The Chitranjan Ranawat Award: Periarticular injections and femoral & sciatic blocks provide similar pain relief after TKA: a randomized clinical trial.
BACKGROUND
Two of the more common methods of pain management after TKA are peripheral nerve blocks and intraarticular/periarticular injections. However, we are not aware of any study directly comparing the commonly used combination of a continuous femoral block given with a single-shot sciatic block with that of a periarticular injection after TKA.


OBJECTIVE
This randomized clinical trial compared a combined femoral and sciatic nerve block with periarticular injection as part of a multimodal pain protocol after total knee arthroplasty with respect to (1) pain; (2) narcotic use; (3) quadriceps function and length of stay; and (4) peripheral nerve complications.


METHODS
One hundred sixty patients completed randomization into two treatment arms: (1) peripheral nerve blocks (PNB; n=79) with an indwelling femoral nerve catheter and a single shot sciatic block; or (2) periarticular injection (PAI; n=81) using ropivacaine, epinephrine, ketorolac, and morphine. All patients received standardized general anesthesia and oral medications. The primary outcome was postoperative pain, on a 0 to 10 scale, measured on the afternoon of postoperative day 1 (POD 1). Secondary outcomes were narcotic use, quadriceps function, length of stay, and peripheral nerve complications.


RESULTS
Mean pain scores on the afternoon of POD 1 were not different between groups (PNB group: 2.9 [SD 2.4]; PAI group: 3.0 [SD 2.2]; 95% confidence interval, -0.8 to 0.6; p=0.76). Mean pain scores taken at three times points on POD 1 were also similar between groups. Hospital length of stay was shorter for the PAI group (2.44 days [SD 0.65] versus 2.84 days [SD 1.34] for the PNB group; p=0.02). Narcotic consumption was higher the day of surgery for the PAI group (PAI group: 11.7 mg morphine equivalents [SD 13.1]; PNB group: 4.6 mg [SD 9.1]; p<0.001), but thereafter, there was no difference. More patients in the PNB group had sequelae of peripheral nerve injury (mainly dysesthesia) at 6-week followup (nine [12%] versus one [1%]; p=0.009).


CONCLUSIONS
Patients receiving periarticular injections had similar pain scores, shorter lengths of stay, less likelihood of peripheral nerve dysesthesia, but greater narcotic use on the day of surgery compared with patients receiving peripheral nerve blocks. Periarticular injections provide adequate pain relief, are simple to use, and avoid the potential complications associated with nerve blocks.


METHODS
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Department of Orthopaedic Surgery, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ, 85054, USA, spangehl.mark@mayo.edu.
Mark J
MJ
Spangehl
Henry D
HD
Clarke
Joseph G
JG
Hentz
Lopa
L
Misra
Joshua L
JL
Blocher
David P
DP
Seamans
D000322:Adrenergic Agonists / Q000008:administration & dosage; D000368:Aged; D000700:Analgesics / Q000008:administration & dosage* / Q000009:adverse effects; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000779:Anesthetics, Local / Q000008:administration & dosage; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000008:administration & dosage; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects*; D001363:Awards and Prizes; D005260:Female; D005267:Femoral Nerve; D006801:Humans; D007270:Injections, Intra-Articular; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D009407:Nerve Block / Q000009:adverse effects / Q000379:methods*; D010147:Pain Measurement; D010149:Postoperative Pain / Q000175:diagnosis / Q000209:etiology / Q000517:prevention & control*; D010523:Peripheral Nervous System Diseases / Q000209:etiology; D052097:Quadriceps Muscle / Q000503:physiopathology / Q000601:surgery*; D020127:Recovery of Function; D012584:Sciatic Nerve; D013997:Time Factors; D016896:Treatment Outcome
D000322:Adrenergic Agonists; D000700:Analgesics; D000701:Analgesics, Opioid; D000779:Anesthetics, Local; D000894:Anti-Inflammatory Agents, Non-Steroidal