In a randomised controlled pragmatic trial we investigated whether local infiltration analgesia would result in earlier readiness for discharge from hospital after total knee replacement (TKR) than patient-controlled epidural analgesia (PCEA) plus femoral nerve block. A total of 45 patients with a mean age of 65 years (49 to 81) received a local infiltration with a peri-articular injection of bupivacaine, morphine and methylprednisolone, as well as adjuvant analgesics. In 45 PCEA+femoral nerve blockade patients with a mean age of 67 years (50 to 84), analgesia included a bupivacaine nerve block, bupivacaine/hydromorphone PCEA, and adjuvant analgesics. The mean time until ready for discharge was 3.2 days (1 to 14) in the local infiltration group and 3.2 days (1.8 to 7.0) in the PCEA+femoral nerve blockade group. The mean pain scores for patients receiving local infiltration were higher when walking (p = 0.0084), but there were no statistically significant differences at rest. The mean opioid consumption was higher in those receiving local infiltration. The choice between these two analgesic pathways should not be made on the basis of time to discharge after surgery. Most secondary outcomes were similar, but PCEA+femoral nerve blockade patients had lower pain scores when walking and during continuous passive movement. If PCEA+femoral nerve blockade is not readily available, local infiltration provides similar length of stay and similar pain scores at rest following TKR. . Cite this article: Bone Joint J 2013;95-B:629–35

This in vivo controlled laboratory study was performed to evaluate various intra-articular clinical injection regimes that might be less toxic than some in vitro studies suggest. We hypothesised that low-concentration, preservative-free, pH-balanced agents would be less toxic than high-concentration non-pH-balanced agents with preservatives, and that injections of individual agents are less toxic than combined injections. The left knees of 12- to 13-week-old Sprague–Dawley rats were injected once with eight different single agents, including low and high concentrations of ropivacaine and triamcinolone, alone and in combination, as well as negative and positive controls. The rats were killed at one week or five months, and live–dead staining was performed to quantify the death of chondrocytes. All injections except pH-balanced 0.2% ropivacaine combined with preservative-free 1 mg/ml triamcinolone acetonide resulted in statistically significant decreases in chondrocyte viability, compared with control knees, after one week and five months (p < 0.001). After one week there was no significant difference in viability between 0.2% and 0.5% ropivacaine; however, 4 mg/ml triamcinolone resulted in a lower viability than 1 mg/ml triamcinolone.

Although many agents commonly injected into joints are chondrotoxic, in this in vivo study diluting preservative-free 10 mg/ml triamcinolone 1:9 in 0.2% pH-balanced ropivacaine resulted in low toxicity.

Cite this article: Bone Joint J 2015; 97-B:933–8.

There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA.

A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve.

The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively.

The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection.

Take home message: The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA.

Cite this article: Bone Joint J 2016;98-B:194–200.

Blood loss during total knee replacement (TKR) remains a significant concern. In this study, 114 patients underwent TKR, and were divided into two groups based on whether they received a new generation fibrin sealant intra-operatively, or a local infiltration containing adrenaline. Groups were then compared for mean calculated total blood volume (TBV) loss, transfusion rates, and knee range of movement. Mean TBV loss was similar between groups: fibrin sealant mean was 705 ml (281 to 1744), local adrenaline mean was 712 ml (261 to 2308) (p = 0.929). Overall, significantly fewer units of blood were transfused in the fibrin sealant group (seven units) compared with the local adrenaline group (15 units) (p = 0.0479). Per patient transfused, significantly fewer units of blood were transfused in the fibrin sealant group (1.0 units) compared with the local adrenaline group (1.67 units) (p = 0.027), suggesting that the fibrin sealant may reduce the need for multiple unit transfusions. Knee range of movement was similar between groups. From our results, it appears that application of this newer fibrin sealant results in blood loss and transfusion rates that are low and similar to previously applied fibrin sealants.

Cite this article: Bone Joint J 2013;95-B, Supple A:135–9.

We have performed a prospective double-blind, randomised controlled trial over two years to evaluate the efficacy and safety of an intra-operative peri-articular injection of triamcinolone acetonide in patients undergoing medial unicondylar knee replacement. We randomised 90 patients into two equal groups. The study group received an injection of triamcinolone acetonide, bupivacaine, and epinephrine into the peri-articular tissues at the end of the operation. The control group received the same injection mixture but without the addition of triamcinolone. The peri-operative analgesic regimen was standardised.

The study group reported a significant reduction in pain (p = 0.014 at 12 hours, p = 0.031 at 18 hours and p = 0.031 at 24 hours) and had a better range of movement (p = 0.023 at three months). There was no significant difference in the rate of infection and no incidence of tendon rupture in either group.

The addition of corticosteroid to the peri-articular injection after unicondylar knee replacement had both immediate and short-term benefits in terms of relief from pain, and rehabilitation with no increased risk of infection.