Pain management and accelerated rehabilitation for total hip and knee arthroplasty

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  • 1. The Journal of Arthroplasty Vol. 22 No. 7 Suppl. 3 2007Pain Management and Accelerated Rehabilitation for Total Hip and Total Knee Arthroplasty Amar S. Ranawat, MD,*y and Chitranjan S. Ranawat, MDyz Abstract: Improved pain management techniques and accelerated rehabilitation programs are revolutionizing our patients postoperative experience after total hip and knee arthroplasty. The process involves regional anesthesia with multimodal pain control using local periarticular injections in combination with enhanced patient education and accelerated rehabilitation provided by a dedicated team of surgeons, physicians, anesthesiologists, physician assistants, physical therapists, and social workers. With this system, it is now possible to achieve a painless recovery after total hip arthroplasty and total knee arthroplasty. Although this is not always the case, it was unheard of in prior years. It is our hope that future research into this area will make painful, difficult recoveries after total hip arthroplasty and total knee arthroplasty a distant memory. Key words: pain management, rehabilitation. © 2007 Elsevier Inc. All rights reserved.Few would argue the incredible impact total hip Any presurgical evaluation regarding informedarthroplasty (THA) and total knee arthroplasty consent in anticipation of THR or TKR should(THA, TKA) have had on the quality of life of now include a detailed discussion of the risks, benefits,people with degenerative joint disease of the hip and and alternatives of the various pain managementknee. They are, arguably, the 2 best elective surgical protocols currently available. General anesthesia withprocedures available to man. Nonetheless, they are intravenous patient-controlled analgesia with a short-both underused procedures. The main reason for acting narcotic has been the gold standard. Newer painthis is the overwhelming fear of severe postopera- management strategies aim to control pain withouttive pain and a prolonged recovery [1]. Although relying on narcotics and its attendant side effects suchthis was certainly the norm in years past, it is now as nausea, vomiting, ileus, pruritis, urinary retention,becoming more of an exception. This is because our confusion, and respiratory depression.understanding of the pain-generating process is This article will outline our current understandingimproving, and our ability to control postoperative of the role regional anesthesia, preemptive analge-pain is also improving. sia, nerve blocks, local periarticular injections, patient education, and accelerated rehabilitation From the *Lenox Hill Hospital, New York, New York; yThe Ranawat programs have in controlling postoperative pain,Orthopaedic Center; and zThe Department of Orthopaedic Surgery, reducing deep venous thrombosis (DVT), andLHH, New York, NY. facilitating an earlier recovery of function. Submitted May 2, 2007; accepted May 24, 2007. No funds were received in support of this article. Chitranjan S.Ranawat and Amar S. Ranawat are consultants for DePuyOrthopaedics, Inc., Warsaw, Ind and Stryker Corp., Mahwah, NJ. What is Pain?Institutional Review Board approval was not obtained for thisarticle because there were no human participants. Reprint requests: Amar S. Ranawat, MD, Lenox Hill Hospital, Pain remains a poorly understood, complex11th Floor, 130 East 77th Street, New York, NY 10021. phenomenon most likely controlled by neural, © 2007 Elsevier Inc. All rights reserved. 0883-5403/07/1906-0004$32.00/0 cellular, and humeral mechanisms, with a strong doi:10.1016/j.arth.2007.05.040 emotional/psychologic component. Any effective 12
  • 2. Pain Management and Accelerated Rehabilitation  Ranawat and Ranawat 13postoperative pain control program for total joint Table 1. Preoperativesurgery should address all of these influences. Preemptive Analgesia Given PreoperativelyTherefore, a multimodal approach is logical andhas been supported by numerous authors [2]. 1. Celecoxib 400 mg orally 2. Acetaminophen 1000 mg orally Not only does the fear of pain limit the number of 3. Tramadol 50 mgpatients who seek total joint surgery, but uncon- 4. Oxycodone 20 mg orallytrolled postoperative pain has many deleterious 5. Pantoprazole 40 mg orally 6. Warfarin 5 mg orallyeffects. It has a profound impact on the recovery offunction, and it is the leading cause of delayeddischarge from the hospital [3]. For all thesereasons, it is the opinion of the senior author that The bottom line is that pain must be controlledthe next great advance in the practice of total joint from the onset for any pain management program tosurgery will be further improvements in postopera- work, and secondly, the anesthetic choice should acttive pain management. to minimize rebound pain, which commonly occurs with the discontinuation of 24-hour epidurals. At our institution, preemptive analgesia begins pre- Anesthesia operatively with most patients receiving 1000 mg of acetaminophen, 400 mg of celecoxib, 50 mg of tra- It has now been well documented that regional madol, and 20 mg of extended-release oxycodone in theanesthesia offers significant advantages over general holding area. In addition, patients are given a proton-anesthesia with regard to intraoperative blood loss, pump inhibitor, an antiemetic, and warfarin (Table 1).DVT, and postoperative pain management [4]. As aresult, single-shot spinal anesthesia is our preferredmethod. To minimize the DVT risk in THA specifi- Nerve Blockscally, this is supplemented with 500 U of IV heparinduring femoral preparation [5]. The use of nerve blocks with and without cathe- There are many other regional anesthetic options ters has been proven to be very effective atbesides spinal anesthesia, such as hypotensive, controlling pain and minimizing narcotic require-epidural anesthesia with or without indwelling ments after THA and TKA. There are, however,catheters for 24 or 48 hours; combined spinal/ several drawbacks, including the increased time itepidurals; intrathecal morphine (Duramorph, Baxter takes to place the blocks; the availability of skilledHeathcare Corporation, Deerfield, IL); and most anesthesiologists to place them; and, perhaps mostrecently, extended-release epidural morphine (Depo- importantly, the associated motor blockade thatdur, Skyepharma, London, England) [6]. Although limits functional recovery and delays rehabilitation.they all offer the aforementioned benefits of regional Nonetheless, several specialized centers have madeanesthesia, they have different risk profiles and femoral nerve blocks for TKA and “3-in-1” blocksrequire different levels of postoperative monitoring. for THA routine for all patients because of itsThe use of epidural catheters also precludes the use of excellent pain-relieving capability [8].certain anticoagulants such as the low-molecular-weight heparins. Unfortunately, because many of Local Periarticular Injectionsthese other modalities also use narcotics as part of theanesthetic, they are not immune from its attendant At our center, we have been focused on usingside effects, as previously described. local, periarticular injections as part of our overall pain management protocol. It is our belief that the Preemptive Analgesia right cocktail in the right patient offers the most effective pain control with the least amount of side The idea of preemptive analgesia is not a new one; effects (Tables 1 and 2). We have demonstrated thenonetheless, it is rarely used. More often than not, safety and efficacy of this program with a rando-patients are only given pain medications well after mized, prospective study, which has been duplicatedthe onset of symptoms. It is now known that by other authors as well [9]. The results of our studycontinuous, around-the-clock dosing of pain med- are pending publication in this journal.ications is far more effective at alleviating pain than Ultimately, we believe that most surgeons acrossthe standard “as-needed or prn” dosing [7]. the country will be using local, periarticular injec-Furthermore, it creates a lower narcotic require- tions for their arthroplasties because of theirment, which has obvious benefits. excellent pain-relieving ability, their low side-effect
  • 3. 14 The Journal of Arthroplasty Vol. 22 No. 7 Suppl. 3 October 2007 Table 2. Intraoperative satisfaction. Most high-volume centers use a variety teaching aids such as audiovisuals, booklets, web-Intraoperative Injection based learning, as well as individual and group 1. 0.5% Bupivacaine 200-400 mg classes to educate patients preoperatively and post- 2. Morphine sulphate (0.4-1.0 cc) 4-10 mg 3. Epinephrine 1/1000 (0.3 cc) 300 μg operatively [10]. To do this effectively requires a 4. Methylprednisolone acetate 40 mg tremendous allocation of time and resources. It 5. Cefuroxime (10 cc) 750 mg usually necessitates a full-time, dedicated, and 6. Normal saline 22 ccNo steroids in diabetic/immunocompromised patients experienced nurse to appropriately handle theVancomycin if allergic to penicillin barrage of patient-generated questions that inevi-Clonidine transdermal patch applied in operating tably arise. It is also a good idea to revisit these room—100 μg/24 hInjection sites for intraoperative periarticular injection classes on a regular basis to ensure proper teaching and training of staff members.THABefore final reduction Anterior capsule Accelerated Rehabilitation Iliopsoas tendon and insertion siteAfter final reduction (before irrigation and closure) Abductors There are 2 factors that permit patients to participate Fascia lata in an accelerated rehabilitation program. The first, and Gluteus maximus and its insertion Posterior capsule and short external rotators perhaps most important, is the motivated patient. Synovium Even with some pain that most patients would consider unbearable, the motivated patient canTKABefore insertion of liner and reduction power through. By extension, the second necessary Posterior capsule factor for most patients is achieving adequate post- Posteromedial and posterolateral structures operative pain control. The focus of any rehabilitationAfter reduction Extensor mechanism protocol should be to control pain because this is the Synovium variable the surgeon can manipulate [11]. No amount Capsule of encouragement or education can convert unmoti- Pes anserinus, anteromedial capsule, and periosteum Iliotibial band vated patients into motivated ones, especially if they Collateral ligaments and origins are experiencing pain. The fact is that many patients, especially younger, active males, could and should participate in aprofile, and their ease of use. Further research in this rehabilitation program on the day of surgery,area will produce improved cocktails with longer- provided they are medically stable. The limitingacting agents. factor for most institutions, however, will be the lack of skilled physiotherapists needed to accomplish this Other Pain-Reducing Adjuvants feat. The benefits include immediate, direct psycho- logic feedback to the motivated patient, with the As the industry becomes more aware of the ultimate potential of reducing his or her length-of-importance of controlling postoperative pain, more stay. The long-term benefits of an acceleratedadjuvant therapies and devices will become avail-able (Table 3). Recently, patient-activated transder- Table 3. Postoperativemal analgesic patches, which obviate the need for Postoperative Analgesia/Medicationsintravenous lines, have been released. Other strate-gies have focused on using anesthetic-coated sutures Recovery room 1. Ketorolac IV every 6 h (15 mg if age N65 y, 30 mg if b65 y, holdand implants as carriers. Newer hemostatic agents if with renal impairment)and drain systems are also now available to help 2. If ketorolac ineffective, morphine 2-4 mg IV every 15 minminimize the risk of developing postoperative 3. Metoclopramide 10 mg IV PRN Orthopedic floorhematomas, which are a significant cause of pain 1. Ketorolac IM every 6 h PRN (15 mg if age N65 y, 30 mg ifand wound complications. b65 y, hold if with renal impairment) 2. If ketorolac ineffective, morphine 2-4 mg IM every 2-4 h 3. Celecoxib 200 mg orally daily for 10 d Patient Education 4. Oxycodone SR 10/20 mg orally every 12 h for 48 h 5. Oxycodone 5 mg orally every 6 h PRN 6. Acetaminophen 1000 mg orally every 6 h Managing patients expectations and preparing 7. Pantoprazole 40 mg orally dailythem for total joint surgery has been shown to bevery effective at improving outcomes and patient PRN, as needed; SR, sustained release.
  • 4. Pain Management and Accelerated Rehabilitation  Ranawat and Ranawat 15program are probably negligible; however, the same length of hospital stay after total joint arthroplasty.could be said for the use of continuous, passive J Arthroplasty 2006;21(6 Suppl 2):132.motion machines, which have become a part of the 3. Horlocker TT, Kopp SL, Pagnano MW, et al. Analgesiacommunity standard despite little evidence to for total hip and knee arthroplasty: a multimodal pathway featuring peripheral nerve block. J Am Acadsupport its use. Orthop Surg 2006;14:126. 4. Indelli PF, Grant SA, Nielsen K, et al. Regional Conclusions anesthesia in hip surgery. Clin Orthop Relat Res 2005;441:250. Achieving the painless THA or TKA is within 5. DiGiovanni CW, Restrepo A, Gonzalez Della Valle AG, et al. The safety and efficacy of intraoperative heparinreach using regional anesthesia and multimodal in total hip arthroplasty. Clin Orthop Relat Res 2000;pain control techniques that avoid the unnecessary 379:178.use of narcotics. This has been documented by 6. Viscusi ER, Parvizi J, Tarity TD. Developments inseveral prospective, randomized studies, including spinal and epidural anesthesia and nerve blocks forour own. The use of local, periarticular injections total joint arthroplasty: what is new and exciting inwill be a major player in these programs in the years pain management. AAOS ICL 2007; come. Further research is still necessary to 7. Skinner HB, Shintani EY. Results of a multimodalidentify longer-acting injectable agents. analgesic trial involving patients with total hip or total Although patient education and accelerated reha- knee arthroplasty. Am J Orthop 2004;33:85.bilitation programs are important in facilitating a 8. Pagnano MW, Hebl J, Horlocker T. Assuring apatients recovery, it cannot be overemphasized that painless total hip arthroplasty: a multimodal approach emphasizing peripheral nerve blocks. J Arthroplastythe focus of any total joint program should be in 2006;21(4 Suppl 1):80.controlling postoperative pain. 9. Parvataneni HK, Ranawat AS, Ranawat CS. The use of local peri-articular injections in the management of postoperative pain after total hip and knee replace- References ment: a multimodal approach. AAOS ICL 2007;56:152. 10. McGregor AH, Rylands H, Owen A, et al. Does pre- 1. Skinner HB. Multimodal acute pain management. operative hip rehabilitation advice improve recovery Am J Orthop 2004;33(5 Suppl):5. and patient satisfaction? J Arthroplasty 2004;19:464. 2. Peters CL, Shirley B, Erickson J. The effect of a new 11. Ranawat CS, Ranawat AS, Mehta A. Total knee multimodal perioperative anesthetic regimen on arthroplasty rehabilitation protocol: what makes the postoperative pain, side effects, rehabilitation, and difference? J Arthroplasty 2003;18(3 Suppl 1):27.