Skip to main content
SpringerLink
Log in

The Chitranjan Ranawat Award: Periarticular Injections and Femoral & Sciatic Blocks Provide Similar Pain Relief After TKA: A Randomized Clinical Trial

  • Symposium: 2014 Knee Society Proceedings
  • Published:
Clinical Orthopaedics and Related Research®

A Symposium: 2014 Knee Society Proceedings to this article was published on 10 June 2014

Abstract

Background

Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA.

Questions/purposes

This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications.

Methods

One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n = 79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n = 81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications.

Results

Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 [SD 2.4]; PAI group: 3.0 [SD 2.2]; 95% confidence interval, −0.8 to 0.6; p = 0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days [SD 0.65] versus 2.84 days [SD 1.34] for the PNB group; p = 0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents [SD 13.1]; PNB group: 4.6 mg [SD 9.1]; p < 0.001), but thereafter, there was no difference. More patients in the PNB group had sequelae of peripheral nerve injury (mainly dysesthesia) at 6-week followup (nine [12%] versus one [1%]; p = 0.009).

Conclusions

Patients receiving periarticular injections had similar pain scores, shorter lengths of stay, less likelihood of peripheral nerve dysesthesia, but greater narcotic use on the day of surgery compared with patients receiving peripheral nerve blocks. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks.

Level of Evidence

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

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

Similar content being viewed by others

References

  1. Abdallah FW, Brull R. Is sciatic nerve block advantageous when combined with femoral nerve block for postoperative analgesia following total knee arthroplasty? A systematic review. Reg Anesth Pain Med. 2011;36:493–498.

    Article  PubMed  Google Scholar 

  2. Affas F, Nygards E-B, Stiller C-O, Wretenberg P, Olofsson C. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthop. 2011;82:441–447.

    Article  PubMed Central  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  4. Ben-David B, Schmalenberger K, Chelly JE. Analgesia after total knee arthroplasty: is continuous sciatic blockade needed in addition to continuous femoral blockade? Anesth Analg. 2004;98:747–749.

    Article  PubMed  Google Scholar 

  5. Browne C, Copp S, Reden L, Pulido P, Colwell C Jr. Bupivacaine bolus injection versus placebo for pain management following total knee arthroplasty. J Arthroplasty. 2004;19:377–380.

    Article  PubMed  Google Scholar 

  6. 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.

    Article  PubMed  Google Scholar 

  7. Cappelleri G, Ghisi D, Fanelli A, Albertin A, Somalvico F, Aldegheri G. Does continuous sciatic nerve block improve postoperative analgesia and early rehabilitation after total knee arthroplasty? A prospective, randomized, double-blinded study. Reg Anesth Pain Med. 2011;36:489–492.

    Article  PubMed  Google Scholar 

  8. Carli F, Clemente A, Asenjo JF, Kim DJ, Mistraletti G, Gomarasca M, Morabito A, Tanzer M. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth. 2010;105:185–195.

    Article  CAS  PubMed  Google Scholar 

  9. Chaumeron A, Audy D, Drolet P, Lavigne M, Vendittoli P-A. Periarticular injection in knee arthroplasty improves quadriceps function [Erratum in Clin Orthop Relat Res. 2013;471:2042]. Clin Orthop Relat Res. 2013;471:2284–2295.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Cook P, Stevens J, Gaudron C. Comparing the effects of femoral nerve block versus femoral and sciatic nerve block on pain and opiate consumption after total knee arthroplasty. J Arthroplasty. 2003;18:583–586.

    Article  PubMed  Google Scholar 

  11. 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.

    CAS  PubMed  Google Scholar 

  12. 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.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Fajardo M, Collins J, Landa J, Adler E, Meere P, Di Cesare PE. Effect of a perioperative intra-articular injection on pain control and early range of motion following bilateral TKA. Orthopedics. 2011;34:354.

    PubMed  Google Scholar 

  14. Feibel RJ, Dervin GF, Kim PR, Beaule PE. Major complications associated with femoral nerve catheters for knee arthroplasty: a word of caution. J Arthroplasty. 2009;24:132–137.

    Article  PubMed  Google Scholar 

  15. Gibbs DMR, Green TP, Esler CN. The local infiltration of analgesia following total knee replacement: a review of current literature. J Bone Joint Surg Br. 2012;94:1154–1159.

    Article  CAS  PubMed  Google Scholar 

  16. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42:377–381.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Hunt KJ, Bourne MH, Mariani EM. Single-injection femoral and sciatic nerve blocks for pain control after total knee arthroplasty. J Arthroplasty. 2009;24:533–538.

    Article  PubMed  Google Scholar 

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

    Article  PubMed  Google Scholar 

  19. Klasen JA, Opitz SA, Melzer C, Thiel A, Hempelmann G. Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty. Acta Anaesthesiol Scand. 1999;43:1021–1026.

    Article  CAS  PubMed  Google Scholar 

  20. Koh IJ, Kang YG, Chang CB, Kwon SK, Seo ES, Seong SC, Kim TK. Additional pain relieving effect of intraoperative periarticular injections after simultaneous bilateral TKA: a randomized, controlled study. Knee Surg Sports Traumatol Arthrosc. 2010;18:916–922.

    Article  PubMed  Google Scholar 

  21. Lareau JM, Robbins CE, Talmo CT, Mehio AK, Puri L, Bono JV. Complications of femoral nerve blockade in total knee arthroplasty and strategies to reduce patient risk. J Arthroplasty. 2012;27:564–568.

    Article  PubMed  Google Scholar 

  22. 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.

    Article  PubMed  Google Scholar 

  23. Mahadevan D, Walter RP, Minto G, Gale TC, McAllen CJ, Oldman M. Combined femoral and sciatic nerve block vs combined femoral and periarticular infiltration in total knee arthroplasty: a randomized controlled trial. J Arthroplasty. 2012;27:1806–1811.

    Article  PubMed  Google Scholar 

  24. 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.

    Article  CAS  PubMed  Google Scholar 

  25. Mullaji A, Kanna R, Shetty GM, Chavda V, Singh DP. Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty: a prospective, randomized trial. J Arthroplasty. 2010;25:851–857.

    Article  PubMed  Google Scholar 

  26. Ng F-Y, Chiu K-Y, Yan CH, Ng K-FJ. Continuous femoral nerve block versus patient-controlled analgesia following total knee arthroplasty. J Orthop Surg. 2012;20:23–26.

    Google Scholar 

  27. Ritter MA, Koehler M, Keating EM, Faris PM, Meding JB. Intra-articular morphine and/or bupivacaine after total knee replacement. J Bone Joint Surg Br. 1999;81:301–303.

    Article  CAS  PubMed  Google Scholar 

  28. Salinas FV, Liu SS, Mulroy MF. The effect of single-injection femoral nerve block versus continuous femoral nerve block after total knee arthroplasty on hospital length of stay and long-term functional recovery within an established clinical pathway. Anesth Analg. 2006;102:1234–1239.

    Article  PubMed  Google Scholar 

  29. Sharma S, Iorio R, Specht LM, Davies-Lepie S, Healy WL. Complications of femoral nerve block for total knee arthroplasty. Clin Orthop Relat Res. 2010;468:135–140.

    Article  PubMed Central  PubMed  Google Scholar 

  30. Spreng UJ, Dahl V, Hjall A, Fagerland MW, Raeder J. High-volume local infiltration analgesia combined with intravenous or local ketorolac + morphine compared with epidural analgesia after total knee arthroplasty. Br J Anaesth. 2010;105:675–682.

    Article  CAS  PubMed  Google Scholar 

  31. Tammachote N, Kanitnate S, Manuwong S, Yakumpor T, Panichkul P. Is pain after TKA better with periarticular injection or intrathecal morphine? Clin Orthop Relat Res. 2013;471:1992–1999.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Tanaka N, Sakahashi H, Sato E, Hirose K, Ishii S. The efficacy of intra-articular analgesia after total knee arthroplasty in patients with rheumatoid arthritis and in patients with osteoarthritis. J Arthroplasty. 2001;16:306–311.

    Article  CAS  PubMed  Google Scholar 

  33. The Joint Comission. Facts about pain management. Available at: http://www.jointcommission.org/topics/pain_management.aspx. Accessed September 22, 2013.

  34. Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tonnesen EK, Soballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop. 2007;78:172–179.

    Article  PubMed  Google Scholar 

  35. Tripuraneni KR, Woolson ST, Giori NJ. Local infiltration analgesia in TKA patients reduces length of stay and postoperative pain scores. Orthopedics. 2011;34:173.

    PubMed  Google Scholar 

  36. 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.

    Article  PubMed  Google Scholar 

  37. Wegener JT, van Ooij B, van Dijk CN, Hollmann MW, Preckel B, Stevens MF. Value of single-injection or continuous sciatic nerve block in addition to a continuous femoral nerve block in patients undergoing total knee arthroplasty: a prospective, randomized, controlled trial. Reg Anesth Pain Med. 2011;36:481–488.

    Article  PubMed  Google Scholar 

  38. Yadeau JT, Goytizolo EA, Padgett DE, Liu SS, Mayman DJ, Ranawat AS, Rade MC, Westrich GH. Analgesia after total knee replacement: local infiltration versus epidural combined with a femoral nerve blockade: a prospective, randomised pragmatic trial. Bone Joint J. 2013;95:629–635.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Debra Ryan, our main study coordinator for this project, and Charles (“Scott”) Clarke and all the physical therapists involved in helping our patients postoperatively and collecting data on quadriceps function. Additionally, we also thank Sundeep Khosla MD.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA

    Mark J. Spangehl MD, Henry D. Clarke MD & Joshua L. Blocher PA-C

  2. Department of Clinical Research, Mayo Clinic Arizona, Scottsdale, AZ, USA

    Joseph G. Hentz MS

  3. Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, AZ, USA

    Lopa Misra MD & David P. Seamans MD

Authors
  1. Mark J. Spangehl MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Henry D. Clarke MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joseph G. Hentz MS
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Lopa Misra MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joshua L. Blocher PA-C
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. David P. Seamans MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mark J. Spangehl MD.

Additional information

Electronic data capture was supported by grant UL1 TR000135 (SK).

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.

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.

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 the Mayo Clinic Arizona, Phoenix, AZ, USA.

About this article

Cite this article

Spangehl, M.J., Clarke, H.D., Hentz, J.G. et al. The Chitranjan Ranawat Award: Periarticular Injections and Femoral & Sciatic Blocks Provide Similar Pain Relief After TKA: A Randomized Clinical Trial. Clin Orthop Relat Res 473, 45–53 (2015). https://doi.org/10.1007/s11999-014-3603-0

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11999-014-3603-0

Keywords

Search

Navigation