Proven Ways to Prevent Post-op Pain

Patient Experience Pain Management Healthcare IT Orthopedics

By: Joe Paone | Senior Editor

Published: 9/22/2022

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Cryoanalgesia and individualized multimodal regimens help orthopedic patients recover comfortably and largely opioid-free.


With a targeted treatment plan in place, your patients won’t need to rely on complication-laden, potentially addictive opioids to recovery from painful and traumatic orthopedic surgeries. Alexander Sah, MD, an orthopedic surgeon at Sah Orthopaedic Associates in Fremont, Calif., says new pain management protocols are providing longer-term relief for patients before, during and after surgery — including the first few days of recovery when pain is usually at its worst. Here are two key approaches an increasing number of orthopods like Dr. Sah are employing to ensure successful opioid-sparing post-op recoveries for their patients.

• Cryoanalgesia. A simple and intuitive proposition: Freeze targeted nerves for weeks or months to cut off pain signals to the brain while leaving muscles at full strength. Cryo can prepare patients for surgery and keep their pain under control long afterward.

Robert Limoni, MD, an orthopedist at Holy Family Memorial (HFM) Lakeshore Orthopaedics Total Joint Clinic, a partner of The Froedtert & the Medical College of Wisconsin health network in Manitowoc, Wisc., has completed thousands of joint replacements over the last two decades, with a particular focus on optimizing patient outcomes after hip and knee surgeries. Right after cryo became FDA-approved for use prior to knee surgeries, he became one of the first surgeons in the Midwest to employ it.

Dr. Limoni likens cryo to placing an ice cube next to the nerve, which stuns and freezes it, and generally provides pain relief for about three months. He believes the treatment, which he calls a “game-changer,” has directly led to many patients rehabbing more quickly and with fewer opioids. “Our whole pursuit is the narcotic-free total knee,” he says. “I do think that is attainable, and cryo is a big player in that.”

While there are potential risks — such as bruising, frostbite and swelling around the treated area that could lead to permanent nerve damage, infection or hematomas — Dr. Limoni says these are largely due to provider inexperience and can usually be avoided with the precision of ultrasound guidance. “Ultrasound enables more directed treatments that are less invasive to the soft tissues by allowing you to visualize the branch of the nerves and place the cold probe directly at the nerve in just a couple spots, as opposed to just picking a location in the leg where the nerves are and doing a pattern that covers a broad area,” he says.

Dr. Limoni’s advanced practitioners usually apply the cryo treatment, which takes around a half-hour, to patients about a week before surgery. “Patients simply walk out afterward, and probably three-fourths of them have near-immediate pain relief,” he says. 

This long-lasting treatment is also helpful for patients who require significant preoperative optimization and interim relief. “When someone isn’t optimized for surgery — they need to lose weight, stop smoking or have another procedure done prior — we’ll use cryo to buy time,” says Dr. Limoni.

Cryo treatments work well in conjunction with perioperative regional blocks of much shorter duration to keep pain at bay for weeks postoperatively. “Blocks provide relief for the first 24 or maybe 48 hours, but then you’re relying on narcotics to get patients through the first two weeks of recovery,” says Dr. Limoni.

Cryo positively impacts the rehab process, too, according to Dr. Limoni. “That first two months is essential to getting range of motion back, and patients who really struggle with this have unacceptable pain levels,” he says. “They don’t want to move their knee and end up having long-term consequences. By adding cryo to their treatment plan, we see a lot less patients having issues with stiffness, needing closed manipulations or having suboptimal outcomes.” The treatments also allows patients to avoid narcotic side effects such as dizziness and urinary issues that can cause falls and delay rehab and healing. It also reduces the likelihood of blood clots.

Despite all the benefits, there are reimbursement challenges associated with cryo treatments due to its limited usage in a clinical setting. “Insurance approval has been a challenge,” says Dr. Limoni. “One issue is that it’s difficult to get large amounts of data and prospective studies on it, and payers want large amounts of data to prove value.” Still, Dr. Limoni and his facility leader believe in the treatment and are committed to using it for their patients when it’s appropriate to do so.

CONSTANT IMPROVEMENT Dr. Alexander Sah consistently investigates and employees a variety of technologies that are helping his joint replacement patients recover more quickly and with better post-op pain management.  |  Alexander Sah

• Multimodal medications. In addition to cryo, Dr. Limoni’s pain management protocol involves about a third of the opioids he once prescribed. “Three to seven days before surgery, patients take pregabalin and an NSAID that is a COX-2 inhibitor. I always start the medications preemptively because I don’t want to add new ones on the day of surgery,” he says. “The last thing my patients need to develop is a side effect that will affect their initial outcome.”

In the perioperative suite, he orders a preoperative adductor block with a spinal. Intraoperatively, a pericapsular injection, usually with bupivacaine, is administered. He does not use IV narcotics intraoperatively or immediately postoperatively to avoid dizziness, breathing issues, PONV and other complications that may require hospital admission.

“I no longer give patients a postoperative narcotic, which is a fairly common practice,” he says. Instead, his patients receive oral tramadol with acetaminophen after surgery. “If that’s not effective, on occasion we will use hydrocodone, and on rare occasions, oxycodone,” he says.

While recovering and rehabbing, Dr. Limoni’s patients continue with NSAIDs, and take aspirin for DVT prophylaxis if they are mobilizing within a few hours of surgery; if not, he puts them on a stronger blood thinner. The multimodal regimen is tailored to each patient, a regimen change which Dr. Limoni says ultimately benefits surgical outcomes. “One thing I’ve changed in my practice in the last five years is not treating everyone the same with multimodal pain management,” he says. “Traditionally, I think orthopedic surgeons were fairly regimented —the same blood thinner, the same pain pills, the same number of pills — but not every patient responds equally.”

Acetaminophen is the foundation of Dr. Sah’s multimodal protocol. “Studies have shown that when you combine acetaminophen with other medications such as an NSAID and an anti-inflammatory, you get a better overall synergistic pain-relieving effect,” he says. Around the time of surgery, he uses a gabapentinoid for nerve pain, which research suggests provides some postoperative relief while reducing opioid requirements. He also employs spinal anesthesia in lieu of intraoperative opioids and uses a local anesthetic cocktail that varies depending on the patient. “I’m currently using bupivacaine plus meloxicam in a topical formulation used prior to wound closure,” he says, adding that tranexamic acid is used to help stabilize blood clotting and reduce blood loss after surgery.

Swelling causes more pressure and more pain, so if you can handle the tissues well, minimize bleeding and then use a medication like tranexamic acid on top of it, patients may have less swelling and less overall pain as well.”

As beneficial as cryo and individualized multimodal regimens can be in reducing or preventing post-op pain, providers must first set realistic expectations with their patients. “If someone goes into surgery expecting their pain to be zero when they wake up, versus someone who’s more realistic and understands they’re undergoing major surgery, those two people have very different expectations of their pain management in terms of what they need and what their goals are,” says Dr. Sah.

You want pain to be tolerable and manageable, but you don’t want patients to think they’re going to have zero pain, he says, adding that informing and educating patients about pain management before surgery empowers them to become the managers of their own recovery pathways. Such empowerment often leads to reduced questions and concerns from patients postoperatively, according to Dr. Sah. “We used to have three follow-up visits after our joint replacements,” he says. “Now it’s typically two, simply because our other strategies are producing more predictable and faster recoveries.” For post-op communication, Dr. Limoni uses an automated text system to keep patients engaged. “That’s been key in reducing the burden on the office and the staff,” he says. “Improved pain management, automated messaging and preoperative education has been a game-changer in terms of a reduced load of phone calls at our office.”

Dr. Sah says the key to success in post-op pain management for ortho facilities is to realize a one-size-fits-all proposition isn’t the answer. “Look at all of the different factors and put together a comprehensive and diverse protocol for your patients,” he says. “You can have the most complex and wide-reaching protocol, but that doesn’t mean it necessarily will work for everybody. You need to adapt and listen to the patient.”

He says preparation and adaptability are paramount. “Give the pain management plan to the patient and share the expectations of what will work, how it will work and what level of discomfort you expect them to have,” says Dr. Sah. “If your intended treatments don’t seem to work, you need to adapt quickly. You need to be nimble.”

This agile process improvement continues for orthopedic surgeons. “We’re always looking at what’s new and what’s better, and trying those things to give patients their best first step forward with pain management without opioids,” says Dr. Sah. OSM

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