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Local infiltration analgesia (LIA) is a new technique for postoperative pain management following knee arthroplasty. LIA involves a long-acting local anesthetic (ropivacaine), a non-steroid anti-inflammatory drug (ketorolac) and epinephrine infiltrated into the knee joint during surgery and injected postoperatively via a catheter. In the first two studies, LIA was compared with placebo in unicompartmental (I) and total (II) knee arthroplasty. Postoperative pain levels, morphine consumption and the incidence of side effects were lower in the LIA groups. In addition, we found a shorter length of hospital stay in the LIA group following unicompartmental knee arthroplasty compared with placebo (I), while the time to home readiness was shorter in the LIA group following total knee arthroplasty (II). In this study, we found that the unbound venous blood concentration of ropivacaine was below systemic toxic blood concentrations in a sub-group of patients. In the third study, LIA was compared with intrathecal morphine for postoperative pain relief following total knee arthroplasty (III). Pain scores and morphine consumption were lower, length of hospital stay was shorter and patient satisfaction was higher in the LIA group. In the final study, we investigated the effect of minimally invasive surgery (MIS) compared with conventional surgery in unicompartmental knee arthroplasty (IV). Both groups received LIA. We found no statistically significant differences in postoperative pain, morphine consumption, knee function, home readiness, hospital stay or patient satisfaction. In conclusion, LIA provided better postoperative pain relief and earlier mobilization than placebo, both in unicompartmental and total knee arthroplasty. When compared to intrathecal morphine, LIA also resulted in improved postoperative pain relief and earlier mobilization. Minimally invasive surgery did not improve outcomes after unicompartmental knee arthroplasty, when both groups received LIA.

Introduction: Hysterectomy is the most common major gynecological operation in the Western World and approximately 5000 benign hysterectomies are performed in Sweden every year. Consequently it is a surgical procedure that affects many women. The procedure comprises challenges concerning perioperative health care, perceived postoperative symptoms, quality of life aspects and health economics. The concept of fast track is a multimodal strategy to reduce hormonal surgical stress response and achieve an enhanced postoperative recovery and is today considered to be evidence based in relation to colorectal surgery. Spinal anesthesia, as an important part of fast track, provides benefits of extended effect on analgesia and reduced postoperative morbidity. It is reasonable to believe that employing the strategies of fast track including spinal anesthesia could also provide substantial benefits for women requiring surgical removal of the uterus. Aims: To determine whether duration of hospital stay, presence and intensity of postoperative symptoms, duration of sick leave and cost-effectiveness differ between women undergoing benign fast track abdominal hysterectomy in spinal anesthesia with intrathecal morphine (SA) and in standard general anesthesia (GA). Material & Methods: 180 women participated in this open randomized multicenter study with five participating hospitals in the southeast region of Sweden. One hundred and sixty two completed the study; 82 women were randomized to SA and 80 to GA. A fast track model comprising premedication without sedatives, intravenous fluid regulation, analgesics based on non-opioids, pre-emptive antiemetic therapy, early enteral nutrition and mobilization and standard criteria for discharge were used. End points were duration of hospital stay, use of analgesics, perceived postoperative symptoms, occurrence of postoperative complications, duration of sick leave and health economic evaluations. Results: Duration of hospital stay did not differ between the two modes of anesthesia. Vomiting and pruritus occurred significantly more often after SA. Complication rates did not differ between groups. Women with SA experienced less overall discomfort and had a reduced need for opioids postoperatively. Abdominal pain, drowsiness and fatigue occurred less often and with lower intensity among the women in the SA group. Health related quality of life improved faster and the duration of sick leave was shorter in women after SA. Total costs (hospital costs plus costs for productivity loss) were lower for the SA group. Within the first 29 days after hysterectomy the women in the SA group gained more QALYs than women in the GA group. Conclusions: The duration of hospitalisation after fast track abdominal hysterectomy was less than 50 hours and mode of anesthesia did not influence this. SA displayed considerable advantages regarding postoperative symptoms and recovery. SA was considered cost-effective in comparison with GA due to lower total costs and more QALYs gained. Our study indicates that SA should be recommended as the first choice of anesthesia in benign abdominal hysterectomy.