JOA - 2026-09-01 - Journal Article; Randomized Controlled Trial; Comparative Study
A Comparison of the Efficacy and Complications Between Intraosseous and Periarticular Multimodal Analgesic Cocktail Injections After Primary Total Knee Arthroplasty: A Randomized Controlled Trial.
Suttikadsanee W, Pinsornsak P, Pinsornsak P
Topics
Key Takeaway
Intraosseous multimodal analgesic cocktail injection reduced VAS pain scores at rest and with motion at 4, 6, and 12 hours and 2 weeks post-TKA compared to periarticular injection, with faster Timed Up and Go at 48 hours but no difference in morphine consumption or discharge timing.
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Summary
This RCT compared intraosseous (IO) versus periarticular (PA) multimodal analgesic cocktail injection (morphine 5mg, ketorolac 30mg, bupivacaine 0.5% 20mL, epinephrine 1:1000 0.6mL) in 86 primary TKA patients. IO injection produced significantly lower VAS scores at rest and with motion at 4, 6, and 12 hours and 2 weeks postoperatively, and faster Timed Up and Go at 48 hours. Total morphine consumption, time to ambulation, length of stay, ROM, and complication rates were equivalent between groups.
Key Limitation
The 2-week maximum follow-up cannot determine whether the early VAS advantage of IO injection translates into meaningful differences in patient-reported outcomes, opioid use, or functional recovery at clinically relevant time points such as 6 weeks or 3 months.
Original Abstract
BACKGROUND
Early postoperative pain control after total knee arthroplasty (TKA) plays a crucial role in patient satisfaction following surgery. Despite current multimodal pain management strategies, postoperative pain remains a concern for patients and can hinder the decision to undergo TKA. With the advent of intraosseous (IO) analgesic injections, the efficacy of IO multimodal analgesic cocktail administration compared to standard periarticular (PA) injections remains controversial.
METHODS
A prospective randomized controlled trial was conducted comparing 45 patients who received an IO multimodal cocktail injection (five mg of morphine, 30 mg of ketorolac, 20 mL of 0.5% bupivacaine, and 0.6 mL of 1:1,000 epinephrine) with 45 patients who received a standard PA cocktail injection. A total of 43 patients in each group completed the study. Postoperative visual analog scale for pain at rest and during motion, morphine consumption, functional outcomes, and postoperative complications were recorded.
RESULTS
In the IO group, visual analog scale for pain was significantly lower both at rest and during motion at four, six, and 12 hours, as well as two weeks postoperatively. The Timed Up and Go test was faster in the IO group at 48 hours, but not at two weeks. However, morphine consumption, time to start walking, time to discharge, postoperative range of motion, and complications showed no differences up to two weeks.
CONCLUSIONS
Intraosseous multimodal cocktail injection resulted in better pain control compared to PA injection during the early postoperative period, as well as improved function in the Timed Up and Go test at 48 hours after TKA, without increasing postoperative complications.
LEVEL OF EVIDENCE
Therapeutic Level I.