PERIARTICULAR LOCAL INFILTRATION
Periarticular injections used in total knee arthroplasty lead to decreased postoperative pain and opioid requirements.

Rationale

We reviewed eight randomized clinical trials that represented the best available evidence. All studies were randomized clinical trials of high quality. These articles assess the ability of a periarticular block (PAB) to reduce postoperative pain after a TKA. One study (Affas 2011) looked at PAB and a femoral block. Three studies (Busch 2006, Fitz 2021, Ikeuchi 2013) looked at PAB compared to control. One study (Chia 2013) looked at adding varying amounts of corticosteroids to the PAB. One study (Kulkami 2019) looked at PAB and adductor canal block. Two studies (Ukai 2020 and Tsukada 2014) looked at PAB and epidurals. Compared with epidural analgesia, periarticular injection offers better postoperative pain relief, earlier recovery of knee flexion angle, and lower incidence of nausea. PAI achieves better pain control as compared to ACB in patients undergoing unilateral TKA. Overall pain scores were low in the study involving local infiltration catheters and PAB (Fitz 2020). An intraarticular pain catheter in conjunction with a multimodal approach with intra-operative PAB after TKA does not improve 48-hour pain scores or opioid consumption compared with PAI alone in this randomized controlled trial. The study involving varying levels of corticosteroids assessed two different doses of triamcinolone acetate (N = 42 in each group) added to local anesthetic in TKA for osteoarthritis (Chia 2013). There were no significant differences in pain scores or ROM between the control and corticosteroid groups. Differences in secondary outcomes were also non-significant. Peri-articular corticosteroids do not appear to be of benefit in TKA. In a study involving periarticular injection versus no injection (Busch 2006), the patients who had received the injection used significantly less patient-controlled analgesia over the first twenty-four hours after the surgery. These patients also had favorable patient satisfaction and pain during activity scores in the post-anesthetic-care unit and four hours post operatively. Affas (2011) showed periarticular infiltration led to slightly lower average pain at rest compared to continuous femoral block. Both LIA and femoral block provide good analgesia after TKA. LIA may be considered superior to femoral block since it is cheaper and easier to perform.

Benefits/ Harms of Implementation

There is significant benefit with pain control with the use of PAB.

Outcome Importance

The outcome of PAB versus no PAB, as well as other forms of anesthesia, is better.

Cost Effectiveness / Resource Utilization

Several high quality studies show cost effectiveness and ease of performing with PAB compared with other forms of anesthesia such as femoral nerve block.

Acceptability

The recommendation comes with high acceptability. There is a low risk to benefit ratio. There are several high quality studies showing the benefit and cost effectiveness of PABs.

Feasibility

The feasibility with this recommendation is high. PAB has been shown to be easier to perform compared to other forms of analgesia.

Future Research

Future research would include comparing different types of PABs. Future guidelines should investigate the combination of Peripheral Nerve Block (PNB) and Periarticular Local Infiltration (PAI) / Periarticular Block (PAB), as it was not included in the scope of this guideline.