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Original Article
The use of an intraarticular catheter on fast-track primary knee arthroplasty, is it a step forward?
Uso de cáteter intraarticular en fast track de artroplastia primaria de rodilla. ¿Supone un avance?
L. Cáceres-Sáncheza,
Corresponding author
libertad_caceres@hotmail.com

Corresponding author.
, J.B. García-Beníteza, V. Coronado-Hijónb, M. Montero-Parientea
a Servicio de Cirugía Ortopédica y Traumatología, Hospital San Juan de Dios del Aljarafe, Sevilla, Spain
b Servicio de Anestesiología y Reanimación, Hospital San Juan de Dios del Aljarafe, Sevilla, Spain
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with early mobilisation of the knee&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> and&#44; in some cases&#44; even the reduction in hospital stay&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> During the last decade&#44; multimodal analgesia techniques have become an alternative to opioid painkillers alone for pain management after TKA&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Numerous methods of adjuvant treatment for postoperative pain have been described&#46; These include standard oral analgesics&#44; periarticular infiltrations &#40;with local analgesics and anaesthetics&#41;&#44; regional anaesthesia with neuroaxial block &#40;spinal or epidural&#41;&#44; peripheral nerve blocks &#40;femoral&#44; sciatic or psoas&#41; or a combination of various&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9&#8211;11</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to compare two modalities in postoperative pain management as part of a multimodal pain protocol after TKA&#46; 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The study was approved by the Bioethics Committee and the Hospital Quality Commission and with the signed informed consent of the patients&#46; The patients included in the study were those who had been diagnosed with tricompartmental gonarthrosis of the knee and referred for TKA&#46; 108 patients were randomly selected from the two groups&#58; CG and IG&#46; The patients selected for the IG were those who had undergone surgery on even days and those of the CG on odd days&#46; The exclusion criteria were as follows&#58; patients allergic to NSAIDS or local anaesthetics&#44; those who refused or had contraindications to intradural regional anaesthesia and those patients with mental&#44; psychiatric or neuromuscular degenerative diseases&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Of the 108 patients&#44; in the CG&#44; two had to abandon the study due to the technical impossibility of administering intradural anaesthesia&#46; In the IG another five patients abandoned the study&#58; three of them due to the failure of implanting the catheter in the operating theatre and two due to possible allergy to NSAIDS&#46; This meant that the elastomeric pump could not be used in the anaesthesia recovery room&#46; One catheter fell to the floor in the operating theatre and was no longer sterile&#44; another was burned with an electric scalpel and in a third patient&#44; a trocar was incorrectly removed and consequently rejected &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The patients were operated on by the same group of orthopaedic surgeons and during the same period of time&#44; which was between January and March 2016&#46; Two knee arthroplasty models were used&#58; PFC Sigma &#40;Johnson &#38; Johnson&#44; Warsaw Ind&#46;&#41; and Advance Medial-Pivot &#40;Wright Medical Technology&#44; Arlington TN&#41;&#44; in both study groups&#46; The positioning of the patient&#44; the approach and cementation type &#40;third generation&#41; was the same in all cases&#46; Prophylactic ischaemia of the operated limb was used in all patients&#44; and was removed after closing the surgical wound&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the CG&#44; after the intradural anaesthesia &#40;9<span class="elsevierStyleHsp" style=""></span>mg of 0&#46;5&#37; hyperbaric bupivacaine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>&#956;g of fentanyl&#41; an epidural catheter was inserted in the operating theatre with a continuous perfusion of 0&#46;2&#37; ropivacaine at 8<span class="elsevierStyleHsp" style=""></span>ml&#47;h&#46; This was complemented with the intravenous administration of paracetamol and metamizol every 8<span class="elsevierStyleHsp" style=""></span>h&#46; If necessary&#44; rescue analgesics of pethidine of 50<span class="elsevierStyleHsp" style=""></span>mg were administered in intravenous boluses&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the IG&#44; with the same intradural anaesthesia as in the CG&#44; the surgeon inserted an intraarticular catheter prior to closure of the arthrotomy&#46; Following this&#44; a continuous perfusion was initiated with an elastomeric pump composed of 0&#46;35&#37; ropivacaine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>dexketoprofen at a constant speed of 5<span class="elsevierStyleHsp" style=""></span>ml&#47;h for 48<span class="elsevierStyleHsp" style=""></span>h&#46; This analgesic was complemented with the gradual intravenous administration of paracetamol and metamizol in the same doses as in the CG&#46; Equally&#44; the rescue analgesics were composed of pethidine in intravenous boluses of 50<span class="elsevierStyleHsp" style=""></span>mg&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Intraarticular catheter insertion technique</span><p id="par0050" class="elsevierStylePara elsevierViewall">Once the final TKA implants had been inserted and the haemostasis reviewed after removal of the prophylactic ischaemia&#44; the intraartcular catheter was inserted &#40;Braun Medical&#44; Spain&#41;&#46; The point of entry was located in the suprapatellar region external to the knee&#44; 2&#8211;3<span class="elsevierStyleHsp" style=""></span>cm proximal to the apical pulse of the kneecap&#44; leaving the aspiration drainage exit point distal to this&#46; The infusion segment of the catheter was positioned on the opposite side to the drainage&#44; in the medial articular interlining &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; After this&#44; closure of the arthrotomy&#44; subcutis and skin were performed&#46; Next&#44; the catheter was attached with an adhesive Skin-fixe Strip<span class="elsevierStyleSup">&#174;</span> &#40;3<span class="elsevierStyleHsp" style=""></span>M<span class="elsevierStyleSup">TM</span>&#41; cutaneous suture &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; A 10<span class="elsevierStyleHsp" style=""></span>ml bolus was then infused with 0&#46;5&#37; bupivacaine and the elastomeric pump sensor of the catheter was attached with non occlusive transparent plaster&#46; Finally&#44; the On-Q Pain Buster<span class="elsevierStyleSup">&#174;</span> &#40;Lake Forest&#44; CA&#44; U&#46;S&#46;A&#41; elastomer was attached&#44; previously loaded with analgesia &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; After the drainage route was opened&#44; continuous perfusion was initiated&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Demographic variables &#40;gender&#44; age&#44; side&#41; were recorded&#46; Pain intensity at rest and during movement was assessed after 24<span class="elsevierStyleHsp" style=""></span>h and 48<span class="elsevierStyleHsp" style=""></span>h using a verbal rating scale of 1&#8211;10&#44; considering pain to be mild &#40;under or equal to 3&#41;&#44; moderate &#40;from 4 to 6&#41;&#44; and severe &#40;over 7&#41;&#46; Request for opioids was noted during the first 48<span class="elsevierStyleHsp" style=""></span>h as were complications and side effects of each anaesthetic technique&#46; We also recorded the degree of flexion of the operated knee&#44; the onset of walking&#44; the number of hospital stay days and the overall patient satisfaction on discharge &#40;very satisfied&#44; acceptable or dissatisfied&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">For analysis of results obtained&#44; the SAS statistical programme software version 9&#46;4 was used &#40;SAS Institute Inc&#46; Cary&#44; NC&#44; U&#46;S&#46;A&#46;&#41;&#46; A descriptive statistic of the study variables was performed&#46; The quantitative variables&#44; depending on whether they followed a normal or non normal distribution&#44; were summarised using the mean and standard deviation or the median and interquartile range&#44; respectively&#46; The qualitative variables were referred to in the form of a number &#40;n&#41; and percentage &#40;&#37;&#41; using continguency tables and the <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup">2</span> or exact Fisher test was applied in the case of low frequencies&#46; Statistical significance level was established at <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;05&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">101 patients were included in the study&#44; 51 &#40;50&#46;49&#37;&#41; in the case study group and 50 &#40;59&#46;50&#37;&#41; in the control group&#46; With regards to the demographic variables studied&#44; there were no significant differences in gender &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;511&#41;&#44; age &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;317&#41;&#44; side &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;427&#41; or ischaemia time &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;384&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to the number of requests for rescue opioid painkillers&#44; there were no significant differences between both groups&#46; The number of patients who required opioid rescue was 45&#46;1&#37; in the IG and 62&#37; in the CG with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;1116&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">On comparing the onset of side effects&#44; it was observed that there was a lower incidence in the IG &#40;17&#46;6&#37;&#41; than in the CG &#40;52&#37;&#41;&#44; with statistically significant results &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;00004&#41;&#46; With respect to paresthesias&#47;motor block&#44; there were no cases in the IG compared with 6 &#40;12&#46;0&#37;&#41; patients in the CG&#46; We found significant differences in the onset of nausea and&#47;or vomiting with 12 &#40;24&#37;&#41; patients in the CG compared with 3 &#40;5&#46;9&#37;&#41; in the IG&#46; There were no differences in the rate of dizziness&#44; low blood pressure&#44; bladder balloon&#44; or the onset of disorientation in space and time since the results were not statistically significant &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">With regard to postoperative pain we observed from the verbal rating scale in the IG that there was a mean &#40;SD&#41; of 1&#46;1 &#40;1&#46;9&#41; compared with that of the CG with C 2&#46;7 &#40;2&#46;4&#41; on the 2nd postoperative day&#44; with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;0002&#46; The following table shows the values collected on assessment of pain after 24 and 48<span class="elsevierStyleHsp" style=""></span>h after TKA &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">On exploring the level of the articular balance of the operated knee&#44; in the IG we observed greater knee flexion during the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; 21&#46;7&#176; more in flexion &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0001&#41; was achieved compared with the CG&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">74&#37; of patients with an intraarticular catheter&#44; were able to walk when the CG patients had not started to do so &#40;31&#46;4&#37; in the first 12<span class="elsevierStyleHsp" style=""></span>h after surgery and 43&#46;1&#37; within 12 and 24<span class="elsevierStyleHsp" style=""></span>h&#41; with <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;001 &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">With regard to satisfaction&#44; there were double &#8220;very satisfied&#8221; patients in favour of the use of the intraarticular catheter &#40;28&#59; 54&#46;9&#37;&#41; compared with the CG &#40;14&#59; 28&#46;8&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Lastly&#44; hospital stay considerably dropped in the IG with a mean &#40;SD&#41; of 62&#46;4 &#40;12&#46;8&#41;<span class="elsevierStyleHsp" style=""></span>h compared with 69&#46;2 &#40;5&#46;6&#41;<span class="elsevierStyleHsp" style=""></span>h for the CG &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#44; with 33&#46;3&#37; of patients being discharged within the first 48<span class="elsevierStyleHsp" style=""></span>h&#44; compared with 0&#37; of the control group &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Postoperative analgesia after TKA is an essential part in achieving success&#44; since it impacts posterior rehabilitation of the patient and the quality of this healthcare procedure&#46; The result obtained in this work&#44; with lower hospital stay&#44; indicates that the use of the intraarticular catheter&#44; and the postoperative analgesia is a highly appropriate technique for a rapid recovery system in knee arthroplasty&#46; This entails saving money without increasing complications&#44; as has now been internationally recognised&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Primary TKA is one of the orthopaedic operations with the highest success rate and leads to great satisfaction for the patient and the surgeon&#46; For this reason&#44; postoperative analgesia using these processes is now an essential part of this success&#44; since it has an impact on posterior rehabilitation of the patient and in the quality of this healthcare process&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">After an exhaustive review of the literature&#44; we found another study which compares the efficacy of postoperative control of pain of patients who underwent primary TKA with the use of the intraarticular catheter and the epidural catheter&#46; A randomised study was carried out to this effect to compare postoperative pain&#44; the use of analgesics&#44; the functioning of the operated knee&#44; the onset of walking&#44; hospital stay duration and the appearance of complications immediately after surgery&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Pain assessment was made on a verbal rating scale on the first and second postoperative day&#44; on the assumption that the highest differences would be found&#44; since after the first 48<span class="elsevierStyleHsp" style=""></span>h following surgery the effects of both analgesics would cease&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9&#44;14&#44;15</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Although no other study used the same pain management protocols&#44; similar studies compared periarticular injection with nerve blocks and showed outcomes similar to our study&#46; In a recent clinical trial Chaumeron et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> used a periarticular infiltration in a single dose&#44; which was repeated through an intraarticular catheter on postoperative day 1 and was compared with a permanent femoral catheter &#40;with no sciatic block&#41; used from 48 to 72<span class="elsevierStyleHsp" style=""></span>h&#46; This study reported a lower pain score for the first 8<span class="elsevierStyleHsp" style=""></span>h after surgery in the periarticular infiltration group and no differences after that&#44; with improvement in quadriceps strength and mobility in the said group&#46; Carli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> compared local infiltration with femoral block and no significant differences were shown in pain intensity in repose or consumption of opioids after TKA&#46; We did observe a reduction in pain when the patients started to walk with femoral block&#46; In contrast&#44; in Toftdahl et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a> study they found better results in patients who received periarticular injection compared with those who received femoral nerve block during the first postoperative day&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">When the studies with intraarticular injection and intraoperative periarticular infiltration were compared after the closure of the capsule&#44; the consumption of narcotics was generally lower in intraarticular infiltration studies&#44; although the difference tended to be greater for periarticular infiltrations&#46; The differences of the pain scores are&#44; generally&#44; more inclined towards periarticular infiltrations&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">14&#44;18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">With regard to the need for opioid rescue&#44; there was no significant difference between IG and CG in the first 48<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; Vendittoli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> compared the consumption of morphine during the first 24<span class="elsevierStyleHsp" style=""></span>h after a TKA in 42 patients who had been randomly assigned to receive a mixture of perioperative articular infiltration with local anaesthesia and self-administered morphine or only self-administered morphine&#46; As with our study&#44; they observed that in the patient group with articular infiltration&#44; pain lessened and side effects were minimalised&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The use of the intraarticular catheter&#44; apart from improving postoperative analgesia&#44; achieves a significant improvement in early onset of walking for the patient&#44; and a reduction in hospital stay &#40;2&#46;6 days&#41;&#46; In a transversal study carried out on a global scale&#44; and by autonomous community out of the total primary arthroplasty of the hip &#40;THA&#41; and TKA reported by Allepuz et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> the median stay was 9 days for THA and 8 days for TKA&#46; Brunenberg et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19&#44;21</span></a> studied the cost-effectiveness of patients who underwent TKA and ATC&#46; Mean hospital stay of the patients who were treated later with physiotherapy was lower than that of patients who did not receive this treatment &#40;the difference was 4&#46;1 days in hip and 6&#46;9 days in knee&#44; with statistically significant differences&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Several studies have shown that there is not a higher risk of infection when an intraarticular catheter is inserted up to 72<span class="elsevierStyleHsp" style=""></span>h&#44;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">19&#44;22</span></a> and they may even be used for the treatment of prosthetic infection in the hip and knee with antibiotic infusion&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Our study had several limitations&#46; We could not prevent the patients and the staff being aware of the analgesic treatment received&#44; since the presence of both the intraarticular catheter and the epidural catheter made it clear to which study group they belonged&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The patients were not operated on by the same surgeon&#44; despite them all belonging to the same working team&#44; and this was a limitation to the study&#46; Moreover&#44; for this study two different prosthesis models were used&#58; PFC Sigma &#40;Johnson &#38; Johnson&#44; Warsaw Ind&#46;&#41; and Advance Medial-Pivot &#40;Wright Medical Technology&#44; Arlington TN&#41;&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">After the outcome obtained with data analysis&#44; we may say that the use of the intraarticular catheter in patients who undergo a total primary knee arthroplasty as postoperative analgesia is a valid and safe alternative&#44; with improvement in immediate postoperative pain&#46; This means a better range of movement in the operated knee&#44; that the onset of walking is earlier&#44; there is a reduction in the onset of the before-mentioned side effects&#44; patient satisfaction improves and hospital stay is reduced&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">We therefore conclude that the use of the intraarticular catheter as a postoperative analgesic technique improves the outcomes compared with the use of the epidural catheter&#44; and it is therefore an effective alternative in the treatment of postoperative pain after total knee arthroplasty&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Level of evidence</span><p id="par0170" class="elsevierStylePara elsevierViewall">Level of evidence III&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical responsibilities</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of people and animal subjects</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that the procedures followed comply with the ethical regulations of the responsible human experimentation committee and with the World Medical Association Declaration of Helsinki&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors declare that they have adhered to the protocols of their centre of work on the publication of patient data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0185" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">This study compares the efficacy in post-operative pain control of the intraarticular catheter compared to the epidural catheter after primary total knee arthroplasty&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Randomised clinical trial consisting of two groups of patients&#46; A control group with intradural anaesthesia and an intraoperative epidural catheter &#40;ropivacaine&#41; and an intervention group using the same anaesthetic technique and an intraarticular catheter with an elastomeric pump &#40;ropivacaine<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>dexketoprofen&#41;&#46; Data such as demographic&#44; anaesthetic and surgical variables&#44; pain intensity according to Verbal Rating Scale&#44; opioid use and complications&#44; joint balance&#44; onset of walking and hospital stay were recorded&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A lower incidence and severity on Verbal Rating Scale and a better control of postoperative pain &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>&#46;0014&#41; were observed in the intervention group&#46; Joint balance also presented significant results in flexion and 74&#37; of these patients started walking before the first 36<span class="elsevierStyleHsp" style=""></span>h and the control group had not yet done so&#46; Regarding patient satisfaction&#44; 54&#46;1&#37; of the patients were &#8220;very satisfied&#8221; with the use of the catheter &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Finally&#44; the hospital stay decreased significantly&#44; with 33&#46;3&#37; of intervention group patients discharged within the first 48<span class="elsevierStyleHsp" style=""></span>h compared to none of the control group&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion and conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of the intraarticular catheter as postoperative analgesia is a useful and safe alternative&#46; It reduces the possibility of side effects&#46; It helps in early improvement of joint balance&#44; onset of walking and control of pain&#46; All of which increase patient satisfaction and result in a shorter period of hospitalisation&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and method"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Discussion and conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Comparar la eficacia en el control del dolor postoperatorio de pacientes sometidos a artroplastia total de rodilla primaria comparando cat&#233;ter intraarticular versus epidural&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Ensayo cl&#237;nico aleatorizado formado por dos grupos de pacientes&#58; un grupo control con anestesia intradural y un cat&#233;ter epidural &#40;ropivaca&#237;na&#41; y un grupo de intervenci&#243;n con la misma t&#233;cnica anest&#233;sica&#44; a la que se a&#241;adi&#243; un cat&#233;ter intraarticular con bomba elastom&#233;rica &#40;ropivaca&#237;na &#43; dexketoprofeno&#41;&#46; Se registraron variables demogr&#225;ficas&#44; anest&#233;sicas y quir&#250;rgicas&#44; intensidad del dolor seg&#250;n Escala Verbal Num&#233;rica&#44; consumo de opi&#225;ceos y complicaciones&#44; balance articular&#44; inicio de la deambulaci&#243;n y estancia hospitalaria&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se observ&#243; menor incidencia y severidad en la Escala Verbal Num&#233;rica en el grupo de intervenci&#243;n y mejor control del dolor postoperatorio &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;0014&#41;&#46; El balance articular present&#243; resultados significativos en la flexi&#243;n y el 74&#37; de estos pacientes deambularon antes de las 36<span class="elsevierStyleHsp" style=""></span>h cuando el grupo control a&#250;n no lo hab&#237;a hecho&#46; El 54&#44;1&#37; de pacientes se mostraron &#171;muy satisfechos&#187; a favor del uso del cat&#233;ter &#40;p&#62;0&#44;001&#41;&#46; Por &#250;ltimo&#44; la estancia hospitalaria disminuy&#243;&#44; siendo el 33&#44;3&#37; de los pacientes del grupo de intervenci&#243;n dados de alta a las 48<span class="elsevierStyleHsp" style=""></span>h de la intervenci&#243;n&#44; hecho que no sucedi&#243; en ninguno de los casos del grupo control&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusi&#243;n y conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El uso del cat&#233;ter intraarticular como analgesia postoperatoria es una alternativa v&#225;lida y segura&#46; Disminuye la aparici&#243;n de efectos secundarios y mejora el balance articular&#44; el inicio de la deambulaci&#243;n y el control del dolor y contribuye a una mayor satisfacci&#243;n del paciente y a un alta m&#225;s precoz&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todo"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Discusi&#243;n y conclusiones"
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; C&#225;ceres-S&#225;nchez L&#44; Garc&#237;a-Ben&#237;tez JB&#44; Coronado-Hij&#243;n V&#44; Montero-Pariente M&#46; Uso de c&#225;teter intraarticular en fast track de artroplastia primaria de rodilla&#46; &#191;Supone un avance&#63; Rev Esp Cir Ortop Traumatol&#46; 2018&#59;62&#58;19&#8211;26&#46;</p>"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow diagram of the study&#46; Progress of selected patients according to the assigned group&#46;</p>"
        ]
      ]
      1 => array:7 [
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The infusor segment is located in the medial interlining&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Attachment of the catheter with adhesive cutaneous suture&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Insertion of elastomer and accessory bag to facilitate the patient&#39;s movement&#46;</p>"
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      4 => array:7 [
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        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Data are collected at the start of walking&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Epidural catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intraarticular catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Gender</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;29&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;26&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;33&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;5149&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71 &#40;70&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;74&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#40;66&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Age</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;7 &#40;7&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">69&#46;5 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;9 &#40;7&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;3172&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Side</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47 &#40;46&#46; 5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;42&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#40;51&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;427&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54 &#40;53&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29 &#40;58&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;4&#46;9&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Time of ischaemia</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mean &#40;SD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&#46;8 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#46;8 &#40;9&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;7 &#40;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;384&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Epidural catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intraarticular catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Some side effects &#40;incidence&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>es&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35 &#40;34&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;52&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;17&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;00004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Side effects</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>n&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nausea and&#47;or vomiting&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;14&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;24&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;5&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;0124&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dizziness and&#47;or hypotension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#40;10&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;14&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;7&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;3573&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Motor block and&#47;or paresthesias&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;5&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;12&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;0125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bladder balloon and&#47;or urine retention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Disorientation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;495&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Others &#40;headaches&#44; fever&#44; &#8230;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;14&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;031&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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            "identificador" => "at3"
            "detalle" => "Table "
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VRS in repose</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Epidural catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intraarticular catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Day 1</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="char" valign="top">&#46;1947</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;3 Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">79 &#40;78&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34 &#40;68&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45 &#40;88&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#8211;6 Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14 &#40;13&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;26&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#8211;10 Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;7&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Day 2</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="char" valign="top">&#46;0025</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;3 Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75 &#40;74&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;60&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45 &#40;88&#46;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#8211;6 Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22 &#40;21&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;34&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#8211;10 Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;4&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;6&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;2&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="4" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">VRS in movement</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Epidural catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intraarticular catheter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-Value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Day 1</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="char" valign="top">&#46;3341</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;3 Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;50&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21 &#40;42&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;58&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#8211;6 Moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26 &#40;25&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17 &#40;34&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;17&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#8211;10 Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;23&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;24&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;23&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Day 2</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="char" valign="top">&#46;0155</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>0&#8211;3 Mild&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18 &#40;36&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30 &#40;58&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>4&#8211;6 Moderate&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20 &#40;40&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;31&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>7&#8211;10 Severe&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12 &#40;24&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;9&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Data on hospital stay in days and hours&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:23 [
            0 => array:3 [
              "identificador" => "bib0120"
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                            0 => "A&#46; Osawa"
                            1 => "K&#46; Yoshida"
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                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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            1 => array:3 [
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              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "PMC&#46; Web"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Continuous Local infiltration analgesia for pain control after total knee arthroplasty&#58; a meta-analysis of randomized controlled trials"
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                      "Revista" => array:4 [
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            2 => array:3 [
              "identificador" => "bib0130"
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                  "contribucion" => array:1 [
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                            1 => "G&#46; Chen"
                            2 => "C&#46; Ruffieux"
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                  "host" => array:1 [
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                      "doi" => "10.1001/jama.2011.2029"
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                      "autores" => array:1 [
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                            0 => "F&#46; Vekeman"
                            1 => "J&#46;C&#46; LaMori"
                            2 => "F&#46; Laliberte"
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                  "host" => array:1 [
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                      "doi" => "10.3111/13696998.2012.669438"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                            0 => "M&#46; Perret"
                            1 => "P&#46; Fletcher"
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                  ]
                  "host" => array:1 [
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            5 => array:3 [
              "identificador" => "bib0145"
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                  "contribucion" => array:1 [
                    0 => array:2 [
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;A&#46; Spangehl"
                            1 => "H&#46;D&#46; Clarke"
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                      "doi" => "10.1007/s11999-014-3603-0"
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              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intraarticular&#44; epidural&#44; and intravenous analgesia after total knee arthroplasty"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "J&#46;A&#46; Klasen"
                            1 => "S&#46;A&#46; Opitz"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Effect of a perioperative intra-articular injection on pain control and early range of motion following bilateral TKA"
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                        0 => array:2 [
                          "etal" => false
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                            0 => "M&#46; Fajardo"
                            1 => "J&#46; Collins"
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es en pt

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