title: Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial.
abstract: BACKGROUND
  Local infiltration analgesia (LIA)--using a combination of local anesthetics, nonsteroidal anti-inflammatory drugs, and epinephrine, injected periarticularly during surgery-has become popular in postoperative pain management after total knee arthroplasty (TKA). We compared intrathecal morphine with LIA after TKA.
  
  
  METHODS
  In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into 2 groups: group M, 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and in group L, LIA using ropivacaine, ketorolac, and epinephrine was infiltrated in the knee during the operation, and 2 bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization, and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during 3 months follow-up. The primary endpoint was IV morphine consumption the first 48 postoperative hours.
  
  
  RESULTS
  Mean morphine consumption was significantly lower in group L than in group M during the first 48 postoperative hours: 26 ± 15 vs 54 ± 29 mg, i.e., a mean difference for each 24-hour period of 14.2 (95% confidence interval [CI] 7.6 to 20.9) mg. Pain scores at rest and on movement were lower during the first 48 hours in group L than in group M (P < 0.001). Pain score was also lower when walking in group L than in group M at 24 hours and 48 hours postoperatively (P < 0.001). In group L, more patients were able to climb stairs at 24 hours: 50% (11 of 22) versus 4% (1 of 23), i.e., a difference of 46% (95% CI 23.5 to 68.5) and at 48 hours: 70% (16 of 23) versus 22% (5 of 23), i.e., a difference of 48% (95% CI 23 to 73). Median (range) time to fulfillment of discharge criteria was shorter in group L than in group M, 51 (24-166) hours versus 72 (51-170) hours. The difference was 23 (95% CI 18 to 42) hours (P = 0.001). Length of hospital stay was also shorter in group L than in group M: median (range) 3 (2-17) versus 4 (2-14) days (P = 0.029). Patient satisfaction was greater in group L than in group M (P = 0.001), but no differences were found in knee function, side effects, or in patient-related outcomes, Oxford Knee score, or EQ-5D.
  
  
  CONCLUSIONS
  LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, than did intrathecal morphine after TKA.
authors.affiliation: Department of Orthopedic Surgery, University Hospital, Örebro, Sweden. per.essving@orebroll.se
authors.forename: Per
authors.initials: P
authors.lastname: Essving
authors.forename: Kjell
authors.initials: K
authors.lastname: Axelsson
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Åberg
authors.forename: Henrik
authors.initials: H
authors.lastname: Spännar
authors.forename: Anil
authors.initials: A
authors.lastname: Gupta
authors.forename: Anders
authors.initials: A
authors.lastname: Lundin
mesh_terms: D000322:Adrenergic Agonists / Q000008:administration & dosage; D000368:Aged; D000369:Aged, 80 and over; D000577:Amides / Q000008:administration & dosage* / Q000009:adverse effects; D000698:Analgesia / Q000009:adverse effects / Q000379:methods*; D000701:Analgesics, Opioid / Q000008:administration & dosage* / Q000009:adverse effects; D000704:Analysis of Variance; D000779:Anesthetics, Local / Q000008:administration & dosage* / Q000009:adverse effects; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D016009:Chi-Square Distribution; D004311:Double-Blind Method; D004434:Early Ambulation; D004837:Epinephrine / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D020910:Ketorolac / Q000008:administration & dosage; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D009020:Morphine / Q000008:administration & dosage* / Q000009:adverse effects; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D017060:Patient Satisfaction; D011446:Prospective Studies; D020127:Recovery of Function; D000077212:Ropivacaine; D011795:Surveys and Questionnaires; D013548:Sweden; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000322:Adrenergic Agonists; D000577:Amides; D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D000894:Anti-Inflammatory Agents, Non-Steroidal; D009020:Morphine; D000077212:Ropivacaine; D004837:Epinephrine; D020910:Ketorolac