J-X, Kuang M-J, Ma XL. Comparison of periarticular local infiltration analgesia with femoral nerve block for total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty. 2018;33:1972–8.e4.CrossRefGoogle Scholar
  34. 34.
    Zhou M, Ding H, Ke J. Adductor canal block in combination with posterior capsular infiltration on the pain control after TKA. Ir J Med Sci. 2018;187:465–471.CrossRefGoogle Scholar

Copyright information

© Hospital for Special Surgery 2018

Authors and Affiliations

  • E. Carlos Rodriguez-Merchan
    • 1
    Email author
  • Alfonso Vaquero-Picado
    • 1
  • Juan S. Ruiz-Perez
    • 1
  1. 1.Department of Orthopedic Surgery, Knee Surgery UnitLa Paz University Hospital—IdiPazMadridSpain

Personalised recommendations