LOCAL INFILTRATION TECHNIQUE IN UNILATERAL TOTAL KNEE REPLACEMENT

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1 Page6604 Indo American Journal of Pharmaceutical Research, 2016 ISSN NO: LOCAL INFILTRATION TECHNIQUE IN UNILATERAL TOTAL KNEE REPLACEMENT Ardeshna A Nishita 1, Bashwanth Pasupulati 1, Dr. Basavaraj CM 2, Dr. Vinay Pawar 2 1 PES College of Pharmacy, Bangalore. 2 BGS Global Hospital, Bangalore. ARTICLE INFO Article history Received 28/07/2016 Available online 08/10/2016 Keywords TKR and THR, LIA Protocol. Corresponding author Ardeshna A Nishita PES college of Pharmacy, Bangalore. ABSTRACT INTRODUCTION: The most effective treatment for osteoarthritis is TKR and THR but sizeable patient experience chronic pain causing discomfort. There has been shift in the usage of local anesthesia technique (LIA) over the general anesthesia in orthopedic surgeries mainly TKR. Pain control is important post surgery which includes opioid use, and other analgesics. LIA technique has taken increased focus due to early rehabilitation in patients with TKR and THR. METHOD: It was prospective, non-interventional and observational study. RESULTS: Outcomes were assessed with regards to the pain score and analgesic use post LIA. Patients with this technique experienced early mobilization and better pain control after surgery. There was decreased in the opioid usage and increased patient satisfaction. Break-through pain was also found to have decreased with LIA comparatively with only analgesic usage. CONCLUSION: The use of preoperative patient education as an important component in their fast-track recovery program. LIA protocol can achieve meaningful results and can be easily implemented both in tertiary care centers & community hospitals. Please cite this article in press as Ardeshna A Nishita et al. Local Infiltration Technique in Unilateral Total Knee Replacement.Indo American Journal of Pharmaceutical Research.2016:6(09). Copy right 2016 This is an Open Access article distributed under the terms of the Indo American journal of Pharmaceutical Research, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 Page6605 INTRODUCTION THR and TKR is an effective treatment for painful osteoarthritis, used these days to treat diseased Joints (1).Sizeable proportion of people often report chronic postoperative pain. After the surgery, pain is usually severe in intensity which causes uneasiness and discomfort to the patients causing influence in functional recovery. Pain is exaggerated during rest and on mobilization by 55% and 70% respectively; may be high or very high intensity and also it goes upto 3-6 hours after the surgery and it can go up to 72 hours also (2). Primary indication for TKR or any surgery is pain which can be rehabilitated to reduce. Both short term and long term pain associated with TKR is very common (3). Pain control can be sometimes insufficient which interferes with patients daily activities (4). Regimens are available which gives immediate relief and early mobilization which includes spinal and epidural anesthetics and also use of opioids may lead to good rehabilitation (5). Studies have shown to have better pain control with continuous intra-articular infusion which leads to less opioid use (6) (7) and consumption of rescue analgesics (8). Despite major side effects, parenteral narcotics also plays an important role in postoperative pain control (9).Easy implementable interventions can be administered to patients undergoing joint replacement which can reduce chronic pain after surgery. At the core of improved recovery of patients, it is important to mobilize early. Therefore, perioperative analgesia is very essential for enhanced recovery, and it starts with group of anesthetics. In recent years, there has been shift in the usage of local anesthesia over the general anesthesia in orthopedic surgeries mainly TKR(10).General anesthesia is found to have lower incidences of hypotension whereas, regional anesthesia is not associated with PONV and it also have reduce risk of pulmonary embolism, MI, DVT, pneumonia, delirium etc (11). To optimize the pain control in early postoperative, many regimens are trying to lead a better outcome. They include, peripheral nerve blocks (e.g., femoral, combined femoral and sciatic, and lumbar plexus blocks) and PAI directly to the joints. Both single and continuous infusion can be used for 24 to 48 hours postoperatively. There has been variable results found with the use of both (12)(13). To develop safe & effective opioid sparing analgesia, were avoiding the complication of peripheral nerve block; resulted in increased focus on LIA in the joint replacement surgeries (14). There is supportive & growing evidences upon the use of LIA techniques. Several case series &randomized controlled trail in last five years have been reported on this. Maximum evidences have been found with the use in TKR when compared to THR. Most studies resulted in the observation related to reduce use of opiates in early postoperative pain and the length of the hospital stay also reduced with minimal complications (15)(16). LIA technique is taken trend which might include with or without local administration with a catheter (17) (18) (19). LIA technique was first introduced by Kohan and Kerr in Sydney which involved the procedure at the surgical site using high volume of anesthesia which was long lasting with adrenaline (20). It acts by mechanism of blocking the pain at the nociceptive stimulus at surgical site (21). LIA offers the benefits of blocking pain influx at its origin and maximizing muscle control. It has many advantages when compared to local or systemic treatment approaches (22)(23). Consideration of the side effects, good analgesia protocol should be made which blocks the pain influx, inhibits venous stasis and optimizes optimize postoperative rehabilitation. LIA achieves these goals. Pain management is also done by the use of IV opioids and epidural analgesia with oral analgesia and cryotherapy (24). But this treatments tend to have several side-effects like nausea, emesis, sedation, urinary retention and hypotension (25). NSAIDs are also used for pain control but it also has side-effects like nausea, respiratory depression (26). Another common method is epidural analgesia which is effective pain control compared to other methods but it has disadvantages of motor block and delay in physiotherapy methods. It also has risk of epidural hematoma when involves in both needs (27). In studies Use of LIA after arthroplasty have shown good analgesia effect when compared to epidural analgesia (28). Preoperative identification of patients at high risk of a poor outcome has proved challenging, and until better predictive models can be developed, it is unfeasible to target interventions at high-risk patients (29). METHODOLOGY The Study site was PES College of Pharmacy in association with quaternary care hospital, orthopedic department, Bangalore. It was prospective and non-interventional observational study. It was carried out from September 2014 till the date. Study includes 76 patients undergoing treatment TKR unilaterally. There was No risk related to participation, sharing of confidential information and change in treatments. Benefit to the patient was given for better quality of life in controlling the post-operative pain. Data collection: Inclusion criteria were Patients who are underwent local infiltration technique for pain control after TKR. Patients of all age groups & both genders who are underwent therapy. All co-morbidity conditions subjects were included. Other conditions like obese, smoker, alcoholics were also included. Patients with history of rheumatoid Arthritis or osteoarthritis were included with both varus and valgus deformity.lia given to the patients were noted with drug administration with respect to content of infiltrate, amount and dosage. Pain assessment: Pain score was measured with visual analogue scale(vas). Were with 0 representing as no pain & 10 as worst imaginable pain. It was measured on daily basis till the patient is discharged to compare the effectiveness of LIA.Those patients who meet the study criteria will be enrolled into the study. Pain was assessed in both rest and mobilizing time. Pain score on daily basis with both before using LIA procedure and after LIA was noted for comparison. TheResults wasanalyzed using suitable methods using MS EXCEL. Outcomes: It was studied were pain at rest and during activity atbefore and after surgery, opioid consumption, mobilization,length of hospital stay in days, and long-termpain and function. Serious complications recorded were noted, if any found.

3 Page6606 Local infiltration technique: The anatomical landmarks of the knee and proposed portals for the arthroscope and instruments were outlined in pen. Routine medial and lateral parapatellar portals were used for the arthroscope and instruments and these were infiltrated with 5 ml of the local anestheticsolution. A drain site marked superolaterally was infiltrated with 5 ml of local anesthetic solution and through this portal the remaining solution was injected into the knee. The patient's leg was then draped with a sterile towel and the patient was encouraged to move the knee in order to spread the solution throughout the joint. The patient was returned to the ward to allow the anesthetic to take effect. The anesthetic took approximately 5 min to work. Logistically, returning the patient to the ward was not a problem, as the Day Ward was adjacent to the theatre suite (30). RESULTS: MEDICATION USED DURING ONLY ANALGESIA CONTROL: VARIABLES N=76 MALE FEMALE AGE DISTRIBUTION TYPE OF DISEASE OSTEOARTHRITIS RHEUMATOID ARTHRITIS 31(40.8%) 45(59.2%) 5(6.5%) 14(18.4%) 26(34.2%) 28(36.8%) 3(3.9%) 68(89.6%) 8(10.4%) MEDICATION USED DURING LIA TECHNIQUE: PAIN SCORE WITH ONLY ANALGESIA CONTROL:

4 Page6607 PAIN CONTROL WITH LIA: AVERAGE BREAK-THROUGH PAIN SCORE: MEAN DISCHARGE TIME AFTER LIA:

5 Page6608 DISCUSSION Our systematic review represents a comprehensive evaluation of the effectiveness of post-operative LIA (local anesthetic infiltration) in TKR. We showed the PAI group manifested better pain control during the first 6 hours postoperatively. There was decreased use of analgesic was observed with LIA technique due to decrease pain scores. Patient was found to have average one scale down compared with non-lia procedure. Length of stay was found to be same but rapid recovery was noted among LIA group of patients. Patients with restricted analgesia had higher pain score and recovery time dropped comparatively.patients been noticed with mobility within 8hours of surgery with greatest range of motion of the knees. Largest flexion range at discharge was observed. Pain and the range of motion was comparatively better with this technique. At the drop of plasma level of analgesics patient receives breakthrough pain. With LIA technique break-through pain was minimal and controllable. Due to which opioids analgesics were not used and was controlled with other NSAIDs. Many evidences have supported to manage early postoperative pain. In one of the studies its show to have reduced morphine consumption than control group upto 40 hours postoperatively. Adding ketorolac to the ropivacaine and epinephrine for LIA technique even more reduces the Pain score. Epinephrine reduces the toxicity caused by the local anesthetics when administrating locally on the area of site (31). FNB (Femoral Nerve Block) can also be done safely compared to epidural block with anticoagulants (32). FNB with SNB (Sciatical Nerve Block) combination was found to be more effective analgesics after surgery (33). But benefit of this combination to improve the analgesia effect is controversial these days (34). The majority use of these are restricted to THR as of only limited supporting evidences are found. With the use of these option many studies have found reduce use of opioids and length of stay without any severe complications. Few studies have found the rapid use of long lasting anesthetics like ropivacaine with adrenaline as it is more long lasting than bupivacaine and have less side effects on cardiac and CNS toxicity (35). Busch et al studied on patients undergoing unilateral TKR were they received either a multimodal infiltration consisting of ropivacaine, ketorolac, epimorphine & adrenaline and other group as nothing. They observed reduction in patient controlled analgesic use for over first 24 hours and also had improved satisfaction from patients. No side effects and no changes in the length of the hospital stay was observed (36). Rehabilitation immediately starts after the surgery is done in the postoperative wards hence they require adequate amount of analgesia. Ideal rehabilitation analgesia should permit knee flexion and reduced pain without any motor impairment which finally results in successful mobilization of the patient (37). This accelerated recovery was attributed to improved walking capacity and less quadriceps impairment. Studies have investigated that local analgesia after TKA proves beneficial (38)(39), except for Badner et al, were the study using intra articular injection failed to reduce the usage of narcotics after orthopedic surgeries (38). One of the studies found decrease in early postoperative pain when comparative study of LIA and narcotics was done (40). Carli et al showed that combining posterior knee capsule local anesthetic infiltration and femoral nerve block reduced morphine consumption and pain at rest during the first 48 hours post-surgery in comparison to PAI alone. These confirms that the sensitive sciatic nerve territory of the knee is not covered by a femoral nerve block alone (41). Combination of this adds a complexity to the patient care and many other factors also have shown for success of LIA protocol. LIA through the evacuation drain, reduced the discharge medications. One study had used increased anesthetic dose were the results varied (42). Addition of adrenaline to the cocktail would slow down the release of ropivacaine in vascular system and it also prolongs the duration of action. No patients in our research study have found to have ADRs. Where, ropivacaine doesnot lead to have toxic blood levels (43). Our cocktail mixture did not contain corticosteroids and ketorolac. It is reported that addition will lead to reduced intensity of pain (44). Corticosteroid provides effective analgesia (45). Possibility of infection exists when it is performed prior to surgery but during operation LIA is reported safe when regard to the infection (46). Approximately % of the TKR cases irrelevant to nerve block had impaired mobility of the area supplied by paroneal nerve after plasty of the nerve (47). Patients response differently to analgesia due to difference in post-operative pain. This can be analyzed by pain test, customized analgesia for each patient to achieve recovery faster. Dosage should be calculated based on pain response and BMI for every patient (48).

6 Page6609 PAI technique have reported to be effective without any major side-effects. Postoperative analgesics is limited by the duration of local infiltration (49)(50). Some Randomized trials investigated the optimal technique for postoperative administration of additional local anesthetics to prolong analgesia are lacking. Except for studies which reported limited or zero analgesic effect of intraarticular administration of local anesthetics(51).it is also found that interventions can reduce neuropathic pain at a span of 12 months were routine use of infiltration can be benefit patient who otherwise experience severe long term neuropathic pain after surgery, which is difficult to treat when established (29). CONCLUSION Use of peri-operative recovery program has decreased hospital stay in TKR patients with no hospital readmission. Furthermore, early rehabilitation with post-operative and pre-operative education were rapid recovery was achieved. Better suggestion can be given if more studies are performed with regards to utilization of analgesia in pain control. Primary concern is the effective management of post-operative pain in TKR, choice of anesthetic is determined by patient comorbidities and other factors offering different clinical pathways. Many regional anesthesia techniques are commonly used like FNB & SNB. Though this techniques are popular, insufficient data are not found on benefits and risk. New physical therapy has also helped in reducing pain and achievement of goals. Preference is highly to local infiltration compared to surgeon controlled analgesia were slight improvement in clinical outcome and patient s satisfaction is seen.this explains the earlymobilization and earlier discharge of patients who received local anesthetic infiltration, irrespective of alternative pain.(52). However, the reason for such a discrepancy might relate to the difference in patient s selection, and different kind oflocal anesthetics used.patients were much satisfied during the first 2 days after TKR and could be discharged earlier from the hospital. It isimportant to identify the program arenecessary and important to achieve positive clinicaloutcomes. Several authors havedescribed the use of preoperative patient education as animportant component in their fast-track program(53). However, this alone does not improve pain, functioning and length of stay (54). In conclusion, LIA protocol achieves meaningful results and can be easily implemented both in tertiary care centers & community hospitals. Authors of this article recommends for future review. REFERENCES 1. National Joint Registry for England and Wales: 10th Annual Report. Hemel Hempstead: NJR; Brasseur L, Boukhatem P: The epidemiology of postoperative pain [in French]. 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