Abstract
Background
Postoperative pain after TKA is a major concern to patients. The best technique to control pain is still controversial. Intrathecal morphine or periarticular multimodal drug injection are both commonly used and both appear to provide better pain control than placebo, but it is unclear whether one or the other provides better pain control.
Questions/purposes
We asked whether intrathecal morphine or periarticular multimodal drug injection provides better pain control with fewer adverse events.
Methods
In a prospective, double-blind, randomized controlled trial we randomized 57 patients with osteoarthritic knees who underwent TKAs into two groups. Group M (n = 28) received 0.2 mg intrathecal morphine while Group I (n = 29) received periarticular multimodal drug injection. Postoperative pain was managed with patient-controlled analgesia using ketorolac. The outcomes were pain levels, the amount of analgesic drug used, and drug-related side effects. Patients and evaluators were blinded. All patients were followed up to 3 months.
Results
We found no difference in postoperative pain level, analgesia drug consumption, blood loss in drain, and knee function. More patients in Group M required antiemetic (19 [69%] versus 10 [34%]) and antipruritic drugs (10 [36%] versus three [10%]) than patients in Group I.
Conclusions
The two techniques provide no different pain control capacity. The periarticular multimodal drug injection was associated with lower rates of vomiting and pruritus.
Level of Evidence
Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Similar content being viewed by others
References
Aksoy Y, Altinel L, Kose KC. The comparison of the effects of intraoperative bleeding control and postoperative drain clamping methods on the postoperative blood loss and the need for transfusion following total knee arthroplasty. Acta Orthop Traumatol Turc. 2011;45:190–194.
Brown CR, Mazzulla JP, Mok MS, Nussdorf RT, Rubin PD, Schwesinger WH. Comparison of repeat doses of intramuscular ketorolac tromethamine and morphine sulfate for analgesia after major surgery. Pharmacotherapy. 1990;10:45S–50S.
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.
Cepeda MS, Vargas L, Ortegon G, Sanchez MA, Carr DB. Comparative analgesic efficacy of patient-controlled analgesia with ketorolac versus morphine after elective intraabdominal operations. Anesth Analg. 1995;80:1150–1153.
Charoencholvanich K, Siriwattanasakul P. Tranexamic acid reduces blood loss and blood transfusion after TKA: a prospective randomized controlled trial. Clin Orthop Relat Res. 2011;469:2874–2880.
Cole PJ, Craske DA, Wheatley RG. Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty. Br J Anaesth. 2000;85:233–237.
DeLoach LJ, Higgins MS, Caplan AB, Stiff JL. The visual analog scale in the immediate postoperative period: intrasubject variability and correlation with a numeric scale. Anesth Analg. 1998;86:102–106.
Dony P, Dewinde V, Vanderick B, Cuignet O, Gautier P, Legrand E, Lavand’homme P, De Kock M. The comparative toxicity of ropivacaine and bupivacaine at equipotent doses in rats. Anesth Analg. 2000;91:1489–1492.
Essving P, Axelsson K, Aberg E, Spannar H, Gupta A, Lundin A. Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial. Anesth Analg. 2011;113:926–933.
Fu P, Wu Y, Wu H, Li X, Qian Q, Zhu Y. Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty: a randomized controlled trial. Knee. 2009;16:280–284.
Gomez-Cardero P, Rodriguez-Merchan EC. Postoperative analgesia in TKA: ropivacaine continuous intraarticular infusion. Clin Orthop Relat Res. 2010;468:1242–1247.
Hassett P, Ansari B, Gnanamoorthy P, Kinirons B, Laffey JG. Determination of the efficacy and side-effect profile of lower doses of intrathecal morphine in patients undergoing total knee arthroplasty. BMC Anesthesiol. 2008;8:5.
Kuptniratsaikul V, Rattanachaiyanont M. Validation of a modified Thai version of the Western Ontario and McMaster (WOMAC) osteoarthritis index for knee osteoarthritis. Clin Rheumatol. 2007;26:1641–1645.
Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB. Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop Relat Res. 2004;428:125–130.
Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res. 2009;467:1418–1423.
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.
Park SY, Moon SH, Park MS, Oh KS, Lee HM. The effects of ketorolac injected via patient controlled analgesia postoperatively on spinal fusion. Yonsei Med J. 2005;46:245–251.
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.
Paul JE, Arya A, Hurlburt L, Cheng J, Thabane L, Tidy A, Murthy Y. Femoral nerve block improves analgesia outcomes after total knee arthroplasty: a meta-analysis of randomized controlled trials. Anesthesiology. 2010;113:1144–1162.
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.
Rasmussen S, Kramhoft MU, Sperling KP, Pedersen JH. Increased flexion and reduced hospital stay with continuous intraarticular morphine and ropivacaine after primary total knee replacement: open intervention study of efficacy and safety in 154 patients. Acta Orthop Scand. 2004;75:606–609.
Scott DB, Lee A, Fagan D, Bowler GM, Bloomfield P, Lundh R. Acute toxicity of ropivacaine compared with that of bupivacaine. Anesth Analg. 1989;69:563–569.
Svensson I, Sjostrom B, Haljamae H. Assessment of pain experiences after elective surgery. J Pain Symptom Manage. 2000;20:193–201.
Szczukowski MJ Jr, Hines JA, Snell JA, Sisca TS. Femoral nerve block for total knee arthroplasty patients: a method to control postoperative pain. J Arthroplasty. 2004;19:720–725.
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.
Acknowledgments
We thank all participants for providing the data used in this study.
Author information
Authors and Affiliations
Corresponding author
Additional information
Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.
All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.
Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.
This study was performed at Thammasat University, Pathumthani, Thailand.
About this article
Cite this article
Tammachote, N., Kanitnate, S., Manuwong, S. et al. Is Pain After TKA Better with Periarticular Injection or Intrathecal Morphine?. Clin Orthop Relat Res 471, 1992–1999 (2013). https://doi.org/10.1007/s11999-013-2826-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11999-013-2826-9