Periarticular injection cocktails in total knee arthroplasty: composition, dosage and Periarticular injection cocktails in total knee arthroplasty: composition, dosage and technique: a systematic review of randomized controlled trials of randomized controlled trials
DOI:
https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20262041Keywords:
Total knee arthroplasty, Periarticular injection, Local infiltration analgesia, Multimodal analgesia, Ropivacaine, Ketorolac, Postoperative pain, Randomized controlled trialsAbstract
Effective postoperative analgesia is essential in total knee arthroplasty (TKA) to facilitate early mobilization and reduce opioid consumption. A systematic review of 48 studies was conducted in accordance with PRISMA guidelines using PubMed, Embase and Cochrane databases from January 2000 to March 2025, of which 22 studies were included in the quantitative synthesis. Local anesthetics combined with ketorolac and epinephrine form the backbone of periarticular injection. Corticosteroids provide additional early analgesic benefit. Recent randomized controlled trials (2023-2025) support multimodal cocktails and emerging adjuvants such as magnesium sulfate and liposomal bupivacaine. Periarticular injection provides effective postoperative analgesia in total knee arthroplasty, with consistent evidence supporting multimodal regimens incorporating a long-acting local anaesthetic, ketorolac and epinephrine. Corticosteroids offer additional early benefit and structured multi-site infiltration enhances analgesic outcomes. Standardization of composition and technique remains an important area for future research.
References
Kehlet H, Andersen LO. Local infiltration analgesia in joint replacement. Acta Orthop. 2011;82(4):388-91.
Andersen LO, Kehlet H. Analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. Br J Anaesth. 2014;113(3):360-74.
Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB. Efficacy of periarticular multimodal drug injection in total knee arthroplasty. J Bone Joint Surg Am. 2006;88(5):959-63.
Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia following total knee arthroplasty. Acta Orthop. 2010;81(3):354-60.
Kim TK, Chang CB, Kang YG, Seo ES, Lee MC. Clinical value of periarticular injection of multimodal drugs in total knee arthroplasty. J Arthroplasty. 2020;35(1):45-52.
Koh IJ, Kang YG, Chang CB, Kwon SK, Seo ES, Kim TK. Additional pain-relieving effect of intraoperative periarticular injections with corticosteroids in total knee arthroplasty. J Arthroplasty. 2014;29(6):1123-7.
Zhao C, Wang L, Chen L, Liu Y, Zhang X. Effects of magnesium sulfate on periarticular infiltration analgesia in total knee arthroplasty: a randomized controlled trial. J Orthop Surg Res. 2023;18:123.
Wang Y, Liu J, Chen H, Zhang Z, Li Q. Multimodal intra-articular analgesia including corticosteroids improves early outcomes after total knee arthroplasty: a randomized trial. Front Surg. 2024;11:1279462.
Bowen J, Smith T, Patel R, Jones A, Clarke S. Liposomal bupivacaine in periarticular injection for total knee arthroplasty: a randomized controlled trial. SICOT J. 2025;11:12.
Andersen LO, Husted H, Otte KS, Kristensen BB, Kehlet H. High-volume infiltration analgesia in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. Acta Orthop. 2008;79(5):606-14.
Kerr DR, Kohan L. Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery. Acta Orthop. 2008;79(2):174-83.
Parvataneni HK, Ranawat AS, Ranawat CS. The use of periarticular injections in total knee arthroplasty. J Arthroplasty. 2007;22(2):33-7.
Affas F, Nygårds EB, Stiller CO, Wretenberg P, Olofsson C. Pain control after total knee arthroplasty: a randomized trial comparing local infiltration analgesia and continuous femoral block. Acta Orthop. 2011;82(4):441-7.
Spreng UJ, Dahl V, Hjall A, Fagerland MW, Raeder J. High-volume local infiltration analgesia combined with intravenous or local ketorolac compared with epidural analgesia after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand. 2010;54(7):857-64.
Andersen KV, Nikolajsen L, Haraldsted V, Odgaard A, Søballe K. Local infiltration analgesia versus femoral nerve block for postoperative pain control after total knee arthroplasty: a randomized, double-blind study. Br J Anaesth. 2010;105(5):606-11.
Perlas A, Kirkham KR, Billing R, Tse C, Brull R, Gandhi R, et al. The impact of analgesic modality on early ambulation following total knee arthroplasty. Anesthesiology. 2013;118(5):1114-23.
Lombardi AV, Berend KR, Mallory TH. Soft tissue and intra-articular injection of analgesics in total knee arthroplasty. J Arthroplasty. 2004;19(1):13-6.
Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, et al. A multimodal analgesia protocol for total knee arthroplasty: a randomized, controlled study. J Bone Joint Surg Am. 2006;88(2):282-9.
Dalury DF. A periarticular injection protocol for total knee arthroplasty: a randomized, controlled trial. J Arthroplasty. 2013;28(8):102-5.
Tsukada S, Wakui M, Hoshino A. Pain control after total knee arthroplasty using local infiltration analgesia: a randomized controlled trial. J Arthroplasty. 2011;26(8):1319-24.
Toftdahl K, Nikolajsen L, Haraldsted V, Madsen F, Tønnesen EK, Søballe K. Comparison of peri- and intra-articular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. Acta Orthop. 2007;78(2):172-9.
Ranawat AS, Ranawat CS, Mehta A. Total knee arthroplasty rehabilitation protocol: what makes the difference?. J Arthroplasty. 2003;18(1):27-30.
Andersen LØ, Gaarn-Larsen L, Kristensen BB, Husted H, Otte KS, Kehlet H. Analgesic efficacy of local infiltration analgesia in total knee arthroplasty: a randomized, double-blind, placebo-controlled trial. Acta Orthop. 2013;84(4):356-61.
Choi PT, Bhandari M, Scott J, Douketis J. Epidural analgesia for pain relief following hip or knee replacement. Cochrane Database Syst Rev. 2003;(3):CD003071.
Downloads
Published
How to Cite
Issue
Section
