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Effect of Local Infiltration Analgesia, Peripheral Nerve Blocks, General Berninger et al. BMC Musculoskeletal Disorders (2018) 19:232 https://doi.org/10.1186/s12891-018-2154-z RESEARCHARTICLE Open Access Effect of local infiltration analgesia, peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in total knee arthroplasty M. T. Berninger1,2* , J. Friederichs2, W. Leidinger3, P. Augat4,5, V. Bühren2, C. Fulghum1 and W. Reng1 Abstract Background: Postoperative pain control and enhanced mobilization, muscle strength and range of motion following total knee arthroplasty (TKA) are pivotal requisites to optimize rehabilitation and early recovery. The aim of the study was to analyze the effect of local infiltration analgesia (LIA), peripheral nerve blocks, general and spinal anesthesia on early functional recovery and pain control in primary total knee arthroplasty. Methods: Between January 2016 until August 2016, 280 patients underwent primary TKA and were subdivided into four groups according to their concomitant pain and anesthetic procedure with catheter-based techniques of femoral and sciatic nerve block (group GA&FNB, n = 81) or epidural catheter (group SP&EPI, n = 51) in combination with general anesthesia or spinal anesthesia, respectively, and LIA combined with general anesthesia (group GA&LIA, n = 86) or spinal anesthesia (group SP&LIA, n = 61). Outcome parameters focused on the evaluation of pain (NRS scores), mobilization, muscle strength and range of motion up to 7 days postoperatively. The cumulative consumption of (rescue) pain medication was analyzed. Results: Pain relief was similar in all groups, while the use of opioid medication was significantly lower (up to 58%) in combination with spinal anesthesia, especially in SP&EPI. The LIA groups, in contrast, revealed significant higher mobilization (up to 26%) and muscle strength (up to 20%) in the early postoperative period. No analgesic technique-related or surgery-related complications occurred within the first 7 days. Due to insufficient pain relief, 8. 4% of the patients in the catheter-based groups and 12.2% in the LIA groups resulted in a change of the anesthetics pain management. Conclusions: The LIA technique offers a safe and effective treatment option concerning early functional recovery and pain control in TKA. Significant advantages were shown for mobilization and muscle strength in the early postoperative period while pain relief was comparable within the groups. Keywords: Local infiltration analgesia, Femoral nerve block, Total knee arthroplasty, Epidural catheter, General anesthesia, Spinal anesthesia * Correspondence: [email protected] 1endogap, Joint Replacement Institute, Garmisch-Partenkirchen Medical Center, Auenstr. 6, 82467 Garmisch-Partenkirchen, Germany 2Department of Trauma Surgery, BG Trauma Center Murnau, Prof.-Küntscher Str. 8, 82418 Murnau, Germany Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Berninger et al. BMC Musculoskeletal Disorders (2018) 19:232 Page 2 of 9 Background analgesia, particularly due to the side effects and early Postoperative pain after total knee arthroplasty (TKA) is mobilization [16–18]. The comparability of the results of still a challenging issue. For a successful outcome, pain previous trials is, however, restricted by different control following TKA is essential to achieve early anesthesia procedures (general versus spinal anesthesia) mobilization, good functional outcome, optimal rehabili- and systemic pain medication. tation and enhanced recovery [1]. Therefore, the primary In literature, there is no study analyzing the effect of goals of peri- and postoperative analgesic treatment are LIA, (peripheral) catheter-based techniques and their to reduce pain and immobilization and to minimize opi- combination with general or spinal anesthesia in one pa- oid requirements and opioid-related adverse events. En- tient collective on pain control, mobilization, muscle hancing these outcomes has a potential beneficial strength and range of motion for up to 7 days postoper- influence on patient morbidity and satisfaction, the de- atively. The hypothesis of this study was that each gree of required postoperative care, as well as economic anesthetic procedure directly influences the immediate perspectives. postoperative status of the patient in terms of pain con- There is a considerable debate on the optimal form of trol, mobilization, muscle strength and range of motion. postoperative analgesia in total knee replacement [2]. Therefore, the aim of the study was to analyze the effect Several peri- and postoperative pain control strategies of femoral nerve block and general anesthesia (group have been established in the last years including periph- GA&FNB), epidural catheter and spinal anesthesia eral nerve blocks, epidural analgesia as well as local infil- (group SP&EPI), LIA combined with general anesthesia tration analgesia (LIA) and (systemic) opioids [1]. (group GA&LIA) and spinal anesthesia (group SP&LIA), Regional anesthesia techniques are widely used to de- respectively, on early functional recovery and pain con- liver intraoperative analgesia and to minimize postopera- trol in primary TKA. tive pain after TKA [1, 3]. In general, femoral nerve blocks (FNB) are the preferred method for postoperative Methods pain reduction by blocking the femoral nerve, the lateral Patients femoral cutaneous nerve and branches of the obturator During the period from January 2016 until August 2016, nerve; however, pain - especially in the popliteal space - 300 patients underwent primary TKA in a single center may not be completely under control [4]. Therefore, the for alloplasty. Finally, a total of 280 patients were eligible combination of FNB with a sciatic nerve block (SNB) for the study having received general or spinal anesthesia seems to be a suitable option to optimize pain manage- in combination with a FNB, epidural catheter or LIA. The ment [5, 6]. In terms of pain control, epidural anesthesia inclusion criterion was primary TKA for osteoarthritis. in knee surgery did not show any advantages compared Patients were excluded if they had a primary constrained to regional analgesia such as FNB [3]. However, it may prosthesis, secondary arthritis due to rheumatoid arthritis result in a higher side-effect profile including severe or trauma, osteonecrosis or revision surgery. This study neuraxial complication compared to FNB [7, 8]. was performed in conformity with the Declaration of As an alternative method for postoperative pain con- Helsinki and was approved by the Ethics Committee of trol after TKA, LIA around the soft tissues of replaced the Bavarian State Chamber of Physicians (ID: 2017–109). knee joints was introduced by Kerr and Kohan in 2008 Patient demographics, surgery details, and clinical data are with an increasing interest in recent years [9]. The anal- shown in Table 1. Pain medication and use of opioids gesic agents are intraoperatively administered by the sur- prior to the surgery in daily life were elaborated from the geon to block pain conduction directly. Thereby, patients’ medical history. systemic side effects associated with postoperative anal- Patients were retrospectively divided into 4 groups ac- gesics as well as additional invasive procedures (e.g. ad- cording to their received anesthetic and peri-and postop- ministration of analgesic catheters) for pain erative analgesic procedure as follows: management are minimized. Moreover, compared to Group GA&FNB: General anesthesia + FNB/SNB n = 81. peripheral nerve blockades LIA lacks the possible disad- Group SP&EPI: Spinal anesthesia + epidural cath- vantage of motor impairment and quadriceps weakness, eter n =51. the risk of nerve injury or limitation of patient ability to Group GA&LIA: General anesthesia + LIA n =86. ambulate in the immediate postoperative period [10]. Group SP&LIA: Spinal anesthesia + LIA n = 61. Several studies successfully demonstrated significant pain relief and reduced opioid requirements in the early Anesthetic techniques postoperative period by use of LIA compared to placebo After induction of general anesthesia, patients allocated [11–13] or (peripheral) analgesic catheters [14, 15]. Data to GA&FNB had a FNB catheter inserted with real-time comparing LIA with continuous epidural analgesia are monitored ultrasound imaging. A total of 20 ml of 0.1% limited and favor LIA over continuous epidural ropivacaine was injected around the femoral nerve; Berninger et al. BMC Musculoskeletal Disorders (2018) 19:232 Page 3 of 9 Table 1 Patients demographics and clinical data GA&FNB SP&EPI GA&LIA SP&LIA Patients n =82 n=51 n=86 n=61 Gender f = 48; m = 34 f = 31; m = 20 f = 52; m = 34 f = 38; m = 23 Age 67 ± 11.4 71 ± 9.3 68 ± 10.2 70 ± 9.0 Chronic pain patient n = 5(6.1%) with opioid: n =2 n=2(3.9%) with opioid: n =1 n=5(5.8%) with opioid: n =3 n=2(3.3%) with opioid: n = 1 Piritramide OP: n =34(41.4%): 10.0 mg ± 5.4 OP: n = 6 (11.8%):
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