Skip to main content
SpringerLink
Log in

Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? Prospective, randomized, double-blind study

  • Knee
  • Published:
Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

Although the analgesic effect of periarticular injection after total knee arthroplasty (TKA) has been well documented, the gold standard for drug combination has not yet been established. In this study, the analgesic effects of six different drug combinations were compared.

Methods

A total of 256 patients undergoing TKA for primary osteoarthritis were randomized into one of six groups: a control group (saline solution, epinephrine, and cefazolin, n = 42), Group 1 (ropivacaine, n = 43), Group 2 (ropivacaine + morphine, n = 43), Group 3 (ropivacaine + ketorolac, n = 42), Group 4 (ropivacaine + morphine + ketorolac, n = 43), and Group 5 (ropivacaine + morphine + ketorolac + methylprednisolone, n = 43). Pain level assessed by visual analogue scale (VAS) and opioid consumption were primary outcomes. The incidence of complications, range of motion (ROM), C-reactive protein (CRP) value, and the amount of post-operative blood drainage were also compared.

Results

Patients in Groups 4 and 5 complained less pain than the control group for the first 12 h after surgery, and the patients in the other groups showed less pain only during the initial 6 h after surgery. Groups 4 and 5 also showed less opioid consumption than the control group during the 24 h period after surgery. Patients in Group 5 showed no significant difference in VAS score and opioid consumption compared with Group 4, but they had lower CRP value and greater ROM than any other groups at post-operative day 2 and day 4.

Conclusion

The combination of ropivacaine, morphine, and ketorolac showed a significantly stronger and sufficiently synergistic analgesic effect without adding methylprednisolone in periarticular injection after TKA. The clinical relevance of the study is that the combination of ropivacaine, morphine, and ketorolac can be a good option for periarticular injection following TKA in terms of synergistic analgesic effect and efficiency of drug combination.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. 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(5):959–963

    Article  PubMed  Google Scholar 

  2. Buttgereit F, Brand MD, Burmester GR (1999) Equivalent doses and relative drug potencies for non-genomic glucocorticoid effects: a novel glucocorticoid hierarchy. Biochem Pharmacol 58(2):363–368

    Article  CAS  PubMed  Google Scholar 

  3. Cashman JN (1996) The mechanisms of action of NSAIDs in analgesia. Drugs 52(Suppl 5):13–23

    Article  CAS  PubMed  Google Scholar 

  4. Chang CB, Cho WS (2012) Pain management protocols, peri-operative pain and patient satisfaction after total knee replacement: a multicentre study. J Bone Joint Surg Br 94(11):1511–1516

    Article  CAS  PubMed  Google Scholar 

  5. Chia SK, Wernecke GC, Harris IA, Bohm MT, Chen DB, Macdessi SJ (2013) Peri-articular steroid injection in total knee arthroplasty: a prospective, double blinded, randomized controlled trial. J Arthroplasty 28(4):620–623

    Article  PubMed  Google Scholar 

  6. 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(11):2550–2555

    Article  PubMed  Google Scholar 

  7. Fischer HB, Simanski CJ, Sharp C, Bonnet F, Camu F, Neugebauer EA, Rawal N, Joshi GP, Schug SA, Kehlet H, Group PW (2008) A procedure-specific systematic review and consensus recommendations for postoperative analgesia following total knee arthroplasty. Anaesthesia 63(10):1105–1123

    Article  CAS  PubMed  Google Scholar 

  8. 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(9):1154–1159

    Article  CAS  PubMed  Google Scholar 

  9. Ikeuchi M, Kamimoto Y, Izumi M, Fukunaga K, Aso K, Sugimura N, Yokoyama M, Tani T (2014) Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 22(7):1638–1643

    Article  PubMed  Google Scholar 

  10. Jiang J, Teng Y, Fan Z, Khan MS, Cui Z, Xia Y (2013) The efficacy of periarticular multimodal drug injection for postoperative pain management in total knee or hip arthroplasty. J Arthroplasty 28(10):1882–1887

    Article  PubMed  Google Scholar 

  11. Kelley TC, Adams MJ, Mulliken BD, Dalury DF (2013) Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: a randomized, double-blinded study. J Arthroplasty 28(8):1274–1277

    Article  PubMed  Google Scholar 

  12. 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(4):253–259

    Article  PubMed  Google Scholar 

  13. Krenzel BA, Cook C, Martin GN, Vail TP, Attarian DE, Bolognesi MP (2009) Posterior capsular injections of ropivacaine during total knee arthroplasty: a randomized, double-blind, placebo-controlled study. J Arthroplasty 24(6 Suppl):138–143

    Article  PubMed  Google Scholar 

  14. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89(4):780–785

    Article  PubMed  Google Scholar 

  15. Lombardi AV, 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 428:125–130

    Article  PubMed  Google Scholar 

  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 260:30–37

    PubMed  Google Scholar 

  17. McNicol E (2009) Opioid equianalgesic conversions. J Pain Palliat Care Pharmacother 23(4):458; author reply 459

  18. Mousa SA, Straub RH, Schafer M, Stein C (2007) Beta-endorphin, Met-enkephalin and corresponding opioid receptors within synovium of patients with joint trauma, osteoarthritis and rheumatoid arthritis. Ann Rheum Dis 66(7):871–879

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  19. 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 Arthroplasty 25(6):851–857

    Article  PubMed  Google Scholar 

  20. 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(1):60–65

    Article  PubMed  Google Scholar 

  21. 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(6):738–744

    Article  PubMed  Google Scholar 

  22. Ranawat AS, Ranawat CS (2007) Pain management and accelerated rehabilitation for total hip and total knee arthroplasty. J Arthroplasty 22(7 Suppl 3):12–15

    Article  PubMed  Google Scholar 

  23. 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. Singapore Med J 52(1):19–23

    CAS  PubMed  Google Scholar 

  24. Sehgal N, Smith HS, Manchikanti L (2011) Peripherally acting opioids and clinical implications for pain control. Pain Physician 14(3):249–258

    PubMed  Google Scholar 

  25. Shoji H, Solomonow M, Yoshino S, D’Ambrosia R, Dabezies E (1990) Factors affecting postoperative flexion in total knee arthroplasty. Orthopedics 13(6):643–649

    CAS  PubMed  Google Scholar 

  26. Sinatra R, Chung KS, Silverman DG, Brull SJ, Chung J, Harrison DM, Donielson D, Weinstock A (1989) An evaluation of morphine and oxymorphone administered via patient-controlled analgesia (PCA) or PCA plus basal infusion in postcesarean-delivery patients. Anesthesiology 71(4):502–507

    Article  CAS  PubMed  Google Scholar 

  27. Sinatra RS, Torres J, Bustos AM (2002) Pain management after major orthopaedic surgery: current strategies and new concepts. J Am Acad Orthop Surg 10(2):117–129

    PubMed  Google Scholar 

  28. Teng Y, Jiang J, Chen S, Zhao L, Cui Z, Khan MS, Du W, Gao X, Wang J, Xia Y (2014) Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 22(8):1949–1957

    Article  PubMed  Google Scholar 

  29. 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(2):282–289

    Article  PubMed  Google Scholar 

  30. Wong SH, Wong CS, Li TT (2010) Steroids in regional analgesia. Expert Opin Pharmacother 11(17):2839–2848

    Article  CAS  PubMed  Google Scholar 

  31. Woolf CJ, Wiesenfeld-Hallin Z (1985) The systemic administration of local anaesthetics produces a selective depression of C-afferent fibre evoked activity in the spinal cord. Pain 23(4):361–374

    Article  CAS  PubMed  Google Scholar 

  32. Yuenyongviwat V, Pornrattanamaneewong C, Chinachoti T, Chareancholvanich K (2012) Periarticular injection with bupivacaine for postoperative pain control in total knee replacement: a prospective randomized double-blind controlled trial. Adv Orthop 2012:107309

    Article  PubMed Central  PubMed  Google Scholar 

  33. 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(4):1240–1246

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Hallym University Hospital, 77, Sakju-ro, Chuncheon-si, Gangwon-do, 200-704, Korea

    Tae Woo Kim

  2. Department of Orthopaedic Surgery, Seoul National University Hospital, 101 Daehang-ro, Jongno-gu, Seoul, 110-744, Korea

    Sang Jae Park, Se Hyeok Lim, Sang Cheol Seong, Sahnghoon Lee & Myung Chul Lee

Authors
  1. Tae Woo Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sang Jae Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Se Hyeok Lim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sang Cheol Seong
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sahnghoon Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Myung Chul Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Myung Chul Lee.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kim, T.W., Park, S.J., Lim, S.H. et al. Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? Prospective, randomized, double-blind study. Knee Surg Sports Traumatol Arthrosc 23, 838–845 (2015). https://doi.org/10.1007/s00167-014-3366-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00167-014-3366-x

Keywords

Search

Navigation