Peripheral Nerve Blocks: Optimal Method to Achieve a Painless Total Hip ArthroplastyOpposes

J. A. Harty, MB, MSc, FRCS(Tr&Orth), and R. B. Bourne, MD, FRCSC

We present the options in managing early postoperative pain in the setting of total hip or knee replacement, as part of a multimodal pain management program. The advantages and disadvantages of peripheral nerve blocks versus periarticular injection are discussed, including their mode of action. We review recent literature on periarticular injections. Intraoperative periarticular injection of multimodal drugs can signicantly reduce requirements for patient-controlled analgesia and improve patient satisfaction, with no apparent risks. Semin Arthro 19:139-143 2008 Elsevier Inc. All rights reserved. KEYWORDS periarticular injections, THR, TKR

rthopedic procedures have been reported to be among the most painful of surgical procedures.1,2 One of the most signicant patient concerns regarding total hip replacement (THR) or total knee replacement (TKR) is the anticipated pain directly related to surgical trauma during the postoperative recovery period. Postoperative pain control is an extremely important part of what orthopedic surgeons do. The aim is to minimize postoperative pain, using a combination of regional anesthesia, multimodal analgesia, and acute pain services. The optimal form of pain relief is one that is applied preoperatively, perioperatively, and postoperatively to avoid the establishment of pain hypersensitivity.3 It has been reported that more than half of postoperative patients receive suboptimal pain control and half of all patients undergoing THR or TKR will experience severe pain in the early postoperative period.4,5 The pain may be a result of trauma to the bone or soft tissues or, in the case of knee replacement, of hyperperfusion after tourniquet release.6 To obtain more effective pain control, it seems logical that a pain protocol must act simultaneously on several of the pain pathways as well as both centrally and peripherally. A multimodal approach uses various techniques and pharmacologic agents, each operating through a different site or mechanism.7 Synergism is obtained when the analgesic effects of

the individual agents or modalities are potentiated and the resultant analgesic effect is greater.8 There is overwhelming evidence for regional anesthesia for both the hip and knee replacements. There is a lower mortality rate and there is a signicant decrease in morbidity in terms of blood loss, nausea, vomiting, respiratory depression, and deep vein thrombosis.9,10 The area of debate actually comes not with the use of spinal or perhaps epidural anesthetics during the procedure, it is in the immediate 24-hour period when the patients have most of their pain (Fig 1). Many surgeons advocate the use of peripheral nerve blocks; we advocate the use of periarticular injections. The challenge of new analgesic regimes is to reduce the occurrence of side effects while maintaining adequate pain relief and maximum muscle control.11

Complications and Side Effects of Current Analgesic Regimens

The typical patient after a hip or knee replacement has most of their pain in the immediate postoperative period and then, fortunately, it decreases.12 Most surgeons believe in preemptive multimodal analgesia. There are a number of blocks that are available: lumbar plexus blocks, femoral blocks, three-inone blocks, sciatic blocks, and obturator blocks. The disadvantages are they do take considerable organization and they require an anesthetist skilled in the procedure and a specic area designated to the blocks, to ensure smooth running of the operative list. Peripheral blocks may also require expensive equipment such as portable ultrasound and nerve stimulators. 139

Department of Orthopaedic Surgery, London Health Sciences Centre, University of Western Ontario, 339 Windermere Road, London, Ontario. Address reprint requests to R.B. Bourne, MD, FRCSC, Division of Orthopaedic Surgery, London Health Sciences Centre, University of Western Ontario, 339 Windermere Road, London, Ontario, N6A 5A5, Canada. E-mail: robert.bourne@lhsc.on.ca.

1045-4527/08/$-see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1053/j.sart.2007.12.028

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J.A. Harty and R.B. Bourne

(1:1000). These are mixed with sterile normal saline solution to make up a combined volume of 100 mL in the operating room. Meticulous injection is performed into the svnovium, ligamentous attachments, deep fascia, capsule, muscle groups deep to the fascia, and into the arthrotomy sites. In the case of knee replacements, the rst aliquot of 20 mL of the mixture is injected, just before implantation of the component, into the posterior aspect of the capsule and the medial and lateral collateral ligaments (Fig 2). Care is taken to avoid excessive inltration in the area of the common peroneal nerve. While the cement is curing, the quadriceps mechanism and the retinacular tissues are inltrated with an additional 20 mL of the mixture. Finally, the remaining 60 mL is used to inltrate the fat and subcuticular tissues.18 In a similar fashion in hip replacements, the periacetabular tissues are inltrated with 20 mL of the mixture; once the components are in situ, the cut margins of the gluteal muscles and the margins of fascia lata are inltrated. The remaining 40 to 60 mL is used to inltrate the fat and subcuticular tissues. These patients have virtually no pain for the rst 12 to 16 hours after their procedure. There is a substantial reduction in the need for patient-controlled analgesia type narcotics in the immediate postoperative period (Fig 3). At the 24-hour time point, there is a highly signicant difference in their cumulative requirement for opioid analgesia (P 0.009). Similarly, we did a visual analog score for pain, and there is a remarkable difference between the injected and noninjected patients (P 0.04 at 4 hours postoperative) (Fig 4).

Figure 1 Time V pain intensity graph, showing reduced analgesic need after 48 hours. (Color version of gure is available online.)

There also is a drawback in that many of these blocks are uncomfortable to the patient. Complications have been reported, most major texts suggest about 0.4%, but they have included some signicant problems, such as infection, hematoma, intraneural injection, perhaps causing ischemia of the nerve, pelvic organ perforation, toxicity, and patient falls.13-15 Epidural analgesia is of proven benet but is associated with side effects such as spinal headache, neurogenic bladder, hypotension, respiratory depression, pulmonary hypertension, cardiac decompensation, and a risk of spinal infection.16,17 Opioid drugs also have side effects, which include nausea, vomiting, respiratory depression, reduced gut motility, and urinary retention.5 Because of the combination of problems that all of these analgesic regimens potentially cause, it is of value to nd alternative postoperative analgesia.

Mode of Action of Periarticular Injection

Intraoperative injection is considered to be the most important and effective component of this pain protocol. The four active ingredients of the inltration mixture used were epimorphine, ketorolac, ropivacaine, and epinephrine. Epimorphine exerts its analgesic effects centrally, regionally, and locally by its effect on opioid receptors. Local administration allows sustained effect with a minimum of the typical opioid adverse effects (sedation,

Periarticular Injection
Instead of the nerve blocks, we suggest the use of periarticular injections, followed by the same multimodal aspects as advocated by many others. A special multimodal wound inltration analgesic technique has been developed by Lawrence Kohan and Dennis Kerr in Sydney, Australia, with extremely effective pain relief, reducing hospital stay to 1 to 2 days (personal communication/visit). Two prospective, blinded, randomized studies to investigate the use of a periarticular injection have been performed at our institution. Multimodal drugs, consisting of an opioid (epimorphine), a nonsteroidal antiinammatory drug (ketorolac), a long-acting local anesthetic (ropivacaine), and epinephrine, were injected in the periarticular tissues to provide analgesia after total knee and total hip arthroplasty. The rst study was published on the results with knee replacements and the second compared the results of hip and knee replacements.18 During the operation, a 16-gauge needle with a small lter is used to inltrate the structures around the hip or knee. The injection contains 400 mg of ropivacaine, 30 mg of Toradol (ketorolac), 5 mg of epimorphine, and 0.6 mL of epinephrine

Figure 2 Technique for injecting collateral ligaments and posterior structures. (Color version of gure is available online.)

Peripheral nerve blocks

141 bined with 55-hour continuous intraarticular infusion in a sample of 37 total knee arthroplasty and total hip arthroplasty patients showed results similar to those mentioned above.35 Previous research evaluating improvement in analgesia from intraarticular injections has mainly been performed after total knee arthroplasty. These studies have given conicting results and are difcult to compare because of different study design. In 1996, Badner and coworkers3 studied the effect of intraarticular injections of bupivacaine and epinephrine in patients undergoing total knee arthroplasty. They reported that injection after wound closure reduces the need for narcotics and increases the range of motion. Browne and coworkers36 studied patients undergoing total knee arthroplasty who underwent intraarticular injection of bupivacaine into the joint space after capsule closure. There were no signicant differences in consumption of narcotics and pain levels compared with the placebo group. Mauerhan and coworkers20 compared four patient groups after total knee arthroplasty who received saline, morphine, bupivacaine, or a combination of morphine and bupivacaine through the drainage tube. There was a short-term reduction in pain scores in all treatment groups compared with placebo. Ritter and coworkers37 also compared four groups of patients after total knee arthroplasty. The comparison groups were given saline, morphine, bupivacaine, or a combination of morphine and bupivacaine. No signicant differences in pain levels were found between any of the groups, but patients in the groups given morphine used signicantly more morphine in the rst 24 postoperative hours than groups not given morphine. Reuben and Connelly38 studied the effect of ketorolac administered as an intraarticular or intravenous injection after knee arthroscopy. There was signicantly improved pain relief in patients receiving intraarticular injection. Rasmussen and coworkers39 studied the effect of continuous intraarticular infusion of ropivacaine with added morphine at two different infusion rates from 24 to 72 hours postoperatively and compared it with no treatment. There was a signicant reduction in pain scores and a reduced need for rescue anal-

Figure 3 Twenty-four hour patient-controlled analgesia morphine consumption for total knee and hip replacement patients.

nausea, and respiratory depression), which occur through central opioid receptors. Local administration of morphine has demonstrated advantages in the reduction of postoperative pain in total joint arthroplasty.19 Opioid receptors are present in peripheral inamed tissues.20,21 These receptors are expressed within hours after surgical trauma and are thought to be responsible for afferent sensory input to the central nervous system.22,23 Nonsteroidal antiinammatory drugs reduce peripheral sensitization and activation of nociceptors by inhibiting the eicosanoid pathway that leads to production of inammatory mediators.24 Ropivacaine is pharmokinetically similar to bupivacaine, but it is longer acting and is associated with less cardiac and central nervous system toxicity, which allows patients to tolerate a larger dose.25,26 The maximum circulating level is reached 20 to 30 minutes after injection. Although the main action of ropivacaine is to block afferent peripheral nociceptive activity, the drug has also been shown to have some antiinammatory properties in human mucosal cells.27 The addition of epinephrine helps to reduce the toxicity of the local anesthetic by keeping it localized to the area of injection.28 It may also have an effect in decreasing postoperative bleeding and hematoma.29

Discussion
The often intense pain after THR is thought to prolong mobilization and hospitalization.12 Wound inltration with multimodal analgesia has been a controversial issue for many years.30 Different modes of perioperative and postoperative local anesthetic instillation have been described in a variety of surgical procedures.18,20,31-33 Recent studies have shown that the combination of intraarticular inltration and injection or infusion of local anesthesia in the surgical area is more effective compared with systemic approaches regarding pain relief and narcotic consumption after various surgical procedures.31,34,35 A study evaluating the effect of inltration com-

Figure 4 Visual analog scores for pain in total knee and hip replacement patients.

142 gesics and hospital admission in the two intraarticular groups. Three recent papers have examined the results of periarticular injection. In a study on knee arthroplasty, Toftdahl and coworkers40 compared the periarticular injection technique to continuous femoral block. They found a signicant reduction of opioid consumption and less pain during physiotherapy in the group receiving intraarticular inltration. They also noted improved walking ability and better quadriceps function in the same group. The authors conclude that the technique of local inltration provides good analgesia after knee arthroplasty without increased risk. Andersen and colleagues5 performed a study on this technique in hip arthroplasty, comparing periarticular injection technique to continuous epidural infusion. Also in this study, the results are in favor of the local inltration technique. Once again, it was found that narcotic consumption was signicantly reduced. Pain relief at rest was good but similar in the two groups in the immediate postoperative period and was signicantly reduced in the periarticular injection technique group from the second day when active treatment had ended. Furthermore, side effects were signicantly lower due to avoidance of epidural analgesia, walking ability was better, and the hospital stay was reduced by 2 days in the periarticular injection technique group. In a randomized, double-blinded, placebo-controlled study from Odense University Hospital, periarticular injection technique was used in hip arthroplasty and compared with a control group receiving pure saline solutions.11 The patients treated with periarticular injection technique experienced less pain up to 2 weeks postoperatively. They needed less additional analgesic and were more satised. Interestingly, this treatment regimen also resulted in less joint stiffness and better function 1 week postoperatively. Parvateneni and coworkers29 reported 50 THRs (in 50 patients) and 52 TKRs (in 36 patients) using intraoperative periarticular injection combined with reduced tissue trauma surgery and a modied pain protocol. For the group of patients who underwent TKR, narcotic pain requirements and the need for prolonged physical therapy were signicantly reduced in comparison with historical control subjects. Overall patient satisfaction was greatly improved. Recovery was described as easy by 83% of patients undergoing unilateral procedures and by 64% of patients undergoing bilateral procedures. For the group who underwent THR, narcotic pain requirements and the need for prolonged physical therapy were also signicantly reduced compared with historical control subjects. Recovery of functional milestones was achieved at an earlier period in 90% of patients. Overall patient satisfaction was greatly improved; 78% of patients described their recovery as easy. As with the TKR patients, there were no instances of delayed wound healing or wound infections, and no patients required repeat surgery.

J.A. Harty and R.B. Bourne

tions are a good substitute for peripheral nerve blocks in minimizing pain after a THR simply because they require less organization, they require fewer facilities, there is less potential morbidity to the patient and certainly less cost, and they require no technical skill. The regimen of multimodal, highdose wound inltration analgesia in major orthopedic surgery thus represents a fascinating tool within the area of fast-track surgery.41 However, there is a need for research on this technique regarding several specic issues. The role of wound administration of nonsteroidal antiinammatory drugs needs to be explored, since other studies have shown inconclusive advantages with local use of these agents.42 The use of a variety of pharmacologic agents exerting effects via different mechanisms that may result in superior pain control with reduction of adverse effects. Additionally, the use of these agents before the physiologic responses are at their peak may produce a superior clinical response. In conclusion, intraoperative periarticular injection of multimodal drugs can signicantly reduce requirements for patient-controlled analgesia and improve patient satisfaction, with no apparent risks. A randomized clinical trial should be done to nd out the advantages and disadvantages of each type of analgesia and what works best for patients.

References
1. Chung F, Ritchie E, Su J: Postoperative pain in ambulatory surgery. Anesth Analg 85:808-816, 1997 2. Rawal N, Hylander J, Nydahl PA, et al: Survey of postoperative analgesia following ambulatory surgery. Acta Anesthesiol Scand 7:10171102, 1997 3. Badner NH, Bourne RB, Rorabeck CH, et al: Intra-articular injection of bupivacaine in knee-replacement operations: Results of use for analgesia and for preemptive blockade. J Bone Joint Surg Am 78:734-738, 1996 4. Follin SL, Charland SL: Acute management: Operative or medical procedures and trauma. Ann Pharmacother 31:1068-1076, 1991 5. Andersen LJ, Poulson T, Krogh B, et al: Postoperative analgesia in total hip arthroplasty: A randomized double-blinded, placebo-controlled study on peroperative and postoperative ropivacaine, ketorolac, and adrenaline wound inltration. Acta Orthop 78:187-192, 2007 6. Estebe JP, Kerebel C, Brice C, et al: Pain and tourniquet in orthopaedic surgery. Cah Anesthesiol 43:573-578, 1995 7. Skinner HB: Multimodal acute pain management. Am J Orthop 33:5-9, 2004 (suppl 5) 8. Hartrick CT: Multimodal postoperative pain management. Am J Health Syst Pharm 61:S4-S10, 2004 9. Giuffre M, Asci J, Arnstein P, et al: Postoperative joint replacement pain: Description and opioid requirement. J Post Anesth Nurs 6:239245, 1991 10. Shoji H, Solomonow M, Yoshino S, et al: Factors affecting postoperative exion in total knee arthroplasty. Orthopedics 13:643-649, 1990 11. Andersen KV, Jensen MP, Haraldsted V, et al: Reduced hospital stay and narcotic consumption, and improved mobilization with local and intra-articular inltration after hip arthroplasty: A randomized clinical trial of an intra-articular technique versus epidural infusion in 80 patients. Acta Orthop 78:180-186, 2007 12. Strassels SA, Chen C, Carr DB: Postoperative analgesia: Economics, resource use, and patient satisfaction in an urban teaching hospital. Anesth Analg 94:130-137, 2002 13. Fischer HBJ, Simanski CJP: A procedure-specic systematic review and consensus recommendations for analgesia after total hip-replacement. Anaesthesia 60:1189-1202, 2005 14. Sinatra RS, Torres J, Bustos AM: Pain management after major orthopaedic surgery: Current strategies and new concepts. J Am Acad Orthop Surg 10:117-129, 2002

Conclusion
The debate centers on whether one needs peripheral nerve blocks or can use periarticular injections. Periarticular injec-

Peripheral nerve blocks

15. Gold BS, Kite DS, Lecky JH, et al: Unanticipated admission to the hospital following ambulatory surgery. JAMA 262:3008-3010, 1989 16. Pettine KA, Wedel DJ, Cabanela ME, et al: The use of epidural bupivacaine following total knee arthroplasty. Orthop Rev 18:894-901, 1989 17. Mahoney OM, Noble PC, Davidson J, et al: The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop Relat Res 260:30-37, 1990 18. Busch CA, Shore BJ, Bhandari R, et al: Efcacy of peri-articular multimodal drug injection in total knee arthroplasty: A randomized trial. J Bone Joint Surg Am 88:959-963, 2006 19. Tanaka N, Sakahashi H, Sato F, et al: The efcacy of intra-articular analgesia after total knee arthroplasty in patients with rheumatoid arthritis and in patients with osteoarthritis. J Arthroplasty 16:306-311, 2001 20. Mauerhan DR, Campbell VL, Miller JS, et al: Intra-articular morphine and/or bupivacaine in the management of pain after total knee arthroplasty. J Arthroplasty 12:546-552, 1997 21. Stein C: The control of pain in peripheral tissue by opioids. N Engl J Med 332:1685-1690, 1995 22. Stein C: Peripheral analgesic actions of opioids. J Pain Symptom Manage 6:119-124, 1991 23. Stein C: Peripheral mechanisms of opioid analgesia. Anesth Analg 76: 182-191, 1993 24. McCormack K, Brune K: Dissociation between the antinociceptive and anti-inammatory effects of the nonsteroidal anti-inammatory drugs: A survey of their analgesic efcacy. Drugs 41:533-547, 1991 25. Feldman HS: Toxicity of local anaesthetic agents, in Rice SA (ed): Anesthetic Toxicity. New York, NY, Raven Press. pp 107133, 1994 26. Denson DD, Hartrick CT, Pither CP, et al: The relationship between free bupivacaine concentration and central nervous system toxicity. Anesthesiology 61:211, 1984 27. Martinsson T, Haegerstrand A, Dalsgaard CJ: Effects of ropivacaine on eicosanoid release from human granulocytes and endothelial cells in vitro. Inamm Res 46:398-403, 1997 28. Solanki DR, Enneking FK, Ivey FM, et al: Serum bupivacaine concentrations after intra-articular injection for pain relief after knee arthroscopy. Arthroscopy 8:44-47, 1992 29. Parvataneni HK, Ranawat AS, Ranawat CS: The use of peri-articular injections in the management of postoperative pain after total hip and

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knee replacement: A multimodal approach. Instr Course Lect 56: 125-131, 2007 Dahl JB, Moiniche S, Kehlet H: Wound inltration with local anaesthetics for postoperative pain relief. Acta Anaesthesiol Scand 38:7-14, 1994 Horn EP, Schroeder F, Wilhelm S, et al: Wound inltration and drain lavage with ropivacaine after major shoulder surgery. Anesth Analg 89:1461-1466, 1999 Fredman B, Shapiro A, Zohar E, et al: The analgesic efcacy of patientcontrolled Ropivacaine installation after cesarean delivery. Anesth Analg 91:1436-1440, 2000 Savoie FH, Field LD, Jenkins RN, et al: The pain control infusion pump for postoperative pain control in shoulder surgery. Arthroscopy 16: 339-342, 2000 Gottschalk A, Burmeister MA, Radtke P, et al: Continuous wound inltration with ropivacaine reduces pain and analgesic requirements after shoulder surgery. Anesth Analg 97:1086-1091, 2003 Bianconi M, Ferraro L, Traina GC, et al: Pharmacokinetics and efcacy of ropivacaine continuous wound instillation after joint replacement surgery. Br J Anaesth 91:830-835, 2003 Browne C, Copp S, Reden L, et al: Bupivacaine bolus injection versus placebo for pain management following total knee arthroplasty. J Arthroplasty 19:377-380, 2004 Ritter MA, Kochler M, Keating EM, et al: Intra-articular morphine and/or bupivacaine after total knee replacement. J Bone Joint Surg Br 81:301-303, 1999 Reuben SS, Connelly NR: Postoperative analgesia for outpatient arthroscopic knee surgery with intra-articular bupivacaine and ketorolac. Anesth Analg 80:1154-1157, 1995 Rasmussen S, Kramhoft MU, Sperling KP, et al: Increased exion and reduced hospital stay with continuous intra-articular morphine and ropivacaine after primary total knee replacement: open intervention study of efcacy and safety in 154 patients. Acta Orthop 75:606-609, 2004 Toftdahl K, Nicolajsen L, Haraldsted V, et al: Comparison of peri- and intra-articular analgesia with femoral nerve block after total knee arthroplasty: A randomized clinical trial. Acta Orthop 78:172-179, 2007 Kehlet H, Dahl JB: Anaesthesia, surgery and challenges in postoperative recovery. Lancet 362:1921-1928, 2003 Romsing J, Miniche S, Postergaard D, et al: Local inltration with NSAIDs for postoperative analgesia: Evidence for a peripheral analgesic action. Acta Anaesthesiol Scand 44:672-683, 2000

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