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Knee: D. Townshend, K. Emmerson, S. Jones, P. Partington, and S. Muller Intra-articular injection versus portal infiltration of 0.5% bupivacaine following arthroscopy of the knee: A PROSPECTIVE, RANDOMISED DOUBLE-BLINDED TRIAL J Bone Joint Surg Br 2009; 91-B: 601-603 [Abstract] [Full text] [PDF]

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Intra-articular injection versus portal

George H Smith, Sunil Sharma   (10 July 2009)

Intra-articular injection versus portal infiltration

Ravi V Badge, Haider Mamoowala, Associate specialist   (8 June 2009)

Intra-articular injection versus portal 10 July 2009
George H Smith, SpR Orthopaedic Surgery South East Scotland Rotation, Sunil Sharma Send letter to journal: Re: Intra-articular injection versus portal georgesmith{at}doctors.org.uk George H Smith, et al.	Sir, We read this paper with interest, and further to the response by Mr Badge we would like to raise a few points. 1. How were the investigators sure that the intra-articular injections of local anaesthetic (LA) were truly intra-articular? Research by Jackson et al showed a ‘hit rate’ as low as 71% for the anterolateral approach.1 Which approach did they use and did they take any precautions to ensure the injections were intra-articular? For the peri-portal injection group how could they prevent intra-articular spread of the LA? Did they also take any safety measures to prevent extrusion of the LA, i.e. were the wounds closed, and if so, how? 2. More important, we feel, is that the authors justified their study by quoting research by Møiniche et al2 as, "intra-articular bupivacaine provides effective post-operative pain relief following arthroscopic knee surgery compared with placebo". That study in fact concluded that there was "weak evidence for a reduction of post-operative pain after intra-articular local anesthesia in patients undergoing arthroscopic knee surgery which although being small to moderate and of short duration, may be of clinical significance in day-case surgery". Other work has found intra-articular bupivacaine to be ineffective, equivalent to a placebo or at best having a small to moderate effect of short duration.3-5 The efficacy of intra-articular LA for post-operative analgesia appears doubtful. If there are concerns with regard to the use of local anaesthetic and chondrotoxicity as suggested by Chu,6 should we be using it in the first place? Perhaps clinicians should consider alternatives to LA such as Ketorolac and Alpha-2-adrenergic agonists which have promising results in the literature.7,8 G.H. Smith, SpR Orthopaedic Surgery, S. Sharma, South East Scotland Rotation, Scotland, UK. 1. Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg [Am] 2002;84-A:1522-7. 2. Møiniche S, Mikkelsen S, Wetterslev J, Dahl JB. A systematic review of intra-articular local anesthesia for postoperative pain relief after arthroscopic knee surgery. Reg Anesth Pain Med 1999;24:430-7. 3. Henderson RC, Campion ER, DeMasi RA, Taft TN. Postarthroscopy analgesia with bupivacaine: a prospective, randomized, blinded evaluation. Am J Sports Med 1990;18:614-7. 4. De Andrés J, Valía JC, Barrera L, Colomina R. Intra-articular analgesia after arthroscopic knee surgery: comparison of three different regimens. Eur J Anaesthesiol 1998;15:10-15. 5. Al-Nasser B. Clinical significance of intra-articular local anesthetics. Arthroscopy Nov 2005;21:1411-12. 6. Chu CR, Izzo NJ, Coyle CH, Papas NE, Logar A. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg [Br] 2008;90-B:814-20. 7. Vintar N, Rawal N, Veselko M. Intraarticular patient-controlled regional anesthesia after arthroscopically assisted anterior cruciate ligament reconstruction: ropivacaine/morphine/ketorolac versus ropivacaine/morphine. Anesth Analg 2005;101:573-8. 8. Al-Metwalli RR, Mowafi HA, Ismail SA, et al. Effect of intra-articular dexmedetomidine on postoperative analgesia after arthroscopic knee surgery. Br J Anaesth 2008;101:395-9.
Intra-articular injection versus portal infiltration 8 June 2009
Ravi V Badge, Clinical Fellow Fairfield General Hospital, Bury BL9 7TD, Haider Mamoowala, Associate specialist Send letter to journal: Re: Intra-articular injection versus portal infiltration raviorth{at}gmail.com Ravi V Badge, et al.	Sir, We read this paper with interest and feel we must congratulate the authors for a very well conducted study. However, we would like to raise a few points: 1. The authors have not specified which isomers of bupivacaine were used, i.e. marcaine or chirocaine. 2. 20 ml subcutaneous injection seems to be a lot for two standard portals. 3. The authors have not specified the duration of arthroscopy which would have an impact on post-operative pain. 4. The condition of the articular cartilage has not been taken into consideration. This could prove to be important since we know that bupivacaine can be detrimental to a damaged rather than intact cartilage.1 5. Was a fluid management pump used? If so, was an outflow cannula inserted? 6. Were the portals sutured? 7. Analysing pain one hour post-operatively may not be the ideal way to assess the pain in practical terms and pain during the first 24 hours should be considered. 8. In spite of knowing about the chondrotoxicity effect of bupivacaine1 why did the authors continue to use intra-articular bupivacaine for this study? 9. Should the 'take-home message' from this article be that even a single intra-articular injection of bupivacaine should be avoided? Since Chu et al published their experimental study on the time and dose dependent effect of bupivacaine on chondrotoxicity, there have been mixed concerns expressed about its use as post-operative analgesia in arthroscopic surgery. But the paper does accept its limitations as an in-vitro study and the chondrotoxic effect may be seen in prolonged, continuous infusion rather than single intra-articular injection. R.V. Badge, Clinical Fellow, H. Mamoowala, Associate Specialist, Fairfield General Hospital, Bury, UK. 1. Chu CR, Izzo NJ, Coyle CH, Papas NE, Logar A. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg [Br] 2008;90-B:814-20.