Download PDF
J Knee Surg 2022; 35(13): 1425-1433
DOI: 10.1055/s-0041-1723982
Original Article

Early Stage Versus Late Stage Periarticular Injection during Unicompartmental Knee Arthroplasty for Postoperative Pain Relief: A Randomized Controlled Trial

Wang Chen   *
1   Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
,
Jian-Ning Sun
1   Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
1   Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
,
Zheng-Hao Hu
1   Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
,
Yu Zhang
1   Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
,
Xiang-Yang Chen    **
1   Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
,
Shuo Feng   **
1   Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
› Author Affiliations Funding None.
› Further Information
    Permissions and Reprints

Abstract

Controlling postoperative pain after unicompartmental knee arthroplasty (UKA) is essential to improve patient satisfaction and promote early recovery. The purpose of this study was to investigate the difference in clinical efficacy between early and late stage periarticular injection during UKA for postoperative pain relief. Eighty-four patients meeting the inclusion and exclusion criteria were randomly divided into the early stage periarticular injection group and late stage periarticular injection group by using a random number tables method. The difference between the two groups was that the early stage periarticular injection group received superficial injection before the joint incision, while the late stage periarticular injection group received superficial injection after implantation of the prosthesis. Deep injection and other perioperative conditions of the two groups were controlled identically. The primary outcome of the study was the recovery room immediate visual analog scale (VAS) at rest. The secondary outcomes were the postoperative VAS (at rest) at 3, 6, 9, 12, 18, 24, 48, 72, 96, and 120 hours, drug dosage of rescue analgesia, range of motion (ROM), and complications. The recovery room immediate VAS (at rest) in the early stage periarticular injection group was significantly lower than that of the late stage periarticular injection group (21 ± 24 vs. 32 ± 34 mm, p = 0.018), the average difference of the VAS reached the minimal clinically important difference. No statistically significant difference in postoperative drug dosage of rescue analgesia, ROM, and complications. Preemptive analgesia combined with the early stage periarticular injection can better alleviate postoperative pain than the late stage periarticular injection.

Keywords

unicompartmental knee arthroplasty - periarticular injection - preemptive analgesia - pain - randomized controlled trial

Note

This study was approved by the Ethics Committee of Affiliated Hospital of Xuzhou Medical University. All participants signed an informed consent form.


Authors' Contributions

W.C. and J.-N.S. did the study and W.C. drafted the manuscript. Z.-H.H. and Y.Z. were involved in the design. X.-Y.C. and S.F. were involved in the study design and made further revision in this manuscript. All authors read and approved the final manuscript.


* Co-first authors.


** Co-corresponding authors.




Publication History

Received: 21 October 2020

Accepted: 02 January 2021

Article published online:
22 February 2021

© 2021. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Amin AK, Patton JT, Cook RE, Gaston M, Brenkel IJ. Unicompartmental or total knee arthroplasty?: results from a matched study. Clin Orthop Relat Res 2006; 451 (451) 101-106
    CrossrefPubMedGoogle Scholar
  • 2 Mont MA, Stuchin SA, Paley D. et al. Different surgical options for monocompartmental osteoarthritis of the knee: high tibial osteotomy versus unicompartmental knee arthroplasty versus total knee arthroplasty: indications, techniques, results, and controversies. Instr Course Lect 2004; 53: 265-283
    PubMedGoogle Scholar
  • 3 Volpi P, Marinoni L, Bait C, Galli M, Denti M. Lateral unicompartimental knee arthroplasty: indications, technique and short-medium term results. Knee Surg Sports Traumatol Arthrosc 2007; 15 (08) 1028-1034
    CrossrefPubMedGoogle Scholar
  • 4 Fuchs S, Rolauffs B, Plaumann T, Tibesku CO, Rosenbaum D. Clinical and functional results after the rehabilitation period in minimally-invasive unicondylar knee arthroplasty patients. Knee Surg Sports Traumatol Arthrosc 2005; 13 (03) 179-186
    CrossrefPubMedGoogle Scholar
  • 5 Tria Jr AJ. Minimally invasive total knee arthroplasty: past, present, and future. Am J Orthop 2007; 36 (9, Suppl): 6-7
    PubMedGoogle Scholar
  • 6 Migliorini F, Tingart M, Niewiera M, Rath B, Eschweiler J. Unicompartmental versus total knee arthroplasty for knee osteoarthritis. Eur J Orthop Surg Traumatol 2019; 29 (04) 947-955
    CrossrefPubMedGoogle Scholar
  • 7 Beswick AD, Wylde V, Gooberman-Hill R, Blom A, Dieppe P. What proportion of patients report long-term pain after total hip or knee replacement for osteoarthritis? A systematic review of prospective studies in unselected patients. BMJ Open 2012; 2 (01) e000435
    CrossrefPubMedGoogle Scholar
  • 8 Smith TO, Chester R, Glasgow MM. Accelerated rehabilitation following Oxford unicompartmental knee arthroplasty: five-year results from an independent centre. Eur J Orthop Surg Traumatol 2012; 22 (02) 151-158
    CrossrefPubMedGoogle Scholar
  • 9 Hurst JM, Ranieri R, Berend KR, Morris MJ, Adams JB, Lombardi Jr AV. Outcomes after arthroscopic evaluation of patients with painful medial unicompartmental knee arthroplasty. J Arthroplasty 2018; 33 (10) 3268-3272
    CrossrefPubMedGoogle Scholar
  • 10 Maheshwari AV, Blum YC, Shekhar L, Ranawat AS, Ranawat CS. Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center. Clin Orthop Relat Res 2009; 467 (06) 1418-1423
    CrossrefPubMedGoogle Scholar
  • 11 Tsukada S, Wakui M, Hoshino A. Pain control after simultaneous bilateral total knee arthroplasty: a randomized controlled trial comparing periarticular injection and epidural analgesia. J Bone Joint Surg Am 2015; 97 (05) 367-373
    CrossrefPubMedGoogle Scholar
  • 12 Bianconi M, Ferraro L, Traina GC. et al. Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery. Br J Anaesth 2003; 91 (06) 830-835
    PubMedGoogle Scholar
  • 13 Nakai T, Tamaki M, Nakamura T, Nakai T, Onishi A, Hashimoto K. Controlling pain after total knee arthroplasty using a multimodal protocol with local periarticular injections. J Orthop 2013; 10 (02) 92-94
    CrossrefPubMedGoogle Scholar
  • 14 Ranawat AS, Ranawat CS. Pain management and accelerated rehabilitation for total hip and total knee arthroplasty. J Arthroplasty 2007; 22 (07, Suppl 3): 12-15
    CrossrefPubMedGoogle Scholar
  • 15 Yadeau JT, Goytizolo EA, Padgett DE. et al. Analgesia after total knee replacement: local infiltration versus epidural combined with a femoral nerve blockade: a prospective, randomised pragmatic trial. Bone Joint J 2013; 95-B (05) 629-635
    CrossrefPubMedGoogle Scholar
  • 16 Kurosaka K, Tsukada S, Ogawa H, Nishino M, Yoshiya S, Hirasawa N. Comparison of early-stage and late-stage periarticular injection for pain relief after total hip arthroplasty: a double-blind randomized controlled trial. J Arthroplasty 2020; 35 (05) 1275-1280
    CrossrefPubMedGoogle Scholar
  • 17 Tsukada S, Kurosaka K, Maeda T, Iida A, Nishino M, Hirasawa N. Early stage periarticular injection during total knee arthroplasty may provide a better postoperative pain relief than late-stage periarticular injection: a randomized-controlled trial. Knee Surg Sports Traumatol Arthrosc 2019; 27 (04) 1124-1131
    CrossrefPubMedGoogle Scholar
  • 18 Mendell LM, Wall PD. Responses of single dorsal cord cells to peripheral cutaneous unmyelinated fibres. Nature 1965; 206: 97-99
    CrossrefPubMedGoogle Scholar
  • 19 Hirasawa N, Kurosaka K, Nishino M, Nakayama T, Matsubara M, Tsukada S. No clinically important difference in pain scores after THA between periarticular analgesic injection and placebo: a randomized trial. Clin Orthop Relat Res 2018; 476 (09) 1837-1845
    CrossrefPubMedGoogle Scholar
  • 20 Kurosaka K, Tsukada S, Nakayama H. et al. Periarticular injection versus femoral nerve block for pain relief after anterior cruciate ligament reconstruction: a randomized controlled trial. Arthroscopy 2018; 34 (01) 182-188
    CrossrefPubMedGoogle Scholar
  • 21 Saito M, Tsukada S, Fujita N. et al. Post-operative pain control following arthroscopic rotator cuff repair: peri-articular injection versus interscalene brachial plexus block. Int Orthop 2019; 43 (06) 1435-1441
    CrossrefPubMedGoogle Scholar
  • 22 Vinson-Bonnet B, Coltat JC, Fingerhut A, Bonnet F. Local infiltration with ropivacaine improves immediate postoperative pain control after hemorrhoidal surgery. Dis Colon Rectum 2002; 45 (01) 104-108
    CrossrefPubMedGoogle Scholar
  • 23 Tegon G, Pulzato L, Passarella L, Guidolin D, Zusso M, Giusti P. Randomized placebo-controlled trial on local applications of opioids after hemorrhoidectomy. Tech Coloproctol 2009; 13 (03) 219-224
    CrossrefPubMedGoogle Scholar
  • 24 Poylin V, Quinn J, Messer K, Nagle D. Gabapentin significantly decreases posthemorrhoidectomy pain: a prospective study. Int J Colorectal Dis 2014; 29 (12) 1565-1569
    CrossrefPubMedGoogle Scholar
  • 25 Stubhaug A, Breivik H, Eide PK, Kreunen M, Foss A. Mapping of punctuate hyperalgesia around a surgical incision demonstrates that ketamine is a powerful suppressor of central sensitization to pain following surgery. Acta Anaesthesiol Scand 1997; 41 (09) 1124-1132
    CrossrefPubMedGoogle Scholar
  • 26 Kissin I. Preemptive analgesia. Anesthesiology 2000; 93 (04) 1138-1143
    CrossrefPubMedGoogle Scholar
  • 27 Ong CK, Lirk P, Seymour RA, Jenkins BJ. The efficacy of preemptive analgesia for acute postoperative pain management: a meta-analysis. Anesth Analg 2005; 100 (03) 757-773
    CrossrefPubMedGoogle Scholar
  • 28 Busch CA, Shore BJ, Bhandari R. et al. Efficacy of periarticular multimodal drug injection in total knee arthroplasty: a randomized trial. J Bone Joint Surg Am 2006; 88 (05) 959-963
    CrossrefPubMedGoogle Scholar
  • 29 Weibel S, Jokinen J, Pace NL. et al. Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis. Br J Anaesth 2016; 116 (06) 770-783
    CrossrefPubMedGoogle Scholar
  • 30 Campbell WI, Patterson CC. Quantifying meaningful changes in pain. Anaesthesia 1998; 53 (02) 121-125
    CrossrefPubMedGoogle Scholar
  • 31 Farrar JT, Portenoy RK, Berlin JA, Kinman JL, Strom BL. Defining the clinically important difference in pain outcome measures. Pain 2000; 88 (03) 287-294
    CrossrefPubMedGoogle Scholar
  • 32 Dworkin RH, Turk DC, McDermott MP. et al. Interpreting the clinical importance of group differences in chronic pain clinical trials: IMMPACT recommendations. Pain 2009; 146 (03) 238-244
    CrossrefPubMedGoogle Scholar
  • 33 Kelly AM. The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J 2001; 18 (03) 205-207
    CrossrefPubMedGoogle Scholar
  • 34 Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med 2001; 38 (06) 633-638
    CrossrefPubMedGoogle Scholar
  • 35 Tashjian RZ, Deloach J, Porucznik CA, Powell AP. Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease. J Shoulder Elbow Surg 2009; 18 (06) 927-932
    CrossrefPubMedGoogle Scholar
  • 36 Farrar JT, Young Jr JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 2001; 94 (02) 149-158
    CrossrefPubMedGoogle Scholar
  • 37 Myles PS, Myles DB, Galagher W. et al. Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state. Br J Anaesth 2017; 118 (03) 424-429
    CrossrefPubMedGoogle Scholar
  • 38 Murata-Ooiwa M, Tsukada S, Wakui M. Intravenous acetaminophen in multimodal pain management for patients undergoing total knee arthroplasty: a randomized, double-blind, placebocontrolled trial. J Arthroplasty 2017; 32 (10) 3024-3028
    CrossrefPubMedGoogle Scholar
  • 39 American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012; 116 (02) 248-273
    CrossrefPubMedGoogle Scholar
  • 40 Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother 2013; 27 (01) 62-70
    CrossrefPubMedGoogle Scholar
  • 41 Sharma V, Morgan PM, Cheng EY. Factors influencing early rehabilitation after THA: a systematic review. Clin Orthop Relat Res 2009; 467 (06) 1400-1411
    CrossrefPubMedGoogle Scholar
  • 42 Wells G, Beaton D, Shea B. et al. Minimal clinically important differences: review of methods. J Rheumatol 2001; 28 (02) 406-412
    PubMedGoogle Scholar
  • 43 Tubach F, Ravaud P, Martin-Mola E. et al. Minimum clinically important improvement and patient acceptable symptom state in pain and function in rheumatoid arthritis, ankylosing spondylitis, chronic back pain, hand osteoarthritis, and hip and knee osteoarthritis: results from a prospective multinational study. Arthritis Care Res (Hoboken) 2012; 64 (11) 1699-1707
    CrossrefPubMedGoogle Scholar