Peripheral nerve block, periarticular injection relieved pain within 3 days of TKA

No significant difference was found by postoperative day 2 in patients’ opioid consumption among three pain modalities.

Use of either peripheral nerve block, periarticular injection with ropivacaine, or periarticular injection with liposomal bupivacaine provided good pain relief after total knee arthroplasty, based on a recent presentation.

“All three pain modalities in a contemporary practice resulted in satisfactory pain relief,” Matthew P. Abdel, MD, said at the American Association of Hip and Knee Surgeons Annual Meeting. “In a comparative analysis, peripheral nerve block provided the best pain relief when looking at maximal pain relief, lowest mean pain scores and lowest use of opioid consumption and this was statistically better than periarticular injection with liposomal bupivacaine, but no significant difference when compared to periarticular injection with ropivacaine,” he said.

Matthew P. Abdel

Pain differences noted

Abdel and his colleagues randomly assigned 165 patients undergoing total knee arthroplasty to receive peripheral nerve block, periarticular injection with ropivacaine or periarticular injection with liposomal bupivacaine. They collected information about the differences in pain and opioid consumption.

The results showed no significant differences in the maximum pain score on postoperative day 1 between peripheral nerve block and periarticular injection with ropivacaine. However, there was a slight difference in the maximum pain score between the peripheral nerve block and the periarticular injection with liposomal bupivacaine.

Periarticular injections were done with either liposomal bupivacaine or ropivacaine, but results showed a peripheral nerve block provided patients undergoing total knee arthroplasty with the best pain relief.

Source: Abdel MP

“Our second outcome was looking at mean pain scores on postoperative day 2,” Abdel said. “As noted here, there was no significant difference between the three groups.”

Opioid consumption results

Abdel noted patients in the peripheral nerve block group had significantly less opioid consumption on postoperative day 0 vs. patients in both periarticular groups.

“On postoperative day 1, peripheral nerve block did better, but only [better] than periarticular injection with liposomal bupivacaine,” he said. “It was virtually equivalent statistically to periarticular injection with ropivacaine.”

However, by postoperative day 2, there was no significant difference in opioid consumption between the three groups, according to Abdel, who noted two patients in the peripheral nerve block group had in-hospital falls vs. none in the periarticular groups. However, one patient in each periarticular group experienced a fall after they left the hospital.

Despite the study limitation that periarticular injections were performed by multiple surgeons, Abdel contends this was a strong study, level 1 randomized clinical trial. He said the decision about which modality to use should be made between the surgeon, anesthesiologist and patient.

“I think the next step would be probably looking at a combination of the … periarticular injections with a limited peripheral nerve block, such as an adductor canal block,” Abdel told Orthopedics Today. – by Casey Tingle

Reference:

Abdel MP, et al. Paper #5. Presented at: American Association of Hip and Knee Surgeons Annual Meeting; Nov. 10-13, 2016; Dallas.

For more information:

Matthew P. Abdel, MD, can be reached at 200 First St. SW, Rochester, MN 55905; email: abdel.matthew@mayo.edu.

Disclosure: Abdel reports no relevant financial disclosures.