Local Infiltration Analgesia 4. Safety Issues 5. Outcomes 6. Thrombophylaxis and Local Infiltration Analgesia 7. Infection and Local Infiltration Analgesia 8. Postoperative Care Implentation - Making It Work Appendixes. More Books in Anaesthetics See All. In Stock. Stoelting's Pharmacology and Physiology in Anesthetic Practice.
Low Back Disorders. Westmead Anaesthetic Manual 4th edition. Pain Free For Women. Pharmacology for Anaesthesia and Intensive Care. Psychiatric Drugs Explained 6e. Giving up the Ghost : A Memoir. Pain is Really Strange Is Really Strange. Perioperative Medicine for the Junior Clinician. Take back control. Item Added: Local Infiltration Analgesia. View Wishlist. Complications were compared between randomised groups using meta-analysis with summary statistics calculated as the Peto odds ratio OR , the method of choice when event rates are low [ 14 , 25 ].
Wound infiltration anaesthesia regimens for interventions and comparators controls. Further analyses report the comparisons C, D and E. We quantified the differences in treatment effects between groups using meta-regression. Sensitivity and sub-group analyses explored risk of bias in the study, use of additional analgesia delivered through a catheter or injection, and inclusion of non-steroidal inflammatory agents or steroids in the infiltrate.
Systematic review flow diagram. Inspection of funnel plots for each meta-analysis gave no strong indication of publication bias or small study effects, but numbers of studies in individual analysis groups were small such that it was difficult to assess asymmetry. Randomised controlled trials of local anaesthetic infiltration in total knee and hip replacement.
Intervention treatment infiltrate volume Further treatment if given. Aguirre et al. Further continuous infusion through catheter. Continuous infusion of saline through catheter. Andersen KV et al. Andersen LJ et al. Spinal anaesthesia, self-administered oral oxycodone as rescue medication.
No losses to follow up Low risk of bias. Saline placebo infiltration Saline placebo infused through catheter on day 1. Bianconi et al. Spinal anaesthesia. Loading dose of intravenous morphine at end of surgery. No placebo infiltration during surgery. Busch et al.
Dobie et al. Intention to treat results. Some data missing for 1 control Low risk of bias. Lee et al. Pre-emptive analgesia with oral Oxycodone and Celecoxib. Epidural anaesthesia. Post-operative oral Oxycodone and paracetamol. No pre-emptive analgesia No epidural No injection during surgery Post-operative intravenous PCA and oral and injected analgesics as required. Liu et al. Lu et al. COX-2 inhibitor before surgery.
COX-2 inhibitor after surgery. No COX-2 inhibitor before surgery. No COX-2 inhibitor after surgery. Lunn et al. Murphy et al. Parvataneni et al.
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Hip [ 28 ] USA — Rikalainen-Salmi et al. Affas et al. TKR, No losses to follow up. Missing data analysis reported.
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Unclear risk of bias blinding of outcome assessment. Further intra-articular infiltration through catheter after surgery. Femoral nerve block. Intravenous ketorolac after surgery. No placebo infiltration. Further continuous infusion through catheter after closure. Epidural infusion of ropivacaine. Post-operative intravenous ketorolac. Carli et al. TKR, OA, tricompartmental, cemented.
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Solution of ropivacaine 0. Further infusion through catheter after closure. Continuous femoral nerve block Saline injection Post-surgical infusion of saline. Chen et al. Essving et al. No placebo injections during surgery. Spinal plus intrathecal saline. Spinal plus intrathecal morphine No injection during surgery Post-surgical infusion of saline through catheter. Fu et al. Missing data imputation described Low risk of bias. Han et al. No losses to follow up reported Low risk of bias. Koh et al. Results reported by intention to treat Low risk of bias.
Krenzel et al. Mahadevan et al. Meftah et al. Pain at rest and ambulation, readiness for discharge. Ng et al. Patients having both knees replaced. Femoral catheter inserted and saline infused. Knee [ 28 ] USA — No infiltration during surgery Femoral nerve block at end of surgery Post surgical PCA Effort to conceal allocation but no sham epidural. Spreng et al. Knee injected through catheter with ropivacaine and ketorolac solution after 22—24 hours Intravenous injection with saline at 22—24 hours.
No injections through sham catheter. No sham epidurals. No wound infiltration during surgery. Thorsell et al. Further infiltrate through catheter intra-articularly on post-operative day 1. Spinal or epidural analgesia No placebo infiltration reported Post-operative pain relief with ropivacaine infusion through epidural catheter. Toftdahl et al. Spinal and after surgery immediate release oxycodone and intravenous morphine if required. Further infiltrate through catheter intra-articularly on day of surgery and post-operative day 1.
Femoral nerve block prior to spinal anaesthesia No placebo infiltration Post-surgical continuous femoral nerve block.
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Vendittoli et al. Infiltrate through catheter intra-articularly on day1. Zhang et al. Meta-analyses of pain and length of hospital stay by anaesthetic regimen compared with controls using a random effects model. Pooled effect size. Confidence Interval.
Local Infiltration Analgesia for Orthopedic Joint Surgery | Anesthesia Key
N: Number of studies in meta-analysis. These data were duplicated for rest and during activity outcomes. Total hip replacement: pain at rest and during activity by local anaesthetic infiltration grouping. In one study, control patients received an epidural analgesia infusion [ 16 ]. In a study where control patients received additional intrathecal morphine, there was no difference in pain outcomes at any time point [ 37 ]. In all 11 studies reporting an outcome, opioid consumption was reduced in patients receiving local anaesthetic infiltration compared with controls [ 10 , 16 , 27 , 30 — 37 ].
There was no suggestion of different effects in groups with or without additional analgesia through a catheter or injection. Several different measures of mobilisation were reported. In three studies patients receiving local anaesthetic infiltration with no additional post-operative component achieved a straight leg raise earlier than control patients [ 28 , 29 , 32 ]. More patients were able to walk during the first post-operative day in two studies where additional post-operative analgesia was provided through a catheter [ 16 , 37 ]. In one study with no additional analgesia, with the exception of those with adverse events, all patients were mobilised on the first post-operative day [ 35 ].
However, in patients receiving local anaesthetic infiltration, walking speed over six metres at a two-day functional assessment was improved. Length of hospital stay by local anaesthetic infiltration grouping. When the comparison group received an epidural infusion [ 16 ], patients with local anaesthetic infiltration had on average a two day shorter hospital stay.
In the study where the comparison group received intrathecal morphine [ 37 ], there was no clear difference in discharge times. The Peto OR for a major complication in patients with local anaesthetic infiltration compared with controls was 0. Five deep infections were reported, four in local anaesthetic infiltration patients and one in controls, Peto OR 3. Four infections occurred in the patients who received post-closure delivery of infiltrate through a catheter. The incidence of vomiting was reduced in patients receiving local anaesthetic infiltration in five studies with patients with data, Peto OR 0.
Five studies reported long-term outcomes. Andersen and colleagues reported a trend for improved Western Ontario and McMaster Universities Osteoarthritis Index WOMAC pain scores at six weeks in local anaesthetic infiltration patients compared with controls [ 27 ]. At eight week follow up, Rikalainen-Salmi and colleagues reported no differences in mobilisation, intensity or duration of pain [ 37 ].
Busch and colleagues reported a trend for improved WOMAC score at two years in local anaesthetic infiltration patients compared with controls [ 30 ]. Overall there were 23 studies including 1, patients with TKR [ 18 , 28 , 38 — 56 ]. The mean number of patients randomised was 63 range 32— We assessed that 17 studies were at low risk of bias and that five studies had unclear risk of bias based on uncertainty about blinding of outcome assessments. One study was assessed to be at high risk of bias due to a large uneven loss to follow up between randomised groups.
Total knee replacement: pain at rest and during activity by local anaesthetic infiltration grouping. Heterogeneity was moderate to low. When we restricted analyses to studies assessed as low risk of bias, pain outcome estimates were slightly attenuated towards zero. We additionally performed separate analyses according to whether additional analgesia was delivered after wound closure through a catheter or injection. In six studies comparing local anaesthetic infiltration with or without additional post-closure analgesia against femoral nerve block, there was no evidence for improvement in pain at any time point [ 18 , 28 , 45 , 50 , 55 , 56 ].
In three studies where both randomised groups received a femoral nerve block D studies [ 43 , 53 , 54 ], there was no evidence for added benefit of local anaesthetic infiltration for pain outcomes. In eight comparisons between local anaesthetic infiltration with controls [ 38 , 39 , 44 , 46 , 48 , 49 , 51 ], additional ketoralac was included in the wound infiltrate. In seven comparisons with data [ 38 , 39 , 44 , 46 , 48 , 51 ], there was strong evidence that patients receiving additional analgesia in the infiltrate on average had lower pain compared with controls.
In four studies, control patients received either an epidural infusion [ 44 , 48 , 49 ] or intrathecal morphine [ 51 ]. Results of all studies supported a reduction in pain for patients receiving local anaesthetic infiltration compared with epidural or intrathecal morphine. In six studies where the control group or both groups received femoral nerve block, there was little difference in opioid consumption between randomised groups [ 18 , 28 , 43 , 45 , 50 , 53 ]. In four studies where patients receiving wound infiltration with further post-closure analgesia were compared with patients receiving epidural anaesthesia, there was no consistent difference between groups [ 44 , 48 , 49 ].
Nineteen studies reported a mobilisation outcome. In two studies with femoral nerve block given to all patients, more patients receiving local anaesthetic infiltration were able to achieve a straight leg raise during the first post-operative day [ 43 , 53 ]. In four out of five studies, patients receiving local anaesthetic infiltration achieved better knee flexion [ 39 , 40 , 47 , 54 ].
In four studies [ 44 , 46 , 51 , 55 ], ambulation was part of discharge readiness criteria. These criteria were met earlier in local anaesthetic infiltration patients in three studies [ 44 , 46 , 51 ], but were similar in one study where control patients received a femoral nerve block [ 55 ]. Improvements to diverse walking goals were reported in patients receiving local anaesthetic infiltration in three studies where some or all of the comparison group patients received epidural analgesia [ 48 , 49 ].
When the comparison group or all patients received femoral nerve block, walking goals were achieved earlier after local anaesthetic infiltration in one study [ 18 ], with trends for benefit in two studies [ 43 , 45 ].
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Data on length of hospital stay were available for 8 studies comparing local anaesthetic infiltration with controls [ 38 , 39 , 44 , 46 , 48 , 49 , 51 ], of which seven had a post-closure analgesia component. In the one A study with no post-closure analgesia component there was no difference in length of hospital stay. In three studies where the comparison group received femoral nerve block [ 18 , 45 , 55 ], there was no suggestion of a difference in length of stay. In one study in which all randomised patients received a femoral nerve block, the length of hospital stay was about 1.
In four studies where the control group received epidural analgesia [ 44 , 48 , 49 ], length of hospital stay was reduced in patients receiving local anaesthetic infiltration with the exception of one study in which the authors reported shorter time to fulfilment of discharge criteria [ 44 ]. Based on 11 events, the Peto OR for a major complication was 1. There were two deep infections in intervention patients [ 18 , 44 ], and one in control groups [ 48 ], Peto OR 1. Two infections occurred in the patients who received post-closure delivery of infiltrate through a catheter.
Excluding one intervention with additional morphine [ 40 ], there was evidence that the incidence of vomiting was lower in local anaesthetic infiltration patients compared with controls in eight studies with patients [ 40 , 42 , 46 — 48 , 51 , 52 ], Peto OR 0.
Five studies reported outcomes measured at six weeks [ 38 , 45 ], or three months [ 28 , 46 , 51 ]. Our systematic review and meta-analyses represent a comprehensive overview of evaluations of the effectiveness of peri-operative local anaesthetic infiltration in THR and TKR. Systematic reviews allow for a more objective appraisal than traditional narrative reviews [ 57 ], which are often biased in their selection of studies and thus may be unreliable in their recommendations of interventions [ 58 ].
Extensive efforts to acquire information from authors on unpublished outcomes and variance data allowed us to apply methods for meta-analyses of continuous and skewed outcomes and to produce more robust results for some outcomes than could be achieved with a purely narrative synthesis. In conducting this systematic review we recognised the problems that can arise when small studies are included in meta-analyses [ 59 ]. Review of studies with data largely collected in highly controlled conditions in the peri-operative and early post-operative period benefitted from low losses to follow up and more complete data.
With the exception of one study where the authors acknowledged uneven losses to follow up due to inadequate protocols, the main risk of bias arose from uncertainty about blind outcome assessment. As most studies reported VAS pain and other self-reported outcomes, we believe that the evidence base on short-term outcomes is of reasonably good quality. In musculoskeletal settings, VAS pain changes of 11 [ 60 ], and 14 [ 61 ], are considered clinically significant [ 62 ].
Patients receiving local anaesthetic infiltration had lower pain levels after their THR, used less opioid medication and had a reduced incidence of vomiting and nausea. This may explain the early mobilisation and earlier discharge of patients who received local anaesthetic infiltration, irrespective of alternative pain management strategies.
Opioid medication is a key strategy in the management of post-surgical pain but its use can delay mobilisation and rehabilitation [ 63 ]. Opioid consumption was reduced compared with untreated control patients and there was a general observation of early mobilisation, reduced vomiting and nausea, and early hospital discharge. Inclusion of the non-steroidal anti-inflammatory agent ketoralac in the infiltrate seemed to enhance post-operative pain relief.
When compared with alternative regimens, results were not so clear. Pain levels after TKR were broadly similar when femoral nerve block was included in the general analgesia regimen or as a comparator. Likewise, opioid consumption was similar. There was some suggestion of benefit for earlier mobilisation, but length of hospital stay was not reduced in patients receiving local anaesthetic infiltration.
Femoral nerve block is a well established method of providing analgesia after TKR and is associated with reduced opioid requirement and thus fewer side effects such as nausea and vomiting. However, femoral nerve block is associated with decreased quadriceps function for a time and an increased risk of falls [ 64 , 65 ]. In studies in patients receiving TKR where control groups received epidural or intrathecal analgesia, benefit was observed for reduced pain in patients receiving local anaesthetic infiltration.
Opioid consumption did not differ between groups but mobilisation and hospital discharge were achieved earlier in patients receiving local anaesthetic infiltration. The improvement in pain control and shorter hospital stay was greatest for patients receiving additional analgesia through a catheter or by injection.
However, we observed a small but potentially important increase in rates of serious infection, particularly in patients receiving further infiltrate through a catheter post-wound closure. Six of these were in patients randomised to wound infiltration analgesia with additional analgesia through a post-surgical catheter. Indeed, all patients with deep infection had been randomised to receiving a catheter although researchers reported that catheters in control groups were not inserted into the joint capsule. Acute post-operative pain is an important risk factor for long-term pain [ 66 , 67 ], and deserves appropriate consideration in future studies of peri-operative pain control.
Our study has limitations. Although meta-analyses performed were enhanced by extensive contact with authors, imputation was required for some measures of variability. The skewed nature of hospital stay required transformation under assumptions of a lognormal distribution [ 26 ]. For opioid consumption and mobilization there was insufficient consistency in measures reported to conduct anything but a systematic narrative overview.