Pain management: How we continue to improve our multimodal approach for better post-operative pain control

At The Leone Center for Orthopedic Care we continue to evolve our strategies to help our patients minimize pain after hip or knee replacement surgery. This includes pre-operative education because we see repeatedly that patients who go into surgery better prepared and knowing what to expect after their surgery, tend to have less pain with a faster, easier recovery and also a better experience. That is our goal.

Our multimodal strategy is designed to preempt and down-regulate pain. Medications are chosen from different classes of drugs and have an effect through varying pathways and mechanisms. This starts with several different medications prescribed prior to  the start  of surgery. Other drugs are administered during the procedure and after the surgery. These include pre and post-operatively administering a steroid, Tylenol, a NSAID, a narcotic, and Lyrica. These medicines work together and individually, down-regulating pain at the receptor site locally and through a central mechanism. IV fluids are also given to maintain an optimal intravascular volume. Medications are also given to prevent post-operative nausea and sometimes a medicine to help make urinating easier after surgery.  Ice or a cold circulation water cuff also helps decrease swelling and pain. Initially, these medicines are given on a schedule and only after several days on an “as needed or PRN” basis.

So, what’s changed since the prior blog articles I’ve written on this subject of pain management? We are now giving Tylenol by mouth (PO), not intravenously (IV). To be honest, this decision and some others have been forced on physicians due to financial realities. These decisions were   based on an extensive literature review where efficacy was found equivalent. That is taking Tylenol by mouth is as effective as IV with considerably less cost. Critically important is the dosage and scheduled consistency when it is administered. Clinically, patients are comfortable, happy and doing very well.

In a prior blog I wrote about Exparel, a local analgesic surrounded by fat molecules to promote the slow release of a local anesthetic into tissues over 12-36 hours. A number of carefully controlled, double blinded, well designed studies failed to show significant differences in terms of pain control or speed in which patients were able to rehabilitate and reach milestones compared to other cocktails that did not include the Exparel.  While once again, financial pressures have pushed these changes, they were based on an extensive review of medical literature. This new “cocktail” of medicines which we’ve been injecting also includes Ketamine. Once again, clinically patients are doing very well, walking hours after surgery and going home quickly.

Ketamine is a medicine which when given IV in very low levels just before the start of surgery, decreases pain, potentiates (that it makes other medicines makes more effective or more active)  other meds including narcotics and results in less narcotics being required.  Avoiding narcotics has many advantages. Too much narcotics can cause mental cloudiness, constipation, respiratory suppression, addiction and more.  Ketamine also significantly lowers narcotic needs in those patients who have built up a resistance or tolerance to narcotics by chronically taking them. On a selective basis, our anesthesiologist gives a low dose Ketamine to our patients. As described above, we’ve recently started adding very low levels of Ketamine to the “cocktail” that we inject into the tissues around a prosthetic knee. This is combined with a local anesthetic and Toradol (a NSAID).  Again, it is proving very effective. Clinically, I see patients recovering very quickly because they’re comfortable.

Patients who are receiving total knee or partial knee replacements are also treated with an adductor nerve block to further minimize pain. A local anesthetic is injected into a specific area of the thigh called the adductor canal, which is located about a hand width  above the knee joint. Multiple sensory nerves that supply sensation to the knee pass through the adductor canal. The adductor canal and structures that pass thought it are precisely located using ultrasound. This results in a pure sensory block and has proven wonderfully effective in further decreasing post-operative pain, especially when combined with the local “cocktail” which is injected.

When patients awake after surgery comfortable and clear headed, they walk just hours after surgery which makes their surgery safer (lessens chance of a blood clot or DVT). It also gives them gives them confidence and allows them to go home that day or the next where invariably people are happier.  

While change and refinement is inevitable and important, it critical that any changes enacted are well thought out, equivalent or better than what was being done before and are being driven by a commitment for better patient care. I define better patient care as a faster, easier recovery and my patients telling me they had absolutely as good an experience as possible and they thank me.

Dr. William A. Leone is head of The Leone Center for Orthopedic Care at Holy Cross Hospital in Fort Lauderdale, Florida and has earned a reputation as one of the nation’s top orthopedic surgeons. An experienced orthopedic surgeon, his specialty is solving complex hip and knee problems. Call 954-489-4575 or visit HolyCrossLeoneCenter.com to schedule a consultation.