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.
- Kulkarni, M. M., Dadheech, A. N., Wakankar, H. M., Ganjewar, N. V., Hedgire, S. S., Pandit, H. G. Randomized Prospective Comparative Study of Adductor Canal Block vs Periarticular Infiltration on Early Functional Outcome After Unilateral Total Knee Arthroplasty. Journal of Arthroplasty 2019; 10: 2360-2364
- Chia, S. K., Wernecke, G. C., Harris, I. A., Bohm, M. T., Chen, D. B., Macdessi, S. J. Peri-articular steroid injection in total knee arthroplasty: a prospective, double blinded, randomized controlled trial. Journal of Arthroplasty 2013; 4: 620-3
- Tsukada, S., Wakui, M., Hoshino, A. Postoperative epidural analgesia compared with intraoperative periarticular injection for pain control following total knee arthroplasty under spinal anesthesia: a randomized controlled trial. Journal of Bone & Joint Surgery - American Volume 2014; 17: 1433-8
- Ukai, T., Kosuke, H., Ebihara, G., Watanabe, M. Comparison of periarticular multidrug infiltration and epidural catheter use in total knee arthroplasty: a prospective randomized controlled study. Journal of orthopaedic surgery (Hong Kong) 2020; 1:
- Ikeuchi, M., Kamimoto, Y., Izumi, M., Sugimura, N., Takemura, M., Fukunaga, K., Yokoyama, M., Tani, T. Local infusion analgesia using intra-articular double lumen catheter after total knee arthroplasty: a double blinded randomized control study. Knee Surgery, Sports Traumatology, Arthroscopy 2013; 12: 2680-4
- Fitz, W., Lichstein, P. M., Trainor, S., Collins, J., Yeung, C. M., McGill, R. Intraarticular Pain Catheter Is Not a Necessary Modality for Postoperative Pain Control After Total Knee Arthroplasty. Arthroplasty Today 2021; 0: 43-46
- Busch, C. A., Shore, B. J., Bhandari, R., Ganapathy, S., MacDonald, S. J., Bourne, R. B., Rorabeck, C. H., McCalden, R. W. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial. Journal of Bone & Joint Surgery - American Volume 2006; 5: 959-63
- Affas, F., Nygårds, E. B., Stiller, C. O., Wretenberg, P., Olofsson, C. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration anesthesia and continuous femoral block. Acta Orthopaedica 2011; 4: 441-7