Advances in Pain Management Mean Less Pain After Joint Replacement Surgery
When considering joint replacement, many patients worry about the pain they could experience after surgery. Just ask Susan Lucanto, who recently turned 60. She says she experienced so much pain after her first knee replacement almost 10 years ago, that she felt a lot of anxiety when the implant started to loosen and she required a second surgery. She was afraid she would experience the same pain all over again.
For the second procedure, known as a revision knee replacement, Ms. Lucanto went to a different orthopedic surgeon: a doctor specializing in revision surgery. This time she consulted with Geoffrey H. Westrich, MD, the Director of Research for the Adult Reconstruction and Joint Replacement Service at Hospital for Special Surgery (HSS) in New York City.
Dr. Westrich assures his patients that orthopedic surgeons and anesthesiologists at HSS have conducted numerous research studies and have developed a protocol that aims to ensure pain is well managed after surgery.
"Of course, every patient is different, but we have found that 'multimodal analgesia' – the administration of two or more drugs targeting multiple pain pathways – is very effective in managing pain," Dr. Westrich notes. "In addition to the epidural anesthesia used during knee replacement, anesthetic pain medication is now administered inside the joint itself during surgery, and the patient then receives the multimodal pain control protocol after the procedure."
Ms. Lucanto says it worked like a charm. Although revision knee replacement is more demanding on the patient than a primary knee replacement, she says pain was not an issue after the second surgery.
On the Hospital for Special Surgery web portal known as "Back in the Game," patients can post their experiences. Ms. Lucanto wrote: "On October 4, 2018, I underwent a left knee revision at HSS located in New York City. My surgeon and hero was Dr. Westrich. It was one of the best experiences in my life, seriously. I went in on a Thursday and I left the next day, walking on my own with the help of a cane. After two weeks… I went back to work!" (https://backinthegame.hss.edu/story/susan-lucanto/)
Ms. Lucanto also described how her second surgery differed from her original knee replacement: "When I was waiting on the day of the revision surgery, I was scared of what I was facing. My original left knee replacement in April 2009 was extremely painful. However, I am totally blown away by how different my knee replacement surgery in April 2009 was from my left knee revision this past October. There was hardly any pain with the revision. With the (first knee) replacement, I was out-of-work for 3 months."
"Multimodal analgesia means using many different ways to reduce pain," explains Jacques T. YaDeau, MD, PhD, an anesthesiologist in the Department of Anesthesiology, Critical Care & Pain Management at Hospital for Special Surgery. "This allows a reduction in both pain and side effects. Most patients at HSS receive a spinal or epidural for the main anesthetic. This is a neuraxial anesthetic, which means it is administered around the nerves of the central nervous system, and this reduces postoperative pain because the brain does not ‘see’ the pain during surgery."
Dr. YaDeau explains that in addition to the epidural, the multimodal protocol includes nerve blocks to reduce pain in both the front and the back of the knee; the injection of a local anesthetic into the surgical site at the end of the surgery; and pain management following surgery, which may include anti-inflammatory drugs, acetaminophen and generally, some narcotic pain medication.
"Most, but not all patients still use some opioids, but the amount used is much less than patients used to need," he adds. "Sometimes there are patient-specific reasons not to receive some aspects of this multimodal therapy, but typically knee replacement patients at HSS receive most or all of these components."
"Clearly, we have seen many advances – and changes – over the years in the way we manage pain after joint replacement. We now know that although opioid medication is highly effective and often part of the overall pain management plan after surgery, it should be used in the lowest dose needed to provide pain relief and for the shortest amount of time necessary," Dr. Westrich notes.
Ms. Lucanto says that by the time she went home the day after revision knee replacement, she no longer needed opioid medication and only took over-the-counter extra-strength Tylenol for pain management. Indeed, she was so pleased with her recovery that she told a patient she met in physical therapy about her experience. "The woman has very bad arthritis in both knees, but says she is 'terrified' to have knee replacement because she’s afraid of the pain. I don’t think anyone should have to suffer with arthritis, especially when these pain blockers can make the surgery a lot easier."
Dr. Westrich, Dr. YaDeau and their colleagues at HSS continuously strive to improve patient care, and studies are ongoing in the realm of pain management. "Our ultimate goal is to have a greater understanding of which multimodal pain protocol is best for a given patient, aiming to minimize the amount of narcotics and limit the side effects associated with such medications," Dr. Westrich said. "We hope to optimize this in future research."