Does PAI Reduce Pain After TKA Among Knee Arthroplasty Patients Receiving ACB & IPACK?

Overview

Kim et al (2019) have shown that addition of ACB/IPACK to PAI improves analgesic outcomes (the nerve blocks reduced pain with ambulation and reduced opioid consumption). TKA patients receiving PAI + ACB/IPACK (along with a comprehensive multimodal analgesic program) had low pain scores with ambulation on POD1: 1.7 +/- 1.4 (mean +/- SD, NRS, 0-10 scale). The opioid consumption in the first 24 hours was 40.6 +/- 32.1 (mg oral morphine equivalents). It is not clear if the PAI component is necessary, given the theoretically nearly complete analgesic effects of the ACB/IPACK block. Additionally, anecdotal evidence indicates that some surgeons at HSS routinely use the PAI and some do not, without obvious large differences in analgesic outcomes. While there may be a 'belt and suspenders' advantage to using PAI in addition to ACB/IPACK, it is not desirable to perform unnecessary procedures. In this study, we seek to compare the efficacy of ACB/IPACK with and without PAI in TKA patients.

Full Title of Study: “Does Periarticular Injection (PAI) Reduce Pain After TKA Among Knee Arthroplasty Patients Receiving Adductor Canal Block and Infiltration Between the Popliteal Artery and the Capsule of the Posterior Knee (ACB&IPACK)? A Blinded, Randomized Controlled Trial.”

Study Type

  • Study Type: Interventional
  • Study Design
    • Allocation: Randomized
    • Intervention Model: Parallel Assignment
    • Primary Purpose: Supportive Care
    • Masking: Triple (Participant, Care Provider, Investigator)
  • Study Primary Completion Date: April 1, 2022

Interventions

  • Drug: Periarticular Injection (PAI)
    • PAI is a widely-utilized, surgeon-performed, analgesic intervention for TKA patients.
  • Drug: Saline Control Periarticular Injection (PAI)
    • equal volume of saline will be used in place of analgesics used in PAI injections

Arms, Groups and Cohorts

  • Placebo Comparator: No PAI + ACB & IPACK
    • Control: saline injection (same injection technique and volumes as described for the active intervention, of normal saline)
  • Active Comparator: PAI + ACB & IPACK
    • Active intervention: Periarticular injection: one deep injection prior to cementation and then a second more superficial injection prior to closure. The deep injection will consist of bupivacaine 0.25% with 1:200,000 epinephrine, 30 cc; morphine, 8 mg/ml, 1cc; methylprednisolone, 40 mg/ml, 1 ml; cefazolin, 500 in 10 ml; normal saline, 22cc. The superficial injection will be 20 ml 0.25% bupivacaine

Clinical Trial Outcome Measures

Primary Measures

  • Pain scores (NRS, 0-10) with ambulation on POD1
    • Time Frame: 24 hours Post Operative Discharge
    • The NRS (numeric rating scale) is a questionnaire that measures pain on a numeric scale, 0 (no pain) to 10 (worst pain imaginable). The questionnaire will be asked on post operative discharge day 1.

Secondary Measures

  • Opioid use (cumulative oral morphine equivalents POD0-POD2, 2 weeks, 3 months)
    • Time Frame: post surgical discharge, 24 hours post surgical discharge, 48 hours post surgical discharge, 2 weeks post surgical discharge, and 3 months post surgical discharge.
    • Cumulative opioid consumption in morphine equivalents will be recorded post surgical discharge, 24h post surgical discharge, 48 hours post surgical discharge, 2 weeks post surgical discharge, and 3 months post surgical discharge.
  • NRS pain with movement on POD0, POD2, 3 months
    • Time Frame: post operative discharge, 48 hours post operative discharge, and 3 months post operative discharge.
    • The NRS (numeric rating scale) is a questionnaire that measures pain on a numeric scale, 0 (no pain) to 10 (worst pain imaginable). The questionnaire will focus on pain during movement. and will be asked post operative discharge, 48 hours post operative discharge, and 3 months post operative discharge.
  • NRS pain score at rest (POD0,POD1, POD2, 3 months)
    • Time Frame: post operative discharge, 24 hours post operative discharge, 48 hours post operative discharge, and 3 months post operative discharge
    • The NRS (numeric rating scale) is a questionnaire that measures pain on a numeric scale, 0 (no pain) to 10 (worst pain imaginable). The questionnaire will focus on pain without movement involved and will be asked post operative discharge, 24 hours post operative discharge, 48 hours post operative discharge, and 3 months post operative discharge.
  • PAIN OUT questionnaire (POD 0, POD1, 2 weeks, 3 months)
    • Time Frame: post surgical discharge, 24 hours post surgical discharge, 2 weeks post surgical discharge, and 3 months post surgical discharge
    • The PAIN OUT questionnaire has multiple numeric scale questions on pain relief as well as pain intensity, along with Yes/No questions. There are also questions asking which pain relief techniques were used (multiple choice). A higher pain relief score is a better result than that of a lower score. While a higher pain score a negative result when compared to a lower score. This questionnaire will be asked post operative discharge, 24 hours post operative discharge, 2 weeks post operative discharge, and 3 months post operative discharge.
  • Quality of Recovery (QOR9) (POD1)
    • Time Frame: 24 hours post surgical discharge.
    • ( Quality of Recovery) This questionnaire has three options for scale (not at all, some of the time, most of the time). The questions focus on the overall well being of the patient. The questionnaire will be asked 24 hours post surgical discharge.
  • Side effects: Opioid-Related Symptom Distress score (POD1)
    • Time Frame: 24 hours post surgical discharge.
    • The questionnaire uses multiple choice answers ranging from rare-almost consistently, not at all- very much, slight- very severe. The questions focus on reported side effects of opioid use. The questionnaire will be asked 24 hours post surgical discharge.
  • Satisfaction with pain management (POD1)
    • Time Frame: 24 hours post operative discharge.
    • This questionnaire is a numeric scale from 0 (strongly dissatisfied) to 10 ( strongly satisfied). A higher number dictates a better outcome. This will be asked 24 hours post operative discharge.
  • Blinding assessment; Bang question (POD1)
    • Time Frame: 24 hours post operative discharge
    • There is no numeric scale for this questionnaire. It focuses on asking the patient which group they believe they were randomized to and why. This will be asked 24 hours post operative discharge.
  • DN4 Neuropathic Assesment (PreOp, 3months)
    • Time Frame: Pre operative, 3 months post operative discharge.
    • The DN4 ( Douleur Neuropathique en 4 Questions) is a Yes/No questionnaire aimed at uncovering neuropathic pain symptoms.
  • Orthopedic Outcome
    • Time Frame: preoperatively, 6 weeks post operative discharge, 3 months post operative discharge, and up to 2 years post operative discharge at routine postoperative visits.
    • The standard KOOS Jr. questionnaire will be asked to evaluate orthopedic outcomes. The KOOS Jr. is non-numerical scale, but rather a wording scale from “none” to “extreme”, with “none” dictating a better outcome. The KOOS Jr. is a series of questions that aim to asses potential pain and knee functionality (stiffness and function during activities). The questionnaire will be asked preoperatively, 6 weeks post operative discharge, 3 months post operative discharge, and up to 2 years post operative discharge at routine postoperative visits.

Participating in This Clinical Trial

Inclusion Criteria

  • Planned use of regional anesthesia – Ability to follow the major components of the study protocol – English speaking (Secondary outcomes include questionnaires validated in English only) Exclusion Criteria:

  • Patients younger than 25 years old and older than 80 – Non-English speaking – Patients intending to receive general anesthesia – Contraindication to nerve blocks or peri-articular injection – Patients with an ASA of IV or higher – Renal insufficiency (ESRD, HD, estimated creatinine clearance < 30 ml/min) – Patients with major prior ipsilateral open knee surgery – Chronic gabapentin/pregabalin use (regular use for longer than 3 months) – Chronic opioid use (taking opioids for longer than 3 months)

Gender Eligibility: All

Minimum Age: 25 Years

Maximum Age: 80 Years

Are Healthy Volunteers Accepted: No

Investigator Details

  • Lead Sponsor
    • Hospital for Special Surgery, New York
  • Provider of Information About this Clinical Study
    • Sponsor
  • Overall Official(s)
    • Jacques YaDeau, MD, PhD, Principal Investigator, Hospital for Special Surgery, New York

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