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Is Opioid-Free Total Joint Arthroplasty Realistic? A Review of Regional and Multimodal Analgesia for TJA

Regional and multimodal analgesia may be instrumental in reducing perioperative opioid use in patients undergoing total joint arthroplasty (TJA), according to a narrative review published in HSS Journal.

Surgery, particularly orthopedic surgery, is a potential risk factor for long-term opioid use and misuse. Because of rising demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA), it is essential that researchers and clinicians develop strategies to minimize opioid use and protect patients from opioid dependence. 

In response, Hospital for Special Surgery (HSS) convened a multidisciplinary symposium in June 2018 to advance clinical care and research towards opioid-free total joint arthroplasty. Ellen M. Soffin, MD, and Christopher L. Wu, MD, anesthesiologists at HSS, presented the evidence to support the role of regional anesthesia and analgesia in achieving this goal. 

“The benefits of regional and multimodal analgesia for total joint arthroplasty have been supported in the literature for years. However, there were few reports focusing specifically on how much these techniques minimize opioid consumption while providing adequate pain control after hip or knee arthroplasty,” said Dr. Soffin.     

Drs. Wu and Soffin conducted a literature review to assess the state of the evidence and identify research gaps and opportunities to use regional and multimodal analgesia to protect patients from opioid-related harm after THA or TKA.

They discuss their findings on multimodal analgesia including IV agents, NSAIDs and acetaminophen; gabapentinoids; other non-opioid analgesic agents including ketamine; and regional techniques (epidural and peripheral nerve blocks and surgeon-administered local infiltration analgesia). 

Their findings support the use of multimodal analgesia as the foundation of post-TJA pain management.  Unless contraindicated, all patients should receive an NSAID and acetaminophen on a scheduled basis. 

Gabapentinoids may decrease opioid consumption, but evidence from this review suggests that the efficacy for pain relief after TJA is uncertain. 

“Some components, such as gabapentin, that were beneficial in other surgical modalities (such as colorectal surgery) did not seem as consistently effective in THA/TKA,” Dr. Wu noted.

Several studies included in the review question the overall analgesic benefits and safety of gabapentinoids. Drs. Soffin and Wu caution that gabapentinoids can be associated with several adverse effects and should be used with caution in older patients and those with renal dysfunction. However, the authors highlight encouraging data, including a recent double-blind, placebo-controlled RCT which concluded that gabapentinoids were opioid sparing after THA and TKA. 

Other non-opioid analgesic agents may be effective in postoperative pain management, although there is less data examining their effectiveness, dose, and timing. IV ketamine may be particularly promising; other options, although with less data available, include IV magnesium, PO dextromethorphan and IV lidocaine. 

Evidence also supports use of regional analgesia to minimize opioid consumption after TJA. Recent evidence suggests that a combination of peripheral nerve blocks (PNBs) facilitates the best balance after TKA, but data is lacking for THA. Novel PNBs such as the IPACK block are an emerging alternative, but also require more research on efficacy. The choice of regional anesthesia must also take into account the resources and local expertise of the facility, as not all institutions have developed regional anesthesiology services. In these cases, surgeon-administered local and intraarticular infiltration analgesia (LIA) and periarticular infiltration (PAI) may be particularly valuable.

In conclusion, effective strategies to minimize opioid use in patients undergoing TJA focus on non-opioid multimodal analgesia, including systemic and local anesthetic-based techniques. 
“Our review provides a framework for clinicians to implement standardized perioperative anesthetic-analgesic pathways with the specific goal of opioid reduction with adequate analgesia,” said Dr. Wu. 

Based on the evidence from their review, Drs. Wu and Soffin noted that acetaminophen, NSAIDs, and peripheral nerve blocks are especially valuable and are recommended for TJA. In addition, N-methyl-D-aspartate (NMDA)-receptor antagonists may help reduce opioid use in patients at risk of developing chronic pain.

More research is needed to determine how gabapentinoids, PNCs, extended-duration local anesthetics and novel PNBs may be of use in reducing risk for long-term opioid use after TJA.

Soffin EM, Wu CL. “Regional and multimodal analgesia to reduce opioid use after total joint arthroplasty: a narrative review. HSSJ. 2018. doi: 10.1007/s11420-018-9652-2