Evidence Based Analgesia for
lower limb arthroplasty
EBPOM SATELITE MEETING
8 TH J U L Y 2 0 1 1
DR ROBERT STEPHENS
DR SARAH BARNETT
Whole talk at www.ucl.ac.uk/anaesthesia/people/stephens
Or Google ucl anaesthesia stephens
FACT
 70% of patients report moderate to extreme post-
operative pain
 PROSPECT – procedure specific postoperative pain
management, evidence based, managed and
developed by anaesthetists and surgeons
 www.postoppain.org
How to think about this..
 ‘Evidence based’
 What do patients want?
 What do surgeons want?
 What do anaesthetists want?
Levels of Evidence
 Oxford Centre for Evidence-based Medicine:
www.cebm.net
From Owww.cebm.net
A
B
C
D
Problems
 Small studies- poor power, less than ideal design
 Most studies 1 centre ie enthusiasts – not ‘real world’
 Rubbish statistics eg ‘average pain score 2.2’ (1-5)
 Many older studies eg pre USS techniques
 Many studies use nerve catheters
 Recent trend to ‘enhanced’ recovery – different




techniques ? Speed ‘important’ vs ‘experience’
Studies looking at only 1 thing eg pain
Many anaesthetists rarely see postop consequences
Local infiltration gives control to surgeons / interest
Previously ‘our’ area
What do patients want?
 Macario et al 2008
 Patients consulting an orthopaedic surgeon about
undergoing either
 total hip arthroplasty (THA) or
 total knee arthroplasty (TKA)
 Rate the importance of different questions about
their care.
What do patients want?
 Macario et al 2008
 Assembled questions patients might have about joint
replacement surgery
 29 considering undergoing THA and
 19 patients considering TKR
 Completed written survey asking them to rate 30
different questions
 5 point from 1 (least) to 5 (most important)
 (Likert scale)
Patients' overall ranking (median scores) of the importance
of addressing questions regarding joint replacement surgery
n=
29
19
Hip Knee
Will the surgery affect my abilities to care for myself?
5
5
Am I going to need physical therapy?
5
5
How mobile will I be after my surgery?
5
5
When will I be able to walk normally again?
5
5
What are my options if I decide not to receive surgery? 5
4
Will the surgery cause pain afterwards?
5
4
How long will I be in the hospital?
5
4
Is there anything I can do to eliminate pain after surgery?4
5
Will I receive medication to manage the pain?
4
4
Additional questions written in by the patients
How will I be able to manage severe pain?
Tell me about my prosthesis?
What is the surgeon's medical background?
Why should I have confidence in him?
Tell me about the surgery procedure
Am I seeing a film of the surgery?
What are my post surgical physical therapy options? (home/outpatient)
Whom do I ask about my medications for pain and inflammation?
How many of these procedures has my surgeon done?
What is the infection rate?
How long is the entire recovery period?
How much will the physical therapy after the surgery cost?
Will this surgery lead to constipation?
What is the average length of time I will need to recover my facilities?
Are there any problems I may face in full recovery?
What do surgeons want?
 Bio-psycho-social approach
 Maintain muscle power
 Minimise complications
 Active patient involvement - education
 Clinical pathways (Barbieri et al 2009)
 Enhanced recovery (Kehlet et al 2008)
 Avoid DVT
 Good physiotherapy
What do anaesthetists want?
 Good quality analgesia for patients
 Regional techniques: Neuraxial block/Nerve block
 Maintain skills
 Provide good surgical field
 Optimise patient outcome
What do anaesthetists want?
 Analgesia
 Spinal
single/ catheter
 Epidural single/ catheter
 Lumbar plexus / Psoas single/ catheter
 Local infiltration single/ catheter
 Femoral; 3 in 1 single/ catheter
 Sciatic single/ catheter
 Systemic: Opioids / NSAID / Paracetamol
 Adjuncts
Neuraxial blocks
 Low dose intrathecal opiods can provide prolonged
analgesia after hip (Murphy et al. 2003) and knee
(Bowrey et al. 2003) surgery. (Lesser effect for knee)
 Optimal dose for hip surgery 100 micrograms
Morphine
 Up to 21 hr analgesia (Murphy et al. 2003)
 Side effects – PONV/Pruritus/rostral spread with
higher doses
Neuraxial block
 Maurer et al. 2003
 Elective hip surgery
 Continous Spinal Anaesthesia
 better
postoperative analgesia
 Less nausea and vomiting
 Compared with single shot spinal followed by patient-
controlled intravenous analgesia with morphine
Spinal fentanyl vs diamorphine
 No direct study
 Not mentioned in any systematic review
 Obstetric literature extrapolation in C-Section
 Fentanyl 20 vs diamorphine 250
 2 x analgesia postop up to ~ 18 hours
 Cowan 2002, Lane 2005
Epidural vs Systemic: Cochrane review 2010
 Choi at al revised 2010
 ‘Epidural analgesia for pain relief following hip or knee
replacement’
 58 found –only 13 studies used
 4 hip/6 knee /3 both
 Outcomes
 Relevance?
 Eg average Hospital Stay 12,16,16,19 days
 Small patient numbers: 21-90
Epidural vs Systemic: Cochrane review 2010
 Choi at al revised 2010
 ‘Epidural analgesia for pain relief following hip or knee
replacement’
 Sedation
 Urine Retention
 Hypotension
 Early rest pain
 Late rest pain
 Early dynamic pain
0.30 [0.09, 0.97]
3.50 [1.63, 7.51]
2.78 [1.15, 6.72]
-0.77 [-1.24, -0.31]
-0.29 [-0.73, 0.16]
-2.45 [-3.43, -1.48]
Epidural, continuous femoral nerve block or PCA
and effect on rehabilitation after hip arthroplasy
 Singelyn et al. 2005
 45 patients; hip arthroplasy
under GA
 3 groups: Epidural / continuous femoral block / PCA
 All
similar pain relief,
 comparable rehabilitation
 duration of hospital stay
 Continuous FNB less side effects (nausea/vomiting,
urinary retention, hypotension, catheter problems)

Epidural analgesia compared with PNB after
major knee surgery
 Fowler et al. BJA 2008; Systematic review
 8 studies included; n=464 knee replacement
Most common PNB :femoral sheath catheter (5), single
shot femoral (2), continuous lumbar plexus block (1)
Only 1 epidural vs femoral single shot study;
n=63 Adams 2002
 Femoral nerve block
 Comparable analgesia to epidural but less hypotension
 No benefit to adding sciatic nerve block at 24 hrs
Peripheral nerve blocks
 Advances in ultrasound imaging and nerve






localisation plus continuous catheter technology
Increased interest in lower limb peripheral nerve
blockade.
Femoral vs PCA
Ng 2001
better analgesia
Hunt 2009
better analgesia
Wang 2002
better analgesia
Allen 1998
better analgesia
Femoral nerve block improves analgesia
outcomes after TKA
 Paul et al 2010 Anaesthesiology
 Meta-analysis of 23 studies
 Comparing FNB with PCA or epidural analgesia
 1016 patients
 Only 153 Femoral single vs PCA
 SSFNB improved analgesia and reduced morphine
doses compared to PCA
 Continuous FNB no better than SSFNB
Femoral nerve block improves analgesia
outcomes after TKA
PAIN SCORE AT REST: 24 HOURS
Paul et al 2010 Anaesthesiology
Psoas compartment block: Hip/Knee
 Psoas compartment: posterior Lumbar plexus


Femoral/Obturator/lateral cutaneous nerve thigh
Technique Mannion 2007
 Touray et al. BJA 2008: Syst review 30 studies- 20 RCTs
 Mildly superior to iv opiates and ‘3-in-1’ block <8 hours
 Single injection reduces pain for 4-8hrs
 As good as epidural if catheter used
 Catheter can extend analgesia beyond 8hrs
 Other analgesia may be required (18% -GA TKA)
 Complications: epidural extension
Lumbar plexus block
 Unlike FNB....side effects related to psoas
compartment block
 Auroy et al 2002 French Survey of 158,083 blocks
 Retrospective study on complications
 Similar to UK National Audits
Lumbar plexus block
 394 Lumbar plexus blocks
 1 cardiac arrest
 2 respiratory failures
 1 seizure
 peripheral neuropathy
 1 death
10,309 Femoral
0
0
0
3
0
 High dermatome level and bilateral mydriasis
 Suggesting intrathecal cephalad spread of LA
Continuous peripheral nerve blocks
 Do they provide superior analgesia?
 What about side effects and outcomes?
Do Continuous Peripheral Nerve Blocks provide
superior pain control to opioids 1?
 Richman et al A+A 2006
 Meta-analysis 12 studies [360 pts] lower limb
 Reduced Pain scores 24/48 hours ~ 50%
 Reduced side effects
Nausea/vomiting
Sedation
Pruritus
OR
.28
.33
.3
 ‘Perineural catheters provided superior analgesia
to opioids for all catheter locations and times’
Do Continuous Peripheral Nerve Blocks provide
superior pain control to opioids 2?
 Pain score at rest 24 hrs
 Pain score at rest 48 hrs

Paul et al 2010 Anaesthesiology
Continuous peripheral nerve blocks & falls
 Ilfeld et al. Anesth Analg 2010
 Pooled data from 3 previously randomised, placebo



controlled studies of continuous – femoral nerve
Knee and Hip arthroplasy
No patients receiving perineural saline fell (n=86)
7 falls in 6/85 patients receiving ropivacaine (7%;
95%CI=3-15%; p=0.013)
Suggests a causal relationship
Continuous femoral versus posterior lumbar
plexus nerve blocks after hip arthroplasy
 Ilfeld et al Anesth Analg 2011
 Hypothesis that in terms of postoperative analgesia
 femoral ~= posterior lumbar plexus block
 n= 47
 2 days catheter infusion;
 No difference in pain scores
 Less walking with femoral block day 1
Local infiltration techniques
Alternative method for postoperative pain relief after
Hip/Knee arthroplasty
Multimodal wound infiltration analgesic technique
consisting of peri-and intraarticular infiltration of
local anesthetics, NSAID, Vasoconstrictor (LIA)
Catheter may be placed intraoperatively
(Kerr and Kohan 2008)
Local infiltration techniques
Several potential advantages
 Analgesia affects only the surgical area with limited
interference of the muscle strength
 Easier rehabilitation of the operated extremity and
earlier discharge from the hospital (Reilly et al. 2005,
Essving et al 2009)
 Reduces the requirement for postoperative analgesia
with opioids
(Tanaka et al. 2001, Busch et al. 2006, Vendittoli et al. 2006)
Local infiltration analgesia
Repopularised by Kerr & Kohan (2008)
 Case study of 325 patients
 Hip and Knee arthroplasty
 Described technique
Local infiltration analgesia
Repopularised by Kerr & Kohan (2008)
 150–170 mL TKR; 150–200 mL THR
 2.0 mg/mL Ropivicaine = total dose 250-300 mg
(~=1.0mg/ml Bupivicaine, max 75kg 175mg @ 2.5mh/kg)
 30 mg ketorolac
 10 μg/mL adrenaline
 50-mL syringes 10-cm-long 19-G spinal needles
 Over 1 hour during operation
Local infiltration analgesia
 Just before wound closure catheter placed
 16-G
Tuohy needle
 18-G epidural catheter
 0.22-μm antibacterial epidural filter
 50ml reinjected at 15-20 hours
 + NSAID + codeine + paracetamol
Kerr & Kohan (2008)
Local infiltration analgesia: Hip resurfacing
Pain scores /10
N=185
Local infiltration analgesia: knee
Pain scores /10
N=86
Local infiltration analgesia
 Morphine use
None
Hip
69%
Knee
57%
 None after 24 hours
 Stay
Mean
days stay
Hip resurface
1.3 [1–16]
THR
TKR
4.3 [1–27] 3.2 [1–42]
Local infiltration techniques
 Essving 2009
 Single centre blinded RCT, n=40
 Knee unicompartmental arthroplasty
200 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine:
total volume 106 mL + 21 hours top up
vs nothing + placebo top up
 All had PCA, paracetamol, tramadol
Local infiltration analgesia
Local infiltration analgesia
Local infiltration techniques
 Essving 2009
 Median hospital stay
infiltration group
1 (1–6) days vs
Placebo
3 (1–6) days
(p < 0.001)
Similar Oxford knee scores / satisfaction at 7 days
/ ability to flew knee at discharge
Local infiltration techniques
 Few investigators have compared LIA with other
methods with proven analgesic effect, eg femoral
block or epidural analgesia
Local infiltration techniques
 Toftdahl et al (2007) n=80 RCT TKA Spinal
 LIA with ropivacaine, ketorolac, and epinephrine
vs Femoral block
Less pain score, less opioids day 1
better ability to walk more than 3 m on the first
postoperative day
No stay difference
No side effect difference
Local infiltration techniques
 Affas et al 2011
 Compared LIA with femoral nerve block
 40 patients undergoing TKA under spinal anesthesia
 randomized to
 femoral nerve block or
 Infiltration with ropivacaine, ketorolac & epinephrine
 All patients had to intravenous Morphine (PCA)
Local infiltration techniques
 The average pain at rest
lower with LIA (1.6) than with femoral block (2.2)
 Total morphine consumption per kg was similar
 Severe pain(> 7 upon movement)
5% patients in the LIA vs 37% in the femoral block
(p = 0.04)
Local infiltration techniques
 ? LIA provide better analgesia vs femoral block after
TKA
 LIA may be considered to be superior to femoral
block since it is cheaper and easier to perform!
Adjuncts
 Ketamine
 Gabapentanoids
Ketamine
 Noncompetitive antagonist at NMDA receptors and
others (Kors et al. 1998)
 Some suggestion a single intra-operative dose
(0.15mg/kg) improves passive knee mobilisation
after arthroscopic anterior ligament repair surgery
(Menigaux et al. 2000)
 Improves functional outcome after day case knee
arthroplasy (Menigaux et al. 2001)
Ketamine: Adam et al. 2008
 Low dose IV ketamine in combination with
continuous femoral nerve block on postoperative
pain and rehabilitation after total knee
arthroplasty.
Ketamine: Adam et al. 2008
 Continuous femoral nerve block
 0.3 mL/kg of 0.75% ropivacaine before surgery
 continued in the surgical ward for 48 h with 0.2%
ropivacaine at 0.1mL/kg/h
 Patients randomised to
 initial bolus of 0.5 mg/kg ketamine
 + continuous infusion of 3 μg/kg/min during surgery
 + 1.5 μg/kg/min for 48 h ketamine group
 vs equal volume of saline control group
Ketamine: Adam et al. 2008
Ketamine group
 needed less morphine (45 mg versus 69 mg; P 0.02).
 reached 90° of active knee flexion more rapidly
than those in the control group
 7 [5–11] versus 12 [8 – 45] days, median [IQR]; P
0.03).
 Outcomes at 6 wk and 3 months were similar
Adam et al. 2008
 Ketamine is a useful analgesic adjuvant in
perioperative multimodal analgesia
 Positive impact on early knee mobilization.
 No patient in either group reported sedation,
hallucinations, nightmares, or diplopia
 No differences in PONV between the two groups
Gabapentanoids
 Reduction of physiological sensitisation induced by
nociception and inflammation
 ? Reduces nerve hyperexcitability
 Pregabalin structurally related to gabapentin but 6x
more binding affinity (Dahl et al. 2010)
Pregabalin
 Buvanendran 2010 Double blind RCT; n=240
 300mg pre-surgery and 150mg BD post operatively




for 14 days vs placebo
Immediate postoperative period, epidural drug
consumption reduced compared to placebo
No difference in pain scores, but less oral opiods in
pregabalin group
Sedation and confusion more frequent in pregabalin
group (Day 0 and 1)
Less Chronic pain @ 3 + 6 months (0, 0 vs 8, 5%)
Summary
 Analgesia
 Spinal
single/ catheter
(diamorph)
 Epidural single/ catheter
yes
 Lumbar plexus / Psoas single/ catheter
?
 Local infiltration single/ catheter
yes
 Femoral; 3 in 1 single/ catheter
Single FNB
 Sciatic single/ catheter
No
 Systemic: Opioids / NSAID / Paracetamol
 Adjuncts
?
Conclusions
 Acute pain relief to optimise general clinical outcome




for the patient
Multi-modal approach
Attempt to prevent persistent post-operative pain
Managing expectations
Context-sensitive environment
Questions
 Problems
 Small studies- poor power, design eg unblinded,
 Statistics rubbish eg
 ‘average pain score 2.2’ (1-5)
 LIA gives control to surgeons +/- interest
 Previously ‘our’ area
 Many anaesthetists rarely see postop consequences
 Recent trend to ‘enhanced’ recovery – different
techniques ? Speed ‘important’ vs ‘experience’
 Studies looking at only 1 thing eg pain
Knee sensory nerves
Lumbar spine (L2 3 4)
Femoral
Saphenous nerve
 Obturator

Sacral plexus (L4 5 S1 2 3)
Posterior cutaneous nerve of the thigh
 Sciatic
Popliteal
Tibial
Common Peroneal – superficial/deep

Hip Sensory nerves
Thoracic Spine (T12 -)
 Cutaneous
Lumbar spine/plexux (L2 3 4)
 Femoral- hip joint and femur
 Obturator - hip joint
 Lateral cutaneous nerve of the thigh (L2 3)
Sacral plexus (L4 5 S1 2 3)
 Sciatic- hip joint
references
 Murphey A & A December 2003 vol. 97 no. 6 1709-
1715
 Adams European Journal of Anaesthesiology (2002),
19: 658-665
 Affas Acta Orthopaedica 2011; 82 (3):
 Kerr & Kohan (2008) Acta Orthopaedica 2008; 79
(2): 174–183
References
 Lane et al Fentanyl and diamorphine for Caesarean






section Anaesthesia, 2005, 60,p453–457
Cowan Br J Anaesth. 2002 Sep;89(3):452-8
Paul Anesthesiology 2010; 113:1144–62
Touray BJA vol 101, 6 p750
Richman Anesth Analg 2006;102:248 –57
Ilfield et al Anesth Analg 2011
Mannion. Psoas compartment block. CEACCP Vol 7
Issue 5 p 162 available at
http://ceaccp.oxfordjournals.org/content/7/5/162.f
ull
references
 Essving. Acta Orthopaedica 2009; 80 (2): 213–219
213
 Adam 2005 Anesth Analg 2005 February; 100(2):
475–480
 Buvanendran A. Anesth Analg. 2010 Jan
1;110(1):199-207. Epub 2009 Nov 12
Glucocorticoids (Kardash et al. 2008)
 Preoperative glucocorticoids reduce postoperative
nausea but may also improve analgesia and decrease
opioid consumption
 Fifty consecutive patients undergoing elective 10 total
hip arthroplasty under spinal anesthesia with
propofol sedation
 randomized, double-blind, placebo-controlled:
 either 40 mg dexamethasone
 or saline placebo IV before the start of surgery
Kardash et al. 2008
 IV PCA morphine, ibuprofen 400 mg po q6 h and
acetaminophen 650 mg po q6 h were given for 48 h.
 Pain (0–10 numeric rating scale, NRS) at rest, side
effects, and total cumulative patient-controlled
analgesia morphine consumption were recorded q4 h
for 48 h.
 Dynamic pain NRS score was recorded at 24 h.
 C-reactive protein levels were measured in a
subgroup of 25 patients at 48 h.
High dose steroids
 The intraoperative sedation requirement with
propofol was significantly increased in the
dexamethasone group (234.6 160.1 vs 138.8 122.7
mg, P 0.02).
 Dynamic pain was greatly reduced in the
dexamethasone group (NRS score:2.7, 95% CI: 2.2–
3.1 vs 6.8, 6.4 –7.2; P 0.0001).
 There was no significant effect on pain at rest or
cumulative morphine consumption at any time.
 C-reactive protein levels at 48 h were markedly
reduced by dexamethasone (52.4 mg/mL, 28.2–76.6
vs 194.2, 168.9 –219.4; P 0.0001).