Knee
Accelerated rehabilitation is a potential pathway for the motivated patient to quickly achieve functional recovery after joint replacement surgery. Improved peri-operative pain management techniques aim to facilitate this accelerated recovery whilst maximizing function and minimising the unpleasant aspect of joint replacement. Patient education undoubtedly has a crucial role in managing expectations and providing satisfactory preparation for the peri-operative period. As pain is a complex phenomenon, a multimodal approach seems logical in improving patient experience after total knee replacement (TKR). Pre-emptive analgesia, various anaesthetic techniques, postoperative pain medication and pain reducing adjuvants all have a role in attempting to minimise pain. ...
Although orthopaedic surgeons are involved in designing the pain management pathway following TKR; in general, anaesthetists are the ones in charge of organizing immediate pain-relief before, during and after surgery. Historically several techniques have been used for peri-operative analgesia, including general anaesthetic with postoperative opiates intravenously, epidurals with or without catheters, regional nerve blocks (femoral and/or sciatic) with or without continuous infusions postoperatively. All of these techniques are still in use and have a well defined and predictable failure and complication rate, such as systemic adverse affects (opiates), prolonged motor blocks1 (regional nerve blocks) just to name a few. They can also be time consuming and require significant expertise to perform safely and efficiently.
Intraoperative local infiltration analgesia (LIA) has recently been advocated for TKR handing the baton back to the orthopaedic surgeons. The use of LIA can provide simple, efficient pain relief with a low side effect profile, whilst avoiding the need for peripheral nerve blocks and/or catheters. Recent reviews2,3 aim to summarise available evidence on the routine use of LIA in comparison with other techniques. In analysing 29 randomised studies,3 admittedly there was variability in study design, including the way LIA applied (the lack of a standardised infiltration technique), exact LIA components and concentrations, standardisation of post-operative oral analgesia and outcome measures. The reviews nonetheless, advocate the use of a cocktail of high-dose ropivacaine, adrenaline and ketorolac delivered by systematic infiltration of all exposed tissues used as an adjunct to regional anaesthesia.
LIA is certainly a promising technique, that surgeons can apply quickly and safely, reducing anaesthetic time and costs without significantly compromising patient comfort. However, several questions still remain to be answered.4 What components in LIA are actually working, and at what dose? Should glucocorticoid be added5 and what is the role of NSAIDs?6 How does LIA compare with best potential alternatives (safety, efficacy, costs)? Can it reduce the time it takes to achieve recovery/physiotherapy goals and can it achieve a shorter length of stay? Answering these questions in well designed studies, will help establish, whether LIA will be a standalone analgesic technique in accelerated rehabilitation after TKR or an adjunct to a femoral nerve block.
Mr Krisztian Sisak, FRCS, Locum Consultant Orthopaedic Surgeon at the The Royal Bournemouth Hospital, UK
May 2013
References:
1. Kandasami M, Kinninmonth AWG, Sarungi M, Baines J, Scott NB. Femoral nerve block for total knee replacement — A word of caution. Knee 2009;16:98–100.
2. Kehlet H, Andersen LO. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011;55:778–84.
3. Gibbs DMR, Green TP, Esler CN. The local infiltration of analgesia following total knee replacement: A review of current literature. J Bone Joint Surg [Br] 2012;94-B:1154–9.
4. Raeder JC. Local Infiltration Analgesia for Pain After Total Knee Replacement Surgery: A Winner or Just a Strong Runner-Up? Anaesth Analg 2011; 113: 684-6.
5. Ikeuchi M, Kamimoto Y, Izumi M, et al. Effects of dexamethasone on local infiltration analgesia in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 2013;Jan 11 [Epub ahead of print].
6. Andersen KV, Nikolajsen L, Haraldsted V, Odgaard A, Søballe K. Local infiltration analgesia for total knee arthroplasty: should ketorolac be added? Br J Anaesth 2013;Mar 20 [Epub ahead of print].
