Abstract
Objective
We have been using continuous epidural block and local infiltration cocktail for the pain management after TKA since 2005, and good pain control has been acquired with this method. During the past few years we have changed our protocol of postoperative pain management. We have stopped the administration of Loxoprofen starting next morning of the operation, instead Celecoxib was given starting before the operation. We have started mixing steroid to the intraoperative local infiltration cocktail to reduce acute pain as well as swelling. We also have stopped using suction drain, and delayed the timing of CPM start from day 2 to day 3.
Methods
This is case control study, and 78 cases of unilateral TKA were investigated for the study. All cases were anesthetized with continuous epidural block with intravenous dosage of phentanyl and propofol. Compositions of local infiltration cocktail are 40ml 0.75% Ropivacaine, 60ml saline, 0.5ml epinephrin. Group1 (n=40) used this cocktail independently, and Group2 (n=38) used this cocktail with addition of 40mg of triamcinolone(Fig.1). Local infiltration cocktail was used during operation, which was injected to the whole joint capsule. In group1 Loxoprofen was given starting next morning, in group 2 Celecoxib was given starting at 7am on the day of operation. In group1 suction tube was left for 2 days, where as in group2 no suction tube was used postoperatively, and continuous epidural block catheter was removed on postoperative day 2 in both groups. CPM was started at postoperative day 2 in group 1 and postoperative day 3 in group 2. Numerical Rating Scale (NRS) was used to analyze the pain. Circumferences of knee and thigh, as well as ROM of knee joint were measured periodically.
Results
Preoperative demographics showed no statistical difference between two groups(Fig. 2). Group 2 showed significantly less pain at 6am next morning postoperatively (Fig.3&4). Group 2 showed significantly lower NRS on motion at postoperative day1, 3, 5 and 7 (Fig.5). Group 2 also showed significantly less swellings of knees and thighs at postoperative day 7 (Fig.6). The ROM of the knee joints at postoperative day 7, 14 and 21 were better in group2(Fig.7).
Discussions
Our new method of multimodal pain control is effective. It significantly decreased the pain at 6am next morning postoperatively, which is due to preoperative administration of Celecoxib. The pain on motion during 1 st week was significantly decreased which is probably due to the addition of steroid to the cocktail. Suction drain was not needed, if you use steroid in the cocktail and delay the timing to start CPM. The swelling was significantly reduced by steroid injection and delay in ROM exercise. As a result better ROM at postoperative day 7,14 and 21 were obtained.
To view tables/figures, please contact authors directly.
