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TKA: Postoperative opiate use lowered by intraoperative periarticular LIA
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March 2015
TKA: Postoperative opiate use lowered by intraoperative periarticular LIA
Study Type:Therapy
OE Level Evidence:1
Journal Level of Evidence:N/A
Single periarticular local infiltration analgesia reduces opiate consumption until 48 hours after total knee arthroplasty. A randomized placebo-controlled trial involving 56 patients.
Acta Orthop. 2014 Dec;85(6):614-9.Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
60 patients undergoing primary total knee arthroplasty were randomized to receive either a periarticular local infiltration analgesia (LIA) with levobupivacaine, ketorolac, and adrenaline versus a placebo injection of saline. Oxycodone consumption, pain, and range of motion were measured over 48 hours postoperatively, and functional outcomes were evaluated 1 year following surgery. The results of this study suggest that LIA reduced cumulative oxycodone consumption over the first 24 postoperative hours, with effect mainly occurring within the first 6 hours after surgery. Knee range of motion was also greater at 6 hours in those who received LIA, though no significant differences were detected at 24 and 48h. Functional outcomes were similar between groups at 1 year.
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.
4/4
Randomization
3/4
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?
Multimodal pain management in total knee arthroplasty aims to reduce opiate use and its inherent side effects. The role of local infiltration analgesia (LIA) in multimodal regimens has yet to be fully characterized within the knee arthroplasty arena. This study aimed to assess the effect of a single, intraoperative periarticular infiltration levobupivacaine, ketorolac, and adrenaline on postoperative pain and opioid consumption following TKA.
What was the principal research question?
Does a single, intraoperative periarticular infiltration of levobupivacaine, ketorolac, and adrenaline have a significant impact on oxycodone consumption following total knee arthroplasty?
Study Characteristics
-
Population:
60 patients (between 18 and 75 year old) undergoing standard primary total knee arthroplasty due to osteoarthritis. Exclusion criteria included rheumatoid arthritis, Patients with rheumatoid arthritis, >15 varus or valgus deformity, BMI >35 or previous high tibial osteotomy/osteosynthesis All cases were performed under spinal anaesthesia. All patients were begun on patient-controlled analgesia (oxycodone) postoperatively (2mg; 8min lockout).
Intervention:
LIA group: Patients received intraoperative administration of periarticular local infiltration analgesia using a 100mL solution of 150 mg levobupivacaine, 30 mg ketorolac and 0.5 mg adrenaline (n=27, 26 completed follow up; 12M/15F) (Mean age: 65 +/- 4.9)
Comparison:
Placebo group: Patients received intraoperative administration of 100mL of isotonic saline periarticularly (n=29, 25 completed follow up; 15M/14F) (Mean age: 64 +/- 6.7)
Outcomes:
The primary outcome was oxycodone consumption over 48 hours postoperatively. Secondary outcomes include functional outcome through the Total Knee Function Questionnaire (TKFQ), Oxford Knee Score (OKS), High-Activity Arthroplasty Score (HAAS). The 15D quality-of-life instrument was used for prospective outcome analysis.
Methods:
RCT; Double blind; Placebo-controlled; Single-centre.
Time:
Oxycodone consumption was measured after 48 hours postoperatively. Total Knee Function Questionnaire (TKFQ), Oxford Knee Score (OKS), High-Activity Arthroplasty Score (HAAS) were measured 1 year following the study. Follow up with a physiotherapist occurred 3 months postoperatively and the 15D instrument was used preoperatively, at 3 months, and at 1 year following surgery.
What were the important findings?
- Cumulative oxycodone consumption for the first 24 hours after surgery was significantly lower in the LIA group than in the placebo group; oxycodone consumption in the LIA group was 17mg lower than the placebo group after 6h (p<0.001), 20mg lower after 12h (p<0.001), and 28mg lower after 24h (p=0.03).
- Time interval-based oxycodone consumption was significantly lower in the LIA group compared to the placebo group from 0-6h (p<0.001), though differences were not statistically significant for 6-12h (p=0.09), 12-24h (p=0.1), or 24-48h (p=0.04) time intervals.
- Median VAS scores of <3 were considered an adequate level of pain management. This was achieved in both groups 48 hours potsoperatively. Groups did not demonstrate statistically significant differences at any time point (all p>0.05).
- Mean range of motion (ROM) at 6 hours was significant greater in the LIA group compared to the placebo group (26deg difference; p<0.001). Groups did not significantly differ in knee ROM at 24h (p=0.08) or 48h (p=0.6).
- Functional outcomes between groups at 1 year follow up were not significantly different between groups, as measured by HAAS, OKS and 15D quality-of-life instrument.
What should I remember most?
In total knee arthroplasty, total consumption of oxycodone over the first 24 hours postoperatively was significant lowered by the use of a single intraoperative infiltration containing levobupivacaine, ketorolac, and adrenaline when compared to those who received placebo. LIA effect was predominantly seen within the first 6 hours after surgery. LIA patients also improved early knee range of motion, although there was no functional difference between groups at 1 year postoperatively.
How will this affect the care of my patients?
The combined use of levobupivacaine, ketorolac, and adrenaline in a single, intraoperative paeriarticular infiltration in total knee arthroplasty appears to be beneficial in terms of lowering the use of patient-controlled opioids in the early postoperative period. The study suggests that local infiltration analgesia may be used as an adjunct to oral medical in patients undergoing total knee arthroplasty, though effects appear to be limited to analgesic outcomes immediately postoperatively. Future research should consider the possible impact of LIA in a multimodal regimen on rehabilitation progression and time to discharge.
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