SYMPOSIUM: ADVANCED TECHNIQUES FOR REHABILITATION AFTER TOTAL HIP
AND KNEE ARTHROPLASTY
Multimodal Pain Management after Total Hip and Knee
Arthroplasty at the Ranawat Orthopaedic Center
Aditya V. Maheshwari MD, Yossef C. Blum MD,
Laghvendu Shekhar MD, Amar S. Ranawat MD,
Chitranjan S. Ranawat MD
Published online: 13 February 2009
? The Association of Bone and Joint Surgeons 2009
in the last decade have had a major impact on the practice
of total hip and knee arthroplasty (THA and TKA).
Although there are a number of treatment options for
postoperative pain, a gold standard has not been estab-
lished. However, there appears to be a shift towards
multimodal approaches using regional anesthesia to mini-
mize narcotic consumption and to avoid narcotic-related
side effects. Over the last 10 years, we have used intra-
venous patient-controlled analgesia (PCA), femoral nerve
block (FNB), and continuous epidural infusions for 24 and
48 hours with and without FNB. Unfortunately, all of these
techniques had shortcomings, not the least of which was
suboptimal pain control and unwanted side effects. Our
practice has currently evolved to using a multimodal pro-
tocol that emphasizes local periarticular injections while
minimizing the use of parenteral narcotics. Multimodal
protocols after THA and TKA have been a substantial
Improvements in pain management techniques
advance; they provide better pain control and patient sat-
isfaction, lower overall narcotic consumption, reduce
hospital stay, and improve function while minimizing
complications. Although no pain protocol is ideal, it is
clear that patients should have optimum pain control after
TKA and THA for enhanced satisfaction and function.
Level of Evidence: Level V, expert opinion. See the
Guidelines for Authors for a complete description of levels
The Bone and Joint Decade (2001–2010) has been charac-
terized by exciting innovations in total hip and knee
arthroplasty (THA and TKA), including minimally invasive
techniques, computer-assisted procedures, advanced reha-
bilitation protocols, and improved perioperative pain
management. It is our opinion and the opinion of others that
recent improvements in pain management have been the
most substantial advances in the practice of total joint sur-
gery [11, 13, 18, 19, 22–24, 26, 34]. It is well-established
that more than half of all patients undergoing THA or TKA
may receive suboptimal pain control and may experience
severe pain inthe earlypostoperative period[6,8,9,15,29].
The International Association for the Study of Pain
(IASP) defines pain as ‘‘an unpleasant sensory and emo-
tional experience associated with actual or potential tissue
damage, or described in terms of such damage’’ .
Detailed descriptions of the pathways involved in pain
generation, perception, and physiologic responses have
been published by the American Academy of Orthopaedic
Surgeons [5, 25, 29]; nevertheless, pain is still a poorly
understood, complex phenomenon. Adequate pain man-
agement has become a priority in the minds of the public
No funding was received for this manuscript. However, the research
foundation of one or more of the authors (ASR, CSR) has received
funding from DePuy Orthopaedics (Warsaw, IN) and Stryker
Orthopaedics (Mahwah, NJ). One or more of the authors (ASR, CSR)
has received royalties from DePuy Orthopaedics (Warsaw, IN) and
Stryker Orthopaedics (Mahwah, NJ). ASR is a consultant for DePuy
Orthopaedics (Warsaw, IN) and Stryker Orthopaedics (Mahwah, NJ).
CSR is designer/consultant for DePuy Orthopaedics (Warsaw, IN)
and Stryker Orthopaedics (Mahwah, NJ).
Each author certifies that his institution has approved the human
protocol for this investigation and that all investigations were
conducted in conformity with ethical principles of research, and that
informed consent for participation in the study was obtained.
A. V. Maheshwari, Y. C. Blum, L. Shekhar,
A. S. Ranawat (&), C. S. Ranawat
Hospital for Special Surgery, 535 East 70th Street, 6th floor,
New York, NY 10021, USA
Clin Orthop Relat Res (2009) 467:1418–1423
and the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) [15, 32]. Pain, which has become
the ‘‘fifth vital sign’’ in the view of the JCAHO, demands
consideration in the care of the patient, including taking
account of pain in the discharge decision as well as in the
entire inpatient and outpatient course .
The importance of pain, however, extends far beyond the
humanitarian and ethical aspects of inadequate pain control.
The consequences of severe postoperative pain are pro-
longed hospital stays, increased hospital readmissions, and
increased opioid use with a subsequent increase in postop-
erative nausea and vomiting, resulting in overall low patient
satisfaction and potentially greater cost . Additionally,
arthrofibrosis and diminished range of motion are closely
related to the degree of postoperative pain [27, 30]. Pain
demands treatment, and failure to provide adequate treat-
ment can result in medicolegal action .
Although several treatment options involving various
combinations of systemic analgesics and/or regional anal-
gesia with or without opioids are available for postoperative
pain, a gold standard has not been established. However,
there does appear to be a shift towards multimodal
approaches which provide adequate analgesia while mini-
mizing opioid-related side effects [11, 19, 22–24, 32, 34].
We will outline the experience at The Ranawat Ortho-
paedic Center with postoperative pain management over
the last 10 years, emphasizing how and why our pain
protocol has evolved to the current multimodal approach.
Our Experience with Multimodal Pain Protocols
Our pain management protocol after THA and TKA has
undergone multiple modifications over the last 10 years
[26, 27]. Regional anesthesia has now taken precedence
over general anesthesia. Initially, we used epidural catheter
infusions with and without patient-controlled epidural
analgesia (PCEA) for 24 hours, but found many patients
suffered rebound pain; we subsequently extended its use
for 48 hours. We then employed combinations of epidural
infusion and femoral nerve blocks, and femoral nerve
blocks in conjunction with or without intravenous patient-
controlled analgesia (IV PCA). Unfortunately, all of these
techniques had shortcomings, not the least of which was
suboptimal pain control and unwanted side effects [1–4,
12, 21, 30, 31, 37]. The major side effects that we have
often observed included respiratory depression, nausea,
vomiting, ileus, urinary retention, pruritis, hypotension,
bradycardia, and cognitive changes.
Multimodal analgesia is a multidisciplinary approach to
pain management with a goal to maximize the analgesic
effect and minimize the side effects of the medications [11,
16, 19, 22–24, 32, 34]. It takes advantage of the additive or
synergistic effects of various analgesics, permitting the use
of smaller doses with a concomitant reduction in side
effects. Because many of the negative effects of analgesic
therapy are related to parenteral opioids , limiting its
use is a major principle of multimodal analgesia.
Over the past decade, a greater understanding of pain
mechanisms has led to the concept of preemptive analgesia
. Preemptive analgesia involves the administration of
analgesics prior to painful stimuli to prevent the estab-
lishment of central sensitization and thus the amplification
of postoperative pain. It starts before surgery and covers
both the period of surgery and the initial postoperative
Another new concept is the evolution of the pain service
. Acute pain management services include caregivers
trained to formulate and provide safe and effective therapy.
We believe standardized therapy should be introduced and
maintained using specific protocols, with nursing education
generally is multidisciplinary and multidepartmental and
consists not only of surgeons and anesthesiologists, but also
nurses, pharmacists, and physician and nursing assistants.
Thus, the primary goal of modern pain management is to
reduce pain at both the central and the peripheral levels, in
combination with preemptive analgesia using a multimodal
protocol. This strategy should enhance restoration of
function by allowing patients to participate in the rehabil-
itation programs more easily, thereby improving the overall
Currently, our practice has evolved to using a multi-
modal protocol which emphasizes local, periarticular
injections, while minimizing the use of parenteral narcotics
(Table 1) [22, 23].
Table 1. Ranawat Orthopaedic Center (ROC) cocktail
Bupivacaine0.5% (200–400 mg) 24 cc
Morphine sulphate 8 mg
Epinephrine (1:1000)0.3 cc
Cefuroxime750 mg 10 cc (reconstituted
in normal saline)
Sodium chloride 0.9%22 cc
Sodium chloride 0.9%20 cc
Clonidine transdermal patch applied in operating room (100 lg/24
hours). No steroid in diabetics, immunocompromised, elderly
([80 years) or revisions. Vancomycin used if patient allergic to
Volume 467, Number 6, June 2009Multimodal Pain Management after THA and TKA1419
Importance of Patient Education
Patients who undergo joint replacement often have unre-
alistic preoperative expectations of recovery, including
those for pain and function, which may lead to high levels
of dissatisfaction [10, 20]. The preoperative class is one of
the best techniques available to educate patients and their
families because it provides information on what will
happen to them throughout the whole process and sub-
stantially eases the fears that the patient may be
experiencing . We have found it beneficial for patients
and their families to learn in a classroom setting with other
patients undergoing the same type of procedure. We
believe preoperative booklets and videos improve the
patients’ expectations, especially if verbally reinforced.
The patients have a better idea of what to expect, as they
meet the team members and have interactive discussions
with them. Patients may thus experience less pain because
they are better prepared to cope with pain. It is essential to
decrease a patient’s anxiety, as this may increase his or her
sensitivity to pain.
General versus Regional Anesthesia
Hypotensive regional anesthesia has been associated with
fewer complications, as compared with general anesthesia.
Apart from lowering the blood loss and preventing deep
vein thrombosis, regional anesthesia avoids central nervous
depression, has a different spectrum of effects on the car-
diopulmonary system, may modify the stress response to
surgery, provides excellent pain relief, and allows early
painless range of motion and weight bearing, enhancing
overall patient satisfaction [13, 17, 28, 36]. For the vast
majority of our patients, hypotensive regional anesthesia is
utilized; we reserve general anesthesia for rare instances in
which the anesthesiologist is unable to perform the spinal
or epidural anesthesia for medical or technical reasons (eg,
severe lumbar degenerative disease).
A variety of single-dose and continuous-infusion neuraxial
(epidural or spinal) techniques may be applied to provide
pain control after THA and TKA and we have tried them
Single Dose Spinal and Epidural Opioids
Neuraxial opioids provide superior analgesia compared
with systemic opioids, but may also be associated with
potentiation of the previously mentioned adverse effects
, as has been our experience. The onset and duration is
determined by lipophilicity of the drug . Lipophilic
opioids such as fentanyl provide a rapid onset of analgesia,
limited spread within the cerebrospinal fluid (and less
respiratory depression), and rapid clearance and resolution.
Conversely, hydrophilic opioids such as morphine and
hydromorphone have a longer duration of action but are
associated with greater frequency of side effects as well as
delayed respiratory depression. A sustained-release for-
mulation of epidural morphine has recently become
available; however, we do not recommend this, as it has
been associated with respiratory depression .
Epidural analgesia may consist of a local anesthetic, an
opioid, or a combination of both. A pure opioid epidural
infusion may not provide adequate analgesia, and a pure
local anesthetic may provide dense sensory and motor
blockade, such that the patient may not be able to walk or
void in the early postoperative period . Thus, a combi-
nation of an opioid and a local anesthetic creates a
synergistic analgesic effect that allows lower concentration
of each component in the solution [4, 11].
Continuous low-dose infusion has been advocated as a
method to control postoperative pain . Continuous
infusion permits analgesia to be more precisely titrated to
the level of pain stimulus and rapidly terminated if prob-
lems occur. The technique avoids peak concentrations that
follow intermittent boluses and reduces the risk of rostral
cerebral spinal fluid spread and delayed respiratory
depression. Epidural infusions provide superior analgesia
but are also associated with technical failures, hypotension,
ileus, urinary retention, motor block that limits ambulation,
unrecognized compartment syndromes, and spinal hema-
toma secondary to anticoagulation [7, 11, 13, 32]. Based on
these drawbacks, we do not routinely employ epidural
infusions in the postoperative period.
A Cochrane database review concluded that epidural
analgesia may be useful after TKA and THA for pain
control, but the benefit must be weighed against the fre-
quency of adverse effects . In our unpublished
prospective study (presented at the 29th Annual Meeting of
the American Society of Regional Anesthesia and Pain
Medicine, March 11–14, 2004, Walt Disney World Swan
Resort, Orlando, FL), 87 patients with TKA were ran-
domized to receive either a femoral nerve block in the
operating room and a bolus on first postoperative day
(Group 1), a combination of continuous epidural infusion
for 24 hours followed by a bolus of femoral nerve block
(Group 2), a continuous epidural infusion for 24 hours
1420Maheshwari et al. Clinical Orthopaedics and Related Research
(Group 3) or a continuous epidural infusion for 48 hours
(Group 4). Groups 1, 2, and 3 received IV PCA as well.
The epidural failed in 20% of cases. Although there was no
difference in pain score based on visual analogue scale
(VAS) between groups 1, 2, and 4, groups 1 and 4 had the
most satisfactory pain control. The worst pain control was
after removal of the epidural catheter at 24 hours (Group 3)
secondary to rebound pain. Less frequent urinary retention
occurred in Group 1. The incidence of nausea and vomiting
was similar between the groups. However, the consumption
of morphine equivalents was different in all groups, and
was highest in Group 1 and lowest in Group 4.
PCEA offers higher analgesic efficacy and lower dose
requirements than IV PCA and provides greater control and
patient satisfaction than do either single-dose or continuous
infusions. However, despite better pain control, patients
still prefer IV PCA because of fewer technical problems
and side effects, and more uniform and sustained analgesia
with more autonomy . We no longer utilize PCA or
PCEA, as we have found both modalities associated with
high rates of the opioid side effects mentioned earlier.
As a result of these findings, we began experimenting
with local periarticular injections in 2004.
Intraoperative Periarticular Injection
We inject a steroid-containing local anesthetic (Table 1)
periarticularly in all the soft tissues surrounding the hip and
knee. The steroid prevents local inflammation, and mor-
phine stimulates all three opiate receptors (l, ð, and k) in
the joint with less adverse systemic effects [18, 19, 22, 23,
33, 34]. Epinephrine prolongs the action of local agents by
decreasing absorption by vasoconstriction via its a-adren-
ergic effect. We consider these injections the most
important and effective component of this pain protocol
[22, 23]. Clonidine exerts its effect via its a-2 adrenergic
actions and results in potentiation of the synergistic action
of local anesthetic and local steroids . Transdermal
application of clonidine allows sustained action for several
days while minimizing potential adverse effects, including
bradycardia and hypotension .
Between October 2005 and October 2006, we enrolled
36 patients undergoing THA along with 35 controls and
31 patients undergoing TKA and 29 controls were enrol-
led in a prospective randomized study with or without a
periarticular injection [22, 23]. Patients in the hip study
group had lower pain scores and better satisfaction scores
(both with p\0.05) on each day of hospitalization.
Further, the overall narcotic consumption was lower in
this group. More patients in the study group (52%) were
able to do active straight leg raise (ASLR) on postoper-
ative day 1. Similarly, the mean duration of hospital stay
was less in the study compared to the control group (3.2
versus 4.2 days, respectively). The knee control group
consumed the highest amount of narcotics in this study.
Functionally, the study group was better able to perform
ASLR on Day 1 than the control group (63% versus 21%,
The goals of the postoperative protocol include adminis-
tration of a variety of agents with different mechanisms of
action which exert local and systemic effects, use of agents
with combined antiinflammatory and analgesic properties,
early conversion of parenteral to oral agents with pro-
longed effect, use of baseline analgesia to provide more
uniform pain control, and minimization of parenteral nar-
cotics and associated adverse effects. We administer three
doses of toradol (30 mg IV if less than 65 years old, 15 mg
IV if over 65 years old), unless the patient has renal
insufficiency. This is augmented with intermittent doses of
morphine sulfate at 15 minute intervals (2 or 4 mg), but
only if the toradol was deemed ineffective. Oxycontin
(oxycodone HCl, Purdue Pharma L.P., Stamford, CT)
(10 mg or 20 mg) is begun as soon as the patient can tol-
erate oral medication, and oxycodone is administered on a
PRN basis. Acetaminophen 1000 mg orally is administered
as standing doses every 6 hours. Celebrex (celecoxib,
Pfizer Inc., New York, NY) (200 mg once daily) is started
8 hours after the last toradol dose and continued for
10 days total. Pantoperazole 40 mg orally is given daily for
Deep Vein Thrombosis Prophylaxis
All patients receive 1000 IU of heparin during femoral
preparation. The subsequent protocol depends on whether
we consider the patients at high or low risk. Patients we
consider high risk include those with a history of prior
thromboembolic events, substantial obesity, and those who
we judge less mobile. For patients that we deem at high
risk for thromboembolic complications, we administer
warfarin with a target INR of 1.5 to 2 (in order to minimize
bleeding complications, especially at the wound site).
Patients who we consider at low risk are given enteric-
coated aspirin 325 mg twice a day for 6 weeks. All patients
also get bilateral pneumatic compression devices in the
immediate postoperative period. A Doppler study is per-
formed for patients with calf pain, tenderness, or swelling.
Patients with a positive scan are continued on warfarin for
Volume 467, Number 6, June 2009 Multimodal Pain Management after THA and TKA 1421
Patients are mobilized out of bed on the first postoperative
day. A continuous passive machine (CPM) is started on all
uncomplicated TKA cases on the first postoperative day.
Patients are discharged after they attain the goals of
walking independently with support for at least 50 feet,
transferring independently in and out of bed and toilet, and
having at least 70? to 80? of flexion for TKAs. Most
patients attain such flexion by the third postoperative day.
All patients have access to physiotherapy after discharge:
for patients discharged home we arrange sessions with a
physical therapist near their home prior to discharge and
for patients discharged to a rehabilitation facility physio-
therapy is performed there. The patients are instructed to
walk every day, gradually increasing their distance with an
eventual goal of 1 mile by 2 months. We encourage dis-
charge to home rather than a rehabilitation facility. Patients
are made weight bearing as tolerated and use crutches or a
walker until they are able to easily ambulate with a cane.
At 6 weeks postoperatively, patients are allowed to walk
without a cane in the house and for short walks; a cane is
encouraged for longer walks.
Over the years, our aim has been to determine the optimal
regimen to control postoperative pain while limiting the
side effects of medications. We have described how our
pain protocol has evolved, and we have detailed how pain
is managed today at the Ranawat Orthopaedic Center.
Achieving a nearly painless TKA and THA is within
reach using regional anesthesia and multimodal pain
management techniques. Patients have greater satisfaction
with their operation when they avoid the complications
caused by parenteral narcotics. Further, with the multi-
modal approach, the safety of the operation is enhanced by
reducing complications such as respiratory depression,
nausea, vomiting, ileus, urinary retention, pruritis, hypo-
tension, bradycardia, and cognitive changes. It is for these
reasons that a multimodal pain program with periarticular
injection has been a substantial advance in perioperative
pain care after TKA and THA.
Unfortunately, we have still not achieved the ideal
technique; we have not eliminated the use of opioids, nor
have we eliminated pain during the postoperative period
entirely. Further research must be conducted to determine
how best to eliminate pain without the use of medications
that cause unwanted side effects. In addition, additional
prospective randomized trials that evaluate innovative
protocols such as ours against well-studied regimens (eg,
PCA, PCEA) are needed. We believe some of the
most exciting developments will be in the realm of pain
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