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Improved outcomes with infiltration and intraarticular injection following THA
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August 2013
Improved outcomes with infiltration and intraarticular injection following THA
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty: A randomized clinical trial of an intraarticular technique versus epidural infusion in 80 patients
Acta Orthop. 2007 Apr;78(2):180-6Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
80 patients with osteoarthritis undergoing total hip replacement surgery were randomized to receive a combination of infiltration with either a single intraarticular injection, or epidural infusion, to compare pain relief in individuals post-surgery. The findings indicated that infiltration with one intraarticular injection resulted in multiple benefits, including improved pain relief, reduced narcotic consumption, decreased occurrence of side effects, improved walking ability, as well as decreased time of hospital stay.
Publication Funding Details
+
Funding:
Not Reported
Conflicts:
None disclosed
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.
2/4
Randomization
2/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
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?
Following total hip replacements, post-operative relief can be provided through a variety of methods, some of which include intravenous analgesia, epidural analgesia, and peripheral nerve block techniques. With the goal of reducing the occurrence of side effects while still maintaining sufficient pain relief, the combination of local infiltration and single-shot injections has been introduced. Infiltration combined with a single-shot intraarticular injection in the hip joint has not been compared with epidural infusion. Therefore, this study was needed to investigate the effects of this combined technique on analgesia in patients undergoing a total hip replacement.
What was the principal research question?
Does the use of infiltration combined with a single-shot intraarticular injection result in increased analgesia and improved overall patient outcome postoperatively, as compared to epidural infusion, in patients undergoing a total hip replacement?
Study Characteristics
-
Population:
80 patients with osteoarthritis undergoing an elective total hip arthroplasty.
Intervention:
Intraarticular injection (Group A): During the first 20 postoperative hours, patients received analgesia using a combination of wound infiltration and a single-shot intraarticular injection at 8 hours postoperative. A solution consisting of 100mL ropivacaine 2mg/mL (Naropine), 1mL ketorolac 30mg/mL (Toradol) and 0.5mL epinephrine 1mg/mL (adrenaline) was loaded into two 50mL syringes. 50mL of the solution was used to infiltrate the deep tissues, while the remaining solution was used to infiltrate fascia, subcutaneous tissue and skin. A multihole 20-G epidural catheter was used, with the catheter tip placed intraarticularly. The injection solution consisted of 20 mL ropivacaine 7.5 mg/mL plus 1 mL ketorolac 30 mg /mL and 0.5 mL epinephrine 1mg/mL (n=40, 38 completed; Mean age: 62+/-14; 18 males).
Comparison:
Epidural infusion (Group E): During the first 20 postoperative hours, patients received analgesia through continuous epidural infusion. The epidural catheter was inserted at the level of the spinal block. Continuous epidural infusion of ropivacaine (2mg/mL) with morphine (5g/mL) was ensured using an electromechanical pump (n=40, 37 completed; Mean age: 61+/-13; 17 males).
Outcomes:
Outcomes included hip pain (measured by visual analogue scale; VAS), walking ability, modified Bromage scale, length of hospital stay, and recurrence of side effects.
Methods:
RCT
Time:
Pain assessments were completed by the patients from rest, up until 96 hours after surgery (at rest and during coughing [first 20hr post-op], and at rest and during walking [>20hr post-op]). Assessments were grouped in tiem periods of: 2-20h, 24-48h, and 52-96h. Walking ability assessed 8 hours post-operatively. Adverse events (ie. nausea) were measured at same time pain scores were recorded.
What were the important findings?
- Pain scores measured by VAS from 2 to 20 hours postoperative were similar between the two groups (p=0.2). However, pain scores in group A were significantly lower compared to group E in the 24-28 hour period (8 [IQR 12-33.5] vs. 20 [3.5-39]; p=0.02) and the 52-96 hour period (0 [IQR 0-0] vs. 11 [5.5-24]; p<0.001).
- During the first 20 hours patients in group A had reduced narcotic consumption compared to group E (17.4 mg [IQR 0-40.5] vs. 26 mg [IQR 21-52]; p=0.004). Total consumption over the 96 hour period was also significantly lower in group A vs group E (258 [IQR 167–366] vs. 324 [IQR 221–543]; p=0.05).
- Eight hours after surgery, walking ability was improved in group A in comparison to group E (33/38 vs. 13/37; p<0.001). Bromage scores also favoured group A over group E (p<0.001).
- Group A had a reduced length of hospital stay compared to Group E; 4.5 (IQR 3-6) and 7 (IQR 5.5-7), respectively (p<0.001).
- With the exception of nausea (p=0.1), group A had lower recurrence of vomiting (p=0.05), urinary retention (p=0.001), itch (p=0.01), and constipation (p<0.001). Additionally, 1 patient in each group developed deep vein thrombosis.
What should I remember most?
Patients who received the combination of wound infiltration and one intraarticular injection following total hip replacement, had reduced narcotic consumption, decreased occurrence of side effects, shorter length of stay in hospital, as well as improved walking ability, when compared to continuous epidural infusion.
How will this affect the care of my patients?
The results of this study indicated that the combination of wound infiltration with a single intraarticular injection provides numerous benefits to patients undergoing total hip arthroplasty. It is important to note that no conclusions were made regarding the risk for deep infection with this technique. Additional studies are needed to confirm these results.
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