PROSPECTIVE STUDY OF EFFICACY OF LOCAL INFILTRATION ANALGESIA IN

PATIENTS UNDERGOING TOTAL KNEE REPLACEMENTS

INTRODUCTION
Total joint replacement is the commonest elective surgery carried out in western
countries. In recent times joint replacements have become popular in our country too. The
economic burden is tremendous for such surgeries especially with regard to hospital stay,
financial implications, post operative complications & early return to usual activity both for the
patients and their relatives. One of the most common indications for TKR is pain of prolonged
duration. Joint movement & ability to walk is markedly impaired due to pain.
For the majority of patients with chronic arthritis, joint replacement is a successful
intervention for relieving chronic joint pain. TKR is associated post-operatively with
considerable pain and analgesic requirements (NIH clinical trials ). Some patients continue to
experience chronic pain after joint replacement and evidence suggests that a risk factor for this
is the severity of acute post-operative pain. In the context of TKR, post-operative pain
management needs to provide effective pain relief, while allowing for early mobilization
ambulation and rehabilitation.
Arthrofibrosis and diminished range of movements are closely related to degree of post
operative pain. (Ranawat 2003, Singelyn 1998 )
Analgesics Opioids and NSAIDS are the main drugs used for post-operative pain relief.
Each group has its own advantages and disadvantages. Local anaesthetic drugs used either
epidurally (through pump, for continuous analgesia ) or local infiltration also play an important
role for immediate post-operative ( first 3 -4 days ) pain relief . Continuous epidural analgesia
using pump has inherent disadvantages hypotension , urinary retention, DVT, epidural catheter
complications, delayed ambulation, need to use anticoagulants , more expensive equipments and
prolonged hospital stay.
LIA overcomes some of these disadvantages. It is cheaper allows early mobilization and
ambulation, there by obviating requirement of anticoagulants, preventing systemic
complications and early discharge from hospital.

Vikki et.al 20(2011 ) concluded that LIA implementation in clinical practice could
reduce the severity of chronic pain after TKR.
B.Garcia Benitez et.al 4( 2009 ) compared three types of post-operative analgesia
epidural catheter, Intradural analgesia along with femoral block and LIA.

REVIEW OF LITERATURE
One of the inevitable post-operative problems faced by patients is pain after total joint
replacements. Patients are likely to experience severe pain as a result of the inflammatory
response of the body that follows surgical trauma inflicted by the various steps carried out
during the procedure. Often post-operative pain is much more severe than the preexisting
disability. This is more excruciating in the immediate post-operative period and can hamper
early mobilization and ambulation besides increasing hospital stay, morbidity and lesser
patient satisfaction.
Therefore satisfactory pain control is the corner stone in successful rehabilitation of
patients undergoing total knee replacements.
B.Garica- Benitez et.al 4 ( 2009 ) Carried out a prospective randomised study using
three types of post-operative analgesia.
Group 1 Epidural catheter
Group 2 Intradural analgesia + femoral block
Group 3 Periarticular infiltration with an analgesic cocktail before incision closure.
They included 90 consecutive TKRs performed between May & December 2006. They
observed that periarticular infiltration with analgesic cocktail before incision closure is a
good treatment option for post-operative pain in TKR
Coolican Myles RJ et.al 7 (2011) studied about the efficacy of femoral nerve block + LIA
with LIA alone in the post-operative pain management following TKR . They studied 56
patients and concluded that there is no significant additive effect of femoral nerve block over
simple wound infiltration, other than reduced fentanyl consumption in the first 24hrs postoperatively.
Kerr DR, Kohan L

11

( 2008 ) conducted a study for the control of acutepostoperative

pain following knee surgeries on 325 patients using LIA. They observed that LIA is simple ,
practical, safe & effective for pain management after TKR surgery.

Pain control was

satisfactory. Most patients were able to walk with assistance between 5 6 hrs after surgery and
independent mobility was achieved 13 22 hrs. after surgery.

In 2010 Martin Thorsell et.al

14

did a prospective study comparing LIA and epidural

analgesia. They studied post-operative morphine consumption, ROM, walking ability, patient
satisfaction, hospital stay and time in recovery room in 85 patients. They observed that LIA
technique is better for post-operative pain relief in TKR than epidural anaesthesia. LIA not only
offers equal pain relief as that of epidural anaesthesia but also faster mobilization and more
patient satisfaction than epidural anaesthesia .
S.J Fowler et.al 17 (2008 ) did a comparative study on epidural analgesia with peripheral
nerve blockade.

They

found that there is no difference in pain intensity and opioid

consumption between the two but the treatment failure rate for epidural was 7.7% and for PNB
is 3.0%. The patient satisfaction is higher in PNB.
Vikki et.al 20 (2011 ) studied the effect of LIA on chronic pain after lower limb joint
replacement. They concluded that LIA is a cost effective intervention and its implementation in
clinical practice could reduce the severity of chronic pain after TKR, and therefore improve long
term pain outcomes for patients undergoing lower limb joint replacements.

AIMS AND OBJECTIVES

To study the efficacy of Local Infiltration Analgesia in patients undergoing unilateral TKR
for varus deformity on the following parameters.
1) Immediate (first 3-4 days ) post operative pain relief
2) Early mobilisation and ambulation
3) The requirement of rescue analgesia.

MATERIAL AND METHODS

This prospective study will be carried out in patients undergoing unilateral TKR for
varus deformity at St.James hospital Chalakudy from July 2012 to October 2013.
Patient Selection :
* Eligibility criteria
-

Patient scheduled for unilateral TKR for varus deformity

Consent for spinal or epidural anaesthesia / LIA.

ASA grade I to III

* Exclusion Criteria:
-

Patient refusal

Mini mental score < 25

Skin lesions or infection at the site of injection

Uncorrected renal dysfunction

Coagulation disorders

Chronic pain condition other than knee pain

Bilateral TKR

TKR in valgus knees

No pre-emptive analgesia will be

given.

TKR

to be

performed using standard

techniques. Patients will receive LIA mixture containing 300mg Ropivacaine ( 250mg in
patients less than 55kg ), 30mg of Ketorolac, 500gm of epinephrine diluted to 130- 150 ml and
injected over a period of 45 60 minute as follows: LIA mixture of 30-50ml is first injected
into posterior capsule of knee joint after making bone cuts followed by another injection of 35
50ml into the deep tissues around medial and lateral collateral ligaments after fixation of
components and torniquet release. The last injection of 35-50ml into the subcutaneous tissue
and adjoining anteromedial/ anterolateral capsule.
Before wound closure, a 19G catheter will be placed into the joint medially and going
posteromedially entering through Vastus Medialis Obliquous and exiting subcutaneously
away from incision approximately 3 inches away from joint and fixed to skin . The catheter
will be filled with an antibacterial filter and packed in separate sterile dressing. 20-24 hrs.

post operatively the surgical field will be reinjected with approximately 20ml of LIA mixture
through the catheter and the catheter will be removed.
Post operatively all patients will be given combination of Paracetamol 400mg with
Dextropropoxyphene 32.5mg

thrice daily, Trypsin - Chymotrypsin 10mg thrice daily

Omeprazole 20mg once daily for first 5 days and injections of Lornoxicam 8mg twice daily
for first 2 days. All patients will receive LMV Heparin for 1 week starting from 24hrs postoperatively.
Standard post-operative protocols will be followed for all patients.
Parameters assessed.
Pain on VAS scale, ROM, Ambulation with support & without support at 6-8hrs, 24hrs,
48hrs & 72hrs. The need for rescue analgesia ( opioids ) and over all patient satisfaction will
also be assessed.

STUDY PROFORMA
1. Case serial no
2. Name of patient
3. Age
4. Sex
5. Hospital O.P and I.P. No.
6. Address
7. Date of admission
8. Physical examination
- General examination
- Systemic examination
* CVS
* RS
* CNS
* Per Abdomen
- Regional Examination
9. Investigations:
-

Blood Hb, TC, DC, ESR, BT, CT, Blood Sugar, Blood group , Rh factor, Du
factor,PTT,INR,CRP, Urea, Creatinine, Sodium , Potassium and Serum Chemistry.

Urine Protein, sugar, microscopy

HIV, HBsAg,

ECG

X-ray - Chest, knee joints ,Scanogram

Other special investigations RA factor, Uric acid, Thyroid Function Tests.

10. Final Diagnosis

11. Treatment
12. Post-operative Analgesia
6 - 8 hrs

24hrs

48hrs

72hrs

VAS Scale
ROM
Ambulation

with support

without support

Rescue Analgesia
Patient satisfaction

13. Visual Analog Scale (VAS)

No Pain

10

Worst
Possible pain

REFERENCES
1. Andersen L, Huested H, Otte KS, Kristensen BB, Kehlet H- High volume infilterative
analgesia in TKR. Acta Anaesthesiolo Scand, 2008; 52 (10 ): 1331 1335
2. Barrington MJ, Olive D, Low K, Scott DA, Brittain J, Choong P- Continous femoral
nerve blockade or epidural analgesis after TKR, Anesth Analg, 2005 ; 101 (6) : 1824 1829.
3. Bush CA, Shore BJ, Bhandari R, et.al-Efficacy of periarticular multimodal drug
injection in TKR. J Bone Joint Surg Am. 2006; 88 (5) 959 963
4. B.Garcia- Benitez, V.Coronado Hijon, M.Villa Gil, M. Cintada-Aviles and F.
Baquera- Garces-Randomised prospective study of three methods of post-operative
analgesia in TKR, J.Bone Joint Surg Br 2009, Vol, 91-B no, Supp II 322.
5. Choi PT, Bhandari M, Scott J, Douketis J- Epidural analgesia for pain relief following
hip & knee replacement, Cochrane Database Syst Rev 2003; (3) CDOO3071
6. Campbell A, McCormick M, McKinlay K, Scott NB- Epidural versus lumbar plexus
infusions following TKR. Eur J Anaesthesiol. 2008; 25 ( 6 ) : 502 507.
7. Coolican Myles RJ, Parker David A, Patullo Gavin- The efficacy of Femoral Nerve
Block with local anaethetic wound infilteration compared to local anaesthetic alone to
manage post-operative pain following TKA, ISAKOS, 8th Biennial Scientific Meeting
Rio De Janeiro, 2011.
8. Deweese FT, Akbari Z, Carline E- Pain control after TKR. Intra-articular versus
epidural anaesthesia, Clin Orthop Relat Res. 2001; ( 392 ) : 226 231.
9. Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A- Reduced hospital
stay, morphine consumption and pain intensity with local infiltration analgesia after
unicompartmental knee arthroplasty. Acta Orthopaedica 2009, 80 (2 ) : 213 219.
10. Gomez Cardero P, Rodriguez- Merchan EC- Post-operative analgesia in TKA:
Ropivacaine continuous intra-articular infusion. Clin Orthop Relat Res 2010, 468 (5 ) :
1242 1247.
11.Kerr DR, KohanL- Local infiltration analgesia: a technique for the control of acute
post- operative pain after knee & hip surgery ; Acta Orthop, 2008; 79 (2) : 174 183.
12. Lombardi AV Jr Berend KR, Mallory TH, Dodds KL, Ada-ms JB- Soft tissue &
intraarticular injection of bupivacaine, epinephrine & morphine has a beneficial effect
after TKR, Clin Orthop Relat Res. 2004; (428) : 125 130
13. Liu SS, Richman JM, Thirlby RC, Wu CL- Efficacy of continuous wound catheters
delivering local anesthetic for post-operative analgesia. JAM Coll Surg 2006 , 203 ( 6 ) :
914 932.

14. Martin Thorsell, Petter Holst, Hans Christian Hyldahl, Lars Weidenhielm- A prospective
study comparing local infiltrative anesthesia and epidural anesthesia, Orthopedics 33
(2), 75-80 ( Feb 2010)
15. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS- Controlling
pain after total hip & knee arthroplasty, using a multimodal protocol with local
periarticular injections: The journal of arthroplasty 2007 , 22 ( 6 suppl) : 33 38.
16. Rasmuseen S, Kramhoft MU, Sperling KP, Pedersen JH- Increased flexian and reduced
hospital stay with continuous intra-articular morphine & ropivacaine after primary TKR.
Acta Orthop Scand 2004; 75 (5 ) 606 609.
17. S.J. Fowler, J. Symons, S.Sabato and P.S. Myles- Comparative study on epidural
analgesia with peripheral nerve blockade. British journal of anesthesia, 100 (2 ): 154-64
( 2008 ).
18. Toftdahl K, NikolajsenL, Haraldsted V, Madsen F, Tonnesen EK, Soballe K- Comparision
of peri & intraarticular analgesia with femoral nerve block after TKR . Acta Orthopedica
2007 , 78 (2 ) : 172 - 179
19. Vendittoli PA, Makinen P, Drolet P, et.al- A multimodal analgesia protocol for TKR. J.
Bone joint Surg Am, 2006 ; 88 (2) : 282 289
20. Vikki Wylde 1, Rachacl Gooberman Hill 1, Jeremy Horwood 1,2,et.al- The effect of
local anaesthetic wound infiltration on chronic pain after lower limb joint replacement,
BMC Musculoskeletal disorders 2011, article / 10. 1186 / 1471 / 2474/12 /53.