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Intraarticular ropivacaine infusion reduces pain intensity during mobilization after TKA

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Author Verified

Intraarticular ropivacaine infusion reduces pain intensity during mobilization after TKA

Vol: 2| Issue: 7| Number:245| ISSN#: 2564-2537
Study Type:Therapy
OE Level Evidence:1
Journal Level of Evidence:N/A

Intraarticular vs. extraarticular ropivacaine infusion following high dose local infiltration analgesia after total knee arthroplasty

Acta Orthop. 2011 Dec;82(6):692-8. Epub 2011 Oct 25

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Synopsis

36 patients with rheumatoid arthritis undergoing total knee arthroplasty were randomized to receive either intra-articular or extra-articular continuous infusion of local anaesthetics. Patients were assessed in terms of patient-controlled analgesia consumption and pain intensity during mobilization. The results demonstrate that patients receiving intra-articular infusion had decreased pain intensity during first exercises compared to the extra-articular infusion group. These findings indicate the potential for improving post-operative mobilization. However, there were no differences in pain relief at rest between the two treatment groups.

Publication Funding Details +
Funding:
Non-Industry funded
Sponsor:
Southern Region Healthcare Committee, Sweden.
Conflicts:
None disclosed

Risk of Bias

8/10

Reporting Criteria

20/21

Fragility Index

N/A

Was the allocation sequence adequately generated?

Was allocation adequately concealed?

Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?

Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?

Blinding Patients: Was knowledge of the allocated interventions adequately prevented?

Was loss to follow-up (missing outcome data) infrequent?

Are reports of the study free of suggestion of selective outcome reporting?

Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?

Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?

Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.

4/4

Randomization

3/4

Outcome Measurements

4/4

Inclusion / Exclusion

4/4

Therapy Description

5/5

Statistics

Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Approximately 66% of patients experience severe pain following total knee arthroplasty. Optimal pain relief must encompass an intervention that is delivered pre-operatively, peri-operatively, as well as post-operatively. Local infiltration and a single-shot injection or the continuous infusion of local anaesthetics is considered an effective alternative method to epidural analgesia and femoral block. Catheter insertion to facilitate continuous infusion of local anaesthetics, performed post-operatively, is an effective substitute for local infiltration. However, the optimal site of local anaesthetic administration is unknown, therefore, indicating the need for this study.

What was the principal research question?

What are the effects of either intra-articular or extra-articular continuous local anaesthetic infusion, on post-operative pain, in patients that have undergone total knee arthoplasty, measured at 48 hours?

Study Characteristics -
Population:
36 patients with rheumatoid arthritis scheduled to undergo total knee arthroplasty.
Intervention:
All patients received infiltration of 300mg ropivacaine, 30mg ketorolac and 0.5mg epinephrine. Further, these patients received intra-articular continuous infusion of 0.5% Ropivacaine (n=18).
Comparison:
Patients received infiltration of 300mg ropicavaine, 30mg ketorolac and 0.5mg epinephrine. Further, these patients received extra-articular continuous infusion of 0.5% Ropivacaine (n=18).
Outcomes:
Outcomes included consumption of patient-controlled analgesia (based on pain measured by VAS at rest and with motion). As well, pain intensity during mobilization was measured (VAS score by patients, Verbal Rating score by physiotherapists). Knee flexion, as well as toxicity symptoms, was measured.
Methods:
Randomized study; Double Blind
Time:
6 months total follow up. Outcomes measured at 48 hours post-operatively.

What were the important findings?

  • At 48 hours post-operatively, the overall patient-controlled analgesia consumption of morphine was similar between both treatment groups.
  • There was no difference in the VAS score between groups during rest or with movement.
  • There was greater physiotherapist satisfaction regarding the first mobilization in the patients receiving intra-articular infusion (p<0.05). At 48 hours post-operatively, patients receiving continuous intra-articular infusion with Ropivacaine had lower mean scores during exercise (p<0.07). Severe pain upon mobilization (VAS score greater than 7) occurred in 11 patients in the extra-articular group compared to 3 patients in the intra-articular group (p=0.03).
  • No toxic side effects or post-operative complications, resulting from wound healing, were observed.

What should I remember most?

Continuous intra-articular infusion with ropivacaine was effective in reducing pain intensity during first exercises. Therefore, early post-operative mobilization (within 24 hours post-op) could be improved following TKA. However, intra-articular infusion was not superior to extra-articular infusion with respect to pain relief at rest.

How will this affect the care of my patients?

Future studies with larger sample sizes are required to provide a more accurate comparison of outcomes between groups and to additionally compare complications rates.

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