Multi-modal pain management encourages quicker recovery after TKA
Recent extraordinary improvements in pain management following total knee arthroplasty (TKA) surgery help patients recover faster and more comfortably, according to a panel of orthopaedic surgeons who discussed the latest strategies and approaches for postoperative pain management and rehabilitation.
The goals of postoperative pain management in the 300,000 annual TKRs are to enable the patient to do the required physical therapy, and to minimize pain and stress. Four renowned orthopaedic surgeons—Daniel J.Berry, MD; Mark W. Pagnano, MD; Steven J. MacDonald, MD; and Paul F. Lachiewicz, MD—addressed the critical importance of balancing effective pain relief with the fewest possible side effects during a media briefing yesterday.
“In the past two years, improvements in our ability to reduce pain after total knee replacement have been dramatic,” said panel member Daniel J. Berry, MD. “With new methods, patients have much less pain, and they also have many fewer side effects of the pain management, such as nausea and grogginess.
These improvements allow patients to get moving faster, get out of the hospital sooner, and recover more quickly and comfortably,” he said.
Pain immediately after TKA surgery can be quite intense, but new methods can reduce the pain dramatically, with fewer side effects than in the past. A local nerve block and medications can offer pain relief in a specific part of the body for a day or two.
Multiple medications used together provide significant improvements in pain suppression. When several medications are marshaled to attack postoperative pain, no dose of a single drug is large enough to cause side effects. A combination can preemptively attack pain to allow the patient to concentrate on reclaiming mobility. This enables clinicians to limit patient-controlled analgesia (PCA) and narcotics, which can leave a patient bed-bound—slowing recovery and increasing side-effects.
According to scientific presentation 86, an Institutional Review Board, prospective, randomized study comparing postoperative pain management protocols also found that a multimodal pain management protocol provided excellent pain control and functional recovery.
The study involved 51 TKA patients, who were randomized to receive either a femoral nerve block (FNB) and PCA for 24 hours after surgery or a local periarticular injection of a proprietary mixture of five medications with different mechanisms of action. All patients received a comprehensive protocol, including perioperative analgesics, anti-inflammatories, patient education, and advanced rehabilitation. Pain, overall satisfaction, recovery of functional milestones, and clinical oucome data were assessed at fixed intervals up to three months after surgery.
Pain control was evaluated using a visual analog scale, patient satisfaction scores, and patient expectations. Pain control on postoperative day 1 was lower in the study group, but pain control and patient satisfaction were similar between the two groups during the remainder of hospitalization and at 6 weeks and 3 months after surgery.
The study group had increased ability to straight-leg raise early as well as earlier stair climbing ability. A larger percentage of patients in the study group were walking without aids at 6 weeks and 3 months. The study group also demonstrated lower narcotic usage and side effects.
According to the study authors, “It appears that pain control plays a much larger role in functional recovery than incision length.” Study authors include Hari Parvataneni, MD, of Reading, Mass.;Vineet P. Shah, DO, of Naperville, Ill.; Amar S. Ranawat, MD, Joanne Weiskopf, PA, and Chitranjan S. Ranawat, MD, all of New York City, and Holly Howard, BA, and Naida Cole BA. Dr. A. Ranawat serves as a consultant to Stryker Howmedica Osteonics; Dr. C. Ranawat serves as a consultant to DePuy and Stryker Howmedica Osteonics.