The Journal of Bone and Joint Surgery (American). 2006;88:282-289.
doi:10.2106/JBJS.E.00173
© 2006 The Journal of Bone and Joint Surgery, Inc.
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A Multimodal Analgesia Protocol for Total Knee Arthroplasty

A Randomized, Controlled Study

Pascal-André Vendittoli, MD, FRCS(C)1, Patrice Makinen, MD1, Pierre Drolet, MD, MSc1, Martin Lavigne, MD, FRCS(C)1, Michel Fallaha, MD, FRCS(C)1, Marie-Claude Guertin, PhD2 and France Varin, BPharm, PhD3

1 Patrice Makinen, MD Pierre Drolet, MD, MSc Martin Lavigne, MD, FRCS(C) Michel Fallaha, MD, FRCS(C) Orthopaedic Surgery Unit, Department of Surgery (P.-A.V., P.M., M.L., and M.F.), and Department of Anaesthesia (P.D.), Maisonneuve-Rosemont Hospital, 5345 boul l'Assomption, Suite 55, Montreal, H1T 4B3 QC, Canada. E-mail address for P.-A. Vendittoli: pa.vendittoli{at}sympatico.ca
2 Montreal Heart Institute, 5000 Belanger Street, Montreal, H1T 1C8 QC, Canada
3 University of Montreal, C.P. 6128 Succursale Centre-ville, Montreal, H3C 3J7 QC, Canada

Investigation performed at Maisonneuve-Rosemont Hospital, Montreal, Quebec, Canada

NOTE: The authors acknowledge the work of Dr. L. Kohan and Dr. D. Ker, Sydney, Australia, who developed a postoperative analgesia protocol that we slightly modified for this study.

In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the Canadian Orthopaedic Foundation (Alexandra Kirkley Grant), the Fondation de Recherche en Orthopédie de l'Université de Montréal (FREOM), and Zimmer, Warsaw, Indiana. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Although numerous methods of postoperative analgesia have been investigated in an attempt to improve pain control after total knee arthroplasty, parenteral narcotics still play a major role in postoperative pain management. Local anesthetics have the advantage of blocking pain conduction at its origin and minimizing the systemic side effects associated with postoperative narcotic use. This study was performed to evaluate the benefits and safety of a multimodal analgesia protocol that included periarticular injection of large doses of local anesthetics in patients undergoing total knee arthroplasty.

Methods: We compared morphine consumption during the first twenty-four hours after unilateral total knee arthroplasty in forty-two patients who had been randomized to receive either (1) a perioperative infiltration mixture, consisting principally of local anesthetic, and self-administered morphine or (2) self-administered morphine only. Narcotics consumption, pain control, medication-related side effects, plasma levels of the local anesthetic (ropivacaine), and postoperative rehabilitation were monitored.

Results: Although there was high satisfaction and good pain control in both groups, morphine consumption was significantly lower in the local analgesia group than it was in the control group (28.8 ± 17.4 mg compared with 50.3 ± 25.4 mg twenty-four hours after surgery, and 46.7 ± 19.4 mg compared with 68.6 ± 38.6 mg forty hours after surgery). Both groups achieved a similar amount of knee flexion on the fifth postoperative day. Over the five-day period after the procedure, the patients in the local analgesia group reported a total of 2.6 ± 3.9 hours of nausea compared with 7.1 ± 12.2 hours in the control group. No complications related to the infiltration of the local anesthetic were observed, and all plasma concentrations of the local anesthetic were below the toxic range.

Conclusions: This multimodal perioperative analgesia protocol that included infiltration of a local anesthetic offered improved pain control and minimal side effects to patients undergoing total knee arthroplasty. Our study also confirmed the safety of the protocol.

Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.


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