The surgical-site injection group demonstrated significantly lower VAS scores than the control cohort at several postoperative time points; the median (and interquartile range) was 1.6 (0 to 4.0) for the injection group and 3.2 (1.3 to 5.7) for the control group in the recovery room (p = 0.017), 1.0 (0 to 3.0) for the injection group and 5.0 (2.0 to 7.0) for the control group at 4 hours (p < 0.0001), 2.0 (0 to 4.0) for the injection group and 5.0 (2.0 to 6.8) for the control group at 8 hours (p = 0.009), and 3.5 (0 to 5.0) for the injection group and 5.0 (2.0 to 8.0) for the control group at 12 hours (p = 0.027). The greatest discrepancy in pain outcomes between the 2 groups was reported at 4 hours postoperatively. Although no significant differences were appreciated over the remainder of the first postoperative day, the injection cohort also had significantly lower pain scores (p = 0.010) at 32 hours: 3.0 (1.0 to 4.0) for the injection group compared with 5.0 (3.0 to 6.0) for the control group (Fig. 2). The highest mean pain level (and standard deviation) for the injection group was at 20 hours after the surgical procedure (VAS, 4.1 ± 2.5) compared with 4 hours postoperatively for the control group (VAS, 4.9 ± 3.0).
Narcotic consumption in morphine equivalents from 0 to 8 hours was significantly lower (p = 0.007) for the injection group (5.0 mg [1.3 to 8.0 mg]) compared with the control group (9.7 mg [3.9 to 15.6 mg]). No other significant differences were appreciated over the following 8-hour intervals or with aggregate narcotic consumption over the first 2 postoperative days (28.0 mg [11.3 to 37.3 mg] compared with 34.8 mg [16.8 to 52.0 mg]; p = 0.072) (Fig. 3).
No cardiac or central nervous system toxicity was observed secondary to local infiltration of the anesthetic cocktail. There were no cases of transient peripheral nerve palsy affecting either the sciatic or common peroneal distributions. There were no patients who developed compartment syndrome or symptomatic pulmonary embolus. One wound complication was identified in each group, with persistent postoperative drainage requiring negative wound vacuum therapy and compressive dressings for resolution. A single, superficial, surgical-site infection was managed with oral antibiotics in the control group. There were no significant differences in the prevalence of wound or infectious complications between the 2 groups.
Multimodal analgesia inclusive of periarticular injection is now commonly utilized in the care of patients undergoing elective lower-extremity arthroplasty, and the efficacy and safety profiles are excellent1,2,4-8,10-12,14-20. Although intraoperative and perioperative anesthesia protocols have evolved over recent years for management of lower-extremity musculoskeletal trauma, surgical-site injection remains a seldom-employed tool in the analgesic arsenal at the current time21-25. To our knowledge, only a single study20 has described its use in the posttraumatic setting for patients undergoing bipolar hemiarthroplasty. This investigation demonstrates the efficacy and safety profile of one such surgical-site injection across a heterogeneous orthopaedic trauma population.
Surgical-site injection is a particularly attractive adjunct for postoperative pain control in the trauma patient as it has an excellent safety profile, preserves motor function, and can limit adverse effects associated with systemic narcotics. Previous work assessing plasma concentrations of ropivacaine following periarticular injection with the same dosing parameters as those employed in the present study found that no patients reached an intravascular concentration at which side effects can occur and the plasma concentrations were 2.5 times less than reported toxic levels1,2,15. The safety of this intervention has been further demonstrated by the absence of clinical cardiac or central nervous system toxicity across numerous therapeutic investigations employing local anesthetic injections1,2,4,8,15,16. Following periarticular injection, limb function is preserved, which allows for early mobilization and rehabilitation. Although transient peroneal nerve palsies have been occasionally reported in the total knee arthroplasty literature18, these palsies completely resolved in <48 hours and can be limited by avoiding excessive infiltration in the area of the common peroneal nerve along the posterolateral aspect of the knee capsule2,35. In contrast, other effective perioperative analgesic options including continuous epidural, lumbar plexus, and femoral and sciatic nerve blocks result in diminished motor control and prolonged time to physical therapy milestones13,36-43. The preservation of motor function with the surgical-site injection technique may lead to a decreased prevalence of in-hospital falls compared with femoral or sciatic nerve blocks. Further, surgical-site injections can be applied in the operating room without substantial change to the duration of the case1,2 or requirement for subspecialized anesthesia personnel4.
Reducing parenteral narcotic consumption is one of the overarching goals of multimodal pain management27. When compared with control cohorts, periarticular injection has been shown to significantly reduce narcotic consumption1,2,15,20, which decreased narcotic-associated adverse effects including nausea, emesis, rash, and pruritus in 2 recently published meta-analyses17,19. Less dependence on systemic narcotics may prove especially valuable in the elderly population in whom opioid adverse effects are potentiated because of physiologic changes including modified volumes of distribution and reduced drug clearance44.
The present study demonstrated that a ropivacaine-based anesthetic cocktail significantly reduced (p = 0.007) postoperative pain (0 to 12 hours), which translated to reduced early narcotic consumption (0 to 8 hours) following operative fixation of femoral fractures. No adverse effects were observed that were directly attributable to the local injection. In the current investigation, the injection cohort had a trend toward less postoperative delirium when compared with the control group (2.2% compared with 9.1%), and, although not significant, this may represent a potential advantage of decreased narcotic consumption. It should be noted that both groups were advanced in age (72.8 ± 15.2 years for the injection group compared with 70.0 ± 15.2 years for the control group) and comorbidity status (ASA physical status classification: 2.8 ± 0.6 for the injection group compared with 2.8 ± 0.7 for the control group). In addition to narcotic use, advanced age, multiple comorbidities, preoperative cognitive impairment, and dependent living status have all been identified as independent risk factors for the development of postoperative delirium following hip fracture45.
Ropivacaine is a long-acting analgesic that blocks afferent pain signals, with properties similar to bupivacaine but with fewer cardiovascular and neurotoxic adverse events29,30,46,47. The addition of epinephrine allows for vasoconstriction via its action on α-adrenergic receptors, thereby slowing the release of ropivacaine into the vascular system and prolonging its local action48. Despite the slow release profile, one potential challenge with implementation of this analgesic technique may be mitigating rebound pain as the efficacy of the local analgesic agent diminishes. Finally, as opioid receptors are known to be expressed in posttraumatic tissues within hours of surgical trauma, morphine is included in the cocktail solution to alter the sensory input to the central nervous system49,50.
This study had several limitations. First, the study population was diverse, including a heterogeneous collection of both injury patterns and surgical interventions. Although this diversity offers support for the generalizability of the analgesic technique, further investigations are required to establish the efficacy of this multimodal protocol for the individual surgical procedures considered. Second, the randomization technique employed resulted in an uneven treatment allocation. If one surgical intervention had proved to be substantially more painful than others, this distribution may have biased the overall results. Further, stratified randomization was not employed, so the cohorts may have been imbalanced with respect to fracture severity or baseline medical comorbidity, which could have similarly skewed the study outcomes. Third, no plasma concentrations were obtained to directly assess pharmacokinetics and drug toxicity levels. Safety parameters were inferred on the basis of prior studies1,2,15 and the absence of identified cardiac or central nervous system toxicity. Our investigation focused exclusively on the early postoperative period. Although we did not expect that the cocktail injection would result in any significant change in pain profiles beyond the first 48 hours because of its rapid metabolism, longer-term observational studies would have been required to assess effects on subacute and chronic pain profiles. Additionally, the heterogeneous nature of the study population obligated nonuniform rehabilitation protocols, which limited the ability to assess the direct impact of the injection on patient mobilization. The study was also limited because of the lack of a standardized postoperative narcotic protocol. Such a homogeneous protocol would better allow for direct intergroup comparisons with respect to narcotic demand and consumption, which instead were accounted for via conversion to morphine equivalents in the present study design. Finally, the present investigation did not assess the impact of this analgesic technique on elapsed operative time or cost, both of which may impact providers’ decisions in the adoption of this technique.
In conclusion, surgical-site injection with a multimodal analgesic cocktail resulted in improved pain control and decreased early postoperative narcotic utilization with no apparent risks across a broad orthopaedic trauma population. This intervention may secondarily limit medication-related adverse effects in a predominantly elderly population.
Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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