Comparing Intraarticular vs Intramuscular Drug injection in Total Knee Arthroplasty

摘要

Periarticular injection with a multimodal protocol provides excellent pain control and functional recovery following total knee arthroplasty. We performed a retrospective study to compare intraarticular versus intramuscular injection of multimodal drugs versus a control group to provide analgesia following TKA. 150 patients undergoing TKA were divided into an intraarticular arm (Group 1, n=50), intramuscular arm (Group 2, n=50) and a control group 3 (n=50). Outcome measures include postoperative pain control and morphine consumption. Group 1 and Group 2 were similar in visual analog scores (p=0.99) and they were statistically significantly lower (p<.001) than the control group. Total morphine consumption was lower in the 2 groups when drugs were administered perioperatively (p<.001). Patients who received perioperative drug injections reported better visual analogue scores and required less patient controlled analgesia than patients in the control group. There appears to have no difference when we compare the intraarticular and intramuscular groups. Introduction Good perioperative pain relief in total knee arthroplasty has been shown to facilitate rehabilitation1, reduce hospital stay and improve patient satisfaction. Multiple modalities of analgesia have been described in the literature and each has its own advantages and risks. They include perioperative local drug infiltration23 and postoperative analgesia with parenteral opioids or epidural analgesia.The use of parental opioids or epidural analgesia is associated with side effects, including nausea and vomiting, respiratory depression, drowiness, reduced gut motility and urinary retention456. Busch7 reported that intraoperative periarticular injection with multimodal drugs can significantly reduce the requirements for patient- controlled analgesia. Parvatanei89 showed that periarticular injection with a multimodal protocol provides excellent pain control and functional recovery and can be substituted for conventional pain modalities. This mode of preemptive analgesia with soft tissue and intraarticular injection of long-acting local anesthetic with epinephrine and morphine has been shown to provide better pain control in the immediate postoperative period, decreases blood loss , and decrease the need for rescue narcotics and reversal agents10. To our knowledge, there is a paucity in the literature comparing the intraarticular and intramuscular drug injection in total knee arthroplasty. We performed a retrospective review to compare intraarticular versus intramuscular injection of multimodal drugs to provide analgesia following total knee arthroplasty and included a control group to establish that periarticular injection is safe and efficacious. Methods And Materials We retrospectively reviewed one hundred and fifty patients who underwent unilateral total knee arthroplasty. Date were retrieved via case notes and radiographs of the patients and analysed . They were grouped into 3 groups of fifty patients each. Group 1 and 2 consist of patients who received intraarticular and intramuscular injections respectively. Group 3 is a control group who received no injection into the joint or periarticular tissue.Inclusion criteria consisted of an age of less than eighty five years, a weight of 45 to 120 kg and an ability to provide informed consent. Exclusion criteria were revision total knee surgery, primary total knee with more than 20 degrees deformity or requiring extensive soft tissue release, primary total knee with significant boss loss that requires augmentation or stem, major psychological problems, allergies to any of the ingredients of the injection and previous drug dependency. Operative anesthesia was either general or regional. The knee arthroplasty was performed through a standard medial parapatellar approach. The drug injection consisted of 30 ml of 0.5% bupivacaine11 with adrenaline of 1:200,000, 40 ml of normal saline, 10 mg of morphine and 30 mg of non-steroidal an