No evidence of a clinically important effect of adding local infusion analgesia administrated through a catheter in pain treatment after total hip arthroplasty

Background and purpose

Postoperative analgesia after primary total hip arthroplasty (THA) using opioids is associated with troublesome side effects such as nausea and dizziness, and epidural analgesic means delayed mobilization. Thus, local infiltration analgesia (LIA) during surgery prolonged with local infusion analgesia (LINFA) into the soft tissue in the hip region through a catheter in the first postoperative days has gained major interest in THA fast-track settings within a short period of time. LIA at the time of surgery is a validated treatment. We investigated the additional effect of giving postoperative LINFA after THA in patients already having LIA during surgery.

Patients and methods

60 consecutive patients undergoing non-cemented THA were randomized into two groups in a double-blind and controlled study. During surgery, all patients received standardized pain treatment with LIA. Postoperatively, they were treated either with a solution of Ropivacain, Ketorolac, and Adrenaline (LINFA group) or placebo (placebo group) administered through a catheter to the hip 10 and 22 h after surgery. Pain score, opioid consumption, and length of stay (LOS) were evaluated.

Results

After adjustment for multiple testing, there was no statistically significant postoperative difference between the LINFA group and the placebo group regarding pain and tiredness. We found some evidence of a short-term effect on nausea and vomiting. Opioid consumption and length of stay were similar in the two groups.

Interpretation

We found some evidence of a short-term effect of LINFA on nausea and vomiting, but no evidence of an effect on postoperative pain and tiredness. Thus, LINFA cannot be recommended as a standard pain treatment in patients with THA.In Denmark, the waiting time for total hip arthroplasty (THA) early in the last decade was more than 1 year. To increase the numbers of surgeries, several hospitals focused on early mobilization and early discharge. Because of this, perioperative pain treatment gained major attention as the most important factor (Kehlet and Dahl 2003, Rostlund and Kehlet 2007).Postoperative pain in THA has traditionally been managed with epidural analgesia (Choi et al. 2003), with peripheral nerve blocks, or solely with opioid drugs (Fischer and Simanski 2005). Opioids are well known to be associated with troublesome side effects such as nausea, vomiting, and dizziness, and epidural analgesic is associated with urinary retention and delayed mobilization. Thus, neither opioids nor epidural pain treatment are attractive as a treatment modality in units focusing on fast rehabilitation after THA. The next generation of analgesia regimes in THA, with reduced or minimal side effects while maintaining adequate pain relief and maximum muscle control, is therefore of considerable interest.Local infiltration analgesia (LIA) was presented by Kerr and Kohan of the Joint Orthopaedic Center in Sydney, Australia, in 2005 (Kerr and Kohan 2008). They reported a multimodal technique including LIA as pain relief in a fast-track setting after total hip and knee replacement. In their intraoperative set-up, soft tissues around the surgical field were infiltrated with a mixture of Ropivacaine, Ketorolac, and adrenaline, followed by LINFA through a catheter after 20 h. In a non-randomized study, they reported effective pain relief with early mobilization and reduced length of stay (LOS) (Kerr and Kohan 2008).Three other publications have presented pain results after LIA in THA (Bianconi et al. 2003, Andersen et al. 2007a, b). In 2003, in a randomized study with a limited number of patients, Bianconi et al. showed intraoperative LIA in combination with postoperative LINFA with Ropivacaine to be superior to intravenous infusion of morphine and Ketorolac postoperatively (Bianconi et al. 2003). In a randomized, double-blind study, Andersen et al. 2007a) showed intraoperative infiltration with a mixture of Ropivacaine, Ketorolac, and adrenaline into the deep tissue in the wound followed after 8 h by intraarticular LINFA with the same mixture through a catheter to be more effective than continuous epidural infusion with Ropivacaine and morphine. Finally, in a randomized, double-blind study Andersen et al. (2007b) found intraoperative LIA with a mixture of Ropivacaine, Ketorolac, and adrenaline combined with postoperative LINFA using same mixture through a catheter in the hip joint to be substantially more effective than saline administered both intraoperatively and postoperatively.Within a short period, LIA during surgery combined with LINFA into the soft tissue in the hip region through a catheter in the first postoperative days has gained major interest in fast-track THA settings. However, there is no evidence from the existing literature of there being any extra benefit from adding postoperative LINFA in patients who have already been treated with LIA during surgery.We investigated whether there was any additional effect of LINFA administered postoperatively through a catheter on pain and opioid consumption over the first 24 h, and its effect on length of hospital stay after THA in patients already treated with LIA during surgery.