Innovative new modalities for managing post-surgical discomfort

By Adrian T. Baddar, MD
Hampton Roads Orthopaedic & Sports Medicine

Every year in the United States, approximately 150,000 hip replacements are performed, and more than 350,000 knee replacements.  By contrast, the number of spinal fusions done each year is a stunning 650,000, reflecting just how many Americans suffer from a seriously aching lower back.  The overwhelming majority of these procedures are successful, reducing or substantially relieving pain and restoring the patients to comfortable, active lifestyles.

It’s well understood by orthopaedic surgeons and patients alike that the pain that accompanies knee replacement surgery can be miserable.  And candidly, in the past, we’ve done a pretty miserable job of controlling it.  The etiology of most of that pain is the work we’ve done in the bone itself, particularly around the area of the periosteum.  And having seen their friends and loved ones suffering – literally – with post-surgical pain, many patients have resolutely avoided knee replacement because of the stigma of those first days of recovery.

Today, fortunately, that no longer need be the case. Now the first few days are actually the easiest, because we’ve learned to control pain significantly better and more efficiently.

It starts with the pre-surgical care:  before putting patients under, we can administer narcotic pain medicine and an anti-inflammatory, as well as pregabalin (Lyrica) when appropriate, which modifies the way they experience pain.  In the case of knee replacements, surgeons can inject a numbing medicine around the femoral nerve, best placed lower down in the quadriceps to avoid loss of motor function.  Because these blocks can last as much as 12 hours, patients are waking up from surgery with essentially no pain.  And because they’ve been premedicated, they don’t require as much anesthesia during the procedure itself.  They wake up not only pain free, but far better able to mobilize and without the groggy, nauseated feeling that often accompanies an “anesthesia hangover.”

In addition, an injection of Exparel during the surgery, while the joint is open, provides as much as 72 hours of pain relief.  Exparel is a non-opioid that slowly releases bupivacaine, numbing the area around the bone in the surgical site.  Because it takes about eight hours for maximum effectiveness, it provides relief just as the block is wearing off and lasts a full three days.

When the knee capsule is closed, we inject the patient’s knee with a fast-acting numbing medicine along with epinephrine to control bleeding, and administer morphine and a strong anti-inflammatory as well.

If this sounds like a lot of medicines in rapid succession, it’s because we’ve learned to approach all of the pathways that produce the searing pain associated with this surgery without overuse of narcotics with all of its attendant complications.  By effectively numbing these patients, preventing inflammation and reducing their sensation of pain – while keeping them mobile and starting PT the same day of surgery – we’re seeing quicker recoveries and more confident patients who are able to participate more fully with their therapists.

Post-surgery, patients remain on the anti-inflammatory, and we’ve found that IV Tylenol works just as effectively as morphine, but without the attendant constipation and mental sluggishness.  In the past, when I saw patients the day after their knee replacements, I became accustomed to often (very) loud complaints of pain.  Now when I visit, I often find them sleeping peacefully – or sitting up, enjoying a pain-free morning.  In fact, I often have to caution them that in a few days, this regimen will start to wear off, and they’re going to experience some increasing pain – but nothing like the pain they’d feared, and nothing that can’t be easily managed.

Dr. Baddar is a graduate of the University of Virginia Medical School, where he completed his orthopaedic residency.  He completed a fellowship in Adult Reconstructive Surgery at the Cleveland Clinic, and is a fellow of the American Society of Orthopaedic Surgeons.  He also serves as the Medical Director for the Multi-Positional MRI Center at Hampton Roads Orthopaedic & Spine Center. www.hrosm.com