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  • 1.
    Essving, Per
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Local infiltration analgesia in knee arthroplasty2012Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Local infiltration analgesia (LIA) is a new technique for postoperative pain management following knee arthroplasty. LIA involves a long-acting local anesthetic (ropivacaine), a non-steroid anti-inflammatory drug (ketorolac) and epinephrine infiltrated into the knee joint during surgery and injected postoperatively via a catheter.

    In the first two studies, LIA was compared with placebo in unicompartmental (I) and total (II) knee arthroplasty. Postoperative pain levels, morphine consumption and the incidence of side effects were lower in the LIA groups. In addition, we found a shorter length of hospital stay in the LIA group following unicompartmental knee arthroplasty compared with placebo (I), while the time to home readiness was shorter in the LIA group following total knee arthroplasty (II). In this study, we found that the unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations in a sub-group of patients.

    In the third study, LIA was compared with intrathecal morphine for postoperative pain relief following total knee arthroplasty (III). Pain scores and morphine consumption were lower, length of hospital stay was shorter and patient satisfaction was higher in the LIA group.

    In the final study, we investigated the effect of minimally invasive surgery (MIS) compared with conventional surgery in unicompartmental knee arthroplasty (IV). Both groups received LIA. We found no statistically significant differences in postoperative pain, morphine consumption, knee function, home readiness, hospital stay or patient satisfaction.

    In conclusion, LIA provided better postoperative pain relief and earlier mobilization than placebo, both in unicompartmental and total knee arthroplasty. When compared to intrathecal morphine, LIA also resulted in improved postoperative pain relief and earlier mobilization. Minimally invasive surgery did not improve outcomes after unicompartmental knee arthroplasty, when both groups received LIA.

    List of papers
    1. Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty: a randomized double-blind study of 40 patients
    Open this publication in new window or tab >>Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty: a randomized double-blind study of 40 patients
    Show others...
    2009 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 80, no 2, p. 213-219Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND AND PURPOSE: The degree of postoperative pain is usually moderate to severe following knee arthroplasty. We investigated the efficacy of local administration of analgesics into the operating area, both intraoperatively and postoperatively. METHODS: 40 patients undergoing unicompartmental knee arthroplasty (UKA) were randomized into 2 groups in a double-blind study (ClinicalTrials.gov identifier: NCT00653926). In group A (active), 200 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine (total volume 106 mL) were infiltrated intraoperatively into the soft tissue, while in group P (placebo), no injections were given. 21 hours postoperatively, 150 mg ropivacain, 30 mg ketorolac, and 0.1 mg epinephrine were injected intraarticularly via a catheter in group A, whereas patients in group P were injected with the same volume of saline (22 mL). RESULTS: Median hospital stay was shorter in group A than in group P: 1 (1-6) days as opposed to 3 (1-6) days (p < 0.001). Postoperative pain in group A was statistically significantly lower at rest after 6 h and 27 h and on movement after 6, 12, 22, and 27 h. Morphine consumption was statistically significantly lower in group A for the first 48 h, resulting in a lower frequency of nausea, pruritus, and sedation. Postoperatively, there were improved functional scores (Oxford knee score and EQ-5D) in both groups relative to the corresponding preoperative values. INTERPRETATION: Local injection of analgesics periarticularly at the end of the operation and intraarticularly at 21 h postoperatively provided excellent pain relief and earlier home discharge following UKA. There was a high degree of patient satisfaction in both groups after 6 months (Clinical Trials.gov: NCT 00653926).

    Place, publisher, year, edition, pages
    Lund: Taylor & Francis, 2009
    National Category
    Medical and Health Sciences Anesthesiology and Intensive Care Surgery
    Research subject
    Orthopaedics
    Identifiers
    urn:nbn:se:oru:diva-11651 (URN)10.3109/17453670902930008 (DOI)19404806 (PubMedID)
    Available from: 2010-08-27 Created: 2010-08-27 Last updated: 2018-04-11Bibliographically approved
    2. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty: a randomized double-blind study involving 48 patients
    Open this publication in new window or tab >>Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty: a randomized double-blind study involving 48 patients
    Show others...
    2010 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 81, no 3, p. 354-360Article in journal (Refereed) Published
    Abstract [en]

    Background and purpose:  Postoperative pain is often severe following total knee arthroplasty (TKA). We investigated the efficacy of local infiltration analgesia (LIA) technique, intra- and postoperatively.

    Methods:  48 patients undergoing TKA were randomized into 2 groups in a double-blind study. In group A, 400 mg ropivacaine, 30 mg ketorolac and 0.5 mg epinephrine were infiltrated periarticularly intra-operatively. In group P, no injections were given. At 21 hours postoperatively, 200 mg ropivacaine, 30 mg ketorolac and 0.1 mg epinephrine were injected intraarticularly in group A, and the same volume of saline was injected in group P. Patients were followed up for 3 months.

    Results:  Median morphine consumption was lower in group A during 0-48 h: 18 (1-74) mg vs. 87 (36-160) mg in group P. Postoperative pain was lower at rest in group A during the first 27 h, and on movement during the first 48 h, except at 21 h. Time to fulfilling discharge criteria was shorter in group A than in group P; 3 (1-7) vs. 5 (2-8) days. Patient satisfaction was higher in group A compared to group P on day 1 and 7. The unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations.

     

    Interpretation:  Local infiltration analgesia (LIA) technique provides excellent pain relief and lower morphine consumption following TKA, resulting in shorter time to home readiness and higher patient satisfaction. Side effects were few and systemic LA concentrations low.

    National Category
    Medical and Health Sciences
    Research subject
    Medicine
    Identifiers
    urn:nbn:se:oru:diva-21434 (URN)10.3109/17453674.2010.487241 (DOI)000279535900014 ()
    Available from: 2012-01-31 Created: 2012-01-31 Last updated: 2018-04-11Bibliographically approved
    3. Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial
    Open this publication in new window or tab >>Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial
    Show others...
    2011 (English)In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 113, no 4, p. 926-933Article in journal (Refereed) Published
    Abstract [en]

    BACKGROUND: Local infiltration analgesia (LIA) using a combination of local anesthetics, non-steroidal anti-inflammatory drugs and epinephrine, injected periarticularly during surgery has become popular in postoperative pain management following total knee arthroplasty (TKA). This study compared intrathecal morphine with LIA following TKA.

    METHODS:  In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into two groups: Group M: 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and Group L: LIA using ropivacaine, ketorolac and epinephrine was infiltrated in the knee during the operation and two bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during three months follow-up. Primary endpoint was IV morphine consumption the first 48 postoperative hours.

    RESULTS: Mean morphine consumption was significantly lower in group L compared to group M during the first 48 postoperative hours: 27 ± 18 vs. 54 ± 30 mg, i.e. a mean difference for each 24-hour-period of 14,2 (CI 95 % 7.6-20.9) mg. Pain scores at rest and on movement were lower during the first 48 h in group L compared to group M (P < 0.001). Pain score was also lower on walking in group L compared to group M at 24 h and 48 h postoperatively (P < 0.01). In group L more patients were able to climb stairs at 24 h: 50 % (11/22) vs. 4 % (1/23), i.e. a difference of 46 % (CI 95 % 23.5-68.5) and at 48 h: 70 % (16/23) vs. 22 % (5/23), i.e. a difference of 48 % (CI 95 % 23-73). Median (range) time to fulfillment of discharge criteria was shorter in group L compared to group M, 51 (24-166) h vs. 72 (51-170) h. The difference was 23 (CI 95 % 18-42) h (P = 0.001). Length of hospital stay also shorter in group L compared to group M: median (range) 3 (2-17) vs. 4 (2-14) days (P = 0.029). Patient satisfaction was greater in group L compared to group M (P = 0.001), but no differences were found in knee function, side effects or in patient-related outcomes, Oxford Knee score or EQ-5D.

    CONCLUSIONS: LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, compared to intrathecal morphine following TKA.

    Place, publisher, year, edition, pages
    Lippincott Williams & Wilkins, 2011
    National Category
    Anesthesiology and Intensive Care
    Identifiers
    urn:nbn:se:oru:diva-21435 (URN)10.1213/ANE.0b013e3182288deb (DOI)000295215100036 ()21821506 (PubMedID)2-s2.0-80053303951 (Scopus ID)
    Note

    Funding Agency:

    Research Committee, Orebro University Hospital 

    Available from: 2012-01-31 Created: 2012-01-31 Last updated: 2019-04-10Bibliographically approved
    4. Minimally invasive surgery did not improve outcome compared to conventional surgery following unicompartmental knee arthroplasty when using local infiltration analgesia
    Open this publication in new window or tab >>Minimally invasive surgery did not improve outcome compared to conventional surgery following unicompartmental knee arthroplasty when using local infiltration analgesia
    Show others...
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Background and purpose: There has recently been focus on the advantages of minimally invasive surgery (MIS) over conventional surgery and on local infiltration analgesia (LIA) during knee arthroplasty. This prospective randomized controlled trial investigated whether MIS would result in earlier home readiness and reduced postoperative pain compared to conventional unicompartmental knee arthroplasty (UKA) where both groups received LIA.

     

    Patients and methods: 40 patients scheduled for UKA were randomized to group MIS or group CON (conventional surgery). Both groups received LIA, with a mixture of ropivacaine, ketorolac, and epinephrine, intra- and postoperatively. The primary endpoint was home readiness (time to fulfillment of discharge criteria). The patients were followed for 6 months.

     

    Results: We found no statistically significant difference in home readiness between group MIS, median (range) 24 (21–71) h compared to group CON, 24 (21–46) h. No statistically significant differences between the groups were found in the secondary endpoints: pain intensity, morphine consumption, knee function, hospital stay, patient satisfaction, Oxford Knee Score and EQ-5D. The side effects between the groups were also similar, except a higher incidence of nausea on the second postoperative day in group MIS compared with group CON.

     

    Interpretation: Minimally invasive surgery did not improve outcome after unicompartmental knee arthroplasty compared to conventional surgery, when both groups received local infiltration analgesia. The surgical approach (MIS or conventional surgery) should be selected according to surgeon’s preferences and local hospital policies. ClinicalTrials.gov. (Identifier NCT00991445). 

    National Category
    Medical and Health Sciences
    Research subject
    Medicine
    Identifiers
    urn:nbn:se:oru:diva-21436 (URN)
    Available from: 2012-01-31 Created: 2012-01-31 Last updated: 2017-10-17Bibliographically approved
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  • 2.
    Essving, Per
    et al.
    Örebro University, School of Health and Medical Sciences.
    Axelsson, Kjell
    Kjellberg, Jill
    Wallgren, Örjan
    Gupta, Anil
    Lundin, Anders
    Reduced hospital stay, morphine consumption, and pain intensity with local infiltration analgesia after unicompartmental knee arthroplasty: a randomized double-blind study of 40 patients2009In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 80, no 2, p. 213-219Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: The degree of postoperative pain is usually moderate to severe following knee arthroplasty. We investigated the efficacy of local administration of analgesics into the operating area, both intraoperatively and postoperatively. METHODS: 40 patients undergoing unicompartmental knee arthroplasty (UKA) were randomized into 2 groups in a double-blind study (ClinicalTrials.gov identifier: NCT00653926). In group A (active), 200 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine (total volume 106 mL) were infiltrated intraoperatively into the soft tissue, while in group P (placebo), no injections were given. 21 hours postoperatively, 150 mg ropivacain, 30 mg ketorolac, and 0.1 mg epinephrine were injected intraarticularly via a catheter in group A, whereas patients in group P were injected with the same volume of saline (22 mL). RESULTS: Median hospital stay was shorter in group A than in group P: 1 (1-6) days as opposed to 3 (1-6) days (p < 0.001). Postoperative pain in group A was statistically significantly lower at rest after 6 h and 27 h and on movement after 6, 12, 22, and 27 h. Morphine consumption was statistically significantly lower in group A for the first 48 h, resulting in a lower frequency of nausea, pruritus, and sedation. Postoperatively, there were improved functional scores (Oxford knee score and EQ-5D) in both groups relative to the corresponding preoperative values. INTERPRETATION: Local injection of analgesics periarticularly at the end of the operation and intraarticularly at 21 h postoperatively provided excellent pain relief and earlier home discharge following UKA. There was a high degree of patient satisfaction in both groups after 6 months (Clinical Trials.gov: NCT 00653926).

  • 3.
    Essving, Per
    et al.
    Örebro University, School of Health and Medical Sciences.
    Axelsson, Kjell
    Kjellberg, Jill
    Wallgren, Örjan
    Gupta, Anil
    Lundin, Anders
    Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty: a randomized double-blind study involving 48 patients2010In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 81, no 3, p. 354-360Article in journal (Refereed)
    Abstract [en]

    Background and purpose:  Postoperative pain is often severe following total knee arthroplasty (TKA). We investigated the efficacy of local infiltration analgesia (LIA) technique, intra- and postoperatively.

    Methods:  48 patients undergoing TKA were randomized into 2 groups in a double-blind study. In group A, 400 mg ropivacaine, 30 mg ketorolac and 0.5 mg epinephrine were infiltrated periarticularly intra-operatively. In group P, no injections were given. At 21 hours postoperatively, 200 mg ropivacaine, 30 mg ketorolac and 0.1 mg epinephrine were injected intraarticularly in group A, and the same volume of saline was injected in group P. Patients were followed up for 3 months.

    Results:  Median morphine consumption was lower in group A during 0-48 h: 18 (1-74) mg vs. 87 (36-160) mg in group P. Postoperative pain was lower at rest in group A during the first 27 h, and on movement during the first 48 h, except at 21 h. Time to fulfilling discharge criteria was shorter in group A than in group P; 3 (1-7) vs. 5 (2-8) days. Patient satisfaction was higher in group A compared to group P on day 1 and 7. The unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations.

     

    Interpretation:  Local infiltration analgesia (LIA) technique provides excellent pain relief and lower morphine consumption following TKA, resulting in shorter time to home readiness and higher patient satisfaction. Side effects were few and systemic LA concentrations low.

  • 4.
    Essving, Per
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Axelsson, Kjell
    Otterborg, Lena
    Spännar, Henrik
    Gupta, Anil
    Magnuson, Anders
    Lundin, Anders
    Minimally invasive surgery did not improve outcome compared to conventional surgery following unicompartmental knee arthroplasty when using local infiltration analgesiaManuscript (preprint) (Other academic)
    Abstract [en]

    Background and purpose: There has recently been focus on the advantages of minimally invasive surgery (MIS) over conventional surgery and on local infiltration analgesia (LIA) during knee arthroplasty. This prospective randomized controlled trial investigated whether MIS would result in earlier home readiness and reduced postoperative pain compared to conventional unicompartmental knee arthroplasty (UKA) where both groups received LIA.

     

    Patients and methods: 40 patients scheduled for UKA were randomized to group MIS or group CON (conventional surgery). Both groups received LIA, with a mixture of ropivacaine, ketorolac, and epinephrine, intra- and postoperatively. The primary endpoint was home readiness (time to fulfillment of discharge criteria). The patients were followed for 6 months.

     

    Results: We found no statistically significant difference in home readiness between group MIS, median (range) 24 (21–71) h compared to group CON, 24 (21–46) h. No statistically significant differences between the groups were found in the secondary endpoints: pain intensity, morphine consumption, knee function, hospital stay, patient satisfaction, Oxford Knee Score and EQ-5D. The side effects between the groups were also similar, except a higher incidence of nausea on the second postoperative day in group MIS compared with group CON.

     

    Interpretation: Minimally invasive surgery did not improve outcome after unicompartmental knee arthroplasty compared to conventional surgery, when both groups received local infiltration analgesia. The surgical approach (MIS or conventional surgery) should be selected according to surgeon’s preferences and local hospital policies. ClinicalTrials.gov. (Identifier NCT00991445). 

  • 5.
    Essving, Per
    et al.
    Örebro University, School of Health and Medical Sciences. Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden.
    Axelsson, Kjell
    Division of Clinical Medicine, Örebro University Hospital, Örebro, Sweden; Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Åberg, Elisabeth
    Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden.
    Spännar, Henrik
    Department of Physiotherapy, Örebro University Hospital, Örebro, Sweden.
    Gupta, Anil
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden; University of Linköping, Linköping, Sweden.
    Lundin, Anders
    Department of Orthopedic Surgery, Örebro University Hospital, Örebro, Sweden; Division of Clinical Medicine, Örebro University Hospital, Örebro, Sweden.
    Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial2011In: Anesthesia and Analgesia, ISSN 0003-2999, E-ISSN 1526-7598, Vol. 113, no 4, p. 926-933Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Local infiltration analgesia (LIA) using a combination of local anesthetics, non-steroidal anti-inflammatory drugs and epinephrine, injected periarticularly during surgery has become popular in postoperative pain management following total knee arthroplasty (TKA). This study compared intrathecal morphine with LIA following TKA.

    METHODS:  In this double-blind study, 50 patients scheduled to undergo TKA under spinal anesthesia were randomized into two groups: Group M: 0.1 mg morphine was injected intrathecally together with the spinal anesthetic and Group L: LIA using ropivacaine, ketorolac and epinephrine was infiltrated in the knee during the operation and two bolus injections of the same mixture were given via an intraarticular catheter postoperatively. Postoperative pain, rescue analgesic requirements, mobilization and home readiness were recorded. Patient-assessed health quality was recorded using the Oxford Knee Score and EQ-5D during three months follow-up. Primary endpoint was IV morphine consumption the first 48 postoperative hours.

    RESULTS: Mean morphine consumption was significantly lower in group L compared to group M during the first 48 postoperative hours: 27 ± 18 vs. 54 ± 30 mg, i.e. a mean difference for each 24-hour-period of 14,2 (CI 95 % 7.6-20.9) mg. Pain scores at rest and on movement were lower during the first 48 h in group L compared to group M (P < 0.001). Pain score was also lower on walking in group L compared to group M at 24 h and 48 h postoperatively (P < 0.01). In group L more patients were able to climb stairs at 24 h: 50 % (11/22) vs. 4 % (1/23), i.e. a difference of 46 % (CI 95 % 23.5-68.5) and at 48 h: 70 % (16/23) vs. 22 % (5/23), i.e. a difference of 48 % (CI 95 % 23-73). Median (range) time to fulfillment of discharge criteria was shorter in group L compared to group M, 51 (24-166) h vs. 72 (51-170) h. The difference was 23 (CI 95 % 18-42) h (P = 0.001). Length of hospital stay also shorter in group L compared to group M: median (range) 3 (2-17) vs. 4 (2-14) days (P = 0.029). Patient satisfaction was greater in group L compared to group M (P = 0.001), but no differences were found in knee function, side effects or in patient-related outcomes, Oxford Knee score or EQ-5D.

    CONCLUSIONS: LIA technique provided better postoperative analgesia and earlier mobilization, resulting in shorter hospital stay, compared to intrathecal morphine following TKA.

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