Intraosseous Infusion May Have a Role in Relieving Pain after Total Knee Arthroplasty
Adding analgesics to an intraosseous infusion in the tibia during total knee arthroplasty (TKA) is a safe and effective method of providing postoperative pain relief, according to a recent study from researchers at Houston Methodist.
The results of their double-blind, randomized trial have been published by The Journal of Arthroplasty.
In a previous study of more than 1000 TKA patients, the researchers demonstrated that an intraosseous infusion of vancomycin directly into the tibia before surgery helped in reducing infection as the result of a higher concentration of the drug in the knee.  Motivated by this success, they investigated whether adding morphine to the standard antibiotic solution could improve postoperative pain management.
The researchers included in this study 48 consecutive patients scheduled for TKA at their institution. Patients were randomly assigned to receive 1 of the following:
- Vancomycin and morphine injected directly into the bone marrow, using an infusion device that was inserted into the tibial tubercle region (experimental group; n=24)
- Vancomycin only injected directly into the bone marrow, using an infusion device that was inserted into the tibial tubercle region (control group; n=24)
The researchers monitored patient-reported pain, nausea, and opioid use for up to 14 days after surgery. In addition, they measured serum levels of morphine and the inflammatory marker interleukin-6 in a subgroup of 20 patients for 10 hours after surgery.
Data analysis showed that patients who were given intraosseous morphine in the tibia had lower pain scores after TKA than those who did not receipt morphine intraosseously, as evidenced by lower Visual Analog Scale pain score at 1, 2, 3, and 5 hours postoperatively in the experimental group. This trend continued through POD9.
Opioid consumption was also lower in the experimental group than in the control group at 48 hours and 2 weeks after surgery, even though patients in the 2 groups had similar interleukin-6 inflammatory marker levels – meaning although the patients had comparable inflammation, those in the experimental group did not need as much pain medication.
Study author Kwan “Kevin” Park, MD, an orthopaedic surgeon at Houston Methodist, summarized the findings: “By infusing pain medication intraosseously, we’re able to reduce postoperative pain for up to 2 weeks, reduce the number of pain pills patients need, and even possibly [contribute to improved] function of the knee over time,” he said. “Our technique also can improve the multimodal pain management protocol we have been using for knee replacement over the years.”
Brozovich AA, Incavo SJ, Lambert BS, et al. Intraosseous morphine decreases postoperative pain and pain medication use in total knee arthroplasty: a double-blind, randomized controlled trial. J Arthroplasty. 2022 Jun;37(6S):S139-S146. doi: 10.1016/j.arth.2021.10.009. Epub 2022 Mar 7.
Park KJ, Chapleau J, Sullivan TC, Clyburn TA, Incavo SJ. 2021 Chitranjan S. Ranawat Award: Intraosseous vancomycin reduces periprosthetic joint infection in primary total knee arthroplasty at 90-day follow-up. Bone Joint J. 2021 Jun;103-B(6 Supple A):13-17. doi: 10.1302/0301-620X.103B6.BJJ-2020-2401.R1.