Total Hip and Knee Arthroplasty Perioperative Pain Management

Abstract

* There are multiple available agents and modalities for controlling pain perioperatively during total joint arthroplasty to improve the patient experience, and their unique mechanisms and applications should be considered for use preoperatively, intraoperatively, and postoperatively, keeping in mind that each has differing efficacy and side-effect profiles.* Preoperative pain control or preemptive analgesia using anti-inflammatory drugs and opioid analgesics appears to be effective in reducing postoperative pain, although the recommended timing and type of agents are unclear.* With regard to intraoperative anesthetic choice and pain control, spinal anesthesia appears to have fewer systemic risks than general anesthesia, and periarticular injections of local anesthetic agents, regardless of technique, and with or without the addition of sympathetic modulators, opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids, have been shown to improve pain scores postoperatively and to overall carry a low risk profile.* When considering postoperative pain control, there are several modalities including cryotherapy, peripheral nerve blockade, and parenteral and enteral medication options including acetaminophen, cyclooxygenase inhibitors, neuromodulators, tramadol, ketamine, and opioid patches, but there is no clearly preferred medication regimen and individual patient risk profiles must be considered when choosing appropriate pain management agents.* Multimodal pain management can decrease opioid usage, improve pain scores, increase patient satisfaction, and enhance early recovery. The ideal preoperative, intraoperative, and postoperative pain medication regimen remains unclear, and an individualized approach to perioperative pain management is recommended. Despite this, good results are demonstrated with the existing variations in pain management protocols in the literature.* Treatment of severe postoperative pain in a multimodal fashion carries the risk for serious side effects, including respiratory depression, mental status changes influencing safe gait mechanics, hypotension, renal and hepatic dysfunction, hematologic variations, gastrointestinal considerations including gastric ulcers, constipation or ileus, nausea or vomiting, infection at injection sites, and peripheral nerve injury with peripheral blockade.

Efficacy of additional corticosteroids to multimodal cocktail periarticular injection in total knee arthroplasty: a meta-analysis of randomized controlled trials

“…Periarticular infiltration analgesia is widely used in the clinic to relieve pain after TKA [5,6]. It can suppress the inflammation at the surgical site, provide satisfactory analgesic effects, maintain muscle strength, and reduce the consumption of opioids and related complications [6][7][8]. Corticosteroids have been widely used in various surgical procedures as an anti-inflammatory drug [9,10].…”

Minimum Effective Concentration of Ropivacaine For Ultrasound-Guided Adductor Canal + IPACK Block In Total Knee Arthroplasty

“…Therefore, we chose postoperative 6 hours as the endpoint of this study. We added epinephrine to our ropivacaine formulations because epinephrine modulates the sympathetic nervous system, which can increase analgesic potency and duration [34].…”

Comparative evaluation of analgesic efficacy of buprenorphine transdermal patch and fentanyl patch in management of postoperative pain after arthroscopic lower limb surgery

“…The durations of action for fentanyl and buprenorphine patches are different, approximately 3 and 7 days, respectively, and usually severity of postoperative pain is of moderate to severe grade in first 48–72 h only so we have decided to compare efficacy of fentanyl and buprenorphine patches and their side effects for 72 h postoperatively. [ 16 17 ] Keeping in mind the onset of action of opioid patch is 12–24 h, all the patients were given transdermal patch 12 h before surgery. We have used non opioid analgesic (diclofenac) in our study as rescue analgesics as adding intravenous or oral opioid with transdermal fentanyl or buprenorphine will further aggravate the side effects like nausea vomiting and respiratory depression related to opioids.…”