In the ensuing years following the discovery of local anesthetic properties by Carl Koller in 1884, [26] cocaine was primarily utilized for topical anesthesia and regional nerve blockade [27]. Carl Ludwig Schleich is credited with introducing and standardizing the technique of “infiltration anesthesia ” in 1892 [28, 29]. His technique involved infiltrating the different layers of the surgical wound with a series of overlapping injections as the surgery proceeded. The earliest cases of infiltration analgesia also revealed the first cases of complications associated with the technique. Schleich noted local anesthetic toxicity after using higher concentration of cocaine (2 and 5 %) and hence recommended the use of dilute solutions (0.001, 0.1, and 0.2 %) and larger volumes (to a total dose of 50 mg). He also noted improved analgesia when cocaine was combined with morphine. Although frowned upon at the time, we have come to realize that all of these ideas apply to LIA even today. Infiltration techniques were found to be efficacious for a wide variety of surgeries subsequently and have been accepted as a part of practice [30–36]. The initial description of local anesthetic infiltration and infusion following lower limb arthroplasty was performed by Bianconi et al. in 2003 (see below). They infiltrated 40 ml of 0.5 % ropivacaine for wound infiltration intraoperatively followed by an infusion of 0.2 % ropivacaine at 5 ml/hr. [37] Local infiltration analgesia was the term coined by Dr. Dennis Kerr and Dr. Lawrence Kohan for high volume local anesthetic infiltration, performed in a systematic way during total knee arthroplasty [16]. The infiltrate is usually a cocktail of a long-acting local anesthetic (ropivacaine), an NSAID (ketorolac ), and a vasoconstrictor (epinephrine ), with or without a corticosteroid.

Total knee arthroplasty (TKA ) can be associated with substantial pain in the perioperative period. Pain that is inadequately controlled may impair mobility, reduce the ability to participate in rehabilitation, and reduce patient satisfaction. In addition, in some patients, inadequately controlled pain may result in the development of chronic pain. Traditional general anesthesia combined with patient-controlled opioid analgesia may be associated with undesirable side effects, including postoperative nausea and vomiting, hypotension, urinary retention, respiratory depression, delirium, and postoperative infections. For many surgeons, local infiltration anesthesia (LIA) in recent years has become a key element of the pain management paradigm for total knee arthroplasty patients.

Interest in local infiltration anesthesia among orthopaedic surgeons has increased since the first trials were published, demonstrating its efficacy as a technique. Subsequently, multiple trials comparing LIA to placebo, peripheral nerve blocks and central neuraxial blocks, were performed which has established the role of LIA in arthroplasty surgery. Busch et al. [38] completed one of the first randomized clinical trials evaluating the use of local infiltration analgesia. Sixty-four TKA patients were randomized to receive either; a periarticular intraoperative injection containing ropivacaine , ketorolac , epimorphine, and epinephrine or to receive no injection. Other aspects of perioperative pain management were standardized between the two groups. The patients who had received the injection used significantly less patient-controlled analgesia at 6 h, 12 h, and over the first 24 h following surgery. In addition, they had higher visual analog scores for patient satisfaction and lower visual analog scores for pain during activity, immediately following surgery and four hours after the operation. No cardiac or central nervous system toxicity was observed in patients who received the injection. Similarly, Vendittoli et al. [39] evaluated patients who received perioperative LIA combined with self-administered morphine, compared to a group of patients who received self-administered morphine alone. Both groups demonstrated high satisfaction rates and good pain control. However, morphine consumption was significantly lower in the local analgesia group than it was in the control group at 24 and 48 h following surgery. Jiang et al. [40] has completed a review of 21 randomized controlled trials evaluating LIA compared to placebo in total hip and total knee arthroplasty patients. Pooled results showed that the LIA group had better pain relief, less opioid consumption, a larger range of motion, and lower rates of nausea and vomiting, than the placebo group.

The contents and dosing of medications in local infiltration analgesia cocktails has varied significantly in the published literature. The mixture used by Busch et al. [38]1 contained 400 mg ropivacaine (80 mL of 0.5 % ropivacaine at 5 mg/mL), 30 mg ketorolac (1 mL at 30 mg/mL), 0.6 mg of 1:1000 epinephrine (0.6 mL at 1 mg/mL), and 5 mg morphine (0.5 mL at 10 mg/mL) diluted to a volume of 100 mL. Kelly et al. [41] reported on a mixture containing ropivacaine, epinephrine, and ketorolac combined with clonidine, an alpha-2 adrenergic receptor agonist intended to produce synergistic effects, with local anesthetics and opioids. Others have described infiltration cocktails with the addition including steroids (methylprednisolone) and antibiotics (cefuroxime) [42].

In order to understand the essential components of a local infiltration anesthetic cocktail, Kelley et al. [41] evaluated 150 patients who received one of four different periarticular injection mixtures when undergoing TKA . The patients were divided into four groups based on the mixture received. Group A received ropivacaine , epinephrine , ketorolac , and clonidine; Group B received ropivacaine, epinephrine, and ketorolac; Group C received ropivacaine, epinephrine, and clonidine and Group D was the control. They found that patients who had received periarticular injections containing ropivacaine, ketorolac, and epinephrine with or without clonidine had substantially less pain in the immediate postoperative period than did those patients who received injections containing ropivacaine and epinephrine alone. This suggested that ketorolac was a key component that should be considered for inclusion in all local infiltration cocktail mixtures.

The technique of administration of local infiltration analgesia in the operating room has also varied in the published literature. In the description by Busch et al. [38], the injection of the cocktail was divided into distinct phases. The first portion of the injection occurred just prior to component implantation. At that point in the procedure, 20 mL mixture of the 100 mL cocktail is injected into the posterior capsule and medial and lateral collateral ligaments (Fig. 24.1). This is completed prior to component implantation to give better access to the posterior aspect of the knee to allow for effective posterior capsular injection. Care is taken to avoid excessive infiltration in the posterolateral corner in the area of the common peroneal nerve. Once the components have been implanted and the cement is curing, 20 mL is injected into the quadriceps and retinacular tissues (Fig. 24.2). Finally, after component implantation is complete and prior to closure, the remaining 60 mL is infiltrated into the fat and subcutaneous tissues. Subsequent authors have included the addition of infiltration into the medial and lateral periosteum, meniscal remnants, PCL, pesanserinus, and illiotibial band [41, 42].

Local infiltration anesthesia has been prospectively compared to peripheral nerve blocks (PNB) in a number of studies. In one of the first such trials, parvataneni et al. [42] evaluated 60 patients in a prospective study comparing local infiltration anesthesia to femoral nerve block (FNB) combined with patient-controlled analgesia (PCA) . The LIA group had an improved ability to perform a straight leg raise on postoperative day 1 (63 % vs. 21 %). Similar pain scores were demonstrated between both groups during their postoperative hospital course. The results suggested that LIA provides pain control equivalent to that of FNB with the added advantage of maintaining quadriceps motor strength. Similarly, Spangehl et al. [43] compared patients receiving LIA to a group of patients who received a continuous femoral nerve block and single shot sciatic nerve block. Although pain scores were lower on the day of surgery in the PNB group, they were similar for the remainder of the hospital stay. The patients in the PNB group experienced more acute postoperative falls and lower quadriceps function measured by the ability to perform a straight leg raise on postoperative day 1 (24 % vs. 79 %). In addition, the patients receiving PNBs had more peripheral nerve dysesthesias at 6 weeks postoperatively.

Approved for use in the United States EXPAREL (Pacira Pharmaceuticals, Inc., San Diego, CA, USA) is a slow releasing bupivacaine medication designed to reduce the risk of bupivacaine toxicity and provide an extended duration of postoperative pain relief following surgery. Bramlett et al. [44] examined four varying doses of liposomal bupivacaine (133, 266, 300, and 532 mg) compared with a control of nonliposomal bupivacaine (150 mg). Treatment with liposomal bupivacaine was associated with greater analgesia while patients were at rest after surgery compared with bupivacaine although this was seen only in the cohort receiving a dose twice the recommended value (532 mg). Subsequent studies have failed to demonstrate significant benefits in morphine consumption, pain scores, knee range of motion, length of stay with the use of liposomal bupivacaine compared to LIA [45–47]. Furthermore, it is important to consider the cost of liposomal bupivacaine compared to traditional techniques. Wholesale costs for a vial of EXPAREL266 mg/20 mL is $14.25 compared to a 10 mL vial of 0.25 % bupivacaine HCl costing $0.29 [48]. Therefore, current available evidence shows no benefit to the use of liposomal bupivacaine compared to a traditional LIA cocktail for the management of pain following total knee arthroplasty.

In conclusion, from a surgeon’s perspective, local infiltration analgesia is an effective strategy for management of pain following lower limb total joint arthroplasty and can be easily employed by all surgeons without the need for specialized training or equipment. LIA can be easily combined as a part of multimodal postoperative pain management protocols. It should continue to be a component of pain control paradigms for the majority of patients undergoing total joint arthroplasty .

Proximal joints of the limbs such as shoulder, hip, and knee have multiple nerves supplying the joints. Upper limb surgeries are effectively covered by brachial plexus blocks since the ensuing motor blockade is not much of a concern for postoperative physiotherapy and rehabilitation.

Proximal lower limb surgeries on the one hand require the patients to actively mobilize after surgery. Ankle and foot surgeries on the other hand does not have the same concerns as that of hip or knee surgeries since they are typically advised not to weight bear for the first couple of days and hence analgesia in these cases can be effectively accomplished with popliteal sciatic nerve block with or without saphenous nerve block. Traditional approaches for hip and knee analgesia have employed neuraxial techniques (intrathecal opioids, epidural analgesia) or peripheral nerve blocks (lumbar plexus or femoral nerve blocks with or without sciatic component) to ensure effective analgesia. The accompanying motor blockade is a cause for concern in lower limb surgeries since they not only interfere with physiotherapy but also may pose a risk for patient falls [49, 50]. Hence, a site-specific modality such as LIA may be suitable for such proximal lower limb surgeries. The popularity of local infiltration analgesia is due to its low cost and ease of administration by the surgeons intraoperatively without the need for regional anesthesia experts to initiate the intervention. LIA being site specific in its action is supposed to lack the motor weakness seen with PNB and thereby may permit early ambulation and physiotherapy.

The following safety concerns need to be considered before LIA:

All local anesthetics are chondrotoxic and hence should not be injected into an intact joint (see section “Chondrotoxicity ”). Fortunately, the articular surfaces are removed in total joint arthroplasties and hence the chondrotoxic effect is not of much concern in these situations. The LIA is avoided in situations when there is a chance of an intact synovial or joint cartilage remaining, such as arthroscopic surgery, unicompartmental knee replacement, hip resurfacing arthroplasty, hand and foot surgery among others [25, 26].

It is essential to know the neuro-anatomy of the joint for the success of the LIA technique since not all areas within a joint have the same amount of mechanoreceptors or free nerve endings. Hence, the technique of LIA should target the areas of higher innervation compared to others.

Most of the joints in body follow Hilton’s law with some exceptions [51]. Hilton’s law states that “The same trunks of nerves whose branches supply the groups of muscles moving a joint furnish also a distribution of nerves to the skin over the insertions of the same muscles; and what at this moment more especially merits our attention the interior of the joint receives its nerves from the same source.” The adaptation of this law is that not all the muscles crossing a joint give articular branches but the source of articular innervation and the overlying skin is derived from the same source supplying the agonist and antagonist muscles acting across a joint.

The success of LIA like that of any other technique depends on the operator’s performance and variability with infiltration technique is a problem especially with newcomers. Traditionally, a “moving needle” technique has been recommended using a non-cutting small gauge needle (22 Ga) attached to a syringe containing the LIA cocktail and injected in small aliquots of 2–3 ml in different tissue planes. The goal of the technique is to deliver a majority of the drugs into those tissues with increased neuro-sensory perception. A staged fashion of infiltration where the LIA is begun with incision and continued until the closure of the wound is widely adapted. Use of smaller syringes with control for aspiration before injection should be used in areas of potential complications such as in the posterior knee area.