Clinical Orthopaedics and Related Research®

, Volume 468, Issue 8, pp 2152–2159 | Cite as

The Efficacy of Periarticular Multimodal Drug Infiltration in Total Hip Arthroplasty

  • Constant A. Busch
  • Michael R. WhitehouseEmail author
  • Benjamin J. Shore
  • Steven J. MacDonald
  • Richard W. McCalden
  • Robert B. Bourne
Clinical Research Hip



Patient-controlled analgesia is a widely used and effective method of controlling pain after THA. This method is associated with substantial undesirable side effects. Local infiltration has been introduced in an attempt to reduce opioid requirements postoperatively, but its ability to reduce pain without complications is still questioned.


We evaluated patient-controlled analgesia use, pain and satisfaction scores, complication rates, and ropivacaine levels associated with the use of periarticular multimodal drug infiltration in THA.

Patients and Methods

We randomized 64 patients undergoing THA to receive a periarticular intraoperative multimodal drug injection or to receive no injection. All patients received patient-controlled analgesia for 24 hours after surgery. The final assessment was at 6 weeks.


Patients receiving the periarticular injection used less patient-controlled analgesia 6 hours postoperatively. The 24-hour patient-controlled analgesia requirement postsurgery also was less. The visual analog scale score for pain on activity in the postanesthetic care unit was less for patients who received an injection. The visual analog scale satisfaction score was similar in the two groups throughout the followup period. Recorded unbound ropivacaine levels were 2.5 times lower than toxic levels.


Periarticular intraoperative injection with multimodal drugs can reduce postoperative patient-controlled analgesia requirements and pain on activity in patients undergoing THA with no apparent increase in risk.

Level of Evidence

Level I, therapeutic study. See the guidelines online for a complete description of level of evidence.


Morphine Visual Analog Scale Score Ropivacaine Central Nervous System Toxicity Periarticular Injection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We acknowledge Dr. L. Kohan and Dr. D. Kerr of Sydney, Australia, for their work in developing the multimodal drug combination used in this study. We also thank Prof C. H. Rorabeck and Dr. R. Bhandari for contributions to work with this research and the previous investigation of multimodal drug infiltration in TKAs.


  1. 1.
    Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Søballe K. Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty: a randomized clinical trial of an intraarticular technique versus epidural infusion in 80 patients. Acta Orthop. 2007;78:180–186.CrossRefPubMedGoogle Scholar
  2. 2.
    Asayama I, Kinsey TL, Mahoney OM. Two-year experience using a limited-incision direct lateral approach in total hip arthroplasty. J Arthroplasty. 2006;21:1083–1091.CrossRefPubMedGoogle Scholar
  3. 3.
    Badner NH, Bourne RB, Rorabeck CH, MacDonald SJ, Doyle JA. Intra-articular injection of bupivacaine in knee-replacement operations: results of use for analgesia and for preemptive blockade. J Bone Joint Surg Am. 1996;78:734–738.PubMedGoogle Scholar
  4. 4.
    Berger RA, Jacobs JJ, Meneghini RM, Della Valle C, Paprosky W, Rosenberg AG. Rapid rehabilitation and recovery with minimally invasive total hip arthroplasty. Clin Orthop Relat Res. 2004;429:239–247.CrossRefPubMedGoogle Scholar
  5. 5.
    Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB, Rorabeck CH, McCalden RW. Efficacy of periarticular multimodal drug injection in total knee arthroplasty: a randomized trial. J Bone Joint Surg Am. 2006;88:959–963.CrossRefPubMedGoogle Scholar
  6. 6.
    Cashman JN. The mechanisms of action of NSAIDs in analgesia. Drugs. 1996;52(suppl 5):13–23.CrossRefPubMedGoogle Scholar
  7. 7.
    Chang RW, Pellisier JM, Hazen GB. A cost-effectiveness analysis of total hip arthroplasty for osteoarthritis of the hip. JAMA. 1996;275:858–865.CrossRefPubMedGoogle Scholar
  8. 8.
    Denson DD, Myers JA, Hartrick CT, Pither CP, Coyle DE, Raj PP. The relationship between free bupivacaine concentration and central nervous system toxicity. Anesthesiology. 1984;61:A211.CrossRefGoogle Scholar
  9. 9.
    DeWeese FT, Akbari Z, Carline E. Pain control after knee arthroplasty: intraarticular versus epidural anesthesia. Clin Orthop Relat Res. 2001;392:226–231.CrossRefPubMedGoogle Scholar
  10. 10.
    Frater RA, Moores MA, Parry P, Hanning CD. Analgesia-induced respiratory depression: comparison of meptazinol and morphine in the postoperative period. Br J Anaesth. 1989;63:260–265.CrossRefPubMedGoogle Scholar
  11. 11.
    Gedney JA, Liu EH. Side-effects of epidural infusions of opioid bupivacaine mixtures. Anaesthesia. 1998;53:1148–1155.CrossRefPubMedGoogle Scholar
  12. 12.
    Giuffre M, Asci J, Arnstein P, Wilkinson C. Postoperative joint replacement pain: description and opioid requirement. J Post Anesth Nurs. 1991;6:239–245.PubMedGoogle Scholar
  13. 13.
    Hallenbeck JL. Palliative Care Perspectives: Chapter 4: Pain Management: Conversion among Different Opioids. Copyright 2003 by Oxford University Press, New York, NY. Available at: Accessed October 13, 2009.
  14. 14.
    Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am. 2005;87(suppl 2):63–70.CrossRefPubMedGoogle Scholar
  15. 15.
    Indelli PF, Grant SA, Nielsen K, Vail TP. Regional anesthesia in hip surgery. Clin Orthop Relat Res. 2005;441:250–255.CrossRefPubMedGoogle Scholar
  16. 16.
    Kerr DR, Kohan L. 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. 2008;79:174–183.CrossRefPubMedGoogle Scholar
  17. 17.
    Kiebzak GM, Vain PA, Gregory AM, Mokris JG, Mauerhan DR. SF-36 general health status survey to determine patient satisfaction at short-term follow-up after total hip and knee arthroplasty. J South Orthop Assoc. 1997;6:169–172.PubMedGoogle Scholar
  18. 18.
    Knudsen K, Beckman Suurkula M, Blomberg S, Sjovall J, Edvardsson N. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth. 1997;78:507–514.PubMedGoogle Scholar
  19. 19.
    Mahoney OM, Noble PC, Davidson J, Tullos HS. The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop Relat Res. 1990;260:30–37.PubMedGoogle Scholar
  20. 20.
    Mauerhan DR, Campbell M, Miller JS, Mokris JG, Gregory A, Kiebzak GM. Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty. J Arthroplasty. 1997;12:546–552.CrossRefPubMedGoogle Scholar
  21. 21.
    McDonald S, Hetrick S, Green S. Pre-operative education for hip or knee replacement. Cochrane Database Syst Rev. 2004;1:CD003526.PubMedGoogle Scholar
  22. 22.
    McNeill JA, Sherwood GD, Starck PL, Thompson CJ. Assessing clinical outcomes: patient satisfaction with pain management. J Pain Symptom Manage. 1998;16:29–40.CrossRefPubMedGoogle Scholar
  23. 23.
    Nikolajsen L, Brandsborg B, Lucht U, Jensen TS, Kehlet H. Chronic pain following total hip arthroplasty: a nationwide questionnaire study. Acta Anaesthesiol Scand. 2006;50:495–500.CrossRefPubMedGoogle Scholar
  24. 24.
    Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty. 2007;22(6 suppl 2):33–38.CrossRefPubMedGoogle Scholar
  25. 25.
    Peters CL, Shirley B, Erickson J. 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. 2006;21(6 suppl 2):132–138.CrossRefPubMedGoogle Scholar
  26. 26.
    Pettine KA, Wedel DJ, Cabanela ME, Weeks JL. The use of epidural bupivacaine following total knee arthroplasty. Orthop Rev. 1989;18:894–901.PubMedGoogle Scholar
  27. 27.
    Pour AE, Parvizi J, Sharkey PF, Hozack WJ, Rothman RH. Minimally invasive hip arthroplasty: what role does patient preconditioning play? J Bone Joint Surg Am. 2007;89:1920–1927.CrossRefPubMedGoogle Scholar
  28. 28.
    Ranawat AS, Ranawat CS. Pain management and accelerated rehabilitation for total hip and total knee arthroplasty. J Arthroplasty. 2007;22(7 suppl 3):12–15.CrossRefPubMedGoogle Scholar
  29. 29.
    Röstlund T, Kehlet H. High-dose local infiltration analgesia after hip and knee replacement: what is it, why does it work, and what are the future challenges? Acta Orthop. 2007;78:159–161.CrossRefPubMedGoogle Scholar
  30. 30.
    Solanki DR, Enneking FK, Ivey FM, Scarborough M, Johnston RV. Serum bupivacaine concentrations after intraarticular injection for pain relief after knee arthroscopy. Arthroscopy. 1992;8:44–47.CrossRefPubMedGoogle Scholar
  31. 31.
    Stein C. Peripheral mechanisms of opioid analgesia. Anesth Analg. 1993;76:182–191.CrossRefPubMedGoogle Scholar
  32. 32.
    Stein C. The control of pain in peripheral tissue by opioids. N Engl J Med. 1995;332:1685–1690.CrossRefPubMedGoogle Scholar
  33. 33.
    Thomas T, Robinson C, Champion D, McKell M, Pell M. Prediction and assessment of the severity of post-operative pain and of satisfaction with management. Pain. 1998;75:177–185.CrossRefPubMedGoogle Scholar
  34. 34.
    Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, Varin F. A multimodal analgesia protocol for total knee arthroplasty: a randomized, controlled study. J Bone Joint Surg Am. 2006;88:282–289.CrossRefPubMedGoogle Scholar
  35. 35.
    Weller R, Rosenblum M, Conard P, Gross JB. Comparison of epidural and patient-controlled intravenous morphine following joint replacement surgery. Can J Anaesth. 1991;38:582–586.CrossRefPubMedGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2009

Authors and Affiliations

  • Constant A. Busch
    • 1
  • Michael R. Whitehouse
    • 2
    Email author
  • Benjamin J. Shore
    • 3
  • Steven J. MacDonald
    • 3
  • Richard W. McCalden
    • 3
  • Robert B. Bourne
    • 3
  1. 1.Ashford and St Peter’s Hospital NHS TrustChertseyEngland
  2. 2.Bristol Implant Research Centre, Avon Orthopaedic CentreSouthmead HospitalBristolEngland
  3. 3.London Health Sciences Centre–University CampusLondonCanada

Personalised recommendations