Single Local Infiltration Analgesia (LIA) Aids Early Pain Management After Total Knee Replacement (TKR): An Evidence-Based Review and Commentary

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Abstract

<div class="section"> <a class="named-anchor" id="d1025948e105">  </a> <h5 class="section-title" id="d1025948e106">Background</h5> <p id="Par1">There is controversy in the literature regarding the role of single local infiltration analgesia (LIA) after total knee replacement (TKR). </p> </div><div class="section"> <a class="named-anchor" id="d1025948e110">  </a> <h5 class="section-title" id="d1025948e111">Questions/Purposes</h5> <p id="Par2">Is single LIA really efficient in controlling pain after TKR?</p> </div><div class="section"> <a class="named-anchor" id="d1025948e115">  </a> <h5 class="section-title" id="d1025948e116">Methods</h5> <p id="Par3">A Cochrane Library and PubMed (MEDLINE) search related to the justification LIA after TKR was analyzed. The main criteria for selection were that the articles were focused in the aforementioned question. </p> </div><div class="section"> <a class="named-anchor" id="d1025948e120">  </a> <h5 class="section-title" id="d1025948e121">Results</h5> <p id="Par4">Two hundred ninety-nine articles were found until February 9, 2017, but only 27 were selected and reviewed because they were focused on clinical experience with LIA following TKR. Fifteen of them were considered level of evidence (I-II) while 12 had a lower level of evidence (III-IV). LIA reduced the amount of perioperative opioid administration and enabled adequate pain management in conjunction with oral medication without adverse effects. No clinically marked effects on the functional outcome after TKR were detected. </p> </div><div class="section"> <a class="named-anchor" id="d1025948e125">  </a> <h5 class="section-title" id="d1025948e126">Conclusion</h5> <p id="Par5">Single dose LIA provides effective analgesia in the initial postoperative period after TKR in most randomized clinical trials, systematic reviews, and meta-analyses. </p> </div><div class="section"> <a class="named-anchor" id="d1025948e130">  </a> <h5 class="section-title" id="d1025948e131">Electronic supplementary material</h5> <p id="d1025948e133">The online version of this article (doi:10.1007/s11420-017-9560-x) contains supplementary material, which is available to authorized users. </p> </div>

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Most cited references 24

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Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review.

L Andersen, H Kehlet (2014)

In recent years, there has been an increasing interest in local infiltration analgesia (LIA) as a technique to control postoperative pain. We conducted a systematic review of randomized clinical trials investigating LIA for total knee arthroplasty (TKA) and total hip arthroplasty (THA) to evaluate the analgesic efficacy of LIA for early postoperative pain treatment. In addition, the analgesic efficacy of wound catheters and implications for length of hospital stay (LOS) were evaluated. Twenty-seven randomized controlled trials in 756 patients operated on with THA and 888 patients operated on with TKA were selected for inclusion in the review. In THA, no additional analgesic effect of LIA compared with placebo was reported in trials with low risk of bias when a multimodal analgesic regimen was administered perioperatively. Compared with intrathecal morphine and epidural analgesia, LIA was reported to have similar or improved analgesic efficacy. In TKA, most trials reported reduced pain and reduced opioid requirements with LIA compared with a control group treated with placebo/no injection. Compared with femoral nerve block, epidural or intrathecal morphine LIA provided similar or improved analgesia in the early postoperative period but most trials had a high risk of bias due to different systemic analgesia between groups. Overall, the use of wound catheters for postoperative administration of local anaesthetic was not supported in the included trials, and LOS was not related to analgesic efficacy. Despite the many studies of LIA, final interpretation is hindered by methodological insufficiencies in most studies, especially because of differences in use of systemic analgesia between groups. However, LIA provides effective analgesia in the initial postoperative period after TKA in most randomized clinical trials even when combined with multimodal systemic analgesia. In contrast, LIA may have limited additional analgesic efficacy in THA when combined with a multimodal analgesic regimen. Postoperative administration of local anaesthetic in wound catheters did not provide additional analgesia when systemic analgesia was similar and LOS was not related to use of LIA with a fast-track set-up.

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Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study.

Hari Parvataneni, Vineet P. Shah, Holly Howard … (2007)

In this prospective randomized study, patients undergoing total hip (THA) or knee arthroplasty (TKA) were randomized to either a study group receiving periarticular injections or a control group receiving patient-controlled analgesia with or without femoral nerve block (TKA patients). All patients received a comprehensive multimodal perioperative protocol. Pain, recovery of functional milestones, and overall satisfaction were assessed. The THA study group demonstrated significantly lower average pain scores and higher overall satisfaction than the control group. There was no significant difference in pain scores between the study and control groups in the TKA cohort. Both study groups demonstrated lower narcotic usage and side effects as well as improved early functional recovery. Periarticular injection with a multimodal protocol was shown to safely provide excellent pain control and functional recovery and can be substituted for conventional pain control modalities.

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Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial.

Enrique Gómez-Barrena, Miguel Ortega-Andreu, Norma G. Padilla-Eguiluz … (2014)

Abundant literature regarding the use of intravenous tranexamic acid (TXA) in primary total knee replacement is available. Randomized controlled trials have confirmed the efficacy of topical TXA compared with placebo, but the comparison between topical and intravenous TXA is unclear. The present study was designed to verify noninferior efficacy and safety of topical intra-articular TXA compared with intravenous TXA in primary total knee replacement with cemented implants.