Effectiveness of intraoperative periarticular cocktail injection for pain control and knee motion recovery after total knee replacement.
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SUBMITTER: Sreedharan Nair V
PROVIDER: S-EPMC6728801 | biostudies-other | 2019 Sep
REPOSITORIES: biostudies-other
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Effectiveness of intraoperative periarticular cocktail injection for pain control and knee motion recovery after total knee replacement.
Sreedharan Nair Vijayamohan V Ganeshan Radhamony Niranj N Rajendra Riju R Mishra Rahul R
Arthroplasty today 20190712 3
<h4>Background</h4>Pain control after total knee replacement (TKR) is pivotal in postoperative rehabilitation. Usage of epidural analgesia or parenteral opioids can cause undesirable side effects hampering early recovery and rehabilitation. These side effects can be avoided by infiltration of an analgesic cocktail locally. Our study was performed to evaluate the benefits of a particular cocktail combination in patients undergoing TKR with respect to pain and knee motion recovery.<h4>Methods</h4> ...[more]
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Project description:BACKGROUND:Total knee replacement is a common operative procedure to improve pain, function, and quality of life in patients with end stage knee osteoarthritis. The current study aimed to compare simultaneous bilateral versus unilateral total knee replacement on pain intensity and recovery of function. METHODS:A total of 80 patients (bilateral 50, unilateral 30) aged 63.28 (9.4) years undergone total knee replacement participated in the current study. The participants were admitted for 5-7?days in the hospital. Participants in both the group received similar inpatient and outpatient physiotherapy sessions. Pain intensity and function capacity were assessed at baseline, day 7, and day 30 postoperatively using visual analogue scale and lower extremity functional scale, respectively. Repeated measures analysis of variance was used to analyze the data. RESULTS:Both groups showed a significant reduction of pain intensity (Day 0, mean 8.9, SD 1.0; Day 30, mean 2.2, SD 1.3 in bilateral total knee replacement; Day 0, mean 8.8, SD 1.1; Day 30, mean 2.0, SD 1.5 in unilateral total knee replacement; p <?0.001) and improvement in the functional capacity (Day 0, mean 16.2, SD 10.1; Day 30, mean 55.6, SD 14.6 in bilateral total knee replacement; Day 0, mean 19.1, SD 9.1; Day 30, mean 56.7, SD 15.8 in unilateral total knee replacement; p <?0.001) following total knee replacement at 30?days post-operatively. However, there was a non-significant difference noted between bilateral versus unilateral total knee replacement on the reduction of pain intensity (mean changes, 6.9 versus 6.8) and improvement in the functional capacity (mean changes, 39.4 versus 37.6) at 30?days post-operatively (p?>?0.05). CONCLUSION:Simultaneous bilateral total knee replacement was associated with a similar reduction of pain intensity and recovery of function compared to unilateral total knee replacement, suggesting the use of simultaneous bilateral total knee replacement in patients with bilateral knee osteoarthritis since its costs and rehabilitation process could be reduced compared to staged bilateral total knee replacement.
| S-EPMC7161292 | biostudies-literature
Project description:Pain is the main impetus for osteoarthritis (OA) patients to seek healthcare including joint replacement. The pain experience in OA is heterogeneous and affected by factors across multiple domains-peripheral, psychological, and neurological. This indicates the existence of homogenous subgroups/phenotypes within OA patients with pain. We recently identified three pain phenotypes using a wide spectrum of pain-related factors, including structural damage on magnetic resonance imaging (MRI), emotional problems, number of painful sites, sex, body mass index, education level and comorbidities (i.e., Class 1: high prevalence of emotional problems and low prevalence of structural damage (25%); Class 2: low prevalence of emotional problems and high prevalence of structural damage (20%); Class 3: low prevalence of emotional problems and low prevalence of structural damage (55%)). This study was to examine whether the total knee replacement (TKR) risk over 12 years was different among these three pain phenotypes. Data on 963 participants (mean age 62.8 ± 7.4 years) from a population-based cohort study were utilised. Data on socio-demographic, psychological and comorbidities were collected. MRI of the right knee structural pathology was performed. TKR history was ascertained by linking to the Australian Orthopedic Association National Joint Replacement Registry. Latent class analysis and the Cox proportional hazards model were applied for the analysis. During the follow-up period, 41 right and 44 left TKRs in 67 participants were identified. In multivariable analyses, participants in Class 1 and 2 had a higher risk of having a TKR (Class 1 vs. Class 3, HR (hazard ratio) 4.81, 95%CI (confidence interval) 2.33-9.93; Class 2 vs. Class 3, HR 9.23, 95%CI 4.66-18.30). These associations were stronger in the imaged right knee but were also significant in the left knee. Participants within distinct pain phenotypes have different risks of TKR, suggesting that the identified phenotypes reflect distinct clinical subgroups with different prognoses. The risk for TKR was higher in Class 1 than that in Class 3, suggesting that pain/emotional status is a stronger driver for TKR than structural damage, and that selecting patients for TKR needs to be optimized in clinical practice.
| S-EPMC7141124 | biostudies-literature
Project description:BackgroundEnhanced recovery following total knee arthroplasty (TKA) has been advocated to enhance postoperative recovery. Multimodal cocktail periarticular injection (MCPI) use for pain control in TKA has gained wide acceptance. MCPI-containing corticosteroids are believed to be an effective solution owing to their local anti-inflammatory effects and ability to reduce the local stress response postoperatively. However, there is conflicting evidence regarding its benefits. This trial aims to compare MCPI with a high dose of corticosteroid, normal dose of corticosteroid, and non-corticosteroid during TKA, to assess the effectiveness of MCPI containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and side effects and provide evidence that high-dose corticosteroids result in prolonged pain control and better recovery following TKA.MethodsThis is a double-blinded, randomized, placebo-controlled study. A total of 234 patients scheduled for TKA will be recruited. During surgery, before wound closure, 80 ml of the cocktail analgesic will be injected into the muscle and joint capsule for local infiltration analgesia; the participants will be randomly assigned to three groups to receive a high dose of betamethasone MCPI (group H), normal dose of betamethasone MCPI (group N), and non-betamethasone MCPI (group C). The following indices will be recorded and analyzed: the strongest knee pain experienced during 90° flexion at 6 h, 24 h, 48 h, 72 h, 5 days, 14 days, and 30 days after surgery; 1 min walking ability; and circumference around the patella at 2, 5, 14, and 30 days after surgery; Knee Society knee score at 14 days and 30 days after surgery; C-reactive protein and blood sedimentation; blood sugar 2, 5, 14, and 30 days following surgery; rescue analgesic consumption; and adverse events. If any participant withdraws from the trial, an intention-to-treat analysis will be performed.DiscussionThe results of this study will provide clinical evidence on the effectiveness of MCPI-containing corticosteroids in postoperative pain relief, functional improvement, rescue analgesia, and adverse events, as well as provide evidence on the efficacy of high-dose corticosteroids in prolonged pain control and better recovery following TKA.Trial registrationChinese Clinical Trial Registry, ChiCTR2000038671 . Registered on September 27, 2020.
| S-EPMC8518286 | biostudies-literature
Project description:Background and purpose - Up to 20% of patients are dissatisfied after total knee arthroplasty (TKA), mainly because of pain and restricted physical function. We developed a prediction model for 6-month knee range of motion, knee pain, and walking limitations in patients undergoing TKA surgery. Patients and methods - We performed a prospective cohort study of 4,026 patients who underwent elective, primary TKA between July 2013 and July 2017. Candidate predictors included demographic, clinical, psychosocial, and preoperative outcome measures. The outcomes of interest were (i) knee extension and flexion range of motion, (ii) knee pain rated on a 5-point ordinal scale, and (iii) self-reported maximum walk time at 6 months post TKA. For each outcome, we fitted a multivariable proportional odds regression model with bootstrap internal validation. Results - At 6 months post TKA, around 5% to 20% of patients had a flexion contracture ³ 10°, range of motion < 90°, moderate to severe knee pain, or a maximum walk time £ 15 minutes. The model c-indices (the probabilities to correctly discriminate between 2 patients with different levels of follow-up TKA outcomes) when evaluating these patients were 0.71, 0.79, 0.65, and 0.76, respectively. Each postoperative outcome was strongly influenced by the same outcome measure obtained preoperatively (all p-values < 0.001). Additional statistically significant predictors were age, sex, race, education level, diabetes mellitus, preoperative use of gait aids, contralateral knee pain, and psychological distress (all p-values < 0.001). Interpretation - We have developed models to predict, for individual patients, their likely post-TKA levels of knee extension and flexion range of motion, knee pain, and walking limitations. After external validation, they can potentially be used preoperatively to identify at-risk patients and to help patients set more realistic expectations about surgical outcomes.
| S-EPMC6461070 | biostudies-literature
Project description:Total knee replacement is acknowledged as a successful and durable operation, but recovery from this surgery is often lengthy and painful. A great deal of attention has recently been directed at enhancing this recovery, most of which has focused on improvements in perioperative pain control. Various protocols have been suggested. This article discusses a pain management program that uses local infiltrative analgesia with a specific "cocktail" which, when combined with an oral multimodal pain regimen, has led to excellent patient satisfaction and a substantially shorter length of stay.
| S-EPMC4957167 | biostudies-literature
Project description:The perioperative care of patients undergoing total knee arthroplasty (TKA) affects functional recovery and clinical outcomes. This study aims to introduce a patient-specific integrated education program (IEP) into the TKA clinical pathway and to evaluate patient outcomes between the intervention and control groups. We performed a two-site, two-arm, parallel-prospective controlled trial. The experiment group received an IEP incorporating verbal preoperative education, prehabilitation, multidisciplinary personalized rehabilitation during hospitalization, and supervised self-executed home-based exercise after discharge. The control group received regular TKA clinical care. We monitored the pain intensity, anxiety scores, and functional scores at six time points from the pre-operation interview to 3 months post-operation. The pain score was significantly decreased in the IEP group during hospitalization (p < 0.01) and before discharge (p < 0.05). The anxiety status was also improved after intervention in terms of state and trait anxiety inventory scores (p < 0.001) during hospitalization. The patient-reported (WOMAC) or physician-reported (American Knee Society Score) functional scores (p < 0.01 at most of the time points) all improved significantly under hospitalization. We found that the patient-specific IEP combining preoperative education, prehabilitation, the in-hospital group education class, and postoperative care navigation is effective in reducing postoperative pain, decreasing perioperative anxiety, and facilitating functional recovery following TKA.
| S-EPMC9146256 | biostudies-literature
Project description:BackgroundAfter total knee arthroplasty (TKA), patients have limited knee range of motion (ROM), trophic changes and pain. Cryotherapy and compression are recommended in the literature, but no study has shown that cryotherapy and compression combined leads to better results than cryotherapy alone. The primary objective was to compare knee ROM after 21 days of rehabilitation post-TKA between patients who underwent rehabilitation with compressive cryotherapy with those who had cryotherapy alone. The secondary objectives were to compare other trophic, pain and functional outcomes.MethodsForty patients were randomized into two groups: Standard Cryotherapy (SC = 20, median age 77 years), which applied cold packs along with their rehabilitation; and Compressive Cryotherapy (CC = 20, median age 76 years), which received cold compression. Knee joint's passive and active ROM (primary outcome) were measured with a goniometer. Knee's circumference, fluctuation test, pain at rest and during activity, 6-minute walking test (6MWT) and KOOS questionnaire were secondary outcomes. The groups were compared on D1 (baseline) and D21 of rehabilitation. A survival analysis has compared the groups on D1, D8, D15, D21.ResultsAll subjects had a significant improvement in all the parameters on D21 relative to D1 (p < .05), except for pain at rest (p = .065 for CC and p = .052 for SC). On D21, the CC group had a significantly larger improvement in the joint effusion (p = .002), pain during activity (p = .005), 6MWT (p = .018) and KOOS (p = .004) than the SC group. Based on the survival analysis, the CC group had significantly faster improvement in the joint ROM (p = .011 for flexion and p = .038 for extension) and knee circumference (p = .013) than the SC group.ConclusionsBoth cryotherapy methods improved joint ROM, trophic changes, pain and function. Adding dynamic compression to a cryotherapy protocol provided further benefits: a significantly faster improvement in passive knee flexion ROM, a greater reduction of swelling, and pain during activity. Similarly, walking distance and KOOS questionnaire were significantly better for CC.Trials registrationThe study was registered in the ClinicalTrials.gov database on 14/09/2023 (identifier: NCT06037824).
| S-EPMC10900683 | biostudies-literature
Project description:BackgroundThe increasing demand for total knee arthroplasty (TKR) and the initiatives to reduce health care spending have put the responsibility for efficient care on hospitals and providers. Multidisciplinary care pathways have been shown to shorten length of stay and result in improved short-term outcomes. However, common problems such as post-op nausea, orthostasis, and quad weakness remain, while reliance on discharge to rehabilitation facilities may also prolong hospital stay.Questions/purposesOur aim was to document that combined modifications of our traditional clinical pathway for unilateral TKR could lead to improved short-term outcomes. We pose the following research questions. Can pathway modifications which include intra-articular infusion and saphenous nerve block (SNB) provide adequate pain relief and eliminate common side effects promoting earlier mobilization? Can planning for discharge to home avoid in-patient rehab stays? Can these combined modifications decrease length of stay even in patients with complex comorbidities indicated by higher ASA class? Will discharge to home incur an increase in complications or a failure to achieve knee range of motion?Patients and methodsA retrospective review was performed and identified two cohorts. Group A included 116 patients that underwent unilateral TKR for osteoarthritis between August 2009 and August 2010. Group B included 171 patients that underwent unilateral TKR for osteoarthritis between February 2012 to February 2013. Group A patients were treated with spinal anesthesia with patient-controlled epidural analgesia (PCEA)/femoral nerve block (FNB) for the first 48 h after surgery. Discharge planning was initiated after admission. Group B had spinal anesthesia with SNB and received a continuous intra-articular infusion of 0.2% ropivicaine for 48 h post-op. Discharge planning was initiated with a case manager prior to hospitalization and discharge to home was declared the preferred approach. An intensive home PT program was made available through a program with our local home care agency. Outcomes assessed and compared between groups included length of stay, incidence of post-op nausea, dizziness, in-hospital falls, occurrence of complications including wound infection and the recovery of range of motion at 6 weeks, 3 months, and 1 year post-op.ResultsPain control was similar between the groups but Group B had fewer side effects. With the new pathway, length of stay (LOS) was reduced from 4.32 to 3.64 days with a similar LOS reduction across all ASA classes. There was no increase in Group B wound or other complications. Return of ROM was similar between groups.ConclusionsOur findings suggest that replacing PCEA and FNB with intra-articular analgesia with a SNB allows for improved early recovery following TKR. That, combined with pre-op discharge planning and initiation of an intensive home PT program, reduced average length of stay.
| S-EPMC4342406 | biostudies-literature
Project description:BACKGROUND:The use of multimodal pain regimens has been shown to be an effective technique for the treatment of postoperative pain after total knee arthroplasty. Periarticular injections, of both short-acting and long-acting anesthetics, have emerged as an additional method of providing significant improvement in postoperative pain relief. The purpose of this study is to compare the efficacy of periarticular injection using long-acting vs short-acting preparations. METHODS:A randomized, prospective study of 80 consecutive patients was performed comparing liposomal bupivacaine vs plain bupivacaine periarticular injection. The primary outcomes included pain relief, total narcotic usage, and completion of physical therapy goals, specifically range of motion. RESULTS:No significant improvements were noted between liposomal bupivacaine and plain bupivacaine injection groups in overall pain reduction, range of motion, or total narcotic usage. At 24 hours, small statistically significant differences in physical therapy pain scores were noted with liposomal bupivacaine vs plain bupivacaine and control patients, but these differences did not persist at later time points. Both preparations demonstrated statistically significant improvements in range of motion when compared to historical controls, but no differences were noted between preparations. CONCLUSION:Overall, minimal significant differences were noted between liposomal bupivacaine and plain bupivacaine at early and late time points. Both preparations of periarticular injection demonstrated superiority over control pain regimens but were relatively equivalent to one another in direct comparison.
| S-EPMC6054911 | biostudies-literature
Project description:Rehabilitation, with an emphasis on physiotherapy and exercise, is widely promoted after total knee replacement. However, provision of services varies in content and duration. The aim of this study is to update the review of Minns Lowe and colleagues 2007 using systematic review and meta-analysis to evaluate the effectiveness of post-discharge physiotherapy exercise in patients with primary total knee replacement.We searched MEDLINE, Embase, PsycInfo, CINAHL and Cochrane CENTRAL to October 4(th) 2013 for randomised evaluations of physiotherapy exercise in adults with recent primary knee replacement. Outcomes were: patient-reported pain and function, knee range of motion, and functional performance. Authors were contacted for missing data and outcomes. Risk of bias and heterogeneity were assessed. Data was combined using random effects meta-analysis and reported as standardised mean differences (SMD) or mean differences (MD).Searches identified 18 randomised trials including 1,739 patients with total knee replacement. Interventions compared: physiotherapy exercise and no provision; home and outpatient provision; pool and gym-based provision; walking skills and more general physiotherapy; and general physiotherapy exercise with and without additional balance exercises or ergometer cycling. Compared with controls receiving minimal physiotherapy, patients receiving physiotherapy exercise had improved physical function at 3-4 months, SMD -0.37 (95% CI -0.62, -0.12), and pain, SMD -0.45 (95% CI -0.85, -0.06). Benefit up to 6 months was apparent when considering only higher quality studies. There were no differences for outpatient physiotherapy exercise compared with home-based provision in physical function or pain outcomes. There was a short-term benefit favouring home-based physiotherapy exercise for range of motion flexion. There were no differences in outcomes when the comparator was hydrotherapy, or when additional balancing or cycling components were included. In one study, a walking skills intervention was associated with a long-term improvement in walking performance. However, for all these evaluations studies were under-powered individually and in combination.After recent primary total knee replacement, interventions including physiotherapy and exercise show short-term improvements in physical function. However this conclusion is based on meta-analysis of a few small studies and no long-term benefits of physiotherapy exercise interventions were identified. Future research should target improvements to long-term function, pain and performance outcomes in appropriately powered trials.
| S-EPMC4333167 | biostudies-other