Post on 05-Jan-2017
Sachiyuki TSUKADA Orthopaedic Surgery, Hokusuikai Kinen Hospital, Japan
Periariticular Multi-Drug Injection
Pain Management after Joint Surgery
orcid.org/0000-0002-1186-5232
Opioid, Local anesthetic, Corticosteroid
Periarticular Multi-Drug Injection
Easy & Safe technique !
Pain afterTKA Total Knee Arthroplasty
Placebo controlled RCT ①
Busch et al. JBJS Am 2006
Opioid, Local anesthetic, NSAIDs
Pain during activity
＊
＊
＊ p < 0.05
Opioid, Local anesthetic, Steroid, NSAIDｓ
Placebo controlled RCT ② Pain at rest
＊ ＊
＊ ＊
Fu et al. Knee 2009
＊ p < 0.05
？ How effective? Why effective? Which drug is effective?
Placebo controlled RCTs → Effective for postoperative pain
TKA Periarticular Mult-Drug Injection
① How effective？
① How effective？
Comparison with Other Pain Management Regimen
a. Continuous epidural analgesia
b. Femoral nerve block
c. Femoral + Sciatic nerve blocks
Epidural analgesia versus
Periarticular injection
Randomized Controlled Trial
Comparison with Continuous Epidural analgesia
Tsukada et al. JBJS Am 2014
１．Epidural Analgesia
Intervention
２．Periarticular Injection
Morphine 8mg Ropivacaine 100mg Total 100ml, 2mg/ml
Morphine 8mg Ropivacaine 300mg Methylprednisolone 40mg Ketoprofen 50mg Bosmin 0.3mg + saline, Total 60ml
Tsukada et al. JBJS Am 2014
Total 111 knees
Epidural analgesia 61 knees
Periarticular injection 50 knees
Allocation
0
1
2
3
4
5
6
7
4 6 8 10 12 14 16 18 20 22 24 32 40 48 56 64 72
70
50
40
30
10
0
20
60
Postoperative hours
◆ Epidural analgesia ■ Periarticular injection
VAS at Rest
＊ ＊ ＊ ＊ ＊ ＊
＊ ＊
＊ p < 0.05
0
20
40
60
80
100
120
140
160
1d 2d 3d 4d 5d 6d 7d 8d 9d 10d 11d 12d 13d 14d 1M 2M 3M 6M 1Y
◆ Epidural analgesia ■ Periarticular injection
Flexion angle
＊ ＊
＊ p < 0.05
0
5
10
15
20
25
30
35
40
嘔気 当日 嘔気 1日 掻痒感 呼吸抑制 創治癒遅延
＊p < 0.0001
◆ Epidural analgesia ■ Periarticular injection
Nausea Day 0
Nausea Day 1
Pruritis Resparatory Disorder
Incision complication
Complication
Lower Rate of Nausea
Periarticular Injection is superior to Continuous Epidural Analgesia
#1
Another advantage: No need of catheter
0
10
20
30
40
50
60
70
80
90
100
4h 1d 2d 3d 7d 14d 21d
VA
S p
ain
sco
res
(0 -
10
0 m
m)
Postoperative time
◆ Femoral nerve block
■ Periarticular injection
Kurosaka, Tsukada et al. J Arthroplasty 2016
＊ ＊
＊ p < 0.05
Comparison with Continuous Femoral Nerve Block
Periarticular Injection is superior to Continuous Femoral Nerve Block
#2
Periarticular Injection is superior to Continuous Femoral Nerve Block
#2
Pain from Posterior knee?
Combined with Sciatic nerve block?
Uesugi, Kitano, Kikuchi et al. Knee 2014
3, 6h postop. → Nerve blocks
24, 30h postop. → Periarticular injection
＊
＊
＊ ＊
Periarticular injection
Femoral + Sciatic Nerve Blocks
＊ p < 0.05
Comparison with Femoral + Sciatic Nerve Blocks
Periarticular injection is equivalent to Femoral + Sciatic nerve blocks
#3
Summary １
① Superior to the Epidural analgesia
② Superior to the Femoral nerve block
③ Equivalent to the Femoral and Sciatic nerve blocks
How effective is Periarticular injection for TKA?
② Why effective?
Maheshwari et al. CORR 2009
Opioid → Stimulating opiate receptors in knee Steroid → Preventing local inflammation Epinephrine → Prolonging the action of local agents （α-adrenergic effect）
② Why effective？
Actually effective for patients?
Pharmacology
Opiate receptors in knee？
Stein N Engl J Med 1995
Inflammation → Peripheral Opioid Receptor
Pain after Knee Arthroscopy Stein et al. N Engl J Med 1991
Supporting the Peripheral Opioid Receptor
＊
＊ p < 0.05
＊
＊
〇 Intravenous morphine
● Intraarticular morphine
Periarticular injection in one knee / Placebo in the contralateral knee
→ 1. Better pain: The knee treated with Periarticular injection
Simultaneous bilateral TKA
Andersen LØ Acta Anaesthesiol Scand 2008
Koh IJ KSSTA 2010
Mullaji A J Arthroplasty 2010
For the patients undergoing TKA for their bilateral knees in a same day
② Why effective？
Periarticular injection in one knee / Placebo in the contralateral knee
→ 1. Better pain: The knee treated with Periarticular injection
Simultaneous bilateral TKA
Andersen LØ Acta Anaesthesiol Scand 2008
Koh IJ KSSTA 2010
Mullaji A J Arthroplasty 2010
Joo JH J Arthroplasty 2011
For the patients undergoing TKA for their bilateral knees in a same day
② Why effective？
→ 2. No difference between the two knees!
n = 286 Pain during activity
Joo et al. J Arthroplasty 2011
Systemically? (Not Topically?)
Cadaver Study How far does 180mL solution reach? Quinn et al. Knee 2013
Assumption of study: Drugs work topically Private opinion： Local anesthetics work topically ／ Other drugs ??
② Why effective？
Summary 2
The detailed mechanism remains Unclear
Why is Periarticular injection effective?
③ Which drug?
③ Which drug is effective?
NSAIDs
0
10
20
30
40
50
2-6h 6-24h 24-48h 48-72h 72-96h
Andersen et al. Br J Anaesth 2013
VA
S p
ain
score
s (0
- 1
00
mm
)
◆ Ketrolac ■ No Ketrolac
＊
＊
＊
＊ p < 0.05
No significant differences!
Schotanus et al. KSSTA, in press
③ Which drug is effective?
Epinephrine
Corticosteroid Ikeuchi et al. KSSTA, 2014
③ Which drug is effective?
Christensen JBJS Am 2009
Chia JoA 2013
No benefit
VS Seah Singapore Med J 2011
Ikeuchi KSSTA 2013
Effective
Previous RCTs Corticosteroid in Periarticular injection
Is Corticosteroid Needed?
Including Corticosteroid
versus
No Corticosteroid
Randomized Controlled Trial
Tsukada et al. Bone Joint J 2016
1. Corticosteroid group
Intervention
2.No corticosteroid group Normal saline
Methylprednisolone 40mg
Morphine 8mg, Ropivacaine 300mg
Ketoprofen 50mg, Epinephrine 0.3 mg (+ Normal saline)
Total 77 knees
Corticosteroid 40 knees
No corticosteroid 37 knees
Allocation
VAS at rest
＊ ＊
＊ p < 0.05
＊
Flexion angle
＊ ＊
＊ p < 0.05
0
5
10
嘔気 当日 嘔気 1日 掻痒感 創治癒遅延 深部感染
■ Corticosteroid ■ No corticosteroid
Complications
n.s.
(%)
Nausea Day 0
Nausea Day 1
Pruritus Deep Infection
Incision complication
Summary 3
Corticosteroid offers better pain relief after TKA
Is including Corticosteroid effective?
Periarticular multi-drug injection
for Other than Unilateral TKA
１．Simultaneous bilateral TKA
２．THA
３．Bipolar hemiarthroplasty of hip
４．HTO
Tsukada et al. JBJS Am 2015
Kang et al. JBJS Am 2013
Busch et al. CORR 2010
Jung, Takeuchi et al. Arthroscopy 2014
Hartog et al. Bone Joint J 2015
Jules-Elysee et al. JBJS Am 2015
Periarticular multi-drug injection
Retrospective comparative study
Simultaneous bilateral TKA
Lombardi et al. CORR 2004
Periarticular injection + intraarticular injection
→ Better pain relief after Bilateral TKA
Epidural Analgesia versus
Periarticular Injection
Randomized Controlled Trial
Simultaneous bilateral TKA
Tsukada et al. JBJS Am 2015
１．Epidural Analgesia
Intervention
２．Periarticular Injection
Morphine 10mg Ropivacaine 100mg Total 100ml, 2mg/ml
Morphine 10mg Ropivacaine 300mg Methylprednisolone 80mg Ketoprofen 50mg Bosmin 0.6mg + saline, Total 120ml
Simultaneous bilateral TKA
Tsukada et al. JBJS Am 2015
Total 140 knees
Epidural analgesia 66 knees
Periarticular injection 74 knees
Allocation
＊
＊ ＊
＊
＊ p < 0.05
＊
VAS at Rest
＊
＊ ＊
＊
＊ ＊ p < 0.05
Flexion angle
0
5
10
15
20
嘔気 当日 嘔気 1日 掻痒感 呼吸抑制 創治癒遅延
◆ Epidural analgesia ■ Periarticular injection
Complication
Nausea Day 0
Nausea Day 1
Pruritis Resparatory Disorder
Incision complication
＊
＊
＊ p < 0.05
＊
Periarticular Injection is superior to Continuous Epidural Analgesia in simultaneous bilateral TKA
Conclusion
THA
Busch et al. CORR 2010
THA
Hartog et al. Bone Joint J 2015
NR
S (M
ost
pai
n t
hat
day
)
0
2
4
6
8
10
Day 0 Day 1 Day 2
カクテル注射
プラセボ
n. s.
■ Placebo ◆ Periarticular injection
THA
Jules-Elysee et al. JBJS Am 2015
0
2
4
6
8
10
POD 1AM
POD 1PM
POD 2AM
POD 2PM
POD 3AM
POD 3PM
N
R
S
■ Patient-controlled epidural analgesia ◆ Periarticular injection
＊
＊ p < 0.05
Bipolar hemiarthroplasty
Kang et al. JBJS Am 2013
Periarticular injection
No injection
＊
＊
Open-wedge HTO
Jung, Takeuchi et al. Arthroscopy 2014
Periarticular injection
No injection ＊
＊ p < 0.05