Osteoarthritis of the knee is one of the most common degenerative joint diseases affecting the adult and elderly population worldwide. It is characterized by progressive degeneration of articular cartilage, subchondral bone changes, synovial inflammation, and formation of osteophytes, leading to chronic pain, joint stiffness, and reduced mobility. As the disease progresses, patients often experience significant impairment in daily activities and overall quality of life. Total knee arthroplasty (TKA) is widely regarded as the most effective surgical treatment for advanced knee osteoarthritis when conservative management fails. The procedure aims to relieve pain, restore joint function, and improve mobility, thereby enabling patients to return to normal daily activities and maintain functional independence [1].

Globally, the prevalence of knee osteoarthritis has been increasing due to population ageing, rising obesity rates, and sedentary lifestyles. According to recent epidemiological estimates, more than 300 million individuals worldwide are affected by osteoarthritis, with the knee being the most frequently involved joint. In developed countries, the number of total knee arthroplasty procedures performed annually has been steadily increasing, reflecting the growing burden of knee osteoarthritis and the effectiveness of surgical intervention in advanced cases. Postoperative pain following total knee arthroplasty, however, remains a major clinical challenge, as inadequate pain control can delay early mobilization, prolong hospital stay, and negatively affect functional recovery [2].

In India, knee osteoarthritis represents a significant public health concern, particularly among middle-aged and elderly populations. Studies have reported that approximately 22–39% of the Indian population above the age of 50 years suffer from symptomatic knee osteoarthritis. With increasing life expectancy and lifestyle changes, the number of patients requiring knee replacement surgery has been rising steadily in both urban and rural areas. Effective postoperative pain management strategies are therefore essential to enhance rehabilitation, facilitate early ambulation, and improve functional outcomes following total knee arthroplasty [3].

Among various multimodal pain management strategies, intraoperative periarticular cocktail injection has gained considerable attention in recent years. This technique involves infiltration of a combination of analgesic agents such as local anesthetics, opioids, non-steroidal anti-inflammatory drugs, corticosteroids, and vasoconstrictors into the periarticular tissues during surgery. The objective of this approach is to provide targeted local analgesia, reduce postoperative pain, minimize systemic opioid requirements, and facilitate early knee mobilization after surgery. Several studies have demonstrated that periarticular infiltration techniques can significantly improve postoperative pain control and enhance early functional recovery following total knee arthroplasty [4].

The concept of periarticular cocktail injection is based on the principle of multimodal analgesia, where multiple pharmacological agents with different mechanisms of action are combined to achieve effective pain control while reducing adverse effects associated with single-drug therapy. By directly infiltrating the tissues around the knee joint during surgery, this technique provides immediate and sustained analgesic effects in the early postoperative period, which is critical for successful rehabilitation after total knee replacement. Improved pain control allows patients to participate actively in physiotherapy, achieve better knee range of motion, and regain functional mobility more rapidly [5].

Several clinical studies have reported encouraging results regarding the use of periarticular cocktail injections in total knee arthroplasty. These studies have shown that patients receiving periarticular infiltration experience reduced postoperative pain scores, decreased opioid consumption, shorter hospital stays, and improved early functional outcomes compared with conventional analgesic methods. Furthermore, periarticular injections are relatively simple to administer, cost-effective, and associated with minimal complications when performed appropriately [6].

In addition to pain relief, early restoration of knee function is an important determinant of successful outcomes following total knee arthroplasty. Functional recovery is influenced by multiple factors, including postoperative pain control, muscle strength, joint stability, and rehabilitation protocols. Effective intraoperative analgesic strategies such as periarticular cocktail injections may contribute significantly to improved functional outcomes by enabling early mobilization and reducing postoperative discomfort [7].

Despite increasing use of periarticular cocktail injections in orthopedic practice, variations exist in the composition of the injection mixture, dosage of drugs used, and clinical protocols followed across different institutions. Therefore, evaluating the clinical and functional outcomes associated with intraoperative periarticular cocktail injection in total knee arthroplasty is important to determine its effectiveness and optimize postoperative pain management strategies [8].

In the regional context of Gujarat and other parts of India, where the burden of osteoarthritis is steadily increasing, improving postoperative recovery following knee replacement surgery is of significant clinical importance. Identifying effective analgesic techniques that promote early mobilization and functional recovery can help improve patient satisfaction, reduce hospital stay, and enhance overall treatment outcomes in patients undergoing total knee arthroplasty [9].

Therefore, the present study aims to evaluate the functional outcome of intraoperative periarticular cocktail injection in patients undergoing total knee arthroplasty. By assessing postoperative pain relief, range of motion, and functional recovery, this study seeks to contribute further clinical evidence regarding the effectiveness of periarticular cocktail injection as a component of multimodal analgesia in total knee arthroplasty [10].

The aim of this study was to assess the functional outcome of intraoperative periarticular cocktail injection for pain control and improvement of knee motion following total knee arthroplasty in patients with osteoarthritis of the knee. The study aimed to evaluate postoperative pain relief, improvement in knee range of motion, and the occurrence of complications associated with the use of periarticular cocktail injection during surgery. Total knee arthroplasty is a widely performed procedure for advanced osteoarthritis; however, postoperative pain and delayed functional recovery remain significant challenges that can affect early mobilization and patient satisfaction. Effective postoperative pain management is essential for improving rehabilitation, reducing hospital stay, and enhancing overall functional outcomes. Intraoperative periarticular cocktail injection has emerged as a multimodal analgesic technique that provides localized pain control by acting on multiple pain pathways around the knee joint. Therefore, this study was conducted to evaluate its effectiveness in improving postoperative recovery. The findings of this study may help in establishing periarticular cocktail injection as an effective strategy for postoperative pain management, facilitating early mobilization, improving functional outcomes, and guiding orthopedic surgeons in optimizing perioperative pain management protocols in total knee arthroplasty.

This prospective observational study was conducted in the Department of Orthopedics at Dhiraj Hospital, S.B.K.S. Medical Institute and Research Centre, Sumandeep Vidyapeeth Deemed to be University, Vadodara, Gujarat from June 2023 to June 2025. Prior approval was obtained from the Sumandeep Vidyapeeth Institutional Ethics Committee (SVIEC) before initiation of the study (IEC Approval No.: SVIEC/2023/Ortho/Manan Parekh/1404/1374 dated 19 October 2023). The study included patients diagnosed with osteoarthritis of the knee who were undergoing total knee arthroplasty at the study centre. All patients fulfilling the inclusion criteria and willing to participate were enrolled after obtaining written informed consent.

A minimum sample size of 27 patients was included in the study using a convenient sampling method during the study period. Patients with osteoarthritis undergoing total knee arthroplasty with intraoperative periarticular cocktail injection were included, while patients who refused to participate, had uncontrolled diabetes mellitus, or had immunocompromised conditions such as HIV, HBsAg infection, or multi-organ failure were excluded from the study.

After preoperative evaluation and routine investigations, patients underwent standard total knee arthroplasty under spinal or general anesthesia. During surgery, a periarticular cocktail injection was prepared under sterile conditions consisting of triamcinolone 40 mg/ml (2 ml), ketorolac 30 mg/ml (2 ml), clonidine 150 mcg/ml (2 ml), plain bupivacaine 0.5% (4 ml), and distilled water (10 ml) making a total volume of 20 ml. The prepared cocktail was infiltrated intraoperatively into the periarticular tissues including the posterior capsule, medial and lateral collateral ligaments, quadriceps tendon insertion, patellar fat pad, and surrounding soft tissues to provide postoperative analgesia and improve functional recovery.

Postoperative assessment was carried out using standardized parameters. Pain intensity was measured using the 10-point Visual Analogue Scale (VAS) at 6 hours, 12 hours postoperatively, and then daily until the fourth postoperative day, followed by 1 month and 3 months follow-up. Active knee range of motion (ROM) was recorded daily during the first four postoperative days and during follow-up visits. Patients were also monitored for postoperative complications, including allergic reactions, nausea, vomiting, urinary retention, respiratory depression, and wound infection. A structured data collection proforma was used to record demographic details, clinical history, surgical details, and follow-up findings.

The collected data were entered into Microsoft Excel and analyzed using appropriate statistical software. Descriptive statistics such as mean, standard deviation, frequency, and percentage were used to summarize the data. Appropriate inferential statistical tests were applied to assess the significance of outcomes, and a p-value < 0.05 was considered statistically significant. Confidentiality and anonymity of the study participants were maintained throughout the study, and participants were free to withdraw from the study at any time without affecting their treatment.

A total of 27 patients with osteoarthritis of the knee undergoing total knee arthroplasty with intraoperative periarticular cocktail injection were included in the present study. The majority of participants belonged to the 61–70 years age group (40.7%), followed by 51–60 years (33.3%), indicating that most cases occurred in the sixth and seventh decades of life. Females constituted 55.6% of the study population while males accounted for 44.4%, demonstrating a slight female predominance. With regard to occupation, the largest proportion of patients were involved in household work (37.0%), followed by unemployed individuals (33.3%), while 22.2% were employed and 7.5% belonged to other occupations. In terms of income distribution, the highest proportion of patients (33.3%) had a monthly income between ₹10,000–20,000, followed by 25.9% earning less than ₹10,000, 22.2% earning ₹20,001–30,000, and 18.5% earning more than ₹30,000 per month.

Clinical evaluation showed that 48.2% of patients experienced symptoms for less than one year, while 25.9% had symptoms for 1–3 years and another 25.9% had symptoms for more than three years prior to surgery. The right knee was involved in 48.1% of patients, the left knee in 44.4%, and 7.5% underwent bilateral surgery. Varus deformity of ≤12° was present in 77.7% of patients, while 22.3% had deformity greater than 12°. Flexion deformity of ≤10° was observed in 85.2% of patients, whereas 14.8% had deformity exceeding 10°. Most patients (62.9%) had no significant comorbidities, while 18.6% had hypertension, 11.1% had diabetes, and 7.4% had both hypertension and diabetes. Radiological evaluation revealed that all patients (100%) had Grade IV osteoarthritis according to the Kellgren–Lawrence classification, indicating advanced disease requiring surgical intervention.

Assessment of postoperative pain using the Visual Analogue Scale (VAS) demonstrated effective pain control following intraoperative periarticular cocktail injection. The mean VAS score at 12 hours was 2.37 ± 0.56, which remained relatively stable during the early postoperative period (Day 1: 2.33 ± 0.48; Day 2: 2.37 ± 0.49). A mild increase in pain was observed by Day 3 (2.70 ± 0.47) and Day 4 (4.07 ± 0.38), possibly related to increased mobilization and inflammatory response. However, substantial improvement was noted during follow-up, with VAS scores decreasing to 1.00 ± 0.00 at 1 month and 0.00 ± 0.00 at 3 months, indicating complete pain relief in the majority of patients.

Functional outcome assessment through knee range of motion (ROM) showed progressive improvement following surgery. The mean ROM was 90.00° ± 0.00 at 12 hours, which increased to 98.89° ± 5.77 on Day 1, 114.44° ± 6.98 on Day 2, 124.07° ± 6.36 on Day 3, and 128.15° ± 3.96 on Day 4, reflecting effective early rehabilitation. At 1 month and 3 months, the mean ROM reached 130° ± 0.00, demonstrating complete functional recovery and excellent joint mobility among the study participants.

Postoperative complications were minimal. Twenty-five patients (92.6%) did not develop any complications, while 2 patients (7.4%) developed infection, which was managed appropriately. No cases of serious complications such as quadriceps or patellar tendon rupture were observed. Overall, the findings of the study indicate that intraoperative periarticular cocktail injection during total knee arthroplasty provides effective postoperative pain control, facilitates early mobilization, improves knee range of motion, and is associated with a low complication rate.

Table 1

Socio-Demographic Characteristics of Study Participants (n = 27)

Table 2

Clinical Characteristics and Comorbidities of Study Participants (n = 27)

Table 3

Postoperative Pain Relief after Intraoperative Periarticular Cocktail Injection (VAS Score) (n = 27)

Statistical Test: Wilcoxon Signed Rank Test

Significance Level: p < 0.05

Table 4

Postoperative Functional Outcome and Complications (n = 27)

Figure 1: Post-Operative Pain Relief VAS Score After Periarticular Cocktail Injection

Figure 2: Post-Operative Knee Range of Motion (ROM) after Periarticular Cocktail Injection

Total knee arthroplasty (TKA) is widely recognized as an effective surgical treatment for advanced osteoarthritis of the knee, providing significant pain relief and functional improvement. However, postoperative pain remains one of the major challenges affecting early mobilization and rehabilitation following surgery. In recent years, intraoperative periarticular cocktail injection has been increasingly used as a component of multimodal analgesia to improve postoperative pain control and enhance early functional recovery.

In the present study, most patients undergoing total knee arthroplasty were elderly, with the majority belonging to the 61–70 years age group, which reflects the higher prevalence of degenerative knee osteoarthritis in older individuals. Similar observations were reported by Kerr and Kohan, who noted that most patients undergoing TKA were older than 60 years due to progressive degenerative changes in the knee joint associated with aging [11]. Likewise, Busch et al. reported a mean patient age of approximately 64 years among individuals undergoing total knee arthroplasty with periarticular analgesic infiltration, further confirming that advanced age is a major risk factor for severe knee osteoarthritis requiring surgical intervention [12].

The gender distribution in the present study showed a slight female predominance, which is consistent with several previous studies indicating that osteoarthritis of the knee is more common among women. Parvataneni et al. reported that females constituted nearly 60% of patients undergoing TKA, which was attributed to hormonal influences, higher prevalence of obesity, and increased life expectancy among women [13]. Similarly, Andersen et al. observed that females accounted for approximately 58% of patients undergoing knee arthroplasty, highlighting the greater burden of knee osteoarthritis in the female population [14].

Pain relief following surgery is a critical factor influencing postoperative recovery. In this study, postoperative pain assessment using the Visual Analogue Scale (VAS) showed significant improvement over time following intraoperative periarticular cocktail injection. The mean VAS score was 2.37 at 12 hours, 2.33 on the first postoperative day, and progressively decreased to 1.00 at one month and 0 at three months, indicating effective postoperative analgesia. Comparable findings were reported by Busch et al., who demonstrated that periarticular multimodal drug injections significantly reduced postoperative pain, with mean VAS scores ranging between 2 and 3 during the early postoperative period [12]. Similarly, Parvataneni et al. reported lower postoperative pain scores among patients receiving periarticular injections compared with conventional analgesic techniques, supporting the effectiveness of local infiltration analgesia in improving postoperative pain control [13].

Functional improvement was also observed in the present study in terms of knee range of motion (ROM). The mean knee flexion increased from approximately 90° in the early postoperative period to around 130° during follow-up, indicating progressive improvement in joint mobility following surgery. Similar results were reported by Kerr and Kohan, who observed that periarticular infiltration analgesia facilitated early mobilization and improved postoperative knee flexion, with patients achieving an average ROM of 120–130° after total knee arthroplasty [11]. Likewise, Andersen et al. demonstrated improved early knee movement and faster rehabilitation among patients receiving periarticular analgesic infiltration compared with other analgesic techniques [14].

The present study also demonstrated a low incidence of postoperative complications, with the majority of patients experiencing uneventful recovery. Only a small proportion of patients developed postoperative infection, which was managed appropriately, and no major adverse drug reactions were observed. These findings are consistent with the study by Andersen et al., who reported that periarticular analgesic injections are generally safe and not associated with a significant increase in complications [15]. Similarly, Busch et al. concluded that periarticular multimodal injections are a safe and effective method for postoperative pain control following total knee arthroplasty without increasing the risk of major complications [12].

Overall, the findings of this study demonstrate that intraoperative periarticular cocktail injection is an effective technique for postoperative pain management in total knee arthroplasty, leading to significant reduction in pain, improvement in knee range of motion, and low complication rates. These findings are consistent with previous studies and support the use of periarticular cocktail injection as an important component of multimodal analgesia protocols in total knee arthroplasty.

The present study demonstrates that intraoperative periarticular cocktail injection during total knee arthroplasty is an effective method for postoperative pain control and functional recovery in patients with osteoarthritis of the knee. The findings showed significant reduction in postoperative pain scores and progressive improvement in knee range of motion during the postoperative follow-up period. Most patients achieved satisfactory functional outcomes with early mobilization and minimal postoperative complications. Therefore, periarticular cocktail injection can be considered a useful component of multimodal analgesia protocols in total knee arthroplasty to enhance postoperative recovery and improve overall patient outcomes.

LIMITATIONS OF THE STUDY

The study had certain limitations that should be considered while interpreting the results. The sample size was relatively small and conducted at a single tertiary care center, which may limit the generalizability of the findings. The study design did not include a control group receiving conventional analgesia for direct comparison of outcomes. In addition, the follow-up period was relatively short and long-term functional outcomes and implant survival could not be assessed. Variations in patient characteristics, rehabilitation protocols, and surgical techniques may also influence postoperative recovery and outcomes.

RECOMMENDATIONS
Based on the findings of this study, intraoperative periarticular cocktail injection may be recommended as an effective technique for postoperative pain management in patients undergoing total knee arthroplasty. The use of this technique may facilitate early mobilization, improve knee function, and enhance patient satisfaction after surgery. Future studies with larger sample sizes, multicenter participation, and longer follow-up duration are recommended to further evaluate the long-term benefits and safety of periarticular cocktail injections. Comparative randomized controlled trials may also help establish standardized protocols for drug combinations and dosage used in periarticular infiltration analgesia in total knee arthroplasty.

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