Can a periarticular levobupivacaine injection reduce postoperative opiate consumption during primary hip arthroplasty?

Abstract

Background: Several reports have confirmed the ability of intraoperative periarticular injections to control pain after THA. However, these studies used differing combinations of analgesic agents and the contribution of each, including the local anesthetic agent, is uncertain. Understanding the independent effects of the various agents could assist in improved pain management after surgery.

Questions/purposes: We therefore determined the ability of intraoperative periarticular infiltration of levobupivacaine to (1) reduce postoperative pain, (2) reduce postoperative morphine requirements, and (3) reduce the incidence of nausea and urinary retention.

Patients and methods: A double-blinded, randomized, placebo-controlled trial of patients undergoing primary THAs was performed. Patients were randomized to receive a periarticular infiltration of 150 mg levobupivacaine in 60 mL 0.9% saline (n = 45) or a placebo consisting of 60 mL 0.9% saline (n = 46). We obtained a short-form McGill pain score, visual analog scale (VAS), and morphine requirements via patient-controlled analgesia (PCA) as primary measures. Postoperative antiemetic requirements and need for catheterization for urinary retention were determined as secondary measures.

Results: Subjectively reported pain scores and the overall intensity scores were similar for both groups in the postoperative period. At the same time the mean morphine consumption was less in the levobupivacaine group, most notable in the first 12 hours after surgery: treatment group 11.5 mg vs control group 21.2 mg. We observed no differences in the frequency of postoperative nausea and vomiting or urinary retention.

Conclusions: Our observations suggest periarticular injection of levobupivacaine can supplement available postoperative analgesic techniques and reduce postoperative morphine requirements after THA.

Level of evidence: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Figures

Fig. 1

The CONSORT flow diagram is shown.

Fig. 2A–B

There was no difference between the control and treatment groups in (A) total pain rating index (p = 0.731) or (B) total McGill score (p = 0.494) as determined by the RM-ANOVA. Values are expressed as averages with standard error bars. Individual p values at each time were calculated using the Mann-Whitney U-test.

Fig. 3A–B

There was no difference between the control and treatment groups in (A) VAS score (p = 0.463) or (B) pain intensity score (p = 0.814) as determined by the RM-ANOVA, suggesting equivalent efficacy in postoperative analgesic control. Values are expressed as averages with standard error bars. Individual p values at each time were calculated using the Mann-Whitney U-test.

Fig. 4A–B

There was a difference between treatment and control groups in average opioid use via PCA measured in (A) milligrams (p < 0.001) and (B) milligrams per kilogram (p < 0.001) during 12-hour periods postoperatively. Values are expressed as averages with standard error bars. Individual p values at each time were calculated using the Mann-Whitney U-test.