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Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA: A Randomized, Double-blind Trial

  • Symposium: Perioperative Pain Management in Orthopaedic Surgery
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Pain management after TKA remains challenging and the efficacy of continuously infused intraarticular anesthetics remains a controversial topic.

Questions/purposes

We compared the side effect profile, analgesic efficacy, and functional recovery between patients receiving a continuous intraarticular infusion of ropivacaine and patients receiving an epidural plus femoral nerve block (FNB) after TKA.

Methods

Ninety-four patients undergoing unilateral TKA were prospectively randomized to receive a spinal-epidural analgesic infusion plus a single-injection FNB or a spinal anesthetic plus a continuous postoperative intraarticular infusion of 0.2% ropivacaine. All patients were blinded to their treatment with placebo saline catheters. Blinded coinvestigators collected data concerning side effect profiles (nausea, hypotension), analgesic efficacy (VAS pain scores, narcotic usage), and functional recovery (timed up and go test, quadriceps strength, WOMAC scores, Knee Society scores, early postoperative ambulatory ability, in-hospital falls). All complications and adverse events were recorded.

Results

The frequency of nausea and hypertension was not different between the study groups. During the first 12 and 24 postoperative hours, the mean maximum VAS pain scores were higher in the ropivacaine group than in the epidural group (first 12 hours: 3.93 versus 1.14, respectively, p < 0.0001; 12–24 hours: 3.52 versus 1.93, respectively, p = 0.008). After 24 hours, pain scores were similar between groups. Narcotic consumption was significantly higher in the ropivacaine group on the day of surgery, but overall in-hospital narcotic usage was similar between groups. There were no clinically important differences in functional recovery between groups at any time point, but patients in the epidural group were more likely to have knee buckling (32.7% versus 6.7%, p = 0.002) and delayed ambulation (16.3% versus 0.0%, p = 0.006) than patients in the ropivacaine group, though not in-hospital falls. No infections occurred in either group, and the frequency of complications was not different between groups.

Conclusions

A continuous intraarticular infusion of ropivacaine can be recommended as a safe, effective alternative to epidural analgesia plus single-injection FNB after TKA. Improved analgesic efficacy in the group that received epidural analgesia plus single-injection FNB must be weighed against the disadvantage of a higher likelihood of knee buckling and delayed ambulation with that treatment approach.

Level of Evidence

Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

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Acknowledgments

We thank Huong Do MA for designing and performing the statistical analysis for this study and Drs. Spencer Liu, Douglas S.T. Green, Yi Lin, and Daniel B. Maalouf for their participation in the care of the patients enrolled in this trial.

Author information

Authors and Affiliations

  1. Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA

    Keith R. Reinhardt MD, Shivi Duggal BS, MBA, Gregory A. Reinhardt MSPT, Denis Nam MD, Michael Alexiades MD & Charles N. Cornell MD

  2. Weill Cornell Medical College, Cornell University, New York, NY, USA

    Ben-Paul Umunna BA

Authors
  1. Keith R. Reinhardt MD
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  2. Shivi Duggal BS, MBA
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  3. Ben-Paul Umunna BA
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  4. Gregory A. Reinhardt MSPT
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  5. Denis Nam MD
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  6. Michael Alexiades MD
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  7. Charles N. Cornell MD
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Corresponding author

Correspondence to Keith R. Reinhardt MD.

Additional information

The institution of one or more of the authors (KRR, SD, GAR, DN, MA, CNC) has received, during the study period, funding from three institutional research grants, namely the Hospital for Special Surgery Adult Reconstruction and Joint Replacement Division research grant, the Surgeon-in-chief fund research grant, and the Eduardo A. Salvati MD resident research grant. The authors did not receive outside commercial funding in support of the research for or preparation of this manuscript.

Each author certifies that he or she, or a member of his or her immediate family, has no 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.

Clinical Orthopaedics and Related Research ® neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.

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 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 work was performed at Hospital for Special Surgery, New York, NY, USA.

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Reinhardt, K.R., Duggal, S., Umunna, BP. et al. Intraarticular Analgesia Versus Epidural Plus Femoral Nerve Block After TKA: A Randomized, Double-blind Trial. Clin Orthop Relat Res 472, 1400–1408 (2014). https://doi.org/10.1007/s11999-013-3351-6

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  • DOI: https://doi.org/10.1007/s11999-013-3351-6

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