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