A comparative study comparing area of extension of posterior knee capsule via posteromedial injection: a cadaveric study
Periarticular multimodal drug injection (PMDI) has gained popularity as common postoperative pain protocols in knee arthroplasty. PMDI sites can vary, but posterior capsule (PC) is a common injection site because of its abundance of pain nociceptors.
To prove the hypothesis whether posteromedial drug injection alone is sufficient to provide enough effect covering the PC in order to reduce risks of neurovascular injury. Secondary outcomes are to find proper volume of injection and safe zone for PMDI injection.
Ten fresh cadaveric knees were allocated into two equal groups, which differed in volume of dye injection: 25 ml and 50 ml. Dyes were injected into posteromedial capsule compartment, and the limbs were stored in a freezer for 2 weeks. Then the posterior compartment was carefully dissected to examine spreading of the dye solution.
No dye staining was seen superficially beneath subcutaneous tissue of the knees. In deeper layer, the dye mostly occupied medially along the fascia covering semimembranosus muscles. However, dispersion was limited distally by intermuscular septa and popliteal vessels. The 50-ml injection group provided wider extension in the superficial layer, but not in the deep layer.
The intermuscular septa and the fascia of popliteal vessels were shown to be the boundary between posteromedial and posterolateral compartments of the knee. Separate PMDI for both compartments is necessary to occupy the entire PC. We suggest that 1.5 cm lateral to lateral border of PCL insertion, just above popliteus tendon, is the safe zone for injecting PMDI into the posterolateral capsule.
KeywordsPeriarticular multimodal drug injection PMDI Total knee arthroplasty Popliteal injury
Compliance with ethical standards
Conflict of interest
Each author certifies that he or she has no commercial associations (e.g., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.
Cadaveric experimental study had been approved by the Khon Kaen University Ethics Committee for Human Research.
- 1.Akbaba YA, Yeldan I, Özdinçler AR, Güney N (2015) Patients’ preoperative perspectives concerning the decision to undergo total knee arthroplasty and comparison of their clinical assessments. J Phys Ther Sci 27(8):2525–2528Google Scholar
- 2.Andersen LO, Husted H, Kristensen BB, Otte KS, Gaarn-Larsen L, Kehlet H (2010) Analgesic efficacy of intracapsular and intra-articular local anaesthesia for knee arthroplasty. Anaesthesia 65:904–912Google Scholar
- 3.Bakirhan S, Bozan O, Unver B, Karatosun V (2017) Evaluation of functional characteristics in patients with knee osteoarthritis. Acta Ortop Bras 25(6):248–252Google Scholar
- 4.Biedert RM, Stauffer E, Friederich NF (1992) Occurrence of free nerve endings in the soft tissue of the knee joint. A histologic investigation. Am J Sports Med 20(4):430–433Google Scholar
- 5.Burger T, Meyer F, Tautenhahn J, Halloul Z, Fahlke J (1998) Percutaneous treatment of rare iatrogenic arteriovenous fistulas of the lower limbs. Int Surg 83(3):198–201Google Scholar
- 6.Deveza LA, Melo L, Yamato TP, Mills K, Ravi V, Hunter DJ (2017) Knee osteoarthritis phenotypes and their relevance for outcomes: a systematic review. Osteoarthr Cartil 25(12):1926–1941Google Scholar
- 7.Dua A, Zepeda R, Hernanez FC, Igbadumhe AA, Desai SS (2015) The national incidence of iatrogenic popliteal artery injury during total knee replacement. Vascular 23(5):455–458Google Scholar
- 8.Dye SF, Vaupel GL, Dye CC (1998) Conscious neurosensory mapping of the internal structures of the human knee without intraarticular anesthesia. Am J Sports Med 26(6):773–777Google Scholar
- 9.Guild GN III, Galindo RP, Marino J, Cushner FD, Scuderi GR (2014) Peri-articular regional analgesia in total knee arthroplasty. A review of the neuroanatomy and injection technique. Ann Orthop Rheumatol 2(3):1025Google Scholar
- 10.Kane I, Post Z, Ong A, Orozco F (2016) Arteriovenous fistula formation after intra-articular injection following total joint arthroplasty. Orthopedics 39(5):e976–e979Google Scholar
- 11.Kerr DR, Kohan L (2008) Local infiltration analgesia: a technique for the control of acute postoperative pain following knee and hip surgery: a case study of 325 patients. Acta Orthop 79(2):174–183Google Scholar
- 12.Ko LJ, DeHart ML, Yoo JU, Huff TW (2014) Popliteal artery injury associated with total knee arthroplasty: trends, costs and risk factors. J Arthroplasty 29(6):1181–1184Google Scholar
- 13.Lavernia CJ, Guzman JF, Gachupin-Garcia A (1997) Cost-effectiveness and quality of life in knee arthroplasty. Clin Orthop Relat Res 345:134–139Google Scholar
- 14.Massin P (2017) How does total knee replacement technique influence polyethylene wear? Orthop Traumatol Surg Res 103(1S):S21–S27Google Scholar
- 15.McDonald DA, Siegmeth R, Deakin AH, Kinninmonth AWG, Scott NB (2012) An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom—follow up at 1 year. Knee 19:525–529Google Scholar
- 16.Michel DM, Peter VR (2004) Normal anatomy and pathology of the posterior capsular area of the knee: findings in cadaveric specimens and in patients. Am J Roentgenol 182:955–962Google Scholar
- 17.Ninomiya JT, Dean JC, Goldberg VM (1999) Injury to the popliteal artery and its anatomic location in total knee arthroplasty. J Arthroplasty 14:803–809Google Scholar
- 18.Pasero C, McCaffery M (2007) Orthopaedic postoperative pain management. J Perianesth Nurs 22(3):160–172 (quiz72–3) Google Scholar
- 19.Quinn M, Deakin AH, McDonald DA, Cunningham IK, Payne AP (2013) An anatomic study of local infiltration analgesia in total knee arthroplasty. Knee 20:319–323Google Scholar
- 20.Seangleulur A, Vanasbodeekul P, Prapaitrakool S (2016) The efficacy of local infiltration analgesia in the early postoperative period after total knee arthroplasty: a systematic review and meta-analysis. Eur J Anaesthesiol 33(11):816–831Google Scholar
- 21.Thomas R, Agarwal M, Lovell M, Welch M (2008) An unusual presentation of a popliteal arteriovenous fistula after primary total knee arthroplasty. J Arthroplasty 23(6):945–948Google Scholar
- 22.Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, Varin F (2006) A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study. J Bone Jt Surg Am 88(2):282–289Google Scholar