ABSTRACT
Adequate pain control after total knee arthroplasty (TKA) has been associated with improved patient mobility and satisfaction, and is a task that has historically relied on opioids. Multimodal analgesic regimens can be considered a therapeutic alternative for postoperative pain control to avoid opioid consumption and its adverse side effects. This study aimed to evaluate the use of a multimodal analgesia protocol based on nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen as an alternative to reduce opioid consumption in Hispanic patients undergoing primary TKA. Methods: An institutional review board-approved, randomized controlled trial evaluated postoperative pain control after TKA in a Hispanic population. The experimental opioid-sparing group received 30-mg ketorolac intravenously every 6 hours and 1-g acetaminophen orally every 6 hours as the patient requested. The experimental group had the option to use morphine and oxycodone combined with acetaminophen as a rescue therapy. The control group received opioids in the form of 0.1-mg/kg morphine intravenously every 6 hours and/or oxycodone combined with acetaminophen (2.5 and 325 mg), 2 tablets orally every 6 hours, as the patient requested. Sociodemographic, operative, and immediate postoperative data and pain intensity measurements according to the numerical rating scale (NRS) were compared between groups. Analgesic efficacy was assessed according to the NRS scores at 12, 24, and 48 hours postoperatively. Results: Eighty-one Hispanic patients met inclusion criteria: 42 patients in the experimental group and 39 patients in the control group. None of the patients in the experimental group requested oxycodone combined with acetaminophen as a rescue therapy. Only 2 patients in the experimental group used a mean of 3.0 ± 1.4 mg of rescue morphine; in comparison, the control group consumed a mean of 28.0 ± 7.9 mg of morphine and 64.8 ± 26.0 mg of oxycodone per patient. A pain intensity decrease was observed in the experimental and control groups, with no postoperative evaluation differences at 12 hours (6.7 ± 2.9 compared with 5.9 ± 2.8; p = 0.209), 24 hours (6.2 ± 2.0 compared with 6.1 ± 2.2; p = 0.813), and 48 hours (4.7 ± 2.1 compared with 4.6 ± 1.7; p = 0.835). Conclusions: The use of a multimodal analgesic regimen based on intravenous ketorolac and oral acetaminophen was adequate in reducing postoperative pain and opioid consumption in Hispanic patients undergoing TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
ABSTRACT
BACKGROUND: Ultrasound guidance has been proposed as an alternative imaging modality for sacroiliac (SI) joint injections. Few studies have been published on the accuracy of this modality for the procedure. OBJECTIVE: The objective of this study was to determine the accuracy of ultrasound-guided SI joint injections using a cadaveric model. DESIGN: Controlled laboratory study. SETTING: The study was performed in the Skills Laboratory of the American Sports Medicine Institute in St. Vincent's Hospital, Birmingham, AL. METHODS: Seventeen cadaveric SI joints were injected under ultrasound guidance and dissected to determine the accuracy of intra-articular injections. MAIN OUTCOME MEASUREMENTS: The presence of intra-articular spread of a white paint marker in the SI joint after ultrasound-guided injection. RESULTS: Of 17 SI joints, 15 (88.2%) were accurately injected intra-articularly. One of the joints with no intra-articular spread was found to be partially frozen at the time of dissection, and the second joint was considered an unsuccessful injection before dissection due to difficulty entering the joint under ultrasound guidance because of marginal osteophytes at the joint line. Of the 15 joints with intra-articular placement, 5 joints (33.3%) showed partial extra-articular spread at the time of initial injection and required redirection of the needle under ultrasound guidance, and 3 joints (20%) had extra-articular spread that was not seen during ultrasound. CONCLUSION: Ultrasound allowed intra-articular injection in 88.2% of joints in this cadaveric study. Ultrasound does not expose the patient to radiation, as seen with fluoroscopic guidance, which is currently the gold standard for this injection. In addition, ultrasound may allow visualization of extra-articular spread when caused by extra-articular needle placement, which can allow for redirection of the needle to achieve intra-articular injection. LEVEL OF EVIDENCE: IV.