Analgesia after total knee replacement: local infiltration versus epidural combined with a femoral nerve blockade

A prospective, randomised pragmatic trial

J. T. YaDeau, E. A. Goytizolo, D. E. Padgett, S. S. Liu, D. J. Mayman, A. S. Ranawat, M. C. Rade, G. H. Westrich

Abstract

In a randomised controlled pragmatic trial we investigated whether local infiltration analgesia would result in earlier readiness for discharge from hospital after total knee replacement (TKR) than patient-controlled epidural analgesia (PCEA) plus femoral nerve block. A total of 45 patients with a mean age of 65 years (49 to 81) received a local infiltration with a peri-articular injection of bupivacaine, morphine and methylprednisolone, as well as adjuvant analgesics. In 45 PCEA+femoral nerve blockade patients with a mean age of 67 years (50 to 84), analgesia included a bupivacaine nerve block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics. The mean time until ready for discharge was 3.2 days (1 to 14) in the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral nerve blockade group. The mean pain scores for patients receiving local infiltration were higher when walking (p = 0.0084), but there were no statistically significant differences at rest. The mean opioid consumption was higher in those receiving local infiltration.

The choice between these two analgesic pathways should not be made on the basis of time to discharge after surgery. Most secondary outcomes were similar, but PCEA+femoral nerve blockade patients had lower pain scores when walking and during continuous passive movement. If PCEA+femoral nerve blockade is not readily available, local infiltration provides similar length of stay and similar pain scores at rest following TKR.

Cite this article: Bone Joint J 2013;95-B:629–35.

Footnotes

  • The additional members of HAARC (HSS (Hospital for Special Surgery) Anaesthesia ARJR (Adult Reconstruction and Joint Replacement) Research Collaboration) are as follows: D. D. Bhagat, R. L. Khan, M. M. Alexiades, K. M. Jules-Elysee, C. S. Ranawat, E. P. Su, Y. Lin, J. Liu, and A. K. Goon. Portions of this work have been presented at the American Academy of Orthopaedic Surgeons Annual Meeting, February 2012, in San Francisco, California.

    The authors would like to thank Dr H. Bang, Department of Public Health, Weill Medical College of Cornell University, performed a power analysis. Dr Bang and P. J. Christos, DrPH, MS, performed statistical analysis and advised on data preparation. They were partially supported by the following grants: Clinical Translational Science Center (CTSC) (UL1-RR024996) and Center for Education and Research in Therapeutics (CERTs) (AHRQ RFA-HS-05-14). The authors would also like to thank J. Liu, MD, PhD for his help with patient enrolment and data analysis, and A. Goon for assistance with manuscript preparation and data analysis.

    No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

    This article was primary edited by D. Rowley and first-proof edited by J. Scott.

  • Supplementary material. A table detailing the mean numerical rating scale scores for pain at each time point is available with the electronic version of this article on our website www.bjj.boneandjoint.org.uk

  • Received July 18, 2012.
  • Accepted January 17, 2013.
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