Perspective

Multimodal anesthesia may offer pain control, patient satisfaction after TKA

New methods in pain management may help decrease side effects compared with traditional methods.

A recently published literature review showed a multimodal pain management approach for total knee arthroplasty effectively controlled postoperative pain and minimized opioid-related adverse effects while improving patient satisfaction.

“There are a variety of different ways of managing pain perioperatively and we still do not know completely the best manner of managing pain postoperatively, but we have a lot more information now that enables us to do more research on this topic and figure out exactly what the best modalities are,” Calin S. Moucha, MD, chief of adult reconstruction and joint replacement at Mount Sinai Hospital and associate professor at the Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine, told Orthopedics Today.

He continued, “If you control pain, you are less likely to have vomiting, nausea infections postoperatively [and] you are less likely to develop chronic regional pain syndrome. Controlling pain will ultimately lead to lower length of stays [and] lower health care costs. It affects everything.”

Analgesia, anesthesia

Using pre-emptive analgesia prior to total knee arthroplasty (TKA) surgery can prevent inflammatory chemicals and improve postoperative pain and reduce the risk for development of chronic neuropathic pain, according to the researchers.

General anesthesia can help reduce perioperative tissue oxygen tension and neuraxial anesthesia can prevent postoperative nausea, vomiting and delirium, Moucha and his colleagues found. However, studies have shown neuraxial anesthesia also has an approximate failure rate of 4%. Similarly, research has shown low complication rate of spinal and epidural anesthesia, including spinal and epidural hematoma, abscess formation, cauda equine syndrome, meningitis, postoperative hypotension and urinary retention.

According to Moucha, use of a femoral nerve block results in quadriceps weakness and increases the risk of falling postoperatively. The adductor canal block, on the other hand, “is becoming increasingly popular because it targets several mostly sensory nerves in the adductor canal while reducing the degree of quadriceps weakness,“ he said, however more large randomized controlled trials are needed on adductor canal blocks.

The researchers note sciatic nerve block as a useful alternative peripheral nerve block which can provide more complete postoperative pain relief when combined with an adductor nerve block. It should, however, be restricted to patients with varus deformity of the knee, as Moucha said “it may complicate the interpretation of a postoperative neurovascular examination in patients with valgus deformity. These blocks, however, take time, and are best performed in a preoperative anesthesia area so there is minimal interference with OR efficiency.” In addition, he noted “the shortest amount of time should be spent in the OR itself performing blocks and neuraxial anesthesia, as infection risk increases with multiple door openings and staff members in the room once the surgical trays have been uncovered.”

Several studies also suggest use of local infiltration anesthesia maintains quadriceps motor strength while providing pain control equivalent to femoral nerve block, he said. When compared with a delayed-release liposomal formulation of bupivacaine recently approved for use in the United States, research has shown similar results to traditional bupivacaine with no statistical differences in morphine consumption, pain scores, knee range of motion, length of stay or walking distance. That said, Moucha and his colleagues noted a 20 mL vial of liposomal bupivacaine is 95 times more expensive than a 10 mL vial of traditional bupivacaine.

“Traditionally, we used a computerized pump, the patient-controlled analgesia...and that has been shown to provide good pain control postoperatively after knee replacement, but...that also has a lot of side effects,” Moucha said. “More recently we are using a lot of regional anesthesia where we do things like a spinal anesthetic with peripheral nerve blocks, local infiltration of analgesia or both and that has been shown to decrease potential side effects and increase patient satisfaction.”

Length of hospital stay

In terms of length of hospital stay, Moucha and his colleagues found several studies that showed a similar or lower length of stay among patients who underwent a multimodal anesthesia protocol compared with a traditional protocol. However, patient preconceptions, medical comorbidities, postoperative complications and social factors can make it challenging to assess whether multimodal techniques reduce the length of hospital stay following TKA and more research is needed, according to Moucha.

“We need stronger, nonindustry-funded prospective randomized trials that look at different peripheral nerve blocks, look at different combinations of local infiltration and try to see what the best pain management modality is in terms of value. The highest value pain management regimen is a complicated recipe, and we still have work to do,” he said. – by Casey Tingle

Disclosure: Moucha reports no relevant financial disclosures.

A recently published literature review showed a multimodal pain management approach for total knee arthroplasty effectively controlled postoperative pain and minimized opioid-related adverse effects while improving patient satisfaction.

“There are a variety of different ways of managing pain perioperatively and we still do not know completely the best manner of managing pain postoperatively, but we have a lot more information now that enables us to do more research on this topic and figure out exactly what the best modalities are,” Calin S. Moucha, MD, chief of adult reconstruction and joint replacement at Mount Sinai Hospital and associate professor at the Leni and Peter W. May Department of Orthopedic Surgery, Icahn School of Medicine, told Orthopedics Today.

He continued, “If you control pain, you are less likely to have vomiting, nausea infections postoperatively [and] you are less likely to develop chronic regional pain syndrome. Controlling pain will ultimately lead to lower length of stays [and] lower health care costs. It affects everything.”

Analgesia, anesthesia

Using pre-emptive analgesia prior to total knee arthroplasty (TKA) surgery can prevent inflammatory chemicals and improve postoperative pain and reduce the risk for development of chronic neuropathic pain, according to the researchers.

General anesthesia can help reduce perioperative tissue oxygen tension and neuraxial anesthesia can prevent postoperative nausea, vomiting and delirium, Moucha and his colleagues found. However, studies have shown neuraxial anesthesia also has an approximate failure rate of 4%. Similarly, research has shown low complication rate of spinal and epidural anesthesia, including spinal and epidural hematoma, abscess formation, cauda equine syndrome, meningitis, postoperative hypotension and urinary retention.

According to Moucha, use of a femoral nerve block results in quadriceps weakness and increases the risk of falling postoperatively. The adductor canal block, on the other hand, “is becoming increasingly popular because it targets several mostly sensory nerves in the adductor canal while reducing the degree of quadriceps weakness,“ he said, however more large randomized controlled trials are needed on adductor canal blocks.

The researchers note sciatic nerve block as a useful alternative peripheral nerve block which can provide more complete postoperative pain relief when combined with an adductor nerve block. It should, however, be restricted to patients with varus deformity of the knee, as Moucha said “it may complicate the interpretation of a postoperative neurovascular examination in patients with valgus deformity. These blocks, however, take time, and are best performed in a preoperative anesthesia area so there is minimal interference with OR efficiency.” In addition, he noted “the shortest amount of time should be spent in the OR itself performing blocks and neuraxial anesthesia, as infection risk increases with multiple door openings and staff members in the room once the surgical trays have been uncovered.”

Several studies also suggest use of local infiltration anesthesia maintains quadriceps motor strength while providing pain control equivalent to femoral nerve block, he said. When compared with a delayed-release liposomal formulation of bupivacaine recently approved for use in the United States, research has shown similar results to traditional bupivacaine with no statistical differences in morphine consumption, pain scores, knee range of motion, length of stay or walking distance. That said, Moucha and his colleagues noted a 20 mL vial of liposomal bupivacaine is 95 times more expensive than a 10 mL vial of traditional bupivacaine.

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“Traditionally, we used a computerized pump, the patient-controlled analgesia...and that has been shown to provide good pain control postoperatively after knee replacement, but...that also has a lot of side effects,” Moucha said. “More recently we are using a lot of regional anesthesia where we do things like a spinal anesthetic with peripheral nerve blocks, local infiltration of analgesia or both and that has been shown to decrease potential side effects and increase patient satisfaction.”

Length of hospital stay

In terms of length of hospital stay, Moucha and his colleagues found several studies that showed a similar or lower length of stay among patients who underwent a multimodal anesthesia protocol compared with a traditional protocol. However, patient preconceptions, medical comorbidities, postoperative complications and social factors can make it challenging to assess whether multimodal techniques reduce the length of hospital stay following TKA and more research is needed, according to Moucha.

“We need stronger, nonindustry-funded prospective randomized trials that look at different peripheral nerve blocks, look at different combinations of local infiltration and try to see what the best pain management modality is in terms of value. The highest value pain management regimen is a complicated recipe, and we still have work to do,” he said. – by Casey Tingle

Disclosure: Moucha reports no relevant financial disclosures.

    Perspective
    Matthew P. Abdel

    Matthew P. Abdel

    This is an excellent review article on a timely area of continued evolution in the perioperative management of patients undergoing total knee arthroplasty (TKA). The authors have nicely highlighted that while no single anesthetic protocol is optimal for all patients, advances have been made. In general, a multimodal protocol that combines several different types of medications and delivery routes is optimal as it minimizes adverse events from particular classes of medications. Moreover, many well-executed investigations have shown short- and mid-term benefits with the use of neuraxial anesthesia when compared to general anaesthesia. Finally, this article highlights the recent popularization of periarticular injections. While definitive data continues to become available, it is clear there is a role for such injections, provided they are utilized by the surgeon with the precision and accuracy the actual TKA itself mandates.

    • Matthew P. Abdel, MD
    • Senior Associate Consultant Associate Professor Department of Orthopedic Surgery Mayo Clinic College of Medicine Rochester, Minn.

    Disclosures: Abdel reports no relevant financial disclosures.