title: Efficacy of Surgical-Site, Multimodal Drug Injection Following Operative Management of Femoral Fractures: A Randomized Controlled Trial.
abstract: BACKGROUND
  Multimodal analgesia inclusive of periarticular injection with a local anesthetic agent has been rapidly assimilated, with demonstrated safety and efficacy, into the care of patients undergoing elective lower-extremity arthroplasty. The present study was performed to evaluate the efficacy and safety of a surgical-site, multimodal drug injection for postoperative pain control following operative management of femoral fractures.
  
  
  METHODS
  There were 102 patients undergoing operative intervention (plate fixation, intramedullary device, or arthroplasty) for a broad range of femoral fracture patterns who were prospectively randomized either to receive an intraoperative, surgical-site injection into the superficial and deep tissues containing ropivacaine, epinephrine, and morphine or to receive no injection. Visual analog scale (VAS) scores were recorded at regular intervals as the primary outcome measure. Narcotic consumption and medication-related side effects were also monitored.
  
  
  RESULTS
  The injection group demonstrated significantly lower VAS scores (p < 0.05) than the control cohort in the recovery room and at the 4, 8, and 12-hour postoperative time points. The median score (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group immediately postoperatively, 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours, 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours, and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours. Additionally, narcotic consumption was significantly lower (p = 0.007) in the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]) over the first 8 hours following the surgical procedure. No cardiac or central nervous system toxicity was observed secondary to infiltration of the local anesthetic.
  
  
  CONCLUSIONS
  Surgical-site injection with a multimodal analgesic cocktail provides improved pain control and reduces narcotic utilization over the first postoperative day, with no observed adverse effects attributable to the local injection, across a diverse orthopaedic trauma population undergoing operative intervention for femoral fractures.
  
  
  METHODS
  Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: 1Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa.
authors.forename: Daniel
authors.initials: D
authors.lastname: Koehler
authors.forename: J Lawrence
authors.initials: JL
authors.lastname: Marsh
authors.forename: Matthew
authors.initials: M
authors.lastname: Karam
authors.forename: Catherine
authors.initials: C
authors.lastname: Fruehling
authors.forename: Michael
authors.initials: M
authors.lastname: Willey
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000577:Amides / Q000627:therapeutic use; D000698:Analgesia / Q000379:methods; D016058:Analgesia, Patient-Controlled; D000700:Analgesics / Q000627:therapeutic use*; D001178:Arthroplasty / Q000009:adverse effects*; D001860:Bone Plates; D004837:Epinephrine / Q000627:therapeutic use; D005260:Female; D005264:Femoral Fractures / Q000601:surgery*; D005592:Fracture Fixation / Q000009:adverse effects*; D006801:Humans; D007270:Injections, Intra-Articular; D008297:Male; D008875:Middle Aged; D009020:Morphine / Q000627:therapeutic use; D010147:Pain Measurement; D010149:Postoperative Pain / Q000188:drug therapy* / Q000209:etiology; D000077212:Ropivacaine; D016896:Treatment Outcome
chemical_list: D000577:Amides; D000700:Analgesics; D009020:Morphine; D000077212:Ropivacaine; D004837:Epinephrine