Progress of injection sites of local infiltration analgesia in total knee arthroplasty_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHENG Yuhang ^1,2 ,  LI Yang ^1,2 , TIAN Hua ^1,2

1. Department of Orthopedics, Peking University Third Hospital, Beijing, 100191, P. R. China;
2. Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing, 100191, P. R. China;

Corresponding author：

LI Yang, Email: liyangdr@bjmu.edu.cn

Keywords：

Total knee arthroplasty; local infiltration analgesia; injection site; nociceptor

DOI：

10.7507/1002-1892.202211105

Video：

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Objective To review the research progress of injection sites of local infiltration analgesia (LIA) in total knee arthroplasty (TKA). Methods The relevant domestic and foreign literature in recent years was extensively reviewed. The neuroanatomy of the knee, and the research progress of the selection and the difference of effectiveness between different injection sites of LIA in clinical studies were summarized. Results Large concentrations of nociceptors are present throughout the various tissues of the knee joint. Patellar tendon, subpatellar fat pad, lateral collateral ligament insertions, iliotibial band insertions, suprapatellar capsule, and posterior capsule were more sensitive to pain. Most current studies support injections into the lateral capsule, collateral ligament, retinaculum, quadriceps tendon, fat pad, and subcutaneous tissue. Whether to inject into the back of the knee and subperiosteum is controversial. Conclusion The relative difference of knee tissue sensitivity to pain has guiding significance for the selection of LIA injection site after TKA. Although researchers have conducted clinical trials on injection site and technique of LIA in TKA, there are certain limitations. The optimal scheme has not been determined yet, and further studies are needed.

Citation： ZHENG Yuhang, LI Yang, TIAN Hua. Progress of injection sites of local infiltration analgesia in total knee arthroplasty. Chinese Journal of Reparative and Reconstructive Surgery, 2023, 37(4): 502-506. doi: 10.7507/1002-1892.202211105 Copy

1.	Jang S, Lee K, Ju JH. Recent updates of diagnosis, pathophysiology, and treatment on osteoarthritis of the knee. Int J Mol Sci, 2021, 22(5): 2619. doi: 10.3390/ijms22052619.
2.	Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: A review. JAMA, 2021, 325(6): 568-578.
3.	Summers S, Mohile N, McNamara C, et al. Analgesia in total knee arthroplasty: Current pain control modalities and outcomes. J Bone Joint Surg (Am), 2020, 102(8): 719-727.
4.	Ighani Arani P, Wretenberg P, Ottosson J, et al. Pain, function, and satisfaction after total knee arthroplasty, with or without bariatric surgery. Obes Surg, 2022, 32(4): 1164-1169.
5.	Husted CE, Husted H, Ingelsrud LH, et al. Are functional outcomes and early pain affected by discharge on the day of surgery following total hip and knee arthroplasty? Acta Orthop, 2021, 92(1): 62-66.
6.	Thiengwittayaporn S, Tangtrakul P, Hongku N, et al. Patellar denervation reduces postoperative anterior knee pain after patellar resurfacing total knee arthroplasty: A randomized controlled trial. J Arthroplasty, 2021, 36(4): 1295-1301.
7.	Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS^®) Society recommendations. Acta Orthop, 2020, 91(1): 3-19.
8.	Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop, 2008, 79(2): 174-183.
9.	Kandarian BS, Elkassabany NM, Tamboli M, et al. Updates on multimodal analgesia and regional anesthesia for total knee arthroplasty patients. Best Pract Res Clin Anaesthesiol, 2019, 33(1): 111-123.
10.	O’Neill A, Lirk P. Multimodal analgesia. Anesthesiol Clin, 2022, 40(3): 455-468.
11.	Li WT, Bell KL, Yayac M, et al. A postdischarge multimodal pain management cocktail following total knee arthroplasty reduces opioid consumption in the 30-day postoperative period: A group-randomized trial. J Arthroplasty, 2021, 36(1): 164-172.
12.	邸申, 黄健. 人工全膝关节置换术中应用 “鸡尾酒” 疗法的研究进展. 中国药物与临床, 2022, 22(2): 188-192.
13.	Abrisham SM, Ghahramani R, Heiranizadeh N, et al. Reduced morphine consumption and pain severity with transdermal fentanyl patches following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1580-1584.
14.	Phillips WJ, Currier BL. Analgesic pharmacology: Ⅰ. Neurophysiology. J Am Acad Orthop Surg, 2004, 12(4): 213-220.
15.	Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, et al. Anterior vs posterior periarticular multimodal drug injections: A randomized, controlled trial in simultaneous bilateral total knee arthroplasty. J Arthroplasty, 2017, 32(7): 2100-2104.
16.	Hirasawa Y, Okajima S, Ohta M, et al. Nerve distribution to the human knee joint: anatomical and immunohistochemical study. Int Orthop, 2000, 24(1): 1-4.
17.	Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med, 1982, 10(6): 329-335.
18.	Cohen D, Backstein D. Nerve injuries in total knee arthroplasty. Orthop Clin North Am, 2022, 53(2): 123-127.
19.	Banios K, Raoulis V, Fyllos A, et al. Anterior and posterior cruciate ligaments mechanoreceptors: A review of basic science. Diagnostics (Basel), 2022, 12(2): 331. doi: 10.3390/diagnostics12020331.
20.	Ariel de Lima D, Helito CP, Lacerda de Lima L, et al. Study of the nerve endings and mechanoreceptors of the anterolateral ligament of the knee. Arthroscopy, 2019, 35(10): 2918-2927.
21.	Biedert RM, Stauffer E, Friederich NF. Occurrence of free nerve endings in the soft tissue of the knee joint. A histologic investigation. Am J Sports Med, 1992, 20(4): 430-433.
22.	Worth RM, Kettelkamp DB, Defalque RJ, et al. Saphenous nerve entrapment. A cause of medial knee pain. Am J Sports Med, 1984, 12(1): 80-81.
23.	Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med, 1998, 26(6): 773-777.
24.	Clockaerts S, Bastiaansen-Jenniskens YM, Runhaar J, et al. The infrapatellar fat pad should be considered as an active osteoarth-ritic joint tissue: a narrative review. Osteoarthritis Cartilage, 2010, 18(7): 876-882.
25.	Ross JA, Greenwood AC, Sasser P, et al. Periarticular injections in knee and hip arthroplasty: Where and what to inject. J Arthroplasty, 2017, 32(9S): S77-S80.
26.	Badalamente MA, Cherney SB. Periosteal and vascular innervation of the human patella in degenerative joint disease. Semin Arthritis Rheum, 1989, 18(4 Suppl 2): 61-66.
27.	Wang Y, Zhou A. A new improvement: subperiosteal cocktail application to effectively reduce pain and blood loss after total knee arthroplasty. J Orthop Surg Res, 2020, 15(1): 33. doi: 10.1186/s13018-020-1563-5.
28.	Bournazou E, Samuels J, Zhou H, et al. Vascular adhesion protein-1 (VAP-1) as predictor of radiographic severity in symptomatic knee osteoarthritis in the New York University Cohort. Int J Mol Sci, 2019, 20(11): 2642. doi: 10.3390/ijms20112642.
29.	Krauspe R, Schmitz F, Zöller G, et al. Distribution of neurofilament-positive nerve fibres and sensory endings in the human anterior cruciate ligament. Arch Orthop Trauma Surg, 1995, 114(4): 194-198.
30.	Nassar I, Fahey J, Mitchell D. Rapid recovery following hip and knee arthroplasty using local infiltration analgesia: length of stay, rehabilitation protocol and cost savings. ANZ J Surg, 2020, 90(3): 355-359.
31.	Kopitkó C, Czermann R, Orosz M, et al. A randomized comparative evaluation of local infiltration analgesia, extended nerve blocks, and conventional analgesia in pain management after total knee arthroplasty. Jt Dis Relat Surg, 2021, 32(2): 290-298.
32.	Guler O, Mutlu S, Isyar M, et al. Efficacy of periarticular injection applied trough knee other than posterior capsule in simultaneous bilateral total knee arthroplasty. J Orthop, 2015, 12(4): 205-210.
33.	Iwakiri K, Ohta Y, Kobayashi A, et al. Local efficacy of periarticular morphine injection in simultaneous bilateral total knee arthroplasty: A prospective, randomized, double-blind trial. J Arthroplasty, 2017, 32(12): 3637-3642.
34.	赵福林. 人工全膝关节置换术改良 “鸡尾酒” 注射方法和传统 “鸡尾酒” 注射方法的有效性比较研究. 长春: 吉林大学, 2022.
35.	Kertkiatkachorn W, Kampitak W, Tanavalee A, et al. Adductor canal block combined with ipack (interspace between the popliteal artery and the capsule of the posterior knee) block vs periarticular injection for analgesia after total knee arthroplasty: A randomized noninferiority trial. J Arthroplasty, 2021, 36(1): 122-129.
36.	李新天, 王炜, 林进, 等. 改良鸡尾酒疗法对全膝关节置换术后疼痛控制的研究. 中华骨与关节外科杂志, 2017, 10(4): 298-301.
37.	李科伟, 侯颖周, 王少华, 等. 不同方式 “鸡尾酒” 注射对全膝关节置换术后的镇痛效果. 中南大学学报 (医学版), 2020, 45(4): 406-410.
38.	Dupont G, Unno F, Iwanaga J, et al. A variant of the sciatic nerve and its clinical implications. Cureus, 2018, 10(6): e2874. doi: 10.7759/cureus.2874.
39.	Balius R, Pujol M, Pérez-Cuenca D, et al. Sciatic nerve movement in the deep gluteal space during hip rotations maneuvers. Clin Anat, 2022, 35(4): 482-491.
40.	Pinsornsak P, Nangnual S, Boontanapibul K. Multimodal infiltration of local anaesthetic in total knee arthroplasty; is posterior capsular infiltration worth the risk? A prospective, double-blind, randomised controlled trial. Bone Joint J, 2017, 99-B(4): 483-488.
41.	Safa B, Gollish J, Haslam L, et al. Comparing the effects of single shot sciatic nerve block versus posterior capsule local anesthetic infiltration on analgesia and functional outcome after total knee arthroplasty: a prospective, randomized, double-blinded, controlled trial. J Arthroplasty, 2014, 29(6): 1149-1153.
42.	Hinarejos P, Capurro B, Santiveri X, et al. Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2016, 24(10): 3299-3305.

1. Jang S, Lee K, Ju JH. Recent updates of diagnosis, pathophysiology, and treatment on osteoarthritis of the knee. Int J Mol Sci, 2021, 22(5): 2619. doi: 10.3390/ijms22052619.
2. Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis: A review. JAMA, 2021, 325(6): 568-578.
3. Summers S, Mohile N, McNamara C, et al. Analgesia in total knee arthroplasty: Current pain control modalities and outcomes. J Bone Joint Surg (Am), 2020, 102(8): 719-727.
4. Ighani Arani P, Wretenberg P, Ottosson J, et al. Pain, function, and satisfaction after total knee arthroplasty, with or without bariatric surgery. Obes Surg, 2022, 32(4): 1164-1169.
5. Husted CE, Husted H, Ingelsrud LH, et al. Are functional outcomes and early pain affected by discharge on the day of surgery following total hip and knee arthroplasty? Acta Orthop, 2021, 92(1): 62-66.
6. Thiengwittayaporn S, Tangtrakul P, Hongku N, et al. Patellar denervation reduces postoperative anterior knee pain after patellar resurfacing total knee arthroplasty: A randomized controlled trial. J Arthroplasty, 2021, 36(4): 1295-1301.
7. Wainwright TW, Gill M, McDonald DA, et al. Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS^®) Society recommendations. Acta Orthop, 2020, 91(1): 3-19.
8. Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop, 2008, 79(2): 174-183.
9. Kandarian BS, Elkassabany NM, Tamboli M, et al. Updates on multimodal analgesia and regional anesthesia for total knee arthroplasty patients. Best Pract Res Clin Anaesthesiol, 2019, 33(1): 111-123.
10. O’Neill A, Lirk P. Multimodal analgesia. Anesthesiol Clin, 2022, 40(3): 455-468.
11. Li WT, Bell KL, Yayac M, et al. A postdischarge multimodal pain management cocktail following total knee arthroplasty reduces opioid consumption in the 30-day postoperative period: A group-randomized trial. J Arthroplasty, 2021, 36(1): 164-172.
12. 邸申, 黄健. 人工全膝关节置换术中应用 “鸡尾酒” 疗法的研究进展. 中国药物与临床, 2022, 22(2): 188-192.
13. Abrisham SM, Ghahramani R, Heiranizadeh N, et al. Reduced morphine consumption and pain severity with transdermal fentanyl patches following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2014, 22(7): 1580-1584.
14. Phillips WJ, Currier BL. Analgesic pharmacology: Ⅰ. Neurophysiology. J Am Acad Orthop Surg, 2004, 12(4): 213-220.
15. Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, et al. Anterior vs posterior periarticular multimodal drug injections: A randomized, controlled trial in simultaneous bilateral total knee arthroplasty. J Arthroplasty, 2017, 32(7): 2100-2104.
16. Hirasawa Y, Okajima S, Ohta M, et al. Nerve distribution to the human knee joint: anatomical and immunohistochemical study. Int Orthop, 2000, 24(1): 1-4.
17. Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med, 1982, 10(6): 329-335.
18. Cohen D, Backstein D. Nerve injuries in total knee arthroplasty. Orthop Clin North Am, 2022, 53(2): 123-127.
19. Banios K, Raoulis V, Fyllos A, et al. Anterior and posterior cruciate ligaments mechanoreceptors: A review of basic science. Diagnostics (Basel), 2022, 12(2): 331. doi: 10.3390/diagnostics12020331.
20. Ariel de Lima D, Helito CP, Lacerda de Lima L, et al. Study of the nerve endings and mechanoreceptors of the anterolateral ligament of the knee. Arthroscopy, 2019, 35(10): 2918-2927.
21. Biedert RM, Stauffer E, Friederich NF. Occurrence of free nerve endings in the soft tissue of the knee joint. A histologic investigation. Am J Sports Med, 1992, 20(4): 430-433.
22. Worth RM, Kettelkamp DB, Defalque RJ, et al. Saphenous nerve entrapment. A cause of medial knee pain. Am J Sports Med, 1984, 12(1): 80-81.
23. Dye SF, Vaupel GL, Dye CC. Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med, 1998, 26(6): 773-777.
24. Clockaerts S, Bastiaansen-Jenniskens YM, Runhaar J, et al. The infrapatellar fat pad should be considered as an active osteoarth-ritic joint tissue: a narrative review. Osteoarthritis Cartilage, 2010, 18(7): 876-882.
25. Ross JA, Greenwood AC, Sasser P, et al. Periarticular injections in knee and hip arthroplasty: Where and what to inject. J Arthroplasty, 2017, 32(9S): S77-S80.
26. Badalamente MA, Cherney SB. Periosteal and vascular innervation of the human patella in degenerative joint disease. Semin Arthritis Rheum, 1989, 18(4 Suppl 2): 61-66.
27. Wang Y, Zhou A. A new improvement: subperiosteal cocktail application to effectively reduce pain and blood loss after total knee arthroplasty. J Orthop Surg Res, 2020, 15(1): 33. doi: 10.1186/s13018-020-1563-5.
28. Bournazou E, Samuels J, Zhou H, et al. Vascular adhesion protein-1 (VAP-1) as predictor of radiographic severity in symptomatic knee osteoarthritis in the New York University Cohort. Int J Mol Sci, 2019, 20(11): 2642. doi: 10.3390/ijms20112642.
29. Krauspe R, Schmitz F, Zöller G, et al. Distribution of neurofilament-positive nerve fibres and sensory endings in the human anterior cruciate ligament. Arch Orthop Trauma Surg, 1995, 114(4): 194-198.
30. Nassar I, Fahey J, Mitchell D. Rapid recovery following hip and knee arthroplasty using local infiltration analgesia: length of stay, rehabilitation protocol and cost savings. ANZ J Surg, 2020, 90(3): 355-359.
31. Kopitkó C, Czermann R, Orosz M, et al. A randomized comparative evaluation of local infiltration analgesia, extended nerve blocks, and conventional analgesia in pain management after total knee arthroplasty. Jt Dis Relat Surg, 2021, 32(2): 290-298.
32. Guler O, Mutlu S, Isyar M, et al. Efficacy of periarticular injection applied trough knee other than posterior capsule in simultaneous bilateral total knee arthroplasty. J Orthop, 2015, 12(4): 205-210.
33. Iwakiri K, Ohta Y, Kobayashi A, et al. Local efficacy of periarticular morphine injection in simultaneous bilateral total knee arthroplasty: A prospective, randomized, double-blind trial. J Arthroplasty, 2017, 32(12): 3637-3642.
34. 赵福林. 人工全膝关节置换术改良 “鸡尾酒” 注射方法和传统 “鸡尾酒” 注射方法的有效性比较研究. 长春: 吉林大学, 2022.
35. Kertkiatkachorn W, Kampitak W, Tanavalee A, et al. Adductor canal block combined with ipack (interspace between the popliteal artery and the capsule of the posterior knee) block vs periarticular injection for analgesia after total knee arthroplasty: A randomized noninferiority trial. J Arthroplasty, 2021, 36(1): 122-129.
36. 李新天, 王炜, 林进, 等. 改良鸡尾酒疗法对全膝关节置换术后疼痛控制的研究. 中华骨与关节外科杂志, 2017, 10(4): 298-301.
37. 李科伟, 侯颖周, 王少华, 等. 不同方式 “鸡尾酒” 注射对全膝关节置换术后的镇痛效果. 中南大学学报 (医学版), 2020, 45(4): 406-410.
38. Dupont G, Unno F, Iwanaga J, et al. A variant of the sciatic nerve and its clinical implications. Cureus, 2018, 10(6): e2874. doi: 10.7759/cureus.2874.
39. Balius R, Pujol M, Pérez-Cuenca D, et al. Sciatic nerve movement in the deep gluteal space during hip rotations maneuvers. Clin Anat, 2022, 35(4): 482-491.
40. Pinsornsak P, Nangnual S, Boontanapibul K. Multimodal infiltration of local anaesthetic in total knee arthroplasty; is posterior capsular infiltration worth the risk? A prospective, double-blind, randomised controlled trial. Bone Joint J, 2017, 99-B(4): 483-488.
41. Safa B, Gollish J, Haslam L, et al. Comparing the effects of single shot sciatic nerve block versus posterior capsule local anesthetic infiltration on analgesia and functional outcome after total knee arthroplasty: a prospective, randomized, double-blinded, controlled trial. J Arthroplasty, 2014, 29(6): 1149-1153.
42. Hinarejos P, Capurro B, Santiveri X, et al. Local infiltration analgesia adds no clinical benefit in pain control to peripheral nerve blocks after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc, 2016, 24(10): 3299-3305.

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