July 16, 2018

The Continuing Evolution of Pain Control Techniques in Knee and Hip Replacements

By Adrian T. Baddar, MD, F.A.A.O.S.

Only a few years ago, the night after a total knee replacement was often fairly miserable. Patients had to rely on frequent doses of narcotics from pain pumps to relieve their discomfort, and they rarely got much sleep. Many were reluctant to start exercising their new joint, fearing even more pain.

Thankfully, ongoing advances in anesthesia have transformed that experience. In fact, our current multi-modal approach to pain relief – a well-tolerated cocktail of medications delivered locally, regionally and systemically – is rapidly moving knee and hip replacements into the realm of outpatient surgery.

Today’s total knee patients often are able to walk within three hours of surgery, sleep peacefully through the night and leave the hospital the next day. The psychological benefit of less initial pain also carries over into rehabilitation and physical therapy, helping patients return to normal activities sooner.

In total knee cases, we begin with a powerful, 12-hour femoral nerve block, precisely placed with ultrasound guidance. That regional anesthetic eliminates 90 percent of pain, while still preserving mobility. Once in the operating room, we can inject a 72-hour numbing agent around the entire joint capsule, while also filling that capsule with medications to reduce pain, inflammation and bleeding.

While total hip replacements are generally not as painful, similar directed injections in and around the joint capsule still provide important relief and lower the risk of swelling and blood transfusions.

These long-lasting anesthetics pose a stark contrast to pain pump doses, which typically wore off within 30 to 45 minutes. In the days after surgery, a majority of patients now can manage remaining soreness with milder oral analgesics and non-steroidal anti-inflammatory drugs, rather than narcotics or intravenous treatments that can cause side effects such as nausea, confusion and weakness.

More than 99 percent of our total knee patients go home the day after surgery, as compared to the two or three nights they’d spend in the hospital a decade ago. Patients who do stay longer almost always have other medical issues, or a lack of caregiving support at home.

As for total hip and partial knee replacement patients, roughly 30 percent leave the hospital on the same day – and those numbers are expanding at a fast clip.

Patients who gain immediate confidence in a new joint will move more in the hours and days after surgery and better tolerate physical therapy. They are more likely to regain strength, function and mobility sooner, as well as avoid the stiffness and blood clot risk that develop due to immobility.

As horror stories of intense post-surgical pain fade, more people also have been willing to seek help for degenerating joints before suffering years of needless discomfort. The future looks even brighter, as regional and local anesthesia options continue to evolve and advance. So not only are long-term outcomes improving, but the road back to good health is growing ever smoother.

Dr. Baddar is a fellowship-trained hip and knee replacement surgeon with Hampton Roads Orthopaedics & Sports Medicine. His specialties include minimally invasive joint replacement, complex joint revisions, sports medicine, arthroscopy and general orthopaedics. hrosm.com