Periarticular multimodal analgesia in decreasing perioperative pain in tibial plateau fractures: A double blind randomized controlled pilot study

Published:September 28, 2022DOI:


      • Multimodal pain injections for tibial plateau fractures appears to have some benefit for post-operative pain control.
      • The use of gel-foam sponges in traumatize soft tissue may not be safe and lead to infection.
      • The use of periarticular multimodal analgesic injections should be further studied in other fractures throughout the musculoskeletal system to determine their benefits.



      The use of periarticular multimodal analgesia injections is increasing and has become commonplace in some surgeries. However, there is no data on the effectiveness of local periarticular multimodal analgesia for tibial plateau fractures. We hypothesized that closed tibial plateau fracture patients receiving the local multimodal analgesic medications would experience a decrease in VAS pain scores.


      Patients aged between 18 and 79 with an isolated closed tibial plateau fracture (AO 41-B and C) were prospectively enrolled and randomized in a 1:1 double blinded fashion to either a placebo or active medication treatment arm. After ORIF, gel-foam sponges soaked in either multimodal analgesic solution or normal saline. Patients were followed for 24 h post-operatively with Visual Analog pain Scores (VAS). Patients were monitored post-operatively for complications including compartment syndrome, infection, and non-union.


      The planned study was terminated prior to completion due to higher than anticipated rates of infection (18%), distributed equally among active (3) and placebo (2) groups, raising concerns that this may have been due to the presence of the delivery device. Twenty-eight patients were enrolled, 15 in the active group and 13 in the placebo group. Patients in the active medication group had significantly decreased pain scores at hours 4 (p = 0.005, 4.2 vs 6.9), 8 (p = 0.05, 5 vs 7), and 12 (p = 0.02, 3.8 vs 6.2). Pain scores at hours 16 (p = 0.10, 4.5 vs 6.5), 20 (p = 0.08, 4.6 vs 6.4), and 24 (p = 0.10, 4.8 vs 6.5) were also decreased but did not reach significance.


      The use of local multimodal periarticular analgesic for closed tibial plateau fractures appears to be beneficial for short-term pain control post-operatively. Concerns regarding an implantable delivery vehicle leading to infection has warranted a change in method of drug administration. Completion of the full study will permit us to validate or refute these findings.

      Level of Evidence

      Therapeutic Level 1


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hanna M.N.
        • González-Fernández M.
        • Barrett A.D.
        • Williams K.A.
        • Pronovost P.
        Does patient perception of pain control affect patient satisfaction across surgical units in a tertiary teaching hospital?.
        Am J Med Qual. 2012; 27: 411-416
        • Koehler R.M.
        • Okoroafor U.C.
        • Cannada L.K.
        A systematic review of opioid use after extremity trauma in orthopedic surgery.
        Injury. 2018; 49: 1003-1007
        • Reid D.B.C.
        • Shah K.N.
        • Shapiro B.H.
        • Ruddell J.H.
        • Evans A.R.
        • Hayda R.A.
        • et al.
        Opioid-limiting legislation associated with reduced postoperative prescribing after surgery for traumatic orthopaedic injuries.
        J Orthop Trauma. 2020; 34: e114-ee20
        • Flanagan C.D.
        • Wysong E.F.
        • Ramey J.S.
        • Vallier H.A.
        Understanding the opioid epidemic: factors predictive of inpatient and postdischarge prescription opioid use after orthopaedic trauma.
        J Orthop Trauma. 2018; 32: e408-ee14
        • Dubina A.G.
        • Paryavi E.
        • Manson T.T.
        • Allmon C.
        • O'Toole R.V.
        Surgical site infection in tibial plateau fractures with ipsilateral compartment syndrome.
        Injury. 2017; 48: 495-500
        • Allmon C.
        • Greenwell P.
        • Paryavi E.
        • Dubina A.
        • OʼToole R.V.
        Radiographic predictors of compartment syndrome occurring after tibial fracture.
        J Orthop Trauma. 2016; 30: 387-391
        • Marchand L.S.
        • Working Z.M.
        • Rane A.A.
        • Elliott I.S.
        • Gilbertson E.
        • Rothberg D.L.
        • et al.
        Compartment syndrome in tibial plateau fractures: do previously established predictors have external validity?.
        J Orthop Trauma. 2020; 34: 238-243
        • Hyder N.
        • Kessler S.
        • Jennings A.G.
        • De Boer P.G.
        Compartment syndrome in tibial shaft fracture missed because of a local nerve block.
        J Bone Joint Surg Br. 1996; 78: 499-500
        • Olson S.A.
        • Glasgow R.R.
        Acute compartment syndrome in lower extremity musculoskeletal trauma.
        J Am Acad Orthop Surg. 2005; 13: 436-444
        • Peters C.L.
        • Shirley B.
        • Erickson J.
        The effect of a new multimodal perioperative anesthetic regimen on postoperative pain, side effects, rehabilitation, and length of hospital stay after total joint arthroplasty.
        J Arthroplasty. 2006; 21: 132-138
        • Mullaji A.
        • Kanna R.
        • Shetty G.M.
        • Chavda V.
        • Singh D.P.
        Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty:a prospective, randomized trial.
        J Arthroplasty. 2010; 25: 851-857
        • Kang H.
        • Ha Y.C.
        • Kim J.Y.
        • Woo Y.C.
        • Lee J.S.
        • Jang E.C.
        Effectiveness of multimodal pain management after bipolar hemiarthroplasty for hip fracture: a randomized, controlled study.
        J Bone Joint Surg Am. 2013; 95: 291-296
        • Lamplot J.D.
        • Wagner E.R.
        • Manning D.W.
        Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial.
        J Arthroplasty. 2014; 29: 329-334
        • Fu P.
        • Wu Y.
        • Wu H.
        • Li X.
        • Qian Q.
        • Zhu Y.
        Efficacy of intra-articular cocktail analgesic injection in total knee arthroplasty - a randomized controlled trial.
        Knee. 2009; 16: 280-284
        • Busch C.A.
        • Shore B.J.
        • Bhandari R.
        • Ganapathy S.
        • MacDonald S.J.
        • Bourne R.B.
        • et al.
        Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial.
        J Bone Joint Surg Am. 2006; 88: 959-963
        • Vendittoli P.A.
        • Makinen P.
        • Drolet P.
        • Lavigne M.
        • Fallaha M.
        • Guertin M.C.
        • et al.
        A multimodal analgesia protocol for total knee arthroplasty. A randomized, controlled study.
        J Bone Joint Surg Am. 2006; 88: 282-289
        • Du J.P.
        • Fan Y.
        • Hao D.J.
        • Huang Y.F.
        • Zhang J.N.
        • Yuan L.H.
        Application of Gelatin Sponge Impregnated with a Mixture of 3 drugs to intraoperative nerve root block to promote early postoperative recovery of Lumbar Disc Herniation.
        World Neurosurg. 2018; 114: e1168-e1e73
        • Hancock K.J.
        • Rice O.M.
        • Anthony C.A.
        • Glass N.
        • Hogue M.
        • Karam M.
        • et al.
        Efficacy of multimodal analgesic injections in operatively treated ankle fractures.
        J Bone Joint Surg. 2019; 101: 2194-2202
        • Koehler D.
        • Marsh J.L.
        • Karam M.
        • Fruehling C.
        • Willey M.
        Efficacy of surgical-site, multimodal drug injection following operative management of femoral fractures: a randomized controlled trial.
        J Bone Joint Surg Am. 2017; 99: 512-519
        • Momaya A.M.
        • Hlavacek J.
        • Etier B.
        • Johannesmeyer D.
        • Oladeji L.O.
        • Niemeier T.E.
        • et al.
        Risk factors for infection after operative fixation of Tibial plateau fractures.
        Injury. 2016; 47: 1501-1505
        • Colman M.
        • Wright A.
        • Gruen G.
        • Siska P.
        • Pape H.-.C.
        • Tarkin I.
        Prolonged operative time increases infection rate in tibial plateau fractures.
        Injury. 2013; 44: 249-252
        • Cho J.W.
        • Kim J.
        • Cho W.T.
        • Kim J.K.
        • Song J.H.
        • Kim H.J.
        • et al.
        Circumferential bone grafting around an absorbable gelatin sponge core reduced the amount of grafted bone in the induced membrane technique for critical-size defects of long bones.
        Injury. 2017; 48: 2292-2305
        • Du J.P.
        • Fan Y.
        • Liu J.J.
        • Zhang J.N.
        • Chang Liu S.
        • Hao D
        Application of gelatin sponge impregnated with a mixture of 3 drugs to intraoperative nerve root block combined with robot-assisted minimally invasive transforaminal lumbar interbody fusion surgery in the treatment of adult degenerative scoliosis: a clinical observation including 96 patients.
        World Neurosurg. 2017; 108: 791-797
        • Hamid N.
        • Ashraf N.
        • Bosse M.J.
        • Connor P.M.
        • Kellam J.F.
        • Sims S.H.
        • et al.
        Radiation therapy for heterotopic ossification prophylaxis acutely after elbow trauma.
        J Bone Joint Surg-Am. 2010; 92 (Volume): 2032-2038
        • Yoo J.-S.
        • Heo K.
        • Kwon S.-M.
        • Lee D.-H.
        • Seo J.-B.
        Effect of surgical-site, multimodal drug injection on pain and stress biomarkers in patients undergoing plate fixation for clavicular fractures.
        Clin Orthop Surg. 2018; 10: 455
        • Chung M.S.
        • Roh Y.H.
        • Baek G.H.
        • Lee Y.H.
        • Rhee S.H.
        • Gong H.S.
        Evaluation of early postoperative pain and the effectiveness of perifracture site injections following volar plating for distal radius fractures.
        J Hand Surg Am. 2010; 35: 1787-1794
        • Jung H.S.
        • Chun K.J.
        • Kim J.Y.
        • Lee J.
        • Lee J.S.
        Does surgical-site multimodal drug injection after palmar plating of distal radius fractures improve pain scores?.
        Clin Orthop Relat Res. 2020;