Secondary Logo

Journal Logo

CORR Insights®

No Clinically Important Difference in Pain Scores After THA Between Periarticular Analgesic Injection and Placebo

A Randomized Trial

Post, Zachary D. MD

Clinical Orthopaedics and Related Research®: September 2018 - Volume 476 - Issue 9 - p 1846–1847
doi: 10.1097/CORR.0000000000000401
CLINICAL RESEARCH
Free

Z. D. Post, Associate Professor, Rothman Institute Thomas Jefferson University, Department of Orthopaedic Surgery, Philadelphia, PA, USA

Zachary D. Post MD, Rothman Institute Thomas Jefferson University, Department of Orthopaedic Surgery, 925 Chestnut St., Philadelphia, PA 19107 USA, Email: zacharypost@gmail.com

This CORR Insights® is a commentary on the article “No Clinically Important Difference in Pain Scores After THA Between Periarticular Analgesic Injection and Placebo: A Randomized Trial” by Hirasawa and colleagues available at: DOI: 10.1097/CORR.0000000000000374.

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

This CORR Insights® comment refers to the article available at DOI: 10.1097/CORR.0000000000000374.

Received June 13, 2018

Accepted June 20, 2018

Back to Top | Article Outline

Where Are We Now?

The evidence base about periarticular injection (PAI) in hip and knee replacement includes a substantial number of studies proclaiming its benefits [2, 9], although others have questioned its value [4, 5]. Not long ago, before the advent of multimodal pain control and rapid-recovery protocols for hip and knee replacement, postoperative pain was an expected, even accepted, part of recovery. Acute pain was a leading cause of delayed discharge [10] with hospital stays routinely exceeding 3 days. Pain management has improved substantially among arthroplasty patients over the last decade, and lengths of stay have decreased correspondingly, with many high-volume centers typically discharging patients the same day or the day after surgery. In addition to multimodal pain control (including PAI), systematic use of early mobilization, tranexamic acid, and less-aggressive anticoagulation have transformed postoperative recovery after joint replacement. But which of these factors has had the greatest effect?

In the current study, Hirasawa and colleagues [6] perform a randomized, double-blind, placebo-controlled trial to evaluate the effect of PAI on VAS-measured pain after THA. This rare Level-1 (yet brilliantly simple) study takes place in the context of one surgeon performing bilateral surgery with patients randomized to get PAI in one hip and placebo in the other. While there was a difference in VAS pain scores, the difference did not achieve the predetermined minimum clinically important difference (MCID) of > 20 mm out of 100 on the VAS scale. This was true at all measured time points, up to 24 hours. There were no complications in either group. The authors correctly conclude that the expense of PAI did not justify its use. Perhaps PAI is not as valuable as we may have thought.

Back to Top | Article Outline

Where Do We Need To Go?

While Hirasawa and colleagues [6] demonstrate important shortcomings as to the clinical efficacy of PAI, their study also raises three important questions that remain unanswered: (1) Which medications typically used in PAI are valuable and which are not? (2) Are systemic medications administered locally having an effect on the contralateral hip? (3) Do patients perceive the difference in the hip treated with PAI versus placebo and is this difference valuable to the patient?

In the current study, the authors use a complex mixture of medications for PAI, including ropivacaine, morphine, methylprednisolone, ketoprofen, and epinephrine. This combination includes many medications frequently found in cocktail formulations for PAI [3, 12]. Still, other surgeons use medications not discussed in the current study, sometimes with little to support why each medication is used. Future studies with more-complex study designs should isolate the effectiveness of each medication. Additionally, methylprednisolone, morphine, and ketoprofen are each known to have systemic effects when administered intramuscularly. Without question, these medications contributed to the overall pain perception of the hip treated with placebo, thereby muddying the comparison of PAI- and placebo-treated hips. The current study has emphasized our need to better understand the effect medications used for PAI are having and how to best use them.

The authors of this study, based on a previous knee study [8], set a difference of > 20 mm on the VAS as the MCID. Recovery after THA requires adequate pain control to enable early ambulation and a return to activities of daily living. Undoubtedly, there is a cumulative effect from preoperative analgesia, local intraoperative injections, regional anesthesia, and postoperative pain medications. Future studies should ask patients if they felt more mobile on or able to use one hip versus the other to understand the clinical value of PAI from a patient’s perspective.

One final question that remains is the effect of newer medications like liposomal bupivacaine [1] on the effectiveness of PAI—a controversial subject [11] as most joint replacement surgeons remain hopeful but unsure of the value of these medications.

Back to Top | Article Outline

How Do We Get There?

Level 1 studies are a joy to read but difficult to execute, as is evident from their scarcity. Hirasawa and colleagues have shown us the way forward. To better understand the effect of PAI on postoperative pain, we must understand which medications are working and what effects they have. More randomized, double-blind, well-controlled studies can help us get there. An even simpler study design, isolating specific medications, performed in a regimented way, could answer these questions. Additionally, we need larger studies; it is often smaller studies that miss a dangerous outcome [7], particularly when medications are combined and used in a patient population that frequently has issues with polypharmacy. Often in our rush to improve our patients’ outcomes we fail to completely understand what we have done or why it works. This is likely true of PAI with its many iterations of cocktails described. It is perhaps time to step back just a bit to more fully understand how PAI is working and in the process, standardize its use and delivery.

Back to Top | Article Outline

References

1. Asche CV, Ren J, Kim M, Gordon K, McWhirter M, Kirkness CS, Maurer BT. Local infiltration for postsurgical analgesia following total hip arthroplasty: a comparison of liposomal bupivacaine to traditional bupivacaine. Curr Med Res Opin. 2017;33:1283–1290.
2. Busch CA, Whitehouse MR, Shore BJ, MacDonald SJ, McCalden RW, Brouen RB. The efficacy of periarticular multimodal drug infiltration in total hip arthroplasty. Clin Orthop Relat Res. 2010;468:2152–2159.
3. Danoff JR, Goel R, Henderson RA, Fraser J, Sharkey PF. Periarticular ropivacaine cocktail Is equivalent to liposomal bupivacaine cocktail in bilateral total knee arthroplasty. J Arthroplasty. [Published online ahead of print March 6, 2018]. DOI: 10.1016/j.arth.2018.02.083.
4. Den Hartog YM, Mathijssen NM, van Dasselaar NT, Langendijk PN, Vehmeijer SB. No effect of the infiltration of local anesthetic for total hip arthroplasty using an anterior approach: A randomised placebo controlled trial. Bone Joint J. 2015;97:734–740.
5. Dobie I, Bennett D, Spence DJ, Murray JM, Beverland DE. Periarticular local anesthesia does not improve pain or mobility after THA. Clin Orthop Relat Res. 2012;470:1958–1965.
6. Hirasawa N, Kurosaka K, Nishino M, Nakayama T, Matsubara M, Tsukada S. No clinically important difference in pain scores after THA between periarticular analgesic injection and placebo: A randomized trial. Clin Orthop Relat Res. [Published online ahead of print]. DOI: 10.1097/CORR.0000000000000374.
7. Leopold SL, MD. Editorial: When “safe and effective” becomes dangerous. Clin Orthop Relat Res. 2014;472:1999–2001.
8. Myles PS, Myles DB, Galagher W, Boyd D, Chew C, MacDonald N, Dennis A. Measuring acute postoperative pain using the visual analog scale: The minimal clinically important difference and patient acceptable symptom state. Br J Anaesth. 2017;118:424–429.
9. Parvataneni HK, Shah VP, Howard H, Cole N, Ranawat AS, Ranawat CS. Controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. J Arthroplasty. 2007;22(suppl 2):33–38.
10. Pavlin D, Janet MD, Chen C, Penaloza D, Polissar A, Nayak L, Buckley F, Peter MB. Pain as a factor complicating recovery and discharge after ambulatory surgery. Anesth Analg. 2002;95:627–634.
11. Perets I, Walsh JP, Mu BH, Yuen LC, Ashberg L, Battaglia MR, Domb BG. Intraoperative infiltration of liposomal bupivacaine vs bupivacaine hydrochloride for pain management in primary total hip arthroplasty: A prospective randomized trial. J Arthroplasty. 2018;33:441–446.
12. Spangehl MJ, Clarke HD, Hentz JG, Misra L, Blocher JL, Seamans DP. The Chitranjan Ranawat award: Periarticular injections and femoral & sciatic blocks provide similar pain relief after TKA: A randomized clinical trial. Clin Orthop Relat Res. 2015;473:45–53.
© 2018 Lippincott Williams & Wilkins LWW