title: Long-term pain, stiffness, and functional disability after total knee arthroplasty with and without an extended ambulatory continuous femoral nerve block: a prospective, 1-year follow-up of a multicenter, randomized, triple-masked, placebo-controlled trial.
abstract: BACKGROUND
  Previously, we have demonstrated that extending a continuous femoral nerve block (cFNB) from overnight to 4 days after total knee arthroplasty (TKA) provides clear benefits during the infusion, but not subsequent to catheter removal. However, there were major limitations in generalizing the results of that investigation, and we subsequently performed a very similar study using a multicenter format, with many health care providers, in patients on general orthopedic wards, thus greatly improving inference of the results to the general population. Not surprisingly, the perioperative/short-term outcomes differed greatly from the first, more limited study. We now present a prospective follow-up study of the previously published, multicenter, randomized controlled clinical trial to investigate the possibility that an extended ambulatory cFNB decreases long-term pain, stiffness, and functional disability after TKA, which greatly improves inference of the results to the general population.
  
  
  METHODS
  Subjects undergoing TKA received a cFNB with ropivacaine 0.2% from surgery until the following morning, at which time patients were randomized to continue either perineural ropivacaine (n=28) or normal saline (n=26). Patients were discharged with their catheter and a portable infusion pump, and catheters were removed on postoperative day 4. Health-related quality of life was measured using the Western Ontario and McMaster Universities Osteoarthritis Index preoperatively and then at 7 days, as well as 1, 2, 3, 6, and 12 months after surgery. This index evaluates pain, stiffness, and physical functional disability. For inclusion in the analysis, we required a minimum of 4 of the 6 time points, including day 7 and at least 2 of months 3, 6, and 12.
  
  
  RESULTS
  The 2 treatment groups had similar Western Ontario and McMaster Universities Osteoarthritis scores for the mean area-under-the-curve calculations (point estimate for the difference in mean area under the curve for the 2 groups [overnight infusion group - extended infusion group]=3.8; 95% confidence interval, -3.8 to +11.3; P=0.32) and at all individual time points (P>0.05).
  
  
  CONCLUSIONS
  This investigation found no evidence that extending an overnight cFNB to 4 days improves (or worsens) subsequent pain, stiffness, or physical function after TKA in patients of multiple centers convalescing on general orthopedic wards.
authors.affiliation: Department of Anesthesiology, University of California San Diego, San Diego, CA 92103-8770, USA. bilfeld@ucsd.edu
authors.forename: Brian M
authors.initials: BM
authors.lastname: Ilfeld
authors.forename: Jonathan J
authors.initials: JJ
authors.lastname: Shuster
authors.forename: Douglas W
authors.initials: DW
authors.lastname: Theriaque
authors.forename: Edward R
authors.initials: ER
authors.lastname: Mariano
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Girard
authors.forename: Vanessa J
authors.initials: VJ
authors.lastname: Loland
authors.forename: Scott
authors.initials: S
authors.lastname: Meyer
authors.forename: John F
authors.initials: JF
authors.lastname: Donovan
authors.forename: George A
authors.initials: GA
authors.lastname: Pugh
authors.forename: Linda T
authors.initials: LT
authors.lastname: Le
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.forename: Scott T
authors.initials: ST
authors.lastname: Ball
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000379:methods*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D005260:Female; D005267:Femoral Nerve; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009407:Nerve Block / Q000379:methods; D010149:Postoperative Pain / Q000503:physiopathology / Q000517:prevention & control*; D011446:Prospective Studies; D020127:Recovery of Function / Q000187:drug effects / Q000502:physiology; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult