Seangleulur Alisa, Vanasbodeekul Pramook, Prapaitrakool Sunisa, Worathongchai Sukhumakorn, Anothaisintawee Thunyarat, McEvoy Mark, Vendittoli Pascal-André, Attia John, Thakkinstian Ammarin
From the Department of Anaesthesiology, Faculty of Medicine, Thammasat University, Pathum Thani (AS, SP, SW); Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok (AS, TA, AT); Orthopaedics Surgery Unit, Chaopraya Abhaibhubejhr Hospital, Prachinburi (PV); Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (TA); Center for Clinical Epidemiology and Biostatistics, School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia (MM, JA); and Orthopaedic Surgery Unit, Department of Surgery, Maisonneuve-Rosemont Hospital, Montreal, Canada (P-AV).
Eur J Anaesthesiol. 2016 Nov;33(11):816-831. doi: 10.1097/EJA.0000000000000516.
Local infiltration analgesia (LIA) has emerged as an alternative treatment for postoperative pain after total knee arthroplasty (TKA). Its efficacy remains inconclusive with inconsistent results from previous studies and meta-analyses. There is no agreement on which local anaesthetic agent and infiltration technique is most effective and well tolerated.
The objective was to compare LIA after primary TKA with placebo or no infiltration in terms of early postoperative pain relief, mobilisation, length of hospital stay (LOS) and complications when used as a primary treatment or as an adjunct to regional anaesthesia. The role of injection sites, postoperative injection or infusion and multimodal drug injection with ketorolac were also explored.
A systematic review and meta-analysis of randomised controlled trials (RCTs).
A literature search was performed using PubMed and SCOPUS up to September 2015.
RCTs comparing LIA with placebo or no infiltration after primary TKA in terms of pain score and opioid consumption at 24 and 48 h, mobilisation, LOS and complications were included.
In total 38 RCTs were included. LIA groups had lower pain scores, opioid consumption and postoperative nausea and vomiting, higher range of motion at 24 h and shorter LOS than no injection or placebo. After subgroup analysis, intraoperative peri-articular but not intra-articular injection had lower pain score at 24 h than no injection or placebo with the pooled mean difference of pain score at rest of -0.89 [95% CI (-1.40 to -0.38); I = 92.0%]. Continuing with postoperative injection or infusion reduced 24-h pain score with the pooled mean difference at rest of -1.50 [95% CI (-1.92 to -1.08); I = 60.5%]. There was no additional benefit in terms of pain relief during activity, opioid consumption, range of movement or LOS when LIA was used as an adjunct to regional anaesthesia. Four out of 735 patients receiving LIA reported deep knee infection, three of whom had had postoperative catheter placement.
LIA is effective for acute pain management after TKA. Intraoperative peri-articular but not intra-articular injection may be helpful in pain control up to 24 h. The use of postoperative intra-articular catheter placement is still inconclusive. The benefit of LIA as an adjunctive treatment to regional anaesthesia was not demonstrated.
局部浸润镇痛（LIA）已成为全膝关节置换术（TKA）术后疼痛的一种替代治疗方法。其疗效尚无定论，先前的研究和荟萃分析结果不一致。对于哪种局部麻醉剂和浸润技术最有效且耐受性良好，尚无共识。
比较初次TKA后LIA与安慰剂或不进行浸润在术后早期疼痛缓解、活动能力、住院时间（LOS）和并发症方面的差异，LIA作为主要治疗方法或区域麻醉辅助方法时均进行比较。还探讨了注射部位、术后注射或输注以及与酮咯酸联合多模式药物注射的作用。
对随机对照试验（RCT）进行系统评价和荟萃分析。
截至2015年9月，使用PubMed和SCOPUS进行文献检索。
纳入比较初次TKA后LIA与安慰剂或不进行浸润在24小时和48小时时疼痛评分、阿片类药物消耗量、活动能力、LOS和并发症方面的RCT。
共纳入38项RCT。与不注射或安慰剂相比，LIA组疼痛评分更低、阿片类药物消耗量更少、术后恶心呕吐发生率更低、24小时时活动范围更大且LOS更短。亚组分析后，术中关节周围而非关节内注射在24小时时疼痛评分低于不注射或安慰剂，静息时疼痛评分的合并平均差值为-0.89 [95%CI（-1.40至-0.38）；I² = 92.0%]。术后继续注射或输注可降低24小时疼痛评分，静息时合并平均差值为-1.50 [95%CI（-1.92至-1.08）；I² = 60.5%]。当LIA作为区域麻醉辅助方法时，在活动时疼痛缓解、阿片类药物消耗量、活动范围或LOS方面没有额外益处。接受LIA的735例患者中有4例报告深部膝关节感染，其中3例术后放置了导管。
LIA对TKA术后急性疼痛管理有效。术中关节周围而非关节内注射在24小时内可能有助于控制疼痛。术后关节内放置导管的益处仍无定论。未证明LIA作为区域麻醉辅助治疗的益处。
