Pain management after total joint replacement: A revolution is under way
Can a minor change in intra- and postoperative pain treatment really have much impact on mobility, discharge and patient satisfaction?
That question was posed to joint replacement surgeons in Denmark less than two years ago in pilot studies, where investigators observed major changes with minor interventions. After those initial findings, they designed more studies to show the true effect of this story and recently the first of these has been published showing the phenomenon to exist.
During the past year, most joint replacement clinics in Denmark have implemented the technique. We adapted a modified technique in our clinic as follows: We prescribe postoperative NSAIDs and low-dose opioid tape placed on the skin for the first 7 days after surgery, which is combined with a massive infiltration in the soft tissue surrounding the hip with a mixture of naropin, keterolac and adrenalin. It has been a big event.
We used to see a breakthrough in patients pain the first day after surgery, but they ended up experiencing nausea from the necessary large amounts of intraveneous or oral opioids. With the new protocol these side effects are now very rare. Total consumed opioids after both hip and knee replacement has dropped to nearly zero, and as a side benefit more patients become mobile on the day of surgery.
A universal solution?
Can adding a new pain treatment strategy account for all the improvements seen in our patients? Probably not. We also maintain a high-volume educational program. We inform our patients in detail at a meeting a week before their surgery about all aspects involving their care. They watch a video of patients going through the full program, instructed by an orthopaedist who tells them about the surgery they will receive, which is illustrated by a computer slide show. They also hear from anesthetists and specialized nurses specially trained to talk with patients and answer questions. This program is probably a major tranquilizer making the patients feel confident and in safe hands and it helps make the program run according to plan.
Therefore, all our patients understand ahead of time from the educational meeting that they are being treated with the new technique, which may bias the scoring of their experience, their mobilization rates and discharge times. Still, we have reduced our inpatient stay for both knee and hip replacements, with the mean stay now 3.5 days for hips and 4.2 days for knees, and we rarely have patients who experience severe pain in the days immediately following surgery. As a government hospital that cares for all submitted patients who need a joint replacement, these figures are very satisfying.
Patients, hospital benefits
We are convinced, however, that the new pain management strategy offers major benefits for our patients. One of our overall goals is to operate on more patients without increasing the number of hospital beds. In our clinic, we have increased the number of joint replacements fourfold within 5 years to 700 joints, all while adding only five new colleagues (ie, nurses, doctors or physiotherapists) to our clinic.
It is not only good business for hospitals to introduce pain and patient educational programs. It also improves the quality of treatment.
In the November/December issue, Orthopaedics Today International will feature additional reports on key pain management issues in orthopaedics.
For more information:
- Per Kjaersgaard-Andersen, MD, is an assistant professor of orthopaedic surgery, Vejle Hospital at South Danish University, Vejle, Denmark. He is an editor for Orthopaedics Today International.
- Andersen LJ, Poulsen T, Krogh B, Nielsen T. Postoperative analgesia in total hip arthroplasty. A randomized-double-blinded, placebo-controlled study on perioperative and postoperative ropivacaine, keterolac, and adrenaline wound infiltration. Acta Orthop. 2007;78 (2):187-192.
- Andersen KV, Pfeiffer-Jensen M, Haraldsted V, Søballe K. Reduced hospital stay and narcotic consumption, and improved mobilization with local and intra-articular infiltration after hip arthroplasty. A randomized clinical trial of an intra-articular technique versus epidural infusion in 80 patients. Acta Orthop. 2007;78(2):180-186.