|Year : 2018 | Volume
| Issue : 4 | Page : 903-906
Validating the role of steroid in analgesic cocktail preparation for local infiltration in total knee arthroplasty: A comparative study
AV Gurava Reddy1, Chiranjeevi Thayi1, Nandkumar Natarajan1, Sukesh Rao Sankineani1, Deepesh Daultani1, Vishesh Khanna1, Krishna Kiran Eachempati2
1 Department of Orthopaedics, Sunshine Hospital, Secunderabad, Telangana, India
2 Department of Orthopaedics, Maxcure Hospital, Hyderabad, Telangana, India
|Date of Web Publication||18-Dec-2018|
Dr. Sukesh Rao Sankineani
Department of Orthopaedics, Sunshine Hospital, P. G. Road, Secunderabad - 500 003, Telangana
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Pain control after total knee arthroplasty (TKA) through local analgesic cocktail preparation has gained widespread popularity in recent times. Local steroids have potent anti-inflammatory effect leading to reduced postoperative swelling and pain which might increase the efficacy and duration of local infiltration analgesia. Aim: The aim is to evaluate whether the addition of local steroid to an injectable analgesic cocktail for periarticular infiltration leads to better pain control and knee range of motion (ROM) in the immediate postoperative period compared to patients who do not receive steroid in their cocktail. Settings and Designs: A prospective study was conducted in a group of 140 patients undergoing unilateral TKA between June 2017 and December 2017. Materials and Methods: All the patients in the study group received either periarticular infiltration with an analgesic cocktail (Group I, n = 70) or analgesic cocktail with 100 mg methylprednisolone (Group II, n = 70) for postoperative pain with ultrasound-guided adductor canal block (ACB). Patients were evaluated with visual analog scale (VAS) for pain at 8, 24, and 48 h postoperatively and ROM at 48 h after surgery. Statistical Analysis: The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis. Student t-test has been used to find the pairwise significance. Results: Group II had a statistically significant decrease in VAS scores at 8 h (P = 0.096), first postoperative day (P = 0.0001) and second postoperative day (P = 0.0001) as compared to Group I. However, there was no statistically significant difference seen with early ROM in both the groups at 48 h (P < 0.361). Conclusion: Patients who received steroid cocktail infiltration plus ACB had an improved and better postoperative analgesia in an early postoperative period of 24–48 h; however, there was no significant difference in clinical ROM and functional outcome when compared to the study group.
Keywords: Analgesic cocktail, periarticular steroid infiltration, total knee arthroplasty
|How to cite this article:|
Gurava Reddy A V, Thayi C, Natarajan N, Sankineani SR, Daultani D, Khanna V, Eachempati KK. Validating the role of steroid in analgesic cocktail preparation for local infiltration in total knee arthroplasty: A comparative study. Anesth Essays Res 2018;12:903-6
|How to cite this URL:|
Gurava Reddy A V, Thayi C, Natarajan N, Sankineani SR, Daultani D, Khanna V, Eachempati KK. Validating the role of steroid in analgesic cocktail preparation for local infiltration in total knee arthroplasty: A comparative study. Anesth Essays Res [serial online] 2018 [cited 2019 Mar 24];12:903-6. Available from: http://www.aeronline.org/text.asp?2018/12/4/903/247641
| Introduction|| |
Moderate-to-severe postoperative pain after total knee arthroplasty (TKA) is reported in approximately 20%–30% of patients even after oral or parenteral analgesic use. Appropriate pain control results in better patient satisfaction reduce hospital stay and allows early hospital discharge. Continuous epidural anesthesia (CSE) or nerve blocks can provide good patient analgesia but have some undesirable side-effects such as muscle weakness or hematoma formation leading to delayed mobilization of the patient and increased risk of venous thromboembolism. Recently multimodal analgesic infiltration techniques have shown promising role in reducing the postoperative pain with a comparable efficacy of CSE or nerve blocks but without the associated side-effects on muscle strength permitting earlier rehabilitation. Multimodal analgesic regimens block the afferent pain receptors at different sites, thereby reducing opiate requirements and avoid side effects associated with it.
The use of multimodal analgesic infiltration in the form of a cocktail along with adductor canal block (ACB) has gained popularity owing to the synergistic effects of these two techniques in controlling pain while preserving quadriceps function. However, the major limitation with the use of single injection of these modalities is the limited duration of action resulting in the requirement for either long-standing indwelling catheters for longer duration of analgesia. Local steroids have a potent anti-inflammatory effect through inhibition of phospholipase A2 (PLA2) pathway leading to reduced postoperative swelling and pain. The efficacy of local infiltration anesthesia following TKA has proved to be efficacious in controlling pain, but not many studies have evaluated the role of inclusion of steroids in their local infiltration analgesia (LIA) formulas. Little is known as to whether or not the inclusion of a steroid in the LIA formula would control pain better, but past research on steroid use seems to indicate a potential benefit. The aim of this study is evaluate whether the addition of local steroid to an injectable analgesic cocktail for periarticular infiltration in patients undergoing unilateral TKA leads to better pain control and knee range of motion (ROM) in the immediate postoperative period compared to patients who do not receive steroid in their cocktail.
| Materials and Methods|| |
This prospective study was conducted in a high-volume arthroplasty center between June 2017 and December 2017 after obtaining approval from the Institute Ethics Committee. The entire treatment protocol was approved by the Institute Ethics Committee (Study no. SS/2017/1EC 113, Date: May 01, 2017) and was conducted according to the principles established in the Declaration of Helsinki. Informed Consent for the publication of clinical details, radiographs, and photographs was obtained from the patients. A total of 140 consecutive patients scheduled for elective unilateral primary TKAs with the American Society of Anesthesiologists (ASA) physical status Class I were assessed and included in the study. Patients undergoing bilateral knee arthroplasty, revision knee arthroplasty, use of general and epidural anaesthesia, patients with severe renal insufficiency, uncontrolled diabetes mellitus, bleeding disorders, history of a vascular surgery involving the femoral vessels on the operative side, history of arrhythmia or seizures, history of chronic pain unrelated to the knee requiring treatment with long-acting opioids, alcohol or drug abuse, allergy to local anesthetics, localized infection, sepsis, preexisting lower extremity neurological abnormality, and difficulties in comprehending visual analog scale (VAS) pain were excluded from the study. All patients received spinal anesthesia and ultrasound-guided ACB.
All patients in Group I (n = 70) received periarticular infiltration with an analgesic cocktail comprising of 60 ml of 0.2% ropivacaine, 1 ml of morphine sulfate (8 mg), 0.3 ml of 1:1000 epinephrine (300 μg), and 2 ml of ketorolac (60 mg) which was infiltrated in nine zones of knee [Table 1]. Patients in Group II (n = 70) received the same cocktail as Group I with additional 1 ml of methylprednisolone (100 mg) in the infiltrated cocktail. All the patients had a uniform postoperative analgesia regimen which involved the use of paracetamol 1 g intravenously every 8 h, pregabalin 75 mg given orally once daily and Buprenorphine patch for 4 weeks. Intravenous morphine was considered in the form of rescue analgesia in patients having breakthrough pain. All the patients underwent a uniform rehabilitation protocol and were discharged from the hospital 3 days after the surgery.
|Table 1: Zones of peri-articular infiltration of analgesic cocktail in the knee joint|
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At the time of enrollment, patients were explained and taught about the visual analog pain scale and mobilization ability assessment. Patient was assessed for pain at 12 h postoperatively, pain at rest on the first postoperative day (POD1), and on second postoperative day (POD2). Pain was evaluated on a VAS scale with 0 = no pain, and 10 = worst imaginable pain. Clinical outcome such as ROM was assessed at POD2.
Descriptive and inferential statistical analysis has been carried out in the present study. Results on continuous measurements are presented on mean ± standard deviation (minimum–maximum) and results on categorical measurements are presented in number (%). The significance is assessed at 5% level of significance. Student t-test has been used to find the pairwise significance. P < 0.05 was considered as significant while a value of P ≤ 0.01 was considered as strongly significant. The SPSS 19.0 software (SPSS Inc., Chicago, IL, USA) was used for the statistical analysis.
| Results|| |
In our study, a total of 140 consecutive patients scheduled for elective unilateral primary TKAs were assessed during the period between June 2017 and December 2017 for the eligibility of this study. Seventy eligible patients were identified as having received cocktail preparation without steroid, and other seventy eligible patients were identified as having received steroid cocktail preparation and both the groups received adductor nerve block with the addition of periarticular infiltration of cocktail injection. All patients were ASA Grade I and no patient developed periprosthetic infection in the postoperative period.
Visual analog scale score (at rest) 8 h postoperatively
In our study, the study group who received cocktail infiltration with steroid had a VAS score of 1.70 ± 1.20 when compared to the study group who received cocktail infiltration without steroid had a VAS score of 2.042 ± 1.16 with a statistically significant P = 0.096* and t = 1.686 [Table 1] and [Table 2].
Visual analog scale score (at rest) first postoperative day
In our study, the study group who received cocktail infiltration with steroid had a VAS score of 1.67 ± 1.28 when compared to the study group who received cocktail without steroid had a VAS score of 3.271 ± 1.40 with a statistically significant P = 0.0001** and t = 6.708 [Table 1] and [Table 2].
Visual analog scale score (at rest) second postoperative day
The study group who received steroid cocktail infiltration had a VAS score of 2.028 ± 1.34 when compared to the study group who received cocktail infiltration had a VAS score of 3.885 ± 1.18 with a statistically significant P = 0.0001** and t = 8.463 [Table 1] and [Table 2].
Clinical outcome-range of motion
The study group who received steroid cocktail infiltration had a mean ROM of 81.50 ± 7.91 when compared the study group who received cocktail infiltration without steroid had a mean ROM of 80.64 ± 7.65 with a statistically insignificant P < 0.361 and t = 0.919 [Table 1] and [Table 2].
| Discussion|| |
This study demonstrates the longer duration of pain control with the addition of steroid in the analgesic cocktail mixture. Patients demonstrated significantly lower pain levels 24 h and 48 h after the surgery in Group II compared to Group I even though there was no significant difference in pain levels 12 h after surgery. This shows that the addition of steroid prolongs the analgesic effect by local inhibition of inflammation leading to better and longer action of local analgesics. However, in this study, patients with better pain control did not demonstrate clinically significant difference in the ROM of knee.
Intravenous methylprednisolone is an intermediate-acting steroid with a half-life of 18–36 h and metabolized in the liver. The proposed clinical benefit is postulated to be due to potent inhibition of inflammatory cascade resulting in decreased pain levels. It affects the transcription of inflammatory markers such as lipocortin-1 which in turn results in reduced function of PLA2. Furthermore, it affects cellular functions directly resulting in decreased release of inflammatory mediators and cytokines. The addition of epinephrine in the cocktail mixture leads to local vasoconstriction, thereby prolonging the local presence of steroid leading to longer duration of anti-inflammatory effect of steroid.
Postoperative pain management may be insufficient and prevent patients from sleeping, ambulating, and participating with physical therapy., Numerous strategies have been devised to control postoperative pain and reduce opioid consumption including neuraxial anesthesia and peripheral nerve blocks. Peripheral nerve blockade has been reported to deliver optimal postoperative pain relief. Continuous infusion with intraarticular catheters was associated with risk of infection, 57% of catheters colonized at 48 h., In addition to peripheral nerve blocks, parenteral narcotics continue to be a mainstay of perioperative pain management despite its significant side effects., Oderda et al. demonstrated that opioid-related adverse drug events following surgery were associated with significantly increased length of stay and hospitalization costs. With the goal of decreasing these adverse drug events, multimodal pain pathways have been developed to block pain at its source. Furthermore, a successful multimodal pathway should not only control pain but also maximize muscle control, promote rehabilitation, and decrease venous stasis. Peri-articular injection, as an adjunct to multimodal pain management pathways, accomplishes both of these goals.
The potential drawback of adding steroid to the local cocktail preparation is the potential for increased infection rate which has been described in certain other situations. Montgomery and Campbell reported three cases of septic arthritis after more than 1500 arthroscopies following intra-articular steroid injection. They postulated that the healing process is delayed by the steroid leading to ingress of bacteria through the portals culminating in infection. However, these reports have not been substantiated in scenarios where peri-articular steroid infiltration has been used after knee arthroplasty. A randomized control trial performed by Parvataneni et al. reported better pain control and functional outcomes with no evidence of increased infection in patients undergoing periarticular steroid infiltration as part of multimodal analgesia regimen compared to those patients who received femoral nerve blocks or patient-controlled analgesia pumps. Similarly, Christensen et al. performed a randomized control trial comparing patients who received periarticular steroid versus those who did not receive steroid. They reported early discharge from hospital in the steroid group albeit with no significant difference in pain relief, motion, or function in the early postoperative period. They reported two cases of infection in the steroid group which they could not attribute directly to the use of steroids. We did not encounter any patient in both groups who developed postoperative infection in our study.
Our study has several limitations. No attempt was made to assess clinical outcomes such as range of movement of knee based on preprocedure status, as the study was not powered for such an analysis. The combination of LIA and ACB implies the use of high total dose of local anesthetic with the potential for local anesthetic systemic toxicity (LAST). In our study, all patients have been closely followed in the perioperative period for signs and symptoms of LAST. Although plasma levels of local anesthetic were not tested, no patient-reported symptoms of LAST including altered sensorium, tinnitus, or changes in taste were documented on any of the cases. Similarly, no changes in neurologic status, evidence of seizure activity, or evidence of cardiac toxicity were noted in any patient. It is unlikely that any major event of LAST was missed, but minor symptoms cannot be excluded. In addition, to minimize the potential for toxicity, the following measures are routinely taken at our institution: (1) only ropivacaine is used for both ACB and LIA; (2) epinephrine is used for both ACB and LIA; (3) LIA is performed in stages during the surgical procedure and while a thigh tourniquet is in place.
| Conclusion|| |
This prospective study of 140 patients undergoing unilateral primary TKA suggests that the study group who received steroid cocktail plus adductor block had an improved and better postoperative analgesia in early postoperative period of 24–48 h; however, there was no significant difference in clinical ROM and functional outcome when compared to the study group who received cocktail without steroid plus adductor block.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]