New pain management strategies key to maximizing patient outcomes after TKR procedures

According to a new literature review in the February issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), a team-based care approach (consisting of the patient, family members, the orthopaedic surgeon and other medical practitioners) on total knee replacement (TKR) procedures, in conjunction with newer pain management strategies, is key to maximizing patient outcomes.

Arthritis of the knee impacts approximately 50 percent of Americans over the age of 60. "TKR is a highly successful procedure used to treat symptomatic knee arthritis that's not responsive to nonsurgical treatments like injections, weight loss, physical therapy and non-narcotic medications," says lead study author and orthopaedic surgeon Calin S. Moucha, MD, chief of adult reconstruction and joint replacement surgery at The Mount Sinai Hospital in New York City.

"Managing post-surgical pain is key to promoting early postoperative mobility, reducing medication side effects, and increasing patient satisfaction," says Dr. Moucha.

Traditional pain management for TKRs include a computerized pump called the patient-controlled analgesia (PCA) with or without an epidural which can lead to nausea, vomiting, urinary retention, low blood pressure, constipation and itching. Newer pain-control strategies--referred to as multimodal protocols--more effectively manage pain and limit side effects. These include:

• a combination of pain management medications (e.g., oral medications and nerve blocks) taken before and after surgery;
• regional anesthesia with pre-operative nerve blocks performed by an anesthesiologist; and,
• intra-operative pain injections performed by the orthopaedic surgeon within the knee.

Multimodal protocols are found to:

• lower patient pain severity ratings in the first few days following surgery;
• minimize unwanted side effects more commonly associated with traditional pain control protocols;
• reduce the overall amount of narcotic pain medication needed for postoperative pain control; and,
• help patients be better able to participate in early postoperative physical therapy and be more satisfied with their postoperative pain control.

The study authors also note that:

• patients should avoid long-term chronic narcotic use for knee arthritis pain control prior to surgery because it can lower the patient's pain threshold and result in increased postoperative pain;
• patients should not abruptly stop oral medications as there is a risk of rebound pain and the development of chronic pain. Many patients will use their prescribed medicines for least the first two weeks after surgery, then taper off as tolerated;
• pain medication may be necessary beyond the first two weeks for certain activities such as physical therapy sessions, but first speak to your orthopaedic surgeon about this; and,
• a strong support system (family, friends, or a combination of both) can be very helpful to the patient in achieving the quickest recovery and return home.