Fast Track Arthroplasty Using Local Infiltration Analgesia

*Timothy Cordingley, Daniel Chepurin, Ghada Younis, Islam Nassar and David Mitchell*

#### **Abstract**

Fast track arthroplasty is a holistic approach to patients who undergo total hip and knee arthroplasty, a journey or care that begins with setting patient's expectation, optimising medical status, using intraoperative local anaesthetic infiltra-tion, decreasing narcotics usage either in spinal or post-operative medication, discouraging usage of patient controlled analgesia or urinary catheters, encouraging day of operation mobilisation and optimising post-operative physiotherapy protocols. The use of local infiltration analgesia (LIA) is a good alternative compared to other traditional pain management techniques. The purpose of adoption of LIA technique is to provide comfort from the trauma associated with hip and knee arthroplasty particularly for the first 36 h post-operatively, during the time of high postoperative pain, to facilitate increased post-operative mobilisation and function. LIA is safe and effective to achieve good outcomes, early mobilisation and decreasing length of stay without jeopardising clinical outcomes. This chapter discusses LIA and its multimodal approach to analgesia, regional anaesthesia and early mobilisation that improves overall patient experience and satisfaction. The chapter discusses LIA techniques, wound catheter placement, and postoperative protocol to achieve fast track hip and knee arthroplasty.

**Keywords:** local infiltration analgesia, fast track arthroplasty, rapid recovery arthroplasty, enhanced recovery after surgery, total hip arthroplasty, total knee arthroplasty

#### **1. Introduction**

Hip and knee joint arthroplasty are effective in reducing pain and improving function and quality of life in patients with osteoarthritis or other destructive joint disease [1, 2]. This brings an increasing demand on healthcare systems to facilitate smooth recovery, not troubled by nausea or the adverse effects of narcotics. Acute pain leads to decreased mobility, increased length of stay, and an increased need for inpatient rehabilitation, chronic pain, subsequently leading to dissatisfied patients and increasing burden on healthcare resources [3–5]. Utilising an optimum analgesic protocol is challenging; outweighing the benefits and risks of each protocol is key in improving clinical outcomes and patient satisfaction.

Rapid recovery following elective hip and knee arthroplasty has been adopted with consistent patient satisfaction without jeopardising clinical outcomes [6–9]. Several modalities for peri-operative analgesia have been used such as

patient-controlled analgesia (PCA), systemic opioids, spinal anaesthetic, epidural catheter, and local anaesthetic blocks. These all carry associated risks and benefits which must be weighed.

The use of local infiltration analgesia (LIA) is a technique adopted in lower limb arthroplasty to improve post-operative pain. LIA is a technique described initially in literature by Kerr and Kohan who used a multimodal approach to relieve pain [10]. A cocktail of locally injected anaesthetic and direct acting analgesics create a prolonged analgesic effect post-operatively reduces the requirement of opioid analgesia and thus reducing nausea and increasing mobility.

This chapter discusses LIA and its multimodal approach to analgesia, regional anaesthesia and early mobilisation that improves overall patient experience and satisfaction. The chapter discusses LIA techniques, wound catheter placement, and postoperative protocol to achieve fast track hip and knee arthroplasty.

## **2. Local infiltration analgesia mixture**

The local anaesthetic cocktail usually comprises of multiple active ingredients. The dose and volume of this cocktail is dependent on many factors including body mass index (BMI), renal function and patient's specific comorbidities. Local anaesthetic mixture has been validated in previous studies which showed that LIA is safe and effective in total hip and knee arthroplasty [11–13].

The anaesthetic mixture initially described by Kerr & Kohen in 2008 contained 2.0 mg/mL ropivacaine, 30 mg ketorolac and 10 μg/mL of adrenaline totalling 150– 170 mL in knee arthroplasty and 150-200 mL in hip arthroplasty [10]. Ropivacaine was reduced to 250 mg if a patient was less than 55 kg, older than 85 years or had an American Society of Anaesthesiology (ASA) class of 3 or more. In this description, ketorolac was omitted in patients with poor renal function.

According to a study conducted in Ballarat, Victoria in 2020, they used a LIA cocktail derived from Kerr's protocol. Their mixture consisted of 350 mg of ropivacaine, 30 mg ketorolac, 4 mg dexamethasone and 0.5 mg adrenaline [14]. The catheter top-up was injected in the morning post-operative with dose of 20 mL including 100 mg ropivacaine, 4 mg dexamethasone, 30 mg ketorolac, 0.5 mg adrenaline (adrenaline given for total hip arthroplasty (THA) only and not total knee arthroplasty (TKA)) and normal saline. The study showed shorter length of stay, decreased incidence of discharge to rehabilitation, and reduction in healthcare cost without negative impact on patient outcomes when compared to the national average outcomes published in Royal Australasian College of Surgeons Variance Report in 2017. PCA (patient-controlled analgesia) was not used.

In a THR study, Busch et al. used a 100 mL mixture of local anaesthetic comprised of 400 mg of ropivacaine, 30 mg of ketorolac, 5 mg of morphine and 0.6 mL of epinephrine [15]. They found that their patients who received LIA, when compared to those who did not receive, had better pain and satisfaction scores, their PCA use was minimised, and their length of stay (LOS) decreased. Krenzel et al. performed a double-blinded randomised control study for patients with TKA that compared a 20 mL solution of 100 mg ropivacaine against 20 mL of saline placebo [16]. They found that patients received LIA had better pain scores and straight leg raise earlier. The systematic review conducted by Marques et al. used a combination of a local anaesthetic (ropivacaine or bupivacaine), ketorolac and epinephrine [17].

The factors that might impact LIA mixture include surgeon and anaesthetist preferences, low BMI, age, comorbidities, and allergies. Pantoprazole, a proton

pump inhibitor, offsets the multiple risks that contribute to gastrointestinal bleeding or peptic ulcer disease in the perioperative period. These factors should be discussed and altered pre-operatively, and still enlist fast track protocol.
