Pain relief options after TJR discussed at media briefing

Though total joint replacement is considered among the most beneficial of surgical procedures in terms of restoring quality of life and mobility, the postoperative pain may leave some patients initially questioning why they underwent the operation. This perception, coupled with patient anxiety pre-surgery and recent manufacturer withdrawals of certain prescription pain relievers, has prompted physicians to explore alternatives to enhance patient care. At a media briefing yesterday, a panel of orthopaedic experts discussed the efficacy of pain management options after joint replacement and their potential impact on bone healing.

“All patients undergoing total hip or knee replacement will experience significant pain; our challenge is to reduce pain to an acceptable level in the early postoperative period,” according to Chitranjan S. Ranawat, MD, of New York City. “Pain control plays a key role in joint-replacement patients’ recovery; patients’ perception of pain most notably affects the time it takes them to regain mobility.”

Nonsteroidal anti-inflammatory drugs (NSAIDs), including over-the-counter aspirin and ibuprofen, are the most prescribed medications to relieve postoperative pain and reduce inflammation. A lesser prescribed—and more potent—set of pain relievers are the COX-2 inhibitors. Unlike COX-2 inhibitors, NSAIDs interfere with normal blood clotting, so patients are required to stop taking these medications one to two weeks prior to surgery to prevent excessive bleeding.

“While over-the-counter or narcotic pain medications are more frequently used to alleviate patients’ pain after joint replacement, COX-2 inhibitors are the next round of alternatives available to manage pain that does not subside after initial treatment,” explained Thomas A. Einhorn, MD, of Boston. “But really, unless there’s a surgical complication, most patients’ post-operative pain is effectively managed within 7 to 10 days. Sometimes the need for pain medication may persist for a several weeks after surgery when patients are undergoing aggressive physical therapy to improve function.”

Postoperative pain is the leading cause for delay of discharge from the hospital, one of the reasons behind Dr. Ranawat’s call for a more aggressive, multi-modal approach to pain management. He emphasized the need to help patients receive optimal pain control, reduce or eliminate the need for narcotic medication. Narcotic medications are known to create significant side effects and delay in patients’ return to function after total hip or knee replacement.

“Prevention of pain is easier and more effective than control of established pain,” stressed Dr. Ranawat. “In certain patients, administering analgesia two hours prior to surgery—followed by a combination of COX-2 inhibitors and sustained-release oral narcotics—have proven to be effective in reducing the pain and inflammation that goes hand in hand with surgical trauma, specifically in the case of joint replacement.”

Recent studies have indicated that both NSAIDs and COX-2 inhibitors may have a delaying effect on bone healing. However, according to Dr. Einhorn, research has proven that short-term use of NSAIDs after joint replacement, spinal fusion or fracture care is generally safe.

“COX-2 inhibitors and NSAIDs do inhibit bone healing,” Dr. Einhorn explained. “We have learned, however, that because these medications are administered for relatively short periods of time after surgery, once the medication is stopped, the bone healing process recovers to where it should be.”

The use of NSAIDs and COX-2 inhibitors involve a risk/benefit ratio, and should be assessed by physicians on a case by case basis in light of each patient's specific conditions.

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