Knee Surgery and Knee Pain Sufferes may receive help with new medical pproccedure.Â
An aggressive, multi-modal approach to pain management for total joint replacement can reduce patients’ use of opioids and perhaps even speed their recovery.
“I think this is the biggest improvement in patient care in my experience of 30 years of total joint replacement surgery,” Dr. Chitranjan Ranawat, chairman of orthopedic surgery at Lenox Hill Hospital in New York, said in a press conference.
Dr. Ranawat said he believed recent improvements in pain control were more significant advances than the less invasive joint replacement techniques introduced in the last several years, which have yet to show a clear advantage in randomized trials.
He discussed preliminary results from 83 patients enrolled in a randomized trial comparing intraoperative periarticular injections with postoperative patient-controlled analgesia (PCA) for total hip replacement and PCA plus femoral nerve block for total knee replacement.
The injections combined bupivacaine, morphine, epinephrine, prednisolone and cefuroxime, and were given with a clonidine transdermal patch to help potentiate the effects of the other agents.
Hip patients who received the injection reported significantly less pain on the 10-point visual analogue scale (3.8 versus 5.6), and 52% could lift their leg on the first postoperative day compared with 15% in the PCA group. Patient satisfaction was also higher and hospital length of stay was reduced by one day.
The lower reported pain levels in the knee injection patients had not yet reached statistical significance; however, 63% could straight-leg raise, compared with 21% in the PCA group.
The multi-modal approach used by Dr. Ranawat and his colleagues also includes spinal anesthesia, as well as “pre-emptive” analgesia before surgery with celecoxib and oxycodone and postoperative analgesia including ketorolac, celecoxib, oxycodone and acetaminophen.
In another study, researchers at the London Health Sciences Centre in Ontario randomly assigned 64 total hip and 64 total knee replacement patients to receive intraoperative periarticular injections of ropivacaine, ketorolac, Epimorph and epinephrine or no injection. All patients underwent standardized general or regional anesthesia protocols and were given PCA machines for 24 hours after surgery.
The injection group showed an advantage in the primary outcome of 24-hour PCA consumption as well as visual-analogue measures of pain and satisfaction within four hours of surgery, orthopedic resident Dr. Ben Shore said in his paper presentation. There was no difference in average hospital length of stay between groups.
“Someone who’s had a total knee on one side the old way, and they have it the new way, they just think it’s night and day,” Dr. Robert Bourne, a study co-author and chairman of orthopedic surgery at the University of Western Ontario, said in an interview at the meeting.
Ropivacaine is potentially toxic to the heart, but analysis of venous bound ropivacaine in five hip and five knee patients showed levels were only half the toxic dose.
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