Efficacy of Multimodal Analgesia With or Without Periarticular Infiltration in Total Knee Arthroplasty: Is Infiltration Worth the Risk? A Prospective Randomized Comparative Study
Abstract
Introduction: Postoperative pain following total knee arthroplasty (TKA) is a major clinical and surgical challenge. This study evaluated the efficacy of periarticular infiltration (PAI) as a key component of a multimodal analgesia protocol. Objective: To compare two multimodal pain management approaches in the immediate postoperative period following TKA. Materials and Methods: A prospective, randomized, controlled clinical trial was conducted in 130 patients with knee osteoarthritis. Patients were assigned to group 1 (multimodal analgesia plus PAI) or group 2 (multimodal analgesia alone). The primary outcomes were pain, rescue opioid consumption, time to ambulation, and length of hospital stay. Results: Patients in group 1 had better outcomes, with lower postoperative pain scores (0.88 ± 1.88 vs. 6.04 ± 0.90 at 24 hours; p < 0.0001), 63% lower tramadol consumption (66.41 ± 55.31 vs. 181.74 ± 57.71 mg; p < 0.0001), earlier ambulation (32 vs. 48 hours; p < 0.0001), a shorter hospital stay (72 vs. 76.19 hours; p = 0.0003), and less postoperative blood loss (229.77 ± 102.77 vs. 337.30 ± 91.61 mL; p < 0.0001). Conclusions: PAI provided superior analgesia and accelerated recovery without impairing muscle strength, unlike motor block-ade. Omitting the posterior capsule from the infiltration was safe and effective. PAI is a highly effective analgesic strategy in TKA that reduces pain and opioid consumption and improves postoperative outcomes. Its inclusion in standard protocols could transform pain management in TKA.Downloads
References
Nakai T, Tamaki M, Nakamura T, Nakai T, Onishi A, Hashimoto K. Controlling pain after total knee arthroplasty
using a multimodal protocol with local periarticular injections. J Orthop 2013;10(2):92-4. https://doi.org/10.1016/j.jor.2013.02.001
Jiang J, Teng Y, Fan Z, Khan Ms, Cui Z, Xia Y. The efficacy of periarticular multimodal drug injection for postoperative pain management in total knee or hip arthroplasty. J Arthroplasty 2013;28(10):1882-7. https://doi.org/10.1016/j.arth.2013.06.031
springer BD. Transition from nerve blocks to periarticular injections and emerging techniques in total joint
arthroplasty. Am J Orthop (Belle Mead NJ) 2014;43(10 suppl):s6-9. PMID: 25303457
Hebl JR, Dilger JA, Byer DE, Kopp sL, stevens sR, Pagnano MW, et al. A pre-emptive multimodal pathway
featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med 2008;33(6):510-7. PMID: 19258965
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(6):851-7. https://doi.org/10.1016/j.arth.2009.09.007
Kellgren JH, Lawrence Js. Radiological assessment of osteo-arthrosis. Ann Rheum Dis 1957;16(4):494-502.
https://doi.org/10.1136/ard.16.4.494
Dye sF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med 1998;26(6):773-7. https://doi.org/10.1177/03635465980260060601
Biedert RM, stauffer E, Friederich NF. Occurrence of free nerve endings in the soft tissue of the knee joint. A
histologic investigation. Am J Sports Med 1992;20(4):430-3. https://doi.org/10.1177/036354659202000411
Tran J, Peng PWH, Lam K, Baig E, Agur AMR, Gofeld M. Anatomical study of the innervation of anterior knee
joint capsule: Implication for image-guided intervention. Reg Anesth Pain Med 2018;43(4):407-14. https://doi.org/10.1097/AAP.0000000000000778
Lauretti GR, Righeti CCF, Mattos AL. Intrathecal ketorolac enhances intrathecal morphine analgesia following total knee arthroplasty. J Anaesthesiol Clin Pharmacol 2013;29(4):503-8. https://doi.org/10.4103/0970-9185.119155
Liu ss, Zayas VM, Gordon MA, Beathe JC, Maalouf DB, Paroli L, et al. A prospective, randomized, controlled trial comparing ultrasound versus nerve stimulator guidance for interscalene block for ambulatory shoulder surgery for postoperative neurological symptoms. Anesth Analg 2009;109(1):265-71. https://doi.org/10.1213/ane.0b013e3181a3272c
Campos-Flores D, Malpica-Ramírez LM, Cariño-Cepeda C, Fernández de Lara-Castilla LG, Gálvez-Romero JL.
Eficacia de la infiltración periarticular con anestésico local y adyuvantes para control del dolor postquirúrgico en la artroplastía total de rodilla. Acta Ortop Mex 2021;35(2):169-73. https://doi.org/10.35366/101861
spangehl MJ, Clarke HD, Hentz JG, Misra L, Blocher JL, seamans DP. The Chitranjan Ranawat Award: Periarticular injections and femoral & sciatic blocks provide similar pain relief after TKA: a randomized clinical
trial. Clin Orthop Relat Res 2015;473(1):45-53. https://doi.org/10.1007/s11999-014-3603-0
Chaumeron A, Audy D, Drolet P, Lavigne M, Vendittoli PA. Periarticular injection in knee arthroplasty improves
quadriceps function. Clin Orthop Relat Res 2013;471(7):2284-95. https://doi.org/10.1007/s11999-013-2928-4
Chung As, spangehl MJ. Peripheral nerve blocks vs periarticular injections in total knee arthroplasty. J Arthroplasty 2018;33(11):3383-8. https://doi.org/10.1016/j.arth.2018.08.006
Calisir C, simsek s, Tepe M. Variations in the popliteal artery branching in 342 patients studied with peripheral CT angiography using 64-MDCT. Jpn J Radiol 2015;33(1):13-20. https://doi.org/10.1007/s11604-014-0373-2
Guler O, Mutlu s, Isyar M, Mutlu H, Bulbul AM, Mahirogullari M. Efficacy of periarticular injection applied trough knee other than posterior capsule in simultaneous bilateral total knee arthroplasty. J Orthop 2015;12(4):205-10. https://doi.org/10.1016/j.jor.2015.05.012
Gardner E. The innervation of the knee joint. Anat Rec 1948;101(1):109-30. https://doi.org/10.1002/ar.1091010111
Terkawi As, Mavridis D, sessler DI, Nunemaker Ms, Doais Ks, Terkawi Rs, et al. Pain management modalities
after total knee arthroplasty: A network meta-analysis of 170 randomized controlled trials. Anesthesiology 2017;126(5):923-37. https://doi.org/10.1097/ALN.0000000000001607
Busch CA, shore BJ, Bhandari R, Ganapathy s, MacDonald sJ, Bourne RB, et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. J Bone Joint Surg Am 2006;88(5):959-63.
https://doi.org/10.2106/JBJs.E.00344
Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, et al. A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Joint Surg Am 2006;88(2):282-9.
https://doi.org/10.2106/JBJs.E.00173
Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK, søballe K. Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop 2007;78(2):172-9. https://doi.org/10.1080/17453670710013645
Duensing I, Peters CL, Monteiro P, Anderson MB, Pelt CE. Higher incidence of manipulation under anesthesia
following TKA associated with the periarticular infiltration of a liposomal bupivacaine cocktail compared to a
modified Ranawat cocktail. J Orthop Surg 2020;28(1):2309499020910816. https://doi.org/10.1177/2309499020910816
Barrington JW, Emerson RH, Lovald sT, Lombardi AV, Berend KR. No difference in early analgesia between
liposomal bupivacaine injection and intrathecal morphine after TKA. Clin Orthop Relat Res 2017;475(1):94-105.
https://doi.org/10.1007/s11999-016-4931-z
Pinsornsak P, Nangnual s, Boontanapibul K. Multimodal infiltration of local anaesthetic in total knee arthroplasty; is posterior capsular infiltration worth the risk? a prospective, double-blind, randomised controlled trial. Bone Joint J 2017;99-B(4):483-8. https://doi.org/10.1302/0301-620X.99B4.BJJ-2016-0877.R1
Manuscript acceptance by the Journal implies the simultaneous non-submission to any other journal or publishing house. The RAAOT is under the Licencia Creative Commnos Atribución-NoComercial-Compartir Obras Derivadas Igual 4.0 Internacional (CC-BY-NC.SA 4.0) (http://creativecommons.org/licences/by-nc-sa/4.0/deed.es). Articles can be shared, copied, distributed, modified, altered, transformed into a derivative work, executed and publicly communicated, provided a) the authors and the original publication (Journal, Publisher and URL) are mentioned, b) they are not used for commercial purposes, c) the same terms of the license are maintained.
In the event that the manuscript is approved for its next publication, the authors retain the copyright and will assign to the journal the rights of publication, edition, reproduction, distribution, exhibition and communication at a national and international level in the different databases. data, repositories and portals.
It is hereby stated that the mentioned manuscript has not been published and that it is not being printed in any other national or foreign journal.
The authors hereby accept the necessary modifications, suggested by the reviewers, in order to adapt the manuscript to the style and publication rules of this Journal.
