How Effective Is Intrawound periarticular Cocktail Injection and Postoperative Intravenous Paracetamol for Analgesia and Early Mobilization after Total Knee Arthroplasty (TKA)

Vishal Ashokraj Pushkarna¹, Vivek Amrithbhai Patel²*, Tej Rudani¹, Pranay Bhatt³, Shlok P Mendiratta³ and Patel Daxesh Jerambhai³

¹Assistant Professor, Department of Orthopaedics, Gujarat Adani Institute of Medical Sciences and GK General Hospital, Bhuj, Gujarat, India
²Professor and HOU, Department of Orthopaedics, Gujarat Adani Institute of Medical Sciences and GK General Hospital, Bhuj, Gujarat, India
³Resident, Department of Orthopaedics, Gujarat Adani Institute of Medical Sciences and GK General Hospital, Bhuj, Gujarat, India

*Corresponding Author: Vivek Amrithbhai Patel, Professor and HOU, Department of Orthopaedics, Gujarat Adani Institute of Medical Sciences and GK General Hospital, Bhuj, Gujarat, India

Received: May 15, 2023; Published: June 20, 2023

Abstract

Introduction: Total knee arthroplasty (replacement) is a treatment of choice in severe osteoarthritis of knee joint and relieve knee pain and improves joint function, but still managing post-surgical pain after Total knee replacement (TKR) is a challenging and crucial step for early rehabilitation of patient and for better outcome. There are some reports demonstrate the 70 to 75% patients of total knee replacement complaint of moderate to severe chronic pain. Clinical practice guidelines recommend multimodal, therapy combining preoperative, intraoperative, and postoperative medications, such as opioids, nonsteroidal anti inflammatory drugs, gabapentin, pregabalin, and local anesthetics. Adequate pain relief is essential for early mobilization and good functional recovery.

Use of intravenous acetaminophen has seen recent enthusiasm as one component of a multimodal approach to pain management. However, there is a lack of literature examining the efficacy of intravenous acetaminophen for pain control in total knee replacement.

Aims: The purpose of this study was to evaluate the efficacy of intravenous acetaminophen with intraarticular cocktail injection as multimodal approach for pain management and its effect on early rehabilitation following total knee replacement.

Material and Methods: Total (n = 82) patent enrolled in the study who underwent total knee replacement. They were divided into two groups, Group A received epidural analgesia with intravenous (I.V) diclofenac and for any breakthrough pain Tramadol injection was given intravenously. Group B received periarticular injection of an anesthetic cocktail of drugs with antibiotic with intravenous acetaminophen (paracetamol) with diclofenac injection. Inclusion criteria was patient with age group of 50-80 years and underwent unilateral TKR. For outcome Knee society score (KSS) and Visual Analog scale (VAS) was used. For functional outcome Post-operative range of movement was also noted.

Results: The mean average KSS score of the study subjects were 52. Group A with epidural analgesic had a score of 58 when compared to 79 for group B where cocktail and IV acetaminophen was used. The mean average functional score was 61 for group A and 75 for group B. Both the scores were better in the analgesic cocktail group B. The mean pain score in group A was 5.2 and in group B was 2.1.

Conclusion: In Conclusion periarticular cocktail with Intravenous acetaminophen is effective in significantly reducing opioid/NSAID’s requirements in the first 24 hours following primary total knee arthroplasty. Additionally, there is a clinically significant decrease in VAS pain scores in patients receiving this intervention.

Keywords:Total Knee Replacement; Pain Control; Early Rehabilitation; Local Infiltration Analgesia; Knee Society Score; Visual Analog Scale

References

1. Fu PL., et al. “Efficacy of a multimodal analgesia protocol in total knee arthroplasty: a randomized, controlled trial”. Journal of International Medical Research 38 (2010): 1404-1412.
2. Macfarlane JR., et al. “Does regional anaesthesia improve outcome after total hip arthroplasty? A systematic review”. British Journal of Anaesthesia 103 (2009): 335-345.
3. Ibrahim MS., et al. “Peri-operative interventions producing better functional outcomes and enhanced recovery following total hip and knee arthroplasty: an evidence-based review”. BMC Medicine 11 (2013): 37.
4. Erlenwein J., et al. “Clinical relevance of persistent postoperative pain after total hip replacement-a prospective observational cohort study”. Journal of Pain Research 10 (2017): 2183-2193.
5. Benditz A., et al. “Implementing a benchmarking and feedback concept decreases postoperative pain after total knee arthroplasty: a prospective study including 256 patients”. Scientific Reports 6 (2016): 38218.
6. Li J., et al. “Postoperative Pain Management in Total Knee Arthroplasty”. Orthopaedic Surgery 5 (2019): 755-761.
7. CM Bach., et al. “Scoring systems in total knee arthroplasty”. Clinical Orthopaedics and Related Research 399 (2002): 184-196.
8. GR Scuderi., et al. “The new knee society knee scoring system”. Clinical Orthopaedics and Related Research1 (2012): 3-19.
9. McCormack HM., et al. “Clinical applications of visual analogue scales: a critical review”. Psychological Medicine 18 (1988): 1007-1019.
10. Galindo RP., et al. “Periarticular regional analgesia in total knee arthroplasty: a review of the neuroanatomy and injection technique”. Orthopedic Clinics of North America 1 (2015): 1.
11. Roos EM., et al. “Knee injury and osteoarthritis outcome score (KOOS)--development of a self-administered outcome measure”. Journal of Orthopaedic and Sports Physical Therapy 2 (1998): 88-96.
12. Kehlet H and Aasvang EK. “Regional or general anesthesia for fast-track hip and knee replacement - what is the evidence?” F1000Research (2015): 1449.
13. DR Kerr and L Kohan. “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 79 (2008): 174.
14. CA Busch., et al. “Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial”. The Journal of Bone and Joint Surgery. American Volume 88 (2006): 959.
15. AV Maheshwari., et al. “Multimodal pain management after total hip and knee arthroplasty at the Ranawat Orthopaedic Center”. Clinical Orthopaedics 467 (2009): 1418.
16. HK Parvataneni., et al. “Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections. A prospective randomized study”. The Journal of Arthroplasty 22 (2007): 33.
17. Ashraf VV Raut., et al. “Pain control after primary total knee replacement. A prospective randomised controlled trial of local infiltration versus single shot femoral nerve block”. Knee20 (2013): 324.
18. K Kurosaka., et al. “Local infiltration analgesia versus continuous femoral nerve block in pain relief after total knee arthroplasty: a randomized controlled trial”. The Journal of Arthroplasty (2015).
19. MJ Spangehl., et al. “The Chitranjan Ranawat Award: periarticular injections and femoral and sciatic blocks provide similar pain relief after TKA: a randomized clinical trial”. Clinical Orthopaedics 473 (2015): 45.
20. Dahl V and Raeder JC. “Non-opioid postoperative analgesia”. Acta Anaesthesiologica Scandinavica 44 (2000): 1191.
21. Kehlet H., et al. “Postoperative opioid analgesia: time for a reconsideration”. Journal of Clinical Anesthesia 8 (1996): 441.
22. Dahl JB and Moiniche S. “Pre-emptive analgesia”. British Medical Bulletin 71 (2004): 17.
23. Jorgensen H., et al. “Effect of epidural bupivacaine vs combined epidural bupivacaine and morphine on gastrointestinal function and pain after major gynaecological surgery”. British Journal of Anaesthesia 87 (2001): 727.
24. Mullaji A., et al. “Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty: Aprospective, randomized trial”. The Journal of Arthroplasty 25 (2010): 851‑857.
25. Busch CA., et al. “Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial”. The Journal of Bone and Joint Surgery. American Volume 88 (2006): 959‑963.
26. Vendittoli PA., et al. “A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study”. The Journal of Bone and Joint Surgery. American Volume 88 (2006): 282‑289.
27. Toftdahl K., et al. “Comparison of peri‑ and intraarticular analgesia with femoral nerve block after total knee arthroplasty: A randomized clinical trial”. Acta Orthopaedica 78 (2007): 172‑179.
28. Alexander I. Clinical Orthopaedics and Related Research 457 (2007): 114-119.
29. Duthie DJ and WS Nimmo. “Adverse effects of opioid analgesic drugs”. British Journal of Anaesthesia 1 (1987): 61-77.
30. Murata-Ooiwa M., et al. “Intravenous Acetaminophen in Multimodal Pain Management for Patients Undergoing Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial”. The Journal of Arthroplasty 32 (2017): 3024-3028.
31. O'Neal JB., et al. “Intravenous vs Oral Acetaminophen as an Adjunct to Multimodal Analgesia After Total Knee Arthroplasty: A Prospective, Randomized, Double-Blind Clinical Trial”. Journal of Arthroplasty 32 (2017): 3029-3033.
32. Tammachote N., et al. “Is pain after TKA better with periarticular injection or intrathecal morphine?” Clinical Orthopaedics and Related Research 471 (2013): 1992‑1999.

Citation

Citation: Vivek Amrithbhai Patel., et al. “How Effective Is Intrawound periarticular Cocktail Injection and Postoperative Intravenous Paracetamol for Analgesia and Early Mobilization after Total Knee Arthroplasty (TKA)”.Acta Scientific Orthopaedics 6.7 (2023): 53-60.

Copyright

Copyright: © 2023 Vivek Amrithbhai Patel., et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.