Post-Operative Urinary Retention on Revision Knee Arthroplasty: the Role of Intrathecal Morphine

Summary

Revision total knee arthroplasty (rTKA) is a frequently performed procedure. Adequate pain management is an important feature, especially for fast-track and Enhanced Recovery After Surgery (ERAS) programs. The multimodal approach, including single shot or continuous nerve blocks with catheters and spinal or epidural morphine, is a stablished strategy. Although the administration of intrathecal morphine (IM) has been shown to significantly reduce pain scores, it is not free of adverse effects. Postoperative urinary retention (POUR) is possible and might increase the risk of periprosthetic infection. The purpose of this study is to compare patients undergoing rTKAS under spinal anesthesia with IM to patients undergoing the same procedure, under the same anesthetic technique, but with no IM, for POUR and postoperative pain related outcomes. All patients will have single shot and continuous adductor canal block (CACB) and single shot IPACK (interspace between the popliteal artery and the posterior knee capsule) block. The hypothesis is that postoperative pain control is comparable between the groups, with lower incidence of POUR in patients with no IM given.

Timeline

Start

2025-06-24

Primary completion

2027-07-01

Completion

2027-08-01

Publications

• Background Lavand'homme PM, Kehlet H, Rawal N, Joshi GP; PROSPECT Working Group of the European Society of Regional Anaesthesia and Pain Therapy (ESRA). Pain management after total knee arthroplasty: PROcedure SPEcific Postoperative Pain ManagemenT recommendations. Eur J Anaesthesiol. 2022 Sep 1;39(9):743-757. doi: 10.1097/EJA.0000000000001691. Epub 2022 Jul 20.
• Background Dana E, Ben-Zur O, Dichtwald S, Feigin G, Brin N, Markushevich M, Fredman B, Brin YS. Postoperative urinary retention following hip or knee arthroplasty under spinal anaesthesia with intrathecal morphine: a retrospective cohort study. Singapore Med J. 2025 Sep 1;66(9):481-485. doi: 10.4103/singaporemedj.SMJ-2022-108. Epub 2023 Jun 13.
• Background Scholten R, Kremers K, van de Groes SAW, Somford DM, Koeter S. Incidence and Risk Factors of Postoperative Urinary Retention and Bladder Catheterization in Patients Undergoing Fast-Track Total Joint Arthroplasty: A Prospective Observational Study on 371 Patients. J Arthroplasty. 2018 May;33(5):1546-1551. doi: 10.1016/j.arth.2017.12.001. Epub 2017 Dec 13.
• Background Staikou C, Paraskeva A. The effects of intrathecal and systemic adjuvants on subarachnoid block. Minerva Anestesiol. 2014 Jan;80(1):96-112. Epub 2013 Jul 9.
• Background Tomaszewski D, Balkota M, Truszczynski A, Machowicz A. Intrathecal morphine increases the incidence of urinary retention in orthopaedic patients under spinal anaesthesia. Anaesthesiol Intensive Ther. 2014 Jan-Mar;46(1):29-33. doi: 10.5603/AIT.2014.0006.
• Background Cha YH, Lee YK, Won SH, Park JW, Ha YC, Koo KH. Urinary retention after total joint arthroplasty of hip and knee: Systematic review. J Orthop Surg (Hong Kong). 2020 Jan-Apr;28(1):2309499020905134. doi: 10.1177/2309499020905134.
• Background Garbarino LJ, Gold PA, Anis HK, Sodhi N, Danoff JR, Boraiah S, Rasquinha VJ, Mont MA. Does Intermittent Catheterization Compared to Indwelling Catheterization Decrease the Risk of Periprosthetic Joint Infection Following Total Knee Arthroplasty? J Arthroplasty. 2020 Jun;35(6S):S308-S312. doi: 10.1016/j.arth.2020.02.055. Epub 2020 Feb 28.
• Background Janiak M, Kowalczyk R, Gorniewski G, Olczyk-Miiller K, Kowalski M, Nowakowski P, Trzebicki J. Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty: A Randomized Trial. J Clin Med. 2022 Nov 25;11(23):6945. doi: 10.3390/jcm11236945.
• Background Li XM, Huang CM, Zhong CF. Intrathecal morphine verse femoral nerve block for pain control in total knee arthroplasty: A meta-analysis from randomized control trials. Int J Surg. 2016 Aug;32:89-98. doi: 10.1016/j.ijsu.2016.06.043. Epub 2016 Jul 6.
• Background Grant AE, Schwenk ES, Torjman MC, Hillesheim R, Chen AF. Postoperative Analgesia in Patients Undergoing Primary or Revision Knee Arthroplasty with Adductor Canal Block. Anesth Pain Med. 2017 Apr 17;7(3):e46695. doi: 10.5812/aapm.46695. eCollection 2017 Jun.
• Background Dos Santos Fernandes H, Siddiqui N, Peacock S, Vidal E, Wolfstadt J, Gleicher Y. Inter-fascial space between SArtorius muscle and FEmoral artery (ISAFE): A suggested approach for Adductor Canal catheter placement. J Clin Anesth. 2022 Feb;76:110571. doi: 10.1016/j.jclinane.2021.110571. Epub 2021 Nov 8. No abstract available.

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