CommentaryFrom OT Europe

Modern pain treatment programs support fast-track hip and knee replacement

During the last decade, a huge development in early mobilization and early discharge has taken place in fast-track total hip and knee replacement, enabling most patients undergoing total joint replacement to be mobilized a few hours after surgery with most patients discharged no later than 24 hours after surgery. Among the most important keys to that development is the dramatic change in pain treatment programs.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

From the earlier days of epidural pain treatment and catheters used for days after surgery — and frequently the added use of patient-controlled analgesia (PCA) with greater amounts of morphine — to the current modern, multimodal approach, there have been many changes in the concepts of pain management to consider for patients who undergo TJR. Having been a part of that development, I am often astonished when I look back to confirm, “How can it be possible?” and at same time questioning, “Why did we not develop these ideas earlier?”

To me, this demonstrates that we should regularly “go up in the helicopter” and look at aspects of practices from another angle, which Edward De Bono calls lateral thinking. Big improvements in treatments and other areas only come when we break the traditions, guidelines and rules of a real scientific approach.

Progress in pain management

In 2007, if someone would have told me that in 2017 we would have an average stay for patients who underwent primary total hip replacement and total knee replacement of 1.8 days; that about 20% of patients would be discharged on the day of surgery; there would be a significant reduction in the use of morphine in the days after surgery; and all of those developments would occur at a time when it is shown we have more patients who are satisfied after TJR, have better joint education and experience fewer complications, I would have doubted it. But, here we are. The keystone to the success is a multidisciplinary team-work approach in the orthopaedic department and the development of an effective pain management program.

However, without the new modern pain management program, we may forget about other aspects that affect getting patients up after surgery and out of the hospital. If a patient is in severe pain, he or she cannot be mobilized early and cannot follow the training program. From that experience, they can get a negative first exposure to the early outcome of surgery, which delays the start of recovery. A key part of all the changes to the pain management program has been the ability to reduce the use of morphine starting in the first hours after surgery. This has been successful over time, such that today only limited amounts of morphine are used and frequently are only used in the postoperative care unit, where patients mostly stay for about 1 hour to 2 hours after surgery.

Preoperatively, the morning of the surgery, all patients start with acetaminophen and NSAIDs, and minutes before surgery they receive a high dose of IV methylprednisolone. During TKR, patients receive local infiltration analgesia in the posterior capsule and during THR, patients do not receive any injections. All the patients have a multimodal postoperative pain management program with only oral treatment with acetaminophen, NSAIDs and gabapentin. Oral morphine is allowed as PCA, but only in limited amounts, and only for first 1 day to 2 days. Of course, there are outliers who cannot follow this program, mainly the preoperative use of morphine, and they are at risk of not being able to follow the program and are at risk.

Modern pain management programs

It is proven that if the program is followed, fewer complications occur and a higher level of patient satisfaction is achieved. Today, we have good scientific knowledge about the behavior of our patients in the weeks after surgery. We have a clear vision on the significant benefits for all, including to society, from running a strict, modern pain management program for lower limb reconstruction.

In my department, we regularly wonder about future pain management programs and where will we be in another 10 years. This is difficult to predict, but by then we will certainly have taken another big step. In these discussions, we wonder if patients who have THR in the future will manage pain with low-dose spinal anesthesia followed only by 1 g acetaminophen and 125 mg methylprednisolone. By then, new steps surely will have been taken and, potentially, more personalized pain programs will be instituted based on a person’s biomarkers and comorbidities. I anxiously await the new trends and scientifically proven programs for pain management that may be just around the corner.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.

During the last decade, a huge development in early mobilization and early discharge has taken place in fast-track total hip and knee replacement, enabling most patients undergoing total joint replacement to be mobilized a few hours after surgery with most patients discharged no later than 24 hours after surgery. Among the most important keys to that development is the dramatic change in pain treatment programs.

Per Kjaersgaard-Andersen, MD
Per Kjaersgaard-Andersen

From the earlier days of epidural pain treatment and catheters used for days after surgery — and frequently the added use of patient-controlled analgesia (PCA) with greater amounts of morphine — to the current modern, multimodal approach, there have been many changes in the concepts of pain management to consider for patients who undergo TJR. Having been a part of that development, I am often astonished when I look back to confirm, “How can it be possible?” and at same time questioning, “Why did we not develop these ideas earlier?”

To me, this demonstrates that we should regularly “go up in the helicopter” and look at aspects of practices from another angle, which Edward De Bono calls lateral thinking. Big improvements in treatments and other areas only come when we break the traditions, guidelines and rules of a real scientific approach.

Progress in pain management

In 2007, if someone would have told me that in 2017 we would have an average stay for patients who underwent primary total hip replacement and total knee replacement of 1.8 days; that about 20% of patients would be discharged on the day of surgery; there would be a significant reduction in the use of morphine in the days after surgery; and all of those developments would occur at a time when it is shown we have more patients who are satisfied after TJR, have better joint education and experience fewer complications, I would have doubted it. But, here we are. The keystone to the success is a multidisciplinary team-work approach in the orthopaedic department and the development of an effective pain management program.

However, without the new modern pain management program, we may forget about other aspects that affect getting patients up after surgery and out of the hospital. If a patient is in severe pain, he or she cannot be mobilized early and cannot follow the training program. From that experience, they can get a negative first exposure to the early outcome of surgery, which delays the start of recovery. A key part of all the changes to the pain management program has been the ability to reduce the use of morphine starting in the first hours after surgery. This has been successful over time, such that today only limited amounts of morphine are used and frequently are only used in the postoperative care unit, where patients mostly stay for about 1 hour to 2 hours after surgery.

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Preoperatively, the morning of the surgery, all patients start with acetaminophen and NSAIDs, and minutes before surgery they receive a high dose of IV methylprednisolone. During TKR, patients receive local infiltration analgesia in the posterior capsule and during THR, patients do not receive any injections. All the patients have a multimodal postoperative pain management program with only oral treatment with acetaminophen, NSAIDs and gabapentin. Oral morphine is allowed as PCA, but only in limited amounts, and only for first 1 day to 2 days. Of course, there are outliers who cannot follow this program, mainly the preoperative use of morphine, and they are at risk of not being able to follow the program and are at risk.

Modern pain management programs

It is proven that if the program is followed, fewer complications occur and a higher level of patient satisfaction is achieved. Today, we have good scientific knowledge about the behavior of our patients in the weeks after surgery. We have a clear vision on the significant benefits for all, including to society, from running a strict, modern pain management program for lower limb reconstruction.

In my department, we regularly wonder about future pain management programs and where will we be in another 10 years. This is difficult to predict, but by then we will certainly have taken another big step. In these discussions, we wonder if patients who have THR in the future will manage pain with low-dose spinal anesthesia followed only by 1 g acetaminophen and 125 mg methylprednisolone. By then, new steps surely will have been taken and, potentially, more personalized pain programs will be instituted based on a person’s biomarkers and comorbidities. I anxiously await the new trends and scientifically proven programs for pain management that may be just around the corner.

Disclosure: Kjaersgaard-Andersen reports no relevant financial disclosures.