Multimodal Pain Management after Total Hip and Knee Arthroplasty at the Ranawat Orthopaedic Center

Hospital for Special Surgery, 535 East 70th Street, 6th floor, New York, NY 10021, USA.
Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 03/2009; 467(6):1418-23. DOI: 10.1007/s11999-009-0728-7
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Improvements in pain management techniques 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 established. However, there appears to be a shift towards multimodal approaches using regional anesthesia to minimize narcotic consumption and to avoid narcotic-related side effects. Over the last 10 years, we have used intravenous 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 protocol that emphasizes local periarticular injections while minimizing the use of parenteral narcotics. Multimodal protocols after THA and TKA have been a substantial advance; they provide better pain control and patient satisfaction, 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 of evidence.

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Available from: Amar S. Ranawat, Jul 09, 2014
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    • "Recently, significance of multimodal approaches including regional anesthesia, patient-controlled intravenous or epidural analgesia, and local periarticular injection has been addressed in literatures.11-15 In 2009, Maheshwari et al. reviewed clinical experiences in their institute over the last 10 years and stated that perioperataive pain management has been the most substantially advanced area in the recent progress in the practice of total joint surgery.16 "
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    ABSTRACT: Thirty-six patients who underwent primary unilateral total hip arthroplasty (THA) were randomly allocated to 4 groups with different pain control protocols; continuous femoral nerve block (FNB group), single-shot caudal epidural block with morphine (EB group), intravenous patient-controlled analgesia with fentanyl (IV-PCA group), and systemic administration of nonsteroidal anti-inflammatory drugs (NSAIDs group). Postoperative pain was assessed using the numerical rating scale (NRS) scores and the analgesic effect was compared among the groups. The NRS upon arrival at the recovery room and 6 hours after surgery in the FNB, EB, and IV-PCA groups were significantly lower than that in the NSAIDs group. The amount of additional analgesics requested by the patient was smaller in the FNB, EB, and IV-PCA groups as compared to the NSAIDs group. Regarding the complications related to the analgesia, 5 of the 9 patients in the IV-PCA group complained nausea and vomiting and received antiemetic drugs. Delay in the rehabilitation process due to drowsiness was encountered in 3 patients in this group, while no patient in the FNB and EB groups suffered from delayed rehabilitation. Considering both the analgesic effect and the potential risk of complications, continuous femoral nerve blocks and caudal epidural blocks for are recommended for postoperative pain control after THA procedure.
    Orthopedic Reviews 01/2014; 6(1):5138. DOI:10.4081/or.2014.5138
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    • "Postoperative pain following total hip replacement arthroplasty is usually moderate to severe in nature. Adequate postoperative pain management is essential for early rehabilitation [1] [2]. "
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    ABSTRACT: Background The aim of this study was to investigate the effect of intravenous infusion vs intrathecal magnesium sulfate during spinal anesthesia on postoperative pain, analgesic consumption, and intraoperative blood loss on patients undergoing total hip arthroplasty surgery. Methods In this prospective randomized controlled study, 75 adult patients, ASA physical status I and II scheduled for total hip arthroplasty, were included and randomized into three groups. Patients in Group I (control) received spinal anesthesia with hyperbaric bupivacaine and fentanyl. In Group II (IT Mg), 50 mg of magnesium sulfate was added to bupivacaine and fentanyl. In Group III (IV Mg), after induction of spinal anesthesia as in group I, a bolus dose of i.v. magnesium sulfate 40 mg kg−1 was injected over 10 min, followed by continuous infusion of 15 mg kg−1 h−1 till the end of surgery. Arterial blood pressure, heart rate, electrocardiography, and O2 saturation were continuously monitored. Onset, duration of sensory and motor block, and postoperative pain scores were assessed. Serum magnesium concentrations were checked before induction of anesthesia, immediately after surgery, at 6 h and 24 h after surgery. Total analgesic consumption and intraoperative blood loss were calculated. Results There were no significant differences between the study groups in terms of onset time and maximum sensory level achieved, as well as onset and duration of motor block. Postoperative pain scores and 24 h analgesic consumption were lower in group II and III with insignificant differences between them. Intraoperative blood loss was significantly lower in group III. Postoperative Mg levels were higher in group III, without significant side effects. Conclusions Both i.v. infusion and intrathecal injection of Mg sulfate improved postoperative analgesia after total hip replacement. In addition, i.v. infusion of Mg sulfate reduced intraoperative blood loss.
    Egyptian Journal of Anaesthesia 10/2013; 29(4):395–400. DOI:10.1016/j.egja.2013.06.004
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    • "irmed the effect of periarticular anesthesia. Maheshwari et al. reported that intraoperative infiltration of ligaments, tendons and other parts of the knee joint with a combination of bupivacaine, methylprednisolone, morphine, epinephrine and cefuroxime enabled significant improvement, not requiring additional redression or extended rehabilitation. 6 "
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    ABSTRACT: The aim of the study was to assess the effect of different types of anesthesia on pain intensity in early postoperative period. A total of 87 patients (77 women, 10 men) scheduled for total knee arthroplasty (TKA) were assigned to receive either subarachnoid anesthesia alone or in combination with local soft tissue anesthesia, local soft tissue anesthesia and femoral nerve block and pre-emptive infiltration together with local soft tissue anesthesia. We assessed the pain intensity, opioid consumption, knee joint mobility, and complications of surgery. Subjects with pre-emptive infiltration and local soft tissue anesthesia had lower pain intensity on the first postoperative day compared to those with soft tissue anesthesia and femoral nerve block (P=0.012, effect size 0.68). Subjects who received pre-emptive infiltration and local soft-tissue anesthesia had the greatest range of motion in the operated knee at discharge (mean 90 grades [SD 7], P=0.01 compared to those who received subarachnoid anesthesia alone, and P=0.001 compared to those with subarachnoid together with soft tissue anesthesia). Despite the differences in postoperative pain and knee mobility, the results obtained throughout the postoperative period do not enable us to favour neither local nor regional infiltration anesthesia in TKA. Level of Evidence II, Prospective Comparative Study.
    Acta Ortopédica Brasileira 03/2013; 21(5):262-5. DOI:10.1590/S1413-78522013000500004 · 0.19 Impact Factor
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