No nerve blocks in joint arthroplasty – a service improvement?

Kerr DR & Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta orthopaedica 2008;  79: 174-183.

RHH Journal Club. April 18th, 2013. Dr Faizan Ahmad

Full-text article (if available)

Can local infiltration analgesia control of acute postoperative pain following knee and hip surgery?

Background

Pain post joint arthroplasty usually required hospitalisation more then 5 days. Prolonged hospital stay and relative immobilisation may invite nosocomial infection and DVT. This study developed a technique called “local infiltration analgesia” (LIA). It is based on infiltration of a mixture of ropivacaine, ketorolac, and adrenaline into the tissues around the surgical field to achieve satisfactory pain control which allows virtually immediate mobilization and earlier discharge from hospital.

Study design

  • Open, non-randomised case series from 1st Jan 2005 to 31st December 2006 in a single centre
  • Patients are from a single surgeon and single physician anaesthetist

Methods

Population

  • 365 patient who undergoing elective hip resurfacing (HRA) (185), primary total knee replacement (TKR) (86) and primary total hip replacement (THR) (54)

Intervention

  • Combined spinal (3.0ml bupivacaine 0.25% at L4/5) and light general anaesthesia used for all patients.
  • The injectant LIA mixture contained of Ropivacaine HCL 2.0 mg/ml, mixed with 30mg ketorolac and 10 mcg/ml adrenaline which diluted to higher volume (150-200 ml) used to flood surgical wound in stages during arthroplasty.
  • 18G portex epidural catheter was placed around the joint for re-injection
  • Ancillary measures was performed such as tourniquet released after implant implementation, compression bandage for TKR and elastic binder for THR, no urinary catheter and wound drain and no aminoglycosides antibiotic as well as ice pack over the incision for 4 hrs postoperatively for each patients.
  • Supplementary morphine with regular paracetamol, tramadol or codeine and ibuprofen regularly for 3 days was prescribed.
  • Re-injection 15 to 20 h postoperatively (50ml of RKA)

Outcome

  • This study does not compare LIA with other methods
  • Endpoint were pain score assessment, mobilisation time postoperatively, morphine usage and length of stay

Validity

  • This is a large number case series documenting outcomes and describing the techniques used.
  • All patient follow-up are completed up to 4 weeks postoperatively

Result

  • Pain scores was satisfactory (range 0-3 on numerical rating scale) both at rest and while walking. Higher pain score at 4 h were mostly related to incomplete block, tourniquet time and longer incision time
  • No patient required morphine after postoperative day
  • Average times to first walk were lowest for HRA (9 h) and highest for TKR patients (13h).
  • Patients in all categories were discharged directly home after a single overnight stay in hospital (HRA 89%, THR 41%, TKR 51%)
  • No serious side effect recorded first 10 days postoperatively, no catheter related infection
  • One elderly lady re-admitted for bleeding gastric ulcer 3.5 weeks postoperatively

Limitation

  • Single centre case series
  • Elective private patients with good social supports
  • Not comparing with other analgesic techniques

Conclusion/in practice

  • Highlighted the option available for pain control in primary hip and knee arthroplasty.
  • LIA is simple, safe, practical, effective and when combined with efficient residual pain management it can facilitates early discharge with possible reduction in the incidence of infection and DVT.
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One thought on “No nerve blocks in joint arthroplasty – a service improvement?

  1. Interesting discussion amongst the Journal Club attendees. The dangers of extrapolating single centre practice were discussed, plus the limitations of the study population (lots of young patients for hip resurfacing)

    The most notable part was how quickly this technique has become standard practice, but with wide variations in volume of LA and additives; we were also concerned that not all orthropods are as meticulous in the administration of the LA. No-one was aware of any surgeons delivering top up doses via indwelling catheters.

    We did acknowledge that anaesthetists need to look at how the perioperative plan fits in with long term goals – in this case function and longevity of arthoplasty are more important that short term pain scores.

    Reply

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