The AAHKS Clinical Research Award: Intraosseous Regional Diclofenac for Postoperative Pain Management in Total Knee Arthroplasty.

Abstract

Effective postoperative pain management is important following primary total knee arthroplasty (TKA). Intraosseous regional administration (IORA) of antibiotics in TKA results in higher local tissue concentrations, potentially improving efficacy. We investigated using IORA diclofenac to improve postoperative pain management in TKA compared to intravenous (IV) diclofenac. There were 46 primary TKA patients (23 per group) enrolled in a prospective, double-blinded, randomized controlled trial. The intervention group received 75 mg IORA diclofenac and an IV normal saline placebo. The control group received 75 mg IV diclofenac and an intraosseous normal saline placebo. Pain levels were measured on a visual analog scale for pain (VAS-P) until postoperative day (POD) seven. The secondary outcomes included opioid consumption, quality of recovery-15, impact of pain on walking and sleep, length of admission, patient satisfaction, the Knee Injury and Osteoarthritis Outcome Score for Joint Replacements, and Oxford Knee Score. Intervention group visual analog scale for pain scores (mm, [95% confidence interval]) were lower at one (21.2 [16.3, 31.4] versus 40.2 [30.8 to 50.8]; P = 0.007), 12 (18.2 [12.1 to 25.6] versus 36.5 [27.6 to 46.6]; P = 0.002), and 24 hours (21.3 [14.6 to 29.2] versus 39.5 [30.2 to 50]; P = 0.003), and POD one (23.5 [17.8 to 30] versus 35.4 [28.3 to 43.3]; P = 0.01). The intervention group consumed fewer opioids (mean morphine milligram equivalent in mg) from POD zero (20.2 [12.4 to 28.0] versus 45.3 [37.7 to 53.0]), POD one (27.7 [19.2 to 34.8] versus 43 [35.4 to 50.6]), POD two (32.1 [24.3 to 39.9] versus 51.5 [43.9 to 59.1]), and POD three (27.4 [19.6 to 35.2] versus 41.3 [33.7 to 48.9]). Moreover, they demonstrated better quality of recovery-15 scores (P = 0.04), POD one walking (P = 0.001) and sleeping (P = 0.003), Knee Injury and Osteoarthritis Outcome Score for Joint Replacements scores (P = 0.03), and patient satisfaction (P = 0.04) at 2 weeks postsurgery. The IORA diclofenac provided enhanced early postoperative pain relief and reduced opioid consumption, with better early knee function and patient satisfaction following TKA.