title: Patient-controlled epidural analgesia or multimodal pain regimen with periarticular injection after total hip arthroplasty: a randomized, double-blind, placebo-controlled study.
abstract: BACKGROUND
  The optimal postoperative analgesia after primary total hip arthroplasty remains in question. This randomized, double-blind, placebo-controlled study compared the use of patient-controlled epidural analgesia (PCEA) with use of a multimodal pain regimen including periarticular injection (PAI). We hypothesized that PAI would lead to earlier readiness for discharge, decreased opioid consumption, and lower pain scores.
  
  
  METHODS
  Forty-one patients received PAI, and forty-three patients received PCEA. Preoperatively, both groups were administered dexamethasone (6 mg, orally). The PAI group received a clonidine patch and sustained-release oxycodone (10 mg), while the PCEA group had placebo. Both groups received combined spinal-epidural anesthesia and used an epidural pain pump postoperatively; the PAI group had normal saline solution, while the PCEA group had bupivacaine and hydromorphone. The primary outcome, readiness for discharge, required the discontinuation of the epidural, a pain score of <4 (numeric rating scale) without parenteral narcotics, normal eating, minimal nausea, urination without a catheter, a dry surgical wound, no acute medical problems, and the ability to independently transfer and walk 12.2 m (40 ft).
  
  
  RESULTS
  The mean time to readiness for discharge (and standard deviation) was 2.4 ± 0.7 days (PAI) compared with 2.3 ± 0.8 days (PCEA) (p = 0.86). The mean length of stay was 3.0 ± 0.8 days (PAI) compared with 3.1 ± 0.7 days (PCEA) (p = 0.46). A significant mean difference in pain score of 0.74 with ambulation (p = 0.01; 95% confidence interval [CI], 0.18 to 1.31) and 0.80 during physical therapy (p = 0.03; 95% CI, 0.09 to 1.51) favored the PCEA group. The mean opioid consumption (oral morphine equivalents in milligrams) was significantly higher in the PAI group on postoperative day 0 (43 ± 21 compared with 28 ± 23; p = 0.002) and postoperative days 0 through 2 (136 ± 59 compared with 90 ± 79; p = 0.004). Opioid-Related Symptom Distress Scale (ORSDS) composite scores for severity and bothersomeness as well as scores for nausea, vomiting, and itchiness were significantly higher in the PCEA group (p < 0.05). Quality of Recovery-40 scores and patient satisfaction were similar.
  
  
  CONCLUSIONS
  PAI did not decrease the time to discharge and was associated with higher pain scores and greater opioid consumption but lower ORSDS scores compared with PCEA. The choice for analgesic regimen may depend on a particular patient's threshold for pain and the potential side effects.
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Kethy M
authors.initials: KM
authors.lastname: Jules-Elysee
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Amanda K
authors.initials: AK
authors.lastname: Goon
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Geoffrey H
authors.initials: GH
authors.lastname: Westrich
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Padgett
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: David J
authors.initials: DJ
authors.lastname: Mayman
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Amar S
authors.initials: AS
authors.lastname: Ranawat
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Chitranjan S
authors.initials: CS
authors.lastname: Ranawat
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Yi
authors.initials: Y
authors.lastname: Lin
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Kahn
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Devan D
authors.initials: DD
authors.lastname: Bhagat
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Enrique A
authors.initials: EA
authors.lastname: Goytizolo
authors.affiliation: Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Avenue, 5th Floor, Washington, DC 20052. E-mail address: yanma@gwu.edu.
authors.forename: Yan
authors.initials: Y
authors.lastname: Ma
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Shane C
authors.initials: SC
authors.lastname: Reid
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Jodie
authors.initials: J
authors.lastname: Curren
authors.affiliation: Departments of Anesthesiology (K.M.J.-E., A.K.G., Y.L., R.L.K., D.D.B., E.A.G., S.C.R., J.C., J.T.Y.) and Orthopedic Surgery (G.H.W., D.E.P., D.J.M., A.S.R., C.S.R.), Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021. E-mail address for K.M. Jules-Elysee: juleselyseek@hss.edu.
authors.forename: Jacques T
authors.initials: JT
authors.lastname: YaDeau
mesh_terms: D000279:Administration, Cutaneous; D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural / Q000379:methods*; D016058:Analgesia, Patient-Controlled / Q000379:methods*; D000700:Analgesics / Q000008:administration & dosage; D019644:Arthroplasty, Replacement, Hip; D003000:Clonidine / Q000008:administration & dosage; D004311:Double-Blind Method; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D007270:Injections, Intra-Articular; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010098:Oxycodone / Q000008:administration & dosage; D010147:Pain Measurement; D010149:Postoperative Pain / Q000517:prevention & control*; D017060:Patient Satisfaction; D011182:Postoperative Care / Q000379:methods; D016896:Treatment Outcome
chemical_list: D000700:Analgesics; D010098:Oxycodone; D003000:Clonidine