|Year : 2017 | Volume
| Issue : 2 | Page : 70-76
Periarticular infiltration of bupivacaine versus levobupivacaine in postoperative analgesia in patients undergoing total knee arthroplasty
Heba M Fathi MD , Gehan F Ezz
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
|Date of Submission||16-Dec-2016|
|Date of Acceptance||16-Mar-2017|
|Date of Web Publication||12-May-2017|
Heba M Fathi
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, 44519
Source of Support: None, Conflict of Interest: None
Pain control is the key in patient’s recovery after arthroplasty. We compared periarticular bupivacaine with levobupivacaine in postoperative analgesia after total knee arthroplasty in this randomized double-blinded study.
Patients and Methods
Totally, 44 patients were randomly distributed to two equal groups. The L group received periarticular 150 mg levobupivacaine HCl, 0.25% concentration+0.3 mg of adrenaline (1/200 000 concentration) diluted in normal saline to be 60 ml.
The B group received periarticular 150 mg bupivacaine HCl, 0.25% concentration+0.3 mg of adrenaline (1/200 000 concentration) diluted in normal saline to be 60 ml. The primary outcomes were the quality of analgesia during 48 h postoperatively, using a visual analog scale score at 6, 12, 18, 24, 36, and 48 h postoperatively and cumulative opioid consumption at 24 and 48 h postoperatively. The secondary outcomes were the functional recovery of the knee and postoperative adverse effects.
There was no significant difference between the two groups as regards preoperative data. Pain control was comparable in the two groups. No significant complication was observed. There was good functional recovery in both groups with a higher mean degree of knee maximal flexion in the B group.
Periarticular levobupivacaine and bupivacaine have comparable analgesic effect in patients undergoing total knee arthroplasty.
Keywords: bupivacaine, levobupivacaine, periarticular, total knee arthroplasty
|How to cite this article:|
Fathi HM, Ezz GF. Periarticular infiltration of bupivacaine versus levobupivacaine in postoperative analgesia in patients undergoing total knee arthroplasty. Res Opin Anesth Intensive Care 2017;4:70-6
|How to cite this URL:|
Fathi HM, Ezz GF. Periarticular infiltration of bupivacaine versus levobupivacaine in postoperative analgesia in patients undergoing total knee arthroplasty. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2017 Oct 22];4:70-6. Available from: http://www.roaic.eg.net/text.asp?2017/4/2/70/206151
| Introduction|| |
Total knee arthroplasty (TKA) is one of the most effective treatment options for patients with end-stage knee arthritis . Uncontrolled pain after TKA can lead to limited postoperative range of motion, arthrofibrosis, poor functional outcomes, and patient’s dissatisfaction . Periarticular injection (PAI) has been reported to have good analgesic efficacy, it is cost-effective, and has few side effects ,,. Studies on PAI showed that it has promising results on pain control, patient satisfaction, morphine consumption during the first 48 postoperative hours, length of stay, and knee function ,. Bupivacaine is used to provide effective sensory block with beneficial postoperative analgesia by inhibiting the nociceptor . However, there are many clinical reports of life-threatening neural and cardiac toxicity of bupivacaine after regional nerve blocks such as brachial, femoral, or scalene ,,, due to its narrow safety margin, given its high lipid solubility ,.
Bupivacaine exists as a racemic solution, containing two enantiomers, R (+) dextrorotatory and S (−) levorotatory stereoisomers. Levorotatory enantiomer is more vasoconstrictive and less toxic ,,. Levobupivacaine, as the pure S (−) isomer, has been developed as an alternative to bupivacaine with a desirable blocking effect of racemic bupivacaine, but with a greater margin of safety. Moreover, levobupivacaine has also been reported to have advantages in terms of cardiotoxicity and central nervous system toxicity in animal and human volunteers ,.
Because there is limited experience when comparing bupivacaine with levobupivacaine in periarticular analgesia after knee arthroplasty, we decided to carry out this randomized study aiming at comparing bupivacaine with its S (+) enantiomer, levobupivacaine, as regards their effectiveness, side effects, and complications.
| Patients and methods|| |
This blinded randomized comparative study was conducted between January 2015 and January 2016 on patients scheduled for TKA, after approval of the Zagazig Ethical Committee and after obtaining patient’s written informed consent. The study was conducted in accordance with the Declaration of Helsinki and conformed to the Consolidated Standards of Reporting Trials guidelines ,. The included patients were between 50 and 69 years of age and of American Society of Anesthesiology physical status 1 and 2. The exclusion criteria were as follows: neurological disorders that prevent cooperation; allergy to the study drugs; renal, hepatic, or heart failure; history of myocardial infarction; peripheral vascular disease; chronic pain syndrome; and opiate abuse.
All patients received 1 g paracetamol 1 h preoperatively. Intraoperatively, patients were monitored using 5 lead ECG, pulse oximetry, and noninvasive blood pressure monitoring. Venous access was obtained by using an 18 G cannula, and then 3–5 mg midazolam was administered and 500 ml Ringer’s acetate solution was initiated.
Surgery was performed using the medial parapatellar approach with patellar resurfacing, under single-shot spinal anesthesia at L2–L3 OR L3–L4 with 15 mg bupivacaine+30 µ fentanyl ([Figure 1]).
Patients were numbered according to their operative date and their orders were randomized using computer-generated random numbers and assigned to two groups that were given periarticular analgesia:
- The L group received 150 mg levobupivacaine HCl, 0.25% concentration (Chirocaine; Nycomed Pharma AS, Elverum, Norway)+0.3 mg of adrenaline (1/200 000 concentration) diluted in normal saline to be 60 ml.
- The B group received 150 mg bupivacaine HCl, 0.25% concentration (Marcaine; Hospira Inc., Pfizer Inc., New York, New York, USA)+0.3 mg of adrenaline (1/200 000 concentration) diluted in normal saline to be 60 ml.
The periarticular drug combinations were injected as follows: posterior capsule (15 ml), medial capsule/synovium/periosteum (15 ml), lateral capsule/synovium/periosteum (15 ml), and subcutaneous tissue around the midline incision (15 ml)  ([Figure 2]).
The anesthetist, the patients, and the staff providing postoperative care were blinded to the group assignment.
Postoperatively, patients received oral 1 g paracetamol/6 h, meloxicam (15 mg) every 24, and subcutaneous enoxaparin (40 mg) every 24 h. Nausea was treated with intravenous ondansetron (4 mg) when needed. Intravenous 2 mg morphine increments at a maximum dose of 10 mg/6 h were administered as rescue analgesia.
Walking was started soon after recovery of motor function assisted by standard adult walker and knee exercise assisted by physiotherapist on the first postoperative day. The primary outcomes were the quality of analgesia during 48 h postoperatively, using a visual analog scale (VAS) score at 6, 12, 18, 24, 36, and 48 h postoperatively and cumulative opioid consumption at 24 and 48 h postoperatively. The secondary outcomes were knee functional recovery that was assessed with walking distance, quadriceps function, and range of motion and postoperative adverse effects.
Sample size was calculated to be 18 in each group based on an expected difference of 2 mm in VAS between group mean with SD 3.2 mm . This was calculated using Open Source Epidemiologic Statistics for Public Health (Open EPI) version 2.3 available at (http://www.openepi.com/OE2.3/Menu/OpenEpiMenu.htm), with a power of 90%, confidence interval 95%, and α value of 0.05. We decided to recruit 44 patients (22 per group) to account for possible study dropouts (20%) or lost data. Data were tabulated and subjected to computer-assisted statistical analysis using the statistical package for the social sciences version 18.0 (SPSS; SPSS Inc., Chicago, Illinois, USA). Continuous data were expressed as mean±SD, whereas categorical data were expressed as frequencies. Student’s t-test was used for comparing the mean of continuous data. Categorical data were compared using Fisher’s exact test. A P value less than 0.05 was considered statistically significant.
| Result|| |
A total of 63 patients were assessed for eligibility. Of them, eight patients declined to participate in this study, and 11 patients did not meet the inclusion criteria; the remaining 44 patients were randomly allocated to two equal groups (22 patients in each group). After allocation, all included patients completed the study ([Figure 3]).
As shown in [Table 1], no significant differences were present in preoperative patient’s characteristics ([Table 2]).
As regards patients’ satisfaction, nine patients in the L group and 10 patients in the B group experienced excellent satisfaction. Six patients in each group experienced good satisfaction and five patients in each group experienced moderate satisfaction. Finally, two patients in the L group and one patient in the B group reported poor satisfaction.
Although total opioid analgesia and VAS scores during rest and mobilization were lower in the B group than in the L group, these differences were not statistically significant ([Table 3] and [Table 4]).
As illustrated in [Table 5], good postoperative function was observed in the operated limbs and no significant differences were observed in its parameters except on day 1 when the mean degree of maximal active flexion of the knee was significantly greater in the B group than in the L group.
As shown in [Table 6], no significant difference was observed between the two groups as regards postoperative adverse effects. Side effects were few and included three cases of nausea without vomiting in the L group, whereas there were four cases of nausea with one case of vomiting in the B group. One patient in the B group experienced hemorrhage with hypotension that was controlled with transfusion of blood and fluid. One case of bradycardia in the B group was controlled with atropine. No other side effects such as persistent anesthesia, paresthesia, weakness, paralysis, restlessness, anxiety, dizziness, tinnitus, blurred vision, tremors, convulsions, drowsiness, unconsciousness, or respiratory arrest were found.
| Discussion|| |
Periarticular infiltration techniques target the joint capsule, deep tissues surrounding the collateral ligaments, and the subcutaneous tissues with wound edges . Several authors had proposed the presence of opioid receptors in the synovial membrane ,. This would suggest that the tissues responsible for generating pain in the setting of TKA may be better targeted using a periarticular technique.
Various studies have described the use of PAIs of various anesthetics with improved postoperative pain control ,,, but the comparison of the effect of levobupivacaine and bupivacaine injection in this site has not been discussed before in the literature.
Vendittoli et al.  reported that the intraoperative PAI of analgesia allowed direct visualization and accurate placement of the injection into the injured tissues around nerve endings. In addition, the entrapment of the medication within the soft tissue enhanced and prolonged the analgesic blockade, and decreased the leakage from the wound .
Perret et al.  compared patient outcomes after periarticular and intra-articular local anesthetic infiltration techniques in TKA and reported a statistically significant decrease in the VAS scores of patients in the periarticular group when compared with the intra-articular group during the first 24 h postoperatively.
In this study, we compared postoperative analgesia of single-dose periarticular bupivacaine with that of pure S (−) isomer Levobupivacaine.
Single periarticular infiltration was proven to reduce total consumption of opioid for 48 h . The benefit of intra-articular catheters to provide supplementary dosages of local anesthetic in the postoperative period is unproven. In addition, catheter placement increases the risk for infection .
In our study, the quality of analgesia was comparable in both groups. No significant differences in VAS or opioid consumption were observed, although the two parameters tend to be lower in the bupivacaine group.
Although an in-vitro study of frog sciatic nerves showed that R-bupivacaine is more potent compared with S-bupivacaine , the nonsignificant difference in the quality of analgesia in our results is in agreement with those obtained from other in-vivo clinical peripheral nerve blocks such as axillary brachial plexus block , sciatic nerve block , mandibular blocks for lower third molar surgery (inferior alveolar nerve block, lingual nerve block, and buccal nerve block) , supraclavicular block , and intra-articular block .
It should be noted that the concentration of levobupivacaine (chirocaine, Nycomed Pharma AS) is denoted on the drug label as the concentration of the base of the molecule and not as the concentrate of the hydrochloride of the molecule, as is the case with racemic bupivacaine. Thus, an ampoule of levobupivacaine contains 13% more molecules of local anesthetic than an ampoule of racemic bupivacaine of the same concentration . Therefore, the anesthetic intensity of levobupivacaine that was comparable to bupivacaine intensity is the consequence of slightly increased levobupivacaine concentrations, not the result of its potency.
When considering the duration of anesthesia, both anesthetics showed long-acting effect without a significant difference in the time to the first request of analgesia. It was 14.5±7 in the L group and 15±7.1 in the B group. Other previous studies that examined these two drugs in different sites also corroborate this finding. Cox et al.  found that the sensory block duration in supraclavicular brachial plexus block was ∼14, 17, and 15 h with 0.25 and 0.5% levobupivacaine and 0.5% bupivacaine, respectively. Liisanantti et al.  detected the mean sensory block duration of 17.8±7.2, 17.1±6.5, and 15±5.4 with bupivacaine, levobupivacaine, and ropivacaine, respectively, in axillary brachial plexus block. Ilham et al. , also in supraclavicular block, reported that the duration was 16.61±8.05 h with bupivacaine and 14.37±7.27 h with levobupivacaine. In the three previous studies, there was no significant difference detected between the duration of levobupivacaine and bupivacaine, which was consistent with our result.
Periarticular infiltration in the current study helps early mobilization and good postoperative functional recovery with better active knee flexion in the bupivacaine group on first day. This may be attributed to the tendency of better pain control in this group that enables better knee movement. The differential block of levobupivacaine with its less motor effect in comparison with bupivacaine showed in intrathecal  and extradural anesthesia  was not illustrated in this study because of the absence of motor block in periarticular analgesia , as the level of PAI is distal to the level of motor innervations supplying quadriceps muscles and the posterior muscle of the thigh (that act as knee extensors and flexors, respectively). Other studies demonstrated that this technique has several advantages over traditional methods as the analgesia affects only the surgical area and causes limited interference with the muscle strength, reduces pain, and improves mobilization after TKA ,.
Compared with bupivacaine, levobupivacaine appears to have a wider margin of safety in terms of cardiovascular and central nervous system adverse effects when used in large doses ,. However, in this study neither bupivacaine nor levobupivacaine showed perioperative complications. The addition of epinephrine to the injection as in case of our study helps in reducing the toxicity of the local anesthetic by keeping it localized to the area of injection . Lombardi et al.  found no perioperative complications directly related to the injection of a combination of bupivacaine, epinephrine, and morphine.
Karaoglu et al.  were able to demonstrate diminished blood loss after the release of the tourniquet when epinephrine was present in the injection; this was also demonstrated in our study.
| Conclusion|| |
In periarticular infiltration, levobupivacaine has a comparable analgesic effect to bupivacaine. It can be used as an alternative to bupivacaine in postoperative periarticular analgesia after TKA. Further studies are recommended in other American Society of Anesthesiology groups.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89:780–785.
Shoji H, Solomonow M, Yoshino S, D’Ambrosia R, Dabezies E. Factors affecting postoperative flexion in total knee arthroplasty. Orthopedics 1990; 13:643–649.
Gibbs DM, Green TP, Esler CN. The local infiltration of analgesia following total knee replacement: a review of current literature. J Bone Joint Surg Br 2012; 94:1154–1159.
Jiang J, Teng Y, Fan Z, Khan MS, Cui Z, Xia Y. The efficacy of periarticular multimodal drug injection for postoperative pain management in total knee or hip arthroplasty. J Arthroplasty 2013; 28:1882–1887.
Teng Y, Jiang J, Chen S, Zhao L, Cui Z, Khan MS et al.
Periarticular multimodal drug injection in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2014; 22:1949–1957.
Essving P, Axelsson K, Kjellberg J, Wallqren O, Gupta A, Ludin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010; 81:354–360.
Park C, Klatman S, Potter HG, Ranawat AS. Acute host reaction after anterior cruciate ligament reconstruction. Am J Orthop (Belle Mead NJ) 2014; 43:78–82.
Lamplot JD, Wagner ER, Mannig DW. Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty 2014; 29:329–334.
Brown DL, Ransom DM, Hall JA, Leicht CH, Schroeder DR, Oford KP. Regional anesthesia and local anesthetic-induced systemic toxicity: seizure frequency and accompanying cardiovascular changes. Anesth Analg 1995; 81:321–328.
Kopp SL, Wynd KP, Horlocker TT, Hebl JR, Wilson JL. Regional blockade in patients with history of a seizure disorder. Anesth Analg 2009; 109:271–278.
Marwick PC, Levin AI, Coetzee AR. Recurrence of cardiotoxicity after lipid rescue from bupivacaine-induced cardiac arrest. Anesth Analg 2009; 108:1344–1346.
Dudley MH, Fleming SW, Garg U, Edwards JM. Fatality involving complications of bupivacaine toxicity and hypersensitivity reaction. J Forensic Sci 2011; 56:1376–1379.
Leone S, Di Cianni S, Casati A, Fanelli G. Pharmacology, toxicology, and clinical use of new long acting local anesthetic, ropivacaine and levobupivacaine. Acta Biomed 2008; 79:92–105.
Werdehausen R, Braun S, Fazeli S, Hermanns H, Hollmann MW, Bauer I et al.
Lipophilicity but not stereospecificity is a major determinant of local anaesthetic-induced cytotoxicity in human T-lymphoma cells. Eur J Anaesthesiol 2012; 29:35–41.
Aps C, Reynolds F. An intradermal study of the local anaesthetic and vascular effects of the isomers of bupivacaine. Br J Clin Pharmacol 1978; 6:63–68.
Vanhoutte F, Vereecke J, Verbeke N, Carmeliet E. Stereoselective effects of the enantiomers of bupivacaine on electrophysiological properties of the guinea-pig papillary muscle. Br J Pharmacol 1991; 103:1275–1278.
Mazoit JX, Boico O, Samii K. Myocardial uptake of bupivacaine: pharmacodynamics of bupivacaine enantiomers in the isolated perfused rabbit heart. Anesth Analg 1993; 77:477–482.
Huang YF, Pryor ME, Veering BT, Mather LE. Cardiovascular and central nervous system effects of intravenous levobupivacaine and bupivacaine in sheep. Anesth Analg 1998; 86:797–804.
Bardsley H, Griswood R, Baker H, Watson N, Nimmo W. A comparison of the cardiovascular effects of levobupivacaine and rac
-bupivacaine following intravenous administration to healthy volunteers. Br J Clin Pharmacol 1998; 46:245–249.
Schulza KF, Altmanb DG, Moher D. CONSORT 2010 Statement: updated guidelines for reporting parallel group randomized trials. J Clin Epidemiol 2010; 63:834–840.
Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001; 357:1191–1194.
Kim TW, Park SJ, Lim SH, Seong SC, Lee S, Lee MC. Which analgesic mixture is appropriate for periarticular injection after total knee arthroplasty? Prospective, randomized, double-blind study. Knee Surg Sports Traumatol Arthrosc 2015; 23:838–845.
Busch CA, Shore BJ, Bhandari R, Ganapathy S, MacDonald SJ, Bourne RB et al.
Efficacy of periarticular multimodal drug injection in total knee arthroplasty: a randomised trial. J Bone Joint Surg Am 2006; 88:959–963.
Kerr DR, Kohan L. 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 2008; 79:174–183.
Kalso E, Tramèr MR, Carroll D, McQuay HJ, Moore RA. Pain relief from intraarticular morphine after knee surgery: a qualitative systematic review. Pain 1997; 71:127–134.
Klasen JA, Opitz SA, Melzer C, Thiel A, Hempelmann G. Intraarticular, epidural, and intravenous analgesia after total knee arthroplasty. Acta Anaesthesiol Scand 1999; 43:1021–1026.
Lombardi AV Jr, Berend KR, Mallory TH, Dodds KL, Adams JB. Soft-tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty. Clin Orthop 2004; 428:125–130.
Kehlet H, Andersen LO. Local infiltration analgesia in joint replacement: the evidence and recommendations for clinical practice. Acta Anaesthesiol Scand 2011; 55:778–784.
Vendittoli PA, Makinen P, Drolet P, Lavigne M, Fallaha M, Guertin MC, Varin F et al.
A multimodal analgesia protocol for total knee arthroplasty: a randomized, controlled study. J Bone Joint Surg Am 2006; 88:282–289.
Perret M, Fletcher P, Firth L, Yates P. Comparison of patient outcomes in periarticular and intraarticular local anaesthetic infiltration techniques in total knee arthroplasty. J Orthop Surg Res 2015; 10:119.
Niemelainen M, Kalliovalkama J, Aho AJ, Moilanen T, Eskelinen A. Single periarticular local infiltration analgesia reduces opiate consumption until 48 hours after total knee arthroplasty: a randomized placebo-controlled trial involving 56 patients. Acta Orthop 2014; 85:614–619.
Essving P, Axelsson K, Kjellberg J, Wallgren O, Gupta A, Lundin A. Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty. Acta Orthop 2010; 81:354–360.
Lee-Son MB, Wang GK, Concus A, Grill E, Strichartz G. Stereoselective inhibition of neuronal sodium channels by local anesthetics. Anesthesiology 1992; 77:324–335.
Liisanantti O, Luukkonen J, Rosenberg PH. High-dose bupivacaine, levobupivacaine and ropivacaine in axillary brachial plexus block. Acta Anaesthesiol Scand 2004; 48:601–606.
Casati A, Chelly JE, Cerchierini E, Santorsola R, Nobili F, Grispigni C et al.
Clinical properties of levobupivacaine or racemic bupivacaine for sciatic nerve block. J Clin Anesth 2002; 14:111–114.
Brajkovic D, Brkovic B, Milic M, Biocanin V, Krsljak E, Stojic D. Levobupivacaine vs. bupivacaine for third molar surgery: quality of anaesthesia, postoperative analgesia and local vascular effects. Clin Oral Investig 2014; 18:1481–1488.
Ilham C, Bombaci E, Yurtlu S, Colakoglu S. Efficiency of levobupivacaine and bupivacaine for supraclavicular block: a randomized double-blind comparative study. Rev Bras Anestesiol 2014; 64:177–182.
Bengisun ZK, Salviz EA, Darcin K, Suer H, Ates Y. Intraarticular levobupivacaine or bupivacaine administration decreases pain scores and provides a better recovery after total knee arthroplasty. J Anesth 2010; 24:694–699.
Schung SA. Correction factor for comparison between levobupivacaine and racemic bupivacaine. Reg Anesth Pain Med 2001; 26:91.
Cox CR, Checketts MR, Mackenzie N, Scott NB, Bannister J. Comparison of S(−)-bupivacaine with racemic (RS)-bupivacaine in supraclavicular brachial plexus block. Br J Anaesth 1998; 80:594–598.
Camorcia M, Capogna G, Berritta C, Columb MO. The relative potencies for motor block after intrathecal ropivacaine, levobupivacaine, and bupivacaine. Anesth Analg 2007; 104:904–907.
Faccenda KA, Simpson AM, Henderson DJ, Smith D, Mc-Grady EM, Morrison LM. A comparison of levobupivacaine 0.5% and racemic bupivacaine for extradural anesthesia for cesarean section. Reg Anesth Pain Med 2003; 28:394–400.
Perlas A, Kirkham KR, Billing R, Tse C, Brull R, Gnadhi R, Chan VW. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med 2013; 38:334–339.
Chaumeron A, Audy D, Drolet P, Lavigne M, Vendittoli PA. Periarticular injection in knee arthroplasty improves quadriceps function. Clin Orthop Relat Res 2013; 471:2284–2295.
Mullaji A, Kanna R, Shetty GM, Chavda V, Singh DP. Efficacy of periarticular injection of bupivacaine, fentanyl, and methylprednisolone in total knee arthroplasty: a prospective, randomized trial. J Arthroplasty 2010; 25:851–857.
Burlacu CL, Buggy DJ. Update on local anesthetics: focus on levobupivacaine. Ther Clin Risk Manag 2008; 4:381–392.
Morrison SG, Dominguez JJ, Frascarolo P, Reiz S. A comparison of the electrocardiographic cardiotoxic effects of racemic bupivacaine, levobupivacaine, and ropivacaine in anesthetized swine. Anesth Analg 2000; 90:1308–1314.
Solanki DR, Enneking FK, Ivey FM, Scarborough M, Johnston RV. Serum bupivacaine concentrations after intraarticular injection for pain relief after knee arthroscopy. Arthroscopy 1992; 8:44–47.
Karaoglu S, Dogru K, Kabak S, Inan M, Halicic M. Effects of epinephrine in local anesthetic mixtures on hemodynamics and view quality during knee arthroscopy. Knee Surg Sports Traumatol Arthrosc 2002; 10:226–228.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]