Advances in Postoperative Pain Management

Patients decide to have their knees, hips and shoulders replaced when the debilitating effects of degenerative joint disease impact their daily lives, preventing them from performing even the most basic tasks. The procedures pay off in the long run, but patients must endure significant pain during the early days of recovery before realizing the life-changing benefits. Our multispecialty ambulatory surgery center is on target to perform more than 500 total joint replacements this year. We lean on the latest pain management techniques to help patients regain an active lifestyle as quickly and as comfortably as possible.

The success of total joints depends heavily on multimodal pain management, which involves the use of general and regional anesthetics — short- and long-acting neuromuscular blockades — to help diminish the level of pain patients experience postoperatively. The anesthesia providers who work  with our surgical team do an amazing job with preoperative neuromuscular blockades, especially for knee replacement patients. They place ultrasound-guided blocks with a long-acting anesthetic to numb the knee preoperatively, which helps to manage surgical pain during the case and provides pain relief during the initial recovery phase.

Five surgeons at the center perform total joints, and it isn’t always easy to get them to color within the same lines. However, they’ve agreed to a standardized course of preoperative medications that includes starting patients on either celecoxib or meloxicam, which is a prescription strength nonsteroidal anti-inflammatory drug (NSAID) that treats joint pain and inflammation. Patients are also given gabapentin, which can help limit nerve pain, as well as methocarbamol or cyclobenzaprine, which controls discomfort caused by muscle spasms.

We’ve made tremendous strides in pain management for our hip and knee replacement patients, who feel comfortable enough to walk out of the facility after surgery. To help manage post-discharge breakthrough pain in total knee patients, anesthesia providers place a catheter at the incision site that connects to a pain pump, which delivers a steady flow of the non-narcotic anesthetic bupivacaine. Pain pumps provide a targeted analgesic effect for three to four days post-op, during what is often the most painful stage of recovery. Their use is a key aspect of efforts to limit the use of opioids for the treatment of breakthrough pain.

Unfortunately, our total hip patients cannot benefit from the devices due to the location of the incision and the area in which they’ll experience pain. For these patients, we inject a bupivacaine liposome suspension at the incision site that provides pain relief for 36 to 48 hours. When the anesthetic bonds with water-soluble fat molecules, the body takes longer to break it down and metabolize it. In short, the single-shot injection performs like a long-acting analgesic.

We’re in the midst of launching a cryoneurolysis program, which has become another layer of our multimodal pain management efforts. Cryoneurolysis provides an effective, safe and non-pharmacological therapeutic option to treat pain in patients suffering from knee osteoarthritis. Anesthesiologists use ultrasound guidance to localize major sensory nerves in and around the knee, and employ cryotherapy to freeze the nerves, which provides temporary pain relief.

The cryotherapy device is a disposable localizing closed-ended needle that acts more like a probe. It uses compressed gas cartridges that send nitrous oxide through the length of the probe, which creates a tiny ice ball that freezes the myelin sheath around targeted nerves. Freezing that insulating layer interrupts the transfer of pain sensations to the brain. The average myelin sheath takes about 90 days to regenerate, so most patients feel relief for about three months.

Many patients who need knee replacements experience more issues with joint instability than significant pain, and cryotherapy will not make their knee more stable. However, patients who do have debilitating pain, which can impact their mobility leading up to surgery, benefit from the treatment because it can help them remain active, achieve and maintain muscle tone, and be in better physical condition prior to their procedures — factors that will also help speed their recoveries.

We began offering the treatments to select total knee patients in July and are slowly incorporating them into the pre-op care of all knee replacement patients. We’ve currently performed the procedure on more than 25 patients and have 27 more scheduled. The goal is to apply the treatment within 30 days of their surgery. We rely on the surgeons to select the best candidates, which include individuals who are having the most pain associated with degenerative joint disease.