Managing Post-Operative Pain

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At the Leone Center for Orthopedic Care, we have found that post-operative pain is one of the most prevalent anxieties that patients have prior to undergoing hip or knee replacement surgery.  Allaying that concern, by outlining what to expect and how pain will be managed, is a major focus of the pre-operative education that is provided one-on-one by me, by my staff and during patient seminars at Holy Cross Hospital.  These pre-operative educational forums provide an opportunity for patients to learn as well as ask questions.

In my experience, I have found that patients who go into surgery with a better understanding of what will happen and what to expect not only have less anxiety, but less post-operative pain.

As part of the Leone Center surgical protocol, we have a two-pronged philosophy for post-operative pain management:

  1. Stay ahead of the pain curve.  It is preferable and easier to prevent pain than to play “catch-up” by trying to decrease pain after it occurs.
  2. Pain is more effectively managed with a multi-modal approach that includes everything from the type of anesthesia used during surgery to the pain medication and physical therapy given after surgery.

Your surgeon should outline the pain-management protocol for you prior to the procedure.  Here is a general outline of the post-operative pain management regimen we use at the Leone Center for Orthopedic Care:

  • Medication administered the morning prior to surgery includes:
    • Intravenous Therapy (IV) of Tylenol to make patients less sensitive to and decrease the amount of pain
    • Another IV medicine to make patients drowsy, which helps to decrease anxiety
    • Oral medications including a long-acting narcotic to dull pain receptors before pain sets in, as well as medication to prevent nausea following surgery.
    • IV antibiotics before (and after) surgery to lower the risk of infection
  • Generally my patients have regional or spinal anesthesia. This is a discussion you will have and a decision you will make with your surgeon and anesthesiologist. There are several advantages to regional anesthesia, including:
    • Patients tend to require fewer drugs for pain.
    • Most report waking up more gradually and with a lot less nausea.
    • Most have no recollection of receiving the anesthetic.
    • Because patients are not intubated during surgery to control breathing, they do not have a sore throat after surgery.
    • Many patients lose less blood when surgery is performed with spinal anesthesia, decreasing the probability of a blood transfusion.
  • In the recovery room, my patients receive an IV NSAD. This is a super version of aspirin called Toradol.  It works to decrease pain via an alternate “pathway” and has proven to be remarkably effective. I do prescribe narcotic injections as a backup, but find that they are used with much less frequency because patients are more comfortable. If possible, I prefer that patients avoid using narcotics because they tend to cause nausea and occasionally confusion.
  • During both hip and knee replacement surgery: after I have placed the implant but prior to closing the surrounding tissue, I locally inject into the tissues a long-acting local analgesic combined with a narcotic (much as a dentist would inject into your mouth, however the anesthetic is much longer-lasting).  This greatly decreases pain for the first 18 to 24 hours after surgery and further decreases the need for IV narcotics.
  • During total or partial knee replacement surgery: the anesthesiologist also will inject a special local anesthetic which bathes the femoral nerve. This nerve is responsible for approximately 70 percent of the sensation to the knee.  This is a very effective way to minimize pain and is administered after the procedure but while the patient still is asleep in the operating room.
  • Also, for those patients having a total knee replacement: after the femoral nerve in the knee is bathed, the anesthesiologist will insert a very tiny catheter (about the diameter of the lead in a #2 pencil), which is attached to a battery-driven pump. The pump will continue to deliver a local anesthetic for two or three days post-surgery.
  • The morning after surgery, patients have breakfast and are given a schedule for two therapy sessions.  About 30 to 45 minutes prior to therapy, one to two pain pills (typically Tylenol with a narcotic) will be administered.
  • Patients are discharged from the hospital when they’re able to get out of bed by themselves, walk unaided to the bathroom and feel confident and comfortable. Typically, patients go home on the second or third day after surgery. Arrangements are made for patients to have pain medication available to them at home.  Many of my patients have told me that they felt more confident just having the pain medication on hand, even if they didn’t have to use it.

At the Leone Center and at Holy Cross Hospital, we are very sensitive to preventing and managing our patients’ pain. How each individual feels and reacts to pain can differ greatly.  Some people are very receptive to pain medications, while others are resistant. We tailor the pain regimen to each patient and make adjustments as needed, by monitoring closely and communicating with patients after surgery.

By managing pain, we facilitate physical therapy and all of the other post-operative practices that help our patients achieve the best range of motion and return to a full and active lifestyle.